Clinical and Radiographic Evaluation of Allium sativum Oil as a New Medicament for Vital Pulp Treatment of Primary Teeth.

BACKGROUND: The objective of this study was to compare between the clinical and radiographic effects of Allium sativum oil and those of formocresol in vital pulpotomy in primary teeth.
MATERIALS AND METHODS: A total of 20 children age ranged from 4 to 8 years were included in the study. In every one of those children, the primary molars indicated for pulpotomy. Pulpotomy procedure was performed, and the radicular pulp tissue of one molar capped with A. sativum oil in a cotton pellet, whereas the other molar capped with formocresol, the teeth evaluated clinically and radiographically before and after 6 months, using standard clinical and radiographical criteria. Statistically, these results revealed no significant difference between the radiographic findings of vital pulpotomy in primary molars with the two medicaments was found.
RESULTS: A. sativum oil offers a good healing potential, leaving the remaining pulp tissue healthy and functioning. Vital pulpotomy with allium sativa oil was given raise 90% success rate while that with formocresol was 85%.
CONCLUSION: A. sativum oil is a biocompatible material that is compatible with vital human pulp tissue. It offers a good healing potential, leaving the remaining pulp tissue healthy and functioning.

Introduction

Preservation of the remaining vital portion of curiously exposed pulpal tissue in primary teeth, where the demand is to keep a functioning tooth in site, was one of the most frequent problems in pediatric dentistry.1 To solve this problem pulpotomy therapy was introduced, developed and classified according to treatment objectives.2 Pulpotomy involves amputation of the coronal portion of affected or infected dental pulp, treatment of the remaining vital radicular pulp tissue surface should preserve the vitality and function of all or part of the remaining radicular portion of the pulp.3 Furthermore, it is an accepted procedure for treating both primary and permanent teeth with carious pulp exposures, several materials have been using for capping the radicular pulp after pulpotomy, these included formocresol, glutaraldehyde,4 ferric sulfate,5 the collagen material,6 and mineral trioxide aggregate.7

However, none of them had met the same degree of effectiveness and success rate as formocresol, possible hazards of formocresol (cytotoxicity, carcinogenicity, immunologic, biochemical, mutagenic, and teratogenic changes) in the host have been reported.8 Moreover, it produced enamel defects in the permanent successors.9 In this regard, the demand for natural medicament to replace formocresol as a pulp dressing material became imperative.

Most widely researched plants in the field of medicine is Allium sativum. The antibacterial activity of A. sativum is mediated by allicin through enzymatic activity of allinase (a cysteine sulfoxidelyase). A wide range of therapeutic effects reported for garlic is mainly from allicin and other thiosulfinates. The antibacterial effects of fresh garlic extract10 have been thoroughly researched via literature and have been found that the extract will inhibit growth of various Gram-positive and Gram-negative bacteria.11 It is also reported that the garlic extract has inhibitory potential on isolated multi drug resistant strains of Streptococcus mutans from human caries teeth.12

Aim of the study

The aim of this study was to compare between the clinical and radiographic effects of A. sativum oil and those of formocresol in vital pulpotomy in primary teeth.

Materials and Methods

Twenty children age ranged from 4 to 8 years were selected from outpatient clinic of Pediatric Dentistry Department, Faculty of Dental Medicine, Al-Azhar University, Egypt.

Ethics of the study:

Care giver approval was taken.

Approval of Al-Azhar University, faculty of oral and dental medicine, Egypt (under number 249/2010).

A comprehensive history was obtained, and a thorough clinical examination was conducted on each of the selected children. A periapical radiograph of the intended tooth was achieved before treatment. Moreover, asking the parents or caregivers about any medical problems that may contraindicate the use of any of the intended procedures. A diagnostic sheet had been made for each child including the personal information, clinical and radiographical evaluations. In every one of those children, a pair of primary molars indicated for pulpotomy was selected for treatment.

Inclusion criteria

Patient and parent cooperation

Absence of any systemic disease, which would contraindicate pulp therapy

Exposure of vital pulp after excavation of caries with no clinical evidence of the extensive pulp degeneration or any periapical pathologic condition

Absence of clinical signs or symptoms suggesting a non-vital tooth such as a suppurating sinus, soft tissue swelling, mobility or tenderness to percussion

Possibility for establishing a final restoration of the tooth.

Radiographic criteria

No pathological external or internal root resorption

No periapical radiolucency

No calcific pulp degeneration.

Technique

Molars to be treated were locally anaesthetized using mepecaine-L (a local anesthetic solution containing 20 mg Mepivacaine hydrochloride with 0.06 mg Levonordefrin hydrochloride). Patients were allowed to wait for 10-15 min before pulpotomy procedure was done, rubber dam or cotton rolls were used to isolate the designated molar. Cavity outline was established with a sterile #330 high-speed pear-shaped carbide bur with air/water spray. Caries was removed with a slow speed sterile round carbide burs. Access to a pulp chamber could be detected with a probe, or if the roof of the pulp chamber were sufficiently thin to see the pulpal tissue. When the pulpal exposure was confirmed, the roof of the pulp chamber was removed with a sterile, non-end cutting slow-speed bur. Removal of the coronal pulp tissue was achieved with a sterile low-speed carbide round bur and/or sharp, large, spoon excavator. Hemostasis was attained by placing small cotton pellet moistened in sterile saline with slight pressure then it was removed.

The pulp stumps of molars in the right side were dressed with a cotton pellet damped with A. sativum oil (Captin company (CAPpharm) registration No 952/94 Cairo, Egypt), and with formocresol (Petrópolis-RJ-Industria Brasileira, Dentsply, Latin America) for molars in the left side for 5 min. Then, pulp stumps of molars treated with A. sativum oil were dressed in zinc oxide - A. sativum oil paste, while those of teeth treated with formocresol were dressed with a thick paste prepared by mixing zinc oxide powder with one drop of eugenol.13,14

Then, a layer of intermediate restorative material zinc phosphate cement had been placed over the dressing materials. After that, molars were restored with suitable final restoration and then with stainless steel crowns. Then, molars were clinically and radiographically evaluated after 6 months, using standard clinical and radiographic criteria.

Clinical evaluation

History of pain related to the treated molars

Sensitivity to percussion

Teeth mobility

Signs of erythema, swelling, the presence of the fistulous tract in the surrounding gingival tissues and mucosa.

Radiographic evaluation

Periapical radiographs were taken for all treated molars (Ultra speed Kodak Periapical films, size 0 or 1 film). All radiographs taken during the follow-up period were screened for their diagnostic quality prior to being included in radiographic evaluation. Acceptable radiographs have non-distorted images of the treated molars and the osseous structures immediately adjacent to the roots. Radiographs that did not meet these criteria were excluded from the evaluation.

During radiographic evaluation, the following were determined:

Presence or absence (or reduce in size) of furcation or periapical radiolucency

Presence or absence of pathologic internal or external root resorption

Presence or absence of widening in the periodontal membrane.

Statistical analysis

Statistical analysis was performed between the clinical and radiographic effects of A. sativum oil and those of formocresol in vital pulpotomy in primary teeth using Chi-square, and the level of significance was taken at α = 0.05.

Results

Clinical findings

The clinical findings of the primary molars treated with A. sativum oil after 6 months appeared as the following, from the 20 vital pulpotomies; only two cases had pain after 6 months. They were accompanied by increased mobility (Grade II) and recorded as treatment failure cases. For this reason, subtotal pulpectomy was performed for them. None of all cases developed a draining sinus.

The clinical outcomes of treated primary molars with formocresol after 6 months appeared as the following, from the 20 vital pulpotomies treated with formocresol, only four children had pain that recorded as treatment failure cases and treated by subtotal pulpectomy. None of all cases developed a draining sinus.

Comparisons between the clinical findings of vital pulpotomy in primary molars treated with allium sativa oil and those of formocresol are presented in Table 1 and Graph 1. Statistical analysis revealed no significant difference.

Table 1

Comparison between the effects of A. sativum oil and those of formocresol on the clinical findings of the first group at 6 months.

Graph 1

A histogram showing a comparison between the effects of Allium sativum oil (AS) and those of formocresol (FC) on the clinical findings at 6 months post-operative.

Radiographic findings

The radiographic outcomes of primary molars treated with A. sativa oil after 6 months showed, from the 20 vital pulpotomies; there were radiographic changes, only two molars showed evidence of widening in the periodontal membrane space. In addition, two cases exhibited periapical and furcation radiolucency after 6 months and considered as treatment failure cases. None of all treated molars exhibited root resorption. Moreover, the pericoronal sac associated with the underlying developing permanent teeth showed no noticeable changes (Figure 1).

The radiographic outcomes of primary molars treated with formocresol showed, from the 20 vital pulpotomies; there were radiographic changes, six primary molars showed evidence of widening in the periodontal membrane space.

In addition, four cases exhibited periapical, and two had furcation radiolucency after 6 months and considered as treatment failure cases. Furthermore, the teeth showed periapical and furcation radiolucency and considered as treatment failure cases, none of all treated molars exhibited root resorption. In addition, the pericoronal sac associated with the underlying developing permanent teeth showed no noticeable changes (Figure 2).

Figure 1

Radiographic features of the teeth treated with Allium sativum oil (vital pulpotomy). Mandibular first primary molar showed no changes at 6 months post-operative (b), compared to pre-operative radiograph (a).

Radiographic features of the teeth treated with formocresol (vital pulpotomy). Mandibular first and second primary molars showed no changes at 6 months post-operative (b) compared to pre-operative radiograph (a).

Comparisons between the radiographic findings of vital pulpotomy in primary molars treated with A. sativa oil and those of formocresol are presented in Table 2 and Graph 2. There was no noticeable difference compared to the aforementioned period.

Table 2

Comparison between the effects of A. sativum oil and those of formocresol on the radiographic findings of the first group at 6 months.

A histogram showing comparison between the effects of Allium sativum oil and those of formocresol on the radiographic findings at 6 months post-operative.

Statistically, these results revealed no significant difference between the radiographic findings of vital pulpotomy in primary molars with the two medicaments was found.

Discussion

In this study, a comparison between the clinical and radiographic outcomes of A. sativum oil and formocresol as pulpotomy medicaments in primary molars was successfully obtained.

Since formocresol is still considered the standard in primary teeth pulp therapy, hence it was used in the present study as a control. Due to its hazardous effects it produced enamel defects in the permanent successors.15 A systemic uptake of formocresol has been found from pulpotomized teeth, and tissue changes have occurred in various internal organs, particularly in kidney and liver, the quantity of circulating formocresol was found to increase with the number of teeth treated.16 It is known to have toxic, mutagenic and carcinogenic potential (Hill et al., 1991).17 In this regard, a demand for medicament to replace formocresol as a pulp dressing material became imperative.

Despite the penetration of the modern medicine, traditional medicine continues to be a viable health alternative for the large underprivileged sections of the world.18 Hence, increase utilization of indigenous plant medicines in developing countries became a World Health Organization policy in the 1970’s.19 Medicinal plants constitute a promising source of several drugs, among the promising medicinal plants, allium sativa, which considered being an amazing herb with a rich historical and religious background.11 In spite of the fact that allium sativa oil was used for the first time in treatment of vital primary molars, the results were remarkable and promising, as none of the succeeded cases showed any signs or symptoms of morbidity during the whole follow-up period. Moreover, no obvious radiographic changes were noticed during the recall visits.

In the present study, the results revealed that the success rate of A. sativum oil was 90%, while the success rate of formocresol was 85%. In general, these results confirmed the success rate of formocresol in treatment of vital pulps of primary molars and it is in agreement with other studies,20 however, the success rate of formocresol in the present study was lower than that suggested by others. In their study, 100% clinical success rate with formocresol was reported.13

The promising clinical outcome of vital pulpotomy performed with allium sativa oil may be explained on the bases that the oil was found to possess a potent analgesic and anti-inflammatory properties and it is used in the folk medicine for treatment of toothache without any side effects, The analgesic effect might be due to ajoene and diallyl sulfide, which inhibit prostaglandin, the anti-inflammatory effect of allium sativa was reported by several investigators.21 It inhibits prostaglandins through the suppression of cyclooxygenase enzyme in the inflamed area, and inflammatory cytokines.22 It also inhibits prostaglandins through suppression of 5-lioxygenase enzyme. In addition, allicin and ajoene appear to inhibit nitric oxide synthesis in macrophages.23 Nitric oxide (a pro-inflammatory mediator) is produced by macrophages.24

In this study, there was a high prevalence of furcation pathosis determined by radiographic examination. This finding is in agreement with another study.25

In the present study, radiographic investigation revealed an improvement, at the end of the follow-up period, with both allium sativa oil and formocresol treated teeth. This finding agrees with other investigators. The clinical and radiographic results revealed success at the aforementioned interval, if the recall periods were continued longer, complete resolution of these changes could be occurred. Statistical analysis revealed no significant difference between the effects of both medicaments on the clinical and radiographic outcomes.

Conclusions

A. sativum oil offers a good healing potential, leaving the remaining pulp tissue healthy and functioning. Statistically, there was no significant difference in the clinical and radiographic success rates of vital pulpotomies in primary molars treated with either A. sativum oil or formocresol.