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The conservative technique provides a more esthetically pleasing result in patients where significant tooth structure remains after completion of a pulpotomy. This technique is particularly beneficial for situations where the access for the pulpotomy was made through only the occlusal surface, leaving all proximal surfaces intact.
Pulpotomy therapy for the primary dentition has developed along three lines: devitalization, preservation, and regeneration. Devitalization, where the intent is to destroy vital tissue, is typified by formocresol and electrocautery. Preservation, the retention of maximum vital tissue with no induction of reparative dentin, is exemplified by glutaraldehyde and ferric sulfate treatment. Regeneration, the stimulation of a dentin bridge, has long been associated with calcium hydroxide. Of the three categories, regeneration is expected to develop the most rapidly in the coming years. Advances in the field of bone morphogenetic protein (BMP) have opened new vistas in pulp therapy. Human BMPs with dentinogenic properties are becoming available through recombinant technology. We are now entering an era of pulpotomy therapy with healing as the guiding principle.
Tetrandrine, a bisbenzylisoquinoline alkaloid with unique broad-spectrum anti-inflammatory properties, was evaluated as a pulpotomy medicament in a canine model. Histological sections were evaluated after three days (acute inflammation) and six weeks (chronic inflammation) by two criteria: 1) intensity and degree of inflammation, and 2) extent of pulp involvement. The results of the three-day dressings revealed significant neutrophil infiltration in only 30% of teeth treated with tetrandrine, compared with 81%, 84%, and 100% of teeth treated with Ledermix, (Lederle Pharmaceuticals, Wolfrathausen, Germany), formocresol (Creighton Pharmaceuticals, Sydney, Australia) and saline (controls) respectively (P < 0.01). After six weeks, there was significant lymphocyte infiltration in only 30% of teeth treated with tetrandrine, compared with 66%, 90%, and 100% on teeth treated with Ledermix, formocresol, and saline controls respectively. (P < 0.01). In both three-day and six-week specimens in tetrandrine-treated teeth the extent of inflammation was limited to less than one-third of the coronal section of the pulp, whereas teeth treated with Ledermix or formocresol showed cellular infiltration extending to greater than two-thirds of the pulp (P < 0.01). Comparative studies with berbamine, a natural analog of tetrandrine, showed that it was less potent than tetrandrine, but significantly better than Ledermix and formocresol on both acute and chronic pulp inflammation (P < 0.05 and P < 0.01 respectively). These results suggest that tetrandrine may have value as a pulpotomy medicament.
The enzymes lactate dehydrogenase (LD), succinate dehydrogenase (SD), alkaline phosphatase (AP), and glucose-6-phosphate dehydrogenase (G-6-PD) were evaluated at specific locations in pulp tissue following glutaraldehyde pulpotomies. Pulpotomies were performed on maxillary first molars in 40 rats after sacrifice at times 0, 24 hr, seven days, or one month, and experimental teeth were treated with 6% buffered glutaraldehyde. Teeth were prepared for frozen sectioning and the sections were subjected to incubation media to detect each enzyme. Significant differences were found regarding the location of staining and the time intervals at which stain was present or absent. Staining for LD and AP was the most intense throughout the four observation time periods, though staining for these enzymes as well as for G-6-PD had begun to diminish by day seven in the coronal thirds. Staining was completely absent in the coronal thirds at one month but remained in the middle and apical thirds throughout one month. SD was the only enzyme that was totally absent in the coronal third at seven days and totally absent in the middle third at one month. These findings suggest that LD, AP, and the biochemical mechanisms that they represent remain active longer than SD and G-6-PD following exposure to glutaraldehyde. This information is important in identifying mechanisms that are important for repair, healing, and recovery following pulpal injury.
The purpose of this study was to assess the pulpal response following application of 1% Feracrylum (Hemolok) to arrest hemorrhage during pulpotomy procedure on 26 sound primary molars. They were filled with ZnOE cement and later restored with silver amalgam. The teeth were followed for clinical, radiographic and later histological success for various intervals of time up to 5 months. Asymptomatic clinical and radiological findings and histological evidence of healing in the form of reparative dentin and fibrous tissue formation the deeper zones of the radicular pulp was observed. The hemostatic and non-toxic nature of feracrylum makes it a promising medicament for pulpotomy procedures.
AIM: The purpose of this paper is to review three prospective and two retrospective studies that have been published on the use of ferric sulphate as a pulpotomy medicament and, also, present the results of a recently completed, 3 year comparative study in pulpotomized primary teeth using ferric sulphate and diluted formocresol. The most important finding from the reviewed studies was that ferric sulphate gives very good clinical and radiographic results with high tooth survival rates and with no statistically significant differences from that of formocresol. Internal resorption is a common radiographic finding in both ferric sulphate and formocresol treatments with no statistically significant differences between them. However, internal resorption differs in size and progression rate among teeth. There were cases reported in which the size of the internal resorption was very small and unchanged over time, and even cases where the area of the resorption was self-repaired with hard tissue. Some of the authors considered only teeth with progressing and/or extensive internal resorption as failures, while small size and unchanged with time internal resorption was not considered as failure. CONCLUSION: Based on the data of the reviewed studies it is suggested that ferric sulphate be used, rather than formocresol, for pulpotomies of primary teeth as the latter has been blamed for systemic and local side effects on the developing successors.
The aim of the present study was to investigate the neuropeptide CGRP in order to determine the effect on dentin bridge formation during the healing process after pulpotomy. First maxillary molars in 56-day-old Wistar rats (n=60) were used. The rats were killed for a neurohistopathological examination at 1, 3, 7, 14, and 28 days postoperatively. Neuronal changes in the residual pulp were studied using CGRP immunohistochemistry. By 1-3 days postoperatively, the CGRP-IR nerve fibers with abnormal beaded or knob-like structures were found to be more swollen than in the control and the leakage of a CGRP-IR-positive substance from the involved end of the nerve fibers was seen. At 7 days postoperatively, a vast number of newly sprouted CGRP-IR nerve fibers appeared in the residual pulp and some of them terminated in the differentiating odontoblast layer and the initial matrix layer of the dentin bridge. By 14-28 days, the nerve density had become progressively lower in the residual pulp. Regenerated axons also terminated in the odontoblast layer and the fibrous matrix layer of the calcified dentin bridge. These findings suggest that such sensory neuropeptides as CGRP may, therefore, play a role in dentin bridge formation in the rat molar.
Close association between nerve terminals and preodontoblasts, odontoblasts and predentine was observed during healing after pulpotomy. The nerve terminals frequently contained large numbers of synaptic vesicles. Terminals with many vesicles tended to be fewer in the predentine than in the odontoblastic layer. The distribution of terminals was more dense at the stage before the regenerated odontoblasts became arranged regularly beneath the predentine. It is suggested that these terminals have some efferent role(s), especially during collagen synthesis at the early stage of dentinogenesis. The nerves may release their abundant synaptic vesicles, in addition to serving a sensory role for monitoring the increased sensitivity in the injured areas.
A strong neurotensin-like immunoreactivity (NT-like IR) was detected in the odontoblast cells of the rat teeth. 4 h after a partial pulpotomy performed in two maxillary molar teeth a decreased NT-like IR was observed in the odontoblast layer located at the vicinity of the lesion together with edema and nuclear pyknosis. NT-like IR became further decreased after 24 h. After 7 days NT-like IR had almost fully disappeared with signs of necrosis of the dental pulp and infiltration of polymorphonuclear lymphocytes. It seems possible that NT like peptides in the odontoblast cell layer may play a role, e.g., in dentinogenesis and/or nociception.
A clinical case report is presented which describes the sequelae of an iatrogenic lateral crown/root perforation and a formocresol pulpotomy. The post-operative course of the initial therapy included significant hard and soft tissue destruction and eventual tooth loss. The possible implication of the role of formocresol is discussed.
Twenty human permanent teeth were used to study the pulpal response of two calcium hydroxide products, Dycal and Pulpdent Multi-Cal, after partial pulpotomy. Teeth were extracted at 4 months, fixed, and prepared for histologic examination. All 10 teeth treated with Dycal showed complete soft tissue healing and bridge formation. No stained bacteria were seen throughout the serial sections. One tooth treated with Dycal showed acceptable histologic results, dentin deposition in the root canal. Six cases dressed with Pulpdent Multi-Cal showed acceptable histologic results, whereas four teeth showed severe inflammation or necrosis associated with bacterial penetration into the pulp tissue. Clinically, one tooth treated with Pulpdent Multi-Cal showed pulpal pain and was extracted at 90 days. Our data support the thesis that human permanent pulps will promote tissue healing and dentin bridge formation as long as bacterial microleakage is excluded.
The histological response of the dental pulp after laser irradiation was studied. After pulpotomy was performed in the premolar and molar teeth of dogs, the exposed pulp tissue at the root canal opening was lased using either a CO2 or Nd:YAG laser. The laser parameters were 2 W, 10 ms, 5 times per second for 1, 2 and 3 s for CO2 laser and 2 W, 20 pulses per second for 1, 2 and 3 s for the Nd:YAG laser. Observations were made 30 and 45 days after treatment. The results revealed that laser irradiation caused carbonization, necrosis, infiltration of inflammation cells, oedema and haemorrhage in the pulp tissue. Under the conditions of this experiment, there was little histological evidence of repair to the treated pulp with a newly formed dentine barrier, which was in contrast to the control samples treated with a calcium hydroxide-containing cement (Dycal).
This study evaluated the clinical, radiographic, and histologic effects of the HGM PC Oralase argon laser on vital pulps of swine teeth. Pulpotomies were performed in vivo on 42 primary teeth from three young pigs and observed for 7 or 60 days. For each time period nine experimental teeth received an argon laser dose of 1 W, 2 sec (24.88 J/cm2), and nine experimental teeth received a dose of 2 W, 2 sec (49.74 J/cm2). Controls consisted of three teeth for each time period and did not receive exposure from the argon laser. There were no significant differences noted between the two energy densities with respect to clinical, radiographic, or histological parameters for either time period. All soft tissues remained normal and all teeth exhibited normal mobility at weekly assessments. Other than physiologic root resorption, there were no differences in pre- and postoperative radiographs in the 7 day sample; calcifications coinciding to dentinal bridges were visible radiographically in 8 of the 60-day samples. Reparative dentin formation was noted histologically in a total of 9 roots in the 7-day group and in 13 roots in the 60-day group. With the exception of teeth which had early restoration loss with resultant bacterial contamination, all other pulps appeared to retain their vitality and capability of normal pulpal healing. Use of the argon laser at the parameters described in this study did not appear to be detrimental to pulpal tissues.
The clinical success and effect upon the age at which teeth exfoliated was prospectively observed in 175 primary molars that had received formoceresol pulpotomies performed by one operator. The success rate among 142 vital teeth was 99.3% and among 33 non-vital teeth 84.8%. There was no significant effect upon age at exfoliation after either type of pulpal treatment.
The aim of this study was to evaluate whether formocresol can be used successfully in teeth with carious exposure and a vital pulp with clinical symptoms of chronic pulpitis. Further, the study concerned the influence on the success rate of the vehicle for formocresol. Pulpotomies were performed on 81 primary molars. Radiographic and other clinical symptoms were used to divide the material into a coronal chronic and a total chronic pulpitis group. Chosen by lot, zinc oxide-eugenol or Pharmatec (a plaster-like non-eugenol cement) was used as the vehicle for formocresol. After an observation period of 2.5 years the success rate for the whole material was 55%. No statistically significant difference in the rate of success could be demonstrated either between the two diagnostic groups or between the two vehicle groups.
Hyperplastic pulpitis, which is regarded as one type of asymptomatic irreversible pulpitis, occurs usually in young teeth where pulps are exposed by caries or trauma. If apices are mature, root canal therapy is recommended. In this case, the success of partial pulpotomy in a crown-fractured permanent incisor with hyperplastic pulpitis, which had been contaminated with oral microflora for six months is reported.
The exposed pulp of incompletely developed permanent incisors of nine monkeys were treated with partial pulpotomy with tungsten carbide fissure burs on an air turbine equipment. The pulps were capped with calcium hydroxide (Dycal) followed by insertion of conventional amalgam. The results were studied by conventional light microscopy after 1 and 6 months. Rod-like mineralized pulpal deposits were seen in five of the nine animals, in 9 out of 67 teeth, evenly distributed at the two observation times. Also the lengths of the deposits appeared similar, while the thickness had increased markedly after 6 months. After 1 month the presence of a central vessel lumen was observed in the deposits. The results seemed to indicate that the mechanism of formation was an initial pathologic mineralization of the vessel wall, and a growth of the deposits by the elaboration of fibrous, atubular dentin on to the outside of this wall.
This paper reviews the history, clinical success and concerns regarding the safety of formocresol as a primary molar pulpotomy medicament. The alternatives to formocresol are discussed and their advantages and disadvantages evaluated.