Wednesday, July 31, 2013

Mineral Trioxide Aggregat Produces Superior Outcomes in Vital Primary Molar Pulpotomy

Resident: Mackenzie Craik

Article: Mineral Trioxide Aggregate Produces Superior Outcomes in Vital Primary Molar Pulpotomy

Journal: Pediatric Dentistry Volume 32, No. 1; Jan/Feb 2010

Authors: Tracy Doyle, Michael Casas, David Kenny, Peter Judd

Purpose: The purpose of this study was to investigate the outcomes of vital primary molar pulpotomy when there is no direct contact between eugenol and the vital pulp.  Four pulpotomy techniques were compared: 1) Ferric Sulfate Pulpotomy (FS); 2) eugenol-free ferric sulfate pulpotomy; 3) mineral trioxide aggregate pulpotomy (MTA); and 4) ferric sulfateMTA Pulpotomy.

Methods: The pulpotomy technique assigned to each molar was determined by random selection.  Two blinded, disinterested raters classified each molar into one of three radiographic outcomes: 1) Normal molar without pathologic change; 2) pathologic change present, follow-up recommended; 3) pathologic change present, extract.

Results: A total of 92 patients with 227 pulpotomy-treated molars returned for at least 1 recall examination.  Median follow-up for molars was 24 months.  MTA molars demonstrated significantly fewer outcomes requiring extraction than ferric sulfate treated molars.  Eugenol-free ferric sulfate molars demonstrated significantly more extractions than MTA molars.  Significantly lower survival was demonstrated for eugenol-free ferric sulfate molars compared to MTA molars over 6-38 months.

Conclusions: Outcomes of MTA pulpotomies were superior to ferric sulfate and eugenol-free ferric sulfate pulpotomy after a median follow-up of 2 years.

Assessment:  I thought to be a very interesting and applicable article that shows once again that MTA seems to be superior to other treatment modalities.  Perhaps MTA will be more widely used in pulpotomies once the price eventually begins to drop.  Also I would have liked to have seen formocresol treated molars in this study to see how they compare to MTA.

Diagnosis dilemmas in vital pulp therapy: Treatment for the toothache is changing, especially in young, immature teeth.

Resident: Todd Bushman

Article: Camp, J. H. Diagnosis dilemmas in vital pulp therapy: Treatment for the toothache is changing, especially in young, immature teeth. Pediart Dent (2008) 30(3): 197-205.

Purpose:  This article reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apex. The apical barrier with mineral trioxide aggregate followed by root strengthening with bonded composite is reviewed.

Key points: Diagnosis in primary and young, permanent, immature teeth varies greatly from that

in fully formed permanent teeth. Most of the diagnostic tests used in conventional endodontic therapy are of very little or no value in primary teeth and of limited value in permanent immature teeth. While admittedly poor for diagnosing the degree of inflammation in this group of teeth, diagnostic tests must be performed to obtain as much information as possible before arriving at treatment options.

Diagnosis of Pulpal Status in Primary Teeth
-Primary teeth with a history of spontaneous pain should not receive vital pulpal treatments and are
candidates for pulpectomy or extraction.
-Electric pulp tests are not valid in primary teeth
-Thermal tests are usually not conducted on primary teeth because of their unreliability
bite-wing radiographs are often best to observe pathologic changes in posterior primary teeth.
Pathologic bone and root resorptions are signs of advanced pulpal pathosis that has spread into the
periapical tissues and is usually treatable only with extraction.
-If internal resorption can be seen radiographically, a perforation usually exists, and the tooth must be extracted
-If there is exposure The size of a pulpal exposure and the amount and color of hemorrhage have been reported as important factors in diagnosing the extent of inflammation under a carious lesion.
-Excessive or deep purple colored hemorrhage is evidence of extensive inflammation, and these teeth are candidates for pulpectomy or extraction. Hemorrhage that cannot be controlled within 1–2 minutes by light pressure with a damp cotton pellet at an exposure site indicates more extensive treatment is necessary

Diagnosis of Pulpal Status in Permanent Immature Teeth
-In teeth with incomplete root formation, correct pulpal and periapical diagnosis is of paramount importance
-Electric pulp tests and thermal tests are of limited value because of the varied responses as roots mature.
-Electric and thermal tests were shown to be unreliable after traumatic injury to a tooth, and no response might be elicited even after circulation has been restored
-Laser Doppler flowmetry has been reported to be very reliable for diagnosing pulpal vitality
-Radiographic examination and interpretation are key elements in the diagnosis of pulpal pathology in teeth with developing apices.
-Discoloration of a tooth crown after trauma is a common sequela and one of the foremost diagnostic indicators. Yellow discoloration is usually indicative of pulp space calcification, and a gray color usually signifies pulpal necrosis
-Universal agreement exists that immature teeth have the greatest potential to heal after trauma or caries, particularly when the apical foramen is wide open.
-The use of calcium hydroxide (for decades the standard for pulp protection), pulp capping, and pulpotomy procedures in permanent teeth is being replaced with composite resins (45, 46) and mineral trioxide aggregate (MTA) (ProRoot; Dentsply Tulsa Dental, Tulsa, OK). Pulp capping with resin composites in monkeys produced the lowest incidence of bacterial microleakage, pulpal inflammation, and incidence of pulpal necrosis when compared with calcium hydroxide and glass ionomer cement
-When compared with calcium hydroxide, MTA produced significantly more dentinal bridging in a shorter time with significantly less inflammation and less pulpal necrosis.
-Revascularization of teeth with necrotic infected canals has been reported by using combinations of antibiotics (57, 58). The canals are accessed and disinfected with copious irrigation of sodium hypochlorite. The canals are not instrumented. A paste of metronidazole, ciprofloxacin, and minocycline is placed in the canals and left for 1 month.  The tooth is re-entered, and endodontic files are inserted through the apices to stimulate bleeding to produce a blood clot at the level of the CEJ. After clotting, MTA is placed over the blood clot, and a permanent external seal is placed. The clot is then revascularized, producing thickening of the canal walls and apical closure.


Assessment:  It was a great article with information regarding pulp therapy and different alternatives for treatment.  Based on the evidence presented it looks likeonce again MTA is the gold standard of treatment and it would be nice if we could work with MTA.

Indirect pulp therapy and stepwise excavation – Conference Paper

Resident: Jeff Higbee
Article: Indirect pulp therapy and stepwise excavation – Conference Paper
Authors: Bjorndal, L.
Journal: Pediatr Dent (2008) 30(3): 225-229

Key Points:

In relation to partial caries removal, the following points were addressed in this review:
- Partial caries removal in symptomless primary or permanent teeth reduces the risk of pulpal exposure.
- No pulpal symptoms were found
- Partial caries removal appeared preferable in deep lesions to reduce the risk of carious exposure of the pulp.
- There is insufficient evidence to show whether it is necessary to re-enter and excavate further in the stepwise excavation technique, but studies that did not re-enter reported no adverse consequences.

How Deep Is a “Deep” Caries Lesion?
- Definition usually points towards the potential for pulp exposure.
- In a study, most dentist considered a lesion with potential for pulp exposure to be a lesion that is ¾ the entire dentin thickness or more radiographically.

 Indirect Pulp Therapy (no re-entry)
- IPT in primary molars has been found to be a successful technique.
- IPT arrests the progression of the underlying caries, regardless of the material used.

Two-Step Approach
- Carious dentin is removed and a 1mm layer of calcium hydroxide is placed and temporary restoration placed.  No final excavation was performed within the first visit.  Re-entry and final excavation were then made after 2-3 weeks followed by final restoration.

-In a survey of dentists, the majority report that they use a more invasive approach (RCT) to treat “deep” caries lesions.  They report they don’t believe in leaving carious dentin behind.
- Irreversible or Reversible pulpitis is difficult to assess and is based somewhat on subjective data provided by the patient.  Children may sometimes not be the most reliable source of good subjective data.
- There is still a need for good research before determining a gold standard for treating the “deep” caries lesion.

Vital Pulp Therapy with New Material for Primary Teeth: New Directions and Treatment perspective.

Resident: Margaret Cannon
Title: Vital Pulp Therapy with New Material for Primary Teeth: New Directions and Treatment perspective
Authors: Anna B. Fuks
Journal: Pediatric Dentistry V30/N3 May/Jun 2008

Purpose: A review of articles comparing clinical trials on primary molars where the vital pulp therapy, pulpotomy was performed. In most of trials reviewed, formocresol (FC) was compared with a different pulpotomy materials i.e. ferric sulfate (FS), mineral trioxide aggregate (MTA), calcium hydroxide (CH) or laser.  One trial compared FS to sodium hypochlorite (NaOCl).

Key Points:
-The author briefly went over the different types or pulp treatments for vital primary teeth; indirect pulp capping, direct pulp capping and pulpotomy.  A brief discription of when they should be used and (not used) was given.
- All six clinical trials comparing FC to MTA showed that MTA has a higher success rate clinically and radiographically.
- Clinical trials comparing FC with FS had varying results, both clinically and radiographically.
- Clinical trials comparing FC for CH showed that CH was a less successful material and FC in all 3 studies provided for review.
- Clinical trials comparing FC with laser treatment varied depending on technique and type of laser used.
- Only one trial comparing NaOCl with FS was available for review, it showed NaOCl to be 100% successful at 1 year.

I thought that the individual articles assessed were very inconsistent in their clinical protocol.  Many things were not noted in the trial procedures. For example, use of rubber dam was not always specified.  Not all the trials placed SSCs on all teeth being evaluated. Waterhouse et al. 2000:  “SSC placed where indicated, others restored with amalgam, glass ionomer, or compomer.”  Also, each trial had a different method and/or number of dentists performing the pulpotomies along with “blind” or “not-blinded” clinicians evaluating the treatments.  Lastly the trials varied substantially in the length of time that molars were evaluated post-operatively.  NaOCl was only monitered for 1 year post operatively where as Holan et all (2005) followed their treatment for 72 months. 

Tuesday, July 30, 2013

Pulpotomy in primary teeth: Review of the literature according to standardized assessment criteria

Resident: Derek Nobrega
Title: Pulpotomy in primary teeth: Review of the literature according to standardized assessment criteria
Authors: A.B. Fuks, L. Papagiannoulis
Journal: European Archives of Paediatric Dentistry (2006) 7(2): 64-71

Main Purpose:
To assess the relevant literature and to review several new publications on pulpotomies with different materials and techniques.

A search of the relevant literature on pulpotomies was identified through Medline between the years 1966 - 2005. Only clinical studies (non-specified) and retrospective studies were included for assessment.

Key Points:
- Formocresol or ferric sulfate medicaments were found to be likely to have similar clinical/radiographic results, and MTA seemed to be a more favorable pulp dressing.
- Despite the considerable amount of literature available, many articles reported on studies that were not randomized clinical trials, had faulty study designs, and failed to provide reliable evidence supporting the superiority of one type of treatment for pulpally involved primary teeth
- The other two studies that compared FC pulpotomy, FS pulpotomy, and electrosurgery pulpotomies showed no statistically significant difference between the treatments. The reviewers remark that these conclusions must be viewed with caution, as there is no evidence supporting the superiority of one type of treatment
- The difference in treatment outcomes may be due to differences in case selection
- No conclusion can be made as to the optimum treatment or technique for pulpally involved primary teeth. More high quality, properly planned prospective studies are necessary to clarify these points

This review of articles did not give any conclusions. They mostly criticized previously published articles, and concluded that there isn’t enough evidence to pick one treatment over another, and that better studies are necessary. 

Guideline on Pulp Therapy for Primary and Immature Permanent Teeth

Resident: Hofelich
Article Title: Guideline on Pulp Therapy for Primary and Immature Permanent Teeth
Revised: 1998, 2001, 2004, 2009

Main Purpose: To aid in the diagnosis of pulp health vs. pathosis and to set forth the indications, objectives, and therapeutic interventions for pulp therapy in primary and immature permanent teeth.

Correct pulpal therapy depends on obtaining a correct diagnosis of vital or nonvital. Tests conclude if the tooth has normal pulp (symptom free and normally responsive to testing), reversible pulpitis (pulp is capable of healing), symptomatic or asymptomatic irreversible pulpitits (inflamed pulp incapable of healing), or necrotic pulp. 

Signs and symptoms of irreversible pulpitis/necrosis (non-vital therapy): history of spontaneous, unprovoked toothache, a sinus tract, soft tissue inflammation not resulting from gingivitis or periodontitis, excessive mobility not associated with trauma or exfoliation, furcal/apical radiolucency, internal/external resorption.

Signs and symptoms of reversible pulpitis (vital therapy): Provoked pain of short duration, relieved with OTC analgesics, by brushing, or upon the removal of stimulus and without signs or symptoms of irreversible pulpitis. 

General recommendations: 1. Always perform pulp therapy with rubber dam or equally effective isolation to minimize contamination 2. Post-op radiographs should be obtained every 6 months as part of the periodic oral exam 3. A radiograph of a primary tooth pulpectomy should be obtained immediately following procedure 4. Radiographs of pulpotomies should be attained annually because the success rate decreases over time, good bitewings will suffice if it shows the interradicular area

Tx for Primary teeth:
Protective liner: thinly applied liquid applied to pulpal surface of a deep cavity preparation, covering exposed dentin tubules to act as protective barrier between the restorative material and the pulp (calcium Hydroxide, dentin bonding agent, glass ionomer cement). Indicated in tooth with normal pulp to preserve the tooth’s vitality, promote pulp tissue healing and tertiary dentin formation, and to minimize bacterial microleakage

Indirect pulp treatment: performed in teeth with deep carious lesions but without signs or symptoms of pulp degeneration. The caries surrounding pulp is left in place to avoid exposure, then covered with a biocompatible material. (bonding agent, RMGI, CaOH2, IRM, GI) If CaOH2 is used, seal with GI or IRM to avoid microleakage. Current literature shows inconclusive evidence as to whether or not the tooth needs to be re-entered to remove residual caries. IDP treatment is preferable to pulpotomies when the pulp is normal or has a diagnosis of reversible pulpitis. 
Direct Pulp Cap: Place MTA or CaOH2 in contact with exposed pulp tissue after pinpoint mechanical exposure during cavity prep or following trauma. Restore with a material that protects from microleakage. Direct pulp capping of carious exposures is not recommended.

Pulpotomy: Performed in a primary tooth with extensive caries but no radicular pathology when caries removal results in carious or mechanical exposure. Coronal pulp amputated and remaining vital radicular tissue is treated with formocresol, ferric sulfate, or MTA. Clinical trials show that MTA performs better or equal to formo or ferric sulfate. Most effective restoration is SSC. Amalgam or composite can be used if there’s enough supporting enamel left and the remaining life span is 2 yrs or less. Do not perform pulpotomy if tooth shows continued suppuration, necrosis or excessive hemorrhage that can’t be controlled with damp cotton pellet after several minutes. Internal root resorption after pulpotomy can be be self-limiting and stable. Remove tooth is resorption casues loss of supportive bone or clinical signs of infection.

Nonvital tx for primary teeth with irreversible pulpitis or necrosis: 
Pulpectomy: Root canal procedure for pulp that is irreversibly infected or necrotic due to caries or trauma. Canals are debrided and shaped with hand file or rotary files. Irrigate with sodium hypochlorite. Dry canals and fill with resorbable nonreinforced zinc oxide/eugenol, iodoform-based paste (KRI), or a combo paste of iodoform and calcium hydroxide (Vitapex). Restore tooth to prevent microleakage. 

Treatment for young permanent teeth:
Protective liner: Same as primary teeth

Indirect pulp treatment: Same as primary teeth

Direct pulp cap: Same as primary teeth

Partial pulpotomy for carious exposures: Inflamed pulp tissue beneath the exposure is removed to depth of 1 to 3 mm or deeper to reach healthy pulp tissue. Pulpal bleeding must be controlled by sodium hypochlorite or chlorhexidine before the site is covered with calcium hydroxide or or MTA (1.5 mm thick). White MTA for anterior teeth. Cover with a layer of RMGI, then restore to prevent microleakage. Indicated in young permanent tooth with carious exposure in which pulpal bleeding is controlled within several minutes. Tooth must be vital, with a healthy pulp or reversible pulptitis. 

Partial pulpotomy for traumatic exposures (Cvek): Same as for carious exposures. Indicated for vital, traumatically-exposed young permanent tooth, especially one with incompletely formed apex.

Apexogenesis (root formation): formation of the apex in vital, young, permanent teeth can be accomplished by using the appropriate vital therapy described 

Nonvital pulp treatment: 
Pulpectomy: conventional endo treatment

Apexification (root end closure): method of inducing root end closure of incompletely formed nonvital permanent tooth by removing the coronal and nonvital radicular pulp just short of the root end. Place CaOH2 in the canals for 2-4 weeks to disinfect the canal space. Root end closure is accomplished with an apical barrier like MTA. When complete closure can’t be accomplished with MTA, an absorbable collagen wound dressing (CollaCote) can be placed to form a matrix for the MTA at the root end. Gutta percha is used to fill the remaining canal space.

Persuasive Evidence that Formocresol Use in Pediatric Dentistry Is Safe

Anna Abrahamian

Author: Milnes AR

Journal of the Canadian Dental Association 2006; 72(3): 247-8

The article uses a thorough review of literature to demonstrate that formocresol is safe for use in children and that the evidence banning or dissuading its use has been misinterpreted and misconstrued or replaced by new understanding.

Key Points:
Formaldehyde is Ubiquitous
Naturally found in air, water, and food; found in/released from many household products
Estimated that adults take in approximately 10.55mg/day
Estimated dose of formaldehyde (by author’s calculation) associated with one pulpotomy procedure 
  (1:5 dilution Buckley’s on a pellet that has been squeezed dry) is 0.02 to 0.1mg.

Pharmacokinetics of Formaldehyde
Formaldehyde is a product of normal cellular metabolism (endogenous levels range from 3-12ng/g tissue)
Oxidative product of formaldehyde is formate -> further oxidized to CO2 and H2O OR a soluble   
  sodium salt that is excreted in the urine
Exogenous formaldehyde taken up from the environment via ingestion, inhalation, and dermal 
  exposure is readily taken up, but not distributed throughout the body: in experiments comparing blood 
  samples before and after exposure, the concentrations after exposure were not significantly different; 
  formaldehyde is cleared from human plasma with a biologic half-life of 1 to 1.5 minutes

Mutagenicity, Genotoxicity, and Cytotoxicity/Carcinogenicity
Formaldehyde does have the potential to complex with amino and sulfhydryl groups in target tissues 
  and with DNA to form unstable protein adducts called DNA-protein cross-links (DPX) BUT DPX 
  have been shown to only occur at the site of initial contact
Some have proposed that formaldehyde could induce the development of DPX at distant sites, but no 
  studies or evidence support this
Recent research has revealed the development of DPX occurs only with high exposures, not with the  
  ambient concentrations consistent with environmental exposures
In summary, the development of DPX (and the development of cancers) has only been shown to  
  occur after long-term exposure to formaldehyde at high concentrations at a specific direct contact site.

Take Home Messages
When performing pulpotomies, apply the lowest dose of formaldehyde possible for the shortest   
   amount time to obtain the desired effect
Many products used in dentistry have potential health risks that have been well documented, but there 
  has not been a call for their elimination from dentistry, whereas the risks of formaldehyde have only 
  been assumed (author cites anaphylactic reactions to antibiotics as an example)

Assessment of Article:
Overall, this was a very good article. Gave multiple citations of earlier research that associated formaldehyde exposure with health risks and demonstrated how these studies often made flawed assumptions or drew conclusions from animal models with very different physiology from human subjects.

One area of clarification that would have been helpful was how the author arrived at the estimated dose of formocresol delivered in his application. It would also be beneficial to examine if his estimation is accurate (i.e. what is the actual dose of formaldehyde that is delivered to pulp tissue during these pulpotomy procedures).

Monday, July 29, 2013

Chapter 22-Pinkham: Pulp Therapy for the Primary Dentition

Resident: Avani Khera
Author: Casamassimo, Fields, Mctigue, Nowak
Title: Chapter 22-Pinkham: Pulp Therapy for the Primary Dentition

1.     Odontoblasts are cells that line the pulp and extend their cytoplasmic processes into the dentinal tubules (main part of pulp-dentin complex).
2.     Odontoblasts form Dentin and protect the pulp from injury (disease or operative procedure)

The Pulp-Dentin Complex/Dentinogenic Response to Injury
1.     In pathologic conditions (such as caries or trauma) odontoblasts are stimulated to produce reactionary tertiary dentin/sclerotic dentin at the injury site to decrease dentin permeability and defend the pulp.
2.     Based on the remaining dentin thickness, three situations are possible:
1.     Initial caries/shallow prep à secretion of reactionary dentin and intratubular mineralizationà protection of pulp.
2.     Deeper caries/prep à reparative dentin formation à protection of pulp.
3.     Very deep caries/prep à odontoblasts unable to provide pulpal protection à pulpal inflammation (chronic pulpitis becomes acute).

Clinical Pulpal Diagnosis
1.     There are two main types of dental pain:
2.     Provoked pain: stimulated by thermal, chemical, or mechanical irritants; reduced or eliminated when stimulus is removed.
a.    Dentin sensitivity due to deep caries
b.    Condition is reversible
3.     Spontaneous pain: throbbing, constant pain; may keep patient awake at night.
a.    Advanced pulpal damage.
b.    Condition is irreversible.

Clinical Examination
1.     Redness/swelling/grossly decayed teeth with drainageà pulpal pathoses.
2.     Tenderness to palpation à possible acute dentoalveolar abscess
3.     Percussion sensitivity à possible periapical involvement
4.     Increased mobility of suspected tooth when compared to contralateral tooth à possible pulpal inflammation (must take into account exfoliation pattern).

Radiographic Examination
1.     Interradicular radiolucencies (often in primary teeth with pulpal pathoses) is best observed in a bitewing.
2.     If you cannot see the apex, you will need a PA.
3.     Assess laminar dura of affected tooth and contralateral tooth.
4.     Note: internal resorption indicates inflammation inflammation of vital pulp, whereas external resorption is nonvital pulp with extensive inflammation.
5.     Note: Any radiolucency associated with a nonvital tooth is usually located in the furcation area, NOT at apices because of the presence of accessory canals on pulpal floor area.
a. Thus, bitewing is useful especially in maxillary molars where developing premolar  obscures the furca in a PA.

Direct Pulp Inspection
1.     There are instances when a final diagnosis can only be reached by evaluating the pulp tissue at time of treatment.
2.     Assess the quality (color) and amount of bleeding:
a.                     Profuse bleeding or purulent exudate indicates irreversible pulpitis.
b.                     For example, continued bleeding after a pulpotomy/formocresol indicates further pulp involvement requiring pulpectomy or extraction.

Pulp Treatment Procedures
Conservative pulp therapies:
1.     Protective Base-  AAPD recommends placement of a base or liner on the pulpal and axial walls of a preparation to serve as a protective barrier between the restoration and tooth. Resin cements, glass ionomers, and dentin bonding agents are used to seal the extremely permeable dentin (protect the pulp).
**protective liners or bases should only be placed in deep cavities approaching the pulp
2.     Indirect Pulp Treatment- indicated for asymptomatic teeth with deep carious lesions near the pulp.  Soft mushy dentin should be removed and hard discolored dentin can be indirectly capped. 
a.    Carisolv is a material used during IPT---sound and carious dentin are clinically separated and only carious dentin is removedàmore conservative preparation, however it takes longer that utilizing a slow speed round bur.
b.    Must make sure that all “mushy” caries are removed at DEJ and on lateral walls.
c.     MTA, calcium hydroxide, and GI are the most commonly used materials in IPT.
d.    Success rate of IPT are reported to be higher than 90% in primary teeth—thus, it is recommended in patients whose pre-op diagnosis suggests no signs of pulp degeneration.
e.    Interim restorative treatment (IRT) is a form of IPT.
3.     Direct Pulp Capping- carried out when a healthy pulp has a pinpoint exposure free or oral contaminants.
a.    Calcium hydroxide is placed over exposure to stimulate dentin formation.
b.    Not recommended in primary teeth but can be used with success on immature permanent teeth.  Direct pulp caps in primary teeth lead to internal resorption.
4.     Pulpotomy- is based on rationale that the radicular pulp tissue is healthy and capable of healing after amputation of the infected coronal pulp.
a.    Contraindications to pulpotomy include: swelling, fistula, pathologic mobility, external/internal root resorption, PAP, pulp calcifications, excessive bleeding from amputated radicular stumps.
5.     Pulpotomy technique-
a.    Remove all superficial caries (prior to pulp exposure to minimize bacterial contamination)
b.    The roof of the pulp chamber shouldbe removed by joining the pulp horns with bur cuts utilizing a 330.
c.     Amputate coronal pulp with large slow round bur.
d.    Cotton pellets+pressure should be placed over
e.    amputation site—hemostasis should be achieved.
                                               i.     Excessive bleeding or deep purple color indicates inflammation (pulpectomy or ext)
f.      Place cotton pellet+formocresol five minutes.
g.     Place zoe over amputation site/cover pulpal floor.
h.    Prep/place SSC.       

Radical Treatment:
1.     Pulpectomy and Root Filling- indicated in teeth that show evidence of chronic inflammation or necrosis in the radicular pulp.  This treatment is contraindicated in teeth with gross loss of root structure, internal or external resoprtion, or a periapical infection involving the crypt of a succedaneous tooth. Certain clinical situations justify a pulpectomy  (ex: pulp destruction of a primary second molar before the first permanent molar erupts)
2.     Root Filling Materials- ZOE paste, iodoform based paste, calcium hydroxide, and calcium hydroxide+iodoform (Vitapex). While ZOE is the most commonly used material, Vitapex is easy to apply, resorbs at a slightly faster rate than that of the roots, has no toxic effect on permanent successor, and is radio-opaque, thus making it an ideal material.
3.     Pulpectomy technique-
a.     Access opening should be prepared with walls flared to access canal openings (similar to pulpotomy)
b.     A barbed broach is used to remove as much organic material as possible from each canal.
c.      Endo files are selected and adjusted to stop 1-2mm short of radiographic apex (WL determined by radiograph).
d.     Irrigation with sodium hypochlorite and or chlorohexidine followed by sterile saline rinses.
e.     Canals should be dried with paper points.
f.      Vitapex is packed in via a sterile syringe that injects the paste into the canal.
g.     Post-op radiograph is taken to:
                                               i.     Evaluate the quality of fill and prescribe antibiotics if overfilled
                                              ii.     Provide a baseline for comparing the success of the RCT with follow-up visits.