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Ferric Sulfate Chapter 39 / Endodontic Therapy for Primary Teeth / 1415 layer and no more bleeding. The teeth received a A study by Liu,129 which was conducted similarly to periapical radiograph prior to extraction and were his previously published case report, using an extracted at 28 or 90 days. The teeth were evaluated Nd:YAG laser with follow-up for up to 64 months radiographically and histologically. These researchers demonstrated a 97% clinical success rate and a 94.1% concluded that on the basis of symptomatic, clinical, radiographic success rate for the laser group that was radiographic, and histological findings, the CO2 laser compared to the 85.5% clinical success rate and a compares favorably to formocresol pulpotomies. 78.3% radiographic success rate for the formocresol A study was performed comparing a conventional control group. formocresol–ZOE pulpotomy with a diode laser- Odabas et al.130 performed a clinical, radiographic, MTA pulpotomy. In this study, the teeth were and histological study of Nd:YAG laser pulpotomies studied clinically and radiographically for a period compared to formocresol pulpotomies on 42 primary of up to 15.7 months. The researchers concluded teeth studied for a period of up to 12 months. This that the laser-MTA pulpotomy showed slightly study was conducted nearly identically to the previous reduced radiographic success rates compared to the studies. The laser group had a clinical success rate of formocresol–ZOE pulpotomy, but the results were 85.71%, and a radiographic success rate of 71.42%, at not statistically significant. They recommended that 9 and 12 months. The formocresol group had a clin- a larger sample with a longer follow-up was needed ical success rate of 90.47% and a radiographic success to consider the laser-MTA as an alternative to the rate of 90.47% at 9 and 12 months. These researchers formocresol–ZOE pulpotomy.127 conclude that the Nd:YAG laser may be considered as In a study by Huth et al.,128 four pulpotomy techni- an alternative to formocresol for pulpotomies for ques were compared: calcium hydroxide, Er:YAG, primary teeth. dilute formocresol, and ferric sulfate on a sample of As lasers become more commonplace in dentistry, 200 primary molars treated and followed for up to 24 dentists who own a laser now have a body of research months. The teeth were anesthetized and isolated with literature to justify the use of the laser to perform a rubber dam, and the caries was excavated and the pulpotomies for children in their practices. roof of each pulp chamber removed with a diamond bur. The coronal pulp was removed with a slow-speed round bur and a spoon excavator. Hemostasis was Ferric Sulfate obtained by placing wet cotton pellets with slight pres- sure in the chamber for 5 minutes. Formocresol-medi- The use of ferric sulfate as a primary tooth pulpotomy cated cotton pellets were applied to the pulp for 5 min- medicament begins to appear in the literature in the utes in the control group. In the laser group, the teeth late 1980s when Landau and Johnson131 published an were treated with an Er:YAG laser set at 2 Hz and abstract describing the use of ferric sulfate as a pulp 180 mJ per pulses without water cooling. The mean medicament in monkey’s teeth. The sample size was number of laser pulses per tooth was 31.5 ± 5.9. In the small and followed for only 60 days. They noted calcium hydroxide group, the teeth were dressed with secondary dentin formation and partial dentin brid- aqueous calcium hydroxide and covered with calcium ging. They also described ferric sulfate as a ‘‘promis- hydroxide cement. In the last group, the teeth were ing medicament for teeth indicated for pulpotomies.’’ treated with cotton pellets wetted with ferric sulfate for Subsequently, Fei et al.132 presented the first clinical 15 seconds. All of the teeth received an IRM base, study of ferric sulfate as a pulpotomy medicament for followed by a glass ionomer cement and a stainless primary teeth. In this study, 29 primary molars steel crown, or a composite resin. The teeth were received ferric sulfate pulpotomies and 27 received followed clinically and radiographically for up to 24 1:5 Buckley’s formocresol pulpotomies. Both groups months. After 24 months, the total (combined clinical received a ZOE base and were followed over 12 and radiographic success rates) and clinical success rate months. Criteria for clinical success included no symp- percentages (in parenthesis) were as follows: formocre- toms of pain, no tenderness to percussion, no swelling sol 85 (96%), laser 78 (93%), calcium hydroxide 53 or fistula, and no pathological mobility. Criteria for (87%), and ferric sulfate 86 (100%). The authors con- radiographic success included normal periodontal liga- cluded that calcium hydroxide was significantly less ment space, no pathological internal or external resorp- effective than formocresol. They also pointed out that tion, and no furcal or apical radiolucency. Results of an increased sample size would be necessary before it the study showed that after 1 year, 28 of 29 of the ferric could be definitively said that this laser technique or sulfate-treated teeth were considered successful while ferric sulfate was equal to, or better, than formocresol. only 21 of 27 of the formocresol-treated teeth were 1416 / Endodontics considered successful. Combined overall success rates formocresol–ZOE produced the least inflammation, were 96.6% for the ferric sulfate group and 77.8% for the use of polycarboxylate cement as a substitute for the formocresol group. They raised some interesting ZOE did not improve the pulpal response, and sig- points in their discussion. The use of ZOE as a base for nificant differences were not found regarding the formocresol pulpotomies is standard for this proce- pulpal inflammation between ZOE and polycarbox- dure. A ZOE base is also paired with ferric sulfate in ylate cements. order to standardize the two pulpotomy treatments. Fuks et al.134 studied ferric sulfate and dilute for- The authors suggested that ZOE is appropriate for mocresol pulpotomies in baboon teeth. Both medica- formocresol because the pulp tissue is somewhat fixed ments produced similar degrees of pulpal inflamma- from formocresol and would not react with the slightly tion and dentin bridging. Sixty percent of the teeth irritating eugenol. Because ferric sulfate is not a tissue had normal pulps and the remaining 40% had severe fixative, and probably leaves the tissue in a more vital inflammation. They recommended more clinical state, using ZOE as a base introduces an irritant that study of ferric sulfate. A number of clinical studies may contribute to failure. They suggested that it would comparing ferric sulfate and formocresol pulpo- be advisable to continue to study ferric sulfate as a tomies have been performed. In 1997, Fuks et al.135 primary tooth pulp medicament for longer periods of performed dilute formocresol and ferric sulfate pul- time and with more inert base materials. potomies and evaluated the teeth for up to 34 Additional animal studies on rat and baboon teeth months. They concluded that dilute formocresol have been performed to assess histologically the pul- and 15.5% ferric sulfate have similar success rates. pal healing response after pulpotomy with ferric sul- Smith et al.136 performed a retrospective study of fate and dilute formocresol. In her study using rats, clinical and radiographic data from the charts of Cotes133 had four test groups pairing ferric sulfate patients who received ferric sulfate pulpotomies and and dilute formocresol each with ZOE and polycar- ZOE base. They followed 242 teeth for 4 to 57 boxylate cements. She demonstrated that in the months (mean, 19 months). Their clinical success coronal third of the teeth tested, there was necrosis rate was 99% and the radiographic success rate was for all groups tested. In the middle third, there 74% to 80%. The longer the teeth were followed, was a lesser degree of inflammation for the dilute the more failures were noted radiographically. The formocresol–ZOE and ferric sulfate–polycarboxylate most common pathological radiographic observa- groups. In the apical third, the dilute formocresol–ZOE tions were calcific metamorphosis and internal group showed the least inflammation. In addition, resorption (Figure 11). Ninety percent of the teeth reparative dentin formation was noted in the apical survived after 3 years. They concluded that ferric third of the pulp in the ferric sulfate–ZOE group sulfate has a success rate similar to dilute formocre- while it was not found in the other groups. Conclu- sol. In addition, if the radiographic changes are sepa- sions from this study include the following: dilute rated into dental and osseous categories, and the A B C Figure 11 A, Radiograph showing internal resorption in a primary molar after ferric sulfate pulpotomy. B, Resorption resulted in perforation (arrow). C, Perforated area resulting from the resorptive process (arrow). Chapter 39 / Endodontic Therapy for Primary Teeth / 1417 dental changes (internal resorption and calcific A study involving rat first molars demonstrated metamorphosis) are reclassified as acceptable varia- that after 2 weeks the treated teeth responded well to tions of success, then the radiographic success rate MTA and were attempting to form dentinal bridges. would be 84% to 92%. The only radiographic changes In the 4-week samples, dentin bridges were comple- that would be classified as failures were interradicu- tely formed at the pulp–MTA interface and the pulps lar or periapical bone destruction and external appeared normal.143 In the dog study, the researchers resorption. These investigators also suggest that tested white and gray MTA as well as regular and since the goal is to keep the pulpotomized tooth white Portland cements as pulpotomy medicaments.
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