Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth

Resident’s Name: Chad Abby Date: 8/22/2008
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Author(s): Joe H Camp, DDS, MSD
Journal: Pediatric Dentistry
Volume (number): volume 30/ NO 3
Month, Year: May/ June 2008
Major topic: Vital Pulp Therapy
Minor topic(s): vital pulp therapy in primary teeth and immature permanent teeth
Type of Article: Literature Review
Main Purpose: This article reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apex.
Overview of method of research:
Findings: Apical closure cannot usually be determined radiographically (except for centrals and laterals) – the x-ray beam is exposed in the faciolingual plane, but the radiograph is read mesiodistally and the faciolingual width of most roots and canals is greater than the mesiodistal width. Therefore the clinician must rely on time to determine root closure. Diagnosis of pulpal status in Primary Teeth: Pain usually accompanies pulpal inflammation – provoked pain that stops after removal of causative agent usually indicates reversible and minor inflammatory changes. Spontaneous pain is constant or throbbing that occurs without stimulation and is indicative of pulpectomy or extraction. Electric pulp tests and thermal tests are not valid in primary teeth. Bitewings are best to diagnose pathological changes in primary molars. Calcified masses are indicative of advanced pulpal degeneration and are candidates for only pulpectomy or extraction. Internal resorption in primary teeth is always associated with extensive inflammation and must be extracted. The size of a pulpal exposure and the amount and color of hemorrhage are important factors in diagnosing inflammation. Deep purple colored hemorrhage or hemorrhage that cannot be controlled after 1-2 minutes of light pressure are candidates for pulpectomy or extraction. Primary teeth typically displace during injury rather then fracture due to shorter roots and might heal normally without sequelae by formation of an amorphous diffuse calcification, formation of a partial or complete obliteration of the canal, or result in pulpal necrosis. In a study of traumatized primary maxillary incisors 53% developed pulpal necrosis and 25% developed pulpal obliteration. *Studies have showed that no relationship between treating injured primary teeth compared with extraction regarding disturbance of the permanent teeth, although others have shown a tendency toward more extensive disturbances in mineralization when injured primary teeth were retained. Avulsed primary teeth should never be reimplanted. Color change of the tooth alone without other findings is not a reliable indicator of pulpal health – when diagnosis cannot be established it is justifiable to wait for further developments. Diagnosis of Pulpal Status in Permanent Immature Teeth: Every attempt should be made to preserve vitality – loss of pulpal vitality before dentin completion leaves a week root more prone to fracture. Provoked pain indicates pulpal inflammation of a lesser degree and is reversible as compared to spontaneous pain. Electric pulp tests and thermal tests are of limited value because of the varied responses as roots mature. Radiographic examination and interpretation are key elements in the diagnosis of pulpal pathology in teeth with developing apices. Yellow discoloration is usually indicative of pulp space calcification, and a gray color signifies pulpal necrosis. Transient apical breakdown occurs after displacement injuries and is linked to the repair process and will return to normal after healing complete – allow for adequate healing time. The use of calcium hydroxide for pulp capping and pulpotomy procedures in permanent teeth is being replaced with composite resins and MTA. The use of MTA as an apical barrier has become the standard for treatment of the open apex pulpless tooth. Revascularization of teeth with necrotic infected canals has been reported by using combinations of antibiotics.
Key points/Summary: The decision to render conservative vital treatment to allow root formation completion or more radical treatment such as root canal therapy might hinge on our diagnosis of root development. In permanent teeth, root formation is not completed until 1-4 years after eruption into the oral cavity. During the formative years treatments should be directed toward maintenance of vitality to allow completion of root formation. Immature teeth have the greatest potential to heal after trauma or caries, particularly when the apical foramen is wide open. If doubtful of treatment do not start, keep patient under close observation until adequate diagnosis can be made.
Assessment of article: Very good article – instead of going through this whole summary you probably should have just read the article! In fact the whole pediatric dentistry journal for May/June 08 is pretty cool.