Long Term Survival of Indirect Pulp Treatment in Immature Teeth with Deep Carious Lesions

There is increasing pressure from the public to remove fluoridation from public water systems and reluctance of many young parents to provide their children with fluoride supplements or appropriate radiographs due to perceived health concerns. The irony of this is that many of the same people leading the anti-fluoridation movements are themselves caries-free as a result of public fluoridation. With childhood caries greatly reduced in the 1970’s and 1980’s from the prevention measures of organized dentistry, it seems that the public consciousness towards prevention has been blunted, resulting in a rebounding in caries once again.
Deep carious lesions in young people provide a unique challenge for dentists. If untreated, these lesions will eventually penetrate to the pulp resulting in pulpal necrosis, peri-apical pathology, and structural tooth loss. When deep carious lesions are discovered, the dentist has a number of issues to consider. Depending on age, the dentist may be faced with an uncooperative patient who does not tolerate dental intervention very well. Taking adequate radiographs in a young patient with a small, growing arch may be difficult or impossible. Obtaining adequate anaesthesia and isolation with a rubber dam may tax the skills of the dental team. Immature teeth also provide challenges when caries are so deep that endodontics may be indicated. Immature teeth have thin root walls which are prone to fracture over time, while large, undeveloped pulp canal systems with many intra-canal communications and wide open apices are difficult to adequately clean, shape, and obturate with contemporary endodontic methods and materials. Alternately, extraction may be considered but that treatment is traumatic to the patient and often requires a commitment to future orthodontic treatment. All in all, immature teeth are a headache when endodontic intervention is likely. A better result for both patient and doctor would be to restore the tooth without involving pulp treatment, allowing natural root development to proceed as the patient matures.

Wu et al, JOE 36:9, investigated the long-term survival of immature teeth treated with indirect pulp treatment (IPT) rather than endodontics. Teeth included in the study were asymptomatic with normal attachment apparatus and caries, which were at least two thirds of the distance to the pulp radiographically. The teeth were anaesthetized, isolated with a rubber dam, and the caries removed with a spoon excavator until the caries was firm overlying the pulp but not exposing it. Sound dentin borders away from the pulp space were obtained to allow for a well-sealed restoration. The carious area was covered with a resin-modified glass ionomer (Vitrebond, 3M ESPE) and a bonded restoration was placed. Patients were recalled at 3-6 month intervals. “Survival” was determined by teeth that were asymptomatic with normal radiographic attachment apparatus.
After three years, the authors found that 44 of 45 permanent teeth were free from symptoms and peri-apical pathology. This study should provide dentists with the confidence to initiate conservative measures when faced with deep caries in immature teeth. Buying time with IPT allows normal root development to proceed and the child to grow and mature. If endodontics is subsequently required, then the dentist will encounter a more compliant patient and normal root canal system.

 

ABOUT DR. HOWARD BITTNER

Dr. Bittner was born and raised in the Surrey/Langley area. Following his pre-dental training at Simon Fraser University, he received his Doctor of Dental Medicine from the University of British Columbia in 1982 and his Certificate in Advanced Graduate Studies in Endodontics from Boston University’s Goldman School of Dental Medicine in 1995.

Dr. Bittner was in private practice in general dentistry for 11 years in Langley prior to his endodontic specialty training. He has a wide background in all facets of general dentistry, with advanced dental training in prosthetic dentistry from respected educational facilities such as Creating Restorative Excellence in Tacoma, Washington, and The Pankey Institute in Miami, Florida. He has been practicing the dental specialty of Endodontics since 1995.

He is a past president of the British Columbia Society of Endodontists, the Dental Specialists Society of British Columbia, and the Concentric Endodontic Study Club. Dr. Bittner is also a guest lecturer in the Faculty of Dentistry at the University of British Columbia.

On October 6, 2011, posted in: News for Doctors by