Document Type : Original Article


Dept. of Pediatric Dentistry and Public Health, Faculty of Dental Medicine, Lebanese University, Beirut, Lebanon.


Statement of the Problem: Internal root resorption after pulpotomy is a pathological phenomenon and can lead to early root resorption and subsequent loss of the tooth.
Purpose: To assess the relationship between initial inflammatory coronal pulp status in decayed primary molars treated by pulpotomy and internal root resorption after one-year follow-up.
Materials and Method: In this clinical in vivo and in vitro experiment, vital pulpotomies were performed on 50 primary molars from 50 patients aged 5 to 10 years. Coronal pulp was carefully removed followed by hemostasis and placement of a reinforced zinc oxide eugenol over the vital radicular pulp. Enzyme-linked immunosorbent assay (ELISA) assay was done on coronal pulp samples and the level of tumor necrosis factor-alpha (TNF- α) and interlukin-6 (IL-6) was measured. After a 12-month follow-up, periapical radiographs were taken from pulpotomized teeth. Kolmogorov-Smirnov, Chi-square, Kruskal–Wallis, and Mann-Whitney tests were implemented.
Results: 11 treated teeth (22%) showed an internal root resorption as diagnosed on X-rays. No significant association was found between TNF- α, IL-6 levels, and pathological root resorption respectively (p= 0.953) and (p= 0.944). A significant association between age and pathological root resorption was observed (p= 0.031). No significant association between remaining dentin thickness and pathological root resorption was established (p= 0.346).
Conclusion: There was no association between pro-inflammatory cytokines levels/ TNF- α, IL-6 and internal root resorption following pulpotomy in pediatric patients.


  • Coll JA, Seale NS, Vargas K, Marghalani AA, Al Shamali S, Graham L. Primary Tooth vital pulp therapy: a systematic review and meta-analysis. Pediatr Dent. 2017; 39: 16-23.
  • Ozdemir Y, Kutukculer N, Topaloglu-Ak A, Kose T, Eronat C. Comparative evaluation of pro-inflammatory cytokine levels in pulpotomized primary molars. J Oral Sci. 2015; 57: 145-150.
  • Hirsch V, Wolgin M, Mitronin AV, Kielbassa AM. Inflammatory cytokines in normal and reversibly inflamed pulps: A systematic review. Arch Oral Biol.2017;82: 38‐
  • Rechenberg DK, Galicia JC, Peters OA. Biological markers for pulpal inflammation: A systematic review. PLoS One. 2016; 11: e0167289.
  • Kokkas AB, Goulas A, Varsamidis K, Mirtsou V, Tziafas D. Irreversible but not reversible pulpitis is associated with up‐regulation of tumour necrosis factor‐alpha gene expression in human pulp. Int Endod J. 2007; 40: 198-203.
  • Parisay I, Ghoddusi J, Forghani M. A review on vital pulp therapy in primary teeth. Iran Endod J. 2015; 10: 6-15.
  • Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: a retrospective study. Pediatr Dent. 2000; 22: 192-199.
  • Sönmez D, Durutürk L. Ca(OH)2 pulpotomy in primary teeth. Part I: internal resorption as a complication following pulpotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008; 106: e94-e98.
  • Aidos H, Diogo P, Santos JM. Root resorption classifications: a narrative review and a clinical aid proposal for routine assessment. Eur Endod J. 2018; 3: 134-145.
  • Lechner J, Rudi T, Von*Baehr V. Osteoimmunology of tumor necrosis factor-alpha, IL-6, and RANTES/CCL5: a review of known and poorly understood inflammatory patterns in osteonecrosis. Clin Cosmet Investig Dent. 2018; 10: 251-262.
  • Shimazaki E, Karakida T, Yamamoto R, Kobayashi S, Fukae M, Yamakoshi Y, et al. TGF-β and Physiological Root Resorption of Deciduous Teeth. Int J Mol Sci. 2016; 18: 49.
  • Padisar P, Hashemi R, Naseh M, Nikfarjam BA, Moham-madi M. Assessment of tumor necrosis factor alpha (TNFα) and interleukin 6 level in gingival crevicular fluid during orthodontic tooth movement: a randomized split-mouth clinical trial. Electron Physician. 2018; 10: 7146-7154.
  • Kitaura H, Kimura K, Ishida M, Sugisawa H, Kohara H, Yoshimatsu M, et al. Effect of cytokines on osteoclast formation and bone resorption during mechanical force loading of the periodontal membrane. Scientific World J. 2014; 2014: 617032.
  • Iglesias-Linares A, Hartsfield JK Jr. Cellular and molecular pathways leading to external root resorption. J Dent Res. 2017; 96: 145-152.
  • Berbari R, Khairallah A, Kazan HF, Ezzedine M, Bandon D, Sfeir E. Measurement reliability of the remaining dentin thickness below deep carious lesions in primary molaars. Int J Clin Pediatr Dent. 2018; 11: 23-28.
  • Berbari R, Fayyad-Kazan H, Ezzedine M, Fayyad-Kazan M, Bandon D, Sfeir E. Relationship between the remaining dentin thickness and coronal pulp status of decayed primary molars. J Int Soc Prevent Communit Dent. 2017; 7: 272-278.
  • American Academy of Pediatric Dentistry. Prescribing dental radiographs for infants, children, adolescents, and individuals with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2020: 248-251.
  • Junqueira MA, Cunha NNO, Caixeta FF, Marques NCT, Oliveira TM, Moretti ABDS, et al. Clinical, radiographic and histological evaluation of primary teeth pulpotomy using MTA and ferric sulfate. Braz Dent J. 2018; 29: 159-165.
  • Guelmann M, Fair J, Turner C, Courts FJ. The success of emergency pulpotomies in primary molars. Pediatr Dent. 2002; 24: 217-220.
  • American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. Pediatr Dent. 2017; 39: 325-3
  • Ghaderi F, Jowkar Z, Tadayon A. Caries color, extent and preoperative pain as predictors of pulp status in prim-ary teeth. Clin Cosmet Investig Dent. 2020; 12: 263-269.
  • Elsalhy M, Azizieh F, Raghupathy R. Cytokines as diagnostic markers of pulpal inflammation. Int Endod J. 2013; 46: 573-580.
  • Waterhouse PJ, Nunn JH, Whitworth JM. Prostaglandin E2 and treatment outcome in pulp therapy of primary molars with carious exposures. Int J Paediatr Dent. 2002; 12: 116-123.
  • Olatosi OO, Sote EO, Orenuga OO. Effect of mineral trioxide aggregate and formocresol pulpotomy on vital primary teeth: a clinical and radiographic study. Niger J Clin Pract. 2015; 18: 292-296.
  • Nagarathna C, Shakuntala BS, Jaiganesh I. Efficiency and reliability of thermal and electrical tests to evaluate pulp status in primary teeth with assessment of anxiety levels in children. J Clin Pediatr Dent. 2015; 39: 447-451.
  • Aminabadi NA, Parto M, Emamverdizadeh P, Jamali Z, Shirazi S. Pulp bleeding color is an indicator of clinical and histohematologic status of primary teeth. Clin Oral Investig. 2017; 21: 1831-1841.
  • Mutluay M, Arikan V, Sari S, Kisa Ü. Does achievement of hemostasis after pulp exposure provide an accurate assessment of pulp inflammation? Pediatr Dent. 2018; 40: 37-42.
  • Fuks AB, Bimstein E, Guelmann M, Klein H. Assessment of a 2% buffered glutaraldehyde solution in pulpotomized primary teeth of schoolchildren. ASDC J Dent Child. 1990; 57: 371-375.
  • Trairatvorakul C, Koothiratrakarn A. Calcium hydroxide partial pulpotomy is an alternative to formocresol pulpotomy based on a 3-year randomized trial. Int J Paediatr Dent. 2012; 22: 382-38
  • Shröder U. Effects of calcium hydroxide-containing pulp-capping agents on pulp cell migration, proliferation, and differentiation. J Dent Res. 1985; 64: 541-548.
  • Atasever G, Keçeli Tİ, Uysal S, Güngör HC, Ölmez S. Primary molar pulpotomies with different hemorrhage control agents and base materials: A randomized clinical trial. Niger J Clin Pract. 2019; 22: 305-312.
  • Ratnakumari N, Thomas B. A histopathological comparison of pulpal response to Chitra-CPC and formocresol used as pulotomy agents in primary teeth: A clinical trial. Int J Clin Pediatr Dent. 2012; 5: 6-13.
  • Sushynski JM, Zealand CM, Botero TM, Boynton JR, Majewski RF, Shelburne CE, et al. Comparison of gray mineral trioxide aggregate and diluted formocresol in pulpotomized primary molars: a 6- to 24-month observation. Pediatr Dent. 2012; 34: 120-128.
  • Lourenço Neto N, Marques NC, Fernandes AP, Rodini CO, Sakai VT, Abdo RC, et al. Immunolocalization of dentin matrix protein-1 in human primary teeth treated with different pulp capping materials. J Biomed Mater Res B Appl Biomater. 2016; 104: 165-169.
  • Bossù M, Iaculli F, Di Giorgio G, Salucci A, Polimeni A, Di Carlo S. Different Pulp Dressing Materials for the Pulpotomy of Primary Teeth: A Systematic Review of the Literature. J Clin Med. 2020; 9:
  • Gonzalez-Lara A, Ruiz-Rodriguez MS, Pierdant-Perez M, Garrocho-Rangel JA, Pozos-Guillen AJ. Zinc Oxide–

Eugenol Pulpotomy in Primary Teeth: A 24-Month Follow-up. J Clin Pediatr Dent. 2016; 40: 107-112.

  • Hui-Derksen EK, Chen CF, Majewski R, Tootla RGH, Boynton JR. Reinforced zinc oxide-eugenol pulpotomy: A retrospective study. Pediatr Dent. 2013; 35: 43-46.
  • Simşek S, Durutürk L. A flow cytometric analysis of the biodefensive response of deciduous tooth pulp to carious stimuli during physiological root resorption. Arch Oral Biol. 2005; 50: 461-468.
  • Bolan M, Rocha MJ. Histopathologic study of physiological and pathological resorptions in human primary teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 104: 680-685.
  • Monteiro J, Day P, Duggal M, Morgan C, Rodd H. Pulpal status of human primary teeth with physiological root resorption. Int J Paediatr Dent. 2009; 19: 16-25.