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ORIGINAL ARTICLE
Year : 2010  |  Volume : 1  |  Issue : 3  |  Page : 146-151 Table of Contents     

Comparative investigation of clinical/radiographical signs of mineral trioxide aggregate and formocresol on pulpotomized primary molars


Department of Pedodontics and Preventive Dentistry, KLES's V.K Institute of Dental Sciences, Belgaum - 590 010, Karnataka, India

Date of Web Publication26-Nov-2010

Correspondence Address:
Shivayogi M Hugar
Department of Pedodontics and Preventive Dentistry, K.L.E.S's Institute of Dental Sciences, Nehru Nagar, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-237X.72779

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   Abstract 

The objectives of this study were (1) to evaluate clinically and radiographically the effects of mineral trioxide aggregate (MTA) as a pulp dressing after coronal pulp amputation (pulpotomy) in primary molars, (2) to compare the effects of MTA and formocresol in pulpotomized primary teeth. Sixty primary mandibular molars of thirty healthy children aged between 5-8 years were treated by conventional pulpotomy technique. The teeth on the right side are assigned to MTA (Group A) and the left side for the Formocresol (Group B). The children were examined clinically and radiographically every 6 months over a period of 36 months. Results of present study revealed that both MTA and Formocresol has the same effect on the first as well as second primary molars, with chi-square value being 1.1483 (P ≥ 0.05). None of the teeth in either group showed any clinical pathology, showing 100% success rate but radiographically formocresol group showed one case of internal resorption that was regarded as failure in the present study. MTA seems to be more promising predictable with positive response in vital pulp therapy in future than formocresol pulpotomy except for the cost factor.

Keywords: Formocresol, mineral trioxide aggregate, primary teeth, pulpotomy


How to cite this article:
Hugar SM, Deshpande SD. Comparative investigation of clinical/radiographical signs of mineral trioxide aggregate and formocresol on pulpotomized primary molars. Contemp Clin Dent 2010;1:146-51

How to cite this URL:
Hugar SM, Deshpande SD. Comparative investigation of clinical/radiographical signs of mineral trioxide aggregate and formocresol on pulpotomized primary molars. Contemp Clin Dent [serial online] 2010 [cited 2017 Mar 24];1:146-51. Available from: http://www.contempclindent.org/text.asp?2010/1/3/146/72779


   Introduction Top


The primary objective of dental treatment is to maintain the integrity of dental arch. The treatment of pulpally involved teeth in primary and immature permanent teeth presents unique challenges. When the carious process exposes the pulp it reacts via inflammation limited to the area close to the carious lesion. If the pulp in the root canal seems to be unaffected, pulpotomy is the treatment of choice. [1] Formocresol, a formaldehyde compound has evolved as the preferred medicament for routine pulpal procedures in the pediatric endodontics. Although formaldehyde has been known to be toxic and have mutagenic potential it is still the drug of choice for the pulpotomy in the primary molars. [2].[3]

The introduction of a new dental material, Mineral Trioxide Aggregate (Proroot MTA, Tulsa, Oklahoma) has been continuously investigated for its ability to seal the pathways of communication between the root canal system and external tooth surface. The ability of the pulp to tolerate this newer dental material and offer the protection against the microleakage has also been compared. MTA has been proposed as a potential medicament for pulpotomy procedures as well as capping of pulp with reversible pulpitis, apexification, and repair of root perforation. [4],[5] In today's world, the approach should be marking the plans for the future and not holding on to the archaic treatment and methodology. Dental professional has both scientific and moral responsibilities to deliver best possible health care to the patients. [6] Formocresol is still the drug of choice in endodontics but there is no reason why dental profession should not consider and be prudent to introduce the latest materials such as MTA. [7] This study was proposed and conducted to evaluate clinically and radiographically the effects of MTA as a pulp dressing after coronal pulp amputation (pulpotomy) in primary molars and to compare the effects of MTA and formocresol in pulpotomized primary teeth.


   Materials and Methods Top


Sixty primary molars of thirty healthy children aged between 5 and 8 years attending the undergraduate and postgraduate outpatient clinics in the Department of Pedodontics and Preventive Dentistry at KLES's Institute of Dental Sciences, BelgaumKarnataka, India, were treated by conventional pulpotomy technique. The teeth indicated for pulpotomy were assessed by the single clinician who also performed the procedures/techniques and were evaluated every 6 months for 36 months. The criteria for the selection of teeth to be included in the study are as follows: [8]

  1. Exposure of vital pulp due to dental caries, approximating to the pulp radiographically.
  2. Absence of symptoms indicative of advanced pulpal inflammation such as spontaneous pain or history of nocturnal pain.
  3. No clinical and radiographical evidence of pulp degeneration such as excessive bleeding from the root canal, tenderness to percussion, swelling or sinus tract, mobility, internal resorption, interradicular and or periapical bone destruction, advanced physiological root resorption.
  4. Teeth should be restorable after completion of the procedure.


The procedure were explained fully to the parents of children involved in the study and their informed consent as approved by the head of the institution and as well as permission of ethical committee was obtained prior to the investigation on an special format.


   Technique Top


The teeth under study in case of selected children were chosen [Figure 1] who required minimum two pulpotomies in either arch or same arch preferably each on the opposite side (i.e. right and left). The teeth on the right side are assigned to the mineral trioxide aggregate (Group A) [Figure 2] and the left side for the formocresol (Group B) [Figure 3] and [Figure 4] respectively.
Figure 1 :Photograph showing selected mandibular primary molars for the study

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Figure 2 :Pre-operative radiograph for MTA pulpotomy (Group a)

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Figure 3 :Post-operative radiograph immediately after the pulpotomy procedure(Group a)

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Figure 4 :Pre-operative radiograph for formocresol pulpotomy (Group b)

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The procedure was carried out step by step in one visit using local anesthesia and rubber dam to isolate the teeth. After the standardized technique, all the right sided (Group A) primary molars were treated by MTA (Proroot, Dentsply, Tulsa Dental, Okla, USA). Using a stiff metal spatula, MTA powder was mixed with distilled water provided by manufacturer in 3:1 (powder: liquid) ratio and then placed over the exposure site with a plastic instrument. Then, the mixture was compressed against the exposure site with a moist cotton pellet. A thick mix of zinc oxide eugenol cement was placed into the coronal pulp chamber. A layer of intermediate restorative material (IRM) was placed at the same appointment as the pulpotomy [Figure 3].

All the left-sided (Group B) primary molars under study were treated with cotton pellet moistened with formocresol duly blotted and virtually dry, and were placed over the radicular pulp for 5 minutes. A thick mix of zinc oxide eugenol cement was then placed into the coronal pulp chamber. Intermediate restorative material cement base was placed over the zinc oxide layer at the same appointment [Figure 5].
Figure 5 :Post-operative radiograph immediately after the pulpotomy procedure (Group b)

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After 8 days, the pulpotomized teeth were restored with a preformed stainless steel crowns. [Figure 6],[Figure 7],[Figure 8]. The children were recalled for clinical and radiographical examination every 6 months over a period of 36 months [Figure 9] and [Figure 10] and were looked for the following signs and symptoms, viz., pain, swelling, sinus/fistula, periapical changes, furcation radiolucency, and internal resorption by the investigator himself who was aware to which the subject group belonged.
Figure 6 :Post-operative radiograph after the stainless steel crown placement for MTA pulpotomized tooth (85)

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Figure 7 :Post-operative radiograph after the stainless steel crown placement for formocresol pulpotomized tooth (75)

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Figure 8 :Definitive restoration with preformed stainless steel crown (Group a and Group b)

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Figure 9 :Thirty-six months post-operative radiograph for MTA pulpotomized tooth (85)

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Figure 10 :Thirty-six months post-operative radiograph for formocresol pulpotomized tooth (75)

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Radiologist's opinion was taken into consideration about the successive evaluation of the radiographs. The treatment was regarded as a failure when one or more of the above mentioned signs and symptoms were present, but pulp canal obliteration (PCO) was not regarded as a failure. Absence of dentinal bridge was not regarded as a failure in case of MTA (Group A). All data were entered into a special format and analyzed statistically by chi-square test and test of proportion Z test to assess the success rate of the treatment with MTA and formocresol every 6 months.


   Results Top


A total of thirty eight first primary molars and twenty two second primary molars were treated by the above technique [Table 1]. Chi-square value for the different tooth types viz. first primary molars, second primary molars was 1.1483 (P ≥ 0.05). This value indicates that MTA and formocresol has the same effect on the first as well as second primary molars.
Table 1 :Distribution of assessed pulpotomized primary molars by tooth type

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The follow-up evaluations revealed 100% clinical success rate in both the groups [Table 2]. Out of thirty pulpotomy carried on primary molars with MTA (Group A), eighteen teeth showed dentin bridge formation, two samples with pulp canal obliteration (PCO), and ten samples did not reveal any calcific bridge but none of them showed signs including internal resorption, furcation involvement, and periapical radiolucency with the 100% success radiographically. However, out of thirty teeth treated with formocresol, twenty nine teeth did not show any pathological changes giving 96.67% of success radiographically. [Table 3]
Table 2 :Clinical assessment in pulpotomized primary molars under study

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Table 3 :Radiographic assessment in pulpotomized primary molars

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Although one case showed internal resorption, radiograph did not reveal any furcation involvement and periapical bone destruction, and clinically the patient did not show adverse reaction. 'Z' test value for the internal resorption was 1.0084 (P ≥ 0.05). This value indicates that there was no significant difference found between MTA-treated and formocresol-treated teeth.


   Discussion Top


Pulpotomy is a common procedure in the treatment of acutely inflamed primary teeth. The importance lies not only with the choice of procedure but also with the different pharmacotherapeutic agent, which have been already used for the above procedure of the primary teeth. Formocresol has been the popular material of choice for the pulpotomy procedure. It has otherwise proved as "gold standard" in pediatric dentistry may be mainly because of its ease in use and excellent clinical success but this clinical success rate has been always in close observation due to its safety considerations and to the availability of the newer materials in the clinical market.

MTA is a relatively new material that has become the material of choice for certain endodontic applications. USA Food and Drug Administration in 1998 approved MTA as an therapeutic and endodontic material in humans. [5] MTA has proved as not an inert material but actively promotes hard tissue formation. [9] In this study, no significant difference was found in clinical outcomes for both the medicaments. The success rate of MTA is promising due to its excellent sealing ability, biocompatibility, and ability to regenerate hard tissues. [9],[10],[11] The present data indicates that under standardized and optimal clinical conditions and defined period of observation MTA has shown very promising success with all thirty samples not showing any adverse effects.

MTA's effects on amputated pulpal tissue seem to suggest that the material preserves the pulp tissue and promotes the regeneration of hard tissues. The nearly normal pulpal architecture, intact and continuous odontoblastic layer, and reparative dentin bridging observed indicate about the material's biocompatibility and regeneration ability. [7]

The stimulatory effect of MTA on the biosynthetic activity of periradicular cells results primarily in stimulation of fibroblasts to lay down a fibrous connective tissue and rapid growth of periodontal ligament due to its high healing capacity. Hard tissue formation seems to be activated progressively from the peripheral root walls to the centre of the MTA. [12],[13] MTA stimulates dentin formation adjacent to the dental pulp, dentinogenesis of MTA can be due to its sealing ability, biocompatibility, alkalinity, and MTA provides a superior seal against bacteria.

The 100% clinical success rate of formocresol pulpotomy (Group B) in our study was attributable to its germicidal action. The chemical bonding with the proteins of microorganisms is the basis of bacteriocidal action of formocresol and also to its fixative qualities. Although the study is imperative to suggest the clinical and radiographic success, it is difficult to forego the actions which are present due to the chemical action of the formaldehyde with reference to fixation with the protein. [3],[14]

One tooth from formocresol (Group B) showed radiographically internal resorption which was considered as failure in the post-treatment evaluation period as per methodology. In this study tooth with internal resorption was not treated and was left for the follow up observation as it was not showing any periapical osseous changes. Radiographically, twenty nine treated teeth out of thirty teeth treated with formocresol with 96.67% success rate should be considered to have a good prognosis except for the tooth with internal resorption that remains questionable. [15],[16],[17]

Formocresol has recently come to critical review and three concerns about the material should be under immediate inspection. First, local toxicity; second, the effects of the material systemically; and last, its effects of mutagenicity and carcinogenicity. [2] However, in this regard in our study clinically and radiographically formocresol as pulpotomy agent can be considered as a clinical success when evaluated under strict standardization technique.

The radiographic success rate of 100% for MTA (Group A) in our study was comparable with the previous results. MTA appears to meet the requirement for pulp capping materials. It stimulates dentin bridge formation and prevents microleakage. The material sets slowly but far from being a disadvantage, this slow setting time prevents setting shrinkage. [18]

Pulp canal obliteration (calcific metamorphosis) was found in the two cases in MTA-treated teeth was not considered as failure, which is the result of the odontoblastic activity and it suggests that the tooth is retaining some degree of vitality and function overtime. [19] MTA's advantages are related to its ability to effectively seal the material tooth interface to prevent bacterial penetration and to its high level of biocompatibility. This is in contrast to calcium hydroxide, which deteriorates overtime and gradually disintegrates thereby leaving space for potential micro leakage. MTA does not appear to change overtime. Therefore, it preserves the protective cover over, for instance developing reparative dentin, preventing bacterial invasion of the pulp. The pulp can tolerate almost any dental material and produce new dentin as long as it can be protected against microleakage, a function that MTA appear to perform better than any material with which it has been compared. [18] MTA not only yields good success rates but it also does not induce internal resorption, a finding seen with formocresol-treated teeth.

As formaldehyde is a small molecule that can penetrate the apical foramen and the mummification of the pulp only treats the symptoms but does not have the healing capacity. The objectives of formocresol pulpotomy are solely clinical, maintaining the tooth in an asymptomatic condition until normal exfoliation. Although enough evidence is present to suggest that the objective is no longer be complete "mummification". However, one may consider and accept that in fixation they may create a tolerable irritation, which replaces an intolerable irritation caused by bacteria. [19]


   Conclusion Top


The principle conclusions of this study are that there are no significant differences in MTA and formocresol. To draw the definitive conclusions whether to withdraw our popular pulpotomy medicament such as formocresol or to include the newer and the highly biocompatible material like MTA, despite of the high success rate observed in our study remains a debatable topic. Further histologic studies on the larger sample size and longer observational period should be carried out. MTA seems to be more promising predictable with positive response in vital pulp therapy in future than formocresol pulpotomy except for the cost factor.

 
   References Top

1.Eidelman E, Holan G, Fuks AB. Mineral trioxide aggregate vs. formocresol in pulpotomized primary molars: A preliminary report. Pediatr Dent 2001;23:15-8.   Back to cited text no. 1
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2.Ranly DM, Horn D. Assessment of the systemic distribution and toxicity of formaldehyde following pulpotomy treatment. Part two. ASDC J Dent Child 1987;54:40-4.  Back to cited text no. 2
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3.Berger JE. Pulp tissue reaction to formocresol and zinc oxide eugenol. J Dent Child 1965;32:13-28.  Back to cited text no. 3
    
4.Castellucci A. The Use of Mineral Trioxide Aggregate in Clinical and Surgical Endodontics. Dent Today 2003;22:74-80.  Back to cited text no. 4
    
5.Schwartz RS, Mauger M, Clement DJ, William A. Mineral trioxide aggregate: A new material for endodontics. J Am Dent Assoc 1999;130:967-75.  Back to cited text no. 5
    
6.Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: A retrospective study. Pediatr Dent 2000;22:192-9.  Back to cited text no. 6
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7.Agamy HA, Bakry NS, Mounir MM, Avery DR. Comparison of mineral trioxide aggregate and formocresol as pulp capping agents in pulpotomized primary teeth. Pediatr Dent 2004;26:302-9.  Back to cited text no. 7
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8.Waterhouse PJ, Nunn JH, Whitworth JM. An investigation of the relative efficacy of Buckley's formocresol and calcium hydroxide in primary molar vital pulp therapy. Br Dent J 2000;188:32-6.  Back to cited text no. 8
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9.Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endo 1999;25:197-205.   Back to cited text no. 9
    
10.Vij Raj, Coll JA, Shelton P, Farooq NS. Caries control and other variables associated with success of primary molar vital pulp therapy. Pediatr Dent 2004;26:214-10.  Back to cited text no. 10
    
11.Salako N, Joseph B, Ritwik P, Salonen J, John P, Junaid TA. Comparison of bioactive glass, mineral trioxide aggregate, ferric sulfate and formocresol as pulpotomy agents in rat molar. Dent Traumatol 2003;19:314-20.  Back to cited text no. 11
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12.Bodem O, Blumenshine S, Zeh D, Koch MJ. Direct pulp capping with mineral trioxide aggregate in a primary molar: A case report. Int J Pediatr Dent 2004;14:376-9.   Back to cited text no. 12
    
13.Economides N, Pantelidou O, Kokkas A, Tziafas D. Short term periradicular tissue response to mineral trioxide aggregate (MTA) as root end filling material. Int Endo J 2003;36:44-8.  Back to cited text no. 13
    
14.Strange DM, Seale NS, Nunn ME, Strange M. Outcome of formocresol / ZOE sub-base pulpotomies utilizing alternative radiographic success criteria. Pediatr Denti 2001;23:331-6.  Back to cited text no. 14
    
15.Roberts JF. Treatment of vital and non-vital primary molar teeth by one stage formocresol pulpotomy: Clinical success and effect upon age at exfoliation. Int J Pediatr Dent 1996;6:111-5.  Back to cited text no. 15
    
16.Rusmah M, Rahim ZH. Diffusion of buffered glutaraldehyde and formocresol from pulpotomized primary teeth. J Dent Child 1992;59:108-10.   Back to cited text no. 16
    
17.Van Amerongen WE, Mulder GR, Vingerling PA. A clinical and radiographic study of the influence of formocresol pulpotomy on the life span of primary molars. ASDC J Dent Child 1986;53:364-70.   Back to cited text no. 17
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18.Bakland LK. Management of traumatically injured pulps in immature teeth using MTA. J Calif Dent Assoc 2000;28:855-8.  Back to cited text no. 18
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19.Ranly DM, Lazzari EP. The formocresol pulpotomy: The past, the present and the future. J Pedod 1978;2:115-27.  Back to cited text no. 19
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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