mta sebagai alternatif psa
TRANSCRIPT
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MTA pulpotomy as an alternative to
root canal
treatment in children’s permanent teeth in a dental
public health setting
Hend E. Alqaderia, Sabiha A. Al-Mutawa a, Muawia A. Qudeimat b,* aOral
Health
Services,
Ministry
of
Health,
KuwaitbDepartment
of
Developmental
and
Preventive
Sciences,
Kuwait
University,
Kuwait
1. Introduction
The dental pulp is an integral element of tooth structure. A
vital pulp tissue is responsible for supporting the tooth
structure
through
reparative
dentine
production.
Preserving
pulp vitality is essential in maintaining vascularization and
nutrition to the tooth that eventually will support tooth
structure and reduce teeth mortality.
j o u rna l o f d en t i s t r y 4 2 ( 2 0 1 4 ) 1 3 9 0 – 1 3 9 5
a r t i c l e i n f o
Article history:
Received 6 March 2014
Received in revised form
17 June 2014
Accepted 18 June 2014
Keywords:
MTA
Pulpotomy
Carious exposurePermanent teeth
Children
a b s t r a c t
Objective: This prospective clinical study evaluated the success of vital pulpotomy treat-
ment for permanent teeth with closed apices using mineral trioxide aggregates (MTA) in a
dental public health setting.
Methods: Twenty-seven mature permanent first molars and 2 premolars (in 25 patients)
with carious exposure were treated using MTA pulpotomy. Age of patients ranged from
10- to 15-years (mean= 13.2 1.74-years). Four trained and calibrated practitioners per-
formed the same clinical procedure for all patients. Following isolation and caries removal,
the inflamed pulp tissue was completely removed from the pulp chamber. This was
followed by irrigation with 2% sodium hypochlorite. Haemostasis was achieved using a
cotton pellet damped in normal saline. A white MTA paste was placed against the pulp
orifices. MTA was covered with a damped cotton pellet and a base of IRM. Patients wererecalled after
1 day where a glass ionomer liner and a final restoration were placed. Teeth
were evaluated clinically and radiographically for up to 47 months.
Results: Mean follow-up period for all teeth was 25 14 months. Twenty-six of the 29 teeth
were clinically asymptomatic with no evidence of periradicular or root pathology during
the follow-up period. The estimated success rate was 90%. Three teeth presented with
clinical symptoms of pain and radiographic evidence of periradicular pathology that
indicated root canal treatment (RCT) or extraction.
Conclusion: When managing carious pulp exposures of permanent teeth with closed root
apices in children, MTA pulpotomy showed a high success rate.
Clinical significance: MTApulpotomyforpermanentmolars in children is a viablealternative
to RCT.
#
2014 Elsevier Ltd.
All rights reserved.
* Correspondingauthorat: Departmentof Developmental andPreventiveSciences, Facultyof Dentistry,Kuwait University, P.O. Box24923,
Safat 13110, Kuwait. Tel.: +965 2463 6747; fax: +965 25326 049.
E-mail address: [email protected] (M.A. Qudeimat).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.intl.elsevierhealth.com/journals/jden
http://dx.doi.org/10.1016/j.jdent.2014.06.007
0300-5712/# 2014 Elsevier Ltd. All rights reserved.
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Root
canal
treatment
for
permanent
teeth
in
children
is
a
complex procedure requiring lengthy appointments and
multiple visits and often requires a full coverage restoration.
On the other hand, vital pulpotomy requires shorter appoint-
ments and usually can be accomplished in one visit. Also,
while an endodontist is usually required to perform RCT, a
paediatric
dentist
or
a
general
dental
practitioner
can
perform
vital pulpotomy for permanent teeth. By providing analternative to the progressive conventional RCT in children,
vital pulp therapy can help retain vital permanent teeth that
are
able
to
withstand
normal
functions.
In
a
recently
published
systematic
review,
authors
concluded
that
vital
pulp therapy should be considered as an alternative treat-
ment to RCT in vital permanent teeth with carious exposed
pulp.1 They also stated that there is a need forfurther studies
in vital pulp therapy, as the current evidence provides
inconclusive
information
regarding
factors
influencing
treat-
ment
outcomes.1
In Kuwait, the total number of children and adolescents
aged 5–19 years is 378,365.2 In this age group, 95,743
permanent tooth canal received RCT between 2007 and 2012in
the
School
Oral
Health
Programme
(SOHP)-Ministry
of
Health. In such a dental public health setting, substituting RCT
with vital pulp therapy can decrease the number of patients
receiving RCT, and consequently, the cost of treatment.
Currently,
mineral
trioxide
aggregates
(MTA)
is
accepted
as
an optimum material for use in vital pulp therapy of
permanent
teeth.3,4 MTA
clinical
outcome
is
reported
to
be
due mainly to its long-term sealing ability and the stimulation
of a high quality and a great amount of reparative dentin.3,5 In
human clinical trials carried out on cariously exposed
permanent
teeth,
the
success
rate
of
vital
pulp
therapy
using MTA was considered to be high and ranged from 93 to
100%.6–12 However, there is a limited number of studiesreporting on the success of vital pulpotomy for mature
permanent
teeth
in
children
and
adolescents
using
MTA.8,10,12 It was therefore the objective of the current study
to investigate the success of vital pulp therapy for mature
permanent teeth using MTA as an alternative to conventional
RCT in children and adolescents in a dental public health
setting.
2.
Materials
and
methods
This
prospective study
was
conducted
at the
School
Oral
HealthProgramme Clinics-Ministry of Health,Kuwait. Ethicalapproval was obtained from Health Sciences Ethical Clear-
ance Committee-Kuwait University. Prior to examination,
consents were taken from parents of all participating
children.
To
be
considered
for
this
study,
patients
were
required
to
be
medically
healthy,
have
a
restorable
mature
permanent
molar or premolar with deep caries and a diagnosis of
reversible pulpitis. Exclusion criteria included patients with
history of severe pain, history of swelling or a fistula
associated
with
the
tooth,
tenderness
on
percussion
or
palpation, pathologic mobility, or an abnormal response to
cold testing (Endo-Ice, Hygenic Corp, Akron, OH). Radio-
graphic inclusion criteria included: teeth with closed apecies
and
the
absence of
radiographically visible periradicular
pathologies. Clinically,teeth with hyperaemicpulpthat could
not be controlled within 5 min were also excluded from the
study. One investigator (with 7-years clinical experience in
treating pulpally affected primary and permanent teeth in
children) trained and calibrated three clinicians for this
study.
Four clinicians carried out diagnosis
and treatment
for all cases.
2.1. Treatment procedure
After
anaesthetizing
and
isolating
the
tooth
using
a
rubber
dam,
caries was removed using a large round, low-speed carbide bur
(Gebr.Brasseler1, Germany). Patients treated with indirect or
direct pulp capping, partial pulpotomy or RCT were excluded
from the study. The treatment decision was made based on the
extent
of
inflammation
in
the
coronal
pulp
and
the
bleeding
time; bleeding
that
stopped
within
few
minutes
indicated
a
healthy status of the remaining pulp in the canals.13 Each
patient received two dental visits in order to complete the
procedure. During the first visit, the standard pulpotomyprocedure
was
performed,
removing
the
infected
coronal
pulp
tissue to the level of the floor of the pulp chamber and orifices by
using a high-speed diamond bur (Gebr.Brasseler1, Germany)
with copious sterile water. A sterile cotton pellet damped in
normal
saline
was
used
to
control
the
bleeding.
A
layer
of
white
MTA (Pro Root1 MTA, Dentsply, Tulsa Dental, USA) paste,
prepared
by
mixing
MTA
powder
with
sterile
saline following
the manufacturer’s instructions was placed on the root canal
orifices. The MTA was condensed lightly with a moistened
sterile cotton pellet to achieve a 2–4-mm thickness. A damped
cotton
pellet
was
then
covered
with
a
temporary
filling
intermediate restorative material (IRM1, type III, Class 1 Caulk
Dentsply, USA). The patients returned the following day for asecond visit to complete the definitive restoration. In the second
visit,
the
cotton
pellet
and
IRM1 were
removed
and
the
MTA
was checked for hardening. Teeth were restored with a layer of
light cure glass ionomer liner (VitrebondTM, 3MTMESPETM, USA),
and incremental layers of composite restoration (Herculite1
XRV UltraTM, Kerr Italia, Italy) were applied and cured according
to the manufacturer’s instructions. Stainless steel crowns
(UnitekTM,
3MTM ESPETM,
USA)
were
used
over
the
composite
when more than two walls of the tooth were damaged. All
patients were instructed to call or return to the clinic if pain or
discomfort occurred, and in this case, symptoms were assessed
and
appropriate
treatment
provided.
All patients were scheduled for routine clinical andradiographic evaluations as per the SOHP guidelines. At each
follow-up visit, the treated tooth was examined for the
following adverse events: pain, swelling, sinus tract forma-
tion, tenderness on percussion or palpation, and radiographic
evidence
of
periradicular
or
furcal
pathology,
or
root
resorp-
tion.
Pulp
therapy
was
considered
successful
if
none
of
the
previous symptoms were present. Also, the quality of the
restoration was checked and the restoration was repaired if
deemed necessary. An examiner who was not involved in the
treatment
phase
of
this
study
evaluated
all
the
pre
and
post
treatment radiographs at the end of the study. The examiner
was blinded to the names of participant and dates of all
radiographs.
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3. Results
Two patients with two treated teeth did not return for recall
visits, leaving 25 patients with 29 tooth for evaluation.
Twenty-seven of the teeth were permanent first molars and
two
were
first
premolars.
Although
many
patients
failed
to
return for regular follow up appointments at scheduled times,all of the cases were available for clinical and radiographic
examination at the closing date of the study. The follow up
evaluation
period
ranged
from
1
to
47
months
with
an
average
of
25
14
months.
Table
1
summarizes
the
characteristics
of
patients, distribution of teeth, clinical and radiographic
findings at the initial visit, the follow up period and fate of
all teeth included in this study. Treatment was considered
successful for 26 teeth (90%). One of the cases that failed
presented
after
one
month
of
pulpotomy
with
severe
pain
and
tenderness
to
touch.
The
second
failed
case
received
RCT
outside the SOHP and at the time of scheduled follow up
appointment the parent and child had no recollection of the
timing of the treatment. The third case failed at 47 months.The
child
presented
with
her
mother
complaining
of
pain
and
after clinical and radiographic assessment a decision was
made to extract the tooth.
Radiographically, no signs of periradicular bone or root
resorption
were
noted
in
any
of
the
successfully
treated
teeth.
Also, no evidence of internal root resorption or pulp canal
calcifications
were
detected
on
radiographs.
A
radiographic
hard
tissue
bridge
underneath
the
MTA
layer
was
observed
in
10 cases (34%).
4. Discussion
Clinically,
a
principal
challenge
faced
by
most
paediatric
dentists, endodontists or general dentists with special interestin treating children is the treatment of pulpally involved and
abscessed teeth in a young patient. This is mainly due to
factors
related
to
patient’s
cooperation,
the
total
number
of
visits
required
to
finish
the
treatment
and
the
cost
of
treatment. This is further complicated by disagreement on
treatment protocols and outcomes among clinicians, which is
often based on little or no documented evidence.14
It has long been known that healthy dental pulp cells have
the
potential
to
develop
into
odontoblasts.15 This
allows
pulp
tissue
to
regenerate
and
repair.15,16 Authors
suggested
that
aged pulp retains the ability to create dentine but at a
diminished rate.17,18 They also concluded that younger pulps
had a better likelihood of potential tissue healing andregeneration.17,18 An
explanation
for
this
could
be
provided
from a recent review on dental pulp stem cells where the
authors demonstrated that ageing was related to reduction of
pulpal cell populations leading to compromised pulpal wound
healing
and
regeneration
with
increasing
age.19
Recent studies have shown high success rates for vital pulp
therapy
in
maintaining
the
vitality
of
dental
pulp
tissues
in
Table 1 – Distribution and fate of 29 teeth that were cariously exposed and treated by pulpotomy using MTA.
Case
number
Gender
Tooth
Age
at
treatment
(years)
Follow-up
time (months)
Final
restoration
Fate
1 F 36 13.1 47 Composite Successful
2 F 36 13 45 Composite Successful
3 F 36 11.5 43 Composite and SSC Successful
4 F 36 13.8 36 Composite Successful
5 F 46 15.4 33 Composite Successful
6 F 36 13 41 Composite Successful
7 F 46 11.8 47 Composite Failure
8 M 46 13 40 Composite Successful
9 F 36 12 22 Composite Successful
10 F 36 14.6 17 Composite Successful
11 M 16 15.1 3 Composite Successful
26 15.1 3 Composite Successful
12 M 26 15.1 21 Composite Successful
16
15.1 21 Composite Successful13 M 36 14.4 24 Composite Successful
14 M 24 14.1 21 Composite Successful
15 M 16 12.2 21 Composite Successful
26
12.2 21 Composite Successful
16 F 14 10.9 21 Composite Successful
17 M 16 14.3 21 Composite Successful
18 F 16 13.7 21 Composite Successful
19 F 16 13.2 38 Composite Successful
20 M 26 14.1 14 Composite Successful
21 F 46 10 5 Composite Successful
22 F 46 11 6 Composite Successful
23 F 26 14.3 41 Composite Successful
24 F 16 14.3 1 Composite Failure
46
11 24 Composite Successful
25 F 36 15.3 Unknown Composite Failure
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young
permanent
teeth
with
open
root
apices.6,7,9,20 On
the
other hand, for teeth with closed root apices, the best
treatment option under similar pulpal conditions is RCT.
Ricucci et al.14 in a recent 5-year prospective study reported on
an overall success rate of 89% for conventional RCT in
816 tooth. However, endodontic treatment for mature molar
teeth
has
been
reported
to
increase
the
incidence
of
tooth
fractures.21 This is usually due to the loss of tooth structureand induced stresses caused by endodontic and restorative
procedures which will eventually weaken the tooth and
make
it
more
susceptible
to
fracture.21Therefore,
maintaining
tooth
vitality
enhances
dentinal
root
deposition
and
results
in stronger root structure.
The aim of vital pulpotomy in permanent teeth in children
is to treat reversible pulpal injuries and to maintain radicular
pulp vitality and function and therefore maintain the tooth in
a
viable
condition.
Few
studies
have
reported
on
the
outcome
of
pulpotomy
for
cariously
exposed
pulps
in
permanent
teeth
with closed apices.10,12 Barngkgei et al.12 evaluated the clinical
and radiographic outcome of pulpotomy treatment with MTA
in symptomatic mature permanent teeth with cariousexposures
in
adults
(mean
age
29
years).
The
authors
reported
on a 100% success rate. The final restoration was either
polycarboxylate cement and amalgam restoration or full
coverage crown.12 However, the sample size was small
(10
patients
with
11
teeth)
of
which
5
teeth
were
molars,
5 premolars and 1 central incisor. In the current study, the
success
rate
was
90%.
The
majority
of
the
treated
teeth
were
molars (27) and two teeth were premolars. Also, the mean age
of patients in this study was 13 years.
The selection of the pulp cap material is a significant factor
in
the
success
of
any
vital
pulp
therapy.9,22 In
this
study,
white-MTA was used for pulp capping after pulpotomy
because of its favourable sealing ability, biocompatibility,dentinogenic activity and its clinical encouraging out-
comes.6,7,9–12,22–25 In
applying
MTA
as
a
pulp
cap
material,
it
is postulated that MTA will provide an impenetrable barrier
against any future bacterial leakage into the vital pulpal
canals.25 This will help in maintaining an intact remaining
vital pulp that could heal and regenerate additional dentinal
root tissues, resulting in more supportive tooth structure.25
Recent
clinical
studies
on
direct
pulp
capping
and
partial
pulpotomy in treating cariously exposed permanent teeth
have supported the concept that dental pulp has the ability to
remain vital after removing infected pulp tissue.6,7,9–12,26–28 In
the
current
study,
after
the
removal
of
the
infected
coronal
pulp tissue and sealing the remaining pulpal canal with MTA,the pulp tissue healed and maintained vitality in 90% of the
teeth during the follow up period. In a previous randomized
clinical study, investigators compared the clinical and
radiographic outcomes of pulpotomy in permanent molars
with
irreversible
pulpitis
using
calcium
enriched
mixture
cement
(CEM)
with
those
treated
with
MTA.10 The
sample
had
an average age of 27
8 years and molars were mature. After a
short follow up period of 12 months, the clinical and
radiographic success rates for the MTA and CEM groups were
98%
and
95%,
respectively.10
Although one advantage for using white MTA in this study
was to reduce the treated tooth’s discolouration potential,
there have been recent reports suggesting that when in
contact
with
sodium
hypochlorite
solution,
white
MTA
can
cause discolouration.29 When the teeth are restored with
stainless steel crowns, this does not seem to represent an
aesthetic problem.30 In this investigation, white MTA wasused
in all cases and 28 teeth received resin restorations. However,
discolouration of treated molars was not investigated. There is
a
possibility
that
for
failed
cases
in
this
study,
the
colour
of
the
tooth was part of the assessment criteria upon which dentistsbased their diagnosis of irreversible pulpitis or a non-vital
tooth. Therefore, it is imperative that parents and dentists are
educated
about
the
possibility
of
teeth
colour
changes
with
the
use
of
MTA
in
vital
pulpotomy.
The experience of root canal associated pain is a major
source of fear for patients and a very important concern of
dentists.31 Oginni and Udoye32 documented that 18% of the
patients who received a single visit RCT reported pain 30 days
postoperatively.
In
a
recent
systematic
review,
it
was
concluded
that
14%
of
patients
receiving
RCT
would
have
postoperative pain 1 week after treatment.31 However, in the
current study and except for the three failed cases, the parents
of participants reported either immediate relive of pain or nopostoperative
flare-ups.
This
is
supported
by
a
study
that
compared the mean pain intensity and pain in response to
percussion tests between a single visit RCT and pulpotomy
for permanent teeth with irreversible pulpitis. Over 7 days
observation
period,
patients
in
the
RCT
group
experienced
statistically significantly more pain than those in the
pulpotomy
group.33
Posterior resin composite restorations placed in children
and adolescents demonstrated good durability and low
annual failure rate.34–36 However, deteriorating surface
restoration
leading
to
bacterial
leakage
is
the
likely
reason
for the increasing failure rate of pulp therapy observed in
clinical follow-ups carried out over long periods of time.37,38
This could lead to marginal bacterial leakage into the
remaining
vital pulp tissue
and can consequently compro-
mise healing, resulting in pulpal necrosis.39 It has been
reported that the most effective restorative materials to
prevent bacterial microleakage and pulp injury from
inflammatory activity were high viscosity glass ionomer,40
resin-modified glass ionomer, bonded amalgam,41 resin
restorations41 and
stainless steel
crowns.6,9 However, the
frequency of bacterial microleakage related to resin com-
posites was found to be 20%.41 This could have been a
possible reason for the failure of the three cases seen in this
study,
especially
that
most
of
the
teeth
in
this
study
required
large restorations.It has been stated that non-vital immature teeth, due to
fragile roots, are more prone to fracture than mature teeth.42,43
Root fractures commonly occur in the cervical third of teeth
that receive apexification treatment.42 For immature end-
odontically
treated
teeth,
it
was
found
that
the
frequency
of
cervical
fractures
ranged
between
28
and
77%
depending
on
the stage of tooth development.44 Studies thus far have not
investigated the frequency of cervical fractures following vital
pulpotomy using MTA in permanent posterior teeth. However,
over
the
follow-up
period
of
this
study,
none
of
the
treated
teeth suffered cervical root fractures.
Limitations of the present study include: (1) the small
experimental sample size, (2) more than one clinician
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performed the diagnosis and treatment procedure, (3) the
relatively short period of follow-up after treatment, in
particular, cases that were followed up for less than 6
months. In this respect, it is important to understand that
the assumption that the effect of different factors (e.g.
operator’s determination of the diagnosis and the quality of
the restoration) in clinical trials remains the same over
time should be routinely checked,35 (4) the inability toperform EPT pulp testing in our public health setting on a
regular basis, and (5) the poor compliance of patients with
routine follow-up appointments. Moreover, to ascertain
the success of pulpotomy as an alternative to RCT, a
randomized control trial is highly recommended to deter-
mine the long-term outcomes and cost effectiveness of
both pulpotomy and RCT.
5. Conclusion
Vital pulpotomy treatment can be used successfully as an
alternative to root canal treatment in the management of carious pulp exposure for fully erupted mature teeth in
children to maintain pulp vitality and provide strength that
supports tooth structure. By validating this new, less
invasive approach, vital pulpotomy has great potential to
further improve patient’s dental care.
Acknowledgments
This study was supported by School Oral Health Program,
Ministry of Health, Kuwait. We would like to thank
Hawally & Mubarak Alkabeer SOHP’s staff who took the
time and effort to contribute to the research.
r
e
f
e
r
e
n
c
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