 Welcome to Peter Don't Take Lecture Series. Today let's learn about pulpotamy. What is pulpotamy? Where is it indicated? It's contraindication. How is it classified and what are the medicaments used in this procedure? We know that the tooth consists of coronal pulp as well as your radicular pulp. As you can see in this picture the coronal pulp and this will be your radicular pulp. So in pulpotamy we are dealing with amputation of affected coronal portion of pulp and replacing it with the suitable medicament. We are completely removing the coronal pulp and we are replacing it with suitable medicaments. So let's see how is it defined. It is defined as a complete removal of the coronal portion of the dental pulp followed by placement of suitable dressing or medicament that will promote healing and preserve the vitality of the tooth. The objective of this procedure is to maintain the tooth and preserve the vitality of the tooth. Let's see where all it is indicated. It is indicated in deep pentane and caries which is involving the coronal pulp and the radicular pulp is unaffected. When there is mechanical exposure of the pulp that is when we are removing the caries and accidentally the pulp gets exposed and this pulpotamy treatment is specific when we need to maintain the tooth more than extracting it. And also you will check based on the history of the patient that is pain. The pain should not be spontaneous nor persistent after the removal of the stimulus and tooth should be restorable tooth with tooth fur of the root length and you also check clinically by checking the hemorrhage that is bleeding. If the bleeding is pale red or if it can be controlled easily then we will go ahead with the pulpotamy procedure. So where all it is indicated? Where all it is contraindicated? In persistent toothache, tenderness on percussion or mobility present, root reduction more than one third of the root length, large carious lesion with non-restorable crown, highly viscous sluggish hemorrhage from canal orifice which is uncontrollable and tooth which is close to natural exfoliation. So let's see how this pulpotamy is classified. It is classified into two types that is vital pulpotamy and non-vital pulpotamy. This vital pulpotamy is further classified as de-vitalization pulpotamy, preservation pulpotamy and regeneration pulpotamy. And the non-vital pulpotamy is also called as mortal pulpotamy. There are different materials which you can use for different pulpotamy. So one doubt we get is when do we have to do non-vital pulpotamy. That I will be telling in the further slides. So now let's see the medicaments used in this procedure. First one is formacrizole which is introduced in the year 1894 and in the 1904 the bulky popularized this formacrizole. So it is called as bulky formacrizole solution which consists of formalin, 19% tri-crizole, 35% glycerin, 15% and water, 31%. So here the glycerin is added to prevent the polymerization of formaldehyde to paraformaldehyde which happens if what happens to the paraformal dehyde is present. It causes clouding of the solution. That is the reason glycerin is added. So let's see its advantage and disadvantages. So the advantage includes it is a commonly used or available medicament. It is stable at room temperature, long shelf life, high clinical and radiographic success of the formacrizole pulpotamy. Disadvantages include it is a very caustic medicament and if you use in high doses it is toxic, it causes potential systemic absorption and distribution throughout the body. It has a mutagenic as well as carcinogenic potential. So let's see how this technique is performed. So in any palp therapy procedure anesthesia is must. Okay so we need to first anesthetize the tooth then we need to isolate the tooth which has to be treated with your rubber dam. We excavate all the caries if it is soft with your spoon excavator or you can go ahead with your aerota and then remove the dentin roof of the palp chamber with your high speed non-end cutting bar and copious water spray has to be done. Remove all the coronal palm tissue with a slow speed that is with your number six or number eight round bar or a sharp spoon excavator. Once the cavity is prepared we need to achieve a hemostasis that is using your moist cotton pellet. So take your small cotton pellet dip it in the formacrizole squeeze it and then place it in the palp chamber for about four minutes. Okay once you place this you remove after four minutes and check for the hemostasis. If the bleeding isn't stopped then this tooth is not indicated for your pulpotomy. If the bleeding has stopped then you can go ahead with the pulpotomy procedure. Once this hemostasis is achieved or when the blood is stopped you can place a zinc oxide eugenol either completely or you can put zinc oxide eugenol as a base and then you can restore it with your GIG material and once this is done immediately you can place your stainless steel crown. So this picture summarizes the procedure using formacrizole that is first one says remove the caries complete removal of your coronal pulp then place the cotton pellet which is wetted with formacrizole solution for four minutes once the hemostasis is achieved the restoration is done with zinc oxide eugenol and finally the stainless steel crown is placed. The second agent that is glutaraldehyde. Glutaraldehyde is a common fixative which has been suggested as an alternative to formacrizole for the various pulp treatment modalities. It has a limited shelf life. Let's see how does it work. It produces a rapid surface fixation of the underlying pulpal tissue so it causes a narrow zone of eosinophilic stained and compressed fixed tissue which is found directly beneath the area of application which blends into the normal vital normal appearing tissue apically. With time this glutaraldehyde fix zone is replaced by collagenous tissue that's the entire root canal tissue is vital. The procedure is same as formacrizole once the hemostasis is achieved 2 to 5 percent of glutaraldehyde is applied to the pulp by cotton pellet for five minutes as it causes minimum alteration to the pulpal tissue. The cavity is then sealed with zinc oxide eugenol and then the tooth is restored with stainless steel crown. Let's see its advantages and disadvantages. The advantages includes reaction with pulp is reversible. Molecules of glutaraldehyde do not diffuse out of apical foramin. It fixes tissue instantly and excess solution is unnecessary. It is not known to be cytotoxic neutrogenic or carthenogenic and it has no known systemic toxic effects. So the disadvantages includes it is expensive and it also causes irritation which results in an internal resorption. The next agent is your calcium hydroxide. This calcium hydroxide is antibacterial which causes an antibacterial effect as well as it possesses an ideal pH which has been offered as a prime reason for its effectiveness. The next is your ferric sulphate. It is a non-haldehyde chemical which has received attention as a pulpotomy agent. It is it was proposed as a pulpotomy medicine for vital primary teeth. A coagulative and a hemostatic agent in dentistry it showed promising results as a dressing material for the primary teeth pulpotomies. So let's see how does this work. The ferric and the sulphate ions causes an agglutination in the blood proteins. Okay this ferric ion protein complex mechanically seals the cut vessels thus produces the hemostasis. By forming the plugs that occlude the capillary orifices the protein complex also prevents the formation of blood clots thereby minimizing the risk of inflammation and internal resorption in the pulp therapy. So let's see the procedure. Hemorrhage is controlled by using a sterile cotton pellet under a slight pressure for 3 to 5 minutes. A solution of 15.5 percent ferric sulphate is applied for 15 seconds. You have to note this it is 15 seconds but whereas your formacosol was for 4 minutes this is 15 seconds on the pulp stems using a cotton pellet. Upon removal of the cotton pellet the wound may appear brown and no bleeding should be evident. Then zinc oxide eugenol base is placed over the pulp stems and allowed to set and then stainless steel crown is placed. So next one is your partial pulpotomy. Generally this question is asked for the UG exams that is called CVEX pulpotomy. It is the removal of only the outer layer of damage and hypodermic tissue in the exposed pulp. It is considered to be the procedure staged between pulpcapping and complete pulpotomy. It is a mode of treatment which is widely used in the permanent indentation but less in the primary teeth. So let's see the rationale and the advantages of CVEX pulpotomy. The main advantage of partial pulpotomy is that a successful outcome will allow the continuation of the normal development of the tooth including further root development and maturation. Upex formation and thickening of a thin root walls may occur in engteeth. The tooth following a partial pulpotomy will retain its natural color and translucency in comparison to the coronal discoloration in many teeth undergo after pulpectomy. And partial pulpotomy have advantage over complete pulpotomy in the preservation of cell-rich coronal pulp tissues. So when is this CVEX pulpotomy indicated? When there is sufficient tooth structure is present to allow a proper restoration and a full coverage of the crown with a bonded resin composite strip crowns. Partial pulpotomy is highly indicated in a very engtoothed with a wide open apex and very thin root dentin walls. The disease factor for selection of the partial pulpotomy and its success is a healthy non-inflamed and asymptomatic vital pulp. So there are other few newer agents which are used in pulpotomy is electrosurgery, laser, MTA, bio-dentine enamel matrix derivatives. I'll show you few of the pictures. This is MTA pulpotomy where you can see the coronal pulp is removed. This is a cross-section coronal pulp is removed completely and MTA is placed which is followed by stainless steel crown. This is electrosurgical pulpotomy. This is laser pulpotomy where the laser is used to remove the coronal pulp and this is bio-dentine pulpotomy and there are few reasons for the failure of pulpotomy therapy. Let's see what are the reasons. We might do the wrong diagnosis by saying that the radical pulp is non-inflamed and non-infected. That is one of the main reasons for the failure of pulpotomy and we also use zinc oxide eugenol. So eugenol causes an irritation for the pulp space filling material. An attempt to preserve a tooth with a deep proximal carousal lesion a condition leading to leakage due to incomplete coverage. There's also signs of failures can be seen on radiographic pathological signs in pulp canal obliteration which can be seen in root canal of pulpotomized primary molars in presence however it is not considered as a failure. With this I would like to conclude by saying there are different various medicaments which are used in pulpotomy which everything has its own pros and cons. So basically it depends on a clinic clinician. So choose your material with more advantages than disadvantages. Thank you.