Clinical evidence indicates that cold testing with carbon dioxide ice is a more reliable prognosticator of pulp status in immature permanent teeth than electronic testing devices. Nair P.N., Duncan H.F., Pitt Ford T.R., et. Repair mechanisms in the dental pulp are similar to those observed in normal connective tissue injured by trauma. In young immature teeth with undeveloped roots and nonvital pulp, the conventional treatment (apexification) can take up to 18 months. The ultimate endodontics goal could be defined, however, as the prevention and/or elimination of apical periodontitis. J Endod 2007; 33: pp. 22. This study shows that indirect pulp therapy performed in primary and permanent teeth of young patients may result in a high 3-year survival rate. 10. This new generation of CSCs appears promising when used as vital pulp therapeutic agents and current investigations appear to support these materials’ future potential. The vital pulp therapy procedure consists of removing a small amount of the nerve (generally 5-7 mm) with a sterile headpiece. Remove soft leathery caries affected tooth structure until dentin consistency changes or pulp exposure is imminent. Direct pulp capping is defined as the placement of a medicament on a pulp that has been exposed in the course of excavating the last portions of deep dental caries. Treatment is performed in the appropriate fashion with strict adherence to the proper technique. Ketterl W.: Age-induced changes in the teeth and their attachment apparatus. Limited to moderate restorative treatment 2. Vital pulp therapy (VPT) encompasses distinct treatment modalities for deep caries that approximate the pulp chamber in vital teeth. Revascularization and vital pulp therapy are suggested as procedures for successful treatment of immature molars diagnosed with pulp necrosis and irreversible pulpitis, respectively. 756-763. No correlations were found between healing and size of pulp exposure, type of trauma, time frame, and root development. Recent investigations also support the use of MTA and other CSCs for application in pulpotomy procedures in permanent teeth. Therefore, MTA or equivalent products should be the material of choice for direct pulp capping procedures instead of hard-setting calcium hydroxide cements. 3. The second study observed 1,075 teeth directly pulp capped with a CH-based agent; these teeth had either healthy pulps or showed signs of reversible pulpitis. Genes Dev 1995; 9: pp. Once a tooth is affected by caries, some form of intervention is necessary to prevent further inflammation and ultimately necrosis. J Endod 2011; 37: pp. Definitive permanent composite restorations were placed 2 weeks later, after confirmation of pulp vitality. 3. The underlying purpose in vital pulp therapy is to avoid or delay root canal therapy and advanced restorative care because these, together, may reduce long-term tooth survival compared to teeth with vital pulps. 643-649. Vital pulps can be successfully treated if the clinician has an improved understanding of diagnosis and case selection, hemostasis, caries removal, magnification systems, bioactive capping materials, bonded composites, and other restorative materials. Partial pulpotomy (shallow pulpotomy, or Cvek pulpotomy) is defined as the removal of a small portion of the vital coronal pulp as a means of preserving the remaining coronal and radicular pulp tissues. al. : Tissue engineering strategies for immature teeth with apical periodontitis. This can induce subsequent pulpal degeneration, further leading to potential dystrophic calcification and pulpal necrosis. : Effect of 2-hydroxyethyl methacrylate on human pulp cell survival pathways ERK and AKT. ‡ Retrospective investigations have shown varying success rates of 30% to 85% for direct pulp capping in humans, depending on the method, hemostatic agent, and dressing material used. J Endod 2008; 34: pp. Int Endod J 2005; 38: pp. 356-366. Indirect pulp capping has been defined as a procedure in which a small amount of carious dentin is retained in deep areas of cavity preparation to avoid an exposure of the pulp. al. Pulp proper: the central mass of the pulp, which consists of larger blood vessels and nerves. The paste is condensed into the radicular pulp chamber after careful pulp extirpation, cleaning of the canal, and irrigation with saline. K S D Ravi Kalyan, C Vinay, Arunbhupathi, K S Uloopi, R Chandrasekhar, and K S RojaRamya (2019) Preclinical Evaluation and Clinical Trial of Chlorhexidine Polymer Scaffold for Vital Pulp Therapy.Journal of Clinical Pediatric Dentistry: 2019, Vol. Heyeraas K.J., Berggreen E.: Interstitial fluid pressure in normal and inflamed pulp. J Endod 2012; 38: pp. More impressive results for pulp maintenance and continued vitality after direct pulp capping procedures have been demonstrated in several other contemporary studies. Moreover, pulpotomies completed with MTA in primary molar teeth do not show pathologic complications such as internal resorption, which typically are seen with CH, formocresol, and ferric sulfate. MTA most likely up-regulates fibroblast secretion of BMP-2 and TGF- β 1 and therefore stimulates and promotes mineralization and hard tissue regeneration. Odontoblasts synthesize mainly type 1 collagen, type V collagen, proteoglycans, dentin sialoprotein, and alkaline phosphatase. If the pulp is injured, wound healing and the repair process can advance only after the initiation of the inflammatory reaction. Treatment is performed in the appropriate fashion with strict adherence to the proper technique. At the molecular level, HEMA and TEGDMA have shown to cause cell death/apoptosis in the pulp cells by a decrease in important transcription factors, such as nuclear factor κB (NF-κB) and increase in c-Jun N-terminal kinases (JNK). Prior to performing vital pulp therapy, it is paramount to obtain a pretreatment pulpal and periradicular diagnosis. HEMA-induced apoptosis has been linked to the decrease in intracellular glutathione levels and the production of reactive oxygen species in the cells. Science 1995; 270: pp. Sodium hypochlorite serves as an excellent diagnostic tool to differentiate irreversible from reversible pulpitis and to help determine whether to proceed with partial pulpotomy, complete pulpotomy, or pulpectomy. Vital Pulp Therapy Using MTA: A Case Series November 1, 2014 by Anu Bhalla, DMD, FRCD(c); Yosef Nahmias, DDS, MSc. Vital pulp therapy is effective as long as proper assessment of the situation is made. Pulpectomy and root canal therapy represent the optimal treatment for carious or mechanically exposed pulps in mature teeth. Inflammation is a tightly regulated process and its main function is to eliminate pathogens and remove damaged tissue with the aim of restoring tissue homeostasis. MTA was clinically easier to use as a direct pulp capping agent and resulted in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal. Dental Clinics of North America, 2013-01-01, Volume 57, Issue 1, Pages 59-73, Copyright © 2013 Elsevier Inc. Mineral trioxide aggregate was introduced as a pulp capping material by Torabinejad and associates in the mid-1990s. Recent clinical investigations have demonstrated that a diagnosis of symptomatic irreversible pulpitis and acute apical periodontitis may not proscribe pulp capping and pulpotomy procedures when MTA or other CSCs that have been shown to reverse the inflammatory process are used. The crystals produced during the calcification process are associated with phosphate and calcium ions, similar to fundamental calcification processes shown by other normal and pathologic calcified tissues. Pressoreceptors and proprioreceptors protect the dentin-pulp complex against excessive occlusal loading while circulating immune competent cells confront bacterial challenges. In a retrospective study, Gruythuysen and colleagues examined clinically and radiographically the 3-year survival of teeth treated with indirect pulp therapy performed between 2000 and 2004. Sodium hypochlorite also shows excellent efficacy as a hemostatic agent at lower dilutions (0.5%). Access the tooth using a high-speed bur. Cvek and colleagues investigated the depth of inflammatory reactions of adult monkey pulps exposed by fracture or cavity prep at different time intervals and found that inflammation extended 1.5 mm to 2 mm into the pulp at the 48-hour mark and only 0.8 mm to 2.2 mm after 1 week. No history of spontaneous, lingering, or severe pain It is subadjacent to the odontoblastic layer and is traversed by capillaries, unmyelinated nerve fibers, and cytoplasmic processes of fibroblasts. Root fractures commonly occur in the cervical third, and have been shown to have a rate of about 28-77% depending on the stage of root development. Immature dendritic cells and T cells contribute to immunosurveillance during the progression of caries. Hunag T.H., Lii C.K., Kao C.T. al. Gomes A.C., Filho J.E., de Oliveira S.H. Pulpotomy is a form of pulp therapy which involves the removal of coronal pulp tissue that is inflamed as a result of deep caries. JNK belongs to the family of mitogen-activated protein kinases that comprise of a group of serine/threonine kinases, which are responsible for phosphorylation and mediation of signal transduction from extracellular stimuli. al. : Root canal sealers cause cytotoxicity and oxidative damage in hepatocytes. al. Cvek M.: A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. The procedure is also known as Cvek pulpotomy. Radiographic monitoring is VITAL. 40. Quintessence Int 2010; 41: pp. It is likely that recommendations going forward will require sealing the orifices as the main objective. 1. 2. Endod Dent Traumatol 1989; 5: pp. The introduction of new bioactive materials, along with modified protocols, make more teeth with deep … 68. J Endod 2011; 37: pp. The activity of NF-κB is tightly regulated by cytokines and other external regulators. Permanent dentition Normal radiographic findings 1. 83. For example, when a decay or trauma has extensively damaged the tooth structure, vital pulp therapy is not advisable. Contraindications al. In this instance, the coronal and radicular pulps should be removed all the way to the apex of the tooth. Appropriate case selection, through a detailed differential diagnosis using multiple tests paired with a careful radiographic interpretation, is paramount for establishing the best treatment for the problem tooth. : Resin monomer 2-hydroxyethyl methacrylate (HEMA) is a potent inducer of apoptotic cell death in human and mouse cells. Summary Pulp sizes are underestimated on radiographs. 63. 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