College of Dentistry

Pedodontic I
Vital Pulp Therapy
Dr. Hazem El Ajrami

Vital pulp therapy

I.

Indirect pulp capping.

II. Direct pulp capping.

III. Pulpotomy.
IV. Partial pulpectomy.
V. Complete pulpectomy (endodontic treatment).

III. Pulpotomy:

 Calcium Hydroxide Pulpotomy:

It is indicated in young permanent teeth with
exposed vital pulp and incomplete root formation.
Under calcium hydroxide, the pulp is able to
maintain its vitality, it organizes an odontoblastic
layer to lay down reparative dentine and give the
chance to the root to complete its apical growth.
After pulpotomy and formation of healthy clot
a layer of Ca (OH)2 is applied then a layer of zinc
phosphate cement and permanent restoration is
inserted this procedure gives 61 % success.

 Formocresol Pulpotomy:
It is recommended for primary teeth with
carious exposure. The formocresol used is
Buckly's formocresol which is composed of 19%
formaline and 35 % cresol in a vehicle of
glycerin and distilled water. Formocresol
solution releases formaldehyde, which diffuse
through the pulp and by combining with cellular
protein fixes the pulp tissues. Formocresol, as
supplied, can be diluted to 1:5 concentration
using 3 parts of glycerin and one part distilled
water.

There are two methods:

A. The

one

step

technique

(one

visit

(2

visits

technique).
B. The

two

techniques).

steps

technique

A. The one step technique:

1. After amputation of the coronal part of the
pulp and removal of debris, stopping of the
bleeding and formation of the clot. Dip a
cotton pledget in formocresol, remove excess
of the solution by dapping on a cotton roll
and place it in the pulp chamber covering the
radicular pulp stumps for 4 - 5 minutes. Do
not allow the solution to lack on the gingival
tissue.

2. Prepare a paste of inforced zinc oxide-eugenol.

Remove the cotton pledget and place just
enough paste to cover the radicular pulp
stumps. Pressure should be avoided on
radicular pulp tissues.
3. After setting of zinc oxide-eugenol base, the
tooth is ready for final restoration.

B. The two steps technique:

After amputation of the pulp and formation
of healthy clot. A pellet of cotton with
formocresol is placed over the floor of the pulp
chamber and cover it with temporary dressing.
In the second visit after 2-3 days isolate the
tooth with rubber dam without local anesthesia
(now the surface of the pulp tissue is fixed and
not sensitive) remove the dressing and the
pellet of cotton previously moistened with
formocresol and complete the procedure as
before in the one visit technique.

 N.B. A chrome steel crown is the ideal

restoration after pulpotomy because the crown
of the tooth treated by pulpotomy is weak, brittle
and may split fracture. If there is any sign of
hyperemia following removal of coronal pulp
(pain or excessive hemorrhage) indicating, that
inflammation is present in the tissue beyond the
coronal portion of the pulp. Pulpotomy should
not be performed but do partial pulpectomy or
even extraction of the tooth.

IV. Partial pulpectomy:

Definition:
It is the removal of coronal pulp tissue
and as much as possible from the content of
the root canal.

 Indications:
1. It is indicated in the primary molars (due to
morphology of the root canal such as lateral
branching and ramification and presence of
accessory root canal where removal of the
all the content of the radicular pulp tissue is
impossible).
2. When the coronal pulp tissue and the tissue
entering the pulp canals are vital but show
clinical evidence of hyperemia.

3. The tooth may or may not have a history of

painful pulpitis.
4. No evidence of necrosis (suppuration).
5. Radiographically,

there

should

be

no

evidence of a thickened periodontal ligament

or radicular diseases.

 Technique:
The technique
appointment:

is

completed

in

one

1. Remove the coronal pulp tissue (same steps in

pulpotomy).
2. Remove as much as possible from the content
of root canal with a serrated broach, care
should be taken not to penetrate the apex (root
canal instruments placed in a special hand
piece may be used for root canal debridement
with extreme care).

3. No widening of the root canal.

4. Irrigation of the canals with normal saline or
mild antiseptic solution (hydrogen peroxide or
sodium hypochlorite).
5. Dry the canal with sterile paper points.
6. The root canal may be filled with zinc oxideeugenol or oxypara (a restorable material
which will be resorbed as normal root
resorption occurs).

 Filling the root canal

A thin mix of zinc oxide-eugenol paste may be
prepared and paper points covered with the
material are used to coat the root canal walls.
A thick mix of the zinc oxide-eugenol should
be prepared, rolled into a point and carried into
the root canal.
Root canal plugger may be used to condense
the material into the canal.
Zinc phosphate is put as a base and the tooth
should be restored with chrome steel crown.

V.

Complete
treatment):

pulpectomy

(endodontic

Pulpectomy of the primary molars is often

considered impracticable because of the
difficulty of obtaining adequate access to the
root canals in the small mouth of children and
because of the complexity of the root canals in
primary molars. The canals are ribbon shaped
(narrow mesiodistally and wide buccolingually) and have lateral branching and
ramification and their complexity increases as
physiological root resorption progresses.

 These difficulties do not exist with primary

anterior teeth and therefore pulpectomy of
these teeth present no technical problems. The
canal may be cleaned and filled with a
resorbable material (zinc oxide or oxypara).

 Treatment of non-vital primary molars:

Ideally, a non-vital tooth should be treated
by pulpectomy and root canal filling. However,
pulpectomy in primary molars is extremely
difficult and often not practical. A non-vital
pulpotomy method is advocated.

 Technique of non-vital pulpotomy:

First visit:
Necrotic coronal pulp is removed (as
pulpotomy) and the infected radicular pulp is
treated with strong antiseptic solution such as
(Beech wood cresote, formocresol camphorated
mono chlorophenol). The material, is applied on
cotton pledget and sealed in the pulp for 1-2
weeks. The strong antiseptic action of these
solutions combats infection in the radicular pulp.

Second visit:
The antiseptic solution is removed and
replaced by antiseptic paste (eugenol &
formocresol & zinc oxide powder) press
antiseptic paste firmly into the root canal with a
cotton pellet. Pressure forces the paste down the
root canal compressing the pulp tissue apically
and then restore the tooth as usual (chrome steel
crown).

 The presence of a sinus associated with a

chronic abscess or of some degree of tooth
mobility is not a contraindication for this
method. A sinus is expected to disappear
following control of infection and a mobile
tooth becomes firm as periapical bone reforms.
A tooth with acute abscess may be treated by
this method after draining the pus and
controlling the infection.

 Pulpectomy in primary anterior teeth:

Primary anterior teeth may be devitalized as a
result of trauma or caries. The basic principles of
endodontics can be applied. Gentle preparation
of the root canals with the help of radiographic
examination will be helpful. Care should be
taken not to traumatize apical region. A
resorbable root canal filling material such as
calcium hydroxide or zinc oxide-eugenolformocresol paste can be used.

College of Dentistry
Pedodontic I
-Vital Pulp Therapy -2
Failure Following the Vital Pulp Therapy
Dr. Hazem El Ajrami

Reaction of the pulp to commonly used

capping materials:
A. Zinc oxide-eugenol:
Zinc oxide-eugenol when placed in contact
with vital tissue will produce chronic
inflammation,
abscess
formation
and
liquefaction necrosis. 24 hours after capping
pulp with zinc oxide-eugenol, the adjacent
underlying tissue contains a mass of red blood
cells and P.N.L. The hemorrhagic mass is
demarcated from the underlying pulp tissue by
a zone of fibrin and inflammatory cells.

Two weeks after the capping, degeneration of

the pulp is apparent at the capping site and
chronic inflammation extended deep to the
apex.
B. Ca(OH)2:
Because of its alkalinity (PH = 12), it is so
caustic such that when placed in contact with
vital pulp tissue, the reaction produces
superficial necrosis of the pulp. The irritant
qualities seen to be related to its ability to
stimulate development of a calcified barrier.

 This is done as follow:

The superficial necrotic area in the pulp
that develops beneath Ca(OH)2 is demarcated
from the healthy pulp tissues below by a new
deeply staining zone comprising basophilic
elements of Ca(OH)2 dressing. Against tins
zone is a new area of coarse fibrous tissue
likened to a primitive type of bone.

 On the periphery of the new fibrous tissue,

cells resembling odontoblasts appear to be
lining-up. One month after the capping
procedure, a calcified bridge is evident
radiographically. This bridge increase in
thickness during the next 12 months. The pulp
beneath the calcified bridge remains vital and
free from inflammatory cells.

C. Formocresol:
The surface of the pulp immediately
under formocresol treatment become fibrous
and

acidophilic.

This

reaction

was

interpreted as fixation of living pulp tissue.

After exposure of pulp to formocresol for
periods of 7 to 14 days three distinct zone
become evident:

 A broad acidophilic zone (Fixation).

A broad pale staining zone in which the cells
and fibers are diminished (Atrophy).
A broad zone of inflammatory cells extend
deeply into tile apex.
The

reaction

of

formocresol

is

progressive fixation of the pulp tissue with

ultimate fibrosis of the entire pulp.

Failure Following the Vital

Pulp Therapy

1. Internal resorption:
Radiographic evidence of internal
resorption occurring within the pulp canal
several months after pulpotomy procedure is
the most frequently seen evidence of abnormal
responses in primary teeth. Internal resorption
is a destructive process generally believed to
be caused by osteoclastic activity. No
satisfactory explanation for post pulpotomy
type of internal resorption has been given. The
possible cause for such condition may be:

1. With a true carious exposure of the pulp

there will be an inflammatory process to
some degree. The inflammation may be
limited to the exposure site or it may diffuse
throughout the coronal portion of the pulp. If
the inflammation extended to the entrance of
the pulp canals osteoclasts may have been
attracted to the area and cause internal
resorption.

2. All pulp capping materials in use are irritating

and produce at least some degree of
inflammation. Inflammatory cells attracted to
the area as a result of placement of capping
material might attract osteoclastic cells and
initiate the internal resorption.
3. Because the roots of primary teeth are
undergoing normal physiological resorption,
vascularity of the apical lesion increased and
there is osteoclastic activity in the area. This
may predispose the tooth to internal resorption
when irritant in the form of pulp capping
material is placed on the pulp.

2. Alveolar abscess:
An alveolar abscess occasionally develops
some months after pulp therapy has been
completed. The tooth usually remains
asymptomatic and the child is unaware of the
infection, which may be present in the bone
surrounding the root apices or in the area of the
root bifurcation.

A fistulation opening may be present indicating

the chronic condition of the infection. Primary
teeth that show evidence of an alveolar abscess
should be removed. Permanent teeth that have
previously been treated by pulp capping or by
pulpotomy and later show evidence of pulpal
necrosis and apical infection may be considered
for endodontic treatment.

General
contraindications
for
pulp
treatment of primary teeth:
1. A patient from family having unfavorable
attitude towards dental health and conservation
of the teeth.
2. A dentition in which multiple teeth have pulp
exposures. Such a dentition is probably
neglected and does not justify pulp treatment.
3. A tooth, with such gross breakdown that
restoration would be impossible following pulp
treatment.

4. A tooth with caries penetrating the floor of

pulp chamber.
5. A tooth close to natural exfoliation.
6. A dentition in which the effect of previous
extraction have not been controlled. Extraction
is preferred, if the contralateral tooth is
missing.
7. A patient in poor general health.

 Electro surgery pulpotomy:

It is known as non-chemical devitalization.
Its mechanism of action is the cauterization of
the pulp tissue. It carbonizes heat denatured pulp
and bacterial contamination.
Laser pulpotomy:
This technique of pulpotomy overcomes
histological effect of electro surgery. It creates
superficial zone of coagulation necrosis that
remain compatible with underlying tissue &
isolate pulp from vigorous effects of the subbase.

Thank You