Pulp preservation in immature permanent teeth

New treatment strategies for direct pulp capping and pulpotomy have shown promising potentials for improved outcomes in immature teeth with extensive caries, traumatic pulp exposures, or anatomical anomalies. Preservation and protection of the dental pulp in developing teeth promote root maturation and extend tooth survivability by postponing or even preventing more complex endodontic and restorative care. Early intervention using hydraulic calcium silicate cements such as mineral trioxide aggregate (MTA) stimulates pulpal cell recruitment and differentiation, up‐regulates transformation factors (gene expression), and promotes dentinogenesis. Calcium hydroxide, resin‐modified glass ionomer cements, hydrophilic resins, and formocresol have been shown to be less effective as bioactive agents when used in vital pulp therapy. Improved treatment procedures for pulp preservation include the use of caries detector dye to preserve the remineralizable inner carious layer and the use of sodium hypochlorite as a hemostatic and diagnostic agent to differentiate reversible from irreversible pulpitis. Although stepwise excavation and the use of calcium hydroxide is still being advocated, pulp capping and pulpotomy procedures using calcium silicate‐based cements are becoming widely accepted as more effective procedures. MTA and new hydraulic calcium silicate cements provide biocompatible environments that predictably promote reparative dentin bridge formation when placed under properly bonded and sealed composite restorations. Hydraulic calcium silicate cements appear to provide a promising future for the preservation of pulpal integrity in immature teeth when used with modified and conservative treatment protocols.     

Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial

AIM: To investigate the pulpal response to direct pulp capping in healthy human teeth with mineral trioxide aggregate (MTA) as against calcium hydroxide cement (Dycal) as control. METHODOLOGY: Twenty healthy human third molars had iatrogenic pulpotomy and direct pulp capping with MTA. Another 13 teeth were capped with Dycal as controls. The teeth were restored, with IRM, clinically reviewed and extracted after a number of pre-determined intervals (1 week, 1 month and 3 months). The specimens were fixed, decalcified, subdivided axially into two halves in the oro-buccal (lingual-buccal) plane, embedded in plastic, serial sectioned and evaluated qualitatively and quantitatively by correlative light and transmission electron microscopy with appropriate statistical evaluation of the quantitative data. RESULTS: Iatrogenic pulpal wounds treated with MTA were mostly free from inflammation after 1 week and became covered with a compact, hard tissue barrier of steadily increasing length and thickness within 3 months following capping. Control teeth treated with Dycal revealed distinctly less consistent formation of a hard tissue barrier that had numerous tunnel defects. The presence of pulpal inflammation up to the longest observation period (3 months) after capping, was a common feature in Dycal specimens. CONCLUSIONS: The MTA was clinically easier to use as a direct pulp-capping agent and resulted in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal. Therefore, MTA or equivalent products should be the material of choice for direct pulp capping procedures instead of hard setting calcium hydroxide cements.     

Mineral trioxide aggregate as a pulpotomy agent in primary molars: an in vivo study

The retention of pulpally involved deciduous tooth in a healthy state until the time of normal exfoliation remains to be one of the challenges for Pedodontists. A scientific noise has been generated about several materials some of which have been popular pulpotomy medicaments. Concerns have been raised about the toxicity and potential carcinogenicity of these materials, and alternatives have been proposed to maintain the partial pulp vitality, however to date no material has been accepted as an ideal pulpotomy agent. Mineral trioxide aggregate (MTA) is a biocompatible material which provides a biological seal. MTA has been proposed as a potential medicament for various pulpal procedures like pulp capping with reversible pulpitis, apexification, repair of root perforations, etc. Hence the present study was done to evaluate the efficacy of MTA as a pulpotomy medicament. A clinical and radiographic evaluation was done on children where MTA was used as pulpotomy medicament in primary molars for a period of 6 months and it was found to be a successful material.     

Vital pulp therapy with new materials: new directions and treatment perspectives--permanent teeth

Pulp necrosis in immature teeth subsequent to caries has a major impact on long-term tooth retention. The aim of vital pulp therapy is to maintain pulp viability by eliminating bacteria from the dentin-pulp complex and to establish an environment in which apexogenesis can occur. A complicating factor in treating immature teeth is the difficulty predicting the degree of pulpal damage. The ability of the clinician to manage the health of the remaining pulpal tissue during the procedure is paramount. Currently, the best method appears to be the ability to control pulpal hemorrhage by using sodium hypochlorite. Mineral trioxide aggregate (MTA) currently is the optimum material for use in vital pulp therapy. Compared with the traditional material of calcium hydroxide, it has superior long-term sealing ability and stimulates a higher quality and greater amount of reparative dentin. In the medium-term clinical assessment, it has demonstrated a high success rate. Thus, MTA is a good substitute for calcium hydroxide in vital pulp procedures.     

Clinical, radiographic and histological analysis of the effects of mineral trioxide aggregate used in direct pulp capping and pulpotomies of primary teeth

Background : Primary teeth pulp exposures have traditionally been treated with formocresol or ferric sulphate pulpotomies or calcium hydroxide pulp capping. The aim of this study was to observe the tissue response when mineral trioxide aggregate (MTA) was used.
Methods : Ten primary teeth had direct pulp caps and 11 had a pulpotomy with MTA. The teeth were restored and then clinically reviewed monthly for five months and before extraction. Radiographs were taken prior to treatment, after one month and prior to extraction. After extraction, the teeth were examined histologically and the responses to treatment were assessed.
Results : One pulpotomy and two pulp capping cases had postoperative pain and signs of pulp degeneration. Radiographs showed no root resorption, no periodontal pockets and no furcation radiolucencies. No cases had draining sinuses or increased mobility. Most pulps responded favourably from a clinical perspective although a variety of responses were noted Histologicallyormal odontoblasts, irregular odontoblasts, intrapulpal calcifications, dentinal bridges, cementum formation, internal resorption, inflammatory infiltrate and pulp necrosis.
Conclusions : The responses of pulps in primary teeth to MTA pulpotomies and pulp caps were favourable from clinical and radiographic perspectives although a variety of histological responses were noted. MTA may be a favourable material for pulp capping and pulpotomies in primary teeth.     

Survival of intentionally retained permanent incisor roots following crown root fractures in children

Retaining tooth roots, following crown loss, confers a number of benefits including the preservation of alveolar bone. Intentional root retention in adults has been widely investigated but little is known about this treatment approach in children. Therefore, the aim of the present study was to investigate the clinical outcomes associated with permanent anterior root retention in a young population. The study group comprised 53 children who had received treatment in the paediatric dentistry clinic, Charles Clifford Dental Hospital, Sheffield, UK, over the past 10 years, following a complicated crown root fracture of a permanent maxillary incisor at or below the gingival margin. Data relating to patient age at crown root fracture, gender, previous trauma history, tooth vitality, treatments performed and clinical outcomes were obtained retrospectively using patient records. The mean age of the subjects at initial crown root fracture was 12.1 years (range 8.3–15.8 years) and there were more than twice as many males (n = 37, 70%) as females (n = 16, 30%). In just over half of the cases seen (n = 29, 54%), the tooth involved was already nonvital at the time of crown root fracture. For the majority of these nonvital teeth (n = 27, 93%), primary treatment had comprised placement/replacement of a calcium hydroxide root dressing. The remaining two teeth did not require root treatment as a satisfactory gutta percha root filling was already present. A variety of treatments was undertaken for the 24 vital roots: in 15 (63%) cases the pulp was extirpated and calcium hydroxide placed; three (12%) cases were subject to a pulpotomy; five (21%) cases were left untreated with the hope that vitality would be maintained following gingival healing and in one case the radicular pulp was extirpated and immediately obturated with gutta percha. The mean time that the roots were kept under review was 2.6 years (± 1.57, range 0.6–6.8). During this period, only five roots (9%) had to be removed due to persistent periapical infection. There were no complications associated with the five cases where vital root submergence had been permitted but all three cases which had initially undergone a pulpotomy subsequently presented with pulpal necrosis necessitating pulpal extirpation and calcium hydroxide therapy. These findings indicate that efforts to retain permanent anterior roots in a young population are justified in view of the high clinical success rate of over 90% over a 2‐year period.     

Vital pulp therapy with mineral trioxide aggregate

Abstract –  The present case report describes the treatment of complicated crown fractures using mineral trioxide aggregate (MTA). MTA was used as pulp-capping material after partial pulpotomy to preserve the vitality of the pulpal tissues in two cases. Follow-up examinations revealed that the treatment was successful in preserving pulpal vitality and continued development of the tooth.     

Clinical assessment of mineral trioxide aggregate (MTA) as direct pulp capping in young permanent teeth

Carious pulp exposure in permanent molars of children is a common incident. Mineral trioxide aggregate is a new material that possesses numerous exciting possibilities for pulp therapy. AIM: The purpose of this study was to evaluate the efficiency of MTA as a direct pulp capping agent in young permanent teeth. METHODS: Thirty asymptomatic permanent molars with pulp exposures were treated by pulp capping using MTA. At each recall (6 12, 18 and 24 months), the teeth were assessed clinically, through pulpal sensitivity tests, as well as radiographically to evaluate periapical healing. RESULTS: None of the cases reported spontaneous pain at the six months follow up and the pulp showed signs of vitality and absence of periapical radiolucency. At 24 months, the clinical and radiographic success rate was 93% with evidence of continued root growth. CONCLUSION: Pulp capping with MTA is recommended for teeth with carious pulp exposures specially immature teeth with high potential for healing.     

Cvek pulpotomy: report of a case with five-year follow-up

Partial pulpotomy (Cvek pulpotomy) is the treatment of choice for injured permanent incisor teeth with exposed vital pulp tissue and immature apices. This treatment preserves pulpal function, thus allowing continued root development. The present report describes the case of a permanent incisor with incomplete root end closure that underwent a Cvek pulpotomy, with subsequent apical closure. Five years post pulp therapy, the tooth remained symptom free.     

三氧化物多聚体应用于活髓切断术的临床疗效研究

目的评价三氧化物多聚体(MTA)用于活髓切断术的临床效果。方法选取外伤冠折露髓的年轻恒前牙48颗,随机分为2组,每组24颗。氢氧化钙组用氢氧化钙盖髓,MTA组用MTA盖髓,追踪观察3年并进行临床评价。结果MTA组成功22颗,失败2颗,氢氧化钙组成功20颗,失败4颗,2组差异无统计学意义。结论MTA是一种较理想的直接盖髓剂。     

Clinical reliability of the dentine bridge formed after pulpotomy: A case report

An exposed pulp in a crown-fractured vital young tooth may be treated with either pulp capping or pulpotomy, using a calcium hydroxide dressing. Calcium hydroxide stimulates dentine bridge formation, which is a good indicator of pulp vitality. In this case it is reported that, although seriously contaminated for a long period with debris from the oral environment, the dentine bridge which formed after pulpotomy was able to function as a protective pulpal barrier. The tooth responded to an electrical pulp tester within normal limits and the periapical radiographic appearance was normal at review after 7 years.     

Human pulpal response to mineral trioxide aggregate (MTA): a histologic study

The purpose of this study was to study the histologic changes in the dental pulp following pulpotomy with Mineral Trioxide Aggregate (MTA) and Calcium hydroxide. Pulpotomies were performed on premolar teeth that were to be extracted for orthodontic reasons. The radicular pulp was capped with either MTA or Calcium hydroxide and restored with IRM. The teeth were extracted at 4 and 8 week intervals, fixed in 10% formalin and then kept in 5% nitric acid for 28 days for demineralization. Longitudinal sections were then prepared and viewed under light microscope. The pulps capped with MTA (at the end of 4 weeks and 8 weeks) showed dentin bridge formation which was more homogenous and continuous with the original dentin when compared to the pulps capped with calcium hydroxide. The pulpal inflammation was also less in the MTA group as compared to the calcium hydroxide group at the end of 4 and 8 weeks.     

Histologic evaluation of pulpotomies in dog using two types of mineral trioxide aggregate and regular and white Portland cements as wound dressings

OBJECTIVE: The purpose of this study was to investigate the pulpal response of dogs' teeth after pulpotomy and direct pulp protection with MTA Angelus, ProRoot, Portland cement and white Portland cement. STUDY DESIGN: Seventy-six teeth were treated with these materials. One hundred twenty days after treatment, the animals were sacrificed and the specimens removed and prepared for histological analysis. RESULTS: All the materials demonstrated similar results when used as pulp-capping materials. Pulp vitality was maintained in all specimens and the pulp had healed with a hard tissue bridge. CONCLUSION: The materials used in this study were equally effective as pulp protection materials following pulpotomy.     

Importance of the diagnosis in the pulpotomy of immature permanent teeth

Pulpotomy is a conservative therapy performed to remove the inflamed coronal portion of the pulp and preserve the vitality of the remaining radicular pulp. This article reports two cases of immature permanent mandibular molars with clinical signs of pulp vitality and radiographic images of periapical bone rarefaction, which were treated with calcium hydroxide pulpotomy. In Case 1, pulpotomy was performed in a single session, while in Case 2 two sessions were required to complete the treatment. Clinical and radiographic follow up within 13 and 9 months, respectively, showed hard tissue barrier and new bone formation as well as progression of root development. These outcomes are confirmatory that an accurate clinical/radiographic assessment of pulp vitality is of paramount importance for the correct diagnosis and indication of pulpotomy in cases of young permanent teeth with incomplete root formation.     

Capping the inflamed pulp under different clinical conditions

Background: A great deal of controversy exists regarding the reliability of capping the inflamed pulp. In particular, the use of calcium hydroxide as a capping agent has come into question. In this study, hard tissue barrier formation after inflamed pulps were capped directly or after partial pulpotomy was compared with calcium hydroxide or bonded resin and with no additional seal or an IRM surface seal. Seventy teeth in five dogs were used. Ten untreated teeth were used as negative controls. In 60 teeth, pulpal inflammation was induced by preparing a cavity close to the pulp and sealing a cotton pellet soaked in plaque in it for 1 to 2 weeks. The cavities were then re-entered and extended to expose the pulps.
Materials and Methods: In half the teeth (n = 30) a partial pulpotomy was performed and in the other half (n = 30) pulpal treatment was performed on the superficial exposed pulp. Both pulpal treatment groups received the same restorative procedures: (1) calcium hydroxide + amalgam + IRM surface seal; (2) OptiBond Solo, Prodigy with IRM surface seal; or (3) OptiBond Solo, Prodigy without IRM surface seal. The presence, absence, and quality of a hard tissue barrier were evaluated histologically.
Results: The calcium hydroxide groups were statistically superior to all other groups. The IRM surface seal resulted in significantly better healing. Although there was no statistically significant difference between direct pulp capping and partial pulpotomy with the numbers in this study, power statistics indicated that in clinical practice a partial pulpotomy would be preferable.     

Cytotoxic effects and pulpal response caused by a mineral trioxide aggregate formulation and calcium hydroxide

PURPOSE: To evaluate the in vivo pulpal response after pulpotomy with different capping agents. In addition, the in vitro cytotoxic effects of both materials were assessed by applying them on culture of pulp cells. METHODS: For the in vivo test, the coronal pulp of 28 teeth of dogs was mechanically removed and the root pulps were capped with the following dental materials: Group 1: Pro-Root MTA (PRMTA); and Group 2 (control): calcium hydroxide saline paste (CH). After 60 days, the animals were sacrificed and the teeth processed for histological analysis. In the in vitro test, experimental extracts obtained from both capping agents were applied on the cultured MDPC-23 odontoblast-like cells. RESULTS: In the root pulps capped with PRMTA or CH, coagulation necrosis partially replaced by dystrophic calcification as well as tubular dentin matrix laid down by elongated pulp cells was observed. None or mild inflammatory response occurred beneath the capped pulpal wound. Regarding the pulpal response, PRMTA and CH presented no statistical difference. However, the teeth capped CH presented greater healthy pulp loss which resulted in convex shape of the hard barrier than PRMTA. When applied on the cultured cells, it was demonstrated that PRMTA and CH solutions decreased the cell metabolic activity by 9.9% and 29.4%, respectively. CH caused higher cytotoxic effects to the MDPC-23 cells as well as deeper healthy pulp tissue loss than PRMTA. However, similar sequence of healing occurred after pulpotomy with both dental materials.     

Treatment of crown fractures with exposed pulps

Traumatic injuries are a common cause of pulpal damage in anterior teeth. Crown fractures with exposed pulps represent 18 percent to 20 percent of the traumatic injuries that involve the teeth. This clinical study comprised 36 patients, who were referred for 40 crown fractures with pulp exposures. There were 39 maxillary incisors and one mandibular incisor. The partial pulpotomy (Cvek's technique) consists of amputating exposed pulp tissue to a depth of 1 to 2 mm below the point of pulp exposure. After partial pulpotomy, the pulpal wound is covered with calcium hydroxide; and the cavity is sealed with glass ionomer cement or a composite crown. Clinical and radiographic assessment of the hard-tissue barrier was done after three months. Patients were monitored for periods ranging from one to 12 years. The purpose of this clinical report was to evaluate Cvek's technique in the management of coronal fractures with pulp exposures and the long-term outcome of the partial pulpotomy in immature and mature teeth. In virtually all of the cases, this treatment was successful. Careful partial pulpotomy remains a prudent treatment choice with proper case selection.     

Management of open apices in thirteen traumatized permanent incisors using mineral trioxide aggregate: Case series

AimThe partial pulpotomy can offer a successful outcome for the treatment of traumatic complicated crown fractures. The aim of this clinical report was to evaluate the effect of mineral trioxide aggregate (MTA) in apexogenesis of traumatized immature permanent incisors with pulp exposure.Case reportAccording to clinical and radiological examinations complicated crown fractures and open apices were identified in 13 permanent upper incisors in ten patients (age range 7–10 years). Partial pulpotomy procedures were performed and the teeth were treated with MTA. In this report, periodic clinical and radiological follow-ups were performed. At recall examinations, all teeth were asymptomatic, and clinical and radiological investigations revealed excellent healing patterns with continued apexogenesis.ConclusionRegular examination of immature traumatized permanent teeth is critical for vitality and apexification. In this report, clinical and radiological findings confirm that partial pulpotomy with MTA is a reliable and effective treatment approach in apexogenesis of traumatized immature permanent incisors with pulp exposure.     

Apexogenesis after initial root canal treatment of an immature maxillary incisor – a case report

Aim To present a case where a traumatized, immature tooth still showed capacity for continued root development and apexogenesis after root canal treatment was initiated based on an inaccurate pulpal diagnosis. Summary Traumatic dental injuries may result in endodontic complications. Treatment strategies for traumatized, immature teeth should aim at preserving pulp vitality to ensure further root development and tooth maturation. A 9‐year‐old boy, who had suffered a concussion injury to the maxillary anterior teeth, was referred after endodontic treatment was initiated in tooth 21 one week earlier. The tooth had incomplete root length, thin dentinal walls and a wide open apex. The pulp chamber had been accessed, and the pulp canal instrumented to size 100. According to the referral, bleeding from the root made it difficult to fill the root canal with calcium hydroxide. No radiographic signs of apical breakdown were recorded. Based on radiographic and clinical findings, a conservative treatment approach was followed to allow continued root development. Follow‐up with radiographic examination every 3rd month was performed for 15 months. Continued root formation with apical closure was recorded. In the cervical area, a hard tissue barrier developed, which was sealed with white mineral trioxide aggregate (MTA). Bonded composite was used to seal the access cavity. At the final 2 years follow‐up, the tooth showed further root development and was free from symptoms. Key learning points

• ? Endodontic treatment of immature teeth may result in a poor long‐term prognosis.
• ? The pulp of immature teeth has a significant repair potential as long as infection is prevented.
• ? Treatment strategies of traumatized, immature permanent teeth should aim at preserving pulp vitality to secure further root development and tooth maturation.
• ? Radiographic interpretation of the periapical area of immature teeth may be confused by the un‐mineralized radiolucent zone surrounding the dental papilla.