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.

Preliminary Evaluation of Sodium Hypochlorite for Pulpotomies in Primary Molars

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Preliminary Evaluation of Sodium Hypochlorite for Pulpotomies in Primary Molars

Author(s): Vargas et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2006. 28:6. 511-517.

Major topic: Sodium Hypochlorite Pulpotomies

Overview of method of research: Scientific Article

Purpose:
To compare the effectiveness of 5% NaOCl and ferric sulfate as medicament agents in pulpotomies of primary molars.

Background:
Studies have shown that up to 40% of pulps treated with either ferric sulfate or formocresol have severe inflammation with 60% of those treated with ferric sulfate experiencing cold sensitivity.
NaOCl has been found to be compatible with the pulp with only superficial effects on vital tissue.

Methods:
23 subjects between the ages of 4 and 9 years old needing at least 2 pulpotomies in primary molars were recruited. They consented to either receive 5% NaOCl and ferric sulfate and restored with IRM and SSC. All teeth with mobility, spontaneous pain, swelling, percussion sensitivity, resorption, furcal radiolucency, widened PDL or unsuccessful hemostasis were excluded from this study. Follow-up appointments were held at 6 and 12 months where clinical and radiographic exams were performed.
The teeth were then treated accordingly; 15 seconds with ferric sulfate or 30 seconds with 5% sodium hypochlorite. If bleeding persisted, the teeth were then excluded from the study. The teeth were restored with IRM and an SSC.
Clinical exam was then performed immediately after treatment, at 6 months and at 12 months by the principal investigator without immediate knowledge of which medicament was used. Radiographic exam was completed by 2 calibrated investigators immediately after treatment, at 6 months and 12 months.

Findings:
A total of 60 primary molars were included in the study. 28 were treated with ferric sulfate and 32 with NaOCl. At 6 months, clinical success (asymptomatic, no mobility, fistula, swelling or inflammation) was found in 100% of treated teeth. At 12 months, 11 of the 13 ferric sulfate teeth that were evaluated (85%) were found to be clinically successful whereas14 of 14 NaOCl teeth that were evaluated were successful.
At 6 months, 32% (9/28) of the ferric sulfate teeth showed radiographic pathologic changes as did 9% (3/32) of those treated with NaOCl. The most common finding was internal resorption in both groups. After 12 months there were 2 new failures among the ferric sulfate group and no new NaOCl failures.
The overall success rates for ferric sulfate were 84% and 74% at 6 and 12 months respectively. Success rates for NaOCl were 96% and 90%.

Key points/Summary:
NaOCl can be used and is superior to ferric sulfate as a pulpotomy medicament.
The most common radiographic finding in 6 and 12 month follow up exams is internal resorption in both groups.

Assessment of Article:
Very interesting article. As always, need more research!

Mineral trioxide aggregate vs. formocresol in pulpotomized primary molars: a preliminary report

Resident: Roberts

Date: 10/6/10

Article title: Mineral trioxide aggregate vs. formocresol in pulpotomized primary molars: a preliminary report

Author: Eidelman, Eliezer

Journal: Pediatric Dentistry

Volume: 23:1

Year: 2001

Discussion:

MTA is biocompatible material and its sealing ability has been shown to be better than amalgam or Zinc Oxide Eugenol. It is a powder that sets in the presence of moisture with a pH of 12.5. The setting time of the cement is four hours and its compressive strength is similar to IRM. MTA has recently been studied and found to to have superior qualities to calcium hydroxide in the treatment of IPC therapies as well as other Endodontic procedures.

Purpose: The aim of this study was to compare the use of mineral trioxide aggregate to that of formocresol as pulp dressing agents in pulpotomized primary molars with carious pulp exposures.

Method: Forty five primary molars in 26 children were treated by a conventional pulpotomy technique. Following removal of the coronal pulp and hemostasis the pulp stumps were covered with an MTA paste in the experimental group. In the FC group, FC was placed over the stumps for 5 minutes and then removed; the teeth were then covered by Zinc Oxide Eugenol paste. The teeth of both groups were restored with SSC.

Results: Only eighteen children and 32 of the original pulpotomized teeth returned for follow up (mean follow up time was 13 months). Only one tooth, treated with FC showed any signs of pathology -internal resorption. Pulp canal obliteration was observed in 2 of the teeth treated with FC and 7 of the teeth treated with MTA. This however was not considered a sign of failure.

Conclusions: MTA has the potential to be a successful medicament in the treatment of carious exposed primary molars.

Assessment: This study would be great on a larger scale with a longer follow up time with the treated teeth.

Ferric sulfate pulptomy in primary molars: A retrospective study

Meghan Sullivan Walsh October 2, 2010

Literature Review - St. Joseph/LMC Pediatric Dentistry

Ferric sulfate pulpotomy in primary molars: A retrospective study

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Ferric sulfate pulpotomy in primary molars: A retrospective study

Authors: Nikki L. Smith, DDS, MS; N. Sue Seale, DDS, MSD; Martha E. Nunn, DDS, PhD

Journal: Pediatric Dentistry

Volume (number), Year, Page #’s; 22:3, 2000, pages 173-180

Major Topic: Success rate of pulpotomies performed using ferric sulfate on primary molars.

Overview of Method of Research: Retrospective study of chart reviews and radiographic data from patients receiving ferric sulfate pulotomies.

Findings: Clinical and radiographic data from a retrospective chart review was collected on 242 primary molars in 171 children receiving ferric sulfate pulpotomies. Data was collected from a private practitioner’s office in Fort Worth, Texas over a five year period (1994 to 1998) and reviewed for clinical success. The study sample comprised of patients with at least one primary molar treatment planned for vital pulpotomy. The criteria were as follows 1) primary teeth with a vital carious exposure with pulp tissue that bled upon entering the pulp chamber, 2) no clinical symptoms or evidence of pulpal degeneration, to include swelling or presence of a sinus tract, 3) a restorable tooth with a posterior stainless steel crown that remained intact at future recalls until the tooth exfoliated or was extracted, and 4) patients who returned for at least one recall visit following the pulpotomy. All molars were treated with RDI, caries removal and coronal access with a 330 high speed with water spray. Hemostasis was obtained with 15.5% solution of ferric sulfate for 10-15 seconds. The pulpal stumps were rinsed, dried with a cotton pellet and covered with zinc oxide-eugenol cement and a stainless steel crown. The radiographic criteria used to describe clinical findings were unremarkable external root resorption, internal root resorption, interradicular bone destruction, calcific metamorphosis, periapical bone destruction, uneven root resorption, early eruption and root perforation. Success was determined as absence of pathological internal or external root resorption, furcation or periapical radioleucency and root perforation. Clinical success was scored if the tooth had no symptoms of pain, tenderness to percussion, swelling, fistula or mobility. The pathological/radiographic success rates of these teeth ranged from 80% at 4-12 months to 74% at >36 months. The clinical findings and success rates were 99% with only 5 teeth extracted due to clinical symptoms and another 4 extracted due to pathological findings. No hypoplastic or hypocalcified areas were noted on the succedaneous teeth. No significant differences were discovered on a type of primary molar on either arch.

Key Points: Summary: Clinical successes in this study were found to be exceptionally high. However, the radiographic/pathological success was low especially compared to recent findings on ferric sulfate pulpotomies and studies comparing formocresol. The most common pathological findings in this study were internal resorption and calcific metamorphosis. The practitioner in this study chose to observe teeth displaying internal resporption instead of extracting these teeth as failures. This practice allowed observation of interesting radiographic changes over time not previously recorded. Interestingly enough these teeth did not seem to interfere with exfoliation time or normal root resorption. If internal resorption was not classified as a failure than the percentages of success for this study would have been higher. The results of this study might indicate our need to redefine success vs failure when evaluating pulpotomies. Defining osseous changes verse clinical changes may be a more realistic measure of defining a successful pulpotomy.

Assessment of the Article: This was a great study and I believe the success rates of ferric sulfate are more accurately described and measured in this article (74-80%.) Ferric sulfate is a great alternative to formocresol, however, I am not convinced that it is a superior medicament nor has the success that a traditional pulpotomy with formocresol has had for our patients for all this time. With more parents concerned about dental materials and requesting and asking about harmful effects of these medicaments, I believe it is good for us as clinicians to offer choices for our patient’s families. However, I believe more research and studies should be performed comparing these medicaments in order for clinicians to help our patient’s parents make a better choice based on accurate success rates and real knowledge concerning side effects of either material.

A Survey of Primary Tooth Pulp Therapy as Taught in US Dental Schools and Practiced by Diplomates of the American Board of Pediatric Dentistry

Resident: Cho

Author(s): Dunston B, Coll JA

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2005. 30. 42-47.

Major topic: Indirect Pulp Therapy, Pulpotomy, Pulpectomy

Minor topic: Formocresol, Ferric Sulfate, Glass Ionomer, Calcium Hydroxide, ZOE

Type of Article: Scientific Article

Main Purpose: The purpose was to replicate Primosch et al survey from 1997 and survey predoctoral pediatric dental program directors and diplomates of American Board of Pediatric Dentistry (ABPD) and to determine whether the philosophies and techniques for primary tooth pulp therapy have changed.

Overview of method of research: A survey of 27 multiple-choice questions was sent to 56 US dental school pediatric departments and to ABPD diplomates. The survey was in a similar format to that of 1997 Primosch et al survey and divided into two parts. Part I was more direct questions about pulp therapy techniques being used and part II was clinical scenarios for pulp therapy.

Findings: 48 of 56 predoctoral pediatric dental program directors returned surveys. 689 out of 1200 diplomates of ABPD returned the survey. More pediatric dental programs taught IPT and direct pulp cap than in 1997. More diplomates and directors are using glass ionomer and less zinc oxide or calcium hydroxide for IPT. Calcium hydroxide remained the base of choice for direct pulp caps. However, more predoctoral pediatric dental programs gave students a choice of calcium hydroxide or glass ionomer for direct pulp caps. Significantly more directors are teaching radiograph exposures immediately after pulpectomy than in 1997.

Key points/Summary: Indirect pulp therapy is being practiced more and most are not re-entering the tooth following IPT. Formocresol is still the preferred medicament for pulpotomy. However, the usage of ferric sulfate has increased. ZOE remains the base of choice after a pulpotomy. More rotary instruments for pulpectomy are being used along with iodoform and calcium hydroxide paste for filling the canals. There is disagreement among dental directors and diplomates of when pulpotomy on a primary tooth is indicated.

Assessment of Article: This was a good comparative survey between philosophies on pulp therapy in 2005 compared to 1997. I was surprised that there was disagreement as to when a pulpotomy was indicated in the clinical scenarios. In a scenario, 4% of diplomates advocated for pulpotomy on a primary tooth with a draining sinus tract. It is surprising that even the ABPD diplomates do not always follow AAPD guidelines when it comes to pulp therapy.

Enamel Matrix Derivative (Emdogain) as Pulpotomy Agent in Primary Teeth

Resident: Swan

Article Title: Histological Evaluation of Enamel Matrix Derivative as a Pulpotomy Agent in Primary Teeth.

Author: Sabbarini, et al.

Journal: Pediatric Dentistry

Volume (Number): 29(6) 2007

Major Topic: Effect of enamel matrix derivative as pulpotomy agent in primary canines.

Main Purpose: to determine if EMD can be used to regenerate reparative dentin and safely enclose remaining radicular pulp after a pulpotomy on deeply decayed primary canines

Overview of method of research: Ten carious primary canines that were planned for serial extraction were selected. Chambers de-roofed and coronal pulp was removed using spoon excavator. Hemostasis obtained, then amputated pulpal stumps were covered with Emdogain gel and then GI cement. 3 teeth extracted after 1 week, 3 after 2 weeks, and 4 after 6 months. Extracted teeth were fixed in formalin and cut into buccal-lingual sections and observed for 1) dentin bridge formation, 2) odontoblastic layer integrity, 3) pulp inflammation, and 4) pulp calcification.

Findings: teeth extracted after 1 week showed pulpal surfaces lined by a thin, nearly continuous cellular layer. Generalized congestion and increased angiogenesis noted in deeper parts of pulp tissue. Teeth extracted after 2 weeks showed small islands of dentin-like tissue at different stages of mineralization. These islands tended to coalesce together. The teeth extracted at 6 months showed different histological patterns; most demonstrated coalescing islands of dentin-like material trying to bridge the width of the coronal pulp. This was accompanied by deposition of reparative dentin along pulpal walls, narrowing the pulp canal. Some areas showed a thick, infiltrating layer of cellular condensation with massive distribution of reparative dentin. One tooth showed small dentin islands that didn’t completely bridge the site.

Key Points/Summary: In agreement with other studies, this study confirms that EMD initiates the process of pulpal regeneration and repair in the area of a wound. This process is similar to classic wound healing. The formation of new dentin starts some distance from the site of amputation.

EMD may

1) Act as a signal for induction of odontoblast differentiation, maturation, and mineralization

2) Form a stable extracellular matrix that provides a beneficial, protective environment for the pulp

Assessment of Article: The idea of renerating pulp tissue and inducing dentin formation is intriguing, and I appreciate the innovative concept at work here. But the real benefit of this treatment wasn’t clear to me because 1. There was no control to compare the Emdogain-treated teeth to (using either formo or some other agent) and 2. The sample size is so small (10 teeth). Future tests using similar inductive agents will hopefully clarify this.

Permanent Versus Temporary Restorations After Emergency Pulpotomies in Primary Molars

Resident’s Name: Jessica Wilson
Program: Lutheran Medical Center - Providence

Article title: Permanent Versus Temporary Restorations After Emergency Pulpotomies in Primary Molars

Author(s): Guelmann et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2005. 27:6. 478-481.

Major topic: Restorations Following Emergency Pulpotomies

Overview of method of research: Scientific Article

Purpose:
To determine whether immediate placement of SSC after emergency pulpotomy in primary molars would produce significantly better results than temporary restorations.

Background:
At times due to lack of time, uncooperative behavior from a patient as well as financial limitations SSCs are not placed at the time of an emergency pulpotomy. Previous studies have shown that due to microleakage, emergency pulpotomies temporarily restored with IRM had significantly lower success rate than those restored with SSCs.

Methods:
Retrospective analysis of records of 94 emergency pulpotomies in primary molars was performed at a university pediatric graduate dental clinic. Teeth with pain and caries in close proximity to the pulp were included while those with signs of pulpal necrosis, internal or external resorption, mobility or swelling were not. Treatment was done by pediatric dental residents under attending supervision. RDI and 5 minute formocresol technique were used. The tooth was then either restored with IRM and an SSC or IRM and Ketac Molar at the discretion of the resident and attending. The statistical analysis also included 216 teeth from a previous study conducted with the same methods which were all restored with IRM only. Those receiving temporary restorations were restored with SSCs at the following recall appointment. Clinical success and survival were then determined based on the placement of definitive SSC in the cases where a temporary restoration had been placed and confirmation of the presence of the SSC at following recare appointments. Failure of the pulpotomy was indicated by the need for extraction due to pain, mobility, sinus tract, swelling, resorption or bone destruction.

Findings:
Although not significantly significant, teeth immediately restored with an SSC had higher success rates (86%) compared to those with IRM and Ketac Molar (77%) or just IRM (61%). However, the survival rate for those restored with SSCs immediately was significantly greater (410 days) than temporary restorations (168 and 173 days). Time between emergency visit and definitive respiration placement or recare, age, sex, tooth type and arch were not found to be significant in success versus failure rate.

Key points/Summary:
Immediate placement of SSC after emergency pulpotomies increases the survival rate for the tooth. This technique should be used whenever possible.

Assessment of Article: Although the article demonstrated a good point, it pretty much proved the same thing that was already shown in several other articles.