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VITAL PULP THERAPY Includes: Indirect Pulp Therapy Direct Pulp Cap

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Presentation on theme: "VITAL PULP THERAPY Includes: Indirect Pulp Therapy Direct Pulp Cap"— Presentation transcript:

1 VITAL PULP THERAPY Includes: Indirect Pulp Therapy Direct Pulp Cap
Pulpotomy Apexification AAE def’n of vital pulp therapy?

2 The PREVENTION or Treatment of
VITAL PULP THERAPY Endodontics: The PREVENTION or Treatment of Apical Periodontitis

3 INDIRECT PULP THERAPY Also called indirect pulp cap DEFINITION:
Placement of protective dressing over thin remaining dentin which, if removed, might expose the pulp PURPOSE: To protect the pulp from further injury and to permit healing and repair Caries becomes arrested; pulp recedes

4 INDIRECT PULP THERAPY INDICATIONS: Primary and permanent teeth
Minimal pulpal inflammation No clinical signs of pulpal degeneration Asymptomatic or symptoms of reversible pulpitis Sharp, fleeting pain to thermal, osmotic stimuli No spontaneous pain Responds WNL to thermal and electric pulp tests No radiographic signs of periapical inflammation No widened pdl No p/a radiolucency Symptoms of exposed dentin

5 INDIRECT PULP THERAPY SUCCESS RATE
99% success for avoiding pulp exposure 92% success – 3½-4½ year follow-up Failed indirect pulp therapy means irreversible pulpal disease Length of study: pulpal degeneration can occur many years after carious insult. Therefore, studies using histological criteria better than clinical criteria.

6 INDIRECT PULP THERAPY TECHNIQUE Anesthetic
Rubber dam to keep bacterial count as low as possible Remove all caries at DEJ and just enough remaining caries to permit placement of a temporary restoration Large round bur less likely to cause accidental exposure than spoon excavator

7 INDIRECT PULP THERAPY TECHNIQUE (cont’d)
Place ZOE dressing (can also use CaOH) SEAL with IRM (toxic to bacterial cells) SEALING is the most important step Can use Amalgam or Glass Ionomer if longer term seal is required Band may be placed if necessary to retain. Marginal seal – no substrates for bacteria; no acid production. If dressing lost - caries re-exposed to oral cavity – failure.

8 INDIRECT PULP THERAPY TECHNIQUE (cont’d)
After 8 weeks, remove remaining caries, evaluate: arrested? exposure? If no pulp exposure – final restoration If pulp exposure – direct pulp cap or pulpotomy or pulpectomy Failed Indirect Pulp Cap means irreversible pulpal disease Rate of Reparative detinogenisis approx. 1.4 microns per day. 8 weeks (56 days) = 0.784mm. Ie. Should be able to see reparative dentin on BW film. Rate of dentinogenisis drops off markedly after 48 days. Practically all bacteria destroyed under ZOE and CaOH dressings. Arrested Caries – ie may not have to drill any deeper

9 INDIRECT PULP THERAPY NOTE re: IMMATURE TEETH
Indirect pulp cap should be used whenever possible to avoid pulp exposure. In immature teeth (open apices) every attempt must be made to maintain pulp vitality until root development is complete. Loss of vitality before complete root development leaves a short, thin, weak root more prone to fracture, poorer crown:root ratio. ALWAYS TRY TO AVOID APEXIFICATION IF APEXOGENISIS IS POSSIBLE

10 DIRECT PULP CAP DEFINITION: PURPOSE
Placement of a protective dressing directly over pulp at site of exposure PURPOSE To permit healing & repair and to maintain the pulp’s vitality and function

11 DIRECT PULP CAP INDICATIONS: Permanent teeth only
Carious or mechanical exposures ie. when indirect pulp therapy fails or in the RARE event of an accidental exposure Best used on teeth with immature permanent with exposed pulps Once root formation is complete – NSRCT Use in mature teeth is controversial. Best considered a temporary or compromise tx

12 DIRECT PULP CAP INDICATIONS (cont’d) Careful Case Selection:
Minimal pulpal inflammation No clinical signs of pulpal degeneration No radiographic signs of p/a inflammation Young pulp better prognosis No pulp calcifications better Little or no bleeding at exposure site Mechanical better than carious

13 DIRECT PULP CAP INDICATIONS (cont’d) Small exposure better
Location of exposure – axial wall worse No purulent or serous exudate at exposure BUT REMEMBER: a pulp with no signs or symptoms is not always a healthy pulp (stressed)

14 DIRECT PULP CAP SUCCESS RATE: Controversial
Depends of definition of success High success rate if judged by absence of clinical signs and symptoms Low success rate based on presence of chronic inflammation on histologic exam

15 DIRECT PULP CAP SUCCESS RATE (cont’d)
Higher success rate in short term Long term – persisting pulpal inflammation. May lead to calcification, internal or external resorption which complicates future NSRCT Therefore: IDEAL treatment for all carious exposures in mature permanent teeth is NSRCT

16 DIRECT PULP CAP TECHNIQUE: Calcium Hydroxide is material of choice
Dycal etc. Marginal seal is critical Careful caries removal to avoid forcing dentin debris and micro-organisms into pulp Dentin bonding agents cause apoptisis and arrest of normal cell cycle – Hanks JDR 2003

17 DIRECT PULP CAP MECHANISM OF ACTION:
CaOH causes necrosis of superficial pulp and inflammation of contiguous tissue. Dentin bridge formation occurs at junction of necrotic and inflamed vital tissue. Dentin bridge consists of superficial bone-like layer and deeper dentin-like layer. Blood clot inhibits bridge formation

18 DIRECT PULP CAP MECHANISM OF ACTION (cont’d)
Radiographic studies of radiolabeled CaOH have shown that Ca in dentin bridge comes from blood – not from CaOH Bridge - irregular porous tubular dentin Becomes thicker & less permeable with time Exact mechanism of action unknown BUT certain concentrations of CaOH known to be mitogenic for pulp fibroblasts (odontoblast replacement cells)

19 PULPOTOMY DEFINITION: PURPOSE:
The surgical amputation of the coronal portion of an exposed pulp PURPOSE: To protect and preserve the remaining radicular pulp’s vitality and function

20 PULPOTOMY INDICATIONS: Exposed vital pulps in carious primary teeth
Exposed vital pulps in carious immature permanent teeth (to allow continued root development prior to NSRCT) Traumatically exposed primary or permanent teeth; mature or immature As an emergency procedure prior to NSRCT

21 PULPOTOMY PROGNOSIS: Questionable in carious exposures in mature teeth. Good for apexogenisis in immature teeth with carious exposures Excellent for traumatic exposures regardless of root maturity, size of exposure or time elapsed since injury

22 PULPOTOMY TECHNIQUE: Carious Exposure:
Pulp removed to cervical line in anterior teeth, to canal orifices in posterior teeth Clinical judgement influences amount of tissue removed High speed diamond with water spray Care to remove all shreds of pulp coronal to amputation site Carious teeth – accelerated aging of pulp. Pulpal inflamm – decrease reparative capacity of pulp. Less vascular, less cellular, fewer nerves, more calcified, more fibrous.

23 PULPOTOMY TECHNIQUE (cont’d) Flush with sterile saline Do Not air dry
Control hemo with moist cotton pellets and gentle pressure for approx. 5 min. If hemo cannot be controlled, amputation should be performed at a more apical level If hemo still continues in immature tooth control with hemostatic agents eg. aluminum chloride or ferric sulfate (compromise treatment)

24 PULPOTOMY TECHNIQUE (cont’d)
Place CaOH dressing – do not use hard setting CaOH deep in canals – use CaOH powder Base – usually IRM or other cement Marginal seal of final restoration critical Regular follow-up until root development complete and NSRCT may be performed

25 PULPOTOMY TECHNIQUE (cont’d) Traumatic Exposure: Cvek Pulpotomy:
Mature or immature teeth Remove only 2-3mm of pulp Place CaOH (eg. Dycal) No further endodontic treatment is usually required 91% success at 4 year follow-up

26 OPEN APEX CASES Open Apex Vital Pulp Necrotic pulp
Apexogenisis Apexification

27 OPEN APEX CASES APEXOGENISIS Treatment: Indirect Pulp Cap
Pulpotomy

28 OPEN APEX CASES APEXOGENISIS Materials: CaOH
Bonded Materials (resins, GICs) MTA

29 OPEN APEX CASES APEXIFICATION:
Indication: Immature tooth with necrotic pulp Traditional Technique: Canal disinfection (instrumentation, irrigation, CaOH dressing); replace dressing periodically over 1-3 years; formation of apical dentin barrier; obturation Alternate Technique: Canal disinfection (instrumentation, irrigation, CaOH dressing); place MTA apical barrier after 1 week (microscope); obturate with gutta-percha and sealer.


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