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Dentine
An avascular and mineralised connective tissue Has a tubular structure connecting the enamel and the pulp About 70% inorganic material, 18% organic material, and 12% water The inorganic portion is mainly hydroxyapatite crystals The organic component is mainly collagen and proteoglycans
Dentine cont.
The basic structural entities of dentine are: (1) the odontoblast with the odontoblast process, (2) the dentinal tubule, (3) the peri-odontoblastic space, (4) the peritubular dentine, and (5) the intertubular dentine.
Odontoblasts
The odontoblasts are specialised cells lining the pulp. They have long odontoblast processes which are located in the dentinal tubules in the dentine. The peri-odontoblastic space lies between the wall of the tubule and the odontoblast process.
Odontoblasts cont.
The peri-odontoblastic space contains tissue fluid and a few organic constituents. The odontoblast processes and tubules may branch, particularly peripherally. Intercellular junctions are found between odontoblasts, and between odontoblasts and the nerve-like fibroblasts in the pulp, and may be important in the transmission of nerve impulses.
The Pulp
The dentine and the pulp constitute the major part of the tooth. The pulp is surrounded by dentine except at the apical foramen where it communicates with the periodontal tissues. There is an intimate relationship between the dentine and pulp both developmentally and functionally.
What is a pulpotomy?
Vital amputation of the (inflamed or infected) coronal pulp Wound surfaces at orifaces of root canals are then treated in order to preserve vitality of radicular pulp, and retain the tooth Success depends on type of wound dressing, pulpal diagnosis at time of treatment, amputation technique and treatment of wound surface
PULPOTOMY
Types of Medicament
Two main groups:
Calcium hydroxide preparations stimulate a hard tissue barrier; promote healing; eg Vitapex, plain Ca(OH)2 Devitalizing medicaments aim to maintain primary tooth irrespective of pulpal condition eg formocresol, Ledermix, glutaraldehyde, ferric sulphate Also - MTA
(2) Formocresol
Use a 1/5 dilution of the original Buckleys solution (1930s):
Tricresol 35% Formaldehyde 19% (a histological fixing agent) Glycerol 15% Water 31%
Bactericidal Devitalizing
Formocresol (cont)
Aim to create a chemically altered zone at the pulp-medicament interface leaving the deeper untreated pulp tissue vital and un-inflamed Diffuses into the pulp tissue - degree of penetration is time and dose-dependent May end up with chronic inflammation or even partial necrosis of residual pulp
Formocresol cont.
Higher success rate than calcium hydroxide Systemic absorption of FC shown in animal studies where large nos of teeth had pulpotomies with full strength FC Suggested FC may have immunogenic, toxic, mutagenic potential but no data to support toxic effects from pulpotomies in humans
(4) Glutaraldehyde
Better fixative cf FC Larger molecules less penetration Toxic properties eg allergies, eye irritation Seldom used
Other Methods
Electrosurgery (may be in combination with FC) Lasers MTA
Radiographs
Must have preoperative radiograph which shows the furcation area (or preferably the whole tooth) PA is best Should also have a post-op radiograph Follow up radiograph at 6 months and then annually
PULPOTOMY TECHNIQUE
Steps
Pre-op radiograph Isolate tooth Remove all caries Remove roof of pulp chamber with high speed bur Remove pulp with no. 6 or 8 round low speed burs and/or large sharp excavator (do NOT cut through furcation!) Arrest bleeding from root orifaces with cotton pellets Place damp cotton pellet with FC or FS in pulp chamber for 1-5 min Mix ZOE or IRM (thick mix) and fill pulp chamber Restore tooth eg with ss crown
Note:
Studies show that if the marginal ridge is broken down, there is often inflammation of the pulp horn Direct pulp capping has a poor success rate in primary teeth pulpotomy better In Cambodia there are many abscessed teeth following placement of deep restorations because pulp already inflamed Teeth with pulpotomies tend to exfoliate early
No abscess or fistula or swelling or mobility >1/2 of root remaining No periapical/furcal bone loss No internal resorption of crown or root Bleeding disorders
ABSCESS
FOLLOW UP
Review clinically and radiographically at 6 mo and then annually PA or PBWs which show furcation area Appearance of a radiolucency, internal resorption, or abscess indicate failure extraction or pulpectomy
Complications/Failures
Notes
If health of pulp doubtful, some dentists add a drop of FC the ZOE/IRM mix