Endodontology Histologic evaluation of pulpotomies in dog using two types of mineral trioxide aggregate and regular and white

Portland cements as wound dressings

Renato Menezes DDS, MS
a ! c d e , ,a

, Clvis Monteiro Bramante DDS, MS, PhDb, Ariadne Letra DDS,

MSc, anessa !raciela !omes Carvalhod and Roberto Brand"o !arcia DDS, MS, PhDe PhD student, Department of Endodontics, Bauru Dental School, University of So Paulo, Bra il Head Professor, Department of Endodontics, Bauru Dental School, University of So Paulo, Bra il PhD student, Bauru Dental School, University of So Paulo, SP, Bra il "S student, #ollege of $eterinary "edicine, University of So Paulo, Bra il Professor, Department of Endodontics, Bauru Dental School, University of So Paulo, Bra il

%eceived &' (cto!er &))*+ %evised &' ,anuary &))'+ accepted - "arch &))'. Bauru and /iter0i, Bra il U/1$E%S123 (4 S5( P6U7( 6/D 47U"1/E/SE 4EDE%67 U/1$E%S123. 6vaila!le online 88 Septem!er &))'.

Abstract #b$ective
2he purpose of this study was to investigate the pulpal response of dogs9 teeth after pulpotomy and direct pulp protection with "26 6ngelus, Pro%oot, Portland cement and white Portland cement.

St%dy design
Seventy:six teeth were treated with these materials. (ne hundred twenty days after treatment, the animals were sacrificed and the specimens removed and prepared for histological analysis.

Res%lts
6ll the materials demonstrated similar results when used as pulp:capping materials. Pulp vitality was maintained in all specimens and the pulp had healed with a hard tissue !ridge.

Concl%sion
2he materials used in this study were e;ually effective as pulp protection materials following pulpotomy.

Article #%tline
8. "aterial and methods &. %esults *. Discussion and conclusion %eferences 2he procedure of pulp capping or pulpotomy relies primarily on the a!ility of pulpal tissue to heal. $arious factors affect this process including age, periodontal condition, and stage of root formation. Procedural factors such as the si e of exposure, its nature <traumatic, mechanical or carious= and micro!ial contamination of the site have also !een descri!ed as determinants of the success of pulp protection.>8.?

6 mineral trioxide aggregate < "26= was studied in a series of investigations, in vivo and in vitro. 2hey reported good sealing a!ility>&. and *.? and tissue healing. >'., @. and A.? 4ormation of new cementum over the material was reported in repair of experimentally perforated furcations, >B.? after root end filling, >&., C. and -.? and in root canal filling of dogs9 teeth. >8).? Bridge:liDe dentin was o!served in cases of pulp capping >A., 88. and 8&.? and pulpotomy >'. and 8*.? in monDey and dog teeth. Eucherpfenning and Freen>8'.? reported that "26 and Portland cement seem almost identical macroscopically, microscopically, and !y x:ray diffraction analysis. 2hey reported that !oth su!stances support matrix formation in a similar fashion in cultures of osteo!last:liDe cells, and also in apposition of reparative dentin when used as direct pulp capping material in rat teeth. (ther studies >8@. and 8A.? affirm that Portland cements contain the same chemical elements as "26. Some of these ingredients are calcium phosphate, calcium oxide, and silica. "26 also contains !ismuth oxide, which increases its radiopacity. 2his is a!sent in Portland cement. Portland cement has great similarity to "26 and offers significant economical incentives if applica!le in !iological systems. 2herefore, the purpose of this study was to evaluate the pulp response of dog9s teeth to & forms of "26, regular Portland cement, and white Portland cement when used as wound dressings after pulpotomy.

&' Material and methods

Seventy:six teeth from ' mongrel dogs 8&:8C months of age were used in this experiment. Under general anesthesia with 2ela ol <4ort Dodge, (verland ParD, Gan= and with a ru!!er dam in place the pulp was mechanically exposed via class $ cavities in canines and incisors and through occlusal cavities in premolars <4ig 8 and 4ig &=. 2he coronal portion of the pulp was removed with a !ur and a surgical spoon. 7ight pressure with sterile cotton pellets and copious irrigation with sterile saline solution was applied to control hemorrhage. 2he pulp wounds were covered with the experimental materials. 2he materials used were "26 6ngelus <6ngelus SoluHIes (dontol0gicas, 7ondrina, Bra il=, Pro%oot <Dentsply, 2ulsa Dental, Ballaigues, Swit erland=, Portland cement <$otorantim:#imentos, So Paulo, Bra il= and white Portland cement <1raJa inho+ $otorantim:#imentos=. 6 total of 8- teeth were used per material. 6ll the animals received the ' materials assigned randomly among incisors, canines and premolars. Portland cement and white Portland cement were previously sterili ed !y gamma rays. 6ll materials were mixed in a *K8 powderLdistilled water ratio and placed on the pulp wound. 7ight pressure was applied with a wet cotton pellet to secure the material. 2he cavities were sealed with #oltosol <#olthene:Ehaledent, #uyahoga 4alls, (hio= and restored with amalgam <SS Ehite, %io de ,aneiro, Bra il=. 2eeth fractured after procedures were removed from the samples

4ig 8. #lass $ access cavities in canine. Pulp tissue covered with Portland cement.

4ig &. #lass 1 access cavity in a premolar. (ne hundred twenty days after treatment, the animals were Dilled and perfused with 8)M !uffered formalin. Sections of the mandi!les were removed and placed in 8)M !uffered formalin !efore deminerali ation in sodium citrate !uffered formic acid. 2issue !locDs were dehydrated and em!edded in paraffin. Serial sections were cut at a setting of A Nm in a !uccolingual direction and stained with hematoxylin and eosin. 2he sections were examined !y & o!servers who were not aware of the source of the specimens. Every sample was evaluated for severity of tissue reactions. 2he type and location of inflammation, presence of necrosis, hyperemia, calcification other than in the area of the !ridge, and regrowth of odonto!lasts. 2he presence and ;uality of the hard tissue !ridge <continuity, morphological aspects, thicDness=, inflammatory reaction <chronic or acute, num!er of cells, and extension of the reaction=, presence of giant cells, particles of capping material, and dentin.

(' Res%lts
6fter 8&) days, the results o!served for the ' materials were very similar. 2he pulp wounds healed with hard tissue formation of considera!le thicDness, completely closing the access cavities. 2he pulp tissue appeared normal. /o pulp necrosis was o!served. 2he tissue reactions were highly favora!le and no difference was o!served !etween any of the ' materials. 1n all specimens, the pulp access openings were closed. 2he coronary third of the root canals were completely closed !y a newly formed homogeneous minerali ed tissue. 6 !asophilic:liDe mass constituting the remnants of the pulp capping materials could !e seen covering the newly formed dentin. 2he pulp tissue was normal and free of inflammatory cells. /o tissue necrosis was noticed. 6 discrete presence of macrophages was also o!served in some cases. See 4ig *, 4ig ' and 4ig @ for details.

4ig *. Pulpotomy with "26 6ngelus. A, Dentin !arrier+ B, "26 6ngelus material used for the pulpotomy+ C, pulp tissue appears normal without inflammatory infiltrate. Htx:eosin <8)O=.

4ig '. Pulpotomy with "26 6ngelus. Higher magnification of 4ig *. Solid dentin !ridge with no tissue inclusions. A, (donto!lasts. Htx:eosin <')O=.

4ig @. Pulpotomy with "26 6ngelus. Higher magnification of 4ig *. A, Pulp tissue healed with a continuous dentin !arrier without tissue inclusions+ B, "26 6ngelus+ C, normal pulp tissue free of inflammation. Htx: eosin <&@O=.

)' Disc%ssion and concl%sion

2he hard tissue formation associated with "26 shows some similarity to healing after pulp capping with calcium hydroxide.>@.? 1t has !een suggested that Portland cement contains the same chemical elements as "26. >8'. and 8@.? 4urthermore, it has !een demonstrated that "26 and Portland cement showed compara!le !iocompati!ility when evaluated in vitro and in vivo. >8B.? 2his suggests that Portland cement has the potential to !e used as a less expensive endodontic wound dressing material. $arious studies>'., A., 88., 8&., 8*. and 8'.? have presented excellent results when using "26 on pulp tissue. (nly & studies reported considera!le success when using Portland cement for conservative pulpal therapy in rats >8'.? and dogs. >'.? (ur results are in agreement with these studies. 2his is the first report on white Portland cement. 2he tissue reaction patterns and cell reactions were identical for Pro%oot, "26 6ngelus, Portland cement, and white Portland cement. 2his is not unexpected, !ecause the high surface pH, especially when these materials are freshly mixed, will cause denaturation of adJacent cells and tissue proteins.>8B.? 2his denaturation includes a few !acteria present in the wound area. 6s the materials set, the pH changes and the cell inJuries su!side. (ur study suggests that "26, Portland cement, and white Portland cement represent !iocompati!le su!strates to which formative cells can attach and produce new soft or hard tissue, preserving pulp vitality. 2his is in agreement with previous data>'.? showing them to !e effective materials for pulp protection. 1t is Dnown that the presence of !acteria is a significant inhi!iting factor for healing of pulp exposures.>8C.? 1n this study, no sections were stained for !acterial presence. 2he Portland cements were sterili ed !y gamma radiation to avoid !acterial contamination and yet preserve characteristics of the materials. 2his might not have !een necessary owing to the high pH of the materials, in which microorganisms are less liDely to survive. 2he a!ility of "26 and Portland cement to support the formation of a dentin !ridge may !e attri!uted to excellent sealing a!ility and fast setting. 2his prevents the diffusion of the material into the tissues, and reduces microleaDage during the healing period.

1t should !e emphasi ed that these pulpotomies were done under ideal conditions+ ie, all teeth were free of caries and pulp inflammation, which may impair the healing. 2herefore, studies under such compromised conditions would !e of great value. 1n a recent study, 6!dullah et al>8-.? o!served that one type of accelerated Portland cement <6P#= is nontoxic and may have the potential to promote !one healing. 2hey also state that further development of 6P# is needed to produce a via!le dental restorative material and possi!ly a material for orthopedic purposes. "26 is commonly used for a variety of endodontic indications !ut the material is expensive and its clinical use is therefore restricted to more affluent patients. 6ccording to many recent clinical and animal studies Portland cement appears to !e an alternative to "26 as the !iologic effects are identical. Such an inexpensive and easily availa!le material could allow very successful pulp treatments in many indigent patient populations. /evertheless, further clinical studies and considerations of limitations and the potential unDnown risDs involved in the use of !uilding materials as medical devices are necessary to define their safe use.

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