Contemporary Approach to Endodontics: THE ENDOVITAL THERAPY: A Case Report

ABSTRACT

Even though non surgical endodontic therapy (root canal treatment) is one of the most common treatment plan in patients with symptomatic irreversible pulpitis, a combination of vital pulp therapy and non-surgical endodontic for the management of mature permanent teeth with apical periodontitis is a minimally invasive treatment option with a good success rate. The case report highlights selective vital pulp therapy treatment of the vital distal canal of a permanent mandibular molar and non-surgical root canal treatment of the necrotic mesial canals with a follow up of one year.

KEYWORDS

Vital pulp therapy, non surgical endodontic therapy, Endovital therapy, Combination of vital pulp therapy and non-surgical endodontic therapy.

INTRODUCTION

Symptomatic irreversible pulpitis, characterized by sharp pain upon thermal stimulus, lingering pain (often 30 seconds or longer after stimulus removal), spontaneity (unprovoked pain) and referred pain ¹ Non surgical endodontic therapy (NSET) is commonly considered as a treatment modality for such tooth with a success rate of up to 95%.² But the drawback associated with root canal treated teeth is that as the masticatory forces are exerted on such teeth there exists a high chance of structural failure, loss of sensation of environmental changes (potentially leading to more or worse caries), rejection of the foreign material, reflection and occurrence of apical periodontitis.^3,4 On the other hand, it has been found that incases of irreversible pulpitis, inflammation is limited to the area adjacent to the carious exposure, not spreading beyond 2mm from the exposure site.⁵ Literature suggests that after the amputation of pulp which has undergone degeneration and irreversible changes, the radicular pulp can be conserved.^6,7 Hence, based on the concept of spread of inflammation in the pulpal tissue, vital pulp therapy (VPT) can be considered as a preferred option for treating teeth with irreversible pulpitis.

Recently, studies have shown that clinical trial of vital pulp therapy in adjunct with non-surgical endodontic therapy on mature permanent mandibular molars with irreversible pulpitis and apical periodontitis has a very good success rate. Thus, the case report aims to present a case of the combination of both invasive and non invasive treatment protocol termed as the Endovital therapy, with a follow up of 1 year.

CASE REPORT

A patient 34 year old reported to the dental facility with a chief complain of pain in lower right back region of jaw since 2 months. Pain was gradual in onset and localized, progressive and lingering in nature. The pain aggravated on food lodgement and relieved on removal of stimulus.

CLNICAL EXAMINATION

Clinical examination of patient revealed deep carious lesion on the mesial aspect of #46 and the tooth was tender on percussion. Vitality check with electric pulp tester (EPT, Waldent, India) resulted in lingering pain lasting for more than 10 seconds.

RADIOGRAPHIC EVALUATION

Radiographic evaluation revealed an ill defined radiolucency on the mesial aspect of #46 involving enamel, dentin and pulp indicative of advanced dental caries. (Fig1 a)

PROCEDURE

On the basis of clinical and radiographic evaluation of the tooth, the tooth was diagnosed with irreversible pulpitis with apical periodontitis and the possible treatment modalities involved non-surgical endodontic treatment, a vital pulp therapy (VPT) or a combination of both. The treatment plan was discussed with the patient and an informed consent was signed by the patient after which the treatment was proceeded. The procedure was completed in single visit.

Local anesthesia was achieved with lidocaine 2% with adrenaline 1:100,000. The procedure involved 2 major steps:

STEP 1: THE VITAL PULP THERAPY

A conventional access opening was done with high speed aerotar handpiece and round carbide bur ensuring complete removal of the coronal pulp (Fig1 b). Bleeding from the canal orifice was arrested using 5.25% sodium hypochlorite, the bleeding was observed to be arrested within time duration of 5-10 minutes suggestive of mild pulpal inflammation (Fig1 c). As the caries involved the mesial canals only, Mineral Trioxide Aggregate (MTA) (Safe Endo, Gujarat, India) was placed over the distal canal orifice as a pulp capping agent following which resin modified GIC was placed over it after setting of the MTA, to ensure a good seal to the distal orifice.(Fig 1 d,e,f)

STEP 2: THE ENDODOTIC THERAPY

Working length for both the mesial canals was determined using apex locator (Root ZX, J Morita USA, Inc. Irvine, CA) which was confirmed radiographically (Fig 2a). Chemo-mechanical preparation in adjunct with ideal irrigation protocol was completed which was succeeded by a master cone radiograph (fig 2b) and final obturation (fig 2c). Post endodontic double seal was then immediately attained using type II GIC (GC Gold, Japan) followed by composite (fig 2d). The patient was then kept on follow up (fig 2e) and is still under observation.

DISCUSSION

Evaluation of the condition of the pulp is highly significant as it aids in deciding the treatment modality depending upon the condition and extent of inflammation of the pulp.8 Clinical signs and symptoms of the patient do not reflect the actual extent of inflammation in pulp tissue. Caries causes degeneration and inflammation in the pulp to various degrees, the direction of which is seen migrating from coronal to apical direction, thus, signifying the probability of the presence of vital pulp tissue which has the potential to recover in the presence of an appropriate material.9

In the above mentioned case a combination of non surgical endodontic therapy and vital pulp therapy was opted as a treatment modality as the caries was not extensive and involved only the mesial aspect of the tooth and histologically, in irreversible pulpitis, inflammation does not spread more than 2 mm out from the carious exposure 5 as a result of which the radicular pulp can be preserved following the removal of the irreversibly damaged pulp.6 Procedure was completed ensuring complete removal of coronal pulp as partial and full pulpotomy are known to sustain a high success rate after 3 year or more as stated in a systematic review by Aguilar & Linsuwanont (2011)8

Non surgical endodontic treatment was not considered as a treatment of choice as only the mesial aspect of the tooth was seen being involved. Thus, a complete removal of pulp from the coronal and radicular pulp space could have resulted in complete debridement of infected as well as healthy pulp tissue, which in turn results in loss of regeneration property and nerve innervation of the pulp. This causes the tooth to be brittle and makes it prone to fractures.3,4,9

Attainment of hemostasis also plays a major role in adoption of the treatment plan. Cessation in bleeding within 5-10 minutes is suggestive of mildly irritated pulp with potential to heal under right condition.9

MTA was used as pulp capping agent for the distal canal as it is highly biocompatible, radiopaque and has been observed to reduce the inflammatory response with dentin bridge formation in the pulp space10,

11. Another property that facilitates its use as a pulp capping agent is its resemblance to dentin. MTA is known to provide a secure barrier to bacterial and fluid leakage because of its property of expansion and contraction alike dentin. Thus, these properties facilitates its role at the best in ensuring clinical success.12

Success rate of 100% was observed in a one year study by Taha et al (2017) on mature permanent teeth with carious exposure which underwent MTA pulpotomy13. Another similar study by Taha et al (2018) stated that use of Biodentin as a pulp capping agent resulted in 100% success rate clinically and 93.8% success rate radiographically when used on mature permanent teeth with irreversible pulpitis.14 Study by Cushley et al (2019) showed clinical success rate of 97.4% and radiographic success rate of 95.4% using the same material.

A combination of vital pulp therapy with root canal therapy had a success rate of 93.3% in mature teeth diagnosed with apical periodontitis in a study by Koli et al, [5] . This treatment modality offers advantage of removal of the infected and the damaged pulp and repair of the inflamed pulp tissue. Hence, for a tooth with mild to moderate carious extension, this treatment protocol can be termed as the “Endo Vital Therapy” 9,15

CONCLUSION

Clinical signs and symptoms indicative of symptomatic irreversible pulpitis (SIP) associated with apical periodontitis (AP) in young adults have shown good response to a combination of NSET and VPT. Therefore, Endovital therapy can be considered as a positive and acceptable substitute for NSET. 

REFERENCES

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14. Outcome of full pulpotomy using Biodentine in adult patients with symptoms indicative of irreversible pulpitis - Taha - 2018 - International Endodontic Journal - Wiley Online Library [Internet]. [cited 2022 Nov 22]. Available from: https://onlinelibrary.wiley.com/doi/epdf/10.1111/iej.1290 3

15. Aishwarya P, Mali GN, Shivani PS, AS Nath. Combination of nonsurgical endodontic and vital pulp therapy for management of mature permanent mandibular molar tooth with symptomatic irreversible pulpitis and apical periodontitis: A case report. International Journal of Applied Dental Sciences. 2023;9(1):233-235.