Pulpotomy

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1		Andreea Igna	+ 1096 word(s)	1096	2021-09-28 07:56:43

This entry is adapted from the peer-reviewed paper 10.3390/children8100841

Pulpotomy has long been the most indicated vital pulp procedure in primary molars with extensive caries. The success of a pulpotomy is highly technique sensitive and it depends upon many factors, such as diagnosis accuracy, caries excavation method, pulp dressing material, quality of the final restoration and operator experience.

primary teeth pulpotomy challenges

1. Introduction

Dental caries is a major health problem still exhibiting a very high prevalence in 2021 in children all around the globe. Due to various reasons (lack of proper dental education, lack of access to dental care, “silent symptomatology”, etc.), treatment is often initiated when the progression degree has reached a deep, cavitary stage, often with pulp involvement. The main objective of pulp therapy in primary dentition is promoting the health of the teeth and their supporting tissues to maintain the proper functions of the oro-facial complex (mastication, speech, aesthetics) and ultimately to retain the teeth in their position to preserve arch length ^[1]^[2]^[3]. In paediatric dentistry, pulpotomy is a conservative clinical procedure commonly performed in primary molars with extensive caries, which implies removal of the coronal pulp and preservation of the radicular pulp. The rationale is based on the healing ability of the remaining pulp tissue following surgical amputation of the affected or infected coronal pulp ^[4]. After having achieved haemostasis, the exposed pulp stumps are covered either with a pulp-capping agent that promotes healing or with an agent to fix the underlying tissue ^[5].

Diagnosis Challenges in Primary Teeth

For primary molars affected by deep carious lesions, pulpotomy has been the most commonly indicated vital pulp therapy ^[6], considering that microorganisms or their toxins may have reached the pulp ^[7]. The caries removal method can decisively influence the treatment choice: while the use of a high-speed handpiece or laser might result in exposure of a “normal” pulp that would otherwise not be exposed ^[8], the stepwise caries removal method (two-visit caries excavation) results in fewer pulp exposures ^[9]. According to the American Academy of Pediatric Dentistry, direct pulp capping is indicated in a primary tooth only when conditions for a favourable response are optimal. Therefore, where bacterial contamination of an otherwise asymptomatic primary tooth is suspected, pulpotomy is considered the procedure of choice. The main indications of pulpotomy are: teeth with extensive caries, no spontaneous pain and no evidence of radicular pathology ^[1]. However, correlation between symptoms and pulpal status is frequently a challenging task for the paediatric dentist. Care should be taken not to misinterpret a throbbing pain, simulating an irreversible pulp condition, with that associated with an inflamed dental papilla owing to food impaction ^[10]. A glass ionomer interim temporary restoration placed for 1–3 months prior to vital pulp therapy (VPT) was found to improve accuracy of diagnosing the pulp’s clinical status and subsequent VPT success ^[11].

2. Factors That Influence the Success of a Pulpotomy

Beside the biological effect of the material used as a pulpotomy agent, the success of the procedure depends on other factors related to diagnosis, technique, final restoration and the operator’s experience. Caries topography and extension can play a role in the treatment decision-making. Primary teeth with proximal carious lesions extending more than 50% through the dentine thickness appear to have more extensive inflammatory pulpal changes than teeth with occlusal caries of a similar depth. An intra-operatory differential diagnosis may be necessary. Furthermore, if caries extends beyond the cemento-enamel junction, it is better to avoid pulpotomy altogether. Obtaining a complete seal of the vital pulp from the oral environment is an essential requirement for a pulpotomy. Complete caries removal should precede opening of the pulp chamber; bacterial contamination of the pulp during caries removal or bacterial infiltration at the tooth-restoration interface can compromise the success of the procedure. Adequate rubber dam isolation is important, especially during pulpotomy in mandibular primary molars, as well as obtaining a good coronal seal of the final restoration. Either intra-coronal restoration or a stainless-steel crown (SSC) may be adequate to achieve a good marginal seal for single-surface (occlusal) restoration on a primary tooth with a life-span of two years or less, whereas for multi-surface restorations (i.e., occlusal-proximal), SSCs are the treatment of choice. The restoration influences the pulp therapy’s long-term results the most. Unfortunately, dentists’ choice of restorative materials in a paediatric dental setting are greatly impacted by patient cooperation.

In most cases, younger children tend to be less cooperative than older ones. More invasive procedures typically result in worse behaviour outcomes and generally cooperation declines through the course of the appointment ^[12]^[13]^[14]^[15]. Thus, temporization of the final restoration is often necessary. Frequently used temporary restorative materials are zinc-oxide-eugenol cement (IRM), glass-ionomer cement (GIC), resin-modified-glass-ionomer cement (RMGIC) or compomers. Biodentine™ could be used both as a dentine substitute and a temporary restoration for up to 6 months. ^[16]. However, immediate final restoration is desirable whenever possible. The most effective long-term restoration for pulpotomised primary teeth has been shown to be a stainless-steel crown (SSC) due to its good sealing and full coverage ^[1]. Higher success rates using a SSC were reported when compared with IRM, RMGI or composite restorations. Full coverage of primary teeth that underwent VPT seems to be the most important factor for further survival of the teeth, especially in young children, when the tooth is expected to be preserved for more than 2 years in the mouth ^[12]^[17]^[18]. The clinician’s experience in the field seems to also be a determining factor for the success rate of primary teeth treated using pulpotomy. A retrospective cohort study carried out at the Department of Pediatric Dentistry of Taipei Chang Gung Memorial Hospital disclosed that when the pulpotomy for primary molars was performed by less-experienced resident doctors, a reduced overall success rate was registered ^[19].

3. Conclusions

In conclusion, the success of a pulpotomy procedure is highly technique sensitive and it depends upon many factors. To start with, an accurate diagnosis at the time of treatment, although frequently a challenging task in primary teeth, is yet an essential requirement. The type and quality of the restoration also influences the success rate of a pulpotomy, as well as the clinician’s experience. The knowledge acquired in the last 100 years allowed scientists to have a better understanding of the biological processes behind the interactions of living tissues with dental materials; important steps have been made in finding materials that are more biocompatible, less toxic and with far less side effects. Minimally invasive treatments have also become more popular and backed by science as alternatives. Although significant progress was registered, the most recent systematic reviews and meta-analyses emphasize the need for further high-quality research in this area, based on uniform standards, to clarify the controversies that still surround this subject.

References

American Academy of Pediatric Dentistry. Pulp Therapy for Primary and Immature Permanent Teeth. The Reference Manual of Pediatric Dentistry; American Academy of Pediatric Dentistry: Chicago, IL, USA, 2020; pp. 384–392.
Fuks, A.B.; Eidelman, E. Pulp Therapy in the Primary Dentition. Curr. Opin. Dent. 1991, 1, 556–563.
Fuks, A.B. Current Concepts in Vital Primary Pulp Therapy. Eur. J. Paediatr. Dent. 2002, 3, 115–120.
Fuks, A.B.; Kupietzky, A.; Guelmann, M. Pulp Therapy for the Primary Dentition. In Pediatric Dentistry—Infancy through Adolescence, 10th ed.; Nowak, A.J., Christensen, J.R., Mabry, T.R., Townsend, J.A., Wells, M.H., Eds.; Elsevier Saunders: St Louis, MO, USA, 2019; Chapter 23; p. 1049. ISBN 978-0-323-60826-8.
Waterhouse, P.J.; Whitworth, J.M.; Camp, J.H.; Fuks, A.B. Pediatric Endodontics: Endodontic Treatment for the Primary and Young Permanent Dentition. In Pathways of the Pulp, 10th ed.; Cohen, S., Hargreaves, K.M., Eds.; Mosby Elsevier: St Louis, MO, USA, 2011; Chapter 23; pp. 822–831. ISBN 978-0-323-06489-7.
Chaollai, A.N.; Monteiro, J.; Duggal, M.S. The Teaching of Management of the Pulp in Primary Molars in Europe: A Preliminary Investigation in Ireland and the UK. Eur. Arch. Paediatr. Dent. 2009, 10, 98–103.
Yildiz, E.; Tosun, G. Evaluation of Formocresol, Calcium Hydroxide, Ferric Sulfate, and MTA Primary Molar Pulpotomies. Eur. J. Dent. 2014, 8, 234.
Fuks, A.B. Vital Pulp Therapy with New Materials for Primary Teeth: New Directions and Treatment Perspectives. Pediatr. Dent. 2008, 30, 211–219.
Coll, J.A. Indirect Pulp Capping and Primary Teeth: Is the Primary Tooth Pulpotomy out of Date? Pediatr. Dent. 2008, 30, 230–236.
Rodd, H.D.; Waterhouse, P.J.; Fuks, A.B.; Fayle, S.A.; Moffat, M.A. Pulp Therapy for Primary Molars. Int. J. Paediatr. Dent. 2006, 16, 15–23.
Coll, J.A.; Campbell, A.; Chalmers, N.I. Effects of Glass Ionomer Temporary Restorations on Pulpal Diagnosis and Treatment Outcomes in Primary Molars. Pediatr. Dent. 2013, 35, 416–421.
Tseveenjav, B.; Furuholm, J.; Mulic, A.; Valen, H.; Maisala, T.; Turunen, S.; Varsio, S.; Auero, M.; Tjäderhane, L. Survival of primary molars with pulpotomy interventions: Public oral health practice-based study in Helsinki. Acta Odontol. Scand. 2021, 31, 1–6.
Kassa, D.; Day, P.; High, A.; Duggal, M. Histological Comparison of Pulpal Inflammation in Primary Teeth with Occlusal or Proximal Caries. Int. J. Paediatr. Dent. 2009, 19, 26–33.
Dhar, V.; Marghalani, A.A.; Crystal, Y.O.; Kumar, A.; Ritwik, P.; Tulunoglu, O.; Graham, L. Use of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions. Pediatr. Dent. 2017, 39, 146E–159E.
Guagnano, R.; Romano, F.; Defabianis, P. Evaluation of Biodentine in Pulpotomies of Primary Teeth with Different Stages of Root Resorption Using a Novel Composite Outcome Score. Materials 2021, 14, 2179.
Koubi, G.; Colon, P.; Franquin, J.C.; Hartmann, A.; Richard, G.; Faure, M.O.; Lambert, G. Clinical Evaluation of the Performance and Safety of a New Dentine Substitute, Biodentine, in the Restoration of Posterior Teeth—A Prospective Study. Clin. Oral Investig. 2013, 17, 243–249.
Guelmann, M.; McIlwain, M.F.; Primosch, R.E. Radiographic Assessment of Primary Molar Pulpotomies Restored with Resin-Based Materials. Pediatr. Dent. 2005, 27, 24–27.
Guelmann, M.; Fair, J.; Bimstein, E. Permanent versus Temporary Restorations after Emergency Pulpotomies in Primary Molars. Pediatr. Dent. 2005, 27, 478–481.
Kuo, H.Y.; Lin, J.R.; Huang, W.H.; Chiang, M.L. Clinical Outcomes for Primary Molars Treated by Different Types of Pulpotomy: A Retrospective Cohort Study. J. Formos. Med. Assoc. 2018, 117, 24–33.

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Andreea Igna

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