Wednesday, April 25, 2018

Success Rates of Mineral Trioxide Aggregate, Ferric Sulfate, and Formocresol Pulpotomies: A 24-month Study


Resident: Hatton DDS
Title: Success Rates of Mineral Trioxide Aggregate, Ferric Sulfate, and Formocresol Pulpotomies: A 24-month Study
Author: Erdem, et al
Journal: Pediatric Dentistry V33/No2 March/April 2011

Purpose:
To determine the clinical and radiographic success rates of MTA, ferric sulfate, one-fifth dilution of Buckley's formocresol, and no pulpotomy medicament except ZOE in primary molars during a 2-year follow-up period.

Methods:
A randomized, single-blind, split-mouth study design of 32 healthy patients, 5-7 years old with at least 4 primary molars each in a different quadrant and similarly carious involvement so as to require a pulpotomy- 128 primary molars total. Inclusion criteria were deep caries, no more than 2/3 root resorption, restorable, and no history of systemic disease, no spontaneous tooth pain or tenderness to percussion, no pathological mobility presence of internal resorption or apical or furcal radiolucency, no widened PDL or sinus tract, or hemostasis requiring more than 5 minutes. Teeth were randomly assigned MTA, FS, FC, or ZOE and teeth were restored with amalgam; clinical and radiographic examinations were conducted after 6 months, 1 year, and 2 years.

Results:
At 6 mo and 1yr: all MTA, FS, and FC had 100% success rates
At 2yr: success rates were as follows: MTA – 96%, FS – 88%, FC – 88%, ZOE – 68%
Longer follow-up times and larger sample sizes could have revealed differences in success


Partial Pulpotomy in Young Permanent Teeth with Deep Carious Lesions


Partial Pulpotomy in Young Permanent Teeth with Deep Carious Lesions
Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Wayne Dobbins                                                                                                           Date: 4.25.18
Article Title: Partial Pulpotomy in Young Permanent Teeth with Deep Carious Lesions
Author(s): Mejare I, Cvek M
Journal: Endodontics and Dental Traumatology
Date: 1993
Major Topic: Endodontics
Type of Article: Case Series
Main Purpose: Evaluation of success rates of partial pulpotomy in young permanent posterior teeth with carious exposure of the pulp
Key Points/Summary:
37 posterior permanent teeth with carious exposure of the pulp in patients aged 6 - 15 were treated with partial pulpotomy and dressed with Calcium hydroxide and follow-up was conducted for 24 months.

The procedure was conducted with rubber dam, caries were excavated and irrigated with sterile saline, 1-1.5mm of dentin and pulp was excavated with a diamond burr and irrigated with sterile saline until hemostasis was achieved, calcium hydroxide was placed, ZOE was placed, and a permanent restoration was placed.

Successful healing was defined as: asymptomatic tooth with no deleterious radiographic changes that reports as vital to pulp testing. 93.5% of asymptomatic teeth met the paper’s criteria for success. 66% of symptomatic teeth met the paper’s criteria for success, though the sample size of symptomatic teeth was too small to draw any conclusions from.

It is postulated that, in advanced stages of a caries lesion, just prior to or soon after pulp exposure, bacterial components cause only irreversible changes at the immediate site of carious exposure, whereas the remainder of the inflamed pulp is merely infiltrated with inflammatory cells. Evidently, bacteria can only thoroughly infiltrate the pulp chamber after necrosis begins, thus pulpal healing may occur in cases where the carious exposure can be excised, eliminating the bacterial infection, removing the stimulus of inflammation, and alleviating the immune response, providing a definitive restoration can ensure the prevention of recontamination from microleakage.


Mineral trioxide aggregate as a pulpotomy medicament: an evidence-based assessment

Mineral trioxide aggregate as a pulpotomy medicament: an evidence-based assessment.
Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Olga Raptis   Date: 04/25/2018

Article Title: Mineral trioxide aggregate as a pulpotomy medicament: an evidence-based assessment.
Author(s): Ng FK, Messer LB
Journal: European Archives of Pediatric Dentistry
Date: 2008
Major Topic: MTA in Pulpotomies
Type of Article: Review Article
Main Purpose: Use the principles of EBD to answer and compare the efficacy of MTA, FC, FS and CH as primary molar pulpotomy medicaments.
Key Points: (2 lines Max): MTA compared with FC, FS and CH as a pulpotomy medicament resulted in significantly higher clinical and radiographic successes in all time periods up to exfoliation.

Key Principles:
-       The principles of evidence-based dentistry were used to compare MTA, formocresol (FC), ferric sulphate (FS) and calcium hydroxide (CH) as primary molar pulpotomy medicaments.
-       FC: Clinical success has been attributed to the antimicrobial characteristics but success rates decline in the long term
-       Histologic findings in pulps treated with FC range from total necrosis to vital pulp with inflammation.
-       FS agglutinates blood proteins and a ferric ion-protein complex seals blood vessels mechanically leads to hemorrhage control à prevention of blood clot formation and chronic inflammation

Methods:
-       Literature was searched for relevant papers by (titles, abstracts and full texts). Included were randomized clinical trials (RCTs) and clinical trials (CTs) comparing the clinical and radiographic successes of MTA, FC, FS and CH pulpotomies. Data were extracted and common odds ratios (CORs) were derived by fixed effects meta-analysis. Mean clinical and radiographic success rates from relevant study were examined.

Results:
-       18 RCTs and 10 CTs (total 1,260 molars) were identified to compare MTA and FC: MTA was significantly more successful clinically and radiographically than FC.

-       14 RCTs and 4 CTs (total 959 molars) were identified to compare MTA and FS. Clinical and radiographic data showed MTA was significantly more successful than FS.  

-       9 RCTs and 7 CTs (total 531 molars) were identified to compare MTA and CH. Clinical and radiographic data confirmed MTA was significantly more successful than CH.

Conclusion:
- Currently available evidence suggests MTA compared with FC, FS and CH as a pulpotomy medicament resulted in significantly higher clinical and radiographic successes in all time periods up to exfoliation.

Tuesday, April 24, 2018

Decoronation of an ankylosed permanent incisor: alveolar ridge preservation and rehabilitation by an implant supported porcelain crown


Resident’s Name:            Carol Caudill                                                                         Date: 4/18/18
Article Title: Decoronation of an ankylosed permanent incisor: alveolar ridge preservation and rehabilitation by an implant supported porcelain crown
Author(s): Sapir S, Kalter A, Sapir MR
Journal: Dental Traumatology
Date: 2009
Major Topic: Pulp Therapy
Type of Article: Case Report
Main Purpose: To present a case where decoronation was used to preserve bone for an implant
Key Points: (2 lines Max): Instead extracting ankylosed young permanent incisors, consider decoronation to preserve the alveolar ridge
·      Replacement resorption and ankylosis are common after severe dental trauma
·      For children that are still growing, an ankylosed tooth should be removed as soon as changes are so pronounced that they may compromise future prosthetic treatment
·      Treatment options for ankylosis of a permanent incisor
1.     Early extraction and esthetic space maintenance until definitive treatment when patient is older
2.     Close space with orthodontics
3.     Extraction and immediate ridge augmentation
4.     Auto-transplantation
5.     Single tooth dento-osseous osteotomy
6.     Decoronation and esthetic space maintenance until definitive treatment
·      Extraction can lead to alveolar bone loss. Decoronation instead of extraction can help prevent this
·      Patient had #8 decoronated at age 12. At age 18 an implant was placed.
·      Advantages of decoronation:
1.     Reliably preserves alveolar process height and width
2.     Simpler and more economic than ridge augmentation
3.     Vertical bone apposition is possible
·      Disadvantages
1.     May be challenging to perform in young children
2.     Need for long-term esthetic space maintainer
·      Decoronation should be done when the ankylosed tooth has a vertical difference of 1/8 to 1/4 to the adjacent teeth. Child’s age, gender, and growth pattern also need to be taken into account
Remarks:
1-
2-
Assessment of Article:  Level of Evidence/Comments: Level III

Pulp exposure occurrences and outcomes after 1- or 2-visit indirect pulp therapy vs. complete caries removal in primary and permanent molars

Resident’s Name: Suhyun Rue, DMD                                                         Date:04 /18 /2018
Article Title: Pulp exposure occurrences and outcomes after 1- or 2-visit indirect pulp therapy vs. complete caries removal in primary and permanent molars
Author(s): Orhan, A. I., Oz, F. T., Orhan, K.
Journal: Pediatr Dent (2010) 32(4): 347-355
Date: 2010
Main Purpose: To examine whether 1 or 2 visit indirect pulp therapy (IPT) is more successful and to determine if the operator can successfully decide when to stop removing caries without exposing the pulp.
Key Points/Summary:
-A total of 154 teeth (94 primary 2nd molars and 60 young permanent 1st molars) were included in the study from a total of 123,  4-to- 15-year-old patients.
-The teeth had deep carious lesions but lacked the preoperative signs and symptoms of irreversible pulpitis.
-The teeth were randomly selected and treated either with 1- visit IPT, 2- visit IPT or direct complete excavation (DCE) of the caries.
-Follow-up exams were conducted on the teeth over 1 year at 3-month intervals.
-In 1-visit IPT on 50 teeth: the innermost layer of carious dentin was covered with calcium hydroxide and sealed with restorative material.
-In the 2 -visit IPT procedure: Calcium hydroxide and IRM for 3 months, pulp testing was done and remaining carious  dentin was removed and teeth were sealed with calcium hydroxide and the teeth were finally restored.
-Direct complete excavation: all carious dentin was removed using excavators and slowly rotating burs until hard dentin was reached or pulp exposure occurred. A caries free cavity was defined as one without softening in the remaining dentin upon the examination of the cavity floor with a blunt probe using moderate pressure.
- Of the 154 teeth 50 were treated with 1 visit IPT, 49 treated with 2 visit IPT, and 55 treated with direct complete excavation (DCE).
- Among the 154 teeth, 19 had pulp exposure – 6% of 1 visit IPT, 8% of 2 visit IPT, and 22% of DCE-treated teeth. There was no statistical significance in pulp exposure in 1-or-2 visit IPT. However, a statistically significant difference was found between IPT and DCE in terms of pulp exposure.
- The teeth without pulp exposure showed normal clinical and radiographic conditions during the 1-year follow-up except for 3 primary teeth.
- Criteria for clinical and radiographic success: absence of spontaneous pain, absence of sensitivity to percussion and palpation, absence of fistula, swelling in periodontal tissues and abnormal tooth mobility, absence of radiolucency and root pathology, continuity of root development.
- Success rates were 100% for 1 visit IPT, 98% for 2 visit IPT, and 95% for DCE.
- IPT in both primary and young permanent teeth can be used successfully with a 1 or 2 visit approach.
- A careful diagnosis of the preoperative pulp status is essential for successful IPT. It is limited to teeth with no signs of irreversible pulp pathology based on a thorough clinical and radiographic examination.
Remarks:


Sunday, April 22, 2018

Incomplete caries removal: a systematic review and meta-analysis

Article Title: Incomplete caries removal: a systematic review and meta-analysis
Author(s): Schwendicke F, et al
Journal: Journal of Dental Research
Date: 2013; 92(4): 306-14
Major Topic: Comparison of incomplete versus complete caries removal
Type of Article: Systematic review and meta-analysis
Main Purpose: This article aimed to compare the results of RCTs that compared incomplete and complete caries excavation.
Key Points: Incomplete caries removal seems advantageous because it reduces the risk of pulp exposure and post-operative pulpal complications while not being more prone to complications.
·      Argued that a completely sea
·      May need less focus on caries removal than on an adequate restoration
·      Sealing/restoring over caries
o   Lots of studies have shown that sealing fissure caries results in shifting the ecologic and metabolic balance of the biofilm to promote remineralization and arrest caries
o   One study found bacteria in 53% of sealed carious lesions with moist and soft dentin under clinically intact sealants
o   Several treatment concepts like sealing caries with composites or SSCs have been successful
·      2 methods of incomplete caries removal
o   1 step
o   2 step (stepwise caries excavation): incompletely remove carious dentin in 1st step and then place a temporary filling. At 2nd step, complete caries removal is performed and a definitive restoration is placed.
·      There was a significant reduction for pulpal exposure for incomplete caries removal compared with complete caries removal. 1-step incomplete caries removal had slightly less pulp exposures than 2-step caries removal, where pulp exposure was most likely during the 2nd step.
·      Incomplete caries excavation resulted in a reduced risk of pulpal complications.
·      Risk of restoration failure did not differ significantly between the complete and incomplete caries removal groups.
·      Resins have lower bonding strengths to carious dentin
·      Incomplete caries removal seems advantages, especially when treatment of caries is close to the pulp, since it significantly reduces risk of pulp exposure and post-operative pulpal symptoms compared to complete excavation
·      No current evidence that incompletely excavated teeth are more prone to complications.

Remarks:
1-
2-
Assessment of Article:  Level of Evidence/Comments: I