symptomatic 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 . however , as the severity of pulpal inflammation can not be measured quantitatively , it must be based on clinical findings rather than histological diagnosis ; moreover , there is poor correlation between the two .
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 .
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 .
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 . 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 .
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 .
an in vitro study revealed that the anti - bacterial properties of cem are similar to calcium hydroxide .
cem has been employed as a root - end filling material , as well as direct pulp capping agent , pulpotomy agent , apical plug , in the repair of furcal perforations , management of root resorption , and regenerative endodontics .
recently , an interesting report demonstrated favorable treatment outcomes of direct pulp capping with cem for management of a permanent mature molar with irreversible pulpitis and associated apical periodontitis .
the 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 .
a 12-year - old female with a symptomatic first left lower molar was observed at a private clinic .
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 ] .
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 .
intraoral pre - operative radiograph showing well - defined radiolucency of mesial and distal roots of symptomatic first lower left molar 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 .
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 .
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 threelayers ofrestorationconsistofindirectpulptherapy / 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 .
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 3 and 4 ] .
six - month follow - up radiograph showing healing process of apical pathology one - year follow - up radiograph showing complete periapical healing
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 .
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 ; 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.[357 ] 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 ,
the inflammatory process should be re - examined to recognize its possible or probable positive effect on pulpal healing .
our clinical / radiographic follow - ups 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 .
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 .
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 .
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 .
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 .
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 .
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 .
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 .
 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 . 
 one - year 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 deep - caries lesion is an easier , more practical and valuable treatment plan than complete caries removal . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSIONS