CATEGORY 74 AUSTRALASIAN DENTIST Summary: Keywords u VOCO MTA vpt u Deep carious lesion u Pulpal exposure u Indirect pulp cap u Direct pulp cap Introduction Dental caries remains one of the highest preventable oral diseases worldwide [World Health Organization, 2017]. If left untreated, caries will advance through the dentine stimulating pulpitis and eventually pulpal necrosis. However, if conservatively managed, pulpal recovery can occur even in cases of deep carious lesions or pulpal exposure, whether due to caries or iatrogenic causes. Management strategies for cariously exposed pulp are shifting with the avoidance of pulpectomy towards the re-emergence of vital pulp therapy techniques. is shift is driven by the development of novel pulp capping materials, such as MTA vpt (VOCO GmbH, Cuxhaven, Germany), leading to more predictable clinical and histological outcomes. In the 1990s, direct pulp caps with dental adhesive materials initially o ered promising results [Cox et al. 1998]; however, after several months, marginal bond deterioration and subsequent in ltration by bacteria occurred, leading to pulpal in ammation or necrosis [Pameijer & Stanley 1998, Bergenholtz 2000]. Resin based adhesive materials were discouraged, and new biologically based materials were developed with the principal aim of promoting mineralised bridge formation [Pitt Ford et al. 1996]. Originally developed as a dental root repair material [Lee et al., 1993], Mineral trioxide aggregate (MTA) has emerged as a versatile and biocompatible material used in various dental procedures, and is now widely recognised for its applications in direct and indirect pulp capping. Its superior sealing ability and promotion of hard tissue formation, as well as excellent biocompatibility and antimicrobial action, make it an ideal choice for managing pulp exposure. When restorative interventions are necessary, prioritising the preservation of pulpal health is essential. Clinical case A 53-year-old male patient was referred to the clinic by his general dentist due to occasional pain in the posterior region of the left mandible. Seeking a second opinion, the patient required alternatives as his dentist believed that a root canal treatment or extraction of the lower left second molar (tooth 37) were the only viable options due to the depth of the carious lesion. After missing a recent recall, despite being a good attender to the dentist generally, the patient began experiencing symptoms in the lower left quadrant, prompting an emergency visit. He had realistic expectations and felt he was attending to require root canal treatment. During the clinical examination, the patient reported experiencing pain while eating on the left side over the past few weeks, leading him to favour his right side for chewing. More recently, he has found that consuming something cold triggered some intermittent sharp pain that would settle after removal of the stimulus, but he could not localise it further. Although the epicentre of the pain seems to be the lower left quadrant, sometimes the upper left quadrant would trigger symptoms too. He has not taken any analgesics and the pain has not been keeping him awake at night. A clinical inspection revealed primary caries in tooth 37, with a small cavity visible on the occlusal surface extending towards the distal area. However, the signi cant opacity of the surrounding dental hard tissue in the occlusal and distoproximal area suggested extensive spread of the underlying carious lesion (Fig. 1). e teeth 26-28 and 38-36 responded negatively to percussion testing. All aforementioned teeth, except for tooth 37, showed normal responses to sensibility testing with ethyl chloride; tooth 37 was hyperresponsive, with pain subsiding after the stimulus was removed. Teeth 36, 37 and 38 displayed normal responses to electric pulp testing. An intraoral periapical radiograph of tooth 37 revealed an extensive radiolucency on the distal aspect, in close proximity to the pulp, due to a deep carious lesion (Fig. 2). ere was no observable apical pathology associated with tooth 37. Additionally, tooth 38 had a slight mesioangular impaction, and 36 showed an initial caries on the distal part as well as an erosion on the occlusal surface that would require further monitoring. e likely diagnosis for tooth 37 was reversible pulpitis. Di erential diagnoses included irreversible pulpitis and cracked tooth syndrome for tooth 37. After evaluating treatment options ranging from the least interventive to the most invasive, and discussing the associated costs, the patient chose to proceed with a likely direct pulp capping using MTA vpt (VOCO GmbH, Cuxhaven, Germany). is choice was due to the extent of the cavity. is procedure would be followed by a direct composite covering layer with GrandioSO Heavy Flow (VOCO GmbH, Cuxhaven, Germany), to seal the MTA vpt plug, and the nal lling with the universal adhesive Futurabond U (VOCO GmbH, Cuxhaven, Germany) and the chromo-adaptive nano-hybrid composite GrandioSO Unlimited (VOCO GmbH, Cuxhaven, Germany). e patient was advised that if there was no pulp CLINICAL Contemporary management of a deep carious lesion and pulpal exposure By Dr. Ashish Soneji, Queen Square Dental Clinic, Bristol, UK Dr. Ashish Soneji Figure 1: Pre-operative situation. Initial clinical presentation of deep carious lesion on tooth 37, displaying symptoms of reversible pulpitis Figure 2: Pre-operative intraoral periapical radiograph of 37. Displaying extensive distal radiolucency of 37 due to a deep carious lesion
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