Pulp Therapy In Primary Teeth — What Does The Future Hold?

The optimal treatment for the management of caries-associated pulpal disease in primary teeth continues to be controversial particularly with respect to some of the medicaments that are currently in use. The dental literature is replete with papers that report on the success or failure of primary tooth pulp therapy using a variety of techniques and medicaments. Some of these studies are well designed and randomised controlled whilst others are poorly designed and/or anecdotal in nature. The techniques used to treat primary tooth pulp may come under three basic categories: pulpotomy or partial removal of diseased pulp tissue; pulpectomy or complete excision of pulp from the coronal pulp chamber and root canal system; and indirect pulp therapy in which the caries closest to the pulp is left in situ and covered with a biocompatitible material. The clinical success of this latter technique is predicated upon the underlying pulp being healthy and vital. The literature produces a wealth of evidence that the capping of vital pulp exposures in primary teeth with calcium hydroxide is rarely successful and is thus contraindicated.

For many years, formocresol (FC) in varying concentrations and application times has been the medicant of choice in the treatment of diseased pulps in the pulpotomy technique. In essence FC fixes the surface of the radicular tissue as it enters the root canal with the result that the radicular tissue remains viable. There are concerns that FC has known mutagenic, carcinogenic and allergenic potentials. There is a wealth of evidence, however, that indicates that in the amounts used there is an inconsequential risk associated with FC use in paediatric pulp therapy. Provided that haemostasis can be achieved within five minutes following amputation of the coronal pulp tissue a one to five minute application of a cotton pellet dampened with FC will achieve successful fixation of the coronal surface of the radicular pulp tissue. For many years now FC has proven to be cost effective and has a safe track record in the treatment of diseased pulps in primary teeth.

In light of the concerns with the use of FC alternative medicaments and techniques have been proposed and their clinical efficacy reported upon. These include ferric sulphate, osteogenic proteins, hyphilized bone, electro-surgery, lasers, sodium hypochlorite, and mineral trioxide aggregate (MTA). Varying degrees of success have been reported in clinical studies in which these medicaments and techniques have been used. With the exception of ferric sulphate and, to a limited extent mineral trioxide aggregate, there is no great body of evidence to suggest that these other techniques and medicaments are viable alternatives to FC. It should be noted that although initial clinical results reported using MTA appear promising its high cost is a potent factor in its gaining universal clinical acceptance and use. The factors that must be considered as these, and yet to be introduced agents, prove their clinical efficacy is their cost and the sensitivity of technique in their placement. Given the short attention span of small children it is imperative that all of these agents should be both simple to use with a minimum amount of time required for their placement.

It may well be that in the future FC will be a historical note in the treatment of diseased primary pulp tooth tissue. Until then, however, it is this authors’ opinion that it is an essential, cost effective, safe and efficacious medicament for use in primary tooth pulp therapy since there is no compelling evidence that contra-indicates its use.