CARIES PATOLOGI –VAD HÄNDAR I TANDEN OCH PULPAN?

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CARIES PATOLOGI – VAD HÄNDAR I TANDEN OCH PULPAN?

Lars Bjørndal

DDS, PHD, DR. ODONT

Section of

Cariology and

Endodontics,

University of

Copenhagen

[email protected]

Treatment concepts

AD 3.

1. There are many different treatment options for the same cariouslesion: We need more consensus!

Dias 2

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At the moment the caries penetrations depths arenot clearly related to one specific treatmentapproach

HOW WOULD YOU TREAT A DEEP CARIES LESION WHEN EXPECTING A PULP EXPOSURE ?

PartialexcavationCompleteexcavationEndodontictreatment

Oen et al. 2007 Gen Dent

Responds from practitioners in a Network survey

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The goal should be to define specific treatment modalities for each lesion stage!

Bjørndal et al 2010, EJOS

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In case of carious exposure in deep caries: Direct pulp capping versus Partial Pulpotomy

Pulp

Ketac Molar

Dycal

Direct capping

Pulp

Ketac Molar

Dycal

Partial Pulpotomy

Let´́́́s define the deep lesions by the x-ray

Deep Caries: Penetrating ¾ into the dentine but still with a well-defined dentinetowards the pulp

Extreme deep caries: Penetrating through the entire thickness of the dentine

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The outcome of all patients

involved in the excavation trial !

Unexposeddeep

caries lesions

Pulp survivalrate:

88.8%

Cariously exposedpulps

Pulp survivalrate:

32.8%

Area of Cariology and Endodontics

Direct pulp capping versus partial pulpotomy

Pulp CappingTrial

N = 58

Treatment visit: Direct Pulp

Capping N = 27

1. month controlvisit

N = 25

At 1-yr follow-upN = 9

Pain N = 11 Lost N = 5

Pain N = 2

Treatment visit: Partial

PulpotomyN = 31


N = 26


Pain N = 11AP N = 1

Lost N = 1

Pain N = 2Haemostasis

N = 2Lost N = 1A lot of pain !


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•Direct pulp caps

•Class I (accident, ie pulp exposure in normal dentine)

•Class II (Intended ie carious dentine)

A suggested classification of DPC:

•Direct pulp caps

•Class I (accident, ie pulp exposure in normal dentine)

• Class II (Intended ie carious dentine)


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• The exposure has occurredfollowing trauma, preperation,

or as an accidential

exposure of normal

dentine during

excavation of caries

Direct pulp cappingClass I

In other words the caries lesions are not deep nor extreme deep

X X

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• The exposure has occurred following trauma preperation or as an accident during excavation of caries

• The pulp is judged to be clinical healthy

Direct pulp cappingClass I

What is a healthy pulp in clinical terms

• It is vital

• The patient is without subjective pain

• Hemostasis can be expected

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Direct pulp capping (Class I)

• The cavity and the pulp exposure are gently flushed with saline in order to remove detritus and to establish a clean non-bleeding pulp wound

• Direct flush at the exposure should be avoided

• Firm pressure with a cotton pellet should be avoided as the removal tends to reactivate bleeding

• Hemostasis should be reach within 5 min.

Direct pulp capping (Class I)

• Pulp capping agent is applied at the exposure site and in contact with the tissue (ex. calcium hydroxide containing base material or MTA) followed by an additional restoration

• A permanent restoration is placed immediately or within a few days in order to prevent secondary bacterial infection

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In short accepting the condition for case selection for the so-called Class I CAP –

The prognosis is traditionally expected to be good !

It is very rare that we get information about the depth of the caries lesions in clinical studies reporting vital pulp therapies!

………. is the pulp exposure performed in sound dentine or is it carried out within carious dentine during treatment of deep / extreme deep caries

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•Direct pulp caps• Class I (accident, ie pulp

exposure in normal dentine)

•Class II (Intended ie carious dentine)


• The pulp exposure is not an accident

• Stringent protocol using magnification, caries detector, high conc. of sodium hypoclorite and MTA –like cement

• Deep or Extreme deep caries (Caries reaching the pulp)

Direct pulp cappingClass II (ad modem Bogen)

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J Am Dent Assoc. 2008 Mar;139(3):305-15; quiz 305-15.Direct pulp capping with mineral trioxide aggregate: an observational study.Bogen G, Kim JS, Bakland LK.

Courtesy G . Bogen

• Initial and follow-up states

• Likelihood of teeth transitioning to next health state

• 6 months simulation cycles

• Sequence of events constructed according to current evidence

The Markow model:

Schwendicke & Stolpe. J Endod 2014

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• Deeply carious molar with a sensible, nonsymptomatic (ie painless) pulp being exposed during caries excavation

• NO discrimination between carious exposures and ‘accidential’ (sound dentine) exposures

• DPC were restored either by Calcium hydroxid or MTA followed by direct restoration

• RCT (vital pulpectomy) followed by cast coronal restoration

• Caries lesion involved both approximal and occlusal caries

COST BENFITE ANALYSES:

The assumptions for the simulated scenario using a Markow model:

• Optimal scenario:• Younger pt (< 40 yrs) occlusal exposure sites in

posterior teeth

• Less effective and more costly scenario:• Older patients (> 40 yrs) approximal sites in anterior

teeth. In particular the time until follow-up treatments was short leading to early need of RCT

Results from the simulation scenario:

Schwendicke & Stolpe 2014 JOE

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State transition diagram simulating the lifetime of a tooth with an exposed, sensible, non-symptomatic pulp


Schwendicke & Stolpe. J Endod 2014

• Optimal scenario:• Younger pt (< 40 yrs) occlusal exposure sites in

posterior teeth

• Less effective and more costly scenario:• Older patients (> 40 yrs) approximal sites in anterior




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Of course many limitations within a simulating environment:

• Can’t integrate all clinical parameters

• Does not account for cost caused by pain and loss of patient time

Direct pulp capping versus partial pulpotomy

Pulp CappingTrial

N = 58

Treatment visit: Direct Pulp

Capping N = 27


N = 25


Pain N = 11 Lost N = 5

Pain N = 2

Treatment visit: Partial

PulpotomyN = 31


N = 26


Pain N = 11AP N = 1

Lost N = 1

Pain N = 2Haemostasis

N = 2Lost N = 1A lot of pain !


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• Prof. experience

• The data building up the the simulation is from the start not the high level evidence data!

• Attitudes toward various treatments

• Exposure in sound or carious dentine (unknown)




• Prof. experience

• The data building up the the simulation is from the start not the high levelevidence data!

• Attitudes toward various treatments

• Exposure in sound or carious dentine (unknown)

• The general lack of being able to estimate pulp inflammation

• The health care system varies

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• Optimal DPC scenario:• Younger pt (< 40 yrs) occlusal exposure sites in

posterior teeth

• Less effective and more costly DPC scenario:• Older patients (> 40 yrs) approximal sites in anterior




The goal would be to define specific treatment modalities for each lesion stage!

DPC Class I

DPC Class IIor RCT Deep/ Extreme deep

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At the moment based on the few high quality RCTs in adults a rather traditional approach is suggested:

If you perform the exposure by accident in deep or ectreme deep caries and without being able to do a Class II protocol you should not consider the direct cap, neither the partial pulpotomy nor the full pulpotomy in deep caries lesions in adults

– but facing the pulpectomy!

…………..or avoid the exposure by a less invasive excavation approach!

CARIES PATOLOGI –VAD HÄNDAR I TANDEN OCH PULPAN?

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