Success of Pulpectomy With Zinc Oxide-Eugenol Vs Calcium Hydroxide/Iodoform Paste in Primary Molars: A Clinical Study

Article title: Success of Pulpectomy With Zinc Oxide-Eugenol Vs Calcium Hydroxide/Iodoform Paste in Primary Molars: A Clinical Study

Author(s): Trairatvorakul & Chunlaslkaiwan.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2008. 30:4. 303-307.

Major topic: ZOE vs. Calcium Hydroxide/Iodoform Pulpectomy

Overview of method of research: Clinical Study

Purpose:
To compare the clinical and radiographic success rates of ZOE cement and Calcium Hydroxide/Iodoform paste (Vitapex).

Background:
ZOE is the most popular root canal filling material in primary teeth.
Previous studies have shown that residual filling material may alter the path of eruption in up to 20% of cases.

Methods:
54 mandibular primary molars in 42 subjects between the ages of 3 and 7 years old needing a pulpectomy were recruited. Carious pulp exposure with unsuccessful hemostasis after coronal pulp removal, mobility not associated with normal exfoliation, spontaneous pain, swelling, chronic apical abscess or fistula, percussion sensitivity, pathological resorption, furcal radiolucency, and discontinuity of lamina dura in radiograph were used as inclusion criteria for this study. Teeth with obliterated root canals, internal resorption and physiologic root resorption of more than 1/3 of its length were excluded. Legal guardians consented for patient to either receive ZOE or Vitapex which were assigned to teeth via block randomization. One pediatric dentist performed all treatment using a rubber dam, barbed broaches, an electronic apex locator, K-Files, irrigation with 2.5% sodium hypochlorite and filled with the corresponding filling material with lentulo spirals. Each tooth was then restored with an SSC and a radiograph was taken in the same appointment. Another single investigator performed follow-up exams at 6 and 12 months.
Clinical success was defined as the absence of pain, swelling, fistula, redness, and abnormal mobility. Radiographic success was demonstrated with the continuity of the lamina dura, reduction in the size of pathologic radiolucencies or evidence of bone regeneration. In addition to success and failure, a third category of further observation was included for teeth demonstrating an absence of change in size of radiolucency or continuity of lamina dura as they could not be classified at this time and needed a longer follow-up period.

Findings:
The overall success rates of ZOE at 6 and 12 months were 48% and 85% respectively while Vitapex demonstrated success rates of 78% and 89%. The difference is only significantly significant for radiographic success at 6 months.
All teeth could be classified in two categories prior to treatment: discontinuity of the lamina dura and furcation pathology involving more than half the length of the shortest root. When comparing these groups, there was no significant difference in the severity of the preoperative infection and the success of teeth treated with either ZOE or Vitapex.
At 6 months, 26 of the 27 teeth in ZOE group showed clinical success (96%) whereas Vitapex teeth showed 100% success rate. At 6 months radiographic success was demonstrated in only 48% of the ZOE teeth with another 37% needing further observation. 9 of the 10 requiring further observation were later found to be successful. The Vitapex group showed 78% success and 11% needed further observation.
All six of the failed teeth were in the preoperative category with the most severe radiographic
pathology. The 3 clinical failures were related to tooth mobility only.

Key points/Summary:
Success rates of 78% for Vitapex and 48% for ZOE at 6 months show Vitapex seems to improve furcal and root pathology more quickly.
After 12 months the two filling materials demonstrate comparable success rates.

Assessment of Article:
Although the article had some interesting findings that were consistent with other studies, matched paired samples in the same patient would have been better. But the only significant finding was actually skewed due to the need for further observation in several teeth.

Concentration of formocresol used by pediatric dentists in primary tooth pulpotomy

Department of Pediatric Dentistry

Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title: Concentration of formocresol used by pediatric dentists in primary tooth pulpotomy
Author(s): Silvia King, DDS, Alton McWorter, DDS MS, et al
Journal: Ped. Dent
Year. Volume (number). Page #’s: 2002. 24:2. 157-160
Major topic: Formocresol concentrations being used by PD
Minor topic(s): Dilution of formo
Main Purpose: To determine the concentration of formocresol used for primary tooth pulpotomy by private practicing PD who use formo.

Overview of method of research:
806 surveys were sent out randomly to active members of the AAPD. The survey questions asked about the PD use of formo, what concentration they use if they use it, and how they dilute it (if they do).

Findings: 422 (52%) responded to the survey. 84% of PD acknowledged using formo. The two main formulations of formo were Buckley’s (19% formo), and a Standard formation (48.5%). Of those who use formo, 69% use full strength, 27% diluted, and 4% don’t know. Those who dilute their formo either buy it that way, dilute it themselves, or have the pharmacy dilute it for them. Interestingly, some of the PD who say they ‘dilute’ their formo consider diluting to be dabbing a formo soaked cotton pellet (FALSE). Also, some of the PD who think they are buying and using diluted formo are mistaken, they are using full strength. This means that 78% of practitioners using formo are using full strength instead of 69%.

Key points/Summary:
Diluted concentration is 1:5 ratio.
Most PD still use full strength formo

Assessment of Article:
Short. To the point. Good.

10/13/2010 Resorption of a CaOH/iodoform paste (Vitapex) in root conal therapy

Resident: J. Hencler
Date: 10/13/2010

Article title: Resorption of a CaOH/iodoform paste (Vitapex) in root conal therapy for primary teeth: A case report

Author(s): Nurko et al
Journal: Pediatric Dentistry-22:6, 2000

Major topic: Vitapex as a root canal medicament in primary teeth
Type of Article: Case report

Main Purpose:
Present a clinical and radiographic follow up (38 months) of pulpectomy treatment performed on maxillary primary anterior teeth using vitapex.

Background:
Resorption of the filling material is one of the requirements of an ideal root-canal medicament for primary teeth. Resorption of the root canal filling material should occur as the primary tooth root is resorbed during exfoliation, permitting normal eruption of the succedaneous tooth. If the material is expressed beyond the apex, it should be resobable and non-toxic to the periapical tissue and permanent tooth germ. Common root canal filling materials for primary teeth include; zinc oxide and eugenol, iodoform paste, and CaOH. Zinc oxide and eugenol is the most problematic because when extruded beyond the apices it sets into hard cement that resists resorption. Disturbances to the succedaneous tooth have been reported and deflection of the perm tooth may occur. Iodoform paste has shown excellent clinical and radiographic results. Vitapex is a viscous mix of CaOH and iodoform. When extruded into furcal or apical areas, vitapex will diffuse and/or be resorbed in part by macrophages. Vitapex is an ideal root canal filler for primary teeth with a easy delivery system.

Case details:
17-month male patient w/ ECC in anterior maxillary teeth and in one primary molar. Occlusal radiograph revealed deep carious lesions involving pulps of the lateral incisors. Dental tx under GA, Teeth #D,G were pulpectomized with Vitapex and restored with Nusmile crowns. An immediate post-op radiograph revealed Vitapex extruded from the apices of #D,G. At 13 months child required tx under GA again. Intra-radicular Vitapex was partially resorbed from #D,G and teeth were asymptomatic with no pathosis. At 16 month, an occlusal radiograph showed complete resorption of the filling material from the canals of #D,G with no signs of clinical and radiographic signs of tx failure. The patient was placed on a 6mrc. 38 months after initial tx, patient presented with chipped esthetic facings on #D,G. When restoring #D,G; the pulp chamber of #D was accessed to take a sample of the pulp chamber with a endo file. Sample was sent to a micro lab where neither anaerobic or aerobic were found in the sample.

Key points in the article discussion:
Because of the anatomy of primary roots and furcal ares, it is difficult to avoid extrusion of filling material beyond the root canals in all pulpectomy cases. This case report confirms that extruded Vitapex can be easily removed from extra-dental sites and the resorption is be a beneficial characteristic in pulpectomies in primary teeth. The effects of intra-radicular resorption are not certain but an unfilled root canal could be a open space for bacterial leakage and infection. Although the canal of the vitapex-treated lateral incisor was free of bacterial contamination, the authors caution overuse of vitapex is certain situations such as cases of acute infection because Vitapex has been shown to have minimal antibacterial properties. Antibiotic therapy may augment tx w/ vitapex. The authors recommended Kri paste (iodoform) may be better suited for more aggressive tx b/c of it’s bactericidal and resorptive properties.

Summary of conclusions:
Vitapex used as a root canal filling material for pulpectomy tx for primary teeth resorbed extra-radicularly and intra-radicularly w/out ill effect and proved to be clinically and radiographically successful.

Assessment of article: Good article and case report.

Comparison of Conventional, Rotary, and Ultrasonic Preparation, Different Final Irrigation Regimens, and 2 Sealers in Primary Molar Root Canal Therapy

Meghan Sullivan Walsh October 12, 2010

Literature Review - St. Joseph/LMC Pediatric Dentistry

Comparison of Conventional, Rotary, and Ultrasonic Preparation, Different Final Irrigation Regimens, and 2 Sealers in Primary Molar Root Canal Therapy

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Comparison of Conventional, Rotary, and Ultrasonic Preparation, Different Final Irrigation Regimens, and 2 Sealers in Primary Molar Root Canal Therapy

Authors: Harun Canoglu, DDS, PhD; Meryem U. Tekcicek, DDS, PhD; Zafer C. Cehreli, DDS, PhD

Journal: Pediatric Dentistry

Volume (number), Year, Page #’s; 28:6, 2006, pages 518-523

Major Topic: Comparison and success of three types of file systems used for preparation of a primary molar for RCT. Comparison of irrigation systems as well as sealer penetration used for RCT on a primary molar.

Overview of Method of Research:

Instrumentation assessment: Distal roots of extracted primary mandibular second molars were gathered. (Number of teeth used for this portion of the study not mentioned) The teeth were selected with non resorbed, curved distal roots. Working length determined 1 mm short of apex and the teeth were prepared using one of the three techniques. Group 1: Mechanical hand filing using a step back techniques, k-files, up to a size 30 and irrigated with NaOCL. Group 2: Crown down technique with a nickel titanium rotary Profile up to a .04/30 file. Irrigation then performed with NaOCL. Group 3: A piezzo ultrasonic instrument with K-files up to a size 30 and lastly irrigated with NaOCL. Removed dentin was measured using reference points. Zipping, the transportation of the outer wall of the apical foramen from an overextended file, was also measured.

Sealer assessment: Distal roots of 56 extracted primary mandibular molars were selected and prepared using mechanical hand filing and irrigated with NaOCL. The roots were then divided up into four groups to receive the final irrigation: Group 1: 10 ml 2.5% NaOCL. Group 2: 10 ml 10% EDTA. Group 3: 10 ml 17% EDTA. Group 4: 10 ml distilled water. Each irrigation group was then divided into two subgroups for sealer. Group one: AH PLUS Group 2: ZOE- based Sealit-Ulta. Final obturation was done with gutta percha.

Findings:

Intrumentation: No significant difference was noted between the three techniques of Intrumentation. Ultrasonic files however did show a decrease in working length as well as the incidence of zip formation. Profile instrumentation showed the best maintenance of root curvature.

Irrigation and Sealer: Final irrigation of NaOCL and distilled water failed to remove the smear layer. The removal of smear plugs by EDTA produced better tubular penetration of sealer. The best tubular penetration was noticed in Group three with 17% EDTA and AH plus as a sealer.

Key Points: Summary: Profile .04 ISO nickel titanium produced the best results and can be a good alternative to hand filing in intrumentation of primary molars. AH plus shows good tubular penetration when used with NaOCL irrigation and 17% EDTA flush. ZOE sealer following irrigation of 10%EDTA showed insufficient tubular penetration and is not recommended as a gutta percha sealer for primary molars.

Assessment of the Article: This article was a good look into the different techniques and materials used for RCT of a primary molar. However, I found that the authors had too many studies being done and too many variables. They were looking at obturation and sealers and irrigation techniques! Would have preferred them to focus on one aspect and give more detailed information regarding their findings (particularly the number of teeth used and compared in the obturation study.)

A Retrospective Assessment of Zinc Oxide-Eugenol Pulpectomies in Vital Maxillary Primary Incisors Successfully Restored With Composite

Resident: Cho

Author(s): Primosch et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2005. 27. 470-477.

Major topic: Vital pulpectomy, Zinc oxide-eugenol paste, Primary incisors

Minor topic: Composite resin crowns

Type of Article: Scientific Article

Main Purpose:

The purpose of this study was to evaluate the clinical and radiographic success of ZOE pulpectomies in vital maxillary primary incisors successfully maintained with composite resin crowns.

Overview of method of research:

A retrospective study was conducted using active patient charts from a pediatric dentist. Patients were identified that had pulpectomies on primary maxillary incisors with vital pulp tissue subsequent to dental caries or trauma. To be included in the study, the incisor needed to be vital (by clinical history, radiographic history, presence of bleeding during extirpation of the pulp), successfully restored with a composite strip crown that remained intact, had diagnostic radiographs for preoperative, immediate postoperative, and recall appointments of at least a 6-month interval, had an identifiable outcome (success or failure) by clinical and radiographic findings.

All pulpectomies were completed by a single operator and completed with the following steps:

RDI, all carious tooth structure removed, pulp tissue removed by broach, root canal cleaned with files, irrigated with water syringe and dried, treated with formocresol-soaked paper point, dried with paper points, obturated with ZOE paste mixed with zinc acetate accelerator crystals, canal orifice sealed with TERM Endo Stop, full-coverage restoration completed by acid etch+bond+composite resin strip crown (if there was insufficient tooth structure for retention, resin-based core build up was placed; if there was inadequate crown height, cervical gingivectomy performed), and immediate post-operative radiograph was taken.

A single examiner evaluated the radiographs. The immediate postoperative radiograph was evaluated for filling extent. The recall radiograph was evaluated for success/failure based on clinical and radiographic findings, degree of physiological root resorption, canal filling extent, and eruption status of the succedaneous tooth.

A tooth was considered to be successful if it was asymptomatic with normal radiographic appearance. A tooth was considered a failure if clinically it had spontaneous pain, percussion sensitivity, parulis/fistula present and if radiographically it had an apical lucency and internal and/or external inflammatory root resorption.

Findings: 48 patient charts with 104 pulpectomized primary maxillary incisors were analyzed in this study. 80 of the incisors were treated due to caries; 24 of the incisors were treated due to trauma. The mean age at the time of treatment was 34 months old. The mean followup time was 18 months after initial treatment. 76% of the incisors were determined to be successful. 75% still had complete root formation and the remaining had various stages of physiologic root resorption.

Key points/Summary:

76% of the incisors were determined to be successful that were treated with ZOE pulpectomy. Incisors treated secondary to dental trauma failed in 42% of the cases compared to 19% for those treated secondary to dental caries. Incisors restored with composite crown failed at a higher rate than those treated with a composite core underneath the composite crown. Gross overfill of ZOE paste beyond the confines of the root canal had high failure rates. Delayed eruption of succedaneous teeth occurred more frequently with failed pulpectomies.

Assessment of Article: Good article. It discussed the shortcomings of the results. Example, even though initial gross overfilled incisors had a 80% failure rate, the article pointed out that number of overfilled incisors was only 5 teeth. The article made me wonder if the ZOE used in the pulpectomies had an influence on the durability of the composite crown.

Clinical Evaluation of Root Canal Obturation Methods in Primary Teeth

Resident: Roberts

Date: 10/13/10

Article title: Clinical Evaluation of Root Canal Obturation Methods in Primary Teeth

Journal: Pediatric Dentistry

Volume: 28:1 Pages 39-47

Year: 2006

Purpose:

To evaluate two differing obturation techniques, their effectiveness and success rates in primary molars

Methods:

50 pulpectomies and their respective filling materials were performed on 24 children( ages 4.5 to 9). Two varying methods were used to obturate the cleaned canals: one in which a lentulo spiral was attached to a slow speed handpiece and the other which consisted of a lentulo spiral that was hand held to perform the same task.

Criteria for this study:

Teeth were include if they:

1. History of spontaneous pain
2. Presence of a sinus tract
3. Periapical bone swelling
4. Continuous bleeding after amputation of coronal pulp tissue
5. No pulp tissue remaining when the pulp chamber was accessed
6. Pus discharge from the canal
7. Evidence of a radicular pathologic lesion with or without caries involvement
8. Periapical or inter-radicular radiolucency

Teeth were excluded if they:

1. Were unrestorable
2. Had pathologic lesion that extended to the tooth germ of the succedaneous tooth
3. Showed signs of extensive internal/ external pathological root resorption

Success rates and results at 6 month follow up

Teeth obturated by lentulo in slow speed handpiece: clinical 96%, radiographic 91%

Teeth obturated by lentulo but performed manually by hand: clinical 92%, radiographic 72%

Combined total of 94% clinical and 81% radiographical success rate

The success were also analyzed by the quality of the obturation

56% (28) were optimally filled, 32% (16)were underfilled, and 12% (6)were overfilled.

Optimal: clinical 92%, radiographic 92%

Underfilled: clinical 94%, radiographic 56%

Overfilled: clinical 100%, radiographic 100%

Conclusion:

There was no statistical significance between the hand held or the handpiece mounted lentulo spiral. Optimally and over filled root canals showed a statistically higher success rate compared to underfilled root canals.

Assessment: His conclusions based on quality of fill and success rates differed from those he quoted, but he didn’t offer up a reason as to why and I would have liked to have had an insight to perhaps why his conclusion was different than others who have performed similar research.

Indirect Pulp Treatment of Primary Posterior Teeth: A Retrospective Study

Resident: Adam J. Bottrill
Date: 13OCT10
Region: Providence
Article title: Indirect Pulp Treatment of Primary Posterior Teeth: A Retrospective Study.
Author(s): Al-Zayer, Mohammed A. et al.
Journal: Pediatric Dentistry
Page #s: 29-36
Year: 2003
Major topic: Primary Molar Indirect Pulp Therapy
Minor topic(s): NA
Type of Article: Retrospective analysis of the success of indirect pulp caps.
Main Purpose: To assess retrospectively the clinical and radiographic success of indirect pulp treatment (IPC) on primary posterior teeth, and to compare the influence of caries risk, skills of the operator, and restorative material on the success of IPT.

Key points in the article discussion:

I. General:

A. 250 records... 132 patients met inclusion criteria... 187 primary posterior teeth treated with IPT.
B. Data analyzed over 2wks-72mos.
C. "Pulp Cap": The procedures or steps taken to protect or maintain the vitality of the carious tooth that, if completely excavated, the decay would result in pulp exposure."

II. Results:

A. Success of IPT was 95% with only 9 failures.
B. 1 yr probability of survival 96%
C. Use of base over CaOH liner greatly increases success of IPT
D. SSC significant improvement over amalgam
E. Primary first molar IPT failed significantly more than primary second molars.
F. No difference in maxillary vs mandibular molars.

II. Conclusion:

A. IPT is a succesful technique and should be considered as an alternative pulp therapy for deeply carious primary posterior teeth.
B. SSC's increase overall prognosis of IPT'd teeth.


Assessment of article: Solid Article. Reinforced what we've come to know as "standard of care"

Light Cured CaOh2 vs Formocresol in Human Primary Molar Pulpotomies: A Randomized Controlled Trial

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title: Light Cured CaOh2 vs Formocresol in Human Primary Molar Pulpotomies: A Randomized Controlled Trial
Author(s): Zurn, DDS MS Derek, N. Sue Seale DDS, MSD
Journal: Ped. Dent
Year. Volume (number). Page #’s: 2008. v30 No1. 34-41
Major topic: Formo(FC) vs CaOh2
Minor topic(s): Follow up criteria to determine success or failure
Main Purpose: Compare light cured CaOH2 with diluted FC for it’s success as a primary molar pulpotomy medicament

Overview of method of research: Selection criteria had to have included two matching, asymptomatic, contralateral primary molars requiring vital pulps. Matched teeth in each separate patient were randomly selected to either receive FC or CaOH. The teeth were then followed for one year. Two blinded, calibrated examiners evaluated and scored the teeth radiographically and clinically.

CaOH2 Teeth
-Pulp chamber was removed
-CaOH2 was placed and light cured
-Resin modified glass ionomer (vitremer) was placed to restore the chamber
-SSC placed

FC Teeth
-Pulp chamber was removed
-FC dampened cotton pellet was placed for 5 min
-ZOE paste was placed to restore pulp chamber
-SSC placed

Teeth were then followed up at 7-12 months, 13-24 months

Findings:
FC, first introduced by Buckley in 1904, has been the medicament of choice for pulps for some time. As discussed in my article last week, recently physicians have been looking for an alternative to FC due to it’s carcinogenicity. One possible alternative that has been proposed is CaOH2. Radiographically, the results favored the FC group after 7-24 months. Clinically, success was similar between the groups for the first 12 months, but then favored the FC group after 12 months. The response of a tooth treated w/ FC vs CaOH2 is completely different. With FC, no healing response is indicated. It essentially seers off the tissue where it was placed, and the need for healthy radicular pulp is far less dependent. With CaOH2, this is not the case. A healthy radicular pulp is needed to allow healing to occur via a reparative dentinal bridge.

Key points/Summary:
While a need to replace FC is great, this study illustrates that CaOH2 will not be the knight in shining armor. Clinically it is not a viable alternative to FC. After 12 months, success rates for FC were 94%, and for CaOH2 were 56%. The study did however prove that in terms of radiographic scoring, minimal radiographic changes that occur over time may be observed, and not considered failures.

Assessment of Article: A more in depth look at FC vs CaOH2 than my article last week. This article did have some weak points ie Sample size, strict patient criteria, some kids being treated in the OR as opposed to the clinic, thus compromising FU appts, etc. For boards, the things to remember are thatCaOH2 is not an alternative for us to use, and that minor radiographic changes over time are not necessarily failures.

Formocresol Blood Levels in Children Receiving Dental Treatment Under GA

Resident: Swan

Article Title: Formocresol Blood Levels in Children Receiving Dental Treatment Under General Anesthesia

Authors: Kahl, et al.

Journal: Pediatric Dentistry

Volume (Number): 30 (5) Sep/Oct 08

Major Topic: Safety of Formocresol use for vital pulpotomies/risk of systemic distribution

Minor Topic: N/A

Type of Article: Scientific Article

Main Purpose: to determine the existence, if any, of formocresol in the plasma of children undergoing comprehensive oral rehabilitation involving vital pulp therapy under general anesthesia

Background: The controversy rages on regarding formocresol and its potentially harmful systemic effects when used for pulpotomies. Animal studies have demonstrated that formaldehyde and tricresol diffuse through the apical foramen within minutes. Studies using monkeys demonstrated distribution to lymph nodes, blood, kidneys, and liver. In another study, high systemic doses (500 times expected dose from 1 pulpotomy) administered IV to dogs, led to liver, kidney, and cardiac pathology.

However, there are no human studies documenting systemic distribution or pathologic tissue. And the only studies to show systemic distribution have used doses way higher than that used for a pulpotomy. There are also many natural and man made sources of formaledehyde to which humans are exposed every day. The WHO estimates the daily intake of Formaldehyde from food alone to be from 1.5 to 14 mg/day. Formaldehyde is rapidly (1-1.5 min) metabolized. The concern is that formaldehyde that escapes metabolism can form DNA-protein cross links, cause mutations and become carcinogenic.

Cresol gets little attention because it shows poor solubility and does not enter systemic circulation.

Overview of method of research: 30 2-6 year old preschoolers were enrolled, all needing expected pulpotomy treatment under general anesthesia. 50 dry cotton pellets were soaked in 2 mL of full strength Buckley’s formocresol. The average mg dose of formo per pellet was calculated (.013 mg/pellet). Each pulpotomy was performed following standard protocol. In each patient, up to 12 blood samples were drawn before, during, and after the procedure (baseline, then once every 30 minutes after the first pulpotomy until several hours after tx was completed). The blood samples were analyzed.

Findings: 85 pulpotomies were performed, 312 blood samples collected. Lower limit of quantitation (LOQ) was 14 ng/mL. (limit at which we can reasonably tell the difference between two different values). Limit of detection (LOD) was 2 ng/mL. (lowest quantity of a substance that can be distinguished from the absence of that substance) On chemical analysis, peaks of formaldehyde were seen in the 2-2.5 ng/mL range-formaldehyde was “detectable” but not quantifiable. Based on 6 adult volunteers’ samples, physiologic concentration of formaldehyde was found to be 2.6 ng/mL. In this study, formaldehyde was undetectable above that physiologic concentration. Cresol was undetectable in all samples.

Key Points/Summary: Formaldehyde and cresol are undetectable above baseline physiologic concentrations in the plasma of subjects receiving pulpotomy treatment under GA. It’s unlikely that formo used in the small doses we use poses any risks to children.

Assessment of Article: I really liked this article. While I didn’t understand all the chemistry behind it, their methods seemed to be sound and their results conclusive. It succinctly summarized the current debate over formo use and gave strong support to the fact that formo is most likely not harmful to our patients.

Evidence-based Assessment: Evaluation of the Formocresol Vs. Ferric Sulfate Primary Molar Pulpotomy

Resident: Cho

Author(s): Loh et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2004. 26. 401-409.

Major topic: Evidence-based practice

Minor topic: Pulpotomy, Primary Molar, Formocresol, Ferric Sulfate

Type of Article: Scientific Article

Main Purpose:

Evidence-based practice (EBP) is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

Research using EBP uses 5 steps: define the clinical research question, search all available literature for evidence, select studies for possible inclusion, appraise and rank the evidence in the selected studies and establish a final set of selected studies, compile and analyze date from the studies to produce a statistically based conclusion.

The aims of this study were to use EBP to examine the relative efficacy of formocresol (FC) and ferric sulfate (FS) as pulpotomy medicaments in primary teeth and produce recommendations on medicament selection for clinicians.

Overview of method of research:

EBP was used to conduct the research. Initially data was pulled using 6 search engines: Medline Ovid Library, Cochrane Library, PubMed, EMBASE, Science Citation Index, and System for Information on Grey Literature in Europe. The literature was limited to studies addressing FC and/or FS, related to pulpotomy, and performed on primary deciduous teeth. In a secondary sieve, the search was limited to actual experiments and studies that lasted for up to the exfoliation of primary molar teeth. The studies were ranked by hierarchy of evidence.

In the end, 13 studies (3 randomized clinical trials and 10 clinical trials) were analyzed statistically using meta-analysis. 1 randomized clinical trial and 1 clinical trail were analyzed by the direct technique, and all 13 trials were analyzed by the indirect technique.

Findings:

Clinical and radiographic data from the indirect technique and radiographic data from the direct technique shows no significant difference between FC and FS, although FS trended toward higher clinical success. FS cannot be concluded to be the superior medicament because only 2 trials were included in the direct technique, which indicates low statistical power and possible skewing. Also, P values observed exceeded 0.05 suggesting inadequate evidence to conclude that FS is more successful than FC. In addition, follow-up times differed between the two studies (20 months vs. 35 months).

Key points/Summary:

EBP concludes that human carious primary molars with reversible coronal pulpitis can be treated with pulpotomy using either ferric sulfate or formocresol and obtain similar clinical and radiographic success.

Assessment of Article:

The results of the study concluded that more prospective random clinical trials should be conducted in order to compare FC vs. FS in primary molar pulpotomies. This article focused more on EBP rather than FC vs. FS and was analyzing data from a limited number of studies. This article could be of value for aiding in how to formulate a clinical research question and research in general.