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Pulpotomy Techniques

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For anyone who has studied pediatric dentistry, you know that there are about one hundred different ways you could perform a pulpotomy and stainless steel crown. Between the different techniques, materials and instruments, it can be confusing as to what is best for the patient. Most of the commonly used techniques and materials have scientific evidence to back them up and plenty of anecdotal evidence as well. 

Different burs and steps for reduction are used. Some pediatric dentists advocate removing all caries first, and then worrying about the form of the preparation. Others have a precise sequence to follow, which they never stray from. Most pediatric dentists advocate flattening the occlusal table at first if they know a pulpotomy will be performed. This reduced the amount of tooth structure that must be penetrated before reaching the pulp chamber. Also, most pediatric dentists advocate reducing inter proximally, buccally and lingually prior to entering the pulp chamber. In this way, different sizes of crowns can be tried on and fitted before the pulp is exposed.

 The reduction of the buccal and lingual surfaces can vary drastically as well. It will also depend on which tooth one is preparing. For instance, the primary first mandibular molars have cervical bulges that need to be reduced before a crown can be fit. Many pediatric dentists report that for most teeth they will simply have a 45 degree bevel on the buccal and lingual surfaces, and this bevel remains within the occlusal third of the tooth. Other pediatric dentists will perform this 45 degree bevel, and then slightly reduce the remaining middle and gingival thirds. 

The “Viscostat and Tempit technique” includes reducing the occlusal surface with a diamond bur (donut shaped diamond reportedly works well), then reducing interproximally with a 557 and a finally a thin diamond for buccal and lingual surfaces. Next, the pulpotomy procedure begins. Unroof the pulp chamber with a slow speed bur (round) and then scrub Viscostat in the chamber for 15-20 seconds and rinse. Then place Temp-it and cement the crown. The dentist should hold the crown while the assistant rinses the excess cement off and flosses to remove cement between the tooth and the adjacent teeth.

Formocreosol is a compound consisting of formaldehyde, cresol, glycerin, and water used in vital pulpotomy of primary teeth and as a temporary intracanal medicament. When used as an intracanal medicament, it is normally put on a cotton pellet and the cotton pellet is placed in the chamber for about 5 minutes. The cotton pellet is then removed and the chamber filled with an IRM. The stainless steel crown is then cemented over the IRM. Formocreosol is controversial because Formaldehyde has been shown to be distributed systemically after pulpotomy. The long term systemic effects are still up for debate, but some studies label it as a carcinogen. For this reason, Europe has banned Formocreosol. Diluting Formocreosol to 1/5 its strength (Buckley's solution) is the most common way that dentists in the United States use this compound.

No matter the pulpotomy technique, following the pulpotomy a stainless steel crown should be placed. Stainless steel crowns, also known as pre-formed crowns, are the restoration of choice for compromised primary molars, although esthetically they are not pleasing. They have superior longevity to amalgam and composite restorations. The most common method of cementing stainless steel crowns contains glass ionomers. These cements are advantageous because they contain Fluoride, which will protect against future caries. These glass ionomer cements also provide chemical retention to the tooth, while still maintaining mechanical retention to the crown. 

Although there are many different ways to prepare for and perform a pulpotomy and then place a stainless steel crown, they all aim to serve as a primary tooth restoration to keep the child out of pain, keep them infection free and to maintain the space for the permanent tooth to erupt in its proper place.