Pulp therapy

Pulp Therapy

Deepak K Gupta

facebook.com/notesdental

Classfication• It may be

– Direct pulp therapy

– Indirect Pulp therapy

• Its also classified as• Vital pulp therapy

– Indirect pulp capping (IPC)

– Direct Pulp Caping (DPC)

– Pulpotomy

– Pupectomy

– Apexogenesis

• Non-vital therapy– Apexofication

– SCAP (stem cell of apical papilla)


A) DECIDUOUS TEETH-indirect pulp capping -direct pulp capping -pulpotomy-pulpectomy

B) YOUNG PERMANENT TEETH-Indirect pulp capping -Direct pulp capping -Pulpotomy/ apexogenesis-Apexification

DIFFERENT TYPES OF PULP THERAPY ACCORDING TO TOOTH



Pulp Capping


Its of either two types based on remaining dentin thickness (RDT):

a) Indirect pulp capping (2 – 0.25 mm)b) Direct Pulp capping (0 – 0.25 mm)


Indirect Pulp Capping

• a procedure in which a material is placed on a thin partition of remaining carious dentin that, if removed, might expose the pulp in immature permanent teeth.

• deep carious lesions where caries excavation was conservative and direct pulp exposures were avoided

• either Ca(OH)2 or zinc oxide–eugenol (ZOE) in a one- or two-stage procedure.


Rational and objective

• Removal of infected dentin (dimineralized and invaded by bacteria)

• Disinfection of residual affected dentin (dimineralized dentin not yet invaded by bacteria).

• Sealing by restorative material causes removal of substrate on which bacteria act.

• Arrest of carious process causes activation of reparative mechanism to lay additional dentin and avoid pulp exposure


INDICATIONS

History

• Mild discomfort from chemical & thermal stimuli

• Negative h/o spontaneous pain

O/E

• Positive pulp sensitivity test

•Negative TOP

•Large carious lesion

•Absence of lymphadenopath

• Normal color of gingiva & tooth

R/F

• Large carious lesion in close proximity of the pulp

• Normal lamina dura & PDL space

• No interradicular or periradicular radiolucencyfacebook.com/notesdental

CONTRAINDICATIONSHistory

• Sharp penetrating pain that persists after withdarwing stimulus

• Prolonged spontaneous pain ,particularly at night

O/E

• Excessive tooth mobility

• Discolored

• Nonresponsiveness to pulp testing techniques

R/E

• Large carious lesion with apparent pulp exposure

• Widened PDL space & interrupted or broken lamina duraa

• Radiolucency at the root apices or furcation areas


Clinical Procedure : 1st Appointment

• Two sitting caries exavation is recommended using slow speed hand piece # 6 or # 8 round burs

• Peripheral dentin is removed with sharp spoon exacavator

• The cavity is flushed and dried with cotton pellet• Exposure site is covered with hard set calcium

hydroxide prep (Ex: Dycal, Caulk, Milford) and sealed with overlying reinforced ZOE prep ( Ex: IRM )

• Patient recalled after 6-8 weeks


Clinical Procedure : 2nd Appointment

• Between two appointment, history must be negative and intermediary restoration must be intact

• After clinical and radiological(bitewing) examination, all the restorative material is removed

• There must be change of color and hardness of affected dentin from deep brownish red and soft to lighter brownish grey color and harder

• The preparation is cleaned and dried• Hard setting calcium hydroxide is placed followed

final restoration


Features

One appointment• difficulty with the procedure is to

determine at what point excavation is halted

• voids under the restorative material result during the remineralization process, in which the carious dentin dries out and loses volume

• Restoration failure and rapid reactivation of a dormant lesion

• not recommended as a predictable treatment for permanent teeth

Two appointment

• Unintended pulp exposure –worsen the prognosis

• Clinically assesed the reaction of tooth and progress of dentin bridge formation

• The final exacavation of caries is safer in 2nd appointment when sufficient formation of dentin has taken place

•


Direct Pulp Capping

• treatment of an exposed vital pulp by sealing the pulpalwound with a dental material placed directly on a mechanical or traumatic exposure to facilitate the formation of reparative dentin and maintenance of the vital pulp


Indication

• Iatrogenic mechanical exposure –assymptomatic vital tooth with sound dentin

• Small carious exposure assymptomaticpermanent tooth with incomplete root formation

• R/r there should be no thickening of PDL space and evidence of periradicular lesion


Contraindication

• Carious exposure of primary tooth

• Large carious exposure in symptomatic permanent teeth Severe Tooth ache at night

• Spontaneous pain

• Excessive tooth mobility

• Thickening of PDL space

• Radiographic evidence of furcal or periradiculardegeneration

• Excessive hemorrhage

• Purulent or serous exudatefrom the exposure site


Factors affecting prognosis

• Seltzer and Bender

– Area and size of exposure

– Microleakage

– Carious v/s mechanical exposure : mechanical has better prognosis

– Time of exposure

– Bacterial contamination

– Treatment Plan


Factors associated with mechanical pulp exposure

• Heat : closer the cavity is to pulp, more likely its to injure the tooth.

• Pressure: pulp damage directly proportional to pressure exerted by bur or instrumentation

• Damage to pulp

• Hemorrhage

• Intrussion of dentin chip


Criteria essential for a successful direct pulp cap.Lin and Langland (1981)

History

• No recurring or spontaneous pain.

• No swelling.

Preoperative assessment

• Normal vitality tests.

• Not tender to percussion.

• No swelling.

• No radiographic evidence of periradicularpathology.

• Young patient.

• Radiographicallyobvious pulp chamber and root canal.

Clinical findings.

• Pink pulp

• Bleed if touched but not excessively.

BDJ 2001 , Vol 191 ,No 11


Pulp capping agent

• CaOH, CaOH with antibiotics and corticosteroid, ZOE and MTA

• Ideal properties of pulp capping agent (Cohen and Combe)– Maintain pulp vitality– Stimulate reparative dentin formation– Bacteriocidal and bacteriostatic, ability to provide

bacterial seal– Adhere well to dentin and restorative material– Resist force under restoration– Radiopaque and sterile


Calcium hydroxide

• Introduced by Hermann in 1930 as a pulp capping agent.

• Used as:– Aqueous suspension of calcium hydroxide

– Commercial products:

• Dycal [Caulk/Dentsply]

• Prisma VLC Dycal [Caulk/Dentsply]

• Life [SybronEndo/ Kerr]

• Nu-Cap [Coe]


• Acts by:– Forming prtotective barrier for pulp tissue

– Blocking patent dentin tubules

– Neutralizing the attack of inorganic acids & their leached

products

– Stimulates formation of - reparative dentin

– Reduction in number of microorganisms remaining in the

dentin.

– Stimulates remineralization of demineralized dentinal tubules,

–


Calcium hydroxide

Calcium Ions

Reduced capillarity permeability

Reduced serum flow

Reduced level of inhibitory pyrophatase

Mineralization

Hydroxyl ions

Neutralizes acid produced by

osteoclast

Optimum pH for Pyrophosphatase

activity

Increase level of calcium ion dependent

pyrophosphatase

ACTION OF CALCIUM

IONS


Healing with Ca(OH)2• Zone of obliteration

– caustic effect causes derangement of contacting pulpaltissue.

– This zone consist of debris, dentinal fragments, blood clots, blood pigments and particles of calcium hydroxide

• Zone of Coagulation necrosis– chemical thrust of CaOH causes necrosis of plasma

protein and thrombosis – Also known as Schroder layer of firm necrosis or

Stanley’s mummified zone– 0.3-0.7 mm thickness

• Zone of Demarcation– a line develops between deepest zone of cogulation

necrosis and subjacent vital pulp– Glass and Zander : line is a result of reaction between

tissue protein to form protein globulesfacebook.com/notesdental

Problem with calcium hydroxide

Tunnel defects.

tend to soften,

disintegrate and dissolve over time

voids and other potential pathways for bacterial infiltration.


Zinc oxide eugenol

• ZOE, in direct contact with the pulp tissue, produce

– chronic inflammation,

– a lack of calcific barrier, and

– an end result of necrosis


Corticosteroids and Antibiotics

• for direct pulp capping and also as mixed in with calcium hydroxide with the thought of reducing or preventing pulp inflammation

Barker BCW, Lockett BC: reaction of dog pulp and periapical tissue to two glucocorticoid preparations. Oral surg 33:249, 1972

• No dentinal bridge formation has been reported.

Baume LJ: survey of dentin biology. Brit Dent J 116:254, 1964


Polycarboxylate Cements

Lack an antibacterial effect and

Did not stimulate calcificbridging in the pulps of

monkey primary and permanent teeth


Mineral trioxide aggregate• Composed of

– Tricalcium silicate– Dicalcium silicate– Tricalcium aluminate– Tetracalcium aluminoferrite– Bismuth oxide

• Exhibits many favourable characteristics which make it a superior material when used as a direct pulp capping material in adult teeth.– Sets in the presence of blood and moisture.– Superior marginal adaptation – Nonabsorbable

• High alkalinity and sustained pH at 12.5 is– Responsible for preventing microbial growth.– Extracts growth factors from adjacent dentin


Mineral trioxide aggregate

• Superior marginal adaptation

• Non absorbable

• Sustained alkaline ph

• Small particle size

• Slow release of calcium ions

• Promotes hard tissue formation

• Osteoinductive, osteoconductive


Technique of DPC

• Excavation of caries is done with # 2 carbide bur and spoon exacavators

• In case of bleeding, hemostasis is achieved with cotton pellet dipped in 3-6% NaOCl for 1-10 min. – If bleeding doesn’t stops then other invasive

procedure is performed

• After control of Bleeding, pulp capping agent is applied followed by GIC

• Bonded restoration – CaOH

• Composite restoration - MTA


Pulpotomy


Pulpotomy

• The surgical removal of the coronal portion of a vital pulp as a means of preserving the vitality of the remaining radicular portion.

• short-term success rates are favourable

• This procedure is generally advocated for deciduous teeth

• Success of pulpotomy is largely dependent on the diagnosis of residual pulp to be healthy or reversible inflammed


Indications• Pulp exposure on primary

teeth in which the inflammation or infection is diagnosed to be confined to the coronal pulp

• If inflammation has spread into the tissues within the root canals– pulpectomy or– root canal filling or– extraction.


Contraindication of Pulpotomy

1. A history of spontaneous toothache (not caused by papillitisresulting from food impaction)

2. Nonrestorable tooth where postpulpotomy coronal seal would be inadequate

3. A tooth near to exfoliation or if no bone overlies the crown of the permanent successor tooth

4. Evidence of periapical or furcal pathosis5. Evidence of pathologic root resorption6. pulp that does not bleed (necrotic) 7. Inability to control radicular pulp hemorrhage following a coronal

pulp amputation8. A pulp with serous or purulent drainage9. Presence of a sinus tract


Technique

• accurate diagnosis of pulp status is very important in aiding appropriate pulpal management– An accurate pain history

– Radiographic findings

– Clinically,

• success of vital pulp therapy in the primary dentition depends upon:– effective control of infection.

– Complete removal of inflamed coronal pulp tissue.

– Appropriate wound dressing.

– effective coronal seal during and after treatment


Coronal Pulp Amputation• After complete isolation and under

L.A., complete removal of caries is done

• Unroofing of pulp chamber with non-cutting high speed bur under copious water irrigation– bleeding indicates vital (if

inflamed) coronal pulp tissue

• coronal pulp is amputated with a slow-speed #6 or #8 round bur or spoon excavator– Care is taken not to leave a single

strain of filament of coronal pulp –bleeding impossible to control


Coronal Pulp Amputation

• Thoroughly washed with sterile water or saline to remove all debris, and the site is dried by vacuum and sterile cotton pellets

• Hemorrhage should be controlled in this manner within 3 minutes, but if bleeding persists– check that all filaments of the pulp were

removed from the pulp chamber– the amputation site is clean.– If after doing this hemostasis is not

achieved within 2 to 3 minutes, then tooth is not a candidate of pulpotomy• Pulpectomy or • tooth should be extracted


Coronal Pulp Amputation

• Once bleeding has stopped at the radicular pulp stumps, either of the following technique– dilute formocresol solution for 5

minutes

– 15% ferric sulfate solution for 15 seconds

– MTA pulpotomy

– electrosurgical pulpotomy

– Laser pulpotomy


Formocresol Pulpotomy

• Formocresol Solution – Full-Strength Buckley’s Formocresol : Formaldehyde 19%,

Tricresol 35%, Glycerin 15%, Water 31%– One-Fifth Dilution of Formocresol Solution: 1 part Buckley’s

formocresol solution + 1part distilled water and 3 part glycerin

• one-fifth dilution formocresol solution on a cotton pellet is blotted to remove excess formocresol and then placed in direct contact with the pulp stumps for 5 minutes

• pellet is removed - tissue appears brown• A cement base of ZOe is placed over the pulp stumps and

allowed to set• tooth may then be restored permanently


Formocresol Pulpotomy• Toxic and corrosive, especially at the point of contact

• Increased penetration radicular root

• FAD is genotoxic, inducing mutations and DNA damage

• fear of damage to the succedaneous tooth

• Unlike the tissue response to Ca(OH)2, no dentin bridge should be anticipated after applying formocresol to exposed pulp tissue

• narrowing of the root canal through the continued deposition of dentin by the preserved radicular pulp may be observed in some case


Prognosis

• internal resorption - formocresol was applied

• accompanied by external resorption,

• May becomes excessively mobile;

• a sinus tract

• Rare occurrence of pain – so formocresol failure can be detected only clinically detected by chance

• The development of cystic lesions is evidenced in some cases

• Above findings emphasize the importance of periodic follow-up to endodontic treatment on primary teeth


Glutaraldehyde Pulpotomy

• Glutaraldehyde has been a suggested alternative to formocresol as a tissue fixative

• little toxic effect

• antigenic action similar to formocresol,

• it is of a lower potential – unstable

• increasing failure rates


Ferric Sulfate Pulpotomy

• After completion of coronal pulp amputation and achievement of hemostasis with moist cotton pellets, a 15.5% solution of ferric sulfate is applied to the radicular pulp stumps for 10 to 15 seconds

• small droplets of the solution to drip from a burnisher tip onto the surface of the pulp tissue

• dento-infuser tip for this purpose


Ferric Sulfate Pulpotomy

• hemostatic agent

• blood reacts with ferric and sulfate ions within the acidic pH of the solution

• form plugs that occlude the capillary orifices and prevent blood clot formation

• hemostatic agent during the Ca(OH)2 pulpotomy


A, extensive dental caries affecting a mandibular first primary

molar. note proximity of radiographic lesion to the mesial pulp horn.

B, Caries removal showing a carious pulpal exposure; bleeding is evident.

C,Partial unroofing of the pulp chamber; note bleeding coronal pulp

prior to amputation.D,Roof of pulp chamber removed

completely. E, 15.5% solution of ferric sulfate is

applied to radicular pulp stumps using a dento-infuser tip supplied by the

manufacturer. F,Hemostasis is evident at radicular

pulp stumps. G,Definitive restoration involves placement of zinc oxide eugenol,

overlaid with glass ionomerintracoronally, followed by a

preformed metal (stainless steel) crown


Mineral Trioxide Aggregate Pulpotomy

• MTA powder is mixed with sterile water until the powder is adherent

• excess moisture is removed from the powder by placing a dry paper point into the mixture to act as a moisture wick.

• Using an excavator or retrograde amalgam carrier - depth of 3 to 4 mm

• Gently packed by blunt end of a large paper point and a broad ended amalgam compactor.


Mineral Trioxide Aggregate Pulpotomy

• ZOe or glass ionomercement is placed gently over the MTA and allowed to set

• It takes several hours to reach its optimum physical strength, once its set the cavity is restored with permanent restoration

• pulp tissue responses to MTA to be superior to those produced using Ca(OH)2


Electrosurgical Pulpotomy

• large sterile cotton pellets are placed in contact with the pulp, and pressure is applied to obtain hemostasis

• The Hyfrecator Plus 7-797 - set at 40% power (high at 12 W)

• The cotton pellets are quickly removed, and the electrode is placed 1 to 2 mm above the pulpal stump

• Heat and electrical transfer are minimized by keeping the electrode as far away from the pulpal stump and tooth structure as possible while still allowing electric arcing to occur.

• may be repeated up to a maximum of three times• dry and completely blackened• ZOE applied and restored as earlier


Electrosurgical Pulpotomy

• coagulation, or electrofulguration can occur

• carbonizes and denatures pulp tissue, producing a layer of coagulative necrosis.

• acts as a barrier between the lining material and healthy pulp tissue below

• produced results comparable to those found with the use of formocresol


Laser Pulpotomy

• carbon dioxide laser for performing vital pulpotomies on primary teeth

• viable alternative to formocresol

• the carbon dioxide laser appeared to compare favorably with formocresoltreatment

• Clinical trials still under way


PARTIAL PULPOTOMY

• Cvek pulpotomy

• the surgical removal of a small portion of the coronal portion of a vital pulp as a means of preserving the remaining coronal and radicularpulp

• expose deeper, healthy coronal pulp tissue

• Direct pulp capping and partial pulpotomy are considered similar procedures and differ only in the amount of undestroyed tissue remaining after treatmen


Partial pulpotomy• immature teeth which have been

subject to pulp exposing trauma• 1- to 2-mm deep cavity is prepared

into the pulp, using a high-speed handpiece with a sterile diamond bur of appropriate size with copious water coolant

• pulp is amputated deeper until only moderate hemorrhage is seen

• 5% sodium hypochlorite (NaOCl; bleach) has been recommended -chemical amputation of the blood coagulum,

• remove damaged pulp cells, dentin chips, and other debris, and provides hemorrhage control facebook.com/notesdental

Partial Pulpotomy• Care must be taken not to allow a

blood clot to develop

• Thin layer of pure calcium hydroxide is mixed with sterile saline or anesthetic solution to a thick mix and carefully placed onto the pulp stump

• Alternatively MTA can be used.

• Cavity preparation is filled with GIC.

• Exposed dentin is acid-etched

• Composite is applied


Follow up• Evidence of maintenance of responses to

sensitivity tests

• radiographic evidence of continued root development

a) pre-op b) peri-op c) 6 months post-op


Pulpectomy


• Complete removal of pulp and subsequent filling of the canals of primary teeth with a suitable resorable material

• Primary root canal filling


Indication

• irreversible pulpitis• pulpal necrosis • hyperemic pulp

– Persistent bleeding during a pulpotomy procedur

• Evidence of furcation involvement by radiograph• Spontaneous pain – child awake• Swelling• Pulp senistivity tests: little benefit in children-

uncoperative• False positive


Contraindication

• An unrestorable tooth• Internal resorption in the roots visible on radiographs• Teeth with mechanical or carious perforations of the

floor of the pulp chamber• Excessive pathologic root resorption involving more

than a third of the root• Excessive pathologic loss of bone support with loss of

the normal periodontal attachment• Presence of a dentigerous or follicular cyst• Periapical or interradicular lesion involving the crypt of

the developing permanent successor


Access Opening• Safe removal of the roof of a pulp

chamber in a primary molar.• A non-end cutting bur ensures that the

relatively thin floor to the pulp chamber is not perforated inadvertently by rotary cutting instruments.

• Lingually anteriors and same path for posteriors, may go for facial opening anteriors followed by GIC restoration

• Overinstrumentation should be avoided as compared to permanent tooth– bulbous shape of the crowns, and the

very thin dentinal walls of the pulpalfloors and roots

– Less distance from the occlusalsurface to the pulpal floor of the pulp chamber facebook.com/notesdental

Biomechanical Preparation

• Following caries removal and unroofing of the pulp chamber,

• the coronal pulp is amputated.

• Irreversibly inflamed tissue will bleed profusely.

• A premeasured hand file is placed approximately 2 mm from the radiographic apex

• canals are gently cleaned with minimal shaping


Biomechanical Preparation• flexible nickel-titanium (NiTi)

instruments– Thin root walls - sonic and

ultrasonic cleaning devices should not be used to prepare the canals

– Gates-Glidden (GG) or Peesodrills - contraindicated because of the danger of perforation or stripping of the roots.

– SS files rarely used, but only after precurving to negotiate curved canals

• Enlarged several sizes past the first file that fits snugly in the canal, with a minimum size of 30 to 35


IRRIGATION• Irrigation with sodium hypochlorite

or chlorhexidine digluconatesolution should be undertaken during the cleaning phase

• Débridement of the primary root canal is more often accomplished by chemical means than by mechanical means

• RC-Prep - digest and emulsify pulp tissue and is an effective lubricant.

• Followed by NaOCl – dissolve organic debris


Obturation

• If root canals are not to be obturated at the same visit, they may be dressed with nonsettingcalcium hydroxide,

• or canals can be left empty and the tooth restored with a small cotton wool pledget and an interim intracoronal restoration

• At the subsequent visit, root canals can be obturated with a resorbable root filling material such as zinc oxide eugenol (ZOe).


Obturation material

• The ideal root canal filling material for primary teeth should:– Resorb at a similar rate as the primary root.– Be harmless to the periapical tissues and the permanent tooth

germ.– Resorb readily if pressed beyond the apex.– Be antiseptic.– Fill the root canals easily.– Adhere to the walls of the root canal not shrink.– Be easily removed if necessary– Be radiopaque.– not discolor the tooth

• ZOE paste, Iodoform paste, and Ca(OH)2


Post-obturation

• Following root canal filling, the tooth is restored definitively using a preformed metal (stainless steel) crown


APEXOGENESIS

• Apexogenesisis treatment designed to preserve vital pulp tissue in the apical part of a root canal in order to complete formation of the root apex

• a deep pulpotomy undertaken to preserve the formative capacity of the radicular pulp in immature teeth that have deep pulpalinflammation

• carious exposures and some trauma cases in which treatment of the exposed pulp is delayed


APEXOGENESISA,Following a deep pulpotomy and hemostasis, the radicular pulp is dressed and a sealing coronal restoration applied. B,Success is evidenced by continued root development (length and wall thickness) and formation of a calcific barrier in response to the wound dressing


technique• Deep resection of pulp tissue

– single-rooted anterior teeth: Small endodontic spoon excavator or round, abrasive diamond bur-

– posterior teeth: endodontic files or reamers– It may be difficult to preserve pulp function by

superficial pulp capping or pulpotomy in teeth with wide-open, blunderbuss apices. So complete pulpotomy is done

• Bleeding controlled with saline-soaked cotton pellets or NaOCl• If hemostasis cannot be secured by conventional means -

treatment will be compromised• hemostatic chemicals such as aluminum chloride or ferric

sulfate despite the risk


technique

• pulp wound is then covered with a dressing material before securely restoring the crown– Calcium hydroxide powder has usually been

preferred over hard-setting products so that it can be easily debrided if further t/t is required

• Radiographic and clinical follow-up is mandatory• no evidence of continued root formation and calcific

barrier formation - apexification or a regenerative technique may be considered


Apexification

• Root-end closure

• process whereby a non-vital, immature, permanent tooth which has lost the capacity for further root development is induced to form a calcified barrier at the root terminus

• Matrix against which root canal filling or restorative material can be compacted

• Treatment of last resort in immature teeth which have lost pulp vitality


Materials

• Calcium hydroxide – most commonly used

– Mixed either with CMPCP, saline, ringer solution, distilled water or anesthetic solution

• Zinc Oxide paste

• Antibiotic paste

• Tricalcium paste

• Collagen – phosphate gel

• Mineral trioxide Aggregate


A,Immature permanent tooth with a nonvitalpulp.B,Traditional approach, with the formation of a “calcified barrier” at the root end following repeated dressing over many months with Ca(OH)2

C, Artificial apical barrier technique, where a 4- to 5-mm plug of mineral trioxide aggregate is placed at the root end. Canal space is subsequently restored with dual-curing composite resin, often accompanied by a fiberpost to provide mechanical support.

Technique


NEW HORIZONS FOR PULP REGENERATION• Immature, nonvital permanent tooth, showing the location of the apical

papilla with its rich collection of stem cells

• Following medication of the canal with triantibiotic paste, the canal is overinstrumented to encourage bleeding up to the cervical level.

• Subsequent blood clot is overlaid with MTA and a sealing restoration and forms a scaffold for invasion by SCAP (stem cells from apical papilla) cells.

• Pulp regeneration is expected to allow continued root formation in a previously pulpless tooth.


Refrences

• Ingles_Endodontics 6th edition

• Cohen _pathways_of_the_pulp : 10th edition

• Grossman 12th edition

• Hartys_Endodontics_in_Clinical_Practice_E-Book

• Textbook of Endodontics - Nisha Garg, AmitGarg – 2007

• McDonalds, dentistry child adolescent 9th


Pulp therapy

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