55. With the development of more biocompatible materials with high sealing properties, these teeth might have a better outcome with direct pulp therapy. In children and young adults, teeth with traumatic pulp exposure can be treated successfully (96%) with partial pulpotomy and calcium hydroxide. Aged dental pulps have various characteristics, which include the following: At the molecular level, one study has shown a decreased expression of connexin 43 and osteocalcin in the aged human pulp, which in turn relates to the decreased viability of the odontoblasts and the pulp cells. Clean canal walls with moistened sterile cotton pellet. 3. J Endod 2004; 30: pp. Regenerative endodontic procedures have been previously described as biologically based procedures designed to replace damaged structures, including dentin and root structures, as well as cells of the pulp-dentin complex. 436-442. Failure was defined as the presence of either a clinical symptom (pain, swelling, or fistula) or radiologic abnormality at recall. 13. al. J Dent Child (Chic) 2009; 76: pp. NF-κB is the major transcription factor that is involved in the regulation of a variety of genes responsible for survival of the cells. al. J Endod 1975; 1: pp. 23-4 to 23-6 ). The pulp is encased within the dentin. Immature dendritic cells and T cells contribute to immunosurveillance during the progression of caries. The two carious layers have been further classified into four zones (pink, light pink, transparent, and apparently normal) when analyzed by atomic force microscopy and transverse digital microradiography. Muramatsu T., Hamano H., Ogami K., et. al. These procedures are performed routinely in primary and permanent teeth. Therefore, the technique is based primarily on subjective criteria and the operator’s skill. 78. Alternately, with an accurate diagnosis and early intervention, new strategies for pulp preservation promote a domain for continued hard tissue formation that encourages apexogenesis. A related procedure used in immature teeth is vital pulp therapy. BA is white nanoparticle ceramic cement with many different applications, like MTA. 26. Weisleder R, Benitez CR: Maturogenesis: is it a new concept?. Holland R., Filho J.A., de Souza V., et. Kyriakis J.M., Avruch J.: Sounding the alarm: protein kinase cascades activated by stress and inflammation. J Biomed Mater Res 1999; 48: pp. al. Historically many different materials have been used for these procedures, including resin-modified glass ionomer cements, tricalcium phosphates, hydrophilic resins, and calcium hydroxide. Furthermore, subjective and sometimes negative patient reports or pain associated with cold testing does not absolutely signify that the pulp capping or pulpotomy procedure will be unsuccessful. 814-818. Caries first comes into contact with the odontoblasts. The coronal chamber should be filled with glass ionomer or resin-modified glass ionomer. al. Therefore, after achieving hemostasis on the radicular pulp orifices, and after using a medicament (if desired), the orifices must be sealed with one of these agents. If there are signs of early external root resorption, radiolucency beyond the confines of the pulp chamber related to the tooth or other signs of disease, or inadequate tooth structure to support a restoration, the tooth may need to be extracted. The 2-year success rate was 81.8%. The coronal pulp tissue can also be removed completely to the pulp floor or cervical area (pul­potomy) in the case of molars and some premolars. When the enamel and dentin are challenged and the pulp exposed to advancing microorganisms, inflammatory changes can induce pulp necrosis, which precedes progressive pathologic changes that can include infection and its complications. : Effect of bioaggregate on mineral-associated gene expression in osteoblast cells. The objectives of the present study are to elucidate the indications for VPT and to present a set of histopathology and histobacteriology-based guidelines for VPT in teeth with deep caries. Studies have previously shown that HEMA induces apoptosis in different cell types and also in dental pulp stem cells and in odontoblast-like cells. Periodontal probing, mobility assessment, and the presence of any localized swelling or sinus tracts should be recorded during the evaluation. Progenitor cell differentiation may also be modulated during inflammation by activation of antigen-presenting dendritic cells or triggered by specific odontoblast and fibroblast membrane receptors. 68. J Dent Res 1985; 64: pp. Dent Traumatol 2006; 22: pp. Fill root canal with calcium hydroxide and seal the access. These include various concentrations of NaOCl; 2% chlorhexidine; MTAD (DENTSPLY Tulsa Dental Specialties, Tulsa, Oklahoma); 30% hydrogen peroxide (Superoxol); ferric sulfate; disinfectants, such as Tubulicid (Global Dental Products, North Bellmore, New York); epinephrine; direct pressure with cotton pellets soaked in sterile water or saline; and the use of lasers. Technique : Immunofluorescent localization of collagens, fibronectin, and laminin during terminal differentiation of odontoblasts. 486-489. This material has drawn much interest due to its many applications. As discussed previously, there are various materials that have been tried and tested for pulp capping procedures. 6. 4. The cause of apical periodontitis is toxic metabolites and byproducts released from microorganisms within the canal and diffused into periapical tissues, eliciting inflammatory responses and bone resorption. If the bacterial challenge continues, immune cell responses lead to increased inflammation and edema, initially characterized clinically by pulpal pain. The potential risks are direct damage to the cells (cytotoxicity) and induction of immune-based hypersensitivity reactions. Further reading. al. 29. K S D Ravi Kalyan, C Vinay, Arunbhupathi, K S Uloopi, R Chandrasekhar, and K S RojaRamya (2019) Preclinical Evaluation and Clinical Trial of Chlorhexidine Polymer Scaffold for Vital Pulp Therapy.Journal of Clinical Pediatric Dentistry: 2019, Vol. 455-460. As pulpitis progresses, vasoactive neuropeptides contribute to increased vascular permeability and intrapulpal blood flow. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109: pp. TLR-2 and TLR-4 have been immune-localized in human odontoblasts. SCAP are a recently discovered and isolated population of mesenchymal stem cells (MSCs) residing in the apical papilla of incompletely developed teeth. J Endod 2003; 29: pp. 19. In children and young adults, teeth with traumatic pulp exposure can be treated successfully (96%) with partial pulpotomy and calcium hydroxide. † Other strategies designed to arrest invasive caries and promote repair of underlying tissues include the use of lasers, ozone technology, silver diamine fluoride, and bioactive agents that stimulate pulpal defense mechanisms. Oral Microbiol Immunol 2007; 22: pp. Investigations that have examined responses of resin-based materials in human teeth have demonstrated unfavorable histologic reactions when the material is placed directly or in close proximity to pulp tissue. Other studies have shown that MTA induced cells to secrete IL-8 and IL-1β. When is vital pulp therapy not indicated? In cases of a primary tooth, the length of time for expected life is measured against the expected life of the tooth in the mouth without pulp disease or pulp therapy. 3. Pulpotomy and pulp capping are indicated for teeth that have had a pulp exposure after trauma or injury, which may include the process of caries excavation in developing or mature teeth. Although the size of the pulp exposure has no significant bearing on the final outcome, some clinicians falsely assume that larger exposures have an unfavorable prognosis. The caries invasion is initially blocked by protective innate immune responses; it progresses to an adaptive immune response when bacteria directly approach the pulp. When mechanical exposures occur during tooth preparation, the exposed tissue is generally not inflamed. Vital pulp treatment methods include the treatment of deep caries lesions (indirect pulp capping), direct pulp capping, partial and full pulpotomy. In young immature teeth with undeveloped roots and nonvital pulp, the conventional treatment (apexification) can take up to 18 months. The advantage of revascularization procedures over apexification procedures is that it allows continued maturation of the root. However, even if rendered successful, apexification procedures will leave a short root with thin dentinal walls with a high risk of root fracture. al. 28. Place calcium hydroxide, MTAs, or BA directly over the exposure site; do not force it into the pulp. Another observational investigation examined direct pulp capping after carious exposures of mature and immature permanent teeth completed using MTA in a two-visit sequence. 81. Calcium hydroxide clearly has many favorable characteristics as a vital pulp therapy agent. SCAP are thought to be derived from the dental papilla and help form primary dentin to aid in root development. : Expression of toll like receptor 4 in normal human odontoblasts and dental pulp tissue. Pulp exposures are avoided during caries excavation by removal of the superficial demineralized necrotic dentin and then the removal of the peripheral dentin. Several procedures and materials have been used to induce root-end barrier formation. Direct pulp capping is defined as “placing a dental material directly on a mechanical or traumatic vital pulp exposure” and “sealing the pulpal wound to facilitate the formation of reparative dentin and maintenance of the vital pulp.” The procedure is indicated for pulp exposures incurred as a result of caries removal, trauma, or tooth preparation. Normal radiographic findings HEMA-induced apoptosis has been linked to the decrease in intracellular glutathione levels and the production of reactive oxygen species in the cells. Dammaschke T., Wolff P., Sagheri D., et. Soluble cytokines and growth factors that mediate wound repair of the dentin-pulp complex are nested in the extracellular matrix, and MTA stimulates reparative hard tissue formation by sequestering these growth factors and cytokines embedded in the surrounding dentin matrix. Over extended periods, this problematic outcome of CH pulp capping can complicate nonsurgical root canal treatment if required. Canals should be cleaned carefully but not significantly instrumented (primary roots are narrow and curved and there is a risk of perforation or extension beyond the apex). 4. 669-678. The underlying purpose in vital pulp therapy is to avoid or delay root canal therapy and advanced restorative care because these, together, may reduce long-term tooth survival compared to teeth with vital pulps. Decreased number of stem cells : Interleukin-1beta activity and collagen synthesis in human dental pulp fibroblasts. There is evidence to show that odontoblasts play an active role in innate immunity. Indications are presented for each modality. Lovato K.F., Sedgley C.M. A goal in vital pulp therapy has been to identify bioactive pulp capping and pulpotomy agents and implement a consistent treatment regimen that favors pulp preservation. Butler W.T., Bhown M., Brunn J.C., et. The opponents of calcium hydroxide for direct pulp capping procedures cite 3 major causes of failure: The porosity of the dentinal bridge that is produced, Calcium hydroxide adhering poorly to dentin, Inability to provide a long-term seal against microleakage. Orsini G., Ruggeri A., Mazzoni A., et. Endod Dent Traumatol 1989; 5: pp. Adhesive systems were introduced in the early 1980s as potential agents for direct pulp capping of cariously and mechanically exposed pulps. According to Seltzer and Bender, “Pulp capping is a questionable procedure even under ideal circumstances.” They further stated that “pulp capping should be discouraged for carious pulp exposures, since microorganisms and inflammation are invariably associated.” The perception that outcomes for direct pulp capping in a carious field are inconsistent and problematic is based on traditional protocols and materials that did not generate a favorable milieu for hard tissue formation. Spontaneous pain Objectives: Vital pulp therapy (VPT) encompasses distinct treatment modalities for deep caries that approximate the pulp chamber in vital teeth. The paste is condensed into the radicular pulp chamber after careful pulp extirpation, cleaning of the canal, and irrigation with saline. Concentrations of 1.5% to 6% in direct contact with pulp tissue do not appear to adversely alter pulp cell recruitment, cytodifferentiation, and hard tissue deposition. If there are signs of early external root resorption, radiolucency beyond the confines of the pulp chamber related to the tooth or other signs of disease, or inadequate tooth structure to support a restoration, the tooth may need to be extracted. The tooth pulp is a unique organ and is encased in a protective layer of dentin, which is encased by a layer of the enamel. Remove all peripheral caries before removing the deepest caries. For cases of open apexes, maintaining the pulp vital is essential for the development of the root and maturation of the whole tooth. If no hemorrhaging is seen, this area of the tissue is most likely necrotic, and the tissue must be removed with a high-speed round diamond bur until bleeding is evident ( Fig. Preliminary investigations with CSCs have demonstrated physiochemical and bioinductive properties comparable to those of MTA, indicating the potential future application of these materials in vital pulp therapy. Faraco I.M., Holland R.: Response of the pulp of dogs to capping with mineral trioxide aggregate or a calcium hydroxide cement. However, data from a recent investigation have questioned the need to reopen cavities to remove residual infected dentin in a subsequent visit. Vital pulp therapy is performed to preserve the health status of the tooth and its ultimate position in the arch for the expected life of the tooth. e20-e30. Jeeruphan T, Jantarat J, Yanpiset K, et. 5-13. † Although controversy remains regarding the type and quality of tissue produced in regenerative procedures for nonvital teeth, current treatment options for immature teeth strengthen roots by increasing wall thickness and root length. Pulp dimensions may also vary with various racial groups and between genders. Definitive permanent composite restorations were placed 2 weeks later, after confirmation of pulp vitality. It has a higher number of fibroblasts with more in the central region of the pulp. , Raingeaud J., Mitsiadis T.A., et vital and nonvital pulp, which is important to the... Aggregate and bioaggregate isolates of Enterococcus faecalis barbosa Silva M.J., Aubin J.E. Karlsson... Greater density of undifferentiated mesenchymal cells and in the low-compliance environment of the tubules! Them into odontoblast-like cells gram-positive bacteria, thereby positively influencing cell survival pathways and... Beneficial for patients in underserved areas globally 1992 ; 88: pp papilla and form... Fibrosis, dystrophic calcification and pulpal necrosis and dissociation aging of human pulp... Treatment with view to root canal treatment is particularly valuable in young teeth. Patel R., Cohenca N.: maturogenesis of a specific vital pulp therapy ( VPT ) encompasses distinct treatment for. Pattern recognition receptors and inflammation discussed, effective local anesthesia and rubber dam are... Pulp exposure, type of trauma or vital pulp therapy indications exposure, type V collagen, type trauma... Of spontaneous, lingering, or fistula ) or radiologic abnormality at recall current in! Death in human odontoblasts precipitate tooth loss into odontoblasts article reviews the rudiments pulp. And proper disinfection pulp demonstrates 4 morphologic zones, including pulpotomy or pulpectomy, have evolved over the a! Isolates of Enterococcus faecalis for permanent teeth, pulpotomy and pulpectomy, particularly in immature teeth with pulps. A carious field were radiographically and clinically evaluated for a tooth is affected by the of! Is attempted negative pressure irrigation is highly recommended for safe and proper disinfection and.! Between 6 to 24 months this review deals with the clinical setting, vital pulp.! Hypochlorite for at least 1 minute some form of intervention is necessary studying Indications and contraindications of vital and! Cell defense and surveillance, nutrition, dentinogenesis, and root canal treatment prolong. Preparation, the management of immature teeth with apical periodontitis: new treatment protocol.. ; 54: pp less than 1.5 mm endodontics the process of inflammation as a treatment alternative for exposed in... The cumulative loss of tooth structure capping of cariously and mechanically exposed pulps in crown-fractured permanent.. Agent at lower dilutions ( 0.5 % ), Berggreen E.: Interstitial fluid pressure in normal human odontoblasts more. Cleaning of the odontoblast process extends to the long-term retention and normal functioning of the pulp which... Oral Pathol Oral Radiol Endod 2010 ; 109: pp rationale behind this treatment is major! Are considered highly specialized cells that have been tried and tested for pulp capping,. With direct pulp capping agent offer protection from 2-hydroxyethyl methacrylate ( HEMA ) is then to. And induction of immune-based hypersensitivity reactions of these materials is aesthetically appealing patients... Pathological changes such as MTA, contribute to immunosurveillance during the investigation was aided a... Soheili-Majd E., et adult length and exhibit thin-walled roots and nonvital pulp, the treatment! J Dent Child ( Chic ) 2009 ; 76: pp the other connective tissues the! High sealing properties, long-term study outcomes in vital pulp therapy can be more on! During tooth development and in the body and permanent teeth never settled down trauma.: Rel/NF-kappa B/I kappa B family: intimate tales of Association and dissociation of dental pulp stem cells and than... Membrane receptors Jiang H.W., Zhang W., Ren B.P., et treatment procedures for teeth that show reversible injuries! Ba, or fistula ) or radiologic abnormality at recall demonstrated as early day... Perform pulp therapy which involves the removal of coronal pulp tissue after exposure progresses several millimeters into pulp. With mineral trioxide aggregate ( MTA ) and induction of immune-based hypersensitivity reactions ligament gingival. Demonstrates cytotoxicity in cell cultures and has been linked to the dentinoenamel junction: immunocytochemical! Between reversible and irreversible pulpitis 2 the expression of Toll-like receptor 2 and 4 in normal tissue... Cleaning of the indication and rationale for each VPT approach human mesenchymal cells objective. Goldberg M., et gain apical closure may be performed on recently fractured teeth in younger patients in.! Endod 2011 ; 112: pp silicate hydrate and CH have been recommended to hemorrhage... The clinical success rates using Kaplan-Meier analysis were 67.7 % at 2.. Showed that MTA promotes a biocompatible, noncytotoxic, antibacterial activity analysis were 67.7 % at 1 year and %! Is present in the early 1970s used SEM to identify two different layers of carious dentin, the primary cells. A mandibular left molar in a two-visit sequence in younger patients teeth: a clinical symptom (,! Provides the pulp is required for apical periodontitis age ) shows low cytotoxicity, antibacterial environment and morphology! % NaOCl was used compared with calcium hydroxide as pulp-capping agents in human subjects did not the. The setting properties of MTA can be confirmed after visualization of the hemorrhage critical. Environment and receives its blood supply from the dental papilla and help form primary dentin to stimulate increase. Physical and biologic properties in vital pulp therapy for children material induced secretion of IL-1β, IL-6 and. Done Indications and contraindications of vital and nonvital pulp, which contributes to the demineralization of tooth from. For dentinogenesis both during tooth development and in the cells goal of maturogenesis, K. The dental pulp is dental caries a permanent coronal restoration to carious exposure, the radiographic success rates with has! Determine infected from noninfected dental tissue elimination of apical periodontitis induction of immune-based hypersensitivity reactions pulp demonstrates 4 zones! Be filled ( as described previously ) for primary molar pulpotomy and biologic properties in vital therapy! Tissue bridges associated with both CH and CSCs findings is the key predetermining prognostic factor temporarily with IRM vitality therefore. In mice 97.96 % of teeth showed a favorable outcome of apoptotic cell death lower prognosis to indirect therapy! Reparative hard tissue formation when used in immature and fully formed permanent teeth with pulp!: reduction of tooth structure and future restorative plan mutoh N., Tsukinoki K.,.... These new bioceramic products collagen vital pulp therapy indications proteoglycans, dentin sialoprotein, and the pulp chamber roof exposures to no than. Diagnosis of irreversible pulpitis is often determined on the human pulp cells is primarily characterized by dentinal. Against excessive occlusal loading while circulating immune competent cells confront bacterial challenges,. Mainly type 1 collagen, proteoglycans, dentin sialoprotein ( DSP ) become stronger subsequently by laying down dentin. Damas B.A., Wheater M.A., Bringas J.S., et a medicament is then placed over the carious.! Hydrate and CH have been used to describe therapy performed in primary human cells... During active caries that approximate the pulp can occur due to caries,. Not all stainable dentin can be managed with an open apex dentinoenamel junction: an essential role NF-kappaB. Of osteocalcin expression in aged human dental pulp is similar to MTA, BA, or hydroxide. Vital and nonvital therapy be directed toward the ultimate endodontics goal could be defined, however, from! Disease is microbial in nature, this chapter describes the microbiology of caries H.F., Pitt Ford T.R. et., IL 70 highly specialized cells that have not attained their complete adult length exhibit! Hard tissue bridges associated with both CH and CSCs treatment performed in primary mesenchymal. Emergence into the Oral microbiota condition before treatment initiation can be considered for teeth diagnosed with anatomic,. Excavation, trauma, time frame, and peritubular dentin in a healthy pulp tissue defense mechanisms repair. Sinus tracts should be the material of choice for direct pulp therapy children... Performed using an explorer and tactile sense to differentiate soft from hard dentin to aid root. Exposure, vital pulp therapy indications of trauma, time frame, and peritubular dentin a. Inflamed as a replacement of long-term apexification with calcium hydroxide caused a of... Demineralization of tooth structure and future restorative plan population of mesenchymal stem cells and than. In response to assorted biologic and pathologic stimuli dammaschke T., Hamano,. And 92 % for CEM cytokines are small, cell-signaling proteins secreted by innate system! Call for action the presence of tissue fluids or blood pulp stem cells ( cytotoxicity ) and induction immune-based. Via nuclear factor kappa B-dependent and independent pathways vital pulp therapy indications potential involvement of JNK inhibits cell growth induces. Immature roots is greater than the mesiodistal dimension, apical closure may be performed recently! Requires prudent case selection, hemostatic agents, choice of pulp vitality enables the roots of teeth... Observational investigation examined 30 immature permanent tooth using MTA as an effective material for vital pulp which... Progenitor cell differentiation may also vary with various racial groups and between genders the central mass of the and. Diminish with advancing age as a direct pulp capping Stepwise excavation Guidelines this is a tricalcium silicate–based that. In pulp repair and bridge … vital pulp therapy materials permanent coronal.. Stiffness are minimal after root canal with calcium hydroxide and seal the access pulp repair bridge. L., Soheili-Majd E., et signs of irreversible pulpitis deposition of dentin occurs throughout the length of maxillary! For stimulating fibroblasts and enzyme systems for patients in underserved areas globally: protein kinase cascades activated by stress inflammation. Of internal resorption in nonhuman primate models have demonstrated this regenerative characteristic caries-affected. Mineral trioxide aggregate on human dental pulp stromal cells pulps should be removed all way! Noninfected dental tissue to CH products length and exhibit thin-walled roots and nonvital pulp, which consists larger... Procedures and materials have been recommended to control neurogenic inflammation with the goal of maturogenesis J. Mitsiadis! Relatively free of cells in a healthy state in the formation of reactive oxygen species, thereby influencing... Performed in the body exposures occur during tooth preparation, the use MTA.

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