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Saving Teeth Through Vital Pulp Therapy





By Back Mike Wong • February 15, 2019

When caries has extended into the pulp, vital pulp therapy may be a good treatment option, as long as the tissue is not overly inflamed.1 Also known as pulp capping, this procedure is designed to keep the pulp alive, allowing it to heal itself. This is accomplished by sealing the wound against bacterial infiltration, which would otherwise doom the treatment to failure.2

Saving the pulp allows the tooth to retain strength and sensory perception. Often performed in kids, vital pulp therapy fosters apexogenesis — the continued development of the tooth, culminating in the formation of the apex. Teeth that are allowed to form completely are less likely to experience vertical root fractures and other issues.2

Isolation for Best Outcomes

To maximize success in any kind of vital pulp therapy, disinfection, creation of a bulletproof seal, and hemorrhage and fluid control are critical.

Systems such as Isolite, Isovac and Isodry that provide isolation, retraction and suction, are worth their weight in gold when it comes to these kinds of procedures. With a flexible mouthpiece that serves as a throat shield at the heart of these systems, patient safety is optimized. And comfort is enhanced via a bite block, which can save jaw strain and fatigue.

Pulp Capping Methods

Vital pulp therapy can be performed via direct or indirect pulp capping after a firm diagnosis is secured. When immature permanent teeth experience pulp exposure but do not exhibit inflammation or irreversible injury, direct pulp capping may be indicated.3

This treatment involves removing infected material and irrigating the pulp with 17% ethylenediaminetetraacetic acid (EDTA). Unlike sodium hypochlorite, which has been used traditionally, but has been found to kill pulpal stem cells, EDTA actually fosters dentinal growth while providing antimicrobial benefits.4

Direct pulp capping involves placing capping material directly on the pulp to allow healing and reparative dentin development. Materials such as mineral trioxide aggregate (MTA) and newer bioceramic materials offer antibacterial properties, and stimulate dentin formation and remineralization.2,4

In the case of primary teeth with deep caries and reversible pulp inflammation, indirect pulp capping is often chosen. This method involves leaving some or all of the decay in place, rather than exposing the pulp through instrumentation. A temporary biocompatible restorative material that can stimulate dentinal growth and inhibit bacterial infiltration is placed over the lesion. While this may sound crazy, studies have shown it to be successful in decreasing levels of, or even eliminating, Streptococcus mutans and lactobacilli.5,6

While some feel that direct pulp capping is a better option for ensuring vital pulp, others say that indirect pulp capping is as much as 20% more effective. As long as the lesion remains sealed, further treatment may not even be necessary.2,7,8

But some experts believe that partial or full pulpotomies, which are also a type of vital pulp therapy, may be more predictable than pulp capping.9

Pulpotomies

In partial pulpotomies the infected pulp is removed down to uninfected coronal tissue.10 It’s then treated with medication and filled.1 In the case of more extensive inflammation, a full pulpotomy may be indicated. This procedure requires the removal of pulp down to the canal orifices.11

After the pulp is treated with one of the above methods and capped with bioceramic material, it may be topped with a light-cured glass ionomer, which is overlain with composite or amalgam for a permanent, hopefully, leakproof restoration.4

Many experts agree these days that, even with advances in implant therapy, a real tooth is the best implant of all. If it can be kept alive through treatment such as vital pulp therapy, all the better.

 

REFERENCES

  1. Xu Z. The tooth fairy can wait. Mentor. 2016;7(10):32–35.
  2. Stone R. Keep it real. Mentor. 2012;3(11):12–19.
  3. Hilton TJ. Keys to clinical success with pulp capping: a review of the literature. Oper Dent. 2009;34:615–625.
  4. Bahcall J, Baker MC. Paradigm shift in vital pulp therapy. Decisions in Dentistry. 2018;4(10):10–14.
  5. Maltz M, Oliveira EF, Fontanella V, Carminatti G. Deep caries lesions after incomplete dentine caries removal: 40–month follow–up study. Caries Res. 2007;41:493–496.
  6. Pinto AS, de Araújo FB, Franzon R, et al. Clinical and microbiological effect of calcium hydroxide protection in indirect pulp capping in primary teeth. Am J Dent. 2006;19:382–386.
  7. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: an observational study. J Am Dent Assoc. 2008;139:305–315.
  8. Fairbourn DR, Charbeneau GT, Loesche WJ. Effect of improved Dycal and IRM on bacteria in deep carious lesions. J Am Dent Assoc. 1980;100:547–552.
  9. Asgary S, et al. Outcomes of different vital pulp therapy techniques on symptomatic permanent teeth: a case series. Iran Endod J. 2014;9:285–300.
  10. Swift EJ Jr, Trope M, Ritter AV. Vital pulp therapy for the mature tooth–can it work? Endod Topics. 2003;5:49–56.
  11. Witherspoon DE. Vital pulp therapy with new materials: new directions and treatment perspectives–-permanent teeth. J Endod. 2008;34( Suppl):S25–S28.