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.