Vital Pulap Therapy w/ New Materials for Primary Teeth: New Directions and Tx Perspectives

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title: Vital Pulap Therapy w/ New Materials for Primary Teeth: New Directions and Tx Perspectives
Author(s): Fuks DDS, Anna B
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2008. v30 No 3 211-219
Major topic: Pulpotomy medicaments
Minor topic(s): Indirect pulp capping vs direct pulp capping/pulpotomies
Main Purpose: Evaluate the use of formocresol(FC) against other medicaments
Overview of method of research: Review of numerous studies

Findings:
Vital pulpal therapy aims to treat reversible pulpal injury in which dentin and pulp are affected by either caries, restorative, or trauma. Tx can either be indirect pulp capping (IPC) or direct pulp capping(DPC) or pulpotomy. When the dentin-pulp complex is affected by any type of injury, three different physiopathological conditions may be observes at the dentin-pulp border.
1. Formation of tertiary dentin(reactionary dentin) in the case of mild injuries
2. Formation of tubular tertiary dentin(reparative dentin) in the case of more serious injuries
3. Pulpal exposure

IPC
IPC is absolutely an acceptable procedure for primary teeth with reversible pulp inflammation. The Ricketts study concluded that “in deep lesions, partial caries removal is preferable to complete caries removal to reduce the risk pf carious exposure”. This article recommend s IPC as the most appropriate treatment for SYMPTOM FREE primary teeth with deep caries, provided that a leak free restoration is placed (SSC is best, only one endorsed by the AAPD).

DPC
A pinpoint pulp exposure can be covered with DiCal. This however is not to be done in primary teeth, unless the tooth is 1 or 2 years from exfoliating. DPC is not recommended because the success rate in primary teeth is not high, and complications include abscess and resorption.

Pulpotomy
Pulpotomies are still the most common tx for cariously exposed pulps in symptom free molars. The aim of this tx is to preserve the radicular pulp, avoiding pain and swelling, and retaining the tooth until it is time to exfoliate. Since 1932, FC has been used as the medication of choice for pulps. More recently, concerns have been raised about the safety of FC, mainly as a result of its toxicity and carcinogenicity. The International Agency for Research on Cancer classified formaldehyde as carcinogenic for humans in 2004, stating that it could lead to nasopharyngeal cancer and possibly leaukemia. This led dental professionals on a quest to look for a FC alternative.

Studies on children who have had FC pulps showed no statistical significant differences in their lymphocytes, although it was found that FC may have been mutagenic for one patient. No correlation between FC pulps and cancer has ever been found. It should be noted the success of FC pulps decreases over time.

Studies comparing Mineral Trioxide Aggregate (MTA) and FC
Six studies from 2001-2005, all different in their methods and sample size, found that MTA (grey MTA being better than the white) had better clinical and radiographic success as compared to FC.
Studies comparing Ferric Sulfate and FC
Seven studies from 1991-2005, all different in their methods and sample size, found that essentially, FS and FC have the same effectiveness. A few found that FS was better, a few that FC was better, and a few found that there was no difference (Anecdotally, I’ve seen numerous failed FS pulps here during my 1.5 years at St.Joe’s, and no FC failures).

Studies comparing Calcium Hydroxide (CH) and FC
One study done by Waterhouse in 2000 found that FC was more effective than CH.

Studies comparing Sodium Hypochlorite (NaOCl) and FS
Only one study, done in 2006 compared FS and NAOCL. The sample size was small, and the recall was done at one year, but NAOCL showed much better success than FS. More research is needed.

Studies comparing Lasers with FC
One study (Saltzman) done in 2005 was reviewed. Promising results, however a larger sample size, and longer follow up is needed before this is replaced as an alternative to the conventional pulps. Conversely, a study done in 2006 (Liu JF) found that the Laser was significantly more effective than the FC pulp. Again, more work needs to be done in this.

Key points/Summary:
MTA showed the best results when compared with all of the other products. FS was about the same, NAOCL has promise, and CH sucks. While MTA is great, it’s extremely expensive, and extremely difficult to use. May be cost and time prohibitive for a pediatric practice. Quick note... when you see a failed pulp, extraction is necessary.

Assessment of Article: Excellent review of numerous studies. Definitely applicable to our daily life in the clinic. Good info to review with parents as well in terms of FC.