- NEED HELP? CALL US NOW
- +919995411505
- [email protected]
PULP THERAPY
General features
- Coronal pulp
- Radicular pulp
- Apical foramen
- Accessory canals
Objectives of pulp therapy
- Preservation of the arch space
- Enhancement of esthetics and mastication,
- prevention of aberrant tongue habits, aid in speech
- prevent psychological effects associated with tooth loss.
- Help maintain healthy oral environment,
- provide relief of pain,
- contribute to the development and maturation of the child, growth of facial skeleton complex and development of the dental complex to its fullest potential.
- Prevention of the deleterious effects on the succedaneous tooth, the periapical tissue and on the systemic health of the child.
Classification
- Direct pulp therapy
- In direct pulp therapy
Indirect pulp capping
Definition (Ingle)
“A procedure where in a small amount of carious dentin is retained in deep areas of the cavity to avoid exposure of the pulp, followed by the placement of a suitable medicament and restorative material that seals off the carious dentin and encourages pulp recovery.”
Rationale
- The carious dentine consists of two distinct layers-
- An outer layer that is irreversibly denatured, infected and non-mineralizable [ should be removed]
- An inner layer that is reversibly denatured, not infected, re-mineralizible [could be retained]
Objectives of Pulp Capping Eidelman (1965)
- Arrest the carious process
- Promote dentinal sclerosis
- Stimulate the formation of tertiary dentin
- Remineralize the carious dentin
INDICATIONS
History
- Mild discomfort from chemical & thermal stimuli
- Negative h/o spontaneous pain
O/E
- Positive pulp sensitivity test
- Negative TOP
- Large carious lesion
- Absence of lymphadenopath
- Normal color of gingiva & tooth
R/F
- Large carious lesion in close proximity of the pulp
- Normal lamina dura & PDL space
- No interradicular or periradicular radiolucency
CONTRAINDICATIONS
History
- Sharp penetrating pain that persists after withdarwing stimulus
- Prolonged spontaneous pain, particularly at night
O/E
- Excessive tooth mobility
- Discolored
- Nonresponsiveness to pulp testing techniques
R/F
- Large carious lesion with apparent pulp exposure
- Widened PDL space & interrupted or broken lamina dura
- Radiolucency at the root apices or furcation areas
PROCEDURE
1st Appointment
- Two sitting caries exavation is recommended using slow speed hand piece # 6 or # 8 round burs
- Peripheral dentin is removed with sharp spoon exacavator
- The cavity is flushed and dried with cotton pellet
- Exposure site is covered with hard set calcium hydroxide prep and sealed with overlying reinforced ZOE prep
- Patient recalled after 6-8 weeks
2nd Appointment
- Between two appointment, history must be negative and intermediary restoration must be intact
- After clinical and radiological(bitewing) 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
- Hard setting calcium hydroxide is placed followed final restoration
Materials used for indirect pulp capping
Calcium hydroxide
- Pulpdent :Calcium hydroxide suspended in aqueous methyl cellulose solution
- Dycal:
- Base - titanium dioxide in a glycol salicylate with a pigment
- Catalyst - calcium hydroxide and zinc oxide
- Hydrex (MPC): - Calcium hydroxide, barium sulfate, titanium dioxide and a selected resin
ZnOE
- Formation of chelate matrix zinc eugenolate
- Near neutral pH/ good sealing properties
- Reinforced ZOE ( Fynal/ IRM)
Dentin bonding agents
Some Newer Materials
- Bioactive molecules
- Enamel Matrix Protein (Emdogain)
- TGF-Beta (Transforming Growth Factor-Beta)
Success of indirect pulp capping
- > 90% in primary teeth in which a preoperative diagnosis suggests that there is no pulp degeneration.
Controversies
- Indirect pulp capping vs vital pulpotomy
- Vital pulpotomy à 90%
- Use of indirect pulp capping leads to pulp death in many cases
- Non vital pulpotomy has a lower success
Direct pulp capping
Definition (kopel 1992)
The placement of a medicament or a non-medicated material on a pulp that has been exposed in course of excavating the last portions of deep dentinal caries or as a result of trauma.
Objective
- To create new dentin in the area of exposure and subsequently healing of the pulp
- To achieve a biological closure of the exposure site by deposition of hard tissue barrier (dentine bridge) between pulp tissue and capping material thus walling off the exposure site
Indications
- Small mechanical exposures surrounded by sound dentin in asymptomatic vital primary teeth in a sterile field
- Exposure should have bright red hemorrhage that is easily controlled by dry cotton pellet with minimal pressure
- Direct pulp capping of a carious pulp exposure is not indicated in primary tooth, but can be used with success on an immature young permanent tooth.
Contraindications
- Severe tooth ache at night
- Spontaneous pain
- Tooth mobility
- Radiographic appearance of pulp, peri-radicular degeneration
- Excess of hemorrhage at the time of exposure
- Serous exudate from the site of exposure
- External/internal resorption
- Swelling /fistula
Treatment considerations
- Debridement: Necrotic and infected dentin chips have to be removed.
- They may be pushed into the exposed pulp during the last stages of caries removal and may affect pulpal healing
- Hemorrhage and clotting: A blood clot should not be allowed to form at the exposure site as it may impede pulpal healing
PROCEDURE
Histological changes illustrated by Glass and Sander
After 24 hrs, the necrotic zone adjacent to Ca(OH)2 ( alkaline pH) paste is separated from healthy pulp by a deep staining basophilic layer (calcium proteinate)
After 7 days: Increase in cellular and fibroblastic activity
After 2-3 weeks: Partly calcified fibrous tissue lined by odontoblastic cells is seen
below the calcium proteinate zone.
Disappearance of the necrotic zone
below the calcium proteinate zone.
Disappearance of the necrotic zone
After 4-5 weeks: Zone of new dentine
After 8 weeks
Medications used
Ca(OH)2
-reparative dentine bridge.
Alkalinity -- activation of enzyme phosphatase
- releases inorganic phosphates from blood (calcium phosphate)
- formation of dentine bridge
ZOE is not used in direct contact with the pulp à chronic inflammation
- Sveen reported 87% success capping primary teeth with ZOEà no histological evidence (1969)
Cortico-steroids and antibiotics
- Brosch-1966
- Neomycin and hydrocortisone
- Ledermix (Ca(OH)2 and prednisolone)
- Penicilin/vancomycin and Ca(OH)2
Inert materials
- Isobutyl cyanoacrylate
- Tri-calcium phosphate ceramic
Collagen fibers
- Influence mineralization
- Less irritant than Ca(OH)2
- Dentine bridge formation in 8 weeks
Direct bonding
- A polygenic film can be layered over an exposure site without displacing the pulp tissue
- And on to the surrounding dentine where it penetrates the dentin tubules
- The adhesive resin is light cured and composite resin is gently placed.
- Hybridization
Isobutyl cyanoacrylate
- Hemostatic
- Forms dentine bridge
- Cytotoxic when freshly polymerized
Denatured albumin
- This protein has calcium binding properties
- Becomes a part of the matrix of calcification and hence increases the chances of biological obliteration
MTA
- Physical and chemical properties were described by Torabinejab in 1995
- Biocompatible and its sealing ability is better than amalgam or ZOE
- Has the ability to stimulate cytokine and interleukin release from the bone cells, indicating that it actively promotes hard tissue formation
Laser
- Andreas Meritz in 1998 evaluated the effect of laser on direct pulp capping and reported a success rate of 89%
Bone Morphogenic Protein
- Urist 1965
- Observed that demineralized bone matrix could stimulate new bone formation when implanted to ectopic sites such as muscles
- Demineralized dentin also has the same inductive properties and it forms both bone and dentin
- Implications for pulp therapy are immense and it is capable of inducing reparative dentin.
Propolis
- Sabir et al (2005)
- Delay pulpal inflammation
- Stimulate reparative dentine formation
Limitations of direct pulp capping in primary teeth
- Internal resorption:
- Caries process or the pulp capping material may stimulate the undifferentiated mesenchymal cells to differentiate into odontoclastic cellsà INTERNAL RESORPTION
- High cellular content, abundant blood supplyà faster inflammatory response and poor localization of infection
PULPOTOMY
Finn 1995
Defined pulpotomy as the complete removal of the coronal portion of the dental pulp, followed by the placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth.
Rationale
- Radicular pulp is healthy and capable of healing after surgical amputation of the infected pulp.
- Preserves vitality of the radicular pulp
- Removes the infected or inflamed pulp
- Maintains tooth in a physiologic condition.
Indications
- Pulp exposure in primary teeth
- Teeth showing a large carious lesion but free of radicular pulpitis
- Hemorrhage from exposure site bright red and can be controlled.
- Absence of abscess or fistula
- No inter-radicular bone loss
- No inter radicular radiolucency
- At least, 2/3rd of root length present to ensure reasonable functional life.
- In young permanent tooth with vital exposed pulp and incompletely formed apex.
Contraindications
- Persistent tooth ache
- Tenderness on percussion
- Root resorption more than 1/3rd root length
- Large carious lesion with non-restorable crown
- Highly viscous sluggish hemorrhage from canal orifice which is uncontrollable.
- Medical contradictions like heart disease, immunocompromised patients.
- Swelling or fistula
- External or internal resorption
- Pathological mobility
- Calcification of the pulp
Formocresol Pulpotomy
- Formocresol was introduced by Buckley in 1904.
- Modifications -
- Sweet (1930) : Multi-visit technique
- Doyle (1962) : Advocated the 2 sitting procedure
- Spedding (1965) : Gave the 5 min protocol (partial devitalization)
- Venham (1967) : proposed the 15 sec procedure
- Current concept uses the 4 min of application time.
Composition of formocresol Buckley’s formula
- Cresol – 35 %
- Glycerol – 15 %
- Formaldehyde – 19 %
- Water - 31%
Preparation
- 1/5th concentration
- Diluent à 3 parts glycerin(90 ml) + 1 part distilled water
- 4 parts Diluent (120ml) +1 part Buckley’s formocresol (30 ml) = 150 ml formocresol of 1/5th strength
Mechanism of action
- Prevents tissue autolysis by bonding to proteins.
- This bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without changing the basic structure of the protein molecules.
Histological changes
- Demonstrated by Mass and Zibermann in 1933.
- and also by Massler and Mansokhani in 1959
- Immediately -
Pulp becomes fibrous and acidophilic
- 7-14 days
- 3 zones appear:
- A broad eosinophilic zone of fixation
- A broad pale- staining zone of atrophy with poor cellular definition
- A zone of inflammation extending apically into normal tissue
- 1 year
Progressive apical movement of these zones with only the acidophilic zone left at the end of 1year
Concerns about formocresol
Toxicity
- Formocresol and formaldehyde have shown to be cytotoxic, mutagenic and carcinogenic in animal experiments by Lewis in 1981
- Ranley calculated that over 3000 pulpotomies must be performed in the same individual for formocresol to reach toxic level.
- Mayers in 1978 demonstrated the distribution of the radio-isotope labeled formaldehyde.
- Antigenicity
- Mutagenicity
OTHER TYPES OF PULPOTOMY
- Glutaraldehyde Pulpotomy
- Ferric Sulfate Pulpotomy
- Mineral Trioxide Aggregate Pulpotomy
- Electrosurgical Pulpotomy
- Laser Pulpotomy
Pulpectomy
Finn defines pulpectomy as the removal of the pulp tissue from the coronal and radicular portions of the tooth.
Indications
- irreversible pulpitis
- pulpal necrosis
- hyperemic pulp – Persistent bleeding during a pulpotomy procedur
- Evidence of furcation involvement by radiograph • Spontaneous pain – child awake
- Swelling
- Pulp senistivity tests: little benefit in children- uncoperative
- False positive facebook.com/notesdental
Contraindications
- An unrestorable tooth
- Internal resorption in the roots visible on radiographs
- Teeth with mechanical or carious perforations of the floor of the pulp chamber
- Excessive pathologic root resorption involving more than a third of the root
- Excessive pathologic loss of bone support with loss of the normal periodontal attachment
- Presence of a dentigerous or follicular cyst
- Periapical or interradicular lesion involving the crypt of the developing permanent successor
Procedure
Classification of root canal instruments
- Exploring:
- To locate the canal orifice and to determine or assist in obtaining the patency of the canal (e.g. smooth broach and endodontic explorer)
- Debridement:
- To extirpate the pulp and remove the debris (E.g. Barbed Broaches)
- Shaping:
- To reshape the root canal laterally and apically ( e.g. reamers and files)
- H files, K files, safety H files, Ni Ti RC files
- Obturating:
- To pack the root canals with material (e.g. pluggers, spreaders and lentulo-spirals)
Irrigation
- 3% hydrogen peroxide
- 5.2 % sod.hypochlorite
- RC prep
Obturation material
- The ideal root canal filling material for primary teeth should: –
- Resorb at a similar rate as the primary root.
- Be harmless to the periapical tissues and the permanent tooth germ.
Resorb readily if pressed beyond the apex.
- Be antiseptic.
- Fill the root canals easily.
- Adhere to the walls of the root canal not shrink.
- Be easily removed if necessary
- Be radiopaque.
- not discolor the tooth
- ZOE paste, Iodoform paste, and Ca(OH)2
APEXIFICATION
- Root-end closure
- process whereby a non-vital, immature, permanent tooth which has lost the capacity for further root development is induced to form a calcified barrier at the root terminus
- Matrix against which root canal filling or restorative material can be compacted
- Treatment of last resort in immature teeth which have lost pulp vitality
Materials
- Calcium hydroxide – most commonly used – Mixed either with CMPCP, saline, ringer solution, distilled water or anesthetic solution
- Zinc Oxide paste
- Antibiotic paste
- Tricalcium paste
- Collagen – phosphate gel
- Mineral trioxide Aggregate
MCQs
1.A tooth that has been treated successfully with a pulpotomy technique should have after 1 year
a. A normal pdl and lamina durab. Radiographic evidence of a calcified bridge if calcium hydroxide had been used as a capping material
c. No radiographic evidence of internal resorption
d. All of the above
Ans. d
All of the above mentioned factor are true regarding success of a pulpotomized tooth.
2.A patient aged 7 years complaints of severe toothache at night in relation to 75. The mode of treatment probably will be;
a. Pulpotomyb. Pulpectomy
c. Direct pulp capping
d. Indirect pulp capping
Ans.b
Nocturnal pain indicated irreversible pulpitis. Hence the treatment options can be pulpectomy or extraction. The nocturnal paim associated with the tooth increases at night because of the patient’s posture which increased the bloodflow to the head and neck. This in turn increases the intrapulpal pressure which results in severe toothache.
3.The most successful treatment for a vital primary second molar with a large carious and pulpal exposure is;
a. Indirect pulp treatmentb. Pulpotomy with formocresol
c. Pulpotomy with calcium hydroxide
d. Pulp capping with calcium hydroxide
Answer. b Option ‘D’ direct pulp capping and option ‘C’ calcium hydroxide pulpotomy are contraindicated in primary teeth as they cause internal resorption.
