Vital pulp therapy

Prognosis of treatment using Endocem MTA

case report about direct pulp capping and partial pulpotomy

Seung Pil Jung DDS• Seoul Pil Dental Clinic: Seoul

• Private Practice Mar.2012 ~

• Seoul Leaders Dental Clinic: Seo-San

• Private Practice Mar.2005~Sep.2010

• Korean Army Service: Seo-San

• Public Health Dentist Mar.2001~Apr.2004

• Graduated from Seoul National Univ. Feb.2000

• Vital pulp therapy

• Pulp capping using MTA

• Endocem MTA

• Pozzolanic reaction

• Characteristics

• Indication

• Directions for use

• Case

• Conclusion

• Discussion

2012 10 13

23m later

2012 10 13

21m later

vital pulp therapy

• pulp capping

• partial pulpotomy

• full pulpotomy

pulp capping, partial pulpotomy, and full pulptomy

pathways of the pulp - 10th edition 625~630

Vital pulp therapy: Requirements for Success

• Treatment of a noninflammed pulp

• Bacteria-tight seal

• Pulp dressing

MTA as a capping agent• high pH similar to calcium hydroxide when unset

• after setting, will create an excellent bacteria-tight seal

• hard enough to act as a base for a final restoration

• need a moist environment for at least 6 hours to set properly—> two step procedure

• cause discoloration in the tooth crown

• high cost

Calcium Hydroxide

success rate

pulp cappingwithout any removal of the

sort tissue80%

partial pulpotomy

the removal of coronal pulp tissue to the level of healthy

pulp95%

full pulpotomy

the removal of the entire coronal pulp to a level the root

orifices75%

partial pulpotomy technique• anesthesia,possibly without a vasoconstrictor

• rubber dam

• superficial disinfection

• 1-to 2-mm deep cavity into the pulp using a high-speed hand piece with a sterile diamond bur

• If bleeding is excessive, the pulp is amputated deeper until only moderate hemorrhage is seen

• excess blood is carefully removed by rinsing with sterile saline and the area is dried with a sterile cotton pellet

• 5% NaOCl is recommended to rinse the plural wound

• chemical amputation of the blood coagulum

• remove damaged pulp cells, dentin chips, and other debris

• provide hemorrhage control with minimal damage the normal pulp tissue underneath

• do not allow blood clot to develop

partial pulpotomy technique

• 1-to 2-mm deep cavity into the pulp

• using a high-speed hand piece with a sterile diamond bur

• until only moderate hemorrhage is seen

• excess blood is carefully removed

• 5% NaOCl

• do not allow blood clot

• little or no history of pain

• absence of radiographic signs, percussion sensitivity, swelling, or mobility

• exposures exceeding 2mm, bleeding could not controlled within 1~2minutes excluded

• 93.5%, 91.4% healing

Partial pulpotomy on asymptomatic young permanent posterior teeth(calcium hydroxide)

pulpotomy on symptomatic young permanent (calcium hydroxide)

• 6 teeth

• temporary pain

• widened PDL ligament space

• condensing osteitis

• 66.7% healed

pulpotomy on symptomatic young permanent teeth(calcium hydroxide)

• 26 permanent vital molars with caries pulp exposures and apical periodontitis

• 16~ 72 months observed

• 24 teeth (92.3%)

methods

• 40 patients (7~45 years)

• pulp-capping treatment

• no more than reversible pulpits (cold test, radiographic examination)

first visit

• remove caries using a caries detector

• hemostasis using NaOCl

• place Pro-root MTA over the exposures and all surrounding dentin

• restore provisionally with un-bonded Clearfil Photocore

second visit

• sensibility test

• confirm MTA curing

• restore with bonded composite

results

• observation period: 9 years

• followed : 49/53 teeth

• favorable outcome: 97.96%

• all teeth having open apexes showed completed root formation(15/15)

MTA• Biocompatibility

• Odontogenicity

• Sealing effect

• Anti-bacterial effect

• Long setting time

• Dentin discoloration

Endocem MTA

• mineral trioxide aggregate-derived pozzolan cement

Pozzolanic Reaction

MTA surface after setting

calcium hydroxidecalcium silicate hydrate

active silica

calcium silicate hydrate

• minimize pulp chamber calcification

Clinical Significance of Pozzolanic Reaction

17

2012 10 18

16m later

• minimize pulp chamber calcification

• Bond strength does not vary significantly across surface treatments (Shin et al, J Endod 2014;40:1210–1216)

Clinical Significance of Pozzolanic Reaction

• minimize pulp chamber calcification

• Bond strength does not vary significantly across surface treatments (Shin et al,J Endod 2014;40:1210–1216)

• not discolor dentinal tubule (Jang et al. J Endod 2013;39:1598–1602)

Clinical Significance of Pozzolanic Reaction

ProRoot MTA

Angelus MTA

baseline 4w 8w

Endocem MTA

baseline 4w 8w

Endocem MTA

• Biocompatibility (Choi et al. J Endod 2013;39(4);467-72)

• MG63 cell

• 3days

• cytoplasmic extension

ProRoot

IRM

Endocem

Endocem MTA

• Biocompatibility (Choi et al. J Endod 2013;39(4);467-72)

• Odontogenic effect (Park et al. J Endod 2014;40(8);1124-31)

Odontogenic Effect of a Fast-setting Pozzolan-based

Pulp Capping Material

Su-Jung Park, DDS, PhD,* Seok-Mo Heo, DDS, PhD,† Sung-Ok Hong, DDS, MSD,*Yun-Chan Hwang, DDS, PhD,jj Kwang-Won Lee, DDS, PhD,‡ and Kyung-San Min, DDS, PhD‡§

Our results indicate that ProRoot and Endocem have similar biocompatibility and odontogenic effects. Therefore, Endocem is as effective a pulp capping material as ProRoot. (J Endod

2014)

Endocem MTA

• Biocompatibility (Choi et al. J Endod 2013;39(4);467-72)

• Odontogenic effect (Park et al. J Endod 2014;40(8);1124-31)

• Sealing effect (Choi et al. J Endod 2013;39(4);467-72)

Endocem MTA

ProRoot MTA IRM

Endocem MTA• Biocompatibility (Choi et al. J Endod 2013;39(4);467-72)

• Odontogenic effect (Park et al. J Endod 2014;40(8);1124-31)

• Sealing effect (Choi et al. J Endod 2013;39(4);467-72)

• Discoloration(Jang et al. J Endod 2013;39:1598–1602)

Endocem MTA• Biocompatibility (Choi et al. J Endod 2013;39(4);467-72)

• Odontogenic effect (Park et al. J Endod 2014;40(8);1124-31)

• Sealing effect (Choi et al. J Endod 2013;39(4);467-72)

• Discoloration(Jang et al. J Endod 2013;39:1598–1602)

• Anti-Bacterial Effect (Shin et al. not published)

•Shin et al. not published

Joo-Hee Shin, DDS, MSD, PhDDepartment of Conservative Dentistry, Korea University Medical Center, Korea University, Seoul, Korea

• Streptococcus mutans; dental caries

• Enterococcus faecalis; failed endodontic lesion

• porphyromonas gingivalis; periodontitis

Endocem MTA• Biocompatibility (Choi et al. J Endod 2013;39(4);467-72)

• Odontogenic effect (Park et al. J Endod 2014;40(8);1124-31)

• Sealing effect (Choi et al. J Endod 2013;39(4);467-72)

• Discoloration(Jang et al. J Endod 2013;39:1598–1602)

• Anti-Bacterial Effect (Shin et al. not published)

• Fast setting Time (Choi et al. J Endod 2013;39(4);467-72)

Indication• Lining of cavity in pulp capping

• Lining of cavity in partial pulpotomy

• Lining of cavity after pulpotomy of deciduous teeth

• Canal filling for apical closure in apexogenesis

• Restoration of root canal perforation

• Restoration of internal resorption lesion

• Root end filling

• Endodontic sealer

Indication

• Lining of cavity in pulp capping

• Lining of cavity in partial pulpotomy

• Lining of cavity after pulpotomy of deciduous teeth

• Endodontic sealer

Directions for use

partial pulpotomy technique• anesthesia,possibly without a vasoconstrictor

• rubber dam

• superficial disinfection

• 1-to 2-mm deep cavity into the pulp using a high-speed hand piece with a sterile diamond bur

• If bleeding is excessive, the pulp is amputated deeper until only moderate hemorrhage is seen

• excess blood is carefully removed by rinsing with sterile saline and the area is dried with a sterile cotton pellet

• 5% NaOCl is recommended to rinse the plural wound

• chemical amputation of the blood coagulum

• remove damaged pulp cells, dentin chips, and other debris

• provide hemorrhage control with minimal damage the normal pulp tissue underneath

• do not allow blood clot to develop

partial pulpotomy technique

• 1-to 2-mm deep cavity into the pulp

• using a high-speed hand piece with a sterile diamond bur

• until only moderate hemorrhage is seen

• excess blood is carefully removed

• 5% NaOCl

• do not allow blood clot

• isolation

• remove decay closest to pulp tissue with a new sterilized high speed diamond bur

Directions for use

• isolation

• remove decay closest to pulp tissue with a new sterilized high speed diamond bur

• rinse thoroughly with 5.25% NaOCl until bleeding stops

Directions for use

• isolation

• remove decay closest to pulp tissue with a new sterilized high speed diamond bur

• rinse thoroughly with 5.25% NaOCl until bleeding stops

• mix Endocem with distilled water and apply a thin layer

• remove excess moisture with a sterile cotton pellet, and gently pack it avoid dead space

• before Endocem hardens, add the rest of Endocem to filled the cavity

Directions for use

• isolation

• remove decay closest to pulp tissue with a new sterilized high speed diamond bur

• rinse thoroughly with 5.25% NaOCl until bleeding stops

• mix Endocem with distilled water and apply a thin layer

• remove excess moisture with a sterile cotton pellet, and gently pack it avoid dead space

• before Endocem hardens, add the rest of Endocem to filled the cavity

• remove part of the exterior Endocem

Directions for use

• isolation

• remove decay closest to pulp tissue with a new sterilized high speed diamond bur

• rinse thoroughly with 5.25% NaOCl until bleeding stops

• mix Endocem with distilled water and apply a thin layer

• remove excess moisture with a sterile cotton pellet, and gently pack it avoid dead space

• before Endocem hardens, add the rest of Endocem to filled the cavity

• remove part of the exterior Endocem

• apply resin

Directions for use

Precautions

Precautions

• depth and width is important

Precautions

• depth : 3 mm

• width: to cover all dentinal tubule

Precautions

• depth and width is important

• use undercut in narrow and shallow area

Precautions

• depth and width is important

• use undercut in narrow and shallow area

• After setting is complete, apply a strong stream of water with a 3way syringe check for wash-out

Endocem Case

#3 direct pulp capping 42 M 20m

#5 direct pulp capping 25 F 30m

#2, #14 direct pulp capping 30 M 25m

#31 partial pulpotomy 38 F 14m

#30 partial pulpotomy 23 F 23m

#6,#7,#8,#9,#29 partial pulpotomy 48 F 15m

deciduous teeth pulpotomy 8 F 3m,16m,22m

endodontic sealer

#3 direct pulp capping follow–up

(42 male)

2012 12 03

20m later

2013 01 19

2012 12 03

2012 12 03

20m later

#5 direct pulp capping follow–up

(25 female)

2012 07 31

30m later

2012 07 31

2012 07 31

30m later

#2, #14 direct pulp capping follow-up

(30 male)

2012 09 18

2012 09 18

25m later

20

2012 09 20 2012 09 27

2012 09 18

25m later

8m later

2012 09 18

8m later

25m later

#31 partial pulpotomy follow-up

(38 female)

2005 03 19 2005 09 28

2007 07 31 48m later

2012 08 29

2012 11 22

14m later

16m later

#30 Partial pulpotomy follow-up case

(23 female)

2013 01 26

2012 10 13

23m later

2012 10 13

26

21m later

#6,#7,#8,#9,#29 partial pulputomy follow-up case

(48 female)

2013 05 20

31

2013 05 20

2013 06 28

2013 05 20

15m later

2013 06 12

15m later

2013 05 20

2013 05 21 #9

2013 05 27 #7

2013 06 04 #6,#8

2013 06 13 #29

2013 05 20

15m later

38

2013 05 20

2013 06 12

15m later

#54,#74,#84 pulpotomy(8 female)

2012 03 27

2014 10 15

#74 2012 12 21

#84 2013 05 28

2014 07 17

#54

2014 10 15

#54#74

#84

22m later

16m later

3m later

Endodontic sealer

#30

#9, #10

#12,#14

#21

#20 #30

2014 11 10 2014 11 18

2014 11 19 2015 02 26

conclusion

• decrease the risk of endodontic treatment

• shorten chair time of removing infected dentin

• safer material in deciduous teeth pulpotomy than FC

• reduce treatment expenses

• improve treated tooth’s prognosis

discussion

• long-term follow-up

• need to examine cytotoxity and calcinogenicity over longer duration

• need to study treating inflamed pulp tissue

THANK YOU