PEDIATRIC DENTISTRY V 30 ' NO 3 MAY ' JUN 08

¡onference Paüer

Indirect Pulp Capping and Primary Teeth: Is the Primary Tooth Pulpotomy Out of Date?James A. Coll. DMD. MS

Abstract: Formocresol pulpotomy (FP) in the United States is most frequently used to treat asymptomatic caries near the pulp in primary teeth. Indirectpulp therapy (IPT) is also indicated and has a significantly higher long-term success. Pulpotomy is thought to be indicated for primary teeth with cariouspulp exposures, but research shows the majority of such teeth are nonvital or questionable for treatment with vitai pulp therapy. IPT has a significantlyhigher success in treating all primary ßrst molars, but especialiy those with reversible pulpitis compared with FP. The purpose of this article wos to reviewthe dental literature and new research in vital pulp therapy to determine the following: (I) Is a pulpotomy indicated for a true carious pulp exposure?(2) /s there a diagnostic method to reliably identify teeth that are candidates for vital pulp therapy? (3) Is primary tooth pulpotomy out of date, and shouldindirect pulp therapy replace pulpotomy? (Pediatr Dent 2008-^0:230-6)

KEYWORDS: INDIREQ PULP THERAPY. PULP EXPOSURE. PULPOTOMY

The guidelines ofthe American Academy of Pédiatrie Dentistry(AAPD) on pulp therapy for primary and young permanentteeth states that a pulpotomy Is a procedure in which thecoronal pulp is amputated, and the remaining radicularpulp tissue is treated with a medicament or eiectrocautery topreserve the pulp's health.' The guidelines state the objectiveof a pulpotomy is to keep the remaining pulp healthy withoutadverse clinical signs or symptoms or radiographie evidenceof internal or external root résorption. The AAPD guidelineskirther state that there is only one other choice for vital pulptherapy in primary teeth where caries approach the pulp. Thischoice is indirect pulp therapy (IPT), hecause the direct pulpcap in a primary tooth is contraindicared for carious expo-sures.' IPTisaprocedurein which the caries closest to the pulpis left in place and covered with a biocompatible material, andthe tooth is restored to prevent microleakage. The objectivesof treatment are the same as for a pulpotomy.'

For deep caries in primary teeth, the indications for IPTand pulpotomy are identical for reversible pulpitis or a normalpulp when the pulp is judged to be vital from clinical andradiographie criteria.' The difference occurs when the cariesremoval process results iti a pulp exposure; a pulpotomy isthen undertaken. IPT purposely avoids an exposure by leavingthe deepest decay in place. IPT is clearly not indicated when

Dr. CDÍÍ IS Cíiními ftw/essor, DepartmemofPsdiatncDentistry. Universityof

Maniand Dental School. Baltimore. Md.. and is pédiatrie dentist in private

practice, York. Pa.

Correspond with Dr. Coll at www.dmdi@comcast.net.

the pulp is exposed by caries, but is pulpotomy indicated fora carious pulp exposure? For deep caries with possible radio-graphic exposures that are asymptomatic, which is the betterchoice of treatment, IPT or pulpotomy?

The purpose of this article was to review the dental lite-rature and new research in vital pulp therapy to determine thefollowing: ( 1 ) Is a pulpotomy indicated for a true carious pulpexposure? (2) Is there a diagnostic method to reliably iden-tify teeth that are candidates for vital pulp therapy? (3) Isprimary tooth pulpotomy out of date, and should IPT replacepulpotomy?

Is Pulpotomy Indicated for Carious Exposures?A primary tooth pulpotomy should be performed on a toothjudged to have a vital pulp.' After the coronal pulp is amputa-ted, this leaves behind vital radicular pulp tissue that has thepotential for healing and repair in 3 general ways, according toRodd.- First, the remaining radicular puip can be rendered inert,such as by using formocresol. It fixes or denatures the vital pulpso it is no longer pulp tissue in addition to its bactericidal proper-ties. Second, the radicular piilp might be preserved throtighminimal inflammatory insult by using a hemostatic agentsuch as ferric sulfate to form a clot barrier to preserve the deeperremaining pulp tissue. The third pulpotomy mechanism encou-rages the radicular pulp to heal and form a dentin bridge byusing calcium hydroxide or mineral trioxide aggregate (MTA).

What is the histologie and clinical research that can helpdentists determine which teeth with deep caries are vital and,thus, candidates for pulpotomy? Reeves and Stanley' foundthat as long as the advancing edge of the carious lesion was

¿30 SHOULD INDIRECT PULP CAPPING REPLACE PULPOTOMY?

PEDIATfilC DtNTlSTRV V 30 NO 3 MAY ]UN 08

1.1 mm from the pulp, no significant pathologic changes wereevident in permanent teeth. Once the caries approached within0.5 mm of the puJp and che reparative dencin was involved, thensignificant pathologic changes were noted. Shovelton* examinedpermanent teeth and showed that as caries approximated0.25-0.3 mm of the pulp, hyperemia and pulpitis were seen.

Regarding the effect of pulp exposures on the pulp's capa-city to repair, Lin and Langland'' showed that thar when no pulpexposure occurred from caries, the pulps repair capacity wasexcellent. After a carious exposure, however, ir was questionahleand unpredictable. They also found that in teeth with a historyof pain, the pulp chamber would have an area of necrosis oftenextending into the radicular pulp. Others have stated thar thedentist risks displacing infccted dentin chips into the pulpwhen performing total excavation of deep carious lesions, thusincreasing the risk of pulpal inflammatory breakdown.''

Srepwise caries removal in permanent teeth thought to haveradiographie pulp exposures has been proposed as a method tominimize pulp exposures and preserve vitality. *** Caries excava-tion is a 2-appointment procedure. Initially, the lesions peri-phery is made caries-free, wh ile the center of the caries is partiallyremoved to leave moisr, soft dentin over rhe pulp. Then, calciumhydroxide and a temporary filling are placed for 6-12 months.The lesion is then re-entered, and all the caries is removed.Bjorndal et aP found no pulp exposures on re-entry in 31 per-manent teeth by using stepwise caries removal. Le.skellet al** tested stepwise caries removal versus conventional in 127permanent teeth with a patient mean age of 10.2 years. After8-24 months, stepwise removal resulted in approximately 18%pulp exposure versus 40% for conventional caries removal.

Many of these permanent tooth findings likely apply toprimary teeth. Rodd' stared that carious primary and perma-nent teeth showed similar neural changes when mounting apulpal defense ro deep caries. Rodd found that primary andpermanent teeth have similar vascularity, except in the midcoro-nal region, and showed a similar degree of vasodilatation andnew vessel formation with caries progression.

Eidelman et al'' studied severely decayed primary incisorswith no pulp pathology in nonrestorable teeth from 20- to42-month-old children. After fixation, caries was removedwith a slow-speed round bur. A sharp explorer was used toevaluate total caries removal and check for a pulp exposure.Teeth without pulp exposures and no total necrosis likely asa result of trauma were hisrologically diagnosed as treatablewith vital pulp therapy in 23 of 26 cases (88%). By contrast,] 6 of 24 (67%) of the incisors judged to be nontreatable (totalnecrosis) or questionable (chronic partial pulpitis) for treatmentwith vital pulp therapy had a carious pulp exposure, leavingonly 33% that were unquestionably vital. Dentists mightthink they can obtain a 90% level of pulpotomy success in sucha case. The simple mathematics of 33% (chance of finding avital pulp) X 90% (chance of puipotomy success), however,would equal a 30% chance of a cariously exposed tooth having

a successfiil pulpotomy. From these histologie and clinicalfindings, the following conclusions can be drawn:

1. Primary tooth pulpotomy requires a vital radicular pulp,no matter what form or type of pulpotomy procedureis used.' • Teeth with a carious pulp exposure have a lowlikelihood of being totally vitaF and are, thus, poor candi-dates for vital pulpotomy.

2. Stepwise caries removal will result in fewer pulp exposuresthan total caries removal performed in 1 visit. "*

3. For teeth without carious pulp exposures, performing apulpotomy likely increases the chance of displacing inÎèct-ed dentin chips into the pulp and impairing the pulp's repaircapacity. '

4. The pulp's repair capacity is excellent when the carious lesionremains 1 mm or more away from the pulp-'

Is There a Diagnostic Method to Identify Teeth with DeepCaries That Are Symptomless or Questionable, Yet Are Can-didates for Vital Pulp Therapy?

Identifying those teeth with deep caries that are vital and treat-able with vital pulp therapy leads to this article's second purpose,which was to describe a new method to reliably diagnose theseteeth. Initially placing an intermediate, therapeutic, temporaryrestoration by using glass ionomer caries control (GICC) for1-3 months before starting pulp therapy has been shown tobe an excellent method of diagnosing the pulp's vitalit)'. Noanesthesia is used to perform minimal caries excavarion withspoon excavators or slow-speed round burs and is a form ofalternative restorative treatment (ART)'" or stepwise cariesremoval This procedure takes less than 5 minutes and can bedone at the initial examination visit of a child presenting withmultiple open carious lesions.

GICC is indicated in cavitated carious lesions to diagnosetheir vitality in teeth with signs and symptoms of reversiblepulpitis or a symptomless tooth thought to have no pulpitisbefore instituting any pulp therapy" The technique involvesminimally removing the superficial, nonpainful decay byusing a slow-speed no. 4 or 6 round bur or spoon excavation.A glass ionomer temporary filling is then placed by using amaterial such as Fuji IX (CC America inc, Alsip, IL). KetacMolar (3M ESPE, St Paul, MN), Voco lonofil Molar AC(Voco Gmbh, Cuxhaven, Germany), or a resin-modified glassionomer. A matrix band does not have to be used, but theintermediate therapeutic temporary restoration should notbe in occlusion. After 1-3 months of GICC, if the tooth hasbeen asymptomatic and shows no signs of irreversible pulpitisclinically or on a new radiograph, vital pulp therapy can beinstituted by using IPT or pulpotomy (Fig. 1).

Numerous studies have reported on the biologic effects ofa glass ionomer temporary filling. Bonecker et al'' studied dentinsamples in 40 primary molars before and after ART excava-tion. The total bacterial count and mutans streptococci were

SHOULD INDIRECT pUtP CAPPING REPLACE PUIPOTOMY? 231

PEDIATRIC DENTISTRV V 3D NO 3 MAY • JUN 08

Figure 1. Example of iLsing glass ionomer caries control to diagnose reversible puipiris or food impaction in a mandibular first primary molarwithahistoryofpain to chewing sweets and solid foods for 2-3 weeks, (a) Preoperative view, (b) I'reoperative radiograph, (i:) View immediatelyafter glass ionomer placement, (d) iwo months after caries control. Pain stopped from day glass ionomer placed. No clinical or radiographiesign of irreversible pulpitis. (c) View of IPT with a glas.s ionomer base. [0 Tooth 16 months after treatment withour signs of pain or irreversiblepulpilis dinicaJty or on the radiograph.

signihcantty reduced from the excavation process alone.l.oyola-Rodriqucz et al''showed in vitro that all glass ionomerliners had good antibacterial activity against Streptococctissohrifitis a\-\d S. mwíí/r¿f associated with their fluoride release.

Wambier et al'*' published an in vino study of 32 primarymolars with open deep carious lesions. Radiographs and exami-nations excluded teeth with apical pathosis. Initially, carious

dentin samples were taken, and then minimal caries excavationwas perfortiied followed by a rcsin-moditied gla.ss ionomer tem-porary filling. After 30 and 60 days of cemporization, the seconddentin samples showed that total bacterial counts decreasedsignificantly (/*<.O5), and all bacterial strains had similar trendsin both time periods. Scanning electron microscopy inspectionof dentin samples in the same time frames showed dentin

III SHOULD INDIRECT PULP CAPPING REPLACE PULPOrOMV?

PEOIATRIC DENÎISTBV V ÎO > NO 3 MAY ' JUN 08

reorganization and narrower dentin tubules. The authors belie-ved the results suggested that sealing the cavitated lesion withglass ionomer contributes to remineraÜzation. Only the outercarious layer needs to be removed to accomplish this result.Oliveira et al''' reported on 32 permanent teeth after minimalcaries excavation and temporization for longer time periods.They concluded that total caries removal did not seem essentialto stop caries progression.

Regarding the effect of glass ionomer on the subsequentvital pulp therapy, Vij et al" reported that GICC temporiza-tion for 1-3 months increased success of the subsequent vitalpulp therapy from 79% to 92%. Teeth temporized with zincoxide-eugenol, however, had a success rate of 67%. They alsoreported a "drying out" effect of the moist caries on re-entryafter GICC similar to that reported by Bjorndal et aF after6-7 months of stepwise caries removal.

Another recently completed study reported on GICC'sdiagnostic success in deeply cavitated carious lesions. " ' A groupof primary moiars had GICC after minimal caries excavationfor a mean time of 3.5 months. The GICC intermediate thera-peutic temporary restoration had to have remained intact withoutdisplacement for 1 ^ months. Another group of primar)' molarshad no GICC. Both groups had IPT or formocresol pulpotomyand were restored with an immediate steel crown the day of treat-ment and were followed for a mean time of more than 3 years.Diagnostic success was based on the vital pulp therapy success,or the tooth was successfully diagnosed with irreversible pulpitisafter 1-3 months of GICC. The GICC group showed a signÍ6-cant increase {P<.OOl) in the subsequent vital pulp therapysuccess (98%) versus the non-GICC group's vital pulp therapysuccess (75%).Therewasasubgroupof 18 teeth that presentedwith pain and/or a questionable diagnosis of their vitality.

r,ibk- I . ALL TYPES Of PULPOTOMY USUALLY SHOW DECREASEDSUCCESS OVER TIMr

Re&tcnces

Dean CI al 2002"

Huth e, . 1 2 0 0 V

Rolling; and Thylsirup1975'"

Vi, R.e. .12004''

Smith « al 2000"

Casas ei al 2004"

Kiclcimanaal2001-'

Jabbjrifer « al 2004-^

Holan CTal 2005"

Pulpo'tomy

Formocresol

1/5 formocresol

Formocresol

Homiocresol

Ferric sultätc

Fcrrk sulfile

Mineral crioxidcaggrr^ate

Mineral trioxide

Mineral irioxideagrégate

SuGce» (%)

92

85

70

70

74-80

67

100

94

91*

Time (mos)

6-12

24

36

40

19

36

L3

12

38

Ail received GICC initially for 1—4 months to diagnose thetooth's vitality. The GICC produced the correct diagnosis forall the teeth in that 7 molars returned with signs of irreversiblepulpitis and were extracted. For the other 11, however, the painwas diagnosed as reversible, and all were treated with vital pulptherapy successfully.

From these microbiologie and clinical snidies, the followingconclusions can be made on using glass ionomer caries control:

1. Treating primary teeth with deeply cavitated cariouslesions after minimal excavation with glass ionomer cariescontrol for 1-3 months initially before instituting pulptherapy causes the bacteria to significantly decrease withinthe lesion.'*'^ In vital, symptomless teeth with apparentradiographie exposures or near exposures, treating themwith caries control will likely stop cades progression."

2. GIGC for 1-3 months changes the character of the den-tin so that it is drier and harder, and the affected dentinlikely remineralizes similar to dentin after stepwise exca-vation.^"''*

3. Using GICC as a diagnostic tool for 1-3 months in teethwith symptomless radiographie exposures or ones with painand questionable vitality will diagnose those that can betreated successfully with vital pulp therapy 98% of the

tmie .

* Internal root rcsorption was not always considered failure; Peng ci al 2006"calculated MTAsucccss at 91% counting internal résorption.

Is the Primary Tooth Pulpotomy out of Date for Treatmentof Deep Caries and Should IPT Replace Puipotomy?Knowing the pulpal diagnosis of primary teeth with deep cariesby using GICC should greatly improve the chance of any vitalpulp therapy. This leads to the article's third purpose: Is IPTor pulpotomy the best choice for vital pulp therapy for deeplycavitated carious lesions?

Most pulpotomy success decreases over time from 90%or more initially (6-12 months) to 70% or less after 3 years ormore"-"'^^ (Table 1, Figure 2). The MTA pulpotomy appearsto have a higher long-term success rate (>90%) than otherpulpotomy types. *"- Yet these reports generally are of shorterduration (only one >24 months)^^ and have small sample sizes(=38 teeth) from which to draw strong conclusions. Most ofthese MTA pulpotomy sttidies were performed on teeth withsymptomless radiographie exposures, and most had immediatesteel crowns placed after pulpotomy. The immediate crownshould have minimized microieakage and increased pulpotomysuccess compared with a large amalgam,'' which had been usedin other pulpotomy studies. ' •'" A recent meta-analysis of MTAversus formocresol pulpotomy studies suggested that MTA wassuperior to formocresol as a result of its lower failure rate. ^

IPT usually shows success rates of 90% or greater no matterthe technique, medicament, or time periods (Table 2, Figure 2).IPT's long-term success (3-4 years) surpasses all other pulpot-omy studies, with the possible exception of the I long-termMTA study." There have been various medicaments used forIPX from calcium hydroxide,'"'-"' glass ionomer,"'" to

SHOULD INDIRECT PULP CAPPING REPLACE PUIPOTOMY?

PEDIATRIC DENTISTRY V 30 • NO 3 MAY ¡UN 08

all of which did not significantly change IPT's success rates, asshown in Table 2. Even using dental students of vastly differ-ent abilities and likely different techniques, as reported by AUZayer et al,-' did not significantly decrease IPT's success below95%. The type of final, immediate restoration did not alterIPT's success when steel crowns were compared with compositefillings and glass ionomcrs."'*" Even when no medicament wasplaced for IPT and the composite filling was bonded to theremaining decay and decay-free dentin, Falster et al'" reportedsuccess greater than 90%.

How are pulpotomy and IPT being taught and practicedin the United States? Dunston and Coll" in 2005 surveyed48 of the 56 pédiatrie program directors in the U.S. dentalschools and 689 of the board-certified pédiatrie dentists. TheyfoLind that 76% of the dental schools taught either diluted oriull-strength forniocresol pulpotomy, whereas the other 24%taught ferric sulfate. Of the 689 pédiatrie dentists, 81% useddiluted or full-strength formoeresol, 18% ferric sulfate, and1 % some other type of pulpotomy (elect rocautery, MTA, etc).Formocresol remains the overwhelming choice for pulpotomy.

Tab le 2 . INDIRECT PULP THERAPY [IPT} STUDIES 5H0WS SUCCESS HATES OF 90% ORGREATFR OVFR TIME USING DIFFFRING TECHNIQUES AND MF.DICAMEWT5

NirschI and Avery 1983"

Al-Zaycr et al 2003'"

Falster c( al* 2002"

Vi¡c[al2004"

Faraoq NS, ct al 2000"

1P1' medicamenu

Ciileium hydroxide

Calcium hyciraxide

—

Glass bnomer

Glass ionomer

Success (%)

94

95

90*

94

93

Time {mos)

6

14 (median)

24

40

50

Sample (N)

33

187

48

108

signifying the toxic concerns regarding formoeresol do notseem to be a concern for most schools or practicing dentists.The International Agency for Research on Cancer stated in a2004 press release that formaldehyde causes nasopharyngealeaneer.'- Milnes'' in 2006 disputed the cancer concern bystating that the amount of formocresol in a pulpotomy waslikely such a small amount that fortnocresol pulpotomy was alow-exposure condition. Zazar et al'' found that when study-ing the white blood cells after formocresol pulpotomy in 20children, 1 ehild showed a 6-fold increase in white blood cellehroniosom;d abnormalities. From a statistical standpoint, theybelieved formocresol was not mutagenie, but further studieswere needed to verify this.

The 2005 survey ' also had a clinical scenario questionregarding deep caries removal in a primary second molar in a5-year-old. Seventy percent of the program directors and morethan 80% of the pédiatrie dentists reported that a pulpotomywas the treatment of choice over IPT. It appears that IPT isnot emphasized in U.S. dental schools as a method to treatdeep asymptomatic caries, and most dentists practice the

way they were taught. In addition, most pédiatriedentists believe it is best to enter the pulp and doa formocresol pulpotomy, even though long-termformoeresol pulpotomy success is significantly lower

• Adhesive resin alone without a liner or calcium hydroxidf liner and adhesive resin.

t Combined success of both groups.

95n

I IPT SuccessIFP Success

0-2 2-3 3-4 >4years years years years

Figure 2, I.on^-term success rates of" formocresol pulporomy and IPTwere statistically diñerent starting in the 2- to 3-year follow-up group-ing. Reproduced with permission from Forooq NS, Coll JA, KiiwabaraA, Shelton P. Success rates of tormocresol pulpotomy and indircst pulptherapy in the treatment of deep dentin il caries in primary teeth. PediatrDent 200Ü;22:278-86.

Other faaors need to be considered when choo-sing IPT or pulpotomy for deep caries in primaryteeth. Vij et al" studied IPT and pulpotomy suc-cess treating molars with reversible pulpitis pain.They reported that in 20 first primary molarswith such pain, IPT success was 85%, which wassignificantly better {P=.O4) than the 53% in19 primary first molars treated with formo-cresol pulpotomy. They also found that there wassignificantly {P=M) low sueeess (61%) when first

primary molars were treated with formoeresol pulpotomycompared with the 92% sueeess with IPT in these molars.When the data of Holan et aF^ were tested with x' analysis;it also showed a significantly lowered sueeess for formocresolpulpotomy in primary first molars.

Another eoneern in the choice of using IPT or pulpotomyis the early exfoliation of pulpotomized teeth. More than 35%of formocresol pulpotomies exfoliate significantly earlier (>6months) than nonpulpotomized teeth, whereas IPT-treatedteeth exfoliate normally."'^ In addition, pulpotomies costmore than 2.3 titnes more than IPT, on the basis of publisheddental insurance reimbursement for the 2 proeedures."'^*' Inthe United States, however, most dental insurers do not coverIPT for primary teeth, which might result in less utilization.For a tooth with deep earies I mm away from the pulp, IPTor puipotomy can be performed. The pulpotomy could bemore painful, because profound anesthesia is always neededfor a pulpotomy, whereas the IPT requires no pulpal entryand, therefore, is potentially less painful.

234 SHOULD INDIRECT PULP CAPPING ftEPLACE PULPOTOMY?

PEDIATRIC DENTISTRY V 30 ' NO 3 MAY ' |UN 08

When performing IPT and leaving residual decayed dentin,what are the concerns of leaving this decay after a 1-visit IPT?.Aponte et ai''' reported performing indirect ptilp capping withcalcium hydroxide followed by amalgam restorations in 30primary molars. After 6-46 months (mean, 29 months), theamalgam and calcium hydroxide were removed, and the cariousdentin that had been left behind cultured. In 28 of 30 teeth(93%), the residual carious dentin was sterile. Oliveira et al"studied 32 permanent teeth judged by radiographs to have a puipexposure. From digitized radiographs taken 6-7 months afterpartial caries removal followed by temporary fillings, therewas mineraiized improvement in the carious dentin over time.Finally, the 10-year prospective study by Mertz-Fairhurst et ai**"conclusively siiowed that in 85 teeth after obvious occlusalcaries was successftilly sealed from mictoleaicage, after 10 yearsin vivo, there was no progress ofthe caries in permanent teeth.

The following conclusions on choosing IPT or pulpotomycan be drawn from these studies:

1. Formocresol atid ferric sulfate pulpotomy have a signifi-cantly lower long-term success for treatment of deepcaries compared with IPT."'^'"'" Most U.S. pédiatriedentists currently choose to use formocresol pulpotomyover IPT."

2. IPT has been shown to have a significantly higher successrate for teeth with reversible pulpitis compared withformocresol pulpotomy."

3. IPT shows higher long-term success rates than any puJpo-tomy other than possibly MTA (Tables 1 and 2). MTApulpotomy has not been shown to be effective in treatingteeth with reversible pulpitis.

4. IPT is less expensive, has fewer potential side effects, anddoes notexhibitearly exfoliation as pulpotomy does."•'"'•' "^

ConclusionsControversy persists as to the best way to perform vital pulptherapy, and additional research is needed ro see whether MTApulpotomy performs as well as IPT. From the present reviewofthe literature and research, the following conclusions canbe made:

1. Do not treat carious exposures in primary teeth with pulp-otomy or direct pulp caps. Consider pulpectomy or extrac-tion because of the high chance of irreversible pulpitisand failure of vital pulp therapy after a carious pulpexposure.

2. For deep caries approaching the pulp, the choice of IPTor pulpotomy is up to the treating dentist.

3. Use glass ionomer caries control tor deep cavitated lesionsto diagnose the status ofthe pulp with or without historyof pain to attain the highest success for vital pulp therapy.Stay out ofthe pulp by using IPT for a higher long-termchance of success compared with formocresol and ferricsulfate pulpotomy.

4. IPT has been shown to have a lower cost, higher successlong-term, better exfoliation pattern, and better successtreating reversible pulpitis than pulpotomy.

References1. American Academy of Pédiatrie Dentistry. Clinical guide-

lines on pulp therapy for primary and young permanentteeth: reference manual 2006-07. Pediatr Dent 2006;28:144-8.

2. Rodd H. A pain in the pulp: innervation inflammationand management ofthe compromised primary toothpulp—synopses. Newsl Aust N Z Soc Paediatr Dent2005;32:3-5.

3. Reeves R, Stanley HR. The relationship of bacterialpenetration and pulpal pathosis in carious teeth. Oral Surg1966;22:59-65.

4. Shovelton DS. A study of deep carious dentin. Int Dentj 1968;18:392^0S.

5. Lin L, Langeland K. Light and electron microscopic studyofteeth with carious pulp exposures. Oral Surg 1981;51:292-316.

6. Bergenholtz C, Spangberg I.. Controversies in endodon-tics. Crit Rev Oral Biol Med 20O4;15:99-l 14.

7. Bjorndal L, Larsen T, Thylstrup A. A clinical and micro-biological study of deep carious lesions during stepwiseexcavation using long treatment intervals. Caries Res1997;31:411-7.

8. Leskell E, Ridell K, Cvek M, Majare 1. Pulp exposure afterstepwise vs direct complete excavation of deep airiouslesions in young posterior permanent teeth. Endod DentTraumatol 1996; 12:192-6.

9. Eidelman E, Ulmansky M, Michaeli Y. Histopathologyof the pain in primary incisors with deep dentinal caries.Pediatr Dent 1992;l4:1372-5.

10. AAPD. Clinical guideline on pédiatrie restorative den-tistry: reference manual 2006-07. Pediatr Dent 2006;28:136-43.

11. Vij R, Coll JA, Shelton P, Farooq NS. Caries control andother variables associated with success of primary molarvital pulp therapy. Pediatr Dent 2004;26:2l4-20.

12. Bonecker M, Toi C, Cleaton-Jones P. Murans strepto-cocci and lactobaccili in carious dentin before and afteracraumatic restorative treatment. J Dent 2003;31:423-8.

13. Loyola-Rodriquez JP, Garcia-Godoy F, Lindquist R.Growth inhibition of glass ionomer cements on mutansstreptococci. Pediatr Dent 1994; 16:346-9.

14. Wambier DS, dos Santos FA, Guedes-Pinto AC, JacqerRG, Simionato MRL. Ultrastructural and microbiologicalanalysis of the dentin layers affected by caries lesions inprimary molars treated by minimal intervention. PediatrDent2007;29:228-34.

SHOULD INDIRECT PULP CAPPING REPLACE PULPOTOMY? 235

PEOIATRiC DE^T15TRY V 30 ' NO 3 MAY • JUN 08

15. Oliveira EF, Carminatti G, Fontaneila V, Maltz M. Themonitoring of deep caries lesions after incomplete cariesremoval: results after 14-18 months. Clin Oral Investig 2006;10:134-9.

16. Campbell A, Coll JA. Thesis: diagnostic success of the glassionomer sedative filling determining pulpal vitality inprimary molars with deep caries. 2007: Baltimore, MD:University of Maryland Pédiatrie Dental Department.

17. Forooq NS, Coll JA, Kuwabara A, Shelton R Success ratesof formocresol pulpotomy and indirest pulp therapy inthe treatment of deep dentinal caries in primary teeth.Pediatr Dent 2000;22:278-86.

18. Dean JA, Mack RB, Fulkerson BT, Sanders BJ. Compari-son of electrosurgical and formocresol pulpotomy proce-dures in children. Int J Paediatr Dent 2002;12:177-82.

19. Huth KC, Paschos E, Hajek-Al-Khatar N, et ai. Effective-ness of 4 pulpotomy techniques: randomized controlledtrial. J Dent Res 2005;84:l 144-8.

20. Rolling I, Thylstrup A. A 3-year clinical follow-up studyof pidpotomized primary molars treated with formocresoltechnique. Scand J Dent Res 1975:83:47-53.

21. Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomyin primary molars: a retrospective study. Pediatr Dent2000;22:192-9.

22. Casas MJ, Kenny DJ, Johnston DH, Judd PL. Long-termoutcomes of primary molar ferric sulfate pulpotomy androot canal therapy. Pediatr Dent 2004;26:44-8.

23. Eidelman E, Holan G, Fuks AB. Mineral trioxide aggre-gate vs formocresol in pulpotomized primary molars: apreliminary report. Pediatr Dent 2001 ;23:15-8.

24. Jabbarifar SE, Khademi A, Ghasemi D. Success rate offormocresol pulpotomy vs mineral rrioxide aggregate inhuman primary molar tooth. J Res Med Sei 2004;6:304-7.

25. Holan C, Eidelman E. Fuks AB. Long-term evaluationoi pulpotomy in primary molars using mineral trioxideaggregate of formocresol. Pediatr Dent 2005;27:129-36.

26. Peng L, Ye L, Tan H, Zhou X. Evaluation of the formo-cresol vs mineral trioxide aggregate primary molar pulp-otomy: a meta-analysis. Oral Surg Oral Med Oral PathoiOral Radiol Endod 2006;I02:e40-4.

27. Holan G, Fuks AB, Keltz N. Success of formocresol pulp-otomy in primary molars restored with steel crowns vsamalgam. Pediatr Dent 2002;24:212-6.

28. Nirschl RF, Avery DR. Evaluation of a new pulp cappingagent in indirect pulp therapy. J Dent Child 1983;50:25-30.

29. Al-Zayer MA, StrafFon LH, Feigal RJ, Welch KB. Indirectpulp treatment of primary posterior teeth: a retrospectivestudy. Pediatr Dent 2003:25:29-36.

30. Falster CA, Araujo FB, Straffon LH, Nor JE. Indirect pulptreatment: In vivo outcomes of an adhesive resin systemvs calcium hydroxide for protection of the dentin-pulpcomplex. Pediatr Dent 2002;24:24l-8.

31. Dunston B, Coll JA. A survey of primary tooth pulp the-rapy as taught in US dental schools and practiced by diplo-mates of the American Board of Pédiatrie Dentistry. PediatrDent 2008:30:42^8.

32. International Agency for Research on Cancer, World HealthOrganization. 1A_RC classifies formaldehyde as carcino-genic to humans. Press release no. 153, June 15, 2004,Available at: "http://wv™'.iarc.fr/ENG/Press_Releases/archives/prl 53a.html". Accessed February 27, 2008.

33- Milnes AR. Persuasive evidence that formocresoi use ¡npédiatrie dentistry is safe. J Can Dent Assoc 2006;72:247-8.

34. Zazar PA, Rosenblatt A, Takahashi CS, Takeuehi PL,Costa Jr LA. Formocresol mutagenicity following primarytooth pulp therapy: an in vivo study. J Dent 2003:31:479-85.

35. Dental Benefits Plus fee schedule. Available at: "http://www.dentalbenefitsplus.com/FeeScheduIe/FeeSeheduIe-Download.asp". Aecessed November 23, 2007.

36. Creighton International dental fee schedule for Pennsylva-nia. Available at: "http://www.nationalinsurancestorc.eom/care/jump.htm". Accessed November 23, 2007.

37. Aponte AJ, Hartsook JT, Crowley MC. Indireet pulpeapping verified. J Dent Child 1966;33:164-6.

38. Mertz-Fairhurst EJ, Curtis JW, Ergle JW, RueggebergFA, Adair SM. Ultraeonservative and cariostatie sealed res-torations: results at year 10. J Am Dent Assoe 1998; 129:55-66.

Conflict of Interest; James A. Coll, DMD, MS, is a paideonsultant to the Maryland State Dental Board in the reviewof dental eharts of pédiatrie patients.

Copyright © 2008 American Academy of PédiatrieDentistry and Ameriean Association of Endodontists.

This article is being published concurrently in journal ofEndodontics ]n\y 2008;34:7S. The articles are identical. Eithercitation can be used when citing this article.

?36 SHOUtD INDIRECT PUtP CAPPING REPLACE PUtPOTOMY?