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Calcium hydroxide vs. mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries.

Abstract

Aim: To prospectively compare the clinical success rate of partial pulpotomy treatment in permanent molars using calcium hydroxide (CH) and mineral trioxide aggregates (MTA) as pulp dressing agents. Methods: Restorable permanent first molars (64) with carious pulp exposures were randomly assigned to two groups; CH and MTA. A standardized operative procedure was followed in both groups. Following isolation and caries removal, the exposed superficial pulp tissue layers were removed with a sterile flame shape diamond bur to a depth of 2-4 mm. Bleeding was controlled and pulp dressed with either a paste of non-setting Ca[(OH).sub.2] followed by a setting layer of Ca[(OH).sub.2], or with grey MTA. The dressing materials in both groups were then covered with a layer of light cured glass ionomer cement. The teeth were either restored using amalgam, or where grossly carious with preformed metal crowns. Patients were scheduled for follow-up at 3, 6, 12 months and annually thereafter. Results: There were 34 patients (17 males and 17 females) with 51 teeth available for evaluation. The age of patients at the time of restoration ranged between 6.8 to 13.3 years (mean of 10.3 [+ or -] 1.8 years). The follow-up period ranged from 25.4 to 45.6 months with an average of 34.8 [+ or -] 4.4 months. There was no statistically significant difference in the success rate of teeth treated with CH (91%) in comparison to teeth treated with MTA (93%). Radiographically, a hard tissue barrier under CH was noticed in 12 (55%) teeth compared with 18 (64%) teeth under MTA (p=0.4). Conclusions: MTA has clinical success rate comparable to CH as a pulp dressing material for partial pulpotomy in permanent molars with carious exposures.

Key words: Pulpotomy, Permanent Molar, Caries, Calcium Hydroxide, MTA.

Introduction

The permanent first molar may, soon after eruption, show extensive caries, sometimes associated with hypoplasia [Carrotte, 2005]. Without treatment, this eventually results in infection of the dental pulp and surrounding periapical tissues [Martin, 2003]. One of the most challenging clinical scenarios for clinicians is the management of the pulpally involved immature permanent first molar. In all teeth, with or without closed apices, root canal treatment would stop apposition of dentine along the canal walls and pulp chamber leaving the tooth with thin dental walls, and making it prone to fracture [Camp et al., 2002]. Direct pulp capping and partial pulpotomy are two clinical modalities to preserve tooth vitality in cases of pulp exposure in young permanent teeth [Mass and Zilberman, 1993; Mejare and Cvek, 1993]. Young permanent teeth are considered good candidates for many pulp healing procedures because of their increased apical perfusion, which is believed to enhance the pulp's ability to react to various insults successfully [Massler, 1972].

Partial pulpotomy for permanent teeth with diagnosis of normal pulp or reversible pulpitis is a procedure in which the inflamed tissue beneath an exposure is removed to a depth of 1 to 3 mm or deeper to reach healthy pulp tissue. Bleeding is then controlled and the site is covered with CH or MTA [AAPD, 2006].

Due to its highly alkaline pH, up to 12.5, CH confers a bactericidal effect and is capable of inducing the formation of a hard tissue barrier [Zander, 1939]. Using CH as a pulp dressing agent, the success rate of partial pulpotomy is reported to be 91-100% in cariously exposed young permanent molars [Zilberman et al., 1989; Mass and Zilberman, 1993; Mejare and Cvek, 1993; Nosrat and Nosrat, 1998]. Recently, encouraging results with MTA have been reported at both experimental and clinical levels [Torabinejad et al., 1993; Tziafas et al., 2002; Fridland and Rosado, 2005; Barrieshi-Nusair and Qudeimat 2006; Camilleri and Pitt Ford, 2006]. MTA has been shown to induce less pulp inflammation and more dentine bridge formation when compared with CH cement [Ford et al., 1996; Aeinehchi et al., 2003; Briso et al., 2006; Takita et al., 2006]. In a preliminary study, the authors reported on a 100% success rate when MTA was used as a pulp dressing agent for partially pulpotomised permanent first molars [Barrieshi-Nusair and Qudeimat 2006].

The aim of this study was to compare the clinical success rate of CH with that of MTA in partial pulpotomy treatment of permanent molars.

Material and Methods

Ethical approval was obtained from Jordan University of Science and Technology ethical clearance committee. Written consents were obtained from the parents of all the participating children prior to examination.

Selection criteria. Teeth were excluded from the study if they had any of the following:

* previous operative procedures;

* history of spontaneous or prolonged pain;

* swelling, tenderness to percussion or palpation, or pathological mobility;

* pre-operative radiographic pathology such as resorption (internal or external); periradicular or furcation radiolucency, or a widened periodontal ligament space;

* did not respond within normal limits to sensibility testing and haemorrhage control was unsuccessful.

A table of randomly allocated numbers for the procedure to be carried out was generated using a computer software. Out of 92 patients with 135 molars screened for this study, 43 healthy patients with 64 carious pulp exposures and restorable permanent first molars satisfied the inclusion/ exclusion criteria and were assigned to two experimental groups. Group I included 32 partially pulpotomised teeth treated with CH. Group II included 32 teeth treated with MTA. Age of the patients at restoration date ranged from 6.8 to 13.3 years (mean of 10.3 [+ or -] 1.8 years).

Treatment procedure. For both experimental groups a standardized operative procedure was followed. Following administration of block or / and infiltration local analgesia, teeth were isolated and caries removed. A large round bur in a low speed handpiece with water coolant and spoon excavators were used during caries excavation of the pulpal floor. The exposed superficial pulp tissue layers were removed with a sterile flame shape diamond bur (Brasseler, FL, USA) in a high speed hand piece under water coolant to a depth of 2-4 mm. The pulp wound was gently flushed with sterile saline until bleeding was controlled. In group I the pulp was then dressed with a paste of non-setting CH (Hypocal, Ellman International Inc, Hewlett, NY, USA) followed by a setting layer of CH (Dycal, Dentsply, USA). For group II, Grey MTA (ProRoot, Dentsply, Tulsa Dental, USA) was mixed according to manufacturer's instructions on a glass mixing pad. The mixture was gently placed against the wound using spoon excavators and plastic instruments. The material was adapted to the wound with a wet cotton pellet and the excess MTA was scraped off. CH and MTA dressings in both groups were covered with a layer of light cured glass ionomer cement (Vitrebond, 3M, ESPE, Minnesota, USA) extended onto dentine. This was followed by placing a base of light cured glass ionomer cement (GC Corp, Tokyo, Japan). The teeth were either restored using amalgam (Amalgam 48, TNMC Medical Devices Ltd, Guildford, UK), or where grossly carious, with pre-formed metal crowns, PMC (3M, ESPE, Minnesota, USA) cemented with glass ionomer cement (Ketac-Cem, ESPE, powder-liquid type).

Follow ups. Patients were scheduled for clinical and sensibility examinations follow ups at 3, 6, 12 months and annually thereafter by one of the investigators. Radiographs were taken at 6, 12 months and annually thereafter. To standardise the radiographic technique for all patients, Rinn XCP film holders (Rinn Manufacturing Company, Elgin, IL) were used. The film holder was set at an angle for the bisecting angle technique and held upright for the paralleling technique. Radiographs were later evaluated independently for root maturity, bridge formation and the periradicular status by two investigators blinded to the technique, with forced consensus in cases of disagreement.

Assessment. At the end of the follow up period the treatment was considered as a failure if one or more of the following were present: history of continuous and persistent pain, swelling, sinus tract, tenderness to percussion, and radiographic evidence of periradicular or furcal pathosis or root resorption. An additional sign of failure would be lack of continuation of root development in immature teeth as evident on radiographs.

Statistical Analysis. Before reaching a forced consensus in cases of radiographs disagreement, the inter-examiner reproducibility was calculated by Cohen's unweighted kappa statistic, it was found to be 0.89 (SD=0.042). The data were entered and tabulated into a computer using the Statistical Package for Social Science (SPSS for Windows version 14.0, SPSS Inc, Chicago, IL). Data analysis included descriptive statistics, t-tests, chi square test, and ANOVA. A probability value of ??0.05 was considered statistically significant.

Results

Nine patients with 13 treated teeth were later excluded from the study. Five failed to return for recalls at any time, two failed to return after the first recall and two received dental treatment for the teeth under investigation from the private sector, leaving 34 patients (17 males and 17 females) with 51 teeth for evaluation. The age of patients at time of restoration ranged between 6.8 to 13.3 years (mean=10.4 [+ or -] 1.8 yrs) for the CH group and 7.2 to 13.1 years (mean= 10.2 [+ or -] 1.8 yrs) for the MTA group (p= 0.77).

At the start of the study, permanent first molars with open apecies constituted 73% of the total number of teeth included. Rubber dam isolation was possible in 55% of the cases and PMC were the final restoration in 59% of carious molars. Characteristics of patients and the distribution of permanent first molars treated by partial pulpotomy using calcium hydroxide or MTA are presented in Table (1). There was no statistically significant difference in the distribution of permanent first molar teeth among the two study groups (Table 2). Excluding the failed cases for both groups, the follow-up examination period ranged from 25.4- 45.6 months with an average of 34.8 [+ or -] 4.4 months.

There was no statistically significant difference in the success rate of teeth treated with CH (91%) in comparison to teeth treated with MTA (93%). Four teeth were considered to have failed during the follow up period of the study (Table 3).

Radiographically, a hard tissue barrier under CH was noticed in 12 (55%) teeth (Figure 1) compared to 18 (64%) teeth under MTA (Figure 2). The difference was not statistically significant (p=0.4). All successfully treated teeth that had open apices at the beginning of the treatment showed continued root maturation. No signs of periradicular bone or root resorption were noted in any of the teeth. In addition, no evidence of internal root resorption or calcification was detected.

[FIGURE 1-2 OMITTED]

Discussion

In deep caries, bacteria may remain in dentinal tubules of the hard cavity floor [Langeland, 1987; Bergenholtz and Spangberg, 2004]. This is in addition to a possible minor area of pulpal necrosis that is left in contact with the dressing agent that could possibly be the major reason for indirect pulp capping failure [Langeland, 1987]. The apparent clinical success of partial pulpotomy is due to the removal of the major portion of the inflamed tissue [Langeland, 1987]. In a study on young posterior teeth, Mejare and Cvek [1993] suggested that deep carious exposures be opened up so that 1 to 3 mm of exposed pulp can be removed and the pulp can be covered with CH.

Clinical series studies of cariously exposed permanent molars treated with partial pulpotomy and dressed with CH have shown high success rates ranging from 91%- 100% over a follow up period of 8-140 months [Baratieri et al., 1989; Zilberman et al., 1989; Mass and Zilberman, 1993; Mejare and Cvek, 1993; Nosrat and Nosrat, 1998]. This is in agreement with the findings of the current study, where the success rate for molars dressed with CH was 91%.

Despite the long history of usage of CH in vital pulp therapy and the high success rate reported, some question the superiority of this dressing material. This is mainly due to the caustic effects of CH on the pulp tissue [Stanley, 2002]. In addition, CH does not adhere to dentine, lacks the ability to seal, and tunnel defects present through dentinal bridges can act as pathways for microleakage [Cox et al., 1985; Schuurs et al., 2000]. This material also has a tendency to dissolve over time [Schuurs et al., 2000].

There have been attempts to find alternative pulp dressing agents that are able to stimulate reparative dentine formation without the caustic effect of CH [Barrieshi-Nusair and Qudeimat, 2006]. Several studies have shown that MTA is biocompatible, prevents microleakage and promotes regeneration of the original tissues when placed in contact with dental pulp or periradicular tissue [Torabinejad et al., 1993; Torabinejad et al., 1995; Torabinejad et al., 1997; Fridland and Rosado, 2005; Camilleri and Pitt Ford, 2006].

The biological response to MTA has been likened to that of CH [Holland et al. 1999] and it was postulated that the mechanisms of action were similar [Holland et al. 2001]. When compared with CH, MTA has been shown to have higher success rate with less pulpal inflammation and more homogenous and complete dentine bridge formation [Ford et al., 1996; Faraco and Holland 2001; Holland et al., 2001; Aeinehchi et al., 2003; Briso et al., 2006; Chacko and Kurikose, 2006; Takita et al., 2006]. In a recent preliminary study Barrieshi-Nusair and Qudeimat [2006], using MTA as a pulp dressing agent for partially pulpotomiesd permanent molars reported a 100% success rate over 12-26 months. Other investigators failed to demonstrate any histologically significant differences between the two materials [Myers et al., 1996; Iwamoto et al., 2006]. Myers et al. [1996] concluded that both MTA and CH performed equally well as pulpcapping agents. In the present investigation, there were no statistically significant differences in the clinical success or bridge formation between the CH and MTA groups.

It has been reported that the potential for healing after pulp therapy depends on several factors such as the pulp status, the prevention of bacterial contamination during the operative procedure, the size of exposure, the sealing quality of the dressing agent and the final restoration and the efficacy of treatment strategy [Cox et al., 1985; Cox, 1992; Subay et al., 1995; Tziafas et al., 2000; Holland et al., 2001; Fong and Davis, 2002; Stanley, 2002; Bergenholtz and Spangberg, 2004; Briso et al., 2006; Silva et al., 2006].

Claimed to be critically important for the outcome of pulpcapping or partial pulpotomy procedure is the degree of pulpal bleeding upon mechanical exposure [Bergenholtz and Spangberg, 2004]. A perfuse bleeding response that is difficult to stop is likely to indicate a more or less grave inflammatory involvement of the tissue. It may be equally important that unstoppable bleeding prevents proper management of the wound site and precludes its adequate closure by the capping agent. A blood coagulum may also be susceptible to wound infection [Bergenholtz and Spangberg, 2004]. In the current study, the pulp wound was gently flushed with sterile saline until bleeding was controlled before a pulp dressing was added.

Isolation using rubber dam was not possible in all cases of the present study, either due to the inability to fit a clamp around a grossly carious molar when the second molar was not erupted or because of difficulties in gaining good access and visibility to the exposure site in some children. All cases considered to have failed were isolated with cotton rolls and salivary ejector, however, de Lourdes Rodrigues Accorinte et al. [2006] when performing direct pulp capping in human premolars concluded that CH as a pulp capping agent can be used with or without rubber dam isolation.

Barthel et al. [2000] found that as a factor of influence, the placement of a definitive restoration within the first 2 days after pulp capping of carious pulp exposures contributes significantly to the survival rate. In this investigation, a definitive restoration for three of the failed pulpotomies was provided immediately after partial pulpotomy.

Increasing age of a patient has also been reported to negatively affect clinical success of pulp therapy. Studies have shown that in older patients, the typically more fibrous dental pulp has a reduced ability to overcome insult [Fong and Davis, 2002]. The present study is in disagreement with this finding, where of all permanent first molars treated, 2 (14%) with open apecies and 2 (5%) with closed apecies failed during the course of follow up.

Despite the numerous advantages of CH, one of the biggest disadvantages is the appearance of tunnel defects in the bridges following capping procedures and thus fails to provide a hermetic seal [Chacko and Kurikose, 2006]. In comparison, the ability of MTA to induce the formation of a dentine bridge has been attributed to its superior sealing ability [Torabinejad et al. 1993; Wu et al., 1998]. However, both materials show little or no adhesion to dentine [Ford et al., 1995; Aeinehchi et al., 2003]. In this investigation, to avoid the possibility of failure due to the sealing quality of the dressing agent, both materials were covered with light cured glass ionomer cement.

In recent years, the concept of coronal leakage has taken on a life of its own in various attempts to explain endodontic treatment failures [Bergenholtz and Spangberg, 2004]. In pulp therapies, bacterial contamination through the restorations' margins should be avoided for the achievement of a successful treatment [Briso et al., 2006]. Surprisingly, two teeth in this study that were restored with PMC and cemented with Ketac-Cem, failed at 18 and 24 months. A possible explanation could be provided from the study carried out by Ettinger et al. [1998], who identified Ketac-Cem as the luting cement with the most extensive leakage when used with PMC as compared to three other cementing materials.

Moreover, in long-term clinical follow-up studies of pulp capping performed with CH, failure rates increased with increasing follow up period [Olsson et al, 2006]. In a study by Mejare and Cvek [1993] failure of partial pulpotomy was observed 48 months after treatment. In the present investigation, one tooth capped with CH showed signs of failure after 24 month and two teeth in the MTA group failed after 18 and 32 months. One possible reason for the uncertain long term prognosis is that no new hard tissue has been formed or that the newly formed hard tissue is not able to act as a functional barrier protecting the pulp against bacterial microleakage along the restoration margins [Olsson et al, 2006]. As evident in this study only 57% and 64% of the teeth in the CH and MTA groups respectively had radiographic evidence of hard tissue barrier.

Finally, although MTA is gaining popularity, there have been concerns about its cost and difficult handling characteristics [Islam et al. 2006]. It has been stated that the long setting time of MTA results in an initial looseness which can make handling rather difficult [Lee, 2000; Islam et al., 2006].

Conclusion

Calcium hydroxide is an effective pulp dressing material for partial pulpotomy in carious pulp exposures of permanent molars, and has an equal ability for inducing a hard tissue barrier. Newly developed and more expensive materials, such as MTA, have shown comparable success rate, however, more clinical research is required before MTA is used as an alternative dressing material to calcium hydroxide.

Acknowledgment

This study was supported by research funding from Jordan University of Science and Technology (Grant No. 143/2001).

References

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M.A. Qudeimat *, K.M. Barrieshi-Nusair **, A.I. Owais ***

* Dept. Developmental and Preventive Sciences, ** Dept. Restorative Sciences, Kuwait University, Kuwait; *** Dept. Preventive Dentistry, Jordan University of Science and Technology, Jordan.

Postal address: Dr. M. A. Qudeimat. Dept. Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, P.O. Box 24923, Safat- 13110, Kuwait Email: mqudeimat@hsc.edu.kw
Table 1 Characteristics of patients and the distribution of permanent
first molars treated by partial pulpotomy using calcium
hydroxide (CH) or mineral trioxide aggregate (MTA).
 [Ca(OH).sub.2] (%) MTA (%)

Teeth 23 (45) 28 (55)

Gender
Females 7 (41) 10 (59)
Males 10 (59) 7 (41)

Apex
Open 8 (35) 6 (21)
Closed 15 (65) 22 (79)

Isolation
Rubber Dam 10 (43) 18 (64)
Cotton Roll and Salivary
Ejector 13 (57) 10 (36)

Final Restoration
Amalgam 8 (35) 9 (32)
Resin 3 (13) 1 (4)
PMC 12 (52) 18 (64)

 Total (%)

Teeth 51 (100)

Gender
Females 17 (50)
Males 17 (50)

Apex
Open 14 (27)
Closed 37 (73)

Isolation
Rubber Dam 28 (55)
Cotton Roll and Salivary
Ejector 23 (45)

Final Restoration
Amalgam 17 (33)
Resin 4 (8)
PMC 30 (59)

Table 2 Distribution of permanent first molar teeth among
the two groups of permanent first molars treated by partial
pulpotomy using calcium hydroxide (CH) or mineral trioxide
aggregate (MTA).

Tooth [Ca(OH).sub.2] (%) MTA (%) Total (%)

 16 6 (26) 5 (18) 11 (22)

 26 3 (13) 6 (21) 9 (18)

 36 6 (26) 10 (36) 16 (31)

 46 8 (35) 7 (25) 15 (29)

Total 23 (100) 28(100) 51(100)

Table 3 Characteristics of failed cases in both groups of permanent
first molars treated by partial pulpotomy using calcium hydroxide (CH)
or mineral trioxide aggregate (MTA).

Group Tooth Gender Age (years)

MTA 36 Female 7.2
 16 Male 12.1

Ca[(OH).sub.2] 36 Male 6.8
 26 Male 11.7

Group Final Time until Survival Time
 Restoration final restoration (months)

MTA Amalgam Immediate 32
 PMC Immediate 18

Ca[(OH).sub.2] PMC 3 weeks 24
 Amalgam Immediate 3

Group Apex Isolation
 Method

MTA Open CR+SE
 Closed CR+SE

Ca[(OH).sub.2] Open CR+SE
 Closed CR+SE

PMC = preformed metal crown.

CR+SE = Cotton Rolls and Salivary Ejector
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Author:Qudeimat, M.A.; Barrieshi-Nusair, K.M.; Owais, A.I.
Publication:European Archives of Paediatric Dentistry
Date:Jun 1, 2007
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