etching and sealing with a dentine-bonding agent has been tried but this resulted in
increased non-vitality, so it is now contraindicated. As in traumatic exposures, pulp
capping has given disappointing results compared with the technique of partial
pulpotomy, so should only be used if a pulpotomy cannot be performed.
For all techniques in which the pulp is preserved it is important to assess the situation
correctly before embarking on the treatment:
- There should be no history of spontaneous pain.
- There should be no swelling, mobility, discomfort to percussion.
- A normal periodontal appearance should be present radiographically.
- Pulp tissue should appear normal and vital.
- Cessation of bleeding from the pulp exposure site should occur with isotonic
irrigation within 2 min.
Pulpotomy
Pulpotomies are successful in young teeth due to their increased pulpal circulation and
ability to repair. The procedure consists of applying rubber dam after local analgesia
and then clearing all lateral margins around the exposure and the pulpal floor of any
caries. The superficial layer of the exposed pulp and the surrounding dentine are
excised to a depth of 2 mm using a high speed diamond bur. The technique is the
same as the Cvek pulpotomy described in 473HChapter 12 for pulp exposure in
traumatized teeth. Only tissue judged to be inflamed should be removed. Whether
sufficient tissue has been removed is ascertained by gently irrigating the remaining
pulp surface with isotonic saline until bleeding stops. If bleeding does not cease
easily, it is probable that the tissue is still inflamed and a further millimetre of pulp
tissue is removed. Similarly if there is no bleeding at all then further pulp tissue
should be removed until bleeding is found. After haemostasis has been obtained a
soluble paste of calcium hydroxide is applied to the wound surface. It is important
that there is no blood clot between the wound surface and the dressing as this will
prevent repair and reduce the chances of success. Recently, MTA (mineral trioxide
aggregate) has been proposed for pulp capping and pulpotomy dressings, but most of
the published studies so far on this topic have been performed on animals. Hence at
present calcium hydroxide, the tried and tested remedy should still be used. In order to
aid repair, the clinician should apply dry sterile pellets of cotton wool carefully with
modest pressure to adapt the calcium hydroxide medicament to the prepared cavity
and remove excess water from the paste.
As in pulp capping it is essential that the operator fills the cavity with a material that
provides a good hermetic seal. The latter can be the final restoration as there is no
need to re-enter the wound site. Although the presence of a dentinal bridge
radiographically represents a success, its absence does not indicate failure. After a
year, success is represented by a tooth where there are no signs of clinical or
radiographic pathology and where the root has developed apically and thickened
laterally. The pulpotomy technique has much to recommend it, viz. a good success
rate and continued root development. It is therefore considered the treatment of choice
when there has been a pulp exposure in an immature permanent tooth.(See 474HFigs. 9.34,
475H9.35, 476H9.36, 477H9.37, and 478H9.38.)