PAEDIATRIC DENTISTRY - 3rd Ed. (2005)

(John Hannent) #1

  • Under local anaesthesia and rubber dam, pulp tissue is excised with a diamond bur
    running at high speed under constant water cooling. This causes least injury to the
    underlying pulp and is preferred to hand excavation or the use of slow-speed steel
    burs.

  • Microbial invasion of an exposed, vital pulp is usually superficial and generally
    only 2-3 mm of pulp tissue should be removed (partial pulpotomy [Cvek]).

  • Excessive bleeding from the residual pulp which cannot be controlled with moist
    cotton wool, or indeed no bleeding at all, indicates that further excision is required to
    reach healthy tissue (coronal pulpotomy).

  • Removal of tissue may occasionally extend more deeply into the tooth (full coronal
    pulpotomy) in an effort to preserve the apical portion of the pulp and safeguard apical
    closure.

  • Gently rinse the wound with sterile saline or sodium hypochlorite (1-2%)and
    remove any shredded tissue. All remaining tags of tissue in the coronal portion must
    be removed as they may act as a nidus for re-infection, and a pathway for coronal
    leakage.

  • Apply a calcium hydroxide dressing to the pulp to destroy any remaining micro-
    organisms and to promote calcific repair. In superficial wounds, a setting calcium
    hydroxide cement may be gently flowed onto the pulp surface, but if the excision was
    deep, it is often easier to prepare a stiff mixture of calcium hydroxide powder
    (analytical grade) in sterile saline or local anaesthetic solution, which is carried to the
    canal in an amalgam carrier and gently packed into place with pluggers.

  • Overlay the calcium hydroxide dressing with a hard cement to prevent its forceful
    injection into the pulp by chewing forces and a final adhesive restoration which will
    seal the preparation against the re-entry of micro-organisms.


REVIEW



  • after a month,

  • 3 months,

  • 6 monthly intervals for up to 4 years in order to assess pulp vitality,

  • periodic radiographic review should also be arranged to monitor dentine bridge
    formation, root growth, and to exclude the development of necrosis and resorption. If
    vitality is lost, non-vital pulp therapy should be undertaken whether or not there is a
    calcific bridge (see below),

  • success rates for partial (Cvek) pulpotomies are quoted at 97%. Those for coronal
    pulpotomies at 75%.


Elective pulpectomy and root canal treatment of a vital pulp may be considered at a
later date only if the root canal is required for restorative purposes.


Key Point
Pulpotomy procedures



  • Give a better prognosis than pulp capping for small exposures exposed for more
    than 24 h,

  • are not recommended if there are signs and symptoms of radicular pathosis.


NON-VITAL PULP THERAPY⎯PULPECTOMY
Premature loss of pulp vitality leaves a thin and relatively weak tooth structure which
should not be weakened further by excessive dentine removal during canal

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