Apexogenesis of an Immature Permanent Molar with Irreversible Pulpitis Using Mineral Trioxide Aggregate Pulpotomy: A Case Report (2024)

ABSTRACT

Carious exposure of an irreversibly inflamed vital pulp in a young permanent tooth presents a significant clinical challenge to clinicians to maintain the vitality. Direct pulp capping, partial pulpotomy, and complete pulpotomy are the available procedures to treat young permanent tooth. Mineral trioxide aggregate and biodentine are currently the material of choice for these procedures. The present case report describes the successful apexogenesis of mandibular left first permanent molar using mineral trioxide aggregate. The 18-month follow-up of the case demonstrated clinical and radiographic success with absence of any signs and symptoms and continued root formation.

KEYWORDS: Apexogenesis, mineral trioxide aggregate, pulpotomy

INTRODUCTION

Pulpal and periapical inflammation are among the primary reasons that bring pediatric patients to dentists.[1] Vital pulp therapy (VPT) comprises various treatment approaches aimed at preserving the health and integrity of teeth to maintain pulpal vitality in cases of deep caries lesions. Pulpotomy is typically performed when a cariously or traumatically exposed vital tooth has a diagnosis of normal pulp or reversible pulpitis. In situations where a tooth exhibits signs of irreversible pulpitis and a periapical lesion, conventional root canal treatment is traditionally recommended.[2] However, managing immature permanent teeth endodontically poses challenges, and root canal treatment for posterior immature multirooted teeth is only considered in specific cases where tooth preservation is crucial for occlusion.

Vital pulp therapy on an immature tooth enables continuous root formation, leading to apical closure, preservation of pulpal vitality, a stronger root structure, and greater structural integrity.[3] The gold standard for vital pulp therapy is mineral trioxide aggregate (MTA), known for inducing hard tissue formation when directly applied to pulpal tissues.[4] MTA placement on exposed pulp tissue triggers the release of growth factors necessary for pulpal cells to recruit and organize odontoblasts, facilitating the deposition of reparative dentine.[5]

The purpose of this paper was to present the long-term success of complete pulpotomy using MTA in a young permanent molar with indications of irreversible pulpitis and a periapical lesion.

CASE REPORT

A 10-year-old healthy male patient presented at the Paediatric Dentistry Clinic, in a specialist dental center, due to pain in the lower left back tooth region while drinking cold liquids and during sleep at night. Clinical examination revealed a large carious lesion involving the occlusal, buccal, and distal surfaces of the mandibular first permanent molar. The tooth’s vitality test was positive. An intraoral periapical radiograph revealed a deep carious lesion extending into the pulp. The radiograph also showed a periapical lesion, loss of lamina dura, and widening of the periodontal ligament space. Based on both clinical and radiographic findings, the diagnosis was concluded as irreversible pulpitis with a periapical lesion in a young permanent molar with CVEK stage IV root development [Figure 1].

The treatment options, along with their risks and benefits, were explained to the parents. Although the parents were against extraction and wanted to save the tooth, a decision was made to either perform a complete pulpotomy using MTA or do a root canal treatment. Informed consent was obtained for the chosen procedure.

The patient exhibited cooperative behavior according to the Frankel’s behavior rating scale. Under inferior alveolar nerve block using local anesthesia with 2% lidocaine (1:80,000 epinephrine), the tooth was isolated using a rubber dam (Optra Dam, Vivadent). The caries lesion was removed using a high-speed air motor handpiece. After removing all the caries from the walls, proper access to the pulp chamber was gained. The coronal pulpal tissue was removed using a sharp spoon excavator until the canal orifices were visible. The exposed pulp appeared bright red, and bleeding was observed from the exposure site. To achieve hemostasis, a 5% NaOCl solution was applied to the exposed pulp for two minutes. As the radicular pulp appeared vital, the decision was made to perform a complete pulpotomy. White ProRoot MTA (Dentsply Sirona, USA) was mixed and placed on the floor of the pulp chamber, near the root canal orifices, at a thickness of approximately 3–4 mm. The MTA was then covered with a light-cured resin-modified glass-ionomer cement (GC LC 2/Fuji 2), and composite resin (TPH Spectrum, Dentsply Sirona, USA) was used to build up the walls of the tooth and restore the cavity [Figure 2].

The patient was instructed to report immediately to the clinic if any pain or discomfort occurred. The patient was recalled after 2 weeks, during which he revealed an absence of symptoms after the treatment. The cold test showed a normal response. The patient was scheduled for follow-ups at 3, 6, 12, and 18 months, with instructions to return immediately in case of any discomfort.

The three-month follow-up intraoral periapical radiograph revealed improvement in the periapical area without any evidence of periapical pathology, interradicular bone resorption, internal resorption, pulp calcification, or pathologic root resorption [Figure 3].

The twelve-month radiograph showed continued root formation without any evidence of pulpal pathology [Figure 4]. The 18th-month follow-up intraoral periapical radiograph revealed complete root development without any evidence of any pulpal pathology, and finally, the tooth was restored with a stainless steel crown [Figure 5].

DISCUSSION

Preoperative radiographic and clinical examinations are crucial for assessing pulpal vitality, but direct evaluation of the pulp should also be considered due to the varying correlation between clinical and histological pulpal status.[6,7] A periapical lesion in a young permanent tooth results from the immunological response to an irritating factor that invades the coronal pulp.[8] A systemic review by Cushley S et al. showed a 97.4% clinical success rate for pulpotomy-treated permanent teeth exhibiting signs of irreversible pulpitis.[9] The appearance of the exposed pulpal tissue, bleeding color, and hemostasis are clinical criteria commonly used to judge pulp vitality. In this case, the exposed pulp appeared vital, with a resilient texture, bright red color, and controlled bleeding, indicating healthy radicular pulp tissue that could be preserved. These were the reasons for performing a complete pulpotomy in this case with signs and symptoms indicative of irreversible pulpitis and a periapical lesion.

Saline and 5% sodium hypochlorite were used as irrigants in this case. Sodium hypochlorite has been commonly used for root canal treatment during vital pulp therapy due to its disinfectant properties, without negatively affecting pulpal cell recruitment, cytodifferentiation, or reparative dentin deposition.[10,11,12] Several factors including sealing ability, antimicrobial activity, and more importantly dentinogenesis should be taken into consideration when choosing a pulpotomy agent.[13] Mineral trioxide aggregate (MTA) is a biocompatible material that prevents microleakage and promotes regeneration when in contact with dental pulp.[14] Studies have reported excellent results when using MTA as a pulp-dressing agent for permanent or primary teeth.[15] Hend Alqaderi et al. reported a success rate of 90 percent when MTA was used as a pulpotomy agent in molar tooth with irreversible pulpitis.[16] Pairoj Linsuwanont et al. in their retrospective study reported success rate of 84 percent when MTA was used as a pulpotomy medicament in carious exposed vital permanent teeth.[17] In this case, MTA was chosen due to its desirable sealing ability, biocompatibility, and properties that promote reparative dentin formation, leading to a favorable outcome without the need for further endodontic intervention during the 18-month follow-up.

While there are numerous literature reviews supporting the success of vital pulp therapy in immature permanent teeth, the uniqueness of this case lies in the almost grossly damaged crown of the affected tooth, which was still salvageable without conventional root canal treatment. Long-term follow-up is recommended as a limitation of this case report.

Success in coronal pulpotomy depends on diagnosing pulpal conditions, ensuring complete isolation during the procedure, employing well-sealing pulp cap materials, and providing proper final restoration for adequate sealing and prevention of bacterial microleakage.[18,19,20] Based on the European Society of Endodontology, success is determined by the absence of clinical symptoms, radiographic changes, and evidence of reparative dentin formation.[21] In this study, the patient was followed up for 18 months, and the tooth remained asymptomatic with complete root formation.

CONCLUSION

In conclusion, this case demonstrates the importance of vital pulp therapy in young permanent molars, showcasing their reparative potential. Complete pulpotomy with MTA proved successful in promoting the healing of pulpal tissue, indicating that even symptomatic carious exposed young permanent molars can respond favorably to this technique if done under complete isolation with adequate coronal seal. Clinicians should prioritize immediate adequate coronal seal and proper isolation in vital pulp therapy cases.

REFERENCES