This month’s British Dental Journal (BDJ. Vol 237: No. 3; August 9, 2024) has highlighted an article from the Journal of the American Dental Association; Clinical and patient-level predictors of procedure and tooth survival after direct pulp capping. (Gencerliler N et al: J Am Dent Assoc 2024).
This article reports on statistics gathered from New York health insurance data between 2006 and 2019. Having followed 4,136 cases of direct pulp capping (DPC), tooth survival rates of 92.9% were achieved. Failures predominantly arose within the first year, with molars having an appreciably higher success rate.
Intriguingly, the same-day placement of a permanent restoration was a significant predictor of DPC survival. This information highlights the requirement for the endodontist to undertake this procedure as part of their clinical responsibility, in a timely manner.
Subsequent to the position statement from the European Society of endodontology (Duncan HF et al, Int Endod J 2019; 52: 923-934), pulpotomy is increasingly recognised as a treatment option for the management of permanent teeth with extremely deep caries, and suitable to manage permanent teeth diagnosed with irreversible pulpitis. This message was endorsed by Nicolas Longridge in his article Restorative Management of the Posterior Tooth that has Undergone a Pulpotomy (Longridge NN et al: Dental Update 2023; 50: 932-940). This article confirms that following irrigation with sodium hypochlorite (NaOCl 0.5-5%), placement of hydraulic calcium silicate cements (HCSCs) have demonstrated superior healing with more consistent dentine bridging over the historic use of calcium hydroxide (Kundzina R et al: Capping carious exposures in adults: a randomised controlled trial investigating mineral trioxide aggregate versus calcium hydroxide, Int Endod J 2017; 50: 924-932).
The American Association of Endodontists’ position statement on vital pulp therapy, while acknowledging the options of both immediate (one-stage) and delayed (two-stage) lamination with the definitive restorative material also recommends immediate placement of the permanent restoration material (AAE Position Statement on Vital Pulp Therapy. J Endod 2021; 47: 1340-1344).
At present, HCSCs are used as dentine replacement materials and as such, lamination with a more conventional and definitive restorative material is currently required. Multiple formulations of HCSCs are now available including the light-curable, resin-based Theracal LC (Bisco, USA). However, further research to understand the influence of di-methacrylate monomers in pulpal irritation and healing is suggested before the use of Theracal in general practice (Arandi NZ, Rabi T: from biochemical and bioactive properties to clinical applications. Int J Dent 2018; 2018: 348-4653).
The initial setting times for the commonly used HCSCs, such as Biodentine and TotalFill BC RRM fast-set putty, are reported as 12 minutes and 20 minutes, respectively, which add considerable time to the length of treatment. In summary, in following the recommendations for immediate lamination of the HCSC, Longridge favours a two-layer lamination with resin-modified GIC and composite resin; while acknowledging that clinicians may alternatively opt for a single layer of composite resin onto the set HCSC.
The same ‘Update’ article goes on to comprehensively describe the long-term restorative management of pulpotomy cases in posterior teeth. Thankfully, this aspect of the treatment can be considered as outside the endodontist’s responsibility and therefore outside the remit of this critique.
In a similar vein, Maria Lessani in her article Endodontic outcomes unveiled (The Dentist: May, 2024; 68-70) hypothesises that in a scenario of 1,000 teeth that were historically treated with conventional root canal treatment (RCT), at an 80% success rate, 200 would have failed. In contrast, 1,000 teeth treated with DPC would be expected to have a 95% success rate, with only 50 teeth failing and requiring conventional RCT. Based on an 80% success rate of these remaining teeth, only 10 would fail. Obviously, these success rates could be further improved upon with retreatment or apical surgery. While these percentages may be food for discussion, the concept still holds.
An opportunity for us all to apply Kaizen?
