Pulp Therapies in Young Permanent Maxillary Molar With Class I Caries

Keywords

Pulp Therapies; Occlusal Caries; Young Permanent Maxillary Molars.

Introduction

The dental pulp is a soft connective tissue confined within the hard walls of the dentin which plays an important role in the prognosis of the tooth,which is often ignored. Exposure of pulp due to various reasons results in inflammation of the pulp which can lead to pulpal necrosis if left untreated [1]. Therapeutics of dental pulp diseases include direct and indirect pulp capping, Pulpotomy and pulpectomy. Preservation of pulp vitality is important as it serves several functions like dentin formation, nutrition, reparative capacity etc. Hence, preserving the pulp vitality is better than to replace it with a root canal filling material [2].

The main objective of pulp therapy in the primary dentition is to retain every primary tooth as a fully functional component in the dental arch to allow for proper mastication, phonation, swallowing, preservation of the space required for eruption of permanent teeth and prevention of detrimental psychological effects due to tooth loss [3].

Pulpotomy is a procedure in which the coronal portion of the pulp is removed surgically and the remaining radical arms pulp is retained. A pulp protecting agent is placed to prevent further damage to the pulp [4]. The rationale behind pulpotomy is based on the ability of remaining radicals to recover following the removal of infected coronal pulp and placement of medicaments [5].

Pulpectomy is a conservative treatment approach in preventing the premature loss of the tooth [6]. An appropriate pulpectomy of the teeth rather than extraction is a reasonable treatment option to ensure long term survival [7]. The primary objective of pulp treatment is to maintain the integrity and health of the oral tissues. Although a tooth can remain functional without a pulp,it is desirable to attempt to maintain the vitality of the pulp [8].

Indirect pulp capping is the procedure in which a small amount of carious dentin is retained in deep areas of cavity preparation to avoid an exposure of the pulp. A medicament is then placed over the carious dentin to stimulate and encourage pulp recovery. Indirect pulp therapy performed in primary and permanent teeth of young patients may result in a high 3-year survival rate. Direct pulp capping is defined as the placement of a medicament on a pulp that has been exposed during excavation of deep dental caries. The rationale behind this treatment is to encourage young healthy pulps to initiate a dentin bridge [9].

It is frequently maintained that pulp capping and pulpotomy procedures should be considered for minimally affected teeth [9-11]. The advantages of preserving the pulp is obvious in cases with large pulp chambers and underdeveloped roots because pulpectomy arrested root development [11-13]. The most radical approach is to remove the entire pulp and replace it with a root canal filling material [13, 14]. Vital pulp therapy is indicated for pulp exposure in teeth with incompletely formed roots, but once root formation has been completed, pulpectomy or root canal therapy should be performed [15].

Previously our team had conducted numerous clinical trials [21- 23, 25-27, 29, 35], and epidemiological surveys [24, 28] over the past 5 years. The idea for this retrospective study was stemmed from the current interest in our community. The aim of this study is to assess the prevalence of pulp therapies done in young permanent maxillary molars with occlusal caries among patients aged between 6-11 years attending the OP of the department of Pedodontics at the University in Chennai.

Materials and Methods

A retrospective study was carried out in patients between the age of 6-11 years who visited University in Chennai who have undergone pulp therapy in young permanent maxillary molars. Data from 1st June 2018 to 30th March 2019 was collected from patient records which includes details of patients, intraoral photographs and treatment being done. Inclusion criteria:Patients between the age of 6-11 years, both males and females are included, patients with occlusal caries (Class I) on young permanent maxillary molars. Exclusion criteria:Tooth with caries on surfaces other than the occlusal surface.

Sample size [N=74] is the total number of patients who visited University in Chennai with occlusal caries on young permanent maxillary molars and underwent pulp therapy. Sample distribution according to age, gender and teeth number were recorded. Ethical clearance was obtained from the Institutional Ethical Committee and Scientific Review Board [SRB] of University in Chennai.

The data collected was entered in an Excel sheet and subjected to statistical analyses using SPSS software. Descriptive statistics were done i.e frequency and cross tabulation. A chi square test was done between age and tooth affected. Independent variables are age and gender, while dependent variables are teeth number and surface affected. The level of significance was p<0.05.

Results and Discussion

A total of 74 patients were seen during the study period. The most predominant pulp therapy procedure done was found to be the pulpectomy with a percentage of 94.6%. Pulpotomy on the other hand was only found to be 5.4% ( Figure 1).It was found that the most commonly affected and treated teeth were the left permanent maxillary molar with a percentage of 58.1% and right permanent maxillary molar were about 41.9% ( Figure 2). It was found the female distribution was higher with a percentage of 51.4% whereas males were about 48.6% ( Figure 3). The statistical analysis Chi-square test shows p-value (0.069) more than the limit of significance p<0.05, a negative correlation between the age of the patients and the pulp therapy procedure as depicted in Figure 4.

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Pulpectomy procedures were most commonly performed for immature permanent maxillary molars in this study. According to a study by Raji Viola Solomon et al, 4 out of 5 cases of pulpotomy was successful and coronal pulpotomy was considered an alternative to pulpectomy procedures [16]. In a systematic review by Gunnar Bergenholtz et al,it is stated that it is not possible to determine whether an injured pulp by deep caries can be maintained or whether it should be removed and replaced with a root filling material [17].

George Bogen et al., in his study states that new treatment strategies for direct pulp capping and pulpotomy have shown promising potentials for improved outcomes in immature teeth with extensive caries [18]. Similarly, a study by Jekaterina Gudkind et al,also states vital pulp therapy has been proven to be repeatedly successful and be recommended routinely for pulp exposure of immature permanent teeth [29]. A study by Imad Hassan et al shows that pulpotomy using MTA could be a good alternative for root canal therapy [20]. Considerable research has been conducted in the field of pedodontics with relevance to the current population under study [21-35]. This study helps to identify the prevalence of pulp therapies done in young permanent maxillary molars with Class I caries among the study population. Further studies with a larger population and considering the extent of caries is advised.

Acknowledgement and Declarations

The authors are thankful to the Director of Saveetha Dental College and Hospitals, Chennai. S.S.Shivanni has contributed in data collection, study design, data analysis, results, tables and manuscript preparation. Dr. Bhagyalakshmi has contributed to manuscript preparation, proof reading of manuscript and reviewing the manuscript. Dr. Balakrishna has contributed to reviewing the manuscript. This study is self funded. There are no conflict of interest.

Conclusion

Root formation is not complete in young permanent teeth. Hence, preserving the pulp is necessary to help in the completion of the root ends. Adequate knowledge on the root anatomical variations and absolute awareness of the radiographic limitations, instrumentation procedures, chemical interactions among different endodontic irrigants and root canal filling techniques are essential prior to commencing pulpectomy procedures. Vital pulp therapy can be considered as an alternative to RCT in young permanent molars clinically diagnosed with irreversible pulpitis. In the current study, pulpectomy was highly performed over pulpotomy although many researches state that pulpotomy is preferred for immature permanent teeth. The future scope of this study is to consider the caries extent and to conduct the study among a larger population.