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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 68-72

Comparative evaluation of three different an obturating materials in pulpectomy; An in vivo study


1 Department of Conservative and Endodontics, St. Joseph Dental College, Duggirala, Eluru, Andhra Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Mallareddy Dental College for Women's, Secunderabad, Telangana, India
3 Private Practitioner, Hyderabad, Telangana, India
4 Department of Oral Pathology, Army College of Dental Science, Secunderabad, Telangana, India

Date of Submission05-Jan-2020
Date of Decision03-Feb-2020
Date of Acceptance01-Mar-2020
Date of Web Publication21-May-2020

Correspondence Address:
Kola Srikanth Reddy
Department of Pedodontics and Preventive Dentistry, Mallareddy Dental College for Women's and Hospital, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_1_20

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  Abstract 


Objectives: The aim of this study was to clinically evaluate, radiographically zinc oxide eugenol (ZOE) paste, metapex, and Alo vera gel with zinc oxide powder as root canal filling material in primary teeth. Methodology: In the present study, pulpectomies were performed on 51 primary second molar in 55 children, aged between 4 and 9 years, of these, 24 children were randomly divided into three groups of 17 teeth each selected for endodontic treatment. Obturation was done with a mixture of ZOE paste, metapex and A. vera gel with ZOE powder. Clinical, radiographic evaluation was done after 3 months, 6 months, and 12 months. Data were analyzed using Fisher's exact test and Cochran's Q-test, and the value of P was set at 0.05. Results: The three pastes achieved convergent clinical and radiographic success within the three observation periods (P > 0.05). ZOE paste was the slowest in its resorption. Conclusion: Zinc oxide powder with A. vera gel can be used as alternatives to ZOE and metapex.

Keywords: Alo vera gel, metapex, primary teeth, pulpectomy, zinc oxide eugenol


How to cite this article:
Goinka C, Reddy KS, Ganapathi A, Nallagula K H, Kondapaneni A, N. Sunil V V. Comparative evaluation of three different an obturating materials in pulpectomy; An in vivo study. Indian J Dent Sci 2020;12:68-72

How to cite this URL:
Goinka C, Reddy KS, Ganapathi A, Nallagula K H, Kondapaneni A, N. Sunil V V. Comparative evaluation of three different an obturating materials in pulpectomy; An in vivo study. Indian J Dent Sci [serial online] 2020 [cited 2020 Jul 4];12:68-72. Available from: http://www.ijds.in/text.asp?2020/12/2/68/284662




  Introduction Top


Pulp therapy for pulpally involved primary teeth continues to be a challenge to clinicians. The success of pulpectomy depends on accomplishment of all operative procedures following specific treatment guidelines and the choice for biocompatibility materials. It can also produce negative impacts on the child's oral health-related quality of life through pain, difficulty in mastication, and absentia from school.[1]

An obturating root canal filling material for primary teeth should be antibacterial, resorble at the same rate of the root, non –inflammatory and non irritating to the underlying permanent tooth germs, and harmless to the periapical tissues and successive developing tooth buds, easy to insert, must adhere to walls, must not shrink, must readily resorb if passed beyond the apex, be easily removed when needed, be radio-opaque, and cause no discoloration of the tooth. At present, there is no such ideal material that meets all the requirements.[2],[3]

Conventionally, zinc oxide eugenol (ZOE) has been the material of choice for filling the root canals of deciduous teeth,[4] and until 2008, it was the only material explicitly recommended in the clinical guidelines development by the American Academy of Pediatric Dentistry (AAPD).[5] In 2009, based on studies recently published, the AAPD Guidelines currently, there is a growing preference for using iodoform paste and Ca (OH)2 (metapex and Vitapex)[6],[7] instead of ZOE paste[8] probably because of its irritant to potential to periapical tissues and slow resorption.[2]

Numerousin vitro studies have proved the efficacy of Alo vera as a good antibacterial agent against resistant microorganisms found in pulp space and its effective role in bone regeneration. Hence, A. vera has shown to be a promising obturate material in primary teeth.[9],[10],[11]

However, there is a paucity of studies on A. vera and its prognosis as an obturating material. Hence, the purpose of this study was to evaluate the role of A. vera gel with zinc oxide powder as an alternative to other traditional obturating material by comparing it with ZOE and metapex in primary molars.

Objectives

  1. Clinical evaluation of the ZOE, zinc oxide powder with A. vera gel, and metapex in primary second molars as an obturating material in pulpectomy at different time intervals
  2. Radiographic evaluation of the ZOE, zinc oxide powder with A. vera gel, and metapex as an obturating material in pulpectomy at different time intervals.



  Methodology Top


The study design was approved by the Institutional Ethical Committee; the purpose of the study was explained to the parents and written informed consent was obtained from parents before start of the study. A total of 51 primary second molars with chronic infection were included from 50 child patients, aged between 4 and 9 years, who attended the pediatric dentistry department from March 2017 to May 2018.

Clinical characteristics, defined as spontaneous pain and the presence of a deep carious lesion with pulp exposure and bleeding that did not halt within five minutes following removal of the coronal pulp tissue. Gingival abscesses or fistula openings were absent or present. Abnormal mobility was requested. On radiographic evaluation, there were discontinuing in lamina dura, limited furcation, or apical radiolucency which were included in the study. The intake of antibiotics within 2 weeks before the treatment, presence of a fistula, extensive root resorption, inadequate bone support, or hypermobility, medically compromised children, and any history of drug allergy were exempted from the study. The selected samples were randomly assigned into the following three groups:

  • Group 1 (17 teeth): The root canals of patients of this group were obturated with ZOE paste. (Vishal Dentocare Pvt., Ltd., Gujarat) (control group)
  • Group 2 (17 teeth): The root canals of patients of this group were obtained with A. vera gel with zinc oxide powder (DPI, Mumbai, India, 0.2 g arsenic free) (experimental group)
  • Group 3 (17 teeth): The root canals of patients in this group were obturated with metapex. (Meta Biomed/Korea), (experimental group).


Procedure

Baseline preoperative clinical and radiographical signs and symptoms were recorded. The teeth were anesthetized using 2% lignocaine with 1:80,000 adrenalin and isolated with a rubber dam. The preparation of zinc oxide powder and A. vera gel was mixed on a mixing pad with the help of stainless steel spatula and the mixing ratio of zinc oxide powder and A. vera gel was 1:2 [Figure 1].
Figure 1: Mixing of ZnOE and Alo vera gel

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Access opening was performed using round bur and both coronal pulp and radicular necrotic pulp were extirpated using barbed broaches [Figure 2]. Biomechanical preparation was done using K-files from size ≠ 10 to ≠ 25. The root canals were chemically cleaned with 5.25% sodium hypochlorite solution and distilled water and dried with paper points (size 25). Then, the filling paste was inserted in the root canals according to each group: ZOE and A. vera gel with zinc oxide powder and metapex group with the help of pluggers and reamers. Radiographic confirmation was done. Then, access cavity was restored with Type 11 glass ionomer cement (GC Corporation, Tokyo, Japan) and further reinforced by placing stainless steel crowns (3M/USA). Patients were recorded after 3 months, 6 months, and 12 months [Figure 3], [Figure 4], [Figure 5], [Figure 6].
Figure 2: Local anesthesia

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Figure 3: Radiological evaluation of ZnOE group after 3, 6, and 12 months

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Figure 4: Radiological failures seen in ZnOE group

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Figure 5: Radiological evaluation of Alo vera and ZnOE group

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Figure 6: Radiological failure seen in Alo vera and ZnOE group

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Criteria for success

Further, these treated teeth were reevaluated both clinically and radiographically at 3rd, 6th, and 12th month intervals postoperatively. During reevaluation, the clinical success was based on the presence of normal mucosa without abnormal mobility, pain, or sensitivity to percussion. Radiographic success was associated with a decrease in the size of radiolucency and the presence of bone regeneration. If the radiolucency remained stable without remarkable changes, the treatment was classified as suspected and required further observation.

Treatment failure was classified into two degrees as (a) the radiolucency slightly increased in size, but it was separated from succeeding bud with adequate bone and (b) the radiolucency threatening the succeeding buds, so the tooth was extracted.[12]

The treated molars were evaluated double blindly by three observers, and the result was determined by an agreement of at least two observers.

Statistical analysis

Statistical analysis of the results for the clinical and radiographic evaluation between the three groups was analyzed using Fisher's exact test and Cochran's Q-test using Microsoft Excel software (SPSS-17.0, SPSS Inc., Chicago, IL, USA). A P < 0.05 was considered statically significant.


  Results Top


Comparison of clinical outcome with three materials

[Table 1] and [Graph 1] represent the comparison of clinical outcome with three materials; at the end of 12 months, ZOE and metapex showed 100% clinical success. There were no significant differences between the groups (P = 1.00).
Table 1: Comparison of clinical results with the three materials

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Comparison of radiological outcome with three materials

[Table 2] and [Graph 2] represent the comparison of radiological outcomes with three materials. At the end of 12 months, ZOE, A. vera, and metapex showed 75%, 50%, and 68.75%, respectively, radiographic success. The differences between the groups were not statistically significant (P = 0.306).
Table 2: Comparison of radiographic out come with the three materials

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Comparison of resorption of the filling pastes compared with root resorption

[Table 3] represents that A. vera gel with zinc oxide powder was corresponding with root resorption in 43.8% of the cases and faster than root resorption in 56.3%. Hence, ZOE resorption was most appropriate for comparing with the other pastes in this study.
Table 3: Resorption of the filling pastes compared with root resorption

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  Discussion Top


The present study showed high clinical success, and there was no statistically significant difference between the three groups, which was similar to various studies done by Ozalp et al.[13] Subramaniam and Endoflas[14] Nurko and Godoy[15] and Mortzavi and Mesbahi and Khairwa et al.[16]

Across all studies, the clinical success rates were as follows: 70%–100% for Ca (OH)2/iodoform, 77%–100% for ZOE, 57%–100% for ZOE/iodoform, and 88%–100% for ZOE/iodoform/Ca(OH)2.

The radiographic success rates were 61%–100% for Ca (OH)2/idoform, 75%–100% for ZOE, 79%–100% for ZOE/iodoform, and 81%–100% for ZOE/iodoform with Ca(OH)2.

The results of the present study show that ZOE was the most effective obturating material both clinically and radiographically; metapex, though is easier to dispense into the root canal, had least success rate with no clinical and five radiographic failures. Although ZOE success rate is very high, various disadvantages like cytogenecity, mutagenecity, soft-tissue irritation, and deflection of succedaneous teeth in overfilled teeth should be kept in mind.

Root canal filling material of primary teeth should be resorbed at an identical rate, or as similarly as possible, to that of physiological root resorption. This study used ZOE paste, Metapex and Alovera gel with Zinc oxide powder. Our results indicated that Alovera gel with Zinc oxide powder was substituted for Eugenol and reported that good clinical and radiographic success rates. Hence, these materials can be used as alternatives to ZOE paste, Metapex.

Barcelos et al. in their systematic review showed that ZOE pulpectomies success rate varied from 85% to 100%.[8] Bahrololoomi and Zamaninejad showed that a two-visit pulpectomy in 76 primary molars with ZOE had an overall success rate of 93.4% in a follow-up study ranging from 6 to 59 months.[17] Interestingly in the present study, clinical and radiographic success of ZOE was highest at 100%.

The high percentage of success for ZOE was independent of variables such as age of the patient, resorption stage of the root, and type of molar as more than two-third of ZOE pulpectomies were done in the higher age group of 4–9 years and in teeth with considerable amount of root resorption.

In 2009, the AAPD Guidelines cited iodoform-based pastes as suitable alternatives to ZOE.[18] Metapex is a combination of 30.3% calcium hydroxide, 40.4% iodoform, and 22.4% silicone oil. The mixture can be dispensed into the root canals using disposable tips. The silicone oil content of metapex neutralizes the alkalinity of the paste to a certain extent, thereby causing lesser injury to the periapical tissues.[19] Machida (1983) cited in Gupta and Das considered calcium hydroxide-iodoform mixture (metapex) to be an ideal pulpal filling material for primary teeth but reported that it resorbs a little faster than the rate of normal physiologic root resorption.[12] Gupta and Daset al. showed overall success rates of 85.71% and 90.48% for ZOE and metapex pulpectomies, respectively, in children aged 4–7 years of age over a 6-month follow-up.[12]

In the present study, metapex showed 100% clinical success and 68.75% radiographic success and the overall success was 92.1%. In the present study, no clinical failures (mobility) and five radiographic failures (internal resorption) were reported with metapex at the end of the study. Only 12 teeth f the total 17 belonged to the age group of 4–9 years and only 6 teeth showed one-third of root resorption in the metapex obturated group. The clinical success declined from 100% at 3 months to 89.4% at 6 months which was statistically significant (P = 0.008). Similarly, the radiographic success declined from 100% at 3 months to 78.9% at 6 months which is highly statistically significant (P < 0.001).

Extrusion of the material was observed in six teeth obturated with metapex. Although it was beyond the scope of the study, it was observed that metapex resorbed both intra-radicularly and also when it extruded beyond the apex.

Limitations

However, further longitudinal study involving a larger sample size and longer follow-up period ranging from 12 to 18 months is necessary to confirm the clinical, radiological, and histological success of the three obturating materials until their eventual exfoliation.


  Conclusion Top


Zinc oxide powder with A. vera gel can be used as alternatives to ZOE and metapex. ZOE and metapex can be recommended in daily practice as they have better antimicrobial property and resorbtion of only extruded materials.

Hence, based on the observations from the present study, this knowledge can be applied to our daily clinical practice and more randomized clinical trials should be conducted in the field of observation materials.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jha M, Patil SD, Sevekar S, Jogani V, Shingare P. Pediatric obturating materials and techniques. J Contemp Dent 2011;1:27-32.  Back to cited text no. 1
    
2.
Huang TH, Hung CJ, Chen YJ, Chien HC, Kao CT. Cytological effects of primary tooth endodontic filling materials. JDS 2009;4:18-24.  Back to cited text no. 2
    
3.
Silva LA, Leonardo MR, Oliveira DS, Silva RA, Queiroz AM, Hernández PG, et al. Histopathological evaluation of root canal filling materials for primary teeth. Braz Dent J 2010;21:38-45.  Back to cited text no. 3
    
4.
Nadkarni U, Damle SG. Comparative evaluation of calcium hydroxide and zinc oxide eugenol as root canal filling materials for primary molars: A clinical and radiographic study. J Indian Soc Pedod Prev Dent 2000;18:1-10.  Back to cited text no. 4
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5.
American Academy on Pediatric Dentistry Clinical Affairs Committee-Pulp Therapy subcommittee, American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on pulp therapy for primary and young permanent teeth. Pediatr Dent 2008;30:170-4.  Back to cited text no. 5
    
6.
Dunston B, Coll AJ. Survey of primary tooth pulp therapy as taught in US dental schools and practiced by dilpomates of the American Board of Pediatric Dentistry. Pedaitric Dent 2008;30:42-8.  Back to cited text no. 6
    
7.
Bergoli AD, Primosch RE, de Araujo FB, Ardenghi TM, Casagrande L. Pulp therapy in primary teeth – Profile of teaching in Brazilian dental schools. J Clin Pediatr Dent 2010;35:191-5.  Back to cited text no. 7
    
8.
Barcelos R, Santos MP, Primo LG, Luiz RR, Maia LC. ZOE paste pulpectomies outcome in primary teeth: A systematic review. J Clin Pediatr Dent 2011;35:241-8.  Back to cited text no. 8
    
9.
Khairwa A, Bhat M, Sharma R. Clinical and radiographic evaluation of zinc oxide with Aloe vera an obturating material in pulpectomy: Anin vivo study. JISPPD 2014;32:33.  Back to cited text no. 9
    
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Kriplani R, Hosar N, Baliga MS, Karmip K, Shah N, Yeluri R. Comparative evaluation of antimicrobial efficacy of various root canal filling material along with Alo vera used in primary teeth. A microbial study. JCPD 2013;37:257-82.  Back to cited text no. 10
    
11.
George D, Bhat SS, Antony B. Comparative evaluation of the antimicrobial efficacy of Alo vera tooth gel and two popular commercial tooth paste. Anin vivo study. Gen Dent 2009;238-41.  Back to cited text no. 11
    
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Gupta S, Das G. Clinical and radiographic evaluation of zinc oxide eugenol and metapex in root canal treatment of primary teeth. J Indian Soc Pedod Prev Dent 2011;29:222-8.  Back to cited text no. 12
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13.
Ozalp N, Saroǧlu I, Sönmez H. Evaluation of various root canal filling materials in primary molar pulpectomies: Anin vivo study. Am J Dent 2005;18:347-50.  Back to cited text no. 13
    
14.
Subramaniam P, Endoflas GK. Zinc oxide eugenol and metapex as root canal filling materials in primary molars – A comparative clinical study. J Clin Pediatr Dent 2011;35:365-9.  Back to cited text no. 14
    
15.
Nurko C, Godoy FG. Evaluation of Ca(OH)2 idoform paste (vitapex) in root canal treatment of necrotic primary teeth. JOCPD 1999;23:289-94.  Back to cited text no. 15
    
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Mortzavi M, Mesbahi M. Comparision of ZOE and vetapex for root canal treatment of necrotic primary teeth. Int J Pediatr Dent 2004;14:417-24.  Back to cited text no. 16
    
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Bahrololoomi Z, Zamaninejad SH. Success rate of zinc oxide eugenol in pulpectomy of necrotic primary molars: A retrospective study. J Dent Mater Tech 2015;4:89-94.  Back to cited text no. 17
    
18.
Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. Pediatr Dent 2016;38:280-8.  Back to cited text no. 18
    
19.
Praveen P, Anantharaj A, Venkataragahavan K, Rani SP, Sudhir R, Jaya AR. A review of obturating materials for primary teeth. Stream Dent 2011;1:1-4.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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