Indirect pulp therapy in a symptomatic mature molar using calcium enriched mixture cement
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.\nExtraoral 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).\nRadiographic examination showed a large carious lesion associated with apical periodontitis []. 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.\nThe 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 [].\nThe 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 and ]. The final diagnosis was normal pulp with normal PDL.