WWW.DENTALLEARNING.NET DENTAL LEARNING A PEER REVIEWED PUBLICATION Knowledge for Clinical Practice
By Johnah C. Galicia, DMD, MS, PhD
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ABSTRACT EDUCATIONAL OBJECTIVES
With our increased understanding of pulpal biology and Upon completing this article, the participant should be the advances in material biocompatibility, the potential able to: to transform the fate of a compromised dental pulp 1. De ne the latest endodontic diagnostic from a condemned tissue to that of hope and recovery terminologies has never been more promising. In this article, several 2. Describe the ideal cases for vital pulp therapy aspects of vital pulp therapy (VPT) in permanent teeth 3. Compare the different vital pulp therapy materials, from diagnosis and indications to treatment outcomes methods, and outcomes will be discussed in detail. 4. Discuss several recommendations when performing vital pulp therapy.
ABOUT THE AUTHOR Johnah C. Galicia, DMD, MS, PhD Dr. Galicia is the Director of the Graduate Program and Dr. Galicia received the certi cate and master’s a tenure-track Assistant Professor with the Department of degree in endodontics from the University Endodontics, University of the Paci c Arthur A. Dugoni of North Carolina at Chapel Hill in 2014 School of Dentistry, where he also practices endodontics. as an American Association of Endodontists He is a member of the Research and Scienti c Affairs Foundation Educator Fellow. Prior to that, Dr. Galicia was a Committee of the American Association of Endodontists and Postdoctoral Fellow in oral microbiology and immunology the American Dental Association’s NBDE and ADAT test with the School of Dentistry, University of Pennsylvania and construction committee. the University of Louisville, KY. He received the PhD degree In addition to clinical and academic pursuits, research in oral biology from Niigata University, Japan, and a diploma also has been an integral part of Dr. Galicia’s career. He in clinical dentistry from the University of Rennes 1, France. has coauthored several peer-reviewed articles in reputable Before entering the PhD program, he was a general dentist international scienti c journals and has presented his work and a faculty member of his dental school alma mater, the in international forums. Dr. Galicia is a Diplomate of the Manila Central University in the Philippines. American Board of Endodontics.
SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. STATEMENTS: Dental Learning, LLC is an ADA CERP recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 2/1/2016 - 1/31/2020. Provider ID: # 346890. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: December 2019. EXPIRATION DATE: November 2022. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the eld related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Joe Riley, does not have a leadership or commercial interest in any products or services discussed in this educational activity. He can be reached at [email protected]. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satis ed with this course can request a full refund by contacting Dental Learning, LLC in writing or by calling 1-888-724-5230. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to [email protected]. Go Green, Go Online to www.dentallearning.net to take this course. © 2019
Copyright 2019 by Dental Learning, LLC. No part of this publication may be reproduced or transmitted in any form without prewritten President Creative Director permission from the publisher. ALDO EAGLE MICHAEL HUBERT CE Project Manager Art Director DENTAL LEARNING MARY BENEDON JOE CAPUTO 500 Craig Road, First Floor, Manalapan, NJ 07726 Vital Pulp Therapy in Permanent Teeth: Sound Option or Pulp Fiction?
Introduction Spread of Pulpal In ammation Trivia: In a published article from 1883, Dr. F.A. Hunter Even in early caries when demineralization is limited to pressed a mixture of sparrow droppings onto exposed dental enamel, histological changes such as leukocytic in ltration pulps and reported achieving success fully equal to 98%. and degeneration of odontoblasts have been observed in the dental pulp.4 These changes become widespread as caries aintaining pulpal health is essential for the spread apically into the dentin.5 The dental pulp, being an longevity of a tooth.1 It is, therefore, immunocompetent tissue, mounts an in ammatory response M important that caries be controlled promptly to the progressing microbial irritation. Its cellular elements and a well-sealing restoration be placed immediately. like odontoblasts and broblasts express Toll-like receptors However, when performing deep caries removal in vital on their surfaces, which can trigger the production of teeth, pulpal exposure can be a concern or an inevitability. cytokines and initiate histopathological alterations upon For a near or an overt pulpal exposure, a decision has to contact with microbial components.6-11 The resulting clinical be made whether vital pulp therapy (VPT) or pulpectomy manifestation of this host–pathogen interaction is commonly then root canal therapy (RCT) would be the more pain from in ammation; however, pulpitis can progress appropriate treatment option. For a tooth with without symptoms.12 asymptomatic irreversible pulpitis that is con rmed after The initial vascular response during the acute phase of caries exposure, root canal therapy is the recommended in ammation causes a rise in tissue pressure due to increasing treatment. The dilemma arises in asymptomatic teeth with blood and interstitial uid volume from vasodilation and normal pulp that becomes exposed after caries control. increased vascular permeability.13 With an unyielding dentin wall Should RCT be performed or is VPT acceptable? encasing the dental pulp, a modest increase in tissue pressure With our increased understanding of pulp biology and the may signi cantly impede blood circulation.14 In fact, some advances in material biocompatibility, an exposed dental pulp’s studies have shown that in ammatory mediators may cause fate of being a condemned tissue can be raised to that of hope a dramatic and persistent fall in blood ow in the pulp.15,16 and recovery. In spite of this, vital pulp-capping principles and These scenarios may have given rise to the self-strangulation techniques are still subject to continuous scrutiny. One concern theory that existed decades ago. However, in vivo studies on the about procedures performed in a vital tooth that has received pathophysiology of pulpal in ammation show that occlusion of a considerable amount of irritation is pulpal degeneration.2 veins at the apex due to a rapid transfer of high pressures from Another one is the possibility of pulpitis or periapical pathoses a site of pulpal in ammation, as suggested by the strangulation resulting from microbial and mechanical insults, which theory of pulpal necrosis, does not occur.17,18 can lead to severe pain and emergency room visits.3 These Tissue pressure is a local phenomenon that does not spread scenarios add a signi cant burden to the patient who could abruptly throughout the pulp tissue. If treatment is not rendered, have received RCT straightaway. a circumferential spread of necrosis and in ammation from Published studies on VPT case selection, procedures, the site of initial pulpal in ammation occurs incrementally and outcomes are numerous. In this review, pulpal until necrosis occurs.17 The fact that most dental pulps survive biology will be revisited and various aspects that a lifetime of irritation from normal functioning of the tooth in uence VPT success and failure will be discussed. In to various clinical procedures, together with their ability to addition, a series of cases will be presented to highlight revert back to health in several circumstances, support the case selection and techniques in VPT. debunking of the strangulation theory.
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Endodontic Diagnosis Conundrum in ammation.5,27 It is up to the clinician to diagnose whether The challenging aspect in endodontic diagnoses is the in ammation is reversible characterized by exaggerated, that it is based on the patient’s subjective interpretation nonlingering pain to cold test, or irreversible that presents with of nonstandardized endodontic clinical examination both exaggerated and lingering response to cold test. methods.19 The classical work by Seltzer et al.20 in the early To better guide clinicians, the American Association of 1960s and those by more recent authors revealed that the Endodontists (AAE) has a recommended list of pulpal and clinical diagnosis of reversible and irreversible pulpitis periapical diagnostic terminologies with the corresponding may not correlate with the gold standard of histological clinical description of each terminology (Table 1).28 examination.21-24 Furthermore, these decades-old diagnostic methods do not stage endodontic disease, and considerable Pulpal Diagnosis and VPT differences exist in the clinician’s interpretation of lingering Performing diagnostic testing to assess pulpal status pain or pain severity. is needed for treatment planning. However, only 30% of Diagnostic dilemmas have actual clinical repercussions general dentists (GDs), 17% of pediatric dentists (PDs), and and are often encountered in various clinical situations. 90% of endodontists (EDs) use diagnostic tests (e.g., cold The most common scenarios are when patients’ symptoms test) when evaluating pulpal health.29 The status of the pulp cannot be localized to a speci c tooth, when deciding to and periapical tissues can have an impact on the prognosis proceed or forgo RCT in continuously symptomatic teeth of the tooth and the perception of patients to dental care; with no lingering or spontaneous pain (i.e., tooth prepared therefore, determining the pulpal periapical status of all for a crown, recent trauma) or in a root canal-treated tooth teeth to be treated and restored is highly recommended. with a small, asymptomatic lesion for years, or when there The most reliable pulp-sensibility testing method is is no clear distinction if the symptoms are odontogenic cold test using a refrigerant spray.25 A response to a cold or nonodontogenic in nature. To this day, this diagnostic stimulus leads to the assumption that the pulp is vital, dilemma has remained to be a clear weakness of the which can be either normal or in amed. A normal or specialty that needs to be addressed. baseline response is determined by the clinician interpreting To come up with the most “accurate” diagnosis, a the patient’s interpretation of the cold test on a control thorough and meticulous pain history and clinical examination tooth rst and then comparing that to the test tooth’s are necessary. The patient’s description of pain such as: response. Sensibility to pulp thermal testing may indicate spontaneous, evoked, lingering, sharp, and others should be injury to the pulp where nociceptors have been sensitized noted, compared to a control tooth and replicated on the by in ammatory mediators, but it cannot be used to predict suspected tooth upon clinical or objective examination by the the extent and severity of pulpal damage. In addition, clinician. In addition, combining diagnostic tests such as cold thermal testing stimulates the nerves, which can persist even and electric pulp testing (EPT) increases both sensitivity and after the vasculature has disintegrated.30 It is, therefore, speci city of the results.25,26 The clinician is also expected to not uncommon for a dental pulp with no blood ow or an take time in educating the patient about the pulpal tests to be essentially necrotic pulp to respond to cold testing. performed and what to expect with the tests. Chances are, the Determining whether or not the response of the test tooth patients have little to no knowledge of what to feel and how is exaggerated or lingering, is left to the judgment of the to communicate the sensations triggered by the cold test or clinician. A slight difference in intensity or lingering time can EPT, for example. A tooth with deep caries is expected to have cause frustration and delay in treatment. Therefore, it is not
4 Vital Pulp Therapy in Permanent Teeth: Sound Option or Pulp Fiction?
TABLE 1. Pulpal Diagnostic Terminologies Formulated by the American Association of Endodontists28
Pulp Diagnostic Terminology De nition Clinical Findings and Descriptors Normal pulp A clinical diagnostic category in which the pulp is No clinical symptoms, transient pain to symptom-free and normally responsive to pulp testing cold test using refrigerant spray Reversible pulpitis A clinical diagnosis based on subjective and objective Transient and exaggerated thermal pain ndings indicating that the in ammation should resolve and the pulp return to normal Symptomatic irreversible pulpitis A clinical diagnosis based on subjective and objective Exaggerated and lingering thermal pain, ndings indicating that the vital in amed pulp is spontaneous pain, referred pain incapable of healing Asymptomatic irreversible A clinical diagnosis based on subjective and objective No clinical symptoms, but in ammation pulpitis ndings indicating that the vital in amed pulp is produced by caries, caries excavation, incapable of healing trauma Pulp necrosis A clinical diagnostic category indicating death of the No response to thermal testing and EPT dental pulp Previously treated A clinical diagnostic category indicating that the tooth No response to thermal testing and EPT has been endodontically treated and the canals are obturated with various lling materials other than intracanal medicaments Previously initiated therapy A clinical diagnostic category indicating that the tooth May or may not respond to cold or EPT. has been previously treated with partial endodontic Endodontic therapy needs to be continued therapy (e.g., pulpotomy, pulpectomy) and nished imperative to combine both the history of the present illness Caries Removal: How Far to Go? and the results of the sensibility tests to arrive at the most A paper in 2017 explored how U.S. dental schools teach probable pulpal diagnosis. The critical part of the diagnostic removal of carious tissues during cavity preparations.33 terminology is delineating reversible from irreversible pulpitis Among the 43 cariology faculty members from dental because the treatment for each of these diagnoses is different. schools across the U.S., hardness was the most common Irreversible pulpitis requires RCT, whereas reversible pulpitis criterion used to assess suf cient removal of carious dentin does not. Clinically, the differences between the two can be in both shallow (100% of respondents) and deep (90.5% stark or subtle. Descriptors such as lingering, spontaneous, of respondents) lesions. Moisture and color were the other or referred pain can be helpful, but these can be subject to criteria. When asked about treatment recommendation interpretation biases. for a vital, asymptomatic tooth with deep carious lesion, When VPT is being considered, the current guidelines by more than 57% would perform partial caries removal, both the AAE31 and the American Association of Pediatric then place a permanent restoration if there was a risk for Dentists (AAPD)32 limit VPT to de nitive treatment (i.e., pulpal exposure. The other 19.1% would attempt complete pulp capping) for teeth without symptoms of irreversible caries removal and leave carious dentin if there was a risk pulpitis (i.e., spontaneous pain) and without periapical for pulpal exposure; then reassess the tooth weeks or even pathosis. An exception is allowed in primary teeth where months later. Direct pulp cap (5%) and root canal treatment pulpotomy can be performed even in the presence of (1%) were also considered if there was a small pulpal pulpitis. Pulpal debridement is recommended in teeth with exposure upon total caries removal. clinical manifestation of irreversible pulpitis when RCT It appears that dental schools in the U.S. teach students cannot be completed in one appointment. to preserve tooth structure and avoid pulpal exposure.
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Clinicians, however, may have a similar or different approach diagnosis should not be symptomatic irreversible pulpitis. depending on their specialty. A nationwide web-based survey For teeth with irreversible pulpitis, pulpotomy can be of 175 GDs, 511 PDs, and 377 EDs showed that most EDs performed as an interim treatment for pain relief until (68%) and GDs (47%) practiced complete caries removal. RCT is accomplished, or for apexogenesis in teeth with PDs (31%) were more likely than GDs (12%) and EDs immature apices. For teeth presenting with pulpal necrosis, (4%) to remove carious tissues partially. In other countries, RCT should be performed. Rubber dam isolation is such as Germany, complete caries excavation is practiced by required before and during all endodontic procedures approximately half of the GDs.34 If caries was to be removed including caries removal, which is considered a diagnostic incompletely, 77% considered two-step excavation. step in endodontics that is performed to determine the From a biological perspective, invasion of dentinal de nitive treatment. tubules by microorganisms occurs immediately and is Hemorrhage control was thought to be a critical step evident within a week of exposure.35,36 Consequently, in achieving a favorable VPT outcome.37 However, from a the dental pulp starts to manifest histological changes biological perspective, control of bleeding at the exposure and signs of in ammation even in incipient decay and site or canal ori ces did not provide an accurate assessment shallow caries.5 As a protective mechanism, odontoblasts of in ammation and could be misleading for diagnosing and form reactive dentin, which blocks the dentinal tubules. A treating a vital pulp.38 In addition, the amount of bleeding layer of hard, affected dentin then forms underneath the was not associated with the outcome of VPT.39 From an soft carious lesion. Complete removal of soft or infected actual clinical perspective though, it would be dif cult to dentin is necessary to eliminate most of the cariogenic perform VPT if bleeding cannot be controlled within a microorganisms and allow the pulp to revert back to health. reasonable amount of time. There are currently no clinical However, since microorganisms do not have to be in direct studies to support the length of time to achieve hemostasis contact with the dental pulp to initiate in ammation, good in order for VPT to proceed; however, if bleeding does diagnostic skills supersede the limits of caries removal. not stop after various hemostatic techniques have been employed for more than 10 minutes, RCT should be VPT: Indications performed. Other VPT indications include mechanical pulp According to the 2013 AAE Guide to Clinical exposure during operative procedures or during carious Endodontics,31 the following are considered as VPT: excavation under rubber dam isolation and traumatic pulp apexogenesis, pulpotomy, pulpal debridement, indirect exposure after removal of super cial pulp. The indications pulp capping, and direct pulp capping. Because pulpal for VPT are summarized in Table 2. debridement is performed as an emergency procedure for teeth needing RCT, this procedure will not be discussed in Stepwise or Complete Caries Excavation? this review. Dr. I.B. Bender once stated that the dental pulp is “a The AAE Guidelines specify that except for pulpotomy, small tissue with a big issue.” This statement reverberates all VPT procedures on restorable permanent teeth with in actual clinical practice on a daily basis. When presented mature apices are to be performed only in teeth with with a permanent tooth with deep caries, the dental pulp no pretreatment symptoms and under strict asepsis becomes a concern. Pulpitis can be a progressive and using rubber dam isolation before the pulp is exposed devastating pain experience that is distressful both to the and during the entire procedure. Therefore, the pulpal patient and to the dentist. The dentist decides whether to
6 Vital Pulp Therapy in Permanent Teeth: Sound Option or Pulp Fiction?
TABLE 2. Indications for Vital Pulp Therapy Formulated by the American Association of Endodontists31
VPT Procedure Indications Indirect pulp capping • Deep carious lesion likely to result in pulpal exposure • No history of subjective pretreatment symptoms • Periapical radiographs should exclude periradicular pathosis • Patient has been fully informed that endodontic treatment may be indicated in the future Direct pulp capping • Mechanical exposure of vital and asymptomatic pulp • Bleeding is controlled at exposure site • Exposure permits capping material direct contact with pulp • Exposure occurs when the tooth is under dental dam isolation • Adequate seal of coronal restoration can be maintained • Patient has been fully informed that endodontic treatment may be indicated in the future Pulpotomy • Exposed vital pulps or irreversible pulpitis of primary teeth • Primary teeth with insuf cient root structure, internal resorption, furcal perforation, or periradicular pathosis that may jeopardize the permanent successor are not indicated for pulpotomy procedures • As an emergency procedure in permanent teeth until root canal treatment can be accomplished • As an interim procedure for permanent teeth with immature root formation to allow continued root development Pulpal debridement • Relief of acute pain prior to conventional root canal treatment when complete root canal treatment cannot be accomplished at this appointment Apexogenesis Indicated on permanent teeth with immature apices if all the following conditions exist: • Tooth has a deep carious lesion that is considered likely to result in pulp exposure during excavation • No history of subjective pretreatment symptoms • Pretreatment radiographs should exclude periradicular pathosis • Mechanical exposure of a clinically vital and asymptomatic pulp occurs • Bleeding is controlled at the exposure site • Exposure occurs when the tooth is under dental dam isolation • Adequate seal of the coronal restoration can be maintained • Exposure permits the capping material to make direct contact with the vital pulp tissue • Patient has been fully informed that endodontic treatment may be indicated in the future avoid pulpal exposure by leaving caries or risk exposing the dental pulp by complete caries excavation (Figure 1). In stepwise excavation, the rst step involves removal of the super cial, necrotic, and demineralized dentin with complete excavation of the peripheral demineralized dentin, avoiding excavation close to the pulp.40 Once it is determined that a temporary restoration could be properly placed, no further excavation is carried out, leaving soft, wet, and discolored dentin centrally on the pulpal wall. A base material like calcium hydroxide is applied over the remaining carious dentin, then the cavity is temporarily Figure 1. A 7-year-old child presents with deep caries on #30. sealed with glass ionomer cement. After four to eight weeks, There were no reported symptoms and the clinical diagnostic the cavity is re-entered if the patient reports no symptoms testing points to a normal pulp. In this case, the clinician decides whether to perform a stepwise or complete caries excavation. associated with the tooth. The nal excavation is performed
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leaving the supposedly formed central yellowish or grayish Pulp Capping or Pulpotomy? hard dentin. A base is applied and the cavity is restored with When a normal or reversibly in amed dental pulp a permanent restorative material. is exposed during treatment, direct pulp capping, One alternative to the stepwise method described above pulpotomy, or RCT can be recommended depending is the one-stage method wherein caries approximating on the degree of in ammation, stage of root formation, the pulp is left behind and the tooth is restored with a patient considerations, and others. Maintaining strict permanent lling instead of a temporary one. The tooth is asepsis using rubber dam isolation and control of not re-entered but symptoms will be monitored. For both bleeding are required for all types of VPT. Direct pulp methods, RCT or extraction is carried out if the tooth capping consists of the application of a biomaterial causes symptoms consistent with irreversible pulpitis. directly over an unin amed pulp tissue. In partial Complete caries removal is determined mostly by pulpotomy, a small portion of the coronal pulp is hardness of the underlying dentin.33 The risk involved with removed after exposure, while in full pulpotomy, this method is pulpal exposure. If the pulp is not exposed, the entire coronal pulp is amputated. For all these the tooth is either restored with a temporary material rst procedures, a biomaterial is applied over the unin amed and then monitored for symptoms, or with a permanent pulp prior to the placement of a permanent restoration. lling material right away. If no symptoms develop, the Indirect pulp capping involves the complete removal temporary material is replaced by a permanent restoration. of caries and the application of a biomaterial on a thin RCT or extraction is recommended for teeth that produce layer of hard dentin covering an intact pulp tissue before symptoms of irreversible pulpitis. placing a permanent restoration. In determining whether to use complete caries A systematic review demonstrated that direct pulp excavation or stepwise technique, the clinician should capping worked better in immature teeth.45 On the other base the decision on the individual patient circumstances hand, the success rate of partial or full pulpotomy in both as the literature is inconclusive as to whether stepwise mature and immature teeth showed no statistical difference. or complete caries excavation is the most successful A meta-analysis study reported that full coronal pulpotomy over time.41,42 One study reported a signi cantly higher had a favorable success rate at 92% (two-year recall) in proportion of unexposed pulps with sustained vitality treating carious vital pulp exposure of permanent mature and without apical radiolucency in stepwise technique teeth with closed root apices.46 In a report with a short than those with direct complete excavation of deep follow-up of one year or less, no difference in success rate was caries lesions in adult teeth.43 However, in this study seen between pulp capping and pulpotomy.47 The literature the complete-excavation patients had higher median appears to support pulp capping in immature teeth. Partial pretreatment pain level, and rubber dam isolation was or full pulpotomy would be the better option for permanent performed only after pulpal exposure. Another report that teeth with mature apices. Radiographic appearance of various performed a systematic review of stepwise excavation VPT procedures are shown in Figure 2. concluded that the stepwise technique was effective in deep caries and in teeth without symptoms of irreversible Calcium Hydroxide or Mineral Trioxide Aggregate? pulpitis.44 The drawbacks of this systematic review Several products purported to be biocompatible are the inclusion of studies with either no control, no are being marketed currently as endodontic materials. randomization, or no clear methods. However, only two products have been extensively
8 Vital Pulp Therapy in Permanent Teeth: Sound Option or Pulp Fiction?
hard dentin bridge formation than CH.52 MTA is, therefore, a suitable replacement to overcome the shortcomings of CH. MTA is not without its challenges, too. The presence of bismuth oxide in the aggregate causes discoloration Figure 2. Indirect pulp cap on #14. Direct pulp cap on #2. in teeth treated with either the gray or white mixtures of Pulpotomy on #19. MTA.53 In addition, MTA is not easy to manipulate and its setting time can last up to 24 hours. To address these researched and utilized for decades: calcium hydroxide shortcomings, newer materials have been introduced (CH) and mineral trioxide aggregate (MTA). CH has during the last few years. These new materials, been used in pulp capping since the 1930s. It has good predominantly calcium silicate (CSC) based cements, antimicrobial effect due to its high pH of 12.5 when in are being characterized as biocompatible, easy to a slurry preparation.48 Extensive clinical documentation manipulate, well-sealing, faster setting, and nonstaining. showed that CH initiates hard tissue repair of the Randomized controlled trials comparing MTA to CSC exposed pulp, thus making it the material of choice for materials have shown that CSCs have favorable and a long time.49 comparable success rates as MTA when used as pulp The shortcomings of CH, like its tendency to dissolve capping or pulpotomy material in permanent mature over time, creates a pathway for microleakage to occur teeth with carious exposure while offering better and underneath restorations, especially with composite esthetic physical properties.54,55 resins where polymerization shrinkage could pull the pulp cap away from tissue surface.50 Furthermore, the VPT or RCT? pH of CH drops rapidly when in contact with dentin, Although the current endodontic diagnostic testing compromising its antimicrobial properties.48 For these provides a speci city of over 90%, the actual level of reasons, the need for a biocompatible and well-sealing in ammation cannot be staged by cold testing or EPT. material gave birth to MTA in the mid-1990s. Since then, An exaggerated response to cold testing is interpreted MTA has been widely utilized for various endodontic as the pulp being “vital,” but the severity and degree of procedures that involve contact between a biomaterial in ammation cannot be reliably determined clinically.27 and the surround tissues. This predicament makes VPT a clinical decision The largest clinical data comparing the long-term wherein the operator judges whether all the in amed outcome of direct pulp capping between CH and tissues have been removed. Hemorrhage control and MTA indicated that MTA provided better long-term direct observation of the pulp tissue, preferably using results after direct pulp capping compared with CH.51 magni cation, are helpful methods in gauging whether Placing a permanent restoration immediately after necrotic or in amed tissues are completely eradicated and direct pulp capping was also recommended. In a study normal pulp tissues are present for the VPT’s outcome to that compared the effectiveness of MTA and CH as be more predictable. pulp-capping materials in humans by means of a meta- Evidence suggests that pulpal in ammation progresses analysis, MTA had a higher success rate and resulted in incrementally and normal tissues can be histologically less pulpal in ammatory response and more predictable identi ed around the in amed ones27 (Figure 3A). It is,
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in pulpally necrotic cases or cases with periapical pathosis (~70%).56,57 Compared to RCT in vital cases, VPT speci cally pulpotomy was shown to have initial success of 89% at one-year recall. However, the success rate drops to 63% at 10 years.58 The decision whether to perform VPT or pulpectomy then RCT should be determined based on individual patient circumstances, restorative goals, and the skill of the operator. Figure 3. Sagittal histological section of a dental pulp with clinical diagnosis of reversible pulpitis (A). Various elements Pulp tissues of young mature teeth tend to recover much better involved in in ammation, necrosis, and repair are labeled than those in older patients. A ow diagram illustrating the yellow and black (B). Normal pulp can be visualized away from recommended course of treatment is presented in Figure 4. the localized area of in ammation. In theory, the in amed tissue can be amputated to prevent capping material to rest on normal tissue. Images from Ricucci et al.27 VPT in Mature Teeth with Irreversible Pulpitis Although the AAE guidelines recommend VPT to be therefore, theoretically feasible to amputate the in amed performed only in cases with no pretreatment symptoms, tissues only so that a VPT biomaterial can be applied recent studies have shown considerable success rates with directly on normal tissues (Figure 3B). However, there are VPT in teeth with symptomatic irreversible pulpitis. In a instances where the extent of the in ammation can be prospective report involving 64 mature molars with clinical dif cult to determine especially in an anxious, young patient signs and symptoms indicative of irreversible pulpitis among where time is of the essence. 19- to 69-year-old subjects, a 98.4% radiographically and Pulpectomy circumvents the need to clinically determine 100% clinically normal outcomes were achieved at one- the extent of in ammation, thus allowing the entire in amed year follow-up.59 In 6% of the cases, a hard tissue layer was and infected pulp tissue to be removed. The long-term success identi ed radiographically. rate (more than 10 years) of performing RCT in a vital To push the treatment boundaries of VPT further, case was reported to be much higher (over 90%) than that another study from the same group included cases with
Figure 4. Recommended course of treatment for teeth without (A) and with pulpal exposure (B) following caries removal. *Can be presented as secondary treatment option. CH = calcium hydroxide
10 Vital Pulp Therapy in Permanent Teeth: Sound Option or Pulp Fiction?
both symptomatic irreversible pulpitis and symptomatic apical periodontitis in young permanent teeth with carious pulpal exposure.60 At one-year recall, 95% of the cases were deemed radiographically and clinically normal. Similar studies with larger sample sizes and longer recall periods reported comparable success rates.61,62 There appears to be an emerging evidence for a paradigm shift toward a more conservative approach in endodontic treatment. Preserving pulpal vitality is de nitely bene cial Figure 5. Preop PA (A) and bitewing radiographs (B) for the tooth. Higher level studies with longer follow-ups showing immature apices and caries on #19, respectively. are encouraged to replicate or increase the level of evidence Full pulpotomy performed using MTA (C). One-year concerning VPT in teeth with irreversible pulpitis. follow-up radiographs (D), (E) show closed apices with normal surrounding bone. Tooth did not respond to cold test but tested positive to EPT. VPT in Immature Teeth When an immature tooth presents with reversible or irreversible pulpitis, VPT is recommended for apexogenesis for as long as good oral hygiene is maintained. A discussion to occur. Young, immature teeth have very high healing with the patient’s pediatric dentist about full cuspal potential;63 thus, every attempt at preserving their vitality coverage restoration on the tooth should be undertaken. should be considered. Even in a clinical diagnosis of irreversible pulpitis, the reasonable rst step would be What Factors Are Associated with VPT Success or complete caries excavation under strict asepsis followed by Failure? pulpotomy to remove in amed pulp tissue. A biomaterial In endodontics, asepsis is everything and seal is the deal. is then applied over the exposed pulp tissue before a The success or failure of treatment relies heavily on strict permanent restoration is placed. elimination and control of microorganisms and the placement To illustrate VPT on immature teeth, an actual case of a well-sealing coronal restoration. VPT is not an exception is presented here of a 6-year-old female patient with a to these principles. In a long-term retrospective study, the diagnosis of symptomatic irreversible pulpitis on #19. The risk factors in uencing the success rates of pulpotomies in preop bitewing (Figure 5A) and periapical radiographs both young and adult populations were evaluated.58 Among (Figure 5B) show a large occlusal caries encroaching the the 273 evaluated cases, 172 (63%) were deemed successful pulp and the tooth’s immature apices, respectively. After at 10 years. The factors considered to have contributed to complete caries removal, pulpotomy was performed. MTA the longevity of these teeth were dentin bridge formation was placed over the pulp tissue and the tooth was restored and placement of a full coverage crown. Teeth restored with composite resin (Figure 5C). At one-year follow-up, with composite resin had the worst outcome. Age, gender, the tooth presented with clinical and radiographic normalcy. smoking, systemic disease, and the number of appointments It did not respond to cold but had a positive response to were equivocal factors to the outcome of VPT. EPT. The periapical radiograph shows normal apical tissues Dentin bridge formation is a sign of a healthy pulp with closed apices (Figure 5D and 5E). With the successful with functioning odontoblasts, a hallmark of complete outcome presented, the tooth is envisioned to be functional recovery after a pulp-capping procedure. It is, therefore,
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3. Nusstein JM, Beck M. Comparison of preoperative pain and medication use in emergency patients presenting with irreversible pulpitis or teeth with necrotic pulps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96(2):207–214. 4. Brannstrom M, Lind PO. Pulpal response to early dental caries. J Dent Res. 1965;44(5):1045–1050. 5. Izumi T, Kobayashi I, Okamura K, Sakai H. Immunohistochemical study on the immunocompetent cells of the pulp in human non-carious and carious teeth. Arch Oral Biol. 1995;40(7):609–614. 6. Adachi T, Nakanishi T, Yumoto H, et al. Caries-related bacteria and cytokines induce CXCL10 in dental pulp. J Dent Res. 2007;86(12):1217–1222. Figure 6. Five-year pulpotomy recall on #30 performed on a 7. Hirao K, Yumoto H, Takahashi K, et al. Roles of TLR2, TLR4, NOD2, and 9-year-old female patient (A). A two-year pulpotomy recall on NOD1 in pulp fibroblasts. J Dent Res. 2009;88(8):762–767. #19 on a 12-year-old male patient (B). 8. Huang GT, Potente AP, Kim JW, Chugal N, Zhang X. Increased interleukin-8 expression in inflamed human dental pulps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88(2):214–220. not surprising that the formation of tertiary dentin bridges 9. Levin LG, Rudd A, Bletsa A, Reisner H. Expression of IL-8 by cells of the odontoblast layer in vitro. Eur J Oral Sci. 1999;107(2):131–137. was associated with favorable outcome. Furthermore, the 10. Rechenberg DK, Galicia JC, Peters OA. Biological markers for pulpal presence of full coverage crown has been linked to increased inflammation: A systematic review. PLoS One 2016;11(11):e0167289. long-term survival of root canal-treated teeth in a large 11. Galicia JC, Henson BR, Parker JS, Khan AA. Gene expression profile of pulpitis. Genes Immun. 2016;17(4):239–243. epidemiological study in the United States.64 Two cases of 12. Michaelson PL, Holland GR. Is pulpitis painful? Int Endod J. successful VPT are presented in Figure 6. 2002;35(10):829–832. 13. Heyeraas KJ. Pulpal hemodynamics and interstitial fluid pressure: Balance of transmicrovascular fluid transport. J Endod. 1989;15(10):468–472. Conclusion 14. Heyeraas KJ, Berggreen E. Interstitial fluid pressure in normal and inflamed pulp. Crit Rev Oral Biol Med. 1999;10(3):328–336. VPT is a conservative endodontic procedure that has a 15. Kim S, Liu M, Simchon S, Dorscher-Kim JE. Effects of selected well-documented history of success. Correct diagnosis, case inflammatory mediators on blood flow and vascular permeability in the dental pulp. Proc Finn Dent Soc. 1992;88 Suppl 1:387–392. selection, microbial control, and the use of a well-sealing 16. Okabe E, Todoki K, Ito H. Microcirculation: Function and Regulation in biocompatible material are essential factors that can dictate Microvasculature. London: Chapman and Hall. 1989. the outcome of this treatment. The current guidelines point 17. Van Hassel HJ. Physiology of the human dental pulp. Oral Surg Oral Med Oral Pathol. 1971;32(1):126–134. to limiting VPT in mature teeth with no pretreatment 18. Kim S. Microcirculation of the dental pulp in health and disease. J symptoms of irreversible pulpitis and in immature teeth to Endod. 1985;11(11):465–471. 19. Levin LG, Law AS, Holland GR, Abbott PV, Roda RS. Identify and permit apexogenesis to occur. However, there is emerging define all diagnostic terms for pulpal health and disease states. J Endod. evidence of considerable VPT success in permanent mature 2009;35(12):1645–1657. 20. Seltzer S, Bender IB, Ziontz M. The Dynamics of pulp inflammation: teeth with clinical symptoms of irreversible pulpitis. VPT Correlations between diagnostic data and actual histologic findings in the can also serve as an alternative option to extraction when pulp. Oral Surg Oral Med Oral Pathol. 1963;16(7):846–871. 21. Dummer PM, Hicks R, Huws D. Clinical signs and symptoms in pulp root canal treatment cannot be performed for low-income disease. Int Endod J. 1980;13(1):27–35. and uninsured patients or in underserved areas.46 22. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol. 1963;16:846–871 contd. References 23. Garfunkel A, Sela J, Ulmansky M. Dental pulp pathosis. 1. Caplan DJ, Cai J, Yin G, White BA. Root canal filled versus non-root canal Clinicopathologic correlations based on 109 cases. Oral Surg Oral Med filled teeth: A retrospective comparison of survival times. J Public Health Oral Pathol. 1973;35(1):110–117. Dent 2005;65(2):90-96. 24. Reynolds R. The determination of pulp vitality by means of thermal and 2. Abou-Rass M. The stressed pulp condition: An endodontic-restorative electrical stimuli. Oral Surg Oral Med Oral Pathol. 1966;22(3):231–240. diagnostic concept. J Prosthet Dent. 1982;48(3):264-267. 25. Jespersen JJ, Hellstein J, Williamson A, et al. Evaluation of dental pulp
12 Vital Pulp Therapy in Permanent Teeth: Sound Option or Pulp Fiction?
sensibility tests in a clinical setting. J Endod. 2014;40(3):351–354. for cariously exposed permanent posterior teeth with closed apices: A 26. Weisleder R, Yamauchi S, Caplan DJ, et al. The validity of pulp testing: A systematic review and meta-analysis. J Dent. 2016;44:1–7. clinical study. J Am Dent Assoc. 2009;140(8):1013–1017. 47. Asgary S, Hassanizadeh R, Torabzadeh H, Eghbal MJ. Treatment outcomes 27. Ricucci D, Loghin S, Siqueira JF Jr. Correlation between clinical and of 4 vital pulp therapies in mature molars. J Endod. 2018;44(4):529–535. histologic pulp diagnoses. J Endod. 2014;40(12):1932–1939. 48. Ida K, Maseki T, Yamasaki M, Hirano S, Nakamura H. pH values of pulp- 28. Glickman GN. AAE Consensus Conference on diagnostic terminology: capping agents. J Endod. 1989;15(8):365–368. Background and perspectives. J Endod. 2009;35(12):1619–1620. 49. Goracci G, Mori G. Scanning electron microscopic evaluation of 29. Koopaeei MM, Inglehart MR, McDonald N, Fontana M. General resin-dentin and calcium hydroxide-dentin interface with resin composite dentists’, pediatric dentists’, and endodontists’ diagnostic assessment and restorations. Quintessence Int. 1996;27(2):129–135. treatment strategies for deep carious lesions: A comparative analysis. J Am 50. Cox CF, Subay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in Dent Assoc. 2017;148(2):64–74. dentin bridges: Their formation following direct pulp capping. Oper Dent. 30. England MC, Pellis EG, Michanowicz AE. Histopathologic study of the 1996;21(1):4–11. effect of pulpal disease upon nerve fibers of the human dental pulp. Oral 51. Mente J, Hufnagel S, Leo M, et al. Treatment outcome of mineral Surg Oral Med Oral Pathol. 1974;38(5):783–790. trioxide aggregate or calcium hydroxide direct pulp capping: Long-term 31. Amer Assoc Endodontists. Guide to Clinical Endodontics. 2013, 6th ed. results. J Endod. 2014;40(11):1746–1751. 32. Guideline on pulp therapy for primary and immature permanent teeth. 52. Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium hydroxide or Pediatr Dent. 2016;38(6):280–288. mineral trioxide aggregate: A meta-analysis. J Endod. 2015;41(9):1412–1417. 33. Nascimento MM, Behar-Horenstein LS, Feng X, et al. Exploring how U.S. 53. Salem-Milani A, Ghasemi S, Rahimi S, et al. The discoloration effect dental schools teach removal of carious tissues during cavity preparations. J of white mineral trioxide aggregate (WMTA), calcium enriched mixture Dent Ed. 2017;81(1):5–13. (CEM), and portland cement (PC) on human teeth. J Clin Exp Dent. 34. Schwendicke F, Meyer-Lueckel H, Dorfer C, Paris S. Attitudes and 2017;9(12):e1397–e401. behaviour regarding deep dentin caries removal: A survey among German 54. Parinyaprom N, Nirunsittirat A, Chuveera P, et al. Outcomes of direct dentists. Caries Res. 2013;47(6):566–573. pulp capping by using either proroot mineral trioxide aggregate or 35. Lundy T, Stanley HR. Correlation of pulpal histopathology and clinical Biodentine in permanent teeth with carious pulp exposure in 6- to 18-year- symptoms in human teeth subjected to experimental irritation. Oral Surg old patients: A randomized controlled trial. J Endod. 2018;44(3):341–348. Oral Med Oral Pathol. 1969;27(2):187–201. 55. Awawdeh L, Al-Qudah A, Hamouri H, Chakra RJ. Outcomes of vital 36. Olgart L, Brannstrom M, Johnson G. Invasion of bacteria into dentinal pulp therapy using mineral trioxide aggregate or Biodentine: A prospective tubules. Experiments in vivo and in vitro. Acta Odontol Scand. 1974;32(1):61–70. randomized clinical trial. J Endod. 2018;44(11):1603–1609. 37. Swift JR, Edward J, Trope M, Ritter AV. Vital pulp therapy for the mature 56. Molven O, Halse A. Success rates for gutta-percha and Kloroperka N-0 tooth – Can it work? Endodont Topics 2003;5(1):49–56. root fillings made by undergraduate students: Radiographic findings after 38. Mutluay M, Arikan V, Sari S, Kisa U. Does achievement of hemostasis 10–17 years. Int Endod J. 1988;21(4):243–250. after pulp exposure provide an accurate assessment of pulp inflammation? 57. Kojima K, Inamoto K, Nagamatsu K, et al. Success rate of endodontic Pediatr Dent. 2018;40(1):37–42. treatment of teeth with vital and nonvital pulps. A meta-analysis. Oral Surg 39. Miles JP, Gluskin AH, Chambers D, Peters OA. Pulp capping with mineral Oral Med Oral Pathol Oral Radiol Endod. 2004;97(1):95–99. trioxide aggregate (MTA): A retrospective analysis of carious pulp exposures 58. Kunert GG, Kunert IR, da Costa Filho LC, de Figueiredo JAP. Permanent treated by undergraduate dental students. Oper Dent. 2010;35(1):20–28. teeth pulpotomy survival analysis: Retrospective follow-up. J Dent. 40. Bjorndal L, Larsen T, Thylstrup A. A clinical and microbiological study 2015;43(9):1125–1131. of deep carious lesions during stepwise excavation using long treatment 59. Taha NA, Abdelkhader SZ. Outcome of full pulpotomy using Biodentine intervals. Caries Res. 1997;31(6):411–417. in adult patients with symptoms indicative of irreversible pulpitis. Int Endod 41. Schwendicke F, Dorfer CE, Paris S. Incomplete caries removal: A J. 2018;51(8):819–828. systematic review and meta-analysis. J Dent Res. 2013;92(4):306–314. 60. Taha NA, Abdulkhader SZ. Full pulpotomy with Biodentine in 42. Thompson V, Craig RG, Curro FA, et al. Treatment of deep carious symptomatic young permanent teeth with carious exposure. J Endod lesions by complete excavation or partial removal: A critical review. J Am 2018;44(6):932–937. Dent Assoc. 2008;139(6):705–712. 61. Asgary S, Eghbal MJ, Bagheban AA. Long-term outcomes of pulpotomy 43. Bjorndal L, Reit C, Bruun G, et al. Treatment of deep caries lesions in in permanent teeth with irreversible pulpitis: A multi-center randomized adults: Randomized clinical trials comparing stepwise vs. direct complete controlled trial. Am J Dent. 2017;30(3):151–155. excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci. 62. Asgary S, Eghbal MJ, Fazlyab M, et al. Five-year results of vital pulp 2010;118(3):290–297. therapy in permanent molars with irreversible pulpitis: A non-inferiority 44. Hayashi M, Fujitani M, Yamaki C, Momoi Y. Ways of enhancing multicenter randomized clinical trial. Clin Oral Investig. 2015;19(2):335–341. pulp preservation by stepwise excavation: A systematic review. J Dent. 63. Huang GT. A paradigm shift in endodontic management of immature 2011;39(2):95–107. teeth: Conservation of stem cells for regeneration. J Dent. 2008;36(6):379–386. 45. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with 64. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large cariously exposed pulp: A systematic review. J Endod. 2011;37(5):581–587. patient population in the USA: An epidemiological study. J Endod. 46. Alqaderi H, Lee CT, Borzangy S, Pagonis TC. Coronal pulpotomy 2004;30(12):846–850.
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1. The following are pulpal diagnostic terminologies formulated by the 8. Clinical diagnostic testing results correlate almost perfectly with American Association of Endodontists (AAE) except one. Which one the actual histological status of the pulp. is the exception? a. True a. Normal pulp b. False b. Chronic pulpitis 9. Lingering pain to cold is a clinical symptom associated with c. Symptomatic irreversible pulpitis ______. d. Previously initiated therapy a. reversible pulpitis 2. Which of the following is not an indication for pulpotomy b. symptomatic Irreversible pulpitis according to the AAE guidelines? c. pulpal necrosis a. Exposed vital pulps or irreversible pulpitis of primary teeth d. asymptomatic irreversible pulpitis b. As an emergency procedure in permanent teeth until root 10. According to a 2017 survey, which one of the following criteria canal treatment can be accomplished is used by most U.S. dental schools in assessing suf cient c. For apexi cation of immature teeth removal of carious dentin? 3. Which one of the following pulpal diagnoses does not a. Luck necessarily require root canal treatment? b. Color a. Asymptomatic irreversible pulpitis c. Hardness b. Symptomatic irreversible pulpitis d. Moisture c. Previously initiated therapy 11. The dental pulp begins to manifest histological signs of d. Previously treated in ammation ______. 4. Tissue pressure is a local phenomenon that does not spread a. in incipient decay abruptly throughout the pulp tissue. This local phenomenon b. when caries has reached the dentin therefore debunks the strangulation theory of the pulp. c. 2 millimeters before pulpal exposure a. Both statements are true d. when the dental pulp is cariously exposed b. Both statements are false 12. This procedure is performed to allow the apices of immature c. The rst statement is true, the second statement is false teeth to naturally close. d. The rst statement is false, the second statement is true a. Apexi cation 5. The following are recommended microbial reduction and control b. Apexogenesis methods when performing vital pulp therapy (VPT) except one. c. Apicoectomy Which one is the exception? d. Apical preparation a. Rubber dam isolation 13. Which of the following materials was shown to result in higher b. Sodium hypochlorite irrigation success rates in VPT? c. Asepsis a. Calcium hydroxide d. Systemic antibiotic treatment b. Intermediate restorative material 6. Which pulpal diagnostic testing has been reported to have c. Glass ionomer cement the highest sensitivity and speci city, therefore providing a d. Mineral trioxide aggregate (MTA) diagnosis that is more accurate than the other tests? 14. Stepwise method was shown conclusively to be more successful a. Heat test over time than complete caries excavation. b. Cold test a. True c. Palpation b. False d. Electric pulp testing 15. A clinical diagnosis indicating the death of the dental pulp is 7. Transient and exaggerated pain to thermal stimulation is typical ______. for a ______. a. reversible pulpitis a. normal pulp b. symptomatic irreversible pulpitis b. reversible pulpitis c. pulpal necrosis c. asymptomatic irreversible pulpitis d. asymptomatic irreversible pulpitis d. symptomatic irreversible pulpitis
14 Vital Pulp Therapy in Permanent Teeth: Sound Option or Pulp Fiction?
16. The following are essential factors to consider when performing 24. Maintaining pulpal health is essential to the longevity of VPT except one. Which one is the exception? the tooth. a. Hemostasis a. True b. Age b. False c. Asepsis 25. Which of the following condition is contraindicated in d. Biomaterial performing apexogenesis? 17. In a long-term outcome study, which of the following a. Controlled bleeding contributed to pulpotomy success? b. Adequate coronal seal can be obtained a. Nonsmoking c. Capping material can be in direct contact with vital tissue b. Single appointment d. Exposure occurs without dental dam isolation c. Dentin bridge formation 26. A clinical diagnosis based on subjective and objective ndings d. Absence of systemic disease indicating that the in ammation should resolve and the pulp 18. Which of the following will have a similar response as a normal return to normal is _____ . pulp to cold testing using refrigerant spray? a. reversible pulpitis a. Reversible pulpitis b. symptomatic irreversible pulpitis b. Symptomatic irreversible pulpitis c. asymptomatic irreversible pulpitis c. Asymptomatic irreversible pulpitis d. previously initiated therapy d. Previously initiated therapy 27. The following are indications for indirect pulp capping except 19. The literature appears to support pulp capping in immature one. Which one is the exception? teeth. Partial or full pulpotomy would be the better option for a. Deep carious lesion likely to result in pulpal exposure permanent teeth with mature apices. b. Pulpal diagnosis of previously initiated therapy a. Both statements are true c. Absence of periapical pathosis b. Both statements are false d. Fully informed patient c. The rst statement is true, the second statement is false 28. Vital pulp is not present in which one the following diagnoses? d. The rst statement is false, the second statement is true a. Previously treated 20. Bacteria is the most common cause of pulpitis. b. Reversible pulpitis a. True c. Asymptomatic irreversible pulpitis b. False d. Symptomatic irreversible pulpitis 21. Transient pain to cold test using refrigerant spray is a clinical 29. In the largest clinical data comparing the long-term outcome nding of ______. of direct pulp capping between calcium hydroxide and MTA, a. normal pulp placing a permanent restoration immediately after direct pulp b. reversible pulpitis capping was also recommended. c. symptomatic irreversible pulpitis a. True d. pulp necrosis b. False 22. All of the following diagnoses will give a sensation of pain to 30. A tooth with pulpal necrosis will ____. cold testing with a refrigerant spray except one. Which one is a. need root canal treatment the exception? b. lose its immunocompetence a. Reversible pulpitis c. be a contraindication for pulpotomy b. Normal pulp d. all of the above c. Asymptomatic irreversible pulpitis d. Previously treated 23. Which of the following is not an indication for direct pulp capping? a. Mechanical exposure of vital and asymptomatic pulp b. Bleeding is controlled at exposure site c. Dental dam isolation is immediately placed after pulp exposure d. Exposure permits capping material direct contact with pulp
DECEMBER 2019 15 Vital Pulp Therapy in Permanent Teeth: Sound Option or Pulp Fiction?
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