In recent years developments across research, technology, and techniques have been leading to more minimally invasive procedures across much of dentistry. This includes endodontics which, for many, now has more of a focus on conserving dental tissues where possible in order to delay the restorative cycle and preserve vital pulp. As such, it is important that those who are interested in endodontics and currently provide treatment in this area have a good understanding of the less invasive alternative to root canal treatment (RCT): vital pulp therapy (VPT).
What to consider during diagnosis
Before providing treatment, it’s important to accurately assess whether there are any diseases associated with the pulp through an assessment of the patient’s symptoms and a clinical exam. Currently, pulpal disease may be diagnosed as normal pulp (responds normally to stimuli), reversible pulpitis (stimulus causes pain which subsides quickly), irreversible pulpitis (stimulus causes more intense pain that lingers), or pulp necrosis (tooth is unresponsive to pulp testing). There is evidence that VPT (specifically pulpotomy) can be used to effectively treat irreversible pulpitis.
Types of vital pulp therapy
Once a diagnosis has been established, it is important to assess which type of VPT would be most appropriate for the specific case. The four types of vital pulp therapy are:
Indirect pulp capping
Indirect pulp capping is indicated when a tooth has dentine loss due to caries, trauma, or a previous iatrogenic intervention. Importantly, this is applicable when there is a cavity which is close to the pulp but there is still dentine covering the pulp tissue. The process involves applying material onto a thin layer of dentine which is close to the pulp in order to produce a positive biological response, protecting it from harm.
Direct pulp capping
This is appropriate in similar cases to indirect pulp capping, however, the soft tissue of the pulp is exposed and, in most cases, is bleeding. In these cases, symptoms will be relatively mild and will not indicate irreversible pulpitis. In this therapy type, material is applied directly to the pulp in order to produce a positive biological response, enabling the pulp to protect itself.
Partial pulpotomy
Indicated when there is a loss of dentine and the soft tissue of the pulp is exposed, bleeding, and appears to be inflamed and contaminated a partial pulpectomy involves the removal of a small amount of superficial coronal pulp tissue and the placement of material directly onto the pulp.
Full pulpotomy
Full pulpotomy is indicated in similar cases to partial pulpotomy, except a larger amount of pulp is exposed. The process involves the complete removal of the coronal pulp to the root canal orifice level and applying material directly onto the remaining pulp in order to produce a positive biological response.
Offering successful minimally invasive outcomes
When carried out well using aseptic techniques, vital pulp therapy can produce predictable results with a high success rate. After one year, direct pulp capping with either CSC or calcium hydroxide shows a success rate of 90 per cent, with partial and full pulpotomy demonstrating 98 per cent and 99 per cent success rates respectively.
However, some clinicians hesitate to provide minimally invasive procedures such as these, as they are less familiar with them than conventional root canal treatment. As such, it’s important to carefully assess each case in order to establish whether they are a suitable candidate and whether an individual is sufficiently confident, competent, and indemnified to provide the treatment.
Decision-making in endodontic treatment planning
Research suggests that there are a number of factors which influence a clinicians decision-making relating to VPT or RCT. Even though it is widely accepted as a potential alternative to RCT in mature permanent teeth with compromised pulp, some dentists wrongly assume that VPT presents a high risk of treatment failures. As such, this contributes to clinicians choosing to provide conventional root canal treatment and avoid any perceived risks. Whilst the research around factors which may influence decision-making is conflicting, those with speciality training and more years of experience often chose VPT over RCT in cases of irreversible pulpitis.
For clinicians looking for assistance in the decision-making process and an informative reference with regards to diagnosis and treatment types surrounding VPT, the British Endodontic Society (BES) has produced a Guide to Good Endodontic Practice. The guide describes a wide range of scenarios relevant to endodontic diagnosis, decision making, and treatment types, in addition to management of complications. This informative resource is just one of the many ways the BES aims to keep its members informed and up to date with the latest research – also hosting multiple educational and networking events every year.
With minimally invasive treatment types showing good success rates, and many clinicians and patients favouring minimally invasive techniques wherever possible, it’s important that those providing endodontic treatment stay informed about developments in vital pulp therapy.
References available on request.
For more information visit www.britishendodonticsociety.org.uk