Non vital pulp therapy power point presentation by Dr. Ram kumar

1. Dept. of PedodonticsDept. of Pedodontics
SeminarSeminar
• Represented byRepresented by
Ram kumar sharmaRam kumar sharma
• Guided byGuided by
Dr. MeghnaDr. Meghna singhsingh

2. Non vital pulp therapyNon vital pulp therapy
• A therapeutic procedure intended toA therapeutic procedure intended to
maintain a non vital tooth in a non-maintain a non vital tooth in a non-
infected state.infected state.

3. Non vital toothNon vital tooth
• A tooth that have a completelyA tooth that have a completely
necrosed pulp.necrosed pulp.
• Also called necrotic tooth.Also called necrotic tooth.
• Hence no living cell either vascularHence no living cell either vascular
or nerve cell present inside the pulpor nerve cell present inside the pulp
canal.canal.
• There fore pulp is not sensitive toThere fore pulp is not sensitive to
any type stimuli.any type stimuli.

4. Diagnostic ConclusionsDiagnostic Conclusions
• Tooth does not respond to any stimuli.Tooth does not respond to any stimuli.
• We have to applyWe have to apply
-Thermal stimuli-Thermal stimuli
-Electrical pulp testing-Electrical pulp testing

6. Non vital pulp therapyNon vital pulp therapy
• PulpectomyPulpectomy
• ApexogenesisApexogenesis
• ExtractionExtraction

7. PulpectomyPulpectomy
• Is also referred to as root canalIs also referred to as root canal
therapytherapy
• Is the total removal of pulpalIs the total removal of pulpal
tissues & subsequent filling of thetissues & subsequent filling of the
canal with a suitable biocompatiblecanal with a suitable biocompatible
material & to maintain the tooth in amaterial & to maintain the tooth in a
non infected state.non infected state.

9. PulpectomyPulpectomy
• Partial pulpectomyPartial pulpectomy
• Complete pulpectomyComplete pulpectomy
In decidious tooth completeIn decidious tooth complete
pulpectomy is not possible becausepulpectomy is not possible because
of many accessary canalsof many accessary canals

10. Rationale or aim for pupectomyRationale or aim for pupectomy
• To remove the dead & infectedTo remove the dead & infected
material as much as possible.material as much as possible.
• Fill the canal with a suitableFill the canal with a suitable
material to maintain the tooth in amaterial to maintain the tooth in a
non infected state.non infected state.

11. Indications/ConsiderationsIndications/Considerations
• When there is poor chance ofWhen there is poor chance of
success of vital pulp treatment.success of vital pulp treatment.
• Inflammation extending to radicularInflammation extending to radicular
pulp.pulp.
• Sufficient remaining tooth structure.Sufficient remaining tooth structure.
• Adequate remaining root length.Adequate remaining root length.

12. Indications/ConsiderationsIndications/Considerations
• Necrosed pulp of primary 2Necrosed pulp of primary 2ndnd
molarmolar
of patient age less than 6 yearsof patient age less than 6 years
• Presence of abscess with or withoutPresence of abscess with or without
cellulitis.cellulitis.
• Cooperative patientCooperative patient

13. ContraindicationsContraindications
• A non-restorable toothA non-restorable tooth
• A tooth with a mechanical or cariousA tooth with a mechanical or carious
perforation of the floor of the pulpperforation of the floor of the pulp
chamberchamber
• Pathologic root resorption involvingPathologic root resorption involving
more than one-third of the rootmore than one-third of the root

14. • Pathologic loss of bone supportPathologic loss of bone support
resulting in loss of the normalresulting in loss of the normal
periodontal attachmentperiodontal attachment
• The presence of a dentigerous orThe presence of a dentigerous or
follicular cystfollicular cyst
• Radiographically visible internal rootRadiographically visible internal root
resorptionresorption

15. Procedure of pulpectomyProcedure of pulpectomy
In 1In 1stst
appointmentappointment
• Application of local anesthesia.Application of local anesthesia.
• Isolation of tooth with rubber dam.Isolation of tooth with rubber dam.
• Removal of caries.Removal of caries.
• Removal of the roof of the pulpRemoval of the roof of the pulp
chamber with a bur and a highchamber with a bur and a high
speed hand piece.speed hand piece.

16. • Amputate the coronal portion of theAmputate the coronal portion of the
pulp with a bur and a low speedpulp with a bur and a low speed
hand piece.hand piece.
• Identification of the orifice of theIdentification of the orifice of the
canalcanal
• A diagnostic radiograph is takenA diagnostic radiograph is taken
with files in the root canalwith files in the root canal ..

17. • The remaining pulp tissue occupyingThe remaining pulp tissue occupying
the root canals is removed usingthe root canals is removed using
endodontic files at a predeterminedendodontic files at a predetermined
working length, approximately 1 to 2working length, approximately 1 to 2
mm short of the root apicesmm short of the root apices
• Clean the canal and carryout theClean the canal and carryout the
irrigation with normal saline or 1%irrigation with normal saline or 1%
sodium hypochlorite solutionsodium hypochlorite solution

18. • Clean the canal and carryout theClean the canal and carryout the
irrigation with normal saline or 1%irrigation with normal saline or 1%
sodium hypochlorite solutionsodium hypochlorite solution
• Drying the canal with paper points.Drying the canal with paper points.
• Application of cotton palate in the canalApplication of cotton palate in the canal
• If no symptoms are found in few days.If no symptoms are found in few days.

19. In 2In 2ndnd
appointmentappointment
• Filling the canal with a suitable materialFilling the canal with a suitable material

20. Ideal requirement of pulp canal fillingIdeal requirement of pulp canal filling
materialsmaterials
• For primary toothFor primary tooth
--should be antisepticshould be antiseptic
– ResorbableResorbable
– Harmless to the adjacent tooth germHarmless to the adjacent tooth germ
– RadiopaqueRadiopaque
– Does not set in to a hard massDoes not set in to a hard mass
– Easily insertedEasily inserted
– Easily removedEasily removed

21. Materials used for root canal fillingMaterials used for root canal filling
• Zinc oxide eugenolZinc oxide eugenol
• VitapexVitapex
• MaistopasteMaistopaste
• KRI paste or Iodoform pasteKRI paste or Iodoform paste
• EudoflasEudoflas
KRI paste is near to ideal root canal fillingKRI paste is near to ideal root canal filling
materialmaterial

22. Zinc-oxide eugenolZinc-oxide eugenol
AdvantagesAdvantages
• ResorbableResorbable
• RadioopaqueRadioopaque
DisadvantagesDisadvantages
• Set in to a hard mass, can causeSet in to a hard mass, can cause
deflection of permanent tooth germ.deflection of permanent tooth germ.
• Can cause irritation to periapical tissuesCan cause irritation to periapical tissues
& necrosis of periapical bone and& necrosis of periapical bone and
cementumcementum

23. vitapexvitapex
CompositionComposition
• Iodoform – 40.4%Iodoform – 40.4%
• Calcium hydroxide - 30.3%Calcium hydroxide - 30.3%
• Silicon oil (editives) - 22.4%Silicon oil (editives) - 22.4%

24. AdvantagesAdvantages
• Resorbs within 2 weeksResorbs within 2 weeks
• Easily deliveredEasily delivered
• Successful history of pulpectomySuccessful history of pulpectomy
• AntibacterialAntibacterial

25. MaistopasteMaistopaste
• CompositionComposition
• Sterilized iodoformSterilized iodoform
• ParachlorophenolParachlorophenol
• CamphorCamphor
• MentholMenthol
• Zinc oxide 14 gmZinc oxide 14 gm
• Iodoform 42gmIodoform 42gm
• Thymol 2gmThymol 2gm
• lanolinlanolin

26. KRI paste or iodoform pasteKRI paste or iodoform paste
AdvantagesAdvantages
• BactericidalBactericidal
• Resorbs within 2 weeksResorbs within 2 weeks
• Harmless to permanent tooth germHarmless to permanent tooth germ
• Radio opaqueRadio opaque
• Does not set in to a hard massDoes not set in to a hard mass
• Easily inserted & removed.Easily inserted & removed.
Is near to ideal root canal filling material.Is near to ideal root canal filling material.

27. EudoflasEudoflas
• Low success rateLow success rate
• ResorbableResorbable

28. Evaluation of SuccessEvaluation of Success
– AsymptomaticAsymptomatic
– Radiographic absence of pathologyRadiographic absence of pathology
– Continued root developmentContinued root development
– Hard tissue barrier at apexHard tissue barrier at apex
– Responsive pulpResponsive pulp

29. ApexogenesisApexogenesis
• A vital pulp therapy procedure perform toA vital pulp therapy procedure perform to
encourage continued physiologicalencourage continued physiological
development and formation of the root end.development and formation of the root end.

30. Goal or rationaleGoal or rationale
• Sustaining a viable HERS (heartwigsSustaining a viable HERS (heartwigs
epithelial root sheet).epithelial root sheet).
• Maintain pulpal vitality.Maintain pulpal vitality.
• Promoting root end closure.Promoting root end closure.
• Generating a dentinal bridge at the site ofGenerating a dentinal bridge at the site of
the pulpectomy.the pulpectomy.

31. IndicationsIndications
• Traumatized or pulpally involved vitalTraumatized or pulpally involved vital
permanent tooth with incomplete rootpermanent tooth with incomplete root
formation.formation.
• No history of spontaneous pain.No history of spontaneous pain.
• Absence of sensitivity or purcussion.Absence of sensitivity or purcussion.
• Absence of haemorrhage.Absence of haemorrhage.
• Normal radiographic appearance.Normal radiographic appearance.

32. ApexificationApexification
• Is the method of inducing root end closure of anIs the method of inducing root end closure of an
incompletely formed non-vital permanent tooth byincompletely formed non-vital permanent tooth by
removing the coronal and non-vital redicular tissuesremoving the coronal and non-vital redicular tissues
• Just short of the root end a suitableJust short of the root end a suitable
biocompatible agent is placing in the canal. Ex-biocompatible agent is placing in the canal. Ex-
-calcium hydroxide-calcium hydroxide
-MTA-MTA
and inducing the formation ofand inducing the formation of
osteocementum.osteocementum.

33. • COHENCOHEN –– Is the method of inducingIs the method of inducing
development of the root apex of andevelopment of the root apex of an
immature pulpless tooth by formation ofimmature pulpless tooth by formation of
osteocementum/bone like tissue.osteocementum/bone like tissue.
• Morse et .al (1990)-Morse et .al (1990)- is a method of apicalis a method of apical
closure through the formation ofclosure through the formation of
mineralized tissue in the apical pulpmineralized tissue in the apical pulp
region of a non-vital tooth with anregion of a non-vital tooth with an
incompletely formed root and apexincompletely formed root and apex
closure.closure.

34. RationaleRationale
• To eliminate periapical infection.To eliminate periapical infection.
• To induce the apical closure , if possibleTo induce the apical closure , if possible
continued root growth.continued root growth.

35. IndicationsIndications
• Immature non-vital tooth with open apex.Immature non-vital tooth with open apex.
• Open apex in mature tooth due to periapicalOpen apex in mature tooth due to periapical
osteoclastic activity.osteoclastic activity.

36. ObjectivesObjectives
• Should induce end closure at the apices.Should induce end closure at the apices.
• Post treatment adverse clinicalPost treatment adverse clinical
sign/symptom should not be evident.sign/symptom should not be evident.
• No evidance of radiographic abnormalitiesNo evidance of radiographic abnormalities
like calcification , root resorption , rootlike calcification , root resorption , root
pathosis , periradicular supporting tissuepathosis , periradicular supporting tissue
loss.loss.

37. Material used for apexificationMaterial used for apexification
• Zinc oxide eugenolZinc oxide eugenol
• Tricalcium phosphate & beta tricalciumTricalcium phosphate & beta tricalcium
phosphatephosphate
• Resorbable tricalcium phosphateResorbable tricalcium phosphate
• Collagen calcium phosphate gelCollagen calcium phosphate gel
• CeramicCeramic
• Calcium hydroxideCalcium hydroxide
• Mineral trioxide aggregate (MTA)Mineral trioxide aggregate (MTA)
• Leaving canal emptyLeaving canal empty
• Iodoform containing pasteIodoform containing paste

38. Calcium hydroxideCalcium hydroxide
• More biologically acceptableMore biologically acceptable
• Promote repairative dentin formationPromote repairative dentin formation
• Maintain pulp vitalityMaintain pulp vitality
• Used 1Used 1stst
by taucher & zander in 1958.by taucher & zander in 1958.

39. HistologicallyHistologically
• Pulp tissue adjacent to the calciumPulp tissue adjacent to the calcium
hydroxide was-hydroxide was-
-first necrotized by the PH of 11-12-first necrotized by the PH of 11-12
-this necrosis was accompanied by acute-this necrosis was accompanied by acute
inflammatory change in theinflammatory change in the
underlying tissuesunderlying tissues
-after 4 weeks , a new odontoblast layer-after 4 weeks , a new odontoblast layer
and a bridge of dentin developed.and a bridge of dentin developed.

40. How often the dressing should be changed ?How often the dressing should be changed ?
• Chawla – place the paste only once and wait forChawla – place the paste only once and wait for
radiographic evidence of barrier formationradiographic evidence of barrier formation
• Chosak – et .al. calcium hydroxide only required toChosak – et .al. calcium hydroxide only required to
initiate the healing reaction.initiate the healing reaction.
• Others – should be replaced only when symptomsOthers – should be replaced only when symptoms
develop or the material appear to have washed outdevelop or the material appear to have washed out
the canal.the canal.
• Abbots – regular replacement is advantageous.Abbots – regular replacement is advantageous.

41. Time required for apical barrier formationTime required for apical barrier formation
• Sheety & roberts - 5-20Sheety & roberts - 5-20
monthsmonths
• Finucane & kiniron - 13-67 weeksFinucane & kiniron - 13-67 weeks
presence of infection delay the closure.presence of infection delay the closure.
• Kleir & barrKleir & barr -- 5-15.9 months5-15.9 months
Delay in presence of infections.Delay in presence of infections.

42. Techniques for apexificationTechniques for apexification
Access –Access –
• straight line access.straight line access.
Instrumentation –Instrumentation –
• Working length is determined.Working length is determined.
• Careful debridement is a primary factor toCareful debridement is a primary factor to
induce apical closureinduce apical closure

43. • Canal enlargement.Canal enlargement.
• Filling motion is needed.Filling motion is needed.
• Avoid over instrumentation.Avoid over instrumentation.
• Drying of the canal.Drying of the canal.
• An inserted coarse paper point is desirable.An inserted coarse paper point is desirable.
• A dry pre fitted paper point.A dry pre fitted paper point.

44. Introduction of paste -Introduction of paste -
• A carrier with a teflon or plastic sleeve isA carrier with a teflon or plastic sleeve is
recommonded.recommonded.
Condensation -Condensation -
• A plugger that occludes the canal at aA plugger that occludes the canal at a
distance of 2-3 mm short of thedistance of 2-3 mm short of the
radiographic apex is selected.radiographic apex is selected.

45. Disadvantage of apexificationDisadvantage of apexification
• Long term span with multiple appointments.Long term span with multiple appointments.
• Patient compliance may be poor.Patient compliance may be poor.
• Reinfection or failure of treatmant.Reinfection or failure of treatmant.

46. Mineral trioxide aggregate (MTA)Mineral trioxide aggregate (MTA)
• Introduced by Torabinjad & colleagues atIntroduced by Torabinjad & colleagues at
loma linda university.loma linda university.
• Used in single visit application.Used in single visit application.

47. compositioncomposition
• Hydrophilic tricalcium silicateHydrophilic tricalcium silicate
• Tricalcium aluminateTricalcium aluminate
• Silicate oxideSilicate oxide
• Tricalcium oxideTricalcium oxide
It is supplied by Densply asIt is supplied by Densply as
– PRO ROOT MTA (brand name)PRO ROOT MTA (brand name)

48. Clinical implication or uses of MTAClinical implication or uses of MTA
• Root end filling material.Root end filling material.
• Prepair of root perforations.Prepair of root perforations.
• Apical plug formation.Apical plug formation.
• Repair of fracture of the tooth.Repair of fracture of the tooth.
• Direct or indirect pulp capping material.Direct or indirect pulp capping material.

49. Properties of MTAProperties of MTA
• PH – 10.2PH – 10.2
but after mixing become - 12.2but after mixing become - 12.2
• Setting time – 3-4 hours.Setting time – 3-4 hours.
• Radio opaque.Radio opaque.
• Solubility – negligible.Solubility – negligible.
• Compressive strength – 70 MPa.Compressive strength – 70 MPa.
• Biocompatible.Biocompatible.

50. • Non mutagenic.Non mutagenic.
• Less cytotoxicity.Less cytotoxicity.
• Sealing ability – very good , with noSealing ability – very good , with no
marginal gaps.marginal gaps.

51. AdvantagesAdvantages
• Time saving.Time saving.
• Better apical seal.Better apical seal.
• Non - resorbable.Non - resorbable.
• Better strengthning of root.Better strengthning of root.

53. • ThanksThanks