Vital Pulpotomy and its Perspectives

The article is devoted to the history of research and the development of materials being the protectors of the pulp used for vital amputation and pulp capping when it is accidentally exposed and also to the use of MTA in dentistry, including pediatric, as well as the prospect of the use of MTA in vital amputation of permanent teeth with the formed apex as a stage of preparation for prosthetics.


Introduction
Different materials for vital amputation and the reaction of the pulp are the subject of many studies [1][2][3][4]. Sometimes vital pulp therapy does not guarantee long-term success compared to endodontic treatment and the implications of various modifications of formocresol for pulpotomy of deciduous teeth are also not clear yet used since the 19th century [5,6]. More than 30 years ago there already had been a huge choice of varnishes and cements for the preservation of pulp vitality [7]. Currently, vital pulp therapy is undergoing a remarkable progress thanks to the invention of new biomaterials in combination with the perfection of adhesive technology [8]. reviewed clinical studies on the pulp survival for 12 months after the intervention  with subsequent meta-analysis concluding any type of pulpotomy in deciduous teeth using the most efficient MTA and formocresol [9]. Overview of clinical studies by [10]. Showed the complexity of the interpretation of these studies and the creation of an ideal clinical conditions for the evaluation of the materials used [11]. There were practically no studies on pulpotomy teeth with carious lesions.

Complete
According to is the most appropriate for the permanent teeth with formed top [12].

The History of the Development
Archaeological research showed that people of the Neolithic have been already familiar with the method of drilling and dental treatment. The remains of people with smooth holes of clearly artificial origin in teeth have been found on the territory of modern Pakistan. These graves are about 9 thousand years. It is assumed that the ancient physicians used substance similar to asphalt as the filling material. The papyri have brought to us a deep knowledge of the Egyptians about the healing properties of plants, which doctors of the time used in the manufacturing of filling materials and anti-inflammatory compounds for gingivitis, erosion and pulpitis treatment.

Annals of Reviews and Research
IV. 1978: Explored the application of a combination of calcium hydroxide and antibiotic-glucocorticoid mixtures in the conservative treatment of pulp in carious posterior teeth [19].

Annals of Reviews and Research Physical Methods Pulpotomy
Showed the same efficiency of the laser and Biodentical MTA for pulpotomy in primary teeth [60]. Noted the great efficiency of the laser pulpotomy compared to ferric sulfate and electrocoagulation in clinical studies of children 4-10 years according to clinical and radiological parameters [61]. Consider the laser and electrocoagulation acceptable alternative to pharmacotherapeutic pulpotomy agents [62]. Determined in vivo high efficiency of the KaVo Gentle Ray Diode Laser compared to formocresol and ferric sulfate consider electrocoagulation being efficient enough in the clinic of pediatric dentistry [63].

MTA in Pediatric Dentistry
Believe that the MTA, in particular white, soon will completely replace the "gold standard" formocresol in pulpotomy of deciduous teeth, outperforming its clinical and radiographic Noted greater efficiency and the potential for the formation of reparative dentin of Biodentin compared to calcium hydroxide (Pulpdent) when conducting pulpotomy in the 5-10 years children identified greater efficiency of MTA in comparison with formocresol during clinical studies of the primary teeth in the 5-8 years children [82][83][84]. Emphasize equally high efficiency of various types of MTA -RetroMTA, OrthoMTA and ProRoot MTA for pulpotomy in deciduous teeth [85]. consider it appropriate to use MTA and Portland cement for pulpotomy in deciduous teeth, affirming their reparative and bioinductive properties by the presence of dentin matrix protein DMP -in their review of the studies revealed a higher and long-term effectiveness of MTA in primary teeth pulpotomy in contrast to the ferric sulfate [86,87]. Recommend the treatment with 5% sodium hypochlorite to ensure maximum effectiveness of calcium in primary teeth pulpotomy [88].

Pulpotomy in Permanent Teeth
consider Biodentin and MTA to be effective for the treatment of traumatized permanent incisors [89]. believe that pulpotomy with MTA is a reliable alternative to endodontic treatment of permanent teeth in children [90]. Confirmed similar efficacy of CEM and MTA in pulpotomy of permanent first molars with incomplete apexogenesis [91]. noted the effectiveness of MTA in pulpotomy of permanent molars with carious lesions [92]. Recommend MTA pulpotomy for permanent teeth with incomplete apexogenesis [13].

The Advantages of Modern Materials
note the absence of toxic and mutagenic effect in C|EM compared to formocresol and ferric sulfate [93]. observed normal apexogenesis in pulpotomy of the 12 years girl second lower molar. confirm the minimum of toxic effect on the fibroblasts of the periodontium of white and grey MTA [94,95]. MTA is superior to calcium hydroxide on efficiency Northwest Practice-based Research Collaborative in Evidence-based According to in vivo studies by MTA and CEM are superior to calcium hydroxide for a favorable response and further healing of the pulp [96,97]. MTA has a lower cytotoxicity compared to calcium hydroxide Histological examination by demonstrated the efficacy of tricalcium phosphate, MTA and Portland cement in contrast to formocresol and ferric sulphate [98,99].

Disadvantages of Modern Materials
In their review of electronic database studies have evaluated the MTA potential for the formation of a protective barrier of hard tissues compared to calcium hydroxide as questionable [100]. In addition, the analysis of electronic databases of studies from 1950 to 2013 by never found out the preferred tactics in the treatment of teeth with deep carious lesions, endodontic treatment or pulpotomy [101]. Found out a weak inhibitory effect on cariogenic bacteria from MTA in primary teeth pulpotomy [102].

MTA Mechanism of Action
MTA is calcium oxide in the form of tri-and di-silicate with tricalcium aluminate prior to setting. The first product of the reaction between MTA and water is calcium hydroxide, which provides its biocompatibility [103]. Thus, MTA has all the properties of calcium hydroxide, and also provides a better connection to the dentin. In addition, the MTA reacts with fluids containing phosphates resulting in a precipitate in the form of hydroxyapatite [104]. Several authors have attributed high solubility in water high duration setting material gray MTA containing iron, can stain the tooth tissue to the shortcomings of MTA [105][106][107]. MTA is a universal material in the clinic of pediatric dentistry, ensuring the preservation of pulp vitality and the root pulp in particular and, therefore, a complete root formation of immature permanent teeth. MTA appears to be an apical barrier during the periodontitis treatment of immature teeth providing normal apex development [108]. Considers the possibility of completing the treatment of the tooth in one visit to be an advantage of MTA over calcium hydroxide, but some MTA types may cause clinical crown discoloration ( Table 1).

Recommendations for the MTA Use
Studies showed that the compound of composite GIC and white MTA was stable regardless the presence of the etching material [116][117]. The authors recommended isolating liner of composite GIC with its further etching along with dentin for pulp capping and restoration of bifurcation using MTA. The review of studies indicates the possibility of the future use of MTA not only medicinally, but also in the preparation of the permanent teeth for prosthetics [118][119]. Even Pierre Foshar in his works, recognized the significant loss of hard tissues during endodontic treatment, leading to additional complicated and sometimes risky prosthetic procedures.