Pulpotomy on temporary tooth
1- Introduction
According to the recommendations of the EAPD (European Academy of Pediatric Dentistry)
2016, in the face of all carious lesions in children and young adults, a clinical and radiographic diagnosis must be carried out and supplemented by an assessment of individual carious risk.
Pulpotomy is an endodontic procedure used in pediatric dentistry in the case of a deep carious lesion on a primary tooth where the coronal pulp is amputated and the vital radicular pulp is retained.
2-Decision-making factors to consider in the case of a deep carious lesion in temporary dentition
To do this, during the first session you must:
- An interview
- A clinical examination (complete exoral and intraoral)
- Appropriate additional examinations.
- Anamnesis/interview
-During the anamnesis, the child’s general health status must first be assessed. A collection of medical history, treatment(s), allergies is necessary in order to assess the risk of infection (which may be linked to a pathology or drug treatment) and the defense and healing capacities of the pulp-dentin complex which influence the prognosis of the therapy.
– Secondly, we must assess the child’s cooperation and anxiety: This is done either by hetero-assessment or self-assessment depending on the child’s age and ability.
– Thirdly, we must then assess the individual caries risk (ICR) which will influence the management, the treatment plan, the choice of materials and the frequency of follow-up visits.
– Finally, we must collect the patient’s symptoms and requests.
– These characteristics make it possible to distinguish reversible pulp inflammation from irreversible inflammation and to establish a presumptive diagnosis which will be confirmed by clinical examination.
2-2 Exoral examination
-During the exoral examination, the practitioner must check that there are no signs of manifestations of an infectious or inflammatory phenomenon such as: facial asymmetry, swelling, erythema, cervico-facial adenopathies.
2-3 Intraoral examination
The visual examination of the affected tooth must be carried out on a cleaned, dried tooth and with suitable light. During this visual examination, the location, severity and activity of the carious lesion must be detected.
-The ICDAS II (International Caries Detection and Assessment System) classification allows us to have
a first idea of the severity of the injury
-From a clinical point of view, in the case of an ICDAS 5 lesion, we can visualize a microcavity with dentin exposure. On the other hand, in the case of an ICDAS 6 lesion, we can visualize a dentin cavity extending to more than half of the coronal surface. These are called “severe” lesions.
-The activity of the carious lesion should be assessed; it may be active or inactive.
2-4 The paraclinical examination
Clinical tests can be performed and adapted according to the patient’s age. However, pulp sensitivity tests (hot, cold, electrical) are of little use and are not recommended in children and rarely allow the determination of pulp status.
2-5 X-ray
The decision factors to be assessed on x-ray are:
- The extent of the carious lesion and the thickness of residual dentin (RDT).
- An ICDAS/ICCMSTM (International Caries Classification and Management System) classification exists for radiographic evaluation.
- The indication for pulpotomy will be made during a class 5 or RC 6, from the carious involvement of the internal 1/3 of the dentin
- The physiological stage of the temporary tooth; there are 3 stages:
-Stage I or F (formation) which corresponds to the period from eruption until closure of the apex
-Stage II or S (stability) which is a phase of stability where the temporary tooth is mature, that is to say its apices are closed
-Stage III or R (resorption) which is characterized by rhizalysis which results in exfoliation of the temporary tooth. In stage III, pulp senescence reduces the repair potential of the pulp
- The presence of the successor tooth: In case of agenesis of the permanent tooth, it is preferable to preserve the temporary tooth in the long term. This is why Musale and Soni prefer to perform a pulpectomy with MTA or gutta percha filling instead of pulpotomy.
3- The objectives of pulpotomy
Pulpotomy is an endodontic procedure where the coronal pulp is amputated and the vital radicular pulp is retained.
This pulp treatment allows the vitality of the root pulp to be preserved by placing a biomaterial in the pulp chamber, allowing the formation of a dentin bridge between the pulp material and the root pulp.
This therapy also allows the tooth to be kept on the arch until its physiological exfoliation and thus preserves the function (mastication, phonation) and aesthetics, maintains the space, allows normal alveolo-dental growth, avoids malocclusions and guides the eruption of the permanent tooth.
4- Indications for pulpotomy
- a cavitary carious lesion, located in the 1/3 or 1/4 of the dentin, near the pulp or even the parapulp. On clinical and radiographic examination, this corresponds, in reference to the ICDAS II classification, to a severe carious lesion (ICDAS 5 and 6).
- Absence of clinical signs of irreversible pulpitis or pulp necrosis.
- Pulp exposure due to carious disease
- Iatrogenic pulp exposure during cavity preparation or partial curettage.
- Short-term traumatic exposure (less than 6 hours)
5- Contraindications
- General pathologies increasing the risk of infection in children.
- Lack of cooperation from the child
- Lack of consent from parents or legal guardian
- Pulpo-periodontal pathology that can alter the eruption of successive teeth (21)
- Periodontal disease, desmodontal enlargement
- Tooth mobility / physiological stage of the tooth: advanced stage III
- Irreversible pulpitis or pulp necrosis
- Tooth not restorable by direct restoration or by preformed pediatric crown
- Less invasive therapy indicated such as selective curettage
- The choice of pulp materials:
The materials placed in the pulp cavity following pulpotomy treatment must meet several criteria:
-Ensure watertightness, immediate sealing of the root pulp
-Be biocompatible, non-toxic in order to preserve pulp vitality and not its degeneration.
-Possess antimicrobial properties.
-Have bioactive properties in order to obtain a mineralized barrier between the biomaterial and the root pulp tissue
-MTA is the most recommended material for Pulpotomy by the AAPD (30), and described as the “gold standard”
- Clinical protocol
- Conclusion
In conclusion, let’s remember that pulpotomy on temporary teeth remains a preventable pulp therapy if effective prevention measures are implemented. Thus, follow-up with check-ups every six months to a year with a dentist allows for preventive action and reduces invasive procedures.
Pulpotomy on temporary tooth
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