From Volume 51, Issue 7, July 2024 | Pages 468-473
This article discusses vital pulp therapy in the adult dentition and describes two cases where a different strategy for caries removal has been used followed by dressing with a contemporary material and tooth restoration on the same visit. A simplified guide for best practice is given.
Vital pulp therapy is an important procedure that requires clinical skill and can be undertaken in general practice.
Preserving the vitality of the dental pulp is a key factor for long-term tooth survival. Vital pulp therapy (VPT) is designed to preserve and maintain the vitality of the pulp tissue in a tooth that has been compromised by trauma, caries, or restorative procedures. The objective is to protect and encourage healing of the areas of the pulp that are reversibly inflamed, while stimulating the formation of tertiary dentine to retain the tooth as a functional unit. The procedures of VPT range from conservative treatments including indirect and direct pulp capping, to more invasive treatments including partial pulpotomy and full pulpotomy.1,2
The decision when to perform vital pulp treatment is dependent upon the histology of the pulp in response to insult. Historically, it has been reported that the histological condition of the pulp could not be determined from clinical symptoms.3 However more recent evidence4 indicates that specific symptoms reflect histological findings with good concordance (Table 1). It is worth noting though that pulpitis is not uniform across the entire pulp and histology will show areas of reversible pulpitis and areas of irreversible pulpitis. Therefore, the decision to categorize a pulp as reversibly or irreversibly inflamed does not determine the actual potential for the inflamed tissue to repair.5
| Reversible pulpitis | Irreversible pulpitis |
|---|---|
| Pain sensation upon symptoms | Spontaneous, radiating pain |
| Symptoms resolve upon removal of stimulus | Pain persists after removal of stimulus |
| Loss of sleep |
When managing carious teeth in the permanent dentition, the removal of caries is necessary, and to date, there seems to be no consensus on the extent of caries removal prior to proceeding with vital pulp therapy. The most conservative approach is the selective caries removal strategy where caries is removed to dentine that is hard on probing in the periphery of the lesion, while leaving dentine that appears soft and cuttable by excavators towards the pulp. A definitive restoration is then placed immediately.6 Non-selective (complete) caries removal is considered to represent overtreatment. Regardless of this, the American Association of Endodontists7 suggest the removal of all caries followed by assessment of the pulp status. The different strategies for vital pulp therapy depend on the extent of loss of the dental hard tissue and the involvement of the dental pulp. Vital pulp therapy can be divided as follows.
This treatment option is referred to by the European Society of Endodontology position statement6 as ‘application of a biomaterial onto a thin layer of dentine barrier in a one-stage carious-tissue removal technique’. This procedure has been used successfully with selective caries removal where follow up for over 2 years has shown high success rates using either polyalkenoate cements or hydraulic calcium silicate cements.8,9
The indication for direct pulp capping is limited to immediately following trauma or to a small carious exposure that has no symptoms of irreversible pulpitis. The exposure of the pulp is sterilized and then covered with dental biomaterial, such as Biodentine (Septodont, Saint Maur-des-Fosses, France), followed by a definitive restoration.
This procedure is indicated where there are symptoms of reversible pulpitis (or irreversible) with a positive reaction to sensibility testing. The procedure involves the removal of the area of the coronal pulp that is irreversibly inflamed (2 mm into pulp or to the orifice), disinfection and then covering the area of reversible inflammation with a hydraulic calcium silicate cement, such as mineral trioxide aggregate or Biodentine (Septodont). Historically, vital pulp treatment has been performed using formocresol or zinc oxide eugenol cement with limited success in permanent teeth. Higher success rates have been achieved using setting calcium hydroxide cement; however, more recently, the efficacy of setting calcium hydroxide cement as a liner has been questioned.10 Despite success rates >90% with hydraulic calcium silicate cements,11 application in general practice is low.
This article focuses on two clinical cases of indirect pulp capping in permanent molars, giving a step-by-step guide for indirect pulp capping that may assist a general dental practitioner in daily practice in understanding the procedure.
Two cases are presented. Case 1 shows the management of a carious tooth following the European Society of Endodontology guidelines6 with selective caries removal. Case 2 follows the American Association of Endodontists guidance7 for caries management with full caries removal and assessment of pulp status. For both cases, a modified hydraulic calcium silicate cement was used for management of the vital pulp and the tooth was restored on the same day with composite resin.
A 45-year-old male presented with intermittent, sharp pain associated with temperature changes, especially cold, but no spontaneous pain in the left maxillary region. The onset of the pain was 1 week prior to the dental visit. The tooth had been restored a few years previously at another practice.
There was no medical history of note and the patient had been a regular attendee for 6 monthly oral prophylaxis.
The clinical examination showed a fractured occluso-distal restoration along with a deep carious lesion occlusally on UL6 (Figure 1). The patient had a low caries risk because he restricted sugar in his diet and regularly followed oral hygiene practices.
After discussing the various treatment options, the patient consented to a single visit indirect pulp capping procedure. The patient was advised that a direct pulp capping would be necessary in case of pulpal exposure during the treatment. Informed consent was obtained from the patient after explaining the procedure and potential risks.
Local anaesthesia was administered by buccal infiltration with lidocaine, and rubber dam isolation was used to maintain aseptic conditions. The existing dental restoration on UL6 was carefully removed, exposing the carious dentine (Figure 1). Carious dentine was selectively excavated using hand instruments, spoon excavator and a slow cutting speed tungsten carbide bur ensuring that a thin layer of affected dentine remained to avoid pulp exposure (Figure 1). An interoperatory radiograph was taken during the treatment after removal of caries to verify the depth of the lesion and its proximity to the dental pulp (Figure 1). Biodentine (Septodont) was mixed according to the manufacturer's instructions and applied to the prepared dentine surface to a thickness of approximately 3 mm (Figure 1). After waiting for 15 minutes to ensure Biodentine (Septodont) setting, the enamel was selectively etched using phosphoric acid (FineEtch 37% phosphoric acid gel, Spident, Korea) avoiding the Biodentine layer (Figure 1). After rinsing the etchant, the tooth surface was prepared to receive a composite restoration by application of a bonding agent (Adper Single Bond/Adper Single Bond Plus, 3M ESPE Oral Care, St Paul, MN, USA). A definitive restoration using a composite resin (Filtek Z350 XT enamel shade A2, 3M) was placed to restore the tooth's form and function (Figure 1). A post-operative radiograph was taken to assess the restoration (Figure 1). The patient was instructed to avoid exposing the treated tooth to extreme temperature changes for a few days. Routine oral hygiene instructions to maintain good dental hygiene were reinforced. The patient was reviewed 1 month later. The patient reported that the tooth was asymptomatic. Clinically there were no signs of endodontic disease associated with UL6, and it responded positively to vitality testing. No radiograph was taken at the 1 month recall visit because the patient was asymptomatic.
A 14-year-old boy presented with intermittent sharp pain associated with temperature changes, particularly cold, but no spontaneous pain on left maxillary region. He was a new patient, but had no medical history of note.
The clinical examination showed a dental amalgam restoration and composite restoration on the occlusal surface on the mesial and distal aspects of UL6 (Figure 2). The patient was at high risk for caries. His dental history indicated that all previous restorations were placed to manage interproximal carious lesions. Furthermore, he had a reported consumption of sugary drinks in the form of soda and artificial fruit juices.
After discussing the various treatment options, the patient consented to a singlevisit indirect pulp capping procedure. He was advised that there would be direct pulp capping in the case of pulpal exposure during the treatment. Informed consent was obtained from the patient's parents after explaining the procedure and potential risks.
Local anaesthesia was administered by buccal infiltration of lidocaine, and rubber dam isolation was used to maintain aseptic conditions. The existing dental restorations on UL6 were carefully removed, exposing the carious dentine on both mesial occlusal and distal aspects of the tooth. Carious dentine was excavated fully using hand instruments, spoon excavator and slow cutting round burs to avoid pulp exposure (Figure 2). The Palodent V3 sectional matrix system (Dentsply, Milford, DE, USA) was used to secure the matrix band (Figure 2). Biodentine (Septodont) was mixed according to the manufacturer's instructions and applied to the prepared dentine surface to a thickness of approximately 3 mm (Figure 2). After waiting for 15 minutes to ensure Biodentine setting, the tooth was selectively etched at the margins and the amelo-dentinal junction using phosphoric acid (Spindent) (Figure 2). After rinsing the etchant, the tooth surface was prepared to receive a composite resin by application of bonding agent (3M ESPE Adper single bond). A final restoration with composite resin (3M Filtek Z350 XT enamel shade A2) material was placed to restore the tooth's form and function (Figure 2). A post-operative peri-apical radiograph taken to ensure restoration quality (Figure 2). The patient was instructed to avoid exposing the treated tooth to extreme temperature changes for a few days. Routine oral hygiene instructions were reinforced to maintain good dental hygiene. The patient was reviewed 1 month later. The patient reported that the tooth was asymptomatic. Clinically there were no signs of endodontic disease associated with UL6, and it responded positively to vitality testing. No further radiograph was taken during recall because the patient was asymptomatic.
The purpose of this article is to describe evidence-based vital pulp therapy. The dental pulp has a high capacity for repair, but is poor at regeneration. It is also vital in maintaining immunity and proprioception of teeth, therefore preservation of dental pulp is crucial: this enhances the long-term prognosis of the tooth.
Definitive diagnosis of pulp status plays an essential role in achieving a higher treatment success rate. Histological assessment provides a clearer understanding of the state of the pulp tissue, but is not achievable in clinical scenarios. Clinical diagnosis, therefore, relies on sensitivity testing. The combination of methods gives the best outcomes,12 with pulse oximeters and doppler flowmetry being promising additions in this area.13 However, as these are currently unavailable in normal practice, electric pulp testers are preferable.14
The cases presented in this article show two different approaches to caries removal. Both techniques have been supported by the American Association of Endodontists (AAE) and the European Society of Endodontology (ESE).6,7 For both techniques, the endpoint of caries removal is based on tactile sensation. This is extremely subjective, meaning complete removal of caries may not be possible. However, additional tools can assist in the inspection of caries, in conjunction with radiographic and visual inspection. Caries detector dye and laser fluorescence have been shown to be effective when used together with conventional methods.15 Where these are unavailable, conventional methods must be relied upon, as in Case 1 where a radiograph was used to ensure adequate caries removal.
During treatment, appropriate isolation with the use of rubber dam should always be followed because it decreases the risk of contamination and allows easy handling of materials. A questionnaire sent out in the UK indicated that rubber dam was used by only 37.1% of practitioners.16 An increased uptake of the use of rubber dam would allow improved working conditions and better outcomes for pulp capping.
Choosing suitable dental materials for treatment is another important aspect. A survey of practitioners in the UK revealed that 66.3% of general dental practitioners and dental care professionals use setting calcium hydroxide cement, while only 19.8% use hydraulic calcium silicate.17 A comparison of Biodentine (Septodont), mineral trioxide aggregate and setting calcium hydroxide cement demonstrated superiority of these hydraulic calcium silicate cements over setting calcium hydroxide cements.18 There has, therefore, been a significant shift in the choice of material for treatment, with both AAE and ESE now recommending hydraulic calcium silicate cements for the management of vital pulp.6,7 It should be noted that it is preferable to use materials that do not include bismuth oxide because it leads to discolouration the tooth, particularly with the use of mineral trioxide aggregate.19–21
Biodentine offers several advantages over traditional materials for direct and indirect pulp capping.22 Biodentine exhibits minimal pulpal irritation, allowing the dental pulp to heal and form reparative dentine over time. Its excellent sealing properties also reduce the risk of bacterial infiltration into the pulp chamber, thereby reducing the risk of bacterial infiltration and further pulpal damage.23 When used for indirect pulp capping, Biodentine shows a high success rate in maintaining pulp vitality and preventing further pulpal degeneration, enhancing the overall prognosis of the tooth.
Material interactions also affect the individual properties of the materials used. Hence the type of restoration must also be considered when planning the treatment. When using Biodentine, care should be taken to carry out a selective rather that total etch technique because this will affect the surface microstructure of Biodentine24 resulting in a weak bond strength.25 Considering the weak properties of Biodentine in the early setting phase, it may be beneficial to delay placement of overlying composite resin for 2 weeks to allow adequate setting of Biodentine to sufficiently withstand the contraction forces of the composite resin.26 Biodentine can be used as a temporary restorative material for several months, after which it can be cut back, and a permanent restoration placed.
Enhanced knowledge and improved materials have resulted in the possibility of maintaining more vital pulps, even when compromised. The main limiting factor is the verification of the pulp status and the tooth restoration. It is important for clinicians to be educated about the most current clinical protocols and updates to materials to enable them to carry out these treatments more regularly. Further studies and investment in the area could lead to it becoming more cost effective and widely available to every general dental practitioner, making preservation of vital pulp more effective.
Knowledge of the difficulty with diagnosis of pulp status and the improvements in materials available for clinical use helps with managing teeth that require vital pulp therapy in the permanent dentition. These cases are presented to help guide other clinicians in the steps to be undertaken in managing a vital pulp.
