PULP CAP FEBRUARY 2013 COMPRESSED VERSION

MTA THERAPIES Root canal therapy – Perforation repair – Apicoectomy Indirect Pulp cap (Pink Dentin) Direct pulp cap (Direct Exposure) Pulpotomy (Coronal extirpation) Pulpectomy (Coronal and radicular extirpation) Adult and pedodontic

WHAT IS MTA CALCIUM SILICATE – GYPSUM, PLASTER OF PARIS DICALCIUM SILICATE – MAIN CONSTITUENT IN PORTLAND CEMENT TRICALCIUM ALUMINATE (MINOR) BIMUTH OXIDE ( 20%) FOR RADIOPACITY

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection Histological repair seal Inflammation management

RETROSPECTIVE STUDIES 1.Bogan G et al JADA 2008:39 (3) % 2.Fuks AB, Pediatr Dent 1982,4: % success on permanent incisors 3.Barthel CR,J Endod 2000; 26: years, years

PULP CAP MATERIALS ? CR NEWS Jan 2010 RMGI Vitrebond Plus or GC Fuji Lining LC – Indirect 40% – Indirect 68% Calcium Hydroxide – 28% Direct, – 14% Indirect Bonding agent – Direct 7% – Indirect 5% Laser 2% Direct Gluteraldehyde Indirect 3% MTA 3% Direct Polycarboxylate – no mention Glass Ionomer – no mention English sparrow poop

CR News Jan 2010 vol 3 issue 1 1.CR respondents; success rates 1.3 years: Direct 58%, Indirect 70% 2.5 years: Direct 48%, Indirect 61%

MTA Bogan G et al JADA 2008:39 (3) Direct pulp capping with Mineral Trioxide aggregate – an Observational Study. Over an observation period of nine years, the authors followed 49 of 53 teeth and found that 97.96% percent had favorable outcomes on the basis of radiographic appearance, subjective symptoms and cold testing.

MTA: SUPPLIER CLINICAL RESEARCH DENTAL LONDON ONTARIO “MTA ANGELUS WHITE”

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection Histological repair seal Inflammation management

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection Histological repair seal Inflammation management

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection Histological repair seal Inflammation management

RADIOGRAPHIC CONTRAINDICATIONS APICAL RADIOLUCENCY APICAL DETERIORATION - CONDENSING OSTEITIS THREADLIKE PULP PULP STONES PROBABLE FUTURE PULP OCCLUSION E.G. CLASS V RADIOGRAPHICLY EVIDENT CARIOUS INVASION OF PULP CHAMBER

DIAGNOSTIC CONTRAINDICATIONS APICAL TENDERNESS SPONTANEOUS LONG STANDING NOCTURNAL THROBBING ENDURING SICKENING CONSTANT NEED OF MEDICATIONS

OPERATIVE CONTRAINDICATIONS EXUDATE – SEROUS PUS PROLONGED CLOTTING TIME > 5 MINS >3MM EXPOSURE GROSS CARIES INTRODUCTION INTO PULP CHAMBER EXPLORER INTO THE PULP (OPERATOR ERROR)

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection Histological repair seal Inflammation management

FORMULA FOR CARIES DETECTOR ACID RED 52 2% IN PROPYLENE GLYCOL COMPOUNDING PHARMACY $30 FOR 200 CC.= 5 YEARS’ SUPPLY ref

CARIES DETECTOR - NO EFFECT ON BOND STRENGTH El-Housseiny and Jamjoum, J Clin Pediat Dent 2000 Kazemi et al, Oper Dent 2002

AFFECTED DENTIN INFECTED DENTIN

SETTING THE STAGE FOR PULPAL HEALING EXPOSURE ZONE: LOW/NIL BACTERIAL COUNT CONTIGUOUS ZONE BIOCOMPATIBLE AND CALCIGENIC AGENT VISIBLE DELINEATION FOR FUTURE INTERVENTIONS PERIPHERAL ZONE PERFECT SEAL (ZERO (ZERO ZERO MICROLEAKAGE)

TUBULES % AREA NUMBER/ MM 2 DIAMETER PRESSURENIL POSITIVE!!! SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP DENTIN 20 K 60K 1u 3u 10% 90%

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection Histological repair seal Inflammation management

LEAVING CARIES? JOE — Volume 36, Number 9, September 2010 Long-term Survival of Indirect Pulp Treatment Performed in Primary and Permanent Teeth with Clinically Diagnosed Deep Carious Lesions Rene´ Gruythuysen, DDS, PhD, Guus van Strijp, DDS, PhD, and Min-Kai Wu, MSD, PhDE

2 APPLICATIONS ONE MINUTE EACH ref CR JAN 2010

CR News Jan 2010 vol 3 issue 1 tal-reports/january-2010-volume-3-issue- 1.php tal-reports/january-2010-volume-3-issue- 1.php Subscription required

POTENTIAL DISINFECTANTS ENDODONTIC SILVER NITRATE IODINE FORMOCRESOL CA(OH)2 PULPAL HYPOCHLORITE - KANCA CHLORHEXEDINE-MANY ref

CHLORHEXEDINE NO EFFECT ON BOND STRENGTH Santos et al, JOE, 2006 Perdiao et, Am J Dent 1994

WHAT ABOUT SURFACE DISINFECTANTS? HYPOCHLORITE 70% ALCOHOL WITH PHENOLS 70% ALCOHOL WITH CHX ACCELERATED PEROXIDE ref

NaOCl IS A STRONG OXIDIZING AGENT REDUCES BOND STRENGTH OF DENTIN BONDING AGENTS Ari et al, JOE, 2003 Erdemir et al, JOE, 2004 Santos eta l JOE, 2006 Lai et al, J Deny Res 2001

REVERSING NaOCl EFFECTS ON DBAS A reducing agent, such as ascorbic acid, or sodium ascorbate, reverses the effect of NaOCl on bonding strength Morris et al, JOE, 2001 Lai et al, J Dent Res, 2001 Yiu et al, J Dent Res, 2002 Weston et al JOE, 2007: 10% Na ascorbate for 1 min restored the original bond strength

EDTA reverses effect of NaOCl Doyle t al, JOE, 2006 A final rinse with EDTA reversed the effects of NaOCl on bonding

H2O2 reduces bond strength of DBAs Erdemir et al JOE, 2004 Nikaido et al, Am J Dent 1999

DEEP CARIES DISINFECTION Optim 33TB Sci Can One minute kill =10 Log -6 TB effective CR tested April 2007 Excellent surface cleaner Tissue compatible

DISINFECTION PRIOR TO EXPOSURE GET CLOSE WITH DETECTOR OPTIM 33TB ONE MINUTE NO DETECTOR FINAL EXCAVATION – SLOW RPMS – SPOON ACID ETCH 10 SECONDS/RINSE – REMOVE SMEAR LAYER OPTIM 33 ONE MINUTE – PENETRATE TUBULES

OPTIONS FOR REMOVING SMEAR LAYER & PENETRATING TUBULES EDTA 14% SmearClear (SybronEndo) – 17%EDTA,surfactant QMix (Tulsa/Dentsply) – CHX digluconate, <15% EDTA, surfactant Phosphoric Acid etch Citric acid

CAPPING THE EXPOSURE: CAP, SEAL CAP WITH RESIN, RESTORE FINAL EXCAVATION; EXPOSE if still carious MTA DIRECT CAP IMMEDIATE OVERSEAL WITH UNMODIFIED GLASS IONOMER (LUTING CEMENT) ALLOW GI TO SET (APPROX 4 MINS) EDTA TO RESTORE BONDABILITY PA ETCH/RINSE/DRY PRIME/DRY+ BOND/THIN/EVAPORATE SEAL CAP PERIMETER FLOWABLE/CURE SEAL REMAINING DENTIN AND GINGIVAL MARGIN WITH FLOWABLE AND CURE RESTORE WITH FINAL RESIN FOLLOWING LOW CONTRACTION STRESS PRINCIPLES, IE, INCREMENTING FINISH AND ARTICULATE METICULOUSLY

MTA MECHANISM Silviera CMM et al. Repair of Furcal Perforation with Mineral Trioxide Aggregate: Long-Term Follow-Up of 2 Cases JCDA October 2008 Vol 74 # /729.html 8/729.html

MTA MECHANISM Saidon J et al. OSOMOPOR Endod 2003:95: “ Cell and tissue reactions to mineral trioxide aggregate (MTA) and Portland cement. ” MTA and Portland cement show comparative biocompatibility when evaluated in vitro and in vivo. The Portland cement was sterilized by ethylene oxide.

MTA MENTE ET AL Johannes Mente, DMD, et al J. Endo May Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: An Analysis of the Clinical Treatment Outcome 5 years, 167 teeth 80% success MTA, 60% Ca(OH) 2 i.e. Twice as much failure with Ca(OH) 2

Mente, DMD, et al J. Endo May 2010 Dentin bridge formation with MTA appears more homogenous (fewer tunnel defects) and more localized than that formed with Ca(OH)2 (20–24). caries was excavated from the cavity walls. Near to the pulp, except for one carious spot, the removal of which resulted in exposure of the pulp, the cavities were routinely disinfected with 0.12% chlorhexidine solution (Glaxo Smith Kline GmbH, Buhl, Germany). Resolution of bleeding from the exposed pulp in less than 5minutes was considered to be indicative of reversible inflammation The MTA pulp cap was overlaid with a thin protective layer of resin modified glass ionomer cement (Vitrebond; 3M Espe) The reduction in clinical success if a direct pulp capping is not followed immediately with permanent restoration has been shown in other clinical studies (11, 12) The longer the follow-up period, the more evident the trend decline in the success rate of the teeth in the Ca(OH)2 group compared with the MTA group.

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection Histological repair seal Inflammation management

RESIN BIOCOMPATIBILITY??? Volk,J, Engelmann,J.,Leyhausen,G.,Geurtsen,W. Dental Materials : Effects of three resin monomers on the cellular glutathione concentration of cultured human fibroblasts See Website: Home>MODXYZ> Biocompatibility ref

DYRACT AND DYRACT-CEM AND VITREBOND J Dent Res Dec;77(12): Residual monomer/additive release and variability in cytotoxicity of light- curing glass-ionomer cements and compomers. Geurtsen W, Spahl W, Leyhausen G. Severe cytotoxic effects were observed in response to both of these materials Mutat Res Jul 5;368(3-4): Genotoxicity of dental materials. Heil J, Reifferscheid G, Waldmann P, Leyhausen G, Geurtsen W. Genotoxic effects were found for Vitrebond and AH 26 (since upgraded to AH26 Plus)

GLASS IONOMER BIOCOMPATIBILITY Biomaterials Mar;19(6): Biocompatibility of various light-curing and one conventional glass-ionomer cement. Leyhausen G, Abtahi M, Karbakhsch M, Sapotnick A, Geurtsen W. Two GIs was found to be very biocompatible, while Vitrebond was found to be cytotoxic.

NEW - BIODENTINE SEPTODONT $17 PER APPLICATION REQUIRES TRITURATOR IS MEANT TO BE A COMPLETE TEMPORARY FILLING STICKY HANDLING INDEPENDENT REVIEW YET TO BE SEEN

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PEDODONTIC PULPOTOMY

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection Histological repair Inflammation management Seal

SEALING THE PULP CAP IMMEDIATE RESTORATION improves prognosis 30% (Mente et al) PROTECT THE CAP from shrinkage FINAL RESTORATION with low sensitivity technique CAREFUL OCCLUSION

CAREFUL AND ACCURATE OCCLUSION

SUCCESSFUL PULP CAPS Healthy patient Recoverable pulp Flawless caries removal Disinfection seal Histological repair Inflammation management

INFLAMMATION MANAGEMNT MEDICATION – Disciplined use of Ibuprofen 400 mg for 24 hours q4h 6 tabs – Instruct to use regardless if painful or not Alternative for NSAID- intolerant patients: dexamethasone COMMUNICATION 1.Cautious prognosis 2.“ Call me I want to know ” 3.Next day follow-up call 11 am 4.Not that night! 5.Inform that success may be temporary

THE END