Pulp Symposium

Vital Pulp Therapy with New Materials: New Directions

and Treatment Perspectives—Permanent Teeth
David E. Witherspoon, BDS, MS

Abstract
Pulp necrosis in immature teeth subsequent to caries
has a major impact on long-term tooth retention. The
aim of vital pulp therapy is to maintain pulp viability by
D ental caries is one of the greatest challenges to the integrity of the developing tooth.
It can result in irreversible pulpal damage, eventually causing necrosis of the pulpal
tissues and associated arrested development of the tooth root. Ultimately, abnormal
eliminating bacteria from the dentin-pulp complex and root development will impact the long-term prognosis for tooth retention (1– 4). Thus,
to establish an environment in which apexogenesis can the primary goal when treating immature permanent teeth should be to maintain pulp
occur. A complicating factor in treating immature teeth vitality so that apexogenesis can occur (5– 8). Direct pulp caps and pulpotomies in
is the difficulty predicting the degree of pulpal damage. teeth with incomplete root formation promote normal development of the root com-
The ability of the clinician to manage the health of the plex. There are long-term prognostic advantages of this treatment outcome over apexi-
remaining pulpal tissue during the procedure is para- fication treatment. The tooth structure formed is of a great quantity, and its composition
mount. Currently, the best method appears to be the appears to have greater structural integrity (3). The result is that the fully developed
ability to control pulpal hemorrhage by using sodium tooth is more resistant to vertical root fractures (4).
hypochlorite. Mineral trioxide aggregate (MTA) cur- The classic study by Kakehashi et al. (9, 10) eloquently established the role of
rently is the optimum material for use in vital pulp bacteria in pulpal health and necrosis. In a germ-free environment, the pulp demon-
therapy. Compared with the traditional material of strated the ability to heal and deposit additional dentin material. In the presence of
calcium hydroxide, it has superior long-term sealing bacteria, pulpal demise was inevitable. This fundamental premise is integral to the
ability and stimulates a higher quality and greater success of all vital pulp procedures. Thus, the basic principle of vital pulpal treatment
amount of reparative dentin. In the medium-term clin- can be broken down into 2 broad phases. The initial phase involves removing the
ical assessment, it has demonstrated a high success diseased and bacterially contaminated tissue. The second phase involves establishing an
rate. Thus, MTA is a good substitute for calcium hy- environment that will prevent any further and future bacterial contamination. The prin-
droxide in vital pulp procedures. (J Endod 2008;34: cipal procedures aimed at maintaining pulpal vitality include direct pulp caps and
S25-S28) pulpotomies. By removing the affected coronal pulp tissue and leaving the unaffected
radicular pulp tissue in situ, sealed from the oral environment, normal root develop-
Key Words ment can take place.
Apexogenesis, direct pulp cap, mineral trioxide aggre- Historically, a number of materials (11–13) have been advocated to induce nor-
gate, pulpotomy mal root development. To date, the material of choice has been calcium hydroxide
(Ca(OH)2) (14 –20). Most recently, an alternative material, mineral trioxide ag-
gregate (MTA), has become available for use in pulpal procedures. Several prop-
erties are necessary when choosing a material to be used in vital pulp treatment. These
Private practice, Plano, Texas. include the ability of the material to kill bacteria, induce mineralization, and establish
Address requests for reprints to Dr David Witherspoon at
[email protected]. a tight bacterial seal. The ideal material for vital pulp treatment should be able to resist
Conflict of Interest: David E. Witherspoon, BDS, MS, has long-term bacterial leakage and stimulate the remaining pulp tissue to return to a
acted as a Workshop Coordinator for the annual session of the healthy state, promoting the formation of dentin. The early data for MTA suggest that it
American Association of Endodontists. is the optimum material for fulfilling these goals when vital pulp therapy is the treatment
0099-2399/$0 - see front matter
Copyright © 2008 American Academy of Pediatric Den-
of choice.
tistry and American Association of Endodontists.
This article is being published concurrently in Pediatric
Dentistry, May/June 2008; Volume 30, Issue 3. The articles are MTA’s Physical and Chemical Properties
identical. Either citation can be used when citing this article. MTA is composed of tricalcium silicate, bismuth oxide, dicalcium silicate, trical-
doi:10.1016/j.joen.2008.02.030 cium aluminate, and calcium sulfate dihydrate. MTA might also contain up to 0.6%
insoluble residue, including free crystalline silica. Other trace constituents might in-
clude calcium oxide, free magnesium oxide, potassium, and sodium sulfate compounds
(21). Hydration of the powder results in the formation of a finely crystalline gel of the
hydrated forms of the components, with some Ca(OH)2 also being formed. This solid-
ifies to a hard structure in less than 3 hours (22). It has a compressive strength equal
to intermediate restorative material (IRM) and Super-EBA IRM but less than that of
amalgam. MTA has been shown to have an antibacterial effect on some of the facultative
bacteria and no effect on strict anaerobic bacteria (23). This limited antibacterial effect
is less than that demonstrated by Ca(OH)2 pastes. MTA’s ability to resist the future
penetration of microorganisms appears to be high. In in vitro leakage studies (24, 25),
MTA has resisted leakage predictably and repeatedly. MTA frequently performs better

JOE — Volume 34, Number 7S, July 2008 Vital Pulp Therapy with New Materials S25
Pulp Symposium
than amalgam IRM or Super EBA (26 –30). Compared with composite pulp cap 30 young, permanent, cariously exposed asymptomatic teeth
resins placed under ideal conditions, MTA’s leakage patterns are simi- with MTA. All the teeth showed signs of vitality and absence of periapical
lar (31, 32). Furthermore, the presence of blood has little impact on the radiolucency, with evidence of continued root growth and no reported
degree of leakage (29, 33). It is commercially available as ProRoot MTA symptoms (53).
(Dentsply Tulsa Dental, Tulsa, OK) and has been advocated for use in
vital pulp therapy (34 –38). Pulpotomy
The human clinical data available on MTA pulpotomies in cari-
Mineralization ously exposed permanent teeth have reported high success rates, which
MTA has demonstrated the ability to induce hard tissue formation ranged from 93%–100%. In a prospective clinical trial comparing suc-
in pulpal tissues when used as either a direct pulp capping or pulpotomy cess rates of partial pulpotomies with treated cariously exposed perma-
material (34, 36, 39 – 45). MTA promotes rapid cell growth in vitro nent molars by using Ca(OH)2 or MTA, there was no statistically signif-
(46). Compared with Ca(OH)2, in animal studies, MTA consistently icant difference in the success rate between each group (Ca(OH)2 ⫽
induces the formation of dentin at a greater rate with a superior struc- 91%, MTA ⫽ 93%). Fifty-one teeth in 34 patients were available for
tural integrity. It develops more complete dentin bridges and demon- recall. The patients ranged from 6.8 –13.3 years old, and the fol-
strates an improved ability to maintain pulp tissue integrity (34, 39). low-up period was from 25.4 – 45.6 months, with an average of 34.8
Histologic evaluation in animal and human studies has shown that MTA months (55).
stimulates reparative dentin formation, with thick dentinal bridging, When comparing MTA and Ca(OH)2 pulpotomies within the same
minimal inflammation, and nominal hyperemia. The net result is that patient at the 12-month recall time frame, 2 of the 15 teeth in the
vital pulp therapy with MTA produces negligible pulpal necrosis (34, Ca(OH)2 group were considered failures, whereas none of the teeth
41– 43, 47). treated with MTA failed (0 of 15 teeth). Calcific metamorphosis was
MTA also appears to induce the formation of a dentin bridge at a evident radiographically in 2 teeth treated with Ca(OH)2 and in 4 teeth
faster rate than Ca(OH)2 (48). In 1 case report (52) partial pulpoto- treated with MTA (56).
mies were conducted on 2 cases of dens evaginatus. After 6 months, the The use of gray MTA for partial pulpotomy in cariously exposed
teeth were removed as part of planned orthodontic treatment. Histo- young permanent first molars diagnosed with reversible pulpitis and
logic examination of these teeth showed an apparent continuous dentin normal periradicular tissue has resulted in a very high success rate.
bridge formation in both teeth, and the pulps were free of inflammation. Exposed pulp tissue was removed with a diamond bur, and after hemo-
The process by which MTA acts to induce dentin bridge formation is not stasis, 2– 4 mm of gray MTA was placed against the fresh wound and
known. It has been theorized (49) that the tricalcium oxide in MTA then covered with a layer of glass ionomer cement. The teeth were
reacts with tissue fluids to form Ca(OH)2, resulting in hard tissue for- restored with amalgam or stainless steel crowns. At the 24-month recall
mation in a similar manner to Ca(OH)2. period, 22 of 28 teeth showed no signs of clinical or radiographic
failure and responded within normal limits to pulp vitality tests. Al-
though 6 of 28 teeth did not respond to vitality testing at the final follow-
Clinical Outcomes up, the radiographic appearance was within normal limits, and the teeth
The initial response reported in case reports has been very positive were asymptomatic. The patients’ ages ranged from 7.2–13.1 years,
(50 –52). Several human clinical studies with MTA for direct pulp cap- with an average age of 10 years (57).
ping and pulpotomies have recently been published. In a case series outcomes report that used MTA pulpotomies to
treat cariously exposed immature permanent teeth (first or second mo-
Direct Pulp Capping lars) that had been diagnosed with irreversible pulpitis, a success rate of
The clinical data available on MTA pulp capping of cariously ex- 92% was reported (58). The key factor in deciding whether to complete
posed permanent teeth are limited to 2 studies. Both of these studies a pulpotomy as opposed to a pulpectomy was the ability to control
have reported a high rate of success, which ranges from 93%–98% (53, pulpal hemorrhage. In cases in which pulpal hemostasis could be
54). In 1 study (54), 53 teeth with carious exposures that had been achieved with NaOCl, a pulpotomy was completed. The patients’ ages
diagnosed with reversible pulpitis and normal periradicular tissue were ranged from 7–15 years, with an average age of 10 years. The recall
treated with MTA pulp caps. A total of 40 patients between 7 and 45 years period ranged from 6 –53 months, with an average recall period of 21
old were treated. Briefly, the treatment consisted of caries removal with months. The single tooth that required nonsurgical root canal treatment
the aid of an operating microscope and extensive use of caries detector had completed normal root development before requiring nonsurgical
dye. Pulpal bleeding was controlled with 5.25%– 6.00% NaOCl applied root canal treatment.
for up to 10 minutes. After hemostasis was achieved, the pulps were
capped with MTA, and the teeth were temporized with unbonded com-
posite Photocore (Kuraray Co Ltd, Osaka, Japan) and a moistened cot- Technique
ton pellet placed directly over the MTA. The teeth were restored with a With the vital pulp therapy technique, the patient is anesthetized
bonded composite 5–10 days later. Forty-nine of the 53 teeth were with a standard local anesthetic protocol. In all cases, a rubber dam is
available for recall at the 1-year time frame, with an average recall used to isolate the tooth being treated. The affected enamel is removed
period of 3.94 years. by using a high-speed bur with copious irrigation. The gross caries can
The maximum period of observation was 9 years. During that time, be removed with either a sharp spoon excavator or a large, round,
98% of the cases presented a favorable outcome, with a normal radio- slow-speed tungsten carbide bur. As the pulp is approached, the cavity
graphic appearance, no symptoms, and a normal response to cold is flushed with NaOCl to decrease the bacterial load. The remaining
testing. In addition, of the 15 teeth in younger patients that were not fully affected tissue is removed by using a coarse, high-speed diamond bur
formed at the time of treatment, all subsequently demonstrated contin- with copious irrigation. In the case of a pulpotomy, the pulp is removed
ued normal apexogenesis to complete root formation (54). In the sec- to a level where adequate hemostasis can be achieved. Hemostasis is
ond study, a 93% clinical and radiographic success rate was reported at achieved by irrigating with 6% sodium hypochlorite (59) for up to 10
the 24-month recall period. The study used a similar protocol to direct minutes. Care should be taken to avoid the application of pressure to the

S26 Witherspoon JOE — Volume 34, Number 7S, July 2008

 Pulp Symposium
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