Vital Pulp TherapyVital Pulp Therapy

Dr Abeer A Elhakim ElgendyDr Abeer A Elhakim ElgendyLecturer of Endodontic Lecturer of Endodontic

Ain Shams UniversityAin Shams University

WhatWhat??All measures that protect the All measures that protect the

vitalityvitality before its irreversibly before its irreversibly damaged.damaged.

Why, When, Why, When, HowHow??? ???

Why I need to preserve Why I need to preserve pulp vitalitypulp vitality??

Pulp is responsible forPulp is responsible for::

11--Formation of reparative dentinFormation of reparative dentin . .

22--Resilience and toughness of dentinResilience and toughness of dentin . .

33--Vital tooth show proprioceptive responseVital tooth show proprioceptive response..

44--Continued root development in immature Continued root development in immature permanent teeth (open apex)permanent teeth (open apex) . .

Why I need vital pulp Why I need vital pulp therapy to treat therapy to treat ImmatureImmature

teethteeth??22 problemsproblems::

Need for complete root Need for complete root formationformation

Open apexOpen apex

Absence of apical constrictionAbsence of apical constrictionApical part of canal is wider than Apical part of canal is wider than

coronal partcoronal partHigh possibility of hypochlorite High possibility of hypochlorite

accident.accident.

Why?Why?

Caries in deciduous teeth

WhenWhen??Indication for vital Indication for vital

pulp therapy:pulp therapy:1.1. Teeth with open Teeth with open

apex.apex.

2.2. Primary teeth.Primary teeth.

3.3. Teeth that would be Teeth that would be difficult to perform difficult to perform root canal ttt.root canal ttt.

4.4. Teeth involved in Teeth involved in simple restoration.simple restoration.

Contraindication for vital Contraindication for vital pulp therapy:pulp therapy:

1.1. Teeth involved in a Teeth involved in a complex restoration .complex restoration .

2.2. Teeth in which the root Teeth in which the root canal space is needed to canal space is needed to hold a post and core. hold a post and core.

3.3. Teeth involved in a Teeth involved in a complex periodontal complex periodontal therapy.therapy.

WhenWhen??

Criteria must be fulfilled to Criteria must be fulfilled to undergo vital pulp therapyundergo vital pulp therapy

1.1. Pulp is asymptomatic or show Pulp is asymptomatic or show symptoms of reversible pulpitis.symptoms of reversible pulpitis.

2.2. Pulp vitality test show normal positive Pulp vitality test show normal positive response.response.

3.3. Radiographic examination show no Radiographic examination show no signs of periapical inflammation signs of periapical inflammation

Success of vital pulp Success of vital pulp therapytherapy

1.1. Removal of noxious stimulus.Removal of noxious stimulus.

2.2. Stimulation of specific Stimulation of specific dentinogenic response dentinogenic response

3.3. Prevention of future Prevention of future microleakage, and dentin-pulp microleakage, and dentin-pulp complex damage.complex damage.

4.4. Type of exposure either Type of exposure either traumatic or pathologic.traumatic or pathologic.

Treatment alternativesTreatment alternatives

1.1.Pulp Pulp cappingcappingIndirect Indirect

directdirect

22. . PlupotomyPlupotomy

How to decide which How to decide which procedure is neededprocedure is needed??

Procedure selection dep. onProcedure selection dep. on::11--Tooth is primary or permanentTooth is primary or permanent..

22--Tooth is mature or immatureTooth is mature or immature..33--Pulp is vital or notPulp is vital or not..

44--Bleeding controlBleeding control..55--Exposure is traumatic or pathologicExposure is traumatic or pathologic..

66--Size of expSize of exp..77--Prescence of aseptic conditions. (rubber Prescence of aseptic conditions. (rubber

dam)dam)88--Involvment of tooth in complex restorationInvolvment of tooth in complex restoration

Pulp cappingPulp capping

A procedure in which an exposed A procedure in which an exposed or nearly exposed pulp is or nearly exposed pulp is covered with a protective covered with a protective

dressing that protects it from dressing that protects it from additional injury and permits additional injury and permits

healing and repairhealing and repair

Pulp capping

Direct Indirect

Indirect pulp cappingIndirect pulp capping

A mean of protecting an injured pulp.A mean of protecting an injured pulp.

Materials used in pulp Materials used in pulp cappingcapping

11--calcium hydroxidecalcium hydroxide

A-UsageA-Usage::

In both direct and indirect pulp In both direct and indirect pulp cappingcapping

B-Effect on pulpB-Effect on pulp::

--necrosis of adjacent pulp tissuenecrosis of adjacent pulp tissue

--stimulate dentin bridge formationstimulate dentin bridge formation..

--Mechanism of actionMechanism of action

Experiments carried with radioactive Experiments carried with radioactive calcium show that calcium ions used calcium show that calcium ions used for dentin bridge formation come for dentin bridge formation come from blood and not from CAHfrom blood and not from CAH. .

It was suggested that its actionIt was suggested that its action

A-alkaline ph 12A-alkaline ph 12

B-low grade irritation to pulpB-low grade irritation to pulp..

DisadvantagesDisadvantages

11--complet Canal calcificationcomplet Canal calcification..

22--Int resorptionInt resorption..

33--Deficient physical properties might Deficient physical properties might lead to microleakagelead to microleakage

44--Resulted dentin bridge is thought to Resulted dentin bridge is thought to be incompletebe incomplete..

22--ZNO-EZNO-E::

--Its usage is controversialIts usage is controversial..

No dentin bridge is formedNo dentin bridge is formed..

Pulp tissue adjacent to it show mass of Pulp tissue adjacent to it show mass of red blood cells and PMNL, with red blood cells and PMNL, with underlying tissue show zone of underlying tissue show zone of fibrosis and infl. cellsfibrosis and infl. cells..

33--ANTIBIOTICSANTIBIOTICS

Eliminate infectionEliminate infection

44--CORTICOSTEROIDESCORTICOSTEROIDES

Decrease inflamnDecrease inflamn..

55--Isobutyl cyanoacrylateIsobutyl cyanoacrylate::

Hemostatic, bacteriostaticHemostatic, bacteriostatic..

66--Tricalcium phosphateTricalcium phosphate::

Show dentin bridge formationShow dentin bridge formation..

77--adhesive resinsadhesive resins::

Are recently used for direct pulp capping due to it Are recently used for direct pulp capping due to it Provide better seal than CAHProvide better seal than CAH..

88--MTA(mineral trioxide MTA(mineral trioxide aggregate)aggregate)::

It is a biocompatible material used in It is a biocompatible material used in direct pulp cappingdirect pulp capping..

It was detected to induce dentin bridge It was detected to induce dentin bridge formation…so is recommended in formation…so is recommended in DIRECT pulp capping procedure and DIRECT pulp capping procedure and many other usagesmany other usages..

Mechanism of action of Mechanism of action of MTAMTA::

MTA act by up-regulation of MTA act by up-regulation of bone bone morphogenicmorphogenic proteinprotein which is which is responsible for bone, collagen responsible for bone, collagen formation and help pulp cells to formation and help pulp cells to differentiate into odontoblasts.differentiate into odontoblasts.

Clinical case showing dentin Clinical case showing dentin bridge formation in direct pulp bridge formation in direct pulp

capping using MTAcapping using MTA::

ProcedureProcedure::

11--diag,anaesth.,isoln(RUBBER DAM)diag,anaesth.,isoln(RUBBER DAM)..22--all caries removed, except in case of all caries removed, except in case of

ind. pulp cappingind. pulp capping..33--swab cavity with antiseptic agentswab cavity with antiseptic agent..

44--apply CAH over cavity floor in case of apply CAH over cavity floor in case of ind.pcind.pcAnd over pulp in case of direct pcAnd over pulp in case of direct pc..

55--cover CAH with ZNO-Ecover CAH with ZNO-E66--seal cavity with permanent seal cavity with permanent

restorationrestoration . .77--follow up the casefollow up the case..

Success of pulp capping Success of pulp capping depends ondepends on::11--size of expsize of exp..

In case of direct pulp capping…not more In case of direct pulp capping…not more than 1mmthan 1mm..

22--type of exptype of exp..Traumatic not pathologicTraumatic not pathologic

33--bleeding controlledbleeding controlled..Note.. it was discov. That pulpal Note.. it was discov. That pulpal contamination by oral env. for 24 hrs contamination by oral env. for 24 hrs has little or no effect on pulpal and hard has little or no effect on pulpal and hard tissue contaminationtissue contamination..

How to judge success of How to judge success of pulp cappingpulp capping??

1.1. tooth has vital pulp and dentin tooth has vital pulp and dentin bridge formation within 75 to 90 bridge formation within 75 to 90 days.days.

2.2. absence of pain.absence of pain.

3.3. absence of any signs of pulpal or absence of any signs of pulpal or periapical lesions.periapical lesions.

4.4. completion of root dev. (in case of completion of root dev. (in case of immat. teeth).immat. teeth).

Failure of pulp cappingFailure of pulp capping

Detected clinically in form ofDetected clinically in form of::11--continous paincontinous pain..

22--abscess formationabscess formation..33--periapical radiolucency can be detected in RGperiapical radiolucency can be detected in RG..

44--internal resorption can be detected in RGinternal resorption can be detected in RG..CausesCauses::

11--non-sterile procedure (absc. of rubber dam)non-sterile procedure (absc. of rubber dam)..22--bacterial microinfilterationbacterial microinfilteration..

This is due toThis is due to::11--contam.of pulp prior to or during cav.preprncontam.of pulp prior to or during cav.preprn..

22--improper seal of cavityimproper seal of cavity..33--improper case selectionimproper case selection..

PulpotomyDefinition:

The surgical amputation of the coronal portion of an exposed vital pulp, usually as a mean of preserving the vitality of the remaining radicular portion.

Indication:

1. Immature teeth with exposed pulp.

2. Primary teeth.

3. Emergency treatment in posterior teeth.

Contraindication:

1. Tenderness to percussion or palpation.

2. Swelling or fistula.

3. Mobility.

4.Non-restorable teeth.

5.Prefuse hemorrhage.

6.Necrotic pulp.

7.Spontaneous pain.

Materials used:1.Calcium hydroxide:

(The most common dressing used)

1-it is anti bacterial

2-high ph 12.5 which cause liquefaction necrosis in super facial layer.

3 -cause coagulative necrosis at junction of necrotic and vital tissue cause mild irritation to the pulp.

4-mild irritation lead to inf response in absence of bacteria will heal with a hard tissue barrier

disadvantageNot seal fractured surface )an additional material must be used to ensure complete sealing of pulp.

Formocresol.

• composition1-cresol 35%

2-formalin 19%

3-in aquous glycerin

• formocresol Toxicity. There is possible spread to distant sites )it is found that 5 minutes

exposure of pulpal tissue to FC result in systemic absorption of about 1% of the dose

Plus: its allergenicity, carcinogenicity and mutagenicity

Actions:

)Three zones in radicular pulp (

1. Fixation zone

2. Coagulation necrosis

3. Vital tissue

1. Remove the roof of the pulp chamber

2. Remove the coronal portion of vital pulp

3. Control hemorrhage

4.Place a cotton pellet dampened with formocresol for five minutes

steps

2. Pulpotomy in young permanent )apexogenesis(:

Diagnosisa. Clinical diagnosis:

• No abscess, no fistula• No mobility

• Large carious

• Mechanical or traumatic exposureb. Radiographic diagnosis:

• incomplete root development

• pulp exposure

• normal bone structure

• no internal or external root resorption

procedure for Ca)OH(2pulpotomy:

1. Anesthesia

2. Rubber dam application

3. Caries removal & access preparation

4. Amputation of the coronal pulp tissue

using sharp spoon excavator or large

diamond stone

6. Hemorrhage control either by saline or NaOCl

7. A layer of Ca)OH(2 preparation is placed against

the amputated pulp stump

8. Mix of ZnOE over Ca)OH(2

9. All cavity sealed with filling material

5. Pulp champer is flushed with sterile water or saline

Prognosis : •Patient recalled at 1& 3 & 6 months intervals for radiographic examination

a. Successful cases:

1. x-ray shows complete root formation & calcific barrier

2. no pain or swelling

3. pulp retain its vitality

b.Unsuccessful cases:1.failure of root development

2. pain & swelling

3. radiographic radiolucency

Prognosis of pulpotomy:Prognosis of pulpotomy:

1- Size of the exposure1- Size of the exposure

2-Exposure to saliva2-Exposure to saliva 3- Microleakage3- Microleakage

4- Systemic factors4- Systemic factors

• If all trails are failed to retain pulp vitality

What is the solution???

• Endodontic mangement of immature non vital teeth

1-conventional ttt 2-surgical ttt

Surgical method

Apical resection )apicectomy (•Def : is the cutting of apical part of the root after root canal is cleaned ,shaped & obturated

•as the greatest width of the canal is at the apex so no way to clean &seal the canal successfully at apex with any thing except anapical approach

Disadvantages

1-aggressive technique

2-the root is left with thin dentinal wall

& unfavorable crown \root ratio

Conventional ttt

1-barrier technique & immediate obturation.

In which amaterial is packed into the apical 2 -4 mm of blunder buss canal to act as abarrier against which gutta percha is condensed

•Material used1-tri calcium phosphate

Athick mix is made &packed into the apical 2 mm of the canal against which gutta percha is condensed in one visit with help of radiographs

2-dentin chips

3-collagen&hydroxy appatite gel

4-MTA

M T A & abarrier techniqueM T A & abarrier techniqueProcedure.

1-root canal is cleaned & shaped.

2-medicated with Ca)OH(2 for 1 week.

3 -on reentry into the canal it irrigate with NaOCl then dried.

4-aplug of MTA is packed into the apical end.

5 -moist cotton pellet is inserted against MTA.& access is sealed for 4-6 hrs.

6 -then canal is obturated.

2 -apexificationDef: induction of apical closure of an immature tooth in which pulp is non vital.

Materials used.

1-calcium hydroxide

2-calcium hydroxide. & camphorated mono chloro phenol.

3-MTA

Diagnosis

clinical Radiographic

•Is complicated because of the normal radiolucency present at the apex as the root develop

1. History )as trauma is the most common cause of pulp necrosis

2. Pulp vitality tests not provide reliable information due to open apex

3. Presence of pain with percussion, mobility or discoloration of crown are indication of pulp necrosis

Procedure for apexification

Ca)OH(2

First appointment

2-access preparation &tooth length determination.

3-thorough cl&sh with irrigation using naocl or saline.

4-root canal is dried with sterile paper point &partially medicated withCMCP.

5 -the cavity is sealed with temporary cement.

1-tooth isolation rubber dam application.

1-tooth isolation &removal of temporary dressing.

2-thorough irrigation of the root canal &proper dryness.

3-place thick mix of Ca)OH(2 &CMCP as apical as possible inside

root canal

4-place sterile cotton pellet in the pulp chamber & seal the

access cavity& final restoration.

5-follow up the case where the pt should be recalled after 6

months for radiographic examination.

•Second appointment )1-2 week later(

Prognosis:

•Time needed for apexification is about 6 to 24 months.

•Factors may lead to increase the time :

1. Presence of radiolucent lesion

2. Interappointment symptoms

3. lose of external seal with reinfection of the canal

•Radiographic examination of the apexified tooth may be:

1.Apical closure with closure of canal

2. Apical closure without change in the canal space

3. No radiographic change is present but clinically a definite apical stop can be probed at the apex

4.Radiographic evidence of a calcified material at or near the apex

5. No radiographic change with evidence of periapical pathosis

•Histology of apexification with Ca)OH(2:

the calcified material that form over the apical foramen has been histologically identified as an osteoid )bone like( or cementoid )cementum like( material.