Clinical evaluation of pulpotomies with ZOE as the vehicle for glutaraldehyde.

The purpose of this study was to evaluate clinically and radiographically pulpotomies in human primary teeth treated with glutaraldehyde (GA) incorporated into the ZOE subbase without prior 5-min cotton pellet application. Thirty-five cariously exposed primary molars of 35 children 4 to 9 years old were pulpotomized and based with ZOE into which 2% unbuffered GA had been incorporated. Clinical and radiographic follow up varied from 6 to 24 months. No clinical or radiographic signs of failure were observed in 51.4% of the cases, while 48.6% of the teeth showed internal root resorption, furcation lesion, and~or fistulous tract. This high rate of failure indicates that the procedure using low concentrations of GA is inadvisable. Because formocresol is strongly toxic, is distributed systemically, and causes immunological, biochemical, mutagenic, teratogenic, and perhaps carcinogenic alterations in the host, I alternative chemicals have been proposed for the pulpotomy treatment (s’Gravenmade 1975; Ranly and Lazzari 1983). One of these, glutaraldehyde, a standard fixative used in electron microscopy, has been evaluated in laboratory and clinical investigations. 2 Although glutaraldehyde has not been approved by the American Dental Association as a pulpal therapeutic agent, in vitro analyses have demonstrated that glutaraldehyde is an excellent fixative (Ranly and Lazzari 1983; Nelson et al. 1979) and the trials in animals (Fuks et al. 1986; Davis et al. 1982) and humans 3 have been promising. A recent study (Seow and Thong 1986) has shown that glutaraldehyde did not produce polymorphonuclear leukocytes (PMN) lysis at high concentrations, nor did it cause activation of PMN Looset al. 1973; Block et al. 1978; Rolling and Lambjerg-Hansen 1978; Pruhs et al. 1977; Myers et al. 1983; Lewis and Chestner 1983. Nelson et al. 1979; Kopel et al. 1980; Garcia-Godoy 1983, 1986; Fuks et al. 1986. Kopel et al. 1980; Garcia-Godoy 1983, 1986. adherence at low concentrations. These findings suggest that glutaraldehyde is not as likely to cause inflammatory destruction of pulpal tissues as is formocresol, eugenol, or calcium hydroxide (Seow and Thong 1986). The traditional method of applying formocresol to the amputation site has been a moistened cotton pellet (McDonald and Avery 1983). In some situations it also is incorporated in the zinc oxide and eugenol cement (ZOE) which is used as a base over the fixed radicular tissue (Berson and Good 1982). In human and monkey teeth, diffusion of formocresol from cement alone effected pulp changes comparable to those observed following treatment with a formocresol-moistened pellet. 4 A histologic study of monkey teeth treated with a ZOE dressing containing glutaraldehyde suggested that pulp might be fixed adequately by this protocol (Tagger and Tagger 1984). An in vitro study demonstrated that 25% of the 2% glutaraldehyde solution incorporated into ZOE had diffused into the incubation solution after 25 days (Ranly and Garcia-Godoy 1985). The purpose of this study was to evaluate clinically and radiographically pulpotomies in human primary teeth treated with glutaraldehyde just incorporated into the ZOE, eliminating the 5-min moistened cotton pellet application. 4 Mejare et al. 1976; Garcia-Godoy 1981, 1984. TABLE 1. Evaluation of Pulpotomies Time in Clinical Status at the Months Last Treatment After Treatment Success Failure Total 1-6 8 4 12 7-12 4 5 9 13-24 6 8 14 Total 18 (51.4%) 17 (48.6%) 35 (I00%) 144 GLUTARALDEHYDE IN ZOE: Garcia-Godoy and Ranly FIG 1. Second primary molar treated with glutaraldehyde in ZOE. A. immediate postoperative radiograph; B. 8-month postoperative radiograph. Note the extensive furcation pathologyMethods and Materials The sample consisted of 35 children 4 to 9 years old with 35 cariously exposed primary molars. The pulps of all teeth used in the study were judged to be cariously exposed by both clinical and radiographic examination. All clinical procedures were performed by one of the authors (FGG) in a private pediatric dental practice in Santo Domingo, Dominican Republic. The criteria used for selection of the teeth included in the study were: (1) radiographically and clinically symptomless pulp exposure by caries; (2) no clinical or radiographic evidence of extensive pulp degeneration; (3) the possibility of proper restoration of the tooth; (4) pulp tissue which exhibited light red blood when exposed using a bur in a high-speed handpiece (and blood flow easily arrested with a dry cotton pellet); and (5) a cooperative patient. The teeth to be treated were anesthetized and the teeth isolated with a rubber dam. Using a bur in a high-speed handpiece, the preparation for a stainless steel crown was performed. All caries was removed before exposing the pulp. At this time, the teeth were irrigated with plain water and a conventional pulpotomy technique was performed with a high-speed bur. After coronal pulp amputation, the blood color and flow were evaluated. Hemostasis then was promoted with dry cotton pellets using slight pressure. The dry cotton pellets were removed and a fast setting ZOE containing 1 drop of eugenol and 1 drop of 2% unbuffered glutaraldehyde with glycerol was placed in the pulp chamber contacting the pulpal stumps. A stainless steel crown was cemented immediately. • IRM—LD Caulk Co; Milford, DE. At regular 6-month intervals following the treatment, clinical and radiographic examinations were made. The treatment was considered a failure if 1 or more of the following signs was present: internal root resorption, furcation and/or periapical bone destruction, pain, swelling, sinus tract, and/or mobility. Clinical and radiographic follow up varied from 6 to 24 months.