International Endodontic Journal (1998) 31, 221–226

Reparative hard tissue formation following calcium

Clinical
hydroxide application after partial pulpotomy Article
in cariously exposed pulps of permanent teeth
I . V. N O S R AT a & C . A . N O S R AT a , b
aDepartment of Neuroscience and bDepartment of Basic Oral Sciences, Division of Oral

Histology, Karolinska Institute, Stockholm, Sweden

Summary parallel to an increased general awareness of the impor-

tance of maintaining the natural dentition. In modern
In a prospective study, partial pulpotomy was performed
dentistry, prophylactic measurements are of greatest
on six permanent molars with deep carious lesions and
importance in maintaining health in oral tissues.
pulpal involvement. The bleeding pulp was irrigated
Nevertheless, teeth are still lost because of dental caries.
with normal tap water until bleeding had stopped and
Once observed, dental caries has to be treated in order to
the exposed pulp was covered with calcium hydroxide
maintain a healthy dental pulp. Carious lesions in-
followed by zinc oxide eugenol, and finally covered with
volving the pulp constitute a major hazard, and if not
a semipermanent restoration. All teeth showed hard
treated will lead to pulpal necrosis and often involve-
tissue barrier formation, both clinically and radiographi-
ment of the periradicular tissues, with pain and discom-
cally, within three months and were free from subjective
fort for the patient.
and objective symptoms through the observation period
Several studies have comprehensively reported on
(average observation period was 26 months). The
pulpal tissue response and histopathological changes in
patients also experienced the therapy positively. These
teeth with carious lesions (Seltzer et al. 1963, Reeves
findings and those of others have helped gain more
& Stanley 1966, Langeland 1987). The correlation
recognition for partial pulpotomy as a strong possible
between pulpal diagnoses and radiographic and histo-
alternative therapy when pulps are exposed by deep
pathological changes of the pulp under carious lesions of
carious lesions and a bleeding pulp is exposed during the
varying size was dealt with in the study by Seltzer et al.
excavation process. The rationale for this therapy is to
(1963). Small carious lesions only induce an increase in
remove the infected and/or inflamed pulpal areas
reparative dentine formation, whilst in moderately large
beneath the carious lesion and disintegrated tissue. A
cavities, macrophages and lymphocytes are observed
rapid and simplified procedure would allow the general
under the involved dentinal tubules of the coronal pulp.
practitioner to perform this procedure when necessary
In very deep lesions, chronic inflammatory exudate
at dental clinics, without specialist facilities under condi-
develops. When the pulp is exposed by caries, acute,
tions that avoid unnecessary contamination of the pulp.
localized inflammation and liquefaction necrosis can be
observed under the exposure site. When the pulp status
Keywords: calcium hydroxide, dental caries, partial
is accurately assessed, conservative procedures aimed at
pulpotomy.
preserving healthy vital pulp or healing the pulp
inflammation may be undertaken. The carious lesion,
Introduction whether or not it involves the pulp, must be treated. In
order to achieve success with any type of treatment, it is
Knowledge about dental caries prevention has made
necessary to remove infected, necrotic and disintegrated
substantial advancements during the past decades,
pulpal tissue (Langeland 1987).
The treatment of cariously exposed pulp may be
Correspondence: C. Nosrat, Department of Neuroscience, Karolinska
Institute, S-171 77 Stockholm, Sweden (fax: + 468-32 37 42; e-mail: different depending on the maturity of the permanent
christopher.nosrat@neuro. ki.se). tooth. Pulpectomy and obturation of the root canal

© 1998 Blackwell Science Ltd 221

222 I. V. Nosrat & C. A. Nosrat
system is usually the treatment of choice in mature teeth
(Kroncke 1970), whilst coronal pulpotomy would be the
treatment for the immature tooth to allow further
root development (Stewart et al. 1982). The cariously
exposed pulp of the immature tooth can be treated with
capping, but according to Massler (1978), the success
rate under optimal conditions is seldom greater than
40–50%. This low success rate might be due partly to
the presence of bacterial residues in the pulpal tissue
and/or inflamed pulp tissue at the capping site. Removal
of the infected/inflamed tissue may thus increase the
success rate of the treatment.
Partial pulpotomy (PP) has gained more recognition
as an alternative treatment for traumatized or cariously
exposed pulps, in deciduous or young permanent teeth.
The success rate for this procedure has been reported to
be 94–95% in fractured permanent incisors (Cvek 1978,
Klein et al. 1985), 83% in cariously exposed primary
molars (Schroder et al. 1987), and 93-94% and in
cariously exposed young permanent molars (Zilberman
et al. 1989, Mejare & Cvek 1993).
Calcium hydroxide is the compound of choice for PP
because of its hard tissue formative capacity. Direct
application of calcium hydroxide to pulp tissue causes a
coagulation necrosis in the adjacent tissue and an
inflammation in the underlying parts of the pulp. Hard
tissue forms in the vital tissue neighbouring the coagula-
tion necrosis (Nyborg 1955, Seltzer & Bender 1984,
Camp 1994). Hard tissue barrier formation in cariously
exposed young permanent teeth was assessed with
radiographs in one prior study (Zilberman et al. 1989);
the success rate was 73%. To our knowledge, in prior
studies, PP has been performed by specialists or
postgraduate students in specialist clinics (Mejare &
Cvek 1993). Based on the published high success rates
and the rationale mentioned above, it was decided that
the PP procedure could be simplified and performed by a
general practitioner at a general dental clinic.
Table 1 Review of different teeth treated by partial pulpotomy
Case Age at Sex Tooth
No. treatment
1 15 F 36
2 14 F 16
3 10 M 46
4 13 F 26
5 27 F 47
6 20 M 36
Materials and methods
Five first molars and one second molar in six different
patients – four adolescents, 10–15 years of age and two
adults, 20 and 27 years of age at the time of treatment –
(Table 1) were included in this study, based on only one
criterion: that of a bleeding exposed pulp beneath a
large carious lesion. The teeth were anaesthetized with
Citanest-Octapressin 3% (Astra, Södertälje, Sweden).
Stepwise excavation was performed prior to PP when
possible. All caries was removed (dentinal hardness
using an explorer was the criterion for excavation) using
a large round bur in a low-speed air-motor with no
water flushing. Low speed and a large round bur were
chosen to minimize the generation of heat during the
caries excavation process. When either the pulp or a
pulphorn were exposed, safety measures were taken to
avoid unnecessary contamination of the pulp (rubber
dam was applied to three teeth, and cotton wool rolls
were used on the other three). The superficial layers of
the exposed parts of the pulps (2–3 mm) were removed
with a cylindrical diamond bur in a high-speed air-
turbine under continuous water flushing. The wound
was gently flushed with normal tap water until bleeding
stopped. One method tested for achieving quicker
haemostasis was to leave calcium hydroxide (Calasept,
Scandia Dental, Knivsta, Sweden) on the wound area for
1–2 min, gently washing it away with normal tap water.
The wound was dried with a gentle stream of air and
sterile cotton pellets. The blood clot-free pulpal wound
was covered with Calasept, dried and moulded with a
sterile cotton pellet, and the excess Calasept was scraped
off. The Calasept dressing was then covered and sealed
with a soft slow-setting zinc oxide-eugenol cement and
the excess eugenol was dried off with a sterile cotton
pellet. Semipermanent restorations were performed
either with IRM (Dentsply, Konstanz, Germany) or glass
ionomer (Ketac-Fil, ESPE Dental-Medizin, Seefeld,
Pathological Radiographic Observation
symptoms pathology period (months)
– – 24
– – 28
– – 33
– – 26
– – 29
– – 14
© 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 221–226

Germany). Patients were reviewed after 1, 3, 6 and 12
months, and thereafter annually, and the teeth were
examined regarding periapical, percussion or coronal
tenderness and pathological mobility. Patients were
asked if they had experienced any discomfort or tender-
ness from the treated tooth. A sensitivity test (electric
pulp test) was also performed and a periapical or
bitewing radiograph was taken. After a period of
3 months, the teeth with IRM as a semipermanent
restoration were opened, rinsed with water and
Tubulicid Plus (Dental Therapeutics, Nacka, Sweden),
the hard tissue barrier was clinically explored gently, the
former wound area covered with glass ionomer
(Vitrebond, 3M Dental Products, St Paul, MN, USA) and
the teeth received a permanent restoration with a
dentine bonding agent (Scotch Bond Multipurpose; 3M
Dental Products, St Paul, MN, USA) using a total etch
technique and a composite resin (Z100 MP; 3M Dental
Products, St Paul, MN, USA). The teeth filled with glass
ionomer (Ketac-Fil, ESPE Dental-Medizin, Seefeld,
Germany) semipermanent restorations were opened
when they were to receive a similar permanent restora-
tion, and the hard tissue barrier was gently explored
clinically. The patients and their parents (when under
age) were informed fully about the treatment they
received.
Results
The patients had no complaints of discomfort or tender-
ness from the treated teeth, and they regarded the treat-
ment as a whole positively. Periapical, percussion or
coronal tenderness tests were negative. The mobility of
the teeth was within the normal physiological range.
The teeth were in all cases sensitive to electrical stimuli.
Some teeth were more sensitive to electrical stimuli at
the one-month recall, but this hypersensitivity disap-
peared by the next control period. The visual inspection
and gentle exploration of the wound area also demon-
strated the presence of a hard tissue barrier. In all of the
cases, existence of the barrier could also be verified
radiographically (see Figs 1–5).
Discussion
The material in the current study is limited to a small
number of permanent teeth. Nevertheless, the successful
results support the value of this alternative therapy for
cariously exposed pulps. This study confirms the high
success rate achieved by Zilberman et al. (1989) and
Mejare & Cvek (1993). It seems that removal of
© 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 221–226
Partial pulpotomy in permanent teeth 223
infected/inflamed pulpal tissue would indeed increase
the success rate of the treatment. This is in agreement
with the findings of Langeland (1987), who suggested
that ‘the success rate of any therapy depends on total
removal of all disintegrated tissue’.
Although aseptic conditions are absolutely desirable
during PP, no differences were noted regarding hard
tissue barrier formation and lack of subjective and objec-
tive symptoms in the three teeth that were treated under
a rubber dam, compared with those that were not.
Regular tap water was also used during the whole
process, in contrast to the methods of others. It appears
that the bactericidal effect of the topically applied
calcium hydroxide is enough to disinfect the wound area
if and when bacteria are introduced to the pulpal tissue
through the tap water. Others have noted that it is
important to protect the pulp against contamination,
such as bacterial leakage through the sealing material
during the healing period (Massler 1967). The short
time the pulp is exposed to the oral environment during
the PP, as in the case of those teeth being treated without
using a rubber dam, may not be significant. As
mentioned by Massler, the greatest cause of failure in
vital tooth therapy is leakage during the healing process
(Massler 1978).
Presence of vascular channels, defects and dead tracts
perforating the hard tissue barrier formed following
pulpotomy, has lead to a controversy regarding the
clinical importance of the barrier (Langeland et al. 1971,
Schroder & Granath 1972, Ulmansky et al. 1972,
Holland et al. 1979). Nevertheless, recent clinical studies
indicate good clinical reliability for the formed hard
tissue barrier (Caliskan 1994, Caliskan 1995, Mass et al.
1995, Subay et al. 1995). Existence of a hard tissue
barrier would possibly therefore be a good indication
that the healing process has been successful, at least
clinically (Massler 1972, Mjor et al. 1991). Whilst the
patients in this study will be monitored, the existence of
the hard tissue barrier is interpreted as a good result, and
changes in the results are not expected. The failure in
Zilberman’s study (Zilberman et al. 1989) occurred after
20 days, and in Mejare’s study (Mejare & Cvek 1993)
one failure occurred after 10 days and the other one was
missing the occlusal restoration. This also strengthens
the assumption that the first few postoperative months
are critical; after that, results remain constant. Matsuo
et al. (1995) suggested a 21-month postoperative
followup to be necessary after direct pulp capping of
carious-exposed pulps. Nevertheless, they found the
success rates to be similar between groups with 3-month
and 18-month follow-up periods (about 80%), and
224 I. V. Nosrat & C. A. Nosrat

Figs 1–5 The number on the radiographs corresponds to the case numbers in Table 1. Radiographs were taken before (a), after (b) performing
partial pulpotomy, and (c) at the completion of the study (see Table 1 for details). Large white arrows point to the treated teeth in (a). The areas for
hard tissue barrier formation are demarcated with black arrows in (b). Figure 1(b), 2(b), 3(b) 4(b), 5(b) are of 2 (Figs 1 and 2) 7, 1.5, and 4 months
after pulpotomy, respectively.

© 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 221–226


suggested that the decision about the outcome of the
treatment could be made after the 3-month followup,
and the permanent therapy performed.
In our study, PP was performed on two adult teeth
that had very large cavities and exposed pulps (and a
bleeding pulp was exposed during the excavation
process). Only in one other study (Mass & Zilberman
1993), has PP been reported on a fully developed maxil-
lary first molar. Despite their closed apices, the result
was satisfactory in both studies. We do not conclude that
this is the treatment of choice for adult patients.
However, if this therapy is performed and the tooth
heals, the patient benefits from not having to go through
an expensive and time- consuming treatment (i.e. root
canal treatment) which may also weaken the tooth
(Sorensen & Martinoff 1984, Howe & McKendry 1990).
The decision about the prognosis of such teeth could
be made within 3 months after the treatment, as
also suggested by Matsuo et al. (1995) in teeth treated
by direct pulp capping. Should the treatment fail, root
canal treatment remains an option in the early stages,
without jeopardizing the prognosis for the endodontic
treatment.
Conclusions
In conclusion, it is suggested that PP should become a
possible alternative therapy in young permanent teeth
with carious lesions exposing the pulp so that a bleeding
pulp is exposed during excavation. It could also be
applied to adult permanent teeth in the same condition,
although this requires further study. This method could
be performed by the general practitioner.
Acknowledgements
We thank Lena Nilsson and Minea Hulting for assisting
us in performing PP, Gunilla Bramme for her support
and Ulla Nilsson for help with some of the postoperative
controls and for her enthusiasm. The study was
supported by the Dental Faculty, Karolinska Institute,
Stockholm, Sweden and the Swedish Dental Associa-
tion.
References
CA L I S K A N MK (1994) Clinical reliability of the dentine bridge formed
after pulpotomy: a case report. International Endodontic Journal 27,
52–5.
CA L I S K A N MK (1995) Pulpotomy of carious vital teeth with periapical
involvement. International Endodontic Journal 28, 172–6.
CA M P JH (1994) Pediatric endodontic treatment. In: Cohen S & Burns
© 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 221–226
Partial pulpotomy in permanent teeth 225
RC, eds. Pathways of the Pulp, 6th edn. St Louis, MO, USA: Mosby-
Year Book, Inc, 640–641.
CV E K M (1978) A clinical report on partial pulpotomy and capping
with calcium hydroxide in permanent incisors with complicated
crown fracture. Journal of Endodontics 4, 232–7.
HO L L A N D R, D E SO U Z A V, D E ME L L O W W, NE R Y MJ, BE R N A B E PF,
OT O B O N I FI L H O JA (1979) Permeability of the hard tissue bridge
formed after pulpotomy with calcium hydroxide: a histologic study.
Journal of the American Dental Association 99, 472–5.
HO W E CA, MC K E N D R Y DJ (1990) Effect of endodontic access prepara-
tion on resistance to crown-root fracture. Journal of the American
Dental Association 121, 712–15.
KL E I N H, FU K S A, EI D E L M A N E, CH O S A C K A (1985) Partial pulpotomy
following complicated crown fracture in permanent incisors: a
clinical and radiographical study. Journal of Pedodontics 9, 142–7.
KR O N C K E A (1970) Treatment of carious lesions. International Dental
Journal 20, 338–43.
LA N G E L A N D K (1987) Tissue response to dental caries. Endodontics and
Dental Traumatology 3, 149–71.
LA N G E L A N D K, DO W D E N WE, TR O N S T A D L, LA N G E L A N D LK (1971)
Human pulpal changes of iatrogenic origin. Oral Surgery, Oral
Medicine, and Oral Pathology 32, 943–80.
MA S S E, ZI L B E R M A N U (1993) Clinical and radiographic evaluation of
partial pulpotomy in carious exposure of permanent molars.
Pediatric Dentistry 15, 257–9.
MA S S E, ZI L B E R M A N U, FU K S AB (1995) Partial pulpotomy: another
treatment option for cariously exposed permanent molars. Journal of
Dentistry for Children 62, 342–5.
MA S S L E R M (1967) Preventive endodontics: vital pulp therapy. Dental
Clinics of North America Nov, 663–73.
MA S S L E R M (1972) Therapy conductive to healing of the human pulp.
Oral Surgery, Oral Medicine, Oral Pathology 34, 122–30.
MA S S L E R M (1978) Preserving the exposed pulp. Journal of Pedodontics
2, 217–27.
MA T S U O T, NA K A N I S H I T, SH I M I Z U H, EB I S U S (1995) A clinical study of
direct pulp capping applied to carious-exposed pulps. Journal of
Endodontics 22, 551–6.
ME J A R E I, CV E K M (1993) Partial pulpotomy in young permanent teeth
with deep carious lesions. Endodontics and Dental Traumatology 9,
238–42.
MJ O R IA, DA H L E, CO X CF (1991) Healing of pulp exposures: an ultra-
structural study. Journal of Oral Pathology and Medicine 20,
496–501.
NY B O R G H (1955) Healing processes in the pulp on capping. Acta
Odontologica Scandinavica 13 (Suppl. 16)
RE H V E S R, ST A N L E Y HR (1966) The relationship of bacterial penetra-
tion and pulpal pathosis in carious teeth. Oral Surgery, Oral Medicine,
Oral Pathology 22, 59–65.
SC H R O D E R U, GR A N A T H LE (1972) Scanning electron microscopy of
hard tissue barrier following experimental pulpotomy of intact
human teeth and capping with calcium hydroxide. Odontologisk
Revy 23, 211–20.
SC H R O D E R U, SZ P R I N G E R-NO D Z A K M, JA N I C H A J, WA C I N S K A M, BU D N Y
J, ML O S E K K (1987) A one-year follow-up of partial pulpotomy and
calcium hydroxide capping in primary molars. Endodontics and
Dental Traumatology 3, 304–6.
SE L T Z E R S, BE N D E R IB (1984) Pulp capping and pulpotomy. In: Seltzer
& Bender ed. The Dental Pulp, Biologic Considerations in Dental
Procedures, 3rd edn. Philadelphia, USA: JB Lippincott Co, pp. 289–291
SE L T Z E R S, BE N D E R IS, ZI O N T Z BA (1963) The dynamics of pulp
inflammation: correlations between diagnostic data and actual
histologic findings in the pulp. Oral Surgery, Oral Medicine, Oral
Pathology 16, 846–71.
226 I. V. Nosrat & C. A. Nosrat
SO R E N S E N JA, MA R T I N O F F JT (1984) Intracoronal reinforcement and
coronal coverage: a study of endodontically treated teeth. Journal of
Prosthetic Dentistry 51, 780–84.
ST E W A R T RE, BA R B E R TK, TR O U T M A N KC, WE I SHY (1982) Pediatric
Dentistry. St. Louis, MO, USA: CV Mosby Co.
SU B A Y RK, SU Z U K I S, SU Z U K I S, KA Y A H, CO X CF (1995) Human pulp
response after partial pulpotomy with two calcium hydroxide
products. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
and Endodontics 80, 330–37.
UL M A N S K Y M, SE L A J, SE L A M (1972) Scanning electron microscopy of
calcium hydroxide induced bridges. Journal of Oral Pathology 1,
244–8.
ZI L B E R M A N U, MA S S E, SA R N A T H (1989) Partial pulpotomy in carious
permanent molars. American Journal of Dentistry 2, 147–50.
© 1998 Blackwell Science Ltd, International Endodontic Journal, 31, 221–226