|Year : 2014 | Volume
| Issue : 1 | Page : 13-18
Evaluation and comparison of white mineral trioxide aggregate and formocresol medicaments in primary tooth pulpotomy: Clinical and radiographic study
Cheranjeevi Jayam1, Malay Mitra2, Jiban Mishra2, Bhaswar Bhattacharya2, Biswanath Jana2
1 Departments of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Sanand, Ahmedabad, Gujarat, India
2 Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||15-Feb-2014|
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Opp. Pleasure Club, Bopal-Ghuma Road, Sanand, Ahmedabad - 382 115, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The primary aim of the following study is to evaluate and secondary aim is to compare clinically and radiographically the success of using white mineral trioxide aggregate (MTA) versus formocresol (FC) medicament for primary tooth pulpotomy. Materials and Methods: A total of 100 teeth were selected for pulpotomy; of which 50 teeth underwent FC pulpotomy and 50 teeth underwent pulpotomy with white MTA. Out of 100 treated teeth, 82 teeth (42 FC and 40 MTA teeth) were available at the end of 24 months for evaluation. 4 failures were found in FC group at 1 st month evaluation and no failures were found in white MTA group. A statistical analysis was performed to evaluate the overall success rate of study and individual success rates of medicaments. Overall success rate of the study was 95%, success rate of FC group was 90.48% and success rate of MTA group was 100%. Results: MTA produced better results as pulpotomy medicament in comparison to FC. The superior success obtained in the present study was matching other studies mentioned in the literature. Conclusion: MTA seems to be a promising pulpotomy medicament for future use.
Keywords: Formocresol, primary tooth, pulpotomy, pulpotomy medicament, mineral trioxide aggregate, success rate, white mineral trioxide aggregate
|How to cite this article:|
Jayam C, Mitra M, Mishra J, Bhattacharya B, Jana B. Evaluation and comparison of white mineral trioxide aggregate and formocresol medicaments in primary tooth pulpotomy: Clinical and radiographic study. J Indian Soc Pedod Prev Dent 2014;32:13-8
|How to cite this URL:|
Jayam C, Mitra M, Mishra J, Bhattacharya B, Jana B. Evaluation and comparison of white mineral trioxide aggregate and formocresol medicaments in primary tooth pulpotomy: Clinical and radiographic study. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2020 Jul 10];32:13-8. Available from: http://www.jisppd.com/text.asp?2014/32/1/13/127043
| Introduction|| |
Pulpotomy is described as "complete removal of coronal portion of the dental pulp followed by the placement of suitable dressing or medicament that will promote healing and preserve vitality of the tooth." ,
The term suitable dressing or medicament has created considerable storm in pulpotomy procedure. Several medicaments have been studied on the effect of amputated pulp. Formocresol (FC) over years has still remained the benchmark medicament for pulpotomy procedure due to its very high and consistent results that date back to even more than a century". ,,, Despite FC's high success rate and its position as "gold standard" in pulpotomy, a substantial shift has occurred from the use of this medicament because of 2 main reasons. (1) FC itself being a connective tissue irritant causes devitalization of vital radicular pulp and (2) concern regarding its systemic effects such as toxicity, mutagenecity, carcinogenicity and antigenecity. ,,, Both proponents and opponents have debated whether to use formocresol for many years now. ,,,,,,, Leaving aside whether it causes systemic effects, devitalization of radicular pulp caused by formocresol cannot be substantiated. Since treatment objective with an ideal pulpotomy agent is to maintain vitality of pulp, search for "ideal pulpotomy agent" had commenced.  In this awakening several regenerative materials like tricalcium phosphate, hydroxy-apatite, mineral trioxide aggregate (MTA), bone morphogenetic protein and several others have been formulated, studied and used over years. These studies have only produced varying and inconsequential results. ,,,, Recently MTA is being widely discussed because of its excellent bioactive properties and ability to induce hard tissue formation. Search of scientific literature regarding MTA have confirmed its unique biological properties. ,
Studies have also been reported on the use of MTA as pulpotomy medicament. Comparative studies comparing MTA with other medicaments have shown good results. ,,,,,,, Hence an attempt was made to study MTA's success as pulpotomy medicament and to compare the same with FC.
| Materials and Methods|| |
A certificate of clearance for undertaking the study was obtained from the institutional ethical committee. Patients were selected from the outpatient department, Dr. R. Ahmed Dental College and Hospital, India. The patients selected belonged to age group ranging from 3 and 7 years of age. A careful history was obtained from the child and the accompanying guardian; followed by a thorough clinical and radiographic examination. The teeth were carefully scrutinized for suitability to undergo pulpotomy treatment [Table 1]. ,, The procedure and its' possible benefits, discomforts and risks were explained fully to the guardians and their informed consent was obtained.
The teeth were randomly assigned to either group. If the same child needed pulpotomy in more than 1 tooth, the second tooth was assigned to alternate agent to assess intergroup success.
| Clinical Procedure|| |
After good anesthesia and isolation with a rubber dam; proper access cavity was prepared and; coronal pulp was amputated carefully up to the entrance of root canals using sharp spoon excavator. Post amputation bleeding was carefully assessed for fit to continue pulpotomy procedure. Later either medicament was applied. MTA (Branco Blanco White Angelus, Londrina, PR, Brasil) mixture was obtained by mixing powder with liquid supplied by manufacturer at a 3:1 ratio to a sandy consistency and applied over pulpal orifices, followed by placement of moistened cotton pellet over MTA for 15 min (as per manufacturer's guidelines). Alternately Fomocresol (Formoacresol, Pharmadent remedies Pvt. Limited, Gujarat, India; Composition: Formalin-20% v/v [B.P.], Cresol-32% v/v [I.P.], Glycerine-q.s. [I.P.]) dampened cotton pellet was placed over pulp stumps for 5 min. Access cavity was restored with zinc-oxide eugenol. Later date the tooth was restored with stainless steel crown and/or glass ionomer restoration and silver amalgam. Subsequently clinical and radiographic evaluations were done at 1-day post-operative, 1-month, 3-month, 6-month and 1- & 2-year evaluation periods and findings were noted [Table 2]. ,, If a failure occurred during the follow-up period, necessary treatment was done and followed-up later.
| Results and Observations|| |
A total of 66 patients were selected for the study yielding 100 teeth. Of 100 teeth 50 teeth received FC pulpotomy and 50 teeth received MTA pulpotomy treatment [Table 3]. After timely evaluation, at the end of 2 year 82 out of 100 treated teeth (of which 50-8 = 42 teeth in FC group and 50-10 = 40 teeth in MTA group) were available for follow-up [Table 4]. No failures were present in MTA group. 4 failures were noted in FC group at 1 st month evaluation period [Table 5] and [Table 6]. For statistical comparison of success between the groups, standard normal deviate test was adopted.
|Table 5: Total distribution of success and failures obtained for both techniques at 1st, 3rd, 6th month and 1st & 2nd year|
Click here to view
Overall success rate of the study
4 failures out of 82 teeth (78 success). Overall success rate was 95% which is highly significant at Z = 16.6, at 0.1% level (P < 0.001).
Success rate in MTA group
No failures out of 40 teeth (40 successful) was observed. Success rate is 100%.
Success rate in FC group
4 failures out of 42 teeth (38 success) were observed. Success rate in this group is 90.48% which is significant at Z = 2.08, at 5% level (P < 0.05). All 4 failures were observed at 1 st month evaluation period. Since no failures occurred at 3 rd month, 6 th month, 1 year and 2 year evaluation periods, the failures occurring at 1 st month is again considered as significant.
Comparison of success rates between MTA and FC
MTA success rate was 100% in comparison to 90.48% success in FC group. This implies that MTA produced better results than FC group.
| Discussion|| |
During the 20 th century, a significant share of dental research effort was devoted to finding better treatment procedures and medicaments for pulpal problems. These efforts have generated considerable controversy and debate as proponents of specific materials and methods attempt to justify their chosen technique(s).These controversies are unsettled even now in the 21 st century despite much impressive scientific advancement. Identifying the best amalgamation of ingredients and techniques to predictably produce pulpal healing is still obscure.
In the present context, it is seen that there is abundant evidence to show FC can produce very good clinical results as pulpotomy agent. MTA, a relatively new material still requires an adequate amount of clinical studies; hence a study was attempted to test whether MTA can produce equal or better results in comparison to FC.
Several authors have quoted histological methods to be a better test to predict pulpal healing followed by radiographical and clinical methods. ,, However in the present study, all teeth were destined for preservation of its function in the oral cavity; so none of the teeth could be extracted and included for histological examination. Hence in the present study only clinical and radiographic evaluation was utilized.
100 teeth were treated with pulpotomy procedure of which 82 teeth (42-FC group and 40-MTA group) were present at 2 nd year of evaluation [Table 3] and [Table 4].
Evaluation of success in MTA group
No failure occurred in this group during the 2 year evaluation period. Success rate of MTA was 100% [Table 5] and [Table 6]. ,,,,,,, The greater success rate in the present study is in accordance with previous studies in literature [Table 7]. The greater success rate of MTA may be due to its biocompatibility, sealing ability and dentin bridge formation.
Evaluation of success and failures in FC group
4 failures occurred out of 42 teeth in this group over an evaluation period of 2 years [Table 5] and [Table 6]. Success rate is 90.48%. The success rate collaborates with the success rate found in the literature [Table 8]. , Probable reasons for failure may be attributed to reversible fixative effect of FC and low pH of a solution. All the failures had occurred within 1 st month. This significant finding is in concordance with several studies, which also obtained similar proportion of failures during the initial months of FC pulpotomy procedure. ,,
Second appraisal was thought whether any other factor apart from medicament played a role in determining the success or failures in FC group in comparison to M.T.A group during the study.
Usually undiagnosed radicular inflammation prior to treatment, presence of bacteria in radicular pulp, failure to provide good isolation, traumatic amputation of coronal pulp, incompletely removed coronal pulp are main factors cited for failure of pulpotomy treatment in the scientific literature. ,, However, in the present study there seems no relation of these factors because the teeth were randomly designated to either group and same protocols were used for the procedure.
Previous investigations have reported on ill-effects of zinc oxide eugenol as a base following pulpotomy. ,, They suggested that unset eugenol can cause pulpal inflammation. MTA because of its better sealing ability can act as an excellent sealer and prevent undesirable effects of free eugenol on pulp. On contrary FC treated pulp lacks this sealing ability.
Few authors have also suggested the type and timing of post-pulpotomy restorative procedures have an influence on the failure rate (pulp contamination due to microleakage). ,,, In the present study, most of the teeth were restored with stainless steel crown and only few with silver amalgam, composite and glass-ionomer restoration. Stainless steel crown were usually given during the 1 st and 3 rd month after pulpotomy procedure. In the present study, however failure was independent of timing and type of post-pulpotomy restoration placed. It can be interpreted that medicament itself rather than type and timing of restoration is responsible for failure.
Overall success rate of the study was 95%. Success rate collaborates with other comparative studies [Table 9]. ,,,,, The high success rate obtained in the study can be attributed to the strict criteria and proper technique followed.
|Table 9: Comparative studies between FC and MTA done by different authors|
Click here to view
The results showed that MTA faired well as pulpotomy medicament in comparison to FC in primary teeth.
| Conclusion|| |
Whilst it is appropriate to search for better alternatives, it is imperative to re-emphasize on the success of FC obtained over 100 years. Before the clinician completely eliminates FC from his armamentarium, the alternatives need to be proven clinically and histologically to be either as successful as/more successful than FC. In this stance, MTA appears to be a promising alternative.
| References|| |
|1.||Finn SB. Clinical Pedodontics. 4 th ed. Philadelphia: WB Saunders; 1998. p. 201-23. |
|2.||American Academy of Pediatric Dentistry. Guidelines on pulp therapy for primary and young permanent teeth. Paediatr Dent 2011;33:212-9. |
|3.||Ranly DM. Pulpotomy therapy in primary teeth: New modalities for old rationales. Pediatr Dent 1994;16:403-9. |
|4.||Waterhouse PJ. "New age" pulp therapy: Personal thoughts on a hot debate. Pediatr Dent 2008;30:247-52. |
|5.||Myers DR, Shoaf HK, Dirksen TR, Pashley DH, Whitford GM, Reynolds KE. Distribution of 14C-formaldehyde after pulpotomy with formocresol. J Am Dent Assoc 1978;96:805-13. |
|6.||Ranly DM. Assessment of the systemic distribution and toxicity of formaldehyde following pulpotomy treatment: Part one. ASDC J Dent Child 1985;52:431-4. |
|7.||van Amerongen WE, Mulder GR, Vingerling PA. Consequences of endodontic treatment in primary teeth. Part I: 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. |
|8.||Milnes AR. Persuasive evidence that formocresol use in pediatric dentistry is safe. J Can Dent Assoc 2006;72:247-8. |
|9.||Kahl J, Easton J, Johnson G, Zuk J, Wilson S, Galinkin J. Formocresol blood levels in children receiving dental treatment under general anesthesia. Pediatr Dent 2008;30:393-9. |
|10.||Srinivasan V, Patchett CL, Waterhouse PJ. Is there life after Buckley's Formocresol? Part I - A narrative review of alternative interventions and materials. Int J Paediatr Dent 2006;16:117-27. |
|11.||Patchett CL, Srinivasan V, Waterhouse PJ. Is there life after Buckley's formocresol? Part II - Development of a protocol for the management of extensive caries in the primary molar. Int J Paediatr Dent 2006;16:199-206. |
|12.||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. |
|13.||Yoshiba K, Yoshiba N, Iwaku M. Histological observations of hard tissue barrier formation in amputated dental pulp capped with alpha-tricalcium phosphate containing calcium hydroxide. Endod Dent Traumatol 1994;10:113-20. |
|14.||Fadavi S, Anderson AW, Punwani IC. Freeze-dried bone in pulpotomy procedures in monkey. J Pedod 1989;13:108-22. |
|15.||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. |
|16.||Nakashima M. Induction of dentine in amputated pulp of dogs by recombinant human bone morphogenetic proteins-2 and -4 with collagen matrix. Arch Oral Biol 1994;39:1085-9. |
|17.||Srinivasan V, Waterhouse P, Whitworth J. Mineral trioxide aggregate in paediatric dentistry. Int J Paediatr Dent 2009;19:34-47. |
|18.||Camilleri J, Pitt Ford TR. Mineral trioxide aggregate: A review of the constituents and biological properties of the material. Int Endod J 2006;39:747-54. |
|19.||Danesh G, Dammaschke T, Gerth HU, Zandbiglari T, Schäfer E. A comparative study of selected properties of ProRoot mineral trioxide aggregate and two Portland cements. Int Endod J 2006;39:213-9. |
|20.||Maroto M, Barbería E, Vera V, García-Godoy F. Dentin bridge formation after white mineral trioxide aggregate (white MTA) pulpotomies in primary molars. Am J Dent 2006;19:75-9. |
|21.||Moretti AB, Sakai VT, Oliveira TM, Fornetti AP, Santos CF, Machado MA, et al. The effectiveness of mineral trioxide aggregate, calcium hydroxide and formocresol for pulpotomies in primary teeth. Int Endod J 2008;41:547-55. |
|22.||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. |
|23.||Jabbarifar SE, Khademi A, Ghasemi D. Success rate of formocresol pulpotomy versus mineral trioxide aggregate in human primary molar tooth. J Res Med Sci 2004;6:304-7. |
|24.||Holan G, Eidelman E, Fuks AB. Long-term evaluation of pulpotomy in primary molars using mineral trioxide aggregate or formocresol. Pediatr Dent 2005;27:129-36. |
|25.||Aeinehchi M, Dadvand S, Fayazi S, Bayat-Movahed S. Randomized controlled trial of mineral trioxide aggregate and formocresol for pulpotomy in primary molar teeth. Int Endod J 2007;40:261-7. |
|26.||Peng L, Ye L, Tan H, Zhou X. Evaluation of the formocresol versus mineral trioxide aggregate primary molar pulpotomy: A meta-analysis. Oral Surg Oral Med Oral Pathol 2006;102:40-4. |
|27.||Farsi N, Alamoudi N, Balto K, Mushayt A. Success of mineral trioxide aggregate in pulpotomized primary molars. J Clin Pediatr Dent 2005;29:307-11. |
|28.||Berson RB, Good DL. Pulp therapy: part 2- pulpotomy and pulpectomy for primary molars. In: Stewart RE, Barber TK, Wei Stephen HY, Troutman KC, editors. St. Louis: CV Mosby Co.; 1982. pp. 917-26. |
|29.||Koch G, Nyborg H. Correlation between clinical and histological indications for pulpotomy of deciduous teeth. J Int Assoc Dent Child 1970;1:3-10. |
|30.||Waterhouse PJ, Nunn JH, Whitworth JM, Soames JV. Primary molar pulp therapy - Histological evaluation of failure. Int J Paediatr Dent 2000;10:313-21. |
|31.||Magnusson BO. Pulpotomy in primary molars: long term clinical and histological evaluation. Int Endod J 1980;13:143-55. |
|32.||Mathewson RJ, Primosch RE. Fundamentals of Pediatric Dentistry. 3 rd ed. USA: Quintessence Publishing Co.; 1995. pp. 257-85. |
|33.||Ingle JI, Bakland LK. Endodontics. 5 th ed. St. Louis: CV Mosby Co.; 2000. p. 2862-900. |
|34.||Rölling I, Thylstrup A. A 3-year clinical follow-up study of pulpotomized primary molars treated with the formocresol technique. Scand J Dent Res 1975;83:47-53. |
|35.||Berger JE. Pulp tissue reaction to formocresol and zinc oxide-eugenol. ASDC J Dent Child 1965;32:13-28. |
|36.||Cotes O, Boj JR, Canalda C, Carreras M. Pulpal tissue reaction to formocresol vs. ferric sulfate in pulpotomized rat teeth. J Clin Pediatr Dent 1997;21:247-53. |
|37.||Strange DM, Seale NS, Nunn ME, Strange M. Outcome of formocresol/ZOE sub-base pulpotomies utilizing alternative radiographic success criteria. Pediatr Dent 2001;23:331-6. |
|38.||el-Kalla IH, García-Godoy F. Fracture strength of adhesively restored pulpotomized primary molars. ASDC J Dent Child 1999;66:238-42, 228. |
|39.||Guelmann M, McIlwain MF, Primosch RE. Radiographic assessment of primary molar pulpotomies restored with resin-based materials. Pediatr Dent 2005;27:24-7. |
|40.||Guelmann M, Bookmyer KL, Villalta P, García-Godoy F. Microleakage of restorative techniques for pulpotomized primary molars. J Dent Child (Chic) 2004;71:209-11. |
|41.||Sonmez D, Duruturk L. Success rate of calcium hydroxide pulpotomy in primary molars restored with amalgam and stainless steel crowns. Br Dent J 2010;208:E18. |
|42.||Srinivasan D, Jayanthi M. Comparative evaluation of formocresol and mineral trioxide aggregate as pulpotomy agents in deciduous teeth. Indian J Dent Res 2011;22:385-90. |
|43.||Erdem AP, Guven Y, Balli B, Ilhan B, Sepet E, Ulukapi I, et al. Success rates of mineral trioxide aggregate, ferric sulfate, and formocresol pulpotomies: A 24-month study. Pediatr Dent 2011;33:165-70. |
|44.||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;34:120-8. |
|45.||Airen P, Shigli A, Airen B. Comparative evaluation of formocresol and mineral trioxide aggregate in pulpotomized primary molars - 2 year follow up. J Clin Pediatr Dent 2012;37:143-7. |
|46.||Fernández CC, Martínez SS, Jimeno FG, Lorente Rodríguez AI, Mercadé M. Clinical and radiographic outcomes of the use of four dressing materials in pulpotomized primary molars: A randomized clinical trial with 2-year follow-up. Int J Paediatr Dent 2013;23:400-7. |
|47.||Mettlach SE, Zealand CM, Botero TM, Boynton JR, Majewski RF, Hu JC. Comparison of mineral trioxide aggregate and diluted formocresol in pulpotomized human primary molars: 42-month follow-up and survival analysis. Pediatr Dent 2013;35:E87-94. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]