Abstract
This case describes a novel indirect pulp capping approach to managing gross caries in a healthy tooth.
References
Randow K, Glantz PO. On cantilever loading of vital and non vital teeth. An experimental clinical study. Acta Odontol Scand. 1986; 44:271-277
Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J. 2006; 39:921-930
Hilton TJ. Keys to clinical success with pulp capping: a review of the literature. Oper Dent. 2009; 34:615-625
Shovelton DS. A study of deep carious dentine. Int Dent J. 1968; 18:392-405
Mertz-Fairhurst EJ, Curtis JW, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc. 1998; 129:55-66
Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev. 2006; 19
Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with Mineral Trioxide Aggregate: a randomized controlled trial. Int Endod J. 2008; 41:128-150
Watson TF, Atmeh AR, Sajini S, Cook RJ, Festy F. Present and future of glass ionomers and calcium silicate cements as bioactive materials in dentistry: Biophotonics-based interfacial analyses in health and disease. Dent Mater. 2014; 30:50-61
Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, Kosierkiewicz A, Kaczamarek W, Buczkowska-Radlinska J. Response of human dental pulp capped with biodentine and mineral trioxide aggregate. J Endod. 2013; 39:743-747
Koubi G, Colon P, Franquin JC, Hartmann A, Gilles R, Faure MO, Lambert G. Clinical evaluation of the performance and safety of a new dentine substitute, Biodentine, in the restoration of posterior teeth – a prospective study. Clin Oral Invest. 2013; 17:243-249
Patel S. The use of cone beam computed tomography in the conservative management of dens invaginatus: a case report. Int Endod J. 2010; 43:707-713
Patel S, Brady E, Wilson R, Brown J, Mannocci F. The detection of vertical root fractures in root filled teeth with periapical radiographs and CBCT scans. Int Endod J. 2013; 46:1140-1152
Hashem D, Mannocci M, Patel S, Manoharan A, Brown JE, Watson TF, Banerjee A. Clinical and radiographic assessment of the efficacy of calcium silicate indirect pulp capping: a randomized clinical trial. J Dent Res. 2015; 94:562-568
Abella F, Patel S, Duran-Sindreu F, Mercade M, Bueno R, Roig M. Evaluating the periapical status of teeth with irreversible pulpitis by using cone beam computed tomography scanning and periapical radiographs. J Endod. 2012; 38:1588-1591
Kanagasingam S, Mannocci F, Lim CX, Yong CP, Patel S. Diagnostic accuracy of cone beam computed tomography scans and periapical radiography in detecting apical periodontitis using histological findings as a gold standard. Int Endod J.
Patel S, Wilson R, Dawood A, Foschi F, Mannocci F. The detection of periapical pathosis using digital periapical radiography and cone beam computed tomography – Part 2: a 1-year post-treatment follow-up. Int Endod J. 2012; 45:711-723
Bender IB, Seltzer S. Roentgenographic and direct observation of experimental lesions in bone II. J Endod. 1961; 11:707-712
Ikram OH, Patel S, Sauro S, Mannocci F. Micro-computed tomography of tooth tissue volume changes following endodontic procedures and post space preparation. Int Endod J. 2009; 42:1071-1076
Grigoratos D, Knowles J, Ng YL, Gulabivala K. Effect of exposing dentine to sodium hypochlorite and calcium hydroxide on its flexural strength and elastic modulus. Int Endod J. 2001; 34:113-119
Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod. 2004; 30:846-850
Case report: single visit indirect pulp cap using biodentine
From Volume 44, Issue 2, February 2017 | Pages 141-145
Article
The function of a vital dentine-pulp complex includes dentinogenesis throughout life and in response to injury. The pulp also contains circulating immune cells designed to confront bacterial challenges, and proprioceptive mechanisms to protect against excessive occlusal loading.1
Indirect pulp capping is indicated on a tooth with a carious lesion in close proximity to the pulp either being asymptomatic or showing signs and/or symptoms of reversible pulpitis. The tooth may be restored permanently, or re-entered 6 months later (stepwise excavation).2 Indirect pulp capping has been shown to have a better prognosis than direct pulp capping.3
There is good evidence to show that, at the advancing front of a carious lesion, considerable demineralization of dentine occurs prior to bacterial invasion.4 A clinical study by Mertz-Fairhurst et al demonstrated that partial caries removal and sealing with composite resulted in the arrest of carious lesions without any signs or symptoms of pulpitis after 10 years.5 Partial caries removal is the preferred treatment as long as the restoration may be well sealed on a caries-free enamel-dentine junction.6 From the available literature it seems that a single visit procedure is preferred not only for patient convenience, but also because it has a comparable outcome to complete caries excavation.3,5,6
Until recently, calcium hydroxide has been the gold standard pulp capping material for vital pulp therapy.3 However, it is subject to degradation over time and does not adhere well to dentine, and also has tunnel defects forming within the hard tissue barrier.7 These properties could allow microleakage and failure of the vital pulp therapy. The introduction of bioactive calcium silicate materials such as mineral trioxide aggregate (MTA, Angelus Soluções Odontológicas, Londrina, Brazil) and Biodentine (Septodont, Saint Maur des Fosses, France) offer advantages over calcium hydroxide. Biodentine has been shown to induce mineralization within the dentine8 and is able to induce hard tissue barrier formation.9 It is also suitable as a long-term provisional direct posterior restoration.10
This case report details the use of Biodentine as an indirect pulp capping material with partial caries removal performed in a single visit.
Case report
A fit and healthy 24-year-old male presented for a routine dental check-up complaining of a ‘chipped’ lower left molar tooth. He had no other symptoms. The patient had a Class 3 skeletal base and edge-to-edge incisal relationship. This resulted in no anterior guidance, and the LL8 being in occlusion with the opposing UL7.
Clinical examination revealed a cavitated carious lesion associated with the LL8 (Figures 1a, b). There were no signs of endodontic or periodontal disease associated with the lower left molar teeth. All the lower left molar teeth responded positively to thermal (EndoFrost Roeko, Coltène Whaledent, West Sussex, UK) and electric (Vitality scanner, SybronEndo, Peterborough, UK) pulp testing.
A periapical radiograph revealed extensive distal and occlusal caries in very close proximity to the root canal system of the LL8 (Figure 2a). A diagnosis of gross caries was made for LL8. After discussing the various treatment options, the patient consented to a single visit indirect pulp capping procedure. A Cone Beam CT (CBCT) scan confirmed that there were no signs of periapical pathology associated with the LL8 (Figure 2b, c).
The tooth was anaesthetized, and rubber dam applied. The dento-enamel junction was cleared of all caries, leaving stained affected dentine over the axial wall of the pulp chamber.
A 3 mm layer of Biodentine was applied over the affected layer of dentine, followed by glass ionomer cement (Fuji IX, GC Corporation, Tokyo, Japan). The tooth was then permanently restored with a direct composite resin restoration Filtek Supreme XTE (3M ESPE, St Paul, USA) (Figure 3a–d).
The patient was reviewed one year later. The patient reported that the tooth was asymptomatic. Clinically and radiographically there were no signs of endodontic disease associated with LL8, and it responded positively to vitality testing (Figure 4a, b).
Discussion
To the authors' knowledge, this is the first case report of a single visit Biodentine indirect pulp cap. This is a promising technique with many advantages. Performing the treatment in a single session by sealing the affected dentine is less traumatic to the pulp, and is also more efficient for both the patient and practitioner. A two-stage indirect pulp cap requires re-accessing the tooth, multiple appointments and potentially further mechanical trauma to the pulp.
The use of CBCT has been shown to be effective in the diagnosis and management of endodontic problems.11,12 CBCT has a higher sensitivity for detection of early periapical change13 and periapical lesion detection than radiographs.13,14 This is because periapical lesions are not visible on radiographs unless they perforate the junction between the cancellous bone and cortical plate, ie the cortical plate acts as anatomical noise masking the changes in the underlying cancellous bone.15
In this case a pre-operative CBCT scan was taken to confirm that there was no periapical radiolucency associated with the LL8. A recent prospective clinical trial study identified that the presence of a pre-operative lesion which was only detectable on the CBCT scan, and not the periapical radiograph, had a negative effect on the outcome of indirect pulp capping.15,16
Maintaining pulp vitality helps to improve the long-term prognosis of a tooth. It is well established that endodontic treatment mechanically and bio-chemically weakens tooth structure. It has been shown, using micro CT, that access cavity preparation and caries removal can remove up to 20% volume of tooth structure.17,18 Sodium hypochlorite has been shown to reduce elasticity and flexural strength of dentine.19 Following root canal treatment, a cuspal coverage restoration is required for posterior teeth in order to reduce the likelihood of a fracture due to the loss of proprioception and weakening of the tooth structure.1,20 Ultimately, the strength of a tooth is proportional to the bulk of remaining dentine21 and performing an indirect pulp cap in this case has preserved tooth structure and maintained vitality of the pulp and longevity of the tooth.