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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 30-34

Biological Approach in the Management of Permanent Molars with Irreversible Pulpitis Using Platelet-Rich Fibrin as a Pulpotomy Medicament: Case Reports with 2-Year Follow Up


1 Department of Conservative Dentistry and Endodontics, GSL Dental College and Hospital, Rajahmundry, India
2 Department of Conservative Dentistry and Endodontics, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India

Date of Web Publication5-Mar-2018

Correspondence Address:
Nalam N. V D. Prasanthi
Department of Conservative Dentistry and Endodontics, GSL Dental College and Hospital, Rajahmundry, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_54_17

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   Abstract 


The aim of vital pulp therapy is to maintain the health of pulp tissue by eliminating bacteria from the dentin pulp complex. Two patients diagnosed with symptomatic irreversible pulpitis in permanent mandibular molars with closed apices were managed using conservative treatment modalities such as vital pulpotomies with regenerative approaches. After caries excavation and pulpotomy, platelet-rich fibrin was used as a pulpotomy medicament followed by Biodentine placement. Final restorations were done with composite resins. At 6, 12, and 24 months recall, both the teeth responded positively to pulp sensibility tests, and radiographic examination revealed a normal periodontal ligament space. Positive results of this case imply the need for more studies with larger sample sizes. Further, a longer recall period is also required to justify the use of this approach for the treatment of pulpitis in human permanent molar teeth.

Keywords: Biodentine, growth factors, platelet-rich fibrin, pulpitis, pulpotomy


How to cite this article:
D. Prasanthi NN, Simpsy GS, Chittem J, Sajjan GS. Biological Approach in the Management of Permanent Molars with Irreversible Pulpitis Using Platelet-Rich Fibrin as a Pulpotomy Medicament: Case Reports with 2-Year Follow Up. J Interdiscip Dentistry 2018;8:30-4

How to cite this URL:
D. Prasanthi NN, Simpsy GS, Chittem J, Sajjan GS. Biological Approach in the Management of Permanent Molars with Irreversible Pulpitis Using Platelet-Rich Fibrin as a Pulpotomy Medicament: Case Reports with 2-Year Follow Up. J Interdiscip Dentistry [serial online] 2018 [cited 2020 Oct 22];8:30-4. Available from: https://www.jidonline.com/text.asp?2018/8/1/30/226638




   Clinical Relevance to Interdisciplinary Dentistry Top


  • Vital pulp therapies are aimed to maintain the health of pulp tissue by eliminating bacteria from the dentin-pulp complex
  • Platelet-rich fibrin which has a high concentration of growth factors plays a major role in wound healing
  • Biodentine is a new bioactive calcium silicate-based material that is used in vital pulp therapies.



   Introduction Top


Pulpotomy is a vital pulp therapy in which the coronal portion of the pulp is removed, and the remaining radicular pulp is preserved intact. Over the radicular pulp tissue, a suitable material is placed which has the potential to protect the pulp from further insult and initiate healing and repair.[1],[2],[3],[4] Mineral trioxide aggregate (MTA) is one of the most widely used materials for such purposes with successful clinical outcomes.[5],[6] However, due to certain inherent drawbacks of MTA, there is a need for the development of newer biomaterials that can fulfil the requirements of pulpotomy therapies, and that can overcome the challenges associated with MTA.

Biodentine is a calcium silicate-based material that was initially designed as a “dentin replacement” material. Biodentine is primarily formulated using the MTA-based cement technology with improvement in its physical qualities and handling.[7],[8] In spite of the recent advancements in material sciences, research still documents mild-to-moderate cytotoxic effects with various biomaterials used for pulpotomies when they are placed in direct contact with the pulp tissue. Hence, there is a constant need for biologically based autologous materials to neutralize the side effects such as to reduce the pulpal inflammation and to promote faster healing.

Platelet-rich fibrin (PRF) is a second generation platelet concentrate introduced by Choukroun et al. Its chief advantages include the ease of preparation and lack of biochemical handling of blood, which makes this preparation strictly autologous.[1],[4],[9]

The present case report describes the management of two pulpally involved carious human adult permanent molars with established symptomatic irreversible pulpitis. The clinical and radiological outcomes of the treated cases were evaluated at 3, 6, 12, and 24 months to gauge the prognosis of the treatment performed using PRF and Biodentine for coronal pulpotomy techniques.


   Case Reports Top


Case 1

A 20-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of pain in the lower right back tooth for the past 1 week. On clinical examination, there was a deep carious lesion involving the occlusal surface of 46 [Figure 1]a. There was no tenderness on percussion and no associated sinus opening adjacent to the tooth. The patient's symptom was confirmed with spontaneous and deep intense pain lingering even after the removal of the thermal stimulus. A similar response was reproduced with electric pulp tester. An intraoral periapical radiograph revealed coronal radiolucency involving the pulp with normal periapex [Figure 1]b. Based on the clinical, radiographical, and pulp sensibility examinations, the diagnosis were established as symptomatic irreversible pulpitis.
Figure 1: Case 1 (a) Preoperative clinical photograph of 46; (b) preoperative radiograph; (c) platelet-rich fibrin membrane; (d) coronal pulpotomy in 46; (e) platelet-rich fibrin placed in the cavity; biodentine placed over platelet-rich fibrin; (f) (g) radiograph after placement of platelet-rich fibrin and biodentine; (h) immediate radiograph after composite restoration; (i) 12 months follow-up radiograph; (j) 24 months follow-up radiograph

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Case 2

A 19-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of pain in the lower right back tooth for the past 10 days. Clinical examination revealed the presence of fractured glass ionomer restoration with secondary caries involving the occlusal surface of 46 [Figure 2]a. Preoperative intraoral periapical radiograph revealed radiopaque restorative material with underlying radiolucency extending into pulp [Figure 2]b. The diagnosis of symptomatic irreversible pulpitis was made on the basis of clinical assessment, including the history of spontaneous pain and intense, lingering pain to a thermal stimulus.
Figure 2: Case 2 (a) Preoperative clinical photograph of 46; (b) coronal pulpotomy in 46; (c) platelet rich fibrin placed in the cavity; (d) biodentine placed over platelet-rich fibrin; (e) preoperative radiograph; (f) radiograph after the placement of platelet-rich fibrin and biodentine; (g) immediate radiograph after composite restoration; (h) 12 months follow-up radiograph; (i) 24 months follow-up radiograph

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Both the patients were informed about the treatment modality – coronal pulpotomy followed by PRF and Biodentine placement as an alternative treatment to conventional root canal treatment. Informed consent was obtained from both the patients. Blood investigations such as bleeding time, clotting time, hemoglobin, and platelet count were performed and found to be in normal range. PRF was obtained by drawing 10 mL of blood from the patient's antecubital vein and then centrifuged (REMI centrifuge machine Model R-8c with 15 mL swing out head) for 10 min under 3000 revolutions (approximately 400 g) per minute. The resultant product consisted of the following three layers:

  • Acellular platelet poor plasma at the top of the tube
  • Fibrin clot PRF in the middle of the tube and
  • Red blood corpuscles at the bottom of the tube.


Due to the absence of an anticoagulant, blood begins to coagulate as soon as it comes in contact with the glass surface. Hence, rapid blood collection and immediate centrifugation, before the clotting cascade gets initiated, are absolutely essential. PRF was obtained in the form of a membrane by squeezing the fibrin clot [Figure 1]c.

Teeth 46 in both the patients were anesthetized by inferior alveolar nerve blocks using 2% Lignocaine with 1:80,000 adrenaline and rubber dam isolation was achieved. Access was gained to the carious lesion, and pulpotomy procedure was done with a high-speed handpiece and round bur under copious irrigation. Coronal pulp tissue was removed to the level of pulp chamber floor [Figure 1]d and [Figure 2]c. Hemostasis was achieved using sterile saline and cotton pellets. Once hemostasis is achieved, the exposed radicular pulp was covered with PRF membrane [Figure 1]e and [Figure 2]d and Biodentine (Septodont, Saint-Maur-des-Fosses, France) of 2 mm thickness was placed over PRF [Figure 1]f and [Figure 2]e. The final restoration was done with direct composite resin. Radiographs were made after Biodentine placement [Figure 1]g and [Figure 2]f and composite restorations [Figure 1]h and [Figure 2]g in both the patients. They were recalled after 1 day for the evaluation of postoperative pain. Both the patients had no pain or discomfort at 6, 12, and 24 months follow-up and the teeth responded positively to pulp sensitivity tests. Radiographic examination revealed normal periodontal ligament space and trabecular bone pattern approaching normal in both the teeth at 6, 12 [Figure 1]i and [Figure 2]h, and 24 months [Figure 1]j and [Figure 2]i follow-up.


   Discussion Top


Vital pulpotomy is basically considered to be an emergency treatment procedure for the temporary relief of symptoms to reduce the swelling if present and to finally maintain the integrity of the tooth and arch in symptomatic irreversible pulpitis.[1],[10],[11] The success rates of these procedures performed on primary teeth and on immature permanent teeth with open apices have been well documented.[12]

The procedure of pulpotomies in adult teeth with mature apices has been investigated to a much lesser extent, and related controversies still exist in the literature. However, a systematic review conducted by Aguilar and Linsuwanont[13] have demonstrated the success rate of vital pulp therapies in vital permanent teeth with closed apices, showing a relatively high success rate of 99.4% for partial pulpotomy and 99.3% for full pulpotomy.

Various studies have reported the cytotoxicity of freshly mixed calcium silicate-based synthetic materials due to their high initial pH. Hence, in the present case reports, the radicular pulp tissue is covered with a biologically based material like PRF to avoid any detrimental effects on the pulp as a result of the synthetic biomaterials.[1]

PRF is a matrix of autologous fibrin with a large quantity of platelet and leukocyte cytokines embedded in it. As the network of fibrin disintegrates the intrinsic incorporation of cytokines within the fibrin mesh allows their progressive release over time (7–11 days).[4],[9]

The main component of PRF is a high concentration of growth factors present in the platelets which are required for wound healing. Among the various growth factors that PRF contains, platelet-derived growth factor, transforming growth factor β (TGF-β1 and β2), insulin-like growth factor, epidermal growth factor (EGF), vascular EGF, and fibroblast growth factors (FGF) are believed to play a major role in bone metabolism and potential regulation of cell proliferation.[1],[4],[9]

MTA is considered to be a reliable alternative to calcium hydroxide in vital pulp therapies due to its biocompatibility and improved sealing ability. It maintains a high pH for longer periods of time and stimulates reparative dentin formation at a faster rate than calcium hydroxide cement.[14]

Based on the outstanding properties of MTA, another new bioactive calcium silicate-based cement of similar composition with modified properties to improve the handling ability and to reduce the setting time was introduced as Biodentine (Septodont, Saint-Maur-des-Fosses, France). It has been advocated in clinical use as a biomaterial for procedures such as pulp capping, pulpotomies, management of perforations, internal and external resorptive defects, apexification, and retrograde filling. The advantage of using Biodentine in the present cases is that it is biocompatible, insoluble, has good mechanical properties, and provides a tight biological seal against the ingress of bacteria.[7],[8] It also helps to stabilize and protect the PRF membrane from the compaction forces of restorative procedures.

During the treatment procedure, pulp should be free from bacteria and its toxins, preventing their invasion into the pulp from the saliva of the oral cavity. Hence, isolation in the present cases was achieved using a rubber dam. Double seal with Biodentine and composite restoration also prevents the bacterial leakage.

At 6, 12 and 24 months follow-up, the tooth was asymptomatic and responded positively to sensibility tests. Radiographic examination revealed normal periodontal ligament space and trabecular bone pattern approaching normal in both the teeth. The potential theory behind the success of the present case could be attributed to a study done by Wang et al.[15] where they concluded that the pulp cells residing in pulp clinically diagnosed with irreversible pulpitis might still have stem cell potential similar to healthy pulp cells and therefore might be a source for autologous pulp regeneration. These findings suggest exciting opportunities for biologically based therapeutic approaches to dental tissue repair as well as providing valuable insights into how natural regenerative processes may be operating in the tooth. Further, a longer recall period is also required to justify the use of this approach for the treatment of pulpitis in human permanent molar teeth.


   Conclusion Top


In the present cases, the advantages of the growth factor releasing the potential of PRF and sealing ability of Biodentine were utilized as a double-edged sword to accelerate healing of the irreversibly inflamed pulp tissue as an alternative to conventional root canal treatment.

It can be concluded that there is reasonable biological evidence to carry out pulpotomy as a possible alternative treatment in mature permanent teeth with pulpitis. Further clinical and histological studies are required to add significant weight to the above statement.

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.



 
   References Top

1.
Choukroun J1, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part IV: Clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e56-60.  Back to cited text no. 1
    
2.
Abarajithan M, Velmurugan N, Kandaswamy D. Management of recently traumatized maxillary central incisors by partial pulpotomy using MTA: Case reports with two-year follow-up. J Conserv Dent 2010;13:110-3.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Ingle JI, Bakland LK, editors. Endodontic considerations in dental trauma. Endodontics. Toronto: BC Decker Inc.; 2002. p. 795-844.  Back to cited text no. 3
    
4.
Hiremath H, Saikalyan S, Kulkarni SS, Hiremath V. Second-generation platelet concentrate (PRF) as a pulpotomy medicament in a permanent molar with pulpitis: A case report. Int Endod J 2012;45:105-12.  Back to cited text no. 4
    
5.
Kumar A, Yadav A, Shetty N. One-step apexification using platelet rich fibrin matrix and mineral trioxide aggregate apical barrier. Indian J Dent Res 2014;25:809-12.  Back to cited text no. 5
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6.
Ng FK, Messer LB. Mineral trioxide aggregate as a pulpotomy medicament: A narrative review. Eur Arch Paediatr Dent 2008;9:4-11.  Back to cited text no. 6
    
7.
Camilleri J. Investigation of biodentine as dentine replacement material. J Dent 2013;41:600-10.  Back to cited text no. 7
    
8.
Shayegan A, Jurysta C, Atash R, Petein M, Abbeele AV. Biodentine used as a pulp-capping agent in primary pig teeth. Pediatr Dent 2012;34:e202-8.  Back to cited text no. 8
    
9.
Shivashankar VY, Johns DA, Vidyanath S, Kumar MR. Platelet rich fibrin in the revitalization of tooth with necrotic pulp and open apex. J Conserv Dent 2012;15:395-8.  Back to cited text no. 9
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Asgary S. Calcium-enriched mixture pulpotomy of a human permanent molar with irreversible pulpitis and condensing apical periodontitis. J Conserv Dent 2011;14:90-3.  Back to cited text no. 10
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11.
Asgary S, Eghbal MJ. The effect of pulpotomy using a calcium-enriched mixture cement versus one-visit root canal therapy on postoperative pain relief in irreversible pulpitis: A randomized clinical trial. Odontology 2010;98:126-33.  Back to cited text no. 11
    
12.
Kabaktchieva R, Gateva N. Vital pulpotomy in primary teeth with mineral trioxide aggregate (MTA). J IMAB Annu Proc (Scientific Papers) 2009;2:102-8.  Back to cited text no. 12
    
13.
Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: A systematic review. J Endod 2011;37:581-7.  Back to cited text no. 13
    
14.
Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth: A preliminary report. Int Endod J 2003;36:225-31.  Back to cited text no. 14
    
15.
Wang Z, Pan J, Wright JT, Bencharit S, Zhang S, Everett ET, et al. Putative stem cells in human dental pulp with irreversible pulpitis: An exploratory study. J Endod 2010;36:820-5.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]



 

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