Braz Dent J (2007) 18(3): 244-247
Importance of the Diagnosis in the Pulpotomy
of Immature Permanent Teeth
1School of Dentistry, University of Ribeirão Preto, Ribeirão Preto, SP, Brazil
2School of Dentistry, Bahia State Foundation for Science Development, Salvador, BA, Brazil
3School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
Pulpotomy is a conservative therapy performed to remove the inflamed coronal portion of the pulp and preserve the vitality of theremaining radicular pulp. This article reports two cases of immature permanent mandibular molars with clinical signs of pulp vitalityand radiographic images of periapical bone rarefaction, which were treated with calcium hydroxide pulpotomy. In Case 1, pulpotomywas performed in a single session, while in Case 2 two sessions were required to complete the treatment. Clinical and radiographicfollow up within 13 and 9 months, respectively, showed hard tissue barrier and new bone formation as well as progression of rootdevelopment. These outcomes are confirmatory that an accurate clinical/radiographic assessment of pulp vitality is of paramountimportance for the correct diagnosis and indication of pulpotomy in cases of young permanent teeth with incomplete root formation.
Key Words: pulpotomy, diagnosis, calcium hydroxide, periapical lesion.
should aim at its complete repair and formation of amineralized barrier that covers the exposed area com-
The dental pulp is an innervated and vascularized
tissue that is able to react to physical, chemical and
Pulpotomy comprises coronal pulp amputation
biological stimuli and promote an adequate healing, with
and placement of a protective agent over the remaining
formation of a hard tissue barrier (1). If the stimulus or
viable root pulp in order to preserve its vitality and
damage is severe, the pulp healing capacity may be
function (2,3). It is indicated for primary or young
exceeded and it may progress to an irreversibly inflamed
permanent teeth with inflamed and/or infected coronal
condition and to necrosis. However, if pulp exposure is
pulp. However, the presence of periapical rarefaction
discrete in primary or young permanent teeth, some
has been presented as a condition that contraindicates
procedures may be performed in an attempt to reestablish
pulpal health and maintain its vitality (1-3).
By presenting two cases of immature permanent
Pulp exposure is defined in the MeSH (Index
mandibular molars with radiographic image of periapi-
Medicus: Medical Subject Headings) as “the result of
cal lesion submitted to calcium hydroxide pulpotomy,
pathological changes in the hard tissue of a tooth caused
the purpose of this article is to discuss, based on the
by carious lesions, mechanical factors or trauma, which
treatment outcomes and on the literature, whether
render the pulp susceptible to bacterial invasion from the
periapical bone rarefaction is actually a contraindication
external environment”. The treatment of pulp exposure
Correspondence: Prof. Ronaldo Araújo Souza, Avenida Paulo VI, 2038/504, Ed. Villa Marta, 41810-001 Salvador, BA, Brasil. Tel/Fax:+55-71-3358-5396. e-mail: [email protected]
Diagnosis and pulpotomy of immature permanent teeth
face due to the drainage of an extraoral fistula. Thepreoperative radiograph showed a furcation lesion com-
municating with the a periapical lesion associated with
A 7-year-old female patient was referred for
the distal root of that tooth (Fig 2A). After anesthesia,
treatment of the mandibular left first molar that pre-
rubber dam placement and carious tissue excavation,
sented a deep caries and radiographic image suggestive
access to pulp chamber was gained. A vital pulp tissue
of periapical lesion (Fig. 1A). Pulp vitality test was not
was observed with normal consistence and bleeding
performed because of the clinical aspect of the carious
lesion associated with the well-defined image of periapi-
As the patient was uncooperative, pulpotomy
was scheduled as two-session procedure. In the first
After anesthesia, rubber dam placement and
session, the coronal pulp was partially excised with
carious tissue excavation, access to pulp chamber was
sharp curettes under copious irrigation with calcium
gained. A vital pulp tissue was observed with normal
hydroxide solution alternated with aspiration. After
consistence and bleeding characteristics. The coronal
hemostasis, the remaining coronal pulp tissue was dried
pulp was excised with sharp curettes under copious
pressureless with sterile cotton pellets and protected
irrigation with calcium hydroxide solution alternated
with a calcium hydroxide/saline paste. The pulp cham-
with aspiration. After hemostasis, the area of the ex-
ber was provisionally sealed with the quick-setting zinc
posed root pulp tissue was dried pressureless with
oxide and eugenol-based cement (Fig. 2B).
sterile cotton pellets and the pulp chamber floor was
At the second session, the patient was anesthe-
capped with a calcium hydroxide/saline paste, sealing
tized, a rubber dam was placed, the provisional restora-
root canal entrances. A sterile cotton mesh was placed
tion was removed and pulpotomy was completed in the
over the paste and the pulp chamber was sealed with a
same way as performed in the first session. The distal
quick-setting zinc oxide and eugenol-based cement
root canal presented darkened bleeding and the pulp
tissue was less resistant to cutting with the curettes.
The periapical radiographs taken 13 months after
Thus, pulp amputation proceeded 2 mm beyond the
pulpotomy revealed complete regression of the periapical
canal entrance, at which point normal live red bleeding
lesion with periradicular bone tissue formation, normal
and resistance to cutting were observed.
root development and recovery of the apical periodontal
After hemostasis, the area of the exposed root
ligament space and lamina dura (Figs. 1B and 1C).
pulp tissue was dried pressureless with sterile cottonpellets and the pulp chamber floor was covered with a
calcium hydroxide/saline paste, sealing root canal en-
A 6-year-old male patient was referred by the
trances. A sterile cotton mesh was placed over the paste
periodontist with a dressing on the lower right side of the
and the pulp chamber was sealed with the quick setting
Figure 1. Radiographic follow-up of a pulpotomized immature permanent mandibular left first molar with vital pulp. (A) Preoperativeperiapical radiograph showing periapical bone rarefaction. (B) Radiographic aspect after calcium hydroxide pulpotomy. (C) Thirteen-month control radiograph, showing resolution of the periapical lesion, normal root development, recovery of the apical periodontalligament space and lamina dura on both roots.
zinc oxide and eugenol-based cement (Fig. 2C).
response to persist and extend to a more apical portion
The periapical radiographs taken 9 months after
of the pulp tissue. This process is repeated successively
pulpotomy revealed complete regression of the periapi-
until the entire pulp tissue is affected (5).
cal and furcation lesions, formation of a hard tissue
In some cases, especially in immature teeth,
barrier and normal root development (Fig. 2D).
before pulp necrosis is completed, chemical mediatorsof bone resorption, enzymes and products from protein
decomposition may cross the remaining healthy pulptissue and cause periradicular alterations (6). Thus, in
Caries progression and pulp exposure permit
spite of their vitality, these teeth develop periapical
microbial invasion into the pulp chamber and vascular
lesions, as shown in both cases reported in this article.
and tissue alterations become strongly evident. The
Therefore, a correct diagnosis is of paramount
severity of the inflammatory response increases pro-
importance for institution of the most indicated treat-
gressively, leading to pulp necrosis and formation of
ment modality. Clinical examination, comprising caries
micro-abscesses. Pulp alterations are, however, local
excavation and observation of sensitivity on tissue
events (5). As the inflammatory reaction becomes
removal, palpation of vestibules and pulp vitality tests
stronger, a greater amount of chemical mediators and
should preceede the radiographic examination in the
enzymes is released, which causes the inflammatory
Figure 2. Radiographic follow-up of a pulpotomized immature permanent mandibular right first molar with vital pulp. (A) Preoperativeperiapical radiograph showing furcation lesion communicating with a periapical lesion on the distal root. (B and C) Radiographic aspectafter calcium hydroxide pulpotomy (note that the deeper level of pulp amputation in the distal root). (D) Nine-month controlradiograph, showing resolution of the furcation and periapical lesion and normal root development.
Diagnosis and pulpotomy of immature permanent teeth
Several materials have been used as pulp-capping
pela técnica da pulpotomia com hidróxido de cálcio. No caso 1 a
agents in pulpotomized teeth, among which formocresol,
pulpotomia foi realizada em sessão única e no caso 2 em duassessões. A proservação clínica e radiográfica com 13 e 9 meses,
calcium hydroxide, ferrous sulfate and more recently
respectivamente, evidenciou formação de barreira mineralizada,
mineral trioxide aggregate (1,3,4,7,8). Some of these
neoformação óssea e desenvolvimento radicular. Conclui-se que a
materials, like calcium hydroxide, are able to induce the
avaliação clínica da vitalidade pulpar, complementada pela análise
formation of a hard-tissue tissue barrier (1,3,8). In
radiográfica, é fundamental para o correto diagnóstico e indicaçãode pulpotomia em casos de dentes permanentes jovens com
addition to this property, calcium hydroxide is also
capable of stimulating pulp tissue repair and presents thebest pulp capping outcomes (1,8-12).
When calcium hydroxide is placed in direct
contact with the pulp tissue, there is an immediate and
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A pulpotomia é uma terapia conservadora indicada para dentes
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vitais com alterações inflamatórias da polpa dental coronária.
Esse artigo relata dois casos de molares inferiores com rizogêneseincompleta e imagem radiográfica de rarefação periapical que,
clinicamente, apresentavam vitalidade pulpar e foram tratados
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