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 CASE REPORT
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 DISCUSSION
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 1. Albuquerque DS, Gominho LF, Santos RA. Histologic evalua- short-term tissue reaction supposedly caused by its high tion of pulpotomy performed with ethyl-cyanoacrylate andcalcium hydroxide. Braz Oral Res 2006;20:226-230.
alkalinity. This alkaline effect is due to the release of 2. Markovic D, Zivojinovic V, Vucetic M. Evaluation of three hydroxyl ions, which, in contact with the vital tissue, pulpotomy medicaments in primary teeth. Eur J Paediatr produce morphological changes that are histologically 3. Huth KC, Paschos E, Hajek-Al-Khatar N, Hollweck R, Crispin characterized by the presence of self-limiting superficial A, Hickel R, Folwaczny M. Effectiveness of 4 pulpotomy necrosis in their early stage (13). Moreover, it has been techniques-randomized controlled trial. J Dent Res reported (14) that the alkaline environment avoids bac- 4. Olsson H, Petersson K, Rohlin M. Formation of a hard tissue terial proliferation, which is of paramount importance barrier after pulp capping in humans. A systematic review. Int because tissue repair and mineralized tissue deposition only occur in the absence of an infectious process.
5. Ricucci D. Apical limit of root canal instrumentation and obturation, part 1. Literature review. Int Endod J In vivo studies (1,8) have demonstrated that calcium hydroxide is an excellent choice for cases of 6. Langeland K. Management of the inflamed pulp associated pulpotomy, present high rates of hard tissue barrier with deep carious lesion. J Endodon 1981;7:169-181.
formation and sealing of pulp exposure, maintaining the 7. Cengiz SB, Batirbaygil Y, Onur MA, Atilla P, Asan E, Altay N, Cehreli ZC. Histological comparison of alendronate, calcium integrity and vitality of the remaining root pulp. Accord- hydroxide and formocresol in amputated rat molar. Dental ingly, in both cases reported in this article, hard-tissue barrier and periapical new bone formation was observed 8. Tunç ES, Saroglu I, Sari S, Günhan Ö. The effect of sodium hypochlorite application on the success of calcium hydroxide in addition to normal root development.
pulpotomy in primary teeth. Oral Surg Oral Med Oral Pathol In view of this, it may be concluded that the diagnosis of pulp and/or periradicular alterations in 9. Trope M, McDougal R, Levin L, May KN, Swift EJ. Capping the inflamed pulp under different clinical conditions. J Esthet immature permanent teeth should not rely exclusively on radiographic findings. A detailed clinical examination, 10. Hörsted-Bindslev P, Vilkinis V, Sidlauskas A. Direct capping of comprising pulp vitality, percussion and palpation tests, human pulps with a dentin bonding system or with calcium should be complemented by the evaluation of character- hydroxide. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2003;96:591-600.
istics such as pulp firmness (resistance to cutting with 11. Conrado CA. Remineralization of carious dentin. I: In vitro curettes), color and type of bleeding. With proper case microradiographic study in human teeth capped by calcium selection and indication, calcium hydroxide pulpotomy hydroxide. Braz Dent J 2004;15:59-62.
12. Briso AL, Rahal V, Mestrener SR, Dezan Junior E. Biological may be a feasible and valuable treatment modality for response of pulps submitted to different capping materials.
immature permanent teeth, even those associated with a radiographic image suggestive of periapical lesion.
13. Schröder U. Effects of calcium hydroxide-containing pulp- capping agents on pulp cell migration, proliferation, anddifferentiation. J Dent Res 1985;64:541-548.
14. Cvek M. Treatment of non-vital permanent incisors with calcium hydroxide. Odont Rev 1972;23:27-44.
A pulpotomia é uma terapia conservadora indicada para dentes 15. Caliskan MK. Pulpotomy of carious vital teeth with periapical involvement. Int Endod J 1995;28:172-176.
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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