This article is intended to familiarize clinicians with several pulp therapy modalities and new materials that are currently available for immature young pulp in the adolescent population. Objectives and considerations for immature young permanent teeth as well as the healing potential of the young pulp tissue after treatment of the inflammatory process are discussed. The article emphasizes that the future holds great possibilities for the regeneration of dental pulp in adolescent patients.
Key points
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Pulp therapy treatment in adolescent patients presents several challenges to clinicians, varying from pulpal diagnosis to restorability considerations for immature young permanent teeth with deep carious lesions or with dental defects approximating the pulp or traumatic dental injuries.
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Efforts should be made by clinicians to achieve completion of root formation in immature young permanent teeth and continued growth and development of the oral facial structures.
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Considerations of behavior guidance options, modification of techniques to account for incomplete root development, and the level of dental homecare must all be balanced when designing endodontic and restorative treatment plans for adolescent patients.
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Being able to provide treatment of this subpopulation is gratifying and critical in setting the path of oral health into adulthood for these patients.
Introduction
Endodontic treatment of adolescent patients does not present any special pulp therapy techniques. However, the considerations for using pulp therapy techniques that are routinely performed on mature patients become complex during early adolescence years. These considerations directly depend on unique factors such as the stage of tooth development, behavior assessment of the patient during the endodontic treatment, caregiver and patient’s general attitude toward oral health, quality of home care, and other factors that interfere with the control of the pulp’s inflammation and/or infection.
A study by Al-Madi and colleagues found that 36.9% of children between the ages of 6 and 18 years required dental treatment that had pulpal involvement. Only 21.8% of the teeth received completed endodontic therapy. The remaining 59% only received temporary restorations and 24% resulted in extraction. It has been suggested that several factors interfered with completion of dental treatment and tooth survival. , The immediate placement of a permanent restorative material is required for achievement of high success rates after completion of vital pulp therapy. ,
This article discusses the specific endodontic therapies that are available for the adolescent population according to the American Academy of Pediatric Dentistry and American Association of Endodontists. , A decision tree is provided to help guide clinicians through the steps to arrive at a therapy that will provide immediate relief for the patient while taking into consideration the future options for follow-up care for the patient when entering into adulthood. There are several factors that can affect the health of the dental pulp. , For the purpose of this article, the focus is primarily on the impact of bacteria being the primary concern, whether their entry was a result of dental caries, restorative procedures, trauma, or genetic conditions affecting the dentin pulp complex.
Dental pulp complex
Dental Pulp and Its Protective Nature
The dental pulp is composed of connective tissue and contains a large number of odontoblasts, fibroblasts, and undifferentiated mesenchymal stem cells that can be used for dentin and pulp regeneration. ,
The dental pulp has a strong propensity for survival, and protection of the periapical tissues specifically. The larger dentinal tubules of the young tooth permit greater access of microbial contaminants to communicate with the pulp. The first cell to respond is the odontoblast. As irritants reach the odontoblastic process, the odontoblast signals the first inflammatory response through the activation of Toll-like receptors , and nucleotide-binding oligomerization domain (NOD)–like receptors starting the cascade of inflammatory reactions leading to the deposition of reactionary and reparative dentin. As the bacteria move closer to the pulp, the ensuing neurogenic inflammatory response leads to sprouting of free nerve endings releasing calcitonin gene–related peptide and substance P. , This process begins the localized inflammatory response at the pulp-dentin interface. Vascular changes follow and lead to increased pulp blood flow, bringing an initial influx of proinflammatory cytokines to the damaged region. It has been shown that this localized inflammatory response is very limited, and tissue as close as several millimeters remains healthy. The arteriovenous anastomosis and its shunts open and redirect pulpal blood flow away from the directly affected region, thus minimizing the spread of contaminants to larger portions of the dental pulp complex. The large diameter of the root canal system of the adolescent tooth and the still-forming anatomic apices permit the rich vascularity of the maturing dental pulp. Maintaining this pulpal tissue permits not only the immunologic protection of the periapices but also the continued deposition of radicular dentin and root formation. The remaining vital pulp tissue prevents the egress of bacterial irritants through the dentinal tubules/accessory canals by the presence of a vital odontoblastic process and the outward flow of dentinal fluid because of the intrapulpal pressure related to vital pulp.
As these basic principles of pulp biology are considered, permitting vital tissues to remain in adolescent patients provides greater opportunity for future treatment if necessary and allows the innate protective function of the dental pulp to aid in long-term tooth survival.
Clinical Evaluation of Pulp Inflammation
Previous histologic studies have shown that there is no association between clinical signs or symptoms and pulp inflammation. However, historically, when collecting evidence of mild or moderate pain, normal pulp vitality, and negative sign to percussion, clinicians have classified the pulp inflammation as reversible, whereas evidence of severe pain or history of pain associated or not with periapical radiolucency was designated as irreversible pulp inflammation with indication for endodontic therapy or extraction.
More recently, there has been strong consensus in the endodontic literature that clinical evaluation of teeth (ie, pain quality and responses to pulp testing) only indicate the probable status of the dental pulp complex. As examples of limitations of the clinical pulpal status categorization currently used, teeth clinically diagnosed as having irreversible symptomatic pulpitis may not present with histologic deep inflammation; comparison, pulp necrosis may happen in asymptomatic patients who were diagnosed with a reversible pulp inflammation. In summary, clinical diagnosis of the dental pulp complex is not reliable, and the severity of pulp inflammation and the pulp’s potential of responding to appropriate endodontic procedures cannot be accurately determined unless other strategies are used.
How to navigate from open apices to complete root formation of permanent teeth of adolescent patients
Treatment Complexity and Team Approach
Management of pulp tissues of immature permanent teeth creates a special set of circumstances. , , The age of the patient dictates specialized behavior guidance skills as well as proper treatment planning because of children’s growth and development considerations. The skill level and various pulp therapies, from nonsurgical root canal therapy with or without placement of a calcium silicate cement biologic plug to partial/full pulpotomies, are best managed by a knowledgeable clinician and require adequate time to perform these procedures. Because of the nature of, and length of time to perform, most of these procedures, patients require treatment under some form of sedation, ranging from nitrous oxide to general anesthesia. This specialized care is best coordinated by a team approach of the pediatric dentist, endodontist, and dental anesthesiologist.
Pulp Therapy Treatment Options
The decision of which course of treatment to follow is arrived at through the objective clinical findings, the subjective clinical assessment, and the level of sedation required to manage the patient ( Fig. 1 ). Conservative therapies are always the goal; however, the ability to perform emergent care should it be required needs to be factored into the treatment plan. Should a child require general anesthesia, a conservative pulpal procedure (eg, direct pulp capping, partial pulpotomy), which would be considered for a patient requiring less behavior guidance, may not be performed. When a patient is treated under general anesthesia, the clinician may consider a more aggressive treatment, such as full pulpotomy or pulpectomy, because of the inability to assess the health of the remaining pulp tissue. Clinicians must always consider what the action plan will be should emergent care needs arise.
Classically, the objective of endodontic therapy has been the prevention and/or treatment of apical periodontitis. The diagnosis of reversible or irreversible pulpitis is controversial in relation to the state of the pulp because of the absence of noninvasive techniques for determining the severity of pulp inflammation. Furthermore, current material science has now provided predictable therapies to manage the dental pulp. Increased awareness and education of clinicians on how to optimally manage the pulp tissue should be of the utmost priority.
Vital Pulp Therapies
The European Society of Endodontology’s position statement on the management of deep caries and exposed pulp defines vital pulp therapy as strategies designed to maintain the health of all or part of the pulp ( Box 1 ). The development of calcium silicate cements (eg, Pro-Root MTA, BC putty, Bio-Dentine) over the past 2 decades has permitted predictable vital pulp therapies to be performed with success and survivability well into the 90% range.
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Direct pulp capping
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Following the preservation of an aseptic working field, application of a biomaterial directly onto the exposed pulp, before immediate placement of a permanent restoration.
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Class I
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No preoperative presence of a deep carious lesion. Pulp exposure judged clinically to be through sound dentine with an expectation that the underlying pulp tissue is healthy (exposure caused by a traumatic injury to the tooth or an iatrogenic exposure).
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Class II
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Preoperative presence of a deep or extremely deep carious lesion. Pulp exposure judged clinically to be through a zone of bacterial contamination with an expectation that the underlying pulp tissue is inflamed. Enhanced operative protocol recommended (aseptic procedure using magnification, disinfectant, and application of a hydraulic calcium silicate cement).
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Partial pulpotomy
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Removal of a small portion of coronal pulp tissue after exposure, followed by application of a biomaterial directly onto the remaining pulp tissue before placement of a permanent restoration.
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Full pulpotomy
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Complete removal of the coronal pulp and application of a biomaterial directly onto the pulp tissue at the level of the root canal orifices, before placement of a permanent restoration.
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