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Pulpotomy (vital pulpotomy), pulpectomy (pulpal debridement), and root canal treatment (RCT) are used for the management of the soft tissue within the tooth structure when inflammation is present.
Dental pain results from arm-like projections of the pulp expanding into the dental tubules through osmotic cell reactions. (1)
When inflammation is too severe, sensitivity (sharp shooting pain and variations of temperature) associated with a cavity becomes a proper toothache (longer and more throbbing), which can further develop into an abscess. Without pulp tissue, the tooth dies, becomes brittle, and breaks more easily, especially under chewing pressure.
Types of Pulpitis
Pulpitis, or inflammation in the tooth pulp can either be reversible or irreversible.
1. Reversible pulpitis
Reversible pulpitis occurs when the tooth is assaulted by a chemical (caries, acid, temperature variation) or trauma (blow, displacement, fracture, avulsion). The first line of defense for any attack on the pulp is to remove the source of irritation.
Fillings, desensitizers, and medicaments (glass ionomers, silver diamine fluoride, and other materials that release fluoride) work to arrest caries or trauma and reduce the swelling.
The tooth then has time to repair itself by generating reparative dentin to further protect and isolate the tooth. This also helps harden the existing enamel with needed minerals.
2. Irreversible pulpitis
Irreversible pulpitis occurs when damage to the tooth structure invades the pulp tissue, making it necessary to disinfect the pulp chamber. This is accomplished either by a pulpotomy or a pulpectomy.
The treatment is evaluated based on how long the pulpitis has been present, the pulp tissue condition based on examination, and the condition of the tooth structure.
Pulpotomy refers to the removal of only part of the pulp tissue and placement of a local disinfectant.
a. Primary teeth
This is the most common treatment for baby teeth when a filling is not enough. A baby tooth is so small that when a cavity becomes large, it will react even on a small exposure.
The dentist will remove only part of the pulp tissue, usually the pulp chamber, and place a medicament to remove any residual bacteria. The materials used frequently are formecresol, ferric sulfate, (2) and/or mineral trioxide aggregate (MTA).
Much of the tooth is removed, so the chamber is filled before primary crown placement. Again, the enamel is more brittle and children grind more than adults, so a full-coverage restoration is advised and placed the same day.
b. Adult teeth
Pulpotomy is performed more often when the tooth is considered immature (up to 3 years following the eruption (3)), and the blood supply to the tooth is better than when the apex of the root is fully formed. It can also be attempted when the exposure is so new or so small that the bacterium has not progressed into the pulp tissue.
In some cases, pulpotomy is done to promote the development of an otherwise short and immature root that would not sustain the tooth for extensive periods. The walls of the pulp chamber are thin, short, and likely to fracture, which might result in early loss of the permanent tooth.
MTA, calcium hydroxide, and other less invasive materials are placed in the exposure to help promote dental formation by the pulp tissue. (4) This is sometimes left under the temporary filling to ensure that healing of pulp tissue occurs with the root’s formation. The observation period usually lasts from several months to several years.
Pulpectomy refers to the removal of all tissue from the pulp chamber and filling of the void to separate and seal the remaining hard tissue structures from the oral cavity. Often, this procedure might be uncomfortable due to the infection, which causes extrusion of the tooth and exudation of liquids and gases.
a. Primary teeth
This procedure is usually performed on anterior primary teeth having only one long root that is not divergent from the pulp chamber. It can also be performed on a distressed posterior primary molar when you wish to retain the tooth for developmental, functional, or esthetic reasons.
The full pulp tissue is removed with endodontic instruments, but the tooth is not fully instrumented so that the root is not thinned and subject to fracture. On the posterior teeth, each root is instrumented separately. After the pulp has been removed, the full chamber is filled with a resorbable material.
b. Immature permanent teeth
When the root is more than 2/3 formed but not fully formed, the walls are thin and the apex is more opened to the oral cavity than a fully closed root. Often, conventional RCT is not as predictable or durable, and apexification is performed to help create a more durable root.
After all the soft tissue has been removed from the pulp chamber, it is filled with a calcium-rich material (calcium hydroxide, iodiform calcium hydroxide) that the bond and apical tissue can use to form a bonelike replacement material to close the root.
Once this has become radiographically visible and the root opening is believed to have healed enough to fill, endodontic obturation is performed.
The apexification treatment usually lasts between 6 and 18 months, (5) with repeat observation and possible replacement, including radiographs, to ensure that the material is fully placed to the tooth’s apex.
c. Mature permanent teeth
Full instrumentation of the pulp chamber is performed with rotary instruments, reamers, and files. The canal is fully cleaned and disinfected, then filled with a nonresorbable material.
Sealers are used to isolate the material from the oral cavity and underlying attachment, and the jawbone from the apex.
Root Canal Therapy
RCT involves a pulpectomy followed by full-coverage restoration usually performed on the same day for a primary tooth and at a later date on a permanent tooth.
Permanent teeth are usually restored with a more cosmetic and lengthy procedure. Repeat visits are required because the crown is fabricated to fit the tooth, and more tooth structure is removed to stabilize the final restoration.
Prefabricated crowns are utilized for primary teeth and immature permanent teeth to ensure less tooth reduction, fewer steps, and less impingement on the adjacent developing teeth.
Importance of Treatment
Once the infection has progressed into the pulp, treatment of the infection is essential. Antibiotic therapy is a systemic treatment for a localized infection and will work for a short time.
- If the source of the infection is not removed, a flare-up will occur down the road.
- Pain, swelling, and loss of the tooth are all consequences of nontreatment.
- Moreover, airway obstructions and/or central nervous system involvement can occur when a head and neck infection progresses, leading to hospitalization or death.
An alternative treatment to root canal therapy, pulpotomy, and pulpectomy is extraction of the tooth. One thing to remember is that anesthetics work well when the infection is controlled and not treated as an emergency.
A pulpotomy is a fast, often painless procedure for primary teeth. Fear is a tremendous influence on the perception of pain. Extractions are always felt, perhaps not as a sharp stabbing pain, but as an extensive pressure to loosen and remove the tooth from its socket.
When pulpitis has progressed to deform the tooth root, internal and external resorption will result. However, if the infection of the tooth has progressed so much so that the seal from pulpal therapy is not a closed or sealed chamber, the infection will worsen, and extraction becomes necessary.
Often, it is difficult to diagnose these root perforations fully, and the treatment is not definitive. X-rays are two-dimensional pictures of a three-dimensional object, so some aspects of the tooth structure are not always visible.
Sometimes, retreatment or surgical endodontic treatment (roots are exposed for examination and treatment) can remove any residual infection present or can seal the chamber better.
Performing any pulpal therapy on a tooth means that timely treatment was not performed or severe trauma has occurred.
- The easiest and safest way to prevent trauma is with the use of mouthguards:
- Sports guards help stop acute trauma from impacts.
- Nightguards help prevent chronic trauma from grinding and clenching.
- Preventative care to maintain optimal oral health is essential.
- Regular home care and treatment visits to the dentist are also imperative. Early treatment of decay improves the likelihood that decay will not progress through the hard tissue structure of the tooth to the pulp.
Replacement of Tooth
When any tooth is extracted, it must be replaced. When spaces are created, teeth will shift to fill that space.
- When the tooth is primary, a small appliance is placed called a space maintainer. This is required to hold the space of the baby tooth until the permanent tooth can erupt.
- When a permanent tooth in the mixed dentition is lost, replacement is with a temporary partial or flipper until the dentition has matured enough to be restored by the permanent solutions.
- When the tooth is permanent, it needs to be replaced with a prosthesis that appears and functions as the tooth that was lost. This can be fixed (bridge), removable (partial denture), or replaced (implant).
Cost of Pulpectomy
It is important to remember that any treatment of a tooth will result in a weakening of the remaining tooth structure. Further treatment is always a possibility, and a good outcome can only occur with full and proper treatment, follow-up visits, and home care.
The more extensive the treatment is needed, the more expensive it will be. Extractions, although less costly, usually results in a larger restorative price to maintain the space.
The cost of pulp treatments varies depending on the tooth being treated and the type of treatment. Primary teeth range in price from $125 to $350. Pulpotomies range in price from $50 to $300 depending on the type of procedure and if further treatment is needed before placing the final fill.
RCT can range from $375 to $1500 depending on the placement and number of roots. Although oral health is a costly and time-consuming endeavor, it is part of overall health. Proper caries control and occlusion results in reducing bacteria and improving mastication, which in turn improve periodontal and digestive health.
Pulpectomy refers to the removal of damaged pulp from the inside of the tooth. This is followed by disinfection and refilling of the area.
Pulpectomy and root canal therapy are often used to help treat inflammation and infection in the tooth. It is essential to maintain good oral hygiene to prevent infections and decay that require pulpectomy procedures.