pulpotomized primary teeth for patients attended the ......and the restorative materials used...

I

Ministry of higher Education

& scientific research

University of Baghdad

College of Dentistry

Pulpotomized primary teeth for patients

attended the department of pediatric

dentistry / college of dentistry / Baghdad

University in two years ago

(a retrospective study)

A Project

Submitted to the College of Dentistry, University of

Baghdad, Department of Paedodontics and Preventive

dentistry in partial fulfillment of the requirement for

B.D.S.

By: Samara Ibraheem Abdlmajeed

[email protected]

Supervised by

Assistant Prof. Zainab Jum’a Ja’far

B.D.S, M.Sc.

2017-2018

I

Dedication

This work is dedicated to my mother and my

niece Ghina.

To my supervisor for her guidance and

Support "Thank you from all my heart.

Samara

Certification of the Supervisor

I certify that this thesis entitled " Pulpotomized primary and permanent

teeth for patients attended the department of pediatric dentistry / college of

dentistry / Baghdad University in two years ago (a retrospective study)"

II

was prepared by Samara Ibraheem Abdlmajeed under my supervision at the

University of Baghdad in partial fulfillment of the requirements for the B.D.S.

Degree.

Signature

Dr. Zainab Jum’a

B.D.S ,M.Sc.

(The supervisor)

Acknowledgement

We thank Allah for giving us the patience and strength accomplish this work.

I would like to express my gratitude to Prof. Dr. Hussain Al Huwaizi , Dean of

College of Dentistry, University of Baghdad.

III

My deepest thanks to Assistant Prof Dr. Nada Jafer Al-Skaikh Radhi, head of

Department of Paedodontic and Preventive Dentistry. My sincere appreciation

is due to my supervisor Assistant Prof Dr. Zainab Jum'a for her thoughtful

guidance, suggestion, invaluable help and advice in planning and conducting

this research.

Special appreciation to ….. )من؟؟؟(for her unlimited help, guidance and

continuous support.

Abstract

Background: Pulpotomy technique basically consists of removing the coronal

pulp and fixing the radicular pulp with a medicament. It is the most widely

accepted clinical procedure for treating primary teeth with coronal pulp

inflammation caused by caries with no involvement of the radicular pulp

IV

Materials and methods: This is a retrospective study conducted to analyze the

work of the department of pedodontics / college of dentistry / Baghdad

University at 2015 – 2016 and 2016-2017 studying year concerning the

pulpotomized primary teeth.

The case sheets records for all children attended the department of pedodontics

\ college of dentistry \ Baghdad university ,were collected from the department

archive then reviewed for the presence of pulpotomized primary teeth ,classified

according to the jaw (upper or lower) , gender (boys or girls) , side (left or right)

and the restorative materials used (amalgam , L.C , semi-permanent restoration

or T.F ) , age group (2-5, 6-9, 10-13,14) and G.V. Black classification ( Cl I, Cl

III, Cl III, Cl VI and compound cavities).Statistical analysis was done by using

IBM SPSS statistic version 19.

Results: According to the age groups; the highest percentage was for the age

group 6-8. According to the gender; boys were more than girls in the total

sample. There were more mandibular pulpotomized primary molars than

maxillary and the right primary molars were pulpotomized more than left.

Higher percentage was found for pulpotomized primary 2nd. molar than the

primary 1st. molar .According to the filling material; amalgam was the most

filling material used for pulpotomized primary teeth and cl II is the most class

in pulpotomized primary teeth.

Conclusions: The percentage for pulpotomized mandibular primary molars

was higher than maxillary primary molars, right more than left, 2nd primary

molar more than 1st primary molar, the amalgam was the most common filling

material used for pulpotomized primary molars cl II was the most class in

pulpotomized primary teeth.

VI

List of content

Title No. subject Page No.

Dedication I

Certification of the Supervisor II

Acknowledgement III

Abstract IV

List of content VI

List of figures VIII

List of tables VIII

List of abbreviation IX

Introduction 1

Aims of The Study 1

Chapter One (Review of Literature) 3

1.1 Definitions 3

1.2 History 3

1.3

Indication for pulpotomy in general 4

1.3.1 Indication for pulpotomy in primary teeth 4

1.3.2 Indication for pulpotomy in immature permanent

teeth

5

1.4 Contraindication 5

1.5 Technique of pulpotomy 6

1.6 Types of pulpotomy 12

1.6.1 Pulpotomy for primary teeth 12

1.6.2 Partial pulpotomy in permanent teeth 12

1.6.3 Pulpotomy with MTA in an immature permanent

molar

14

1.7 Capping material for pulpotomy 15

VII

1.7.1 Formocresol 15

1.7.2 Calcium hydroxide 16

1.7.3 Ferric sulfate 17

1.7.4 Mineral trioxide aggregate MTA 17

1.7.5 Biodentine 18

1.7.6 Formaldehyde 18

1.7.7 Gluteraldehyde 18

1.7.8 Laser 19

1.7.9 Electrosurgery 19

1.8 Previous studies concerning pulpotomized teeth

according to:

20

1.8.1 Tooth type 20

1.8.2 Gender

20

1.8.3 Age

20

1.8.4 Jaw distribution 20

1.8.5 Side of jaw 21

1.8.6 Filling material 21

Chapter Two(Materials and Methods)

Chapter Three(The Results)

22

23

Chapter Four(Discussion) 29

Conclusions 31

References 32

VIII

List of figures

1.1 Administer local anesthesia. 6

1.2 Isolate tooth with rubber dam. 7

1.3 Remove caries and determine site of pulp 7

1.4 Remove roof of pulp chamber. 8

1.5 Remove roof of pulp chamber 9

1.6 Apply formocresol on a pledget of cotton 9

1.7 Remove formocresol pledge after 4 minutes 10

1.8 Fill pulp chamber with cement 10

1.9 Restore the tooth with a stainless steel crown. 11

1.10 Post-operative radiograph 11

1.11 Calcified bridge covering an amputated pulp that was

capped with calcium hydroxide

16

2.1 Sample collection 22

List of tables

Table

No.

Title Page No.

3.1 Distribution of the total sample by age and gender 22

3.2 pulpotomized primary teeth according to gender 25

3.3 pulpotomized primary teeth according to age group

26

3.4 pulpotomized primary teeth according to filling

material

27

3.5 Black‟s classification for pulpotomized primary teeth 28

IX

List of abbreviation

symbol Abbreviation

UA Upper primary central incisor

UB Upper primary lateral incisor

UC Upper primary canine

UD Upper primary first molar

UE Upper primary second molar

LA Lower primary central incisor

LB Lower primary lateral incisor

LC Lower primary canine

LD Lower primary first molar

LE Lower primary second molar

U1 Upper permanent central incisor

U2 Upper permanent lateral incisor

U3 Upper permanent canine

U4 Upper permanent first premolar

U5 Upper permanent second premolar

U6 Upper permanent first molar

U7 Upper permanent second molar

L1 Lower permanent central incisor

L2 Lower permanent lateral incisor

L3 Lower permanent canine

L4 Lower permanent first premolar

L5 Lower permanent second premolar

L6 Lower permanent first molar

L7 Lower permanent second molar

Introduction

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Introduction

Vital pulpotomy is the clinical treatment of choice for primary teeth with exposed

pulp. Pulpotomy can be defined as the surgical removal or amputation of the

coronal pulp of the vital tooth. This step is generally followed by the placement of

a particular medicament over the intact stump to fix, mummify or stimulate repair

of the remaining radicular pulp (Purba, 2015).

The objectives of pulp therapy are removal of inflamed and infected coronal pulp

at the site of exposure thus preserving the vitality of the radicular pulp and

allowing it to heal (Marwah, 2014).

Material of choice for the pulpotomy in primary teeth is formocresol (Srivastava,

2011; Holan et al., 2005). The success rate of FC pulpotomy is reported to be 70-

98%( Haghgoo and Abbasi, 2012).

The Importance of Archives can be abstracted by Kapalan conclusion who stated

that “This power over the evidence of representation, and the power over access to

it, endows us with some measure of power over history, memory, and the past.”

(Kapalan , 2002).

AIMS OF THE STUDY

This study aimed to record and sort the work of the department of pedodontics /

college of Dentistry/ University of Baghdad at two studying years (2015-2016 and

2016-2017) concerning pulpotomized primary teeth, and to have a base line data

for future comparison of the achievements of the department about pulpotomized

primary teeth for children came to this department in the past two years according

to:

1) Age groups.

2) Gender.

Introduction

2 | P a g e

3) Arch distribution.

4) The side of the arch.

5) Tooth type

6) Filling material.

7) Black‟s classification of the dental filling.

Chapter One Review of Literature

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Chapter one

Review of literature

1.1 Definition of pulpotomy :

is the most widely used endodontic technique in the primary dentition. The suffix

„otomy‟ means „to cut‟, so pulpotomy is „to cut the pulp‟. The aim of pulpotomy in

the primary tooth is to amputate the inflamed coronal pulp and preserve the vitality

of the radicular pulp, thereby facilitating the normal exfoliation of the primary

tooth. A pulpotomy cannot be done if the pulp is necrotic (Cameron and Widmer,

2013).

The removal of the coronal portion of the pulp is an accepted procedure for

treating both primary and permanent teeth with carious pulp exposures. The

justification for this procedure is that the coronal pulp tissue, which is adjacent to

the carious exposure, usually contains microorganisms and shows evidence of

inflammation and degenerative change. The abnormal tissue can be removed, and

the healing can be allowed to take place at the entrance of the pulp canal in an area

of essentially normal pulp. Even the pulpotomy procedure, however, is likely to

result in a high percentage of failures unless the teeth are carefully selected (Dean,

2016).

1.2 History:

The contemporary pulpotomy traces its origins to nineteenth-century techniques

for the mummification of painful, inflamed or putrescent pulpal tissue. Over the

twentieth century, the pulpotomy technique changed with fewer stages and reduced

duration of application and concentration of medicament. Emphasis is now placed

on the preservation of healthy radicular pulp rather than mummification (Cameron

and Widmer, 2013).


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The objectives of pulpotomy is to remove the inflamed and infected pulp tissue

and allowing the vital pulp in the root canals to heal, thus maintaining the vitality

of the tooth. (Roa, 2012)

1.3 Indications for pulpotomy in general

Large carious lesion with substantial loss (one- third or more) of the

marginal ridge in an otherwise restorable tooth.

Tooth free of radicular pulpitis. This is established by the following:

No history of spontaneous or persistent pain. This would imply

irreversible pulpitis extending to the radicular tissue.

Haemorrhage from amputation site after removal of coronal pulp, the

haemorrhage from the root canal tissue should be pale red and easy to

control. Extensive and persistent bleeding implies inflammation of the

radicular tissue.

At least two-thirds of the root length of the primary tooth present.

Absence of an abscess sinus.

No inter-radicular bone loss. Any loss would suggest a more extensive

involvement indicating the need for pulpectomy.

No evidence of internal resorption in either he the pulp chamber or the root

canal.

Instances where extraction of the primary tooth is contraindicated, such as

in some blood dyscrasias (eg, haemophilia) (Cameron and Widmer, 2012;

Marwah, 2014) .

1.3.1 Indication for pulpotomy in primary teeth

o Carious pulp exposure.

o Tooth asymptomatic or mild transient pain.

o Preoperative radiograph confirms the absence of radicular pathology.


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o Restorable tooth.

o Mechanical pulp exposure in primary teeth.

o Teeth showing a large carious lesion but free of radicular pulpitis.

o History of only spontaneous pain.

o Hemorrhage from exposure sites bright red and can be controlled.

o Absence of abscess or draining sinus.

o No interradicular bone loss.

o No interradicular radiolucency (Srivastava, 2011; Cameron and Widmer,

2012; Marwah, 2014).

1.3.2 Indications for pulpotomy in immature permanent teeth:

● Asymptomatic tooth – but may have mild episodic pain. Preoperative

radiograph confirms immature roots with open apices

● Absence of radicular pathology

● Restorable tooth (Cameron and Widmer, 2008;Srivastava,2011).

1.4 Contraindications:

o Unrestorable tooth.

o Bi-or trifurcation involvement or the presence of abscess.

o Less than two thirds of root remaining.

o Permanent successor close to eruption.

o Medical contraindications:

Heart disease; a pulpotomy should not be performed in a child with a

heart defect, or if there is any history of heart disease, heart surgery,

rheumatic fever etc. This is because these children are at risk of developing

bacterial endocarditis from any invasive procedures.

Immuno-compromised children, such as those with malignant disease (eg

leukemia) who are neutropaenic for considerable periods during the

treatment of the condition Even a low infection such as that from an


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unsuccessful pulpotomy can make such children habit, and therefore should

not be undertaken

o Persistent toothache.

o Tenderness on percussion.

o Highly viscous, sluggishhemorrhage from canal orifice, which is

uncontrollable.

o Medical contradictions like heart disease, immunocompromised patient.

o Swelling or draining sinus.

o External or internal resorption.

o Pathological mobility.

o Calcification of pulp ( Dugal et al.,2005; Marwah, 2008; Srivastava, 2011).

1.5 Technique of pulpotomy:

The step-by-step pulpotomy technique implies a thorough pre-operative

assessment by taking a good history, clinical examination and radiographs.

Step I: Administer local anesthesia with the use of a topical anesthetic. It is

essential to achieve profound anesthesia. This would usually mean an inferior

dental nerve block for lower teeth and an infiltration for the upper teeth (Fig.1.1).

( Fig.1.1)Administer local anesthesia.


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Step 2: Isolate tooth with rubber dam. This is important to prevent any further

contamination of the pulp to aid patient comfort and to prevent leakage of

formocresol onto the soft tissues.(Fig.1.2)

(Fig.1.2) Isolate tooth with rubber dam.

Step 3: Remove caries and determine site of pulp exposure It is important to

remove all visible caries before the pulp chamber is bleeding from the pulp will

make visualization of areas difficult it is also necessary to determine the exposure

site arrow) since it is easier to pin access to the chamber through the

exposure.(Fig.1.3)

(Fig.1.3) Remove caries and determine site of pulp


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Step 4: Remove roof of pulp chamber (Figure 1.4). The bur is placed in the

exposure, and the site is widened until the whole of the roof of the chamber is

removed. There is no apparent exposure. the cavity is made deeper until a 'dip is

felt, when the bur passes through the roof into the void of the pulp chamber, Once

the pulp chamber has been entered, the bur is not taken any deeper but is moved

sideways to remove the roof of the chamber , Hemorrhage from the pulp will be

evident at this stage .

(Fig.1.4) Remove roof of pulp chamber.

Step 5: Remove coronal pulp with a large excavator or a large round bur. (Fig.1.5)

A large excavator is preferred to remove the coronal pulp tissue (A). When a round

bur is used; care must be taken that it is only moved tightly along the floor of the

pulp chamber excessive pressure can result in perforation of the floor and failure of

the pulpotomy (B). After removal of the inflamed coronal tissue, the hemorrhage

into the cavity should be reduced.


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(Fig.1.5) Remove roof of pulp chamber.

Step 6: A small pledge of cotton wool is dipped in formocresol and squeezed in a

piece of gauze remove excess before it is placed in the pulp chamber for four

minutes ).(Fig.1.6)

( Fig.1.6) Apply formocresol on a pledget of cotton

Step 7: Remove after four minutes and check that the haemorrhage has stopped;

continued bleeding from the root canal tissue signifies inflammation of the


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radicular tissue. this occurs the pulp should be extirpated and a pulpectomy

performed .(Fig.1.7)

(Fig.1.7)Remove formocresol pledge after 4 minutes.

Step 8: Fill pulp chamber with cement. A thick paste of hard-setting zinc oxide–

eugenol is prepared and placed over the pulp stumps. (Fig.2.8)

(Fig.1.8) Fill pulp chamber with cement.


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Step 9: Restore the tooth with a stainless steel crown.(Fig.1.9)

( Fig.1.9) Restore the tooth with a stainless steel crown.

Step 10: Take a postoperative radiograph. (Fig.1.10) .( Duggal et al, 2002;

Srivastava, 2011; Cameron and Widme, 2012; Duggal et al., 2013; Walker et al.

,2013; Dean, 2016).

(Fig.1.10) Post-operative radiograph


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1.6 Types of pulpotomy:

1.6.1 Pulpotomy for primary teeth

Laboratory and clinical observations indicate that a different technique and

capping materials are necessary in the treatment of primary teeth than in the

treatment of permanent teeth. As a result of these observations, two specific

pulpotomy techniques have evolved and are in general use. Although the

formocresol pulpotomy technique has been recommended for many years as the

principal method for treating primary teeth with carious exposures, a substantial

shift away from use of this medicament has occurred because of concerns about its

toxic effects. Many alternatives, including MTA, ferric sulfate, electrosurgery, and

lasers, have been investigated to replace formocresol as the medicament of choice

for pulpotomy. Despite this, formocresol continues to be a very commonly used

pulpotomy medicament (Dean, 2016).

Indeed, Milnes‟ reevaluation of earlier and more recent research about

formaldehyde metabolism, pharmacokinetics, and carcinogenicity led him to

suggest that there is an inconsequential risk associated with the use of formocresol

in pediatric pulp therapy (Milnes, 2008).

1.6.2 Partial pulpotomy in permanent teeth:

partial pulpotomy has been shown to be the treatment of choice in traumatically as

well as cariously exposed pulps of young permanent teeth .The partial pulpotomy

makes physiologic narrowing of the coronal pulp lumen possible, which means a

mechanically stronger tooth less prone to future compared to a tooth subjected to

coronal pulpotomy. Partial pulpotomy is also to be preferred to pulp capping, since

there is a much better possibility to control the wound surface, avoid any

extrapulpal blood clot, to get sufficient retention for wound dressing and a tight

seal, and thereby prevent bacterial infection. Partial pulpotomy of traumatized


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incisors has a success rate of 95% following an observation period of 3–15 years

(Cvek, 1993).

Partial pulpotomy is also the therapy for young permanent teeth with carious

exposure of the pulp. The outcome is favorable. Studies show 89–91% success rate

with a follow-up of about 3–4.5 years, irrespective of root development at the time

of treatment. (Mejàre and Cvek, 1993).

A recent study using MTA as wound dressing showed high success rate, 93% after

about 3 years (Qudeimat et al., 2007).

Partial pulpotomy is a permanent treatment and should only be followed by a

pulpectomy if there is a need for a post in the root canal in the future.( Koch et al.,

2017).

Technique:

The procedure involves the removal of pulp tissue beneath the exposure site judged

to be inflamed (usually 1 to 3 mm) to reach healthy tissue below . Pulpal bleeding

must be controlled quickly and the site should be covered with calcium hydroxide

or mineral trioxide aggregate (MTA), followed by a restoration that seals the tooth

from microleakage .Before initiating treatment, it is critical to evaluate the degree

of pulp inflammation in an attempt to distinguish between reversible and

irreversible pulpitis. Vital pulp therapy in permanent teeth with history of pain has

traditionally been considered contra-indicated. Although the correlation between

clinical and histologic evaluation is poor, young permanent teeth are good

candidates for this conservative treatment because of their rich blood supply that

enhances the healing ability. Because the loss of the pulp in teeth with immature

apices is so devastating, it seems advisable to attempt the partial pulpotomy

procedure. If failure occurs, apexification can always be performed (Fuks and

Heling, 2005; Camp and Fuks, 2006; Dean, 2016; Moursi et al. , 2012 ).


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1.6.2 Pulpotomy with MTA in an Immature Permanent Molar

Differential Diagnosis :

Pulp.

Reversible pulpitis.

Irreversible pulpitis.

Complete or partial necrosis of the pulp.

Periapex.

Normal: Dental sac.

Chronic apical periodontitis.( Moursi et al.,2012)

Procedure:

The pulpotomy procedure involves removing part of the pulp tissue that is

profusely bleeding or has degenerative changes, leaving intact the remaining vital

tissue. The depth to which the tissue is removed is determined by clinical

judgment. The pulp stump is then covered with a pulp capping agent, the aim of

which is to promote reparative dentin formation at the amputation site. In

multirooted teeth, the procedure is done by removing the pulp tissue to the orifices

of the root canals. (Camp and Fuks, 2006)

Ca(OH)2 has been traditionally used for pulpotomies with relatively good results.

When used over healthy pulp tissue, it stimulates dentin bridge formation. Due to

its high alkalinity and causes superficial tissue necrosis and stimulation of tertiary

dentin formation, together with an antibacterial effect (Witherspoon et al,2006).

Recent studies have demonstrated that the dentin matrix is a reservoir of growth

factors and other bio-active molecules that have been sequestered during

dentinogenesis. These molecules may be released into the pulp tissue and

contribute to dentin repair and regeneration. The beneficial effect of Ca(OH)2 is

probably due to its effect on releasing growth factors from the dentin matrix.


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Another material with a similar mechanism of action is MTA (Dean, 2016 ; Moursi

et al., 2012).

1.7 Capping materials for pulpotomy:

1.7.1 Formocresol:

Formocresol has been used in dentistry for over 100 years, and for vital pulpotomy

in deciduous teeth for over 80 years. Its efficacy has been extensively studied, with

clinical success rates ranging from 70% to 100%, making it the standard against

which newer techniques are compared. The formaldehyde component of

formocresol is strongly bactericidal and reversibly inhibits many enzymes in the

inflammatory process. Originally, the aim of using formocresol was to completely

mummify (fix) all residual pulpal tissue and necrotic material within the root canal.

Current techniques however, aim to create a very superficial layer of fixation while

preserving the vitality of the deeper radicular pulp. Contemporary pulpotomy is

explicitly contraindicated in the presence of radicular pulpitis or pulp necrosis.

Formocresol is applied to the pulpotomy site on a cotton wool pledget. Any excess

material should be blotted off the pledget prior to application. Traditionally, a 5-

minute application time has been recommended; however, contact times of only a

few seconds are probably equally effective. It is prudent to limit both dose and

contact time. Formocresol should only be applied to the pulpotomy site after

hemostasis has been obtained. It should never be applied to bleeding tissue

(Cameron and Widmer, 2013).

Some studies have indicated that the formocresol pulpotomy technique may be

applied to permanent teeth, but its use in permanent teeth remains an interim

procedure, to be followed by conventional endodontic therapy. The clinical success

experienced in the treatment of primary pulps with these materials is possibly

related more to the drug‟s germicidal action and fixation qualities than to its ability

to promote healing (Dean, 2016).


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1.7.2 Calcium hydroxide:

Herman first introduced calcium hydroxide as a biological dressing (Herman B,

1936).

Because of its high alkalinity (pH =12) superficial necrotic area in the pulp that

develops beneath the calcium hydroxide is demarcated from the healthy pulp tissue

below by a new, deeply staining zone comprised of basophilic elements of the

calcium hydroxide dressing. The original proteinate zone is still present. However,

against this zone is a new area of coarse fibrous tissue likened to a primitive type

of bone. On the periphery of the new fibrous tissue, cells resembling odontoblasts

appear to be lining up. One month after the capping procedure, a calcified bridge is

evident radiographically. This bridge continues to increase in thickness during the

next 12 months (Fig. 2.11). The pulp tissue beneath the calcified bridge remains

vital and is essentially free of inflammatory cells (Dean, 2016).

(Fig.1.11)Calcified bridge covering an amputed pulp that was capped with calcium hydroxide.


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1.7.3 Ferric sulfate:

Ferric sulfate (15.5%) has been used as pulpotomy agent as a substitute for

formocresol for 15–20 years. Ferric sulfate (Fe2SO4) in contact with blood forms a

ferric ion–protein complex, which seals the cut blood vessels mechanically,

producing hemostasis. The effect of ferric sulfate is hemostatic but not bactericidal

or fixative. After application of ferric sulfate for 15 seconds, the pulp is covered

with zinc oxide–eugenol and the cavity sealed. Research has shown similar results

both regarding clinical, radiographic, and histologic results as formocresol.

Healing has not been achieved, but the teeth could be retained in the dentition for

shorter or longer intervals. There are no known systemic risks of using ferric

sulfate in pulpal treatment (Koch and Poulsen, 2009).

1.7.4 Mineral trioxide aggregate MTA:

It is emerging as a popular product for pulpotomies secondary to a variety of

factors. Originally developed as a root-end filling material, its main components

are tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicate oxide

(Dean, 2016).

Mineral trioxide aggregate (MTA) a relatively newer material has been

introduced to dentistry in 1995 by Torabinejad who had suggested it for

endodontic root filling. It is composed of tricalcium silicate, tricalcium aluminat,

tricalcium oxide and silicate oxide. It also contains oxides of iron, magnesium and

bismuth which is added for radiopacity purpose (Agamy, 2004).

MTA can be recommended in the treatment of primary teeth with carious pulp

exposures when there is a pathologic change in the pulp at the exposure site

(Chailertvanitul et al., 2014).

It is also indicated for a primary tooth with a pulp exposure resulting from crown

fracture when the trauma has also produced a root fracture of the same tooth. The

procedure is completed during a single appointment. (Walker et al., 2013).


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Only teeth free of symptoms of painful pulpitis are considered for treatment. The

treatment is also completed during a single appointment. The positive properties of

MTA are biocompatibility, good sealing properties, antimicrobial activity, and the

ability to set in the presence of moisture and blood. The negative attributes include

difficulty of handling and the exceptional cost. In addition, along with formocresol

and ferric sulfate, MTA can cause pulp canal obliteration. Despite this, it seems to

come closest to our goal of formation of a natural dentinal bridge across the

exposed pulpal tissue (Dean, 2016).

1.7.5 Biodentine :

It is a calcium-silicate based material that has drawn attention in recent years and

has been advocated to be used in various clinical applications, such as root

perforations, apexification, resorptions, retrograde fillings, pulp capping

procedures, and dentin replacement. Due to its major advantages and unique

features as well as its ability to overcome the disadvantages of other materials,

biodentine has great potential to revolutionize the different aspects of managing

both primary and permanent in endodontics as well as operative dentistry

(Allazzam et al., 2015).

1.7.6 Formaldehyde:

Formaldehyde has been shown to be distributed systemically after pulpotomy. Up

to 10% of the formaldehyde from a formocresol pulpotomy was absorbed

systemically in dogs (Pashley et al., 1980).

In a separate study, radioactively labeled formaldehyde was distributed throughout

the viscera of rats following formocresol pulpotomy in a single molar (Ranly,

1985). At least 3 areas of concern have been reported with regard to formocresol:

mutagenicity, carcinogenicity and immune sensitization (Block et al., 1978)


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1.7.7 Gluteraldehyde:

It is used as an alternative medicament for formacresol. 2 percent to 4 percent

aqueous Gluteraldehyde produces rapid surface fixation of the underlying pulpal

tissues. Its fixative property is better than those of formaldehyde. It is less

penetrative than formacresol, thus less able to diffuse into periapical tissues. It has

relatively low antigenicity compared with formacresol. Clinical studies have

shown high success rate by using 2 percent solution (Srivastava, 2011).

1.7.8 Laser:

Since the early 1960s, lasers have been introduced to medicine and dentistry.

Different lasers are used in pediatric dentistry. Several studies have revealed that

laser have proper effects in pulpotomy of primary teeth with results similar or even

better than Ferric sulfate ( Liu et al., 2006)

The advantages of laser: compared to conventional pulpotomy, such as

hemostasis, preservation of vital tissues near the tooth apex, absence of vibration

and odor may lead to satisfaction of children and their parents. Nd: YAG laser with

output power of 2 W and frequency of 20 Hz.( Huth et al., 2012).

1.7.9 Electrosurgery:

Electrosurgery uses radiofrequency energy to produce a controlled superficial

tissue burn. It is both hemostatic and antibacterial. Excessive energy or contact

time causes a deep tissue burn with necrosis of the radicular pulp and subsequent

internal root resorption. Electrosurgical pulpotomy has a success rate of 70–94%.

The electrosurgery unit should be set to coagulate, with a low power setting. A

small ball or round-ended tip is applied to the pulpotomy site and briefly activated.

The site should immediately be flooded with water to remove excess heat. Each

pulp stump is treated in turn. If necessary, electrocoagulation can be repeated to

control persistent bleeding, until the total cumulative application time is 2 seconds.


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Persistent bleeding after this time is an indication for pulpectomy or extraction.

Electrosurgical equipment has the potential to interfere with pacemakers and

implanted electronics. The patient must be correctly grounded with a dispersive

plate to prevent earth leakage burns, which can occur in the extremities, a long way

from the surgical site. Electrosurgical equipment should be set up, maintained and

used according to the manufacturer‟s direction (Cameron and Widmer, 2013).

1.8 Previous studies concerning pulpotomized teeth according to:

1.8.1 Tooth type:

The percentage of pulpotomized primary2nd

molars (84%) was found to be higher

than the 1st molars (78%) (Enunn et al, 1999).

Similarly; other researchers found that the pulpotomized primary 2nd

molars were

more than primary 1st molars ( Guelmann et al.,2002; Ja‟far and Essa, 2017).

1.8.2Gender:

Relating to gender distribution; some researchers found that the percentage of boys

underwent pulpotomized primary molars were higher than girls. (Marwha et al.,

1975; Guelmann et al., 2002; Ja‟far and Essa, 2017).

1.8.3 Age:

With reference to the age groups; the age group (less than 6), as found by some

researchers, have more pulpotomized primary molars than the age group (more

than 6) (Guelmann et al., 2002).

1.8.4 Jaw distribution:

A previous study found that the percentage of pulpotomized maxillary molars

(89%) was higher than Mandibular molars (73%) (Enunn et al.,1999).

On the contrary; another study found that mandibular primary molars that undergo

pulpotomy treatment were more than maxillary primary molars. (Guelmann et al.,

2002). Similarly; Ja‟far and Essa (2017) found that there were more mandibular


21 | P a g e

pulpotomized primary molars (67.5%) than maxillary pulpotomized primary

molars (32.5%).

1.8.5 Side of jaw:

About the side distribution; some studies found that pulpotomized right primary

molars were more than left primary molars. (Enunn et al.,1999; Guelmann et al.,

2002; Ja‟far and Essa, 2017).

1.8.6 Filling material:

Pertaining to the filling material; Ja‟far and Essa (2017) found that amalgam was

the most common filling material used for pulpotomized primary molars (65.83%)

than composite (3.75%) or semi-permanent restoration (11.25%) in addition to

temporary filling (19.16%).

The use of amalgam over zinc oxide eugenol layer in pulpotomized primary molars

decreases microleakage (Bargrizan, 2011).

Chapter Two Materials and Method

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Chapter Two

Materials and methods

This is a retrospective study conducted to analyze the work of the department of

pedodontics / college of dentistry / Baghdad University at 2015 – 2016 and 2016-

2017 studying year concerning the pulpotomized primary teeth.

The case sheets records for all children attended the department of pedodontics \

college of dentistry \ Baghdad university ,were collected from the department

archive then reviewed for the presence of pulpotomized primary teeth ,classified

according to the jaw (upper or lower) , gender (boys or girls) , side (left or right)

and the restorative materials used (amalgam , L.C , semi-permanent restoration or

T.F ) , age group (2-5, 6-9, 10-13,14) and G.V.Black classification ( Cl I, Cl III, Cl

III, Cl VI and compound cavities).

Statistical analysis was done by using IBM SPSS statistic version 19.

(Fig.2.1) Sample collection

Chapter Three Results

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Chapter three

Results

A total of (1484) children attended to the pediatric department in college of

dentistry/University of Baghdad form (2016-2017), consisted of (776) boys and

(708) girls and the highest number was for the age group 9-11(527). Furthermore

total number of (1513) children attended to the pediatric department in college of

dentistry/University of Baghdad form (2015-2016), consisted of (775) boys and

(738) girls, the highest number was for the age group 9-11(557). [Table 3.1].

Table 3.1: Distribution of the total sample by age and gender

Regarding 2016-2017 studying year; boys had more pulpotomized teeth 141

(9.5%) than girls 135(9%), and it was found that more pulpotomized primary teeth

in mandibular arch 159 (10.8%) than maxillary arch 117 (7.7%). Among primary

teeth the lower primary second molar 97 (5.7%) was found to be the most

Year Age groups gender

Total Boys girls

2016-2017

3-5 79 59 138

6-8 264 249 513

9-11 278 249 527

12-14 155 151 306

Total 776 708 1484

2015-2016

3-5 58 81 139

6-8 265 271 536

9-11 302 255 557

12-14 150 131 281

Total 775 738 1513


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pulpotomized primary tooth. More pulpotomized primary teeth in the Right side

140 (9.4%) than the Left side 136 (9.1%).

About 2015-2016 studying year; the boys also had more pulpotomized primary

teeth 126(8.4%) than girls124 (8.3%), more pulpotomized primary teeth in

mandibular arch 135(9%) than maxillary arch 115 (7.7%), among primary teeth

also the lower primary second molar 75 (4.9%) was found to be the most

pulpotomized primary tooth, more pulpotomized primary teeth in the Right side

131 (8.8%) than the Left side 119 (8%)[Table 3.2].


25 | P a g e

Table 3.2: pulpotomized primary teeth according to gender

Primary teeth

Gender

total boys girls

Right Left Right Left

No. % No. % No. % No. % No. % No. %

2016-2017

UE 14 0.9 12 0.8 17 1.1 13 0.9 56 3.7

117 7.7

UD 14 0.9 18 1.2 12 0.8 15 1 59 3.9

UC 0 0 2 0.1 0 0 0 0 2 0.1

UB 0 0 0 0 0 0 0 0 0 0

UA 0 0 0 0 0 0 0 0 0 0

LE 25 1.7 22 1.5 22 1.5 15 1 84 5.7

159 10.8

LD 18 1.2 15 1 18 1.2 20 1.3 71 4.8

LC 0 0 1 0.1 0 0 2 0.1 3 0.2

LB 0 0 0 0 0 0 1 0.1 1 0.1

LA 0 0 0 0 0 0 0 0 0 0

Total 71 4.8 70 4.7 69 4.6 66 4.4 276 18.5 276 18.5

141 (9.5%) 135 (9%)

2015-2016

UE 17 1.1 8 0.5 18 1.2 10 0.7 53 3.5

115 7.7

UD 14 0.9 19 1.3 18 1.2 8 0.5 59 3.9

UC 1 0.1 1 0.1 0 0 1 0.1 3 0.3

UB 0 0 0 0 0 0 0 0 0 0

UA 0 0 0 0 0 0 0 0 0 0

LE 13 .9 24 1.5 12 .8 26 1.7 75 4.9

135 9

LD 18 1.2 10 0.7 18 1.2 12 0.8 58 3.9

LC 1 0.1 0 0 1 0.1 0 0 2 0.2

LB 0 0 0 0 0 0 0 0 0 0

LA 0 0 0 0 0 0 0 0 0 0

Total 64 4.3 62 4.1 67 4.5 57 3.8

250 16.7 250 16.7 126 (8.4 ) 124 (8.3 )


26 | P a g e

The age group 6-8 get the highest frequency of pulpotomized primary teeth in

both 2016-2017 and 2015-2016 studying years 186(12.4%) and 145 (9.6%)

respectively. [Table 3.3]

Table 3.3: pulpotomized primary teeth according to age group

Primary teeth

Age groups total

3-5 6-8 9-11 12-14

No. % No. % No. % No. % No. %

2016-

2017

E 11 0.7 90 6 39 2.6 0 0 140 9.4

D 11 0.7 91 6.1 28 1.9 0 0 130 8.7

C 0 0 5 0.3 0 0 0 0 5 0.3

B 1 0.1 0 0 0 0 0 0 1 0.1

A 0 0 0 0 0 0 0 0 0 0

Total 23 1.5 186 12.4 67 4.5 0 0 276 18.5

2015-

2016

E 18 1.2 68 4.4 42 2.8 0 0 128 8.5

D 7 0.4 74 4.9 36 2.4 0 0 117 7.9

C 2 0.1 3 0.2 0 0 0 0 5 0.3

B 0 0 0 0 0 0 0 0 0 0

A 0 0 0 0 0 0 0 0 0 0

Total 27 1.8 145 9.6 78 5.3 0 0 250 16.7


27 | P a g e

Dental amalgam was found to be the most filling material used for pulpotomized

primary teeth 192(12.5%) and 151(10.1%) in the years 2016-2017 and 2015-2016

respectively. [table 3.4]

Table 3.4: pulpotomized primary teeth according to filling material

Primary

teeth

Filling materials total

amalgam Composite GIF T.F.

No. % No. % No. % No. % No. %

2016-

2017

E 97 6.6 14 0.9 25 1.7 4 0.3 140 9.4

D 95 6.4 28 1.8 6 0.4 1 0.1 130 8.7

C 0 0 5 0.3 0 0 0 0 5 0.3

B 0 0 1 0.1 0 0 0 0 1 0.1

A 0 0 0 0 0 0 0 0 0 0

Total 192 12.6 48 3.1 31 2.1 5 0.4 276 18.5

2015-

2016

E 75 5 25 1.7 26 1.7 2 0.1 128 8.5

D 76 5.1 23 1.5 14 0.9 4 0.3 117 7.9

C 0 0 5 0.3 0 0 0 0 5 0.3

B 0 0 0 0 0 0 0 0 0 0

A 0 0 0 0 0 0 0 0 0 0

Total 151 10.1 53 3.5 40 2.6 6 0.4 250 16.7


28 | P a g e

According to GV Black‟s classification class II was found to be the most

class in pulpotomized primary teeth among other classes for both 2016-

2017 and 2015-2016 studying years,138 (9.2%) and 107(7.1%)

respectively.[table 3.5].

Table 3.5: Black‟s classification for pulpotomized primary teeth

Primary

teeth

Classification total

Cl I Cl II Cl III Cl IV Compound

No. % No. % No. % No. % No. % No. %

2016-

2017

E 63 4.2 65 4.3 0 0 0 0 12 0.8 140 9.4

D 42 2.8 73 4.9 0 0 0 0 15 1 130 8.7

C 0 0 0 0 4 0.3 1 0.1 0 0 5 0.3

B 0 0 0 0 0 0 1 0.1 0 0 1 0.1

A 0 0 0 0 0 0 0 0 0 0 0 0

Total 105 7 138 9.2 4 0.3 2 0.2 27 1.8 276 18.5

2015-

2016

E 53 3.5 65 4.3 0 0 0 0 10 0.7 128 8.5

D 54 3.6 45 2.9 0 0 0 0 18 1.2 117 7.9

C 0 0 0 0 5 0.3 0 0 0 0 5 0.3

B 0 0 0 0 0 0 0 0 0 0 0 0

A 0 0 0 0 0 0 0 0 0 0 0 0

Total 107 7.1 110 7.2 5 0.3 0 0 28 1.9 250 16.7

Chapter Four Discussion

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Chapter four

Discussion

This study was designed to investigate prevalence of pulpotomized

primary teeth for children attended the pediatric department in college of

dentistry/University of Baghdad.

The comparison of data with other studies may not be completely valid

due to variation in methods of examination used by different researchers

and variation in the environment of other countries.

According to age group: the results of this study showed that the

prevalence of pulpotomized teeth was highest for the age group 6-8 [table

3.3] which disagrees with Guelmann et al. (2002) that said the age group

(less than 6) have more pulpotomized primary molars than the age group

(more than 6), which may be explained by that the age group of 6-9 years

are more aware about the importance of primary teeth and may cooperate

more likely in dental clinic.

According to gender; the results of this study showed that the prevalence

of pulpotomized teeth in boys more than girls [Table 3.2] which agree

with Marwha et al. (1975); Guelmann et al.(2002); Ja‟far and Essa

(2017).

According to the arch distribution; the results of this study showed that

the prevalence of pulpotomized primary teeth in mandibular arch were

more than the maxillary arch [Table 3.2]. This agree with Guelmann et al.

(2002); Ja‟far and Essa (2017) but disagree with Enunn et al. (1999) that

found the percentage of pulpotomized maxillary molars was higher than

mandibular molars .

According to the side of jaw; the results of this study showed that the

prevalence of pulpotomized teeth in the right side was more than the left

Chapter Four Discussion

31 | P a g e

side [Table 3.2]. This is in accordance with Enunn et al. (1999);

Guelmann et al. (2002); Ja‟far and Essa (2017).

According to the filling materials; the results of this study showed that the

dental amalgam was the most filling material used for pulpotomized

primary teeth [table 3.4], which is similar to that of Ja‟far and Essa

(2017) Which may be explained by that the use of amalgam over zinc

oxide eugenol layer in pulpotomized primary molars decreases

microleakage (Bargrizan, 2011).

According to the type of tooth; the results of this study showed that the

primary second molar was the most pulpotomized primary tooth [Table

3.2].This study agree with Enunn et al. (1999); Guelmann et al.(2002);

Ja‟far and Essa (2017).

According to GV Black‟s classification class II was found to be the most

class in pulpotomized primary teeth among other classes in 2016-2017,

this may give a clue that the pulpotomized teeth had more destructive

carious lesion than simple Cl I and the need for more dental care and

attention than other teeth this could be due to unsatisfactory oral hygiene

and lack of proper tooth brushing technique, lack of proper awareness of

the patients, as well as posterior teeth complex morphology, the enamel

and dentin are thinner than they are in permanent molars also primary

teeth contact areas are broad and flattened rather than being a small

distinct circular contact point, as in permanent teeth (Waggoner, 2005).

Conclusions

31 | P a g e

Conclusions:

1. The occurrence of pulpotomized teeth was highest for the age

group 6-8.

2. According to gender; the occurrence of pulpotomized teeth in boys

more than girls.

3. According to the arch distribution; the occurrence of pulpotomized

primary teeth in mandibular arch was more than the maxillary arch.

4. According to the side of jaw; the occurrence of pulpotomized teeth

in the right side was more than the left side.

5. According to the filling materials; the dental amalgam was the

most filling material used for pulpotomized primary teeth.

6. According to the type of tooth; the primary second molar was the

most pulpotomized primary tooth.

7. According to GV Black‟s classification class II was found to be the

most class in pulpotomized primary teeth among other classes.

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pulpotomized primary teeth for patients attended the ......and the restorative materials used...

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