Formocresol Pulpotomy

[zoothslooth]

Any contraindication to formocresol pulpotomy in adult teeth? Not young permanent teeth, I'm talking mature adult teeth? Anyone know what's the standard of care, formo vs. partial pulpectomy? Just a question, thanks.

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[Lily143]

Formocresol is damaging to vital tissue, from what I understand. CaOH and MTA are better choices.

 

[DrJeff]

If I'm just opening up a "hot tooth" to get the patient out of pain prior to having them return for the complete endo/ or referring them out to the endodontist for completion of the case, then I used to very regularly after debriding the canal space of any and all tissue that I could find place a foromocreosol pellet in the pulp chamber prior to closing the tooth up. No problems with this way, and very low incidences of the patients with post pulpectomy pain this way.

Nowadays, I'll rarely use formocreosol on adult teeth this way, and instead use calcium hydroxide past as an interim intracanal medicament. I've changed mainly for 2 reasons 1) an endo CE lecture where the CaOH paste was touted as just as effective with ALOT less potential for post tx tissue burns(I've inadvertantly done that a couple of times where the formocreosol gets on the surround tissue ) and 2) I've really over the years just plain and simple gotten sick of the smell of formocreosol

Since I've made the switch from formo to CaOH as an interim medicament, I really haven't noticed any change in the inter appointment pain levels of my patients, and the office smells ALOT better too!

 

[Dentyte]

An older pediatric dentist taught me that formocresol was not needed in on a pulpotomy on a childs tooth. I have just put ZOE in them for the past 7 years and have had only 1 fail. I am talking about all of them. Just try it and you'll see! Also, when prepping a baby tooth for a SSC, just break the mesial and distal contacts, cut a donut hole in the middle to open the nerve chamber, round the corners of all the top, then use a round #4 or #6 to remove the pulp and slap in your ZOE and push it down with a small wet cotton roll. Then take your pre-crimped crowns (usually a #4) and fill it with cement and cement it on. Immediately wash out the cement w/ water around the crown for easy cleanup and then have the child bite on a cotton roll until it sets up. You can do this in less than 10 minutes. In dental school it would take sometimes up to 1 hr until you got to this point. What a joke!

 

[JavadiCavity]

An older pediatric dentist taught me that formocresol was not needed in on a pulpotomy on a childs tooth. I have just put ZOE in them for the past 7 years and have had only 1 fail. I am talking about all of them. Just try it and you'll see! Also, when prepping a baby tooth for a SSC, just break the mesial and distal contacts, cut a donut hole in the middle to open the nerve chamber, round the corners of all the top, then use a round #4 or #6 to remove the pulp and slap in your ZOE and push it down with a small wet cotton roll. Then take your pre-crimped crowns (usually a #4) and fill it with cement and cement it on. Immediately wash out the cement w/ water around the crown for easy cleanup and then have the child bite on a cotton roll until it sets up. You can do this in less than 10 minutes. In dental school it would take sometimes up to 1 hr until you got to this point. What a joke!

Ooooooooooooo....love it. I'm going to try this next time. I had a patient in last week who did well until right before it was time to put in the formocreosol. Then, with the formo in the chamber, he uses his tongue to push off the dam...that stuff must have tasted nasty. Mom came back to the op and made things even worse. I'm so glad I'm not a pediatric dentist...I referred mom and child to the pedo doc. Good luck

 

[capisce?]

An older pediatric dentist taught me that formocresol was not needed in on a pulpotomy on a childs tooth. I have just put ZOE in them for the past 7 years and have had only 1 fail. I am talking about all of them. Just try it and you'll see! Also, when prepping a baby tooth for a SSC, just break the mesial and distal contacts, cut a donut hole in the middle to open the nerve chamber, round the corners of all the top, then use a round #4 or #6 to remove the pulp and slap in your ZOE and push it down with a small wet cotton roll. Then take your pre-crimped crowns (usually a #4) and fill it with cement and cement it on. Immediately wash out the cement w/ water around the crown for easy cleanup and then have the child bite on a cotton roll until it sets up. You can do this in less than 10 minutes. In dental school it would take sometimes up to 1 hr until you got to this point. What a joke!

You share some good tips but I would change your order a little bit. Also, I'm glad you've only had 1 failure but that approach is not supported by the literature and formo is the gold standard.

I would recommend you not do your interproximal slices before opening the chamber. If you do and you can't control heme, you can have a hard time trying to determine if it's from the canal itself or leaking in from the interproximal. Also, by doing the occlusal reduction first, it makes unroofing it MUCH easier from a visibility staindpoint. This is my general sequence:

1. Rubber dam isolation
2. Occlusal reduction with an 8 round high speed (in dental school i was taught to keep anatomy...hogwash! Just flat plane it and leave the buccal cervical bulge)
3. Decay excavation with slow speed
4. Unroof the chamber with a 169. I "pop the top"- start where the pulp exposure is, keep the bur at that exact depth, and cut a circle around the top of the chamber...it will "pop" right off into the high speed evac
5. slow speed with upward motion on pulp stumps to remove tissue, spoon excavate if needed. If you have less experience put the slow speed in reverse for this
6. at this point heme should be controlled. place formo cotton pellot. interproximal slices with a 169, try on your crown (good tip to start with the ssc size 4) Also, if the D is usually 1 size bigger than the E, so if you use an E4 for tooth T for example S is likely a D5. If you did contralateral tooth size is usually the same)
7. remove formo, heme should be controlled. if it is not, it means one of two things: either you didn't sufficiently remove the coronal pulp tissue or it's hyperemic. Remove excess tissue, reapply formo, and this time use hand pressure with it. If it still bleeds it's hyperemic and needs ext/space maintenance
8. place irm, I prefer tempit due to ease of use
9. cement SSC, clean excess, check bite
10. follow thru with bribery and give child praise and prizes

Sorry to hijack

 

[ItsGavinC]

An older pediatric dentist taught me that formocresol was not needed in on a pulpotomy on a childs tooth. I have just put ZOE in them for the past 7 years and have had only 1 fail. I am talking about all of them. Just try it and you'll see! Also, when prepping a baby tooth for a SSC, just break the mesial and distal contacts, cut a donut hole in the middle to open the nerve chamber, round the corners of all the top, then use a round #4 or #6 to remove the pulp and slap in your ZOE and push it down with a small wet cotton roll. Then take your pre-crimped crowns (usually a #4) and fill it with cement and cement it on. Immediately wash out the cement w/ water around the crown for easy cleanup and then have the child bite on a cotton roll until it sets up. You can do this in less than 10 minutes. In dental school it would take sometimes up to 1 hr until you got to this point. What a joke!

You have some good points (as does capisce!), but make sure to examen the pulp after you unroof the chamber and clean out the coronal portion. The success of a pulpotomy (with formo, ferric, or pressure) depends on the vitality of the radicular pulp. If the pulp is necrotic (no bleeding) or hyperemic (excessive bleeding), the odds of success are not good and the tooth should be extracted.

 

[ItsGavinC]

I would recommend you not do your interproximal slices before opening the chamber. If you do and you can't control heme, you can have a hard time trying to determine if it's from the canal itself or leaking in from the interproximal.

I do it opposite (many ways to skin a cat?). I prep the entire SSC first (occlusal reduction and proximal slices) and then chase the decay. If it pulps then it pulps. If it doesn't the tooth is ready for the crown. If it is apparent radiographically or clinically that it will pulp, I still prep the SSC first then do the pulp.

 

[mlle]

An older pediatric dentist taught me that formocresol was not needed in on a pulpotomy on a childs tooth. I have just put ZOE in them for the past 7 years and have had only 1 fail.

I thought ZOE was contra-indicated with pulpal involvement. It's considered necrotizing on soft tissue... wouldn't that be painful if you didn't do a full root canal?

 

[aphistis]

I thought ZOE was contra-indicated with pulpal involvement. It's considered necrotizing on soft tissue... wouldn't that be painful if you didn't do a full root canal?

It can't be any worse for soft tissue than formocresol.

 

[phantasmagoriun]

Wow, reading this stuff is like WHEW way over my head.

 

[dr hanna]

Hi there,ur quote is similar to what i practice,but recently,2 of my pulpotomy cases failed,and the kids returned with huge swellings(after 2 months of initial treatment done),i still cant figure out why,i unroofed the pulp chamber & removed pulp (which was hyperemic),applied formocresol in cotton pellet,re-applied 3 times as bleeding didnt stop,n then while it was still bleeding a little,inserted Zinc oxide eugenol filling (although some of my colleagues do NOT use ZOE,they put a cotton pellet inside n then do the temp filling ZO only,or they even do gic :S
what do you suggest?where was i wrong?
and one other query,in patients with deep decayed cavities (almost near pulp),i excavated & applied CAOH as lining and did a temp filling over it,after 2 months,the patient returned with severe pain :S that means the pulp capping failed?any suggestions

An older pediatric dentist taught me that formocresol was not needed in on a pulpotomy on a childs tooth. I have just put ZOE in them for the past 7 years and have had only 1 fail. I am talking about all of them. Just try it and you'll see! Also, when prepping a baby tooth for a SSC, just break the mesial and distal contacts, cut a donut hole in the middle to open the nerve chamber, round the corners of all the top, then use a round #4 or #6 to remove the pulp and slap in your ZOE and push it down with a small wet cotton roll. Then take your pre-crimped crowns (usually a #4) and fill it with cement and cement it on. Immediately wash out the cement w/ water around the crown for easy cleanup and then have the child bite on a cotton roll until it sets up. You can do this in less than 10 minutes. In dental school it would take sometimes up to 1 hr until you got to this point. What a joke!

 

[DrJeff]

Hi there,ur quote is similar to what i practice,but recently,2 of my pulpotomy cases failed,and the kids returned with huge swellings(after 2 months of initial treatment done),i still cant figure out why,i unroofed the pulp chamber & removed pulp (which was hyperemic),applied formocresol in cotton pellet,re-applied 3 times as bleeding didnt stop,n then while it was still bleeding a little,inserted Zinc oxide eugenol filling (although some of my colleagues do NOT use ZOE,they put a cotton pellet inside n then do the temp filling ZO only,or they even do gic :S
what do you suggest?where was i wrong?
and one other query,in patients with deep decayed cavities (almost near pulp),i excavated & applied CAOH as lining and did a temp filling over it,after 2 months,the patient returned with severe pain :S that means the pulp capping failed?any suggestions

You answered you're own question with what I highlighted. If you've got a pullp that you can't stop the bleeding without having to use "heroic" measures (laser cautery, etc) the longterm chances of success of the pulpotomy and final restoration are much, much lower than if you're able to achieve hemostasis quickly. Same thing goes if the you're dealing with a necrotic pulp when the chamber is opened, the success rate is much lower than if you have a vital pulp with controlable hemostasis when the chamber is opened.

part two - yup, more than likely not a failed pulp cap, but an injury to the nerve (the initial caries and it's proximity to the nerve) that could not be fixed. I'll always tell a patient on whom I did a deep caries excavation that at some point in the futures, odds are that a root canal or extraction will be needed for that tooth. That way if the nerve fares fine, you look like the greatest dentists ever, if the pulp does indeed go, the patient heard you say that this could happen (just document it in the chart)

 

[KinKs]

I am pretty sure that I read that Formacresol is MUTAGENIC and thus contraindicated in permanent teeth. Maybe someone else can chyme in on this.

 

[ODEP PEDO]

You have some good points (as does capisce!), but make sure to examen the pulp after you unroof the chamber and clean out the coronal portion. The success of a pulpotomy (with formo, ferric, or pressure) depends on the vitality of the radicular pulp. If the pulp is necrotic (no bleeding) or hyperemic (excessive bleeding), the odds of success are not good and the tooth should be extracted.

Would anyone consider pulpectomy prior to jumping on the extraction wagon?
I know that is not recommended/advised in certain cases. but surprises me that no one brought it up this procedure yet

 

[daisy25]

I believe that formocresol is a carcinogenic and it may cause root resorption if not properly rinsed. I've also heard that some dentist only use the fumes of the formocresol on a cotton pellot and not place it directly onto the pulp chamber. I'm not sure if these ideas are correct, someone please correct me if i'm wrong. Also, what do people think about formocresol vs ferric sulfate? Anyone prefer one over the other?

 

[Demeter]

An older pediatric dentist taught me that formocresol was not needed in on a pulpotomy on a childs tooth. I have just put ZOE in them for the past 7 years and have had only 1 fail. I am talking about all of them. Just try it and you'll see! Also, when prepping a baby tooth for a SSC, just break the mesial and distal contacts, cut a donut hole in the middle to open the nerve chamber, round the corners of all the top, then use a round #4 or #6 to remove the pulp and slap in your ZOE and push it down with a small wet cotton roll. Then take your pre-crimped crowns (usually a #4) and fill it with cement and cement it on. Immediately wash out the cement w/ water around the crown for easy cleanup and then have the child bite on a cotton roll until it sets up. You can do this in less than 10 minutes. In dental school it would take sometimes up to 1 hr until you got to this point. What a joke!

You have only had one Pulpotomy fail?
How have done more than one?
I gotta call BS on this one. I do P/SSC every day. Pulpotomies in primary teeth have a success rate in the 80's. Whether you are using Formo or Ferric Sulfate or simple pressure pulpotomy, No one will have a 99% success rate. That is not possible.

 

[DrJeff]

I believe that formocresol is a carcinogenic and it may cause root resorption if not properly rinsed. I've also heard that some dentist only use the fumes of the formocresol on a cotton pellot and not place it directly onto the pulp chamber. I'm not sure if these ideas are correct, someone please correct me if i'm wrong. Also, what do people think about formocresol vs ferric sulfate? Anyone prefer one over the other?

When I place the formocreosol, I blot the cotton pellet after it comes out of that jar of "lovely smelling stuff" on a couple of pieces of 2x2 gauze to dry it, so that while saturated with the formocreosol, the cotton pellet isn't by any means dripping wet.

Also, as soon as I'm done with the college pliers I use to handle that formocreosol cotton pellet, I have my assistant completely remove them from the bracket table and set them aside so that we WON'T use them again - if you've ever seen an inadvertant formocreosol tissue burn, you know why I do this

 

[DrJeff]

You have only had one Pulpotomy fail?
How have done more than one?
I gotta call BS on this one. I do P/SSC every day. Pulpotomies in primary teeth have a success rate in the 80's. Whether you are using Formo or Ferric Sulfate or simple pressure pulpotomy, No one will have a 99% success rate. That is not possible.

+1 A 99% pulpotomy success rate means 1 of 2 things. 1) you're doing pulpotomies on teeth that will naturally exfoliate within the next week or 2 or 2) you either haven't done too many of them/been doing them that long.

Do enough of them in situations where the "natural life span" of the primary tooth in question is a few years, and you'll see failures, no if's, and's, or but's about it.

 

[daisy25]

When I place the formocreosol, I blot the cotton pellet after it comes out of that jar of "lovely smelling stuff" on a couple of pieces of 2x2 gauze to dry it, so that while saturated with the formocreosol, the cotton pellet isn't by any means dripping wet.

Also, as soon as I'm done with the college pliers I use to handle that formocreosol cotton pellet, I have my assistant completely remove them from the bracket table and set them aside so that we WON'T use them again - if you've ever seen an inadvertant formocreosol tissue burn, you know why I do this

Good ideas, thanks DrJeff

 

[DIRTIE]

Hi there,ur quote is similar to what i practice,but recently,2 of my pulpotomy cases failed,and the kids returned with huge swellings(after 2 months of initial treatment done),i still cant figure out why,i unroofed the pulp chamber & removed pulp (which was hyperemic),applied formocresol in cotton pellet,re-applied 3 times as bleeding didnt stop,n then while it was still bleeding a little,inserted Zinc oxide eugenol filling (although some of my colleagues do NOT use ZOE,they put a cotton pellet inside n then do the temp filling ZO only,or they even do gic :S
what do you suggest?where was i wrong?
and one other query,in patients with deep decayed cavities (almost near pulp),i excavated & applied CAOH as lining and did a temp filling over it,after 2 months,the patient returned with severe pain :S that means the pulp capping failed?any suggestions

Pulpectomy with vitapex irrigated with NaOCL

 

[ou_jay]

I am pretty sure that I read that Formacresol is MUTAGENIC and thus contraindicated in permanent teeth. Maybe someone else can chyme in on this.

Yes you should never use it on permanent teeth because it is mutagenic and might cause pulp cancer. We all know about the high incidence of pulp cancer.

Seriously thought, I had a discussion about this topic with the endodontist attending in my AEGD residency. He agrees with its use for a sedative pulpotomy on permanent teeth with an acute irreversible pulpitis ("hot tooth") as discussed above. Realize however that a sedative pulpomy is different than a therapeutic pulpotomy that you would do on a primary tooth. It is should be followed by an RCT ASAP. It is only intended to temporarily get the patient out of pain.

 

[dmddentist]

Hi guys

I am considering changing to CaOH instead of formo... but there are few instances where I don't know if Ca OH would be applicable or not..

For example in adult permenant teeth;

-- when opening up the pulp space and only using one file to remove bulk pulp and radicular tissue without cleaning, filling or shaping... I routinely put a cotton dry pellet of formo in the pulp chamber and seal it with temp filling until next time when a full debridment is possible.

I don't think CaOH would be a substitute in this case as far as I know since CaoH needs a cleaned and shaped canal before its placement.. right?!


Same thing, if during a cleaning and shaping session of the canals and for some reason, I had to stop before complete debridement.. Can I put CaOH until next time.. or formo to "fixate" remnant pulp tissue until the next appointment.

Cheers

 

[Halcion]

Is it true you can use Viscostat for pulpotomy on primary teeth instead of Formocresol? I have heard this from some practicing pediatric and general dentists-- I have not tried it myself since Formocresol is the gold standard. What does everyone think?

 

[sleeplessinsf]

To the OP:

For permanent symptomatic tooth with closed apices, pulp cap is not reliable. Best to do RCT. If you must do pulp cap, use CaOH2 or MTA (MTA is better)

Now if you've decided to do RCT but short on time and can't finish treatment one visit and just need to get patient stabilized first, do not use FC. Completely unroof chamber, remove all coronal pulp and observe. If tooth is vital (bleeding from all canals) then use a file/broach and remove bulk tissues from as many canals as you can, starting from the biggest canal (P of upper premolar/molar, D of lower molars), copious irrigation with NaOCl. If you are getting patien back within a week or two, no need for CaOH2 for vital teeth as apical portion is still sterile. CaOH2 can only go into a cleaned/shaped canal and not just covering the coronal orifices. If you have live tissues remaining in canal or chamber, there is a possibility CaOH2 (or MTA) will stimulate dentinal bridge formation and you may not find the canals anymore when patient returns to get the RCT completed!

If the tooth is necrotic, pulpotomy will not relieve patient's symptoms. You need to do a pulpectomy and debride canals as best as you can and then place CaOH2 in canals until you can finish RCT.

For young permanent vital teeth with open apices, you can attempt MTA pulpotomy to see if roots will continue to form. Remove all caries and superficial layer of pulp, place MTA, let it set up for a few hours before restoring. Dentinal bridge hopefully will form and we can avoid the RCT.

 

[dmddentist]

To the OP:

For permanent symptomatic tooth with closed apices, pulp cap is not reliable. Best to do RCT. If you must do pulp cap, use CaOH2 or MTA (MTA is better)

Now if you've decided to do RCT but short on time and can't finish treatment one visit and just need to get patient stabilized first, do not use FC. Completely unroof chamber, remove all coronal pulp and observe. If tooth is vital (bleeding from all canals) then use a file/broach and remove bulk tissues from as many canals as you can, starting from the biggest canal (P of upper premolar/molar, D of lower molars), copious irrigation with NaOCl. If you are getting patien back within a week or two, no need for CaOH2 for vital teeth as apical portion is still sterile. CaOH2 can only go into a cleaned/shaped canal and not just covering the coronal orifices. If you have live tissues remaining in canal or chamber, there is a possibility CaOH2 (or MTA) will stimulate dentinal bridge formation and you may not find the canals anymore when patient returns to get the RCT completed!

If the tooth is necrotic, pulpotomy will not relieve patient's symptoms. You need to do a pulpectomy and debride canals as best as you can and then place CaOH2 in canals until you can finish RCT.

For young permanent vital teeth with open apices, you can attempt MTA pulpotomy to see if roots will continue to form. Remove all caries and superficial layer of pulp, place MTA, let it set up for a few hours before restoring. Dentinal bridge hopefully will form and we can avoid the RCT.

Thanks for your input..

Regarding closed apex permanent teeth requiring RCT

1) In the first situation where there is hyperaemia from the radicular pulp and no time for a cleaning and shaping session.... do you just remove the radicular tissue and put a dry cotton pellet with no formo or any other meds and then seal with a temporary filling until next visit.. Will this "quiets" the symptoms in your experience? with no formo


2) if the canal is necrotic usually there is no pain that needs a temporary fix unless its an exacerbation of chronic lesion. If its draining pus I 'd leave it to drain with no formo or any other thing until next appointments

My question still remains, if during a cleaning and shaping session (whether the initial pulp status was vital or it was necrotic) and you had to stop for what ever reason and the canals are not fully cleaned and shaped, what inter appointments canal medicament will you put?!?!

 

[sleeplessinsf]

Thanks for your input..

Regarding closed apex permanent teeth requiring RCT

1) In the first situation where there is hyperaemia from the radicular pulp and no time for a cleaning and shaping session.... do you just remove the radicular tissue and put a dry cotton pellet with no formo or any other meds and then seal with a temporary filling until next visit.. Will this "quiets" the symptoms in your experience? with no formo


2) if the canal is necrotic usually there is no pain that needs a temporary fix unless its an exacerbation of chronic lesion. If its draining pus I 'd leave it to drain with no formo or any other thing until next appointments

My question still remains, if during a cleaning and shaping session (whether the initial pulp status was vital or it was necrotic) and you had to stop for what ever reason and the canals are not fully cleaned and shaped, what inter appointments canal medicament will you put?!?!

1) you don't need to completely clean and shape.. if possible, do try to at least remove bulk tissues out of the biggest canal. NaOCl irrigation will dissolve tissues and slow bleeding. use cotton pellet apply pressure to stop heme, although the quickest way to stop heme is to remove pulp tissues. if you can get pt back < 2 weeks, no intracanal meds necessary (see reason below). usually removing coronal pulp is enough to get patients out of pain if the tooth is vital, because the pain is usually from either the superficial nerve sensation or the pressure build-up from inflamed pulp. by removing pulp in chamber you removed both causes. we don't use formo on permanent teeth at all.. that is really old school. formo is a carcinogen that has minimal antimicrobial properties. CaOH2 is much better but again, it needs to be placed "inside" the canals.

2) if pt has a draining sinus tract, the tooth is usually relatively asymptomatic since there's an outlet for the puss/pressure and does not require emergency treatment. for otherwise symptomatic necrotic teeth pulpectomy is needed to get pt out of pain (you don't need to completely clean and shape but at least file-up a little and irrigate) and interappointment CaOH2 strongly suggested until RCT can be finished.

Current interappointment intracanal medication of choice: CaOH2 (or CaOH2 iodo combo). however, it needs to be INSIDE the canals to work and also takes time (~7days) to reach optimal antibacterial pH. therefore for vital teeth if you have only time to remove coronal pulp and no time to remove any tissues in any canals at all, in my experience no meds are necessary - just by removing coronal pulp is usually enough to calm tooth. for necrotic teeth, pulpotomy will most likely not help you. you either try to do pulpectomy then place meds, or I&D. I hope this is not too confusing and helps a little. feel free to PM if you need clarification.