vital pulp therapy.pptx

VITAL PULP THERAPY

1. VITAL PULP THERAPY PRESENTED BY DR. SRAVYANJALI

2. INTRODUCTION

3. CLASSIFICATION

4. DIRECT PULP CAPPING

5. American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:415-23. DIRECT PULP CAPPING

6. American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:415-23 OBJECTIVES (AAPD2020)

7. American Academy of Pediatric Dentistry. Pulp therapy for primary and immature permanent teeth. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2022:415-23

8. Procedure of dpc Once an exposure is encountered, further manipulation of pulp is avoided Cavity should be irrigated with saline or distilled water or chlorhexidine Hemorrhage is arrested with light pressure from sterile cotton pellets

9. Place temporary restoration Place the pulp capping material, on the exposed pulp with application of minimal pressure so as to avoid forcing the material into pulp chamber

10. Final restoration is done after determining the success which is done by determination of dentinal bridge, maintenance of pulp vitality and lack of pain.

11. FACTORS AFFECTING SUCCESS OF DPC

12. INDIRECT PULP CAPPING

13. INDIRECT PULP CAPPING

14. INDICATIONS

15. CONTRAINDICATIONS

16. OBJECTIVES AAPD's guidelines on pulp therapy for primary and immature permanent teeth( MARCH 2013)

17. TREATMENT PROCEDURE

18. OUTCOME OF IPC

19. PULP CAPPING AGENTS

20. CALCIUM HYDROXIDE Grossmam 13 th edition

21. ADVANTAGES Reparative dentin formation Antibacterial action Pulp protection The tissue-dissolving property DISADVANTAGES Pulp obliteration Internal resorption Lack of adhesion to hard tissues Microleakage Short working time of self cured preparation

22. HISTOLOGY OF HEALING AFTER PULP CAPPING WITH CA(OH)2

23. A calcified barrier may be induced when calcium hydroxide is used as a pulp-capping agent or placed in the root canal in contact with healthy pulpal or periodontal tissue 2 WEEKS 6 -8WEEKS 4 WEEKS

24. Because of the high pH of the material, up to 12.5, a superficial layer of necrosis occurs in the pulp to a depth of up to 2 mm. Beyond this layer only a mild inflammatory response is seen, and providing the operating field was kept free of bacteria when the material was placed, a hard tissue barrier may be formed.

25. The alkaline pH induced not only neutralizes lactic acid from the osteoclasts, thus preventing a dissolution of the mineral components of dentine, but could also activate alkaline phosphatases which play an important role in hard tissue formation. The hydroxyl group is considered to be the most important component of calcium hydroxide as it provides an alkaline environment which encourages repair and active calcification. The calcified material which is produced appears to be the product of both odontoblasts and connective tissue cells and may be termed osteodentine. The barrier, which is composed of osteodentine, is not always complete and is porous.

26. Zinc oxide-eugenol ZOE is a Germicidal agent Used in indirect pulp capping due to its This gives the pulp the chance for healing & regeneration Palliative affect Excellent initial seal Kills bacteria present in carious lesions So arrests the caries process

27. Glass and Zander found that ZOE, in direct contact with the pulp tissue, produced chronic inflammation, a lack of calcific barrier , and an end result of necrosis. Hembree and Andrews, in a literature review of ZOE used as a DPC material, could find no positive recommendations. Watts also found mild to moderate inflammation and no calcific bridges in the specimens under his study, and this was confirmed by Holland et al. Weiss and Bjorvatn , on the other hand, noted negligible necrosis of the pulp in direct contact with ZOE but stated that any calcific bridging of an exposure site was probably a layer of dentinal chips. Sven reported 87% success with the capping of primary teeth with ZOE in ideal situations of pulp exposure. He offered no histologic evidence, but Tronstad and Mör , Comparing ZOE with calcium hydroxide, found ZOE more beneficial for inflamed, exposed pulps and felt that the production of a calcific bridge is not necessary if the pulp is free of inflammation following treatment.

28. INDICATION Injurious to pulp when used as DPC agent. Chronic inflammation, Internal resorption (Nixon – 1972) Bridging of exposure site Reparative dentin formation Healing & hard tissue formation ( Kitagava – 1968 )

29. Mineral Trioxide Aggregate (MTA) MTA is a unique material with several exciting clinical applications. Mineral Trioxide Aggregate (MTA) was introduced by Mohmoud Taorabinejad at Loma Linda University, California, USA in 1993 MTA is biocompatible in nature and have excellent potential in endodontic use. MTA provide better microleakage protection and it is a traditional endodontic repair materials. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. Journal of endodontics . 1999 Mar 1;25(3):197-205.

30. MTA is available in two types based on the color known as GRAY AND WHITE. water ratio for MTA should be 3:1 Mixing can be done on paper pad or on a glass slab using a plastic or metal spatula to achieve putty like paste consistency. Immediately after mixing MTA has a pH of 10.2. After 3 hours of setting the pH increased to 12.5. The pH of set MTA is almost similar to calcium hydroxide mixing time should be less than 4 minute. Torabinejad et al. (1993) found setting time about 2 hours and 45 minutes (± 5 minutes) of grey MTA and 2 hours and 20 minutes for white MTA ,

31. MTA being hydrophilic material it requires moisture to set. Presence of moisture during setting improves the flexural strength of the set cement . Therefore , it is advised to place a wet cotton pellet over the MTA in the first visit followed by placement of a permanent restoration at the second visit. The long setting time is one of the drawbacks of MTA. MTA powder must be kept tight to avoid degradation by moisture. if the mixing time is prolonged; it results in dehydration of the mixture. MTA may be placed into the desired location using ultrasonic condensation, plugger , paper point or specially designed carriers like MTA PUSHER

32. TYPE OF MTA GREY MTA = contain tetracalcium almino ferrite { ferrous oxide } which cause GREY discolouration , not used for ant. Tooth WHITE MTA = ferrous oxide replaced by magnesium oxide which is not cause discolouration COMPOSITION MTA contains 50-75% of calcium hydroxide Tricalcium silicate Tricalcium aluminate Tricalcium oxide Silicate oxide Bismuth oxide 15-25% of silicon dioxide Bismuth oxide powder has been added to make the aggregate radiopaque   Main 3 ingrident are Portland cement Bismuth oxide Gypsum Rao A, Rao A, Shenoy R. Mineral trioxide aggregate—a review. Journal of Clinical Pediatric Dentistry. 2009 Sep 1;34(1):1-8.

33. Properties of MTA PH - 10.2 at the time of mixing but after mixing it become 12.5 Setting time - 3-4 hours. Radio opaque. Compressive strength - 70 MPa . Biocompatible. Non mutagenic. Less cytotoxicity. Sealing ability is very good with no marginal gaps.

34. PULPOTOMY

35. PULPOTOMY

36. INDICATIONS

37. CLASSIFICATION

38. CONTRAINDICATION

39. FORMOCRESOL PULPOTOMY Formocresol was introduced in 1904 by Buckley, who contended that equal parts of formalin and tricresol would react chemically with the intermediate and end products of pulp inflammation to form a "new, colorless, and non-infective compound of a harmless nature COMPOSITION tricresol 19 % aqueous formaldehyde glycerine water Formocresol pulpotomy technique currently used as an modification.

40. FORMOCRESOL PULPOTOMY TECHNIQUE IN PRIMARY TEETH ( ONE APPOINTMENT PULPOTOMY ) This method of treatment should be carried out only on those restorable teeth in which it has been determined that inflammation is confined to coronal portion of pulp when coronal pulp is amputed , only vital healthy pulp should remain in the root canal. CONTRAINDICATION Tooth with spontenous pain Pathologic root resorption Two third root resorbed Internal root resorption Interradicular bone loss Fistula pus present in chamber

41. PROCEDURE

42. Technique C O H E N ’ S P A T H W A Y S of the PULP, KENNETH M. HARGREAVES, LOUIS H. BERMAN ELEVENTH EDITION

43. But Milnes , 2006 published an extensive and detailed review of the more recent research on the metabolism, pharmacokinetics, and carcinogenicity of formaldehyde and concluded that formaldehyde is not a potent human carcinogen under conditions of low exposure. He concluded that extrapolation of these research results to pediatric dentistry suggests an inconsequential risk of carcinogenesis associated with formaldehyde use in pediatric pulp therapy. Toxicity: Ranly calculated that, over 3000 pulpotomies must be performed in the same individual for formocresol to reach toxic level. Systemic distribution : When used in pulpotomies in animals, formaldehyde has been found in periodontal ligament, bone, dentine and urine. Antigenocity : Thoden Valzen in 1977 has shown immunogenic potential of formaldehyde in rabbits, dogs and guinea pigs. Mutagenicity and cytogenicity : Nongentini in 1980 postulated that mutational changes were achieved by application of formaldehyde and cytogenicity for 15 minutes, in monkey kidney cells. Concerns about Formocresol Milnes AR. Persuasive evidence that formocresol use in pediatric dentistry is safe. J Can Den Assoc. 2006;72:247–8

44. TWO APPOINTMENT PROCEDURE INDICATION If there is sluggish and profuse bleeding at the amputation site. Difficulty to control bleeding. Thickening of pdl History of spontenous pain CONTRAINDICATION Non restorable tooth Soon to be exfoliated Necrotic tooth

45. Partial pulpotomy / cvek pulpotomy Also known as CVEK pulpotomy is define as the removal of small portion of vital coronal pulp as a means of preserving the remaining coronal and radicular pulp tissue. The coronal pulp is reduced approximately 2-3 mm in order to remove necrotic inflamed irreversible damaged tissue.

46. C O H E N ’ S P A T H W A Y S of the PULP, KENNETH M. HARGREAVES, LOUIS H. BERMAN ELEVENTH EDITION

47. COMPLETE PULPOTOMY Complete pulp amputation is a more intrusive procedure defined by AAE as a removal of the coronal portion of vital pulp as a means of preserving the vitality of remaining radicular portion.

48. ALTERNATIVES TO FORMOCRESOL PULPOTOMY

49. GLUTRALDEHYDE PULPOTOMY Suggested by gravenmade that formaldehyde did not represent ideal pulp fixation. Inflammed tissue that produce toxic by product should be fixed rather then treated with strong disinfectant Glutraldehyde solution might replace formocresol in endodontic therapy because of its fixative properties and bactericidal effectiveness and result in less destruction of tisue Glutraldehyde found less toxic when using 3.125 % of concentration

50. Bactericidal Superior fixative properties Less necrosis of pulpal tissue Less dystrophic calcification in pulp canals. Less toxicity Less systemic distribution. Low tissue binding – 90% of it is gone in 3 days Less mutagenicity and antigenicity C O H E N ’ S P A T H W A Y S of the PULP, KENNETH M. HARGREAVES, LOUIS H. BERMAN ELEVENTH EDITION

51. Problems with glutaraldehyde Glutaraldehyde solutions are reported to be unstable. Neither the optimum concentration nor optimal duration of application of glutaraldehyde solution have been established conclusively. Clinical studies reported increasing failure rates with increasing time after pulpotomy , with lower levels of clinical success than with formocresol . C O H E N ’ S P A T H W A Y S of the PULP, KENNETH M. HARGREAVES, LOUIS H. BERMAN ELEVENTH EDITION

52. NON PHARMACOTHERAPEUTIC PULPOTOMY TECHNIQUE CONTROLLED ENERGY Controlled energy in the form of laser and electrosurgical heat application to the pulp stump at the canal orifice has been alternative to pharmacotheraputic .

53. Mark was the first US dentist routinely to perform electrosurgical pulpotomy in 1993 with a success rate of 99% for primary molars. ELECTROSURGICAL Pulpotomy The steps in the electrosurgical pulpotomy technique are basically the same as those for the formocresol technique through the removal of the coronal pulp tissue. D ental electrode is used to deliver the electric arc. The cotton pellets are quickly removed, and the electrode is placed 1 to 2 mm above the pulpal stump. The electric arc is allowed to bridge the gap to the pulpal stump for 1 second, followed by a cool-down period of 5 seconds. Heat and electrical transfer are minimized by keeping the electrode as far from the pulpal stump and tooth structure as possible while still allowing electric arcing. When the procedure is properly performed, the pulpal stumps appear dry and completely blackened. C O H E N ’ S P A T H W A Y S of the PULP, KENNETH M. HARGREAVES, LOUIS H. BERMAN ELEVENTH EDITION

54. DENTAL ELECTRODE

55. Laser Pulpotomy Several reports have appeared in the literature on the use of the carbon dioxide laser for performing vital pulpotomy on primary teeth. Elliott RD, Roberts MW, Burkes J, et al- Evaluation of the carbon dioxide laser on vital human primary pulp tissue,  Pediatr Dent 21:327, 1999.  Liu JF, Chen LR, Chao SY: Laser  pulpotomy  of primary  teeth,  Pediatr Dent 21:128, 1999. On the basis of these initial studies, the use of the carbon dioxide laser could be considered a viable alternative to formocresol . C O H E N ’ S P A T H W A Y S of the PULP, KENNETH M. HARGREAVES, LOUIS H. BERMAN ELEVENTH EDITION

56. Ferric sulphate pulpotomy Method of application is similar to formocresol pulpomy . Mechanism : agglutination of blood proteins results from the reaction of blood with both ferric and sulphate ions . A gglutinated proteins form plugs to occlude capillary orifice . Minimises the chance of internal resorption

57. technique C O H E N ’ S P A T H W A Y S of the PULP, KENNETH M. HARGREAVES, LOUIS H. BERMAN ELEVENTH EDITION

58. CURRENT CONCEPTS IN PULPOTOMY

59. PROPOLIS It is a wax - resin substance that is produced by bees. S hown to have antibacterial, antiviral, antifungal, immunostimulation hypotensive and cytostatic activity mainly due to the presence of lavonoids (2-phenyl- 1,4-benzopyrone), aromatic acids, and esters. Carmen et al. showed that 10% propolis tincture was as effective as FC pulpotomy in primary molars . Lima et al. following histological analysis - inflammatory response was less severe, the area of pulp necrosis was smaller, and more frequent formation of a mineralized tissue barrier was evident . Ozorio et al. in their histologic study noted the complete calcific bridge formation in propolis group. Rodriguez G, del Carmen W, Carpio C, Hortensia M, Ramos M, Raquel M, et al. Pulpotomies of dead pulps in temporal molars using 10% propolis tinction . Revista Cubana De Estomatología . 2007; 44. 56. Ozório JE, Carvalho LF, de Oliveira DA, de Sousa- Neto MD, Perez DE. Standardized Propolis Extract and Calcium Hydroxide as pulpotomy agents in primary Pig Teeth. Journal of Dentistry for Children. 2012; 79: 53-58. Lima RV, Esmeraldo MR, de Carvalho MG, de Oliveira PT, de Carvalho RA, da Silva FL Jr , de Brito Costa EM. Pulp Repair after pulpotomy Using Different Pulp Capping Agents: A Comparative Histologic Analysis. Pediatric Dentistry. 2011; 33: 14-18. 57.

60. APEXOGENESIS

61. Apexogenesis is a histological term used to describe the continued physiologic development and formation of the root’s apex in vital young permanent teeth can be accomplished by implementing the appropriate vital pulp therapy. (AAPD) Rationale Maintenance of integrity of the radicular pulp tissue to allow for continued root growth . Indications Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed No history of spontaneous pain No sensitivity on percussion No hemorrhage Normal radiographic appearance.

62. CASE

63. Contraindications Evidence that radicular pulp has undergone degenerative changes Purulent drainage History of prolonged pain Necrotic debris in canal Periapical radiolucency

64. RECENT ADVANCEMENTS IN VITAL PULP THERAPY MATERIALS

65. CONCLUSION:- “Successful treatment of pulpally involved tooth is to retain it in a healthy condition so that it may fulfill its role as a useful component of primary and young permanent dentition.” - Lewis and Law