The vitality of dental pulp can be compromised by deep caries lesions, traumatic dental injuries, and subsequent iatrogenic restorative interventions. Strategies to preserve pulp vitality aim at the prolonged retention of natural dentition. These strategies include vital pulpal therapies such as selective caries removal techniques, indirect pulp capping, direct pulp capping (DPC), and pulpotomy procedures.
Challenges in Vital Pulpal Therapies
Historically, unpredictable outcomes associated with vital pulpal therapies, particularly DPC, have contributed to clinicians’ skepticism about the procedure. This has often led to more invasive procedures like root canal therapy being considered a more predictable treatment alternative in cases of pulpal exposure, especially when root development is complete.
However, advancements in biomaterials and increased biological understanding of dental pulp have refocused attention on vital pulpal therapy procedures within the global endodontic community. Position statements published by the European Society of Endodontology in 2019 and the American Association of Endodontists in 2021 highlighted predictable outcomes for vital pulpal therapy procedures. These statements emphasized aseptic techniques, enhanced visualization facilitated by magnification, disinfection protocols, and enhanced coronal seals using calcium silicate materials to achieve predictable outcomes.
Techniques and Preferences in Caries Removal
While some guidelines advocate for avoiding pulpal exposure through selective caries removal, other position statements suggest that complete caries removal is often preferred even if it results in pulpal exposure. Besides caries, phenomena such as mechanical injury and dental trauma may also result in vital pulp exposure. In such cases, DPC is the most minimally invasive vital pulpal therapy accessible to many clinicians. Furthermore, DPC has been described as a more cost-effective alternative to root canal therapy after pulpal exposure of an asymptomatic tooth.
A recent study aimed to evaluate DPC procedure outcomes performed on permanent teeth focusing on patient-centered outcomes like procedure survival and tooth survival. Researchers identified 4,710 teeth treated with DPC during the study period; after applying exclusion criteria, the final sample included 4,136 unique teeth from 3,716 patients treated with DPC procedures.
In alignment with previous findings, it was observed that DPC was predominantly performed on multirooted teeth—a clinically relevant observation since alternatives like root canal therapy are more expensive and technically challenging for multirooted teeth.
The findings support previous reports that DPC is a predictable procedure with an overall high success rate:
After three years:
- Procedure survival rate: 86%
- Tooth survival rate: 95%
- Procedure survival remained greater than 80% for up to six years.
- Tooth survival remained greater than 90% six years post-DPC.
Factors influencing successful outcomes include patient age:
- Older patients were significantly more likely to require tooth extraction following DPC failure.
Tooth type also played a role:
- Molars were less likely to experience procedural failure but were more likely extracted when failure occurred.
Time taken to place permanent restorations also influenced success rates:
- Prompt placement correlated positively with better outcomes.
Comparative analysis with similar studies revealed slight differences potentially attributable to methodological variations or differences in clinical techniques across regions (e.g., U.S. vs Germany).
Preserving natural dentition through minimally invasive methods like Direct Pulp Capping (DPC) offers promising results both procedurally and economically.
Future research should continue optimizing these techniques while emphasizing consistent reporting mechanisms integrating both clinician-centered metrics and crucially important patient-reported outcome measures ensuring comprehensive evaluations reflecting real-world scenarios accurately fostering informed clinical decision-making processes benefiting broader populations and effectively enhancing oral healthcare standards globally!
Source: British Journal of Dentistry
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