Original Research. Doi: /jioh

Transcription

1 MTA and electrosurgical pulpotomy Girish MS et al Journal of International Oral Health 2016; 8(5): Received: 07 th December 2015 Accepted: 03 th March 2016 Conflict of Interest: None Source of Support: Nil Original Research Doi: /jioh Clinical and Radiographic Evaluation of Mineral Trioxide Aggregate and Electrosurgical Pulpotomies in Primary Molars: An In-Vivo Study M S Girish 1, Prakash Chandra 2, Latha Anandakrishna 3 Contributors: 1 Reader, Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, Constituent College of JSS University, Mysuru, Karnataka, India; 2 Senior Professor, Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India; 3 Professor and Head, Department of Pedodontics and Preventive Dentistry, Faculty of Dental Sciences, M S Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India. Correspondence: Dr. Girish M S. Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, Constituent College of JSS University, Mysuru, Karnataka, India. Phone: drgirish@gmail.com How to cite the article: Girish MS, Chandra P, Anandakrishna L. Clinical and radiographic evaluation of mineral trioxide aggregate and electrosurgical pulpotomies in primary molars: An in-vivo study. J Int Oral Health 2016;8(5): Abstract: Background: Pulpotomy is the most common treatment modality employed to preserve a cariously exposed symptom-free primary molars, which aims to preserve the vitality of radicular pulp till its exfoliation. Such pulpotomy agent should bactericidal, should not damage surrounding tissues, promote healing of remaining of pulp tissue, and should not affect physiological resorptive process of the tooth. The quest for one such ideal pulpotomy material/procedure is never conclusive. Hence, this study was conducted to assess and compare the clinical and radiographic outcomes of mineral trioxide aggregate (MTA) and electrosurgical pulpotomies in human primary molar teeth. Materials and Methods: A total of 60 carious mandibular primary molars from 46 children whose pulpal status was indicated for pulpotomy were considered. The selected teeth were randomly divided into two groups using simple randomization number table. MTA and electrosurgical pulpotomies were performed for the respective group followed by the placement of stainless steel crown. Pulpotomized patients were recalled for further follow-up at 1 st, 3 rd, 6 th, 9 th, and 12th month for clinical and radiological evaluation. McNemar s test was used to determine the differences between groups. Results: At the end of the 12 months follow-up, the overall success rate for MTA was at 96.7% and for electrosurgery was at 90%. However, there was no statistically significant difference between the groups compared. Conclusion: Success of electrosurgical pulpotomies can be comparable with that of MTA. Key Words: Electrosurgery, Mineral trioxide aggregate, Pulpotomy Introduction Pulpotomy is a therapeutic procedure which is commonly employed in reversible inflammation of the coronal pulp of the primary teeth. This is required where radicular pulp tissue has to be maintained in a healthy condition for long-term, until exfoliation. The preservation of vitality of radicular portion of pulp tissue through pulpotomy procedure in the primary dentition is quite valuable from the point of view that, it not only helps in maintaining the arch integrity but also guides the erupting successor in correct path. 1 Formaldehyde derivatives have been used as an acceptable, highly successful, and most common agent for the fixation of pulp for many years. 2,3 Despite its success, the empiricism supporting the use of formocresol as a pulpotomy agent has been questioned for many years. 4 The search for the medicament to replace formocresol became vital after several negative reports questioned its local and systemic toxic effects. The greatest concerns seeking the alternatives for formaldehyde derivatives are: 1. Pulpal response with inflammation and necrosis 5 2. Cytotoxicity 6 3. Systemic disturbances 7 4. Mutagenic and carcinogenic potential 8 5. Immunologic responses. 9 Electrosurgery has been proposed as an alternative treatment avoiding the toxic effects of chemical drugs applied over the pulp. 4,10,11 The exceedingly few investigations carried out with this method have reported a promising result. The electrosurgical pulpotomy appears to have its merit as it is self-limiting, 12,13 pulp penetration when activated is few cells deep, excellent visualization and hemostasis is possible without chemical coagulation or systemic involvement. It is also less time consuming than the formocresol approach. 14 Mineral trioxide aggregate (MTA) which was introduced by Dr. Mahmoud Torabinejad as root end/root canal repair material, has been advocated for other uses. In primary teeth, MTA is predominantly used for pulp capping and pulpotomy procedures. The major benefits of MTA are that it is biocompatible, bactericidal, and able to stimulate osteocementum like structure. Its sealing, mineralizing, osteogenic and dentinogenic properties have made it a material of choice in various clinical scenario s

2 MTA and electrosurgical pulpotomy Girish MS et al Journal of International Oral Health 2016; 8(5): For the above cited reasons, and considering the concerns regarding the formocresol and its adverse reaction, the predated studies formed the basis for current investigations. The aim of the study was to evaluate the effect of MTA and electrosurgical pulpotomies which are considered as safe for clinical and radiologic success on human primary molar for 12-month. Materials and Methods The patients were recruited from the out patients walking into the Department of Pedodontics and Preventive Dentistry of M S Ramaiah Dental College and Hospital, Bengaluru were included in the study. The parents and the children involved in the study were explained about the procedure, its possible discomforts, and benefits. Prior approval from the Institutional Ethical Committee was obtained. The intended sample of 60 carious mandibular primary molars from 46 children whose pulpal status indicated for pulpotomy was considered using the results of previous studies. The sample size was arrived at, using the formula: ( ) Za + Za 2( S1+ S2 ) n= 2 ( X + X ) 1 2 Where, Zá = 3.28, Zâ = 1.28, power 90%, S1 = Standard deviation of MTA group, S2 = Standard deviation of electrosurgery group, X 1 = Mean of MTA group and X 2 = Mean of electrosurgery group. The children were in the age group of 4-9 years. The indicated teeth were evaluated clinically and radio graphically. All the children belonged to the American Society of Anesthesiologists I and II grading were included in the study. The inclusion criteria were: cooperative children, the presence of a deep carious lesion, no clinical sign of profuse bleeding from amputated radicular pulp, tenderness to percussion, no more than two third of root resorption, and a tooth which is restorable. Children with a history of systemic illness contraindicating for pulpotomy, spontaneous tooth pain or tenderness to percussion, pathologic mobility, the presence of any internal or external resorption, apical or furcal radiolucency, widened periodontal ligament space, and sinus tract were excluded from the study. Allocation Selected Mandibular primary molars were randomly divided into two groups using simple randomization number table. The allocation was done according to consort guidelines (Flow Chart 1). Mandibular primary molars were preferred in our study because the radiological changes during follow-up are better appreciated in mandibular molars when compared to maxillary tooth due to the favorable anatomy of mandibular molar for radiological examinations. Allocations were Flow Chart 1: Consort flow chart of pulpotomised teeth for 12 months. concealed from the clinician performing pulpotomies until baseline assessments were finished. MTA group A total of 30 primary molars to be pulpotomised with MTA (ProRoot MTA - DENTSPLY Tulsa Dental Specialties White MTA) mixed as per the manufacturers instruction. Electrosurgery group A total of 30 primary molars in electrosurgery group were pulpotomised using U-shaped loop no S-6015A of perfect TCS TM (Coltene Whaledent). Intervention Before the start of pulpotomy technique, local anesthesia, placement of rubber dam, and treatment procedure was explained, to gain the confidence of the child. After inducing anesthesia, all the peripheral infected caries was excavated with an excavator. The roof of the pulp chamber was outlined and removed using No. 558 straight crosscut fissure bur; 16 sharp spoon excavator was used for complete mechanical coronal pulp amputation. The pulp stumps were clearly excised with no tags of tissue extending across the floor of the pulp chamber and then irrigated with light flow of sterile water syringe and evacuated. A wet cotton pellet (soaked in sterile water) was placed over the amputated pulp stones for 3 min to achieve hemostasis. 17 The status of the radicular pulp was assessed, 602

3 MTA and electrosurgical pulpotomy Girish MS et al Journal of International Oral Health 2016; 8(5): and the tooth was considered for pulpotomy once the bleeding was arrested naturally. MTA group The amputated pulp stumps were covered with thick paste of MTA (ProRoot MTA, DENTSPLY, Tulsa, USA) obtained by mixing MTA powder with sterile water at 3:1 powder to water ratio according to manufacturer s instruction. Followed by the placement of zinc oxide eugenol cement. Electrosurgery group In the electrosurgical group, large sterile cotton pellets were placed into the chamber with pressure to obtain initial hemostasis. The cotton pellets were removed, and the U-shaped electro surgery dental electrode was immediately placed at 1-2 mm above the tissue. The electrosurgery unit was set at 40% power. The electrode was allowed to bridge the gap on the first pulpal stump for one second followed by a cool down period of 5 s. Heat and electrical transfer were lessened by keeping the electrode secluded from the pulpal stumps and tooth structures as it would still allow electrical arcing to occur. This procedure was reiterated up to a maximum of 3 times on each pulpal orifice. On completion, the pulpal stumps appeared dry and fully blackened, which was later restored with zinc oxide eugenol cement. 18 Following pulpotomy, stainless steel crowns were placed on all the pulpotomised teeth. Follow-up assessment During the follow-up recall, post-operative intraoral periapical digital radiographs Radovisiograph were taken by using paralleling cone technique with cone positioners. The children were recalled for clinical and radiological evaluation for 1 year. (1 st, 3 rd, 6 th, 9 th, and 12th months, respectively) (Figures 1 and 2). The tooth was considered as clinically success if they had: (1) No symptoms of pain (2) no swelling, fistula or pathologic mobility and (3) tenderness to percussion. The tooth was considered as radio graphically success if they had: (1) Absence of pathologic internal or external resorption, (2) absence of inter-radicular or periapical radiolucency, (3) absence of pulp canal calcification, and (4) crypt of surrounding tooth was intact. Clinical and radiographic assessments were done by an investigator who was blind to the pulpotomy technique employed. Statistical analysis The data thus obtained was analyzed using SPSS Version 20. McNemar s test was used to determine difference between the groups at 95% confidence level (P = 0.05). Results The final sample consisted of 60 primary molars from 46 children (27 male and 19 females) with a mean age of 5 years 6 months at the time of intervention. All patients were recalled at assigned times post-operatively for clinical and radiographic evaluation. Once the pulpotomised tooth was considered as a failure, it was no longer included for forthcoming evaluation. None of the pulpotomised teeth presented with adverse effects for the medicament or the technique employed for pulpotomy. One tooth in MTA group showed radiological sign of failure, pulp canal obliteration (PCO) during the 6 th month of followup (Table 1), which was subsequently extracted and dropped from further follow-up. a b a b c d Figure 1: (a) Pre-operative radiograph of primary molar selected for electrosurgical pulpotomy, (b) immediate postoperative radiograph of electrosurgically pulpotomized primary molar, (c) 1 st month post-operative radiograph of electrosurgically pulpotomized primary molar, (d) 3 rd month post-operative radiograph of electrosurgically pulpotomized primary molar. c Figure 2: (a) 6 th month post-operative radiograph of electrosurgically pulpotomized primary molar, (b) 9 th month post-operative radiograph of electrosurgically pulpotomized primary molar, (c) 12 th month post-operative radiograph of electrosurgically pulpotomized primary molar. 603

4 MTA and electrosurgical pulpotomy Girish MS et al Journal of International Oral Health 2016; 8(5): Table 1: Success rate of MTA and electrosurgical pulpotomies at recall visits. Materials Result Follow up times in months, N (%) 1 st 3 rd 6 th 9 th 12 th MTA Success 30 (100) 30 (100) 29 (96.7) 29 (96.7) 29 (96.7) Electrosurgery Success 29 (96.7) 29 (96.7) 28 (93.3) 27 (90) 27 (90) McNemar s test P= MTA: Mineral trioxide aggregate In the electrosurgery group, one tooth showed internal resorption at 1 st month, another with mobility, swelling, and furcal radiolucency and external resorption at 6 th month and one more with internal resorption at 9 th month of follow-up. All the teeth which failed in electrosurgery were extracted, and necessary space management steps were taken during subsequent appointments. Internal resorption was the ubiquitous radiographic failure at 12 th month follow-up. It was noted in 6.6% of sample with two in electrosurgery group. By the end of 12 th month follow-up when the data was analyzed for success rates, the overall clinical success was 96.7% for MTA and 90% (Table 1) for electrosurgery. However, there was no statistically significant difference between the two groups (P = 0.353), but there was a decrease in success rate as the follow-up period was increased in both groups. Discussion Over the years, lot of concern has been raised regarding the use of formocresol in dentistry. Even though it was the gold standard medicament for pulpotomy procedures in primary molars, lot of other materials were introduced to overcome adverse effects of formocresol With this in mind, this study was an attempt find a non-chemical alternative to formocresol, which proved to be success with 96.7% success for MTA and 90% for electrosurgery. The success rates of this study were comparable to most of the studies in the past irrespective of the pulpotomy procedure employed. 15 The procedure of pulpotomy for primary teeth has been developed along three lines: Devitalization, preservation, and regeneration. Devitalization where the intent is to destroy vital tissue, typified by formocresol, preservation, where the retention of maximum vital tissue with no induction of reparative dentine, is epitomized by glutaraldehyde and ferric sulfate. Regeneration, where the stimulation of dentine bridge has been associated with calcium hydroxide, MTA 23 and recently bioactive materials like biodentine 24 enamel matrix derivative 25 and has been tried as a pulpotomy agent. Devitalization was the first approach in pulpotomy of primary teeth. The multiple visit formocresol technique as introduced by Sweet was designed to mummify the tissues completely. 18 The only rationale for using formocresol is it succeeds than fails. Even with its stupendous success over the years as a pulpotomy agent, it has received a lot of criticism, which have shown formaldehyde to be toxic, mutagenic, and carcinogenic In an attempt altogether to avoid chemicals, MTA and electrosurgical pulpotomies were given importance. For electrosurgical pulpotomy, an undamped, fully rectified, high-frequency current with an electrode is placed in direct contact with tissues. It has the merit of having limited pulpal penetration, complete hemostasis, and clear visualization without using any chemical preparation, 4 which has been acknowledged by many such studies. 33,34 Several studies exist comparing the radiographic and clinical results of electrosurgery to other medicaments. 4,10-14 Although many pulpotomy techniques have been suggested, a review article 15 and available literature suggest that evidence is lacking as to state which pulpotomy procedure is the appropriate one. 35 It has been reported that clinical evaluation is the most optimistic criteria for the success of any pulpotomy procedure, 36 but the first sign of failure was usually detected radiographically. In the MTA group, one case presented with the radiological finding of PCO in the 6th month follow-up. Even it is debatable whether PCO is due to inflammatory response or due to inductive properties of MTA. However, considering our postoperative evaluation criteria the case was considered as failure and excluded from further follow-up. A systemic review has presented with a higher incidence of PCO when MTA was used as a pulpotomy medicament. 37 Internal resorption is usually the first radiological sign of failure. 38 In this study, two from electrosurgery group were considered as a failure due to internal resorption. It has been suggested previously that similar failures were the result of - improper coronal seal, 11 inflammatory response to zinc oxide eugenol, 2 inconsistency in techniques using multiple operators, or improper selection of cases. 38 However, in cases of electrosurgery, lateral heat, which was dissipated from the electrode, could be the cause of chronic inflammatory changes such as internal resorption. 4,39 Both the clinical and radiological success rates of electrosurgical pulpotomy were in par with the studies published in the recent past. 40,41 Other radiological signs of failure like furcal and periapical radiolucency, external resorption was noted in a case in electrosurgery group. Clinical signs of failure like, mobility and swelling were also observed in one of the cases in electrosurgery group. The first sign of failure among pulpotomised teeth will be normally detected radiographically as the tooth may remain asymptomatic. Such signs of failure which emphasizes the importance of a periodic radiological follow-up even in the absence of clinical signs and symptoms. Similar to ample of studies which have reported having a decrease in success rate with increased follow-up period, 2,15,18,35,42 There was also a decrease in both clinical and radiographic success rates, in this study. 604

5 MTA and electrosurgical pulpotomy Girish MS et al Journal of International Oral Health 2016; 8(5): Conclusion Considering the limitation of this in-vivo study: That is a larger sample size and longer follow-up period, it can be concluded that since there was no statistically significant difference between the two groups (P = 0.353), the success of electrosurgical pulpotomy in primary teeth is comparable to that of MTA. If the concerns regarding, the use of formocresol were to be true, MTA, and electrosurgery can be the method of choice for pulpotomy procedures in primary molar teeth. References 1. Milledege GT. Endodontic therapy for primary teeth. Ingle s Endodontics, 6 th ed. Hamilton: B C Decker Inc.; p Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: a retrospective study. Pediatr Dent 2000;22(3): Schwartz RS, Mauger M, Clement DJ, Walker WA 3 rd. Mineral trioxide aggregate: a new material for endodontics. J Am Dent Assoc 1999;130(7): Ruemping DR, Morton TH Jr, Anderson MW. Electrosurgical pulpotomy in primates a comparison with formocresol pulpotomy. Pediatr Dent 1983;5(1): García-Godoy F, Novakovic DP, Carvajal IN. Pulpal response to different application times of formocresol. J Pedod 1982;6(2): Hill SD, Berry CW, Seale NS, Kaga M. Comparison of antimicrobial and cytotoxic effects of glutaraldehyde and formocresol. Oral Surg Oral Med Oral Pathol 1991;71(1): Myers DR, Pashley DH, Whitford GM, McKinney RV. Tissue changes induced by the absorption of formocresol from pulpotomy sites in dogs. Pediatr Dent 1983;5(1): Lewis BB, Chestner SB. Formaldehyde in dentistry: a review of mutagenic and carcinogenic potential. J Am Dent Assoc 1981;103(3): Wu MK, Wang ME, Chang SP. Antibody formation to dog pulp tissue altered by a paste containing paraformaldehyde. Int Endod J 1989;22(3): Sasaki H, Ogawa T, Koreeda M, Ozaki T, Sobue S, Ooshima T. Electrocoagulation extends the indication of calcium hydroxide pulpotomy in the primary dentition. J Clin Pediatr Dent 2002;26(3): Bahrololoomi Z, Moeintaghavi A, Emtiazi M, Hosseini G. Clinical and radiographic comparison of primary molars after formocresol and electrosurgical pulpotomy: a randomized clinical trial. Indian J Dent Res 2008;19(3): Shulman ER, McIver FT, Burkes EJ Jr. Comparison of electrosurgery and formocresol as pulpotomy techniques in monkey primary teeth. Pediatr Dent 1987;9(3): Mack RB, Dean JA. Electrosurgical pulpotomy: a retrospective human study. ASDC J Dent Child 1993;60(2): El-Meligy O, Abdalla M, El-Baraway S, El-Tekya M, Dean JA. Histological evaluation of electrosurgery and formocresol pulpotomy techniques in primary teeth in dogs. J Clin Pediatr Dent 2001;26(1): Anthonappa RP, King NM, Martens LC. Is there sufficient evidence to support the long-term efficacy of mineral trioxide aggregate (MTA) for endodontic therapy in primary teeth? Int Endod J 2013;46(3): Kurji ZA, Sigal MJ, Andrews P, Titley K. A retrospective study of a modified 1-minute formocresol pulpotomy technique. Part 1: Clinical and radiographic findings. Pediatr Dent 2011;33(2): Curzon MEJ, Roberts JF, Kennedy DB. Kennedy s Pediatric Operative Dentistry, 4th ed. USA: Wright; p Dean JA, Mack RB, Fulkerson BT, Sanders BJ. Comparison of electrosurgical and formocresol pulpotomy procedures in children. Int J Paediatr Dent 2002;12(3): Redig DF. A comparison and evaluation of two formocresol pulpotomy technicques utilizing Buckley s formocresol. J Dent Child 1968;35(1): Buckley JP. The chemistry of pulp decomposition, with a rational treatment for this condition and its sequelae. Am Dent J 1904;3: Avram DC, Pulver F. Pulpotomy medicaments for vital primary teeth: Surveys to determine use and attitudes in pediatric dental practice and in dental schools through-out the world. J Dent Child 1989;56: 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(2): Ranly DM. Pulpotomy therapy in primary teeth; new modalities for old rationales. Pediatr Dent 1994;16(6): Kusum B, Rakesh K, Richa K. Clinical and radiographical evaluation of mineral trioxide aggregate, biodentine and propolis as pulpotomy medicaments in primary teeth. Rest Dent Endod 2015;40(4): Yilidirm C. Basak F, Akgun OM, Polat GG, Altun C. Clinical and radiographic evaluation of the effectiveness of formocresol, mineral trioxide aggregate, Portland cement, and enamel matrix derivative in primary teeth pulpotomies: A two year follow up. J Clin Pediatr Dent 2016;40(1): Waterhouse PJ, Nunn JH, Whitworth JM, Soames JV. Primary molar pulp therapy histological evaluation of failure. Int J Paediatr Dent 2000;10(4): Eidelman E, Holan G, Fuks AB. Mineral trioxide aggregate vs. formocresol in pulpotomized primary molars: A preliminary report. Pediatr Dent 2001;23(1): Agamy HA, Bakry NS, Mounir MM, Avery DR. Comparison of mineral trioxide aggregate and formocresol as pulpcapping agents in pulpotomized primary teeth. Pediatr Dent 2004;26(4): Saltzman B, Sigal M, Clokie C, Rukavina J, Titley K, Kulkarni GV. Assessment of a novel alternative to conventional formocresol-zinc oxide eugenol pulpotomy for the treatment of pulpally involved human primary teeth: 605

6 MTA and electrosurgical pulpotomy Girish MS et al Journal of International Oral Health 2016; 8(5): Diode laser-mineral trioxide aggregate pulpotomy. Int J Paediatr Dent 2005;15(6): Papagiannoulis L. Clinical studies on ferric sulphate as a pulpotomy medicament in primary teeth. Eur J Paediatr Dent 2002;3(3): Ibricevic H, Al-Jame Q. Ferric sulphate and formocresol in pulpotomy of primary molars: Long term follow-up study. Eur J Paediatr Dent 2003;4(1): Casas MJ, Kenny DJ, Johnston DH, Judd PL, Layug MA. Outcomes of vital primary incisor ferric sulfate pulpotomy and root canal therapy. J Can Dent Assoc 2004;70(1): Ranly DM, Garcia-Godoy F. Current and potential pulp therapies for primary and young permanent teeth. J Dent 2000;28(3): Rivera N, Reyes E, Mazzaoui S, Morón A. Pulpal therapy for primary teeth: Formocresol v/s electrosurgery: A clinical study. J Dent Child (Chic) 2003;70(1): Erdem AP, Guven Y, Balli B, Ilhan B, Sepet E, Ulukapi I, Aktoren O. Success rates of mineral trioxide aggregate, ferric sulfate, and formocresol pulpotomies: A 24-month study. Pediatr Dent 2011;33(2): Berger JE. Pulp tissue reaction to formocresol and zinc oxide-eugenol. ASDC J Dent Child 1965;32: Marghalani AA, Omar S, Wei Chen J. Clinical and radiographic success of mineral trioxide aggregate compared with formocresol as a pulpotomy treatment in primary molars. JADA 2014;145(7): Vostatek SF, Kanellis MJ, Weber-Gasparoni K, Gregorsok RL. Sodium hypochlorite pulpotomies in primary teeth: A retrospective assessment. Pediatr Dent 2011;33(4): Yildiz E, Tosun G. Evaluation of formocresol, calcium hydroxide, ferric sulphate and MTA primary molar pulpotomies. Eur J Dent 2014;8(2): Khorakian F, Mazhari F, Asgary S, Sahebnasagh M, Alizadeh Kaseb A, Movahhed T, et al. Two-year outcomes of electrosurgery and calcium-enriched mixture pulpotomy in primary teeth: A randomised clinical trial. Eur Arch Pediatr Dent 2014;15(4): Yadav P, Indushekar K, Saraf B, Sheoran N, Sardana D. Comparative evaluation of ferric sulfate, electrosurgical and diode laser on human primary molars pulpotomy: An in-vivo study. Laser Ther 2014;23(1): Farsi DJ, El-Khodary HM, Farsi NM, El-Ashiry EA, Yagmoor MA. Sodium hypochlorite versus fromocresol and ferric sulphate pulpotomies in primary molars: 18-month follow up. Pediatr Dent 2015;37(7):