Outcome of Direct Pulp Capping with Mineral Trioxide Aggregate (MTA) A Prospective Clinical Study

Transcription

1 Outcome of Direct Pulp Capping with Mineral Trioxide Aggregate (MTA) A Prospective Clinical Study Miguel Marques Amsterdam, 2 nd April 2016

2 Direct Pulp Capping with Mineral Trioxide Aggregate Outline 1. Different treatment concepts 2. Literature review 3. Aim 4. Methods 5. Results 6. Discussion 7. Conclusions

3 Direct Pulp Capping with Mineral Trioxide Aggregate Different treatment concepts of carious treatment Selective/ partial excavation Stepwise excavation Figures adapted from: Bjørndal L. Dentin and pulp reactions to caries and operative treatment: biological variables affecting treatment outcome. Endodontic Topics 2002; 2:

4 Direct Pulp Capping with Mineral Trioxide Aggregate Different treatment concepts of carious treatment Complete excavation Figures adapted from: Bjørndal L. Dentin and pulp reactions to caries and operative treatment: biological variables affecting treatment outcome. Endodontic Topics 2002; 2:

5 Direct Pulp Capping with Mineral Trioxide Aggregate Caries depth (2 dimensional criteria) 1. Initial/ shallow caries (1/4 dentine depth) 2. Medium (2/4 dentine depth) 3. Deep (3/4 dentine depth) 4. Extremelly deep (all dentine depth) Figures adapted from: Bjørndal L, Reit C, Bruun G, Markvart M, Kjældgaard M, Näsman P, Thordrup M, Dige I, Nyvad B, Fransson H, Lager A, Ericson D, Petersson K, Olsson J, Santimano EM, Wennström A, Winkel P, Gluud C. Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci 2010; 118:

6 Direct Pulp Capping with Mineral Trioxide Aggregate Initial/ shallow caries Medium caries

7 Direct Pulp Capping with Mineral Trioxide Aggregate Deep caries Extremelly deep caries

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9 Direct Pulp Capping with Mineral Trioxide Aggregate Permanent dentition Partial excavation Complete excavation Shallow and Medium Deep Extremely deep Mertz-Fairhurst et al (N=312) No controlled trial No controlled trial

10 Direct Pulp Capping with Mineral Trioxide Aggregate Permanent dentition Stepwise excavation Complete excavation Shallow No controlled trial Medium No controlled trial Deep Extremely deep Leksell et al (N=127) Bjorndal et al (N=314) No controlled trial

11 Direct Pulp Capping with Mineral Trioxide Aggregate Permanent dentition Partial excavation Stepwise excavation Shallow Medium and Deep Extremely deep No controlled trial Maltz et al (N=299) No controlled trial

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24 Direct Pulp Capping with Mineral Trioxide Aggregate Aim Assess the outcome of direct pulp capping with mineral trioxide aggregate (MTA) after complete caries excavation in permanent dentition with a twovisit treatment protocol.

25 Direct Pulp Capping with Mineral Trioxide Aggregate Methods Between 2008 and 2011, 64 sequential teeth with deep carious lesions were treated. Inclusion criteria: Complaints history Cold testing Radiographic examination

26 Direct Pulp Capping with Mineral Trioxide Aggregate Methods Caries excavation was performed under rubber dam and operating microscope magnification, using caries detector dye and carious excavator Pulp exposure was rinsed with water from the dental unit No case was excluded based on bleeding time

27 Figure addapted from: Neves AA, Coutinho E, de Munck J, van Meerbeek B. Caries-removal effectiveness and minimalinvasiveness potential of caries-excavation techniques: A micro-ct investigation. J Dent 2011;

28 Direct Pulp Capping with Mineral Trioxide Aggregate Methods Cotton pellet was used occasionally for bleeding control Thin layer of white MTA Provisional restoration with coltosol F

29 Direct Pulp Capping with Mineral Trioxide Aggregate Methods Outcome was described as success or failure. Success was defined as: Positive reaction on cold testing No pain complaints No pain on percussion No widening of the periodontal ligament

30 Direct Pulp Capping with Mineral Trioxide Aggregate Gender Female n=34 Male n=30 Sample size (N=64 teeth)

31 Direct Pulp Capping with Mineral Trioxide Aggregate Sample description - Age range ,1 ± 15 (mean ± SD)

32 Direct Pulp Capping with Mineral Trioxide Aggregate Dental arch Mandibule n=26 Maxilla n=38 Sample size (N=64 teeth)

33 Direct Pulp Capping with Mineral Trioxide Aggregate Treated teeth Incisors n=5 Premolars n=17 Molars n=42 Sample size (N=64 teeth)

34 Direct Pulp Capping with Mineral Trioxide Aggregate Caries Secondary 59% Primary 41% Sample size (N=64 teeth)

35 Direct Pulp Capping with Mineral Trioxide Aggregate Caries location Proximal 81% Occlusal 19% Sample size (N=64 teeth)

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41 Direct Pulp Capping with Mineral Trioxide Aggregate Figure addapted from: Sezinando A. Looking for the ideal adhesive A review. Rev Port Estomatol Med Dent Cir Maxilofac

42 2 years follow-up

43 Direct Pulp Capping with Mineral Trioxide Aggregate

44 Direct Pulp Capping with Mineral Trioxide Aggregate Completed 2nd appointment Yes (n=59) 92,2% No (with haemorrhage) (n=2) No (without haemorrhage) (n=2)

45 Direct Pulp Capping with Mineral Trioxide Aggregate 30 3,8 ±0,8 (Mean ± SD) year 2 years 3 years 4 years 5 years Follow-up period

46 Direct Pulp Capping with Mineral Trioxide Aggregate Recall Rate 77,9% Recalled n=46 Non recalled n=13

47 Direct Pulp Capping with Mineral Trioxide Aggregate Success and Failure 90,5% 92% 19 2 With haemorrhage 23 Without haemorrhage p value >.05 (not statistically significant) Difference in the 2 groups (90,5%-92%) = 1,5% [-54,1-51,1] The 95% confidence interval for the true difference in the 2 percentages is -54,1% to 51,1% 2 Success Failure

48 Direct Pulp Capping with Mineral Trioxide Aggregate 40 89,7% % Success Failure Success Failure Occlusal Proximal p value >.05 (not statistically significant) Difference in the 2 groups (100%-89,7%) = 10,3% [8,5-89,1] The 95% confidence interval for the true difference in the 2 percentages is 8,5% to 89,1%.

49 Direct Pulp Capping with Mineral Trioxide Aggregate 30 22,5 15 7,5 0 94,7% 18 88,9% Success Failure Success Failure Primary Secondary p value >.05 (not statistically significant) Difference in the 2 groups (94,7%-88,9%) = 5,8% [-48,1-59,7] The 95% confidence interval for the true difference in the 2 percentages is -48,1% to 59,7%

50 Direct Pulp Capping with Mineral Trioxide Aggregate % 20 80% <40 years-old p value =.033 (statistically significant) Odds ratio (26/0 / 16/4) = 6,5 Difference in the 2 groups (100%-80%) = 20% [4,2-35,8] The 95% confidence interval for the true difference in the 2 percentages is 4,2% to 35,8%. 4 >40 years-old Success Failure

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52 Direct Pulp Capping with Mineral Trioxide Aggregate

53 3 years follow-up

54 Direct Pulp Capping with Mineral Trioxide Aggregate Discussion Low power study Single researcher Low external validity High internal validity

55 Direct Pulp Capping with Mineral Trioxide Aggregate Conclusions Direct pulp capping with MTA could maintain pulp vitality when a two-visit treatment protocol is observed.

56 Direct Pulp Capping with Mineral Trioxide Aggregate Case 1 - Tooth 36 Female patient Age: 12 years old Medical history: non contributory Chief complaint: pain with cold stimulus Dental history: composite restoration 16 weeks ago Clinical findings: deep caries Referring dentist request: diagnosis and treatment

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63 Direct Pulp Capping with Mineral Trioxide Aggregate Key learning point Controlled clinical trials support complete excavation strategies. Non controlled clinical trials support direct pulp capping with MTA.

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