بسم الله الرحمن الرحيم
Vital Pulp therapy
Assist prof. Dr. Emad Alkhalidi PhD conservative dentistry
Vital pulp therapy is defined as treatment initiated to preserve and maintain pulp tissue in a healthy state, tissue that has been compromised by caries, trauma, or restorative procedures.
The objective is to stimulate the formation of reparative dentin to retain the tooth as a functional unit. This is particularly important in the young adult tooth, where apical root development may be incomplete. The focus is directed toward the preservation of the pulpally involved permanent tooth, based on the premise that pulp tissue has an innate capacity for repair in the absence of microbial contamination.
young adult tooth
1- Vital pulp therapy–Indirect pulp capping (IPC)–Direct Pulp Caping(DPC)–Pulpotomy–Apexogenesis2-Non-vital therapy–Apexofication–SCAP (stem cell of apical papilla). Classification of pulp therapyPulp Capping
Two types of pulp capping based on remaining dentin thickness (RDT): a) Indirect pulp capping. b) Direct Pulp capping.Indirect Pulp Capping
•a procedure in which a material is placed on a thin partition of remaining carious dentin that, if removed, might expose the pulp.•deep carious lesions where caries excavation was conservative and direct pulp exposures were avoided.•either Ca(OH)2 or MTA is used either in a one-or two-stage procedure.
objective
•Removal of infected dentin (dimineralized and invaded by bacteria)•Disinfection of residual affected dentin (dimineralized dentin not yet invaded by bacteria).•Sealing by restorative material causes removal of substrate on which bacteria act.•Arrest of carious process causes activation of reparative mechanism to lay additional dentin and avoid pulp exposure.INDICATIONS
History•Mild discomfort from chemical & thermal stimuli.•Negative spontaneous pain.Oral finding•Positive pulp sensitivity test.•Absence of lymph adenopath.•Normal color of gingiva & tooth.Radiographical finding•Large carious lesion in close proximity of the pulp .•Normal lamina dura & PDL space.•No inter radicular or peri radicular radiolucency.CONTRAINDICATIONS
History•Sharp penetrating pain that persists after with drawing the stimulus•Prolonged spontaneous pain ,particularly at night. O/F•Excessive tooth mobility•Discolored•No response to pulp testing techniquesR/F•Large carious lesion with apparent pulp exposure. •Widened PDL space & interrupted or broken lamina duraa•Radiolucency at the root apices or furcation areasClinical Procedure
1stAppointmentThe tooth is anesthetized and isolated with the rubber dam, All the caries except that immediately over the pulp is removed(use large round bur at low speed) # 6 or # 8 round burs.•The cavity is flushed and dried with cotton pellet.•the deep area is covered with calcium hydroxide and sealed with glass ionomer cement.•Patient recalled after 6-8 weeks.Clinical Procedure
2ndAppointment•Between two appointment, history of pain must be negative and intermediary restoration must be intact.(why)?•After clinical and radio graphical examination, all the restorative material is removed.•There must be change of color and hardness of affected dentin from deep brownish red and soft to lighter brownish grey color and harder.•The preparation is cleaned and dried.•calcium hydroxide is placed followed final restoration.Direct Pulp Capping
•treatment of an exposed vital pulp by sealing the pulpal wound with a dental material placed directly on a mechanical or traumatic exposure to facilitate the formation of reparative dentin and maintenance of the vital pulp.Indication
•Iatrogenic mechanical exposure –asymptomatic vital tooth with sound dentin.•Small carious exposure asymptomatic permanent tooth with incomplete root formation.•radiographically there should be no thickening of PDL space and evidence of periradicular lesion.
Contraindication
•Carious exposure of primary tooth.•Large carious exposure in symptomatic permanent teeth Sever Tooth ache at night.•Spontaneous pain.•Excessive tooth mobility.•Thickening of PDL space.•Radiographic evidence of periradicular degeneration.•Excessive hemorrhage.•Purulent or serous exudate from the exposure site.Factors affecting prognosis
–Area and size of exposure–Microleakage–Carious v/s mechanical exposure : mechanical has better prognosis. (why)–Time of exposure–Bacterial contamination–Treatment PlanFactors associated with mechanical pulp exposure
•Heat : in deep cavity the pulp may injure from heat generated from cutting.•Pressure: pulp damage directly proportional to pressure exerted by bur or instrumentation.•Damage to pulp.•Hemorrhage.•Intrusion of dentin chip.Criteria essential for a successful direct pulp cap.
No recurring or spontaneous pain. No swelling.1-History
2-Preoperative assessment
•Normal vitality tests.•Not tender to percussion.•No swelling.•No radiographic evidence of periradicular pathology.•Young patient.•Radiographically obvious pulp chamber and root canal.3-Clinical findings.
•Pink pulp•Bleed if touched but not excessively.Pulp capping agent
•CaOH, MTA , dia root bioaggregate, and biodentine.•Ideal properties of pulp capping agent:–Maintain pulp vitality–Stimulate reparative dentin formation–Bacteriocidal and bacteriostatic, ability to provide bacterial seal–Adhere well to dentin and restorative material–Resist force under restoration–Radiopaque and sterile
Technique of Direct pulp capping
•Excavation of caries is done with # 2 carbide round bur and spoon excavator.•In case of bleeding, hemostasis is achieved with cotton pellet dipped in 3-6% NaOCl for 1-10 min. –If bleeding doesn’t stops then other invasive procedure is performed (ferric sulfate material is used.)•After control of Bleeding, pulp capping agent is applied followed by GIC.Calcium hydroxide
•Introduced by Hermann in 1930 as a pulp capping agent.•Used as:–Aqueous suspension of calcium hydroxide–Commercial products:•Dycal [Caulk/Dentsply]•Prisma VLC Dycal [Caulk/Dentsply]•Life [SybronEndo/ Kerr]•Acts by:–Forming protective barrier for pulp tissue –Blocking patent dentinal tubules –Neutralizing the attack of inorganic acids& their leached products–Stimulates formation of –reparative dentin–Reduction in number of microorganisms remaining in the dentin. –Stimulates remineralization of demineralized dentinal tubules.
Healing with Ca(OH)2•Zone of obliteration–caustic effect causes derangement of contacting pulpal tissue. –This zone consist of debris, dentinal fragments, blood clots, blood pigments and particles of calcium hydroxide.•Zone of Coagulation necrosis–chemical thrust of CaOH causes necrosis of plasma protein and thrombosis –Also known as Schroder layer of firm necrosis or Stanley’s mummified zone–0.3-0.7 mm thickness•Zone of Demarcation–a line develops between deepest zone of coagulation necrosis and subjacent vital pulp.
Reparative dentinogenesis
The tissue reactions of the pulp to pulp capping with calcium hydroxide in a teeth as four stages: the exudative stage (1–5 days), the proliferative stage (3–7 days), osteodentin formative stage (5–14days), and the tubular dentin formative stage (14 days and more).Recal and Prognosis
3-4w, 3-6m, 12m, every year. 80% Depend on the ability to disinfect the superficial pulp and to necrosis the superficial inflamed pulp.Problem with calcium hydroxide
Tunnel defects. tend to soften, disintegrate and dissolve over time. voids and other potential pathways for bacterial.Mineral trioxide aggregate•Composed of–Tricalciumsilicate–Dicalciumsilicate–Tricalciumaluminate–Tetracalciumaluminoferrite–Bismuth oxide
•Exhibits many favorable characteristics which make it a superior material when used as a direct pulp capping material in adult teeth.
Advantages of Mineral trioxide aggregate:–Sets in the presence of blood and moisture.–Superior marginal adaptation –Non absorbable-High alkalinity and sustained pH at 12.5.–Responsible for preventing microbial growth.–Extracts growth factors from adjacent dentin-Small particle size-Slow release of calcium ions-Promotes hard tissue formation-Osteoinductive, osteoconductive.
pulpatomy
Partial pulpotomyThe procedure in which the inflamed pulp tissue beneath an exposure is removed to a depth of 1-3mm to reach the deeper healthy pulp tissue The phrase 'partial pulpotomy' or 'Cvek pulpotomy' describes removal of inflamed pulp tissue to the level of healthy coronal pulp. The rationale for the Cvek pulpotomy is this: if the inflamed tissue is removed, the healthy underlying tissue is more likely to remain healthy and to seal the exposure with hard tissue bridging of the exposure site. Of course, the other requirements for successful pulp capping, such as hemostasis and a bacteria-tight seal, are met.
Pulpotomies have been used routinely in treatment of primary and young permanent teeth after traumatic pulp exposures, but their use in mature permanent teeth is a relatively new concept, and is considered unproven for carious exposures.
Indications
Indications for a partial pulpotomy are similar to those for direct pulp capping. As with simple direct pulp capping, an immature permanent tooth or a mature permanent tooth with uncomplicated restorative needs is preferable. The partial pulpotomy should be selected as an alternative to direct pulp capping when the extent of pulpal inflammation is expected to be greater than normal.Technique
RecallSchedule follow-up examinations, using the time intervals and procedures described for pulp capping.