To Evaluate and Compare the Clinical and Radiographic Outcomes of Formocresol, Mineral Trioxide Aggregate, Electrocautery, and Bioactive Glass when used for Pulpotomy in Human Primary Teeth.

AIMS: The aim of the present study is to evaluate and compare the clinical and radiographic outcomes of formocresol (FC), mineral trioxide aggregate (MTA), electrocautery, and bioactive glass (BAG) when used for pulpotomy in human primary teeth. SETTINGS AND
DESIGN: The present study comprised of total four Groups A, B, C, and D; the selected children for the procedure were randomly divided into four groups according to the type of agent used as Group A, Group B, Group C, and Group D, respectively, having 20 teeth.
METHODOLOGY: In this study, pulpotomies were performed on the respective teeth. The teeth were treated using either FC, MTA, electrocautery, and BAG. Following the pulpotomy procedure, the teeth were evaluated for the clinical and radiographic success for 3, 6, and 12 months. The teeth were evaluated for the presence of pain, swelling, internal and external resorption, and radiolucency. STATISTICAL ANALYSIS USED: Fisher's exact test and Yates corrected Chi-square test is used.
RESULTS: After 12 months of follow-up, the clinical and radiographic success rates were high. Comparing the frequency (%) of overall clinical success rate of four groups at 12 months, the Chi-square test revealed significantly different and higher overall clinical success rate in MTA as compared to other groups, especially FC and EC at 12 months. Comparing the frequency (%) of overall radiographic success rate of four groups at 12 months, the Chi-square test revealed significantly different and higher overall radiographic success rate in MTA as compared to other groups, especially FC and EC at 12 months.
CONCLUSIONS: In this study, the success rates of MTA, BAG, and FC are matching their physical and chemical properties which have been detailed and explained earlier. Copyright:

INTRODUCTION

Treating primary and permanent teeth that are pulpally inflamed is a type of challenge unique in many aspects. As clinical symptoms do not match the histological pulpal status, often its diagnosis is less accurate. Usually, pain is an indicator to the extent of pulp inflammation, but it can be compromised by age and behavior. There are different goals in the treatment of primary teeth that must be satisfied in comparison to the treatment of permanent teeth.

The life span of primary teeth is limited and if proper treatment is given according to the need of patient it becomes possible to treat the primary teeth in a better way.

Pulpotomy is regarded as an advantageous procedure in primary as well as permanent teeth. It is described as: A minimally invasive procedure that is performed in children, on a primary tooth with extensive caries but without evidence of root pathology followed by the placement of medicament that supports healing and preservation of radicular pulp with relief in pain.

When the coronal pulp is exposed due to trauma caries or any of operative procedures inflammatory changes occurs within the tissue due to infiltration of bacteria within that area. Here, the infected and inflamed area of the coronal pulp is removed by surgical excision leaving healthy pulpal tissue in the root canal.

Within this if therapeutic material is placed in direct contact with the pulp, it stimulates the tissue healing response.

The dressing material should be such that it should be nontoxic to pulp and surrounding structures with being bactericidal and also biocompatible. It should also support healing of radicular pulp, without obstructing in any of physiologic processes like root resorption that can have clinical, histological, or radiological outcomes.[3]

Pulpotomy therapy for primary teeth involves basically three steps:

Devitalization

Preservation and

Regeneration.

In devitilization, the vital tissues are fixed by formocresol (FC) and electrocautery.

In regeneration, the dentinal bridge is stimulated by the action of MTA, bone morphogenetic protein, and bioactive glass (BAG).

Out of these regeneration is always said to develop most rapidly and most effectively.[2]

Thus, the study was undertaken to evaluate and compare FC, mineral trioxide aggregate (MTA), electrocautery, and BAG when used for pulpotomy in human primary teeth by clinical and radiographical method.

METHODS

Criteria for selection of teeth

Vital primary molars that were indicated for pulpotomy with deep caries without pulp exposure and healthy periodontium, with no history of spontaneous and persistent pain, the presence of 2/3rd of root length, no clinical or radiographic evidence of pulp degeneration, restorable crowns and readiness to appear for follow-up at 3, 6, and 12 months were included. Pre- and postoperative intraoral periapical X-rays were recorded for each tooth.

Materials used

FC (Pharmadent Remedies Pvt Ltd, Gujrat, India) – A

Electrocautery (Bonart ART E-1 India) - B

MTA (ProRoot MTA, Dentsply, Tulsa Dental, OK, USA) - C

BAG (PerioGlas, US Biomaterials, Alachua, FL) – D.

METHODOLOGY

Parents/guardians were informed about the condition of the child's dentition and the procedure to be conducted. After obtaining written consent from the parent/guardian and clearance from the Ethical committee of Career Post Graduate Institute of Dental Sciences and Hospital, Lucknow, the selected children for the procedure were randomly divided into four groups according to the type of agent used as Group A, Group B, Group C, and Group D, respectively, having 20 teeth each.

The clinical procedure in all the teeth of four groups was performed step by step in one visit under local anesthesia and rubber dam. Following the establishment of cavity outline form, all caries were removed, and coronal access of the pulp was performed with a round bur with high-speed handpiece to expose the pulp chamber. A spoon excavator was used for coronal pulp amputation. Pulp was amputated up to the orifice of the root canal; sterile cotton pellet was used with pressure on the amputated pulp stumps to achieve hemostasis.

In each tooth of Group-A after amputation of the coronal pulp and achieving hemostasis FC (Pharmadent Remedies Pvt. Ltd., Gujrat, India) in 1:5 dilution was applied using a sterile cotton pledget and extra was dapped and placed for 5 min. After removal of the FC soaked cotton pledget a thick mix of zinc oxide eugenol cement was then placed into the coronal pulp chamber. Tooth was then restored with intermediate restorative material and permanent restoration with preformed stainless steel crown was given. The whole procedure was completed in one visit, and an immediate postoperative IOPA radiograph obtained.

In each tooth of Group B (Electrocautery) (Bonart ART E-1 India) after amputation of the coronal pulp, sterile cotton pellets were placed in the chamber with pressure to obtain temporary hemostasis. The cotton pellets were then removed, and the electrocautery dental heavy ball electrode (Bonart ART E-1) was immediately placed 1–2 mm above the tissue. The electrocautery unit power was set at 40%. The electrical arc was allowed to bridge the gap to the first pulpal stump for 1 s followed by a cool down period of 10–15 s. Heat was minimized by keeping the electrode as far away from the pulp stumps and the tooth structure as possible while still allowing electrical arcing to occur. This procedure was repeated up to three times at each pulpal orifice. To avoid heat build-up in any one area of the tooth, single applications of 1 s were performed to each orifice in a rotational sequence. After each current application, a new large sterile cotton pellet was placed with pressure on the next pulpal orifice to be electrocauterized to absorb any blood or tissue fluid before the next current application (i.e. pellet-electrode-pellet-electrode). Pulpal stumps were dry and blackened upon completion of the procedure. An intermediate restoration was then placed into the coronal pulp chamber followed by an permanent restoration with preformed stainless steel crown. The whole procedure was completed in one visit, and an immediate postoperative IOPA radiograph recorded.

In each tooth of Group–C MTA (ProRoot MTA, Dentsply, Tulsa Dental, OK, USA) after amputation of the coronal pulp and achieving hemostasis, using a stiff metal spatula MTA powder was mixed with distilled water (according to manufacturer's instruction) provided by manufacturer in 3:1 (powder :Liquid) ratio and then placed over the site with a plastic instrument. Then, the mixture was compressed against the amputated site with a moist cotton pellet. An intermediate restoration was then placed into the coronal pulp chamber followed by permanent restoration with preformed stainless steel crown. The whole procedure was completed in one visit, and an immediate postoperative IOPA radiograph recorded.

In each tooth of Group – D (BAG) (PerioGlas, US Biomaterials, Alachua, FL) after amputation of the coronal pulp and achieving hemostasis with cotton pellets, BAG powder was mixed on a glass slab (according to manufacturer's instruction) with a small amount of normal saline to make a creamy suspension and BAG was placed directly on the pulpal stump. Tooth was then restored with intermediate restorative material and permanent restoration with preformed stainless steel crown. The whole procedure was completed in one visit, and an immediate postoperative IOPA radiograph recorded.

In each tooth of all the groups, clinical and radiographical evaluation was done at 3, 6, and 12 months interval postoperatively. Clinically, the teeth were evaluated for the presence/absence of spontaneous pain, tenderness to percussion, mobility, abscess/sinus tract, whereas radiographically for the presence/absence of internal resorption, furcation radiolucency, and periapical radiolucency.

The data thus collected were tabulated and analyzed statistically for each group.

RESULTS

Clinical evaluation

Pain

The frequency distribution of pain in percentage of four groups at 3, 6, and 12 months posttreatments are summarized in Table 1. At 3 months, 2 (10.0%) cases had pain in FC group, 2 (10.0%) in EC group, 0 (0.0%) in MTA and 01 (5%) in BAG group. Comparing the pain frequency (%) of four groups at 3 months, Fisher exact test revealed similar pain frequency among the groups at 3 months (P = 0.747), i.e., not differed statistically. Similarly, at 6 months, 4 (20.0%) had pain in FC group, 4 (20.0%) in EC group, 0 (0.0%) in MTA group, and 2 (10.0%) in BAG group. Comparing the pain frequency (%) of four groups at 6 months, Fisher test further revealed similar pain frequency among the groups at 6 months (P = 0.157), i.e., also not differed statistically. Similarly, at 12 months, 8 (40.0%) had pain in FC group, 4 (20.0%) in EC group, 2 (10.0%) in MTA group, and 4 (20.0%) in BAG group. Comparing the pain frequency (%) of four groups at 12 months, Fisher test further revealed similar pain frequency among the groups at 12 months (P = 0.175), i.e., also not differed statistically.

Table 1

Distribution of pain of four groups over the periods

Months	FC (n=20), n (%)	EC (n=20), n (%)	MTA (n=20), n (%)	BAG (n=20), n (%)	P	Significance
3 months	2 (10.0)	2 (10.0)	0	1 (5.0)	0.747	NS
6 months	4 (20.0)	4 (20.0)	0	2 (10.0)	0.157	NS
12 months	8 (40.0)	4 (20.0)	2 (10.0)	4 (20.0)	0.175	NS

Fisher exact test is used. FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass, NS: Not significant

Overall clinical success rate

The overall clinical success rate (pain + swelling + sinus tract) of four groups at 3, 6, and 12 months posttreatments is summarized in Table 2. At 3 months, FC, EC, MTA, and BAG showed 13.33%, 10.0%, 0.0%, and 3.33%, overall clinical failure, respectively, with highest being in both FC followed by EC. Comparing the frequency (%) of overall clinical success rate of four groups at 3 months, the Chi-square test revealed similar overall clinical success rate among the groups at 3 months (χ2 = 7.768, P = 0.052), i.e., not differed statistically. In contrast, at 6 months, FC, EC, MTA, and BAG showed 20.0%, 16.670%, 0.0%, and 8.33% overall clinical failure, respectively, with the highest being in FC followed by EC, BAG, and MTA the least. Comparing the frequency (%) of overall clinical success rate of four groups at 6 months, the Chi-square test revealed significantly different and higher overall clinical success rate in both BAG and MTA as compared to both FC and EC at 6 months (χ2 = 11.81, P = 0.008). Conversely, at 12 months, FC, EC, MTA, and BAG showed 33.33%, 23.33%, 6.67%, and 16.67% overall clinical failure, respectively, with the highest being in FC followed by EC, BAG, and MTA the least. Comparing the frequency (%) of overall clinical success rate of four groups at 12 months, the Chi-square test revealed significantly different and higher overall clinical success rate in MTA as compared to other groups, especially FC and EC at 12 months (χ2 = 11.08, P = 0.0088).

Table 2

Distribution of patients according overall clinical success rate in four groups over period of time

Period months	FC (n=60), n (%)	EC (n=60), n (%)	MTA (n=60), n (%)	BAG (n=60), n (%)	χ 2	P
3 months	8 (13.33)	6 (10.00)	0	2 (3.33)	7.768	0.052
6 months	12 (20.00)	10 (16.67)	0	5 (8.33)	11.81	0.008
12 months	20 (33.33)	14 (23.33)	4 (6.67)	10 (16.67)	11.08	0.0088

*Yates corrected Chi-square test is used. FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass

Radiographic evaluation

Internal resorption

The internal resorption of four groups at 3, 6, and 12 months posttreatments is summarized in Table 3. At 3 months, EC, MTA, and BAG showed no internal resorption, giving 100.0% success while FC showed resorption in 2 case giving 10.0% success. Comparing the frequency (%) of internal resorption of four groups at 3 months, internal resorption among the groups at 3 months (P = 0.2405), i.e., not significant statistically. In contrast, at 6 months, FC, EC, MTA and BAG showed 5%, 20.0%, 0.0%, and 0.0% failure in internal resorption, respectively, with highest being in EC. Comparing the frequency (%) of internal resorption of four groups at 6 months, similar internal resorption among the groups at 6 months (P = 0.097), i.e., not significant statistically. Conversely, at 12 months, FC, EC, MTA, and BAG showed 40.0%, 20.0%, 5.0%, and 15.0% failure in internal resorption, respectively, with the highest being in FC and least in MTA. Comparing the frequency (%) of internal resorption of four groups at 12 months, similar internal resorption among the groups at 12 months (P = 0.109), i.e., also not significant statistically.

Table 3

Internal resoption of four groups over the period

Period months	FC (n=20), n (%)	EC (n=20), n (%)	MTA (n=20), n (%)	BAG (n=20), n (%)	P	Significant
3 months	2 (10)	0	0	0	0.2405	NS
6 months	1 (5)	4 (20)	0	0	0.052	NS
12 months	8 (40)	4 (20)	1 (5)	3 (15)	0.0621	NS

*Fisher exact test used. FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass, NS: Not significant

Furcation radiolucency

The furcation radiolucency of four groups at 3, 6, and 12 months posttreatments is summarized in Table 4. At 3 months, all four showed no furcation radiolucency, exhibiting that here test was not applicable. In contrast, at 6 months, FC, EC, MTA, and BAG showed 30.0%, 20%, 0.0%, and 15.0% failure in furcation radiolucency, respectively, with highest being in FC followed by EC and both MTA and BAG the least. Comparing the frequency (%) of furcation radiolucency of four groups at 6 months revealed similar furcation radiolucency among the groups at 6 months (P = 0.053), i.e., statistically nonsignificant. Conversely, at 12 months, FC, EC, MTA, and BAG showed 40%, 30.0%, 0.0%, and 20% failure in furcation radiolucency, respectively, with the highest being in FC followed by EC and both MTA and BAG the least. Comparing the frequency (%) of furcation radiolucency of four groups at 12 months revealed being significant (P = 0.0077).

Table 4

Furcation radiolucency of four groups over the periods

Period months	FC (n=20), n (%)	EC (n=20), n (%)	MTA (n=20), n (%)	BAG (n=20), n (%)	P	Significant
3 months	0	0	0	0	NA	NA
6 months	6 (30)	4 (20)	0	3 (15)	0.053	NS
12 months	8 (40)	6 (30)	0	4 (20)	0.0077	S

*Fisher exact test used. NA: Not applicable, FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass, NS: Not significant, S: Significant

Periapical radiolucency

The periapical radiolucency of four groups at 3, 6, and 12 months posttreatments is summarized in Table 5. At 3 months, EC, MTA, and BAG showed no periapical radiolucency, while FC showed periapical radiolucency in 2 case giving 10.0% success. Comparing the frequency (%) of periapical radiolucency of four groups at 3 months revealed similar periapical radiolucency among the groups at 3 months (P = 0.2406), i.e., nonsignificant statistically. In contrast, at 6 months, FC, EC, MTA, and BAG showed 30.0%, 20.0%, 0.0%, and 15.0% failure in periapical radiolucency, respectively, with the highest being in FC and least in MTA. Comparing the frequency (%) of periapical radiolucency of four groups at 6 months, Fisher test revealed similar periapical radiolucency among the groups at 6 months (P = 0.0529), i.e., not significant statistically. Conversely, at 12 months, FC, EC, MTA, and BAG showed 45.0%, 40.0%, 10.0%, and 25.0% failure in periapical radiolucency, respectively, with the highest being in FC and least in MTA. Comparing the frequency (%) of periapical radiolucency of four groups at 12 months, Fisher test revealed similar periapical radiolucency among the groups at 12 months (P = 0.06275) and is nonsignificant.

Table 5

The periapical radiolucency of four groups over the period

Period months	FC (n=20), n (%)	EC (n=20), n (%)	MTA (n=20), n (%)	BAG (n=20)	P	Significant
3 months	2 (10)	0	0	0	0.2406	NS
6 months	6 (30)	4 (20)	0	3 (15)	0.0529	NS
12 months	9 (45)	8 (20)	2 (10)	5 (25)	0.06275	NS

*Fisher exact test used. FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass, NS: Not significant

Overall radiographic success rate

The overall radiographic success rate (internal resorption + furcation radiolucency + periapical radiolucency) of four groups at 3, 6, and 12 months posttreatments is summarized in Table 6. At 3 months, EC, MTA, and BAG showed no radiographic changes, exhibiting 100.0% success while FC showed 4 failure giving 6.67% success. Comparing the frequency (%) of overall radiographic success rate of four groups at 3 months, yates Chi-square test revealed similar overall radiographic success rate among the groups at 3 months (χ2 = 7.12, P = 0.068). In contrast, at 6 months, FC, EC, MTA, and BAG showed 21.67%, 20.0%, 0.0%, and 10.0% overall radiographic failure, respectively, with the highest being in both FC and EC. Comparing the frequency (%) of overall radiographic success rate of four groups at 6 months, yath Chi-square test revealed significantly different and higher overall radiographic success rate in both BAG and MTA as compared to both FC and EC at 6 months (χ2 = 13.45, P = 0.003). Conversely, at 12 months, FC, EC, MTA, and BAG showed 41.67%, 30.0%, 5.0%, and 20.0% overall radiographic failure, respectively, with highest being in FC and least in MTA. Comparing the frequency (%) of overall radiographic success rate of four groups at 12 months, yath Chi-square test revealed significantly different and higher overall radiographic success rate in MTA as compared to other groups, especially FC and EC at 12 months (χ2 = 21.28, P < 0.001).

Table 6

Overall radiographic success rate in four groups over the period

Period months	FC (n=60), n (%)	EC (n=60), n (%)	MTA (n=60), n (%)	BAG (n=60), n (%)	χ²	P
3 months	4 (6.67)	0	0	0	7.12	0.068
6 months	13 (21.67)	12 (20)	0	6 (10)	13.45	0.003
12 months	25 (41.67)	18 (30)	3 (5)	12 (20)	21.28	<0.001

*Yates corrected Chi-square test is used. FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass

Overall success rate

The overall success rate (radiographic + clinical) of four groups at 3, 6, and 12 months posttreatments is summarized in Table 7. At 3 months, FC, EC, MTA, and BAG showed 10.0%, 5.0%, 0.0%, and 1.67% overall failure, respectively, with the highest being in both FC followed by EC and both MTA and BAG the least. Comparing the frequency (%) of overall success rate of four groups at 3 months, the Chi-square test revealed significantly different and higher overall success rate in both MTA and BAG as compared to both FC and EC at 3 months (χ2 = 14.40, P = 0.0024) and is significant. In contrast, at 6 months, FC, EC, MTA, and BAG showed 20.83%, 18.33%, 0.0%, and 9.17% overall failure, respectively, with the highest being in FC followed by EC, BAG, and MTA the least. Comparing the frequency (%) of overall success rate of four groups at 6 months, the Chi-square test revealed significantly different and higher overall success rate in both BAG and MTA as compared to both FC and EC at 6 months (χ2 = 27.77, P < 0.001). Conversely, at 12 months, FC, EC, MTA, and BAG showed 37.50%, 26.67%, 5.83%, and 18.33% overall failure, respectively, with the highest being in FC followed by EC, BAG, and MTA the least. Comparing the frequency (%) of overall success rate of four groups at 12 months, Chi-square test revealed significantly different and higher overall success rate in MTA as compared to other groups especially FC and EC at 12 months (χ2 = 35.16, P < 0.001).

Table 7

Overall success rate in four groups over the period

Period months	FC (n=120), n (%)	EC (n=120), n (%)	MTA (n=120), n (%)	BAG (n=120), n (%)	χ²	P	Significant
3 months	12 (10)	6 (5)	0	2 (1.67)	14.40	0.0024	Significant
6 months	25 (20.83)	22 (18.33)	0	11 (9.17)	27.77	<0.001	Significant
12 months	45 (37.50)	32 (26.67)	7 (5.83)	22 (18.33)	35.16	<0.001	Significant

Yates corrected Chi-square test is used. FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass

DISCUSSION

The observations and results of the study are depicted in Tables 1–9. This study showed best outcomes with MTA followed by BAG, EC, and FC. The participants included were healthy children in the age range of 4–9 years as children would be uncooperative below this age, full primary dentition erupts at the age of 3 years and above 9 years physiologic root resorption starts.

Table 9

Distribution of sinus tract in four groups over a period of time

Period months	FC (n=20), n (%)	EC (n=20), n (%)	MTA (n=20), n (%)	BAG (n=20), n (%)	P	Significant
3 months	4 (20)	2 (10)	0	1 (5)	0.1240	NS
6 months	4 (20)	4 (20)	0	2 (10)	0.1572	NS
12 months	6 (30)	4 (20)	1 (5)	4 (20)	0.2284	NS

FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass, NS: Not significant

Hundered teeth were treated with pulpotomy procedure out of which only eighty turned up for follow-ups and thus were selected in the study. Although histological methods are a better test to predict pulpal healing, followed by radiograhical and clinical methods, this study incorporated only clinical and radiographical evaluations as the teeth used were destined for the preservation in the oral cavity.

In the present study, clinical success rate was higher with FC which was 67% when compared to the radiographic success, i.e., 57%. This was comparable to the results of Havale et al. study who reported clinical 86.7% and radiographical 56.7%; also comparable to Srinivasan Daya study with clinical success of 91.3% and radiographic 78.26%; Magnusson reported clinical success 100% and radiographical 62%; Neamatollahi and Tajik observed clinical and radiographic success of 100 and 92.5%, respectively, which was in accordance with the present study. Previous studies have shown a gradual decrease in the success rate with time, as was noticed in the current study with FC which could be attributed to physiological resorption, accelerated root resorption, and the approach of the time for exfoliation of primary molars.[4101112]

The most common failure finding in this study was internal root resorption like in Eidelman and Magnesson studies.[11] Internal resorption may be due to a chronically inflamed pulp, reversible fixative effect of FC, irritating pH, chemical and physical effects of ZOE on connective tissue to variation in the pulpotomy techniques used, or to lack of predentine.[7]

The present study showed interradicular radiolucency with FC group which may be due to smaller molecular size of FC with higher degree of penetrability and the potential to cause antigenic alteration in the pulp tissues can cause seepage into the apical region through the pulpal canals or into the furcation area through accessory canals or the pulpal floor, as it is thin, porous and permeable in nature, in deciduous molars, thereby increasing the probability of a periradicular and interradicular radiolucencies.[59]

Clinical and radiographic success with EC in the present study was 77% and 70% with an overall success of 73% which was in accordance with Bahrololoomi Zehra et al. (2008) study with 100 and 96.8% clinical and radiographic success rates, respectively. In the study conducted by Mack and Dean, the success rate for electrosurgical pulpotomy was significantly higher than that for FC pulpotomy which is similar with the present study. El-Melgy et al. compared pulpal and periapical tissue reactions to electrosurgery FC pulpotomy in primary teeth of dogs and observed FC pulpotomy. Rivera et al. evaluated postoperative clinical and X-ray findings from 80 primary molars after FC and electrosurgery vital pulpotomy. They did not find any significant difference between the two techniques after 6 months of follow-up.[6]

In the present study, MTA clinical and radiographic success was 97 and 100% and overall success rate of 98% which was comparable to Eidelman et al. who compared MTA's effects to those of FC in 32 pulptomized primary molars during a follow-up evaluation from 6–30 months with clinical and radiographic success rate in MTA group was 100% while there was an internal resorption in one molar treated with FC. In the studies of Naik and Maroto et al., the clinical and radiographic evaluations were done at 6 months after pulpotomy in primary molars. Their studies also showed that MTA was a successful material which was in accordance with the present study.[13] Furthermore, in a study conducted by Agamy et al. 2004 reported that the clinical and radiographic success rate of pulpotomy was 100% for gray MTA and 90% for FC in a period of 12 months postoperatively. Holan et al. 2005 observed 97% success rate of pulpotomy for MTA which is close to the present study.[14] Furthermore, in a study conducted by Godhi et al. in 2011 observed 100% clinical success at 1, 3, 6, and 12 months, whereas radiographic success at 3 months for FC and MTA were 92% and 96% and at 6 and 12 months were 88% and 96%.[8] MTA pulpotomy had favorable success rates; it does not induce internal root resorption, which has been observed in teeth treated with calcium hydroxide and FC (Fucks, 2002; Peng et al. 2006). The study showed only one case of pain with MTA at 12 months follow up, routine radiographic evaluation revealed no periapical pathology. The patient was given symptomatic treatment for pain with systemic medication and thus was relieved. The probable reasons could have been food impaction and/or subclinical periodontal problems. The best results with MTA in this study could be attributed to its biocompatibility and tight seal. Salako et al. in a histological study on rat molars reported dentin bridge formation which continued over time and resolve inflammation leaving a healthy pulp, in this context Schwartz et al. (1999) reported cementogenesis.[15]

In the present study, clinical and radiographic success with BAG was 83 and 90% with overall success of 87%, respectively, which was second best. Salako et al. in a histopathological study on pulpotomized molar teeth of Spragu–Dawley rats with MTA, BAG, and FC and reported that BAG induces acute inflammatory responses of pulp at 2 weeks, with its resolution of the pulpal morphology, whereas MTA at 2 weeks showed some inflammatory response which has been discussed earlier in context with MTA.[1]

A PubMed searched for the use of BAG as a pulpotomy medicament in human primary teeth did not yield any references. Since no relevant literature could be found, so a retrospective comparison could not be made.

CONCLUSIONS

The clinical results in this were in agreement with the previous studies that had compared different agents for pulpotomy. The success rates of MTA, BAG, and FC reflect their previously proved physical and chemical properties. These clinical findings need to be corroborated with histological findings of experimental study. For definitive conclusion, a larger sample size with clinical, radiographical, and histological investigations into the effects of chemical and physical pulpotomy agents or/are suggestive for future study. Since BAG is a recent development and its use and investigation in pulpotomy procedures for human primary teeth has not been previously studied and hence is recommended for a detailed investigation for further studies in pulpotomy in human primary teeth. Electrocautery pulpotomy is a nonpharmacological and easy technique, but the high cost of equipment is a drawback.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 8

Distribution of swelling in four groups over period of time

Period months	FC (n=20), n (%)	EC (n=20), n (%)	MTA (n=20), n (%)	BAG (n=20), n (%)	P	Significant
3 months	2 (10)	2 (10)	0	0	0.3221	NS
6 months	4 (20)	2 (10)	0	1 (5)	0.1975	NS
12 months	6 (30)	6 (30)	1 (5)	2 (10)	0.0904	NS

FC: Formocresol, MTA: Mineral trioxide aggregate, BAG: Bioactive glass, NS: Not significant