• Primary tooth pulp therapy is aimed at preserving the
primary teeth until normal exfoliation.
• Management of the cariously involved primary tooth where
the carious lesion approximates the pulp requires a
knowledgeable approach to pulp therapy, and a successful
outcome depends on accurate diagnosis of the status of the
pulp prior to therapy.
• Preliminary data gathering and interpretation must be
focused on determining whether the primary tooth pulp is
normal, reversibly inflamed, irreversibly inflamed or
• If it is determined to be vital or reversibly inflamed,
the vital pulp therapy techniques of pulpotomy or
indirect pulp treatment (IPT) are indicated.
• If the pulp is determined to be irreversibly inflamed
or necrotic, either a pulpectomy or extraction would
• This presentation is limited to a discussion of
the vital pulp therapy procedure of pulpotomy
for primary teeth.
• Complete removal of the coronal portion of the dental pulp,
followed by placement of a suitable dressing or medicament
that will promote healing and preserve the vitality of the
• Pulpotomy is defined as the amputation of vital pulp from the
coronal pulp chamber followed by placement of a
medicament over the radicular pulp stumps to stimulate
repair, fixation or mummification of the remaining vital
radicular pulp (Braham and Morris)
When the coronal pulp is exposed by trauma or operative procedures, or
caries ingress of bacteria, it produces inflammatory changes in the
tissue.The surgical excision of the infected and inflamed coronal pulp,
the vital uninfected pulpal tissue can be left behind and preserved in the
The removal of the inflamed portion of the pulp affords temporary, rapid
relief of pulpalgia and further may undergo repair while completing
apexogenesis that is root end development and calcification.
Materials used for this procedure either mummify or fix the tissue or
promote healing by formation of a bridge.
Objectives (AAPD Guidelines )
The radicular pulp should remain asymptomatic without adverse
clinical signs or symptoms such as sensitivity, pain, or swelling.
There should be no postoperative radiographic evidence of
pathologic external root resorption.
Internal root resorption can be self limiting and stable.
The clinician should monitor the internal resorption, removing
the affected tooth if perforation causes loss of supportive bone
and/or clinical signs of infection and inflammation.
There should be no harm to the succedaneous tooth.
• A correct diagnosis of pulp conditions in primary and young
permanent teeth is important for treatment planning.
• McDonald and Avery have outlined several diagnostic aids in
selecting teeth for vital pulp therapy.
• Eidelman et al and Prophet and Miller have emphasized that
no single diagnostic means can be relied on for determining a
diagnosis of pulp conditions.
• A suggested outline for determining the pulpal status of cariously involved
teeth in children involves the following:
1.Visual and tactile examination of carious dentin and
2. Radiographic examination of
a. periradicular and furcation areas
b. pulp canals
c. periodontal space
d. developing succedaneous teeth
3. History of spontaneous unprovoked pain
4. Pain from percussion
5. Pain from mastication
6. Degree of mobility
7. Palpation of surrounding soft tissues
8. Size, appearance, and amount of hemorrhage associated with pulp
Endodontics : Ingle 5th edi
Electric pulp tests are not valid in primary teeth.
• Andreasen et al. Textbook and color atlas of traumatic
injuries to the teeth. 4th ed, 2007
Thermal tests are usually not conducted on primary teeth
because of their unreliability.
• Cohen S, Hargreaves K : 9th ed. 2006:822– 82.
Numerous studies have reported the unreliability of electric
pulp tests in permanent teeth with open and developing
• J Dent Child 1978;45:199 –202.
• J Endod 1986;12:301–5.
• Aust Dent J 1977;22:272–9.
Laser Doppler flowmetry might be of greater help in
• Endod Dent Traumatol 1999;15:284 –90.
• Dent Traumatol 2001;17:63–70
• Endod Top 2003;5:12–25.
Cariously exposed primary teeth, when their retention is more
advantageous than extraction.
Vital tooth with healthy periodontium
Pain, if present not spontaneous nor persists after removal of the
Tooth which is restorable
Tooth with-2/3rd root length
Hemorrhage from the amputation site is pale red & easy to
Absence of abscess and fistula
No inter-radicular bone loss
No inter-radicular radiolucency
On young permanent tooth
with vital exposed pulp and
incompletely formed apices
Persistent tooth ache.
Tenderness on percussion / mobility present.
Root resorption more than 1/3rd of root length.
Large carious lesion with non-restorable crown.
Highly viscous, sluggish hemorrhage from canal orifice which is
Evidence of internal resorption
Presence of inter radicular bone loss
Tooth close to natural exfoliation
Medical contraindications ; immuno-
FACTORS THAT AFFECT
PROGNOSIS OF PULPOTOMY:
Size of exposure
Location of exposure
Exposure to saliva
Age and status of the pulp (Stahl et al 1970)
Evidence of success in therapy includes the
Vitality of the majority of the radicular pulp
No prolonged adverse clinical signs or symptoms,
such as prolonged sensitivity, pain, or swelling
No radiographic evidence of internal resorption
No breakdown of periradicular tissue
No harm to succedaneous teeth
Pulp canal obliteration (abnormal calcification)
• Pulpotomy can be classified according to treatment objectives
given by Ranley et al:
• Vital pulpotomy
I. Devitalization Pulpotomy (Mummification, Cauterization)
a. Formocresol pulpotomy.
b. Electrosurgical pulpotomy.
c. Laser pulpotomy.
II. Preservation (Minimal devitalization, Non – inductive)
• Ferric sulfate.
III. Regeneration (Inductive, Reparative)
• Calcium Hydroxide.
• Bone morph genetic Protein.
• Mineral trioxide aggregate
II.NON –VITAL PULPOTOMY:
- Beechwood cresol
• The first approach to be used with the intention of
“mummifying’ the radicular pulp tissue.
• The term “mummified” has been ascribed to chemically
treated pulp tissue that is inert, sterilized, metabolically
suppressed, and incapable of autolysis. This approach
involved the original two- sitting formocresol
pulpotomy, which resulted in complete devitalization of
the radicular pulp.
• Also included were the 5- minute formocresol and 1:5
diluted formocresol techniques, which both result in
partial devitalization with persistent chronic
• This approach involved medicaments and techniques
that provide minimal insult to the orifice tissue and
maintain the vitality and normal histologic appearance
of the entire radicular pulp.
• Pharmacotherapeutic agents included in this category
are corticosteroids, glutaraldehyde and ferric sulfate.
• Nonpharamcotherpeutic techniques in this category
include electrosurgical and laser pulpotomy.
• This approach includes pulpotomy agents that have cell-
inductive capacity to either replace lost cells or induces
existent cells to differentiate into hard tissue forming
Examples of true cell- inductive agents include:
– Transforming growth factor- (TGF- ) in the form
of bone morphogenetic
– Proteins freeze dried bone
– Mineral trioxide aggregate (MTA)
There Are Three Pulpotomy Techniques:
• Vital Formocresol pulpotomy technique: also known as the 1-minute
• Devitalization pulpotomy: This is two- stage technique and relied
upon paraformaldehyde to fix the coronal and radicular pulp tissue.
• Non –vital Pulpotomy: This technique is carried out when the
inflammatory process affecting the coronal pulp extends to the
radicular pulp leading to an irreversible change in the pulp tissue .
Aramentarium For The Pulptomy Technique
• Topical and local Anaesthesia.
• Burs No 330 FG high speed and No 8 RA Slow speed.
• Rubber dam kit.
• Mouth mirror, probe and tweezers.
• Cotton pellets (small).
• Large and small excavators.
• Mixing spatula, flat plastic instrument.
• Formocresol, 1/5 dilution.
• Dappens pot, syringe.
• Zinc oxide eugenol.
• Glass ionomer cement for lutting
• Stainless steel crown
Single Visit Pulpotomy
• Step 1: Administration of local anesthesia
• Step 2: Apply a rubber dam
• Step 3: Use a sterile No.4 or 8 round bur (slow speed) to
remove all carious dentin .If possible, remove all carious dentin
before exposing the pulp horns
• Step 4: Place a No. 330' bur in the high-speed hand piece. Gain
occlusal access to the pulp chamber by preparing a Class 1
cavity preparation. It is better to make too large an opening
than one that is too small. Remove all overhanging enamel.
• Step 5: Excise the pulpal tissue to the orifices of the root
canal. Use a large spoon excavator to remove any
remaining pulpal tissue.The pulpal tissue should be
amputated to the entrance of the root canals.
• Step 6: After completing the amputation, evaluate the
hemorrhage. If the pulpal tissue has been removed
completely, hemorrhage should be minimal.A vital pulp
with minimal chronic inflammation should achieve
hemostasis in 3 to 5 minutes.
• Step 7: Over the exposed pulp stump, place sterile cotton
pellet moistened (but not saturated) with formocresol,
• Step 8:Leave the formocresol in place for 1 minute, and then
remove the pellet. The pulp stump should appear blackish
brown .If there is bleeding, check for residual pulpal tissue.
Reapply formocresol for 2 minutes.
• Step 9: Fill the pulp chamber to about half its volume with a
thick mixture of zinc oxide-eugenol.
• Step 10:Prepare the tooth for a stainless steel crown
Two Visit Pulpotomy
Indications for two-visit pulpotomy procedure in
primary teeth are
• Inability to arrest hemorrhage from the
amputated pulp stumps during a single visit
• Non-vital coronal and/or radicular pulp without
the presence of an abscess.
• In two-stage procedure, this involves the use of
paraformaldehyde to fix the entire coronal and
radicular pulp tissue. The paraformaldehyde
paste is most commonly used (Hobson 1970)
• The paste is placed over the pulpal exposure on a small pledget of cotton
wool, the larger the exposure then the more successful the outcome.
• The paraformaldehyde paste is sealed into the cavity with a thin mix of
zinc eugenol and left for 1-2 weeks.
• Formaldehyde gas liberated from the paraformaldehyde permeates
through the coronal and radicular pulp, fixing the tissues.
• On the second visit, the dressing is removed, there is no need to
administer a local anesthetic as the pulp contents should be nonvital,
pulpotomy is carried out and then covered with hard setting zinc oxide
cement or alternatively an antiseptic paste (equal parts of eugenol and
formocresol with zinc oxide) over the radicular pulp before restoring the
• Hobson (1970) reported a success rate of 77% after 3 years.
Non Vital Pulpotomy (Mortal Pulpotomy)
• When the inflammatory process affecting the
coronal pulp extends to the radicular pulp leading
to an irreversible change in the pulp tissue.
• When the pulp is completely non-vital, where
there may be an abscess present with or without
• The necrotic coronal pulp is first removed, as
recommended in the vital pulpotomy technique.
• The necrotic debris in the pulp chamber is then
cleared. If there is sufficient access to the radicular pulp
canals then as much as possible of the necrotic tissue is
removed with a small excavator.
• A small pledget of cotton wool dipped in beechwood
cresol is then sealed into the cavity with temporary zinc
oxide eugenol cement.
• IInd visit:
• Usually 1-2 weeks later the dressing is removed, provided the signs
and symptoms of infection have cleared,
• The cavity is then restored in the same manner as used in the vital
• If it appears that there is no resolution of the symptoms then the
beechwood cresol should be replaced for a further 1-2 weeks,
• Other medcaments like formocresol and camphorated
monochlorophenol (Arnold and Rock, 1993) have been equally
effective, at the second visit, after one to two weeks an antiseptic paste
that is placed over the radicular pulp remnants before restoring the
tooth replaces the antiseptic solution.
• Hobson (1970) reported a success rate of 66% after 3 years.
Partial Pulpotomy (Cvek’s Pulpotomy)
• Definition: It is the removal of only the outer layer of
damaged and hyperemic tissue in exposed pulps, is considered
to be a procedure staged between pulp capping and complete
pulpotomy. It is a mode of treatment which is widely used in
the permanent dentition but less so in primary teeth.
Radionale And Advantages
• The main advantage of Partial pulpotomy is that a successful
outcome will allow the continuation of normal development of
the tooth, including further root development and maturation.
Apex formation and thickening of thin root walls may occur in
• The tooth following a partial pulpotomy will retain its natural
color and translucency in comparison to the coronal
discoloration in many teeth undergo after pulpectomy.
• Partial pulpotomy have advantage over complete pulpotomy is
the preservation of cell rich coronal pulp tissue.
Indications• A small and recent pulpal exposure of up to approximately 14 days in a non
carious primary incisor.
• A sufficient tooth structure is present to allow proper restoration and full
coverage of the crown with a bonded resin- composite strip crown.
• Partial pulpotomy is highly indicated in a very young tooth with a wide- open
apex and very thin root dentin walls.
• The decisive factor for selection of the partial pulpotomy and its success is a
healthy, non inflammed and asymptomatic vital pulp.
• During the procedure, an operative diagnosis should be made by assessing the
pulpal with regard to the bleeding from the amputation site, including the
color, viscosity, and ability of the tissue to achieve hemostasis
• Exposure is very large or when more than 2 weeks have passes
between injury and treatment time allowing oral contaminants
to cause extensive infection or inflammation beyond 2 to 3
mm of the exposure.
• Purulent drainage.
• History of prolonged pain.
• Necrotic debris in canal.
• Periapical radiolucency.
The clinical procedure is described as follows
• Proper patient management should be achieved with or without
• Local anesthesia and rubber dam placement should be
administered with the slit technique.
• A no. 330 tungsten bur is used to ampute the pulp close to the
exposure site to a depth of 2mm.
• Continuous rinsing of the amputed pulp with saline will assist
in achieving hemostasis without blood clot formation within 4
minutes (if hemostasis is not achieved, all the coronal tissue
should be removed and a cervical pulpotomy should be
• A dressing of calcium hydroxide paste should be
placed followed by base/line of glass ionomer
such as Vitrebond.
• The tooth is restored using a bonded resin-
composite strip crown.
• Scheduled follow- ups should be made after 1
month and then every 6 months. A dentin bridge
will begin to form, separating the exposure site
from the rest of the pulp. The bridge may be
evidenced radio graphically after 6 to 8 weeks in
future occlusal/ periapical view.
• Formocresol was introduced in 1904 by Buckley, who
contended that equal parts of formalin and tricresol would
react chemically with the intermediate and end products of
pulp inflammation to form a “new, colorless, and non-
infective compound of harmless nature.
• Buckley’s formula of formocresol, consists of tricresol,
aqueous formaldehyde, glycerine, and water.
Dilution of formocresol
• Loos and Han have led to the conclusion that a dilute (1: 5
concentration) of Buckley’s formocresol applied to tissue
achieved the desired cellular response.
• The orginal buckley’s formula for formocresol calls for
equal parts of formaldehyde and cresol. The 1:5
concentration of this formula is prepared by first
thoroughly mixing three parts of glycerin with one part of
distilled water, then adding four parts of this diluent to
one part of Buckley’s Formocresol and thoroughly mixing
• It is therefore recommended that 1/5th concentration formocresol
be utilized for pulpotomy procedure since it is as effective as and
less damging than the traditional preparation.
• In recent years formocresol has been extensively evaluated using
animal models. It was concluded that 20% dilution causes the
least histologic damage and that a 1 minute application of
formocresol is adequate to produce the desired results.
• Garcia – Godoy (1984) advocated the use of 20% dilution of
formocresol for partial pulpotomies. He showed a success rate
Step 1: Access opening of the carious tooth.
Step 2: Removal of coronal part of the carious tooth.
Step 3: Formocresol dressing placed on the amputed pulp.
Step 4 : Stainless steel crown placed on the pulpotomised tooth.
Berger- compared effect of formocresol medication with those
97% success - formocresol
58% success - ZnOE
Rolling and Thylstrup –(1975) 3 year follow up
83% - 12 months
78% - 24 months
70% - 36 months
• Buckley 1904 – recommended for treating the
• 5 visit therapy was reduced to 3 visit(1955)
• Sweet (1960), advocated single visit, and
placement of ZnOE cement containing some
formocresol over the pulp stumps– widely
• Miyamoto 1974 – suggested 2 visit technique
for unco-operative children
• Verco and Allen 1984- no difference between
single visit and two visit technique
• Kennedy and Curzon highlighted the
convenience of single visit technique for child
Effect on succedaneous tooth
• Pruhs et al 1977 ,
• Messer et al 1980
• Wright & Widmer 1979,
• Rolling & Poulsen 1978,
• Fuks & Bimstein 1981,
• Mulder et al 1987
Histologic investigation of the effect of formocresol
on the pulp
• Massler and Mansukhani conducted a detailed histologic
investigation of the effect of formocresol on the pulps of 43 human
primary and permanent teeth in multiple treatment intervals.
• Fixation of the tissue directly under the medicament was apparent.
After a 7 to 14-day application, the pulps developed three distinctive
• A broad eosinophilic zone of fixation
• A broad pale-staining zone with
poor cellular definition
• A zone of inflammation diffusing
apically into normal pulp tissue
• After 60 days, in a limited number of samples, the remaining tissue
was believed to be completely fixed, appearing as a standard of
eosinophilic fibrous tissue.In general, the results of many histologic
studies on the formocresol pulpotomy have shown that several distinct
zones are usually present in the pulp following the application of the
• Superficial debris along with the dentinal chips at the amputation site
• Eosinophil-stained and compressed tissue
• A palely stained zone with loss of cellular definition
• An area of fibrotic and inflammatory activity
• An area of normal-appearing pulp tissue considered to be vital
• Commonly available medicament
• Stable at room temperature
• Long shelf life
• High clinical and radiographic success of
• It is a very caustic medicament.
• In high doses it is toxic.
• Potential systemic absorption and distribution
throughout the body.
• It has a mutagenic and carcinogenic potential .
Toxicity• Local toxicity
• The classical description of a 5 minute application is
• Immediately beneath the site of amputation there is
eosinophilic tissue interpreted as the zone of fixation.
• The next zone is the pale staining amorphous zone with
diminished cellular and fiber definition which is the result of
lipid dissolving property of cresol. Stagnation necrosis as a
consequence of formocresol induced vascular thrombosis.
• Broad zone with inflammatory cells first of acute variety and
then of chronic variety.
• Muller 1978 stated topical application of formalin causes
leukoplakia and lesions resembling carcinoma in situ.
• Formocresol seeps in through accessory canals into
developing tooth germ and causes enamel defects like
hypoplasia and might alter position of underlying
permanent tooth (Messler 1980)
• Jerell and Ronk 1982 described arrested development of
bicuspid while Grundy and coworkers in 1984 described
cyst in primary teeth treated with formaldehyde
• After systemic administration of formocresol in experimental
animals, formocresol is distributed throughout the body.
Metabolism and excretion of a portion of the absorbed
formocresol occur in the kidneys and lungs.
• The remaining drug bound to tissue predominantly in the
kidney and lungs. When administered systemically in large
doses, acute toxic effects (e.g., cardiovascular changes, plasma
and urinary enzyme changes, histologic evidence of cellular
injury to the vital organs) were noted.
• The degree of tissue injury appeared to be closely related, with
some of the changes being reversible in the early stages.
• With the use of isotope-labeled, 19% formaldehyde, the
presence of the drug was demonstrated in the lung, liver,
kidney, muscle, serum, urine and carbon dioxide after 5-minute
application of pulpotomy sites. The concentrations achieved in
the tissues were equivalent to those found after an infusion of
30% of the amount placed in the pulp chamber.
• Pashley and Myers et al (1980) in their study on dogs
determined the fate of the C-formaldehyde following an
application to pulpotomy sites and confirmed (with their
previous finding) that C-formaldehyde containing formocresol
was absorbed from pulpotomy sites and appeared in body
fluids. They concluded that formocresol is absorbed and
distributed rapidly and widely throughout the body within
minutes after being placed on a pulpotomy site.
• Menstrual and reproductive disorder.
• Eye , ear and nose irritation.
• Asthamatic bronchitis
• Dermatitis, rhinitis, wheezing
• Pharyngitis, chronic cough
• Shortness of breath
• Sexual dysfunction
• Possible cancer.
• The rationale of this technique is the tissue of the
coronal pulp is removed during pulpal amputation, a
layer of coagulation necrosis carried by the electro
surgery application provides a barrier between healthy
radicular tissue and any base material placed in the
• The odontoblasts are stimulated to form a denim
bridge and the tooth is maintained in the arch with
vital radicular tissue until it exfoliates.
• Step1: Local anesthesia and isolation with a rubber dam
• Step2 :Pulp chamber opened
• Step 3 : Coronal pulp removed
• Step 4: Radicular pulp amputated
• Step 5 : Pulp hemostasis obtained
• Step 6 : Electrosurgical current applied for 2 - 5sec to
• Step 7 : Calcium hydroxide paste placed
• Step 8: Light-cured glass ionomer cement seal obtained
• Step 9: Stainless steel crown .
Histological Findings Of Electrosurgical
• The study done by Sheller B et al on eleven human caries –free
deciduous cuspid teeth showed following histological features
• One Hour Posttreatment
• Teeth were free of acute inflammation. Mild signs of chronic
inflammation were restricted to the coronal third of the
radicular pulp. Slight fibrosis was observed in the coronal third
of the teeth.
Six Days Posttreatment
• Histological evaluation revealed acute inflammatory cells limited to the
apical third of the radicular pulp, diffuse edema and necrosis replacing the
entire pulp tissue, and external resorption involving the apical and middle
thirds of the roots.
Thirteen Days Posttreatment
• Acute inflammatory cells were observed in the apical area and there was
external resorption of the apical third of the root.
• Edema, chronic inflammatory cells and localized necrosis involving
apical third .Pulpal calcifications were located in the coronal third of the
• Apparently unaffected vital tissue may be present in the middle and apical
thirds of the pulp. Secondary dentin deposits were located on the canal
walls in the coronal portion of the radicular pulp.
Seventeen Days Posttreatment
• There will be acute and chronic inflammatory cells present along with
edema restricted to the coronal third of the pulp. Necrosis was
localized to the pulp to the pulp chamber interface.
• Secondary dentin deposits on the canal walls in the coronal and middle
third of the root.
Seventy Days Posttreatment
• The teeth showed small number of acute and chronic inflammatory cells
restricted to the coronal third of the radicular pulp.
• Secondary dentin deposits were present both as canal wall deposits and
One Hundred Days Posttreatment
• Chronic inflammatory infiltrate and edema can be present in the tissue
sub adjacent to pulp amputation.
• Secondary dentin formation includes canal deposits
• Patient selection criteria
• Primary teeth required a pulpotomy because of
pulpal exposure to caries.
• Teeth have normal mobility.
• No tenderness to percussion.
• No swelling or fistulation
• Teeth presented a carious pulpal exposure
without furcation or periapical pathology.
• Root resorption was confirmed to less than
one third of the root.
Ebimara (1985) Nd:YAG laser
• L.A & isolation
• Excavation & hemorrhage control
• Complete hemostasis by exposure
to Nd:YAG laser at 2 W,20 Hz (100 mJ)
• IRM & composite
• Stainless steel crown
• In 1996, Wlkerson et al evaluated the clinical,
radiographic and histologic effects of argon laser on vital
pulpotomy of swine teeth. The results showed that
• All soft tissue remained normal
• All teeth exhibited normal mobility
• Reparative dentine formation was noted histologically
• They concluded that use of argon laser for pulpotomy did
not appear to be detrimental to pulp tissues. These studies
led to the use of Nd: YAG laser for pulpotomy in primary
Jeng –fen liu (1999)
• Treated 23 teeth – 6 months evaluation, one teeth
showed internal resorption
Peschek et al 2002 -- CO2 laser
Wildersmith 1997 and Day 1998 found CO2 laser
pulpotomy to be very successful
Calcium hydroxide pulpotomy
• Most favored in 1940s and mid 1950s
• Teuscher & Zander (1938)- termed vital
technique; demonstrated necrosis of pulp lying
close to Ca(OH)2 and secondary dentin formation
3 distinct zones :
• Coagulation necrosis
• Deep staining basophilic areas of varied
• Relatively normal pulp( slightly hyperemic)
• Young permanent tooth owing to its less
cellular activity than the primary
• Mechanical, Carious, Traumatic exposure with
incomplete apical closure
• Not recommended for primary teeth
-Internal resorption– Tronstad1988
• Anesthesia, isolation
• Caries removed with out pulp exposure
• Deroofing the pulp chamber
• Coronal pulp amputation
• Control of haemorrhage
• Ca(OH)2 placed over the orifice and dried with
• Quick setting ZOE cement placed over it
• Stainless steel crown (post. teeth)
• Restoration / composite (ant. teeth)
Calcium Hydroxide Pulpotomy Outcomes In Primary
• Internal resorption may result from over stimulation of the primary
pulp by the highly alkaline calcium hydroxide. This alkaline
induced over stimulation could cause metaplasia within the pulp
tissue, leading to the formation of odontoclasts. In addition,
undetected microleakage could allow large number of bacterial to
overwhelm the pulp and nullify the beneficial effects of calcium
• Via, in a 2 year study of calcium hydroxide pulpotomies in primary
teeth, had only a 31% success.
• Law reported only a 49% success in a 1 year study. In year study,
in all investigations, failure rates with hydroxide in pulpotomized
Histological Findings Of Calcium Hydroxide
Pulpotomy –By Siu et al
Short Term Study (Seven Days)
• For seven days in comparison between Life, Dycal
, Nu-Cap and calcium hydroxide in 28 teeth. It
showed that the calcium hydroxide saline paste
causes a greater inflammatory response within
the pulp, and also resulted in wide zone of
mummification. This finding may be associated
with greater alkalinity of the calcium hydroxide
LONG TERM STUDY (sixty-three days)
• Here, the trend showed increased inflammation with the calcium
hydroxide- saline paste was noted.
• Specific instances of high inflammatory reaction were associated
with deep maceration of the pulp during the initial preparation and
inclusion of dentinal chips and medicaments.
• All medicaments stimulated dentinal bridges , there were important
differences in quality and position. The calcium hydroxide – saline
paste consistently formed thick bridges, but they occurred deep
within the pulp at the junction of the mummified zone and the
normal pulp tissue.
• Excessive and deep bridge formation may result in the areas of
necrotic pulpal tissue, secondary to vascular constriction.
1) Reaction to pulp is irreversible.
2)Molecules of glutaraldehyde do not diffuse out of
3)It fixes tissue instantly and excess solution is
4)It is not known to be cytotoxic, mutagenic or
5) It has no systemic toxic effects.
– Short shelf life.
– It has to be freshly prepared.
– Buffered solution has to be refrigerated.
Properties Of Glutaraldehyde
• Superior fixation with relatively little
• Mild effects on pulp tissue
• Lesser Systemic Distribution
• Positive clinical results (Garcia-Godoy1986,
Fuks et al 1986)
• Less damage apically and less necrosis
• Less clearly demarcated zones within radicular
• No evidence of in growth of granulation tissue.
• Less intense dystrophic calcification limited to
coronal portion of canal
• Fibroblastic proliferation observed
immediately below Glutaraldehyde fixed tissue
in coronal 3rd indicating repair replacement.
Glutaradehyde Vs Formocresol
• Ranly and associates recommened 4% buffered
glutaraldehyde with a 4 minute application time or 8% for 2
minutes. Glutaraldehyde seems to be superior to
formaldehyde for pulp canal therapy in many respects.
• Most formaldehyde reactions are reversible , glutaraldehyde
reactions are not as they are bound to protein tissue.
• Formaldehyde is a small molecule and pentrates the
periapical end easily .Glutaraldehyde being a large molecule
does not penetrate into the periapical tissue. Less pulpal
irritation is seen because of less apical diffusion.
• Formaldehyde fixes tissue with a long reaction time and an
excess of solution , glutaraldehyde fixes tissue
instantaneously and an excess of solution is not necessary.
• Zone of inhibition is more restricted following
• Formocresol caused lysis of PMN and at high
concentration but activation of PMN adherence
at low concentration.
• In contrast glutaraldehyde did not produce
PMN lysis at high concentration, nor did it
cause activation of PMN adherence at low
• Ranley has mentioned that it is hard to agree that
two drugs are similarly toxic at equimolar
• Gluteraldehyde excels over formocresol relative to
Cytotoxicity because it is an effective fixative at a
lesser concentration and it does not have
compound cresol, a repulsive ,caustic chemical
that ravages the tissues.
• The effect of glutaraldehyde from available
studies appears to be gentle and, localized.
• Monsels Solution
[20% ferric subsulfate]
• Strong styptic,1st used in military
hospital in Bordeaux ,France 1857 [Larson 1988]
• It was proposed as a Pulpotomy medicament for vital primary
• Feraculum Solution 1% [prabhu etal 1997]
• Advantage Over FC
15 sec for manipulation compared to 5 min FC
• Landau and Johnsen in which ferric sulphate was
used to control hemorrhage before calcium
• Vital pulpal tissue was found at the apical third of all
teeth with ferric sulphate after 60 days, compared
to four of seven teeth in the sterile water calcium
hydroxide control group.
• However, the sample sizes were small and the recall
period was short. Although, the ferric sulphate
technique appeared successful histologically, the
long term effect of this drug on the teeth and rest of
the body was not addressed.
Advantages Of Ferric Sulfate Over Formocresol
• According to Bimstein - replacement of Formocresol with
ferric sulfate in general anesthesia cases, where several
puipotomies have to be done, can reduce systemic toxic
effects caused by Formocresol.
• Manipulation time of 15 seconds for Ferric suifate is
advantageous when compared to 5 min for formocresol,
with same success rates. Systemic distribution of Ferric
suifate is unknown, because the clot avoids distribution
Lemon Additional long-term studies with increased sample
sizes should be conducted before ferric suifate can be
recommended as a substitute for the "gold standard"
• Burnett and Walker conducted a retrospective radiographic survey
in order to compare the success rates of ferric sulfate pulpotomies
versus formocresol pulpotomies in a Native American population in
Arizona. The results of comparison shows over 3 times the clinical
failure rate in Ferric sulfate pulpotomies compared to Formocresol
pulpotomies long term success in best with Formocresol and worst
with a combination of formocresol and Ferric sulfate technique.
Results also conformed that radiographic failures are significantly
higher than clinical failures.
• Ibricevic H, AI-Jame Q compared the effects of ferric sulphate to
that of full strength of formocresol as pulpotomy agents in primary
teeth and after long term follow up concluded that ferric sulphate
showed similar clinical and radiographic success rate as
Bone Morphegenic Protien
• In 1938 Levander reported that there must be some
stimulating agent which originated from bone and possibly
a substance which was soluble in lymph tissue.
• Urist referred the bone inducing substance to “Bone
Morphogenic Proteins” which were originally identified by
their presence in bone inductive extracts of demineralized
bone in 1965.
• Inducing substance i.e. Bone Morphorgenic Protein acting
upon a responding cell i.e. - undifferentiated mesenchymal
cell to become progenitor cell. Levander thus concluded
that there is an extractable substance from bone which is
able to activate mesenchymal cells to form tissue.
• Due to their amino acid sequences BMP-2 through BMP-9 are
classified as belonging to the Transforming Growth Factor-
• Bone Morphogenic proteins are divided into 3 groups
• BMP –2 and BMP-4 form one group having 92% identical
• BMP –5 through BMP-9 form a second group having 82%
identical amino acid.These two groups have 59%homology
with one another and only 45%homology with BMP-3.
• BMP –7 and BMP-8 are also known as osteogenic protein OP-
1 AND OP-2 respectively.
Sources Of Bone Morphogenic Protiens
• BMP exists in the bone matrix (Sampath and
Reddi 1983, Muthukumaran et al 1985)
• Osteosarcoma tissue (Takaaka etal 1980)
• In dentin matrix (Butler et al 1977, Conover and
• In wound tissue after tooth extraction (Bessho et
Carrier For Bone Morphogenic Proteins
For the delivery ideally, the carrier for Bone
Morphogenic Protein should be,
- Immunogenically inert
Factors influencing the inductive process of
• Timing of the response (considering both the exposure time
required as well as the time the inducer is capable of
• Location or proximity of competent cells able to respond.
• In case of Vital Pulp Therapy we have inducing substance
(BMP) acting upon a responding cell (an undifferentiated
mesenchymal cell) to become an osteoprogenitor cell
capable of forming reparative dentin.
• Dental pulp consists of several types of cell including
odontoblast, fibroblasts and undifferentiated mesenchymal
cells. Pulpal fibroblast can be regarded as odontoprogenitor
Lyophilized Freeze Dried Platelet Derived
• Platelet derived growth factor ,insulin growth factor
derived from platelet have generated considerable
intreast in the past.these compounds act as signaling
proteins that could be directly involved in the regulation
of cell proliferation,migration and extra cellular matrix
production in the dental pulp.
• These proteins have been extensively used in oral and
maxillofacial reconstruction adjunctive procedures
related to the placement of osseo integrated implant in
humans and periodontal regeneration.animal and human
invivo and invitro studies have shown that these proteins
stimulates differentiated cell of the pulp to diffrenciate
into odontoblast to deposit a layer of dentin.
• Damle and R. R. Kalaskan et al Compared the
efficiency of lyophilized freeze dried platelet derived
with calcium hydroxide as pulpotomy agents in
primary molars. It was found that success rate of
lyophilized freeze dried platelet derived pulpotomy
proved to be more efficient.
Enamel Matrix Derivatives
• Syngcuk Kim et al in 2004 conducted a study on
enamel matrix derivative induced reparative dentin
formation in a pulpotomy model in pig incisors. The
findings demonstrated that enamel matrix molecules
have the capacity to induce rapid pulpal wound healing
in pulpotomized teeth, and suggest that the longevity
and continued presence of enamel matrix
maromolecules at the application site can be utilized to
stimulate growth and repair of dentin over a period
consistent with a favorable treatment outcome.
PULPOTOMY IN PRIMARY MOLARS USING FORMOCRESOL, FERRIC
SULFATE AND MINERAL TRIOXIDE AGGREGATE
Tajik et al Journal of Dentistry (2006; Vol:3, No.1)
ENAMEL MATRIX DERIVATIVE
Causes bio induction of dentin formation
JOE 2008, 34:3 Jumana Sabbarani
MTA vs FC
Ped dent 2005 27:2 ; 145
Success rate: 97% 83%
Pulp canal obliteration: 58% 52%
Reasons for failure of pulpotomy therapy
• Erroneous diagnosis of a chronically inflamed radicular pulp as non-
inflame and non-infected.
• The irritating effect of eugenol as a component of the pulp space
• Attempt to preserve a tooth with a deep proximal carious lesion a
condition leading to leakage due to incomplete coverage.
• Signs of a failure can be seen on radiographic pathologic signs in
pulp canal obliteration (sometime termed “cacific metamorphosis”),
which can be seen in root canal of pulpotomized primary molars. In
presence, however is not considered as a failure.
• No area of treatment in pediatric dentistry has been more
controversial than pulp therapy. In particular, the vital
pulpotomy procedure has been a topic of debate for decades.
• Pulpotomy therapy for the primary dentition has developed a
long three lines: devitalization, preservation, and
• Devitalization, where the intent is to destroy vital tissue, is
typified by formocresol and electrocautery.
• Preservation, the retention of maximum vital tissue with no
induction of reparative dentin, is exemplified by
glutaraldehyde and ferric sulfate treatment.
• Regeneration, the stimulation of a dentin bridge, has long
been associated with calcium hydroxide.
• Of the three categories, regeneration is expected to
develop the most rapidly in the coming years.
Advancesin the field of bone morphogenetic protein
(BMP) have opened new vistas in pulp therapy.
Human BMPs with dentinogenic properties are
becoming available through recombinant technology.
• We are now entering an era of pulpotomy therapy
with healing as the guiding principle.