Clinical and Radiographic Evaluation of Vital Pulp Therapy in Open Apex Teeth with MTA and ZOE

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1 ENDODONTICS Clinical and Radiographic Evaluation of Vital Pulp Therapy in Open Apex Teeth with MTA and ZOE Jamileh Ghoddusi, D.D.S., M.Sc; Fatemeh Shahrami, D.D.S., M.Sc; Mahyareh Alizadeh, D.D.S.; Kamyar Kianoush, D.D.S.; Maryam Forghani, D.D.S., M.Sc. ABSTRACT The purpose of this study was to report the success rate of using mineral trioxide aggregate (MTA) and zinc oxide eugenol (ZOE) as vital pulp therapy agents in immature permanent teeth with carious or traumatic pulp exposure. Subjects were children with permanent teeth requiring pulpotomy (apexogenesis) and without systemic diseases. Both ZOE and MTA treatments as pulpotomy agents showed clinical and radiographie success in immature permanent teeth. Although MTA was more successful, it is more expensive, and dentin bridges may develop over canal orifices, complicating future root canal therapy. It is important to preserve dental pulp in a healthy state when treating teeth with exposed vital pulp.^ Although vital pulp capping and pulpotomy of cariously exposed pulp in mature teeth remain controversial methods, vital pulp therapy is the accepted treatment of choice for immature teeth. Pulpotomy is the most widely used technique in vital pulp therapy for primary and young permanent teeth with carious pulp exposure. A pulpotomy is defined as the surgical removal of the entire coronal pulp presumed to be partially or totally inflamed and infected, leaving the intact vital radicular pulp within the canal. A germicidal medicament is then placed over the remaining vital radicular pulp stumps at their point of communication with the floor of the coronal pulp chamber. Different materials have been used in vital pulp therapy, such as calcium hydroxide, formocresol, zinc oxide eugenol (ZOE) and mineral trioxide aggregate (MTA). Calcium hydroxide Ca(OH)2, a widely used pulpotomy agent, has long been recognized as problematic. In its pure state and original formulation, its alkalinity (PH=12) causes a reaction that produces superficial necrosis of the pulp when placed in contact with vital pulp tissue.'' Ca(OH)2 may also cause diffuse calcification in root canals that complicate any future root canal therapy. Before the introduction of Ca(OH)2, ZOE was the material of choice for direct pulp capping.^ ZOE has a good working and setting time, is an antiseptic and antimicrobial agent, and a nontoxic material for pulp cells.*'' Additionally, this material does not cause diffuse calcification of canals. MTA (Pro Root MTA, Tulsa Dental), currently being used in pulp therapy, has been shown to provide an enhanced nonresorbable seal over the vital pulp.^'' Like Ca(OH)2, MTA also has a high PH (12.5) that causes denaturizing of adjacent cells, tissue protein and some bacteria in the wound area. As the material sets, however, the PH changes and the cell injuries subside.^ MTA has been shown to have a sealing ability superior to amalgam, ZOE or intermediate restorative material (IRM)," and has shown high clinical and radiographie success rates as a pulpotomy dressing in immature permanent teeth. ^^ It is, however, problematic for future root canal therapy. 34 APRIL 2O12 The New York State Dental Journal

2 - Figure 1. Before freafmenf. Figure 2. Three months Figure 3. Eight months Figure 4. Eighteen months Figure 5. Before treatment Figure 6. Three months after treatment. Figure 7. Eight months after treatment. Figure 8. Eighteen months The purpose of this study was to compare MTA and ZOE as pulpotomy agents in immature permanent teeth. The study contains two sections. Part I was a prospective clinical and radiographie evaluation comparing results in teeth treated with each of the agents. Part II was a retrospective evaluation of treatment files from Mashhad Dental School in Iran, in which teeth were treated with either MTA or ZOE. Materials and Methods For the first part of the study, we selected 28 roots from patients referred to the dental school of Mashhad University of Medical Sciences. All patients gave informed consent and supplied medical and dental histories. The criteria for inclusion in the study were clinical and radiographie. The following clinical criteria were adopted: vitality of teeth; no history of fistula; no history of high sensitivity to percussion and palpation of teeth; no history of spontaneous or nocturnal dental pain; and exposure of pulp caused by caries or trauma; or previous caries with deep restoration. Radiographie criteria included: tooth with an open apex or with parallel apical walls; and absence of radiographically visible lesions. Vitality tests were performed on teeth. Those with acute irreversible pulpitis were selected. The teeth were randomly divided into two groups. In each group, local anesthesia (alveolar block in the mandible and infiltration in the maxilla) of 2% lidocaine with 1: epinephrine was administered, and the caries and roof of the pulp chamber were removed with a diamond bur. The teeth were then isolated with a rubber dam and pulp tissue was removed to the orifices of the canal with a carbide round bur. If bleeding could be controlled with irrigation by normal saline or sodium hypochlorite 2.5%, treatment was continued. If not, the sample was removed from the study. This process was the same for all patients. The samples were randomly divided into two groups. MTA (MTA-Angelus Londrina PR, Brazil) was used for capping the pulp in Group A. It was prepared according to manufacturer's instructions and placed over the canal orifices. Wet cotton was placed over the MTA during setting. In Group B, zinc oxide powder plus eugenol (Kemdent/Associated Dental Product LTD, SwinDon, HT, UK) was placed over the orifices and zinc phosphate (Harvard Dentai-Smbt Berlin Germany) placed over it. In both groups, all teeth were temporarily restored with light-cured glass ionomer (Glass lonomer, Ghemfill-superior, Dentsply Detroy Konstanz, Germany). Patients were asked to subjectively evaluate their symptoms 24 hours after the procedure. The patients were evaluated clinically two weeks later. If there were no problems, the teeth were restored permanently with amalgam or composite resin. All patients were evaluated clinically and radiographically at 3-, 6- and 12-month follow-up examinations, and clinical and radiographie data were recorded. The criteria for successful treatment were: absence of clinical symptoms, such as pain or fistula; closure of the apex; and absence of radiolucent lesions. Treatment was considered unsuccessful if pain, fistula or swelling were present, if the apex did not develop, or if a radiolucent lesion was present. The New York State Dental Journal APRIL 2O12 3 5

3 For the second part of the study, we collected forms for all patients treated in Mashhad Dental School. The materials and methods described above for Part I of the study were also used in Part II. The Part II subjects were followed up clinically and radiographically. Results Part I: Prospective Data Of 28 roots examined, 13 cases were placed in the ZOE group and 15 in the MTA group. Data were analyzed using chi-squared and Fisher's exact tests. Of the total sample, 96.4% of the roots were exposed by caries and 3.6% by trauma. At the initial examination, 14.3% had pain; 53.6% had previously experienced pain; and 32.1% had no pain. After two weeks, all cases in the two groups were normal and without clinical complication. After three months, 84.6% in Group A and 100% in Group B were clinically normal; the difference between the groups was not statistically significant (Figures 1-4). Clinical evaluation after 12 months showed that 91.7% in Group A and 100% in Group B were clinically normal, with no significant differences between the groups. At the start of the study, 5 8.3% of roots in Group A and 46.7% in Group B had a blunderbuss apex. There were no significant differences between the groups in the position of the apical walls. After three months, 25% of roots in Group A and 33.3% in Group B were closed. Between 6 and 12 months, 58.3% of roots in Group A and 75% in Group B had closed apices. There was no significant difference between the groups (P=0.28) (Figures 5-8). Part II: Retrospective Data A total of 29 roots from 22 patients fell into the ZOF group of the retrospective study; six roots of four patients were in the MTA group. After 6 to 12 months, success rates were 83.3% in the ZOE group and 100% in the MTA group. Discussion Many studies have examined the use of a variety of materials to treat teeth with open apices and vital pulp, with the aim of introducing material that does not damage pulp and is able to affect root development.^^ Our goal in this study was to determine the clinical and radiographie conditions of teeth with open apices and pulp exposure that underwent cervical pulpotomy with MTA or ZOE and recommend the preferable material based upon our results. When pulp life is lost before maturation and development in these teeth, dentin walls remain thin and the probability of breakage increases. Under these conditions, apices can remain open and cause problems in root treatments, roots would remain short, and ower Your Credit Card Processing Fees an Average 23% NYSDA is introducing Best Card LLC, a new credit card acceptance program to help members lower their processing fees. Best Card specializes in assisting dental practices qualify for the lowest BEST CARD LLC rates possible, while providing unparalleled customer service. The average dental practice saves 23% ($1,066 annually) when it switches to Best Card. For more information, call or visit For more information about this and other Endorsed Programs call: ENERCYPLUsn Demandbrce PAYCHEX CareCredit Altfest^^^ PRS.SITES IPMS. Bankof America "^^ BEST CARD LLC 36 APRIL 2O12 The New York State Dental Journal

4 the ratio of crovm-to-root length would be disturbed and cause difficulties in prosthodontic treatments.''' Tbe aim of vital pulp tberapy is to maintain pulp viability and to establish an environment in which apexogenesis can occur. Previous investigation found that the response to treatments such as pulpotomy was better for teeth affected solely by trauma tban decayed teeth or tbose with botb conditions.''* Altbough Egbbal et al. found favorable results in MTA pulpotomy of permanent teetb vnth irreversible pulpitis. Formocresol and ZOE are commonly used in pulpotomy of primary teetb, and bave been recommended as preferred materials.''' Formocresol treatment success bas been equivalent to or better tban that of MTA.''''-^^ In permanent teetb, the most commonly used material is Ca(OH)2^ wbicb, despite acceptable success in tbe long term, causes root cbannel calcification and internal erosion.^^ Svizero et al." report on tbe use of Ca(OH)2 in partial pulpotomy of immature maxillary incisors damaged by trauma. After 250 days, no symptoms of constant pain were reported, and tbere was indication of vital pulp. After 90 days of treatment, no radiolucency was observed. Aeinecbi et al.^ evaluated the use of MTA and Ca(OH)2 as pulp capping materials in third maxillary molars of patients 20 to 25 years old. Histological examination after extraction indicated that teeth treated with MTA had less infiammation and necroüc pulp and tbicker dentin walls compared to Ca(OH)2. However, because of the small sample size (11 patients), statistical examinations were not performed. Tabarsi et al.^' examined the response of dental pulps to different pulp capping agents and found that calcified bridge formation, pulp vitality and lack of inflammation were higher with MTA in comparison to Ca(OH)2. In light of prior findings of dentin wall development two months after MTA treatment and tbree months after Ca(OH)2 treatment,^^ we expected to observe radiographie changes in our sample after three months of treatment. We did not. However, lack of change did not necessarily indicate treatment failure. In our prospective study, 5 of 13 cases in the ZOE group evidenced positive change in apex condition; 10 of 15 cases in the MTA group showed this type of change. Six months after treatment, follow-up was done and changes in the apex were observed in 10 ZOE cases and 11 MTA cases. None of the differences between groups was statistically significant. In tbe retrospective study, the results of both metbods indicated that both MTA and ZOE materials resulted in successful cervical pulpotomy treatment and caused immature tooth apex development and maturation. One reason for the success was that the teeth were restored immediately It was stated that tbe greatest cause of failure in vital pulp therapy is leakage during the bealing process.^^ IT 18 NOW NY STATE LAW. ALL NEW YORK DENTAL OFFICES MUST HAVE AN AED! " authorized Philips retailer VEAR PHILIPS WARRANTY! FREE GIFTS! -1 CPR Shield Key Chain -1 Maintenance Chech Tag -1 Proof of Compliance Window Sticber -1 AED Training Video - Enrollment in our Preferred Customer Database Dental AED Compliance Package - Philips HeartStart OnSite AED - Slim Carrying Case - Prelnstalled Battery - Prelnstalled Adult Pads - Set-Up Guide - Maintenance Booklet - Owners Manual which includes pad and battery replacement reminders, special discountsand more! NmhStar 'MEDICAL EQUIPMENT PHILIPS ORDER NOW Best-In-Quality Philips HeartStart AEDs and AED Supplies. 30-Day Money Bacb Guarantee. Customer Service Representatives are standing-by. Special NVDental Professionals purchase price $500 NV State Tax Credit After Tax Credit **A value of over $1540 Convenient Online Ordering! use discount code NVDENTAL at the end of checkout l-äfi»aa y>f%'r l"c»llo"3o*l"73w7 The New York state Dental Journal APRIL 2Ol2 37

5 The high price of MTA and, thus, its more limited application is an important issue to consider. In addition, MTA requires three to four hours to cure, during which time it must be covered by moist cotton. Other issues with the use of MTA are the probability of dentin wall formation on canal entrances and the increase of inner canal calcification, both of which may cause problems for future root treatment. One of our retrospective samples, presenting with trauma-related mechanical exposure, was pulpotomized by MTA and showed dentin wall formation in the canal entrance. Conclusion and Suggestion The results of this study made apparent the following: 1. ZOE and MTA are suitable materials for cervical pulpotomy. MTA can be used with assurance on cases diagnosed as irreversible pulpitis, as it is associated with high cure rates in these cases. Complete root treatment is usually necessary after apex closure. MTA, however, is expensive and increases the probability of canal calcification. Our results indicate that ZOE is suitable and reliable for this treatment, but additional comparative studies are required. 2. Since this research was done clinically, preparation of tissue cross-sections and histological examinations was not possible. It is obvious that to obtain better and accurate results, histological examinations are useful. Another limitation of this plan was In-House Dental Studio Dental Laboratory for complex esthetic and implont restorations Visit our website and blog 40 West Elm St, Greenwich, CT that periapical radiographs were two-dimensional, while opinions had to be made on three-dimensional root ends. 3. Although the need for long interval control was minimized with the retrospective comparison, a prospective study conducted over a longer time period would be valuable. 4. This study did not distinguish whether tooth type had any role in the success of each material because, in the prospective portion, the majority of treatments were conducted on permanent mandibular molars (n=9) and permanent maxillary molars (n=5). Pulp exposure in these molars could be attributed to decay. A clearer and more decisive conclusion regarding the success of MTA treatment in immature teeth and their subsequent development would require a longer follow-up period and histological examinations. Á Queries about this article can be sent to Dr. Ghoddusi at ghoddusii@mums.ac.ir. REFERENCES 1. Nair PNR, Duncan HF, PittFord TR, Lunder HU. Histological, ultra structural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. Int Endod J 2007i41: Fong CD, Davis MJ. Partial pulpotomy for immature permanent teeth: its present and future. Pediatr Dent 2002;24: Finn SB. Morphology of Primary Teeth. In: Finns SB, editor. Clinical Pedodontics. 4th Fd. Philadelphia: WB Saunders; McDonald RE, Avery DR, Dean JA. Treatment of Deep Caries, Vital Pulp Exposure and Pulpless Teeth. In: Dentistry for the Child and Adolescent. 8th Ed. St Louis, IWo: Mosby Co; 2004: Walton R, Torabinejad M. Principle and Practice of Endodontics. 3rd Ed. Philadelphia, PA:W.B. Company, Pertot WJ, Camps J, Remusat M, Proust JP. In vitro comparison of the biocompatibility of two root canal sealers implanted into the mandibular bone of rabbits. Oral Surg Oral Med Oral Pathol 1992;73: Geurtsen W, Biocompatibility of root canal filling materials. Aust Endod J 2001;27: Holland R, de Souza V, Nery M], Otoboni Filho JA, Bernabé PF, Dezan JE. Reaction of connective tissue to implanted dentin tubes filled with mineral trioxide aggregate or calcium hydroxide. J Endod 1999;25: Torabinejad M, Chivian M. Clinical application of mineral trioxide aggregate. J Endod 1999; 130: Torabinejad 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 Jun;21(6): Sluky SR, Moon PC, Hartwell GR. Evaluation of setting properties and retention characteristics of mineral trioxide aggregate when used as a perforation repair material. J Endod 1998;24: Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol. J Endod 2004; 30: Cohen, S, Hargreaves KM. Pathways of the Pulp. 9th Ed. St. Louis: Mosby, Raslan N, Wetzel WE. Exposed human pulp caused by trauma and/or caries in primary dentition: a histological evaluation. Dental Traumatology 2006; 22: Eghbal MJ, Asgary S, Baglue RA, Parirokh M, Ghoddusi J. MTA pulpotomy of human permanent molars with irreversible pulpitis. Aust Endod J 2009 Apr;35(l): Holand G, Eidelman E, Fuks AB. Long term evaluation of pulpotomy in primary molars using mineral trioxide aggregate and formocresol. Pediatr Dent 2005;27: Castro A. Current concepts in vital pulpotomy in primary teeth. J Mich Dent Assoc 2005;l: Eidelman E, Holand G, Fuks AB. Mineral trioxide aggregate vs. formocresol in pulpotomized primary molars. Pediat Dent 2001;23: Svizero Nda, Bresciani E, Frandschone CE, Franco EB, Pereira C. Partial pulpotomy and tooth reconstruction of a crown fractured permanent incisor a case report. Quintessence Int 2003:34: Aeinehchi M, Eslami B, Ghanbariha M, Saffar As. Mineral trioxide aggregate and calcium hydroxide as pulp-capping agent in human teeth: a preliminary report. Int Endod J 2003; 36: Tabarsi B, Parirokh M, Eghbal MJ, Haghdoost AA, Torabzadeh H, Asgary S. A comparative study of dental pulp response to several pulpotomy agents. Int Endod J 2010 Jul;43(7): Epub 2010 Apr Omar AS, EL-Meligy OA, Avery DR. 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