vital pulp therapy includes: indirect pulp therapy direct pulp cap pulpotomy apexification
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VITAL PULP THERAPY
Includes: Indirect Pulp Therapy Direct Pulp Cap Pulpotomy Apexification
VITAL PULP THERAPY
Endodontics:
The PREVENTION or Treatment of
Apical Periodontitis
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
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
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
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
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
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
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
DIRECT PULP CAP
DEFINITION: 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
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
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
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)
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
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
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
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
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)
PULPOTOMY DEFINITION:
The surgical amputation of the coronal portion of an exposed pulp
PURPOSE: To protect and preserve the remaining radicular pulp’s vitality and function
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
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
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
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)
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
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
OPEN APEX CASES
Open Apex
Vital Pulp Necrotic pulp
Apexogenisis Apexification
OPEN APEX CASES
APEXOGENISIS Treatment:
Indirect Pulp Cap Direct Pulp Cap Pulpotomy
OPEN APEX CASES
APEXOGENISIS Materials:
CaOH Bonded Materials (resins, GICs) MTA
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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