CONSORT RANDOMIZED CLINICAL TRIAL

Kamile Nur Tozar, DDS and

Evaluation of the Efficacy of Merve Erkmen Almaz, PhD

Erbium, Chromium-doped
Yttrium, Scandium, Gallium,
and Garnet Laser in Partial
Pulpotomy in Permanent
Immature Molars: A
Randomized Controlled Trial

ABSTRACT
SIGNIFICANCE
Introduction: The use of the erbium, chromium-doped yttrium, scandium, gallium, and
garnet (Er,Cr:YSGG) laser in vital pulp therapy contributes to the formation of dentin bridges This study provides a
and a sterile zone as well as the maintenance of the vitality of the pulp. However, no prior comparative perspective to
studies have used the Er,Cr:YSGG laser in partial pulpotomy of immature permanent teeth. partial pulpotomy using the
The aim of this study was to compare the efficacy of partial pulpotomy treatment using mineral Er,Cr:YSGG laser with MTA or
trioxide aggregate (MTA) alone and MTA with the Er,Cr:YSGG laser in permanent immature only MTA in immature
molars. Methods: A total of 90 caries-exposed permanent immature molar teeth were permanent molars. Both
included and randomly divided into 2 groups: the MTA group (n 5 45) and the laser 1 MTA treatment methods in partial
group (n 5 45). In the MTA group, MTA was applied to the exposed area on the pulp after pulpotomy are successful
bleeding control. In the same session, the tooth was restored with a composite resin. In the treatment options with similar
laser 1 MTA group, before MTA condensation, the Er,Cr:YSGG laser was applied to the success rates.
exposure area. Patients were recalled at 1, 3, 6, and 12 months after treatment. The Mann-
Whitney U and chi-Square tests were used for statistical analysis. Results: The success rate
(95.5%) of the laser 1 MTA group was similar to that of the MTA group (88.8%). There was no
significant difference between groups in terms of the frequency of at least 1 pathologic clinical
or radiographic failure at 12 months (P . .05). Conclusions: Partial pulpotomy treatment
showed a high success rate in immature permanent molars; however, the use of the laser did
not contribute to the success rate compared with MTA alone. (J Endod 2020;-:1–9.)

KEY WORDS
Erbium, chromium-doped yttrium, scandium, gallium, and garnet laser; immature teeth;
mineral trioxide aggregate; partial pulpotomy

From the Department of Pediatric

Deep dentin caries, which are frequently observed in immature permanent molar teeth, require a
Dentistry, Faculty of Dentistry, Kırıkkale
challenging treatment process for both the patient and the dentist because of the open apex. Because University, Kırıkkale, Turkey
root canal treatment arrests dentin deposition along the canal walls, eventually the root becomes fragile1.
Address requests for reprints to Dr Merve
Therefore, in immature permanent teeth, treatment methods protecting the vital pulp tissue gain €
Erkmen Almaz, Kırıkkale Universitesi, Diş
importance, and the guideline of the American Academy of Pediatric Dentistry suggests vital pulp Hekimligi Faku
€ltesi Pedodonti AD,
therapies to achieve physiological development and formation of the root end2. With partial pulpotomy, Kırıkkale, Turkey.
one of the vital pulp treatment methods, the infected pulp tissue is removed compared with direct pulp E-mail address: dt.merveerkmen@gmail.
com
capping3, and the cell-rich coronal pulp tissue is protected in immature teeth, which is more 0099-2399/$ - see front matter
advantageous than total pulpotomy4.
Copyright © 2020 American Association
In the treatment of partial pulpotomy, preventing future bacterial contamination is an important of Endodontists.
issue for the success of the treatment; therefore, the exposed pulpal area should be coated with a https://doi.org/10.1016/
biocompatible pulp-capping material5. Mineral trioxide aggregate (MTA) is used as the gold standard in j.joen.2020.02.003

JOE  Volume -, Number -, - 2020 Efficacy of Er,Cr:YSGG Laser 1

vital pulp therapies6 because of its good
sealing ability7, biocompatibility, low toxicity,
and high antimicrobial activity and also
because it allows the formation of a dentin
bridge8.
Recently, the erbium, chromium-doped
yttrium, scandium, gallium, and garnet
(Er,Cr:YSGG) laser has been recommended to
be used for hemostasis and coagulation in vital
pulp therapies9,10. With the coagulation effect
of the laser, a drier operation area is obtained,
and the laser creates a more superficial
necrosis region compared with chemical pulp-
coating materials. The use of the Er,Cr:YSGG
laser in pulp-capping treatment has been
reported to contribute to the formation of
dentin bridges and a sterile zone as well as the
maintenance of the vitality of the pulp11,12. In
vital pulp therapies, the advantageous effects
of laser therapy on the tissue are reported as
follows: decontamination, hemostasis,
coagulation effects, and biostimulation11,13,14.
To the best of our knowledge, no prior
studies have evaluated the efficacy of the
Er,Cr:YSGG laser in partial pulpotomy of
immature permanent teeth. The aim of the
present study was to evaluate and compare
the clinical and radiographic success of the
partial pulpotomy treatment with the
Er,Cr:YSGG laser 1 MTA and MTA alone. The
following null hypothesis was tested: there is
no significant difference between treatment
with the Er,Cr:YSGG Laser 1 MTA and
treatment with MTA alone in partial pulpotomy
in immature permanent molar teeth with deep
dentin caries.
MATERIALS AND METHODS
The present study is a randomized, single-
blinded, controlled trial with 2 parallel groups
(NCT04010929). The study was independently
reviewed and approved by Kırıkkale University
Clinical Research Ethics Committee (decision
no: 01/17, date: January 3, 2017). The study
was performed in healthy and cooperative 6-
to 15-year-old patients with deep dentin caries
in at least 1 permanent mandibular immature
molar tooth who were treated at the
Department of Pediatric Dentistry, Faculty of
Dentistry, Kırıkkale University, Kırıkkale,
Turkey. Patients and their guardians were
informed about the treatment procedures, and
their written informed consent was obtained.
The research was conducted in full
accordance with ethical principles including
the World Medical Association Declaration of
Helsinki.
Selection of the Participants
The inclusion criteria were as follows: deep
dentin caries in at least 1 permanent
2 Tozar and Erkmen Almaz
mandibular immature molar tooth, no
spontaneous or long-term pain history, no
percussion or palpation sensitivity, and no soft
tissue pathology (abscess or fistula). During
excavation, the exposure area should be 1–2
mm in diameter, and after the pulp is exposed,
bleeding should be ceased within 5 minutes.
Based on the statistical power analysis,
the number of teeth to be included in the study
with a power of 80% at a 5% significance level
was determined as at least 40 per group with a
total of 80 teeth. Considering the loss to follow-
up, it was decided to set a baseline sample of
45 teeth per group (a total of 90 teeth). Sample
size estimation was performed using G*Power
version 3.0.10 software (University of Kiel, Kiel,
Germany).
Treatment Procedures
Ultracain D-S anesthetic solution (Sanofi
Aventis Medicine LLC, Istanbul, Turkey) was
used for local anesthesia before treatment.
Under isolation with a rubber dam (Hygenic
Dental Dam Kit, H02779; Coltene, Altst€atten,
Switzerland), the cavity was prepared using a
high-speed rotary instrument (Kavo
MASTERtorque M9000L; KaVo Dental,
Biberach an der Riss, Germany) under water
cooling. Carious dentin was removed with a
slow-speed steel round bur. If the diameter of
the exposure area was less than 1 mm, direct
pulp capping was applied, and these teeth
were excluded from the study. The teeth with
an exposure area of 1–2 mm were treated with
partial pulpotomy. A slow-speed sterile steel
round bur was used to remove the exposed
pulp tissue to a depth of 2–3 mm. In the
exposure area, bleeding was ceased within 5
minutes after the application of 5.25% sodium
hypochlorite15.
Study Groups
Under the supervision of an experienced
dentist (K.N.T.), allocation was implemented
by simple randomization by the dentist’s
assistant. The teeth were randomly divided
into 2 groups. In this random selection
method, the patient was asked to flip a coin;
those with “heads” were included in the MTA
(control) group, and those with “tails” were
included in the laser 1 MTA (study) group.
After the number of teeth in a group reached
45, the rest of the teeth were included in the
other group. The groups were as follows: the
MTA group (n 5 45) and the laser 1 MTA
group (n 5 45).
MTA Group
MTA (ProRoot White; Dentsply Tulsa Dental
Specialties, Tulsa, UK) was prepared and
applied to the exposed area according to the
manufacturer’s instructions. A moist cotton
pellet was placed on the MTA for 3 minutes to
allow the initiation of the hardening reaction of
the MTA.
The resin-modified glass ionomer
cement (Photac Fil Quick Aplicap Light-Cured
Glass Ionomer Restorative; 3M ESPE, St Paul,
MN) was then placed in the cavity base, and
the tooth was permanently restored with
composite resin (Clearfil Majesty Posterior;
Kuraray America, Inc, New York, NY) using a
self-etch adhesive agent (Clearfil SE Bond Kit,
Kuraray America, Inc).
Laser 1 MTA Group
Before laser application, the patient and the
dentist put on safety glasses. After bleeding
control in the exposure area, the Er,Cr:YSGG
laser (WaterLase iPlus; Biolase, Irvine, CA) was
applied with a MG6 Sapphire 6 mm tip
(WaterLase iPlus; Biolase, Irvine, CA) on the
hard tissue noncontact mode at an energy
level of 0.5 W, a repetition rate of 20 Hz, and a
140-millisecond pulse duration with 0% water
and 45% air for 10 seconds16. After laser
application, the treated area was sealed with
MTA. All restoration steps were then
completed similar to those of the MTA group.
All treatment procedures were performed by 1
operator (K.N.T.).
Follow-up
Patients were recalled for follow-up
appointments at 1, 3, 6, and 12 months after
treatment, and all teeth were clinically and
radiographically examined. Two blinded
independent interpreters (K.N.T. and M.E.A.)
evaluated the clinical and radiographic
findings. Standardized forms were used to
record the findings. The assistant of the dentist
(K.N.T.) prepared the filled forms for the
evaluation of the interpreters, so the
interpreters were blinded to the group division.
Before assessments, examiners were
calibrated by evaluating 40 radiographs. A
forced consensus was sought in any case of
disagreement. After calibration, the kappa
statistic was used to test interexaminer
reliability, and the kappa score was found to be
0.81.
The following clinical signs and
symptoms were regarded as failure:
spontaneous pain, tenderness to percussion/
palpation, mobility, presence of fistula, and
swelling. The radiographic findings that were
regarded as failure were as follows: widened
periodontal ligament, loss of lamina dura,
internal/external root resorption, and periapical
radiolucency.
All assessments were independently
performed twice with a 1-week interval. The
JOE  Volume -, Number -, - 2020
inter- and intraexaminer reproducibility were
calculated using the Cohen unweighted kappa
statistic. The kappa coefficients for inter- and
intrarater reproducibility were found to be 0.86
and 0.82, respectively. When a tooth showed
clinical and radiographic signs of failure, root
canal treatment was performed.
Also, the following findings were
radiographically examined: hard tissue
formation under the pulpotomy area, root
canal narrowing, apexogenesis formation, root
length increase, and an increase in dentin
thickness in the apical third of the root.
Radiographic Analysis
ImageJ analysis software (version 1.44p;
National Institutes of Health, Bethesda, MD)
was used to convert all radiographs to TIFF
files. Because the preoperative and follow-up
radiographs were nonstandardized, the
TurboReg plug-in (Biomedical Imaging
Group, Swiss Federal Institute of Technology,
Lausanne, Switzerland) was used to
transform the radiographs into
mathematically aligned pairs of images17.
FIGURE 1 – A flow diagram.
JOE  Volume -, Number -, - 2020
After alignment, the measuring scale in the the cell distribution. The level of statistical
ImageJ program was used to measure the significance was set at P , .05.
root lengths and root wall thicknesses as
described previously17. In order to evaluate
the root length increase, both mesial and RESULTS
distal root lengths were calculated
A total of 112 teeth were recruited (between
separately. If there was an increase in at
January 1, 2017, and March 1, 2018). Ninety
least one of the roots, the root length
teeth met the inclusion criteria, and 22 teeth
increase was recorded for the treated tooth.
were excluded because of no pulp perforation
after caries removal or bleeding in the
exposure area for more than 5 minutes (Fig. 1).
Statistical Analysis Ninety immature permanent molar teeth (45 in
Statistical analysis of the data was performed
each group) were treated with partial
using the SPSS 21.0 package program (IBM
pulpotomy. Sixty-four patients (34 females and
Corp, Armonk, NY). The normality of the data
30 males) were included in the study. The age
set was checked with the Kolmogorov-
of the patients was between 6 and 15 years
Smirnov and Shapiro-Wilks tests. Because the
with a mean of 8.6 6 2.2 years.
data were not normally distributed,
The sex and mean age of the patients
nonparametric tests were used for statistical
and the location of the treated teeth are
analysis. The Mann-Whitney U test was used
provided in Table 1. There was no statistically
for group comparisons, and chi-square
significant difference between groups in terms
analysis was used to evaluate periodic clinical
of sex, age of the patients, and the location of
and radiographic success rates. The Fisher
the teeth (P . .05).
exact test was used instead of the chi-square
After the 12-month follow-up, 3 teeth (2
test when expected values were less than 5 in
in the MTA group at the 1- and 9-month follow-
Efficacy of Er,Cr:YSGG Laser 3
TABLE 1 - The Sex and Mean Age of the Participants and the Location of the Treated Teeth depth of 1–3 mm, and after hemostasis the
perforated area should be coated with a
MTA, n (%) Laser 1 MTA, n (%) Total, N (%) P value biocompatible material. Following this
Sex guideline, in the present study, exposed pulp
Male 24 (53.4) 23 (51.2) 47 (52.3) .996 tissue was removed with a depth of 1–3 mm.
Female 21 (46.6) 22 (48.8) 43 (47.7) One of the important criteria to be
Age (mean 6 SD) 8.74 6 2.14 8.57 6 2.30 8.6 6 2.2 .303 considered in partial pulpotomy is the diameter
First molar 36 (80) 38 (84.4) 74 (82.2) .477 of the exposed area after caries removal. It was
Second molar 9 (20) 7 (15.6) 16 (17.8) reported that 4 mm or less in diameter of the
MTA, mineral trioxide aggregate; SD, standard deviation.
exposed area of the pulp affects the prognosis
positively, whereas the prognosis of the teeth
with a pulp exposure greater than 4 mm was
reported to be unclear21. Chailertvanitkul
up and 1 in the laser 1 MTA group at the 1- DISCUSSION et al22 compared the use of MTA and calcium
month follow-up) showed clinical and hydroxide in a randomized controlled clinical
The present study was a randomized
radiographic signs of failure, and root canal trial for partial pulpotomies in cariously
controlled trial that aimed to compare the
treatment was performed. The clinical, exposed pulps of permanent molars. They
efficacy of the use of MTA alone and the
radiographic, and overall success rates of both reported that the rate of unsuccessful
Er,Cr:YSGG laser with MTA in immature
groups are shown in Table 2. The 12-month treatment was found to be higher in the teeth
permanent molar teeth in partial pulpotomy.
survival rates of the MTA and laser 1 MTA with an exposure area larger than 5 mm2.
Histologic studies have shown that caries-
groups were 88.8% (40/45) and 95.5% (43/ Teeth with an exposed area less than 2 mm in
exposed teeth with vital pulp are not always
45), respectively. During the 12-month follow- diameter were included in the present study23.
completely infected19. It has been reported
up period, no significant difference was found In the treatment of partial pulpotomy
that inflammation is often localized only in
between groups in terms of the frequency of or pulp capping, the status of bleeding in
areas near the carious lesion, not spreading
clinical and radiographic findings and overall the exposure area is important because it
over the entire coronal and radicular pulp.
success rates (P . .05). provides information about the health of the
Therefore, it is possible to maintain the health
Of the 90 teeth treated, complete apical pulp8,24. Prolonged dark red bleeding
of the remaining pulp if the infected pulpal
closure occurred in 46 teeth (25 in the MTA indicates that the pulp is infected8. If the
tissue is removed20. The American Academy
group and 21 in the laser 1 MTA group) (Figs. bleeding in the exposure area cannot be
of Pediatric Dentistry guideline2 on pulp
2A and B and 3A and B), partial apical closure ceased in 10 minutes, it is assumed that the
therapy recommends that in partial pulpotomy
occurred in 41 teeth (18 in the MTA group and coronal pulp is irreversibly infected and
treatment, in order to reach the healthy pulp
23 in the laser 1 MTA group), and 3 (3.3%) should be removed25. Also, Webber15
tissue, exposed pulp should be removed to a
teeth (2 in the MTA group and 1 in the laser 1 reported that the pulp is irreversibly
MTA group) showed signs of failure (Table 3).
No statistical difference between groups was
observed in terms of root development TABLE 2 - Clinical and Radiographic Findings and Overall Success Rates at 12 Months according to Postoperative
(P . .05). Findings
In the MTA group, periapical
radiolucency was observed in 1 tooth at 6 MTA, n (%) Laser 1 MTA, n (%) Total, N (%) P value
months and in 2 teeth at 12 months (Fig. 4A– Clinical findings
C). In the laser 1 MTA group, a widened Spontaneous pain 2 (4.5) 1 (2.3) 3 (3.4) 1.00
periodontal ligament was observed in 1 tooth Tenderness to 2 (4.5) 1 (2.3) 3 (3.4) 1.00
at 6 months. Although these teeth were percussion
excluded because of radiographic signs of Tenderness to 1 (2.3) 0 (0) 1 (1.2) 1.00
failure, root development was continuing. palpation
Therefore, it was decided to continue the Mobility 1 (2.3) 0 (0) 1 (1.2) 1.00
follow-up, and in case of progression of the Fistula 1 (2.3) 0 (0) 1 (1.2) 1.00
Swelling 2 (4.5) 0 (0) 2 (2.2) .495
pathology or after the completion of root
Clinical success 2 (4.5) 1 (2.3) 3 (3.4) 1.00
development, root canal treatment was
Radiographic findings
planned18. Widened 2 (4.5) 1 (2.3) 3 (3.4) 1.00
Table 4 presents the cases with an periodontal
increase in the thickness of the dentin in the ligament
apical third of the root, hard tissue formation Periapical 5 (11.2) 1 (2.3) 6 (6.7) 1.00
under the pulpotomy material, and root canal radiolucency
narrowing at 12 months. There was no Internal/external 1 (2.3) 0 (0) 0 (0) 1.00
significant difference between groups in terms root resorption
of these radiographic data (P . .05) (Fig. 4). Loss of lamina 1 (2.3) 0 (0) 0 (0) 1.00
dura
According to the radiographic findings,
Radiographic 5 (11.2) 1 (2.3) 6 (6.7) .361
no internal/external root resorption or loss of
success
lamina dura was observed in any teeth. No side Overall success 40/45 (88.8) 43/45 (95.5) 83/90 (92.2) .435
effects or adverse events were reported during
treatment and within the 12-month follow-up. MTA, mineral trioxide aggregate.

4 Tozar and Erkmen Almaz JOE  Volume -, Number -, - 2020

FIGURE 2 – The (A ) baseline and (B ) 12-month follow-up radiograph of the tooth with complete apical closure in the laser 1 MTA group.

damaged in cases in which pulpal bleeding
lasts longer than 5 minutes. In the present
study, cases in which bleeding was ceased
within 5 minutes were included.
In the literature, the differences between
the success rates of vital pulp therapies in teeth
with open or closed apices were not definite;
however, it was reported that a better
prognosis was observed in teeth with open
apices21. In studies performed in teeth with
open apices, the results were more successful
in direct pulp capping (open apices: 94.5%,
closed apices: 69.2%), partial pulpotomy
(open apices: 94.6%, closed apices: 90.6%),
and total pulpotomy (open apices: 91.4%,
closed apices: 85.9%) compared with teeth
with closed apices26. In studies, dental pulp of
the teeth with open apices is richer in cellular
structure, so it has been observed that the
regeneration and healing potential were high in
the residual pulp tissue after the removal of the
infected pulp tissue27. Heide28 performed
partial pulpotomy treatment with Dycal
(Dentsply Caulk, Milford, DE) in 70 teeth with
incomplete root development and reported a
success rate of 94% after 1–6 months of
follow-up. Mass and Zilberman18 reported that
the success rate was 93.9% as a result of an
average 49-month follow-up of partial
pulpotomy treatment with calcium hydroxide in
young permanent molar teeth. Similarly, in the
present study, the success rate of partial
pulpotomy treatment for immature permanent

FIGURE 3 – The (A ) baseline and (B ) 12-month follow-up radiograph of the tooth with complete apical closure in the MTA group.

JOE  Volume -, Number -, - 2020 Efficacy of Er,Cr:YSGG Laser 5

TABLE 3 - Root Development Status by Groups Based at 12 Months
MTA, n (%)
Complete apical closure 24 (53.3)
Partial apical closure 16 (35.6)
Excluded teeth 5 (11.1)
MTA, mineral trioxide aggregate.
molar teeth was found to be 92.2% after a 12-
month follow-up.
Qudeimat et al8 compared the use of
MTA and calcium hydroxide in partial
pulpotomy treatment in permanent molar teeth
and reported a success rate of 93% in the MTA
group after a 34.8 6 4.4-month follow-up.
Chailertvanitkul et al22 compared the use of
MTA and calcium hydroxide in partial
pulpotomy treatment of permanent molar teeth
and reported that the use of MTA showed a
success rate of 93.1% after a 24-month follow-
up. In another clinical study, a success rate of
79% was achieved with partial pulpotomy
treatment using MTA in a 24-month follow-up
in caries-exposed permanent teeth7. Ozgur
et al23 compared the use of MTA and calcium
hydroxide in partial pulpotomy treatment with
different hemorrhage control materials and
reported success rates of 94.4% and 100% for
MTA groups with different hemorrhage control
materials after 24 months. In the present study,
compared with previous partial pulpotomy
studies, the success rate of the MTA group
(88.8%) was similar; therefore, MTA can be
considered as a successful partial pulpotomy
agent. The success rate of the laser 1 MTA
group (95.5%) was found to be similar with that
of the MTA group (88.8%). Although it was not
statistically significant, the number of
successful teeth in the laser 1 MTA group was
FIGURE 4 – Observation of continuing root development and periapical radiolucency of the tooth in the MTA group at (A ) baseline, (B ) 6 months, and (C ) 12 months. Arrows show the
periapical radiolucency at the root end.
6 Tozar and Erkmen Almaz
Laser 1 MTA, n (%) Total, N (%) P value
21 (46.6) 45 (50.0) .596
22 (48.9) 38 (42.2)
2 (4.5) 7 (7.8)
higher. However, because there was no partial
pulpotomy study using a laser in the literature,
the success rate of the laser group could not
be compared with another study.
In the study of Cengiz and Yilmaz16, the
authors evaluated the efficiency of Er,Cr:YSGG
laser irradiation combined with a resin-based
tricalcium silicate material (TheraCal; Bisco,
Inc., Schaumburg, IL) and calcium hydroxide in
direct pulp capping in permanent teeth. The
authors concluded that the Er,Cr:YSGG laser–
irradiated TheraCal and Er,Cr:YSGG laser–
irradiated calcium hydroxide groups showed
higher success rates than the TheraCal-alone
and CH-alone groups. Also, other previous
studies evaluating laser-assisted direct pulp
capping showed significant benefits of laser in
comparison with conventional
procedures14,29. The biostimulation effect, the
decontamination effect, and the hemostatic
and coagulant effect of lasers provide
considerable advantages for vital pulp therapy;
therefore, the use of lasers has been
suggested11,14,16. Also, Toomarian et al10
histologically investigated whether pulpotomy
with the Er,Cr:YSGG laser is an acceptable
alternative for formocresol. The authors
concluded that the pulpotomy with the
Er,Cr:YSGG laser group showed better
integrity of the odontoblastic layer; a lower
number of odontoclasts; and less hemorrhage,
inflammation, internal resorption, tissue
necrosis, vascularization, and abscess
formation compared with formocresol. The use
of the Er,Cr:YSGG laser system for pulpotomy
of deciduous teeth was considered an
acceptable alternative for formocresol.
In the present study, it was
hypothesized that there is no significant
difference between treatment with the
Er,Cr:YSGG laser 1 MTA and treatment with
MTA alone in partial pulpotomy in immature
permanent molar teeth with deep dentin
caries. The hypothesis was accepted because
no statistically significant difference was found
between the groups.
Mass and Zilberman18 reported an
increase in pulp calcification in 13 of 46 teeth
after partial pulpotomy treatment with 7–154
months (mean 5 49 months) of follow-up.
However, total pulp obliteration was not
observed in any of the treated teeth. Total
pulpal obliteration is a pathologic finding in the
treatment of total pulpotomy30. Similar to the
study of Mass and Zilberman, total pulp
obliteration was not observed in any of the
teeth treated with partial pulpotomy in the
present study. Root canal narrowing was
observed in 40% of the treated teeth; however,
because narrowing occurred with root length
increase and thickening of the dentin walls
along the root, it would not be correct to
associate it directly with pathologic
obliteration. For evaluating pathologic
obliteration, it is considered that a follow-up
period longer than 12 months is necessary.
In the present study, hard tissue
formation under the pulpotomy material was
not considered as a success criterion4,8. It was
evaluated only as a radiographic finding.
JOE  Volume -, Number -, - 2020
TABLE 4 - Cases with an Increase in the Thickness of the Dentin in the Apical Third of the Root, Hard Tissue Formation
under the Pulpotomy Material, and Root Canal Narrowing at 12 Months
12-Month Follow-up MTA, n (%)
Hard tissue formation 24 (53.3)
Increase in dentin thickness 27 (60)
Root canal narrowing 20 (44.4)
MTA, mineral trioxide aggregate.
Bakhtiar et al31 performed partial pulpotomy
treatment using TheraCal, Biodentine
(Septodont, Saint-Maur-des-Fosse s, France),
and MTA and evaluated them comparatively. It
was observed in their study that hard tissue
formation was observed in 100% of the teeth in
the Biodentine group, in 11% in the TheraCal
group, and in 56% in the MTA group. In the
present study, similar to the MTA group in
Bakhtiar et al’s study, hard tissue formation
was observed under the pulpotomy material in
24 teeth (53.3%) in the MTA group and in 22
teeth (48.8%) in the laser 1 MTA group. There
was no statistically significant difference
between groups in terms of hard tissue
formation (P . .05). In the present study, it was
determined that the biostimulation property of
the laser did not add an additional contribution
to MTA material in terms of hard tissue
formation.
The formation of apexogenesis has
been previously reported in various partial
pulpotomy studies4,8,18,23. In the present
study, it was observed that 46% of the teeth
had completed root development. Root length
increase was observed in 41% of the teeth;
however, the completion of root development
could not be observed because of the limited
follow-up period of 12 months. This is because
of the fact that the teeth involved in the study
were first or second molars, and their root
development stages are different from each
Laser 1 MTA, n (%) Total, N (%) P value
22 (48.8) 46 (51.1) .919
34 (75.5) 61 (67.7) .117
16 (35.5) 36 (40) .727
other. In the present study, the total root length
increase rate was 86.6% in the laser 1 MTA
group and 82.2% in the MTA group during the
12-month follow-up period. Based on this
finding, it can be considered that partial
pulpotomy treatment is effective in maintaining
the continuity of root development in immature
permanent molar teeth.
In the present study, although root
development was continuing in 1 tooth in the
laser 1 MTA group, the tooth showed a
widened periodontal ligament at the 6- and 12-
month follow-up periods. Also, in the MTA
group, periapical radiolucency was observed
at the 6- and 12-month follow-up
appointments in 3 teeth along with continuing
root development. In previous studies, it has
been reported that pulp cells that can survive
even in the presence of a pathology in the
periradicular region in immature teeth can be
proliferated by the influence of the Hertwig
epithelial root sheath32,33. These cells
stimulate apexogenesis by increasing the
odontoblasts forming the atubular dentin at the
apical end32–34. For this reason, although
those teeth with radiologic pathologies were
considered to be unsuccessful, it was
preferred not to have pulpectomy immediately
because of the continuing root development18.
This is the first study comparatively
evaluating the combined use of the
Er,Cr:YSGG laser and MTA in the treatment
of partial pulpotomy. The vitality of the teeth
treated was not evaluated, which can be
considered as a limitation of the present
study. The response of the teeth with
incomplete root development to the electric
pulp test and thermal tests is limited
because of the changes in the root length.
In addition, responses to these tests are not
reliable because of the fear and lack of
cooperation in children35. Another limitation
of the present study is the weakness of
randomization sequence and concealment.
Allocation was implemented by simple
randomization, but because we did not use
a sham laser for the MTA group, the children
and the parents/guardians of the children
were not blinded to the group division.
Therefore, the present study was a single-
blinded clinical trial.
CONCLUSIONS
The use of the laser, which was used for
biostimulation on exposed pulpal surface, did
not contribute to the success rate compared
with MTA alone. The success rate (95.5%) of
the laser group was similar with that of the MTA
group (88.8%), with no significant difference
between groups. After the 12-month follow-
up, the overall success rate of partial
pulpotomy treatment in immature permanent
teeth was found to be 92.2%.
ACKNOWLEDGMENTS
Supported by the Kırıkkale University Scientific
Research Projects Coordination Unit (project
number 2017/75).
The authors deny any conflicts of
interest related to this study.

REFERENCES
1. Camp JH, Barrett EJ, Pulver F. Pediatric endodontics: endodontic treatment for the primary and
young permanent dentition. In: Cohen SB, editor. Pathway of the Pulp. 8th ed. St Loius, MO:
Mosby; 2002. p. 823–33.

2. American Academy of Pediatric Dentistry. Guideline on pulp therapy for primary and immature
permanent teeth. Pediatr Dent 2016;38:280–8.
3. Kiatwateeratana T, Kintarak S, Piwat S, et al. Partial pulpotomy on caries-free teeth using
enamel matrix derivative or calcium hydroxide: a randomized controlled trial. Int Endod J
2009;42:584–92.
4. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study of mineral trioxide aggregate for
partial pulpotomy in cariously exposed permanent teeth. J Endod 2006;32:731–5.

5. de Blanco LP. Treatment of crown fractures with pulp exposure. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 1996;82:564–8.

JOE  Volume -, Number -, - 2020 Efficacy of Er,Cr:YSGG Laser 7

 6. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment
perspectives-permanent teeth. J Endod 2008;34:25–8.

7. Barrieshi-Nusair KM, Hammad HM. Intracoronal sealing comparison of mineral trioxide

aggregate and glass ionomer. Quintessence Int 2005;36:539–45.
8. Qudeimat MA, Brrieshi-Nusair KM, Owais AI. Calcium hydroxide vs mineral trioxide aggregates
for partial pulpotomy of permanent molars with deep caries. Eur Arch Paediatr Dent 2007;8:99–
104.
9. Marx I, Op’t Hof J. The Er,Cr:YSGG hydrokinetic laser system for dentistry–clinical applications.
SADJ 2002;57:323–6.

10. Toomarian L, Fekrazad R, Sharifi D, et al. Histopathological evaluation of pulpotomy with

Er,Cr:YSGG laser vs formocresol. Lasers Med Sci 2008;23:443–50.

11. Olivi G, Genovese MD. Erbium chromium laser in pulp capping treatment. J Oral Laser Appl
2006;6:291–9.
12. Riccitiello F, D’ambrosio C, Simeone M, et al. Pulpotomia: indicazioni, diagnosi, terapia. Dentista
Moderno 2005;2:23–46.

13. Moritz A, Schoop U, Goharkhay K, et al. The CO2 laser as an aid in direct pulp capping. J Endod
1998;24:248–51.

14. Yazdanfar I, Gutknecht N, Franzen R. Effects of diode laser on direct pulp capping treatment: a
pilot study. Lasers Med Sci 2015;30:1237–43.
15. Webber RT. Traumatic injuries and the expanded endodontic role of calcium hydroxide. In:
Gerstein H, editor. Techniques in Clinical Endodontics. Philadelphia: WB Saunders; 1983.
p. 175.
16. Cengiz E, Yilmaz HG. Efficacy of erbium, chromium-doped:yttrium, scandium, gallium, and
garnet laser irradiation combined with resin-based tricalcium silicate and calcium hydroxide on
direct pulp capping: a randomized clinical trial. J Endod 2016;42:351–5.
17. Bose R, Nummikoski P, Hargreaves K. A retrospective evaluation of radiographic outcomes in
immature teeth with necrotic root canal systems treated with regenerative endodontic
procedures. J Endod 2009;35:1343–9.
18. Mass E, Zilberman U. Long-term radiologic pulp evaluation after partial pulpotomy in young
permanent molars. Quintessence Int 2011;42:547–54.

19. Mitchell DF, Tarplee RE. Painful pulpitis; a clinical and microscopic study. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1960;13:1360–70.

20. Trowbridge H, Kim S, Suda H. Structure and functions of the dentin and pulp complex. In:
Cohen S, Burns RC, editors. Pathways of the Pulp. St Louis, MO: Mosby Inc; 2002. p. 411–55.
21. Bimstein E, Rotstein I. Cvek pulpotomy-revisited. Dent Traumatol 2016;32:438–42.

22. Chailertvanitkul P, Paphangkorakit J, Sooksantisakoonchai N, et al. Randomized control trial

comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously
exposed pulps of permanent molars. Int Endod J 2014;47:835–42.

23. Ozgur B, Uysal S, Gungor HC. Partial pulpotomy in immature permanent molars after carious
exposures using different hemorrhage control and capping materials. Pediatr Dent
2017;39:364–70.

24. Bergenholtz G, Spangberg L. Controversies in endodontics. Crit Rev Oral Biol Med 2004;15:99–
114.
25. Bogen G, Chandler NP. Pulp preservation in immature permanent teeth. Endod Topics
2012;23:131–52.

26. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp:
a systematic review. J Endod 2011;37:581–7.

27. Matsuzaka K, Muramatsu T, Katakura A, et al. Changes in the homeostatic mechanism of

dental pulp with age: expression of the core-binding factor alpha-1, dentin sialoprotein,
vascular endothelial growth factor, and heat shock protein 27 messenger RNAs. J Endod
2008;34:818–21.

28. Heide S. The effect of pulp capping and pulpotomy on hard tissue bridges of contaminated
pulps. Int Endod J 1991;24:126–34.
29. Moritz A, Schoop U, Goharkhay K, et al. Advantages of a pulsed CO2 laser in direct pulp capping:
a long-term in vivo study. Lasers Surg Med 1998;22:288–93.
30. Luks S. Pulpotomy a critical evaluation. J Dent Child 1954;21:249.

8 Tozar and Erkmen Almaz JOE  Volume -, Number -, - 2020

 31. Bakhtiar H, Nekoofar MH, Aminishakib P, et al. Human pulp responses to partial pulpotomy
treatment with TheraCal as compared with Biodentine and ProRoot MTA: a clinical trial. J Endod
2017;43:1786–91.

32. Heithersay GS. Stimulation of root formation in incompletely developed pulpless teeth. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1970;29:620–30.

33. Araujo PR, Silva LB, Neto A, et al. Pulp revascularization: a literature review. Open Dent J
2017;10:48–56.
34. Saad AY. Calcium hydroxide and apexogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1988;66:499–501.

35. Camp JH. Diagnosis dilemmas in vital pulp therapy: treatment for the toothache is changing,
especially in young, immature teeth. J Endod 2008;34:6–12.

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