PEDIATRIC DENTISTRY/Copyright © 1982 byThe American Academy of Pedodontics/Vol. 4, No. 3

Clinical and radiographic assessment of direct pulpcapping and pulpotomy in young permanent teeth

Anna B. Fuks, CDSimon Bielak, CDAubrey Chosak, BDS, MSD

Abstract

Seventy-six vital permanent incisors withcomplicated crown t’ractures in 72 children wereassessed clinically and radiographically for the healingof pulp exposures treated by direct pulp capping or bypulpotomy. Thirty-eight of these teeth had pinpointexposures, complete roots, and were treated by pulpcapping. Pulpotomy was the treatment for the other 38teeth that had incomplete root development, regardlessof the size of the exposure. A success rate of 92% wasobserved in the teeth which were treated bypulpotomy, and 81.5% was the success rate of thosetreated by ch’rect pulp capping.

Traumatic injuries resulting in pulp exposure in

young patients present a challenge in treatment. Theimmediate objective would be the selection of a pro-cedure designed to maintain the vitality of thepulp.1 An exposed vital pulp can be treated by capping,pulpotomy, or pulpectomy, depending on several fac-tors such as: degree of pulp exposure, the intervalbetween the accident and examination, and the stageof root development. A partial pulpotomy techniquehas been recently described as another choice for suc-cessfully treating vital exposures.~

The exact indication of pulp capping has not yetbeen established. It is currently accepted that thistreatment should only be performed in teeth wherethe exposure is confined to a small area, where ex-posure occurred not more than a few hours before,and when there are no associated injuries to the sup-porting structure2

Incompletely formed teeth with vital pulps ex-posed by trauma that presented the above conditionshave been also treated by pulp capping, but a vitalpulpotomy has been considered the treatment ofchoice.4 The rationale for pulpotomy is based on theassumption that inflammation and impaired vascu-larity caused by the injuries would be confined to

the superficial part of the coronal pulp, while theradicular pulp would be normal.3

It is important to emphasize that the pulpotomyprocedure has been considered the first step in en-dodontic therapy? When apicalroot formationis com-pleted, a conventional root canal filling has beenrecommended, thus preveuting calcific degenerationand obliteration of the pulp canal2,~ This has been ac-cepted policy followed by both general practitionersand endodontists. Evidence of long-term successfuloutcome of vital pulpotomy has been presented byBodenham2 Krakov et al., suggested that root canaltreatment subsequent to pulpotomy which hasresulted in completion of the root is indicated onlywhen a post and core are required to adequatelyrestore the tooth2

The purpose of the current investigation was toassess clinically and radiographically the healing ofpulp exposures treated by direct pulp capping or bypulpotomy, and the effect on the results of the inter-val between the accident and treatment.

Methods and Materials

The study sample consisted of 76 vital permanentincisors with a complicated crown fracture in 72children. These patients, whose age varied from 7 to14 years, received emergency treatment at theDepartment of Pedodontics of the Hadassah Facultyof Dental Medicine in Jerusalem. Preoperative exam-ination revealed that the teeth showed no mobilityor slightly increased mobility, and all of them weresensitive to the electric pulp tester" stimulation.Pulp capping was performed in 38 teeth with pinpointexposures and with complete roots; pulpotomy wasthe treatment of choice for another 38 teeth that hadincomplete root development, regardless of the size~Vitapulp: The Pelton & Crane Company, Box 3664, Charlotte,NC.

240 PULPOTOMY Vs DIRECT PULP CAPPING: Fuks et at.

Sucessful follow up period in months,

Table 1. Distribution ofteeth treated by pulp cappingwith calcium hydroxide intraumatized incisors withclosed apices.

Time elapsed fromtrauma to treatment

Up to 12 hrs.13 - 24 hrs.1 - 4 days5 - 7 days

Total

Number ofteeth treated

131753

38

FailuresNo.

2302

7

9

1511066

18

0

41

.6

.5

3-5No.

2211

6

6-11No.

542

11

12-23No.

15

—6

24-35No.

121

4

36+No.

211

4

of the exposure.

The TechniquesPulp capping. The teeth were isolated with cotton

rolls, rinsed with saline and dried with cotton ap-plicators. The exposure site was then covered by acalcium hydroxide paste (CalxylborDycalc). A pinchband was fabricated and cemented with zinc oxide-eugenol cement to protect the pulp dressing andpreserve arch length.

Pulpotomy. After local anesthesia, the teeth wereisolated with a rubber dam and access to the pulpchamber was obtained with a pear-shaped N 330 car-bide bur mounted on a high speed handpiece andcooled by water. Coronal pulp amputation was doneat low speed using a sterile round bur. The amputa-tion site was placed approximately at the level of thecementoenamel junction, where the pulp canal showsa slight constriction. The wound surface was irri-gated with a sterile saline solution, and hemorrhagewas controlled by applying sterile cotton pellets.Calcium hydroxide (Calxyl)b was then applied to theamputation surface and covered by a zinc oxide-eugenol cement. A permanent filling (usuallyamalgam) was inserted to seal the access orifice tothe pulp chamber.

The treatment was considered to be successfulwhen the following criteria were observed:1. Absence of clinical symptoms (pain, tenderness

to percussion, swelling);2. No intraradicular or periapical pathology could be

detected radiographically;3. Continued root development and the presence of

a dentin bridge;4. In cases of direct pulp capping, a continuous hard

tissue barrier determined by direct clinical ex-amination and a positive response to electric pulptester stimulation. Radiographs were of littlevalue in determining the presence of a dentinbridge.

ResultsThe success rate of direct pulp capping in

traumatized incisors with closed apices can beobserved in Table 1. From a total of 38 pulp cappedteeth 7(18.5%) became necrotic; among these, 5 weretreated within 24 hours after the accident. In onlybCalxyl: Dental Preparation, Otto & Co. Frankfurt/Main - W.Germany

one case, pulp necrosis occurred as early as one weekafter treatment; in 4 cases, necrosis was observed 2or 3 months after pulp capping, and in the last 2cases, necrosis appeared after 6 and 7 months. Figure1 shows a central incisor prior to direct pulp cap-

Figure 1. Upper central incisor with complicated crown frac-ture treated by direct pulp capping: (a) immediately beforepulp capping, (b) 52 months after pulp capping.

ping 52 months after treatment. The binomialdistribution was used to calculate the probability offailure under each of two models. Model I assumedthat the probability of failure (7TPHO"") does not de-pend on the time interval between accident and treat-ment; model II assumed that the probability offailure (TTPHl"") is different in different time inter-vals. The results of the binomial distribution was7TPHO"" = 0.00208 and 7TPH1"" = 0.0322. This dif-ference was non-significant at a 5% level.

The outcome of 38 immature permanent incisorswith complicated crown fractures treated by acalcium hydroxide pulpotomy is presented in Table 2.

All but two of the teeth were vital, as assessed bycontinued root formation and apical closure (Figures2 & 3). Of these, one became necrotic 3 weeks, andthe other 6 months, after the emergency treatment.Another tooth had a pulp canal obliteration, but noperiapical pathology could be observedradiographically 4l/2 years postoperatively (Figure 4).

cDycal: The L. D. Caulk Company, Division of Dentistry, Inter-national Inc. Milford, DW.

PEDIATRIC DENTISTRY: Volume 4, Number 3 241

Figure 2. (Above, left to right) Uppercentral incisor with complicated crownfracture treated by pulpotomy: (a) im-mediately before treatment — noticethe incompletely formed root and thewide open apex, (b) 15 months aftertreatment — a dentin bridge is evidentand the root apex is almost closed, (c)5'/2 years after the pulpotomy; nopathology is observed.

Figure 3. (At right) Upper central in-cisor with complicated crown fracturetreated by pulpotomy: (a) immediatelybefore treatment — the root is in-completely formed and the apex iswide open, (b) 25 months after treat-ment — the root is fully formed andthe apex is closed.

This tooth was listed as a failure although there wereno other clinical signs or symptoms.

The binomial distribution was similarly used toevaluate the probability of failure as related to thetime interval between accident and treatment. Thefindings were 7TPHO"" = 0.000968 and 7TPH1"" =0.2938, this difference being non-significant at a 5%level.

DiscussionThe treatment of complicated crown fractures may

involve either pulp capping, pulpotomy, or partialpulpectomy.' Direct pulp capping has been indicated incases of pinpoint exposures that occurred not morethan a few hours before, without special considera-tion to the degree of root development.3 The primaryobjective in the treatment of an incompletely form-ed tooth in which the pulp has been exposed, is toinduce continued root formation.

A succession of cases in which there was pulp

necrosis following direct pulp capping, and the poorprognosis of a non-vital young permanent incisorwith only a partially developed root and wide openapex, caused a change of treatment policy here someeight years ago. We felt that some of the failures ofpulp capping may have been due to contaminationof the pulp at the time of, or following trauma whichwas impossible to diagnose clinically. We also feltthat debridement by pulpotomy technique mightgive a higher success rate. Because of the importanceof continued vitality in teeth with underdevelopedroots, pulpotomy with calcium hydroxide became thetreatment of choice in these cases.

The growing use of the apexification technique,3

although allowing for adequate conventional rootcanal filling, still leaves a root with thin dentin wallsand a poor long-term prognosis. The failure rate forteeth treated by pulpotomy is low, and the percent-age of pulp necrosis in this study (5%), is even lowerthan the ones described in the literature.69Theinter-

242 PULPOTOMY Vs DIRECT PULP CAPPING: Fuks et al.

Figure 4. Complicated crown fracture in upper central incisor treated by pulpotomy followed by complete obliterationof the root canal (left to right): (a) preoperative radiograph taken before treatment, revealing an immature tooth, (b) adentin bridge was already evident 4 months postoperatively, (c) 10 months after treatment — notice the presence of athick dentin bridge; the root apex is almost closed, (d) complete obliteration of root canal is evident 41/z years after pulpotomy.

val between the accident and treatment does notseem to be critical for healing (Table 2). This confirmsthe conclusions of Cvek, who utilized a partialpulpotomy technique.2 The present results are basedon a rather small number of cases however; it is pos-sible that with a larger sample the time interval maybecome statistically significant.

In germ-free animals it has been demonstrated thatthe major determinant in the healing of exposed ro-dent pulps, was the presence or absence of microbialflora.10 In the case of pulpotomy, the dressing is placedwithin the confines of the pulp chamber, and not overa contaminated exposed pulp. Although it has beenshown experimentally that traumatized pulp tissuemay become infected by bacteria reaching the pulpvia the blood stream, unexposed tissue is less liableto be infected." Good clinical results in the differentstudies seems to justify this hypothesis.610

In a pulpotomy, the calcium hydroxide paste is pro-tected by a cement base, and therefore the remain-ing pulp is less liable to become contaminated, evenwhen the temporary filling is lost. In cases of pulpcapping, the loss of a temporary restoration wouldresult in the loss of the dressing and recontamina-tion, and would consequently lead to a possiblefailure. In teeth with fully developed roots, failure ofa pulp capping would still allow for a favorable prog-

nosis following good endodontic therapy.Pulpotomy has been advocated as an interim treat-

ment — a conventional root filling has been recom-mended when root formation is completed. Degen-erative changes like pulp calcifications, fibrosis, ordry gangrene have been the justification of such apolicy.6 Another reason why many endodontistsroutinely perform endodontic therapy in the casesmentioned above, is that the dentin bridges formedmay contain dead tracts, and are not always com-pletely calcified.12 Complete hard tissue barriers pro-tect and keep the pulps free of inflammation, butseveral degrees of inflammation have been describedunder incomplete bridges in monkey teeth.13 The factthat dead tracts and porosity have been observedhistologically in these bridges is not of clinicalsignificance, and therefore routine endodontictherapy would not be indicated.414 In the casepresented in Figure 2, despite the fact that almosttotal obliteration of the root canal occurred, noperiapical pathology was observed. Tendency toobliteration was not found in any of the other thirty-five successful cases.

ConclusionPulpotomy should not be considered an interim

treatment that should be followed by a complete root

Successful follow up period in months

Table 2. Distribution ofteeth treated by pulpotomywith calcium hydroxide intraumatized incisors withopen apices.

Time elapsed fromtrauma to treatment

Up to 1 day2 - 6 days7 - 13 days14+ days

Total

Number ofteeth treated

23744

38

FailuresNo. %

0 -3 -0 -0 -

3 7.9

6 - 11No.

2111

5

12- 23No.

62

1

9

24- 35No.

61

I

7

36+No.

9032

14

PEDIATRIC DENTISTRY: Volume 4, Number 3 243

filling. Regular periodical radiographic check-upsshould be performed in order to disclose anypathology that might eventually develop.

Direct pulp capping failed in 18.5% of the eases sotreated. However, it is still an acceptable treatmentfor traumatic exposures in teeth with fully formedroots, as these teeth have a good prognosis follow-ing root canal therapy if pulp capping fails.

Dr. Fuks is lecturer, Dr. Bielak is assistant, and Dr. Chosak isassociate professor, Department of Pedodontics, Hadassah Facultyof Dental Medicine -- ttebrew University, Jerusalem -- Israel, POBox 12 000. Requests for reprints should be sent to Dr. Fuks.

1. McDonald, R. E. Management of traumatic injuries to theteeth and suppor~ing tissues, in Dentistry for the Child &Adolescent. The (3. V. Mosby Company, Saint Louis, 1974,pp 287-323.

2. Cvek, M. A clinical report of partial pulpotomy and cappingwith calcium hydroxide in permanent incisors with com-plicated crown fractures. J Endo 4:232, 1978.

3. Andreasen, J. O. Crown fractures, in Traumatic Injuries tothe Teeth. Munksgaard, Copenhagen, Denmark, 1972, pp79-88 and 167-169.

4. Krakow, A. A., Berk, H., and Gron, P. Therapeutic inductionof root formation in the exposed incompletely formed toothwith vital pulp. Oral Surg, Oral Med, Oral Path 43:755, 1977.

5. Patterson, S. S. Pulp calcification due to operative procedures- pulpotomy. Int Dent J 17:409, 1967.

6. Hallett, G. E. M. and Porteous, J. R. Fractured incisorstreated by vital pulpotomy -- a report on 100 consecutivecases. Brit Dent J 115:279, 1963.

7. Goldmann, M. Root-end closure techniques including apex-ification. Dent Clin N Am 18:297, 1974.

8. Bodenham, R. S. The prognosis for vital pulpotomy oftraumatized permanent incisors. Dent Practit 17:327, 1967.

9. Kisling, E. Om Behandlingen a skader sore folge af acuttemekaniske traumer pa unge permanente incisiver.Tandlaegebladet 57:61 and 109, 1953.

10. Kakehashi, S., Stanley, H. R., and Fitzgerald, R. J. The ef-fects of surgical exposures of dental pulps in germ-free andconventional laboratory rats. Oral Surg, Oral Med, Oral Path20:340, 1965.

11. Burke, G. W. and Knighton, H. T. The localization ofmicroorganisms in inflamed dental pulp of rats followingbaeteremia. J Dent Res 39:205, 1960.

12. Langeland, K., Dowden, W. E., Tronstad, L., and Langeland,L. K. Human pulp changes of iatrogenic origin. Oral Surg,Oral Med, Oral Path 34:944, 1972.

13. Holland, R., Souza, V., Mello, W., Nery, M. J., Bernabe, P.E. E., and Otoboni, J. A. Permeability of the hard tissue bridgeformed after pulpotomy with calcium hydroxide: a histologiestudy. JADA 99:472, 1979.

14. Berk, H. and Krakow, A. A. A comparison of the manage-ment of pulpal pathosis in deciduous and permanent teeth.Oral Surg, Oral Med, Oral Path 34:944, 1972.

Quotable QuoteThe issue (evolution) was seen by Darwin’s defenders, such as T. H. Huxley, as a straight conflict between

bigotry and enlightened rationalism. Darwin’s theory was misinterpreted as a vindication of the political doc-trine that a policy of laissez-faire will inevitably result in Progress with a capital ’P’: on and on and on andup and up and up. What Darwin’s theory really said was that species tend to become adapted to increasinglyspecialized environments; it was not concerned with the notion of ’Progress’ at all. Yet one still encountersbiologists who refer to ’advanced’ and ’primitive’ species and who are quite evidently predisposed to thinkthat mankind can be sub divided into ’advanced’ and ’primitive’ ’races’, ’cultures’ or what have you. Needless

to say it is ’we’ who are ’advanced’, ’we’ being the particular human collectively to which the author himselfhappens to belong.

From: Leach, E. R. Men, Bishops andApes. Nature, 293:19-21, September 3,

1981.

244 PULPOTOMY Vs DIRECT PULP CAPPING: Fuks et