The ultimate decision the practitioner must make is
whether to treat or not to treat the tooth, and if treat-ment is indicated,
whether to treat the pulp or the root
canal system. The alternative management is to extract
the tooth and then to consider a prosthesis to replace it.
Accurate diagnosis and identification of the cause(s) of
the problem(s) will lead to effective management of the
offending tooth. Table 5
summarizes the treatment strategies for the management of the various pulp
diseases.
Management strategies vary considerably for the
various pulp conditions which emphasizes the need for
an accurate diagnosis before considering any treatment.
Conditions such as a pulp with atrophy or pulp canal
calcification do not require any treatment (unless the
pulp has become necrotic and the canal has been
infected). A conservative approach should be adopted
when dealing with conditions such as pulp necrosis
without infection since pulp tests are not entirely
reliable and the periapical tissues only become inflamed
once the canal is infected, rather than as a response to
the necrosis itself. In cases of pulpitis, the key to
favourable treatment outcomes is to accurately diagnose
the status of the pulp and this means deciding whether
the inflammation is reversible (in which case it may be
treated conservatively) or irreversible when the pulp (or
the tooth) must be removed.
The first principle of managing any diseases is to
remove the cause of the problem.
Since the presence of
micro-organisms is the main cause of pulp diseases, an
essential part of the diagnosis and assessment of the
tooth is to identify how the bacteria have entered the
tooth and the pulp space. In the case of pulp diseases,
the cause is often a defective restoration, caries and/or
cracks that have allowed bacteria to enter the root
canal system. In recent years, Abbott
has advocated
that all restorations should be removed prior to
endodontic treatment in order to remove the causes of
the pulp and periapical diseases. A clinical study has
shown that signs of bacterial entry via restoration
breakdown, caries or cracks were found in only 40 per
cent of restored teeth with pulp and periapical disease
when they were examined prior to restoration removal
but these pathways for bacterial entry were
subsequently found in 99 per cent of the teeth following
removal of the restorations.
Removal of all the restorations, caries, cracks and
any other factors that may be causing the pulp and
periapical diseases provides the clinician with an ideal
opportunity to fully assess whether the tooth is suitable
for further restoration following endodontic or other
pulp therapy. One of the key factors affecting the
treatment outcome and the long-term survival of
endodontically-treated teeth is the quality and longevity
of the coronal restoration since breakdown of the
restoration provides the most likely pathway of entry
for bacteria to enter the tooth again in the future, which
then leads to a new lesion of apical periodontitis.
Hence, it is essential to assess the amount and quality
of remaining tooth structure prior to continuing with
endodontic and restorative dental treatment. The
removal of the restorations, caries and cracks (Fig 4)
can be considered as “investigation” of the tooth and
it should be done routinely for every tooth that requires
a restoration (Table 3).
When treating teeth with reversible pulpitis, the aim
is to preserve the pulp and return it to a clinically
normal state. Measures to minimize iatrogenic pulp
injury should be incorporated into routine restorative
techniques. Since pulp inflammation occurs with
polymicrobial infection, it is prudent to avoid the
contamination of all cavities with microbial-rich saliva.
The use of rubber dam during routine restorative
dentistry will limit the number of bacteria in deep
cavities to only the cariogenic bacteria, which are weak
pathogens to the pulp.
Irreversible pulpitis, pulp necrobiosis and their
sequelae (such as pulp necrosis with infection, pulpless
infected canals) require root canal therapy or tooth
extraction. Likewise, a tooth that has had previous
endodontic therapy (such as pulpectomy, pulpotomy)
but has remained infected or has become infected again
will require endodontic re-treatment or extraction.
When root canal treatment (or re-treatment) is the
treatment of choice, the pulp tissue and tissue
breakdown products as well as the bacteria and their
by-products should be completely eliminated from the
root canal system, which is subsequently filled as
completely as possible. Coronal restorations should
prevent recurrent bacterial entry during and after root
canal treatment.
These procedures should also be
performed under rubber dam isolation. Occlusal
reduction may be performed to reduce postoperative
pain in patients whose teeth initially exhibit pulp
inflammation, tenderness to percussion, and pre-operative pain.
After root canal treatment, adequate
healing is evidenced clinically by resolution of symptoms
and radiographically by bone filling in the radiolucent
area at the root apex if it was present prior to
treatment. Thereby, a functioning tooth is established
with a healthy periodontium.
Internal root resorption is rare in permanent teeth
and it can sometimes mimic external invasive root
resorption radiographically. Management for internal
inflammatory root resorption is usually via endodontic
treatment in order to remove the blood supply to the
resorbing cells through the apical foramina. Several
dressings of calcium hydroxide may be required if the
lesion is active, to ensure complete removal of all
dentinoclasts and to encourage hard tissue repair on the
external surface of the root if there has been a
perforation. Currently there is no treatment available
to prevent the disease progression of internal replace-ment
resorption. Extraction of the affected tooth is the
treatment of choice. However, if the lesion is diagnosed
early enough, endodontic treatment with calcium
hydroxide dressings may be attempted.
With all pulp diseases, post-treatment follow-up is
extremely important due to the diagnostic uncertainties
with some conditions and the possible need for further
treatment such as periapical surgery when periapical
healing is not evident.