Apexogenesis of a symptomatic molar with Calcium hydroxide

Dr.Foysal Sirazee
MS (PART B) Dept. of Conservative Dentistry & Endodontics BSMMU

ABSTRACT
Aim: This presentation describes a clinical and radio-graphical outcome of a 8 years old boy who was treated by apexogenesis of a mandibular right first molar. Summary: A 8 years old boy presented at the dept. of Conservative dentistry and Endodontics, BSMMU, with a lingering irradiating and bite pain on his right lower jaw. The tooth responsible was examined clinico-radiographically. On clinical examination, the right mandibular first molar had extensive caries and it was sensitive to percussion but not on palpation. The tooth was sensitive to cold. Radiographic examination revealed immature root with thin dentinal wall of the affected tooth. Conservative treatment (apexogenesis) was performed; caries was removed followed by pulp exposure and access cavity preparation. Pulpotomy was performed and remaining radicular pulp was capped with calcium hydroxide paste. 1 and 3 months later, the tooth was functional with no clinical signs and symptomps. Radiographical examination also revealed continuation of root development. These findings suggested that long term prognosis is required for the complete outcome of the treatment. Keywords: apexogenesis, calcium hydroxide , pain, pulpotomy, tooth apex.

INTRODUCTION
Apexogenesis is defined as a vital pulp therapy procedure performed to encourage continued physiologic development and formation of the root end. The objective is to maintain the vitality of the radicular pulp. Therefore the pulp must be vital and capeable of repair.5 In clinical practice it is not uncommon to find incompletely developed teeth that require some form of endodontic intervention due to extensive caries or traumatic injury. When such a clinical situation presents itself, an assessment of the pulpal status and the degree of tooth development must be made in order to develop an appropriate treatment plan that is conducive to long term tooth retention. It has been shown that when a direct pulp capping procedure is performed on a tooth with an exposed and inflamed pulp, the probability of pulp repair and long term success is low.1,2 This often will lead to pulp necrosis and arrested tooth development of the involved immature tooth. The resulting wide-open apical foramina, canals with reverse taper (blunderbuss) and thin dentinal walls represent three major clinical concerns when an incompletely developed tooth fails to mature. As such, subsequent endodontic

procedures and the remaining strength of the root structure may be compromised, resulting in a poor long-term prognosis.3 Apexogenesis is a procedure that addresses the shortcomings involved with capping the inflamed dental pulp of an incompletely developed tooth. The main theme of apexogenesis is the preservation of vital pulp tissue so that continued root development with apical closure may occur. Most or all of the coronal pulp is removed, often to the level of the canal orifices, and calcium hydroxide paste is placed as a wound dressing.4-8 An aseptic technique combining the use of the rubber dam and sterile burs is strongly recommended. According to Granath et al,5 the instrument of choice for tissue removal is an abrasive diamond bur at high speed with adequate watercooling. The goal is to minimize any further damage to the underlying pulpal tissue. Following coronal pulp amputation, the pulp chamber is rinsed with sterile saline or sterile water to remove all debris. The excess liquid should then be carefully removed via vacuum or sterile cotton pellets. Air should not be blown on the exposed pulp, as this may cause desiccation and calcium hydroxide paste is placed over the amputation site. Care must be taken to avoid placing the calcium hydroxide on a blood clot6 and the entire pulp surface must be covered. Once this is accomplished, a restorative base material should be placed over the calcium hydroxide and then allowed to set completely. A coronal restoration should then be placed that will ensure the maximum long-term seal. The patient should be re-evaluated every three months for the first year, and then every 6 months for 2 to 4 years to determine if successful root formation is taking place and that there are no signs of pulp necrosis, root resorption ,calcification or periradicular pathosis. Many different materials have been used for pulpal wound dressing, however, the use of calcium hydroxide has been shown to be the available and most predictable with regard to long-term clinical success.7

CASE REPORT
A 8 years old boy, hailing from Naril, came to the dept. of conservative dentistry and Endodontics, BSMMU with the complaints of lingering and irradiating pain and pain on chewing in the mandibular right jaw. Clinical examination showed extensive caries in the mandibular right first molar and sensitivity to percussion but not to palpation. The tooth was sensitive to cold. Radiological examination shows that the tooth had immature roots with thin dentinal walls. My diagnosis was it was a case of reversible pulpitis due to caries. Treatment Plan: Apexogenesis. The patient had epileptic history. Informed consent was obtained from the patients legal guardians after explanation of the possible risks of treatment. Dizepam 5 mg was administered orally 1 hour before the procedure. Local anaesthesia with 2% lidocaine and 1: 80000 epinephrine was administered, caries were removed and an access cavity was prepared with a diamond round bur and high-speed handpiece with copious water spray. After removing the roof of the pulp chamber, the pulp was removed to the orifice level with a round bur and a high speed handpiece. Associated bleeding indicated pulp vitality. Haemostasis was achieved by irrigating with sterile normal saline along with gentle

application of small pieces of moistened sterile cotton pellets 2-5 minutes; then was rinsed with 2.5% hypochloride solution. Calcium Hydroxide (METAPEX) paste of approximately 2-mm-thick layer was placed over the exposed pulp with a sterile instrument and gently adapted to the dentinal walls with a dry cotton pellet. Then, the tooth was filled with temporary filling of 1 mm thickness. Then on the temporary restoration an approximately 2-mm layer of self-cure GlassIonomer (Fuji, Fuji Corporation, Japan) was then placed. The patient was recalled 1, 3 and 6 months later for clinical/radiographic follow-ups and this follw up visits may be extended upto 3 to 4 years. At the clinical examinations, the tooth was functional with no signs/symptoms. Radiographic examination revealed advancement of root development beneath the METAPEX in both mesial and distal roots at 3-months.

DISCUSSION
The primary goal of apexigenesis is to maintain pulp vitality, thus allowing dentin formation and root end closure. Then the remaining odontoblasts can form dentin, producing a thicker root that is less prone to fracture. The time required to produce a thicker root varies between 1 and 2 years, depending on the degree of root development at the time of procedure. The patient should be recalled at six months interval to determine the vitality of pulp and the extent of apical maturation. Absence of symptoms does not indicate absence of disease. At each recall appointment, signs and symptoms are monitored; pulp vitality tested and radiographs are obtained to determine periapical status. Vital pulp therapy is the treatment of choice in immature teeth with reversible pulpitis in which damage to the pulp and associated arrested root development occur as a result of carious pulp exposures24. Vital pulp therapy is primarily based on the healing potential of the pulp26, and the primary goal is to maintain the health of the pulp to promote root development and apical closure25. In my presented case, after two consequent visits on 1st and 3rd months, the clinical and radiological prognosis was good. Clinically, the patient had no pain and was free of any other discomfort. Radiologically, the root completion process advanced more than that it was 3 months ago. However, the distal root completion process seemed faster than the mesial root, comparing the different radiological films on different visits. Here, I have used Calcium hydroxide as the pulp capping material as it was available. The success of this treatment mostly depend on the sterility of the instruments. Hence, use of disposable instruments and rubber dam are advised. A pulp-capping material needs to be biocompatible, able to provide a biological seal, and able to induce hard tissue formation24. Traditionally, calcium hydroxide was the most popular material for vital pulp therapy27. Despite its common use as pulp-capping material, calcium hydroxide has some disadvantages such as unpredictable dentinal bridge formation21 that could contain tunnel defects28 and poor adherence to dentine that can compromise the long-term biological seal29. An alternative standard pulp-capping biomaterial, mineral trioxide aggregate (MTA), has been introduced for vital pulp therapies. There is a body of evidence emphasizing the biocompatibility and sealing ability of MTA19. It has been shown in several animal and human studies that MTA is capable of inducing hard tissue formation adjacent to pulp

tissue21,30. In comparison with calcium hydroxide, MTA induced dentine bridge formation more frequently, caused less pulp inammation, and resulted in a signicantly thicker dentine bridge21,10. However, MTA has several disadvantages, which can include delayed setting time, poor handling characteristics, and high cost19. Studies have revealed that the formation of a hard tissue barrier beneath a pulp-capping material is a good indicator for ongoing health of the pulp and might act as a protective pulpal barrier20. The hard tissue formed beneath MTA, unlike calcium hydroxide10, is uniform, and it can resemble tertiary dentine with respect to its form and staining for dentine sialoprotein9. The ability of Calcium Hydroxide to induce hard tissue formation in mature permanent teeth has been shown in several animal and human studies9,10,1823. CEM (Bionique dent, Tehran, Iran), a newly introduced material for apexigenesis. Dentine bridge induced by Calcium Hydroxide cement has been shown to be similar to one induced by CEM (Calcium Enriched Mixture) Cement (Bionique dent, Tehran, Iran) in terms of thickness, absence of tunnel defects, and presence of adjacent odontoblast-like cells10,23. A recent case report study showed that Calcium Hydroxide has favourable treatment outcomes in terms of dentine bridge formation as well as apexogenesis in traumatic exposure18. The exact biological mechanism by which Calcium Hydroxide cement promotes dentine bridge formation is currently unknown. This characteristic is likely to be the result of several properties such as sealing ability11,17, reduced cytotoxicity16,13, biocompatibility10,22,23, high alkalinity14, antibacterial effect11, hydroxyapatite formation12, and similarity to dentine.10 Calcific metamorphosis is the main disadvantage of calcium Hydroxide while it is used in pulpotomy or apexigenesis. When there is evidence of such calcification, it has been suggested that root canal therapy should be initiated. This is probably unwarranted as calcific metamorphosis is not in itself pathogenic. However, should the pulp become necrotic at some future date, the canals may not be negotiable, surgery should be necessary. If it is determined that the pulp has become irreversibly inflamed or necrotic before root development is complete, or if internal resorption is evident, the pulp is removed and apexification therapy is initiated.25 In the presented case, apexogenesis with Calcium Hydroxide (METAPEX) paste is intended to be completed within 12 to 24 months and sometime more than that (3-4 years). However, regular ongoing radiographic and clinical recalls are necessary to ensure long-term success.

CONCLUSION
Based on the present study, it can be suggested that apexogenesis using the Ca(OH)2 may be favorable specially in pediatric dentistry. However, before making a conclusion, long term clinical evaluation is necessary.

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