Eur Arch Paediatr Dent DOI 10.1007/s40368-015-0177-9
ORIGINAL SCIENTIFIC ARTICLE
Clinical and radiographic evaluation of Portland cement added to radiopacifying agents in primary molar pulpotomies N. Lourenc¸o Neto • N. C. T. Marques • A. P. Fernandes • M. A. Hungaro Duarte • R. C. C. Abdo • M. A. A. M. Machado T. M. Oliveira
•
Received: 9 December 2014 / Accepted: 6 February 2015 Ó European Academy of Paediatric Dentistry 2015
Abstract Aim This was to evaluate the clinical and radiographic outcomes of Portland cement (PC) added to radiopacifying agents in primary molar pulpotomies. Methods Thirty primary mandibular molars of children aged between 5 and 9 years were randomly assigned to the following groups: PC; PC with iodoform (PC ? CHI3); PC with zirconium oxide (PC ? ZrO2) and treated by pulpotomy technique. Clinical and radiographic follow-up assessments were performed at 6, 12 and 24 months. Statistical analysis was performed by Fisher’s exact test (P \ 0.05). Results The clinical and radiographic evaluations showed 100 % success rates, and the results showed no statistically significant difference between groups. Conclusions According to this study, PC added to radiopacifying agents exhibited satisfactory clinical and radiographic results in primary molar pulpotomies. Keywords Deciduous tooth Pulpotomy Portland cement Iodoformium Zirconium
N. Lourenc¸o Neto N. C. T. Marques A. P. Fernandes R. C. C. Abdo M. A. A. M. Machado T. M. Oliveira (&) Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry, University of Sa˜o Paulo, Alameda Dr. Octa´vio Pinheiro Brisolla, 9-75, Bauru, Sa˜o Paulo 17012-901, Brazil e-mail: [email protected] M. A. Hungaro Duarte Department of Operative Dentistry, Endodontic and Dental, Bauru School of Dentistry, University of Sa˜o Paulo, Bauru, Brazil
Introduction Pulpotomy is one of the most frequently used treatments in vital pulp therapy, helping to maintain the integrity and avoiding the premature loss of decayed primary teeth (Sakai et al. 2009; Blanchard and Boynton 2010; Seale and Coll 2010). The success of this therapy depends on correct diagnosis of the inflamed dental pulp and biocompatible material selection (Moretti et al. 2008; Sakai et al. 2009; Oliveira et al. 2013). Properties such as adhesion, sealing ability, insolubility in tissue fluids, dimensional stability, radiopacity and biocompatibility are characteristics of an ideal endodontic material (Roberts et al. 2008; Bortoluzzi et al. 2009). However, none of the medicaments available and recommended for pulp therapy present all the requirements of an ideal pulp capping agent (Lin et al. 2014). Several studies demonstrated the similarity between mineral trioxide aggregate (MTA) and Portland cement (PC) in respect to the composition of the basic elements, antimicrobial action and biological properties (Kim et al. 2008; Hungaro Duarte et al. 2009; Parirokh and Torabinejad 2010; GomesCorne´lio et al. 2011). PC is the main chemical component of MTA, with the exception that MTA also contains bismuth oxide, which provides radiopacity (Coutinho-Filho et al. 2008). Recently, great interest has focused on PC evolution as a low-cost alternative to MTA (Sakai et al. 2009; Hungaro Duarte et al. 2012; Oliveira et al. 2013; Koc¸ak et al. 2014). Among the ideal properties of pulp capping materials, radiopacity should be sufficient to allow distinction from dentine and adjacent anatomical structures (ANSI/ADA 2000; ISO 2001). One of PC limitations is the radiopacity absence, requiring a radiopacifier addition to its composition. However, it is not known what is the best radiopacifying agent to be associated with PC. Some studies showed associations of PC with different radiopacifying agents,
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such as zirconium oxide or iodoform. Both of these radiopacifying agents have demonstrated no interference in chemical and biological properties of PC. (Hungaro Duarte et al. 2009, 2012; Camilleri et al. 2011; Cutajar et al. 2011; Gomes-Corne´lio et al. 2011). The aim of this study was to evaluate the clinical and radiographic outcome of PC when added to radiopacifying agents in primary molar pulpotomies.
Materials and methods Participants The institutional review board approved the protocol of this study (process #121/2009) regarding ethical aspects. During the pre-treatment screening period, the parents or guardians of the children received detailed information concerning the procedures involved in the study and signed informed consent forms. The inclusion criteria for tooth selection comprised mandibular primary first or second molar compromised by deep caries with vital pulp from children between 5 and 9 years with cooperative behaviour; absence of history of spontaneous pain; no clinical or radiographic evidence of fistula or abscess, absence of internal and external root resorption, inter-radicular and/or furcal bone destruction and the possibility of proper restoration of the teeth. Exclusion criteria consisted of teeth with more than 2/3 of radicular resorption, the presence of systemic pathology and history of allergic reaction to latex, local anaesthetics or to the constituents of the pulp dressing agents tested. Sample size The sample size was calculated to detect a difference of 40 % points, assuming that 100 % of success would be obtained in the control teeth based on a previous study (Sakai et al. 2009). Considering a significance level of 5 %, power of 80 %, 10 teeth per group would be necessary. Clinical procedures Thirty mandibular primary molars were selected after initial radiography. A list of numbers generated by a computer system was used to allocate the teeth into the following groups: PC, PC with iodoform (PC ? CHI3) and PC with zirconium oxide (PC ? ZrO2). Two previously calibrated paediatric dentists performed the pulpotomies with a standardised single-session protocol (Moretti et al. 2008). After inferior alveolar nerve block with 4 % articaine with 1:100,000 epinephrine and rubber dam isolation, caries removal was accomplished with a
123
handpiece with a round bur (Fernandes et al. 2014). The opening of the pulp chambers was conducted with highspeed and round carbide bur (#1014, #1015, KG Sorensen, Cotia, SP, Brazil) under water spray. Complete coronal pulp tissue was removed manually with an excavator, followed by irrigation with saline solution in order to clear the debris. The wound surface was continuously irrigated with saline solution, and a dry sterile cotton pellet was placed on the radicular pulp stumps under slight pressure for 5 min until haemostasis was achieved. All the cements used on the pulpotomies were based on PC (CAS 65997-15-1, Votorantim-Cimentos, Sa˜o Paulo, Brazil) with addition of iodoform (Biodinaˆmica Quı´mica e Farmaceˆutica LTDA, Parana´, Brazil) or zirconium oxide (Sigma-Aldrich Co., Saint Louis, USA). A ratio of 20 % radiopacifier and 80 % PC was used as a pulp dressing in primary teeth as described in previous research (Hungaro Duarte et al. 2009). In all groups, the cements were prepared using as the measure parameter one MTA kit spoon (1 g) of power to two drops (0.3 ml) of distilled water and mixed in sterilised glass to obtain a paste consistency. The materials were then placed into the pulp chambers with a spatula. Next, a layer of reinforced zinc oxide–eugenol (IRMÒ, Dentsply, Petro´polis, PR, Brazil) was placed prior to restoration with resin modified glass ionomer cement (VitremerÒ, 3M ESPE, Sa˜o Paulo, Brazil) (Moretti et al. 2008). Immediate post-operative periapical radiographs were taken to assure that the tested cements were correctly placed over the remaining radicular pulp and to serve as the initial parameter for further post-operative evaluations. Follow-up Periodic follow-up examinations were carried out at 6, 12 and 24 months after treatments (Oliveira et al. 2013). A positioner for periapical radiographs was used for standardisation as well as the same incidence of radiographs vertical and horizontal angles and exposure times. At each follow-up examination two investigators who were blinded to the identification of the medicaments used were calibrated (k = 0.96 and 0.97 for inter- and intra-examiner reproducibility, respectively) performed clinical and periapical radiographic examination of the pulpotomised teeth. Clinical success was confirmed in teeth presenting absence of spontaneous pain, mobility, swelling or fistula. Radiographic success was considered as presence of hard tissue barrier formation and pulp calcifications, and absence of internal or external root resorption and furcation radiolucency. Statistical analysis Data were submitted to statistical analysis that was performed using the statistical software Statistica 9 (StatSoft
Eur Arch Paediatr Dent Table 1 Flow diagram showing the conduct of a study of Portland cement use in pulpotomies at 6, 12 and 24 month follow-up
Inc, Tulsa, Oklahoma, USA). Inter-examiner and intraexaminer reproducibility was determined by kappa test. Fischer’s exact test was used to determine statistical significant differences between groups. P value \0.05 was considered significant.
Results A total of thirty primary molars (10 primary mandibular first molars and 20 primary mandibular second molars) from 22 children (13 males and nine females), with mean age (±SD) of 6.6 (±1.4) years, were randomly allocated to the three treatment groups. During the evaluation period, one child in the PC ? CHI3 group and another in PC ? ZrO2 group gave up on participating of the study after 12 months of follow-up. In the PC group, one tooth exfoliated after 24 months of follow-up. At 24-month follow-up, 27 teeth were available to be evaluated clinically and radiographically. In the clinical and radiographic evaluations, 100 % success rates were found for the test groups at 6-, 12- and 24-month follow-up period. No tooth presented internal resorption, inter-radicular bone destruction, mobility and fistula (Table 1). The clinical and radiographic results showed no statistically significant difference between groups. During the radiographic analysis, it was impossible to notice the radiopacity in the PC group (Fig. 1), differing from the
capping material with addition of radiopacifying agents on PC ? CHI3 and PC ? ZrO2 groups (Figs. 2, 3).
Discussion Some studies have reported that beneficial effects of MTA are also found in PC (Ribeiro et al. 2005; Morais et al. 2006; Camilleri 2010; Parirokh and Torabinejad 2010; Koc¸ak et al. 2014). However, there are few human clinical trial studies using this alternative material to MTA. The reports that use PC in conservative pulp therapy have shown considerable success in human primary teeth (Sakai et al. 2009; Oliveira et al. 2013; Petrou et al. 2014). A histological description of MTA and PC groups showed no inflammation and revealed the presence of dentine-like mineralised material deposition obliterating the root canal (Oliveira et al. 2013). These materials were capable of inducing hard tissue deposition, shown to be effective pulp capping materials. Another study reported similar clinical properties to MTA and PC in indirect pulp treatment (Petrou et al. 2014). Among the ideal properties, radiopacity is a key physical property for all endodontic materials. This property is necessary to distinguish the material from the surrounding anatomical structures, such as tooth and bone (Kim et al. 2008; Bortoluzzi et al. 2009; Hungaro Duarte et al. 2009, 2012; Camilleri 2010). An ideal material must achieve the
123
Eur Arch Paediatr Dent Fig. 1 Periapical radiographs of molar treated with PC. a Preoperative periapical radiograph. b 6 months post-operative periapical radiograph. c 12 months post-operative periapical radiograph. d 24 months post-operative periapical radiograph
Fig. 2 Periapical radiographs of molar treated with PC ? CHI3. a Pre-operative periapical radiograph. b 6 months post-operative periapical radiograph. c 12 months post-operative periapical radiograph. d 24 months post-operative periapical radiograph
minimum values of radiopacity recommended by the American National Standards Institute/American Dental Association (ANSI/ADA) Specification No. 57/2000 and by ISO 6876/2001. The addition of bismuth oxide to PC dramatically changed the material constants by acting as flaws within the cement matrix. Bismuth oxide decreases mechanical stability and increases porosity by leaving more unreacted water within the PC. Flaws in the cement matrix setting might exacerbate existing cracks, whereas greater porosity is known to increase the solubility of materials and
123
promote degradation over time, which might potentially affect its longevity (Coomaraswamy et al. 2007; Weckwerth et al. 2012). In addition, bismuth oxide is reduced to bismite and leads to coronary colour alteration (Marciano et al. 2014). Results like these have stimulated the search for an alternative radiopacifying agent to be associated with PC. The ideal radiopacifying material should be inert, free from any contaminants, nontoxic and be added in minimal amounts (Camilleri et al. 2011; Hungaro Duarte et al. 2012; Lee et al. 2013). Iodoform presents high molecular weight,
Eur Arch Paediatr Dent Fig. 3 Periapical radiographs of molar treated with PC ? ZrO2. a Pre-operative periapical radiograph. b 6 months post-operative periapical radiograph. c 12 months post-operative periapical radiograph. d 24 months post-operative periapical radiograph
biocompatibility, satisfactory radiopacity and high availability to dentists, and this has been suggested as a radiopacifying agent for PC (Morais et al. 2006). This radiopacifying agent does not affect PC properties of calcification and setting time of the cement and also has an antimicrobial action (Bortoluzzi et al. 2009). Zirconium oxide is a bioinert material with high mechanical strength, excellent resistance to corrosion and good biocompatibility (Bortoluzzi et al. 2009; Hungaro Duarte et al. 2009). Recently, studies suggests that the ratio of 20 % of zirconium oxide does not interfere with the physicochemical properties of PC or cause damage to pulp tissues in direct contact with this capping material (Hungaro Duarte et al. 2009, 2012; Gomes-Corne´lio et al. 2011). In the present study, the clinical and radiographic success rates revealed that the addiction of these radiopacifying agents did not compromise the PC biological effects as described previously (Hungaro Duarte et al. 2009, 2012; Lourenc¸o Neto et al. 2014), and it suggests the applicability of this therapeutic approach. However, further long-term follow-up studies are needed to evaluate the efficacy of PC added to radiopacifying agents.
Conclusion Portland cement when added to radiopacifying agents exhibited satisfactory clinical and radiographic results in primary molar pulpotomies. Acknowledgments The authors would like to acknowledge the financial support—FAPESP (process #2009/11284-4) and all the patients and families who helped us carry out this study. The authors
would like to thank Gentı´lia Borges Carvalho Tavares, Lilian Rosana Candida and Maria Estela Alves de Lima Ferrari for excellent assistance. This study was funded by Sao Paulo Research Foundation (FAPESP Grant Number 2009/11284-4). Conflict of interest of interest.
The authors declare that they have no conflict
Ethical standard All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
References ANSI/ADA Specification no 57—endodontic sealing material. American Dental Association. 2000. Blanchard S, Boynton J. Current pulp therapy options for primary teeth. J Mich Dent Assoc. 2010;92:40–1. Bortoluzzi EA, Guerreiro-Tanomaru JM, Tanomaru-Filho M, Duarte MA. Radiographic effect of different radiopacifiers on a potential retrograde filling material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:628–32. Camilleri J, Cutajar A, Maallia B. Hydration characteristics of zirconium oxide replaced Portland cement for use as a root-end filling material. Dent Mater. 2011;27:845–54. Camilleri J. Evaluation of the physical properties of an endodontic Portland cement incorporating alternative radiopacifiers used as root-end filling material. Int Endod J. 2010;43:231–40. Coomaraswamy KS, Lumley PJ, Hofmann MP. Effect of bismuth oxide radiopacifier content on the material properties of an endodontic Portland cement-based (MTA-like) system. J Endod. 2007;33:295–8. Coutinho-Filho T, De-Deus G, Klein L, et al. Radiopacity and histological assessment of Portland cement plus bismuth oxide. Oral Med Oral Pathol Oral Radiol Endod. 2008;106:e69–77. Cutajar A, Mallia B, Abela S, Camilleri J. Replacement of radiopacifier in mineral trioxide aggregate; characterization
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Eur Arch Paediatr Dent and determination of physical properties. Dent Mater. 2011;27:879–91. Fernandes AP, Lourenc¸o Neto N, Marques NCT, et al. Clinical and radiographic outcomes of the use of low level laser therapy in vital pulp of primary teeth. Int J Paediatr Dent. 2014. doi:10. 1111/ipd.12115. Gomes Corne´lio AL, Salles LP, Campos da Paz M, et al. Cytotoxicity of Portland cement with different radiopacifying agents: a cell death study. J Endod. 2011;37:203–10. Hungaro Duarte MA, de Oliveira El, Kadre GD, et al. Radiopacity of Portland cement associated with different radiopacifying agents. J Endod. 2009;35:737–40. Hungaro Duarte MA, Minotti PG, Rodrigues CT, et al. Effect of different radiopacifying agents on the physicochemical properties of white Portland cement and white mineral trioxide aggregate. J Endod. 2012;38:394–7. International Organization for Standardization ISO 6876. Dental root sealing materials. Geneva: Switzerland; 2001. pp. 1–10. Kim EC, Lee BC, Chang HS, et al. Evaluation of the radiopacity and cytotoxicity of Portland cements containing bismuth oxide. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:54–7. Koc¸ak S, Erten H, Baris E, Tu¨rk S, Alac¸am T. Evaluation of the biocompatibility of experimentally manufactured Portland cement: an animal study. J Clin Exp Dent. 2014;6:17–21. Lee SJ, Chung J, Na HS, et al. Characteristics of novel root-end filling material using epoxy resin and Portland cement. Clin Oral Investig. 2013;17:1009–15. Lin PY, Chen HS, Wang YH, Tu YK. Primary molar pulpotomy: a systematic reviw and network meta-analysis. J Dent. 2014;42:1060–77. Lourenc¸o Neto N, Marques NCT, Fernandes AP, et al. Biocompatibility of Portland cement associated with different radiopacifying agents. J Oral Sci. 2014;56:29–34. Marciano MA, Costa RM, Camilleri J, et al. Assessment of color stability of white mineral trioxide aggregate angelus and bismuth oxide in contact with tooth structure. J Endod. 2014;40:1235–40.
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Morais CA, Bernardineli N, Garcia RB, Duarte MA, Guerisoli DM. Evaluation of tissue response to MTA and Portland cement with iodoform. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102:417–21. Moretti AB, Sakai VT, Oliveira TM, et al. The effectiveness of mineral trioxide aggregate, calcium hydroxide and formocresol for pulpotomies in primary teeth. Int Endod J. 2008;41:547–55. Oliveira TM, Moretti ABS, Sakai VT, et al. Clinical, radiographic and histologic analysis of the effects of pulp capping materials used in pulpotomies of human primary teeth. Eur Arch Paediatr Dent. 2013;14:65–71. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review—part III: clinical applications, drawbacks, and mechanism of action. J Endod. 2010;36:400–13. Petrou MA, Alhamoi FA, Welk A, Altarabulsi M, Splieth CH. A randomized clinical trial on the use of medical Portland cement, MTA and calcium hydroxide in indirect pulp treatment. Clin Oral Investig. 2014;18:1383–9. Ribeiro DA, Hungaro Duarte MA, Matsumoto MA, Marques ME, Salvador DM. Biocompatibility in vitro tests of mineral trioxide aggregate and regular and white Portland cements. J Endod. 2005;31:605–7. Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: a review of the literature. Dent Mater. 2008;24:149–64. Sakai VT, Moretti AB, Oliveira TM, et al. Pulpotomy of human primary molars with MTA and Portland cement: a randomised controlled trial. Br Dent J. 2009;207:128–39. Seale NS, Coll JA. Vital pulp therapy for the primary dentition. Gen Dent. 2010;58:194–200. Weckwerth PH, Machado AC, Kuga MC, et al. Influence of radiopacifying agents on the solubility, pH and antimicrobial activity of Portland cement. Braz Dent J. 2012;23:515–20.
ORIGINAL SCIENTIFIC ARTICLE
Clinical and radiographic evaluation of Portland cement added to radiopacifying agents in primary molar pulpotomies N. Lourenc¸o Neto • N. C. T. Marques • A. P. Fernandes • M. A. Hungaro Duarte • R. C. C. Abdo • M. A. A. M. Machado T. M. Oliveira
•
Received: 9 December 2014 / Accepted: 6 February 2015 Ó European Academy of Paediatric Dentistry 2015
Abstract Aim This was to evaluate the clinical and radiographic outcomes of Portland cement (PC) added to radiopacifying agents in primary molar pulpotomies. Methods Thirty primary mandibular molars of children aged between 5 and 9 years were randomly assigned to the following groups: PC; PC with iodoform (PC ? CHI3); PC with zirconium oxide (PC ? ZrO2) and treated by pulpotomy technique. Clinical and radiographic follow-up assessments were performed at 6, 12 and 24 months. Statistical analysis was performed by Fisher’s exact test (P \ 0.05). Results The clinical and radiographic evaluations showed 100 % success rates, and the results showed no statistically significant difference between groups. Conclusions According to this study, PC added to radiopacifying agents exhibited satisfactory clinical and radiographic results in primary molar pulpotomies. Keywords Deciduous tooth Pulpotomy Portland cement Iodoformium Zirconium
N. Lourenc¸o Neto N. C. T. Marques A. P. Fernandes R. C. C. Abdo M. A. A. M. Machado T. M. Oliveira (&) Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry, University of Sa˜o Paulo, Alameda Dr. Octa´vio Pinheiro Brisolla, 9-75, Bauru, Sa˜o Paulo 17012-901, Brazil e-mail: [email protected] M. A. Hungaro Duarte Department of Operative Dentistry, Endodontic and Dental, Bauru School of Dentistry, University of Sa˜o Paulo, Bauru, Brazil
Introduction Pulpotomy is one of the most frequently used treatments in vital pulp therapy, helping to maintain the integrity and avoiding the premature loss of decayed primary teeth (Sakai et al. 2009; Blanchard and Boynton 2010; Seale and Coll 2010). The success of this therapy depends on correct diagnosis of the inflamed dental pulp and biocompatible material selection (Moretti et al. 2008; Sakai et al. 2009; Oliveira et al. 2013). Properties such as adhesion, sealing ability, insolubility in tissue fluids, dimensional stability, radiopacity and biocompatibility are characteristics of an ideal endodontic material (Roberts et al. 2008; Bortoluzzi et al. 2009). However, none of the medicaments available and recommended for pulp therapy present all the requirements of an ideal pulp capping agent (Lin et al. 2014). Several studies demonstrated the similarity between mineral trioxide aggregate (MTA) and Portland cement (PC) in respect to the composition of the basic elements, antimicrobial action and biological properties (Kim et al. 2008; Hungaro Duarte et al. 2009; Parirokh and Torabinejad 2010; GomesCorne´lio et al. 2011). PC is the main chemical component of MTA, with the exception that MTA also contains bismuth oxide, which provides radiopacity (Coutinho-Filho et al. 2008). Recently, great interest has focused on PC evolution as a low-cost alternative to MTA (Sakai et al. 2009; Hungaro Duarte et al. 2012; Oliveira et al. 2013; Koc¸ak et al. 2014). Among the ideal properties of pulp capping materials, radiopacity should be sufficient to allow distinction from dentine and adjacent anatomical structures (ANSI/ADA 2000; ISO 2001). One of PC limitations is the radiopacity absence, requiring a radiopacifier addition to its composition. However, it is not known what is the best radiopacifying agent to be associated with PC. Some studies showed associations of PC with different radiopacifying agents,
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such as zirconium oxide or iodoform. Both of these radiopacifying agents have demonstrated no interference in chemical and biological properties of PC. (Hungaro Duarte et al. 2009, 2012; Camilleri et al. 2011; Cutajar et al. 2011; Gomes-Corne´lio et al. 2011). The aim of this study was to evaluate the clinical and radiographic outcome of PC when added to radiopacifying agents in primary molar pulpotomies.
Materials and methods Participants The institutional review board approved the protocol of this study (process #121/2009) regarding ethical aspects. During the pre-treatment screening period, the parents or guardians of the children received detailed information concerning the procedures involved in the study and signed informed consent forms. The inclusion criteria for tooth selection comprised mandibular primary first or second molar compromised by deep caries with vital pulp from children between 5 and 9 years with cooperative behaviour; absence of history of spontaneous pain; no clinical or radiographic evidence of fistula or abscess, absence of internal and external root resorption, inter-radicular and/or furcal bone destruction and the possibility of proper restoration of the teeth. Exclusion criteria consisted of teeth with more than 2/3 of radicular resorption, the presence of systemic pathology and history of allergic reaction to latex, local anaesthetics or to the constituents of the pulp dressing agents tested. Sample size The sample size was calculated to detect a difference of 40 % points, assuming that 100 % of success would be obtained in the control teeth based on a previous study (Sakai et al. 2009). Considering a significance level of 5 %, power of 80 %, 10 teeth per group would be necessary. Clinical procedures Thirty mandibular primary molars were selected after initial radiography. A list of numbers generated by a computer system was used to allocate the teeth into the following groups: PC, PC with iodoform (PC ? CHI3) and PC with zirconium oxide (PC ? ZrO2). Two previously calibrated paediatric dentists performed the pulpotomies with a standardised single-session protocol (Moretti et al. 2008). After inferior alveolar nerve block with 4 % articaine with 1:100,000 epinephrine and rubber dam isolation, caries removal was accomplished with a
123
handpiece with a round bur (Fernandes et al. 2014). The opening of the pulp chambers was conducted with highspeed and round carbide bur (#1014, #1015, KG Sorensen, Cotia, SP, Brazil) under water spray. Complete coronal pulp tissue was removed manually with an excavator, followed by irrigation with saline solution in order to clear the debris. The wound surface was continuously irrigated with saline solution, and a dry sterile cotton pellet was placed on the radicular pulp stumps under slight pressure for 5 min until haemostasis was achieved. All the cements used on the pulpotomies were based on PC (CAS 65997-15-1, Votorantim-Cimentos, Sa˜o Paulo, Brazil) with addition of iodoform (Biodinaˆmica Quı´mica e Farmaceˆutica LTDA, Parana´, Brazil) or zirconium oxide (Sigma-Aldrich Co., Saint Louis, USA). A ratio of 20 % radiopacifier and 80 % PC was used as a pulp dressing in primary teeth as described in previous research (Hungaro Duarte et al. 2009). In all groups, the cements were prepared using as the measure parameter one MTA kit spoon (1 g) of power to two drops (0.3 ml) of distilled water and mixed in sterilised glass to obtain a paste consistency. The materials were then placed into the pulp chambers with a spatula. Next, a layer of reinforced zinc oxide–eugenol (IRMÒ, Dentsply, Petro´polis, PR, Brazil) was placed prior to restoration with resin modified glass ionomer cement (VitremerÒ, 3M ESPE, Sa˜o Paulo, Brazil) (Moretti et al. 2008). Immediate post-operative periapical radiographs were taken to assure that the tested cements were correctly placed over the remaining radicular pulp and to serve as the initial parameter for further post-operative evaluations. Follow-up Periodic follow-up examinations were carried out at 6, 12 and 24 months after treatments (Oliveira et al. 2013). A positioner for periapical radiographs was used for standardisation as well as the same incidence of radiographs vertical and horizontal angles and exposure times. At each follow-up examination two investigators who were blinded to the identification of the medicaments used were calibrated (k = 0.96 and 0.97 for inter- and intra-examiner reproducibility, respectively) performed clinical and periapical radiographic examination of the pulpotomised teeth. Clinical success was confirmed in teeth presenting absence of spontaneous pain, mobility, swelling or fistula. Radiographic success was considered as presence of hard tissue barrier formation and pulp calcifications, and absence of internal or external root resorption and furcation radiolucency. Statistical analysis Data were submitted to statistical analysis that was performed using the statistical software Statistica 9 (StatSoft
Eur Arch Paediatr Dent Table 1 Flow diagram showing the conduct of a study of Portland cement use in pulpotomies at 6, 12 and 24 month follow-up
Inc, Tulsa, Oklahoma, USA). Inter-examiner and intraexaminer reproducibility was determined by kappa test. Fischer’s exact test was used to determine statistical significant differences between groups. P value \0.05 was considered significant.
Results A total of thirty primary molars (10 primary mandibular first molars and 20 primary mandibular second molars) from 22 children (13 males and nine females), with mean age (±SD) of 6.6 (±1.4) years, were randomly allocated to the three treatment groups. During the evaluation period, one child in the PC ? CHI3 group and another in PC ? ZrO2 group gave up on participating of the study after 12 months of follow-up. In the PC group, one tooth exfoliated after 24 months of follow-up. At 24-month follow-up, 27 teeth were available to be evaluated clinically and radiographically. In the clinical and radiographic evaluations, 100 % success rates were found for the test groups at 6-, 12- and 24-month follow-up period. No tooth presented internal resorption, inter-radicular bone destruction, mobility and fistula (Table 1). The clinical and radiographic results showed no statistically significant difference between groups. During the radiographic analysis, it was impossible to notice the radiopacity in the PC group (Fig. 1), differing from the
capping material with addition of radiopacifying agents on PC ? CHI3 and PC ? ZrO2 groups (Figs. 2, 3).
Discussion Some studies have reported that beneficial effects of MTA are also found in PC (Ribeiro et al. 2005; Morais et al. 2006; Camilleri 2010; Parirokh and Torabinejad 2010; Koc¸ak et al. 2014). However, there are few human clinical trial studies using this alternative material to MTA. The reports that use PC in conservative pulp therapy have shown considerable success in human primary teeth (Sakai et al. 2009; Oliveira et al. 2013; Petrou et al. 2014). A histological description of MTA and PC groups showed no inflammation and revealed the presence of dentine-like mineralised material deposition obliterating the root canal (Oliveira et al. 2013). These materials were capable of inducing hard tissue deposition, shown to be effective pulp capping materials. Another study reported similar clinical properties to MTA and PC in indirect pulp treatment (Petrou et al. 2014). Among the ideal properties, radiopacity is a key physical property for all endodontic materials. This property is necessary to distinguish the material from the surrounding anatomical structures, such as tooth and bone (Kim et al. 2008; Bortoluzzi et al. 2009; Hungaro Duarte et al. 2009, 2012; Camilleri 2010). An ideal material must achieve the
123
Eur Arch Paediatr Dent Fig. 1 Periapical radiographs of molar treated with PC. a Preoperative periapical radiograph. b 6 months post-operative periapical radiograph. c 12 months post-operative periapical radiograph. d 24 months post-operative periapical radiograph
Fig. 2 Periapical radiographs of molar treated with PC ? CHI3. a Pre-operative periapical radiograph. b 6 months post-operative periapical radiograph. c 12 months post-operative periapical radiograph. d 24 months post-operative periapical radiograph
minimum values of radiopacity recommended by the American National Standards Institute/American Dental Association (ANSI/ADA) Specification No. 57/2000 and by ISO 6876/2001. The addition of bismuth oxide to PC dramatically changed the material constants by acting as flaws within the cement matrix. Bismuth oxide decreases mechanical stability and increases porosity by leaving more unreacted water within the PC. Flaws in the cement matrix setting might exacerbate existing cracks, whereas greater porosity is known to increase the solubility of materials and
123
promote degradation over time, which might potentially affect its longevity (Coomaraswamy et al. 2007; Weckwerth et al. 2012). In addition, bismuth oxide is reduced to bismite and leads to coronary colour alteration (Marciano et al. 2014). Results like these have stimulated the search for an alternative radiopacifying agent to be associated with PC. The ideal radiopacifying material should be inert, free from any contaminants, nontoxic and be added in minimal amounts (Camilleri et al. 2011; Hungaro Duarte et al. 2012; Lee et al. 2013). Iodoform presents high molecular weight,
Eur Arch Paediatr Dent Fig. 3 Periapical radiographs of molar treated with PC ? ZrO2. a Pre-operative periapical radiograph. b 6 months post-operative periapical radiograph. c 12 months post-operative periapical radiograph. d 24 months post-operative periapical radiograph
biocompatibility, satisfactory radiopacity and high availability to dentists, and this has been suggested as a radiopacifying agent for PC (Morais et al. 2006). This radiopacifying agent does not affect PC properties of calcification and setting time of the cement and also has an antimicrobial action (Bortoluzzi et al. 2009). Zirconium oxide is a bioinert material with high mechanical strength, excellent resistance to corrosion and good biocompatibility (Bortoluzzi et al. 2009; Hungaro Duarte et al. 2009). Recently, studies suggests that the ratio of 20 % of zirconium oxide does not interfere with the physicochemical properties of PC or cause damage to pulp tissues in direct contact with this capping material (Hungaro Duarte et al. 2009, 2012; Gomes-Corne´lio et al. 2011). In the present study, the clinical and radiographic success rates revealed that the addiction of these radiopacifying agents did not compromise the PC biological effects as described previously (Hungaro Duarte et al. 2009, 2012; Lourenc¸o Neto et al. 2014), and it suggests the applicability of this therapeutic approach. However, further long-term follow-up studies are needed to evaluate the efficacy of PC added to radiopacifying agents.
Conclusion Portland cement when added to radiopacifying agents exhibited satisfactory clinical and radiographic results in primary molar pulpotomies. Acknowledgments The authors would like to acknowledge the financial support—FAPESP (process #2009/11284-4) and all the patients and families who helped us carry out this study. The authors
would like to thank Gentı´lia Borges Carvalho Tavares, Lilian Rosana Candida and Maria Estela Alves de Lima Ferrari for excellent assistance. This study was funded by Sao Paulo Research Foundation (FAPESP Grant Number 2009/11284-4). Conflict of interest of interest.
The authors declare that they have no conflict
Ethical standard All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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