An Update on Newer Pulpotomy Agents in Primary Teeth: A Literature Review

Abstract

Primary molars with asymptomatic reversible pulpitis are commonly treated by pulpotomy procedure. Different pulpotomy materials used so far for pulpotomy that have been mentioned in the literature have been included in this article. This literature review includes all medicaments including natural alternatives. Many significant medicaments with their success rates have been mentioned in this paper. To increase the therapeutic success of pulpotomy procedure, it is necessary to identify a novel effective and preferably natural pulpotomy medicament.

INTRODUCTION

Dental caries, a progressive bacterial damage to teeth brings about loss of tooth minerals that starts on the external surface of the tooth and can advance through the dentin to the pulp, eventually trading off essentialness of the tooth.[1] Vital pulp treatment has been progressively considered as a negligibly obtrusive methodology for the administration of teeth with excited pulps contrasted with the regular methodology of root canal treatment.[2] Pulpotomy is one of the vital pulp therapy techniques used for preserving decayed primary teeth with extensive caries but without evidence of radicular pathology, which if not performed will lead ultimately in extraction. The ideal qualities of any pulpotomy material should be bactericidal, innocuous to pulp and encompassing structures, advance healing of remaining radicular pulp without meddling with the physiologic root resorption and ought not have any toxicity.[3] Among, the pulpotomy medicaments, formocresol (FC) remains the gold standard of all the medicaments reported in the literature. Despite the high success rate, the use of FC has raised various concerns that includes its mutagenic, carcinogenic, and allergenic potentials.[4] The objective of this literature review is to determine the types of material used in pulpotomy.

FORMOCRESOL

In 1930, Sweet introduced the FC pulpotomy technique. FC has successively become a popular pulpotomy medicament for primary teeth. It acts as both bactericidal and devitalizing agent.[1] El Meligy et al. at 12 months' follow-up found 100% clinical and 98.1% radiographic success rate with FC pulpotomy.[5] Concerns have been raised about the toxicity and potential carcinogenicity of FC in humans. Studies have demonstrated FC treated teeth shows systemic uptake of FC and produce defects in succedaneous teeth.[6]

CALCIUM HYDROXIDE

In 1930, Herman presented calcium hydroxide as Calxyl, which was utilized for pulp capping, was likewise pursued for pulpotomy.[7] Calcium hydroxide pulpotomy in deciduous teeth commonly causes internal resorption.[8] Success rate of calcium hydroxide pulpotomy in primary teeth is comparatively less to that observed in permanent dentition.[9] However, calcium hydroxide is the material of choice for direct pulp capping (DPC) and Pulpotomy techniques in permanent teeth (Mc Donald 1996).

GLUTARALDEHYDE

S'Gravenmade in 1975 used glutaraldehyde and furthermore, expressed that glutaraldehyde can possibly supplant FC. Two percent buffered glutaraldehyde was found to be least effective as a pulpotomy agent when compared with ferric sulfate and mineral trioxide aggregate (MTA).[10,11] Internal resorption has been found as inadequate fixation leaves a deficient barrier to subbase irritation.[12]

ZINC OXIDE EUGENOL

Zinc oxide eugenol (ZOE) was the first in the field to be used for the preservation process. ZOE provides an effective seal thereby limiting microleakage and recurrent infection. James E. Berger 1965, observed active inflammatory reactions in all the teeth treated with ZOE as a pulpotomy medicament. The reactions varied from simple chronic to acute suppurative pulpitis. FC pulpotomy when performed by incorporating FC in the zinc oxide-eugenol subbase showed 99% clinical success rate.[13]

MINERAL TRIOXIDE AGGREGATE

MTA is novel endodontic cement that was at first presented as material for root perforation repair by Mohmond Torabinajad Atlomalinda University in 1993. The use of MTA was recommended by the American Academy of Pediatric Dentistry for pulpotomies of primary teeth with typical pulps or reversible pulpitis when caries expulsion brings about pulp presentation or after a traumatic pulp exposure.[14] The presentation of MTA for pulpotomy defeated the downsides of FC, for example, its likely harmfulness, harsh nature, and tissue disturbance and irritation on contact with delicate tissue.[15] Farsi et al. found that pulpotomized essential molars treated with MTA had altogether more accomplishment than those treated with FC.[16]

BIODENTINE

Biodentine became commercially available in 2009 (septodont) and that was especially designed as a “dentine replacement” material.[17] Various studies have reported a high success rate of biodentine used as a pulpotomy medicament, stating it as a positive and promising option for the current pulpotomy medicaments.[18] Nasseh et al. evaluated outcomes of biodentine pulpotomies in deciduous molars with physiologic root resorption and found 100% clinical and radiographic success rates at 6 and 12 months' follow-up.[19]

CALCIUM ENRICHED MIXTURE

Calcium-enriched mixture (CEM) cement, a novel endodontic material also known as new endodontic cement was introduced to dentistry by Asgary et al. in 2006. Nosrat in 2012 compared MTA with CEM pulpotomy, result showed 100% clinical and radiographical success rate for both the groups at 6 and 12 months' follow-up.[20]

PORTLAND CEMENT

In 1824, Joseph Aspdin licensed an item purported Portland cement which was gotten from the calcination of the combination of limestones coming from Portland in England and silicon-argillaceous material.[21] Portland cement has procured interest as an alternate to MTA.[12] The number of studies used Portland cement as material of reference and showed that the only difference between Portland cement and MTA material is the bismuth oxide.[22] For the reason of its low cost, it is reasonable to consider port land cement as a possible substitute for MTA.[12]

SODIUM HYPOCHLORITE

Sodium hypochlorite most popular endodontic irrigants seems to be an acceptable alternative for FC owing to its antimicrobial property and hemostatic agent. Kola SR (2019) showed promising results of 5% NaOCl as a primary molar pulpotomy agent.[23]

HYDROXYAPATITE

The recently developed interest for nanotechnology in many fields, is producing interesting and imminent applications in dentistry for nanohydroxyapatite, which presents crystals ranging in size between 50 and 1000 nm.[24] Nanohydroxyapatite was used as pulpotomy and DPC agent in pig teeth by Shayegan et al.[25] Adlakha et al. in his study found 100% clinical and 80.33% radiographic success rate with hydroxyapatite crystal pulpotomy in deciduous molars.[26]

BIOACTIVE GLASS

Bioactive glasses were first developed by Hench et al, which represents a group of reactive materials that are able to bond to mineralized bone tissue in physiological environment.[27] Haghgoo and Ahmadvand conducted a study to evaluate the pulpal response of of primary teeth after DPC with MTA and bioactive glass (BAG), result showed no significant difference between the two groups.[28] A major limitation of BAG is its biodegradable nature that depends on glass composition and environment pH. A highly reactive bioglass composition will degrade at a faster rate.[29]

PLATELET CONCENTRATE

Platelet-rich fibrin (PRF) was first developed in France by Choukroun et al. in 2001. Mostafa AA (2018) performed pulpotomy using PRF and showed clinical success rate of 89.5% and radiographic success rate of 78.9%, and concluded that PRF can be used as alterantive pulpotomy agent to FC.[30]

THERACAL LIGHT-CURED

In 2011, a light curable resin-modified tricalcium silicate (theracal light-cured) was introduced by Bisco Inc., Schamburg, Chicago, IL, USA.[31] When the chemical and physical properties of theracal were compared to MTA and calcium hydroxide, theracal displayed significantly higher calcium releasing ability and lower solubility than either MTA and calcium hydroxide.[32] Bakhtiar et al. compared theracal with biodentine and pro root MTA to see human pulp responses to partial pulpotomy and concluded overall, biodentine and MTA performed better than theracal when used as partial pulpotomy agent.[33]

PROPOLIS

Propolis, a natural resinous and balsamic substance, which in dentistry is used as mouth rinses, anti-cariogenic, in DPC, pulpotomy, endodontic therapy, root canal irrigant, intracanal medicament, as a storage media for avulsed tooth.[34] Carmen et al., (2007) compared the effectiveness of 10% propolis tincture and formocresol pulpotomy in primary in primary molars and showed that 10% propalis tincture was effective as FC.[35] Allergic reaction to propolis may be seen as contact cheilitis, contact stomatitis, perioral eczema, labial edema, oral pain, peeling of lips, and dyspnea.[34]

ENAMEL MATRIX DERIVATIVE

Enamel matrix derivative (EMD, Emdogain) has been advocated for the regeneration of dental tissues.[36] Emdogain gel (Straumann, Switzerland) has been successfully employed for pulpotomies in noninfected teeth in animal studies.[37] Yildirim et al. have suggested that clinical and radiographic success rate of EMD was similar to MTA, Portland cement and formocresol.[36]

CHLORHEXIDINE POLYMER

Chlorhexidine is a popular and proven disinfectant to get rid of broad spectrum of oral microbiota. Chlorhexidine is loaded into polymer scaffold by electrospinning and placed as a pulp dressing following vital pulp therapy. Polyvinyl alcohol polymer of molecular weight 124,000 g/mol, 2% chlorhexidine gluconate and distilled water are used in the preparation of chlorhexidine-loaded scaffold.[38]

3MIX-TATINS

3Mix-tatin has been used as a DPC and root canal filling material in primary teeth. It is composed of 3Mix (a combination of metronidazole, minocycline, and ciprofloxacin) and statin. The successful outcome of 3Mix-tatin could be attributed to the bio-inductive effect of simvastatin. 3Mix-tatin in a study by Jamali et al. showed success rate of 90.5% for pulpotomy of primary molars.[39]

BONE MORPHOGENETIC PROTEIN

Bone morphogenic protein was used as pulpotomy agent by Nakashima in 1991.40 Pulpotomy was performed in dogs teeth using bone morphogenic proetein-7. Apical and periapical responses were not satisfactory, also BMP-7 did not show any mineralised tissue deposition.[40]

ENRICHED COLLAGEN

Collagen in the field of dentistry is used as guided tissue regeneration, root conditioning, hemostatic, and wound dressing agent.[41] Michaeli Y (1984) studied pulp healing purpose in baboons after pulpotomy using an enriched collagen solution as a pulp dressing. The result induced 80% of teeth vital pulp and dentin bridges into the pulp chamber.[42⁴³]

NATURAL ALTERNATIVES

Many natural products such as Nigella sativa, curcuma longa, turmeric, thymus vulgaris, honey, Allium sativum oil, Aloe vera, acemannan have claimed to play a vital role and appear to be a feasible replacement to FC. However, higher level of evidence is needed to hold up its usage in pediatric dentistry.[4]

CONCLUSION

For the success of pulpotomy technique it is important to investigate, diagnose, and select the medicament properly. Despite various drawbacks of FC, it is still most commonly used pulpotomy agents. Alternative medicaments have studied and used which has its own advantages and disadvantages. In replacement to FC various medicaments including MTA and natural products affirm to be a viable alternative. Till date, an ideal pulpotomy agent has not been recognized. Greater number of long-term studies with highest levels of evidence (randomized control trial) is required to determine the best medicament for pulpotomy of primary teeth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.