Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache Is Changing, Especially in Young, Immature Teeth

Biodentine™ Pulpotomy in Stage I primary Molars: A 12-month Follow-up

Aim

This study aims to evaluate, over 12 months of clinical and radiographic follow-ups, the performance and outcomes of Biodentine™ pulpotomy in stage I primary molars.

Materials and methods

A total number of 20 stage I primary molars requiring pulpotomy were selected from eight healthy patients aged between 34 and 45 months. Patients presenting a negative attitude toward dental treatment on the dental chair were scheduled for dental treatments under general anesthesia.Pulpotomy with Biodentine™ as a pulp-dressing material was performed on all selected molars. The patients were called back at 1 and 3 months for clinical follow-ups, then at 6 and 12 months for clinical and radiographic follow-ups. Data were tabulated according to follow-up intervals and occurrence of any changes in root maturation, pulp canal obliteration (PCO), periodontal ligament space (PLS), and bone or root lesion.

Results

No statistically significant differences were recorded at 1, 3, 6, and 12 months. There was a statistically significant increase in number of roots with closed apices from six roots at 6 months to 50 roots at 12 months (p < 0.0005) and the PCO was present in all 50 roots at 12 months, after it was present in 36 roots only at 6 months (p = 0.0001).

Conclusion

This is the first randomized clinical trial that evaluates the performance of Biodentine™ as a pulp-dressing agent in stage I primary molar pulpotomy over 12 months of follow-up. Contrary to previous studies, the present work highlights the continued root formation and apical closure (AC) in pulpotomized immature primary molars.

How to cite this article

Nasrallah H, Noueiri BE. Biodentine™ Pulpotomy in Stage I primary Molars: A 12-month Follow-up. Int J Clin Pediatr Dent 2022;15(6):660-666.

A Diagnostic Insight of Dental Pulp Testing Methods in Pediatric Dentistry

The accurate diagnosis of pulpal pathology in pediatric dentistry is essential for the success of vital pulp therapy. Pulp testing is often a challenging task due to understanding and cooperation issues of pediatric patients, as well as the particularities of pulpal physiology encountered in primary and immature permanent teeth. Sensibility tests, although still widely used by dental practitioners, are no longer recommended by pediatric specialists mainly due to their subjective nature. Vitality pulp tests have gained popularity in the last decade in light of some encouraging results of clinical studies. However, their use is not a routine practice yet. This paper is a literature review aimed to guide dental practitioners towards selecting the appropriate pulp testing method for their pediatric cases. It provides an overview on a multitude of pulp testing methods and an update in recommendations for primary and immature permanent teeth.

A randomized clinical trial of hyaluronic acid gel pulpotomy in primary molars with 1 year follow-up

OBJECTIVE

This randomized clinical study aimed to evaluate the success of hyaluronic acid (HA) as a pulpotomy medicament of human primary molars and to compare it with formocresol (FC) and ferric sulphate (FS) pulpotomy treatments up to 12 months.

MATERIALS AND METHODS

The study was conducted with 130 primary molars of 44 children. The ethical approval and registration to clinical trials (No: NCT04115358) were completed. After the removal of all the coronal pulp tissue, a 0.5% HA gel, or a FC, or a 20% FS solution were applied randomly to the radicular pulp tissues of the primary molars. Then, the pulp chambers were filled with a zinc oxide eugenol cement and restored either with a composite filling material or with a stainless-steel crown. The treatment success rates of the 3 groups were followed and compared clinically and radiographically at 1st-, 3rd-, 6th- and 12th-months.

RESULTS

Primary molars treated with FC, FS and HA dressings were clinically successful 77.5%, 86.8% and 87.5% respectively after 12th-month follow-up (p > .05). Radiographic successes of FC, FS and HA groups were lower than clinical successes (57.6%, 68.8%, 57.9% respectively at the 12th-month) but the difference between the groups was not statistically significant (p > .05). Equivalence analysis assuming not more than 10% difference between the materials suggested that HA was not inferior to FC or FS.

CONCLUSIONS

Within the limitations of this study, our randomized clinical trial shows that HA is a promising pulpotomy medicament in primary molars. However, further studies are justified to further improve the HA material success.

Radiographic evaluation of immature traumatized incisors following different endodontic treatments

BACKGROUND/AIMS

Indirect pulp capping, pulpotomy, and apexification are three common endodontic treatments for immature traumatized incisors. They all affect tooth root development to some extent. The aim of this retrospective study was to compare the influence of these treatments on root development of immature permanent incisors following dental trauma.

MATERIALS AND METHODS

Twenty-one indirect pulp capping, 48 pulpotomy, and 58 apexification cases with a mean age of 8.4 ± 1.0 years and median follow up of 12 months were included. NIH ImageJ with TurboReg plug-in was used to correct angular differences between the pre-operative and recall periapical radiographs, and to calculate variations of root length, dentin wall thickness, and apical closure. Kruskal-Wallis ANOVA followed by pairwise comparisons was applied to compare the radiographic variations. The type of apical closure was assessed qualitatively and analyzed using Fisher's exact test.

RESULTS

The apexification group had a lower trend toward apical closure than the other two groups (P < .05). It also showed thinner dentin wall thickness compared with the pulpotomy group (P = .001). There was no significant difference between pulpotomy and indirect pulp capping in the trend to apical closure (P > .05) or dentin wall thickness (P = .775). There was no significant difference in the variation of root length among the three groups (P = .06). There was a moderate correlation between the treatment and the type of apical closure (Cramer's V Coefficient = .375). Pulpotomy tended to form a normal apical constriction rather than a calcific barrier while apexification showed the opposite inclination. Indirect pulp capping had no specific inclination toward any type of apical closure.

CONCLUSIONS

Apexification resulted in an abnormal root development mostly by affecting the dentin wall thickness and apical closure. Pulpotomy was beneficial for normal root development of immature traumatized teeth.

Is there an association between crown discoloration and pulp necrosis in traumatized per in vitro manent teeth? A meta-analysis

The present study aimed to identify the scientific evidence regarding the association between crown discoloration and pulp necrosis in traumatized permanent teeth. A systematic literature search was conducted in the PubMed/Medline, Lilacs/BBO, Scopus, Web of Science, Cochrane Library databases, and grey literature. Quality assessment and bias control were carried out according to the Fowkes and Fulton guidelines. Meta-analysis was performed, and the odds ratio was calculated with a 95% confidence interval. The quality assessment of the evidence was determined for the meta-analysis outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. From 2,702 studies identified, five articles met the inclusion criteria. One among these showed no methodological soundness and was excluded from the meta-analysis, and the remaining four studies were included in the meta-analysis. The total number of traumatized permanent teeth evaluated in the meta-analysis was 367. The results showed a positive association between crown discoloration and pulp necrosis in permanent teeth. Teeth with crown discoloration showed 23 times more chance to present pulp necrosis than teeth without crown discoloration (OR 23.82 [1.25, 452.87]; p = 0.03), with a very low certainty of evidence. There is a significant association between crown discoloration and pulp necrosis of traumatized permanent teeth. Due to the very low strength of evidence according to GRADE, this result should be viewed with caution.

Evaluation of the Efficacy of Erbium, Chromium-doped Yttrium, Scandium, Gallium, and Garnet Laser in Partial Pulpotomy in Permanent Immature Molars: A Randomized Controlled Trial

INTRODUCTION

The use of the erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser in vital pulp therapy contributes to the formation of dentin bridges and a sterile zone as well as the maintenance of the vitality of the pulp. However, no prior studies have used the Er,Cr:YSGG laser in partial pulpotomy of immature permanent teeth. The aim of this study was to compare the efficacy of partial pulpotomy treatment using mineral trioxide aggregate (MTA) alone and MTA with the Er,Cr:YSGG laser in permanent immature molars.

METHODS

A total of 90 caries-exposed permanent immature molar teeth were included and randomly divided into 2 groups: the MTA group (n = 45) and the laser + MTA group (n = 45). In the MTA group, MTA was applied to the exposed area on the pulp after bleeding control. In the same session, the tooth was restored with a composite resin. In the laser + MTA group, before MTA condensation, the Er,Cr:YSGG laser was applied to the exposure area. Patients were recalled at 1, 3, 6, and 12 months after treatment. The Mann-Whitney U and chi-Square tests were used for statistical analysis.

RESULTS

The success rate (95.5%) of the laser + MTA group was similar to that of the MTA group (88.8%). There was no significant difference between groups in terms of the frequency of at least 1 pathologic clinical or radiographic failure at 12 months (P > .05).

CONCLUSIONS

Partial pulpotomy treatment showed a high success rate in immature permanent molars; however, the use of the laser did not contribute to the success rate compared with MTA alone.

Long-term survival and vitality outcomes of permanent teeth following deep caries treatment with step-wise and partial-caries-removal: A Systematic Review

OBJECTIVES

A systematic review was performed to compare the long-term survival of deep dentine caries-affected permanent teeth treated with partial-caries-removal (PCR) versus similar teeth treated with stepwise-caries-removal techniques (SWT).

DATA

Clinical studies investigating long-term PCR and SWT outcomes in unrestored permanent teeth with deep dentine caries were evaluated. Failures were defined as loss of pulp vitality or restorative failures following treatment.

SOURCES

PubMed, Web of Science, Dentistry and Oral Sciences Source, and Central databases were systematically searched.

STUDY SELECTION

From 136 potentially relevant articles, 9 publications utilizing data from 5 studies (2 RCTs, and 3 observational case-series) reporting outcomes for 426 permanent teeth over two to ten years were analyzed. Regarding restorative failures, >88% success at two years for both techniques was reported. For loss of pulp vitality, observational studies reported >96% vitality at two years for each technique, while one RCT reported significantly higher vitality (p<0.05) at three years for PCR (96%) compared to SWT (83%). Risk of bias was high in all studies.

CONCLUSION

Successful vitality and restorative outcomes for both PCR and SWT have been demonstrated at two years and beyond in permanent teeth with deep dentine caries. Partial-caries-removal may result in fewer pulpal complications over a three year period than SWT, although claims of a therapeutic advantage are based on very few, limited-quality studies.

CLINICAL SIGNIFICANCE

Partial-caries-removal and SWT are deep caries management techniques that reduce pulp exposure risk. Permanent teeth with deep dentine caries treated with either technique have a high likelihood for survival beyond two years.

Oxygen Saturation in Dental Pulp of Permanent Teeth: Difference between Children/Adolescents and Adults

INTRODUCTION

The objective of this study was to use pulse oximetry to measure oxygen saturation in permanent maxillary central incisors with normal pulp in 2 different age groups: children/adolescents and adults.

METHODS

Blood oxygen saturation levels were measured using a pulse oximeter in 110 maxillary central incisors of 57 individuals, in 1 of 2 possible age bands, as follows: 28 children/adolescents (7-13 years old) and 29 adults (22-36 years old). The following factors were also analyzed: (1) heart rate (beats/min); (2) oxygen saturation rate measured at the patient's index finger, also using a pulse oximeter; (3) tooth crown dimensions; and (4) the time taken by the oximeter to provide a reading.

RESULTS

The mean oxygen saturation level in normal central incisors was higher among children/adolescents (84.35%) than adults (77.88%, P = .003). Oxygen saturation rates measured at the patients' fingers were not correlated with saturation obtained at the teeth (r = 0.10). There was no correlation between oxygen saturation readings and tooth dimensions (buccal surface area), heart rate, or oximeter reading time (P > .05).

CONCLUSIONS

Oxygen saturation values measured in maxillary central incisors using a pulse oximeter revealed differences between children/adolescents and adults, showing that children/adolescents have higher oxygen saturation levels. There was no correlation between oxygen saturation levels in patients' fingers and values from their teeth or between oxygen saturation readings from central incisors and tooth dimensions (buccal surface), heart rate, or oximeter reading time.

Management of a nonvital young permanent tooth by pulp revascularization

This report presents the case of a 10-year-old patient with a nonvital young permanent tooth which was managed by pulp revascularization. Following disinfection of the canal by irrigation with NaOCl and use of a triantibiotic paste, a scaffold was created by inducing the formation of a blood clot within the canal. At the subsequent follow-up visits, the patient was asymptomatic, with normal response to percussion, normal periodontal probing depths, and no abnormal mobility. The radiographs showed evidence of continued apical root development with increase in root length, signs of apical closure and increase in thickness of dentinal walls. Thus, this case adds to the growing evidence supporting the revascularization approach as an option for management of nonvital young permanent teeth. How to cite this article: Chandran V, Chacko V, Sivadas G. Management of a Nonvital Young Permanent Tooth by Pulp Revascularization. Int J Clin Pediatr Dent 2014;7(3):213-216.

"MTA"-an Hydraulic Silicate Cement: review update and setting reaction

OBJECTIVES

To review the current status and understanding of Portland cement-like endodontic materials commonly referred to by the trade designation "MTA" (alias "Mineral Trioxide Aggregate"), and to present an outline setting reaction scheme, hitherto unattempted.

METHOD

The literature was searched using on-line tools, overlapping an earlier substantial review to pick up any omissions, including that in respect of ordinary Portland cement (OPC), with which MTA shares much. The search was conducted for the period January 2005 to December 2009 using 'MTA', 'GMTA', 'WMTA', and 'mineral AND trioxide AND aggregate' as keywords, with various on-line search engines including ScienceDirect (http://www.sciencedirect.com), SAGE Journals Online (http://online.sagepub.com), Wiley Online Library (http://onlinelibrary.wiley.com), SciELO Scientific electronic library online (http://www.scielo.br/scielo.php), JSTOR (http://www.jstor.org), and Scopus (http://www.scopus.com). References of articles found were cross-checked where appropriate for missed publications. Manufacturers' and related websites were searched with Google Search (http://www.google.com.hk).

RESULTS

A generic name for this class of materials, Hydraulic Silicate Cement (HSC), is proposed, and an outline reaction scheme has been deduced. HSC has distinct advantages apparent, including sealing, sterilizing, mineralizing, dentinogenic and osteogenic capacities, which research continues to demonstrate. However, ad hoc modifications have little supporting justification.

SIGNIFICANCE

While HSC has a definite place in dentistry, with few of the drawbacks associated with other materials, some improvements in handling and other properties are highly desirable, as are studies of the mechanisms of the several beneficial physiological effects. Reference to the extensive, but complex, literature on OPC may provide the necessary insight.

Apexification: the beginning of its end

Apexification is a procedure for treating and preserving immature permanent teeth that have lost pulp vitality. It contrasts apexogenesis in terms of its outcome in that apical maturation and normal root thickness cannot be obtained. Apexification has been a routine practice for such teeth for many decades, and despite a literature replete with discussion, including recent artificial barrier methods with mineral trioxide aggregate, ultimately there has been no major breakthrough to improve this treatment. Recently, two new clinical concepts have emerged. One involves a revitalization approach to achieve tissue generation and regeneration. In this method, new living tissue is expected to form in the cleaned canal space, allowing continued root development in terms of both length and thickness. The other is the active pursuit of pulp/dentine regeneration via tissue engineering technology to implant or re-grow pulps. Although the technology is still at its infancy, it has the potential to benefit immature pulpless teeth by allowing continued growth and maturation. With this understanding, it may be predicted that apexification will become less needed in years to come. This study will overview the recent concept of pulp revitalization in the treatment of immature teeth with nonvital pulps and the emerging research on pulp tissue engineering and regeneration.