Pulp Therapy by nishtha


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Pulp Therapy by nishtha

  1. 1. DEPARTMENT OF PEDODONTICS AND PREVENTIVE DENTISTRY <ul><li>SANTOSH DENTAL COLLEGE AND HOSPITAL </li></ul><ul><li>(GHAZIABAD) </li></ul><ul><li>Assignment on “Indirect Pulp Capping, Direct Pulp </li></ul><ul><li>Capping and Pulpotomy” </li></ul><ul><li>Guided by : Submitted by: </li></ul><ul><li>Dr. Binita Srivastava Navneet kaur bhatia </li></ul><ul><li>Dr. H.P.Bhatia Narendra kumar singh </li></ul><ul><li>Dr. Archana Aggarwal Mohita gupta </li></ul><ul><li>Dr. Ashish Singh Batch (2005 - 2006) </li></ul><ul><li>Dr. Aarti Puri </li></ul>
  8. 8. INTRODUCTION Ref:20
  9. 9. INTRODUCTION <ul><li>Pulp protection is the term coined by AAPD which recommends the placement of a protective base or a liner on the pulpal and axial walls of the cavitypreparation to act as a protective barrier betweeen the restorative material and the tooth.This procedure is indicated in cases where the floor of the cavity is completely clean or in other words not infected. In deep cavities the dentin covering the pulp is very thin and dentinal tubules are closely packed.This dentine is highly permeable and needs a protective base which seals the dentinal wall.materials that can be used as a protective linerinclude glass inomers,resin modified glass inomer cements,and dentinal bonding agents.the use of bonded amalgam restorations is still to be justifiedto be used in daily clinical practice. </li></ul><ul><li>Pulp treatment modality can be classified to 2 categories- </li></ul><ul><li>A-CONSERVATIVE TREATMENT-Which aims at maintaining pulp vitality,include </li></ul><ul><li>Protective base. </li></ul><ul><li>Indirect pulp treatment. </li></ul><ul><li>Direct pulp capping. </li></ul><ul><li>PULPOTOMY. </li></ul><ul><li>B-Radical treatment-consisting of pulpectomy and root filling. </li></ul><ul><li>Ref1,pg398 9 </li></ul>
  10. 10. Ref 16, page 22 DEFINITION OF THE PRINCIPAL TERMS USED IN PULPAL PROTECTION AND VTAL PULP THERAY TERM DEFINITION Pulp cap Treatment of an exposed vital pulp in which the pulpal wound is sealed with a dental material, such as calcium hydroxide or MTA, to facilitate the formation of reparative dentine and maintenance of vital pulp. Direct pulp cap A dental material placed directly on a mechanical or traumatic vital pulp exposure. Step wise caries excavation A material is placed on a thin partition of remaining carious dentin that if removed might accidentally expose the pulp (for immature permanent tooth) Pulpectomy (pulp extirpation) The complete surgical removal of the vital pulp Pulpotomy( pulp amputation) The surgical removal of the coronal portion of the vital pulp as a means of preserving vitality of the remaining radicular portion is usually is performed as an emergency procedure for temporary relief of symptoms or therapeutic measure.
  11. 11. Partial pulpotomy(shallow pulpotomy; cvek pulpotomy) The surgical removal of the small diseased portion of vital pulp as the means of preserving the remaining corona and radicular pulp tissue. apexification Inducing a calcified or artificial barrier in a root with an open apex or the continued apical development of an incompletely formed root in teeth with a necrotic pulp. apexogenesis A vital pulp therapy procedure performed to enable continued physiologic development and formation of the root end; term frequently used to describe vital pulp therapy that encourages the continuation of this process. Ref 16, page 22
  13. 13. <ul><li>INDIRECT PULP CAPPING </li></ul><ul><li>Definition </li></ul><ul><li>Objectives </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Indirect pulp therapy </li></ul><ul><li>Indirect pulp capping technique </li></ul><ul><li>DIRECT PULP CAPPING </li></ul><ul><li>Definition </li></ul><ul><li>Objectives </li></ul><ul><li>Indications </li></ul><ul><li>Direct pulp capping technique </li></ul><ul><li>Histologic changes after pulp capping </li></ul><ul><li>contraindication </li></ul>
  14. 14. <ul><li>INDIRECT PULP CAPPING - </li></ul><ul><li>DEFINITION -It is defined by Ingle as a procedure where in small amount of carious dentin is retained in deep areas of cavity to avoid exposure of pulp, followed by placement of a suitable medicament and restorative material that seals off the carious dentin and encourages pulp recovery. </li></ul><ul><li>Its rationale is that carious dentin consists of two distinct layers-an outer layer is irreversibly denatured ,infected, not remineralizable and should be removed and an inner layer that is reversibly denatured ,not infected, remineralizable and should be preserved. </li></ul><ul><li>ref no.5, page 179 </li></ul><ul><li>To remove the infected dentin and leaving intact the affected dentin, so that the affected dentin will reminralize and act as a barrier above the healthy pulp. </li></ul><ul><li>ref no. 6, page 286 </li></ul>The procedure involving a tooth with a deep carious lesion where removal is left incomplete, and the decay process is treated with a biocompatible material for some time in order to avoid pulp tissue exposure is termed as indirect pulp capping. -A radiopaque base is placed over the remaining affected dentin to stimulate healing and repair. The tooth is then restored with a material that seals the involved dentin from the oral environment. ref no.1, page 398
  15. 15. <ul><li>- The procedure in which only gross caries is removed from the lesion and the cavity is sealed for a time with a biocompatible material is reffered to as direct pulp capping. </li></ul><ul><li> ref no.4, page 393 </li></ul><ul><li>- Is used when a tooth has a deep carious lesion,in which case total removal of all carious dentin would most certainly result in a large pulp exposure necessiating complex and experience dental endodontic treatment. </li></ul><ul><li> ref no.3, page 3 </li></ul><ul><li>Indirect pulp capping is a technique in which an effort is made to avoid pulpal exposure during the treatment of teeth with deep carious lesions ,without any evidence of `pulpal degeneration or periapical pathology.the procedure allows the tooth to utilize the natural protective defence mechanism. </li></ul><ul><li>ref no.17, page 360 </li></ul>
  16. 16. <ul><li>JUSTIFICATIONS- </li></ul><ul><li>1. reduction of hyperemia in pulp </li></ul><ul><li>2. remineralization of carious or precarious dentin </li></ul><ul><li>3. reduction of anaerobic bacteria </li></ul><ul><li>4. formation of reparative dentin </li></ul><ul><li>5. pulp vitality maintained </li></ul><ul><li>6. continued normal root closure in immature permanent teeth </li></ul><ul><li> ref no.1, page 398 </li></ul><ul><li>OBJECTIVES- </li></ul><ul><li>These were given by eidelman in 1965- </li></ul><ul><li>arresting the carious process </li></ul><ul><li>promoting dentin sclerosis </li></ul><ul><li>stimulating formation of tertiary dentin </li></ul><ul><li>remineralization of carious dentin ref no.5, page 179 </li></ul>
  17. 17. <ul><li>The restorative material should seal completely the involved dentin from the oral environment. </li></ul><ul><li>The vitality of the tooth should be preserved. </li></ul><ul><li>No prolonged post treatment signs or symptoms of sensitivity ,pain or swelling should be evident. </li></ul><ul><li>The pulp should respond favorably and tertiary dentin or reparative dentin should be formed ,as evidenced by radiographic evaluation(1.5 microns/ day after 30 days of pulp capping) </li></ul><ul><li>There should be no evidence of internal resorption or other pathologic changes. </li></ul><ul><li>ref no.1, page 399 </li></ul>
  18. 18. Ref no. 1,pg 400
  19. 19. <ul><li>INDICATIONS FOR INDIRECT PULP CAPPING- </li></ul><ul><li>history clinical examination radiographic examination </li></ul><ul><li>>mild pain associated >deep carious lesion,which >normal laminadura and </li></ul><ul><li>eating are close to,but not involving PDL space. </li></ul><ul><li> the pulp in vital primary or </li></ul><ul><li> young permanent teeth </li></ul><ul><li>>negative history of >no mobility >no radiolucency in the </li></ul><ul><li>Spontaneous ,extreme >when pulp inflammation is bone around the apices of pain seen as nominal roots or in the furcation </li></ul><ul><li>and there is a definite </li></ul><ul><li>layer of affected dentin </li></ul><ul><li> after removal of infectd dentin. </li></ul><ul><li>ref no.5, page 179 </li></ul><ul><li>It is indicated in teeth with deep carious lesion which are free from the signs and symptoms of pulpitis that is when pulpal inflammation has been judged to be minimal and complete removal of caries would probably cause a pulp exposure. </li></ul><ul><li> ref no.3, page 3 </li></ul><ul><li>-No tenderness to percussion </li></ul><ul><li>-No radiographic evidence </li></ul><ul><li>of radicular disease </li></ul><ul><li>-No internal or external root resorption detectable radiographically </li></ul><ul><li>ref no.2, page 339 </li></ul>
  20. 20. <ul><li>CONTRAINDICATIONS- </li></ul><ul><li>history clinical examination radiographic examination </li></ul><ul><li>>sharp,penetrating >mobility of the tooth >definite pulp exposure </li></ul><ul><li>pulpalgia indicating >discoloration of the >interrupted or broken lamina dura </li></ul><ul><li>acute pulpal tooth >radiolucency about the apices </li></ul><ul><li>inflammation. >negative reaction of of the roots . </li></ul><ul><li>electric pulp testing </li></ul><ul><li>>prolonged night pain </li></ul><ul><li>ref no.5, page 179 </li></ul><ul><li>-History of spontaneous pain </li></ul><ul><li>-Tenderness to percussion </li></ul><ul><li>-Radiographic evidence of interradicular bone loss or root resorption. </li></ul><ul><li> ref no.2, page 339 </li></ul><ul><li>-Any signs of pulpal or periapical pathology </li></ul><ul><li>-Soft leathery dentin covering a very large area of the cavity,in a non restorable - tooth . ref no.1, page 399 </li></ul>
  21. 21. <ul><li>INDIRECT PULP THERAPY- </li></ul><ul><li>Indirect pulp therapy is a technique for avoiding pulp exposure in the treatment of teeth with deep carious lesions in which there exists no clinical evidence of pulpal degeneration or periapical disease. </li></ul><ul><li>The procedure allows the tooth to use the natural protective mechanisms of the pulp against caries. It is based on the theory that a zone of affected, demineralized dentin exist between the outer infected layer of dentin and the pulp. When the infected dentin is removed, the affected dentin can remineralize and the odontoblasts form reparative dentin, thus avoiding pulp exposure. </li></ul><ul><li>Kopel has identified three distinct layers in active caries:- </li></ul><ul><li>1. Necrotic, soft dentin not painful to stimulation and grossly infected with bacteria. </li></ul><ul><li>2. Firm but softened dentin, painful to stimulation but containing few bacteria. </li></ul><ul><li>3. Slightly discolored, hard, sound dentin containing few bacteria and painful to stimulation. </li></ul>
  22. 22. <ul><li>In indirect pulp therapy the outer layer of carious dentin are removed. Thus most of the bacteria are eliminated from the lesion. When the lesion is sealed, the substrate on which the bacteria act to produce acid is also removed. Exposure of the pulp occurs when the carious process advances faster than the reparative mechanism of the pulp. Care must also be taken in removing the caries to avoid exposure of the pulp. With the arrest of caries process, the reparative mechanism is able to lay down additional dentin and avoid a pulp exposure. </li></ul><ul><li>Although carious dentin left in the tooth probably contains some bacteria, the number of organisms can be greatly diminished when this layer is covered with ZOE or calcium hydroxide. </li></ul><ul><li>If the preliminary caries removal is successful, the inflammation will be resolved and deposition of reparative dentin beneath the caries will allow subsequent eradication of the remaining caries without pulpal exposure. </li></ul>
  23. 23. <ul><li>The rate of reparative dentin deposition has been shown to average 1.4um/day after cavity preparation in dentin of human teeth. The rate of reparative dentin formation decreases markedly after 48days. Dentin is laid down fastest during the first month after IPC and the rate diminishes steadily with time. </li></ul><ul><li>If the initial treatment is successful, when the tooth reentered the caries appears to be arrested. The color changes from deep red rose to light grey to light brown. The texture changes from spongy and wet to hard, and the caries appears dehydrated. (Ref no.8, pg 636-637) </li></ul><ul><li>The goal is to promote pulpal healing by removing the majority of the infected bacteria and sealing the lesion, which stimulates sclerosis of dentin and reparative dentin formation. As the procedure was originally practiced, after a minimum of 6 weeks the zinc oxide and eugenol, calcium hydroxide, and remaining carious dentin are removed. It was intended that the second instrumentation of the tooth would confirm the intended goals and would be followed by For the experienced clinician using good case selection, however it may be preferable to avoid second instrumentation (and the potential risk of pulpal exposure). (Ref 20) </li></ul>
  24. 24. <ul><li>Periodic follow up of the tooth’s history along with pulp vitality testing and radiographic assessment is necessary. Indirect pulp capping is the excellent and conservative treatment option for some deep carious lesions in permanent teeth (especially if it avoids complete root canal treatment). It should be emphasized that the indirect pulp cap procedure is intended to avoid direct caries exposure. </li></ul><ul><li>(Ref21, pg 526) </li></ul>
  25. 25.
  26. 26. <ul><li>TREATMENT PROCEDURE- </li></ul><ul><li>FIRST APPOINTMENT- </li></ul><ul><li>Use local anesthesia and isolation </li></ul><ul><li>with Rubber dam. </li></ul><ul><li>! </li></ul><ul><li>establish cavity outline with high speed </li></ul><ul><li>handpiece </li></ul><ul><li>! </li></ul><ul><li>remove the superficial debris and majority </li></ul><ul><li>of the soft necrotic dentin with slow speed </li></ul><ul><li>handpiece using large round bur. </li></ul><ul><li>! </li></ul><ul><li>stop the excavation as soon as the firm </li></ul><ul><li>resistance of soft dentin is felt. </li></ul><ul><li>! </li></ul><ul><li>peripheral carious dentin is removed </li></ul><ul><li>with a sharp spoon excavator. </li></ul><ul><li>! </li></ul><ul><li>cavity flushed with saline and dried with </li></ul><ul><li>cotton pellet. </li></ul><ul><li>! </li></ul><ul><li>site is covered with calcium hydroxide- </li></ul><ul><li> ca(oh)2 </li></ul><ul><li>! </li></ul><ul><li>remainder cavity is filled with reinforced Ref 5 , pg180 </li></ul><ul><li>zinc oxide eugenol(ZOE) cement </li></ul>INDIRECT PULP CAPPING TECHNIQUE
  27. 27. <ul><li>SECOND APPOINTMENT (6-8 WEEKS LATER)- </li></ul><ul><li>between the appointment history must be </li></ul><ul><li>negative and temporary restoration should </li></ul><ul><li>be intact. ! </li></ul><ul><li>take a bit wing radiograph and observe </li></ul><ul><li>for sclerotic dentin. </li></ul><ul><li> ! </li></ul><ul><li>carefully remove all temporary filling </li></ul><ul><li>material. </li></ul><ul><li> ! </li></ul><ul><li>previous remaining carious dentin will </li></ul><ul><li>have become dried out ,flaky and easily </li></ul><ul><li>removed </li></ul><ul><li> ! </li></ul><ul><li>the area around the potential exposure </li></ul><ul><li>will appear whitish and may be soft, </li></ul><ul><li>which is predentin .do not disturb this </li></ul><ul><li>area. </li></ul><ul><li> ! </li></ul><ul><li>the cavity preparation is washed out </li></ul><ul><li>and dried gently. </li></ul><ul><li> ! </li></ul><ul><li>cover the entire floor withca (oh)2 </li></ul><ul><li> ! </li></ul><ul><li>base is built up with reinforced </li></ul><ul><li>ZOE cement or GIC </li></ul><ul><li> ! </li></ul><ul><li>final restoration is then placed. </li></ul><ul><li> ref no.5, pg 180 </li></ul>
  28. 28. <ul><li>DIAGRAM DEPICTING INDIRECT PULP CAPPING </li></ul>(Ref 5, pg 180)
  29. 29. <ul><li>-It is important to remove the carious tissue completely from the dentinoenamel junction and from lateral walls of the cavity in order to achieve optimal interfacial seal between the tooth and the restorative material ,so preventing micro leakage. </li></ul><ul><li>pg 580,ref 22 </li></ul><ul><li>After 6-8 weeks </li></ul><ul><li>-The color would have changed from red rose to light gray or light brown .the texture changes from spongy and wet to hard. </li></ul><ul><li>ref no.6, pg 286 </li></ul><ul><li>-If the remaining tooth structure is insufficient to retain the temporary filling ,a stainless steel band or temporary crown must be adapted to the tooth to maintain the dressing within the tooth. </li></ul><ul><li>ref no.1, pg 400 </li></ul><ul><li>-The sedative filling of either ZOE or calcium hydroxide helps to form a reparative dentin barrier and reduces the hyperemia in pulp ,remineralization the remaining carious dentin ,and maintain the vitality of pulp. </li></ul><ul><li>ref no. 3, pg 6 </li></ul><ul><li>-The dilemma that clinicians face lies in the assessment of how much caries to leave at the pulpal or axial floor .the carious tissue that should remain at the end of the cavity preparation is the quantity that ,if removed ,would result in overt exposure. </li></ul><ul><li>ref 20 </li></ul><ul><li>-Its is difficult to determine whether an area is an infected carious lesion or a bacteria-free demineralized zone .the best clinical marker is the quality of dentin :soft ,mushy dentin should be removed ,and hard discolored dentin can be indirectly capped. </li></ul><ul><li>ref 20 </li></ul>
  30. 30. (Ref 20)
  31. 31. <ul><li>In last decade , a chemical mechanical approach to caries excavation known as CARISOLV has been developed .this method consists of gel ,made of three amino acids and a low concentration of sodium hypochlorite rubbed into the carious dentin with specially designed hand instruments with carisolv ,sound and carious dentin is removed ,resulting in a more conservative preparation .when a bur is used, healthy tissue is frequently removed .the main drawback in this technique is the time needed to complete the procedure ,as it is much slower than with the use of a bur. </li></ul><ul><li>Atraumatic restorative treatment ,an approach for managing caries of dentin with hand instrument without local anesthesia ,and use of glass ionomer creates conditions that leads to reminralization and suggest that it can be recommended as a good base for indirect pulp capping. -Success rates of ipc have been reported to be higher than 90% in primary teeth ,and thus its use is recommended in patients in whom a preoperative diagnosis suggests no sign of pulp degeneration </li></ul><ul><li>New strategies utilizing bioactive molecules such as enamel matrix protein (emdogain) or tgf –b have been utilized experimentally to stimulate tertiary dentin formation and decrease dentin permeability .however ,these are not yet in clinical use. Ref 21, Pg580 </li></ul>
  32. 32. <ul><li>If a small pulp exposure is encountered ,a different type of treatment, based on the clinical signs and symptoms and local conditions, must be used. </li></ul><ul><li>Studies by traubman ,who used television linear and density measurement instruments ,indicated that the rate of regular dentin formation during the indirect pulp treatment was highest during the year of experimental observation .at the end of one year observation period ,some teeth had formed as much as 390um of new dentin on the pulpal floor .this observation provides justification for leaving the sealed interim restoration in place for longer than the minimal 6 weeks. </li></ul><ul><li>ref no.4, pg393 </li></ul>
  33. 33. <ul><li>The reentry procedure is still questionable .research has shown that carious dentin will reminralize with the initial reaction .if restoration has a good margin and as the recall visit a layer of secondary dentin is evident ,reentry is not necessary .(such cases are followed radiographically) </li></ul><ul><li>ref no.1 pg 338 </li></ul>
  34. 34. Gross caries was removed and calcium hydroxide was placed over the remaining caries. Tooth was restored with amalgam and not reentered for complete caries removal for 3 months Sclerotic dentine can be seen below the remaining caries and the covering of calcium hydroxide . The tooth was reentered and the remaining caries was removed a sound dentine barrier is observed at the base of the cavity. A new amalgam restoration was placed after complete caries removal. RADIOGRAPH OF THE FIRST PERMANENT MOLAR (Ref 4, pg 395)
  35. 35. INDIRECT PULP CAPPING Ref 6, Pg 287
  40. 40. ▪ Highly demineralized ▪ Unremineralizable ▪ Superficial layer ▪ Lacking sensation ▪ Stained by 0.5% fuschin or i.e. 1.0% acid red solution Ultrastructure : intertubular dentin greately demineralized, with irregular scattered crystals. Presence of deteriorated collagen fibers that have only distinct cross bands and no interbands. ▪ Should be excavated ▪ Intermediately demineralized ▪ Remineralizable collagen ▪ Deeper layer ▪ Sensitive ▪ Does not stain Ultrastructure : intertubular dentin Partially demineralized, but apatitie crystals bound like fringes to the Sound fibers with distinct Cross bands and interbands. ▪ Should be left remineralize. Ref 1, pg 401 Infected dentin Affected dentin
  41. 41. INFECTED DENTIN AFFECTED DENTIN www. Cudental.com www. Cudental.com
  43. 43. <ul><li>DIRECT PULP CAPPING- </li></ul><ul><li>DEFINITION- </li></ul><ul><li>The procedure in which the small exposure of the pulp ,encountered during cavity preparation or following a traumatic injury or due to caries, with a sound surrounding dentin ,is dressed with an appropriate biocompatible radio-opaque base in contact with the exposed pulp tissue prior to placing a restoration is termed as a direct pulp capping. </li></ul><ul><li>(ref no1, pg 401Shobha tandon) </li></ul><ul><li>Is defined by KOPEL (1992) as the placement of a medicament or non –medicated material on a pulp that has been exposed in course of excavating the last portions of deep dentinal caries or a result of trauma. </li></ul><ul><li>(ref no 5, Pg 181 Nikhil marwah) </li></ul>
  44. 44. <ul><li>This procedure involves the placement of a layer of protective material directly over the exposed pulp. </li></ul><ul><li>( ref no. 2, pg 339 S.G.damle) </li></ul><ul><li>Direct pulp capping procedure involves the placement of biocompatible material over the site of pulp exposure to maintain vitality and promote healing .when a small mechanical exposure of pulp occurs during cavity preparation or following a trauma ,an appropriate protective base should be placed in contact with the exposed pulp tissue so as to maintain the vitality of remaining pulp tissue. </li></ul><ul><li>( ref no. 13, pg 434 Nisha garg) </li></ul>
  45. 45. <ul><li>OBJECTIVES- </li></ul><ul><li>1. The vitality of tooth should be maintained. </li></ul><ul><li>2. No prolonged post-treatment signs or symptoms of sensitivity, pain or swelling should be evident. </li></ul><ul><li>3. Pulp healing and tertiary dentin formation should result. </li></ul><ul><li>4. There should be no pathologic changes. </li></ul><ul><li>( Ref1, pg 399 Shobha Tandon) </li></ul><ul><li>5. To create new dentin in the area of the exposure and subsequent healing of pulp. ( Ref 5, pg 181Nikhil marwah) </li></ul><ul><li>RATIONALE- </li></ul><ul><li>To achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge) between pulp tissue and capping material thus walling off the exposure site. </li></ul><ul><li>( Ref 5, pg 181Nikhil marwah) </li></ul>
  46. 46. <ul><li>INDICATIONS- </li></ul><ul><li>Small mechanical exposures less than 1 mm which is surrounded by sound dentin. </li></ul><ul><li>Light red bleeding from the exposure site that can be controlled by cotton pellet. </li></ul><ul><li>Traumatic exposures in a dry ,clean field ,which report to the dental office within 24 hrs. ( ref no.1, pg 399 Shobha Tandon) </li></ul><ul><li>The exposure site should be of minimal diameter ,there should be either no bleeding/bleeding is free of contaminants and haemorrhage should be arrested with a small pledget of cotton not indicative of hyperemic or inflamed pulp. the tooth shoud be free of any pain , except of discomfort caused by food intake. </li></ul><ul><li>( ref no. 3, pg 7 Class notes) </li></ul>
  47. 47. <ul><li>Small pulp exposures produced during cavity preparation i.e. pinpoint exposures surrounded by sound dentin. </li></ul><ul><li>( ref no.2, pg 339 S.G.Damle) </li></ul>
  48. 48. <ul><li>CONTRAINDICATIONS- </li></ul><ul><li>Pain at night </li></ul><ul><li>Spontaneous pain </li></ul><ul><li>Tooth mobility </li></ul><ul><li>Thickening of periodontal membrane </li></ul><ul><li>Intraradicular radiolucency </li></ul><ul><li>Excess bleeding at the exposure site </li></ul><ul><li>Purulent or serous exudates </li></ul><ul><li>( ref no.1, pg 399 Shobh tandon) </li></ul><ul><li>Wide pulp exposure </li></ul><ul><li>Radiographic evidence of pulp pathology </li></ul><ul><li>( ref no.13, pg 434Nisha garg) </li></ul><ul><li>External /internal root resorption </li></ul><ul><li>Swelling/fistula </li></ul><ul><li>( ref no.5, pg 181Nikhil marwah) </li></ul>
  49. 49. <ul><li>Excessive bleeding indicates hyperemia or pulpal inflammation. </li></ul><ul><li>( ref 2, pg 340 S.G. DAMLE) </li></ul><ul><li>In some teeth affected by deep carious ,pulp inflammation might have reached the stage of irreversible pulpitis without provoking spontaneous pain .in these cases ,the pulp tissue is diffusely inflamed and some times partially necrotic .for these reason ,a dentin bridge will not form. </li></ul><ul><li> ( ref no. 20) </li></ul>
  50. 50. <ul><li>TREATMENT CONSIDERATIONS- </li></ul><ul><li>Debridement: </li></ul><ul><li>Necrotic and infected dentin chips have to be removed else they will invariably be pushed into the exposed pulp during last stages of caries removal and impede healing and increase pulpal inflammation. </li></ul><ul><li>(Ref 5, pg 181) </li></ul><ul><li>Therefore it is prudent to remove all peripheral caries. If exposure occurs, non irrigating solution of normal saline or anesthetic solution is used to cleanse the area and keep he pulp moist. </li></ul><ul><li>(Ref 6, pg288) </li></ul>
  51. 51. <ul><li>Hemorrhage and clotting </li></ul><ul><li>A blood clot formed after cessation of bleeding, impedes the pulpal healing. Therefore care must be taken not to allow clot formation. The clot that is formed does not allow the capping material to contact the pulp tissue directly, or the clot material itself could break down, producing degradation products that act as substitute to the bacteria. </li></ul><ul><li>Bacterial contamination </li></ul><ul><li>Adequate seal following pulp capping is a must to prevent bacterial contamination. </li></ul><ul><li>(Ref 6, pg288) </li></ul>
  52. 52. <ul><li>Exposure enlargement : </li></ul><ul><li>The exposure site must be enlarged because: </li></ul><ul><li>a. It removes inflammation and infected tissue in the exposed area. </li></ul><ul><li>b. It facilitates washing away carious and non carious debris. </li></ul><ul><li>c. It allows closer contact of more capping medicament material to the actual pulp tissue. </li></ul><ul><li>(Ref 5, pg181) </li></ul>
  53. 53. Exposure to bleeding of molar Hard tissue Formation of the exposure Histological section showing hard tissue Formation following 90 days with a calcium Hydroxide cement DIRECT PULP CAPPING Ref 20
  54. 54. <ul><li>TECHNIQUES OF DIRECT PULP CAPPING- </li></ul><ul><li>Rubber dam provides only means of working in a sterile environment, so it has to be used. </li></ul><ul><li>↓ </li></ul><ul><li>Once an exposure is encountered, further manipulation of pulp is avoided. </li></ul><ul><li>↓ </li></ul><ul><li>Cavity should be irrigated with saline, chloramines T or distilled water. </li></ul><ul><li>↓ </li></ul><ul><li>Hemorrhage is arrested with light pressure from sterile cotton pellets. </li></ul><ul><li>↓ </li></ul><ul><li>Place the pulp capping material, on the exposed pulp with application of minimal pressure so as to avoid forcing the material into pulp chamber. </li></ul><ul><li>↓ </li></ul><ul><li>Place temporary restoration. </li></ul><ul><li>↓ </li></ul><ul><li>Final restoration is done after determining the success pulp of capping which is done by determination of dentinal bridge, maintenance of pulp vitality, lack of pain and minimal inflammatory response. </li></ul><ul><li>(Ref 5, pg 182) </li></ul>
  55. 55. DIRECT PULP CAPPING Ref 6,pg289
  56. 56. <ul><li>Complete caries should be excavated. </li></ul><ul><li>The exposure site is dried and calcium hydroxide is placed over the exposure dycal is the material of choice. </li></ul><ul><li>Dycal was first introduced in 1962 by L.D. caulk company . </li></ul><ul><li>two paste system </li></ul><ul><li>Base-titanium dioxide in calcium salicylate ,calcium tungstate. </li></ul><ul><li>Catalyst-calcium hydroxide in ethyl toluene sulfonamide and zinc oxide. </li></ul><ul><li>The tooth is restored with an interim restoration. </li></ul><ul><li>If treated tooth is asymptomatic for 6-8 weeks a permanent restoration can be carried out. </li></ul><ul><li>ref 2, pg 340 </li></ul><ul><li>The cavity should be rinsed with sodium hypochlorite ,which disinfects the cavity and removes the blood clot ,if present .if bleeding persists ,application of pressure to the exposure site with a cotton pellet moistened with saline will stop it. </li></ul><ul><li>ref 21, pg 583 </li></ul>Sodium hypochlorite For rinsing the cavity Ref 20
  57. 57. DIRECT PULP CAPPING (Ref2, pg 339)
  58. 58. Calcium Hydroxide Technique Dentin Bonding System Hemostasis Hemostasis Disinfect Cavity Disinfect Cavity Calcium Hydroxide Bonding Agent Restoration Adhesive IRM Dentin Bonding System Restoration Resin-modified GIC Ref 1,pg 402 PULP EXPOSURE
  59. 59. <ul><li>HISTOLOGICAL CHANGES AFTER PULP CAPPING- </li></ul><ul><li>These were illustrated by Glass and Zander in 1949. </li></ul><ul><li>After 24 hours: Necrotic zone adjacent to ca (oh) 2 pastes is separated from healthy pulp tissue by a deep staining basophilic layer. </li></ul><ul><li>After 7 days: Increase in cellular and fibroblastic activity. </li></ul><ul><li>ref 5, pg 183 </li></ul>
  60. 60. <ul><li>After 14 days: Partly calcified fibrous tissue lined by odontoblastic cells is seen below the calcium protienate zone; disappearance of necrotic zone. </li></ul><ul><li>After 28 days: Zone of new dentin. (Ref 5, pg 183) </li></ul>24 HOURS AFTER APPLICATION OF ca(oh)2
  61. 61. After 2- 3 weeks After 4-5 Weeks After 8 weeks HISTOLOGICAL CHANGES AFTER PULP CAPPING (Ref 5, pg 181)
  62. 62. DIRECT PULP CAPPING Ref 20
  63. 63. <ul><li>Features of successful pulp capping- </li></ul><ul><li>1. Maintenance of pulp vitality. </li></ul><ul><li>2. Lack of undue sensitivity or pain </li></ul><ul><li>3. Minimal pulp inflammatory response. </li></ul><ul><li>4. Ability of the pulp to maintain itself without progressive degeneration. (Ref 6, pg 288) </li></ul><ul><li>5. Lack of internal resorption and intradicular pathosis. (Ref 1, pg402) </li></ul>
  64. 64. <ul><li>Characteristic of pulp capping material- </li></ul><ul><li>It must be biocompatible </li></ul><ul><li>Non resorbable </li></ul><ul><li>Capable of adhering to the dentin </li></ul><ul><li>Capable of establishing and maintaining a good seal to prevent bacterial contamination ,and </li></ul><ul><li>Capable of promoting pulp repair. </li></ul><ul><li>Ideally the dentin bridge formed after direct pulp capping should be without tunnel defects that could allow the penetration of bacteria into the pulp at later stages. ref 21, Pg582 </li></ul>
  65. 65. <ul><li>MEDICATIONS AND MATERIAL USED FOR PULP CAPPING- </li></ul><ul><li>CA (OH)2 </li></ul><ul><li>The greatest benefit of Ca(OH)2 is the stimulation of reparative dentin bridge, due to a high alkalinity, which leads to enzyme phosphatase being activated and thus releasing of inorganic phosphate from the blood (calcium phosphate) leading to formation or dentinal bridge. It also has an antibacterial action. (Ref5, pg 182) </li></ul><ul><li>When calcium hydroxide is applied directly to pulp tissue, there is necrosis of the adjacent pulp tissue and inflammation of the contiguous tissue. Compounds of similar alkalinity cause liquefaction necrosis when applied to pulp tissue. </li></ul><ul><li>Internal resorption may occur after pulp exposure and capping with calcium hydroxide. </li></ul><ul><li>Calcium from Dentin Bridge comes from the blood stream. The action of calcium hydroxide to form Dentin Bridge appears to be a result of low grade irritation in the underlying pulpal tissue after application. (Ref 8, pg 640) </li></ul>Ref 20
  66. 66. Ref 8,pg 640
  67. 67. <ul><li>Mechanism of action of ca(oh)2-when calcium hydroxide is applied directly to pulp tissue ,there is necrosis of adjacent pulp tissue and an inflammation of the contiguous tissue .dentin bridge formation occurs at the junction of the necrotic tissue and the vital inflamed tissue .although calcium hydroxide work effectively ,the exact mechanism is not understood .compounds of similar alkalinity (ph of 11) cause liquefaction necrosis when applied to the pulp tissue .beneath the region of necrosis ,cells of the underlying pulp tissue differentiate into odontoblasts and elaborate dentin matrix. </li></ul><ul><li>Ref1, pg 403 </li></ul><ul><li>If the tooth is small (such as a first primary molar) ,the hard setting calcium hydroxide may also be used as the base for the restoration. </li></ul><ul><li>Ref 4, pg 397 </li></ul>
  68. 68. Ca(OH)2 : Ref 20
  69. 69. <ul><li>Corticosteroids and antibiotics: </li></ul><ul><li>BROSCH J.W introduced this combination in 1966. These agents include Neomycin and hydrocortisone; Ledermix (Ca (OH) 2 and prednisolone), Penicillin or Vancomycin with Ca (OH) 2. </li></ul><ul><li>ref 5, pg 182 </li></ul><ul><li>Inert materials: </li></ul><ul><li>Isobutyl Cynoacrylate and Tricalcium phosphate ceramic. </li></ul><ul><li>Collagen fibers: </li></ul><ul><li>Collagen fibers influence mineralization and are less irritant than Ca (OH) 2 with dentin bridge formation in 8 weeks. </li></ul><ul><li>ref 5 , pg 182 </li></ul>
  70. 70. Materials used in direct pulp capping Ref 20
  71. 71. <ul><li>Advantages:- </li></ul><ul><li>Initially bactericidal then bacteriostatic </li></ul><ul><li>Promotes healing and repair </li></ul><ul><li>High pH stimulates fibroblasts </li></ul><ul><li>Neutralizes low pH of acids </li></ul><ul><li>Stops internal resorption </li></ul><ul><li>Particles may obturate open tubules </li></ul><ul><li>ref 1, pg403 </li></ul>
  72. 72. <ul><li>Disadvantages:- </li></ul><ul><li>Does not exclusively stimulate dentinogenesis </li></ul><ul><li>Does not exclusively stimulate reparative dentin </li></ul><ul><li>Associated with primary tooth resorption </li></ul><ul><li>May dissolve after one year with cavosurface dissolution </li></ul><ul><li>May degrade acid etching </li></ul><ul><li>Degrades upon tooth flexure </li></ul><ul><li>Marginal failure with amalgam condensation </li></ul><ul><li>Does not adhere to the dentin or resin restoration </li></ul><ul><li>ref1,pg403 </li></ul>
  73. 73. <ul><li>4-META adhesive: The main advantage of 4-META adhesive is that it can soak into the pulp, polymerize there and form a hybrid layer with the pulp thereby providing adequate sealing. </li></ul><ul><li>Direct bonding: </li></ul><ul><li>Recent advances in total etch direct bonding have evoked an interest in application for pulp therapy. Here polygenic film can be layered over an exposure site without displacing pulp tissue and onto surrounding dentin where it penetrates the tubules. </li></ul><ul><li>(Ref 5, pg 182) </li></ul>
  74. 74. <ul><li>Isobutyl cyanoacrylate: </li></ul><ul><li>It is an excellent pulp capping agent because of its haemostatic and bacteriostatic properties; at the same time it causes less inflammation than calcium hydroxide. But it can not be regarded as an adequate therapeutic alternative to calcium hydroxide since it does not produce a continuous barrier of a reparative dentin following application of the exposed pulp tissue. (Ref 1, pg 403) </li></ul><ul><li>Disadvantage is that it is cytotoxic when freshly polymerized. (Ref 20) </li></ul><ul><li>Denaturated albumin: </li></ul><ul><li>This protein has calcium binding properties. If a pulp exposure is capped with a protein, the protein may become a matrix for calcification, thereby increasing the chances of biologic obliteration. (Ref 20) </li></ul>
  75. 75. <ul><li>ANDREAS MERITZ 1n 1998 evaluated the effect of direct pulp capping. </li></ul><ul><li>Bone morphogenic protein (BMP): </li></ul><ul><li>The demineralized bone matrix could stimulate new bone formation when implanted to ectopic sites such as muscles. </li></ul><ul><li>The implications for pulp therapy are immense as it is capable of inducing reparative dentin. </li></ul><ul><li>(Ref 5, pg183) </li></ul><ul><li>Mineral trioxide aggregate (MTA): TORABINEJAB described the physical and chemical properties of MTA in 1995. it is ash colored powder made primarily of fine hydrophilic particles of tricalcium aluminates, tricalcium silicate, silicate oxide, tricalcium oxide and bismuth oxide is added for radio-opacity. </li></ul><ul><li>(Ref 5, pg 182) </li></ul>
  76. 76. <ul><li>When compared with calcium hydroxide, MTA produced significantly more dentinal bridging in shorter period of time with significantly less inflammation. Dentin deposition has began earlier with MTA. </li></ul><ul><li>The disadvantage of this technique is that 3 to 4 hours is needed for setting of MTA after placement. The procedure involves placing MTA directly over the exposure site and sealing the tooth temporarily to allow the cement to harden. The tooth is later reentered and permanently sealed over the set MTA with an etched, dentin bonding agent and composite resin to prevent future bacterial micro leakage. </li></ul><ul><li>hard tissue formation. (Ref 20) </li></ul><ul><li>properties- </li></ul><ul><li>1. It is biocompatible material and its sealing ability is better than that of amalgam or ZOE. </li></ul><ul><li>2. Initial pH is 10.2and set pH is 12.5. </li></ul><ul><li>3. The setting time of cement is 4 hours. </li></ul><ul><li>4. The compressive strength is 70 MPA, which is comparable to that of IRM. </li></ul><ul><li>5. Low cytotoxity- it presents with minimal inflammation if extended beyond the apex. </li></ul><ul><li>Action: It has ability to stimulate cytokine and interleukins release from blood cells, indicating that it actively promotes. </li></ul><ul><li>Ref no.5 ,pg 182 </li></ul>
  77. 77. www. Cudental.com
  78. 78. <ul><li>Other pulp capping agents used are –isobutyl cyanoacrylates ,resinbonding agents , antibiotics , corticosteroids,polycarboxylateenamel,dentin,ZOE, fromocresol ref no.1, pg 403 </li></ul><ul><li>DIRECT PULP CAPPING IN PRIMARY TEETH- </li></ul><ul><li>Traditionally ,direct pulp capping in the primary teeth has been viewed with skepticism. the reasons cited were ,the abundant blood supply and a consequent faster inflammatory response and poorer localization of infection. ref no.1, pg 401 </li></ul><ul><li>-Guidelines developed by the American academy of pediatric dentistry (AAPD) recommend that direct pulp capping should be reserved for small mechanical or traumatic exposures in primary teeth. </li></ul>
  79. 79. <ul><li>LIMITATION OF DIRECT PULP CAPPING IN PRIMARY TEETH </li></ul><ul><li>Caries process or pulp capping material may stimulate the undifferentiated mesenchymal cells that differentiate into odontoblastic cells which lead to internal resorption. High cellular content, abundant blood supply and consequently faster inflammatory response and poor localization of infection are some of the reasons that direct pulp capping is contraindicated in primary teeth. (Ref 5, pg183) </li></ul><ul><li>Calcification, chronic inflammation, necrosis and intraradicular involvement. (Ref1, pg 401) </li></ul><ul><li>Further ,because of the aging of the dental pulp ,the likelihood of successful pulp capping diminishes with age .this may be explained by the increase in fibrous and calcific deposits also ,a reduction in the pulpal volume may be observed in older pulps. </li></ul><ul><li>(ref no 8, pg 639) </li></ul><ul><li>Recently however animal studies have suggested that healing of the pulp may take place even in the presence of inflammation. several studies have found varying success rates. </li></ul><ul><li>(ref 1, pg 401) </li></ul>
  80. 80. <ul><li>POINTS TO BE KEPT IN MIND DURING PROCEDURE OF IPC AND DPC </li></ul><ul><li>Staining carious lesion was proposed many years ago by FUSAYAMA to allow differentiation of remineralizable and non remineralizable dentin. These harmless dyes demonstrate non remineralizable dentin. Parts of the tooth that remain stain should be removed. Any tooth structure that does not stain can remain, since this soft dentin will remineralize. Examples of some brands of caries dentin test; caries detector, caries funder and sable seek. This method will limit the removal of decay to non - remineralizable dentin during divert and indirect pulp capping. </li></ul><ul><li>Location of the pulp exposure is an important consideration in the prognosis. If the exposure occurs on the axial wall of the pulp, with the pulp tissue coronal to exposure site, this tissue may be deprived of its blood supply and undergo necrosis, causing a failure. Then a pulpotomy or pulpectomy should be performed rather than a pulp cap. </li></ul>
  81. 81. <ul><li>When pulp capping is done, care must be exercised while removing the deep carious dentin over the exposure site to keep to a minimum the pushing of dentin chips into the remaining pulp chamber. Studies have shown decreased success when dentin fragments are forced into the underlying pulp tissue. Inflammatory reaction and formation of dentin matrix are stimulated around these dentin chips. In addition, microorganisms may be forced into the tissue. The resulting inflammatory reaction can be so severe as to cause a failure. </li></ul><ul><li>Marginal seal over the pulp capping procedure is of prime importance since it prevents the ingress of bacteria and reinfection. </li></ul><ul><li>After pulpal injury, reparative dentin is formed as part of repair process. Although formation of Dentin Bridge has been used as one of the criteria for judging successful pulp capping, bridge formation can occur in teeth with irreversible inflammation. Moreover, a successful pulp. </li></ul><ul><li>Capping has been reported without the presence of reparative dentin bridge over the exposure site. </li></ul><ul><li>(Ref3, pg 09) </li></ul>
  82. 82. <ul><li>When pulp capping is done, care must be exercised while removing the deep carious dentin over the exposure site to keep to a minimum the pushing of dentin chips into the remaining pulp chamber. Studies have shown decreased success when dentin fragments are forced into the underlying pulp tissue. Inflammatory reaction and formation of dentin matrix are stimulated around these dentin chips. In addition, microorganisms may be forced into the tissue. The resulting inflammatory reaction can be so severe as to cause a failure. </li></ul><ul><li>Marginal seal over the pulp capping procedure is of prime importance since it prevents the ingress of bacteria and reinfection. </li></ul><ul><li>After pulpal injury, reparative dentin is formed as part of repair process. Although formation of Dentin Bridge has been used as one of the criteria for judging successful pulp capping, bridge formation can occur in teeth with irreversible inflammation. Moreover, a successful pulp. </li></ul><ul><li>Capping has been reported without the presence of reparative dentin bridge over the exposure site. </li></ul><ul><li>(Ref3, pg 09) </li></ul>
  83. 83. PULPOTOMY
  84. 84. <ul><li>DEFINITION: </li></ul><ul><li>Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp,followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth. [Ref.5,pg.183] </li></ul><ul><li>“ Surgical removal of the entire coronal pulp,leaving intact the vital tissue in the canals,followed by placement of a medicament or dressing over the remaining pulp stump in an attempt to promote healing and retention of this vital tissue”. [Ref.6,pg.290] </li></ul><ul><li>Pulpotomy(cutting of coronal part) is defined as a procedure in which non-infected vital coronal pulp is amputated and a medicament is placed over it to enable the radicular pulp to maintain its vitality. </li></ul><ul><li>[Ref.2,pg.340] </li></ul><ul><li>The complete removable of the coronal portion of the dental pulp,followed by placement of a suitable dressing or medicament that will promote healing and preserve the vitality of the remaining pulp. </li></ul><ul><li>[Ref.3,pg.14] </li></ul>
  85. 85. <ul><li>Pulpotomy is a procedure for teeth with healthy pulps or teeth with symptoms of reversible pulpitis and deep caries where carious pulp exposure is encountered. Radiographically ,the tooth should not show signs of pathological resorption or radiolucency. </li></ul><ul><li>[Ref.11,pg.1406] </li></ul><ul><li>Pulpotomy refers only to coronal extirpation of vital pulp tissue </li></ul><ul><li>[Ref.13,pg.435] </li></ul><ul><li>The pulpotomy procedure involves removing the coronal pulp tissue that has undergone inflammation or degenerative changes and leaving intact the remaining vital tissue in the root canals,which is then covered with a pulp capping agent to promote healing at the amputation site or an agent for fixation of the underlying tissue. </li></ul><ul><li>[Ref.17,pg.361] </li></ul>
  86. 86. CLASSIFICATION OF PULPOTOMY VITAL PULPOTOMY Types Other name Features Examples Devitalization Preservation Regeneration Mummification, cauterization Minimal devitalization, noninductive Inductive, reparative It is intended to destroy or mummify the vital tissue This implies maintaining the maximum vital tissue,with no induction of reparative dentin This has formation of dentin bridge <ul><li>Single sitting </li></ul><ul><li>Formocresol </li></ul><ul><li>Electrosurgery </li></ul><ul><li>Laser </li></ul><ul><li>Two stage </li></ul><ul><li>Gysi triopaste </li></ul><ul><li>Easlick’s formaldehyde </li></ul><ul><li>Paraform devitalizing paste </li></ul><ul><li>ZnO Eugenol </li></ul><ul><li>Glutaraldehyde </li></ul><ul><li>Ferric sulphate </li></ul><ul><li>Ca(OH)2 </li></ul><ul><li>Bone morphogenic protein </li></ul><ul><li>Mineral trioxide aggregate </li></ul><ul><li>Enriched collagen </li></ul><ul><li>Freezed dried bone </li></ul><ul><li>Osteogenic protein </li></ul>
  87. 87. NON-VITAL PULPOTOMY [Ref.5,pg.183,184 Mortal pulpotomy ------ It is done in compromised cases <ul><li>Beechwood cresol </li></ul><ul><li>formocresol </li></ul>
  88. 88. <ul><li>OBJECTIVE: </li></ul><ul><li>Removal of inflamed and infected pulp at the site of exposure thus preserving the vitality of the radicular pulp and allowing it to heal. </li></ul><ul><li>[Ref.5,pg.187] </li></ul><ul><li>INDICATION: </li></ul><ul><li>Carious or mechanical exposure of vital primary teeth and young permanent teeth,where inflammation is restricted to coronal pulp only. </li></ul><ul><li>[Ref.6,pg.291] </li></ul><ul><li>History of only spontaneous pain. </li></ul><ul><li>Hemorrhage from exposure sites bright red and be controlled. </li></ul><ul><li>Absence of abscess or fistula. </li></ul><ul><li>No interradicular bone loss. </li></ul><ul><li>No interradicular radiolucency. </li></ul><ul><li>At least 2/3rd of root length still present to ensure reasonable functional life. </li></ul><ul><li>In young permanent tooth with vital exposed pulp and incompletely formed apices. </li></ul><ul><li>[Ref.5,pg.184] </li></ul>
  89. 89. <ul><li>CONTRAINDICATIONS: </li></ul><ul><li>History of spontaneous pain </li></ul><ul><li>Swelling </li></ul><ul><li>Fistula </li></ul><ul><li>Tenderness to percussion </li></ul><ul><li>Pathological mobility </li></ul><ul><li>External/internal root resorption </li></ul><ul><li>Periapical or interradicular radiolucency </li></ul><ul><li>Pulp calcifications </li></ul><ul><li>Pus or exudate from exposures site </li></ul><ul><li>Uncontrolled bleeding from the amputated pulp stump </li></ul><ul><li>[Ref.6,pg.291] </li></ul><ul><li>Root resorption more than 1/3rd of root length </li></ul><ul><li>Large carious lesion with non-restorable crown </li></ul><ul><li>Highly, viscous, sluggish hemorrhage from canal orifice, which is uncontrollable </li></ul><ul><li>Medical contraindications like heart disease, immunocompromised patient [Ref.5,pg.184] </li></ul>
  90. 90. <ul><li>PULPOTOMY IN PRIMARY TEETH </li></ul><ul><li>The 2003-2004 AAPD(American Academy of Pediatric dentistry) for pulp therapy for primary and young permanent teeth as the amputation of the affected or infected coronal portion of the dental pulp, preserving the vitality and function of all or part of the remaining radicular pulp. Evidence of success in therapy includes the following: </li></ul><ul><li>Vitality of the majority of the radicular pulp </li></ul><ul><li>No prolonged adverse clinical signs or symptoms </li></ul><ul><li>No radiographic evidence of internal resorption reaching the alveolar bone </li></ul><ul><li>No breakdown of periradicular tissue </li></ul><ul><li>No harm to succedaneous teeth </li></ul><ul><li>Pulp canal obliteration(abnormal calcification:not considered a failure [Ref.20] </li></ul>
  91. 91. <ul><li>FORMOCRESOL PULPOTOMY </li></ul><ul><li>Formocresol was introduced by Buckley in 1904 and since then a lot of modifications have been tried and advocated regarding the techniques of formocresol pulpotomies. </li></ul><ul><li>History </li></ul><ul><li>Sweet (1930)- formulated the technique and was a multivisit formocresol technique. </li></ul><ul><li>Doyle (1962)- advocated 2 sitting procedure </li></ul><ul><li>Spedding (1965)- Gave 5 minute protocol </li></ul><ul><li>(partial devitilization). </li></ul><ul><li>Venham (1967)- Proposed 15 seconds procedure. </li></ul><ul><li>Current concept uses 4 minutes of application time. </li></ul><ul><li>[Ref.5,pg.184] </li></ul><ul><li>Formocresol by its chemical nature is the combination of : </li></ul><ul><li>Formaldehyde – 19% </li></ul><ul><li>Cresol – 35% </li></ul><ul><li>Glycerin – 19% </li></ul><ul><li>Water </li></ul><ul><li>Formaldehyde interacts with the protein portion of the cell and cresol enhances the action of formaldehyde. </li></ul><ul><li>[Ref.6,pg.291] </li></ul>PYROCRESOL (Ref.pedo dept.) COMPOSITION (Ref. Pedo dept.)
  92. 92. <ul><li>Success following formocresol pulpotomy:Clinical success = 90-100%Histological success = 70-80%Success depends on accurate selection of the case. </li></ul><ul><li>[Ref.6,pg.292] </li></ul><ul><li>Mechanical of action : it prevents tissue autolysis by bonding to the proteins. This bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without changing the basic structure of protein molecules. </li></ul><ul><li>Histological changes : These were demonstrated by Mass and Zilbermann in 1933 and also by Massler and Mansokhani in 1959. </li></ul><ul><li>Immediately : Pulp becomes fibrous and acidophilic. </li></ul><ul><ul><li>After some days : Three zones appear: </li></ul></ul><ul><li>A broad eosinophilic zone of fixation </li></ul><ul><li>A broad pale staining zone of atrophy with poor cellular definition </li></ul><ul><li>[Ref.5,pg.185] </li></ul>
  93. 93. (ref.2,pg no.341)
  94. 94. Composition of formocresol :Buckley’s formula Cresol – 35% Glycerol – 19% Formaldehyde – 19% Water – 31% Preparation: currently we use 1/5th conc.of Buckley’s formula,which is prepared by the following method: 3 parts glycerine (90ml)+1 part distilled water (30ml)=Diluent (120ml) 4 parts Diluent (120ml)+1 part Buckley’s formocresol of 1/5th strength [Ref.5,pg.185] To prepare a 1:5 concentration of this formula,first thoroughly mix 3 parts of glycerine with1 part of distilled water,then add 4 parts of this preparation to 1 part Buckley’s formocresol,and thoroughly mix again [Ref.1,pg.405]
  95. 95. <ul><li>Broad pale staining zone of atrophy with few cells and fibres </li></ul><ul><li>Broad zone of inflammatory cells extending cells extending apically from the border of the pale staining zone </li></ul><ul><li>[Ref.6,pg.293] </li></ul><ul><li>1 year : Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year. </li></ul><ul><li>[Ref.5,pg.185] </li></ul>
  96. 96. <ul><li>Formocresol binds and renders tissue incapable of autolysis, but capable of replacement by granulation tissue. </li></ul><ul><li>[Ref.6,pg.293] </li></ul><ul><li>Devitalization (single sitting) </li></ul><ul><li>PROCEDURE </li></ul><ul><li>Anesthetize the tooth and isolate with rubber dam. </li></ul><ul><li>↓ </li></ul><ul><li>Remove all caries using high-speed straight fissure bur without entering the pulp chamber. </li></ul><ul><li>↓ </li></ul><ul><li>Remove dentinal roof with a large diamond stone or slow speed round bur for minimal trauma. </li></ul><ul><li>↓ </li></ul><ul><li>Enlarge the exposed area and deroof the pulp chamber. </li></ul><ul><li>↓ </li></ul><ul><li>Remove any ledges or overhanging enamel with slow speed round bur. </li></ul><ul><li>↓ </li></ul><ul><li>Sharp spoon excavators are used to scoop out coronal pulp and pulpal remnants. </li></ul><ul><li>↓ </li></ul><ul><li>Clean the pulp chamber with saline and remove all debris. </li></ul><ul><li>↓ </li></ul>
  97. 97. <ul><li>Place a cotton pellet over the pulp stumps to achieve hemostasis. </li></ul><ul><li>↓ </li></ul><ul><li>Using a cotton pellet apply diluted formocresol to the pulp for 4 min. </li></ul><ul><li>↓ </li></ul><ul><li>Place a small dry pellet over this to avoid contact of tissues with formocresol. </li></ul><ul><li>↓ </li></ul><ul><li>Remove cotton pellets and check for fixation,brownish discoloration of the pellet as well as the pulp stump is an indicator of fixation. </li></ul><ul><li>↓ </li></ul><ul><li>Place ZOE cement in the pulp chamber </li></ul><ul><li>↓ </li></ul><ul><li>Recall after one week and restore with a permanent restoration if patient is asymptomatic </li></ul><ul><li>↓ </li></ul><ul><li>Place a stainless steel crown [Ref.5,pg.185] </li></ul>
  98. 98. STEPS OF FORMOCRESOL PULPOTOMY (ref.1,pg no.405)
  99. 99. (Ref.20)
  100. 100. <ul><li>DISADVANTAGES OF FORMOCRESOL </li></ul><ul><li>Local toxicity: There is no actual healing of the pulp and the tooth becomes devitalized. </li></ul><ul><li>Systemic toxicity: studies have shown that full strength formocresol, is absorbed in to the systemic circulation from the pulpotomy site. Excretion is via the kidney and lungs. Some amount of formocresol remains cell bound in the liver,kidney and lungs. Cytogenic and mutagenic effect is observed due to its ability to denature nucleic acids by forming methylol derivatives and methylene cross links. Formocresol is also said to produce irreversible damage to the protein portion of enzymes,genetic material,membranes, and connective tissue. It affects directly the protein biosynthesis and cell reproduction by interacting with DNA and RNA and destroys the lipid component of the cell membrane. </li></ul><ul><li>Damage to succedaneous: it is seen that 1ml of formocresol diffuses through the apical foramen in 3 min.Thus there is high risk for the formation of enamel defects in the permanent successor following the use of formocresol in a primary teeth. </li></ul><ul><li>[Ref.6,pg.293] </li></ul><ul><li>Mutagenicity and carcinogenicity </li></ul><ul><li>Occurrence of dermatitis and pharyngitis </li></ul><ul><li>Antigenicity </li></ul><ul><li>[Ref.3,pg.16] </li></ul>
  101. 101. (ref.8,pg no.651)
  102. 102. <ul><li>ELECTROSURGICAL PULPOTOMY(MACK AND DEAN,1993) </li></ul><ul><li>It is a non-chemical devitalization,whereas mummification eliminates pulp infection and vitality with chemical crosslinking and denaturation. Electrocautery carbonizes and heat denatures the pulp and bacterial contamination. Electrosurgery does little to improve on the formocresol pulpotomy but does not use any chemicals. </li></ul><ul><li>After amputation of the coronal pulp,the pulp stumps are cauterized through this method. After completion,the pulp chamber is filled with zinc oxide and eugenol paste. The tooth is restored with a stainless crown. </li></ul><ul><li>[Ref.1,pg.408] </li></ul><ul><li>PROCEDURE: </li></ul><ul><li>Rubber dam isolation and administration of local anesthesia </li></ul><ul><li>↓ </li></ul><ul><li>Caries removal with large round slow speed bur </li></ul><ul><li>↓ </li></ul><ul><li>Sterile cotton pellets are placed in contact with pulp and pressure is applied to obtain hemostasis </li></ul>
  103. 103. <ul><li>The hyfrecator plus 7-797 is set at 40% power and the 705A dental electrode is used to deliever the electrical arc </li></ul><ul><li>↓ </li></ul><ul><li>Cotton pellet is quickly removed and the electrode is placed 1-2mm above the pulpal stump </li></ul><ul><li>↓ </li></ul><ul><li>Electrical arc is allowed to bridge the gap to the pulpal stump for 1 second,followed by a cool-down period of 5 seconds </li></ul><ul><li>↓ </li></ul><ul><li>When the procedure is properly performed,the pulpal stumps appear dry and completely blackened </li></ul><ul><li>↓ </li></ul><ul><li>Pulp chamber is filled with ZOE placed directly against the pulpal stumps </li></ul><ul><li>↓ </li></ul><ul><li>Final restoration is then placed </li></ul><ul><li>[Ref.5,pg.188] </li></ul>
  104. 104. <ul><li>LASER PULPOTOMY </li></ul><ul><li>Jeng-fen-liuet al in 1999 studied the effect on Nd:YAG laser pulpotomy in primary teeth and noted 100% success with no signs or symptoms,and only one tooth had internal root resorption at the six-month follow up visit. </li></ul><ul><li>ref.1,pg.408 </li></ul><ul><li>TWO-VISIT DEVITALIZATION PULPOTOMY </li></ul><ul><li>This is two stage procedure involving the use of paraformaldehyde to fix the entire coronal and radicular pulp tissue. </li></ul><ul><li>INDICATIONS : </li></ul><ul><li>There is evidence of sluggish bleeding at the amputation site that is difficult to control. </li></ul><ul><li>Pus in the chamber , but none at the amputation site. </li></ul><ul><li>There is thickening of pdl. </li></ul><ul><li>History of pain. </li></ul><ul><li>Contraindications : </li></ul><ul><li>Non-restorable tooth </li></ul><ul><li>Tooth with necrotic pulp ref 5, pg 187 </li></ul>
  105. 105. <ul><li>PROCEDURE </li></ul><ul><li>FIRST VISIT: </li></ul><ul><li>Isolation with rubber dam </li></ul><ul><li>↓ </li></ul><ul><li>Preparation of the cavity </li></ul><ul><li>↓ </li></ul><ul><li>Deep caries excavated </li></ul><ul><li>↓ </li></ul><ul><li>Enlarge the exposure with round bur </li></ul><ul><li>↓ </li></ul><ul><li>Incorporate paraformaldehyde paste into the pellet and </li></ul><ul><li>Place over exposure </li></ul><ul><li>↓ </li></ul><ul><li>Seal the tooth for 1-2 weeks so that formaldehyde gas liberated from paraformaldehyde enters coronal and radicular pulp, thereby fixing the tissue. </li></ul><ul><li>SECOND VISIT: </li></ul><ul><li>Pulpotomy is carried out under local anesthesia </li></ul><ul><li>↓ </li></ul><ul><li>Remove the cotton pellet and deroof the pulp chamber </li></ul><ul><li>↓ </li></ul><ul><li>Clean the cavity with saline and dry with cotton pellet </li></ul><ul><li>↓ </li></ul><ul><li>Pulp chamber filled with antiseptic paste and tooth is </li></ul><ul><li>Restored. </li></ul><ul><li>[Ref.5,pg.187] </li></ul>
  106. 106. <ul><li>MODIFIED FORMOCRESOL PULPOTOMY </li></ul><ul><li>This technique was used by Trask(1972) in young permanent molars that have to be retained for a short period of time only. The technique is identical to that described for primary teeth,except that tha formocresol pellet is sealed permanently in the tooth. </li></ul><ul><li>[Ref.5,pg.187] </li></ul><ul><li>GLUTARALDEHYDE PULPOTOMY </li></ul><ul><li>It has been widely tested,to replace formocresol. Studies have shown that application of 2-4%produces rapid surface fixation of the underlying pulp tissue. </li></ul><ul><li>[Ref.6,pg.293] </li></ul><ul><li>Mechanism of action: Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue. A narrow zone of eosinophilic,stained and compressed fixed tissue is found directly beneath the of application,which blends into vital normal appearing </li></ul><ul><li>tissue apically. With time,glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue,thus the entire root canal tissue is vital. </li></ul><ul><li>[Ref.5,pg.187] </li></ul><ul><li>Procedure: local anesthesia and a rubber dam are applied. The operative procedure is in principle is in principle the same as for FC pellets soaked in a 2% buffered freshly prepared glutaraldehyde solution are placed on the wound surfaces and left in place for 3-5 min. The pellets are removed and a slow-setting zinc oxide-eugenol cement covered with a fast-setting cement is placed and the cavity restored. </li></ul><ul><li>[Ref.14,pg.100] </li></ul>
  107. 107. <ul><li>ADVANTAGES OF GLUTARALDEHYDE OVER FORMOCRESOL: </li></ul><ul><li>it is bifunctional reagent,which allows it to form strong intra and intermolecular protein bonds leading to superior fixation by cross linkage. </li></ul><ul><li>it is excellent antimicrobial. </li></ul><ul><li>causes less necrosis of the pulpal tissue. </li></ul><ul><li>less toxicity-does not perfuse through the pulp tissue to the apex. </li></ul><ul><li>demonstrates less systemic distribution. </li></ul><ul><li>it is low tissue binding,readily metabolized,eliminated in urine and expired in gases-90% of the drug is gone in 3 days. </li></ul><ul><li>mutagenicity-Glutaraldehyde does not reach the nucleus of the liver cell. </li></ul><ul><li>antigenicity-less as compared to formocresol. </li></ul><ul><li>[Ref.6,pg.187] </li></ul>
  108. 108. <ul><li>ATTRIBUTES OF GLUTARADEHYDE OVER FORMOCRESOL </li></ul><ul><li>Forms strong and intra molecular protein bonds leading to superior fixation by cross linkage. </li></ul><ul><li>Diffusability is limited, thus reducing the apical extension of the material. </li></ul><ul><li>Excellent antimicrobial property. </li></ul><ul><li>Less dystrophic calcification. </li></ul><ul><li>Produces initial zone of fixation that does not produce apically. </li></ul><ul><li>Readily excreted from the body . about 90% is eliminated in 3 day. </li></ul><ul><li>15-20 times less toxic than formacresol and have little potential for chromosomal interference or mutagenicity. </li></ul><ul><li>[Ref.6,pg.293] </li></ul>
  109. 109. <ul><li>DISADVANTAGES </li></ul><ul><li>Neither the optimal concentration,nor the amount of time period of application has been coclusively established. </li></ul><ul><li>Failure rate is more than formocresol. </li></ul><ul><li>[Ref.17,pg.364] </li></ul>
  110. 110. <ul><li>FERRIC SULPHATE </li></ul><ul><li>This nonaldeyhde hemostatic compound was proposed on the theory that it might prevent problems encountered with clot formation and thereby minimize the chances for inflammation and internal resorption. Ferric sulphate forms a metal-protein clot at the surface of the pulp stump and this acts as a barrier to irritating components of the sub-base. If true,the ferric sulfate may function solely in a passive manner. </li></ul><ul><li>[Ref.1,pg.347] </li></ul><ul><li>Regeneration </li></ul><ul><li>CALCIUM HYDROXIDE PULPOTOMY </li></ul><ul><li>Indications </li></ul><ul><li>It is indicated in young permanent teeth with incomplete root information. </li></ul><ul><li>[Ref.13,p.435] </li></ul>
  111. 111. <ul><li>CVEK’S PULPOTOMY </li></ul><ul><li>This is called as calcium hydroxide pulpotomy or young permanent partial pulpotomy. This was proposed by Mejare Cvek in 1993. </li></ul><ul><li>PROCEDURE: </li></ul><ul><li>Application of rubber dam </li></ul><ul><li>↓ </li></ul><ul><li>All carious material is removed with excavators or slow speed round bur. </li></ul><ul><li>↓ </li></ul><ul><li>Coronal pulp removed,to perform a pulpotomy. </li></ul><ul><li>↓ </li></ul><ul><li>After arrest of the hemorrhage,Ca(OH)2 is applied to the exposed pulp,ensuring that there is no blood clot. </li></ul><ul><li>↓ </li></ul><ul><li>The cavity is then sealed with temporary restorative material. </li></ul><ul><li>↓ </li></ul><ul><li>A tooth should remain symptom free at recall and radiograph should show formation of a secondary dentine bridge. </li></ul><ul><li>↓ </li></ul><ul><li>Then permanent restoration with amalgam is done. </li></ul><ul><li>[Ref.5 ,pg.187] </li></ul>
  112. 112. <ul><li>First local anesthesia and a rubber dam is applied. Access to the pulp chamber is gained. The coronal pulp is removed with a spherical diamond bur and high-speed equipment. The wound surface is irrigated with saline or water. Bleeding is stopped by applying cotton pellets at the orifices of the root canals are covered by a layer of gently pressed calcium hydroxide. A layer of slow-setting zinc oxide-eugenol cement covered with a fast-setting cement is placed and the cavity is restored. The restoration is crucial and a stainless-steel crown is probably the most effective for preventing bacterial leakage. </li></ul><ul><li>[Ref.14,pg.100] </li></ul>
  113. 113. (ref.2,pg no.342)
  114. 114. (ref.8,pg no.645)
  115. 115. <ul><li>Calcium hydroxide:advantages and disadvantages </li></ul>(ref.1 pg no.403) Advantages Disadvantages <ul><li>Initially bacteriocidal then bactstatic </li></ul><ul><li>Promotes healing and repair </li></ul><ul><li>High pH stimulates fibroblasts </li></ul><ul><li>Neutralizes low pH of acids </li></ul><ul><li>Stops intrnal resorption </li></ul><ul><li>Inexpensive and easy to use </li></ul><ul><li>Particles may obturate open tubules </li></ul><ul><li>Does not exclusively stimulate dentinogenesis </li></ul><ul><li>Does exclusively stimulate reparative dentine </li></ul><ul><li>Associated with primary tooth resorption </li></ul><ul><li>May dissolve after one year with cavosurface dissolution </li></ul><ul><li>May degrade during acid etching </li></ul><ul><li>Degrades upon tooth flexure </li></ul><ul><li>Marginal failure with amalgam condensation </li></ul><ul><li>Does not adhere to the dentin or resin restoration </li></ul>
  116. 116. <ul><ul><li>BONE MORPHOGENIC PROTEINS(BMP) </li></ul></ul><ul><li>Bone morphogenic proteins initiate endochondral bone formation. The main action of BMP’s is to stimulate undifferentiated pluripotent cells to differentiate in to cartilage and bone forming cells. BMP’s are abundant in bone and dentin and promote osteogenesis and reparative dentin formation. </li></ul><ul><li>(ref.2,pg no.343) </li></ul>
  117. 117. <ul><li>PARTIAL PULPOTOMY </li></ul><ul><li>PROCEDURE: </li></ul><ul><li>Local anesthesia and a rubber dam are applied. All caries is removed and 1-1.5mm of the exposed pulp tissue is removed with a spherical diamond bur and high-speed equipment (with water). It is not critical to use sterile saline but a coolant with a ample flow is important. Remove all carious dentine adjacent to the pulp exposure before cutting the pulp tissue. Jeppesen (21) emphasized the importance of careful cleansing of possibly injected dentine chips from the area of amputation before applying the wound dressing. Bleeding is stopped by irrigation with sterile cotton pellets. A layer of calcium hydroxide is applied and gently pressed in contact with the wound surface. A layer of slow setting zinc oxide-eugenol cement or a fast-setting calcium-hydroxide-containing cement is placed and the cavity restored. [Ref.14,pg.100] </li></ul>
  118. 118. <ul><li>It implies removal of the coronal pulp tissue to the level of healthy pulp. Calcium hydroxide is material of choice for pulpotomy in </li></ul><ul><li>young permanent teeth to stimulate the formation of dentine bridge in cariously exposed pulp. </li></ul><ul><li>Technique </li></ul><ul><li>After anesthetizing the tooth rubber dam is applied. Thereafter </li></ul><ul><li>1-2mm deep cavity into the pulp is prepared using a diamond bur. A thin coating of calcium hydroxide mixed with saline solution or anesthetic solution is placed over it and the access cavity is sealed with a temporary restoration like IRM </li></ul><ul><li>COMPLETE PULPOTOMY </li></ul><ul><li>Cervical or complete pulpotomy involves removal of entire coronal pulp to the level of root orifices. It is performed when pulp is inflamed to deeper levels of coronal pulp. </li></ul><ul><li>Technique </li></ul><ul><li>Coronal pulp is removed same as in partial pulpotomy except that it is up to level of root orifice. </li></ul><ul><li>[Ref.13pg.435] </li></ul>
  119. 119. (ref.13,pg no.435)
  120. 120. (ref.13,pg no.435)
  121. 121. <ul><li>MINERAL TRIOXIDE AGGREGATE(MTA ) </li></ul><ul><li>MTA is the new medicament with an alkaline pH. It has shown significant improvement over the materials in promoting the healing of pulp and periradicular tissue. It is biocompatible,prevents bacterial leakage and is effective even in moist environment. </li></ul><ul><li>Composition </li></ul><ul><li>Tricalcium silicate </li></ul><ul><li>Dicalcium silicate </li></ul><ul><li>Tricalcium aluminate </li></ul><ul><li>Tetracalcium aluminoferrite </li></ul><ul><li>Calcium silicate </li></ul><ul><li>Bismuth oxide </li></ul><ul><li>Other uses of MTA are : </li></ul><ul><li>pulp capping </li></ul><ul><li>root end filling </li></ul><ul><li>perforation repair in furcation,coronal,mild or apical portion of the root </li></ul><ul><li>repair of resorptive perforation if not too extensive </li></ul><ul><li>[Ref.2,pg.343] </li></ul>
  122. 122. <ul><li>MORTAL PULPOTOMY </li></ul><ul><li>(Non vital pulpotomy) Ideally,non-vital tooth should be treated by pulpectomy,but sometimes it is impracticable due to non- negotiable root canals and limited patient cooperation </li></ul><ul><li>Selection criteria: </li></ul><ul><li>History of spontaneous pain </li></ul><ul><li>Swelling,redness or soreness of mucosa </li></ul><ul><li>Tooth mobility </li></ul><ul><li>Tenderness to percussion </li></ul><ul><li>Radiographic evidence of pathological root resorption or periradicular bone destruction </li></ul><ul><li>Pulp at the exposed site does not bleed </li></ul><ul><li>[Ref.1,pg.407] </li></ul>
  123. 123. <ul><li>PROCEDURE: </li></ul><ul><li>FIRST APPOINTMENT: </li></ul><ul><li>Necrotic coronal pulp is removed </li></ul><ul><li>↓ </li></ul><ul><li>Pulp chamber is irrigated with saline and dried with cotton pellet </li></ul><ul><li>↓ </li></ul><ul><li>Infected radicular pulp is treated with strong antiseptic solution like beechwood cresol </li></ul><ul><li>↓ </li></ul><ul><li>Seal cavity with temporary cement for 1-2 weeks </li></ul><ul><li>SECOND APPOINTMENT: </li></ul><ul><li>If the tooth is asymptomatic the pulp chamber is filled with an antiseptic paste </li></ul><ul><li>↓ </li></ul><ul><li>The tooth then restored with stainless steel crown </li></ul><ul><li> [Ref.5, pg.188] </li></ul>
  124. 124. (ref.1,pg no.406)
  125. 125.
  126. 126. CONCLUSION <ul><li>Pulp therapy for primary dentition includes a variety of treatment option depending on the vitality of pulp.Conservative treatment is performed when vital pulp remains because vitality is possible once the irritation is removed. </li></ul><ul><li>125 </li></ul>