Treatment Of Vital Pulp Conditions
A multitude of harmful elements, alone or in combination
, may cause adverse reactions in the dental pulp under clinical conditions . If not properly managed they may result in:
painful pulpitis
pulp tissue breakdown
root canal infection, leading to periapical inflammatory lesion .
These effects are the result of inflammation and associated tissue destruction. Tissue destruction per se is a basic feature of inflammation in general and is a means by which the host carries out an effective defense against foreign matter, including bacteria and bacterial elements. However, as far as the pulp is concerned it can be devastating and result in total breakdown of the tissue.
Clinical scenarios:
Any direct exposure of the pulp to the oral environment involves the risk of destructive inflammatory breakdown . It should be noted that a pulpal wound has little self-healing capacity unless properly treated. In contrast to the skin and mucosal tissues, where cuts or wounds normally heal within a short period of time, the pulp has no epithelia that can bridge the defect. This means that even a small exposure may present the bacterial flora of the oral cavity with the potential to cause a destructive and irreversible (non-healing) inflammatory condition.
Factors influencing choice of treatment:
It is a most difficult task for a clinician to advocate the proper treatment when a pulp is exposed or when clinical signs and symptoms suggest inflammatory involvement. A conservative measure saves effort, time and money, whereas a pulpectomy, especially in the posterior tooth region, is often a technically demanding and timeconsuming procedure. This is why direct pulp capping has enjoyed some popularity over the years for the management of pulp exposures: it is non-invasive, easy to carry out and normally does not require an elaborate dental restoration afterwards. Nevertheless, a pulpectomy is the treatment of choice when the prognosis for pulpal survival is deemed questionable. If the pulp is assumed to be in an irreversible condition, a pulpectomy is always to be preferred in a fully developed tooth. The treatment is predictable and eliminates the risk for subsequent inflammatory breakdown of the tissue and associated infections and painful events.
Management of exposed pulps by direct pulp capping/partial pulpotomy:
Pulp capping and partial pulpotomy are procedures to consider when there is no history of lingering pain to external stimuli and when the pulp has been:
accidentally exposed to the oral environment by cavity preparation and traumatic injury;
exposed in conjunction with excavation of caries or hemisection in periodontal therapy.
Type of injury:
An accidental pulp exposure through intact dentin occurring during cavity and crown preparation has the greatest potential for a successful outcome. In this situation the pulp may be healthy and the bacterial contamination limited, therefore the immediate condition for healing is optimal.
Age:
Although not consistently observed it seems reasonable that the prognosis for capping and partial pulpotomy would be better in young than in old individuals . The fact that the pulp of young teeth is rich in cells and blood vessels makes it prone to react favorably to microbiological and traumatic challenges. On the other hand, in an aged tooth and/or tooth exposed to previous injury the pulp is often poor in cells, fiberrich and partly mineralized. Therefore it is likely to be more vulnerable and less able to survive a capping procedure. The size of the pulpal space in an old tooth is also much smaller, thus providing a greater risk for pulpal breakdown upon destructive stimuli . In the study by Hrstedetal. pulpal survival 5 years after pulp capping was 70% for 5080-year-olds but 85% for 3050-year-olds and 92% for 1030-year-olds.
Size and location of the pulp exposure:
The high success rate in clinical and radiographic follow- up studies after partial pulpotomy (16, 26, 50) has further put to question the relevance of exposure size as a significant parameter. It was once believed that cappings should be reserved only for pinpoint exposures. Current knowledge suggests that the total volume of the pulp tissue in relation to the size of the exposure is more pertinent.
Emergency treatment:
Emergency treatment is primarily carried out to give relief from painful symptoms. It may also be driven by an unforeseen complication that is not associated with pain but that requires temporary treatment until a definitive treatment can be conducted. As for teeth with vital pulps, emergency treatment may occur due to:
painful pulpitis
pulp exposure because of caries, iatrogenic injury or trauma in an otherwise non-painful tooth
mid-treatment or post-treatment pain subsequent to pulpectomy.
Time often sets limits for what is possible to achieve. Time constraints may be due to unscheduled appointments
in between regularly scheduled patients in the clinic, or because a complication occurred at the end of a scheduled treatment session.
by: hawary1
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