Indirect pulp capping and primary teeth: is the primary tooth pulpotomy out of date?

Formocresol pulpotomy (FP) in the United States is most frequently used to treat asymptomatic caries near the pulp in primary teeth. Indirect pulp therapy (IPT) is also indicated and has a significantly higher long-term success. Pulpotomy is thought to be indicated for primary teeth with carious pulp exposures, but research shows the majority of such teeth are nonvital or questionable for treatment with vital pulp therapy. IPT has a significantly higher success in treating all primary first molars, but especially those with reversible pulpitis compared with FP. The purpose of this article was to review the dental literature and new research in vital pulp therapy to determine the following: (1) Is a pulpotomy indicated for a true carious pulp exposure? (2) Is there a diagnostic method to reliably identify teeth that are candidates for vital pulp therapy? (3) Is primary tooth pulpotomy out of date, and should indirect pulp therapy replace pulpotomy? )     

Contemporary perspectives on vital pulp therapy: views from the endodontists and pediatric dentists

The purpose of this study was to determine the level of agreement between pediatric dentists and endodontists at a pulp therapy symposium conjointly sponsored by the American Association of Endodontists (AAE) and the American Academy of Pediatric Dentistry (AAPD) on November 2-3, 2007. Presymposium and postsymposium tests were administered, and respondent answers were compared between pediatric dentists and endodontists. Opinions on 3 areas were sought: pulp therapy for cariously involved primary teeth; indirect pulp treatment (IPT) for cariously involved immature permanent teeth; and innovative treatment options including pulpal revascularization and regeneration. Results were analyzed with chi2 tests. Comparisons of presymposium and postsymposium responses and between the 2 groups of attendees indicated that the pediatric dentistry and endodontic communities agree that formocresol will be replaced as a primary tooth pulpotomy agent, that mineral trioxide is the first choice to take its place, that IPT in primary teeth holds hope as a replacement for pulpotomy, and that IPTis an acceptable pulp therapy technique for cariously involved young permanent teeth. Both groups believe that pulp revascularization and regeneration will be viable treatment modalities in the future. The AAE and the AAPD are positioned to begin preparation of best practice guidelines that share common language and treatment recommendations for pulp therapies performed by both specialties.     

乳牙牙髓切断术在乳牙深龋治疗中的应用

乳牙牙髓切断术是指在乳牙牙髓感染仅局限于冠髓时,将感染的冠髓去除后,用盖髓材料覆盖牙髓断面,保留健康的根部牙髓,进而保存患牙牙髓活力的治疗方式。随着微创治疗理念的普及以及新型生物材料的问世,乳牙牙髓切断术的疗效被重新认识。本文就乳牙牙髓切断术的疗效与应用现状、适应证、牙髓断面的处理方式、影响成功率的因素等方面作一综述。     

Vital pulp therapy with new materials for primary teeth: new directions and Treatment perspectives

Vital pulp therapy aims to treat reversible pulpal injury and includes 2 therapeutic approaches: (1) indirect pulp treatment for deep dentinal cavities and (2) direct pulp capping or pulpotomy in cases of pulp exposure. Indirect pulp treatment is recommended as the most appropriate procedure for treating primary teeth with deep caries and reversible pulp inflammation, provided that this diagnosis is based on a good history, a proper clinical and radiographic examination, and that the tooth has been sealed with a leakage-free restoration. Formocresol has been a popular pulpotomy medicament in the primary dentition and is still the most universally taught pulp treatment for primary teeth. Concerns have been raised over the use of formocresol in humans, and several alternatives have been proposed. Controlled clinical studies have been critically reviewed, and mineral trioxide aggregate and ferric sulfate have been considered appropriate alternatives to formocresol for pulpotomies in primary teeth with exposed pulps. In most of the studies reviewed, the caries removal method has not been described. The use of a high-speed handpiece or laser might result in an exposure of a "normal" pulp that would otherwise not be exposed.     

Management of intruded primary teeth after traumatic injuries

Intrusions occur frequently in the primary dentition. It has been reported that conservative treatment of the intruded primary tooth is preferred if the apex is away from the permanent tooth germ. Conservative treatments include waiting for spontaneous re-eruption, and surgical re-positioning and fixation. Few papers have been published in Japan comparing the prognoses of intruded primary teeth between these two different modes of treatment. Therefore, optimal treatment for intruded primary teeth has been a topic of controversy among clinicians. The aim of this study was to compare the outcomes of intruded primary teeth between these two modes of treatment. Moreover, we examined the issue of treatment of choice for intruded primary teeth. The subjects consisted of 17 children referred to the Hiroshima University Hospital Department of Pediatric Dentistry for the treatment of 21 intruded primary teeth. Fourteen teeth were allowed to spontaneously re-erupt (group W), and 7 teeth were repositioned and fixed (group R). Antibiotic therapy and irrigation were performed in all intruded teeth. Treatment outcomes were evaluated using the following parameters: re-eruption, pathological pulp changes, increased mobility, discoloration, pulp canal obliteration, pathological root resorption, and disturbances of permanent teeth. In group W, root canal treatment or extraction were not performed since re-erupted teeth reveal no signs of infection. On the other hand, in group R, 57% of teeth required endodontic treatment or extracted due to signs of infection. The result showed treatment outcomes in group R were worse than those in group W. Our study indicates that most intruded primary teeth re-erupt with a favorable prognosis. Therefore, observation with irrigation and antibiotic therapy should be the treatment of first choice.     

The ability of pulp sensibility tests to evaluate the pulp status in primary teeth

BACKGROUND. Accurate determination of the pulp status is the most important part of conservative pulp therapy. AIM. The aim of this study was to assess the ability of thermal and electrical pulp tests to assess the pulp status in primary teeth. DESIGN. Seventy-eight primary molar teeth in 36 children were investigated. Fifty-six teeth had unknown pulp status in need of endodontic treatment, and 22 were intact teeth with no signs of pulp disease. Cold, hot and electrical pulp testing (EPT) were performed on each tooth. The gold standard was established by direct inspection of the pulp after an access cavity had been made. The sensitivity, specificity, positive and negative predictive values for each test and different sequential combinations of pulp testing were calculated. Sequential combination test analysis was used for data analysis. RESULTS. The highest accuracy was found for EPT, followed by heat and cold tests. No significant difference was found between the accuracy of EPT and the heat test (P-values > 0.05); however, the accuracy of EPT was significantly higher than that of the cold test (P-value< 0.05). CONCLUSION. Based on this study, EPT can be used as a reliable test for diagnosing the pulp status in primary teeth.     

Pulp therapy in the primary dentition.

Several treatment options for pulp therapy in primary teeth are reviewed. Conservative treatments are recommended for primary teeth whose pulps have the potential to recover once the irritation has been removed. The role of dentin permeability and microleakage is emphasized when protective basis and indirect pulp treatment are discussed. Alternative dressings for formocresol pulpotomies such as 6.25% glutaraldehyde solution, antigen-extracted allogeneic dentin matrix, and crude bone morphogenetic protein are reported with promising results. Pulpectomy is recommended for teeth with evidence of chronic inflammation involving radicular pulp or pulp necrosis with and without periapical involvement. The main disadvantage of zinc oxide-eugenol paste, widely used for primary root fillings in the United States, is its slow resorption rate, frequently much slower than that of the root. Other root canal pastes containing iodoform, or a modification of this with the addition of calcium hydroxide, are being utilized in South America, Japan, and Europe.     

正畸治疗对根管治疗牙及对侧同名活髓牙根吸收影响的Meta分析

目的    分析正畸治疗对根管治疗牙及对侧同名活髓牙根吸收的影响。方法    计算机检索Cochrane Library、PubMed、Embase、Google Scholar、中国知网、万方等数据库,查找研究根管治疗牙经正畸治疗后牙根吸收情况的相关文献。应用Meta分析比较正畸治疗对根管治疗牙及对侧同名活髓牙根吸收的影响。结果    纳入了10篇相关文献。Meta分析结果发现,正畸治疗患者根管治疗牙根吸收情况与对侧同名活髓牙比较,差异无统计学意义（P > 0.05）。在男性正畸治疗患者中,根管治疗牙牙根吸收量小于对侧同名活髓牙,差异有统计学意义（P < 0.05）;而女性正畸治疗患者两侧牙根吸收量比较,差异无统计学意义（P > 0.05）。正畸治疗方式（拔牙矫治与非拔牙矫治）和牙位（前牙与后牙）对正畸治疗患者根管治疗牙及对侧同名活髓牙根吸收的影响比较,差异均无统计学意义（均P > 0.05）。结论    正畸治疗过程中移动根管治疗后的牙齿是一种相对安全的操作。     

Primary molar pulp therapy--histological evaluation of failure

Objectives. Qualitative comparison of the clinical, radiographic and histological outcomes in a small sample of cariously exposed primary molars, extracted after unsucessful pulp treatment by two vital pulpotomy methods. Subjects and methods. The primary molars were extracted, because of treatment failure, during a longitudinal clinical investigation of the relative efficacy of 20% Buckley’s Formocresol versus calcium hydroxide powder as pulp dressings in vital pulp therapy (in press). Fifty‐two child patients were sequentially enrolled in the longitudinal clinical investigation, 26 boys and 26 girls. Primary molar teeth requiring vital pulp therapy were randomly allocated to either the formocresol group (F) or the calcium hydroxide group (C). Coronal pulp amputation was prescribed only in teeth with vital, cariously‐exposed pulp tissue. All cases were reviewed using predefined clinical and radiological criteria. Seventy‐nine cariously‐exposed primary molars required vital pulp therapy. Forty‐four teeth were included in group F and 35 in group C. Five per cent (n = 2) of teeth in group F and 11 per cent of teeth (n = 4) in group C were terminated from the trial due to clinical and/or radiographic failure. Of the six teeth extracted, five were sufficiently intact to be retained for histological evaluation. Results. Post‐extraction radiographs taken before specimen preparation showed reactionary dentine barrier (bridge) formation in teeth treated with calcium hydroxide. However, the narrowing of root canals, indicative of appositional reactionary dentine deposition, was seen in both groups (F and C). Histological examination confirmed these findings and revealed that pus cells were evident in all specimens examined. There was also histological evidence of resorption of reactionary dentine within the root canal and that forming the calcified barrier (dentine bridge). Conclusion. The clinical and radiographic outcomes for the five teeth correlate well with the reported findings from decalcified histological section. Although numbers are small, the histological findings may indicate possible reasons for treatment failure. There are few reports of this sort in the literature of this under‐researched treatment modality.     

Evaluation of the carbon dioxide laser on vital human primary pulp tissue.

PURPOSE: The purpose of this study was to evaluate the response of the human primary pulp to the carbon dioxide laser and formocresol for vital pulp therapy. METHODS: Fifteen healthy children with intact, caries-and-restoration-free, contralateral primary cuspids with at least two-thirds of the roots remaining who were scheduled for orthodontic extraction were randomly assigned to pulpotomy treatment with a carbon dioxide laser or formocresol. The treated teeth were clinically and radiographically evaluated at 28 and 90 days post-treatment prior to extraction. The extracted teeth were evaluated histologically for pulpal response. RESULTS: All teeth were asymptomatic and clinically normal at both observation periods. Internal root resorption was observed in one formocresol and two laser treated teeth. There was a significant inverse correlation between the laser energy applied to the pulp and the degree of inflammation at 28 days (P = .01) but not at 90 days (P = .27). CONCLUSION: Carbon dioxide laser treatment compared favorably to formocresol for pulpotomy in primary teeth.     

An investigation of the relative efficacy of Buckley's Formocresol and calcium hydroxide in primary molar vital pulp therapy

OBJECTIVE: To compare the clinical and radiological outcomes following two different, single visit vital pulp therapy techniques, in cariously exposed primary molar teeth. SETTING: A paediatric dental clinic within the Dental Hospital, Newcastle upon Tyne, UK. SUBJECTS: Fifty two child patients were sequentially enrolled in the clinical investigation, 26 males and 26 females with an age range of 3.3-12.5 years. Primary molar teeth requiring vital pulp therapy were randomly allocated to either the formocresol group (F) or the calcium hydroxide group (C). The total number of teeth treated was 84. DESIGN: Recruitment was on the basis of strict inclusion criteria. Coronal pulp amputation was prescribed only in teeth with vital, cariously exposed pulp tissue. Treatment was undertaken between October 1994 and December 1996. All cases were reviewed using predefined clinical and radiological criteria. The statistical tests used were logistic regression of a triple nested data structure, chi-squared analysis of equality of treatment and probability of success with relation to subject age. RESULTS: Eighty-four cariously exposed primary molars required vital pulp therapy. Forty six (55%) teeth were included in the F group and 38 (45%) allocated to the C group. Five teeth were lost to follow-up, leaving 79 teeth: forty four (56%) in group F and 35 (44%) in group C. Eighty four percent (37/44) of teeth treated with formocresol and 77 percent (27/35) treated with calcium hydroxide were classed as clinically and radiographically successful at the cut-off date, December 1997, after a mean clinical review of 22.5 months (range 6.1-38.5 months) and a mean radiographic review of 18.9 months (range 1.3-36.9 months). CONCLUSION: This investigation confirms the clinical efficacy of a one-fifth dilution of Buckley's Formocresol as an agent in pulp treatment of cariously exposed, vital primary molar teeth. However, calcium hydroxide in its pure, powder form is a clinically acceptable alternative when combined with strict selection criteria for this method of restorative care. There was a statistically insignificant difference in successful clinical and radiological outcome between the two treatment groups. Success was unrelated to the duration of time taken to achieve haemostasis and the presence or absence of bleeding after placement of the medicament.     

乳牙深龋的间接牙髓治疗

乳牙是人类的第一副牙齿,其正常萌出建并行使生理功能对儿童的身心发育具有重要意义。乳牙龋病是儿童慢性疾病之首,是儿童口腔医学临床最常见的疾病之一。根据世界卫生组织调查数据显示,世界范围内60%~90%的学龄儿童患有龋病。乳牙龋病在我国具有患龋率高,就诊率低下的特点,如不及时治疗,可导致牙体组织缺损、生理间隙丢失、牙髓和根尖周病变及颌面间隙感染,严重者可致乳牙早失并伴发牙列畸形及后续恒牙萌出障碍等不良结果,影响儿童口腔健康及身心发育。因此,对深龋乳牙采取积极有效的治疗措施对保存必要乳牙及其牙髓活力,恢复正常生理功能,维持牙列完整性,诱导后续恒牙正常萌出建具有重要意义。本文从目前深龋乳牙间接牙髓治疗的研究认识现状出发,通过文献资料收集整理,对间接牙髓治疗、间接盖髓术、暂时性保髓充填、部分去龋法、分步去龋法和非创伤性修复治疗等相关概念进行了对比分析,阐明了乳牙间接牙髓治疗的技术内涵和治疗意义,对乳牙深龋的临床治疗路径完善提供了理论依据。     

根管治疗应用于颌骨牙源性囊肿受累牙的处理

 手术是治疗颌骨牙源性囊肿的主要方法，但颌骨牙源性囊肿的特殊性在于手术方案的制定涉及患区牙的处理，目前对于受累牙的处理国内外并无公认的指南。当受累牙突入颌骨牙源性囊肿的囊腔时，特别是有功能的活髓牙，仍有不同的治疗方案。大量的研究支持受累牙的保守治疗，而根管治疗是将颌骨牙源性囊肿受累牙长期保存于口腔中的一个重要治疗策略。近年来，随着各类材料和器械的更新，根管治疗更加精密、微创，疗效显著提高。文章收集整理近年来的文献，对受累牙评估、根管治疗及根尖切除术在颌骨牙源性囊肿处理方面的应用做一概述。     

根管治疗应用于颌骨牙源性囊肿受累牙的处理

手术是治疗颌骨牙源性囊肿的主要方法,但颌骨牙源性囊肿的特殊性在于手术方案的制定涉及患区牙的处理,目前对于受累牙的处理国内外并无公认的指南。当受累牙突入颌骨牙源性囊肿的囊腔时,特别是有功能的活髓牙,仍有不同的治疗方案。大量的研究支持受累牙的保守治疗,而根管治疗是将颌骨牙源性囊肿受累牙长期保存于口腔中的一个重要治疗策略。近年来,随着各类材料和器械的更新,根管治疗更加精密、微创,疗效显著提高。文章收集整理近年来的文献,对受累牙评估、根管治疗及根尖切除术在颌骨牙源性囊肿处理方面的应用做一概述。     

Caries control and other variables associated with success of primary molar vital pulp therapy

PURPOSE: This research evaluated initial treatment of deep dental caries with caries control (CC) procedure and the effect of other factors on the success of indirect pulp therapy (IPT) and formocresol pulpotomy (FP). METHODS: Retrospective chart audits were performed on 226 primary molars with deep caries approaching the pulp that were treated using IPT and FP. Mean follow-up was 3.4 years. CC with glass ionomer cement (GIC) was performed on 50 of the 226 teeth 1 to 3 months before pulp therapy. RESULTS: IPT therapy was successful 94% of the time, whereas FP was successful 70% of the time. The initial use of CC increased the IPT/FP success rate to 92% vs a 79% success rate in teeth without CC. Primary molar FP success on primary first molars was 61% vs 83% in second molars. IPT therapy was successful 92% of the time for first molars vs 98% of the time for second molars. Thirty-six percent of the FP-treated teeth exfoliated early vs 2% of the IPT-treated teeth. Primary first molars with reversible pulpitis had a higher success with IPT (85%) vs FP (53%). The type of final restoration did not affect IPT or FP success, except that FPs restored with an immediate IRM (Dentsply/Caulk, Milford, Del) restoration decreased success to 39%. CONCLUSIONS: IPT for the treatment of deep dental caries lesions produced greater long-term success than FP. FP success in primary first molars was lower compared to IPT success, especially in teeth with reversible pulpitis. Also FP-treated teeth showed significantly earlier exfoliation patterns. The prior treatment of deep dental caries lesions with CC procedures improved the subsequent IPT or FP success.     

恒牙牙髓炎的活髓保存治疗

活髓保存治疗是尽最大限度保留健康牙髓组织、提高患牙远期保存率的方法,但其被认为适应范围有限,疗效不确定。牙髓组织的病理学改变是决定临床治疗方案和评估疗效的组织学基础,而常用的检查方法无法全面反映牙髓的病理学改变。随着对牙髓生物学研究的深入、现代诊疗技术及盖髓材料的革新,活髓保存治疗越来越多地被应用在以往被认为需要摘除牙髓的患牙上。本文根据循证文献,就牙髓炎病理改变、恒牙牙髓炎活髓保存治疗的临床研究等方面进行分析讨论和总结。在活髓保存治疗的过程中综合运用包括激光多普勒血流仪、组织氧检测仪、核磁共振成像、牙科显微镜等技术与方法准确判断牙髓炎症状态,并依此决定牙髓的去留程度;结合严格的感染控制与高生物相容性盖髓材料的使用,活髓保存治疗可运用在部分龋源性露髓患牙与出现不可复性牙髓炎症状的恒牙上。未来的研究则需从牙髓修复再生机制、牙髓炎诊断精准化、盖髓材料的升级等方面提高恒牙牙髓炎活髓保存治疗的成功率。     

开窗减压术联合囊肿塞治疗青少年大型下颌骨囊肿的临床研究

目的 观察开窗减压术联合囊肿塞治疗青少年大型下颌骨囊肿的疗效.方法 对21例青少年大型下颌骨囊肿患者行开窗减压联合囊肿塞治疗,术后随访1～4年,观察不同时期囊腔体积变化以及受累牙手术前后牙髓活力的变化情况.结果 应用CBCT测量囊腔体积变化情况,术后囊腔体积明显缩小,以术后6个月内缩小速度最快;术后12月较术后6月囊腔...     

Radicular cyst associated with a primary molar following pulp therapy: a case report

A radicular cyst arising from the primary second molar and causing displacement of the permanent successor to the lower border of the mandible, with accompanying buccal expansion, was examined clinically and radiographically. Extraction of the primary molar and extirpation of the cyst led to uneventful healing. The primary molar had received pulp treatment with therapeutic agents approximately 1·5 years prior to the patient’s first visit. The relationship between pulp treatment and rapid growth of the radicular cyst is discussed.     

Endodontic treatment in the primary dentition

A number of factors are involved in the development of pulp and periapical disease in primary and permanent teeth, with dental caries being the main factor. Although these factors are similar, the clinical management of a primary or permanent tooth with pulp or periapical disease may be quite different. This is based mainly on the differences between the two types of teeth, with primary tooth longevity, coronal structural integrity, root canal morphology, and root anatomy being important features to be taken into account when treatment planning. This paper reviews some aspects of primary teeth and the various treatment options for the management of pulp and periapical disease.