Abstract
Vital pulp treatment (VPT) is a therapeutic strategy aimed at conservatively managing deep carious lesions and the exposed pulp. VPT has recently expanded through the use of hydraulic-calcium-silicate cement (HCSC), cone-beam CT, and dental operating microscopy (DOM), as well as an improved understanding of pulpal repair mechanisms. Consensus documents have concluded that non-selective removal of caries is not necessary in the absence of clinical symptoms, as partial or non-selective caries removal techniques reduce the likelihood of pulp exposure. Alternatively, others suggest that leaving carious tissue may help sustain pulpal inflammation and lead to failure of VPT. The presence of a purulent discharge from the exposed pulp is considered indicative of an irreversible damage and a need for pulpectomy. This report documents the successful VPT in a symptomatic molar with deep caries that exhibited purulent discharge from the pulp after exposure. A female patient presented with spontaneous pain in the maxillary left second molar. One year before, she had received a cast-metal restoration over a resin-based-composite (RBC) restoration. The tooth had been largely asymptomatic since; however, after experiencing spontaneous pain, she consulted the hospital clinic. Radiographs indicated that the restoration was not deep with visible dentin between the restoration and the pulp. Pulp sensibility tests yielded a positive response. There was no pain on percussion and no periodontal problems. Removal of the restoration and carious dentin using a DOM resulted in a pulpal exposure with purulent discharge and bleeding. A partial pulpotomy using HCSC was performed. Six months later, the clinical symptoms had completely resolved; however, due to concerns of partial necrosis, the patient was re-assessed. DOM examination revealed an incomplete hard-tissue barrier; moreover, there were also signs of residual tissue with inflammation. As a result, the defected area was enlarged, the pulp tissue debrided, and the HCSC reapplied. After review at 1 year, the tooth remains symptomless, with no apical radiolucency. Notably, this report visually illustrates that exposed pulp tissue containing limited region pus can maintain vitality after VPT. This finding raises two questions: (1) whether leaving infected dentin in situ and avoiding visualization of the pulp exposure is appropriate; and (2) whether the presence of purulent tissue in the pulp warrants a pulpectomy.
Highlights
Vital pulp treatment (VPT) is a biologically based and minimally invasive procedure, which has recently become the focus of extensive research activity and interest in endodontics
The European Society of Endodontology (ESE) position statement for management of deep caries and the exposed pulp [3] concluded that in the absence of clinical symptoms, non-selective removal of caries is not warranted, as partial or selective caries removal techniques reduce the likelihood of pulp exposure
A 46-year-old female patient presented with spontaneous pain around her left maxillary second molar, which had previously received an indirect metal restoration above a resin-based-composite (RBC) restoration placed as a liner at a private dental clinic 1 year previously
Summary
Vital pulp treatment (VPT) is a biologically based and minimally invasive procedure, which has recently become the focus of extensive research activity and interest in endodontics. On her first visit, a 46-year-old female patient presented with spontaneous pain around her left maxillary second molar, which had previously received an indirect metal restoration above a resin-based-composite (RBC) restoration placed as a liner at a private dental clinic 1 year previously. A decision was made to reenter the tooth, as the previous finding of purulent discharge, suspected irreversible pulpitis, and two reported incidences of mild pain occurring after the partial pulpotomy and just 2 weeks before the patient appointment suggest that inflamed tissue may have remained in situ. The exposed pulp was identified, alongside minimal bleeding, and the patient complained of slight pain in spite of the anesthesia At this stage, the reentry was considered sufficient and as for the intraoperative diagnosis that supplemented preoperative information with clinical information, it was concluded reversible pulpitis.
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