Tuesday, November 13, 2007

How to carry out successful pulpotomy

Alec Rifkin guides you through his procedures on both primary and permanent posterior teeth.

One of the most valuable services a dentist can provide for a child patient is adequate treatment of pulp involved primary teeth.

It is very important to keep the primary molar tooth as a space maintainer (see Figure 1), as premature extraction of a primary molar tooth usually leads to unnecessary orthodontic treatment when the child is older. Also, the actual extraction of the primary molar is a traumatic procedure compared to the relatively easy pulpotomy procedure.

Figure 1: The pulpotomised upper primary second molar maintains the space for the erupting permanent premolar

I examined 38 patients an average of 18 months after pulpotomy procedures were carried out on primary molar teeth. Of these, 36 (94%) were successful in terms of both health of the gum and space maintenance.

Most of the primary molar pulpotomy procedures in the study were performed on non-vital teeth. The clinical signs of non-vitality are:
1) If there is a buccal swelling and/or inflammation on the gum (see Figure 2)
2) The tooth is slightly mobile
3) The tooth is sensitive to percussion.

Figure 2: Buccal abscess and surrounding inflammation of the gum of a lower primary molar

If one or more of the signs listed above is present, a pulpotomy is indicated. A local anaesthetic is not usually required. If there is doubt, a probe can be gently inserted into the pulp chamber and if the patient experiences pain a local anaesthetic should be given.

• The pulp chamber is completely opened up and cleaned with a large excavator
• A mixture of one drop of Tricresol and Formalin (Wright Cottrell), and one drop of Sedanol Liquid are mixed with Sedanol powder to make a thickish paste and placed on the floor of the pulp chamber
• After setting, which takes 1-2 minutes, amalgam is placed directly onto the set paste
• If swelling of the gum or glands is present, Penicillin V 125mg QID is usually given (Erythromycin can be used for penicillin allergic patients).

Tricresol and Formalin contain formaldehyde, which is both a mummifying and devitalising agent. Sedanol powder and liquid is a quick-setting zinc oxide and eugenol cement (Budget Dental).

Because of my success with primary molar pulpotomies, I have done numerous pulpotomies on permanent molar and premolar teeth. In fact, I had a pulpotomy done for me over 20 years ago on my upper right wisdom tooth which is still symptomless and functional (see Figure 3).

Figure 3: Pulpotomised upper wisdom tooth still functional and asymtomatic after 20 years

I usually do pulpotomies for patients who don’t want the expense or the extra time it takes to do a root treatment and who don’t want the tooth extracted. Unlike primary molars, I do not do pulpotomies on septic or abscessed permanent teeth (when a root treatment is preferable). I only do pulpotomies on vital permanent teeth where the patient experiences uncontrollable pain. My success rate is clinically good.

The technique and materials used are the same as described in primary teeth, except that local anaesthetic is used as the tooth is vital. Usually the pulpotomy and filling is done in one visit. However, if there has been long-term severe pain, there are time constraints or it is difficult to control the bleeding, I will then do the pulpotomy over two visits.

At the first visit, the coronal pulp is removed and Tricresol and formalin on a small pledget of cotton wool is placed over the opening of the root canals and sealed in with a temporary filling for at least two weeks.

At the second visit, no local anaesthetic is required as the radicular pulp remnants have been devitalised (this takes 10 days). After removing the temporary filling and cotton wool pledget, a paste of one drop each of Tricresol and Formalin and Sedanol liquid are mixed with Sedanol powder to make a thickish paste which is placed on the floor of the pulp chamber and allowed to set. An amalgam filling is then inserted.

If the patient prefers a ‘white filling’, I put a layer of glass ionomer over the sedanol and Tricresol Formalin paste as a barrier because the eugenol (present in the sedanol liquid) interferes with the setting of the composite filling.

Alec Rifkin qualified in South Africa with BDS, MSc and BChD (Hons) degrees. He practised in Johannesburg and was a part-time lecturer in postgraduate paedodontics at the University of Witwatersrand. Alec has worked for the past 20 years as a general dental practitioner in Islington, London.