Vital Pulp Therapy

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Clinical Endodontics
Fifth Year

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Vital Pulp Therapy

  1. 1. VITAL PULP THERAPY
  2. 2. Physical / Chemical / Thermal injuries Dental Caries Pulpal Irritation Inflammation Reversible Irreversible Vital Pulp Therapy Repair Pulp Necrosis
  3. 3. Vital pulp therapy is defined as a treatment initiated to preserve and maintain pulp tissue in a healthy state → tissue that has been compromised by caries, trauma or restorative procedures.
  4. 4. OBJECTIVE REPARATIVE → DENTIN STIMULATE THE FORMATION OF TO RETAIN THE TOOTH AS FUNCTIONAL UNIT VITAL PULP THERAPY → Capacity of the pulp for repair in the absence of microbial contamination A
  5. 5. Outcome of Vital Pulp Therapy will depend on:  Age of the patient  Size of the pulp chamber  Bacterial contamination  The pulp capping material  Quality of final restoration
  6. 6. Most important aspects for the Vital Pulp Therapy are  Diagnosis of pulpal condition  Case selection
  7. 7. According to the American Academy of Pediatric Dentistry: “ Teeth exhibiting provoked pain of short duration, that is relieved upon the removal of the stimulus, with analgesics, or by brushing , without signs and symptoms of irreversible pulpitis are candidates for Vital pulp Therapy
  8. 8. Primary Goals of Vital Pulp Therapy  Dentin bridge formation  Continuation of root development :
  9. 9. STIMULATION UNDIFFERENTIATED MESENCHYMAL CELLS PRE EXISTING ODONTOBLASTS ODONTOBLAST LIKE CELLS REPARATIVE DENTIN REACTIONARY DENTIN TERTIARY DENTIN DENTINAL BRIDGE
  10. 10. VITAL PULP THERAPY  Includes:  Indirect Pulp Capping  Direct Pulp Capping  Pulpotomy  Apexification
  11. 11. INDIRECT PULP CAPPING A procedure in which a material is placed on a thin partition of remaining carious dentin, that if removed, may expose the pulp  Indirect pulp capping – stepwise excavation of caries  Indirect pulp capping without re-entry and further excavation
  12. 12. Stepwise excavation of caries : Technique in which caries is removed in increments in two or three appointments over a few months to a year rather than removing the caries in one sitting [ in deep carious lesions ] Each time caries is removed Glass ionomer base is placed which may contribute to mineralization, followed by a well sealing temporary restoration
  13. 13.  The deeper affected but not infected dentin may remineralize and tertiary dentin may form  Case selection : No signs or symptoms of irreversible pulpitis  Periodic follow up • Radiographs and • Pulp testing
  14. 14. TECHNIQUE  Local Anesthesia  Rubber dam isolation to keep bacterial count as low as possible  Removal of as much caries as leaving a thin layer of affected dentin to permit placement of a temporary restoration  Large round bur less likely to cause accidental exposure than spoon excavator
  15. 15.  Place a layer of Glass ionomer [or calcium hydroxide] and restore the tooth with a provisional restoration  The seal provided by the restoration is very important  After 1-2 months remove the restoration and excavate the remaining caries.  If any exposure then – direct pulp capping Pulpotomy pulpectomy If no exposure - permanent restoration
  16. 16. Indirect pulp capping without re-entry and further excavation This is similar to stepwise excavation but differs in the sense that the innermost layer of carious dentin is deliberately and permanently left behind
  17. 17. DIRECT PULP CAPPING: The treatment of an exposed vital pulp by sealing the pulpal wound with a dental material placed directly on the exposure site to facilitate the formation of reparative dentin and maintenance of the vital pulp Exposure of the pulp may be due to  Traumatic exposure  Mechanical exposure  Caries removal
  18. 18.  Success rate for Mechanical exposure > Carious exposures Materials commonly used • • MTA [Mineral Trioxide Aggregate] Calcium hydroxide  These materials should be covered by a permanent restoration with a good marginal seal
  19. 19. Success of Direct pulp capping depends on Size of exposure Presence of good isolation Condition of the pulp Absence of symptoms Age of the patient Restorative material used
  20. 20. PULPOTOMY The pulpotomy procedure involves removing only part of the pulp, eliminating tissue that has inflammatory or degenerative changes and leaving intact the underlying healthy pulp tissue The surgical amputation of the coronal portion of an exposed pulp to protect and preserve the remaining radicular pulp’s vitality and function
  21. 21. Indications:  Exposed vital pulps in carious primary teeth  Exposed permanent vital pulps teeth (to in carious allow immature continued root development prior to NSRCT)  Traumatically exposed primary or permanent teeth [mature or immature]  As an emergency procedure prior to NSRCT
  22. 22. Prognosis for traumatic/mechanical exposures exposures Case selection -Vital pulp -Reversible pulpitis -No symptoms of irreversible pulpitis > carious
  23. 23. Steps:  All the carious dentin and pulp to the level of radicular pulp are removed - level of CEJ in anteriors - level of canal orifices in posteriors  Bleeding from the pulp stump is controlled with moist cotton pellets and gentle pressure  The chamber is rinsed with Sodium hypochloride  The severed pulp is capped with - Calcium hydroxide - MTA
  24. 24.  This is then covered with Glass ionomer and the tooth is restored with a restoration that seals completely  Follow up • No signs of irreversible pulpitis • No radiographic signs of o internal resorption o external resorption o calcification o periapical radioluscency
  25. 25. CVEK PULPOTOMY / PARTIAL PULPOTOMY: The surgical removal of a small portion of the coronal portion of a vital pulp as a means of preserving the remaining coronal and radicular pulp.
  26. 26. OPEN APEX  An open apex is the developing root of an immature tooth until apical closure occurs .  Apical closure occurs 2-3 yrs after tooth eruption  Any injury to the pulp at this stage will stop the closure of the apex  Such a tooth will have short , thin walls at the apical portion of the root
  27. 27.  Open apex can also be caused by extensive resorption of a previously mature apex after orthodontic treatment or severe periapical inflammation
  28. 28. Diagnosis and assessment:  History  Subjective symptoms  Diagnostic tests  Radio graphs A radiolucent area usually surrounds the apex of an immature root with a healthy pulp
  29. 29. OPEN APEX VITAL PULP APEXOGENESIS NON VITAL PULP APEXIFICATION
  30. 30. APEXOGENESIS A Vital Pulp Therapy procedure performed to encourage continued physiologic development and formation of the root end. Since the main objective is to maintain the vitality of the radicular pulp the pulp must be vital and capable of repair
  31. 31. Trauma / mechanical exposure / Caries  Small exposure - Pulp capping  Large exposures - Cvek pulpotomy Pulpotomy
  32. 32. Technique: 1. Anesthesia and rubber dam isolation 2. The inflamed pulp tissue is removed using a sharp round bur in a high speed hand piece with water coolant for superficial 2-3mm of pulp amputaion [Cvek pulpotomy] 3. Or removal of the entire pulp to the level of the canal orifices using a large Spoon excavator 4. Hemorrhage is controlled by pressure on a cotton pellet moistened with saline. [ failure to achieve hemorrhage indicates pulpal inflammation]
  33. 33. The exposed pulp is rinsed with 2.5% sodium hypochlorite MTA or hard set calcium hydroxide is placed over the amputated pulp. MTA is prepared by mixing MTA powder with saline in the ratio of 3:1 on a glass slab. The mixture is placed on the exposed pulp and patted with a moist cotton pellet. MTA sets in the presence of moisture. Wet cotton pellet is placed over MTA and the tooth is restored.
  34. 34. The patient is then put on a periodic recall for 1-2yrs at every 6 month interval. Commonly encountered • Calcific metamorphosis • Internal resorption In such cases NSRCT initiated.
  35. 35. APEXIFICATION Induction of a calcific barrier or creation of an artificial barrier across an open apex Technique: Local anesthesia and Rubber Dam isolation Access cavity preparation and extirpation of the pulp Working length is established slightly short of the apex [to prevent injury to apical tissues] Instrumentation and copius irrigation Drying the canal and introducing MTA into the canal
  36. 36.  Packing MTA using endodontic pluggers or special system like MAP SYSTEM [Micro Apical placement]  MTA acts as an artificial barrier against which Gutta percha can be condensed.  Calcium hydroxide produces a biologic barrier but takes longer time.
  37. 37. TISSUE ENGINEERING : Science of design and manufacturing of new tissues to replace tissues lost to disease or trauma. It involves three key elements 1. Stem cells/ progenitor cells 2. Signals or morphogens that induce morphogenesis 3. A scaffold that provides a 3D microenvironment for cell growth and environment
  38. 38. Tissue Regeneration Bone morphogenetic protein scaffold Undifferentiated mesenchymal cells Odontoblasts
  39. 39. 1. The bone morphogenetic proteins are directly applied over the exposed amputated pulp 2. Ex-vivo - stem/progenitor cells are isolated from the pulp and differentiated into odontoblasts with recombinant BMP and BMP genes. These odontoblasts are autogenously transplanted into the exposed pulp.
  40. 40. Other techniques: Revascularization Retrograde MTA

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