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 PulpotomyApexificationAAE def’n of vital pulp therapy?
2 The PREVENTION or Treatment of VITAL PULP THERAPYEndodontics:The PREVENTION or Treatment ofApical 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 pulpPURPOSE:To protect the pulp from further injury and to permit healing and repairCaries becomes arrested; pulp recedes
4 INDIRECT PULP THERAPY INDICATIONS: Primary and permanent teeth Minimal pulpal inflammationNo clinical signs of pulpal degenerationAsymptomatic or symptoms of reversible pulpitisSharp, fleeting pain to thermal, osmotic stimuliNo spontaneous painResponds WNL to thermal and electric pulp testsNo radiographic signs of periapical inflammationNo widened pdlNo p/a radiolucencySymptoms of exposed dentin
5 INDIRECT PULP THERAPY SUCCESS RATE 99% success for avoiding pulp exposure92% success – 3½-4½ year follow-upFailed indirect pulp therapy means irreversible pulpal diseaseLength 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 possibleRemove all caries at DEJ and just enough remaining caries to permit placement of a temporary restorationLarge 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 stepCan use Amalgam or Glass Ionomer if longer term seal is requiredBand 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 restorationIf pulp exposure – direct pulp cap or pulpotomy or pulpectomyFailed Indirect Pulp Cap means irreversible pulpal diseaseRate 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 exposurePURPOSETo 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 exposureBest used on teeth with immature permanent with exposed pulpsOnce root formation is complete – NSRCTUse in mature teeth is controversial. Best considered a temporary or compromise tx
12 DIRECT PULP CAP INDICATIONS (cont’d) Careful Case Selection: Minimal pulpal inflammationNo clinical signs of pulpal degenerationNo radiographic signs of p/a inflammationYoung pulp better prognosisNo pulp calcifications betterLittle or no bleeding at exposure siteMechanical better than carious
13 DIRECT PULP CAP INDICATIONS (cont’d) Small exposure better Location of exposure – axial wall worseNo purulent or serous exudate at exposureBUT 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 successHigh success rate if judged by absence of clinical signs and symptomsLow success rate based on presence of chronic inflammation on histologic exam
15 DIRECT PULP CAP SUCCESS RATE (cont’d) Higher success rate in short termLong term – persisting pulpal inflammation. May lead to calcification, internal or external resorption which complicates future NSRCTTherefore: 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 criticalCareful caries removal to avoid forcing dentin debris and micro-organisms into pulpDentin 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 CaOHBridge - irregular porous tubular dentinBecomes thicker & less permeable with timeExact 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 pulpPURPOSE: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 immatureAs an emergency procedure prior to NSRCT
21 PULPOTOMYPROGNOSIS:Questionable in carious exposures in mature teeth.Good for apexogenisis in immature teeth with carious exposuresExcellent 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 teethClinical judgement influences amount of tissue removedHigh speed diamond with water sprayCare to remove all shreds of pulp coronal to amputation siteCarious 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 levelIf 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 powderBase – usually IRM or other cementMarginal seal of final restoration criticalRegular follow-up until root development complete and NSRCT may be performed
25 PULPOTOMY TECHNIQUE (cont’d) Traumatic Exposure: Cvek Pulpotomy: Mature or immature teethRemove only 2-3mm of pulpPlace CaOH (eg. Dycal)No further endodontic treatment is usually required91% 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