PULP CAP

PULP CAPFEBRUARY 2013

COMPRESSEDVERSION

MTA THERAPIES• Root canal therapy

– Perforation repair– Apicoectomy

• Indirect Pulp cap (Pink Dentin)• Direct pulp cap (Direct Exposure)• Pulpotomy (Coronal extirpation)• Pulpectomy (Coronal and radicular extirpation)• Adult and pedodontic

WHAT IS MTA

• CALCIUM SILICATE – GYPSUM, PLASTER OF PARIS

• DICALCIUM SILICATE– MAIN CONSTITUENT IN PORTLAND CEMENT

• TRICALCIUM ALUMINATE (MINOR)• BIMUTH OXIDE ( 20%) FOR RADIOPACITY

SUCCESSFUL PULP CAPS

Healthy patient

Recoverable pulp

Flawless caries removal

Disinfection

Histological repair

seal

Inflammationmanagement

RETROSPECTIVE STUDIES

1. Bogan G et al JADA 2008:39 (3) 305-315 97%2. Fuks AB, Pediatr Dent 1982,4: 240-244 81%

success on permanent incisors 3. Barthel CR ,J Endod 2000; 26: 525-528 37%

@ 5 years, 13% @10 years

PULP CAP MATERIALS ?CR NEWS Jan 2010

• RMGI Vitrebond Plus or GC Fuji Lining LC– Indirect 40% – Indirect 68%

• Calcium Hydroxide – 28% Direct,– 14% Indirect

• Bonding agent – Direct 7% – Indirect 5%

• Laser 2% Direct• Gluteraldehyde Indirect 3%• MTA 3% Direct• Polycarboxylate – no mention• Glass Ionomer – no mention• English sparrow poop

CR News Jan 2010 vol 3 issue 1

1. CR respondents; success rates

1. 3 years: Direct 58%, Indirect 70%

2. 5 years: Direct 48%, Indirect 61%

0102030405060708090

100

3 5 10

DIRECTINDIRECTBOGANFUKSBARTHEL

MTA

• Bogan G et al JADA 2008:39 (3) 305-315 • Direct pulp capping with Mineral Trioxide

aggregate – an Observational Study. • Over an observation period of nine years, the

authors followed 49 of 53 teeth and found that 97.96% percent had favorable outcomes on the basis of radiographic appearance, subjective symptoms and cold testing.

MTA: SUPPLIER

• CLINICAL RESEARCH DENTAL• LONDON ONTARIO• 1800 265 3444

• “MTA ANGELUS WHITE”


Healthy patient

Recoverable pulp


Disinfection

Histological repair

seal



Healthy patientRecoverable pulp


DisinfectionHistological repair

seal



Healthy patient

Recoverable pulp


Disinfection

Histological repair

seal


RADIOGRAPHIC CONTRAINDICATIONS

• APICAL RADIOLUCENCY • APICAL DETERIORATION -CONDENSING

OSTEITIS• THREADLIKE PULP

• PULP STONES• PROBABLE FUTURE PULP OCCLUSION E.G.

CLASS V• RADIOGRAPHICLY EVIDENT CARIOUS

INVASION OF PULP CHAMBER

DIAGNOSTIC CONTRAINDICATIONS

• APICAL TENDERNESS• SPONTANEOUS • LONG STANDING • NOCTURNAL • THROBBING • ENDURING • SICKENING • CONSTANT NEED OF MEDICATIONS

OPERATIVE CONTRAINDICATIONS

• EXUDATE – SEROUS• PUS• PROLONGED CLOTTING TIME > 5 MINS• >3MM EXPOSURE • GROSS CARIES INTRODUCTION INTO PULP

CHAMBER • EXPLORER INTO THE PULP (OPERATOR ERROR)


Healthy patient

Recoverable pulp


Disinfection

Histological repair

seal


FORMULA FOR CARIES DETECTOR

• ACID RED 52 2% IN PROPYLENE GLYCOL• COMPOUNDING PHARMACY• $30 FOR 200 CC.= 5 YEARS’ SUPPLY

ref

CARIES DETECTOR - NO EFFECT ON BOND STRENGTH

• El-Housseiny and Jamjoum, J Clin Pediat Dent 2000

• Kazemi et al, Oper Dent 2002

AFFECTED DENTIN

INFECTED DENTIN

SETTING THE STAGE FOR PULPAL HEALING

• EXPOSURE ZONE:• LOW/NIL BACTERIAL COUNT

• CONTIGUOUS ZONE• BIOCOMPATIBLE AND CALCIGENIC AGENT• VISIBLE DELINEATION FOR FUTURE INTERVENTIONS

• PERIPHERAL ZONE• PERFECT SEAL (ZERO (ZERO ZERO

MICROLEAKAGE)

• TUBULES % AREA

• NUMBER/ MM2

• DIAMETER

• PRESSURE NIL POSITIVE!!!

• SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP DENTIN

20 K60K

1u3u

10% 90%


Healthy patient

Recoverable pulp


Disinfection

Histological repair

seal


LEAVING CARIES?JOE — Volume 36, Number 9, September 2010

Long-term Survival of Indirect Pulp Treatment Performed in Primary and Permanent Teeth with Clinically Diagnosed Deep Carious LesionsRene´ Gruythuysen, DDS, PhD, Guus van Strijp, DDS, PhD, and Min-Kai Wu, MSD, PhDE

2 APPLICATIONS ONE MINUTE EACH

ref

CR JAN 2010

• CR News Jan 2010 vol 3 issue 1• http://www.cliniciansreport.org/products/den

tal-reports/january-2010-volume-3-issue-1.php

• Subscription required

http://www.cliniciansreport.org/products/dental-reports/january-2010-volume-3-issue-1.php



POTENTIAL DISINFECTANTS

• ENDODONTIC• SILVER NITRATE• IODINE• FORMOCRESOL• CA(OH)2

• PULPAL• HYPOCHLORITE - KANCA• CHLORHEXEDINE-MANY

ref

CHLORHEXEDINE NO EFFECTON BOND STRENGTH

• Santos et al, JOE, 2006• Perdiao et , Am J Dent 1994

WHAT ABOUT SURFACE DISINFECTANTS?

• HYPOCHLORITE• 70% ALCOHOL WITH PHENOLS • 70% ALCOHOL WITH CHX • ACCELERATED PEROXIDE

ref

NaOCl• IS A STRONG OXIDIZING AGENT• REDUCES BOND STRENGTH OF DENTIN

BONDING AGENTS• Ari et al, JOE, 2003• Erdemir et al, JOE, 2004• Santos eta l JOE, 2006• Lai et al, J Deny Res 2001

REVERSING NaOCl EFFECTS ON DBAS

A reducing agent, such as ascorbic acid, or sodium ascorbate, reverses the effect of NaOCl on bonding strength

Morris et al, JOE, 2001Lai et al, J Dent Res, 2001Yiu et al, J Dent Res, 2002Weston et al JOE, 2007: 10% Na ascorbate for 1 min restored the original bond

strength

EDTA reverses effect of NaOCl

• Doyle t al, JOE, 2006• A final rinse with EDTA reversed the effects of

NaOCl on bonding

H2O2 reduces bond strength of DBAs

• Erdemir et al JOE, 2004• Nikaido et al, Am J Dent 1999

DEEP CARIES DISINFECTION

• Optim 33TB Sci Can• One minute kill =10 Log -6

• TB effective• CR tested April 2007• Excellent surface cleaner• Tissue compatible

DISINFECTION PRIOR TO EXPOSURE

• GET CLOSE WITH DETECTOR• OPTIM 33TB ONE MINUTE• NO DETECTOR• FINAL EXCAVATION

– SLOW RPMS– SPOON

• ACID ETCH 10 SECONDS/RINSE– REMOVE SMEAR LAYER

• OPTIM 33 ONE MINUTE– PENETRATE TUBULES

OPTIONS FOR REMOVING SMEAR LAYER &PENETRATING TUBULES

• EDTA 14%• SmearClear (SybronEndo)

– 17%EDTA ,surfactant• QMix (Tulsa/Dentsply)

– CHX digluconate, <15% EDTA, surfactant

• Phosphoric Acid etch• Citric acid

CAPPING THE EXPOSURE:CAP, SEAL CAP WITH RESIN, RESTORE

• FINAL EXCAVATION; EXPOSE if still carious• MTA DIRECT CAP• IMMEDIATE OVERSEAL WITH UNMODIFIED GLASS IONOMER (LUTING

CEMENT)• ALLOW GI TO SET (APPROX 4 MINS)• EDTA TO RESTORE BONDABILITY• PA ETCH/RINSE/DRY PRIME/DRY+ BOND/THIN/EVAPORATE• SEAL CAP PERIMETER FLOWABLE/CURE • SEAL REMAINING DENTIN AND GINGIVAL MARGIN WITH FLOWABLE AND

CURE• RESTORE WITH FINAL RESIN FOLLOWING LOW CONTRACTION STRESS

PRINCIPLES , IE, INCREMENTING• FINISH AND ARTICULATE METICULOUSLY

MTA MECHANISM

• Silviera CMM et al. Repair of Furcal Perforation with Mineral Trioxide Aggregate: Long-Term Follow-Up of 2 Cases JCDA October 2008 Vol 74 #8 729-732

• http://www.cda-adc.ca/jcda/vol-74/issue-8/729.html

http://www.cda-adc.ca/jcda/vol-74/issue-8/729.html

http://www.cda-adc.ca/jcda/vol-74/issue-8/729.html

MTA MECHANISM• Saidon J et al. OSOMOPOR Endod 2003:95:483-489 “Cell and tissue reactions to mineral trioxide aggregate (MTA) and Portland cement.”

• MTA and Portland cement show comparative biocompatibility when evaluated in vitro and in vivo. The Portland cement was sterilized by ethylene oxide.

MTA MENTE ET AL

• Johannes Mente, DMD, et al J. Endo May 2010 806-814

• Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: An Analysis of the Clinical Treatment Outcome

• 5 years, 167 teeth • 80% success MTA, 60% Ca(OH)2

• i.e. Twice as much failure with Ca(OH)2

Mente, DMD, et al J. Endo May 2010• Dentin bridge formation with MTA appears more homogenous (fewer tunnel

defects) and more localized than that formed with Ca(OH)2 (20–24). caries was excavated from the cavity walls.

• Near to the pulp, except for one carious spot, the removal of which resulted in exposure of the pulp, the cavities were routinely disinfected with 0.12% chlorhexidine solution (Glaxo Smith Kline GmbH, Buhl, Germany).

• Resolution of bleeding from the exposed pulp in less than 5minutes was considered to be indicative of reversible inflammation

• The MTA pulp cap was overlaid with a thin protective layer of resin modified glass ionomer cement (Vitrebond; 3M Espe)

• The reduction in clinical success if a direct pulp capping is not followed immediately with permanent restoration has been shown in other clinical studies (11, 12)

• The longer the follow-up period, the more evident the trend decline in the success rate of the teeth in the Ca(OH)2 group compared with the MTA group.


Healthy patient

Recoverable pulp


Disinfection

Histological repair

seal


RESIN BIOCOMPATIBILITY???• Volk,J, Engelmann,J.,Leyhausen,G.,Geurtsen,W.• Dental Materials 2006 22:499-505• Effects of three resin monomers on the cellular

glutathione concentration of cultured human fibroblasts

See Website: Home>MODXYZ> Biocompatibility

ref

DYRACT AND DYRACT-CEM AND VITREBOND

• J Dent Res. 1998 Dec;77(12):2012-9.Residual monomer/additive release and variability in cytotoxicity of light-curing glass-ionomer cements and compomers. Geurtsen W, Spahl W, Leyhausen G. Severe cytotoxic effects were observed in response to both of these materials

• Mutat Res. 1996 Jul 5;368(3-4):181-94.• Genotoxicity of dental materials. Heil J, Reifferscheid G, Waldmann P,

Leyhausen G, Geurtsen W. Genotoxic effects were found for Vitrebond and AH 26 (since upgraded to AH26 Plus)

GLASS IONOMER BIOCOMPATIBILITY

• Biomaterials. 1998 Mar;19(6):559-64.Biocompatibility of various light-curing and one conventional glass-ionomer cement.Leyhausen G, Abtahi M, Karbakhsch M, Sapotnick A, Geurtsen W.

Two GIs was found to be very biocompatible, while Vitrebond was found to be cytotoxic.

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PEDODONTIC PULPOTOMY


Healthy patient

Recoverable pulp


Disinfection

Histological repair


Seal

SEALING THE PULP CAP

IMMEDIATE RESTORATION improves prognosis 30% (Mente et al)

PROTECT THE CAP from shrinkage FINAL RESTORATION with low sensitivity

technique CAREFUL OCCLUSION

CAREFUL AND ACCURATE OCCLUSION


Healthy patient

Recoverable pulp


Disinfection

seal

Histological repair


INFLAMMATION MANAGEMNT

• MEDICATION– Disciplined use of Ibuprofen 400 mg for 24 hours

q4h 6 tabs– Instruct to use regardless if painful or not

• Alternative for NSAID- intolerant patients: dexamethasone

• COMMUNICATION 1. Cautious prognosis2. “Call me I want to know”3. Next day follow-up call 11 am4. Not that night!5. Inform that success may be temporary

THE END

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PULP CAP