Original Article
Evaluation and comparison of white mineral trioxide
aggregate and formocresol medicaments in primary
tooth pulpotomy: Clinical and radiographic study
Cheranjeevi Jayam, Malay Mitra1, Jiban Mishra1, Bhaswar Bhattacharya1, Biswanath Jana1
Departments of Pedodontics and Preventive Dentistry, College of Dental Sciences and Research Centre, Sanand, Ahmedabad, Gujarat,
1
Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India
ABSTRACT
Aim: The primary aim of the following study
is to evaluate and secondary aim is to compare
clinically and radiographically the success of using
white mineral trioxide aggregate (MTA) versus
formocresol (FC) medicament for primary tooth
pulpotomy. Materials and Methods: A total of 100
teeth were selected for pulpotomy; of which 50 teeth
underwent FC pulpotomy and 50 teeth underwent
pulpotomy with white MTA. Out of 100 treated
teeth, 82 teeth (42 FC and 40 MTA teeth) were
available at the end of 24 months for evaluation.
4 failures were found in FC group at 1st month
evaluation and no failures were found in white
MTA group. A statistical analysis was performed
to evaluate the overall success rate of study and
individual success rates of medicaments. Overall
success rate of the study was 95%, success rate of FC
group was 90.48% and success rate of MTA group
was 100%. Results: MTA produced better results as
pulpotomy medicament in comparison to FC. The
superior success obtained in the present study was
matching other studies mentioned in the literature.
Conclusion: MTA seems to be a promising
pulpotomy medicament for future use.
KEYWORDS: Formocresol, primary tooth, pulpotomy,
pulpotomy medicament, mineral trioxide aggregate,
success rate, white mineral trioxide aggregate
Introduction
Pulpotomy is described as “complete removal of
coronal portion of the dental pulp followed by the
placement of suitable dressing or medicament that will
promote healing and preserve vitality of the tooth.”[1,2]
The term suitable dressing or medicament has created
considerable storm in pulpotomy procedure. Several
13 Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 |
Address for correspondence:
Dr. Cheranjeevi Jayam,
Department of Pedodontics and Preventive Dentistry, College
of Dental Sciences and Research Centre, Opp. Pleasure Club,
Bopal-Ghuma Road, Sanand, Ahmedabad - 382 115, Gujarat, India.
E-mail: cheranjeevij@gmail.com
Access this article online
Quick response code Website:
www.jisppd.com
DOI:
10.4103/0970-4388.127043
PMID:
medicaments have been studied on the effect of
amputated pulp. Formocresol (FC) over years has still
remained the benchmark medicament for pulpotomy
procedure due to its very high and consistent results that
date back to even more than a century”.[2-5] Despite FC’s
high success rate and its position as “gold standard”
in pulpotomy, a substantial shift has occurred from
the use of this medicament because of 2 main reasons.
(1) FC itself being a connective tissue irritant causes
devitalization of vital radicular pulp and (2)  concern
regarding its systemic effects such as toxicity,
mutagenecity, carcinogenicity and antigenecity.[5-8]
Both proponents and opponents have debated whether
to use formocresol for many years now.[5-12] Leaving
aside whether it causes systemic effects, devitalization
of radicular pulp caused by formocresol cannot be
substantiated. Since treatment objective with an ideal
pulpotomy agent is to maintain vitality of pulp, search
for “ideal pulpotomy agent” had commenced.[4] In
this awakening several regenerative materials like
tricalcium phosphate, hydroxy-apatite, mineral trioxide
aggregate (MTA), bone morphogenetic protein and
several others have been formulated, studied and used
over years. These studies have only produced varying
and inconsequential results.[13-17] Recently MTA is being
widely discussed because of its excellent bioactive
properties and ability to induce hard tissue formation.
Jayam, et al.: Comparison of formocresol and MTA in primary molar pulpotomy

Search of scientific literature regarding MTA have Results and Observations

confirmed its unique biological properties.[18,19]
Studies have also been reported on the use of MTA
as pulpotomy medicament. Comparative studies
comparing MTA with other medicaments have shown
good results.[20-27] Hence an attempt was made to study
MTA’s success as pulpotomy medicament and to
compare the same with FC.
Materials and Methods
A certificate of clearance for undertaking the study
was obtained from the institutional ethical committee.
Patients were selected from the outpatient department,
Dr. R. Ahmed Dental College and Hospital, India. The
patients selected belonged to age group ranging from 3
and 7 years of age. A careful history was obtained from
the child and the accompanying guardian; followed
by a thorough clinical and radiographic examination.
The teeth were carefully scrutinized for suitability to
undergo pulpotomy treatment [Table 1].[25,27,28] The
procedure and its’ possible benefits, discomforts and
risks were explained fully to the guardians and their
informed consent was obtained.
A total of 66 patients were selected for the study
yielding 100 teeth. Of 100 teeth 50 teeth received FC
pulpotomy and 50 teeth received MTA pulpotomy
treatment [Table 3]. After timely evaluation, at the
end of 2 year 82 out of 100 treated teeth (of which
50-8  = 42 teeth in FC group and 50-10 = 40 teeth in
MTA group) were available for follow-up [Table  4].
No failures were present in MTA group. 4 failures
were noted in FC group at 1st month evaluation
period [Tables 5 and 6]. For statistical comparison of
success between the groups, standard normal deviate
test was adopted.
Table 1: Criteria for selection of teeth
Pain, if present, is neither spontaneous nor persistent
The tooth is restorable
The tooth is free of radicular pulpitis
The tooth should possess at least two thirds of its root length
There is no evidence of internal resorption
There is no evidence of inter-radicular bone loss
No abscess or fistulae exist

Test design
The teeth were randomly assigned to either group. Table 2: Criteria used during follow-up to
If the same child needed pulpotomy in more than 1 assess success/failure
tooth, the second tooth was assigned to alternate agent Clinical evaluation was done to note
to assess intergroup success. History of pain, if any
Tenderness to palpation/percussion
Pathological mobility
Clinical Procedure Intra or extra-oral swelling
Intra or extra oral sinus
After good anesthesia and isolation with a rubber dam;
Radiograph evaluation was done to note
proper access cavity was prepared and; coronal pulp
Integrity of lamina dura
was amputated carefully up to the entrance of root canals
Presence or absence of radiolucencies in the apical or bifurcation
using sharp spoon excavator. Post amputation bleeding areas of tooth
was carefully assessed for fit to continue pulpotomy Pathological internal or external root resorption
procedure. Later either medicament was applied. MTA Pulp canal obliteration
(Branco Blanco White Angelus, Londrina, PR, Brasil) Dentin bridge formation
mixture was obtained by mixing powder with liquid
supplied by manufacturer at a 3:1 ratio to a sandy
consistency and applied over pulpal orifices, followed Table 3: Distribution of number of teeth to
by placement of moistened cotton pellet over MTA for different groups
15 min (as per manufacturer’s guidelines). Alternately Medicament Total number of teeth Percentage of teeth
Fomocresol (Formoacresol, Pharmadent remedies Pvt. FC 50 teeth 50
Limited, Gujarat, India; Composition: Formalin-20% MTA 50 teeth 50
v/v [B.P.], Cresol-32% v/v [I.P.], Glycerine-q.s. [I.P.]) FC = Formocresol; MTA = Mineral trioxide aggregate
dampened cotton pellet was placed over pulp stumps
for 5 min. Access cavity was restored with zinc-oxide
eugenol. Later date the tooth was restored with stainless Table 4: Total teeth available for follow-up after
steel crown and/or glass ionomer restoration and silver 2 years
amalgam. Subsequently clinical and radiographic Sample size attrition Teeth available Teeth not present
evaluations were done at 1-day post-operative, after 2 years for evaluation
1-month, 3-month, 6-month and 1- & 2-year evaluation Total teeth 100-18=82 18
periods and findings were noted [Table 2].[25,27,28] If a FC 50-8=42 8
failure occurred during the follow-up period, necessary MTA 50-10=40 10
treatment was done and followed-up later. FC = Formocresol; MTA = Mineral trioxide aggregate

Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 14
 Jayam, et al.: Comparison of formocresol and MTA in primary molar pulpotomy

Table 5: Total distribution of success and failures obtained for both techniques at 1st, 3rd, 6th month
and 1st & 2nd year
Time versus Treatment 1st month 3rd month 6th month 1st & 2nd year
Success FC MTA Total FC MTA Total FC MTA Total FC MTA Total
Assessed 42 40 82 38 40 78 38 40 78 38 40 78
Success 38 40 78 38 40 78 38 40 78 38 40 78
Failure 4 0 4 0 0 0 0 0 0 0 0 0
FC = Formocresol; MTA = Mineral trioxide aggregate

Table 6: Distribution of failures as assessed at each appointment

Failure 1st month 3rd month 6th month 1st & 2nd year
Criteria Clinical Radiological Clinical Radiological Clinical Radiological Clinical Radiological
FC 0 4 0 0 0 0 0 0
MTA 0 0 0 0 0 0 0 0
Total 0 4 0 0 0 0 0 0
FC = Formocresol; MTA = Mineral trioxide aggregate

Table 7: MTA pulpotomy success rate obtained and debate as proponents of specific materials and
by different authors methods attempt to justify their chosen technique(s).
Year Author Time period Material Success rate %
These controversies are unsettled even now in the
21st century despite much impressive scientific
2001 Eidelman et al. 6-30 months Grey MTA >90
advancement. Identifying the best amalgamation of
2006 Morato et al. 6 months White MTA 100
ingredients and techniques to predictably produce
2006 Percinoto et al. 1 year Grey MTA 95
pulpal healing is still obscure.
2006 Morato et al. 42 months White MTA 100
2007 Moretti et al. 1 year White MTA Successful
In the present context, it is seen that there is abundant
MTA = Mineral trioxide aggregate
evidence to show FC can produce very good clinical
results as pulpotomy agent. MTA, a relatively new
Overall success rate of the study material still requires an adequate amount of clinical
4 failures out of 82 teeth (78 success). Overall success studies; hence a study was attempted to test whether
rate was 95% which is highly significant at Z = 16.6, at MTA can produce equal or better results in comparison
0.1% level (P < 0.001). to FC.

Success rate in MTA group
No failures out of 40 teeth (40 successful) was observed.
Success rate is 100%.
Success rate in FC group
4 failures out of 42 teeth (38 success) were observed.
Success rate in this group is 90.48% which is significant
at Z = 2.08, at 5% level (P < 0.05). All 4 failures were
observed at 1st month evaluation period. Since no
failures occurred at 3rd month, 6th month, 1 year and
2 year evaluation periods, the failures occurring at 1st
month is again considered as significant.
Comparison of success rates between MTA and FC
MTA success rate was 100% in comparison to 90.48%
success in FC group. This implies that MTA produced
better results than FC group.
Discussion
During the 20th century, a significant share of dental
research effort was devoted to finding better treatment
procedures and medicaments for pulpal problems.
These efforts have generated considerable controversy
Several authors have quoted histological methods to
be a better test to predict pulpal healing followed by
radiographical and clinical methods.[29-31] However
in the present study, all teeth were destined for
preservation of its function in the oral cavity; so
none of the teeth could be extracted and included for
histological examination. Hence in the present study
only clinical and radiographic evaluation was utilized.
100 teeth were treated with pulpotomy procedure of
which 82 teeth (42-FC group and 40-MTA group) were
present at 2nd year of evaluation [Tables 3 and 4].
Evaluation of success in MTA group
No failure occurred in this group during the 2 year
evaluation period. Success rate of MTA was 100%
[Tables 5 and 6].[20-27] The greater success rate in the
present study is in accordance with previous studies
in literature [Table 7]. The greater success rate of MTA
may be due to its biocompatibility, sealing ability and
dentin bridge formation.
Evaluation of success and failures in FC group
4 failures occurred out of 42 teeth in this group over an
evaluation period of 2 years [Tables 5 and 6]. Success rate

15 Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 |
Jayam, et al.: Comparison of formocresol and MTA in primary molar pulpotomy

is 90.48%. The success rate collaborates with the success failures had occurred within 1st month. This significant
rate found in the literature [Table  8].[32,33] Probable finding is in concordance with several studies, which
reasons for failure may be attributed to reversible also obtained similar proportion of failures during the
fixative effect of FC and low pH of a solution. All the initial months of FC pulpotomy procedure.[32-34]

Table 8: FC pulpotomy success rate obtained by different authors

Year Author No. of teeth Success rate
Histological % Radiological % Clinical %
1965 Berger (mean time=22 weeks) 31 82 97 100
1966 Beaver 60 Varied 97 100
1975 Rolling and Thylstrup
3 months 98 91 91
36 months 70 70
1978 Magnusson 84 62 100
56 20
1981 Fuks and Bimstein 70 65 94
1983 Garcia-Godoy 45 96 96
FC = Formocresol

Table 9: Comparative studies between FC and MTA done by different authors

Year Author Time period Material Success rate %
2004 Agamy et al. 1 year FC 90
Grey MTA 100
White MTA 84.2
2004 Jabbarifar et al. 1 year FC 90.2
MTA 93.7
2005 Holan et al. 4-74 months FC 83
Grey MTA 97
2005 Eidelman et al. 6-30 months FC 94.11
Grey MTA 100
2005 Najat Farsi et al. 2 years FC 98.6-clinical
86.8-radiological
MTA 100-both
2010 Hugar and Deshpande 3 years FC 100
MTA 100
2011 Godhi et al. 1 year FC 100-clinical
88-radiological
MTA 100-clinical
96-radiological
2011 Srinivasan and Jayanthi 1 year FC 91.3-clinical
90-radiological
MTA 100-clinical
100-radiological
2011 Erdem et al. 24 months FC 96-clinical and radiological
MTA 88-clinical and radiological
2012 Sushynski et al. 6-24 months FC MTA showed better results under statistical
MTA analysis
2012 Airen et al. 6-24 months FC 85-clinical
88.6-radiological
MTA 97-clinical
54.3-radiological
2012 Fernández et al. 24 months FC MTA showed better results under statistical
MTA analysis
2013 Mettlach et al. 42 months FC MTA showed better results under statistical
MTA analysis
FC = Formocresol; MTA = Mineral trioxide aggregate

Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2014 | Vol 32| Issue 1 | 16
 Jayam, et al.: Comparison of formocresol and MTA in primary molar pulpotomy
Second appraisal was thought whether any other factor
apart from medicament played a role in determining
the success or failures in FC group in comparison to
M.T.A group during the study.
Usually undiagnosed radicular inflammation prior to
treatment, presence of bacteria in radicular pulp, failure
to provide good isolation, traumatic amputation of
coronal pulp, incompletely removed coronal pulp are
main factors cited for failure of pulpotomy treatment in
the scientific literature.[29,32,33] However, in the present
study there seems no relation of these factors because
the teeth were randomly designated to either group
and same protocols were used for the procedure.
Previous investigations have reported on ill-effects of
zinc oxide eugenol as a base following pulpotomy.[35-37]
They suggested that unset eugenol can cause pulpal
inflammation. MTA because of its better sealing ability
can act as an excellent sealer and prevent undesirable
effects of free eugenol on pulp. On contrary FC treated
pulp lacks this sealing ability.
Few authors have also suggested the type and timing
of post-pulpotomy restorative procedures have an
influence on the failure rate (pulp contamination due
to microleakage).[38-41] In the present study, most of the
teeth were restored with stainless steel crown and only
few with silver amalgam, composite and glass-ionomer
restoration. Stainless steel crown were usually given
during the 1st and 3rd month after pulpotomy procedure.
In the present study, however failure was independent
of timing and type of post-pulpotomy restoration placed.
It can be interpreted that medicament itself rather than
type and timing of restoration is responsible for failure.
Overall success rate of the study was 95%. Success
rate collaborates with other comparative studies
[Table  9].[42-47] The high success rate obtained in the
study can be attributed to the strict criteria and proper
technique followed.
The results showed that MTA faired well as pulpotomy
medicament in comparison to FC in primary teeth.
Conclusion
Whilst it is appropriate to search for better alternatives,
it is imperative to re-emphasize on the success of FC
obtained over 100 years. Before the clinician completely
eliminates FC from his armamentarium, the alternatives
need to be proven clinically and histologically to be
either as successful as/more successful than FC. In this
stance, MTA appears to be a promising alternative.
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How to cite this article: Jayam C, Mitra M, Mishra J,
Bhattacharya B, Jana B. Evaluation and comparison of white
mineral trioxide aggregate and formocresol medicaments in
primary tooth pulpotomy: Clinical and radiographic study.
J Indian Soc Pedod Prev Dent 2014;32:13-8.
Source of Support: Nil, Conflict of Interest: None declared.
18
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