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Mineral trioxide aggregate and formocresol pulpotomy of primary teeth: A 2-

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Mineral trioxide aggregate and formocresol
pulpotomy of primary teeth: a 2-year follow-up
G. Ansari & M. Ranjpour
Deptartment of Paedodontics, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Abstract
Ansari G, Ranjpour M. Mineral trioxide aggregate and
formocresol pulpotomy of primary teeth: a 2-year follow-up.
International Endodontic Journal, 43, 413–418, 2010.
Aim To compare the clinical and radiographic
response of primary teeth to vital pulpotomy
using mineral trioxide aggregate (MTA) or formocresol
(FC).
Methodology A group of 17 children aged 4–9
were selected from those referred to the Paedodontic
Department at Shahid Beheshti University, Dental
School. Cases with at least two matching teeth were
selected (40 teeth), showing signs of pulp involvement.
A pulpotomy procedure was carried out in all cases
with FC in control teeth whilst MTA was placed in
experimental teeth. Clinical and radiographic evalua-
tions were performed at 1-, 6-, 12- and 24-month
recall. Statistical analysis using a Fischer exact test was
Introduction
Several reports support the use of formocresol (FC) for
pulpotomy procedure in primary teeth (Primosch et al.
1997, Vij et al. 2004). However, concerns have been
raised over its use in children during the last three
decades (Pruhs et al. 1977, Myers et al. 1978, Judd &
Kenny 1987, Sun et al. 1990, Primosch et al. 1997,
Block et al. 1997). Studies have also been conducted on
the effectiveness as well as safety of other materials and
techniques, including the use of glutaraldehyde (GA),
ferrous sulphate and more recently mineral trioxide
aggregate (MTA) (Tziafas et al. 2002, Salako et al.
Correspondence: Ghassen Ansari, Department of Paedodon-
tics, Dental School, Shaheed Beheshti University MC, Tehran,
Iran (Tel.: +0098 21 22 666 174; Fax: 0098 21 22 666 330;
e-mails: bujdent@yahoo.co.uk, or drgansari@yahoo.com).
ª 2010 International Endodontic Journal
doi:10.1111/j.1365-2591.2010.01695.x
performed on the data to determine significant differ-
ences between the groups.
Results Overall, 22 second and 18 first primary molars
were included. The gender ratio was one male to three
female. No significant difference was found between the
clinical and radiographic outcomes of the two groups at
6-, 12- and 24-month follow-up (P > 0.05). Internal
resorption was seen significantly more often in FC cases
after 12 months than MTA cases. Overall radiographic
appearance of normal structures at 24th month was seen
in more than 95% of the cases in MTA and 90% in the
FC-treated group (P > 0.05).
Conclusion Mineral trioxide aggregate for pulp
treatment of primary teeth can be considered a
replacement for FC.
Keywords: mineral trioxide aggregate, primary
teeth, pulp, pulpotomy.
Received 21 October 2007; accepted 3 January 2010
2003). This change in clinical practice has been
directed at reducing the need for fixation of remaining
pulp tissue and has included electrosurgical techniques
and the use of lasers for enhancing coagulation and
healing of remaining pulp tissue (Myers & Pashley
1983, Ruemping et al. 1983, Shoji et al. 1985, Shaw
et al. 1987, Smith et al. 2000).
Mineral trioxide aggregate has been used for pulp
capping, cervical pulpotomy and root canal perfora-
tions in permanent teeth (Torabinejad et al. 1995, Pitt
Ford et al. 1996, Tuna & Olmez 2008). Torabinejad
et al. (1995) reported that MTA had a high success rate
when used as an apical barrier in permanent teeth.
Mineral trioxide aggregate consists of tricalcium
silicate, bismuth oxide, tetra calcium alumino-ferrite
and calcium sulphate dehydrate (Torabinejad et al.
1995). In association with water the powder becomes
hydrated and forms a colloid gel with a pH of 12.5
International Endodontic Journal, 43, 413–418, 2010 413
 Clinical evaluation of primary teeth pulpotomy using MTA Ansari & Ranjpour

similar to that of calcium hydroxide (Torabinejad et al.

1995, Fuks et al. 1997a,b, Aeinehchi et al. 2002, Peng
et al. 2006). The clinical applicability of MTA in
pulpotomy of primary teeth has been investigated
(Holan et al. 2005, Maroto et al.2007, Noorollahian
2008), and a similar result to that of FC was reported.
As MTA has antimicrobial effects (Torabinejad et al.
1995), it could be hypothesized that this property
would also benefit remaining pulp tissue from damage
because of residual bacteria (Block et al. 1978, Pitt Ford
et al. 1996, Fuks et al. 1997a,b, Saltzman et al. 2005).
Pulp vitality as well as its physiologic function has been
Figure 1 Two mandibular teeth needing pulp treatment as an
reported as being preserved when pulps have been
example of cases for this investigation.
treated with MTA in several earlier investigations
(Holan et al. 2005, Maroto et al. 2007, Noorollahian
2008). The aim of this study was, therefore, to compare
the clinical and radiographic response of primary teeth
to vital pulpotomy using MTA or FC.

Methods and materials

A randomized, controlled clinical trial was designed to
assess the clinical performance of MTA (Pro-root;
Dentsply Int, Tulsa, OK, USA) in pulpotomies in
primary teeth in children. To standardize the design
of the investigation, Consort guidelines were used.
Cases were selected from those referred to Shahid
Beheshti University, Dental School, Tehran, Iran for
routine dental care. Ethical approval was obtained from
Shahid Beheshti University Medical Ethics Committee.
Male and female patients aged 4–9 were included with
at least two similar-sized cavities on teeth needing pulp
treatment based on recent signs of initial pulpal
reactions. Based on the nature of pulp intervention,
pairs of teeth were selected to act as matched individ-
uals with a second pair included where available. This
was judged as having no interference to the statistical
analysis. Patients with signs or symptoms on candidate
teeth were not included. Periapical radiographs were
obtained pre- and postoperatively to assess the perira-
dicular tissues (Fig. 1–5). Two teeth in each patient
(total teeth = 40) were selected with one randomly
being assigned to the MTA group and the other to the
FC group.
Each case was anaesthetized using Persocaine-E (2%)
(Lidocaine; Daroupakhsh, Tehran, Iran Licenced by
Merk Co, Hb, Germany) followed by access cavity
preparation under rubber dam. Pulp tissue was then
removed, from the pulp chamber only, using a sharp
spoon excavator. Haemeostasis was achieved using a
saline-moistened cotton pallet placed over the orifices of
Figure 2 Both molar teeth treated with formocresol, seen at
the 12-month recall.
the canals. MTA was then placed in the pulp chamber
in the experimental group, whilst FC soaked into a
cotton pellet (Buckley’s formula, 1/5 diluted) was
placed over the orifices into control group for 5 min.
Reinforced ZOE cement (Zonalin, Kem Dent, ADP,
Swindon, UK) was then placed over the treated pulp
after the pulp tissue was deemed to be fixed in the FC
group. The MTA mixture was covered with a moistened
cotton pellet and then temporarily filled using a
reinforced ZOE dressing (Coltosol, Coltene, Altstatten,
Switzerland), until the second visit for placement of ZOE
base (Zonalin, Kem Dent, ADP). All teeth were restored
with either stainless steel crowns (3M ESPE, St Paul,
MN, USA) as part of the protocol using polycarboxylate
cement (Dentsply DeTrey GmbH, Konstanz, Germany),
or amalgam (Degussa, Frankfurt, Germany) with all
pairs treated in the same manner. Tooth assignment

414 International Endodontic Journal, 43, 413–418, 2010 ª 2010 International Endodontic Journal
 Ansari & Ranjpour Clinical evaluation of primary teeth pulpotomy using MTA
Figure 3 Both molar teeth treated with formocresol, seen at
the 24-month recall.
Figure 4 First and second molar teeth treated with mineral
trioxide aggregate, seen at the 12-month recall.
and pulp treatment process were performed by one
operator with assessments being carried out by two
independent observers (Paedodontists). Clinical and
radiographic criteria for assessing teeth were explained
along with a calibration process to the two observers on
three initial cases. Evaluations were carried out at 1, 6,
12 and 24 months using clinical symptoms and signs
as well as 6-, 12- and 24-month radiographic signs.
Treated teeth were inspected for any sign of failure
including internal resorption, radiographic signs of
pathosis (periapical radiolucency), report of pain, pres-
ence of gingival swelling and sinus tract. Data were
ª 2010 International Endodontic Journal
Figure 5 First and second molar teeth treated with mineral
trioxide aggregate, seen at the 24-month recall.
analysed using a Fischer exact test in addition to chi-
square tests to perform inter- and intra-group compar-
isons, respectively.
Results
From the total of 40 teeth in 17 children, 22 were
primary second molars and 18 primary first molars.
Recall of patients was 100% at 6 months, 80% at
12 months and 75% at 24 months (Fig. 6). One tooth
developed a fistula in the FC group after 12 months
(Table 2). This figure remained the same for the FC
group at 24-month recall (Table 3). No cases in the
MTA group developed a fistula (Tables 1–3). Fischer
exact test revealed no significant difference between the
failure rate of the two groups (Table 4). These data
remained the same at the 24-month recall with two
Figure 6 Flowchart of participants with the numbers lost and
the final number included in the data analysis process.
International Endodontic Journal, 43, 413–418, 2010 415
 Clinical evaluation of primary teeth pulpotomy using MTA Ansari & Ranjpour

Table 1 Radiographic signs seen at the 6-month follow-up for Table 4 Chi-squared test result in 12- and 24-month follow-
cases of formocresol (FC) and mineral trioxide aggregate up of the different evaluating signs between formocresol and
(MTA) (n = 40) mineral trioxide aggregate
FC MTA 12 month 24 month
n (%) n (%)
Chi Chi
Signs Sign No sign Sign No sign Signs square P value square P value

Internal resorption 2 (5) 18 (45) 0 20 (50) Internal resorption 3.243 0.231 4.485 0.068
External resorption 0 20 (50) 0 20 (50) External resorption 0 0 0.084 1.000
Furcation lesion 5 (12.5) 15 (37.5) 0 20 (50) Furcation lesion 5.714 0.047 3.468 0.127
Periapical lesion 0 20 (50) 0 20 (50) Periapical lesion 0 0 0 0
Periodontal ligament 3 (7.5) 17 (42.5) 4 (10) 16 (40) Periodontal ligament 0.173 1.000 3.199 0.169
widening widening
Pulp canal 3 (7.5) 17 (42.5) 1 (2.5) 19 (47.5) Pulp canal obliteration 1.111 0.605 0.765 0.650
obliteration Pain 0 0 0 0
Swelling 0 0 0 0
Mobility 0 0 1.233 0.458
Table 2 Radiographic signs seen at the 12-month follow-up Percussion 0 0 0 0
Fistula 0 0 1.233 0.458
for cases of formocresol (FC) and mineral trioxide aggregate
Soft tissue redness 1.026 1.000 2.579 0.199
(MTA) (n = 32)
FC MTA
n (%) n (%) Furcation lesions were observed and detected in
Signs Sign No sign Sign No sign radiographs of five cases treated with FC compared to
Internal resorption 2 (6.25) 14 (43.75) 0 (0) 16 (50) one case in the MTA group. However, external root
External resorption 2 (6.25) 14 (43.75) 2 (6.25) 14 (43.75) resorption was seen equally in both groups. Furcation
Furcation lesion 4 (12.5) 12 (37.5) 1 (3.25) 15 (46.75) involvement was observed in only one case in the MTA
Periapical lesion 0 (0) 16 (50) 0 (0) 16 (50) group but in four cases in the FC group. The difference,
Periodontal 5 (15.75) 11 (34.25) 2 (6.25) 14 (43.75)
however, was not statistically significant (P = 0.127).
ligament
widening Periodontal ligament (PDL) widening was seen in
Pulp canal 4 (12.5) 12 (37.5) 3 (9.5) 13 (40.5) radiographs of two MTA-treated and five FC-treated
obliteration teeth. Statistical comparison of the data between two
groups revealed a significant difference (P < 0.05) in
favour of MTA (Tables 2 and 3).
Table 3 Radiographic signs seen at the 24-month follow-up
Assessment of the cases after 24 months revealed
for cases of formocresol (FC) and mineral trioxide aggregate
(MTA) (n = 30) similar results in clinical and radiographic conditions
with more of the FC cases showing PDL widening. The
FC MTA
number of teeth judged as failed was six in the FC-
n (%) n (%)
treated group with only one failed case in the MTA-
Signs Sign No sign Sign No sign
treated group. Figures 2 and 3 illustrate treated teeth
Internal resorption 3 (10) 12 (40) 0 (0) 15 (50) with FC after 12 and 24 months, respectively. In
External resorption 2 (6.5) 13 (43.5) 2 (6.5) 13 (43.5) comparison, Figs 4 and 5 illustrate treated teeth with
Furcation lesion 6 (20) 9 (30) 2 (6.5) 13 (43.5)
MTA at 12- and 24-month recall.
Periapical lesion 0 (0) 15 (50) 0 (0) 5 (50)
Periodontal ligament 8 (26.75) 7 (23.25) 2 (6.5) 13 (43.5)
widening
Pulp canal 4 (13.75) 11 (36.25) 6 (20) 9 (30)
Discussion
obliteration This clinical investigation was conducted to determine
the potential effectiveness of MTA as a reliable replace-
extra failed teeth in the FC group but still with no ment for FC when undertaking pulpotomy in primary
significant difference between the groups (P = 0.199). teeth. Based on the results achieved, it seems that MTA
Internal root resorption was observed in radiographs could be used successfully. A series of clinical studies as
of three cases (15%) from the FC group but none in the well as some animal studies have been conducted on
MTA group with no statistically significant difference the use of the MTA on pulps in primary teeth. The
between the two groups (P = 0.231). successful use of the MTA has been reported but with

416 International Endodontic Journal, 43, 413–418, 2010 ª 2010 International Endodontic Journal
 Ansari & Ranjpour Clinical evaluation of primary teeth pulpotomy using MTA
limitations over the clinical availability and follow-up
lengths. In this regard, poor patient compliance
throughout clinical trials is a real problem, and it is
acknowledged that the number of cases might drop, as
was the case in the present study. The number of failed
cases following FC pulpotomy was higher than that of
MTA. As MTA is highly biocompatible (Torabinejad
et al. 1995), it seems that the potential use of this
material could successfully eliminate side effects asso-
ciated with FC in pulpotomy procedures for primary
teeth. Several earlier animal reports have described the
effectiveness and safety of MTA through histological
and clinical evaluations (Holand et al. 1995, Salako
et al. 2003). Fuks et al. (1990) reported an improved
pulpal preservation status in the presence of MTA
compared to that of FC use. It seems that with primary
teeth undergoing a period of physiologic root resorp-
tion, many signs of root complication could be ignored
several years postoperatively as tooth exfoliation takes
place spontaneously. Eidelman et al. (2001) has
reported a success rate of 100% in pulpotomy tech-
niques using FC and MTA. The results of the current
study revealed a 15% failure rate in the control (FC)
group and a 1% failure rate in the MTA group at 6- and
12-month recall. The early exfoliation of primary teeth
has been reported following pulp treatment with FC at
a higher rate (47%) compared to 15.2% for GA-treated
cases (Hicks et al. 1986, Fuks et al. 1990). Several
different pulpal responses to different treatment meth-
ods and medicaments have been reported following
their use including the rate of internal root resorption.
This phenomenon has been reported to be 17% by Fuks
et al. (1997 a,b) and 20% by Hicks et al. (1986), whilst
this figure was 27% in the current investigation, in FC-
treated cases. Eidelman et al. (2001) reported a single
case of FC-treated group showing signs of internal
resorption with no cases in the MTA group. This
finding is not clinically relevant bearing in mind that
external root resorption is a natural physiologic phe-
nomenon in primary teeth following restoration.
Mineral trioxide aggregate has been reported to have
no side effects on the developing dentition when used
during pulpotomy of primary teeth (Koh et al. 1995,
Eidelman et al. 2001). External root resorption and
furcation involvement were seen in 25% and 37% of
the FC group at 6 and 12 months, which were slightly
higher figures than earlier reported by Holan et al.
(2005). Interestingly, there was only a single case in
the MTA group with radiographic signs of furcation
lesions at the 24-month recall. The difference of
radiographic signs was statistically significant between
ª 2010 International Endodontic Journal
MTA and FC groups (P < 0.05), indicating a successful
result when MTA was used with little to no resorption
activity seen on radiographs. As routine radiographic
examination of primary teeth at 6-, 12- and 24-month
interval is recommended for caries detection and
monitoring in primary teeth (Miles & Parks 2004),
the same pattern was adopted for this investigation.
However, this protocol is not accepted universally
because of potential over exposure to radiation (Pitt
Ford 2008).
Conclusion
Mineral trioxide aggregate pulpotomy of primary teeth
was as successful as conventional FC pulpotomies.
More clinical trials with larger sample size and possibly
longer follow-up periods with similar clinical conditions
are recommended.
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