Pulpotomy for permanent teeth
Pulpotomy for permanent molars/premolars (vital pulp therapy)
Suitable for:
- pulpitis with irreversible symptoms and normal apical tissues
- permanent molars and premolars with an extensive carious lesion with no clear band of dentine visible radiographically that separates the lesion and pulp, and normal apical tissues (i.e. no signs of periapical pathology)
Aim: Partial or complete removal of coronal pulp tissue and application of a biomaterial (i.e. a material that is bioactive and biocompatible) directly onto the pulp tissue, prior to placement of a permanent restoration.
- Pulpotomy (partial or complete) is indicated for permanent molar and premolar teeth with extremely deep carious lesions which will inevitably lead to pulp exposure. These teeth are most likely associated with pulpitis with irreversible symptoms.
- In an immature permanent tooth, pulpotomy is preferable to pulpectomy to enable continued root development.
- Pulpotomy may be contraindicated in the presence of clear periapical radiolucency and corresponding clinical symptoms that suggest apical periodontitis.
- A strict aseptic technique, with rubber dam and ideally magnification, is required to optimise success.
- Carious lesions should be fully removed to reduce the bacterial load prior to penetrating the pulp chamber.
- It will not be clear whether a partial or full pulpotomy is required until the pulp is exposed. Incremental removal of the inflamed coronal pulp tissues is performed until haemostasis can be achieved; the procedure is deemed a partial pulpotomy if there is non-inflamed coronal pulp tissue present at this point.
- A full pulpotomy involves complete removal of coronal pulp tissue to the level of the pulpal floor followed by haemostasis of pulp stumps at canal orifice level.
Technique
Ensure that the tooth is restorable prior to initiating treatment.
Administer local anaesthetic and isolate using rubber dam.
Disinfect the tooth surface with sodium hypochlorite (NaOCl).
Images show a radiograph of an extensive carious lesion (left), clinical image of carious lesion (centre) and excavated access cavity (right)
Note for this technique, the clinical images are of an adult patient
Remove caries and any defective restorations using high-speed/slow-speed burs and excavators, as required.
Disinfect the access cavity using a sterile cotton wool pellet soaked in 1 - 5.25% NaOCl.
Access the pulp chamber using a new sterile bur.
Enlarge access and, if performing a full pulpotomy, deroof the pulp chamber using a long diamond or endo-Z bur.
Disinfect the pulp chamber with NaOCl.
Amputate and remove the coronal pulp tissue incrementally using either a high-speed diamond bur, a slow-speed rose head bur or a spoon excavator.
After each increment, apply light pressure with a sterile cotton pellet soaked in NaOCl and check for haemostasis to determine if all of the inflamed tissue has been removed; haemostasis may take up to 5 minutes.
If all of the coronal pulp tissue has been removed (full pulpotomy), identify all canal orifices and ensure that the canal pulp tissue is healthy by applying pressure and checking for haemostasis as detailed above.
Gently dry the pulp chamber with a fresh dry cotton pellet.
Reassess the tissue status in all canal orifices to ensure haemostasis.
Images show the pulp chamber after amputation of the coronal pulp tissue (left), application of a cotton pellet soaked in NaOCl (centre) and the pulp chamber after haemostasis has been achieved (right)
Place a biomaterial (e.g. a hydraulic calcium-silicate cement or suitable alternative), mixed according to the manufacturer’s instructions, and fill up to the level of the enamel-dentine junction.
- Follow the manufacturer’s instructions to determine the setting time prior to restoration.
Images show placement of a biomaterial into pulp chamber (left) and clinical image (centre) and radiograph (right) of final restoration
Restore the crown of the tooth with a direct restoration based on the clinical presentation.
- If indicated by clinical judgement, restore the tooth with a cuspal coverage restoration.
Note that the pulpotomy procedure should be abandoned and pulpectomy/root canal therapy provided instead if the following scenarios are encountered:
- Necrotic tissue is observed when accessing pulp chamber.
- Unable to control haemostasis following full removal of coronal pulp tissue.
Aftercare
Advise the child or young person and the parent/carer that there may be some discomfort when the anaesthesia wears off, and that the child or young person might need analgesia.
If these symptoms do not settle after 48 hours or increase in intensity, the tooth may require pulpectomy/root canal therapy.
Conduct a clinical and radiographic review of the treated tooth annually unless symptomatic.
- The European Society of Endodontology recommends annual review for four years.95