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.

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.

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.

Success of Pulpectomy With Zinc Oxide-Eugenol Vs Calcium Hydroxide/Iodoform Paste in Primary Molars: A Clinical Study

Article title: Success of Pulpectomy With Zinc Oxide-Eugenol Vs Calcium Hydroxide/Iodoform Paste in Primary Molars: A Clinical Study

Author(s): Trairatvorakul & Chunlaslkaiwan.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2008. 30:4. 303-307.

Major topic: ZOE vs. Calcium Hydroxide/Iodoform Pulpectomy

Overview of method of research: Clinical Study

Purpose:
To compare the clinical and radiographic success rates of ZOE cement and Calcium Hydroxide/Iodoform paste (Vitapex).

Background:
ZOE is the most popular root canal filling material in primary teeth.
Previous studies have shown that residual filling material may alter the path of eruption in up to 20% of cases.

Methods:
54 mandibular primary molars in 42 subjects between the ages of 3 and 7 years old needing a pulpectomy were recruited. Carious pulp exposure with unsuccessful hemostasis after coronal pulp removal, mobility not associated with normal exfoliation, spontaneous pain, swelling, chronic apical abscess or fistula, percussion sensitivity, pathological resorption, furcal radiolucency, and discontinuity of lamina dura in radiograph were used as inclusion criteria for this study. Teeth with obliterated root canals, internal resorption and physiologic root resorption of more than 1/3 of its length were excluded. Legal guardians consented for patient to either receive ZOE or Vitapex which were assigned to teeth via block randomization. One pediatric dentist performed all treatment using a rubber dam, barbed broaches, an electronic apex locator, K-Files, irrigation with 2.5% sodium hypochlorite and filled with the corresponding filling material with lentulo spirals. Each tooth was then restored with an SSC and a radiograph was taken in the same appointment. Another single investigator performed follow-up exams at 6 and 12 months.
Clinical success was defined as the absence of pain, swelling, fistula, redness, and abnormal mobility. Radiographic success was demonstrated with the continuity of the lamina dura, reduction in the size of pathologic radiolucencies or evidence of bone regeneration. In addition to success and failure, a third category of further observation was included for teeth demonstrating an absence of change in size of radiolucency or continuity of lamina dura as they could not be classified at this time and needed a longer follow-up period.

Findings:
The overall success rates of ZOE at 6 and 12 months were 48% and 85% respectively while Vitapex demonstrated success rates of 78% and 89%. The difference is only significantly significant for radiographic success at 6 months.
All teeth could be classified in two categories prior to treatment: discontinuity of the lamina dura and furcation pathology involving more than half the length of the shortest root. When comparing these groups, there was no significant difference in the severity of the preoperative infection and the success of teeth treated with either ZOE or Vitapex.
At 6 months, 26 of the 27 teeth in ZOE group showed clinical success (96%) whereas Vitapex teeth showed 100% success rate. At 6 months radiographic success was demonstrated in only 48% of the ZOE teeth with another 37% needing further observation. 9 of the 10 requiring further observation were later found to be successful. The Vitapex group showed 78% success and 11% needed further observation.
All six of the failed teeth were in the preoperative category with the most severe radiographic
pathology. The 3 clinical failures were related to tooth mobility only.

Key points/Summary:
Success rates of 78% for Vitapex and 48% for ZOE at 6 months show Vitapex seems to improve furcal and root pathology more quickly.
After 12 months the two filling materials demonstrate comparable success rates.

Assessment of Article:
Although the article had some interesting findings that were consistent with other studies, matched paired samples in the same patient would have been better. But the only significant finding was actually skewed due to the need for further observation in several teeth.

Concentration of formocresol used by pediatric dentists in primary tooth pulpotomy

Department of Pediatric Dentistry

Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title: Concentration of formocresol used by pediatric dentists in primary tooth pulpotomy
Author(s): Silvia King, DDS, Alton McWorter, DDS MS, et al
Journal: Ped. Dent
Year. Volume (number). Page #’s: 2002. 24:2. 157-160
Major topic: Formocresol concentrations being used by PD
Minor topic(s): Dilution of formo
Main Purpose: To determine the concentration of formocresol used for primary tooth pulpotomy by private practicing PD who use formo.

Overview of method of research:
806 surveys were sent out randomly to active members of the AAPD. The survey questions asked about the PD use of formo, what concentration they use if they use it, and how they dilute it (if they do).

Findings: 422 (52%) responded to the survey. 84% of PD acknowledged using formo. The two main formulations of formo were Buckley’s (19% formo), and a Standard formation (48.5%). Of those who use formo, 69% use full strength, 27% diluted, and 4% don’t know. Those who dilute their formo either buy it that way, dilute it themselves, or have the pharmacy dilute it for them. Interestingly, some of the PD who say they ‘dilute’ their formo consider diluting to be dabbing a formo soaked cotton pellet (FALSE). Also, some of the PD who think they are buying and using diluted formo are mistaken, they are using full strength. This means that 78% of practitioners using formo are using full strength instead of 69%.

Key points/Summary:
Diluted concentration is 1:5 ratio.
Most PD still use full strength formo

Assessment of Article:
Short. To the point. Good.

10/13/2010 Resorption of a CaOH/iodoform paste (Vitapex) in root conal therapy

Resident: J. Hencler
Date: 10/13/2010

Article title: Resorption of a CaOH/iodoform paste (Vitapex) in root conal therapy for primary teeth: A case report

Author(s): Nurko et al
Journal: Pediatric Dentistry-22:6, 2000

Major topic: Vitapex as a root canal medicament in primary teeth
Type of Article: Case report

Main Purpose:
Present a clinical and radiographic follow up (38 months) of pulpectomy treatment performed on maxillary primary anterior teeth using vitapex.

Background:
Resorption of the filling material is one of the requirements of an ideal root-canal medicament for primary teeth. Resorption of the root canal filling material should occur as the primary tooth root is resorbed during exfoliation, permitting normal eruption of the succedaneous tooth. If the material is expressed beyond the apex, it should be resobable and non-toxic to the periapical tissue and permanent tooth germ. Common root canal filling materials for primary teeth include; zinc oxide and eugenol, iodoform paste, and CaOH. Zinc oxide and eugenol is the most problematic because when extruded beyond the apices it sets into hard cement that resists resorption. Disturbances to the succedaneous tooth have been reported and deflection of the perm tooth may occur. Iodoform paste has shown excellent clinical and radiographic results. Vitapex is a viscous mix of CaOH and iodoform. When extruded into furcal or apical areas, vitapex will diffuse and/or be resorbed in part by macrophages. Vitapex is an ideal root canal filler for primary teeth with a easy delivery system.

Case details:
17-month male patient w/ ECC in anterior maxillary teeth and in one primary molar. Occlusal radiograph revealed deep carious lesions involving pulps of the lateral incisors. Dental tx under GA, Teeth #D,G were pulpectomized with Vitapex and restored with Nusmile crowns. An immediate post-op radiograph revealed Vitapex extruded from the apices of #D,G. At 13 months child required tx under GA again. Intra-radicular Vitapex was partially resorbed from #D,G and teeth were asymptomatic with no pathosis. At 16 month, an occlusal radiograph showed complete resorption of the filling material from the canals of #D,G with no signs of clinical and radiographic signs of tx failure. The patient was placed on a 6mrc. 38 months after initial tx, patient presented with chipped esthetic facings on #D,G. When restoring #D,G; the pulp chamber of #D was accessed to take a sample of the pulp chamber with a endo file. Sample was sent to a micro lab where neither anaerobic or aerobic were found in the sample.

Key points in the article discussion:
Because of the anatomy of primary roots and furcal ares, it is difficult to avoid extrusion of filling material beyond the root canals in all pulpectomy cases. This case report confirms that extruded Vitapex can be easily removed from extra-dental sites and the resorption is be a beneficial characteristic in pulpectomies in primary teeth. The effects of intra-radicular resorption are not certain but an unfilled root canal could be a open space for bacterial leakage and infection. Although the canal of the vitapex-treated lateral incisor was free of bacterial contamination, the authors caution overuse of vitapex is certain situations such as cases of acute infection because Vitapex has been shown to have minimal antibacterial properties. Antibiotic therapy may augment tx w/ vitapex. The authors recommended Kri paste (iodoform) may be better suited for more aggressive tx b/c of it’s bactericidal and resorptive properties.

Summary of conclusions:
Vitapex used as a root canal filling material for pulpectomy tx for primary teeth resorbed extra-radicularly and intra-radicularly w/out ill effect and proved to be clinically and radiographically successful.

Assessment of article: Good article and case report.

Comparison of Conventional, Rotary, and Ultrasonic Preparation, Different Final Irrigation Regimens, and 2 Sealers in Primary Molar Root Canal Therapy

Meghan Sullivan Walsh October 12, 2010

Literature Review - St. Joseph/LMC Pediatric Dentistry

Comparison of Conventional, Rotary, and Ultrasonic Preparation, Different Final Irrigation Regimens, and 2 Sealers in Primary Molar Root Canal Therapy

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Comparison of Conventional, Rotary, and Ultrasonic Preparation, Different Final Irrigation Regimens, and 2 Sealers in Primary Molar Root Canal Therapy

Authors: Harun Canoglu, DDS, PhD; Meryem U. Tekcicek, DDS, PhD; Zafer C. Cehreli, DDS, PhD

Journal: Pediatric Dentistry

Volume (number), Year, Page #’s; 28:6, 2006, pages 518-523

Major Topic: Comparison and success of three types of file systems used for preparation of a primary molar for RCT. Comparison of irrigation systems as well as sealer penetration used for RCT on a primary molar.

Overview of Method of Research:

Instrumentation assessment: Distal roots of extracted primary mandibular second molars were gathered. (Number of teeth used for this portion of the study not mentioned) The teeth were selected with non resorbed, curved distal roots. Working length determined 1 mm short of apex and the teeth were prepared using one of the three techniques. Group 1: Mechanical hand filing using a step back techniques, k-files, up to a size 30 and irrigated with NaOCL. Group 2: Crown down technique with a nickel titanium rotary Profile up to a .04/30 file. Irrigation then performed with NaOCL. Group 3: A piezzo ultrasonic instrument with K-files up to a size 30 and lastly irrigated with NaOCL. Removed dentin was measured using reference points. Zipping, the transportation of the outer wall of the apical foramen from an overextended file, was also measured.

Sealer assessment: Distal roots of 56 extracted primary mandibular molars were selected and prepared using mechanical hand filing and irrigated with NaOCL. The roots were then divided up into four groups to receive the final irrigation: Group 1: 10 ml 2.5% NaOCL. Group 2: 10 ml 10% EDTA. Group 3: 10 ml 17% EDTA. Group 4: 10 ml distilled water. Each irrigation group was then divided into two subgroups for sealer. Group one: AH PLUS Group 2: ZOE- based Sealit-Ulta. Final obturation was done with gutta percha.

Findings:

Intrumentation: No significant difference was noted between the three techniques of Intrumentation. Ultrasonic files however did show a decrease in working length as well as the incidence of zip formation. Profile instrumentation showed the best maintenance of root curvature.

Irrigation and Sealer: Final irrigation of NaOCL and distilled water failed to remove the smear layer. The removal of smear plugs by EDTA produced better tubular penetration of sealer. The best tubular penetration was noticed in Group three with 17% EDTA and AH plus as a sealer.

Key Points: Summary: Profile .04 ISO nickel titanium produced the best results and can be a good alternative to hand filing in intrumentation of primary molars. AH plus shows good tubular penetration when used with NaOCL irrigation and 17% EDTA flush. ZOE sealer following irrigation of 10%EDTA showed insufficient tubular penetration and is not recommended as a gutta percha sealer for primary molars.

Assessment of the Article: This article was a good look into the different techniques and materials used for RCT of a primary molar. However, I found that the authors had too many studies being done and too many variables. They were looking at obturation and sealers and irrigation techniques! Would have preferred them to focus on one aspect and give more detailed information regarding their findings (particularly the number of teeth used and compared in the obturation study.)

A Retrospective Assessment of Zinc Oxide-Eugenol Pulpectomies in Vital Maxillary Primary Incisors Successfully Restored With Composite

Resident: Cho

Author(s): Primosch et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2005. 27. 470-477.

Major topic: Vital pulpectomy, Zinc oxide-eugenol paste, Primary incisors

Minor topic: Composite resin crowns

Type of Article: Scientific Article

Main Purpose:

The purpose of this study was to evaluate the clinical and radiographic success of ZOE pulpectomies in vital maxillary primary incisors successfully maintained with composite resin crowns.

Overview of method of research:

A retrospective study was conducted using active patient charts from a pediatric dentist. Patients were identified that had pulpectomies on primary maxillary incisors with vital pulp tissue subsequent to dental caries or trauma. To be included in the study, the incisor needed to be vital (by clinical history, radiographic history, presence of bleeding during extirpation of the pulp), successfully restored with a composite strip crown that remained intact, had diagnostic radiographs for preoperative, immediate postoperative, and recall appointments of at least a 6-month interval, had an identifiable outcome (success or failure) by clinical and radiographic findings.

All pulpectomies were completed by a single operator and completed with the following steps:

RDI, all carious tooth structure removed, pulp tissue removed by broach, root canal cleaned with files, irrigated with water syringe and dried, treated with formocresol-soaked paper point, dried with paper points, obturated with ZOE paste mixed with zinc acetate accelerator crystals, canal orifice sealed with TERM Endo Stop, full-coverage restoration completed by acid etch+bond+composite resin strip crown (if there was insufficient tooth structure for retention, resin-based core build up was placed; if there was inadequate crown height, cervical gingivectomy performed), and immediate post-operative radiograph was taken.

A single examiner evaluated the radiographs. The immediate postoperative radiograph was evaluated for filling extent. The recall radiograph was evaluated for success/failure based on clinical and radiographic findings, degree of physiological root resorption, canal filling extent, and eruption status of the succedaneous tooth.

A tooth was considered to be successful if it was asymptomatic with normal radiographic appearance. A tooth was considered a failure if clinically it had spontaneous pain, percussion sensitivity, parulis/fistula present and if radiographically it had an apical lucency and internal and/or external inflammatory root resorption.

Findings: 48 patient charts with 104 pulpectomized primary maxillary incisors were analyzed in this study. 80 of the incisors were treated due to caries; 24 of the incisors were treated due to trauma. The mean age at the time of treatment was 34 months old. The mean followup time was 18 months after initial treatment. 76% of the incisors were determined to be successful. 75% still had complete root formation and the remaining had various stages of physiologic root resorption.

Key points/Summary:

76% of the incisors were determined to be successful that were treated with ZOE pulpectomy. Incisors treated secondary to dental trauma failed in 42% of the cases compared to 19% for those treated secondary to dental caries. Incisors restored with composite crown failed at a higher rate than those treated with a composite core underneath the composite crown. Gross overfill of ZOE paste beyond the confines of the root canal had high failure rates. Delayed eruption of succedaneous teeth occurred more frequently with failed pulpectomies.

Assessment of Article: Good article. It discussed the shortcomings of the results. Example, even though initial gross overfilled incisors had a 80% failure rate, the article pointed out that number of overfilled incisors was only 5 teeth. The article made me wonder if the ZOE used in the pulpectomies had an influence on the durability of the composite crown.

Clinical Evaluation of Root Canal Obturation Methods in Primary Teeth

Resident: Roberts

Date: 10/13/10

Article title: Clinical Evaluation of Root Canal Obturation Methods in Primary Teeth

Journal: Pediatric Dentistry

Volume: 28:1 Pages 39-47

Year: 2006

Purpose:

To evaluate two differing obturation techniques, their effectiveness and success rates in primary molars

Methods:

50 pulpectomies and their respective filling materials were performed on 24 children( ages 4.5 to 9). Two varying methods were used to obturate the cleaned canals: one in which a lentulo spiral was attached to a slow speed handpiece and the other which consisted of a lentulo spiral that was hand held to perform the same task.

Criteria for this study:

Teeth were include if they:

1. History of spontaneous pain
2. Presence of a sinus tract
3. Periapical bone swelling
4. Continuous bleeding after amputation of coronal pulp tissue
5. No pulp tissue remaining when the pulp chamber was accessed
6. Pus discharge from the canal
7. Evidence of a radicular pathologic lesion with or without caries involvement
8. Periapical or inter-radicular radiolucency

Teeth were excluded if they:

1. Were unrestorable
2. Had pathologic lesion that extended to the tooth germ of the succedaneous tooth
3. Showed signs of extensive internal/ external pathological root resorption

Success rates and results at 6 month follow up

Teeth obturated by lentulo in slow speed handpiece: clinical 96%, radiographic 91%

Teeth obturated by lentulo but performed manually by hand: clinical 92%, radiographic 72%

Combined total of 94% clinical and 81% radiographical success rate

The success were also analyzed by the quality of the obturation

56% (28) were optimally filled, 32% (16)were underfilled, and 12% (6)were overfilled.

Optimal: clinical 92%, radiographic 92%

Underfilled: clinical 94%, radiographic 56%

Overfilled: clinical 100%, radiographic 100%

Conclusion:

There was no statistical significance between the hand held or the handpiece mounted lentulo spiral. Optimally and over filled root canals showed a statistically higher success rate compared to underfilled root canals.

Assessment: His conclusions based on quality of fill and success rates differed from those he quoted, but he didn’t offer up a reason as to why and I would have liked to have had an insight to perhaps why his conclusion was different than others who have performed similar research.