Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2005  |  Volume : 23  |  Issue : 1  |  Page : 13--16

Mineral trioxide aggregate as a pulpotomy agent in primary molars: An in vivo study


S Naik, Amitha M Hegde 
 Department of Pedodontics and Preventive Dentistry, A. B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore - 575018, India

Correspondence Address:
Amitha M Hegde
Department of Pedodontics and Preventive Dentistry, A. B. Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore - 575018
India

Abstract

The retention of pulpally involved deciduous tooth in a healthy state until the time of normal exfoliation remains to be one of the challenges for Pedodontists. A scientific noise has been generated about several materials some of which have been popular pulpotomy medicaments. Concerns have been raised about the toxicity and potential carcinogenicity of these materials, and alternatives have been proposed to maintain the partial pulp vitality, however to date no material has been accepted as an ideal pulpotomy agent. Mineral trioxide aggregate (MTA) is a biocompatible material which provides a biological seal. MTA has been proposed as a potential medicament for various pulpal procedures like pulp capping with reversible pulpitis, apexification, repair of root perforations, etc. Hence the present study was done to evaluate the efficacy of MTA as a pulpotomy medicament. A clinical and radiographic evaluation was done on children where MTA was used as pulpotomy medicament in primary molars for a period of 6 months and it was found to be a successful material.



How to cite this article:
Naik S, Hegde AM. Mineral trioxide aggregate as a pulpotomy agent in primary molars: An in vivo study.J Indian Soc Pedod Prev Dent 2005;23:13-16


How to cite this URL:
Naik S, Hegde AM. Mineral trioxide aggregate as a pulpotomy agent in primary molars: An in vivo study. J Indian Soc Pedod Prev Dent [serial online] 2005 [cited 2020 Dec 2 ];23:13-16
Available from: https://www.jisppd.com/text.asp?2005/23/1/13/16020


Full Text

Pulpotomized teeth help in maintaining arch integrity by allowing preservation of the teeth that would otherwise be destined for extraction.[1,2]

Formocresol has been critically evaluated for its toxic effects on pulp tissue. For decades formocresol has been a popular pulpotomy medicament. Concerns have been raised about the toxicity and potential carcinogenicity of formocresol in humans,[3] and alternatives have been proposed to maintain partial pulp vitality. These include electrosurgery,[4] laser,[5] glutaraldehyde,[6] ferric sulfate,[7] and enriched collagen solution.[1] Mineral Trioxide Aggregate (MTA) is compositionally formulated to have physical properties,[8] setting requirements[9] and characteristics necessary for an ideal repair and medicament materials.[10],[11],[12] MTA, with an excellent long term prognosis, relative ease at which it can be used and with its numerous exciting clinical applications promises to be one of the most versatile materials of this century in the field of dentistry. When the physical and chemical properties of MTA,[8]-[12] were described it was found to be biocompatible[13] and its sealing ability[12],[13] was better than zinc oxide eugenol.

MTA has been proposed as a potential medicament for pulpotomy procedures[3] as well as capping of pulps with reversible pulpitis.[11]-[14] MTA was tested in dog′s teeth as a pulp capping material and produced favorable pulp responses.[11] Not many clinical studies have been done with MTA as a pulpotomy medicament and hence in the present study MTA was used as a pulpotomy medicament in the primary molars and its efficacy were observed both clinically and radiographically over a period of 6 months.

 Materials and Methods



50 primary molars in children whose pulpal status warranted pulpotomy and who reported to the Department of Pedodontics and Preventive Children Dentistry, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore were treated by a conventional pulpotomy technique. The procedure and its possible discomfort, or risks, and benefits were explained fully to the parents of the children involved, and their informed consent, as approved by the institutional review board of human subjects experiments, were obtained prior to the investigation.

Teeth with asymptomatic deep carious lesion involving the marginal ridge without any frank pulp exposure were selected for the pulpotomy procedure.

Pulpotomy procedure

50 selected teeth were randomly assigned to either control (formocresol) or experimental (MTA) group of 25 teeth each [Table 1].

The pulpotomy procedure were then performed on the selected teeth as follows:

Anesthetize the tooth.Obtain Rubber dam isolationCaries removal and coronal access obtained with high speed bur with water spray to expose the pulp chamber.Removal of the coronal pulp with a spoon excavator.Hemostasis obtained. (A moistened cotton pellet was gently pressed against the amputated pulp stumps in both the group.

In formocresol (control) group - cotton pellet dipped and squeezed in 1/5th dilution of Buckley formocresol, was placed in pulp chamber for 5 minutes. The pulp chamber was then covered with a Zinc oxide Eugenol thick mix.

In the MTA (experimental) group - the MTA paste was obtained by mixing 3 parts of powder with 1 part of water to obtain a putty consistency. This mix was then placed in the pulp chamber and condensed lightly with a moistened cotton pellet.[9],[10] This was followed by a layer of Zinc oxide Eugenol thick mix.

Following pulpotomy all the 50 teeth were restored with stainless steel crown after 24 hours.[15] Finally the patients were recalled after 1 month, 3 months and 6 months respectively and evaluated clinically and radiographically [Table 2], [Table 3], [Table 4] and [Table 5].

 Results



Of the 50 teeth selected, 3 were not available for further follow-up after 1 month. The follow up after 1 month, 3 months and 6 months did not reveal any clinical or radiographic pathological findings in the rest of the 47 teeth. Hence, no statistical analysis was performed regarding the success of the treatment.

The only significant findings were the discoloration of 60% of the teeth where MTA was used as a medicament after 24 hours, but which was later masked by restoring with a stainless steel crown.

 Discussion



Mineral trioxide aggregate (MTA), as a pulpotomy medicament was used in the present study and its clinical and radiographical success was assessed. Formocresol was selected as the control group, since it is still considered the gold standard in primary tooth pulp therapy, in spite of the reported toxic, mutagenic and carcinogenic properties.[3]

Mineral trioxide aggregate (MTA) is a fine hydrophilic powder developed by Mahmoud Torabinejad in Loma Linda University (USA).[10],[11] It consists of tricalcium silicate, tricalicum aluminate, tricalcium oxide, silicate oxide and bismuth oxide which are supplied as a grey powder. Each pack of PROROOTTM (Densply) MTA comes with a pre measured unit dose of water for convenience in mixing.[8],[10]

Studies by Mahmoud Torabinejad and co-workers have shown that MTA prevents microleakage,[16],[17],[18] is biocompatible,[13],[14] and promotes regeneration of the original tissues when it is placed in contact with the dental pulp or periradicular tissues.[19],[20]

The success rates of MTA in this study has been promising, with all 24 molars in the experimental group being clinically and radiographically successful.

Pulp canal obliteration was a common finding in both formocresol and MTA group in a study conducted by Eidelman 2001.[3] But in the present study we did not come across any such findings which may be due to the short follow up period of 6 months.

The time duration taken to complete the procedure in case of MTA group was longer, since first MTA had to be manipulated and placed in the pulp chamber followed by manipulation and placement of zinc oxide eugenol. There are reports of complete dentine bridge formation when MTA was used as a pulp capping agent.[11]-[14] Hard tissue bridge deposition next to MTA may occur because of its sealing properties,[12],[13],[21] biocompatibility,[10],[22] alkalinity and other properties[9],[18],[23],[24].[25] associated with this material. In the present study, no dentin bridge formation was observed radiographically after a period of six months.

In case of the MTA group, discoloration of the crown was observed in 15 cases, which was later masked by placement of a stainless steel crown. No such discoloration was reported by any other authors, but in most of the studies MTA was used as root end filling material. Only in a few selected cases it had been used in clinical crown where studies have been limited to case reports only.[14],[24] In any case it′s mandatory to give stainless steel crown following MTA pulpotomy, which in addition to restoring the tooth, helps in masking the discolored crown.

During the manipulation of MTA we observed that the mix was messy when excess of moisture was present in the preparation which results in the material becoming soupy and difficult to use. Similar observations have been reported by Schwartz et al.[14] This often makes it important to follow some guidelines to prepare the site for MTA. All irrigation should be performed before the material is placed because irrigation after placement will cause significant wash out of the material.[26] The increased cost and non-availability of MTA is another factor to be noted. In contrast the placement of formocresol as a medicament is very simple, neat and very economical.

There are reports that, in the formocresol procedure the cotton pellet sometimes adheres to the clot and bleeding reoccurs when the pellet is removed.[3] But no such problems were encountered with formocresol in the present study. However this does not occur with MTA which is directly applied over the amputated pulp.

The mutagenic potential of MTA was assessed using the Ames test and was compared with those of intermediate restorative material and super EBA and they concluded that MTA was less cytotoxic and non-mutagenic.[22] This further supports the superiority of MTA over formocresol as a pulpotomy medicament.

Though clinically and radiographically the success rates of MTA in this study are quite promising, a histological evaluation of MTA and a longer follow up period is necessary to reach sound conclusions. Mineral trioxide aggregate (MTA) showed clinical and radiographic success as a dressing materials following pulpotomy in primary teeth after a short term evaluation period and has a promising potential to become a replacement for formocresol in primary teeth. Further long term clinical evaluation of MTA as a pulpotomy agent needs to be carried out.

References

1Llewelyn DR. The Pulp treatment of the primary dentition. Int J Paediatr Dent 2000;10:248-52.
2Primosch RE, Glomb TA, Jerrel RG. Primary tooth pulp therapy as taught in predoctoral pediatric dental programs in the United States. Am Acad Pediatr Dent 1997;19:118-22.
3Eidelman E, et al. Mineral Trioxide Aggregate Vs formocresol in pulpotomized primary molars. Am Acad Pediatr Dent 2001;23:250-4.
4Dean JA, Mack RB, Fulkerson BT, Sanders BJ. Comparison of electrosurgical and formocresol pulpotomy procedures in children. Int J Paediatr Dent 2002;12:177-82.
5Jeng-fen Liu, Chen LR, Chao SY. Laser Pulpotomy of primary teeth. Am Acad Pediatr Dent 1999;21:2.
6Su HW, Feigal RJ, Messer HH. Cytotoxicity of glutaraldehyde and formaldehyde in relation to time of exposure and concentration. Am Acad Pediatr Dent 1990;12:303-7.
7Cotes O, Boj JR, Canalda C, Carreras M. Pulpal tissue reaction to formocresol vs. ferric sulfate in pulpotomized rat teeth. J Clin Pediatr Dent 1997;3:247-54.
8Torabinejad M, Hong CU, McDonald F, Pitt Ford TR Physical and Chemical properties of a new root-end filling materials. J Endod 1995;21:349-53.
9Sluyk SR, Moon PC, Hartwell GR. Evaluation of setting properties and retention characteristics of Mineral Trioxide Aggregate when used as a furcation Perforation repair materials. J Endod 1998;24:768-71.
10Schmitt D, Lee J, Bogen G. Multifaceted use of TK/f ProRoot MTA root canal repair material. Am Acad Pediatr Dent 2001;23:326-30.
11Myers K, Kaminski E, Miller. The effects of mineral trioxide Aggregate on the Dog Pulp. J Endod 1996;22:198.
12Lee SJ, Monsef M, Torabinejad M. Sealing ability of a Mineral Trioxide Aggregate for repair of lateral root perforations. J Endod 1993;19:541-4.
13Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling materials. J Endod 1993;19:591-5.
14Schwartz RS, Mauger M, Clement DJ, Walker WA III. Mineral trioxide aggregate: A new material for endodontics. J Am Dent Assoc 1999. p. 130.
15Holan G, Fuks AB, Keltz N. Success rate of formocresol pulpotomy in primary molars restored with stainless steel crown Vs amalgam. Pediatr Dent 2003;24:212-6.
16Pitt Ford TR, Torabinejad M, McKendry DJ, Hong CU, Kariyawasam SP. Use of mineral trioxide aggregate for repair of furcal perforations. Oral Surg Oral Med Oral Pathol Oral Radial Endod 1995. p. 756-62.
17Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial leakage of Mineral Trioxide Aggregate as a Root-End Filling Material. J Endod 1995;21:489-92.
18Arens DE, Torabinejad M. Repair of furcal perforation with mineral trioxide aggregate. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:84-8.
19Kettering JD, Torabinejad M. Investigation of Mutagenicity of Mineral Trioxide Aggregate and other commonly used Root end filling materials. J Endod 1995;21:537-42.
20Torabinejad M, Hong CU, Lee SJ, Monsef M, Pitt Ford TR. Investigations of Mineral Trioxide Aggregate for Root-End filling in Dogs. J Endod 1995;21:603-8.
21Nakata TT, Bae KS, Baumgartner JC. Perforation repair comparing Mineral Trioxide Aggregate and Amalgam using an anaerobic bacterial leakage model. J Endod 1998;24:184-6.
22Torabinejad M, Pitt Ford TR, Abedi HR, Kariyawasam SP, Tang HM. Tissue reaction to implanted Root End filling materials in the Tibia and Mandible of Guinea Pigs. J Endod 1998;24:468-71.
23Torabinejad M, Smith PW, Kettering JD, Pitt Ford TR. Comparative investigation of Marginal Adaptation of Mineral Trioxide aggregate and other commonly used Root-End Filling Materials. J Endod 1995;21:295-8.
24Torabinejad M, Chivian N, et al. Clinical Applications of Mineral Trioxide Aggregate. J Endod 1999;25:197-205.
25Koh ET, Pitt Ford TR, Kariyawasam SP, Chen NN, Torabinejad M. Prophylactic treatment of Dens Evaginatus using Mineral trioxide aggregate J Endod 2001;27:540-1.
26Giuliani V, Baccetti T, Pace R, Pagavino G. The use of MTA in teeth with necrotic pulps and open apices. Dent Traumatol 2002;18:217-21.