Dental Tribune Middle East & Arica Edition

DENTALTRIBUNE Middle East & Africa Edition Media CME 7 According to the literature, N2 VA on deciduous teeth ren- ders significantly better results thanCa(OH)2pulpotomy.There- fore, Frankl performed N2 pulpo- tomies on permanents as well.19,20 He selected only asymptomatic teeth whose pulp had been accidently exposed for treatment. The treatment was performed under a rubber dam and thus pulp bleeding did not have any effect. Two hundred andfiftycaseswerere-examined for up to 13 years. The age of the patients ranged between 22 and 55 years. Failures manifested by pain within 48 hours amounted to 2 %. The aim of the following study was to analyse the success andfailureratesofN2VAsonper- manent molars, and to compare theserateswithvitalmolarextir- pations done within the same pe- riod. Material and method The study was conducted in my dental practice, which is lo- cated in a rural area. Between 1992 and 1998, 795 VAs and 945 vitalextirpations(VEs)wereper- formed on molars. After treat- ment, 85 VA and 93 VE patients did not return to the practice and were thus excluded from the study, leaving 710 VAs and 852 VEs for analysis. During the treatment period, only N2, which was approved by the district president of Düssel- dorf, Germany, on 8 February 1990, was used as therapeu- tic agent (see Table II for composi- tion). The root canals were pre- pared according to the N2 method: relative isolation, no root-canal rinsing and root- canal preparation with reamers only.21 For the RCF, N2 mixed to a creamy consistency was ap- pliedwithalentulospiral.TheVA cavities were prepared 1 to 2 mm into the canals. N2 mixed to a pastewas insertedintothecavity with a filling instrument and lightly pressed with cotton. Mi- nor bleeding was irrel- evant. In cases of heavier bleeding, the in- serted N2 was removed after a few minutes and then replaced with freshly mixed N2. A syn- thetic closure of the cav- ity per- formed within the same sitting required a lining, which is not necessary for an amalgam clo- sure. X-ray controls were later viewed at double and sevenfold magnification. The apical condi- tion was differentiated as fol- lows: apically without patholog- ical findings, apically uncertain and apically pathological. The root with the worst apical find- ingswasevaluated.Thiswasalso applicable for the classification of RCF levels. Failures without accompany- ing X-rays were termed Mi1 and failures with accompanying X- rays were termed Mi2. The total failurepercentagewasnotdeter- mined by simply adding Mi1 and Mi2, but by adding the number of Mi1s to the number of X-rays taken.Thepercentageoffailures was then determined from this sum. The statistical analysis was performed using SPSS (version 18). Results OftheVApatients47.6%were male and of the VE patients 52.4 % were male. The practice owner treated 70.1 % (n = 498) of the VA pa- tients and 49.1 % (n = 418) of the VE patients and all the rest were treated by an assistant. The aver- age age of VA patients was 34.6 years and that of VE patients was 30.6 years. The average observa- tion period was 53.8 months (max. 165) for VAs and 49.4 months(max.169)forVEs.Ofthe 710 VA cases 504 (71 %) and of the 852 VE cases 496 (58.1 %) were subject to follow-up X-ray controls. A total of 61 VA and 77 VE fail- ures were registered and classi- fied as without accompanying X- ray (Mi1) or with accompanying X-ray(Mi2).Fifty-oneofthe61VA failures were followed-up with X-rays. Not all of the accompany- ing X-rays of the Mi2 failures re- vealed a failure. Two VA failure X-rays and ten VE failure X-rays were wrongly evaluated as negative. Ten VA Mi1 cases were removed be- cause of pain, three of them within a few hours after VA. In two cases, a granuloma at an extracted root was indicated in the patient files. In two addi- tional cases, the extraction fol- lowed after six and 11 days. In 12 of the 16 VE cases, extractions were performed because of pain (one day to 21 months after VE). Patients who visited the practice after pulpotomy made positive a negative reference to anamnes- tic symptomatic pain 241 times and 157 times, re- spectively. Subsequently, the failure rate was 10.8 % (n = 26) in the first case and 7.0 % (n = 11) in the latter case. The difference was in- sig- nificant statistically (p = 0.114). The failure diagnosis after VA wasmostfrequentlymadeforthe lower second molar (18.5 %) and after VE for the lower first molar (19 %). The lower wisdom teeth were conspicuous because the failure rate was only 4.7 % after VA, and no failure at all was ob- served after VE. Not every failure diagnosis led to therapeutic con- sequences such as extractions. Altogether, 206 (28.6 %) VA and 123 (14.4 %) VE teeth were extracted during the follow-up phase (very statistically signifi- cant difference; p = 0.000). The largest number of extractions, namely51.9%(n=107)oftheVAs and 46.3 % (n = 57) of the VEs, were performed because the teeth had been destroyed or frac- tured. The lower wisdom teeth were the most frequently af- fected in the case of pulpotomy (61.8 %; n = 21) and the upper second molars in the case of VE (64 %; n = 16). A failure was decisive for the removal of 23.3 % (n = 48) of the extracted VA teeth and 36.6 % (n = 45) of the extracted VE teeth. Most frequently extracted due to failure were the vitally ampu- tateduppersec-ondmolars(34.8 %; n = 8), and the vitally extir- pated lower second molars (54.2 %; n = 13). The lower wis- dom teeth (34 extractions (n = 3; 8.8 %) in the pulpo- tomy group) and the upper second molars (42 ex- trac-tions(n=13;31%)intheVE group) were extracted least of- ten. The VE and VA results are shown in Tables III and IV. Furthermore, the question of whether the RCF level following VE had any significance with re- gard to the failure rate was pur- sued. The RCF levels were di- vided into three levels. The total failures of these three groups were calculated as described un- der material and method (Table V). Without considering the indi- cation range, anamnestic symp- toms, tooth position and RCF level, the total failure rate was 11.9 % for VAs and 15 % for VEs (statistically insignificant; p = 0.644). The VE failure rate of the RCF level of -4, -3 corresponded exactly to the VA failure rate of 11.9%.Therewasnostatistically significant difference (p = 0.226) in fail- ure between RCF levels - 4,-3and-2,-1,0.TheRCFlevelof -5 showed significantly more failures com- pared with the RCF levels of -4, -3 (p = 0.020) and -2, -1 , 0 (p = 0.002). Discussion A direct comparison between VAs and VEs, espe- cially as re- gards incomplete root fillings, was only possible within limits, as the number of VAs consisted mainly of a negative selection, which otherwise would have been entrusted to the pliers. The twice as high extraction fre- quencyofvitallyamputatedteeth compared with that of vitally ex- tirpated teeth (28.6% versus 14.4 %) may be attributed to the ad- verse base- line situation. Frac- turedordestroyedteethwerethe reason for extraction for 51.9 % of all extractions in the case of VAs.ForVEs,thisratewas46.3%. However, the extraction reason “endodontic failure” was attrib- uted in 36.6 % of the extractions totheVAteethandin23.3%ofthe VE teeth. Anamnestic pain causing an increased frequency of failure in VA cases, which was also ob- served by Teixeira et al. follow- ing Ca(OH)2 treatment,7 was statistically in- significant. Stern3 und Frankl19,20 also point out increased pain follow- ing VA. This was observable dur- ing our study as well. Neverthe- less, the total failure rate for vi- tallyampu-tatedteethwaslower (11.9 %) than the average rate of 15.1 % for vitally extirpated teeth. The evaluation of pulpotomy cases only with ac- companying X-rays revealed a failure rate of 10.1 %, which is comparable to the 9 % Fisch encountered with the Triopaste.17 Frankl reports only 2 % of fail- ures after N2 VA, al- thoughhehaddonestrin- gent case selec- tion.19,20 In contrast, the radiological-pathologi- cal find- ings concerning eugenol pulpotomies in pain-freeteethamounted to 58 % after 12 months.4 Fifty per cent of all Ca(OH)2 pulpotomies of aching teeth resulted in failure after six to eight months.7 Massler et al. observed a total fail- ure of 65 %, two to five years after Ca(OH)2 VAs.12 The correlation between failure and RCF level follo- wing VEs was investigated. Ade- quately filled teeth (-2,-1 adapicem) showed a failure rate of 8.9 %, heavily un- derfilled teeth a rate of 22.1 %. Hence, the conclusion may be drawn that the success rate of VAs corre- spondstotheoneofproperlyper- formed root fillings following VEs, and is far superior to a no- ticeably underfilled root filling. Molven attributes a more favourable peri-apical situation to pulpotomized than to root- filled roots.14 In their study, Asgary and Eghbaldonotexplainthetechni- cal performance of the RCF.15 However, they es- tablish that pulpotomies are statistically sig- nificantly superior to RCTs of vi- tal molars, although radiological failure is neither defined nor nu- merically expressed. Addition- ally, the follow-up time of six months is considered very brief. Summary A comparison of 710 N2 VAs and 852 N2 root- filled molars af- terVEwasdone.Theaveragefol- low- up period was 53.8 months forVAsand49.4forVEs.Thetotal failure rate (radiological and clinical) was 11.9 % following VAs,whichisequivalenttothatof VEs with slight underfilling (RCF level -4, -3). Ade- quately filled root canals led to fewer failures (8.9 %) than VAs. With a failure rate of approximately 19 %, the lower first VE- and second VA- molars were most frequently af- fected. During the follow-up period, 28.6 % of all VA and 14.4 % of VE teeth were ex- tracted. Fractured or de- stroyed teeth were the reason for extrac- tion in 51.9% of all VA and in 46.3 % of all VE cases. The extraction reason “endodontic failure” oc- curred less frequently after VA (23.3 %) than VE (36.6 %). For the practice Thepatientshouldbeadvised of possible pain fol- lowing the subsiding anaesthetic effect. AnalgesicsareindicatedafterVA. An N2 VA is more successful than an insufficient root filling after VE. Vital ampu- tation is indi- cated in cases of almost inacces- sible canal systems, open apical foramina andforeco-nomicrea- sons. Insteadofanextractionorthe impossibility of a VE with ade- quate root filling, it is possible to consider— besides a full pulpo- tomy, which was the subject of the present study—a partial pulpotomy on: _ upper molars: VA of the buc- calcanals,fillingofthepalati- nal root; _ lowermolars:VAofthemesial canals, filling of the distal root; and _ deep crown margin caries, partial removal of the pulp cavum. I II III Failure IV V VI Tooth Recall Extraction X-ray post VA IV a Mi 1 IV b Mi 2 IV c Mi 3 X-ray + Mi 1 Fail. n n % n % n % n n % n n % 16/26 109 98 89.9 23 23.5 73 74.5 1 7 9.6 8 74 10.8 17/27 202 179 88.6 45 25.1 127 70.9 3 9 7.1 12 130 9.2 18/28 112 100 89.3 41 41.0 72 72.0 2 9 12.5 11 74 14.9 36/46 118 111 93.2 28 27.0 78 70.3 2 8 10.3 10 80 12.5 37/47 140 123 87.6 35 37.8 90 73.2 2 15 16.7 17 92 18.5 38/48 114 99 86.8 34 34.3 64 64.6 – 3 4.7 3 64 4.7 795 710 89.3 206 28.6 504 71.0 10 51 10.1 61 514 11.9 Table IV_Summarised VA results. I II III Failure IV V VI Tooth Recall Extraction X-ray post VE IV a Mi 1 IV b Mi 2 IV c Mi 3 X-ray + Mi 1 Fail. n n % n % n % n n % n n % 16/26 269 241 89.6 42 17.4 142 58.9 3 22 15.5 25 145 17.2 17/27 168 152 90.5 25 16.4 89 58.6 4 7 7.9 11 93 11.8 18/28 5 5 100 1 20.0 2 40.0 – – – – 2 – 36/46 274 249 90.9 24 9.6 148 59.4 4 25 16.9 29 152 19.0 37/47 201 177 88.1 25 14.1 97 54.8 3 9 9.3 12 100 12.0 38/48 28 28 100 6 21.4 18 64.3 – – – – 18 0,0 945 852 90.2 123 14.4 496 58.2 14 63 12.7 77 510 15.1 Table III_Summarised VE results. I RCF level X-ray + Mi1 Failures n n % -5 195 43 22,1 -4, -3 194 23 11,9 -2, -1, 0 124 11 8,9 Table V_VE failures of molars according to RCF levels. 1st group (31 teeth) 2nd group (6 teeth) (no pathological findings radiographi- cally, no anamnestic pain) 17 teeth with complete root growth, 14 teeth with incomplete root growth 3 with periodontal gap enlargement – 2 of them with pain, 3 with apical ostitis, 5 teeth with complete root growth, 1 tooth with incomplete root growth. Table I P Powder Liquid Zinc oxide 63.0 % Titanium dioxide 3.6 % Bismuth subcarbonate 10.0 % Bismuth subnitrate 15.0 % Paraformaldehyde 7.0 % Red lead (lead oxide) 1.4 % Eugenol 77.0 % Rose oil 1.8 % Lavender oil 1.2 % Peanut oil 20.0 % Table II I