4 cotton pellet that has been squeezed dry, is approximately 0.02– 0.10 mg. Calcium hydroxide has had success in a variety of clinical situations including pulpotomy, root resorption, root-end closure, control of exudation and root canal infection.18, ANNA B. FUKS, JOE CAMP, in A Clinical Guide to Dental Traumatology, 2007. The Cox-regression analysis revealed that patient's age at the time of pulpotomy impacted the "hazard of exfoliation." Although the formocresol pulpotomy technique has been recommended for many years as the principal method for treating primary teeth with carious exposures, a substantial shift away from use of this medicament has occurred because of concerns about its toxic effects. The reduction of pain through pharmacological control of the inflammatory process has also been attempted in endodontics by the application of eugenol,13 and later corticosteroids and other anti-inflammatory drugs,14 as dressings. Formocresol, a mixture of formaldehyde and tricresol, has been used for pulpotomy for over six decades now. In addition, Dean et al demonstrated no statistically significant difference between the electrosurgical and formocresol pulpotomy techniques in a prospective clinical study involving 50 children requiring at least one pulpotomy.70 The children were randomly divided into two groups, with 25 undergoing the electrosurgical technique and 25 undergoing the formocresol technique. Jeffrey A. However, a study has suggested that a 1-minute exposure to full-strength formocresol is sufficient and comparable in clinical success to the 5-minute technique.93 When the pellet is removed, the amputation site should appear dark brown (when a full concentration of formocresol is used) or dark red (when the one-fifth dilution is employed). In a recent prospective study125 comparing NaOCl with formocresol examined treatment outcomes after 1 year, NaOCl demonstrated clinical and radiographic success comparable to formocresol pulpotomies. Its efficacy has been extensively studied, with clinical success rates ranging from 70% to 100%, making it the standard against which newer techniques are compared. The gray MTA had 100% radiographic success, and the white had a 93% success rate. sixty primary molars were either treated with Theracal LC or formocresol pulpotomy. Since the material cannot be kept once the envelope is opened, its clinical use in pediatric dentistry practice becomes almost prohibitive. Care must be taken to ensure that all the coronal pulp tissue has been removed. Mack and Dean reported the results of a retrospective human study of electrosurgical pulpotomies performed on primary molars. Formaldehyde is volatile and releases antimicrobial vapors when applied to a cotton pellet for pulp chamber disinfection. 69 The mean postoperative observation time for the 164 teeth studied was 2 years, 3 months. Four parts of this diluent are then mixed with one part Buckley solution to make the one-fifth dilution. Formaldehyde-containing materials, e.g. Patients have also suffered earth leakage burns from incorrectly grounded dispersive plates used in electrosurgical equipment. The alternatives are better antiseptics with significantly lower toxicity. Indeed, a Cochrane review141 concluded that among possible pulpotomy agents, two medicaments may be preferable: MTA or formocresol. Glutaraldehyde (GA) has been proposed as an alternative to formocresol because it is a mild fixative and is potentially less toxic. Calcium hydroxide, while advocated since 1930,17 has gained popularity in endodontics in the last three decades. (A) Pulp chamber after coronal pulp amputation; wide access opening prevents leaving tissue tags. The other half (experimental group) received a calcium hydroxide cap after first undergoing CO2 laser radiation until the “exposed pulps were completely sealed.” The teeth were monitored monthly. 7-18).56 Research must still pursue the conditions in which a pulpotomy is the preferred treatment regimen rather than a direct pulp cap. A second layer is then condensed to fill the access opening completely (see Fig. This solution is prepared by making a diluent of three parts glycerin and one part water. MTA paste is applied to cover the exposed radicular pulp surface with a margin of not less than 1 mm beyond the pulp dentin interface. A pulpotomy was performed on each molar; 53 teeth were treated with LLLT, and 53 teeth were treated using FC. The treatment is also completed during a single appointment. It is beyond the scope of this chapter to elaborate on these newer and still experimental techniques, but the reader is encouraged to look for future developments in the field. When using FS, the amputated pulps at the canal orifices are wiped with 15.5% solution of FS (Astringedent) for 10 to 15 seconds. However, before routine clinical use of PC can be recommended, further studies with large samples and long follow-up assessments are needed. All formaldehyde preparations are potent toxins with an antimicrobial effectiveness much lower than their toxicity.371,372. 23.14).118 Success rates comparable to those of formocresol were also reported by Smith and coworkers.120 A higher percentage of internal resorption using FS and formocresol was reported by Papagiannoulis121 after a longer follow-up time; comparable results were seen in shorter postoperative examinations. All of these preparations have a formaldehyde content well above the 10% normally used for fixation of pathologic specimens. In the same study sample at 42 months follow-up, the authors noted that 45% of the teeth that underwent pulpotomy with GA resorbed faster than their controls.109. Results: One hundred ninety-two NaOCl primary molar pulpotomies were completed in 118 patients; 131 (68%) primary molars from 77 children were available for follow-up examination (mean time since pulpotomy=10.5 months). Pulpectomy is a procedure to save a severely damaged tooth; usually a baby tooth, and it can prevent problems with chewing, speech, and overcrowding that can … The focus on the possible adverse toxic effects of medicaments15,16 led to a more systematic selection from the list of disinfectants available for use. Excessive bleeding that persists in spite of cotton pellet pressure and a deep purple color of the tissue may indicate that the inflammation has extended to the radicular pulp. 0000001347 00000 n treatment of reversible pulpitis in the University of Ghana Dental School. Although these techniques are currently being used by a number of practitioners, no long-term controlled clinical studies are available to evaluate their success, and studies have shown conflicting results.144–146, In summary, the search for alternatives to formocresol as a pulp dressing in primary tooth pulpotomies has yet to reveal an ideal agent or technique. 0000043706 00000 n 23.15. In both cases, very little or no hemorrhage is present. Each group began with 25 treated teeth, and at the end of 24 months of follow-up, of the teeth available for study, no statistically significant difference was found among the 4 groups. It is important to emphasize that the key to success, regardless of the clinician's choice of agents, is the prevention of marginal microleakage of the restoration, which could lead to bacterial contamination. James L. Gutmann DDS, Cert Endo, PhD (honoris causa), FACD, FICD, FADI, Paul E. Lovdahl DDS, MSD, FACD, FADI, in Problem Solving in Endodontics (Fifth Edition), 2011. formocresol,8 and iodoform pastes9 belong to this category and remained popular for decades. However, further studies with longer observation periods are needed before NaOCl may be recommended for routine use when performing pulpotomies on primary teeth, as demonstrated in a study126 evaluating outcomes after 18 months which found the success rate of NaOCl as being significantly less than formocresol. The systematic review and meta-analysis on primary tooth vital pulp therapy,74 mentioned previously, will be the evidence-based material to be used in the new Guideline for Pulp Therapy for Primary Teeth for the AAPD. Next, a pellet of cotton moistened with a 1:5 concentration of Buckley’s formocresol and blotted on sterile gauze to remove the excess is placed in contact with the pulp stumps and allowed to remain for 5 minutes. The area remained unchanged for 30 months. (C) The pulps stumps are covered by a zinc oxide–eugenol base. At issue was the previous pediatric dentistry specialist's recomme… PAULA J. WATERHOUSE, ... ANNA B. FUKS, in Cohen's Pathways of the Pulp (Tenth Edition), 2011, Localized accumulation of formocresol or FAD has been demonstrated in pulp, dentin, periodontal ligament, and bone surrounding the apices of pulpotomized teeth.93,193, Although animal studies have identified radioisotope-labeled formocresol or FAD in major organs following systemic injection or multiple pulpotomies, researchers concluded that the doses of formocresol were far in excess of those used in normal clinical practice. The wide acceptance of formocresol owes to factors like ease of use and excellent bactericidal properties. Rivera and colleagues71 obtained results similar to those of Dean and associates; however, Fishman and colleagues72 found considerably lower success rates with the use of electrosurgical pulpotomy. The coronal pulp is then amputated using either a sharp excavator or a slowly revolving large round bur. It has therefore been suggested that the findings should not be extrapolated to clinical use in humans.192,196,197 More recently, a review of the safety of formocresol, including FAD metabolism, suggested that FAD is rapidly metabolized, so the findings of previous studies may have been identifying FAD metabolites systemically and not FAD itself.182 Notwithstanding this, the amount of formocresol absorbed systemically by way of the pulpotomy route is small and may not contraindicate the use of the drug.220, ZVI METZGER, ... HAROLD E. GOODIS, in Cohen's Pathways of the Pulp (Tenth Edition), 2011, Formaldehyde, used as formocresol, has been used extensively in endodontic therapy despite its high toxicity and mutagenic and carcinogenic potential.221 The formaldehyde component of formocresol may vary substantially between 19% and 37%. There was no statistically significant difference between results for the two techniques, although the electrosurgical group did have four failures whereas two failures occurred in the formocresol group. When MTA was first commercialized, it had a gray coloration; but in 2002 a new white formula was created to improve on the dark color properties exhibited by the gray preparation. A case of a deep subgingival fracture treated with a formocresol pulpotomy is illustrated in Figure 3-9. Objective. 0000029620 00000 n Until such an agent is found, formocresol (either in a one-fifth dilution or full strength), FS, or MTA can be used as capping agents in primary tooth pulpotomies.147. Mandibular second primary molar presenting internal root resorption following pulpotomy with ferric sulfate. A recent 18-month follow-up randomized clinical study found similar results when Biodentine was compared with ProRoot MTA.143, Nonpharmacotherapeutic approaches to pulpotomy include the treatment of radicular pulp tissue by electrocautery or laser to eliminate residual infectious processes. 23.13A). Traditionally, a 5-min application time has been recommended; however, contact times of only a few seconds are probably equally effective. Endogenous formaldehyde is present at low levels in body fluids, with a concentration of 2–3 mg/L in human blood. It should never be applied to bleeding tissue. The roof of the pulp chamber should be removed by joining the pulp horns with bur cuts. 0000001784 00000 n Indeed, a study examined the presence of formocresol in the plasma of children undergoing oral rehabilitation involving pulp therapy under general anesthesia, and showed that formaldehyde and cresol were undetectable above baseline plasma concentration in subjects receiving pulpotomy treatment under general anesthesia.105 The authors concluded that the levels present were far below those recommended by the US Food and Drug Administration (FDA). An excellent prospective randomized clinical trial was conducted by Fernandez and others,18 comparing the use of formocresol, MTA, sodium hypochlorite, and ferric sulfate. Pulp canal obliteration was detected in 13% of the teeth treated with formocresol and in 41% of those treated with MTA. The tooth is then restored with a stainless steel crown (Fig. In all cases, if bleeding does not stop, then one should proceed to primary molar root canal therapy or extraction. They concluded that the low success rate (53%) of the pulpotomies during the first 3 months could be attributed to undiagnosed subclinical inflammation of pulps, whereas long-term failures might be associated with microleakage of the temporary restorations. This procedure should be done carefully to prevent further damage to the pulp and perforation of the pulpal floor. Guelmann and colleagues95 analyzed the success rates of emergency pulpotomies in primary molars. Before local anesthesia administration, a thorough clinical examination should be repeated, including visual examination of the vestibulum, palpation, and percussion of the involved and neighboring teeth. A recent study142 compared the success rates of PC, MTA, formocresol, and enamel matrix derivative in primary molar pulpotomies and found similar clinical and radiographic effectiveness after 24 months. 0000046650 00000 n If there is evidence of hyperemia after the removal of the coronal pulp, which indicates that inflammation is present in the tissue beyond the coronal portion of the pulp, the technique should be abandoned in favor of pulpectomy or the removal of the tooth. Rolling and Thylstrup99 demonstrated that its clinical success rate decreased as follow-up time increased. The pellets are then removed, and the pulp chamber is dried with new pellets. 0000029072 00000 n The short-term success of 2% GA as a pulpotomy agent has been demonstrated in several studies.106–111 However, longer-term success rates matching those of formocresol have not been reported. The mean age at treatment was 63.6 months and the mean postoperative observation time was 10.9 months. In 1971, Loos and Han evaluated the effects of different concentrations of formocresol and found that a 1:5 dilution was as effective as the full strength . Formocresol has been the medicament of choice for many years and its use is still widespread, mainly because of its high success rate.122 Calcium hydroxide may promote internal root resorption in primary teeth.101 Formocresol presumably fixes affected and/or radicular tissue so that a chronic inflammation replaces an acute inflammation.101, Because of the topical and systemic toxicity of formocresol and the assumption that calcium hydroxide causes internal resorption in primary teeth, other alternative agents and techniques have been suggested and studied.50,79 Numerous agents and techniques have been suggested, including ferric sulfate, glutaraldehyde, bone morphogenetic proteins, electrocautery, and lasers for pulp amputation.50,79,99. A 39-month-old girl was brought in by her mother to receive a second opinion regarding treatment for a severe occlusal caries lesion on her mandibular right primary second molar (Figure 1). Such signs indicate that the tooth is not a good candidate for formocresol pulpotomy, and pulpectomy or extraction should be done. The role of microorganisms in pulpless teeth was recognized more than a century ago,7 and strong, caustic antiseptics were popular as intracanal medicaments at the turn of the twentieth century. Mack and Dean reported the results of a retrospective human study of electrosurgical pulpotomies performed on primary molars.69 The mean postoperative observation time for the 164 teeth studied was 2 years, 3 months. 0000049843 00000 n The IARC has determined that silica is a known human carcinogen. The reparative, biologic approach to pediatric pulp therapy is either devitalization approach of formocresol pulptomy or pulpectomy. 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URL: https://www.sciencedirect.com/science/article/pii/B9780723436959000079, URL: https://www.sciencedirect.com/science/article/pii/B9780323064897000230, URL: https://www.sciencedirect.com/science/article/pii/B9780323064897000084, URL: https://www.sciencedirect.com/science/article/pii/B9780323057240500230, URL: https://www.sciencedirect.com/science/article/pii/B9780323287456000132, URL: https://www.sciencedirect.com/science/article/pii/B9780702031564000140, URL: https://www.sciencedirect.com/science/article/pii/B9780323608268000237, URL: https://www.sciencedirect.com/science/article/pii/B9780323068888000076, URL: https://www.sciencedirect.com/science/article/pii/B9780702031564000115, URL: https://www.sciencedirect.com/science/article/pii/B9780323040396500093, Pulp therapy for primary and immature permanent teeth, Handbook of Pediatric Dentistry (Fourth Edition), PAULA J. WATERHOUSE, ... ANNA B. FUKS, in, Cohen's Pathways of the Pulp (Tenth Edition), Treatment of Deep Caries, Vital Pulp Exposure, and Pulpless Teeth, Ralph E. McDonald, ... Jeffrey A. If your child complains of pain when cold, hot or sweet things touch their tooth/teeth, it may mean that he/she has pulpitis. Although the recommendation is that the blotted cotton pellet moistened with a 1:5 concentration of formocresol be applied to the pulp stumps for 5 minutes, the 5-minute application time has been determined somewhat arbitrarily. The indication was primarily the presence of a carious exposure and desire to retain the primary tooth until exfoliation. Following coronal pulp amputation, one or more cotton pellets should be placed over each amputation site, and pressure should be applied for a few minutes. Pellets are then mixed with one part water bactericidal properties, amid controversies. Help provide and enhance our service and tailor content and ads pledget prior to application alternative formocresol... 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