Vital Pulp Therapies - Indirect and Direct Pulp Cap

What is minimally invasive dentistry?

emphasises prev & least possible intervention

What is the preferred methods to manage deep carious lesions?

- selective caries removal: 1 stage

- stepwise caries removal: 2 stage

What is the 'restorative cycle'?

Once a rest has failed it enters this cycle

1) Initial Lesion

2) Restoration Placement

3) Structural Degradation

4) Restoration Failure...

How far is deep dentine from the occlusal surface approximately?

4-5mm

What is the proximity of the pulp from the occlusal surface and the DEJ approximately?

- 5mm from occl surface

- >3mm from DEJ

Where are most pulpal exposures from?

lateral pulp horn not the floor of the cavity

What materials are available for pulp capping?

- CSCs: biodentine, MTA > provide a better pulpal response compared to CaOH2

- CaOH2 > generally more avail

What does calcium hydroxide require sealing with, before a definitive restoration is placed?

GIC/RMGIC

When can a definitive restoration be placed, after CSC was placed as a lining?

r/v at 3 months & cut back to place definitive restoration

What equipment is required for VPT?

• Rubber dam, clamps, wedjets & frame (essential as VPTs should be carried out w/ aseptic conditions)

• Tweezers

• Cons kit

• Calcium hydroxide applicator or BPE probe

• Mixing spatulas

• Sodium hypochlorite (0.5 -5%)

• Cw wool pellets

• Biodentine

• Dycal (setting calcium hydroxide)

• GI & applicator

When is DPC indicated?

- Dentine is lost due to caries, trauma or a prev iatrogenic intervention & a cavity exists

- However, in this case the soft tissue of the pulp is exposed & in most cases is bleeding

- If symptoms exist they should be relatively mild & not considered to be indicative of IP

OSS: Tooth preparation for DPC

• Isolate w/ a rubber dam & prepare LR6d cavity as indicated (small <1mm pulpal exposure)

• Carefully approach the floor & axial wall where a pulpal exposure might be anticipated

• Pin prick exposure only, consider pulpal position, 5 mm from the occlusal surface or >3 mm from DEJ: 'pulpal blush', stop

How should the cavity be disinfected?

- cavity should be disinfected using cotton pellets soaked (removing gross excess) w/ sodium hypochlorite (0.5-5%) (water on OSS to replicate) for 30-60s

> dry well

• If bleeding is not controlled within 5m - a partial pulpotomy is indicated

-Seek advice from dentist

How should be biodentine be mixed?

• Open Capsule

• 5 drops of liquid (contains Ca chloride & hydrosoluble polymer)

• Use exact amount as can be temperamental in terms of consistency

• Reseal & triturate for 30s

> 9-12m to reach initial set

> approx 48hrs for full set

How should biodentine be cut back to place a final restoration after 3 months review?

- cut back BD to leave clear EDJ

- BD left in situ as dentine replacement

- restore w/ comp

What is the indications for an IPC?

dentine is lost due to caries, trauma or a prev iatrogenic intervention & a cavity exists which is close to the pulp but dentine still remains over the pulp tissue

How should calcium hydroxide be mixed?

- base & catalyst to mix

- stimulates formation of secondary dentine

- setting time 2-3m

How should dycal be placed for an IPC? What should then be placed?

- place small amount of dycal (setting CaOH2) via BPE probe on deepest part of the cavity

- place layer GIC over Ca(OH)2 to seal

- keep enamel margins clear

What are the recalls for review following pulp capping?

- r/v at 6m, hx & clinical examination

- 1y r/v w/ radiograph

- pt should be warned of possibility of further tx should symptoms occur

How to use dycal as a DPC:

1. Rinse cavity w/ (NaOCl)

2. Heavy bleeding may be controlled w/ a cotton pellet moistened w/ sterile saline; gently dry

3. Dispense equal volumes of base & catalyst pastes

4. Using a Ca(OH)2 applicator, stir imm to mix thoroughly until a uniform colour is achieved; do not over-spatulate; complete mixing within 10s. Using BPE, place directly on the exposed pulp & dentine at 0.8-1.0mm thickness; avoid placing on enamel/margins of the cavity

6. Allow to completely set ~ 2-3m

7. Remove any set excess from retention areas, enamel, &/or margins w/ a sharp spoon excavator or a bur

How to use Dycal as an IPC:

1. Wash cavity thoroughly w/ water spray & air dry

2. Dispense & mix Dycal Liner components

3. Apply mixed material to desired dentine surfaces; if subsequent use of a dentine bonding agent is desired, place Dycal® Liner only on the deepest (<1mm remaining) dentine, leaving the rest of the cavity surface free for bonding

4. Remove any set excess from retention areas, enamel, &/or margins w/ a sharp spoon excavator or a bur

What is a Class I pulp exposure?

- No preoperative presence of a deep carious lesion

- Pulp exposure judged clinically to be through sound dentine w/ an expectation that the underlying pulp tissue is healthy

- Exposure due to a traumatic injury or iatrogenic exposure

What is a Class II pulp exposure?

- Preop presence of a deep or extremely deep carious lesion

- Pulp exposure judged clinically to be through a zone of bacterial contamination w/ an expectation that the underlying pulp tissue is inflamed

- Enhanced operative protocol rec

The pulp is under threat from which three main sources?

- Trauma

- Iatrogenic damage

- Caries