Thursday, April 27, 2017

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

Department of Pediatric Dentistry
Lutheran Medical Center
           
Resident’s Name: John Diune                                                                                   Date: 4/26/2017
Article Title: Caries Control and Other Variables Associated With Success of Primary Molar Vital Pulp Therapy
Author(s): Raj Vij BDS DDS, James Coll DMD MS, Preston Shelton DDS MS, Naila Farooq BDS MSc DDPH
Journal: Pediatric Dentistry
Date: 2004
Major Topic: Pulp Therapy
Type of Article: Retrospective chart audit
Main Purpose: Evaluate treatment of teeth with deep carious lesions with GIC CC prior to pulpotomy in some cases, and investigating other factors that could contribute to success/failure of these teeth treated with either Formocresol pulpotomy (FP) or indirect pulp therapy (IPT)
Key Points: (2 lines Max): “IPT, therefore, appears to be better alternative to pulpotomy procedures to treat caries close to the pulp”
 
2 groups of patients with a total of 226 teeth were treated with either caries control 1-3 months prior to IPT or FP, and then restored with either IRM or with SSC, amalgam, GIC, or composite.
-          Breakdown:
o   Group 1: 133 teeth
§  78 à FP
§  55 à IPT
o   Group 2: 93 teeth
§  40à FP
§  53à IPT
o   Caries control: 75 of 226 teeth (1-3 months prior to IPT or FP)
§  ART, no local anesthetic, spoon or low-speed IRM or GIC placed.
§  Done in cases with reversible pulpitis symptoms
o   FP (118) restored with SSC, amalgam, GIC, or composite
§  EXCEPT 13 in Group 1 restored with IRM
o   IPT (108) - 80% GIC liner/base used to cover dentin
§  All restored with SSC, amalgam, GIC, or composite
-          Teeth selected for IPT and FP were identical upon radiographic presentation, with deep caries approaching the pulp
o   For FP complete caries removal resulted in mechanical pulp exposure
o   For IPT deepest layer of decayed dentin left in place to avoid pulp exposure

RESULTS
 
Success over time
 
0-1 year
1-2 years
2-3 years
>3 years
FP success
95%
84%
76%
70%
IPT success
98%
96%
94%
94%
 
Effect on exfoliation
-          IPT (101) and FP(74) assessed for exfoliation
o   2% of IPT and 36% of FP were categorized as early exfoliation
o   These exfoliations were significantly different
 
Caries lesion control
-          GIC CC restorations (50 teeth) had 92% success rate
-          No GIC CC restorations (176 teeth) had 79% success rate
-          Broken down regarding IRM (15 teeth)
o   Had 67% success rate
 
Tooth type (1st vs 2nd primary molars)
-          Combined 1st molars (IPT+FP) à 76% success rate
-          Combined 2nd molars (IPT+FP) à 92% success rate
-          Further broken down:
o   1st molars IPT à 92%
o   1st molar FP à 61%
o   2nd molar IPT à 98%
o   2nd molar FP à 83%
 
Pain consistent with reversible pulpitis
-          1st molars 39 (of 131) had treated for reversible pulpitis
o   20 IPT à 85% success
o   19 FP à 53% success
-          2nd molars 30 (of 95) with history of pain
o   14 IPT à 93% success
o   16 FP à 75% success
 
Type of restoration final
-          198 IPT/FP restored with SSC immediately à 83% success
-          15 IPT/FP restored with amalgam, composite, GI à 87% success
-          13 (FP only) restored with IRM only à 39%
 
Take aways:
-          “IPT, therefore, appears to be better alternative to pulpotomy procedures to treat caries close to the pulp”
-          GIC CC prior to further treatment either with FP or IPT
o   “drying out” of leathery dentin
o   Allows for more accurate case selection (irreversible pulpitis not diagnosed initially can become diagnosed subsequently)
-          2nd primary molars had greater successful treatments than 1st primary molars
o   Controversial
o   Holan et al 2002 in agreement though
-          Poor seal compromises treatment
o   IRM placed in emergency FP’s with low success rate in this study
o   Those restored with conventional restorations were occlusal only (allowing good seal)
-          IPT treated teeth had much greater percentage with normal exfoliation
o   Concurs with other research
o   Possibly due to chronic infection not clinically or radiographically evident in FP-treated teeth
 
Remarks:
 
 
Assessment of Article:  Level of Evidence/Comments:
 

Tuesday, April 25, 2017

Formocresol Mutagenicity following primary tooth pulp therapy: an in vivo study

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Nicholas Paquin                                                                           Date: 04/26/17

Article Title: Formocresol Mutagenicity following primary tooth pulp therapy: an in vivo study
Author(s): P.A. Zarzar, Rosenblatt, Takashashi, Takeuchi, Costa Junior
Journal:  Journal of Dentistry
Date:  April 2003
Major Topic: Formocresol
Type of Article: Case-Control study
Main Purpose: Determine the mutagenicity of formocresol
Key Points/Summary:  This study was designed to look at the mutagenicity of full strength Buckley’s formocresol on in vivo lymphocytes cultures obtained from the peripheral blood of children, ages 5-10, who had one pulpotomy completed in the clinics of Recife City Council and the University of Pernambuco School of Dentistry, Brazil

Methods:  A blood sample from 20 children was collected prior to the pulpotomy (control group) and 24 after treatment was completed with Buckley’s full strength formocresol.  The peripheral lymphocytes were grown in a complete culture medium and assessed for chromosomal aberrations via a previously published method that was modified.  The cytogenetic analysis was performed in a blind test.

Results:  There was no statistically significant difference between the groups using Wilcoxon’s Signed Ranks test for chromosomal aberrations and for the total chromosomal breaks.  However the solution was mutagenic for one patient, raising concern for use as a pulp treatment.

Conclusion: Results revealed that, from a statistical standpoint, formocresol is not mutagenic.  However, further investigations are required, preferably with a larger sample, in patients needing more than one pulpotomy to determine if an increase in the quantity of the drug would increase the quantity of the chromosomes aberrations. 

Thursday, April 20, 2017

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: Jonathan Kaczmarski   Date: 04/20/2017
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 a compare the efficacy of MTA, FC, FS and CH as primary molar pulpotomy medicaments.
Key Points: (2 lines Max): Main conclusion or the most interesting


Aim:
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: Zone of necrosis à zone of fixation à inflammatory infiltration à normal pulp /
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 àhemorrhage control à prevention of blood clot formation and chronic inflammation
(In animal histological studies have shown FS and FC produce similar pulpal responses).
CH is more technique sensitive than FC, and extensive IR may follow. The IR may be related to the residual (clot prior to CH application, previous chronic inflammation of radicular pulp or the inability of CH to provide a long-term seal resulting in bacterial microleakage and pulp 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. Direct MAs found 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 radiographicdata showed MTA was significantly more successful than FS. Indirect MAs found no statistically significant difference in clinical successes, but a statistically significant difference in the radiographic successes of MTA and FS.

9 RCTs and 7 CTs (total 531 molars) were identified to compare MTA and CH. Indirect MAs found statistically significant differences in the clinical and radiographic successes of 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.

Remarks:
1-     Results due to the better seal in MTA?
2-
Assessment of Article:  Level of Evidence/Comments:

Partial Pulpotomy in Young Permanent Teeth with Deep Carious Lesions

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Michael Hatton                                                                   Date: 4.20.17
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.







Wednesday, April 19, 2017

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

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Albert Yamoah, DDS                        Mentor: Dr. Sapir                                              Date: 04/019/2017
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): Orhan, A. I., Oz, F. T. and Orhan K.
Journal: Pediatric Dentistry
Date: Jul/Aug 2010
Major Topic: Pulp Therapy
Type of Article: Comparative Study
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: There was no significant difference between 1 and 2-visit IPT. Carious removal with IPT resulted in fewer pulp exposures compared to direct complete excavation. 
o   Background: 
It is often
 hard to distinguish the infected vs. the affected dentin clinically during caries removal. Certain providers 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. 
o   Purpose: 
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.
o   Methods: 
§  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. 
o   Results: 
§  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. 
Remarks:

1.      
Assessment of Article:  Level III