Apulpotomy is performed in aprimary tooth with extensive caries but without evidence of radicular pathology . (when radicular pathology present we do pulpectomy or extract the tooth).
Asymptomatic tooth or tooth with transient pain.
To remove the caries and we have caries of dental exposure of vital coronal pulp tissue we go for pulpetomy rather than direct pulp capping .
The coronal pulp is amputated ,and the remaining vital radicular pulp tissue surface(pulp stumps) is treated with along- term clinically –successful medicament .
Good local anesthesia(never starts pulpotomy, even a deep cariesremoval without giving anesthesia before; don’t wait until the patient is in pain). The type of local anesthesia is determined according to the rule of 10 (in the lower arch anesthesia: age of the patient + number of the tooth <= 10 , we give infiltration local anesthesia , otherwise we give a nerve block anesthesia)
Isolation (rubber dam,cotton roll,suction)
Ideally it is recommended that all pulp therapy be performed with rubber-dam or other equally effective isolation (suction and cotton rolls) to minimize bacterial contamination of the treatment site.
Remove all the caries from dentinoenamel junction first then from the surface close to the pulp with large round bur or with large sharp spoon excavator .
If a small carious pulp exposure is disclosed, evaluate the pulp condition, and perform a coronal pulpotomy following complete caries removal.
(if drop happen and bleeding doesn’t occur that mean the pulp is necrotic then the treatment plan will change )
So after complete removal of caries open wide access to the pulp chamber using high speed bur (complete unroofing using high speed or low speed bur because we afraid from perforation when the child close his mouth and we use high speed bur)
When the bur passes through the roof of the chamber, a ‘dip’ is felt.( Once this is felt the bur isn’t taken any deeper but side way to remove the roof of pulp chamber) .
Complete removal of roof of pulp chamber.
Then again we Judge the condition of the exposed pulp based on the pulp tissue color and hemorrhage
1- none (no bleeding, no pulp tissue) necrotic pulp tissue
2- profuse inflammation of the coronal pulp tissue and radicular one, so the tooth needs pulpectomy.
Removal of coronal pulpal tissue with sharp sterile excavator or large round bur in a slow handpiece.
Attain initial radicular pulpal hemostasis by gentle application of cottonpledget moistened with saline(don’t put it dry because when we remove it tear to blood vessels will happen and bleeding will reoccur) (hemostasis should be achieved within four minutes).
Evaluate bleeding again :
1- No bleeding indicates that your diagnosis was right and the tooth needs pulpotomy
2- Profuse bleeding we need to remove the coronal pulp tissue and the radicular one (your diagnosis was wrong and the tooth needs pulpectomy)
What if you do not achieve hemostasis?
This indicates :
1- Inadequate unroofing of the pulp chamber(the most common reason )( blood vessels still present in the pulp chamber) , we need to check for that :