EGYPTIAN Vol. 64, 951:962, April, 2018 DENTAL JOURNAL I.S.S.N 0070-9484 Orthodontics, Pediatric and Preventive Dentistry www.eda-egypt.org • Codex : 214/1804 CLINICAL AND RADIOGRAPHIC ASSESSMENT OF PULPOTOMY MATERIALS IN PRIMARY MOLARS Gihan Abuelniel* and Sherif Eltawil* ABSTRACT Aim or purpose: Clinical and radiographic evaluation of four different materials utilized in vital pulpotomy in mandibular primary molars Materials and methods: one hundred and sixty mandibular primary molars in forty children were included as split mouth design. Patients were medically free with an age range from 4-6 years. Inclusion criteria: patients presented with deep carious lesions including the first and second primary molars bilaterally, no evidence of any clinical pathology, mobility and had no tenderness to percussion. Pre-operative radiographs showed no evidence of external or internal root resorption, absence of furcal, periapical radiolucency or widened periodontal ligament space and no more than one-third root resorption detected. The included molars undergone vital pulp therapy and bilaterally randomly divided into four equal groups, group (1) formocresol, group (2) ferric sulphate, group (3) MTA (mineral trioxide aggregate) and group (4) Metapex (calcium hydroxide &iodoform). All treated molars were evaluated both clinically and radiographically for 12 months evaluation period. Data were collected and analysed statistically. Results: It was shown that, at base line, there was no statistically significant difference between clinical as well as radiographic success rates among the four groups. After 3 as well as 6 months, there was a statistically significant difference between clinical and radiographic success rates among the four groups. FS, MTA and Metapex groups showed higher clinical and radiographic success rates than FC group. Conclusions: Ferric sulphate, mineral trioxide aggregate (MTA) and Calcium hydroxide and iodoform paste (Metapex) provide clinically acceptable alternative to formocresol in vital pulp therapy in primary teeth. INTRODUCTION pulpotomy, which is defined as ‘the amputation of Dental caries is a continuous process especially infected coronal pulp, and treatment of the radicular in children till degradation of the dental hard tissues uninflamed tissues with pulpotomy medicaments, occur leading to infection of the dental pulp. Infected pulpotomy rather than direct pulp capping that pulp tissue in primary teeth is usually treated with proved to have poor success is performed. [1,2] * Pediatric Dentistry, Cairo University, Egypt (952) E.D.J. Vol. 64, No. 2 Gihan Abuelniel and Sherif Eltawil Ranly classified pulpotomy based on treatment inflammation and internal resorption. When ferric objectives into devitalization (Mummification, sulphate comes in contact with pulp tissue forms Cauterization), preservation (minimal devitalization, ferric ion-protein complex that mechanically noninductive) and regeneration (inductive, occludes capillaries on amputation site forming reparative). Non-chemical methods of pulpotomy barrier for irritants of sub-base [3,9]. include use of electro surgery and lasers [3]. Regenerative pulpotomy It is also called as The first pulpotomy treatment modality of inductive pulpotomy or reparative pulpotomy. primary teeth was devitalisation using formocresol This mechanism encourages the radicular pulp to that was introduced by Buckley in 1904. Since then heal and form a dentin bridge/hard tissue barrier. various modifications have been tried and advocated Ranly stated that “Ideal pulpotomy treatment regarding the techniques of FC pulpotomy and the should leave the radicular pulp vital and healthy and concentrations [3]. Buckley’s formula of formocresol completely enclosed within an odontoblast-lined includes formaldehyde 19%, Cresol 35%, glycerine dentin chamber.” In this situation, the tissue would 15%, and water with an approximate pH of 5.1. be isolated from noxious restorative materials in Currently 1:5 dilution of Buckley’s formocresol is the chamber, thereby diminishing the chances of commonly used [4,5]. Formocresol prevents tissue internal resorption. Moreover, the odontoclasts of autolysis by binding to peptide group of side chain an uninflamed pulp could enter into the exfoliative of amino acid. It is a reversible process without process at the appropriate time and sustain it in a changing of basic structure of protein molecules [6]. physiologic manner. On the opposite of the other two categories i.e devitalization and preservation, the Despite the popularity of formocresol as a rationale for developing regeneration is dependent pulpotomy medicament in the primary dentition, upon on sound biologic principle [3]. concerns have been raised over its use in humans, mainly as a result of its toxicity and potential Calcium hydroxide and mineral trioxide carcinogenicity [7]. A survey conducted in the United aggregate are two materials included in this states reported that majority of dentists used FC as category. Calcium hydroxide was the first agent pulpotomy medicament and they were not concerned used in pulpotomies that demonstrated any capacity about adverse effects, while a survey conducted in to induce regeneration of dentin. The action of the UK showed that 66.5%of pediatric dentists used calcium hydroxide was attributed to a modification FC for pulpotomy, 54.2% were concerned regarding of the solubility product of Calcium, phosphate their preferred medicament and were considering and a precipitation of salt into an organic matrix. change of the chosen technique [8]. Additionally, the high pH of calcium hydroxide stimulates the pulp to begin the intrinsic reparative Preservative pulpotomy technique produce cascade. Unfortunately, the stimulus evoked by this minimal insult to orifice tissue, thereby maintaining compound is delicately balanced between one of vitality and normal histological appearance of repair and one of resorption. It was claimed that the radicular pulp. Ferric sulphate is one of the materials main disadvantage of this alternative intervention is included in this category which is a non-aldehyde internal resorption [10]. chemical that has received attention recently as a pulpotomy agent. This haemostatic compound was Mineral Trioxide Aggregate (MTA) was intro- proposed on the theory that it prevents the problem duced by Torabinejad and has proven good success in clot formation thereby minimizing chances of rates as pulpotomy agent [7]. MTA studies revealed CLINICAL AND RADIOGRAPHIC ASSESSMENT OF PULPOTOMY MATERIALS (953) that it possesses not only good sealing ability, excel- Inclusion criteria lent long-term prognosis and good biocompatibility but also favours tissue regeneration. MTA has an A) Clinical inclusion criteria: alkaline pH of 10.2 immediately after mixing and · patients presented with deep carious lesions in- increases to 12.5 after 3 hours of setting that induces cluding the first and second primary molars bi- dentin bridge formation by the pulp tissue. MTA on laterally the histological level caused minimal pulpal inflam- · mation [11]. No evidence of any clinical pathology · Debates surrounding formocresol urged for fur- No mobility and had no tenderness to percus- ther search for various safer and effective alterna- sion. tive medicaments as pulpotomy agents presented in B) Radiographic inclusion criteria: this study. · Pre-operative radiographs showed no evidence SUBJESTS AND METHODS of external or internal root resorption. This study was conducted at the Department · Absence of furcal radiolucency. of Pediatric Dentistry, Faculty of Dentistry, Cairo · Absence of periapical radiolucency or widened University. The study protocol was approved by periodontal ligament space the Ethical Committee of Faculty of Dentistry, Cairo University. The clinical procedure and · No more than one-third root resorption detected. associated risks and benefits were fully explained All the included molars undergone vital pulp to the parents or legal guardian of the participants. therapy and were bilaterally randomly divided into Written informed consent was obtained from the four equal groups of 40 each, depending on the type parents or legal guardian of the participants prior of pulpotomy medicament used. Randomization to investigation. All participants were screened by taking a detailed history and performing a thorough of the pulpotomy medicament used was done by clinical and radiographic examination. envelope draw method for all the selected molars in the same patient. After administering local One hundred and sixty mandibular primary anaesthesia, the molars were isolated with a rubber molars in forty children were included as split dam. All caries was removed and coronal access mouth design. Patients were medically free with an was gained using a sterile No. 330 high speed bur age range from 4-6 years. with water coolant to deroof the pulp chamber. A Sample size calculation sterile spoon excavator was used for coronal pulp Sample size determination was based upon the amputation. One or more sterile cotton pellets results of Kusum B et al. Using alpha level of 0.05 moistened with distilled water were placed over the (5%) and β level of 0.20 (20%) i.e. power = 80%; pulp stumps, and light pressure was applied for 5 the estimated minimum required sample size (n) minutes for obtaining haemostasis. If bleeding did was 32 cases. Over-sampling was performed to not stop after 5 minutes, the molar was excluded compensate for 20% drop-out rate so the required from the study. Depending on