VITAL PULP THERAPY- BY

MAHAK RALLIROLL NO. 42

IV/I

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)

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 OF INDIRECT PULP CAPPING

•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 OF INDIRECT PULP CAPPING•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.

CLINICAL PROCEDURE

•Performed as single or two-step approach.

•TREATMENT OUTCOME DEPENDS ON :

1. Remaining dentin thickness2. Choice of indirect pulp capping agent

FIRST APPOINTMENT•Use of local anesthesia and isolate with rubber

dam.•A slow speed hand-piece with 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 APPPOINTMENT• A bitewing radiograph of treated tooth is

obtained.• Use local anesthesia and isolate with rubber dam.• The previous remaining soft, deep brownish red

colour affected dentin will have changed lighter brownish grey colour 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.

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 peri-radicular lesion.

CONTRAINDICATIONS•In cases of carious exposures of primary tooth.

•Large carious exposures in symptomatic permanent tooth

FACTORS AFFECTING PROGNOSIS OF DIRECT PULP CAPPING

PPROPERTIES OF PULP CAPPING AGENTS

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 : Pulpdent paste and Dycal

MECHANISM OF ACTION

HEALING WITH CALCIUM HYDROXIDE

•Zone of obliteration•Zone of coagulation necrosis•Zone of dentin bridge formation•Line of demarcation

ZONE OF OBLITERATION•Pulp tissue immediately in contact to calcium hydroxide is usually completely deranged and distorted because of the caustic effect of the drug.

•This zone consists of debris, dentinal fragments, hemorrhage, blood clot, blood pigment and particles of calcium hydroxide.

•This zone is a result of high conc of hydroxyl ions and high pressure od medicament application.

ZONE OF COAGULATION NECROSIS

•A weaker chemical effect reaches the subjacent, more apical tissues and results in a zone of coagulation necrosis and thrombosis

•Also called Schroeder’s layer of “firm necrosis” and Stanley’s “mummified zone”

ZONE OF DENTINE BRIDGE FORMATION

•Area of mineralization initiated by calcium hydroxide

•No structural configuration is seen in the mineralised dentine initiated by calcium hydroxide

•Zone ranges from 0.3-0.7mm in thickness

LINE OF DEMARCATION•A line of demarcation between the deepest level and subjacent vital pulp tissue

•It is believed to be resulted from the reaction of calcium hydroxide with tissue protein to form proteinate globules

MINERAL TRIOXIDE AGGREGATE

•COMPOSTION1. Tricalcium silicate2. Dicalcium silicate3. Tricalcium aluminate4. Tetracalcium alumino ferrite5. Bismuth oxide6. Traces of free crystalline silica7. Other trace constituents include calcium

oxide, free magnesium oxide, potassium and sodium sulphate compounds

SETTING REACTION OF MTA

ADVANTAGES OF MTA•Produces more dentinal bridging with

superior structural integrity than calcium hydroxide in a shorter span

•Better resistance to bacterial penetration•Highly biocompatible•Set MTA is alkaline and may induce

dentinogenesis•Hydrophilic•Significant antimicrobial activity•Presence of blood has little impact on the

degree of leakage of MTA

TECHNIQUES OF DIRECT PULPCAPPING

BIODENTINE•A calcium silicate-based material used for

repair of perforations and resorption, apexification and root-end fillings

•Can also be used in class II fillings as temp restoration

•COMPOSITIONPowder Liquid -Tricalcium silicate -calcium chloride in -Dicalcium silicate aqueous solution with -Calcium carbonate an admixture of -Zirconium dioxide polycarboxylate

SETTING REACTION•Powder is dispensed in a capsule that is

mixed with liquid in a triturator for 30 seconds

•Hydration of tricalcium silicate produces a hydrated calcium silicate gel and calcium hydroxide

•Unreacted tricalcium silicate grains are surrounded by layers of calcium silicate hydrated gel, which are relatively impermeable to water, thereby slowing the effects of further reaction

•Setting time is 10 mins

ADVANTAGES•Pulp capping and to bulk fill the cavity

•Does not stain the tooth•Excellent radiopacity•No need for d=surface preparation or tedious bonding due to micr0-mechanical anchorage

•Higher compressive strength than dentine, promotes pulp healing and preserves the pulp

•Microleakage resistance is enhanced

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.

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

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

•An accurate diagnosis of the pulpal status and case selection plays a major role in the predictable outcome of vital pulp therapy procedures