- Email: [email protected]
The effect of sodium hypochlorite application on the success of calcium hydroxide pulpotomy in primary teeth
The effect of sodium hypochlorite application on the success of calcium hydroxide pulpotomy in primary teeth Emine S¸en Tunç, PhD,a Is¸ıl S¸arog˘lu, PhD,b S¸aziye Sarı, PhD,c and Ömer Günhan, DDS, PhD,d Samsun, Kırıkkale, and Ankara, Turkey UNIVERSITY OF ONDOKUZ MAYIS, UNIVERSITY OF KIRIKKALE, UNIVERSITY OF ANKARA, AND GULHANE MILITARY MEDICAL ACADEMY
Objective. The aim of this study was to evaluate the effects of 3% sodium hypochlorite (NaOCl) used as a hemostatic agent on the outcome of calcium hydroxide pulpotomies of primary teeth. Study design. A total of 18 primary molars with advanced caries and root resorption of approximately half the root length were randomly placed into 2 groups. Conventional calcium hydroxide pulpotomies were performed on teeth in both groups; however, a cotton pellet saturated with 3% sodium hypochlorite was applied to teeth in the treatment group for 30 seconds before the pulpotomy to control hemorrhage. After the extraction of the teeth, they were examined histologically. Results. In the histologic evaluation it was found that none of the specimens in the control group showed necrosis and 1 specimen in the treatment group showed partial necrosis. Conclusion. It was found that the use of 3% NaOCl as a hemostatic agent had no effect on the outcome of calcium hydroxide pulpotomies with the given concentration and timing of the NaOCl treatment and the given observation period. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e22-e26)
Formocresol has been a popular pulpotomy medicament in pediatric dentistry for the past 60 years. It is the most universally taught and preferred pulp therapy for primary teeth.1 Although the efficacy of formocresol is unquestionable, doubts have recently arisen as to its safety. There have been worrisome reports of toxicity,2 postoperative systemic transport,3 negative effects on succedaneous tooth enamel,4 negative radiographic changes in treated teeth,5 and possible reversible fixation leading to auto-antibody formation.6 Most disturbing of all, formaldehyde, one of the components of formocresol, is now believed to pose a carcinogenic threat to humans.7 These findings have led researchers to look for a suitable alternative to replace formocresol.1,8,9 Calcium hydroxide, [Ca(OH)2] has been widely used in dentistry owing to its antibacterial properties and its favorable biocompatibility compared with other antia
Assistant Professor, Department of Pediatric Dentistry, Faculty of Dentistry, University of Ondokuz Mayıs. b Assistant Professor, Department of Pediatric Dentistry, Faculty of Dentistry, University of Kırıkkale. c Associate Professor, Department of Pediatric Dentistry, Faculty of Dentistry, University of Ankara. d Professor, Department of Pathology, Gulhane Military Medical Academy, Ankara. Received for publication Dec 6, 2005; returned for revision Dec 13, 2005; accepted for publication Dec 13, 2005. 1079-2104/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.12.013
e22
bacterial agents.9 In spite of its wide application, low success rates in pulp capping and pulpotomy procedures have limited the use of Ca(OH)2 as a dressing in pulpotomies of primary dentition.10 Research has shown that the use of Ca(OH)2 frequently results in the development of chronic pulpal inflammation and internal root resorption.11 However, some researchers have asserted that internal resorption following Ca(OH)2 pulpotomies of primary teeth may in fact be caused by pulpal inflammation that existed prior to treatment.12 The control of pulpal bleeding has been mentioned as a significant variable in the outcome of a Ca(OH)2 pulpotomy.13 In fact, clinical studies have reported proper hemorrhage control to be perhaps the single most important factor in the clinical success of vital pulp therapy.13,14 Because a blood clot on the wound surface interferes with healing by producing inflammation and necrosis, a technique that results in minimal clot formation, through the control of pulp bleeding before the application of medicaments, may be recommended in Ca(OH)2 treatment.15 A number of procedures and agents have been used to control pulpal hemorrhaging following mechanical exposure in both vital noncarious and carious pulps. Most clinicians are taught to control pulpal bleeding at the exposure site by applying mechanical pressure to the exposure interface with a sterile cotton pellet until hemorrhage subsides.16 Other techniques include the application of mechanical pressure using pellets soaked in saline solution,14 hydrogen peroxide,8 anesthetic so-
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lutions containing epinephrine17 or ferric sulfate,18 and coagulation modalities, such as electrosurgery or laser irradiation. Since the 1950s, histologic studies have reported sodium hypochlorite (NaOCl) to be biologically compatible with exposed pulp tissue and highly successful when used as a hemostatic agent in direct pulp capping.14,19 The purpose of this study was to compare the success of Ca(OH)2 pulpotomies with and without NaOCl as a hemostatic agent in primary teeth. MATERIAL AND METHODS Ten children between 9.5 to 13 years of age (mean 10.4 yrs) were selected from among the patients attending the Pediatric Dentistry Clinic. Each child had one or more primary molars with advanced caries. Teeth were selected for inclusion in the study according to the following criteria: 1. No clinical symptoms or evidence of pulp degeneration, such as pain on percussion, history of swelling, mobility, or fistula; 2. Root resorption of approximately half of the root length; 3. No radiographic signs of internal or pathologic external root resorption and no furcation radiolucency; and 4. Teeth would be restorable. In total, 18 primary molars (1 mandibular primary first molar, 5 mandibular primary second molars, 6 maxillary primary first molars, and 6 maxillary primary second molars) fit these criteria. The research protocol was reviewed and approved by the Ethics Committee, and informed consent was obtained from the parents of all participants before the initiation of clinical procedures. Topical anesthesia was applied (Xylocain; Astra, Södertalje, Sweden) and a local anesthetic solution (Ultracain D-S; Aventis Pharma San. ve Tic, Istanbul, Turkey) administered. Cavities were outlined using a high-speed drill fitted with round and fissure diamond burs (Zenith Dental, Agerskov, Denmark). Caries were removed using a slow-speed handpiece with round steel burs (Hager and Meisinger, Neuss, Germany). In cases where pulpal exposure was confirmed, the roof of the pulp chamber was removed using a sterile nonendcutting low-speed bur. Dentin debris was cleared using a sterile physiologic saline solution delivered by syringe and needle. Coronal pulpal tissue was removed using a sterile sharp spoon excavator, and the chamber was irrigated with sterile physiologic saline. Hemorrhage was initially controlled using dry sterile cotton pellets. In the experimental group (n ⫽ 9), a cotton pellet saturated with 3% NaOCl was also applied for 30
S¸en Tunç et al. e23
seconds to control hemorrhaging. The pellet was removed, and the cavity was rinsed with sterile physiologic saline and gently air dried for 3 seconds to remove excess moisture. In the control group (n ⫽ 9), only cotton pellets saturated with sterile physiologic saline were used for hemorrhage control. Care was taken to prevent recurring hemorrhage. Pulpotomies were performed in both the control group and the treatment group by delivering a mixture of calcium hydroxide powder (Aktu Tic, Istanbul, Turkey) and physiologic saline to the pulp chamber. The mixture was gently packed over pulp stumps using an amalgam condenser and small cotton pellets. Excess agent was meticulously removed from the cavity walls using an excavator, and the coronal pulp chamber was sealed with zinc oxide eugenol cement (Kemdent-Associated Dental Product; Purton, Swindon, Wiltshire, UK). Teeth were restored using amalgam (Southern Dental Industries, Boyswater, Victoria, Australia). Details of each pulpotomy were recorded together with details of the findings of subsequent clinical and radiographic reviews conducted at 3-month intervals that evaluated tenderness to percussion, the presence of fistulus tract or abscess, mobility, periodontal ligament widening, furcation radiolucency, and internal or pathologic external root resorption. It was planned to extract the tooth when two-thirds of its succedenous tooth root has developed. Mean extraction time for the 18 teeth was 6.3 months (range 3-8 mos). Following extraction, teeth were immediately immersed in 10% buffered formalin as a preservative and forwarded for decalcification and histologic examination. Sections were stained using hematoxylin– eosin. Pulpal cell reactions were recorded according to the parameters described by Fuks et al.20 Table I lists the assessment criteria. RESULTS Clinical and radiographic examinations At the 3-month postoperative evaluation, all of the teeth were clinically symptomless without any sign of pulpal or periapical pathology. They were clinically and radiographically assessed as successes. At the 6-month evaluation, 1 tooth from the treatment group was radiographically assessed as a failure because of internal resorption. The remaining 17 teeth did not show tenderness to percussion. None of the 17 teeth showed any fistulus tract or abnormal mobility. In the radiographic examination there was no sign of pulpal, periapical, or furcation pathology in those teeth, so they were clinically and radiographically judged to be successes until the time of extraction.
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e24 S¸en Tunç et al. Table I. Pulpal assessment criteria Pulpal vitality
Inflammation
Odontoblastic layer change
Hard tissue bridge formation Pulp calcification
Table II. Histologic findings No necrosis Partial necrosis Total necrosis Absent/mild Moderate Severe Regular Irregular Absent Present Absent Present Absent
Histologic examination Histologic findings of the control group and treatment group are outlined in Table II. Control group. None of the control specimens showed necrosis. All canals maintained their normal pulpal structure. None of the pulps showed inflammation. In 2 specimens, the beginning of a cementoidstructured hard tissue bridge was observed at the amputation site, and organized fibrous tissue that was expected to turn into a hard-tissue barrier was observed above the uncompleted bridges. Although the remaining 7 teeth showed no hard-tissue formation, they were found to have healthy pulps. The odontoblastic layer of all specimens was normal. The formation of a calcific mass was detected in 1 specimen (Figs. 1 and 2). Treatment group. One specimen in the treatment group showed partial necrosis and inflammation. The remaining 8 teeth had regular odontoblastic layers and healthy pulp structures. Four of the 9 teeth showed the formation of an incomplete dentin bridge of cellular and cementoid structure at the amputation site. The formation of a calcified mass was detected in 2 specimens (Figs. 3 and 4). DISCUSSION A number of studies have examined the application of NaOCl of varying concentrations and durations for the control of pulpal hemorrhage following mechanical exposure in both vital noncarious and carious pulps.14,21-23 A study by Hafez et al.,14 in which primate pulps treated with 3% NaOCl showed no evidence of pulpal necrosis at 7 or 27 days, demonstrated that 3% NaOCl is biocompatible as a hemorrhage control agent. Hafez and other authors support the use of NaOCl for disinfection and chemical amputation of operative, clot, and coagulum debris and for the establishment of a dentinpulp interface free of organic biofilm before the place-
Assessment criteria Vitality
No necrosis Partial necrosis Total necrosis Inflammation Absent/mild Moderate Severe Odontoblastic layer change Regular Irregular Absent Hard tissue bridge formation Present Absent Pulp calcification Present Absent
Control Treatment group group (n ⫽ 9) (n ⫽ 9) 9 0 0 9 0 0 9 0 0 2 7 1 8
8 1 0 8 0 1 8 0 1 4 5 2 7
Fig. 1. Histologic appearance of a tooth from the control group (50⫻). A, Organized fibrous tissue that will most likely develop into a hard tissue barrier. B, Cementoid-structured hard tissue. C, The area between the eozinofilic connective tissue and the cementoid hard tissue. D, Healthy fibrous tissue. E, Healthy odontoblast cells.
ment of medicament.14,22 For these reasons 3% NaOCl was used to control pulpal hemorrhage in this study. A study by Sarı et al.24 that examined the histologic structure of primary pulp of teeth with different root resorption levels found no differences between the pulp of teeth with no root resorption and those with root resorption levels of between one-third and two-thirds. In another study, no differences were found in the responses to vital pulp therapy among pulp of primary teeth with varying levels of root resorption.25 S¸ims¸ek and Durutürk26 showed that there were no differences between the defense potential of primary teeth with
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Fig. 2. Tooth in Fig 1 seen at higher magnification (200⫻). A, Cementoid-structured hard tissue. B, The area between the eozinofilic connective tissue and the cementoid hard tissue. C, Cellular fibriller connective tissue.
Fig. 3. Histologic appearance of a tooth from the treatment group (50⫻). A, Healthy pulp tissue. B, Partially organized cementoid hard tissue formation. C, Debris.
varying resorption levels and caries depths. With these findings in mind, this study selected teeth with root resorption levels of approximately one-half, so that histologic examination could be completed in a short period of time. In this study, all of the teeth in the control group and 8 of the 9 teeth in the treatment group were clinically and radiographically found to be successful. One tooth in the treatment group exhibited internal resorption and was therefore judged to be a failure. In the histologic examination, all of the teeth from the control group and 8 of the 9 teeth from the treatment group were found to have preserved their vitality and
S¸en Tunç et al. e25
Fig. 4. Tooth in Fig 3 seen at higher magnification (200⫻). A, Cementoid tissue. B, Partially organized cementoid hard tissue formation. C, Hard tissue barrier and odontoblast cells.
showed no inflammation, whereas the remaining tooth from the treatment group showed partial necrosis; however, the necrosis may have been caused by an initially undetected condition.12 In fact, Schröder27 reported a consistency rate of only 81% between the clinical and histologic diagnosis of chronic coronal pulpitis in carious primary teeth. One of the signs of a successful vital pulpotomy is the presence of a “dentin bridge” at the site of pulp amputation.28 However, the formation of a dentin bridge has also been reported in teeth with irreversible inflammation,29 whereas successful pulp capping has been reported without the presence of a reparative dentin bridge over the exposure site.30,31 Indeed, the 1 tooth in this study with partial necrosis showed partial hard-tissue formation, whereas only 2 of the 4 teeth in the control group showed hard-tissue bridge formation. Although there were no indications of a hard-tissue bridge in the remaining 7 teeth in the control group, these teeth exhibited normal pulp structure and showed no sign of inflammation and therefore cannot be considered to be failures. An analysis of the findings of this study makes it difficult to conclude that the use of NaOCl in hemorrhage control enhances the success of Ca(OH)2 pulpotomies. However, this may be related to the concentration and application time of NaOCl used in this study. Further studies with larger study groups and long-term follow-ups are required to clarify the role of NaOCl in the success of Ca(OH)2 pulpotomies. CONCLUSION This study found that the use of 3% NaOCl as a hemostatic agent had no effect on the outcome of
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e26 S¸en Tunç et al. Ca(OH)2 pulpotomies with the given concentration and timing of the NaOCl treatment and the given observation period. REFERENCES 1. Eidelman E, Holan G, Fuks AB. Mineral trioxide aggregate vs. formocresol in pulpotomized primary molars: a preliminary report. Ped Dent 2001;23:15-8. 2. Ranly DM, Horn D. Assessment of the systemic distribution and toxicity of formaldehyde following pulpotomy treatment. Part 2. J Dent Child 1987;54:40-4. 3. Block RM, Lewis RD, Hirsch J, Coffey J, Langeland K. Systemic distribution of 14 C-labeled paraformaldehyde incorporated within formocresol pulpotomies in dogs. J Endod 1983;9:176-89. 4. Alaçam A. Long term effects of primary teeth pulpotomies with formocresol, gluteraldehyte-calcium hydroxide and gluteraldehyde-zinc oxide eugenol on succedaneous teeth. J Pedodont 1989;13:307-12. 5. Garcia-Godoy F. Radiographic evaluation of root canal calcification following formocresol pulpotomy. J Dent Child 1983;50:430-2. 6. Block RM, Lews RD, Sheats JB, Burke SG. Antibody formation to dog pulp tissue altered by formocresol within the root canal. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1978;45:282-92. 7. Lewis BB, Chestner SB. Formaldehyde in dentistry: a review of mutagenic and carcinogenic potential. J Am Dent Assoc 1981;103:429-34. 8. Shumayrikh NM, Adenubi JO. Clinical evaluation of gluteraldehyde with calcium hydroxide and gluteraldehyde with zinc oxide eugenol in pulpotomy of primary molars. Endod Dent Traumatol 1999;15:259-64. 9. Gruythuysen RJM, Weerheijm KL. Calcium hydroxide pulpotomy with a light cured cavity-sealing material after two years. ASDC J Dent Child 1997;64:251-3. 10. Avram CA, Pulver F. Pulpotomy medicaments for vital primary teeth. J Dent Child 1989;56:426-34. 11. Law DB. An evaluation of vital pulpotomy technique. J Dent Child 1956;23:40-4. 12. Heilig J, Yates J, Siskin M, McKnight J, Turner J. Calcium hydroxide pulpotomy for primary teeth: a clinical study. J Am Dent Assoc 1984;108:775-8. 13. 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. 14. Hafez AA, Fox JF, Tarim B, Otsuki M, Akimoto N. An in vivo evaluation of hemorrhage control using sodium hypochlorite and direct capping with a one-or two-component adhesive system in exposed nonhuman primate pulps. Quintessence Int 2002; 33:261-72. 15. Fishman SA, Udin RD, Good DL, Rodef F. Success of electrofulgration pulpotomies covered by zinc oxide and eugenol or calcium hydroxide: a clinical study. Pediatr Dent 1996; 18:385-90.
16. Seelig A. The formation of calcified tissue in dental pulps. N Y State Dent J 1956;22:260-72. 17. Hebling J, Giro E, Costa C. Biocompatibility of an adhesive system applied to exposed human dental pulp. J Endod 1999;25:676-82. 18. Ibricevic H, Al-Jame Q. Ferric sulfate as pulpotomy agent in primary teeth: twenty-month clinical follow-up. J Clin Pediatr Dent 2000,24:269-72. 19. Hafez AA, Kopel HM, Fox CF. Pulpotomy reconsidered: application of an adhesive system to pulpotomized permanent primate pulps. Quintessence Int 2000;31:579-89. 20. Fuks AB, Michaeli Y, Sofer-Saks B, Shoshan S. Enriched collage solution as a pulp dressing in pulpotomized teeth in monkeys. Pediatr Dent 1984;6:243-7. 21. Katoh M, Kidokoro S, Kurosa K. A study of the amputation of pulp using NaOCl. Jpn J Pediatr Dent 1978;16:107-16. 22. Akimoto N, Momoi Y, Kohno A, Suzuki S, Otsuki M, Suzuki S, Cox CF. Biocompatibility of Clearfil Liner Bond 2 and Clearfil AP-X system on nonexposed and exposed primate teeth. Quintessence Int 1998;29:177-88. 23. Tsuneda Y, Hayakawa T, Yamamoto H, Ikemi T, Nemoto K. A histopathological study of direct pulp capping with adhesive resins. Operative Dent 1995;20:223-9. 24. Sarı S¸, Aras S¸, Günhan Ö. The effect of physiological root resorption on the histological structure of primary tooth pulp. J Clin Pediatr Dent 1999;23:221-5. 25. Sarı S¸, Aras S¸, Günhan Ö. The effect of physiological root resorption on repair potential of primary tooth pulp. J Clin Pediatr Dent 1999;23:227-33. 26. S¸ims¸ek S¸, Durutürk L. A flow cytometric analysis of the biodefensive response of deciduous tooth pulp to carious stimuli during physiological root resorption. Arch Oral Biol 2005;50:461-8. 27. Schröder U. Agreement between clinical and histologic findings in chronic coronal pulpitis in primary teeth. Scand J Dent Res 1977;85:583-7. 28. Waterhouse PJ, Nunn JH, Withworth JM, Soames JV. Primary molar pulp therapy-histological evaluation of failure. Int J Paediatr Dent 2000;10:313-21. 29. Camp JE, 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. 8th ed. St. Louis (MO): Mosby; 2002. p. 808. 30. Sayegh FS. The dentinal bridge in pulp-involved teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1969;28:579-86. 31. Weiss MB, Bjorvatn K. Pulp capping in deciduous and newly erupted permanent teeth of monkeys. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1970;29:769-75. Reprint requests: Is¸ıl S¸arog˘lu ¨ niversitesi Kırıkkale U Dis¸ Hekimlig˘i Fakültesi Pedodonti ABD Kırıkkale, Türkiye [email protected]
Objective. The aim of this study was to evaluate the effects of 3% sodium hypochlorite (NaOCl) used as a hemostatic agent on the outcome of calcium hydroxide pulpotomies of primary teeth. Study design. A total of 18 primary molars with advanced caries and root resorption of approximately half the root length were randomly placed into 2 groups. Conventional calcium hydroxide pulpotomies were performed on teeth in both groups; however, a cotton pellet saturated with 3% sodium hypochlorite was applied to teeth in the treatment group for 30 seconds before the pulpotomy to control hemorrhage. After the extraction of the teeth, they were examined histologically. Results. In the histologic evaluation it was found that none of the specimens in the control group showed necrosis and 1 specimen in the treatment group showed partial necrosis. Conclusion. It was found that the use of 3% NaOCl as a hemostatic agent had no effect on the outcome of calcium hydroxide pulpotomies with the given concentration and timing of the NaOCl treatment and the given observation period. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e22-e26)
Formocresol has been a popular pulpotomy medicament in pediatric dentistry for the past 60 years. It is the most universally taught and preferred pulp therapy for primary teeth.1 Although the efficacy of formocresol is unquestionable, doubts have recently arisen as to its safety. There have been worrisome reports of toxicity,2 postoperative systemic transport,3 negative effects on succedaneous tooth enamel,4 negative radiographic changes in treated teeth,5 and possible reversible fixation leading to auto-antibody formation.6 Most disturbing of all, formaldehyde, one of the components of formocresol, is now believed to pose a carcinogenic threat to humans.7 These findings have led researchers to look for a suitable alternative to replace formocresol.1,8,9 Calcium hydroxide, [Ca(OH)2] has been widely used in dentistry owing to its antibacterial properties and its favorable biocompatibility compared with other antia
Assistant Professor, Department of Pediatric Dentistry, Faculty of Dentistry, University of Ondokuz Mayıs. b Assistant Professor, Department of Pediatric Dentistry, Faculty of Dentistry, University of Kırıkkale. c Associate Professor, Department of Pediatric Dentistry, Faculty of Dentistry, University of Ankara. d Professor, Department of Pathology, Gulhane Military Medical Academy, Ankara. Received for publication Dec 6, 2005; returned for revision Dec 13, 2005; accepted for publication Dec 13, 2005. 1079-2104/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2005.12.013
e22
bacterial agents.9 In spite of its wide application, low success rates in pulp capping and pulpotomy procedures have limited the use of Ca(OH)2 as a dressing in pulpotomies of primary dentition.10 Research has shown that the use of Ca(OH)2 frequently results in the development of chronic pulpal inflammation and internal root resorption.11 However, some researchers have asserted that internal resorption following Ca(OH)2 pulpotomies of primary teeth may in fact be caused by pulpal inflammation that existed prior to treatment.12 The control of pulpal bleeding has been mentioned as a significant variable in the outcome of a Ca(OH)2 pulpotomy.13 In fact, clinical studies have reported proper hemorrhage control to be perhaps the single most important factor in the clinical success of vital pulp therapy.13,14 Because a blood clot on the wound surface interferes with healing by producing inflammation and necrosis, a technique that results in minimal clot formation, through the control of pulp bleeding before the application of medicaments, may be recommended in Ca(OH)2 treatment.15 A number of procedures and agents have been used to control pulpal hemorrhaging following mechanical exposure in both vital noncarious and carious pulps. Most clinicians are taught to control pulpal bleeding at the exposure site by applying mechanical pressure to the exposure interface with a sterile cotton pellet until hemorrhage subsides.16 Other techniques include the application of mechanical pressure using pellets soaked in saline solution,14 hydrogen peroxide,8 anesthetic so-
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lutions containing epinephrine17 or ferric sulfate,18 and coagulation modalities, such as electrosurgery or laser irradiation. Since the 1950s, histologic studies have reported sodium hypochlorite (NaOCl) to be biologically compatible with exposed pulp tissue and highly successful when used as a hemostatic agent in direct pulp capping.14,19 The purpose of this study was to compare the success of Ca(OH)2 pulpotomies with and without NaOCl as a hemostatic agent in primary teeth. MATERIAL AND METHODS Ten children between 9.5 to 13 years of age (mean 10.4 yrs) were selected from among the patients attending the Pediatric Dentistry Clinic. Each child had one or more primary molars with advanced caries. Teeth were selected for inclusion in the study according to the following criteria: 1. No clinical symptoms or evidence of pulp degeneration, such as pain on percussion, history of swelling, mobility, or fistula; 2. Root resorption of approximately half of the root length; 3. No radiographic signs of internal or pathologic external root resorption and no furcation radiolucency; and 4. Teeth would be restorable. In total, 18 primary molars (1 mandibular primary first molar, 5 mandibular primary second molars, 6 maxillary primary first molars, and 6 maxillary primary second molars) fit these criteria. The research protocol was reviewed and approved by the Ethics Committee, and informed consent was obtained from the parents of all participants before the initiation of clinical procedures. Topical anesthesia was applied (Xylocain; Astra, Södertalje, Sweden) and a local anesthetic solution (Ultracain D-S; Aventis Pharma San. ve Tic, Istanbul, Turkey) administered. Cavities were outlined using a high-speed drill fitted with round and fissure diamond burs (Zenith Dental, Agerskov, Denmark). Caries were removed using a slow-speed handpiece with round steel burs (Hager and Meisinger, Neuss, Germany). In cases where pulpal exposure was confirmed, the roof of the pulp chamber was removed using a sterile nonendcutting low-speed bur. Dentin debris was cleared using a sterile physiologic saline solution delivered by syringe and needle. Coronal pulpal tissue was removed using a sterile sharp spoon excavator, and the chamber was irrigated with sterile physiologic saline. Hemorrhage was initially controlled using dry sterile cotton pellets. In the experimental group (n ⫽ 9), a cotton pellet saturated with 3% NaOCl was also applied for 30
S¸en Tunç et al. e23
seconds to control hemorrhaging. The pellet was removed, and the cavity was rinsed with sterile physiologic saline and gently air dried for 3 seconds to remove excess moisture. In the control group (n ⫽ 9), only cotton pellets saturated with sterile physiologic saline were used for hemorrhage control. Care was taken to prevent recurring hemorrhage. Pulpotomies were performed in both the control group and the treatment group by delivering a mixture of calcium hydroxide powder (Aktu Tic, Istanbul, Turkey) and physiologic saline to the pulp chamber. The mixture was gently packed over pulp stumps using an amalgam condenser and small cotton pellets. Excess agent was meticulously removed from the cavity walls using an excavator, and the coronal pulp chamber was sealed with zinc oxide eugenol cement (Kemdent-Associated Dental Product; Purton, Swindon, Wiltshire, UK). Teeth were restored using amalgam (Southern Dental Industries, Boyswater, Victoria, Australia). Details of each pulpotomy were recorded together with details of the findings of subsequent clinical and radiographic reviews conducted at 3-month intervals that evaluated tenderness to percussion, the presence of fistulus tract or abscess, mobility, periodontal ligament widening, furcation radiolucency, and internal or pathologic external root resorption. It was planned to extract the tooth when two-thirds of its succedenous tooth root has developed. Mean extraction time for the 18 teeth was 6.3 months (range 3-8 mos). Following extraction, teeth were immediately immersed in 10% buffered formalin as a preservative and forwarded for decalcification and histologic examination. Sections were stained using hematoxylin– eosin. Pulpal cell reactions were recorded according to the parameters described by Fuks et al.20 Table I lists the assessment criteria. RESULTS Clinical and radiographic examinations At the 3-month postoperative evaluation, all of the teeth were clinically symptomless without any sign of pulpal or periapical pathology. They were clinically and radiographically assessed as successes. At the 6-month evaluation, 1 tooth from the treatment group was radiographically assessed as a failure because of internal resorption. The remaining 17 teeth did not show tenderness to percussion. None of the 17 teeth showed any fistulus tract or abnormal mobility. In the radiographic examination there was no sign of pulpal, periapical, or furcation pathology in those teeth, so they were clinically and radiographically judged to be successes until the time of extraction.
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e24 S¸en Tunç et al. Table I. Pulpal assessment criteria Pulpal vitality
Inflammation
Odontoblastic layer change
Hard tissue bridge formation Pulp calcification
Table II. Histologic findings No necrosis Partial necrosis Total necrosis Absent/mild Moderate Severe Regular Irregular Absent Present Absent Present Absent
Histologic examination Histologic findings of the control group and treatment group are outlined in Table II. Control group. None of the control specimens showed necrosis. All canals maintained their normal pulpal structure. None of the pulps showed inflammation. In 2 specimens, the beginning of a cementoidstructured hard tissue bridge was observed at the amputation site, and organized fibrous tissue that was expected to turn into a hard-tissue barrier was observed above the uncompleted bridges. Although the remaining 7 teeth showed no hard-tissue formation, they were found to have healthy pulps. The odontoblastic layer of all specimens was normal. The formation of a calcific mass was detected in 1 specimen (Figs. 1 and 2). Treatment group. One specimen in the treatment group showed partial necrosis and inflammation. The remaining 8 teeth had regular odontoblastic layers and healthy pulp structures. Four of the 9 teeth showed the formation of an incomplete dentin bridge of cellular and cementoid structure at the amputation site. The formation of a calcified mass was detected in 2 specimens (Figs. 3 and 4). DISCUSSION A number of studies have examined the application of NaOCl of varying concentrations and durations for the control of pulpal hemorrhage following mechanical exposure in both vital noncarious and carious pulps.14,21-23 A study by Hafez et al.,14 in which primate pulps treated with 3% NaOCl showed no evidence of pulpal necrosis at 7 or 27 days, demonstrated that 3% NaOCl is biocompatible as a hemorrhage control agent. Hafez and other authors support the use of NaOCl for disinfection and chemical amputation of operative, clot, and coagulum debris and for the establishment of a dentinpulp interface free of organic biofilm before the place-
Assessment criteria Vitality
No necrosis Partial necrosis Total necrosis Inflammation Absent/mild Moderate Severe Odontoblastic layer change Regular Irregular Absent Hard tissue bridge formation Present Absent Pulp calcification Present Absent
Control Treatment group group (n ⫽ 9) (n ⫽ 9) 9 0 0 9 0 0 9 0 0 2 7 1 8
8 1 0 8 0 1 8 0 1 4 5 2 7
Fig. 1. Histologic appearance of a tooth from the control group (50⫻). A, Organized fibrous tissue that will most likely develop into a hard tissue barrier. B, Cementoid-structured hard tissue. C, The area between the eozinofilic connective tissue and the cementoid hard tissue. D, Healthy fibrous tissue. E, Healthy odontoblast cells.
ment of medicament.14,22 For these reasons 3% NaOCl was used to control pulpal hemorrhage in this study. A study by Sarı et al.24 that examined the histologic structure of primary pulp of teeth with different root resorption levels found no differences between the pulp of teeth with no root resorption and those with root resorption levels of between one-third and two-thirds. In another study, no differences were found in the responses to vital pulp therapy among pulp of primary teeth with varying levels of root resorption.25 S¸ims¸ek and Durutürk26 showed that there were no differences between the defense potential of primary teeth with
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Fig. 2. Tooth in Fig 1 seen at higher magnification (200⫻). A, Cementoid-structured hard tissue. B, The area between the eozinofilic connective tissue and the cementoid hard tissue. C, Cellular fibriller connective tissue.
Fig. 3. Histologic appearance of a tooth from the treatment group (50⫻). A, Healthy pulp tissue. B, Partially organized cementoid hard tissue formation. C, Debris.
varying resorption levels and caries depths. With these findings in mind, this study selected teeth with root resorption levels of approximately one-half, so that histologic examination could be completed in a short period of time. In this study, all of the teeth in the control group and 8 of the 9 teeth in the treatment group were clinically and radiographically found to be successful. One tooth in the treatment group exhibited internal resorption and was therefore judged to be a failure. In the histologic examination, all of the teeth from the control group and 8 of the 9 teeth from the treatment group were found to have preserved their vitality and
S¸en Tunç et al. e25
Fig. 4. Tooth in Fig 3 seen at higher magnification (200⫻). A, Cementoid tissue. B, Partially organized cementoid hard tissue formation. C, Hard tissue barrier and odontoblast cells.
showed no inflammation, whereas the remaining tooth from the treatment group showed partial necrosis; however, the necrosis may have been caused by an initially undetected condition.12 In fact, Schröder27 reported a consistency rate of only 81% between the clinical and histologic diagnosis of chronic coronal pulpitis in carious primary teeth. One of the signs of a successful vital pulpotomy is the presence of a “dentin bridge” at the site of pulp amputation.28 However, the formation of a dentin bridge has also been reported in teeth with irreversible inflammation,29 whereas successful pulp capping has been reported without the presence of a reparative dentin bridge over the exposure site.30,31 Indeed, the 1 tooth in this study with partial necrosis showed partial hard-tissue formation, whereas only 2 of the 4 teeth in the control group showed hard-tissue bridge formation. Although there were no indications of a hard-tissue bridge in the remaining 7 teeth in the control group, these teeth exhibited normal pulp structure and showed no sign of inflammation and therefore cannot be considered to be failures. An analysis of the findings of this study makes it difficult to conclude that the use of NaOCl in hemorrhage control enhances the success of Ca(OH)2 pulpotomies. However, this may be related to the concentration and application time of NaOCl used in this study. Further studies with larger study groups and long-term follow-ups are required to clarify the role of NaOCl in the success of Ca(OH)2 pulpotomies. CONCLUSION This study found that the use of 3% NaOCl as a hemostatic agent had no effect on the outcome of
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