Sodium hypochlorite pulpotomies in primary teeth: A retrospective assessment

Sean F.V, Michael J.K, Karin W. Pediatr Dent 2011; 4: 327-32

contents
Introduction Definition of pulpotomy Objectives Indications and contraindications Types of pulpotomy Formocresol pulpotomy and its limitations Ferric Sulfate pulpotomy Sodium hypochlorite pulpotomy
Methodology Results Discussions Limitations of the study

introduction
Primary goal of pediatric dental care

Maintaining the primary dentition until the permanent successors erupt.

Therapeutic pulpotomy
A clinical procedure to remove the infected coronal pulp tissue in order to preserve the vitality of radicular pulp1

Rationale for pulpotomy

Pulpotomy is done in a tooth where inflammation is limited only to the coronal pulp and radicular pulp is non infected. Thus, it promotes the healing and retention of vital radicular pulp within the canals.

Indications
Tooth with vital radicular pulp Pain, if present is not spontaneous or persistent Tooth which is restorable Atleast 2/3rd of the root length present No signs of periapical inflammation Hemorrhage from the amputated site is pale and easy to control

Contra-indications
Signs of pus drainage Tooth tender on percussion Mobility with locally aggressive gingivitis Calcific globules in pulp chamber Furcal or periradicular radiolucency Tooth crown non-restorable Viscous, sluggish, or absent hemorrhage at canal orifice More than 1/3rd of the root resorbed

Types of pulpotomies
Devitalization/ mummification

Single sitting

Two sitting

1. Formocresol 2. Electrosurgery 3. Lasers 1. Gysi Triopaste 2. Easlicks formaldehyde 3. Paraform devitalising paste

Preservation Regeneration

1. Glutaraldehyde 2. Ferric sulfate 1. Bone morphogenic protein, MTA

Formocresol pulpotomy

Concerns about formocresol

Ranly et al(1994)2

Local toxicity - it does not induce healing process

Systemic toxicity - possible diffusion from pulpal site into systemic circulation.3,4

Mutagenicity and carcinogenicity - In June 2004, International Agency for Research on Cancer(IARC) declared formaldehyde as carcinogenic to humans.5

Concentration of Formocresol used

Investigation by King et al6 on clinicians knowledge on correct dilution and concentration of Formocresol showed

only 2% were using correct dilution And 32% mistakenly believed that they were purchasing dilute form.

there is also concerns about uncertainty related to shelf life of diluted Formocresol.

Other alternatives
Ferric sulfate- introduces by Fei et al It has haemostatic properties. It showed higher success rate after 1year in primary teeth than formocresol7 But other studies have shown that ferric sulfate causes severe inflammatory changes, widespread necrosis and complete pulpal destruction similar to formocresol.8

Sodium Hypochlorite
Application of NaOCl selectively dissolves superficial necrotic pulp While leaving deeper healthy pulp unharmed.9 NaOCl shows not only haemostatic properties but also has effective antiseptic property. 10

Methodology
It was a retrospective study Clinical and radiographic data of patients who received 5% sodium hypochlorite pulpotomy followed upto 12 months was collected. This was evaluated and compared with published data for ferric sulfate and formocresol pulpotomy.

Inclusion criteria
5% NaOCl was the sole agent used to treat the pulp No clinical sign of periapical pathology Absence of pathological external & internal root resorption. Haemostatis easily achieved with dry cotton pellets Restoration remained intact till natural exfoliation

5% NaOCl technique
Local anesthesia given & rubber dam placed. Pulp chamber accessed with no.330 carbide bur in high speed Pulp amputated using spoon excavator or no.6 round bur in slow speed. Bleeding control by using dry cotton pellets for 5min Next, cotton pellet saturated in 5% NaOCl placed for 3035 sec. Pellete was removed, & pulp chamber filled with IRM , then restored with stainless steel crown.

Follow up
Upon completion of the pulpotomy procedure, follow up was carried out by 6 month recall examination. A standard set of criteria were designed to determine clinical and radiographic success or failure.

Clinical criteria for success

Absence of Spontaneous pain Abscess or draining fistula Mobility Gingival inflammation Indicated for extraction due to lack of intact restoration

Radiographic criteria for success

No external root resorption No internal root resorption No inter-radicular bone destruction Absence of any other abnormalities compared to contra-lateral tooth

Result
Out of 192 NaOCl pulpotomies completed on 118 children at University of Iowa, 77 children met the selection criteria. Mean age was 5 years 11months. Follow up time ranged from 3 to 21 months grouped into 2 increments( 3-12 months & 13- 21 months) Once the tooth was identified as failure it was no longer followed.

Radiographic finding
Radiographic finding N
Normal External root resorption Internal root resorption Inter-radicular bone destruction Other abnormalities
3-12 months radiographic N Success Failures Total 52 9 61 % 85 15 100

3-12 months 13-21months

52 7 4 5 0
13-21 months N 20 7 27 % 74 26 100

72 /88 10 8 8 1

20 3 4 3 1
3-21 months N 72 16 88 % 82 18 100

Clinical findings
Clinical finding
Normal Spontaneous pain Abscess/ fistula Mobility Gingival inflammation Extraction done

N
0 5 5 1 4

3-12 months 13-21months

35 0 1 1 0 1 0 4 4 1 3

125/131 90

3-12 months
Clinical Success Failures Total N 90 5 95 % 95 5 100

13-21 months
N 35 1 36 % 97 3 100

3-21 months
N 125 6 131 % 95 5 100

Discussion
Purpose of this retrospective study was to compare the clinical and radiographic success rates with previously published data on formocresol and ferric sulfate pulpotomy.

From previously published data11, 12

Clinical success rates Formocresol 84-100% Radiographic success
Formocresol 73-96% Ferric sulfate 74-97%

Ferric sulfate 89-100%

95% clinical & 82% radiographic success found in this study fall within the above range.

External root resorption was more common compared to internal root resorption usually seen in formocresol and ferrous sulfate pulpotomy. More clinical failures have occurred within first time interval(3-12months) Improper diagnosis may have attributed to these failures.

Limitations of this study

Pulpotomies were completed by multiple operators. No comparable control group was utilized, since it was a retrospective study. Zinc oxide eugenol placed directly placed over the tissue may affect the success rate.

Critical evaluation
No comparisons are made with other agents used for pulopotomy like
Bone

morphogenic protein Trioxide Aggregate(MTA)13 matrix proteins e.g. Emdogaine gel,14 Freeze dried platelet derivatives15 pulpotomy16

Mineral Enamel

Lyophilized

Electrosurgical

Histological reaction of pulp to NaOCl not discussed. Study by Haghgoo R & Abbasi F(2010) showed dentin bridge formation with mild inflammation with NaOCl as compared to formocresol17.

References
1.

American Academy of Pediatric Dentistry: Clinical Guidelines on pulp therapy for primary and young permanent teeth. Reference Manual 2008-09.Pediatr Dent 2008; 30: 171

2.

Ranly DM. Formocresol toxicity: Current Knowledge. Acta Osontol Pedatr 1994; 34: 950-5

3.

Pashley EL, Myers DR,Whitford GM. Systemic distribution of 14C-Formaldehyde from formocresol treated pulpotomy sites. J Dent Res 1980; 59: 603-10

4.

Mayers DR, Pashley DH, Whiford GM, McKinney RV. Tissue changes induced by absorption of formaldehyde from pulpotomy sites in dogs. Pediatr Dent 1983; 5: 6-8

5. International Agency for Research on Cancer. Available at: http://www.iarc.fr/en/Media-Centre/IARC-Press releases/ Archives-200604/2004/IARC 6. King SA, McWhorter AG, Seale NS. Concentration of formocresol used by Pediatric dentists in primary tooth pulpotomy. Pediatr Dent 2002; 4: 157-9 7. Wright FA, Widemar J.Pulpal therapy in primary molar teeth, A retrospective study. J Pedod 1979; 3: 195-206 8. Casas MJ, Layug MA. Two year outcome of primary molar ferric sulfate pulpotomy. Pediatr Dent 20043; 25: 97-102

9. Senia ES, Marshall FJ. The solvent action of Sodium hypochlorite on pulp tissue of extracted teeth. Oral Surg 1971; 31: 96-103 10. Ercan E, Ozekichi T. Antimicrobial activity of 5.25% of sodium hypochlorite: in vivo study. J Endod 1999; 30: 84-71 11.Loh A, OHoy P. Evidence-based assessment: Evaluation of formocresol verses ferric sulfate primary molar pulpotomy. Pediatr Dent 2004; 26: 401-9 12. Barnet S, Walker J. Comparison of ferric sulfate, formocresol in primary tooth pulpotomy. A retrospective radiographic survey. J dent child 2002; 69:44-8

13. Naik S, Hegde A.H. Mineral trioxide aggregate as pulpotomy agent in primary teeth: In vivo study. J Ind Soc Pedod Preven Dent 2005; 3:45-50 14. Jumana S, Maha M, Jeffrey D. Histological Evaluation of Enamel Matrix Derivative as a Pulpotomy Agent in Primary Teeth. Pediatr dent 2007; 29:43-55 15. RR Kalaskar, SG Damle. Comparative evaluation of lyophilized freeze dried platelet derived preparation with calcium hydr.oside. Journal of Indian Society of Pedod and Preven Dent 2004; 22: 24-9 16. Zahra B, Amir M, Maryam E. Clinical and radiographic comparison of primary molars after formocresol and electrosurgical pulpotomy: A randomized clinical trial. Indian J Dent Res 2008; 3: 23-30 17. Haghgoo, R.; Abbasi, F.. Journal of Dental Medicine, 2010, Vol. 22 Issue 1, p27-30

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