Cell-rich zone: lies subadjacent to the cell-poor zone. Results: Treatment selection is dependent on the extent of remaining healthy pulp tissue, and includes direct pulp capping and partial or complete pulpotomy. One of the main causes of inflammation of the pulp is dental caries. 2013 Mar;17(2):431-9. doi: 10.1007/s00784-012-0712-6. A stainless steel crown is the restoration of choice after performing a primary molar pulpotomy. Conversely, if the pulp is vital, there should be few or no bacteria present in the root pulp space and thus the disease (apical periodontitis) should not be present. If you continue browsing the site, you agree to the use of cookies on this website. 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. It is subadjacent to the odontoblastic layer and is traversed by capillaries, unmyelinated nerve fibers, and cytoplasmic processes of fibroblasts. CEM cement; Calcium-enriched mixture; endodontics; periapical periodontitis; pulp capping; pulpitis; pulpotomy; randomized controlled trial. Studies have previously shown that HEMA induces apoptosis in different cell types and also in dental pulp stem cells and in odontoblast-like cells. Indirect pulp capping is achieved by applying a protective agent on the thin layer of dentin remaining over a nearly exposed pulp, in order to allow the underlying dental pulp … Friedlander LT, Coates D, Seymour G, Cullinan M, Rich AM. There are two common types of vital pulp therapy: Indirect pulp cap and direct pulp cap: Sometimes the decay on a child’s tooth is close to or just touching the pulp. Other studies have shown that MTA induced cells to secrete IL-8 and IL-1β. The survival rate was 96% for primary molars (mean survival time, 146 weeks) and 93% for permanent teeth (mean survival time, 178 weeks). It is subadjacent to the predentin and is composed of cell bodies of the odontoblasts, capillaries, nerve fibers, and dendritic cells. The crown is then restored with a stainless steel crown, a composite strip crown, or a preveneered, commercially available composite-faced stainless steel crown. Although the use of these materials is aesthetically appealing in patients, they carry the risk of local and systemic adverse effects. Therefore, preservation and treatment of the vital pulp are critical for the prevention of apical periodontitis. 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. Studies have reported this material to have similar cytotoxicity levels as MTA De-Deus and colleagues found that BA was as biocompatible as MTA and another study reported that BA up-regulated the gene expression of collagen 1, osteocalcin, and osteopontin in osteoblasts and differentiation of human periodontal ligament fibroblasts compared with MTA. Strassler HE(1), Levin R. Author information: (1)Department of Restorative Dentistry, University of Maryland Dental School, USA. The cellular components of this layer include mainly macrophages and lymphocytes. With the development of more biocompatible materials with high sealing properties, these teeth might have a better outcome with direct pulp therapy. Teeth were extracted and then histologically evaluated at 1 week and 2, 3, 4, and 6 months. It will also demonstrate how capping materials affect the pulp inflammation and regeneration and the overall outcome of vital pulp therapy. IL-1β has been shown to induce the synthesis of collagen, resulting in a more organized response of the pulp and assisting in the healing process. Cell poor zone: also called the cell free zone of Weil because it is relatively free of cells. In a different randomized clinical study, Nair and colleagues investigated the pulpal response to direct pulp capping in healthy human teeth with MTA versus calcium hydroxide cement (Dycal) as control. There are two types of pulp therapy: Vital pulp therapy is when only the decayed pulp is removed and the healthy pulp tissue is preserved inside the Disclosing the physiology of pulp tissue for vital pulp therapy. 2020 Mar-Apr;23(2):121-125. doi: 10.4103/JCD.JCD_179_19. J Clin Med. Aluminum Compounds/therapeutic use; Calcium Compounds/therapeutic use Although not specifically discussed, effective local anesthesia and rubber dam usage are always required. When caries has extended into the pulp, vital pulp therapy may be a good treatment option, as long as the tissue is not overly inflamed. Dentin-pulp complex regeneration therapy for non-vital teeth after pulpectomy or pulp necrosis. In this case, after removing the tooth decay, a therapeutic and biocompatible material that prevents infection and heals the pulp is placed over the affected area and then the tooth is restored with a normal filling material. The odontoblasts have odontoblastic processes that extend into the dentinal tubules and occupy most of the space of the dentinal tubules. Vital pulp therapy--a review J Ir Dent Assoc. Aust Endod J. VPT is a wide term including indirect pulp capping, direct pulp capping, pulp debridement, pulpotomy, and apexogenesis. On the molecular level, MTA has been shown to induce the secretion of angiogenic factors, such as vascular endothelial growth factor, which plays an important role in healing. 4. Certain treatments are also used in deciduous teeth, please see 'Endodontic role in Paediatrics' lesson in the Paediatrics topic for more information. J Int Soc Prev Community Dent. Vital pulp therapy is exactly what it sounds like – treating the pulp in an effort to keep it vital (alive) and leave the patient with a living, pain-free tooth. Cohenca N(1), Paranjpe A, Berg J. They are known as indirect pulp capping and direct pulp capping, and both are used in their own significant circumstances. The mature pulp demonstrates 4 morphologic zones, including. As with a primary anterior tooth, when there is disease beyond the confines of the tooth related to the tooth, consideration for extraction must be given. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. After baseline pain adjustment, pain relief was continuous with similar patterns in all treatment groups. The groups were homogenous in terms of age, sex, marital status, education, and practitioner; pre- and intraoperative conditions were similar in all arms and did not affect the long-term success. The radicular orifices are assessed to determine that bleeding can be controlled only by direct pressure with a damp cotton piece for a minute or 2. The ultimate endodontics goal could be defined, however, as the prevention and/or elimination of apical periodontitis. hstrassler@umaryland.edu PMID: 23189909 [Indexed for MEDLINE] Publication Types: Case Reports; MeSH terms. Epub 2012 Feb 6. cohenca@u.washington.edu Vital pulp therapy is performed to preserve the health status of … Mechanically or traumatically exposed primary and young permanent teeth, No history of spontaneous or irreversible inflamed pulp, Radiographic evidence of pulpal or periradicular pathosis, Exposures with purulent or serous exudates. Pulp tissue can be affected as the result of deep caries lesions and accidental trauma or by preparation techniques used during the restoration of teeth affected by carious lesions (Mattos et al. Deep carious lesion; Enamel-dentine fracture with no pulpal exposure Cases of permanent tooth mean long-term preservation of the tooth in a healthy state in the mouth. This is accomplished by sealing the wound against bacterial infiltration, which would otherwise doom the treatment to failure. da Rosa WLO(1), Piva E(1), da Silva AF(1). Disinfect the cavity using 2.5% sodium hypochlorite for at least 1 minute. Vital pulp therapy encompasses apexogenesis, pulpotomy, pulpal debridement, and direct and indirect pulp capping. The best sealing agents seem to be MTA or glass ionomer. Another study, by Matsuzaka and colleagues, demonstrated that expression of core binding factor alpha-1 subunit and dentin sialoprotein was higher in the younger pulp whereas the adult pulp demonstrated higher levels of vascular endothelial growth factor and heat shock protein 27. The odontoblasts are particularly important because they are responsible for dentinogenesis both during tooth development and in the mature tooth. The opponents of calcium hydroxide for direct pulp capping procedures cite 3 major causes of failure: The porosity of the dentinal bridge that is produced, Calcium hydroxide adhering poorly to dentin, Inability to provide a long-term seal against microleakage. Place calcium hydroxide or glass ionomer directly over the carious region. USA.gov. Other studies had given a lower prognosis to indirect pulp therapy, however, especially in permanent teeth. HEMA-induced apoptosis has been linked to the decrease in intracellular glutathione levels and the production of reactive oxygen species in the cells. Author information: (1)Department of Restorative Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil. It is a highly specialized layer for the synthesis and secretion of the organic components of the dentin and has an epithelial layer that serves as a liner for the dental pulp. Vital pulp therapy (VPT) is performed in cases of trauma, caries, and restorative procedures to preserve the vital pulp tissue. Vital pulp therapy is performed to preserve the health status of the tooth and its ultimate position in the arch. Apexification is defined as a method of inducing a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in teeth with necrotic pulp. The entire coronal pulp is removed circumferentially with a large round bur, pulling coronally to adequately deroof the pulp chamber and to avoid leaving any ledges or pulp tissue therein. Clean canal walls with moistened sterile cotton pellet. 4 Due to advances in science and technology, vital pulp treatment has changed over the last five years in regard to the procedures and materials used. NIH 2013 Jan;23(1):56-63. doi: 10.1111/j.1365-263X.2012.01224.x. When decay or tooth preparation extends into the coronal pulp, and the pulp is deemed vital (as described previously), a pulpotomy may be performed. TYPES OF VITAL PULP THERAPY • Indirect Pulp Capping • Direct Pulp Capping • Pulpotomy • Apexification 4. Place calcium hydroxide, MTAs, or BA directly over the exposure site; do not force it into the pulp. In terms of bacterial penetration, Kakoli and colleagues showed that bacterial infection of the dentinal tubules occurs to a lesser extent in older patients than in younger patients. COVID-19 is an emerging, rapidly evolving situation. The most important factors in success of VPT are the early diagnosis of pulp and periradicular status, preservation of the pulp vitality and p … At the cellular level, MTA has also been shown to induce the recruitment and proliferation of undifferentiated cells to form a dentinal bridge, while reducing inflammation compared with calcium hydroxide. HHS 2020 Jun 15;10(3):300-308. doi: 10.4103/jispcd.JISPCD_69_19. During your child’s pulp therapy procedure, our dentist will first visually examine the affected area then take dental X-rays. 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. Published by Elsevier Inc. All rights reserved. It is recommended that practitioners gather additional information in each of the referenced areas before engaging in pulp therapy for children. One-year results of vital pulp therapy in permanent molars with irreversible pulpitis: an ongoing multicenter, randomized, non-inferiority clinical trial. The structure of the dental pulp is similar to the other connective tissues in the body. Pre- and intraoperative data including vitality test results, pulpal/periapical status, and exposure type/location were recorded. Embryologically, histologically, and functionally, the dentin and the pulp are the same and are considered together, which is why they are also referred to as the pulp-dentin complex. In cases of a primary tooth, the length of time for expected life is measured against the expected life of the tooth in the mouth without pulp disease or pulp therapy. 2. Vital pulp therapy for children is simple. Please enable it to take advantage of the complete set of features! If there are signs of early external root resorption, radiolucency beyond the confines of the pulp chamber related to the tooth or other signs of disease, or inadequate tooth structure to support a restoration, the tooth may need to be extracted. Carious or traumatically exposed primary and permanent teeth, Vital pulp, which responds to sensitivity tests, Limited to moderate restorative treatment. Methods: Calcium hydroxide has been considered the gold standard for pulp capping; however, previous research has shown that it is not ideally suited for this procedure. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Temporomandibular Joint Disorders in Children, Overview of Trauma Management for Primary and Young Permanent Teeth, Providing Dental Treatment for Children in a Hospital Setting. If the caries does progress to the pulp, it leads to inflammation, which is caused by several proinflammatory cytokines, such as interleukin (IL)-1β and tumor necrosis factor α, and chemokines, which cause cell death, increased vascular permeability, and an increase in inflammatory cells into the area along with production of acute phase proteins. Recently a new material has been introduced, BioAggregate (BA) (Innovative BioCeramix, Vancouver, British Columbia, Canada). Vital pulp therapy is effective as long as proper assessment of the situation is made. Aged dental pulps have various characteristics, which include the following: At the molecular level, one study has shown a decreased expression of connexin 43 and osteocalcin in the aged human pulp, which in turn relates to the decreased viability of the odontoblasts and the pulp cells. This provides the pulp a low-compliance environment and receives its blood supply from the blood vessels that traverse through the apical foramen. There is evidence to show that odontoblasts play an active role in innate immunity. Maintaining deciduous teeth in function until their natural exfoliation is absolutely necessary. This should be done before the procedure via radiographic assessment or by direct examination of pulp and its color, texture, and bleeding during the procedure. Canals should be cleaned carefully but not significantly instrumented (primary roots are narrow and curved and there is a risk of perforation or extension beyond the apex). The radicular pulp chamber may be filled with a resorbable paste of either zinc oxide–eugenol or, preferably, calcium hydroxide with iodoform within the paste. Author information: (1)Department of Endodontics, School of Dentistry, University of Washington, Seattle, WA 98195-7448, USA. Other studies have demonstrated that HEMA causes increased phophorylation of extracellular-signal-regulated kinases (ERK 1 and 2) and decreased phosphorylation of phosphokinase B (p-AKT). Once a tooth is affected by caries, some form of intervention is necessary to prevent further inflammation and ultimately necrosis. These procedures are performed routinely in primary and permanent teeth. After placement of a layer of resin-modified glass ionomer as liner over carious dentin, the teeth were restored. eCollection 2020 May-Jun. Furthermore, GDNF may act as a cell survival factor and mitogen during tooth injury and repair. This review is divided into 2 parts: the first aims to illustrate the basic biology of the pulp and the effects on the pulp due to various procedures; the second focuses on the clinical aspects of treatment and the use of various dental materials during different vital pulp therapy procedures performed in the primary and permanent teeth. Vital pulp therapy can be used in immature and fully formed permanent teeth. From a clinical perspective, the control of the hemorrhage is critical to determine the level of pulp inflammation. Hence, the second part of this review deals with the clinical aspects of treatment of the primary and permanent dentition. Learn about the types of pulp therapy, risk factors & when treatment is needed. The tooth pulp is a unique organ and is encased in a protective layer of dentin, which is encased by a layer of the enamel. Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial. Some studies have reported that the pulp has some physiologic feedback mechanisms to counteract inflammation and increased tissue pressure, which in turn explains why inflammation of the pulp could be long standing and could heal if appropriate measures are taken in a timely manner. Clinically, vital pulp therapy can be divided into two main groups: indirect pulp capping and direct pulp capping/pulpotomy (Figure 1). Pulp therapy removes the decayed tissue to prevent the loss of the tooth or the spread of infection. 3. BA has also been shown have antifungal and antibacterial activity. BA is white nanoparticle ceramic cement with many different applications, like MTA. The potential risks are direct damage to the cells (cytotoxicity) and induction of immune-based hypersensitivity reactions. Vital pulp therapy can be used in immature and fully formed permanent teeth. There are two major forms of vital pulp therapy. Apply pressure with a moist sterile cotton pellet on the pulp stump to control hemorrhage. Thus, to be effective, calcium hydroxide needs to be in contact with noninflamed tissue located approximately 2 mm of pulp beneath exposure site. 1 Also known as pulp capping, this procedure is designed to keep the pulp alive, allowing it to heal itself. Vital pulp therapy with pulp capping. Another pulp capping material recently developed is mineral trioxide aggregate (MTA). Pulpotomy and pulp capping are indicated for teeth that have had a pulp exposure after trauma or injury, which may include the process of caries excavation in developing or mature teeth. Knowing the background about the dental pulp, the various cell types, and their interactions with each other and with various dental materials is important because this could ultimately lead to a better treatment modalities. 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). 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. However, pulpotomy and pulpectomy are the most popular procedures. Postendodontic Pain after Pulpotomy or Root Canal Treatment in Mature Teeth with Carious Pulp Exposure: A Multicenter Randomized Controlled Trial. Epub 2020 Nov 5. Int J Paediatr Dent. According to the American Association of Endodontists glossary, apexogenesis is defined as a vital pulp therapy procedure performed to encourage continued physiologic development and formation of the root end. eCollection 2020. Irreversibly injured odontoblasts are replaced by cells that migrate from this layer. The pulpal and periapical status as well as pulpal exposure type/location had no effect on treatment outcomes. Some of the more common restorative materials currently used are resin based. 2020 Apr 1;9(4):984. doi: 10.3390/jcm9040984. Therefore, after achieving hemostasis on the radicular pulp orifices, and after using a medicament (if desired), the orifices must be sealed with one of these agents. No history of spontaneous, lingering, or severe pain, No extensive restoration or full crown requirements, History of spontaneous pain or signs of irreversible pulpitis, Clinical or radiographic evidence of pulpal or periradicular pathosis, Tooth requires extensive restoration or full crown.  |  MTA, BA, or calcium hydroxide is laid over the pulp stump to a thickness of 2–3 mm. Wound Lavage in Studies on Vital Pulp Therapy of Permanent Teeth with Carious Exposures: A Qualitative Systematic Review. Thus, in clinical terms, a necrotic infected pulp is required for apical periodontitis to be present. Success of pulpotomy in mature permanent teeth with irreversible pulpitis: A systematic review. This material has drawn much interest due to its many applications. Vital pulp therapy has a high success rate if the following conditions are met: (1) the pulp is not inflamed, (2) hemorrhage is properly controlled, (3) a nontoxic capping material is applied, and (4) the capping material and restoration seal out bacteria. Vital pulp therapy (VPT) is a way of saving deciduous teeth. Both involve the process of pulp capping, which is a restorative process your dentist will partake in to prevent your dental pulp from dying after open exposure. Pulp proper: the central mass of the pulp, which consists of larger blood vessels and nerves. Vital pulp therapy is performed to preserve the health status of the tooth and its ultimate position in the arch for the expected life of the tooth. In cases of persistent bleeding, partial pulpotomy might be indicated. A good rule of thumb limits the diameter of the exposure site to less than 1.5 mm. A material that further seals, such as glass ionomer or resin-modified glass ionomer, should then be used to fill the coronal pulp chamber. The literature and standard of care is to use one of these agents (not discussed in this article because of the length limitations); however, there seems to be a directional change toward sealing the orifices completely as the primary objective. According to the American Association of Endodontists glossary, partial 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 to encourage continued physiologic development and formation of the root end. Random allocation was disregarded when visible pulp exposures did not happen after complete caries removal and the tooth was transferred to the IPC arm. 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.