Article title: Comparison of Mineral Trioxide Aggregate and Calcium Hydroxide as Pulpotomy
Agents in Young Permanent Teeth (Apexogenesis)
Author(s): Meligey & Avery.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2006. 28:5. 399-404.
Major topic: Apexogenesis with MTA
Overview of method of research: Scientific Article
Purpose:
To compare the clinical and radiographic success rates of MTA and CaOH as pulpotomy agents in immature permanent teeth (apexogenesis).
Methods:
15 children from 6-12 years old with at least 2contralateral immature permanent teeth requiring a pulpotomy participated in this study. 4 traumatized incisors, 2 carious premolars and 24 carious first molars were used. Teeth that had affected coronal pulp with no signs or symptoms of affected radicular pulp or periapical pathosis and a restorable crown were included in this study. One tooth in the individual was treated with MTA and the other was treated with CaOH.
The control group was treated with 1-2mm CaOH paste over the pulp stump, a layer of ZOE cement and then anterior teeth were restored with composite while posterior teeth were restored with amalgam.
The experimental group was treated with MTA, then a damp cotton pellet and IRM. The IRM and pellet were removed after 1 week and a final restoration of composite in the anterior and amalgam in the posterior were placed. All treatments were provided by one operator.
The participants were re-evaluated at 3, 6 and 12 months by 2 blinded evaluators. Treatment was considered successful if the tooth experienced no signs or symptoms or radiographic evidence of pathology.
Findings:
2 teeth treated with CaOH were found to have failed at 12 months due to pain and swelling while the remaining 28 teeth were still considered successful at 12 months. There was no significant difference found between the two materials.
Calcific metamorphosis was found radiographically in 2 teeth treated with CaOH and 4 teeth treated with MTA.
Key points/Summary:
MTA seems to be a successful pulpotomy agent in immature permanent teeth and a valid alternative to CaOH.
Assessment of Article:
I think this was a great article although the sample size was small.
Wednesday, October 27, 2010
Two Case Reports of Complicated Permanent Crown Fractures Treated With Partial Pulpotomies
Resident: Adam J. Bottrill
Date: 27OCT10
Region: Providence
Article title: Two Case Reports of Complicated Permanent Crown Fractures Treated With Partial Pulpotomies
Author(s): McIntyre, Judy
Journal: Pediatric Dentistry
Page #s: 117-122
Date: Mar/Apr 2009, V31:No2
Major topic: Par
Minor topic(s): NA
Type of Article: Case Reports
Main Purpose: The purpose of this paper was to review scientific evidence supporting partial pulpotomy and its high success rate and illustrate the clinical technique by presenting 2 challenging cases of complicated crown fractures with long term follow-up.
Key points in the article discussion:
I. General:
A. Partial pulpotomy/vital pulp amputation/Cvek Pulpotomy, is a procedure that involves the surgical amputation of a TRAUMATICALLY EXPOSED pulp.
B. Dr. Cvek reported in 1978 that 96% of traumatically exposed pulps that were treated within 30 hours experienced "healing".
C. Procedure:
1. High speed with sterile diamond bur.
2. RDI
3. Saline rinse
4. Chlorhexidine antiseptic
5. 2 mm partial pulpotomy
6. CaOH placed on the NON-hemorrhaging pulp
7. Layer of ZOE
8. Final resin restoration.
9. MANY studies since then with varying results and techniques.
II. CASE REPORT #1
A. Healthy, 10yo, male, dental injury on swimming pool bottom, sheared-off maxillary centrals.
B. Nurse concluded his centrals had been "knocked out" and transported the fragments in milk to pedodontist... within 30 minutes (***immediate neuro screening***).
C. Exam and radiographs taken. No other significant injury other than fractured centrals.
D. Maxillary Centrals: non-hemorrhagic pulp exposures, no root fractures, PDL concussion, nearly closed apices.
E. Tx: 2-3 mm cvek pulpotomy, saline rinse, CaOH, GI cement, composite restoration.
F. Recc: soft diet, perfect OH, Tx options discussed.
G. 3wks: fractured segments re-bonded
H. Mouthgaurd delivered.
I. 3mo recare for a yr and then normal visits.
J. At 42 mo, no periapical pathology and normal vitality test responses.
K. SUCCESS! ... tooth vitality maintained and final closure of the root end obtained.
L. Ortho performed at 24 months with no adverse outcomes.
M. 2 uneventful debonds of the bonded fragments, but no other sequelae.
III. CASE REPORT #2
A. Healthy, 7yo, female, dental injury during archeological dig (totally normal activity for 7yo's), sheared-off maxillary centrals.
B. Dig was 5hr away from nearest civilization... 6.5 hours between trauma and dental care.
C. Exam performed and radiographs taken. No other significant intraoral injury other than fractured/SLIGHTLY mobile centrals. Unsure whether fracture extended sub-g or more apically toward the roots.
D. Same procedure as Case #1
E. Teeth continued to erupt normally and apices closed.
F. At 12 mo, fully erupted and complete restoration/seal placed.
G. At 24 mo, ortho.
H. By 60 mo, Rt central showed delayed response to cold. Increased pulp canal obliteration (PCO) evidence over the next several years.
I. Partial eruption made this case more difficult. Definitive sealing of the coronal pulp was delayed until full eruption.
Assessment of article: Quality write-ups... HOWEVER. I didn't really learn anything new.... "Medium Likey"
Date: 27OCT10
Region: Providence
Article title: Two Case Reports of Complicated Permanent Crown Fractures Treated With Partial Pulpotomies
Author(s): McIntyre, Judy
Journal: Pediatric Dentistry
Page #s: 117-122
Date: Mar/Apr 2009, V31:No2
Major topic: Par
Minor topic(s): NA
Type of Article: Case Reports
Main Purpose: The purpose of this paper was to review scientific evidence supporting partial pulpotomy and its high success rate and illustrate the clinical technique by presenting 2 challenging cases of complicated crown fractures with long term follow-up.
Key points in the article discussion:
I. General:
A. Partial pulpotomy/vital pulp amputation/Cvek Pulpotomy, is a procedure that involves the surgical amputation of a TRAUMATICALLY EXPOSED pulp.
B. Dr. Cvek reported in 1978 that 96% of traumatically exposed pulps that were treated within 30 hours experienced "healing".
C. Procedure:
1. High speed with sterile diamond bur.
2. RDI
3. Saline rinse
4. Chlorhexidine antiseptic
5. 2 mm partial pulpotomy
6. CaOH placed on the NON-hemorrhaging pulp
7. Layer of ZOE
8. Final resin restoration.
9. MANY studies since then with varying results and techniques.
II. CASE REPORT #1
A. Healthy, 10yo, male, dental injury on swimming pool bottom, sheared-off maxillary centrals.
B. Nurse concluded his centrals had been "knocked out" and transported the fragments in milk to pedodontist... within 30 minutes (***immediate neuro screening***).
C. Exam and radiographs taken. No other significant injury other than fractured centrals.
D. Maxillary Centrals: non-hemorrhagic pulp exposures, no root fractures, PDL concussion, nearly closed apices.
E. Tx: 2-3 mm cvek pulpotomy, saline rinse, CaOH, GI cement, composite restoration.
F. Recc: soft diet, perfect OH, Tx options discussed.
G. 3wks: fractured segments re-bonded
H. Mouthgaurd delivered.
I. 3mo recare for a yr and then normal visits.
J. At 42 mo, no periapical pathology and normal vitality test responses.
K. SUCCESS! ... tooth vitality maintained and final closure of the root end obtained.
L. Ortho performed at 24 months with no adverse outcomes.
M. 2 uneventful debonds of the bonded fragments, but no other sequelae.
III. CASE REPORT #2
A. Healthy, 7yo, female, dental injury during archeological dig (totally normal activity for 7yo's), sheared-off maxillary centrals.
B. Dig was 5hr away from nearest civilization... 6.5 hours between trauma and dental care.
C. Exam performed and radiographs taken. No other significant intraoral injury other than fractured/SLIGHTLY mobile centrals. Unsure whether fracture extended sub-g or more apically toward the roots.
D. Same procedure as Case #1
E. Teeth continued to erupt normally and apices closed.
F. At 12 mo, fully erupted and complete restoration/seal placed.
G. At 24 mo, ortho.
H. By 60 mo, Rt central showed delayed response to cold. Increased pulp canal obliteration (PCO) evidence over the next several years.
I. Partial eruption made this case more difficult. Definitive sealing of the coronal pulp was delayed until full eruption.
Assessment of article: Quality write-ups... HOWEVER. I didn't really learn anything new.... "Medium Likey"
Pulp Revascularization of a Necrotic, Infected, Immature, Permanent Tooth
Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:Case Report: Pulp Revascularization of a Necrotic, Infected, Immature, Permanent Tooth
Author(s): Thibodeau DMD MS, Blayne
Journal: Ped. Dent.
Year. Volume (number). Page #’s: 2009. v31 N2. 145-149
Major topic: Pulp Revasc.
Minor topic(s): Methods/new treatment options
Main Purpose: Present the case of a 9 yo pt. Wherein revasc. Of the infected, necrotic pulp space of an immature permanent maxillary central incisor was induced in vivo by stimulation of a blood clot from the periapical tissues into the canal space
Overview of method of research:
9 yo Caucasian male was seen in the ER clinic at UNC School of Dentistry for evaluation of a maxillary anterior swelling assoc. with #8. Dental hx revealed that the pt. Had suffered dental trauma approx. 2 years ago. There was an Ellis III fracture, which was treated with a cvek pulpotomy 2 days after the incident. RDI was NOT used during this procedure due to the tooths partial eruption. At the current ER visit, the tooth tested necrotic to cold, WNL to percussion, palpation, and probing depths. #8 was diagnosed w/ a necrotic pulp and PA abscess. It was initially treated by I and D.
At the next visit, the tooth was disinfected w/ betadine, anesthesized, and isolated w/ RDI. Pulp was accessed, irrigated copiously w/ 1.25% NaOCl, and dried w/ paper points. A creamy past of equal portions of metronidazole, ciprofloxacin, and ceclor mixed w/ sterile water was put in the canal by lentulo spiral. The paste was tapped down by the blunt ends of paper points. A cotton pellet was placed, and IRM was used to restore the prep. Notice that no instrumentation was done.
At the 11 week FU appt. the pt. Was asymptomatic. Again, under LA the tooth was disinfected w/ betadine, and RDI was sued. The paste was irrigated away w/ NaOCl and 10 ml of sterile water. Again, no instrumentation of the canal space was done. The apical tissue was stimulated with an endo file to induce bleeding. 15 minutes was allowed for a blood clot to form that approximated the CEJ. MTA was mixed w/ sterile water and was placed over the clot. A cotton pellet was placed over the MTA. After one hour of letting the MTA set, the cotton pellet was removed, and a bonded composite was used to restore the tooth.
At the 3 months FU, pulp test was WNL for all but cold, to which there was no response. The pt. Was asymptomatic. Radiographically there was diffuse radiopacities w/I the canal space. At the 6 and 9 ½ month FU, the was the same pulp responses as the3 month FU, and there were more and more radiopacities at each FU visit.
At the 1 year appt., the tooth tested the same, however radiographically there was normal PA structure w/ cont. root development and calc. Of the canal space.
at the 16 month FU, the tooth cont. to develop nicely. 41 months after the blood clot induction, the pt is in full ortho tx, and completely asymptomatic.
Findings:
Traditional techniques of chemomechanical instrumentation/disinfection of the root canal used in mature permanent teeth are limited in immature permanent teeth due to anatomy. The open apex is difficult to seal b/c the is no apical stop. Also, arrested development of the dentinal walls from necrosis leaves the tooth weak, and susceptible to fracture. Traditional tx included long term application of CaOH2, However, Andreason has showed that this may lead to even weaker walls, making a fracture easier. Under the new treatment philosophy, the necrotic pulp acts as a scaffold for the in growth of new tissue. The KEY FACTOR for success is proper disinfection of the root canal system. This is theorized to be essential to create the environment in which revasc. Can occur. Various combinations of topical antibiotics such as metro, cirpo, and ceclor have been used to disfinect the carious dentitn and necrotic roots.
A bacteria free canal is necessary for tissue regeneration, however tissue cannot grow into a dead space. Thus, the idea of using the disinfected necrotic tissue as a scaffold was introduced. The blood clot that is induced to form over the tissue consists of many growth and differential factors, important in wound healing, and it contains cross linked fibrin, serving as a pathway for the migration of cells.
Key points/Summary:
The case report illustrates the potential for revasc. Of a necrotic, infected tooth. Even if the tissue undergoes necrosis and subsequent infection at a later time, the prognosis for conventional RCT is much better than had it been with the open apex. If progressive calcification continues to proliferate to the point of canal obliteration, vitality will most likely be maintained. It’s important to remember that case selection is important with this treatment protocol. It is encouraged for teeth with pulpal necrosis with an immature apex that is open >1mm MD radiographically. Materials for the procedure can be obtained and mixed at any pharmacy. If revasc is not successful, traditional tx should be completed.
Assessment of Article:
Very interesting article to read. Took a different approach than the conventional treatment/wisdom.. I’d like to try it.
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:Case Report: Pulp Revascularization of a Necrotic, Infected, Immature, Permanent Tooth
Author(s): Thibodeau DMD MS, Blayne
Journal: Ped. Dent.
Year. Volume (number). Page #’s: 2009. v31 N2. 145-149
Major topic: Pulp Revasc.
Minor topic(s): Methods/new treatment options
Main Purpose: Present the case of a 9 yo pt. Wherein revasc. Of the infected, necrotic pulp space of an immature permanent maxillary central incisor was induced in vivo by stimulation of a blood clot from the periapical tissues into the canal space
Overview of method of research:
9 yo Caucasian male was seen in the ER clinic at UNC School of Dentistry for evaluation of a maxillary anterior swelling assoc. with #8. Dental hx revealed that the pt. Had suffered dental trauma approx. 2 years ago. There was an Ellis III fracture, which was treated with a cvek pulpotomy 2 days after the incident. RDI was NOT used during this procedure due to the tooths partial eruption. At the current ER visit, the tooth tested necrotic to cold, WNL to percussion, palpation, and probing depths. #8 was diagnosed w/ a necrotic pulp and PA abscess. It was initially treated by I and D.
At the next visit, the tooth was disinfected w/ betadine, anesthesized, and isolated w/ RDI. Pulp was accessed, irrigated copiously w/ 1.25% NaOCl, and dried w/ paper points. A creamy past of equal portions of metronidazole, ciprofloxacin, and ceclor mixed w/ sterile water was put in the canal by lentulo spiral. The paste was tapped down by the blunt ends of paper points. A cotton pellet was placed, and IRM was used to restore the prep. Notice that no instrumentation was done.
At the 11 week FU appt. the pt. Was asymptomatic. Again, under LA the tooth was disinfected w/ betadine, and RDI was sued. The paste was irrigated away w/ NaOCl and 10 ml of sterile water. Again, no instrumentation of the canal space was done. The apical tissue was stimulated with an endo file to induce bleeding. 15 minutes was allowed for a blood clot to form that approximated the CEJ. MTA was mixed w/ sterile water and was placed over the clot. A cotton pellet was placed over the MTA. After one hour of letting the MTA set, the cotton pellet was removed, and a bonded composite was used to restore the tooth.
At the 3 months FU, pulp test was WNL for all but cold, to which there was no response. The pt. Was asymptomatic. Radiographically there was diffuse radiopacities w/I the canal space. At the 6 and 9 ½ month FU, the was the same pulp responses as the3 month FU, and there were more and more radiopacities at each FU visit.
At the 1 year appt., the tooth tested the same, however radiographically there was normal PA structure w/ cont. root development and calc. Of the canal space.
at the 16 month FU, the tooth cont. to develop nicely. 41 months after the blood clot induction, the pt is in full ortho tx, and completely asymptomatic.
Findings:
Traditional techniques of chemomechanical instrumentation/disinfection of the root canal used in mature permanent teeth are limited in immature permanent teeth due to anatomy. The open apex is difficult to seal b/c the is no apical stop. Also, arrested development of the dentinal walls from necrosis leaves the tooth weak, and susceptible to fracture. Traditional tx included long term application of CaOH2, However, Andreason has showed that this may lead to even weaker walls, making a fracture easier. Under the new treatment philosophy, the necrotic pulp acts as a scaffold for the in growth of new tissue. The KEY FACTOR for success is proper disinfection of the root canal system. This is theorized to be essential to create the environment in which revasc. Can occur. Various combinations of topical antibiotics such as metro, cirpo, and ceclor have been used to disfinect the carious dentitn and necrotic roots.
A bacteria free canal is necessary for tissue regeneration, however tissue cannot grow into a dead space. Thus, the idea of using the disinfected necrotic tissue as a scaffold was introduced. The blood clot that is induced to form over the tissue consists of many growth and differential factors, important in wound healing, and it contains cross linked fibrin, serving as a pathway for the migration of cells.
Key points/Summary:
The case report illustrates the potential for revasc. Of a necrotic, infected tooth. Even if the tissue undergoes necrosis and subsequent infection at a later time, the prognosis for conventional RCT is much better than had it been with the open apex. If progressive calcification continues to proliferate to the point of canal obliteration, vitality will most likely be maintained. It’s important to remember that case selection is important with this treatment protocol. It is encouraged for teeth with pulpal necrosis with an immature apex that is open >1mm MD radiographically. Materials for the procedure can be obtained and mixed at any pharmacy. If revasc is not successful, traditional tx should be completed.
Assessment of Article:
Very interesting article to read. Took a different approach than the conventional treatment/wisdom.. I’d like to try it.
Partial pulpotomy for immature permanent teeth, it’s present and future
Resident: J. Hencler
Date: 10/27/2010
Article title: Partial pulpotomy for immature permanent teeth, it’s present and future
Author(s): Fong, Davis
Journal: Pediatric Dentistry 24:1, 2002
Major topic: Pulp treatment options
Type of Article: Review Article
Main Purpose:
Review the application of partial pulpotomy in immature permanent teeth and provide prognostic and technical guidance.
Background:
In a mature tooth w/ fully formed roots, an exposed pulp should be completely removed, and the root canals should be obturated permanently. However definitive RCT in an immature tooth will arrest dentin deposition, resulting in a root w/ a thin dentinal wall and predisposed to fracture. Therefore it is appropriate to preserve as much vital pulp as possible, which will enable continued dentin deposition and root formation. There are 3 techniques available for tx of immature teeth w/ exposed vital pulps: direct pulp capping, complete pulpotomy, and partial pulpotomy. Direct pulp capping is considered to be so unpredictable that several authors suggest it be removed from tx consideration. Complete pulpotomy will arrest dentin formation in immature permanent teeth and can result in root canal obliteration. It should be followed with complete endo when root development is complete. Partial pulpotomy is the removal of the outer layer of damaged, hyperemic tissue in exposed pulps. Recent reports of partial pulpotomy for teeth w/ cariously exposed pulps and crown fracture exposed pulps have shown high success rates and good results. Indications for permanent tooth partial pulpotomy include: 1) tooth has no hx of spontaneous pain, 2) tooth has acute minor pain that subsides w/ analgesics, 3) tooth has no discomfort to percussion, no vestibular swelling, and no mobility, 4) radiographic exam shows normal PDL, 5) pulp is exposed during caries removal or recent trauma, 6) tissue appears vital, 7) bleeding from pulp excision site stops with isotonic saline irrigation w/in 2 mins.
Partial Pulpotomy Technique:
LA, RDI, smooth sharp edges or remove caries. The exposed pulp and surrounding dentin are flushed clean with isotonic saline solution. The superficial layer of exposed pulp and surrounding dentin are excised to a depth of about 2mm using a high-speed sterile diamond bur w/ light touch and waterspray cooling. The remaining is irrigated gently w/ isotonic saline until bleeding has stopped and a pulpal medicament containing CaOH is applied to the wound surface. Care should be taken to avoid a blood clot. Dry, sterile cotton pellets are used to apply modest pressure to adapt the medicament to the prepared cavity and to remove excess water from the paste. The remaining coronal cavity is restored with a material that provides a long-term seal to avoid subsequent leakage.
Discussion:
When considering a tooth w/ pulp exposure the most important factor in determining tx is degree of infection and inflammation. Studies show that in the pulp subjacent to a carious lesion, just prior to or soon after pulp exposure, bacterial components cause local irreversible changes, abscesses or necrosis just beneath the exposure. The deeper remaining pulp continues to be free from significant inflammatory changes. When pulpal infection and/or inflammation are restricted to the coronal portion of the pulp chamber, unaffected healthy pulp tissue remains in the deeper portion of the root canal system. Theoretically, removal of the compromised/infected tissue should lead to preservation of a remaining vital, functioning pulp. Currently, the pulpal dx is based on the extent of pulpal hemorrhages. Failur of bleeding to stop after 2 min of saline irrigation reveals an extensive pulpal inflammation and suggests that more tissue needs to be removed or instead another procedure such as a complete pulpotomy is indicated. In trauma cases, reports show that time b/t injury and tx actually has limited influence on the outcome of partial pulpotomy. Partial pulpotomy, rather than direct pulp capping or complete pulpotomy, is the tx of choice following traumatic or carious pulp exposure in immature permanent teeth. Size of the pulp exposure plays a limited role in tx decision, instead the condition of the pulp and the degree of bacterial contamination largely determine the progress of vital pulp tx. One of the advantages of partial pulpotomy is the preservation of cell-rich coronal tissue, which possesses better healing potential and can maintain the deposition of dentin in the cervical area. Healing of the dental pulp after tx is dependent on the capacity of restorative material to seal and prevent leakage and bacterial invasion.
Summary of conclusions:
Partial pulpotomy is a worthy alternative to direct pulp capping and complete pulpotomy when tx immature permanent teeth with exposed pulps.
Assessment of article:
Great review article, very interesting. I wish it offered more info on available medicaments used during partial pulpotomies
Date: 10/27/2010
Article title: Partial pulpotomy for immature permanent teeth, it’s present and future
Author(s): Fong, Davis
Journal: Pediatric Dentistry 24:1, 2002
Major topic: Pulp treatment options
Type of Article: Review Article
Main Purpose:
Review the application of partial pulpotomy in immature permanent teeth and provide prognostic and technical guidance.
Background:
In a mature tooth w/ fully formed roots, an exposed pulp should be completely removed, and the root canals should be obturated permanently. However definitive RCT in an immature tooth will arrest dentin deposition, resulting in a root w/ a thin dentinal wall and predisposed to fracture. Therefore it is appropriate to preserve as much vital pulp as possible, which will enable continued dentin deposition and root formation. There are 3 techniques available for tx of immature teeth w/ exposed vital pulps: direct pulp capping, complete pulpotomy, and partial pulpotomy. Direct pulp capping is considered to be so unpredictable that several authors suggest it be removed from tx consideration. Complete pulpotomy will arrest dentin formation in immature permanent teeth and can result in root canal obliteration. It should be followed with complete endo when root development is complete. Partial pulpotomy is the removal of the outer layer of damaged, hyperemic tissue in exposed pulps. Recent reports of partial pulpotomy for teeth w/ cariously exposed pulps and crown fracture exposed pulps have shown high success rates and good results. Indications for permanent tooth partial pulpotomy include: 1) tooth has no hx of spontaneous pain, 2) tooth has acute minor pain that subsides w/ analgesics, 3) tooth has no discomfort to percussion, no vestibular swelling, and no mobility, 4) radiographic exam shows normal PDL, 5) pulp is exposed during caries removal or recent trauma, 6) tissue appears vital, 7) bleeding from pulp excision site stops with isotonic saline irrigation w/in 2 mins.
Partial Pulpotomy Technique:
LA, RDI, smooth sharp edges or remove caries. The exposed pulp and surrounding dentin are flushed clean with isotonic saline solution. The superficial layer of exposed pulp and surrounding dentin are excised to a depth of about 2mm using a high-speed sterile diamond bur w/ light touch and waterspray cooling. The remaining is irrigated gently w/ isotonic saline until bleeding has stopped and a pulpal medicament containing CaOH is applied to the wound surface. Care should be taken to avoid a blood clot. Dry, sterile cotton pellets are used to apply modest pressure to adapt the medicament to the prepared cavity and to remove excess water from the paste. The remaining coronal cavity is restored with a material that provides a long-term seal to avoid subsequent leakage.
Discussion:
When considering a tooth w/ pulp exposure the most important factor in determining tx is degree of infection and inflammation. Studies show that in the pulp subjacent to a carious lesion, just prior to or soon after pulp exposure, bacterial components cause local irreversible changes, abscesses or necrosis just beneath the exposure. The deeper remaining pulp continues to be free from significant inflammatory changes. When pulpal infection and/or inflammation are restricted to the coronal portion of the pulp chamber, unaffected healthy pulp tissue remains in the deeper portion of the root canal system. Theoretically, removal of the compromised/infected tissue should lead to preservation of a remaining vital, functioning pulp. Currently, the pulpal dx is based on the extent of pulpal hemorrhages. Failur of bleeding to stop after 2 min of saline irrigation reveals an extensive pulpal inflammation and suggests that more tissue needs to be removed or instead another procedure such as a complete pulpotomy is indicated. In trauma cases, reports show that time b/t injury and tx actually has limited influence on the outcome of partial pulpotomy. Partial pulpotomy, rather than direct pulp capping or complete pulpotomy, is the tx of choice following traumatic or carious pulp exposure in immature permanent teeth. Size of the pulp exposure plays a limited role in tx decision, instead the condition of the pulp and the degree of bacterial contamination largely determine the progress of vital pulp tx. One of the advantages of partial pulpotomy is the preservation of cell-rich coronal tissue, which possesses better healing potential and can maintain the deposition of dentin in the cervical area. Healing of the dental pulp after tx is dependent on the capacity of restorative material to seal and prevent leakage and bacterial invasion.
Summary of conclusions:
Partial pulpotomy is a worthy alternative to direct pulp capping and complete pulpotomy when tx immature permanent teeth with exposed pulps.
Assessment of article:
Great review article, very interesting. I wish it offered more info on available medicaments used during partial pulpotomies
Multifaceted Use of ProRoot MTA Root Canal Repair Material
Date: 10/27/2010
Resident: Cho
Author(s): Schmitt et al.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2001. 23. 326-330.
Major topic: ProRoot MTA
Minor topic: Root Canal Repair
Type of Article: Review Article
Main Purpose: The purpose is the review MTA’s physical and biological properties and the clinical techniques of direct pulp capping, apexification, and repair of failed calcium hydroxide therapy.
Overview of method of research: Review of research studies
Findings: MTA is an ash-colored powder made of fine hydrophilic particles of tricalcium aluminate, tricalcium silicate, silicate oxide, and tricalcium oxide. When the material is hydrated it becomes a colloidal gel. The main components of MTA are calcium phosphate and calcium oxide. The material sets in 3-4 hours and bismuth oxide powder is added for radiopacity. The setting ability is uninhibited by blood or water. The pH of MTA when it is set is 12.5, which is similar to calcium hydroxide. MTA has a compressive strength of about 70 MPA, which is approximately equal to that of IRM but less than amalgam (311 MPA). MTA also has some antimicrobial properties and low cytotoxicity. The biocompatibility of MTA has been found to be equal or superior to amalgam, IRM, and ZOE. In non-human studies of perforation repair using MTA, cementum was shown to grow over MTA with minimal inflammation, even when material was extruded beyond the perforation site. MTA stimulated the release of cytokines and production of interleukin. The price of one box of 5 one-gram packets with a carrier cost about $300 (each packet is for one-time use only). MTA can be used for direct pulp capping, repair of internal and external resorption, root end filling, apexification, and repair of root perforations.
In direct pulp capping, once caries has been removed, irrigate with NaOCl for 5-10 minutes to achieve hemostasis of the pulpal exposure. Rinse out NaOCl and place 1-1.5mm layer of MTA directly over the exposed pulp. Place wet cotton pellet over the MTA and temporize. After one week, the proper setting of MTA should be verified and a final restoration can be placed directly over the MTA. The patient should be followed up in six months.
In apexification, after extirpirating the pulp and canals, irrigate with NaOCl. Place CaOH in canals to disinfect the canals. After one week, rinse canals with NaOCl, then place 3-4mm MTA in the apical end of the root to form an apical plug. Take an xray to confirm the fill. Place a moist cotton pellet and temporize. After one week, the canal can then be obturated and then should have radiographic and clinical re-assessments every 2-3 months. MTA is non-resorbable and shows excellent marginal adaptability which makes it a more superior material for apexification as opposed to CaOH. Also, with MTA, apexogenesis of immature root apices can be stimulated. MTA in the repair of failed calcium hydroxide therapy can be used in a way much like the method described for apexification.
Key points/Summary:
MTA can be used for immature permanent teeth that have a pulpal exposure due to caries or trauma. Animal studies and short-term clinical studies using MTA have shown to have good results. However, long-term studies still need to be conducted regarding MTA.
Assessment of Article:
Good summary of the composition of MTA and step-by-step explanation of how to use MTA for various circumstances. I agree that more research needs to be conducted to test the long-term success of MTA.
Tuesday, October 26, 2010
Obturation of Avulsed Immature Permanent Incisor with MTA
Resident: Swan
Article Title: Complete Endodontic Obturation of an Avulsed Immature Permanent Incisor with Mineral Trioxide Aggregate: A Case Report
Author: Karp, et al.
Journal: Pediatric Dentistry; case report
Volume (Number): 28:3, 2006
Major Topic: novel therapy for treating avulsed immature permanent incisor
Type of Article: case report
Overview of Case: 9 y.o. boy was struck in mouth at close range by a golf ball. Left central incisor was avulsed, placed in water for 10 mintues, in cold milk for 10 minutes, then replaced in socket by they family. PA revealed immature incisors with open apices. Incisor was repositioned and splinted with fishing line. Splint removed after two weeks, with no symptoms or radiographic change noted. One month later, tooth showed normal mobility, color, and response to percussion/palpation. PA revealed external inflammatory resorption in the middle to cervical 3rd of the root. Apexification was carried out using CaOH powder/2% lidocaine mixture. Material was placed into root canal space using a 25 mm lentulo spiral in a slow-speed handpiece.
One month later, tooth presents the same clinically with further external root resorption noted radiographically.
Three months later, tooth clinically normal, with cessation of external resorption. A well-defined PDL space was evident along with osseous regeneration in the areas of previous inflammation. CaOH paste was changed out.
After three months, calcific barrier had not formed yet; CaOH paste was changed for last time.
At one year mark post injury, pt reports no symptoms, but radiographically the tooth had undergone pulp canal obliteration.
Three months later, after consultation with an endodontist, the tooth was obturated with MTA to the CEJ. MTA was mixed with sterile water and placed in canal with a large amalgam carrier and condensed with a plugger. After 865 days, the patient was asymptomatic with no signs of replacement resorption or pathology on radiograph.
Findings: MTA (powder made of mainly lime, silica, and bismuth oxides) mixed with water has been advocated as a root-end-filling material for endo on immature permanent teeth. The authors described clinical success using MTA as an obturation material. They used MTA because they feared the external resorption had possibly perforated the middle to cervical third of the root; MTA has superior marginal integrity resulting in reduced bacterial microleakage; it also is believed to be able to induce hard tissue formation in areas of previous external resorption. Thus, MTA was chosen as opposed to Gutta percha or composite resin. The described case showed excellent clinical results after 2+ years.
Key Points/Summary: Another great potential use for MTA—canal obturation of immature permanent teeth.
Assessment of Article: Great case. Technique should definitely be examined in larger numbers.
Pulpal blood flow in vital and nonvital young permanent teeth measured by transmitted-light phtoplethysmography: a pilot study
Resident: Roberts
Date: 10/27/10
Article title: Pulpal blood flow in vital and nonvital young permanent teeth measured by transmitted-light phtoplethysmography: a pilot study
Author: Miwa, Zenzo
Journal: Pediatric Dentistry
Volume:24:6
Year: 2002
Discussion
Transmitted light Photoplethysography(TLP) is a non-invasive technique used to monitor PBF, and has been applied in various circumstances for the testing of cats, dogs, and other animals( including humans- adult teeth that are fully mature). In this study, 26 healthy and 7 nonvital upper maxillary incisors in 17 children(ages 7 - 14) were examined. Recordings revealed that pulse waves from a TLP were synchronous with those from a Finger photopethysmography(FPP) when evaluating vital and healthy teeth, whereas no pulse signals were recognized in nonvital teeth. Also, in healthy teeth there was a significant correlation between the TLP pulse amplitude and that o the patients age.
Conclusion: TLP can detect pulpal blood flow in young permanent teeth. This technique is considered to be applicable in the assessment of pulp vitality.
Assessment: This is the first that I have ever heard of a study of this kind. I think that its interesting but have a hard time seeing this as common practice in dentistry in the near future
Friday, October 22, 2010
Do you miss me??? - Comparison of Apexification with Mineral Trioxide Aggregate and Calcium Hydroxide
Meghan Sullivan Walsh October 22, 2010
Literature Review - St. Joseph/LMC Pediatric Dentistry
Comparison of Apexification With Mineral Trioxide Aggregate and Calcium Hydroxide
Resident: Meghan Sullivan Walsh
Program: Lutheran Medical Center- Providence
Article Title: Comparison of Apexification with Mineral Trioxide Aggregate and Calcium Hydroxide
Authors: Omar A.S. El Meligy, BDS, MSc, PhD; David Avery, DDS, MSD
Journal: Pediatric Dentistry
Volume (number), Year, Page #’s; 28:3, 2006, pages 248-253
Major Topic: Comparing success of MTA vs. Calcium Hydroxide used for Apexification
Overview of Method of Research: 30 traumatized or carious, necrotic teeth requiring root-end closure on 15 children were used for this study. Each child had two teeth requiring apexification. In each child one tooth was placed in control group 1 and the second tooth placed in group 2. In Group 1, 15 teeth were treated with Ca (OH)2 powder and an IRM seal. In Group 2, 15 teeth were first disinfected with Ca (OH)2 paste for one week, rinsed and then filled with MTA powder and sterile water, a moist cotton pellet and IRM. The children were then recalled at 3, 6, and 12 month intervals for clinical and radiographic success.
Findings: The clinical and radiographic success rates for Ca(OH)2 and MTA were 87% and 100% respectively. Of the 15 teeth in control group 1 there were two failures. At 6 months these two teeth showed widened lamina dura and periapical radioleucencies. These teeth were re-treated and at 12 months still showed signs of a persistent radioleucency.
Key Points: Summary:
While Calcium Hydroxide may be today’s material of choice for apexification, there are some disadvantages to this material. Some of these disadvantages include variability of treatment time, unpredictability of apical closure, difficulty in patient follow-up and delayed treatment. MTA has shown a diversity when it comes to applications in dentistry. With regards to apexification, studies have shown that MTA induces hard tissue formation more than Ca(OH)2, allows for bone healing and elimination of clinical symptoms. MTA shows superior biocompatibility in the oral cavity, prevents micro leakage and promotes regeneration of the original tissues when it is placed in contact with the dental pulp or periradicular tissues. All of the 15 teeth treated with MTA were successful at the 12 month follow-up visit. MTA, however, does have the disadvantage of being difficult to work with as well as expensive.
Assessment of the Article: The believe the strength of this research was that fact that the comparing treatments were performed on two teeth with similar dental pathologies in the same oral environment. While the author recognizes that the sample size was small, I believe these result are very close to accurate. We are discovering many uses for MTA and are seeing extremely successful results. Perhaps the cost will decrease as more practitioners start using MTA. I do find it unfortunate that many dentists choose not to use an extremely successful and predictable material due to cost.
Wednesday, October 20, 2010
Contemporary Perspectives on Vital Pulp Therapy: Views From the Endodontists and Pediatric Dentists
Article title: Contemporary Perspectives on Vital Pulp Therapy: Views From the Endodontists and Pediatric Dentists
Author(s): Seale & Glickman.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2008. 30:3. 261-267.
Major topic: Pulp Therapy Perspectives by Specialists
Overview of method of research: Conference Paper
Purpose:
To compare the attitudes of endodontists and pediatric dentists at a pulp therapy symposium sponsored by both the American Academy of Endodontists (AAE) and AAPD regarding opinions of vital pulp therapies.
Methods:
Pre and post symposium surveys were administered and completed via a real-time electronic audience response system (ARS). There were three main areas of interest: pulp therapy for cariously involved primary teeth, indirect pulp treatment (IPT) of carious young permanent teeth and the future of regenerative/revascularization of teeth. The pretest was 8 questions and the posttest was 20 questions and the responses were analyzed. This was the first attempt to bring these specialties together in such a manner.
This identical article was also published in the Journal of Endodontics in 2008.
Findings:
Responses of 79 endodontists and 231 pediatric dentists were used for analysis. The pretest showed that 80% of pediatric dentists strongly agreed that formocresol is an acceptable primary tooth pulpotomy agent versus 29% of endodontists. Only 5 % of pediatric dentists agreed with a statement identifying formocresol as presenting documented danger to the patient yet 15% of the endodontists agreed. 78% and 76% of pediatric dentists and endodontists respectively agreed that formo would be replaced as a pulpotomy agent due to its controversy about its potential dangers not because of its actual danger to patients.
When asked their pulpotomy agent of choice, MTA was the overwhelming top choice by both types of specialists.
Significantly more pediatric dentists (94%) than endodontists (69%) agreed that indirect pulp capping is an acceptable and contemporary technique for cariously involved young permanent teeth. Both specialists’ posttest responses significantly differed regarding symptoms of irreversible pulpitis being a contraindication to IPT from their pretest responses. 31% and 26% agreed to this statement at first, but after the symposium only 7 or 8% agreed.
47% of pediatric dentists and 58% of endodontists chose IPT as the best treatment for a reversibly inflamed primary molar with a large carious lesion encroaching the pulp. 74% of pediatric dentists and 70% of endodontists strongly agreed that IPT is successful as pulpotomy in primary teeth with reversible pulpitis.
Key points/Summary:
Practitioners in both specialties seem to agree that formocresol will eventually be replaced as a primary tooth pulpotomy medicament, MTA is by far the material of choice to take its place, IPT in primary dentition may be a replacement for pulpotomy, IPT is also an acceptable therapy for cariously involved young permanent teeth with open apices, and that pulp revascularization and regeneration are potential therapies to be utilized in the future.
Assessment of Article:
Very interesting comparison of the 2 specialties, but it would have been nice if they gave the same survey both before and after the symposium in order to draw better conclusions.
Author(s): Seale & Glickman.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2008. 30:3. 261-267.
Major topic: Pulp Therapy Perspectives by Specialists
Overview of method of research: Conference Paper
Purpose:
To compare the attitudes of endodontists and pediatric dentists at a pulp therapy symposium sponsored by both the American Academy of Endodontists (AAE) and AAPD regarding opinions of vital pulp therapies.
Methods:
Pre and post symposium surveys were administered and completed via a real-time electronic audience response system (ARS). There were three main areas of interest: pulp therapy for cariously involved primary teeth, indirect pulp treatment (IPT) of carious young permanent teeth and the future of regenerative/revascularization of teeth. The pretest was 8 questions and the posttest was 20 questions and the responses were analyzed. This was the first attempt to bring these specialties together in such a manner.
This identical article was also published in the Journal of Endodontics in 2008.
Findings:
Responses of 79 endodontists and 231 pediatric dentists were used for analysis. The pretest showed that 80% of pediatric dentists strongly agreed that formocresol is an acceptable primary tooth pulpotomy agent versus 29% of endodontists. Only 5 % of pediatric dentists agreed with a statement identifying formocresol as presenting documented danger to the patient yet 15% of the endodontists agreed. 78% and 76% of pediatric dentists and endodontists respectively agreed that formo would be replaced as a pulpotomy agent due to its controversy about its potential dangers not because of its actual danger to patients.
When asked their pulpotomy agent of choice, MTA was the overwhelming top choice by both types of specialists.
Significantly more pediatric dentists (94%) than endodontists (69%) agreed that indirect pulp capping is an acceptable and contemporary technique for cariously involved young permanent teeth. Both specialists’ posttest responses significantly differed regarding symptoms of irreversible pulpitis being a contraindication to IPT from their pretest responses. 31% and 26% agreed to this statement at first, but after the symposium only 7 or 8% agreed.
47% of pediatric dentists and 58% of endodontists chose IPT as the best treatment for a reversibly inflamed primary molar with a large carious lesion encroaching the pulp. 74% of pediatric dentists and 70% of endodontists strongly agreed that IPT is successful as pulpotomy in primary teeth with reversible pulpitis.
Key points/Summary:
Practitioners in both specialties seem to agree that formocresol will eventually be replaced as a primary tooth pulpotomy medicament, MTA is by far the material of choice to take its place, IPT in primary dentition may be a replacement for pulpotomy, IPT is also an acceptable therapy for cariously involved young permanent teeth with open apices, and that pulp revascularization and regeneration are potential therapies to be utilized in the future.
Assessment of Article:
Very interesting comparison of the 2 specialties, but it would have been nice if they gave the same survey both before and after the symposium in order to draw better conclusions.
Regenration Potential of the Young Permanent Tooth
Resident: Swan
Article Title: Regeneration Potential of the Young Permanent Tooth: What Does the Future Hold?
Authors: Hargreaves, M. et al. (Endodontists)
Journal: Pediatric Dentistry May/June 2008 V 30 No 3
Type of Article: Conference Paper
Main Purpose: Discuss the current therapies for necrotic teeth with incompletely developed roots, along with need for continued development of biologically-based treatments that offer potential for hard tissue regeneration.
Points of Discussion:
1. Discussion of the best current therapies (apexification with long-term CaOH or MTA) that achieve good clinical results
2. Discussion of recent case reports offering offering biologically based alternative treatments
Estbalished precepts:
-revascularization occurs more predictably in teeth with open apices
-Instrumentation with NaOCl irrigation is not sufficient to reliably create needed conditions for revascularization of necrotic tooth (antibiotic paste also necessary to clear infection)
-use of "3 mix-MP" triple antibiotic paste (Cipro, Metronidazole, minocycline) is effective for disinfection of necrotic tooth canal space, setting conditions for revascularization (deliver with Lentulo spiral)
-Placement of CaOH in canal prevents revascularization coronal to location of CaOH paste
3. Key features of published cases:
a. immature permanent with wide apical opening is conducive to tissue ingrowth
b. younger patients (8-13) have greater healing capacity or stem cell regenerative potential
c. no case used instrumentation of the root canal walls; all used NaOCl as an irrigant
d. CaOH paste and combinations of multiple antibiotics were used in these patients (many of the CaOH-treated patients displayed intracanal calcifications that appear to impede dentinal wall thickening
e. formation of a blood clot might serve as a protein scaffold, permitting ingrowth of tissue.
f. nearly every study reported continued thickening of dentinal walls and subsequent apical closure
Main Concepts of Tissue Engineering:
1. Cell source
-odontoblasts can come from dental pulp, apical papilla
-apical papilla=dental papilla at apex of developing tooth. It's loosely attached to the apex,
can be detached with tweezers. Has collateral circulation, unlike pulp, so possibly can
better survive necrosis.
-it's unclear where the root development described in the cases above comes from
-could be from residual vital pulp cells, cells from apical papilla that proliferated, or
bleeding-induced angiogenesis that recruited stem cells from the apical tissues.
2. Physical scaffold
-extracellular matrices needed to promote cell growth and differentiation
-Platelet Rich Plasma (PRP) may be the best available option
3. Signaling molecules
-EDTA effectively releases growth factors from human dentin
Assessment: Interesting article discussing the concept of dentin/pulp regeneration and what's on the horizon there. Me likey.
Regenerative Potential of Dental Pulp
Resident: J. Hencler
Date: 10/20/2010
Article title: Regenerative Potential of Dental Pulp
Author(s): Martin Trope, DMD
Journal: Pediatric Dentistry V30/ No 3 May/Jun 2008
Major topic: Pulp regeneration
Type of Article: Conference paper
Main Purpose: Explore the potential for pulp regeneration as a routine dental procedure.
Background: The inflamed pulp unexposed by caries or trauma has potential for repair. Our diagnostic ability to differentiate vital from necrotic is good, but reversible from irreversible inflamed pulp remains an educated guess. The younger the pulp, the better it’s repair potential. Vital therapy (pulp capping, partial or full pulpotomy) on traumatically exposed pulps is very successful, whereas vital pulp therapy on cariously exposed tooth is not nearly as successful. The difference in success rates is explained by the status of the pulp at the time of the procedure. A very important factor in the success of treating a vital exposure is the coronal seal. PEDO approach: B/c the young vital pulp has good potential for repair, it is accepted to perform an indirect or direct pulp cap on a carious exposure as long as a ideal coronal restoration can be placed. ENDO approach: Perform a full pulpotomy and treat the presumable healthy pulp at the canal orifices. When the root canal has developed thick dentinal walls and apices are closed, a full pulpectomy can be performed.
Pulp Revascularization: Revascularization of an immature necrotic tooth has many potential advantages. It has been shown that under certain conditions revascularization can be achieved in young teeth that have been traumatically avulsed, leaving a necrotic but uninfected pulp. Attempting to reproduce these conditions when the pulp space is infected could possibly lead to revascularization of an infected pulp. It has been experimentally shown that the apical portion of the pulp might remain vital and proliferate after reimplantation, replacing the necrotized coronal portion of the pulp. The ischemically necrotic pulp that is unique to an avulsion injury acts as a scaffold into which the new tissue grows, and the fact that the crown is usually intact slows bacterial penetration. Revascularization of the pulp space in a necrotic, infected tooth w/ apical periodontitis in the 1960’s but was unsuccessful. A more recent case report found that it might be possible to replicate the unique circumstances of an avulsed tooth to revascularize the pulp in infected necrotic immature roots. CASE DETAILS: An immature 2nd lower right pre-molar presents with radiographic and clinical signs of apical periodontitis w/ presence of sinus tract/fistula. The canal was disinfected w/out mechanical instrumentation but w/ copious irrigation w/ 5.25% sodium hypochlorite and the use of a mixture of ciprofloxacin, metronidazole, and minocycline. A blood clot was produced to the level of the CEJ to provide a scaffold for the in growth of new tissue followed by a double seal of MTA in the cervical area and a bonded resin coronal restoration above it. The large radiolucency had disappeared w/in 2 months and at the 24-month recall it was obvious that the root walls were thick, and the root development continued. The antibacterial effectiveness of the tri-antibiotic paste was confirmed in a study using a dog model w/ infected immature roots. This study also showed that a blood clot was essential as a scaffold. It is unknown what factors in the blood clot are important, but if isolated, they can be incorporated into a synthetic scaffold that will be easier for clinicians to manipulate compared to a blood clot.
Summary of conclusions: Recreating the pulp conditions of a young avulsed tooth may be the key to pulp revascularization in carious infected pulps.
Assessment of article: Great article, very interesting.
Date: 10/20/2010
Article title: Regenerative Potential of Dental Pulp
Author(s): Martin Trope, DMD
Journal: Pediatric Dentistry V30/ No 3 May/Jun 2008
Major topic: Pulp regeneration
Type of Article: Conference paper
Main Purpose: Explore the potential for pulp regeneration as a routine dental procedure.
Background: The inflamed pulp unexposed by caries or trauma has potential for repair. Our diagnostic ability to differentiate vital from necrotic is good, but reversible from irreversible inflamed pulp remains an educated guess. The younger the pulp, the better it’s repair potential. Vital therapy (pulp capping, partial or full pulpotomy) on traumatically exposed pulps is very successful, whereas vital pulp therapy on cariously exposed tooth is not nearly as successful. The difference in success rates is explained by the status of the pulp at the time of the procedure. A very important factor in the success of treating a vital exposure is the coronal seal. PEDO approach: B/c the young vital pulp has good potential for repair, it is accepted to perform an indirect or direct pulp cap on a carious exposure as long as a ideal coronal restoration can be placed. ENDO approach: Perform a full pulpotomy and treat the presumable healthy pulp at the canal orifices. When the root canal has developed thick dentinal walls and apices are closed, a full pulpectomy can be performed.
Pulp Revascularization: Revascularization of an immature necrotic tooth has many potential advantages. It has been shown that under certain conditions revascularization can be achieved in young teeth that have been traumatically avulsed, leaving a necrotic but uninfected pulp. Attempting to reproduce these conditions when the pulp space is infected could possibly lead to revascularization of an infected pulp. It has been experimentally shown that the apical portion of the pulp might remain vital and proliferate after reimplantation, replacing the necrotized coronal portion of the pulp. The ischemically necrotic pulp that is unique to an avulsion injury acts as a scaffold into which the new tissue grows, and the fact that the crown is usually intact slows bacterial penetration. Revascularization of the pulp space in a necrotic, infected tooth w/ apical periodontitis in the 1960’s but was unsuccessful. A more recent case report found that it might be possible to replicate the unique circumstances of an avulsed tooth to revascularize the pulp in infected necrotic immature roots. CASE DETAILS: An immature 2nd lower right pre-molar presents with radiographic and clinical signs of apical periodontitis w/ presence of sinus tract/fistula. The canal was disinfected w/out mechanical instrumentation but w/ copious irrigation w/ 5.25% sodium hypochlorite and the use of a mixture of ciprofloxacin, metronidazole, and minocycline. A blood clot was produced to the level of the CEJ to provide a scaffold for the in growth of new tissue followed by a double seal of MTA in the cervical area and a bonded resin coronal restoration above it. The large radiolucency had disappeared w/in 2 months and at the 24-month recall it was obvious that the root walls were thick, and the root development continued. The antibacterial effectiveness of the tri-antibiotic paste was confirmed in a study using a dog model w/ infected immature roots. This study also showed that a blood clot was essential as a scaffold. It is unknown what factors in the blood clot are important, but if isolated, they can be incorporated into a synthetic scaffold that will be easier for clinicians to manipulate compared to a blood clot.
Summary of conclusions: Recreating the pulp conditions of a young avulsed tooth may be the key to pulp revascularization in carious infected pulps.
Assessment of article: Great article, very interesting.
Tuesday, October 19, 2010
Indirect Pulp Therapy and Stepwise Excavation
Resident: Cho
Author(s): Bjorndal, Lars.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2008. 30. 225-229.
Major topic: Indirect Pulp Treatment, Stepwise Excavation
Minor topic: Randomized Clinical Trial
Type of Article: Conference Paper
Main Purpose: The purpose was to provide information on the latest systematic reviews regarding indirect pulp therapy and stepwise excavation.
Overview of method of research: Systematic review
Findings:
IPT procedure involves almost complete removal of affected dentin, leaving a thin layer of demineralized dentin, and no re-entry is attempted. Stepwise excavation is similar to IPT, but it involves re-entry at varying intervals.
Very few studies on caries and pulp treatment are randomized clinical trials. Some problems arise in relation to the steps of IPT: how do you define “deep” on a carious lesion. Less than 10 studies were compared and no difference in symptoms were found at 12 months using Life, Dycal, and Cavitec formulations of calcium hydroxide for IPT.
The primary aim of the first excavation of the stepwise excavation is to change the caries environment by removing caries only up to the residual level close to the dentin-pulp interface. Microbiologic and clinical studies have shown that it is possible to decrease the number of bacteria and arrest the caries process. More detailed microbiologic data indicate that during the treatment interval the bacteria become “slow-growing.”
The final step of the stepwise excavation is to assess the tooth’s reaction and then to remove the slowly progressing lesion in the slightly infected discolored demineralized dentin before adding the final restoration.
18% of respondents would partially remove caries in a deep lesion in which one would expect that complete caries removal would lead to pulp exposure. This low percentage may be fear that leaving infected dentin may stimulate obliteration of the root canals, making future endodontic treatment more difficult. In this case, a stepwise approach may be an alternative treatment.
Clinical guidelines for stepwise excavation based on an observational study and a high-quality RCT: deep lesion evaluated by x-ray that involves ¾ or more of the dentin (no periapical pathosis, no history of spontaneous pain, mild to moderate pain on thermal stimulation is accepted), excavate the outermost necrotic and infected demineralized dentin, place a provisional material, and the final excavation should be less invasive due to dentinal changes gained, and place permanent restoration. The temporary and final restorations should provide a good seal and long-term recall should be carried out in order to have success.
Key points/Summary: More studies that are randomized clinical trials must be conducted on indirect pulp therapy and stepwise excavation to obtain a higher level of evidence. Whether the bacteria beneath a permanent restoration in a deep cavity truly remains “inactive” also needs to be further investigated. More research must be conducted whether a two-step excavation or IPT has a better clinical outcome.
Assessment of Article: This article raises a valid point that it is difficult to compare different studies involving IPT since a “deep carious lesion” is a vague term. I agree that more research needs to be conducted in this field to determine whether a one-step IPT or two-step stepwise excavation shows better clinical results.
Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Resident: Adam J. Bottrill
Date: 20OCT10
Region: Providence
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Author(s): Camp, Joe DDS MSD
Journal: Pediatric Dentistry
Page #s: 197-205
Date: May/Jun 2008, V30:No3
Major topic: Immature Tooth Vital Pulp Therapy
Minor topic(s): NA
Type of Article: Review of Literature
Main Purpose: Reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apezx. The apical barrier with mineral trioxide aggregate followed by root strengthening with bonded composite is reviewed.
Key points in the article discussion:
I. General:
A. Most of the diagnostic tests used used with endodontic therapy are of little to no value on primary teeth or immature permanent teeth.
B. Much of our Tx decisions are based on Dx of root development age... therefore it is necessary to have thorough knowledge of the rot development timeline for primary and permanent teeth.
1. Root formation is not completed for 1-4 years after eruption into the oral cavity.
C. Radiographs cannot accurately depict apical closure due to the development of canals in the lingual-facial direstion.
D. During formation and closure, Tx must be oriented at maintaining vitality and allowing the completion of root formation.
II. Dx of Pulpal Status in Primary Teeth.
A. Differentiation between provoked and spontaneous pain is vital.
1. Provoked: deep caries, faulty restorations, soreness around exfoliation and erupting permanent teeth.
2. Spontaneous: extensive degenerative changes extending into the root canals... should NOT receive vital pulp Tx. There may be other evidence of pulpal pathosis as well... mobility, fistula, percussive sensitivity etc...
B. ELECTRIC PULP TESTS ARE NOT VALID ON PRIMARY TEETH.
C. THERMAL TESTS ARE USUALLY NOT CONDUCTED ON PRIMARY TEETH.
D. Radiographic exam is necessary
1. Calcified masses are a sign of advanced pulpal degeneration... Pulpectomization or Extraction.
2. Internal resorption is also associated with extensive inflammation... Extraction.
3. Keep in mind the lucency of the succedaneous follicle.
4. Other obvious pathosis... fracture, abscess, bone fractures etc...
E. Excessive or oddly colored hemorrhage is evidence of excessive inflammation.
F. Studies have shown that trauma LIKELY will result in pulpal necrosis or at least pulpal obliteration (depending on degree of trauma, luxation, mobility etc...)
G. AVULSED PRIMARY TEETH SHOULD NOT BE REIMPLANTED.
H. About half of traumatized primary teeth will undergo discoloration.
1. Correlation of type of color change to pulpal health is controversial and inconclusive.
III. Diagnosis of Pulpal Status in Permanent Immature Teeth
A. Loss of pulp vitality before completion of root formation leaves the tooth MUCH more susceptible to root fracture.
B. Again, a history should be taken WRT history of trauma and type of pain etc...
C. Clinical and radiographic examination MOST important when diagnosing immature permanent teeth.
D. Electric pulp test and thermal test not reliable for immature, open apex teeth... also for children.
E. Electrical and Thermal tests unreliable for traumatized teeth.
F. Laser doppler flowmetry reportedly very reliable to diagnose pulpal vitality.
G. Discoloration also usually indicative of pulpal changes but not completely accurate.
H. There is MUCH better potential for an immature tooth to heal after trauma.
I. If doubtful of diagnosis, DO NOT start treatment. Attempt to allow formation of the root until definitive diagnosis can be made.
J. Lately, MTA and composite resins have been replacing CaOH, pulp cappng and pulpotomy.
K. Vital treatment of teeth with MTA, once considered taboo, is being used much more often in order to allow continued root formation.
L. Revascularization of necrotic pulps has even been reported using combinations of AB's.
M. And of course... he had to mention stem cells.
Assessment of article: Good Summary
Date: 20OCT10
Region: Providence
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Author(s): Camp, Joe DDS MSD
Journal: Pediatric Dentistry
Page #s: 197-205
Date: May/Jun 2008, V30:No3
Major topic: Immature Tooth Vital Pulp Therapy
Minor topic(s): NA
Type of Article: Review of Literature
Main Purpose: Reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apezx. The apical barrier with mineral trioxide aggregate followed by root strengthening with bonded composite is reviewed.
Key points in the article discussion:
I. General:
A. Most of the diagnostic tests used used with endodontic therapy are of little to no value on primary teeth or immature permanent teeth.
B. Much of our Tx decisions are based on Dx of root development age... therefore it is necessary to have thorough knowledge of the rot development timeline for primary and permanent teeth.
1. Root formation is not completed for 1-4 years after eruption into the oral cavity.
C. Radiographs cannot accurately depict apical closure due to the development of canals in the lingual-facial direstion.
D. During formation and closure, Tx must be oriented at maintaining vitality and allowing the completion of root formation.
II. Dx of Pulpal Status in Primary Teeth.
A. Differentiation between provoked and spontaneous pain is vital.
1. Provoked: deep caries, faulty restorations, soreness around exfoliation and erupting permanent teeth.
2. Spontaneous: extensive degenerative changes extending into the root canals... should NOT receive vital pulp Tx. There may be other evidence of pulpal pathosis as well... mobility, fistula, percussive sensitivity etc...
B. ELECTRIC PULP TESTS ARE NOT VALID ON PRIMARY TEETH.
C. THERMAL TESTS ARE USUALLY NOT CONDUCTED ON PRIMARY TEETH.
D. Radiographic exam is necessary
1. Calcified masses are a sign of advanced pulpal degeneration... Pulpectomization or Extraction.
2. Internal resorption is also associated with extensive inflammation... Extraction.
3. Keep in mind the lucency of the succedaneous follicle.
4. Other obvious pathosis... fracture, abscess, bone fractures etc...
E. Excessive or oddly colored hemorrhage is evidence of excessive inflammation.
F. Studies have shown that trauma LIKELY will result in pulpal necrosis or at least pulpal obliteration (depending on degree of trauma, luxation, mobility etc...)
G. AVULSED PRIMARY TEETH SHOULD NOT BE REIMPLANTED.
H. About half of traumatized primary teeth will undergo discoloration.
1. Correlation of type of color change to pulpal health is controversial and inconclusive.
III. Diagnosis of Pulpal Status in Permanent Immature Teeth
A. Loss of pulp vitality before completion of root formation leaves the tooth MUCH more susceptible to root fracture.
B. Again, a history should be taken WRT history of trauma and type of pain etc...
C. Clinical and radiographic examination MOST important when diagnosing immature permanent teeth.
D. Electric pulp test and thermal test not reliable for immature, open apex teeth... also for children.
E. Electrical and Thermal tests unreliable for traumatized teeth.
F. Laser doppler flowmetry reportedly very reliable to diagnose pulpal vitality.
G. Discoloration also usually indicative of pulpal changes but not completely accurate.
H. There is MUCH better potential for an immature tooth to heal after trauma.
I. If doubtful of diagnosis, DO NOT start treatment. Attempt to allow formation of the root until definitive diagnosis can be made.
J. Lately, MTA and composite resins have been replacing CaOH, pulp cappng and pulpotomy.
K. Vital treatment of teeth with MTA, once considered taboo, is being used much more often in order to allow continued root formation.
L. Revascularization of necrotic pulps has even been reported using combinations of AB's.
M. And of course... he had to mention stem cells.
Assessment of article: Good Summary
Vital Pulp Therapy with New Materials: New Directions and Treatment Perspectives - Permanent Teeth
Resident: Roberts
Date: 10/20/10
Article title: Vital Pulp Therapy with New Materials: New Directions and Treatment Perspectives - Permanent Teeth
Author: Witherspoon, David
Journal: Pediatric Dentistry
Volume: 30:3 pages: 220 - 224
Discussion:
The basic principle of vital pulpal treatment an be broken down in to two phases. The initial phase involves removing the diseased and bacterially contaminated tissue. The second phase involves establishing an environment that will prevent any further and future bacterial contamination. Calcium Hydroxide has been advocated as the material of choice for various forms of vital pulp therapy, but recently MTA has received a lot of attention as a potential replacement because of its ability to kill bacteria, induce mineralization and establish a tight bacterial seal.
MTA is composed of tricalicum silicate, bismuth oxide, dicalcium silicate, tricalcium aluminate, calcium sulfate and may contain other trace particles. It has a compressive strength equal to that of IRM and has been shown to have antibacterial effects on facultative but not anaerobic bacteria. Its ability to prevent long term leakage appears to be high and better than amalgam or IRM.
Compared with Calcium hydroxide, in animal studies, MTA consistently induces the dentin at a greater rate with superior structural integrity. There seems to be a greater effect of dentinal bridging, minimal effect on pulpal inflammation, and nominal hyperemia. The process by which this happens is not fully understood but it has been suggested that the tricalcium oxide reacts with the tissue fluids to form calcium hydroxide and works in a similar way as does strait calcium oxide.
Various studies have shown that the potential for success is higher than that of Ca. hydroxide. In one such study, MTA was assessed as a medicament for direct pulp cap therapy and proved to have a 98% success rate. In another study, where pulpotomies were assessed using MTA as its choice of medicament, it showed a lower percentage of failures than other techniques being applied. In short MTA is a good substitute for calcium hydroxide and would be an acceptable choice for replacement and may be desired where teeth are immature and root development is dependent and pulpal vitality.
Assessment: Good article, resonated with other studies that we have all read and heard about.
Monday, October 18, 2010
Pulpal Status of Hypomineralized Permanent Molars
Meghan Sullivan Walsh October 18, 2010
Literature Review - St. Joseph/LMC Pediatric Dentistry
Pulpal Status of Hypomineralized Permanent Molars
Resident: Meghan Sullivan Walsh
Program: Lutheran Medical Center- Providence
Article Title: Pulpal Status of Hypomineralized Permanent Molars
Authors: Helen D. Rodd, BDS, PhD; Fiona M. Boissonade, BDS, PhD; Peter F. Day, BDS, M Paed Dent
Journal: Pediatric Dentistry
Volume (number), Year, Page #’s; 29:6, 2007, pages 514-520
Major Topic: Determining the pulpal status of Hypomineralized teeth.
Overview of Method of Research: Permanent first molars were obtained from children requiring a routine dental extraction under general anesthesia. 44 children with a mean age of 9.4 years provided the teeth for this study. Of these teeth, 25 were sound and 19 were hypomineralized, (9 with intact enamel and 10 with enamel loss.) The patients were interviewed for sensitivity and of the 19 hypomineralized samples 6 had reported sensitivity and 5 had been asymptomatic. The teeth were sectioned and analyzed for enamel loss. The coronal pulps were removed and prepared for analysis. The pulps were divided into three parts, mesiobuccal pulp horn, occlusal subodontoblastic region between 2 pulp horns and the midcoronal pulp region.
Findings: Pulpal innervation: In hypomineralized teeth both with or without enamel loss, there was an increase in neural density within both the pulp horns as well as the occlusal subodontoblastic region. In hypomineralized samples with intact enamel there was significantly greater innervation density than sound teeth. In the subodontoblastic region, innervation density was significantly greater in the pulps of hypomineralized teeth with enamel loss than was the case for sound teeth. There was no difference in the two groups between the midcoronal region.
Immune cells: In sound samples there were few signs of leukocyte common antigen-immunoreactive cells. However, more LCA-ir cells were found within the pulps of hypomineralized samples with enamel loss compared to sounds teeth or hypomineralized samples with intact enamel surfaces.
Pulpal vascularlty: No significant differences in vascularity between the two samples.
Pain history: For those patients who complained of tooth sensitivity the samples showed greater staining of immune cells discovered in the pulp horn and midcoronal region.
Key Points: Summary:
Frequently young patients with hypomineralized teeth complain of tooth sensitivity even during restorative management and treatment. This study shows evidence that there may be pulpal changes associated with many of these patient’s teeth. Our clinical management is to protect their teeth from caries, and alleviate sensitivity These patients may have an underlying pulpal inflammation as demonstrated by the increase in pulpal innervation density and immune cell accumulation noted in this study. The presence of dentin in many of these subjects may leave the dentin vulnerable to the ‘hydrodynamic theory’ of dentinal fluid movement. In addition exposed dentin may predisposed bacteria and oral irritants into the pulp. This study shows that our treatment and management of these patients may go beyond prevention but instead early intervention and prevention of hypersensitivity. A reliable dental pain history of our young patients should always be obtained.
Assessment of the Article: While the science behind these studies were way over my head, I liked the subject matter and the method of research. The sample size was small and determining pain in a young child is often subjective, nonetheless, I believe there is something significant with these results. Perhaps with further research on prevention and early treatment of these patients with hypomineralized dentition we can prevent our patients from the discomforts of sensitivity at an earlier age.
Guideline on Pulp Therapy for Primary and Young Permanent teeth
Department of Pediatric Dentistry
Resident’s Name:Murphy Program:Lutheran Medical Center - Providence
Article title: Guideline on Pulp Therapy for Primary and Young Permanent teeth
Author(s): Pulp therapy Subcommittee
Journal: Pediatric Dentistry Clinical Guidelines
Year. Volume (number). Page #’s: 2004
Major topic: Pulp therapy
Main Purpose: Describe the diagnosis of pulp pathosis and set forth the indication, objectives, and medications for pulp therapy in primary and young permanent teeth.
Overview of method of research: MEDLINE search for pulpotomy, pulpectomy, IPT, stepwise excavation, pulp therapy, pulp exposure, calcium hydroxide, formocresol, ferric sulfate, and glass ionomer.
Findings:
The primary objective of pulp therapy is to maintain the integrity and health of the teeth and the supporting tissues. Vitality is best if possible (duh), however non vital teeth can remain clinically functional. Every treatment plan, regardless of the tooth should include the patients medical history, the value of each tooth involved with regards to the child’s development, alternatives to pulp treatment, and restorability of the tooth. When all treatment options fail, bony support cannot be regained, there is not enough tooth structure left for a restoration, there is resorption, or complications, extraction should be considered.
Apexification, reimplantation, and post and cores are not indicated for primary teeth.
All pulpal therapy should be completed w/ RDI to minimize bacterial contamination of the site.
Primary Teeth
Vital Tx
Protective Base-Material placed on the pulpal surface of a prep covering exposed dentin tubules, acting as a barrier between the restorative material or cement and the pulp, sealed restoration.
Indications- Normal vital pulp, all caries removed
Objectives- Preserve vitality, promote pulp tissue healing and tertiary dentin formation, minimized micro-leakage, have no post op sensitivity.
IPT-Deep carious lesion close to the pulp is covered by a biocompatible material to stimulate healing and repair, sealed restoration.
Indications-Either normal or reversible pulpitis, deepest carious dentin is not removed to avoid exposure.
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.
Direct Pulp Capping-Small mechanical exposure during prep or following traumatic injury to tooth is covered with Calcium Hydroxide, sealed restoration.
Indications- Normal pulp following small mechanical exposure of trauma when conditions are optimal. Direct pulp capping of carious exposed primary teeth is not indicated
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.
Pulpotomy-Deep carious lesion adjacent to pulp is excavated, radicular pulp is left, treatment with formo, ferric, or electrocautery to preserve radicular pulp health, pulp chamber is filled, tooth sealed with restoration.
Indications-Carious pulp exposure with normal or reversible pulpitis, or after traumatic exposure.
Objectives-Maintain radicular pulp health, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.
Non Vital Teeth
Pulpectomy- Irreversible pulpitis or necrotic pulps is removed and filled with resorbable material such as zinc oxide eugenol, restored with sealed restoration.
Indications- Irreversible pulpitis or necrotic pulps
Objectives-symptomes should resolve in 1-2 weeks, infectious process should resolve in +/- 6 months, radiographic evidence of no over/under filliing, no resoprtion, no harm to permanent successor.
Young Permanent Teeth
Vital Teeth
For Protective base, IPT see above.
Direct Pulp Capping
Same as for primary teeth except that a small carious exposure can be treated with DPC.
Partial Pulpotomy
Indications-small (<2mm) carious exposure in which enflamed tissue beneath the exposure is removed at a depth of 1-3mm, or until healthy tissue is reached. Bleeding must be controlled within 1-2 min and the site should be covered with CaOh or MTA, sealed with rest.
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption or canal calcification or periradicular radiolucency, tooth should continue to develop normally.
Cvek Pulpotmy
Same treatment for partial pulpotomy except it is indicated for traumatic exposures.
Apexogenesis (root formation)
Vital pulp procedure that allows the continued physiological development and formation of the roots apex by use of the treatment previously described .
Pulpectomy(Conventional RCT)
Indications- Traumatized, infected, exposed, or necrotic fully formed teeth. Entire pulpal tissue is debrided, irrigated, canal is shaped, obturation with non restorable filling material.
Objectives- symptoms should resolve in 1-2 weeks, infectious process should resolve in +/- 6 months, radiographic evidence of no over/under filling, no resoprtion, no further breakdown of periradicular tissue.
Apexification
Indications-Incompletely formed non vital tooth. Coronal and no vital tissue is removed just short of the root end, CaOh or MTA is placed. Once an apical closure is obtained RCT should be completed.
Objectives-Induce root end closure, no resoprtion, no further breakdown of periradicular tissue.
Key points/Summary:
Apexification, reimplantation, direct pulp capping of a carious pulp exposure, and post and cores are not indicated for primary teeth.
All pulpal therapy should be completed w/ RDI to minimize bacterial contamination of the site.
Assessment of Article: This article was tough to “summarize” as it is itself a summary of ALL pulpal tx. Good guideline overall. We should all know this stuff backwards and forwards.
Resident’s Name:Murphy Program:Lutheran Medical Center - Providence
Article title: Guideline on Pulp Therapy for Primary and Young Permanent teeth
Author(s): Pulp therapy Subcommittee
Journal: Pediatric Dentistry Clinical Guidelines
Year. Volume (number). Page #’s: 2004
Major topic: Pulp therapy
Main Purpose: Describe the diagnosis of pulp pathosis and set forth the indication, objectives, and medications for pulp therapy in primary and young permanent teeth.
Overview of method of research: MEDLINE search for pulpotomy, pulpectomy, IPT, stepwise excavation, pulp therapy, pulp exposure, calcium hydroxide, formocresol, ferric sulfate, and glass ionomer.
Findings:
The primary objective of pulp therapy is to maintain the integrity and health of the teeth and the supporting tissues. Vitality is best if possible (duh), however non vital teeth can remain clinically functional. Every treatment plan, regardless of the tooth should include the patients medical history, the value of each tooth involved with regards to the child’s development, alternatives to pulp treatment, and restorability of the tooth. When all treatment options fail, bony support cannot be regained, there is not enough tooth structure left for a restoration, there is resorption, or complications, extraction should be considered.
Apexification, reimplantation, and post and cores are not indicated for primary teeth.
All pulpal therapy should be completed w/ RDI to minimize bacterial contamination of the site.
Primary Teeth
Vital Tx
Protective Base-Material placed on the pulpal surface of a prep covering exposed dentin tubules, acting as a barrier between the restorative material or cement and the pulp, sealed restoration.
Indications- Normal vital pulp, all caries removed
Objectives- Preserve vitality, promote pulp tissue healing and tertiary dentin formation, minimized micro-leakage, have no post op sensitivity.
IPT-Deep carious lesion close to the pulp is covered by a biocompatible material to stimulate healing and repair, sealed restoration.
Indications-Either normal or reversible pulpitis, deepest carious dentin is not removed to avoid exposure.
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.
Direct Pulp Capping-Small mechanical exposure during prep or following traumatic injury to tooth is covered with Calcium Hydroxide, sealed restoration.
Indications- Normal pulp following small mechanical exposure of trauma when conditions are optimal. Direct pulp capping of carious exposed primary teeth is not indicated
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.
Pulpotomy-Deep carious lesion adjacent to pulp is excavated, radicular pulp is left, treatment with formo, ferric, or electrocautery to preserve radicular pulp health, pulp chamber is filled, tooth sealed with restoration.
Indications-Carious pulp exposure with normal or reversible pulpitis, or after traumatic exposure.
Objectives-Maintain radicular pulp health, form a complete restorative seal, have no post op sensitivity, no evidence of resorption, no harm to permanent successor.
Non Vital Teeth
Pulpectomy- Irreversible pulpitis or necrotic pulps is removed and filled with resorbable material such as zinc oxide eugenol, restored with sealed restoration.
Indications- Irreversible pulpitis or necrotic pulps
Objectives-symptomes should resolve in 1-2 weeks, infectious process should resolve in +/- 6 months, radiographic evidence of no over/under filliing, no resoprtion, no harm to permanent successor.
Young Permanent Teeth
Vital Teeth
For Protective base, IPT see above.
Direct Pulp Capping
Same as for primary teeth except that a small carious exposure can be treated with DPC.
Partial Pulpotomy
Indications-small (<2mm) carious exposure in which enflamed tissue beneath the exposure is removed at a depth of 1-3mm, or until healthy tissue is reached. Bleeding must be controlled within 1-2 min and the site should be covered with CaOh or MTA, sealed with rest.
Objectives- Preserve vitality, promote pulp tissue healing, form a complete restorative seal, have no post op sensitivity, no evidence of resorption or canal calcification or periradicular radiolucency, tooth should continue to develop normally.
Cvek Pulpotmy
Same treatment for partial pulpotomy except it is indicated for traumatic exposures.
Apexogenesis (root formation)
Vital pulp procedure that allows the continued physiological development and formation of the roots apex by use of the treatment previously described .
Pulpectomy(Conventional RCT)
Indications- Traumatized, infected, exposed, or necrotic fully formed teeth. Entire pulpal tissue is debrided, irrigated, canal is shaped, obturation with non restorable filling material.
Objectives- symptoms should resolve in 1-2 weeks, infectious process should resolve in +/- 6 months, radiographic evidence of no over/under filling, no resoprtion, no further breakdown of periradicular tissue.
Apexification
Indications-Incompletely formed non vital tooth. Coronal and no vital tissue is removed just short of the root end, CaOh or MTA is placed. Once an apical closure is obtained RCT should be completed.
Objectives-Induce root end closure, no resoprtion, no further breakdown of periradicular tissue.
Key points/Summary:
Apexification, reimplantation, direct pulp capping of a carious pulp exposure, and post and cores are not indicated for primary teeth.
All pulpal therapy should be completed w/ RDI to minimize bacterial contamination of the site.
Assessment of Article: This article was tough to “summarize” as it is itself a summary of ALL pulpal tx. Good guideline overall. We should all know this stuff backwards and forwards.
Wednesday, October 13, 2010
Ferric Sulfate Pulpotomy vs RCT in Primary Molars
Resident: Swan
Article Title: Long-term Outcomes of Primary Molar Ferric Sulfate Pulpotomy and Root Canal Therapy
Author: Casas, et al.
Journal: Pediatric Dentistry
Volume (Number): 26:1 2004
Major Topic: Ferric Sulfate Pulpotomy vs. Root Canal Therapy in Primary Molars
Type of Article: Scientific; a prospective, random, controlled trial
Main Purpose: Compare long-term outcomes (>3 years) for vital primary molars treated with ferric sulfate pulpotomy and root canal therapy
Overview of method of research: Healthy children with 1 or more primary molars with caries likely to produce an exposure on removal were included. Total enrollment was 291 primary molars in 130 patients. FS group had 182 molars in 86 patients, RCT group had 109 molars in 54 patients. PA radiograph was taken for each of the molars prior to treatment. Pulp therapy technique was randomly assigned to each child.
Root canal procedure: pulp chamber accessed, coronal pulp amputated using round bur, pulp tissue removed using files, short of the apex. Canals irrigated, air-dried using air-water syringe. Obturation using Sedanol (fine grained, non-reinforced ZOE). Restored with SSC.
Ferric Sulfate Pulpotomy procedure: Accessed, coronal pulpal tissue removed using slow speed/round burs, 16% Ferric sulfate gently burnished on pulp stumps for 15 seconds, chamber flushed with water. If bleeding hadn’t stopped at this point, molar was eliminated from study. With hemostasis, chamber was sealed with fortified ZOE. Restored with SSC.
36 month follow-up: If molar was still present, 4 things recorded 1) missing restorations 2) recurrent decay 3) mobility 4) percussion sensitivity. Soft tissue abnormalities/pathologies noted. PA radiograph of each tooth taken with subsequent categorizations by two pediatric dentists not previously involved; 1) normal molar, no radiographic changes 2) radiographic changes associated with normal physiologic resorption 3) pathologic radiographic change not requiring immediate extraction 4) pathologic change, immediate ext recommended.
Findings: Final sample=29 molars (29 patients; where one pt had multiple treatments, only one tx was evaluated) No statistically different observations of widened PDL space, PA/furcal radiolucencies, or pathological root resorption between the two techniques. PCO was most common radiographic finding for FS treated molars.
“Survival”=molar was not extracted during recall interval or prematurely exfoliated. 3 year probability of survival for FS molars was .62, probability for RCT molars was .92.
Key Points/Summary: Survival curves for both groups were similar until about 24 months post treatment. After that, the FS molars demonstrated decreased survival that was statistically significant.
RCT treated vital primary molars had greater survival than vital primary molars treated with FS, 3 years post-treatment.
Assessment of Article: I liked the study. The authors point out that it’s logistically very hard to come up with a huge, randomly selected group of samples over a long time period. Most get lost in follow-up. I think this was a good effort, even though 10 percent of the molars treated were actually analyzed 3 yrs later. It’s a great point to build from. All this being said and with the results in mind, most clinicians will probably still choose pulpotomy as their tx of choice because of reliability, technical ease, and time required.
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