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ORIGINAL ARTICLE
Year : 2014  |  Volume : 32  |  Issue : 1  |  Page : 13-18
 

Evaluation and comparison of white mineral trioxide aggregate and formocresol medicaments in primary tooth pulpotomy: Clinical and radiographic study


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 Publication15-Feb-2014

Correspondence Address:
Cheranjeevi Jayam
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Opp. Pleasure Club, Bopal-Ghuma Road, Sanand, Ahmedabad - 382 115, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.127043

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   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 2019 Dec 6];32:13-8. Available from: http://www.jisppd.com/text.asp?2014/32/1/13/127043



   Introduction Top


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." [1],[2]

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". [2],[3],[4],[5] 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. [5],[6],[7],[8] Both proponents and opponents have debated whether to use formocresol for many years now. [5],[6],[7],[8],[9],[10],[11],[12] 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. [4] 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. [13],[14],[15],[16],[17] 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. [18],[19]

Studies have also been reported on the use of MTA as pulpotomy medicament. Comparative studies comparing MTA with other medicaments have shown good results. [20],[21],[22],[23],[24],[25],[26],[27] Hence an attempt was made to study MTA's success as pulpotomy medicament and to compare the same with FC.


   Materials and Methods Top


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]. [25],[27],[28] The procedure and its' possible benefits, discomforts and risks were explained fully to the guardians and their informed consent was obtained.
Table 1: Criteria for selection of teeth

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Test design

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 Top


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]. [25],[27],[28] If a failure occurred during the follow-up period, necessary treatment was done and followed-up later.
Table 2: Criteria used during follow-up to assess success/failure

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   Results and Observations Top


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 3: Distribution of number of teeth to different groups

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Table 4: Total teeth available for follow-up after 2 years

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Table 5: Total distribution of success and failures obtained for both techniques at 1st, 3rd, 6th month and 1st & 2nd year

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Table 6: Distribution of failures as assessed at each appointment

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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 Top


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. [29],[30],[31] 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]. [20],[21],[22],[23],[24],[25],[26],[27] 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.
Table 7: MTA pulpotomy success rate obtained by different authors

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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]. [32],[33] 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. [32],[33],[34]
Table 8: FC pulpotomy success rate obtained by different authors

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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. [29],[32],[33] 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. [35],[36],[37] 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). [38],[39],[40],[41] 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]. [42],[43],[44],[45],[46],[47] 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

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The results showed that MTA faired well as pulpotomy medicament in comparison to FC in primary teeth.


   Conclusion Top


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 Top

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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.  Back to cited text no. 44
    
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.  Back to cited text no. 45
    
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.  Back to cited text no. 46
    
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.  Back to cited text no. 47
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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