Scand. J . dent. Res.

1971: 79: 13-23

Vital pulpotomy in primary molars

A clinical and histologic investigationof the effect of
zinc oxide-eugenol cement and Ledermixo
HARRY P. HANSEN, JENS J 0 R G E N RAVN AND D O R T E U1,KICH

Institutes of Operative Dentistry and Pedodontic s,

Royal Dental College, Copenhagen, Denmurk

ABSTRACT - Vital pulpotomy was carried out on 28 primary molars o f 15 children between
the ages of 3 and 6 years. As dressing material zink oxide-eugenol ctmrnt was used in
14 teeth and Lederrnix@ cement in 14 teeth. Contralateral teeth were treated in 13 of the
children. T h e observation period varied from 1 to 42 months. None of the treated teeth
were painful during the period of observation. Internal resorption, evaluated radiographic-
ally, occurred in six teeth treated with zinc oxide-eugenol cement. and in three teeth
treated with Lederrnix cement. No other complications were observed. Evaluated clinically
and radiographically. the treatment was thus successful in 575% of the cases with zinc
oxide-eugenol cement and in 79% of the cases with Lederrnix cement. Histologically,
the occurrence of internal resorption was of alniost the sanie frequenry in the two groups,
but the degree of resorption was considerably less in the group treated with Ledermix
cement. T h e inflammation of the pulp tissue in the area of the aniputation was clearly
more severe in the group treated with zinc oxide-eugenol cement than in the group
treated with Ledermix cement. Accepting the importance of correct diagnosis, this histo-
logic study indicates that Lederrnix cement, as dressing material in vital pulpotomy of
primary molars, is superior to zinc oxide-eugenol cement.

(Received f o r publication 1 1 September, accepted I N0uembt.r 1970)

Pulp treatment of primary teeth is fre- and periapical abscesses, lrequently occur
quently required. There is, however, in as a result of the use of these materials
the relevant literature a difference of (VIA 1955, LAW 1956, MAGNUSSON &
opinion regarding the method to be em- RINCQUIST 1964, RAVN& SVARRER 1968).
ployed. Zinc oxide-eugenol cement (ZnO/ Periapical abscesses and internal resorp-
eug.) and calcium hydroxide are often tion are often complications of inflam-
used in primary teeth as a dressing cover- matory type (JAMES, ENGLANDER & MASS-
ing the pulpal wound ( REICH1951, BERGH LER 1957, BERGER1965 I . There exists
& M~RTENSSO N
1955, VIA 1955, LAW therefore the possibility of their reduction
1956, MAGNUSSON & RINGQUIST 1964, by the use of materials containing gluco-
RAVN & SVARRER 1968, MAGNUSSONcorticoid.
1970, KISLING1970). 'The anti-inflammatory effect of corti-
Several studies, however, suggest that coids used locally in pulp rapping of per-
coniplications. such as internal resorption manent teeth is dealt with in several rt=-
 14 HANSEN, RAVN AND ULRICH
ports (SCHROEDER & TRIADAN 1962, VICC
1962, ULMANSKY & LANGER 1967, HAN-
SEN 1969a and 196913). As far as it is
known to the present authors, there are
no reports on the use of materials con-
taining corticoid as a dressing to cover
the pulpal wound in pulpotomy of pri-
mary teeth. This has motivated the pres-
ent work, in which ZnO/eug. and Leder-
mix@ cement (Ledermix) have been used
in vital pulpotomy of primary molars.
Material and methods
CLIN1C;AI.
The study was carried out on children be-
tween the ages of 3 and 6 years (mean 5 2/12).
The study includes a total of 28 teeth from 15
patients, where ZnOleug. was used 011 14
teeth and Ledermix on 14 teeth (Table 1). I n
13 patients contralateral teeth were treated, and
in two patients one tooth was treated with
ZnOleug. and one with Lederrnix. Only teeth
with exposed pulps following caries are in-
cluded in the investigation.
The following requirements had to be met
before the teeth could be included in the study.
Prior to treatment, only slight pain of short
duration, a vital pulp, no looseness or pain on
percussion were permissible. In addition, the
presence of pathologic changes in the surround-
ing area was excluded radiographically. Finally
the hemorrhage from the amputated pulp sur-
'Table 1
Number of tePth and distribution in the dental groups together with the dressing
material used"
1- 05 - 0 5 1 04 - 0 4
material
ZnO/eug.-cement
Iderrnix-cement
1 3 1 9
8 1
Total ) 6 1 1
* According to the HADERUP system of dental notation, + signifies the maxilla, - the mandible.
If the symbol is placed to the right of the figure, the right side is indicated, and vice versa.
0 before the figure indicates a primary tooth.
face had to be bright in color, of low viscosity,
and easily controlled.
Treatment was carried out by the same per-
son, under a local anesthetic and aseptically (by
the use of a rubber dam). After excavation of
the cavity and removal of the coronal part
of the pulp by an excavator, the pulp amputa-
tion was performed with a sterile round bur
extending 1-2 mm into the root canal. After
hemostasis, obtained by flushing with a 2%
aqueous chloramine solution and the applica-
tion of a compress of sterile cotton wool pellets,
the dressing material was applied directly to
the pulp tissue. Either a thin ZnOleug. paste
or Ledermix was used, after which the coronal
pulp cavity was filled with ZnOleug. cement.
At the next sitting the cavity was filled with
either silver amalgam or copper amalgam, or a
steel cap used when necessary.
The observation period varied from 1 to 42
months. I n 15 cases it was from 1 to 12 months
and in 13 cases from 13 to 42 months (Table
2). The teeth were reexamined both clinically
and radiographically prior to extraction. Any
percussion pain, mobility, and changes in the
mucous membrane in the surrounding area
were (clinically) noted. Finally, radiographic
studies of the teeth were made. The contra-
lateral teeth were examined a t the same sitting.
When painful complications occurred, or the
teeth were painful on percussion or loosened,
or when inflammatory changes in the mucous
membranes were present, treatment was con-
sidered unsuccessful. In addition, teeth with
pathologic periapical changes or internal re-
sorptions, evaluated by radiographs, were also
1 05 +05 1 04 + 0 4 1 Total
21 1 I 1 14
4
7 1 3 1 2 1 2 8
 V I T A L PULPOTOMY I N PRIMARY MOI,ARS
Observation period
oxide-
eugenol
considered as indications of unsuccessful treat-
ment. I n all other cases, treatment was con-
sidered as having been successful.
HISTOI.OGY
Immediately after extraction, the teeth were
fixed in 10% formalin and then demineralized
in a neutral 15% EDTA solution. T h e teeth
were embedded in Paraplast@, cut into sections
of 6-8 p, and then stained with hematoxylin-
eosin or by the van Gieson-Hansen method.
I n the histologic study the material was di-
vided according to the number of root canals.
I n each tooth, two root canals were examined:
the mesio-facial and the palatinal for maxillary
teeth and the mesial and distal for mandibular
teeth.
Of the 14 teeth treated with ZnOlcug., one
had to he excluded from the histologic study
owing to total resorption of the roots (Fig. 5 A ) ,
and in one of the others examination could
only be performed on one root. T h e histologir
examination of the 14 teeth treated with ZnOl
eug. was thus reduced to 25 root canals. Of
the 14 teeth treated with Ledermix, histologic
examination of one of the teeth could only be
carried out on one root. Thus the study in-
cluded 27 root canals treated with Ledermix.
T h e histologic study included evaluation of
inflarnmation in the area of amputation, oc-
currence of total necrosis of the pulp tissue,
and interrial resorption. Finally, inflammation
of the apical pulp tissue was evaluated.
T h e inflammation was evaluated according
to the following criteria: 0: no infiltration by
inflammatory cells (no inflammation), + : in-
15
1-12 months 13-42 nionths
Zinc Zinc Total
Lederrnix oxide- 1,eclermix
eugenol
filtration by a few lymphocytes (slight inflani-
mation), + + : infiltration by many lympho-
cytes and plasma cells (moderate inflamma-
tion), and + + + : infiltration by many lyrn-
phocytes, plasma cells, and polyniorphonurlear
leukocytes (severe inflammation),
Results
CLINICAL A N D RADIOORAIHIC RESULTS
In none of the 28 treated teeth did pain
occur during the period of observation. Of
the 14 teeth treated with %nO/eug., none
showed clinical symptoms or complica-
tions such as tenderness, loosening, or in-
flammation of the mucous menibrane, but
in the case of 6 twth t l ~ e radiographs
showed the presence of intwnal resorption
(Table 2 ) . I n two twth the resorption
was observed 9 and 12 months, respective-
ly, after the treatment. Of the remaining
4 teeth, resorption wa5 present 13 to 42
months after the treatment (Fig. 2A,B and
Fig. 4A,B,C). Treatment with ZnO/eug.
was thus successful in 8 o f 1.2 teeth ( 5 7 % ) ~
evaluated hoth clinic ally arid radiograph-
ically.
Of the 14 teeth trratrd with Ledermix.
one had 3 loosening following external
resorption. In the same tooth internal
resorption was also sern. Thr remaining 13
16 HANSEN. RAVN AND ULRICH

Fig. 1. <, 4 years and 7 montlis, 04 - 04. Observation period: LO months. A,C: 04 -, vital pulp-
otomy, dressing material: ZnO/eug. I n the mesial root extensive internal resorption and gran-
ulation tissue is seen in the amputation area. A: x 10, C : x 40. B,D: -04, vital pulpotomy,
dressing material Ledermix. External resorption of the mesial root and degenerated vital tissue
with slight infiltration with lymphocytes in the distal root. No hard tissue formation is seen in the
amputation area, hut is seen in the apical part ot the root. B: x 10, D: x 40.

teeth showed no signs of clinical complica-

tions. Radiographic examination demon-
strated that in two teeth internal resorp-
tion was observed after 5-10 months. The
remaining teeth were without radiographic
alterations (Fig. 2C,D, Fig. 6C,D, and Fig.
4D,E,F). Treatment with Ledermix was
thus clinically and radiographically suc-
cessful in 11 of the 14 teeth (79%)
(Table 2 ) .
HISTOLOGIC RESULTS
From Table 3 it can be seen that none to
slight ( 0 and + ) inflammation was found
in 8 of the 25 root canals treated with
ZnO/eug. and in 22 of the 27 root canals
treated with Ledermix (Fig. 1 B,D and
Fig. 5 B,D). Moderate to severe inflam-
mation ( + + and + + + ) occurred in
17 root canals treated with ZnO/eug. (Fig.
 V I T A L PULPOTOMY I N PRIMARY MOLARS 17

Fig. 2. Radiographs of the teeth from Fig. 1. A : 04 -, condition a t t h e of treatment, B: 04 -,

condition at time of extraction 20 months later. Internal resorption is seen in the distal root. C :
-04, condition a t time of treatment, D: --04, condition at time of extraction 20 months later,
with external resorption of 'the mesial root.

Table 3
T h e results of the histologic study after uital pulpotorny treated with zinc
o d e - e u g e m o l cement or Ledermin

Dressing
triaterial Zinc oxide-eugenol Ledermix
(No. of root canals) (No. of root canals)
T ~ s s u rrcactiori

Inflaiririiation in
arnputation area
(coronal)
I +
0 3
5

3
8
4
18

2
22

14 3
17 5

Total necrosis of the pulp 8 2

~~~

Intri nal re\orption 11 10

____
22"
I +
0 12"
Inilariiriiatioii in I 5 1
p u l p tisauc 17 23
(apical ) 4 2
3 1
7 3

* Hi.;tologic study could not be made of one root canal in each group.
18 HANSEN, RAVN AND ULRICH

Fig. 3. P, 6 years and 11 months, 04 - 04. Observation period: 24 months. A: 04 -, vital pulpo-
tomy, dressing material ZnO/eug. Total resorption of both roots. x 10. B: - 04, vital pulpotomy,
dressing material: Ledermix. Vital tissue in both roots. -4trophic degeneration and slight inflamma-
tion is observed in the amputation area. No resorption or hard tissue formation on the root canal
wall is seen. x 10.

1 A$), whereas it only occurred in 5 erate to severe inflammation ( + + and

root canals treated with Ledermix (Fig.
3 B) . The last-mentioned group included
total necrosis of the pulp tissue in 8 root
canals treated with ZnO/eug. (Fig. 5
A,C), and in two root canals treated with
Ledermix. In spite of total necrosis of the
pulp tissue and periapical inflammation,
the tooth in Fig. 5 A,C was without radio-
graphic alterations (Fig. 6 A,B) .
Internal resorption was observed with
almost the same frequency in both groups:
11 cases treated with ZnO/eug. and 10
cases treated with Ledermix. The degree
of internal resorption was, however, much
more advanced in the group treated with
ZnOleug. (Fig. 1 A,C and Fig. 3).
When evaluating the inflammation in
the pulp tissue of the apical part of the
root canal, none to slight inflammation
(0 and + ) was observed in 17 root canals
treated with ZnO/eug. and in 23 root
canals treated with Ledermix, while mod-
+ +
+ ) occurred in 7 canals treated with
ZnO/eug. and in three canals treated with
Ledermix.
Discusslon
The object of the present work has been
to throw some light on the question of
whether a pulp dressing containing glu-
cocorticoid can reduce the inflammation
and the degree of internal resorption fol-
lowing vital pulpotomy of primary teeth.
BUTTNEK( 1963) advised against corticoid
treatment of the pulp, particularly in
children, owing to the possibility of caus-
ing disturbances in the hormonal balance.
The probability of such disturbances, par-
ticularly with the kind of treatment des-
cribed here, must, however, be considered
as slight owing to the amount of gluco-
corticoid in the preparation ( HANSEN
1969a). To avoid spreading of micr+
 VITAL PULPOTOMY I N PRIMARY MOLARS 19

Fig. 4. Radiographs of the teeth from Fig. 3. A,B,C: 04-. A: At time of treatment, B: 15 months
later with internal resorption and C: 24 months later a t time of extraction, where total resorp-
tion of the roots is seen. D,E,F: - 0 4 at corresponding intervals of time without alterations.

organisms, if any, from the pulpal surface that painfuI complications have been no
following local application o f corticoids, therapeutic problem in this study. The
the antibiotic LedermycinB is added to results following pulpotomy are, however,
Ledennix. 'The necessity of this measure quite often compromised by internal re-
is indicated by SCHROEDER & TRIADAN sorption, particularly occurring after an
(1962). observation period of two years or more
The use of corticosteroid-containing ma- (VIA1955, BERCH& ~ I ~ R T E N S 1955,
SON
terials are contraindicated in the treat- LAW 1956, MCDONALD 19.56, RAVN&
ment of purulent pulpitis (SCHROEDER & SVARRER 1968). This is in agreement with
TRIADAN 1962) ; therefore the diagnosis the present study. Furthermore, the oc-
plays a decisive role for the prognosis. currence of internal rrsorption. evaluated
Thus, in the present work pulpotomy with by radiographs, was most frequent after
corticosteroid-containing material has in- pulpotomy with ZnO/txug. Evaluated his-
cluded only simple, non-purulent pulpitis. tologically, internal resorption occurred
From the clinical results it can be seen almost equally in the two group, but the
20 HANSEN, RAVN AND ULRICH

Table 4
MCNEMAR'S test (CIIILTON 1967) was used to evaluate the difference of inflammation in the
amputation area in the two groups. I n this test three teeth had to be excluded. T h e distribution
of the root canals was as s h o m . P = (112 + 112)fg = 0.013

Zinc oxide-eugenol
Inflammation
0 and + I++ and +++
Tntr11

0 and + 8 12 20
Ledermix
++ and -t ++ 2 3 5

degree of resorption was clearly more
pronounced in the group treated with
ZnO/eug. (Fig. 1 A,C) .
Following the low frequency of bridg-
ing and persisting inflammation in the
pulp tissue the use of corticoid-containing
preparations in the conservative treatment
of pulpitis by capping has been contra-
indicated by various authors ( FIORE-
DONN~O & BAUME1962, ULMANSKY & in the apical part of the root canal, it can
LANGER1967, HANSEN 1969b). This
agrees with the present study where bridg-
ing in the amputation area did not occur
in any case. It also can be seen from the
histologic study that inflammation in the
area of the amputation still persists, but it
is clearly more pronounced in the group
treated with ZnO/eug. Thus, moderate
to severe inflammation was found in 17 of
the 25 root canals treated with ZnOleug.
and in only 5 of the 27 root canals treated
with Ledermix. Similarly, none to slight
inflammation was found in 8 and 22 of
the examined root canals, respectively,
(Table 3 ) , and the observed difference
(Table 4 ) was statistically significant ( P
= 0.013).
As for inflammation of the pulp tissue
be seen that none or slight inflammation
occurred in 17 root canals treated with
ZnO/eug. and in 23 root canals treated
with Ledermix. Correspondingly. moder-
ate to severe inflammation was seen in
seven and three root canals, respectively.
Here no difference could be observed ( P
= 0,45). Although all teeth used in the
investigation had the same clinical pulp

Fig. 5. 0 , 4 years and 11 months, 04 -- 04. Observation period: 12 months. A,C: 04 -, vital pulp-
otomy, dressing material ZnOleug. Total necrosis of the pulp tissue in both root canals, with
periapical abcess on the distal root. A: x 10, C : x 40. B,D: -04, vital pulpotomy, dressing ma-
terial: Ledermix. I n the amputation area slight chronic inflammation and small resorption lacunae
are seen in the root canal wall in both roots. Superficially in the distal root necrotic tissue is
observed, of which a small area is calcified. B: x 10, D: x 40.
VI'I'~41, F'LJ1,POlOMY I N PRIMARY MOLARS 21
22 HANSEN, RAVN AND ULRICH
Fig. 6. Radiographs of the teeth from Fig. 5. A: 04-, condition a t time of treatment, B: 04-,
condition 12 months later where only small alterations can be observed. C: -04, condition at
time of treatment, D: - 04, condition 12 months later without alterations.
diagnosis, the pulpal condition before the
treatment need not be the same (GRETH
1933, HERBERT 1945, KISLING 1956, MAG-
NUSSON 1970). To reduce this uncertain
factor the treatment therefore was per-
formed by the same dentist and for the
same reason two teeth from the same in-
dividual was used. I n this way the un-
certain factors must be equal for both of
the used materials. To get an impression
of the pulpal condition outside the am-
putation area, the inflammation in the
apical part of the treated roots was com-
pared in the two groups. Here no dif-
ference could be observed.
As significantly less inflammation was
seen in the amputation area in the group
treated with Ledermix than in the group
treated with ZnO/eug., with no difference
in the apical part of the canal, it is prob-
able that the difference occurring in the
amputation area is due to the dressing
material used.
References
BERGER, J. E.: Pulp tissue reaction to formocre-
sol and zinc oxide-eugenol. J . Dent. Child.
1965: 32: 13-28.
BERGH,C. & MARTENSSON, K.: Pulpabehand-
ling av mjolktander. En efterundersokning av
pulpaamputationer och overkappningar.
Odont. Reuy 1955: 6 : 135-162.
BUTTNER,M.: Die hortnonale und antibiotiscl;e
Therapie in der Wurzelbehandlung. Schweiz.
Mschr. Zahnheilk. 1963: 73: 122-126.
CHILTON, N. V.: Design and analysis in dental
and oral research. J. B. Lippencott Co.,
Philadelphia & Toronto 1967.
FIORE-DONNO, G. & BAUME,L. J.: Effects of
capping compounds containing corticoste-
roids on the human dental pulp. H e l v . odoitt.
Acta 1962: 6 : 23-32.
GRETH,H.: Diagnostik der Pulpaerkrankungen.
Hermann Meusser, Berlin 1933.
HANSEN, H.: Pulp capping with corticoid con-
taining materials. Odont. T . 1969a: 77:
223-210.
HANSEN, H.: Kortikoider i endodontien. T a n d -
hgebladet 1969b: 73: 539-556.
HERBERT,W. E.: A correlation of the clinical
signs and symptoms and histological condi-
tion of the pulps of 52 teeth. Brit. dent. J .
1945: 78: 161-174.
JAMES,V., ENGLANDER, H. & MASSLER,M.:
Histologic response of amputated pulps to
calcium compounds and antibiotics. Oral
,Surg. 1957: 10: 975-986.
KISLING,E. : Histologiske underkegelser af mel-
ketamdernes pulpae som grundlag for en kli-
nisk diagnose. Dens sapiens 1957: 17: 52-61.
KISLING, E.: Nordisk Larobok i Pedodonti.
Sberiges Tandlakareforbunds Forlagsforening,
Stockholm 1970, p. 255-267.
LAW, D. B.: An evaluation of vital pulpotomy
technique. J . Dent. Child. 1956: 23: 4044.
MAGNUSSON, B. : Attempts to predict prognosis
of pulpotomy in primary molars. Bacteriolo-
gic. and histologic examination. Scand. J .
dent. Res. 1970: 78: 232-240.
 B. & KINGQVIST,M.: Forekoinst
MAGNUSSON;,
av interna rotresorptionrr i pulpaamputerade
molarer. Suensk tandliik. T . 1964: 57: 11-26.
MCDONALD, R. E.: Diagnostic aids and vital
pulp therapy for deciduous teeth. J. Amer.
dent. Ass. 1956: 52: 14-22.
KAVN, J. J. & SVARRER: M.: En klinisk-radio-
logisk efterundersegelse af koronal vitalarn-
putation i 200 prirnzre molarer behandlet
nied zinkilte-eugenol som amputationspasta.
Tandlcegebladet 1968: 12: 718-726.
REICH,J.: Basic consideration underlying the
treatment of exposed vital pulps in the teeth
Addre,\:
Harry P . Hanseri
Institute of Operative Dentistry
Royal Dental College
I60 Jagt uej
DK-2100, Copenhagen 0 , Denmark
o f children. Aust. I. Ife7ir. 1951: 55: 171-
175.
SLHROEDER, A. & IKIAUAH.H.: T h e pharma-
cotherapy of pulpitis. O r a l Surg. 1962: 15:
345-350.
ULMANSKY. M. & L ~ N G E KM.:
, Reaction of
dental pulp to Ledermix and Calxyl. Israel
J. m e d . Sci. 1967: 3: 739 746.
VIA, W. F.: Evaluation of deciduous molars
treated by pulpotomy and ralcium hydroxide.
J. A m e r . dent. Ass. 1955: 50: 34-43.
Vrcc, J.: Hydrocortisone in pulp therapy.
Dent. Progr. 1962: 2: 285 287.