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O7B Conservative Pulp II

6 min read

Conservative Pulp Treatment II1

Some treatment dilemmas23

Pulp exposures

NOTE

The primary dilemma is deciding between root canal treatment and conservative pulp therapy for a tooth with a carious pulp exposure. This decision is entirely dependent on an accurate diagnosis of the pulp’s condition.

Key questions and considerations

NOTE

A correct diagnosis is paramount and requires a thorough:

  • Patient history
  • Clinical examination
  • Radiographs
  • Pulp sensibility tests
  • When to do endodontic treatment?
    • Irreversible pulpitis
    • Pulp necrosis + infection
    • Pulpless + infected
  • Must consider: Apexification
    • If open apices in immature teeth
    • apexification is a pulp cap waiting until you see apical repair

Treatment options

NOTE

For cases of reversible pulpitis or a relatively healthy pulp, the conservative options are similar to those for traumatic exposures, but the compromised state of the pulp affects the prognosis.

  • Pulp capping
  • Pulpotomy – partial, cervical
  • Pulpectomy – partial
    • (Rarely used in these situations, but may be considered for very immature teeth to promote root development)

Case study: Apexification – lower first molar4

Study Pulpotomy of Carious Vital Teeth with Periapical Involvement

Study by Çalışkan et al. found that pulpotomy of carious vital teeth with periapical involvement had a 92.3% favourable outcome over long-term follow-up.

Comparing treatment outcomes5

Conservative pulp therapy

  • Favourable outcome rates between 80–96%

Conclusion

Given the similar success rates of conservative therapy and endondontic treatment, conservative pulp therapy should be the preferred first choice when the diagnosis is appropriate. If it fails, it simply confirms the need for root canal treatment.

Factors affecting outcome of conservative pulp therapy

  • original state of pulp
  • atraumatic technique
  • use of vasoconstrictor
  • extra-pulpal bloodclot
  • material used on pulp
  • restorative material use

Major problems in pulp therapy6

Diagnosis

  • Difficult to distinguish between reversible and irreversible pulpitis
    • It is also possible, though rare, for the treatment procedure itself to convert a reversible pulpitis into an irreversible one.
  • The pain history provided by young patients may not be very accurate
  • accurate responses to pul psensibility tests vary between individuals
  • lack of correlation between clinical findings and histological state of the pulp
  • Existing attitudes and approaches to treatment
    • Outdated beliefs or unfamiliarity with current materials and techniques can lead dentists to default to root canal treatment.
  • Poor understanding of pulp disease
  • Poor understanding of treatment modalities
  • Poor understanding of materials
  • Often financial considerations dominate the decision making processes
    • Dentists may prefer more expensive treatments, or patients may opt for cheaper ones, sometimes influencing the clinical decision.
      • ± Both ways!

Materials for pulp treatment7

Choices

  • Calcium hydroxide
  • Corticosteroid / antibiotic
  • MTA – mineral trioxide aggregate

Calcium hydroxide8

  • Very commonly used material
    • Well researched and supported
  • But usually leads to:
    • Pulp canal calcification, or
    • Diffuse calcifications throughout the root canal
      • Both make future endodontic treatment very difficult, or even impossible
        • The dentine bridge it forms can have dead tissue and necrotic tissue inside

Recommendation: anti-inflammatory dressing910

  • Success may be increased by using an anti-inflammatory dressing followed by calcium hydroxide
  • Ledermix cement:
    • Triamcinolone – 0.67%
    • Calcium hydroxide – 33.4%
    • Zinc oxide-eugenol – 47.2%
    • Keeps options open for future treatment – if required

Ledermix cement11

NOTE

This material was developed by Schroeder to combine an anti-inflammatory agent with a hard-setting base in a single application.

Composition & properties

Therapeutic effects

Ledermix cement provides multiple therapeutic effects:

  • Short-term anti-inflammatory effect: From the corticosteroid triamcinolone.
  • Longer-term reparative effect: From calcium hydroxide.
  • Obtundent/antimicrobial effect: From eugenol in the ZOE base.
  • Triamcinolone
    • Anti-inflammatory agent
      • 70% released by the end of day 1
      • Rest by end of day 3 (Hume & Kenney – JoE 1981)
  • Calcium hydroxide
    • Sedative and promotes dentine repair (numerous studies)
  • Zinc oxide – eugenol
    • Anti-inflammatory and anti-bacterial (Hume 1984, 1986, 1987; Brannström 1979)

Full composition

  • Triamcinolone – 0.67%
  • Calcium hydroxide – 33.4%
  • Zinc oxide-eugenol – 47.2%

Healing response with Ledermix cement12

  • Normal pulp (e.g., trauma): Heals with normal, inflammation-free pulp tissue.
  • Carious/compromised pulp: Healing is slightly different, often showing some dentine bridge formation and/or diffuse calcifications throughout the pulp space.
  • Typical healing response – Ledermix cement
    • Robertson 1977

Ledermix cement application13

Case example

A case of an indirect pulp cap on a dental student was presented. The tooth was later extracted for orthodontic reasons, and histology showed a completely normal, inflammation-free pulp, demonstrating the material’s effectiveness.

  • Indirect pulp cap

Study: MTA in direct pulp capping and pulpotomies1415

Pulp treatment with ProRoot™ (MTA)16

  • Major disadvantages:
    • Very long setting time (approx. 4 hours), making it clinically impractical for single-visit procedures.
    • Potential for tooth discoloration, especially in anterior teeth.
  • Procedure: Due to the long setting time, a temporary restoration must be placed over the MTA, requiring a second appointment for the final restoration.

Study: MTA vs. Ca(OH)₂ partial pulpotomies17

Results1819

  • More unfavourable outcomes when pulp exposure > 5 mm
    • This contrasts with trauma cases, where exposure size is not a significant factor.
  • Median survival time: 24 months
  • No difference between Ca(OH)₂ and MTA

CONCLUSION

The primary difference between the materials is the poor handling and very slow setting time of MTA, making it clinically less practical.

The final restoration is key

After achieving a correct diagnosis, the single most important factor for long-term success is the quality of the final restoration and its ability to provide a long-term seal against bacterial leakage. The amount of remaining tooth structure is also critical.

Material choice

The choice of pulp-capping material plays a role, particularly in the immediate post-operative period. The lecturer’s preference is Ledermix cement due to its beneficial combination of anti-inflammatory, reparative, and hard-setting properties.

Prognosis considerations

The healing response and outcomes differ between traumatic exposures (normal pulp) and carious exposures (compromised pulp). Most animal research is on normal pulps, making clinical studies on carious teeth, like Çalışkan’s, invaluable.

Final recommendation

Conservative pulp treatment is a highly effective and desirable procedure. It should be considered for any tooth without irreversible pulp disease, especially in immature teeth where continued root development is the goal.

Footnotes

  1. Original PDF page 1: 7b ConservativePulpTreatmentII, p.1 ↩

  2. Original PDF page 2: 7b ConservativePulpTreatmentII, p.2 ↩

  3. Original PDF page 3: 7b ConservativePulpTreatmentII, p.3 ↩

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  5. Original PDF page 30: 7b ConservativePulpTreatmentII, p.30 ↩

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  8. Original PDF page 33: 7b ConservativePulpTreatmentII, p.33 ↩

  9. Original PDF page 35: 7b ConservativePulpTreatmentII, p.35 ↩

  10. Original PDF page 36: 7b ConservativePulpTreatmentII, p.36 ↩

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  12. Original PDF page 38: 7b ConservativePulpTreatmentII, p.38 ↩

  13. Original PDF page 39: 7b ConservativePulpTreatmentII, p.39 ↩

  14. Original PDF page 40: 7b ConservativePulpTreatmentII, p.40 ↩

  15. Original PDF page 41: 7b ConservativePulpTreatmentII, p.41 ↩

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  17. Original PDF page 50: 7b ConservativePulpTreatmentII, p.50 ↩

  18. Original PDF page 14: 7b ConservativePulpTreatmentII, p.14 ↩

  19. Original PDF page 15: 7b ConservativePulpTreatmentII, p.15 ↩

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