Vital pulp therapy

/dr.aravind-odontopediatrician/ topic discusses about management of pulpal pathoses while maintaining the vitality in primary& young permanent teeth.

1. Vital Pulp Therapy Dr. ARAVINDHAN A, JR-2, Dept. of Paediatric & Preventive Dentistry

2. Introduction Vital pulp therapy is the treatment initiated on an exposed pulp to repair and maintain the pulp vitality. - Grossman Pulpal exposure by mechanical or bacterial means leading to direct communication between pulp and external environment. Conservation of tooth in a healthy state. Preservation of arch space. Enhances esthetics and function. Prevents peri radicular infection and its sequalae .

3. contents Indirect pulp capping Direct pulp capping Pulpotomy Apexogenesis

4. Indirect pulp capping Definition: “a procedure wherein small amounts of carious dentin is retained in deep areas of cavity to avoid exposure of pulp, followed by placement of suitable medicament and restorative material that seals off the carious dentin and encourages pulp recovery” -Ingle

5. Objectives of indirect pulp capping: (Eidelman-1965) Arresting the carious process Promoting dentin sclerosis Stimulating the formation of tertiary dentin Remineralisation of carious dentin. A successful vital pulp treatment requires, 1. a good sealant against bacteria, 2. no severe inflammatory reactions, 3. and stable haemodynamic within the pulp. - R. Vij , J. A. Coll , P. Shelton, and N. S. Farooq , “Caries control and other variables associated with success of primary molar vital pulp therapy,” Pediatric Dentistry, vol. 26, no. 3, pp. 214– 220, 2004.

6. Rationale of IPC

7. Indication contraindication Mild pain while eating Spontaneous pain Deep carious lesion with no pulpal involvement Pulpo periapical invlovement Normal periodontium , gingiva and no mobility Mobility ,abscess/ fistula .

8. Procedure Single appointment procedure Two appointment procedure Under LA and rubber dam Removal of infected dentin Site is covered with Ca(OH)2 Remainder cavity is filled with suitable restorative material 2 nd appointment is given after 6-8 weeks of placement of Ca(OH)2 Re entry of the cavity Removal of caries if needed Placement of Ca(OH)2 Restoration of the cavity

9. Indirect pulp capping agent Titanium dioxide in glycol salicylate Ca(OH)2 and ZnO in ethyl toluene sulfonamide Method of application Blunt probe Mixing pad

10. Sequalae of IPC 1. cellular fibrillar dentin – first 2 months 2. globular dentin- 3 months 3. tubular dentin- after 3 months (0.1 mm) Step wise excavation technique -Re entry of the cavity is done at various intervals -After Superficial carious lesion is excavated, suitable interim restoration is done depends on treatment interval (ranges between 6-8 months) Bjorndal L et al., Indirect pulp therapy and step wise excavation . J Endod.2008

11. Pulp response to high fluoride releasing glass ionomer , silver diamine fluoride, and calcium hydroxide used for indirect pulp treatment: An  in-vivo  comparative study- Logani A et al.,JCCD (2015).

12. Direct pulp capping “Placement of medicament or non medicated material on a pulp that has been exposed in course of excavating the last portions of deep dentinal caries or as a result of trauma .”- Kopel (1992) “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 .”- Grossman.

13. Creation of new dentin in the area of the exposure and subsequent healing of the pulp

14. Indications -Small mechanical exposure -True pin point exposure -Exposure with bright red hemorrhage -Asymptomatic vital primary/permanent tooth contraindications -Spontaneous pain -Tooth mobility -Uncontrollable bleeding at exposure site -External/internal resorption

15. T echnique Rubber dam isolation Cavity should be irrigated with saline, chloramine T, or distilled water Arresting of hemorrhage with sterile cotton pellets in light pressure Passive placement of pulp capping agent Temporary restoration Final restoration of evaluating the success of DPC clinically/ radiologically .

16. Histological changes after DPC -GLASS &ZANDER (1949)

17. Histological evaluation of hard tissue formation after direct pulp capping with a fast-setting mineral trioxide aggregate ( RetroMTA ) in humans-Till  Dammaschke et al.,JCOI (2019).

18. Limitations of direct pulp capping in primary tooth Internal resorption High cellular content Faster inflammatory response Poor localisation of infection.

19. Materials used for direct pulp capping Calcium hydroxide Corticosteroids and antibiotics: neomycin and hydrocortisone ( Brosch,1966) ledermix ( Ca(OH)2 and prednisolone ). penicillin/ vancomycin with Ca(OH)2. Inert materials: isobutyl cyanoacrylate tricalcium phosphate ceramic Collagen fibres 4- META adhesives

20. Direct bonding Denatured albumin ( Berkman , 1971) MTA Bone Morphogenic Protein Laser (laser assisted direct pulp capping has 89% success rate ,1998)

21. Pulpotomy “Amputation of the affected or infected coronal portion of the dental pulp, preserving the vitality & function of all or part of the remaining radicular pulp”- AAPD-1998. VITAL NON- VITAL Devitalisation preservation regeneration Mortal pulpotomy

22. Objectives: 1. removal of inflammed / infected coronal pulp 2. preserving the vitality of the pulp 3. Maintain the integrity of tge arch Indications contraindicatons Mechanical pulp exposure in primary teeth Persistent tooth ache No sinus / fistula Presence of furcal / periapical infection Presence of atleast 2/3 rd root External /internal resorption /physiological resorption of more than 1/3 rd of root Controllable Hemorrhage from the exposure site Uncontrollable sluggish hemorrhage No peri radicular pathology Mobilty of tooth

23. Criteria for case selection Teeth with deep carious lesion Restorable tooth No signs of periapical lesion, abscess, fistula No internal/ external resorption Hemorrhage should be arrested within 5 minutes from the amputated pulp stumps. - Heilig J et al.,(1984) & Waterhouse et al., (2000).

24. Formocresol pulpotomy / single stage pulpotomy Introduced by Buckley (1904). Sweet(1930)- multivisit pulpotomy Doyle(1962)- two sitting procedure Spedding (1965)- 5 minutes protocol Venham (1967)- 15 seconds procedure -Current concept used 4 minutes application time.

25. Mechanism of action : it prevents tissue autolysis by bonding to the proteins. Composition : Cresol- 35% Glycerol- 15% Formaldehyde- 19% Water- 31%

26. Procedure

27. Histological changes after formocresol pulpotomy

28. Comparative evaluation of formocresol and mineral trioxide aggregate as pulpotomy agents in deciduous teeth- Daya srinivasan et al., IJDR (2011).

29. Concerns about formocresol Toxicity: Lewis(1981) - cytotoxic , mutagenic and carcinogenic in animals. “over 3000 pulpotomies must be done in an individual to reach the toxic level of formocresol ”.- Ranly . Systemic distribution: formocresol was found in PDL, bone, dentine, and urine- Myers (1978). Antigenocity : immunogenicity is found with fromocresol - Thoden valzen (1977).

30. Mutagenicity and cytotoxicity : formaldehyde denatures nucleic acids Formation of methylol compounds Genetic biosynthesis blockade (interaction with DNA & RNA) - Nongentini,1980. “formaldehyde is not a potent human carcinogen under conditions of low exposure” - Milnes et al ., persuasive evidence that formocresol use in pediatric dentistry is safe . J Can Den Assoc.2006

31. Modified formocresol pulpotomy Trask (1972) Used in tooth that have to be retained for a short period of time only Technique is identical to primary tooth only but formocresol , soaked cotton pellet was kept inside the permanent tooth.

32. Two visit devitalisation pulpotomy Fixation of entire coronal and radicular pulp tissue by paraformaldehyde in two visits. Indications: 1. sluggish bleeding at the ampuatation site that is difficult to control. 2.pus in the chamber but none at the amputation site Contraindications: 1. tooth with necrotic pulp. 2. non restorable tooth.

33. Materials used for 2 visit pulpotomy Gysi trio paste Easlicks paraformaldehyde paste Paraform devitalising paste tricresol paraformaldehyde paraformaldehyde cresol Procaine base lignocaine ZOE Powdered asbestos Propylene glycol glycerin Petroleum jelly carbowax paraformaldehyde Carmine to color

34. Procedure 1st visit 2 nd visit After 1-2 weeks - Nikhil Marwah , 4 th edition

35. Gluteraldehyde pulpotomy Kopel-1979 Mechanism: -rapid surface fixation of pulpal tissue. -blends into vital normal apical tissue. -fixed tissue is replaced by dense collagenous tissue with time. - 2% gluteraldehyde is applied for 1-3 minutes over the ampuated pulp. ( garcia & godoy ,1986)

36. Adavntages over formocresol … 1.superior fixation by protein cross linkage. 2. excellent antimicrobial. 3. less necrosis of pulp 4. doesn’t perfuse through apex. 5. less mutagenicity and antigenicity .

37. Ferric sulphate pulpotomy Method of application is similar to formocresol pulpomy . 15.5% concentration of solution is applied for 15 seconds. Mechanism: agglutination of blood proteins results from the reaction of blood with both ferric and sulphate ions. -agglutinated proteins form plugs to occlude capillary orifice. Minimises the chance of internal resorption . “Controlled clinical studies have been critically reviewed, and mineral trioxide aggregate and ferric sulfate have been considered appropriate alternatives to formocresol for pulpotomies in primary teeth with exposed pulps.”- Fuks et al., J Endodontology .(2008).

38. Laser pulpotomy Ebimara-1985 used Nd -YAG laser in pulpotomy at 20Hz . Diode laser 810 nm 3W power Non contact mode Continuous wave

39. “Postoperative assessment of diode laser zinc oxide eugenol and mineral trioxide aggregate pulpotomy procedures in children: A comparative clinical study”- Pratima I et al., JISPPD (2018).

40. Cvek pulpotomy Partial pulpotomy / calcium hydroxide pulpotomy Mejare & cvek-1978 Indicated in young permanent tooth where the radicular pulp is judged vital by clinical/ radiological criteria and root formation is incomplete. According to American Academy of Pediatric Dentistry (AAPD) guidelines, partial pulpotomy for traumatic exposures is a procedure, in which the inflamed pulp tissue beneath an exposure is removed to a depth of 1-3 mm or more to reach the deeper healthy tissue.

41. Non vital pulpotomy Mortal pulpotomy Non vital tooth should be treated with pulpectomy , but sometimes it is impracticable due to non negotiable root canals. Mortal pulpotomy is done in such patients. Beechwood cresol is used in this procedure. If the tooth is asymptomatic after 1-2 weeks , definite restoration is given.

42. Current concepts in pulpotomy … MTA pulpotomy Portland cement Nano hydroxy apatite and BMP Calcium enriched mixture Allium sativum oil Lyophilised freeze dried platelet with calcium hydroxide. Enamel matrix derivative Propolis Ankaferd blood stopper Platelet rich plasma Pulpotec Calcium phosphate cement Biodentine

43. -Journal of conservative dentistry,(2015)

44. Apexogenesis It is defined as “the treatment of a vital pulp by capping or pulpotomy in order to permit continued growth of the root and closure of the open apex”. Rationale: maintanence of integrity of the radicular pulp tissue to allow for continued growth.

45. Procedure

46. -PJ Van der vyver et al., SADJ (2018)

47. Thank you!