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Case Report

Apexogenesis of irreversible inflamed young permanent

molar using calcium hydroxide gluconate pulpotomy:
A case report with review of literature

Ritesh Rambharos Kalaskar, Arti Dolas, Ashita Ritesh Kalaskar1

Departments of Pedodontics and Preventive Dentistry and 1Oral Medicine and Radiology, Government Dental College and Hospital,
Nagpur, Maharashtra, India

ABSTRACT
Carious exposure of an irreversibly inflamed vital pulp in a young permanent tooth presents
a significant clinical challenge to maintain vitality. Direct pulp capping, partial pulpotomy
and complete pulpotomy are the available procedures to treat young permanent tooth.
Currently, calcium hydroxide is the material of choice for apexogenesis. The present
case report describes the successful apexogenesis of mandibular left first permanent
molar using calcium hydroxide‑chlorhexidine paste within 7 months and also discussed
prognostic and technique guidance.

Key words: Calcium hydroxide, carious exposure, chlorhexidine gluconate gel, complete
pulpotomy, young permanent tooth

INTRODUCTION There are three techniques available for the treatment of

It is universally accepted that vital pulp therapy is the
treatment of choice for carious or traumatically exposed
young permanent teeth (incompletely developed apex).[1]
Such vital pulp therapy, often called as apexogenesis, is
defined as vital pulp therapy of young permanent teeth
that permits continued root formation and apical closure.[2]
Endodontic management of young permanent teeth presents
several problems such as larger apical diameter versus smaller
coronal canal diameter making debridement difficult; lack
of an apical stop makes obturation impossible; and thin root
canal walls become root prone to fracture.[3]
Address for correspondence:
Dr. Ritesh Rambharos Kalaskar,
Department of Pedodontics and Preventive Dentistry, Government
Dental College and Hospital, Nagpur, Maharashtra, India.
E‑mail: riteshpedo@gmail.com
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young permanent teeth with exposed vital pulp: direct pulp
capping, complete pulpotomy, and partial pulpotomy (pulp
curettage).[4]
According to Seltzer and Bender,[5] direct pulp capping is
indicated mainly for mechanical small exposure in young
permanent teeth and should be discouraged for carious pulp
exposures. Partial and complete pulpotomy is the technique
indicated for traumatically or carious exposed asymptomatic
anterior and posterior young permanent teeth pulp until
root develops, but the treatment of irreversible involved or
symptomatic immature posterior teeth remains a problem
in pediatric endodontic.[5‑7] Calcium hydroxide has been a
popular agent for this type of vital pulp therapy including
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How to cite this article: Kalaskar RR, Dolas A, Kalaskar AR.

DOI: Apexogenesis of irreversible inflamed young permanent molar using
10.4103/srmjrds.srmjrds_8_18 calcium hydroxide gluconate pulpotomy: A case report with review of
literature. SRM J Res Dent Sci 2018;9:141-4.

141
© 2018 SRM Journal of Research in Dental Sciences | Published by Wolters Kluwer ‑ Medknow
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Kalaskar, et al.: Apexogenesis in a young permanent molar
pulpotomy in the primary and young permanent teeth. It
is widely used clinically and is also economical. Calcium
hydroxide has a high pH, and its dental use relates chiefly to its
ability to stimulate mineralization and also to its antibacterial
property.[8] However, specific microorganisms have been
proven resistant to calcium hydroxide powder mixed with
saline.[9] Alternative medicaments or additional agents have
been investigated to facilitate microbial eradication. Studies
have shown that chlorhexidine gluconate is particularly
effective against Enterococcus faecalis and Candida strains,
which have been implicated in endodontic failure and are
resistant to treatment with calcium hydroxide.[10,11] To obtain
a wide spectrum of antimicrobial activity, paste consisting of
calcium hydroxide mixed with chlorhexidine gluconate has
been investigated.[10‑12] The present case report demonstrates
successful apexogenesis of a symptomatic young permanent
tooth using calcium hydroxide‑chlorhexidine gluconate
complete pulpotomy technique.
CASE REPORT
A 10‑year‑old boy with a noncontributory medical history
reported to the Department Pediatric Dentistry, Sharad
Pawar Dental College, Wardha, with the chief complaint
of spontaneous and nocturnal pain in lower left posterior
region for 10 days. Intraoral examination revealed deep
occlusal caries with mandibular left first permanent
molar, which does not show any clinical sign of pulpal
degeneration such as mobility, pain on percussion and
palpation, swelling, and intraoral sinus. The tooth was fairly
intact, restorable, and showed respond to thermal (cold
test [pulfofofluorange, Pharma Dental Handelsges]) and
electric pulp testing (Parkell Farmingdate). Periapical
radiograph of mandibular left first permanent molar showed
caries (radiolucent area) approaching the pulp chamber
and incompletely formed root apices [Figure 1]. There
was no evidence of periapical pathology, interradicular
bone resorption, internal resorption, pulp calcification,
Figure 1: Intraoral periapical radiograph of 36 showed
incompletely formed root apices
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SRM Journal of Research in Dental Sciences | Volume 9 | Issue 3 | July-September 2018
and pathologic external root resorption suggesting pulpal
degeneration. After local anesthesia (Dentocaine 2%
Pharma Health Care Product, Mumbai) and rubber dam
isolation, a conventional access cavity was made with a
high‑speed bur using copious water spray. Amputation of
the coronal pulp was performed with a sharp, spoon‑shaped
excavator (Dentsply Maillefer) to the level of root canal
orifices. After hemostasis was achieved calcium hydroxide
powder (Deepti Dental Products, Raigarh) mixed with
chlorhexidine gluconate gel (thick paste) (Hexigel, ICPA
Health product Ltd., Ankleshwar) was placed over the
amputated pulp surface and the tooth was restored with
thick paste of zinc oxide eugenol cement (Dentifiss India
Product) to protect it against microleakage. Checkup
after 1 week showed tooth to be asymptomatic. Clinical
examination was carried out at a monthly interval during this
period tooth was asymptomatic. Radiographs were taken at
an interval of 3 months. Three‑month radiograph showed
continued root formation without any evidence of pulpal
degeneration such as periapical pathology, interradicular
bone resorption, internal resorption, pulp calcification,
and pathologic root resorption [Figure 2]. Radiograph after
7 months showed complete root formation with narrowing of
the root canals [Figure 3]. In the subsequent visits, cleaning
and shaping was carried and obturation was done using
gutta‑percha [Figure 4]. After a follow‑up of 1 month, the
tooth was restored with stainless steel crown (3M).
DISCUSSION
Successful endodontic management of irreversibly
inflamed young permanent molar is difficult because of
thin dentinal walls, wide open apex, and reduced crown
root ratio. Thin dentinal walls make the tooth more prone
for fracture during obturation, obtaining hermetic seal
at apex is almost impossible due to open apex.[3,13] In
addition, reduced crown root ratio makes the tooth a poor
abutment.[14] Due to these complications, it is always
Figure 2: Three-month radiograph showed continued root
formation
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Kalaskar, et al.: Apexogenesis in a young permanent molar
Figure 3: Radiograph after 7 months showed complete root
formation
beneficial to initiate root development in irreversibly
inflamed young permanent molar due to caries. It has been
documented that remaining viable Hertwig’s epithelial root
sheet can promote root end closure once inflammation is
reduced.[14] Pulpotomy has been the choice of treatment
employed in such situations. The goal of pulpotomy is to
remove infected coronal portion of pulp, maintaining pulp
vitality, generating dentinal bridge formation, and apical
closure.[15,16] Partial pulpotomy and cervical pulpotomy
have been the recommended options in such situations.
Partial pulpotomy technique is generally recommended
in traumatically exposed permanent incisors.[17] This
procedure has also been successfully employed in cariously
exposed asymptomatic young permanent molar. However,
when symptomatic young permanent molar was treated
by partial pulpotomy, it resulted in failure.[18,19] Cervical
pulpotomy has been recommended for cariously exposed
symptomatic young permanent molar.[19]
Treatment of symptomatic young permanent molar has not
received much attention in the literature. Apexification
has been the only recommended treatment for managing
irreversibly inflamed young permanent molar.[7] However,
there is no lateral thickening of dentinal walls and
continued root development in apexification; therefore,
the original disadvantages of tooth fracture and poor
abutment still persist.[7] Therefore, in the present case,
although the tooth was symptomatic, hemostasis on
amputation was achieved within 5 min; therefore, calcium
hydroxide cervical pulpotomy was done. This observation
was similar to Mitchell and Tarplee,[20] who stated that
only 25% of the teeth with pulpitis showed spread of
inflammation in root canals. Apexogenesis is preferred
over apexification in young permanent molar because
apexogenesis leads to continuous root development with
thickening of dentinal walls making tooth less prone for
fracture. Second, increased crown root ratio makes the
tooth withstand masticatory forces.
SRM Journal of Research in Dental Sciences | Volume 9 | Issue 3 | July-September 2018
Figure 4: Postobturation radiograph of 36
Calcium hydroxide has been the choice of pulpotomy agent
in young permanent molar because of its ability to repair
tissue. The exact mechanism of tissue repair is not known
but it is stated that high alkaline pH might stimulate cells
in the region to stimulate hard tissue formation.[21] However,
some claim that calcium hydroxide is caustic in nature. The
positive benefits of calcium hydroxide in apexogenesis had
been well documented. Thus, because it’s of exceptional
qualities, calcium hydroxide has been used for hyperplastic
pulpitis.[22,23]
After cervical pulpotomy, pulp has a tendency to undergo
extensive calcification because of reduced blood supply.[24]
Some authors suggest that, once the apexogenesis is complete,
the root canal should be obturation with gutta‑percha, as
they might undergo extensive calcification making further
restorations or endodontic treatment (if required) difficult.
Whereas other believes that, as the vital pulp tissue is present
in canal, it need not be removed.[20] In the present case,
we preferred to obdurate the canal considering the future
complications. The tooth was later restored with stainless
steel crown.
Patient age is another disputable factor which may negatively
affect clinical success. Studies have shown that, in older
patients, the typically more fibrous dental pulp has a reduced
ability to overcome insult.[25] Horsted et al.[26] demonstrated
a slightly lower tooth survival rate in the older age. Mass and
Zilberman[19] suggested that pulpotomy is limited to children
and young adults.
The present case encompasses the importance of
conservative treatment in symptomatic immature
permanent molar demonstrating tremendous reparative
potential. The outcome of the cervical pulpotomy was
in accordance with the goals given by Webber. Tendency
toward extensive calcification is the only disadvantage
of this procedure which might be overcome with regular
follow‑up.
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Kalaskar, et al.: Apexogenesis in a young permanent molar
CONCLUSION
In this case report, complete pulpotomy with calcium
hydroxide chlorhexidine gluconate paste proved successful
in promoting the healing of pulpal tissue. This confirms that
even the symptomatic carious exposed young permanent
molar can response favorably to complete pulpotomy
technique using calcium hydroxide and chlorhexidine
gluconate paste.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not
be published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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