Open in a separate window According to the clinical exams, no failure was observed in the FC during the month period. In the FS, 1 tooth was considered failed because of tenderness to percussion. One tooth in the MTA was recorded as unsuccessful due to tenderness to percussion. In the CH, three teeth were observed as unsuccessful. One tooth was diagnosed as having tenderness to percussion after 18 months.
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The alternatives to formocresol are discussed and their advantages and disadvantages are evaluated. Formocresol, still a controversial material for pulpotomy: A critical literature review. It is very difficult for clinicians to diagnose the level of pulpal inflammation. The ideal pulp dressing material after pulpotomy should leave radicular pulp vital, healthy and enclosed within an odontoblastic-lined dentine chamber,  but such material has not been found till now.
An effective pulpotomy medicament should show clinical and radiographic success as well as compatibility between pulp and surrounding tissue physiologically. The reparative, biologic approach to pediatric pulp therapy is either devitalization approach of formocresol pulptomy or pulpectomy.
Formocresol was introduced to treat non-vital permanent teeth in the United States by Buckley in Formocresol has subsequently become a popular pulpotomy medicament for primary teeth. Initially, the technique involved five visits. Sweet reduced the number of visits over the years, because of economic and behavior management considerations.
Within a few years, Spedding et al. By , a single visit procedure was advocated. Formocresol is still considered a gold standard by which all new modalities are compared. The presence of para-formaldehyde causes clouding of the solution. It is therefore both a bactericidal and devitalizing agent. It kills off and converts bacteria and pulp tissue into inert compounds. It has a potent antibacterial action that justifies its use in long curative in endodontic treatment.
With formocresol as the pulptomy medicament, a zone of fixation usually is evident where the pulp is in direct contact with the medicament.
Coagulation necrosis of the tissue occurs at the amputation site and is supported by the fact that true coagulation necrosis is produced by poisons such as phenol, formaldehyde or mercuric chloride, which denatures the protein of the cells.
It may also have some effect on hyaluronidase action. Apical to this is a zone of chronic inflammation, which blends into normal tissue. An interesting finding with low concentrations of formocresol was the significant stimulation of PMN adherence. The authors postulate that stimulation of PMNs by pulpotomy medicaments may contribute to the chronic inflammatory changes seen with their use.
Initial stimulation followed by depressions is a well-known response of PMNs following activation by various stimuli. Same activation-deactivation phenomenon was observed clearly with formocresol. This may be attributed to inflammation of the residual pulp.
On the other hand, pulpotomy treatment with formocresol in monkeys has been associated with the formation of reparative dentin. Formocresol is toxic to living tissues because of the formaldehyde component. Formocresol applied to vital pulp tissue is absorbed readily into the systemic circulation and distributed throughout the body. Pharmacokinetics of formaldehyde Formaldehyde exposure occurs daily as it is present in air, water and food.
Inhaled formaldehyde appears to be readily absorbed by the upper respiratory tract, but it is not distributed throughout the body because it is rapidly metabolized. Cytosolic alcohol dehydrogenase, mitochondrial aldehyde dehydrogenase, and glutathione-dependent and glutathione-independent dehydrogenases are important enzymes in the metabolism of formaldehyde in hepatocytes, oral mucosa and nasal respiratory mucosa. Formate is further oxidized to carbon dioxide and water by the action of formyl-tetrahydrofolate synthetase.
These C-atoms deposit in 1 C-atom pool, which in turn is used in the biosynthesis of purine, pyrimidine and proteins. Histological studies demonstrate the true biological damage after formocresol treatment. Physiologically, with the vascular damage, the balance between osmotic pressure and hydrostatic pressure is disrupted in tissue.
As a result, there is absorption of inflammatory fluid insult by pulp tissue and decrease in the osmotic pressure. So hemostatic balance is re-established. If this does not occur, pressure necrosis of the pulp occurs.
In addition, lymphatic and venous vascular flow from the coronal pulp must dissipate this excess inflammatory fluid. This excess is distributed apically and to regional vascular vessels. Therefore, the local insult results in systemic distribution. Studies report that formaldehyde labeled with radioactive carbon 14C was apparently distributed among the muscle, liver, kidney, heart, spleen and lungs.
Pharmacokinetics of cresol The second active ingredient in formocresol, cresol, has received little attention in investigations of formocresol efficacy. Cresol has poor solubility, so it is assumed that it does not enter systemic circulation. This would allow deeper tissue fixation by the formaldehyde component of formocresol. Benzyl alcohol is a by-product of tricresol oxidation. Formaldehyde, a primary component in formocresol, is a hazardous substance.
Instead of preserving vital pulpal tissue, chronic inflammation and necrotic tissue were found. Pruhs et al. The allergenic and mutagenic properties of formaldehyde have been demonstrated in animal models, but not in humans.
Cysts have also been found to be associated with the pulpotomized teeth. The author suggests that a longitudinal study is needed to determine whether the injured kidney and liver cells would recover as there is only cell injury, and no evidence of onset of inflammatory reaction. This study cannot make any direct clinical implications regarding toxicity of formocresol.
The most common types of DNA damage induced by formaldehyde are clastogenic lesions, including sister chromatid exchanges SCEs , micronuclei and chromosomal aberrations, and deletions. It has been proposed that formaldehyde could induce the development of DPX at distant sites, but no convincing evidence has been obtained from in vivo experimental studies. So role of DPX in formaldehyde-induced carcinogenesis is again questionable.
Blood samples were collected from each child immediately before and 24 hours after the pulpotomy. No statistically significant differences were found between the two groups in terms of chromosomal aberrations, chromatid breaks or chromatid gaps.
Also, Zarzar et al. With a mouse lymphoma cell line, cultured human fibroblasts and a series of formocresol dilutions similar to clinical doses, these authors found that formocresol did not produce detectable DNA damage and should not be considered genotoxic.
Because large quantities of formaldehyde are produced from sealers than pulpotomy, large quantities of sealers are used. Root canal sealer remains in root canal and forms part of restoration and may lead to further release of formaldehyde. A minute quantity used in pulpotomy for few minutes that will produce distant site genotoxicity is not evidence-based. The cancer can occur after a long-term direct contact with susceptible tissues. The toxic effects on initial contact sites like ulceration, hyperplasia and squamous metaplasia may subsequently contribute to cancer.
Formaldehyde is not delivered to these distant sites. Those who have argued against the continued use of formocresol in pediatric dentistry on the basis that "formaldehyde causes cancer" have failed to recognize this very important distinction. They do not undertake the dose response analyses and possible threshold. The possibility that inhaled or ingested formaldehyde might induce cancer at sites distant from the respiratory or gastrointestinal tracts has been investigated in numerous long-term toxicity studies performed in rodents.
Considering these facts, exposure of children to the formaldehyde component of formocresol during a pulpotomy is insignificant and inconsequential. The B cells may produce antibodies to foreign pulp protein and host necrotic tissue. Further, non-specific pro-inflammatory mediators and chemotactic cytokines can illicit further immune factor responses.
One response is osteogenic activating factor that destroys bone. This has not been quantified in either children or adults. Hence, the suggestion that formocresol "sensitizes" children has not been supported. Thus, systemic distribution of glutaraldehyde is limited. Although it depresses PMN adherence at intermediate concentrations, it does not seem to stimulate PMN adherence and cause inflammatory tissue damage at low concentrations.
In this study, they compared the clinical and radiological effects of formocresol and glutaraldehyde pulpotomies in various exposed vital human primary molars.
The only limitations of glutaraldehyde are instability due to short shelf-life and it has to be freshly prepared.
In this study, the clinical and radiographic success of formocresol, glutaraldehyde and ferric sulfate were compared as a pulpotomy medicament in primary molars at 3-month intervals over 1 year.
Internal resorption was found in all the medicaments. Clinical success was higher than the radiological success. Internal resorption and external resorption were listed as failures. Resorption rate of pulpotomized teeth was similar to that of other teeth.
The canal obliteration was noted in 22 treated teeth. The relative high failure rate in this long-term follow-up indicates that clinicians should be cautious before extensively using glutaraldehyde as pulpotomy agent. The advantages of electrosurgical pulpotomy are similar.
There is good visualization and homeostasis without chemical coagulation or systemic involvement. It is less time-consuming than the formocresol approach. Electrocautery carbonizes and heat denatures pulp and bacterial contamination.
It may not be suitable if apical root resorption has occurred. Studies show that there is no significant difference between clinical and radiographic success rates for electrosurgical and formocresol pulpotomies. This is in the form of bridging at the pulpal amputation sites or along the canal walls. It indicates the present healthy vital pulp efforts to heal the area of insult. On the basis of the use of electrosurgical current intensity, there is a chance of peri-apical or furcal involvement.
Ruemping et al. This is due to the excess amount of lateral heat that can accumulate, causing necrosis and resorption. Heat transfer through accessory canals on pulpal chamber floor of molars was responsible for internal resorption.
Evaluation of formocresol, calcium hydroxide, ferric sulfate, and MTA primary molar pulpotomies
Objectives[ edit ] In primary tooth[ edit ] After the pulpotomy treatment, the radicular pulp should remain asymptomatic without any adverse clinical signs or symptoms such as sensitivity, pain, or swelling. From the radiographs, there should be absence of postoperative evidence of pathologic root resorption. There should be absence of clinical signs of infection and inflammation and no harm to the succedaneous tooth. For example, the aspects we considered are the extension of caries in the primary tooth, and the development of the succedaneous permanent tooth. The radiograph shows a primary tooth with succedaneous permanent teeth. Radiographs are needed to determine if pulpotomy can be carried out. In mature permanent tooth[ edit ] The tooth should be asymptomatic.
Rate this article! Pulpotomy and Pulpectomy in Children When the nerve or pulp tissue of a primary or permanent tooth is infected, it needs to be treated to prevent a dental abscess and loss of the tooth. The two methods of treating infected dental nerve tissue are the pulpotomy and pulpectomy. The ultimate objective of these procedures is to save the tooth, so that it will maintain the integrity and function of the dental arch.