Direct pulp capping


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Direct pulp capping

  1. 1. Direct Pulp Capping: A recent update Lebanese University –School of DentistryDepartment of Restorative and Aesthetic Dentistry Dr S.Artine Dr P.Hajjar Dr S. Mouawad
  2. 2. I- What is direct pulp capping?Placement of a protective dressing directly over the exposed pulp Pulp exposed 2
  3. 3. Why? Saves the tooth and Preserves vitalityConservative treatment No need for RCT 3
  4. 4. o Healing/ Repair.o Pulp’s vitality and function.o Normal responsiveness toelectrical and thermal pulp tests.o Preventing breakdown of theperi-radicular supporting tissue.oFormation of secondary dentine. 4
  5. 5. 1930, Hermann 1921, Dätwyler 1826, Koecker1756,Pfaff 5
  6. 6. II- Indications of direct pulp capping•Immature permanent teeth or mature permanent teeth with simple restorative needs. 6
  7. 7. •Recent traumatic (<24 h)/Mechanical pulp exposureSmall pinpoint pulp exposure=1mm 7
  8. 8. •Little or no bleeding at the exposure site 8
  10. 10. •No pulp calcification 10
  11. 11. •Adequate coronal restoration can be made 11
  12. 12. III-Contraindications•Systematic diseases: diabetes, cancer… 12
  13. 13. •primary teeth root resorption •Inflammatory signs/ symptoms 13
  14. 14. •Pre-operativetooth sensitivity 14
  15. 15. •Largepulp exposures•Uncontrolled bleeding 15
  16. 16. •Non-restorable toothor restorable with low prognostic Dentin Bridge 16
  17. 17. IV- Pulp capping materials•Calcium Hydroxide Ca(OH)2•Mineral Trioxide Aggregate MTA•Tri-calcium phosphate•Bioaggregate•Biodentine•Bonding Systems 17
  18. 18. Calcium hydroxide Ca(OH)2:•The most common direct pulp-capping agent •Antibacterial anddisinfects the superficial pulp •High pH (about 12.5) Pure Calcium hydroxide 18
  19. 19. How does Ca(OH)2 work??•Liquefaction necrosis of the superficial pulp•Neutralization of toxicity in deeper layers•Coagulative necrosis…Irritation of adjacentpulp•Minor inflammation response… Hard tissuebarrier 19
  20. 20. Properties:•Pure calcium hydroxide are morecaustic than Hard-setting calciumhydroxide pastes (Dycal, Life,…)but both have been shown toinitiate the same type of healing 20
  21. 21. • Dentin bridges beneath calciumhydroxide pulp caps contain ‘tunneldefects’, therefore an additionalbase material is necessary to seal theexposed pulp from the externalenvironment.•Calcium hydroxide materials tend to soften, disintegrate,and dissolve over time. 21
  22. 22. Mineral Trioxide Aggregate or MTA:ProRootTo seal communications betweenthe root canal system and theexternal tooth surface at alllevels and recently indicated inpulp treatment as direct pulpcapping. Dr M.Torabinejad 22
  23. 23. Composition:•Tricalcium silicate•Tricalcium aluminate•Tricalcium oxide•Silicate oxideMixed with sterile water in a 3:1 powder-to-liquid ratio, MTA sets in 5 minutes 23
  24. 24. Application of MTA 24
  25. 25. Properties: •Low or no solubility •PH value10.2 after mixing and rises to 12.5 after 3 hours •Antibacterial effect •Induces pulpal cell proliferation •Stimulation of mineralized tissue formation(Mineral Trioxide Aggregate: A Comprehensive LiteratureReview—Part I: Chemical, Physical, and Antibacteria lProperties) 25(Direct pulp capping with mineral trioxide aggregateJ Am Dent Assoc 2008;139;305-315) (MTA AND CALCIUM HYDROXIDE FOR PULP CAPPINGJ Appl Oral Sci 2005; 13(2): 126-30)
  26. 26. How does MTA work?? Process not yet knownTri-calcium oxide + tissue fluids = calcium hydroxide Hard-tissue formation 26
  27. 27. MTA v/s calcium hydroxide •Rapid cell growth promotion in vitro •Greater ability to maintain the integrity of pulp tissue •Thicker dentinal bridge, less inflammation, less hyperemia and less pulpal necrosis •Induce the formation of a dentin bridge at a faster rate •High ability to resist the penetration of microorganisms •Limited antibacterial effect 27(Mineral trioxide aggregate pulpotomies A case series outcomes assessment J Am Dent Assoc 2006;137;610-618)
  28. 28. Tri-calcium phosphate: - Bone regeneration procedures (promotes effects on hard tissue formation by osteoblasts) - Studies (by Heller) showed that dentinal bridge formation does take place, by direct apposition, on the pulpal wall The bridge: •Contiguous •Thick •Minimal pulpal inflammation •Odontoblasts directly under and in contact with the bridge 28Use of a Resorbable Ceramic (SYNTHOS) in Direct Pulp-Capping Driskell, T., Heller, A., and Koenigs, J., The Ohio StateUniversity,Columbus 1974
  29. 29. Bio-AggregateBio-Aggregate is a root canalrepair material composed of bio-ceramic nano-particlesIndicated as:• Repair of Root Perforation• Repair of Root Resorption• Apexification• Pulp Capping 29
  30. 30. Pure white powder and liquid mixed together to form a thick paste-like mixture. 30
  31. 31. MTA and Bio-Aggregate show similar chemical composition with some differences VSTantalum oxide Bismuth oxide 31
  32. 32. Biodentine™ : Active Biosilicate Technology™ /calcium Silicate based cement Dentin substitute from Septodont Saint Maur-des Fossés, France 32
  33. 33. Indications:•Endodontic indications (repair of perforations orresorptions, apexification, root-end filling)•Permanent dentine substitute and temporary enamelsubstitute•Restoration of deep or large crown carious lesions•Direct pulp capping in adults presenting healthy pulp 33
  34. 34. Formulation:PowderTri-calcium Silicate (C3S) Main core materialDi-calcium Silicate (C2S) Second core materialCalcium Carbonate and Oxide FillerIron Oxide ShadeZirconium Oxide RadiopacifierLiquidCalcium chloride AcceleratorHydrosoluble polymer Water reducing agent 34
  35. 35. Clinical Case After 3 months: Final filling 35 BIODENTINE™ A NEW BIOACTIVE CEMENT FOR DIRECT PULP CAPPING Till Dammaschke, assistant professor, DDM Department of Operative Dentistry Waldeyerstr. 30 48149 Münster Germany
  36. 36. Other:Bonding systems = Sealing potential of resin adhesive systems direct pulp capping 36
  37. 37. Resin adhesives Vs calcium hydroxide•Less porous dentinal bridges = Better seal against bacterialleakage•Less pulpal inflammation•Less successful (Pameijer and Stanley: ‘disastrous effects’causing hemorrhage that was difficult to control)•Less success rates with inflamed pulps (lack the inherenthaemostatic and bactericidal properties) 37
  38. 38. V- Biocompatibility & Cytotoxicity of pulp capping materialsCH•Stimulating sclerotic and reparative dentin formation due torelease some proteins and growth factors•Protecting the pulp against thermal stimuli and antibacterialaction•Inducing pulp tissue to form a mineralized barrier•Biological and therapeutic potential (Material of choice) 38
  39. 39. MTA•Abedi et al. (1996) MTA: less inflammation•Pitt Ford et al. (1996): dentine bridge formation in all pulpscapped with MTA and no inflammation except in one sample•MTA: excellent sealing ability (Torabinejad et al. 1993, 1994,Bates et al. 1996, Fischer et al. 1998, Wu et al.1998)• Excellent biocompatibility (Kettering & Torabinejad1995,Torabinejad et al.1997, 1998, Holland et al. 1999, Mitchell et al.1999, Keiser et al. 2000). Supposedly due to CH andHydroxyapatite formation 39
  40. 40. VI- Techniques of direct pulp capping 1- Anesthesia 2- Rubber dam 40
  41. 41. 3- Chlorhexidine solution 4- Rinse with anesthetic or sterile saline 41
  42. 42. 5- sterile cotton pellet to control bleeding6-Mix capping agent 42
  43. 43. 7- Apply to exposure site 8- Base/liner then restore 43
  44. 44. 44
  45. 45. VII- Temporary or Permanent Filling? What’s the best choice? A permanent restoration seals the margin moreeffectively than does a temporary restoration, thus preventing or reducing the microleakage. 45 (Ahmad S. Al-Hiyasat, Kefah M. Barrieshi-Nusair,Mohammad A. Al-Omari: The radiographic outcomes of direct pulp-capping procedures performed by dental students A retrospective study)
  46. 46. The best Permanent filling process consists ofcovering the pulp capping material with a RMGIC followed by a hermetic composite resin restoration to prevent bacterial leakage and recontamination of the exposed area. 46
  47. 47. VIII- Prognosis of direct pulp capping: Success rates range from 13% to 98% in one to 10 years retrospective studies: • Armstrong and Hoffman: 97.8% success rate after 1.5 years. • Fitzgerald and Heys: 79% success rate after one year. • Haskell and colleagues: success rate of 87.2% after five years. • Barthel and colleagues: success rate of 37% after five years and 13% after 10 years for 123 pulp-capping procedures performed by dental students. • Baume and Holz: The operator’s skill seems to be one factor that influences the outcome of pulp-capping procedures 47(Baume LJ, Holz J. Long term clinical assessment of direct pulp capping. Int Dent J 1981;31(4):251-60)
  48. 48. Not Significant Significant Age  Type of Exposure Sex  Type of Restoration Tooth Location  Class of Restoration Tooth Position 48
  49. 49. Age of patient Sex of patient Tooth location Tooth position 49
  50. 50. 1. Type of Exposure:Mechanical exposure: Direct pulp capping + permanent restoration to conserve the vital pulp. Carious exposure: Avoid Pulp capping & opt for endodontic therapy. 50
  51. 51. 2. Type of Restoration:An hermetic seal against bacterial infiltration is a must to guarantee the success of the pulp treatment. 51
  52. 52. 3. Class of Restoration:The prevention or reduction in the microleakage reflects the higher success rate of pulp capping in Class I restorations relative to that in the Class II, III, IV and V and MOD restorations 52
  53. 53. Periapical radiolucency and need for RCT Need for extraction Failure Good to know: time devoted to the teaching of vital-pulp therapy to undergraduate students < teaching of formal endodontic treatments 53
  54. 54. 1. Calcium Hydroxide:•At the 7th day, the pulp tissue capped with CalciumHydroxide exhibited: o Odontoblast-like cells organized underneath o A zone of coagulation necrosis• Pulp repair and apparent complete dentin bridgeformation after 60 days. 54
  55. 55. 2. MTA® (Mineral Trioxide Aggregate):• A comparative study of WMTA (White MTA) andCalcium Hydroxide concluded that at the 136th recallday: o 23 teeth of 23 Capped with WMTA, were clinically diagnosed as successful 100% as well as o 22 teeth of 23 of the Calcium Hydroxide group. 55 (Iwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, Jeffries S. Clinical and histological evaluation of white ProRoot MTA in direct pulp capping. Am J Dent. 2006;19:85-90)
  56. 56. 3. Biodentine® (Tri-Calcium Silicate) Applied in 116 patients with at least one year follow-up. It’s very well tolerated and can be used as cavity lining with a permanent composite restoration. 56
  57. 57. Success Rates 92.2% Mechanical 1. Type of Exposure 33.3% Carious 80.8% Permanent2. Type of Restoration 47.3% Temporary 83.8% Cl I O3.Class of Restoration 28.6% Cl II MOD 57
  58. 58. IX- New perspectives and future trends:• Other innovative technical advances include the use of: • Lasers • Ozone technology • Bioactive agents that induce and stimulate pulpal defenses•Gene-enhanced Tissue Engineering•Dental Pulp Stem Cell Therapy: o Potential to improve on conventional pulp-capping with calcium hydroxide or other artificial materials. o Ex vivo cell therapy may have an advantage and might result in copious amounts of reparative dentin formation. o Skin fibroblasts transduced with BMP7-adenovirus induce reparative dentin formation (Rutherford, 2001) o Techniques have to be established and optimized before cell therapy with BMP2 can become a clinical reality for caries and endodontic therapy. 58
  59. 59. THANK YOU 59