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Vital Pulp Therapy

Vital pulp therapy plays important role in preserving tooth and tooth vitality in both primary and permanent teeth.
Direct pulp capping, indirect pulp capping, pulpotomy has been covered in this presentation. All materials possibly useful in vital pulp therapy as well as recent advances have been included with all the evidences.

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Vital Pulp Therapy

  1. 1. Presented By: Dr Susmita Shah II MDS Vital Pulp Therapy in Primary & Permanent Teeth 1
  2. 2. Contents Introduction Indirect pulp capping Direct pulp capping Pulpotomy Conclusion Bibliography 2
  3. 3. INTRODUCTION • Exposure of the dental pulp exists when the continuity of the dentin surrounding the pulp is broken by physical or bacterial means leading to direct communication between the pulp and external environment. • The primary objective of pulp therapy is to maintain the integrity and health of the teeth and their supporting tissues. • It is a treatment objective to maintain the vitality of the pulp of a tooth affected by caries, traumatic injury, or other causes. •John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 3
  4. 4. OBJECTIVES • Conservation of tooth in a healthy state of functioning • Preservation of arch space • Enhance aesthetics • Mastication • Prevents possible speech problems • Prevention of deleterious effect on the succedaneous tooth and the periapical tissue. • Prevents aberrant tongue habits • Preserves pulpally involved primary tooth in the absence of a succedeneous tooth • Guidance to the developing permanent dentition • Helps in normal growth and development of jaws Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014. 4
  5. 5. • The clinical diagnosis is derived from: 1. a comprehensive medical history. 2. a review of past and present dental history and treatment 3. a subjective evaluation of the area associated with the current symptoms/chief complaint by questioning the child and parent on the location, intensity, duration, stimulus, relief, and spontaneity. 4. a objective extraoral examination as well as examination of the intraoral soft and hard tissues. 5. if obtainable, radiograph(s) to diagnose pulpitis or necrosis showing the involved tooth, furcation, peri- apical area, and the surrounding bone. 6. clinical tests such as palpation, percussion, and mobility Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014. 5
  6. 6. Dental Caries or physical/ thermal/ chemical injury Pulpal Irritation Inflammation Reversible Repair Necrosis Irreversible Vital pulp therapy 6
  7. 7. VITAL PULP THERAPY PRIMARY TEETH PERMANENT TEETH INDIRECT PULP CAPPING DIRECT PULP CAPPING PULPOTOMY INDIRECT PULP CAPPING DIRECT PULP CAPPING PULPOTOMY APEXOGENESIS 7
  8. 8. • INDIRECT PULP CAPPING • Definition: It is defined as a procedure wherein small amount of carious dentin is retained in deep areas of cavity to avoid exposure of pulp, followed by placement of a suitable medicaments and a restorative material that seals off the carious dentin and encourages pulp recovery(Ingle) • A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a time with a biocompatible material(McDonald). •John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 8
  9. 9. OBJECTIVES • Given by eidelman in 1965: 1) arresting the carious process 2) promoting dentin sclerosis 3) stimulating formation of tertiary dentin 4) remineralization of carious dentin •John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 9
  10. 10. •John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 10
  11. 11. History Clinical Examination Radiographic Examination Indication Mild pain associated with eating Negative history of spontaneous, extreme pain -Deep carious lesion that are closed to pulp, but not involving the pulp in vital primary or young permanent teeth -No mobility -Where pulp inflammation is seen as nominal and there is definite layer of affected dentin after removal of infected dentin -Normal lamina Dura and PDL space -No radiolucency in the bone around the apices of the roots in the furcation Contraindication -Sharp penetrating pulpalgia indicating acute pulpal inflammation. -Prolonged spontaneous pain particularly at night. -Mobility of tooth -Discoloration of tooth -Negative reaction of electric pulp testing -Definite pulp exposure -Interrupted or break in lamina dura -Radiolucency about the apices of the roots -Widened PDL space 11
  12. 12. TREATMENT PROCEDURE • The earlier approach was 2 appointment procedure but now single session is preferred as;  The re-entry to remove the residual minimal carious dentin may not be necessary if the final restoration maintains a seal and tooth is asymptomatic  After cavity preparation, if all the carious dentin was removed except the portion that would expose the pulp, re entry might be unnecessary.  If a pulp exposure occurs during a re-entry a more invasive vital pulp therapy technique would be indicated. •John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 12
  13. 13.  1st appointment 1) use LA and rubber dam isolation 2) establish cavity outline 3) remove all caries using caries detector dye, infected dentin has to be removed 4) stop excavation as soon as firm resistance sound dentin is felt 5) if there is probability of exposure while removing further caries, then a conservative approach is chosen by placing a hard set calcium hydroxide and temporizing the tooth 6) cavity flushed with saline and direct with cotton pellet 7) site is covered with Ca(OH)2 8) remaining cavity is filled with ZOE cement •John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 13
  14. 14.  2nd appointment (6-8 weeks later) 1) between the appointment history must be negative 2) If a reparative dentin bridge is formed, a permanent restoration followed by a full coverage restoration is chosen 3) If some amount of caries present on re-entry, carefully removal of caries, without pulp exposure. 4) Previous remaining carious dentin will have become dried out, flaky and easily removed 5) The cavity preparation is washed out and dried gently 6) Cover entire floor with Ca(OH)2 7) Base is built up with reinforced ZOE cement or GIC 8) Final restoration is then placed •John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 14
  15. 15. Parisay I, Ghoddusi J, Forghani M. A Review on Vital Pulp Therapy in Primary Teeth. Iranian Endodontic Journal 2015;10(1):6-15 15
  16. 16. Akhlaghi N, Khademi A. Outcomes of vital pulp therapy in permanent teeth with different medicaments based on review of the literature. Dental Research Journal / September 2015 / Vol 12 / Issue 5 16
  17. 17. 17 Title Author Journal L O E Aim Materials and methodology Results Conclusion Material s used for indirect pulp treatme nt in primary teeth: a mixed treatme nt compari sons meta- analysis Pablo Silveir a dos. Djessi ca, Minate l M, Oliveir a R, Lariss a T. Braz. Oral Res. 2017; 31:e1 01 1 a to systematical ly review the literature to address the question regarding the influence of different materials in the clinical and radiographic success of indirect pulp treatment in primary teeth. A comprehensive literature search was undertaken using PubMed/MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and TRIP databases to identify studies that were related to the research question and that were published prior to January 2017. The material type did not significantly affect the risk of failure of the indirect pulp treatment. However, calcium hydroxide presented a higher probability of failure. In conclusion, there is no scientific evidence showing the superiority of any material used for indirect pulp treatment in primary teeth
  18. 18. John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 18 The rate of reparative dentin deposition has been shown to average 1.4um/day after cavity preparation in dentin of human teeth. The rate of reparative dentin formation decreases markedly after 48days. Dentin is laid down fastest during the first month after IPC and the rate diminishes steadily with time. First 30 days- 1/5th Tubular dentin is formed First 2 months- Cellular fibrillar dentin is formed Third month- Globular dentin is formed More than3 months- 0.1mm Tubular dentin is formed
  19. 19. 19 Title Author Journa l L O E Aim Materials and methodology Results Conclusion In vivo Outco mes of Indirect Pulp Treatm ent in Primar y Posteri or Teeth: 6 Months ’ Follow- up Chau han A, Dua P, Saini S, Mangl a R, Butail A, Ahluw alia S. Conte mpora ry Clinic al Dentis try 2018 3 b to evaluate & compare the clinical &radiographic outcomes of IPT when a layer of calcium hydroxide (Dycal), mineral trioxide aggregate (MTA), or Biodentine was placed over the affected dentin in primary molars A clinical trial with sample size of 45 primary molars between the age group of 4–9 years, of which 15 teeth were considered, each for Group I (Dycal), Group II (MTA), and Group III (Biodentine). Measurements on digitized radiographs were made at baseline, 3, and 6 months using Corel Draw software a statistically significant difference in dentin thickness (P < 0.05) in all the groups. Within Group I, the thickness of dentin was 0.066 ± 0.009 mm at 3 months and 0.099 ± 0.011 mm at 6 months. In Group II, 0.081 ± 0.010 mm at 3 months and 0.123 ± 0.016 mm at 6 months. In Group III, 0.102 ± 0.021 mm at 3 months and 0.154 ± 0.022 mm at 6 months. Clinically, 100% success rate was observed in all the groups whereas radiographicall y, Biodentine was superior to both the groups.
  20. 20. 20 1. Biodentine 2. Stem cells 3. Propolis 4. Theracal LC 5. Caster oil Bean Cement 6. Emdogain 7. Novel Endodontic Cement 8. Lasers 9. Endo Sequence root repair material
  21. 21. 21
  22. 22. • DIRECT PULP CAPPING 22 The first method of capping exposed pulps, using gold foils, was described by Pfaff in 1756. Thereafter, numerous agents for direct pulp capping have been recommended. Until the end of the 19th century, most materials were used empirically with the idea that the pulp tissue must be irritated by etching or cauterization to heal. Hunter(1883) suggested 1st pulp capping materials. He recommended covering an exposure with a mixture of Sorghum molasses and the droppings of the English sparrow and claimed 98% success rate The first scientific clinical study to compare different capping materials was made by Dätwyler in 1921, whereupon zinc oxide-eugenol showed the best results. One year later, Rebel performed the first animal experiments with disastrous results, so he regarded the he regarded the exposed pulp as a doomed organ.
  23. 23. 23 In 1920 Hermann, introduced calcium hydroxide for root canal fillings. Between 1928 and 1930 he studied the reaction of vital pulp tissue to calcium hydroxide to prove that it was a biocompatible material. Since then, calcium hydroxide has been recommended by several authors for direct pulp capping, but it took until the middle of 20th century until it was regarded as the standard of care. Placement of a medicated or a nonmedicated material on a pulp that has been exposed in the course of preparing a cavity in a carious tooth or as the result of trauma.[Kopel, 1997]
  24. 24. OBJECTIVE a) preservation of vitality of the pulp b) Pulp healing and reparative dentin formation Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014. 24 RATIONALE • To achieve a biologic closure site by deposition of hard tissue barrier between pulp tissue and capping material thus walling off the exposure site
  25. 25. INDICATION • Small mechanical exposure surrounded by sound dentin is asymptomatic vital primary teeth or young permanent teeth(1sq mm) • Exposure should have bright red haemorrhage that is easily controlled by dry cotton pellet with minimal pressure • True pin point exposure • Traumatic exposure reported to dental office- within 24 hours. Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014. 25 CONTRAINDICATIONS • Large pulp exposure • Severe toothache at night • Spontaneous pain • Tooth mobility • Radiographic appearance of pulp, periradicular degeneration • Excess of haemorrhage at the time of exposure • Serous exudate from the exposure • External/internal root resorption • Swelling/fistula • Tooth mobility
  26. 26. TECHNIQUE • Rubber dam isolation • Once an exposure is encountered, further manipulation of pulp is avoided • irrigation with saline • Hemorrhage is arrested with light pressure from sterile cotton pellets • Place the pulp capping material, on the exposed pulp with application of minimal pressure so as to avoid forcing the material into pulp chamber • Place temporary restoration • Final restoration is done after determining the success of pulp capping which is done by determination of dentinal bridge. • Maintenance of pulp vitality, lack of pain, and minimal inflammatory response. John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 26
  27. 27. 27Akhlaghi N, Khademi A. Outcomes of vital pulp therapy in permanent teeth with different medicaments based on review of the literature. Dental Research Journal / September 2015 / Vol 12 / Issue 5
  28. 28. Outcome of Direct Pulp Capping • Acc. To Kennedy & Kopel (1985): • Dentin bridge formation • Maintenance of pulp vitality • Lack of undue sensitivity or pain • Minimum pulpal inflammation response • Ability of pulp to maintain itself without progressive degeneration • Lack of internal resorption and/ or interradicular pathosis John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 28
  29. 29. Ideal requirements of pulp capping agents 1. Bactericidal 2. Biocompatible 3. Harmless to the pulp, surrounding structures and the permanent tooth germ. 4. Promote healing 5. Not interfere with physiologic process of resorption. John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 29
  30. 30. Liang CHEN and Byoung In SUH. Cytotoxicity and biocompatibility of resin-free and resin-modified direct pulp capping materials: A state-of-the-art review. Dental Materials Journal 2017; 36(1): 1–7. 30
  31. 31. 1. CALCIUM HYDROXIDE • Colorless crystal or white powder • Prepared by reacting calcium oxide with water. • Hermann (1920-1930): use of calcium hydroxide in endodontics • Most favored as a pulpotomy agent in the 1940s and mid- 1950s. • Teuscher and Zander(1938): Ability to form reparative dentin this • Lim and Kirk(1987): review of direct pulp capping literature, found little support for pulp obliteration and internal resorption being a major complication of pulp capping • Estrela et al(1995). summarized the antibacterial properties of calcium hydroxide. 31
  32. 32. • Base paste – • Glycol salicylate-40%-reacts with • Calcium hydroxide and ZnO • Titanium dioxide-Inert fillers • Calcium tungstate - Fillers • Barium sulphate-provide radio-opacity • Catalyst paste • Calcium hydroxide-50%-principal reactive ingredient • Zinc oxide-10% • Zinc stearate-0.55%-accelerator • Sulphonamide-39.5%-oily • compound acts as carrier. John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 32
  33. 33. • Advantages • Reparative dentin formation • Antibacterial action • Pulp protection • The tissue-dissolving property • Newer preparation shows Improved strength, essentially no solubility in acid, and minimal solubility in water and control the over working time • Disadvantages • Pulp obliteration • Internal resorption • Lack of adhesion to hard tissues • Microleakage • Short working time of self cured preparation John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 33 • Disadvantages • Pulp obliteration • Internal resorption • Lack of adhesion to hard tissues • Microleakage • Short working time of self cured preparation
  34. 34. HISTOLOGICAL CHANGES • After 24 hrs: necrotic zone adjacent to calcium hydroxide paste is separated from healthy pulp tissue by a deep staining basophilic layer • After 7 days: increase in cellular or fibroblastic activity • After 14 days: partly calcified fibrous tissue lined by odontoblastic cells is seen below the calcium protienate zone; disappearance of necrotic zone • After 28 days: zone of new dentin •John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 34
  35. 35. 2. Mineral Trioxide Aggregate (MTA) • Pioneered by Dr. Mahmoud Torabinejad, Loma Linda University, in 1993. • COMPOSITION • MTA is a mechanical mixture of 3 powder ingredients: • Portland cement (75%) • Bismuth oxide (20%) • Gypsum (5%) • Composition includes : • Tricalcium silicate • Dicalcium silicate • Tricalcium aluminate • Tetracalcium aluminoferrite • Calcium sulfate • Bismuth oxide (provides radio-opacity) TJ Hilton. Keys to Clinical Success with Pulp Capping: A Review of the Literature Oper Dent. 2009 ; 34(5): 615–625. 35
  36. 36. TJ Hilton. Keys to Clinical Success with Pulp Capping: A Review of the Literature Oper Dent. 2009 ; 34(5): 615–625. 36 • Advantages • Antimicrobial Activity • Prevents Micro-Leakage over vital pulp • Non toxic and Non-mutagenic • Cell adherence & growth • Alkaline phosphotase/ osteocalcin • Interleukin production • Periodontal ligament attachment to cementum growth • Dentinal bridge formation • Disadvantages • More difficult to manipulate • Longer setting time • Properties • Powder: Water = 3: 1 • SETTING TIME: 3-4 hours • pH=12.5
  37. 37. 37 Title Auth or Jour nal L O E Aim Materials and methodology Results Conclusion Direct Pulp Cappin g with Calciu m Hydrox ide or Minera l Trioxid e Aggreg ate: A Meta- analysi s Li Z, Cao L, Fan M, Xu Q. Jou rnal of End odo ntic s. 201 5 1 a to compare the effectivene ss of mineral trioxide aggregate (MTA) and calcium hydroxide (CH) as pulp capping materials in humans by means of a meta- analysis. The PubMed, Cochrane Library, Embase, and Web of Knowledge databases were used in the literature search from their establishment date until December 7, 2014. Studies that met the inclusion criteria were accepted, and necessary information was extracted by 2 authors independently using a standardized form. The success rate, inflammatory response, and dentin bridge formation were evaluated. Thirteen studies met the inclusion criteria. The MTA treatment groups showed a significantly higher success rate compared with CH- capped groups. MTA was superior to CH in terms of the absence of an inflammatory response as well as dentin bridge formation, MTA has a higher success rate and results in less pulpal inflammato ry response and more predictable hard dentin bridge formation than CH.
  38. 38. 3. Zinc Oxide eugenol • Germicidal agent • Used in indirect pulp capping due to its – Palliative effect – Excellent initial seal – Kills bacteria present in carious lesions – arrests the caries process • This gives the pulp the chance for healing & regeneration • Direct contact →chronic inflammatiom,abscess formation and liquefaction necrosis. • After 24Hr of capping →a mass of red blood cells &PNLs. demarcated from the underlying tissue by zone of fibrin and inflammatory cells. • After 2W of capping → pulp degeneration &chronic inflammation • extends deep to the apex. John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. 38
  39. 39. 4. Lasers • Used in Direct pulp capping & pulpotomy. • Co2 Laser , Argon Laser, Diode Laser, Erbium:Yttrium-Aluminum Garnet (Er.YAG). • Laser radiation has been proposed for pulp treatment based on its haemostatic, coagulative and sterilizing effects. • Laser irradiation creates a superficial zone of coagulation necrosis that remains compatible with the underlying tissue and isolate pulp from effects of the subbase. • Mortiz et al., reported that the thermal effects of laser radiation caused sterilization and scar formation in the irradiated area, which in turn preserves the pulp from bacterial invasion. TJ Hilton. Keys to Clinical Success with Pulp Capping: A Review of the Literature Oper Dent. 2009 ; 34(5): 615–625. 39
  40. 40. 40 Title Author Journa l L O E Aim Materials and methodology Results Conclusion Laser use in direct pulp cappin g: A meta- analys is Deng Y, Zh u X, Zh eng D, Ya n P, Jia ng H. J Am Dent Asso c. 20 16 Dec 3 b to evaluate the effects of lasers on the outcome of direct pulp capping by means of a meta- analysis a literature search on PubMed, Cochrane Library, Embase, and China National Knowledge Infrastructure, as well as a manual search of the reference lists of all identified articles since the introduction of lasers in endodontics in 1971 through May 30, 2016. The authors systematically evaluated the studies that met the inclusion criteria and performed a meta-analysis. results showed that the success rate (89.9%) of the laser groups was higher than that of 67.2% of the control groups, and the difference was statistically significant (risk ratio, 1.35; 95% confidence interval, 1.23- 1.49; P < .00001). On the basis of the limited evidence, the use of lasers effectively improved the prognosis of direct pulp capping treatment for permanent teeth.
  41. 41. 5. Biodentine • Biodentine (Septodont, Lancaster, PA, USA), launched in 2009 • Composition: – tricalcium silicate – Calcium Carbonate – Calcium Oxide – zirconium oxide (radiopacifier) • mixed with calcium chloride solution containing modified polycarboxylate instead of water • setting times (from 10 to 12 min). 41
  42. 42. 42 Title Author Journa l L O E Aim Materials and methodology Results Conclusion Clinical evaluat ion of minera l trioxide aggreg ate and bioden tine as direct pulp cappin g agents in carious teeth Hegd e S, Math ew S, Bhan di S, Naga raja S, K. Dine sh. 2017 Journ al of Cons ervati ve Denti stry 3 b The aim of the present study was to evaluate the clinical response of pulp-denti n complex after DPC with MTA and biodentine in carious teeth. Twenty-four permanent molars with carious exposure having no signs and symptoms of irreversible pulpitis were selected and assigned to one of the two groups, Group I - MTA and Group II - biodentine. Patients were recalled at 3 weeks, 3 months, and 6 months for clinical and radiographic evaluation. Fisher’s exact test was used along with Chi-square test for statistical analysis. Over a period of 6 months, MTA and biodentine showed 91.7% and 83.3% success rate, respectively, based on the subjective symptoms, pulp sensibility tests, and radiographic appearance. MTA and biodentine may be used as DPC agents when the pulpal diagnosis is not more than reversible pulpitis.
  43. 43. 43 Pulp Capping agents Advantages Disadvantages Calcium Hydroxide Antibacterial properties Promotes remineralization Low Cytotoxicity Highly soluble in oral fluids Tunnel defect Lack of adhesion Zinc Oxide Eugenol Reduces inflammation Lack of calcific bridge formation High cytotoxicity Interfacial leakage Polycarboxylate Cements Chemically bond to tooth surface Lack of antibacterial activity Fail to stimulate calcific barrier Inert Materials(Isobutyl Cyanoacrylates & Tricalcium Phosphate Ceramic Stimulates dentin bridge formation Reduces pulpal inflammation Not recommended by dentists Collagen Less irritating than calcium hydroxide Promotes remineralization Do not help in thick dentin formation
  44. 44. 44 Pulp Capping agents Advantages Disadvantages Bonding agents Superior adhesion to hard tissues Effective seal against micro leakage Cytotoxic effect Absence of calcific bridge formation Calcium phosphate Helps in bridge formation Significant absence of pulp inflammation Good physical properties Clinical trials are necessary Hydroxyapatite Biocompatible Acts as scaffold for newly formed dentin Mild pulpal inflammation Carbon dioxide laser Formation of secondary dentin Bactericidal effect Technique sensitive Thermal damage Glassionomer /Resin Modified glassionomer cement Excellent seal Fluoride release Biocompatible Chronic inflammation Lack dentin bridge formation High Cytotoxic activity Mineral trioxide aggregate Biocompatible Less pulpal inflammation Hard tissue barrier formation Radiopacity Expensive Poor handling characteristics High solubility
  45. 45. 45 Pulp Capping agents Advantages Disadvantages MTA 1- Calcium Dentin bridge formation without necrosis High shear bond strength Residual monomer causes cytotoxicity Growth factors Formation of osteodentin & tubular dentin Homogenous reparative dentin Superior to calcium hydroxide High concentration required Less half life Appropriate dose required to prevent uncontrolled obliteration of pulp Odontogenic ameloblast associated proteins Biocompatible Accelerates reactionary dentin formation Normal pulp tissue appearance Invivo studies not conducted Endo sequence root repair material Antibacterial property Less cytotoxic than MTA, dycal Bioactivity of cells were decreased Caster oil bean cement Good antibacterial property Less cytotoxic Good mechanical properties Facilitates tissue healing Cost effective Better sealing ability Bioinert rather than bioactive Clinical trials required Thera cal Act as protectant Strong physical properties High calcium releasing activity Whitish in colour- need thin layer to prevent discoloration of composite
  46. 46. LIMITATION OF DIRECT PULP CAPPING IN PRIMARY TEETH • Localization of infection & inflammation in primary teeth is poorer than in permanent teeth. [McDonalds,1956] • Incidence of reparative dentin formation in primary teeth is more extensive than permanent Teeth. [Sayegh, 1968] • Primary pulp contain high cellular content which might be responsible for failures. Primary pulp responds more rapidly to the effects of dentinal caries then the perm. Teeth. [Rayner & Southam, 1979] • Undifferentiated mesenchymal cells may differentiate into osteoclasts in response to caries or pulp capping material which could lead to internal resorption. [Kennedy,1985] Casamassimo,fields,Pediatric dentistry,infancy through adolescence,5th edition 2013 46
  47. 47. • PULPOTOMY • Definition: Complete removal of coronal portion of the dental pulp, followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of tooth (Finn 1995). Amputation of affected, infected coronal portion of the dental pulp preserving the vitality and function of the remaining part of the radicular pulp (AAPD 1998). 47
  48. 48. INTRODUCTION • Primary tooth pulp therapy is aimed at preserving the primary teeth until normal exfoliation. • Management of the cariously involved primary tooth where the carious lesion approximates the pulp • successful outcome depends on accurate diagnosis of the status of the pulp prior to therapy. • Preliminary we should focus on determining whether the primary tooth pulp is normal, reversibly inflamed, irreversibly inflamed or necrotic. 48Casamassimo,fields,Pediatric dentistry,infancy through adolescence,5th edition 2013
  49. 49. • If it is determined to be vital or reversibly inflamed, the vital pulp therapy techniques of pulpotomy or indirect pulp treatment (IPT) are indicated. • If the pulp is determined to be irreversibly inflamed or necrotic, either a pulpectomy or extraction would be appropriate. 49Casamassimo,fields,Pediatric dentistry,infancy through adolescence,5th edition 2013
  50. 50. Objectives  The radicular pulp should remain asymptomatic without adverse clinical signs or symptoms such as sensitivity, pain, or swelling.  There should be no postoperative radiographic evidence of pathologic root resorption.  The clinician should monitor the internal resorption, removing the affected tooth if perforation causes loss of supportive bone and/or clinical signs of infection and inflammation.  There should be no harm to the succedaneous tooth. 50 Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014.
  51. 51. INDICATION 51 History • Pain, if present not spontaneous or persists after removal of the stimulus McDonald, Avery, Dean, Dentistry for the Child and Adolescent, 8th edition,2007 Clinical Examination • Cariously exposed primary teeth, when their retention is more advantageous than extraction. • Tooth which is restorable • Vital tooth with healthy periodontium • Hemorrhage from the amputation site is pale red & easy to control • Absence of abscess and fistula • On young permanent tooth with vital exposed pulp and incompletely formed apices
  52. 52. Radiographically • Nointer-radicular boneloss • Nointer-radicular radiolucency • Tooth with-2/3rd root length 52McDonald, Avery, Dean, Dentistry for the Child and Adolescent, 8th edition,2007
  53. 53. CONTRAINDICATION 53 History • Persistent tooth ache. Clinically • Tenderness on percussion / mobility present. • Large carious lesion with non-restorable crown. • Highly viscous, sluggish hemorrhage from canal orifice which is uncontrollable. • Tooth close to natural exfoliation. Radiographically • Root resorption more than 1/3rd of root length • Evidence of internal resorption • Presence of inter radicular bone loss McDonald, Avery, Dean, Dentistry for the Child and Adolescent, 8th edition,2007
  54. 54. 54 Pulpotomy Vital Devitalization Single sitting Fromocresol Laser Electrosurgery Two stage Glysi triopaste, Paraform, Easlick’s formaldeyde Preservation Glutraldehyde Ferric Sulphate Regeneration BMP, MTA, Enriched collagen, Freezed dried bone, Osteogenic protein Non-vital Beechwood cresol Formocresol
  55. 55. A. DevitalizationPulpotomy 57 The first approach to pulpotomy treatment of primary teeth was devitalisation. Pulpotomy using formocresol was introduced by Buckley in 1904. Since then various modifications have been tried and advocated regarding the techniques of FC pulpotomy and the concentrations. John I. INGLE,DDS,MSD Ingle’s Endodontics 6th edition 1. FormocresolPulpotomy
  56. 56. 58 History 1904 Formocresol was introduced to treat non-vital permanent teeth by Buckley 1930 Sweet introduced the formocresol pulpotomy technique for primary teeth. Which involved five visits. 1955 Sweet reduced the number of visits over the years. 1962 Doyle et al used a two-visit procedure for 5 min pulpotomy 1960 A single visit procedure was advocated
  57. 57. • Buckley’sformulaofformocresol • formaldehyde19%, • Cresol35%, • glycerin15%, • WaterwithanapproximatepHof5.1. 59 John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition
  58. 58. Formocresol concentration •It was concluded that 20% dilution causes the least histologic damage and that a 1 minute application of formocresol is adequate to produce the desired results. •Garcia – Godoy (1984) advocated the use of 20% dilution of formocresol for partial pulpotomies. •showed a success rate 96%. 60 John I. INGLE,DDS,MSD Ingle’s Endodontics th Edition
  59. 59. Histologic investigation of the effect of formocresol on the pulp •Massler and Mansukhani suggested •Immediately pulp becomes fibrous and acidophillic. •7 to 14 days : 3 zones appears •A broad eosinophilic zone of fixation •A broad pale-staining zone of atrophy With poor cellular definition • A zone of inflammation diffusing apically into normal pulp tissue 61JOHN I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition
  60. 60. • Easily available medicament • Stable at room temperature • Long shelf life • High clinical and radiographic success 62 • It is a very caustic medicament. • Toxic if used in high dosage. • Potential systemic absorption and distribution throughout the body. • It has a mutagenic and carcinogenic potential . Advantages John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition DisadvantagesAdvantages Disadvantages
  61. 61. 63 Title Author Journal L O E Aim Materials and methodology Conclusion Evaluation of Four Pulpotomy Technique s in Primary Molars: A Randomiz ed Controlled Trial Ansari G, Pouya Morovati S, Asgary S. Iranian Endodon tic Journal 2018;13( 1): 7-12 3 a to evaluate the clinical and radiographic success rates of calcium- enriched mixture (CEM) cement with and without low level laser therapy (LLLT) and compare them to that of formocresol (FC) and ferric sulfate (FS) in primary molar pulpotomies. This randomized clinical trial was conducted on a total of 160 teeth selected from 40 patients aged 3-9 years. Patients with at least four primary molars needing pulpotomy, were included in order to have each tooth assigned randomly in one of the four following groups; FC, FS, CEM, and LLLT/CEM. Six- and twelve-month follow-up periods were conducted in order to enable a clinical and radiographic evaluation of the treated teeth. Collected data were analyzed using Cochran Q Test Favorable outcomes of four treatment techniques in pulpotomy of primary molar teeth were comparable. CEM with/without LLLT may be considered as a safe and successful pulpotomy treatment modality compared to current conventional methods.
  62. 62. 2. Electrosurgical pulpotomy  In 1982, Anderman described the electrosurgical pulpotomy in primary teeth as a time-efficient method  In 1983 Ruempling et al suggested cautery to fix radicular pulp tissue after amputation.  Routinely performed by Mack & Dean,1993,Non-pharmacotherapeutic devitalization technique.  Electrocautery carbonizes and heat denatures the pulp and bacterial contamination. 64 John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition
  63. 63. 65 1. the electrosurgery dental U-shaped electrode should immediately placed 1-2 mm above the tissue. 2. The electrosurgery unit power should set at 40%. 3. The electrical arc should allowed to bridge the gap to the first pulpal stump for 1s followed by a cooldown period of 10-15 s. This procedure was repeated up to three times at each pulpal orifice.
  64. 64. • Itcanbeperformedmorequickly • Nodrugsinvolvedthatmayproduce undesirablesystemiceffects. • Easeofuse • Favorableresults. 66 • Heatleadstotissuedestruction • Persistentinflammation • Energycannotbeisolatedtosurface • Rootresorption • Pulpinflammation John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition Advantages Disadvantages
  65. 65. 67
  66. 66. 3.LaserPulpotomy • Non-pharmacologichemostatictechnique. • Advantages: 1. Quickandefficient 2. Self-limiting 3. Goodhemostasis 4. Goodvisibilityofthefield 5. Nosystemiceffects 6. Sterilizationatthesiteofapplication 68 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  67. 67. • Liu JF,2006 compared the effects of ND:YAG laser pulpotomy with formocresol on human primry teeth. • In the ND:YAG laser group,clinical success was 97%,and radiographic success was 94%. • In formocresol pulpotomy the success rate was 85% and 78% respectively. 69 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  68. 68. 70 Title Author Journal L O E Aim Materials and methodology Results Conclusion Laser Pulpot omy- An Effectiv e Alterna tive to Conve ntional Techni ques: A 12 Months Clinico radiogr aphic Study. G Gupta, V Rana, N Srivas tava, P Chand na. Int J Clin Pediat r Dent. 2015 Jan- Apr;8( 1):18- 21 2 a compare the clinical and radiogra phic success rates for ferric sulfate (FS), electros urgery (ES) and laser pulpoto my in human primary molars. n a randomized clinical trial, 30 primary molars indicated for pulpotomy in children aged 4 to 10 years were treated using either a FS (10 teeth), ES technique (10 teeth) and laser (10 teeth). Following the pulpotomy, the teeth were evaluated for clinical and radiographic success at 3, 6, 9 and 12 months on the basis of the presence of pain, sinus, mobility, internal and external resorption, periapical radiolucency, calcification in the canal and bone loss. After 12 months of follow-up, both clinical and radiographic success rates were 100% in the laser group but only 80% in both ES and FS groups. There was statistically significant difference between the success rates of three groups (p < 0.05). •Laser pulpotomy showed better clinical as well as radiographical results than ES and FS pulpotomy. •Laser pulpotomy was also found superior in terms of operating time, patient cooperation, ease of use and pain. •Although results of the study showed the failure rates for electrosurgical pulpotomy to be equal to those for FS pulpotomy, electrosurgical pulpotomy being a nonpharmacological technique considered more favorable.
  69. 69. 71
  70. 70. • In two stage devitalizing pulpotomy entire coronal and radicular pulp tissue is fixed. • Indications 1. Profuse or sluggish bleeding at amputation site 2. Difficult to control bleeding 3. Slight pus in the chamber but none at the amputation site 4. PDL Widening 5. spontaneous pain 6. Uncooperative patients. 7. Time factor 72 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  71. 71. 73 Procedure for 2 visit pulpotomy 1st visit Anesthetize the tooth Isolate with rubber dam Cavity preparation Enlarge the exposure with round bur Incorporate paraformaldehyde paste in to pallet Place over the exposure Seal the tooth for 5-7 days Formaldehyde gas liberated from paraformaldehyde There will be fixing of tissue John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition
  72. 72. 74 2nd visit JOHN I. INGLE,DDS,MSD Ingle’s Endodontics 6th edition Pulpotomy Is carried out under local anesthesia Remove the old cotton pallet and Clean the cavity with saline & dry with cotton pallet Pulp chamber filled with antiseptic paste & tooth is restored Final restoration with stainless steel crown
  73. 73. Preservation: •This approach involved medicaments and techniques that provide minimal insult to the orifice tissue and maintain the vitality and normal histologic appearance of the entire radicular pulp. •GLUTERALDEHYDE •FERRIC SULPHATE 75 B. PRESERVATION PULPOTOMY Franklin Garcia-Godoy. Clinical Evaluation of Gluteraldehyde Pulpotomies in primary teeth. Acta de odontología pediátrica ·
  74. 74. 1. Glutaraldehyde  Glutaraldehyde for pulp fixation was proposed by • S-Gravenmade in 1975.  This di-aldehyde has a limited shelf life and a cross- linking ability superior to that of formocresol.  In recent years, glutaraldehyde has been proposed as an alternative to formocresol based on its superior fixative properties, self-limiting penetration, low antigenicity, low toxicity and elimination of cresol. 76 INTRODUCTION Franklin Garcia-Godoy. Clinical Evaluation of Gluteraldehyde Pulpotomies in primary teeth. Acta de odontología pediátrica · January 1984
  75. 75.  formaldehyde reactions are reversible  Glutaraldehyde has irreversible because it has better protein bonding capacity  Formaldehyde fixes tissue with a long reaction time and an excess of solution  glutaraldehyde fixes tissue instantaneously and an excess of solution is not necessary.  Formaldehyde is a small molecule and penetrates the periapical end easily.  Glutaraldehyde being a large molecule does not penetrate into the periapical tissue. Less pulpal irritation is seen because of less apical diffusion.  Formocresol caused lysis of PMN and at high concentration but activation of PMN adherence at low concentration.  In contrast glutaraldehyde did not produce PMN lysis at high concentration, nor did it cause activation of PMN adherence at low concentration. 77Franklin Garcia-Godoy. Clinical Evaluation of Gluteraldehyde Pulpotomies in primary teeth. Acta de odontología pediátrica · January 1984
  76. 76. 78 2. FERRIC SULPHATE Larson 1988 Strong styptic,1st used in military hospital in Bordeaux ,France 1857 prabhu et al 1997 It was proposed as a Pulpotomy medicament for vital primary teeth
  77. 77. 79  Ferric sulfate (Fe2[SO4]3) as a 15.5% solution (AstringedentTM, Ultradent Products, Inc., Salt Lake City, UT), has been used commonly as a coagulative and hemostatic retraction agent for crown and bridge impressions and is slightly acidic.  The mechanism of action of ferric sulfate is still debated, but agglutination of blood proteins results from the reaction of blood with both the ferric and sulfate ions.  The agglutinated protein forms plugs to occlude the capillary orifices. Raghavendra Havale, Rajesh T Anegundi, KR Indushekar, P Sudha. Clinical and Radiographic Evaluation of Pulpotomies In Primary Molars With Formocresol, Glutaraldehyde and Ferric Sulphate. Oral health and dental management. Vol. 12 - No. 1. March 2013.
  78. 78. Advantages Of Ferric Sulfate Over Formocresol • According to Bimstein- replacement of Formocresol with ferric sulfate in general anesthesia cases, where several pulpotomies have to be done, can reduce systemic toxic effects caused by Formocresol. • Manipulation time of 15 seconds for Ferric sulfate is advantageous when compared to 5 min for formocresol, with same success rates. • Systemic distribution of Ferric sulfate is unknown, because the clot avoids 80 Raghavendra Havale, Rajesh T Anegundi, KR Indushekar, P Sudha. Clinical and Radiographic Evaluation of Pulpotomies In Primary Molars With Formocresol, Glutaraldehyde and Ferric Sulphate. Oral health and dental management. Vol. 12 - No. 1. March 2013.
  79. 79. Raghavendra Havale, Rajesh T Anegundi, KR Indushekar, P Sudha. Clinical and Radiographic Evaluation of Pulpotomies In Primary Molars With Formocresol, Glutaraldehyde and Ferric Sulphate. Oral health and dental management. Vol. 12 - No. 1. March 2013.
  80. 80. 82Akhlaghi N, Khademi A. Outcomes of vital pulp therapy in permanent teeth with different medicaments based on review of the literature. Dental Research Journal / September 2015 / Vol 12 / Issue 5
  81. 81. Regeneration: •This approach includes pulpotomy agents that have cell- inductive capacity to either replace lost cells or induces existent cells to differentiate into hard tissue forming elements. 83 C. REGENERATIVE PULPOTOMY JOHN I. INGLE,DDS,MSD Ingle’s Endodontics 6th edition
  82. 82. Examples of true cell- inductive agents include:  Calcium hydroxide  Mineral trioxide aggregate (MTA)  Transforming growth factor- beta1 (TGF- b1) in the form of bone morphogenetic protein  Freeze Dried bone  Enamel matrix derivative 84
  83. 83. 1. Calcium Hydroxide Single paste System – Ex: Hypocal, Metapex . • Available as – Dry powdered Ca(OH)2. – Single paste system. – Two paste system. – Root canal sealer. • These solutions help as carriers / vehicles for easy placement of the material • which can be used mixing it either with: – Distilled water. – Saline – Glycerine. – L.A solution without vasoconstrictor. – Methyl cellulose. 85
  84. 84. • Two paste system – E.g.: Alkaliner, Dycal, Basic. • These system contains an acid paste and a base paste. • This setting reaction based on the reaction between calcium and zinc ion and a salicylate chelating agent and is accelerated by the presence of water. DYCAL Acid paste Organic components – Methyl salicylate ester. Inorganic fillers Titanium dioxide. Calcium sulphate. Calcium tungsten. Alumina Base paste Inorganic components Calcium hydroxide. Zinc oxide. Plasticizers Ortho and Para 4-ethyl toluene. Sulphonamide 86
  85. 85. How Calcium Hydroxide Works ???? • Anti-microbial properties. • Tissue Dissolution Properties. • Biologic Properties. – Pulp therapy procedures. – Hard Tissue formation 87
  86. 86. 88
  87. 87. Procedure 89 Grossman’s Endodontic Practice. 13th Edition.
  88. 88. 90 Title Author Journal L O E Aim Conclusion Properties and applicatio ns of calcium hydroxide in endodonti cs and dental traumatol ogy Z. Moham madi & P. M. H. Dumme r. Internat ional Endodo ntic Journal, 44, 697– 730, 2011 5 is to review the properties and clinical applications of calcium hydroxide in endodontics and dental traumatology including its antibacterial activity, antifungal activity, effect on bacterial biofilms, the synergism between calcium hydroxide and other agents Chemically, calcium hydroxide is classified as a strong base with a high pH (approximately 12.5–12.8). Its main properties come from the ionic dissociation of Ca2+ and OH ions and their effect on vital tissues, generating the induction of hard-tissue deposition and being antibacterial. Although some studies have confirmed its efficacy against endodontic bacteria, other studies have questioned it effectiveness. their cytotoxicity appears to be milder than for other groups of sealers. Ca(OH)2 is a suitable material for pulp capping and pulpotomy. MTA apical barrier technique may replace it. Ca(OH)2 has been successfully used to manage perforations, horizontal root fracture and root resorption.
  89. 89. 2. Mineral Trioxide Aggregate (MTA) • INTRODUCED:1993 by Mahmoud Torabinejad (LOMA LINDA UNIVERSITY) • FDA APPROVAL -1998 • Available as 91
  90. 90. Macwan C, Deshpande A. Mineral trioxide aggregate (MTA) in dentistry: A review of literature. Journal of Oral Research and Review Vol. 6, Issue 2, | July-December 2014 92
  91. 91. 93Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review – Part III: Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-13. The MTA paste is obtained by mixing 3 parts of powder with 1 part of water to obtain putty like consistency (distilled water, local anesthesia, normal saline). Mixing can be done on paper or on a glass slab using a plastic or metal spatula. This mix is then placed in the desired location and condensed lightly with a moistened cotton pellet. MTA has a pH of 10.2 immediately after mixing and increases to 12.5 after 3 hours of setting which is almost similar to calcium hydroxide. The mixing time of MTA is crucial. If the mixing of MTA is prolonged, it results in dehydration of the mix. Sluyk et al in 1998 reported that the mixing time should be less than 4 minutes.
  92. 92. Mechanism • The exact mechanism of dentinal bridge formation when MTA is used is not known completely and detailed research should be carried out for understanding this mechanism. • However, it was found that when MTA was used as a pulpotomy agent it induces cytologic and functional changes within pulpal cells, resulting in formation of fibrodentine and reparative dentin at the surface of mechanically exposed dental pulp. • When placed it causes proliferation, migration and differentiation of odontoblast-like cells that produce a collagen matrix. • This formed umineralized matrix is then mineralized by osteodentin initially and then by tertiary dentin formation. 94 Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review – Part III: Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-13.
  93. 93. • The high pH also extracts growth factors from adjacent dentin thought to be responsible for promoting dentinal bridging. • It is hypothesized that soluble components of MTA during and after setting on the dentin interface may cause the release of growth factors and other bioactive molecules, such as transforming growth factor beta (TGF-b1). • According to Tomson et al., the bioactive properties of MTA that stimulate reparative bridge formation can be attributable to the material providing a biocompatible noncytotoxic antibacterial environment. 95 Koh ET, Pitt Ford TR, Torabinejad M, McDonald F. Mineral trioxide aggregate stimulates cytokine production in human osteoblasts. J Bone Miner Res 1995;10S:S406.
  94. 94. 96 Title Author Journal L O E Aim Materials and methodology Results Conclusion Mineral trioxide aggreg ate and formocr esol pulpoto my of primary teeth: a 2-year follow- up G. Ansari & M. Ranjp our. Intern ational Endod ontic Journ al, 43, 413– 418, 2010 3 b To compare the clinical and radiogra phic respons e of primary teeth to vital pulpoto my using mineral trioxide aggregat e (MTA) or formocre sol (FC). A group of 17 children aged 4–9 were selected from those referred to the Paedodontic Department at Shahid Beheshti University, Dental School. Cases with at least two matching teeth were selected (40 teeth), showing signs of pulp involvement. A pulpotomy procedure was carried out in all cases with FC in control teeth whilst MTA was placed in experimental teeth. Clinical and radiographic evaluations were performed at 1-, 6-, 12- and 24-month recall. Internal resorption was seen significantly more often in FC cases after 12 months than MTA cases. Overall radiographic appearance of normal structures at 24th month was seen in more than 95% of the cases in MTA and 90% in the FC-treated group (P > 0.05). Mineral trioxide aggregate for pulp treatment of primary teeth can be considered a replacement for FC.
  95. 95. 3. Biodentine • Recently new calcium silicate material • Available as.. – Biodentine (Septodont; Lancaster, PA) Consist of Powder in a capsule and liquid in a pipette. – Powder consist of dicalcium and tricalcium silicate – Liquid is calcium chloride with admixture of modified polycarboxylate 97
  96. 96. Mechanism Of Action • After the application Mineralization occurs in the form of osteodentine by expressing markers of odontoblasts & increases TGF-Beta1 secretion from pulpal cells enabling early mineralization. • During the setting of the cement Calcium hydroxide is formed. • Due to its high pH, Calcium hydroxide causes irritation at the area of exposure. • Biodentine induces apposition of reactionary dentine by odontoblast stimulation and reparative dentin by cell differentiation. • Because of its high alkality it has inhibitory effects on microorganism. 98 Biodentine induces TGF-Beta 1 release from Human pulp cells and early dental pulp mineralization DEC 2011 1365-2591.2011.01995
  97. 97. 99 Journal of Clinical and Diagnostic Research. 2017 Aug, Vol-11(8): ZG01- ZG05
  98. 98. Journal of Clinical and Diagnostic Research. 2017 Aug, Vol-11(8): ZG01- 100
  99. 99. BioMed Research International Volume 2014, Article ID 160951, 10 pages 101
  100. 100. Ozlem M et. al,.A review of biodentine. BioMed Research International Volume 2014, Article ID 160951, 10 pages 102
  101. 101. 4. Growth factors: Bone Morphogenic Protien In 1938 Levander reported that there must be some stimulating agent which originated from bone and possibly a substance which was soluble in lymph tissue. •Urist referred the bone inducing substance to “Bone Morphogenic Proteins” which were originally identified by their presence in bone inductive extracts of demineralized bone in 1965. •Inducing substance i.e. Bone Morphorgenic Protein acting upon a responding cell i.e. - undifferentiated mesenchymal cell to become progenitor cell. Levander thus concluded that there is an extractable substance from bone which is able to activate mesenchymal cells to form tissue. 103 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  102. 102.  Bone morphogenetic proteins (BMPs) are a group of growth factors also known as cytokines and as metabologens.  Originally discovered by their ability to induce the formation of bone and cartilage by promoting cell proliferation and differentiation. 104 Kirker-Head CA1Recombinant bone morphogenetic proteins: novel substances for enhancing bone healing.
  103. 103. • BMP belongs to super family transforming growth factor beta (TGF- b). • BMP-2, 4, and 7 plays a role in the differentiation of adult pulp cells into odontoblasts during pulpal healing. • Formation of more homogeneous reparative dentin. • Superior to Ca(OH)2 in the mineralization inducing properties. 105
  104. 104. the application of BMP on exposed pulp is dissolved within two weeks stimulates mitosis of the adjacent cells differentiate into osteodentinoblasts lay down osteodentin matrix differentiation of odontoblasts were capable of inducing dentin formation. 106 Kirker-Head CA1Recombinant bone morphogenetic proteins: novel substances for enhancing bone healing.
  105. 105. 5. Lyophilized Freeze Dried Platelet Derived Preparation • Platelet derived growth factor ,insulin growth factor derived from platelet have generated considerable intreast in the past. • These compounds act as signaling proteins that could be directly involved in the regulation of cell proliferation,migration and extra cellular matrix production in the dental pulp. • These proteins have been extensively used in oral and maxillofacial reconstruction adjunctive procedures related to the placement of osseo integrated implant in humans and periodontal regeneration. • animal and human in-vivo and invitro studies have shown that these proteins stimulates differentiated cell of the pulp to differentiate into odontoblast to deposit a layer of dentin. 107 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  106. 106. Damle & Kalaskan R et al compared efficiency of lyophilized freeze dried platelet derived with calcium hydroxide as pulpotomy agents in primary molars. It was found that success rate of lyophilized freeze dried platelet derived pulpotomy proved to be more efficient. 108 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  107. 107. 5. Emdogain (EMD) • EMD is enamel matrix derivative secreted from Hertwig’s epithelial root sheath during tooth development. • It is an important regulator of enamel mineralization and plays an important role during periodontal tissue formation. • It stimulates the regeneration of acellular cementum, periodontal ligaments, and alveolar bone. 109 Qureshi A, E. S, Nandakumar, Pratapkumar, Sambashivarao. Recent Advances in Pulp Capping Materials: An Overview. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(1):316-321. doi:10.7860/JCDR/2014/7719.3980.
  108. 108. • EMD contains BMP like molecules and BMP expressing cells. It promote odontoblast differentiation and reparative dentin formation • It was reported that EMD suppresses the inflammatory cytokine production by immunocytes and contains TGF-β like molecules. It might create a favourable environment for promoting wound healing in the injured pulp tissues . • Nakamura Y et al., concluded that amount of hard tissue formed in EMD treated teeth was more than twice that of the calcium hydroxide treated control teeth •Qureshi A, E. S, Nandakumar, Pratapkumar, Sambashivarao. Recent Advances in Pulp Capping Materials: An Overview. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(1):316-321. doi:10.7860/JCDR/2014/7719.3980. 110
  109. 109. Sodiumhypochlorite(NaOCl) • Sodiumhypochlorite(NaOCl)hasbeensuccessfullyusedfordecadesin endodontictherapyasanirrigant. • Sincethe1950s,studieshaveverifiedthatNaOClisbiocompatible, nonirritatingtoexposedpulpaltissueandaneffectivehemostaticagent. • Hafezetal(2002)andothersdemonstratedthattheapplicationofNaOCl selectivelydissolvesthesuperficialnecroticpulptissuewhileleavingthe deeperhealthypulptissueunharmed 111 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  110. 110. • Cox et al(2002) reported that hemostasis is best achieved with NaOCl. reported similar success rate of NaOCl/RMGIC when compared to FC/ZOE in their 3 month evaluation. • Vargas et al. (2006) showed promising results from a pilot study using 5% NaOCl as a primary molar pulpotomy agent. • Histologically Roza et al (2012) noted mild inflammation and also dentin bridge formation after 2 months following NaOCl pulpotomy 112 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  111. 111. 113
  112. 112. 114
  113. 113. 115 Title Author Journal L O E Aim Materials and methodology Results Conclusi on A histopatho logical compariso n of pulpal response to formocres ol and sodium hypochlori te used as pulpotomy medicame nts: In primary teeth – A clinical trial Reddy S, Red dy V, T Sneha, Reddy A, P Niharik a,Kum ar J. JISPP D 2019 3b to evaluate and compare formocresol (FC) and 5% Sodium hypochlorite (NaOCl) as pulpotomy medicaments and to assess the histological features of both pulpotomy medicaments in primary teeth In the present study, pulpotomies were performed on 60 primary molars in 55 children aged 5–8 years. The teeth were divided into two groups NaOCl and FC were placed on the canal orifices, respectively, and crowns were restored with intermediate restorative material and glass ionomer cement. No statistically significant difference was found between the two groups with respect to inflammatory response, soft-tissue organization, and dentin bridge formation (P > 0.005) Based on the results of this study Sodium hypochlo rite may be a suitable medicam ent for conducti ng pulpotom y in primary teeth.
  114. 114. 6.Bioactiveglass • Bioactive glass has been studied more than 30 years as a bone substitute. • It reacts with aqueous solution and form a carbonate apatite layer. • BAGs considered as osteoconductive. • BAGs are biocompatible, antibacterial and stimulate osteoblasts. [Salako N, 2003] 116 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  115. 115. • Some authors state odontoblast stimulation and subsequent reparative dentin formation; however studies are ongoing to prove exact mechanism of bridge formation. • Animal study by Salako et al(2003), reported that BAG showed localized areas of inflammation in the pulp especially in the mid root portion and 4 week old samples showed comparative better results where the inflammation was resolved and odontoblastic layer was evident. 117
  116. 116. 118 Title Author Journal L O E Aim Methodology Conclusion Compa rison of bioactiv e glass, mineral trioxide aggreg ate, ferric sulfate, and formocr esol as pulpoto my agents in rat molar. Salako N, Josep b B, Ritwik P, Salone n R, Jobn, Junaid T. Dentil ! Trau matol ogy 2003: 19: 314- 320 4 to evaluate BAG as a pulpotomy agent and to compare it with three commercially available pulpotomy agents such as formocresol (FC), ferric sulfate (FS), and mineral trioxide aggregate (MTA). Pulpotomies were performed in 80 maxillary first molars of Sprague Dawley rats, and pulp stumps were covered with BAG, FC, FS, and MTA. Histologic analysis was performed at 2 weeks and then at 4 weeks after treatment. Experimental samples were compared with contra-lateral normal maxillary first molars. Among the materials tested, MTA performed ideally as a pulpotomy agent causing dentine bridge formation while simultaneously maintaining normal pulpal histology. It appeared that BAG induced an inflammatory response at 2 weeks with resolution of inflammation at 4 weeks.
  117. 117. 7. Ankaferd Blood Stopper (ABS) • Ankaferd Blood Stopper (ABS) is a herbal extract obtained from 5 different plants: Thymus vulgaris (mint), Glycyrrhiza glabra (mulethi or jetthi muth), Vitis vinifera (grape vine), Alpinia officinarum, and Urtica dioica. • Each of these plants has some effect on the endothelium, blood cells, angiogenesis, cellular proliferation, vascular dynamics and also as cell mediators. 119 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan Pulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  118. 118. • Goker et al(2008) explained following application of ABS, it forms an encapsulated protein network that provides focal points for vital erythrocyte aggregation. • ABS- induced protein network formation with blood cells particularly erythrocytes covers the primary and secondary haemostatic system without disturbing individual coagulation factors. • It is suggested that ABS may be used to control pulpal haemorrhage following the mechanical exposure of pulps. • StudiesonpulpotomywithABShaveshownsuccessraterangingfrom89%to100% (OdabaşME2011, YamanE,2012). 120 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan Pulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  119. 119. 8.NanoHydroxyApatite • NanoHydroxyApatitehasbeenintroducedforaugmentationproceduresinosseousdefects. • NHA is biocompatible and non-irritating to pulp tissue. 121Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  120. 120. • Shayegan et al.(2010) following histological evaluation reported that there was a significant difference between NHA and FC in terms of pulp response. • The results of the study show that NHA appears to be more biocompatible and provokes only mild inflammatory reaction in pulp tissue in both pulpotomy and direct pulp capping treatments. 122
  121. 121. 9. Platelet Rich Plasma • Platelet Rich Plasma was introduced by Marx in 1998 for reconstruction of mandibular defects, and it represents a relatively new biotechnology that is part of the growing interest in tissue engineering and cellular therapy. • Gibble and Ness in 1990 introduced fibrin glue, alternatively referred to as fibrin sealant or fibrin gel, a biomaterial developed in response to the necessity for improved haemostatic agents with adhesive properties. 123 Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014
  122. 122.  Platelet Rich Plasma gel (PRP gel) is an autologous modification of fibrin glue obtained from autologous blood used to deliver growth factors in high concentrations.  It is an autologous concentration of human platelets in a small volume of plasma, mimics the coagulation cascade, leading to formation of fibrin clot, which consolidates and adheres to application site.  Its biocompatible and biodegradable properties prevent tissue necrosis, extensive fibrosis and promote healing. 124 Kevy SV, Jacobson MS. Comparison of methods for pointof care preparation of autologous platelet gel. The Journal of Extra-corporeal Technology. 2004; 36: 28.
  123. 123. • Platelet rich plasma has been found to work via three mechanisms a)Increase in local cell division (producing more cells): According to Nathan E Carlson after the injury, platelets begin to stick to exposed collagen proteins and release granules containing adenosine diphosphate, serotonin and thromboxane, all of which contribute to the hemostatic mechanism and the clotting cascade. b)Inhibition of excess inflammation by decreasing early macrophage proliferation. c)Degranulation of the granules in platelets, which contain the synthesized and prepackaged growth factors. 125 Kevy SV, Jacobson MS. Comparison of methods for pointof care preparation of autologous platelet gel. The Journal of Extra-corporeal Technology. 2004; 36: 28.
  124. 124. 10. Platelet rich fibrin • Platelet rich fibrin (PRF) was first developed in France by Choukroun et al. in 2001. • Scientific rationale behind the use of platelet preparation lies in the fact that PRF serve as a reservoir for continuous release of growth factor which directs the process of reparative dentinogenesis.[Smith AJ,2001] • Huang et al.,[2012] investigated the effect of PRF on cultured primary dental pulp cells and concluded that PRF can increase dental pulp cell proliferation and differentiation. 126 Kevy SV, Jacobson MS. Comparison of methods for pointof care preparation of autologous platelet gel. The Journal of Extra-corporeal Technology. 2004; 36: 28.
  125. 125. 127 Journal of Indian Society of Pedodontics and preventive dentistry 2017
  126. 126. Partial Pulpotomy(Cvek’s Pulpotomy) • Definition: It is the removal of only the outer layer of damaged and hyperemic tissue in exposed pulps, is considered to be a procedure staged between pulp capping and complete pulpotomy. • Proposed by Mejare and Cvek in 1978 • The tooth following a partial pulpotomy will retain its natural color and translucency in comparison to the coronal discoloration in many teeth undergo after pulpectomy. • preserves cell rich coronal pulp tissue. 128
  127. 127. • A small and recent pulpal exposure approximately 14 days in a non carious tooth. • A sufficient tooth structure is present to allow proper restoration. • young permanent tooth with a wide- open apex and very thin root dentin walls. • During the procedure, an operative diagnosis should be made by assessing the pulpal with regard to the bleeding from the amputation site, including the color, viscosity, and ability of the tissue to achieve hemostasis 129 Indications
  128. 128. Contraindications • Very large Exposure • More than 2 weeks have passes between injury and treatment time • Inflammation beyond 2 to 3 mm of the exposure. • Purulent drainage. • History of prolonged pain. • Necrotic debris in canal. • Periapical radiolucency. 130
  129. 129. • Proper patient management should be achieved with or without premedication. • Local anesthesia and rubber dam placement should be administered with the slit technique. • A no. 330 tungsten bur is used to ampute the pulp close to the exposure site to a depth of 2mm. • Continuous rinsing of the amputed pulp with saline will assist in achieving hemostasis without blood clot formation within 4 minutes (if hemostasis is not achieved, all the coronal tissue should be removed and a cervical pulpotomy should be performed). 131 Technique
  130. 130. 132 Title Autho r Journa l L O E Aim Materials and methodology Results Conclusion Outcome of Partial Pulpoto my in Cariousl y Exposed Posterior Permane nt Teeth: A Systema tic Review and Meta- analysis Ems mari F, Ruiz F, Miro Q, Feijo o N, Dura n F, Gonz alo J. JOE Vol. No. 2019 1 a to evaluate the success rate of partial pulpotomy in treating permanent posterior teeth with carious vital pulp exposure. A secondary aim was to assess the prognostic factors using a meta- regression An electronic search was performed for studies from January 1950 to November 2018 in the following databases: PubMed, ScienceDirect, and Cochrane. All searches were performed following the Preferred Reporting Items for Systematic Reviews and Meta- Analyses guidelines. From the 218 studies identified through the initial search, 11 studies qualified for the final analysis (5 randomized clinical trials and 6 retrospective studies). The results of the meta- analysis indicate a success rate of 98% , 96% and 92% after 6 months and 1 and 2 years of follow-up. The available data suggest that a partial pulpotomy results in high success rates in treating cariously exposed permanent posterior teeth up to 2 years
  131. 131. 133
  132. 132. Journal of endodontics 2017 134
  133. 133. Non Vital Pulpotomy (Mortal Pulpotomy) • Indications • When the inflammatory process affecting the coronal pulp extends to the radicular pulp leading to an irreversible change in the pulp tissue. • When the pulp is completely non-vital, where there may be an abscess present with or without acute cellulites 137
  134. 134. MEDICAMENTS USED: Constituents of Beechwood cresol • 2 Methoxy, 4 methyl phenol (Cresol): 13% • Methoxyl phenol • M-Methoxy phenol • P-Methoxy phenol • Unknown :47% :7% :26% :7%
  135. 135. Technique Ist visit: •The necrotic coronal pulp is first removed, as recommended in the vital pulpotomy technique. •The necrotic debris in the pulp chamber is then cleaned. •If there is sufficient access to the radicular pulp canals then as much as possible of the necrotic tissue is removed with a small excavator. •A small cotton pellet dipped in beechwood cresol is then sealed into the cavity with temporary zinc oxide eugenol cement. 139
  136. 136. • IInd visit: • Usually 1-2 weeks later the dressing is removed, provided the signs and symptoms of infection have cleared. • The cavity is then restored • If it appears that there is no resolution of the symptoms then the beechwood cresol should be replaced for a further 1-2 weeks, Other medicaments like formocresol, monochlorophenol (Arnold and Rock, 1993) have been equally effective, at the second visit, after one to two weeks an antiseptic paste that is placed over the radicular pulp remnants before restoring the tooth replaces the antiseptic solution. •Hobson (1970) reported a success rate of 66% after 3 years. 140
  137. 137. • Pulp capping is a procedure that maintains pulp vitality and function, promotes healing/repair, prevents breakdown of peri radicular supporting tissues, and promotes formation of secondary dentin • Pulpotomy therapy for the primary dentition has developed a long three lines: devitalization, preservation, and regeneration. • Preservation, the retention of maximum vital tissue with no induction of reparative dentin, is exemplified by glutaraldehyde and ferric sulfate treatment. • Regeneration, the stimulation of a dentin bridge, has long been associated with calcium hydroxide. 141
  138. 138. Bibliography • John I. INGLE,DDS,MSD Ingle’s Endodontics 6th Edition. • Cohen M, Burns RC. Pathways of Pulp. 9th ed. St. Louis: Mosby Inc.; 2002. • Mcdonald RE, Avery DR, Dean JA. Dentistry for the Child and Adolescent. 8th ed. 2004: Mosby; Elsevier. p. 390-412. • Grossman’s Endodontic Practice. 13th Edition. • Textbook of Pediatric Dentistry by Nikhil Marwah. 3rd edition. • Policy on Acute Pediatric Dental Pain Management. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2017 • Pulp Therapy for Primary and Immature Permanent Teeth. AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. REFERENCE MANUAL V 4 0 / N O 6 1 8 / 19. 2014. • Parisay I, Ghoddusi J, Forghani M. A Review on Vital Pulp Therapy in Primary Teeth. Iranian Endodontic Journal 2015;10(1):6-15. • Mohammadi Z, Dummer M H. Properties and applications of calcium hydroxide in • endodontics and dental traumatology. International Endodontic Journal, 44, 697–730, 2011. • Tandon S,Textbook of pedodontics,3rd edition,2009 142
  139. 139. 143 • Franklin Garcia-Godoy. Clinical Evaluation of Gluteraldehyde Pulpotomies in primary teeth. Acta de odontología pediátrica · January 1984. • Raghavendra Havale, Rajesh T Anegundi, KR Indushekar, P Sudha. Clinical and Radiographic Evaluation of Pulpotomies In Primary Molars With Formocresol, Glutaraldehyde and Ferric Sulphate. Oral health and dental management. Vol. 12 - No. 1. March 2013. • Macwan C, Deshpande A. Mineral trioxide aggregate (MTA) in dentistry: A review of literature. Journal of Oral Research and Review Vol. 6, Issue 2, | July-December 2014. • Kumar Praveen NH, Nayak Rashmi, Bhaskar Vipin K, Mopkar Pujan PPulpotomy Medicaments: Continued Search for New Alternatives- A Review, OHDM - Vol. 13 - No. 4 - December, 2014 • Kevy SV, Jacobson MS. Comparison of methods for pointof care preparation of autologous platelet gel. The Journal of Extra-corporeal Technology. 2004; 36: 28. • Qureshi A, E. S, Nandakumar, Pratapkumar, Sambashivarao. Recent Advances in Pulp Capping Materials: An Overview. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(1):316-321. doi:10.7860/JCDR/2014/7719.3980.
  140. 140. Thank You 144

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