Success rate of calcium hydroxide pulpotomy in primary molars restored with amalgam and stainless steel crowns

IN BRIEF • • • • Success rates were found to be higher in teeth restored with stainless steel crowns than in teeth restored with amalgam. Amalgam is a suitable alternative to a stainless steel crown only for teeth with mechanically exposed pulp. Pulpotomy success rates are higher in teeth with pinpoint carious exposure. Under the conditions of this study, restoration failure did not appear to affect treatment prognosis. RESEARCH Success rate of calcium hydroxide pulpotomy in primary molars restored with amalgam and stainless steel crowns D. Sonmez1 and L. Duruturk2 Objectives To compare the success rate of calcium hydroxide (Ca(OH)2) pulpotomies in primary molars restored with a stainless steel crown (SSC) to that of teeth restored with amalgam and to evaluate the role of restoration failure in treatment outcome. Study design Pulpotomies were performed in 154 primary molars. Teeth were grouped according to pulpal exposure type as either mechanically or cariously exposed, with cariously exposed teeth further divided according to size of exposure site (pinpoint or larger than pinpoint). Seventy teeth were restored with amalgam and 84 with a SSC. Teeth were followed up for 12 months. Results Pulpotomy success rates were 79.9% for teeth restored with a SSC and 60% for those restored with amalgam. The difference between these rates was statistically significant (p <0.01). Restoration failure rates were 14.3% for amalgams and 2.4% for SSCs. The difference between these rates was also statistically significant (p <0.01). Among the 12 failed restorations, treatment was found to be successful in five cases (41.7%) and unsuccessful in seven cases (58.3%). This difference was not statistically significant (p >0.05). Conclusions The pulpotomy success rate for teeth restored with a SSC was higher than for those restored with amalgam. Restoration failure did not appear to have an effect on treatment prognosis. INTRODUCTION One of the most common causes of failure in vital pulp therapy is bacterial penetration from the salivary environment into the pulp through open dentinal tubules. Since bacterial contamination and infection are the prime threat to pulpal healing, prevention of marginal leakage is an important aspect of vital pulp therapy.1–4 For this reason, leakage-free restorations and cavity-sealing materials are emphasised as an important factor for successful pulp therapy.1,3–8 At the same time, a primary molar treated by pulpotomy has a weak, unsupported crown that is liable to fracture9–11 and therefore requires a restoration material capable of strengthening the weakened crown. Accordingly, stainless 1, 2* Ankara University School of Dentistry, Department of Pedodontics, Besevler, Ankara, 06500 Turkey *Correspondence to: Leyla Duruturk Email: Onine article number E18 Refereed Paper - accepted 10 December 2009 DOI: 10.1038/sj.bdj.2010.446 © British Dental Journal 2010; 208: E18 steel crowns (SSCs) have been recommended as the restoration of choice for the long-term success of pulp therapy and retention of the treated tooth among the functional dentition.1,7,9,12–16 However, the literature reports variations in the material used for restoration following vital pulp therapy in primary teeth. In some studies, all teeth were restored with SSCs,1,7,12,14,17– 24 whereas other studies also used amalgam10,17,25–31 and other literature shows the use of resin-based materials.10,11,16 Amalgam has a poor coronal seal that permits bacterial contamination and provides no reinforcement for the remaining tooth structure, 4,11 however it has many positive properties that sustain its popularity, including ease of manipulation, durability, comparatively low cost and reduction in microleakage over time. Because amalgam reportedly does not contribute to tooth fracture, it has also been recommended as the material of choice for restoration of posterior primary teeth when a crown is not necessary.30,32 Moreover, amalgam has been reported to be more appropriate than a SSC for restoring posterior primary teeth when tooth isolation or patient co-operation is difficult to obtain.30 Finally, financial constraints have prevented the widespread use of SSCs in some countries.31 In Turkey for example, the use of SSCs are limited to university dental clinics. All the above factors are likely to ensure that amalgam continues to be used as an alternative to the SSC. Although the final restoration plays an important role in the outcome of pulpotomies of primary molars, most studies in the literature have concentrated on the role of dressing material, with only a few studies investigating the effects of tooth restoration type on pulpotomy success rates.21,33 Therefore, this study aimed to compare the success rates of calcium hydroxide (Ca(OH)2) pulpotomies in primary molars restored with SSCs to those restored with amalgams and to evaluate the role of restoration failure on treatment outcome. MATERIALS AND METHOD Subjects were selected from among those patients applying to the Ankara University Faculty of Dentistry’s paediatric dentistry BRITISH DENTAL JOURNAL 1 © 2010 Macmillan Publishers Limited. All rights reserved. RESEARCH clinic requiring pulpotomy treatment of one or more primary molars. The research protocol was reviewed and approved by the faculty ethics committee, and informed consent was obtained from the parents of all children who participated in the study. A total of 163 mandibular primary molars (78 first and 85 second primary molars) from 88 healthy and co-operative children (45 boys, 43 girls) aged 4-9 years were selected according to the following criteria: presence of deep carious lesions (radiographically shown to approximate the pulp); exposure of vital pulp during caries excavation; root resorption of less than one third the total root length; possibility of restoration following pulpotomy; absence of any symptoms indicating advanced pulpal inflammation; absence of clinical signs or symptoms suggesting a non-vital tooth; absence of radiographically demonstrable pathology; and cessation of haemorrhaging of the amputated pulp stump within five minutes.5,7,18,31,32 The pulpotomy procedure Ultracaine D-S with 1:200,000 epinephrine (Aventis, Istanbul, Turkey) was administered as a local anaesthetic. Cotton rolls and suction were used for isolation in all patients (in order to standardise procedures, since some children under age 6 could not tolerate a rubber dam). All caries was removed. The status of the exposure site and the amount and characteristics of bleeding were evaluated upon pulpal exposure during cavity preparation. When pulpal bleeding could not be stopped in 5 minutes, teeth were identified as having inflamed or necrotic pulp and underwent pulpectomies. These teeth were not included in the study. If the bleeding was easily controlled and light red in colour, the inflammatory process was judged to be limited to the coronal pulp. Following this diagnosis, the pulp (...truncated)