journal of dentistry 42 (2014) 1390–1395
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.intl.elsevierhealth.com/journals/jden
MTA pulpotomy as an alternative to root canal treatment in children’s permanent teeth in a dental public health setting Hend E. Alqaderi a, Sabiha A. Al-Mutawa a, Muawia A. Qudeimat b,* a b
Oral Health Services, Ministry of Health, Kuwait Department of Developmental and Preventive Sciences, Kuwait University, Kuwait
article info
abstract
Article history:
Objective: This prospective clinical study evaluated the success of vital pulpotomy treat-
Received 6 March 2014
ment for permanent teeth with closed apices using mineral trioxide aggregates (MTA) in a
Received in revised form
dental public health setting.
17 June 2014
Methods: Twenty-seven mature permanent first molars and 2 premolars (in 25 patients)
Accepted 18 June 2014
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 performed the same clinical procedure for all patients. Following isolation and caries removal,
Keywords:
the inflamed pulp tissue was completely removed from the pulp chamber. This was
MTA
followed by irrigation with 2% sodium hypochlorite. Haemostasis was achieved using a
Pulpotomy
cotton pellet damped in normal saline. A white MTA paste was placed against the pulp
Carious exposure
orifices. MTA was covered with a damped cotton pellet and a base of IRM. Patients were
Permanent teeth
recalled after 1 day where a glass ionomer liner and a final restoration were placed. Teeth
Children
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: MTA pulpotomy for permanent molars in children is a viable alternative to RCT. # 2014 Elsevier Ltd. All rights reserved.
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.
* Corresponding author at: Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait. Tel.: +965 2463 6747; fax: +965 25326 049. E-mail address: [email protected] (M.A. Qudeimat). http://dx.doi.org/10.1016/j.jdent.2014.06.007 0300-5712/# 2014 Elsevier Ltd. All rights reserved.
journal of dentistry 42 (2014) 1390–1395
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 appointments 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 an alternative 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 treatment to RCT in vital permanent teeth with carious exposed pulp.1 They also stated that there is a need for further studies in vital pulp therapy, as the current evidence provides inconclusive information regarding factors influencing treatment 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 2012 in 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 studies reporting 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 Health Programme Clinics-Ministry of Health, Kuwait. Ethical approval was obtained from Health Sciences Ethical Clearance 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). Radiographic inclusion criteria included: teeth with closed apecies
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and the absence of radiographically visible periradicular pathologies. Clinically, teeth with hyperaemic pulp that 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 pulpotomy procedure 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 a second 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, 3MTM ESPETM, 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 and radiographic 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 formation, tenderness on percussion or palpation, and radiographic evidence of periradicular or furcal pathology, or root resorption. 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.
journal of dentistry 42 (2014) 1390–1395
hard tissue bridge underneath the MTA layer was observed in 10 cases (34%).
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
4.
Discussion
Clinically, a principal challenge faced by most paediatric dentists, endodontists or general dentists with special interest in 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 and regeneration.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
1 2 3 4 5 6 7 8 9 10 11
F F F F F F F M F F M
12
M
13 14 15
M M M
16 17 18 19 20 21 22 23 24
F M F F M F F F F
25
F
Tooth
Age at treatment (years)
36 36 36 36 46 36 46 46 36 36 16 26 26 16 36 24 16 26 14 16 16 16 26 46 46 26 16 46 36
13.1 13 11.5 13.8 15.4 13 11.8 13 12 14.6 15.1 15.1 15.1 15.1 14.4 14.1 12.2 12.2 10.9 14.3 13.7 13.2 14.1 10 11 14.3 14.3 11 15.3
Follow-up time (months)
Final restoration
Fate
47 45 43 36 33 41 47 40 22 17 3 3 21 21 24 21 21 21 21 21 21 38 14 5 6 41 1 24 Unknown
Composite Composite Composite and SSC Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite
Successful Successful Successful Successful Successful Successful Failure Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Failure Successful Failure
journal of dentistry 42 (2014) 1390–1395
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 structure and induced stresses caused by endodontic and restorative procedures which will eventually weaken the tooth and make it more susceptible to fracture.21 Therefore, 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 carious exposures 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 outcomes.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
1393
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 was used 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 dentists based 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 no postoperative 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 compromise 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 composites 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 endodontically 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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journal of dentistry 42 (2014) 1390–1395
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 to perform 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 determine the long-term outcomes and cost effectiveness of both pulpotomy and RCT.
8.
9.
10.
11.
12.
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.
13. 14.
15.
16. 17.
18.
references
1. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review. Journal of Endodontics 2011;37:581–7. 2. Annual Statistical Abstract 2011. Population. Kuwait Central Statistical Bureau. 2011. [Chapter 3]. 3. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives—permanent teeth. Journal of Endodontics 2008;34:S25–8. 4. Bakland LK, Andreasen JO. Will mineral trioxide aggregate replace calcium hydroxide in treating pulpal and periodontal healing complications subsequent to dental trauma? A review. Dental Traumatology 2012;28: 25–32. 5. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review—Part III: clinical applications, drawbacks, and mechanism of action. Journal of Endodontics 2010;36:400–13. 6. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth. Journal of Endodontics 2006;32:731–5. 7. El-Meligy OA, Avery DR. Comparison of mineral trioxide aggregate and calcium hydroxide as pulpotomy agents in
19.
20.
21.
22.
23.
24.
young permanent teeth (apexogenesis). Pediatric Dentistry 2006;28:399–404. Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp management for caries in adults: maintaining pulp vitality. The Cochrane Database of Systematic Reviews 2007; 18. [CD004484]. Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries. European Archives of Paediatric Dentistry 2007;8:99–104. Asgary S, Eghbal MJ. Treatment outcomes of pulpotomy in permanent molars with irreversible pulpitis using biomaterials: a multi-center randomized controlled trial. Acta Odontologica Scandinavica 2013;71:130–6. Ghoddusi J, Shahrami F, Alizadeh M, Kianoush K, Forghani M. Clinical and radiographic evaluation of vital pulp therapy in open apex teeth with MTA and ZOE. New York State Dental Journal 2012;78:34–8. Barngkgei IH, Halboub ES, Alboni RS. Pulpotomy of symptomatic permanent teeth with carious exposure using mineral trioxide aggregate. Iranian Endodontic Journal 2013;8:65–8. Duncan HF, Nair PNR, Pitt Ford TR. Vital pulp treatment: a review. Endo 2008;2:247–58. Ricucci D, Russo J, Rutberg M, Burleson JA, Spa˚ngberg LS. A prospective cohort study of endodontic treatments of 1,369 root canals: results after 5 years. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 2011;112:825–42. Huang GT. A paradigm shift in endodontic management of immature teeth: conservation of stem cells for regeneration. Journal of Dentistry 2008;36:379–86. Tziafas D. The future role of a molecular approach to pulpdentinal regeneration. Caries Research 2004;38:314–20. Matsuzaka K, Muramatsu T, Katakura A, Ishihara K, Hashimoto S, Yoshinari M, et al. Changes in the homeostatic mechanism of dental pulp with age: expression of the corebinding factor alpha-1, dentin sialoprotein, vascular endothelial growth factor, and heat shock protein 27 messenger RNAs. Journal of Endodontics 2008;34:818–21. Holland GR, Torabinejad M. The dental pulp and periradicular tissues. In: Torabinejad M, Walton RE, editors. Endodontics: principles and practice. 4th ed. St. Louis, Missouri: Saunders Elsevier; 2009. p. 1–20. Sloan AJ, Waddington RJ. Dental pulp stem cells: what, where, how? International Journal of Paediatric Dentistry 2009;19:61–70. Nosrat A, Seifi A, Asgary S. Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial. International Journal of Paediatric Dentistry 2013;23:56–63. Tang W, Wu Y, Smales RJ. Identifying and reducing risks for potential fractures in endodontically treated teeth. Journal of Endodontics 2010;36:609–17. Tomson PL, Grover LM, Lumley PJ, Sloan AJ, Smith AJ, Cooper PR. Dissolution of bio-active dentine matrix components by mineral trioxide aggregate. Journal of Dentistry 2007;35:636–42. Karabucak B, Li D, Lim J, Iqbal M. Vital pulp therapy with mineral trioxide aggregate. Dental Traumatology 2005; 21:240–3. Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. International Endodontic Journal 2008; 41:128–50.
journal of dentistry 42 (2014) 1390–1395
25. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review-part II: leakage and biocompatibility investigations. Journal of Endodontics 2010;36:190–202. 26. Meja`re I, Cvek M. Partial pulpotomy in young permanent teeth with deep carious lesions. Endodontics and Dental Traumatology 1993;9:238–42. 27. Mente J, Geletneky B, Ohle M, Koch MJ, Friedrich Ding PG, Wolff D, et al. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. Journal of Endodontics 2010;36::806–13. 28. Cho SY, Seo DG, Lee SJ, Lee J, Lee SJ, Jung IY. Prognostic factors for clinical outcomes according to time after direct pulp capping. Journal of Endodontics 2013;39:327–31. 29. Camilleri J. Color stability of white mineral trioxide aggregate in contact with hypochlorite solution. Journal of Endodontics 2014;40:436–40. 30. Cardoso-Silva C, Barberı´a E, Maroto M, Garcı´a-Godoy F. Clinical study of mineral trioxide aggregate in primary molars. Comparison between Grey and White MTA—a long term follow-up (84 months). Journal of Dentistry 2011;39:187–93. 31. Pak JG, White SN. Pain prevalence and severity before, during, and after root canal treatment: a systematic review. Journal of Endodontics 2011;37:429–38. 32. Oginni A, Udoye CI. Endodontic flare-ups: comparison of incidence between single and multiple visits procedures in patients attending a Nigerian teaching hospital. OdontoStomatologieTropicale 2004;27:23–7. 33. Asgary S, Eghbal MJ. The effect of pulpotomy using a calcium-enriched mixture cement versus one-visit root canal therapy on postoperative pain relief in irreversible pulpitis: a randomized clinical trial. Odontology 2010;98: 126–33. 34. Sunnega˚rdh-Gro¨nberg K, van Dijken JW, Funega˚rd U, Lindberg A, Nilsson M. Selection of dental materials and longevity of replaced restorations in Public Dental Health
35.
36.
37.
38.
39. 40.
41.
42.
43.
44.
1395
clinics in northern Sweden. Journal of Dentistry 2009; 37:673–8. Pallesen U, van Dijken JW, Halken J, Hallonsten AL, Ho¨igaard R. Longevity of posterior resin composite restorations in permanent teeth in Public Dental Health Service: a prospective 8 years follow up. Journal of Dentistry 2013;41:297–306. Lynch CD, Opdam NJ, Hickel R, Brunton PA, Gurgan S, Kakaboura A, et al. Guidance on posterior resin composites: academy of operative dentistry – European Section. Journal of Dentistry 2014;42:377–83. Horsted-Bindslev P, Bergenholtz G. Treatment of vital pulp conditions. In: Bergenholtz G, Horsted-Bindslev P, Reit C, editors. Textbook of endodontology. 2nd ed. London: WileyBlackwell; 2010. p. 47–69. Bergenholtz G. Evidence for bacterial causation of adverse pulpal responses in resin-based dental restorations. Critical Reviews in Oral Biology and Medicine 2000;11:467–80. Mjo¨r IA. Pulp-dentin biology in restorative dentistry. Part 7: the exposed pulp. Quintessence International 2002;33:113–35. Holmgren CJ, Lo EC, Hu D. Glass ionomer ART sealants in Chinese school children-6-year results. Journal of Dentistry 2013;41:764–70. Murray PE, Hafez AA, Smith AJ, Cox CF. Bacterial microleakage and pulp inflammation associated with various restorative materials. Dental Materials 2002;18:470–8. Desai S, Chandler N. The restoration of permanent immature anterior teeth, root filled using MTA: a review. Journal of Dentistry 2009;37:652–7. Cauwels RG, Lassila LV, Martens LC, Vallittu PK, Verbeeck RM. Fracture resistance of endodontically restored, weakened incisors. Dental Traumatology 2014. http:// dx.doi.org/10.1111/edt.12103. Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with guttapercha. A retrospective clinical study. Endodontics and Dental Traumatology 1992;8:45–55.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.intl.elsevierhealth.com/journals/jden
MTA pulpotomy as an alternative to root canal treatment in children’s permanent teeth in a dental public health setting Hend E. Alqaderi a, Sabiha A. Al-Mutawa a, Muawia A. Qudeimat b,* a b
Oral Health Services, Ministry of Health, Kuwait Department of Developmental and Preventive Sciences, Kuwait University, Kuwait
article info
abstract
Article history:
Objective: This prospective clinical study evaluated the success of vital pulpotomy treat-
Received 6 March 2014
ment for permanent teeth with closed apices using mineral trioxide aggregates (MTA) in a
Received in revised form
dental public health setting.
17 June 2014
Methods: Twenty-seven mature permanent first molars and 2 premolars (in 25 patients)
Accepted 18 June 2014
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 performed the same clinical procedure for all patients. Following isolation and caries removal,
Keywords:
the inflamed pulp tissue was completely removed from the pulp chamber. This was
MTA
followed by irrigation with 2% sodium hypochlorite. Haemostasis was achieved using a
Pulpotomy
cotton pellet damped in normal saline. A white MTA paste was placed against the pulp
Carious exposure
orifices. MTA was covered with a damped cotton pellet and a base of IRM. Patients were
Permanent teeth
recalled after 1 day where a glass ionomer liner and a final restoration were placed. Teeth
Children
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: MTA pulpotomy for permanent molars in children is a viable alternative to RCT. # 2014 Elsevier Ltd. All rights reserved.
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.
* Corresponding author at: Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait. Tel.: +965 2463 6747; fax: +965 25326 049. E-mail address: [email protected] (M.A. Qudeimat). http://dx.doi.org/10.1016/j.jdent.2014.06.007 0300-5712/# 2014 Elsevier Ltd. All rights reserved.
journal of dentistry 42 (2014) 1390–1395
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 appointments 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 an alternative 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 treatment to RCT in vital permanent teeth with carious exposed pulp.1 They also stated that there is a need for further studies in vital pulp therapy, as the current evidence provides inconclusive information regarding factors influencing treatment 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 2012 in 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 studies reporting 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 Health Programme Clinics-Ministry of Health, Kuwait. Ethical approval was obtained from Health Sciences Ethical Clearance 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). Radiographic inclusion criteria included: teeth with closed apecies
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and the absence of radiographically visible periradicular pathologies. Clinically, teeth with hyperaemic pulp that 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 pulpotomy procedure 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 a second 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, 3MTM ESPETM, 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 and radiographic 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 formation, tenderness on percussion or palpation, and radiographic evidence of periradicular or furcal pathology, or root resorption. 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.
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hard tissue bridge underneath the MTA layer was observed in 10 cases (34%).
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
4.
Discussion
Clinically, a principal challenge faced by most paediatric dentists, endodontists or general dentists with special interest in 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 and regeneration.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
1 2 3 4 5 6 7 8 9 10 11
F F F F F F F M F F M
12
M
13 14 15
M M M
16 17 18 19 20 21 22 23 24
F M F F M F F F F
25
F
Tooth
Age at treatment (years)
36 36 36 36 46 36 46 46 36 36 16 26 26 16 36 24 16 26 14 16 16 16 26 46 46 26 16 46 36
13.1 13 11.5 13.8 15.4 13 11.8 13 12 14.6 15.1 15.1 15.1 15.1 14.4 14.1 12.2 12.2 10.9 14.3 13.7 13.2 14.1 10 11 14.3 14.3 11 15.3
Follow-up time (months)
Final restoration
Fate
47 45 43 36 33 41 47 40 22 17 3 3 21 21 24 21 21 21 21 21 21 38 14 5 6 41 1 24 Unknown
Composite Composite Composite and SSC Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite Composite
Successful Successful Successful Successful Successful Successful Failure Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Successful Failure Successful Failure
journal of dentistry 42 (2014) 1390–1395
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 structure and induced stresses caused by endodontic and restorative procedures which will eventually weaken the tooth and make it more susceptible to fracture.21 Therefore, 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 carious exposures 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 outcomes.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
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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 was used 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 dentists based 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 no postoperative 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 compromise 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 composites 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 endodontically 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 to perform 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 determine the long-term outcomes and cost effectiveness of both pulpotomy and RCT.
8.
9.
10.
11.
12.
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.
13. 14.
15.
16. 17.
18.
references
1. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review. Journal of Endodontics 2011;37:581–7. 2. Annual Statistical Abstract 2011. Population. Kuwait Central Statistical Bureau. 2011. [Chapter 3]. 3. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives—permanent teeth. Journal of Endodontics 2008;34:S25–8. 4. Bakland LK, Andreasen JO. Will mineral trioxide aggregate replace calcium hydroxide in treating pulpal and periodontal healing complications subsequent to dental trauma? A review. Dental Traumatology 2012;28: 25–32. 5. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review—Part III: clinical applications, drawbacks, and mechanism of action. Journal of Endodontics 2010;36:400–13. 6. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study of mineral trioxide aggregate for partial pulpotomy in cariously exposed permanent teeth. Journal of Endodontics 2006;32:731–5. 7. El-Meligy OA, Avery DR. Comparison of mineral trioxide aggregate and calcium hydroxide as pulpotomy agents in
19.
20.
21.
22.
23.
24.
young permanent teeth (apexogenesis). Pediatric Dentistry 2006;28:399–404. Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp management for caries in adults: maintaining pulp vitality. The Cochrane Database of Systematic Reviews 2007; 18. [CD004484]. Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries. European Archives of Paediatric Dentistry 2007;8:99–104. Asgary S, Eghbal MJ. Treatment outcomes of pulpotomy in permanent molars with irreversible pulpitis using biomaterials: a multi-center randomized controlled trial. Acta Odontologica Scandinavica 2013;71:130–6. Ghoddusi J, Shahrami F, Alizadeh M, Kianoush K, Forghani M. Clinical and radiographic evaluation of vital pulp therapy in open apex teeth with MTA and ZOE. New York State Dental Journal 2012;78:34–8. Barngkgei IH, Halboub ES, Alboni RS. Pulpotomy of symptomatic permanent teeth with carious exposure using mineral trioxide aggregate. Iranian Endodontic Journal 2013;8:65–8. Duncan HF, Nair PNR, Pitt Ford TR. Vital pulp treatment: a review. Endo 2008;2:247–58. Ricucci D, Russo J, Rutberg M, Burleson JA, Spa˚ngberg LS. A prospective cohort study of endodontic treatments of 1,369 root canals: results after 5 years. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 2011;112:825–42. Huang GT. A paradigm shift in endodontic management of immature teeth: conservation of stem cells for regeneration. Journal of Dentistry 2008;36:379–86. Tziafas D. The future role of a molecular approach to pulpdentinal regeneration. Caries Research 2004;38:314–20. Matsuzaka K, Muramatsu T, Katakura A, Ishihara K, Hashimoto S, Yoshinari M, et al. Changes in the homeostatic mechanism of dental pulp with age: expression of the corebinding factor alpha-1, dentin sialoprotein, vascular endothelial growth factor, and heat shock protein 27 messenger RNAs. Journal of Endodontics 2008;34:818–21. Holland GR, Torabinejad M. The dental pulp and periradicular tissues. In: Torabinejad M, Walton RE, editors. Endodontics: principles and practice. 4th ed. St. Louis, Missouri: Saunders Elsevier; 2009. p. 1–20. Sloan AJ, Waddington RJ. Dental pulp stem cells: what, where, how? International Journal of Paediatric Dentistry 2009;19:61–70. Nosrat A, Seifi A, Asgary S. Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial. International Journal of Paediatric Dentistry 2013;23:56–63. Tang W, Wu Y, Smales RJ. Identifying and reducing risks for potential fractures in endodontically treated teeth. Journal of Endodontics 2010;36:609–17. Tomson PL, Grover LM, Lumley PJ, Sloan AJ, Smith AJ, Cooper PR. Dissolution of bio-active dentine matrix components by mineral trioxide aggregate. Journal of Dentistry 2007;35:636–42. Karabucak B, Li D, Lim J, Iqbal M. Vital pulp therapy with mineral trioxide aggregate. Dental Traumatology 2005; 21:240–3. Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. International Endodontic Journal 2008; 41:128–50.
journal of dentistry 42 (2014) 1390–1395
25. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review-part II: leakage and biocompatibility investigations. Journal of Endodontics 2010;36:190–202. 26. Meja`re I, Cvek M. Partial pulpotomy in young permanent teeth with deep carious lesions. Endodontics and Dental Traumatology 1993;9:238–42. 27. Mente J, Geletneky B, Ohle M, Koch MJ, Friedrich Ding PG, Wolff D, et al. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. Journal of Endodontics 2010;36::806–13. 28. Cho SY, Seo DG, Lee SJ, Lee J, Lee SJ, Jung IY. Prognostic factors for clinical outcomes according to time after direct pulp capping. Journal of Endodontics 2013;39:327–31. 29. Camilleri J. Color stability of white mineral trioxide aggregate in contact with hypochlorite solution. Journal of Endodontics 2014;40:436–40. 30. Cardoso-Silva C, Barberı´a E, Maroto M, Garcı´a-Godoy F. Clinical study of mineral trioxide aggregate in primary molars. Comparison between Grey and White MTA—a long term follow-up (84 months). Journal of Dentistry 2011;39:187–93. 31. Pak JG, White SN. Pain prevalence and severity before, during, and after root canal treatment: a systematic review. Journal of Endodontics 2011;37:429–38. 32. Oginni A, Udoye CI. Endodontic flare-ups: comparison of incidence between single and multiple visits procedures in patients attending a Nigerian teaching hospital. OdontoStomatologieTropicale 2004;27:23–7. 33. Asgary S, Eghbal MJ. The effect of pulpotomy using a calcium-enriched mixture cement versus one-visit root canal therapy on postoperative pain relief in irreversible pulpitis: a randomized clinical trial. Odontology 2010;98: 126–33. 34. Sunnega˚rdh-Gro¨nberg K, van Dijken JW, Funega˚rd U, Lindberg A, Nilsson M. Selection of dental materials and longevity of replaced restorations in Public Dental Health
35.
36.
37.
38.
39. 40.
41.
42.
43.
44.
1395
clinics in northern Sweden. Journal of Dentistry 2009; 37:673–8. Pallesen U, van Dijken JW, Halken J, Hallonsten AL, Ho¨igaard R. Longevity of posterior resin composite restorations in permanent teeth in Public Dental Health Service: a prospective 8 years follow up. Journal of Dentistry 2013;41:297–306. Lynch CD, Opdam NJ, Hickel R, Brunton PA, Gurgan S, Kakaboura A, et al. Guidance on posterior resin composites: academy of operative dentistry – European Section. Journal of Dentistry 2014;42:377–83. Horsted-Bindslev P, Bergenholtz G. Treatment of vital pulp conditions. In: Bergenholtz G, Horsted-Bindslev P, Reit C, editors. Textbook of endodontology. 2nd ed. London: WileyBlackwell; 2010. p. 47–69. Bergenholtz G. Evidence for bacterial causation of adverse pulpal responses in resin-based dental restorations. Critical Reviews in Oral Biology and Medicine 2000;11:467–80. Mjo¨r IA. Pulp-dentin biology in restorative dentistry. Part 7: the exposed pulp. Quintessence International 2002;33:113–35. Holmgren CJ, Lo EC, Hu D. Glass ionomer ART sealants in Chinese school children-6-year results. Journal of Dentistry 2013;41:764–70. Murray PE, Hafez AA, Smith AJ, Cox CF. Bacterial microleakage and pulp inflammation associated with various restorative materials. Dental Materials 2002;18:470–8. Desai S, Chandler N. The restoration of permanent immature anterior teeth, root filled using MTA: a review. Journal of Dentistry 2009;37:652–7. Cauwels RG, Lassila LV, Martens LC, Vallittu PK, Verbeeck RM. Fracture resistance of endodontically restored, weakened incisors. Dental Traumatology 2014. http:// dx.doi.org/10.1111/edt.12103. Cvek M. Prognosis of luxated non-vital maxillary incisors treated with calcium hydroxide and filled with guttapercha. A retrospective clinical study. Endodontics and Dental Traumatology 1992;8:45–55.
