CSL 10 pulpotomy ( easy)

Chief Complaint

• Pain while eating, subsiding after a few minutes without analgesics.

Examination

• Extra-oral and intra-oral soft and hard tissues examined.

Investigations

• Periapical radiograph taken.
• Bitewing radiograph taken to visualize the involved tooth, furcation, periapical area, and surrounding bone.

Diagnosis

• Reversible pulp inflammation.

Pulp Therapy

• Pulpal therapy determined by pulp vitality (vital or non-vital). Normal pulp is symptom-free and responsive to vitality testing.
• Reversible pulpitis means the pulp can heal, and symptomatic or asymptomatic pulpitis involves a vital inflamed pulp that cannot heal, or a necrotic pulp.

Clinical Diagnosis

• Comprehensive medical history taken.
• Past and present dental history reviewed, including current symptoms and chief complaint.
• Subjective evaluation of the area associated with pain in terms of location, intensity, duration, stimulus, relief, and spontaneity.
• Objective extraoral and intraoral examination of soft and hard tissues performed.
• Radiographs taken when possible to diagnose pulpitis or necrosis of the involved tooth.
• Clinical tests conducted, including palpation, percussion, and mobility testing.
• The combination of history, clinical examination and radiographs together gives an approximate diagnosis.

Diagnosis and Pulpal Treatment Planning

• Clinical history includes history of pain and symptoms of pain.
• Spontaneous, throbbing pain simulating irreversible pulp condition occurs when food impaction affects the inflamed inter-dental gingiva.

Clinical Assessment

• Assessment of tooth includes checking for abscess, excessive mobility, swelling or if there is tenderness to percussion.
• Examination of the extent of marginal ridge breakdown and the site of caries (occlusal or proximal). Also an assessment for missing or fractured restorations.

Mobility

• Comparison of mobility of the tooth with its contralateral tooth is important. Significant differences may indicate pulpal disease and abnormal mobility in the normal time of exfoliation is not usually problematic.

Percussion Test

• Sensitivity to percussion may reveal a painful tooth in which inflammation of the periodontal ligament has progressed to involve the apical periodontitis.
• Percussion should be done very gently.

Electrical and Thermal Tests

• Electrical and thermal tests are not helpful clinically when diagnosing a painful tooth and can produce false positive results due to apprehension.

Radiographic Assessment

• High-quality bitewing radiograph taken.
• Perifurcational pathology and internal resorption in the root canal are noted in the radiograph.

Operative Diagnosis

• Acute inflammation and pain, with exposed pulp tissue in the pulpotomy, persistent bleeding.

Treatment Options (Table)

• Table shows various treatment options (caries removal, pulpotomy, vital pulpotomy, non-vital pulpotomy, extraction) based on different clinical scenarios. Options are listed depending upon the extent of root breakdown.

Pulpotomy Treatment Objectives

• Eradication of infection.
• Maintenance of tooth in a quiescent state.
• Preservation of space for underlying permanent teeth.
• Retention of primary tooth in case the permanent tooth is congenitally absent.

Indications for Pulpotomy

• Deep caries without pulp exposure is an indication.
• Carious or traumatic pulp exposures with transitory thermal and/or chemical stimulated pain.
• Physiologically mobile teeth with normal soft tissues, no percussion sensitivity (except in cases of food impaction) that show an intact continuous ligament space and intact periapical and/or furcation bone.

Confours in Pulp Status Diagnosis

• Color of pulpal hemorrhage is not a reliable indicator of pulp histological status.
• Excessive bleeding is strongly correlated with degenerative changes.
• Different types of carious pulp exposure have varying aspects of normal and abnormal pulps.

Must for Successful Pulp Therapy

• Co-operation
• Local anesthetic
• Rubber dam placement
• Post-operative restoration
• Follow-up

Steps of Pulpotomy

• Local anesthetic administration and isolation.
• Caries removal, and identification of pulp exposure or access to the pulp chamber.
• Complete removal of the roof of the pulp chamber, but not deeper.
• Removal of the coronal pulp using a large spoon excavator or round bur.
• Application of saline cotton pellet for one minute.
• Application of medication.
• Pulp chamber filling with ZOE cement, condensed with damp cotton pledget.
• Placing a coronal restoration using SSC.

Materials for Pulpotomy

• Ferric sulphate.
• MTA.

Ferric Sulphate

• Current gold standard, applied to radicular pulp, for 15 seconds.
• Creates ferric ion protein complex sealing cut vessels.
• Astringent to stop hemorrhage.

Problems

• Perforating the pulpal floor.
• Approximately at the gingival margin.

Safe Ended Burs

• Tungsten carbide (Endo-Z bur).
• Diamond abrasive bur.

Additional Considerations

• Additional images and notes provide details of dental procedures, highlighting important aspects such as locating the canal orifices.