Partial pulpotomy in young permanent teeth with deep carious lesions

Abstract The material comprised 37 young posterior teeth with deep carious lesions and exposed pulps, treated with partial pulpotomy and dressed with calcium hydroxide. The teeth were divided into two groups. Group 1 consisted of 31 teeth with no clinical or radiographic symptoms before treatment, Group 2 of 6 teeth with temporary pain, widened periodontal space periapically and/or productive osteitis, i.e. increased density of the surrounding alveolar bone. After an observation time of 24 to 140 months (x?= 56 months), healing had occurred in 29 of 31 teeth in Group 1 (93.5%) and in 4 of 6 teeth in Group 2. It was concluded that the present, as well as previously reported results indicate that partial pulpotomy may be an adequate treatment for young permanent molars with a carious exposure, although more studies are needed before the treatment can be recommended for routine clinical use.     

Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth

Abstract The aim was to assess the prevalence of pulp exposure alter stepwise versus direct complete excavation of permanent posterior teeth with deep carious lesions. The material, representing 116 patients aged 6-l6yrs (= 10.2 yrs), consisted of 127 teeth with radiographs revealing carious lesions to such a depth that pulp exposure could he expected if direct complete excavation was performed. Teeth with clinical symptoms, other than transient pain shortly before treatment, were not accepted. The teeth were randomly selected for either treatment procedure. Stepwise excavation implied removal of the bulk of carious tissue and application of calcium hydroxide, followed by sealing of the cavity with zinc-oxide eugenol cement. After a period of 8–24 weeks the rest of the carious dentin was removed and the cavity sealed with calcium hydroxide, zinc-oxide-eugenol (ZOE) and a restorative material. Direct complete excavation entailed removal of all carious dentin followed by sealing as mentioned above. In case of pulp exposure, pulp treatment was performed. The pulp was exposed in 40 of the teeth treated by direct complete excavation. The corresponding figure for those treated by stepwise excavation was 17.5%. The difference was statistically significant. The teeth with no pulp exposure after direct or stepwise excavation showed normal clinical and radiographic conditions at the last check-up (= 43 mouths).     

深龋基牙固定修复后发生牙髓病变的危险性分析

目的：探讨深龋基牙固定修复后发生牙髓病变的危险性。方法：选择2002年1月至2004年12月,在口腔中心就诊患深龋且治疗成功又作为固定冠、桥修复基牙的患者510例,男272例,女238例,年龄19-72岁。将这些患者中的深龋基牙542颗作为深龋组;正常牙体基牙312颗为对照组。观察2组基牙固定冠桥修复后牙髓状况,深龋组进一步分析牙髓病变与牙位的关系。421例患者661颗基牙成功回访。结果：2年内深龋组397颗基牙中41颗出现牙髓病变,发生率10．33％;对照组264颗基牙3颗出现牙髓病变,发生率1．14％,2组间有显著的统计学差异。发生牙髓病变多在修复后的半年内。深龋下颌前牙牙髓病变率23．08％;下颌双尖牙牙髓病变率17．31％。结论：深龋基牙固定修复后发生牙髓病变的危险性显著高于牙体正常牙。固定修复尤其对患深龋的下颌前牙、下颌双尖牙牙髓健康影响较大,临床在选做冠桥修复的基牙时应谨慎。     

人龋病牙髓中降钙素基因相关肽阳性神经纤维的研究

目的：研究人牙髓降钙素基因相关肽（calicitonin gene-related peptide CGRP）在龋病发展过程中的变化特点，为探讨牙髓局部免疫系统如何参与牙髓的各种病理改变提供理论基础。方法：用免疫组织化学染色法标记牙髓中CGRP并进行定量研究。结果：正常及龋病牙髓中均存在CGRP，牙髓CGRP阳性神经纤维的数量随龋病进展而增多，各组间比较有显著差异。结论：正常牙髓中存在CGRP并与龋坏深度相关。龋坏早期，神经肽对龋源性刺激做出了反应，随着龋坏的发展，局部反应增强，提示CGRP可能参与了牙髓炎症修复过程。     

Treatment decisions for deep carious lesions in the Public Health Service in Southern Brazil

Objectives: The aim of the present study was to assess Public Health Service clinicians' treatment decisions about deep carious lesions in the city of Porto Alegre, Brazil. Methods: Treatment decisions were assessed with a structured questionnaire (open/discursive and containing information about gender, university and year of college graduation, and college major) and three simulated clinical cases composed of teeth with primary deep carious lesion. All professionals working for the Public Health Service in the city were addressed. Results: Out of 122 professionals, 54 participated in the study (response rate of 44 percent). There was no difference between respondents and non‐respondents regarding gender, year of college graduation, or college major. The most commonly indicated procedure was direct complete excavation (71.1 percent), followed by stepwise excavation (17.6 percent), partial caries removal (8.8 percent), and pulp therapies (direct pulp capping, partial or complete pulpotomy, and endodontics) (2.5 percent). Year of college graduation was the only variable influencing treatment decision. Logistic regression analysis showed that professionals who had graduated after the year 2000 were significantly more likely to indicate a conservative treatment than were dentists who graduated through 1979 (odds ratio = 5.5). Conclusions: The most commonly proposed treatment is the one with the highest risk of pulp exposure, and consequently the poorest prognosis. Younger dentists tended to indicate more conservative approaches, compared with those indicated by older dentists.     

龋源性露髓成熟恒牙活髓保存治疗的研究进展

保存牙髓活力、维持牙髓功能、尽可能保留患牙的微创治疗理念是当代成熟恒牙牙髓治疗的重要发展趋势。本文基于最新研究,归纳龋源性露髓的成熟恒牙活髓保存治疗的临床疗效及其影响因素,简要介绍相关研究的新进展,以期为临床开展活髓保存治疗及今后该领域的发展提供参考。     

Outcome of Partial Pulpotomy in Cariously Exposed Posterior Permanent Teeth: A Systematic Review and Meta-analysis

IntroductionThe current systematic review and meta-analysis aimed to evaluate the success rate of partial pulpotomy in treating permanent posterior teeth with carious vital pulp exposure. A secondary aim was to assess the prognostic factors using a meta-regression.MethodsAn electronic search was performed for studies from January 1950 to November 2018 in the following databases: PubMed, ScienceDirect, and Cochrane. All searches were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical studies evaluating the success rate of cariously exposed vital human permanent posterior teeth treated with a partial pulpotomy were selected. Only randomized clinical trials and prospective clinical studies were included for evaluation. The Newcastle-Ottawa Scale and the Cochrane Collaboration’s tool were used to evaluate risk assessment.ResultsFrom the 218 studies identified through the initial search, 11 studies qualified for the final analysis (5 randomized clinical trials and 6 prospective studies). The results of the meta-analysis indicate a success rate of 98% (confidence interval [CI]: 0.94–1), 96% (CI: 0.92–0.99), and 92% (CI: 0.83–0.97) after 6 months and 1 and 2 years of follow-up. Examining the probable prognostic factors using meta-regression analysis, only preoperative pulp status (P = .001) was identified as a significant factor, with studies including teeth with the presumptive diagnosis of irreversible pulpitis displaying significantly lower results. The final solution, pulp capping material, apex closure, and the age of the patient did not affect the treatment success rate (P > .05).ConclusionsThe available data suggest that a partial pulpotomy results in high success rates in treating cariously exposed permanent posterior teeth up to 2 years. Six months of monitoring can be considered an appropriate period when evaluating the success of a partial pulpotomy although more clinical and radiographic controls are essential to ensuring success.     

Clinical and radiographic appearance of proximal carious lesions at the time of operative treatment in young permanent teeth

Clinical tissue changes were recorded during restorative treatment of proximal carious lesions of young premolars and molars. 60 proximal surfaces with radiolucencies in the inner half of the enamel or the outer half of the dentin were treated. The extent and character of the tissue changes were documented with photographs taken during drilling and evaluated after magnification. The maximum extent for each lesion was correlated to the extent of the radiographically observed lesion. The results showed that 70% of the restored surfaces were associated with a breakdown of the enamel surface. When the radiolucency did not extend deeper than into the inner half of the enamel, cavities were found in 61%; for lesions with a radiolucency extending into the outer half of the dentin the percentage was 78%. In the majority of cases the cavity was limited to the enamel. In all cases discoloration was observed in the enamel. The dentin was soft and discolored in 83%. Severe damage of tooth substance was found in 12% of the teeth.     

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。     

Variation in radiographic interpretation and restorative treatment decisions on approximal caries among dentists in Norway

Of a random sample of dentists in Norway (n = 741), 83% responded to a questionnaire about their use of radiographs in and their opinions and knowledge about the diagnosis of approximal caries. There was great disparity in criteria for initiation of restorative treatment of approximal caries based on radiographic appearance. Two thirds of the dentists would do restorative treatment of lesions confined to enamel, the others would wait until lesions had reached the dentin before treatment was commenced. The criteria for restoration based on radiographic appearance was best correlated with the dentists' opinions about cavity formation. About 20% of the variation in criteria among dentists was explained by the radiographic appearance dentists associated wih the presence of a cavity. The majority of the dentists believed that approximal caries progressed faster than is indicated by progression studies. The interval between recall examinations using radiographs was not consistently shorter for dentists who decided to carry out operative caries treatment at a relatively advanced stage.     

A practice-based study on stepwise excavation of deep carious lesions in permanent teeth: a 1-year follow-up study

This study reports results from a practice-based study in which deep carious lesions were treated by general dental practitioners using stepwise excavation. The material comprised 94 teeth with deep carious lesions which the clinicians considered would result in pulp perforation if treated by a single and terminal excavation. At therst visit excavation of the peripheral dentine was completed. The outermost part of the central and necrotic dentine was gently removed with a sharp excavator. Standardized assessments of the dentine colour and consistency were made before application of a calcium hydroxide-containing base material and temporarylling. Thenal excavation was completed after a treatment interval ranging from 2 to 19 months, with a median of 6 months. Reassessments of the dentine colour and consistency were made before complete removal of demineralized dentine. The central dentine was signicantly browner and less softened after the sealing period. After removal of the dark-brownish dentine during thenal excavation, the colour and consistency of the exposed central dentine was found to resemble that of the completely excavated peripheral dentine. Onlyve cases resulted in pulp perforation during thenal excavation. The high success rate of teeth surviving thenal treatment without pulp exposure after 1 year of observation shows that it was possible for dentists in general practice to administer and manage the treatment of deep carious lesions, a process which may prolong tooth survival compared with conventional endodontic techniques.     

Neuropeptide Y Y1 receptor in human dental pulp cells of noncarious and carious teeth

Aim To determine the distribution of the NPY Y1 receptor in carious and noncarious human dental pulp tissue using immunohistochemistry. A subsidiary aim was to confirm the presence of the NPY Y1 protein product in membrane fractions of dental pulp tissue from carious and noncarious teeth using western blotting. Methodology Twenty two dental pulp samples were collected from carious and noncarious extracted teeth. Ten samples were processed for immunohistochemistry using a specific antibody to the NPY Y1 receptor. Twelve samples were used to obtain membrane extracts which were electrophoresed, blotted onto nitrocellulose and probed with NPY Y1 receptor antibody. Kruskal–Wallis one‐way analysis of variance was employed to test for overall statistical differences between NPY Y1 levels in noncarious, moderately carious and grossly carious teeth. Results Neuropeptide Y Y1 receptor immunoreactivity was detected on the walls of blood vessels in pulp tissue from noncarious teeth. In carious teeth NPY Y1 immunoreactvity was observed on nerve fibres, blood vessels and inflammatory cells. Western blotting indicated the presence and confirmed the variability of NPY Y1 receptor protein expression in solubilised membrane preparations of human dental pulp tissue from carious and noncarious teeth. Conclusions Neuropeptide Y Y1 is expressed in human dental pulp tissue with evidence of increased expression in carious compared with noncarious teeth, suggesting a role for NPY Y1 in modulation of caries induced pulpal inflammation.     

European Society of Endodontology position statement: Management of deep caries and the exposed pulp

This position statement on the management of deep caries and the exposed pulp represents the consensus of an expert committee, convened by the European Society of Endodontology (ESE). Preserving the pulp in a healthy state with sustained vitality, preventing apical periodontitis and developing minimally invasive biologically based therapies are key themes within contemporary clinical endodontics. The aim of this statement was to summarize current best evidence on the diagnosis and classification of deep caries and caries‐induced pulpal disease, as well as indicating appropriate clinical management strategies for avoiding and treating pulp exposure in permanent teeth with deep or extremely deep caries. In presenting these findings, areas of controversy, low‐quality evidence and uncertainties are highlighted, prior to recommendations for each area of interest. A recently published review article provides more detailed information and was the basis for this position statement (Bjørndal et al. 2019, International Endodontic Journal, doi: 10.1111/iej.13128 ). The intention of this position statement is to provide the practitioner with relevant clinical guidance in this rapidly developing area. An update will be provided within 5 years as further evidence emerges.     

Caries removal strategies for deep carious lesions in primary teeth: Systematic review

The study aimed to compare the efficacy of three caries removal techniques—complete caries removal (CCR), selective caries removal (SCR), and stepwise caries removal (SWR)—for deep carious lesions in vital temporary teeth by conducting a systematic review and meta‐analysis of randomized controlled trials (RCTs). Electronic databases (PubMed [MEDLINE], Cochrane Library, EMBASE) were searched for corresponding references up to 31 May 2019. Possible outcomes were pulp exposure, pulpo‐periodontal complications, or restorative failures . Three reviewers independently selected studies, extracted data, and assessed the risk of bias using RoB 2. Meta‐analyses for intention‐to‐treat and per‐protocol scenarios were performed using Revman5. Of 1374 potentially eligible articles, ten relevant references corresponding to eight studies were included. Pooled results showed decreased risk of pulp exposure after SCR (OR: 0.10, 95% CI [0.04, 0.25]) or SWR (OR: 0.20, 95% CI [0.09, 0.44]), compared with CCR. There was a higher risk of composite restorative failure (OR: 2.61, 95% CI [1.05, 6.49]) using USPHS criteria, after SCR compared with CCR only in intention‐to‐treat analysis. Risk of clinical or radiographic failure of pulpo‐periodontal complications was unchanged when compared with SCR and CCR or SWR. SCR and SWR may result in lower pulp exposure risk than CCR. RCTs with lower risk of bias, higher power, and longer follow‐up are required to choose between these three caries removal techniques for deep carious lesions in vital temporary teeth.     

Management of deep caries and the exposed pulp

Caries prevalence remains high throughout the world, with the burden of disease increasingly affecting older and socially disadvantaged groups in Western cultures. If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs even in deep carious lesions. Traditionally, deep caries management was destructive with nonselective (complete) removal of all carious dentine; however, the promotion of minimally invasive biologically based treatment strategies has been advocated for selective (partial) caries removal and a reduced risk of pulp exposure. Selective caries removal strategies can be one‐visit as indirect pulp treatment or two‐visit using a stepwise approach. Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy and the re‐emergence of vital pulp treatment (VPT) techniques such as partial and complete pulpotomy. These changes stem from an improved understanding of the pulp–dentine complex's defensive and reparative response to irritation, with harnessing the release of bioactive dentine matrix components and careful handling of the damaged tissue considered critical. Notably, the development of new pulp capping materials such as mineral trioxide aggregate, which although not an ideal material, has resulted in more predictable treatments from both a histological and a clinical perspective. Unfortunately, the changes in management are only supported by relatively weak evidence with case series, cohort studies and preliminary studies containing low patient numbers forming the bulk of the evidence. As a result, critical questions related to the superiority of one caries removal technique over another, the best pulp capping biomaterial or whether pulp exposure is a negative prognostic factor remain unanswered. There is an urgent need to promote minimally invasive treatment strategies in Operative Dentistry and Endodontology; however, the development of accurate diagnostic tools, evidence‐based management strategies and education in management of the exposed pulp are critical in the future.     

Management of deep carious lesions and pulps exposed during carious tissue removal in adults: a questionnaire study among dentists in Finland

Objectives

To find out which management methods are preferred by dentists in Finland for a deep carious lesion or a pulp exposed during carious tissue removal in adult patients.

Materials and methods

An electronic questionnaire consisting of 25 questions was sent to 1000 randomly sampled dentists in Finland. The response rate was 32%.

Results

Less invasive excavation strategies (stepwise or selective removal) were preferred by 64% for an asymptomatic deep lesion, while 34% chose nonselective removal to hard dentine. In the presence of an asymptomatic pulpal exposure, vital pulp therapy was preferred, as 71% of the respondents chose direct pulp capping (DPC) or partial pulpotomy, compared to root canal treatment (26%). Mineral trioxide aggregate (MTA) and calcium hydroxide-based materials were both chosen by 40% for vital pulp therapy. In the management of a deep carious lesion, less invasive excavation strategies were significantly associated with having clinical guidelines vs. no guidelines at the practice [odds ratio (OR) 3.5, confidence interval (CI) 1.4–9.0]. MTA was favored over other DPC materials significantly more often by those who had attended continuing education courses during the last 3 years (OR 2.8, CI 1.2–6.5).

Conclusions

Less invasive management strategies have been adopted into clinical practice by the majority of dentists in Finland. There is a need to encourage the use of MTA in the case of a pulpal exposure.

Clinical relevance

The results of this study can be utilized in continuing education, to raise awareness of management strategies supported by present scientific evidence.

     

A simplified dental examination for detection of cavitated carious lesions in school setting

Objective:  The objective of the study was to compare a simplified dental examination involving the use of a wooden spatula and a toothpick (TS examination) with the conventional dental mirror and probe examination (MP examination) for detection of cavitated carious lesions in schoolchildren.
Methods:  The study involved three groups of caries-positive schoolchildren aged 4–5, 9–10 and 13–14 years with 179, 188 and 202 children, respectively. All children were examined by a trained and calibrated examiner using a wooden spatula and a toothpick under natural light. After a week the same examiner examined the three groups of children by a dental mirror and a Community Periodontal Index (CPI) probe. 'Teeth' were considered as units of measurement for data analysis. The WHO recommended criteria (2) for decayed, missing and filled teeth were followed for recording dental caries on a specially designed recording form. The sensitivity, specificity, positive predictive value, negative predictive value, false-positive rate and false-negative rate of TS examination were calculated using MP examination as the standard method.
Results:  The specificity of TS examination was well above 95% in three types of dentition. Although the sensitivity of this type of examination in deciduous and mixed dentitions was almost comparable with that of MP examination, it was the lowest for permanent dentition but still within the acceptable limits.
Conclusion:  The TS examination can provide an alternative to traditional MP examination to undertake regular check-ups of schoolchildren for dental caries.