Vital pulp therapy is practiced daily in dentistry. We routinely arrest or remove carious lesions in our offices using a variety of treatments. There is some debate, though, in the fields of pediatric dentistry and endodontics about therapy for vital permanent teeth with deep carious lesions. There are several clinical techniques for treating vital carious permanent teeth in children and adolescents. Maintaining pulp vitality is important in an effort to avoid root canal therapy or extraction.
Developments in the use of calcium silicates led by ProRoot MTA proved beneficial in the management of vital immature permanent teeth affected by deep carious lesions. Mineral trioxide aggregate, or MTA, is a biocompatible material made of tricalcium and dicalcium silicates. It has been used successfully for indirect pulp caps, direct pulp caps, partial pulpotomies and complete pulpotomies in permanent teeth. When MTA contacts tissue fluid, it releases calcium, which in turns results in the formation of hydroxyapatite. This appears to form a chemical bond to dentin and will entomb bacteria in dentinal tubules. MTA has a basic pH, which creates an unfavorable environment for bacteria and can create adequate seal against leakage. The setting time of MTA is two to four hours, which can impose difficulty when attempting to restore teeth at the same time of treatment. It has been associated with a high cost and difficult handling. MTA can create a dark discoloration when in contact with sodium hypochlorite, a commonly used endodontic irrigant. Staining has been attributed to bismuth oxide, which is added to the material as a radiopaquing agent. Other compositions often have less discoloration.
A 17-year-old male presented with a history of pain in the maxillary right region. The patient localized the pain to tooth #14. The tooth had a large carious lesion on the occlusal surface and tested positive to sensibility testing without lingering pain. The patient complained of pain when biting. He was anesthetized and the tooth isolated with rubber dam isolation. Caries removal was completed without pulpal exposure, and NeoMTA from NuSmile was placed as an indirect pulp cap using an amalgam carrier and cotton pellet. The tooth was restored with a composite resin.
The goal of all treatment modalities presented is to maintain pulpal vitality to avoid extraction or root canal therapy. These modalities have an advantage of being more cost effective in maintaining teeth than root canal therapy given the proper diagnosis is reached. The practitioner is charged with making the proper clinical diagnosis based off the subjective and objective findings that are gathered during examination to help guide the correct treatment of the disease. If done properly, clinicians can obtain a high level of success when treating deep carious lesions on vital permanent teeth. Every attempt should be made to maintain a viable and healthy pulp when treating children and adolescents.