1- Diagnosis 2- Indications / Contraindications 3- StepStep-byby-step pulpotomy technique 4- Mechanism of action of formocresol 5- Alternatives to formocresol
B. The Pulpectomy Technique Reporter:
1- Rationale for pulpectomy 2- Indications / Contraindications 3- Root canal filling material 4- Types of pulpectomy techniques 5- Success rates for primary tooth pulpectomies
許修銘
2004/03/30
Introduction Preservation of primary teeth in the arch – Management of developing dentition – Nurturing a positive attitude in children towards dental health
A. The Pulpotomy Technique
Introduction Use of pulp therapy to conserve carious primary teeth – Preserve pulp involved primary molar when missing permanent successor – Prevent possible aberrant habits – Maintain masticatory function – Preserve aesthetics – Future dental attitudes
A pulpotomy is the procedure of removing coronal part of pulp tissue, inflamed or infected as a result of deep caries, & maintenance of vital radicular pulp tissue
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A1A1- Diagnosis 1/5 dilution of the original Buckley’ Buckley’s formocresol
Primary tooth with deep caries OD (with GIC) or Pulpotomy
NISHIKA Root canal disinfectant
Cresol 40mL Formalin 40mL Ethanol 20mL
A1A1- Diagnosis
A1A1- Diagnosis The reason for this is that caries in primary teeth compromises pulp very early on, with pulp inflammation setting in even before pulp is exposed
A1A1- Diagnosis Hobson (1970) In over 50% of the primary molars Loss of marginal ridge Æ irreversible pulp inflammation
A1A1- Diagnosis Duggal et al (1999) –The need for pulp therapy for most primary molars where proximal caries has involved the marginal ridge –The importance of early diagnosis of proximal caries with the use of bitewing radiographs
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A1A1- Diagnosis
A1A1- Diagnosis
Proximal caries that involved less than half the intercuspal distance from buccal to lingual cusp
A1A1- Diagnosis
A1A1- Diagnosis
By the time the caries exposes the pulp, the inflammation is irreversible irreversible Direct pulp capping is contraindicated
A2A2- Indications Large caries with substantial loss (≧ (≧1/3 ) of marginal ridge in restorable tooth Tooth free of radicular pulpitis At least 2/3 of root remaining Absence of abscess or fistula No interinter-radicular bone loss No evidence of internal resorption Instances where extraction is C/I
A2A2- Contraindications An unrestorable tooth BiBi- or trifurcation involvement Less than 2/3 of root remaining Presence of abscess or fistula Permanent successor close to eruption Medical contraindications – Heart disease – ImmunoImmuno-compromised children
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A3A3- StepStep-byby-step Step 1: Administer local analgesia with the use of a topical analgesic
Nerve block
A3A3- StepStep-byby-step Step 2: Isolate tooth with rubber dam
Buccal infiltration
A3A3- StepStep-byby-step Step 3: Remove caries & determine site of pulp exposure
A3A3- StepStep-byby-step Step 5: Remove coronal pulp with large excavator or large round bur
A3A3- StepStep-byby-step Step 4: Remove roof of pulp chamber
A3A3- StepStep-byby-step Step 6: Apply FC on a pledget of cotton wool for 4 minutes
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A3A3- StepStep-byby-step Step 7: Remove FC pledget after 4 mins & check that haemorrhage has stopped
A3A3- StepStep-byby-step Step 8: Fill pulp chamber with cement
A3A3- StepStep-byby-step Step 9: Restore tooth with SSC
A3A3- StepStep-byby-step Step 10: Take a postpost-OP radiograph
A3A3- StepStep-byby-step
A3A3- StepStep-byby-step
FollowFollow-up –Regularly reviewed both clinically & radiographically 66-monthly –Appearance of rarefaction of bone in furcation area or a worsening of bone condition in furcation usually signifies failure of the procedure
PrePre-OP
PostPost-OP
3M
12 M
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A4A4- Mechanism of action of FC
FC acts through aldehyde group of formaldehyde, formaldehyde, forming bonds with sideside-groups of amino acids of both bacterial proteins & remaining pulp tissue Both bactericidal & devitalizing agent
A5A5- Alternatives to FC Concern about possible toxicity of FC, both locally & systemically Alternatives – Ferric sulphate [Fe2(SO4)3] – Glutaraldehyde – Calcium hydroxide – Other experimental methods
A5A5- Alternatives to FC Glutaraldehyde – Introduced by s’Gravenmade (1975) – Better fixative agent – Toxic properties
A4A4- Mechanism of action of FC
Reported success rate of FC pulpotomy
A5A5- Alternatives to FC Ferric sulphate [Fe2(SO4)3, 15.5%] – Excellent haemostatic agent (ferric ionion-protein complex) – As effective as FC – No “fixative” fixative” effect
A5A5- Alternatives to FC Calcium hydroxide – Poor (around 60%) success rate – Extensive internal resorption below amputation
• Allergic reactions • Eye irritation
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A5A5- Alternatives to FC Other experimental methods – Electrosurgery – CO2 lasers – Enriched collagen solution
B. The Pulpetomy Technique
B1B1- Rationale for pulpectomy It is true that some primary teeth do have a complex root morphology (with many fine accessory root cancals), cancals), but this does not contraindicate pulpectomy
B2B2- Indications
Irreversible inflammation extending to radicular pulp Primary teeth with necrotic pulps Evidence of furcation pathology Presence of an abscess
Gain access to the root canals Remove Remove as much dead & infected material as possible Fill the root canals with a suitable material Maintain primary tooth in a nonnoninfected state
B2B2- Contraindications
Unrestorable crown Advanced pathological root resorption Medical contraindications – Heart disease – ImmunoImmuno-compromised children
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B3B3- Root canal filling material
B3B3- Root canal filling material
Being totally resorbed at the same rate as the roots – Pure zinc oxide & eugenal mixed as a slurry – Maisto’ Maisto’s paste – Iodoform paste – Vitapex
B3B3- Root canal filling material Ca(OH)2-Iodoform Mixture
- Vitapex, Endoflas - Machida (1983): Ca(OH)2-iodoform mixture to be a nearly ideal primary tooth filling material 1) easy to apply 2) resorbs at a slightly faster rate than that of the roots 3) has no toxic effects on the permanent successor 4) radiopaque
B4B4- Single-visit of pulpectomy Indications – Presence of inflamed but vital radicular pulp – An asymptomatic primary tooth with necrotic pulp tissue without any associated acute symptoms, such as cellulitis – Presence of a chronic buccal lesion without any active discharge or acute symptoms
Step 1: Give local analgesia & isolate tooth with rubber dam
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B4B4- Single-visit of pulpectomy
Step 2: Remove caries & identify exposure site
B4B4- Single-visit of pulpectomy
Step 4: Take a diagnostic radiograph with files in the root canals
B4B4- Single-visit of pulpectomy
Step 3: Remove roof of pulp chamber, & identify opening of root canals
B4B4- Single-visit of pulpectomy
Step 5: Clean out root canals with H files & remove remnants of pulp tissue & irrigate canals with saline
Within 11-2 mm File lightly Reaming is not advisable File to no more than size 30
B4B4- Single-visit of pulpectomy
Step 6: Dry root canals with paper points & place a pledget of FC in pulp chamber for 4 minutes
B4B4- Single-visit of pulpectomy
Step 7: Select a spiral root canal filler of appropriate size
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B4B4- Single-visit of pulpectomy
Step 8: Mix ZnO & eugenol as a slurry,
B4B4- Single-visit of pulpectomy
Step 9: Fill pulp chamber with cement
& spin it into root canals using spiral root canal filler
B4B4- Single-visit of pulpectomy
Step 10: Restore the tooth with SSC
B4B4- Single-visit of pulpectomy
Step 11: Take a postpost-op radiograph to check root filling
B4B4- Singleingle-visit of pulpectomy
B4B4- Singleingle-visit of pulpectomy
FollowFollow-up –Regularly reviewed both clinically & radiographically 66-monthly
PrePre-OP
PostPost-OP
6 M later
PrePre-OP
3 M later
PostPost-OP
12 M later
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B4B4- Singleingle-visit of pulpectomy
92/08/21 (F/U 9M)
PrePre-OP
PrePre-OP 91/11/12 (Root canal filling)
6 M later
92/12/29 (F/U 13M)
PostPost-OP
B4B4- Two-visit of pulpectomy
B4B4- Singleingle-visit of pulpectomy Spiral root filler
Indications – Presence of an acute abscess with or without associated cellulitis – Presence of active & persistent discharge from the root canals
B4B4- Two-visit of pulpectomy Visit 1: Emergency management of the acute abscess – Gaining drainage through carious cavity or puncturing fistula – LAÆ LAÆ Filed to drain Æ FC pledgetÆ pledgetÆ IRM – Antibiotics: 22-dose regimen of amoxycillin
B4B4- Two-visit of pulpectomy Visit 2: Final root canal filling – 7~10 days later – Rubber dam Æ Access root canals Æ Pulpectomy procedure
