,.
,.
Pulp Thera py for Vital
ln_direct Pulp Capping
' Cif"
·.:. Current Concepts in Pulpotomy
.~ Direct Pulp Capping
: qr Pulpotomy
Pulp exposure. of the dental pulp exists wh en th e continuity
. .
of the d.al
entm surrounding the pulp is broken byp hys1calor.
bacten means leading to direct cornrnu mca
. ti' on b etween
the pulp and external environment. Pieter Van Forest
was the first to speak about root canal thera and in 1910
ove esigned instruments that could prep~re a canal to
a certain ~ize and taper. The objectives of pulp therapy are
consei:vation of the tooth in a healthy state of functioning
as an mtegral component of the dentition; preservation
of the arch space; enhance esthetics, mastication; help in
maintenance of a healthy oral environment; prevention
of deleterious effects on the succedaneous tooth, and the
periapical tissue.
INDIRECT PULP CAPPING
~direct pulp capping is defined as a procedure wherein
small amount ofcarious dentin is retained in deep areas
ofcavity to avoid exposure ofpulp, followed by placement
of a suitable medicament and restorative material that
seals offthe carious dentin and encourages pulp recovery
(Ingle)
A procedure in which only the gross caries i: rem~ved th
from the lesion and the cavity is sealed for a tzme wi a
biocompatible material (McDonald)
{~,t~
-D Apexogenesi s
Objectives of indirect pulp capping (IPC}
These were given by Eidelman in 1965:
D Arresting the carious process ,
D Promoting dentin sclerosis
Stimulating formation of tertiary dentin
Remineralization of carious dentin.
Ricketts ~t al. stated that "in deep lesions, partial caries
removal is preferable to complete caries removal to reduce
the risk of carious exposure"
In 1961, Damle SG termed IPC as "Reconstructed Dentin"
to prevent pulp exposure.
Rationale
Its rationale is that carious dentin consists of two distinct
layers. An outer layer that is irreversibly denatured,
infected, not remineralizable and should be removed
and an inner layer that is reversibly denatured, not
infected, remineralizable and should be preserved
Removing the outer layers of the carious dentin that
contain the majority of the microorganisms thus
reducing the continued demoralization of the deeper
dentin layers from bacterial toxins, and sealing the
lesion to allow the pulp to regenerate reparativE
dentin.
 Section 1O+ Pediatric Endodontics
~2a
Layers of Carious Dentin Clinical

Outer layer Middle layer Inner layer

L istory
Aexamination
Mobility of the Definite P' •!p
A firm (leathery), A hard, discolored Sharp,
Necrotic, soft, tooth exposure
discolored dentin dentin deep layer penetrating
brown dentin outer Discoloration lnterrupteJ or break
layer pulpalgia in lamina dura
layer of the tooth
Minimal amount of indicating Radiolucency about
Teeming with Fewer bacteria Negative
bacterial invasion acute pulpal the apices of the
bacteria inflammation reaction of
Painful to electric pulp roots
Not painful to Painful to remove Prolonged
instrumentation Widened
spontaneous testing
remove periodontal
pain particularly ligament space
at night

Treatment Procedure (Figs. 54.1 A to D)

Deep carious lesion, Normal lamina
D Mildpain
dura and The earlier approach was the two-appointment procedure
associated which are close to,
with eating but not involving the periodontal but now single session is preferred as:
pulp in vital primary ligament (POL) The re-entry to remove the residual minimal carious
D Negative
history of or young permanent space dentin may not be necessary if the final restoration
No
spontaneous, teeth
radiolucency
maintains a seal and the tooth is asymptomatic
extreme pain No mobility
in the bone After cavity preparation, if all the carious dentin was
When pulp
inflammation is seen around the removed except the portion that would expose the pulp,
as nominal and there apices of the re-entry might be unnecessary.
is a definite layer of roots or in the If pulp exposure occurs during re-entry, the main
furcation
affected dentin after objective of IPC is compromised. So a more invasive vital
removal of infected pulp therapy technique has to be done or would be indicated.
dentin

The three layers of carious dentine:

B
Remove the caries with
a slow-speed bur
m (A) Necrotic tissue/infected dentine
(B} Leathery infected dentine
(C) Affected dentine

m Place calcium hydroxide over m Final restoration in place

the carious dentin
Figs. 54.1 A to D: Procedure of indirect pulp capping.
 Chapter 54 + Pulp Therapy for Vital Teeth

Use local anesthesia and isolation with rubber dam

Establish cavity outline with high-speed handpiece

Single
appointment
Remove all caries using caries detector dye, i.e. infected dentin
has to be removed
procedure

Stop the excavation as soon as the firm resistance of sound

dentin is felt

+
If their is a probability of exposure while removing further caries,
then a conservative approach is chosen by placing a hard set
calcium hydroxide and temporizing the tooth

Cavity flushed with saline and dried with cotton pellet

Site is covered with calcium hydroxide (Ca(OHh)

Remainder cavity is filled with reinforced zinc

oxide eugenol (ZOE) cement

Two
appointment
Final restoration is done followed
by placement of crown
l
2nd appointment (6-8 weeks later)
Between the appointment history must be negative and temporary
procedure restoration should be intact

If a reparative dentin bridge is formed

(clinical and radiographical confirmation), a permanent
restoration followed by a full coverage restoration is chosen

But if there is some amount of caries remaining on re-entry,

carefully removal of caries, now somewhat sclerotic may
reveal a sound base of dentin without pulp exposure

Previous remaining carious dentin will have become dried

out, flaky and easily removed

The area around the potential exposure will appear whitish

and may be soft; which is predentin . Do not disturb this area

The cavity preparation is washed out and dried gently

+
Cover the entire floor with Ca(OH)2

l
Base is built up with reinforced ZOE cement or GIC

Final restoration is then placed

 Section 10 + Pediatric Endodontics
Procedure of application of pulp capping agent
Most frequent used material for indirect pulp capping is Dycal
(calcium hydroxide). This is supplied as two-paste system, one
containing base (brown) (titanium dioxide in glycol salicylate)
and the other catalyst (white) (calcium hydroxide and zinc oxide
in ethyl toluene sulfonamide)
One drop of each paste is dispensed in the mixing pad. Now
the catalyst paste (white) is lifted with a blunt probe and carried
to the cavity where it is spread all over the cavity floor only. In
similar fashion the base paste (brown) is taken to the cavity and
the two pastes are then mixed in the cavity and spread evenly
with the help of ball burnisher. This not only evenly mixes the
pastes but also allows a uniform thickness to be attained in
cavity. Although dycal can be mixed on the pad and carried to
the cavity also the above described method is more convenient
as dycal sets very fast after mixing.
Sequelae/Outcome of IPC
Three distinct types of new dentin formation take place: 1
I. Cellular fibrillar dentin-first 2 months
2. Globular dentin-3 months
3. Tubular dentin ( uniform mineralized dentin): One-fifth
of reparative dentin formation begins in less than 30
days. After 3 months, 0.1 mm is formed.
Stepwise excavation technique: The basic difference between
stepwise excavation technique and indirect pulp treatment (IPT) is
that in IPT re-entry may or may not be attempted but in stepwise
excavation re-entry is attempted at various intervals.
Guidelines for stepwise excavation: 2
1. Deep lesion considered likely to result in pulp exposure if
treated by a single and terminal excavation. Evaluated by X-ray,
the dentinal lesion involves three-fourth or more of the dentin
thickness.
2. No history of pretreatment symptoms such as spontaneous pain
and provoked pulpal pain. However, mild to moderate pain on
thermal stimulation is accepted.
3. Positive pulp sensibility tested by an electric pulp tester, thermal
stimulation, or test cavity.
4. Pretreatment radiograph that rule out apical pathosis.
5. Finish the peripheral excavation of the cavity followed by a
central excavation removing the outermost necrotic and infected
demineralized dentin, in order that a provisional restoration can
be properly placed.
6. Do not excavate as closely as possible during the first step,
thereby reducing the risk of pulp exposure.
7. Select a provisional restorative material on the basis of the
length of the treatment interval, ranging between 6 months and
8 months.
8. The final excavation is often less invasive than expected, as a result
of the altered dentinal changes gained during the treatment
interval.
Procedure is very similar to IPT except the less invasive first step.
Research studies regarding IPC
1. Mathur et al. 3 in 2017 compared the efficacy of .
. ) I . 1
cac,urn
hydroxide (setting type , g ass ,onomer cement (GIC) (
VII), and mineral trioxide aggregate as an indirect pulp ca/~Pe
agent and found that all are equally suitable as IPC a Ping
suggesting mineral gain. gents
4
2. Korwar A et a_l. in 201 s_studi_ed the_pul~ response of two hi
fluoride releasing materials silver d1amine fluoride (SDF} gh
nd
Type VII GIC when used as IPT materials and concluded ~
both are equally effective in tertiary dentin formation. at
3. According to Coll JA 5 (2008) IPT has been shown to have
a lower cost, higher success lo~g-term, better exfoliation
pattern, and better success treating reversible pulpitis than
pulpotomy.
4. Sujlana A et al. 6 in 2017 conducted as study on direct pulp
capping (DPC) in primary teeth and concluded that DPC
should not be disregarded as a treatment option in primary
teeth. With regard to the pulp capping material of choice,
calcium hydroxide still remains the "gold standard"for DPC in
primary teeth and is even the active product providing success
with mineral trioxide aggregate (MTA).
DIRECT PULP CAPPING
It is defined by Kopel (1992) as the placement ofa medicament
or nonmedicated material on a pulp that has been exposed in
course ofexcavating the last portions ofdeep dentinal caries
or as a result of trauma.
Objective
To create new dentin in the area of the exposure and
subsequent healing of the pulp.
Rationale
To ac?~eve a biologic closure of the exposure site by
depos1!10n of hard tissue barrier (dentin bridge) between
pulp tissue and capping material thus walling off the
exposure site.
Indications
Small mechanical exposure surrounded by sound
dentin in asymptomatic vital primary teeth or young
permanent teeth. Exposure should have bright red
hemorrhage that is easily controlled by dry cotton pellet
with minimal pressure
•:• True pin point exposure.
Contraindications
Severe toothache at night
Spontaneous pain
 Tooth mobility
Radiographic appe aran c e of r , 11(p, p c,·n :J :1 icul ,1r t
degeneration
Excess of hemorrhage at the time o fexposure
Serous exudate from the exposu re
External or internal root resorption
Swelling or fistula.

Treatment considerations
Debridement: Necrotic and infected dentin chips have to be
removed else they w ill invariably be pushed into the exposed
1 h\ ;
Remove the caries with Place pulp capping agent
pulp during last stages of caries removal and impede healing
and increase pulpal inflammation
rJ a slow-speed bu r m over the exposed pulp

Hemorrhage and clotting: A blood clot should not be

allowed to form at the exposure site beca use it may impede
pulpal healing or formation of reparat ive dentin
Bacterial contamination: Once all the caries or debris is
removed, the cavity should be irrigated with saline, if not the
debris may interfere with healing
Exposure enlargement: The exposure site must be enlarged
because:
It removes inflammation and infected tissue in the exposed
area m Direct pulp capping
It facilitates washing away carious and noncarious debris
Figs. 54.2A to C: Direct pulp capping.
It allows a closer contact of more capping medicament
material t o the actual pulp tissue.
Histological Changes after Pulp Capping
(Fig. 54.3)
Technique of Direct Pulp Capping
These were illustrated by Glass and Zander in 1949.
(Figs. 54.2A to C)
After 24 hours: Necrotic zone adjacent to calcium
Rubber dam provides only means of working in a sterile hydroxide paste is separated from healthy pulp tissue by
environment, so it has to be used a deep staining basophilic layer

+ .
Once an exposure is encountered , further manipulation o
f
pulp is avoided

+
Cavity should be irrigated with saline, chloramine Tor distilled water

.
Hemorrhage is arrested with light pressure ,rom sterile cotton pellets

Place the pulp capping material, on the exposed pulp wi th

application of minimal pressure --;-- - r -- Osteodentin
• 1·in to pulp chamber
so as to avoid forcing the matena calcified zone

+ + - - - - Normal fibroblast

-----'.~~~==_:__---
l
Place temporary restoration
- - r - - - - - - - Odontoblasts

. . • the success of - - ; - - - - Normal pulp

Final restoration is done after dete~min_ing f dentinal bridge.
PUip capping which is done by determination ° .
maintenance of pulp vitality, lack of pain
and minimal inflammatory response Fig. 54.3: Zone of histological changes.
 Section 10-+- Pediatric Endodontics
After 7 days: Increase in cellular and fibroblastic activity
After 14 days: Partly calcified fibrous tissue lined by
odontoblastic cells is seen below the calcium protienate
zone; disappearance of necrotic zone
After 28 days: Zone of new dentin.
Medications and Materials Used for Pulp
Capping
Calcium hydroxide:
Calcium hydroxide is a white, crystalline, slightly
soluble basic salt that dissociates into calcium ions
and hydroxyl ions in solution and exhibits a high
alkalinity(pH 11). It is used in both setting and non-
setting forms in dentistry. Dentists also use calcium
hydroxide because of its antimicrobial properties
and its ability to induce hard tissue formation
Calcium hydroxide forms a dentin bridge when
placed in contact with pulpal tissues (Rasmussen
P,MjorlA, 1971)7
Initially, a necrotic zone is formed adjacent to the
,I material, and, depending on the pH of the calcium
!
hydroxide material, a dentin bridge is formed
directly against the necrotic zone. Under this the
tissue differentiates into odontoblasts, which then
elaborate into matrix
The necrotic zone is resorbed and replaced by a
dentin bridge; however this barrier is not always
complete (HollandR et al.1979) 8
An enzyme involved in mineralization. (Foreman
PC, Barnes IE, 1990; HeithersayGS, 1978; Siqueira
JF Jr, Lopes HP, 1999). 9- 11 Several theories exist
as to how calcium hydroxide induces hard tissue
formation. These include the high alkalinity (pH of
11 ), which produces a favorable environment for the
activation of alkaline phosphatase
Some common calcium hydroxide agents used for
direct pulp capping are calcium hydroxide powder
with distilled water, pulpdent (52.5% calcium
hydroxide in an aqueous sol. of methyl cellulose),
Dycal, and Hydrex (calcium hydroxide, barium
sulfate, titanium dioxide).
Corticosteroids and antibiotics:
Brosch JW introduced this combination in 1966
These agents include neomysin and hydrocortisone;
ledermix [Ca(OH) 2and prednisolone], penicillin or
vancomycin with Ca(OH) 2.
Inert materials:
Isobutyl cyanoacrylate and tricalcium phosphate
ceramic.
Collagen fibers:
Collagen fibers influence mineralization and are less
irritant than Ca(OH)2with dentin bridge formation
in8weeks.
4-META adhesive:
The main advantage of 4-META acl i· r: ·,\ve is th
it can soak into the pulp, polyme ri ,: • there at
form a hybrid layerwith the pulp thereby ProVi:d
adequate sealing. g
Direct bonding:
Recent advances in total etch direct bonding hav
evoked an interest in application for pulp therapy. 1he
attractiveness of these systems is that a polygenic
can be layered over an exposure site without displacin
pulp tissue and onto surrounding dentin where i~
penetrates the tubules. The adhesive film is cured by
light and acts as a barrier as a composite resin is gently
spread over the pulp onto the surrounding dentin.12
lsobutyl cyanoacrylate:
Berkmaninl971 useditascappingagentandproved
it to be an excellent hemostatic agent as well as a
reparative dentin bridge stimulator
The disadvantage of this material is that it is cytotoxic
when freshly polymerized.
Denatured albumin:
This protein has calcium-binding properties
If a pulp exposure is capped with a protein, the protein
may become a matrix for calcification, thereby
increasing the chances of biologic obliteration.
Mineral trioxide aggregate:
Mineral trioxide aggregate has demonstrated the
ability to induce hard tissue formation in pulpal
tissues and it promotes rapid cell growth
. f:Iis_tol(?gic evaluation ofpulpal tissue demonstrated
that MTA produces a thicker dentinal bridge, less
inflammation, less hyperemia and less pulpal
necrosis compared with calcium hydroxide. MTAalso
appears to induce the formation ofa dentin bridge at
a faster rate than does calcium hydroxide
The process by which MTA acts to induce dentin
bridge formation, however, is not known. Ford 13
et al. theorized that the tricalcium oxide in MTA
reacts with tissue fluids to form calcium hydroxide,
resulting in hard tissue formation in a manner similar
to that of calcium hydroxide
Caicedo et al. (2006) demonstrated good pulp re-
sponse in primary teeth after direct pulp capping MTA.
According to Farsi1 4 et al. (2006) and Bogen 15 et al.
(2008) they have shown high success rate in pulp
capping nearly about 93-98%.
Laser:
Andreas Meritz in 1998 evaluated the effect oflaser
on direct pulp capping and reported a success rate
of89%.
Bone morphogenic protein:
Urist discovered bone morphogenic protein (BMP)
in 1965.
 Chapter 54 + p 1
• He observed that demi . u P Therapy for Vital Teeth
nera1ized b
stimulate new bone form . one matrix could
. . ation whe .
ectopic sites such as muscl I n implanted to
demineralized dentin also ~:d also ~bserved that
and it forms both bone and d . ducuve properties
. . . entm e
•

•
1
1he rmp 1cations for pulp thera a .
is capable of inducing reparati!y
1hey concluded that recombin h
d:~~:mense
as it

protein-I in a collagen carrier ;;ttr~an osteogenic

suitable as bioactive capping a IXaipeared to be
exposed dental pulp. agent or surgically

Limitation of direct pulp capping in primary

• teeth
Direct pulp capping is primarily contraindicated • .
however, recently lasers are the only option that h in pdnmary teeth,
f d" I • . ave emonstrated
success o irect pu p capping in primary teeth. So Of h
for this contraindication are: me t e reasons
As the inherent potential of primary tooth ceII s ·1s to resorb
the tooth hence more odontoclasts are present as compared
to o~ontoblasts. So when pulp capping material is placed
it stimulates the undifferentiated mesenchymal c II th Figs. 54.4A to D: Pulpotomy: (A) Carious tooth; (B) Pulpotomizec
·a • . d e s at
d111erent1ate
• into. o ontoclastic
h cells. These cells exert th e1r
· tooth; (C) Tooth restored; (D) Complete rehabilitation with SSC.
resorptive potent1a 1w ich leads to internal resorption
High c:llular content, abundant blood supply and consequently
faster inflammatory response and poor localization of infection Indications of Pulpotomy
are some of the other reasons that direct pulp capping is
_ _ _ _ _ __ _ _ _ _ _____J
Mechanical pulp exposure in primary teeth
contraindicated in primary teeth. Teeth showing a large carious lesion but free of radicula
pulpitis
History of only spontaneous pain
PULPOTOMY Hemorrhage from exposure sites bright red and can b
Finn (1995) deji •,, ., ' ,:
:'. ;,S the complete removal of the controlled
coronal portion ofi :,, <mtal pulp,followed by placement Absence of abscess or fistula
of a suitable dressh ,: ur medicament that will promote No interradicular bone loss
No interradicular radiolucency
healing and preseru~ uitality of the tooth At least two-thirds of root length still present to ensur
American Acade my o f Pediatric Dentistry (1998)
reasonable functional life
defined pulpotomy a s the amputation of affected, In young permanent tooth with vital exposed pulp an
infected coronal portion ofthe dental pulp preservi~g the incompletely formed apices.
vitality andJunction of the remaining part of radzcular
pulp. Contraindications of Pulpotomy
Persistent toothache
Objectives Tenderness on percussion
Removal of inflamed and infected coronal pulp at Root resorption more than one-thirds of root length
th
the site of exposure thus preserving the vitality of e Large carious lesion with nonrestorable crown
radicular pulp and allowing it to heal . th Highly viscous, sluggish hemorrhage from canal orific1
The next main objective is to maintain the tooth Ill e which is uncontrollable
dental arch. Medical contradictions like heart disease, immunocorr
promised patient
Rationale (Figs. 54.4A to D) Swelling or fistula
bl of healing after External or internal resorption
Radicular pulp is healthy and capa e ul
surgical amputation of the infected coronal P P Pathological mobility
Calcification of pulp.
Preserves vitality of the radicular pulp ..
Maintains tooth in a physiologic co nd iuon.
 Section 10 + Pediatric Endodontics
Sweet (1930): Formulated m ulti ·, d m ique
Doyle (1962): Ad vocated t ,\ ,, · · '8 procedure
(complete devitalization)
Spedding (1965): Gave 5 min:. :, · ;:., '.llocol {partial
It is intended Single sitting: devitalization)
Devitalization Mummifica-
tion, cauter- to destroy or Formocresol Venham (1967): Proposed 15 seu Yids procedure
mummify the Electrosurgery
ization Current concept uses 4 minutes 01 a;:n lication time.
vital tissue Laser
Two stages:
GysiTriopaste Composition of Formocresol: Buckley's
Easlick's
formaldehyde
Formula
Paraform Cresol-35%
devitalizing paste. Glycerol- IS%
Preservation Minimal This implies ZnO Eugenol Formaldehyde-19%
devitalization, maintaining Glutaraldehyde Water-31 %.
non inductive the maximum Ferric sulfate
vital tissue,
with no
Preparation
induction of Currently we use I/5th cone. of Buckley's formula, which is
reparative prepared by the following method:
dentin Dilute 3 parts (90 mL) glycerine with 1 part (30 mL)
This has Ca(OH) 2
Regeneration Inductive,
Bone morpho-
diluted sterile water
reparative formation of
dentin bridge genic protein
Mineraltrioxide Add 1 part [30 mL] formocresol to 4 parts diluent
aggregate -J,
Enriched collagen Add 30 mL of formocresol to 120 rnL of diluent to obtain
Freezed dried 150 mL of dilute formocresol, i.e. I/5th strength.
bone
Osteogenic
protein, Mechanism of Action
It prevents tissue autolysis by bonding to the proteins. This
Nonvital pulpotomy
It is done in Beechwood cresol bonding is of peptide groups of side chain amino acids and
Mortal
compromised Formocresol is a reversible process accomplished without changing the
pulpotomy
cases basic structure of protein molecules.

Formocresol Pulpotomy/Single Stage Histological Changes

Pulpotomy
Formocresol was introduced by Buckley in 1904 and since
then a lot of modifications have been tried and advocated
regarding the techniques of formocresol pulpotomies.
16
These were demonstrated by Mass and Zilbermann
in 1933 and also by Massler and Mansokhani in 1959
(Fig. 54.5). Immediately the pulp becomes fibrous and
acidophillic

Criteria for case selection (Heilig J et al. 1984 and

Waterhouse et al. 2000)
Teeth with deep carious lesion (radiographically the caries
should be approximating to the pulp), Teeth should be
restorable after completion of the procedure
Absence of symptoms indicative of advanced pulpal inflammation
such as spontaneous pain or history of nocturnal pain, Absence of , .,,__--1----Fixation
clinical signs or symptoms
Absence of clinical or radiographic signs of pulpal necrosis, Le.
furcation involvement, periapical pathology, internal resorption, Coagulation
calcification in canal necrosis
Hemorrhage should stop within five minutes from the
amputated pulp stumps using a sterile pledget of moist cotton, ~ --Vital tissue
After assessment of clinical and radiographical criteria, single
visit pulpotomy procedure was performed on the selected
molars, Fig. 54.5: Zones after fixing with formocresol.
 Chapter 54
7-14 days: Three zones appear:
A broad eosinophilic zone of fixation
A broad pale-staining zone of atrophy with poor
cellular definition
+ Pulp Therapy for Vital Teeth
A broad zone ofintlammation extending apically into
normal pulp tissue.
Oneyear .
Progressive apical movement of these zones with
only acidophillic zone left at the end of 1 year.

procedure ofFormocresol Pulpotomy (Figs. 54.6A to G)

. . (B) Excavating coronal pulp; (C) After complete removal of coronal

Figs, 54,6A to G· p d f pulpotorny: (A) Cavity preparation, rative X-ray of mandibular second molar showing carious lesion;
Pol . • roce ure o . ·on of cavity; (Fl Preope
(G) P, (D) Postformocresol fixation; (E) Ternporizati
Po st0 Perative X-ray after pulpotorny.
 Section 10 + Pediatric Endodontics
Anesthetize the tooth and isolate with rubber dam
i ,h
Remove all caries using high-speed straight fissure bur wit out
enterin the ul chamber
i
Remove the dentinal roof with a large diamond stone or slow
speed round bur for minimal trauma
Enlarge the exposed area and deroof the pulp chamber
i denaturates nucleic acids by forming methylol
Remove any ledges or overhanging enamel with slow speed
round bur
i by interacting with DNA and RNA. Milnes 2006, 17
Sharp spoon excavators are used to scoop out coronal pulp
and ul al remnants
Clean the pulp chamber with saline and remove all debris
Place a cotton pellet over the pulp stumps to achieve hemostasis
Using a cotton pellet apply diluted formocresol to the
ul for 4 minute
formaldehyde. When used in pulpotomies in animals,
labeled formaldehyde has been found in periodontal
ligament, bone, dentine, and urine
Antigenocity: Thoden Valzen in 1977 has shown
immunogenic potential of formaldehyde in rabbits,
dogs, and guinea pigs
Mutagenicity and cytogenicity: Nongentini in 1980
postulated that mutational changes were achieved
by application of formaldehyde and cytogenicity for
15 minutes, in monkey kidney cells. Formaldehyde
derivatives that renders genetic machinery inoperable.
It may also effect biosynthesis and cell reproduction
published an extensive and detailed review of the more
recent research on the metabolism, pharmacokinetics,
and carcinogenicity of formaldehyde and concluded
that formaldehyde is not a potent human carcinogen
under conditions of low exposure. He concluded
that extrapolation of these research results to
pediatric dentistry suggests an inconsequential risk of
carcinogenesis associated with formaldehyde use in
pediatric pulp therapy.

Place a small dry pellet over this to avoid contact of tissues with
Modified Formocresol Pulpotomy
formocresol This technique was used by Trask (1972) in young
i
Remove cotton pellets and check for fixation , brownish
permanent molars that have to be retained for a short
period of time only
discoloration of the pellet as well as the pulp stump is an The technique is identical to that described for primary
indicator of fixation
teeth, except that the formocresol pellet is sealed
i permanently in the tooth.
Place ZOE cement in the pulp chamber

i
Recal1after one week and restore with a permanent restoration
Two-visit Devitalization Pulpotomy
This is two-stage procedure involving the use of
if atient is as m tomatic
paraformaldehyde to fix the entire coronal and radicular
pulp tissue in two visits.
Place a stainless steel crown
Indications
Concerns about Formocreso/
There is evidence of sluggish bleeding at the amputation
Toxicity: Formocresol and formaldehyde have site that is difficult to control
shown to be cytotoxic, mutagenic, and carcinogenic Pus in the chamber, but none at the amputation site
in animal experiments by Lewis in 1981. But Ranly There is thickening of the POL
calculated that, over 3,000 pulpotomies must be History of pain.
performed in the same individual for formocresol to
reach toxic level Contraindications
Systemic distribution: Myers in 1978 demonstrated
Nonrestorable tooth
systemic distribution of radioisotope-labeled
Tooth with necrotic pulp.
 Chapter 54 + Pulp Therapy for Vital Teeth
Procedure
First visit Success rate of formocresol pulpotomies
-----
Anesthetize the tooth and isolate with rubber dam Author I ~bservation ' Clinical Radiographic

•t
Preparation of the cavity Doyl et al. (1962)
Morawa et al.
time
5 18 months
6-60 months
success
100
I 98
success
-
98
Deep caries excavated (1974)
--

•
Enlarge the exposure with round bur
Mejare (1979)
Fuks et al. (1996)
60 months
33 months
55
85
55
78
--

•
fncorporate paraformaldehyde paste into the pellet and place
overeyosure
lbricevic and Al-
Jame(2003)
Subramaniam et
al. (2009)
48 months

24 months
97

100
91

85

Seal the tooth for 1-2 weeks so that formaldehyde gas liberated Hugarand 36 months 100 96
form paraformaldehyde ent~rs coronal and radicular pulp, Deshpande (201 0)
thereby fixing the tissue Yildiz and Tosun 30 months 100 95
(2014)
Second visit

.
Pulpotomy is carried out under local anesthesia

Glutaraldehyde Pulpotomy
Remove the old cotton pellet and deroof the pulp chamber
It was first suggested by S Gravenmade and was
t introduced by Kopel in 1979
Clean the cavity with saline and dry with cotton pellet
He suggested that inflamed tissue that produces toxic
t by-products should be fixed, rather than being treated
Pulp chamber filled with antiseptic paste and tooth is restored with strong disinfectants. He felt that satisfactory fixation
with formocresol required an excessive amount of
Materials used for two-visit pulpotomy
medication, as well as longer period of interaction but
Paraform glutaraldehyde solution might replace formocresol
Gysitriopaste Easlick's paraform-
in endodontics, because it appears to have fixative
aldehydf!J?,OSte
properties with less destruction of tissue and at the same
Tricresol Paraformaldehyde
Lignocaine
time appears to be bactericidal.
Cresol Procaine base
Propylene glycol
Glycerin Powdered asbestos Mechanism of Action
Petroleum jelly Carbowax
Paraformal- Glutaraldehyde produces rapid surface fixation of the
dehyde
Carmine to color underlying pulpal tissue
Zincoxide A narrow zone of eosinophilic, stained, and compressed
eugenol (ZOE)
fixed tissue is found directly beneath the area of
application, which blends into vital normal appearing
Reasearch studies regarding formocresol pulpotomy tissue apically
nd
l. In l956, Nacht 18 undertook study using formaldehyde pa_s!e a With time, the glutaraldehyde fixed zone is replaced by
found that the teeth were maintained in good clinical cond1t1on for macrophagic action with dense collagenous tissue, thus
approximately 2 years and reported evidence of resorption and a
lack of clinical symptoms over a 5 years period.
the entire root canal tissue is vital. 21
2· th
~mmerson et al.' 9 reported a histologic study. They reported at
immediately, below the amputation area, there was a homogene~us Advantages of Glutaraldehyde over
Yellow-stained area, and below that area was a normal-a~peanng
fixed zone of pulp tissue. Below the fixed zone, there was evidence of Formocresol
th
degenerated odontoblasts and linear pulp calcification. The au ors It is bifunctional reagent, which allows it to form strong
~lso reported that, throughout the pulp, there was an absence ~f
inflammatory cells, with no evidence of resorption or metaplast1c
intra- and intermolecular protein bonds leading to
changes. superior fixation by cross linkage
3· th
Fuks and Bimstein 20 observed clinically and radiographically at It is excellent antimicrobial
children treated with pulpotomies using a 1:5 dilution of form~cr~sol Superior fixative properties, self-limiting penetration
had aclinical success of 943% and concluded that in that 1:5 d1~ut1on
0~ formoeresol was an effective alternate medicament for primary
Causes less necrosis of the pulpal tissue
Yitai Pulpotomy procedures in children.
Causes less dystrophic calcification in pulp canals
I
I
-
 Section 10 -+ Pediatric Endodontics
Less toxicity does not perfuse through the pulp tissue to
the apex
Demonstrates less systemic distribution
It is low tissue binding, readily metabolized, eliminated
in urine and expired in gases-90% of the drug is gone
in3days
Mutagenicity and antigenicity-less as compared to
formocresol.
Research studies using glutaraldehyde pulpotomy
1. Garcia-Godoy22 used a 2% buffered glutaraldehyde solution
on pulpotomies in children and reported the technique to be
clinically and radiographically successful 98% of the time.
2. Fuks et al.23 reported that the use of a 2% buffered glutar-
aldehyde solution in primary molars in children was clinically
and radiographically successful 94% of the time after six months;
then, the success rate decreased to 90% after 12 months.
3. Davis et al.24 reported a histological study that compared 5%
buffered glutaraldehyde to 2% diluted formocresol as medicaments
on treated teeth. They reported that glutaraldehyde showed less
penetration than formocresol; that only mild inflammation was
seen in the glutaraldehyde group and was confined to the middle
third of the radicular tissue, with only limited necrosis; and that the
apical tissue was still vital in 78% of the cases.
Ferric sulfate as a 15.5% solution has
been commonly used as a coagulative
and hemostatic retraction agent for
crown and bridge impressions and is
slightly acidic
The mechanism of action is still debated
but agglutination of blood proteins
results from the reaction of blood with
both ferric and sulfate ions. The agglutinated proteins
form plugs to occlude the capillary orifices
Ferric sulfate as a pulpotomy agent on the theory that its
mechanism of controlling hemorrhage might minimize
the chances for inflammation and internal resorption.
Research studies of ferric sulfate pulpotomy
Ranly proposed that metal protein clot at the surface of the pulp
stump acts as a barrier to irritating components of the sub base
Fuks 25 (1997) showed 93% of success rate of FS when compared
with formocresol pulpotomy which showed 84% of success rate
Smith 26 (2000) reported a clinical success rate of 99% but
radiographic success rate of74% in FS pulpotomy
Markovic et al. (2005) showed 91% success rate with
formocresol and 89% success rate with FS pulpotomy.

Success rate of glutaraldehyde pulpotomies

1--· . -·-· Success rate of FS pulpotomies
Author Observation Clinical I Radiographic -
r-- - -
time
- - --- - - .,__ - -- --- - -·
success , success 1
Author · ! Observation f Clinical / Radiographi c-i
; • I !

: Kopel et al. (19~Q)_ .. _g~!2 m~!:Jths _ 1_g9 . _ _ - _______ _ ; time success i success
l Garcia-Godoy (1985)___48 mor,_ths _ __9_
~ __ . _ :·F;i ;; al~(1990)-· ,-12 months
- - - -· --------r -· ..
; 100 I 97 !
, Tsai et al. (1993) 36 months 98 79 Papagiannoulis et
al. (2002)
: 36 months : 90 74 I
I 100 83
_J ____ -

--Y~d~; ~tal. (2014) ----9 months ' 86______ : 80 - - - - - ~

-----------------4- - ---- - - - - ----- 7 -- - --- -----:
' Yildiz and Tosun 30 months 95 · 85 I
Ferric Sulfate Pulpotomy (2014)
1

Ferric Sulfate (FS) a nonaldehyde chemical has received

attention recently as a pulpotomy agent
The methods of pulpotomy are similar to formocresol Laser Pulpotomy
pulpotomy with the only difference in the agent used. The use oflasers in pulpotomywas based on their ability
(Figs. 54.7A to C) ofrapid control of bleeding and coagulation

Figs. 54.7A to C: Ferric sulfate pulpotomy. (A) Preoperative radiograph; (8) Postoperative radiograph;
(C) Pulpal appearance after application of agent.
 Chapter 54 + Pulp Therapy tor Vital Teeth 111111
In 1985, Ebimara reported the effects of Nd: YAG laser
Procedure
on the wound healing of amputed pulps using Nd: YAG
laser at 20 Hz and placing intermediate restorative Rubber dam isolation and administration of local anesthesia
material (IRM) paste
Many authors have compared various lasers in the endo-
dontic use and have used CO2 or Nd: YAG or diode lasers. Caries removal with large round slow speed bur

procedure {Figs. 54.8A to C)

Sterile cotton pellets are placed in contact with pulp and
Anesthetize the tooth and apply rubber dam pressure is applied to obtain hemostasis
+
Remove all caries with burs and open the pulp chamber
The hyfrecator plus 7-797 is set at 40% power and the 705A
dental electrode is used to deliver the electrical arc
Remove coronal pulp with spoon excavators

•
Use Diode laser 810 nm wavelength set at 3 W of power in
continuous wave. Laser was delivered through 400 µm
o tical fiber in non-conatct mode
Cotton pellet is quickly removed and the electrode is placed
1-2 mm above the pulpal stump

•
Directly apply the beam on amputated pulp stumps with all
necessary laser precautions
Electrical arc is allowed to bridge the gap to the pulpal stump
for 1 second, followed by a cool-down period of 5 seconds

When the proced ure is properly performed, the pulpal stumps

Apply till ablation and hemostasis is achieved but appear dry and completely blackened
not exceeding 2-3 minutes

Place the IRM paste and restoration
...
Seal with SSC
27
O Liu JF (2006) compared the effects of Nd:YAG laser pulpotomy
with formocresol on human primary teeth. In the Nd:YAG laser
group, clinical success was 97%, and radiographic success was
94%. Whereas in formocresol pulpotomy, the success rates were
85% and 78%, respectively.
Electrosurgical Pulpotomy
Mark was the first US dentist routinely to perform
electrosurgical pulpotomies in 1993 with a success rate of
99%for primary molars.
Pulp chamber is fill ed with ZOE placed directly aga inst the
pulpal stum ps
Final restoration is then placed
Cvek's Pulpotomy
This is also called as calcium hydroxide pulpotomy or
young permanent partial pulpotomy
This was proposed by Mejare and Cvek28 in 1978
Indicated in young permanent teeth where the pulp
is exposed by mechanical or bacterial means and the
remaining radicular tissue is judged vital by clinical
and radiographic criteria whereas the root closure is
not complete.

Figs. 54 .sA to c: Laser pulpotomy. (A) Preoperative radiograph; {B) Postoperative radiograph·
(Cl Pulpal appearance after application of laser. '
 Section 1O+ Pediatric Endodontics
Rationale: Caries
To preserve vitality of radicular pulp and allow for
Zone 1 - microabscess
normal root closure. (necrosis and
inflammation)
Procedure (Figs. 54.9A to E) Zone 2 - inflammation
Zone 3 - normal pulp
Anesthetize the tooth and isolate with rubber dam

All carious material is removed with excavators or slow speed

round bur

Restoration
Coronal pulp removed , to perform a pulpotomy

After arrest of the hemorrhage, Ca(OH) 2 is applied to the exposed

pulp, ensuring that there is no blood clot ~--c--1- - Normal pulp

The cavity is then sealed with temporary restorative material

A tooth should remain symptom free at recall and radiograph

should show formation of a secondary dentine bridge

Then pennanent restoration with amalgam is done

Mortal Pulpotomy
It is also called nonvital pulpotomy
Ideally, nonvital tooth should be treated by pulpectomy,
but sometimes it is impracticable due to non-negotiable
root canals and limited patient cooperation, mortal
pulpotomy is indicated for such patients.
Procedure
First appointment

Necrotic coronal pulp is removed

+
Pulp chamber irrigated with saline and dried with cotton pellet
Infected radicular pulp Is treated with strong antiseptic solution
like beechwood cresol
Figs. 54.9A to E: Cvek's pulpotomy: (A) Diagrammatic description
of inflammation extending till pulp; (B) Extension of preparation;
(C) Placement of calcium hydroxi de on the part ial amputated pulp;
(D) Preoperative X-ray of lesion; (E) Postoperative appearance of
Cvek's pulpot omy.

Seal cavity with temporary cement for 1-2 weeks

CURRENT CONCEPTS IN PULPOTOMY
Second appointment
Portland Cement
If the tooth is asymptomatic the pulp chamber is filled with an
antiseptic paste Pulpotomies with Portland cement as a medicament in
+ human primary molars were performed by Conti
MTA and Portland cement had the same clinical,
The tooth then restored with stainless steel crown
biological, and mechanical characteristics. The only
 Chapter 54 + Pulp Therapy for Vital Teeth
difference was bismuth oxide was added to MTA f
.
improve d ra d 10pacity or
37
Sakai et al. compared the clinical and radiographic
effectiveness of MTA and Portland cement as pulp
dressing agents in carious primary teeth. They reported
that all of the pulpotomized teeth were clinically and
radiographically successful at 2 years. The authors
reported that no statistically significant difference
regarding dentin bridge formation was found between
the groups throughout the follow-up period.
Mineral Trioxide Aggregate (MTA)
~ orabinejad described the physical and chemical
properties of MTA in 1995.
It is an ash-colored powder made primaril~ of ~ine
hydrophilic particles of tricalci~m alu~ate, tnc_alcmm
silicate, silicate oxide, tricalcmm made, and bismuth
oxide is added for radio-
opacity. Hydration of
the powder results in a
colloidal gel composed of
calcium oxide crystals in
an amorphous structure.
This gel solidifies into
a hard structure in less
than 3 hours OE •th polymer
It has a compressive strength equal to Z Wl
reinforcement (IBM).
Properties of Mineral Trioxide Aggregate . .
It is biocompatible matenal . and its. sealing abihty is
better than that of amalgam or ZOE
Initial pH is 10.2 and set pH is 12.5
The setting time of cement is 4 hours . . om arable
The compressive strength is 70 MPa, which is c P
with that of IRM . . .
Low cytotoxicity-it presents with mirumal inflarnID
if ~xtended beyond the apex
Mineral trioxide aggregate has demonstrat~d th e a d it
to induce hard-tiss4e formation in pulpal tiSSUes an
promotes rapid cell growth
According to Torabtnejad 29 et al., MTA h~s b t
antibacterial effect on some facultative bacteria u
no effect on strict anaerobic bacteria. This limited
antibacterial effect is less than that demonstrated
by calcium hydroxide pastes. The ability of MTA to
resist the penetration of microorganisms appears
to be high
The use of MTA as an agent for pulp capping or for
providing apical seal is well-documented. 30 The use
of this agent in pulp capping was doubted as it was
hypothesized that the hard tissue barrier formed by
MTA could deflect the permanent tooth bud once the
primary tooth was near to exfoliation. But recent studies
have indicated that MTA can be used successfully as a
pulpotomy agent also.
Procedure (Figs. 54. 1OA and B)
Anesthetize the tooth and apply rubber dam
Remove all caries with burs and open the pulp chamber
-,..---,--::::
R:-
i
emove coronal pulp with spoon excavators
i
Using moistened cotton pellets and m?derate pressure
achieve pulp hemostas1s.
th x osed radicular pulp surface and a
Apply M:A paste to cothve~ 1 teyond the pulp dentin interface
margin of not less a
~ - - - --;;A-:
p:;
pl~y7.'
w~et':
t c~o"itton to helJ;! the MTA set
. . - - - ~Seal with ZOE (IRM or other fortified ZOE)
...- ----.=Restore w1·th SSC using glass ionomer cement
Research studies regarding MTA pulpotomy
onducted pulpotomy in 60 molars and
Cuisia31 et al. (2001) c 93% for formocresol and
showed clinical succes~h~~:d:a;raphic success was 77% for
97% for MTA, whereas
I d 93% for MTA
formocreso an d t d a clinical trial and compare
d·
ation Agamy32 et al. (2004) con uc e sol in 72 molars of 24
h"t MTA and formocre
gray MTA, w I end 100% clinical and radiographic success rate
bility children. They fou ss rate with formocresol
with MTA and 90% succe h d 100% clinical and radiographic
Naik and Hedgen(2005) s owe I d MTA
th ith formocreso an d
success rate bo w I t d the effects of MTA an
an Godhl B:M et al. _(2011) ev\~a :lpotomy of primary molars
formocresol on vital pulp aft .P Contd...
 662
Section 1O+ Pediatric Endodontics
'

/ Figs. 54.1 OA and B: Mineral trioxide aggregate pulpotomy.

,,
I

Contd... molars and concluded that it can be used and has

I and concluded that MTA has more success rate as compared to
formocresol
similar properties to MTA.

Sonmez et al. 35 did comparison of four pulpotomy Allium Sativum Oil

techniques (formocresol, ferric sulfate, calcium hydroxide
(Ca(OH) 2), and MTA) as pulp dressing agents in pulpotomized
primary molars with clinical and radiographic examinations
every 6 months over 2 years. The success rates were 76.9% for
formocresol, 73.3% for ferric sulfate, 46.1 % for Ca(OH) 2, and
66.6% for MTA
Shirvani A et al. 36 compared MTA versus formacresol pulpotomy
via meta-analysis of randomized clinical trials and concluded
that MTA is more effective.
Mohammad et al. 38 compared the clinical and
radiographic effects of A. sativum oil and those of
formocresol in vital pulpotomies of primary teeth
A. sativum oil had good healing potential, leaving the
remaining pulp tissue functioning and healthy and is
a biocompatible material that is compatible with vital
human pulp tissue.

Use of Lyophilized Freeze Dried Platelet

Success rate of MTA pulpotomies with Calcium Hydroxide as Pulpotomy
Author Observation Clinical Radiographic Agent
time success success
These compounds act as signaling proteins that could be
Agamy et al. (2004) 12 months 100 100 directly involved in the regulation of cell proliferation,
Holan et al. (2005) 74 months 97 97 migration, and extracellular matrix production in the
Subramaniam et al. 24 months 100 95 dental pulp
(2009) A lyophilized freeze dried platelet-derived preparation
Hugarand 36 months 100 100 is containing transforming growth factor (TGF), platelet
Deshpande (2010) derived growth factor (PDGF), bone morphogenetic
Olatosi et al. (2015) 12 months 100 96 proteins (BMPs), and insulin growth factor (IGF)
These proteins have been used extensively in oral and
maxillofacial reconstruction, adjunctive procedures
Nanohydroxyapatite and Bone related to the placement of osseointegrated implant in
Morphogenic Protein humans and periodontal regeneration.
Appeared to be biocompatible and produced no pulpal
Research regarding lyophilized freeze dried
reaction
platelet with pulpotomy agent
Studies only done in animals and no human trials yet.
Animal and human in vivo and in vitro studies have shown
that these proteins stimulates differentiated cell of pulp to
Calcium-enriched Mixture differentiate into odontoblast to deposit a layer of cementum
Malekafzali et al. compared calcium-enriched Kalaskar R and Damle SG (2004)3 9 evaluate the potential
of lyophilized freeze dried platelet with calcium hydroxide as
mixture cement and MTA as pulp dressing
pulpotomy agent and found out that it had 100% success.
biomaterials in vital pulpotomies of carious primary

.. 7
1'ftea1
 Chapter 54 .., Pulp Therapy for Vital Teeth
E1:11do?ain is a bioinductive material that is compatible
-----------i i:. .:. . :. :. : : .______J
Local anesthesia
with vital human tissues
!t off~rs a good healing potential and is capable of
The teeth were isolated using rubber dam •?ducmg dentin formation leaving the remaining pulp
tissue healthy and functioning
+ Emdogain may act in a multitude of ways on
--------,i- - ~ - - _ J
Cavity outline was established
mesenchymal cells that provide pulp protection.

Caries was excavated with a spoon excavator
D According to Nakamura et a1.•0 when a pulp wound is exposed
The pulp chamber was entered and the roof was removed
Coronal pulp tissue amputation was achieved using spoon
excavator
The chamber was irrigated with normal saline
Hemorrhage was controlled using a sterile pledget of moist
cotton under pressure
After control of hemorrhage within five minutes, the lyophilized
preparation was placed over the pulp stump and the
D Jumana et at.4 1 reported the clinical success of 93% using
preparation was gently packed over the pulp stumps
using a sterile pledget of moist cotton
Research regarding EMD as pulpotomy agent
to EMD, substantial steps occur in a process resembling classic
wound healing with subsequent neogenesis of normal pulp
tissues and repair of dental pulp which includes rapid fibrodentin
matrix formation and subsequent reparative dentinogenesis.
The pulp matrix itself showed homogeneous fibrous deposition
together with reparative dentin islands. The formation of new
dentin started from within the pulp at some distance from
the amputated site. There was also a marked tendency for
angiogenesis in the deeper parts of the pulps, indicating an
increased level of cell growth and/or metabolism. After the
initial phase of healing in these teeth, a web of odontoblast-like
cells was also observed growing from the central part of the pulp
toward the pulp chamber walls, forming a dentin bridge. The
EMO-induced hard tissue closely resembled osteodentin early
in the process and later became more like secondary dentin
emdogain for pulpotomy

Local anesthesia

i
A thick mix of zinc oxide eugenol cement was placed over the
lyophilized preparation to seal the coronal pulp chamber
The teeth were isolated using rubber dam

Enamel Matrix Derivative as Pulpotomy Agent

Cavity outline was established
Enamel matrix derivate (EMD) is obtained from
embryonic enamel as amelogenin has been
The pulp chamber was entered and the roof was removed
demonstrated in vitro to be capable of stimulating
periodontal ligament cell proliferation sooner when +
compared to gingival fibroblasts and bone cells Coronal pulp tissue amputation was-achieved using spoon
excavator
The ability of EMD to facilitate regenerative processes
in mesenchymal tissues is well-established. 1he EMD-
induced processes actually mimic parts of normal The chamber was irrigated with normal saline
odontogenesis. It is believed that the EMD proteins
P_articipate in the reciprocal ectodermal-mesenchymal Hemorrhage was controlled using a sterile pledget of moist
signaling that control and pattern these processes. cotton under pressure
Based on these observations, it has been suggested
that amelogenin participates in the differentiation of Teeth were acid etched (35% phosphoric acid gel) and primed
odontoblasts and the subsequent predentin formation
Emdogain gel (Straumann, Switzerland) has been
The cotton pellet was removed and the amputated pulpal stumps
5uccessfully employed for pulpotomies in uninfected were covered with emdogain gel from a 0.3-011 syringe
te eth in animal studies. EMD components act as a
signal for induction of mesenchymal cell differentiation,
Light cured glass ionomer cement was applied as the restorative
maturation and biornineralization material
Form a stable extracellular matrix that provides a
beneficial and protective pulp environment
 Section 10 -+- Pediatric Endodontics
Propolis
It is a wax-cum-resin substance that is Prod uced _by beet
It is shown to have antibacterial, antiviral, antifu~g~ '
immunostimulation hypotensive, and cytoStatic actIVIty
mainly due to the presence of lavonoids (2-phenyl-
1,4-benzopyrone), aromatic acids, and eS t ers. As ~n
antiinflammatory agent, it inhibits prostaglandm
synthesis.
Carmen et al. compared the effectiveness of 10% propolis
tincture and formocresol pulpotomy in primary molars and
showed that 10% propolis tincture was as effective as FC
Lima et al. following histological analysis concluded that the
inflammatory response was less severe, the area of pulp necrosis
was smaller, and more frequent formation of a mineralized
tissue barrier was evident.
Ankaferd Blood Stopper (ABS)
It is a herbal extract obtained from five different plants:
Thymus vulgaris, Glycyrrhiza glabra, Vitis vinifera,
Alpinia officinarum, and Urtica dioica
The42
possible mechanism is explained by Goker et
al. who concluded that following application of
ABS, it forms an encapsulated protein network that
provides focal points for vital erythrocyte aggregation.
ABS-induced protein network formation with blood
cells particularly erythrocytes covers the primary
and secondary hemostatic system without disturbing
individual coagulation factors.
Platelet-Rich Plasma
It was introduced by Marx in 1998 for reconstruction of
mandibular defects, and it represents a relatively new
biotechnology that is part of the growing interest in
tissue engineering and cellular therapy
Platelet-rich plasma gel (PRP gel) is an autologous modi-
fication of fibrin glue obtained from autologous blood
used to deliver growth factors in high concentrations
It is an autologous concentration of human platelets
in a small volume of plasma, mimics the coagulation
cascade, leading to formation of fibrin clot, which
consolidates and adheres to application site
Its biocompatible and biodegradable properties prevent
tissue necrosis and extensive fibrosis and promote
healing
Platelet-rich plasma has been found to work via three
mechanisms: Increase in local cell division; Inhibition
of excess inflammation by decreasing early macrophage
proliferation, and degranulation of the agranules in
platelets.
....---- 14:J:_c_o-:-
. - t --:- n-:;
cl~ud:;e: d;-:;
th:::a;;t-;P;;R;P~w~as~ fo~u~ndd~t~o~b:e-:a=-:-
n ideal
Ram e a . . I . ffi .
material for pulpotomy with ow to~': el ect, increased tissue
regenera t.ing properties' and good chnica results.
Pulpotec
It is a newly available radiopaque, nonre~orbable paste
th t is used for pulpotomy treatment. It 1s available as
a D .
powder liquid system (Produits enta1res SA, Vevey.
Switzerland)
Powder consists of polyoxymethylene, iodoform and
liquid consists of dexamethasone acetate, formaldehyde,
phenol, and guaiacol . . .
Its mode of action is by c1catr1zation of the pulpal stump
at the chamber-canal interface, while maintaining the
structure of underlying pulp.
Calcium Phosphate Cement
Several formulations of calcium phosphate cement
(CPC) have been successfully designed for various
orthopedic and dental applications
Calcium phosphate cement possesses the combination
of biocompatibility, osteoconductivity, and mouldability
along with being nontoxic and nonimmunogenic
Chitra-CPC is a new CPC formulation with good
rheological properties developed in India.
Ratnakumari et al.
44
used chitra-CPC and reported favorable
results with mild pulpal inflammation and improved quality of
dentin bridge formation.
Biodentine
Bio ceramic materials in pediatric endodontics, now can
be safely considered as a munificent entity which has
changed the prognosis of many cases which were once
considered as unsalvagable
Biodentin new bioactive calcium silicate-based cement
has been recently launched in the dental market as a
'dentin substitute'
This new biologically active material aids its penetration
through opened dentinal tubules to crystallize
interlocking with dentin and provide mechanical
properties. Biodentin has been formulated using
MTA-based cement technology and hence; claims
improvements of some of the properties such as physical
qualities and handling (Table 54.1), including its other
wide range of applications like endodontic repair and
pulp capping in restorative dentistry
Bogen G et al. in a study have shown that the dynamic
interaction of Biodentine with the dentin and pulp
 Chapter 54 + Pulp Therapy for Vital Teeth

~
~
Materi~I
lltf-:::::::
:...:..,:.:.,_1,,:
..,, Initial - - .,- . Fi,;a, - -~---,,o,;;ny cha;JJ;;-
after several days of traumatic pulp exposure, single visit
apexification, massive resorptive lesion with multiple
perforations, combined endodonticperiodontic lesion and
setting time setting time istics [density (g/ incomplete vertical root fracture .
•J~ t~} l(mJnutesJ · cnr,JJ
Research studies regarding biodentine
MTA (ProRoot) 70 175 1.882 (0.002)
2.260 (0.002) Rajasekharan et al 46 highlights Biodetine's spectrum of
6 10.1
Siodentine clinical applications in pediatric dentistry per se and overall in
endodontics, restorative dentistry and dental traumatology
Kusum et al 47 evaluated 25 primary molars in 3 to 10 year old
Table 54.2: Composition of biodentine
children were treated with Blodentlne and MTA and showed
'PoWder l:eercentage 92 and 80% radiographic success respectively after 9 months
Tricalcium silicate (3Ca0.SI0 2) (main core material) 80.1 follow-up and 100% cllnlcal success was observed in both the
Dicalcium silicate (2Ca0.SIO} (second core material) groups
Calcium carbonate (CaCO} (filler) 14.9 In the study by Nlranjanl et al.48, no statistically significant
Zirconium oxide (ZnO,) (radioopacifier) 5 difference was observed between MTA and Biodentlne as a
Iron oxide (coulouring agent) pulpotomy medicament after 6 months follow-up
Togaru et al.49, evaluated 90 decayed primary molars that
required pulpotomy treatment with either Biodentine or MTA.
tissue interface stimulates pulp cell recruitment and Both the groups showed a 95.5% success rate at the end of 12
differentiation, upregulates transformation factors (gene months
Rajasekharan S et al 50 did RCT of 25 primary molars treated
expression), and promotes dentinogenesis45 with Blodentine, reported 95.2% clinical and 94.4% radiographic
Biodentine is available in the form of a capsule success after 18 months. In both RCTs, clinical and radiographic
containing the ideal ratio of its powder and liquid. The findings did not show any significant difference between
composition of powder is Tricalcium silicate (3Ca0.SIOz) Biodentine and MTA.
(main core material), Dicalcium silicate (2CaO.SIOz)
(second core material), Calcium carbonate (CaCO)
(filler), Zirconium oxide (ZnO) 2
(radioopacifier), Iron APEXOGENESIS
oxide (coloring agent) (Table 54.2) while the liquid
contains calcium chloride which act as an acclerator, It is defined as the treatment of a vital pulp by capping or
hydrosoluble polymer function as water reducing agent pulpotomy in order to permit continued growth of the root
andwateL and closure of the open apex.

Rationale

-
Procedure
After hemostasis
Maintenance of integrity of the radicular pulp tissue to allow
for continued root growth.
Biodentine (Septodont, Saint Mi r des Fosse's , France) is mixed
lh!i _iodentme
rd mg_lo the manufacturer's instructions and applied (First,
capsule is struck gently on a solid surface and then
Indications
mix th e powder inside , further mix with 5 droplets of liquid for Indicated for traumatized or pulpally involved vital
30 seconds using a triturator) permanent tooth when root apex is incompletely
formed
Thee· . i
u . todent1ne mixture is condensed to the pulp stumps
No history of spontaneous pain
Sin an amal am carrier and mois1ened cotton pellet •!• No sensitivity on percussion
No hemorrhage
The cavity is filled with Biodentine after~ time of 9-12 minutes Normal radiographic appearance.

Restore bY using
- a stainless steel crown ancl cementecl
Contraindications
with glass ionomer cement ~vidence that radicular pulp has undergone degen -
tlve changes era
Uses Purulent drainage
B· History of prolonged pain
lodenu
llnconve~~ has b:en reported to be successful in certain Necrotic debris in canal
0 nal Clrcumstances which include pulpotomy Periapical radiolucency.
 Section 10 + Pediatric Endodontics

Procedure (Figs. 54.11 A to C) . local anesthesia

Application of rubber dam fo 11 owing

Remove all of carious tooth structure and open up the pulp chamber

J
'= i
,: = = =-==-'--~R~e:'.m~o~v~e~c~o~ro~n~a~l~p~ul~p~t~is~su~e:._w~ith~ex~c:':a~v~at~o::_:rs:::_,_:cTa:..: .:.:.s..:.ta_ke_n to
re:_:1 prevent damage to radicular pulp
_...:.___________ - ---

- - -~R!in~s'.:e~a~IIJth~e:_r~e~s~id~u~al~d~e~b~ri~s~a~nd~co~n~t~ro~l~h.:_em~o~rr~ha~gre:..b'.:'.:y~f
pl:a::
:::ce::m
.:..:e
:..n
...:...
t of____________ --
8 moist cotton pellet over the amputed pulp _ J

·~ ii
I '---'--'= ---=----C:'..a~(~O~H~)i~~mix~tu~re:_:is~p:la'.'..'.c'.:'.e~d_::o:.:_ve::_:r_;t~he:..:.pu::_p"Ts.:..::
I tu::.:m...::p_s.:...
, followed
_ _ _by_temporary
_ _ _ _restora 10n_ _ _ _ _ __
_ _ t'_ J
Follow-up radiographs are taken periodically to check the root development
J
l
Once root development is complete, the conventional root canal treatment is d one

Figs. 54.11 A to C: Apexogenesis. (A) Traumatic injury to young permanent teeth; (8) Calcium hydroxide apexogenesis done;
(C) Continued root growth with maintenance of vitality.

51
Recent research regarding pulpotomy in primary teeth
o Erdem AP et al. (2011) evaluated the total success rates of MTA, FS, and FC as pulpotomy agents in primary molars and concluded that
both MTA and FS showed comparable results to FC and can be used an alternative pulpotomy agents
o Alam F et al."(2013) ca<ried out a study to compa,e the effectiveness of dllute FC and FS In the pulpotomie, of 60 prima,y molao
clinkally
be used asand
an radlog,aphkally
alternative to FCafte, 3 and 5 months and .concluded that both the agents have slmlla, outcome, but Fs being nontoxic urn
for pulpotomy

o YUdiz Eetal.• (2014) conducted a study to evaluate fou, dlffe,ent pulpotomy medicaments (FC, fo,moae,ol, FS, fe,,ic sulfate, CH, calcium
hydroxide, and MTk mineral trioxide agg,egate) In p,lma,y molae;. At 30 month,, clinical success ,ate, we,e 100%, 95.2%, 96.4%, and 85%
in the FC, FS, MTA, and CH gm ups, ,especti,ely. In radiographic analysis, the MTA g,oup had the highest (96.4%), and the CH group had the
0 lowest success rate (85%). So it was concluded that FS and MTA can be used as an alternative to FC pulpotomy
Gupta G et al. M (2015) also had conducted a study on lase, pulpotomy, FS pulpotomy, and elect,osu,glcal pulpotomy In human prima,y
0
molars for 12 months and stated that laser is an effective alternative to conventional techniques
Niranjani Ket al." (2015) ca"led out a study to evaluate the success and efficacy of MTA, lasee; and biodentlne as pulpotomy agents both
clinically and radlog,aphkallyfo, 6 ".'onth,_in ••. P_Oma,y m~la,s and It was concluded that pulpotom1e, perlonned with eltho, MTA. lase,
or biodentine are equally efficient with s1m1lar chnical or rad1ograph1c success and hence can be con,sidered as alternat,ves ,to FC.

Contd ..