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

Resident: Roberts
Date: 9/4/09
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Journal: Pediatric Dentistry
Volume #30 Pages 197-205
Year: June 2008

Findings:

Most of the diagnostic test used in conventional endodontic therapy are of very little use when involving primary teeth and permanent immature teeth. Thus it is important for a clinician to understand normal root formation and exfoliation of primary teeth. Root development begins when enamel and dentin formation reach the CEJ. Hertwigs Epithelial root sheath is formed by the epithelial dental organ, with one tube for each root. As formation proceeds apically, the apices are wide open diverging apically. Once root length is established, odontoblast that line the internal surface begin to lay dentin until root formation is complete and the apices are closed. In permanent teeth root formation is not complete until 1-4 years after eruption into the oral cavity, in primary teeth it is a shorter duration. During this formative period, treatments should be oriented toward keeping the tooth vital until root formation is complete.

Young immature teeth: Loss of vitality before completion of root length will lead to a poorer crown to root ratio and weak roots leading to periodontal breakdown and possible fracture. Therefore, all treatment for this group should be geared towards maintaining pulpal vitality. EPT and thermal testing are of limited value when testing for pulp vitality in immature permanant teeth. Most diagnoses to these type of teeth occur from radiographic and clinical interpretation. Recently different materials used to treat immature teeth have also began to surface. MTA has recently been the scrutiny of much research. It has been shown to be more successful in stimulating tertiary dentin and maintaining pulpal vitality in direct pulp caps when compared to calcium hydroxide. It has also been proven to be an effective barrier for the treatment of open apex pulpless teeth. It has also been shown to be a be a better cemento-conductive material than calcium hydroxide allowing for stronger root formation in a shorter period of time.

Summary: When assessing primary and permanant immature teeth a clinician should be fully aware of growth and development of the dentition. A clinician should take every opportunity to keep a tooth vital when possible. Primary teeth should not be kept at the risk of damaging permanant teeth. When dealing with immature permanant teeth, one should look for ways to strengthen root formation. MTA has been proven to be a successful agent when dealing with these difficult circumstances.
Assessment of article: The article was good but I would have liked to have seen more discussion involving different materials.