How to do a primary tooth pulpotomy

A pre-op radiograph and clinical assessment are paramount.

STEP BY STEP GUIDE

Although the management of dental caries is moving towards a minimally invasive approach, in some cases, pulpotomies in primary teeth are still indicated. Preservation of the posterior primary dentition, particularly the E’s, is paramount for normal growth and development of the mouth and jaws. This month’s post will run through a step-by-step guide for how to perform a primary tooth pulpotomy.

A previous post we did https://www.kidsdentaltips.com/posts/what-are-the-best-materials-for-primary-pulpotomies discussed the best material for pulpotomies, which is MTA. Any other material will give you poorer results. A future post will discuss the indications and contraindications for pulpotomies.

Step 1 – Local Anaesthetic and Rubber Dam.

Good local anaesthesia is paramount to achieving a pulpotomy. Compliance in children is hard enough without performing a procedure on them that is painful! Generally, all primary molars are able to achieve adequate anesthesia with a buccal infiltration of Articaine. However, on occasions, you may need to place a block for a lower E.

Rubber dam is mandatory. Failure to use it is far from best practice and is as contraindicated as performing a root canal treatment on an adult without rubber dam. A previous post (https://www.kidsdentaltips.com/blog/one-simple-step-to-improve-your-restorative-success-in-primary-teeth) addressed how to place rubber dam on kids.

Step 2 - Reduce Occlusal Height

Reduce the occlusal surface by around 1.5 – 2 mm with a (diamond) football bur (starting with this step will make caries removal and pulpal access quicker and easier).

Step 3 – Remove caries and gain access

Caries removal prior to pulpal access is required to reduce the bacterial load that the pulp may be exposed to and to ensure that the tooth is restorable. Then gain a small access to the pulpal chamber through the pulpal roof using a flat fissure bur.

Step 4 – Pulpal extension

Once you have gained some access, transition to a non-end cutting bur (we use an Endo-Z bur). Extend the opening over the entire pulpal roof to make sure you gain access to the whole pulp chamber. A common mistake is to not fully remove the roof, which leads to incomplete pulp removal from the chamber. Remain far from the floor of the pulp chamber with the high speed bur as it is very thin in primary teeth and easy to perforate. Use a spoon excavator to remove the remaining pulp in the chamber. On occasion, you may also need to use a large slow speed bur under irrigation to remove the remaining coronal pulp. Take great care around the floor of the chamber.

Non-End Cutting Bur

Step 5 – Ensure all tags are removed

Removal of tags.

There is nothing more frustrating that waiting for haemostasis to only find you have one small area that does not stop bleeding. As such, ensure that you inspect the floor, walls, and roof very carefully for any tags that may be present. If they are present, use a small slow speed bur under irrigation to remove these (with GREAT care again!).

Step 6 – Haemostasis

This is a crucial step and one of several reasons many Paediatric Dentists do not like Ferric Sulphate (FS). The best indication of a healthy pulp is haemostasis within 5 minutes. Failure to achieve this means the tooth is indicated for extraction. If you use FS, you will achieve haemostasis immediately which can give you a false positive. We place a wet cotton pellet into the chamber and leave it for 3 – 5 minutes (until haemostasis is achieved). We follow this with a hydrogen peroxide soaked pellet to assist with decontamination.

Hydrogen Peroxide soaked pellet after haemostasis achieved

Step 7 – Medicament

We use wet gauze to pack the MTA into the chamber. The MTA ideally should extend slightly into the canal opening and be very well condensed

As mentioned in the previous post, the only real material that is now accepted is MTA, other materials are inferior and will affect your success rate. We use NeoMTA due to its lower cost, ease of use and accessibility. You can get NeoMTA putty (super easy to use) or powder and liquid from https://tp-dc.com.au

MTA condensed into the chamber.

We use a flat plastic or an amalgam plugger to transport the MTA ‘sausage’ into the canals (an amalgam carrier also works well if you are struggling to make the ‘sausage’ shape). Place enough for at least a 2-4 mm covering over the canal openings. We then use a damp gauze to firmly pack the MTA down with a plugger so that there are no voids.

Step 8 – Core

We fill the the remaining bulk of the chamber with GIC, we use Fuji II LC as we can cure it quickly.

Post Core Placement

We used IRM in the past, but the additional time taken to mix and set this in an active child can be bothersome.

Step 9 – Crown

This is a non-negotiable step, a stainless-steel or zirconia crown MUST be placed following the pulpotomy. Failure to do this is a massive contraindication and a resin or GIC will result in an inevitable failure. A future post will discuss how to place stainless steel crowns.

Summary

Performing pulpotomies can initially be a daunting experience and the correct diagnosis is paramount to success (we will cover this down the track). Once you have completed a few, you will find your confidence will grow. We hope this post has been of some help for you.