VITAL PULP THERAPY

CONTENTS

1. INTRODUCTION2. INDIRECT PULP CAPPING3. DIRECT PULP CAPPING4. PULPOTOMY5.APEXIFICATION

N ever m u st th e p h ysician say th e d isease is in cu rab le. B y th at ad m issio n h e d en ies G o d , o u r creato r; H e d o u b ts N atu re w ith h er p ro fu sen ess o f h id d en p o w ers an d m ysteries. - Paracelsu s

INTRODUCTION

• Hard tissue covering of tooth structure provides protective armour to sensitive pulpal tissues from external insults.

• Carious and non carious diseases result in progressive destruction of these hard tissues rendering the pulp tissue more and more vulnerable.

WHAT IS VITAL PULP THERAPY ?

• Vital pulp therapy is the treatment initiated on an exposed pulp to repair and maintain the pulp vitality.

• All these procedures involve removal of local irritant and placement of protective material directly or indirectly over the pulp.

• Common objective is to induce a physical protective barrier over pulp to maintain its vitality and function.

GOALS

• Treat reversible pulpal injuries.• Neutralization of any existing pulpal

contamination.• Prevention of further contamination

(microleakage)

PULPAL INFLAMMATION AND ITS SEQUELAE

INDIRECT PULP CAPPING

DEFINITION: Indirect pulp capping is defined as a procedure wherein 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 pulp.

• OBJECTIVE: The ultimate objective is to preserve the vitality of the pulp by completely removing the carious infected dentin followed by placement of material that would enable the affected dentin to remineralise by stimulating the underlying odontoblasts to form tertiary dentin.

RATIONALE

• Disinfection of residual affected dentin is more readily accomplished.

• It eliminates the need for more difficult pulp therapy by arresting the carious process and allowing the pulp reparative process to occur.

• Patient comfort is immediate.• Rampant dental caries is halted when all

carious teeth are treated.

DIAGNOSTIC DATA

• HISTORY

• CLINICAL EXAMINATION

• RADIOGRAPHIC EXAMINATION

CLINICAL PROCEDURE

• Performed as single or two-step approach.

FIRST APPOINTMENT:

• Use of local anesthesia and isolate with rubber dam.

• A slow speed hand-piece with large burs is used to remove the superficial debris and majority of the soft infected dentin without exposing the pulp.

• Deepest layer of infected dentin is covered with a hard-setting calcium hydroxide preparation, and sealed with an overlying base of reinforced zinc-oxide eugenol preparation.

• This sealed cavity is not disturbed for 6-8 weeks.

SECOND APPOINTMENT

• A bitewing radiograph of treated tooth is obtained.• Use local anesthesia and isolate with rubber dam.• The previous remaining soft, deep brownish red color

affected dentin will have changed lighter brownish gray color and most importantly harder in nature.

• The entire floor is covered with calcium hydroxide preparation.

• When clinical and radiographic findings are negative, the final restoration is placed.

TREATMENT OUTCOME

• Remaining dentin thickness • Choice of indirect pulp capping agent

DIRECT PULP CAPPING

Definition : Its defined as the 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 the pulpal vitality.

INDICATIONS

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

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

• Radiographically there should be no thickening of PDL space and no evidence of periradicular lesion.

CONTRAINDICATIONS

• In cases of carious exposures of primary tooth.• Large carious exposures in symptomatic

permanent tooth

FACTORS AFFECTING PROGNOSIS OF DIRECT PULP CAPPING

PHYSICAL PHENOMENA ASSOCIATED WITH MECHANICAL PULP EXPOSURES

• Heat• Pressure• Damage to pulp tissue• Hemorrhage• Intrusion of dentin chips

PULP CAPPING AGENTS AND THEIR TREATMENT PROTOCOLS

CALCIUM HYDROXIDE

• In 1920, a new era in the treatment of exposed pulp began when Hermann introduced a calcium hydroxide mixture that induced the bridging of the exposed pulp with reparative dentin

• The examples of calcium hydroxide products that have been widely used are Pulpdent paste and Dycal

MECHANISM OF ACTION

HEALING WITH CALCIUM HYDROXIDE1. Zone of obliteration2. Zone of coagulation necrosis3. Line of demarcation

MINERAL TRIOXIDE AGGREGATE

COMPOSTION• Tricalcium silicate• Dicalcium silicate• Tricalcium aluminate• Tetracalcium alumino ferrite• Bismuth oxide• Traces of free crystalline silica• Other trace constituents include calcium oxide, free

magnesium oxide, potassium and sodium sulphate compounds

TECHNIQUES OF DIRECT PULP CAPPING – TREATMENT PROTOCOL

PULPOTOMY

• Its defined as a procedure in which a portion of exposed vital pulp is surgically removed as a means of preserving the vitality and function of the remaining radicular portion. The procedure is similar in concept to direct pulp capping except in the amount and extent of pulp tissue removal.

OBJECTIVES

• Preservation of vitality of radicular pulp• Relief of pain in patients with acute pulpalgia

and inflammatory changes in the tissue• Ensuring the continuation of normal

apexogenesis in immature permanent teeth by retaining the vitality of pulp

RATIONALE

• The severity of the imflammatory process dictates the quality and quantity of reparative dentin produced in dentinal bridge.

• Severe inflammation produces limited reparative dentin devoid of dentinal tubules

• Mild inflammation produces reparative dentin with varying number of dentinal tubules

INDICATIONS

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

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

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

• Carious pulp, exposure in an asymptomatic primary tooth; for eg., a child’s posterior tooth with wide open apices that has a small, asymptomatic carious exposure.

CONTRAINDICATIONS

• Patients with irreversible pulpitis• Abnormal sensitivity to heat and cold• Chronic pulpalgia• Tenderness to percussion or palpation

because of pulpal disease• Periradicular radiographic changes• Marked constriction of pulp chamber or root

canals [calcifications]

PROGNOSIS

• Vitality• Absence of adverse clinical signs or symptoms• No radiographic evidence of internal

resorption or abnormal canal calcification• No breakdown of peri radicular supporting

tissues• No harm to succedaneous tooth

CLASSIFICATIONBased on1. Amount of pulpal tissue involved• Cervical pulpotomy• Partial pulpotomy [Cvek’s pulpotomy]2. Type of medicament employed• Calcium hydroxide pulpotomy• MTA pulpotomy• Formacresol pulpotomy

CLINICAL PROTOCOL FOR PULPOTOMYSTEP 1 : Anaesthesia STEP 2 : Caries removalSTEP 3 : IsolationSTEP 4 : Accessa) For cervical pulpotomy – the

access cavity should be large enough to expose the entire chamber

b) For a partial pulpotomy – only the pulp horns or superficial chamber tissue is exposed with access preparation

STEP 5 : Pulp tissue removal

STEP 6 : Control of bleedingSTEP 7 : Placement of medicamentA] for pulpotomy with calcium hydroxide 

B] for pulpotomy with MTAC] for pulpotomy with formacresol

STEP 8 : Coronal sealSTEP 9 : Recall

TREATMENT OUTCOME

• The hard tissue barrier over the pulp may be observed as early as 6 weeks.

• The apexogenesis or completion of root may take up upto 2-4years

• The therapy is considered successful if following features are observed

1. Clinically the tooth should be asymptomatic without tenderness and mobility

2. The periodontium should remain healthy without pockets or sinus

3. The tooth should respond normally to the pulp vitality tests

4. Radiographically a calcific barrier should be seen5. There should not be external or internal resorption6. The root formation should have been completed

with the apex closed

APEXIFICATION

Definition : Its defined as a method to induce a calcific barrier across an open apex of an immature, pulpless tooth.

Objective : The aim of apexification is to induce either closure of the open apical third of the root canal or the formation of an apical “calcific barrier” against which obturation can be achieved

RATIONALE

The residual pulp tissue, if any, and the odontoblastic layer associated with the pulp tissue resume their matrix formation and subsequent calcification, guided by the reactivated sheath of hertwig.

DIAGNOSIS AND CASE SELECTION

• It is indicated in a permanent tooth with incompletely formed root apex and the following symptoms

1. With signs and symptoms suggestive of advanced irreversible pulpitis

2. With persistent negative finding in pulp testing suggestive of non vital pulp

3. With swelling, tenderness, mobility and sinus, suggestive of pulpo-periapical pathosis

CLINICAL PROCEDUREMULTIPLE STEP APEXIFICATION WITH CALCIUM HYDROXIDESTEP 1 : Access cavity preparation

STEP 2 : Isolation

STEP 3 : Pulp extripation

STEP 4 : Working length estimation

STEP 5 : Instrumentation

STEP 6 : Drying

STEP 7 : Interim dressing

STEP 8 : Calcium hydroxide mixing

STEP 9 : Calcium hydroxide placement

STEP 10 : Temporary coronal sealing

STEP 11 : Recall

SINGLE STEP APEXIFICATION WITH MTA

TREATMENT OUTCOME

Weine has stated that around the 6th month recall the following outcomes may be observed radiographically

1. Radiographically no change is seen but a blockage at the apex is felt on insertion of instrument

2. Calcific material is seen at or near the apex

3. Apex closes without any change in the canal space

4. Apex closes but canal remains flaring

5. A thin barrier short of apex

CONCLUSION• Diseases affecting the hard tissues of the tooth as well

as most operative procedures are traumatic to the pulp• Though the pulp has remarkable recuperative powers

all efforts must be made to minimise insults to it• Hence a gentle approach to cavity preparation and

restoration should be employed• The vital pulp therapy is a viable alternative to the non

vital pulp therapy, whenever the situation permits• An accurate diagnosis of the pulpal status and case

selection plays a major role in the predictable outcome of vital pulp therapy procedures

REFERENCES

1. Grossman’s endodontic practice..12th ed2. Textbook of endodontics…Anil kohli