|Year : 2017 | Volume
| Issue : 4 | Page : 327-331
A comparative evaluation of clinical and radiographic success rate of pulpotomy in primary molars using antioxidant mix and mineral trioxide aggregate: An in vivo 1-year follow-up study
Sommyta Kathal, Shilpi Gupta, Deepak P Bhayya, Ashish Rao, Amrita Pal Roy, Anubhuti Sabhlok
Department of Pedodontic and Preventive Dentistry, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India
|Date of Web Publication||15-Sep-2017|
Department of Pedodontic and Preventive Dentistry, Hitkarini Dental College and Hospital, Jabalpur - 482 004, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Pulpotomy technique is most widely accepted clinical procedure for treating primary teeth with coronal pulp inflammation caused by caries with no involvement of the radicular pulp. Aim and Objective: The aim of the study was to evaluate the success and efficacy of mineral trioxide aggregate (MTA) and antioxidant mix as pulpotomy agents both clinically and radiographically. Materials and Methods: A total of forty primary molars in children aged between 6 and 9 years, requiring for pulpotomy procedures, were selected. Random samples distribution was done, antioxidant mix (n = 20) and MTA (n = 20) both were used as pulpotomy agent. Under rubber dam isolation, pulpotomy procedure was performed in all samples followed by restoration with stainless steel crowns. Later, the patients were recalled after 6 and 12 months for clinical and radiographic evaluation. The data were evaluated using Fisher's exact test. Results: Statistically analysis shows no significant difference between the two groups (P > 0.05) with respect to clinical and radiographic success rate, but antioxidant mix showed more efficient result than MTA. Conclusion: Antioxidant mix pulpotomy is more biocompatible and cost effective than any other commercially available medicament.
Keywords: Antioxidant mix, mineral trioxide aggregate, primary teeth, pulpotomy
|How to cite this article:|
Kathal S, Gupta S, Bhayya DP, Rao A, Roy AP, Sabhlok A. A comparative evaluation of clinical and radiographic success rate of pulpotomy in primary molars using antioxidant mix and mineral trioxide aggregate: An in vivo 1-year follow-up study. J Indian Soc Pedod Prev Dent 2017;35:327-31
|How to cite this URL:|
Kathal S, Gupta S, Bhayya DP, Rao A, Roy AP, Sabhlok A. A comparative evaluation of clinical and radiographic success rate of pulpotomy in primary molars using antioxidant mix and mineral trioxide aggregate: An in vivo 1-year follow-up study. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Jul 24];35:327-31. Available from: http://www.jisppd.com/text.asp?2017/35/4/327/214921
| Introduction|| |
Pediatric endodontic is most controversial than any others procedure in pediatric dentistry. The pulp tissue has a complex blood flow, and it is rich in cellular and neural elements. Hence, it is challenging for clinicians to diagnose the level of pulp inflammation. Vital pulp therapy for treating reversible pulpitis is the treatment of choice in both primary and permanent teeth for maintaining pulp vitality and its function. Pulpotomy is one of the approaches which is most widely accepted clinical procedure for treating cariously exposed pulp in primary teeth. The technique is based on the removal of coronal pulp to preserve the vitality of remaining radicular pulp free from any pathological alterations till it's exfoliation.
Various pulpotomy medicaments and techniques have been introduced in the recent years. Various medicaments include glutaraldehyde, ferric sulfate, formocresol, calcium hydroxide, osteogenic protein, bone morphogenetic protein, laser, electrosurgery, and many more. Recently introduced, mineral trioxide aggregate (MTA) and biodentine have been said as an ideal medicament for pulpotomy. A new bioactive glass cement has been introduced by Dr. Mahmoud Torabinejad. MTA is biocompatible, bactericidal, promotes regeneration of the original tissues when comes in contact with dental pulp tissue., Its sealing, dentinogenic and osteogenic properties have made it a material of choice in various clinical setup.,
In past few years, most of the literature has focused on the regenerative material. However, the current scenario is about safety pulpotomy medicaments regarding toxicity and potential carcinogenicity. Alternative to all these medicaments, researcher had showed interest toward the wound healing phenomenon as a pulpotomy medicament. Very few analyser had concentrate on wound healing for the restoring anatomical continuity of damaged pulp tissue and disturbed functional status of the radicular tissue. Free radicals which are released during inflammation get inactive by antioxidant before they attack human cells. Humans have generated highly complex antioxidant systems (enzymes or nonenzymes), which work synergistically and in combination with each other to prevent cells or organs against free radicals, so elimination of these free radicals enhances the healing process and repairs the remaining radicular tissue. Antioxidant mix has major advantages that are biocompatibility and various other unique features that overcome the disadvantages of another medicament. Antioxidant mix seems to be a newer choice of medicament for pulpotomy. In literature, MTA has showed to be the most successful medicament for pulpotomy. Hence, the present study was done to evaluate and compare the pulpotomy outcomes using antioxidant mix and MTA both clinically as well as radiographically under 1-year follow-up.
| Materials And Methods|| |
The study population includes 5–9 years (17 boys and 23 girls) healthy and a cooperative patient who was walked in the outpatient Department of Pedodontics and Preventive Dentistry, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India. The study was carried between May 15, 2015 and June 23, 2016 in children with good general health and no history of the systemic illness or hospitalization. Before the admission of the child, parents and children were explained about the procedure and its possible discomfort and the benefits. Before the onset of procedure, Institutional Ethical Committee head approval had attained.
Forty primary carious molar teeth were selected (19 maxillary and 21 mandibular) and randomly assigned into the two groups that include antioxidant mix and MTA allocating 20 teeth in each group according to the American Academy of Pediatric Dentistry guidelines.
- Tooth with no spontaneous pain
- At least two-thirds of the root length is still present
- No sign of internal or other kind root resorption
- Hemorrhage from the amputation site is easy to control.
- Any of the abovementioned clinical or radiographic inclusion criteria if not satisfied
- Hemostasis could not be achieved within 5 min by direct contact with a wet cotton pellet
- Before material placement, the remaining radicular tissue was nonvital (with suppuration or purulence necrosis).
Group A: Commercially available antioxidant mix (Oxyfruit 40) in capsule form [Figure 3]. It is present in paste form within the capsule [Table 1] and [Table 2].
Group B: MTA (Angelus Industria de Produtos Odontologicos S/A, Londrina, Brazil).
Cavity preparation and pulp exposure
In both the groups, rubber dam isolation was done. Under local anesthesia, the access opening of the pulp chamber was done using air rotor handpiece with small round diamond bur (Number BR 49 Mani), followed by irrigation with saline solution. The coronal part of pulp tissue was removed using spoon excavator and achieving hemostasis of remaining radicular pulp tissue by slight pressure with a sterile cotton pellet.
In randomly distributed samples, antioxidant mix which was available in capsule form was broken to get thick paste-like consistency mix which was applied on the prepared cavity. MTA in powder and liquid form was mixed in 3:1 ratio to get ball-like consistency which was placed in cavity. Later on, both the cavities were filled by application of a layer of zinc oxide eugenol soon after by glass ionomer cement. An immediate postoperative radiograph was taken. All pulpotomies teeth were restored with stainless steel crowns (SSCs) (3M ESPE). Both clinically and radiographically, all the cases were evaluated for a period of 6 and 12 months interval.
Data were tabulated in Microsoft Excel 2010 for Windows. Data analyses were performed using version 21.0 of Statistical Package for Social Science (IBM Corporation, Armonk, New York, USA).
| Results|| |
A total of 40 pulpotomies were performed using two different pulpotomy materials. Out of 40, only 39 cases turned up, which means 20 case of MTA and 19 cases of antioxidant were evaluated at 6-month follow-up.
At the end of 1 year, only 37 cases were evaluated. Three cases did not turn up (lost to follow-up), 1 case of antioxidant and 2 cases of MTA. The clinical and radiographic success rate of the pulpotomy agents was compared using a Fisher's exact test for each follow-up period.
Comparison of clinical criteria, i.e., the status of pain, sinus tract, swelling, and mobility at 6- and 12-month interval showed a nonsignificant difference (P > 0.05) for each agent. Furthermore, with respect to radiographic criteria, periapical or furcal radiolucency, we observed a nonsignificant difference (P > 0.05) for each agent after follow-up [Table 3].
|Table 3: Comparison of clinical and radiographic success rates between antioxidant mix and mineral trioxide aggregate for primary teeth pulpotomy at 6 and 12 months|
Click here to view
| Discussion|| |
The present study is one of the recent prospective clinical trials about vital pulpotomy with antioxidant mix on the human primary molar. In teeth with deep caries lesions, pulpotomy treatment is common treatment when the microorganisms or their toxins may have been reached to the pulp. Over the pulpotomized teeth restoration has been shown to have an impact on the prognosis of pulp therapy, all pulpotomized teeth were finally covered with SSCs, which represent the most effective long-term restoration for pulpotomized primary teeth. In various studies, primary teeth were restored with a SSC after endodontic treatments.,
The study was intended to assess the rate of antioxidant mix pulpotomy in comparison with MTA which is evidence-based successful material in much endodontic procedure. MTA is selected as control pulpotomy medicament because it is biocompatible, prevents microleakage, and promotes regeneration of the original tissue when comes in contact with dental pulp.
[Figure 1] and [Figure 2] showing Radiographic success rate of 6 and 12 months follow up of Antioxidant and MTA Pulpotomy respectively.
|Figure 1: Radiographic success rate of antioxidant mix in pulpotomy tooth|
Click here to view
|Figure 2: Radiographic success rate of mineral trioxide aggregate in pulpotomy tooth|
Click here to view
Antioxidant mix is newer pulpotomy medicament which works on the principle of wound healing and maintains anatomically continuity of damaged tissue. Healing involves the activity of an intricate network of blood cell, growth factors, and cytokines which ultimately leads to the restoration to a normal condition of the injured radicular tissue. Antioxidants encounter excess of proteases and free radicals which are often formed by neutrophils accumulation in the wounded area and protect protease inhibitors from oxidative damage.
Possible explanation for the success rate observed in this study may be due to elimination of reactive oxygen species as it was an important strategy for improving healing of radicular pulp. Success shows that combinations of antioxidants comprising Vitamin A, B, and C along with trace elements such as zinc are capable in wound remodelling, including reorganization of new collagen fibers in radicular tissue healing, tissue repair, and regeneration. The high success rate of pulpotomy clinically and radiographically with antioxidant mix (95%) is impressive, especially considering the long-term follow-up period. In 6 months follow up 1 failure was recorded and in 12 months follow up 2 failure were recorded. All molars treated with antioxidant mix presented a successful outcome. One failure reasons may owe to that dislodged restoration or mishandling of the medicament while performing the procedure.
MTA-treated pulpotomy teeth showed stable success rate with no failures till 6 months. While the success rate of MTA decreased with time as expected 88.89% with the last failure being detected postoperatively at 12 months.
Another possible explanation for failure of pulpotomy in primary teeth can be mark attributed to undiagnosed inflammation in the residual pulp before the treatment or pulp contamination occurs due to a microleakage of restorative material., Dentin bridge formation is not always regarded as a success in pulpotomy. Caicedo et al. observed that infection exists before the formation of dentine bridge and thought that an infection may have occurred after dentin bridge formation. In contrast, it was previously showed that dentin bridge may occur as a response by infected pulp. According to the Fisher's exact tests, the present group's success rates were statistically similar, but the antioxidant mix showed a higher clinical and radiographic success rate at 6 and 12 months than MTA.
| Conclusion|| |
Antioxidant mix pulpotomy is more cost-effective, ease in handling, biocompatible and does not have any disadvantage than any other commercially available medicament. It has been proven potentially to be an ideal pulpotomy agent clinical and radiographic. Hence, understanding the characteristics, tissue uptake metabolism, biochemical interactions, and the other biological activities of various antioxidants on pulpal healing may provide a reliable biological method for vital pulp therapy of primary teeth and young permanent teeth in the clinical practice. To overcome the limitation of the sample size in present study, further study is required.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ranly DM. Pulpotomy therapy in primary teeth: New modalities for old rationales. Pediatr Dent 1994;16:403-9.
Chandrashekhar S, Shashidhar J. Formocresol, still a controversial material for pulpotomy: A critical literature review. J Restor Dent 2014;2:114.
Bhagat D, Sunder RK, Devendrappa SN, Vanka A, Choudaha N. A comparative evaluation of ProRoot mineral trioxide aggregate and Portland cement as a pulpotomy medicament. J Indian Soc Pedod Prev Dent 2016;34:172-6.
] [Full text]
Parisay I, Ghoddusi J, Forghani M. A review on vital pulp therapy in primary teeth. Iran Endod J 2015;10:6-15.
El Meligy OA, Allazzam S, Alamoudi NM. Comparison between biodentine and formocresol for pulpotomy of primary teeth: A randomized clinical trial. Quintessence Int 2016;47:571-80.
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.
Niranjani K, Prasad MG, Vasa AA, Divya G, Thakur MS, Saujanya K. Clinical evaluation of success of primary teeth pulpotomy using mineral trioxide aggregate(®), laser and biodentine (TM) - An in vivo
study. J Clin Diagn Res 2015;9:ZC35-7.
Akcay M, Celik B, Sari S, Gunhan O. Management of internal resorption observed after a mineral trioxide aggregate pulpotomy in a primary molar tooth: A case report with a 36-month follow-up. J Pediatr Dent 2016;4:14. [Full text]
GirishMS, Prakash Chandra LA. Clinical and radiographic evaluation of mineral trioxide aggregate and electrosurgical pulpotomies in primary molars: An in vivo
study. J Int Oral Health 2016;8:601-6.
Yildiz E, Tosun G. Evaluation of formocresol, calcium hydroxide, ferric sulfate, and MTA primary molar pulpotomies. Eur J Dent 2014;8:234-40. [Full text]
Reddy MA, Niharika P, Reddy H, Reddy NV, Manoj Kumar MG, Pranitha V. Antioxidant mix: A novel pulpotomy medicament: A scanning electron microscopy evaluation. Contemp Clin Dent 2014;5:428-33.
] [Full text]
Aksakalli S. Antioxidants in dentistry: Review of literature. Dentistry 2013;4:1-3.
Originating Committee, Review Council. Guideline on pulp therapy for primary and immature permanent teeth. Am Acad Pediatr Dent 2014;34:179-86.
Maroto M, Barbería E, Planells P, García Godoy F. Dentin bridge formation after mineral trioxide aggregate (MTA) pulpotomies in primary teeth. Am J Dent 2005;18:151-4.
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:e94-8.
Jeba ER, Saravanan T, Balasubramanian B. Natural antioxidants in dentistry – Review article. International Journal of Dental Sciences and Research 2015;3:20-3.
Holan G, Fuks AB, Ketlz N. Success rate of formocresol pulpotomy in primary molars restored with stainless steel crown vs. Amalga. Pediatr Dent 2002;24:212-6.
Caicedo R, Abbott PV, Alongi DJ, Alarcon MY. Clinical, radiographic and histological analysis of the effects of mineral trioxide aggregate used in direct pulp capping and pulpotomies of primary teeth. Aust Dent J 2006;51:297-305.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]