Vital Pulp Therapy, a Highly Effective Treatment – Testimonial & Case Report by Jenner Argueta D.D.S. – M.Sc.

​Introduction

A high percentage of the population decides to visit the dentist when their teeth are considerably affected by caries. In many cases, the patients opt for early extraction of teeth due to the costs of root canal therapy and the posterior restoration process (1, 2). The importance of keeping the pulp-dentin complex vital, the search for alternatives to root canal therapy, and the clinical application of minimally invasive dentistry have led to the increased popularity of conservative approaches to pulp damage. The high success rate reported for vital pulp therapy (VPT) procedures nowadays has been a key factor in bringing a higher frequency of application of this type of therapy (3, 4). The good prognosis of these procedures has been partly achieved thanks to current treatment protocols, and understanding of the biological processes involved, and the materials available for use in cases of reversible pulp disease.

A good diagnosis is the most important and complex factor when making decisions and establishing a course of treatment. Determining the exact degree of pulp inflammation is not an easy task, given the limitations of current diagnostic tests, subjective factors inherent to the patient, and the correct interpretation of the clinical information by the operator (5-7). It is well-known that, for a VPT procedure to work, the pulp inflammation should be in a reversible stage (reversible pulpitis). It is important to bear in mind that current pulp sensitivity tests are not 100% reliable  (6, 8).

Direct pulp capping. Clinical technique

In the clinical case below, we describe the recommended technique for performing direct pulp capping in cases of frank pulp exposure with a diagnosis of reversible pulpitis. This clinical case was selected because it is the one that occurs most frequently.

The patient attended reported short-term pain in tooth no. 19 (Fig. 1). Through radiography, a clinical assessment, and an analysis of the patient’s clinical history, an extensive carious lesion was diagnosed (Fig. 2) as the cause of the pain, due to a process of reversible pulpitis.

Complete sealing was achieved using a rubber dam, a stainless-steel Clamp, and a light-curing Flowable dam located around the clamp to prevent bacterial contamination of the area to be treated. The caries were removed circumferentially from the coronal towards the cervical margin to limit the movement of bacteria to the pulp tissue space (9). An exploration of the cavity preparation floor showed a pulp exposure (Figs 3 & 4). It is always advisable to explore the cavity preparation floor with an endo explorer, because smaller carious-exposed pulps may be overlooked.

In cases where there is hemorrhaging in the exposed pulp region,  it is necessary to apply sustained pressure for 40–60 seconds with a cotton swab dampened with sterile saline solution (10), followed by the disinfection of the cavity with 0.5% sodium hypochlorite. After this, Biodentine bioactive material was placed to directly cap the pulp (Figs. 5 & 6), the material was placed in bulk increments as a dentinal replacement, as the material sets in 12 minutes, it was possible just to wait until the indicated time and the restoration could be done in the same session (11). The definitive restoration was done afterward, using composite resin with the oblique layer technique (Figs. 7) with the aim of minimizing the contraction of the material (12).

The quality of the definitive restoration and its close adaptation to the dentine structure to prevent leaks are key factors in the long-term success of the procedure. Correct marginal adaptation and the continuity of the restoration with the dental tissue can be seen in the final radiograph of the procedure (Fig. 8). An assessment was made seven days after treatment to ensure that the patient was completely asymptomatic and responded to sensitivity tests in a normal manner. A normal tissue response was obtained in all the tests.

One of the main characteristics of Biodentine is that it is easy to manipulate, it can be used as a dentine substitute due to its high compression strength, and offers good adhesion to the tooth structure. Its characteristics mean that it is easy to place it in the region to be treated and can be used as a base for the definitive adhesive coronal restoration. Fig. 9 shows the vital pulp therapy procedure. In radiographic form, on follow-up after two years, it is possible to observe mesial pulp horn retraction. One of the most appreciated advantages of Biodentine is that it does not pigment the tooth structure, making it an ideal material for performing pulp capping in the anterior sector.

Fig. 1. Tooth no. 19 with deep caries. Total isolation prior to the removal of caries.

Fig. 2. Bite radiograph shows evidence of a carious lesion of tooth 19. Undermineralized tissue is found close to the mesial pulp horn.

Fig. 3. & Fig. 4. Pulp exposure at the level of the cavity preparation floor, with minimum hemorrhaging that was easy to control.

Fig. 5. & Fig. 6. Placing of Biodentine in bulk increments with the help of an endodontic compactor.

Fig. 7. Definitive adhesive restoration in tooth no. 19.

Fig. 8. Final radiograph of the vital pulp therapy procedure. The different layers of materials used, and the correct marginal adaptation can be seen.

Fig. 9. Vital pulp therapy at tooth no. 19 . At follow-up after 2 years the retraction of the mesial pulp horn can be seen

Materials used in Vital Pulp Therapy

Among the materials described to carry out pulp therapy procedures, calcium hydroxide-based cement and bioceramics (10) have been mentioned. The latter are biocompatible materials that are divided into three basic groups: 1. High-resistance bioinert cement 2. Bioactive types of cement create chemical bonds with mineralized tissue, and 3. Biodegradable materials actively participate in the metabolic processes of the organism (13). There are many materials that can be used for vital pulp therapy procedures, the best-known being MTA and the latest-generation calcium silicate-based cement such as EndoSecuence BC RRM, Biodentine, and CeraPutty, among others. All the materials mentioned above belong to the bioactive types of cement group.

Biodentine is a dentin substitute that helps to promote dentinogenesis and shows next biological properties: alkaline pH, biocompatibility, anti-bacterial capacity, the release of calcium and hydroxyl ions, good margin sealing properties, and insoluble when coming into contact with oral fluids. Its radiopacity is also similar to that of dentin, the setting time is approximately 12 minutes, and it does not cause pigmentation in the dental structure (14-18). This last property makes it one of the materials of choice when it is necessary to perform treatments that involve the coronal and cervical zones, especially in anterior teeth.

Prognosis

Obtaining the right diagnosis is essential for the success of VPT. An ideal case is one diagnosed with reversible pulpitis without a history of spontaneous dental pain or long duration (6). It is generally accepted that a history of spontaneous pain or nocturnal pain is associated with the existence of a process of irreversible pulp inflammation (19, 20). In such cases, the success of direct pulp capping could be questioned (21), although some studies indicate that VPT can even be successful in this kind of situation. (1, 22-24).

As for long-term success in VPT procedures, it is extremely important to give the tooth a definitive restoration that guarantees suitable margin sealing, because this factor, together with the absence of bacterial contamination during the procedure, are among the most important aspects to be taken into account to avoid later pulp inflammation (25, 26).  The reported success rate for vital pulp therapy using bioactive types of cement and follow-up of up to 10 years is higher than 85% (3, 27), quite a high percentage for a dental procedure over that length of time.

Conclusions

From a completely optimistic standpoint, the ultimate aim of any dentist when carrying out a restorative and/or endodontic procedure should be to maintain pulp vitality and functionality of the tooth with an absence of symptoms. (28).

Based on the results reported in a number of clinical research studies (1-5, 17, 18, 25, 29-31), we can conclude that VPT on teeth with reversible pulpitis is a highly effective treatment option for maintaining pulp vitality.

Jenner Argueta D.D.S. – M.Sc.

jennerargueta@gmail.com

1ª. Av. 13-29 zona 10. Edificio Dubai Center 5to. Nivel, Oficina 501. Guatemala, Guatemala C.A.

Dr. Jenner Argueta holds a dentistry and endodontics master’s degree in endodontics from San Carlos de Guatemala University, where he achieved multiple awards as an outstanding student. He Is the former president of the Guatemalan Endodontics Academy (2016–2020) and is a certified researcher at the Guatemalan National Council for Science and Technology. International Speaker, Faculty endodontics professor at Mariano Galvez de Guatemala University. His clinical practice is focused on micro-endodontics and micro-restorative dentistry.

Co-author

Ana Lucía Orellana D.D.S.

Private Practice. Argueta-Orellana microscopic dental offices.

Clinical Coordinator