PULP CAP KAMLOOPS APRIL 14, 2012. RETROSPECTIVE STUDIES 1. Bogan G et al JADA 2008:39 (3) 305-315 97% 2. Fuks AB, Pediatr Dent 1982,4: 240-244 81%

PULP CAPPULP CAP

KAMLOOPSKAMLOOPS

APRIL 14, 2012APRIL 14, 2012

RETROSPECTIVE STUDIESRETROSPECTIVE STUDIES

1.1. Bogan G et alBogan G et al JADA 2008:39 (3) 305- JADA 2008:39 (3) 305-315 315 97%97%

2.2. Fuks ABFuks AB, Pediatr Dent 1982,4: 240-, Pediatr Dent 1982,4: 240-244 244 81%81% success on permanent success on permanent incisors incisors

3.3. Barthel CRBarthel CR ,J Endod 2000; 26: 525- ,J Endod 2000; 26: 525-528 528 37%37% @ 5 years, @ 5 years, 13%13% @10 years @10 years

PULP CAP MATERIALS ?PULP CAP MATERIALS ?CR NEWS Jan 2010CR NEWS Jan 2010

RMGIRMGI Vitrebond Plus Vitrebond Plus or GC Fuji Lining LCor GC Fuji Lining LC Indirect 40% Indirect 40% Indirect 68%Indirect 68%

Calcium HydroxideCalcium Hydroxide 28% Direct,28% Direct, 14% Indirect14% Indirect

Bonding agentBonding agent Direct 7% Direct 7% Indirect 5%Indirect 5%

LaserLaser 2% Direct 2% Direct GluteraldehydeGluteraldehyde

Indirect 3%Indirect 3% MTA MTA 3% Direct3% Direct PolycarboxylatePolycarboxylate – no – no

mentionmention Glass IonomerGlass Ionomer – no – no

mentionmention English sparrow poopEnglish sparrow poop

CR NewsCR News Jan 2010 vol 3 issue 1 Jan 2010 vol 3 issue 1

1.1. CR respondents; CR respondents; success ratessuccess rates

1.1. 3 years: Direct 3 years: Direct 58%,58%, Indirect Indirect 70%70%

2.2. 5 years: Direct 5 years: Direct 48%,48%, Indirect Indirect 61%61%

0102030405060708090

100

3 5 10

DIRECTINDIRECTBOGANFUKSBARTHEL

MTA MTA Bogan G et alBogan G et al JADA 2008:39 (3) 305-315 JADA 2008:39 (3) 305-315 Direct pulp capping with Mineral Trioxide Direct pulp capping with Mineral Trioxide

aggregate – an Observational Study.aggregate – an Observational Study. Over an observation period of Over an observation period of nine nine

years, the authors followed years, the authors followed 49 of 53 49 of 53 teethteeth and found that and found that 97.96%97.96% percent percent had favorable outcomes on the basis of had favorable outcomes on the basis of radiographic appearance, subjective radiographic appearance, subjective symptoms and cold testing.symptoms and cold testing.

0

1020304050607080

90100

BarthelFuksCRA indirectCRA directBogan

MTABOGAN

PEDOFUKS

PULP CAP SUCCESS RATESPULP CAP SUCCESS RATES

0

10

20

30

40

50

60

70

INDIRECT DIRECT

RMGICA(OH)2GLUTBONDMTA

SUCCESSFUL PULP CAPSSUCCESSFUL PULP CAPS

Healthy patient

Recoverable pulp

Flawless caries removal

Disinfection

Histological repair

seal

Inflammationmanagement

SUCCESSFUL PULP CAPSSUCCESSFUL PULP CAPS

Healthy patientRecoverable pulp

Flawless caries removal

DisinfectionHistological repair

seal

Inflammationmanagement

SUCCESSFUL PULP CAPSSUCCESSFUL PULP CAPS

Healthy patient

Recoverable pulp

Flawless caries removal

Disinfection

Histological repair

seal

Inflammationmanagement

RADIOGRAPHIC RADIOGRAPHIC CONTRAINDICATIONSCONTRAINDICATIONS

APICAL RADIOLUCENCY

APICAL DETERIORATION -CONDENSING OSTEITIS

THREADLIKE PULP

PULP STONES PROBABLE

FUTURE PULP OCCLUSION E.G. CLASS VCLASS V

RADIOGRAPHICLY EVIDENT CARIOUS INVASION OF PULP CHAMBER

DIAGNOSTIC DIAGNOSTIC CONTRAINDICATIONS = CONTRAINDICATIONS = HISTORY OF HISTORY OF ++ PAIN++ PAIN

APICAL TENDERNESSAPICAL TENDERNESS SPONTANEOUS SPONTANEOUS LONG STANDING LONG STANDING NOCTURNAL NOCTURNAL THROBBING THROBBING ENDURING ENDURING SICKENING SICKENING CONSTANT NEED OF MEDICATIONSCONSTANT NEED OF MEDICATIONS

OPERATIVE OBSERVATIONS OPERATIVE OBSERVATIONS CONTRAINDICATIONS AT CONTRAINDICATIONS AT

EXPOSURE EXPOSURE EXUDATE – SEROUSEXUDATE – SEROUS PUSPUS PROLONGED CLOTTING TIME > 5 PROLONGED CLOTTING TIME > 5

MINSMINS >3MM EXPOSURE >3MM EXPOSURE EXPLORER INTO THE PULP EXPLORER INTO THE PULP

(OPERATOR ERROR)(OPERATOR ERROR)

SUCCESSFUL PULP CAPSSUCCESSFUL PULP CAPS

Healthy patient

Recoverable pulp

Flawless caries removal

Disinfection

Histological repair

seal

Inflammationmanagement

FORMULA FOR CARIES FORMULA FOR CARIES DETECTORDETECTOR

ACID RED 52 2% IN PROPYLENE ACID RED 52 2% IN PROPYLENE GLYCOLGLYCOL

COMPOUNDING PHARMACYCOMPOUNDING PHARMACY $30 FOR 200 CC.= 5 YEARS’ SUPPLY$30 FOR 200 CC.= 5 YEARS’ SUPPLY

ref

CARIES DETECTOR - NO CARIES DETECTOR - NO EFFECT ON BOND STRENGTHEFFECT ON BOND STRENGTH

El-Housseiny and Jamjoum, J Clin El-Housseiny and Jamjoum, J Clin Pediat Dent 200Pediat Dent 200

Kazemi et al, Oper Dent 2002Kazemi et al, Oper Dent 2002

AFFECTED DENTIN

INFECTED DENTIN

SETTING THE STAGE FOR SETTING THE STAGE FOR PULPAL HEALINGPULPAL HEALING

EXPOSURE ZONE:EXPOSURE ZONE: LOW/NIL BACTERIAL COUNT LOW/NIL BACTERIAL COUNT

CONTIGUOUS ZONECONTIGUOUS ZONE BIOCOMPATIBLE AND BIOCOMPATIBLE AND

CALCIGENIC AGENTCALCIGENIC AGENT VISIBLE DELINEATION FORVISIBLE DELINEATION FOR

FUTURE INTERVENTIONSFUTURE INTERVENTIONS

PERIPHERAL ZONEPERIPHERAL ZONE SEAL (ZERO MICROLEAKAGE)SEAL (ZERO MICROLEAKAGE)

TUBULESTUBULES % AREA% AREA

NUMBER/ MMNUMBER/ MM22

DIAMETERDIAMETER

PRESSUREPRESSURE NILNIL POSITIVEPOSITIVE

SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP DENTINDENTIN

20 K

58K

1u 3u

10% 88%

SUCCESSFUL PULP CAPSSUCCESSFUL PULP CAPS

Healthy patient

Recoverable pulp

Flawless caries removal

Disinfection

Histological repair

seal

Inflammationmanagement

LEAVING CARIES?LEAVING CARIES?

REFERENCEREFERENCE

2 APPLICATIONS 2 APPLICATIONS

ONE MINUTE EACHONE MINUTE EACHref

CR CR

JAN 2010JAN 2010

CR News Jan 2010 vol 3 issue 1CR News Jan 2010 vol 3 issue 1 http://www.cliniciansreport.org/produhttp://www.cliniciansreport.org/produ

cts/dental-reports/january-2010-volucts/dental-reports/january-2010-volume-3-issue-1.php me-3-issue-1.php

Subscription requiredSubscription required

OTHER INTRAORAL OTHER INTRAORAL DISINFECTANTSDISINFECTANTS

ENDODONTICENDODONTIC SILVER NITRATESILVER NITRATE IODINEIODINE FORMOCRESOLFORMOCRESOL CA(OH)2CA(OH)2

PULPALPULPAL HYPOCHLORITE - HYPOCHLORITE -

KANCAKANCA CHLORHEXEDINE-CHLORHEXEDINE-

MANYMANY

ref

CHLORHEXEDINE NO EFFECTCHLORHEXEDINE NO EFFECTON BOND STRENGTHON BOND STRENGTH

Santos et al, JOE, 2006Santos et al, JOE, 2006 Perdiao et , Am J Dent 1994Perdiao et , Am J Dent 1994

WHAT ABOUT SURFACE WHAT ABOUT SURFACE DISINFECTANTS?DISINFECTANTS?

70% ALCOHOL WITH PHENOLS 70% ALCOHOL WITH PHENOLS 70% ALCOHOL WITH CHX 70% ALCOHOL WITH CHX ACCELERATED PEROXIDEACCELERATED PEROXIDE HYPOCHLORITEHYPOCHLORITE

ref

NaOClNaOCl

IS A STRONG OXIDIZING AGENTIS A STRONG OXIDIZING AGENT REDUCES BOND STRENGTH OF REDUCES BOND STRENGTH OF

DENTIN BONDING AGENTSDENTIN BONDING AGENTS Ari et al, JOE, 2003Ari et al, JOE, 2003 Erdemir et al, JOE, 2004Erdemir et al, JOE, 2004 Santos eta l JOE, 2006Santos eta l JOE, 2006 Lai et al, J Deny Res 2001Lai et al, J Deny Res 2001

REVERSING NaOCl EFFECTS ON REVERSING NaOCl EFFECTS ON DBASDBAS

A reducing agent, such as ascorbic acid, or A reducing agent, such as ascorbic acid, or sodium ascorbate, can reverse the effect of sodium ascorbate, can reverse the effect of NaOCl on bonding strengthNaOCl on bonding strength

Morris et al, JOE, 2001Morris et al, JOE, 2001

Lai et al, J Dent Res, 2001Lai et al, J Dent Res, 2001

Yiu et al, J Dent Res, 2002Yiu et al, J Dent Res, 2002

Weston et al JOE, 2007: 10% Na ascorbate for Weston et al JOE, 2007: 10% Na ascorbate for 1 min restored the origonal bond strenghts1 min restored the origonal bond strenghts

EDTA reverses effect of EDTA reverses effect of NaOClNaOCl

Doyle t al, JOE, 2006Doyle t al, JOE, 2006 A final rinse with EDTA reversed the A final rinse with EDTA reversed the

effects of NaOCl on bondingeffects of NaOCl on bonding

H2O2 reduces bond strength of H2O2 reduces bond strength of DBAsDBAs

Erdemir et al JOE, 2004Erdemir et al JOE, 2004 Nikaido et al, Am J Dent 1999Nikaido et al, Am J Dent 1999

DEEP CARIES DISINFECTIONDEEP CARIES DISINFECTION

Optim 33TB Sci CanOptim 33TB Sci Can One minute kill One minute kill

==10 Log 10 Log -6-6

TB effectiveTB effective CR tested April 2007CR tested April 2007 Excellent surface Excellent surface

cleanercleaner Tissue compatible Tissue compatible

WALFORD DEEP CARIES / WALFORD DEEP CARIES / EXPOSURE PROTOCOLEXPOSURE PROTOCOL

GET CLOSEGET CLOSE OPTIM 33TB ONE MINUTEOPTIM 33TB ONE MINUTE NO DETECTORNO DETECTOR CAREFUL ECAVATIONCAREFUL ECAVATION

SLOW RPMSSLOW RPMS SPOONSPOON

SMEAR CLEAR ONE MINUTESMEAR CLEAR ONE MINUTE REMOVE SMEAR LAYERREMOVE SMEAR LAYER

OPTIM 33 ONE MINUTEOPTIM 33 ONE MINUTE PENETRATE TUBULESPENETRATE TUBULES

REMOVING SMEAR LAYER &REMOVING SMEAR LAYER &PENETRATING TUBULESPENETRATING TUBULES

EDTAEDTA SmearClear (SybronEndo)SmearClear (SybronEndo) QMix (Tulsa/Dentsply)QMix (Tulsa/Dentsply) Acid etchAcid etch

WALFORD DEEP CARIES / WALFORD DEEP CARIES / EXPOSURE PROTOCOLEXPOSURE PROTOCOL

GET CLOSE: OPTIM 33TB GET CLOSE: OPTIM 33TB ONE MINUTEONE MINUTE

NO DETECTORNO DETECTOR CAREFUL ECAVATIONCAREFUL ECAVATION

SLOW RPMSSLOW RPMS SPOONSPOON

SMEAR CLEAR ONE SMEAR CLEAR ONE MINUTEMINUTE REMOVE SMEAR LAYERREMOVE SMEAR LAYER

OPTIM 33 ONE MINUTEOPTIM 33 ONE MINUTE PENETRATE TUBULESPENETRATE TUBULES

SMEAR CLEAR (as SMEAR CLEAR (as reducer)reducer)

EXPOSE if still cariousEXPOSE if still carious MTA DIRECT CAPMTA DIRECT CAP OVERSEAL WITH GLASS OVERSEAL WITH GLASS

IONOMER or CA(OH)2IONOMER or CA(OH)2 ALLOW TO SETALLOW TO SET ETCH PRIME BONDETCH PRIME BOND OVERSEAL OVERSEAL

FLOWABLE/CURE FLOWABLE/CURE FLOWABLE /CUREFLOWABLE /CURE RESTORE FOLLOWING RESTORE FOLLOWING

LOW CONTRACTION LOW CONTRACTION STRESS PRINCIPLESSTRESS PRINCIPLES

MTA: SUPPLIERMTA: SUPPLIER

CLINICAL RESEARCH DENTALCLINICAL RESEARCH DENTAL LONDON ONTARIOLONDON ONTARIO 1800 265 34441800 265 3444

““MTA ANGELUS WHITE”MTA ANGELUS WHITE”

MTA MECHANISMMTA MECHANISM

Silviera CMM et al.Silviera CMM et al. Repair of Furcal Repair of Furcal Perforation with Mineral Trioxide Perforation with Mineral Trioxide Aggregate: Long-Term Follow-Up Aggregate: Long-Term Follow-Up of 2 Cases of 2 Cases JCDA October 2008 Vol JCDA October 2008 Vol 74 #8 729-73274 #8 729-732

http://www.cda-adc.ca/jcda/vol-74/isshttp://www.cda-adc.ca/jcda/vol-74/issue-8/729.htmlue-8/729.html

MTA MECHANISMMTA MECHANISM

Saidon J et al.Saidon J et al. OSOMOPOR Endod OSOMOPOR Endod 2003:95:483-2003:95:483-489 “Cell and tissue 489 “Cell and tissue reactions to mineral trioxide reactions to mineral trioxide aggregate (MTA) and Portland aggregate (MTA) and Portland cement.”cement.”

MTA and Portland cement show MTA and Portland cement show comparative biocompatibility when comparative biocompatibility when evaluated in vitro and in vivo. The evaluated in vitro and in vivo. The Portland cement was sterilized by Portland cement was sterilized by ethylene oxide.ethylene oxide.

MTA MENTE ET ALMTA MENTE ET AL

Johannes Mente, DMD, et al J. Endo May 2010 806-814

Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: An Analysis of the Clinical Treatment Outcome

5 years, 167 teeth 78% success MTA, 60% Ca(OH)2

i.e. Twice as much failure with Ca(OH)2

Mente, DMD, et al J. Endo May 2010

Dentin bridge formation with MTA seems to be more homogenous (fewer tunnel defects) and more localized than that formed with Ca(OH)2 (20–24). caries was excavated from the cavity walls.

Near to the pulp, except for one carious spot, the removal of which resulted in exposure of the pulp, the cavities were routinely disinfected with 0.12% chlorhexidine solution (Glaxo Smith Kline GmbH, Buhl, Germany).

Resolution of bleeding from the exposed pulp in less than 5minutes was considered to be indicative of reversible inflammation

The MTA pulp cap was overlaid with a thin protective layer of resin modified glass ionomer cement (Vitrebond; 3M Espe)

The reduction in clinical success if a direct pulp capping is not followed immediately with permanent restoration has been shown in other clinical studies (11, 12)

The longer the follow-up period, the more evident the trend became to a decline in the success rate of the teeth in the Ca(OH)2 group compared with the MTA group.

SUCCESSFUL PULP CAPSSUCCESSFUL PULP CAPS

Healthy patient

Recoverable pulp

Flawless caries removal

Disinfection

Histological repair

seal

Inflammationmanagement

RESIN BIOCOMPATIBILITY???RESIN BIOCOMPATIBILITY???

Volk,J, Volk,J, Engelmann,J.,Leyhausen,G.,Engelmann,J.,Leyhausen,G.,Geurtsen,WGeurtsen,W..

Dental Materials 2006 22:499-505Dental Materials 2006 22:499-505 Effects of three resin monomers on the Effects of three resin monomers on the

cellular glutathione concentration of cellular glutathione concentration of cultured human fibroblastscultured human fibroblasts

SeeSee Website: Home>MODXYZ> Website: Home>MODXYZ> BiocompatibilityBiocompatibility

ref

DYRACT AND DYRACT-CEM DYRACT AND DYRACT-CEM AND VITREBONDAND VITREBOND

J Dent Res. 1998 Dec;77(12):2012-9.J Dent Res. 1998 Dec;77(12):2012-9.Residual monomer/additive release and variability in Residual monomer/additive release and variability in

cytotoxicity of light-curing glass-ionomer cements and cytotoxicity of light-curing glass-ionomer cements and compomers. Geurtsen W, Spahl W, Leyhausen G. compomers. Geurtsen W, Spahl W, Leyhausen G. Severe Severe cytotoxic effects were observed in response to both of cytotoxic effects were observed in response to both of these materialsthese materials

Mutat Res. 1996 Jul 5;368(3-4):181-94.Mutat Res. 1996 Jul 5;368(3-4):181-94. Genotoxicity of dental materials. Heil J, Reifferscheid G, Genotoxicity of dental materials. Heil J, Reifferscheid G,

Waldmann P, Leyhausen G, Geurtsen W. Waldmann P, Leyhausen G, Geurtsen W. Genotoxic effects Genotoxic effects were found for Vitrebond and AH 26were found for Vitrebond and AH 26 (since upgraded to (since upgraded to AH26 Plus)AH26 Plus)

GLASS IONOMER GLASS IONOMER BIOCOMPATIBILITYBIOCOMPATIBILITY

Biomaterials. 1998 Mar;19(6):559-64.Biomaterials. 1998 Mar;19(6):559-64.Biocompatibility of various light-curing Biocompatibility of various light-curing and one conventional glass-ionomer and one conventional glass-ionomer cement.cement.Leyhausen G, Abtahi M, Karbakhsch M, Leyhausen G, Abtahi M, Karbakhsch M, Sapotnick A, Geurtsen W.Sapotnick A, Geurtsen W.

Two GIs was found to be very Two GIs was found to be very biocompatiblebiocompatible, while Vitrebond was , while Vitrebond was found to be cytotoxic. found to be cytotoxic.

MTA THERAPIESMTA THERAPIES

Indirect Pulp cap (Pink Dentin)Indirect Pulp cap (Pink Dentin) Direct pulp cap (Direct Exposure)Direct pulp cap (Direct Exposure) Pulpotomy (Coronal extirpation)Pulpotomy (Coronal extirpation) Pulpectomy (Coronal and radicular Pulpectomy (Coronal and radicular

extirpation)extirpation) Root canal therapy Root canal therapy

Perforation repairPerforation repair ApicoectomyApicoectomy

NEW - BIODENTINENEW - BIODENTINE

SEPTODONTSEPTODONT $17 PER APPLICATION$17 PER APPLICATION REQUIRES TRITURATORREQUIRES TRITURATOR IS MEANT TO BE A COMPLETE IS MEANT TO BE A COMPLETE

TEMPORARY FILLINGTEMPORARY FILLING STICKY HANDLINGSTICKY HANDLING INDEPENDENT REVIEW YET TO BE SEENINDEPENDENT REVIEW YET TO BE SEEN

PEDODONTIC PULPOTOMYPEDODONTIC PULPOTOMY

SUCCESSFUL PULP CAPSSUCCESSFUL PULP CAPS

Healthy patient

Recoverable pulp

Flawless caries removal

Disinfection

Histological repair

Inflammationmanagement

Seal

SEALING THE PULP CAPSEALING THE PULP CAP

IMMEDIATE RESTORATION improves IMMEDIATE RESTORATION improves prognosis 30% (Mente et al)prognosis 30% (Mente et al)

PROTECT THE CAP from shrinkage PROTECT THE CAP from shrinkage FINAL RESTORATION with low FINAL RESTORATION with low

sensitivity techniquesensitivity technique CAREFUL OCCLUSIONCAREFUL OCCLUSION

CAREFUL AND ACCURATE CAREFUL AND ACCURATE OCCLUSION OCCLUSION

SUCCESSFUL PULP CAPSSUCCESSFUL PULP CAPS

Healthy patient

Recoverable pulp

Flawless caries removal

Disinfection

seal

Histological repair

Inflammationmanagement

INFLAMMATION INFLAMMATION MANAGEMNTMANAGEMNT

MEDICATIONMEDICATION Disciplined use ofDisciplined use of

Ibuprofen Ibuprofen 400 mg 400 mg for 24 hours q4h 6 for 24 hours q4h 6 tabstabs

Instruct to use Instruct to use regardless if painful regardless if painful or notor not

COMMUNICATIONCOMMUNICATION 1.1. Cautious prognosisCautious prognosis2.2. ““Call me I want to Call me I want to

know”know”3.3. Next day follow-up Next day follow-up

call 11 amcall 11 am4.4. Not that night!Not that night!5.5. Inform that success Inform that success

may be temporarymay be temporary

THE ENDTHE END