Apexification , bleeding pulp - Courtesy ROOTS The opinions within this web page are not ours. Authors have been credited for the individual posts where they are. Photos courtesy Sashi Nallapati - ROOTS

From: sashi
To: ROOTS
Sent: Friday, June 02, 2006 8:38 AM
Subject: [roots] most interesting case

This is by far the most interesting case for me at the program dec 04:

14 y male came to the endo clinic with a h/o i was told i needed a root canal by my dentsit.
past H/o carious exposure with an IRM pulp cap in 31 a month previous.
he was asymptomatic with no response to cold at the time of exam. i didnt perform EPT.

I decided to do an apexification (BASED ON THE FACT THAT I GOT NEGATIVE RESPONSE TO COLD)  and opened the tooth. there was
bleeding pulp in the chamber. So i changed my mind and did a cvek pulpotomy. placed caoh usp mixed with anesthetic and
packed with an amalgam plugger. IRM over the caoh and GI over the IRM.

Mrch 05 : recall. wnl to EPT. dentin bridge forming

Dec 05 ( 1 yr recall) : wnl EPT dentin bridge formed.

Jun 06 : 18m recall) wnl to EPT. there was decay under the GI , so i removed the GI, IRM and was staring at this complete
dentin bridge formed under the caoh base (last 2 pics). Check out the pulp horn i failed to unroof during the initial cvek
and dentin bridge formed underneath .i irrigated the chamber, placed dycal and bonded the whole access today.

he will be back in a year for further recall. the root growth seem close to completion.
we will try to recall this case as long as we can at the program. i have a feeling this tooth may not need an endo in a
long time to come.

what do oyu guys think?

by the way, this is the last procedure for me at the school. i have a few more to finish. 65 recalls i was able to do so far, 75 i would be very happy about - sashi nallapati




Excellent case sashi!

You might find this article intresting: Resolution of perioapical radiolucency following pulpotomy; Alexander j. Moule, and Robert j. Oswald. JOE September 1983 vol 9, no: 9. 383- 84.
I have a hard copy but no pdf. Somebody can post it if possible. otherwise i could scan and post.  - Siju

sashi, In the absence of any signs or symptoms, I find it difficult making a
diagnosis of pulp necrosis in immature teeth. I would probably wait
for clinical and/or radiographic signs of pulpal necrosis to manifest
rather than rely on Thermal testing alone. This is however my personal opinion - Siju

I would be happy with this and observe with pulp testing also. BUT seems to me There have been LOUD typing on this from
Terry Pannuk and others about waiting to do the endo. When do we know to wait? I would not loose any sleep waiting here
for at least a year, and if fine then, let it alone. ? -   Alan Cady

Could someone please post the technique of the Cvek pulpotomy.  Medicaid does not pay for molar endo in Georgia and some
great kids are becoming dental cripples before the age of 12 here.  No matter how far they progress economically,
educationally, or financially they are losing their posterior teeth by the thousands.  People simply extract them because
Medicaid does not pay for molars.

I'm now doing endo free of charge on the kids we can identify who have great potential.  I know limiting to "great
potential" is crass but I have to have someway to limit this.  It could take over my practice.  I've done over fifty molar
endos already this year.  I did eight on one beautiful young lady who was spared from the forceps by a teacher I work with
on identifying these kids.  I've got my son, the head social worker for the school systems here, helping me with this but
after seeing this result from Sashi, I think this type pulpotomy would be God sent for many more kids.  Thanks in advance, -  Guy

For cariously exposed teeth, a coronal pulpotomy is often required due to the degree of pulpal inflammation (bleeding).
- Fred

You are using MTA for this?  Are you disinfecting with something other than sodium hypochlorite?  Guy

Aloha Guy-

I've attached some useful reading from Endo Topics 2003.  Endo Topics IMO is the bread and butter of clinical endo lit:

1. Swift, Trope, Ritter.  Vital Pulp Therapy for the Mature Tooth.  Can it work?
2. Horsted & Lovschall. Treatment Outcome of Vital Pulp Therapy.  (Table 1 is a very important table for making your Tx
decisions)

One issue that you will strongly have to consider is good follow-up in young patients.  While a pulpotomy/pulpotomy of a
grossly carious permanent immature tooth may solve the issue of a root canal for a patient in the short term, these teeth
may fail later, and if they do, calcific obliteration may be one untoward effect that will hinder an otherwise
straightforward root canal.

With regards to pulpotomies on non-pediatric patients, McDougal at UNC in JADA Dec 2004 showed that it's a viable
treatment method for irreversible pulpitis for patients who can't afford RCTs or dont' want extractions.

You're doing a great public health service, Guy. - Jason

Jason, follow up on a lot of these kids is not going to be possible.  Hell, many of the parents don't care about them
anyway.  They are just dumped on the system.  I'll just have to depend on teachers and social workers.  Teachers are our
main source.  Pain is ruining weeks of school for these kids.  The necrotic pulps have to be treated endodontically but if
I could find a method of doing a half way predictable pulpotomy my partner could join in and we could treat twice the
number of these kids.  Imagine being a beautiful twelve year old young lady with no molars.  Guy

Aloha Guy- I admire what you are doing, and I cannot argue with you that you are providing a viable, completely legitimate
dental care for these patients.

When I was a medicaid provider as a GP in the Hawaii countryside, the circumstances surrounding these patients were
frustrating to me- especially for the young ones.  I always had to remind myself that dental issues were only a small
portion of the daily adversities these patients faced. Hawaii is usually top 3 in DMFT rates in the USA.   Fluoridation
has never really been an acceptable idea in Hawaii.

A tooth is small thing in the big picture for many of these young patients.  Whatever service you can provide is
significant service, and maybe ivory tower endodontics need not apply in certain situations.

I certainly understand where your empathy comes from- years and years of experience looking out for a needy population.
Keep up the responsible work - -Jason