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COMPARATIVE EVALUATION OF VARIOUS
PULPOTOMY MEDICAMENTS USED IN
PEDIATRIC DENTISTRY
BIKASH CHAURASIA
JR,PEDODONTICS1 8 / 0...
CONTENTS
INTRODUCTION
IMPORTANCE OF DIAGNOSIS
PULPOTOMY TECHNIQUE'S FOR PRIMARY TEETH
PULPOTOMY MEDICAMENTS
COMPARATI...
INTRODUCTION
• The conservation of primary teeth in form and function until their
normal exfoliation is one of the fundame...
DIAGNOSIS
• Outline for determining the Pulpal status of cariously involved teeth involves:
1. Visual and tactile examinat...
Diagnostic Criteria
1.Clinical criteria:
• No spontaneous pain
• No swelling
• No tenderness on percussion
• No pathologic...
AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
GUIDELINES 2014
• The pulpotomy procedure is indicated when caries removal
results...
Objectives:
• The radicular pulp should remain asymptomatic without adverse
clinical signs or symptoms such as sensitivity...
PULPOTOMY TECHNIQUE'S FOR PRIMARY
TEETH
• Formocresol Pulpotomy Technique
• Glutaraldehyde Pulpotomy Technique
• Ferric Su...
OTHERS
• Enriched collagen (Fuks 1984)
• Freeze Dried Bone (Fadavi et al. 1988)
• Demineralized Dentin (Nakashima 1989)
• ...
PULPOTOMY MEDICAMENTS
• Ideally, a pulpotomy medicament should be
– bactericidal,
– easy to use,
– harmless to the remaini...
• The search for this ideal material has been ongoing since the early 1900s
when Buckley first introduced Formocresol.
• O...
CLASSIFICATION OF VITAL PULP THERAPY
TYPES OTHER NAME
Devitalizing Mummification; cauterization
Preserving Minimal devital...
Timeline Devitalizing Preserving Regenerating
1930 Multiple Visits with
Formocresol. (Sweet)
1938 CaOH Pulpotomy for
Prima...
Timeline Devitalizing Preserving Regenerating
1983 Electrosurgical Pulpotomy
animal (Ruemping et al.)
1985 Laser animal (S...
FORMOCRESOL
• Formocresol was first introduced by Buckley in 1904.
• It was first introduced by Sweet as a pulpotomy agent...
• In 2004, International Agency for Research on Cancer (IARC) reclassified
formaldehyde as a known carcinogen known to cau...
GLUTARALDEHYDE
• Glutaraldehyde is a colorless, oily liquid that is used as an antimicrobial agent
• Mechanism of Action: ...
FERRIC SULPHATE
• Mechanism of Action: Ferric sulfate is an agglutinating agent thought to produce
hemostasis by blood rea...
SODIUM HYPOCHLORITE
• Sodium hypochlorite (NaOCl) has been used as a root canal irrigant for
permanent teeth since the 192...
CALCIUM HYDROXIDE
• Calcium hydroxide (CaOH2 ) was first introduced by Herman in the 1920s.
• Mechanism of Action: Its ant...
DENTIN BRIDGE FORMATION
Ca(OH)2
Due to Alkalinity
Dissociates
into Ca++ and
OH- ions
Ca++ ions react with CO2
in the tissu...
• Internal resorption is the most frequent reason for failure following pulpotomy with
CH in primary teeth, which indicate...
MTA(MINERAL TRIOXIDE AGGREGATE)
• Introduced by Torabinejad in 1993.
• MTA is a powder consisting of fine hydrophilic part...
Once the pulp
chamber is accessed,
pulp tissue removed
and hemostasis
achieved.
3:1 MTA to sterile
saline is mixed into a
...
BIODENTINE
• A relatively newer material which is a ‘tricalcium silicate’ having
biocompatibility and bioactivity develope...
Once the pulp chamber is
accessed, pulp tissue
removed and hemostasis
achieved with moistened
cotton pellet with 2.5%
NaOC...
LASER PULPOTOMY
• Nd: YAG, Er:YAG, CO2 and Diode laser have also been used for pulpotomy.
• Laser pulpotomy has advantages...
COMPARATIVE STUDIES
Title Clinical and radiographic success of mineral trioxide aggregate compared with formocresol as a
pulpotomy treatment i...
Title In vivo Comparative Evaluation of Mineral Trioxide Aggregate and Formocresol Pulpotomy in
Primary Molars: A 60-month...
Title Clinical and Radiographic Evaluation of the Effectiveness of Formocresol(fs), Mineral Trioxide
Aggregate, Portland C...
Title Evaluation of formocresol, calcium hydroxide, ferric Sulfate, and MTA in primary molar
pulpotomies.
Aim The aim of t...
Title Primary molar pulpotomy: A systematic review and network meta-analysis
Aim The aim of this study is to evaluate four...
• Clinical significance:
The network meta-analyses showed that MTA
is the first choice for primary molar
pulpotomies. Howe...
Title Two-year outcomes of electrosurgery and calcium-enriched mixture (CEM) pulpotomy in
teeth: a randomized clinical tri...
Title Short-term treatment outcome of pulpotomies in primary molars using mineral
aggregate (MTA) and Biodentine: a random...
Results 1. A total of four clinical failures were observed; all involved gingival inflammation.
2. The clinical success ra...
Title Clinical and radiographic outcomes of laser pulpotomy in vital primary teeth: a systematic
and meta-analysis.
Aim Th...
Uloop
i et al.
(2016)
county Tooth
type
Treatment
agent
Pulp
capping
material
Final
restoration
Initial
sample
size
(teeth...
Title Comparative Evaluation of Ankaferd Blood Stopper (ABS), Ferric Sulfate, and Formocresol as
Pulpotomy Agent in Primar...
Aim This study aimed to evaluate and compare the Platelet-rich fibrin (PRF) and Mineral trioxide
aggregate (MTA) as a pulp...
Aim This study aimed to evaluate and compare Fresh Aloe barbadensis Plant Extract and Mineral
Aggregate as Pulpotomy Agent...
Title Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis
Aim The aim of this meta-...
Title Pulpotomy of Traumatized Anterior Permanent Immature Teeth.
Aim The aim of this study was to assess the clinical and...
Title Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-analysis.
Aim This systematic review and meta-analysi...
Result Forty-one articles qualified for meta-analysis (six IPT, four DPC, and 31 pulpotomy) from 322
screened articles.
Th...
SUMMARY OF CLINICAL RECOMMENDATION ON VITAL PULP
THERAPIES IN PRIMARY TEETH WITH DEEP CARIES (AAPD 2017)
Question Recommen...
In vital primary teeth with deep caries lesions treated
with pulpotomy due to pulp exposure during caries
removal, does th...
Thomas P, Pillai RK, Ramakrishnan BP, Palani J . An Insight Into Internal Resorption. ISRN Dentistry. Hindawi Publishing C...
Thomas P, Pillai RK, Ramakrishnan BP, Palani J . An Insight Into Internal Resorption. ISRN Dentistry. Hindawi Publishing C...
SUMMARY AND CONCLUSION
• Despite of number of materials that have been used as pulpotomy medicaments
since the early 1900s...
Therefore, clinically, one should take into consideration numerous factors before deciding what
treatment to perform. Thes...
FUTURE IMPLICATIONS FOR RESEARCH
• Concerning pulpotomy in primary teeth, well designed long-term trials
could compare MTA...
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  1. 1. COMPARATIVE EVALUATION OF VARIOUS PULPOTOMY MEDICAMENTS USED IN PEDIATRIC DENTISTRY BIKASH CHAURASIA JR,PEDODONTICS1 8 / 0 3 / 2 0 2 0
  2. 2. CONTENTS INTRODUCTION IMPORTANCE OF DIAGNOSIS PULPOTOMY TECHNIQUE'S FOR PRIMARY TEETH PULPOTOMY MEDICAMENTS COMPARATIVE STUDIES SUMMARY CONCLUSION REFERENCES
  3. 3. INTRODUCTION • The conservation of primary teeth in form and function until their normal exfoliation is one of the fundamental objectives of pediatric dentistry. • In asymptomatic primary teeth with deep carious lesions approximating the pulp, the coronal pulpotomy is one of the common ways of achieving the goal of tooth preservation. Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young permanent teeth. Springer International Publishing Switzerland.2016,52-68
  4. 4. DIAGNOSIS • Outline for determining the Pulpal status of cariously involved teeth involves: 1. Visual and tactile examination of carious dentin and associated periodontium. 2. Radiographic examination of a. periradicular and furcation areas b. pulp canals c. periodontal space d. developing succedaneous teeth 3. History of 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 exposures H. D. RODD, P. J. WATERHOUSE, A. B. FUKS, S. A. FAYLE & M. A. MOFF AT. Pulp therapy for primary molars. UK National Clinical Guidelines in Paediatric Dentistry. International Journal of Pediatric Dentistry 2006 (Suppl. 1): 15–23
  5. 5. Diagnostic Criteria 1.Clinical criteria: • No spontaneous pain • No swelling • No tenderness on percussion • No pathological mobility • No sinus tract opening • No initially unsuccessful haemorrhage control 2.Radiographic criteria: • Teeth without inter-radicular radiolucency. • No loss of lamina dura and widened periodontal ligament space. • No physiologic root resorption of more than 1/3rd. H. D. RODD, P. J. WATERHOUSE, A. B. FUKS, S. A. FAYLE & M. A. MOFF AT. Pulp therapy for primary molars. UK National Clinical Guidelines in Paediatric Dentistry. International Journal of Pediatric Dentistry 2006 (Suppl. 1): 15–23
  6. 6. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY GUIDELINES 2014 • The pulpotomy procedure is indicated when caries removal results in pulp exposure in a primary tooth with a normal pulp or reversible pulpitis or after a traumatic pulp exposure. • The coronal tissue is amputated, and the remaining radicular tissue is judged to be vital without suppuration, purulence, necrosis, or excessive hemorrhage that can be controlled by a damp cotton pellet after several minutes, and there are no radiographic signs of infection or pathologic resorption. Pulp Therapy for Primary and Immature Permanent Teeth. American Academy of Pediatric Dentistry. Clinical Affairs Committee-Pulp Therapy. Latest Revision 2014.
  7. 7. Objectives: • 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 may 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. Pulp Therapy for Primary and Immature Permanent Teeth. American Academy of Pediatric Dentistry. Clinical Affairs Committee-Pulp Therapy. Latest Revision 2014.
  8. 8. PULPOTOMY TECHNIQUE'S FOR PRIMARY TEETH • Formocresol Pulpotomy Technique • Glutaraldehyde Pulpotomy Technique • Ferric Sulfate Pulpotomy Technique • Sodium Hypochlorite Pulpotomy Technique • Calcium Hydroxide Pulpotomy Technique • MTA Pulpotomy Technique • Laser • Partial Pulpotomy Secondary to Trauma or Non-caries associated Resorption
  9. 9. OTHERS • Enriched collagen (Fuks 1984) • Freeze Dried Bone (Fadavi et al. 1988) • Demineralized Dentin (Nakashima 1989) • Bone Morphogenetic Protein Animal (Nakashima 1991) • Osteogenic Protein (Rutherford 1993) • Calcium Enriched Mixture (CEM) (Asgary 2008 ) • Enamel Matrix Derivatives (EMD) • Ankaferd Blood Stopper (ABS) • Herbal agents (plant and animal extracts like Turmeric, Aloe vera, Thymus, Propolis etc.) • Biodentine
  10. 10. PULPOTOMY MEDICAMENTS • Ideally, a pulpotomy medicament should be – bactericidal, – easy to use, – harmless to the remaining pulp tissue and the surrounding structures, – should not interfere with physiologic root resorption, and – should be relatively inexpensive. • Needless to say, the ideal dressing material has not been found, and studies are constantly being conducted in both endodontics and pediatric dentistry to find such a product. Fuks AB, Kupietzki A, Guelmann M. Pulp therapy for the primary dentition. In: infancy through adolescence. In: Casamassimo PS, Fields Jr HW, McTigue DJ, Nowak AJ, editors. Pediatric dentistry: infancy through adolescence. 5th ed. St. Louis: Elsevier Saunders; 2015. p. 333–51
  11. 11. • The search for this ideal material has been ongoing since the early 1900s when Buckley first introduced Formocresol. • Over the years, many other materials have surfaced as potential agents and have been classified into three major categories according to their effects on the remaining radicular pulp. Buckley JP. The chemistry of pulp decomposition with a rational treatment for this condition and its sequelae. Am Dent 1904;3:764–71.
  12. 12. CLASSIFICATION OF VITAL PULP THERAPY TYPES OTHER NAME Devitalizing Mummification; cauterization Preserving Minimal devitalization; noninductive Regenerating Inductive; reparative
  13. 13. Timeline Devitalizing Preserving Regenerating 1930 Multiple Visits with Formocresol. (Sweet) 1938 CaOH Pulpotomy for Primary Teeth (Teuscher and Zander) 1962 2 Visit FC Pulpotomy Human (Doyle et al.) 1965 5 min FC Pulpotomy Animal (Spedding et al.) 1966 Formocresol Pulpotomy Human (Redig) 1970 Dilution of FC Animal (Straffon and Han) CaOH Evaluated Human 1975 Dilution of FC; Human (Morawa) 1978 Glutaraldehyde(GA) Proposed Pulpotomy (Ranly and Lazzari) 1980 GA Proposed Humans (Kopel) Don M. Ranly. Pulpotomy therapy in primary teeth: new modalities for old rationales. Pediatric Dentistry:1994;403-09
  14. 14. Timeline Devitalizing Preserving Regenerating 1983 Electrosurgical Pulpotomy animal (Ruemping et al.) 1985 Laser animal (Shoji et al.) 1991 Ferric Sulfate Human (Fei) 1993 Electrosurgical Pulpotomy Human (Mack) 1996 Argon Laser Animal (Wilkerson) MTA Animal (Ford et al.) 2001 MTA Human (Eidelman et al.) 2002 Sodium Hypochlorite Animal (Hafez et al.) 2006 Sodium Hypochlorite Human(Vargas KG et al.) Don M. Ranly. Pulpotomy therapy in primary teeth: new modalities for old rationales. Pediatric Dentistry:1994;403-09
  15. 15. FORMOCRESOL • Formocresol was first introduced by Buckley in 1904. • It was first introduced by Sweet as a pulpotomy agent in 1930. • Mechanism of Action: Devitalization and Prevents tissue autolysis by bonding to protein and fixes the pulp tissue which further prevents liquefactive necrosis of the remaining pulp tissue.Once the pulp tissue has been removed from the pulp chamber and hemostasis achieved. A cotton pellet dipped in a 1:5 dilution of the original Buckley’s Formocresol The dampened cotton pellet is applied in the pulp chamber for 5 min. The cotton pellet is removed, and the root canal orifices are expected to look like “black eyes”, with no bleeding. The pulp chamber is then filled with a thick paste of zinc oxide eugenol (ZOE) or intermediate restorative material (IRM) Tooth is restored with the material of choice depending on the remaining tooth structure. Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young permanent teeth. Springer International Publishing Switzerland.2016,52-68
  16. 16. • In 2004, International Agency for Research on Cancer (IARC) reclassified formaldehyde as a known carcinogen known to cause Nasopharyngeal carcinoma, leukemia and lymphoma (with sufficient evidence in human trials). • It is highly unlikely that formocresol, when judiciously used, is genotoxic or immunotoxic or poses a cancer risk to children who undergo one or more formocresol pulpotomy procedures. • Defiitive data to support this hypothesis are still lacking. • Until a biologic and reparative alternative has been identified that is clearly and reproducibly superior to formocresol, there are no scientific or toxicologic reasons to discontinue its use in pediatric dentistry. • When used judiciously, formocresol is a safe medicament.Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young permanent teeth. Springer International Publishing Switzerland.2016,52-68
  17. 17. GLUTARALDEHYDE • Glutaraldehyde is a colorless, oily liquid that is used as an antimicrobial agent • Mechanism of Action: GA is a di-aldehyde that has superior fixative properties over Formocresol and has self-limiting penetration, low antigenicity, low toxicity, and eliminates cresol. • Glutaraldehyde has no bactericidal ability at low pH and therefore must be alkalinized to a pH of between 7.5 and 8.5 before it is effective. This increase in pH renders glutaraldehyde unstable, thus decreasing its shelf life to approximately 14 days. Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young permanent teeth. Springer International Publishing Switzerland.2016,52-68
  18. 18. FERRIC SULPHATE • Mechanism of Action: Ferric sulfate is an agglutinating agent thought to produce hemostasis by blood reaction with both the ferric and sulfate ions as well as with the acidic pH of the solution. • The hemostasis achieved by this agglutination is thought to reduce the likelihood of clot breakdown and subsequent inflammatory response. • It has been shown that the application of ferric sulphate prior to calcium hydroxide in pulpotomized primary teeth had more favorable results than calcium hydroxide alone.Once the pulp chamber is accessed, pulp tissue removed and hemostasis achieved. 15.5 % ferric sulfate solution is applied for 15 sec to the pulp stumps until complete hemostasis is achieved. The typical dark appearance of the tissue affected by the ferric sulfate is noted. A thick paste of ZOE or IRM is placed in the chamber. Tooth is restored with the material of choice depending on the remaining tooth structure.
  19. 19. SODIUM HYPOCHLORITE • Sodium hypochlorite (NaOCl) has been used as a root canal irrigant for permanent teeth since the 1920s and has been shown to be a very good antibacterial agent without being a significant irritant to the pulp tissue. Once the pulp chamber is accessed, pulp tissue removed and hemostasis achieved. A cotton pellet is moistened in 3 % or 5 % NaOCl Cotton pellet placed in the chamber for 30 sec. The pellet is removed, the chamber is gently irrigated ensuring no clot is present. A thick paste of ZOE or IRM is placed in the chamber. Tooth is restored with the material of choice depending on the remaining tooth structure. Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young permanent teeth. Springer International Publishing Switzerland.2016,52-68
  20. 20. CALCIUM HYDROXIDE • Calcium hydroxide (CaOH2 ) was first introduced by Herman in the 1920s. • Mechanism of Action: Its antibacterial properties are due to protein denaturation and cytoplasmic damage of bacteria and is achieved through ionic dissolution of Ca+ and OH – ions and their effect on vital pulp tissue by formation of calcific bridge. • The effect of the very high pH of CaOH2 that most likely initiates the reparative dentin cascade. Once the pulp chamber is accessed, pulp tissue removed and hemostasis achieved. CaOH2 paste is placed in the pulp chamber. A thick paste of ZOE or IRM is placed in the chamber over CaOH2 paste. Tooth is restored with the material of choice depending on the remaining tooth structure.
  21. 21. DENTIN BRIDGE FORMATION Ca(OH)2 Due to Alkalinity Dissociates into Ca++ and OH- ions Ca++ ions react with CO2 in the tissues producing “Calcite Granulations” This process leads to an accumulation of “Fibronectin” Further promotes Cellular adhesion and differentiation Resulting in formation of Dentin bridge(Hard tissue) Thomas P, Pillai RK, Ramakrishnan BP, Palani J . An Insight Into Internal Resorption. Hindawi Publishing Corporation ISRN Dentistry.2014
  22. 22. • Internal resorption is the most frequent reason for failure following pulpotomy with CH in primary teeth, which indicates that, despite pulp vitality, a silent chronic inflammation develops after treatment with CH and remains undiagnosed, thus triggering odontoclast activity. • Studies have shown that thick blood clot remains may also result in internal resorption. • Thus, bleeding control after coronal pulp amputation may significantly influence the outcome of pulpotomies with CH. • Some authors suggested that avoiding blood clot formation between the pulp tissue and the CH cap prevents the occurrence of internal resorption, however, this is technically difficult since the incision into vital tissue produces both hemorrhage and exudation. Internal Resorption with Ca(OH)2 Sakai VT, Moretti AB, Oliveira TM, Fornetti AP, Santos CF, Machado MA, et al. Pulpotomy of human primary molars with MTA and Portland cement: a randomised controlled trial. Br Dent J. 2009;207(3):128-9
  23. 23. MTA(MINERAL TRIOXIDE AGGREGATE) • Introduced by Torabinejad in 1993. • MTA is a powder consisting of fine hydrophilic particles that sets in the presence of moisture. • Mechanism of Action: it is bactericidal (high pH, 12.5), and it is able to stimulate cementum-like formation, osteoblastic adherence, and bone regeneration. • Moreover, its sealing, mineralizing, dentinogenic, and osteogenic potentials make it the preferred choice for numerous clinical applications. • The major benefits of MTA are that it is biocompatible. Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young permanent teeth. Springer International Publishing Switzerland.2016,52-68
  24. 24. Once the pulp chamber is accessed, pulp tissue removed and hemostasis achieved. 3:1 MTA to sterile saline is mixed into a paste and applied to the pulpal floor 1.5mm thickness. A thick paste of ZOE or IRM is placed in the chamber over MTA. Tooth is restored with the material of choice depending on the remaining tooth structure.
  25. 25. BIODENTINE • A relatively newer material which is a ‘tricalcium silicate’ having biocompatibility and bioactivity developed by Septodont (Lancaster, USA). • In addition to hard tissue regeneration, Biodentine also has excellent sealing ability, biocompatibility and antimicrobial properties. • The average success rate of Biodentine pulpotomy has been reported to be 95.2% to 100%. Kaaren G. Vargas, Anna B.Fuks,Benjamin Peretz. Pulpotomy techniques: Cervical(Traditional) and Partial. Current concepts in pulp therapy for primary and young permanent teeth. Springer International Publishing Switzerland.2016,52-68
  26. 26. Once the pulp chamber is accessed, pulp tissue removed and hemostasis achieved with moistened cotton pellet with 2.5% NaOCl for 2 minutes. Biodentine mixed according to the manufacturer’s instructions and placed in a 3 mm layer above the pulp tissue using an amalgam carrier and gently packed using a condenser. After 12 minutes of waiting for the initial setting, a layer of resin- modified glass ionomer liner is applied. The tooth is restored with glass ionomer cement and a stainless steel crown or resin composite
  27. 27. LASER PULPOTOMY • Nd: YAG, Er:YAG, CO2 and Diode laser have also been used for pulpotomy. • Laser pulpotomy has advantages like better hemorrhage control, absence of mechanical contact and stimulation of regenerative cells. • Reports of many authors have proven that lasers reduce the bacterial load and seldom cause dentin bridge formation. • Diode laser pulpotomy along with other medicaments reported a success rate of 71% to 100%, but it is technique sensitive, costly and found to cause internal root resorption in some cases.
  28. 28. COMPARATIVE STUDIES
  29. 29. Title Clinical and radiographic success of mineral trioxide aggregate compared with formocresol as a pulpotomy treatment in primary molars: A systematic review and meta-analysis. Aim The aim of this study was to compare the long-term clinical and radiographic success of using mineral trioxide aggregate (MTA) and formocresol (FC) as a pulp-dressing material in pulpotomy treatment in primary molars Authors Abdullah A, Marghalani, Samah Omar, Jung-Wei Chen Journal/Year JADA,2014 Material and Method 1. The authors searched MEDLINE, Thomson Reuters Web of Science and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) published from Jan. 1, 1990, to May 9, 2013. 2. For an RCT to be included, the authors required that the primary molars treated with a pulpotomy procedure must have received stainless steel crowns as a final restoration and that rubber dam isolation was used during treatment; that the pulp must have been vital as determined clinically by means of hemorrhage control with a cotton pellet; and that the RCT must have included a follow- up period of at least two years. 3. For each included RCT, two authors assessed the risk of bias independently. Results The authors identified 20 trials. A total of 377 primary molars were treated. The authors judged that none of the included RCTs had a low risk of bias. They noted no significant differences in clinical success (relative risk [RR] = 1.01; 95 percent confidence interval [CI], 0.98-1.05) and radiographic success (RR = 1.09; 95 percent CI, 0.97-1.21) for primary molars treated with MTA versus those treated with FC. Conclusions On the basis of the limited evidence, pulpotomy procedures performed in primary molars involving the
  30. 30. Title In vivo Comparative Evaluation of Mineral Trioxide Aggregate and Formocresol Pulpotomy in Primary Molars: A 60-month Follow-up Study. Aim The aim was to evaluate and compare clinically and radiographically the effects of MTA as a pulp dressing after coronal pulp amputation (pulpotomy) in primary molars. Authors Hugar SM, Reddy R, Deshpande SD, Shigli A, Gokhale NS, Hugar SS Journal/Year Contemporary Clinical Dentistry,2017 Material and Method 1. Sixty primary mandibular molars of thirty healthy children aged between 4 and 6 years were treated by pulpotomy technique. 2. The teeth on the right side were assigned to MTA (Group A) and the left side for the formocresol (Group B). 3. The children were then examined clinically and radiographically every 6 months. 4. Statistical analysis used: Chi-square test using the SPSS version 19.0 was used to compare between the two groups. Results Results showed that both MTA and formocresol have the same outcome on the primary molars, with Chi-square value being 1.1483 (P ≥ 0.05). None of the teeth in any children in the study showed any clinical pathology. Conclusions The principle conclusions of this study is that there are no significant differences in MTA and formocresol. The success rate of MTA and formocresol pulpotomy can be considered comparable till this therapy influences the development and growth of the permanent teeth.
  31. 31. Title Clinical and Radiographic Evaluation of the Effectiveness of Formocresol(fs), Mineral Trioxide Aggregate, Portland Cement, and Enamel Matrix Derivative in Primary Teeth Pulpotomies: A Year Follow-Up. Aim The aim of this study was to evaluate and to compare clinical and radiographic outcomes of 4 materials (formocresol, mineral trioxide aggregate (MTA), Portland cement and enamel matrix derivative) using in primary teeth pulpotomies. Authors Yildirim C, Basak F , Akgun OM, Polat GG, Altun C. Journal/Year The Journal of Clinical Pediatric Dentistry,2016 Material and Method 1. Sixty-five patients aged 5–9 years (32 female, 33 male)were included in this study. 2.A total of 140 primary fist and second molars with deep caries were treated with pulpotomy. 3. All teeth were then restored with stainless steel crowns. 4.The treated teeth were evaluated clinically and radiographically at 3, 6, 12, 18 and 24 months. Results At 24 months, the clinical success rates of formocresol, MTA, Portland cement, and enamel matrix derivative were 96.9%, 100%, 93.9%, and 93.3%, respectively. The corresponding radiographic success rates were 84.4%, 93.9%, 86.7% and 78.1%, respectively Conclusions Although there were no statistically significant differences in clinical and radiographic success rates among the 4 groups, MTA appears to be superior to formocresol, Portland cement, and enamel matrix derivative as a pulpotomy agent in primary teeth.
  32. 32. Title Evaluation of formocresol, calcium hydroxide, ferric Sulfate, and MTA in primary molar pulpotomies. Aim The aim of this study is to evaluate four different pulpotomy medicaments in primary molars. Authors Yildiz E , Tosun G Journal/Year European Journal of Dentistry,2014 Material and Method 1. A total of 147 primary molars with deep caries were treated with four different pulpotomy medicaments (FC: formocresol, FS: ferric sulfate, CH: calcium hydroxide, and MTA: mineral trioxide aggregate) in this study. 2. The criteria for tooth selection for inclusion were no clinical and radiographic evidence of pulp pathology. 3. During 30 months of follow-up at 6-month intervals, clinical and radiographic success and failures were recorded. 4. The differences between the groups were statistically analyzed using the Chi-square test and Kaplan-Meier analysis. Results At 30 months, clinical success rates were 100%, 95.2%, 96.4%, and 85% in the FC, FS, MTA, and CH groups, respectively. In radiographic analysis, the MTA group had the highest (96.4%), and the CH group had the lowest success rate (85%). There were no clinical and radiographic differences between materials (P > 0.05). Conclusions Although there were no differences between materials, only in the CH group three teeth require extraction due to further clinical symptoms of radiographic failures during the 30-month follow-up period. None of the failed teeth in the other groups required extraction during the 30-month follow-
  33. 33. Title Primary molar pulpotomy: A systematic review and network meta-analysis Aim The aim of this study is to evaluate four different pulpotomy medicaments in primary molars. Authors Lin PY , Chen HS , Wang YH , Tu YK Journal/Year Journal of dentistry, 2014 Material and Method 1. An electronic literature search was performed within MEDLINE (via PubMed), ScienceDirect, Web of Science, Cochrane, and Clinical Key databases until December 2012. Medications for pulpotomy including formocresol, ferric Sulfate, calcium hydroxide, and mineral trioxide aggregate (MTA), and laser pulpotomy are compared using Bayesian network meta-analyses. 2. Three authors performed data extraction independently and in duplicate using data collection forms. Disagreements were resolved by discussion. 3. The outcome is the odds ratio for clinical and radiographic failure including premature tooth loss at 12 and 24 months after treatments amongst different treatment procedures. 4. 37 studies were included in the systematic review, and 22 of them in the final network meta- analyses. Results After 18–24 months, in terms of treatment failure, the odds ratio for calcium hydroxide vs. formocresol was 1.94 [95% credible interval (CI): 1.11, 3.25]; 3.88 (95% CI: 1.37, 8.61) for lasers vs. formocresol; 2.16 (95% CI: 1.12, 4.31) for calcium hydroxide vs. ferric Sulfate; 3.73 (95% CI: 1.27, 11.67) for lasers vs. ferric Sulfate; 0.47 (95% CI: 0.26, 0.83) for MTA vs. calcium hydroxide; 3.76 (95% CI: 1.39, 10.08) for lasers vs. MTA. Conclusions After 18–24 months, formocresol, ferric Sulfate, and MTA showed significantly better clinical and
  34. 34. • Clinical significance: The network meta-analyses showed that MTA is the first choice for primary molar pulpotomies. However, if treatment cost is an issue, especially when the treated primary molars are going to be replaced by permanent teeth, ferric sulfate may be the choice.
  35. 35. Title Two-year outcomes of electrosurgery and calcium-enriched mixture (CEM) pulpotomy in teeth: a randomized clinical trial. Aim The purpose of this prospective split-mouth, randomized clinical trial was to assess the clinical and radiographic success rate of pulpotomy in primary molars using calcium-enriched mixture (CEM) cement or placement of zinc oxide eugenol after electrosurgery (ES/ZOE). Authors Khorakian F , Mazhari F, Asgary S , Sahebnasagh M, Kaseb AA , Movahhed T , Shirazi ARS Journal/Year Eur Arch Paediatr Dent,2014 Material and Method 1. Pulpotomy was performed for 102 primary second molars in 51 children aged between 4 and 6 years. 2. Considering a split-mouth design, for each patient the right and left second primary molars randomly underwent pulpotomy using CEM cement or ES/ZOE. 3. All teeth were restored using preformed metal crowns. 4. Following pulpotomy procedure, teeth were blindly evaluated for clinical and radiographic success after 6, 12 and 24 months. 5. McNemar test and SPSS 16 software were used for the statistical analysis. Results After 24 months, clinical success rates were 100 % in both groups, however, radiographic success rates of ES/ZOE and CEM were calculated as 95.2 and 90 %, respectively, with no significant difference (p = 0.625). The most common radiographic sign of failure was internal resorption. Conclusions The results of this investigation show that the treatment success rate with CEM cement was similar to the electrosurgical pulpotomy.
  36. 36. Title Short-term treatment outcome of pulpotomies in primary molars using mineral aggregate (MTA) and Biodentine: a randomized clinical trial Aim The purpose of this study is to compare the preliminary clinical results obtained using Biodentine and mineral trioxide aggregate (MTA) as pulp-dressing agents in pulpotomies of primary molars. Authors Fernández CC, Rodríguez AIL , Martínez SS, Binimelis JG, About I, Mercadé M Journal/Year Clin Oral Invest, 2015 Material and Method 1. A randomized clinical study was performed in children aged 4–9 years with at least one primary tooth with decay or caries requiring pulp treatment. 2. A total of 90 primary molars requiring pulpotomy were randomly allocated to the MTA or Biodentine group, and 84 pulpotomies were performed. 3. Clinical and radiographic evaluations were undertaken 6 and 12 months after treatment. 4. All teeth were restored with a reinforced zinc oxide–eugenol base and stainless steel crowns. 5. Statistical analysis using Fisher’s exact test was performed to determine the significant
  37. 37. Results 1. A total of four clinical failures were observed; all involved gingival inflammation. 2. The clinical success rate in the MTA Group after 12 months was 92 % (36/39), whereas the Biodentine Group obtained 97 % (38/39) ( p = 0.346). 3. One molar from MTA Group showed internal resorption obtaining a radiographic success rate of 97 % (38/39). 4. Two molars from the Biodentine Group showed radiographic failure (one internal resorption and one periradicular radiolucency) obtaining a radiographic success rate of 95 % (37/39). Conclusions Biodentine showed similar clinical results as MTA with comparable success rates when used for pulpotomies of primary molars. However, longer follow-up studies are still required to confirm such findings.
  38. 38. Title Clinical and radiographic outcomes of laser pulpotomy in vital primary teeth: a systematic and meta-analysis. Aim The aim of this study is to compare clinical and radiographic success rates of laser pulpotomy with those of other pulpotomy techniques in primary teeth. Authors Nematollahi H, Shirazi AS, Mehrabkhani M, Sabbagh S Journal/Year European Archives of Paediatric Dentistry,2018 Material and Method 1. PubMed, SCOPUS, EMBASE, Cochrane and ISI Web of Knowledge databases were searched electronically without time or language limitations. 2. Clinical trials in which laser pulpotomy was compared with at least one other pulpotomy modality in primary teeth were selected. 3. The bibliographic reference lists of eligible articles were also hand-searched. Odds ratios, risk differences and 95% confidence intervals were calculated with the aid of Comprehensive Meta- Analysis software (Version 2.2.050, Biostat, Englewood, NJ, USA). 4. The methodological quality of articles included in the meta-analysis was determined using the Jadad scale. Results Twelve pulpotomy studies were selected for systematic review and underwent data extraction. Of these studies, statistical analysis was conducted on Eleven. All clinical trials had low to moderate risks of methodological bias. The meta analysis showed no significant differences in clinical and radiographic pulpotomy outcomes with laser compared with other techniques (p > 0.05). Likewise, no differences were found in the outcomes at 1, 3, 6, 9, 12 or ≥ 18 months (all p > 0.05). Conclusions For primary molar pulpotomy, the laser technique showed comparable clinical and radiographic results to other conventional pulpotomy medicaments, including formocresol and mineral trioxide
  39. 39. Uloop i et al. (2016) county Tooth type Treatment agent Pulp capping material Final restoration Initial sample size (teeth) Follow- up period (months) Sample size at each follow-up visit (teeth) Radiograp hic success rate (%) India Primary mandibul ar molars MTA (3:1 distilled water) Diode laser (LLLT) (810 nm, 2 J/cm 2 , 10 mW, continuous mode, ~10 s, noncontact ) MTA NM(Not mentione d) SSC SSC 20 20 3 6 12 3 6 12 19 19 19 20 20 20 94.7 94.7 94.7 95 85 80
  40. 40. Title Comparative Evaluation of Ankaferd Blood Stopper (ABS), Ferric Sulfate, and Formocresol as Pulpotomy Agent in Primary Teeth: A Clinical Study. Aim The aim of the study was to provide a comparative evaluation of the clinical and radiographic success of Ankaferd blood stopper (ABS), formocresol (FC), and ferric sulfate (FS) as pulpotomy agent in primary teeth. Authors Ozmen B, Bayrak S Journal/Year Nigerian Journal of Clinical Practice,2017 Material and Method 1. A total of 45 primary mandibular molar teeth in 26 children aged 6–9 were selected for the study. 2. Teeth were randomly divided into three groups according to the pulpotomy agents (ABS, FC, FS). 3. Following treatment, for 24 months, teeth were clinically and radiographically evaluated once every 3 and 6 months respectively. Results After follow-up periods ranging from 6 to 24 months (average 20.8±0.56), the clinical success rates for ABS, FC, and FS were 87%, 87%, and 100% respectively. The overall radiographic success was 87%, 80%, and 87%. When success rates of the ABS were compared with other agents, there were no significant differences between groups (P > 0.05). Conclusions Similar success was achieved in the pulpotomy treatment of primary teeth that using ABS, FC, and FS. ABS would be considered a suitable agent for pulpotomy treatment and can be used as an alternative to other agents.
  41. 41. Aim This study aimed to evaluate and compare the Platelet-rich fibrin (PRF) and Mineral trioxide aggregate (MTA) as a pulpotomy agent in primary molars. Authors Patidar S, Kalra N, Khatri A, Tyagi R Journal/Year Journal of Ind Soc of Ped and Pre Dent,2017 Material and Method 1. In this study, 50 primary molars from 50 healthy children aged 5–9 years requiring pulpotomy were randomly allocated into two groups. 2. In PRF group, after coronal pulp removal and hemostasis, remaining pulp tissue was covered with PRF preparation. 3. In the MTA group, the pulp stumps were covered with MTA (Pro Root MTA-Root Canal Repair Material, Dentsply International Inc.) paste obtained by mixing MTA powder with sterile water at a 3:1 powder to water ratio. 4. All teeth were restored with reinforced zinc oxide eugenol base and glass – ionomer cement. 5. Stainless steel crowns were given in both groups 24h after treatment. 6. Clinical evaluation was undertaken at 1, 3, and 6 months intervals whereas radiographic evaluation of the treated teeth was carried out at the interval of 6 months. Results By the end of 6 months, the overall success rate was 90% in PRF group and 92% in MTA Group. A statistically significant difference was observed between the groups at 6 months of follow-up (P < 0.05). At the end of 6-month, overall radiographic success rate was 87% for PRF group whereas for MTA group it was 92% and this result was statistically nonsignificant (P > 0.05) between the groups. Conclusions Radiographic and clinical outcome in PRF group could suggest it as an acceptable alternative in
  42. 42. Aim This study aimed to evaluate and compare Fresh Aloe barbadensis Plant Extract and Mineral Aggregate as Pulpotomy Agents in Primary Molars: A 12-month Follow-up Study Authors Kalra M, Garg N, Rallan M, Pathivada L, Yeluri R Journal/Year Contemporary Clinical Dentistry,2017 Material and Method 1. Pulpotomy procedure was performed in sixty primary molar teeth which were randomly allocated to two groups, i.e. Aloe vera pulpotomy (Group A) and MTA pulpotomy (Group B). 2. All the pulpotomized teeth were evaluated clinically and radiographically at 1, 3, 6, 9, and 12 months of time interval using predetermined criteria Results The success rates between Groups A and B at the end of the 1st month were 24.1% and 96.4%, at the end of 3rd month were 57.1% and 100%, at the end of 6th month were 75% and 100%, at the end of 9th month were 66.6% and 100%, and at the end of 12 months were 100% and 100% respectively. The overall success rates at the end of 12-month follow-up period were 6.9% and 71.4%, respectively, after taking dropout patients into consideration, and the difference was statistically significant (P < 0.001). Conclusions MTA pulpotomy was found to be superior when compared to fresh A. barbadensis plant extract
  43. 43. Title Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis Aim The aim of this meta-analysis and systemic review is to synthesize the available evidences to compare different pulpotomy dressing agents for pulpotomy treatment in immature permanent teeth. Authors Chen Y, Chen X, Zhang Y, Zhou F, Deng J, Zou J, Wang Y Journal/Year BMC Oral Health,2019 Material and Method 1. Electronic databases including MEDLINE (via PubMed), EMBASE, the Cochrane library (CENTRAL) and the clinicaltrials.gov database were searched. 2. The references of all included articles or relevant reviews were cross-checked. 3. Only randomized controlled trials (RCTs) comparing two or more pulp dressing agent in permanent teeth with open apex was included. 4. Also, the studies should have at least 6 months of follow-up, report clinical and radiographic success in detail and publish in English. Results Five RCTs were included for a systematic review, and all of them had a high risk of bias. There is little difference in success rate between mineral trioxide aggregate (MTA) and calcium hydroxide (CH) at 6-month follow-up (risk ratio (RR) 1; 95% confidence interval (CI) 0.94 to 1.06) and 12-month follow- up (RR 1.04; 95% CI 0.96 to 1.13). There is no difference between MTA versus platelet-rich fibrin and MTA versus calcium-enriched mixture (CEM). There is only weak evidence of increased success rate in using MTA and triple antibiotic paste (TAP) rather than abscess remedy. Conclusions Based on the present evidence, similar success rates with MTA were found between the dressing agents CH, CEM, PRF and TAP as pulpotomy-dressing agents in the treatment of immature permanent teeth. More high-quality RCTs are needed in this field in future studies.
  44. 44. Title Pulpotomy of Traumatized Anterior Permanent Immature Teeth. Aim The aim of this study was to assess the clinical and radiographic outcomes when using mineral trioxide aggregate (MTA) and Biodentine as pulpotomy materials to maintain the vitality of traumatized immature anterior permanent teeth with pulp exposure. Authors Abuelniel GM, Duggal MS, Kabel N Journal/Year Dent Traumatol,2020 Material and Method 1. Fifty traumatized immature anterior permanent teeth with exposed pulps were included in the study. 2. Teeth were equally divided and randomly assigned two groups MTA or Biodentine. 3. After pulpotomy, pulp stumps were covered with MTA or Biodentine followed by a permanent restoration. 4. Blinded clinical and radiographic evaluations were performed at base line, immediate postoperative, and after 6, 12 and 18 months according to pre-determined clinical and radiographic criteria. Results No statistically significant differences were observed between MTA and Biodentine for any of the clinical parameters, except for discoloration, which was significantly more prevalent in the MTA group (p<0.001). No significant statistical difference was observed in the radiographic outcomes between MTA and Biodentine, as evidenced by continued root development and by an increased prevalence of root formation stage H (i.e. The apical end of the root canal is completely closed. The periodontal membrane has a uniform width around the root and the apex) in both groups. Conclusions Both MTA and Biodentine showed similar clinical and radiographic outcomes when used as
  45. 45. Title Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-analysis. Aim This systematic review and meta-analysis assessed outcomes in primary teeth for the vital pulp therapy (VPT) options of indirect pulp therapy (IPT), direct pulp capping (DPC), and pulpotomy after a minimum of 12 months to determine whether one VPT was superior. Authors Coll JA, Seale NS, Vargas K, Marghalani AA, Al Shamali S, Graham L Journal/Year Pediatr Dent. 2017 Jan Material and Method 1.Databases were searched from 1960 to September 2016 (MEDLINE, EMBASE, CENTRAL, ICTRP, Dissertation abstracts, and grey literature for parallel and split-mouth randomized controlled trials of at least 12 months duration comparing the success of IPT, DPC, and in children with deep caries in primary teeth) 2. Three authors determined the included RCTs, performed data extraction, and assessed the of bias (ROB). Meta-analysis and assignment of quality of evidence by Grading of Recommendations Assessment, Development and Evaluation(GRADE) approach were done.
  46. 46. Result Forty-one articles qualified for meta-analysis (six IPT, four DPC, and 31 pulpotomy) from 322 screened articles. The 24-month success rates were: IPT=94.4 percent, and the liner material (calcium hydroxide [CH]/bonding agents) had no effect on success (P=0.88), based on a moderate quality of evidence; DP =88.8 percent, and the capping agent (CH/alternate agent) did not affect success (P=0.56), based on a low quality of evidence. The combined success rate for all pulpotomies was 82.6 percent based on 1,022 teeth. Mineral trioxide aggregate (MTA) (89.6 percent) and formocresol (FC) (85.0 percent) success rates were the highest of all pulpotomy types and were not significantly different (P=0.15), with a high quality of evidence. MTA's success rate (92.2 percent) was higher than ferric sulfate (FS) (79.3 percent) and approached significance (P=0.06), while FS's success rate (84.8 percent) was not significantly different from FC (87.1 percent), both with a moderate quality of evidence. MTA and FC success rates were significantly better than CH (P=0.0001), with a moderate quality of evidence. At 18 months, sodium hypochlorite (NaOCl) success rate was significantly less than FC (P=0.01) with a low quality of evidence. Conclusion The highest level of success and quality of evidence supported IPT and the pulpotomy techniques of MTA and FC for the treatment of deep caries in primary teeth after 24-months. DPC showed similar success rates to IPT and MTA or FC pulpotomy, but the quality of the evidence was lower.
  47. 47. SUMMARY OF CLINICAL RECOMMENDATION ON VITAL PULP THERAPIES IN PRIMARY TEETH WITH DEEP CARIES (AAPD 2017) Question Recommendation In vital primary teeth with deep caries lesions requiring pulp therapy, is one particular therapy (IPT, DPC, pulpotomy) more successful* than others? Th panel was unable to make a recommendation on superiority of any particular type of vital pulp therapy owing to lack of studies directly comparing these interventions. Panel noted the high success rates among IPT, DPC, and pulpotomy and recommends that the choice of pulp therapy in vital primary teeth with deep caries lesions should be based on a biologic approach. ^ In vital primary teeth treated with indirect pulp treatment (IPT) due to deep caries lesions, does the choice of medicament affect success*? Th panel found that the success of IPT in vital primary teeth with deep caries lesions is independent of the type of medicament used, and therefore conditionally recommends that clinicians choose the medicament based on individual preferences. † In vital primary teeth with deep caries lesions treated with DPC due to pulp exposure (one mm or less) encountered during carious dentin removal, does the choice of medicament affect success*? Th panel found that in vital primary teeth with deep caries lesions treated with DPC due to pulp exposure (one mm or less) encountered during carious dentin removal, the success of DPC is independent of the type of medicament used, and therefore conditionally recommends that clinicians choose the medicament based on individual preferences. ‡ * Success was defied as overall success simultaneously observed both clinically and radiographically. ^ The panel suggests clinicians take the most biological approach considering caries-affected dentin removal, pulp exposures (if any), reported adverse effects (if any), clinical expertise, and patient preferences. † The medicaments evaluated were calcium hydroxide and alternates such as bonding agents/liners. ‡ The medicaments evaluated were calcium hydroxide and alternates such as dentin bonding agents, MTA, and Formocresol.
  48. 48. In vital primary teeth with deep caries lesions treated with pulpotomy due to pulp exposure during caries removal, does the choice of medicament or technique affect success*? The panel strongly recommends the use of MTA in vital primary teeth with deep caries treated with pulpotomy due to pulp exposure during carious dentin removal. The panel strongly recommends the use of formocresol in vital primary teeth with deep lesions treated with pulpotomy due to pulp exposure during carious dentin removal. The panel conditionally recommends the use of ferric sulfate in vital primary teeth with caries lesions treated with pulpotomy due to pulp exposure during carious dentin removal. The panel conditionally recommends against the use of calcium hydroxide in vital primary teeth with deep caries lesions treated with pulpotomy due to pulp exposure during carious dentin removal. The panel conditionally recommends the use of lasers in vital primary teeth with deep lesions treated with pulpotomy due to pulp exposure during carious dentin removal. The panel conditionally recommends the use of sodium hypochlorite in vital primary teeth deep caries lesions treated with pulpotomy due to pulp exposure during carious dentin removal. The panel conditionally recommends the use of tricalcium silicate in vital primary teeth deep caries lesions treated with pulpotomy due to pulp exposure during carious dentin removal.
  49. 49. Thomas P, Pillai RK, Ramakrishnan BP, Palani J . An Insight Into Internal Resorption. ISRN Dentistry. Hindawi Publishing Corporation.2014
  50. 50. Thomas P, Pillai RK, Ramakrishnan BP, Palani J . An Insight Into Internal Resorption. ISRN Dentistry. Hindawi Publishing Corporation.2014
  51. 51. SUMMARY AND CONCLUSION • Despite of number of materials that have been used as pulpotomy medicaments since the early 1900s. • A recent Cochrane Database of Systematic Reviews (Smaïl-Faugeron V et al.) of pulpotomy medicaments showed that Mineral trioxide aggregate (MTA) may be the best medicament to apply on the pulp stumps after pulpotomy of a deciduous tooth. • Formocresol is effective, but there are known concerns about toxicity. Where MTA is not accessible, Biodentine, enamel matrix derivatives (EMD), laser treatment or may be Ankaferd Blood Stopper (ABS) seem to be the second choices. • Where none of these treatments can be used, application of sodium hypochlorite (NaOCl) could be the safest option.
  52. 52. Therefore, clinically, one should take into consideration numerous factors before deciding what treatment to perform. These factors include: 1. Pulp status 2. Extent of the carious lesion 3. Age of the patient at the time of treatment 4. Goals of the treatment 5. Cost of the treatment  If the child is very young and there is a carious exposure, a pulpectomy may be the treatment of choice.  Conversely in an older child with a similar carious exposure, where no long-term maintenance is needed, a pulpotomy may be adequate with any of the materials discussed earlier. Diagnosis is the key to the success of any of these materials and techniques and should always at the forefront of our thought process when making any decision on pulp therapy.
  53. 53. FUTURE IMPLICATIONS FOR RESEARCH • Concerning pulpotomy in primary teeth, well designed long-term trials could compare MTA with Biodentine, laser therapy (diode or Er:Yag), EMD, Ankaferd Blood Stopper and may be simple NaOCl application in terms of efficacy and cost-effectiveness. • Cost-effectiveness trials from different countries could be useful to determine which medicament should be advocated in which economic setting. • Laboratory research could also be encouraged to elaborate a calcium silicate or inorganic material as safe and effective as MTA for primary tooth pulpotomy, but with a shorter setting time.
  54. 54. THANK YOU !

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