VITAL PULP THERAPY

AND PULPOTOMY
 INTRODUCTION

It is the treatment initiated on an exposed pulp to repair

and maintain the pulp vitality.
 AIM

To treat reversible pulpal injuries in order to maintain

pulp vitality in both primary and permanent teeth.
PULP THERAPY APPROACHES
Collagen is irreversibly denatured Collagen cross linking
 INDIRECT PULP CAPPING

DEFINITION :
Defined as a procedure wherein the deepest layer of the
remaining affected dentin is covered with a layer of
biocompatible material in order to prevent pulpal
exposure and further trauma to the pulp.
OBJECTIVE:
To preserve the vitality of the pulp by completely
removing the carious infected dentin followed by
placement of a material that would enable the affected
dentin to re-mineralize by stimulating the underlying
odontoblasts to form reparative dentine.
INDICATIONS
• Pulpal inflammation has to be minimal
• In deep carious lesion where complete excavation of carious
part will lead to obvious pulpal exposure

CONTRAINDICATIONS
• Pulpal or periapical pathology present
• Soft leathery dentin which is covering greater surface area of
tooth and tooth is non restorable
Physiological re-mineralization
occurs only if the affected dentin layer contains :-

SOUND COLLAGEN FIBRES

- Function as a base to which apatite crystals attach

LIVING ODONTOBLASTIC PROCESSES

- Supply CALCIUM PHOSPHATE from the vital pulp
 RATIONALE
• Disinfection of residual affected dentin is more readily
accomplished.
• It eliminates the need for more difficult pulp therapy by
arresting the carious process and allowing the pulp reparative
process to occur
• Patient comfort is immediate
• Rampant dental decay is halted when all carious teeth are
treated
 DIAGNOSTIC DATA

History:
• A tolerable, dull pain with mild discomfort associated with
eating.
• Mild-to-moderate pain is experienced on thermal stimulation.
• There is no history of spontaneous or excruciating pain.
On Clinical Examination:
• A large carious lesion is found without any frank pulpal exposure.
• There is positive response to electric pulp sensitivity test,
thermal stimulation, and test cavity.
• The tooth responds normally to percussion.
• The gingiva in relation to the tooth appears normal and is
asymptomatic on palpation.
Radiographic Examination:
• Radiograph shows a large carious lesion with a possible pulp exposure.
• The extent of caries penetration depth is up to three-fourth of the entire
thickness of dentin.(dentin thickness ->3-10mm )
• The lamina dura appears normal.
 CLINICAL PROCEDURE
Indirect pulp capping can be performed as:
1. Single step approach
2. Two step approach (recommended)
TWO-STEP APPROACH is recommended for
the following reasons:
a) It avoids unintentional pulpal exposures which might
deteriorate the pulpal prognosis.
b) The dentist gets a chance to assess the reaction of the tooth
and gain information of the changes in caries activity.
c) It gives an opportunity to remove the slowly progressing
lesion in slightly infected, discoloured, demineralized dentin
before the placement of the final restoration.
d) The final excavation of the caries is safer in the second
sitting as it is easier to remove the dry carious dentin.
TWO STEP APPROACH
HARD SET
FACTORS DETERMINING SUCCESS OF
INDIRECT PULP CAPPING
1) Remaining dentin thickness:
The amount of remaining dentin present between the floor of the
cavity and the pulp space.
Remaining dentin thickness (RDT) of
2.0-0.5 mm have a good prognosis
0.5-0.25 mm have reduced prognosis*
(*reactive dentine is reduced due to decreased odontoblastic
activity)
2)Choice of indirect pulp capping agent:

Calcium hydroxide
• Practically all bacteria are destroyed under calcium hydroxide
dressing sealed in deep carious lesions.
• It has high alkalinity
• It has ability to produce a dentinal barrier or a dentinal bridge.
 DIRECT PULP CAPPING
DEFINITION:
Defined as a procedure in which the exposed vital pulp is
covered with a protective dressing or base placed directly
over the site of exposure in an attempt to preserve pulpal
vitality.
 INDICATIONS:
• Iatrogenic mechanical exposure of pulp which is <1mm in
diameter.
• Traumatic injury to tooth provided the area is dry, clean and
reported to dentist within 24 hrs
• Radiographically, there should be no thickening of periodontal
ligament space and no evidence of peri-radicular lesion.
• Bleeding is light in colour and readily controllable.
 CONTRA-INDICATIONS:
• Direct pulp capping is not recommended in cases of carious
exposure of a primary tooth.
• Large carious exposures in symptomatic permanent tooth.
• Pain, pulpal inflammation, mobility of tooth or thickening of
PDL or any periradicular infection.
FACTORS AFFECTING PROGNOSIS OF
DIRECT PULP CAPPING
 PHYSICAL PHENOMENA ASSOCIATED
WITH MECHANICAL PULP EXPOSURE
HEAT: The closer a cavity preparation is to the pulp, the greater is the
chance of heat injury.

PRESSURE: When the pulp is exposed, pressure is transmitted directly to

the pulp (by bur or hand instrument). Greater the pressure, poorer the
prognosis.

DAMAGE TO PULP TISSUE: The breakdown products of dead or

injured pulp cells acts as a irritants that cause an inflammatory response.
HAEMORRAGE: Exposure of the pulp results in
haemorrhage. Extravasated blood itself cause damage to
underlying pulp by means of increased pressure.

INTRUSION OF DENTIN CHIPS: Dentin debris from the grinding of

dentin is pushed into remaining pulp tissue.
The reactions of underlying pulp vary with
a) Numbers
b) Virulence
c) Pathogenicity of microorganisms
d) Resultant effects of all other factors influencing repair of CT
IDEAL PROPERTIES OF A PULP CAPPING
AGENT
 Recommended materials as potential pulp
capping agents:

1. CALCIUM HYDROXIDE

2. MINERAL TRIOXIDE AGGREGATE (MTA)

Soaked with 3-6%
SODIUM
HYPOCHLORITE

*
Two techniques have demonstrated success with direct
pulp capping:

1.In Calcium Hydroxide technique,

a hard-setting Ca( OH)2 paste is applied over the exposed
pulp followed by a glass ionomer lining.
• In a One Step pulp capping procedure, the final bonded restoration can
be placed on top of the set glass ionomer in the same sitting.
• In Two-Step pulp capping procedure, an intermediate restoration is
placed over the glass ionomer and the patient is called back for the final
restoration in the next sitting.
2. In MTA direct pulp capping technique,
• the MTA is mixed and is carried to the exposure site with the help of an
MTA carrier gun.
• A minimum thickness of 1.5 mm of MTA is placed over the exposure site
and a moist cotton pellet is placed completely covering the MTA.
• In a One Step pulp capping procedure, On top of the MTA, a light-cure
flowable compomer or a glass ionomer liner is placed. The remaining
cavity is then etched with 37% phosphoric acid, washed and dried, and
the tooth is restored with a suitable bonded composite restoration.
• In Two-Step pulp capping procedure, A nonbonded composite material is
placed over this and the treatment is completed in the next visit after a
period of 5-10 days with the help of a bonded composite restoration.
CLINICAL PROTOCOL FOR DIRECT PULP CAPPING
 PULPOTOMY
Definition:
Defined as a procedure in which a portion of the exposed
coronal vital pulp is surgically removed as a means of preserving
the vitality and function of remaining radicular portion.
NOTE:
Pulpotomy is similar in concept to direct pulp capping
except in the amount and extent of pulp tissue removal
 OBJECTIVES
• Preservation of vitality of radicular pulp
• Relief of pain in patient with acute pulpalgia and inflammatory
changes in tissue
• Ensuring the continuation of normal apexogenesis in immature
permanent teeth by retaining the vitality of radicular pulp.
 INDICATIONS
1. Mechanical or carious exposure in permanent teeth with
incomplete root formation.
2. Traumatic exposure of longer duration where coronal pulp is
likely to be inflamed in young permanent teeth.
3. Carious pulp exposure in an asymptomatic primary tooth with
wide open apices, when retention is more advantageous than
extraction.
4. Selected cases of chronic hyperplastic pulpitis
 CONTRAINDICATIONS
1. Patients with irreversible pulpitis
2. Abnormal sensitivity to heat and cold
3. Chronic pulpalgia
4. Tenderness to percussion or palpation because of pulpal
disease
5. Periradicular radiographic changes resulting from extension of
pulpal disease into the periradicular tissues
 PROGNOSIS
Success of this procedure depends upon:
• Vitality of the majority of radicular pulp
• No prolonged adverse clinical signs or symptoms (prolonged
sensitivity, pain, swelling)
• No radiographic evidence of internal resorption
• No breakdown of periradicular tissue
• No harm to succedaneous teeth
• Pulp canal obliteration (abnormal calcification)
 CLASSIFICATION
A. Amount of pulpal tissue removed
1) Cervical pulpotomy
2) Partial pulpotomy

B. Type of medicament employed

1) Calcium hydroxide pulpotomy
2) MTA pulpotomy
3) Formocresol pulpotomy
Diagnosis:
Radiograph to determine
i. The approach to pulp chamber
ii. Evaluate shape and size of root canals to ascertain conditions of
periradicular tissues

Anesthesia:
Tooth is anesthetized with a local anesthetic agent.

Isolation:
Rubber dam is used
Hemorrage control:
• Hemostatic agent (e.g- 6% sodium hypochlorite)
• Pressure application with moist cotton pellet
• Electro surgery
• Lasers

Instrumentation:
• Sharp spoon excavator
• Large round bur in slow speed
• Diamond drill in high speed
• Lasers
 CERVICAL PULPOTOMY
Anterior pulpotomy:
(a) The rubber dam is applied.
(b)Access is gained into the pulp chamber.
(c) The coronal portion of the pulp is removed with a sharp spoon excavator.
(d)The pulp chamber is irrigated with sterile water and is dried with a sterile
cotton pledget.
(e) Calcium hydroxide/MTA paste is applied to the pulp stump.
(f) A glass ionomer base/flowable compomer is applied.
(g) The tooth is restored by composite restoration.
Posterior pulpotomy:
(a) The rubber dam is applied.
(b) Access is gained into the pulp chamber.
(c) The coronal portion of the pulp is removed with a sharp spoon excavator.
(d) The pulp chamber is irrigated with 6% sodium hypochlorite and is dried
with a sterile cotton pledget.
(e) Calcium hydroxide/MTA paste is applied to the pulp stump.
(f) A glass ionomer/flowable compomer base is applied.
(g) The tooth is restored by permanent restoration.
Preoperative radiograph of Postoperative radiograph of
second and third lower left second and third molar after a
molars week.
Calcium Hydroxide Pulpotomy
• Calcium hydroxide is presently recommended as one of the
preferred medicament for vital pulp therapy in the permanent
dentition but not indicated as an agent for pulpotomy in
primary teeth.
• Calcium hydroxide is applied to the amputated pulp and is
tamped against the pulp with a sterile pledget of cotton. The
pulp chamber should be filled to a depth of at least 1-2 mm
with calcium hydroxide, on which a base of glass ionomer
cement or a flowable compomer is applied.
MTA Pulpotomy
• The MTA powder is mixed as per the manufacturer’s
instructions with distilled water to get a putty consistency.
• MTA has been proved to be a better material of choice than
calcium hydroxide in terms of healing, quality of seal provided,
and superior Biocompatibility.
• This MTA mix is placed over the amputated pulp with the help
of an MTA carrier gun or amalgam carrier.
• It should be placed in the pulp chamber and condensed lightly
with moist cotton pellet.
• Care must be taken to ensure that a minimum thickness of 2
Formocresol Pulpotomy
• It is indicated for pulpotomy of primary teeth only.
• It has been a popular pulpotomy medicament in the primary
dentition for the past 70 years since its introduction by Sweet
in 1932.
• A cotton pellet containing formocresol liquid is placed over
the amputated pulp for a period of 3-5 minutes.
• There is a lot of controversy and discussion regarding the use
of formocresol in pediatric dentistry across the world mainly
due to concerns over the carcinogenicity of formocresol.
 PARTIAL PULPOTOMY
(ALSO KNOWN AS CVEK’S PULPOTOMY)

A kind of pulpotomy in which only a portion of coronal

pulp is removed or removalof tissues until normal tissue
that is free of inflammation is reached before placing a
medicament.
1. When the coronal pulp is exposed by trauma or operative
procedures or caries, it produces inflammatory changes in the
tissue.

2. The uninfected vital pulp tissue can be preserved in the root

canal by the surgical excision of the inflamed coronal pulp.
3. The removal of the infected portion of the pulp affords
temporary, rapid relief of pulpalgia and further the remaining
tissue may undergo repair while completing apexogenesis
(root-end development and calcification).

4. Partial pulpotomy has been recommended for crown-fractured

teeth that have a pinpoint exposure and can be treated within
15-18 hours of the accident and in carious exposure of
asymptomatic permanent tooth with an open apex.
APEXIFICATION
 DEFINITION:

It is a method of inducing a calcific barrier

across an open apex of an immature,
pulpless tooth.
 OBJECTIVE
The aim of apexification is to induce either closure of
the open apical third of root canal or formation of an
apical calcific barrier against which obturation can be
achieved.
Multiple-Step Apexification
with Ca1cium Hydroxide
1. A preoperative radiograph is taken to find the apparent length
of the tooth.
2. The tooth is anesthetized, the rubber dam is applied, access is
gained to the pulp chamber and root canal, and irrigation is
performed with sterile water or saline solution.
3. A file is inserted and the stop is set to the apparent length of
the tooth and a radiograph is taken to measure the actual
length of the tooth. The measured difference between the file
tip and the root tip in the radiograph is used to adjust the
apparent length to the actual length.
4. Root canal is dried with blunt absorbent points
5. Calcium hydroxide is mixed with sterile water or anesthetic
solution to a thick consistency on a sterile glass slab.
6. Barium sulfate can be added to the paste (1 part barium
sulfate to 10 parts calcium hydroxide) to increase radiopacity
of the mixture. The paste is picked up in an amalgam carrier
and is ejected into the pulp chamber.
7. By means of a thick, blunt finger plugger, the paste is forced
into the root canal.
8. A mound dry pledget of calcium hydroxide is then ejected into
the pulp chamber and is forced against the paste ahead of it.
9. Excess calcium hydroxide is removed from the pulp chamber
and around the cavity margins.
10.The access cavity is sealed with an intermediate restorative
material.
11.The patient should be recalled in 3 months to take a radiograph
and determine whether a calcific barrier has developed at or
near the roo If not, a fresh supply of calcium hydroxide paste is
applied to the root canal, and the patient is recalled every 3
months until one sees radiographic evidence of an apical barrier
denoting apexification.
 SINGLE-STEP APEXIFICATION
WITH MTA
1. After proper isolation and anesthesia, an appropriate access cavity is
prepared to allow the debridement of the necrotic pulp tissue.
2. Circumferential filling is done to facilitate effective cleaning and sodium
hypochlorite irrigation is done.
3. MTA is mixed and introduced in canal with help of MTA carrier and later
condensed with pluggers into apical 3-4mm.
4. A moist cotton pellet is introduced to condense final increment.
5. Patient is recalled after 48hrs for obturating remaining part of root canal.
 RE-VASCULARISATION
Concept introduced by Ostby in 1961
DEFINITION:
Procedure to re establish the vitality in a non
vital tooth to allow repair and regeneration of
tissues.
 RATIONALE
Development of normal sterile granulation tissue with in
root canal, aid in
I. revascularization and
II. stimulation of cementoblasts or undifferentiated
mesenchymal cells at peri apex, leading to deposition
of calcific material at apex and lateral dentinal walls.
 STEPS
1. Tooth is anesthetized with LA
2. A sterile 23-gauge needle is taken and rubber stopper is placed at 2mm
beyond working length.
3. Needle is pushed with sharp strokes, past the confines of canal into
periradicular tissue to intentionally induce bleeding into canal.
4. After frank bleeding at cervical portion of the root canal, a tight dry
cotton pellet is inserted at a depth of 3-4mm into canal and pulp
chamber for 7-10mins to allow formation of clot.
5. Access opening is sealed with glass inomer cement extending 4mm into
coronal portion of root canal system.
THANK YOU