Читать книгу Endodontic Materials in Clinical Practice - Группа авторов - Страница 26

A traumatic pulpal exposure in a mature tooth, treated by pulp capping or pulpotomy, is a predictable procedure with a similar prognosis to RCT of >90% success [60, 61]. By contrast, if the pulp is cariously exposed, it has by its very nature been subjected to a sustained bacterial onslaught for a considerable period of time; this reduces the predictability of the VPT procedure, with quoted success rates ranging from as low as 20% [52, 62] to over 80% [11, 63]. The wide range of success highlights the difficulties in treating carious exposures and comparing individual pulp‐capping studies, which show heterogeneous data, with some defining patient symptoms and pulpal diagnosis [11] and others including a mixed sample of both carious and traumatic exposures [64].

Although there is general agreement when managing deep lesions that the margins of the cavity should be clear of caries, there is less concurrence over whether all carious dentine overlying the pulp should be removed [63, 65]. In a tooth with a deep carious lesion which responds within normal limits to sensibility testing, selective (or partial) caries removal and avoidance of pulp exposure is recommended in preference to nonselective (or complete) removal and subsequent risk of exposure [1, 62, 66, 67]. This management strategy for deep caries can be carried out in one visit as indirect pulp therapy, or in two as a stepwise excavation technique [21]. There are a small number randomized controlled trials investigating caries management strategies in permanent teeth, but recent five‐year results of a previously published trial [66] showed that selective (partial) caries removal and stepwise excavation increased the number of teeth that remained vital compared with a nonselective (complete) removal technique [62]. However, this assumes that pulp exposure is the principal problem, which is not convincingly shown in either study [62, 66]. Other conflicting prospective studies have demonstrated opposing results, with high success rates for conservative treatment of the cariously exposed pulp in an endodontic practice setting [63], general practice setting [68], and university setting investigating teeth with signs and symptoms of irreversible pulpitis [11]. All these studies used HCSCs such as MTA and Biodentine, but notably were not randomized in design.

At present, it appears that careful aseptic handling of the pulp tissue under magnification, judicious removal of pulpal tissue, and appropriate restoration of the tooth exposure may produce results comparable with or better than RCT [62, 63, 69].