VITAL PULP THERAPY

DR Rekha P Thankachan

Innes NP, Frencken JE, Bjorndal L, Maltz M, Manton DJ, Ricketts D, et al. Managing carious lesions: consensus recommendations on terminology. Adv Dent Res. 2016;

• It is the treatment initiated on an inflammed pulp (reversible pulpal injuries) to repair and maintain the pulp vitality.

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• Include two distinct therapeutic approaches

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Indirect pulp capping- in cases of deep carious lesions

Direct pulp capping or pulpotomy- in cases of pulpal exposure.

Requirements for a successful vital pulp therapy

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(1) Pulp is mild to moderately inflamed

(2) Hemorrhage is properly controlled

(3) A non-toxic capping material is applied

(4) Capping material and restoration seal out bacteria.

Indirect pulp capping

• Procedure where in the deepest layer of the remaining affected carious dentin is covered with a layer of biocompatible material in order to prevent pulpal exposure and further trauma to the pulp.

Grossman’s – 13^th edition

Objectives

• To preserve the vitality of the pulp by completely removing the carious-infected dentin

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• Studies have shown that physiological remineralization can occur only if the affected dentin layer contains sound collagen fibers and living odontoblastic processes.

Collagen fibers - base to which apatite crystals attach.

Living odontoblastic processes - supply calcium phosphate from the vital pulp for physiological remineralization.

• Outer layer - infected dentin removed. Thus most of the bacteria are eliminated from the lesion.

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• When the lesion is sealed, the substrate on which the bacteria act to produce acid is also removed

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• Reparative mechanism - lay down additional dentin and avoid a pulp exposure.

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• Exposure of the pulp occurs when the carious process advances faster than the reparative mechanism of the pulp.

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• Several studies - ‘teeth with partial caries removal have equal success compared with restored teeth with complete caries removal’

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• clinical and microbiologic assessment of the caries lesion

partial caries removal - liner and restoration is placed for a period of 4 to 12 months before the tooth is re entered and reassessed.

These studies find that

1) Color change - light brown to dark brown

(2) Tissue consistency - soft and wet to hard and dry

(3) Streptococcus mutans and Lactobacillus have been significantly reduced to a limited number or even zero viable organisms

(4) Radiographs - decrease in the radiolucent zone

Role of caries disclosing dyes in caries removal

• Assist in excavation of carious dentin .
• Identification and removal of demineralized dentin and to greatly reduce remaining viable bacteria.

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• Dyes stain not only demineralized dentin but also anything porous, such as debris that may have been left in the cavity preparation.

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• Noncarious deep dentin will absorb the dye because of the increased number and size of the dentinal tubules in deep dentin

Protocol for indirect pulp capping procedures

DIAGNOSIS

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• Preoperative status of the pulp and periradicular tissues
• No history of spontaneous pulpal pain.
• Pulpal vitality -thermal or electric pulp testing.

Pain occurring during application of a hot or cold stimulus does not linger after the tooth returns to mouth temperature.

• A periapical radiograph shows no evidence of a periradicular lesion of endodontic origin

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1. ISOLATION:

After administering anesthetic, isolate the tooth with a rubber dam.

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2. PREPARATION:

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• Prepare the tooth for the definitive restoration, leaving demineralized dentin only in the area immediately adjacent to the pulp.

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• All peripheral carious tooth structure, particularly at the cavosurface margins, must be removed.

• Use a caries disclosing dye if necessary to ensure complete carious dentin removal (other than that immediately adjacent to the pulp).

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• After this is accomplished, use a spoon excavator or a large round bur in a low-speed handpiece at very low speed.

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• Use very gentle, featherweight strokes over the area of the demineralized dentin to remove only the wet (soft, amorphous) carious dentin.

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• Leave the dry,fibrous, demineralized dentin that gives some moderate resistance to gentle scraping with a spoon excavator

3. LINING:

• Place a calcium hydroxide liner over the remaining demineralized dentin

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• Then place a layer of resin-modified glass ionomer that covers the calcium hydroxide and extends onto sound dentin on the periphery to provide a seal.

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4. RESTORATION:

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1. Direct restorations:
1. For direct restorations (bonded amalgam, resin composite, glass ionomer), place the definitive restoration.

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• If time does not allow for placement of a definitive restoration at the first appointment, a glass-ionomer or reinforced ZOE provisional restoration should be placed and another appointment scheduled for the definitive restoration as soon as possible.

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• The indirect pulp capping liner should not be disturbed during the subsequent restoration process.

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b. INDIRECT RESTORATIONS:

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• For indirect restorations (cast metal restorations, ceramic onlays, or crowns), place a definitive buildup (bonded amalgam, resin composite, glass ionomer) at the appointment in which the indirect pulp capping procedure was performed if time allows.

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• Delay placement of the definitive restoration for 4 to 8 months.

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• Before proceeding with the definitive restoration, ensure normal pulp vitality.

PRECAUTIONS

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• Use care in removing carious dentin near the pulp to prevent accidental pulp exposure.

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• Prior to excavation, use tactile exploration to confirm that dye-stained dentin lacks hardness.

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• If a provisional restoration has previously been placed over an indirect pulp capping liner and the tooth is re entered for a restorative procedure, do not remove the indirect pulp capping material.

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CLINICAL MANAGEMENT OF PULP EXPOSURE

The clinician has to decide upon one of the treatment option when faced with exposed pulp

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• Direct pulp capping

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• Pulpotomy

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A) Partial or Cvek pulpotomy

B ) Full pulpotomy

Pulpectomy

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��Direct Pulp Capping�

• Procedure in which the exposed vital pulp is covered with a protective dressing or base placed directly over the site of exposure in an attempt to preserve pulpal vitality.

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INDICATIONS

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• Iatrogenic mechanical exposure of pulp in an asymptomatic vital tooth with sound dentin at the periphery.

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• Small carious exposures in an asymptomatic permanent tooth with incomplete root formation.

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• Radiographically, there should be no thickening of periodontal ligament space and no evidence of peri radicular lesion.

CONTRAINDICATIONS

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• Large carious exposures in symptomatic permanent tooth.

FACTORS AFFECTING PROGNOSIS OF DIRECT PULP CAPPING

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1) According to Seltzer and Bender, carious pulpal exposure is normally associated with inflammation and subsequent necrosis.

• Hence mechanical exposures - better prognosis than a carious exposure.

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2) Sizes of exposure, with larger exposures having lower healing potential than smaller pinpoint exposures.

3. The time gap between the exposure and the pulp capping procedure

longer the time gap the higher are the chances of bacterial microleakage and contamination of the pulp space.

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• Mechanical exposures should be pulp-capped immediately.
• Care should be taken to ensure that the bleeding is controlled before the pulp is capped.

TECHNIQUES OF DIRECT PULP CAPPING

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• Two techniques have demonstrated success with direct pulp capping:

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• Calcium hydroxide technique
• MTA technique.

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Treatment Protocol

1. After achieving proper anesthesia and isolation of the involved tooth, the undermined enamel is removed with a carbide bur and spoon excavator.

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2. In cases of carious exposure in permanent teeth, the use of a caries-detecting dye is recommended for 10 seconds, tooth is washed and dried.

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3. Caries removal is completed with the #2 carbide bur and spoon excavators.

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4. Control of bleeding

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• Pulpal bleeding is normally controlled with a cotton pellet saturated in 2% CHX solution applied to the exposure site.

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• A variety of solutions have been used in this situation.
• Water or saline are the most benign to the pulp.

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• Sodium hypochlorite, in concentrations ranging from 0.12% to 5.25%, is more caustic to the pulp but is extremely effective at controlling bleeding and is very effective at disinfecting the area

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• Chlorhexidine -- effectual antibacterial but is not as effective for controlling hemorrhage.

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• Other solutions, such as those used to control gingival bleeding during impression taking, have less evidence to support their use in pulp capping

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• One exception to this might be ferric sulfate, for which multiple clinical studies have indicated increased postoperative pain when it was used in conjunction with pulp capping.

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5. After control of bleeding, either Ca(OH)2 or MTA direct pulp capping procedure can be employed.

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Calcium hydroxide technique

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• A hard-setting Ca(OH)2 paste is applied over the exposed pulp followed by a glass ionomer lining.

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• In a one- step pulp capping procedure, the final bonded restoration can be placed on top of the set glass ionomer in the same sitting

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• in two-step pulp capping procedure, an intermediate restoration is placed over the glass ionomer and the patient is called back for the final restoration in the next sitting.

MTA direct pulp capping procedure

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• MTA is mixed according to the manufacturer’s instruction and is carried to the exposure site with the help of an MTA carrier gun or an amalgam carrier.

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• A minimum thickness of 1.5 mm of MTA is placed over the exposure site and a moist cotton pellet is placed completely covering the MTA.

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• A nonbonded composite material is placed over this and the treatment is completed in the next visit after a period of 5-10 days with the help of a bonded composite restoration.

• If MTA pulp capping is to be completed in one sitting then the following procedure is advocated.

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• On top of the MTA, a light-cure flowable compomer (Dyract Flow, Dentsply) or a glass ionomer liner is placed.
• The remaining cavity is then etched with 37% phosphoric acid, washed and dried, and the tooth is restored with bonded composite restoration.

PULPOTOMY

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• Procedure in which a portion of the exposed coronal vital pulp is surgically removed as a means of preserving the vitality and function of the remaining radicular portion.

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• This procedure is similar in concept to direct pulp capping except in the amount and extent of pulp tissue removal.

OBJECTIVES

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• Preservation of vitality of the radicular pulp. Through the surgical excision of the coronal pulp, the infected and inflamed area is removed, leaving vital, uninfected pulpal tissue in the root canal.

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• Relief of pain in patients with acute pulpalgia and inflammatory changes in the tissue.

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• Removal of the inflamed portion of the pulp affords temporary, rapid relief of pulpalgia.

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• Ensuring the continuation of normal apexogenesis in immature permanent teeth by retaining the vitality of the radicular pulp.

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• The remaining pulp may undergo repair while completing apexogenesis, i.e., root-end development and calcification.

RATIONALE

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• Dressing is placed over the pulp stump to protect it and to promote healing.
• The severity of the inflammatory process dictates the quality and quantity of reparative dentin produced in the dentinal bridge.

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• Severe inflammation produces limited reparative dentin devoid of dentinal tubules.
• Mild inflammation produces reparative dentin with varying numbers of dentinal tubules.

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• Experiments have shown that the formation of reparative dentin bridges is reduced in the presence of an inflammatory process.

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• Therefore, in the presence of severe inflammation of the pulp, pulpotomy procedures to preserve pulp vitality are contraindicated.

INDICATIONS

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• Mechanical or carious exposure in permanent teeth with incomplete root formation.

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• Traumatic exposures of longer duration where coronal pulp is likely to be inflamed in young permanent teeth.

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• Pulpotomy should be undertaken in teeth with healthy, hyperemic, or slightly inflamed pulp.

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• Pulpotomy is indicated in pulpally involved children’s permanent teeth in which the root apex is not completely formed

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( pulp extirpation and obturation are contraindicated because of the immature root and wide-open foramen, and extraction is not justified because of the effect on the eruption of adjacent teeth and the development of the dental arches )

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• Although pulpotomy may be attempted in selected cases of chronic hyperplastic pulpitis, where only the coronal pulp is involved, in teeth of young, healthy persons, the procedure is still questionable because of the restorability of the tooth.

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Contraindications

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• Patients with irreversible pulpitis

• Abnormal sensitivity to heat and cold

• Chronic pulpalgia

• Tenderness to percussion or palpation because of pulpal disease

• Periradicular radiographic changes

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Prognosis

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The success of this procedure depends upon:

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• Vitality of the majority of the radicular pulp

• Absence of adverse clinical signs or symptoms such as prolonged sensitivity/pain or swelling

• No radiographic evidence of internal resorption or abnormal canal calcifications

• No breakdown of periradicular supporting tissues

• No harm to succedaneous teeth

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Classification

• Pulpotomy procedure can be classified into two on the basis of the following:

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1. Amount of pulpal tissue removed

2. Type of medicament employed

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BASED ON AMOUNT OF PULPAL TISSUE REMOVAL

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1. Cervical pulpotomy. Involves the complete removal of the coronal portion of the dental pulp, followed by placement of a suitable dressing or medicament that will promote healing and preserve the vitality of the tooth.

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2. Partial pulpotomy (Cvek’s pulpotomy). A portion of the coronal pulp is removed or removal of tissues until normal tissue that is free of inflammation is reached before placing a medicament.

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Partial pulpotomy and direct pulp capping - similar procedures and differ only in the amount of undestroyed tissue remaining after the procedure.

• Partial pulpotomy has been recommended for crown-fractured teeth that have a pinpoint exposure and can be treated within 15-18 hours of the accident

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and in carious exposure of asymptomatic permanent tooth with an open apex

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Based on Type of Medicament Employed

• Three types of medicaments are employed in pulpotomy procedures

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1. Calcium hydroxide pulpotomy

2. MTA pulpotomy

3. Formocresol pulpotomy

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��Clinical Protocol for Cervical Pulpotomy

Diagnosis

• A diagnostic radiograph should be examined to determine the approach to the pulp chamber, to evaluate the shape and size of the root canals, and to ascertain the condition of the periradicular tissues.
• The tooth should be tested for vitality, and the result should be recorded.

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Anesthesia

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Either infiltration or conduction methods.

Isolation and Caries Removal

• A rubber dam is applied for isolation.
• On removal of carious tooth structure, access is gained to the pulp chamber along a straight line, using the area of exposure as a starting point and removing the roof of the pulp chamber entirely with a sterile bur.

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Hemorrhage Control

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Bleeding may be controlled with:

• Hemostatic agent, e.g., 6% sodium hypochlorite

• Pressure application with moist cotton pellet

• Electro surgery

• Lasers

Instrumentation

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• During pulpotomy procedure, the pulp is amputated with any one of the following methods:

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• Sharp spoon excavator

• Large rotating round bur in slow speed

• Diamond drill in high speed

• Lasers

• Electrosurgery

• The coronal portion of the pulp is removed with a sharp, sterile, large spoon excavator or periodontal curette.

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• High-speed drill with coolant is superior to spoon excavator or slow-speed round bur and is least traumatic to the underlying pulp.

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• It may be necessary to use a bur to remove the coronal portion of the pulp in anterior teeth in which the pulp chamber is small and indistinct from the root canal.

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• In posterior teeth, the bulbous portion of the pulp contained in the pulp chamber down to the orifices of the root canals should be removed.

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• As much pulp tissue as possible should be left in the root canal to allow maturation of the entire root, rather than just of a portion of it.

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• Excavators with extralong shanks are often necessary for reaching into the pulp chambers of molar teeth to scoop out pulp remnants adhering to the pulpal floor.

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• A sharp No. 31 L endodontic excavator is excellent for this purpose

• Twisting of the pulp stump compresses the tissue, with consequent necrosis.
• The pulp tissue at the entrance to the root canals and that confined within the root canals should not be disturbed.

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PLACEMENT OF MEDICAMENT

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• Calcium Hydroxide Pulpotomy

It is presently recommended as one of the preferred medicament for vital pulp therapy in the permanent dentition but not indicated as an agent for pulpotomy in primary teeth.

• The pulp chamber should be filled to a depth of at least 1-2 mm , on which a base of glass ionomer cement or a flowable compomer is applied.

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Calcium hydroxide can be used in many forms like:

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• A paste made by mixing calcium hydroxide powder with one of the following mediums, namely, saline, distilled water, local anesthetic solution, or glycerin

• A nonsettable commercial paste consisting of calcium hydroxide and methyl cellulose like Metapex

• A fast-setting commercial paste like Dycal

MTA pulpotomy�

• The MTA powder is mixed as per the manufacturer’s instructions with distilled water to get a putty consistency

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• Better material of choice than calcium hydroxide in terms of healing, quality of seal provided, and superior biocompatibility .

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• This MTA mix is placed over the amputated pulp with the help of an MTA carrier gun or amalgam carrier.

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It should be placed in the pulp chamber and condensed lightly with moist cotton pellet.

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• Care must be taken to ensure that a minimum thickness of 2 mm of the material is placed.

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Formocresol Pulpotomy

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• It has been a popular pulpotomy medicament in the primary dentition for the past 70 years since its introduction by Sweet in 1932.

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• A cotton pellet containing formocresol liquid is placed over the amputated pulp for a period of 3-5 minutes.

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• There is a lot of controversy and discussion regarding the use of formocresol in pediatric cases - Toxicity and carcinogenecity

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PERMANENT RESTORATION�

• A glass ionomer or flowable compomer base is recommended over the MTA/Ca(OH)2 medicament.

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• A permanent restoration is placed over this base.

• The rubber dam is then removed, and the occlusion is checked.

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A radiograph should be taken as a record of the operation for future comparison of apical closure, bridge formation, internal resorption, calcific degeneration, or development of periradicular disease.

FOLLOW-UP

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• The tooth should be checked with radiographs and vitality tests every 3 months. Slightly more current than normal may be necessary to elicit a response to the electric pulp test.

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• In the event of pain or death of the pulp, the root canal contents should be removed as soon as possible, and endodontic therapy should be started if the apex is mature.

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• If the apex is immature, apexification therapy should be initiated.

• After Ca(OH)2 implantation for longer periods of time, 89 % of the dentin bridges display tunnel defects, failing to provide a hermetic seal against infection to the underlying pulp. Due to micro- leakage, after 6 months, most of the Ca(OH)2 capping material disintegrates and disappears
• (Cox et al. 2007).

Future of direct pulp capping materials

• Hydroxyapatite - scaffold for dentin formation

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• Bone morphogenetic protein (BMP)
• Bone sialoprotein (BSP)

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More effective for inducing reparative dentin than was calcium hydroxide

Assessment of Treatment outcome

Conclusion

• Development in our understanding of pulp biology and the response of the pulp to the release of dentine bound bioactive growth factors have made it clear that the pulp has substantial regenerative capabilities and that inflammation is a normal part of the healing response of the pulp.

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• Vital pulp tissue that has been managed properly is quite resilient and a diseased pulp can heal if most of the inflammed or necrotic tissue is removed.

References

• Summits fundamentals of operative dentistry

A contemporary approach-4^th edition

• Grossmans endodontic practice-13^th EDITION
• Grossmans endodontic practice-14^th EDITION
• Edward j. swift, jr., martin trope & andre´ v. ritter . Vital pulp therapy for the mature tooth – can it work? Endodontic Topics 2003, 5, 49–56

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THANK YOU…

• In the indirect procedure, all carious dentin is removed except for the last portion of firm, leathery carious dentin immediately overlying the pulp. At this point, a calcium hydroxide liner is placed over the demineralized area of dentin .
• Placement of calcium hydroxide over this layer of leathery dentin has been shown to virtually eliminate all remaining bacteria and to render the residual carious dentin operationally sterile.
• Then a layer of resin-modified glass ionomer is placed, covering the calcium hydroxide and extending onto sound dentin on the periphery to provide a seal.
• Resin-modified glass ionomer alone (without calcium hydroxide as an initial layer) is also effective at providing favorable clinical and microbiologic changes when used as a liner on remaining caries.

• If any vital bacteria remain, a well-sealed restoration should isolate them from life-sustaining substrate and prevent further acid production, thereby arresting the caries process.
• These facts argue against a two-step procedure in which the tooth is reentered for the purpose of excavating the remaining acid-affected dentin to confirm reparative dentin formation.
• Bacterial levels in caries lesions are reduced most significantly after the initial caries excavation and liner placement, with little additional benefit from the subsequent excavation.

• In addition, a second caries removal procedure risks creating a pulp exposure and causing further traumatic insult to the pulp.
• A glass-ionomer liner should be placed over the calcium hydroxide liner to improve strength during amalgam condensation and to enhance the seal .
• The definitive restoration should be placed to minimize microleakage at the interface of the restoration with the cavity-preparation walls