R E V I E W
I N G
P U L P
T R E A T M
E N T
F O R
PRIMARY TEETH DON M. RANLV, D.D.S., PH.D.; FRANKLIN G A R CIA-G O D O V , D.D.S., M.S.
anatomy of the roots of primary teeth and their proximity to the developing permanent tooth buds compelled practitioners to deviate from conventional endodontic treatment. Most modalities used in the pulp treatm ent of primary teeth have evolved through observation and experience.
ABSTRACT
PULPOTOMY THERAPY
D eficien cies o f pulpotom y and pulpectom y treatm ent o f prim ary teeth have prom oted considerable laboratory and clinical research. Som e o f these findings and their im plications are review ed.
Dentists have vacillated between calcium hydroxide and formocresol as a pulpotomy agent in the treatm ent of primary teeth.1 The rationale for use of calcium hydroxide is more biologically sound: it is capable of promoting reparative dentin formation and physiologically sound roots.2In contrast, the components of formocresol, formaldehyde and cresol, have no healing attributes; they are intended to fix pulp tissue.3 Despite the desirable properties of calcium hydroxide, it often results in internal resorption.4 Formocresol, by default, remains the preferred drug, although its success rate is still less than desirable, and its components have been criticized for their toxicity.5"7
To resurrect calcium hydroxide as a viable pulpotomy agent, hardsetting preparations such as Dycal (L.D. Caulk) or Life (Sybron/Kerr) have recently been recom mended.8These cements release fewer hydroxyl ions than pure calcium hydroxide and are gentler to the pulp.9 It has not been determined, however, whether the internal resorption seen in calcium hydroxide pulpotomies results from excessive or inadequate tissue necrosis or failures from faulty technique.10Some failures may result from faulty techniques when extra-pulpal blood clots are left between the calcium hydrox ide and the cut tissue. In these cases, the hydroxal ions would be trapped in the clot and the requis
ite induction of odontoblast dif ferentiation could not occur. In a 1984 pulpotomy study using Life,11hemostatic control was emphasized. While the results were encouraging, the study was too short-term and lacked sufficient numbers to legitimately compare the efficacy of hardsetting preparations with conventional calcium hydroxide. Whether the reduction in the alkalinity beneath these cements help the initiation of reparative dentin and prevent internal resorption is unknown. One study suggests that this is false.12 Studies have disclosed that most commercial preparations of formocresol (19 percent formal dehyde and 35 percent cresol) are stronger than necessary.13It was recommended some years ago that the full-strength preparations be diluted 1:5 with a mixture of water and glycerol.14Although this dilution was arbitrary, any reasonable dilution would probably be just as effective and still reduce the amount of formal dehyde and cresol exposure. Diluted formocresol has been shown to be effective in practice, but its use has not become wide spread, presumably because it is JADA, Vol. 122, September 1991
83
not commercially available.'4,16 Recently, alternatives to formo cresol have been investigated extensively. Formocresol is derived from two active components—formaldehyde and cresol—having completely disparate properties. Formaldehyde is a well-known fixative that reacts with the proteins of the pulp and bacteria. It presumably denatures the toxins and the autolytic enzymes and converts an acute inflammation into a chronic state.16 Cresol is a caustic, phenol-like drug that dissolves cell membranes and homogenizes pulp.17Like formaldehyde, it is a strong disinfectant, but it has no fixative properties.18The combination of formaldehyde and cresol affects the radicular pulp to a considerable depth, even after a short five-minute exposure.19 Cresol may dissolve natural tissue barriers and permit formaldehyde to prenetrate further into the canals than it would normally. In an effort to mimic the posi tive properties of formocresol, while at the same time eliminating the causticity of cresol, alternative fixative agents have been suggested. One of these, glutaraldehyde, was first proposed as a disinfectant and irrigant for endodontic therapy,20but many of its highly touted properties were soon appreciated by those seeking an alternative pulpotomy agent.21'22 Glutaraldehyde is a better fixative than formaldehyde and can be used at a lesser concen tration.23Its reaction products are less antigenic than those of formaldehyde,24but extensive toxicity testing has shown that any systemically distributed glutaraldehyde would be easily metabolized or excreted.25 Glutaraldehyde fixation is limited to shallow, well-demarcated zones, 84
JADA, Vol. 122, September 1991
and pulp tissue distal to the fixed stratum is vital and minimally inflamed.21'26 Clinical results with glutaral dehyde have been mixed, with the success ranging from 98 percent to 82 percent.2728The latter followed the protocol for formocresol, where the pellet is squeezed dry to reduce the causticity of the agent. We speculate that when 2 percent glutaraldehyde is so handled, insufficient fixative remains to treat the tissue, resulting in unfixed pulp tissue in direct contact with zinc oxide-eugenol, a base known to provoke internal resorption in primary teeth.29We recommend that excess glutaral dehyde be removed from the pellet by blotting and not squeezing.27 To avoid aldehydes altogether, one proposition is eliminating pulpotomies by pulpectomies.30 Such a move would make children’s pulp therapy labor intensive. Another drawback to this proposal is the recommended use of ZOE as a root canal filler. Another alternative includes electrosurgery to heat, denature or obliterate infected radicular tissue. Histologic sections of electrosurgerized teeth of animals show a spectrum of necrotic and inflamed tissue.31,32Clearly, the argument in favor of electrosurgery is convenience and not the preservation of vital tissue. PULPECTOMY THERAPY
In cases of infection or clinical signs of radicular involvement after coronal amputation, the preferred treatment is a pulpectomy. Traditionally, a pulpectomy has involved mechanical debride ment of the canals, followed by obturation with ZOE.5Putting formocresol into the root canal filler is strongly discouraged; reinforced ZOE and even pure ZOE can sometimes inflict damage33,34;
in the majority of cases, it resists resorption.34When this occurs, there is a chance for the eruption path of the succedaneous tooth to be obstructed. Anterior permanent teeth are particularly vulnerable to ectopic eruption when pulpectomized antecedents fail to exfoliate properly. Other studies have advocated iodoform paste (Kri Paste, Pharmachemie) as a root canal filler in primary teeth.35,36The advantages of this paste are: *■ As a disinfectant, it has been used for many years to treat osteitis after an extraction. *■ As a very smooth, viscous material, it can be spun in with a lentulo spiral or injected with a pressure syringe. "" The paste is resorbable, so that any paste inadvertently expressed into extra-dental spaces is quickly removed. ■* It satisfies the criterion of an ideal pulpectomy agent: it disinfects, handles well and resorbs in synchrony with the root. Our results with iodoform paste have been excellent. We have seen many cases in which infection is dispelled and lost furcal bone is quickly replaced. In cases where the paste is extruded extradentally, it was resorbed without incidence. Dr. Ranly is
professor, Pediatric Dentistry, The
University of Texas Health Science
C en ter, 7 7 0 3 Floyd Curl Dr., San
Antonio, 7 8 2 8 4 -7 8 8 8 . Address requests for reprints to Dr. Ranly.
SUMMARY
Many traditional pulp treatment modalities for primary teeth are still used. The current trend is in reducing the toxicity of the standard drugs or finding new biocompatible agents. New pulp
SUGARLESS GUM
Dr. G arcia-G odoy is professor, P ediatric Dentistry, The University o f Texas H ealth Science C en ter, San Antonio.
agents are complex and not discovered as rapidly as dental materials; however, we are continuously trying to improve pulp therapy in children. ■
In f o rm a tio n a b o u t th e m a n u fa c tu re rs o f th e p ro d u c ts m e n tio n e d in th is a r tic le m a y b e av a ila b le fro m th e a u th o rs . N e ith e r th e a u t h o r s n o r th e A m e ric a n D e n ta l A s s o c ia tio n h a s a n y c o m m e r ic a l i n t e r e s t in th e p ro d u c ts m e n tio n e d . 1. R a n ly DM . P u lp t h e r a p y in p r im a r y te e th . A re v ie w a n d p ro s p e c tu s . A c ta O d o n to l P e d ia t 1982;3:63-8. 2. Z a n d e r HA. R e a c tio n o f th e p u lp to c a lc iu m h y d ro x id e . J D e n t re s 1939;18:373-9. 3. S w e e t CA. P ro c e d u re fo r t r e a t m e n t o f e x p o s e d a n d p u lp le s s d e c id u o u s te e th . JA D A 1930;17:1150-3. 4 . D o y le WA, M cD o n ald R E , M itc h ell D F. F o rm o c re s o l v e r s u s c a lc iu m h y d ro x id e in p u lp o to m y . J D e n t C h ild 1962;29:86-97. 5. M a th e w s o n R J, P rim o s c h R E, R o b e rts o n D. F u n d a m e n ta ls o f p e d ia tr ic d e n tis try . 2 n d ed . C hicago: Q u in tessen c e;1 9 8 7 :2 7 8 . 6. L ew is BB, C h e s te r SB. F o rm a ld e h y d e in d e n tis try : a re v ie w o f m u ta g e n ic a n d c a rc in o g e n ic p o te n tia l. JADA 1981;103:429-34. 7. R a n ly DM , B o y an BD. T h e e ffe c ts o f fo rm o c re s o l o n lip id s o f b o v in e p u lp . J E n d o d 1986;12:559-63. 8 . S ta n le y HR. P u lp c a p p in g : c o n s e rv in g th e d e n ta l p u lp —c a n it b e d o n e ? Is it w o r th it? O ra l S u rg O ra l M ed O ra l P a th 1989:68:628-39. 9. S ta e h le H J, P io c h T, H o p p e W. T h e alk a liz in g p r o p e r tie s o f c a lc iu m h y d ro x id e c o m p o u n d s . E n d o d D e n t T r a u m a to l 1989;5:147-52. 10. S c h ro e d e r U, G r a n a th L. O n in t e r n a l d e n tin e r e s o r p tio n in d e c id u o u s m o la rs tr e a te d b y p u lp o to m y a n d c a p p e d w ith c a lc iu m h y d ro x id e . O d o n to l R ev y 1971;22:17987. 11. H e ilig J , Y a te s J, S is k in M, M cK n ig h t J, T u r n e r J. C a lc iu m h y d ro x id e p u lp o to m y fo r p r im a r y te e th : a clin ica l stu d y . JA D A 1984;108:775-8. 12. K irk E E J, L im DC, K h a n MOG. A c o m p a ris o n of d e n tin o g e n e s is o n p u lp c a p p in g w ith c a lc iu m h y d ro x id e in p a s te a n d c e m e n t fo rm . O ra l S u rg O ra l M ed O ral P a th o l 1989;68:210-9. 13. L oos P J, S tr a ff o n LH, H a n SS. B iological effe c ts of fo rm o c re s o l. J D e n t C h ild 1973;40:193-7. 14. M o ra w a A P, S tra ffo n LH, H a n SS, C o rp ro n RE. C lin ica l e v a lu a tio n o f p u lp o to m ie s u s in g d ilu te fo rm o c re s o l. J D e n t C h ild 1975;42:360-3. 15. F u k s AB, B im s te in E. C lin ica l e v a lu a tio n o f d ilu te d fo rm o c re s o l p u lp o to m ie s in p r im a r y te e th o f sch o o l c h ild re n . P e d ia tr D e n t 1981;3:321-3. 16. R a n ly DM, L az za ri E P . T h e F o rm o c re s o l p u lp o to m y — th e p a s t, th e p r e s e n t, a n d th e fu tu re . J P e d o d o n t 1978;2:115-27. 17. R a n ly DM, G a rcia-G o d o y F . A c o m p a ris o n o f th e e ffe c ts o f c r e s o l a n d e u g e n o l o n b o v in e p u lp . E n d o d D e n t T ra u m a to l 1988;4:70-5.
18. N e ls o n JR , L az za ri E P , R a n ly DM, M a d d e n RM. B io c h e m ic a l effe c ts o f tis s u e fix a tiv e o n b o v in e p u lp . J E n d o d 1979;5:139-44. 19. G arcia-G o d o y F. P e n e t r a t io n a n d p u lp a l re s p o n s e by tw o c o n c e n tr a tio n s of fo rm o c re s o l u s in g tw o m e th o d s o f a p p lic a tio n . J P e d o d 1981;5:102-35. 20. ‘s -G ra v e n m a d e E J . S om e b io c h e m ic a l c o n s id e r a tio n s o f fix a tio n in e n d o d o n tic s . J E n d o d 1975;1:233-7. 21. K o p e l HM , B e rn ic k S, Z a c h ris s o n E , D e R o m ero SA. T h e effe c ts o f g lu ta ra ld e h y d e o n p r im a r y tis s u e fo llo w in g c o r o n a l a m p u ta tio n . A n in vivo h is to lo g ic s tu d y . J D e n t C h ild 1980;47:425-30. 22. D a v is MG, M yers R, S w itk e s MD. G lu ta ra ld e h y d e : a n a lte r n a tiv e to fo r m o c re s o l fo r vita l p u lp th e ra p y . J D e n t C h ild 1982;49:176-80. 2 3 . F litn e y FW . T h e tim e c o u r s e o f th e fix a tio n of a lb u m in b y fo r m a ld e h y d e , g lu ta ra ld e h y d e , a c ro le in , a n d o t h e r h ig h e r a ld e h y d e s . J R M icrosc S o c 1986;85:353-4. 24. R a n ly DM, H o rn D, Z islis T . T h e e f fe c t o f a lte r n a tiv e s to fo r m o c re s o l o n a n tig e n ic ity o f p ro te in s . J D e n t R es 1985;64:1225-8. 2 5 . R a n ly DM, H o rn D. D is trib u tio n , m e ta b o lis m , a n d e x c re tio n o f [14C] g lu ta ra ld e h y d e . J E n d o d 1990;16:135-9. 2 6 . G arcia-G o d o y F, H e rn a n d e z P e r e y r a J , T ello d e H e r n a n d e z T, R a n ly DM. H u m a n p u lp a l re s p o n s e to g lu ta ra ld e h y d e . (A b s tr a c t no. 148) J D e n t R es 1989;68:200. 27. G a rcia-G o d o y F . A 4 2 m o n th c lin ic a l e v a lu a tio n o f g lu ta r a ld e h y d e p u lp o to m ie s in p r im a r y te e th . J P e d o d 1986;10:148-55. 28. F u k s A B , B im s te in E, G u e lm a n n M, K lein H. A s s e s s m e n t o f a 2 p e r c e n t b u ffe re d g lu ta ra ld e h y d e s o lu tio n in p u lp o to m iz e d p rim a r y te e th o f s c h o o lc h ild re n . J D e n t C h ild 1990;57:371-5. 29. M a g n u s s o n B. T h e r a p e u tic p u lp o to m y in p rim a r y m o la r s - c lin ic a l a n d h is to lo g ic follow -up. II. Z inc oxidee u g e n o l a s w o u n d d re s s in g . O d o n to l R evy 1971;22:45-54. 30. Y acobi R , K e n n y D J, J u d d PL, J o h n s to n DH. E v o lv in g p r im a r y p u lp t h e r a p y te c h n iq u e s . JA D A 1991;122(2):83-85. 31. S h a w DW, S h e lle r B, B a rru s BD, M o rto n T H J r. E le c tr o s u rg ic a l p u lp o to m y —a 6 -m o n th s tu d y in p rim a te s . J E n d o d 1987;10:500-5. 32. S h u lm a n ER , M c lv e r FT, B u rk e s E J J r . C o m p a ris o n o f e le c tro s u rg e ry a n d fo rm o c re s o l a s p u lp o to m y t e c h n iq u e s in m o n k e y p r im a r y te e th . P e d ia tr D e n t 1987;9:189-94. 33. J e r r e l l RG, R o n k SI. D e v e lo p m e n ta l a r r e s t o f a s u c c e d a n e o u s to o th fo llo w in g p u lp e c to m y in a p rim a r y to o th . J P e d o d o n t 1982;6:337-42. 34. C oll JA , J o s e ll S, N a s so f S, S h e lto n P, R ic h a r d s MA. A n e v a lu a tio n o f p u lp a l t h e r a p y i n p rim a r y in c is o rs . P e d ia tr D e n t 1988;178-84. 35. R ifk in A. A s im p le , e ffec tiv e , s a f e te c h n iq u e fo r th e ro o t c a n a l t r e a t m e n t o f a b s c e s s e d p rim a r y te e th . J D e n t C h ild 1980;47:435-41. 36. G arcia-G o d o y F. E v a lu a tio n o f a n io d o fo rm p a s te in ro o t c a n a l t h e r a p y fo r in fe c te d p rim a r y te e th . J D e n t C h ild 1987;54:30-4.
passes the “acid” test
The CARE*FREE way makes snacks “OK” Studies show that CARE » F R E E ® Su garless G um effectively neutralizes acids after snacks. In te r p ro x im a l p la q u e pH w ith s u g a r le s s g u m a ft e r s n a c k 1 Before CARE FREE«
During CARE FREE®
\
After CARE-FREE®
"Safety Zone"
/
\ /
Dem ineralization "Acid Zone"
^1-----------1---------- 1-------- — I------ 1------------- 1------- r- ' 0
10
20
30
40
50
60
Tim e in minutes
In caries-active patients, a snack can mean 2 hours in the acid “ dem ineralization zon e.” However, w hen patients chew sugarless gu m for ju st 10 m inutes im m ediately after snacking, acid levels return to the norm al or “ safe” level. W hen they can ’t brush, rinse o r floss after snacking, C A R E * F R E E ® Su garless G um provides a valuable alternative.
Now it’s even easier and faster to order CARE*FREE® Sugarless Gum C harge you r order o f C A R E *F R E E ® Sugarless G um , Sugarless BU BBLE YU M ® Bubble G um , and BREATH SA V ER S® S u g a r Free Mints on VISA o r M asterCard and we can even ship it to you overnight. Call 1-80 0 -44 1-4 193 to order, or to receive our free cavity-fighting fact booklet. 1J e n se n ME. Effects of chew ing sorbitol gu m on h u m an salivary a n d interproxim al plaque pH . J C lin Dent. 1988;1:6-19.
© 1991, P lanters LifeSavers C om pany
I N G
P U L P
T R E A T M
E N T
F O R
PRIMARY TEETH DON M. RANLV, D.D.S., PH.D.; FRANKLIN G A R CIA-G O D O V , D.D.S., M.S.
anatomy of the roots of primary teeth and their proximity to the developing permanent tooth buds compelled practitioners to deviate from conventional endodontic treatment. Most modalities used in the pulp treatm ent of primary teeth have evolved through observation and experience.
ABSTRACT
PULPOTOMY THERAPY
D eficien cies o f pulpotom y and pulpectom y treatm ent o f prim ary teeth have prom oted considerable laboratory and clinical research. Som e o f these findings and their im plications are review ed.
Dentists have vacillated between calcium hydroxide and formocresol as a pulpotomy agent in the treatm ent of primary teeth.1 The rationale for use of calcium hydroxide is more biologically sound: it is capable of promoting reparative dentin formation and physiologically sound roots.2In contrast, the components of formocresol, formaldehyde and cresol, have no healing attributes; they are intended to fix pulp tissue.3 Despite the desirable properties of calcium hydroxide, it often results in internal resorption.4 Formocresol, by default, remains the preferred drug, although its success rate is still less than desirable, and its components have been criticized for their toxicity.5"7
To resurrect calcium hydroxide as a viable pulpotomy agent, hardsetting preparations such as Dycal (L.D. Caulk) or Life (Sybron/Kerr) have recently been recom mended.8These cements release fewer hydroxyl ions than pure calcium hydroxide and are gentler to the pulp.9 It has not been determined, however, whether the internal resorption seen in calcium hydroxide pulpotomies results from excessive or inadequate tissue necrosis or failures from faulty technique.10Some failures may result from faulty techniques when extra-pulpal blood clots are left between the calcium hydrox ide and the cut tissue. In these cases, the hydroxal ions would be trapped in the clot and the requis
ite induction of odontoblast dif ferentiation could not occur. In a 1984 pulpotomy study using Life,11hemostatic control was emphasized. While the results were encouraging, the study was too short-term and lacked sufficient numbers to legitimately compare the efficacy of hardsetting preparations with conventional calcium hydroxide. Whether the reduction in the alkalinity beneath these cements help the initiation of reparative dentin and prevent internal resorption is unknown. One study suggests that this is false.12 Studies have disclosed that most commercial preparations of formocresol (19 percent formal dehyde and 35 percent cresol) are stronger than necessary.13It was recommended some years ago that the full-strength preparations be diluted 1:5 with a mixture of water and glycerol.14Although this dilution was arbitrary, any reasonable dilution would probably be just as effective and still reduce the amount of formal dehyde and cresol exposure. Diluted formocresol has been shown to be effective in practice, but its use has not become wide spread, presumably because it is JADA, Vol. 122, September 1991
83
not commercially available.'4,16 Recently, alternatives to formo cresol have been investigated extensively. Formocresol is derived from two active components—formaldehyde and cresol—having completely disparate properties. Formaldehyde is a well-known fixative that reacts with the proteins of the pulp and bacteria. It presumably denatures the toxins and the autolytic enzymes and converts an acute inflammation into a chronic state.16 Cresol is a caustic, phenol-like drug that dissolves cell membranes and homogenizes pulp.17Like formaldehyde, it is a strong disinfectant, but it has no fixative properties.18The combination of formaldehyde and cresol affects the radicular pulp to a considerable depth, even after a short five-minute exposure.19 Cresol may dissolve natural tissue barriers and permit formaldehyde to prenetrate further into the canals than it would normally. In an effort to mimic the posi tive properties of formocresol, while at the same time eliminating the causticity of cresol, alternative fixative agents have been suggested. One of these, glutaraldehyde, was first proposed as a disinfectant and irrigant for endodontic therapy,20but many of its highly touted properties were soon appreciated by those seeking an alternative pulpotomy agent.21'22 Glutaraldehyde is a better fixative than formaldehyde and can be used at a lesser concen tration.23Its reaction products are less antigenic than those of formaldehyde,24but extensive toxicity testing has shown that any systemically distributed glutaraldehyde would be easily metabolized or excreted.25 Glutaraldehyde fixation is limited to shallow, well-demarcated zones, 84
JADA, Vol. 122, September 1991
and pulp tissue distal to the fixed stratum is vital and minimally inflamed.21'26 Clinical results with glutaral dehyde have been mixed, with the success ranging from 98 percent to 82 percent.2728The latter followed the protocol for formocresol, where the pellet is squeezed dry to reduce the causticity of the agent. We speculate that when 2 percent glutaraldehyde is so handled, insufficient fixative remains to treat the tissue, resulting in unfixed pulp tissue in direct contact with zinc oxide-eugenol, a base known to provoke internal resorption in primary teeth.29We recommend that excess glutaral dehyde be removed from the pellet by blotting and not squeezing.27 To avoid aldehydes altogether, one proposition is eliminating pulpotomies by pulpectomies.30 Such a move would make children’s pulp therapy labor intensive. Another drawback to this proposal is the recommended use of ZOE as a root canal filler. Another alternative includes electrosurgery to heat, denature or obliterate infected radicular tissue. Histologic sections of electrosurgerized teeth of animals show a spectrum of necrotic and inflamed tissue.31,32Clearly, the argument in favor of electrosurgery is convenience and not the preservation of vital tissue. PULPECTOMY THERAPY
In cases of infection or clinical signs of radicular involvement after coronal amputation, the preferred treatment is a pulpectomy. Traditionally, a pulpectomy has involved mechanical debride ment of the canals, followed by obturation with ZOE.5Putting formocresol into the root canal filler is strongly discouraged; reinforced ZOE and even pure ZOE can sometimes inflict damage33,34;
in the majority of cases, it resists resorption.34When this occurs, there is a chance for the eruption path of the succedaneous tooth to be obstructed. Anterior permanent teeth are particularly vulnerable to ectopic eruption when pulpectomized antecedents fail to exfoliate properly. Other studies have advocated iodoform paste (Kri Paste, Pharmachemie) as a root canal filler in primary teeth.35,36The advantages of this paste are: *■ As a disinfectant, it has been used for many years to treat osteitis after an extraction. *■ As a very smooth, viscous material, it can be spun in with a lentulo spiral or injected with a pressure syringe. "" The paste is resorbable, so that any paste inadvertently expressed into extra-dental spaces is quickly removed. ■* It satisfies the criterion of an ideal pulpectomy agent: it disinfects, handles well and resorbs in synchrony with the root. Our results with iodoform paste have been excellent. We have seen many cases in which infection is dispelled and lost furcal bone is quickly replaced. In cases where the paste is extruded extradentally, it was resorbed without incidence. Dr. Ranly is
professor, Pediatric Dentistry, The
University of Texas Health Science
C en ter, 7 7 0 3 Floyd Curl Dr., San
Antonio, 7 8 2 8 4 -7 8 8 8 . Address requests for reprints to Dr. Ranly.
SUMMARY
Many traditional pulp treatment modalities for primary teeth are still used. The current trend is in reducing the toxicity of the standard drugs or finding new biocompatible agents. New pulp
SUGARLESS GUM
Dr. G arcia-G odoy is professor, P ediatric Dentistry, The University o f Texas H ealth Science C en ter, San Antonio.
agents are complex and not discovered as rapidly as dental materials; however, we are continuously trying to improve pulp therapy in children. ■
In f o rm a tio n a b o u t th e m a n u fa c tu re rs o f th e p ro d u c ts m e n tio n e d in th is a r tic le m a y b e av a ila b le fro m th e a u th o rs . N e ith e r th e a u t h o r s n o r th e A m e ric a n D e n ta l A s s o c ia tio n h a s a n y c o m m e r ic a l i n t e r e s t in th e p ro d u c ts m e n tio n e d . 1. R a n ly DM . P u lp t h e r a p y in p r im a r y te e th . A re v ie w a n d p ro s p e c tu s . A c ta O d o n to l P e d ia t 1982;3:63-8. 2. Z a n d e r HA. R e a c tio n o f th e p u lp to c a lc iu m h y d ro x id e . J D e n t re s 1939;18:373-9. 3. S w e e t CA. P ro c e d u re fo r t r e a t m e n t o f e x p o s e d a n d p u lp le s s d e c id u o u s te e th . JA D A 1930;17:1150-3. 4 . D o y le WA, M cD o n ald R E , M itc h ell D F. F o rm o c re s o l v e r s u s c a lc iu m h y d ro x id e in p u lp o to m y . J D e n t C h ild 1962;29:86-97. 5. M a th e w s o n R J, P rim o s c h R E, R o b e rts o n D. F u n d a m e n ta ls o f p e d ia tr ic d e n tis try . 2 n d ed . C hicago: Q u in tessen c e;1 9 8 7 :2 7 8 . 6. L ew is BB, C h e s te r SB. F o rm a ld e h y d e in d e n tis try : a re v ie w o f m u ta g e n ic a n d c a rc in o g e n ic p o te n tia l. JADA 1981;103:429-34. 7. R a n ly DM , B o y an BD. T h e e ffe c ts o f fo rm o c re s o l o n lip id s o f b o v in e p u lp . J E n d o d 1986;12:559-63. 8 . S ta n le y HR. P u lp c a p p in g : c o n s e rv in g th e d e n ta l p u lp —c a n it b e d o n e ? Is it w o r th it? O ra l S u rg O ra l M ed O ra l P a th 1989:68:628-39. 9. S ta e h le H J, P io c h T, H o p p e W. T h e alk a liz in g p r o p e r tie s o f c a lc iu m h y d ro x id e c o m p o u n d s . E n d o d D e n t T r a u m a to l 1989;5:147-52. 10. S c h ro e d e r U, G r a n a th L. O n in t e r n a l d e n tin e r e s o r p tio n in d e c id u o u s m o la rs tr e a te d b y p u lp o to m y a n d c a p p e d w ith c a lc iu m h y d ro x id e . O d o n to l R ev y 1971;22:17987. 11. H e ilig J , Y a te s J, S is k in M, M cK n ig h t J, T u r n e r J. C a lc iu m h y d ro x id e p u lp o to m y fo r p r im a r y te e th : a clin ica l stu d y . JA D A 1984;108:775-8. 12. K irk E E J, L im DC, K h a n MOG. A c o m p a ris o n of d e n tin o g e n e s is o n p u lp c a p p in g w ith c a lc iu m h y d ro x id e in p a s te a n d c e m e n t fo rm . O ra l S u rg O ra l M ed O ral P a th o l 1989;68:210-9. 13. L oos P J, S tr a ff o n LH, H a n SS. B iological effe c ts of fo rm o c re s o l. J D e n t C h ild 1973;40:193-7. 14. M o ra w a A P, S tra ffo n LH, H a n SS, C o rp ro n RE. C lin ica l e v a lu a tio n o f p u lp o to m ie s u s in g d ilu te fo rm o c re s o l. J D e n t C h ild 1975;42:360-3. 15. F u k s AB, B im s te in E. C lin ica l e v a lu a tio n o f d ilu te d fo rm o c re s o l p u lp o to m ie s in p r im a r y te e th o f sch o o l c h ild re n . P e d ia tr D e n t 1981;3:321-3. 16. R a n ly DM, L az za ri E P . T h e F o rm o c re s o l p u lp o to m y — th e p a s t, th e p r e s e n t, a n d th e fu tu re . J P e d o d o n t 1978;2:115-27. 17. R a n ly DM, G a rcia-G o d o y F . A c o m p a ris o n o f th e e ffe c ts o f c r e s o l a n d e u g e n o l o n b o v in e p u lp . E n d o d D e n t T ra u m a to l 1988;4:70-5.
18. N e ls o n JR , L az za ri E P , R a n ly DM, M a d d e n RM. B io c h e m ic a l effe c ts o f tis s u e fix a tiv e o n b o v in e p u lp . J E n d o d 1979;5:139-44. 19. G arcia-G o d o y F. P e n e t r a t io n a n d p u lp a l re s p o n s e by tw o c o n c e n tr a tio n s of fo rm o c re s o l u s in g tw o m e th o d s o f a p p lic a tio n . J P e d o d 1981;5:102-35. 20. ‘s -G ra v e n m a d e E J . S om e b io c h e m ic a l c o n s id e r a tio n s o f fix a tio n in e n d o d o n tic s . J E n d o d 1975;1:233-7. 21. K o p e l HM , B e rn ic k S, Z a c h ris s o n E , D e R o m ero SA. T h e effe c ts o f g lu ta ra ld e h y d e o n p r im a r y tis s u e fo llo w in g c o r o n a l a m p u ta tio n . A n in vivo h is to lo g ic s tu d y . J D e n t C h ild 1980;47:425-30. 22. D a v is MG, M yers R, S w itk e s MD. G lu ta ra ld e h y d e : a n a lte r n a tiv e to fo r m o c re s o l fo r vita l p u lp th e ra p y . J D e n t C h ild 1982;49:176-80. 2 3 . F litn e y FW . T h e tim e c o u r s e o f th e fix a tio n of a lb u m in b y fo r m a ld e h y d e , g lu ta ra ld e h y d e , a c ro le in , a n d o t h e r h ig h e r a ld e h y d e s . J R M icrosc S o c 1986;85:353-4. 24. R a n ly DM, H o rn D, Z islis T . T h e e f fe c t o f a lte r n a tiv e s to fo r m o c re s o l o n a n tig e n ic ity o f p ro te in s . J D e n t R es 1985;64:1225-8. 2 5 . R a n ly DM, H o rn D. D is trib u tio n , m e ta b o lis m , a n d e x c re tio n o f [14C] g lu ta ra ld e h y d e . J E n d o d 1990;16:135-9. 2 6 . G arcia-G o d o y F, H e rn a n d e z P e r e y r a J , T ello d e H e r n a n d e z T, R a n ly DM. H u m a n p u lp a l re s p o n s e to g lu ta ra ld e h y d e . (A b s tr a c t no. 148) J D e n t R es 1989;68:200. 27. G a rcia-G o d o y F . A 4 2 m o n th c lin ic a l e v a lu a tio n o f g lu ta r a ld e h y d e p u lp o to m ie s in p r im a r y te e th . J P e d o d 1986;10:148-55. 28. F u k s A B , B im s te in E, G u e lm a n n M, K lein H. A s s e s s m e n t o f a 2 p e r c e n t b u ffe re d g lu ta ra ld e h y d e s o lu tio n in p u lp o to m iz e d p rim a r y te e th o f s c h o o lc h ild re n . J D e n t C h ild 1990;57:371-5. 29. M a g n u s s o n B. T h e r a p e u tic p u lp o to m y in p rim a r y m o la r s - c lin ic a l a n d h is to lo g ic follow -up. II. Z inc oxidee u g e n o l a s w o u n d d re s s in g . O d o n to l R evy 1971;22:45-54. 30. Y acobi R , K e n n y D J, J u d d PL, J o h n s to n DH. E v o lv in g p r im a r y p u lp t h e r a p y te c h n iq u e s . JA D A 1991;122(2):83-85. 31. S h a w DW, S h e lle r B, B a rru s BD, M o rto n T H J r. E le c tr o s u rg ic a l p u lp o to m y —a 6 -m o n th s tu d y in p rim a te s . J E n d o d 1987;10:500-5. 32. S h u lm a n ER , M c lv e r FT, B u rk e s E J J r . C o m p a ris o n o f e le c tro s u rg e ry a n d fo rm o c re s o l a s p u lp o to m y t e c h n iq u e s in m o n k e y p r im a r y te e th . P e d ia tr D e n t 1987;9:189-94. 33. J e r r e l l RG, R o n k SI. D e v e lo p m e n ta l a r r e s t o f a s u c c e d a n e o u s to o th fo llo w in g p u lp e c to m y in a p rim a r y to o th . J P e d o d o n t 1982;6:337-42. 34. C oll JA , J o s e ll S, N a s so f S, S h e lto n P, R ic h a r d s MA. A n e v a lu a tio n o f p u lp a l t h e r a p y i n p rim a r y in c is o rs . P e d ia tr D e n t 1988;178-84. 35. R ifk in A. A s im p le , e ffec tiv e , s a f e te c h n iq u e fo r th e ro o t c a n a l t r e a t m e n t o f a b s c e s s e d p rim a r y te e th . J D e n t C h ild 1980;47:435-41. 36. G arcia-G o d o y F. E v a lu a tio n o f a n io d o fo rm p a s te in ro o t c a n a l t h e r a p y fo r in fe c te d p rim a r y te e th . J D e n t C h ild 1987;54:30-4.
passes the “acid” test
The CARE*FREE way makes snacks “OK” Studies show that CARE » F R E E ® Su garless G um effectively neutralizes acids after snacks. In te r p ro x im a l p la q u e pH w ith s u g a r le s s g u m a ft e r s n a c k 1 Before CARE FREE«
During CARE FREE®
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After CARE-FREE®
"Safety Zone"
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Dem ineralization "Acid Zone"
^1-----------1---------- 1-------- — I------ 1------------- 1------- r- ' 0
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Tim e in minutes
In caries-active patients, a snack can mean 2 hours in the acid “ dem ineralization zon e.” However, w hen patients chew sugarless gu m for ju st 10 m inutes im m ediately after snacking, acid levels return to the norm al or “ safe” level. W hen they can ’t brush, rinse o r floss after snacking, C A R E * F R E E ® Su garless G um provides a valuable alternative.
Now it’s even easier and faster to order CARE*FREE® Sugarless Gum C harge you r order o f C A R E *F R E E ® Sugarless G um , Sugarless BU BBLE YU M ® Bubble G um , and BREATH SA V ER S® S u g a r Free Mints on VISA o r M asterCard and we can even ship it to you overnight. Call 1-80 0 -44 1-4 193 to order, or to receive our free cavity-fighting fact booklet. 1J e n se n ME. Effects of chew ing sorbitol gu m on h u m an salivary a n d interproxim al plaque pH . J C lin Dent. 1988;1:6-19.
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