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Your Opinion: How would you treat this case?

This case was submitted by Dr. Matt Gilchrist

An 11 year-old presented to my office in December 2013 for a routine recall examination. The right bitewing revealed what appeared to be gross decay on the 1-4 occlusal. Upon further review of the bitewing from last year, it was noted that this exact same lesion had been present since the tooth first erupted into the child’s mouth (sorry, no picture, as we were not digital at that time). The tooth has been symptomatic, and a PA was taken which was within normal limits. Clinically there was no evidence of gross decay, no shadow / halo, not even a detectable pit.

I decided today that it would be best to investigate this a bit further, so I thought that I would prepare through the enamel to see what was happening. It turned out that there was gross decay undermining the buccal cusp, which then lead to a pulp exposure (roughly 1mm in diameter). The pulp appeared to be in good health, therefore I made the decision to do a direct pulp cap with Dycal, followed by a RMGIC base, and finally a resin restoration. The tooth is still immature, and I feel that it might have the ability to heal from this procedure. I have informed the child’s parents that a future root canal is most likely.

I am wondering how a caries could be this extensive on a tooth that has only been present in the mouth for a short time. As mentioned above, it has looked like this since last year when the tooth first erupted and the child was 10 years old.

Would this be your treatment of choice? Would you have initiated a pulpectomy?

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  1. Matt – I believe what you are seeing is pre-eruptive resorption. See: http://www.ncbi.nlm.nih.gov/pubmed/11048303

    Some years ago I noticed a similar lesion on an unerupted #36. Since I have access to GA facilities I brought the child to the OR, exposed the tooth and removed the lesion. It was dissimilar to caries when removing it. It was kind of yellowish and scooped out easily. I restored it with RMGIC. I have photos but I can’t see here how to post them

    • Thank you so much for that response…it sounds absolutely plausible! I have never come across this before and I was dumbfounded!

  2. http://www.ncbi.nlm.nih.gov/pubmed/11048303

    Matt – I believe what you are seeing is pre-eruptive resorption. Several years ago I noticed a similay lesion in an unerupted #36. Since I have access to hospital, I brought the child to the OR, exposed the tooth, and restored it with RMGIC. I have photos but can’t see here how to post them.

  3. On behalf of Dr. David Rose

  4. I’ve seen 2 cases like yours in the last 2 years. First case…tooth 35…on a 14 year old. I placed a direct pulp cap and restored but the tooth became very sensitive. Endodontic therapy was done by the endodontist but the tooth would not settle down. We ended up extracting the tooth and will do an implant in a few years. Case 2…a partially erupted tooth 37 on a 12 year old. We referred to a periodontist to fully expose the tooth and a pulpectomy was performed by an endodontist. We are waiting for the roots to mature before completion of the root canal treatment. I’m baffled at both cases.

    • I have a patient 23 years old .In the last couple of years we noticed on the bite wings that he has a 36 with a large internal resorption that is asympthomatic ever since diagnosed . The lesion did not change in size and doesn’t have any clinical indication that something is wrong with the tooth .
      We advised the patient about all of this and we decided that for the time being we will observe the evolution of the lesion .
      Interesting case !

  5. I saw a similar bicuspid but only once. I believe we removed the tooth. It is rare.

  6. HI Matt,
    Great post. This is a presentation that baffles everyone. I have personally seen it 4-5 times, generally first permanent molars, and learned about it in residency. Pre-eruptive caries, as it is often referred to, is enigmatic and best treated just as you have done. Simply put, there is no magic to it. Removal of decay followed by appropriate pulp therapy, preferably indirect, should yield an acceptable result. Should pulp exposure occur, then the prognosis for the tooth to remain vital over the long term is questionable. With luck, the tooth will at least mature to closed apices to allow for RCT at a later time. Depending how much tooth structure is left, full coverage with an SSC in the interim is appropriate, rather than a huge multi-surface resin. In some cases, depending on the tooth and age, extraction is appropriate. We must treat the person, not the tooth. Often with a treatment planning conversation (informed consent), families will opt for strategic extraction, perhaps even with a balancing extraction, to avoid being tethered to the dental chair for RCT, post, core, crown etc. over the long term. David Rose supplied an excellent link for review. Best of luck! Keep posting!

  7. Hi Matt,

    I had a similar case out East. I think it looks like some type of dens invaginatus which through no fault of the patient, is like a cave in which bacteria can foster and cause problems. I commend you on your treatment of the symptomatic tooth. I would have done the same, and hopefully given the age and the immaturity of the apex, this tooth should not require endodontic treatment.

    Nice case report.


  8. Dear Matt,

    The pre-prep picture looks as if there is possibility of decay in the distal Pit and grove. Slow erupting teeth, with immature enamel in the pits and fissures will get bacterial infection from the saliva seepage below the punctured gingival tissue. This is plain decay. Worst yet many of these types of teeth with smaller lesions are sealed by us dentists, trapping the decay and making diagnosis even more difficult in the future. I see this in erupting molars but less so in premolars. As for choice of treatment, after pulpal disinfection with a slight chlorohexidine rinse, once bleeding has stopped, MTA capping with a GI cover over the MTA seems to be the recommended method of treatment by our endodontic colleagues. Hope this helps,

  9. I would have used MTA for the pulp cap. These do pose a dillemma as the apices are rarely fully formed allowing you to do an adequate RCT. The MTA will allow for continued root development and often the tooth will not require RCt.

  10. gdicasmirro@shaw.ca

    Doesn’t anyone do indirect pulp caps anymore??? I’ve used it many times over the years for this type of lesion, and in all cases we were able to develop a thick layer of secondary dentin in the pulp chamber, and then followed up with a normal composite restoration. No exposures, no endo needed…generally a happier patient…thanks for allowing me to comment.

  11. It is difficult to further comment on the etiology of this lesion without previous radiographs or even a panoramic radiograph taken well before any eruption of this tooth. However, if there is no visible communication or direct detection of caries from a clinical examination, then this would point to a condition sometimes referred to as either “hidden caries”, pre-eruptive caries, occult caries, or pre-eruptive intracoronal radiolucent defect. Although relatively rare, it poses numerous challenges to clinicians. Some of these lesions present as small radiolucent images which sometimes do not progress any further while others (similar to the one shown) clearly show an immediate threat to pulpal integrity. The pediatric dental literature seems to have some very good documentation of this clinical findings.
    Clinicians, sometimes find it difficult to understand how such caries can develop prior to eruption without any obserable break in enamel integrity. A different mode of etiology and even distinctly different bacterial flora associated with “hidden caries” has been reported.
    This remains an interesting facet of cariology and clinician challenge which deserved such posting in this forum.

    • I have been doing some direct pulp caps, but before placing the material, I have been disinfecting the tooth with sodium hypoclorite for 90 seconds, as advocated by Dr John Kanca. I have found that my success rate increases dramatically with this addition to my technique. In addition, for small pulp exposures I have bonded directly over top, for larger ones, I have placed durelon, as the pulp capping material.
      Have a great day.

  12. with regard to pulp capping I agree with Robert, following John Kanca’s protocol. The bleeding can be controlled with a 3% hypochlorite solution followed by placement of Durelon cement (yes Durelon cement!) over the exposure. He has been doing this for years andI have done this many times with good success. I have also seen excellent results with MTA (mostly in lectures) and have recently tried Theracal by Bisco..

    what is most important in these situations is not to expose the pulp. It is clinically acceptable to leave a small amount of decay over the pulp, as long as you have solid tooth structure (preferably enamel) surrounding the lesion to get a good seal. Of course regular monitoring with radiographs should be done to monitor progression

  13. My protocol for small carious pulp exposures with minimal bleeding is putting a chx-soaked pellet in contact with all of the dentin and the exposure site for 3 minutes followed by some diode laser irradiation on a low setting to stimulate healing. I believe that disinfection of dentin is paramount once the inside will be sealed over with a permanent restoration of any kind.

  14. Hi, I have seen a number of cases of pre-eruptive resorption, and in fact a case report is being published in the O.D.A. journal this spring. I have seen it on second premolars and second molars. The following is a great review article http://www.aapd.org/assets/1/25/Seow-22-05.pdf
    Kathie Schenk

  15. I have seen several cases of pre-eruption resorption in my practice. In fact, a case study is being published in the O.D.A. journal this spring. Early detection using radiographs is important as these lesions can be in patients with a low caries rate and there is no de-calcification in the grooves. In that case, of course, conservative treatment with a restoration is all that may be required.

  16. great post! As a pediatric dentist I see this type of lesion in young children quite often. You may see this type of pre-eruptive hypoplasia, also known as occult caries, or internal defects in primary molars or that of permanent dentition. the key is that the tooth is asymptomatic. All one has to do is to open up the lesion and do an indirect pulp cap with a RMGIC (e.g. Vitrebond), then temporize it with GIC. If the tooth remains asymptomatic leave it for as long as you can to allow for tertiary dentin formation. After a few years and once the pulp receded one can go back in and clean it up completely and restore it for good. Delaying pulpal exposure and endodontic treatment in such immature teeth with huge pulp chambers, wide root canals, and open apices is the best thing you can do for your patient. I’ve treated many of them with this approach and I cannot recall any of them needing RCT. Having said that however I have not done a proper retrospective study on them. I hope this helps.

  17. Thanks for that great post and all the comments which are very helpful!

  18. I have seen a number of these lesions and they do seem to be progressive. As already noted, they have been written up in pediatric literature as resorptive lesions. I would recommend restoring as soon as practical. If the lesion is close to the pulp, an indirect pulp cap with a later definitive restoration is recommended. There was an Oasis topic on this last year as well.
    K. Schenk

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