VITAL PULP THERAPY

Improvement in the field of endodontics in the past few decades have raised the quality of treatment and prognosis. Even the most complicated case will give excellent long term results after correct treatment. Some dentists continue to use alternatives to routine endodontic therapy particularly when treating a vital pulp exposure. Vital pulp therapy is a term used to describe all procedures that are taken to deal with deep carious lesions, to avoid having to do complete pulp extirpation. Why vital pulp therapy ? Here seem to be three main reasons why dentists select vital pulp therapy rather than routine endodontic treatment for teeth with exposed vital pulps... 1- The limited endodontic skills of the practitioner. 2- Anatomic difficulties offered by some teeth; numerous canals, severe curvatures, and/or dentinal sclerosis 3- Limited financial resources of the patient. History and review of literature: In the infancy of endodontics the objective of treatment of the exposed pulp was its retention because of the severe pain involved in pulp removal. Many endodontic treatments administered in the nineteenth and early twenties were pulp capping procedures. Many materials were described. During the late 1920s, a number of pulp amputations took place in Germany, and Hermann first introduced the use of Calcium hydroxide. Teuscher and Zander reported on the action of the material used in pulpotomies, describing the formation of a dentin-like layer beneath the site of exposure and above a layer of odontoblasts. This was called the dentin bridge, corresponding to the frequent radiographic appearance of a radiopaque line apical to the dressing in a tooth treated with vital pulp therapy. Clinical observations have been that pulps treated with calcium hydroxide often present problems if endodontic treatment later becomes necessary because of heavy deposition of secondary dentin that takes place, even if the tooth involved develops a necrotic pulp. For this reasons, other medications were used in vital pulp therapy that did not produce the potentially harmful extensive bridging. Mixtures of zinc oxide and eugenol plus other additives have been described with excellent results by some, and areas of necrosis, abscess formation, and inflammatory infiltration described by others.

Formocresol have been widely used as a pulpotomy dressing and extensively described, usually compared with the action of calcium hydroxide or zincoxide / eugenol. When formocresol is sealed over the exposed vital pulp stump it produces chemical fixation of the tissue contacted. Underneath, the pulp remains vital and the periapical tissues normal.

Management of deep carious lesions: W hen dealing with deep carious lesions proper diagnosis of pulp condition is essential to select the proper line of treatment. Both clinical & radiographic examination are essential. Treatment choice depends on: 1- The extent & location of caries. 2- The status of the pulp. 3- The clinical signs & symptoms. 4- The personal & economical factors. Important factors to achieve successful vital pulp therapy: 1- Treatment should be performed on non-inflamed pulp. 2- A bacterial tight seal should be obtained. 3- A suitable pulp dressing should be applied. Best indications for successful vital pulp therapy: Recognizing the potential problems that might occur, its suggested that the following types of cases of exposed vital pulps would appear to give the best indications for alternatives to routine endodontic treatment: 1- Teeth with incomplete apical development. 2- Primary teeth. 3- Teeth that would be difficult to treat endodontically. 4- Teeth involved in simple restorations. 5- Teeth with pulpal inflammation confined to a small segment of the coronal pulp. Contra-indications for vital pulp therapy: 1- Teeth in which the canal space could be well utilized to hold a post and core. 2- Teeth that will be used as splint, bridge, and partial denture abutments. 3- Teeth involved in complex periodontal therapy and resultant periodontal prosthesis.

I- INDIRECT PULP CAPPING It involves the removal of caries from the cavity floor just short of clinically exposing the pulp. The overlying dentin is then treated in a manner that permits the pulp to recover and continue functioning physiologically as the soft tissue support for the dentin. Indirect pulp capping is indicated only if: 1- There is no history of severe or spontaneous pain. 2- There is normal response to electric & thermal pulp tests. 3- There is no radiographically detectable change. 4- The residual dentin overlying the pulp must be at least leathery ( as hard as a finger nail surface ) and intact. Technique of indirect pulp capping: 1- Rubber dam isolation. 2- Prepare the cavity in a proper form. 3- Remove the soft demineralized dentin on the floor until you reach sound dentin short of actual pulp exposure, or until the outline of the pulp space can be seen through a layer of firm leathery dentin. 4- W ash the floor with saline or with diluted solution of sodium hypochlorite. 5- Place a fast-setting calcium hydroxide over the deep portions of the floor. 6- Seal the cavity floor with glass_ionomer cement, or re_enforced zincoxide/eugenol over the calcium hydroxide. N.B If composite will be the final restoration, use glass-ionomer cement over the calcium hydroxide. 7- Do the final restoration. 8- Advise the patient about expectations of pain. 9- Follow ups should be done every 6 months, even if the patient didnt report pain. However if the patient reported severe pains, we should expect failure of the procedure. Prognosis: W hen indirect pulp capping is done on properly selected teeth, reported success in terms of the teeth remaining clinically asymptomatic and functional is high. Therefore it represents a useful practical adjunct to restorative dentistry

II- DIRECT PULP CAPPING This involves removal of caries from the cavity base to the point of exposing the pulp space, or it might be traumatic exposure, and dressing of the pulp wound, without physically removing any of the pulp tissue. Indications of direct pulp capping: Direct pulp capping is indicated in permanent teeth with carious as well as traumatic or mechanical pulp exposure. However: - There should be no history of swelling. - There should be no symptoms of moderate to severe or recurring spontaneous pain. - The tooth should not be tender to percussion. - The tooth should have normal response to vitality testing. - The tooth should have no periapical pathology in radiographs. Contraindications to direct pulp capping: 1- Teeth with superficially necrotic pulps. 2- Teeth with extensive pulp calcifications. 3- Teeth that cannot be adequately restored restored without utilization of the pulp space. 4- Teeth in which the exposure site cannot be sealed in a manner that prevents contamination by microorganisms. 5- All primary teeth. The relation between the size of pulp exposure and success of pulp capping: Under ideal circumstances, the actual size of exposure is not a significant factor in postoperative prognosis, since the pulp has the capacity to undergo repair even after complete removal of the roof of the pulp chamber ( as in pulpotomy.) Whats important is : 1- Removal of the grossly carious (contaminated) dentin. 2- The preoperative status of the pulp. and 3- The effective sealing of the exposure site and prepared cavity. Capping materials: Different materials have been used for pulp capping. Calcium hydroxide is the material of choice at the present time.

Advantages of calcium hydroxide & its mode of action: 1- It is antibacterial& will disinfect the superficial pulp. 2- Pure calcium hydroxide necroses about 1.5 mm of superficial pulp, removing superficial layers of inflamed pulp if present. * The high pH of 12.5 of calcium hydroxide causes a liquifaction necrosis in the most superficial layers , and the toxicity of Ca(OH)2 appears to be quickly neutralized as deeper layers of the pulp are affected ( causing coagulative necrosis at this level). The coagulative necrotic tissue causes a mild irritation to the adjacent pulp tissue. This mild irritation will initiate an inflammatory response & in the absence of bacteria ( because of the bacterial tight seal ) will heal with a hard tissue barrier. Summary of the mode of action Ca(OH)2 over pulp Superficial necrosis Neutralization of toxicity in deeper layers Coagulative necrosis Irritation of adjacent pulp Inflammation ( well sealed tissue) Hard tissue barrier

Disadvantages of calcium hydroxide:

A major disadvantage of Ca(OH)2 is that it does not seal the fractured surface. Thats why an additional material must be used sealing, particularly during the healing phase. Zinc oxide-eugenol & glass-ionomer cements have been used for sealing. Materials other than Ca(OH)2: Zinc oxide-eugenol, tricalcium phosphate & composite resin have been proposed as medicaments for vital pulp therapy. However none have afforded the predictability of Ca(OH)2 in conjunction with a maximally sealed coronal restoration. Mineral trioxide aggregate (MTA) has been reported to show promise as pulp capping agent, but the reproducibility of these results & its long-term success has not been tested. Technique of direct pulp capping: It is also similar to that of indirect capping. The rubber dam should be applied to: 1- Provide good visual access to the tooth and exposure site. 2- Reduce the potential for bacterial contamination. 3- Facilitate placement of the pulp dressing. 4- Create more favorable environment for hermetic sealing of the cavity. 5

N.B. Placement of the rubber dam prior to initiation of cavity preparation permits dressing and sealing of the pulp wound without undue delay after decay is removed. Although brief periods of salivary contamination do not appear to adversely affect the capacity of the pulp to repair after treatment. The pulp tissue at the exposure site should appear pink & intact. It should bleed freely when touched. If pulp tissue is absent at the exposure site, or if the quality of tissue leaves some question to its integrity, a pulpotomy or RCT would be the treatment of choice. Bleeding at the exposure site should be arrested before the pulp dressing is applied. Pressure applied with plain sterile gauze or sterile gauze moistened with 1:10,000 epinephrine is helpful. Timing of tooth restoration after pulp capping: If the prognosis appears favorable, and if composite or amalgam restoration would be adequate, final restoration of the coronal portion of the tooth is made at the same appointment. If the prognosis appears less favorable or if a crown is to be made, it may be advisable to place a temporary restoration, considering the necessity of keeping the cavity hermetically sealed until the permanent restoration is made. This would allow time for the pulp to recover from inflammation induced by caries before subjecting it to the mechanical trauma associated with complex restorations such as crowns or pin-retained restorations. Prognosis of direct & indirect pulp capping: W hen the case is properly selected the prognosis is rather favorable. Ten follow up studies reported an 87% success rate, where the absence of pain and no adverse radiographic changes were used as criteria. If treatment failed, pulpotomy or RCT will be undertaken. Failure of pulp capping: Short or long term failure may be in the form of: 1- Spontaneous pulpal pain. 2- Acute thermal sensitivity. 3- Development of periapical pathology. 4- Internal resorption. Failure of the pulp capping procedure can often be detected in the first 18 months, but there are many teeth that fail many years after the procedure is performed. Since irregular 2ry dentin formed at the exposure site is often porous. Many pulp capping failures develop when recontamination of the exposure site occurs due to: i) recurrent caries, or ii) loss, fracture, or replacement of the coronal restoration.

III- PULPOTOMY It is surgical removal of a portion of the pulp subsequent to a traumatic, or carious exposure. It is followed by placement of a pulp dressing. A- Partial pulpotomy It implies the removal of coronal pulp tissue to the level of healthy pulp. This procedure is also called Cvek pulpotomy. B- Full (cervical) pulpotomy: It involves removal of the entire coronal pulp to the level of the root orifices. This level of pulp amputation is chosen arbitrarily because of its anatomic convenience. Indications of pulpotomy: 1- To remove damaged or infected pulp tissue from the superficial portion of the pulp. 2- As an emergency treatment as a temporary procedure. 3- As permanent or semi-permanent treatment, pulpotomy improves the prognosis for success when the remaining portion of the pulp is capped with a dressing that promotes its repair & regeneration. 4- It is particularly useful in apexogenesis of partially developed permanent teeth where the size and shape of the pulp space make such teeth unfavorable candidates for RCT. 5- After trauma with fracture & exposure of the pulp in an anterior tooth. By removing a portion of the coronal pulp, the pulp dressing can be applied deeper, which will protect the residual pulp from microleakage that occurs following the placement of some esthetic coronal restorations. 6- It allows immediate placement of an esthetic restoration in a fractured anterior tooth, even when extensive fracture and accompanying periodontal injury have occurred.

Technique of pulpotomy: The clinical procedures involved in pulpotomy is similar to that used in direct pulp capping with the exception that pulp tissue below the exposure site is surgically removed. 1- Local anesthesia. 2- Rubber dam isolation. 3- Cavity preparation to accommodate restoration and removal of all decay. 4- Pulpotomy is performed just before placement of the final restoration. 5- The amount of pulp tissue removed (the depth at which pulpotomy is performed) depends on: a) the amount of infected & necrotic tissue present at the exposure site. b) the ability to control bleeding at the level at which amputation has been performed. 6- W ith carious pulp exposures & with very large or long standing traumatic exposures, removal of the entire coronal pulp is often necessary. 7- Normal endodontic access is performed. 8- coronal pulp tissue is removed with either a sharp spoon excavator, a surgical curette, or large sharp round bur in a slow speed handpiece. N.B. The size of the instrument should be as large or slightly larger than the diameter of the pulp canal at the level of amputation. 9- W ash the pulp surface with sterile saline or anesthetic solution & arrest the bleeding with sterile gauze and pressure. 1:10,000 epinephrine may be used. 10- In instances of severe bleeding, the pulpotomy may have to be extended more apically. Avoid toxic strong styptic agents such as alum or formocresol. 11- After hemostasis, the surface of the pulp should be examined to ensure that it is clean and appears healthy. This requires professional experience. If it appears inflamed & granulomatous more pulp is removed apically. If it is firm & pink, cover it with pulp dressing. 12- Cover the surface of the pulp with 1-2 mm of calcium hydroxide, making sure it contacts the pulp tissue. 13- Cover Ca(OH)2 with glass-ionomer cement or re-enforced zinc oxide/eugenol mixed to a putty consistency to allow its placement with gentle pressure to contact the Ca(OH)2 and the surrounding pulp chamber walls for sealing. 14- Place the coronal restoration.

Formocresol pulpotomy: When the exposure is found, the roof of the chamber is removed. A sharp sterile no 4 rose head bur is used to remove the coronal pulp tissue so that the bleeding pulpal stumps are only seen on the floor of the chamber. Formocresol was introduced in 1904 by Buckley, who contended that equal parts of formalin and tricresol would react chemically with the intermediate and end products of pulp inflammation to form a new, colorless, and noninfective compound of a harmless nature. Buckleys formula, formocresol, consists of tricresol,19% aqueous formaldehyde, glycerine, and water.* Hemorrhage is absorbed with cotton pellets. A cotton pellet is lightly dampened with formocresoland applied to the pulp stumps for 3 minutes. A thin mix of formocresol and zinc oxide/eugenol is prepared and placed on the fixed pulp. A thick mix of ZOE accelerated with zinc acetate crystals is placed to provide occlusal seal. The tooth may be restored if symptom free from 1 to 4 weeks later. One of the best reasons for using formocresol rather than calcium hydroxide as a pulpotomy medication is the implication for further treatment if the pulp therapy should fail.

Steps for formocresol pulpotomy 1. Anesthetize the tooth and tissue. 2. Isolate the tooth to be treated with a rubber dam. 3. Excavate all caries. 4. Remove the dentin roof of the pulp chamber with a high-speed fissure bur 5. Remove all coronal pulp tissue with a slow-speed No. 6 or 8 round bur Sharp spoon excavators can remove residual tissue remnants. 6. Achieve hemostasis with dry cotton pellets under pressure. 7. Apply diluted formocresol to the pulp on a cotton pellet for 3 to 5 minutes. 8. Place a ZOE cement base without incorporation of formocresol. 9. Restore the tooth with a stainless steel crown. Radiographs should be taken and clinical symptoms evaluated at regular 6 month intervals. Ideally the treated tooth should remain comfortable with no sinus tract development. Radiographically, the periapical area should remain normal. In addition the to x ray exam of the periapical area, the dentist must be certain to examine the interior of the tooth and specifically the shape of the canals as well. If the canal suddenly starts to decrease in size greatly, the dentist should consider routine endodontic intervention while a patency to the apex still exists.

If the canal shows a sudden enlargement in a specific area, indicating internal resorption, routine endodontics must be initiated immediately before the defect becomes too large. When evaluating primary teeth, the dentist should further see that the tooth is resorbing at a relatively normal rate, comparing to the contralateral part. The finding of a dentin bridge does not always indicate success by itself and negate the need for any further evaluation. Prognosis of pulpotomy: The patient is rescheduled for examination 3 months postoperatively, and then every 6 months. A favorable response will be reflected by i) absence of clinical symptoms and ii) continued normal development of the root. The presence of dentinal bridging is also an indication of success. The prognosis for long term success with pulpotomy is high ( 66 95% ) Factors that affect the prognosis are: 1- The preoperative status of the pulp, which in turn is affected by the type and length of time of exposure, and the factors that compound the pulp injury when the exposure is produced by trauma, e.g. luxation or root fracture. 2- Treatment variables such as: pulp debridement, hemostasis, type of pulp dressing and cavity seal. 3- Presence or absence of post treatment contamination ( integrity of cavity seal). 4- Recurrent physical injury. 5- Repair capacity of the patient. The prognosis is also influenced by the postoperative expectations of the clinician. If pulpotomy is viewed as interim procedure RCT would follow once maturation of the root has occurred. An undesirable sequala of pulpotomy is calcific metamorphosis which may render the canals non- negotiable if RCt is necessary in the future.

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Treatment alternatives: In case of failure, alternative treatment forms must be considered such as RCT or apexification. The choice depends on the degree of root maturation. Failure of pulpotomy Failure will be in the form of: 1- Pain and/or swelling. 2- Lack of apical maturation. 3 - Formation of a periapical lesion with or without sinus formation. 4- Internal root resorption. Good luck Dear Student : Note that there is no limit to knowledge and every possible effort should be made to add valuable knowledge from texts

References : Clinical handbook of endodontics, textbook, Walton and Torabinegad Endodontics, textbook, Buckland & Ingle

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