Periodontal Problems in Children and Adolescents










340 Part 3 The Primary Dentition Years: Three to Six Years
of any signs and/or symptoms of inammation extending beyond
the coronal pulp is a contraindication for a pulpotomy. us, a
pulpotomy is contraindicated when any of the following are present:
swelling (of pulpal origin), stula, pathologic mobility, pathologic
external root resorption, internal root resorption, periapical or
interradicular radiolucency, pulp calcications, or excessive bleeding
from the amputated radicular stumps. Other signs, such as a history
of spontaneous or nocturnal pain or tenderness to percussion or
palpation, should be interpreted carefully (see Fig. 23.4A and B).
e ideal dressing material for the radicular pulp should (1)
be bactericidal, (2) be harmless to the pulp and surrounding
structures, (3) promote healing of the radicular pulp, and (4) not
interfere with the physiologic process of root resorption. A good
deal of controversy surrounds the issue of pulpotomy agents, and
unfortunately the “ideal” pulp dressing material has not yet been
identied. A decade ago, the most commonly used pulp dressing
material was formocresol (Buckley solution: formaldehyde, cresol,
glycerol, and water). Primosch and associates
89
reported in 1997
that the majority of the predoctoral pediatric dental programs in
the United States advocated the use of either full-strength formo-
cresol (22.6% of programs) or a one-fth dilution of formocresol
(71.7% of programs) as the preferred pulpotomy medicament for
vital primary teeth. However, more recent surveys have shown
that formocresol is no longer the most commonly taught medica-
ment for pulpotomy. In the United States, a 2008 survey detected
a trend away from the teaching of 1 : 5 diluted formocresol, with
more using ferric sulfate (FS) for pulpotomy; still, 22% of programs
recommended full-strength formocresol.
90
Conversely, in Brazilian dental schools, the pulpotomy agent
that students are most frequently taught to use is diluted formo-
cresol.
91
A study surveying the teaching practices in the United
Kingdom and Ireland showed a preference for FS, with 93% of
respondents advocating its use for pulpotomy.
92
Evidently, phi-
losophies and approaches to pulpotomy agents vary among countries
and regions, and even among dental schools. Issues regarding the
selection of pulpotomy medicaments will be discussed later in this
chapter.
Pulpotomy Technique
Before local anesthesia administration, a thorough clinical examina-
tion should be repeated, including visual examination of the
vestibulum, palpation, and percussion of the involved and neighbor-
ing teeth. After local anesthesia has been given and the rubber
dam placed, all supercial caries should be removed before pulpal
exposure to minimize bacterial contamination following exposure.
e roof of the pulp chamber should be removed by joining the
pulp horns with bur cuts. is procedure is usually accomplished
using a no. 330 bur mounted in a water-cooled high-speed turbine.
e coronal pulp is then amputated using either a sharp excavator
or a slowly revolving large round bur. is procedure should be
done carefully to prevent further damage to the pulp and perforation
of the pulpal oor. Care must be taken to ensure that all the
coronal pulp tissue has been removed. Tags of tissue remaining
under ledges of dentin may continue to bleed, masking the actual
status of the radicular pulp stumps and thus obscuring a correct
diagnosis (Fig. 23.13A).
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. When the cotton pellets are removed,
hemostasis should be apparent, although a minor amount of wound
bleeding may be evident (see Fig. 23.13B). Excessive bleeding that
persists in spite of cotton pellet pressure and a deep purple color
and the exposed pulp with an antibacterial solution such as
chlorhexidine or a xative such as formocresol or a weak glutar-
aldehyde solution,” replacing calcium hydroxide with dentin-bonding
agents. In another publication a year later, Araujo and colleagues
82
examined histologically primary molars with microexposures that
were successfully treated with a composite acid etch technique and
then extracted or exfoliated. ese authors observed microabscesses
adjacent to the exposure site, and no dentin bridge was formed
in any specimen. ese results were conrmed by Pameijer and
Stanley,
83,84
who concluded that “the belief that any material placed
on an exposed pulp will allow bridge formation as long as the
cavity is disinfected is a fallacy.” In a review on pulp capping with
dentin-adhesive systems, Costa and coworkers
85
reported that
self-etching adhesive systems led to inammatory reactions, delay
in pulpal healing, and failure of dentin bridging in human pulps
capped with bonding agents. ey state that vital pulp therapy
using acidic agents and adhesive resins seems to be
contraindicated.
Although guidelines published by the AAPD do not recommend
DPC for caries exposed primary teeth,
31
promising results (over
90% success) of recent clinical trials may challenge that policy in
the near future.
86–88
MTA, bonding agents, and enamel derivate
protein (Emdogain), with or without prior rinsing of the exposed
pulp with saline or an antibacterial solution such as sodium
hypochlorite or chlorhexidine, were compared with calcium
hydroxide as capping agents. Regardless of the methodology used,
very strict inclusion criteria were common to all tested teeth: absence
of clinical and radiographic signs and symptoms such as swelling,
abnormal mobility, presence of stula, spontaneous pain, sensitivity
to percussion, and furcation involvement. In addition, all exposed
pulps had to be limited to 1.0 mm or less. In only one study,
rubber dam isolation was not used,
88
and bonding agents’ techniques
were compared with calcium hydroxide as pulp protection. Relative
isolation did not interfere with the outcome. A high success rate
was only obtained when phosphoric acid and non-rinse conditioners
did not directly contact the pulp. Restorations of the treated teeth
were performed with amalgam only,
88
amalgam and resin-based
materials followed by a sealant coverage,
86
and stainless steel
crowns.
87
Coll et al.
74
reported that up to 24 months, “DPC showed
similar success rates to IPT and MTA or FC pulpotomies, but the
quality of evidence was lower.” When long-term results (beyond
24 months) of these procedures are available, more denitive
conclusions can be drawn regarding this technique for primary
teeth.
Presently, DPC in primary teeth should still be viewed with some
reservations. However, this treatment could be recommended for exposed
pulps in older children, 1 or 2 years before normal exfoliation. In
these children, a failure of treatment would not require the use of a
space maintainer following extraction, as it would in younger
children.
Pulpotomy
As stated previously, recent evidence suggests that IPT (selective
removal to soft dentin) is preferred over the traditional pulpotomy.
All eorts should be made to avoid pulpal exposure when treating
deep carious lesions. However, when the carious process has reached
the pulp or in incidences of direct pulpal exposure during excavation
of a carious lesion, the pulpotomy procedure is indicated and is
the treatment of choice.
e pulpotomy procedure is based on the rationale that the
radicular pulp tissue is healthy or is capable of healing after surgical
amputation of the aected or infected coronal pulp.
1,2
e presence

You're Reading a Preview

Become a DentistryKey membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Was this article helpful?

340 Part 3 The Primary Dentition Years: Three to Six Yearsof any signs and/or symptoms of inammation extending beyond the coronal pulp is a contraindication for a pulpotomy. us, a pulpotomy is contraindicated when any of the following are present: swelling (of pulpal origin), stula, pathologic mobility, pathologic external root resorption, internal root resorption, periapical or interradicular radiolucency, pulp calcications, or excessive bleeding from the amputated radicular stumps. Other signs, such as a history of spontaneous or nocturnal pain or tenderness to percussion or palpation, should be interpreted carefully (see Fig. 23.4A and B).e ideal dressing material for the radicular pulp should (1) be bactericidal, (2) be harmless to the pulp and surrounding structures, (3) promote healing of the radicular pulp, and (4) not interfere with the physiologic process of root resorption. A good deal of controversy surrounds the issue of pulpotomy agents, and unfortunately the “ideal” pulp dressing material has not yet been identied. A decade ago, the most commonly used pulp dressing material was formocresol (Buckley solution: formaldehyde, cresol, glycerol, and water). Primosch and associates89 reported in 1997 that the majority of the predoctoral pediatric dental programs in the United States advocated the use of either full-strength formo-cresol (22.6% of programs) or a one-fth dilution of formocresol (71.7% of programs) as the preferred pulpotomy medicament for vital primary teeth. However, more recent surveys have shown that formocresol is no longer the most commonly taught medica-ment for pulpotomy. In the United States, a 2008 survey detected a trend away from the teaching of 1 : 5 diluted formocresol, with more using ferric sulfate (FS) for pulpotomy; still, 22% of programs recommended full-strength formocresol.90Conversely, in Brazilian dental schools, the pulpotomy agent that students are most frequently taught to use is diluted formo-cresol.91 A study surveying the teaching practices in the United Kingdom and Ireland showed a preference for FS, with 93% of respondents advocating its use for pulpotomy.92 Evidently, phi-losophies and approaches to pulpotomy agents vary among countries and regions, and even among dental schools. Issues regarding the selection of pulpotomy medicaments will be discussed later in this chapter.Pulpotomy TechniqueBefore local anesthesia administration, a thorough clinical examina-tion should be repeated, including visual examination of the vestibulum, palpation, and percussion of the involved and neighbor-ing teeth. After local anesthesia has been given and the rubber dam placed, all supercial caries should be removed before pulpal exposure to minimize bacterial contamination following exposure. e roof of the pulp chamber should be removed by joining the pulp horns with bur cuts. is procedure is usually accomplished using a no. 330 bur mounted in a water-cooled high-speed turbine. e coronal pulp is then amputated using either a sharp excavator or a slowly revolving large round bur. is procedure should be done carefully to prevent further damage to the pulp and perforation of the pulpal oor. Care must be taken to ensure that all the coronal pulp tissue has been removed. Tags of tissue remaining under ledges of dentin may continue to bleed, masking the actual status of the radicular pulp stumps and thus obscuring a correct diagnosis (Fig. 23.13A).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. When the cotton pellets are removed, hemostasis should be apparent, although a minor amount of wound bleeding may be evident (see Fig. 23.13B). Excessive bleeding that persists in spite of cotton pellet pressure and a deep purple color and the exposed pulp with an antibacterial solution such as chlorhexidine or a xative such as formocresol or a weak glutar-aldehyde solution,” replacing calcium hydroxide with dentin-bonding agents. In another publication a year later, Araujo and colleagues82 examined histologically primary molars with microexposures that were successfully treated with a composite acid etch technique and then extracted or exfoliated. ese authors observed microabscesses adjacent to the exposure site, and no dentin bridge was formed in any specimen. ese results were conrmed by Pameijer and Stanley,83,84 who concluded that “the belief that any material placed on an exposed pulp will allow bridge formation as long as the cavity is disinfected is a fallacy.” In a review on pulp capping with dentin-adhesive systems, Costa and coworkers85 reported that self-etching adhesive systems led to inammatory reactions, delay in pulpal healing, and failure of dentin bridging in human pulps capped with bonding agents. ey state that vital pulp therapy using acidic agents and adhesive resins seems to be contraindicated.Although guidelines published by the AAPD do not recommend DPC for caries exposed primary teeth,31 promising results (over 90% success) of recent clinical trials may challenge that policy in the near future.86–88 MTA, bonding agents, and enamel derivate protein (Emdogain), with or without prior rinsing of the exposed pulp with saline or an antibacterial solution such as sodium hypochlorite or chlorhexidine, were compared with calcium hydroxide as capping agents. Regardless of the methodology used, very strict inclusion criteria were common to all tested teeth: absence of clinical and radiographic signs and symptoms such as swelling, abnormal mobility, presence of stula, spontaneous pain, sensitivity to percussion, and furcation involvement. In addition, all exposed pulps had to be limited to 1.0 mm or less. In only one study, rubber dam isolation was not used,88 and bonding agents’ techniques were compared with calcium hydroxide as pulp protection. Relative isolation did not interfere with the outcome. A high success rate was only obtained when phosphoric acid and non-rinse conditioners did not directly contact the pulp. Restorations of the treated teeth were performed with amalgam only,88 amalgam and resin-based materials followed by a sealant coverage,86 and stainless steel crowns.87 Coll et al.74 reported that up to 24 months, “DPC showed similar success rates to IPT and MTA or FC pulpotomies, but the quality of evidence was lower.” When long-term results (beyond 24 months) of these procedures are available, more denitive conclusions can be drawn regarding this technique for primary teeth.Presently, DPC in primary teeth should still be viewed with some reservations. However, this treatment could be recommended for exposed pulps in older children, 1 or 2 years before normal exfoliation. In these children, a failure of treatment would not require the use of a space maintainer following extraction, as it would in younger children.PulpotomyAs stated previously, recent evidence suggests that IPT (selective removal to soft dentin) is preferred over the traditional pulpotomy. All eorts should be made to avoid pulpal exposure when treating deep carious lesions. However, when the carious process has reached the pulp or in incidences of direct pulpal exposure during excavation of a carious lesion, the pulpotomy procedure is indicated and is the treatment of choice.e pulpotomy procedure is based on the rationale that the radicular pulp tissue is healthy or is capable of healing after surgical amputation of the aected or infected coronal pulp.1,2 e presence CHAPTER 23 Pulp Therapy for the Primary Dentition 341 acceptable interim restoration until the stainless steel crown can be placed.e MTA and FS procedures are essentially the same with either of the medicaments used in place of formocresol. e MTA is prepared as per manufacturer’s instructions. 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. When using FS, the amputated pulps at the canal orices are wiped with 15.5% solution of FS (Astringedent) for 10 to 15 seconds. Next, Astringe-dent is ushed from the pulp chamber with water. In all cases, if bleeding does not stop, then one should proceed to primary molar root canal therapy or extraction.Guelmann and colleagues95 analyzed the success rates of emergency pulpotomies in primary molars. ey concluded that the low success rate (53%) of the pulpotomies during the rst 3 months could be attributed to undiagnosed subclinical inammation of pulps, whereas long-term failures might be associated with microleakage of the temporary restorations.Clinical and radiographic studies have demonstrated that formocresol pulpotomies have success rates ranging from 70% to 97%.96–99 e use of a one-fth dilution of formocresol has been advocated by several authors96,97 because of its reportedly equal eectiveness and potential for less toxicity. is solution is prepared by making a diluent of three parts glycerin and one part water. of the tissue may indicate that the inammation has extended to the radicular pulp. Such signs indicate that the tooth is not a good candidate for formocresol pulpotomy, and pulpectomy or extraction should be done. No intrapulpal local anesthesia or other hemostatic agent should be used to minimize hemorrhage, because bleeding is a clinical indicator of the radicular pulp status. Following hemostasis, a cotton pellet moistened with Buckley solution (full concentration or one-fth solution) is placed over the pulp stumps for 5 minutes. However, a study has suggested that a 1-minute exposure to full-strength formocresol is sucient 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-fth dilution is employed). In both cases, very little or no hemorrhage is present. A base of ZOE (either plain or reinforced) is placed over the amputation site and lightly condensed to cover the pulpal oor. A second layer is then condensed to ll the access opening completely (see Fig. 23.13C). e nal restoration is preferably a stainless steel crown, which should be placed at the same appointment (see Fig. 23.13D). Holan and coworkers94 observed that pulpotomized primary molars could be successfully restored with one-surface amalgams if their natural exfoliation is expected within 2 years or less. However, if placing the nal restoration is not possible, the ZOE base will serve as an A BC D• Figure 23.13 Pulpotomy technique steps. (A) Pulp chamber after coronal pulp amputation; wide access opening prevents leaving tissue tags. (B) After hemostasis and formocresol application, the tissue at the entrance of the canals shows dark color, a sign of tissue xation. (C) The pulps stumps are covered by a zinc oxide–eugenol base. (D) The tooth is restored with a stainless steel crown. (Courtesy Nathan Rosenfarb, DDS.) 342 Part 3 The Primary Dentition Years: Three to Six Yearsinitial ndings. Areas listed initially as internal resorption on the preliminary report remained unchanged after 30 months, and thus were reassessed as normal in the last evaluation (Fig. 23.14).118 Success rates comparable to those of formocresol were also reported by Smith and coworkers.120 A higher percentage of internal resorp-tion using FS and formocresol was reported by Papagiannoulis121 after a longer follow-up time; comparable results were seen in shorter postoperative examinations. A recent systematic review and meta-analysis concluded that pulpotomies performed with either formocresol or FS in primary molars have similar clinical and radiographic success, and that FS may be recommended as a suitable replacement for formocresol.122 Based in these studies, FS can still be an appropriate and inexpensive solution for pulpotomies in primary teeth.Preliminary studies have investigated the use of 5% sodium hypochlorite (NaOCl) as a primary molar pulpotomy agent. A pilot study by Vargas and colleagues123 showed promising results after a 12-month period, and a retrospective study124 conrmed these ndings. Both studies concluded that clinical and radiographic success rates for NaOCl pulpotomies are comparable to FS and formocresol pulpotomies. 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. 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 signicantly less than formocresol.An evidence-based proven alternative to formocresol with reported success rates equal and even surpassing those of formocresol and all other pulpotomy agents is MTA.127 MTA was developed by Torabinejad at Loma Linda University in the 1990s, rst described in the dental scientic literature by Lee and colleagues128 in 1993, and approved by the FDA in 1998. It is a mixture of a rened Portland cement (PC), dicalcium silicate, tricalcium silicate, tricalcium aluminate, gypsum, and tetracalcium aluminoferrite; bismuth oxide is also added, making the material radiopaque. Both in vitro and in vivo investigations have shown that MTA has many positive properties such as excellent biocompatibility, an alkaline pH, radiopacity, a high sealing capacity, and the ability to induce the formation of dentin, cement, and bone.129In a preliminary study comparing MTA with formocresol, with follow-ups ranging from 6 to 30 months, none of the MTA-treated teeth showed a clinical or radiographic pathologic process. Pulp Four parts of this diluent are then mixed with one part Buckley solution to make the one-fth dilution.Although many studies have reported the clinical success of formocresol pulpotomies, an increasing body of literature has ques-tioned the use of formocresol. Rolling and ylstrup99 demonstrated that its clinical success rate decreased as follow-up time increased. Furthermore, the histologic response of the primary radicular pulp to formocresol appears to be unfavorable. A classic study claims that, subsequent to formocresol application, xation occurs in the coronal third of the radicular pulp, chronic inammation in the middle third, and vital tissue in the apical third.100 Others report that the remaining pulp tissue is partially or totally necrotic.101 Several reports have questioned the safety of formocresol,102,103 and most authorities now agree that formocresol is at least potentially mutagenic, carcinogenic, and toxic when used in high concentrations and under specic conditions in animal studies. However, there are no documented cases of systemic distribution or pathologic tissue changes associated with the use of formocresol in humans.104 e doses used in animal models far exceed those used in clinical practice; normal clinical doses carry little risk for patients. 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 e authors concluded that the levels present were far below those recommended by the US Food and Drug Administration (FDA). It is unlikely that formocresol, when used in the doses typically employed for a vital pulpotomy procedure, poses any risk to children. Nevertheless, amid the controversies and concerns, eorts have increased to nd a substitute medicament.Potential Substitutes for FormocresolGlutaraldehyde (GA) has been proposed as an alternative to formocresol because it is a mild xative and is potentially less toxic. Because of its cross-linking properties, penetration into the tissue is more limited, with less eect on periapical tissues. e 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. Fuks and associates107 reported a failure rate of 18% in human primary molars 25 months after pulpotomy, using a 2% concentration of GA. 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.109Some biological materials have been proposed as pulp dressings, on the theoretical basis that they would promote physiologic healing of the pulpotomy wound. Varying levels of success in early experimental studies have been reported with freeze-dried bone112 autolyzed, antigen-extracted, allogeneic dentin matrix113; allogeneic BMP,14 a fully synthetic nanocrystalline hydroxyapatite paste114; enriched collagen solutions115; and Biodentine, a calcium-silicate–based material.116 Clinical studies have reported promising results using FS, a hemostatic agent, in pulpotomized human primary teeth.117,118 Fuks and colleagues119 reported a success rate of 93% in teeth treated with FS and 84% in those where diluted formocresol (DFC) was employed. ese teeth were followed up from 6 to 35 months. In a preliminary report of the same study, a much lower success rate was described (77.5% for the FS group and 81% for the DFC teeth), with internal resorption evident in ve teeth treated with FS and four teeth xed with DFC.118 is discrepancy can be explained by an excessively severe interpretation of the • Figure 23.14 Mandibular second primary molar presenting internal root resorption following pulpotomy with ferric sulfate. The area remained unchanged for 30 months. CHAPTER 23 Pulp Therapy for the Primary Dentition 343 before routine clinical use of PC can be recommended, further studies with large samples and long follow-up assessments are needed.Newer bioactive cements such as Biodentine have been used as pulpotomy agents with promising results. A recent 18-month follow-up randomized clinical study found similar results when Biodentine was compared with ProRoot MTA.143Nonpharmacotherapeutic approaches to pulpotomy include the treatment of radicular pulp tissue by electrocautery or laser to eliminate residual infectious processes. 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 conicting results.144–146In summary, the search for alternatives to formocresol as a pulp dressing in primary tooth pulpotomies has yet to reveal an ideal agent or technique. Until such an agent is found, formocresol (either in a one-fth dilution or full strength), FS, or MTA can be used as capping agents in primary tooth pulpotomies.147e 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 erapy for Primary Teeth for the AAPD. is review demonstrated that the “highest level of success and quality of evidence supported IPT and the pulpotomy techniques of MTA and FC for the treatment of deep caries in primary teeth after 24 months. Direct pulp capping showed similar success rates to IPT and MTA or FC pulpotomies, but the quality of evidence was lower.” e comparable success rates for all three vital pulp therapy techniques (IPT, DPC, and pulpotomy) provide more latitude in treatment choices for the practitioner in managing a vital primary tooth with deep caries.Nonvital Pulp Therapy for Irreversible Pulpitis or Necrotic Pulp: Pulpectomy and Root Fillinge pulpectomy procedure is indicated in teeth that show evidence of chronic inammation or necrosis in the radicular pulp. Con-versely, pulpectomy is contraindicated in teeth with gross loss of root structure, advanced internal or external resorption, or periapical infection involving the crypt of the succedaneous tooth. e goal of pulpectomy is to maintain primary teeth that would otherwise be lost. However, clinicians disagree about the utility of pulpectomy procedures in primary teeth. Diculty in the preparation of primary root canals that have complex and variable morphologic features and uncertainty about the eects of instrumentation, medication, and lling materials on developing succedaneous teeth dissuade some clinicians from using the technique. e behavior management problems that sometimes occur in pediatric patients have surely added to the reluctance among some dentists to perform root canal treatments in primary teeth. ese problems notwithstanding, the success of pulpectomies in primary teeth has led most pediatric dentists to prefer them to the alternative of extractions and space maintenance.Certain clinical situations may justify pulpectomy, even with the knowledge that the prognosis may not be ideal. An example of such a case is pulp destruction of a primary second molar that occurs before the rst permanent molar erupts. A premature extraction of the primary second molar without placement of a space maintainer usually results in mesial eruption of the rst permanent molar with subsequent loss of space for the second premolar (Fig. 23.16A and B). Although a distal shoe space maintainer could be used, maintaining the natural tooth is denitely the treatment of choice. erefore, a pulpectomy in a primary second molar is preferable, even if that tooth is maintained only canal obliteration was detected in 13% of the teeth treated with formocresol and in 41% of those treated with MTA. A radiograph of two primary molars treated with MTA is presented in Fig. 23.15. Internal root resorption, a nding seen both in FS- and DFC-treated teeth in other studies,119,121 was not observed in MTA-treated teeth in the preliminary report.130 Longer clinical studies have since been published with high success rates.131–137 Holan and associates138 investigated MTA eects in 33 pulpotomized molars during a median follow-up evaluation period of 38.2 months, reporting a success rate of 97%. Farsi and coworkers139 compared the eect of MTA in 60 pulpotomized molars with those of formocresol followed during 2 years and noted a success rate of 100%.When MTA was rst 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. White MTA has smaller particles and does not contain tetracalcium aluminoferrite or iron, both were found in gray MTA. Cardoso-Silva and colleagues140 compared the results of gray and white MTA pulpotomies in a sample of 233 primary molars, with a maximum follow-up period of 84 months. e gray MTA had 100% radio-graphic success, and the white had a 93% success rate. Another interesting nding was that gray MTA showed a signicantly higher number of dentine bridge formation than white MTA. MTA is commercially available as ProRoot MTA (DENTSPLY Tulsa Dental Products, Tulsa, OK), and more recently as MTA-Angelus (Angelus Soluções Odontológicas, Londrina, Brazil), but its price is very high. Since the material cannot be kept once the envelope is opened, its clinical use in pediatric dentistry practice becomes almost prohibitive. Indeed, a Cochrane review141 concluded that among possible pulpotomy agents, two medicaments may be preferable: MTA or formocresol. However, the authors state that the cost of MTA may preclude its routine clinical use. Consequently, great interest has been focused on the evolution of PC as an alternative to MTA, and several experimental studies have compared both materials.PC diers from MTA by the absence of bismuth ions and the presence of potassium ions. Both materials have comparable antibacterial activity and almost identical properties macroscopically, microscopically, and by x-ray diraction analysis. 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 eectiveness after 24 months. However, • Figure 23.15 Mandibular rst and second primary molars 36 months after pulpotomy with mineral trioxide aggregate. Pulp canal obliteration is evident in the distal root of the second molar; both procedures were rated as successful. 344 Part 3 The Primary Dentition Years: Three to Six Yearsthe endodontic pressure syringe to overcome the problem of underlling, a relatively common nding when thick mixes of ZOE are employed. However, underlling is frequently clinically acceptable. Primary teeth frequently present with interradicular radiolucent areas but without periapical lesions, and they sometimes even have some vital pulp at the apex (Fig. 23.18A and B). Conversely, overlling may cause a mild foreign body reaction, and it has also been associated with increased failure rate when compared with underlling or ush nishing.157 Success rate with this material varied between 65% and 100%, with an average of 83%, and no signicant dierence could be observed when ZOE was compared with other calcium hydroxide and/or iodoform pastes.157–161Another disadvantage of ZOE is that it may remain in the alveolar bone for a long time, although it is not certain that this has a clinically signicant eect (Fig. 23.19A and B).Iodoform-Based Pastes. Several authors have reported the use of Kri paste (Pharmachemie, Zurich, Switzerland), which is a mixture of iodoform, camphor, parachlorophenol, and menthol. It resorbs rapidly and has no undesirable eects on succedaneous teeth when used as a pulp canal medicament in abscessed primary teeth. Further, Kri paste extruded into periapical tissues is rapidly replaced with normal tissue.157 Sometimes the material is also resorbed inside the root canal (Fig. 23.20A and B).A paste developed by Maisto has been used clinically for many years, with good results reported.162,163 is paste has the same components as the Kri paste, with the addition of zinc oxide, thymol, lanolin, and calcium hydroxide.Although not very popular, calcium hydroxide, in a ready-mixed paste delivered via syringe or in a combination of two pastes (base and catalyst), has also been used as root canal lling in primary teeth. Clinical studies report an average success rate of 88%.160,161 When iodoform and silicone oil were added to calcium hydroxide, a new paste, Vitapex (Neo Dental Chemical Products, Tokyo) or Diapex (DiaDent Group International, Burnaby, British Columbia, Canada), as commercialized in North America, has been clinically and histologically investigated.164 ese authors found that this material is easy to apply, resorbs at a slightly faster rate than that of the roots (complete resorption of the excess paste is expected within 2 to 8 weeks164), has no toxic eects on the permanent successor, and is radiopaque. For these reasons, Machida148 considers the calcium hydroxide–iodoform mixture to be a nearly ideal primary tooth lling material.until the rst permanent molar has adequately erupted and is followed eventually by extraction of the primary second molar and placement of a space maintainer (Fig. 23.17A–D).Root Canal Filling MaterialsDevelopmental, anatomic, and physiologic dierences between primary and permanent teeth call for dierences in the criteria for root canal lling materials. e ideal root canal lling material for primary teeth should resorb at a rate similar to that of the primary root, be harmless to the periapical tissues and to the permanent tooth germ, resorb readily if pressed beyond the apex, be antiseptic, ll the root canals easily, adhere to their walls, not shrink, be easily removed if necessary, be radiopaque, and not discolor the tooth.148 No material currently available meets all of these criteria. Several investigators assessed clinically and radiographically dierent root lling materials.149–155 ese studies had no controls, and their relevance is limited.e lling materials most commonly used for primary pulp canals are ZOE paste, iodoform-based paste, calcium hydroxide, and calcium hydroxide and iodoform in combination.2Zinc Oxide–Eugenol Paste. ZOE is a commonly used lling material for primary teeth in the United States. Camp156 introduced • Figure 23.17 Nonvital maxillary second primary molar, treated by pulp-ectomy with zinc oxide–eugenol (ZOE). Top left, Before pulpectomy. Top right, Contralateral vital tooth. Bottom left, Excess of ZOE in palatal and distobuccal canals. Bottom right, Primary tooth successfully retained until eruption of rst permanent molar. AB• Figure 23.16 (A) Occlusal view of the permanent dentition following bilateral premature extractions of the maxillary primary second molars. The right second bicuspid erupted ectopically, and the left is impacted. (B) Radiograph of the area showing the impacted left premolar. (Courtesy Ilana Brin, DMD.) CHAPTER 23 Pulp Therapy for the Primary Dentition 345 A B• Figure 23.18 (A) Mandibular second primary molar immediately after completion of root canal treat-ment with Endoas. Note the interradicular radiolucent area and lling slightly short of the apex on the distal canal. (B) The same tooth 3 years later showing healing of the lesion. (Courtesy Moti Moskovitz, DMD.)A B• Figure 23.19 (A) Maxillary primary central incisor with excessive zinc oxide–eugenol (ZOE) immediately after pulpectomy. (B) Permanent successor of the root-treated primary tooth showing remnants of ZOE in the alveolar bone. (From Fuks AB, Eidelman E. Pulp therapy in the primary dentition. Curr Opin Dent. 1991;1:556–563.)A B• Figure 23.20 (A) Mandibular second primary molar pulpectomy with Kri paste. Note the excess of material immediately after treatment. (B) Nine months after treatment, the material has resorbed consider-ably and the lamina dura appears normal. (Courtesy Gideon Holan, DMD.) 346 Part 3 The Primary Dentition Years: Three to Six Yearsof organic debris is the main purpose for ling. e canal should be periodically irrigated to aid in removing debris. A sodium hypochlorite and/or a chlorhexidine solution should be used to ensure optimal decontamination of the canal(s).154 However, because of the possibility that sodium hypochlorite solution could be forced into the periapical tissues, it should be used very carefully and with the minimum irrigation pressure.172 Sterile saline rinses should follow each chemical irrigant. e canal is dried with appropriately sized paper points. Other methods of canal preparation use nickel-titanium (Ni-Ti) instrumentation,151,173,174 laser therapy,175 and ultrasonic instrumentation.176,177 Advantages of these techniques may include better cleaning and shaping of the canal, promoting a more uniform paste ll. Disadvantages include equipment cost and the learning curve necessary to become procient with the techniques.When a ZOE mixture is used, several lling techniques may be employed. For large canals, as in primary anterior teeth, a thin mixture can be used to coat the walls of the canal, followed by a thick mixture that can be manually condensed into the remainder of the lumen. An endodontic plugger or a small amalgam condenser is useful for compacting the paste at the level of the canal orice. Care should be taken not to overll the canal. In primary molars, some of the canals may be quite small and dicult to ll. Com-mercial pressure syringes have been developed for this purpose. An alternative technique is to use a disposable tuberculin syringe or a local anesthetic syringe, in which the anesthetic capsule is emptied, after which the canal is dried and lled with ZOE paste.When the root canal is lled with a resorbable paste such as Kri, Maisto, or Endoas, a Lentulo spiral mounted on a low-speed turbine can be used, facilitating introduction of the material into the canal. When the canal is completely lled (observed by diculty in introducing more paste), the material is compressed with a cotton pellet. Excessive extruded material is rapidly resorbed (see Fig. 23.19A and B).Vitapex (Diapex) is packed in a very convenient and sterile syringe, and the paste is injected into the canal with disposable plastic needles. is technique is particularly easy to use for primary incisors but less practical for narrow canals of primary molars.152Regardless of the root lling material used, an immediate postoperative periapical radiograph should be taken with two purposes:1. Evaluate the quality of the ll and consider prescribing antibiotics in cases of excessive overll.2. Provide a baseline for assessing and comparing the success of the root canal treatment in follow-up visits.Another preparation with similar composition is available in the United States under the trade name Endoas (Sanlor Labora-tories, Cali, Colombia). e results of root canal treatments using Endoas in a student’s clinic reported similar results to those observed with Kri paste.153 A complete review of lling materials for primary root canals has been published by Kubota and associ-ates.165 A recent systematic review indicated that Vitapex has better results when compared with ZOE.141e goals of the “lesion sterilization technique” are to sterilize the lesion and avoid use of mechanical instrumentation in the canal. In an eort to eliminate bacteria and promote disinfection of oral infections, a mixture of three antibacterial drugs (metro-nidazole, ciprooxacin, and minocycline) in a ratio of 1 : 3 : 3 with propylene glycol has been suggested.166 A high success rate has been reported treating carious lesions with or without pulpal and periapical involvement, but concerns about spreading resistant bacteria have been raised.166,167 us this technique should be recommended for revascularization of immature, necrotic, perma-nent teeth, and its success has been widely documented in the endodontic literature.168–170 See Chapter 34 for a comprehensive discussion of this technique.Pulpectomy Techniquee pulpectomy procedure should be performed as follows: An access opening should be prepared similar to the methods used in a pulpotomy, but the walls may need aring more to facilitate access of the canal openings for broaches and les.156 Each canal orice of the roots should be located and a properly sized barbed broach selected. Primary molar roots are usually curved to allow for the development of the succedaneous tooth. During instrumenta-tion, these curves increase the chance of perforation of the apical portion of the root or the coronal one-third of the canal into the furcation.171 e instruments should be slightly bent to adjust to the curvature of the canals, thus preventing perforations on the outer and inner portions of the root (Fig. 23.21).e broach is used gently to remove as much organic material as possible from each canal. Endodontic les are selected and adjusted to stop 1 or 2 mm short of the radiographic apex of each canal, as determined by a radiograph (Fig. 23.22). is is an arbitrary length but is intended to minimize the chance of apical over-instrumentation that may cause periapical damage. e removal • Figure 23.21 Perforations on the convex (1) and concave (2) aspects of a root of a primary molar caused by injudicious use of root canal instruments. • Figure 23.22 Radiographic determination of the length of the canals. CHAPTER 23 Pulp Therapy for the Primary Dentition 347 Criteria for Radiographic SuccessAnother point to consider is the criteria for radiographic assessment. Traditionally, root treatments were considered successful when no pathologic resorption associated with bone rarefaction was present.149,158 Payne and associates178 claim that most clinicians are prepared to accept pulp-treated primary teeth that have a limited degree of radiolucency or pathologic root resorption (Po), in the absence of clinical signs and symptoms. is is contingent on the assurance that the parent will contact the dentist if there is an acute problem and the patient will return for recall in 6 months. According to Payne and colleagues,178 most of the pulp therapy studies in the existing literature have considered such teeth to be “successfully treated.” ese criteria seem to be more suitable for pediatric dentist practices and have been adopted clinically by Fuks and coworkers.153 ese authors, despite describing a low overall success rate (69%) because it did not include teeth in which the pathologic lesion was not completely healed (Po), extracted only one tooth (Px), whereas the remaining (Po) teeth were left for follow-up.Adverse eects of root canal treatment of primary teeth may occur. Disturbances of the development of permanent tooth bud, radicular cysts, and deviation in the eruption of the permanent tooth have been documented.179Regardless of the pulp treatment performed, treatment success relies on a leakage-free restoration.SummaryPulp therapy for the primary dentition includes a variety of treat-ment options, depending on the vitality of the pulp. Vital pulp therapy is performed when vital pulp remains, because the potential for recovery exists once the irritation has been removed. Pulpectomy is indicated in teeth showing evidence of chronic, irreversible inammation or necrosis in the radicular pulp.References1. Fuks AB. Pulp therapy for the primary dentition. In: Pinkham JR, ed. Pediatric Dentistry: Infancy rough Adolescence. Philadelphia: Saunders; 2005.2. Fuks A, Hebling J, Costa CAS. e primary pulp: developmental and biomedical background. In: Fuks AB, Peretz B, eds. Pediatric Endodontics. Switzerland: Springer International Publishing; 2016.3. Tziafas D, Kodonas K. Dierentiation potential of dental papilla, dental pulp, and apical papilla progenitor cells. J Endod. 2010;36:781–789.4. Smith AJ. Dentin formation and repair. In: Hargreaves KM, Goodies HE, eds. Seltzer and Bender’s Dental Pulp. Chicago: Quintessence; 2002.5. Lesot H, Osman M, Ruch JV. Immunouorescent localization of collagens, bronectin, and laminin during terminal dierentiation of odontoblasts. Dev Biol. 1981;82:371–381.6. Linde A, Goldberg M. Dentinogenesis. Crit Rev Oral Biol Med. 1993;4:679–728.7. Torneck CD. Dentin-pulp complex. In: Ten Cate AR, ed. Oral Histology, Development, Structure and Function. 2nd ed. St Louis: Mosby; 1985.8. Baume LJ. e biology of pulp and dentine. In: Myers HM, ed. Monographs in Oral Science. Basel, Switzerland: Karger; 1980.9. Mjor IA, Heyeraas KJ. Pulp–dentin and periodontal anatomy and physiology. In: Orstavik D, Pitt Ford TR, eds. Essential Endodontology. London: Blackwell; 1998.10. Smith AJ, Cassidy N, Perry H, et al. Reactionary dentinogenesis. Int J Dev Biol. 1995;39:273–280.11. Byers M, Narchi M. e dental injury model: experimental tools for understanding neuroinammatory interactions and poly-modal nociceptors functions. Crit Rev Oral Biol Med. 1999;10: 4–39.12. Messagne J. e transforming growth factor-beta family. Annu Rev Cell Biol. 1990;6:597–641.13. O’Kane S, Ferguson MWJ. Transforming growth factor betas and wound healing. Int J Biochem Cell Biol. 1997;29:63–78.14. Nakashima M. Induction of dentine in amputated pulp of dogs by recombinant human bone morphogenetic proteins-2 and -4 with collagen matrix. Arch Oral Biol. 1994;39:1085–1089.15. Di Nicolo R, Guedes-Pinto AC, Carvalho YR. Histopathology of the pulp of primary molars with active and arrested dentinal caries. J Clin Pediatr Dent. 2000;25:47–49.16. Furseth Klinge R. Further observations on tertiary dentin in human deciduous teeth. Adv Dent Res. 2001;15:76–79.17. Kakehashi S, Stanley HR, Fitzgerald RJ. e eect of surgical exposures of dental pulp in germ free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol. 1965;20:340–349.18. Cox CF, Keall CL, Keall HJ, et al. Biocompatibility of surface-sealed dental materials against exposed pulps. J Prosthet Dent. 1987; 57:1–8.19. Murray PE, About I, Franquin JC, et al. Restorative pulpal and repair responses. J Am Dent Assoc. 2001;132:482–491.20. About I, Murray PE, Franquin JC, et al. Pulpal inammatory responses following non-carious class V restorations. Oper Dent. 2001;26:336–342.21. Qvist V. Correlation between marginal adaption of composite resin restorations and bacterial growth in cavities. Scand J Dent Res. 1980;88:296–300.22. Qvist V, Staltze K, Qvist J. Human pulp reactions to resin restorations performed with dierent acid-etch restorative procedures. Acta Odontol Scand. 1989;47:253–263.23. About I, Murray PE, Franquin JC, et al. e eect of cavity restoration variables on odontoblast cell numbers and dental repair. J Dent. 2001;29:109–117.24. Camps J, Dejou J, Remusat M, et al. Factors inuencing pulpal response to cavity restorations. Dent Mater. 2000;16:432–440.25. Sloan AJ, Smith AJ. Stimulation of the dentine-pulp complex of rat incisor teeth by transforming growth factor-beta isoforms 1-3 in vitro. Arch Oral Biol. 1999;44:149–156.26. Tecles O, Laurent P, Zygouritsas S, et al. Activation of human dental pulp progenitor/stem cells in response to odontoblast injury. Arch Oral Biol. 2005;50:103–108.27. Goldberg M, Smith AJ. Cells and extracellular matrices of dentin and pulp: a biological basis for repair and tissue engineering. Crit Rev Oral Biol Med. 2004;15:13–27.28. Murray PE, About I, Lumley PJ, et al. Cavity remaining dentin thickness and pulpal activity. Am J Dent. 2002;15:41–48.29. Levin LC, Law AS, Holland GR, et al. Identify and dene all diagnostic terms for pulpal health and disease status. J Endod. 2009;35:1645–1657.30. Camp JH. Diagnosis dilemmas in vital pulp therapy: treatment for the toothache is changing, especially in young, immature teeth. Pediatr Dent. 2008;30:197–205.31. American Academy of Pediatric Dentistry Reference Manual. Guideline on pulp therapy for primary and immature perma-nent teeth. Pediatr Dent. 2016-17;38(Reference Manual): 280–288.32. Guelmann M. Clinical pulpal diagnosis. In: Fuks AB, Peretz B, eds. Pediatric Endodontics. Switzerland: Springer International Publishing; 2016.33. Malmgren B, Andreasen JO, Flores MT, et al. Guidelines for the management traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol. 2012;28:174–182.34. Jespersen JJ, Hellstein J, Williamson A, et al. Evaluation of dental pulp sensibility tests in a clinical setting. J Endod. 2014;40: 351–354.

Related Articles

Leave A Comment?