Journal

of
Dentistry
Journal of Dentistry 28 (2000) 153–161
www.elsevier.com/locate/jdent
Review

Current and potential pulp therapies for primary and young

permanent teeth
D.M. Ranly a,*, F. Garcia-Godoy b
a
Department of Pediatric Dentistry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78284-7888, USA
b
Department of Restorative Dentistry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78284-7888, USA
Received 1 April 1999; received in revised form 25 June 1999; accepted 10 September 1999

Abstract
Objectives: This paper aims to alert the dental practitioner to the rapidly evolving therapies for treating the pulps of primary and young
permanent teeth.
Data sources: Experimental research on animals, clinical studies and case reports.
Study selection: Indirect pulp capping, direct pulp capping, pulpotomies, and pulpectomies are standard procedures for treating primary
teeth. However, direct pulp capping, heretofore not very successful, is being revisited. Based on studies in animals and clinical findings in
humans, there has been a movement in pediatric dentistry to find alternatives to formocresol and calcium hydroxide for pulpotomy therapy.
Venues range from eradication by cautery to the possibility of healing with growth factors. New studies with iodoform paste for pulpectomies
are confirming the success rates of previous publications. The new dental adhesives are being tested as agents for direct pulp capping, as well
as partial and complete pulptomy protocols.
Conclusions: More thought is being given by clinicians to preserving pulp, either through more ambitious indirect pulp therapy or partial
pulpotomy. Formocresol and calcium hydroxide pulpotomies, while still popular, may soon be challenged by other chemical treatments,
electrocautery or stimulation of reparative dentine by growth factors. Iodoform pastes are promising easier and more successful pulpectomy
therapy. Total etch direct bonding materials could soon transform direct pulp capping, as well as partial and complete pulpotomy protocols.
q 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Current pulp therapies; Potential pulp therapies; Primary teeth; Young permanent teeth

Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
2. Indirect pulp therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
2.1. The past . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
2.2. The future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
3. Direct pulp capping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
3.1. The past . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
3.2. The future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
3.2.1. Calcium hydroxide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
3.2.2. Direct bonding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
4. Pulpotomy therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
4.1. The past . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
4.2. Current alternative modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
4.3. The future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
5. Pulpectomy therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
5.1. The past . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
5.2. The future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

* Corresponding author. Tel.: 11-210-567-3553.

E-mail address: ranly@uthscsa.edu (D.M. Ranly).

0300-5712/00/$ - see front matter q 2000 Elsevier Science Ltd. All rights reserved.
PII: S0300-571 2(99)00065-2
154 D.M. Ranly, F. Garcia-Godoy / Journal of Dentistry 28 (2000) 153–161
1. Introduction
This article will review current modalities for the treat-
ment of pulps of primary and young permanent teeth and
describe new and exciting therapies that might supplant
them in the future. Over the years, pulp treatment of primary
and young permanent teeth have become so dissimilar that
their descriptions are rigidly delimited in textbooks and
review articles. Classically, for example, a pulpotomy in a
young permanent tooth is undertaken to promote apexogen-
esis; under these conditions, retention of the vitality of the
radicular pulp is imperative. In contrast, the pulpotomized
primary tooth is commonly treated with formocresol (FC), a
caustic formulation that kills tissues. However, innovations
in materials and advances in biology suggest that there may
soon be a convergence of therapies for teeth of either denti-
tion needing pulp treatment. For this reason, we will depart
from tradition and add some thoughts about young perma-
nent teeth to our discussion of pulp therapy for primary
teeth.
2. Indirect pulp therapy
Giving a pulp the opportunity to recover from the toxins
of dental caries by judiciously removing infected dentine
and isolating the remaining carious lesion from oral fluids
with a restorative material is now an accepted treatment for
badly decayed primary and permanent teeth [1,2]. Clinical
studies have shown that when a pulp is “affected”, but not
“infected”, the resultant pulpitis can be reversed [3].
Another positive response is the deposition of secondary
or reparative dentine beneath the affected zone [4]. Leksell
et al. [5] have determined that a slower, “stepwise” excava-
tion protocol in deeply carious permanent teeth resulted in
significantly fewer pulp exposures.
Indirect pulp therapy in primary teeth is probably less
common than in permanent teeth. There are probably
several reasons for this. First, pulp exposure resulting
from aggressive dentine removal is easier to resolve in
primary teeth; a pulpotomy treatment in a primary tooth is
less complex and costly than root canal therapy in a perma-
nent tooth. Secondly, the thinner dentine layer in primary
teeth necessitates a higher degree of clinical judgement
about the thickness of the remaining carious dentine and
how closely it approximates the pulp. And thirdly, behavior
management considerations perhaps tilt the choice to some-
thing perceived to be definitive, like a pulpotomy, rather
than the uncertainty of an ambitious indirect pulp cap.
2.1. The past
The pulps of primary teeth have been shown to be quite
resilient, and the few studies that have weighed the recovery
of indirectly treated primary teeth have been encouraging.
The most comprehensive evaluation was carried out at the
Eastman Dental Center in the early 1960s [6]. The
investigators estimated from a separate histologic evalua-
tion that 75% of the teeth selected for indirect pulp therapy
would have been exposed if all carious dentine were
removed. Despite the advanced state of the disease in the
majority of these teeth, only 3% of 475 teeth treated indir-
ectly exhibited frank clinical failure. Unfortunately, this
seminal study was reported only in abstract form and
never published in a peer-reviewed journal. However, it
does suggest that clinicians should not so aggressively
leap from deep caries removal into pulpotomy therapy.
Perhaps a bias toward removing all unsound dentine artifi-
cially expands the number of primary teeth that daily
receive more involved treatment. In this vein, Coll and
Foaoq [7] recently urged that the use of indirect pulp ther-
apy in primary teeth be expanded.
2.2. The future
Research has demonstrated that the capping agent used in
an indirect pulp treatment is immaterial as long as it seals
the carious dentine from oral fluids [2]. This mode of ther-
apy is essentially passive. Provided the inflammation is not
too severe, nutrient deprivation inhibits further bacterial
metabolism and the pulp is able to recover. Unfortunately,
no therapy exists for more advanced disease states.
Dentistry needs a way to actively treat carious dentine in
situ. We suggest that the direct treatment of diseased dentine
with agents that neutralize toxins, stifle microbes and
mollify pulp inflammation is an objective second only to
decay prevention in worthiness. To be able to arrest pulp
pathology without reverting to pulp removal supercedes all
of the other modalities we will discuss in this article.
Although Massler felt in 1958 [8] that sterilization of deep
carious dentine as an alternative to pulp exposure was nearly
realized, events since have not proved him prophetic. We
hope that researchers in the 21st century will address the
most important shortcoming of dentistry—our inability to
promote healing of the infected pulp.
3. Direct pulp capping
Direct pulp capping of teeth exposed during caries
removal has not been viewed as mainstream treatment for
either primary or permanent teeth [9]. Stanley and Cox are
at the forefront of a movement to disprove the axiom “the
exposed pulp is a doomed organ”. They wish us to consider
pulp as a tissue with many more regenerative powers than
has been traditionally held.
3.1. The past
The introduction of inorganic calcium hydroxide (CH) to
dentistry spawned a biologic revolution [10]. Because CH
can elicit dentine bridge formation when applied to pulp
tissue, pulp capping as a modality became feasible. At the
same time, the very properties of CH, which provoke
 D.M. Ranly, F. Garcia-Godoy / Journal of Dentistry 28 (2000) 153–161
healing, can also elicit untoward reactions [11]. Attitudes of
clinicians in response to these side effects, justified or not,
have stalled the acceptance of CH as a universal inductor of
reparative bridge formation. This is particularly true as it
applies to pulp capping in primary teeth.
When pulps of primary teeth are minutely exposed during
caries removal—or even when they are exposed iatrogeni-
cally or by trauma—most dentist opt for a pulpotomy. The
reluctance to cap the pulp with CH under any circumstance
is the fear that it will promote internal resorption. While it is
true that CH pulpotomy has fallen from favor because of the
high incidence of internal resorption [12], there is no
evidence, of which we are aware, that demonstrates that
the application of CH to coronal pulp will automatically
elicit a similar response. It is our opinion that many primary
teeth are needlessly pulpotomized because of a generaliza-
tion.
There are two conditions that might favor internal resorp-
tion in pulpotomies but not in pulp caps: geometry and
inflammation. First, the ratio of surface area of tissue in
contact with CH relative to the remaining tissue volume is
considerably higher in the case of a pulpotomy than in a
pulp capping. If, by itself, CH can elicit side effects, it is
more likely to do it in narrow pulp canals. Second, pulpo-
tomies are performed on carious teeth with inflamed pulps,
whereas, in pulp capping, this may not be the situation. The
negative actions of CH may reflect as much its inability to
quell inflammation, as its ability to stimulate on its own.
This thesis seems to be borne out by the findings of
Sawusch [13]. In a pulp capping study using inorganic CH
and Dycal he reported a failure rate of 13% and 7%, respec-
tively, in teeth where radiographic evidence indicated ques-
tionable carious exposures, but a failure rate of 29% and
41% when teeth were classified as definitely exposed. Prior
to capping, the exposure was debrided with either saline or
eugenol. We conclude from this and other studies that extant
inflammation amplifies CH failures, and until it can be
moderated, direct pulp capping of primary teeth with CH
should be restricted to mechanical exposures.
3.2. The future
3.2.1. Calcium hydroxide
CH may have a rebirth in the form of hard-setting or light
cured products. According to Stanley [9], inorganic CH,
with its very basic pH, creates zones of obliteration and
coagulation necrosis superficial to the deeper zones where
reparative dentine ultimately begins. Thus in the process of
initiating repair, CH injures the pulp. The lower pH CH
products such as Dycal may avoid major tissue damage
and stimulate reparative dentine more directly. In studies
on non-inflamed primary canines, Turner et al [14] found
that pulps directly capped with inorganic CH differed from
those treated with hard-setting products by the amount of
necrosis and thickness of the dentine bridge. The cements
were less injurious and their bridges were thinner. This
155
meant that less of the pulp was encroached upon by new
dentine. These investigators found no evidence of internal
resorption within the study period of 63 days. In our estima-
tion, the use of CH cements on non-inflamed primary pulps
is an acceptable treatment.
For those willing to try CH cements on cariously exposed
primary teeth, the prospects for success would probably
benefit from the following protocol: more extensive debri-
dement and absolute hemostasis. The latter might be
prompted with the use of an astringent, as recommended
by Stanley [9]. The former might be obtained with sodium
hypochlorite as an irrigant (as suggested by Cox for total
etch bonding pulp treatment [15]) or by frank tissue excision
(as suggested by Cvek [16] for the treatment of traumatic
pulp exposures). Mechanical removal of infected tissue may
be the only means currently at our disposal, since results of
attempts [17,18] to quell experimental pulp inflammation,
while provocative, have not been definitive.
3.2.2. Direct bonding
Recent advances in total etch direct bonding have evoked
an interest in applications for pulp therapy. The key compo-
nent of the system is the multipurpose dentine bonding
adhesive, which, when it infiltrates into acid etched dentine,
forms an impermeable hybrid layer. Several groups have
investigated the responses of non-exposed and exposed
pulp to dentine bonding systems and have proposed them
for pulp capping [15,19,20]. Based on preliminary findings,
Kopel [21] strongly advocated their adoption as capping
agents for primary teeth.
The attractiveness of these systems is that a polymeric
film can be layered over an exposure site without displacing
pulp tissue and onto surrounding dentine where it permeates
the tubules. Furthermore, these adhesives are hydrophilic,
meaning that dentine and pulp need not be dehydrated prior
to their application. The adhesive film is cured by light, and
then acts as a barrier as a composite resin is gently spread
over the pulp onto the surrounding dentine. After the
composite resin is cured, the exposure is sealed against
microleakage.
Provided dentine adhesives exhibit favorable biologic
properties, the advantages of this system are obvious.
First, the primer and dentine adhesive work in a wet envir-
onment, a property that must surely reduce the potential for
dehydration injury. And secondly, these hydrophilic adhe-
sives apparently flow well over the wet pulp and form a
continuous seal onto the dentine. And thirdly, this prelimin-
ary covering helps prevent the displacement of composite
into the pulp chamber. However, despite these theoretical
attributes, solid evidence is necessary before they can be
recommended as pulp capping agents. As a prerequisite,
the dental adhesive, or the primer, must not be cytotoxic;
at a minimum, they must be at least neutral with respect to
living cells. And as a bonus, the formulation should be
antimicrobial and have an ability to stimulate reparative
dentine like CH.
156 D.M. Ranly, F. Garcia-Godoy / Journal of Dentistry 28 (2000) 153–161
Whether dentine adhesives are toxic, neutral or inductive
of reparative dentine is important in the light of previous
findings. Several investigators have theorized that pulp irri-
tation following placement of a restoration is most often the
result of marginal microleakage [22,23] and not the materi-
als per se. Substantiating these earlier conclusions, Cox et
al. [24] have demonstrated that pulps of primates exposed
directly to a variety of restorative materials respond favor-
ably, provided that there is no microleakage. Furthermore,
silica cement, zinc phosphate cement, a hard-setting CH
cement and a composite, all initiated dentine bridging.
Only amalgam failed to stimulate reparative dentine,
although inflammation abated with time. These investiga-
tors concluded that pulp responds favorably to capping with
any number of materials, provided bacterial contamination
is prevented. They also speculated that some degree of irri-
tation is necessary to incite dentine formation, something
that amalgam did not provide. The failure of dentine adhe-
sive to stimulate dentine would not necessarily rule it out as
a capping agent, but one might question the long-term
compatibility of pulp cells against an artificial surface.
Because acid in some form is used in dentine adhesive
systems to remove the smear layer and open dentine tubules,
pulp tissue must tolerate an acidic environment in order for
direct capping to succeed. Snuggs et al. [25] have provided
evidence to suggest that pulp does indeed have a high toler-
ance for acidic conditions. When monkey teeth were
directly capped with silicate or zinc phosphate cements
and sealed with ZOE to exclude bacteria, an inherent heal-
ing capacity of cell reorganization and dentineal bridging
was observed.
An overall statement about the antibacterial properties of
dentine adhesives is impossible at this time. The current
products variably use cleaners, primers, sealers and etchants
preparatory to adhesives. Any or all could be antibacterial.
However, an in vitro study by Emilson and Bergenholtz [26]
found that antibacterial properties were exhibited only by
cleaners, primers and etchants. Of the four systems they
evaluated, none of the cured adhesives demonstrated anti-
bacterial effects. This study suggests that the antibacterial
properties of dentine adhesives will be short-term, unless
efforts are made to incorporate releasable antibacterials.
Some of the biologic properties of dentine adhesives are
currently being examined in vivo. From preliminary animal
and human studies evaluated by clinical criteria, the accep-
tance of direct bonding by the pulp has been encouraging.
Unfortunately, the histologic response of pulp to these mate-
rials is less clear-cut.
Clinical studies on the use of dental adhesives as direct
pulp capping agents in human permanent [20,27] and
primary teeth [28] have demonstrated short-term success.
Heitmann and Unterbrink [27] reported no symptoms in
all eight teeth they treated; Kashiwada and Takagi [20]
had four failures out of 64 direct capping procedures; and
Araujo et al [28] observed no adverse clinical or radio-
graphic findings in 15 primary molars. While the overall
results are encouraging, it must be emphasized that these
studies were relatively short-term.
Findings from histologic studies in primates have gener-
ated controversy [15,29–32], while those in humans have
revealed some significant deficits [33–35].
In the majority of studies with primates, exposed pulps
capped using the total etch procedure and dentine bonding
agents underwent a typical healing cascade which culmi-
nated in some degree of dentine deposition [15,29–31,36].
However, one study reported disastrous results with these
agents, and the authors stated flatly that their use in vital
pulp capping is contraindicated [32]. Unfortunately, the
same protocols and materials were not used in all studies,
so that any sweeping conclusion about the state of the art is
far too premature.
Histologic studies of human teeth capped directly with
dentine bonding agents suggest that they possess less recup-
erative powers than those of primates. Mechanically
exposed primary teeth demonstrated microabscesses adja-
cent to the exposure site, with no dentine bridging in any
specimens [34]. Pulps of sound premolars, exposed and
capped with an adhesive system, exhibited a persistent
mild inflammation and no evidence of repair after several
months [33]. In another study on sound premolars, resin
particulates were observed in the pulp [35]. They appeared
to have triggered a foreign body response and prevented
calcific bridge formation. Inokoshi et al. [19] found chronic
ulcerative pulpitis in the teeth they capped. In contrast,
Katoh [37] found pulp irritation to be minimal, with
evidence of dentine bridging in 95% of cases.
The discrepancies between species and laboratories may
be related to protocols, materials or both. Cox, who reports
favorable results in primates, contends that hemostasis is the
crucial step, and that it is obtained best with sodium hypo-
chlorite (NaOCl) [15]. This solution dissolves tissue and has
been evaluated as an agent for pulp amputation [38–40].
Therefore, its attributes, other than hemorrhage control,
may be its ability to purge bacteria, superficial inflamed
tissue and dentine debris from the exposure site.
Recently, reports for several studies have been
controversial, with some showing severe responses [41],
others reporting minimal to moderate reactions [42], while
others observed excellent results including dentine bridge
after etching and covering the pulp with dentine adhesives
[43–46]. Another study reported that capping the pulp with
a polyacid-modified resin-based composite (compomer)
also produced satisfactory pulpal response [47]. From a
clinical and radiographic standpoint, dentine adhesives
used as a direct pulp capping material have also been
reported as successful [48].
Because of these controversial results, at present we
cannot recommend dentine adhesives for direct pulp
capping until more favorable human studies have been
reported. One of the shortcomings of current testing in
monkeys and humans is the shotgun approach to testing
products. Because components and protocols are so
 D.M. Ranly, F. Garcia-Godoy / Journal of Dentistry 28 (2000) 153–161
different, negative findings do not necessarily condemn
dental adhesives in general as direct capping agents. Before
more clinical trials are undertaken, we suggest that the most
biologically acceptable dental materials and ancillary agents
be determined first in vitro. As a step in that direction, a
recent study determined that the components of three one-
bottle adhesive systems were highly cytopathic to an odon-
toblast cell line [49]. Such assays can eliminate less promis-
ing candidates, and in this way, the number of variables in
clinical trials can be minimized and the findings more easily
interpreted.
4. Pulpotomy therapy
4.1. The past
FC has long been the standard pulpotomy agent in
primary teeth, and CH the standard for immature permanent
teeth [50]. While the rationale for the use of FC is not clear,
it presumably fixes affected and infected radicular tissue so
that a chronic inflammation replaces an acute inflammation.
It is the intent of the fomocresol pulpotomy that pulp
remains in a metastable condition until the tooth is exfo-
liated. Even under this dubious rationale, the success rates
with FC have been clinically acceptable.
In recent years, voices have been raised against FC
because of its toxicity [51], and it has been banned in at
least one country. However, the FC pulpotomy technique is
still being taught in virtually every dental school in the
United States [52] and in many other countries. For better
or for worse, FC promises to be with us for some time.
CH is considerably less harsh on pulp tissue than FC
[53,54]. Under optimal conditions it can stimulate a dentine
bridge, but it is not ordinarily used for that purpose in a
pulpotomy procedure on permanent teeth. Instead, it serves
to maintain the vitality of radicular tissue until apexogenesis
is complete. Once the apex is closed, a root canal is
performed. The practice of obturating the canals immedi-
ately upon root completion is based on anecdotal evidence
that CH will precipitate dystrophic calcification in the
canals and prevent endodontics later, if it should be needed.
The negative impact of CH in a classic pulpotomy, if real,
may result from too little pulp tissue confined with too much
chemical. When partial pulpotomies were performed, with
the objective of removing only infected tissue, dentine brid-
ging was stimulated in the coronal area, and the canals were
free of dystrophic calcification [55].
For a time, CH was touted as an alternative to FC for
pulpotomies in primary teeth [56], but too often it was
observed to stimulate internal resorption rather than dentine
formation [12], and its popularity has waned. The observed
resorption has been ascribed to a blood clot intervening
between the chemical and pulp tissue and not to CH per
se. However, even with stringent conditions taken to avoid
157
clotting, the internal resorption of primary teeth was still
observed [57].
In an attempt to minimize the cutting of major pulp
vessels and resultant blood clots, Schroeder et al. [58]
performed partial pulptomies on primary teeth. Internal
resorption was apparently reduced, but the overall success
rate was only about 80%. This rate of success is certainly no
better than that reported for FC, and the procedure is more
demanding. It does, however, eliminate the use of a toxic
agent.
4.2. Current alternative modalities
The failure of CH and the desire to find a drug less toxic
than FC initiated an extensive search for alternative pulpot-
omy agents in the 1970s [51]. The efforts of a considerable
number of investigators have culminated in a spectrum of
ways to pulpotomize primary teeth.
One of the early attempts to reduce FC toxicity was to
lower its concentration. Based on preliminary in vitro
analyses [59], a 1/5 dilution was selected and subjected to
clinical trials [60]. It was found to be as effective as full-
strength preparations. In an attempt to further reduce FC
toxicity, glutaraldehyde (GA) was advocated as an alterna-
tive to formaldehyde because it is a true cross-linking fixa-
tive [61]. It also demonstrates less antigenicity, self-limiting
penetration, and reduced toxicity [62]. Clinical trials in
primary and permanent teeth have been promising [63–
65]. The rationale for GA is the establishment of a biocom-
patible seal over the amputated pulp, which separates it
from the adjacent base.
Ferric sulfate (FS) has gained support as a pulpotomy
agent in primary teeth although the original rationale for
its introduction has been forgotten. It was first investigated
as a hemostatic agent preparatory to the placement of CH
over amputated pulp [66]. The intent was to determine if
hemorrhage control improved the efficacy of CH, since
earlier investigators speculated that the failures of CH
were due to the persistence of blood clots between it and
pulp tissue [57]. For unknown reasons, subsequent studies
have evaluated FS alone [67,68], and not as an adjunct to
CH, and its success rate has approximated that of FC. From
what we know, it does not stimulate reparative dentine, and
it does not improve pulp responses compared to FC [69,70].
Perhaps the mechanisms of action of FS are to prevent clot
formation—and its attendant inflammatory cascade—and
to precipitate a protein barrier at the amputation site.
A widely divergent approach to pulpotomies in primary
teeth has also evolved in recent years. Instead of devitaliz-
ing pulp with a chemical, electrocautery is used to burn and
coagulate radicular tissue. A pulp so treated displays the
remnants of a burn—coagulated protein, necrosis and
inflammation [71]. Clinically, the success rate of electro-
cautery has been reported high [72], similar to FC [73],
and very poor [74].
Lasers have been suggested as a more sophisticated
158 D.M. Ranly, F. Garcia-Godoy / Journal of Dentistry 28 (2000) 153–161
instrument for devitalizing pulps, but in a recent studies on
human canines, the histologic pictures of FC and laser-trea-
ted pulps were not significantly different, and the pretext for
further laser research was only the avoidance of FC [75].
Certainly in the pulps of dogs, irradiation with laser caused
carbonization, necrosis, inflammation, edema and hemor-
rhage—with little evidence of repair [76].
As mentioned previously, Stanley is a strong propo-
nent of CH for pulp capping and pulpotomies [9]. He
avers that the negative side effects of inorganic CH
have been eliminated in the lower pH hard-setting
cements. He suggests that the internal resorption and
the dystrophic calcification seen in pulpotomized
primary and permanent teeth, respectively, are less
likely to occur with commercial CH preparations.
However, these claims have not been adequately
substantiated. Only one small, short-term clinical study
using a CH cement in primary teeth has been reported
[77]. Because CH does have favorable properties,
perhaps pulpotomies with hard-setting cements should
be revisited.
4.3. The future
Interestingly, in the future, pulpotomies for primary and
permanent teeth may be handled in exactly the same way.
Advances in material and biological sciences offer us at
least two therapeutic approaches, either of which could
become common to both dentitions. From material sciences
we have seen the development of dentine adhesives, which
we have already discussed in another context. From biolo-
gical research we have seen an explosion of knowledge
about growth factors that induce bone and dentine. The
potential to acquire pulp therapeutics from these burgeoning
fields is worth discussing.
If dentine adhesives can be developed for direct pulp
capping, then there is no reason that they cannot be used
for pulpotomies. In fact, the chances for success should
improve in the latter, simply because the purpose of pulp
amputation is to reach a level of healthy pulp. With diseased
tissue removed, the response of the remaining pulp should
be more favorable. Although we do not know of any studies
in this area, it does seem a logical progression of the
technology. Just as for direct capping, we urge a stepwise
approach in evaluating dentine adhesive for pulpotomies.
Even more exciting than dental adhesives are the recent
advances in the field of bone morphogenetic proteins
(BMPs). The discovery of this family of growth factors
sprang from the observation by Urist [78] that deminera-
lized bone matrix could stimulate new bone formation when
implanted in ectopic sites such as muscle. Urist concluded
rightly that bone matrix contains a factor capable of
autoinduction, and he named it bone morphogenetic
protein. Because these factors exist in such minute
quantities, it was not until the development of molecular
biology that their physiologic roles could be explored.
We have learned that there is a family of proteins that has
bone inductive properties, and BMP is a generic term for
this family.
BMPs are members of a highly conserved family of signal
molecules that have been recycled during evolution to
mediate interactions between tissues during embryonic
development. For this reason, BMP is a misleading nomen-
clature in that it implies a single gene product responsible
for bone formation, when, instead, each probably accounts
for multifunctional gene products expressed throughout
ontogeny. Because the osteogenic role was discovered in
mammals and the embryonic role in phylogenetically
lower organisms, a confusing multiplicity of names has
arisen.
To establish some order to the terminology, the BMP
family of proteins has been renamed the DVR(decapenta-
plegic-Vg-related) family, based on the first two members to
be identified—Drosophila decapentaplegic and Xenopus
Vg1. Table 1 of Ref. [79] lists the family by DVR, BMP
and osteogenic protein (OP) names. The DVR family
belongs to the much larger transforming growth factor b
(TGF-b) superfamily.
From our yet inchoate knowledge, the implications of
BMPs to dentistry are nonetheless enormous. The availabil-
ity of commercial BMPs to predictably induce bone forma-
tion in orthopedic, oral and periodontal surgery will be
momentous [80]. Shortly after his original report, Urist
[81] observed that demineralized dentine also had inductive
properties, and since then it has been demonstrated that
BMP from both bone and dentine will promote dentineogen-
esis [82–84]. Thus, the implications for pulp therapy are
immense. If BMPs can be packaged in a form suitable for
clinical usage, dentists might at last have a true biological
pulp capping and pulpotomy agent. Table 2 of Ref. [79] lists
the known BMPs and their actions when implanted into
receptive tissue. Osteogenic potential was evaluated using
subcutaneous implants in rats; pulp responses were deter-
mined in dog and primate teeth.
The data from the several pulp studies summarized in
Table 2 of Ref. [79] suggest that a number of BMPs are
capable of inducing reparative dentine. This should not be
surprising since BMPs probably play a regulatory role in
pulp cell differentiation [85–87] and human tooth
morphogenesis [88]. In addition, receptors for them have
been identified in human dental pulp [89].
As expected, demineralized bone and dentine have
proved inductive of the same tissues, but more impor-
tantly, recombinant human BMPs have also been shown
to be effective. Progress from crude preparations to pure
protein has been rapid. Fadavi et al. [90] dressed pulpo-
tomized monkey teeth with freeze-dried bone and Naka-
shima [83] used dentine matrix to treat amputated pulps
of dogs. Narrowing the focus further, crude BMP
prepared from bovine bone was used to treat pulpto-
mized dog teeth [82,91,92]. The latter studies reported
the sequential induction of osteo- and tubular dentine.
 D.M. Ranly, F. Garcia-Godoy / Journal of Dentistry 28 (2000) 153–161
The preparations of BMP were ill-defined; presumably
they included BMP-2, BMP-3, and BMP-7 (OP1).
While BMP preparations from bovine or human bone
would not be feasible for human teeth, molecular biology
techniques have fortunately circumvented the necessity of
isolating BMP from bone. Recombinant human BMP-2,
BMP-4 and OP-1 have been purified and characterized,
and all have shown dentine inductive potential in host
teeth [93,94]. Most importantly, the response to hOP-1 in
primate teeth was dose dependent, a property never before
attributed to a pulp agent. Equally exciting is the finding that
reparative dentine can be stimulated transdentine by OP-1 in
a dose dependent manner. The demonstration that reparative
dentine can be induced by direct or indirect contact with a
biologic agent—and its thickness determined by dose—
elevates pulp therapy to a new level. Clearly, this regenera-
tive approach, if successful, would transcend all other
modalities.
We are now entering an era when commercially available
recombinant human BMPs will be available for experimen-
tation and clinical trials. Several authors have encouraged
the evaluation of these factors as new modalities for pulp
therapy [62,95,96]. It is exciting to think that someday we
might treat a pulpotomized primary or permanent molar
with growth factors and predictably induce sound dentine
bridges, leaving the radicular tissue completely enclosed in
healthy dentine. Primary teeth would be free of inflamma-
tion and could exfoliate normally; the need for root canal
therapy in permanent teeth would be eliminated.
5. Pulpectomy therapy
5.1. The past
Endodontic therapy for primary teeth has long been advo-
cated when the criteria for a classical pulpotomy treatment
cannot be met [97]. The procedure involves debridement
and enlargement of the canals with graded files prior to
obturation with ZOE [98]. The latter should be unfilled so
that they will resorb in synchrony with the roots. Unfortu-
nately, even pure ZOE cement is resistant to foreign body
giant cells, and very often fragments of cement can be seen
at the site of a pulpectomized tooth that has exfoliated [99].
In addition to its bioincompatibility, ZOE is not particu-
larly antibacterial once it has set. This is a glaring deficit
because it has been shown that the root canals of primary
teeth are fenestrated and torturous [100], and it is unlikely
that they could ever be filed and obturated in the traditional
sense. What is needed is a filling material that is resorbable
and has long lasting antibacterial properties. Iodoform
pastes seem to fulfill these requirements.
5.2. The future
Rifkin first demonstrated that a commercial preparation,
Kri paste, which was originally developed for root canal
159
therapy in permanent teeth, might be adapted to the needs
of primary teeth [101,102]. Garcia-Godoy [103], confirmed
the efficacy of this preparation. Primary teeth with signifi-
cant infection, furcal involvement and mobility were routi-
nely salvaged and retained. The rate of healing was notable.
The material is clinically forgiving. After the canals are
prepared, the paste can be easily injected into them with a
CR syringe. Filling to the apices is unusual and apparently
unnecessary. What is crucial is the placement of the paste
over the floor of the chamber, in order to ensure that the
auxiliary canals traversing to the furcation are medicated.
Should the paste be expressed into extradental spaces, it is
resorbed within a week or two. Evidence of significant heal-
ing occurs within weeks.
A newer preparation, Vitapex, a mixture of iodoform and
CH, is now available in North America. Preliminary studies
suggest that it, too, is efficacious for pulpectomies in
primary teeth [104].
6. Conclusion
The old standbys of pulp therapy, FC, CH, and ZOE are
being superceded by new agents. On the horizon are biolo-
gics and newer materials that may completely transform our
whole philosophy of treatment. We seem to be on the brink
of an era when a diseased pulp can be a saved pulp.
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