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 Table of Contents  
Year : 2018  |  Volume : 9  |  Issue : 4  |  Page : 181-185

Pulpotomy medicaments in primary teeth: A literature review of natural alternatives

1 Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication18-Dec-2018

Correspondence Address:
Rekhalakshmi Kamatham
Department of Paedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore - 524 003, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_14_18

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Pulpotomy is a procedure which involves complete amputation of the coronal pulp, followed by employment of an appropriate medicament that will stimulate healing and preserve the vitality of the tooth. This is the choice of treatment for cariously exposed vital primary molars, with formocresol considered as golden standard. However, controversies surrounding this medicament have generated inquisitiveness to exploration for natural alternatives. This narrative review is to focus on the use of natural products as alternative pulpotomy agents to formocresol so as to guide the clinicians in choosing proper medicament.

Keywords: Medicaments, natural, primary teeth, pulpotomy

How to cite this article:
Saikiran KV, Kamatham R, Sahiti PS, Nuvvula S. Pulpotomy medicaments in primary teeth: A literature review of natural alternatives. SRM J Res Dent Sci 2018;9:181-5

How to cite this URL:
Saikiran KV, Kamatham R, Sahiti PS, Nuvvula S. Pulpotomy medicaments in primary teeth: A literature review of natural alternatives. SRM J Res Dent Sci [serial online] 2018 [cited 2023 May 31];9:181-5. Available from:

  Introduction Top

Pulpotomy is executed in the primary tooth when caries removal results in a carious or mechanical pulp exposure and tooth with extensive caries without evidence of radicular pathology.[1] Among the pulpotomy medicaments, formocresol remains the gold standard of all the medicaments reported in the literature.[2] Despite the high success rate, the use of formocresol has raised various concerns that include its mutagenic, carcinogenic, and allergenic potentials.[3]

The use of natural products in dentistry has been a recent trend. Hence, the purpose of this literature review was to give an overview of these natural products as alternatives to conventional pulpotomy agents.

  Nigella Sativa Oil Top

Nigella sativa (NS) is an indigenous herbaceous plant traditionally used worldwide in herbal medicine. It is commonly known as black seed or black cumin. The seeds from this plant have proclaimed medicinal usage dating back to the ancient Egyptians, Greeks, and Romans. NS plant is especially used in the Middle East and in Southeast Asia to promote health and fight disease for centuries. Many of the medicinal uses of this plant have been scientifically tested, and some have been confirmed. In particular, the black seed extract has shown to possess the following beneficial medical effects: bronchodilator, immune-potentiating activity, hypotensive, analgesic, antibacterial, and anti-inflammatory.[4] Abu-Zinadah found that NS possess wound healing capacity as it contains proteins which may stimulate the dermal fibroblast to express fibronectin by human keratocytes and this might help in reducing the burn wound.[5] Lotfy and Zayed found that NS can be used as a prophylactic adjunct to conventional chemotherapy in the treatment of oral mucositis in rats.[6] Due to its proven analgesic, anti-inflammatory and antibacterial action of NS oil extract, it has been employed as a pulpotomy agent. Omar et al. performed a histopathologically study on dogs to know the pulpal reaction to NS oil and formocresol. They reported that NS has anti-inflammatory properties, and the pulpal vitality is maintained after its application. Hence, the material was suggested as a pulpotomy medicament for primary teeth.[7] The other applications of NS in dentistry are as a treatment modality for oral ulcerations, gingival and periodontal diseases, oral mucositis, and also in the prevention of dental caries.[8],[9],[10]

  Turmeric Powder Top

Curcuma longa is a perennial herb cultivated extensively in India, China, and other countries with a tropical climate. It has a wide range of pharmacological applications, owing to its antioxidant, anti-inflammatory, and antimicrobial properties.[11] It is widely used in foods for its color and flavor. It is extensively used in Ayurvedic systems of medicine for the treatment of flatulence, menstrual difficulties, jaundice, hemorrhage, hematuria, and colic diseases.[12] It has specific lipoxygenase and cyclooxygenase 2-inhibiting property which acts as a potent anti-inflammatory agent.[13]

The following are the reported uses of turmeric in dentistry; as a mouth rinse, a dentifrice, coloring agent in pit and fissure sealants and staining agent in dental-plaque detection system.[14],[15],[16] Due to the medicinal and anti-inflammatory properties, turmeric powder was used as a pulpotomy medicament in primary teeth by Purohit et al. with good clinical and radiographic success.[12] Hugar et al. also used turmeric gel as a pulpotomy medicament in primary molar teeth with an acceptable clinical and radiographic outcome.[17]

  Thymus Vulgaris Top

Thymus vulgaris is a perennial plant, indigenous in the Mediterranean region and is cultivated in several countries. Due to its antimicrobial, antitussive, spasmolytic, and antioxidant activity, it has been used in medical field for thousands of years.[18] Some studies revealed that thyme extract has anti-inflammatory and wound healing properties.[18] Conventionally, thyme is the most commonly recommended herb in European countries for treating cough and upper respiratory congestion. The German expert panel has approved thyme for relieving bronchitis and whooping cough.[19] Thymol, one of the ingredients of thyme, is most commonly used as antiseptic mouthwash which showed a reduction in plaque formation, gingivitis, and caries.[20] Alolofi et al. (2016) performed clinical and radiographical assessment on thymus vulgaris as a pulpotomy agent in primary molar teeth and showed good clinical success rate. This has been ascribed to the antibacterial, anti-inflammatory and hemostatic properties of thymus components such as thymol, carvacrol flavonoids, and apigenin.[21]

  Antioxidant Top

Antioxidants have a capacity of deactivating free radicals in human cells. This can be exogenous or endogenous as a part of the diet or dietary supplements. The endogenous component is generated through a highly multifaceted antioxidant systems (enzymic or nonenzymic), which work synergistically and in combination with each other to prevent cells or organs against free radicals whereas, exogenous ones are produced from several sources and available as supplements.[22],[23] In dentistry, there are mouth rinses, toothpastes, or oral sprays containing antioxidant supplements. The majority of enhancements include propolis, green tea, pine bark, or grape seed extracts.[24],[25] Antioxidants have potential to alteration the progress of oral problems such as gingivitis and periodontitis by negotiating antioxidant volume of crevicular fluid and plasma.[26] Studies revealed that antioxidants such as green tea have a role in restorative dentistry on caries prevention as it has been reported that epigallocatechin-3-gallate molecule had scavenging effect on caries prevention.[27] The antioxidant mix works on the principle of wound healing and maintaining anatomic continuity of the damaged tissue.[28] Kathal et al. stated that antioxidant mix pulpotomy is more biocompatible and cost-effective than any other commercially available medicament. This may be due to the elimination of reactive oxygen species as it was an important strategy for improving healing of radicular pulp.[29]

  Copaifera Langsdorffii Oil Resin Top

This phytomedicine chemically defined as a solution of diterpene acids in an essential oil that is mostly constituted by sesquiterpenes.[30] It has a wide range of pharmacological applications due to its reported analgesic, anti-inflammatory, antiulcer, antinociceptive, gastric protection, antioxidant, antitumoral, antimicrobial, and wound-healing properties.[31],[32] Copaifera langsdorffii oil resin (CLOR) is largely used in alternative medicine as a dietary supplement to produce flavoring agents and food additives.[33] This encouraged CLOR usage in dentistry as a pulpotomy medicament, anticariogenic agent, bioendodontic sealer, and to treat periodontal conditions.[34] Lima et al. conducted a study using fibrin sponge as a vehicle for application of CLOR in the pulpotomized teeth. They concluded that the fibrin sponge without CLOR showed the worst healing and inflammatory response outcomes, and they graded the inflammatory response of the pulpal tissue to CLOR as less severe compared to fibrin sponge. The impervious resinous layer of CLOR provided topical wound healing properties to the amputated radicular pulp tissue.[35] Musale PK and Soni AS (2016) also stated CLOR as a pulpotomy agent for primary teeth.[36]

  Allium Sativum Oil Top

It is commonly recognized as garlic and it is one of the widely investigated medicinal plants. The antibacterial activity of Allium depends on allicin produced by enzymatic activity of alliinase. Thus, the therapeutic effects of garlic are due to allicin and other thiosulfinates.[37] Garlic extract has been stated to prevent growth of numerous Gram-positive and Gram-negative bacteria.[38] Allium sativum extract has been identified to take inhibitory action on several pathogenic bacteria, fungi and viruses. There is inhibitory activity of garlic extract on multidrug-resistant strains of Streptococcus mutans isolated from human carious teeth.[39] One of the utmost prominent features in specimens of A. sativum oil was the presence of osteodentin.[40] Mohammad et al. compared the effects of formocresol and A. sativum oil on the pulpal tissue of the pulpotomized primary teeth and stated that A. sativum oil had more powerful antimicrobial effect than formocresol on the bacteria of the infected root canals.[41]

  Honey Top

Among the natural products, honey has been well documented in the literature due to its medicinal importance. It has both antimicrobial as well as wound healing property.[42] From ancient times, honey has been cast-off by human beings as food substance as well as medicine for treating systemic diseases such as asthma, gastrointestinal, urinary, and skin diseases including ulcers, psoriasis, wounds, eczema, seborrheic dermatitis, and dandruff.[43],[44],[45],[46] Honey consists of polyphenols that have beneficial effects on dental caries, oral cancer, and periodontal diseases.[47] It can be used to develop oral hygiene products such as toothpastes and mouthwashes to prevent dental caries.[48] Honey have been successfully used against halitosis. Studies revealed that usage of honey chewing gum 3 times a day after meals considerably reduces plaque and the risk of gingivitis. It has also been useful in the treatment of oral ulcers as well as stomatitis following radiotherapy.[49] Honey when applied topically is effective in the management of oral lesions. Aphthous stomatitis and oral lesions such as recurrent intraoral herpes, recurrent herpes labialis, atrophic/erosive oral lichen planus, oral psoriasis, and oral candidiasis are effectively treated using honey.[50] In the view of above-mentioned properties of honey, this natural product was selected as a pulpotomy agent by Kumari et al. with promising results both clinically and radiographically.[51] The other important factor that has been attributed to the success of honey as pulpotomy agent is the increased rate of anti-inflammatory and healing properties due to its acidic nature. The acidity of honey aids in providing oxygen to regenerating tissue as it drops the pH of the wound and creates more oxygen available from hemoglobin in the blood. Honey has been reported to considerably stimulate the release of cytokines such as tumor necrosis factor-α, interleukin (IL)-1 β, and IL-6 from monocytes, identified to play a significant role in healing as well as tissue repair.[52]

  Aloe Vera Top

Aloe vera, native to Africa, is also known as “medicinal plant.” It has got various properties such as immunomodulatory, antiviral and anti-inflammatory, anti-bacterial, antifungal as well as protective nature against a broad range of microorganisms.[53] It also exhibits excellent antioxidative property. It is also implicated in the treatment of healing of skin burns and wounds. It contains 75 potentially active constituents such as vitamins, enzymes, minerals, sugars, anthraquinones, fatty acids, hormones, and other useful substances.[54] In dentistry, it is used as a healing agent in treating aphthous ulcers, extraction socket, and chronic oral lesions as well as in the treatment of lichen planus.[55] The anti-inflammatory role of steroids present in A. vera gel is well established, leading to the production of low levels of prostaglandins.[56] Due to this properties, A. vera, was used as a pulpotomy agent by Gupta et al. evaluated the effect of freshly extracted A. vera gel from its leaves as a pulpotomy agent in primary molar teeth. Clinical and radiographical evaluation of all pulpotomized teeth was carried out for about 1 month followed by histopathological evaluation. They concluded that freshly extracted A. vera gel can be used as a successful pulpotomy agent.[57] Gala-Garcia et al. (2008) concluded that the application of A. vera placed directly on exposed rat pulpal tissue has suitable biocompatibility and helps in tertiary dentin bridge development. They attributed the reason behind this result to the various bioactive constituents such as polysaccharides, glycoprotein, and beta-sitosterol in the stimulation of wound healing, angiogenesis and cell proliferation.[58] Kalra et al. evaluated the effect of freshly extracted A. vera plant extract and mineral trioxide aggregate (MTA) as a pulpotomy agent in primary molar teeth, with clinical and radiographical evaluation of all pulpotomized teeth carried out for about 12-month followed by histopathological evaluation. However, MTA pulpotomy was found to be superior when compared to fresh A. vera plant extract pulpotomy in primary molars.[59]

  Acemannan Top

The b-(1, 4) acetylated polymannose is an extract from A. vera, that is biocompatible with various oral mesenchymal cell types. This compound has been known to have immunostimulant, antiviral, antineoplastic, and gastrointestinal properties.[60] In dentistry, acemannan claimed a positive result in extraction socket bone formation, oral ulcer healing, periodontium formation in class II defects, and reparative dentin formation in iatrogenic pulp exposures.[61],[62],[63] Acemannan when placed as a direct pulp-capping agent on rat molars stimulated proliferation, differentiation and dentine bridge formation and encouraged pulp tissue organization.[64] Songsiripradubboon et al. reported the properties of acemannan, a polysaccharide from A. vera, on human deciduous pulp cells and concluded that acemannan is biocompatible with the dental pulp. Furthermore, acemannan in reversible pulpitis teeth encouraged dentin regeneration. The results of the pulpotomy treatment indicated that acemannan stimulated dentine bridge formation covering the exposure site and predominantly normal pulp tissue organization.[65]

  Conclusion Top

Natural products claimed to play a vital role and appear to be a viable replacement to formocresol. Although these natural products are being projected for their advantages and having a wide scope; there is lack of higher level of evidence to support its usage in pediatric dentistry. Hence, appropriate attention should be paid while using these products and randomized clinical trials should be conducted to evaluate their efficacy in children.

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Conflicts of interest

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