J Conserv Dent. 2013 Jan-Feb; 16(1): 8386.

doi: 10.4103/0972-0707.105306

INDIRECT PULP THERAPY IN A SYMPTOMATIC MATURE MOLAR USING

CALCIUM ENRICHED MIXTURE CEMENT
Hassan Torabzadeh and Saeed Asgary1
Preventive Dentistry Research Center, Dental Research Center, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
1Iranian Center for Endodontic Research, Research Institute of Dental Sciences, Shahid
Beheshti University of Medical Sciences, Tehran, Iran
Address for correspondence: Prof. Saeed Asgary, Iranian Center for Endodontic Research,
Research Institute of Dental Sciences, Shahid Beheshti Dental School, Evin, Tehran, Iran. E-mail:
saasgary@yahoo.com

ABSTRAK
Dental pulp has the ability of repair/regeneration. Indirect pulp therapy (IPT) is
recommended for pulp preservation in asymptomatic teeth with extremely deep caries as
well as teeth with clinical symptoms of reversible pulpitis. In this case study, we
performed IPT with calcium enriched mixture (CEM) cement on a symptomatic
permanent molar. After clinical/radiographic examinations the tooth was diagnosed with
irreversible pulpitis and associated apical periodontitis. IPT involved partial caries
removal, the placement of CEM cement pulp cap and overlying adhesive permanent
restoration. At the 1 week follow-up, patient's spontaneous symptoms had resolved. Oneyear follow-up demonstrated pulp vitality, clinical function, as well as the absence of
pain/tenderness to percussion/palpation/cold sensitivity tests; periapical radiograph
showed a healing periradicular lesion with newly formed bone, that is normal pulp with
normal periodontium. These favorable results indicate that IPT/CEM may be a good
treatment option in comparison to endodontic treatment in young patients. IPT of deepcaries lesion is an easier, more practical and valuable treatment plan than complete caries
removal.
Keywords: Apical periodontitis, calcium enriched mixture cement, endodontic, pulp cap,
pulpitis, stepwise excavation
INTRODUCTION
Aymptomatic irreversible pulpitis
is a pulpal state characterized by
mild/severe pain that lingers after removal
of a
stimulus.
In such cases,
pulpectomy/extraction is required to
alleviate the symptoms and prevent apical
periodontitis.[1] However, as the severity
of pulpal inflammation cannot be measured
quantitatively, it must be based on clinical
findings rather than histological diagnosis;
moreover, there is poor correlation
between the two.[2] In addition, pulps of

teeth clinically diagnosed with irreversible

pulpitis were shown to have the potential
to heal after pulpotomy with appropriate
biomaterials such as mineral trioxide
aggregate (MTA) and calcium enriched
mixture (CEM) cement.[37]
A systematic review revealed that
to reduce the risk of carious pulp exposure,
partial caries removal (indirect pulp
therapy [IPT]) can result in long-term
success compared with complete caries
removal in the deep lesion.[8] A clinical
trial demonstrated high survival rate of

permanent teeth when deep carious lesions

were managed without exposing the pulp
by placing an indirect pulp cap.[9] These
results demonstrated that the teeth pulps
remained symptomless and maintained
their healing potential and defensive
capacity after treatment. Elimination of the
bulk of the infected dentin and sealing the
remaining carious lesion from oral fluids
with appropriate materials is an accepted
treatment for badly decayed teeth.[10] In
addition, performance of IPT is
simpler/more economical than RCT.
CEM cement has been introduced
as a water-based and tooth-colored
endodontic biomaterial. After mixing with
liquid, the pH of CEM increases to >10.
[11] It is assumed that in a high pH
environment the calcium ions that are
released from CEM react with endogenous
phosphates to form hydroxyapatite; this
would explain the favorable sealing
ability/biocompatibility of the cement.[12]
An in vitro study revealed that the antibacterial properties of CEM are similar to
calcium hydroxide.[13] CEM has been
employed as a root-end filling material,
[14] as well as direct pulp capping agent,
[15] pulpotomy agent,[5,6,16,17] apical
plug,[18] in the repair of furcal
perforations,[19] management of root
resorption,[20]
and
regenerative
endodontics.[21] Recently, an interesting
report demonstrated favorable treatment
outcomes of direct pulp capping with CEM
for pulpitis and associated apical
periodontitis. following report discusses
the first case of successful management of
a symptomatic permanent tooth with
irreversible pulpitis and associated apical
periodontitis using IPT with CEM,
followed by a sandwich glass-ionomer
composite restoration.
CASE REPORT
A 12-year-old female with a
symptomatic first left lower molar was
observed at a private clinic. She
complained of severe lingering pain to cold
lasting for few minutes. She also

complained of spontaneous pain during the

day and at night time. Review of the
patient's medical history revealed no
significant findings.
Extraoral evaluation revealed normal soft
tissue structures with no apparent pathosis.
Intraoral examination showed a first left
lower molar with a large carious lesion.
Diagnostic tests were performed; the
involved tooth responded with mild pain to
percussion and severe lingering pain to
Endo-Frost cold spray (Roeko; Coltene
Whaledent, Langenau, Germany).
Radiographic examination showed
a large carious lesion associated with
apical periodontitis [Figure 1].

Intraoral pre-operative radiograph showing

well-defined radiolucency of mesial and distal
roots of symptomatic first lower left molar

The
adjacent/opposing
teeth
were
asymptomatic and responded normally to
all diagnostic tests. Based on the clinical
and radiographic examinations, the
diagnosis of irreversible pulpitis with
apical periodontitis was made. Thereafter,
IPT of the tooth was decided; an informed
consent was obtained from the patient's
legal guardian.
The patient was instructed to rinse
her mouth with 0.2% chlorhexidine. The
tooth was anesthetized with 2% lidocaine
with 1:80,000 epinephrine (DarouPakhsh,
Tehran, Iran) and then isolated with rubber
dam. Subsequently the dentin-enamel
junction was completely excavated. The
bulk of soft carious dentin was carefully

removed by tungsten-carbide round burs

(Komet, Lemgo, Germany) at low speed;
medium and large spoon excavators (Ash,
London, UK) were also used. Excavation
was terminated once the remaining carious
dentin showed increased resistance to
manual instrumentation. After that, the
remaining carious dentin in pulpal floor
was covered by 1.5 mm layer of CEM
cement (BioniqueDent, Tehran, Iran). The
remaining tooth cavity was then
restored/sealed with glass-ionomer cement
and composite resin sandwich technique
[Figure 2].

Post-operative Orthopantomogram (OPG)

showing threel ayers of restoration consist ofi
ndirect pulptherapy/calcium enriched mixture,
glass ionomer and composite resin. Left:
Higher magnification of treated first lower left
molar revealing well defined periapical
radiolucency of both roots

The patient was re-examined

clinically after 1 and 7 days. At the 1-day
follow-up the patient complained of
sensitivity to cold which had significantly
decreased 1 week post-operatively.
Tenderness to percussion was not reported
in both follow-ups. Patient was recalled at
1 year for clinical/radiographic follow-up.
Clinical examination with cold test showed
a vital tooth which was functional,
asymptomatic, with normal physiologic
mobility, normal probing depths, and a
satisfactory
coronal
restoration.
Radiographic examinations showed normal
periodontium, and evidence of periapical
healing [Figures [Figures33 and and4].4].

Six-month follow-up radiograph

healing process of apical pathology

showing

The final diagnosis was normal

pulp with normal PDL.

One-year follow-up radiograph

complete periapical healing

showing

DISCUSSION
This study conducted IPT with
CEM cement for a pulp with
sign/symptoms of irreversible pulpits along
with apical periodontitis. Though, apical
periodontitis seemed evident on the
radiograph, the pulp was still vital. The
general consensus in cases where
irreversibly inflamed pulp has been
diagnosed, is that the pulp no longer has
the potential to heal and will not survive
with any form of treatment. However, it
should be considered that irreversible
pulpitis is a clinical term for the
classification of pulpal diseases; when
treating the deep carious lesion clinicians

have to diagnose irreversible pulpitis on

the basis of indirect diagnostic methods.
There is little evidence to correlate the
clinical signs/symptoms with histological
feature of the diseased pulp.[2]
Therefore, dentists are trained to
diagnose irreversible pulpitis when patient
complains of pain lasting for a few minutes
to several hours, pain exacerbating with
hot/cold fluids, and radiating pain;[23] as
well as tender to percussion. However,
there is no information to indicate which
symptom is an indication that the pulp no
longer can repair itself. Conversely, recent
reports have demonstrated that teeth with
irreversible pulpitis showed favorable
treatment outcomes with pulpotomy using
CEM/MTA as pulp cappings.[35,7]
Though the diseased pulps in these cases
were inflamed, they were still vital; that is
they still maintained a blood supply and
therefore the most important factor for
healing. In the light of recent high-level
evidences,[7] the inflammatory process
should be re-examined to recognize its
possible or probable positive effect on
pulpal healing.[23]
Our clinical/radiographic followups also showed favorable treatment
outcomes for IPT/CEM. These results
reveal that severe local inflammation in
pulpal tissue may heal and be repaired if
the irritant is removed and the pulp is well
protected from further irritants. If further
studies support this, there may be a need
for reclassification of dental pulp diseases.
The concept of complete caries removal is
currently being challenged for permanent
teeth.[24] A growing body of evidence has
demonstrated that IPT is successful for the
management of deep caries lesion in
primary molars as well as two-stage
technique in immature permanent teeth;
however, some recent studies have shown
similar results in mature permanent teeth.
IPT reduces the risk of carious pulp

exposure, diminishes the substrate for

microorganisms,
prevents
lesion
development and promotes a physiological
reaction in the pulp-dentin complex.[25]
Several studies have demonstrated
that once cariogenic bacteria are isolated
from their nutritional supply by an
adequate coronal seal, they either perish or
become inactive.[24] Furthermore, once a
seal is applied to carious dentin, it becomes
dry/hard, arresting the carious process after
IPT with a one-visit method. Accordingly,
the second appointment may not be
needed, if the coronal restoration preserves
the seal of cavity. Our 1-year clinical
follow-up showed that the one-visit IPT
coronal filling was satisfactory, and
therefore a second appointment was not
scheduled.
Several dental materials have been
suggested for capping the remaining
carious lesion in IPT, that is calcium
hydroxide,
polycarboxylate
cement
combined with tannin-fluoride preparation,
zinc-oxide eugenol cements, resin-bonded
composite, glass ionomer cements and
copper phosphate cement.[24] The ideal
capping material should be anti-bacterial,
non-toxic,
dimensionally
stable,
biocompatible, and create a hermetic seal
as well as be able to induce regeneration of
the pulp. CEM cement as a new
endodontic
biomaterial
demonstrated
reasonable characteristics. Considerable
data has shown favorable properties of
CEM cement namely; anti-bacterial
properties, sealing ability, dimensional
stability and biocompatibility when
compared with other gold standard
materials such as calcium hydroxide or
MTA.[6,11,13,15,16]
The favorable results in this case
study may be partly attributed to the
patient's age. A young patient's tooth may
have slightly open apices and the dental

pulp may respond more positively to pulp

capping than a mature pulp.
CONCLUSIONS
Based on our clinical and
radiographic
observations,
we
can
conclude that despite apparent pulpal and
periradicular inflammation from the deep
caries lesion, a conservative IPT can
generate pulpal repair and periradicular
healing in a mature permanent molar tooth.
In addition, IPT/CEM of deep caries lesion
in young patients is an easier, more
practical and valuable treatment plan than
complete caries removal which may result
in pulp exposure and root canal treatment.
However, well-conducted clinical trials on
this proposed technique will be required
for more grounding clinical evidence.
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