Tuesday, July 31, 2012

Pulpal Therapy for Primary Teeth: Formocresol vs. Electrosurgery: A Clinical Study

Resident: Derek Nobrega

Title: Pulpal Therapy for Primary Teeth: Formocresol vs. Electrosurgery: A Clinical Study
Author: Nancy Rivera, Eleida Reyes, Soraya Mazzaoui, Alexis Morón
Journal: Journal of Dentistry for Children. 2003. Jan-Apr 70(1) 1-73

Main Purpose: To compare the post-op successes and failures following pulpotomies with formocresol and electrosurgery on primary molars of children.

Methods: 40 Children of both sexes between the ages of 4 and 7 with at least 2 primary vital molars referred for pulpotomies due to exposed pulps by caries were used. Subjects were excluded if they had one of the following: mobility, sensitivity to percussion, fistula(e), groove drainage, apical or internal resorption, fetid odor, or compromised furcation. Also excluded were patients with diabetes, cardiopathy, and renal alterations. Both molars were treated in each patient: 1 with formocresol (concentration 1:5 applied for 5 minutes) and 1 with electrosurgery (electrode placed to each orifice with current flow for 1 second, followed by 5 second cooling off period up to a maximum of 3 times/orifice). Teeth were then filled with ZOE at the entrance of the canals and filled the rest of the way with amalgam. PAs and a clinical exam were performed at 1, 3, and 6 months after treatment. A failure was noted if at least one of the exclusion criteria was met.

Key Points:
1. Of the 40 teeth that underwent formocresol pulpotomy, 3 were considered failures (7.5%).
2. The same number of failures (3) were noted with electrosurgical pulpotomies (7.5%).
3. No significant differences were found between both techniques at the end of the evaluation period.
4. Electrosurgery had 2 advantages: faster application and no risk of formocresol side effects.
5. None of the formocresol treated failures showed clinical signs of failure at any point during the evaluation. Failures were only noted on radiographic examination after 6 months.
 
Assessment: The sample size was small for statistical significance. Also, the evaluation period of 6 months was short. Furthermore, the amalgam restorations placed after pulpotomies were not ideal treatment. The electrosurgery failures were all noted clinically after 1 or 3 months, but the formocresol failures were noted only after 6 months radiographically, but not clinically. Overall, a good introductory study that indicates more research is required. 

Success of Pulpectomy with Zinc oxide-eugenol vs Calcium hydroxide/iodoform paste in primary molars: A clinical study

Resident Name: Todd Bushman

Article Info: Success of Pulpectomy with Zinc oxide-eugenol vs Calcium hydroxide/iodoform paste in primary molars: A clinical study, by Chutima Trairatvorakul DDS and Salinee Chunlasikaiwan DDS MS from Pediatric Dentistry Vol 30 no 4 July/Aug 08

Main Purpose: To compare the clinical and radiographic success rates of Zoe and Vitapex in pulpectomized primary mandibular molars at 6 and 12 months.                                                   
Methods: clinical and radiographic diagnosis of 54 infected mandibular primary molars from 42 healthy kids ranging from 3 years to 7 years. Zoe or vitapex was assigned to each tooth by block randomization.  The canals were then debrided with barbed broaches and cleaned with k-files 1mm shy of the apex.  Canals were shaped to 35 or 40mm in length. 

Key Points: Vitapex appeared to resolve furcation and periapical pthology at a faster rate than ZOE at 6 months (78% vs 48%) but at 12 months Vitapex and ZOE yielded similar success rates (89% vs 85%).


Assessment of Article: Vitapex appears to be the superior product over ZOE due to the fact that the success rate is fairly consistant at 12 months yet substantially better at 6 months

Is Formocresol Obsolete? A Fresh Look at the Evidence Concerning Safety Issues

Resident Name: Mackenzie Craik

Article Info: Milnes, Alan R. “Is Formocresol Obsolete? A Fresh Look at the Evidence
Concerning Safety Issues”, Pediatric Dentistry vol. 30/no. 3, May/June 2008.

Main Purpose:
To examine more recent research about formaldehyde metabolism,
pharmacokinetics, and carcinogenicity.

Methods:
-Prior studies did not perform dose-response analysis, consequently,
formaldehyde was given at extremely high doses and then deemed a carcinogen when
it caused cancer...New research examined dose-response analysis to “provide the most
defensible estimates of cancer risk”.
-Previous studies predicted the cancer risk posed by low dose exposure by
extrapolating from lab animal data...researchers recognized that significant anatomic
and physiologic differences between humans and other animal models have
confounded extrapolation of animal data to humans.

Key points:
-Evidence shows that formocresol when used in minor amounts (a pulpotomy) is
unlikely to be genotoxic, immunotoxic, or carcinogenic in children.
-There are no scientific or pharmacologic reasons to abandon formocresol in
pediatric dentistry.

Assessment of Article: A review of many different research projects pertaining to the
possible carcinogenic effects of formocresol when used in pulpotomies in pediatric
dentistry

Guideline on Pulp Therapy for Primary and Immature Permanent Teeth


Resident Name: Sadler
Article Info: Guideline on Pulp Therapy for Primary and Immature Permanent Teeth

AAPD Reference Manual V33 no.6 212-219
Background
·         Goal of pulp therapy is to maintain integrity of teeth and supporting tissue
·         Preservation of vital pulp is the primary  goal however a tooth with a non-vital pulp can remain clinically functional
·         Review of radiographs clinical exam is necessary to make a proper diagnosis which will determine treatment
Recommendations
·         Pathologic root resorption or lack of bony support or tooth structure should be considered when determining if extraction is necessary
·         Rubber dam or other effective isolation should be used-Isolite-?
·         Pulpotomies and pulpectomies should be monitored at routine recall visits.  Radiographs of the furcation of treated teeth should be taken
·         Apexification, reimplantion, splinting, or posts and cores are not indicated for primary teeth
Vital Pulp therapy for primary teeth diagnosed with a normal pulp or reversible pulpitis
·         Protective liner-Thinly applied layer placed at the bottom of a deep restoration to act as a protective barrier.  Materials include CaOH, bonding agent, or GI. 
·         Indirect Pulp treatment-Used for deep carious lesions near the pulp but without signs or symptoms of pulpal degeneration.  Caries is left near the pulp and covered with a material (Bonding agent, CaOH, GI or ZOE).  If CaOH is used, then GI should be placed over it.  GI is good because of its inhibitory effect on bacteria.  ITR is also effective in these situations. No conclusive evidence exists that suggests it is necessary to reenter the tooth to remove decay.  It is extremely important to have a well sealed restoration which isolates the caries from any nutrition.  Indirect pulp capping is preferred to pulpotomy for teeth with reversible pulpitis. 
Direct pulp cap
·         When a pulp is exposed by mechanical means or trauma a pulp cap using CaOH or MTA can be used.  The tooth should be restored to prevent microleakage.  Direct pulp capping of carious exposures is not indicated in primary teeth.
Pulpotomy
·         Used for teeth with extensive caries but no radicular pathology.  Removal of coronal pulp is accomplished with remaining tissue treated with a medicament (Formo, FS, MTA, Bleach, etc.) ZOE is used to fill the cavity and the tooth is restored with a SSC.  If sufficient tooth remains then composite or amalgam can be used if the tooth has less than 2 years to exfoliate
Nonvital pulp treatment for primary teeth diagnosed with irreversible pulptitis or necrotic pulp.
Pulpectomy
·         Root canal procedure where necrotic tissue is removed with use of hand or rotary files.  Mechanical instrumentation is insufficient and the tooth must be decontaminated with bleach.  Canals are filled with restorable material (Vitapex) and restored
Young permanent teeth
Vital pulp therapy for teeth diagnosed with normal pulp or reversible pulpitis
Preventive liner
·         Same as previously mentioned-Used to insulate pulp with lining base
Indirect pulp cap
·         Same as previously mentioned-Older approach was to allow 3-6 months for reparative dentin formation and reenter to remove caries.  Recent developments have shown inconclusive evidence if the 2 step process is necessary.  Critical to success is a well-sealed restoration free of microleakage. 
Direct Pulp cap
·         Small exposures were bleeding is controlled can be capped with CaOH or MTA.  Well sealed restoration is important. 
Partial pulpotomy for carious exposures
·         Inflamed tissue beneath the exposure is removed 1-3mm below healthy pulp tissue.  Bleeding control and irrigation with disinfectant is needed.  Tissue can then be covered with CaOH or MTA with MTA at least 1.5 mm thick being the preferred material.  The area should then be covered with RMGI and restored with a non-leaking restoration
Cvek pulptomy-traumatic exposures
·         Treatment is similar to carious exposure.  White MTA should be used in anterior teeth.  Time between exposure and treatment is not important as long as vital pulp tissue is exposed. 
Apexogenesis
·         Allowing for normal formation of root structure with use previously mentioned techniques to allow for vital pulp tissue to remain.   
Nonvital pulp treatments
·         Pulpectomy-Completed in the same way as tradition root canal with removal of infected tissue and irrigated with disinfectant
Apexification-
·         Inducing root closure of a incompletely formed root.  Accomplished by placing a biocompatible agent in the canals to disinfect the space.  Root end closure with a material like MTA.  Canals are then obturated with gutta percha.  MTA or composite can also be used to obdurate canals to strengthen the tooth

Monday, July 30, 2012

Dentin Rehardening after Indirect Pulp Treatment in Primary Teeth

Resident: Elliot Chiu
Title: Dentin Rehardening after Indirect Pulp Treatment in Primary Teeth
Journal: Journal of Dentistry for Children, 2009
Main Purpose: To investigate dentin rehardening in the remaining carious dentin after IPC
Methods
-62 primary molars with deep carious lesions
-Decay excavated with slow-speed round burs and spoon excavators
-4 groups
    -21 CaOH liner (incomplete caries removal)
    -21 Gutta percha liner (incomplete caries removal)
    -10 Positive control group (complete caries removal, sound dentin)
    -10 Negative control group (incomplete caries removal, no IPC)
-All teeth restored with composite
-Teeth collected after exfoliation / extraction to analyze microhardness at different depths
Key Points
-Microhardness ratings: positive control > treatment groups > negative control
-This confirms the rehardening of dentin after IPT
-No statistically significant difference between GP and CaOH liners
-Treated teeth were successful clinically and radiographically for 37-71months
Assessment
-Small sample size – started out with 42 teeth in the treatment group, only 18 were analyzed for microhardness
-Since we use Vitrebond, it would be interesting to see how GI liners perform
-It wasn’t very clear at which point the authors decided to stop drilling, leave decay, and place IPC
-The authors didn’t specify how many operators were working on the cases, so different operators may have a different opinion on when to stop
-No information on the type of lesions: Class I vs Class II