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Ounsi et al

Figure 2: Pre and postoperative bite-wing and periapical radiographs of a pulpotomy procedure, following which a stainless-steel crown and distal shoe were placed on tooth #74. Again, notice the total ablation of the cameral pulp and the extension of the cameral filling to the entrances of the root canals.

standpoint, concerns regarding systemic distribution,12

potential toxicity,13


carcinogenicity,7 and

mutagenicity15 of formaldehyde led to seeking alternatives to this product. Among these alternatives glutaraldehyde,16



ferric sulfate,19



dried bone,21 morphogenetic bone proteins,22 and MTA23 (Mineral Trioxide Aggregate). For the same efficacy,

glutaraldehyde is less toxic,24

less allergenic,25

and less

teratogenic.26 However, in a 24-months follow-up study regarding pulpomies performed with 2% glutaraldehyde, the authors could not justify replacing formocresol.27 Other authors have examined the 2 products from the toxicity, mutagenicity, and systemic distribution and were not able to conclude to the necessity of replacing formocresol by glutaraldehyde.26 Finally, a Cochrane review28 found that evidence is still lacking to determine which agent is the most appropriate for pulpotomies in primary teeth. Nevertheless, formocresol is banned in some countries mainly for safety concerns.29

Indications Vital pulpotomy (calcium hydroxide, MTA) is indicated in case of minimal iatrogenic pulp exposure and in case of stage I primary teeth and in permanent teeth. Non-vital pulpotomy is indicated for pulp exposure of primary teeth where inflammation/infection is limited to the coronal portion of the pulp.

Contra-indications Contra-indications of pulpotomy include unrestorable


teeth, teeth nearing exfoliation, absence of bone between the temporary tooth and the erupting permanent tooth,







spontaneous pain, presence of periodontal lesions, absence of bleeding when opening the access cavity, uncontrollable hemorrhage after pulp amputation, presence of purulent or serous drainage, or presence of fistulous tract6.

Modus Operandi After anesthesia and rubber dam isolation, complete excision of carious tissue is performed with a high-speed handpiece. The pulp chamber roof is the removed and the pulp content entirely eliminated using a low-speed handpiece under spray or a sharp excavator. Eliminating these tissues has to be complete otherwise hemorrhage would be uncontrollable. The cavity is rinsed with water then dried with cotton pellets. Hemostasis is obtained by compressing the cotton pellets the fixative agent against the pulp stumps in the canal entrances. Hemostasis is normally performed in 4-5 minutes. Failure to achieve it in on time is a sign that inflammation is deeper than suspected. The tooth is not treatable by pulpotomy and the only remaining therapeutic option is pulpectomy.

If formocresol is used to achieve fixation, vapor of formocresol diluted to the fifth is placed in contact with the pulp stumps using a squeezed cotton pellet for 5 minutes. It should be noted that fixation couldn’t occur without direct contact between the pulp stumps and the fixative agent. Dilution to the fifth is advised, as it is as effective as full strength while having less toxicity30. When the cotton pellet is removed, tissues should be brownish without signs of bleeding. Zinc-oxide eugenol cements can be used to seal the entrances, covered by a glass-ionomer filling. After setting, either amalgam or composite materials can be used to restore the tooth.

Postoperative follow-up The failure of a pulpotomy treatment is generally detected radiographically7. First signs are generally internal root resorption facing the point of application of fixative agent. It can later be followed by an external resorption. Radiolucent areas develop at the furcation level, at the apex, or laterally on the roots. A fistula may be present and the tooth becomes mobile however, pain is a rare occurrence in failing pulpotomy. Thus, unless the patient is followed regularly, it can go unnoticed until the appearance of the terminal sign which is the loss of the tooth by mobility. Parents and patient alike might attribute this loss to the natural exfoliation phenomenon. From another standpoint, the apparition of a dental abcess that

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