This document provides an overview of pulp therapy procedures for permanent and young primary teeth. It discusses the histology and structural elements of the dental pulp, as well as the reactions of pulp to dental caries and operative procedures. Indirect and direct pulp capping techniques are described, along with the medicaments and materials used. The document also notes the limitations of direct pulp capping in primary teeth and points to consider during these procedures.
Gingivectomy is the surgical excision of gingiva to remove diseased pocket walls and expose tooth surfaces. It is indicated for conditions like suprabonny pockets, fibrous enlargement, and crown lengthening. There are several types of gingivectomy including surgical, chemosurgery, electrosurgery, cryosurgery, and laser gingivectomy. The surgical procedure involves marking pockets, making internal beveled incisions, removing diseased tissue and calculus, and placing a periodontal pack. Post-operative healing occurs through clot formation, granulation tissue growth, and epithelialization over 2-3 weeks.
Pulpotomy is the removal of the coronal portion of the pulp while preserving the radicular pulp. It is indicated for cariously exposed primary teeth when extraction is less advantageous than retention. There are various techniques for pulpotomy including devitalization with formocresol or other chemicals to fix the pulp, preservation techniques using less harmful chemicals to maintain pulp vitality, and regeneration techniques aiming to stimulate reparative dentin formation. The goal of pulpotomy is to disinfect the exposed pulp, maintain pulp vitality, and avoid periapical issues.
This document discusses principles of minimal intervention dentistry. It begins with an introduction defining minimal intervention dentistry and outlining its benefits for patients. It then covers principles of minimal intervention adopted by the FDI, including controlling disease, remineralizing early lesions, performing minimally invasive procedures, and repairing defective restorations. The document also discusses recent cavity classification systems based on site and size of lesion. It provides examples and guidelines for treating lesions of different sizes and locations using a minimal intervention approach.
1. Osseous surgery involves modifying the alveolar bone support of teeth and includes techniques like osteoplasty and ostectomy. It aims to eliminate pockets and correct unphysiological bone architecture.
2. Factors in selecting a technique include the amount and location of bone loss, root trunk length, and anatomical limitations. Techniques range from non-resective procedures like osteoplasty to resective procedures like ostectomy.
3. Outcomes of osseous surgery generally include pocket elimination and establishment of physiological bone contours and architecture, though some bone loss from remodeling is expected in the range of 0.06mm to 1.2mm.
working length estimation in endodontic Marwa Ahmed
The document discusses methods for determining working length in root canals. It describes both radiographic and non-radiographic methods. Radiographic methods include Grossman's formula, Ingles method, Weine's modification, and use of xeroradiography and radiovisiography. Non-radiographic methods discussed are digital tactile sense, apical periodontal sensitivity, paper point measurement, and use of electronic apex locators. Electronic apex locators are highlighted as an important advancement, with different generations discussed varying in their measurement of resistance, impedance, or frequency. Accuracy and limitations of different methods are also reviewed.
Periodontal probing and techniques involve using calibrated probes to measure pocket depth and determine periodontal pocket configuration. There have been several generations of probes developed with improvements in standardization, precision, and automation. First generation probes were manual and included the Williams probe. Second generation probes aimed to standardize pressure, like the TPS probe. Third generation probes were automated, like the Florida Probe. Fourth generation probes utilized 3D technology while fifth generation probes combine ultrasound for more accurate measurement without pocket penetration. Studies show electronic probes provide more reproducible measurements than manual probes, though manual probes can have good reproducibility as well depending on the examiner.
This document discusses the process and techniques for coronoplasty, which is a selective reduction of occlusal areas to influence mechanical contact situations and neural sensory input patterns. It describes the 10 basic steps for performing coronoplasty, which include adjusting the intercuspal position and retruded contact position, removing prematurities, establishing stable simultaneous contacts, testing and adjusting incisal contacts and excursions, and finishing with polishing rough surfaces. The goal is to establish an optimal occlusion with stable contacts, smooth excursions, and decreased tooth mobility and stress on the teeth and temporomandibular joints.
Gingivectomy is the surgical excision of gingiva to remove diseased pocket walls and expose tooth surfaces. It is indicated for conditions like suprabonny pockets, fibrous enlargement, and crown lengthening. There are several types of gingivectomy including surgical, chemosurgery, electrosurgery, cryosurgery, and laser gingivectomy. The surgical procedure involves marking pockets, making internal beveled incisions, removing diseased tissue and calculus, and placing a periodontal pack. Post-operative healing occurs through clot formation, granulation tissue growth, and epithelialization over 2-3 weeks.
Pulpotomy is the removal of the coronal portion of the pulp while preserving the radicular pulp. It is indicated for cariously exposed primary teeth when extraction is less advantageous than retention. There are various techniques for pulpotomy including devitalization with formocresol or other chemicals to fix the pulp, preservation techniques using less harmful chemicals to maintain pulp vitality, and regeneration techniques aiming to stimulate reparative dentin formation. The goal of pulpotomy is to disinfect the exposed pulp, maintain pulp vitality, and avoid periapical issues.
This document discusses principles of minimal intervention dentistry. It begins with an introduction defining minimal intervention dentistry and outlining its benefits for patients. It then covers principles of minimal intervention adopted by the FDI, including controlling disease, remineralizing early lesions, performing minimally invasive procedures, and repairing defective restorations. The document also discusses recent cavity classification systems based on site and size of lesion. It provides examples and guidelines for treating lesions of different sizes and locations using a minimal intervention approach.
1. Osseous surgery involves modifying the alveolar bone support of teeth and includes techniques like osteoplasty and ostectomy. It aims to eliminate pockets and correct unphysiological bone architecture.
2. Factors in selecting a technique include the amount and location of bone loss, root trunk length, and anatomical limitations. Techniques range from non-resective procedures like osteoplasty to resective procedures like ostectomy.
3. Outcomes of osseous surgery generally include pocket elimination and establishment of physiological bone contours and architecture, though some bone loss from remodeling is expected in the range of 0.06mm to 1.2mm.
working length estimation in endodontic Marwa Ahmed
The document discusses methods for determining working length in root canals. It describes both radiographic and non-radiographic methods. Radiographic methods include Grossman's formula, Ingles method, Weine's modification, and use of xeroradiography and radiovisiography. Non-radiographic methods discussed are digital tactile sense, apical periodontal sensitivity, paper point measurement, and use of electronic apex locators. Electronic apex locators are highlighted as an important advancement, with different generations discussed varying in their measurement of resistance, impedance, or frequency. Accuracy and limitations of different methods are also reviewed.
Periodontal probing and techniques involve using calibrated probes to measure pocket depth and determine periodontal pocket configuration. There have been several generations of probes developed with improvements in standardization, precision, and automation. First generation probes were manual and included the Williams probe. Second generation probes aimed to standardize pressure, like the TPS probe. Third generation probes were automated, like the Florida Probe. Fourth generation probes utilized 3D technology while fifth generation probes combine ultrasound for more accurate measurement without pocket penetration. Studies show electronic probes provide more reproducible measurements than manual probes, though manual probes can have good reproducibility as well depending on the examiner.
This document discusses the process and techniques for coronoplasty, which is a selective reduction of occlusal areas to influence mechanical contact situations and neural sensory input patterns. It describes the 10 basic steps for performing coronoplasty, which include adjusting the intercuspal position and retruded contact position, removing prematurities, establishing stable simultaneous contacts, testing and adjusting incisal contacts and excursions, and finishing with polishing rough surfaces. The goal is to establish an optimal occlusion with stable contacts, smooth excursions, and decreased tooth mobility and stress on the teeth and temporomandibular joints.
The document discusses the history and development of periodontal probes over several generations. It describes the key characteristics of 1st generation manual probes and 2nd generation pressure-sensitive probes. It then focuses on 3rd generation computer-assisted probes which standardize pressure and digitally record readings to reduce errors. Some examples provided are the Foster Miller Probe, Florida Probe, and True Pressure Sensitive probe. Overall the document traces the evolution of probes to become more precise, standardized, and integrated with digital systems.
Plaque Indices commonly used in dentistryAmir Rajaey
This document summarizes several plaque indices used to assess oral hygiene:
1) The Plaque Index measures plaque on 6 key teeth using a scale of 0-3, with a total score divided by number of teeth indicating excellent to poor hygiene.
2) The Simplified Oral Hygiene Index assesses debris and calculus on 6 teeth using a scale of 0-3, with total scores for each indicating good to poor oral hygiene.
3) The Patient Hygiene Performance Index measures debris on 6 teeth using a scale of 0-5, with a total score divided by 6 indicating excellent to poor hygiene.
4) The Plaque Control Record examines all tooth surfaces for
A detailed description about endo perio interrelationship, including introduction, development and etiology, historical aspects, definition, classification, diagnosis, differential diagnosis, management, special consideration in management,controversies prognosis, conclusion.
Occlusal equilibration is a procedure to precisely alter the occlusal surfaces of teeth to improve the contact pattern. It involves selectively grinding tooth structures that interfere with terminal hinge axis closure, lateral excursion, and protrusive movement. Common tools used include paste, spray or paint to identify contact points requiring adjustment. The basic rules of selective grinding include narrowing cusp tips before reshaping fossae, and adjusting the inclines of upper and lower teeth in opposing directions depending on the path of slide. Occlusal errors in complete dentures can be caused by incorrect registration of the retruded contact position or irregularities during setting and processing of the teeth.
This document provides an overview of pulpotomy procedures for primary teeth. It begins with definitions of pulpotomy and discusses the rationale, objectives, indications, contraindications and classification of different pulpotomy techniques. It then describes various medicaments that can be used, including formocresol, glutaraldehyde, calcium hydroxide, and ferric sulfate. The document outlines techniques for formocresol pulpotomy, electrosurgical pulpotomy, and laser pulpotomy. It also discusses recent concepts in pulpotomy including the use of bone morphogenetic protein and enamel matrix derivatives. The document concludes by examining reasons for failure of pulpotomy therapy.
- Trauma from occlusion occurs when occlusal forces exceed the adaptive capacity of the periodontium, causing injury. It can be acute or chronic.
- The magnitude, direction, duration, and frequency of forces impact the periodontium's ability to adapt. Excessive pressure or tension can damage tissues.
- Primary trauma from occlusion is caused by changes in occlusal forces, while secondary trauma occurs when reduced bone support impairs the tissues' resistance to normal forces.
- The periodontium responds to trauma in three stages - injury, repair through new tissue formation, and adaptive remodeling to better withstand forces. Trauma can cause reversible damage if forces are reduced, or lead to irreversible injury if
Various Plaque Hypothesis are proposed to prove how plaque becomes pathogenic and cause periodontitis. Helpful in understanding pathogenesis of periodontitis especially how Gingivitis change to Periodontitis. All the details have been added and made in easy language to understand.
Useful for BDS and MDS students
1. The document discusses electronic apex locators (EALs), which are devices used to determine the working length of a root canal without radiography.
2. It describes the six generations of EALs, from first-generation resistance-based devices to sixth-generation adaptive apex locators. Key EAL models are provided for each generation.
3. The mechanisms of EALs are explained, noting they measure changes in resistance or impedance as a file tip approaches the apex. Accuracy and limitations of each generation are summarized.
This document outlines a treatment plan for periodontal disease. It includes 5 phases: emergency, etiotropic (non-surgical), surgical, restorative, and maintenance. The etiotropic phase involves nonsurgical therapies like scaling, root planing, and oral hygiene instruction. The surgical phase uses various periodontal surgeries to further treat pockets and furcations. The restorative phase focuses on final restorations. Lastly, the maintenance phase provides periodic recall visits to monitor the patient's condition. The overall goal is to resolve inflammation and reduce pocket depths through a coordinated approach involving multiple dental specialists.
This document discusses direct and indirect pulp capping procedures. Indirect pulp capping involves covering the deepest layer of remaining carious dentin with a biocompatible material to prevent pulp exposure and stimulate tertiary dentin formation. Direct pulp capping places a protective dressing directly over an exposed pulp to preserve its vitality. Various materials used for both procedures are discussed, along with their advantages and disadvantages. The document provides details on performing indirect and direct pulp capping clinically and factors affecting their success.
Splinting is one of the oldest forms of aids to periodontal therapy. By redistribution of forces on the affected teeth the splint minimizes the effects caused by loss of support. Splinting teeth to each other allows weakened teeth to be supported by neighbouring teeth. This presentation reviews the rationale, techniques, advantages and ill effects of stabilization of teeth by splinting as an aid to periodontal therapy. With the acceptance and clinical predictability of adhesive procedures, the use of conservative bonding techniques to splint teeth offers a useful alternative to more invasive restorative procedures. Loss of tooth-supporting structures results in tooth mobility. Increased tooth mobility adversely affects function, aesthetics, and the patient’s comfort. Splints are used to overcome all these problems. When faced with the dilemma of how to manage periodontally compromised teeth, splinting of mobile teeth to stronger adjacent teeth is a viable option. This prolongs the life expectancy of loose teeth, gives stability for the periodontium to reattach, and improves comfort, function and aesthetics.
This document provides an overview of periodontal flap surgery techniques. It defines a periodontal flap as incising the gingival tissues to control or eliminate periodontal disease by elevating the gingiva and oral mucosa from underlying tissues for improved accessibility and visibility of bone and roots. The document discusses the classification, indications, advantages, and types of incisions for various flap techniques used in pocket therapy, including modified Widman flap, undisplaced flap, apically displaced flap, and distal wedge procedure. Healing processes and outcomes for different flap techniques are also summarized.
This document provides information on intracanal medicaments used in endodontic treatment. It defines intracanal medicaments as temporary medications placed in root canals to inhibit bacterial invasion and discusses their ideal requirements. Various commonly used medicaments are described, including their composition, mechanisms of action, and antimicrobial efficacy. In particular, it focuses on chlorhexidine, formocresol, calcium hydroxide, antibiotics, and corticosteroid combinations such as Ledermix paste. The document also reviews the root canal and deciduous tooth microflora that intracanal medicaments aim to eliminate.
The document discusses incipient carious lesions, also known as white spot lesions. It defines incipient caries as the earliest sign of demineralization appearing as a chalky white spot. Diagnosis involves visual examination and aids like radiographs, fluorescence systems, and LED cameras to detect early mineral changes. Management focuses on remineralization through fluoride and remineralizing agents like CPP-ACP to control demineralization using non-operative procedures and potentially reverse early lesions.
This document discusses periodontal flaps, which are sections of gingiva surgically separated from underlying tissues to provide access to bone and roots. It defines different types of flaps classified by bone exposure, placement, and papilla design. Indications and contraindications for various flaps are outlined. Procedures for modified Widman, undisplaced, apically displaced, and regenerative flaps are described. Distal molar surgery techniques and use of periodontal packs are also summarized.
The document discusses various topics related to indirect pulp capping, direct pulp capping, and pulpotomy procedures. Indirect pulp capping involves sealing a tooth with a deep carious lesion using a protective material to stimulate healing and repair, avoiding direct pulp exposure. It is aimed at maintaining pulp vitality. Direct pulp capping places a material directly on an exposed pulp to encourage reparative dentin formation. Pulpotomy involves removing part of the coronal pulp as an emergency procedure to preserve the remaining radicular pulp. Various materials used and techniques for each procedure are described.
Pulp vitality and sensitivity tests are important diagnostic tools for assessing pulp status. Thermal tests using cold or heat are commonly used to stimulate pulp nerves. The electric pulp test provides a controlled electric stimulus to activate Aδ nerve fibers if the pulp is vital. Proper placement of the stimulus and interpretation of responses are needed for accurate results. Additional tests like bite testing can identify cracked teeth or evaluate periapical pathology responses. Combining history, examination findings, and multiple test results provides the best assessment of pulp conditions.
This document discusses the use of lasers in endodontics. It begins with a brief history of lasers, describing their development from Einstein's work in the early 1900s to their first use in dentistry in the 1970s. It then covers laser physics and components, different types of lasers including wavelengths used in dentistry, and laser tissue interactions. The main body discusses several clinical applications of lasers in endodontics such as pulp testing, pulp capping, pulpotomy, root canal disinfection and shaping, and endosurgery. Lasers can provide benefits like reduced need for anesthesia, hemostasis, and less collateral damage compared to other tools. Training is required and no single laser can perform all
This document discusses root resorption, including its history, types, causes, pathogenesis, classification, and treatment. It describes internal resorption in detail, noting that it begins with a breach in the dentin layer that allows resorption to spread towards the cementum. Internal resorption can be inflammatory or replacement, and treatment involves root canal therapy to remove pulpal tissue and arrest resorption, as well as disinfecting and sealing the root canal system. For large defects, biocompatible materials like MTA or Biodentine may be used to fill the area.
This document discusses pulp therapy in pediatric dentistry. It outlines several reasons for preserving teeth with pulp involvement, including preventing malocclusion, aiding mastication, and preventing psychological impacts of early tooth loss. The primary objectives of pulp treatment are to maintain oral health and integrity. A thorough diagnosis involves assessing factors like pain characteristics, tooth mobility, discoloration, periapical changes on radiographs, and pulpal hemorrhage in response to exposure. Pulp testing can help evaluate vitality, though results may be inconclusive for primary teeth. The goal of treatment is to restore the tooth when possible while considering the extent of pulpal inflammation or necrosis.
Management of Deep caries /certified fixed orthodontic courses by Indian dent...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
The document discusses the history and development of periodontal probes over several generations. It describes the key characteristics of 1st generation manual probes and 2nd generation pressure-sensitive probes. It then focuses on 3rd generation computer-assisted probes which standardize pressure and digitally record readings to reduce errors. Some examples provided are the Foster Miller Probe, Florida Probe, and True Pressure Sensitive probe. Overall the document traces the evolution of probes to become more precise, standardized, and integrated with digital systems.
Plaque Indices commonly used in dentistryAmir Rajaey
This document summarizes several plaque indices used to assess oral hygiene:
1) The Plaque Index measures plaque on 6 key teeth using a scale of 0-3, with a total score divided by number of teeth indicating excellent to poor hygiene.
2) The Simplified Oral Hygiene Index assesses debris and calculus on 6 teeth using a scale of 0-3, with total scores for each indicating good to poor oral hygiene.
3) The Patient Hygiene Performance Index measures debris on 6 teeth using a scale of 0-5, with a total score divided by 6 indicating excellent to poor hygiene.
4) The Plaque Control Record examines all tooth surfaces for
A detailed description about endo perio interrelationship, including introduction, development and etiology, historical aspects, definition, classification, diagnosis, differential diagnosis, management, special consideration in management,controversies prognosis, conclusion.
Occlusal equilibration is a procedure to precisely alter the occlusal surfaces of teeth to improve the contact pattern. It involves selectively grinding tooth structures that interfere with terminal hinge axis closure, lateral excursion, and protrusive movement. Common tools used include paste, spray or paint to identify contact points requiring adjustment. The basic rules of selective grinding include narrowing cusp tips before reshaping fossae, and adjusting the inclines of upper and lower teeth in opposing directions depending on the path of slide. Occlusal errors in complete dentures can be caused by incorrect registration of the retruded contact position or irregularities during setting and processing of the teeth.
This document provides an overview of pulpotomy procedures for primary teeth. It begins with definitions of pulpotomy and discusses the rationale, objectives, indications, contraindications and classification of different pulpotomy techniques. It then describes various medicaments that can be used, including formocresol, glutaraldehyde, calcium hydroxide, and ferric sulfate. The document outlines techniques for formocresol pulpotomy, electrosurgical pulpotomy, and laser pulpotomy. It also discusses recent concepts in pulpotomy including the use of bone morphogenetic protein and enamel matrix derivatives. The document concludes by examining reasons for failure of pulpotomy therapy.
- Trauma from occlusion occurs when occlusal forces exceed the adaptive capacity of the periodontium, causing injury. It can be acute or chronic.
- The magnitude, direction, duration, and frequency of forces impact the periodontium's ability to adapt. Excessive pressure or tension can damage tissues.
- Primary trauma from occlusion is caused by changes in occlusal forces, while secondary trauma occurs when reduced bone support impairs the tissues' resistance to normal forces.
- The periodontium responds to trauma in three stages - injury, repair through new tissue formation, and adaptive remodeling to better withstand forces. Trauma can cause reversible damage if forces are reduced, or lead to irreversible injury if
Various Plaque Hypothesis are proposed to prove how plaque becomes pathogenic and cause periodontitis. Helpful in understanding pathogenesis of periodontitis especially how Gingivitis change to Periodontitis. All the details have been added and made in easy language to understand.
Useful for BDS and MDS students
1. The document discusses electronic apex locators (EALs), which are devices used to determine the working length of a root canal without radiography.
2. It describes the six generations of EALs, from first-generation resistance-based devices to sixth-generation adaptive apex locators. Key EAL models are provided for each generation.
3. The mechanisms of EALs are explained, noting they measure changes in resistance or impedance as a file tip approaches the apex. Accuracy and limitations of each generation are summarized.
This document outlines a treatment plan for periodontal disease. It includes 5 phases: emergency, etiotropic (non-surgical), surgical, restorative, and maintenance. The etiotropic phase involves nonsurgical therapies like scaling, root planing, and oral hygiene instruction. The surgical phase uses various periodontal surgeries to further treat pockets and furcations. The restorative phase focuses on final restorations. Lastly, the maintenance phase provides periodic recall visits to monitor the patient's condition. The overall goal is to resolve inflammation and reduce pocket depths through a coordinated approach involving multiple dental specialists.
This document discusses direct and indirect pulp capping procedures. Indirect pulp capping involves covering the deepest layer of remaining carious dentin with a biocompatible material to prevent pulp exposure and stimulate tertiary dentin formation. Direct pulp capping places a protective dressing directly over an exposed pulp to preserve its vitality. Various materials used for both procedures are discussed, along with their advantages and disadvantages. The document provides details on performing indirect and direct pulp capping clinically and factors affecting their success.
Splinting is one of the oldest forms of aids to periodontal therapy. By redistribution of forces on the affected teeth the splint minimizes the effects caused by loss of support. Splinting teeth to each other allows weakened teeth to be supported by neighbouring teeth. This presentation reviews the rationale, techniques, advantages and ill effects of stabilization of teeth by splinting as an aid to periodontal therapy. With the acceptance and clinical predictability of adhesive procedures, the use of conservative bonding techniques to splint teeth offers a useful alternative to more invasive restorative procedures. Loss of tooth-supporting structures results in tooth mobility. Increased tooth mobility adversely affects function, aesthetics, and the patient’s comfort. Splints are used to overcome all these problems. When faced with the dilemma of how to manage periodontally compromised teeth, splinting of mobile teeth to stronger adjacent teeth is a viable option. This prolongs the life expectancy of loose teeth, gives stability for the periodontium to reattach, and improves comfort, function and aesthetics.
This document provides an overview of periodontal flap surgery techniques. It defines a periodontal flap as incising the gingival tissues to control or eliminate periodontal disease by elevating the gingiva and oral mucosa from underlying tissues for improved accessibility and visibility of bone and roots. The document discusses the classification, indications, advantages, and types of incisions for various flap techniques used in pocket therapy, including modified Widman flap, undisplaced flap, apically displaced flap, and distal wedge procedure. Healing processes and outcomes for different flap techniques are also summarized.
This document provides information on intracanal medicaments used in endodontic treatment. It defines intracanal medicaments as temporary medications placed in root canals to inhibit bacterial invasion and discusses their ideal requirements. Various commonly used medicaments are described, including their composition, mechanisms of action, and antimicrobial efficacy. In particular, it focuses on chlorhexidine, formocresol, calcium hydroxide, antibiotics, and corticosteroid combinations such as Ledermix paste. The document also reviews the root canal and deciduous tooth microflora that intracanal medicaments aim to eliminate.
The document discusses incipient carious lesions, also known as white spot lesions. It defines incipient caries as the earliest sign of demineralization appearing as a chalky white spot. Diagnosis involves visual examination and aids like radiographs, fluorescence systems, and LED cameras to detect early mineral changes. Management focuses on remineralization through fluoride and remineralizing agents like CPP-ACP to control demineralization using non-operative procedures and potentially reverse early lesions.
This document discusses periodontal flaps, which are sections of gingiva surgically separated from underlying tissues to provide access to bone and roots. It defines different types of flaps classified by bone exposure, placement, and papilla design. Indications and contraindications for various flaps are outlined. Procedures for modified Widman, undisplaced, apically displaced, and regenerative flaps are described. Distal molar surgery techniques and use of periodontal packs are also summarized.
The document discusses various topics related to indirect pulp capping, direct pulp capping, and pulpotomy procedures. Indirect pulp capping involves sealing a tooth with a deep carious lesion using a protective material to stimulate healing and repair, avoiding direct pulp exposure. It is aimed at maintaining pulp vitality. Direct pulp capping places a material directly on an exposed pulp to encourage reparative dentin formation. Pulpotomy involves removing part of the coronal pulp as an emergency procedure to preserve the remaining radicular pulp. Various materials used and techniques for each procedure are described.
Pulp vitality and sensitivity tests are important diagnostic tools for assessing pulp status. Thermal tests using cold or heat are commonly used to stimulate pulp nerves. The electric pulp test provides a controlled electric stimulus to activate Aδ nerve fibers if the pulp is vital. Proper placement of the stimulus and interpretation of responses are needed for accurate results. Additional tests like bite testing can identify cracked teeth or evaluate periapical pathology responses. Combining history, examination findings, and multiple test results provides the best assessment of pulp conditions.
This document discusses the use of lasers in endodontics. It begins with a brief history of lasers, describing their development from Einstein's work in the early 1900s to their first use in dentistry in the 1970s. It then covers laser physics and components, different types of lasers including wavelengths used in dentistry, and laser tissue interactions. The main body discusses several clinical applications of lasers in endodontics such as pulp testing, pulp capping, pulpotomy, root canal disinfection and shaping, and endosurgery. Lasers can provide benefits like reduced need for anesthesia, hemostasis, and less collateral damage compared to other tools. Training is required and no single laser can perform all
This document discusses root resorption, including its history, types, causes, pathogenesis, classification, and treatment. It describes internal resorption in detail, noting that it begins with a breach in the dentin layer that allows resorption to spread towards the cementum. Internal resorption can be inflammatory or replacement, and treatment involves root canal therapy to remove pulpal tissue and arrest resorption, as well as disinfecting and sealing the root canal system. For large defects, biocompatible materials like MTA or Biodentine may be used to fill the area.
This document discusses pulp therapy in pediatric dentistry. It outlines several reasons for preserving teeth with pulp involvement, including preventing malocclusion, aiding mastication, and preventing psychological impacts of early tooth loss. The primary objectives of pulp treatment are to maintain oral health and integrity. A thorough diagnosis involves assessing factors like pain characteristics, tooth mobility, discoloration, periapical changes on radiographs, and pulpal hemorrhage in response to exposure. Pulp testing can help evaluate vitality, though results may be inconclusive for primary teeth. The goal of treatment is to restore the tooth when possible while considering the extent of pulpal inflammation or necrosis.
Management of Deep caries /certified fixed orthodontic courses by Indian dent...Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
This document discusses different types of vital pulp therapy including indirect pulp capping, direct pulp capping, pulpotomy, apexogenesis, apexification, and revascularization. It provides definitions, indications, contraindications, techniques, and criteria for success or failure for each procedure. The document also includes examples of cases and references an endodontist, Dr. Ashraf Refai, who specializes in these types of vital pulp therapies.
Direct pulp capping involves placing a protective material directly over an exposed dental pulp to encourage healing and formation of reparative dentin. It is a conservative treatment alternative to root canal therapy to save a tooth's vitality when the exposure is small. Success rates range widely from 13-98% depending on factors like the type of exposure, quality of the restoration, and operator skill. Calcium hydroxide and mineral trioxide aggregate are commonly used capping materials that induce healing, but newer options like Biodentine show promise as well. Future trends may involve techniques like lasers, gene therapy, or stem cells to further improve pulp capping outcomes.
This document summarizes different techniques for pulp capping including direct and indirect pulp capping. It discusses the history of various materials used for pulp capping such as calcium hydroxide and mineral trioxide aggregate. Key points covered include the indications and contraindications for pulp capping, the ideal properties of capping materials, and the histological response after pulp capping including zone formation. The document provides an overview of pulp capping procedures and factors influencing their success.
This document discusses pulp capping, which involves placing a biocompatible material over exposed dental pulp to avoid pulp tissue exposure and promote healing. It describes indirect pulp capping, which leaves decayed dentin behind to avoid pulp exposure, and direct pulp capping, which dresses small pulp exposures with calcium hydroxide or resin bonding agents. Successful pulp capping requires maintaining pulp vitality without pain or pathology and promoting dentin bridge formation. Calcium hydroxide is commonly used but can degrade over time, while resin bonding agents may provide a better seal but with less evidence of success.
Pulp Therapy In Pediatric Dentistry Revised 2jinishnath
The document discusses various pulp therapy techniques for treating diseased or injured dental pulps in primary and young permanent teeth in pediatric dentistry. It describes the objectives and procedures for vital pulp therapy, such as pulpotomy, and non-vital pulp therapy techniques like pulpectomy and apexification. For pulpectomy, the procedure involves removing all caries, amputating the coronal pulp, and instrumenting and filling the canals with a resorbable paste like zinc oxide eugenol. Apexification is used when apexogenesis fails to encourage apical closure, and involves repeated calcium hydroxide placements in the canals.
Nonvital pulp therapy in pediatric dentistryPriyank Pareek
The document discusses techniques for pulpectomy procedures in primary teeth. It describes removing necrotic pulp tissue from the root canals and coronal portion of teeth to maintain the tooth. Key steps include isolating the tooth, removing caries, accessing and cleaning canals, drying canals, and filling canals with zinc oxide eugenol. The goals are to resolve infection, show healing on x-rays, and allow normal resorption and eruption of permanent teeth.
Pulpectomy is a dental procedure to remove infected or dead pulp from the root canals of primary teeth. It aims to maintain the tooth in a non-infected state by cleaning and filling the root canals. A partial pulpectomy removes pulp from a single visit, while a complete pulpectomy is done over two visits with emergency treatment followed by root canal filling. Common filling materials for primary teeth include zinc oxide eugenol paste and iodoform paste, which resorb at a rate similar to the tooth root. The procedure involves local anesthesia, access through the crown, pulp removal, canal cleaning and shaping, irrigation, drying and obturation.
Vital pulp therapy aims to preserve healthy pulp tissue and includes procedures like indirect/direct pulp capping, pulpotomy, and apexification. The goal is to stimulate reparative dentin formation and maintain the tooth as a functional unit. Success depends on factors like the patient's age, pulp chamber size, bacterial contamination, and quality of the restoration. Indirect pulp capping involves stepwise caries removal and capping the remaining dentin layer, while direct capping places a material directly over an exposed pulp. Pulpotomy and apexification procedures are used to treat immature teeth and maintain root development.
Difference between pulpotomy and pulpectomyOwais92
Pulpotomy involves removing the coronal portion of the pulp and placing a medicament, indicated for large carious lesions involving the marginal ridge in a vital tooth with no pain or infection. Pulpectomy removes all pulp tissue from the chamber and root canals, indicated for teeth with irreversible pulpitis throughout the pulp or abscessed primary teeth. Contraindications for both procedures include the presence of infection, bone loss, or non-restorable teeth.
The document discusses pulp therapy for primary and permanent teeth. Pulp therapy is divided into vital pulp therapy and non-vital pulp therapy. Vital pulp therapy is used for primary teeth with normal pulps or reversible pulpitis, and involves procedures like pulpotomy to maintain the vitality of the remaining pulp. Non-vital pulp therapy is used for primary teeth with irreversible pulpitis or necrotic pulps, and involves procedures like pulpectomy to remove the entire pulp. Maintaining primary teeth has benefits such as preventing malocclusion, aiding mastication, and preserving space for permanent teeth.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Vital pulp therapy aims to maintain pulp vitality by removing irritants and placing protective materials over exposed pulp. Indirect pulp capping covers deep caries with a biocompatible material to stimulate tertiary dentin formation and arrest decay. Direct pulp capping places protective dressings directly over pulp exposures to induce reparative dentin bridges. Calcium hydroxide and mineral trioxide aggregate are commonly used capping agents. Apexification forms apical barriers in open-apexed teeth while pulpotomy removes coronal pulp to preserve radicular vitality. Gentle techniques and accurate diagnoses are important for predictable outcomes of vital pulp therapies.
In this lecture I explain in step-by-step fashion the basics of Direct Pulp Capping. a photo guide is attached to the guide to aid in better understanding of the topic
Toothaches are caused by issues like dental caries, cracks, injuries, or gum disease. A toothache feels like a sharp or dull pain in or around a tooth and it may be sensitive to temperature, pressure, or sweets. Seeing a dentist right away is important to diagnose and treat the underlying cause. The dentist will examine the mouth to identify the problem tooth and determine if infection or damage is present. Treatment depends on the cause but may include fillings, root canals, extractions, or antibiotics to address infection. Proper oral hygiene and regular dental visits can help prevent toothaches.
Resins in orthodon 2 /certified fixed orthodontic courses by Indian dental ac...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Dentin /certified fixed orthodontic courses by Indian dental academy Indian dental academy
Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients
State of the art comprehensive training-Faculty of world wide repute &Very affordable.
Direct pulp capping involves applying a medicament directly to an exposed dental pulp to preserve its vitality and involves indications such as a small exposure less than 4 mm with no observable hemorrhage or signs of infection. Indirect pulp capping involves removing gross caries and sealing the cavity with a biocompatible material to avoid exposing the pulp during caries removal when inflammation is minimal. Both procedures aim to maintain pulp vitality and healing through complete sealing and an aseptic technique, though failures can occur due to factors such as the degree of trauma, sealing ability, host resistance, presence of microorganisms, or aseptic technique failures.
A 4-year-old male patient presented with pain and swelling on the left side of his face. Examination revealed a carious and exposed primary tooth 64 with pulpal involvement visible on radiograph, leading to a diagnosis of chronic irreversible pulpitis. The treatment plan involved pulpectomy of tooth 64, which was performed - the pulp was removed, the tooth was temporarily filled, and the patient advised to return after 7 days for permanent filling, which occurred uneventfully.
This document provides an overview of pulp therapy in deciduous and young permanent teeth. It discusses the histology and structure of the dental pulp, how the pulp reacts to dental caries and operative procedures, diagnosis and evaluation of pulp pathology, and techniques for indirect and direct pulp capping. The goal of pulp therapy is to maintain pulp vitality and integrity whenever possible by using appropriate medicaments and materials to encourage healing of the exposed pulp. Factors like the depth and rate of the carious lesion, use of proper cooling and gentle technique during procedures can impact the pulp's reaction and healing.
This document provides an overview of dentinal hypersensitivity. It defines dentinal hypersensitivity as pain from exposed dentin in response to stimuli like heat, cold, sweet or tactile sensations. The hydrodynamic theory is discussed, which proposes that fluid movement in dentinal tubules stimulates nerve endings and causes pain. Natural defenses against sensitivity like reparative dentin formation and methods of measuring sensitivity like air or tactile tests are also summarized. Causes of exposed dentin like erosion, abrasion, or periodontal procedures are described as common etiologies of dentinal hypersensitivity.
Lect.1 2018 - biologic considerations of enamelAmir Hamde
Dentin forms the bulk of the tooth and protects the pulp. It provides strength, support, and protection for the tooth. Dentin is composed of hydroxyapatite crystals embedded in an organic matrix. It is softer than enamel. The dentin tubules allow for fluid flow, which is important for dentin sensitivity. Sealing the tubules can reduce sensitivity. Dentin is laid down throughout life, including secondary dentin deposition and reparative dentin in response to trauma.
Lect.1 2018 - biological consideration of the enamel and dentine structures ...Amir Hamde
Dentin forms the bulk of the tooth and protects the pulp. It provides strength and support to the tooth. Dentin is softer than enamel and contains dentinal tubules that extend from the pulp cavity to the outer surface. The tubules allow for permeability of dentin, which can cause sensitivity if exposed. Different theories explain the hydrodynamic movement of fluid in the tubules that is thought to stimulate nerve endings and cause sensitivity. Dentin is vital for tooth function and different types form throughout life in response to stimuli.
The document discusses the dentin pulp complex and its reaction to inflammation. It describes the composition and structure of dentin and pulp, as well as their functions. When exposed to irritants like caries, restorative procedures, or trauma, the dentin pulp complex mounts inflammatory and immune responses to protect the tooth. This includes dentin sclerosis, tertiary dentin formation, and recruitment of inflammatory cells. The degree and type of pulpal inflammation depends on factors like the severity and duration of the irritant.
The document discusses diagnosis and treatment of peri-implant disease. It begins by introducing the history of dental implants and defines peri-implant mucositis and peri-implantitis. The main causes are bacterial infection and biomechanical overload. Treatment involves non-surgical and surgical approaches to arrest disease progression and maintain the implant site. The document then examines the histology and microbiology of healthy and diseased peri-implant tissues.
Dentin hypersensitivity is a painful condition caused by exposed dentin. It occurs most commonly in 30-40 year old females and affects canines and premolars. Dentin contains tubules that normally contain fluid and extend into the tooth from the pulp. When factors like erosion expose the tubules, stimuli can cause fluid movement, activating nerves and causing sharp pain. Current trends to manage this include products that occlude tubules, such as arginine-based compounds, and treatments like lasers, bio-glass, and casein phosphopeptides. Proper diagnosis and removal of predisposing factors are important to effectively treat dentin hypersensitivity.
Dentin hypersensitivity is a painful condition caused by exposed dentin. It is characterized by short, sharp pain from thermal, evaporative, tactile, osmotic, or chemical stimuli. Several theories explain its pathogenesis, but the hydrodynamic theory of fluid movement in dentinal tubules is most widely accepted. Management involves diagnosis, prevention of predisposing factors, and treatment. Traditional treatments include occluding tubules with adhesives, fluoride varnishes, or oxalates. Current trends include arginine products, lasers, bioactive glass, and casein phosphopeptides, which act by occluding tubules or modulating nerve sensitivity.
Pulpal response to various dental procedures restorative materials Dr Nagarajan
The document discusses the pulp's response to various dental procedures and restorative materials. It explains that the pulp can be sensitive to external stimuli that threaten its integrity or irritants brought into contact with exposed dentin. The reaction is usually physiological, but pathological changes can occur depending on the intensity of the stimulus. It then covers topics like the structural organization of the pulp, the pulp-dentin organ relationship, stages of pulpal inflammation, and the pulp's response to specific procedures and materials like local anesthesia, cavity preparation, acid etching, laser use, bleaching, and thermal testing. It emphasizes the importance of factors like remaining dentin thickness, cooling, and power/time settings to minimize pulpal damage.
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
middle layer of tooth the dentin which has yellowish in colorRenu710209
dentin is the resilient structure of tooth which gives yellowish color and protect the underlying dentalpulp and innervated structures from external stimuli
This document discusses the intimate relationship between dentin and dental pulp and how this relationship has important clinical implications. It notes that the pulp will react when dentin is injured, whether by caries, attrition, abrasion, erosion or operative procedures. It then discusses various irritants that can affect the pulp, including bacteria, iatrogenic factors like thermal changes from procedures, chemicals from materials, aging, trauma and more. It focuses on the pulpal reactions to factors like caries, local anesthetics, restorative procedures, dental materials, bleaching, periodontal procedures and orthodontic movement. It provides details on how each of these can irritate the pulp and the pulp's defensive reactions.
This document discusses the relationship between periodontal and endodontic diseases. It begins by establishing that the tooth, pulp, and supporting structures should be viewed as one biologic unit. There are various pathways by which communication can occur between the pulp and periodontium, including developmental pathways like lateral canals, pathological pathways caused by trauma or resorption, and iatrogenic pathways from dental procedures. Pulpal and periodontal problems are responsible for over 50% of tooth mortality. The document goes on to classify periodontal-endodontic lesions based on whether the primary source of disease is endodontic or periodontal and whether secondary involvement occurred.
The document discusses the structure and development of dentin. It describes dentin as the layer beneath enamel that provides shape and structure to teeth. Dentin forms in stages that mirror tooth development from the lamina bud stage through late bell stage. Key features of dentin include dentinal tubules that contain odontoblastic processes and layers like peritubular dentin, intertubular dentin, and predentin near the pulp. Dentin is laid down in primary, secondary, and tertiary forms throughout life.
1. Introduction To Endodonticsss (1).pdfssusere7b3c41
This document provides an overview of a course on endodontics, including:
- The objectives of the course which are to provide knowledge about endodontic morphology, physiology, and pathology and to train students in root canal treatment procedures.
- Required and recommended textbooks and journals.
- A definition of endodontics as the branch of dentistry concerned with dental pulp and tissues surrounding the roots of teeth.
- Some key causes and conditions that may require endodontic treatment.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
This document discusses various methods and materials used for pulp protection during restorative procedures. It describes the pulp-dentin complex and factors that can irritate the pulp. Methods for protecting the pulp include indirect and direct pulp capping. Direct pulp capping involves placing a biocompatible material over an exposed pulp. Indirect pulp capping leaves a thin layer of dentin and caries to avoid exposure. Materials traditionally used include calcium hydroxide, zinc oxide eugenol, and glass ionomers. Newer materials like Biodentine, a calcium silicate-based cement, have shown promising results for pulp capping and stimulation of reparative dentin formation.
Dense Evaginatus: Management Using Novel Materials A Case ReportQUESTJOURNAL
ABSTRACT: Dens evaginatus is an uncommon developmental anomaly of human dentition characterized by a projection of enamel and dentin that usually encloses pulp tissue. Most commonly found as the tubercle on the occlusal surface of mandibular premolars and lingual surface of anterior teeth.Due to occlusal trauma this tubercle tends to fracture thus exposing the pathway to the pulp chamber of teeth. This case reports about the presentation of dens evaginatus in mandibular premolar 35 which was associated with open apex and chronic apical periodontitis. Root canal treatment was performed with tooth 35. DFDBA apical barrier and Biodentine as an apical plug was placed showing successful management of the same.
Diagnosis & treatment plan for periimplant desease/ dental implant coursesIndian dental academy
This document discusses diagnosis and treatment of peri-implant disease. It begins by describing the history of dental implants and defines peri-implant mucositis and peri-implantitis. Peri-implant tissue breakdown can result from microbial and mechanical factors. Treatment aims to arrest disease progression and maintain implant sites. Bacterial infection and biomechanical overload are major causes of peri-implant bone loss. Implant shape, surface, and soft tissue attachment can also influence peri-implant health.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
pulp therapy
1. DEPARTMENT OF PEDODONTICS AND PREVENTIVE DENTISTRY SANTOSH DENTAL COLLEGE AND HOSPITAL GHAZIABAD
2. ASSIGNMENT ON PULP THERAPY PERMANENT TEETH (INDIRECT PULP IN DECIDUOUS AND YOUNG CAPPING AND DIRECT PULP CAPPING) GUIDED BY: - PRESENTEDBY:- Dr. BINITA SRIVASTAVA DEEPIKA SINGHAL Dr. H.P. BHATIA B.D.S FINALYEAR Dr. ARCHANA AGGARWAL BATCH 2003-2004 Dr. HARSHITA KAUSHIK
3. INDEX INTRODUCTION HISTOLOGY OF PULP STRUCTURAL ELEMENTS OF PULP PULPAL ASSESMENT DIAGNOSIS of pulp pathology EVALUATION OF TREATMENT PROGNOSIS BEFORE PULP THERAPY INDIRECT PULP CAPPING INDIRECT PULP THERAPY TECHNIQUE INFECTED VS AFFECTED DENTIN DIRECT PULP THERAPY TECHNIQUE HISTOLOGICAL CHANGES AFTER PULP THERAPY MEDICAMENTS AND MATERIAL USED FOR PULP CAPPING LIMITATIONS OF DIRECT PULP CAPPING IN PRIMARY TEETH POINTS TO BE KEPT IN MIND DURING PROCEDURE OF IPC AND DPC CONCLUSION REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. CONTENTS S.NO
4. INTRODUCTION PEDIATRIC ENDODONTICS is a relatively new terminology, which deals with the management of pulpally involved teeth in children. (Ref I, pg 328) Preservation of primary tooth whose pulp has been endangered by deep carious lesions or trauma is a major problem in caring for the teeth of children. (Ref G, pg 201) The Pulp therapy in children is still a subject of controversy due to mainly the lack of efficacious medicaments and skill, which requires a lot of patience on the part of the operator in handling this group of patients. Despite the modern advances in the prevention of dental caries and an increased awareness regarding the importance of deciduous teeth, premature loss of primary and young permanent teeth continues to be common, leading to malocclusion of varying degrees, and esthetic, phonetic and functional problems. Retention of the pulpally involved primary tooth to preserve arch space is preferable to space maintenance if the tooth can be restored to normal function and is free of pathology. Maintaining the integrity and health of the oral tissues is the primary objective of pulp treatment. It is also desirable to maintain pulp vitality whenever possible. (Ref A, pg 01) Greeks and Romans were the initiators of pulpal treatment by cauterization using hot needles, boiling oil and fomentation of opium. (Ref B pg 173)
5. DEVELOPMENT OF PULP Development of dental pulp begins at 8th week of embryonic life at the location of future incisor. As peripheral dental papilla cells transform into columnar shaped odontoblast, they develop cell processes. The odontoblasts then begin dentin formation. During dentinogenesis, the papilla becomes surrounded by dentin and is then termed the pulp organ. In the area of proliferating future papilla, it causes oral epithelium to invaginate and form enamel organ. These enlarge and enclose dental papillae in the central portion. Cells of the pulp organ are seen to be fibroblasts and appear in a delicate reticulum. Young dental papilla is highly vascularized and capillaries crowd among of the odontoblast during actual dentinogenisis. Large vessels traverse the central area of the pulp while smaller once are seen in the periphery. Although large nerve trunks are located near the developing young teeth, only a few nerves associated with blood vessels enter the developing young pulps. As teeth erupt and come to function the larger myelinated nerve become more abundant. (Ref B, pg173)
6. APPLIED HISTOLOGY OF THE PRIMARY TOOTH PULP The histology of primary tooth pulp is similar to that of permanent tooth. Odontoblasts line the periphery of the pulp space and extend cytoplasmic processes into the tubules of the dentin. These processes extend through full thickness of the dentin to the dentino-enamel junction. Odontoblasts are joined to one another by numerous cell junction that function according to design, not only to retain the relative position of one cell to another but also to provide means of intercellular communication. The odontoblast is the most specialized and distinctive cell of the dental pulp and is responsible for the formation of primary, secondary, and reparative dentin. The odontoblast is also an end cell that cannot divide. Replacement of odontoblasts necessitates by normal cell attraction and/or disease occurs through a differentiation and migration of other mesenchymal type cell in the dental pulp. Just below the odontoblast layer is a relatively cell free zone where there is an extensive plexus of unmyelinated nerve endings and blood capillaries that support the odontoblasts and provide sensitivity to the dentin. The core of dental pulp contains the large blood vessels and nerves surrounded by a loose alveolar type of connective tissue. The dental pulp is the soft tissue support of the dentin, and it functions to form and maintain the dentin under physiologic and stressed conditions.
7. When pulps are injured by infectious and noninfectious causes, it is best to attempt maintenance of pulp vitality. However, once a tooth is fully formed, it may continue to remain functional in the clinical sense without a physiologically active pulp. Consequently, in the mature tooth it is possible to stabilize pulp autolysis (as in the mummification of the primary tooth pulp) or eliminate the pulp entirely without significantly compromising tooth behavior. In partially developed teeth it is best to retain pulp activity, at least until dental development has been completed. (Ref A, pg 1-2)
8. REACTION TO DENTAL CARIES When the caries progresses from the enamel into the dentin, sclerotic dentin is formed by the opposition of minerals into and between the tubules (intratubular and intertubular dentin) and reparative and tertiary dentin is secreated by other mesenchymal type cell of the pulp that differentiate into new odontoblasts. The quality and amount of tertiary dentin depends on the depth and rate of progression of the carious lesion. The faster the lesion progresses, the poorer and more irregular is the reparative dentin. If the noxious stimulus is too intense, the cytoplasmmic processes of the odontoblasts degenerate and “dead tracts “are formed. When the caries process advances more rapidly than the elaboration of reparative dentin, the blood vessels of the pulp dilate, and scattered inflammatory cells become evident, particularly subadjacent to the areas of the involved dentinal tubules (transition stage). If the carious lesion remains untreated, a frank exposure eventually occurs. The pulp reacts with an infiltration of acute inflammatory cells, and the chronic pulpitis becomes acute. A small abscess may develop under the region of the exposure, and the chronic inflammatory series may be formed further away from the central area of the irritation. the remainder of the pulp may be uninflammed (chronic partial pulpitis with acute exacerbation). As the exposure progresses, the pulp may undergo partial necrosis, followed in some instance by total necrosis.
9. Drainage is the factor determining whether or not partial or total necrosis will occur. If the pulp is open and drainage can occur, the apical tissue may remain uninflammed or chronically inflamed. If the drainage is impeded by food impaction or restoration, the entire pulp may become necrotic more rapidly. (Ref E, pg 342)
10. REACTONS TO OPERATIVE PROCEDURE The factors affecting the dentin pulp complex during operative procedures (cavity or crown prepration) are mainly the cutting of dentin per se, the generation of heat, and the dessication the tissues. When uninvolved dentin undergoes operation, as in extention for prevention or in crown prepration, tubules that are not protected by reparative dentin are cut. The tissue reaction that occurs is similar to that occurring with caries: intratubular and intertubular mineralization takes place, resulting in sclerotic dentin formed by the formation of tertiary dentin. The amount and regularity of tertiary dentin are related to the depth of the cavity prepration. As the depth is increased, producton of reparative dentin is enhanced but its regularity and quality is compromised. Also, dead tracts may result in damage done to odontoblastic processes. Pulp reaction to operative procedure can be mild or severe, depending on the technique used. When the technique is gentle, the reaction is mild, and minor alterations in the odontoblastic layers can be observed as a result of fluid accumulation. In a severe reaction the nuclei of the odontoblasts may be aspirated into the dentinal tubules, haemmorage may be present, and inflammation is extensive, sometimes resulting in cell necrosis. A gentle technique implies using appropriate cooling nad minimal pressure. Cutting a cavity without using water cooling might ledt to irreversible changes in the pulp owing to the heat ganarated at the tip of the bur. The application of pressure increases the damage. Prolonged air blasts also deleterious to the pulp.
11. It has been demonstrated by LANGELAND (1957) that a blast of air on dentin for 10 seconds is enough to produce displacement of odontoblastic nuclei. This in order to prevent the generation of heat and damage to the pulp, the following measures should be taken: 1. The cavity should be prepared as shallowly as possible, respecting the principle of cavity prepration. 2. Small and sharp burs should be used. 3. Appropriate cooling should be employed and minimal pressure exerted. 4. Excessive drying of dentin by air syringe should be avoided. (Ref E, pg 342)
12. STRUCTURAL ELEMENTS OF THE PULP CELLULAR COMPONENTS EXTRACELLULAR COMPONENTS (Ref I, pg 330) Produces matrix and collagen Pleuripotent Phagocytosis Glycoprotein synthesis (predentin matrix) Throughout the cell rich zone Capillaries and cell rich zone Connective tissue First cell type as pulp is approached from the dentin 1.Fibroblast 2.Reserve cell 3.Histiocyte 4.Odontoblast FUNCTION LOCATION CELL Provide support for structural elements. Gel like medium in which all elements are placed. Transmit pain impulses only (because of the presence of free nerve ending only) Through out Makes up the bulk of the pulp 1.Fibers 2. Ground substances 3.Nerve fiber(A delta and C) 4.Arterioles, venules and lymphatics Function distribution Components
13. PULPAL ASSESMENT Assessment of pulp status of young permanent teeth is divided into the same five categories as are used for the deciduous teeth: 1. Patient history 2. Clinical examination 3. Clinical diagnostic procedure 4. Radiograph examination 5. Direct pulpal evaluation (Ref E, pg 522)
14. DIAGNOSIS OF PULP PATHOLOGY 1. PAIN An accurate history must be obtained of the type of pain, duration, frequency, location, spread, aggregating and relieving factors. Mode : is the onset spontaneous or provoked? Periodicity : do symptoms have temporal pattern or are they sporadic or occasional? Early pulpitis- symptoms seen in evening or after meal. Frequency : have the symptoms persisted since they began/ have they been intermittent? Duration : how long do symptoms last when they occur? Quality of pain : Dull, aching - pain of bony origin. Throbbing, pounding, pulsing - pain of vascular origin. Sharp, recurrant, stabbing - pathosis of nerve root complexes, irreversible pulpitis. Postural change : pain accentuates by bending over, Time of day : pain in the mastigatory muscles on working may indicate occlusal disharmony or TMJ dysfunction or possible acute pulpalgia. Hormonal : menstrual tooth ache due to increase in body fluid retention. Teeth may ache and may become tender on percussion, symptoms disappear when cycle ends. (Ref B, pg174-175)
15. TYPES OF PAIN:- Momentary pain : Immediate stresses to hot or cold that disappear on the removal of the stimulus indicate that the pathosis is limited to the coronal pulp. Persistent pain : pain from thermal stimuli would indicate wide spread inflammation of the pulp, extending into the radicular filaments. Spontaneous pain : throbbing, constant pain that may keep the patient awake at night. This type of pain indicates pulpal damage-irreversible pulpitis. (Ref B, pg 175) It suggests that pulpal disease has progressed too far and treatment confined to pulp chamber would be inadequate. (Ref F, pg 336) Provoked pain : stimulated by thermal, chemical or mechanical irritant, and is eliminated when noxious stimulus is removed. This sign indicates dentin sensitivity due to deep carious lesion or faulty restoration. The pulp is in the transition state and the condition is usually reversible. (Ref E, pg 344)
16. 2. VISUAL AND TACTILE EXAMINATION This is one of the simplest tests, but most often is done casually during examination and as a result valid information is lost. A thorough visual, tactile examination of hard and soft tissue relies on checking of 3 C’s that is color, contour, consistency. (Ref B, pg 175) 3. MOBILITY Mobility in the primary tooth may result from physiological or pathological cause. Tooth mobility is directly proportional to the integrity of the attachment apparatus. Clinician should use two mouth mirror handles to apply alternating lateral forces in the facial lingual direction to observe the degree of mobility of the tooth. A measure of mobility is:- (Ref B, pg 174-175) >2mm and vertically Horizontal 3- 1-2mm Horizontal 2- 0.2-1mm Horizontal 1- <0.2 mm Horizontal 0-
17. 4. PERCUSSION Pain from pressure on a tooth indicates that periodontal ligament is inflamed. A useful clinical test is to apply finger pressure to the tooth and check the child’s response by watching the eyes. (Ref B, pg 174-175) 5. PALPATION Simple test done with fingertips using light pressure to examine tissue consistency and pain response. It determines presence, intensity and location of pain and presence of bony crepitus. (Ref B, pg 174) 6. RESTORABILITY Only a tooth which can be restored after endodontic therapy should be considered for pulp therapy. 7. PRESENCE OF DISCHARGING SINUS Indicates a non vital pulp (or an irreversibly diseased pulp) and should be considered for non vital pulp therapy. (Ref A, pg 3) 8. CHANGES IN COLOR Discolored teeth may indicate a necrotic pulp. (Ref A, pg 03)
18. 9. RADIOGRAPHS Recent pre- operative radiographs are requisites to pulp therapy in primary and young permanent teeth. It demonstrates pathological conditions, position of succedaneous permanent tooth. These will dictate the decision on performing pulp therapy for primary tooth. (Ref B, pg 174) One factor that must be remembered is that the lesion must be of sufficient dimensions to appear radio graphically and must involve cortical bone. Pathological entities that are observed are:- a. Pulp calcification : represents the pulp response to long standing lesion and is associated with pulp degeneration. This contraindicates single visit pulpotomy. b. Internal resorption : it is associated with spontaneous pain at night and inflammation extending into radicular pulp. This contraindicates single visit pulpotomy. c. External resorption : pathologic resorption is invariably associated with no vital pulp and extensive inflammation in the supporting tissues. The only viable treatment is pulpectomy or extraction. d. Bone resorption : if minimum, pulpectomy is the choice but when the born loss is extensive, extraction is indicated. (Ref H, pg 223) Current radiographs are essential to examining for caries and periapical changes. Interpretation of radiographs is complicated in children by physiologic root resorption of primary teeth and by incompletely formed roots of permanent teeth.
19. Several additional factors worthy of consideration are as follows:- a. More than one view of the area of interest, each taken at different angle, is helpful for locating subtle changes (e.g., root fractures). b. Pathologic changes should not be confused with the normal anatomy (e.g., mandibular canal, mental foramen, incisive fossa, nasopalatine canal). c. Internal resoption is possible in permanent teeth but does not occur as often as in primary teeth. d. Treatment- induced calcification (i.e., bridging or apical closure) may be too thin to visualize radio graphically. (Ref E, pg 525) Pathologic changes in the periapical tissues surrounding primary molars are most often apparent in the bifurcation or trifurcation areas, rather than at the apexes (such as in permanent teeth). (Ref C, pg 803) The radiograph does not always demonstrate periapical pathosis, nor can the proximity of caries to the pulp always be accurately determined. What may appear as the intact barrier of secondary dentin overlying the pulp may always be a perforated mass of irregularly calcified and carious dentin overlying a pulp with extensive inflammation? The presence of calcified masses with in the pulp is important to making a diagnosis of pulpal status.
20. 10. PULPAL EXPOSURES AND HEMORRHAGE The size of the exposure, the appearance of the pulp, and the amount of hemorrhage are important factors in diagnosing the extent of inflammation in a cariously exposed pulp. A true carious exposure is always accompanied by pulpal inflammation. The pin point carious exposure may have pulpal inflammation varying from minimal to extensive to complete necrosis. However the massive exposure always has wide spread inflammation or necrosis and is not the candidate for any form of vital pulp therapy except in young, permanent teeth with incomplete root development. Excessive hemorrhage at an exposure site or during pulp amputation is evidence of extensive inflammation. These teeth should be considered candidates for pulpectomy or extraction. (Ref C, pg 804)
21. 11. PULP TESTING Pulp testing is widely used to assess vitality of mature permanent teeth but these are not reliable in deciduous teeth as fear of unknown makes the child patient apprehensive of the electric vitalometer and may give inaccurate results. Another reason is that newly erupted teeth may have incomplete innervations and there fore may not give correct results. Thermal test : This was first reported by jack in 1899 and it involved application of cold or heat to determine sensitivity to thermal changes. Cold test : It can be applied in several different ways like stream of cold air, cold- water bath, ethyl chloride, dry ice, pencil of ice. Agent is kept on the middle third of the facial structure of crown for 5 seconds and the response is determined. Heat test : These include warm sticks of temporary stopping, rotating dry prophycup, heated water bath, hot burnisher, hot gutta - percha and hot compound. RESPONSE TO THERMAL TEST:- 1. No response- non vital pulp. 2. Mild-moderate pain subsides in 1-2sec - normal. 3. Strong-momentary pain subsides in 1-2sec revesible pulpitis. 4. Moderate to strong painful response that lingers for several seconds or longer after the stimulus has been removed-irreversible pulpitis. (Ref B, pg 175-176)
22. 12. ANESTHETIC TESTING If the patient continues to have vague, diffuse, strong pain and prior testing has been inconclusive, intra ligamentary anesthetic may be used to identify the source of pain. 13. TEST CAVITY This test is performed when other methods have failed. The test cavity is made by drilling the enamel dentin junction of an un-anesthetized tooth using a slow speed hand piece without water coolant. If patient feels sensitivity it is indication of pulp vitality. 14. PHYSIOMETRIC TEST It describes such tests that assess the state of the pulpal circulation, rather than the integrity of the nervous tissue thus providing valuable information. 15. PHOTOPLETHYSMOGRAPHY This method involves passing light on the tooth and measuring the existing wavelength using a photocell and galvanometer. If a tooth with an intact blood supply is warmed there should be vascular dilatation, and this would register as a current from the photo cell. 16. THERMOGRAPHY A hot object emits infrared radiation in proportion to its temperature. Measurement of this radiation may provide information on pulpal circulation. (Ref B, pg 175-176)
23. 17. PULP HAEMOGRAM It was suggested that taking the first drop of blood from an exposed pulp and subjecting it to differential white cell count might be useful in diagnosis of pulpal conditions. 18. DUAL WAVELENGTH SPECTROMETRY Measures blood oxygenation changes within the capillary bed of dental tissue and thus is not dependent on a pulsatile blood flow. 19. HUGES PROBEYE CAMERA This is used in detecting temperature changes as small as 0.1◦c hence can be used to measure pulp vitality experimentally. 20. LIQUID CRYSTAL TESTING Cholesteric fluid crystals have been used to show the difference in tooth temperature with vital pulp being hotter and necrotic pulp being cooler. (Ref B, pg 176-177)
24. 21. LASER DOPPLER FLOWMETRY The laser doppler flowmeter, developed in 1970s to measure the velocity of red blood cells in capillaries, is a non invasive, objective, painless alternative to traditional neural- stimulation methods, and therefore is a promising test for young children. (Ref I, pg 332) A near infrared with a wavelength of 632.8 nm is produced by 1mw helium neon laser with in the flowmeter and this is transmitted along a flexible fiber optical conductor inside a specially designed round dental probe with a diameter of 2 mm. Enamel prisms and dentinal tubules guide the light to the pulp, where it is scattered both by static tissues by moving RBC’s. A fraction of backscattered light from the tooth is returned to the flowmeter along the pair of afferent optical fibers within the probe. The scattered light beams from moving RBC’s will be frequently shifted, while those from static tissue are unshifted indicating non vital pulp.
25. 22. PULSE OXIMETRY It is proven atraumatic method of measuring vascular health by evaluating oxygen saturation. Pulse oximetry is based on placing arterial blood between light source and detector. Light source diode emits both infrared and red light, which is received by a photo -detector diode. Blood pulsating through the vessel changes the light path, which modifies the amount of detected light. This determines the pulse rate. (Ref B, pg 175-177)
26. EVALUATION OF TREATMENT PROGNOSIS BEFORE PULP THERAPY The diagnostic process of selecting teeth that are good candidates for vital pulp therapy has at least two dimensions:- 1. Dentist must decide that the tooth has a good chance of responding favorably to the pulp therapy. 2. The advisability of performing the pulp therapy and restoring the tooth must be weighed against extraction and space management. 3. The level of patient and parent cooperation and motivation in receiving the treatment. 4. The level of patients and parent desire and motivation in maintaining oral health and hygiene. 5. The caries activity of the patient and overall prognosis of oral rehabilitation. 6. The degree of difficulty anticipated in performing the pulp therapy in particular case. 7. Space management issues resulting from previous extractions, preexisting malocclusion, ankylosis, congenitally missing teeth, and space loss caused by extensive carious destruction of teeth and subsequent drifting. 8. Excessive extrusion of pulpally involved tooth resulting from the absence of opposing teeth (Ref D, pg 392)
27. INDIRECT PULP CAPPING DEFINITION The procedure involving a tooth with a deep carious lesion where carious dentin removal is left incomplete, and the decay process is treated with a biocompatible material for sometime in order to avoid pulp tissue exposure is termed indirect pulp capping. (Ref I pg 335)
28. INDICATIONS 1. The teeth when pulpaly inflammation has been judged to be minimal and complete removal of caries would cause pulp exposure. (Ref I, pg336) 2. Mild pain associated with eating. 3. Negative history of spontaneous, extreme pain. 4. No mobility. 5. When pulp inflammation is seen as nominal and there is a definite layer of affected dentin after removal of infected dentin. 6. Normal lamina dura and PDL space. 7. No radiolucency in the bone around the apices of the roots or in the furcation. 8. Deep carious lesion, which are close to, but not involving he pulp in vital primary or young permanent teeth. (Ref B, pg 179)
29. CONTRAINDICATIONS 1. Any signs of pulpal or periapical pathology. 2. Soft leathery dentin covering a very large area of the cavity, in a non restorable tooth. (Ref I, pg 336) 3. Sharp, penetrating pulpalgia indicating acute pulpal inflammation. 4. Prolonged night pain. 5. Mobility of the tooth. 6. Discoloration of the tooth. 7. Negative reaction of electric pulp testing. 8. Definite pulp exposure. 9. Interrupted or broken lamina dura. 10. Radiolucency about the apices of the roots. (Ref B, pg179)
30. OBJECTIVES 1. The restorative material should seal completely the involved dentin from the oral environment. 2. The vitality of the tooth should be preserved. 3. No prolonged post-treatment signs or symptoms of sensitivity, pain or swelling should be evident. 4. The pulp should respond favourably and tertiary dentin or reparative dentin should be formed, as evidenced by radiographic evaluation. 5. There should be no evidence of internal resorption or other pathologic changes. (Ref I, pg 336) 6. Arresting of carious process. 7. Promoting dentin sclerosis. 8. Stimulating formation of tertiary dentin. 9. Remineralization of carious dentin. (Ref B, pg 179)
31. INDIRECT PULP THERAPY 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. 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. Kopel has identified three distinct layers in active caries:- 1. Necrotic, soft dentin not painful to stimulation and grossly infected with bacteria. 2. Firm but softened dentin, painful to stimulation but containing few bacteria. 3. Slightly discolored, hard, sound dentin containing few bacteria and painful to stimulation. 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.
32. 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. 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. 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. 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 C, pg 804-807) 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 placement of a permanent restoration.
33. For the experienced clinician using good case selection, however it may be preferable to avoid second instrumentation (and the potential risk of pulpal exposure). 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. (Ref E, pg 526)
35. First appointment Use local anesthesia and isolation with rubber dam. ↓ Establish cavity outline with high speed hand piece. ↓ Remove the superficial debris and majority of the soft necrotic dentin with slow speed hand piece using large round bur. ↓ Stop the excavation as soon as the firm resistance of sound dentin is felt. ↓ Periapical carious dentin is removed with a sharp spoon excavator. ↓ Cavity flushed with saline and dried with cotton pellet. ↓ Site is covered with calcium hydroxide. ↓ Remainder cavity is filled with reinforced ZOE cement.
36. Second appointment (6-8 weeks later) Between the appointment history must be negative and temporary restoration should be intact. ↓ Take a bitewing radiograph and observe for sclerotic dentin. ↓ Carefully remove all temporary filling material. ↓ Previous remaining carious dentin will have become dried out, flaky and easily removed. ↓ The area around the potential exposure will appear whitish and may be soft; which is predentin. Do not disturb this area. ↓ The cavity preparation is washed out and dried gently. ↓ Cover the entire floor with calcium hydroxide. ↓ Base is built up with reinforced ZOE cement or GIC. ↓ Final restoration is then placed. (Ref B, pg 180)
40. A B C D E A INDIRECT PULP CAPPING (Ref F, pg 338)
41. INFECTED VS AFFECTED DENTIN (Ref I, pg 336) Affected dentin Infected dentin ▪ Intermediately demineralized ▪ Remineralizable ▪ Deeper layer ▪ Sensitive ▪ Does not stain ▪ Ultrasyructure : intertubular dentin Partially demineralized, but apatitie crystals bound like fringes to the Sound collagen fibers with distinct Cross bands and interbands. ▪ Should be left remineralize. ▪ 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
42. DIRECT PULP CAPPING DEFINITION: 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 radiopaque base in contact with the exposed pup tissue prior to placing a restoration is termed as direct pulp capping. (Ref I, pg 338)
43. INDICATIONS 1. Light red bleeding from the exposure site that can be controlled by cotton pellet. 2. Traumatic exposures in a dry, clean field, which report to the dental office within 24 hours. (Ref I, pg 336) 3. Mechanical exposures less than I sq mm, surrounded by clear dentin in an asymptomatic vital deciduous tooth. 4. Mechanical or carious exposures less than 1 sq mm in an asymptomatic vital young permanent tooth. (Ref H, pg 225) 5. Small pulp exposures produced during cavity preparation i.e. pin point exposure surrounded by sound dentin. 6. When the tooth is not painful, with the exception of discomfort caused by food intake. 7. Minimal or no bleeding from the exposure site. (Ref F, pg339)
44. CONTRAINDICATIONS 1. Large pulp exposures. 2. Presence of caries surrounding the exposure site. 3. Excessive bleeding indicates hyperemia or pulpal inflammation. (Ref F, pg339-340) 4. Pain at night. 5. Spontaneous pain. 6. Tooth mobility. 7. Thickening of periodontal membrane 8. Intraradicular radiolucency (Ref I, pg 336) 9. Purulent or serous exudates 10. Swelling 11. Fistula 12. Root resorption 13. Pulpal calcification(Ref H, pg 225)
45. OBJECTIVES 1. The vitality of tooth should be maintained. 2. No prolonged post-treatment signs or symptoms of sensitivity, pain or swelling should be evident. 3. Pulp healing and tertiary dentin formation should result. 4. There should be no pathologic changes. (Ref I, pg 336) 5. To create new dentin in the area of the exposure and subsequent healing of pulp. (Ref B, pg 181)
46. TREATMENT CONSIDERATIONS Debridement: 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. (Ref B, pg 181) 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. (Ref H, pg225) Hemorrhage and clotting 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. Bacterial contamination Adequate seal following pulp capping is a must to prevent bacterial contamination. (Ref H, pg225) Exposure enlargement : The exposure site must be enlarged because: a. It removes inflammation and infected tissue in the exposed area. b. It facilitates washing away carious and non carious debris. c. It allows closer contact of more capping medicament material to the actual pulp tissue. (Ref B, pg181)
48. Rubber dam provides only means of working in a sterile environment, so it has to be used. ↓ Once an exposure is encountered, further manipulation of pulp is avoided. ↓ Cavity should be irrigated with saline, chloramines T or distilled water. ↓ Hemorrhage is arrested with light pressure from sterile cotton pellets. ↓ Place the pulp capping material, on the exposed pulp with application of minimal pressure so as to avoid forcing the material into pulp chamber. ↓ Place temporary restoration. ↓ Final restoration is done after determining the success of pulp capping which is done by determination of dentinal bridge, maintenance of pulp vitality, lack of pain and minimal inflammatory response. (Ref B, pg 182)
50. HISTOLOGICAL CHANGES AFTER PULP CAPPING These were illustrated by Glass and Zander in 1949. After 24 hours: Necrotic zone adjacent to ca (oh) 2 pastes is separated from healthy pulp tissue by a deep staining basophilic layer. After 7 days: Increase in cellular and fibroblastic activity. After 14 days: Partly calcified fibrous tissue lined by odontoblastic cells is seen below the calcium protienate zone; disappearance of necrotic zone. After 28 days: Zone of new dentin. (Ref B, pg 183)
52. FEATURES OF SUCCESSFUL PULP CAPPING 1. Maintenance of pulp vitality. 2. Lack of undue sensitivity or pain 3. Minimal pulp inflammatory response. 4. Ability of the pulp to maintain itself without progressive degeneration. (Ref H, pg 225) 5. Lack of internal resorption and intaradicular pathosis. (Ref I, pg 340)
54. Ca(OH) 2 : 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. (Ref B, pg 182) 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. Internal resorption may occur after pulp exposure and capping with calcium hydroxide. 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 C, pg 809)
55. Corticosteroids and antibiotics: 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. (Ref B, pg 182) Inert materials: Isobutyl Cynoacrylate and Tricalcium phosphate ceramic. Collagen fibers: Collagen fibers influence mineralization and are less irritant than Ca (OH) 2 with dentin bridge formation in 8 weeks. 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 Direct bonding: 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. (Ref B, pg 182)
56. Isobutyl cyanoacrylate: 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 I, pg 341) Disadvantage is that it is cytotoxic when freshly polymerized. (Ref B, pg 182) Denaturated albumin: This protein has calcium binding properties. If a pulp exposure is capped with a protein, the protein may become a matrix for calcifation, thereby increasing the chances of biologic obliteration. Laser: ANDREAS MERITZ 1n 1998 evaluated the effect of direct pulp capping. Bone morphogenic protein (BMP): The demineralized bone matrix could stimulate new bone formation when implanted to ectopic sites such as muscles. The implications for pulp therapy are immense as it is capable of inducing reparative dentin.(Ref B , pg183)
57. Properties: 1. It is biocompatible material and its sealing ability is better than that of amalgam or ZOE. 2. Initial pH is 10.2and set pH is 12.5. 3. The setting time of cement is 4 hours. 4. The compressive strength is 70 MPA, which is comparable to that of IRM. 5. Low cytotoxity- it presents with minimal inflammation if extended beyond the apex. Action: It has ability to stimulate cytokine and interleukins release from blood cells, indicating that it actively promotes 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.(Ref B, pg 182) 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. 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. (Ref C, pg 810) hard tissue formation.
58.
59. LIMITATION OF DIRECT PULP CAPPING IN PRIMARY TEETH 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 B, pg183) Calcification, chronic inflammation, necrosis and intraradicular involvement. (Ref I, pg 339)
60. POINTS TO BE KEPT IN MIND DURING PROCEDURE OF IPC AND DPC
61. 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. 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. 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. Marginal seal over the pulp capping procedure is of prime importance since it prevents the ingress of bacteria and reinfection.
62. 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 capping has been reported without the presence of reparative dentin bridge over the exposure site. (Ref A, pg 09)
63. CONCLUSION Pulp therapy for primary dentition includes a variety of treatment options, depending on the vitaliy of the pulp. Conservative treatment is performed when vital pulp remains because recovery is possible once the irritation has been removed. (Ref E, pg 354)