Conservative Management of Mature Permanent Teeth with Carious Pulp Exposure

Abstract

Vital pulp therapy (VPT) in mature permanent teeth with carious pulp exposure has been a matter of debate, with root canal therapy being the conventional standard of care. Previously reported negative outcomes for VPT in these teeth were based on data from studies that have used calcium hydroxide in direct pulp capping and partial and full pulpotomy. The introduction of hydraulic calcium silicate-based materials with sealing and bioactive potentials have opened a new era in VPT with more favorable results. Understanding the histopathology and histobacteriology of the cariously exposed pulp and the healing potential of the inflamed pulp could guide the decision-making process toward an ultraconservative management of these teeth. However, proper case selection, strict aseptic condition, capping material, and good coronal seal are crucial for long-term success. (J Endod 2020;46:S33-S41.) KEY WORDSCaries; mature teeth; pulp biology; pulpitis; vital pulp therapy Epidemiologic studies consistently show a high global prevalence of dental caries, particularly in adults 1 . A prerequisite for any intervention intended to preserve the pulp is the presence of either healthy pulp tissue or pulpal damage that can be reversed. Inflammation of the pulp accompanies the carious process well before carious pulp exposure; however, the severity of the inflammation increases as the caries progresses toward the pulp. Nonetheless, even in the presence of carious pulp exposure, inflammation is typically limited to within 2 mm of the exposure site unless the carious exposure is of long standing, and it is not uncommon to find healthy pulpal architecture in the opposing pulp horn or further away in the pulp chamber 2,3 .Historically, the use of vital pulp therapy (VPT) for mature permanent teeth with carious pulp exposure has been discouraged, with the majority recommending pulpectomy and root canal therapy 4 . The consensus that the pulp should be regarded as irreversibly inflamed whenever a carious exposure occurs in mature permanent teeth has been based on clinical outcomes of direct pulp capping with calcium hydroxide (CH). The biological rationale for this conclusion is that underlying pulpal inflammation has spread throughout the pulp and that the blood supply through a mature apex is insufficient to promote healing even after the insult is removed.Significant improvement has occurred in the understanding of pulp biology and the response of the pulp to the carious process; the release of dentin-bound growth factors and active molecules such as stem cell factor, insulin-like growth factor binding protein, nerve growth factor, glial cell line-derived neutrophilic factor, and transforming growth factor beta 1 has highlighted the fact that the pulp in mature teeth has greater regenerative potential than what was previously thought 5,6 . Placement of bioactive materials, specifically tricalcium silicate-based materials (mineral trioxide aggregate [MTA], Biodentine, Bioceramics) has been shown to induce the release of these growth factor...

Association between concentration of active MMP‐9 in pulpal blood and pulpotomy outcome in permanent mature teeth with irreversible pulpitis – a preliminary study

“…Although the degree of bleeding has low specificity to predict the VPT outcome, excessive bleeding even after removal of superficial pulp tissue at the exposure site indicates that a more radical amputation is warranted in order to reach uniflamed pulp tissue (Taha et al . 2020). Control of haemorrhage for radicular pulps is paramount for the successful outcome of the pulpotomy procedure.…”

Partial Pulpotomy to Successfully Treat a Caries-Induced Pulpal Micro-Abscess: A Case Report

“…Unfortunately, spontaneous pain is also subjective and difficult to evaluate quantitatively, highlighting the problem in selective caries removal for managing deep caries lesions. Taha et al (20) reported that "current pulp testing is not reliable to the extent that determining pulpal status has been described as 'at best an educated guess, ' and an urgent need exists for more definitive tests." A pulp examination method that includes an analysis of pulpal inflammatory biomarkers to assess the level of pulpitis intra-operatively is expected to develop.…”

Evaluation of Success of Pulpotomy in Mature Permanent Teeth with Carious exposure using Mineral Trioxide

“…Dental caries shows high worldwide prevalence particularly in adults, according to epidemological studies. 1 Before exposure of pulp, carious process goes hand in hand with inflammation of the pulp. Inflammation severity escalates as the carious lesion advances towards the dental pulp.…”

“…Inflammation severity escalates as the carious lesion advances towards the dental pulp. 1 If left untreated caries headway to extensive lesions, persuading inflammatory reactions in dental pulp. This leads to pulp necrosis, abscess formation and eventual loss of tooth 2 .…”

“…This leads to pulp necrosis, abscess formation and eventual loss of tooth 2 . Nevertheless, dental pulp has an inbred ability to heal if the challenge is uprooted and the tooth is aptly restored 1,2,3 .…”