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.

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.

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.

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

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.