|Year : 2015 | Volume
| Issue : 1 | Page : 24-29
Is pulpotomy obsolete? A clinical study on the success rates of indirect pulp capping and pulpotomy in the treatment of deep dentinal caries in primary second molars
KB Vidya1, Shruthi B Patil2, Rajesh T Anegundi2
1 Department of Pediatric Dentistry, Farooqia Dental College and Hospital, Farooqia Educational Complex, Eidgah, Mysore, Karnataka, India
2 Department of Pediatric Dentistry, Sri Dharmasthala Manjunatheshwara College of Dental Sciences, Sattur, Dharwad, Karnataka, India
|Date of Web Publication||18-Mar-2015|
Dr. K B Vidya
Department of Pediatric Dentistry, Farooqia Dental College and Hospital, Farooqia Educational Complex, Umar Khayam Road, Eidgah, Mysore - 570 021, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives: Traditionally, there are two treatment modalities for vital primary teeth with deep carious lesion, which include indirect pulp therapy (IPT) and pulpotomy. Enormous research and review in vital pulp therapy gave rise to a question, if primary tooth pulpotomy is obsolete, and should IPT replace pulpotomy? IPT has shown higher long-term success rates than any pulpotomy procedures other than mineral trioxide aggregate (MTA). Hence, the objectives of this study were to evaluate the success rates of IPT using calcium hydroxide and MTA pulpotomy clinically and radiographically. Materials and Methods: Eighty primary second molars were selected and randomly divided into two therapeutic groups of 40 each. Group 1 were treated with IPT using calcium hydroxide paste and Group 2 were treated with conventional pulpotomy using MTA paste followed by stainless steel crown. Follow-up evaluation was done at an interval of 6 weeks, 3 months, and 6 months. Results: The follow-up evaluation revealed 100% clinical success in teeth treated with MTA pulpotomy and one radiographic failure of internal resorption detected at 3 months. There was 100% clinical and radiographic success with teeth treated with IPT. Though there was one radiographic failure with MTA pulpotomy, it was not statistically significant (P > 0.05). Conclusion: Indications being the same for both the procedures why not opt for IPT which offers several advantages over pulpotomy like fewer potential side effects, non-invasive, decreased chair time, child cooperation, and cost-effectiveness.
Keywords: Deep dentinal caries, IPT, MTA pulpotomy, primary second molar
|How to cite this article:|
Vidya K B, Patil SB, Anegundi RT. Is pulpotomy obsolete? A clinical study on the success rates of indirect pulp capping and pulpotomy in the treatment of deep dentinal caries in primary second molars. J Int Clin Dent Res Organ 2015;7:24-9
|How to cite this URL:|
Vidya K B, Patil SB, Anegundi RT. Is pulpotomy obsolete? A clinical study on the success rates of indirect pulp capping and pulpotomy in the treatment of deep dentinal caries in primary second molars. J Int Clin Dent Res Organ [serial online] 2015 [cited 2018 Dec 17];7:24-9. Available from: http://www.jicdro.org/text.asp?2015/7/1/24/153491
| Introduction|| |
Management of the cariously involved primary teeth where the carious lesion approximates the pulp requires a knowledgeable approach to pulp therapy, and a successful outcome depends on accurate diagnosis of the status of the pulp prior to therapy. Preliminary data gathering and interpretation must be focused on determining whether the primary tooth pulp is normal, reversibly inflamed, irreversibly inflamed, or necrotic. If it is determined to be vital or reversibly inflamed, the vital pulp therapy techniques are indicated. Traditionally, there are two treatment modalities for vital primary teeth which include indirect pulp therapy (IPT) and pulpotomy. The indications for IPT and pulpotomy are identical i. e, reversible pulpitis or a normal pulp where the pulp is judged to be vital from clinical and radiographic criteria.  The difference lies with the caries removal process. IPT purposely avoids an exposure by leaving the residual deepest decay in place while pulpotomy is undertaken when it results in a pulp exposure. There have been various medicaments used for IPT, like calcium hydroxide, ,, glass ionomer to none, ,, all of which did not significantly change IPT's success rates. IPT usually shows success rates of 90% or greater no matter the technique, medicament, or time periods. 
Formocresol (FC) has been used as a "gold standard" in pulpotomy, but concerns over the use of formocresol currently exists as it has been shown to be mutagenic and carcinogenic. Various medicaments such as formocresol, glutaraldehyde, ferric sulfate, and calcium hydroxide have been used in pulpotomy procedures. But success rates for pulpotomy decreases over time from 90% or more initially (6-12 months) to 70% or less after 3 years or more. But more recently mineral trioxide aggregate (MTA) used as a primary molar medicament for pulpotomies reported a 97% success rate. 
IPT has shown higher long-term success rates than any pulpotomy procedures other than MTA.  Controversy persists as to the best way to perform vital pulp therapy, and additional research is needed to confirm whether MTA pulpotomy performs as well as IPT. 
So the present study was an attempt to clinically and radiographically evaluate the success rates of IPT using calcium hydroxide and MTA pulpotomy for managing deep dentinal caries with reversible pulpitis in primary second molars.
| Materials and Methods|| |
This study was carried out in the Department of Pediatric and Preventive dentistry. The study population consisted of children with deep dentinal caries whose pulpal status warranted vital pulp therapy. The procedure and its possible discomforts and benefits were explained to the parents of the children. And a written consent was obtained from the parents. Ethical clearance as approved by the institutional review board of human subjects experiments was obtained prior to the investigation. 80 primary second molars were selected and randomly divided into two therapeutic groups of 40 teeth each i. e.,
Group 1- Indirect pulp therapy, Group 2 - Pulpotomy
Inclusion criteria were as follows:
- No spontaneous pain.
- No clinical signs of gingival swelling or sinus tract opening.
- No tooth mobility.
- No radiolucency in periapical or inter-radicular area.
- No internal resorption.
- Class I cavities involving only the occlusal surface were selected.
- Children between the ages of 6-10 yrs were chosen for the study.
In Group 1 following administration of local anesthesia and rubber dam isolation [Figure 1]a Indirect pulp capping with dycal [Figure 1]b, followed by zinc oxide eugenol (ZOE) cement base and restoration with miracle mix was done [Figure 1]c.
|Figure 1: Indirect pulp therapy (IPT) procedure; (a) Rubber dam isolation with 75 showing deep carious lesion; (b) Excavation of caries followed by placement of dycal over affected dentin; (c) Miracle mix restoration|
Click here to view
In Group 2 after the administration of local anesthesia and rubber dam isolation [Figure 2]a standard pulpotomy procedure was followed, and the pulp stumps were covered with mineral trioxide aggregate (MTA Angelus, Londrina, PR, Brazil) [Figure 2]b. Then zinc oxide eugenol cement base was placed and restored with miracle mix cement followed by placement of stainless steel crown (SSC) [Figure 2]c.
|Figure 2: Follow-up radiographs of indirect pulp therapy (IPT) (a) Pre-operative; (b) 6-weeks follow-up; (c) 3-months follow-up; (d) 6-months follow-up|
Click here to view
The entire procedure in both the groups was completed in the same visit.
The study groups were recalled after 6 weeks, 3months, and 6 months for clinical and radiographic evaluation [Figure 3] and [Figure 4].
|Figure 3: Mineral trioxide aggregate (MTA) pulpotomy procedure; (a) Rubber dam isolation with 75 showing deep carious lesion; (b) Placement of MTA over pulp stumps after excavation of coronal pulp; (c) Placement of stainless steel crown|
Click here to view
|Figure 4: Follow-up radiographs of pulpotomy; (a) Pre-operative; (b) 6-weeks follow-up; (c) 3-months follow-up; (d) 6-months follow-up|
Click here to view
Pulp therapy was considered successful if all the following were noted during follow up visits. , For clinical evaluation:
- No history of pain,
- No fistula or gingival swelling,
- No abnormal mobility, and
- No pain on percussion.
Radiographic evaluation was done with intraoral periapical X-rays taken at regular intervals and following were noted.
- Internal resorption.
- External resorption.
- Widening of periodontal ligament (PDL).
Analysis of the data was accomplished by using Wilcoxan matched paired test.
| Results|| |
All 40 teeth treated with IPT were free of any clinical or radiographic symptoms or sign. Out of the 40 teeth treated with MTA pulpotomy, there was only one radiographic failure of internal resorption seen at 3 months follow-up. Rest of the teeth were free of any clinical symptoms. Statistical analysis of the data revealed 100% results with both groups since one failure was statistically insignificant.
| Discussion|| |
Management of the grossly decayed primary molar is common and also challenging to the pediatric dentist. A successful outcome to pulp therapy depends on accurate diagnosis of the status of the pulp prior to therapy. And this should include history, clinical, and radiographic diagnostic data aimed at determining the vitality of the pulp. If it is determined to be vital or reversibly inflamed, the vital pulp therapy techniques of IPT or pulpotomy are indicated.
Previous research has investigated the use of IPT in primary and permanent teeth with varied success. Aponte et al., 1966 evaluated the post operative bacteriologic status of carious dentin following IPT in teeth with an interim of at least 6 months following treatment. The study was based on the premise that at least two problems arise for clinicians that use IPT, first from the history, radiographic and clinical examinations, the operator must make a value judgment to determine whether the pulp has sufficient vitality to produce reparative dentin and continue its vitality, and second the fate of the bacteria contained in the residual carious dentin should be able to be ascertained. The investigators concluded that 93% of the 30 teeth investigated were free of bacterial contamination. Additionally, the dentin appearance upon re-entry was hard and shiny with radiographic evidence of reparative dentin formation.  Even when no medicament was placed for IPT and the composite filling was bonded to the remaining decay and decay-free dentin, Falster et al., reported success greater than 90%.  Al-Zayer et al., 2003 retrospectively assessed the clinical and radiographic success of IPT on primary posterior teeth based on the influence of caries risk, skills of operator and restorative material. The authors concluded that IPT success rate was 95%. The authors concluded that IPT is a successful technique and should be considered as an alternative pulp therapy procedure. 
There were several factors associated with the success or failure of IPT. One such factor that influenced the success of IPT was the restorative material used after the IPT procedure. Teeth treated with IPT, lined by Ca (OH) 2 , and then based by a resin modified glass iomoner cement (RMGIC) or ZOE were significantly more successful than teeth treated with only a calcium hydroxide liner.  Traditionally, in the 1960s and 1970s, both ZOE and Ca (OH) 2 were used as a liner/base over IPT. Many studies showed that both ZOE and Ca (OH) 2 were effective in promoting reparative dentin as well as having the ability to sterilize the remaining carious lesion.  Most of the failures were among teeth restored with an amalgam restoration (77% of the total failures), whereas a glass ionomer forms hydrogen bonds to dentin compared to the acid-etched hybrid layer of a composite. 
Vij et al., evaluated the effect of the restoration placed at the time of pulp therapy. The 83% success rate for the IPT restored with stainless steel crowns was not statistically different from the 87% success in teeth restored with intra-coronal restorations. 
In our study, teeth treated with IPT were lined by Ca (OH) 2 and then based by a ZOE, followed by miracle mix restoration.
Considering the life-span of the teeth treated with IPT, which would be a maximum of 4 years and the cases selected were restricted to class I (occlusal lesions), they were restored with miracle mix. All 40 teeth were free of any clinical or radiographic sign or symptom [Table 1] and [Table 2].
Lin and Langland 1981 showed that when no pulp exposure occurred from caries, the pulp's repair capacity was excellent. 
Formocresol remains the most widely studied pulpotomy procedure for vital pulp therapy in primary teeth. Clinical success rates in primary tooth pulpotomies using formocresol have varied from 55-98%.  Treatment failures in these studies are described as internal and external resorption, as well as abscess formation. Concerns over the use of formocresol as a pulpotomy medicament currently exist. Studies on alternative vital pulp therapy techniques include the use of medicaments such as glutaraldehyde, ferric sulfate, calcium hydroxide, and MTA. Clinical studies evaluating the use of glutaraldehyde in primary tooth pulpotomies have reported success rates ranging from 82-98%. , Its systemic distribution from pulpotomy sites, cytotoxicity and mutagenicity has been reported to be similar to formocresol. Clinical studies evaluating the use of ferric sulfate in primary tooth pulpotomies have reported success rates ranging from 74-97%. , Based on the available evidence so far, ferric sulfate and formocresol produce equivalent outcomes, despite the radiographic evidence of internal resorption. Clinical studies evaluating the use of calcium hydroxide in primary tooth pulpotomies have reported success rates ranging from 56-77%. ,,
Vij et al., studied IPT and pulpotomy success, treating molars with reversible pulpitis pain. They reported that in 20 first primary molars with such pain, IPT success was 85%, which was significantly better than the 53% in 19 primary first molars treated with formocresol pulpotomy. 
Formocresol and ferric sulfate pulpotomy have a significantly lower long-term success for treatment of deep caries compared with IPT. 
Few clinical studies exist evaluating MTA in primary tooth pulpotomies. The long-term evaluation of MTA used as a primary molar medicament in pulpotomies reported a 97% success rate.  MTA has no toxic side effects - systematic or local. MTA is a material with proven therapeutic properties in different endodontic procedures of primary teeth already.
In our study, teeth treated with MTA pulpotomy were free of any clinical pathology [Table 3] and [Table 4] except for one radiographic failure of internal resorption (97.85%) with MTA pulpotomy seen at 3-months follow-up [Figure 5], which was not statistically significant.
|Figure 5: Radiographic failure with mineral trioxide aggregate (MTA) pulpotomy; (a) Pre-operative; (b) 6-weeks follow-up; (c) 3-months internal resorption; (d) 6-months internal resorption|
Click here to view
The reasons for internal resorption could be ZOE cement which was used as a base or due to undiagnosed chronic inflammation existing in the radicular pulp prior to pulpotomy. Previous investigations of ZOE as a pulpotomy agent or as a base for pulpotomies suggest that ZOE can cause pulp inflammation, with a risk for subsequent internal resorption.  Smith et al., 2000 claimed that internal resorption is associated with eugenol.  When used together with zinc oxide (as in a sub-base following pulpotomy), eugenol comes into direct contact with the vital tissue and causes a moderate to severe inflammatory response, resulting in chronic inflammation and necrosis. Cotes et al., 1997 claimed that, in pulpotomized rat teeth, if the pulp tissue is fixed by FC it will not be affected by eugenol.  This, however, cannot explain the internal resorption observed in the present study. Though ZOE was used to fill the pulp chamber prior to coronal restoration, it has been placed over the MTA layer and not directly over the pulp stumps. Because MTA is an excellent sealer, it is more likely that internal resorption was the result of undiagnosed chronic inflammation existing in the radicular pulp prior to pulpotomy than the result of exposure of the radicular pulp to eugenol.  Internal resorption, as an obvious pathologic process, cannot be considered a sign of pulpotomy success as suggested by Smith et al., 2000.  Conversely, it is not necessarily an indication of failure, as shown by Holan et al., 2005 because the aim of pulpotomy he said, is to retain a symptom-free, functional primary tooth until it reaches the age of its physiologic exfoliation.  The guidelines of American Academy of Pediatric Dentistry (AAPD) 2006, states that the objective of a pulpotomy is to keep the remaining pulp healthy without adverse clinical signs or symptoms or radiographic evidence of internal or external root resorption.  So in the present study, we considered internal resorption as a sign of failure.
| Conclusion|| |
- Indications for both IPT and pulpotomy are the same. Hence, why not opt for lesser invasive procedure.
- IPT offers several advantages over pulpotomy, fewer potential side effects, conservative procedure, non-invasive, decreased chair time, and cost-effectiveness.
- Child cooperation is increased.
- A careful diagnosis plus appropriate removal of the caries from the lateral walls, therefore, leaving deep carious dentin to avoid a microscopic exposure, achieves a high success with IPT for primary molars.
Limitation of this study was the short evaluation period. Further long-term studies are needed to evaluate the success rates for the procedures.
| References|| |
Coll JA. Indirect pulp capping and primary teeth: Is the primary tooth pulpotomy out of date? Pediatr Dent 2008;30:230-6.
Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB. Indirect pulp treatment of primary posterior teeth: A retrospective study. Pediatr Dent 2003;25:29-36.
Falster CA, Araujo FB, Straffon LH, Nor JE. Indirect pulp treatment: In vivo
outcomes of an adhesive resin system vs calcium hydroxide for protection of the dentin-pulp complex. Pediatr Dent 2002;24:241-8.
Vij R, Coll JA, Shelton P, Farooq NS. Caries control and other variables associated with success of primary molar vital pulp therapy. Pediatr Dent 2004;26:214-20.
Farooq NS, Coll JA, Kuwabara A, Shelton P. Success rates of formocresol pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries in primary teeth. Pediatr Dent 2000;22:278-86.
Holan G, Eidelman E, Fuks AB. Long-term evaluation of pulpotomy in primary molars using mineral trioxide aggregate or formocresol. Pediatr Dent 2005;27:129-36.
American Academy of Pediatric Dentistry. Clinical guidelines on pulp therapy for primary and young permanent teeth: Reference manual 2006-07. Pediatr Dent 2006;28:144-8.
Aponte AJ, Hartsook JT, Crowley MC. Indirect pulp capping verified. J Dent Child 1966;33:164-6.
Lin L, Langeland K. Light and electron microscopic study of teeth with carious pulp exposures. Oral Surg Oral Med Oral Pathol 1981;51:292-316.
Magnussun BO. Therapeutic pulpotomies in primary molars with the formocresol technique. A clinical and histological follow-up. Acta Odontol Scand 1978;36:157-65.
Fuks AB, Bimstein E, Kelin H. Assessment of a 2% buffered glutaraldehyde solution in pulpotomized primary teeth of school children: A preliminary report. J Pedod 1986;10:323-30.
Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: A retrospectic study. Pediatr Dent 2000;22:192-9.
Casas MJ, Kenny DJ, Johnston DH, Judd PJ. Long-term outcomes of primary molar ferric sulfate pulpotomy and root canal therapy. Pediatr Dent 2004;26:44-8.
Magnusson B. Therapeutic pulpotomy in primary molars - clinical and histological follow up. I. Calcium hydroxide paste as wound dressing. Odontol Revy 1970;21:415-31.
Waterhouse PJ, Nunn JH, Whitworth JM, Soames JV. Primary molar pulp therapy - histological evaluation of failure. Int J Paediatr Dent 2000;10:313-21.
Zurn D, Seale NS. Light-cured calcium hydroxide vs formocresol in human primary molar pulpotomies: A randomized control trial. Pediatr Dent 2008;30:34-41.
Cotes O, Boj JR, Canalda C, Carreras M. Pulpal tissue reaction to formocresol vs. ferric sulfate in pulpotomized rat teeth. J Clin Pediatr Dent 1997;21:247-53.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4]