Vital pulp therapy with new materials for primary teeth: new directions and treatment perspectives.

Summary
Objective. The purpose of this study was to investigate whether a diode laser pulpotomy with mineral trioxide aggregate (MTA) sealing could be an acceptable alternative to the conventional formocresol pulpotomy and zinc oxide eugenol (ZOE) sealing in human primary teeth.

Methods. A randomized, single-blind, split-mouth study was used with a sample of 16 children aged from 3 to 8 years (mean age = 5·10 years). A total of 26 pairs of teeth from these 16 patients were selected based on clinical and radiographic criteria. One tooth from each pair was randomly assigned to either the laser-MTA pulpotomy group or the formocresol-ZOE pulpotomy group. All teeth were followed up clinically and radiographically at 2·3, 5·2, 9·5 and 15·7 months. All extracted failures were sectioned and photographed to assess possible reasons for this.

Results. A total of seven laser-MTA-treated teeth were deemed to be radiographic failures (mean time until failure = 9·1 months) compared to three formocresol-ZOE treated teeth (mean time until failure = 12·5 months). These results were not significant using Fisher's exact test (P > 0·05). Six of the laser-MTA failures and all three formocresol-ZOE failures exhibited furcal and/or periapical radiolucencies with or without pathologic root resorption. One of the laser-MTA failures displayed premature root resorption and is being observed for exfoliation. Analysis of photographs of teeth available for extraction revealed errors in clinical technique in addition to expected signs of a disease process such as the presence of granulation tissue and areas of pathologic root resorption.

Conclusions. The laser-MTA pulpotomy showed reduced radiographic success rates compared to the formocresol-ZOE pulpotomy at 15·7 months; however, these results were not statistically significant. Improved success rates among a larger patient sample and a longer follow-up period would be required for the laser-MTA pulpotomy to be considered a routine alternative to the conventional formocresol-ZOE procedure. Meticulous restorative techniques must be followed to ensure the success of laser-MTA pulpotomies.

Assessment of a novel alternative to conventional formocresol‐zinc oxide eugenol pulpotomy for the treatment of pulpally involved human primary teeth: diode laser‐mineral trioxide aggregate pulpotomy

A pulpotomy is the therapy for management of pulp exposures due to caries in symptom-free primary molars. The aim was to longitudinally compare the relative effectiveness of the Er:YAG laser, calcium hydroxide and ferric sulphate techniques with dilute formocresol in retaining symptom-free molars. Two hundred primary molars in 107 healthy children were included and randomly allocated to one technique. The treated teeth were blindly reevaluated after 6, 12, 18, 24 and 36 months. Descriptive data analysis and logistic regression analysis accounting for multiple observations per patient by generalised estimating equation were used. Additionally, various influences including tooth type, upper and lower jaws, type of anaesthesia, operator and the final restoration on treatment success were evaluated (Wald chi-square test). After 36 months, the following total (considering clinical and clinically symptom-free radiographic failures) and clinical success rates were determined (in percent): Formocresol 72 (92), laser 73 (89), calcium hydroxide 46 (75), ferric sulphate 76 (97). No significant differences were detected between formocresol and any other technique after 36 months. However, the odds ratio of failure appeared to be three times higher for calcium hydroxide than for formocresol. No significant differences in total success rates were seen regarding the aforementioned influencing clinical parameters. The correct diagnosis of the pulpal status, bleeding control and the specific technique are highly important for long-term success of pulpotomies in primary molars. According to the presented long-term data, pulpotomies using ferric sulphate revealed the best treatment outcome among the used techniques, while calcium hydroxide resulted in the lowest success rates after 3 years. Therefore, we can recommend ferric sulphate for easy and successful treatment of primary molars with caries-exposed pulps.

Long-term effectiveness of four pulpotomy techniques: 3-year randomised controlled trial.

Purpose: The purpose of this study was to compare the effectiveness of 5% sodium hypo- chlorite (NaOCl) to that of ferric sulfate (FeSO 4 ) as a pulpotomy medicament in decayed primary molars. Methods: Healthy subjects between 4 and 9 years with at least 2 primary molars need- ing pulpotomy consented to receive either NaOCl or FeSO 4 and restoration with IRM base/stainless steel crown in a prospective, randomized design. Clinical and radiographic signs/symptoms were recorded at 0, 6, and 12 months. Results: Twenty-three subjects were recruited. Six-month results are based on the fi rst 32 teeth in the NaOCl group and 28 teeth in the FeSO 4 group. Twelve-month results are based on 13 teeth in the FeSO 4 group and 14 in the NaOCl group. Results show 100% restoration retention in both groups and no signs/symptoms of pain at 6 and 12 months. At 6 months, 100% clinical success was found with both FeSO 4 and NaOCl. Radiographic success for FeSO 4 was 68%, with internal resorption being the most common fi nding. The NaOCl group showed 91% radiographic success, P=.050. At 12 months, FeSO P=.050. At 12 months, FeSO P 4 had 85% clinical success and 62% radiographic success. NaOCl had 100% clinical success and 79% radiographic success. Conclusion: Preliminary evidence shows that NaOCl can be used successfully as a pulp- otomy medicament. (Pediatr Dent 2006;28:511-517)

Preliminary evaluation of sodium hypochlorite for pulpotomies in primary molars.

Most pediatric dentists in the United Kingdom and North America1,2 use formocresol pulpotomy for vital primary pulp therapy. In the United Kingdom, 54% of pediatric dentists reported concerns about possible sensitization, toxic, mutagenic or carcinogenic effects of formocresol; 42% of specialists surveyed in 2002 were considering changing their pulp technique to avoid formocresol.1 We performed a telephone survey of directors of Canadian pediatric dentistry programs to determine undergraduate teaching for management of vital primary pulps. The formocresol pulpotomy, one-fifth dilution or full-strength, continues to be the standard for didactic and clinical training of Canadian undergraduates. Although many programs provide didactic instruction in alternative techniques, fewer than a third offer clinical exposure to nonaldehyde methods. One program does not offer didactic or clinical training in formocresol pulpotomy. Clinicians who are considering alternatives to formocresol use in pediatric dentistry will benefit from this review of clinical investigations. Alternatives to the formocresol pulpotomy should demonstrate equivalent efficacy in well-designed clinical trials and reduce safety concerns through the use of nonaldehyde alternatives. Concerns about Formocresol Concerns about the safety of formocresol have been appearing in the dental and medical literature for more than 20 years.3–7 Cresol is locally destructive to vital tissue, but its potential for systemic distribution following pulpotomy treatment is negligible.8,9 The major concern has been with the formaldehyde component of formocresol. Although a 1:5 dilution of formocresol is specified in undergraduate curricula, most (78%) American pediatric dentists who use formocresol in primary tooth pulpotomy use it at full strength (19% or 48.5% formaldehyde). Only 2% of American pediatric dentists use a predictably accurate dilution of formocresol.10 Formaldehyde has been shown to be distributed systemically after pulpotomy. Up to 10% of the formaldehyde from a formocresol pulpotomy was absorbed systemically in dogs.11 In a separate study, radioactively labelled formaldehyde was distributed throughout the viscera of rats following formocresol pulpotomy in a single molar.12 At least 3 areas of concern have been reported with regard to formocresol: mutagenicity, carcinogenicity and immune sensitization. Antibody formation leading to immune sensitization to formaldehyde after formocresol pulpotomy has been demonstrated in dogs.13 Mutagenic and carcinogenic effects of formaldehyde exposure were demonstrated in Dr. Casas E-mail: mcasas@sickkids.ca Contact Author Do We Still Need Formocresol in Pediatric Dentistry?

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L.A Costa Júnior

Papers

Formocresol mutagenicity following primary tooth pulp therapy: an in vivo study.