What is Pulpotomy
Pulpotomy refers to a common endodontic procedure in which dental pulp is removed from the pulp chamber. This procedure is usually done on primary teeth (children’s teeth) by a pediatric dentist.
Pulpotomy is necessary in instances where the pulp of a tooth has become infected due to deep decay or a crack within the tooth and the infected areas need to be removed. A pulpotomy can also be performed on an adult tooth where a root canal procedure is not needed.
When a tooth is injured, decay is present, or there is a crack in the tooth, the nerve, (pulp) can become irritated which causes the toothache people most often feel. If the tooth was bumped or hit with a foreign object, which happens often with children, the tooth will either begin to feel better or the nerve in the tooth will begin to die. When the nerve begins to die, the tooth will most often be sore and the tooth will begin to darken. To relieve the toothache and prevent infection, the pulp of the tooth is removed.
If the decay in the tooth is too close to the nerve or into the nerve, the decay is then removed and a pulpotomy is performed. When decay is too close to the nerve or touching the nerve, the nerve is constantly irritated, which leads to a toothache, and eventually, infection will occur in the tooth. The infection is known as an abscess. In order to prevent infection, relieve the toothache, and to save the tooth from having to be extracted, the decay is removed and a pulpotomy is performed.
In pediatric endodontics another technique is sometimes used when the remaining pulp of a deciduous tooth is not considered free from inflammation. Formocresol, a necrotizing (mummification) agent is used as a wound dressing. This method is unique – necrotic tissue is intentionally left in the human body. However, proper endodontic treatment may be difficult to carry out in very young children. (Also, a nonresorbable root filling material will be left after the resorption of the deciduous tooth if for example gutta-percha is used.)
How is Pulpotomy performed?
In pulpotomy all of the coronal pulp tissue is removed from the crown (visible portion of the tooth above the gums) but the pulp tissue in the root canals remain. This is different that pulpectomy in which all of the pulp is removed from both the root canals and crown. Damage to the pulp becomes visible when a pocket of pus forms at the tip of the tooth root (abscess). If left alone the infection in the tooth will spread and cause further damage to the bone around the tooth. This can lead to the tooth falling out.
The only alternative to pulpotomy is tooth extraction which although initially cheaper requires further implementation of a dental implant or a bridge. Extraction could also cause a shift in the surrounding teeth resulting in crooked teeth and eventually possible teeth loss.
The Pulpotomy Procedure
When a tooth is showing signs that a pulpotomy is needed, an x-ray is taken and the tooth is evaluated to determine if the tooth can be treated or if it needs to be extracted.
The area is then numbed. If decay is present in the tooth, the decay is removed. After the decay has been removed, the pulp of the tooth is then removed. Only the top section of the pulp is removed, not the pulp within the roots of the tooth.
After the pulp has been removed, a cotton pellet damp with formocresol is placed in the tooth. The formocresol will sterilize the inside of the tooth as well as “mummify” the remaining pulp. Formocresol is the most common method used, but some dentists may choose to use a laser, Ferric Oxide, electro surgery, or MTA.
The cotton pellet remains on the tooth for a few minutes, then it is removed. Once the cotton pellet is removed, the opening is sealed with a Zinc Oxide and Eugenal material. The most common material is IRM, which is a putty like material that can be molded to the inside of the tooth and will harden after a few minutes.
Once the material has hardened, a permanent or temporary restoration can be placed on the tooth. For many children, a stainless steel crown is used to protect a primary tooth. Stainless steel crowns are often used because they provide enough protection for the tooth until the tooth will naturally loosen and fall out. A Stainless steel crown is also less expensive than a more permanent porcelain crown. If the tooth is a permanent tooth, a porcelain crown may be recommended.
A pulpotomy procedure offers a very good alternative to extracting a tooth, especially a primary tooth. Primary teeth not only help with a child’s ability to chew food and pronounce words, they also serve as space holders for when the adult teeth erupt. If a child begins to lose their baby teeth too early, due to decay, accidents, or disease, other procedures need to be performed to preserve space for the adult teeth. A pulpotomy is one procedure in which the tooth can be saved and still be functional until the tooth naturally falls out. The success rate of a pulpotomy is quite high and the procedure can be completed within one to two visits.
How A Pulpotomy Works
The first step the dentist will take is to x-ray the damaged tooth to ensure he knows exactly how far the damage has gone and exactly which procedure is best. So long as the damage is away from the nerve, he will be able to save it with a pulpotomy. If it has gone too far, he or she will likely have to pull it or perform a root canal.
The dental professional will inject freezing solution into the area and then remove the decay with a drill or laser. Once the dental professional has access to the pulp, he will remove the interior of the tooth until all that is left is the pulp inside the root. A special sterilized cotton pad known as a formocresol and treated pulp is inserted firmly into the void and left to treat the infection and decay.
After a short while, the dentist will remove the treatment and fill the entrance into the tooth. Eugenal material, zinc oxide, and IRM are some of the options the dental professional has available as a sealant. This is a strong material, but not strong enough to withstand the pressure of normal activities such as chewing. Therefore, a crown or cap is needed to cover the tooth.
To those who are unfamiliar with Endodontic procedures, the idea of a pulpotomy can be very intimidating. In fact, this treatment is often the better option since you will still have a tooth left behind without having to suffer the pain. It is a relatively simple procedure that will keep you or your child’s smile looking great while providing the best chance at a healthy smile.
Partial pulpotomy is mainly carried out in immature teeth to give the root a chance to develop: Apexogenesis. In the fully developed tooth a pulpectomy is preferred. There reasons for this are the same as for direct pulp capping. It has recently been shown that partial pulpotomy has a high success rate in fully developed young teeth. It has also been shown that this form of treatment will yield a continuous hard tissue barrier which is essential for the long term prognosis as restorations may leak.
The outcome for partial pulpotomy is better than the outcome for direct pulp capping. Therefore, partial pulpotomy is the preferred treatment when there is a choice between pulp capping and partial pulpotomy.
The indications for this treatment are the same as for direct pulp capping.
- The treatment is carried out under aseptic conditions using a rubber dam.
- The exposure is widened with a high speed diamond under constant water cooling to a depth of 1.5-2 mm.
- The wound is irrigated with isotonic saline until bleeding has stopped. Note: it is imperative to avoid an “extra pulpal ” blood clot. The presence of a blood clot will mean that the wound dressing (calcium hydroxide) will be placed on the clot and not on the pulp tissue.
- A paste of calcium hydroxide and water is placed on the exposed pulp tissue. Excess water is removed by means of sterile cotton pellets.
- The wound dressing is covered with a sealing cement.
- The permanent filling is placed.
- The tooth should be followed clinically and radiographically for 4-5 years.