Recent concepts in vital pulp therapy Dr. Sarjeev Singh Yadav
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    Recent concepts in vital pulp therapy Dr. Sarjeev Singh Yadav Recent concepts in vital pulp therapy Dr. Sarjeev Singh Yadav Presentation Transcript

    • Recent Concepts in Vital pulp therapy6/17/2013 1YES YES WHY
    • Dr. Sarjeev Singh YadavProfessor & HODDept. of Conservative dentistry and EndodonticsGovt. Dental College and Hospital6/17/2013 2YES YES WHY
    • Greatest challenges to the integrityof the developing tooth6/17/2013 3YES YES WHY
    • Abnormal root developmentImpact on long-term prognosis fortooth retention6/17/2013 4YES YES WHY
    • Primary goalMaintain pulp vitalityNormal tooth development occursPromotes healing by regeneration ratherthan repair6/17/2013 5YES YES WHY
    • The Pulp-Dentin Complex in Primary andYoung Permanent TeethDeep dentin is more porous than superficial dentin.Normally in primary and young permanent teeth, thedentin is thinner and more porous than in their maturepermanent counterparts.The pulps of primary and immature permanent teeth areat special risk from deep carious lesions, deep cavities,and traumatic injuries.Key Points of Clinical Relevance:6/17/2013 6YES YES WHY
    • Superficial dentinDeep dentin6/17/2013 7YES YES WHY
    • Sensory innervations to the pulp does not mature untilthe late stages of root formation; pulp testing maytherefore be inconclusive in immature teeth.Young, well-perfused pulps have enormous reparativecapacity in the face of injury.The Pulp-Dentin Complex in Primary andYoung Permanent Teeth6/17/2013 8YES YES WHY
    • Key responses of the dentin-pulp to caries / injuryTertiary dentin6/17/2013 9YES YES WHY
    • Reactionary dentinogenesisCariesOdontoblastsDentinTertiary, reactionary dentin laiddown by primary odontoblastsas they retreat from injury6/17/2013 10YES YES WHY
    • Reparative dentinogenesisTertiary,reparative dentinDeep dentin injury killsprimary odontoblasts andstimulates recruitment ofreplacements fromthe cell-rich layerNewodontoblast-likecells migrate tothe wound6/17/2013 11YES YES WHY
    • 6/17/2013 12YES YES WHY
    • 6/17/2013 13YES YES WHY
    • • A correct diagnosis of pulp conditions in primary andyoung permanent teeth is important for treatmentplanning.• McDonald and Avery have outlined several diagnosticaids in selecting teeth for vital pulp therapy.• Eidelman et al and Prophet and Miller haveemphasized that no single diagnostic means can be reliedon for determining a diagnosis of pulp conditions.• A suggested outline for determining the pulpal status ofcariously involved teeth in children involves the following:6/17/2013 14YES YES WHY
    • 1. Visual and tactile examination of carious dentin andassociated periodontium2. Radiographic examination ofa. periradicular and furcation areasb. pulp canalsc. periodontal spaced. developing succedaneous teeth3. History of spontaneous unprovoked pain4. Pain from percussion5. Pain from mastication6. Degree of mobility7. Palpation of surrounding soft tissues8. Size, appearance, and amount of hemorrhageassociated with pulp exposuresEndodontics : Ingle 5th edi6/17/2013 15YES YES WHY
    • Electric pulp tests are not valid in primary teeth.Andreasen et al. Textbook and color atlas of traumaticinjuries to the teeth. 4th ed, 2007Thermal tests are usually not conducted on primary teethbecause of their unreliability.Cohen S, Hargreaves K : 9th ed. 2006:822– 82.Numerous studies have reported the unreliability of electricpulp tests in permanent teeth with open and developingapices.J Dent Child 1978;45:199 –202.J Endod 1986;12:301–5.Aust Dent J 1977;22:272–9.6/17/2013 16YES YES WHY
    • Laser Doppler flowmetry might be of greater help indetermining vitality.Endod Dent Traumatol 1999;15:284 –90.Dent Traumatol 2001;17:63–70Endod Top 2003;5:12–25.6/17/2013 17YES YES WHY
    • - Type of injury- age of the pt- size & location of the pulp exposure- bacterial contamination- pulp capping material &- quality of the final restorationThe outcome of VPT depends on:6/17/2013 18YES YES WHY
    • 1. Indirect pulp capping2. Direct pulp capping3. Coronal pulpotomyVital pulp therapy for primary and youngpermanent teeth involves the following techniques:6/17/2013 19YES YES WHY
    • 6/17/2013 20YES YES WHY
    • • to arrest the carious process,• provide conditions conducive to the formation ofreactionary dentin, and• promote remineralization of the altered dentin that wasleft.• This in turn is expected to promote pulpal healing andpreserve/maintain the vitality of the pulp.Def: The application of a medicament over a thin layer ofremaining carious dentin, after deep excavation,with no exposure of the pulp.The aims of indirect pulp capping is:6/17/2013 21YES YES WHY
    • 1. Historya. Mild discomfort from chemical and thermal stimulib. Absence of spontaneous pain2. Clinical examinationa. Large carious lesionb. Absence of lymphadenopathyc. Normal appearance of adjacent gingivad. Normal colour of tooth3. Radiographic examinationa. Large carious lesion in close proximity to the pulpb. Normal lamina durac. Normal periodontal ligament spaced. No interradicular or periapical radiolucency6/17/2013 22YES YES WHY
    • 1. Historya. Sharp, penetrating pain persisting after withdrawingstimulusb. Prolonged spontaneous pain, particularly at night2. Clinical examinationa. Excessive tooth mobilityb. Parulis in the gingiva approximating the roots of the toothc. Tooth discolorationd. Non responsiveness to pulp testing techniques3. Radiographic examinationa. Large carious lesion with apparent pulp exposureb. Interrupted or broken lamina durac. Widened periodontal ligament spaced. Radiolucency at the root apices or furcation areas6/17/2013 23YES YES WHY
    • • Two appointment technique• One appointment technique6/17/2013 24YES YES WHY
    • Hard setting Ca(OH)2ZOEGIC (Glass ionomer caries control approach)Resin modified glass ionomerBonded compositeMTA6/17/2013 25YES YES WHY
    • • IPC studies show success rates of 90% or greater over timewith differing techniques and medicaments.J Endod Vol 34, No 7S, July 2008IPT medicaments Success(%)Time (mo) Sample(N)Nirschl and Avery1983Calcium hydroxide 94 6 33Al-Zayer et al.2003Calcium hydroxide 95 14(median)187Vij et al. 2004 Glass ionomer 94 40 108Farooqet al. 2000 Glass ionomer 93 50 556/17/2013 26YES YES WHY
    • • To manage lesions in primary molars (that are symptomfree and free from radiographic signs of periradicularpathology) by cementing a preformed metal (stainlesssteel) crown in place without local anaesthesia, toothpreparation, or any attempt at caries removal.Innes NP, Stirrups DR, Evans DJ, Hall N, Leggate M: A novel techniqueusing preformed metal crowns for managing carious primary molars ingeneral practice–a retrospective analysis. Br Dent J 200:451, 20066/17/2013 27YES YES WHY
    • • The Hall technique was preferred to conventionalrestorations by the majority of children, guardians, andclinicians.• After a review period of 2 years, comparing the teethmanaged using Hall preformed metal (stainless steel)crowns with conventional restorations, the “Hall crowns”showed better treatment outcomes for both pulpal healthand restoration longevity.Innes NP, Evans JP, Stirrups DR: The Hall technique; a randomizedcontrolled clinical trial of a novel method of managing carious primarymolars in general dental practice: acceptability of the technique andoutcomes at 23 months. BMC Oral Health 7:18, 2007.6/17/2013 28YES YES WHY
    • • The pulps of young permanent teeth are at risk ofbreakdown following traumatic injuries, dental caries, andrestorative dentistry.• There is good evidence that RDT is a key determinant ofpulp survival after cavity preparation, and avoiding pulpexposure has been considered advantageous.Int Endod J 41:389, 2008.• The management of deep caries by partial and serialexcavation has gained considerable support in recentyears, reducing the risks of pulp exposure and harnessingthe natural defences of the pulp in laying down protectivetertiary (reactionary) dentin.J Endod 34(7S):S29, 2008.In YOUNG PERMANENT TEETH..6/17/2013 29YES YES WHY
    • • Researchers continue to investigate the role of antimicrobialtreatments, including• ozone fumigation, Eur J Oral Sci 114:349, 2006• photo-activated disinfection (PAD), and• antimicrobial resins in sterilizing deep layers of affecteddentin and creating the conditions for arrest andremineralisation.Int Endod J 40:58, 2007.• Considerable interest has also focused on the activeupregulation of reactionary dentinogenesis by applyingbioactive agents such as the TGF-β family of molecules tothe depths of cavity preparations.Caries Res 38:314, 2004.6/17/2013 30YES YES WHY
    • 6/17/2013 31YES YES WHY
    • Def: Direct pulp capping involvesthe placement of a biocompatibleagent on healthy pulp tissue thathas been inadvertently exposedfrom caries excavation ortraumatic injury.Oral Surg 1972;34:477.Objective: is to seal the pulp against bacterial leakage,encourage the pulp to wall off the exposure site byinitiating a dentin bridge, and maintain the vitalityof the underlying pulp tissue regions.6/17/2013 32YES YES WHY
    • • Vital pulp therapy has a high success rate if thefollowing conditions are met:(1) The pulp is not inflamed;(2) Hemorrhage is properly controlled;(3) A non-toxic capping material is applied; and(4) The capping material and restoration seal outbacteria.6/17/2013 33YES YES WHY
    • 1. Small pin point mechanical exposures of diameter< 1.0mm2. Pulp exposed without previous symptoms of pulpitis.6/17/2013 34YES YES WHY
    • (1) Spontaneous and nocturnal toothaches.(2) Excessive tooth mobility.(3) Thickening of the PDL.(4) Radiographic evidence of furcal or periradiculardegeneration.(5) Uncontrollable hemorrhage at the time of exposure, and(6) purulent or serous exudate from the exposure.6/17/2013 35YES YES WHY
    • (1) Maintenance of pulp vitality,(2) Absence of sensitivity or pain,(3) Minimal pulp inflammatory responses, and(4) Absence of radiographic signs of dystrophic changes.Salient features of a clinically successful DPC (with orwithout bridging) are:6/17/2013 36YES YES WHY
    • • The first method of capping exposed pulps, using goldfoils was described by Pfaff in 1756. Thereafter,numerous agents for direct pulp capping have beenrecommended. (Dammaschke T 2008)6/17/2013 37YES YES WHY
    • • Ca(OH)2• ZOE• Corticosteroids andantibiotics• Polycarboxylatecements• Inert materials• Collagen fibers• Formocresol• Bonding agents• Cell Inductive agents• Hydroxyapatite• Bioactive glass• MTA• Calcium phosphate cement• Calcium enriched mixture• Lasers• Biodentine• Emdogain6/17/2013 38YES YES WHY
    • • Calcium hydroxide (CH) or calcium hydroxide compoundshave, for many years, been the material of choice.• But calcium hydroxide and most calcium hydroxidecements are liable to dissolution, dentin bridge formationbeneath CH has tunnel defects and, in cases ofmicroleakage around restorations, bacteria may gainaccess to the exposure site.Asgary et al, 2008, Cox et al, 1985, Pitt ford, Roberts 1991• Therefore, much research has been devoted to generatealternative materials.6/17/2013 39YES YES WHY
    • • Self-etching adhesive and calcium hydroxide onhuman pulp tissue:• The clearfil SE ability to induce reparative dentin wassignificantly weaker than Dycal.Lu et al, 2008• Direct pulp capping in dogs teeth with self-etchingadhesive system did not allow pulp tissue repair and failedhistopathologically in 100% of the cases.da Silva La et al, 20096/17/2013 40YES YES WHY
    • • Tri-calcium phosphate based cement:• Dentin bridge formation was observed on exposed pulpsof rats with no evidence of necrosis or markedinflammation.Yoshimine and Maeda, 1995• Tricalcium phosphate was most active when used incombination with CH.Yoshiba K, Yoshiba N, Iwaku M, 19946/17/2013 41YES YES WHY
    • • Adhesive resin-based composite:• The globules of resin can migrate into the pulp tissue andstimulate inflammation.Kitasako et al, 1999• In addition, polymerization shrinkage during theplacement of these materials can create marginal gapsto permit bacterial leakage to occur.Pashley, 19966/17/2013 42YES YES WHY
    • • Calcium hydroxide combined with Vancomyin:• The combination of CH with vancomycin in monkeys wassomewhat more successful in stimulating regularreparative dentin bridges.Gardner et al, 19716/17/2013 43YES YES WHY
    • 6/17/2013 44YES YES WHY
    • • The disadvantages of CH:• The presence of tunnel defects in dentin barrier.• Extensive dentin formation.• High solubility in oral fluids.• Lack of adhesion and degradation afer acid etching.6/17/2013 45YES YES WHY
    • • It was introduced in 1993 by Torabinejad.• Pitt Ford et al, 1996 were the first to evaluate theperformance of MTA for pulp capping in monkey’s teeth.• Pulp capping with MTA is recommended for teeth withcarious pulp exposures specially immature teeth withhigh potential for healing.Farsi N, et al 20066/17/2013 46YES YES WHY
    • • MTA is superior in terms of dentin bridge formationduring the early healing process in human dental pulp.Min et al, 2008• MTA seemed to heal the pulp tissue at a faster rate thanCH cement in human teeth.Accornite et al, 2008• MTA was clinically easier to use as a direct pulp cappingagent and resulted in less pulpal inflammation and morepredictable hard tissue barrier formation than Dycal.Nair PN et al, 20096/17/2013 47YES YES WHY
    • • It has excellent sealing ability.Torabinejad et al, 1993, 1994, Bates et al, 1996,Fischer et al, 1998, Wu et al, 1998.• Biocompatibility.Kettering & Torabinejad 1995, Torabinejad et al,1997, 1998, Holland et al, 1999, Mitchell et al, 1999,Keiser et al, 20006/17/2013 48YES YES WHY
    • initial deep caries and immature apicesFive-minute application of 5.25% sodium hypochloritehemostasis, on two 1.5- to 2.0-mm exposuresPulpal exposure6/17/2013 49YES YES WHY
    • Radiograph of molar with MTA afterinitial visitRadiograph taken at the 5.5-year recallappointment showing permanentrestoration and evidence of completeroot formation.(From Bogen G, Kim JS, Bakland LK: Direct pulp capping with mineral trioxideaggregate. An observational study. J Am Dent Assoc 139:305-315, 2008.6/17/2013 50YES YES WHY
    • • Biodentine™ consists of a powder in a capsule and liquid ina pipette.• The powder mainly contains tricalcium and dicalciumsilicate, the principal component of Portland cement andMTA, as well as calcium carbonate.• Zirconium dioxide serves as contrast medium.• The liquid consists of calcium chloride in an aqueoussolution with an admixture of modified polycarboxylate.• The powder is mixed with the liquid in a capsule in atriturator for 30 sec.• Once mixed, Biodentine™ sets in about 12 to 15 Min.• During the setting of the cement calcium hydroxide isformed.6/17/2013 51YES YES WHY
    • • On the biological level, it is perfectly biocompatible(Laurent et al., 2008) and capable of inducing the appositionof reactionary dentin by stimulating odontoblast activity(Goldberg et al., 2009) and reparative dentin, by induction ofcell differentiation (Shayegan et al., 2010).• It is in effect a dentin substitute that can be used as acoronal restoration material (for indirect pulp capping), butcan also be placed in contact with the pulp.• Its faster setting time allows either immediate crownrestoration (Tran et al., 2008), or to make it directlyintraorally “functional” without fear of the materialdeteriorating.6/17/2013 52YES YES WHY
    • Clinical view Distal pulp horn involvementAfter removal of restoration Biodentine placement6/17/2013 53YES YES WHY
    • Post--‐operative clinical view Post‐operative X‐ray follow‐up imageCeramic onlay, final restorationafter 2 monthsPost ‐operative X‐ray follow‐up image- Dr. Lucile Goupy6/17/2013 54YES YES WHY
    • • Biodentine, Ca(OH)2, MTA and Xeno III:• Biodentine™ induced mineralized foci formation earlyafter its application. The mineralization appeared underthe form of osteodentine and expressed markers ofodontoblasts.• Biodentine™ significantly increased TGF- β1 secretionfrom pulp cells ( P < 0.03) independently of the contactsurface increase. This increase was also observed withcalcium hydroxide and MTA, but not with the resinousXeno®III.Laurent P, Camps J, About I: Int Endod J; May 2012, Vol. 45 Issue5, p439-448.6/17/2013 55YES YES WHY
    • • Calcium enriched mixture (CEM) cement is a newendodontic cement with similar clinical applications as MTAbut different chemical composition.J Endod 2008;34:990–3, J Endod 2009;35:243–50.• CEM cement has antibacterial effect comparable to CHand superior to MTA (Asgary S, Kamrani FA 2008) and sealingability similar to MTA (Asgary S, Eghbal MJ, Parirokh M 2008).• The biologic response of the pulpal tissue to MTA andCEM cement has been shown to be similar in dogs’ teeth.Asgary S et al, 20086/17/2013 56YES YES WHY
    • • In addition, Asgary and Ehsani showed in a case seriesstudy that CEM cement has favourable clinical success inpulp capping of permanent molars with irreversible pulpitis.J Conserv Dent 2009;12:31–6.• It has been shown that CEM cement provides anendogenous source of calcium and phosphate ions thataccelerates hydroxyapatite (HA) crystal formation as asecond-seal on its surface even in normal saline storagemedia.Aust Endod J 2009;35:147–52.• The composition of the set form of CEM cement is similarto dentin.J Endod 2009;35:243–50.6/17/2013 57YES YES WHY
    • • Bioactive glass is often used as a filler material for repair ofdental bone defects.• They react with aqueous solutions and produce acarbonated apatite layer.• BAG is biocompatible and can bind to the bone.• BAG can be the material of choice for pulp capping andperiapical bone healing because it is biocompatible andhas antibacterial property.Schepers et al, 19916/17/2013 58YES YES WHY
    • • Bioactive glass and calcium hydroxide in primarymolars:• Less inflammation, dentin bridge formation and no internalresorption, necrosis or abscess in BAG group.Journal of Dentistry, Tehran University of Medical Sciences, Tehran,Iran (2007; Vol: 4, No.4)Pulpal response CH BAGMild inflammation 2 0Mild inflammation 5 2Severe inflammation 3 1Internal resorption 6 0Abscess 5 0Necrosis 0 0Dentinal bridge 7 26/17/2013 59YES YES WHY
    • • Novamin® compared with calcium hydroxide asa pulp-capping agent:• Novamin® showed less or no inflammation whencompared to Ca(OH)2.• There was no presence of bacteria on any sample forboth NovaMin® and Ca(OH)2 groups.Bioceramics: Volume 8, 1995. 512 pg6/17/2013 60YES YES WHY
    • • ODAM has been shown to be specifically expressed inameloblasts and odontoblasts and has been suggested toplay a role in the mineralization of the enamel, possiblythrough the regulation of matrix metalloproteinase20. However, its function in dentin is not clear.White MTA and rODMA comparison on formation ofreactionary dentine formation:• rODAM accelerates reactionary dentin formation close tothe pulp exposure area, thereby preserving normalodontoblasts in the remaining pulp.J Endod; Dec 2010, Vol. 36 Issue 12, p1956-1962.6/17/2013 61YES YES WHY
    • • Enamel Matrix Derivative (EMD) is a rich amelogenin andamelin biomaterial that has been demonstrated to inducea reparative process similar to normal odontogenesiswhen placed in contact with pulp tissue.• Numerous in vivo and in vitro studies, as well as clinicaltrials, have shown that EMD is clinically useful inpromoting periodontal regeneration.Esposito M et al 2003• Several studies have also shown its promising effect indirect pulp capping.6/17/2013 62YES YES WHY
    • • Histological evaluation of EMD as a pulpotomyagent in primary teeth:Pediatric Dent 2007 Nov-Dec;29(6):475-9.Extraction ofprimarycaninesHistology of pulpafter 1 week surface was lined by a thin, nearly continuouscellular layer. Generalized congestion wasaccompanied by an increase in angiogenesisafter 2 weeks small islands of dentin-like tissue at differentstages of mineralization.after 6 months coalescing islands of dentin-like tissue trying tobridge the full width of the coronal pulp at theinterface between the wounded and unharmedpulp tissue below the amputation site.6/17/2013 63YES YES WHY
    • • A Hybrid Approach to Direct Pulp Capping byUsing Emdogain with a Capping Material:• Calcium hydroxide, ProRoot White MTA, white Portlandcement were used after Emdogain application on theexposed pulp.• MTA produced a better quality reparative hard tissueresponse with the adjunctive use of Emdogain, whencompared with the use of calcium hydroxide.J Endod 35 , Pages 667-672, May 20116/17/2013 64YES YES WHY
    • • Comparison of histologic healing processes witheither tetracalcium phosphate cement or calciumhydroxide cement to the exposed pulp of the ratmaxillary incisors:• In teeth applied with Ca(OH)2, necrotic tissue was presentbeneath the cement before new hard tissue formed.• In contrast, tetracalcium phosphate cement elicited adentine bridge formation with no evidence of eitherintervening tissue necrosis or marked inflammation.6/17/2013 65YES YES WHY
    • • Furthermore on ultrastructural examination the newlyformed hard tissue was in direct contact with the material.• This study suggests that 4CP cement possesses abiocompatible property, which indicates its potential foruse as a direct pulp-capping agent.Yoshimine Y, Maeda K, 19956/17/2013 66YES YES WHY
    • • Brasseler USA (Savannah, GA) has formulated abioceramic material for root repair needs. Currently thereis limited research on the Endosequence Root RepairMaterial (ERRM).• It has mainly been evaluated for use as a root-end fillingmaterial.• Its properties include exceptional stability, highmechanical bond strength, high pH, radiopaque, andhydrophilic setting properties, and it is premixed.J Endod 2011;37:372–5.6/17/2013 67YES YES WHY
    • • MTA-Angelus, Brasseler Endosequence Root Repair Putty(ERRP) , Dycal and Ultra-blend Plus (UBP):• MTA-Angelus, (ERRP) , and Ultra-blend Plus hadstatistically similar adult human dermal fibroblastcytotoxicity levels.• Relative to the negative control, only Dycal was shown tohave a statistically significant cytotoxic effect on adulthuman dermal fibroblasts at all tested intervals.• ERRM and UBP did not negatively influence cell survival.Hirschman et al, J Endod 2012; 1–4 (Article in press)6/17/2013 68YES YES WHY
    • • TheraCal LC is a light-cured resin-modified calciumsilicate pulp protectant / liner designed to perform as abarrier and to protect the dentin-pulp complex.• The light-cured set permits the practitioner immediateplacement and condensation of the restorative material.• TheraCal is indicated in both indirect and pulp cappingprocedures.6/17/2013 69YES YES WHY
    • • Comparison of chemical-physical properties ofTheraCal, ProRoot MTA and Dycal:• TheraCal displayed higher calcium-releasing ability andlower solubility than either ProRoot MTA or Dycal.• The capability of TheraCal to be cured to a depth of1.7 mm may avoid the risk of untimely dissolution.• These properties offer major advantages in direct pulp-capping treatments.Int Endod J , 45: 571–579, June 2012.6/17/2013 70YES YES WHY
    • 6/17/2013 71YES YES WHY
    • Def: “amputation of the affected or infected coronal portionof the dental pulp, preserving the vitality and functionof all or part of the remaining radicular pulp”.AAPD guidelines 2003-2004• Outcome of the treatment – influenced by type, conc &time of tissue contact of the medicament.6/17/2013 72YES YES WHY
    • • clinical and radiographic signs of radicular pulp vitality,• absence of pathologic change,• restorability, and• at least two-thirds remaining root length.• young permanent teeth with incompletely formed apicesand cariously exposed pulps.6/17/2013 73YES YES WHY
    • (1) root resorption exceeding >1/3rd of the root length(2) Nonrestorable tooth crown(3) highly viscous, sluggish, or absent hemorrhage at theradicular canal orifices(4) marked tenderness to percussion(5) mobility with locally aggravated gingivitis associatedwith partial or total radicular pulp necrosis(6) radiolucency in the furcal or periradicular areas(7) persistent toothaches & coronal pusAccording to Mejare:6/17/2013 74YES YES WHY
    • - Vitality of the majority of the radicular pulp- No prolonged adverse clinical signs or symptoms,such as prolonged sensitivity, pain, or swelling- No radiographic evidence of internal resorption- No breakdown of periradicular tissue- No harm to succedaneous teeth- Pulp canal obliteration (abnormal calcification)Evidence of success in therapy includes the following:6/17/2013 75YES YES WHY
    • Agents forpulpotomyPharmacotherapeuticFormocresolGlutaraldehydeCalcium hydroxideCollagenFerric sulfateCaPo4 cementHydroxyapatiteBMP 2 & 4Freeze dried boneMTACEMBiodentineNon-pharmacologicElectro surgeryLasers6/17/2013 76YES YES WHY
    • • Most popular – Formocresol- because of its ease in use and- excellent clinical success.but concerns  systemic distributionpotential for toxicityallergenicitycarcinogenicity andmutagenicity6/17/2013 77YES YES WHY
    • • Studies Directly Comparing MTA and Formocresol6/17/2013 78YES YES WHY
    • • Studies Comparing Directly Ferric sulphate andFormocresol6/17/2013 79YES YES WHY
    • • Studies Directly Comparing CH and FC6/17/2013 80YES YES WHY
    • • This clinical study compared the effects of Nd:YAG laserpulpotomy with FC on human primary teeth.• In the Nd:YAG laser group, clinical success was achievedin 66 of 68 teeth (97%), and 94% were radiographicallysuccessful.• In the control group, 85% and 78% achieved clinical andradiographic success, respectively.• The success rate of the Nd:YAG laser was significantlyhigher than that of the FC pulpotomy.• The permanent successors of the laser-treated teetherupted without any complications.J Endod, 2006: 32:404-7• Study Comparing Laser With FC:6/17/2013 81YES YES WHY
    • • Study Comparing Sodium Hypochlorite With FS:Vargas etal, 2006• The authors concluded that preliminary evidence showedthat NaOCl can be used successfully as a pulpotomymedicament.Paediatr Dent 2006, 28: 511-7Duration Ferric sulphate NaOClClinicalsuccessRadiographicsuccessClinicalsuccessRadiographicsuccessAt 6 months 100% 68% 100% 91%At 12 months 85% 62% 100% 79%6/17/2013 82YES YES WHY
    • • Case reports showing successful pulpotomy with MTAJADA, Vol. 137 May 200618 month19 month6/17/2013 83YES YES WHY
    • • Case report showing successful pulpotomy withCEM cement in permanent molar with irreversiblepulpitis and condensing apical periodontitis:Saeed Asgary. J Conser Dent 2011, 14: 90-936 months1 year 2 years6/17/2013 84YES YES WHY
    • 6/17/2013 85YES YES WHY
    • • During the last 10–15 years, there has been a tremendousincrease in our clinical “tools” (ie, materials, instruments,and medications) and knowledge from the trauma andtissue engineering fields that can be applied toregeneration of a functional pulp-dentin complex.• In addition, recent case reports indicate that biologicallybased endodontic therapies can result in continued rootdevelopment, increased dentinal wall thickness, and apicalclosure when treating cases of necrotic immaturepermanent teeth.6/17/2013 86YES YES WHY
    • • Several groups recently have published preclinical researchor case reports that offer a biologically based alternative toconventional endodontic treatment of these complex clinicalcases.6/17/2013 87YES YES WHY
    • 6/17/2013 88YES YES WHY
    • J Conser Dent 2012, 15: 97-1036/17/2013 89YES YES WHY
    • 6/17/2013 90YES YES WHY
    • • The pulp-capping agents used, and not the procedureitself, has been the subject of controversy amongresearchers.• Development of new capping materials for delivery ofexogenous signaling molecules offers excitingopportunities for the future.• However, a number of critical considerations, such asthe dose-response effects, the nature of the deliverysystem, half-life of the molecules, their possible side-effects and long term clinical studies need to beaddressed before any introduction of new treatmentmodalities into clinical practice.6/17/2013 91YES YES WHY
    • 6/17/2013 92YES YES WHY