Dental caries causes gradual
weakening of tooth enamel, leading to inflammation of the tooth pulp if left
untreated. This persistent infection is a major global health concern, with
untreated cavities being widespread, affecting approximately 34.1% of the
population worldwide.
Managing dental decay involves
preventing it through primary preventive methods and removing decayed tissue
through operative interventions. Preserving the health and vitality of the
tooth pulp, preventing complications like abscess formation, and developing
minimally invasive biological treatments are key focuses in modern
clinical practice.[1,6]
In cases of irreversible pulpitis, the
histological condition of the pulp may not always correlate with the clinical
diagnosis. Studies have shown that even in advanced inflammation, only certain
areas of the coronal pulp show bacterial invasion, while the underlying pulp
remains unaffected. It has also been revealed that after the removal of the
infected coronal pulp, the remaining pulp tissue has excellent regenerative
capabilities.[5]
Traditionally, root canal
treatment (RCT) has been the recommended approach for irreversibly inflamed
pulp following exposure to decay [2]. Although
nonsurgical root canal treatment (RCT) has positive results, it also comes with
drawbacks such as advanced equipment, higher expenses, and occasionally
requiring multiple appointments [3]. The management of
irreversible pulpitis has been reevaluated in recent years due to increasing
evidence from clinical trials demonstrating positive outcomes of vital pulp
therapy (VPT) in such cases. Consequently, professional societies have issued
new position statements regarding the treatment of teeth with carious pulp
exposure and diagnosed with reversible or irreversible pulpitis (AAE, 2021;
Duncan et al., 2019) [3].
Vital pulp therapy
(VPT) is viewed as a simpler and more cost-effective approach compared to
traditional methods like pulpectomy and root canal filling. Among VPT methods,
pulpotomy and indirect pulp capping have proven to be a more reliable and
successful intervention compared to direct pulp capping procedures.[4]
With advancements in understanding pulp
biology and the use of newer materials, the concept of "vital pulp
therapy" (VPT) has been revisited, leading to successful outcomes in teeth
with carious pulp exposures or pulpitis.[4]
Pulpotomy is a surgical procedure
where the coronal part of the pulp tissue is removed to protect the radicular
part, encouraging the growth of dentin bridge using various materials to cover
the remaining pulp tissue, taking advantage of the pulp cells’
ability to form dentin.[6]
There’s a belief that if a pulpotomy
fails, retreatment might be easier compared to a root-filled tooth. Both the
European Society of Endodontology (ESE) and the American Association of
Endodontists (AAE) now endorse VPT as a viable treatment for symptomatic
carious pulp exposure. The ESE’s 2019 position aimed to change clinicians’
mindset, advocating for VPT instead of immediately resorting to root canal
treatment (RCT).[2]
(add about the ‘position statement by AAE and
ESE about use of VPT’ application of same in prim teeth, for ref AAPD 2024
guidelines. Then a line or two about disinfecting agents in VPT for sym irr
pulpitis like NaOCl and recent being laser)
Sodium
hypochlorite (NaOCl) is one such agent recognized and recommended for its dual
effectiveness as a haemostatic and antibacterial agent in dental procedures. It
has been found to have no negative impact on pulp repair, healing, or tertiary
dentinogenesis. Studies have examined its use in controlling pulpal haemorrhage
during pulpotomy in primary teeth, with current research endorsing its safe
application at concentrations between 1% to 5% for vital pulp
therapy procedures. [8,9]
Recent studies show, that Nd: YAG, Er: YAG, CO2,
and diode lasers have become popular for pulpotomy due to advantages like
improved haemorrhage control, and stimulation of regenerative cells. Among
these, diode lasers have the benefit of causing less thermal damage and
promoting faster pulpal wound healing because the dental pulp has a high-water
content, which enhances the absorption of diode laser wavelengths. Studies have
shown diode lasers to be more effective than other treatments for pulpotomy in
primary molars.[7] (talk about lasers as a disinfecting agent
ONLY and not as a pulpotomy agent)
Historically,
VPT faced challenges due to misconceptions about pulp healing and limited
material options. Calcium hydroxide was traditionally used, but its success
rate was lower than MTA.[7] A full pulpotomy with haemostasis
and coronal pulp coverage using calcium silicate cement (CSCs) can be
successful. The AAE’s 2021 position statement also supports direct
visualization and achieving haemostasis to assess the suitability of pulpotomy
for teeth with symptomatic irreversible pulp, emphasizing the use of CSCs and
immediate coronal restoration.[2]
MTA is a bioactive substance,
that excels in forming apatite and sealing, with high pH, radiopacity, and
biocompatibility. Despite its strengths.[7] An alternative
material Bio dentine was developed as a dentine substitute; it shows great
results with its short setting time and similar biocompatibility to MTA. MTA
putty, another calcium silicate-based material, developed using bio-ceramic
technology, is designed in pre-mixed injectable form as a clinical substitute
for MTA.
It has superior handling, improved colour
stability, adaptability, and comparable physical and chemical properties to
MTA. Importantly, it releases calcium and phosphate ions necessary for
hydroxyapatite deposition.[7]
So, the present study aims to evaluate the
success rate of pulpotomy with 3 different CSC in symptomatic irreversible
pulpitis in primary teeth as a treatment option.
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