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ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 254-259

Clinical and radiographic evaluation of results of MTA pulpotomy and laser-assisted MTA pulpotomy


1 Division of Periodontology, Department of Preventive Dental Sciences, College of Dentistry, University of Ha'il, Ha'il, Kingdom of Saudi Arabia
2 Department of Dentistry, Government Doon Medical College, Dehradun, Uttarakhand, India
3 Division of Dental Biomaterials, Department of Restorative Dentistry, College of Dentistry, University of Ha'il, Ha'il, Kingdom of Saudi Arabia
4 Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-graduate Research Institute, Parbhani, Maharashtra, India

Date of Submission12-Sep-2019
Date of Decision09-Nov-2019
Date of Acceptance04-Dec-2019
Date of Web Publication27-Aug-2020

Correspondence Address:
Dr. Pratyaksha S Panwar
Department of Dentistry, Government Doon Medical College, Dehradun, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_139_19

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  Abstract 


Introduction: The present in vivo study was carried out to compare the clinical and radiographic success rates of mineral trioxide aggregate (MTA) pulpotomy and laser-assisted MTA pulpotomy in human primary molars.
Materials and Methods: The present study was a randomized clinical trial in design, wherein forty human primary teeth requiring pulpotomy treatment which met the selection criteria (clinical and radiographic) were divided into two groups, Group 1 (n = 20) wherein the pulpotomy was performed with MTA alone and Group 2 (n = 20) wherein laser-assisted pulpotomy was performed with diode laser-assisted MTA (L-MTA). The patients were recalled after 3, 6 and 9 months, respectively, and evaluated clinically and radiographically. Data were analyzed statistically, while P< 0.05 was considered statistically significant.
Results: The clinical success rate in the MTA group was 90%, 84.21%, and 88.23% at 3, 6, and 9 months, respectively, with no clinical signs or symptoms reported at the said follow-up visits, while the radiographic success rate was found to be 85%, 84.21%, and 82.3%, respectively. On the contrary, the clinical success rate in the L-MTA group was found to be 95%, 94.74%, and 94.44% at 3, 6, and 9 months, respectively, with the radiographic success rate reported being 90%, 89.47%, and 88.89%, respectively.
Conclusion: The combination of diode laser and MTA yielded better clinical and radiographic success rates over the pulpotomy procedures done with the help of MTA alone, thereby, concluding that lasers may be considered as adjuvant alternatives for vital pulp therapy on human primary teeth.

Keywords: Diode lasers, formocresol, mineral trioxide aggregate, primary teeth, pulpotomy, vital pulp therapy


How to cite this article:
Swarnalatha C, Babu J S, Panwar PS, Alquraishi MA, Almalaq SA, Alnasrallah FA, Nayyar AS. Clinical and radiographic evaluation of results of MTA pulpotomy and laser-assisted MTA pulpotomy. Saudi Endod J 2020;10:254-9

How to cite this URL:
Swarnalatha C, Babu J S, Panwar PS, Alquraishi MA, Almalaq SA, Alnasrallah FA, Nayyar AS. Clinical and radiographic evaluation of results of MTA pulpotomy and laser-assisted MTA pulpotomy. Saudi Endod J [serial online] 2020 [cited 2020 Oct 30];10:254-9. Available from: https://www.saudiendodj.com/text.asp?2020/10/3/254/293566




  Introduction Top


Formocresol has remained the benchmark medicament for pulpotomy procedures over the years due to its consistent results that date back to even more than a century.[1] However, concerns have been expressed about formocresol pulpotomy because of the unpredictability of the observed pulpal response with inflammation and necrosis, cytotoxicity, systemic disturbances, mutagenic and carcinogenic potential, and possible immunologic responses.[2] Alternatives to formocresol such as glutaraldehyde, ferric sulfate, mineral trioxide aggregate (MTA), bone morphogenic proteins, dentin bonding agents, enamel matrix derivatives, freeze-dried bone, growth factors, and various techniques and procedures including electrosurgery and lasers have, also, been tried, though, with variable clinical, radiological, and histological success rates.[3]

Amongst these, MTA has the ability to stimulate cytokine release from the bone cells indicating that it actively promotes hard tissue formation to provide an enhanced seal over the vital pulp and is nonresorbable.[4] Furthermore, MTA was reported to have superior biocompatibility, better sealing ability, dentinal bridge-inducing constituents, and is relatively less cytotoxic than other materials currently used for pulp therapies.[4],[5],[6]

Lasers have been used for carrying out pulpotomy procedures in primary teeth, as they maintain a sterile environment and reduce inflammation.[3],[5] It was first applied for pulpotomy procedure by Shoji et al.[7] using dog's teeth, wherein no detectable damage was observed in the radicular portion of the remaining pulps tissue. Lasers, also, possess hemostatic, antimicrobial, and cell-stimulating properties with added advantages of an improved wound healing and no mechanical damage on the remaining pulp tissue.[8] For the said reasons, laser irradiation was suggested as a promising alternative to the conventional pharmacotherapeutic strategies.

Lasers that have been tested and have demonstrated predictable outcomes in pulpotomy procedures include CO2, neodymium-doped yttrium aluminum garnet (Nd:YAG), and erbium: yttrium-aluminum-garnet (Er:YAG) lasers. Recently, diode lasers have been used for pulpotomy in primary teeth and have shown clinical success rates comparable to formocresol.[3],[4],[5] The presentin vivo study was carried out to compare the clinical and radiographic success rates of MTA pulpotomy and diode laser-assisted MTA (L-MTA) pulpotomy in human primary molars.


  Materials and Methods Top


The presentin vivo study was designed as a randomized clinical trial planned to compare the clinical and radiographic success rates of MTA pulpotomy and diode laser-assisted MTA (L-MTA) pulpotomy in human primary molars. The study protocol was approved from the Institutional Ethics Committee through Letter approval no. SDDC/IEC/01-29-2018. The inclusion criteria for the study was children aged between 6 and 8 years with deeply carious primary molars (maxillary or mandibular) with vital pulp and with no history of spontaneous pain or, any other clinical or, radiographic evidence of an abscess or, sinus opening and with absence of internal and external root resorption, interradicular, furcal and/or periapical radiolucencies, and with the possibility of proper restoration of the teeth. Forty primary teeth requiring pulpotomy treatment which met the selection criteria (clinical and radiographic) were selected randomly from 60 children who had attended the Department of Pedodontics and Preventive Dentistry and were divided into two groups: Group 1 (n = 20) wherein the pulpotomy was performed with MTA alone and Group 2 (n = 20) wherein diode laser-assisted MTA pulpotomy was performed.

Clinical procedure

After anesthetizing the tooth, isolation was done with the help of rubber dams of the required sizes. Caries and unsupported enamel/dentin were removed with spoon excavator. Pulp chamber was approached using a round bur and further, caries was removed and coronal access was made using a #245 bur (Dentsply, USA) in a high-speed handpiece (Dentsply, USA) with water as coolant. Coronal pulp was removed to the canal orifices with the help of Hu-Friedy sharp spoon excavator. Pulp chamber was irrigated with saline to remove debris. Hemostasis was achieved using a dry, sterile cotton pledget gently pressed against the amputated pulp tissues for about 5 min. In the MTA group, after achieving hemostasis, MTA (ProRoot; Dentsply, USA) was mixed as per the prescribed manufacturer's instructions and placed on the amputated pulp tissues with a thickness of approximately 2–3 mm using a plastic filling instrument. A wet cotton pledget was, then, placed over MTA for approximately 10 min. In the L-MTA group, after achieving primary hemostasis, the root canal orifices were exposed to the Diode Laser (Picasso, Germany) of 810 nm with continuous mode of application for approximately 2 s delivered by 200 μ optical fiber tip in contact mode at 1.5W power [Figure 1]. All the patients and operator wore appropriate eye protection wears during application of the laser. In both the groups, the treated teeth were restored with GIC Type IX (GC Fuji IX, GC Corporation Tokyo, Japan) followed by stainless steel crowns. The patients were recalled after 3, 6, and 9 months, respectively, and evaluated clinically and radiographically [Figure 2]. The clinical symptoms assessed included spontaneous pain, draining sinus, swelling or abscess, mobility, premature exfoliation while the radiological assessment included evidence of interradicular radiolucency, periodontal ligament space widening, peri-apical radiolucency, and internal and/or external root resorption.
Figure 1: Laser and mineral trioxide aggregate group: (a) Preoperative photograph, (b) Preoperative radiograph, (c) Postoperative photograph, (d) Postoperative radiograph

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Figure 2: Laser and mineral trioxide aggregate group: (a-c) 3, 6, and 9 months follow-up radiographs

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Data were analyzed using the Statistical Package for the Social Sciences (SPSS) Version 22 (IBM Corporation, Washington, DC, United States). Descriptive statistics were used to analyze the data, while the Pearson's correlation coefficient test was used to analyze the statistical correlation between the overall success rates observed in the clinical and radiographic findings of both the groups. P < 0.05 was considered statistically significant.


  Results Top


The mean age of patients in the present study was 7.08 years in the MTA group and 6.92 years in the L-MTA group. In the MTA group, male patients accounted for 40% and female patients were 60%, while in the L-MTA group, male and female patients were equal in distribution. A total of 10 left and 10 right mandibular molars were treated in the MTA group, while 13 left and 7 right mandibular molars were treated in the L-MTA group [Table 1]. The clinical success rate in the MTA group was 90%, 84.21%, and 88.23% at 3, 6, and 9 months, respectively, with no clinical signs or symptoms reported at the said follow-up visits, while the radiographic success rate was found to be 85%, 84.21%, and 82.3%, respectively [Table 2]. On the contrary, the clinical success rate in the L-MTA group was found to be 95%, 94.74%, and 94.44% at 3, 6, and 9 months, respectively, with the radiographic success rate reported being 90%, 89.47%, and 88.89%, respectively [Table 3].
Table 1: Distribution of pulpotomized teeth according to mean age and gender in the two groups

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Table 2: Clinical and radiographic evaluation of pulpotomized teeth using mineral trioxide aggregate at various follow-up intervals

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Table 3: Clinical and radiographic evaluation of pulpotomized teeth using mineral trioxide aggregate and laser at various follow-up intervals

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  Discussion Top


The vital pulpotomy procedures have always been a topic of debate.[9] Of late, numerous studies on the use of lasers for carrying out pulpotomy procedures have shown promising results, though, a large database is still lacking. Lasers that have been tested and have demonstrated predictable outcomes in pulpotomy procedures include CO2, Nd: YAG, and Er: YAG lasers. In the previous studies conducted by Shoji et al.[7] and Elliott et al.,[10] CO2 lasers exhibited moderate degree of success when compared with the Nd:YAG and Er:YAG lasers in pup treatments. Miserendino et al.,[11] also, showed negative attributes of CO2 lasers causing medium-extent peripheral thermal damage to the surrounding pulpal tissues.

Mareddy et al.[8] reported 810 nm at 2W for 1 and 3 s applications to be the most ideal for diode laser pulpotomy procedures as most of the specimens showed intact odontoblasts. Thus, in the present study, also, Diode Laser (Picasso, Germany) of 810 nm with continuous mode of application for approximately 2 s delivered by 200 μ optical fiber tip in contact mode at 1.5W power was used. This was in accordance with the study conducted by Saltzman et al.[5] Liu et al.,[12] also, found high clinical success for cavity preparation procedures in children with Nd: YAG lasers at 2W power without having significant detrimental effects on the deeper pulpal tissues.

Furthermore, since MTA, too, is a material which is known to have proven therapeutic advantages in various endodontic procedures of primary teeth,[13],[14],[15],[16] the presentin vivo study intended to compare the clinical and radiographic success rates of MTA pulpotomy and diode laser-assisted MTA (L-MTA) pulpotomy in human primary molars.

In the present study, the clinical and radiographic success rate in the L-MTA group was found to be higher than the group, in which MTA was used alone. This was in close accordance with the studies conducted by Agamy et al.,[2] wherein a clinical success rate of 84.2% was found at 12 months follow-up visit for MTA pulpotomy and Liu et al.[12] who reported a clinical and radiographic success rate of 97% and 95.38%, respectively, in case of Nd: YAG laser-assisted pulpotomy.

The clinical outcome in the L-MTA group in the present study was found to be a little lower than those observed in the studies of Golpayegani et al.,[17] Durmus and Tanboga,[18] Yadav et al.,[19] and Gupta et al.[20] who reported 100% clinical success rates, respectively, in their studies. The noncompliance of the patients and patient dropouts might be the reasons for the relatively low success rate seen in the present study as compared to the said studies. Huth et al.,[21] also, observed a comparatively lower clinical success rate of 78% in their study.

The radiographic success rate of 90%, 89.47%, and 88.89%, respectively, in the L-MTA group in the present study, was, also, found to be in close accordance with the study conducted by Elliott et al.[10] who reported a radiographic success rate of 86.7% when CO2 laser was used for pulpotomy procedures. Furthermore, this was in accordance with the studies conducted by Saltzman et al.,[5] Liu et al.,[12] and Golpayegani et al.[17] who reported a success rate of 70.8%, 94%, and 67%, respectively, in their studies using diode laser-MTA pulpotomy, Er: YAG laser, and low-level laser therapy for pulpotomy procedures in their studies. Similarly, Peng et al.,[22] Subramaniam et al.,[23] and Kabaktchieva and Gateva[24] reported 95%, 95%, and 90.9% success rates, respectively, in their studies in cases where MTA pulpotomy was chosen to be the mode of treatment as the pulp therapy.

Furthermore, among the evaluated cases, 1 tooth each revealed symptom of pain and tenderness to vertical percussion on clinical evaluation, while 2 teeth showed periodontal ligament space widening and furcation radiolucency and 1 tooth, furcation and/or peri-apical radiolucency on radiographic evaluation in the MTA group. On the contrary, only 1 tooth revealed symptom of pain on clinical evaluation while 1 tooth each showed periodontal ligament space widening and furcation radiolucency and furcation and/or peri-apical radiolucency on radiographic evaluation in the L-MTA group in the present study.

Caicedo et al.,[25] also, reported one case with postoperative pain in MTA pulpotomized tooth while Saltzman et al.[5] reported no pain in the diode laser-MTA pulpotomy. Jayam et al.,[1] Agamy et al.,[2] and Eidelman et al.,[26] also, reported 100% clinical success rates with no postoperative morbidity in the MTA pulpotomy group. Caicedo et al.,[25] also, reported one case each with swelling and fistulation postoperatively in the MTA group. The observation of swelling and fistulation postoperatively may be attributed to the chronic inflammation of the pulp seen, and subsequently, the periapical tissues leading to edema and eventual, fistula formation in the said cases. Golpayegani et al.[17] reported signs of periapical radiolucency in two of the cases with low-level laser pulpotomy procedure while Saltzman et al.[5] reported six of the laser-MTA cases with furcal and/or periapical radiolucency with or without pathologic root resorption. Caicedo et al.,[25] also, reported furcal radiolucency in one case in the MTA group apart from Agamy et al.[2] who reported furcal radiolucency in four of the selected cases after a span of 12-month with the first case showing radiolucency at 3-month follow-up visit in the MTA treated group.

The clinical success rate in the L-MTA group of the present study was found to be a little on the higher side than that observed in the studies of Cuadros-Fernández et al.[27] and Uloopi et al.[28] who reported 73.3% and 80% success rates, respectively. in their studies. The higher clinical success rate of 94.44% at 9 months in the present study could be attributed to the strict aseptic/sterilization protocol and the settings of the laser used in the study which might have been responsible for a faster and efficient healing of the pulpal tissue. Nonetheless, compliance of the patients is an important attribute to the success of any procedure done. In addition, human clinical trials that compare laser pulpotomies with existing pulpotomy techniques have, also, shown conflicting results with any variation in the laser application parameters including the power, frequency, exposure time, and water/air dry-mode bringing variations in the response of the pulpal tissues varying the clinical and radiographic outcomes.[18]

A detailed analysis of failures is seldom reported followingin vivo clinical trials of pulpal-treated human teeth. It is quite possible that the laser-assisted MTA pulpotomy is more sensitive to operator technique. Because of the design of the present study, it is difficult to tell whether diode laser or, the MTA was having the primary effect on the treatment outcomes. The diode laser itself may produce medium-extent peripheral thermal damage to the surrounding pulp tissue similar to CO2 lasers as was reported by Miserendino et al.[11] Nevertheless, with appropriate (water) cooling of the tissues, charring can be prevented. Potential thermal damage may, also, be prevented by reducing the wattage of the power emitted through the laser tip by reducing the pulse frequency or, by reducing the total laser application time in addition to the use of copious water irrigation during laser application. Futurein vitro studies, though, with histological analysis as suggested by Kimura et al.,[29] thus, may be necessary to determine the appropriate settings for the diode laser when treating pulpally involved human primary teeth.

Failures of pulpotomy procedures are attributed to several reasons one of which is the failure in diagnosing chronically inflamed pulp as noninflamed and noninfected with the lesions being silent in the process of chronic inflammation. More accurate diagnostic methods might be the prerequisite in a proper case selection of teeth with healthy radicular pulps for successful clinical outcomes of pulpotomy procedures. The difference in the results obtained in the various studies conducted is due a number of factors that decide the long-term success of the procedures starting from a proper case selection to a strict aseptic protocol, parameters of the laser being used and last, but not the least, the compliance of the patient for the procedure performed.

Limitations

Despite the promising findings regarding the use of the combination of diode laser and MTA in the present study, the follow-up period was relatively short because of which it was difficult to predict the long-term outcomes of the said therapy and procedures. Furthermore, the present study did not take into consideration the evaluation of histological changes in the pulp and relied solely on the clinical and radiographic findings which might be misleading in certain situations mandating the need for further studies to be conducted in this regard taking into consideration the said limitations of the present study.


  Conclusion Top


Combination of diode laser and MTA yielded better clinical and radiographic success rates over the pulpotomy procedures done with the help of MTA alone, though, considering certain factors such as the cost, the clinical setup required for lasers, and ease of manipulation make the use of lasers a little restricted.

Acknowledgment

To all the patients who contributed in the study without whom this study would not have been feasible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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