|Year : 2017 | Volume
| Issue : 4 | Page : 367-373
Clinical and radiographic comparison of platelet-rich fibrin and mineral trioxide aggregate as pulpotomy agents in primary molars
Surendra Patidar, Namita Kalra, Amit Khatri, Rishi Tyagi
Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
|Date of Web Publication||15-Sep-2017|
Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi - 110 095
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: This study aimed to evaluate and compare the Platelet-rich fibrin (PRF) and Mineral trioxide aggregate (MTA) as a pulpotomy agent in primary molars. Material and Methods: In this study, 50 primary molars from 50 healthy children aged 5–9 years requiring pulpotomy were randomly allocated into two groups. In PRF group, after coronal pulp removal and hemostasis, remaining pulp tissue was covered with PRF preparation. In the MTA group, the pulp stumps were covered with MTA (Pro Root MTA-Root Canal Repair Material, Dentsply International Inc.) paste obtained by mixing MTA powder with sterile water at a 3:1 powder to water ratio. All teeth were restored with reinforced zinc oxide eugenol base and glass – ionomer cement. Stainless steel crowns were given in both groups 24 h after treatment. Clinical evaluation was undertaken at 1, 3, and 6 months intervals whereas radiographic evaluation of the treated teeth was carried out at the interval of 6 months. Results: By the end of 6 months, the overall success rate was 90% in PRF group and 92% in MTA Group. A statistically significant difference was observed between the groups at 6 months of follow-up (P < 0.05). The results were statistically nonsignificant between the groups (P > 0.05). Conclusion: Radiographic and clinical outcome in PRF group could suggest it as an acceptable alternative in pulpotomy of primary teeth. PRF holds a promising future in the area of primary tooth vital pulp therapy.
Keywords: Mineral trioxide aggregate, Platelet-rich fibrin, Pulpotomy
|How to cite this article:|
Patidar S, Kalra N, Khatri A, Tyagi R. Clinical and radiographic comparison of platelet-rich fibrin and mineral trioxide aggregate as pulpotomy agents in primary molars. J Indian Soc Pedod Prev Dent 2017;35:367-73
|How to cite this URL:|
Patidar S, Kalra N, Khatri A, Tyagi R. Clinical and radiographic comparison of platelet-rich fibrin and mineral trioxide aggregate as pulpotomy agents in primary molars. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2019 Nov 14];35:367-73. Available from: http://www.jisppd.com/text.asp?2017/35/4/367/214917
| Introduction|| |
The vitality of the dentin-pulp complex is fundamental to the health of tooth and is a priority for targeting clinical management strategies. The overall response of the tooth to injury such as dental caries represents the complex interplay between injury, defense, and regenerative processes. If a carious primary molar tooth remains untreated or inadequately treated, bacterial invasion of the coronal pulp will occur, producing an inflammatory response in the coronal pulp. At this stage, pulp inflammation is often confined to the coronal pulp and if the affected tissue is removed and the radicular pulp stumps dressed with an appropriate agent, the remaining tissue has a capacity to recover. This facility to recover is used when cariously exposed vital primary teeth are treated by vital pulp therapy.
Pulpotomy is a vital pulp therapy for cariously exposed pulps in primary molar teeth and its aim is to retain a functional tooth in an oral cavity until its exfoliation through the preservation of the radicular pulp., This procedure mainly consists of removing the coronal pulp and treating the radicular pulp with a medicament to maintain the treated tooth asymptomatic until its exfoliation.
To increase the success rate, a critical need exists to develop new biologically based therapeutics that reduce pulp inflammation and promote the formation of dentin-pulp tissues and increasing tooth longevity. Formocresol, a devitalizing agent, has been reported to be carcinogenic and mutagenic. Glutaraldehyde, a preservative agent, has been proposed as an alternative to formocresol that results in inadequate fixation and leaves a deficient barrier to subbase irritation, resulting to internal resorption. Most often the pulp tissue is altered by the formaldehyde and appears “fixed” in situ and therefore does not undergo immediate liquifactive necrosis in the root canal. Ferric sulfate has received some attention as a pulpotomy agent although the metal protein clot at the surface of the pulp stump acts as a barrier to the irritating components at the subbase, it functions solely in a passive manner. The frequency of normal appearing pulps decreased over time, the most frequently observed pulpal responses were calcific metamorphosis and internal resorption. Calcium hydroxide has been reported to be a failure in primary teeth due to a higher incidence of the development of chronic pulpal inflammation and internal resorption.
Mineral trioxide aggregate (MTA), which has excellent physical and chemical properties, has been proposed as a potential medicament for use in pulpotomies. MTA is developed and recommended for pulp capping, pulpotomy, apical barrier formation in teeth with necrotic pulps and open apexes, repair of root perforations, root-end filling, and root canal filling.
Despite its many advantages, it has some drawbacks that include the high solubility, presence of toxic elements in the material composition, higher cytotoxicity in its freshly mixed state, and high pH during setting, difficult handling characteristics, long setting time, high price, and discoloring effect of both gray and white forms. Hence, the need arises to discover a pulpotomy agent that potentiates the natural pulp healing process is biocompatible and is cost-effective.
Recent advances in the field of bone and dentin formation have opened new vistas for pulp therapy. Bone morphogenetic proteins, use of barrier membranes, growth factors, enamel matrix proteins, and bone grafts with added modifications are being used. One of the exciting channels is the topical use of platelet concentrates. Platelet rich fibrin (PRF) was first developed in France by Choukroun et al., in 2001. Scientific rationale behind the use of platelet preparation lies in the fact that PRF serve as a reservoir for continuous release of growth factor which directs the process of reparative dentinogenesis. Huang et al., investigated the effect of PRF on cultured primary dental pulp cells and concluded that PRF can increase dental pulp cell proliferation and differentiation.
Considering this the present study was proposed to evaluate the efficacy of PRF, both clinically and radiographically, as a pulpotomy agent in comparison with MTA.
| Material and Methods|| |
Ethical clearance and consent
Ethical clearance to conduct the study was obtained from the institutional review board. The parents of the children received detailed information regarding procedure, benefits, and possible risk involved in the study. In PRF Group, blood was collected from each child, written consent was obtained from parents before treatment.
Study design and sampling
The study was carried out on primary molars of children aged 5–9 years who visited outpatient clinics in the Department of Pedodontics and Preventive Dentistry, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi with a chief complaint of one or more decayed teeth.
The study was carried out on 50 primary molars requiring pulpotomy treatment. Each tooth was randomly assigned to one of the two treatment groups, the PRF and MTA group on the basis of computer-generated random table (Block randomization). A power analysis was conducted, and a minimum sample of 25 teeth in each group was set to ensure that an adequate sample size was collected to show 80% power and 5% level of significance.
The teeth requiring pulpotomy were selected according to the following clinical criteria: a carious or mechanical exposure of the vital coronal pulp, absence of symptoms indicative of advanced pulpal inflammation such as spontaneous pain or history of nocturnal pain, absence of clinical signs or symptoms suggesting a nonvital tooth such as suppurating sinus, soft tissue swelling. The absence of radiographic signs of pulpal necrosis, i.e., furcation involvement, periapical pathology, internal resorption, calcification in canal. Teeth should be restorable after completion of the procedure.
Exclusion criteria included: teeth which showed excessive bleeding during the amputation of coronal pulp tissue which is difficult to control. Patients having medical conditions such as the history of heart surgery, leukemia, or immune-compromised conditions and congenital heart defects were also excluded from the study.
Local anesthesia was administrated using 2% lignocaine with 1:100,000 adrenaline. The tooth was isolated using the rubber dam, cavity outline was established with a high-speed round diamond bur with water coolant. Caries was excavated with a spoon excavator. The pulp chamber was entered and the roof was removed with the round bur using high-speed air rotor. Normal saline (0.9% w/v) was used to wash away the debris. Coronal pulp tissue amputation was achieved using spoon excavator, the chamber was irrigated with normal saline. Hemorrhage was controlled using a sterile pledget of moist cotton under pressure.
Platelet-rich fibrin group
After control of hemorrhage, PRF preparation was placed in PRF Group. PRF was prepared using Choukroun's procedure.
The required quantity of blood was drawn by a trained medical staff into 10 ml test tubes without an anticoagulant and centrifuged immediately centrifugation was done using a tabletop centrifuge for 12 min at 2700 rounds per minute. The resultant product exhibits following three layers; platelet-poor plasma at the surface, PRF clot in the middle, and red blood cells at the bottom [Figure 1]a. Sterile tweezers inserted into a test tube to retrieve the PRF clot [Figure 1]b. The platelet fibrin membrane was obtained by squeezing the PRF clot between the sterile dry gauges to drive out the fluids trapped in the fibrin matrix [Figure 1]c. The prepared fibrin membrane was gently packed over the pulp stumps using a sterile pledget of moist cotton.
|Figure 1: (a) Three layers formed after centrifugation: Topmost layer consisting of acellular platelet poor plasma; Platelet-rich fibrin clot in the middle and a base layer of red blood cells. (b) Sterile tweezer inserted into test tube to retrieve the intraoral periapical radiograph clot. (c) Platelet-rich fibrin membrane|
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Mineral trioxide aggregate group
The pulp stumps were covered with MTA (Pro Root MTA-Root Canal Repair Material, Dentsply International Inc.) paste obtained by mixing MTA powder with sterile water at a 3:1 powder to water ratio according to manufacturer's instruction. The mixture was placed on the pulp stump surface and patted with a moist cotton pellet, and the remaining cavity in both groups was filled with fortified zinc oxide eugenol cement and afterward by glass ionomer cement.
Stainless steel crowns were given in both groups 24 h after treatment. Clinical examinations were undertaken at 1, 3, and 6 months intervals whereas radiographic evaluation of the treated teeth was performed at the interval of 6 months.
At each follow-up appointment, the pulpotomy was considered clinically successful if the treated primary molars showed the following clinical findings: no symptom of pain, no tenderness to percussion. No soft tissue swelling, no pathologic mobility, and no sinus formation. The pulpotomy was considered radiographically successful at follow-up appointment if the radiograph showed the following radiographic findings: No furcal or periapical radiolucency, no canal calcification, and no internal and external resorption. Deviation from any one of these clinical and/or radiographic signs was regarded as a failure of treatment. At each follow-up visit, each assessment involved a clinical and periapical radiographic examination of the pulpotomized teeth, which was performed by three blinded and previously calibrated investigators having inter- and intra-examiner reproducibility.
Data were presented in number and percentage. Chi-square test/Fisher exact test was used to compare proportion of pain, swelling, sinus formation, tenderness on percussion, tooth mobility, change in color, presence of internal resorption, external resorption, furcal radiolucency, periapical radiolucency, canal calcification, and recurrent caries between the groups at the different time points and P < 0.5% was adjusted. One sample bionomial test is used to study the improvement over the time point within the same group.
| Results|| |
A total of 50 primary molars in fifty children of both genders age 5–9 years (mean age-6.8 years), were randomly allocated to the two treatment groups, i.e., 25 teeth per group. Fifty teeth were treated and follow-up evaluation is done after 1, 3, and 6 months. Out of 50 primary molars; 2 molars in each group had failure of restoration after 3-month follow-up; hence, they excluded from the study; 46 primary molars were available for assessment at the end of 6 months [Figure 2].
At 24 h postpulpotomy interval, none of the groups had the presence of any clinical finding. In addition, at 1 month there was no clinical finding observed in both groups. After 3 months, only one patient in MTA group had complained of pain but the finding was statistically insignificant (P > 0.05). After 6 months, 4 primary molars were lost to follow-up and a total of 23 patients in each group were available for clinical and radiological follow-up. The pain was noted in 4.3% of primary teeth in both the groups while mobility was noticed only in MTA group in only 4.34% of teeth whereas 4.34% of teeth in PRF group showed sign of tenderness on percussion [Table 1].
|Table 1: Clinical evaluation of platelet-rich fibrin and mineral trioxide aggregate pulpotmy at 1, 3, and 6 months follow-up|
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In radiological parameter, internal resorption was noticed in 4.34% of teeth in MTA group. However, furcal radiolucency was noticed in 13.04% of teeth in PRF group, and 4.34% of teeth in MTA group and findings were statistically nonsignificant between the groups (P > 0.05) [Table 2]. The cases which showed furcation radiolucency with PRF pulpotomy and regarded as a failure are shown in [Figure 3]. The cases which showed internal resorption with MTA pulpotomy and regarded as a failure are shown in [Figure 4].
|Table 2: Radiographic evaluation of platelet-rich fibrin and mineral trioxide aggregate pulpotomy at 6-month follow-up|
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|Figure 3: Failure case of PRF Group - (a) Preoperative intraoral periapical radiograph showing radiolucency close to the mesial pulp horn of mandibular 1st primary molar. (b) Postoperative intraoral periapical radiograph showing treated mandibular 1st molar with platelet-rich fibrin pulpotomy. (c) Follow-up intraoral periapical radiograph after 6 months showing furcal and periapical radiolucency related with mandibular 1st primary molars|
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|Figure 4: Failure case of mineral trioxide aggregate Group – (a) Preoperative intraoral periapical radiograph showing radiolucency close to the mesial pulp horn of mandibular 2nd primary molar. (b) Postoperative intraoral periapical radiograph showing treated mandibular 2nd molar with Mineral trioxide aggregate pulpotomy. (c) Follow-up intraoral periapical radiograph after 6 months showing internal resorption related with mandibular 2nd primary molar|
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At 6-month follow-up, the clinical assessment showed 92% success rate in both groups. A statistically significant difference (P < 0.05) was observed within the groups using one sample bionomial test whereas the results were statistically nonsignificant (P > 0.05) between the groups [Table 3]. At the end of 6-month, overall radiographic success rate was 87% for PRF group whereas for MTA group it was 92% and this result was statistically nonsignificant (P > 0.05) between the groups [Table 3].
In overall, success for PRF group was 90% after 6 months of follow-up while for MTA group it was 92%. There was a statistically significant difference (P < 0.05) within the groups whereas the results were statistically nonsignificant (P > 0.05) between the groups [Table 3].
| Discussion|| |
In the present study, two materials, PRF and MTA were used as pulpotomy agents in children of age 5–9 years as both materials are used in regenerative pulpotomy procedure. Children from 5 to 9 years of age were selected as per the inclusion and exclusion criteria of the study, irrespective of their gender. The age group was selected taking into consideration the lack of cooperation of children of <5 years and physiologic root resorption (>3/4 of root) above 9 years of age. MTA is composed mainly of tricalcium silicate, dicalcium silicate, tricalcium aluminate, calcium sulfate dehydrate and bismuth oxide, which are supplied as a gray powder. It has proven to be successful in vital pulp therapy procedures both in animals  and humans., Many studies were carried out with MTA , and proposed MTA as excellent pulpotomy agent although it has some drawback also Fridland and Rosado  showed that a high pH of 12.5 created in the area adjacent to the MTA remains high for at least 8 weeks. This high pH of MTA during setting has been found to affect cell growth and exert a cytotoxic effect on both macrophages and fibroblast. Therefore, it is important to develop biocompatible treatments directed at maintaining pulp vitality and increasing tooth longevity.
PRF, a second-generation platelet concentrate, is considered to be an autologous biomaterial incorporating leukocytes, platelets, and a wide range of key healing proteins in a dense fibrin matrix. PRF is used as an immune concentrate with a specific composition and has a three-dimensional architecture. It contains a multitude of growth factors such as platelet derived growth factor, transforming growth factor β1, and insulin like growth factor exhibiting varied potent local properties such as cell migration, cell attachment, cell proliferation and cell differentiation. These findings served as a basis for the present study that addresses the role of PRF as a pulpotomy agent in primary molar.
In the present study, both PRF and MTA had similar and favorable clinical outcomes. There are no studies to date reporting the use of PRF on pulpotomized teeth, the results of the present study were compared with studies using the regenerative materials of same mode of action. Preoperatively, the pain was present in all patients in PRF group and MTA group. A statistically significant difference was observed between the groups at 6 months of follow-up appointment. Similar types of results were obtained in the study by Kalaskar and Damle, in which initially pain was present in all the patients and after 6 months, resolution of pain was observed in all the patients. In present study, internal resorption was present in a single tooth (4%) in MTA group at 6 months of follow-up, while in PRF group no tooth had internal resorption the reason for such a radiographic outcome with MTA may be due to the presence of inflamed radicular pulp which showed no sign of inflammation during pulpotomy procedure, i.e., profuse bleeding. Similarly Holan et al., reported internal root resorption in 6.1% (1/17) of the tooth treated with MTA pulpotomy and Jabbarifar et al., reported internal resorption in 2 (6.2%) out of 32 patients after 1 year follow-up period. Since MTA contains high alkaline substances, the possibility of the exaggerated response of pulp cannot be ruled out. Overstimulation induced by high alkalinity could cause metaplasia within the pulp tissue, leading to the formation of odontoclast.
It has been discovered that the restorations of pulpally treated teeth have an impact on the prognosis of the pulp therapies. Stainless steel crowns are highly recommended for treating pulpotomized teeth based on the assumption that there is less leakage in crowned teeth than those restored with amalgam or glass ionomer cement only. Thus, in the present study, stainless steel crowns were placed in all the teeth contrarily Guelmann et al., reported in their in vitro study that stainless steel crown did not prevent microleakage even if the marginal adaptation was perfect. This leads to marginal leakage and secondary pulpal infection showing radiographic signs such as furcal radiolucency and periapical radiolucency. Similar results were found in the study by Saltzmann et al., and Neamatollahi and Tajik  in which two of the treated pulpotomy teeth showed periapical and furcal radiolucency.
In PRF group, three teeth (13.04%) showed furcal radiolucency during the radiographic observation at 6-month follow-up. The exact reason is difficult to explain hence further investigation with histological collaboration in this area is needed since previously no in vivo study using PRF as a pulpotomy agent in primary molars is present.
The result of present study using PRF as pulpotomy agent may lead to paradigm shift in vital pulp therapy of primary teeth in future.
| Conclusion|| |
Based on the findings from present study, it can be concluded that PRF can be used successfully as an appropriate alternative material in pulpotomy of primary teeth. Furthermore, to arrive at the whole truth of efficacy of one biocompatible pulpotomy agent over the other, it is necessary to undertake studies with more number of treated teeth followed up over a longer period of time and to clinch them with histopathological back up. As of now in the reviewed literature, no study used PRF in vivo for pulpotomy of primary teeth. Hence, a cross comparison of PRF outcome is not possible at this juncture. Last but not the least, no child howsoever young turned uncooperative at the time of drawing the blood sample or pulpotomy procedure. Thus, it is safe to say that PRF holds a promising future in the area of primary tooth vital pulp therapy.
The authors would like to thank Dr. A. K. Tripathi Professor and other staff members of Department of Biochemistry, UCMS and GTB Hospital, Delhi for his assistance, and the parents and children for participating in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]