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Giving the pulp another chance: a case report of vital pulp therapy retreatment
The following is a synopsis of the full article, which appears in the July/August issue of General Dentistry. Read the full article here.
In the July/August issue of General Dentistry, Machareonsap et al challenge the assumption that symptomatic teeth automatically require full endodontic therapy after the failure of vital pulp therapy (VPT). They offer an important reminder that the regenerative potential of the dental pulp should be harnessed whenever possible, allowing the pulp to maintain its formative, nutritive, protective, and reparative functions. Their clear, detailed description of a clinical case explains the coronal pulpotomy technique that resulted in successful resolution of a periapical lesion after a failed partial pulpotomy. In addition, the authors conduct an in-depth review of the literature to examine factors that influence the outcomes of VPT.
A second chance to survive
Vital pulp therapy has been increasingly advocated due to its high success rates in preserving tooth vitality.(1) However, inadequate removal of infected pulp tissue or reinfection can lead to posttreatment failure.(2) When initial VPT fails, it may still be possible to avoid root canal treatment if the tooth has vital pulp, especially in pediatric patients. Young patients have higher numbers of stem cells and greater pulpal blood supply that could improve healing ability.(3) The tooth may be given a second chance to survive through the removal of infection and inflammation, placement of a bioactive pulp dressing material, and establishment of an effective coronal seal.
The case report
Machareonsap et al detail the case of a healthy 10-year-old boy who sought treatment of his permanent mandibular right first molar because of pain in response to cold stimuli. The molar had a carious lesion with hypomineralized surfaces and was diagnosed with reversible pulpitis. The tooth was initially treated with partial pulpotomy, which included the use of tricalcium silicate cement as a pulp dressing, a resin-modified glass ionomer cement base, and a composite resin restoration. The patient did not present for the 6-month recall, but radiographs taken 19 months after partial pulpotomy revealed no detectable lesions. At 34 months, the restoration had dislodged without causing symptoms, and a stainless steel crown was placed on the tooth.
Approximately 15 months later (49 months after partial pulpotomy), the patient returned with symptoms in the treated tooth. The tooth was diagnosed with irreversible pulpitis and asymptomatic apical periodontitis but responded positively to cold testing, and the pulp appeared clinically vital on direct inspection. The tooth was re-treated with coronal pulpotomy, including the use of mineral trioxide aggregate as a dressing material, and examination 21 months posttreatment revealed successful resolution of the periapical lesion.
A viable treatment option
Although the tooth in this case had complete root formation when the partial pulpotomy failed, coronal pulpotomy was offered as an alternative to root canal treatment. The long-term treatment success of endodontically treated teeth in patients aged 8 to 16 years is reported to be 36%.(4) In contrast, a recent systematic review and meta-analysis found high success rates after pulpotomy (partial or coronal) in teeth with symptomatic (84%) and asymptomatic (91%) irreversible pulpitis.(5) Histologic analyses have shown that infection and inflammation in teeth diagnosed with irreversible pulpitis can be confined to a portion of the pulp and may not extend to the root portion.(6) Therefore, once infection and inflammation are adequately addressed, VPT can be considered a viable treatment option for teeth with irreversible pulpitis and periapical lesions, provided that the remaining pulp appears healthy and bioactive materials such as calcium silicate–based cement are used.(7)
An essential factor affecting VPT outcome is the quality of the coronal seal, and the events described in this case report highlight the importance of periodic evaluation after treatment. Although VPT was initially successful, the treatment failed due to a defective coronal seal that was identified only after a long period with no follow-up. While restoration with composite resin over a resin-modified glass ionomer cement is recommended for teeth affected by hypomineralization, the resulting bond strength is significantly lower than that to normal enamel.(8) In this case, the loading force on the poorly bonded area, which was a functional cusp, may have contributed to restoration failure. After the restoration was dislodged, the exposed tricalcium silicate cement could not provide an effective coronal seal against bacterial invasion, as its mechanical properties and bond strength to intraradicular dentin are significantly decreased in acidic environments.(9)
In summary
As this case highlights, failure of conservative VPT may not be an absolute indication for root canal treatment when the tooth still has vital pulp, especially in pediatric patients with high potential for pulpal healing. Preservation of the pulp may be feasible if the tooth is given a second chance to survive via renewed removal of infection and inflammation, placement of a bioactive pulp dressing material on the remaining healthy pulp, and establishment of an effective coronal seal to foster successful healing. The treated tooth must be examined regularly to ensure tooth survival and early detection of problems that may adversely affect treatment outcomes.
Read the full article here.
References
Li Y, Sui B, Dahl C, et al. Pulpotomy for carious pulp exposures in permanent teeth: a systematic review and meta-analysis. J Dent. 2019;84:1-8. doi:10.1016/j.jdent.2019.03.010
Dammaschke T, Galler K, Krastl G. Current recommendations for vital pulp treatment. Scientific communication. Dtsch Zahnärztl Z Int. 2019;1(1):43-52. doi:10.3238/dzz-int.2019.0043-0052
Fuks A, Peretz B, eds. Pediatric Endodontics. Current Concepts in Pulp Therapy for Primary and Young Permanent Teeth. Springer International Publishing; 2016.
Peretz B, Yakir O, Fuks AB. Follow up after root canal treatment of young permanent molars. J Clin Pediatr Dent. 1997;21(3):237-240.
Ather A, Patel B, Gelfond JAL, Ruparel NB. Outcome of pulpotomy in permanent teeth with irreversible pulpitis: a systematic review and meta-analysis. Sci Rep. 2022;12(1):19664. doi:10.1038/s41598-022-20918-w
Ricucci D, Loghin S, Siqueira JF Jr. Correlation between clinical and histologic pulp diagnoses. J Endod. 2014;40(12):1932-1939. doi:10.1016/j.joen.2014.08.010
Asgary S, Parhizkar A. The role of vital pulp therapy in the management of periapical lesions. Letter. Eur Endod J. 2021;6(1):130-131. doi:10.14744/eej.2020.04706
William V, Burrow MF, Palamara JE, Messer LB. Microshear bond strength of resin composite to teeth affected by molar hypomineralization using 2 adhesive systems. Pediatr Dent. 2006;28(3):233-241.
Elnaghy AM. Influence of acidic environment on properties of Biodentine and white mineral trioxide aggregate: a comparative study. J Endod. 2014;40(7):953-957. doi:10.1016/j.joen.2013.11.007
