Deep caries management /certified fixed orthodontic courses by Indian dental academy


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Deep caries management /certified fixed orthodontic courses by Indian dental academy

  1. 1. MANAGEMENT OF DEEP CARIESINDIAN DENTAL ACADEMYLeader in Continuing Dental Education
  2. 2. Three vital techniques: • Indirect pulp capping • Direct pulp capping • Coronal pulpotomy
  3. 3. . Vital pulp therapy aims to treat reversible pulpal injuryand maintain pulp vitality and function. It includes twotherapeutic approaches: indirect pulp capping in cases of deep dentinal cavities and direct pulpcapping/pulpotomy in cases of pulp exposures. Successful outcome for vital pulp therapy is verydependent on the type and location of injury, age of the tooth, treatment modality (capping material) andintegrity of the cavity restoration[ Mjör, 2002; Horsted-Bindslev and Bergenholtz,2003].
  4. 4.  Whilst the biological processes directed by the treatment strategy have received much attention during the last four decades, controversy still exists regarding the biological basis of the mechanism by which the capping material regulates healing and repair of the pulp in vital pulp therapy [Nyborg, 1955; Fitzgerald, 1979; Cox et al., 1985; Horsted et al., 1985; Schroder, 1985; Cvek et al.,1987; Stanley, 1989; Mjör et al., 1991]
  6. 6.  Indirect pulp capping sometimes called the rest treatment. It is a procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a time with a bactericidal agent. This procedure is more successful in permanent teeth as bacterial contamination is less in infected dentin compare to primary dentition.
  7. 7. ☻IPC is based on the theory that a zone of affected demineralised dentin exist between the outer infected layer of the dentin and pulp. Affected dentin is an inner layer of uninfected carious dentin which is vital and sensitive, not infused with bacteria, and may be somewhat softened and demineralized, but which is capable of remineralizing☻ Removal of infected dentin and effectively sealing them off from their source of substrate a favorable environment is created. Infected dentin is an outer layer of infected carious dentin which is soft, discolored, nonvital, nonsensitive and cannot remineralize.
  8. 8. Following which firstly remineralisation of remaining decalcified dentin will occur and secondly secondary dentin pulpal to carious lesion is initiated. Secondary deposits contain less calcium, phosphorous, and collagenous matrix per unit volume than the primary dentine. Secondary dentin is less mineralized
  9. 9. What causes secondary dentin? Generally, the answer is irritation.Secondary dentin is dentin that is formed throughoutthe pulp chamber and pulp canal from the time oferuption Its sort of like callous formation on skin. If the irritation is serious enough inflammation occurs.If the case ,secondary dentin is laid down byodontoblasts in the layer of the pulp immediatelyadjacent to the dentin lining the canal or pulp chamber.Sources of that irritation are usually heat, cold, occlusalpressures and the aging process
  10. 10. IndicationsSymptom freeNo radiological evidenceof
  11. 11. Pain history – no extremes. May be associated with eating, sometimes dullClinical examination.  No gingival Pathological condition  No mobility and large carious Lesion.Radiographic examination  Probable carious exposure  Normal periodontal tissue
  12. 12. Procedure The tooth is anesthetized and isolated with rubber dam. Gross caries is removed using large round bur or sharp spoon excavator. High speed rotary instrumentation is contraindicated as tactile sensation is lost. For judging the affected dentin and infected dentin the colour difference between the two is not a reliable index.
  13. 13. Caries overlying the pulp alone is left. All caries at DEJ is removed. Undermined enamel can be left as it helps in retention of temporary restoration. ↓The base of cavity dried and bactericidal dressing of calcium hydroxide or Zinc Oxide eugenol placed.Both the materials will contribute insulating protection to the pulp at a thickness of 5 mm or more and provide pulpal protection from pressure of amalgam condensation forces at a thickness of 1 to 1.5mm or more. If pulp exposure is suspected CH is the choice. A radiography is taken
  14. 14.  This is followed by interim dressing of thick ZOE or Zincpolycarboxylate or amalgam. Preformed stainless steel band can support interim restoration. Patient is recalled after 4-6 weeks if capping materials is CH or 6 to 8 weeks if it is ZOE. The radiographic evidence is evident only after 10 to 12 weeks though rehardening occurs in 6 to 8 weeks.
  15. 15. Caries-Detector DyesHow Accurate and Useful Are They?Commercially available caries-detector dyes are purported to aid the dentist in differentiation of infected dentin, yet research has established that these dyes are not specific for infected dentin. They are non-specific protein dyes that stain the organic matrix of less mineralized dentin, including normal circumpulpal dentin and sound dentin in the area of the amelo-dentinal junction. A considerable body of evidence indicates that conventional tactile and optical criteria provide satisfactory assessment of caries status during cavity preparation. There is reason for concern that subsequent use of a caries-detector dye would result in unnecessary removal of sound tooth structure. operative treatment.
  16. 16. The use of caries-detector dyes has also been suggested as adiagnostic aid for occlusal caries.Although diagnosis of carious dentin beneath apparentlysound enamel can be challenging, there is a lack ofsubstantive evidence supporting the use of dyes for thispurpose and false positives are a significant concern.Careful visual inspection combined with bitewing radiographic diagnosis has been shown to be the most reliable diagnostic method for the presence of infected dentin requiring
  17. 17. Commercial products SNOOP(Pulpdent) is a propylene glycol based caries detector Carisolv(Omega trading) is a chemo- mechanical method for non-invasive caries removal. Τhe method comprises two parts : 1) a two component gel designed to soften carious dentine and 2) the special hand instruments needed to remove this softened tissue without damaging adjacent healthy tissue
  18. 18.  Composition of Carisolv Gel : Sodium hypochlorite solution 0,5%, ALT- K, glutamic acid, leucine, lysine, sodium chloride, erythrocin (E127B), CMC 200-800 cps, purified water, sodium hydroxide, pH 11.
  19. 19. ± ReEntry The tooth is anacsthetized, CH and the remaining caries removed and may reveal asound base without exposure. The colour willhave changed from deep red rose to light gray or brown. ↓ A liner material containing CH is applied and cavity prepared and restored in conventional way.
  20. 20.  The rate of reparative dentin deposition has been shown by Stanley et al (1996) to average 1.4µm / day following cavity preparation. It is fastest in the first month. Controversy exist concerning the basing materials. One group supports that CH must be in direct contact with pulpal tissue to form reparative dentin. Another group says that CH is soluble and hence is transmitted by the fluid in the dentinal tubules to the pulp & form reparative dentin.
  21. 21. MATERIALS USED  Calcium Hydroxide  Zinc Oxide Eugenol  Glass ionomer
  22. 22. Calcium Hydroxide It is used for vital pulp therapy (direct and indirect pulp capping, pulpotomy apexogenesis) root amputation and apexification. It serves as blocking patent dentin tubules, neutralizing the attack of inorganic and their leaching products from certain cements. The caustic action associated with its high PH (11-13) induces superficial necrosis and is assumed to be responsible for reparative dentin formation.
  23. 23.  Sowden (1956) had reported the recalcification of dentin following dressing with calcium hydroxide in IPC Law and Lewis (1961) is also worked with calcium Hydroxide and reported success.
  24. 24. Cacium Hydroxide, used in IPC appears to arrest the lesion (Smirrow – 1989) sterilize the residual deep layer of caries (King J.B., Crow ford J.J 1965) remineralise the caries dentin (Kerkove et al 1965 & Law D.B. et al – 1961).The main CH products available now are Pulpdent Dycal Hydrex.
  25. 25. Pulpdent is 55% CH suspended inaqueous ethyl cellulose solution.Pulpdent is most capable for earlybridge formation as found out by Berk& Stanley (1979)The bridge formed is readily visualizedradiographically as degeneratednecrotic zone separates the CH layerfrom bridge.
  26. 26. Dycal was introduced in 1962 and its is 2 paste CH compound.Base containing TiO2 in glycol salicylate with a pigment and catalyst containing CH and Zinc oxide ethyl toluene sulfonamide. The calcified bridge forms directly against the CH hence difficult to observe radiographically.
  27. 27.  Hydrex is a 2 paste – non essential oil, CH, Ba S04, Ti2 and a selected lesion. Bridging occurs at CH pulp interface with out induction of visible coagulated necrotic layer because of lower PH
  28. 28.  Sufficient Hydroxyl concentration still exist for stimulating the differentiation of odontoblast to produce high quality of dentinal bridge. Sciaky & Pisanti (1960) performed autoradiography with Ca to demonstrate that the Ca to form to bride does not come from CH dressing as first proposed by Zander (1939) but is probably derived from pulp tissue.
  29. 29. Calcitonin in direct and indirect pulp capping Calcitonin, the hormone produced by C cells of the thyroid playing a great role in calcium homeostasis, was used for direct and indirect pulp capping . The usefulness of calcitonin for biological treatment of pulp is unquestionable. Czas Stomatol. 1990 Aug;43(8):441-6
  30. 30.  Jn 1963 Sawusch (1963) reported Dycal was slightly superior to other as it adapted to cavity wall with fairly tight seal and had characteristic of sedative. Sometimes particles of capping material may enter the vascular channels and travel as emboli and gets lodged deeper in pulp tissue causing perivasular foci of coagulation necrosis. If too many emboli phenomenon occur the foci may coalesce and cause destruction of pulp.
  31. 31. Zinc Oxide Eugenol The unmodified ZOE have uncalcined ZNO small amount of Zinc stearate. Zinc acetate and rosin. Eugenol is 85% (Eugenol – 4 ally 1 – 2 methoxy phenol).
  32. 32.  Cavit a modified form of ZOE, has been suggested in IPC because of its good sealing capability but its strength is half of ZOE. Because of water absorption it created a negative pressure which caused odontoblast to be aspirated into dentinal tubules and caused pain. Hence Cavit should be spatulated with H2O or cavity should be moistened with eugenol prior insertion.
  33. 33. Glass ionomer cementsIn general, glass ionomer cements are classified into three main categories: Conventional- first introduced in 1972 by Wilson and Kent Metal-reinforced- 1977. Resin-modified - 1992
  34. 34.  Glass ionomer cement caused a greater inflammatory response than zinc-oxide eugenol cement, the inflammation resolved spontaneously with no increase in reparative dentin formation In an in vitro study, freshly mixed conventional glass ionomer cement was found to be cytotoxic, but the set cement had no effect on cell cultures
  35. 35.  More recently, Snugs and others have even demonstrated dentin bridging in monkey teeth where mechanical exposures in otherwise healthy pulps were capped with a glass ionomer liner. Therefore, lining is normally not necessary under conventional glass ionomer restorations when there is no pulpal exposure. Mount G. Making the most of glass ionomer cements. Dent Update 1991; 18:276-9.
  36. 36.  Concern has been raised regarding the biocompatibility of resin-modified materials since they contain unsaturated groups. A cell culture study revealed poor biocompatibility of a resin-modified liner. In contrast, Cox and others showed that a resin- modified glass ionomer cement did not impair pulp healing when placed on exposed pulps. As a result of this uncertainty, use of resin-modified materials in deep unlined cavities is probably not advisable. Sidhu SK, Watson TF. Resin-modified glass ionomer materials. A status report for the American Journal of Dentistry. Am J Dent 1995; 8:59-67 .
  38. 38.  Researchers have demonstrated that exposed pulps will heal and form reparative dentin. It is realized now that the variable prognosis of vital pulp capping is predominately a restorative issue. Vital pulp capping is the dressing of an exposed pulp with the aim of maintaining pulp vitality DPC involves the application of a medicament or dressing to exposed pulp in an attempt to preserve the vitality. The criteria for success is formation of dentin bridge (unbroken)
  39. 39.  Throughout the life of a tooth, vital pulp tissue contributes to the production of secondary dentin, peritubular dentin (sclerosis) and reparative dentin in response to biologic and pathologic stimuli. The pulp tissue , with its circulation extending into the tubular dentin , keeps the dentin moist, which in turn ensures that the dentin maintains its resilience and toughness.
  40. 40. Major advances in the practice of vital pulp capping have been made, and the emphasis has shifted from the "doomed organ" concept of an exposed pulp to one of hope and recovery. Long-term assessments of vital pulp caps with calcium hydroxide have shown very high success rates.Stanley HR. Pulp capping: conserving the dental pulp , can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol 1989; 68:628-39.
  41. 41. Studies have demonstrated that the exposed pulp possesses an inherent capacity for healing through cell reorganization and bridge formation when a proper biologic seal is provided and maintained against leakage of oral contaminants.. Stanley HR. Pulp capping: conserving the dental pulp , can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol 1989; 68:628-39. . Cox CF. Biocompatability of dental materials in the absence of bacterial infection. Oper Dent 1987; 12:146-52. Cox CF. Microleakage related to restorative procedures. Proceedings of the Finnish Dental Society; 1992.. Baume U, Holz J. Long term clinical assessment of direct pulp capping. Int Dent J 1981; 31:251- 60.
  42. 42. Direct pulp capping should be used only on avital pulp that has been accidentally injured andshows no other symptoms.Direct pulp capping should not be performed ona pulp that has been exposed as a result ofpenetrating caries.A successful pulp cap has a vital pulp and adentin bridge within 75 to 90 days.
  43. 43. Indication1. Absence of history of pain2. The exposure is small less than( 5mrn in diameter). If the exposure is a result of operators’ error (mechanical plup exposure) DPC is more successful. Carious pulpal exposure has lesser success because of presence of microorganism.
  44. 44. No observable hemorrhage or the hemorrhage fromexposure site is easily controlled.It is also important in control any excessive oozing ofserum of plasma that occupies, fills or create a space issubjected to secondary infection which can lead to lossof vitality.The excessive blood clot or thick fibropurulentmembrane favours organization and differentiation offibroblast & odontoblast to create ectopic reparativedentin formation i.e. in the cavity preparation ratherthat exposure site.
  45. 45. Exposure occurred in cleanuncontaminated field hence the importanceof rubber dam.Invasion of pulp relatively atraumatic withminimal physical irritation to pulp tissue.Dentin at periphery is repairable.Exposure site not at a constricted orpotentially constricting area in pulpchamber or root canal system.
  46. 46.  DPC has higher rate of failure in primary dentition as they have faster response to caries and resultant pulpal inflammation is faster. DPC is reserved only for mechanical exposure is primary dentition. Disagreement also exist concerning DPC and pulpotomy as permanent procedure in mature secondary teeth but it is accepted for permanent teeth with incompletely formed root with exposed pulp as it favours apexogenesis.
  47. 47.  Teeth with calcification of pulp chamber are also not candidate for direct pulp capping as they are indicative of previous inflammatory process. Periodontal involved teeth are poor risk because of diminished blood supply.
  48. 48. MATERIALS USED/ATTEMPTEDCH Zinc oxide eugenolFormocresol Tri calcium phoshateCorticosteroid Iso butyl cyanoacrylate4 META Adhesives Ortho saminoseridineCollagen Light cured CHChondroitin SO4 LaserSodium hyaluronate Enamel Matrix Derivatives(EMD)Antibiotics MTA www.indiandentalacademy.comPolycorboxylate cementDenatured albumin
  49. 49. Calcium hydroxide The opponents of calcium hydroxide claim that it does not exclusively stimulate sclerotic dentin formation, dentinogenesis, reparative dentin formation or dentin bridge formation. Cox CF, Suzuki S. Re-evaluating pulp protection: calcium hydroxide liners vs. cohesive hybridization. JADA 1994; 125:823-31.
  50. 50. They also claim that it may dissolve after one year, that acids will degrade the interface during etching, and that calcium hydroxide does not adhere to dentin and will not adhere to bonding resin composite systems One study(1996) found that calcium hydroxide bases under resin composite restorations tended to pull away from the cavity surface during resin polymerization, leaving a gap between the calcium hydroxide and dentin Goracci G, Mon G. Scanning electron microsocpic evaluation of resin-dentin and calcium hydroxide-dentin interface with resin composite restorations. Quintessence Int 1996; 27:129-35
  51. 51. Cox and others found a high rate of multiple tunnel defects (89%) in dentin bridges under calcium hydroxide. This high rate of defects, they suggest, places the long-term therapeutic effect of calcium hydroxide in serious doubt. They also suggest that calcium hydroxide disintegrates and is lost over a period of time. Cox CF, Subay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in dentin bridges: their formation following direct pulp capping. Oper Dent 1996; 21:4-11
  52. 52. Zinc oxide eugenol Glass and Zander discount the use of ZOE as capping agent in direct contact with pulp as chronic inflammation ensure. No secondary dentin bridge occurred but pulp remained vital. Hence when using ZOE sound dentin shaving are cut from surrounding walls and deposited before placement of creamy mix of unmodified ZOE.
  53. 53. Formocresol Ibrahim et al (1970) reported absence of inflammation or dentin bridging in 15 teeth using formocresol mixed ZOE. A histopathologic study of the effects of formocresol in pulp capping of permanent teeth. Egypt Dent J. 1970 Jul;16(3):219-34
  54. 54. Tri calcium phosphateHeller et al (1975) used restorableTri calcium phosphate ceramic forDPC and found a directappositional dental bridgeformation in monkeys. Longerterms study are needed on humanteeth.
  55. 55. Formation of a dentinal bridge appears to be predictable. The bridge is contiguous and thick, pulpal inflammation is minimal, and odontoblasts are observed directly under and in contact with the bridge.The ceramic form of tricalcium phosphate appears to enhance the formation of a dentinal bridge in contrast with the calcium hydroxide that was used on the control.Direct Pulp Capping of Permanent Teeth in Primates using a Resorbable Form of Tricalcium Phosphate Ceramic Journal of endodontics,volume1,number3
  56. 56. (Sawusch – 1982). Tri Calcium phosphate ceramic – this material exhibited no hard tissue barrier and had mild inflammation.There was absence of pathological sequelae such as internal resorption.
  57. 57. Ortho saminoseridine Sapone (1982) placed Ortho saminoseridine on bleeding pulp for 5 min followed by a mixture of 65% CH & 35% BaS04 and reported 95% success.
  58. 58. CorticosteroidOn applying Corticosteroid, only the paindisappears. It only preserves chronicinflammation.Germuth et al (1952) & Minkin (1953)reported increased susceptibility toinfection and spread of existing infectionincluding bacterimia and septicemia resultof antiphysiologic effect of Corticosterioid.
  59. 59. Topically applied corticosteroids cause degenerative changes in the tissue and reduce the pulpal ability to form a hard tissue barrier in the presence of calcium hydroxide Flumetazone has a general excellent effect towards rapid elimination of trauma-induced oedema in animals. Effects of Flumetazone on Exposed Dental Pulp of DogsI. CAPÍK, V. LEDECK¯, A. ·EVâÍK 2002
  60. 60. Paterson RC (1977) & Lakshmanan CD (1972) evalauated the effect of CORTICOSTEROIDS in pulp capping and reported low success rateMondo Odontostomatol. 1977 Jul-Aug;19(4):52-9.The evaluation of a corticosteroid antibiotic agent in pulp capping.J Br Endod Soc. 1972 Summer;6(2):24-34. 
  61. 61. Iso butyl cyanoacrylateIt is proved to be an excellent hemostatic agent as well as a reparative dentin bridge stimulator as reported by Berkman et al (1971) and Bhasker et al (1969).It provides an adequate seal that permits regeneration Pulp inflammatory response is minimal.No Zone of necrosis was shown. Human pulp capping with isobutyl cyanoacrylate JDent Res. 1972 Jan-Feb;51(1):58-61 Bhaskar SN, Beasley JD, Ward JP, Cutright DE.
  62. 62. Micro abscess which are morecommon in CH treated teeth alsowere fewer.It also inhibits growth of certainmicroorganism. (Spanberg & et al1974)..
  63. 63. Denatured albumin Molven (1970) used denatured albumin as it has calcium binding properties but found that it cannot be sued as a capping material as no dentine bridge was observedOral Surg Oral Med Oral Pathol. 1970 Sep;30(3):413-24.
  64. 64.  AntibioticsAntibiotic like neomycin, penicillin, keflin were used with corticosteroids. But they were found only to preserve chronic inflammation. The low rate of satisfactory responses of pulps capped with Keflin, as used, precludes its use of pulp capping.Long-term study of pulp capping in monkeys with three agents J Am Dent Assoc. 1976 Jul;93(1):105-10 (McWalter GM, el-Kafrawy AH, Mitchell DF. )
  65. 65. Polycorboxylate cement Polycorboxylate cement – though suggested as DPC material, lacked an antibacterial effect and did not stimulate calcific bridging in pulp . Durelon is not recommended for pulp capping since the material apparently lacks an antibacterial effect and does not stimulate reparative dentinogenesis at the exposure site.Long-term study of pulp capping in monkeys with three agents J Am Dent Assoc. 1976 Jul;93(1):105-10 (McWalter GM, el-Kafrawy AH, Mitchell DF .)
  66. 66. Light cured calcium hydroxideLight cured CH pulp capping products used as a linershowed all characteristic of healing and bridgeformation (Stanley and Parmeijer (1995).The success rate for DPC was 70 percent.IPC had a success rate of 85 percentBecause of the improved physical properties, VLC- Dycal was evaluated in a clinical trial for biological properties and proved to be a useful cavity liner for young permanent teeth( ASDC J Dent Child. 1991 Mar-Apr;58(2):124-8.Straffon LH, Corpron RL, Bruner FW, Daprai F. )
  67. 67. The pulpal response to mechanical exposure and capping either immediately or after 24 hours was investigated in 64 teeth of four cynomolgus monkeys with the use of Dycal, VLC Dycal, or Prisma-Bond. Dentine bridges were present in almost all teeth filled with Dycal or VLC Dycal, and pulpal inflammation was observed in only one tooth that showed evidence of infection.(Immediate and delayed direct pulp capping with the use of a new visible light-cured calcium hydroxide preparation Pitt Ford TR, Roberts GJ. Oral Surg Oral Med Oral Pathol. 1991 Mar;71(3):338-42.)
  68. 68. 4 META Adhesives Miakoshi (1993) showed that this material could soak in to the pulp, polymerize there and form hybrid layer with pulp. COX (1993) demonstrated reparative dentin deposition without subjacent pulp pathosis. This may well lead to future pulp capping material. Capping agents may have an effect on pulp apoptosis and that 4MMT may actively induce apoptosis during pulp wound healing The distribution pattern of apoptotic cells was more broadly spread, and the number of apoptotic cells was significantly larger J Endod. 2003 Jan;29(1):41-3.
  69. 69. Obersztyn (1966) Rowe A.H. (1967) used collagen, chondroitin SO4, sodium hyaluronate. The first material gave good result.
  70. 70. Collagen Dick HM (1980)studied Reconstituted antigen- poor collagen preparations as potential pulp- capping agents Wet collagen sponge and wet collagen fabric are better tolerated as pulp capping materials than dry collagen sponge or dry collagen fabric. Dentin bridge formation seems to occur only when an area of surface necrosis subsequently undergoes dystrophic calcificationJ Endod. 1980 Jul;6(7):641-4.
  71. 71. Chondroitin SO4 The word chondrotin comes from the root chondro- which means a word related to cartilage. The full word, chondrotin has a complex chemical definition, but let’s leave it here that when you add some of this material to your "calcium" formula, the matrix becomes more capable of attracting and holding the hunks of calcium.
  72. 72. Sodium hyaluronate . Sodium hyaluronate is similar to synovial fluid, a substance that occurs naturally in the joints. Synovial fluid acts as a lubricant and shock absorber Sodium hyaluronate is injected into the knee joints for the treatment of pain in individuals with osteoarthritis
  73. 73. Laser Moritz et al 1996 & 1998 have shown favourable result in DPC using continues wave and superpulsed mode CO2 laser. A study was conducted on the effects of CO2 laser irradiation on the dental pulp Among the conditions examined, an output of 60 W and an irradiation period of 0.5 s produced the most favorable border between normal and necrotic tissues. No detectable damage was observed in the radicular portions of pulps that were irradiated Histopathological Changes in Dental Pulps Irradiated by CO2 Laser: A Preliminary Report on Laser Pulpotomy Shigeru Shoji, Masanori Nakamura, and Hiroshi Horiuchi september1985,vol 11,number 9
  74. 74.  The laser and Vitrebond direct pulp cap produces a significantly more predictable pulpal response after the first 6 months than the Dycal direct pulp cap. The survival rate of teeth treated with the laser and Vitrebond direct pulp cap is significantly greater than those treated with the Dycal direct pulp cap over intervals of 9 to 54 monthsDycal versus Nd:YAG laser and Vitrebond for direct pulp capping in permanent teeth. Santucci PJ. . J Clin Laser Med Surg. 1999 Apr;17(2):69-75
  75. 75.  Lou Graham (2003)The CO2 laser showed a 89% success versus a 68% success versus Ca(OH)2 therapy The use of lasers in treating carious lesions has become more common and provides certain major advantages where the vitality of the pulp is concerned Direct Pulp Capping Using an Er, Cr:YSGG Laser Blanken, Jan Walter J Oral Laser Applications 5 (2005), No 2
  76. 76.  Complete but thin dentin bridges and no inflammation were observed after 90 days CO2 laser irradiation and/or capping with Clearfil Megabond could result in pulp healing that is similar to CaOH capped teeth. Histopathologic Responses to CO2 Laser and Two-step Adhesive System M. SHIRONO, T. EBIHARA, and Y. KATOH ,
  77. 77. Enamel MatrixDerivative (EMD)
  78. 78. During odontogenesis,amelogenins from thepreameloblasts are translocated todifferentiating odontoblast in thedental papilla, suggesting thatamelogenins may be associatedwith odontoblast changes duringdevelopment
  79. 79. Enamel matrix derivative exerts a considerableinfluence on odontoblasts and endothelial cellsof capillaries in dental pulp tissue.Enamel matrix derivative used as a pulp cappingmaterial may play a role in the calcification ofdental pulp tissue.
  80. 80.  In the EMD-treated teeth, substantial amounts of dentine-like tissue formation consistently led to a complete hard-tissue bridging of the defects. The onset of hard tissue formation could be observed after 2 weeks and was located only on the pulpal wound. More limited dentine formation was also observed in Dycal-treated teeth. Nakamura YThe induction of reparative dentine by enamel proteins--- (2003)
  81. 81. However, in these teeth the new hard tissue formed at the expense of pulp chamber width, causing narrowing of root canals. The total amount of reparative dentine formed in the EMD-treated teeth was higher P<0.005) than in the Dycal-treated specimens Nakamura YThe induction of reparative dentine by enamel proteins--- (2003)
  82. 82. The potential of EMD as a biologically activepulp-dressing agent that specifically inducespulpal wound healing and dentine formation inthe pulpotomized teeth without affecting thenormal function of the remaining pulp. Nakamura YThe induction of reparative dentine by enamel proteins--- (2003)
  83. 83.  In the EMD-treated teeth, large amounts of newly formed dentin-like hard tissue with associated formative cells outlined the pulpal wound separating the cavity area from the remaining pulp tissue. Inflammatory cells were present in the wound area but not subjacent to the newly formed hard tissue. Adv Dent Res. 2001 Aug;15:105-7
  84. 84. Morphometric analysis showed that the amountof hard tissue formed in EMD-treated teeth wasmore than twice that of the calcium-hydroxide-treated control teeth (p < 0.001), suggesting thatEMD is capable of promoting reparativeprocesses in the wounded pulp more stronglythan is calcium hydroxide. Adv Dent Res. 2001 Aug;15:105-7
  85. 85.  Enamel matrix derivative exerts a considerable influence on odontoblasts and endothelial cells of capillaries in dental pulp tissue. These results imply that enamel matrix derivative used as a pulp capping material may play a role in the calcification of dental pulp tissue. Histopathological study of dental pulp tissue capped with enamel matrix derivative -J Endod. 2003 Mar;29(3):176-9.
  86. 86.  Postoperative symptoms were less frequent in the EMDgel-treated than in the calcium hydroxide-treated teeth, especially during the first six weeks. In the EMDgel-treated teeth, new tissue partly filled the space initially occupied by the gel and hard tissue was formed alongside the exposed dentine surfaces and in patches in the adjacent pulp tissue. EMD was detected in the areas where new hard tissue had been formed. Dental pulp capping: effect of Emdogain Gel on experimentally exposed human pulps -Int Endod J. 2005 Mar;38(3):186-94.
  87. 87.  The wound area of the EMDgel-treated teeth exhibited inflammation in the majority of the teeth whereas less inflammation was seen in the calcium hydroxide-treated teeth where the hard tissue was formed as a bridge. In the EMDgel-treated teeth, postoperative symptoms were less frequent and the amount and pattern of hard tissue formation were markedly different than in the teeth treated with calcium hydroxide.Dental pulp capping: effect of Emdogain Gel on experimentally exposed human pulps -Int Endod J. 2005 Mar;38(3):186-94.
  88. 88.  However, the operative procedure and the formulation with EMD in a PGA vehicle do not seem to be effective for the formation of a hard tissue barrier. Emdogain Gel (Biora AB, Malmo, Sweden), consisting of a enamel matrix derivative (EMD) in a propylene glycol alginate (PGA) vehicle,Dental pulp capping: effect of Emdogain Gel on experimentally exposed human pulps -Int Endod J. 2005 Mar;38(3):186-94.
  89. 89. Mineral TrioxideAggregate (MTA)
  90. 90. GREY &WHITE MTA Electron probe microanalysis results indicated that lime (CaO), silica (SiO2), and bismuth oxide (Bi2O3) were the dominant compounds in each case And were present at comparable levels in either of the types of mineral trioxide aggregate analyzed. It was concluded that the most significant differences observed were between the measured concentrations of Al2O3 (+122%), MgO (+130%), and especially FeO (+1000%) when gray mineral trioxide aggregate was compared with white mineral trioxide aggregate. Chemical Differences Between White and Gray Mineral Trioxide Aggregate . Journal of Endodontics. 31(2):101-103, February 2005. Asgary, Saeed DDS, MSc; Parirokh, Masoud DDS, MSc; Eghbal, Mohammad Jafar DDS, MSc; Brink, Frank BAppSc, MSc
  91. 91.  Mineral Troxide Aggregate (MTA) is a sealing agent that has been developed to close communication between the pulp canal system and external surfaces of the teeth The material has been well studied in experiments that showed good sealing ability and bio- compatibility. It has been successfully used to close iatrogenic perforations of furcations, as retrograde filling of root ends and for orthograde filling of root canals. MTA has the same chemical properties as Portland cement except that MTA also has bismuth to give it a more opaque look in a radiograph.
  92. 92.  MTA can be used as a pulp capping material in vital mechanical exposure or in primary tooth pulpotomy.  Ford et al (October 1996) found that pulps capped with MTA had no pulpal inflammation after five months in five of six samples and all six pulps in this group had a complete dentin bridge formation.  In contrast, all the pulps capped with Ca(OH)2 showed pulpal inflammation, and bridge formation occurred in only two samples.
  93. 93.  Eidelman, Holan, and Fuks (January 2001) did a study to compare the effect of MTA with that of formocresol as pulp-dressing agents in pulpotomized primary molars with carious pulp exposure.  They found that none of the MTA- treated teeth showed any clinical or radiographic pathology at a 17-month recall.
  94. 94.  MTA did not induce apoptosis MTA induced proliferation, and not apoptosis, of pulp cells in vitro These findings suggest a potential mechanism to explain the regenerative effect observed in the dentin- pulp complex when MTA was used for direct pulp capping. Effect of ProRoot MTA on Pulp Cell Apoptosis and Proliferation In Vitro. Journal of Endodontics. 31(5):387-391, May 2005. . Moghaddame-Jafari, Sasan; Mantellini, Maria G.; Botero, Tatiana M.; McDonald, Neville J.; Nor, Jacques E
  95. 95.  Histological evaluation demonstrated less inflammation, hyperaemia and necrosis plus thicker dentinal bridge and more frequent odontoblastic layer formation with MTA than calcium hydroxide. MTA and calcium hydroxide as pulp-capping agents in human teeth: a preliminary report. Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS Int Endod J. 2003 Mar;36(3):225- 31
  96. 96. GREY &WHITE MTA Gray MTA setting time was lower than that of white MTA. According to Holland et al. (2002), the mechanism of action of white MTA is very similar to that reported for gray MTA Granulations birefringent to polarized light at the opening of dentin tubes filled with white MTA. These granulations were similar to the calcite crystals observed with calcium hydroxide.
  97. 97.  MTA has no calcium hydroxide, but rather calcium oxide that could react with tissue fluids to form calcium hydroxide. Next to these granulations, there was a deposit of von Kossa-positive hard tissue that resembled a mineralized bridge. The mechanism of action of white MTA were very similar to that reported for gray MTA . Considering these results, we believe that the white MTA may be considered to be an effective pulp capping material. Braz. Dent. J. vol.15 no.2 Ribeirão Preto 2004
  98. 98.  Mineral Trioxide Aggregate (MTA) is a new material approved by the FDA for use in pulpal therapy. MTA has been reported to have superior biocompatibility and sealing ability and is less cytotoxic than other materials currently used in pulpal therapy Schmitt, D., J. Lee, and G. Bogen, Multifaceted use of ProRoot MTA root canal repair material. Pediatr Dent, 2001. 23(4): p. 326- 30.
  99. 99. ProcedureAfter anaesthetizing and isolation, undermined enamel and unsound dentin is removed. ↓The cavity floor and exposure site is washed gently with sterile water and dried with cotton pellet.The basing material is prepared and placed directly over exposure site. ↓ Permanent restoration is then placed. ↓Patient is recalled after 6 to 8 weeks for CH and 8 to 9 weeks if unmodified ZOE is used.
  100. 100.
  101. 101. Although both techniques can achievesuccessful vital pulp caps, the calcium hydroxide technique has demonstrated its success over a longer period of time.Which technique offers the better prognosisawaits the results of many more long-term studies.
  102. 102.  Failures of pulp capping could be due to microbial contamination  dentinal debris and  lack of peripheral seal apart from operators  inability to perform proper surgical procedures.
  103. 103.
  104. 104.  Partial pulpotomy (Cvek technique) (1978). This consisted of amputation of only 1 to 2mm of exposed pulp and then placement CH. This is also called as pulp curettage.
  105. 105.  It is defined as the surgical excision of the coronal portion of a vital pulp. Thereby vitality of radicular pulp is maintained by the placement of medication at the amputated area. Pulpotomy is accepted procedure for both primary & permanent teeth with carious exposure..
  106. 106.  The goal of an ideal pulpotomy in primary teeth are to maintain arch length preserve masticatory function and remove infection and chronic inflammation from oral cavity
  107. 107.  The justification of this procedure is that the coronal pulp tissue adjacent to carious exposure, contains microorganism & inflammatory changes. This abnormal tissue is removed & healing allowed to take place at entrance of pulp canal. Traditionally the term pulpotomy has implied removal of pulp tissue to the cervical line. However the depth to which the tissue is removed is determined by clinical judgment.
  108. 108. Indication History of patient  Carious tooth with neither spontaneous nor persistent pain.  Immediate trauma with history of occurrence within one hour without bleeding from tooth.  Complaint of slight pain on taking hot and cold which is not persistent.
  109. 109. Clinical Examination Deep carious lesion which is restorable. Fracture of tooth where the fracture line is near to pulp horn. Absence of mobility, gingival pathology and fistulous tract. If exposure is recent one the hemorrhage from the site of amputation is pale red & easy to control. The size of exposure not more than 1.2mm. Tooth is vital.
  110. 110. Radiological Tooth has at least two third of root. No evidence of external & internal root resorption. Carious lesion very near to pulp. Tortuous and ribbon shaped root canals.
  111. 111. CONTRAINDICATIONTeeth with 1. Spontaneous pain 2. Mobile 3. Tenderness to percussion 4. Pulp calcification
  112. 112. Therapeutic approaches to pulpotomy Uses CH over amputated pulp The CH pulpotomy is predicated on the healing of pulp stumps under a dentin bridge where as formocresol pulpotomy is predicated on sterilization of the subjacent tissue. Uses formocresol Dannerberg (1974) said that the mummified pulp under formocresol is inert, fixed and incapable of bacterial or autolytic breakdown.
  113. 113. ProcedureAfter anesthetization and isolation remaining dental caries is removed with slow speed round bur. ↓ The entire roof of pulp chamber is removed with a fissure bur in high speed hand piece. ↓After unroofing, amputate the coronal pulp using sterile round bur or a sterile sharp discoid spoon excavator. ↓ The pulp tissue should be cleanly excised with no tags of tissues. (In 1998 Winter has suggested a conservative approach where in dentinal roof of pulp chamber is preserved thus obtaining an important reinforcement of the tooth )
  114. 114. Haemostasis is obtained in radicular pulp by exerting pressure with sterile cotton pellets. ↓After post amputation the blood clot is formed after the use of saline moistened cotton pellet to if radicular pulp is healthy. ↓ If bleeding continues pulp stump are exposed to air for few minutes and even then bleeding persists it indicates inflamed radicular pulp tissue also. ↓Therefore plain anaesthetic solution is used so as not to mask the diagnosis.
  115. 115. INDICATIONS FOR CH PULPOTOMY CH pulpotomy is recommended for permanent teeth with immature root development but with healthy pulp tissue in root canals. It is also indicated for a permanent tooth with a pulp exposure resulting form crown fracture when trauma has produced root fracture also. The technique is completed in single appointment.
  116. 116.  After the amputation procedure as described and control of hemorrhage the CH capping material is placed to provide adequate seal and then the tooth is prepared for full coverage. Polycarboxylate cement can also be used as a cavity sealing material instead of ZOE. Successfully treated tooth should have after 1 year a normal periodontal ligament and lamina dura, radiographic evidence of calcific bridge and no readiographic evidence of internal resorption or pathologic resorption. Thus its use can cause apicogencsis of young permanent tooth.
  117. 117.  The formocresol pulpotomy is recommended for the primary dentition. The use of CH in primary dentition causes internal resorption which may be due to over stimulation of primary pulp causing mateplasia in the pulp tissue leading to odontoclast formation.
  118. 118. Formocresol pulpotomy is done in 2 methods.  One appointment pulpotomy  Two appointment pulpotomyFormocresol used has  Cresol – 35%  Formalin 19%  Glycerin and water.
  119. 119. One appointment pulpotomyThe orifice of root canals are covered by cotton pellet moistened in formocresol solution for 1 minute. ↓The cotton pellet should be compressed between two layers of gauze sponge to remove excess. ↓After removal of the cotton pellet, ZOE base is placed.
  120. 120.  Alternatively diluted formocresol into ZOE dressing can be placed instead of moistered formocresol pellet followed by ZnPO4 cement & silver amalgam. If silver amalgam is not possible a stainless steel crown is placed. Periodic checkup at 6 weeks, 12 weeks and six months is made where tooth is clinically and radiologically assessed. Clinical evaluation includes history of pain, tenderness on percussion & mobility. Vitality is assessed with pulp tester.
  121. 121. Two appointment pulpotomy.Indication: where there is sluggish bleeding at amputation site or profuse, uncontrollable bleeding pus or infection in the chamber only and not at amputation site when shorter appointments are necessary when there is problem in patient management.
  122. 122. Procedure:The procedure is same for 1 appointment except for few steps. The cotton pellet moistened with formocresol is sealed into the chamber for 5 to 7 days instead of taking out within one min., above it temporary filling is placed. At second visit it is replaced with ZOE followed ZnP04 cement and amalgam. Emerson (1959) reported that five minute application of formocresol resulted in surface fixation or normal tissue whereas an application sealed in for 3 days produced calcific degeneration. Hence formocresol pulpotomy may be classified as vital or non vital depending on duration of formocresol application.
  123. 123.  Maste rand Mansukhiani in 1959 found 3 distinctive zones in pulp after placement of formocresol within 7 to 14 days 1) broad eosinoptic zone of fixation 2) a broad pale staining zone with poor cellular definition 3) a zone of inflammation diffusing apically into normal tissue.
  124. 124.  Formocresol is known to have carcinogenic effect. Alternative to formocresol, 2% gultheraldehyde can be used for pulpotomies in primary teeth as suggested by Kopel and his colleague in 1980. They found that there is a initial zone of fixation adjacent to the dressing that did not proceed apically. The tissue adjoining the fixed zone and down to the apex had cellular detail of normal pulp Gluteraldehyde is less antigenic.
  125. 125. MATERIALS USED/ATTEMPTEDCalcium HydroxideFormocresolGluteraldehydeMTAToveruds pasteN2Ferric sulfateLaserElectrosurgeryRecombinant human insulin-like growth factor I (rhIGF-I)
  126. 126. Calcium Hydroxide Calcium hydroxide, a regenerative pulpotomy agent, has been reported to be a failure in primary teeth due to higher incidence of the development of chronic pulpal inflammation and internal resorption (Evaluation of deciduous teeth treated by pulpotomyand calcium hydroxide J Am Dent Assoc 1955; 50: 34 40 A comparative Evaluation of Two Pulpotomy Agents in Primary Molars 10. Magnusson B.: Therapeutic pulpotomy in primary molarclinical and histologic follow up. Odontol Revy 1970; 21: 415-431). However, recent studies have reported a favorable result for calcium hydroxide by controlling the variables of treatment such as pulpotomy technique, strict selection criteria, etc .( Br DentJ 2000; 188: 32-36. J Am Dent Assoc 1984; 108: 775-778 , J Am Dent Assoc 1984; 108: 775-778 , Br DentJ 2000; 188: 32-36)
  127. 127. . Recent advances in the field of bone and dentin formation have opened new vistas for pulp therapy. Bone morphogenetic proteins (BMPs) and Growth factor [such as transforming growth factor (TGF), platelet derived growth factor(PDGF),insulin growth factor (IGF)] derived from platelet have generated considerable interest during the last few years..Int. J. Periodont Rest Dent 1996; 16: 8-19., Int. J Periodont Rest Dent 2002; 22: 45-53.
  128. 128. Lyophilized Freeze Dried Platelet Derived Preparation with Calcium Hydroxide Lyophilized freeze dried platelet derived preparation showed a 100% success rate, as all these teeth were asymptomatic and not showing any signs of pulpal degeneration clinically and radiographically Animal and human invivo and invitro studies have shown that these proteins stimulates differentiated cell of pulp to differentiate into odontoblast to deposit a layer ofdentin (S.G.Damle 2004)
  129. 129. Formocresol Sweet popularized the formocresol pulpotomy technique in the 1930s and clinical and radiographic success rates of 98% have been reported. The primary concern regarding the use of formocresol is related to its toxicity and possible bloodborne spread to distant sites. Meyers, et al, demonstrated this phenomenon in a study of rhesus monkeys that found that a five-minute exposure of pulpal tissue to 14C-formocresol resulted in the systemic absorption of approximately 1% of the dose Formocresol, a devitalizing agent has been reported to be carcinogenic and mutagenic
  130. 130. Gluteraldehyde Glutaraldehyde, a preservative agent has been proposed as an alternative to formocresol, that results in inadequate fixation and leaves a deficient barrier to sub base irritation, resulting to internal resorption. Sharon D. H, SueSeale N., Quintero M. and Guo L. Y: Effect of glutaraldehyde pulpotomy treatment on pulpal enzymes.Pediatr Dent 1993; 15: 337-342. . Kopel M. H., Bernick S., Zachrisson E. and Deromero S. A.: The effect of glutaraldehyde on primary pulp tissue following coronal amputation: an in vivo histologic study. J Dent Child 1980; 47: 425-430.
  131. 131. It would appear that glutaraldehydemay offer distinct advantages overformocresol, in the treatment ofcariously exposed primary and youngpermanent teeth.In particular, due to its chemicalstructure, it is more active in fixing thesurface tissues and is more rapidlylimited in its depth of penetrationthrough these tissues.
  132. 132. Glutaraldehyde does not exhibit assignificant an ability to induce the totalloss of vitality, in the radicular pulptissues.The progression of formocresol treatedpulps to apparent fibrotic replacementvia granulation-tissue ingrowth,through the apex, does not occur withthe glutaraldehyde-treated pulp tissues.
  133. 133. There may, however, be a slow progression of fibrotic replacement of the glutaraldehyde fixed tissue, in the coronal portion of the radicular pulp. Perhaps most importantly it would seem that since the glutaraldehyde does not perfuse the tissues to the apex, it will not demonstrate systemic distribution and other extradental phenomena, as have been identified with the use of formocresolGlutaraldehyde: an alternative to formocresol for vital pulp therapy.Davis MJ, Myers R, Switkes MD. ASDC J Dent Child. 1982 May-Jun;49(3):176-80
  134. 134. Mechasism of fixation Lactic dehydrogenase, a respiratory enzyme, wassharply affected by 0.5 percent and one percent glutaraldehyde and a 1:5 dilution of formocresol, exhibiting 7-, 71-, and 40-fold decreases in activity, respectively. Alkaline phosphatase was much less responsive to these same agents, giving only 4.5-, 17-, and 2.5-fold reductions after treatment, respectively.These findings support histochemical studies which have suggested the sensitivity of respiratory enzymes of the pulp to fixative medicamentsThe effect of formocresol and glutaraldehyde on certain enzymes in bovine dental pulp.Cunningham KW, Lazzari EP, Ranly DM.Oral Surg Oral Med Oral Pathol. 1982 Jul;54(1):100-3. KW, EP, DM.Oral
  135. 135. MummificationDental pulp mummification atechnique of producing dry gangreneof the pulp by means ofdrugs, in which the dental pulp driesand shrivels
  136. 136.  The primary reaction of formaldehyde is with the functional groups which are nucleophillic. These may be found in various anion – acid side chains of proteins and the amino group of nucleic acids. Thus formaldehyde serves as an addictive, non- coagulative fixative and as a bactericide. Also suggested that, a hemi – acetal, formed between formaldehyde and cresol would diffuse through the tissues less rapidly which might explain the reduction in the irritating preparation.
  137. 137. Buckley’s formula of formocresol Formation : 19ml Cresol : 35ml Glycerin : 25ml Water : 21mlThe action of glycerin is to decrease the polymerization of paraformaldehyde, which causes clouding in the solution as it was observed by Stephen in 1971.
  138. 138. GLUTARALDEHYDE Glutaraldehyde is a bactericide and a tissue fixative. It is an apliphatic dialdehyde. It forms direct intermolecular links between adjacent protein chasing and underlines its properties as a tissue fixative. Similarly the cross linking of the proteins or micro- orgainsms accounts for its powerful antiseptic action. As it cross links very fast, it does not diffuse through the periapical tissues.
  139. 139.  In 1995 Waly NG suggested the used of CH – gluteradelyed for pulpotomy and reported 100% success in comparison to 80% success when CH was used alone.
  140. 140. Toveruds paste Sveen OB(1970) studied Toveruds paste as Pulpotomy medicament in Primary molar teeth
  141. 141. N2 PROMINENT TOXICOLOGIST CONFIRMS N2 IS SAFE! Dr. Brent, who is associate professor of Medicine, Surgery and Pediatrics at the University of Colorado Health Science Center, testified that given the extremely small amounts of material (N2) used in endodontic therapy, a prior dose response makes any systemic illness from this treatment implausible
  142. 142.  "I would say that given the many, many years of use of this material, given the large number of people that have been treated with it, given the fact that there hasnt been a single report in the scientific literature of a systemic effect attributed to Sargenti paste, given the scientific implausibility, given the small amounts of formaldehyde and lead that somebody would be exposed to from such a Sargenti paste, I would say that it would just be a waste of time to look for systemic effects. It cant happen." Dr. Brent (1988)
  143. 143.  N2 earlier formulations had lead oxide and mercury, newer formulations do not . The reaction is coagulative necrosis and reaches maximum in 3 days. Blood-lead levels after root canal treatment with N2 cement were elevated when compared to preoperative controls. Lead 210 was incorporated into the leadfree N2 cement to identify the source of lead. Analyses of blood samples for 210Pb indicated that the lead originated from the filling material. September 1975, Volume 1, Number 9Shapiro, Iaquinta, Mitchell and Grossman
  144. 144. Ferric sulfateferric sulfate or iron (III) sulfate, chemicalcompound, Fe 2 (SO 4 ) 3 , a yellow rhombiccrystalline hygroscopic water-soluble salt thatdecomposes when heated to a temperature of480°C. The enneahydrate, Fe 2 (SO 4 ) 3 ·9H 2O, is a deliquescent rhombic crystalline salt that occursin nature as the mineral coquimbite. It is used as amordant in dyeing, as a coagulant for industrial wastesin pickling baths for aluminum and steel, and in pigments
  145. 145. Ferric sulphate has been proposed as a substitute to formocresol, and the success rates were comparable to those of formocresol. FS has been used as a hemostatic agent for crown and bridge impressions [Fisc her, 1987]. Even though the mechanism of the haemostatic action of FS is still debated, it seems that agglutination of blood proteins results from the reaction of blood with ferric and sulphate ions with the acidic pH of the solution. The agglutinated proteins form plugs that occlude the capillary orifices [Lemon et al., 1993].
  146. 146.  The use of FS was recommel on the grounds that it may prevent problems arising from clot formation after the removal of the coronal pulp. It may also minimize the chances for inflammation and internal resorption that, according to Schroder [1978], was an important factor for the failure of pulpotomies with calcium hydroxide. A histological study on baboon teeth produced pulp responses utilizing ferric sulfate that compared favorably to formocresol pulpotomies. Ferric sulfate also demonstrated as good or better clinical and radiographic success in human clinical trials.
  147. 147. The most common pathologic finding for FSpulpotomy-treated incisors was widenedperiodontal ligament space (in 67% of FS-treated incisors but only 18% of RCT incisors).Internal resorption was observed in 17% of FS-treated incisors, and was sufficiently severe insome incisors to be rated unacceptable.Outcomes of Vital Primary Incisor Ferric Sulfate Pulpotomy and Root CanalTherapy J Can Dent Assoc 2004; 70(1):34–8
  148. 148. Laser Laser therapy is a non-pharmacologic hemostatic technique for pulpotomy procedure. But research on laser therapy for primary tooth pulpotomy is sparse . Success rate of Nd:YAG laser pulpotomy was higher than formocresol pulpotomy. The permanent successors of the laser treated group erupted without any complications. Therefore, Nd:YAG laser pulpotomy can be considered for use as pulpotomy technique in clinical practice.Nd:YAG laser pulpotomy of human primary teeth International Congress Series Volume 1248 , May 2003, Pages 251-256Jengfen Liu
  149. 149.  At 1 week after treatment, no inflammation or resorption was observed in any cases in the control or 34 mJ/pulse-irradiated groups. However, moderate to severe inflammation was observed in 9 of 10 cases (90%) in the 68 and 102 mJ/pulse- irradiated groups. Effects on pulp tissues during a pulpotomy procedure by Er:YAG laser irradiation are minimal, if appropriate parameters are selected, and this is a potential therapy for pulpotomy of human teeth. Journal of Clinical Laser Medicine & Surgery Histopathological Changes in Dental Pulp Irradiated by Er:YAG Laser: A Preliminary Report on Laser Pulpotomy Dec 2003, Vol. 21, No. 6: 345- 350
  150. 150. Electrosurgery Ruemping et al (1983) found Electrosurgery pulpotomy gave favourable tissue response Shulmen et al (1987) gave a negative result. Another form of Electrosurgery is Electrofulguration which need further histologic investigation.
  151. 151.  Daniel W. Shaw (1987)Pulps of the treated teeth were evaluated histologically for the presence of inflammation, fibrosis, necrosis, resorption, and reparative dentin formation. Results indicated that the electrosurgery pulpotomy technique produced a tissue response comparable to that induced with the conventional formocresol pulpotmy technique
  152. 152. Recombinant human insulin-like growth factor I (rhIGF-I) The pulp was covered with one dose of sterile 4% methylcellulose gel containing either 400 ng rhIGF-I or saline in contralateral controls. The exposure site was closed with sterile Teflon membrane, and the cavity was filled with IRM cement. The reparative dentin response to capping with rhIGF- I was similar to that after the use of Dycal. Pulp-capping with recombinant human insulin-like growth factor I (rhIGF-I) in rat molars Advances in Dental Research, Vol 15, Issue 1, 108-112
  153. 153. Therapeutic Regulation of Tertiary Dentinogenesis: Existing Knowledge and Future Perspectives for Research The ability of the pulp-dentin complex to respond to therapeutic applications by specific cellular processes and hard tissue formation has long been recognized. Current researchs has provided insights into the basic molecular events underlying dental tissue repair, induction of tertiary dentin formation, competence of the responsive cells and how these phenomena could be integrated into the clinical approach to the problem of vital pulp therapy [Lesot et al., 1994; Smith et al., 1995; Rutherford, 1999; Tziafas et al., 2000].
  154. 154. Application of biologically active growth and morphogenetic factors and extracellular matrix molecules as capping materials resulted in hard tissue formation.Bone morphogenetic proteins (BMP), such as BMP-2, BMP-4 and BMP-7 (osteogenic protein- 1), induced formation of osteodentin in large amounts followed by tubular reparative dentin [Nakashima, 1994a, b; Rutherford et al., 1993; Jepsen et al., 1997].Capping experiments with insulin-like growth factor-I have demonstrated complete dentinal bridging and occasionally tubular reparative dentin formation [Lovschall et al., 2001]
  155. 155. Transdentinal Stimulation of Reactionary Dentinogenesis The aim of a regenerative treatment strategy in the case of mild dentinal injuries is to stimulate localized peritubular dentin formation and to provide a regional and time-limited effect on surviving odontoblasts, in order to up- regulate their biosynthetic activity
  156. 156. Transdentinal Stimulation of Reparative Dentinogenesis The ultimate goal of a regenerative treatment strategy is to favour the biological activity of dentin matrix, which in an appropriate pulpal environment is able to trigger differentiation of new odontoblastlike cells replacing lost primary odontoblasts. result in differentiation of odontoblast-like cells for replacement of the lost odontoblasts and a time-limited formation of reparative dentin corresponding to the involved area.
  157. 157. Direct Induction of Reparative Dentinogenesis The ultimate goal of a regenerative treatment strategy is to induce differentiation of odontoblast-like cells at the pulp-capping material interface and to up-regulate the biosynthetic activity of primary odontoblasts around the pulpal exposure to reconstitute the lost continuum
  158. 158. Conclusion For unknown reasons, the pulp-capping agent used, and not the procedure itself, has been the subject of controversy among researchers Development of new capping materials for delivery of exogenous signaling molecules offers exciting opportunities for the future. However, a number of critical considerations, such as the dose-response effects, the nature of the delivery system, half-life of the molecules and their possible side-effects need to be addressed before any introduction of new treatment modalities into clinical practice.
  159. 159. THANK