17474477, 2002, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1747-4477.2002.tb00364.x by Natl Defense Medical, Wiley Online Library on [04/05/2024].

See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Recombinant human BMP-2, -4 and -7 has been shown to periodic monitoring is essential ( I 5).
induce reparative dentine formation in experimental models of large Generally, partial pulpotomy of carious permanent teeth, most
direct pulp exposures in permanent teeth (53-55). N e w reparative often with calcium hydroxide, serves to maintain the vitality of
dentine replaces the stimulating agents applied directly to the radicular tissue until apexogenesis is complete (5). Once the apex is
partially amputated pulp. This new tissue forms contiguous with, closed, root canal treatment is performed. This practice is based
and not at the expense of, the remaining vital pulp tissue. This on anecdotal evidence that calcium hydroxide will precipitate
permits the induction of a predetermined and controlled amount of dystrophic calcification in the canals and prevent endodontic
reparative dentine. treatment later, if needed (5). This obliteration of the root canals
These results provide experimental support for the potential of results in diminished blood supply, which could lead to pulp necrosis
biologic agents to stimulate reactionary dentine formation (53-55). (35). This relates t o full coronal pulpotomy where too little pulp
Further development of proper carrier vehicles that will optimise tissue is confined with too much calcium hydroxide. With partial
clinical handling characteristics and delivery will add t o further pulpotomy, where the objective is to remove only infected tissue,
possible uses (53). In the future, pulpotomies for primary and dentine bridging is stimulated in the coronal area and canals are free
permanent teeth may be handled in exactly the same way (5). of dystrophic calcification (5). Stanley (36) proposes that the
Pulpal innervation has traditionally been regarded t o serve a negative side effects of inorganic calcium hydroxide, such as
purely nociceptive function. This concept is being challenged by dystrophic calcification, have been eliminated in the lower pH,
increasing evidence that sensory nerves also serve important hard-setting, commercial calcium hydroxide preparations.
effector functions (56). Rodd and Biossonade (56) showed a caries-
induced dynamic increase in neural density in both primary and Success
young permanent teeth and speculated that this may be critical for A limit to determining success of vital pulp therapy in permanent
the regulation of pulpal inflammation and healing. teeth is the ability to recall patients regularly to determine success.
In endodontics, it has been proposed that the laser has an Although histologic success cannot be determined, clinical success is
application in direct pulp therapy as well as i-oot-end preparation judged by the absence of any clinical or radiographic signs of
and canal disinfection (57). Moritz et al (57) used a CO, laser at I W pathosis and the presence of continued root development in teeth
to irradiate non-inflamed pulps for 0. I sec pulses at I sec intervals with incompletely formed roots (22). Success rates decrease with
until exposed pulps were completely sealed. A hard setting calcium time. Barthel et al (14) showed a success rate of 37% at 5 years,
hydroxide cement and a glass ionomer restoration were then which dropped to 13% at 10 years. Canal calcification, internal
placed over the pulp. In the control group, a hard setting calcium resorption and/or pulpal necrosis are potential sequelae of vital pulp
hydroxide cement and a glass ionomer restoration were placed therapy and careful monitoring is needed to diagnose these
directly on the pulp without prior laser treatment. At I 2 months, potential problems as early as possible.
laser Doppler flowmetry assessed 89% of the laser treated cases to
be vital as compared to 68% of the non-laser treated cases. Age
The amount of data that has been accumulated over the years The patient's age may be another limiting factor in the success
on the biology and the clinical behaviour of the dental pulp are of vital pulp therapy in cariously exposed permanent teeth. In
impressive (58). Yet there are considerable gaps in our knowledge older patients, the histological state of the pulp may affect its ability
of the defence and repair mechanisms of the dentine-pulp complex t o overcome an insult. Pulpal vasculature constantly undergoes
that future research should address. morphological changes incident t o various conditions such as
growth, maturation and inflammation. Over time, owing to the
Limitations apposition of secondary and tertiary dentine, this leads to the pulp
cavity becoming narrower and the vasculature within undergoes a
Research data on vital pulp therapy can be misleading and reconstruction ( 12). The resistance of the pulp becomes reduced
confusing ( I 3) In categorising success and failure of vital pulp with age ( 12). This becomes significant when one considers that the
therapy, many more factors need t o be considered than just vascular reaction to inflammation is considered a protective
the presence or absence of microorganisms ( 13) In addition to the mechanism of the pulp against invading factors ( I 2). Horsted et al
presence of microorganisms, degrees of inflammatory response (59) demonstrated a significantly lower tooth survival rate in the
and dentine bridges one must differentiate between true tissue older age group (50-79 years of age) over longer observation
necrosis and mummification, t ecognise the potential for washout periods. From the clinical point of view, the vitality of the dental pulp
of microorganisms, leukocytes and loss of extruded pulp tissue of an aged person appears to be weaker than that of a young
elements, the influence of impaction of particles of pulp therapy person ( I 2). Mass and Zilberman (35) achieved a 9 I .4% success
agents and dentine chips, the control of haemorrhage and rate in a sample limited to children, teenagers and young adults and
embolisation of particles of pulp therapy agents, the size of the pulp suggested that vital pulp therapy of cariously exposed permanent
exposure, the final location of the dentine bridge, and the quality of teeth be limited to children or young adults. Chronological age does
its formation ( 13) A distinction between failure of the pulp therapy not always reflect physiological age, and neither one should be seen
and failure of the overlying resoration must also be made as an absolute contraindication for vital pulp therapy in permanent
While there are indications for vital pulp therapy in young teeth (26).
permanent molars, it must be remembered that ultimately, none of Controversy exists as to whether the pulp should be re-entered
these procedures enjoy the success of complete root canal therapy after the completion of root development in the pulpotomised
( I 5) In the mature permanent tooth, pulpectomy and root filling tooth (22). Root canal therapy is recommended because of the
are the preferred treatment ( I 7) This is because firstly, pulpectomy chance that calcification would render the canals non-negotiable at
with a subsequent root filling has a high success rate (90-96%), and a future date. Recent research has shown that with good case
secondly, with the wound placed apically, inflammatory responses selection, a gentle, aseptic technique and careful placement of
to infection can radiographically be detected early When vita pulp calcium hydroxide onto the pulp, progressive calcification is an
therapy has been performed, problems may develop later and infrequent sequela of pulpotomy (22).

AUSTRALIAN ENDODONTICJOURNAL VOLUME 28 No. I APRIL 2002 33