Wednesday, April 20, 2016

The effect of sodium hypochlorite application on the success of calcium hydroxide and mineral trioxide aggregate pulpotomies in primary teeth

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Mark Dawoud, DMD                                                         Date: 04/20/16
Title: The effect of sodium hypochlorite application on the success of
calcium hydroxide and mineral trioxide aggregate pulpotomies in primary teeth
Authors: Akcay, M., Sari, S Major Topic: resin composites in pediatric dentistry
Journal: Pediatr Dent (2014) 36: 316-321
Type: randomized, controlled, clinical trial
Main Purpose: This study’s purpose was to evaluate the success of calcium hydroxide (CH) and mineral trioxide aggregate (MTA) pulpotomies following the use of five percent sodium hypochlorite (NaOCl) as an antibacterial agent to clean the chamber prior to application of the pulpotomy agent.

·      Methods: A total of 128 teeth in 64 children were randomly divided into two pulpotomy groups (CH or MTA). The teeth in each pulpotomy group, CH and MTA, were further randomly divided into subgroups to receive either the NaOCl (experimental) or saline (control) cleaning agent prior to applying the pulpotomy agent.
o   The following inclusion criteria were used to select the teeth in this study:
o   1. no clinical symptoms or evidence of pulp degeneration, such as pain on percussion, history of swelling, or sinus tracts;
o   2. no spontaneous pain;
o   3. no radiographic signs of internal/external resorption or widened periodontal ligament space or furcal/ periapical radiolucency;
o   4. no more than one third physiological root resorption;
o   5. teeth would be restorable with stainless steel crowns (SSCs).
·      The treatments were followed clinically and radiographically for 12 months.
o   clinical success was confirmed by the absence of spontaneous pain, pathologic mobility, tenderness to percussion, swelling, fistula, or gingival inflammation. Radiographic success was considered when internal/external root resorption and periapical/furcal radiolucency was not observed. Calcific metamorphosis of the pulp was not considered a failure.
·      Results: The radiographic success rates were 84 percent for CH NaOCl, 74 percent for CH saline control, 97 percent for MTA NaOCl, and 100 percent for MTA saline control.
·      There were no significant differences between the radiographic success rates in the CH and MTA subgroups (CH NaOCl-CH control and MTA NaOCl-MTA control); no significant differences were observed when comparing the CH NaOCl-MTA NaOCl groups and the CH NaOCl-MTA control groups.

·      Conclusion: Use of sodium hypochlorite as an antibacterial agent prior to application of the pulpotomy agent improved the success of calcium hydroxide pulpotomies to equal the success of mineral trioxide aggregate pulpotomies for observation up to 12 months

Indirect Pulp Therapy and Stepwise Excavation

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: John Kiang                                                                                                Date: 4/20/16
Article Title: Indirect Pulp Therapy and Stepwise Excavation
Author(s):  Lars Bjorndal  
Journal: Pediatric Dentistry  
Date: May/Jun 2008
Major Topic: Pulp Therapy  
Type of Article: Conference Paper
Main Purpose: To highlight the current trends in indirect pulp therapy and discuss a stepwise approach to caries excavation.  Recent systematic review are presented.
Key Points:
·      Various treatment concepts have been suggested to solve the deep carious lesion
·      Their conclusions are based on very few studies, and the main message is that optimized clinical studies are lacking.
·      What makes a good randomized clinical trial: Well-defined inclusion and exclusion criteria, prognostic factors are equally distributed between the two interventions that are being compared, The number of treatments needed to show a difference between control and experimental groups is generated by a computer, Adequate allocation concealment, Follow-up by blinded investigator, and Trial should be carried out at different centers.
·      Observational studies on indirect pulp tx and stepwise excavation demonstrate that these treatments avoid pulp exposures, but it cannot be said which approach is best.
·      There are different approaches to a multi-step technique: Caries removal, calcium hydroxide placement, and temporary restoration (return for perm filling in 2-3 weeks). Another is leaving a thin soft layer of dentin, placing zinc oxide eugenol cement, temp restoration and returning 4-6 weeks for final restoration.
·      A less invasive modified stepwise excavation approach is described, focusing on changing an active lesion into an arrested lesion even without performing an excavation close to the pulp.
·      Deep lesion considered likely to result in pulp exposure if treated by a single and terminal excavation. Evaluated by x-ray, the dentinal lesion involves three fourths or more of the dentin thickness
·      No hx of pretreatment symptoms such as spontaneous pain and provoked pulpal pain. However mild to moderate pain on thermal stimulation is accepted.
·      Positive pulp sensibility tested by an electric pulp tester, thermal stimulation or test cavity
·      Pretreatment radiographs that rule out apical pathosis
·      Finish the peripheral excavation of the cavity followed by a central excavation removing the outermost necrotic and infected demineralized dentin
·      Do not excavate as closely as possible during the first step thereby reducing the risk of pulpal exposure
·      Select a provisional restoration material on the basis of the length of tx (lasts 6-8months)
·      Final excavation is often less invasive than expected as a result of the altered dentinal changes gained during tx interval.

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

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Christa Rodenas                                                            Date: 4/20/2016

Article Title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Tootache is Changing, Especially in Young, Immature Teeth
Author(s): Joe Camp, DDS, MSD
Journal: Pediatric Dentistry
Date: 2008
Major Topic: Pulp Therapy
Type of Article: Conference Paper
Main Purpose: To summarize current approaches to pulp therapy of deciduous and immature permanent teeth
Key Points/Summary:
·      To properly diagnose and treat primary and young permanent teeth, it is necessary to have thorough knowledge of normal root formation and the difference between developing and fully formed teeth.
·      In permanent teeth, root formation is not completed until 1-4 years after eruption into the oral cavity
o    Apical closure cannot usually be determined radiographically as faciolingual width of most roots and canals is greater than the mesiodistal width; X-ray beam is exposed in faciolingual plane but radiograph is read mesiodistally
·      Diagnosis of Pulpal Status in Primary Teeth
o   Provoked pain that stops after removal of the causative stimulant is usually reversible and indicative of minor inflammatory changes
o   Spontaneous pain is a constant or throbbing pain that occurs without stimulation or continues long after the causative factor has been removed; history of spontaneous toothache is usually associated with extensive degenerative changes extending into the root canals. Treatment recommended is pulpectomy or extraction
o   In primary molars, pathologic changes are most often apparent in the bifurcation or trifurcation area-bitewings are often best to observe pathologic changes in posterior primary teeth.
o   With acute or rapid onset as the disease reaches the pulp of primary teeth, calcified masses might form away from the caries exposure site – this is indicative of advanced pulpal degeneration extending into the root canals. These teeth are candidates for pulpectomy or extraction.
o   Excessive or deep purple colored hemorrhage is evidence of extensive inflammation. Also, hemorrhage that cannot be controlled within 1-2 minutes by light pressure with a damp cotton pellet indicated that more extensive treatment is necessary. These signs are indicative of pulpectomy or extraction.

·      Diagnosis of Pulpal Status in Permanent Immature Teeth
o   In teeth with incomplete root formation, correct pulpal and periapical diagnosis is of paramount importance
o   Discoloration of a tooth crown after trauma is a common sequel and one of the foremost diagnostic indicators
§  Yellow discoloration-indicative of pulp space calcification
§  Gray color-indicative of pulpal necrosis
o   Transient apical breakdown occurs after displacement injuries and might lead to misdiagnosis
§  Transient periapical radiolucency, coronal discoloration, negative electric pulp test and cold response up to 4 months was shown to subsequently regain the original color and normal pulpal responses
o   Universal agreement exists that immature teeth have the greatest potential to heal after trauma or caries, particularly when the apical foramen is wide open
o   If doubtful, do not start treatment; keep the patient under close observation

Level of Evidence: Level I

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

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:  Leslie M Slowikowski                                                                 Date: 04/20/2016
Article Title: Success Rate of Mineral Trioxide Aggregate, Ferric Sulfate, and Formocresol Pulpotomies: A 24-month Study
Author(s): Arzu Pinar Erdem, DDS, PHD et al.
Journal: Pediatric Dentistry
Date:  March/April 2011
Major Topic: Success rate for pulpotomies
Type of Article: Research Article
Main Purpose: Comparing success rate of different medicaments for pulpotomies
Key Points/Summary:  Pulpotomies are a way of vital pulp treatment in primary teeth.  However when it comes to treatment of the pulp stumps after removal of the coronal tissue there are several choices of material to be used. 

Ferric sulfate: nonaldehyde chemical, hemostatic agent by agglutination of blood protein without the presence of a blood clot
Formocresol:  formaldehyde containing treatment that fixes the tissue that has reported toxic, mutagenic, and carcinogenic properties
MTA: biocompatible, alkaline material with good sealing ability and it appears to encourage dentin bridge formation
ZOE: treatment objective was classified as preservation, which implies maintaining the maximum vital tissue with not induction of reparative dentin

Methods: 32 healthy children 5-7 years old with at least 4 primary molars, one in each quadrant that needed treatment with pulpotomy where there was no radiographic or clinical evidence of pulp degeneration.  128 teeth were treated and follow up was done at 6, 12, 24 month intervals.  All teeth were restored with amalgam.  Pulpotomy considered a failure it one or more of the following are present: pain, swelling, mobility, percussion pain, internal root resorption, and furcation and/or periapical bone destruction.  Pulp canal obliteration was not considered a failure.

Results:  There was no statically significant difference between any treatment at 6 months and 12 months, however there was a significant difference between MTA and ZOE at 24 months.   No significant but observed success was higher in radiographic follow-up with MTA compared to ferric sulfate and formocresol.  

Assessment of Article:  Level of Evidence/Comments: II

Wednesday, April 13, 2016

Pulp Therapy for the primary dentition. Cassamassimo ch 22

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Nicholas Paquin                                                             Date:   04/13/2016

Article Title: Pulp therapy for the primary dentition
Authors: Anna Blinder Fuks, Ari Kupietzki, Marcio Guelmann
Journal: Cassamassimo
Major Topic: Pulp treatment in primary teeth
Type of Article: Text book, literature review
Main Purpose: To outline treatment modalities for primary pulp

1.     Odontoblasts are cells that line the pulp and extend their cytoplasmic processes into the dentinal tubules (main part of pulp-dentin complex).
2.     Odontoblasts form Dentin and protect the pulp from injury (disease or operative procedure)

The Pulp-Dentin Complex/Dentinogenic Response to Injury
1.     In pathologic conditions (such as caries or trauma) odontoblasts are stimulated to produce reactionary tertiary dentin/sclerotic dentin at the injury site to decrease dentin permeability and defend the pulp.
2.     Based on the remaining dentin thickness, three situations are possible:
1.     Initial caries/shallow prep - secretion of reactionary dentin and intratubular mineralization - protection of pulp.
2.     Deeper caries/prep - reparative dentin formation - protection of pulp.
3.     Very deep caries/prep - odontoblasts unable to provide pulpal protection -  pulpal inflammation (chronic pulpitis becomes acute).

Clinical Pulpal Diagnosis
 There are two main types of dental pain:
1.     Provoked pain: stimulated by thermal, chemical, or mechanical irritants; reduced or eliminated when stimulus is removed.
a.    Dentin sensitivity due to deep caries
b.    Condition is reversible
2.     Spontaneous pain: throbbing, constant pain; may keep patient awake at night.
a.    Advanced pulpal damage.
b.    Condition is irreversible.

Clinical Examination
1.     Redness/swelling/grossly decayed teeth with drainage - pulpal pathoses.
2.     Tenderness to palpation -  possible acute dentoalveolar abscess
3.     Percussion sensitivity -  possible periapical involvement
4.     Increased mobility of suspected tooth when compared to contralateral tooth - possible pulpal inflammation (must take into account exfoliation pattern).

Radiographic Examination
1.     Interradicular radiolucencies (often in primary teeth with pulpal pathoses) is best observed in a bitewing.
2.     If you cannot see the apex, you will need a PA.
3.     Assess laminar dura of affected tooth and contralateral tooth.
4.     Note: internal resorption indicates inflammation of vital pulp, whereas external resorption is nonvital pulp with extensive inflammation.
5.     Note: Any radiolucency associated with a nonvital tooth is usually located in the furcation area, NOT at apices because of the presence of accessory canals on pulpal floor area.
a. Thus, bitewing is useful especially in maxillary molars where developing premolar obscures the furca in a PA.

Direct Pulp Inspection
There are instances when a final diagnosis can only be reached by evaluating the pulp tissue at time of treatment.
1.     Assess the quality (color) and amount of bleeding:
a.    Profuse bleeding or purulent exudate indicates irreversible pulpitis.
b.  For example, continued bleeding after a pulpotomy/formocresol indicates further pulp involvement requiring pulpectomy or extraction.

Pulp Treatment Procedures
Conservative pulp therapies:
1.     Protective Base-  AAPD recommends placement of a base or liner on the pulpal and axial walls of a preparation to serve as a protective barrier between the restoration and tooth. Resin cements, glass ionomers, and dentin bonding agents are used to seal the extremely permeable dentin (protect the pulp).
**protective liners or bases should only be placed in deep cavities approaching the pulp
2.     Indirect Pulp Treatment- indicated for asymptomatic teeth with deep carious lesions near the pulp.  Soft mushy dentin should be removed and hard discolored dentin can be indirectly capped. 
a.    Carisolv is a material used during IPT---sound and carious dentin are clinically separated and only carious dentin is removed - more conservative preparation, however it takes longer that utilizing a slow speed round bur.
b.    Must make sure that all “mushy” caries are removed at DEJ and on lateral walls.
c.     MTA, calcium hydroxide, and GI are the most commonly used materials in IPT.
d.    Success rate of IPT are reported to be higher than 90% in primary teeth—thus, it is recommended in patients whose pre-op diagnosis suggests no signs of pulp degeneration.
e.    Interim restorative treatment (IRT) is a form of IPT.
3.     Direct Pulp Capping- carried out when a healthy pulp has a pinpoint exposure free or oral contaminants.
a.    Calcium hydroxide is placed over exposure to stimulate dentin formation.
b.    Not recommended in primary teeth but can be used with success on immature permanent teeth.  Direct pulp caps in primary teeth lead to internal resorption.
4.     Pulpotomy- used when radicular pulp tissue is healthy and capable of healing after amputation of the infected coronal pulp.
a.    Contraindications to pulpotomy include: swelling, fistula, pathologic mobility, external/internal root resorption, PAP, pulp calcifications, excessive bleeding from amputated radicular stumps.
5.     Pulpotomy technique-
a.    Remove all superficial caries (prior to pulp exposure to minimize bacterial contamination)
b.    The roof of the pulp chamber should be removed by joining the pulp horns with bur cuts utilizing a 330.
c.     Amputate coronal pulp with large slow round bur.
d.    Cotton pellets+pressure should be placed over
e.    amputation site—hemostasis should be achieved.
                                               i.     Excessive bleeding or deep purple color indicates inflammation (pulpectomy or ext)
f.      Place cotton pellet+formocresol five minutes.
h.    Prep/place SSC.       g.     Place zoe over amputation site/cover pulpal floor.

Radical Treatment:
1.     Pulpectomy and Root Filling- indicated in teeth that show evidence of chronic inflammation or necrosis in the radicular pulp.  This treatment is contraindicated in teeth with gross loss of root structure, internal or external resoprtion, or a periapical infection involving the crypt of a succedaneous tooth. Certain clinical situations justify a pulpectomy  (ex: pulp destruction of a primary second molar before the first permanent molar erupts)
2.     Root Filling Materials- ZOE paste, iodoform based paste, calcium hydroxide, and calcium hydroxide+iodoform (Vitapex). While ZOE is the most commonly used material, Vitapex is easy to apply, resorbs at a slightly faster rate than that of the roots, has no toxic effect on permanent successor, and is radio-opaque, thus making it an ideal material.
3.     Pulpectomy technique-
a.     Access opening should be prepared with walls flared to access canal openings (similar to pulpotomy)
b.     A barbed broach is used to remove as much organic material as possible from each canal.
c.      Endo files are selected and adjusted to stop 1-2mm short of radiographic apex (WL determined by radiograph).
d.     Irrigation with sodium hypochlorite and or chlorohexidine followed by sterile saline rinses.
e.     Canals should be dried with paper points.
f.      Vitapex is packed in via a sterile syringe that injects the paste into the canal.
g.     Post-op radiograph is taken to:
                                               i.     Evaluate the quality of fill and prescribe antibiotics if overfilled
                                              ii.     Provide a baseline for comparing the success of the RCT with follow-up visits.

Q1: Why don't we use glass Ionomers to seal exposed pulps?

Q2: What are the 2 most important factors to ensure success of indirect pulp capping (IPT) in primary teeth. 

A1:When resin-modified glass ionomers are placed into a cavity preparation or on an exposed pulp, their initial pH within the first 24 hours is approximately 4.0 to 5.5. Therefore the glass ionomer demineralizes the adjacent dentin, releasing ions and potentially the sequestered bioactive materials as well. The pulpal response to glass ionomer is favorable when a layer of dentin remains between the material and the pulp.
Studies of direct pulp capping with glass ionomer show that both patient tolerance and clinical success rates are lower with ionomer than calcium hydroxide. This finding suggests that the acidic environment created by the glass ionomer is more damaging to the pulp than the basic environment of calcium hydroxide or MTA

A2: AsymptomaticOne can conclude that, on the basis of these biological changes, and the growing evidence of the success of IPT in primary teeth, we can recommend IPT as the most appropriate treatment for symptom-free primary teeth with deep caries, provided that a proper, leakage-free restoration can be placed.