Clinical and Computed Tomographic ( Cbct ) Evaluation of Portland Cement Pulpotomy in Primary Molar : A Case Report

The present case describes the clinical & radiographic outcome of a Portland Cement pulpotomy. The 5 years old girl presenting extensive carious exposure in her mandibular left 2nd deciduous molar and was suffering pain in her left lower jaw only on exposure to cold for last 2 days. She was ultimately diagnosed clinic-radio-graphically as a case of irreversible pulpitis. Coronal pulpotomy procedure was carried out in the responsible tooth and Portland cement (PC) was applied as a medicament after pulpotomy. At the 3 & 6-months follow-up appointments, treated tooth was asymptomatic clinically and radiographic examinations revealed no sign of periradicular pathosis in the pulpotomized teeth. Additionally, the formation of a dentin bridge immediately below the PC in the treated tooth was confirmed by RVG and CBCT.

tion, furcal involvement, internal or external pathological root resorption, or patholo gical thickening of the periodontal membrane (fig 1) as well as no clinically detectable increased mobility.A diagnosis of reversible pulpitis of mandibular left 2"d deciduous molar due to caries was made.Since the patient had no systemic pathology or known allergies to the compounds from which PC is made Pulpotomy with Portland Cement (pC) of the tooth was the planed as treatment.    months follow up X-ray, No evidence of periapical lesion, no sign of resorption, formation of a dentin bridge (DB), immediately below the PC; especially in the mesial root of the treated tooth  (6) months follow up radiograph by Radio-Viseo Graphy (RVG).All Gray scale view, multicolor view and 3D view confirrns formation of a dentin bridge (DB), immediately below the PC; especially in the mesial root of the treated tooth.

Fig 6z
Six (6) months follow up radiograph by Cone Beam Computed Tomography (CBCD confirms formation of a dentin bridge (DB), immediately below the PC; especially in the mesial root of the treated tooth.
Treatment Procedure: Disinfection of the operative field and proper sterilization of instruments was ensured.After profound anesthesia and proper Isolation of the teeth, surroundin g cafles was removed by using number-4 new sterile round bur with a high speed hand piece using copious water spray.Then, the roof of the pulp chamber was removed with the same bur running with high-speed hand-piece.
Coronal pulp from pulp chamber was removed manually by using sterile excavator until the orifices of can al are seen.Finally, the pulp chamber was rinsed with normal saline and a small cotton pellet soaked with normal saline was pressed until bleeding was controlled.
Sterilized Portland Cement (PC) was mixed with Bismuth Oxide at a ratio of 4:1.PC was then mixed with sterile water using plastic spatula in a ratio 3:I.The smooth mix was applied over the amputed pulp and into the base of the prepared cavity using a cement lifter.Mixed cement was then condensed properly over the chamber by using a sterile cotton pellet moistened with distilled water.A moist cotton pellet was then placed over the PC and the rest of the cavity was filled with Zinc oxide eugenol cement to allow the PC to set initially.After thour, the cotton pellet was removed; initial setting of the Cement was confirmed by probing its surface.Fuji-IX Glassionomer cement was then placed over the rest of the cavity.
Bite was checked for any high spot and 2 coatsof Varnish were applied over the Glassionomer Filling.A Post opera- tive radiograph was taken (fig Z).Thepatient was recalled on the next day for evaluation and the treated tooth found asymptomatic.
The periodic follow-up examinations were carried out 3 & 6 months after the end of the treatment.Each check-up involved a clinical and radiographic examination of the pulpotomrzed teeth.Clinically, the tooth was asympto- There was no inflammation of the suffounding gingival tissue swelling, sinus tract or mobility and radiographi- cally there was nothing suggestive of internal root resorp- tion and furcation radiolucency.All these were deter- mined as the criteria of success by Sakai et alre The clinical and radiological findings of the present case also came out with similarity when observing the study carried out by Conti et a1.22The clinical and radiological evaluation of three primffiy molars after Portland cement pulpotomy by Conti et al22 reveals that these 3 teeth remained asymptomatic and vital with the formation of dentin bridge immediately below the PC.
However, present case differs with the study by Conti et aL22 in respect of time needed for dentin bridge formation.
Conti et al22 when comparing pulpotomy of 30 human primary molar with MTA & PC, dentin bridge deposition was radiographically detected in all available teeth at 6 months after placement.In the present case a hard tissue barrier was observed immediately below the PC after 3-month follow-up, which was confirmed at the 6-month follow-up appointment.But faster pulp tissue reactions with afi earlier formation of the mineraltzed barrier "is supported by the study of Barbos a20 and Sampaio.zrBoth of them found a faster pulp tissue reactions with an earlier formation of the min eralized barrier over the capped pulp when used PC as a pulp capping material.While it has been claimed that minimum time requirement for the induced hard tissue barrier formation is 6 week.23The success of PC utilizatron may be explained by the strong initial stimulus, able to cause an immediate response of osteo-dentin formation in an attempt to isolate the remain- ders of the pulp from the action of the mateial.2a The beginning of mineralized deposition could be radio- graphically detected in I007o of the teeth treated with PC and 57 .I4vo of the teeth treated with MTA25, whereas after MTA pulpotomy Soares2s reported 89.287o,Hollad et al.la and by Pitt Ford et a126 reporte d 1007o complete tubular bridge & 84.6Vo complete tubular dentin bridge formation was reported after PC-pulpotomy; Although The dentinal bridge formation in the present case was finally evaluated by CBCT but the type of the bridge could not observed histologically, as the patient was too younger for exfolia- tion of the tooth.
Portland cement in its natural state is slightly radio opaque but it fails to meet the ISO requirement for radiopacity.
The lack of radiopacity in pure PC is due to the absence of bismuth, a chemically inert radiopacifier, in its compositionT.To overcome this disadvantage, and radiopacifier additions have been carried out in this case.
Comparing different radiopacifier, bismuth oxide presented the highest radiopacity value than that of dentin & may potentially be added to the Portland cement as radiopacifyin g agent2T .The compressive strength of PC is not altered with 207o bismuth oxide, and the material continues to be biocompitablelo .
A major concern regarding the use of water-based cements is the amount of leachable arsenic present in the material.Arsenic are impurities of limestone that is used in the manufacture of PC 12. Duarte, et a1.28 showed that the concentration of arsenic is in PC (0. OO7 mglkg body wt after 3 h and 0.006 mglkg body wt after 168 h.) is below the toxic level (140-210 mglkg body wt) and below the toxic levetr (L40-210 mglkg body wt) and closely similar to that present in MTA(0 .002mglkg body wt) .Moreover, the highest content does not necessarily indicate a gre atrcIease demonstrate no contraindication of the use of that material in clinical practice concerning the presence of this chemical element.In my case, the patient was clinically assessed in every follow-up and no sign of arsenic poisoning was detected by this time.

Conclusion :
The Clinical and Radiographic evaluation of Portland cement pulpotomy result a successful outcome in the present case.Combining scientific information, human health and social value which are very encouraging.But before unlimited clinical use, further studies with large samples and long follow-up assessments are needed. t42

Fig 1 :
Fig 1: Preoperative X-ray showing Tooth no 65 having deep carious lesion extending upto pulp horn but no sign of periapical lesion.

Fig
Fig 2z Immediate post operative X-ray, pulpotomry carried out, pulp chamber filled with radio-opaque Portland cement and restorative Gl,ass lonomer filling material

Fig 3 :
Fig 3: Three (3) montls follow up X-ray, No evidence of periapical lesion, no sign of resorption.Initial formation of dentin bridge immediately below PC observed.

Fig 5 :
Fig 5: Six(6) months follow up radiograph by Radio-Viseo Graphy(RVG).All Gray scale view, multicolor matic and functioning.Radiographic examinations revealed formation of a dentin bridge, immediately below the PC; especially in the mesial root of the treated tooth (fig 3 & 4).The dentin bridge was confirmed by RVG & CBCT at 6 months follow-up period (fig 5&6).Discussion :Pulpotomy with Portland cement as medicament in the present case resulted in an uneventful post operative condition immediately and over a period of six months.