Tipping the Cap: New Developments in Materials

Used in Vital Pulp Therapy Jarod W. Johnson, D.D.S.

The Problem

The Great Pretenders

Anatomy

• Root development does not complete for 1-4 years after eruption

• Buccal/Lingual Width > Mesial/Distal Width • Radiographs pass through the Buccal/Lingual

Plane • Apical closure cannot always be verified by

radiographic examination

Diagnosis

1. Chief Complaint 2. Medical, Dental, Social History 3. Clinical Examination 4. Radiographic Examination 5. Diagnostic Aids 6. Consultation/Referral

Diagnosis

• Subjective Findings • Objective Findings • Diagnosis Reached On:

• Combination of Findings • Not a Single Finding

• Treatment • Based on Presence or Absence of Pathology

Pulp Testing

• EPT was significantly less effective than CO2 and DDM • p < 0.05

Mature Permanent

Tooth

Immature Permanent

Tooth

Trauma

Open Apex Pulp Canal Mineralization

Pulp Canal Mineralization

Patent Canal Space

Cold EPT EPT Cold EPT Heat

Pulp Testing

False Positives • Multi-rooted Teeth • Adjacent Teeth • Soft Tissues • Patient

False Negatives • Root Development • Trauma • Calcified Roots • Analgesics • Patient

The Dilemma…

Reversible Pulpitis

Irreversible Pulpitis

Restorable Teeth with Immature Root Development

History Diagnostic Testing

Radiographic Examination

Vital Necrotic

Regeneration* Repair (Apical Barrier)

Irreversible Pulpitis Reversible Pulpitis

Pulp Not Exposed Pulp Exposed

Vital Pulp Therapy (Direct Pulp Cap)

Restore Monitor for Symptoms

1. Pulpotomy 2. Repair

3. Regeneration**

*Cases that require a post for coronal restorations are not good candidates for Regeneration. **Cases that have multiple roots may be more difficult to perform Regeneration.

• “The presence or absence of a microbial flora is the major determinant of healing”

• Control Rats • Pulpal necrosis • No instance showed evidence of repair

• Germ-free Rats • No devitalized pulps • Dentin bridging evident at 14 day

Bacterial Progression Affected Dentin Infected Dentin Pulpal Response?

• Affected Tissue • Bacterial Byproducts • No Bacteria

• Infected Tissue • Bacteria Present

48 Lesions (No Exposures) As Size Progressed: • Changes in the Odontoblast Layer • Changes in Vascularity • Changes in Cell Free Zone

12 Lesions > 3/4 Dentin • Coagulative/Liquefactive Necrosis • Inflammatory Cells Present • Bacteria not seen in adjacent vital pulp

Infected Pulp • Affected Pulp Below Necrosis • Inflamed Radicular Pulp

Remaining Dentin Thickness

• > 1.1 mm • No pathologic changes

• < 0.5 mm • Pathologic pulpal changes

Biocompatibilty of surface sealed dental materials against exposed pulps

• Zinc Oxide Eugenol • Variety of reactions at 7 days

• chronic pulpal inflammation • deeper pulp was free of inflammation

• No sign of hard tissue repair

• Amalgam • 5/8 inflammation free at 21 days • No hard tissue barrier • Concluded Amalgam is either:

• Inert (Does not initiate inflammation) • Or Inhibits Matrix Formation

Biocompatibilty of surface sealed dental materials against exposed pulps

• Composite • Unsealed: inflammation/necrosis • Sealed: healing, hard tissue barrier formation

• Ca(OH)2 • Minimal inflammation at 7 days • No inflammation at 21 (4/5 teeth) • Hard tissue repair (4/5 teeth)

• Conclusions: • Bacteria associated with inflammation • No bacteria associated with healing • Calcium, hydroxyl ion, or pH are not necessary to initiate pulp

healing but rather the prevention of bacterial leakage

Ca(OH)2

• Properties • Forms a layer of necrosis over

the superficial (1.5 mm ) pulpal tissue

• Coagulative Necrosis • In absence of bacteria pulp will

heal

• Advantages – Fast Setting – Ease of Placement – Antibacterial (basic pH)

• Disadvantages – Slower formation of barrier – Tubular Defects (89% at 2

years) – Deterioration over time – Not Resistant to

Condensation – Dissolution with A/E

Mineral Trioxide Aggregate (MTA) • Properties

– Similar to Portland Cement – Ca2+ ions release to combine

with PO43- ions to form

hydroxyapatite – pH is supportive of dentin

formation

• Advantages – Faster bridging than Ca(OH)2 – Bioactive – Biocompatible – Antibacterial (basic pH)

• Disadvantages – Long Setting Time – Difficult to Handle – Co$t – Staining

MTA Placement

Bioceramics

• Properties – Contains main components

of Portland Cement • Tricalcium Silicate • Dicalcium Silicate

– Forms reparative dentin

• Advantages – Placement – Bioactive – Biocompatible

• Disadvantages – Changes in components may

make it inferior to MTA – Lack of Research – Different Formulations

Indirect Pulp Therapy

• Incomplete Caries Removal • Avoid Pulpal Exposure • Seal Bacteria from Substrate • Dentin Changes

• Tertiary Dentin, Dentin Sclerosis, Remineralization

• Types • No Re-entry (1 Visit) • Re-entry (2 Visit, Stepwise Caries

Excavation)

IPT Material

Material N (Teeth) CFU Reduction Re-entry

IRM Dycal

40 p<0.001 p<0.01

5 months Fairbourn et al

Dycal Vitrebond Fuji Lining LC

27 p<0.05 p<0.05 p<0.05

3 months Duque et al

• Reduction in CFU/mg in all groups • No difference between materials respectively • Re-entry may be unnecessary provided coronal

seal is intact

Oops? Or What?

Indirect Pulp Cap

• Despite conscious effort to avoid the pulp; pulp exposures still occur.

• Magnusson et al – 15% • Leksell et al – 18% • Bjorndal, Thylstrup – 5% • Bjorndal et al – 0%

Direct Pulp Cap

Material N % Length

Ca(OH)2 149 87.3% > 5 yrs Haskell et al

MTA 49 96% 1-9 yr Bogen et al

MTA 51 67.7%/56.2% 1 yr, 2 yr Miles et al

MTA/Ca(OH)2 229 80.5% MTA 59% Ca(OH)2 OR: 2.67

2-5 yrs Mente et al*

*Immediate restoration after capping increased success regardless of material (OR: 3.18, p=0.004)

TheraCal LC

• No Human or Animal Studies • Releases Ca2+ions • Physiologic pH after 7 days • Depth of cure 1.7 mm

Biodentine

• Radiographic Bridge • Biodentine – 96.8% • MTA – 72.2%

• Histologic Bridge • Both Groups – 100%

• Bridge Thickness • Biodentine (P < .0001) • < 0.5 mm; radiographs not reliable

Biodentine

• “Regarding the histologic evaluation criteria, our investigation showed that there was no statistically significant difference between the responses of teeth to Biodentine compared with MTA as a pulpcapping agent (P > .05)”

Success

• Indirect Pulp Therapy • 93% in Primary Teeth, Marchi et al • 96% in Primary Teeth, Gruythuysen et al • 10 year survival in Permanent Teeth, Maltz et al

• Direct Pulp Cap • 96% in Permanent Teeth, Bogen et al • 80.5% in Permanent Teeth, Mente et al • 93% at 3 months, Song et al • 87.5% in Permanent Teeth, Haskell et al

Thank you!

• Contact: jarod.w.johnson@gmail.com

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