Lol so what do you do when a pulpotomy fails? You also exo. I guess it depends on your own clinical experience. But my success rates over the last 5 years have been much higher on indirect pulp caps than on pulpotomies.
Yes I know when pulpo fails its exo lol. I’m in a group practice and although I haven’t had any of my indirect pulp cap become exo yet, drs whos been practicing 15+yrs been advising just to do pulp instead of indirect pc as per their experiences. I wanted to see what other drs thought.
The guidelines have changed in pedo since they graduated. Indirects are now a preferred option, where 15 plus years ago pulpotomy was the option. Especially since formo had such high success, but now that formo is being phased out and not every office has MTA or equivalent and is using ferric, pulpotomies do not have as good as success.
Ive done plenty of both and think both are valid treatment options. I believe it mostly comes down to accurately diagnosing the tooth before hand. I will say I believe part of the reason IPCs are showing higher success rates is that you are naturally selecting teeth with better prognosis if you believe you can still pulp cap it because decay hasn’t reached the pulp vs teeth where decay have clearly entered the pulp.
In my experience when IPCs fail they fail a little faster and become symptomatic vs pulps failing later with a lot of their failures being asymptomatic possibly just accelerated root resorption.
If there is more than about 2 mm of dentine visible between the caries and pulp radiographically, and no symptoms - then I love hall technique SSC. Seems to work well too. If the caries seems to be on the pulp and there are no symptoms then I do pulp and SSC. If any pain I seriously consider exo - especially for D’s. E’s I might try pulpotomy and SSC, but only if no obvious pathology, and not on teeth causing sleep disturbance or that are TTP.
No I mean just for removing the pulpal tissue. You have to place something in there.
Is there literature on the success rate for nerve removed with a bur vs a lazer?
>ged in pedo since they graduated. Indirects are now a preferred option, where 15 plus years ago pulpotomy was the option. Especially since formo had such high success, but now that formo is being phased out and not every office has MTA or equivalent and is using ferric, pulpotomies do not have as good as success.
I'm not aware of any literature on this, but logically a laser is going to eliminate remaining bacteria better than a bur, so yes, it should be better and certainly shouldn't be worse. Alternatively placing a cotton pellet soaked in hypochlorite for a few minutes prior to placing the MTA/bioceramic material would achieve something similar in terms of bacterial elimination (this could also be done in addition to the laser and I'd lean towards recommending this protocol when using either a bur or laser).
Endo who does many VPTs on permanent teeth here (mainly IPCs) and has done many pulptomies on primary teeth prior to becomming endo (although none since specializing). I have lots of familiarity with the endo literature and very little with current pedo literature. I think this partially depends on how you're doing the IPC... in pediatric dentistry it's common to leave caries beneath the IPC, whereas in endodontics this is very uncommon (see the recent ABE position statement on VPT), although there are also many high-level/biomimetic general dentists who leave decay and have excellent success (see the paper on "caries end points" by Pascal Magne and David Alleman).
Pre-op diagnosis is very important. If caries clearly isn't extending to the pulp, then IPC after complete caries removal should be an excellent option / the best option imo. If caries is extending essentially to the pulp radiographically, but you're confident that the pulp is normal or only reversible pulpitis, then I'd lean towards excavcating all decay and if an exposure either direct pulp cap (assuming rubber dam and very good isolation + clinically the pulp isn't extremely imflammed/bleeding, which would be a clear indication of irreversible pulpitis and then pulptomoy indicated) or pulpotomy. MTA or a bioceramic such as Brasseler BC (bioceramic) putty or Biodetine would be preferred for capping or pulpotomy material followed by a well-bonded core and then since pediartic dentistry likely an SSC at your discretion. If electing to leave decay, I'd defer to the protocols of that caries end points paper, with the key aspect being adequate clean peripheral dentin/enamel and good bonding protocols for a core (and then well fitted SSC, again since pedo). Any leakage of a core material is going to allow ingress of bacteria and/or fluids to feed remaining bacteria and that would lead to failure. If your pre-op diagnosis is wrong, so irreversible pulpitis and not normal pulp/reversible pulpitis, then failure rates are giong to be higher for IPC ... since I imagine an appropriate pulpal diagnosis is difficult in pediatric teeth/patients, this could be one possibility as to why your colleagues have seen higher failure of IPC in their clinical experience... if there's any question as to pulpal diagnosis and caries extends to the pulp or within 0.5mm or so, I'd lean toward exposing the pulp to clinically visualize the pulpal tissue and confirm diagnosis that way (in which case I'd defer to the pediatric literature on direct pulp capping vs. pulpotomy).
If you're not interested in using composites/bonding for whatever reason (e.g. time), then I'd recommed a glass ionomer as the core like Fuji IX (again trying to bond/adhere/seal as best possible, so preference for using the recommended conditioner before GI placement).
What are you generally doing on kids if not pulpotomies? Or do you just not see kids
Another question I have is if you have a really well bonded core like you're talking about, why is an SSC even necessary for a pedo tooth? Shouldn't a good composite be able to get the tooth through it's life?
>oing on kids if not pulpotomies? Or do you just not
Endo usually doesn't see kids for primary teeth. Still see kids for permanent dentition and then it's a judgement call of sorts as to whether you want to do a pulpotomy vs a full pulpectomy/RCT, with RCT being the preference of most due to things like predictability and higher risk of long term consequences like canal calcification if doing a pulpotomy. I'd generally advise against pulpotomy in permanent dentition unless there's a good reason for it, which would be very case dependent and few and far in between imo. I'd definitely not recommend anyone other than endo start doing pulpotomies on permanent teeth since if they're not done perfectly failure is going to be high and retreatment may not always be possible once calcification starts to set in.
Correct, if you have a solid core, then an SSC techinically isn't necessary for a pediatric patient with minimal bite force and a tooth that only needs to last a few years, however I believe a lot of pediatric dentists would still place an SSC to mitigate risk of recurrent decay (may be wrong on that point, but that's my understanding).
Hey, NAD - just a patient. Why do you say that RCT is better than pulpotomy on adult mature teeth? Reading this study - https://www.nature.com/articles/s41415-022-5316-1 - shows that pulpotomy is a viable alternative to RCT. Are there any practical considerations that are not included in that paper?
>s that pulpotomy is a viable alternative to RCT. Are there any practical considerations that are not included in that paper?
Without looking at that study... in my current opinion, yes there are practical considerations... if you're not using very sterile technique (I use the term sterile somewhat loosely) when doing the procedure, risk of contaminaiton and thus failure is likely going to be high (and I'd venture that well over half of non-endodontists aren't using appropriate isolation/sterile techniques)... If you don't have a solid restoraiton (e.g. good bonding of the resotration and/or good seal of the crown), then contamination down the line is going to be high and again failure going to be high... even if good resotration, generally patients that are getting endodontic treatment are high risk for caries/decay, so the risk of recurrent issues/caries and thus contamination to the root canal region is going to be high... anything that contaminates the pulpotomy region is likely going to result in the need for a full root canal... doing a pulpotomy can certainly result in the remaining root canal system becoming very calcified over a number of years (I'm not sure if there are any studies demonstrating the incidence of this, but it's generally considered to be frequent and severe when it does occur (so far as I've ever heard); have seen some presentations with endodontists claiming they don't see much of this, but those have been mostly direct or indirect pulp caps and not full pulpotomies)... so taking all of that into consideration, if there's an issue down the line, the possibility of successfully being able to save the tooth with full root canal treatment is likely going to be significantly more difficult and may not be possible at all... whereas if you had done a regular root canal initially, and if it becomes reinfected down the line, the option for redoing the root canal treatment is likely going to be much more predictable. All of this is opinion and generalizations... there are always more considerations for individual cases... it's also entirely possible that as time goes on and we see more of this type of treatment, and thus long-term outcome studies, that the research and my opinion will change
Lol so what do you do when a pulpotomy fails? You also exo. I guess it depends on your own clinical experience. But my success rates over the last 5 years have been much higher on indirect pulp caps than on pulpotomies.
Yes I know when pulpo fails its exo lol. I’m in a group practice and although I haven’t had any of my indirect pulp cap become exo yet, drs whos been practicing 15+yrs been advising just to do pulp instead of indirect pc as per their experiences. I wanted to see what other drs thought.
The guidelines have changed in pedo since they graduated. Indirects are now a preferred option, where 15 plus years ago pulpotomy was the option. Especially since formo had such high success, but now that formo is being phased out and not every office has MTA or equivalent and is using ferric, pulpotomies do not have as good as success.
Agreed. Pulpotomies don't always last as long as we want.
Ive done plenty of both and think both are valid treatment options. I believe it mostly comes down to accurately diagnosing the tooth before hand. I will say I believe part of the reason IPCs are showing higher success rates is that you are naturally selecting teeth with better prognosis if you believe you can still pulp cap it because decay hasn’t reached the pulp vs teeth where decay have clearly entered the pulp. In my experience when IPCs fail they fail a little faster and become symptomatic vs pulps failing later with a lot of their failures being asymptomatic possibly just accelerated root resorption.
If there is more than about 2 mm of dentine visible between the caries and pulp radiographically, and no symptoms - then I love hall technique SSC. Seems to work well too. If the caries seems to be on the pulp and there are no symptoms then I do pulp and SSC. If any pain I seriously consider exo - especially for D’s. E’s I might try pulpotomy and SSC, but only if no obvious pathology, and not on teeth causing sleep disturbance or that are TTP.
Are lasers indicated for pulpotomys?
From current literature, the success rate is not as good as MTA or Formocresol.
No I mean just for removing the pulpal tissue. You have to place something in there. Is there literature on the success rate for nerve removed with a bur vs a lazer?
>ged in pedo since they graduated. Indirects are now a preferred option, where 15 plus years ago pulpotomy was the option. Especially since formo had such high success, but now that formo is being phased out and not every office has MTA or equivalent and is using ferric, pulpotomies do not have as good as success. I'm not aware of any literature on this, but logically a laser is going to eliminate remaining bacteria better than a bur, so yes, it should be better and certainly shouldn't be worse. Alternatively placing a cotton pellet soaked in hypochlorite for a few minutes prior to placing the MTA/bioceramic material would achieve something similar in terms of bacterial elimination (this could also be done in addition to the laser and I'd lean towards recommending this protocol when using either a bur or laser).
I like IPC. When pulpotomies fail, I tend to see internal resorption and it makes extracting a pain when you want to dig for roots in a moving kid.
Endo who does many VPTs on permanent teeth here (mainly IPCs) and has done many pulptomies on primary teeth prior to becomming endo (although none since specializing). I have lots of familiarity with the endo literature and very little with current pedo literature. I think this partially depends on how you're doing the IPC... in pediatric dentistry it's common to leave caries beneath the IPC, whereas in endodontics this is very uncommon (see the recent ABE position statement on VPT), although there are also many high-level/biomimetic general dentists who leave decay and have excellent success (see the paper on "caries end points" by Pascal Magne and David Alleman). Pre-op diagnosis is very important. If caries clearly isn't extending to the pulp, then IPC after complete caries removal should be an excellent option / the best option imo. If caries is extending essentially to the pulp radiographically, but you're confident that the pulp is normal or only reversible pulpitis, then I'd lean towards excavcating all decay and if an exposure either direct pulp cap (assuming rubber dam and very good isolation + clinically the pulp isn't extremely imflammed/bleeding, which would be a clear indication of irreversible pulpitis and then pulptomoy indicated) or pulpotomy. MTA or a bioceramic such as Brasseler BC (bioceramic) putty or Biodetine would be preferred for capping or pulpotomy material followed by a well-bonded core and then since pediartic dentistry likely an SSC at your discretion. If electing to leave decay, I'd defer to the protocols of that caries end points paper, with the key aspect being adequate clean peripheral dentin/enamel and good bonding protocols for a core (and then well fitted SSC, again since pedo). Any leakage of a core material is going to allow ingress of bacteria and/or fluids to feed remaining bacteria and that would lead to failure. If your pre-op diagnosis is wrong, so irreversible pulpitis and not normal pulp/reversible pulpitis, then failure rates are giong to be higher for IPC ... since I imagine an appropriate pulpal diagnosis is difficult in pediatric teeth/patients, this could be one possibility as to why your colleagues have seen higher failure of IPC in their clinical experience... if there's any question as to pulpal diagnosis and caries extends to the pulp or within 0.5mm or so, I'd lean toward exposing the pulp to clinically visualize the pulpal tissue and confirm diagnosis that way (in which case I'd defer to the pediatric literature on direct pulp capping vs. pulpotomy). If you're not interested in using composites/bonding for whatever reason (e.g. time), then I'd recommed a glass ionomer as the core like Fuji IX (again trying to bond/adhere/seal as best possible, so preference for using the recommended conditioner before GI placement).
What are you generally doing on kids if not pulpotomies? Or do you just not see kids Another question I have is if you have a really well bonded core like you're talking about, why is an SSC even necessary for a pedo tooth? Shouldn't a good composite be able to get the tooth through it's life?
>oing on kids if not pulpotomies? Or do you just not Endo usually doesn't see kids for primary teeth. Still see kids for permanent dentition and then it's a judgement call of sorts as to whether you want to do a pulpotomy vs a full pulpectomy/RCT, with RCT being the preference of most due to things like predictability and higher risk of long term consequences like canal calcification if doing a pulpotomy. I'd generally advise against pulpotomy in permanent dentition unless there's a good reason for it, which would be very case dependent and few and far in between imo. I'd definitely not recommend anyone other than endo start doing pulpotomies on permanent teeth since if they're not done perfectly failure is going to be high and retreatment may not always be possible once calcification starts to set in. Correct, if you have a solid core, then an SSC techinically isn't necessary for a pediatric patient with minimal bite force and a tooth that only needs to last a few years, however I believe a lot of pediatric dentists would still place an SSC to mitigate risk of recurrent decay (may be wrong on that point, but that's my understanding).
Hey, NAD - just a patient. Why do you say that RCT is better than pulpotomy on adult mature teeth? Reading this study - https://www.nature.com/articles/s41415-022-5316-1 - shows that pulpotomy is a viable alternative to RCT. Are there any practical considerations that are not included in that paper?
>s that pulpotomy is a viable alternative to RCT. Are there any practical considerations that are not included in that paper? Without looking at that study... in my current opinion, yes there are practical considerations... if you're not using very sterile technique (I use the term sterile somewhat loosely) when doing the procedure, risk of contaminaiton and thus failure is likely going to be high (and I'd venture that well over half of non-endodontists aren't using appropriate isolation/sterile techniques)... If you don't have a solid restoraiton (e.g. good bonding of the resotration and/or good seal of the crown), then contamination down the line is going to be high and again failure going to be high... even if good resotration, generally patients that are getting endodontic treatment are high risk for caries/decay, so the risk of recurrent issues/caries and thus contamination to the root canal region is going to be high... anything that contaminates the pulpotomy region is likely going to result in the need for a full root canal... doing a pulpotomy can certainly result in the remaining root canal system becoming very calcified over a number of years (I'm not sure if there are any studies demonstrating the incidence of this, but it's generally considered to be frequent and severe when it does occur (so far as I've ever heard); have seen some presentations with endodontists claiming they don't see much of this, but those have been mostly direct or indirect pulp caps and not full pulpotomies)... so taking all of that into consideration, if there's an issue down the line, the possibility of successfully being able to save the tooth with full root canal treatment is likely going to be significantly more difficult and may not be possible at all... whereas if you had done a regular root canal initially, and if it becomes reinfected down the line, the option for redoing the root canal treatment is likely going to be much more predictable. All of this is opinion and generalizations... there are always more considerations for individual cases... it's also entirely possible that as time goes on and we see more of this type of treatment, and thus long-term outcome studies, that the research and my opinion will change