Devitalizing agents, non-vital

methods of root canal therapy, non-

vital pulpotomy and pulpectomy,
indications, description of techniques
 Pediatric pulp therapy for primary and
young permanent teeth involves the
following techniques:

 1. Indirect pulp capping (car.pulp.prox.,hyper.pul.)

 2. Direct pulp capping (trauma, caries excavation)
 3. Coronal pulpotomy (vital)
 4. Pulpectomy
 1. PRIMARY TEETH
 A. Vital Pulp Therapy
 INDIRECT PULP CAPPING
 Indirect pulp capping is defined as the
application of a medicament over a thin
layer of remaining carious dentin, after deep
excavation, with no exposure of the pulp.

Figure 17-4 Indirect pulp-capping

technique. A, Medicament,
either zinc oxide–eugenol cement, calcium
hydroxide, or both,
against remaining caries. B, Lasting
temporary restoration.
Following repair, both materials are
removed along with softened
caries, and final restorations are placed.
 INDIRECT PULP CAPPING
 In a tooth with a deep carious lesion, carious
dentin removal sometimes is left incomplete,
and the decay process is treated with a
biocompatible material in order to avoid pulp
tissue exposure. A radiopaque base is
placed over the remaining affected dentin to
stimulate healing and repair. The tooth then
is restored with a material that seals the
involved dentin from the oral environment.
 INDIRECT PULP CAPPING
 Indications: In a tooth that has a carious lesion near
the dental pulp, a protective dressing or cement may
be placed over a layer of remaining carious dentin to
prevent operative pulp exposure and stimulate
healing and repair.
 Objectives: The restorative material should seal
completely involved dentin from the oral environment.
The vitality of the tooth should be preserved. No
prolonged post-treatment signs or symptoms of
sensitivity, pain, or swelling should be evident. The
pulp should respond favorably and tertiary dentin
should be formed, as evidenced by radiographic
evaluation. There should be no evidence of internal
resorption or other pathologic changes.
 DIRECT PULP CAPPING
 Direct pulp capping involves the placement
of a biocompatible agent on healthy pulp
tissue that has been inadvertently exposed
from caries excavation or traumatic injury
(Figure 17-6).

Figure 17-6 Direct pulp-capping technique.

A, Capping material (calcium hydroxide)
covers pulp exposure and the floor of the
cavity. B, Protective base
of zinc oxide–eugenol cement. C,
Amalgam restoration.
 DIRECT PULP CAPPING
 When a small exposure of the pulp is encountered
during cavity preparation or following a traumatic
injury, an appropriate biocompatible radiopaque
base may be placed in contact with the exposed
pulp tissue prior to placing a restoration.
 Indications: This procedure is valid for small
mechanical or traumatic exposures in primary
teeth when conditions for a favorable response are
optimal. Direct pulp capping of a carious pulp
exposure in a primary tooth is not recommended.
 Objectives: The vitality of the tooth should be
maintained.
 No prolonged post-treatment signs or symptoms of
sensitivity, pain,or swelling should be evident. Pulp
healing and tertiary dentin formation should result.
There should be no pathological changes.
 Vital Pulpotomy- amputation
 Definition
 Removal or amputation of the entire
coronal pulp-leaving the remaining
tissue intact in the canals.
 PULPOTOMY
 Pulpotomy is the most widely used technique in
vital pulp therapy for primary and young
permanent teeth with carious pulp exposures.

 A pulpotomy is defined as the surgical removal of

the entire coronal pulp presumed to be partially or
totally inflamed and quite possibly infected, leaving
intact the vital radicular pulp within the canals.

 A germicidal medicament is then placed over the

remaining vital radicular pulp stumps at their point
of communication with the floor of the coronal pulp
chamber
 PULPOTOMY
 The pulpotomy procedure involves amputation of
the coronal portion of the affected or infected
dental pulp. Treatment of the remaining vital
radicular pulp tissue surface should preserve the
vitality and function of all or part of the remaining
radicular portion of the pulp. The coronal pulp
chamber is filled with a suitable base and the tooth
restored.
 Indications: The pulpotomy procedure is indicated
in primary teeth when the infected coronal tissue
can be amputated and the
remaining radicular tissue is judged to be vital, or
affected but still vital, by clinical and radiographic
criteria.
 PULPOTOMY
 Objectives: The vitality of the majority of the
radicular pulp should be maintained. No prolonged
adverse clinical signs or symptoms such as
prolonged sensitivity, pain, or swelling should
occur.
 There should be no evidence of internal resorption
or abnormal canal calcification as determined by
radiographic evaluation. There should be no
breakdown of periradicular supporting tissues, and
there should be no harm to succedaneous teeth.
 VITAL PULPOTOMY
 Procedure
 • Local anaesthetic
 • Good isolation with rubber dam
 • Removal of caries
 Complete removal of roof of pulp chamber
preferably with a non-end cutting bur
 VITAL PULPOTOMY
 Attain initial radicular pulpal haemostasis by
gentle application of sterile cotton pledget moistened with
saline (haemostasis should be achieved within four
minutes)
 Selection of medicament for direct application to radicular
pulp stumps to include any of the following:
 1) 15.5% ferric sulphate solution (AstringedentTM
Ultradent Products Inc., Salt Lake City, UT)
burnished on pulp stumps with microbrush for
15 seconds to achieve haemostasis, followed by
thorough rinsing and drying
 VITAL PULPOTOMY
 2) 20% (1:5 dilution) Buckley’s formocresol solution
applied to radicular pulp on a cotton pledget for five
minutes to achieve superficial tissue fixation

 3) MTA paste applied over radicular pulp with proprietary

carrier

 4) Well-condensed layer of pure calcium hydroxide powder

applied directly over radicular pulp

 Application of a lining (if appropriate) such as reinforced

glass ionomer or zinc oxide eugenol cement
 • Definitive restoration to achieve optimum external coronal
seal (ideally an adhesive restoration of preformed metal
crown)
Non- vital Pulpotomy.

1. Visit Removal of caries,

Complete removal of roof of
pulp chamber preferably with
a non-end cutting bur.
Attain initial radicular pulpal
haemostasis by gentle
application of sterile cotton
pledget moistened with saline
(formocresol,GA) for 5-10
days.Aplication –temporary
fill.
2.Visit Removal of temp.fill and
cotton pledget with
formocresol.Application of
mumif.paste,cement.,amalga
m fill.
 1. PRIMARY TEETH
 B. Nonvital Pulp Therapy
 Objectives of Non-Vital Pulp Treatment
(Primary Teeth)

– Maintain tooth free of infection

– Achieve biomechanical cleansing and canal
obturation
– Promote physiologic resorption
– Maintain space and function
 Non-Vital Pulp Treatment
(Primary Teeth)
– Choices
 Pulpectomy (most are partial due to anatomy)
 Extraction
 Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy-

 Pulpectomy Indications/Considerations

 Strategic importance of tooth (2nd primary molar

with unerupted 6-yr molar)
 Sufficient remaining tooth structure
 Poor chance of vital pulp treatment success
 Adequate remaining root
 Cooperative patient
 Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy-

 Pulpectomy Contraindications

– A non-restorable tooth
– A tooth with a mechanical or carious perforation of
the floor of the pulp chamber
– Pathologic root resorption involving more than one-
third of the root
– Pathologic loss of bone support resulting in loss of
the normal periodontal attachment
– The presence of a dentigerous or follicular cyst
– Radiographically visible internal root resorption
 Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy-
 Pulpectomy Technique
1. Achieve adequate anesthesia and rubber dam isolation.
2. Remove all caries.
3. Remove the roof of the pulp chamber with a high-speed
handpiece.
4. Amputate the coronal aspect of the pulp tissue with a large
round bur in a slow-speed handpiece.
5. The remaining pulp tissue occupying the root canals is removed
using endodontic files at a predetermined working length,
approximately 1 to 2 mm short of the root apices.
6. The canals should be enlarged several sizes beyond the size of
the first file that fits snugly into the canal to a minimum final
size of 30 to 35.
7. Throughout root canal instrumentation, the canals should be
irrigated with sodium hypochlorite to aid in debridement.
 Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy-

 Pulpectomy Technique
(continued)

8. Dry the canals with

sterile paper points.
9.The canals are filled
with a treatment paste
(Zinc Oxide/Eugenol at
UKCD) using a pressure
syringe.
10. The tooth is restored
with a stainless steel
crown.
 Criteria for an ideal pulpectomy obturant
(treatment paste)

– Antiseptic
– Resorbable
– Harmless to the adjacent tooth germ
– Radiopaque
– Non-impinging on erupting permanent tooth
– Easily inserted
– Easily removed
 Apexification (Young Permanent Teeth)
– Apical closure of an incompletely formed root
– Implemented when apexogenesis has failed
– Necrotic tissue removal short of the
apexification site
– Agent is placed in canals to achieve
closure/apical stop

 Apexification Recall Schedule

– Calcium Hydroxide Rotation
 3-6 month intervals (Andreasen, 1994)
 Action of Calcium Hydroxide in Apexification

– Bactericidal
– Low grade irritation inducing hard tissue barrier
formation
– Dissolves necrotic debris

 Forms of Calcium Hydroxide

– Caliscept
– Self-mixed (CaOH + sterile water or local
anesthetic)
 Evaluation of Success

– Asymptomatic
– Radiographic absence of pathology
– Continued root development
– Hard tissue barrier at apex
– Responsive pulp
Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy--
 Fixing material
 Glutaraldehyde (2%) 1-3 min
 Formokrezol
Devitalizing agent
 Paraformaldehyde paste-Toxavit
TOXAVIT
DEPULPIN
 Technique: 2 visits
 1st.visit:
 application of paraformaldehyde paste, we
apply it by cotton woll in the cavity and cover
with temporary filling and then wait for 10-12
days
 2st.visit:
 The coronal pulp is removed and the remaining
pulp is covered with mumifying paste –
resorcine formaldehyde paste, then mumifying
paste is covered with cement and amalgam.
 Indication:
 In primary teeth only- its not
recommended in permanent teeth
because of development of chronic
periapical involvement.
 In patients with blood diseases, when
extraction is contraindicated
 Local factors-fine lumen/ tortuous canal
anatomy
 Non-vital pulpectomy
 Definition: extirpation or removal of the whole
pulp which is before devitalized with
devitalizing agent
 In the past: arsenic trioxide, formaldehyde was
prefered devitalizing agents
 In the present time: paraphormaldehyde
 paraformaldehyde 1 g, lignocaine 0.06 g, carmine
(colour) 0.01 g, carbowax 1500 1.3 g, propylene
glycol 0.5 ml.
 Pulpectomy
 Pulpectomy is a root canal procedure for pulp tissue that is
irreversibly infected or necrotic due to caries or trauma. The
root canals are debrided, enlarged, disinfected, and filled with a
resorbable material such as nonreinforced zinc oxide-eugenol.
The tooth then is restored with a restoration that seals the tooth
from microleakage.

 • Indications: A pulpectomy is indicated in a primary tooth with

irreversible pulpitis or necrosis or a tooth treatment planned for
pulpotomy in which the radicular pulp exhibits clinical signs of
pulp necrosis such as excessive hemorrhage. The roots should
exhibit minimal or no resorption.
 The technique can be carried out in one or two visits.
 The procedures need 2 appointments, in the
first one devitalizing agent is put on the pulp,
and in 2nd, root canal therapy is ended.

 Indication: When anaesthetic can not be

administered due to heart diseases,
hypertension, blood diseases

 With multirooted tooth, because performance

of vital pulpectomy and complete root canal
therapy in one-appointment is difficult or
problematic.
 Pulpectomy Technique
1. Achieve adequate anesthesia and rubber dam isolation.
2. Remove all caries.
3. Remove the roof of the pulp chamber with a high-speed
handpiece.
4. Amputate the coronal aspect of the pulp tissue with a large
round bur in a slow-speed handpiece.
5. The remaining pulp tissue occupying the root canals is
removed using endodontic files at a predetermined working
length, approximately 1 to 2 mm short of the root apices.
6. The canals should be enlarged several sizes beyond the size
of the first file that fits snugly into the canal to a minimum
final size of 30 to 35.
7. Throughout root canal instrumentation, the canals should be
irrigated with sodium hypochlorite to aid in debridement.
 Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy--
 Pulpectomy Technique
(continued)

8. Dry the canals with sterile

paper points.
9.The canals are filled with a
treatment paste (Zinc
Oxide/Eugenol at UKCD)
using a pressure syringe.
10. The tooth is restored with a
stainless steel crown.
 Pulpectomy Contraindications
– A non-restorable tooth
– A tooth with a mechanical or carious perforation of
the floor of the pulp chamber
– Pathologic root resorption involving more than one-
third of the root
– Pathologic loss of bone support resulting in loss of
the normal periodontal attachment
– The presence of a dentigerous or follicular cyst
– Radiographically visible internal root resorption
– Criteria for an ideal pulpectomy obturant
(treatment paste)
– Antiseptic
– Resorbable
– Harmless to the adjacent tooth germ
– Radiopaque
– Non-impinging on erupting permanent tooth
– Easily inserted
– Easily removed
 Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy--
 Action of Calcium Hydroxide
– Bactericidal
– Low grade irritation inducing hard tissue barrier
formation
– Dissolves necrotic debris

 Forms of Calcium Hydroxide

– Caliscept
– Self-mixed (CaOH + sterile water or local
anesthetic)
 Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy--
 Evaluation of Success

– Asymptomatic
Pulp Therapy in Pediatric Dentistry
– Radiographic absence
--Non-Vital of pathology
Pulp Therapy--

– Continued root development

– Hard tissue barrier at apex
– Responsive pulp
Pulp Therapy in Pediatric Dentistry
--Non-Vital Pulp Therapy--