- Email: [email protected]
Ca(OH)2 pulpotomy in primary teeth. Part I: internal resorption as a complication following pulpotomy
Ca(OH)2 pulpotomy in primary teeth. Part I: internal resorption as a complication following pulpotomy Deniz Sönmez, DDS, PhD, and Leyla Durutürk, DDS, Ankara, Turkey ANKARA UNIVERSITY
Objectives. The aim of this study was to analyze the outcomes of Ca(OH)2 pulpotomies, to investigate the incidence of internal resorption following pulpotomy, and to investigate the relationship between internal resorption and physiological root resorption. Study design. Pulpotomies were performed in 84 primary molars. Teeth were grouped according to type of exposure (mechanical or carious) and according to whether or not physiological root resorption has started. All teeth were followed for 12 months. Results. Teeth with larger-than-pinpoint carious exposure had the lowest success rate (65.5%). Internal resorption accounted for 15 out of 17 failures (88.2%). There was no significant difference in the rate of internal resorption between teeth with and without physiological root resorption (19.6% and 15.8%, respectively; P ⬎ .05). Conclusion. The greater the area of carious exposure, the lower the success rate in pulpotomies. Internal resorption was the main reason for failure; however, internal resorption was not affected by physiological root resorption. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e94-e98)
The pulpotomy procedure is based on the rationale that following the surgical amputation of affected or infected coronal pulp, the remaining radicular pulp tissue is healthy or capable of healing if it is protected by a biological wound dressing material that promotes the formation of a hard-tissue barrier.1,2 An increasing number of studies examining the use of Ca(OH)2 as a safe alternative to formocresol suggest that the idea of leaving vital, healthy radicular pulp and covering it with Ca(OH)2, which is capable of promoting pulp repair and healing, has regained popularity.3-7 At the same time, the use of Ca(OH)2 in pulpotomies of vital primary teeth has been called into question due to the occurrence of internal root resorption following pulpotomy. In such cases, treatment is considered to be a failure, as internal root resorption is viewed as an indication of chronic inflammation of the residual pulp. However, judging from the literature, the exact mechanism behind the inflammation that promotes internal resorption is not yet properly understood.8,9 Some studies have suggested that the healing capacity of primary pulp decreases in connection with the progress of root resorption8,10 and that physiological root resorption may stimulate internal resorption,11,12 whereas others have suggested that no substantial Faculty of Dentistry, Department of Pedodontics, Ankara University, Ankara, Turkey. Received for publication Jun 12, 2007; returned for revision Apr 10, 2008; accepted for publication Apr 16, 2008. 1079-2104/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2008.04.008
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changes occur in the structural features or vital functions of primary teeth pulp, despite advanced stages of root resorption.9,13 This study aimed to analyze the outcomes of Ca(OH)2 pulpotomies, to determine the incidence of internal resorption among overall treatment failures, and to evaluate the role of physiological root resorption on internal resorption in primary teeth. MATERIALS AND METHODS Subjects were selected from among those patients applying to the Pediatric Dentistry Clinic at the Ankara University, Faculty of Dentistry, requiring pulpotomy treatment of 1 or more primary molars. The research protocol was reviewed and approved by the Faculty of Dentistry Ethics Committee, and informed consent was obtained from the parents of all children who participated in the study. A total of 84 mandibular primary molars (39 first and 45 second primary molars) from 48 healthy and cooperative children (24 boys, 24 girls) aged 4 to 9 years were selected according to the following criteria: presence of deep carious lesions (radiographically shown to approximate the pulp); exposure of vital pulp during caries excavation; root resorption of less than one third the total root length; possibility of restoration following pulpotomy; absence of any symptoms indicating advanced pulpal inflammation; absence of clinical signs or symptoms suggesting a non-vital tooth; absence of radiographically demonstrable pathology; cessation of hemorrhaging of the amputated pulp stump within 5 minutes.2,6,13-16
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The pulpotomy procedure Ultracaine D-S with 1:200,000 epinephrine (Aventis, Istanbul, Turkey) was administered as a local anesthesic. Cotton rolls and suction were used for isolation in all patients (in order to standardize procedures), since some children under age 6 could not tolerate a rubber dam. All caries were removed. Upon pulpal exposure during cavity preparation, the status of the exposure site and the amount and characteristics of bleeding were evaluated. If the bleeding was easily controlled and light red in color, the inflammatory process was judged to be limited to the coronal pulp. Following this diagnosis, the pulp chamber roof was removed, and the coronal pulp was amputated using a high-speed instrument with a sterile diamond bur and continuous water spray (gentle technique). All remaining pulp tissue was excavated, and the chamber was irrigated with normal saline. Hemorrhaging was controlled by placing a sterile cotton pellet over the radicular pulp stump using light pressure. The pellet was removed within 5 minutes, and the hemorrhaging was reevaluated to determine whether or not the radicular pulp was free from inflammation. Amputation stumps were covered with a Ca(OH)2 paste composed of Ca(OH)2 powder (Kalsin, Aktu Ticaret, Izmir, Turkey) and sterile saline. A sterile cotton pellet was used to gently press the paste against the wound surface to ensure direct contact with the pulp tissue. The cavity was sealed with zinc oxide-eugenol cement, and the tooth was restored with a stainless steel crown (3M ESPE Dental Products, St. Paul, MN, USA) during the same visit. Study groups Teeth were grouped according to the status of pulpal exposure as either Mechanically Exposed or Cariously Exposed, with the Cariously Exposed Group subdivided into 2 groups according to the size of the exposure site (pinpoint or larger-than-pinpoint). Teeth were also grouped according to physiological root resorption status. Patient age was used as the criterion in distributing teeth between the groups, since physiological root resorption begins at as early as 6 years of age for mandibular primary first molars and eight years of age for second molars, as described by Kronfeld and Ireland.17 The study groups were as follows: A. According to Pulpal Exposure (84 teeth) Mechanically Exposed Group: Larger-than-pinpoint pulpal exposure (26 teeth) Cariously Exposed Groups: Cariously Exposed Group 1 (Pinpoint) (29 teeth) Cariously Exposed Group 2 (Larger-than-pinpoint) (29 teeth)
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B. According to Physiological Root Resorption (84 teeth) Teeth in which physiological root resorption has started (38 teeth) Teeth in which physiological root resorption has not started (46 teeth) Postoperative evaluation Postoperative periapical radiographs were taken immediately after treatment, and subjects were recalled for clinical and radiographic examinations at 1, 3, 6, and 12 months post-treatment. Treatment was judged a failure if one or more of the following clinical or radiographic findings were present: history of pain, thermal sensitivity, sensitivity to sweet/sour, swelling, sinus tract, tenderness to percussion, tooth mobility, loss of lamina dura, furcation radiolucency, periapical bone loss, internal resorption. Failures were either treated by pulpectomy or extracted. Clinical and radiographic evaluations were performed at each follow-up visit by 2 blind examiners. Radiographic assessments were based on periapical radiographs taken under standardized conditions using ORIX 65/10 (AET; Ardet, Buccinasco, Italy) and KODAK ultraspeed film (Speed Group D) with similar exposure times and fixed film:object:tube distance. All film was developed with an automatic processor (Dürr Dental, DL 24, Bietigheim Bissingen, Germany). Follow-up radiographs were compared with preoperative radiographs using a radiographic view box with no magnification. Reevaluation of 10% of the radiographs assessed demonstrated intra-examiner reliability. In cases where, following discussion, the 2 examiners continued to disagree on the treatment outcome, the treatment was judged a failure. Chi-square tests were used to identify significant differences between groups. RESULTS Clinical and radiographic findings At the end of a 12-month follow-up period, 31 (79.5%) of 39 primary first molars and 36 (80%) of 45 primary second molars were judged successful. The difference in success rates between tooth types was not statistically significant (P ⬎ .05). (The rates reported below are combined rates for all molars.) Pulpotomy success rates at the end of the 12-month follow-up period for each group are shown in Table I. There were no significant differences in success rates between the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint exposure) or between Cariously Exposed Group 1 (pinpoint exposure) and Cariously Exposed Group 2 (larger-than-pinpoint exposure) (P ⬎ .05); however, the difference in success
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Table I. Success rate of the groups after 12 months Groups
Successful (%)
Mechanically exposed Group (n ⫽ 26) Cariously exposed Group 1 (n ⫽ 29) Cariously exposed Group 2 (n ⫽ 29) Total (n ⫽ 84)
23 (88.5) 25 (86.2) 19 (65.5) 67 (79.7)
rates between the Mechanically Exposed Group and Cariously Exposed Group 2 (larger-than-pinpoint exposure) was found to be statistically significant (P ⬍ .05). The distribution of causes of failure at the end of the 12-month follow-up period is shown in Table II. Whereas internal resorption was found in 15 (17.9%) of the 84 treated teeth, periradicular pathological changes were found in only 4 teeth (4.8%). The difference in these rates was statistically significant (P ⬍ .05). Moreover, internal resorption was observed in all groups at similar rates (P ⬎ .05), whereas periradicular pathological changes were observed in the Cariously Exposed Group 2 (larger-than-pinpoint exposure) only. Out of a total of 17 teeth judged to be failures, 15 (88.2%) showed internal resorption. Internal resorption was present in all of the failed cases in the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint exposure) (100%) and 8 (80%) of the 10 failed teeth in Cariously Exposed Group 2 (larger-thanpinpoint exposure) (Table III). When looked at in connection with physiological resorption, internal resorption was found to be present in 6 (15.8%) of the 38 teeth with physiologically resorbed roots and 9 (19.6%) of the 46 teeth with nonresorbed roots. The difference in these rates was not statistically significant (P ⬎ .05). DISCUSSION Internal resorption following pulpotomy is generally considered to be indicative of inflammation of the residual pulp.11,18,19 For this reason, the condition of the pulp at the time of operation and the factors thought to influence the response of pulpal tissue to treatment should be the first items to be discussed with regard to pulpotomy treatment outcomes. Although it has been suggested that pulpal healing is not affected by the size of pulpal exposure when exposure occurs as a result of mechanical injury to healthy pulp,20,21 there is general agreement that extensive exposure may lead to extensive tissue destruction.22 For this reason, deciduous teeth with larger-than-pinpoint exposure do not lend themselves to direct pulp capping, even if they are surrounded by sound dentin.12 Accordingly, teeth with larger-than-pinpoint mechanical expo-
sure and little or no hemorrhaging at the point of exposure are considered candidates for pulpotomy, since their radicular pulp tissue is considered capable of maintaining its vitality following the pulpotomy procedure. In teeth with carious exposure, the pulp is usually inflamed, and the degree of inflammation is usually directly related to the size of exposure.18,23 For this reason, cariously exposed teeth in this study were also grouped according to the size of exposure. This study defined the success of pulpotomy treatment as the absence of clinical or radiographic pathology at follow-up appointments. A number of studies have reported that reparative dentin formation is not necessary for successful pulpotomy treatment6,11,15; therefore, reparative dentin formation was not included among the treatment evaluation criteria in this study. Since the overwhelming majority of the literature considers internal resorption to be an indication of pulpotomy failure,1,8,11,12,15,18,19,24-28 internal resorption in one or more canal was considered to be a sign of treatment failure in the present study. Although this study applied accepted diagnostic criteria to indicate which teeth were suitable candidates for pulpotomy,1,12,13,18,29-32 the statistically lower success rate observed in Cariously Exposed Group 2 (larger-than-pinpoint) when compared to the Mechanically Exposed Group may be attributed to an incorrect initial diagnosis resulting from a lack of correlation between clinical symptoms and histopathological conditions; i.e., undetected inflammation of the coronal pulp in Cariously Exposed Group 2. The large area of exposure surrounded by carious dentin in this group implies a greater chance for contamination by microorganisms and expansion of inflammation deeper into the pulp.18,30 Since the difference in success rates between the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint) was not statistically significant, it may be stated confidently that the possibility of misdiagnosing the pulpal condition in Cariously Exposed Group 1 seems low. The difference in success rates between Cariously Exposed Group 1 (pinpoint) and Cariously Exposed Group 2 (larger-than-pinpoint) was also insignificant; however, the rate was higher in Cariously Exposed Group 1. It may be emphasized that the smaller the area of carious exposure, the higher the possibility of limiting inflammation to the coronal pulp, which affects healing potential.1,13,18,30,33 In addition to the condition of the pulp at the time of amputation, the success of pulpotomy depends on proper sealing of the cavity.1,26,27,30,34,35 If the remaining pulp is free from inflammation following pulpotomy, the pulp can be expected to heal itself, as it is
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Table II. Causes of pulpotomy failure Cause of Failure
Mechanically Exp. Group (n ⫽ 26)
Cariously Exp. Group 1 (n ⫽ 29)
Cariously Exp. Group 2 (n ⫽ 29)
Total (n ⫽ 84)
Periradicular pathology I˙nternal resorption
__ 3 (11.5%)
__ 4 (13.8%)
4 (13.8%) 8 (27.6%)
4 (4.8%) 15 (17.8%)
Table III. Scores of internal resorption in failed cases in groups Groups
Total failure
Internal resorption
Mechanically Exposed Group (n ⫽ 26) Cariously Exposed Group 1 (n ⫽ 29) Cariously Exposed Group 2 (n ⫽ 29) Total (n ⫽ 84)
3
3 (100%)
4
4 (100%)
10
8 (80%)
17
15 (88.2%)
effectively protected against bacterial invasion by the SSC.3,14,18,30,35,36 In this study, the absence of periradicular pathology in the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint) can be explained by the fact that the remaining pulp tissue was either healthy or capable of healing, since the SSC would prevent contamination by oral fluids. Conversely, the periradicular pathology observed in 4 of the 29 teeth in Cariously Exposed Group 2 (larger-thanpinpoint) may be said to have developed as a complication resulting from a preexisting infection of the pulp tissue at the time of treatment (Table II). A number of previous studies have also suggested that the presence of undiagnosed chronically inflamed residual pulp is the main reason for internal resorption.1,6,9 Given that osteoclastic activity occurs only in the presence of inflammation and not in healthy pulp,26,33 internal resorption and pulpal inflammation should be discussed together. Viewed from this perspective, it is possible to suggest that the internal resorption observed in Cariously Exposed Group 2 (larger than-pinpoint) in this study occurred as the result of a pre-existing inflammation of the radicular pulp; however, considering the fact that the pulp remaining after pulpotomy in the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint exposure) was considered to be either healthy or only slightly inflamed and capable of self-healing, it remains to be explained why internal resorption continued to be observed in these groups at the end of the 12-month follow-up period. It should be noted that some earlier studies have shown resorption to be arrested during the course of healing and to remain unchanged over longterm observation11,19,37; therefore, it has also been con-
sidered acceptable to assess as normal the continued presence of resorptive areas in the final treatment evaluation.37 Many authors claim that morphological, histological, and biochemical changes occur with the initiation of physiological root resorption in primary teeth,22,33 and that as osteoclastic activity increases, the risk of internal resorption may also increase.6,8,18,33 However, this study found no relationship between internal resorption and physiological root resorption. The same finding was also reported by Magnusson (1978).27 In conclusion, this study indicated that internal resorption occurring as a complication following Ca(OH)2 pulpotomy is the main reason for treatment failure and that physiological root resorption does not affect internal resorption. We thank Prof. Fikret Gurbuz for his kind help with the statistical analysis in this study. REFERENCES 1. Schröder U, Heide S, Höskuldsson E, Rolling I. Endodontics. In: Koch G, Modeer T, Paulsen S, Rasmussen P, editors. Pedodontics: A clinical approach. Copenhagen: Munksgaard; 1994. p. 185–201. 2. Fuks AB. Current concepts in vital primary pulp therapy. Eur J Pediatr Dent 2002;3:115-20. 3. 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. 4. Lewis BB, Chestner SB. Formaldehyde in dentistry a review of mutagenic and carsinogenic potential. J Am Dent Assoc 1981; 103:429-34. 5. Ranly DM, Garcia-Godoy F. Current and potential pulp therapies for primary and young permanent teeth. J Dent 2000;28:153-61. 6. Mejare I. Endodontics in primary teeth. In: Bergenholtz G, Horsted-Bindslev T, Reit C, editors. Textbook of endodontology. Blackwell: Munksgaard; 2003. p. 92–104. 7. Hunter L, Hunter B. Vital pulpotomy in the primary dentition: attitudes and practices of specialists in paediatric dentistry practicing in the United Kingdom. Int J Paeditr Dent 2003;13:246-50. 8. Papagiannoulis L. Clinical studies on ferric sulphate as a pulpotomy medicament in primary teeth. Eur J Paediatr Dent 2002;3:126-32. 9. Schröder U. A 2-year follow-up of primary molars pulpotomized with a gentle technique and capped with calcium hydroxide. Scand J Dent Res 1978;86:273-8. 10. Kennedy DB, Kapala JT. The dental pulp: biologic principles of protection and treatment. In: Braham L, Morris E. Textbook of pediatric dentistry. Baltimore: Williams-Wilkins; 1985. p. 237-49. 11. Kalaskar RR, Damle G. Comparative evaluation of lyophilized
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freeze dried platelet derived preparation with calcium hydroxide as pulpotomy agents in primary molars. J Indian Soc Pedod Prev Dent 2004;22:24-9. Magnusson BO. Pulpotomy in primary molars: long-term clinical and histological evaluation. Int Endod J 1980;13:143-55. Troutman KC, Reisbick H, Berson RB, Good DL, Gutmann JL. Pulp therapy. In: Stewart RE, Barber TK, Troutman KC, Wei SHY, editors. Pediatric dentistry - Scientific foundations and clinical practice. St. Louis: Mosby; 1982. p. 908 – 41. Guelmann M, Fair J, Turner C, Courts FJ. The success of emergency pulpotomies in primary molars. Pediatr Dent 2002; 24:217-20. Markovic D, Zivojinovic V, Vucetic M. Evaluation of three pulpotomy medicaments in primary teeth. Eur J Paediatr Dent 2005;6:133-8. Heilig J, Yates J, Siskin M, McKnigth J, Turner J. Calcium hydroxide pulpotomy for primary teeth: a clinical study. J Am Dent Assoc 1984;108:775-7. Kronfeld R. The resorption of the roots of deciduous teeth. Dent ¨ Cosmos 1932;74:103-20. In: Günhan A. Pedodonti. I˙stanbul: I˙ U Basımevi; 1994. p. 46-9. McDonald RE, Avery DR, Dean JA. Treatment of deep caries, vital pulp exposure and pulpless teeth. In: McDonald RE, Avery DR, editors. Dentistry for the child and the adolescent. St. Louis: Mosby; 2000. p. 413–37. Smith NL, Seale NS, Nunn ME. Ferric sulfate pulpotomy in primary molars: a retrospective study. Pediatr Dent 2000;22: 192-9. Cvec M A. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fractures. J Endod 1978;4:232. Pereira JC, Stanley HR. Pulp capping: influence of the exposure site on pulp healing— histologic and radiographic study in dog’s pulp. J Endod 1981;7:213. Greeley MCB. Pulp therapy for the primary and the young permanent dentition. In: Forrester DC, Wagner ML, Fleming J, editors. Pediatric dental medicine. Philedelphia; Lea & Febiger; 1981. p. 456-60. Koch G, Nyborg H. Corelation between clinical and histological indications for pulpotomy of deciduous teeth. J Int Assoc Dent Child 1970;1:3-10. Law DB. An evaluation of vital pulpotomy technique. J Dent Child 1956;23:40-4. Waterhouse PJ, Nunn JH, Whitworth JM. An investigation of the
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relative efficacy of Buckley’s formocresol and calcium hydroxide in primary molar vital pulp therapy. Brit Dent J 2000; 188:32-6. Waterhouse PJ, Nunn JH, Whitworth JM, Soames JV. Primary molar pulp therapy— histological evaluation of failure. Int J Paediatric Dent 2000;10:313-21. Magnusson B. Therapeutic pulpotomies in primary molars with the Formocresol technique. Acta Odontol Scand 1978;36:157-65. Fishman SA, Udin RD, Good DL, Rodef F. Success of electrofulguration pulpotomies covered by zinc oxide and eugenol or calcium hydroxide: a clinical study. Pediatr Dent 1996;18: 385-90. Mathewson RJ, Primosch RE, editors. Fundamentals of pediatric dentistry. Chicago; Quintessence; 1995. p. 257-80. Camp JH, Barrett EJ, Pulver F. Pediatric endodontics: endodontic treatment for the primary and young permanent dentition. In: Cohen S, Burns RC, editors. Pathways of the pulp. St. Louis: Mosby; 2002. p. 797– 816. Carotte P. Endodontic treatment for children. Br Dent J 2005; 198:9-15. Fuks AB. Pulp therapy for the primary and young permanent dentitions. Dent Clin North Am 2000;44:571-96. Hobson P. Pulp treatment of deciduous teeth. Part 1: Factors affecting diagnosis and treatment. Br Dent J 1970;128:232-8. Gruythuysen RJM, Weerheijm KL. Calcium hydroxide pulpotomy with a light-cured cavity sealing material after two years. J Dent Child 1997;64:251-3. Stanley HR. Pulp capping: conserving the dental pulp—Can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol 1989; 68:628-39. Croll TP, Killian CM. Zinc oxide-eugenol pulpotomy and stainless steel crown restoration of a primary molar. Quintessence Int 1992;23:383-8. Fuks AB, Holan G, Davis JM, Eidelman E. Ferric sulphate versus dilute formocresol in pulpotomized primary molars. Long-term follow-up. Pediatr Dent 1997;19:327-30.
Reprint requests: Prof. Leyla Duruturk Ankara University Faculty of Dentistry Department of Pedodontics Besevler 06500 Ankara, Turkey [email protected]
Objectives. The aim of this study was to analyze the outcomes of Ca(OH)2 pulpotomies, to investigate the incidence of internal resorption following pulpotomy, and to investigate the relationship between internal resorption and physiological root resorption. Study design. Pulpotomies were performed in 84 primary molars. Teeth were grouped according to type of exposure (mechanical or carious) and according to whether or not physiological root resorption has started. All teeth were followed for 12 months. Results. Teeth with larger-than-pinpoint carious exposure had the lowest success rate (65.5%). Internal resorption accounted for 15 out of 17 failures (88.2%). There was no significant difference in the rate of internal resorption between teeth with and without physiological root resorption (19.6% and 15.8%, respectively; P ⬎ .05). Conclusion. The greater the area of carious exposure, the lower the success rate in pulpotomies. Internal resorption was the main reason for failure; however, internal resorption was not affected by physiological root resorption. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:e94-e98)
The pulpotomy procedure is based on the rationale that following the surgical amputation of affected or infected coronal pulp, the remaining radicular pulp tissue is healthy or capable of healing if it is protected by a biological wound dressing material that promotes the formation of a hard-tissue barrier.1,2 An increasing number of studies examining the use of Ca(OH)2 as a safe alternative to formocresol suggest that the idea of leaving vital, healthy radicular pulp and covering it with Ca(OH)2, which is capable of promoting pulp repair and healing, has regained popularity.3-7 At the same time, the use of Ca(OH)2 in pulpotomies of vital primary teeth has been called into question due to the occurrence of internal root resorption following pulpotomy. In such cases, treatment is considered to be a failure, as internal root resorption is viewed as an indication of chronic inflammation of the residual pulp. However, judging from the literature, the exact mechanism behind the inflammation that promotes internal resorption is not yet properly understood.8,9 Some studies have suggested that the healing capacity of primary pulp decreases in connection with the progress of root resorption8,10 and that physiological root resorption may stimulate internal resorption,11,12 whereas others have suggested that no substantial Faculty of Dentistry, Department of Pedodontics, Ankara University, Ankara, Turkey. Received for publication Jun 12, 2007; returned for revision Apr 10, 2008; accepted for publication Apr 16, 2008. 1079-2104/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2008.04.008
e94
changes occur in the structural features or vital functions of primary teeth pulp, despite advanced stages of root resorption.9,13 This study aimed to analyze the outcomes of Ca(OH)2 pulpotomies, to determine the incidence of internal resorption among overall treatment failures, and to evaluate the role of physiological root resorption on internal resorption in primary teeth. MATERIALS AND METHODS Subjects were selected from among those patients applying to the Pediatric Dentistry Clinic at the Ankara University, Faculty of Dentistry, requiring pulpotomy treatment of 1 or more primary molars. The research protocol was reviewed and approved by the Faculty of Dentistry Ethics Committee, and informed consent was obtained from the parents of all children who participated in the study. A total of 84 mandibular primary molars (39 first and 45 second primary molars) from 48 healthy and cooperative children (24 boys, 24 girls) aged 4 to 9 years were selected according to the following criteria: presence of deep carious lesions (radiographically shown to approximate the pulp); exposure of vital pulp during caries excavation; root resorption of less than one third the total root length; possibility of restoration following pulpotomy; absence of any symptoms indicating advanced pulpal inflammation; absence of clinical signs or symptoms suggesting a non-vital tooth; absence of radiographically demonstrable pathology; cessation of hemorrhaging of the amputated pulp stump within 5 minutes.2,6,13-16
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The pulpotomy procedure Ultracaine D-S with 1:200,000 epinephrine (Aventis, Istanbul, Turkey) was administered as a local anesthesic. Cotton rolls and suction were used for isolation in all patients (in order to standardize procedures), since some children under age 6 could not tolerate a rubber dam. All caries were removed. Upon pulpal exposure during cavity preparation, the status of the exposure site and the amount and characteristics of bleeding were evaluated. If the bleeding was easily controlled and light red in color, the inflammatory process was judged to be limited to the coronal pulp. Following this diagnosis, the pulp chamber roof was removed, and the coronal pulp was amputated using a high-speed instrument with a sterile diamond bur and continuous water spray (gentle technique). All remaining pulp tissue was excavated, and the chamber was irrigated with normal saline. Hemorrhaging was controlled by placing a sterile cotton pellet over the radicular pulp stump using light pressure. The pellet was removed within 5 minutes, and the hemorrhaging was reevaluated to determine whether or not the radicular pulp was free from inflammation. Amputation stumps were covered with a Ca(OH)2 paste composed of Ca(OH)2 powder (Kalsin, Aktu Ticaret, Izmir, Turkey) and sterile saline. A sterile cotton pellet was used to gently press the paste against the wound surface to ensure direct contact with the pulp tissue. The cavity was sealed with zinc oxide-eugenol cement, and the tooth was restored with a stainless steel crown (3M ESPE Dental Products, St. Paul, MN, USA) during the same visit. Study groups Teeth were grouped according to the status of pulpal exposure as either Mechanically Exposed or Cariously Exposed, with the Cariously Exposed Group subdivided into 2 groups according to the size of the exposure site (pinpoint or larger-than-pinpoint). Teeth were also grouped according to physiological root resorption status. Patient age was used as the criterion in distributing teeth between the groups, since physiological root resorption begins at as early as 6 years of age for mandibular primary first molars and eight years of age for second molars, as described by Kronfeld and Ireland.17 The study groups were as follows: A. According to Pulpal Exposure (84 teeth) Mechanically Exposed Group: Larger-than-pinpoint pulpal exposure (26 teeth) Cariously Exposed Groups: Cariously Exposed Group 1 (Pinpoint) (29 teeth) Cariously Exposed Group 2 (Larger-than-pinpoint) (29 teeth)
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B. According to Physiological Root Resorption (84 teeth) Teeth in which physiological root resorption has started (38 teeth) Teeth in which physiological root resorption has not started (46 teeth) Postoperative evaluation Postoperative periapical radiographs were taken immediately after treatment, and subjects were recalled for clinical and radiographic examinations at 1, 3, 6, and 12 months post-treatment. Treatment was judged a failure if one or more of the following clinical or radiographic findings were present: history of pain, thermal sensitivity, sensitivity to sweet/sour, swelling, sinus tract, tenderness to percussion, tooth mobility, loss of lamina dura, furcation radiolucency, periapical bone loss, internal resorption. Failures were either treated by pulpectomy or extracted. Clinical and radiographic evaluations were performed at each follow-up visit by 2 blind examiners. Radiographic assessments were based on periapical radiographs taken under standardized conditions using ORIX 65/10 (AET; Ardet, Buccinasco, Italy) and KODAK ultraspeed film (Speed Group D) with similar exposure times and fixed film:object:tube distance. All film was developed with an automatic processor (Dürr Dental, DL 24, Bietigheim Bissingen, Germany). Follow-up radiographs were compared with preoperative radiographs using a radiographic view box with no magnification. Reevaluation of 10% of the radiographs assessed demonstrated intra-examiner reliability. In cases where, following discussion, the 2 examiners continued to disagree on the treatment outcome, the treatment was judged a failure. Chi-square tests were used to identify significant differences between groups. RESULTS Clinical and radiographic findings At the end of a 12-month follow-up period, 31 (79.5%) of 39 primary first molars and 36 (80%) of 45 primary second molars were judged successful. The difference in success rates between tooth types was not statistically significant (P ⬎ .05). (The rates reported below are combined rates for all molars.) Pulpotomy success rates at the end of the 12-month follow-up period for each group are shown in Table I. There were no significant differences in success rates between the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint exposure) or between Cariously Exposed Group 1 (pinpoint exposure) and Cariously Exposed Group 2 (larger-than-pinpoint exposure) (P ⬎ .05); however, the difference in success
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Table I. Success rate of the groups after 12 months Groups
Successful (%)
Mechanically exposed Group (n ⫽ 26) Cariously exposed Group 1 (n ⫽ 29) Cariously exposed Group 2 (n ⫽ 29) Total (n ⫽ 84)
23 (88.5) 25 (86.2) 19 (65.5) 67 (79.7)
rates between the Mechanically Exposed Group and Cariously Exposed Group 2 (larger-than-pinpoint exposure) was found to be statistically significant (P ⬍ .05). The distribution of causes of failure at the end of the 12-month follow-up period is shown in Table II. Whereas internal resorption was found in 15 (17.9%) of the 84 treated teeth, periradicular pathological changes were found in only 4 teeth (4.8%). The difference in these rates was statistically significant (P ⬍ .05). Moreover, internal resorption was observed in all groups at similar rates (P ⬎ .05), whereas periradicular pathological changes were observed in the Cariously Exposed Group 2 (larger-than-pinpoint exposure) only. Out of a total of 17 teeth judged to be failures, 15 (88.2%) showed internal resorption. Internal resorption was present in all of the failed cases in the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint exposure) (100%) and 8 (80%) of the 10 failed teeth in Cariously Exposed Group 2 (larger-thanpinpoint exposure) (Table III). When looked at in connection with physiological resorption, internal resorption was found to be present in 6 (15.8%) of the 38 teeth with physiologically resorbed roots and 9 (19.6%) of the 46 teeth with nonresorbed roots. The difference in these rates was not statistically significant (P ⬎ .05). DISCUSSION Internal resorption following pulpotomy is generally considered to be indicative of inflammation of the residual pulp.11,18,19 For this reason, the condition of the pulp at the time of operation and the factors thought to influence the response of pulpal tissue to treatment should be the first items to be discussed with regard to pulpotomy treatment outcomes. Although it has been suggested that pulpal healing is not affected by the size of pulpal exposure when exposure occurs as a result of mechanical injury to healthy pulp,20,21 there is general agreement that extensive exposure may lead to extensive tissue destruction.22 For this reason, deciduous teeth with larger-than-pinpoint exposure do not lend themselves to direct pulp capping, even if they are surrounded by sound dentin.12 Accordingly, teeth with larger-than-pinpoint mechanical expo-
sure and little or no hemorrhaging at the point of exposure are considered candidates for pulpotomy, since their radicular pulp tissue is considered capable of maintaining its vitality following the pulpotomy procedure. In teeth with carious exposure, the pulp is usually inflamed, and the degree of inflammation is usually directly related to the size of exposure.18,23 For this reason, cariously exposed teeth in this study were also grouped according to the size of exposure. This study defined the success of pulpotomy treatment as the absence of clinical or radiographic pathology at follow-up appointments. A number of studies have reported that reparative dentin formation is not necessary for successful pulpotomy treatment6,11,15; therefore, reparative dentin formation was not included among the treatment evaluation criteria in this study. Since the overwhelming majority of the literature considers internal resorption to be an indication of pulpotomy failure,1,8,11,12,15,18,19,24-28 internal resorption in one or more canal was considered to be a sign of treatment failure in the present study. Although this study applied accepted diagnostic criteria to indicate which teeth were suitable candidates for pulpotomy,1,12,13,18,29-32 the statistically lower success rate observed in Cariously Exposed Group 2 (larger-than-pinpoint) when compared to the Mechanically Exposed Group may be attributed to an incorrect initial diagnosis resulting from a lack of correlation between clinical symptoms and histopathological conditions; i.e., undetected inflammation of the coronal pulp in Cariously Exposed Group 2. The large area of exposure surrounded by carious dentin in this group implies a greater chance for contamination by microorganisms and expansion of inflammation deeper into the pulp.18,30 Since the difference in success rates between the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint) was not statistically significant, it may be stated confidently that the possibility of misdiagnosing the pulpal condition in Cariously Exposed Group 1 seems low. The difference in success rates between Cariously Exposed Group 1 (pinpoint) and Cariously Exposed Group 2 (larger-than-pinpoint) was also insignificant; however, the rate was higher in Cariously Exposed Group 1. It may be emphasized that the smaller the area of carious exposure, the higher the possibility of limiting inflammation to the coronal pulp, which affects healing potential.1,13,18,30,33 In addition to the condition of the pulp at the time of amputation, the success of pulpotomy depends on proper sealing of the cavity.1,26,27,30,34,35 If the remaining pulp is free from inflammation following pulpotomy, the pulp can be expected to heal itself, as it is
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Table II. Causes of pulpotomy failure Cause of Failure
Mechanically Exp. Group (n ⫽ 26)
Cariously Exp. Group 1 (n ⫽ 29)
Cariously Exp. Group 2 (n ⫽ 29)
Total (n ⫽ 84)
Periradicular pathology I˙nternal resorption
__ 3 (11.5%)
__ 4 (13.8%)
4 (13.8%) 8 (27.6%)
4 (4.8%) 15 (17.8%)
Table III. Scores of internal resorption in failed cases in groups Groups
Total failure
Internal resorption
Mechanically Exposed Group (n ⫽ 26) Cariously Exposed Group 1 (n ⫽ 29) Cariously Exposed Group 2 (n ⫽ 29) Total (n ⫽ 84)
3
3 (100%)
4
4 (100%)
10
8 (80%)
17
15 (88.2%)
effectively protected against bacterial invasion by the SSC.3,14,18,30,35,36 In this study, the absence of periradicular pathology in the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint) can be explained by the fact that the remaining pulp tissue was either healthy or capable of healing, since the SSC would prevent contamination by oral fluids. Conversely, the periradicular pathology observed in 4 of the 29 teeth in Cariously Exposed Group 2 (larger-thanpinpoint) may be said to have developed as a complication resulting from a preexisting infection of the pulp tissue at the time of treatment (Table II). A number of previous studies have also suggested that the presence of undiagnosed chronically inflamed residual pulp is the main reason for internal resorption.1,6,9 Given that osteoclastic activity occurs only in the presence of inflammation and not in healthy pulp,26,33 internal resorption and pulpal inflammation should be discussed together. Viewed from this perspective, it is possible to suggest that the internal resorption observed in Cariously Exposed Group 2 (larger than-pinpoint) in this study occurred as the result of a pre-existing inflammation of the radicular pulp; however, considering the fact that the pulp remaining after pulpotomy in the Mechanically Exposed Group and Cariously Exposed Group 1 (pinpoint exposure) was considered to be either healthy or only slightly inflamed and capable of self-healing, it remains to be explained why internal resorption continued to be observed in these groups at the end of the 12-month follow-up period. It should be noted that some earlier studies have shown resorption to be arrested during the course of healing and to remain unchanged over longterm observation11,19,37; therefore, it has also been con-
sidered acceptable to assess as normal the continued presence of resorptive areas in the final treatment evaluation.37 Many authors claim that morphological, histological, and biochemical changes occur with the initiation of physiological root resorption in primary teeth,22,33 and that as osteoclastic activity increases, the risk of internal resorption may also increase.6,8,18,33 However, this study found no relationship between internal resorption and physiological root resorption. The same finding was also reported by Magnusson (1978).27 In conclusion, this study indicated that internal resorption occurring as a complication following Ca(OH)2 pulpotomy is the main reason for treatment failure and that physiological root resorption does not affect internal resorption. We thank Prof. Fikret Gurbuz for his kind help with the statistical analysis in this study. REFERENCES 1. Schröder U, Heide S, Höskuldsson E, Rolling I. Endodontics. In: Koch G, Modeer T, Paulsen S, Rasmussen P, editors. Pedodontics: A clinical approach. Copenhagen: Munksgaard; 1994. p. 185–201. 2. Fuks AB. Current concepts in vital primary pulp therapy. Eur J Pediatr Dent 2002;3:115-20. 3. 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. 4. Lewis BB, Chestner SB. Formaldehyde in dentistry a review of mutagenic and carsinogenic potential. J Am Dent Assoc 1981; 103:429-34. 5. Ranly DM, Garcia-Godoy F. Current and potential pulp therapies for primary and young permanent teeth. J Dent 2000;28:153-61. 6. Mejare I. Endodontics in primary teeth. In: Bergenholtz G, Horsted-Bindslev T, Reit C, editors. Textbook of endodontology. Blackwell: Munksgaard; 2003. p. 92–104. 7. Hunter L, Hunter B. Vital pulpotomy in the primary dentition: attitudes and practices of specialists in paediatric dentistry practicing in the United Kingdom. Int J Paeditr Dent 2003;13:246-50. 8. Papagiannoulis L. Clinical studies on ferric sulphate as a pulpotomy medicament in primary teeth. Eur J Paediatr Dent 2002;3:126-32. 9. Schröder U. A 2-year follow-up of primary molars pulpotomized with a gentle technique and capped with calcium hydroxide. Scand J Dent Res 1978;86:273-8. 10. Kennedy DB, Kapala JT. The dental pulp: biologic principles of protection and treatment. In: Braham L, Morris E. Textbook of pediatric dentistry. Baltimore: Williams-Wilkins; 1985. p. 237-49. 11. Kalaskar RR, Damle G. Comparative evaluation of lyophilized
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Reprint requests: Prof. Leyla Duruturk Ankara University Faculty of Dentistry Department of Pedodontics Besevler 06500 Ankara, Turkey [email protected]