‫بسم هللا الرحمن الرحيم‬

College of Dentistry

Pedodontic I

Vital Pulp Therapy -2-

Failure Following the Vital Pulp Therapy

Dr. Hazem El Ajrami

 Vital pulp therapy

I. Indirect pulp capping.

II. Direct pulp capping.

III. Pulpotomy.

IV. Partial pulpectomy.

V. Complete pulpectomy (endodontic treatment).

V. Complete pulpectomy (endodontic
treatment):
Pulpectomy of the primary molars is often
considered impracticable because of the
difficulty of obtaining adequate access to the
root canals in the small mouth of children and
because of the complexity of the root canals in
primary molars. The canals are ribbon shaped
(narrow mesiodistally and wide bucco-
lingually) and have lateral branching and
ramification and their complexity increases as
physiological root resorption progresses.
• These difficulties do not exist with primary
anterior teeth and therefore pulpectomy of
these teeth present no technical problems. The
canal may be cleaned and filled with a
resorbable material (zinc oxide or oxypara).
• Treatment of non-vital primary molars:

Ideally, a non-vital tooth should be treated

by pulpectomy and root canal filling. However,
pulpectomy in primary molars is extremely
difficult and often not practical. A non-vital
pulpotomy method is advocated.
• Technique of non-vital pulpotomy:
First visit:
Necrotic coronal pulp is removed (as
pulpotomy) and the infected radicular pulp is
treated with strong antiseptic solution such as
(Beech wood cresote, formocresol camphorated
mono chlorophenol). The material, is applied on
cotton pledget and sealed in the pulp for 1-2
weeks. The strong antiseptic action of these
solutions combats infection in the radicular pulp.
Second visit:
The antiseptic solution is removed and
replaced by antiseptic paste (eugenol &
formocresol & zinc oxide powder) press
antiseptic paste firmly into the root canal with a
cotton pellet. Pressure forces the paste down the
root canal compressing the pulp tissue apically
and then restore the tooth as usual (chrome steel
crown).
• The presence of a sinus associated with a
chronic abscess or of some degree of tooth
mobility is not a contraindication for this
method. A sinus is expected to disappear
following control of infection and a mobile
tooth becomes firm as periapical bone reforms.
A tooth with acute abscess may be treated by
this method after draining the pus and
controlling the infection.
• Pulpectomy in primary anterior teeth:
Primary anterior teeth may be devitalized as
a result of trauma or caries. The basic principles
of endodontics can be applied. Gentle
preparation of the root canals with the help of
radiographic examination will be helpful. Care
should be taken not to traumatize apical region.
A resorbable root canal filling material such as
calcium hydroxide or zinc oxide-eugenol-
formocresol paste can be used.
• Reaction of the pulp to commonly used
capping materials:
A. Zinc oxide-eugenol:
Zinc oxide-eugenol when placed in contact
with vital tissue will produce chronic
inflammation, abscess formation and
liquefaction necrosis. 24 hours after capping
pulp with zinc oxide-eugenol, the adjacent
underlying tissue contains a mass of red blood
cells and P.N.L. The hemorrhagic mass is
demarcated from the underlying pulp tissue by
a zone of fibrin and inflammatory cells.
• Two weeks after the capping, degeneration
of the pulp is apparent at the capping site and
chronic inflammation extended deep to the
apex.
B. Ca(OH)2:
Because of its alkalinity (PH = 12), it is
so caustic such that when placed in contact
with vital pulp tissue, the reaction produces
superficial necrosis of the pulp. The irritant
qualities seen to be related to its ability to
stimulate development of a calcified barrier.
• This is done as follow:
The superficial necrotic area in the pulp
that develops beneath Ca(OH)2 is demarcated
from the healthy pulp tissues below by a new
deeply staining zone comprising basophilic
elements of Ca(OH)2 dressing. Against tins
zone is a new area of coarse fibrous tissue
likened to a primitive type of bone.
• On the periphery of the new fibrous tissue,
cells resembling odontoblasts appear to be
lining-up. One month after the capping
procedure, a calcified bridge is evident
radiographically. This bridge increase in
thickness during the next 12 months. The pulp
beneath the calcified bridge remains vital and
free from inflammatory cells.
C. Formocresol:
The surface of the pulp immediately
under formocresol treatment become fibrous
and acidophilic. This reaction was interpreted
as fixation of living pulp tissue. After
exposure of pulp to formocresol for periods
of 7 to 14 days three distinct zone become
evident:
 A broad acidophilic zone (Fixation).
 A broad pale staining zone in which the cells
and fibers are diminished (Atrophy).
 A broad zone of inflammatory cells extend
deeply into tile apex.
The reaction of formocresol is a
progressive fixation of the pulp tissue with
ultimate fibrosis of the entire pulp.
Failure Following the Vital

Pulp Therapy
1. Internal resorption:
Radiographic evidence of internal resorption
occurring within the pulp canal several months
after pulpotomy procedure is the most
frequently seen evidence of abnormal responses
in primary teeth. Internal resorption is a
destructive process generally believed to be
caused by osteoclastic activity. No satisfactory
explanation for post pulpotomy type of internal
resorption has been given. The possible cause
for such condition may be:
1. With a true carious exposure of the pulp
there will be an inflammatory process to
some degree. The inflammation may be
limited to the exposure site or it may diffuse
throughout the coronal portion of the pulp. If
the inflammation extended to the entrance of
the pulp canals osteoclasts may have been
attracted to the area and cause internal
resorption.
2. All pulp capping materials in use are irritating
and produce at least some degree of
inflammation. Inflammatory cells attracted to
the area as a result of placement of capping
material might attract osteoclastic cells and
initiate the internal resorption.
3. Because the roots of primary teeth are
undergoing normal physiological resorption,
vascularity of the apical lesion increased and
there is osteoclastic activity in the area. This
may predispose the tooth to internal resorption
when irritant in the form of pulp capping
material is placed on the pulp.
2. Alveolar abscess:
An alveolar abscess occasionally develops
some months after pulp therapy has been
completed. The tooth usually remains
asymptomatic and the child is unaware of the
infection, which may be present in the bone
surrounding the root apices or in the area of the
root bifurcation.
• A fistulation opening may be present indicating
the chronic condition of the infection. Primary
teeth that show evidence of an alveolar abscess
should be removed. Permanent teeth that have
previously been treated by pulp capping or by
pulpotomy and later show evidence of pulpal
necrosis and apical infection may be considered
for endodontic treatment.
• General contraindications for pulp treatment
of primary teeth:
1. A patient from family having unfavorable
attitude towards dental health and
conservation of the teeth.
2. A dentition in which multiple teeth have pulp
exposures. Such a dentition is probably
neglected and does not justify pulp treatment.
3. A tooth, with such gross breakdown that
restoration would be impossible following
pulp treatment.
4. A tooth with caries penetrating the floor of
pulp chamber.
5. A tooth close to natural exfoliation.
6. A dentition in which the effect of previous
extraction have not been controlled. Extraction
is preferred, if the contra-lateral tooth is
missing.
7. A patient in poor general health.
• Electro surgery pulpotomy:
It is known as non-chemical devitalization.
Its mechanism of action is the cauterization of
the pulp tissue. It carbonizes heat denatured pulp
and bacterial contamination.
• Laser pulpotomy:
This technique of pulpotomy overcomes
histological effect of electro surgery. It creates
superficial zone of coagulation necrosis that
remain compatible with underlying tissue &
isolate pulp from vigorous effects of the sub-
base.
• Pulp therapy for young permanent teeth:
 Apexogenesis (vital pulpotomy):
• Indications:
1. Treatment of young permanent teeth with
carious exposures.
2. Exposed teeth with no symptoms of painful
pulpitis.
3. Pulp exposure resulting from crown fracture.
4. Permanent teeth with immature root
development but with healthy pulp tissue.
• The goal of apexogenesis is to maintain the
radicular pulp vital to allow the complete
development of the root. Calcium hydroxide
placed directly on the radicular pulp stump
stimulates a calcific response immediately
adjacent to it, which is seen later on as a
radiographic "bridge" over the amputation site. If
degenerative and irreversible coronal pulp
changes have not progressed into the radicular
pulp, successful root closure can progress to
completion. So, a periodic radiograph should be
taken to confirm that no pathologic periapical
changes are present, also periodic clinical
evaluation is mandatory.
Apexification (Root end closure in non vital
tooth):
If a young permanent tooth has a pulp with
extensive degeneration or necrosis throughout,
the pulp should be totally debribed and the
canal treated with calcium hydroxide.
Apexification is used to promote root
elongation and/or a calcific root closure. Even
though the pulp has been necrotic and is
removed, Hertwig's epithelial root sheath is
tough to persist and be capable of generating
the response.
• A conventional endodontic procedure is done
after apexification is complete. In apexification,
the entire pulp contents are removed to the level
of the radiographic apex, using endodontic
broaches & files. Calcium hydroxide is placed at
the apical end of the radicular canal. The Ca
(OH)2 gradually washes out; therefore, it must
be replaced every several months until apical
closure occurs.
Thank You