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Management of Endodontic Emergencies: Pulpotomy Versus Pulpectomy

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Management of Endodontic Emergencies: Pulpotomy Versus Pulpectomy Management of Endodontic Emergencies: Pulpotomy Versus Pulpectomy Fall 2017 ENDODONTICS: Colleagues for Excellence Published for the Dental Professional Community by the www.aae.org/colleagues ENDODONTICS: Colleagues for Excellence Recent studies report a 60-82% incidence of endodontic emergencies among all dental emergencies (1, 2). Within this group, 20-42% of patients seek care for teeth with symptomatic irreversible pulpitis (SIP) (1-3). Additionally, about pulp is characterized by dull, throbbing and lingering pain sensations, it can be spontaneous or in response to an external60% of SIP stimulus, patients such also as complain hot, cold of or symptomatic chewing. This apical makes periodontitis SIP the bulk (SAP) of the (3). emergency While pain cases due seen to a inseverely dental inflamedclinics. The goal of management of endodontic emergencies is to quickly and effectively manage pain and infections thereby also minimizing the development of persistent pain and the formation of periapical pathology. Pharmacological oralmanagement administration such as of intramuscular ibuprofen sodium or infiltration dihydrate injection over a one-hour of ketorolac time trimethamine period (6). These (injectable treatments NSA ID)have can yet to be evaluatedsignificantly over attenuate days or painweeks in afterpatients drug with administration moderate to but severe before pulpal completion pain over of a endodontic three-hour therapy. tested time Therefore, (4, 5) or until research becomes available substantiating the long-term effectiveness of pharmacological management, procedural interventions remain the gold standard. emergency treatments with pulpectomy being the preferred choice of treatment (Figure 1). As seen in Figure 1, a surveyOn the otherof Diplomates hand, procedural of the American interventions Board suchof Endodontics as pulpotomies demonstrated and pulpectomies that more have endodontists been the first were line inclined of towards pulp extirpation/pulpectomy compared to pulpotomy-only procedures for both vital and necrotic cases or(7-9). pulpectomies. Moreover, more However, than this50% trend of endodontists changed by preferreda cumulative complete 27% increase instrumentation in preference compared towards to pulpeccompletetomy-only instrumentationprocedures, especially over a in 10-year necrotic period cases. (Figure Insufficient 1-B) (9).time This was shift the primaryin preference reason is forlikely performing explained ei byther the pulpotomies increase in the literature on the effect of complete instrumentation and placement of an intracanal medicament on the reduction of bacterial toxins and cytokines that directly activate and sensitize nociceptors (10-13). Additionally, the advent of contemporary tools such as the electronic apex locator (EAL), surgical operating microscope (SOM), ultrasonic instruments and cone beam computed tomography (CBCT) have almost entirely eliminated the lack of time as a factor for selecting pulpotomy and pulpectomy without complete instrumentation. Of course, many emergency cases with pulpalgia and SAP also can be completed in one visit. However, this issue of Colleagues will focus and present scenarios related to endodontic pulpotomy and pulpectomy procedures where appropriate. A B Fig. 1. Graphical representation of survey of Diplomates of the ABE regarding endodontic emergency procedures. Adapted from Dorn et al., 1977a, Dorn et al., 1977b and Gatewood et al., 1990 (7-9). system.Pulpotomy Although and pulpectomy pulpectomy differ is a terminologyessentially in best that suited pulpotomy for vital protocols pulps, it are also limited is used to inthe reference removal toof theinflamed removal tissue ofrestricted necrotic to tissues the pulp from chamber root canals. while Generally pulpectomy speaking, protocols both require procedures extirpation have greater of the inflamed than a 90% tissue success in the rate root in canal protocols has led to new advances and highly predictable outcomes. reducing postoperative pain from moderate to severe to mild to no pain (5, 14-18). Continued research on these 2 Management of Endodontic Emergencies: Pulpotomy Versus Pulpectomy Pulpotomy Emergency cases with a diagnosis of SIP due to caries, large restorations, cracked tooth syndrome or trauma are potential candidates for pulpotomies. The primary reason for electing to do a pulpotomy over complete sensoryinstrumentation nerves due is the to upregulationlack of sufficient of genes time suchto clean as nerve and shape growth canal factor systems. responsible Additionally, for peripheral partial pulpectomy nerve sprouting of andseverely therefore inflamed greater teeth postoperative has been strongly pain (14, discouraged 19). over pulpotomy due to an arbitrary method of axotomizing Prior studies determining pulpotomy protocols suggest that an effective procedure can be accomplished with canadequate be initiated removal is theof the primary inflamed purpose pulp tissue,of an adequate preferably coronal at the seal.level To of thisthe canalend, many orifice/s clinicians followe preferd by a placement well-suited of ancoronal antibacterial seal. Prevention chamber of dressing bacterial following penetration a pulpotomy. during the It intermediateshould be noted time that until there definitive appears endo to bedontic no difference therapy between various antibacterial chamber dressings compared to a dry cotton pellet with regards to attenuation of pain must(16). However,be initiated the within length six of monthstime between of an emergency an emergency pulpotomy pulpotomy to avoid and definitiveanother painful endodontic episode treatment (20). Case does #1 appear is an exampleto be a critical of a 14-year-old factor for pain patient relief. with A study a history by McDougal of spontaneous and colleagues pain of two-month suggests that duration definitive and tendernessendodontic totreatment biting scale. Clinical and radiographic examination revealed a diagnosis of SIP with SAP. Patient-related factors permitted on tooth #3 who received an emergency pulpotomy procedure. Pre-operative pain was reported as three on a 0-5 (Figureonly a quick 2-C) pulpotomyand coronal at seal the with first Intermediatevisit, which involved Restorative maxillary Material™ infiltration, (Figure rubber 2-D). The dam patient isolati wason, removal asymptomatic of pulp at chamber tissue, hemostasis with 8.25% sodium hypochlorite, placement of cotton-soaked eugenol over orifices composite24 hours and resin at one-week(Figure 2-E). post treatment. At one week, definitive endodontic treatment was initiated and completed. Due to loss of the mesial marginal ridge, a fiber post was cemented in the palatal canal and tooth was restored with A B C D E Fig. 2. Case #1: Emergency pulpotomy of #3. Courtesy Dr. Saeed Bayat, Department of Endodontics, UTHSCSA. With our increasing understanding of the biology and pathogenesis of pulpitis and the evolution of various procedures (See Figures 3 and 4). Case #2 represents a unique case of a “restorative emergency.” A 16-year-old patient wasbiocompatible referred for materials, emergency emergency treatment pulpotomy of #8 and procedures9 due to severe can nowcaries-induced also be applied weakening as definitive of the treatmfacial surfacesent (Figures 3-A and 3-B). Diagnosis of reversible pulpitis and normal periradicular tissues was made. Following local following this step (Figure 3-C). Due to the patient’s age and the open apices, a decision to perform a pulpotomy anesthesia, rubber dam isolation and caries excavation,®, a bioactive the dentin inflamed substitute, pulp was was removed. placed Hemostasisover the amputated was achievable pulps 3 as definitive treatment was made. Biodentine ENDODONTICS: Colleagues for Excellence restorations (Figures 3-E and 3-F). Case #3 is an example of a pulpotomy performed in a trauma case. A 10-year-old female(Figure patient 3-D) followed reported by for Fuji tooth IX glass #8 four ionomer. days afterAccess a bicyclecavities accident were restored and emergency to contour room with treatment Z-100 composite of her upper lip (Figure 4-A and 4-B). Clinical presentation revealed a complicated crown fracture (enamel and dentin fracture with pulp exposure) with no treatment initiated. A diagnosis of reversible pulpitis with SAP was made. Following rubber ® was placed 4-D).dam isolation, A one-year a partial follow pulpotomyup documented to eliminate a vital #8, the no inflamed discoloration pulp was and done a dense (Figure dentin 4-C) bridge and Biodenti below thene restorative material.immediately This (Figure is one of4-C). two The reports tooth of was Biodentine-induced restored with Fuji osteo-induction IX and a Vitalescence™ in a patient composite (21). restoration (Figure A B Pulpectomy from pulpectomy procedures. As mentioned above, although theEmergency success casesof pulp with extirpation vital and is necrotic high, partial pulps pulpectomy can benefit can be problematic in certain scenarios and should be avoided due to reasons such as 1) sensory nerve sprouting from C source of pain; and 3) residual necrotic tissue that precludes adequate“random” chemo-mechanicalperipheral axotomy; debridement. 2) residual inflamed Therefore, tissue several as a protocol changes have been seen over the years; complete instrumentation with placement of an intracanal medicament is now the preferred choice among most endodontists (22). D E As stated earlier, technological advancements such as the EAL make it seamless to determine the ideal
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