Supervisors info:
Βαδιάκας Γεώργιος, Επίκουρος Καθηγητής, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Γκιζάνη Σωτηρία, Αναπληρώτρια καθηγήτρια, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Αγουρόπουλος Ανδρέας, Επίκουρος Καθηγητής, Τμήμα Οδοντιατρικής, Σχολή Επιστημών Υγείας, ΕΚΠΑ
Summary:
Introduction: Direct Pulp Capping (DPC) described as the application of a material to an exposed pulp to maintain its vitality and induce the formation of reparative dentine, is an alternative pulp treatment method for vital primary teeth. The ideal direct pulp capping material should biologically stimulate odontoblasts or pulp cells and induce the formation of new hard dental tissue around the exposed pulp. The fast setting Ca(OH)2 has been traditionally the material of choice for DPC in permanent teeth. Nevertheless, it exhibits a number of shortcomings that question its use in clinical praxis. MTA was introduced to overcome several of calcium hydroxide’s limitations. Over the last few years, a new set of ΜΤΑ-resembling materials have been manufactured and demonstrate improved characteristics when compared to MTA. Neo MTA is a new material that has excellent biocompatibility, similar to MTA sealing ability and long term seal. It offers dentin bridge formation and hard tissue induction. In addition, it has better mixing and handling properties, shorter setting time and less coronal discoloration, compared to MTA.
Aim: Τhe aim of the present clinical study was to investigate the clinical outcome of direct pulp capping in carious primary molars with pulp exposure, following caries removal, after 12 months of follow-up. A new MTA-resembling material (neoMTA) was used as a pulp capping agent.
Materials and Methods: This is a clinical trial, which includes: a) a complete medical and dental history and written consent from the parents, b) initial clinical and radiographic examination and assessment of the primary molars that are candidates for the study, based on the selection criteria, c) caries removal, direct capping of the exposed pulp and final restoration of the primary molars, d) clinical and radiographic evaluation at 3, 6 and 12 months and e) statistical analysis of the results. Prior to the examination, a detailed medical and dental history of the child and a written consent regarding the treatment was taken from the parents (Ethics committee, Dental School, National and Kapodistrian University of Athens). The study sample consisted of healthy patients aged 4-11 years old that presented in the Postgraduate clinic of Paediatric Dentistry of National and Kapodistrian University of Athens, seeking for dental treatment. All participating children received a full preventive treatment and restoration of all carious teeth. Teeth were included in the study if they met the following eligibility criteria: first and second primary molars with deep caries lesions, leading to pulp exposure after caries removal, negative history of pain and free of signs and symptoms indicative of irreversible pulp inflammation, while the teeth had to be restorable with composite resin. More specifically, all included teeth presented with lack of mobility and percussion sensitivity and healthy periodontal tissues, in the absence of fistula or swelling. Radiographically, the presence of periapical or furcal radiolucency, internal or external resorption, calcification and pathological sign in the permanent successor were all findings for exclusion. The lamina dura should be continuous and intact and the remaining root length at least half of the original. Caries should extent to the inner half of the dentine approaching the pulp. Pulp exposure as a result of caries removal should not exceed 1-2 mm, while bleeding should be controlled by using a dry cotton pellet under light pressure, within 2-3 min. If haemorrhage control was unsuccessful, the tooth was excluded from the study and followed a different treatment approach. Primary molars, that were candidates for the participation into the study were examined clinically and radiographically by a paediatric dentist, to determine whether they met all the inclusion clinical and radiographic criteria mentioned above. The initial radiographic examination included a periapical radiograph. neoMTA was used as pulp capping material. All direct pulp capping procedures were performed by the same paediatric dentist. Following clinical and radiographic examination (periapical radiograph), the teeth were anaesthetized locally with articaine 4% with epinephrine 1/200.000 and isolated by rubber dam. Enamel and dentine caries were removed. Teeth with an exposure less than 2 mm, surrounded by sound dentine were candidates of direct pulp capping. The cavity was washed with 0.5% NaOCl for disinfection followed by application of dry sterile cotton pellets to achieve hemostasis and remove the excess moisture. neoMTA was placed on the exposed pulp. After its mixture according to the manufacturer's instructions, the material was left to set, a light-cured glass ionomer cement was placed on top of the pulp capping material and the tooth was restored with composite resin. A periapical radiograph was taken immediately post-treatment. Patients were re-examined at 3, 6 and 12 months after treatment. The recall examination comprised a clinical and radiographic examination of the treated teeth, to assess pulp vitality. The clinical parameters used for assessment included the presence/absence of pain symptoms as reported by the child and the parent, sensitivity to percussion and palpation, fistula, swelling and mobility (not related to natural exfoliation). All radiographs were assessed for findings indicative of pulp necrosis, including the presence of pathological internal and external resorption, furcal or periapical radiolucency and disruption of lamina dura. Statistical analysis: Descriptive statistics with cross tabulations were performed.
Results: A total of 41 patients, 21 girls and 20 boys with a mean age of 7,5 years , mean age 7.1 years for girls and 7.1 years for boys and range from 4 to 11 years old participated in the study.
The total number of primary molars included in the study and treated with DPC was 47. Of them 19 were first primary molars, 28 were second, 27 lower and 20 upper, 29 right and 18 left. Class II composite resin restorations were placed in 39 teeth, while only 8 teeth were restored with a Class I restoration. Available for examination at 3,6 and 12 months were 39 teeth, since 8 patients with 8 teeth (3 first primary molars, 5 second primary molars, 4 upper, 4 lower, 2 right and 6 left)treated with DPC failed to attend the follow-up visits. The overall failure for direct pulp capping was 10.3%. With regard to the type of failure, of the 4 teeth failed, 3 appeared with swelling and 1 with a furcal radiolucency. The event of failure, for all the failed teeth, occurred within the first 6 months, post-treatment.
Conclusions: Direct pulp capping in asymptomatic primary molars with a cariously exposed pulp, using neoMTA as a pulp capping material, exhibited an overall success rate of 89.7% based on clinical and/or radiographic diagnostic criteria, after a follow-up period of 12 months. The event of a failed pulp treatment was diagnosed within the first 6 months, post-treatment. Longer follow-up periods are needed to further assess the long-term clinical and radiographic effectiveness of direct pulp capping after application of the material studied.
