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
Apexogenisis
Necrotic pulp
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.
