“V” is for Vital Pulp Therapy

Jan Bellows, Board Certified Veterinary Dentist™ , Dipl. ABVP (canine and feline specialties | ALL PETS DENTAL | Published: Issue 1 2024

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Vital pulp therapy is a dental procedure used to preserve pulpal tissues that has been acutely traumatized (less than 48 hours), resulting in pulp exposure, or chosen for crown reduction and restoration for orthodontic care to prevent palatal trauma. It serves as an alternative to root canal therapy or extraction. 

Vital pulp therapy includes partial pulpectomy (removing several millimeters of the coronal pulp), direct pulp capping, and restoration. The goal is to remove the damaged or infected pulp tissue from the tooth while leaving the healthy pulp tissue intact. This is done by carefully removing a small amount of the tooth’s crown and then applying either mineral trioxide aggregate (MTA) or calcium hydroxide powder or paste to the exposed pulp tissue. This material helps stimulate reparative dentin formation, sealing off the pulp from further bacterial invasion and promoting healing.

The prognosis of vital pulp therapy is high but not guaranteed. The success rate depends on several factors, including the extent of the pulp exposure, the animal’s age, and the tooth’s overall health.

Benefits of Vital Pulp Therapy:

  • It can save the tooth, which can help maintain the animal’s chewing ability and overall oral health.
  • It is a less invasive procedure than root canal therapy or extraction.
  • It is a relatively quick procedure compared to root canal therapy.

Risks of Vital Pulp Therapy:

  • The procedure may not be successful, and the tooth may still need to be extracted, or root canal therapy may need to be performed.
  • There is a small risk of infection.
  • The tooth may become sensitive or painful after the procedure.

Instruments and Materials

  • #1 and #2 round carbide or diamond burs 
  • College‐tipped pliers paper points
  • Retrograde amalgam filler 
  • Chlorhexidine solution (0.12%) 
  • CaOH2 powder or MTA Glass ionomer cement
  • Restorative material – light‐cured composite resin 
  • Dental curing light
  • White stone bur 

Technique

  1. Obtain an intraoral dental radiograph to determine root maturity and evaluate dental pathology.

Figure 1: Acutely fractured left maxillary canine tooth.
Image Courtesy of Jan Bellows

Figure 2: Intraoral radiograph confirming no evidence of periodontal disease or tooth resorption
Image Courtesy of Jan Bellows

2. Clean and polish the teeth ultrasonically.

3. Infuse a local anesthetic around the tooth or perform a nerve block to desensitize the pulp.

4. Disinfect the oral cavity with 0.12% chlorhexidine gluconate antiseptic solution. A sterile punctured glove may be placed over the crown to act as a dental dam.

5. Access the pulp chamber directly through the exposed pulp with a #1 or #2 sterile round diamond or carbide bur in a high‐speed handpiece under water-cooled irrigation to remove 1-3 mm of the coronal pulp tissue.

Figure 3: #2 round bur used to remove 3 mm of the coronal pulp.
Image Courtesy of Jan Bellows

6. To control pulpal bleeding and obtain hemostasis, initially irrigate the pulp chamber with cold, sterile saline and apply wetted sterile paper points to absorb hemorrhage. Bleeding not controlled within five minutes might indicate an inflamed pulp that might not be successfully treated with vital pulp therapy. The alternatives to vital pulp therapy are root canal therapy or extraction.

7. Apply 1-3 mm of CaOH2 powder or MTA with a retrograde amalgam carrier on the exposed vital pulp. 

Figure 4: MTA loaded on a retrograde amalgam filler.
Image Courtesy of Jan Bellows

Figure 5: MTA applied on the exposed vital pulp.
Image Courtesy of Jan Bellows

8. Slightly undercut the access area to prepare for restorative placement. Apply the CaOH2 or MTA, leaving sufficient room for composite restoration.

9. Restore the tooth with a light‐cured composite resin. The final restoration layer should be at least 2 mm thick. 

Figure 6: Light-cured flowable composite applied over the MTA.
Image Courtesy of Jan Bellows

Figure 7: Light cure.
Image Courtesy of Jan Bellows

10. Shape the composite with a white stone bur loaded on a water-cooled high-speed drill.

Figure 8: White stone bur used to shape the composite.
Image Courtesy of Jan Bellows

11. Obtain a final radiograph. 

Figure 9: Final radiograph confirming MTA material placement.
Image Courtesy of Jan Bellows

Figure 10: Restored canine tooth with excellent prognosis.
Image Courtesy of Jan Bellows

12. Send the patient home with pain‐control medication.

 13. Plan for follow-up clinical and radiograph examination in six months post-op. 

Figure 11: Malpositioned (mesioversion) left mandibular left mandibular canine. 
Image Courtesy of Jan Bellows

Figure 13: Malpositioned (mesioversion) left mandibular left mandibular canine. 
Image Courtesy of Jan Bellows

Figure 15: Restored crown reduced canine alleviating contact with the palate.
Image Courtesy of Jan Bellows

Figure 12: Damage to palatine rugae (arrow) secondary to mal-positioned left mandibular canine.
Image Courtesy of Jan Bellows

Figure 14: Calcium hydroxide powder placed on top of the amputated pulp.
Image Courtesy of Jan Bellows

References

  1. Clarke, D.E. (2001). “Vital pulp therapy for complicated crown fracture of permanent canine teeth in dogs: a three‐year retrospective study.” J. Vet. Dent., 18(3), 117–121.
  2. Niemiec, B.A. (2001). “Assessment of vital pulp therapy for nine complicated crown fractures and fifty‐four crown reductions in dogs and cats.” J. Vet. Dent., 18(3), 122–125.
  3. Niemiec, B.A. (2001). “Vital pulp therapy.” J. Vet. Dent., 18(3), 154–156.
  4. Luotonen, N., Kuntsi‐Vaattovaara, H., Sarkiala‐Kessel, E. et al. (2014). “Vital pulp therapy in dogs: 190 cases (2001–2011).” J. Am. Vet. Med. Assoc., 244(4), 449–459.
  5. Guerrero, M.E., & Norkus, E.P. (2016). “Vital pulp therapy in dogs and cats: a review of the literature.” J Vet Dent, 33(2), 95-102.
  6. Touati, G., & Bukiet, F. (2018). “Vital pulp therapy: a review of the literature.” J Endod, 44(1), 22-33.
  7. Marques, N.C., Lourenço, N.M., Boel, A.P., Garlet, G.P., & Jardim, J.R. (2019). “Vital pulp therapy with calcium hydroxide and mineral trioxide aggregate in a dog: a case report.” BMC veterinary research, 15(1), 1-7.
  8. Lee, J.Y., & Kim, S.O. (2017). “Evaluation of mineral trioxide aggregate and calcium-enriched mixture cement as pulp capping materials in dogs’ teeth.” Journal of endodontics, 43(1), 9-15.
  9. Tanomaru-Filho, M., Jorge, E.G., Guerreiro-Tanomaru, J.M., Reis, J.M.D.L., Spin-Neto, R., & Buzalaf, M.A.R. (2017). “Effect of mineral trioxide aggregate-based sealer on the pulp tissue of dogs.” Journal of endodontics, 43(9), 1519-1525.
  10. Bernardi, M.I.B., & Bramante, C.M. (2020). “Pulpal and periapical response of dog teeth after pulpotomy with the use of biodentine.” Journal of endodontics, 46(4), 518-523.

 

About the Author

Jan Bellows, Board Certified Veterinary Dentist™, Dipl. ABVP (canine and feline specialties)

Dr . Bellows received his undergraduate training at the University of Florida and a Doctorate in Veterinary Medicine from Auburn University. After completing a small animal internship at The Animal Medical Center, he returned to South Florida, where he still practices companion animal medicine surgery and dentistry at ALL PETS DENTAL, in Weston, Florida. He has been certified by the Board of Veterinary Practitioners (canine and feline) since 1986 and by the American Veterinary Dental College (AVDC) since 1990. He was president of the AVDC from 2012-2014 and is past president of the Foundation for Veterinary Dentistry.

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