Pulpotomy

Pulpotomy or amputation of the pulp (vital or devital)
Pulp therapy in primary teeth is the most common endodontic procedure in pedodontics. During this therapeutic procedure, the coronary part of the pulp is removed while preserving the radicular pulp. Depending on whether we are working on vital or medically devitalized pulp, different procedures for the treatment of radicular pulp are applied.

For vital pulpotomy, first of all, we need to have a cooperative patient that can be anesthetized, which is a requirement without which this procedure is impractical. After anesthesia, it is necessary to apply a cofferdam or, if necessary, to isolate the tooth with rubber dam. The roof of the pulp and the coronary pulp are removed by a turbine diamond grinder with water cooling to the entrance to the root canals.

Removal of coronary pulp tissue can also be performed with a sterile steel drill or a sharp excavator. Thereafter, comes to the treatment of the radicular part of the pulp, for which, according to the clinical finding, is assumed that does not have inflmmatory changes. The surface of radicular pulp needs to be fixated to as much available devices as we have).

Formocresol now has a historical significance, and for a long time it was a preparation of selection. Due to its systemic toxicity it is increasingly avoided and is almost abandoned. Today, more advantage is given to glutaraldehyde and iron sulphate. Ca-hydroxide and thermal fixation of the surface part of the radicular pulp (electrofiltration) are methods that are used more in everyday clinical practice.

After removing the coronary pulp into the cavum, a sterile cotton wool soaked with a selected remedy is put on for 5 minutes, which will fix the surface layer of the radicular pulp. If this part of the treatment has succeeded, the bleeding should be stopped and the protective bandage of zinc oxide of eugenol cement is then placed on the remaining radicular pulp, and the procedure is completed with a permanent filling.

This method has the advantage because it is simple, fast and effective (80-90% of success) and leaves a minimal risk of eventual complications during and after therapy. The disadvantages are the necessity of anesthesia and the demanding securing of a dry working field. Devitalization pulpotomy is a clinical procedure that is most commonly performed on baby teeth. After exposing the pulp to caries or during its removal with the preservation of its vitality, where bleedin from the pulp and painful sensation of the patient are the basic clinical criteria, it is approached to medicinal devitalization of the pulp.

The mumification (antiseptic) paste is placed on the entrance of root canals, and the tooth is definitely reconstructed. Pulpectomy for baby teeth is a procedure that is rarely performed, mainly because of its difficulty and complexity.

Paste based on paraformaldehyde (Toxavit, Depulpin, Caustinerf) is applied to the pulp through the trepanation hole. After 10-14 days, in a second visit, the coronary part of the devitalized pulp is removed by turbine drill with water cooling until the entrance to the root canals. All this is done without the access of saliva (without rinsing).

The remaining part of the radicular pulp is mumifified on a paraformaldehyde or iodoform base (Caustinerf Pedodontiqe, Crisphea, Maisto paste). Instead of these preparations we can use a paste based on eugenol zinc oxide. Through such protected radical pulp, the base and the definitive filling are placed. If we are not sure about the outcome or asepticity of working conditions during amputation, after the amputation of the coronary pulp at 7 to 14 days, we can put an antiseptic insert on the basis of phenolcamphora or paraclorophenolcamphora (Chlumsky, Cresophene) in a cavum with sterile cotton wool, and then perform the previously described procedure of the final supply of teeth with filling.

This method is relatively fast, simple and effective. The disadvantages are the use of aggressive preparations which puts the method into non-biological procedures and the need for more visits during the treatment of one tooth.

Mortal pulpotomy is a therapeutic procedure that is indicated for necrosis or gangrene pulp of the baby teeth. Given the indication and the therapeutic procedure, this method is not used in some countries. This primarily applies to the US and Scandinavian countries, while most European countries use this method. An alternative to this procedure is pulpectomy and endodontic surgery in its entirety, by processing and filling the root canal or tooth extraction with the afterward makin of the site holder. The clinical procedure for mortal amputation is performed as follows.

After opening the cavum, the necrotic content is removed from it, entrances in the root canals are displayed and the caries is completely removed, after this the tooth is rinsed (cavum pulp) and disinfected (Na-hypochlorite). Then an antiseptic insert based on phenolcamphora or paraklorfenolcamphora (Chlumsky, Chresophene salt) is placed in the cavum pulp, and the tooth is closed with a temporary filling for 7-14 days. If the tooth remains „calm“, that is without objective and subjective disturbances, the process of final reconstruction of the teeth is performed, as with devitalization amputation.

The procedure assumes full co-operability of a patient, anesthesia, X-ray record due to the position of root canals, cofferdam and multiple visits, which largely limits the indications for this procedure. A special feature that distinguishes this procedure from endodoncy in permanent dentition is the filling of the root canal that must be made by material that can be resorbed (ZOE paste, Ca-hydroxide or some of the iodoform paste, Crystalline).

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PhD Milica Čelebić

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