ORIGINAL RESEARCH Clinical and radiographic comparison of primary molars after formocresol and electrosurgical pulpotomy: A randomized clinical trial Zahra Bahrololoomi, Amir Moeintaghavi1, Maryam Emtiazi2, Ghofran Hosseini2
Department of Pedodontics, Shahid Sadoughi University of Medical Sciences, Yazd, 1 Department of periodontics, Mashhad University of Medical Sciences, Mashhad, Iran 2 Dentist
Received Review completed Accepted PubMed ID
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ABSTRACT
08-06-07 12-12-07 13-12-07 18797098
Background: Vital pulpotomy is a single-stage procedure defined as the surgical amputation of the coronal portion of exposed vital pulp, usually as a means of preserving the vitality and function of the remaining radicular portion. Objectives: The aim of this study was to compare the clinical and radiographic success rates for electrosurgical vs formocresol pulpotomy in human primary molar teeth. Settings and Design: This was a prospective, randomized clinical trial. Materials and Methods: In this randomized clinical trial, pulpotomies were performed on 70 primary molars in children aged 5-10 years. The teeth were treated using either a conventional formocresol (35 teeth) or electrosurgical technique (35 teeth). Following the pulpotomy procedure, the teeth were evaluated for clinical and radiographic success for three, six and nine months. The teeth were evaluated for the presence of pain, abscess, fistula, mobility, internal and external resorption, and radiolucency. Statistical Analysis: The data were assessed with Fishers’ Exact test. Results: After nine months of follow-up, the clinical and radiographic success rates were 96 and 84% respectively in the electrosurgical group and 100 and 96.8% respectively in the formocresol group. There was no statistically significant difference between the success rates in the two groups (P > 0.05). Conclusions: Our results showed the failure rates for electrosurgical pulpotomy to be equal to those for formocresol pulpotomy. Although electrosurgical pulpotomy is a nonpharmacological technique giving favorable results, it is still a preservative technique. Further studies using larger samples and longer evaluation periods are recommended. Key words: Electrosurgery, formocresol, pulpotomy
Vital pulpotomy is a single-stage procedure deÞned as the surgical amputation of the coronal portion of exposed vital pulp. Various pulpotomy-covering medications have been used in the pulpotomy of primary teeth.[1] Formocresol was Þrst used for pulpotomy by Sweet (1904) and since then, it has been the drug of choice in pulpotomy of primary teeth due to the ease of use and high clinical success rate. Nevertheless, formocresol is under close observation due to safety considerations.[2-7] Other medications such as glutaraldehyde, calcium hydroxide (Ca(OH)2), and ferric sulfate, have been suggested as possible replacements for formocresol.[4,8,9] The use of electrosurgery as a nonpharmacological pulpotomy technique has been well documented.[10] Correspondence: Dr. Amir Moeintaghavi, E-mail: Moeentaghavia@mums.ac.ir 219
Electrosurgery leads to good visualization and homeostasis, and is less time-consuming than the formocresol approach.[8,11] In the study conducted by Mack and Dean, the success rate for electrosurgical pulpotomy was signiÞcantly higher than that for formocresol pulpotomy.[10] El-Melgy et al, compared pulpal and periapical tissue reactions to electrosurgery vs formocresol pulpotomy in the primary teeth of dogs. They found that the teeth treated by electrosurgery pulpotomy with either mechanical or electrosurgical coronal pulp removal exhibited less histopathological reactions than the teeth treated by formocresol pulpotomy.[12] Dean and colleagues did not Þnd any signiÞcant difference between the success rates for the electrosurgical and formocresol pulpotomy techniques.[13] Rivera et al, evaluated postoperative clinical and X-ray Indian J Dent Res, 19(3), 2008
Formocresol and electrosurgical pulpotomy
Þndings from 80 primary molars after formocresol and electrosurgery vital pulpotomy. They did not Þnd any signiÞcant difference between the two techniques after six months of follow-up.[14] This study was designed to compare the clinical and radiographic success of electrosurgical and formocresol pulpotomy techniques used on human primary molar teeth requiring vital pulpotomy.
MATERIALS AND METHODS This study was performed on 70 primary molars of 46 patients aged 5-10 years (mean age: 6.1 ± 1.4 years), selected from among patients referred to the Pedodontics Department of Yazd Faculty of Dentistry. This study was approved by the Statistics and Methodology Committee as well as by the Research Ethics Committee of Yazd University of Medical Sciences, Iran. Primary molar teeth were selected based on the following criteria: 1. Being symptom-free 2. Carious exposure of the vital pulp 3. No clinical or radiographic evidence of pulpal degeneration 4. No radiographic evidence of physiologic root resorption 5. Possibility of proper restoration of primary molars with amalgam 6. Enjoying complete medical health Upon enrollment, the children’s parents signed letters of informed consent. The patients had no contraindications to pulpotomy in their medical history and were willing to submit to periodic examinations of the pulpotomised teeth. All pulpotomy procedures were performed by the principal investigator or co-investigators of the study to ensure consistency in the two techniques. The experimental technique of the investigators was standardized by an experienced clinician. The teeth were assigned randomly to one of two treatment groups: electrosurgical (ES group, 35 teeth) or formocresol (FC group, 35 teeth). Following profound local anesthesia and quadrant rubber dam isolation, dental caries were removed with a large slow-speed round bur. When pulpal exposure occurred, the roof of the coronal pulp chamber was removed with a high-speed bur. The coronal pulp was then amputated with hand instruments and/or with the previously mentioned large slow-speed round bur without irrigation. In the FC group, hemorrhage control was achieved by using dry, sterile cotton pellets. A sterile cotton pellet was then lightly moistened with a 1:5 dilution of formocresol (PD Inc. Indian J Dent Res, 19(3), 2008
Bahrololoomi, et al.
Switzerland) and placed against the pulpal stumps for Þve minutes. If hemorrhage persisted, pulpectomy was performed and the tooth was eliminated from the study. In the experimental ES group, a series of large, sterile cotton pellets were placed in the chamber with pressure to obtain temporary hemostasis. The cotton pellets were then removed and the electrosurgery dental U-shaped electrode (Whaledent perfect TCS, Colten Whaledent Inc., USA) was immediately placed 1-2 mm above the tissue. The electrosurgery unit power was set at 40%. The electrical arc was allowed to bridge the gap to the Þrst pulpal stump for 1s followed by a cooldown period of 10-15 s. Heat was minimized by keeping the electrode as far away from the pulpal stumps and the tooth structure as possible while still allowing electrical arcing to occur. This procedure was repeated up to three times at each pulpal oriÞce. To avoid heat build-up in any one area of the tooth, single applications of 1s were performed to each oriÞce in a rotational sequence. After each current application, a new large sterile cotton pellet was placed with pressure on the next pulpal oriÞce to be electrosurgically treated to absorb any blood or tissue ßuid before the next current application (i.e., pellet-electrode-pellet-electrode). Pulpal stumps were dry and blackened upon completion of the procedure. In both groups, a reinforced zinc oxide-eugenol (ZOE) dressing was then placed directly on the radicular pulpal stumps and in the coronal pulp space, and the tooth was restored with amalgam. The teeth were then checked after three, six and nine months by the same examiner who was one of the investigators, but blind to the treatments. As it has been shown in the ßowchart, 2 teeth in the ES group were extracted and excluded from the study. At each visit, a clinical examination and periapical radiography of the tooth were conducted. Clinical success was deÞned as the absence of pain, abscess, Þstula or excessive mobility. The radiographs of the teeth in this study were evaluated by the same examiner who had no knowledge as to which group the particular tooth was assigned to. Radiographic success was deÞned as the presence of a normal periodontal ligament space, absence of pathologic root resorption or canal calciÞcation, and no periradicular or furcal radiolucency. Data were collected and analyzed using Fisher’s Exact test. Figure 1 shows the ßow diagram of this study. The diagram includes the number of teeth enrolled, treated and followed during the study.
RESULTS Clinical findings A: Formocresol group: All patients were free of signs 220
Formocresol and electrosurgical pulpotomy
and symptoms three, six, and nine months following treatment. B: Electrosurgery group: Fistula was seen in one patient in the second and third recalls. Table 1 shows the clinical Þndings.
Radiographic findings A: Formocresol: Internal resorption was seen in one tooth three, six, and nine months following treatment. B: Electrosurgery: Internal resorption was observed in two teeth in the second and third recalls. External resorption was observed in two, three and four teeth in the Þrst, second and third recalls, respectively. Furca radiolucency was observed in one, two and three teeth in the Þrst, second and third recalls, respectively. Table 2 shows the radiographic Þndings. After nine months of follow-up, the clinical and radiographic success rates were 96 and 84%, respectively in the ES group, and 100 and 96.8%, respectively in the FC group. There was no statistically signiÞcant difference between the success rates for the two groups (P > 0.05).
DISCUSSION Our findings were similar to those of Dean et al, who demonstrated the clinical and radiographic success rates for electrosurgical pulpotomy to be comparable to those for formocresol pulpotomy. Clinical and radiographic success rates were 96 and 84%, respectively in the electrosurgical group, and 100 and 92%, respectively in the formocresol group.[13] Our results were however, different from those of Sheler and Morton[15] and Mack and Dean.[10] This could be attributed to the differences in the applied techniques and lengths of the studies. We cannot compare our results with those of Reumping[16] and Shulman[17] because they performed pulpotomies on noninßamed, noncariously exposed dental pulps of animals. In addition, they were histological studies. Success or failure of pulpotomy is dependent upon an accurate diagnosis at the time of treatment. It is worth noting that all teeth treated in this study were affected by caries. It is necessary for the radicular pulp to be healthy at the time of treatment for electrosurgical pulpotomy to achieve a successful outcome as electrosurgery cannot be expected to penetrate and sterilize the contaminated radicular tissue.[11] Zinc oxide-eugenol (ZOE) is used as a base in pulpotomized teeth. In a prospective human study of electrosurgical pulpotomy conducted by Fishman and colleagues,[18] the clinical and radiographic success rates for ZOE were 77 and 81%, respectively, compared to 55 and 57%, respectively for Ca(OH)2. These success rates are lower than those of the current study and earlier studies.[10,13] Fishman and 221
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colleagues[18] concluded that it was premature to recommend pulpotomy using the electrosurgical approach. We do not believe this to be the best conclusion as their study was intended to compare two pulpal medications following electrosurgical pulpotomy, and not to compare the success rates for electrosurgical vs formocresol pulpotomy. Our Þndings show comparable outcomes for electrosurgical and formocresol pulpotomies of human primary molar teeth during nine months of follow-up. Although the electrosurgical group had more negative signs, there was no signiÞcant difference between the two groups. Studies with larger sample sizes are needed to clarify any possible difference. It was not possible to differentiate between the effects of the ZOE base and electrosurgical treatment with the methodology used in this study. Ruemping et al,[16] speculated that the coagulation layer produced when using electrosurgery might block the pulpal effects of ZOE. However, we found no evidence of the protective effect of such a coagulation layer in the current study. Success or failure of pulpotomy treatment is dependent upon an accurate diagnosis at the time of treatment. Formocresol has proven to be a forgiving technique where teeth are maintained in the arch with chronic, silent inßammation. Electrosurgical pulpotomy however, appears to need a more sensitive diagnosis.[11,13,16-19] Another consideration with electrosurgical pulpotomy is lateral heat production. In this study, repetition of electrocoagulation became necessary due to the large size of the canal openings of some teeth. Although a 10-15 second interval was given for cooling, the heat build-up might lead to side effects. However, the electrosurgical procedure has two distinct advantages: it can be performed more quickly, and there are no drugs involved that may produce undesirable systemic effects. Electrosurgical pulpotomy has gained popularity due to its nonpharmacological nature, ease of use, and favorable results. The results of our study are comparable to others reported in the literature comparing electrosurgical and formocresol pulpotomies.[10,15,19-21] Our Þndings also support the hypothesis that the success rate for electrosurgical pulpotomy is comparable to that for formocresol pulpotomy. Although electrosurgical pulpotomy is a nonpharmacological and easy technique with favorable results, it is still a preservative technique and the cost of electrosurgical equipment is a drawback.
CONCLUSION This study did not show any significant difference between the clinical and/or radiographic success rates for Indian J Dent Res, 19(3), 2008
Formocresol and electrosurgical pulpotomy
Bahrololoomi, et al.
Assessed for eligibility (n = 100 primary molars in 50 patients)
Excluded (n = 30 teeth)
Enrollment
Allocated to intervention (ES group) (n = 35) Received allocated intervention (n = 35) Did not receive allocated intervention (n = 0)
Lost to follow-up (n = 2 teeth) Give reasons: Due to extraction
Allocation
Allocated to intervention (FC group) (n = 35) Received allocated intervention (n = 35) Did not receive allocated intervention (n = 0)
Lost to follow-up (n = 0) Give reasons
Follow-Up
Discontinued intervention (n = 0)
Analyzed (n = 33)
Not meeting inclusion criteria (n = 20 teeth) Refused to participate (n = 4 patients with 8 teeth) Other reasons (n = 2 teeth)
Analysis
Excluded from analysis (n = 0)
Discontinued intervention (n = 0)
Analyzed (n = 35) Excluded from analysis (n = 0)
Figure 1: Flow diagram to show number of teeth enrolled, treated and followed
Table 1: Number of teeth with clinical signs in each recall Clinical finding Pain Fistula Abscess Mobility
3 months 0 0 0 0
Electrosurgical pulpotomy 6 months 9 months 0 0 1 1 0 0 0 0
3 months 0 0 0 0
Formocresol pulpotomy 6 months 0 0 0 0
9 months 0 0 0 0
Table 2: Number of teeth with radiographic signs in each recall Radiographic finding Internal resorption External resorption Furca radiolucency Indian J Dent Res, 19(3), 2008
3 months 0 2 1
Electrosurgical pulpotomy 6 months 9 months 2 2 3 4 2 3
3 months 1 0 0
Formocresol pulpotomy 6 months 9 months 1 1 0 0 0 0 222
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Bahrololoomi, et al.
electrosurgical vs formocresol pulpotomy. Further studies with longer evaluation periods are warranted.
10.
ACKNOWLEDGMENTS
12.
The authors would like to acknowledge Dr. Falahzadeh for his contribution in statistical analysis.
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REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.
Sweet CA. Treatment of vital primary teeth with pulpal involvementtherapeutic pulpoptomy. J Colorado State Dent Assoc 1955;33:10-4. American Academy of Pediatric Dentistry. Guidelines on pulp therapy for primary and young permanent teeth. Pediatr Dentist 2004; 26:115-9. Llewelyn DR; Faculty of Dental Surgery, Royal College of Surgeons. UK National Clinical Guidelines in Paediatric Dentistry: The pulp treatment of the primary dentition. Int J Pediatr Dentist 2000;10:248-52. Hill SD, Berry CW, Seale NS, Kaga M. Comparison of antimicrobial and cytotoxic effects of glutaraldehyde and formocresol. Oral Surg Oral Med Oral Pathol 1991;71:89-95. Myers DR, Shoaf HK, Dirksen TR, Pashley DH, Whitford GM, Reynolds KE. Distribution of 14c-formaldehyde after pulpotomy with formocresol. J Am Dent Assoc 1978;86:805-13. Myers DR, Pashley DH, Whitford GM, Sobel RE, Mckinney RV. The acute toxicity of high doses of systemically administered formocresol in dogs. Pediatr Dentist 1981;3:37-41. Nunn JH, Smeaton I, Gilroy J. The development of formocresol as a medicament for primary molar pulpotomy procedures. ASDC J Dentist Child 1996;63:51-3. Waterhouse PJ, Nunn JH, Whitworth JM. An investigation of the relative efficacy of Buckley’s Formocresol and calcium hydroxide in primary molar vital pulp therapy. Br Dent Jr 2000;188:32-6. Ibricevic H, Al-Jame Q. Ferric sulphate and formocresol in pulpotomy of primary molars: Long term follow-up study. Eur J Pediatr Dentist 2003;4:28-32.
11.
14. 15. 16. 17. 18. 19. 20. 21.
Mack RB, Dean JA. Electrosurgical pulpotomy: A retrospective human study. ASDC J Dentist Child 1993;60:107-14. Shaw DW, Sheller B, Barrus BD, Morton TH Jr. Electrosurgical pulpotomy: A 6-month study in primates. J Endod 1987;13:500-5. El-Meligy O, Abdalla M, El-Baraway S, El-Tekya M, Dean JA. Histological evaluation of electrosurgery and formocresol pulpotomy techniques in primary teeth in dogs. J Clin Pediatr Dentist 2001;26:81-5. Dean JA, Mack RB, Fulkerson BT, Sanders BJ. Comparison of electrosurgical and formocresol pulpotomy procedures in children. Int J Pediatr Dentist 2002;12:177-82. Rivera N, Reyes E, Mazzaoui S, Moron A. Pulpal therapy for primary teeth: Formocresol vs electrosurgery: A clinical study. J Dentist Child (Chic) 2003;70:71-3. Sheller B, Morton TH Jr. Electrosurgical pulpotomy: A pilot study in humans. J Endodont 1987;13:69-76. Ruemping DR, Morton TH Jr, Anderson MW. Electrosurgical pulpotomy in primates: A comparison with formocresol pulpotomy. Pediatr Dentist 1983;5:14-8. Shulman ER, McIver FT, Burkes EJ Jr. Comparison of electrosurgery and formocresol as pulpotomy techniques in monkey primary teeth. Pediatr Dentist 1987;9:189-94. 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 Dentist 1996;18:385-90. Anderman II. Indications for use of electrosurgery in Pedodontics. Dent Clin North Am 1982;26:711-28. Berger JE. Pulp tissue reaction to formocresol and zinc oxide-eugenol. ASDC J Dentist Child 1965;32:13-28. Hicks MJ, Barr ES, Flaitz CM. Formocresol pulpotomies in primary molars: A radiographic study in a pediatric dentistry practice. J Pedod 1986;10:331-9.
How to cite this article: Bahrololoomi Z, Moeintaghavi A, Emtiazi M, Hosseini G. Clinical and radiographic comparison of primary molars after formocresol and electrosurgical pulpotomy: A randomized clinical trial. Indian J Dent Res 2008;19:219-23 Source(s) of support: Grant of vice chancellor of research, Yazd university of Medical sciences, Yazd, Iran, Conflict of Interest: None declared.
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There is no data on follow-up of these patients. Authors’ Reply: The follow up of patients have been included in the results section [Page 3, para 2] Authors should highlight the relation of complication to duration of diabetes. Authors’ Reply: The complications as seen in our study group has been included in the results section [Page 4, Table]
Indian J Dent Res, 19(3), 2008