Teeth

Complications following traumatic injuries to primary teeth may appear shortly after the injury (e.g.,
infection of the PDL or dark discoloration of the crown) or after several months (e.g., yellow
discoloration of the crown and external root resorption). It is currently not possible to accurately
identify the histopathologic condition of a dental pulp based on clinical symptoms. The following terms
describe a spectrum of clinical signs and symptoms that accompany inflammation and degeneration of
the pulp and/or PDL.

Reversible Pulpitis

The pulp's initial response to trauma is pulpitis. Capillaries in the tooth become congested, a condition
that can be clinically apparent upon transillumination of the crown with a bright light. Teeth with
reversible pulpitis may be tender to percussion if the PDL is inflamed (e.g., following a luxation injury).
Pulpitis may be totally reversible if the condition causing it is addressed, or it may progress to an
irreversible state with necrosis of the pulp.

Infection of the Periodontal Ligament

Infection of the PDL becomes possible when detachment of the gingival fibers from the tooth in a
luxation injury allows invasion of microorganisms from the oral cavity along the root to infect the PDL.
Loss of alveolar bone support can be seen on a periapical radiograph (Fig. 16.14). This diminishes the
healing potential of the supporting tissues. Subsequently, increased tooth mobility accompanied by
exudation of pus from the gingival crevice will require extraction of the injured tooth. Parents should be
informed about the risk of infection and provided with appropriate instructions to minimize such risk.

Irreversible Pulpitis

Irreversible pulpitis may be acute or chronic, and it may be partial or total. Acute, irreversible pulpitis
following a dental injury can be painful if the exudate accompanying the pulpal inflammation cannot
vent. Most frequently in children, however, inflammatory exudates are quickly vented and the pulpitis
progresses to a chronic, painless condition.

Pulp Necrosis and Infection

Two main mechanisms can explain how the pulp of injured primary teeth becomes necrotic: (1) infection
of the pulp in cases of untreated crown fracture with pulp exposure and (2) interrupted blood supply to
the pulp through the apex in cases of luxation injury leading to ischemia. Not all luxation injuries result
in a necrotic pulp. Surprisingly, intruded primary teeth, unlike permanent teeth, maintain the vitality of
their pulp. Though untreated teeth with exposed pulps are expected to develop swelling or fistulas,
injured teeth with avascular necrosis may remain asymptomatic both clinically and radiographically. Loss
of pulp vitality due to a traumatic injury at an early stage of root development results in the arrest of
dentin apposition and cessation of root development
Periapical radiolucencies indicative of a granuloma or cyst are frequently evident radiographically in
necrotic anterior teeth. In addition, a parulis is often clinically evident at the level of the involved tooth's
root apex (see Fig. 16.16B). Controversy exists regarding the most appropriate treatment of primary
anterior teeth with necrotic pulps. Some clinicians treat them with a pulpectomy technique similar to
that used in permanent teeth. A resorbable paste is packed into the thoroughly cleansed canal (see
Chapter 23). Other clinicians choose to extract these teeth because of the potential for damage to the
developing permanent tooth buds. It is generally agreed that pulpectomy is contraindicated in primary
teeth with gross loss of root structure, advanced internal or external resorption, or periapical infection
involving the crypt of the succedaneous tooth.

Coronal Discoloration

As a result of trauma, the capillaries in the pulp occasionally hemorrhage, leaving blood pigments
deposited in the dentinal tubules. In mild cases, the blood is resorbed and very little discoloration
occurs, or that which is present becomes lighter in several weeks. In more severe cases, the
discoloration persists for the life of the tooth.

Rapidly Progressing Root Resorption

Rapidly progressing root resorption (previously referred to as “inflammatory” resorption) can occur
either on the external root surface or internally in the pulp chamber or canal (see Fig. 35.13). It occurs
subsequent to luxation injuries and is related to a necrotic pulp and an inflamed PDL.61 It can progress
very rapidly, destroying a tooth within months. Clinicians who choose to treat a patient with this
condition when it occurs in the primary dentition use a resorbable paste of calcium hydroxide, iodoform
or zinc oxide, and eugenol as an endodontic filling material. The operator should be aware of the
possibility that the zinc oxide eugenol paste may not be completely resorbed with the root of the
primary incisor and remain permanently in the surrounding tissue.62

Internal Resorption

The predentin, an unmineralized layer of organic material, covers the inner aspect of the dentin and
protects it against access of odontoclasts. When the pulp becomes inflamed, as in cases of traumatic
injury, the odontoblastic layer may lose its integrity and expose the dentin to odontoclastic activity,
which is then seen on radiographs as radiolucent expansion of the pulp space. Eventually this process
reaches the outer surface of the root, causing root perforation. If the coronal dentin is completely
resorbed, the red color of the resorbing tissue becomes visible through the enamel.

External Resorption

The cementoblast layer and the precementum serve as a shield, protecting the root from involvement in
the perpetual remodeling process of the surrounding bone. In nontraumatized primary teeth, external
root resorption is part of the physiologic process of replacing the primary dentition with permanent
teeth. In primary incisors sustaining traumatic injuries, external root resorption may appear as an
accelerated unfavorable pathologic reaction. A variety of patterns of pathologic external root resorption
can be seen in primary incisors following traumatic injury.

Pulp Treatment Procedures

The most important and also the most difficult aspect of pulp therapy is determining the health of the
pulp or its stage of inflammation so that an appropriate decision can be made regarding the best form of
treatment. Different pulp treatment modalities have been recommended for primary teeth. They can be
classified into two categories: vital pulp therapy for primary teeth diagnosed with a normal pulp or
reversible pulpitis (pulp protection, IPT, DPC and pulpotomy) and nonvital pulp therapy for primary
teeth diagnosed with irreversible pulpitis or necrotic pulp (pulpectomy and root filling). When the
infection cannot be arrested by any of the methods listed, bony support cannot be regained, and the
tooth is not restorable, extraction is the treatment of choice (see Fig. 23.8).

Vital Pulp Therapy for Normal

Pulp/Reversible Pulpitis

Complete removal of all carious tissue followed by “extension for prevention” to place the margins of
the restoration in areas less vulnerable to caries was considered the gold standard 150 years ago. A
paradigm shift in carious lesions treatment has occurred, and in 1997 Fusyama44 suggested that in the
superficial layer, grossly denaturated infected dentin should be removed, while in the underlying layer,
partially demineralized caries-affected dentin (containing intact, undenaturated collagen fibrils
amenable to remineralize) should be preserved during caries excavation. These terms are now
considered outdated, particularly the term infected, which conveys the idea that dental caries is an
infectious or communicable disease that needs to be cured by removing bacteria. Presently, managing a
carious lesion includes several options, from the complete surgical excision, where no visible carious
tissue is left prior to placement of the restoration, to the opposite extreme, where no caries is removed
and noninvasive methods are used to prevent progression of the lesion.
Soft dentin will deform when a hard instrument is pressed onto it and can be easily scooped up
(e.g., with a sharp excavator), with little force being required. Leathery dentin does not deform when an
instrument is pressed onto it, but it can still be lifted without much force. There might be little difference
between leathery and firm dentin, while leathery is a transition in the spectrum between soft and firm
dentin. Firm dentin is physically resistant to hand excavation, and some pressure needs to be exerted
through an instrument to lift it. Hard dentin: A pushing force needs to be used with a hard instrument to
engage the dentin. Only a sharp cutting-edge instrument or a bur will lift it. A scratchy sound or “cri
dentinaire” can be heard when a straight probe is taken across the dentin.
As dental caries is a biofilm disease, the ICCC suggests both prevention of new lesions and
management of existing lesions should focus primarily on control or management rather than tissue
removal. Noncavitated (cleansable) lesions can be managed with biofilm removal (toothbrushing)
and/or remineralization. Cavitated (noncleansable) dentin carious lesions cannot be managed by biofilm
removal, and remineralization and restorative interventions are indicated.
 To remove carious tissue in teeth with vital pulps and without signs of irreversible pulp
inflammation, several strategies are available, based on the previously mentioned level of hardness of
the remaining dentin.48 The decision among these strategies will be guided by the depth of the lesion
and by the dentition (primary or permanent). Nonselective removal to hard dentin (complete excavation
or complete caries removal) uses the same criteria for carious tissue removal both peripherally and
pulpally, and only hard dentin is left. This is considered overtreatment and is no longer advocated (ICCC).
Selective removal to firm dentin leaves leathery dentin pulpally, while the cavity margins are left hard
after removal. This is the treatment of choice for both dentitions in shallow or moderately cavitated
dentinal lesions (radiographically extending less than the pulpal third or quarter of dentin). Selective
removal to soft dentin is recommended in deep cavitated lesions (radiographically extending into the
pulpal third or quarter of dentin). Soft carious tissue is left over the pulp to avoid exposure and further
injury to the pulp, while peripheral enamel and dentin are prepared to hard dentin to allow a tight seal
and a durable restoration. Selective removal to soft dentin reduces the risk of pulp exposure significantly
when compared with nonselective removal to hard or selective removal to firm dentin. Stepwise
removal is carious tissue removal in two stages. Soft carious tissue is left over the pulp on the first step,
and the tooth is sealed with a provisional restoration that should be durable to last up to 12 months to
allow changes in the dentin and pulp to take place. In reentering, after removing the restoration, as the
dentin is drier and harder, caries removal is continued. There is some evidence that in such deep lesions
the second step might be omitted, as it increases the risk of pulp exposure.

Protective Base

Guidelines published by the AAPD recommend placement of a protective base or liner on the
pulpal and axial walls of a cavity preparation to act as a protective barrier between the restorative
material and the tooth. Dentin is permeable and allows the movement of materials from the oral cavity
to the pulp and vice versa. It was believed for several years that pulp inflammation was caused by the
toxic effects from dental materials. However, there is sufficient evidence to show that pulpal
inflammation resulting from dental materials is mild and transitory, with adverse reactions occurring as
the result of pulpal invasion by bacteria or their toxins. Continued marginal leakage with secondary
recurrent caries is probably the most common cause of pulp degeneration under restorations. In deep
cavities, the dentin covering the pulp is thin, and the tubules are large in diameter and packed closely
together. This dentin is extremely permeable and should be covered with a material that seals dentin
well, usually glass ionomer cement.
The materials most recently used as cavity sealers are those that have demonstrated
multisubstrate bonding ability to bond the restorative material to the tooth. These include resin
cements, glass ionomers, and dentin-bonding agents. The benefits of using these materials to bond
composite to tooth structure is a well documented and accepted procedure.56 However, employing
them with amalgam is more controversial. Mahler and colleagues observed no difference between
amalgam restorations placed with and without bonding after 2 years, and concluded that the use of
bonding agents under traditional amalgam fillings should not be recommended. Thus protective liners or
bases should only be placed in deep cavities approaching the pulp.
Indirect Pulp Treatment (Selective Removal to Soft Dentin)

IPT is recommended for teeth that have deep carious lesions approximating the pulp but have
no signs or symptoms of pulp degeneration. In this procedure, the deepest layer of the remaining
carious dentin is covered with a biocompatible material. This results in the deposition of tertiary dentin,
increasing the distance between the remaining soft dentin and the pulp, and in the deposition of
peritubular (sclerotic) dentin, which decreases dentin permeability. It is important to remove the carious
tissue completely from the dentinoenamel junction and from the lateral walls of the cavity to achieve
optimal interfacial seal between the tooth and the restorative material, thus preventing microleakage.
As previously described, IPT (selective removal to soft dentin) is recommended in deep cavitated
lesions (radiographically extending into the pulpal third or quarter of the dentin). Soft carious tissue is
left over the pulp to avoid exposure and further injury, while peripheral enamel and dentin are prepared
to hard dentin, to allow a tight seal and a durable restoration. Selective removal to soft dentin reduces
the risk of pulp exposure significantly when compared with nonselective removal to hard dentin or
selective removal to firm dentin (see Fig. 23.9A–E). Clinical experience and a good understanding of the
process of caries progression can allow for better control of the “partial removal caries (selective
removal to soft dentin)” step. A large round bur (no. 6 or 8) can provide better results than spoon
excavators.58 The ultimate objective of this treatment is to maintain pulp vitality59 by (1) arresting the
carious process, (2) promoting dentin sclerosis (reducing permeability), (3) stimulating the formation of
tertiary dentin, and (4) remineralizing the carious dentin.
It is current knowledge that, in the appropriate metabolic state of the dentin-pulp complex, a
new generation of odontoblast-like cells might differentiate and form tubular tertiary dentin (reparative
dentinogenesis). It must be emphasized that under clinical conditions, the matrix formed at the pulp-
dentin interface often comprises reactionary dentin, reparative dentin, or fibrodentin formation. It is
impossible to distinguish these processes in vivo, and the process might also be indistinguishable at both
biochemical and molecular levels.
Presently, the materials most commonly used in IPT (selective removal to soft dentin) are
calcium hydroxide, glass ionomer, and mineral trioxide aggregate (MTA). Many historical studies have
examined the interaction between tooth tissues and calcium hydroxide, and more recently with MTA.
The main soluble component from MTA has been shown to be calcium hydroxide.
The clinical response of the tooth to both materials is based on comparable mechanisms
involving the dissolution of calcium hydroxide and release of calcium and hydroxyl ions, raising the pH of
the environment well above 7.0. Because dentin contains a large store of potentially bioactive
molecules, it has been considered that the interaction of a high pH material, such as calcium hydroxide
or MTA, may cause the release of some of these molecules. This action is similar to that occurring during
the demineralization of dentin during a caries attack, where the pH of the local environment is low.
When resin-modified glass ionomers are placed into a cavity preparation or on an exposed pulp,
their initial pH within the first 24 hours is approximately 4.0 to 5.5. Therefore the glass ionomer
demineralizes the adjacent dentin, releasing ions and potentially the sequestered bioactive materials as
well. The pulpal response to glass ionomer is favorable when a layer of dentin remains between the
material and the pulp. Studies of DPC with glass ionomer show that both patient tolerance and clinical
success rates are lower with ionomer than calcium hydroxide. This finding suggests that the acidic
environment created by the glass ionomer is more damaging to the pulp than the basic environment of
calcium hydroxide or MTA.
Dentin-bonding agents have been recommended for use in DPC and IPT. However, there are
some concerns regarding IPT (selective removal to soft dentin) with these materials. Nakajima and
coworkers found a significant loss of bond strength to human carious dentin when compared with sound
dentin. This finding leads one to further question the integrity of the bond and subsequent ability to
prevent bacterial invasion of a carious substrate.
Contrary to previous beliefs, IPT can also be an acceptable procedure for primary teeth with
reversible pulp inflammation, provided that the diagnosis is based on a good history and proper clinical
and radiographic examination and the tooth has been sealed with a leakage-free restoration.
The tooth treated with an MTA pulpotomy presents internal root resorption, whereas its
antimere, restored conservatively with a composite over an IPT, looks normal. These findings were
probably attributable to the preoperative status of the pulp. The radicular pulp of the pulpotomized
tooth was probably chronically inflamed at the time of treatment but could not be disclosed even by
operative diagnosis.
Success rates of IPT have been reported to be higher than 90% in primary teeth, and thus its use
is recommended in patients whose preoperative diagnosis suggests no signs of pulp degeneration.
Ricketts and colleagues concluded that “in deep lesions, partial caries removal is preferable to complete
caries removal to reduce the risk of carious exposure.” Several articles reported the success of this
technique in primary teeth. The overall success of IPT (selective removal to soft dentin) has been
reported to be higher than the success rates of DPC or pulpotomy, the alternative pulp treatments for
primary molars with deep dentinal caries. One can conclude that, on the basis of these biological
changes and the growing evidence of the success of IPT in primary teeth, we canrecommend IPT
(selective removal to soft dentin) as the most appropriate treatment for symptom-free primary teeth
with deep caries, provided that a proper, leakage-free restoration can be placed.
A recent systematic review and meta-analysis on primary tooth vital pulp therapy 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. DPC showed similar
success rates to IPT and MTA or FC pulpotomies, but the quality of evidence was lower.” New
experimental strategies use bioactive molecules such as enamel matrix protein (Emdogain [Straumann
Canada Limited, Burlington, Ontario]) or TGF-β to stimulate tertiary dentin formation and decrease
dentin permeability. However, these are not yet in clinical use.

Direct Pulp Capping

DPC is carried out when a healthy pulp has been inadvertently exposed during an operative
procedure. The tooth must be asymptomatic, and the exposure site must be pinpoint in diameter and
free of oral contaminants. A calcium hydroxide medicament is placed over the exposure site to stimulate
dentin formation and thus “heal” the wound and maintain the vitality of the pulp. The effectiveness of
TGF-β and BMPs in inducing reparative dentinogenesis in pulp capping situations in vivo75–77 provides
the basis for development of a possible new generation of biomaterials. Because the specificity of these
growth factors to induce reparative processes is not clear, more studies are required to fully explain the
kinetics of growth factor release and the sequence of growth factor– induced reparative dentinogenesis.
DPC of a carious pulp exposure in a primary tooth is not recommended but can be used with success on
immature permanent teeth. The direct pulp cap is indicated for small mechanical or traumatic exposures
when conditions for a favorable response are optimal. Even in these cases, the success rate is not
particularly high in primary teeth. Failure of treatment may result in internal resorption (Fig. 23.12A and
B) or acute dentoalveolar abscess. Kennedy and Kapala78 claim that the high cellular content of the
primary pulp tissue may be responsible for the increased failure rate of DPC in primary teeth. These
authors believe that undifferentiated mesenchymal cells may differentiate into odontoclasts, leading to
internal resorption, a principal sign of failure of DPC in primary teeth.
Some investigators advocate the use of dentin-bonding agents for DPC. The rationale for this is
based on the belief that if an effective, permanent seal against bacterial invasion is provided, pulp
healing will occur. Araujo and associates reported good clinical and radiographic results in cariously
exposed primary teeth 1 year after acid etching and capping with a bonding agent and restoration with a
resin-based composite. Based on these reports, Kopel81 proposed a “revisitation” of the DPC technique
in primary teeth. He suggested “gently wiping the dentin floor and the exposed pulp with an
antibacterial solution such as chlorhexidine or a fixative such as formocresol or a weak glutaraldehyde
solution,” replacing calcium hydroxide with dentin-bonding agents. In another publication a year later,
Araujo and colleagues examined histologically primary molars with microexposures that were
successfully treated with a composite acid etch technique and then extracted or exfoliated. These
authors observed microabscesses adjacent to the exposure site, and no dentin bridge was formed in any
specimen. These results were confirmed 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 inflammatory reactions, delay in pulpal
healing, and failure of dentin bridging in human pulps capped with bonding agents. They 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 fistula, 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,amalgam and resin-based materials followed by a sealant coverage,86 and stainless steel
crowns. Coll et al. 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 definitive 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.
1048
Pulpotomy
As stated previously, recent evidence suggests that IPT (selective removal to soft dentin) is
preferred over the traditional pulpotomy. All efforts 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. The pulpotomy procedure is based on the rationale that the radicular
pulp tissue is healthy or is capable of healing after surgical amputation of the affected or infected
coronal pulp. pulp. The presence . . . – sambungannya di kertas-
Conversely, in Brazilian dental schools, the pulpotomy agent that students are most frequently
taught to use is diluted formocresol. 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, philosophies 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 . . . – sambungannya dikertas-
Holan and coworkers 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 final restoration is not possible, the ZOE base will serve as an acceptable interim restoration
until the stainless steel crown can be placed.
The MTA and FS procedures are essentially the same with either of the medicaments used in
place of formocresol. The 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 orifices are wiped with 15.5% solution of FS
(Astringedent) for 10 to 15 seconds. Next, Astringedent is flushed 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. They concluded that the low success rate (53%) of the pulpotomies during the first 3 months
could be attributed to undiagnosed subclinical inflammation of pulps, whereas long-term failures might
be associated with microleakage of the temporary restorations.
Clinical and radiographic studies have demonstrated that formocresol pulpotomies have success
rates ranging from 70% to 97%.96–99 The use of a one-fifth dilution of formocresol has been advocated
by several authors96,97 because of its reportedly equal effectiveness and potential for less toxicity. This
solution is prepared by making a diluent of three parts glycerin and one part water. Four parts of this
diluent are then mixed with one part Buckley solution to make the one-fifth dilution.
Although many studies have reported the clinical success of formocresol pulpotomies, an
increasing body of literature has questioned the use of formocresol. Rolling and Thylstrup 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, fixation occurs in the coronal third of the radicular pulp, chronic
inflammation in the middle third, and vital tissue in the apical third. Others report that the remaining
pulp tissue is partially or totally necrotic. Several reports have questioned the safety of formocresol, and
most authorities now agree that formocresol is at least potentially mutagenic, carcinogenic, and toxic
when used in high concentrations and under specific 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. The 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 The 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, efforts have increased to
find a substitute medicament.

Potential Substitutes for Formocresol

Glutaraldehyde (GA) has been proposed as an alternative to formocresol because it is a mild
fixative and is potentially less toxic. Because of its cross-linking properties, penetration into the tissue is
more limited, with less effect on periapical tissues. The short-term success of 2% GA as a pulpotomy
agent has been demonstrated in several studies.106–111 However, longer-term success rates matching
those of formocresol have not been reported. Fuks and associates 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.
Fuks and colleagues reported a success rate of 93% in teeth treated with FS and 84% in those
where diluted formocresol (DFC) was employed. These 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 five teeth treated with FS and four
teeth fixed with DFC. This discrepancy can be explained by an excessively severe interpretation of the
initial findings. 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. Success rates comparable to
those of formocresol were also reported by Smith and coworkers.120 A higher percentage of internal
resorption using FS and formocresol was reported by Papagiannoulis 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. 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 confirmed these findings. Both studies concluded that
clinical and radiographic success rates for NaOCl pulpotomies are comparable to FS and formocresol
pulpotomies. In a recent prospective study 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 significantly 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. It is a mixture of a refined
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.
In 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 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 finding seen both in FS- and DFC-treated teeth in other studies, was not observed in MTA-
treated teeth in the preliminary report. Longer clinical studies have since been published with high
success rates. Holan and associates investigated MTA effects 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 effect of MTA in 60 pulpotomized molars with those of formocresol followed during 2
years and noted a success rate of 100%.
When MTA was first commercialized, it had a gray coloration; but in 2002 a new white formula
was created to improve on the dark color properties exhibited by the gray preparation. 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. The gray MTA had 100%
radiographic success, and the white had a 93% success rate. Another interesting finding was that gray
MTA showed a significantly 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 MTAAngelus (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 review 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 differs 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 diffraction 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 effectiveness after 24 months. However, 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.
Nonpharmacotherapeutic 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 conflicting results.
In summary, the search for alternatives to formocresol as a pulp dressing in primary tooth
pulpotomies has yet to reveal an ideal agent or technique. Until such an agent is found, formocresol
(either in a one-fifth dilution or full strength), FS, or MTA can be used as capping agents in primary tooth
pulpotomies.
The systematic review and meta-analysis on primary tooth vital pulp therapy,74 mentioned
previously, will be the evidence-based material to be used in the new Guideline for Pulp Therapy for
Primary Teeth for the AAPD. This 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.” The 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
The pulpectomy procedure . . . – sambungannya di kertas-
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 first permanent molar erupts. A premature extraction of the primary second molar without
placement of a space maintainer usually results in mesial eruption of the first permanent molar with
subsequent loss of space for the second premolar. Although a distal shoe space maintainer could be
used, maintaining the natural tooth is definitely the treatment of choice. Therefore, a pulpectomy in a
primary second molar is preferable, even if that tooth is maintained only until the first permanent molar
has adequately erupted and is followed eventually by extraction of the primary second molar and
placement of a space maintainer
Criteria for Radiographic Success
Another 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. Payne and associates 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. This 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, most of the pulp therapy studies in the existing literature have considered such
teeth to be “successfully treated.” These criteria seem to be more suitable for pediatric dentist practices
and have been adopted clinically by Fuks and coworkers.153 These 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 effects 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.
Regardless of the pulp treatment performed, treatment success relies on a leakage-free
restoration.

Summary
Pulp therapy for the primary dentition includes a variety of treatment 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 inflammation or necrosis in the radicular pulp.