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Trauma; Vital Pulp Therapy (VPT); Pulp capping; Apex

Introduction

The patient’s immune system, which is present in the pulp, as well as the saliva the patient secretes, which prevents the impaction of contaminated debris/bacteria, can fend off bacterial invasion when the pulp is exposed [1]. Despite being more vulnerable to harm due to its inadequate compliance environment, the pulp has the ability to heal itself. The vital pulpal therapy is based on this important notion. Overall, it has been shown that VPT has a very high success rate [2]. Because it has an impact on two key objectives for the treatment of the critical pulp, the degree of pulpal amputation is significant: There shouldn’t be much tooth structure destroyed, and non-inflamed tissue should be treated with a wound dressing. If a tooth with a cracked crown still has viable pulp tissue after exposure, no more than 2 mm of the pulp underneath the exposure should be removed [3].

Discussion

Part of the pulp tissue is removed during a partial pulpotomy, often referred to as a cvek pulpotomy. The majority of the time, it is utilised to treat teenagers and young adults whose teeth have had the pulp exposed by a crown fracture. The main benefit of maintaining healthy pulp in developing teeth is that it encourages continual root development. The exposure size that can be treated by partial pulpotomy typically ranges in size from 0.5 to 4 mm [4].

This technique is possible on older permanent teeth in addition to young permanent teeth. Some studies show a higher success rate using vpts on an immature permanent tooth when compared to a mature permanent tooth with a closed apex. This is due to the pulp’s Janreased cellularity, increased fibrosis, Janreased blood flow, and Janreased capacity for self-healing in older patients [5]. Furthermore, it is not practical to provide essential pulpal therapy on a fully formed tooth that you anticipate will need full root canal therapy, even though doing so may make future entry into the root canal more difficult. The majority of these teeth were treated within 4 days after being exposed to damage in a clinical report on 60 adolescent teeth treated with partial pulpotomies, which found a 96.7 percent success rate. A different wellknown study by cvek involved the partial pulpotomy of 178 teeth with traumatic pulpal exposures. Patients were followed up for 3 to 15 years clinically and radio graphically. Hard-tissue barriers were used in 95% of cases to promote healing while maintaining pulp vitality [6]. Three days or fewer after the incident, the majority of these cases were resolved.

The advantages of partial pulpotomy over pulp capping are better management of the surgical incision and sealing material retention.

Pulp capping is only suggested for extremely small exposures (less than 1 mm in size) that may be handled rapidly after an accident [7]. Since only a few teeth meet these requirements, partial pulpotomies are frequently performed in certain cases. Due to the greater management of subacute inflammation below the exposure, the majority of studies also imply that partial pulpotomy has a significantly higher success rate than pulp capping after a traumatic pulpal exposure11–13. The effectiveness of pulp capping has been conclusively shown to significantly Janrease over time (from one hour to seven days after injury; from 93% to 56%). Vital pulpal therapies are a permanent therapeutic option for adult and immature permanent teeth with significant crown fractures. Reentering the pulp is not necessary as long as it is still necessary [8].

The dentin pulp interface is cleaned using an antibacterial solution called sodium hypochlorite. Biofilms are also removed, blood clots and fibrin are chemically broken down, and dentinal chips and injured cells are cleared away from the area of mechanical exposure. It also aids in halting bleeding. As a result, after a pulpotomy, the exposed location can be cleansed with sodium hypochlorite before the pulpal wound is healed (Saline or Chlorhexidine can be used as well). The pulpal wound is covered by pressing a cotton-soaked pellet over it [9].

Examining the pulp tissues after exposure is a crucial step in the pulp assessment process. Controlled bleeding is necessary for a successful partial pulpotomy. If Hemostasis cannot be achieved, the pulp should not be “topped,” as this suggests that the pulp is inflamed. When additional pulp tissue needs to be removed in order to achieve Hemostasis, a partial pulpotomy that was initially meant to be partial may wind up becoming a full pulpotomy. With a pulp diagnosis of necrosis or the inability to produce Hemostasis, it is obviously impossible to do vital pulpal procedures like a pulp cap or pulpotomy [10].

One of the most cutting-edge endodontic materials available today is Mineral Trioxide Aggregate (MTA). This compound, the first of the Calcium Silicate Cements (CSCs), was developed in 1993 and was used to plug up root holes. They have been extensively approved for use in apicoectomies, apexogenesis, and closing root holes since they have been shown to be so biocompatible and successful in their applications throughout time [11].

The CSCs class of materials includes “bioceramics,” hydraulic calcium silicate cements, Tricalcium silicates, and Dicalcium silicates, Endosequence BC RRM. The application of Cscs in vpt operations has grown in popularity [12]. These materials are used to cover the pulpal wound. Despite the fact that Calcium Hydroxide (CH) has historically been used for vital pulpal treatments, the bulk of recent studies have Janisively proven that cscs have superior healing and success rates and are the preferred materials to utilise on a pulpal exposure. MTA was the first material created for this purpose, although more recent materials have flooded the market. One of the advantages of the newer materials is that they don’t noticeably discolour teeth, which can be helpful, especially when used in the aesthetic zone [13].

In order for CH to function, a dentinal bridge must form right beneath the capping layer. These compounds cause low-grade irritation and superficial coagulation necrosis, which induces differentiation in the pulp’s undifferentiated cells. As these cells create predentin, which is then mineralized, the coagulated tissue is calcified. Predentin is finally transformed into dentin by further mineralization [14]. Due to the low-grade irritation caused by coagulation necrosis, the hard-tissue barrier forms immediately beneath the capping material. This minor irritation does not cause considerable damage to the pulp. Even so, it is sufficient to initiate an immunological response, which leads to the formation of a dentin bridge that protects the pulp below. The benefit of creating a stronger dentin bridge is one that cscs like mta have over CH, which has the disadvantage of resulting in a zone of necrosis. Pitt Ford et al. examined CH and mta and found that all of the calcified bridge structures in the mta-capped pulps were free of inflammation after 5 months [15-17]. As opposed to teeth without CH caps, the pulp of teeth with CH caps displayed inflammation and significantly reduced calcified bridge formation. The first two weeks see the formation of an osteodentin matrix right beneath the mta, and the third week sees the formation of a full layer of reparative dentin at the capping site. This causes odontoblast-like cells to proliferate, migrate, and differentiate when mta is applied to pulp tissue in order to create a collagen matrix, which is then mineralized to make osteodentin. This is subsequently replaced with a tertiary dentinal bridge a few weeks following pulp capping [18].

The advantages of cscs as pulpotomy agents are numerous. They are biocompatible, provide high resistance to micro leakage, permit dentin bridging at the site of pulp exposure, are dimensionally stable over time, and seem to be associated with very favourable clinical outcomes [19]. The main difference between cscs and CH might be that the former provides a good defence against micro leakage and does not wear out, necessitating replacement, as does the latter. CSCs produce a dentin bridge that is significantly better in quality than CH. Bacteria may be able to reach the pulp through the dentin bridge, which frequently has many tunnelling holes, should micro leaking occur in the case of CH. This is not a serious problem because the dentin bridge made by cscs does not have tunnelling faults [20].

Conclusion

When care is carefully planned, vital pulpal procedures like a partial pulpotomy can be a desirable Janision with a high success rate. In addition to traumatic pulpal exposures, they can be used successfully for carious pulpal exposures as well. The secret to this high success rate is a precise diagnosis and a well-sealed restoration on top of the capping material. Bacterial leakage can ultimately cause any essential pulpal treatment to fail. A satisfactory follow-up following vpt would include dentin bridge development, on-going root growth, a good response to pulp vitality testing, the absence of symptoms, and the absence of radiographic evidence of apical periodontitis or root resorption.

Acknowledgement

The author appreciates the doctors’ insightful comments and counsel.

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