PEDIATRIC DENTISTRY V 32 , NO 5 SEP ; OCT 10

Comparing Gray Mineral Trioxide Aggregate and Diluted Formocresol in PulpotomizedHuman Primary MolarsCameron M. Zealand, MSc, DMD, MS' • Daniel M. Briskie, DDS^ • Tatiana M. Botero, DDS, MS' • James R. Boynton, DDS, MS'' • Jan C.C. Hu, BDS,

Abstract: Purpose: The purpose of this muitisite, muitioperator, prospective, randomized, controlled clinical trial was to evaluate the 6-month outcomes

of diiuted formocresoi (DEC) compared to gray mineral trioxide aggregate (GMTA) as puipotomy medicament. Methods: Determined by a power analysis,

252 molars of 152 children were recruited The teeth were randomly assigned to receive GMTA or DEC. At the 6-month foiiow-up, 118 children with

203 treated teeth were evaiuated. Results: Eour blinded and calibrated evaluators scored each radiograph for pathoiogies. Clinical success was similar for

DEC (97%) and GMTA (100%), (P<.09). Radiographic success differed significantiy (P<.04) for DEC (86%) and GMTA (95%). Pulp canal obliteration was

radiographically observed in 25% of the DEC group and in 37% of the GMTA group (P=.O7). Dentin bridging was observed in 22% of the GMTA group

but was not found in the DEC group (P<.OI). Conclusion: Teeth treated with GMTA showed more favorable radiographie outcomes than DEC at 6 months

post-treatment. (Pediatr Dent 20l0;32:393-9) Received April 28, 2009 I Last Revision June 26, 2009 I Accepted June 29,2009

KEYWORDS: PULP THERAPY/ENDODONTICS. DENTAL MATERIALS/BIOMATERIALS. DENTIN BRIDGE. PULP CANAL OBLITERATION

Formocresol (FC) has been a popular medicament for vitalpulp therapy since its introduction 75 years ago, and is stillconsidered to be the most universally taught and widely usedmedicament for pulp treatment in primary teeth.' ' The for-mocresol pulpotomy, 1:5 dilution or full-strength, continuesto be the gold standard for didactic and clinical training ofdental students in the United States' and Ganada.^ Formo-cresol pulpotomy has teported clinical and radiographiesuccess rates, ranging from 53% to 100%/' Formocresol,however, is associated with potential adverse effects, whichhave been demonstrated in numetous studies.'

ProRoot mineral trioxide aggregate (MTA) has been usedexperimentally for a number of years and was given approvalfor human usage by the FDA in 1998." MTA is a powdercomposed of tricalcium silicate, bismuth oxide, dicalcium si-licate, tricalcium aluminate, tetracalcium aluminoferrite, andcalcium sulfate dihydrate.'' '" There is no difference betweenthe healing property of MTA and Portland cement as a pulp-capping material." ProRoot MTA contains Portland cementclinker 75% w/w, bismuth oxide 20% w/w, and gypsum

'Dr. Zealand is a pédiatrie dentist. The Center for Pédiatrie Dentistry. Calgary, ^liberta.

Canada: ^Dr. Briskie is a pédiatrie dentist in private practice. Rochester, Mieh.: and

'Dr. Botero is clinical associate professor. Departments of Cariology, Restorative Scien-

ces, and Endodontics. *Dr. Boynton is clinical assistant professor and Program Director.

Departments of Orthodontics and Pédiatrie Dentistry, and 'Dr. Hu is Samuel D. Harris

Collegiate Professor of Dentistry. Department of Biologic and Materials Sciences,

all ot Ihe University of Michigan. Ann Arbor. Mich.

Correspond with Dr. Hu at jan,hulg>umich.edu

5% w/w; these three major components of GMTA are com-mon chemicals, especially bismuth oxide and gypsum whichhave long been used in dental materials.

There are some trace elements/imptirities at the maxi-mum of 0.6% w/w existing in ProRoot MTA, which may in-clude free crystalline silica, calcium oxide, free magnesiumoxide, potassium, and sodium sulfate compounds.'' It is abiocompatible material and allows bone regeneration andovergrowth of cementum when used as a root-end filling ma-terial.'"'' Its sealing ability is better than amalgam, zinc oxide-eugenol, or Super EBA (Harry J. Bosworth Company, Skokie,111) with low cytotoxicity.'^'* It sets via hydration in the pre-sence of moisture to become a colloidal gel with a pH of 12.5.The setting time of the cement is 4 hours, and its compres-sive strength is 70 MPa, which is comparable to intermedi-ate restorative material (IRM). It has been demonstrated tostimulate cytokine release from bone cells, promoting hardtissue formation.'^

The use of MTA also has shown promising short-termresults in primary teeth. Most of the recent literature has fo-cused on comparing full-strength FG and gray mineral trio-xide aggregate (GMTA) for pulpotomy of primary teeth.'^'"''In 2006, a meta-analysis was conducted to compare the cli-nical and radiographie effects of GMTA with full-strength FGwhen used for pulpotomies of primary molars.''' Six qualifiedstudies,^'*'" comprising of 381 teeth, met the strict inclusioncriteria. Based on the current available evidence, there was asignificant difference between full-strength FG and GMTA-treated primary molars. GMTA appears to be superior tofull-strength FG for pulpotomy with a higher clinical and

MTA PULPOTOMY 393

PEDIATRIC DENTISTRY V 32 • NO 5 SEP i OCT 10

radiographie success rate and a lower rate of internal résorp-tion. This preliminary study was designed to clinically andradiographically compare the effect of GMTA to that of DFCas a pulpal medicament in a primary molar pulpotomy.

MethodsThe Institutional Review Board at The University of Michi-gan, Ann Arbor, Michigan, and Mott Children's Health Center(MCHC), Flint, Michigan, approved thestudy protocol. The procedure and its pos-sible discomforts, risks, and benefits werefully explained to the parents/legal guardianof the children involved, and their informedconsents were obtained prior to investi-gation. A power analysis indicated that203 teeth were needed for the study. Onehundred sixty-eight American Society ofAnesthesiology (ASA) Class I or II 21/2- to10-year-old children (81 girls and 87 boys)with a mean age of 5.6±1.5 years, attendingeither the Children's Clinic of the Universityof Michigan School of Dentistry or MCHCwho met the strict inclusion criteria wererandomly selected, contributing a total of270 teeth for treatment in the study. Clini-cal and radiographie data were collectedover a 1 -year period.

All pédiatrie dental residents, assistants,and faculty involved in the study underwenta calibration session on typodont teeth. Pre-operative periapical radiographs of the teethconsidered for treatment in the study met thefollowing criteria: proper film density andcontrast for radiographie diagnosis; displayeda minimum of 3 mm past the furcation area;taken at a bitewing angle perpendicular tothe film to prevent foreshortening/elonga-tion of the tooth; and covering of the furca-tion with the stainless steel crown (SSC).

Randomization of the medicament usedwas done by an envelope draw. Only teethwith a clinical diagnosis of reversible pulpi-tis were included in the study. Teeth with ne-crotic pulp chambers were excluded. Alltreated teeth were anesthetized using 2%lidocaine with 1:100,000 epinephrine andisolated with a rubber dam. All teeth exhibit-ing carious pulp exposure, whose pulp bledupon entering, had the decay removed priorto pulp access were prepared for the pla-cement of a SSC. Initial occlusal access wasprepared using a high-speed dental handpieceand a no. 330 carbide bur with water spray.Removal of the coronal pulp was completedusing a slow-speed handpiece with a roundbur and spoon excavator. In the DFC con-trol group, after hemostasis was achieved

with direct pressure, a sterile cotton pellet containing di-luted formocresol (Buckley's Formo Cresol from SultanHealthcare containing 19% formaldehyde, 35% cresol, 17.5%glycerin) 20% or one fifth strength, was squeeze dried andplaced in contact with the amputated pulp for 5 minutes,followed by the placement of IRM.

In the GMTA experimental group, once the hemorrhagewas under control using direct pressure of a sterile cotton

FOR n iMifAi ANin RAninr.RAPHir s r f

Clinical score

l=asymptomatic.6-month recall

2=slight discotnfort, short-lived3-month recall

3=minor discomfort, short-lived1-month recall

4=major discomfort, long-livedExtract immediately

Radiographie score

l=no changes present6-month follow-up

2=pathological changes ofqtiestionable clinicalsignificance

3-month follow-up

3=pathological changes present1-month follow-up

4=pathological changes presentExtract immediately

Definition

• Pathology: Absent• Normal functtontng• Naturally extohated• Exfoliation prematurely due to ectopic eruption• Mobility (physiological) s i mtii

• Pathology: Questionable• Percussion sensitivity• Chewing sensitivity, short-lasting• Gingival inflammation (due to poor oral hygiene)• Mobility (physiological) >l mm but <2 mm

• Pathology: Initial changes present• Chewing sensitivity, long-lastitig• Cingival swelling (not due to poor oral hygiene)• Periodontal pocket formation (no exudare)• Mobility >2 mtn but <3 mm

• Pathology: Late changes present• Spontaneous pain• Gingival swelling (not due to poor oral hygiene)• Periodontal pocket formation (exúdate)• Sinus tract present• Mobility a3 mm• Premature tooth loss, due to pathology

Definition

• Internal roor canal form rapering from chamber to the apex• PDL/periapical regions; normal width and trabecularion

• External changes are not allowed (widened periodontalligament widenitig (PDL), abnormal inter-radiculartrabeculation or variation in radiodensity

• Internal résorption acceptable (nonperforated)

• Calcific metamorphosis is acceptable and defined as:uniformly thin root canal; shape (nontapering); variationin radiodensity from catial to canal (one cloudier thantbe other); dentin bridge formation (one or more canals)

• External changes are present, but not large• Mildly widened PDL• Minor inter-radicular radiolucency with trabcctilation

still present• Minor external root résorption; internal résorption changes

are acceptable, but not if external change is also present(perforated form)

• Frank osseous radiolucency present, endangeringpermanent successor

' Adapted from Zurn and Sealc, 2008.

394 MTA PULPOTOMY

PEDIATRIC DENTISTRY V 32 ; NO 5 SEP I OCT 10

pellet, the amputated pulp stumps and chamber floor werecovered with GMTA paste prepared by mixing MTA powderwith sterile saline on a glass slab using a metal spatula. A 3:1powder/saline ratio was prepared according to the manufactu-rer's recommendations to obtain a putty consistency. The mixwas delivered to the pulp stumps with an amalgam carrier andcondensed lightly with a moistened sterile cotton pellet to en-sure a 3- to 4-mm thickness. In both groups, the pulp chamberwas filled with IRM, and then a SSC was fitted and cementedusing glass ionomer cement (Rely-X 3M ESPE, St. Paul,Minn). The occlusion was checked, and a postprocedure peri-apical radiograph was taken.

At the 6-month recall visit, the blinded clinical examina-tion was performed by 1 of the 19 operators who were cali-brated to the clinical scoring criteria. Periapical radiographswere taken and evaluated for the presence of various patho-logies. All radiographs were viewed by 4 blinded, calibratedevaluators: 2 pédiatrie dentists and 1 endodontist who arefull-time faculty members: and 1 pédiatrie dentist from privatepractice. The practice experience of the 4 evaluators rangedfrom 4 to 22 years, with a mean of 15 years. The criteria,based on Zurn and Seale 2008,'"' used to score the clinical andradiographie findings are described in Table 1. The scoringsystem was devised to represent severity of changes but not to

Ann Artxit Recniiicd(n=64)

txchidat(n"ll•^•itnl Radiographie

lnchifiion Cnicrta

Flini Recruited

Entered

\

TaialE<clu<lc<l(n*t8lFait«] RK]iosrq,htKhiiJonrmcns

Fxcludcdin-IT)

Failed Radiogr^hInchition Critena

Enlcred

Entered(n-t89)

DKI not «tend 6 monthfollow-up (n=< 19)

Did H>t attend 6 monthlow-up In = IO|

1 4Analyzed i/i 6 month

follow-up (n ^ IX)Analy/nl fa. 6 month

follow-up ( n ^ 16)

4Excluded un.ÜM(noftK (i.mtmlli

radioiiai« ln-2|

1Aiuilv/eil ¡11 6 mtmih

totlow-up(n -' Ib)Analyzed {a t> monlh

follow-up (n = 16)

1 1l Analywd (p. 6 monlh in Ann

Albor (n'.12)

DFC group(n-06)

MTA group

Did not aticnij 6 niiinthfollow-up ( n - 9 )

Did not attend 6 monthfollow-up In 9)

1 1Anaty/ed i^ 6 munlh

falkm-up In -1(7)Analyzed ifL 6 tnotiih

fullow-upfn^ tl4)

Tiiul Analyzed (K t, munlh in Flinl

Combine«] Analyzed in b monlhIn = 203)

Figure I. Distribulion of recruited teeth through study.

label an individual tooth as a "success" or "failure" (ie, as thescore gets larger, the pathologies get progressively more invasiveand require more frequent follow-up). Data was analyzed usingthe Statistical Package for Social Sciences v 16.0 (SPSS Inc.,Chicago, 111). The difference between the 2 materials was ana-lyzed using chi-square and Fisher's exact test. Intra- and inter-rater agreement was measured for the radiographie assessmentusing Cohen's kappa test.

ResultsThe number of recruited teeth that satisfied the inclusion cri-teria and entered the study was 252. Overall, 203/252 (81%)teeth were available for the 6-month evaluation, resulting in19% lost at follow-up (Figure 1). The age of patients at recall,in both genders, ranged from 2'/2 to 10 years, with a mean of5.5±1.5 years. A total of 17 operators were involved in treat-ing the 203 teeth recalled between the 2 study sites, althoughhalf of the recruited teeth were treated by 3 operators. Theintra- and inter-rater agreement for each pathology was mea-sured using Cohen's kappa (±SD) and found to be at mode-rate to good agreement range." Specifically, intra-rateragreement scores were: no change (NC: O.57±O.O5): dentina!bridging (DB: O.57±O.ll): pulp canal obliteration (PCO:0.52±0.07): internal root résorption (IRR: 0.54±0.21): exter-nal root résorption (ERR: 0.59±0.09): periodontal ligamentwidening (PDL; 0.49±0.12): and periradicular lesion (PRL:0.70±0.13). Inter-rater agreement scores were: NC (0.64±0.03):DB (O.65±O.14): PCO (0.63±0.02): IRR (0.47±0.08): ERR(0.52±0.15): PDL (0.57±0.10): and PRL (0.66±0.27). Overall,intra- and inter-rater reliability was good, with kappa valuesof 0.65±0.10 and 0.64±0.05, respectively.

The average clinical scores were the same for the DFCand the GMTA. Clinical outcomes of recalled teeth are sum-marized in Table 2. All teeth in the CMTA group were judgedto be clinically successful (100%), and 3 out of 103 teeth inthe DFC group were judged to have failed (success rate 97%).No significant difference was found between these 2 groups(7^.05).

The radiographie pathologies observed include: NC: DB(Figure 2A-B): PCO (Figure 2A-B): IRR/nonperforated form(IRR-NP: Figure 2C-D): PDL: ERR: IRR/perforated form(IRR-P: Figure 2E-F): and PRL (Figure 2CÍ-H). Radiographicfailures incltided: IRR-NP: ERR: IRR-P: and PRL. Wide-ning of PDL alone was not considered a failure. The 2 mostcommon radiographie findings in the DFC-treated teethwere: PCO (25%): and PDL widening (11%). The 2 mostcommon radiographie findings in the GMTA-treated teethwere: PCO (37%): and DB (22%). The only pathology thatwas significantly different (/•"<.05) between the 2 treated groupswas DB in the CMTA-treated teeth, whereas the DFC-treated teeth did not have any occurrence of DB (Table 3).

In the DFC group, 27% of the teeth scored a 2, 18% ofwhich involved IRR-NP In the GMTA group, 39% of theteeth scored a 2 and only 10% of those teeth involved IRR-NP. The average radiographie scores were equal for the DFC(1.6) and the GMTA (1.6) groups, indicating the same num-ber of radiographie changes over the 6-month evaluation

MTA PULPOTOMY 395

PEDIATRIC DENTISTRY V 32 I NO 5 SEP / OCT 10

period. In the DFG group, most scores came from IRR-NPand PGO. In the GMTA group, most scores came from DBand PGO. These changes were not significant in the 6-monthperiod (/*>.O5). Radiographic success in the GMTA group(95%) was judged to be higher than in the DFG group(86%), which was statistically different (P<.05).

DiscussionThe outcome of GMTA pulpotomy, with all 100 (100%) mo-lars being clinically successful compared to 100 out of 103(97%) in the control group after a 6-month follow-up, wasnot statistically different. The 3 clinical failures in the DFGgroup involved: 1 primary maxillary first molar; 1 primarymandibular first molat; and 1 primary mandibular secondmolar. Othet studies have reported 90% to 100% clinicalsuccess rates with FG aftet 12-months.' In the present study,DFG and GMTA had similar efficacy and corroborated thefindings of other reports.

The radiographie outcome in this studyrevealed that 95 of 100 (95%) molars in theexpetimental group were deemed successful,while only 89 of 103 (86%) of the DFGgroup were radiographicaily successful at the6-month follow-up. This difference was statis-tically significant. Other studies have reportedradiographie success rates of 93% to 100%with GMTA after 12-months,"'-^''2''"-''while lower radiographie success rates of 77%to 100% with DFG after 12-months."'-'•^s'»

Dentin bridge formation can be detectedin calcium hydroxide and GMTA-treated teeth,which supports the suggestion that both ma-terials have a similar mechanism of action re-garding bridging."'^' ' ' ' PGO or calcificmetamorphosis is a common radiographie find-ing in pulpotomized teeth treated with FG ''and DFG."' PGO occurs as a result of odonto-blastic activity and suggests that the affectedtooth has retained some degree of vitality^ ' '—therefore, PGO is not tegarded as a failure.The difference in PGO between the 2 groupswas not found to be statistically significant.

Internal résorption in primary teeth isassociated with persisted inflammation. Becauseof the thinness of the primary molar roots, ifinternal résorption can be seen radiographicaily,a perforation usually exits.' Internal résorptionis a common tadiographic finding in pulpoto-mized teeth. In the present study, it was re-garded as a radiographie failure. A wide range offrequencies have been reported in teeth tteatedwith both FG (7-40%)"'''"-« and DFG (1-150/0)26.37 jj^ jj jj study, the DFG group showed5 of 103 (5%) cases with internal résorption,which is in the range reported in the literature.The GMTA group showed 4 of 100 (4%) caseswith IRR, which also has been reported in

6% of teeth treated with GMTA over a 12- to 38-monthperiod.'" The difference in IRR-NP between the 2 gtoupswas not found to be statistically significant. It is teasonable tomention that, regardless of the material employed, a periodicclinical and radiographie evaluation of teeth subjected to pulptreatment must be emphasized.

Interpretation of radiographs of primary teeth is alwayscomplicated by the presence of the succedaneous tooth andsuttounding follicle. Widening of the PDL spaces occurred in11% (11/103) of DFG-treated teeth and 9% (9/100) of theGMTA-treated teeth without clinical symptoms. More speci-fically, PDL widening in conjunction with ERR occurred in3% (3/103) of teeth in the DFG group and 1/100 (1%) ofteeth in the GMTA group. The differences between the 2groups were not statistically significant.

Six percent (6/103) of DFG-treated teeth presented withexternal root résorption without any clinical signs and symp-toms, and only 1% (1/100) in the GMTA group showed ERR.

•sTx-MONTH CLINICAL X N Ü RADlöGRAPHlC SCORE OF RECALLED TEETH (N=2O3) ' *

Material

Clinical score

1 (NC) 2 (poor OH) 3 (perio) 4(%) (%) (%)

DFC 97(94) 3(3)

GMTA 95(95) 5(5)

Chi-square (2 degrees of freedom)=0.29

Material

DFC

GMTA

Chi-square (1 d

Material

Clinical outcome

Success (%) Failure (%)

100 (97) 3 (3)

100 (100) 0 (0)

egree of freedom)=0.09. Fisher's exact test=0.25

Radiographic score

1 (NC) 2 (DB, PCO, 3 (ERR, PDL, 4(%) IRR-NP) IRR-P)

(%) (%)

DFC 58(56) 28(27)* 14(14)

GMTA 51(51) 39(39)* 10(10)

Chi-square (3 degrees of freedom)=0.12

Material

DFC

GMTA

Chi-square ( 1 c

Radiographic outcome

Success (%) Failure (%)«

89(86) 14(14)

95(95) 5(5)

egree of freedom)=0.04. Fisher's exacr test=0.05"

(PRL)(%)

3(3)0(0)

(PRL)(%)

3(3)

0(0)

Total (%)

103(51)100 (49)

Total (%)

103(51)100 (49)

Total (%)

103(51)100 (49)

Total (%)

103(51)

100(49)

NC=no change; DB=dcntin bridge; PCO=pulp canal obliteration; lRR-NP=internal root resorption-nonperforated form; PDL=periodontal ligament widening; ERR=external résorption; IRR-P=internal rootresorption-perforated form; PRL-periradiciilar lesion.

IRR-NP=5/28(I8%).

IRR-NP=4/.39 (10%).Radiographie failures included; IRR, ERR. IRR-P. and PRL; PDL occurring alone was not considered a failure.

Statistically significant at the /*s.O5 level.

396 MTA PULPOTOMY

PEDIATRIC DENTISTRY V 32 I NO 5 SEP I OCT 10

Figure 2. Radiographic changes observed at 6-month follow-up. (A) Preope-rative view and (B) 6-month postoperative view of GMTA-treated tooth Kshowing dentin btidgc and pulp canal obliteration (mesial and distal canal).(C) Preoperativc view and (D) 6-month postoperative view of diluted formo-cresol (DFC)-treated tooth S showing internal root resorption-nonperforatedform (IRR-NP) in distal canal. (E) Preoperative view and (F) 6-month postope-rative view of DFC-treated tooth S showing IRR-P (perfotated form). (G) Pre-operative view and (H) 6-month postoperative view of DFC-tteated tooth Tshowing a periradicular lesion.

One percent (1/103) of DFC-treated teeth and 0% in theGMTA group presented IRR-P without any clinical signs andsymptoms (/*>.()5). Although ERR and IRR-P were consideredradiographie failures, clinically it may not justify an imme-diate extraction. Instead, a 1-month follow-up exam is war-ranted. Three percent (3/103) of DFC-treated teeth clinicallypresented with abscesses and radiographicaiiy presented withradiolucencies in the furcation or PRL. None of the teethtreated in the GMTA group presented with PRL. This typeof radiographie pathology indicates immediate extraction,regardless of the clinical signs and symptoms experienced bythe patient.

It was speculated that a pulpotomy's success may be in-fluenced by 4 variables: arch type (maxilla vs mandible); molartype (first molars vs second molars); gender (male vs female);and locale of treatment (clinic vs operating room). The onlyvariable that showed a statistically significant difference wasthe treatment location. In the clinic, there was a statisticallysignificant difference in success rates between DFC-treatedteeth (82%) and GMTA-treated teeth (94%). Interestingly,none of the teeth treated in the operating room under generalanesthesia failed, regardless of the pulpal medicament. Thiscould potentially be explained by the fact that cleaner condi-tions are easier to achieve in the operating room environment,as patient behavior is not a factor. Furthermore, there is a ten-dency to be more aggressive in the operating room when itcomes to pulp therapy than in the clinic. That is, a tooth thatmay undergo indirect pulp therapy in the clinic is more likelyto receive a pulpotomy in the operating room.

This study's results show that GMTA has the potentialto become a replacement for DFC in primary molar pulpo-tomies. The list price of a ProRoot MTA refill kit, as ofAugust 2010, is $251.50. In this study, 0.2 gm of MTA wasused to seal off the canal orifices lollowing the pulpotomyprocedure. Each refill kit containing 5 1-gm packets wassufficient for 25 pulpotomies. Therefore, the estimatedcost of MTA per pulpotomy is approximately $10. Eventhough the sample size was adequate, it is still premature todraw definitive conclusions, as the follow-up period is short.

"lable 3. SIX-MONTH RADIOGRAPHIC OUTCOME OF RECALLED TEETH: DISTRIBUTION AND FREQUENCY OF RADIOGRAPHIC CHANGES OF DFCAND GMTA PULPOTOMIES*

Radiographicchanges

Tteatnient

Combined

number (N)Frequency

Chi-square/Fisher s exacttests

I

NC

DFC GTMA

54(52) 52(52)

0.95/1.0

DB

DFC GTMA

0(0) 22(22)

<0.01t/<0.01t

2

PCO

DFC GMTA

26(25) 37(37)

0.07/0.10

Radiographic outcome

IRR-NP

DFC GMTA

5(5) 4(4)

0.77/1.0

PDL

DFC GMTA

11(11) 9(9)

0.69/0.82

3

ERR

DFC GMTA

6(6) 1(1)

0.06/0.12

IRR-P

DFC GMTA

1(1) 0(0)

0.32/1.0

4

PRL

DFC GMTA

3(3) 0(0)

0.09/0.50

231(100)

' NC=no change: DB = ilcriiin hmlge; PCO=pulp canal obliteration; IRR-NP=internal root resorption-nonperforated form; PDL=pcriodontal ligament widening;F,RR-external résorption; 1RR-P=intetnal root tesotption-perforated form; PRL=periradicular lesion.

t Statistically significant at the Ps.Oi level.

MTA PULPOTOMY 397

PEDIATRIC DENTISTRY V 32 ' NO 5 SEP ' OCT 10

This study provided a scientific basis fot a large-scale, on-going investigation that includes multicenter, large cohort,long-term follow-ups, split-mouth design, and histologicalexamination on treated teeth.

ConclusionsBased on this study's results, the following conclusions canbe made:

1. Overall, the combined clinical and radiographie suc-eess rates at the 6-month follow-up were 95% forgray mineral trioxide aggregate pulpotomies and86% for diluted formocresol pulpotomies.

2. Variables such as arch type, molar type, and genderdid not appear to influence pulpotomy success overa 6-month period.

3. Locale of treatment (clinic vs operating room) seemedto influence pulpotomy success, regardless of mate-rial used. A significant difference in success rates wasfound in the operating room compared to a clinicenvironment.

AcknowlegmentsWe would like to thank the supporting staff at the Ghildren'sGlinic, University of Michigan School of Dentistry and MottGhildren's Health Genter, Flint, Mich., for their contributionsto this study. This study was supported by Michigan Institutefor Glinical & Health Research and Delta Dental Foundationof Michigan. The authors declare no conflict of interest.

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)sti"ac1 of the St:ieiililic Literature

Reported barriers for physicians to adopt and implement preventive dental services in their practicesThe aim of this study WÜÍ to examine the barriers experienced by physicians in adopting and implementing early childhood preventive dental services in

their medical practices. Physicians enrolled into a randomized controlled trial comparing the effectiveness of different continuing education strategies on

providing preventive dental care were asked to complete a questionnaire. The questionnaire asked participants about 11 potential different barriers that

hindered them from providing basic dental prevention to children under 3 years of age. They were also asked whether or not they hod overcome the

obstocle(s). The most common barrier wos difficulty in Integrating dentol procedures into medical practice routines (42%). The next most frequent barrier

was difficulty in applying fluoride varnish to toddlers (29%), followed by staff resistance to these extra duties (26%), and challenges in referring children to

dentists (21%). Among these four main barriers, the one reported to be the easiest to overcome was applying fluoride varnish (62%). In general, as the number

of barriers reported by respondents in this survey increased, the actual percentage of those adopting preventive dental services in their offices decreased.

Physicians unable to address external factors were less likely to provide preventive dental cere. In order for primary care physicians to include dental pre-

vention in their practices potential barriers for adopting ond implementing this practice must be identified and targeted.

Comment: This paper highlights the fact that the promotion and advocacy for good early childhood oral health can be shared responsibilities of different

health professionals, not just dental team members. Physicians can play a key role, but do face several challenges to reaching young children in need. One

might speculate whether many of these reported barriers are similar to those identified by general dentists in opening their offices as dental homes for

infants ond toddlers and providing essential caries prevention regimens such as fluoride varnish. RJS

Address correspondence to Leslie Zeldin, MSUP, MPH, University of North Carolina, Department of Health Policy and Management, II05-F McCarvan-Greenberg Hall, 135 Dauer Dr, CB 7411, Chapel Hill, NC, 27499: e-mail: leslie_zeldin<s>unc.edu

Close K, Rozier RG, Zeldin LP, Gilbert AR. Barriers to the adoption and implementation of preventive dental services in primary medical care. Pediatrics2010 Mar:l25(3):509-17. Epub 20)0 Feb 1.

33 references

MTA PULPOTOMV 399

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