Re-treating a Hyperemic Tooth With Deep Caries

What if clinicians consider the growing body of evidence on pulpal treatment success and spend the time and effort to take a tooth with deep pulpal pathosis that is still vital (albeit hyperemic) and preserve its vitality? In many instances, that dreaded RCT can be avoided while still saving teeth that would previously have been condemned. This case report illustrates a procedure that utilizes a calcium silicate-based pulpal liner to help stimulate an alkaline pH and apatite formation,¹ pushing the boundaries of material science to show that, indeed, the times are changing.

A patient presented to our office for an emergency appointment for a tooth (ie, No. 28) that was extremely hyperemic with sensitivity to cold and sweets with slightly lingering discomfort. The clinical presentation was a failed amalgam restoration with deep caries approximating the pulp (Figure 2). Regarding treatment options, the patient wanted to try anything other than an RCT procedure to save the tooth and, ultimately, preferred to have an extraction if vitality could not be restored.

The area was anesthetized, the tooth was isolated, and the carious lesion was removed, resulting in a large pulpal exposure (Figure 3). There was some initial bleeding, but it subsided after rinsing with ozonated water. The area was then disinfected with ozone gas. Once the bleeding had stopped (Figure 4), the resin-modified calcium silicate pulp protectant/liner (TheraCal LC^®, BISCO Dental) was placed over the pulp in very thin increments and polymerized with a curing light (Figure 5). This material's calcium release¹ stimulates hydroxyapatite and secondary dentin bridge formation, which leads to a protective seal and insulation of the pulp.^2,3

Once the liner was in place covering the exposure, the rest of the prepared tooth structure was air abraded to create surface texture to improve its ability to bond.⁴ The area was then total etched, a bonding agent was applied, and the tooth was restored with a direct-filled composite resin restoration. After the pulp cap and restoration were completed on tooth No. 28, the adjacent failing restoration, which also exhibited excess material, was removed from tooth No. 29, and the tooth was retreated in the same manner. An immediate final radiograph (Figure 6) and final postoperative clinical photograph (Figure 7) were taken to confirm the seal of the restorations and the current state of the apices. The next day, the patient was called to confirm that the tooth was calm and comfortable.

The practice has been able to follow this case for more than 6 years since its completion, and the tooth has remained comfortable and vital to thermal pulpal testing with no adverse responses to percussion or palpation. A 57-month posttreatment radiograph (extraoral view) demonstrates no radiographic evidence of pulpal pathosis (Figure 8).

New patient beliefs and new products have changed the way that a hyperemic tooth is approached. Rather than following the traditional route of RCT, post, core, and crown, in some cases, it may be possible to maintain tooth integrity and even maintain pulpal health using updated materials and techniques. To date, this author's practice has restored more than 250 direct and indirect pulpal exposures using the protocol described in this case report, maintaining greater than 96% pulpal vitality.

Mark Malterud, DDS
Private Practice
Saint Paul, Minnesota

For more information, contact:
BISCO, Inc.
bisco.com
800-247-3368