Clinical and radiographic evaluation of pulpotomies performed under intrapulpal injection of anaesthetic solution

One-year outcome of selective caries removal versus pulpotomy treatment of deep caries: A pilot randomized controlled trial

AIM

This study aimed to compare the outcome of SCR and Pulpotomy in teeth with deep caries extending at least 75% into dentine.

METHODOLOGY

This two-armed, parallel-group, randomized, superiority trial included vital mature permanent teeth with deep primary or secondary caries diagnosed radiographically as being at least 75% into the thickness of dentine, without clinical signs of symptomatic irreversible pulpitis or radiographic evidence of a periapical lesion. Carious teeth were blindly allocated to receive either SCR or Pulpotomy using computer-generated randomized patient codes concealed in opaque envelopes. All teeth were reviewed clinically and radiographically at 6 months and 1 year post-treatment. Using a significance level of p < .05, the log rank test and Cox proportional hazards regression were used to compare the outcome of SCR and Pulpotomy and to identify potential prognostic factors, respectively.

RESULTS

In all, 58 teeth in the SCR group and 55 teeth in the pulpotomy group completed treatment, after excluding 6 teeth because they did not complete the allocated treatment and another due to severe periodontal disease. At one year, 57/58 (98.3%) teeth from the SCR group and 48/55 (87.3%) teeth from the Pulpotomy group were available for analysis. One tooth in the Pulpotomy group (2.1%) and eight teeth in the SCR group (14.0%) required the further intervention of root canal treatment (p < .05). There were no other significant prognostic factors for survival. Overall, 91.4% of teeth treated with either SCR or Pulpotomy survived without requiring further intervention over a period of one year. No other adverse events occurred over the review period.

CONCLUSION

Within the limitations of this study, Pulpotomy fares better than SCR in preserving the remaining pulp and periapical health. As a treatment modality, Pulpotomy carries greater cost outlay to patient and takes a longer time to complete treatment than SCR. Long-term follow-up is needed to study the pulpal and restorative outcomes of Pulpotomy and SCR.

Conservative pulp therapy in the management of reversible and irreversible pulpitis

Conservative pulp therapy is an alternative treatment option to tooth removal and root canal treatment in the management of deep caries, traumatic pulp exposures and developmental anomalies. Pulp tissue preservation can extend the long-term survival of teeth through relatively simple restorative procedures. This article aims to update clinicians on the current state of research in materials, techniques and outcomes of vital pulp therapies and provide practical guidelines for their implementation into daily practice.

Which procedures and materials could be applied for full pulpotomy in permanent mature teeth? A systematic review

Objective: Coronal pulpotomies were recently re-investigated as an alternative to root canal treatment in vital permanent teeth. General dentists may be interested in knowing how to perform full pulpotomy, in particular in face of difficult endodontic cases of vital teeth. Material and methods: A systematic review was undertaken on the PubMed and Cochrane databases in order to determine which procedure should be applied for pulp capping and coronal restoration in routine dental practice. Fifty-three publications were included and allocated to one of two methodological categories: histological and clinical studies. Results and conclusions: There is no evidence to recommend one single procedure for full pulpotomy in vital permanent teeth that can be indicated for different pulpal diagnoses which differ greatly in terms of the inflammation process from healthy teeth to irreversible pulpitis. For each clinical case, all actions aiming to prevent pre-operative contamination, to control per-operative infection and to achieve a complete seal above the radicular pulp sections are unavoidable steps that should be complied with. Reproducing procedures adopted in high quality trials could insure high success rates.

Role of intraseptal anesthesia for pain-free dental treatment

Pain control during the dental procedure is essentials and challenging. A complete efficacious pulp anesthesia has not been attained yet. The regional anesthesia such as inferior alveolar nerve block (IANB) only does not guarantee the effective anesthesia with patients suffering from irreversible pulpitis. This main aim of this review was to discuss various aspects of intraseptal dental anesthesia and its role significance in pain-free treatment in the dental office. In addition, reasons of failure and limitations of this technique have been highlighted. Literature search was conducted for peer-reviewed articles published in English language in last 30 years. Search words such as dental anesthesia, pain control, intraseptal, and nerve block were entered using a web of knowledge and Google scholar databases. Various dental local anesthesia techniques were reviewed. A combination of block anesthesia, buccal infiltration and intraligamentary injection resulted in deep anesthesia (P = 0.003), and higher success rate compared to IANB. For pain-free management of conditions such as irreversible pulpitis, buccal infiltration (4% articaine), and intraosseous injection (2% lidocaine) are better than intraligamentary and IANB injections. Similarly, nerve block is not always effective for pain-free root canal treatment hence, needing supplemental anesthesia. Intraseptal anesthesia is an efficient and effective technique that can be used in maxillary and mandibular adult dentition. This technique is also beneficial when used in conjunction to the regional block or local dental anesthesia.

A comparative investigation of cone-beam computed tomography and periapical radiography in the diagnosis of a healthy periapex

INTRODUCTION

This research aimed to compare the appearance of healthy periapical tissues on cone-beam computed tomography (CBCT) with periapical radiography and to measure the periodontal ligament (PDL) space on CBCT for teeth with healthy and necrotic pulps.

METHODS

Patient records from specialist endodontic practices were examined for teeth that had a high-resolution (0.08-mm voxel) and small field-of-view CBCT scan, a periapical radiograph, and clinical pulp tests (CO2 and electric pulp testing). The periapical regions of the CBCT scans and radiographs were scored individually by 2 calibrated, blinded examiners by using a modified CBCT-periapical index (CBCT-PAI) for both and represented as CBCT-PAI and PAI, respectively. The Fisher exact and χ(2) statistics tested the relationships between CBCT-PAI, PAI, and pulp status.

RESULTS

Of 200 teeth included in the study, 166 showed clinical signs of pulpal health, and the CBCT-PAI score was greater than the PAI in 72% (119 of 166), with a vital pulp likely to have a radiographic PDL space widening of 0-1 mm (P < .001). Although 2 healthy teeth showed radiolucencies 2-4 mm on CBCT scan when the periapical radiograph showed none, a PDL space of greater than 1-2 mm was indicative of a necrotic pulp (P < .001).

CONCLUSIONS

Teeth with necrotic pulps were more likely to have PDL widening, but the PDL space of a healthy tooth demonstrated significant variation when examined by CBCT. The radiographic interpretation of health and disease on CBCT must be further investigated before usage in outcome or epidemiologic investigations. This research questions the traditional radiographic interpretation of the PDL space.

Reattachment using a fragment from an extracted tooth to treat complicated coronal fracture

Reattachment of fragment is the preferred alternative to restore the fractured teeth, offering several advantages. Partial pulpotomy has demonstrated satisfactory results as a conservative treatment for pulp exposures because of trauma. This study reports a case in which the treatment of a complicated coronal fracture was accomplished by partial pulpotomy and reattachment of a dental fragment obtained from an extracted tooth using composite resin. The results show the feasibility of the conservative pulp therapy and the restorative approach.

Mineral trioxide aggregate pulpotomies

BACKGROUND

The greatest threats to developing teeth are dental caries and traumatic injury. A primary goal of all restorative treatment is to maintain pulp vitality so that normal root development or apexogenesis can occur. If pulpal exposure occurs, then a pulpotomy procedure aims to preserve pulp vitality to allow for normal root development. Historically, calcium hydroxide has been the material of choice for pulpotomy procedures. Recently, an alternative material called mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in pulpal tissue. The authors describe the clinical and radiographic outcome of a series of cases involving the use of MTA in pulpotomy procedures.

METHODS

Twenty-three cases in 18 patients were treated with MTA pulpotomy procedures in an endodontic private practice. All of the patients had been referred to the practice for diagnosis and treatment of a symptomatic tooth. All of the authors provided treatment. Pulpal exposures were either due to caries or complicated enamel dentin fractures.

RESULTS

Nineteen teeth in 14 patients were available for recall. The mean time of recall was 19.7 months. Of the 19 cases, 15 involved healed teeth, and three involved teeth that were healing. One of 19 cases involved a tooth with persistent disease.

CONCLUSIONS

MTA may be useful as a substitute for calcium hydroxide in pulpotomy procedures. Further research, however, is required to clarify this conclusion.

CLINICAL IMPLICATIONS

MTA conceivably could replace calcium hydroxide as the material of choice for pulpotomy procedures, if future research continues to show promising results.

The use of an intra-oral injection of ketorolac in the treatment of irreversible pulpitis

AIM

To examine whether an intra-oral injection of a nonsteroidal anti-inflammatory drug (ketorolac), in association with conventional local anaesthetic techniques, would improve the pulp extirpation rate in teeth with irreversible pulpitis.

METHODOLOGY

A two group double-blind clinical trial was undertaken in the Dental Casualty Department of the University of Manchester School of Dentistry. Patients were randomly allocated to either the test or control group. The test group received an intra-oral injection of ketorolac (30 mg in 1 mL) in the buccal sulcus adjacent to the tooth being treated. After an interval of 15 min, they then received 2.2 mL of 2% lidocaine with 1 : 80 000 epinephrine by buccal infiltration in the maxilla or by inferior dental block in the mandible. The control group received an intra-oral injection of normal saline (1 mL) in the buccal sulcus adjacent to the tooth being treated, followed by the same local anaesthetic regime as the test group after the 15 min interval. Fifteen minutes after the local anaesthetic injections, pulp extirpation was attempted. All patients completed the short-form McGill pain questionnaire prior to treatment and completed identical questionnaires at 6 and 24 h after treatment.

RESULTS

The study protocol set the number of patients to be treated at twenty. However, as the study progressed it became apparent that the intra-oral injection of ketorolac caused significant pain to four of the five patients who received it; therefore the study was terminated after ten patients had been treated. The results from the patients treated showed no significant difference in the pulp extirpation rate between the test and control groups. However, patients with higher pain scores at baseline were less likely to have the pulp completely extirpated, irrespective of whether they were in the test or control group. Pain scores for all patients decreased significantly from baseline to 24 h.

CONCLUSION

An intra-oral injection of ketorolac did not improve the pulp extirpation rate in a small group of patients with irreversible pulpitis compared with a placebo. In addition, it was associated with such significant pain on injection that it cannot be recommended as a treatment in this situation.

Influence of the restoration quality on the success of pulpotomy treatment: a preliminary retrospective study

The aim of this study was to evaluate the clinical status of pulpotomy treatment with calcium hydroxide and to correlate it with the quality of restoration of the treated teeth. Patients were retrieved from the files of the Operative Dentistry clinics (FOUFPel) between 1996 and 2000. Twenty-two patients were recalled, which had 23 teeth treated with pulpotomy due to exposure by caries. Seven anterior and 16 posterior teeth composed the evaluated group, being all restored with composite resin. The age varied from 15-50 years (mean 23.9) and the follow-up mean was 34.52 months. Clinical and radiographic examinations were performed to evaluate the clinical status of treatment. The criteria used, clinically favorable and failure, were based on the following clinical exams: pulp vitality; sensitivity; and periapical alterations. The quality of the restorations was based on the USPHS criteria. Pulpotomy treatment was ranked as clinically favorable in 10 teeth (43.5%), 4 in anterior and 6 in posterior teeth. Failure was verified in 13 teeth (56.5%), 4 anterior and 9 posterior. From the group clinically favorable, 90% of the restorations were ranked as clinically satisfactory, while only 10% were unsatisfactory. In the failure group, 77.8% of the restorations were classified was unsatisfactory and 22.2% were ranked as satisfactory. The statistical analysis (Fisher´s exact test) demonstrated that there is a statistically significant association between the clinical status of pulpotomy and restoration quality (p<0.05). Within the limitation of the study, it was verified that the quality of restoration could influence the favorable clinical status of pulpotomized teeth. Randomized clinical trials are required to confirm these preliminary data.