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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. - PowerPoint PPT Presentation
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PULP CAPFEBRUARY 2013
COMPRESSEDVERSION
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
Inflammationmanagement
RETROSPECTIVE STUDIES
1. Bogan G et al JADA 2008:39 (3) 305-315 97%2. Fuks AB, Pediatr Dent 1982,4: 240-244 81%
success on permanent incisors 3. Barthel CR ,J Endod 2000; 26: 525-528 37%
@ 5 years, 13% @10 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%
0102030405060708090
100
3 5 10
DIRECTINDIRECTBOGANFUKSBARTHEL
MTA
• Bogan G et al JADA 2008:39 (3) 305-315 • 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• 1800 265 3444
• “MTA ANGELUS WHITE”
SUCCESSFUL PULP CAPS
Healthy patient
Recoverable pulp
Flawless caries removal
Disinfection
Histological repair
seal
Inflammationmanagement
SUCCESSFUL PULP CAPS
Healthy patientRecoverable pulp
Flawless caries removal
DisinfectionHistological repair
seal
Inflammationmanagement
SUCCESSFUL PULP CAPS
Healthy patient
Recoverable pulp
Flawless caries removal
Disinfection
Histological repair
seal
Inflammationmanagement
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
Inflammationmanagement
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/ MM2
• DIAMETER
• PRESSURE NIL POSITIVE!!!
• SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP DENTIN
20 K60K
1u3u
10% 90%
SUCCESSFUL PULP CAPS
Healthy patient
Recoverable pulp
Flawless caries removal
Disinfection
Histological repair
seal
Inflammationmanagement
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 LesionsRene´ 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• http://www.cliniciansreport.org/products/den
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 EFFECTON 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, 2001Lai et al, J Dent Res, 2001Yiu et al, J Dent Res, 2002Weston 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 #8 729-732
• http://www.cda-adc.ca/jcda/vol-74/issue-8/729.html
MTA MECHANISM• Saidon J et al. OSOMOPOR Endod 2003:95:483-489 “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 2010 806-814
• 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
Inflammationmanagement
RESIN BIOCOMPATIBILITY???• Volk,J, Engelmann,J.,Leyhausen,G.,Geurtsen,W.• Dental Materials 2006 22:499-505• 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. 1998 Dec;77(12):2012-9.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. 1996 Jul 5;368(3-4):181-94.• 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. 1998 Mar;19(6):559-64.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
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FILLING• STICKY HANDLING• INDEPENDENT REVIEW YET TO BE SEEN
Theracal- Bisco
PEDODONTIC PULPOTOMY
SUCCESSFUL PULP CAPS
Healthy patient
Recoverable pulp
Flawless caries removal
Disinfection
Histological repair
Inflammationmanagement
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
Inflammationmanagement
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 prognosis2. “Call me I want to know”3. Next day follow-up call 11 am4. Not that night!5. Inform that success may be temporary
THE END