endo tx for young permanent dentition

pulp cap

tx of an exposed vital pulp by sealing the pulpal wound w a dental material such as calcium hydroxide or MTA to facilitate the formation of reparative dentin and maintenance of vital pulp

direct pulp cap

a dental material placed directly on a mechanical or traumatic vital pulp exposure

indirect pulp cap

a procedure in which a material is placed on a thin portion of remaining carious dentin that, if removed, might expose the pulp in immature permanent teeth

pulpotomy is also refered to as

pulp amputation

pulpotomy

the removal of the coronal portion of a vital pulp as a means of preserving the vitality of the remaining radicular portion

a pulpotomy may be performed as…

emergency procedure for temporary relief of symptoms or therapeutic measure, as in the instance of a Cvek pulpotomy

partial pulpotomy is also referred to as

• shallow pulpotomy

• cvek pulpotomy

partial pulpotomy

the removal of small portion of the vital coronal pulp as a means of preserving the remaining coronal and radicular pulp tissue

__________ and the __________ are the major factors in tx planning

pupal status; degree of root formation

tx for reversible pulpitis

vital pulp therapy

tx for irreversible pulpitis w a closed apex

RCT

tx for irriversible pulpitis w an open apex

vital pulp therapy OR root end closure + obturation

tx for pulp necrosis w a closed apex

rct

tx for pulp necrosis w an open apex

root end closure and obturation OR regeneration

_______________ is preferable to RCT, if possible, especailly in immature permanent teeth

maintaining a healthy pulp

teeth w open apices have ________ (thin/thick) dentin walls

thin → maintain vitality if possible

types of vital pulp therapies

• indirect pulp cap

• direct pulp cap

• pulpotomy or cvek pulpotomy

success of vital pulp therapy depends on…

• status of the pulp before procedure, and proper dx and clinical judgement

• technique success depends on the placement of a restoration that precludes bacterial microleakage

indirect pulps caps are recommended in teeth w…

deep carious lesions close the pulp but no signs or symptoms of pulpal pathosis

is this scenario a candidate for an indirect pulp cap:

a tooth w a hx of spontaneous, lingering, or severe pain, or clinical or radiographic evidence of periapical pathosis

NO

indirect pulp caps are used when pulpal inflammation is ________ and complete removal of caries would like result in __________

minimal; pulp exposure

in an indirect pulp cap, the deepest layer of carious dentin is covered w a material to prevent ________ and _________ to the tooth

pulpal exposure; additional trauma

objective of indirect pulp caps is to maintain pulp vitality by… (4)

• arresting the carious process

• promoting peritubular (sclerotic) dentin, which dec dentin permeability

• stimulating the formation of tertiary dentin, which inc the distance between the affected dentin and the pulp

• remineralizing the carious dentin

direct pulp capping and pulpotomy involve application of a dressing to…

the exposed pulp in an attempt to preserve its vitality

pulpotomy differs from pulp capping in that…

a portion of the remaining pulp is removed before placing the capping material

what happens to odonotblasts during a pulp exposure

at the site of exposure, odontoblasts will be lost → progenitor cells from the pulp must differentiate into odontoblast-like cells to secrete dentin matrix

direct pulp capping and pulpotomy have been used for ________, ________, and _______ exposure of the pulp

carious; mechanical; traumatic

it is universally accepted that ______________ are the tx of choice for young permanent teeth w open apices

direct pulp caps or pulpotomy

goal of tx young permanent teeth w pulp exposures

maintain pulp vitality and continued root formation

once root formation has been completed, _____________ may be performed, if necessary

RCT

is this a good candidate for a direct pulp cap:

absence of a hx of pain and little/no bleeding at exposure site

YES

there is ____________ (agreement/disagreement) concerning direct pulp capping after a carious exposure in mature permanent teeth

disagreement

bc of normal aging of the dental pulp, chances of successful pulp capping ________ w age

diminish

ideal tx for carious pulp exposures on mature permanent teeth

rct

if rct is unfeasible (or based on clinical judgement), what can be done on a pulp exposure in mature permanent teeth

a direct pulp cap can be attempted → if fails → RCT

is this a good candidate for a direct pulp cap:

permanent teeth w a hx of spontaneous pain, radiographic evidence of pulpal or periapical pathosis, calcification of the pulp chamber or root canals, excessive hemorrhage at the exposure site, or exposures w purulent or serous exudate

NO

how is prognosis affected if there is a larger area of carious exposure

poorer the prognosis → more pulpal tissue is inflamed → greater chance for contamination by microorganisms

why must you be careful removing caries over an exposure site

want to minimize pushing dentin chips or microogranisms into pulp → this would lead to inflammatory rxn that can be severe and cause failure

after mechanical exposure of the pulp, ___________ occurs at the exposure site. but if the initial tissue damage is severe…

acute inflammation; pulp may become chronically inflamed, w eventual pulpal necrosis

prognosis of mechanical exposure vs carious exposures

mechanical better → they lack previous inflammation associated w carious exposures

type of direct pulp cap materials

• calcium hydroxide- Ca(OH)₂

• MTA (mineral trioxide aggregrate)

• bioceramics

what happens when Ca(OH)₂ is directly applied to pulp tissue

• necrosis of adjacent pulp tissue and inflammation of the subadjacent tissue occurs

• dentin bridge formation occurs at the junction of the necrotic tissue and the vital inflammed tissue

understanding of mechanisms of Ca(OH)₂

not fully understood

ability of Ca(OH)₂ to form a dentin bridge is a result from…

a low-grade irritation of the underlying pulp tissue → beneath the region of necrosis, cells of the pulp tissue differentiate into odontoblast-like cells and produce dentin matrix

where does calcium from the dentin bridge come from if Ca(OH)₂ was used as the direct pulp cap material

from the blood stream, NOT Ca(OH)₂

overall results of using MTA as a direct pulp cap material

excellent results

MTA vs Ca(OH)₂ as a direct pulp cap material

MTA produced more dentinal bridging in a shorter period of time w less inflammation

mechanism of MTA as a direct pulp capping material

interacts w synthesis fluid to produce an adherent precipitate w the same composition and structure as hydroxyapatite

Ca from MTA reacts w Ph in tissue fluid → producing hydroxyapatite

sealing ability, biocompatibility, and dentinogenic activity of MTA may occur bc of these rxns

what is the dominant ion released from MTA

Ca

commercially available MTA. products

ProRoot MTA (Dentsply Tulsa Dental) in gray and white versions

MTA is a ____________ cement w a ____________

portland; radiopacifier (bismuth oxide)

MTA hydrates in the presence of…

water formed a colloidal gel that solidifies

main components of MTA

• tricalcium silicate

• tricalcium aluminate

• tricalcium oxide

pH of MTA

~12.5

properties of MTA

• low solubility

• low compressive strength

• biocompatible

• seals well

setting of MTA

• long setting time → ~4 hrs

• sets in the presence of tissue fluid or blood

pulpal response to direct pulp capping in healthy human teeth w MTA vs calcium hydroxide cement

MTA resulted in less pulpal inflammation and more predictable hard tissue barrier formation than dycal (calcium hydroxide)

RCT success of direct pulp capping in permanent teeth w MTA vs CaOH

failure at 24 mo:

• 31.5% for CaOH

• 19.7% for MTA

large RCT provides confirmatory evidence for superior performance w MTA as a direct-pulp capping agent compared to CaOH when evaluated in a PBRN for up to 2 yrs

direct pulp capping w MTA

direct pulp capping w MTA after pulp exposure during excavation of deep caries could maintain pulp vitality in permanent teeth when a 2-visit tx protocol is observed

pros of MTA

• evaluated extensively

• biocompatible

• sealing ability

• clinical outcomes for perforation repairs, vital pulp therapy, root-end fillings, and apical plugs

drawbacks of MTA

• long setting time

• tooth discoloration

• high cost

• difficult handling characteristics

new _____________ have been developed to address drawbacks of MTA

bioceramics

difference between pulpotomy and pulp capping

additional tissue is removed form the exposed pulp in a pulpotomy

depth to which tissue is removed in a pulpotomy is determiend by…

clinical judgement → all tissue judged to be inflamed should be removed to place the dressing on healthy, uninflamed pulp tissue

what to do prior to exposing pulp in pulpotomy technique

remove as much carious dentin as possible

traumatic pulp exposures undergoing pulpotomy technique

the pulp has a proliferative response w inflammation extending only a few mm into pulp → when this hyperplastic inflamed tissue removed → healthy pulp tissue is uncovered

carious pulp exposures undergoing pulpotomy technique

it may be necessary to remove pulp tissue to a greater depth, compared to a traumatic pulp exposure, to reach uninflammed tissue

how to remove inflammed pulp tissue in pulpotomy

round carbide bur or diamond bur w high speed and water → creates the least damage to underlying tissue

all tissue coronal to the amputation site must be removed to control hemorrhage

what to do after inflamed pulp has been removed in pulpotomy

tooth is washed w physiologic saline or sterile water to remove debris → dry by vacuum and cotton pellets, NOT air

how to control hemorrhage in pulpotomy technique

• cotton pellets slightly moistened w saline placed against the pulp

• NaOCl on the cotton pellet can also be used

• dry cotton pellets should NOOTTTT be used directly on pulp but will be used over moist pellets w pressure to control

in the pulpotomy technique, hemorrhage should be controlled within __________, and the pellets may need to be changed

several minutes

if hemorrhage continues after several mins, ensure…

• all pulp coronal to the amputation site was removed and the site is clean

• if still not controlled: amputation should be performed at a more apical level

what to do in pulpotomy technique once hemorrhaging is controlled

place MTA against the pulp stump

bc MTA takes several hrs to set, what do you do after you place this for a pulpotomy

a moist cotton pellet is placed over MTA and tooth is temporized → pt will return at a later date for removal of cotton and temp restoration so the definitive restoration can be placed

tx for necrotic teeth w open apices can be a challenge. the 3 most used historically and today are:

• calcium hydroxide apexification- past

• MTA apical barrier- present

• regeneration/revascularization- present/future ?

_________ was historically a widely used material to promote apexification

calcium hydroxide

apexification occurs w many material, and had been reported even w/o canal-filling material after removal of necrotic tissue. the most important factors in achieving apexification are:

• thorough debridement of the canal (to remove all necrotic pulp tissue)

• sealing the tooth coronally (to prevent ingress of bacteria and substrate)

what type of calcified tissue formed a calcium hydroxide apexification

osteoid or cementoid

in calcium hydroxide apexification, deposits are adjacent to…

the filling material- may be short or RG apex

in calcium hydroxide apexification, calcified tissue can be continuous w the ____________

lateral root surfaces → “cap” or “bridge”

characteristic of calcified tissue in calcium hydroxide apexification

porous

calcium hydroxide apexification technique

1. access, establish WL, debridement, irrigation

2. fill canal w CaOH paste and seal coronally

3. recall at 3-6 mo intervals

4. calcified barrier verified RG and clinically

5. if barrier not present, repack w CaOH and continue periodic recall

6. if barrier present, obturate and restore

the total time calcium hydroxide apexification technique takes usually requires…

6-18 mo

calcium hydroxide apexification is _____________ (not/predictable)

is predictable

disadvantages of calcium hydroxide apexification

• pt compliance

• fractures

• long-term CaOH may weaken dentin

alternatives using an artificial apical barrier that allows immediate obturation are…

replacing calcium hydroxide apexification → MTA is the material of choice

MTA apical barrier technique

1. access, establish WL, debridement, irrigation

2. resorbable barrier is pushed through the apex to create an extraradicular matrix against which to pack MTA

3. MTA plug compacted into apical 4-5 mm

4. wet cotton pellet + seal coronally or immediate filling

5. entire canal obturated (GP or composite)

6. restore

regeneration of necrotic pulp has been considered possible only after…

avulsion of an immature permanent tooth

advantages of regeneration

possible further root development and reinforcement of dentin walls → strengthening the root against fx

regeneration technique

• if it is possible to create an environment similar to the avulsed tooth, regeneration should occur

• if canal is disinfected, matrix into which new tissue can grow is provided, and the coronal access is sealed, regeneration should occur

apexification

a method to induce a calcified barrier in a root w an open apex of continued apical development of an incompletely formed root in teeth w necrotic pulps

apexogenesis

a vital pulp therapy procedure performed to encourage continued physiological development and formation of the root end

frequently used to describe vital pulp therapy performed to encourage the continuation of this process