journal of dentistry 42 (2014) 1390–1395

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MTA pulpotomy as an alternative to root canal

treatment in children’s permanent teeth in a dental
public health setting

Hend E. Alqaderi a, Sabiha A. Al-Mutawa a, Muawia A. Qudeimat b,*

a
Oral Health Services, Ministry of Health, Kuwait
b
Department of Developmental and Preventive Sciences, Kuwait University, Kuwait

article info abstract

Article history: Objective: This prospective clinical study evaluated the success of vital pulpotomy treat-
Received 6 March 2014 ment for permanent teeth with closed apices using mineral trioxide aggregates (MTA) in a
Received in revised form dental public health setting.
17 June 2014 Methods: Twenty-seven mature permanent first molars and 2 premolars (in 25 patients)
Accepted 18 June 2014 with carious exposure were treated using MTA pulpotomy. Age of patients ranged from
10- to 15-years (mean = 13.2  1.74-years). Four trained and calibrated practitioners per-
formed the same clinical procedure for all patients. Following isolation and caries removal,
Keywords: the inflamed pulp tissue was completely removed from the pulp chamber. This was
MTA followed by irrigation with 2% sodium hypochlorite. Haemostasis was achieved using a
Pulpotomy cotton pellet damped in normal saline. A white MTA paste was placed against the pulp
Carious exposure orifices. MTA was covered with a damped cotton pellet and a base of IRM. Patients were
Permanent teeth recalled after 1 day where a glass ionomer liner and a final restoration were placed. Teeth
Children were evaluated clinically and radiographically for up to 47 months.
Results: Mean follow-up period for all teeth was 25  14 months. Twenty-six of the 29 teeth
were clinically asymptomatic with no evidence of periradicular or root pathology during
the follow-up period. The estimated success rate was 90%. Three teeth presented with
clinical symptoms of pain and radiographic evidence of periradicular pathology that
indicated root canal treatment (RCT) or extraction.
Conclusion: When managing carious pulp exposures of permanent teeth with closed root
apices in children, MTA pulpotomy showed a high success rate.
Clinical significance: MTA pulpotomy for permanent molars in children is a viable alternative
to RCT.
# 2014 Elsevier Ltd. All rights reserved.

1. Introduction structure through reparative dentine production. Preserving

pulp vitality is essential in maintaining vascularization and
The dental pulp is an integral element of tooth structure. A nutrition to the tooth that eventually will support tooth
vital pulp tissue is responsible for supporting the tooth structure and reduce teeth mortality.

* Corresponding author at: Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, P.O. Box 24923,
Safat 13110, Kuwait. Tel.: +965 2463 6747; fax: +965 25326 049.
E-mail address: mqudeimat@hsc.edu.kw (M.A. Qudeimat).
http://dx.doi.org/10.1016/j.jdent.2014.06.007
0300-5712/# 2014 Elsevier Ltd. All rights reserved.
 journal of dentistry 42 (2014) 1390–1395 1391

Root canal treatment for permanent teeth in children is a and the absence of radiographically visible periradicular
complex procedure requiring lengthy appointments and pathologies. Clinically, teeth with hyperaemic pulp that could
multiple visits and often requires a full coverage restoration. not be controlled within 5 min were also excluded from the
On the other hand, vital pulpotomy requires shorter appoint- study. One investigator (with 7-years clinical experience in
ments and usually can be accomplished in one visit. Also, treating pulpally affected primary and permanent teeth in
while an endodontist is usually required to perform RCT, a children) trained and calibrated three clinicians for this
paediatric dentist or a general dental practitioner can perform study. Four clinicians carried out diagnosis and treatment
vital pulpotomy for permanent teeth. By providing an for all cases.
alternative to the progressive conventional RCT in children,
vital pulp therapy can help retain vital permanent teeth that 2.1. Treatment procedure
are able to withstand normal functions. In a recently
published systematic review, authors concluded that vital After anaesthetizing and isolating the tooth using a rubber dam,
pulp therapy should be considered as an alternative treat- caries was removed using a large round, low-speed carbide bur
ment to RCT in vital permanent teeth with carious exposed (Gebr.Brasseler1, Germany). Patients treated with indirect or
pulp.1 They also stated that there is a need for further studies direct pulp capping, partial pulpotomy or RCT were excluded
in vital pulp therapy, as the current evidence provides from the study. The treatment decision was made based on the
inconclusive information regarding factors influencing treat- extent of inflammation in the coronal pulp and the bleeding
ment outcomes.1 time; bleeding that stopped within few minutes indicated a
In Kuwait, the total number of children and adolescents healthy status of the remaining pulp in the canals.13 Each
aged 5–19 years is 378,365.2 In this age group, 95,743 patient received two dental visits in order to complete the
permanent tooth canal received RCT between 2007 and 2012 procedure. During the first visit, the standard pulpotomy
in the School Oral Health Programme (SOHP)-Ministry of procedure was performed, removing the infected coronal pulp
Health. In such a dental public health setting, substituting RCT tissue to the level of the floor of the pulp chamber and orifices by
with vital pulp therapy can decrease the number of patients using a high-speed diamond bur (Gebr.Brasseler1, Germany)
receiving RCT, and consequently, the cost of treatment. with copious sterile water. A sterile cotton pellet damped in
Currently, mineral trioxide aggregates (MTA) is accepted as normal saline was used to control the bleeding. A layer of white
an optimum material for use in vital pulp therapy of MTA (Pro Root1 MTA, Dentsply, Tulsa Dental, USA) paste,
permanent teeth.3,4 MTA clinical outcome is reported to be prepared by mixing MTA powder with sterile saline following
due mainly to its long-term sealing ability and the stimulation the manufacturer’s instructions was placed on the root canal
of a high quality and a great amount of reparative dentin.3,5 In orifices. The MTA was condensed lightly with a moistened
human clinical trials carried out on cariously exposed sterile cotton pellet to achieve a 2–4-mm thickness. A damped
permanent teeth, the success rate of vital pulp therapy cotton pellet was then covered with a temporary filling
using MTA was considered to be high and ranged from 93 to intermediate restorative material (IRM1, type III, Class 1 Caulk
100%.6–12 However, there is a limited number of studies Dentsply, USA). The patients returned the following day for a
reporting on the success of vital pulpotomy for mature second visit to complete the definitive restoration. In the second
permanent teeth in children and adolescents using visit, the cotton pellet and IRM1 were removed and the MTA
MTA.8,10,12 It was therefore the objective of the current study was checked for hardening. Teeth were restored with a layer of
to investigate the success of vital pulp therapy for mature light cure glass ionomer liner (VitrebondTM, 3MTM ESPETM, USA),
permanent teeth using MTA as an alternative to conventional and incremental layers of composite restoration (Herculite1
RCT in children and adolescents in a dental public health XRV UltraTM, Kerr Italia, Italy) were applied and cured according
setting. to the manufacturer’s instructions. Stainless steel crowns
(UnitekTM, 3MTM ESPETM, USA) were used over the composite
when more than two walls of the tooth were damaged. All
2. Materials and methods patients were instructed to call or return to the clinic if pain or
discomfort occurred, and in this case, symptoms were assessed
This prospective study was conducted at the School Oral and appropriate treatment provided.
Health Programme Clinics-Ministry of Health, Kuwait. Ethical All patients were scheduled for routine clinical and
approval was obtained from Health Sciences Ethical Clear- radiographic evaluations as per the SOHP guidelines. At each
ance Committee-Kuwait University. Prior to examination, follow-up visit, the treated tooth was examined for the
consents were taken from parents of all participating following adverse events: pain, swelling, sinus tract forma-
children. tion, tenderness on percussion or palpation, and radiographic
To be considered for this study, patients were required to evidence of periradicular or furcal pathology, or root resorp-
be medically healthy, have a restorable mature permanent tion. Pulp therapy was considered successful if none of the
molar or premolar with deep caries and a diagnosis of previous symptoms were present. Also, the quality of the
reversible pulpitis. Exclusion criteria included patients with restoration was checked and the restoration was repaired if
history of severe pain, history of swelling or a fistula deemed necessary. An examiner who was not involved in the
associated with the tooth, tenderness on percussion or treatment phase of this study evaluated all the pre and post
palpation, pathologic mobility, or an abnormal response to treatment radiographs at the end of the study. The examiner
cold testing (Endo-Ice, Hygenic Corp, Akron, OH). Radio- was blinded to the names of participant and dates of all
graphic inclusion criteria included: teeth with closed apecies radiographs.
1392 journal of dentistry 42 (2014) 1390–1395

hard tissue bridge underneath the MTA layer was observed in

3. Results 10 cases (34%).

Two patients with two treated teeth did not return for recall
visits, leaving 25 patients with 29 tooth for evaluation. 4. Discussion
Twenty-seven of the teeth were permanent first molars and
two were first premolars. Although many patients failed to Clinically, a principal challenge faced by most paediatric
return for regular follow up appointments at scheduled times, dentists, endodontists or general dentists with special interest
all of the cases were available for clinical and radiographic in treating children is the treatment of pulpally involved and
examination at the closing date of the study. The follow up abscessed teeth in a young patient. This is mainly due to
evaluation period ranged from 1 to 47 months with an average factors related to patient’s cooperation, the total number of
of 25  14 months. Table 1 summarizes the characteristics of visits required to finish the treatment and the cost of
patients, distribution of teeth, clinical and radiographic treatment. This is further complicated by disagreement on
findings at the initial visit, the follow up period and fate of treatment protocols and outcomes among clinicians, which is
all teeth included in this study. Treatment was considered often based on little or no documented evidence.14
successful for 26 teeth (90%). One of the cases that failed It has long been known that healthy dental pulp cells have
presented after one month of pulpotomy with severe pain and the potential to develop into odontoblasts.15 This allows pulp
tenderness to touch. The second failed case received RCT tissue to regenerate and repair.15,16 Authors suggested that
outside the SOHP and at the time of scheduled follow up aged pulp retains the ability to create dentine but at a
appointment the parent and child had no recollection of the diminished rate.17,18 They also concluded that younger pulps
timing of the treatment. The third case failed at 47 months. had a better likelihood of potential tissue healing and
The child presented with her mother complaining of pain and regeneration.17,18 An explanation for this could be provided
after clinical and radiographic assessment a decision was from a recent review on dental pulp stem cells where the
made to extract the tooth. authors demonstrated that ageing was related to reduction of
Radiographically, no signs of periradicular bone or root pulpal cell populations leading to compromised pulpal wound
resorption were noted in any of the successfully treated teeth. healing and regeneration with increasing age.19
Also, no evidence of internal root resorption or pulp canal Recent studies have shown high success rates for vital pulp
calcifications were detected on radiographs. A radiographic therapy in maintaining the vitality of dental pulp tissues in

Table 1 – Distribution and fate of 29 teeth that were cariously exposed and treated by pulpotomy using MTA.
Case number Gender Tooth Age at treatment Follow-up Final restoration Fate
(years) time (months)
1 F 36 13.1 47 Composite Successful
2 F 36 13 45 Composite Successful
3 F 36 11.5 43 Composite and SSC Successful
4 F 36 13.8 36 Composite Successful
5 F 46 15.4 33 Composite Successful
6 F 36 13 41 Composite Successful
7 F 46 11.8 47 Composite Failure
8 M 46 13 40 Composite Successful
9 F 36 12 22 Composite Successful
10 F 36 14.6 17 Composite Successful
11 M 16 15.1 3 Composite Successful
26 15.1 3 Composite Successful
12 M 26 15.1 21 Composite Successful
16 15.1 21 Composite Successful
13 M 36 14.4 24 Composite Successful
14 M 24 14.1 21 Composite Successful
15 M 16 12.2 21 Composite Successful
26 12.2 21 Composite Successful
16 F 14 10.9 21 Composite Successful
17 M 16 14.3 21 Composite Successful
18 F 16 13.7 21 Composite Successful
19 F 16 13.2 38 Composite Successful
20 M 26 14.1 14 Composite Successful
21 F 46 10 5 Composite Successful
22 F 46 11 6 Composite Successful
23 F 26 14.3 41 Composite Successful
24 F 16 14.3 1 Composite Failure
46 11 24 Composite Successful
25 F 36 15.3 Unknown Composite Failure
 journal of dentistry 42 (2014) 1390–1395 1393

young permanent teeth with open root apices.6,7,9,20 On the contact with sodium hypochlorite solution, white MTA can
other hand, for teeth with closed root apices, the best cause discolouration.29 When the teeth are restored with
treatment option under similar pulpal conditions is RCT. stainless steel crowns, this does not seem to represent an
Ricucci et al.14 in a recent 5-year prospective study reported on aesthetic problem.30 In this investigation, white MTA was used
an overall success rate of 89% for conventional RCT in in all cases and 28 teeth received resin restorations. However,
816 tooth. However, endodontic treatment for mature molar discolouration of treated molars was not investigated. There is
teeth has been reported to increase the incidence of tooth a possibility that for failed cases in this study, the colour of the
fractures.21 This is usually due to the loss of tooth structure tooth was part of the assessment criteria upon which dentists
and induced stresses caused by endodontic and restorative based their diagnosis of irreversible pulpitis or a non-vital
procedures which will eventually weaken the tooth and tooth. Therefore, it is imperative that parents and dentists are
make it more susceptible to fracture.21 Therefore, maintaining educated about the possibility of teeth colour changes with
tooth vitality enhances dentinal root deposition and results the use of MTA in vital pulpotomy.
in stronger root structure. The experience of root canal associated pain is a major
The aim of vital pulpotomy in permanent teeth in children source of fear for patients and a very important concern of
is to treat reversible pulpal injuries and to maintain radicular dentists.31 Oginni and Udoye32 documented that 18% of the
pulp vitality and function and therefore maintain the tooth in patients who received a single visit RCT reported pain 30 days
a viable condition. Few studies have reported on the outcome postoperatively. In a recent systematic review, it was
of pulpotomy for cariously exposed pulps in permanent teeth concluded that 14% of patients receiving RCT would have
with closed apices.10,12 Barngkgei et al.12 evaluated the clinical postoperative pain 1 week after treatment.31 However, in the
and radiographic outcome of pulpotomy treatment with MTA current study and except for the three failed cases, the parents
in symptomatic mature permanent teeth with carious of participants reported either immediate relive of pain or no
exposures in adults (mean age 29 years). The authors reported postoperative flare-ups. This is supported by a study that
on a 100% success rate. The final restoration was either compared the mean pain intensity and pain in response to
polycarboxylate cement and amalgam restoration or full percussion tests between a single visit RCT and pulpotomy
coverage crown.12 However, the sample size was small for permanent teeth with irreversible pulpitis. Over 7 days
(10 patients with 11 teeth) of which 5 teeth were molars, observation period, patients in the RCT group experienced
5 premolars and 1 central incisor. In the current study, the statistically significantly more pain than those in the
success rate was 90%. The majority of the treated teeth were pulpotomy group.33
molars (27) and two teeth were premolars. Also, the mean age Posterior resin composite restorations placed in children
of patients in this study was 13 years. and adolescents demonstrated good durability and low
The selection of the pulp cap material is a significant factor annual failure rate.34–36 However, deteriorating surface
in the success of any vital pulp therapy.9,22 In this study, restoration leading to bacterial leakage is the likely reason
white-MTA was used for pulp capping after pulpotomy for the increasing failure rate of pulp therapy observed in
because of its favourable sealing ability, biocompatibility, clinical follow-ups carried out over long periods of time.37,38
dentinogenic activity and its clinical encouraging out- This could lead to marginal bacterial leakage into the
comes.6,7,9–12,22–25 In applying MTA as a pulp cap material, it remaining vital pulp tissue and can consequently compro-
is postulated that MTA will provide an impenetrable barrier mise healing, resulting in pulpal necrosis.39 It has been
against any future bacterial leakage into the vital pulpal reported that the most effective restorative materials to
canals.25 This will help in maintaining an intact remaining prevent bacterial microleakage and pulp injury from
vital pulp that could heal and regenerate additional dentinal inflammatory activity were high viscosity glass ionomer,40
root tissues, resulting in more supportive tooth structure.25 resin-modified glass ionomer, bonded amalgam,41 resin
Recent clinical studies on direct pulp capping and partial restorations41 and stainless steel crowns.6,9 However, the
pulpotomy in treating cariously exposed permanent teeth frequency of bacterial microleakage related to resin com-
have supported the concept that dental pulp has the ability to posites was found to be 20%.41 This could have been a
remain vital after removing infected pulp tissue.6,7,9–12,26–28 In possible reason for the failure of the three cases seen in this
the current study, after the removal of the infected coronal study, especially that most of the teeth in this study required
pulp tissue and sealing the remaining pulpal canal with MTA, large restorations.
the pulp tissue healed and maintained vitality in 90% of the It has been stated that non-vital immature teeth, due to
teeth during the follow up period. In a previous randomized fragile roots, are more prone to fracture than mature teeth.42,43
clinical study, investigators compared the clinical and Root fractures commonly occur in the cervical third of teeth
radiographic outcomes of pulpotomy in permanent molars that receive apexification treatment.42 For immature end-
with irreversible pulpitis using calcium enriched mixture odontically treated teeth, it was found that the frequency of
cement (CEM) with those treated with MTA.10 The sample had cervical fractures ranged between 28 and 77% depending on
an average age of 27  8 years and molars were mature. After a the stage of tooth development.44 Studies thus far have not
short follow up period of 12 months, the clinical and investigated the frequency of cervical fractures following vital
radiographic success rates for the MTA and CEM groups were pulpotomy using MTA in permanent posterior teeth. However,
98% and 95%, respectively.10 over the follow-up period of this study, none of the treated
Although one advantage for using white MTA in this study teeth suffered cervical root fractures.
was to reduce the treated tooth’s discolouration potential, Limitations of the present study include: (1) the small
there have been recent reports suggesting that when in experimental sample size, (2) more than one clinician
1394 journal of dentistry 42 (2014) 1390–1395

performed the diagnosis and treatment procedure, (3) the young permanent teeth (apexogenesis). Pediatric Dentistry
relatively short period of follow-up after treatment, in 2006;28:399–404.
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