The major concern after pulpal exposures in immature teeth is the prevention of
physical, chemical, and microbial invasion and the preservation of pulpal vitality in
order to allow continued root growth. The radicular pulp has enormous capacity to
remain healthy and undergo repair if all infected and inflamed coronal tissue is
removed and an appropriate wound dressing and sealing coronal restoration is
applied. Pulp amputation by partial pulpotomy or complete coronal pulpotomy is
often the treatment of choice but pulp capping can be considered in certain
circumstances.
Vital pulp therapy
- Pulp capping
- Pulpotomy ← partial/complete
Non-vital pulp therapy
- Pulpectomy
VITAL PULP THERAPY⎯PULP CAPPING
The procedure must be done within 24 h of the incident. The tooth should be isolated
with rubber dam and no instruments should be inserted into the exposure site. Any
bleeding should be controlled with sterile cotton wool which may be moistened with
saline or sodium hypochlorite, and not with a blast of air from the 3 in 1 syringe
which may drive debris and micro-organisms into the pulp. A layer of setting calcium
hydroxide cement is gently flowed onto the exposed pulp and surrounding dentine
quickly overlaid with a 'bandage' of adhesive material. for example, compomer
pending definitive aesthetic restoration at a later date. A successful direct pulp cap
will preserve the remaining pulp in health and should promote the deposition of a
bridge of reparative dentine to seal off the exposure site.
Review after a month, then 3 months, and eventually at 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. On the radiograph check the following:
- root is growing in length;
- root canal is maturing (narrowing);
- Compare with antimere.
If growth is not occuring the pulp should be assumed to be non-vital.
VITAL PULP THERAPY⎯PULPOTOMY
In pulpotomy a portion of exposed vital pulp is removed to preserve the radicular
vitality and allow completion of apical root development (apexogenesis) and further
deposition of dentine on the walls of the root. This procedure is the treatment of
choice following trauma where the pulp has been exposed to the mouth for more than
24 h.
Operative procedure (696HFig. 12.20)