|Year : 2019 | Volume
| Issue : 4 | Page : 399-404
Biological approach in repair of partially inflamed dental pulp using second-generation platelet-rich fibrin and mineral trioxide aggregate as a pulp medicament in primary molars
Maria Manhas, Sudhir Mittal, AK Sharma, KK Gupta, V Pathania, V Thakur
Department of Pedodontics, Himachal Dental College, Sundar Nagar, Himachal Pradesh, India
|Date of Web Publication||7-Nov-2019|
Dr. Maria Manhas
Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Sunder Nagar - 175 002, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The purpose of this study was to evaluate and compare clinically and radiographically PRF, MTA and Ca(OH)2 as a pulp dressing material in primary molars. Material and Methods: The study was conducted on 30 children between 6-9 years of age. Pulpotomy was performed using MTA(Gp I), PRF + MTA(Gp II) and PRF +Ca(OH)2(Group III). The teeth were evaluated clinically and radiographically after 1,3 and 6 months and were subjected to statistics analysis. Results: After 6 months follow-up the overall success rate was found to be highest in Gp I with success rate of 97% followed by Gp II 95% and Gp III 78.3%. The results were found to be statistically insignificant (P ≤ 0.05). Conclusion: All materials used in the present study were equally effective as the success rates are statistically insignificant.
Keywords: Calcium hydroxide, dental pulp, mineral trioxide aggregate, platelet-rich fibrin, pulpal medicaments, regeneration
|How to cite this article:|
Manhas M, Mittal S, Sharma A K, Gupta K K, Pathania V, Thakur V. Biological approach in repair of partially inflamed dental pulp using second-generation platelet-rich fibrin and mineral trioxide aggregate as a pulp medicament in primary molars. J Indian Soc Pedod Prev Dent 2019;37:399-404
|How to cite this URL:|
Manhas M, Mittal S, Sharma A K, Gupta K K, Pathania V, Thakur V. Biological approach in repair of partially inflamed dental pulp using second-generation platelet-rich fibrin and mineral trioxide aggregate as a pulp medicament in primary molars. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2020 Mar 29];37:399-404. Available from: http://www.jisppd.com/text.asp?2019/37/4/399/270474
| Introduction|| |
Pulp therapy for primary teeth describes the pulpotomy procedure as the amputation of the affected or infected coronal portion of the dental pulp by preserving the vitality and function of all or part of the remaining radicular pulp. Pulpotomy is a common therapy for cariously exposed pulps in asymptomatic primary molar teeth to retain a functional tooth in the oral cavity until it is exfoliated by preserving the radicular pulp. The overall success depends on (1) effective control of infection, (2) complete removal of inflamed coronal pulp tissue, (3) appropriate wound dressing, and (4) effective coronal seal during and after treatment.
Formocresol has been a popular pulpotomy medicament in the primary dentition for the past 60 years. It produces an area of necrosis in the pulp adjacent to the wound. Mostly, pulp tissue is altered by the formaldehyde and appears fixed and does not undergo liquefactive necrosis immediately and is considered as the gold standard dressing agent for pulpotomy therapy, but safety concerns are an issue.
With the introduction of calcium hydroxide (Ca(OH)2), a new era in vital pulp therapy began. The alkaline pH induced by Ca(OH)2 counterpoises lactic acid from osteoclasts and prevents the dissolution of the mineral components of dentin, thereby activating alkaline phosphatases and resulting in hard tissue formation. There are controversies regarding its use in primary tooth pulpotomies because of internal resorption, but it has the advantages over formocresol of promising a healing response and avoiding the issue of systemic uptake.
Recently, with the development of materials that are not only biocompatible but also bioinductive and bioconductive, the prominence has shifted from mere preservation to regeneration.
One such material showing immense potential for regeneration is mineral trioxide aggregate (MTA). It was introduced by Dr. Torabinajad in 1993 with the motive of serving as an apical root-end filling material and has also proven to be successful in vital pulp therapy procedures both in animals and humans. Its sealing ability is better than that of amalgam and zinc oxide–eugenol. It stimulates cytokine release from bone cells and actively promotes hard tissue formation.
An ideal autologous biomaterial for pulp-dentin complex regeneration is platelet-rich fibrin (PRF) first developed by Choukroun in France. PRF has a very significant slow sustained release of growth factors such as platelet-derived growth factors, thereby releasing growth factors with its own biological scaffold for wound healing process. Its clinical applications include root coverage, bone regeneration, treatment of endo-perio lesions, sinus elevation, socket preservation, and various medical fields.
The present study is aimed to develop the biocompatible treatment modalities in maintaining pulp vitality and increasing tooth longevity in primary teeth.
| Materials and Methods|| |
The present study was conducted on thirty children between 6 and 9 years of age attending the Outpatient Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India, seeking dental treatment. Ethical clearance was taken from the Institutional Ethical Committee Review Board.
The treatment plan was explained in detail to the parents, and their informed consent was taken.
- Deep carious lesion with exposure during excavation in an otherwise asymptomatic primary tooth
- No sensitivity and, if present to hot and cold, it subsides after removal of the stimulus
- Pain, if present, is neither spontaneous nor persistent
- No radiographic appearance of internal resorption
- No interradicular bone loss/periapical lesion.
- Any history of spontaneous or persistent pain
- Any clinical evidence of abscess, fistula, or mobility
- Any medically compromised condition or systemic illness
- Radiographic evidence of internal or external root resorption
- Nonrestorable tooth
- Teeth which are about to exfoliate.
The participants were randomly divided into three groups:
- Group I: Teeth treated with MTA as pulpal dressing
- Group II: Teeth treated with PRF and MTA as pulpal dressing
- Group III: Teeth treated with PRF and light-activated Ca(OH)2 as pulpal dressing.
Profound local anesthesia was given to the teeth to be treated. After rubber dam isolation, PRF was prepared by drawing a 5-ml blood into a 10-ml test tube without anticoagulant and centrifuged immediately using tabletop centrifuge at 2400/2700 rpm for 12 min [Figure 1] and [Figure 2]. Dental caries was removed with an excavator followed by a large slow-speed round bur. The access cavity preparation for pulpotomy was done with a round bur followed by extension of access cavity with a fissure bur to remove the roof of the pulp chamber. The coronal pulp chamber was extirpated or amputated with a sharp spoon excavator, and all the filaments (tissue tags) of the coronal pulp were extirpated. Bleeding control was achieved using a sterile moistened cotton pellet which was placed against the pulpal stumps for 5 min. After 5 min, bleeding was checked and then further treatment was carried out accordingly to the groups assigned as follows, and if bleeding was not controlled and persisted after 5 min, it showed pulpal inflammation and tooth was recommended for pulpectomy and was excluded from the study.
In Group I, MTA dressing will be placed into the pulp chamber followed by a thick mix of glass inomer cement (GIC), In Group II, PRF membrane will be placed into the pulp chamber followed by MTA dressing and then restored with GIC, and in Group III, PRF membrane will be placed into the pulp chamber followed by Ca(OH)2 dressing and then restored with GIC to achieve peripheral sealing.
Teeth were restored with stainless steel crowns within a week time after postoperative evaluation. These patients were then recalled after 1-, 3-, and 6-month interval for the clinical and radiographic evaluation.
The data were obtained and tabulated and subjected to statistical analysis.
| Results and Observations|| |
The present clinical study was conducted on thirty patients aged between 6 and 9 years to clinically and radiographically evaluate MTA, PRF + MTA, and PRF + Ca(OH)2 as a pulpotomy agent in primary molars at 1-, 3-, and 6-month follow-up.
The data obtained were tabulated and subjected to statistical analysis using IBM SPSS Version 22.0 [Table 1], [Table 2] and [Figure 3]. Pearson's Chi-square test was done to know the effect of each variable and to reveal the statistical significance. P ≤ 0.05 was considered as statistically significant.
The overall success rate was found to be highest in Group I with the success rate of 97% in which 9 of 10 cases were successful at 1, 3, and 6 months followed by Group II with the success rate of 95% in which 9 cases were successful and in Group III in which 7 cases were successful giving it a success rate of 78.3%.
On intergroup comparison, the success rate between all the groups was found to be statistically insignificant (P ≥ 0.05).
| Discussion|| |
Pulp therapy was first described in 1756 by Philip Ptaff who performed pulp capping by covering the exposed pulp with a small piece of gold in an attempt to promote healing.
Preservation of the remaining vital portion of a cariously exposed pulpal tissue in primary teeth, where the demand is to keep a functioning tooth in site, was one of the most frequent challenges in pediatric dentistry. To solve this problem, pulpotomy therapy was introduced, developed, and classified according to the treatment objectives. Pulpotomy involves the amputation of the coronal portion of the affected dental pulp. The ideal pulp-dressing material after pulpotomy should leave radicular pulp vital, healthy, and enclosed within an odontoblastic-lined dentin chamber.
This pulpotomy procedure has been developed along 3 lines: devitalization, preservation and regeneration; (Koppel et al. 1995):
- Preservation, is the retention of maximum vital tissue with no induction of reparative dentin, isexamplified by ZOE, glutraldehyde and ferric sulphate treatment.
Various pulpotomy agents used in the primary dentition are formocresol, glutaraldehyde, ferric sulfate, electrosurgery, laser, freeze-dried bone, bone morphogenetic protein, Portland cement, and sodium hypochlorite, but still, formocresol has been a popular pulpotomy medicament in the primary dentition for the past 60 years and remains the “gold standard” for therapeutic pulpotomy in human primary teeth at 1:5 dilution because it is economical and easily available.,
Hess (1929) reported a technique of pulpotomy using Ca(OH)2. Stanley (1989) strongly advocated Ca(OH)2 for vital pulp therapy, and this material has been used for the protection of exposed dental pulps up to the present time.
Several case series have suggested pulpotomy as a viable treatment for pulp exposures with pulpitis; the rationale being the healing potential of the remaining radicular tissue and the biocompatibility of pulpotomy agents, especially MTA. MTA was introduced by Dr. Torabinajad in 1993. It is osseo-conductive, osseo-inductive, and biocompatible material and developed, recommended initially as a root-end filling material and subsequently has been used for pulp capping, pulpotomy, apexogenesis, apical barrier formation in teeth with open apexes, repair of root perforations, and as a root canal filling material. Therefore, it is important to develop biocompatible treatments directed at maintaining pulp vitality and increasing tooth longevity. 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 tissue.,
In regenerative endodontic therapy, an ideal autologous biomaterial for pulp-dentin complex regeneration is PRF. PRF was first developed by Choukroun in France. It has been referred to as a second-generation platelet concentrate, which has been shown to have several advantages over traditionally prepared platelet-rich plasma.
PRF has a very significant slow sustained release of many key growth factors such as platelet-derived growth factor and transforming growth factor-β for at least 1 week and up to 28 days, which means that PRF could release growth factors with its own biological scaffold for wound healing process.
Various clinical applications of PRF include, root coverage, bone regeneration, treatment of endo-perio lesions, sinus floor elevation, stabilize graft material in ridge augmentation, socket preservation, filling cystic cavities, and in various medical fields. Its chief advantages include ease of preparation and lack of biochemical handling of blood, which make this preparation strictly autologous.
Because of these properties, we have used MTA, PRF, and Ca(OH)2 in the present study to develop the biocompatible treatment modalities in maintaining pulp vitality and also increasing the tooth longevity in primary teeth.
In the finding of the present study, in Group I, none of the patients reported with any problem, whereas only one patient showed clinical symptoms of abscess and root resorption at 6 months; the results were in accordance with the previous study done by Patidar et al. with a success rate of 86%, Leye Benoist et al., Aeinehchi et al., Nair et al., and Fransson et al., respectively, and the results of our study were not in accordance with a study conducted by Sundar et al. with a success rate of 100% after 6 months.
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. The cause of failure in Group I could be a shortcoming of patient selection and inflammation beyond coronal into the radicular pulp.
In Group II, all patients were comfortable with no clinical signs and symptoms, but at 6-month interval, one case reported clinically with pain and Grade I mobility, and root resorption was seen radiographically. These results were in accordance with a study conducted by Patidar et al., Jabbarifar et al., and Holan et al., respectively, whereas the results of our study were contradictory with a study conducted by Hiremath et al. giving a success rate of 100%. The reason of failure may be that PRF disintegrates within a very short time, and the patient did not report for a month's time for crown placement though coronal seal was intact but can contribute to failure or a cause for coronal leakage.
Since there are very few studies present till date using PRF as a scaffold for dressing material, the exact reason is difficult to explain; hence, further investigation with histological collaboration in this area is needed, and this may lead to a paradigm shift in vital pulp therapy of primary teeth.
In Group III, one patient reported with clinical signs of pain at 3 months, and after 6 months, one patient reported clinically with abscess along with Grade 1 mobility of and root resorption which was then subjected to pulpectomy and two patients were accounted with clinical signs of pain along with Grade 1 mobility. The results of our study were in accordance with a study done by Derek Zurn, 2008 with a success rate of 78%, Kumar et al., Huth et al., Fishman et al., and Gruythuysen and Weerheijm, respectively. Our results are contradictory to a study done by Heilig et al. and Sasaki et al. with an 88% success rate after 6 months. The failed case with abscess may represent a tooth in which spread of inflammation into the radicular pulp rendered it incapable of mounting the requisite healing process. Furthermore, Ca(OH)2 being very caustic could be a cause of inflammation. At present, strong clinical diagnostic aids are present, but additional ones are needed to assess the degree of inflammation and pulpal pressure which are not used in the present study, and this could be the cause of failure.
For those that failed radiographically or clinically, perhaps, it is the inappropriateness of the medicament choice for the degree of inflammation or infection of the pulpal tissues remaining that is to blame for this failure. Interestingly, these successes occurred using a material with neutral pH in cured form (Derek Zurn, 2008).
Overall success rate of treatment at 1, 3, and 6 months
The overall comparison of the success rates of Groups I, II, and III was evaluated on the basis of clinical and radiographic parameters.
In Group I, all teeth were free from clinical signs and symptoms at 1- and 3-month follow-up except one at the end of 6 months giving it a success rate of 90%.
In Group II, the clinical success rate was 100% at 1- and 3-month follow-up as all the teeth were free from clinical signs and symptoms, but at 6 months, all teeth except 1 were asymptomatic. Therefore, the clinical success rate dropped down to 90% at the end of 6 months.
In Group III, after 1-month follow-up, the clinical success rate was 100% with all teeth free from clinical signs and symptoms which reduced to 90% at 3 months with 1 tooth being symptomatic which further reduced to 70% with 3 teeth being symptomatic at the end of 6 months.
Treatment was considered to be radiographically successful in case of no resorption or no signs of interradicular radiolucencies. The cases showing an increase in size of radioleucency or resorption or radioleucency after the treatment were considered as failure.
In Group I, one patient reported with root resorption at 6 months making the success rate of 90%. In Group II, one patient reported with root resorption at 6 months making the success rate of 90%. In Group III with three failure cases, one reported with root resorption at 3 months and two at 6 months making the success rate of 70%, respectively.
Therefore, the overall success rates clinically and radiographically at 1, 3, and 6 months were 97% for Group I, 95% for Group II, and 78.3% for Group III, and on intergroup comparison of all the groups, the overall success rate was found to be statistically insignificant (P > 0.05).
The clinical and radiographic success of Groups I and II shows its excellent healing capabilities. Though the difference in all the three groups is insignificant but failure is more in group III, however Ca(OH)2 can be considered as a secondary alternative material for pulpotomy after MTA and PRF.
| Conclusion|| |
The present clinical study was conducted on thirty patients to evaluate and compare the efficacy of MTA, PRF + MTA, and PRF + Ca(OH)2 as a pulp-dressing material in primary teeth.
The following conclusions can be drawn:
- All materials used in the present study are equally effective as the success rates of all the materials are statistically insignificant
- MTA is the best material used as having osseo-conductive and inductive properties as a pulp dressing material and PRF along with MTA has 1 failure but the results are statistically insignificant, so is the second best material followed by PRF + Ca(OH)2 having more failure but can be used as another alternative material in pulpotomy.
MTA is a recently developed biocompatible material advances to propose potential pulpotomy material for various pulpal procedures. Based on this clinical and radiographic evaluation study of 1-, 3-, and 6-month follow-up, MTA pulpotomies have a high success rate than PRF and Ca(OH)2 pulpotomies. Hence, it is a safe material for pulpotomy in cariously or mechanically exposed primary teeth and could be a substitute for PRF and Ca(OH)2.
Finally, 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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hargreaves KM, Cohen S. Pathways of the Pulp. 9th
ed. p. 842.
Moretti AB, Sakai VT, Oliveira TM, Fornetti AP, Santos CF, Machado MA. The effectiveness of mineral trioxide aggregate, calcium hydroxide and formocresol for pulpotomies in primary teeth. Int Endod J 2008;41:547-55.
Derek Zurn N, Seale S. Light-cured Calcium Hydroxide vsFormocresol in Human primary molar PulpotomiesPediatric Dentistry 2008;30.
Sundar JS, Varma KM, Satish RK, Sajjan GS, Tanikonda R. A biological approach in repair of damaged dental pulp and periapical tissues using platelet Rich fibrin, mineral trioxide aggregate and laser biostimulation. IJSS Case Rep Rev 2015;1.
Jumana S. Alternative interventions to formocresol as a pulpotomy medicament in primary dentition: A review of literature. Jordian Board Pediatr Dent 2015; p. 232.
Ranly DM. Pulpotomy therapy in primary teeth: New modalities for old rationales. Pediatr Dent 1994;16:403-9.
Primosch RE, Glomb TA, Jerrell RG. Primary tooth pulp therapy as taught in predoctoral pediatric dental programs in the United States. Pediatr Dent 1997;19:118-22.
Hicks MJ, Barr ES, Flaitz CM. Formocresol pulpotomies in primary molars: A radiographic study in a pediatric dentistry practice. J Pedod 1986;10:331-9.
Ingle JI, Bankland LK, Baumgartner JC. Textbook of Endodontics. 6th
ed; 2008. p. 6.
Goyal S, Abuwala T, Joshi K, Mehta J, Indushekar KR, Hallikerimath S, et al.
The clinical, radiographic and histological evaluation of three different concentrations of formocresol as a pulpotomy agent. J Int Oral Health 2014;6:118-25.
Sujeet VK, Ritam NT. Platelet-rich fibrin as a biofuel for tissue regeneration. Int Sch Res Biomater 2013; p.1-6.
Shivashankar VY, Johns DA, Vidyanath S, Kumar MR. Platelet rich fibrin in the revitalization of tooth with necrotic pulp and open apex. J Conserv Dent 2012;15:395-8.
] [Full text]
Huang FM, Yang SF, Zhao JH, Chang YC. Platelet-rich fibrin increases proliferation and differentiation of human dental pulp cells. J Endod 2010;36:1628-32.
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.
] [Full text]
Leye Benoist F, Gaye Ndiaye F, Kane AW, Benoist HM, Farge P. Evaluation of mineral trioxide aggregate (MTA) versus calcium hydroxide cement (Dycal(®)) in the formation of a dentine bridge: A randomised controlled trial. Int Dent J 2012;62:33-9.
Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth: A preliminary report. Int Endod J 2003;36:225-31.
Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: A randomized controlled trial 2008. Int Endod J 2009;42:422-44.
Fransson H, Wolf E, Petersson K. Formation of a hard tissue barrier after experimental pulp capping or partial pulpotomy in humans: An updated systematic review. Int Endod J 2016;49:533-42.
Jabbarifar SE, Khademi AA, Ghasemi D. Success rate of formocresol pulpotomy versus mineral trioxide aggregate in human primary molar tooth. J Res Med Sci 2004; p.304-7.
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.
Hiremath H, Saikalyan S, Kulkarni SS, Hiremath V. Second-generation platelet concentrate (PRF) as a pulpotomy medicament in a permanent molar with pulpitis: A case report. Int Endod J 2012;45:105-12.
Kumar V, Juneja R, Duhan J, Sangwan P, Tewari S. Comparative evaluation of platelet-rich fibrin, mineral trioxide aggregate, and calcium hydroxide as pulpotomy agents in permanent molars with irreversible pulpitis: A randomized controlled trial. Contemp Clin Dent 2016;7:512-8.
] [Full text]
Huth KC, Paschos E, Hajek-Al-Khatar N, Hollweck R, Crispin A, Hickel R, et al.
Effectiveness of 4 pulpotomy techniques – Randomized controlled trial. J Dent Res 2005;84:1144-8.
Fishman SA, Udin RD, Good DL, Rodef F. Success of electrofulguration pulpotomies covered by zinc oxide and eugenol or calcium hydroxide: A clinical study. Pediatr Dent 1996;18:385-90.
Gruythuysen RJ, Weerheijm KL. Calcium hydroxide pulpotomy with a light-cured cavity-sealing material after two years. ASDC J Dent Child 1997;64:251-3.
Heilig J, Yates J, Siskin M, McKnight J, Turner J. Calcium hydroxide pulpotomy for primary teeth: A clinical study. J Am Dent Assoc 1984;108:775-8.
Sasaki H, Ogawa T, Koreeda M, Ozaki T, Sobue S, Ooshima T, et al.
Electrocoagulation extends the indication of calcium hydroxide pulpotomy in the primary dentition. J Clin Pediatr Dent 2002;26:275-7.
Gutmann JL. Clinical, radiographic, and histologic perspectives on success and failure in endodontics. Dent Clin North Am 1992;36:379-92.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]