Canis ISSN: 2398-2942

Endodontics: vital pulp therapy

Synonym(s): Partial coronal pulpectomy and direct pulp capping, pulpotomy

Contributor(s): Brook A Niemiec, Rachel Perry, Alex Smithson

Introduction

  • The endodontic system is the pulp tissue (vessels, nerves, lymphatic and connective tissue) that are in the root canals and pulp chambers.
  • Endodontic disease refers to pulp inflammation (pulpitis) or necrosis (partial or complete) of the pulp tissues.
  • Vital pulp therapy (VPT) is a technique in endodontics designed to maintain a living (vital) tooth.
  • Vital pulp procedures involve direct and indirect pulp capping.
  • Partial coronal pulpectomy is a stage in vital pulp treatment, and describes the removal of part of the coronal portion of pulp tissue. This is followed by direct pulp capping.
  • Direct pulp capping refers to placement of a dressing directly onto the pulp to stimulate healing, before a final restoration is placed.
  • Pulpotomy is a term that has also been used in the past, but by definition means cutting into the pulp, rather than excision of pulp. As part of the pulp in the crown is removed, partial coronal pulpectomy is the preferrred term.
  • Indirect pulp capping refers to placement of a dressing onto a layer of dentine over the pulp.
  • This therapy presents a potential, but controversial, alternative to extraction.
  • Radiographic indications of success do not guarantee a pain-free tooth.
  • Radiographic monitoring is VITAL.
  • Use is generally limited to temporary treatment with view to root canal therapy Endodontics: root canal therapy long-term.
    These are advanced procedures requiring significant study and practice. They should only be attempted by suitably qualified colleagues.

Uses

  • Repair of recent complicated crown factures (ie fractured teeth with pulp exposure Teeth: acute complicated crown fracture Dental fracture ) in mature tooth. If treated within 48 hours there is an 88% success rate, which drops to 42% if left for 1 week, and 23% if left for >1 week. Therefore, in longstanding complicated crown fractures (or those of unknown duration), a full pulpectomy (ie root canal procedure Endodontics: root canal therapy ) should be performed.
  • Management of vital immature teeth with complicated crown fractures (ie pulp exposure) to induce root apical closure and continued tooth maturation (apexogenesis).
  • Crown shortening as used for certain occlusions, such as lingually displaced mandibular canine teeth Teeth: crown shortening due to malocclusion Teeth: class II malocclusion 01 Teeth: class II malocclusion 02 (orthodontic or post-operative mandibulectomy).
  • Disarming aggressive patients (in USA).
  • Pulpal or near pulpal exposure during restorative procedure, for instance caries treatment Teeth: restoration of dental caries.
    NOT recommended for mature teeth (standard RCT is preferred).

Advantages

  • Allows continued maturation of a tooth due to its pulp vitality. In young dogs, this allows teeth to mature and therefore become stronger and root apices to completely form (apexogenesis). Immature teeth with thin detinal walls are fragile. Furthermore, thin-walled immature teeth with open apices cannot be treated by standard root canal procedures.
  • Much less traumatic procedure than extraction Dental extraction (especially with strategic teeth).
  • Quicker to perform than standard root canal procedure.

Disadvantages

Technically demanding and if not performed perfectly will fail - with painful consequences.

  • Can be time intensive.
  • Expensive set-up.
  • Long term follow-up is required.
  • High failure rate if incorrectly performed.
  • Success rate significantly lower than with root canal therapy.
  • Follow-up with root canal therapy results in multiple procedures and expense.
  • Other options for malocclusion Dental malocclusion and disarming available with greater success rates.
  • Other less expensive options for malocclusion and disarming available.
  • Lack of clinical signs with failure.
  • Radiographic signs of success do not guarantee a pain-free tooth.
  • For complicated crown fractures, VPT shold be performed as soon as possible after the fracture occurs for the best chance of success.
  • Insufficient removal of inflamed/infected pulp will lead to treatment failure.
  • Treatment failure must be addressed and treated by full root canal therapy or extraction.

Requirements

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Preparation

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Procedure

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Aftercare

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Outcomes

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Prognosis

  • Very good prognosis when performed on an intact tooth by qualified referral specialist.
  • Elective crown shortening may carry up to 100% success rate if performed with skill.
  • VPT success depends on the age of the dog, and time since fracture occurred. The best success rates are seen when the fracture is treated within 48 hours.
  • Prognosis based on radiographic indication of pulp viability (continued tooth maturation, formation of dentinal bridge below dressing, periapical health Teeth: vital pulp therapy 09 - radiograph ), however this does not guarantee a pain-free tooth.

Further Reading

Publications

Refereed papers

  • Recent references from PubMed and VetMedResource.
  • Parirokh M, Torabinejad M (2010) Mineral trioxide aggregate: a comprehensive literature review - Part I: Chemical, physical, and antibacterial properties. J Endodontics 36 (1), 16-27 PubMed.
  • Parirokh M, Torabinejad M (2010) Mineral trioxide aggregate: a comprehensive literature review - Part III: Clinical applications, drawbacks, and mechanism of action. J Endodontics 36 (3), 400-413 PubMed.
  • Niemiec B A (2005) Fundamentals of Endodontics. Vet Clin North Am Small Anim Pract 35 (4), 837-68, vi PubMed.
  • Niemiec B A (2005) Dental radiographic interpretation. J Vet Dent 22 (1), 53-59 PubMed.
  • Clarke D E (2001) Vital pulp therapy for complicated crown facture of permanent canine teeth in dogs: a three-year retrospective study. J Vet Dent 18 (3), 117-121 PubMed.
  • Mulligan T W, Niemiec B A (2001) Endodontic treatment of vital pulp tissue. Clin Tech Small Anim Pract 16 (3), 159-167 PubMed.
  • Niemiec B A (2001) Assessment of vital pulp therapy for nine complicated crown fractures and fifty-four crown reductions in dogs and cats. J Vet Dent 18 (3), 122-125 PubMed.
  • Niemiec B A, Mulligan T W (2001) Vital pulp therapy. J Vet Dent 18 (3), 154-156 PubMed.

Other sources of information


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