Vital Pulp Therapy

A look at treatments modalities for cases involving deep dentin involvement and pulp therapy for vital teeth.

John C Comisi, DDS, MAGD

Incomplete Caries Removal

“The Evidence states you will be saving pulps”

John C Comisi, DDS, MAGD

Incomplete Caries Removal

Indirect Pulp Treatment Types: 1.Indirect Pulp Cap (2 Step or Stepwise Method)

2.Partial Caries Removal (1 Step Method)

John C Comisi, DDS, MAGD

John C Comisi, DDS, MAGD

• A cascade of events lead to the mineralization of the collagen based tissue.

• Calcium ions interact with acidic residues and then combine with Phosphates to initiate a nucleation process.

• The collagen matrix provides a spatial template upon which the mineral crystals deposit.

• Collagen is synthesized and subsequently controlled by the odontoblasts.

John C Comisi, DDS, MAGD

Significant Challenges in Clinical Dentistry

Maintaining a vital pulp

Dentin replacement due to caries: Introduction of a variety of dental materials over

the past five decades to solve these issues Calcium Hydroxide Glass Ionomers Composites Calcium Silicates

John C Comisi, DDS, MAGD

More challenging situations

In daily clinical practice, the following situations are encountered in vital, asymptomatic teeth:

• Small pinpoint mechanical pulpal exposure • Carious pulpal exposure • Very deep caries, but no pulpal exposure

Choices: endodontic treatment or vital pulp therapy with pulp capping…

John C Comisi, DDS, MAGD

Apatite Formation

John C Comisi, DDS, MAGD

The Magic of Calcium Hydroxide

High pH/Bactericidal

Stimulates formation of reparative dentin/ability to extract growth factors from the dentin matrix

Ability to neutralize bacterial by-products (acids)

Clinical proven as a direct pulp capping agent

John C Comisi, DDS, MAGD

John C Comisi, DDS, MAGD

Glass

CaO+ Leach

Chemical

Dissolve

CaO are stable forms of Calcium Hydroxide

John C Comisi, DDS, MAGD

Examples of bioactive products for vital pulp therapy

▪ Biodentine ▪ Dycal ▪ EndoSequence ▪ MTA Filapex ▪ MTA - Angelus ▪ Multi-Cal ▪ ProRoot MTA ▪ TheraCal LC

John C Comisi, DDS, MAGD

Bioactive Pulpal Therapies

Direct: Biodentine, Dycal, Endo Sequence, MTA, Multi-Cal, TheraCal

Indirect: ACTIVA BioACTIVE-BASE/LINER, Biodentine, TheraCal

John C Comisi, DDS, MAGD

Bioactive Restoratives with Significant Ion Release

▪ 3M Ketac Products ▪ GC GI and RMGI Products ▪ Pulpdent Bioactive Restoratives ▪ SDI GI and RMGI Products ▪ Shofu Giomer Products

John C Comisi, DDS, MAGD

Constructedfrommedicalgrade,glass-beadreinforcedpolymer

Single-patient-useinstruments

Foruseinslowspeedhandpieceonly

3sizes:RA#4,RA#6,RA#8

John C Comisi, DDS, MAGD

Create access to caries

Cut through harder tooth structure or restoration to reach underlying caries

Caries access instruments: - Fissurotomy type burs - carbide burs/diamonds

appropriate to the shape and location of the lesion,

- air abrasion system

John C Comisi, DDS, MAGD

harderthaninfected(carious)dentin

softerthanhealthy(affected)zonesofdentin

Polymer Bur

John C Comisi, DDS, MAGD

When contacting healthy dentin:

-Tactilely sense a vibration through the handpiece

- Unable to cut healthy dentin

- Prolonged contact with hard surfaces degrades the working end

John C Comisi, DDS, MAGD