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Dental Tribune Middle East & Arica Edition

Media CME DENTALTRIBUNE Middle East & Africa Edition 6 Author_ Dr Robert Teeuwen, Germany _The vital amputation (VA) of deciduous teeth with the goal of maintaining their function- ality for a limited period is a widelyacceptedmeasure.Vital amputation of permanents, however, is only ap- proved for limited indications. While therapeutic agents such as cal- cium hydroxide (Ca(OH)2) and min- eral trioxide aggre- gate (MTA) are recommended for VAs, formaldehyde (CH2O) containingagentsareacontro- versial subject. The European Society of En- dodontology (ESE) defines pulp amputation as a procedure dur- ing which part of the exposed vi- tal pulp tissue is removed with the aim of maintaining vitality and function of the remaining parts of the pulp.1 ESE recog- nises the fol- lowing indications for VAs (i.e. pulpotomy): 1. treatment of deciduous teeth; 2. treatment of permanents with incomplete root growth; and 3. emergency measure. Indications 2 and 3 include the option of a later definitive root-canal treatment (RCT). Seidler recommends VA for the accidentally opened pulp of young molars and extremely curved, narrow root canals.2 Stern considers difficulty in opening the mouth an indication for VAs as well.3 McDougaletal.extendthein- dication for pulpotomy when there are economic concerns, as some patients are unable or un- willing to bear the expense of a RCT.4 AccordingtoSwiftetal.,asuc- cessful VA may be expected fol- lowing traumatic or mechanical carious pulp exposure.5 We con- sider predictable success with the following prerequisites: _non-inflamed pulp; _bacteria-proof closure; and _use of a pulp-compatible cap- ping material. Seidler states the following regarding the success of VA:2 _A higher rate of success is observed in cases of iatrogenic pulp exposure. _Treatment success is re- duced in cases of complete root growth. _Molars are more success- fully treated than incisors. For a pulpotomy with Ca(OH)2, Jensen presup- poses that there is no pain existent anamnestically.6 Teixeiraetal.corroboratethe significance of pain prior to VA.7 In their study of 41 Ca(OH)2 vi- tally am- putated permanent teeth, anamnestic pain existed in 12 cases. The pulpotomy of these aching teeth led to failure after six to eight months in 50 % ofthecases(n=6),whileallother vitally amputated teeth were considered successfully treated. McDougal et al. report on 73 eugenol pulpotomies on aching permanent molars and premo- lars.4 Aclinicalsuccessrateof90 % after six months and 78 % after 12 months was ob- served. The teeth, which were free of pain at check-up, were ra- diologically controlled and it was shownthat49%oftheteethwere freeofpathologicalfindingsafter six months and 42 % after 12 months. According to Jensen, pulpo- tomy is an attempt to stimulate hard tissue healing at the area of amputa- tion.6 Fountain and Camp point out that a pulpotomy may result in canal calcification, internal resorption or necrosis of the pulp.8 Kozlow and Massler refertoliteraturethatreportsthe formation of a dentine bridge in rat teeth under non-calcium- containing materials, such as wax, amalgam, acrylic resin and zinc oxide eugenol.9 In human teeth, the bridging under Ca(OH)2 was successful in 43 % ofthecasesandunderantibiotics in 23 % of the cases. During their owntestsonratteeth,theauthors assessed good reparative reac- tions with complete bridging fol- low- ing pulpotomy with Ca(OH)2, zinc oxide eugenol, cortisone and silver amalgam. According to Alacam, various materialsarerec-ommendedfor pulpotomy: Ca(OH)2, formocre- sol, glutaraldehyde, ferrous sul- phate, zinc oxide eugenol and polycarboxylate cement.10 Salako et al. com- pared MTA, formocresol, ferrous sulphate and bio- active glass with regard to their pulpotomy compat ibility and found MTA to be the ideal pulpotomy agent.11 Agents that contain CH2O and Ca(OH)2 are histor- ically establishedVAagentsfordecidu- ous and per- manent teeth. Massler et al. report a clinical success rate of 92 % following VA with Ca(OH)2.12 Taking post- operative X-rays into account, the success rate was reduced to 75 % after one year and dropped to65%aftertwotofiveyears.The authors suggest several reasons for this failure: _pulp already heavily inflamed initially; _too much pressure applied dur- ing application; and _disposal of the blood coagulum via haemostatic agents. Mejàre and Cvek performed partial pulpotomies using Ca(OH)2 on 37 permanent teeth (35 molars, 2 premolars).13 The patients were six to 15 years old andtheirpulpotomyhadtobe performed at least two years prior to inclusion in the study. Check-ups were performed at an average of 56 months (24 to 140). The teeth were separated into two groups (Table I). Two fail- ures occurred in the first group, in teeth with in- complete root growth (after ten days and 48 months).Theother29teeth(93.5 %) were treated successfully. In the second group, two failures occurred (after 10 and 24 months) in teeth with periodontal gap enlarge- ment (one tooth with complete root growth and the other with incomplete root growth). Molven states that there were no pathological findings in 1,391 root-filled roots in 51.6 % of the cases and in 236 pulpotomized roots in 65 % of the cases.14 As- gary and Eghbal report the suc- cessful use of a new VA agent called CEM, a cement mixture enriched with Ca, in 205 pulpo- tomies on molars.15 For comparison, 202 molars were extirpated vitally. The root- canal filling (RCF) was per- formed via lateral condensation with AH Plus (DENTSPLY De- Trey) as sealant. After seven days, 38 % of the pulpotomy- treated and 60 % of the root- canal-treated patients reported needing analgesics. After six months, 88.94% of the patients underwent a radiological check- up. The pulpotomy patients re- vealed a significantly higher suc- cess rate (p < 0.001). The most frequently used VA agent for deciduous teeth is formocresol, a mix of CH2O, cresol, glycerine and water. A survey showed that formocresol pulpo-tomiesondeciduousteeth were performed by general den- tists in 73 % of the cases and by paediatric den- tists in 98.2 % of thecases.16Thefrequencyofuse on permanent teeth was lower: 18.9 % for general and 55.4 % for paediatric dentists. Fisch published the results of pulp amputations of 600 teeth, which were performed with the CH2O-con- taining preparation Triopaste.17 Check-ups were done between six months and 18 years after amputation. Exami- nation of the X-ray controls re- vealed a patho- logical apex in 9 %. Eleven teeth were histologi- cally examined. Hard substance formation was observed in the form of apical foramen closures and apposition at the lateral canalwalls,whichpartiallyledto obliter- ation of the canal lumen. During an accelerated test lasting up to 2.5 months, Overdiek tested N2 as CH2O- containing VA agent on human teeth. He observed that for sev- eral weeks fol- lowing N2 appli- cation there was a possibility of a hard substance barrier form- ing.18 Over a period of 12 years, Stern3 carried out 175 N2 pulpo- tomies under relative isolation on teeth with complete root growth, regardless of possible anamnestic pain. Fifteen per cent of the patients experienced increased pain after treatment, which subsided within 48 hours. Four patients, however, devel- oped pulpitis, which resulted in the extraction of three teeth and conservative RCT of one tooth. Stern was able to track the out- come of 35 vitally amputated teeth over a longer period. Dur- ing the course of check-ups, two teethwereextracted,oneofthem due to a fracture. Five years after treatment, Stern ob- served ad- vancingcalcificationofthenerve channels. Frankl considers the advan- tage of pulpotomy compared with RCT as there being no in- strument fractures or perfora- tions during pulpotomy.19 A possi- ble failure could always be countered with a RCT. He asserts that Ca(OH)2 pulpotomies can be successful only if teeth are asymptomatic prior to treatment and for accidentally opened pulp and,therefore,bleedingfromthe pulp. Vital amputation of permanent teeth (mCME articles in Dental Tribune (always page 6) has been approved by HAAD as having educational content accept- able for (Category 1) CME credit hours. Term of approval covers issues published within one year from the distribution date (September, 2010). This (Volume/Issue) has been approved by HAAD for 2 CME credit hours. 2 Hours Fig. 1a Fig. 1c Fig. 1d Figs. 1a–d_24-year-old patient, VA 16 (16 July 1993): before VA (a); heavy bleeding from the pulp after N2 VA, 16 July 1993 (b); after VA and amalgam filling (c); X-ray control, 29 September 1999 (d). Fig. 1bFig. 1b Fig. 2b Fig. 2cFig. 2a Figs. 2a–c_ 30-year-old patient, VA 28 (3 May 1993): prepared cavity (a); after VA and amalgam filling (b); X-ray control, 17 December 1994 (c). Figs. 3a–d_53-year-old patient, VA 38 (31 October 1995): prepared cavity (a); N2 applied (b); after VA and amalgam filling (c); X-ray control after six years (d) . Fig. 3c Fig. 3d Fig. 3a Fig. 3b