a major goal in pediatric dentistry is to maintain primary dentition in an intact state until permanent successors erupt .
primary dentition is essential for maintenance of arch length , mastication , speech and esthetics and prevention of abnormal oral habits .
this does not mean that tooth needs removal ; it can be retained in oral cavity in a functional state with appropriate treatment .
this is accomplished through various procedures which include indirect pulp capping , direct pulp capping , pulpotomy , pulpectomy and apexification .
pulpotomy is a procedure performed in a tooth with deep carious lesion adjacent to pulp , where coronal pulp is amputated to preserve the vitality of radicular pulp .
a wide range of materials such as formocresol ( fc ) , glutaraldehyde , ferric sulfate , zinc oxide eugenol and calcium hydroxide have been used over the years for pulpotomy .
fc has been a popular pulpotomy medicament in primary dentition for the past 60 years .
concerns have been raised about the toxicity and potential carcinogenicity of fc in humans.[46 ] studies have demonstrated systemic uptake of fc from pulpotomized teeth and have also shown fc to produce defects in succedaneous teeth . alternative technique and pulp therapy agents have been proposed to maintain partial pulp vitality .
these include glutaraldehyde , electrosurgery , laser , freeze - dried bone , bone morphogenic protein , osteogenic protein and mineral trioxide aggregate ( mta ) . in recent times , with the introduction of new materials , which are not only biocompatible but also bioinductive , the emphasis has shifted from mere preservation to regeneration .
mta attracted attention in the field of endodontics with its excellent sealing ability , biocompatibility , and ability to form dentinal bridge , and cementum and periodontal ligament regeneration .
mta has the ability to stimulate cytokine release from bone cells , indicating that it actively promotes hard tissue formation .
it has also been proved that mta has antimicrobial properties similar to zinc oxide eugenol ( zoe ) and has no cytotoxic effect .
mta has been proposed as a potential medicament for pulpotomy procedure , capping of pulps with reversible pulpitis , apexification , repair of root perforation and repair of resorptive defects .
hence , the present study was conducted with an aim to assess clinically and radiographically the effects of mta as a pulp dressing after coronal pulp amputation in human primary molars and compare them to those of fc .
the procedure , possible discomfort and benefits were explained fully to parents of the children involved and their written consent was obtained prior to the treatment .
normal , healthy and cooperative children for the study were selected from the patients attending the department of pedodontics and preventive dentistry , i. t. s. 
a total of 50 maxillary and mandibular primary molar teeth were selected from 33 children requiring pulp therapy and aged between 5 and 8 years , who were selected after clinical and radiographic assessment .
the criteria for selection of teeth to be included in the study are given in table 1 .
the teeth were divided into two equal groups : in group a , fc ( pharmadent remedies pvt . ltd . , gundlav , india )
was used as the pulp dressing agent and gray mta ( proroot mta , dentsply , tulsa dental , tulsa ok , usa ) was used in group b. cases which came under the exclusion criteria were eliminated and they are not represented in the study . in case a child had two molars needing pulpotomy , the second tooth was assigned to alternative group .
the teeth treated were assessed postoperatively after 1 , 3 , 6 and 12 months .
the criteria for the selection of teeth to be included in the study the conventional pulpotomy procedure was carried out step - by - step in one visit using local anesthesia and isolating the teeth with rubber dam .
after caries removal with round bur , coronal access was obtained using a # 330 high - speed bur with water spray to expose the pulp chamber .
de - roofing of pulp chamber was done by connecting the pulp horns by a non - end cutting bur .
the coronal pulp was excised until root canal orifices could be seen , with no tags remaining on the pulpal floor , by using hu - friedy sharp spoon excavator .
after the pulp was amputated , the pulp chamber was irrigated with saline to wash away dentin debris .
following irrigation , sterile , saline - wetted cotton pellets were applied for 5 minutes on the amputated pulp stumps to achieve hemostasis .
after the standardized technique was completed , the teeth assigned for group a were treated with sterile cotton pellet moistened with fc squeezed twice , which was placed over the radicular pulp for 5 minutes and then removed .
a thick mix of zinc oxide eugenol paste was placed over the fc fixed tissue .
intermediate restorative material ( irm ) was placed over the zinc oxide eugenol layer at the same appointment . within 1 week
b , pulp stumps were covered with mta paste , obtained by mixing mta powder with distilled water provided by the manufacturer in 3:1 ( powder : liquid ) ratio , which was placed over the exposure site with a plastic instrument .
then , the mixture was compressed against the exposure site with a moist cotton pellet .
wet cotton pellet was placed in pulp chamber and the cavity was covered with irm . in the second session ( after 1 day ) , the patient was recalled , cotton pellet was removed and the cavity was restored with irm . within 1 week , the tooth was restored with a preformed stainless steel crown . in both the groups ,
the children were recalled for clinical and radiographic examination postoperatively after 1 , 3 , 6 and 12 months .
the children were examined at follow - up clinically for the signs and symptoms like pain , swelling and sinus / fistula and radiographically for periapical changes , furcation radiolucency and internal resorption .
the treatment was regarded as a failure when one or more of the above - mentioned signs and symptoms were present , but pulp canal obliteration ( pco ) was not regarded as a failure .
all data were entered in ms excel sheet and analyzed by epi - info 2002 software to assess the success rate of the treatment with mta and fc after 12 months .
the difference between the effects of two materials was statistically analyzed by fisher 's exact test and p < 0.05 was considered statistically significant .
all 50 teeth in 33 children were available for analysis of success / failure rate .
the age of the subjects ranged from 5 to 8 years , with a mean ( sd ) age of 6.04 ( + 0.84 ) years in fc group and 6.44 ( 1.12 ) years in mta group .
the distribution of teeth by type of tooth and material used is shown in table 2 .
distribution of assessed teeth according to type of material a total of 12 first primary molars and 38 second primary molars were treated by conventional pulpotomy technique .
the follow - up evaluation revealed 100% success with regard to the clinical signs and symptoms for both the groups .
none of the teeth in either group showed any clinical pathology at the end of 12 months when observed by the same observer .
fisher 's exact test was not necessary for the clinical signs as none of the samples showed signs of clinical evidence of failure , giving 100% success .
the radiographic evaluation at 3 , 6 and 12 months follow - up period for both the groups is shown in table 3 .
the cases which showed furcation radiolucency and internal resorption with fc pulpotomy and regarded as failure are shown in figures 1 and 2 . the case which showed internal resorption with mta pulpotomy
is shown in figure 3 . however , both the groups did not show any periapical changes at the above intervals .
pulp canal obliteration ( calcific metamorphosis ) was found in the three cases in mta treated teeth ( group b ) and was not considered as failure . out of 25 teeth treated in each group , 22 in group a and 24 in group b did not show any radiographic changes , giving 88% and 96% success , respectively .
assessment of radiographic signs at 3 , 6 and 12 months preoperative and postoperative radiographs of mandibular second primary molar treated with formocresol pulpotomy revealed internal resorption and furcation radiolucency .
( a ) preoperative radiograph ; ( b ) radiograph taken 3 months postoperatively showing features of failure in pulpotomy ; ( c ) radiograph taken 6 months postoperatively showing features of failure in pulpotomy ; ( d ) radiograph taken 12 months postoperatively showing features of failure in pulpotomy preoperative and postoperative radiographs of mandibular second primary molar treated with formocresol pulpotomy revealed furcation radiolucency .
( a ) preoperative radiograph ; ( b ) postoperative radiograph taken immediately after formocresol pulpotomy and restored with stainless steel crown ; ( c ) radiograph taken 6 months postoperatively showing feature of failure in pulpotomy ; ( d ) radiograph taken 12 months postoperatively showing feature of failure in pulpotomy preoperative and postoperative radiographs of mandibular second primary molar treated with mta pulpotomy revealed internal resorption .
( a ) preoperative radiograph ; ( b ) postoperative radiograph taken immediately after mta pulpotomy and restored with stainless steel crown ; ( c ) radiograph taken 3 months postoperatively showing feature of failure in pulpotomy ; ( d ) radiograph taken 6 months postoperatively showing feature of failure in pulpotomy the statistical analysis was carried out by fisher 's exact test pertaining to radiographic findings in both the groups .
there was no significant difference found between the two groups after 12 months of radiographic evaluation ( p = 0.61 ) .
the objective of pulp therapy in a child patient is the successful treatment of a pulpally involved tooth and to retain the tooth in a healthy condition so that it may fulfil its role as a useful component of a primary and young permanent dentition .
this report intended to examine the clinical and radiographic success rates of pulpotomies with mta , a material with evidence - based success in many endodontic procedures .
several in vitro and in vivo studies have shown that mta prevents microleakage , is biocompatible , and promotes regeneration of the original tissues when it is placed in contact with the pulp or periradicular tissues .
fc was selected as it is still considered  gold standard  in pediatric dentistry , may be mainly because of its ease in use and excellent clinical success . the estimated dose associated with one pulpotomy procedure , assuming a 1:5 dilution of fc placed on a no .
4 cotton pellet that has been squeezed dry , is approximately 0.020.10 mg .. children from 5 to 8 years of age were selected as per the inclusion and exclusion criteria for the study , irrespective of their sex .
the age group was selected taking into consideration the lack of cooperation of children less than 5 years of age and physiologic root resorption ( > 3/4 of root ) above 8 years of age .
the first and second primary molars of both arches were included in the present study .
clinically , the success rate was 100% with both the groups at all observation periods .
the results are in agreement with the results of various previous studies.[4151820 ] the clinical success of fc pulpotomy in this study could be attributed to proper case selection , high aseptic standards , proper technique protocol and appropriate use of medicament .
in addition to this , the germicidal and bactericidal action of fc , and also its fixative qualities , might have contributed to the success .
the clinical success of mta in this study could also be considered to be due to the above - mentioned factors and also its excellent sealing ability , biocompatibility , alkalinity and ability to regenerate the hard tissues .
effects of mta on amputated pulpal tissue seem to suggest that the material preserves the pulp tissue and promotes the regeneration of hard tissues .
radiographically , in group a , at 3 months , internal resorption and furcal changes were seen in one tooth and furcal changes alone in another tooth . at 6 months follow - up
, furcal changes were seen in one more tooth , similar to the results of a previous study .
internal resorption is the result of odontoclastic activity and suggests that the tooth is retaining some degree of vitality and function over time .
although the cause of internal resorption is unknown , there is a speculation that whatever the precipitating factor , it produces a vascular change in the pulp that involves an inflammation and formation of granulation tissue .
the reason for internal resorption following pulpotomy is believed to be the irritating effects of the medicaments present in the paste .
previous investigation of zoe as a pulpotomy agent or as a base for pulpotomies suggests that zoe can cause pulp inflammation , with a risk for subsequent internal resorption .
zoe , when used as a base in pulpotomies , comes in contact with highly perfused environment of pulp and undergoes hydrolysis of the zinc eugenolate to yield free eugenol and zinc hydroxide .
this eugenol comes in direct contact with the vital tissue and causes moderate to severe inflammatory response , resulting in chronic inflammation and necrosis .
this , however , can not explain the internal resorption in the present study because zoe paste was placed as a sub - base on fc fixed tissue .
cotes et al . claimed that if the pulp tissue is fixed by fc it will not be affected by eugenol , and smith et al . also claimed that application of fc on pulp serves as a barrier to eugenol . in the present study ,
it is more likely that internal resorption was the result of undiagnosed chronic inflammation existing in radicular pulp prior to pulpotomy rather than due to exposure of radicular pulp to eugenol . due to this
, the recovery of pulpal tissue to the normality might have been hampered , causing a delay in the completion of technique .
increasing time of procedure leading to a certain amount of inflammation in the pulpal tissue might have led to exaggerated response in the form of internal resorption . however , since the progress of such activity was limited , such response can not be taken as failure of the procedure at microlevel .
another probable reason for internal resorption could be the reversible fixative effect of fc and its irritative ph .
furcation changes might be seen due to the presence of micro pulp remnants even after the amputation of coronal pulp tissue .
the occurrence of such changes might be dependent on the medicament concentration and application time offc . in the mta group ,
one tooth showed internal resorption at 3 months , which did not progress any further over a period of the next 9 months .
this could be more likely the result of undiagnosed chronic inflammation existing in the radicular pulp prior to pulpotomy .
a similar finding was seen at a duration of 2538 months in two cases in a study by holen et al . and at a duration of 12 months in a study by jabbarifar et al .
since mta contains highly alkaline substances , the possibility of exaggerated response of pulp can not be ruled out .
it is known from various studies that calcium hydroxide placed on primary pulp reacts by producing internal resorption .
internal resorption may result from overstimulation of primary pulp by the highly alkaline calcium hydroxide .
overstimulation induced by high alkalinity could cause metaplasia within the pulp tissue , leading to the formation of odontoclasts .
though mta does not contain calcium hydroxide , it has calcium oxide that forms calcium hydroxide when mixed with water . according to holland et al . , the reaction of calcium from calcium hydroxide with the carbon dioxide from pulpal tissue produces calcite crystals .
therefore , we believe that the mechanism of action of mta is similar to that of calcium hydroxide . in the present study , in group b ,
internal resorption was noticed at a duration of 3 months and did not progress to root perforation and osseous changes .
therefore , such internal resorption may be ignored as being a reason for the amount of inflammation at the time of pulpotomy .
pulp canal obliteration ( calcific metamorphosis ) was found in the three cases in mta treated teeth ( group b ) and was not considered as failure , but was a result of the odontoblastic activity , and this might suggest that the tooth is retaining some degree of vitality and function overtime . in the current study , radiographic success rates of fc and mta were 88% and 96% , respectively , at 12 months follow - up . however , this difference in success rates was not statistically significant ( p = 0.061 ) as reported in previous studies .
the mummification of the pulp induced by fc only treats the symptoms , but does not have any healing capacity .
the objectives of fc pulpotomy are solely clinical , that is , maintaining the tooth in an asymptomatic condition until normal exfoliation .
enough evidence is present to suggest that the objective should no longer be complete  mummification .
 stated in modern terms , the rationale of the fc pulpotomy is to fix the radicular tissue while allowing recovery of cells and possible replacement of fixed tissue .
there is also a reported case of dentigerous cyst and necrosis of crestal bone associated with the use of fc in pulpotomy .
fc has recently come to critical review and three concerns about the material should be under immediate inspection : firstly local toxicity , secondly the effects of the material systemically and lastly its effects of mutagenicity and carcinogenicity . mta appears to meet the requirements for pulp capping materials .
mta 's advantages might be related to its sealing ability to prevent bacterial penetration and to its high level of biocompatibility .
mta is a technique - sensitive material and takes about 4 hours to set when in contact with moisture .
histological evaluation of pulpal tissue in animals and humans demonstrated that mta produces thicker dentin bridge formation , with less inflammation , hyperemia , and pulpal necrosis compared to calcium hydroxide .
mta also appears to induce dentin bridge at a faster rate than calcium hydroxide at amputation sites .
an important clinical advantage of mta over fc is the fact that less time is required for the procedure .
while fc requires 35 minutes application before the cotton pellet is removed , with mta the pulp chamber is filled with irm immediately after application of the dressing material .
moreover , during the removal of fc - soaked cotton pellet , there is a possibility of the cotton fibers adhering to clot , resulting in reoccurrence of bleeding .
presently one of the factors limiting the routine use of mta is the high cost of the material .
although high success rates have been reported with mta , re - entry into canal in cases further indicated for pulp therapy may not be possible in teeth with pulp canal obliteration .
mta showed clinical and radiographic success as a dressing material following pulpotomy in primary teeth after a short - term evaluation period and has a promising potential to become a replacement for fc in primary teeth .
though fc is in the center of much controversy for the past 20 years , it is still used extensively in pulpotomy procedure .
however , mta seems to have more promising potential to become a replacement for fc in primary teeth except for the cost factor and technique sensitivity .
further histological studies using larger sample size and longer observational period should be carried out in future .
 background : preservation of pulp vitality is of utmost importance to the normal physiological functioning of tooth in situ and physiological process of exfoliation in a tooth affected by disease or trauma . 
 pulpotomy serves such a purpose using various medicaments applied directly on vital pulp.aim:the aim of this study was to evaluate clinically and radiographically the effects of mineral trioxide aggregate ( mta ) and formocresol ( fc ) as a pulp dressing after coronal pulp amputation ( pulpotomy ) in primary molars prospectively over a period of 1 year.materials and methods : thirty - three healthy children , aged between 5 and 8 years , requiring pulp therapy were selected after clinical and radiographic assessment . 
 a total of 50 maxillary and mandibular primary molars were treated by the conventional pulpotomy technique . 
 the teeth were divided into two equal groups . in group 
 a , fc was used as the pulp dressing agent , and in group b , mta was used before restoration with stainless steel crowns . 
 the research employed was a prospective study . 
 the teeth treated were assessed postoperatively after 1 , 3 , 6 and 12 months . 
 the observations were tabulated and statistically analyzed.results:clinically , both the groups showed 100% success at 1 , 3 , 6 and 12 months . at 3 months , the radiographic success rates of fc and mta were 92% and 96% , respectively , and at 6 and 12 months , the radiographic success rates of fc and mta were 88% and 96% , respectively.conclusion:mta showed a higher success rate than fc and may be a favorable material for pulpotomy in primary molars whose pulps have been compromised by a carious or mechanical pulp exposure 
Introduction
Materials and Methods
Results
Discussion
Conclusions