Partial pulpotomy for immature permanent teeth, it’s present and future

Resident: J. Hencler
Date: 10/27/2010

Article title: Partial pulpotomy for immature permanent teeth, it’s present and future
Author(s): Fong, Davis
Journal: Pediatric Dentistry 24:1, 2002

Major topic: Pulp treatment options
Type of Article: Review Article

Main Purpose:
Review the application of partial pulpotomy in immature permanent teeth and provide prognostic and technical guidance.

Background:
In a mature tooth w/ fully formed roots, an exposed pulp should be completely removed, and the root canals should be obturated permanently. However definitive RCT in an immature tooth will arrest dentin deposition, resulting in a root w/ a thin dentinal wall and predisposed to fracture. Therefore it is appropriate to preserve as much vital pulp as possible, which will enable continued dentin deposition and root formation. There are 3 techniques available for tx of immature teeth w/ exposed vital pulps: direct pulp capping, complete pulpotomy, and partial pulpotomy. Direct pulp capping is considered to be so unpredictable that several authors suggest it be removed from tx consideration. Complete pulpotomy will arrest dentin formation in immature permanent teeth and can result in root canal obliteration. It should be followed with complete endo when root development is complete. Partial pulpotomy is the removal of the outer layer of damaged, hyperemic tissue in exposed pulps. Recent reports of partial pulpotomy for teeth w/ cariously exposed pulps and crown fracture exposed pulps have shown high success rates and good results. Indications for permanent tooth partial pulpotomy include: 1) tooth has no hx of spontaneous pain, 2) tooth has acute minor pain that subsides w/ analgesics, 3) tooth has no discomfort to percussion, no vestibular swelling, and no mobility, 4) radiographic exam shows normal PDL, 5) pulp is exposed during caries removal or recent trauma, 6) tissue appears vital, 7) bleeding from pulp excision site stops with isotonic saline irrigation w/in 2 mins.

Partial Pulpotomy Technique:
LA, RDI, smooth sharp edges or remove caries. The exposed pulp and surrounding dentin are flushed clean with isotonic saline solution. The superficial layer of exposed pulp and surrounding dentin are excised to a depth of about 2mm using a high-speed sterile diamond bur w/ light touch and waterspray cooling. The remaining is irrigated gently w/ isotonic saline until bleeding has stopped and a pulpal medicament containing CaOH is applied to the wound surface. Care should be taken to avoid a blood clot. Dry, sterile cotton pellets are used to apply modest pressure to adapt the medicament to the prepared cavity and to remove excess water from the paste. The remaining coronal cavity is restored with a material that provides a long-term seal to avoid subsequent leakage.

Discussion:
When considering a tooth w/ pulp exposure the most important factor in determining tx is degree of infection and inflammation. Studies show that in the pulp subjacent to a carious lesion, just prior to or soon after pulp exposure, bacterial components cause local irreversible changes, abscesses or necrosis just beneath the exposure. The deeper remaining pulp continues to be free from significant inflammatory changes. When pulpal infection and/or inflammation are restricted to the coronal portion of the pulp chamber, unaffected healthy pulp tissue remains in the deeper portion of the root canal system. Theoretically, removal of the compromised/infected tissue should lead to preservation of a remaining vital, functioning pulp. Currently, the pulpal dx is based on the extent of pulpal hemorrhages. Failur of bleeding to stop after 2 min of saline irrigation reveals an extensive pulpal inflammation and suggests that more tissue needs to be removed or instead another procedure such as a complete pulpotomy is indicated. In trauma cases, reports show that time b/t injury and tx actually has limited influence on the outcome of partial pulpotomy. Partial pulpotomy, rather than direct pulp capping or complete pulpotomy, is the tx of choice following traumatic or carious pulp exposure in immature permanent teeth. Size of the pulp exposure plays a limited role in tx decision, instead the condition of the pulp and the degree of bacterial contamination largely determine the progress of vital pulp tx. One of the advantages of partial pulpotomy is the preservation of cell-rich coronal tissue, which possesses better healing potential and can maintain the deposition of dentin in the cervical area. Healing of the dental pulp after tx is dependent on the capacity of restorative material to seal and prevent leakage and bacterial invasion.

Summary of conclusions:
Partial pulpotomy is a worthy alternative to direct pulp capping and complete pulpotomy when tx immature permanent teeth with exposed pulps.

Assessment of article:
Great review article, very interesting. I wish it offered more info on available medicaments used during partial pulpotomies