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Clinical and Radiographic Evaluation of Mineral Trioxide Aggregate and

Electrosurgical Pulpotomies in Primary Molars: An In-Vivo Study

Article · January 2016

DOI: 10.2047/jioh-08-05-14

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MTA and electrosurgical pulpotomy … Girish MS et al
Received: 07th December 2015  Accepted: 03th March 2016  Conflict of Interest: None
Source of Support: Nil
Clinical and Radiographic Evaluation of Mineral Trioxide Aggregate and
Electrosurgical Pulpotomies in Primary Molars: An In-Vivo Study
M S Girish1, Prakash Chandra2, Latha Anandakrishna3
Contributors:
1
Reader, Department of Pedodontics and Preventive Dentistry,
JSS Dental College and Hospital, Constituent College of
JSS University, Mysuru, Karnataka, India; 2Senior Professor,
Department of Pedodontics and Preventive Dentistry, Faculty
of Dental Sciences, M S Ramaiah University of Applied Sciences,
Bengaluru, Karnataka, India; 3Professor and Head, Department of
Pedodontics and Preventive Dentistry, Faculty of Dental Sciences,
M S Ramaiah University of Applied Sciences, Bengaluru, Karnataka,
India.
Correspondence:
Dr. Girish M S. Department of Pedodontics and Preventive
Dentistry, JSS Dental College and Hospital, Constituent College of
JSS University, Mysuru, Karnataka, India. Phone: +91-9845499588.
Email: drgirish@gmail.com
How to cite the article:
Girish MS, Chandra P, Anandakrishna L. Clinical and radiographic
evaluation of mineral trioxide aggregate and electrosurgical
pulpotomies in primary molars: An in-vivo study. J Int Oral Health
2016;8(5):601-606.
Abstract:
Background: Pulpotomy is the most common treatment modality
employed to preserve a cariously exposed symptom-free primary
molars, which aims to preserve the vitality of radicular pulp till its
exfoliation. Such pulpotomy agent should bactericidal, should not
damage surrounding tissues, promote healing of remaining of pulp
tissue, and should not affect physiological resorptive process of the
tooth. The quest for one such ideal pulpotomy material/procedure
is never conclusive. Hence, this study was conducted to assess and
compare the clinical and radiographic outcomes of mineral trioxide
aggregate (MTA) and electrosurgical pulpotomies in human
primary molar teeth.
Materials and Methods: A total of 60 carious mandibular primary
molars from 46 children whose pulpal status was indicated for
pulpotomy were considered. The selected teeth were randomly divided
into two groups using simple randomization number table. MTA and
electrosurgical pulpotomies were performed for the respective group
followed by the placement of stainless steel crown. Pulpotomized
patients were recalled for further follow-up at 1st, 3rd, 6th, 9th, and
12th month for clinical and radiological evaluation. McNemar’s test
was used to determine the differences between groups.
Results: At the end of the 12 months follow-up, the overall success
rate for MTA was at 96.7% and for electrosurgery was at 90%.
However, there was no statistically significant difference between
the groups compared.
Conclusion: Success of electrosurgical pulpotomies can be
comparable with that of MTA.
Key Words: Electrosurgery, Mineral trioxide aggregate, Pulpotomy
601
Journal of International Oral Health 2016; 8(5):601-606
Original Research
Doi: 10.2047/jioh-08-05-14
Introduction
Pulpotomy is a therapeutic procedure which is commonly
employed in reversible inflammation of the coronal pulp of
the primary teeth. This is required where radicular pulp tissue
has to be maintained in a healthy condition for long-term, until
exfoliation. The preservation of vitality of radicular portion
of pulp tissue through pulpotomy procedure in the primary
dentition is quite valuable from the point of view that, it not
only helps in maintaining the arch integrity but also guides the
erupting successor in correct path.1
Formaldehyde derivatives have been used as an acceptable,
highly successful, and most common agent for the fixation
of pulp for many years.2,3 Despite its success, the empiricism
supporting the use of formocresol as a pulpotomy agent
has been questioned for many years.4 The search for the
medicament to replace formocresol became vital after several
negative reports questioned its local and systemic toxic
effects. The greatest concerns seeking the alternatives for
formaldehyde derivatives are:
1. Pulpal response with inflammation and necrosis5
2. Cytotoxicity6
3. Systemic disturbances7
4. Mutagenic and carcinogenic potential8
5. Immunologic responses.9
Electrosurgery has been proposed as an alternative treatment
avoiding the toxic effects of chemical drugs applied over
the pulp.4,10,11 The exceedingly few investigations carried
out with this method have reported a promising result. The
electrosurgical pulpotomy appears to have its merit as it is
self-limiting,12,13 pulp penetration when activated is few cells
deep, excellent visualization and hemostasis is possible without
chemical coagulation or systemic involvement. It is also less
time consuming than the formocresol approach.14
Mineral trioxide aggregate (MTA) which was introduced
by Dr. Mahmoud Torabinejad as root end/root canal repair
material, has been advocated for other uses. In primary
teeth, MTA is predominantly used for pulp capping and
pulpotomy procedures. The major benefits of MTA are
that it is biocompatible, bactericidal, and able to stimulate
osteocementum like structure. Its sealing, mineralizing,
osteogenic and dentinogenic properties have made it a material
of choice in various clinical scenario’s.15
MTA and electrosurgical pulpotomy … Girish MS et al  Journal of International Oral Health 2016; 8(5):601-606

For the above cited reasons, and considering the concerns

regarding the formocresol and its adverse reaction, the
predated studies formed the basis for current investigations.
The aim of the study was to evaluate the effect of MTA and
electrosurgical pulpotomies which are considered as safe for
clinical and radiologic success on human primary molar for
12-month.

Materials and Methods

The patients were recruited from the out patients walking into
the Department of Pedodontics and Preventive Dentistry of
M S Ramaiah Dental College and Hospital, Bengaluru were
included in the study. The parents and the children involved
in the study were explained about the procedure, its possible
discomforts, and benefits. Prior approval from the Institutional
Ethical Committee was obtained. The intended sample of 60
carious mandibular primary molars from 46 children whose
pulpal status indicated for pulpotomy was considered using
the results of previous studies.

The sample size was arrived at, using the formula:

n=
(
2 Za′+Za )
 2(S12 +S 2 2 )
(X1 +X 2 )2
Flow Chart 1: Consort flow chart of pulpotomised teeth for
Where, Zá = 3.28, Zâ = 1.28, power 90%, S1 = Standard 12 months.
deviation of MTA group, S2 = Standard deviation of
electrosurgery group, X1 = Mean of MTA group and X2 = Mean concealed from the clinician performing pulpotomies until
of electrosurgery group. baseline assessments were finished.

The children were in the age group of 4-9 years. The indicated
teeth were evaluated clinically and radio graphically. All the
children belonged to the American Society of Anesthesiologists
I and II grading were included in the study. The inclusion
criteria were: cooperative children, the presence of a deep
carious lesion, no clinical sign of profuse bleeding from
amputated radicular pulp, tenderness to percussion, no
more than two third of root resorption, and a tooth which
is restorable. Children with a history of systemic illness
contraindicating for pulpotomy, spontaneous tooth pain or
tenderness to percussion, pathologic mobility, the presence
of any internal or external resorption, apical or furcal
radiolucency, widened periodontal ligament space, and sinus
tract were excluded from the study.
Allocation
Selected Mandibular primary molars were randomly divided
into two groups using simple randomization number table.
The allocation was done according to consort guidelines (Flow
Chart 1). Mandibular primary molars were preferred in our
study because the radiological changes during follow-up are
better appreciated in mandibular molars when compared to
maxillary tooth due to the favorable anatomy of mandibular
molar for radiological examinations. Allocations were
MTA group
A total of 30 primary molars to be pulpotomised with MTA
(ProRoot MTA - DENTSPLY Tulsa Dental Specialties –
White MTA) mixed as per the manufacturers instruction.
Electrosurgery group
A total of 30 primary molars in electrosurgery group were
pulpotomised using U-shaped loop no S-6015A of perfect
TCSTM (Coltene Whaledent).
Intervention
Before the start of pulpotomy technique, local anesthesia,
placement of rubber dam, and treatment procedure was
explained, to gain the confidence of the child. After inducing
anesthesia, all the peripheral infected caries was excavated with
an excavator. The roof of the pulp chamber was outlined and
removed using No. 558 straight crosscut fissure bur;16 sharp
spoon excavator was used for complete mechanical coronal
pulp amputation. The pulp stumps were clearly excised with
no tags of tissue extending across the floor of the pulp chamber
and then irrigated with light flow of sterile water syringe and
evacuated. A wet cotton pellet (soaked in sterile water) was
placed over the amputated pulp stones for 3 min to achieve
hemostasis.17 The status of the radicular pulp was assessed,

602
MTA and electrosurgical pulpotomy … Girish MS et al
and the tooth was considered for pulpotomy once the bleeding
was arrested naturally.
MTA group
The amputated pulp stumps were covered with thick paste of
MTA (ProRoot MTA, DENTSPLY, Tulsa, USA) obtained by
mixing MTA powder with sterile water at 3:1 powder to water
ratio according to manufacturer’s instruction. Followed by the
placement of zinc oxide eugenol cement.
Electrosurgery group
In the electrosurgical group, large sterile cotton pellets
were placed into the chamber with pressure to obtain initial
hemostasis. The cotton pellets were removed, and the
U-shaped electro surgery dental electrode was immediately
placed at 1-2 mm above the tissue. The electrosurgery unit was
set at 40% power. The electrode was allowed to bridge the gap
on the first pulpal stump for one second followed by a cool
down period of 5 s. Heat and electrical transfer were lessened
by keeping the electrode secluded from the pulpal stumps and
tooth structures as it would still allow electrical arcing to occur.
This procedure was reiterated up to a maximum of 3 times
on each pulpal orifice. On completion, the pulpal stumps
appeared dry and fully blackened, which was later restored
with zinc oxide eugenol cement.18 Following pulpotomy,
stainless steel crowns were placed on all the pulpotomised
teeth.
Follow-up assessment
During the follow-up recall, post-operative intraoral periapical
digital radiographs – Radovisiograph were taken by using
paralleling cone technique with cone positioners. The children
were recalled for clinical and radiological evaluation for 1 year.
a b
c d
Figure 1: (a) Pre-operative radiograph of primary molar
selected for electrosurgical pulpotomy, (b) immediate post-
operative radiograph of electrosurgically pulpotomized
primary molar, (c) 1st month post-operative radiograph of
electrosurgically pulpotomized primary molar, (d) 3rd month
post-operative radiograph of electrosurgically pulpotomized
primary molar.
603
Journal of International Oral Health 2016; 8(5):601-606
(1st, 3rd, 6th, 9th, and 12th months, respectively) (Figures 1
and 2).
The tooth was considered as clinically success if they had: (1)
No symptoms of pain (2) no swelling, fistula or pathologic
mobility and (3) tenderness to percussion. The tooth was
considered as radio graphically success if they had: (1) Absence
of pathologic internal or external resorption, (2) absence
of inter-radicular or periapical radiolucency, (3) absence of
pulp canal calcification, and (4) crypt of surrounding tooth
was intact.
Clinical and radiographic assessments were done by an
investigator who was blind to the pulpotomy technique
employed.
Statistical analysis
The data thus obtained was analyzed using SPSS Version 20.
McNemar’s test was used to determine difference between the
groups at 95% confidence level (P = 0.05).
Results
The final sample consisted of 60 primary molars from 46
children (27 male and 19 females) with a mean age of 5 years
6 months at the time of intervention. All patients were recalled
at assigned times post-operatively for clinical and radiographic
evaluation. Once the pulpotomised tooth was considered as a
failure, it was no longer included for forthcoming evaluation.
None of the pulpotomised teeth presented with adverse effects
for the medicament or the technique employed for pulpotomy.
One tooth in MTA group showed radiological sign of failure,
pulp canal obliteration (PCO) during the 6th month of follow-
up (Table 1), which was subsequently extracted and dropped
from further follow-up.
a b
c
Figure 2: (a) 6 th month post-operative radiograph of
electrosurgically pulpotomized primary molar, (b) 9th month
post-operative radiograph of electrosurgically pulpotomized
primary molar, (c) 12th month post-operative radiograph of
electrosurgically pulpotomized primary molar.
MTA and electrosurgical pulpotomy … Girish MS et al 
Table 1: Success rate of MTA and electrosurgical pulpotomies at
recall visits.
Materials Result Follow‑up times in months, N (%)
1st 3rd 6th 9th 12th
MTA Success 30 (100) 30 (100) 29 (96.7) 29 (96.7) 29 (96.7)
Electrosurgery Success 29 (96.7) 29 (96.7) 28 (93.3) 27 (90) 27 (90)
McNemar’s test P=0.353. MTA: Mineral trioxide aggregate
In the electrosurgery group, one tooth showed internal
resorption at 1st month, another with mobility, swelling, and
furcal radiolucency and external resorption at 6th month and
one more with internal resorption at 9th month of follow-up.
All the teeth which failed in electrosurgery were extracted,
and necessary space management steps were taken during
subsequent appointments. Internal resorption was the
ubiquitous radiographic failure at 12th month follow-up. It was
noted in 6.6% of sample with two in electrosurgery group. By
the end of 12th month follow-up when the data was analyzed for
success rates, the overall clinical success was 96.7% for MTA
and 90% (Table 1) for electrosurgery. However, there was
no statistically significant difference between the two groups
(P = 0.353), but there was a decrease in success rate as the
follow-up period was increased in both groups.
Discussion
Over the years, lot of concern has been raised regarding the
use of formocresol in dentistry. Even though it was the gold
standard medicament for pulpotomy procedures in primary
molars, lot of other materials were introduced to overcome
adverse effects of formocresol.19-22 With this in mind, this study
was an attempt find a non-chemical alternative to formocresol,
which proved to be success with 96.7% success for MTA and
90% for electrosurgery. The success rates of this study were
comparable to most of the studies in the past irrespective of
the pulpotomy procedure employed.15
The procedure of pulpotomy for primary teeth has been
developed along three lines: Devitalization, preservation, and
regeneration. Devitalization where the intent is to destroy
vital tissue, typified by formocresol, preservation, where
the retention of maximum vital tissue with no induction of
reparative dentine, is epitomized by glutaraldehyde and ferric
sulfate. Regeneration, where the stimulation of dentine bridge
has been associated with calcium hydroxide, MTA23 and
recently bioactive materials like biodentine24 enamel matrix
derivative25 and has been tried as a pulpotomy agent.
Devitalization was the first approach in pulpotomy of
primary teeth. The multiple visit formocresol technique as
introduced by Sweet was designed to mummify the tissues
completely.18 The only rationale for using formocresol is “it
succeeds than fails.” Even with its stupendous success over the
years as a pulpotomy agent, it has received a lot of criticism,
which have shown formaldehyde to be toxic, mutagenic, and
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Journal of International Oral Health 2016; 8(5):601-606
carcinogenic.26-32 In an attempt altogether to avoid chemicals,
MTA and electrosurgical pulpotomies were given importance.
For electrosurgical pulpotomy, an undamped, fully rectified,
high-frequency current with an electrode is placed in direct
contact with tissues. It has the merit of having – “limited pulpal
penetration, complete hemostasis, and clear visualization
without using any chemical preparation,4 which has been
acknowledged by many such studies.33,34
Several studies exist comparing the radiographic and clinical
results of electrosurgery to other medicaments.4,10-14 Although
many pulpotomy techniques have been suggested, a review
article15 and available literature suggest that evidence is lacking
as to state which pulpotomy procedure is the appropriate one.35
It has been reported that clinical evaluation is the most
optimistic criteria for the success of any pulpotomy procedure,36
but the first sign of failure was usually detected radiographically.
In the MTA group, one case presented with the radiological
finding of PCO in the 6th month follow-up. Even it is debatable
whether PCO is due to inflammatory response or due to
inductive properties of MTA. However, considering our post-
operative evaluation criteria the case was considered as failure
and excluded from further follow-up. A systemic review has
presented with a higher incidence of PCO when MTA was
used as a pulpotomy medicament.37
Internal resorption is usually the first radiological sign of
failure.38 In this study, two from electrosurgery group were
considered as a failure due to internal resorption. It has been
suggested previously that similar failures were the result
of - improper coronal seal,11 inflammatory response to zinc
oxide eugenol,2 inconsistency in techniques using multiple
operators, or improper selection of cases.38 However, in cases
of electrosurgery, lateral heat, which was dissipated from the
electrode, could be the cause of chronic inflammatory changes
such as internal resorption.4,39 Both the clinical and radiological
success rates of electrosurgical pulpotomy were in par with the
studies published in the recent past.40,41
Other radiological signs of failure like furcal and periapical
radiolucency, external resorption was noted in a case in
electrosurgery group. Clinical signs of failure like, mobility and
swelling were also observed in one of the cases in electrosurgery
group. The first sign of failure among pulpotomised teeth
will be normally detected radiographically as the tooth may
remain asymptomatic. Such signs of failure which emphasizes
the importance of a periodic radiological follow-up even in
the absence of clinical signs and symptoms. Similar to ample
of studies which have reported having a decrease in success
rate with increased follow-up period,2,15,18,35,42 There was also
a decrease in both clinical and radiographic success rates, in
this study.
MTA and electrosurgical pulpotomy … Girish MS et al
Conclusion
Considering the limitation of this in-vivo study: That is a
larger sample size and longer follow-up period, it can be
concluded that since there was no statistically significant
difference between the two groups (P = 0.353), the success of
electrosurgical pulpotomy in primary teeth is comparable to
that of MTA. If the concerns regarding, the use of formocresol
were to be true, MTA, and electrosurgery can be the method
of choice for pulpotomy procedures in primary molar teeth.
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