Wednesday, August 31, 2011

Success of an alternative for interim management of irreversible pulpitis

Kyung-Hong Cal Kim

Success of an alternative for interim management of irreversible pulpitis

Author: McDougal RA, Delano EO, Caplan D, Sigurdsson A, Trope M.

JADA, 2004

-To determine whether pulpotomy of vital pulp would result in interim relief of pain.
-There was a difference between the incidence of AP when the tooth was restored w/ either ZOE or ZOE w/ a GI surface seal
-There was a difference in the durability of restorations of ZOE alone and ZOE w/ GI surface seal over six and 12 months.

-Pulpotomy was performed at least to the level of the root canal orifice on 73 teeth patients chose to have extraction exclusively for financial reasons.
-PAs were taken w/ a custom bite block using PVS bite registration material at the time of pulpotomy and each following recall appointments, and radiographs were analyzed using computerized densitometric ratio analysis.

Interim pain relief
-”Immediate failures”: 5/73 felt continuous pain. (1 vertical fracture for which fracture lines were noted at the time of pulpotomy)
-”Late failures”: 4/73 felt pain and swelling sometime after their 6month recall. (4 didn’t show up for 6month recall)
-Overall success rate in pain prevention dropped from 90% at 6 months to 78% at 12 months.

Radiographic assessment
-6month: 49% of pain-free teeth were successful at maintaining periapical status.
-12month: 42%

Integrity of restoration
-6month recall: 1 in each group required repair.
-12month recall: 6 of ZOE only and 3 of ZOE + GI required repair.

-Pulpotomy w/ a restoration of IRM base + GI core may be a viable alternatives to extraction or endodontic tx up to 12 months, but failure to follow up after 12 months may result in the inability to receive complete endo tx due to dystrophic calcification of the pulp space or further breakdown of the coronal structures.

Assessment of Article:
Interesting article trying to find a viable third option for the tooth w/ an irreversible pulpitis.I liked the design of the study where they attempted to objectively analyze radiographs by computer. I believe pulpotomy has been commonly used for temporary pain relief on teeth with irreversible pulpitis, so the important question to ask is not whether pulpotomy is effective in temporarily treating teeth with irrreversible pulpitis but how we can get them back in the chair to finish endo tx later.

Treatment Options for Teeth with Open Apices and Apical Periodontitis

Resident’s Name: Jessica Wilson
Program: Lutheran Medical Center - Providence
Article title: Treatment Options for Teeth with Open Apices and Apical Periodontitis
Author(s): Raldi et al.
Journal: JCDA
Year. Volume (number). Page #’s: 2009. 75:8. 591-596.
Major topic: Pulp treatment in immature permanent teeth
Overview of method of research: Case Report

Treating teeth with immature apices can present major challenges such as achieving complete debridement, canal disinfection and creating an optimal seal.
The authors note that the risk of pushing toxic irrigate out of an immature, open apex is much higher, therefore they use 1% NaOCl in all three cases to decrease the toxicity.
One recent retrospective study showed the mean time for formation of an apical barrier with the CaOH dressing technique is more than 12 months, however it is dependant on how wide the apex is to begin with.

Three clinical cases involving apical periodontitis and open apicies were treated using 3 different protocols.

CASE 1: A16 year old female had experienced subluxation trauma on #7,8 at 10 years old and presented with symptomatic #8, sinus tract, and a radiographic open apex with apical periodontitis. #7 had inadequate obturation, overextended gutta percha (GP) and an intracanal post.
#8 was treated at the first appointment with RDI, hand files to radiographic working length, 1% NaOCl, dried with paper points, a CaOH and saline paste was placed with amalgam carrier, a cotton pellet and the access was sealed with Cavit.
#7 was retreated at a second appointment with similar technique, but 17% EDTA was used after NaOCl rinse to remove the smear layer, CaOH and saline paste was placed, and the canal was temporarily sealed as stated above.
After 1 week, the patient was asymptomatic and the sinus tract had healed. Both teeth were re-accessed and new intracanal dressing was placed. It was renewed every 2 months until a hard barrier was detected with a hand file. At one year the teeth were obturated with GP and sealer and referred for a permanent restoration. Follow-up radiographs were taken at 6, 12 and 24 months.

CASE 2: 30 yo female reported severe pain on #31 which had been endodontically treated at 13 years old. Clinical exam revealed gingival swelling around #31 and a radiographically evident inadequate RCT with apical periodontitis. The same protocol as above was used to place intracanal dressing, but after 2 weeks a master GP point was measures 3mm short of working length and an MTA plug was placed with an amalgam carrier and adapted with the GP cone, a wet cotton pellet was placed and the canal was temporarily sealed. 1 week later, GP and sealer were placed on top of the set MTA and the patient was referred for a final restoration. At follow up appointments at 1, 2 and 5 years, the patient remained asymptomatic and demonstrated increasing hard tissue formation.

CASE 3: A 28 year old female previously experienced subluxation and uncomplicated crown fracture of tooth #8 at 7 years of age. Clinical exam revealed darkening of the crown and radiographs showed a wide open apex with apical periodontitis. The same clinical protocol was used as the above two, but after 4 weeks of itracanal dressing, the MTA was placed throughout the entire canal because of the excessive canal width. A cotton pellet was placed and the tooth was eventually restored with composite. Radiographs at a 9 month follow up revealed early bone healing.

All 3 cases revealed signs of bone healing and were asymptomatic regardless of the treatment protocol used.

Assessment of Article:
Not having much experience with these types of procedures, I found this article very interesting. Not sure how widely applicable the results were, but they seem to be consistent with other current literature.

Pulp Exposure Occurrence and Outcomes after 1- or 2-visit Indirect Pulp Therapy Vs Complete Caries Removal in Primary and Permanent Molars

Resident’s Name: Matthew Freitas
Article title: Pulp Exposure Occurrence and Outcomes after 1- or 2-visit Indirect Pulp Therapy Vs Complete Caries Removal in Primary and Permanent Molars
Author(s): A. Orhan et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2010. 32:4. 347-355.
Major topic: Permanent Pulp Therapies

-It is often hard to distinguish the infected vs. the affected dentin clinically during caries removal. Many believe a 1-visit indirect pulp cap (IPT) is more successful because of placement of a final restoration. While others believe a 2-visit IPT is better because the 2nd visit allows you time for the tooth to react, form tertiary dentin, and aid in the final excavation of carious dentin clinically.

-Determine which type of IPT is more successful (1- or 2-visit) and whether the operator can successfully avoid a pulp exposure by leaving only the thinnest layer of demineralized, carious dentin.

-154 teeth with deep caries: 94 primary mandibular 2nd molars; 60 permanent 1st molars.
-Criteria: deep carious lesion with risk of pulp exposure and cold sensitivity; absence of PA involvement or irreversible pulpitis.
-One pediatric dentist randomly and blindly performed all of the procedures.
-50 treated with 1-Visit IPT (31 primary, 19 permanent): calcium hydroxide and final restoration.
-49 treated with 2-Visit IPT (32 primary, 17 permanent): calcium hydroxide with ZOE for 3 months, then re-entry and removal of carious dentin, then calcium hydroxide and final restoration.
-55 treated with direct complete excavation (31 primary, 24 permanent): removal of all carious dentin.
-Follow-up every 3mo for 1 year; radiographic and clinical assessment.

-19 pulp exposures (12%); 12 of them from direct complete excavation.
-1-Visit IPT: 100% success.
-2-Visit IPT: 98% success (1 failure).
-Direct complete excavation: 95% (2 failures).
-All 3 failures were primary teeth.
*No significant difference between 1 vs 2-visit IPT.
*Carious removal with IPT resulted in fewer pulp exposures compared to direct complete excavation.

-Well-controlled study, however only 1 year follow-up, one operator, and many different types of final restorations.

The Caries Process and Its Effect on the Pulp: The Science is Changing and So is Our Understanding

Submitted by: Fotini Dionisopoulos

Auther: Bjorndal, Lars, DDS, PhD

Pediatric Dentistry, May/Jun 2008, 192-196

Purpose: The purpose of the article was to highlight the process of caries and the effect of caries on the pulp. The effect of caries on the pulp is related to the types of rates of progression--there is not one type or rate of progression of caries on the pulp.

Key Points:

  • It is important to understand the activity of the carious lesion in order to properly treat dental caries. The article highlights the importance that there is not always a steady progression of caries through the tooth leading to the same results---there are many different rates of progression of decay that can lead to different pulpal reactions.

  • As caries progresses, the rate of progression can by evaluated by the quality of tertiary dentin.

  • Normal tubular dentin represents the slowly progressing lesion. On the other hand, atubular dentin or the total abscence of tertiary dentin, pulp necrosis and apical pathology represents the rapidly progressing lesion.

  • The last thing is the untreated deep carious lesion, which can include different rates of progression, even in one tooth. The nature of the deep carious lesion may undergo significant changes--the untreated carious lesion often undergoes a decrease in lesion activity at a certain point, but ultimately does lead to severe breakdown of tooth structure. (See figures 1 and 2 page 1996)

Assessment: Because there are different understandings and opinions on the process of dental caries and how to treat caries, the author makes certain that clinicans understand that caries is not a black and white process. I thought this was a well-constructed informative article with a good historical background and up-to-date information that assists the clinician in addressing deep caries, especially with pediatric patients.

Regenerative Potential of Dental Pulp

Regenerative Potential of Dental Pulp

by Martin Trope

Pediatric Dentistry Volume 30/NO 3 May/June 08

Resident Meg

Abstract: Converence paper on the current knowledge and potential of regenerating pulp tissue for dental procedures.

Main Ideas:
*The younger the pulp the better it's potential repair
*Capping healthy teeth have a higher success rate as opposed to carious exposures with unpredictable depths of inflammation.
*A well-sealed coronal seal is much more important for success than the material used for pulpal capping.
*Young pulps can heal as long as a good coronal seal does not allow for leakage of inflammatory stimulants and microorganisms.
*Under certain conditions revascularization can occur in young traumatized teeth leaving necrotic but uninfected pulp tissue.
*An open apex allows for proliferation to reach coronal horns after an avulsion. The apical portion of the pulp may remain vital and proliferate coronally after reimplantation replacing the necrotic coronal portion of the pulp.
*Studies are being performed and showing success of producing a blood clot to the level of the CEJ providing ingrowth of new tissue.
*Dog studies show that potential for revasculization does exist and the blood clot is essential as the scaffold.


Good conference paper. I am most interested in this new idea of the blood clot being used for regenerating pulp tissue.... Would love to see where this new technique takes us as well as use of stem cells.

The Complete Endodontic Obturation of an Avulsed Permanent Incisor with Mineral Trioxide Aggregate: A Case Report

Resident Name: Elliot Chiu

Article Info

Title: The Complete Endodontic Obturation of an Avulsed Permanent Incisor with Mineral Trioxide Aggregate: A Case Report

Author: Jeffrey Karp DMD, MS

Journal: Pediatric Dentistry 2006

Case Report

­-9 year old male was struck with a golf ball at close range. #10 was avulsed (open apex)

-The tooth was placed in water for 10min, then milk for 10min, then replanted and splinted in the ER.

2 weeks: all tests wnl, radiograph wnl

6 weeks: all tests wnl, radiograph – external root resorption in middle 1/3 of root

-CaOH apexification was initiated

10 weeks: resorption approached root canal space, CaOH changed.

5mon: radiograph – resorption stopped, PDL space evident, CaOH changed.

1yr: apical stop was still has not been formed,

14mon: pt referred to endodontist

-due to extent of external root resorption and lack of apical stop, root canal was completely obturated with MTA

2 years: all tests wnl, no radiographic evidence of ankylosis or pathology


-The author was able to get a good 2 year result using this new technique.

-Can MTA substitute gutta percha in teeth with an open apex?

-Longer follow-up time is needed

-Further studies to test this

Tuesday, August 30, 2011

Vital Pulp Therapy with New Materials: New Directions and Treatment Perspectives-Permanent Teeth

Resident Name: Sadler
Article Info: Vital Pulp Therapy with New Materials: New Directions and Treatment Perspectives-Permanent Teeth

David E. Witherspoon BDS

Pediatric Dentistry V 30 No 3 May/Jun 08

Main Purpose: Discussion of present techniques and materials used in pulpal therapy of permanent teeth.

Methods: Conference paper written by one individual who did not actually perform the studies

Key Points: MTA continues to shine. The author states that MTA is the material of choice for direct pulp caps and pulpotomy. Long term success rates are very high (usually 90% or better). Although sometimes the difference is not statically significant than CaOH the success rate is still better. The dentin formed under MTA is stronger and thicker. He also states that NaOCl is the treatment of choice for hemorrhage control. If bleeding cannot be controlled with bleach then pulpectomy would be necessary.

Assessment of Article: Fairly simple and good concise summary of what materials would be best used. Again, MTA seems to be the magic compound that seals well and allows the tooth to heal as well as using the bleach to control bleeding in permanent teeth.

MTA: A (Not So) New Material For Endodontics

Resident: Swan
Article Title: Mineral Trioxide Aggregate: A New Material for Endodontics
Authors: Schwartz et al.
Journal: JADA, Vol 130 July 1999

Main Purpose: Describe MTA's successful use with 5 different clinical endodontic problems

Main Points:
-MTA is one of the few materials that is ideal for use against bone. It consisently allows for overgrowth of cementum and continued formation of bone. It may faciliate regeneration of the PDL.

-Physical properties: Powder of tricalcium (silicate, aluminate, oxide) and silicate oxide. After hydration, the colloidal gel solidifies in 3 hours. pH=12.5, similar to Ca(OH)2. Low solubility, low compressive strength. Seals very well, better than amalgam or IRM. Very biocompatible--allows cementum overgrowth and stimulates osteoblast activity.

-Case Reports
1. horizontal root fractures to 8 and 9 resulted in necrosis of both teeth. Necrotic pulp coronal to fractures was removed and initially filled with Ca(OH)2 for 6 weeks of splinting. Then, MTA was placed as apical barrier; canals obturated, fixation removed. Teeth asymptomatic on recall.

2. Resorptive defect of #9 18 months s/p trauma (subluxation). Likely external resorption. Tooth was necrotic. Pulpectomy with Ca(OH)2 placement for 3 months, 1 X monthly, to debride granulation tissue that had formed. When Ca(OH)2 reached bone on radiograph, dentist placed MTA as barrier before placing post and core buildup. (canal apical to defect was obturated with GP. Asymptomatic at 6 Mo. recall

3. MTA used to repair furcation perforation done as dentist mistakenly used Dycal instead of sealer while obturating #19. While removing Dycal, perforated root. Pt was very tender to percussion. Apical portion of root obturated with GP, coronal portion packed with MTA. MTA extruded into the furcation. Tooth became asymptomatic in several days, fine at 6 mo recall.

4. 72 yr old--MTA used to repair strip perforation of Mesiobuccal root done during root canal therapy. Tooth became symptomatic. Again, pt healed nicely and was symptomatic within a short period of time.

5. Chronic infection #8 in 29 yo female pt, no hx of trauma. Chief complaint was discoloration of tooth. Tooth root incompletely formed-"Blunderbuss apex." Sinus tract present. Doctor used MTA to form apical plug and then obturate. Tooth was asymptomatic 20 months later.

Assessment: These studies were done one year after MTA received FDA approval, and therefore don't have long follow up times. Current studies support idea that MTA is a wonder material. Wish I would have thought of it...

Monday, August 29, 2011

Pulp Revascularization of a Necrotic Infected Immature Permanent Tooth: Case Report and Review of the Literature

Resident: Cho

Author: Thiboedeau B, Trope, M.

Journal: Pediatric Dentistry Jan/Feb 2007

Type of Article: Case Report

Main Purpose: To show an example of revascularization for treatment of a necrotic immature permanent tooth.

Key Points:
- 9 year old Caucasian male seen at UNC Chapel Hill Endo Department
- Hx. of trauma 2 years ago, had Cvek pulpotomy 48 hrs after accident
- Presented with maxillary anterior swelling with necrotic #8
- Visit 1: tooth disinfected with Betadine, access made and irrigated with NaOCl and dried, creamy paste of metronidazole, ciprofloxacin, and cefaclor mixed with sterile water applied to canal space with lentulospiral slow-speed handpiece, paste tamped down using blunt sterile paper points, cotton pellet and IRM.
- Visit 2 (11 weeks later): disinfected with Betadine, tooth reaccessed, antibiotic paste irrigated away with NaOCl and sterile water to make room for blood clot, apical tissues stimulated with endo file to induce bleeding for 15 mins to reach level of CEJ, MTA mixed with sterile water placed over blood clot, moist cotton pellet placed over MTA for an hour, removed wet cotton pellet and verified firm set of MTA, restored with composite.
- At subsequent followup visits, tooth remained asymptomatic and radiographic examination revealed continued apical development and radiopacities associated with partial pulp canal obliteration and narrowing of the canal space.

Assessment of Article: This case study shows that revascularization may be used as an alternative method to the traditional used of apexification using Ca(OH)2 and MTA. Interesting article and further research still needed.

Wednesday, August 24, 2011

Indirect Pulp Therapy and Stepwise Excavation

Submitted by: Dionisopoulos

Title: Indirect Pulp Therapy and Stepwise Excavation

Journal: Pediatric Dentistry 30:3 225-229

Authors: Bjorndal, Lars, DDS, PhD

Main Purpose: This article presents recent systematic reviews of various treatment concepts that have been reccommended to treat deep carious lesions.

Key Points: 1) The main message in the article is that random clinical trials are lacking
that focus on the issue of treating deep carious lesions

2) Two approaches that both avoid exposing the pulp, Indirect Pulp Treatment (IPT) and Stepwise Excavation are both featured in the article. It is not determined which approach is the best approach.

3) The differences in the two methods is that IPT involves almost complete removal of the affected dentin, leaving a thin layer of demineralized dentin with no re-entry. The Stepwise Excavation recommends re-entry at varying intervals.

4) In the article, there is mention of the CAP Trial (Caries and Pulp) whose purpose is to investigate the beneficial and harmful effects of stepwise excavation during 2 visits, versus complete excavation in one visit. Results are were the process of being analyzed still at the time of this article, but preliminary data on the outcome of pulp exposure favor the use of stepwise excavation.

Overall, the author strongly reccommends more high-quality random clinical trials to compare IPT and stepwise excavation.

Dealing with deep carious lesions is very concerning, especially in private practice. When a pediatric dentist, or any dentist expects that there is a potential for pulp exposure, it is important to know the best and most successful method to maintain the integrity of the pulp. I often find this to be one of the more concerning situations and one that still does not have a good long term answer. Therefore, I agree with the author that clinicians would benefit from more high-quality random clinical trials to treat deep carious lesions because treatment of this type of lesion of often a time, financial/insurance and clinical concern especially for the pediatric dentist.

Cvek pulpotomy: Report of a case with five-year follow-up

Kyung-Hong Cal Kim

Cvek pulpotomy: Report of a case with five-year follow-up

Author: Sari, S

Journal of Dentistry For Children, 2002

Case report of treatment of fractured #8 and #9 on a six-year-old boy sixteen hours after a bicycle accident.

-#9: Pulp exposure (temporary restoration lost one hour after being placed)
-#8: ZOE restoration at the fracture site
-No mobility
-Apices incomplete
-No evidence of fractures involving root or alveolar bone
-Positive response to electric pulp testing
-Cvek pulpotomy on #9, resin restoration on #8 performed

Cvek pulpotomy on #9
-Local anesthesia
-Cleaned crown with iodine
-Pulp was amputated to a depth of 1-2mm within dentin with a spoon excavator
-Bleeding was controlled by flushing with a sterile saline solution to avoid clot formation
-CaOH2 powder + distilled water applied over the pulp wound
-Sealed with ZOE

Tooth #9 was monitored at 3 month, 6 month, 12 month, yearly up to five years both clinically and radiographically.

-Symptomless clinically and radiographically after 5 years
-Apex is closed

Advantages of Cvek pulpotomy
-When compared to cervical pulpotomy, Cvek pulpotomy preserves cell-rich coronal pulp tissue that will 1)Promote physiologic apposition of dentin in the cervical area, thus preventing cervical fracture, and 2)Conserve tooth structure, which facilitates future restoration of the fractured tooth.
-For direct pulp cap to be successful, time between trauma and treatment should be short.
-When completed properly, it will form a dentinal bridge and root formation will continue.

Case Report: Pulp Revascularization of a Necrotic, Infected, Immature, Permanent Tooth

Case Report: Pulp Revascularization of a Necrotic, Infected, Immature, Permanent Tooth
Resident’s Name: Matthew Freitas
Article title: Case Report: Pulp Revascularization of a Necrotic, Infected, Immature, Permanent Tooth
Author(s): B. Thibodeau
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2009. 31:2. 145-148.
Major topic: Permanent Pulp Therapies

-Pulpal necrosis of an immature permanent tooth secondary to caries or trauma is traditionally treated with long-term application of calcium hydroxide to induce apexification (achieve an apical seal without encouraging canal wall development). Research has shown that this treatment may leave the tooth even weaker and more susceptible to fracture, thus emphasizing a need for an improved treatment.

-The purpose of this case report was to provide an example to support the use of revascularization of necrotic infected pulp space of an immature permanent tooth by stimulation of a blood clot.

Case Report:
-9 year-old Caucasian male seen in endo for eval and tx of a max anterior swelling associated with tooth #8. Tooth traumatized 2 years ago with a complicated crown fracture and treated with a pulpotomy 48hrs later; rubber dam isolation not possible. Testing: cold test negative, although percussion, palpation, and probing depths wnl. Diagnosis: necrotic pulp and an acute apical abscess. Immediate Tx: IND for swelling.
-Next appt. the tooth was disinfected with Betadine (10% Povidone Iodine Topical Solution) using rubber dam isolation. Access achieved and necrotic pulp confirmed clinically. Canal was irrigated with 1.25% sodium hypochlorite and dried with paper points. A creamy antibiotic paste was applied to the canal space. Access was then closed with cotton pellets and temporary restoration.
-11 weeks later: patient was asymptomatic, rubber dam placed and tooth disinfected with Betadine and reentered. Antibiotic paste irrigated away to make space for the blood clot. Periapical tissues were then stimulated with a sterile endo file to induce bleeding into the canal space until it reached the level of the CEJ. MTA was then applied over the blood clot. A moist cotton pellet over the MTA, and 1 hour later the cotton pellet removed; MTA was hard set. Tooth was then sealed and restored with composite.
-3, 9, 12, 16, and 41-month follow-ups: asymptomatic, wnl to percussion, palpation, and probing depths, but non-responsive to cold test or electric pulp test. However, radiographic analysis revealed continued radicular wall thickening, apical closure, and narrowing of the canal space.

-Revascularization of an immature permanent tooth with necrotic pulp with a blood clot may provide a better long-term outcome of the tooth by encouraging normal root development, which strengthens the tooth against future fracture.
-Case selection is important and the author recommends an open immature apex > 1mm mesiodistally.

Pulpectomy Success in Vital Primary Incisors

Resident: Swan
Title: A Retrospective Assessment of Zinc Oxide Eugenol Pulpectomies in Vital Maxillary Primary Incisors Successfully Restored with Composite Resin Crowns
Journal: Pediatric Dentistry 27:6, 2005
Authors: Primosch, et al.

Main Purpose: evaluate, using clinical and radiographic measurements, treatment outcomes of ZOE pulpectomies in vital primary incisors
**104 VITAL incisors pulpectomized subsequent to trauma or decay, all by one operator. **Procedure: 1) isolated 2) carious tooth structure removed 3) pulp tissue removed with broach 4) canal cleaned with rotary or endodontic files, then irrigated w/ water, formo paper point for 4 min, paper points, obturation with ZOE using lentulo spiral 5) restored with Strip Crown.

**Preop, immediate post op, and recall radiographs were evaluated (outcome (s or f), root resorption, canal filling extent, eruption status of succ. tooth (mean follow up time 18 mos.)

Key Points:

Reasons to pulpectomize rather than pulptomize a vital primary tooth:
1) residual pulp tissue provides potential for acute inflammatory reaction
2) no clear anatomical demarcation between coronal/radicular pulp as in prim. molars.

Of 104 incisors treated as described, failure was 24%, statistically sig for
1) Reason for tx: traumatized incisors treated this way failed 42%; 19% for carious incisors
2) Type of restoration: conventional strip crown failed at much higher rate than with core buildup technique
3) extent of fill: Gross overfill associated with failure
4) eruption status of succ. perm. tooth: Delayed eruption occurred more with failed pulpectomies (9 of 11 delayed perm teeth)

I often wonder about doing more pulpectomies, even for anterior teeth. This article agrees with other published studies that place its failure rate, for vital and non-vital primary teeth, at around 20-25%. Not a bad option for a parent who REALLY wants to avoid extraction. The study was well done, has limitations, one being the fact that all the traumatized teeth were restored with conventional Strip Crowns instead of with core buildups. All pulpectomy failures were in teeth with conventional crowns, so hard to relate failure to restoration type and not be confounded by the reason for restoration.

Tuesday, August 23, 2011

Mineral trioxide aggregate pulpotomies: A case series outcomes assessment

Resident’s Name: Jessica Wilson

Article title: Mineral trioxide aggregate pulpotomies: A case series outcomes assessment
Author(s): Witherspoon et al
Journal: JADA
Year. Volume (number). Page #’s: 2006. 37. 610-617.
Major topic: Permanent Pulp Tx

19 teeth in 14 patients with symptomatic carious or traumatic pulp exposures were treated with MTA pulpotomies in an endodontic private practice by the three authors. The treatment consisted of RDI, coronal pulp debridement, NaOCl irrigation, avoiding cotton pellet pressure as to not crush delicate tissue or incorporate fibers into pulp and the placement of a 2mm thick layer of MTA. These patients were then followed up at 3 month intervals for as long as possible and teeth were categorized as “healed”, “healing” or “persistent disease”.

15 (79%) of teeth were categorized as “healed”, 3 (16%) of the teeth were “healing” and 1 (5%) had “persistent disease”.

MTA may be useful as a substitute for CaOH for pulpotomy procedures.

Assessment of Article:
Although the results were consistent with existing literature, it was a very informative article. The background section was full of specific properties of MTA as well as CaOH, a good review. I also liked reading an article from an endo point of view for a change.

Direct Pulp Capping with Mineral Trioxide Aggregate

Resident Name: Elliot Chiu

Article Info

Title: Direct Pulp Capping with Mineral Trioxide Aggregate

Author: George Bogen, Jay S. Kim, Leif K. Bakland

Journal: JADA 2008

Main Purpose

-To observe the success of MTA over time.


­-Direct pulp caps were done on 49 teeth by one operator

-37 patients aged 7-45 years old (mean age = 16.6)

-Caries was removed until caries detecting dye no longer stained, even after pulp exposure.

-NaOCl was used to achieve hemostasis

-1.5-3mm thick layer of MTA was placed over the exposure and surrounding dentin.

-Cotton pellet placed, composite core build-up material placed as temporary. After 5-10 days, MTA was assessed for hardness and the tooth was restored with composite.

-Recall at 6 weeks, 6mon, yearly for up to 9 years for pulp testing and radiographs

Key Points

-Probability of pulp surviving at least 5 years was 94.87%.

-15/15 teeth with open apices progressed to complete apex closure

-Radiographic evidence of dentin bridge formation in 82% teeth


I thought this study was very well done. The variables were well controlled and it offers very promising results.


-Small sample size

-All done by one operator. MTA is technique sensitive, can these results be achieved by all of us??

-The interpretation of radiographs was not blinded.

-No control group to compare results to (CaOH)

Comparison of Mineral Trioxide Aggregate and Calcium Hyroxide as Pulpotomy Agents in Young Permanent Teeth (Apexogenesis)

Comparison of Mineral Trioxide Aggregate and Calcium Hydroxide as Pulpotomy Agents in Young Permanent Teeth (Apexogenesis)

Omar A.S. El Meligy, BDS, MSc, PhD; Davide R. Avery, DDS, MSD

Pediatric Dentistry - 28:5, 2006

Purpose: Comparing effectiveness of MTA with calcium hydroxide

Method: Fifteen children ages 6-12 with 30 traumatized or carious teeth were used. Each child has at least two contralateral qualifying teeth. The selected teeth were randomly assigned into two groups; Group one treated with Ca (OH)2 and Group two treated with MTA. Each child had both treatments; one on each side of the mouth. The children were recalled at 3,6, and 12 months for clinical and radiographically examination.

*No signs or symptoms were seen after 6 months.
*At 12 months two teeth in group one had a history of pain and swollen tissues.
*In group two all 15 teeth were free of any clinical signs and symptoms.
*Calcific metamorphosis was seen in 2 teeth of Group one and four of Group 2.
*At 12 months 13 teeth in group 1 and all 15 of group 2 demonstrated root growth and canal narrowing.

Discussion: This study showed a 87% success rate for Ca(OH)2 and 100% for MTA! MTA once again has shown amazing results for biocompatibity and uses for dental treatment. Would love to use more MTA here in clinic. Not sure how true this is, but John says MTA is the same as good ol' cement. He says rather than purchase a $300 5 gram bag of MTA he can get a 6 dollar 80 g bag at lowes with his military discount .

Comparative Evaluation of Endodontic Management of Teeth with Unformed Apices with Mineral Trioxide Aggregate and Calcium Hydroxide

Resident: Cho

Author: Pradhan et al.

Journal: Journal of Dentistry for Children, 2006.

Main Purpose: Compare Calcium hydroxide and MTA as effective medicaments for devitalized immature permanent teeth.

Methods: Twenty nonvital immature permanent maxillary incisors (19 central incisors and 1 lateral incisor) with past history of trauma were selected for the study. The patients were from Postgraduate Institute of Medical Education and Research from Chandigarh, India. All teeth had pulp extirpated and filled with Ca(OH)2 paste and sealed with ZOE. The Ca(OH)2 group was left as such.

In the MTA group, after a period of 7 days, Ca(OH)2 was removed by using reamers and irrigation of savlon, MTA was inserted into the apical one third of the root canal until root barrier of 3-4mm created, moist cotton pellet was left in canal close to MTA to faciliate its setting and the access opening was sealed with ZOE. After 3 to 4 days, the wet cotton pellet was taken out and the apical plug of MTA was checked for its set and hardness and then obturated with gutta percha.

The teeth in both groups were assessed every 4 weeks for clinical and radiographic findings.

Key Points: Treatment was successful in both groups. The total treatment time was less in the MTA group (3 weeks) than the Ca(OH)2 group (7 months). The mean time for biological barrier formation assessed radiographically was less in MTA (3 months) than the Ca(OH)2 group (7 months). The mean healing time for large radiolucencies was found to be similar.

Assessment of Article: This article shows that use of calcium hydroxide and MTA are successful medicaments for achieving a biologic barrier for devitalized immature permanent teeth. Weakness of the study is the small sample size. This study did not consider ease of use or differences in cost of the two medicaments.

Monday, August 22, 2011

Importance of The Diagnosis in the Pulpotomy of Immature Permanent Teeth

Resident Name: Sadler
Article Info: Importance of The Diagnosis in the Pulpotomy of Immature Permanent Teeth

Souza et al

Brazil Dental Journal 2007 18(3):244-247

Main Purpose: Case Study of two patients who underwent pulpotomy procedures on immature permanent molars

Methods: Permanent molars in two patients were treated. The first had deep radiographic and clinical caries with a corresponding periapical lesion. Tooth was treated with calcium hydroxide pulpotomy and monitored. The second was treated similarly although the two appointments were needed and a lesion was present in the furcation.

Key Points:

Both cases show resolution of the periapical/furcal lesions and normal root development. The author contends that the presence of a periapical lesion does not necessarily mean a full root canal is necessary. After careful clinical exam taking into account pulp status/vitality, percussion, palpation etc. a CaOH pulpotomy may be a good treatment for permanent teeth with immature apex.

Assessment of Article: Very interesting case study. Both patients were treated in the same manner and radiographs appear to support the finding that normal root development occurs. I would be interested in long term prognosis. Is traditional RCT needed in the future, crown fracture, restoration leakage? Also, in patients with such high risk that they have caries to the pulp on 6 yr. molars when they are only 6 and 7 years old perhaps drastic changes in hygiene would need to accompany the treatment.

Wednesday, August 17, 2011

Modified 1 minute Formocresol Pulpotomy Technique--effect on Exfoliation Times and Successors

Resident: Swan
Title: A Retrospective Study of a Modified 1 minute Formocresol Pulpotomy Technique Part 2: Effect on Exfoliation Times and Successors
Authors: Kurji, et al.
Journal: Pediatric Dentistry, 33(2) Mar/Apr 2011

Main Purpose: evaluate the effect of 1 minute full-strength formo application in primary teeth on their successors, specifically enamel defects and exfoliation times of their permanent successors

-Condition of the contralateral tooth served as control for treated tooth in evaluating exfoliation times
-any abnormality in the surface morphology or color between treated and untreated side was noted.
-Observations noted until both treated/untreated teeth either exfoliated or were extracted.

Main Points:
-studies show conflicting results regarding altered exfoliation times/other abnormalities resulting from puloptomy treatment
-In this study, intra and inter-rater reliability was "substantial" (86% and 70% respectively)
-mean age teeth were lost was 10.7 yrs
-191 of exfoliated teeth had contralateral non-pulpotomized teeth to compare with
-29% exfoliated earlier, 65% within same time period, 6% later than secondary
-average exfoliation occurred 2.7 months earlier on average. (Statistically significant)
-of the 191 teeth secondary to treated teeth, 3% had enamel defects, 1% in control group. (Not significant)
-mofidifed 1 minute formo tx showed tendency toward earlier exfoliation times--clinically significant?? Also, no increased negative effect on succedaneous teeth.
-This technique could be considered as an alternative to the 5 minute formo technique

Assessment: This study was pretty well set up, with good inter-examiner reliability and large sample size. One weakness is the method of estimating exfoliation times--the reported exfoliation time was based on the first noted absence of the tooth at a specific recall date. So if the patient lost their tooth 3 days after a recall visit, it wasn't noted as "exfoliated" until 6 months later. This could have definitely skewed the reporting. There's no great way to get accurate dates, however--parents probably wouldn't give a much more accurate date. The fact that both treated and untreated teeth were dated this way probably mitigated this problem.

Pulp Repair after Pulpotomy Using Different Pulp Capping Agents: A Comparative Histologic Analysis

Submitted by: Fotini M. Dionisopoulos

Author: Lima, et. al.

Journal: Pediatric Dentistry, January/February 2011

Main Purpose: To histologically evaluate the repair of rat pulp tissue after pulpotomy and covering the pulp with 1) Copaifera langsdorffi oil-resin, 2) green propolis extract,
3) iodoform-based paste and 4) fibrin sponge

Methods: The study involved pulpotomies on the first molars (84 teeth total) of Wistar rats. Histological evaluations were performed at 1 day, 15 days, and 30 days. There were two scoring systems involved: 1) The severity of inflammatory infiltrate and the extension of pulp necrosis into the radicular pulp and 2) The deposition of mineralized tissue.

Key Points: 1) In the 3 evaluation periods, the inflammatory response consisted primarily of a netrophil infiltrate. The Copaifera langsdorffii oil-resin group had the least amount, while the fibrin-sponge group was most severe.

2) Coagulation or liquefaction necrosis was observed in all cases, and the extension of necrotic pulp increased over time, except for the group in which the remaining vital radicular pulp tissue was covered with Copaifera langsdorffii.

3) Only the teeth treated with Copaifera Langsdorffii showed deposition of mineralized tissue close to the capping material, starting from the 15the day. In the teeth capped with the other materials, there was deposition far from the pulp exposure area.

4) Vascular congestion, edema, and hemoohage were observed in all cases.

Overall, Copaifera langsdorffii was associated with smaller area of pulpal necrosis, more frequent formation of mineralized tissue after pulpotomy, and less severe inflammatory response.

Assessment of article: This, overall, was a well-constructed study. I do think it may be effective to check the results during a time span longer than 30 days, if possible-- i.e. 3 months or 6 months or even one year. But it was difficult to read that the animals were sacrificed, decapitated, and then their maxillas or mandibles were dissected for gross/histological evaluation

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

Kyung-Hong Cal Kim

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

Author: Camp JH

Journal of Pediatric Dentistry, 2008


Most of the diagnostic tests used in conventional endodontic therapy are of very little or no value in primary teeth and in permanent immature teeth.

For immature permanent teeth, treatments should be oriented toward maintenance of vitality to allow completion of root formation.
-Early treatment of immature teeth can lead to loss of vitality, cervical root fractures (frequency was dependent on the stage of root development).
-Loss of vitality before completion of root length will lead to a poor crown-to-root ratio, periodontal breakdown due to mobility.
-When in doubt, closely monitor the tooth for further development.
-Vital procedures like apexification, apical barrier techniques are preferred to allow the teeth to complete root formation, if indicated.

-Most injuries are displacements rather than fractures.
-Treatment least likely to damage the permanent tooth should be chosen.
-Avulsed primary incisors should not be replanted because of the possibility of danger to the permanent tooth bud.
-1/2 of traumatized primary teeth develop transient or permanent discoloration, usually after 1-3 weeks.
-dark gray discoloration associated with necrotic pulps 50-82%
-yellow discoloration associated with pulp canal calcification
-discoloration alone shouldn’t be used as a reliable indicator of pulpal health

Thorough medical history, thorough history and characteristics of pain, and good quality radiographs are key in proper diagnosis and treatment of primary and immature permanent teeth.
-Provoked pain vs. spontaneous pain
-Bifurcation or trifurcation areas in primary molars
-Signs of internal resorption
-Size of pulpal exposure and the amount and color of hemorrhage

Caries Control and Other Variables Associated With Success of Primary Molar Vital Pulp Therapy

Caries Control and Other Variables Associated With Success of Primary Molar Vital Pulp Therapy
Resident’s Name: Matthew Freitas
Article title: Caries Control and Other Variables Associated With Success of Primary Molar Vital Pulp Therapy
Author(s): R. Vij et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2004. 26:3. 213-220.
Major topic: Primary Pulp Therapies

-Caries control procedures with glass ionomer cements have been recommended as a pretreatment before definite pulp therapy in primary teeth. Glass ionomer cements provide an antimicrobial and remineralization effect on caries.

-The purpose of this research was to evaluate the success of initial treatment of deep dental caries with caries control and the effect on the success of indirect pulp therapy (IPT) and formocresol pulpotomy (FP).

-Retrospective study of 2 combined groups: (226 teeth total; 118 FPs and 108 IPTs)
-Six pediatric dentists treated these 141 patients in 3 private dental offices.
-Caries control performed on 78 teeth exhibiting reversible pulpitis 1-3 months prior to FP or IPT and restored with GI or ZOE.
-Glass ionomer cement liner/base used in IPT.
-Almost all of the teeth restored immediately with SSC, amalgam, glass ionomer, or composite.
-Clinical and radiographic assessment used to assess success; mean follow-up 3.5 years.

-1 year follow-up/success: FP: 95%; IPT: 98%.
-3 year follow-up/success: FP: 70%; IPT: 94%.
-Early exfoliation: FP: 36%; IPT: 2%.
-GIC CC vs. IPT/FP: 92% success rate vs. 79% .
-Primary First Molar vs. Primary Second Molar IPT/FP: 76% success rate vs. 91%.
-No significant difference found in type of restoration placed. However, 216 were SSC and only 15 teeth were restored with amalgam, GI, or composite. Teeth restored with just a temporary IRM restoration had high failure rates most likely due poor marginal seal.

Critical Ideas:
-IPT may be a better treatment over FP therapy in primary molars, showing higher success and less early exfoliation.
-CC with GI restoration may provide a better long-term prognosis before IPT or pulp therapy.
-Primary first molars may be more likely to fail vs. primary second molars.
-Important to always restore the tooth with an immediate restoration that prevents microleakage.

Tuesday, August 16, 2011

Vital Pulp Therapy with New Materals for Primary Teeth: New Directions and Treatment Perspectives

Resident Name: Sadler
Article Info: Vital Pulp Therapy with New Materials for Primary Teeth: New Directions and Treatment Perspectives

Anna B. Fuks DDS

Pediatric Dentistry V 30 No.3 May/June 08

Main Purpose: Literature Review of Pulp Therapies

Key Points:

Pulp Caps: Indirect pulp caps have been shown to be successful. Direct pulp caps are still not recommended in primary teeth.

Pulpotomy is widely accepted as treatment of choice for vital primary tooth. Materials and techniques used still vary. Formocresol is losing favor and its use is declining. MTA seems to have the best result but has other drawbacks. Ferric Sulfate still has acceptable results and bleach is being investigated as an acceptable treatment as well. Lasers also have shown promise as a hemostatic agent.

Assessment of Article: Authored reviewed a good amount of current literature. MTA still is the star of the show and shows the best success rate. Lasers are an interesting aspect that should be further investigated. The summation seems to be use high speed for intial prep, avoid pulp exposure if possible and pulp cap if possible. If not, MTA is best but ferric and bleach are acceptable as well.