Formacresol used in:
a- Full concentration
b- 5th concentration
c- One fifth concentration.***
----------------------------
Alternatives to Formocresol in the Treatment of Pulpotomies:
Written by: Javier Araujo Dental Clinic | Tags: araujo dental clinic, pediatric dentistry, pulpotomy
Pulpotomy is a pulp treatment that can be performed on both temporary teeth and young permanent teeth with the root not fully formed.
In the history of dentistry the most widely disseminated and used material over the years has been formocresol. However, it has not been in controversy for many years. Some studies have shown that it has important undesirable effects, such as its toxicity or its carcinogenic and mutagenic potential.
Given these drawbacks, there are numerous studies that seek alternatives to this material to perform pulpotomies. Some speak of ferric sulfate as the strongest substitute for formocresol. Biocompatible materials, such as MTA, have also been valued as the most reliable and safe alternative for performing pulpotomies in temporary teeth. And on the other hand, the most recent works study the results with electrocoagulation and laser in pulp treatments.
The following explains in detail what the pulpotomy consists of, its technique, indications, contraindications, classification and the materials that can be used in this procedure, which includes formocresol and the alternatives to this agent described so far.
The term pulpotomy refers to the amputation of the coronal portion of the affected dental pulp. In this way, the remaining root tissue in the absence of inflammation is able to heal once the affected or infected coronal part is removed. It is, in other words, the elimination of cameral pulp and the preservation of root pulp.
The pulpotomy technique follows a procedure that consists of the following steps:
- Local anesthesia.
- Insulation with rubber dam.
- Cameral opening: The superficial caries tissue is removed before pulp exposure to minimize bacterial contamination. Then the roof of the pulp chamber is removed, leaving a sufficiently wide access that allows the removal of all the coronal pulp tissue through the use of a sharp excavator or with a round contra-angle drill at low speed. The use of a sharp excavator is preferable as it will facilitate a clean cut without debridement that lessens the remaining pulp root tissue less.
- Hemorrhage control: At this point we will carry out the evaluation of the remaining pulp tissue, to confirm our diagnosis. The appearance of the pulp should not be excessively dark and the bleeding should be easy to control with the application of cotton balls. In order to achieve hemostasis, we should not use any hemostatic, since if we did not achieve it, we would be faced with an affectation of the root tissue with irreversible inflammation that would indicate the need for a pulpectomy or an extraction depending on the case.
- Application of the agent: Once the bleeding control has been achieved, a cotton ball impregnated with the material we have chosen (formocresol, ferric sulfate, MTA) will be applied in the amounts determined according to the agent, and the indicated time will be left. When removing the cotton, the appearance should be garnet-dark and without bleeding. Subsequently a zinc oxide-eugenol base will be placed. It will condense very slightly to avoid damaging the surface fixing layer and a good adaptation on the walls will be attempted to avoid marginal filtration.
- Restoration: The importance of adequate final restoration in the teeth in which a pulp treatment has been performed is very important, since it is essential to avoid the marginal filtration that can compromise the treatment, in addition to the possibility of fracturing the rest of the dental structure .
a- Full concentration
b- 5th concentration
c- One fifth concentration.***
----------------------------
Alternatives to Formocresol in the Treatment of Pulpotomies:
Written by: Javier Araujo Dental Clinic | Tags: araujo dental clinic, pediatric dentistry, pulpotomy
Pulpotomy is a pulp treatment that can be performed on both temporary teeth and young permanent teeth with the root not fully formed.
In the history of dentistry the most widely disseminated and used material over the years has been formocresol. However, it has not been in controversy for many years. Some studies have shown that it has important undesirable effects, such as its toxicity or its carcinogenic and mutagenic potential.
Given these drawbacks, there are numerous studies that seek alternatives to this material to perform pulpotomies. Some speak of ferric sulfate as the strongest substitute for formocresol. Biocompatible materials, such as MTA, have also been valued as the most reliable and safe alternative for performing pulpotomies in temporary teeth. And on the other hand, the most recent works study the results with electrocoagulation and laser in pulp treatments.
The following explains in detail what the pulpotomy consists of, its technique, indications, contraindications, classification and the materials that can be used in this procedure, which includes formocresol and the alternatives to this agent described so far.
The term pulpotomy refers to the amputation of the coronal portion of the affected dental pulp. In this way, the remaining root tissue in the absence of inflammation is able to heal once the affected or infected coronal part is removed. It is, in other words, the elimination of cameral pulp and the preservation of root pulp.
The pulpotomy technique follows a procedure that consists of the following steps:
- Local anesthesia.
- Insulation with rubber dam.
- Cameral opening: The superficial caries tissue is removed before pulp exposure to minimize bacterial contamination. Then the roof of the pulp chamber is removed, leaving a sufficiently wide access that allows the removal of all the coronal pulp tissue through the use of a sharp excavator or with a round contra-angle drill at low speed. The use of a sharp excavator is preferable as it will facilitate a clean cut without debridement that lessens the remaining pulp root tissue less.
- Hemorrhage control: At this point we will carry out the evaluation of the remaining pulp tissue, to confirm our diagnosis. The appearance of the pulp should not be excessively dark and the bleeding should be easy to control with the application of cotton balls. In order to achieve hemostasis, we should not use any hemostatic, since if we did not achieve it, we would be faced with an affectation of the root tissue with irreversible inflammation that would indicate the need for a pulpectomy or an extraction depending on the case.
- Application of the agent: Once the bleeding control has been achieved, a cotton ball impregnated with the material we have chosen (formocresol, ferric sulfate, MTA) will be applied in the amounts determined according to the agent, and the indicated time will be left. When removing the cotton, the appearance should be garnet-dark and without bleeding. Subsequently a zinc oxide-eugenol base will be placed. It will condense very slightly to avoid damaging the surface fixing layer and a good adaptation on the walls will be attempted to avoid marginal filtration.
- Restoration: The importance of adequate final restoration in the teeth in which a pulp treatment has been performed is very important, since it is essential to avoid the marginal filtration that can compromise the treatment, in addition to the possibility of fracturing the rest of the dental structure .
If it is a molar, the most appropriate restoration is a stainless steel crown. Although in some cases the possibility of an amalgam restoration has been suggested, the results of different studies show that it would be indicated only when the lesion affects the occlusal surface, keeping the rest of the walls intact, and when the time to normal exfoliation does not be over two years old The superiority of the stainless steel crown is clear compared to cases of a multi-surface restoration with amalgam.
In anterior teeth, the final restoration will be with composite resin, if there is enough dental structure, or with crowns with an aesthetic front if the teeth are more affected. If we apply a composite, the prior application of a zinc phosphate base will be necessary, so that the contact of the composite with eugenol is avoided, which interferes with its polymerization. In general, pulp and restorative treatment is performed in the same session, thus preventing the child from having to endure more visits.
In temporary dentition, the pulpotomy will be indicated in those cases with involvement of the coronal pulp while the remaining root tissue is considered vital without clinical or radiological signs of inflammation.
It will be contraindicated in the presence of signs and symptoms such as spontaneous pain, percussion pain, abnormal mobility, fistulas, internal resorption, pulpal calcifications, pathological external resorption, periapical and interradicular radiolucency or excessive bleeding. In addition, it must be susceptible to restoration and at least two thirds of the root length must remain in order to ensure a reasonable functional life. There are several studies that emphasize the importance of bleeding control, once the coronal pulp has been amputated, thus confirming the diagnosis of non-involvement of the remaining root tissue.
Root pulp treatment should preserve the function or vitality of all remaining tissue. Thus, the material to be used, ideally, should be bactericidal, harmless to the pulp tissue and adjacent structures, should promote the healing of the root pulp and not interfere with the root resorption process of the temporary tooth.
We can classify pulpotomies according to their therapeutic objectives:
- Devitalization: (mummification, cauterization) refers to a destruction of vital tissue and is typified by formocresol.
- Preservation: (minimum devitalization) indicates that there is an attempt to maintain the maximum vital tissue although without the induction of reparative dentin, as is the case with ferric sulfate and at the time was glutaraldehyde.
- Regeneration: (repair) has the most important objective to maintain vital tissue and stimulate the formation of restorative dentin.
In temporary dentition, the treatment is aimed at preserving the root pulp to facilitate tooth replacement. There are various materials and techniques.
Formocresol: So far it is the most widespread treatment. The most commonly used formula was introduced by Buckley in the early twentieth century and consists of 19% formaldehyde, 35% cresol, 15% glycerin and water. The active components are formaldehyde which is a fixative and cresol, which allows diffusion. Glycerin is used as an emulsion and to prevent the polymerization of formaldehyde.
It comes as a liquid. This is applied to the root pulp, in the treatment of pulpotomies of temporary teeth, by means of a cotton swab slightly moistened with this liquid.
Even despite the use of 20% formocresol and only for 5 minutes, clinical and radiological success is very favorable. According to different authors it ranges between 70-97%, which supports the use of this technique and makes it continue to be a standard technique in pulpotomies of temporary and reference teeth for comparison with other agents.
The direct contact of the formocresol with the root pulp, the closest to the cameral pulp, determines a mummification of it. The effect not only occurs in this area but also diffuses through the rest of the root pulp, affecting it to a greater or lesser extent. The mummification of the pulp occurs when interacting with its proteins, and is due to formaldehyde, although cresol also contributes to this action.
Formocresol has long been the medication of choice in the treatment of pulpotomies of temporary teeth. However, there are many studies in which the application of formocresol is widely questioned due to its undesirable effects:
- Local and systemic toxicity
- Immunogenic potential
- Carcinogenic
- Mutagenic
Taking into account different studies, the local toxicity of formocresol does not decrease as the concentration decreases, and even at minimal concentrations, cytotoxicity can be seen at the pulp level. Regarding systemic toxicity, although this has not been studied in humans, animal research has shown that formocresol accumulates in the pulp and dentin, spreading through dentin and cement and reaching the periodontal ligament and bone. Thus, it can produce inflammatory reactions in the pulp and periodontal tissues, pulp necrosis, root resorption and apical resorption, ankylosis and permanent successor tooth lesions. There is also evidence that when performing multiple pulpotomies in a dog, histological changes were found at the level of the liver and kidney. Regarding its mutagenic and carcinogenic potential, studies with rats show that after long contact with formaldehyde, the epithelium can enter a precancerous state. Regarding the immunological response capacity, this has been demonstrated in different studies, however there are doubts due to the intense awareness they have used in these works.
Given these considerations, there are several agents proposed as alternatives to formocresol.
Ferric Sulfate:
It is the most accepted currently. It is an acidic material. Its purpose is to act as an antiseptic and provide a precipitate of particles that seal the exposed surface.
Although dentistry has long been known as a hemostatic agent, its use for the treatment of pulpotomies in temporary teeth is relatively recent.
It comes in gel form in a concentration of 15 or 20%. Once the cameral pulp is removed, it is applied to the root pulp for 15 seconds. It acts by inhibiting bleeding, is a potent hemostatic, and prevents, to a large extent, the formation of a clot. After application, the pulp chamber is thoroughly washed and then dried. It can be reapplied, if the pulp bleeds again.
Like formocresol and glutaraldehyde, it does not stimulate dentin formation. The treated area will heal through the formation of fibrous tissue. It is currently considered the product of choice for the treatment of pulpotomies of temporary teeth.
The use of this material has various desirable effects. It is a hemostatic agent with no known toxicity or systemic distribution. In the treated area the inflammatory reaction is minimal; which is due to the inhibition of bleeding and, therefore, to the formation of a clot, which would largely be responsible for the inflammation. Therefore, there are no internal resorption due to inflammation. Some authors point out that ferric sulfate, in addition to hemostatic is bactericidal.
A favorable pulp response has been observed with it, similar to that obtained with formocresol and a high clinical and radiological success. It is currently one of the agents that is studied with more interest and is considered as the alternative to formocresol.
Its use has some disadvantage. Nor is it possible to promote regeneration and repair of pulp tissue with ferric sulfate, nor to keep it free from inflammation. In this sense, Cortés, Boj and Canalda, conducted a comparative study of the effect of formocresol and ferric sulfate as agents for pulpotomies in rat molars and observed that the degree of inflammation was similar in the 2 groups and even with more extension towards apical in the ferric sulfate group.
In the treatment of pulpotomies of temporary teeth many professionals use zinc oxide eugenol as a cavitary base, however this should not be used when ferric sulfate has been chosen. OZE is an irritating product, when it comes into contact with the pulp treated with ferric sulfate, it remains vital. The irritation and, therefore, the inflammation will be greater than in the case of using glutaraldehyde or formocresol, since these mummify the pulp. To obviate the problem it will be necessary to resort to other cements such as MTA, on pulps treated with ferric sulfate.
Formocresol has long been the medication of choice in the treatment of pulpotomies of temporary teeth. However, there are many studies in which the application of formocresol is widely questioned due to its undesirable effects:
- Local and systemic toxicity
- Immunogenic potential
- Carcinogenic
- Mutagenic
Taking into account different studies, the local toxicity of formocresol does not decrease as the concentration decreases, and even at minimal concentrations, cytotoxicity can be seen at the pulp level. Regarding systemic toxicity, although this has not been studied in humans, animal research has shown that formocresol accumulates in the pulp and dentin, spreading through dentin and cement and reaching the periodontal ligament and bone. Thus, it can produce inflammatory reactions in the pulp and periodontal tissues, pulp necrosis, root resorption and apical resorption, ankylosis and permanent successor tooth lesions. There is also evidence that when performing multiple pulpotomies in a dog, histological changes were found at the level of the liver and kidney. Regarding its mutagenic and carcinogenic potential, studies with rats show that after long contact with formaldehyde, the epithelium can enter a precancerous state. Regarding the immunological response capacity, this has been demonstrated in different studies, however there are doubts due to the intense awareness they have used in these works.
Given these considerations, there are several agents proposed as alternatives to formocresol.
Ferric Sulfate:
It is the most accepted currently. It is an acidic material. Its purpose is to act as an antiseptic and provide a precipitate of particles that seal the exposed surface.
Although dentistry has long been known as a hemostatic agent, its use for the treatment of pulpotomies in temporary teeth is relatively recent.
It comes in gel form in a concentration of 15 or 20%. Once the cameral pulp is removed, it is applied to the root pulp for 15 seconds. It acts by inhibiting bleeding, is a potent hemostatic, and prevents, to a large extent, the formation of a clot. After application, the pulp chamber is thoroughly washed and then dried. It can be reapplied, if the pulp bleeds again.
Like formocresol and glutaraldehyde, it does not stimulate dentin formation. The treated area will heal through the formation of fibrous tissue. It is currently considered the product of choice for the treatment of pulpotomies of temporary teeth.
The use of this material has various desirable effects. It is a hemostatic agent with no known toxicity or systemic distribution. In the treated area the inflammatory reaction is minimal; which is due to the inhibition of bleeding and, therefore, to the formation of a clot, which would largely be responsible for the inflammation. Therefore, there are no internal resorption due to inflammation. Some authors point out that ferric sulfate, in addition to hemostatic is bactericidal.
A favorable pulp response has been observed with it, similar to that obtained with formocresol and a high clinical and radiological success. It is currently one of the agents that is studied with more interest and is considered as the alternative to formocresol.
Its use has some disadvantage. Nor is it possible to promote regeneration and repair of pulp tissue with ferric sulfate, nor to keep it free from inflammation. In this sense, Cortés, Boj and Canalda, conducted a comparative study of the effect of formocresol and ferric sulfate as agents for pulpotomies in rat molars and observed that the degree of inflammation was similar in the 2 groups and even with more extension towards apical in the ferric sulfate group.
In the treatment of pulpotomies of temporary teeth many professionals use zinc oxide eugenol as a cavitary base, however this should not be used when ferric sulfate has been chosen. OZE is an irritating product, when it comes into contact with the pulp treated with ferric sulfate, it remains vital. The irritation and, therefore, the inflammation will be greater than in the case of using glutaraldehyde or formocresol, since these mummify the pulp. To obviate the problem it will be necessary to resort to other cements such as MTA, on pulps treated with ferric sulfate.
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