Pulpotomy in Primary Teeth: An Overview

Pulpotomy in Primary teeth

Pulpotomy is a widely performed dental procedure in pediatric dentistry, particularly for the treatment of primary (baby) teeth. It is designed to maintain the vitality of a tooth affected by caries or trauma by removing the infected or inflamed pulp tissue from the crown portion of the tooth, leaving the healthy pulp in the root canals intact. This procedure helps preserve the tooth until it naturally exfoliates, thereby maintaining the space required for the eruption of permanent teeth.

What is Pulpotomy?

The pulp of a tooth consists of soft tissue containing nerves, blood vessels, and connective tissue. In primary teeth, the pulp is more vulnerable to infections and inflammation due to the proximity of the pulp chambers to the surface and the relatively thin enamel and dentin layers. When a carious lesion or trauma extends into the pulp, it can lead to pulpitis, which is inflammation of the pulp. If left untreated, this can result in pain, abscess formation, or premature tooth loss.

Pulpotomy is indicated when the inflammation is confined to the coronal portion of the pulp, and the radicular (root) pulp remains healthy and vital. The procedure involves the removal of the infected coronal pulp, followed by the application of a medicament to the remaining radicular pulp to promote healing and prevent further infection. The tooth is then restored with a suitable filling material or crown.

Indications and Contraindications

Indications of pulpotomy in primary teeth:

1. Deep Carious Lesions: When a primary tooth has a deep carious lesion that has caused reversible pulpitis, but the inflammation is limited to the coronal portion of the pulp. The radicular (root) pulp remains healthy and vital.

2. Pulp Exposure: Pulpotomy is indicated in cases of pulp exposure due to caries or trauma, particularly when the exposure is small, and there are no signs of irreversible pulp damage.

3. Absence of Systemic Symptoms: The procedure is suitable when there are no systemic symptoms such as fever or malaise, which could indicate a more severe infection.

4. No Evidence of Periapical Pathology: The tooth should not show any radiographic signs of periapical or furcal pathology, such as abscesses or cysts, which would suggest that the infection has spread beyond the coronal pulp.

5. Restorable Tooth: The tooth should have sufficient structure remaining to be restored after the procedure, ensuring that it can function until it is naturally exfoliated.

6. Good Patient Cooperation: Pulpotomy is typically performed in children who can cooperate with the procedure, as it requires them to remain still and follow instructions during treatment.

Contraindications of pulpotomy in primary teeth:

1. Irreversible Pulpitis or Pulp Necrosis: If the pulp inflammation has progressed to irreversible pulpitis or the pulp has become necrotic (dead), pulpotomy is contraindicated, and alternative treatments, such as pulpectomy or extraction, may be necessary.

2. Presence of Abscess or Fistula: The existence of an abscess, sinus tract, or fistula indicates that the infection has spread beyond the coronal pulp and involves the radicular pulp or surrounding tissues. Pulpotomy is not appropriate in these cases.

3. Radiographic Evidence of Root Resorption or Periapical Pathology: If radiographs reveal internal or external root resorption, periapical radiolucency, or furcal involvement, these are signs of advanced pulp pathology that contraindicate pulpotomy.

4. Non-Restorable Tooth: If the tooth is significantly decayed or damaged and cannot be adequately restored after the procedure, pulpotomy should not be performed.

5. Poor Patient Cooperation: If the child is unable to cooperate due to fear, anxiety, or behavioral issues, the procedure may be contraindicated, and alternative treatment approaches may be considered.

6. Compromised Systemic Health: In children with certain medical conditions that affect immune function or healing, pulpotomy might be contraindicated, as they may be at higher risk for complications.

Steps of Pulpotomy in Primary Teeth

The goal is to remove the infected coronal pulp while preserving the vitality of the remaining radicular (root) pulp. Here’s a step-by-step guide to the pulpotomy procedure in primary teeth:

1. Diagnosis and Treatment Planning:

   pulpotomy diagnosis and treatment planning

   
   

   pulpotomy diagnosis and treatment planning

   
   

   • Thorough clinical examination and radiographic assessment to determine the extent of the caries and pulp involvement.
   • Confirm that the inflammation is limited to the coronal pulp and that there are no signs of irreversible pulpitis or periapical pathology.
   • Ensure the tooth is restorable and the patient is a suitable candidate for the procedure.

2. Anesthesia:

   • Administer local anesthesia to numb the affected tooth and surrounding tissue, ensuring the child’s comfort during the procedure.

3. Isolation:

   isolation for pulpotomy

   
   

   • Place a rubber dam around the affected tooth to isolate it from saliva and maintain a dry working field, reducing the risk of contamination.

4. Access Opening:

   access cavity for pulpotomy

   
   
   • Use a high-speed handpiece with a sterile bur to create an access cavity through the occlusal surface of the tooth, exposing the pulp chamber.
   • Carefully remove all caries from the periphery of the cavity to prevent further infection.

5. Coronal Pulp Removal:

   • Use a sterile sharp spoon excavator or a low-speed round bur to remove the coronal pulp tissue completely.
   • Avoid damaging the radicular pulp tissue during this process.
   • If the pulp is hyperemic and bleeding, apply gentle pressure with a sterile cotton pellet to achieve hemostasis.

6. Hemostasis:

   • Achieve hemostasis by applying gentle pressure with a dry, sterile cotton pellet for a few minutes. If bleeding persists, it may indicate that the inflammation has extended into the radicular pulp, which could contraindicate pulpotomy.
   • A hemostatic agent like ferric sulfate can be applied if necessary to control bleeding.

7. Medicament Application:

   mta application for pulpotomy

   
   

   • Place a medicament on the radicular pulp stumps to promote healing and prevent bacterial growth. Common medicaments include:
     • Formocresol: Applied for a few minutes and then removed, leaving a thin film on the pulp.
     • Mineral Trioxide Aggregate (MTA): A biocompatible material that provides a good seal and promotes tissue regeneration.
     • Ferric Sulfate: Applied for a brief period to achieve hemostasis and then removed.
   • Ensure the medicament is evenly applied and confined to the pulp chamber.

8. Base Placement:

   • Place a zinc oxide-eugenol (ZOE) base or another suitable material over the medicament to seal the pulp chamber and provide a foundation for the final restoration.

9. Tooth Restoration:

   tooth restoration after pulpotomy

   
   

   stainless steel crown after pulpotomy

   
   

   • Restore the tooth with a suitable restorative material. In primary molars, a stainless steel crown is often recommended for durability and protection.
   • In anterior teeth or smaller cavities, composite resin or other esthetic materials may be used for restoration.

10. Post-Operative Instructions:

    • Provide the patient and their caregivers with post-operative care instructions, including guidance on pain management, oral hygiene, and what to expect during healing.
    • Schedule follow-up visits to monitor the success of the treatment and ensure the tooth remains asymptomatic and functional.

11. Follow-Up:

    • Regular follow-up appointments are essential to assess the success of the pulpotomy, check for any signs of failure, and ensure the treated tooth is maintained until its natural exfoliation.

Success and Prognosis

The success rate of pulpotomy in primary teeth is generally high, with studies reporting success rates ranging from 70% to 95%, depending on the materials and techniques used. The prognosis is favorable when the procedure is performed on teeth with vital, non-infected pulp and in the absence of significant periapical pathology. Regular follow-up is essential to monitor the treated tooth and to intervene promptly if any complications arise.

Materials Used in Pulpotomy

Read this article for more detailed information about material used in pulpotomy

Over the years, several materials have been used for pulpotomy procedures, each with its advantages and limitations:

• Formocresol: Traditionally used as a gold standard, formocresol has bactericidal properties, but concerns about its potential toxicity and mutagenicity have led to a decline in its use.

• Ferric Sulfate: Acts as a hemostatic agent and has gained popularity due to its biocompatibility and effectiveness in maintaining the pulp’s vitality.

• Mineral Trioxide Aggregate (MTA): Known for its excellent sealing properties and biocompatibility, MTA promotes healing and is considered one of the most successful materials for pulpotomy.

• Calcium Hydroxide: Though once widely used, it is now less favored due to its potential for causing internal resorption.

• Biodentine: A newer material with properties similar to MTA, offering good biocompatibility and handling characteristics.

Conclusion

Pulpotomy remains a critical procedure in pediatric dentistry for preserving primary teeth that would otherwise be lost due to caries or trauma. By maintaining the tooth’s vitality and function, pulpotomy plays a crucial role in ensuring proper dental arch development and alignment, ultimately contributing to the overall oral health and well-being of children. Advances in materials and techniques continue to improve the outcomes of pulpotomy, making it a reliable and effective treatment option in pediatric dental care.