Tuesday, April 10, 2018

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

Resident’s Name: Suhyun Rue, DMD                                                         Date: 4/04/2018
Article Title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Author(s): Joe Camp, DDS, MSD
Journal: Pediatric Dentistry
Date: May/June 2008
Main Purpose: This article reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apex. The apical barrier with mineral trioxide aggregate followed by root strengthening with bonded composite is reviewed.
Key Points/Summary:
-To properly diagnose and treat primary and young permanent teeth, it is necessary to have thorough knowledge of normal root formation and the difference between developing and fully formed teeth.
-In permanent teeth, root formation is not completed until 1-4 years after eruption into the oral cavity
-Apical closure cannot usually be determined radiographically as faciolingual width of most roots and canals is greater than the mesiodistal width; X-ray beam is exposed in faciolingual plane but radiograph is read mesiodistally
· Diagnosis of Pulpal Status in Primary Teeth
-Provoked pain that stops after removal of the causative stimulant is usually reversible and indicative of minor inflammatory changes
-Spontaneous pain is a constant or throbbing pain that occurs without stimulation or continues long after the causative factor has been removed; history of spontaneous toothache is usually associated with extensive degenerative changes extending into the root canals. Treatment recommended is pulpectomy or extraction
-Electric pulp tests are not valid in primary teeth
-Thermal tests are usually not conducted on primary teeth because of their unreliability;
bite-wing radiographs are often best to observe pathologic changes in posterior primary teeth.
Pathologic bone and root resorptions are signs of advanced pulpal pathosis that has spread into the
periapical tissues and is usually treatable only with extraction.
-If internal resorption can be seen radiographically, a perforation usually exists, and the tooth must be extracted
-If there is an exposure, the size of a pulpal exposure and the amount and color of hemorrhage have been reported as important factors in diagnosing the extent of inflammation under a carious lesion.
-In primary molars, pathologic changes are most often apparent in the bifurcation or trifurcation area.
-With acute or rapid onset as the disease reaches the pulp of primary teeth, calcified masses might form away from the caries exposure site – this is indicative of advanced pulpal degeneration extending into the root canals. These teeth are candidates for pulpectomy or extraction.
-Excessive or deep purple colored hemorrhage is evidence of extensive inflammation. Also, hemorrhage that cannot be controlled within 1-2 minutes by light pressure with a damp cotton pellet indicated that more extensive treatment is necessary. These signs are indicative of pulpectomy or extraction.
· Diagnosis of Pulpal Status in Permanent Immature Teeth
-In teeth with incomplete root formation, correct pulpal and periapical diagnosis is of paramount importance
-Electric pulp tests and thermal tests are of limited value because of the varied responses as roots mature.
-Electric and thermal tests were shown to be unreliable after traumatic injury to a tooth, and no response might be elicited even after circulation has been restored
-Laser Doppler flowmetry has been reported to be very reliable for diagnosing pulpal vitality
-Radiographic examination and interpretation are key elements in the diagnosis of pulpal pathology in teeth with developing apices.
-Discoloration of a tooth crown after trauma is a common sequel and one of the foremost diagnostic indicators.  Yellow discoloration is indicative of pulp space calcification,  and gray color signifies pulpal necrosis
-Transient apical breakdown occurs after displacement injuries and might lead to misdiagnosis: transient periapical radiolucency, coronal discoloration, negative electric pulp test and cold response up to 4 months was shown to subsequently regain the original color and normal pulpal responses
-Universal agreement exists that immature teeth have the greatest potential to heal after trauma or caries, particularly when the apical foramen is wide open
-If doubtful, do not start treatment; keep the patient under close observation
-The use of calcium hydroxide (for decades the standard for pulp protection), pulp capping, and pulpotomy procedures in permanent teeth is being replaced with composite resins  and mineral trioxide aggregate (MTA) (ProRoot; Dentsply Tulsa Dental, Tulsa, OK). Pulp capping with resin composites in monkeys produced the lowest incidence of bacterial microleakage, pulpal inflammation, and incidence of pulpal necrosis when compared with calcium hydroxide and glass ionomer cement
-When compared with calcium hydroxide, MTA produced significantly more dentinal bridging in a shorter time with significantly less inflammation and less pulpal necrosis.
-Revascularization of teeth with necrotic infected canals has been reported by using combinations of antibiotics . The canals are accessed and disinfected with copious irrigation of sodium hypochlorite. The canals are not instrumented. A paste of metronidazole, ciprofloxacin, and minocycline is placed in the canals and left for 1 month.  The tooth is re-entered, and endodontic files are inserted through the apices to stimulate bleeding to produce a blood clot at the level of the CEJ. After clotting, MTA is placed over the blood clot, and a permanent external seal is placed. The clot is then revascularized, producing thickening of the canal walls and apical closure.

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