Pulpal

 therapy  
 Carious  Lesion  
Producing  Pain  

Spontaneous   Thermal  
Nocturnal   Induced  
Prolonged   IntermiAent  

IRREVERSIBLE   REVERSIBLE  

Nonvital  Pulp   Vital  Pulp  

Extrac=on  
Therapy   Therapy  
 Candidates  for  Vital  Pulp  Therapy  
•  Carious  or  trauma=c  pulp  exposure  
•  Transitory  pain  
•  Normal  soC  =ssues  
•  No  percussion  sensi=vity  
•  Con=nous  ligament  space  
•  No  furcal  involvement  
•  Less  than  1/3  physiological  root  resorp=on  
•  Tooth  is  restorable  
 Vital  Primary  Tooth  Therapy  Op=ons  
•  Indirect  pulp  treatment  
•  Direct  pulp  capping  
•  Pulpotomy  
 Indirect  Pulp  Treatment  
•  Indica=ons:  deep  carious  lesion,  vital  pulp,  
restorable  tooth  
•  Objec=ves:  arrest  caries  advance,  allow  
forma=on  of  ter=ary  den=n,  preserve  vitality  
•  Technique:  excavate  most  of  the  caries.  
•  *  must  have  sound  margins*  and  no  pulpal  
exposure  
•  Restora=on  must  seal  completely!!!!  
 IPC  Technique  
•  Indica=on:  asymptoma=c  teeth  only!  
•  Incomplete  excava=on  of  caries  –  leave  a  layer  
of  leathery  den=n,  1  –  2  mm.  
•  Layer  of  glass  ionomer  
•  Must  have  a  good  seal  
•  Re-­‐evaluate  every  6  months  with  a  radiograph  
Direct  Pulp  Cap  
•  26%  CaOH  
•  High  pH  (>11)  
•  Protects  pulp  
•  Supports  forma=on  of  
secondary  den=ne  
•  radiopaque  
 MTA  as  a  pulp  cap  
•  BeAer  success  rate  than  
CaOH  
•  Cement  composed  of  
tricalcium  silicate,  
dicalcium  silicate,  
tetracalcium  
aluminoferrite,  calcium  
sulfate,  and  bismuth  
oxide  
•  Mixed  with  water  
•  4  hours  to  set  
Nair  et  al,  2009  
 Pulpotomy  
•  Indica=ons:  pulp  exposure,  vital  pulp,  
restorable  tooth  
•  Objec=ves:  to  maintain  the  tooth  in  a  
func=onal  asymptoma=c  manner  for  
mas=ca=on,  space  maintenance,  and  speech.    
•  Technique:  excavate  caries,  amputate  coronal  
pulp,  achieve  hemostasis,  treat  radicular  pulp  
with  medicament.      Seal  restora=on  
completely  WITH  FULL  COVERAGE  
 Pulpotomy  Medicament  Op=ons  
•  Formocresol  
•  Ferric  Sulfate  
•  Mineral  Trioxide  Aggregate  
 Formocresol  Pulpotomy  –  the  Gold  
Standard  
 Buckley’s  Formocresol  19%  formaldehyde  and  
35%  cresol  and  15%  glycerin  in  a  water  base  
 3  –  5  minute  applica=on  
 Results  in  3  zones  
1  Fixa=on  (coronal  1/3)  
2  Atrophy  (middle  1/3)  
3  Inflamma=on  (apical  1/3)  
62  –  97%  success  
used  since  1904  
 Ferric  Sulfate  
•  15.5%  FS  in  an  aqueous  base  pH  1  
•  Hemosta=c  
•  Aggressive  inflammatory  reac=on  
•  Applica=on  =me  10  –  15  seconds  
•  Must  wash  away  the  coagulum  to  decrease  
chance  of  resorp=on  
•  Bonus:  resorp=on  without  pain  
 Mineral  Trioxide  Aggregate  
•  Works  to  mineralize  the  canals,  oblitera=on  is  
common  
•  Results  are  comparable  or  superior  to  FC  
•  BUT  expen$ive  
 Summary  Mechanism  of  Ac=on  
Formocresol  denatures  pulpal  =ssue,  rendering  
it  inert  

Ferric  Sulfate  forms  a  clot  barrier  preserving  the  

deeper  =ssue  

MTA  leads  to  pulpal  healing  by  forming  a  

den=nal  bridge  
 Method  for  Pulpotomy  
•  Prepare  tooth  for  Stainless  steel  crown  
•  Remove  majority  of  caries  before  entering  the  
pulp  chamber  
•  Remove  the  roof  of  the  pulp  chamber  with  a  
wide  access  
 Candidates  for  Non  Vital  Pulp  Therapy  
or  Extrac=on  
•  Carious  or  trauma=c  pulp  exposure  
•  Spontaneous  pain  
•  Persistent  pain  
•  Inflamed  soC  =ssue  ie.  Parulis  or  pustule  
•  Percussion  sensi=vity  
•  Widened  or  discon=nuous  ligament  
•  Furcal  involvement  
•  External  or  internal  root  resorp=on  
 Signs  and  Symptoms  of  Irreversible  
Pulpi=s  
•  1.  inability  to  achieve  hemostasis  aCer  coronal  
pulp  amputa=on  or  no  bleeding  aCer  
exposure  of  coronal  pulp.    

•   2.  the  presence  of  any  swelling  (due  to  

infec=on),  fistula,  or  radiographic  evidence  of  
pathological  periapical  bone  resorp=on.  
 LSTR  for  primary  teeth  

LSTR  –  lesion  steriliza=on  and  =ssue  repair  

Used  for  endodon=c  treatment  of  primary  
teeth  with  irreversible  pulpi=s.  
An  alterna=ve  to  pulpectomy.  
Supplied  in  liquid  form.  
A  combina=on  of  metronidazole  3%,  
ciprofloxacin  1%,  and  minocycline  3%  in  
propylene  glycol  and  polyglycol  
 Method  for  LSTR  

1)  Complete  pulpotomy  without  

ex=rpa=ng  the  pulp  canals.  
2)  Flush  with  chlorhexidine  gluconate.  
3)  Mix  1  drop  of  the  an=bio=c  liquid  with  
1  scoop  IRM  powder.  
4)  Place  mixture  at  the  boAom  of  the  
pulp  chamber.  
 Indica=ons  for  Pulpectomy  
•  Chronic  inflamma=on  or  necrosis  in  the  
radicular  pulp.  
•  Efforts  to  retain  the  tooth  by  endodon=c  
therapy  should  be  made  to  maintain  esthe=cs  
and  func=on.  
 Contraindica=ons  
•  Extreme  loss  of  coronal  tooth  structure  
making  future  restora=on  difficult  
•  Advanced  internal  and/or  external  root  
resorp=on  
•  Periapical  infec=on  involving  the  crypt  of  the  
succedaneous  tooth  
Choice  of  Pulpectomy  Filling  Materials  
•   Zinc  oxide  and  eugenol  –  resistance  to  
resorp=on  
•  Iodoform  paste–  resorbable  and  have  long-­‐
las=ng  an=bacterial  proper=es  
•  CH    
•  CH/iodoform  paste  (Vitapex,  Calcimol*)  
 Vital  Primary  Root  Canal  Therapy  
or  Pulpectomy  
•  Technique:  eradicate  the  radicular  pulp,  
irrigate  with  NaOH,  obturate  with  resorbable  
cement  (IE  Viatpex:  iodoform  and  CaOH  in  a  
glycerin  base),  seal  restora=on  completely  –  
full  coverage!!!    
•  Technically  very  difficult  
•  Very  =me  consuming