PULP

THERAPY
MEDICAMENT
S FOR
PRIMARY
TOOTH
CONTENTS
 INTRODUCTION

 PULPOTOMY
TECHNIQUE'S FOR
PRIMARY TEETH

 PULPOTOMY
MEDICAMENTS

 CONCLUSION
 INTRODUCTION
• The conservation of primary teeth in form and function until their normal
exfoliation is one of the fundamental objectives of pediatric dentistry.

• In asymptomatic primary teeth with deep carious lesions approximating the

pulp, the coronal pulpotomy is one of the common ways of achieving the goal
of tooth preservation.

Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young
permanent teeth. Springer International Publishing Switzerland.2016,52-68
 PULPOTOMY TECHNIQUE'S FOR
PRIMARY TEETH
• Formocresol Pulpotomy Technique
• Glutaraldehyde Pulpotomy Technique
• Ferric Sulfate Pulpotomy Technique
• Sodium Hypochlorite Pulpotomy Technique
• Calcium Hydroxide Pulpotomy Technique
• MTA Pulpotomy Technique
• Laser
• Partial Pulpotomy Secondary to Trauma or Non-caries associated
Resorption
 OTHERS
• Enriched collagen (Fuks 1984)

• Freeze Dried Bone (Fadavi et al. 1988)

• Demineralized Dentin (Nakashima 1989)

• Bone Morphogenetic Protein Animal (Nakashima 1991)

• Osteogenic Protein (Rutherford 1993)

• Calcium Enriched Mixture (CEM) (Asgary 2008 )

• Enamel Matrix Derivatives (EMD)

• Ankaferd Blood Stopper (ABS)

• Herbal agents (plant and animal extracts like Turmeric, Aloe vera, Thymus, Propolis etc.)

• Biodentine
 PULPOTOMY MEDICAMENTS

• Ideally, a pulpotomy medicament should be

– bactericidal,
– easy to use,
– harmless to the remaining pulp tissue and the surrounding structures,
– should not interfere with physiologic root resorption, and
– should be relatively inexpensive.

• Needless to say, the ideal dressing material has not been found, and studies are
constantly being conducted in both endodontics and pediatric dentistry to find such a
product.

Fuks AB, Kupietzki A, Guelmann M. Pulp therapy for the primary dentition. In: infancy through adolescence. In: Casamassimo PS, Fields Jr HW, McTigue DJ, Nowak AJ, editors. Pediatric
dentistry: infancy through adolescence. 5th ed. St. Louis: Elsevier Saunders; 2015. p. 333–51
• The search for this ideal material has been ongoing since the early 1900s when
Buckley first introduced Formocresol.

• Over the years, many other materials have surfaced as potential agents and have been
classified into three major categories according to their effects on the remaining
radicular pulp.

Buckley JP. The chemistry of pulp decomposition with a rational treatment for this condition and its sequelae. Am Dent 1904;3:764–71.
CLASSIFICATION OF VITAL PULP THERAPY

TYPES OTHER NAME

Devitalizing Mummification; cauterization

Preserving Minimal devitalization;

noninductive

Regenerating Inductive; reparative

 Timeline Devitalizing Preserving Regenerating

1930 Multiple Visits with

Formocresol. (Sweet)

1938 CaOH Pulpotomy for

Primary Teeth (Teuscher and
Zander)
1962 2 Visit FC Pulpotomy
Human (Doyle et al.)

1965 5 min FC Pulpotomy Animal (Spedding

et al.)

1966 Formocresol Pulpotomy Human

(Redig)

1970 Dilution of FC Animal CaOH Evaluated

(Straffon and Han) Human

1975 Dilution of FC; Human

(Morawa)
1978 Glutaraldehyde(GA) Proposed
Pulpotomy (Ranly and Lazzari)

1980 GA Proposed Humans

(Kopel)

Don M. Ranly. Pulpotomy therapy in primary teeth: new modalities for old rationales. Pediatric Dentistry:1994;403-09
 Timeline Devitalizing Preserving Regenerating

1983 Electrosurgical Pulpotomy

animal (Ruemping et al.)

1985 Laser animal (Shoji et al.)

1991 Ferric Sulfate Human (Fei)

1993 Electrosurgical Pulpotomy

Human (Mack)

1996 Argon Laser Animal MTA Animal (Ford

(Wilkerson) et al.)

2001 MTA Human

(Eidelman et al.)

2002 Sodium Hypochlorite

Animal (Hafez et al.)

2006 Sodium Hypochlorite

Human(Vargas KG et al.)

Don M. Ranly. Pulpotomy therapy in primary teeth: new modalities for old rationales. Pediatric Dentistry:1994;403-09
 FORMOCRESOL

• Formocresol was first introduced by Buckley in 1904.

• It was first introduced by Sweet as a pulpotomy agent in 1930.

• Mechanism of Action: Devitalization and Prevents tissue autolysis by bonding to protein and fixes
the pulp tissue which further prevents liquefactive necrosis of the remaining pulp tissue.

Once the pulp tissue has A cotton pellet dipped in a The dampened cotton
been removed from the 1:5 dilution of the original pellet is applied in the pulp
pulp chamber and Buckley’s Formocresol chamber for 5 min.
hemostasis achieved.

Tooth is restored with the The cotton pellet is

The pulp chamber is then
material of choice removed, and the root
filled with a thick paste
depending on the canal orifices are expected
of zinc oxide eugenol
remaining tooth structure. to look like
(ZOE) or intermediate
“black eyes”, with no
restorative material (IRM)
bleeding.

Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young
permanent teeth. Springer International Publishing Switzerland.2016,52-68
• In 2004, International Agency for Research on Cancer (IARC) reclassified formaldehyde
as a known carcinogen known to cause Nasopharyngeal carcinoma, leukemia and
lymphoma (with sufficient evidence in human trials).

• It is highly unlikely that formocresol, when judiciously used, is genotoxic or immunotoxic

or poses a cancer risk to children who undergo one or more formocresol pulpotomy
procedures.

• Defiitive data to support this hypothesis are still lacking.

• Until a biologic and reparative alternative has been identified that is clearly and
reproducibly superior to formocresol, there are no scientific or toxicologic reasons to
discontinue its use in pediatric dentistry.

•Kaaren
When used judiciously, formocresol is a safe medicament.
G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young
permanent teeth. Springer International Publishing Switzerland.2016,52-68
 GLUTARALDEHYDE

• Glutaraldehyde is a colorless, oily liquid that is used as an antimicrobial agent

• Mechanism of Action: GA is a di-aldehyde that has superior fixative properties over

Formocresol and has self-limiting penetration, low antigenicity, low toxicity, and
eliminates cresol.

• Glutaraldehyde has no bactericidal ability at low pH and therefore must be

alkalinized to a pH of between 7.5 and 8.5 before it is effective. This increase in pH
renders glutaraldehyde unstable, thus decreasing its shelf life to approximately 14
days.

Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young
permanent teeth. Springer International Publishing Switzerland.2016,52-68
 SUMMARY AND CONCLUSION
• Despite of number of materials that have been used as pulpotomy medicaments since the
early 1900s.

• A recent Cochrane Database of Systematic Reviews (Smaïl-Faugeron V et al.) of

pulpotomy medicaments showed that Mineral trioxide aggregate (MTA) may be the
best medicament to apply on the pulp stumps after pulpotomy of a deciduous tooth.

• Formocresol is effective, but there are known concerns about toxicity. Where MTA is
not accessible, Biodentine, enamel matrix derivatives (EMD), laser treatment or
may be Ankaferd Blood Stopper (ABS) seem to be the second choices.

• Where none of these treatments can be used, application of sodium hypochlorite

(NaOCl) could be the safest option.
Therefore, clinically, one should take into consideration numerous factors before deciding what treatment to
perform. These factors include:
1. Pulp status
2. Extent of the carious lesion
3. Age of the patient at the time of treatment
4. Goals of the treatment
5. Cost of the treatment

 If the child is very young and there is a carious exposure, a pulpectomy may be the treatment of choice.
 Conversely in an older child with a similar carious exposure, where no long-term maintenance is needed, a
pulpotomy may be adequate with any of the materials discussed earlier.

Diagnosis is the key to the success of any of these materials and techniques and should always be at the
forefront of our thought process when making any decision on pulp therapy.
THANK YOU !