Y2 S4 Pulp exposure: pulpotomies

Question 1

What type of pulp exposure requires a partial pulpotomy?

Answer 1

• Class II exposure
• Carious
• Exposure site is contaminated with bacteria

Question 2

What is a partial pulpotomy?

Answer 2

Also known as pulp amputation, a procedure in which part of an exposed vital pulp is removed, usually as a means of preserving the vitality and function of the remaining part.
- Surgical removal of the infected pulp and dentine surrounding an exposure to a depth of approximately 2mm followed by the placement of a wound dressing on the non-infected tissue
- High speed handpiece used to remove infected tissue
- Dentine bridge forms (porous)

Different to a full/cervical pulpotomy.

Question 3

What type of tooth is suitable for a partial pulpotomy?

Answer 3

• A restorable tooth
• Reversible pulpitis
• Healthy, non-infected pulp tissue below the disease, infected tissue

Question 4

When is a cervical/full pulpotomy indicated?

Answer 4

Used to treat normal pulp or reversible pulpitis associated with a large carious lesion or after traumatic pulp exposure in primary and immuature permanent teeth.
Aim is to allow continued physiological development and formation of the root end and, in particular, the development of the apex (apexogenesis).

Question 4

Describe the treatment steps of a partial pulpotomy.

Answer 4

1) Apply rubber dam and maintain a saliva free operating site
2) Remove diseased tissue carefully, minimising further trauma to the pulp
3) Amputate pulp with high-speed diamond bur (cut 2mm of pulp)
4) Clean pulp wound and tooth tissue with sterile saline
5) Disinfect site with sodium hypochlorite on cotton wool to establish haemostasis, remove dentine debris and kill micro-organisms
6) Place hydraulic calcium silicate on exposed pulp tissue and cover with moist cotton wool and restore (for MTA)
7) Long term follow-up to monitor pulp condition (and root development in young people)

Question 5

What is a cervical/full pulpotomy?

Answer 5

Complete removal of the coronal pulp and application of a biomaterial (BioDentine or MTA) directly onto the pulp tissue at the level of the canal orifice(s), prior to the placement of a permanent restoration.

Question 6

Is a full pulpotomy recommended in mature permanent teeth?

Answer 6

Only considered as an emergency or intermediate treatment option.

Question 7

What is the rationale behind complete pulpotomies for immature permanent teeth?

Answer 7

Question 8

What issues/concerns exist regarding pulpotomies?

Answer 8

• An extremely good seal is very important against microleakage
• Treatment will result in some mechanical trauma which may have a negative impact on outcome
• Presence of dentine particles may induce increased inflammation
• Removal of pulp tissue must be as atraumatic as possible
• Control of haemorrhage and exudate is essential – development of a blood clot has a negative impact on treatment outcome as it can induce dystrophic calcification and internal resorption, it also forms a culture medium for bacteria
• Haemorrhage must be controlled without resorting to ferrous sulphate (sodium hypochlorite used instead)
• Quality of dentinal bridge is typically poor (often porous)