PULP TREATMENT MODALITIES

By,Mythreyee Thakur.

TREATMENT MODALITIES

• PULP TREATMENT• CONSERVATIVE

RADICAL

• Protective base Pulpectomy

• Indirect pulp therapy Root filling

• Direct pupl therapy• pulpotomy

PULP PROTECTION

• AAPD coined this term

• It recommends placement of a protective base liner on the pulpal and axial walls of cavity prepared to act as protective barrier between restoration and tooth.

• INDICATIONS:• Floor of cavity should not be

infected• In deep cavity preparations• MATERIALS:• GIC• Resin modified GIC• DBA

INDIRECT PULP CAPPING THERAPY

• ‘’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 .’’

INDICATIONS AND CONTRAINDICATIONS

• When pulp inflammation is minimal and complete removal of caries would cause pulp exposure.

• Any signs of pulpal or periapical pathology

• Non restorable tooth

PROCEDURE

• Tooth is anesthetized and isolated.• • All the caries except that immediately

over the pulp is removed.(use a large round bur at low speed)

• A zone of AFFECTED demineralized dentin is left behind

• A sedative dressing of ZOE or calcium hydroxide is placed

• Restore with ZOE or amalgam.

• Formation of REPARATIVE DENTIN beneath the caries.(1.4microns/day)

• The tooth is reentered after 6-8 weeks and the remaining caries is excavated.

• Permanent Tooth restoration along with pulp protection with base placement is done

PATENTED DENTIN MEASURING DEVICE

• Electronically measures the thickness of dentin layer above the pulp chamber during crown preparation with a simple touch of probe

• GREEN LIGHT:safe zone• ORANGE LIGHT:limit of

safe zone• RED LIGHT:danger of

penetration through dentin.

PREPOMETER

DIRECT PULP CAPPING• DEFINITION:The procedure in which small exposure of

the pulp which is encountered 1.During cavity preparation 2.Following a traumatic injury3.Due to caries,with a sound surrounding

dentin,is dressed with an appropriate biocompatible radioopaque base in contact with the exposed pulp tissue prior to placing a restoration .

LIMITATIONS IN PRIMARY TEETH

• Abundant blood supply and a consequent faster inflammatory response.

• Internal resorption• Calcification• Chronic pulp inflammation• Necrosis• Intra radicular involvement

Indications and Contraindications

• Small mechanical exposure less than 1mm,surrounded by sound dentin.

• Bleeding from the exposure site can be controlled easily.

• Traumatic exposured in a dry clean field(within 24hrs)

• Pain at night.• Spontaneous pain• Tooth mobility• Thickening of

periodontal ligament

• Inta radicular radiolucency

• Excess bleeding• Purulent or serous

exudate

STAINING CARIOUS LESIONS

• Proposed by FUSAYAMA to allow differentiation between infected and affected dentin.

• Infected dentin gets stained.• Ex-Cari-D test,• Caries Detector,• Caries Finder,• Sable Seek.

• Location of pulp exposure is important.

• Pushing of dentin chips and microorganisms into the pulp should be avoided.

PROCEDURECALCIUM HYDROXIDE TECHNIQUE

• Hemostasis• Disinfect cavity• Calcium hydroxide• resin mod.

GIC• IRM • DBS• •

restotation

DENTIN BONDING SYSTEM

• Hemostasis• Disinfect cavity• Bonding agent • Adhesive• restoration

CALPLUS

FEATURES OF SUCCESSFUL PULP

CAPPING• Maintenance of pulp vitality.• Lack of undue sensitivity or pain.• Minimal inflammatory response.• Lack of internal resorption and intra

radicular pathosis.

PULP CAPPING AGENTS

• Calcium hydroxide is the material of choice.

• Herman in 1930 1st introduced Ca(OH)2 for pulp capping.

• Ca(OH)2 causes necrosis of adjacent pulp tissue and inflammation of contiguous tissue.

• Dentin bridge formation accurs at the junction of necrotic and inflammed tissue.

Advantages and Disadvantages

• Initially bactericidal then bacterostatic.

• Promotes healing and repair

• High pH stimulates fibroblasts

• Neutralization of acids

• Stops internal resorption

• Inexpensive and easy to use

• Particles may obturate open tubules

• Doesn’t exclusively stimulate Dentinogenesis

• May dissolve after 1yr• May degrade during

acid etching and tooth flexure

• Marginal failure with amalgam condensation

• Doesn’t adhere to dentin or resin restoration

• Three main calcium hydroxide products-

• Pulpdent paste:52.5% calcium hydroxide suspended in aq.methyl cellulose sol.

• Hydrex is a two paste system-calcium hydroxide,barium sulfate,titanium dioxide and a selected resin.

• Dycal.

ISOBUTYL CYANOACRYLATE

• Hemostatic and bacteriostatic properties.

• Less inflammation than calcium hydroxide

• Doesn’t produce continuous barrier of reparative dentin.

RESIN BONDING AGENTS

• Suggested as means to achieve a hermetic seal at the dentin/pulpal interface by means of resinous‘’hybrid’’ layer.

• 4-methacryloxyethyl trimellitate anhydride(4-META) can be used on exposed pulp.

LASER

• Andreas Moritz in 1998 evaluated the effect of Co2 laser on direct pulp capping.

• Success rate-89%

PROPOLIS

• Recently used material.• Equally effective as calcium

hydroxide.• Sabir et al (2005) conducted

experiments.

OTHER MATERIALS

• Antibiotics• Corticosteroids• Dentin• Albumin• Poly carboxylate cements

3rd Molar in ‘’SEERSHASANAM’’

PULPOTOMY

• DEFINITION:• It can be defined as the complete

removal of the coronal portion of dental pulp,followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth.(finn,1959)

PULPOTOMY

VITAL PULPOTOMY• DEVITALIZATION:Single sitting:1. Formocresol2. Electrosurgery3. LaserTwo stage:1. Gysi triopaste2. Easlick’s formaldehyde3. Paraform devitalising paste PRESERVATION:GlutaraldehydeFerric sulphateMTAREGENERATION:Bone morphogenetic protein.

NON VITAL PULPOTOMY

• Beechwood cresol.• Formocresol

Indications and Contraindications

• Vital tooth• No spontaneous nor

persisting pain• Tooth is restorable• Tooth which

possesses 2/3rd of its root length

• Hemorrhage-pale red

• Primary tooth preffered to a space maintainer.

• Internal resorption• Inter radicular bone

loss• Abscess or fistula in

relation to teeth• Calcific globules in

pulp chamber • Caries penetating to

floor of pulp chamber

• Tooth close to natural exfoliation

DIAGNOSTIC CONSIDERATIONS

• Inflammation should be confined to the coronal pulp for a successful PROGNOSIS.

• Radiographic interpretation-• Extent of carious lesion• Status of lamina dura• Abnormal resorptive processes

READY??

DEVITALIZATON(SINGLE SETTING)

• FORMOCRESOL PULPOTOMY TECHNIQUE:

• 1st advocated by SWEET.

• formocresol is a solution of-

• 19% formaldehyde,• 35% cresol,• In a vehicle of

15%glycerine and water.

MECHANISM OF ACTION

• It prevents tissue autolysis by bonding to protein.

• This is a reversible process with out change in overall structure of proteins.

• IARC in june 2004 classified formocresol as CARCINOGENIC.

PROCEDURE

• Tooth anesthetized and isolated with rubber dam.

• All remaining dental caries should be removed and overhanging enamel should be planed.

• Entire roof of pulp chamber should be removed with bur.

• Amputate coronal pulp with spoon excavator.

• Irrigate pulp chamber.

• Moist cotton pellets should be placed until a clot forms.

• Haemorrhage controls readily-safe to proceed.

• Pulp chamber is dried with a sterile cotton pellet.

• Place a cotton moistened with 1:5 conc of buckley’s formocresol for 5min.

• Pellet is removed and pulp chamber is again dried with new pellet.

• Thick paste of ZOE is placed over pulp stump

• Zinc polycarboxylate cement is placed.

• Tooth restored with stainless steel crown.

DEVITALIZATION PULPOTOMY(TWO STAGE)• Paraformaldehyde is used to fix the

entire coronal and radicular pulp.• Agents used-• Gysi trio paste• Easlick’s paraformaldehyde paste• Paraform devitalizing paste.

TECHNIQUE

• 1st appointment:• STEP 1:1.Preparation of instruments and

materials2.Isolation of the affected teeth with

rubber dam3.Preparation of the cavity4.Excavation of deep carious dentin

• STEP 2:• When pulp exposure is

encountered,ensure it is free of debris• Enlarge with round bur• Prepare a cotton pellet to cover the

exposure.• Incorporate paraformaldehyde paste

into the pellet• Seal the tooth for 1 to 2 weeks.• Formaldehyde gas-fixes tissues

SECOND APPOINTMENT

• Pulpotomy is carried out under LA.• Roof of pulp chamber removed and

cleaned,dried.• Pulp chamber is filled with antiseptic

paste and tooth is restored.• If pulp found vital-repeat the

dressing for one more week

ELECTROSURGICAL PULPOTOMY

• Electocautery carbonizes and heat denatures the pulp and bacterial contamination

• Disadvantage:• Contaminated pulp tissue doesn’t

allow adequate current penetration.

LASER PULPOTOMY

• Non pharmacologic hemostatic technique for the pulpotomy procedure.

• Jeng-fen Liiu in 1999 studied the effect of Nd:YAG laser for pulpotomy in primary teeth and noted 100% success.

ONE MINUTE PULPOTOMY

• Garcia Godoy,Novakovic,Carvajal have suggested shorter application time(1 min).

• Equally effective.

PARIAL PULPOTOMY

• Cvek pulpotomy• Done for the traumatic exposures of

pulp in which inflamed pulp tissue is removed to a depth of 1 to 3mm.

• Sealed with calcium hydroxide or MTA

PRESERVATION

• Chemicals which induce minimal insult to tissues are used.

• They help to conserve vitality of radicular pulp

• Gluteraldehyde and Ferric sulfate are used.

GLUTARALDEHYDE

• Introduced by Kopel in 1979.

• Superior to formocresol in view of its-

• Superior fixative properties

• Self limiting penetration

• Low antigenicity• Low toxicity• Elimination of cresol.

PROPERTIES

• Better and non reversible fixation of tissues.

• Excellent antimicrobial• Pulp tissue remains vital• Clinical success 98-100%• Less dystrophic calcification• Less pulpal necrosis • Application in 2-5%conc safe for clinical

success

FERRIC SULFATE

• Non aldehyde hemostatic compound which prevents problems encountered with clot formation and thereby minimizes inflammation and internal resorption.

• Forms metal protein clot and this acts as a barrier to irritating components of the sub base.

PROPERTIES

• 100% clinical success

• 97.2% radiographic success

• Pulpal response favourable

• No systemic or local side effects

REGENERATION

• In this technique reparative dentin formation by pulpotomy agent occurs.

• BMP’s are osteogenic proteins which form a part of TGF-beta.

• They are implicated in-• Cell differentiation• Tissue morphogenesis• Regeneration and repair.

• Domingue AT in 2003 stated that MTA(mineral trioxide aggregate) forms crystals of calcium oxide in an amorphous structure of:33%Ca,49%P04,2%C,3%Cl,6%Si.

This new era was found when Urist in 1965 concluded that bone contains a factor capable of AUTO INDUCTION called as BMP(bone morphogenic protein).

Recombinant human BMP-2 and BMP-4 induce differentiation of adult pulp cell into odontoblast.

MORTAL PULPOTOMY

• Non vital tooth.• Pulpectomy of primary 1st molar may

sometimes be difficult due to non negotiable canals,limited patient cooperation.

TWO STAGES

• 1st appointment:necrotic coronal pulp removed.

• Irrigated and dried• Place a cotton pellet dipped in

Beechwood Cresol over Radicular pulp.

• Seal with Temporary cement for 1 or 2 weeks.

Second appointment

• Remove temporary dressing.• Note for resolution of signs and

symptoms• Then fill pulp chamber with

antiseptic solution• Restore with stainless steel crown.

PULPECTOMY

• Pulpectomy involves removal of the roof and contents of pulp chamber in order to gain access to the root canals which are debrided,enlarged and disinfected.

• Canals are filled with RESORBABLE MATERIALS.

OBJECTIVES

• Infectious process should resolve• Radiographic evidence of successful filling• Treatment should allow reosrption of

primary root structures and filling materials at appropriate time

• No post treatment pain,swelling or sensitivity

• No radiographic evidence of further break down of supporting tissue

• No internal or external resorption.

Indications and Contraindications

• Stratergically imp tooth

• Irreversible pulpitis• Minimal periapical

changes• Atleast 2/3rd of root

length available• Internal resorption

with out any obvious perforation

• Excessive mobility• Non restorable tooth• Underlying DC or

follicular cyst• Less than 2/3rd of root

length• Perforation of pulpal

floor• Medically

compromised children

TECHNIQUE

• ACCESS OPENING FOR PULPECTOMY OF PRIMARY TEETH

• First part of treatment also known as ENDODONTIC ENTRY

• Two phases-CORONAL phase,RADICULAR phase.

RULES FOR PROPER ACCESS PREPARATION

• Endodontic Dogma:’’careful cavity preparation and root canal obturation are the key stones to successful root canal therapy.’’

1.Objective of entry-gain direct access to apical foramena.

2.Internal anatomy of the tooth under treatment must be determined.

3.Access cavity preparations are not guided by topography of ooclusal grooves,pits and fissures

4.Endodontic entries are prepared always through the occlusal or the lingual

surface.5.Unsupported cusps of the posterior

teeth must be reduced to avoid weakening of tooth structure.

THREE FACTORS OF INTERNAL ANATOMY

• SIZE OF PULP CHAMBER

• Young patients have large pulp chambers and root canals-so they require large Instruments and Filling materials.

• SHAPE OF PULP CHAMBER:• The finished outline form should

accurately reflect the shape of the Pulp chamber.

NUMBER,POSITION AND CURVATURE OF THE ROOT

CANALS• PRIMARY ANTERIORS• Teeth no.of roots shape

accessory c• Max.In 1 Round Rare• Man.In 1;2 in<10%flat M n D

Occasional• Max n 1 Rounded Mand. Cn shape

Rare

PRIMARY MOLARS

• Teeth no.of roots shape accessorycanals• Max.1st 2 to 4 Round(p) 75%mesio-

facial root

bifurcation• Max.2nd 2 to 5 exterior 85% to 95% root shape mesiofacial

root

bifurcation.

• Teeth no.of canals shape accessory canals• Mand.1st 2 to 4 roughly 75%(m)25%(d)• external contain

2canals• root• Man. 2nd 2 to 5 anatomy 85%(m)25%(d)• conatin

2canals

• Access opening for primary anterior teeth is through the lingual surface-except max.primary incisors due to the problem of discolouration.

• Facial approach followed by acid etch composite restoration is recommended.

• Access opening for posterior primary root canals is mostly same as that for permanent teeth.

• Important differences-• Bulbous shape of crowns• Depth necessary to peretrate pulp

chamber is less• Occlusal surface to pulp floor distance

is less

• Entire roof of the pulp chamber is removed with a bur.

Canal cleaning and shaping:1.ISOLATION:best method is use of

Rubber dam.(Barnum)2.DEBRIDEMENT:canal cleaning and

shaping. The main objective of chemico-

mechanical preparation of primary tooth is debridement.

• Relative pulpectomy:due to tortuous course of root canal coupled with the numerous accessory canals,complete removal of pulp in primary teeth is often difficult.

• Selective filling:resorption,slender roots with thin apical ends may predispose the tooth to a root fracture.thus selective filling of canals should be followed.

WORKING LENGTH

• Working length be shortened,2-3mm short of the radiographic root length.

• ELECTRONIC APEX LOCATOR for working length determination.

APEX LOCATOR (Root ZX)

• It is a third generation electronic apex locator manufactured by J.Morita Corp.

• Consists of LCD monitor,a file holder tip and a contrary electrode to complete the circuit.

• Working principle of Root ZX:• Meter in the display indicates position

of file tip.• As file approaches the apex,the audible

alarm will beep slowly,meter reaches 2

APEX LOCATOR

• Apical constriction-0.5 on meter,sound of alarm will change,image of root canal will start flashing.

• Major foramen-meter reading 0,alarmwill give single sustained beep,word APEX will flash.

OPERATOR INSTRUCTIONS

• Length of filling material is calculated by-• Subtracting 0.5-1.0mm from the working

length indicated by 0.5 reading on the meter.

• Instrument should be gently curved to help negotiate the canals.

• Canals are enlarged several file sizes past the 1st file.

• Since many of pulpal ramifications cannot be reached mechanically,chemical debridement with sodium hypochlorite to digest organic debris should be done.

ROTARY INSTRUMENTS

• Rotary ni-ti files are specially designed to provide superior flexibility and unmatched efficiency.

• Can be attached to a hand piece.

• If iflammation is beyond the coronal pulp with only interradicula but no periapical radiolucency-single visit pulpectomy is done.

• If pulp is necrotic with periapical involvement,filling is done at subsequent appointement.

Ni-Ti FILES

Advantages and Disadvantages

• More consistent dense fill due to uniform debridement.

• Greater apical enlargement

• Prevent apical exposure

• Provide better shape• Reduce

instrumentation time

• Skill required• Resorption may be

a problem• Breakage of files in

the canal.• Repeated use

increases risk of fracture.

FILLING OF PRIMARY ROOT CANALS

• IDEAL REQUIREMENTS:• Should resorb at the same rate as

primary roots.• Should be harmless• Should have stable disinfecting power• Ease of use• Should not shrink• Insoluble in water• Radio opaque,not discolour teeth.

ZOE paste

• Most commonly used.• Camp in 1984 introduced endodontic

pressure syringe.• Disadvantages:• Overfilling causes Foreign body

reaction• Difference in rate of resorption from

that of tooth root.• Success rate 65%

IODOFORM PASTE• KRI paste:• Iodoform

80.8%,camphor 4.86%,parachlorophenol 2.025%,menthol 1.215%

• Advantages:• Resorbs rapidly• Extruded paste in

periapical tissue is replaced with normal tissue.

• Bactericidal potential• Can be removed if re

treatment is required• Success rate 84%

CALCIUM HYDROXIDE

• Calcium hydroxide and iodoform mixture-Vitapex,Neo Dental Chemical Products Co;Tokyo,has been published by Fuchino and Nishino in 1980.

• Properties:• Non toxic• Easy to apply• Resorbs at slightly faster rate than root• Radio opaque• 100% success rate.

ENDOFLAS

• Composition:• Zno-56.5%,Barium sulphate

1.63%,Iodoform 40.6%,Calcium hydroxide 1.07%,Eugenol Pentachlorophenol.

• Microleakage should be prevented.• 70% success rate.

OBTURATION TECHNIQUES

• Larger canals can be filled with the thin mix coating the walls of the canal with reamer in ANTICLOCL WISE direction and then with a thicker mix.

• Lentulo spiral mounted on a micromotor hand piece.96-92% success rate.

• Endodontic pressure syringe-ZOE,Vitapex

• After obturation,temporary cement is filled in pulp chamber.

• Then restoration with stainless steel crown.

FOLLOW UP

• Rate of success-high• Primary tooth should be free form

pathosis,pain,firm in alveolus and resorb normally.

• Over retention may be a problem.

Whom do u like to have on ur Tooth??

HELLO!!!!

ONCE AGAIN :p

MTA

• MTA(Mineral Trioxide Aggregate)is a new material.

• 1st described in Dental literature in 1993 by Torabinejad for repair of lateral root perforations.

• Developed in the LOMA LINDA university in 1990’s as ROOT END FILLING MATERIAL.

Advantages over Ca(oH)2

• Thicker dentinal bridge• Less inflammation• Less hyperemia• Less pulpal necrosis• Dentin bridge formation at faster

rate

• APPLICATIONS:• Root end fillings• DPC• Apexification• pulpotomy• perforation repairs

COMPOSITION

• Tricalcium silicate• Dicalcium silicate• Tricalcium aluminate• Calcium sulphate dehydrate• Bismuth oxide

PROPERTIES

• pH is 12.5• Setting strength similar to IRM• Non cytotoxic• Long term success in primary tooth

pulpotomy• Biocompatible• Provides agood seal• Promotes hard tissue formation• Takes lesser time for biological barrier

formation than Ca(OH)2.

MINERALIZATION

• Hydration of MTA(neutral phosphate buffer saline sol)

• Two separate reactions.• Tricalcium

aluminate+water(caso4)=ETTRINGITE.

• Tricalcium silicate,dicalcium silicate+water=calcium silicate hydrate+Ca(oH)2.

• Ca(oH)2 leaches Ca• Reacts with tissue fluid forming

HYDROXYAPETITE.(physicochemical basis for biologic properties)

Antimicrobial effect

• Less antibacterial than calcium hydroxide.

• More resitant to microbial leakage.• Why??

procedure

• Standard pulpotomy• Hemostasis by sodium hypochlorite• 2mm thick layer of MTA applied

LIMITATIONS

• Cost• Problems of storage.??

Conclusion

• MTA can be used as a substitution for Ca(oH)2 in pulpotomy-further research however is needed!!!

Thank u 4 ur patient listening