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Vital Pulp Treatment
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Vital Pulp Treatment
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Edited by
Henry F. Duncan
Professor and Consultant in Endodontics
Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital
Trinity College Dublin, Lincoln Place, Dublin 2, Ireland
Ikhlas A. El-Karim
Clinical Professor and Consultant in Restorative Dentistry
School of Medicine, Dentistry and Biomedical Sciences, Queen’s University
Belfast, Northern Ireland, UK
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This edition first published 2024
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© 2024John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in
any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by
law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/
permissions.
The right of Henry F. Duncan and Ikhlas A. El-Karim to be identified as the authors of the editorial material in this
work has been asserted in accordance with law.
Registered Offices
John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
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Trademarks: Wiley and the Wiley logo are trademarks or registered trademarks of John Wiley & Sons, Inc. and/
or its affiliates in the United States and other countries and may not be used without written permission. All other
trademarks are the property of their respective owners. John Wiley & Sons, Inc. is not associated with any product
or vendor mentioned in this book.
Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only
and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or
treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes
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Library of Congress Cataloging- in- Publication Data
Names: Duncan, Henry, 1971- editor. | El-Karim, Ikhlas A., editor.
Title: Vital pulp treatment / edited by Henry F. Duncan, Ikhlas A.
El-Karim.
Description: Hoboken, NJ : Wiley-Blackwell, 2024. | Includes index.
Identifiers: LCCN 2023043780 (print) | LCCN 2023043781 (ebook) |
ISBN 9781119930389 (hardback) | ISBN 9781119930396 (adobe pdf) |
ISBN 9781119930402 (epub)
Subjects: MESH: Dental Pulp Diseases–therapy
Classification: LCC RK351 (print) | LCC RK351 (ebook) | NLM WU 230 | DDC
617.6/342–dc23/eng/20231107
LC record available at https://lccn.loc.gov/2023043780
LC ebook record available at https://lccn.loc.gov/2023043781
Cover Design: Wiley
Cover Images: © Henry Duncan
Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India
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Contents
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List of Contributors x
Foreword
Preface
1 TheImportanceofMaintainingPulpVitality 1
Bruno Cavalcanti and Daniel Chiego, Jr.
Introduction 1
Dental Pulp Development 1
Stem Cell Reserve andHealing/Regeneration Potential ofthe Dental Pulp 6
Pulp Vascularization andits Clinical Implications 6
Pulp Innervation andits Contribution toPhysiologic Changes 9
Pulp Response toRestorative Processes 11
Pulp Vitality andInflammation 12
Mechanisms ofPulp Repair 12
Conclusions 14
References 15
xii
xiv
Cell Signalling andDental Pulp Development 2
The Role ofthe Apical Papilla 5
v
2 BiologicalBasisforVitalPulpTreatment 20
Fionnuala T. Lundy, Lara T. Friedlander, and Paul R. Cooper
Dental Pulp– Structure and Function 20
Development andAnatomy ofthe Dental Pulp 20
Cells ofthe Dental Pulp 21
Odontoblasts 21
Fibroblasts 22
Stem Cells 22
Immune Cells 23
ECM 23
Nerves 24
Vasculature 24
Ageing 24
Healing Capability ofthe Dental Pulp 25
Molecular andCellular Regulatory Processes inTertiary Dentinogenesis 26
Bioactive Molecules 26
Cellular Responses 27
Immune-Inflammatory Response inDentine-Pulp
Repair– ADouble-Edged Sword 27
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Contentsvi
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Immunological Response inthe Dental Pulp 28
Diagnostics forPulpal Disease 32
Future Vital Pulp Treatments 33
References 35
3 PulpalDiagnosis 47
Johnah C. Galicia and Asma A. Khan
Introduction 47
Diagnoses ofPulpal Status andTheir Associated Diagnostic Terminologies 48
The Diagnostic Process 48
Pain History 49
Pulp Sensitivity/Sensibility Testing 50
Diagnostic Accuracy ofSensibility Tests 50
Other Diagnostic Tests 51
Radiographic Examination 51
Preoperative Diagnosis versus Direct Observation 51
Clinical toMolecular Diagnostic Tests: Possibilities andChallenges 52
Conclusion 55
References 55
4 VitalPulpTreatmentModalities:TheManagementofDeepCariesUsingSelectiveand
Non-SelectiveRemovalofCariousTissue,StepwiseExcavationandIndirectPulpCapping 59
Helena Fransson and Lars Bjørndal
Introduction 59
Vital Pulp Treatment Modalities Aiming Not toExpose thePulp 60
Indications– APragmatic Subdivision ofExtensive Carious Lesions 60
Caries Profunda 1 62
Caries Profunda 2 62
Caries Profunda 3 63
Understanding Caries Pathology– AReason to‘Dare’ Leaving Carious Dentine Behind 64
The Non-cavitated Enamel-Dentine Lesion 64
The Approximal andOcclusal Cavitated Carious Lesion 65
Cavitated Deep andExtremely Deep Carious Lesions 66
Consequences ofChanging theCariogenic Ecosystem– Knowhow forLess Invasive
Treatments 67
Formation ofIntra-Pulpal Cartilage-Like andHyperplastic Tissue inthe Pulp 68
Intra-Pulpal Mineralized Tissue– ASign ofPulp Pathology andAvoidance ofNon-
exposing Treatments? 68
Outcomes 68
Reported Outcome fromClinical Studies 72
Monitoring 74
Evidence-based andConsensus Recommendations 75
Epidemiology ofCurrent Practice 76
How Often Is Stepwise Excavation Performed? 76
Future 77
References 79
5 VitalPulpTreatmentModalities:DirectPulpCapping 84
Till Dammaschke
Is Exposing thePulp aProblem? AnIntroduction 84
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Management ofTraumatic andIatrogenic Pulp Exposures 85
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Indications forDirect Pulp Capping 86
Factors Affecting theOutcomes ofDirect Pulp Capping 87
Patient Age 87
Exposure Size 89
Location ofthe Pulp Exposure 89
Microorganisms 90
Caries Excavation 90
Haemostasis andCavity Disinfection 91
Selection ofthe Pulp Capping Material 92
Definitive Restoration 94
Contraindications forDirect Pulp Capping 95
Evidence-based Outcomes ofDirect Pulp Capping 98
Outcome ofDirect Pulp Capping After Deep Caries Excavation 98
Outcome ofDirect Pulp Capping After Dental Trauma 99
Future Developments inDirect Pulp Capping 99
Conclusions 100
References 101
6 VitalPulpTreatmentModalities:Pulpotomy–PartialandComplete 108
Roberto Careddu, Mark Lappin, Henry F. Duncan, and Ikhlas A. El-Karim
Introduction 108
Definitions 109
Indications 109
Definitive Treatment forAsymptomatic Cariously Exposed Pulp 109
Definitive Treatment forSymptomatic Irreversible Pulpitis 110
Definitive Treatment forTraumatically Exposed Pulp 111
Other Indications 112
Contraindications 112
The Procedure 113
Aseptic Operatory Field 113
Magnification andCaries Detection 114
Bleeding Control andAntibacterial Lavage 114
Capping Materials 115
Clinical Protocol 118
Armamentarium 118
Assessment andAnaesthesia 118
Pre-VPT Preparatory Procedures 120
Caries Removal 121
Pulp Tissue Removal (Pulpotomy) 121
Achieving Haemostasis 123
Placement ofthe Pulp Capping Material 124
Placement ofFinal Restoration 126
Outcomes ofPulpotomy 126
Which Outcome toAssess? 126
When andHow Outcomes Are Assessed? 127
Factors That May Influence theOutcomes of Pulpotomy 127
Conclusions 127
References 127
Contents vii
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Contentsviii
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7 VitalPulpTreatment–MaterialSelection 133
Renan Dal-Fabbro, Isaac J. de Souza Araújo, and Marco C. Bottino
Introduction 133
Native Pulp Conditions 136
Pulp Response toTraumatic or Carious Injuries 136
Decision-making forPulp Exposures 138
Historical Background on VPT Materials and Their Influence on Success 139
Current Gold Standard and Limitations of VPT Materials 141
Biology ofthe Tissue Response andMechanisms ofRepair– Matrix Proteins, Signalling
Molecules andPathways 143
Opportunities and Next-generation VPT Materials 144
Acknowledgements 148
References 148
8 VitalPulpTreatmentforTraumaticDentalInjuries 154
Bill Kahler and Giampiero Rossi-Fedele
Introduction 154
Traumatic Dental Injuries 154
Diagnosing thePulp Condition 155
Direct Pulp Capping andPulpotomies forManaging Traumatised Teeth 156
What is theEvidence forthe Preferred Treatment Choice? 156
Factors that Affect Outcomes of VPT in TDI 160
Restorations 160
Mobility 160
Delay inTreatment 161
Size ofPulp Exposure 163
Stage ofRoot Development 164
Material Choice for CCFs 165
Time Taken toAchieve Haemostasis 166
Time or Patient Limited Options 166
Initial Pulp Cap Followed by aLater Partial Pulpotomy 167
Complications from VPT in Traumatised Teeth 167
Pulp Canal Calcification 167
Discolouration 170
Resorption 171
Oral Health-Related Quality of Life 172
Differences Between Trauma andCaries Management 172
Complicated Crown Fracture withLuxation andComplex Injuries 174
Clinical Protocols forDirect Pulp Capping andPulpotomy 177
Pulpotomy 177
Direct Pulp Capping 177
Follow-up Protocol 177
Future Directions 178
References 178
9 RegenerativeEndodontics 185
Matthias Widbiller and Kerstin M. Galler
Introduction 185
Biological andMechanical Goals ofPulp Regeneration 186
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Historical Development ofRegenerative Endodontics 187
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Revitalization 188
Indications andContraindications 189
Clinical Protocol 189
Follow-Up 191
Outcome Measures 191
Clinical Outcome 192
Revitalization ofMature Teeth 193
Biological Result 193
Endodontic Tissue Engineering 195
Classification 195
Autologous Platelet Products 196
Conclusion 196
References 196
10 OutcomeofVitalPulpTreatmentandRegenerativeEndodontics 201
Siobhan Cushley, Emi Shimizu, Yoshifumi Kobayashi, andVenkateshbabuNagendrababu
Introduction 201
Outcomes Reporting in VPT 202
Success 202
Pain 202
Timing ofMeasurement ofPain 204
Sensibility/Vitality ofPulp 204
Timing ofSensibility Testing 205
Absence ofApical Periodontitis, Root Resorption and, inthe Case ofImmature Teeth,
Continued Root Development 205
Timing ofRadiographic Assessment 205
Other Outcomes Reported inVPT Studies 206
Quality ofthe Definitive Restoration 207
Survival 207
Histopathological Outcomes 207
Formation ofHard Tissue Barrier 208
Oral Health-Related Quality ofLife 208
Composite Outcomes 208
Stakeholder Considerations inOutcome Reporting 209
Pulp Revitalization asa Regenerative Endodontic Therapy 209
Outcomes andOutcome Measures 209
Success/Survival 209
Radiographic Measurement ofOutcomes 210
Pain 211
Tooth Function 211
Seek Emergency Treatment 211
Adverse Effects 211
Follow-Up andOptimal Timing forReporting Outcomes 211
Improvement ofCurrent RET by Assessing OHRQoL 212
References 213
Contents ix
Index 218
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