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