PREVENDODONTICS!
What is it ?
No, its not a spelling error, but it’s a new portmanteau word and as far as I am aware I am introducing this term to dental terminology.
Minimally Invasive Deep caries treatments or Prevendodontics (as I like to call it), pertains to preventing or avoiding endodontics (which is essentially prevention and treatment of apical periodontitis), in deep carious lesions or teeth with pulp exposures due to caries or in some cases trauma or during treatment by the dentist. Modern Endodontic procedures involve maintaining the pulp vitality. The use of modern bioceramic materials and MTA used during these procedures is dependent on harnessing of stem cells/progenitor cell population(1)
Why ?
- It can be delivered by general dentists who tend to see more of these deep lesions.
- Especially useful in post COVID era where aerosol-generating treatments need to be kept to absolute minimal but should become more commonly used treatment for treating deep caries.
- Use of these techniques in General practice use will provide us the more clinical evidence for validation and further insight into success of such procedures.
- Avoidance of root canal treatment and the complications associated with it, but if needed can be performed.
- Delay the next stage of restorative intervention, hopefully for a very long time!
- Saves precious irreplaceable tooth structure.
- Improved long term outcome of restorative treatment and survival of tooth
- Less stress for patient and the dentist!
How ?
Good lighting and magnification (dental loupes or operating microscope) is required.
Tooth vitality tests.
Radiographs (preferable two PA radiographs in parallax)
Isolation: rubber dam is essential.
Caries removal at the margins. Essentially to make the margin caries free, easy to keep biofilm free and to get a good seal with sound tooth structure and sealing the infected dentine from oral environment. Removal of wet and soft caries from around the 3D pulp chamber space only (this bit needs some experience, careful-cautious approach and excellent lighting/magnification to differentiate).
Pulp protection: in deep lesions, preferably MTA/bioceramics. Protect them with light cured GIC and then composite(direct or indirect) or RMGIC only.
Vitality tests and PA radiograph in 6months in case of deep lesions to confirm continued vitality.
In case of pulp exposure: after removal of excessive inflamed pulp tissue, part or all coronal pulp(partial or complete pulpotomy), apply the MTA/bioceramic directly then follow the same restorative steps as above.
The biggest challenge in this treatment is the difficulty in assessing accurately the amount of inflamed tissue to be removed, based on the diagnostic tests available, as the clinical signs/symptoms are not an accurate determinant of pulpal health.
What if??
If this fails, as in, tooth becomes symptomatic then:
1. process to pulpectomy /RCT
2. Or refer to a dentist with more experience in endodontic management.
Where’s the Evidence??
Below are a few of the papers but there are plenty more, and even more evidence will be emerging in the near future about the outcome of such treatments, so please do your own research and make up your mind, but in my opinion modern endodontics is more about maintenance of pulp vitality and then some more, we just need to keep up with current evidence and try to implement it in our daily clinical practice. This will help our patients who will benefit from keeping their own teeth for longer.
1. Bjørndal L (2008) The caries process and its effect on the pulp: the science is changing and so is our understanding. Pediatr Dent 30(3):192– 196
2. Taha NA, Ahmad MB, Ghanim A (2017) Assessment of mineral trioxide aggregate pulpotomy in mature permanent teeth with carious exposures. Int Endod J 50(2):117– 125.
3. Tomson PL, Lumley PJ, Smith AJ, Cooper PR (2017) Growth factor release from dentine matrix by pulp-capping agents promotes pulp tissue repair-associated events. Int Endod J 50(3):281– 292.
4. Alqaderi H, Lee CT, Borzangy S, Pagonis TC (2016) Coronal pulpotomy for cariously exposed permanent posterior teeth with closed apices: a systematic review and meta-analysis. J Dent 44:1– 7.
5. Asgary S, Eghbal MJ, Fazlyab M, Baghban AA, Ghoddusi J (2015) Five-year results of vital pulp therapy in permanent molars with irreversible pulpitis: a non-inferiority multicenter randomized clinical trial. Clin Oral Investig 19(2):335– 341.
6. Cao Y, Song M, Kim E, Shon W, Chugal N, Bogen G, Lin L, Kim RH, Park NH, Kang MK (2015) Pulp-dentine regeneration: current state and future prospects. J Dent Res 94(11):1544– 1551.
7. Murray PE, Garcia-Godoy F, Hargreaves KM (2007) Regenerative endodontics: a review of current status and a call for action. J Endod 33(4):377– 390