PULP

THERAPY
Goals:
1. Successful treatment of the
cariously involved pulp, allowing the
tooth to remain in the mouth in a
non-pathologic state.
Goals:
1. Successful treatment of the cariously involved
pulp, allowing the tooth to remain in the mouth
in a non-pathologic state.
2. Maintenance of arch length and
tooth space.
Goals:
1. Successful treatment of the cariously involved
pulp, allowing the tooth to remain in the mouth
in a non-pathologic state.
2. Maintenance of arch length and tooth space.
3. Restoration of comfort with
ability to chew.
Goals:
1. Successful treatment of the cariously involved
pulp, allowing the tooth to remain in the mouth
in a non-pathologic state.
2. Maintenance of arch length and tooth space.
3. Restoration of comfort with ability to chew.
4. Prevention of speech
abnormalities and abnormal habits.
Factors Influencing
Success of Pulp Therapy:
Factors Influencing
Success of Pulp Therapy:
1. Type and amount of pulpal
hemorrhage
Factors Influencing
Success of Pulp Therapy:
2. Depth of penetration from the
carious process into the pulpal tissue
- Pulp Inflammation / Infection
Factors Influencing
Success of Pulp Therapy:
2. Depth of penetration from the
carious process into the pulpal tissue
- Pulp Inflammation / Infection

• Primary Tooth
- 1.8 mm away from the pulp
• Permanent Tooth
- 0.6 mm away from the pulp
Factors Influencing
Success of Pulp Therapy:
3. Speed of carious attack on the pulp
Diagnostic Conditions:
1. The length of time the tooth/
teeth in question are to be retained
- more than 6 months
Diagnostic Conditions:
1. The length of time the tooth/teeth in question
are to be retained

2. The health of the patient

- contraindicated in medically
compromised patient
Diagnostic Conditions:
1. The length of time the tooth/teeth in question
are to be retained
2.The health of the patient

3. The status of the remaining

dentition
Diagnostic Conditions:
1. The length of time the tooth/teeth in question
are to be retained
2.The health of the patient
3.The status of the remaining dentition

4. The restorability of the tooth/

teeth in question
Diagnostic Conditions:
1. The length of time the tooth/teeth in question
are to be retained
2.The health of the patient
3.The status of the remaining dentition
4.The restorability of the tooth/teeth in question
5. Patient and parent cooperation in
accepting the prevention program,
including periodic evaluation.
Radiographic Assessment:
1. The depth of carious process
related to pulpal tissue
Radiographic Assessment:
1. The depth of carious process related to
pulpal tissue

2. The presence of calcified bodies in

the pulpal tissue indicates chronic
inflammation
Radiographic Assessment:
1. The depth of carious process related to pulpal
tissue
2.The presence of calcified bodies in the pulpal
tissue indicates chronic inflammation

3. Involving of the bifurcation and

trifurcation regions of primary
molars
Radiographic Assessment:
1. The depth of carious process related to pulpal
tissue
2.The presence of calcified bodies in the pulpal
tissue indicates chronic inflammation
3.Involving of the bifurcation and trifurcation
regions of primary molars

4. Pathologic external root and bone

resorption
Radiographic Assessment:
1. The depth of carious process related to pulpal
tissue
2.The presence of calcified bodies in the pulpal
tissue indicates chronic inflammation
3.Involving of the bifurcation and trifurcation
regions of primary molars
4.Pathologic external root and bone resorption
5.The presence of internal root
resorption in the coronal or apical
portion of the involve tooth.
Clinical Assessment:
1. Any discomfort when eating ice
cream?
Clinical Assessment:
1. Any discomfort when eating ice cream?

2. …when you eat something warm

such as soup?
Clinical Assessment:
1. Any discomfort when eating ice cream?
2. …when you eat something warm such as soup?

3. What happens when you eat

sweets?
Clinical Assessment:
1. Any discomfort when eating ice cream?
2. …when you eat something warm such as soup?
3.What happens when you eat sweets?

4. Does your tooth bother you at

night when you go to sleep?
Clinical Assessment:
1. Any discomfort when eating ice cream?
2. …when you eat something warm such as soup?
3.What happens when you eat sweets?
4.Does your tooth bother you at night when you
go to sleep?
5. Is it un-comportable for long
time?
Clinical Assessment:
1. Any discomfort when eating ice cream?
2. …when you eat something warm such as soup?
3.What happens when you eat sweets?
4.Does your tooth bother you at night when you
go to sleep?
5.Is it un-comportable for long time?
6. Does it jump when you hit it with a
toothbrush or fork or spoon?
Pulp Treatment:
1. Pulp Capping
a. Indirect Pulp Capping (IPC)
b. Direct Pulp Capping (DPC)
Pulp Treatment:
1. Pulp Capping
a. Indirect Pulp Capping (IPC)
b. Direct Pulp Capping (DPC)
2. Pulpotomy
a. Formocresol Pulpotomy
b. Calcium Hydroxide Pulpotomy
or Apexogenesis
Pulp Treatment:
1. Pulp Capping
a. Indirect Pulp Capping (IPC)
b. Direct Pulp Capping (DPC)
2. Pulpotomy
a. Formocresol Pulpotomy
b. Calcium Hydroxide Pulpotomy
or Apexogenesis
3. Pulpectomy
4. Apexification
DIRECT PULP CAPPING
 DIRECT PULP CAPPING
• can not be done in primary teeth
 DIRECT PULP CAPPING
Indication:
1. Mechanical exposure of the pulp
during restoration with a moderate
deep carious lesion.
 DIRECT PULP CAPPING
Indication:
2. No history of pain
 DIRECT PULP CAPPING
Indication:
3. No clinical or radiographic signs
of pathology
 DIRECT PULP CAPPING
Indication:
4. Vital pulp
Materials:
Mouth Mirror
Explorer
Cotton Plier
Spoon Excavator
Syringe
Anesthetic agent
Topical Anesthesia
Rubber Dam set
Materials:
Hand Piece High Speed
Round Bur No.2
Woodson
Cement spatula
Glass slab
IRM
Calcium Hydroxide paste
Amalgam or Composite sets
Procedure:
1. Anesthesia
2. Isolation
3. Caries removal
4. Dis-infection
5. Hemostasis or
control the bleeding
6. Ca(OH) application
7. Base placement
8. Restoration
9. Observation
Procedure:
1. Anesthesia
2. Isolation
3. Caries removal*
4. Dis-infection
5. Hemostasis or
control the bleeding
6. Ca(OH) application
7. Base placement
8. Restoration
9. Observation
Procedure:
1. Anesthesia
2. Isolation
3. Caries removal
4. Dis-infection
5. Hemostasis or
control the bleeding
6. Ca(OH) application
7. Base placement
8. Restoration
9. Observation
Procedure:
1. Anesthesia
2. Isolation
3. Caries removal
4. Dis-infection
5. Hemostasis or
control the bleeding
6. Ca(OH) application
7. Base placement
8. Restoration
9. Observation
Procedure:
1. Anesthesia
2. Isolation
3. Caries removal
4. Dis-infection
5. Hemostasis or
control the bleeding
6. Ca(OH) application
7. Base placement
8. Restoration
9. Observation
INDIRECT PULP CAPPING
INDIRECT PULP CAPPING
Indication:
1. Mild pain associated with eating
INDIRECT PULP CAPPING
Indication:
2. No extreme penetrating,
throbbing and night pain
INDIRECT PULP CAPPING
Indication:
3. No gingival pathology
INDIRECT PULP CAPPING
Indication:
4. No mobility
INDIRECT PULP CAPPING
Indication:
5. Radiographically; normal
periapacal tissue with probable
carious pulp exposure.
Materials:
Mouth Mirror
Explorer
Cotton Plier
Spoon Excavator
Syringe
Anesthetic agent
Topical Anesthesia
Rubber Dam set
Materials:
Hand Piece High Speed
Round Bur No.2
Woodson
Cement spatula
Glass slab
IRM
Calcium Hydroxide paste
Amalgam or Composite sets
Procedure:
1. Local Anesthesia
2. Isolation
3. Caries Removal
4. Ca(OH) paste application
5. Base placement
- can be IRM and GIC
6. Restoration
- Amalgam or Composite
PULPOTOMY
 PULPOTOMY
-Treatment involving the amputation
of coronal portion of affected or
infected dental pulp while
maintaining the radicular portion
of the pulp.
- Cvek Pulpotomy
 Pulpotomy vs Pulpectomy

Pulpotomy Pulpectomy
- remove coronal pulp - remove coronal and
tissue radicular pulp tissue
- Vital - Non-Vital
 Two kinds of Pulpotomy
1. Formocresol Pulpotomy
2. Calcium Hydroxide Pulpotomy or
Apexogenesis

Apexogenesis Apexification
- Vital tooth - Non-Vital tooth

for young permanent teeth

with open apex
Formocresol Pulpotomy
Indications:
TOOTH
1. Primary teeth
2. Permanent teeth where there
are financial constraints
Formocresol Pulpotomy
Indications:
PAIN
1. No extreme night pain
Formocresol Pulpotomy
Indications:
PAIN
2. No gingival pathology or
evidence of a chronic fistula
Formocresol Pulpotomy
Indications:
PAIN
3. No disagreeable odor from the
pulp chamber
Formocresol Pulpotomy
Indications:
RADIOGRAPHIC
1. Probable pulp exposure
2. Normal interradicular periapical tissues
3. Normal root development
Formocresol Pulpotomy
Indications:
RADIOGRAPHIC
4. No calcification in the pulp
chamber or root canal/s
5. No internal root resorption
6. No premature or abnormal external
root resorption
Procedure:
1. Local Anesthesia
2. Isolation
Procedure:
3. Caries excavation
Procedure:
4. Drop or access preparation
Procedure:
5. Deroofing and outline form
Procedure:
6. Pulp Amputation
Procedure:
6. Pulp Amputation
Procedure:
7. Hemostasis or Control the bleeding
Procedure:
8. Medicament application
Primary teeth
- use Formocresol (5 mins.) (2 to 3 mins.)
(1 mins.)
- used: mummify the pulp, devitalising
& bactericidal action
Formocresol Pulpotomy
Composition:
19% Formaldehyde
35% Tricresol
15% Glycerin
31% Water Base
Formocresol Pulpotomy
Objectives:
1. Amputate the infected coronal pulp
2. Neutralize any residual infectious process
3. Preserve the vitality of the radicular pulp
4. Avoid breakdown of periradicular area
5. Treat remaining pulp with medicament
6. Avoid dystrophic pulpal changes
Procedure:
8. Medicament application
Primary teeth
- apply IRM
Procedure:
8. Medicament application
Permanent teeth
- difference:
- use Calcium Hydroxide Powder
mix with:
1. Distilled water
2. Normal Saline Solution (NSS)
3. Anesthetic Solution
Procedure:
8. Medicament application
Permanent teeth
Procedure:
9. Final Restoration
Primary Teeth
a. Stainless Steel Crown
b. Amalgam
c. Composite or GIC
Procedure:
9. Final Restoration
Primary Teeth
a. Stainless Steel Crown
b. Amalgam
c. Composite or GIC
Permanent Teeth
a. Amalgam
b. Composite or GIC
Alternative For Formocresol
1. Calcium hydroxide
2. MTA
3. Glutaraldehyde
4. Viscostat
5. Ferric sulphate
6. Lasers & Electrosurgery
Laser Pulpotomy
Jeng - Fen Liu et al in 1999

Laser for pulpolomy in primary tooth,

Non pharmocologic hemostatic
technique -100% success with no
signs or symptoms.
Electro Surgery Pulpotomy
Mack & dean 1993

• non–pharmacological technique
• non-chemical devitalization whereas
mummification eliminates pulp
infection & vitality with chemical
cross-linking and denaturation
Electro Surgery Pulpotomy
Mack & dean 1993

Procedure

• after amputation of the coronal pulp

• the pulp stumps are cauterised
• the pulp chamber is filled with ZnOE
• restored with stainless steel crown
Electro Surgery Pulpotomy
Mack & dean 1993

Disadvantages;

• contaminated pulp tissue does not

promote adequate current
penetration. It cannot eliminate
radicular pulp inflammation.
Cause of Failure:

POOR or WRONG
DIAGNOSIS AND TREATMENT
SELECTION
Indications of Failure:
1. Increased mobility
2. Fistulous tract
3. Radiographic evidence of
interradicular or periapical pathology
4. Internal or external root resorption
5. Premature exfoliation
PULPECTOMY
 PULPECTOMY
- complete removal of infected coronal
and radicular pulp
 PULPECTOMY
Indications:
1. Primary incisors with periapical
pathology in a child under age 4
when esthetic is of prime concern.
 PULPECTOMY
Indications:
2. Primary 1st molars prior to eruption
of primary 2nd molars.
 PULPECTOMY
Indications:
2. Primary 1st molars prior to eruption
of primary 2nd molars.
Primary 2nd molars prior to
eruption of permanent 1st molars.
 PULPECTOMY
Indications:
3. Patient presents with history of
pain and or elevated temperature
 PULPECTOMY
Indications:
4. Clinical examination reveal the
tooth may be discolored, carious,
fracture or mobile.
 PULPECTOMY
Indications:
5. Gingival tissue may show varying
degree of abscess formation and
may be sensitive to percussion.
 PULPECTOMY
Indications:
6. Radiographic examination may reveal
periodontal ligament thickening and
periapical or furcation radioluscency.
 PULPECTOMY
Indications:
7. Roots not more than 2/3 resorbed.
 PULPECTOMY
Contraindications:
1. Non-restorable tooth
2. Pathology extending to the
developing teeth buds
3. Roots are more than 2/3 resorbed
4. Calcified root canals
5. Medically compromise or ill patient
like leukemia, RHD or Kidney disease.
Procedures:
First Appointment
Pre-working length measurement
Procedures:
First Appointment
1. Local Anesthesia
2. Isolation
Procedures:
First Appointment
3. Caries excavation
Procedures:
First Appointment
4. Drop or access preparation
5. Deroofing
Procedures:
First Appointment
6. Pulp extirpation
Procedures:
First Appointment
7. Irrigation
1. Sodium Hypochlorite
2. NSS
3. Dist. H20
Procedures:
First Appointment
8. Canal debridement
Procedures:
First Appointment
9. Dry the canal
Procedures:
First Appointment
9. Dry the canal
Procedures:
First Appointment
10. Obturation
- ZOE, Vitapex, Metapex or
Iodoform Paste
Procedures:
First Appointment
11. Obturation and Radiograph
Procedures:
First Appointment
12. Base
- put IRM
Procedures:
First Appointment
13. Final Restoration
- Composite, Amalgam and Crown
- post-radiograph
Procedures:
First Appointment
Wet Canal
1. Irrigate and dry
2. Dressing
a. ZOE
b. CMCP
c. Dry cotton
3. Temporary Filling
Procedures:
Second Appointment
1. Local Anesthesia
2. Isolation
3. Remove temporary filling
4. Evaluate the canal
5. Irrigate and dry
Procedures:
Second Appointment
6. Obturation
- ZOE, Vitapex, Metapex or
Iodoform Paste
7. Post radiograph
8. Final Restoration
APEXIFICATION
 APEXIFICATION

-for non vital young permanent

teeth with open apex.
 APEXIFICATION
Indications:
1. Patient presents with history of pain
and or elevated temperature

2. Clinical examination reveals the

tooth may be discolored, carious,
fracture or mobile.
 APEXIFICATION
Indications:
3. Gingival tissue may show varying
degree of abscess formation and may
be sensitive to percussion.

4.Radiographic examination may reveal

periodontal ligament thickening and
periapical or furcation radioluscency.
Procedures:
First Appointment
1. Local Anesthesia
2. Isolation
Procedures:
First Appointment
3. Caries excavation
Procedures:
First Appointment
4. Drop or access preparation
5. Deroofing
Procedures:
First Appointment
6. Pulp extirpation
Procedures:
First Appointment
7. Irrigation
Procedures:
First Appointment
8. Working length
9. Cleaning of the canal/s
Procedures:
First Appointment
10. Irrigation and dry
Procedures:
First Appointment
11. Obturation
- Calcium Hydroxide Powder mix
with:
a. Distilled water
b. Normal Saline Solution (NSS)
c. Anesthetic Solution
Procedures:
First Appointment
11. Obturation
Procedures:
First Appointment
12. Post radiograph
13. Restoration
14. Recall the patient
Procedures:
First Appointment
Wet Canal/s
1. Irrigate and dry
2. Dressing
3.Temporary Filling
Procedures:
Second Appointment
1. Local Anesthesia
2. Isolation
3. Remove temporary filling
4. Evaluate the canal
5. Irrigate and dry
6. Obturation
7. Post radiograph
8. Restoration
9. Recall the patient
Recall:
1. Take radiograph
2. Apical closure –proceed to Root
Canal Treatment
3. No apical closure –either repeat
procedure No. 3–9 or may not
Results may be:
Our Goal
Results may be:
Our Goal
Results may be:
1. No apparent closure of the apex but
there is resistance when a file is
inserted
1
Results may be:
2. Radiographic evidence of a
calcified bridge at the apex
1 2
Results may be:
3. Apical Closure without canal space
changes
1 2 3
 Results may be:
4. Normal continuance of apical
closure
1 2 3 4
Results may be:
5. Increased radiographic evidence
of a pathological change
5