Dentists are trained to thoroughly review medical and dental histories and perform comprehensive extraoral and intraoral examinations. Yet, in spite of these efforts to optimally serve patients, the dominant clinical reality is...
Vital Pulp Therapy Regenerative Endodontics in Adolescents
Have you noticed any patients lately with excessive tooth erosion? Ruddle and Lisette open the show with a warning about DIY teeth whitening trends. Then, Dr. Beth Ann Damas gives a presentation on vital pulp therapy as an alternative treatment option for adolescent teeth. After, Ruddle and Lisette share insights in a brief post-presentation discussion. The episode concludes with a Case Report; see how Ruddle treated an adolescent trauma case where the VPT failed and further treatment was needed.
Show Content & Timecodes00:43 - INTRO: Dangers of DIY Teeth Whitening 07:59 - SEGMENT 1: Guest Presentation by Dr. Beth Ann Damas 34:52 - SEGMENT 2: Post-Presentation Discussion 50:45 - CLOSE: Case Report – Adolescent Trauma Case
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…And then finally it was really impressive to see the root formation on some of those teeth; I was very impressed by that. What did you think?
Well, you took two of my items, so I have nothing left…
INTRO: Dangers of DIY Teeth Whitening
Welcome to The Ruddle. Show. I’m Lisette and this my dad, Cliff.
How you doing today?
Pretty good. How about you?
I’m great. And now I’m going to go to an area that you’re going to steer me to, and we’re going to not do walk-in; we’re going to do teeth bleaching externally. Let’s go!
Okay. Well, teeth whitening is not a new thing, but consumers’ demand for whiter teeth has never been higher. And this is fueled in large part by social media, influencers and television. Nowadays many people go to the dentist to get their teeth whitened, but a growing number of people are now starting to turn to social media for the latest at-home trends that are generally less expensive and often touted as natural or organic. So some substances that are being used to whiten teeth are baking soda, apple cider vinegar, activated charcoal, kaolin clay, mashed fruit and fruit peels. So when I was looking at this list, I had not really heard of activated charcoal and kaolin clay. Do you know what those are?
Well I didn’t really know what they were related to tooth bleaching, but I’ve heard of them for other things.
Yeah, me too.
Charcoal is manufactured from wood, peat, coconut shells and stuff like that to produce the product. But then it’s superheated in a special, low oxygen environment to produce activated charcoal. And activated charcoal, I understood it was a great filter and it can pick up poisons and detox from drug overdoses and things like that. So it can be taken orally, presumably, and it would absorb a lot of the toxins in the stomach.
Yes, I’ve seen it in skin care, like charcoal face masks. They must draw out the toxins from -
I haven’t started that; that’ll be tonight. Lots of toxins to be removed. Yes, he’s a toxic man.
All right. And kaolin, I was aware of that because it’s very rich in minerals; it has calcium, magnesium and aluminum. So for some teeth there’s low calcification, enamel pits and stuff like that. People are trying it and it’s a powerful oxidizing agent. So that would be the bleaching part I guess.
Okay. Well apparently these materials do work to some degree, but the results are relatively temporary. Most experts think that professional teeth whitening is more convenient and will yield more long-term results. There are some experts though that believe that these at home remedies just pose too much risk of damaging your teeth, and that they should probably avoided altogether. So what can happen to your teeth if you use these products?
They can fall out. You know abrasion comes to mind. I didn’t really say this just a second ago, but this is the perfect time. If you look at activated charcoal as compared to what was it – kaolin?
Clay? Kaolin clay is much, much kinder to enamel and dentin if there was some loss of enamel. And charcoal is very, very abrasive. So what can happen is – you know it’s normal for people as we all know – we’re all dentists out there, pretty much all of you are dentists. And there’s some recession around the necks of teeth, the cervical area, and that means there could be exposed cementum or dentin. Sometimes in the enamel there can be little deficiencies right round the CEJ; it might not be a perfect scalloped border. And if you get some of these chemicals and you’re brushing and being aggressive, it can cause a lot of abrasive results as wear against materials. Abrasion is defined as teeth wearing against different materials, so that would be that. And then erosion would be another possibility. A lot of erosion occurs from an acidic environment, so a lot these are basic, so your acid based type things.
So I think you have to work about that, those two things, abrasion and attrition. Erosion – I said attrition, so I’d better define that. Attrition would be tooth against tooth wear, abrasion is loss of tooth structure from another material, and erosion is acidic.
Now magnitude of accident or injury is the – I’ll start again. An injury is depending on the magnitude of the injury and the duration. So if you’re doing this once a week, twice a week, an hour at a time, two hours, overnight; you can see there’s a lot of variation in times. And a lot of times variation means more chance for injury. So it is the magnitude and the duration, so keep that in mind.
And then finally what do I want to say about this more harmful stuff? You need to be really aware if you’re just a patient; there are intrinsic and extrinsic factors, and if you don’t know – okay, coffee, tea, things like that; those are extrinsic factors. But what if the patient doesn’t know? They’ve had previous treatment, maybe there’s some MTA out in the pulp chamber, maybe there’s some gutta-percha, maybe there’s sealers that discolor, maybe the canal is filling in and calcifying, becoming very mineralized. That can cause a dark tooth. So they may be trying to bleach something that’s not possible.
Okay. Earlier this year my kids tried Crest White Strips. And Crest, by the way, is the top dentist-recommended teeth whitening brand, and the Crest 3-D White Strips are the only ADA approved teeth whitening product that you can buy like at a drug store. So my kids tried Crest White Strips, and I have to say the results were pretty amazing. Eva’s teeth got so white that she actually stopped using it because she thought it was looking a little weird. And Isaac, my son, tried it for a few days, but had a little bit of gum sensitivity, but I think he’s going to try it again. And I actually kind of want to try it too.
But didn’t you just get some teeth whitening trays from your recent dentist appointment? Have you tried them yet?
Oh yeah. They made these really sexy, they’re flexible, they’re clear, polymer, soft polymer, very nice. I sleep with it, but it wasn’t into my gums. Yeah, I’m supposed to fill those with carbamide peroxide, and that’s a pretty – we have it up here somewhere, don’t we? No, we don’t. But that’s not a common, over-the-counter ingredient, this carbamide peroxide.
Maybe you should fill them with something like apple cider vinegar.
Maybe I’ll try all of those before I see him next and have him decide which one worked. But that is about 20%. In the office as we’ll talk about later when we talk about the walk-in technique which is internal, it would be about 40%.
Okay, well this little opener was inspired by a Dentistry Today news article, so we’ll have access to that in our show notes. In the future we’re going to do another segment on teeth whitening, but we’re going to do it from an endodontist perspective, and we’re going to talk about internal bleaching. So stay tuned for that fun topic.
But today we actually have a guest presentation, so let’s get to that because that’s exciting.
SEGMENT 1: Guest Presentation by Dr. Beth Ann Damas
Okay, so today we have a guest presentation which you will see momentarily. The presentation is by Dr. Beth Ann Damas, who is an endodontist, born and raised in Illinois. And she is an expert in regenerative endodontics, and the presentation we’re going to watch today is called Vital Pulp Therapy: Alternative Treatment Options for Adolescent Teeth.
Before we get to that though, why don’t you tell us how you know Dr. Damas and how it came about that we have the opportunity to show this presentation today.
Well, I broke a rule. It’s called Ruddle Rule. Actually I learned the rule from Daniel Nobs years ago. But you never invite a clinician to speak for you or on behalf of an organization unless you have personally heard the speaker; and that means you were in the room. And Nobs’ rule isn’t just you heard the speaker for an hour; he wants to see them all day long. He wants to see are they holding the room through the morning; usually most speakers do. Lunchtime is when you have to worry, because sometimes when you come back after lunch, you’ll notice with some speakers the rooms are almost empty. They weren’t very inspired.
So I broke rule. I’ve never heard Beth and David Landwehr, who’s been on this show, did a marvelous job. Long-time friend, outstanding clinician. I was just shooting the breeze with him one day, and I said David, I need to get into a topic that is a little off of what we normally talk about. And he said – or I didn’t even ask him, or I never told him what the topic was – he said I have the person. And I said well who is he? He said it’s a she and her name is Beth. Beth.
And he said Cliff, she holds the room. She holds the room all day long. He said I’ve been in her room all day long, and he said at the end of the day, I can’t even get up to her to ask her a question or say, “Nice job Beth.” Because he said there are so many students around her. And I thought so she’s not only a good lecturer, but she’s engaging and she’s capturing their hearts and minds. I want her on the show. What does she talk about, apical surgery? He said no. She’ll be excellent at pediatric stuff, adolescent stuff, immature stuff; she’s really, really good. So that’s how that happened.
And then of course I’ve been pretty interested in this for years. I’ve never really talked about this, so you’d never know this, so I’m now exposing something very unusual about myself. Back in the day, in the middle ‘70s when I was at Boston, Harvard School of Dental Medicine, my mentor was Al Krakow. He taught a continuum course on pediatric endodontics, mixed dentition. We were baptized. We’ll have to go into his pressure syringe sometime. I’ll bet Beth knows about it.
Anyway, then he used to get another guy in there called Harold Burke, who was a chair of pediatric dentistry I believe at Tufts, and they gave us our pediatrics. So I have always been interested in the next dentition. I never saw a lot of it, but that’s a little bit about my interests.
And finally, I think Beth’s got the right message at the right time, especially in the advent of minimally invasive dentistry. What more timely topic?
Yes, I agree. Well, just to tell you a little bit more about Dr. Beth Damas. She completed her endodontic residency program in 2010 from Detroit University in Michigan. And then in 2015, she completed her American Board of Endodontics Diplomat certification, which is the highest academic honor in the profession. She is an active member of the AAE, the ADA, and she is current president of the South Suburban branch of the Chicago Dental Society. And like I said, she is an expert in regenerative endodontics and she has presented her research to study clubs nationally. And finally she is married and she has two young children so we’ll see how maybe having these children has influenced and inspired her work.
So with that said, let’s see the presentation.
[Damas Presentation Begins]
Hi Cliff, hi Lisette. I’m honored to be here with both of you today. Thank you so much for this opportunity to sit down to spend a little bit of time with you and your audience to talk about a more conservative approach to endodontic therapy when we are presented with people of mixed dentition in underdeveloped adolescent teeth. So what exactly am I talking about? I’m referring to vital pulp therapy, so let’s get to it.
Today we’re going to talk about vital pulp therapy as an alternative treatment option for adolescent teeth. Let’s first talk a little bit about what we’re trying to accomplish with vital pulp therapy. The main goal is to remove the carious or traumatic source and leave behind healthy functioning pulp tissue, so that that healthy tissue can produce a dentin barrier at the injury site to prevent further ingress of bacteria or trauma. The health pulp tissue that’s left behind then continues on with its normal development of the entire tooth structure, essentially postponing a more aggressive treatment such as root canal therapy that would have potentially lowered the overall prognosis of that underdeveloped tooth.
Both historically and today, unlike other parts of the world, vital pulp therapy is primarily performed on underdeveloped adolescent teeth, allowing that healthy pulp tissue to perform continued root development just as nature intended it to do. You can see here in this example, a carious exposure of an underdeveloped second molar was treated with conventional vital pulp therapy. Here’s our immediate post-op. This last image is two years later, and we can clearly see the apex has closed and the roots have thickened significantly, resulting in a much stronger and healthier tooth had I initiated full root canal therapy from the onset of her appointment.
Vital pulp therapy maintains full functioning and vitality of the pulp tissue. So when this procedure is performed, the patient will still have thermal sensitivity, as you would expect in a normal vital tooth. The method of vital pulp therapy procedures historically has included an indirect, direct pulp cap, of full pulpotomy. In this series today, we’re going to be focusing on a full pulpotomy on all cases that will be presented.
Cases that would present to most offices where vital pulp therapy would be considered a viable option are going to include some type of traumatic injury to an anterior tooth, or some type of carious exposure on a posterior underdeveloped tooth. So let me show you exactly what I mean.
In all three examples here, each of these teeth present with underdeveloped, wide open apices and very thin dentin on the roots. Certainly we can perform full root canal therapy on each and every one of these teeth. But by doing so, that would result in halting any further development of that root structure. And if this patient were to encounter a situation where trauma would occur, the tooth is then at a much higher risk for fracture. So by performing vital pulp therapy, in theory we’re going to do just the opposite and give those roots a chance to grow and develop, resulting in a much stronger tooth for potentially greater long-term success. If and when these teeth would require root canal therapy, the outcome of that procedure would then also be significantly increased.
Vital pulp therapy in immature teeth allows the teeth to continue to develop in the way that nature intended it to do. Allowing for continued root development increases the chance of survival by eliminating the risk of premature fracture. Children in that 7-12 year age grouping are what we historically refer to as the ugly duckling phase. They present with very large anterior teeth in the mixed dentition. And if these kids are going to fall or be in some type of sports injury, there’s a high probability that those upper anterior teeth are going to take the brunt of that trauma and sustain some type of fracture. If this was a situation where we actually had to remove these teeth, we really don’t have an excellent way to replace them while the child is still developing. They can’t have an implant placed or a fixed bridge, and a flipper is never a perfect solution. So by performing vital pulp therapy, we can not only keep the tooth in their mouth and functioning, we can also aid in further development of that tooth.
What exactly does it mean to place a direct pulp cap? In situations of a pulpotomy for vital pulp therapy, what we’re actually looking to do here is to place that pulp capping material of choice directly on top of the healthy pulp tissue that we’re leaving behind in the root. This material then essentially seals off that healthy pulp tissue and facilitates its ability to start to form that reparative dentin we’re looking for to bridge the gap.
We know from the classic literature that if we can perform and provide a germ-free environment, the pulp tissue possesses an amazing ability to actually heal itself. This is accomplished by depositing the dentin-like bridges in the root structure. Interestingly enough, all of these factors listed here have no impact on the overall success of the vital pulp therapy. Age of the patient, size of the exposure and percussion sensitivity are especially interesting to note, because I feel most people would consider this counterintuitive to the treatment.
Although not a deal breaker, these factors can significantly influence the overall outcome of vital pulp therapy. As with all endodontic therapy, the rubber dam placement here is a must. The notion that the final restoration should be placed within 5-10 day stems from the original protocol back in 2008, and I feel it’s within reason to expect even better results from immediate placement of the final restoration at this time.
This is the current protocol for vital pulp therapy compiled by Bogan back in 2008, and it’s still utilized as best practices today. Once anesthesia is administered, the rubber dam is placed, all caries is removed from the access, hemostasis of that pulp tissue is obtained by placing a full strength hypochlorite pellet with pressure directly onto the pulp tissue. This entire process can take up to 5 minutes and can be repeated as necessary until hemostasis is obtained. The area is then rinsed and dried, and the pulp capping material of choice is placed directly onto that healthy pulp tissue. Preferably an immediate restoration is then placed.
Most practitioners today are going to utilize one of these three materials as their vital pulp therapy material of choice: MTA, Biodentine, or a Bioceramic putty. I cannot tell you that one is superior to the other; they all yield excellent results. Simply use whichever is best for you and works best in your hands. This is what the most common materials utilized currently in the US look like when they’re received from the manufacturer or the supplier.
So just to differentiate between the two, MTA and Biodentine are the only two that require preparation chairside prior to the placement of the material. MTA is simply mixed on a glass slab, and as you can see here has a gritty, sandy type texture. Its delivery is carried to the tooth with an instrument similar to an amalgam plugger as you just saw here in the video.
Contrasting to MTA is the bioceramic premixed putties that can be expressed and are ready for immediate use. These are not sticky and they have a bit of a firmer texture similar to IRM. Delivery can be placed with a flat instrument or a plugger and placed directly into the patient’s mouth.
So let’s get right into some cases. As I mentioned previously, most often the opportunity for vital pulp therapy to present itself in underdeveloped adolescent teeth is through some sort of traumatic injury to the anterior teeth, or through carious exposure to posterior teeth. This is my son Caden, and as you can see, he’s right in the middle of that ugly duckling stage. He has two giant incisors with a mixed dentition and loves playing baseball. The probability for a sports injury to occur on his two front teeth at this stage in his life is extremely high.
Here we have an 11-year old boy that experienced a traumatic injury to both 8 and 9 with pulpal exposure. The apex is larger at this stage, and the dentinal walls are thinner than if this had happened to a grown adult male. No pathology or decay is present; it’s simply a traumatic pulpal exposure. In this case, the decision was made to perform vital pulp therapy in order to allow for continued root development of these teeth. Bogan’s protocol was followed that we discussed earlier, and in these particular teeth, a bioceramic putty was the material of choice. And the patient had one fracture segment, so that was immediately bonded back into place, and the other tooth was temporized.
Let’s go through this case step by step. Here you can see exactly how the patient presented to the office. These fractures are pretty significant, so after anesthesia and isolation were obtained, all that needed to be done then was to widen the access ever so slightly. In the upper left-hand corner you now see the sodium hypochlorite salt pellets are helping to achieve hemostasis. And once the pellets are removed, the chamber is cleaned and dried and we can see there is no more bleeding. At this stage, it’s okay to pack the bioceramic putty right over the pulp tissue. One tooth was temporized and the other was restored with the fractured segment being bonded.
In these images we can review the sequence of pre-op and post-op. Then at the one-year mark, you can clearly see radiographic evidence of dentinal bridging, as well as further development and thickening of the root structure and closure of the root apex. This tooth responds within normal limits to pulp testing and there’s no pathology present, indicating no further need for treatment at this time. Here we are at the two-year mark, and the patient is still doing very well. The pulp testing remains within normal limits, there are not symptoms or pathology, and the teeth remain vital and functional for this patient.
Here's a case of one of my son’s teammates. The baseball tipped off the top of his mitt and hit him square in the mouth, resulting in incisal fractures of 8 and 9. Even at 10 years old, these teeth are very underdeveloped. Although full root canal therapy is a viable option for this case, the decision was made to perform vital pulp therapy in the hope that we could achieve further root development to strengthen the overall longevity of these teeth, all while maintaining vitality.
Here's our immediate post-op, and as soon as the six-month follow up, we can clearly see evidence of dentinal bridging. The teeth remained vital and showed evidence of continued root development at that time. Even if at some point we would need to convert to full root canal therapy on this patient, every bit of root thickening and development pushes the overall outcome to something much more favorable than if that would have been our first line of defense.
Let’s move on to yet another example, this one with CBCT evidence and interpretation. This 11-year old girl tripped and fell in gym class. She fractured the incisal edge of her lower anterior tooth on the gym floor. The tooth looked significantly developed on the periapical radiograph, but a closer look at that CBCT shows final development has not yet occurred. The radiolucency at the apex of these teeth are not pathology, yet the end stages of the developing tooth bud. Again as was the cases before, full root canal therapy could have been performed here. But the decision was made to go with vital pulp therapy in hopes of allowing that last big of root to develop, the walls to thicken, and the apex to fully close.
Here is the one-year follow up. The tooth remains vital and functional in this child’s mouth. And although there’s not much difference seen on the periapical radiograph, you can clearly see on the CBCT that full development of the root has been met. Vital pulp therapy in this particular case was a successful conservative approach to this child’s endodontic treatment.
Now that we’ve seen and discussed traumatic injuries to anterior teeth, let’s shift gears a little bit and talk about carious pulp exposure on underdeveloped posterior teeth. How often have we been in a situation where a child is 10 or 11 years old and there is gross decay into the pulp and the roots are extremely thin with wide open apices. This was the exact scenario here where this patient, who is now 20 years old, presented to my office for retreatment. Root canal therapy initially in these situations is very difficult, not only because of the anatomy of the tooth at this developmental stage, but also due to the age and nature of the patient. Is it unreasonable to perform a more conservative treatment in these cases with the hopes of facilitating further development and vitality of the tooth? Then if further treatment is necessary down the line, we’re setting ourselves up for a much more favorable outcome.
I was first introduced to the concept of utilizing vital pulp therapy back in my endodontic residency. In this first image, let’s focus on the second molar, because clearly that first molar is beyond repair and would need extraction. But it’s the second molar that presents with a moderate amount of decay on an underdeveloped tooth. Discussion with my director led to this office performing vital pulp therapy in this particular case to allow for further development of this tooth. The thought process in doing so was that we would develop a much stronger tooth for this child down the road, knowing they’d already be losing the first molar without a very good option for replacement at this stage in their life.
In that second image, you can see that an MTA pulpotomy was performed on the tooth, and it was temporized and sent back to the referring doctor. At that time, I completed my residency and moved on to private practice. But the resident that took over my cases after I left the program called me and told me that my patient had returned for treatment. Unfortunately, somewhere along the way communications were lost and the dentist said when they were going for the restoration, they were not able to find the gutta-percha and thought something must be wrong.
In this last image that was sent, yes, there is no gutta-percha and now all the MTA has since been drilled away. But let’s look at the development of that root structure in such a short amount of time. By simply removing the bacteria that was infecting the pulp tissue and creating a sterile and clean environment, the pulp relied on its natural ability to heal itself. And now this child is left with a much stronger tooth than if I would have done conventional root canal therapy from the beginning. This was my introduction into the concept of conservative endodontic treatment.
So let’s walk through this step by step. Vital pulp therapy on a posterior underdeveloped tooth. Many people have been in a situation like this where you’re presented with a first molar with occlusal decay. On the PA, the depth of the caries doesn’t look terrible, and clinically, that whole occlusal surface has that mottled enamel look. More likely than not, once this tooth is opened up, the decay is going to be much extensive than we originally thought.
Sure enough, once caries excavation was initiated, the whole intaglio of this tooth has pretty much pulled out. At this point if I had performed conventional root canal therapy, which is also a viable option, I would leave this child not only with dead roots, but a thin occlusal table as well. The rationale for performing vital pulp therapy on this patient was in the hopes of giving a much longer life span of the tooth by allowing the roots to develop to their full and anatomic potential. Certainly at any point in time in the lifespan of the tooth, conversion to full root canal therapy still could be performed. Once all the caries was removed, a full strength type of chlorite pellet was packed directly onto the remaining pulp tissue to obtain hemostasis. MTA was then placed directly on top of that remaining pulp tissue, and the tooth was temporized and referred back to the general dentist for final restoration within that 5-10 day period.
Let’s take a look at another example. This patient was only 6 years old when he presented to my office for deep caries into the pulp on tooth #19. This tooth is barely even erupted into his mouth, let alone fully developed. The decision was made to perform vital pulp therapy on this tooth in the hopes of gaining further development of the tooth root. After anesthesia was obtained, the tooth was isolated, the caries was excavated, and the healthy pulp tissue was left behind. A bioceramic putty was packed directly over that remaining pulp tissue, and the tooth was immediately restored with a composite resin.
In a little over just six months at the patient’s next recall appointment, you can see in this last image here that the dentin bridging is already beginning to occur. We don’t have complete root closure or development at this point, but remember that this patient was six when this started so at this stage the tooth is still vital and I’m happy with the progress that we’ve made thus far.
At about the year mark, we can see that the mesial roots have developed quite a bit at this stage. The distal roots here are still developing, but we’re getting a lot more closure on this patient from where we started. The tooth remains vital and normal and is functioning appropriately in this patient’s mouth.
In the center image here we can clearly see that full development and closure of the root apices has occurred. There is significant dentin bridging present in both the mesial and distal roots, there is no pathology present at this time, the tooth responds normally to vitality testing, and remains functional in the mouth.
Here at the two-year follow up, not much has changed. But the tooth still remains vital and functionable, and at this stage, shall this patient require full root canal therapy, the continued growth and development that vital pulp therapy has provided is going to put it at a much higher success rate should further endodontic treatment be required.
Here is a limited CBCT scan of this patient, both at the initial appointment and the two-year follow up. You can see just how much of a difference that two-year time span has made by allowing healthy pulp tissue to remain functionable in the roots of this tooth. We started with very thin roots and wide open apices and finished with full root development and closure of those apices. In this circumstance, conservative treatment resulted in a highly successful outcome.
Just like with conventional endodontic therapy, the ultimate success of vital pulp therapy is going to rely on the quality of that final restoration. If you can immediately place the restoration, I encourage you to do so. It’s ultimately your decision whether you leave this with a simple composite restoration or move to something like a full coverage restoration. I’ll leave that to your better judgment and discussions with your patient on how it’s best for you both to move forward.
Knowing that we can see radiographic evidence of a dentin barrier forming as soon as five months after this treatment has been performed, my suggestion is to recall your patient at the six week, three month, six month and year marks. Pulp vitality should be reassessed at each of these appointments. If at any point in time the patient is symptomatic, or pathology is present clinically or on the radiograph, you could always move and convert to full root canal therapy. Use your best judgment and clinical skills to evaluate each and every situation. Vital pulp therapy is an excellent conservative and endodontic option to treat our patients with underdeveloped mixed dentition.
Thank you everyone for your time and attention. I really appreciated the opportunity to share with all of you a little bit more about how I utilize vital pulp therapy in my practice. I hope one day you can bring it back to your patients to help them in the same way that I help mine.
SEGMENT 2: Post-Presentation Discussion
All right, well I thought that was an excellent presentation. I can see why people maybe gathered around her and wanted to ask questions. Dr. Damas seems very knowledgeable and friendly. And I really liked her documentation as well too, because vital pulp therapy does require a lot of monitoring, so the documentation seems very important. And then finally it was really impressive to see the root formation on some of those teeth; I was very impressed by that. What did you think?
Well, you took two of my items, so I have nothing left. Like you, I was very impressed with the documentation. It’s easy to say the word documentation, but these were kids. And when you have people hurting or fidgeting around, it’s not as easy to get the photographs, x-rays, etcetera; so that was great, Beth. And Beth, you gave us all a reminder of the importance of preserving vital pulp. Because I loved how those roots got thicker, more bulk, more form. I liked how through apex genesis or stimulating Hertwig’s epithelial root sheath, that vital pulp elaborated dentin and we got root enclosure. So I liked bigger, bulky, stronger teeth; I liked closed roots, and I liked more fracture resistant teeth. That’s what I got.
Okay, that’s nice. I know I needed a little clarification from you regarding the difference between a pulp cap and a pulpotomy. So maybe just review for our audience very quickly just the different levels of vital pulp therapy.
Oh absolutely. In fact I kind of wondered if I put Beth in a restrictive jacket. Because it’s a huge field, and I gave her – so the audience knows, I gave her 20-25 minutes, so she had to pare down a lot of stuff. We didn’t get to talk about or hear Beth’s philosophy.
But there’s pulp capping, and that happens every day to you out there. You’re doing crown preps, your caries removal, you’re chasing, you’re using those drills – don’t you love those things – and you’re cleaning teeth up for the restorative procedure ahead. So you see pulp quite often. You see a little nick, a pulp horn is amputated, you see a little red dot.
And so we didn’t really talk about pulp caps, but we went to the next step which would be the pulp chamber is so involved, or the tissues may be involved to the extent a deeper pulp cap – that would be an amputation at the orifice – that’s a pulpotomy. And of course we have pulpectomy.
So those are the three things, and Beth only had time to talk about the pulpotomy. But the pulp cap, I’m sure a lot of you are doing that. And you probably have some success with it; I’m sure you do.
What else do I want to say here? I guess we’ll get into it a little bit later, but I think the decision between those two would be clinical symptomology and we talked about it or will talk about decision making.
Okay. Well I know towards the beginning of the presentation, Dr. Damas gave a list of factors that she said did not impact treatment. And she said when she gave her list that a few things on the list maybe would seem counterintuitive to some. And I know that you had some questions specifically with regard to the sensitivity to percussion and thermal sensitivity. So maybe can you explain more of what you were thinking; because maybe some of our audience also was watching and was wondering the same things as you.
Probably if I sat down with Beth, the important thing to say here; there’s probably not a nickel’s worth of difference in our philosophy. Again, time was part of the restrictive moment. But I was trained that by the time a patient comes in and is reporting symptoms, then I want to know is it spontaneous pain or is it elicited pain? If it’s elicited pain, okay, they might have a huge carious blowout into the tooth and they say it hurts to cold. It really hurts to cold; I keep cold ice – okay; they swallow, it’s gone. So it’s immediate, it’s intense, but it’s of short duration. That suggests the pulp is probably okay.
If it starts to hurt to heat and I hear that, I’m thinking some area of necrosis; bacteria present producing gasses that expand when we do our hot test. So I was taught heat is pretty much irreversible and the pulp isn’t going to be viable enough to induce the things we want. That might be one reason she went right on down to the pulp chamber floor and amputated instead of doing a pulp cap; because we aren’t histologists chairside, we’re clinicians. So if you ask the right questions, you get the right answers.
Percussion? Again, if they don’t complain about it, I’m probably not going to pay attention to it. But if I tap on their tooth with a mirror handle gently, and it’s unlike the adjacent contralateral opposing teeth and it actually hurts them a little bit, I’m thinking there’s peri radicular extension. That means the disease process has already left the tooth and now it’s out in the surrounding attachment apparatus. And we have maybe not infection, but we might have inflammation. That’s what would make the tooth sore to tap, tap, tap.
Right. I guess it’s probably a spectrum where it’s like the tooth is healthy and then it’s completely dead. And it’s like how much pulpitis can progress before it’s irreversible? So maybe the irreversible area, or possibly irreversible is quite a large area I’m thinking. I don’t know.
You hear that? We were talking about this yesterday, and we talked about a continuum and total health, focal health, never healthier. And down here gangrene necrosis that stinks. And then you have this continuum. And pulps tend to march down this continuum over life. And you can drop a vertical bar here and you could say everything on that side is reversible, and everything over here is irreversible. And Lisa is talking about the line; she’s saying it’s not an actual, bam, line; it should be thought of as a zone. And that’s where we can – some people will say well pulp caps don’t work. Well maybe they were in a zone where they should have done a deeper pulp cap, pulpotomy.
Okay. Another question I had was related to success rates. So Dr. Damas gave a list of various factors that can improve success, like for example it being a virgin tooth, no periapical radiolucency, adequate hemostasis to name a few. But I had a question regarding maybe the tooth seems like a pulp cap would be sufficient. I’m wondering if maybe that would go – like maybe she would think that it’s maybe a little more invasive but she’s going to take out the whole pulp because then there’ll be a better chance of success. An analogy I can think of is like when they remove skin cancer. They draw around it and they take what they think is enough. But then say it comes back that they didn’t get enough because they can still see some cancer cells out in the margins. So then they have to come back and get more. I was wondering if it kind of worked a similar way in this situation with the pulp. Like if you got more of it, would you have a better chance of getting all the disease?
Wow. You know, that was a pretty good analogy, wasn’t it Lisette? Good job!
I actually thought of it in bed last night.
Well it’s called in medicine, broad incisions to include complete enucleation. So you do your surgical, you take out a biopsy and you send it off to the pathologist to get a report. And they want to find the diseased tissue, and then finally there’s a margin and everything beyond that margin is clean; all cellular activity appears normal and there’s no cells there that don’t belong there. So that would be a successful biopsy, broad incision.
So I think back to your analogy, a pulp cap is just a smaller biopsy of a bigger issue about the tissue in the pulp chamber. (Don’t you like that; the issue about the tissue?) So I think just to say it another way; pulp caps come down to decision making. Is it clean; is it dirty? How about that for just a single example? Beth’s not here. But if she were, she would probably make that distinction. A fractured tooth that happened right now, and there’s the piece needing – sometimes it doesn’t even – have them bring it in and they’ll put it back and bond it through adhesion dentistry – that’s clean; that’s sterile. But how about decay that’s been invading from external in, and it’s been going on for weeks or months. We know the tubules, every square millimeter. In one square millimeter, there’s 60,000 dentinal tubules; and they’re about 1-2 microns so we know that you have a highway going out to the outside. So all of a sudden you have to worry about bacteria, microbes.
So I think, to your point, a pulp cap can be very successful. And I want you to know, keep doing them. But if you’re having some failures, maybe it was bleeding too long. Remember she talked about that pellet of sodium hypochlorite; nothing lives in Clorox for longer than 10 seconds on contact. All microbes, viruses, microorganisms destroyed. So what if you take that pellet and you hold it there for five minutes, or your assistant does, and you take it off and blood keeps spilling and gushing. It should arrest!
So those are chairside decisions, and I’ve been talking about decisions and I’m not through talking about decisions. I’m going to talk about decisions a little bit later. But decision making; I bet you Beth has enough experience doing this kind of treatment – which is really part of endodontics, but a lot of times endodontists tend to avoid it because we don’t know. So this is a great session she did for endodontists and general dentists alike. I’m sure if you start to have some failures on your pulp caps, maybe follow Beth’s advice and make a little broader incision, per your coaching, to make sure you get down to healthy tissue.
Okay. That answered my question very well actually. But I have another question, because I actually really enjoyed this presentation and it made me think a lot. So here’s another question I had. It seems that the vital pulp therapy requires a lot of vigilance, and I know that Dr. Damas said that the recalls should be at six weeks, three months, six months and twelve months. And I was just wondering what you would be monitoring, besides the patient reporting pain or something? What would you be looking for to determine if it was actually on a healing path or maybe treatment was going south? What would be the first thing that you would notice if it wasn’t working?
Well it would be your endodontic exam, and the endodontic exam is radiographic, so you’d want to have evidence. She makes it very clear; she’s followed these cases to get radiographic feedback. Then there is the clinical exam, and the clinical exam is probe the sulcus and make sure everything is intact – 2 or 3mm; whatever is normal. Palpate. Look for fistulas; they can be in the lining mucosa, attached to gingiva through the sulcus. Discolored teeth: the tooth that looked pretty good because probably she’s taken a lot of photographs. And if you start to notice and the mom’s noticing, everybody’s starting to notice hey, it might be getting a little bit dark; that’s a clear indication that something’s leaking or going downhill.
And so I would say your full endodontic exam – I didn’t mention vital pulp testing because we’re not going to do vital pulp testing or pulpal sensitivity testing. Except – oh I’m glad I thought of this – always do that on adjacent teeth and contralateral teeth. Because most blows that come in don’t just hit one tooth, and that’s the one we all look at and focus on because it’s broken and there’s pulp; oh my God, what are we going to do? But a lot of times that blow is absorbed over adjacent teeth, and sometimes they can begin to go south. So the exam should be looking at all that stuff.
Okay. And then of course did you say lesions if there’s a lesion forming?
Radiographic after breaking down. And we’ll just throw in for our audience – because you asked me about it – we’ll also throw in look for resorptions. External and internal, not just lesions of endodontic origin – LEOs.
I want to now ask you about the bridging of the dentin. Because it seemed in her presentation that this is a victory. But you told me that in the endodontics world, there’s a little bit of controversy around the concept of bridging of the dentin. So maybe explain.
Yeah. We love bridging of dentin because what does that prove or suggest? It suggests that the pulp was viable enough for the odontoblast to elaborate reparative dentin. And so we can see it – finally – radiographic evidence; and that would tend to suggest that apical to the bridge, you might have perfectly healthy pulp. So bridging is that; that’s what it means to most of us.
The negative part – and I don’t think we should think it’s negative – it’s just always in life there’s the good news/bad news dilemma. And you have to worry I think – okay. Endodontists sometimes worry needlessly about things that they don’t need to worry about. But some of them will say well gee; what if the radicular pulp starts to fill in? What if it starts to get smaller? At what point will I not be able to get in there? If the dentin begins to mineralize and if it strangles the narrow vascular bundle, and then it becomes necrosis, how will I ever find the canal? Well I would say pat your microscope and be glad you’ve got technology all around you. And remember, things can look pretty mineralized radiographically and we almost always discover them clinically.
So I would say follow the cases. This just takes us right back to Beth Damas 101. I mean if you are so worried about all these – oh, the tooth might get dark; oh, it might become mineralized and hard to treat; oh, it might become a rock, calcified dentin; oh, I might have to do surgery. Follow the cases. That’s what she said, six months? Well she said six weeks, and then I always do six months, one year, two years, five years. And just keep following your patient so you don’t get into that. And then you also alert the general dentist, if you’re an endodontist, because you want four eyes on it. How about that?
Okay. Well that’s all I really had to ask you about, but do you have any final comments for our audience?
Yeah, I want to thank Beth a lot.
Yes, thank you very much.
I can hardly wait to meet her. I guess I have met her. I failed to mention this earlier – sorry Beth – but I do Zoom with all of the people I have on the show because Lisa makes me. She says you have to be sure. So I did have a delightful one-hour Zoom with Beth some weeks ago, and she’s a delightful person. And I hadn’t thought I met her, and she reminded me I had met her. In fact, I guess some years ago I was in Chicago and I was giving a lecture. And she said I walked over to her and her friend – they were sitting there – and said some words and she said she’s never forgotten them.
So Beth; thanks a lot we’re going to have to have you back on. Because I know we just talked about pulpotomies; there’s got to be more!
Yes, thank you very much.
CLOSE: Case Report – Adolescent Trauma Case
Okay, so we just saw some cases where the vital pulp therapy worked very well. And that probably also has something to do with the clinician who performed the procedure. So with that said, now you’re going to show us a case where the vital pulp therapy did not work well, and then it actually went from bad to worse, and then it came to you. So why don’t I step away and you can show us this case?
You got it! Let’s take a look at where vital pulp treatment goes south.
When Lisa said it had probably a lot to do – this case – with previous operators, or in Beth’s case all that success she showed us, it had to do with Beth being a top-notch clinician. But I want to just explain a little further. It was her decision making. Let’s talk about decision making.
Okay, we’ll open the proverbial curtain, and what I will do is set up the history. So we have a general practitioner, and he does a pulp cap. Then it became necrotic after the pulp cap. There was trauma so I’ll just put that up here; so we started off with trauma. I didn’t see any of this stuff. Then there was a pulp cap. And when that didn’t work, it went to Endo #1, and Endo #1 said let’s go ahead. And by this time, I heard this was all necrotic, so the pulp cap did not work, which means maybe as we saw a deeper pulp cap; maybe a pulpotomy might have worked.
So anyway, it was necrotic; there was no tissue in here to do this root information. So this endo guy filled the best as he could, so he filled a blunderbuss. I better write that down so you don’t forget. I mean it’s pretty hard to do this, right; to fill something that is actually going the wrong way at the end.
And when that failed – I guess I’ll use more board – but when that failed it went to Endo #2, and Endo #2 – I’ll get this out of here – Endo #2 then decided to retreat and did non-surgical retreatment and was removing the other guy’s filling material, and in the process, pushed the retrograde – pushed the retro out into the peri-radicular tissues. That’s the history. Boy, I filled the whole board up and we’re just now getting started.
So what do you do? What do you do? You see something like this. We have vital pulp here – do your testing – we have a vital pulp in this so do your vital pulp testing. Check for intact PDLs on the adjacent teeth – this seems to be a one-tooth problem. So I can’t induce root formation; the pulp is necrotic; it’s been removed. The tissue, the pulp then was replaced with rubber pulp; it was replaced. The amalgam is out; what do you do? Well we’re going to have to do is probably an orthograde procedure where both ends of the tooth are open. And that’s exactly what I did.
So you’ve got to talk to – this is an adult now. I mean this has all been going on for years. I’d say the patient, if I recall, is early 20s; so there’s not really a parent to talk to. But the patient readily understood and wanted to go ahead and proceed. So we’re going to go ahead and remove the retro in the lingual surface. We’re going to not really scrape the walls with files. I have paper thin walls, paper thin walls. And if you start to really appreciate what Beth was saying; she wants to get bulk and form, wants that root to develop. She wants to stimulate root enclosure. Those opportunities are long gone. So here’s how I managed it; we’ll just cut to the chase.
So took out the lingual composite, lifted a flap, and you can see the alloy here that has pushed out. You can see how this wall is pretty regular; probably went right down to the canal like this. You can see how it probably came over like this; it rolls up like this and goes across like that. You can actually see how the material from the previous endodontics was pushed like gears, interlocking gears, like sawtooth formation. Wow, I hope they’re pushing in!
So that’s a big piece of alloy. We used a big magnet and just sucked it right out of there! No we didn’t. And then with the amalgam out, we’ve got it opened up, did our osteotomy, got a curettage and got out all that granulation tissue, pretty big lesion. You can get a really good sense of how thin that is. You can get a sense of what we have left in terms of circumferential dentin… circumferential dentin. If you look really close and they push in – they push in – you can see Kerr... listen, this is awesome... Kerr pulp canal sealer. It’s closing the interface between warm thermal softened gutta-percha and dentinal walls. And that’s my seal. In today’s world, I might have done a little bit more. But back then, I thought that’s good; it’s corked, it’s sealed, it should work.
So if we kind of slide this over and look at our result, we’ve come from a disaster to putting in three telephone poles parallel to each other. That’s a straight shot; do you see any taper? And then of course apically I could clean it up; I could burnish my gutta-percha. If I had enough volume of GP that I could get out with a little bit of heat, even from the apical end, and I could pack a little bit and close it off. And then of course it healed. And this is about 10 years later, but look. We’ve got PDLs going up and around. I mean that’s just about a perfect world.
So what I’ll say in closing... Follow Beth’s advice. Timing is everything. Decision making is important. But you can only induce root end formation, apical genesis, if you have vital pulp.
So there’s a little lesson about the whole thing; doing it right, using the patient’s own pulp to develop a tooth. Versus Ruddle having to come in and now we have a prognosis that’s still questionable because of such thin lateral walls and such a huge surface area to seal.
So what do you think Lisette?
Well hello! I think it’s actually quite inspiring in a different way than the cases we saw from Beth. Like I mentioned earlier, I was very inspired to see the root formation and all that healing. I was very impressed. And this is also very impressive to see all this bone grow in.
So our job is to keep those teeth as long as long as those patients live. So keep it going out there.
Okay, thanks for presenting that and we’ll see you next time on The Ruddle Show.
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