The Effect of Mineral Trioxide Aggregate as a Direct

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Original Research

The Effect of Mineral Trioxide Aggregate as a Direct Pulp Capping Agent in Permanent Teeth Tayyaba Tahira1, Rizwan Jouhar1,2, Huwaina Abd Ghani2, Naseer Ahmed3,4, Ahmad Zahid Rao5, Sara Jamil1 Departments of 1Operative Dentistry and 3Prosthodontics, Altamash Institute of Dental Medicine, 5Department of Biomedical Engineering, Barret Hodgson University, Karachi, Pakistan, 2Conservative Dentistry Unit, School of Dental Sciences, USM, 4Prosthodontics Dentistry Unit, School of Dental Sciences, USM, Kelantan, Malaysia

Abstract Aims and Objectives: Direct pulp capping is a procedure which aims at protecting pulp vitality. When the dental pulp is exposed as a result of trauma, caries or by the dentist preparing for a deep restoration, then, it can be capped with a biocompatible material. It is expected that this procedure was allowed the pulp to heal normally and regenerate reparative dentine, thus preventing the need for more extensive and expensive root canal treatment (RCT). Materials and Methods: A total of 86 teeth of 85 patients diagnosed with reversible pulpitis were included in this study. After administration of local anesthesia, teeth were isolated with rubber dam. Mineral trioxide aggregate (MTA) was mixed according to manufacturers’ instructions and 1–2 mm of MTA was placed over the pulpal exposure with a plastic filling instrument. All patients were scheduled for routine recall visits after 1, 3, and 6 months to monitor for pain on visual analog scale. All these readings were recorded on pro forma. The collected data were entered into SPSS version 19 and analyzed accordingly. Mean and standard deviation was calculated for quantitative variables like age. Frequency and percentage were calculated for qualitative variables such as the efficacy of MTA and gender. Stratification with respect to age and gender was done. Poststratification Chi‑square test was applied. P ≤ 0.05 was considered statistically significant. Results: The average age of the patients was 37.59 ± 10.88 years. There were 30 (35.29%) male and 55 (64.71%) female. The effectiveness of MTA as a direct pulp capping material in cariously exposed mature permanent teeth was observed in 87.06% (74/85). Conclusion: Taking into consideration, the results of this study, it seems that when an exposure site is immediately sealed with MTA, the prognosis is promising. We found success rate of 87.06%. MTA can induce the formation of reparative dentine thus allow the pulp to heal normally and maintain pulp’s vitality and regenerative potential so the need of RCT can be avoided. Keywords: Mineral trioxide aggregate, pulp capping material, root canal treatment

Introduction Direct pulp capping is a procedure which aims at protecting pulp vitality. When the dental pulp is exposed as a result of trauma, caries or during preparation for a deep restoration; then, it can be capped with a biocompatible material. It is expected that this procedure was allowed the pulp to heal normally and regenerate reparative dentine, thus preventing the need for more extensive and expensive root canal treatment (RCT). A number of materials have been previously suggested for use as direct pulp capping agents. However, there is little human clinical research to support these materials as direct pulp capping agents. Over the past many decades, calcium hydroxide has remained the gold standard for pulp capping.[1] Access this article online Quick Response Code:

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DOI: 10.4103/jioh.jioh_201_18

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However, there are a number of disadvantages linked to it, which are as follows: 1. The long time required for induction of hard tissue barriers (2–3 months), results in delayed completion of treatment and risk of patients’ compliance[2] 2. Areas of sterile pulp necrosis[3] 3. Tunnel defects are formed in reparative dentine. These may allow bacterial invasion[4,5] 4. The use of calcium hydroxide causes a decrease in root fracture resistance[6‑8] Address for correspondence: Dr. Rizwan Jouhar, Altamash Institute of Dental Medicine, Defence Campus, 2-R Sunset Boulevard, DHA, Phase-4, Karachi - 75500, Pakistan. E‑mail: [email protected] This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected]

How to cite this article: Tahira T, Jouhar R, Ghani HA, Ahmed N, Rao AZ, Jamil S. The effect of mineral trioxide aggregate as a direct pulp capping agent in permanent teeth. J Int Oral Health 2018;10:310-3. © 2018 Journal of International Oral Health | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.jioh.org on Monday, December 24, 2018, IP: 149.255.226.26] Tahira, et al.: Pulp capping in permanent teeth with MTA

5. Calcium hydroxide has no inherent adhesive/sealing property.[9] A new biocompatible material, mineral trioxide aggregate (MTA), has generated considerable interest as a direct pulp‑capping material. MTA provides a tight seal which prevents bacterial penetration.[10] It forms a physical bond with dentine,[11] thus providing a tight seal which prevents and reduces bacterial penetration to the pulp amputation site.[12,13] However, there are very few studies on cariously exposed pulps of mature permanent teeth. This study is designed to compare the effectiveness of MTA as a direct pulp capping material in cariously exposed mature permanent teeth. Therefore, the objective of this research was to evaluate the effectiveness of MTA as a direct pulp capping material in cariously exposed mature permanent teeth. The rationale was to prevent the need for more extensive and expensive RCT as MTA can stimulate the formation of reparative dentine thus allow the pulp to heal normally and maintain pulp’s vitality and regenerative potential so the need of RCT can be avoided.

Materials and Methods The descriptive study case series was conducted at the Operatives Dentistry Department of Altamash Institute of Dental Medicine, Karachi, Pakistan, by taking the percentage of effectiveness of MTA as 83%,[14] level of confidence 95%, margin of error 8%, a total sample of 85 teeth were included in the research using nonprobability consecutive sampling technique for 6 months from September 22, 2015, to March 22, 2016. The sample was scrutinized using inclusion and exclusion criteria based on the following.

Inclusion criteria • • • • • • • •

Either gender Age limit: 20–60 years of age Patient diagnosed with reversible pulpitis with a history of 5 days or less Caries just involving the pulp/pulp horn radiographically Clinically with no signs of extraoral/intraoral swelling Teeth negative to percussion and palpation tests Teeth with no mobility Mature permanent teeth (teeth from permanent dentition, showing fully formed converging roots with closed apex on posteroanterior [PA] radiograph).

Exclusion criteria • • • • • • • •

History of spontaneous sharp lingering pain Teeth tender to percussion Intraoral/Extraoral swelling Sinus tract formation Nonvital teeth (gives no response to refrigerant CO2) Mobile teeth Deciduous teeth Teeth with open apices (showing divergent roots on PA radiograph).

After approval from the Ethical Review Committee (AIDM/09/2018/03) of Altamash Institute of Dental Medicine and taking patients’ informed consent, patients were included in this study. After administration of local anesthesia, rubber dam was placed to isolate the teeth. Sterile round bur no. 4 was used for caries removal, with copious water irrigation. During or after removal of caries, pulp exposure was clinically evaluated. A sterile, moist with saline, cotton pellet was used to achieve hemostasis. Sodium hypochlorite (2.5%) was used to disinfect the surgical exposure and dentine as well as to remove the surgical clot and debris. MTA was mixed according to manufacturers’ instructions and 1–2 mm of MTA was placed over the pulpal exposure with a plastic filling instrument. MTA mix was pressed with moist cotton pellet to ensure optimum contact with exposed pulp tissue and cavity was restored with cavit. Patients were scheduled for 24 h follow‑up to evaluate the setting of MTA. The rubber dam was placed for isolation, the temporary restoration and cotton pellet were removed. The probe was used on MTA surface to check its complete setting. Light‑cured glass‑ionomer cement was placed over the MTA and teeth were permanently restored with light‑cured composite. All patients were scheduled for routine recall visits after 1, 3, and 6 months to monitor for pain on visual analog scale (VAS). Clinical examination was done to evaluate an intact restoration. Teeth were tested for vitality by refrigerant CO2. Patients were informed about the potential need for RCT in case of moderate‑to‑severe pain. The absence of sharp lingering pain at 6 months’ posttreatment (VAS = 3) was considered as success. All these readings were recorded on pro forma attached as Anex “A” by an Endodontist. The collected data were entered into SPSS version 19 (IBM, Armonk, NY, USA) and analyzed accordingly. Mean and standard deviation was calculated for quantitative variables like age. Frequency and percentage were calculated for qualitative variables like the efficacy of MTA and gender. Stratification with respect to age and gender was done. Poststratification Chi‑square test was applied. P ≤ 0.05 was considered statistically significant.

Results A total of 86 teeth of 85 patients diagnosed with reversible pulpitis were included in this study. The average age of the patients was 37.59 ± 10.88 years and mean duration of symptoms was 3.53 ± 1.14 days. There were 30 (35.29%) male and 55 (64.71%) female. MTA, when placed as a direct pulp capping material in cariously exposed mature permanent teeth was effective in 87.06% (74/85) [Figure 1]. Stratification analysis was performed, and it was seen that the effectiveness of MTA was significantly high in below and equal to 50 years of age (P = 0.001) [Table 1]. The

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Table 1: Effectiveness of mineral trioxide aggregate as a direct pulp capping material in cariously exposed mature permanent teeth by age groups (n=85)

No (11)

Variables Age groups (years) ≤30 31-40 41-50 >50

YES (74)

No

YES

Figure 1: Effectiveness of mineral trioxide aggregate as a direct pulp capping material in cariously exposed mature Permanent teeth n = 85

effectiveness of MTA was also observed between males and females, but there was no significant difference. Stratification of the duration of symptoms was also observed, but there were no significant effect [Table 2].

Discussion Following pulp exposure, it is beneficial to preserve its vitality rather than replacing it with a root canal filling material. The placement of any biomaterial over a cariously exposed pulp was controversial, and instead conventional RCT was recommended. [15] In cariously exposed pulps, the effectiveness of direct pulp cap varies. Data from retrospective studies have shown success rate, ranged between 30% and 85%.[15,16] In our research, similar findings were found, when MTA placed as a direct pulp capping material in cariously exposed mature permanent teeth it was effective in 87.06% (74/85). MTA is a bioactive, inert and nonresorbable silicate cement and has very high pH 12.5, slow release of calcium ions, great sealing ability, and prevent bacterial penetration.[16‑18] Studies have shown that MTA induces pulp cell proliferation,[19] allows cytokine release,[20] hard tissue induction, and the formation of an interface with dentin that resembles hydroxyapatite in composition.[20] Studies have shown that setting reaction of MTA involves generation of a high pH (12.5) which remains high for at least 8 weeks.[21] This high pH induces release of bioactive dentine matrix proteins.[22] These proteins have the ability to stimulate pulpal repair. This hard tissue bridge is formed earlier than under calcium hydroxide, with fewer tunnel defects and vascular inclusions.[5,23] In vitro and in vivo studies have confirmed MTA’s excellent sealing ability and biocompatibility.[24] Contrary to our study, a clinical study on MTA pulp caps on cariously exposed pulps has shown 98% success,[25] while in our study, the success rate was 87%, possibly due to age group variation as they selected younger group patients (7–45 years) as compared to our study (20–60 years) and found 312

Effective Yes (%)

No (%)

33 (94.3) 14 (100.0) 22 (84.6) 5 (50.0)

2 (5.7) 0 (0.0) 4 (15.4) 5 (50.0)

Total

P

35 14 26 10

0.001

Table 2: Effectiveness of mineral trioxide aggregate as a direct pulp capping material in cariously exposed mature permanent teeth by duration of symptoms (n=85) Duration of symptoms

Effective

Total

P 0.551

Yes (%)

No (%)

≤3

34 (89.5)

4 (10.5)

38

>3

40 (85.1)

7 (14.9)

47

more success in younger open apex cases. Another study on cariously exposed pulp of mature permanent teeth has shown 83% success when pulp capping was done with MTA.[14] The findings are similar to our research where a success of 88% is seen. Direct pulp capping can be assumed to be one of the best treatments if the connection between the oral cavity and pulp is totally sealed with a biocompatible material.[26] Several short‑term studies, investigating partial pulpotomies and direct pulp capping with MTA have shown good results.[27] Several other studies which have analyzed MTA dressing over mechanical exposures, have shown MTA to be effective.[28,29] Nowicka et al. studied both MTA and calcium hydroxide as a pulp capping material in human teeth with mechanical pulp exposures and observed scarce inflammation and thick dentinal bridge with MTA as compared to calcium hydroxide.[28] Accornite et al., reported that MTA’s good sealing ability and biocompatibility could be the reason of its effectiveness.[30] MTA has proven to be one of the very few exogenous materials that is not only well tolerated by connective tissues but also contributes to a bacteria-tight seal.[31,32] In our study, stratification analysis was performed, and it was seen that the effectiveness of MTA was significantly high in below and equal to 50 years of age, in contrast, some studies have shown that the age of the patient is not a significant factor in the success of the treatment.[14,33] A key aspect for the practitioners is the application of pulp cap material at the exposure site. MTA needs moist environment for setting after placement, whereas, placing other capping materials, for example, hard setting calcium hydroxide agent is very difficult.[34] Therefore, it is a supplementary advantage besides its histologic superiority.



The present research endorses the application of constant informative methods to boost the understanding of dental practitioners about incomes of prevention and restoring with direct pulp capping through MTA keeping in mind the aftermath. The recent study emphases on practices and procedures accessible in dental world since quite long now, therefore, we recommend specifically planned and accomplished researches by knowledgeable fellows, moreover, contemporary clinical techniques, and pulp capping materials are immensely needed to enhance longevity of teeth without compromising pulp vitality; however, distinctions in clinical outsets and procedures should not be implemented until agreeable time has passed to approve the consequences of the research by practical clinical likeness.

Conclusion Based on the results of our study, it seems that when an exposure site is immediately sealed with MTA, the prognosis is promising. We found a success rate of 87.06%. MTA can induce the formation of reparative dentine thus allow the pulp to heal normally with preservation of pulp’s vitality and regenerative potential so that the need for RCT could be avoided.

Acknowledgment

The authors would like to thank all the department staff and postgraduate colleagues who cooperates and honestly participates in the research.

Financial support and sponsorship Nil.

Conflicts of interest

There are no conflicts of interest.

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