Mta

Success of Mineral Trioxide Aggregate in Pulpotomized Primary Molars

INTRODUCTION 

Pulpotomy as defined by FINN

Pulpotomy can be defined as the complete removal of the coronal portion of the dental pulp, followed by placement of a suitable dressing or medicament that will promote healing & preserve vitality of the tooth  Classification { Ranly} – Devitalization( mummification, cauterization) – Preservation ( minimal devitalization , Non inductive ) – Regeneration ( inductive , reparative )

Devitalization  Intends to destroy or mummify the vital tissue  Agents used – Formocresol – Electro surgery – Laser

Preservation  Implies maintaining the maximum vital tissue with no induction of reparative dentine (Infl. spreads progressively through the pulp & that radicular pulp has great capacity to maintain healthy function if the infected, inflamed coronal tissue is removed & an appropriate wound dressing applied)  Agents used – ZOE – Glutaraldehyde – Ferric sulphate

Regeneration  Formation of dentine bridge( Dental pulp has an inherent capacity to produce reparative dentine when the local env. is favorable -Yamunara et al)

 Agents used – – – – – –

Calcium hydroxide Emdogain ( Enamel extra cellular matrix) Bone morphogenic protein Freeze dried bone Mineral trioxide aggregate Transforming growth factor

Pulpotomy agents remain unsatisfactory  Due to several biologic reasons  FC – most popular agent for past 60 yrs ( 1st advocated by Sweet in 1930)  Concerns about safety ? – – – – –

Pulpal response with inflammation & necrosis Systemic toxicity Immunogenic response( antigenecity) Mutagenecity & carcinogenecity Permanent tooth hypoplasia

MineralTrioxideAggregate  Was approved for human usage by FDA in 1998  Introduced to clinical dentistry By Torabinejad & Chivian in 1999  Torabinejad ( 1995 ) proved MTA to be most effective in preventing bacterial leakage & stated that its antibacterial effect is comparable to that of Calcium hydroxide  Pittford et al ( 1996 ) MTA placed on mechanically exposed pulp of monkeys stimulated pulp healing with min. inflammation & dentinal bridge formation

Several potential clinical applications of MTA  Apexification( root end induction with 3-5mm thickness of MTA)  Obturating material for permanent teeth but apical seal of GP may be better than MTA ( Paul Vizigirda et al J Endo 2004)  Seal furcation perforation  Capping agent for mechanically exposed pulp  Case report: MTA used to obturate primary molar where no succedaneous  Pulpotomy agent for primary teeth

Composition & Properties  Tricalcium silicate , dicalcium silicate , Tricalcium aluminate , calcium sulfate dehydrate , bismuth oxide & tetra calcium aluminoferrite  Consists of fine hydrophilic particles that set in the presence of moisture. Hydration of the powder results in a colloidal gel that solidifies to a hard structure in less than 4 min  PH 12.5  CS 70 Mpa  Inductive effect on cementoblasts ( root end filling)  Biocompatible & Low cytotoxicity  Superior sealing ability  Ability to set in presence of blood  Bactericidal  Schmitt et al 2001 reported PRO ROOT ( TULSA DENTAL ) which can be placed in tooth with Tulsa carrier, amalgam carrier, Messing gun , or hand instrument

 MTA possess new exciting potential for pulp therapy in pediatric dentistry  AIM : clinically and radiographically determine effects of MTA as pulpotomy agent & compare with Formocresol  Long term evaluation

Materials & methods  100 children selected randomly 3 –8 yrs  120 teeth ,coronal pulp amputated with conventional pulpotomy tech & divided into 2 groups ( I- MTA , II- FC )  Criteria for tooth selection: – Exposed vital tooth without signs & symptoms of

acute infl ( NO H/o nocturnal pain) – NO C/R evidence of pulp degeneration ( Excess bleeding from RC, int. root resorption, interradicular / periapical bone destruction, swelling/ sinus tract – Restorable tooth

Technique    

L.A Rubber dam application Caries removal, coronal access to de-roof the chamber Complete removal of coronal pulp, hemostasis obtained using damp sterile cotton pellet  Experimental group- pulp stump covered with MTA ( 3:1 powder/saline ratio)  Control group-squeezed cotton pellet moistened with Formocresol placed for 5 min on pulp stump  Then covered by ZOE paste, IRM placed prior to

restoration with SSC

Follow up  Clinical & radiographic evaluation every 6 months upto period of 2 years  Failure : – Internal root resorption – Furcation radiolucency – Periapical bone destruction – Pain,swelling,sinus tract

 Pulp canal obliteration not regarded as failure

Results  Only 74/120 teeth were assessed upto 24 months  First 12 mo, no C/R pathosis recorded in either group  18 mo, 4/38 FC treated showed R pathosis no C symptoms of failure , none of MTA treated showed C/R failure ( NO statistical difference)  24 mo, 5 FC cases showed pulp pathosis, 1 reported pain ; all MTA cases showed C/R success. ( Statistically significant )

Review of literature  C/R studies demonstrated success rate of FC range from 70-97% ( Berger1965, Fuks & Bimstein 1981 , Morown et al 1975,rolling & Thylstrup 1975 )  Effectiveness judged by histological criteria, method can not be considered ideal coz it does not promote pulp healing ( Magnusson 1978 )

 Eidelman et al 2001 compared the effect of MTA to Fc as pulp dressing agent in 45 pulpotomized M ( C/R evaluation 6-30 Mo).MTA showed 100 % success ( No int. resorption). PCO was found in 7/41 cases not regarded as failure.concluded that MTA has promising potential to become replacement of FC in primary teeth.

 Hadeer A.Agamy et al 2004 conducted 12 Mo postoperative evaluation (C/R/H) to compare the success of gray MTA, White MTA & Fc as pulpotomy agents.C/R success were similar with both gray & white MTA which was better than FC.Histologically gray MTA was better than White and concluded that gray MTA is superior to white MTA |& Fc as pulp dressing for pulpotomized primary teeth.

 Naik .S & Hegde A.H 2005 conducted a study to evaluate the clinical efficacy of MTA as pulpotomy agent on Primary molars & found the promising 100% success rate at 6 Mo evaluation( C/R).No dentine bridge formation observed .discoloration of crown was observed with MTA which was masked by SSC.concluded MTA to be superior pulpotomy medicament over Fc.

DISCUSSION  Present study also showed perfect success rate with MTA throughout 24 Mo.  Though Fc has been a gold standard, according to Block it should not be brought in contact with human tissue.  MTA placed directly on pulp tissue reduces the risk of subsequent inflammation.  ZOE can cause pulpal inflammation & subsequent int. resorption in Fc treated cases while MTA separates pulp from the irritating effects of ZOE( possible reason for lack of int. resorption)  PCO/ calcific metamorphosis is the result of odontoblastic activity & suggests that tooth retains vitality hence not regarded as Failure.

 Dentine bridge formation( release of cytokines which stimulate bone cell proliferation and mature osteoblast activity).preserves odontoblastic layer and delicate fibro cellular matrix with reparative dentine formation.  Less cytotoxic, non mutagenic  Biocompatible material material which prevents micro leakage as well.  Less time for the procedure  Increased cost & less availability to be noted.  Mix gets messy if excess moisture present.so all irrigation to be done before MTA placement.

CONCLUSION  Based on all the evidences, we conclude that MTA can be used as a safe medicament for pulptomy in cariously exposed vital primary teeth and could be a promising alternative for formocresol