Recent Concepts in Vital pulp therapy

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Dr. Sarjeev Singh YadavProfessor & HOD

Dept. of Conservative dentistry and Endodontics

Govt. Dental College and Hospital 04/11/2023 2YES YES WHY

Greatest challenges to the integrity of the developing tooth

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Abnormal root development

Impact on long-term prognosis for tooth retention

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Primary goal

Maintain pulp vitality

Normal tooth development occurs

Promotes healing by regeneration rather than repair

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The Pulp-Dentin Complex in Primary and Young Permanent Teeth

Deep dentin is more porous than superficial dentin. Normally in primary and young permanent teeth, the dentin is thinner and more porous than in their mature permanent counterparts.

The pulps of primary and immature permanent teeth are at special risk from deep carious lesions, deep cavities, and traumatic injuries.

Key Points of Clinical Relevance:

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Superficial dentin

Deep dentin

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Sensory innervations to the pulp does not mature until the late stages of root formation; pulp testing may therefore be inconclusive in immature teeth.

Young, well-perfused pulps have enormous reparative capacity in the face of injury.

The Pulp-Dentin Complex in Primary and Young Permanent Teeth

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Key responses of the dentin-pulp to caries / injury

Tertiary dentin 04/11/2023 9YES YES WHY

Reactionary dentinogenesis

Caries

Odontoblasts

Dentin

Tertiary, reactionary dentin laid down by primary odontoblasts

as they retreat from injury

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Reparative dentinogenesis

Tertiary, reparative dentin

Deep dentin injury kills primary odontoblasts and stimulates recruitment of

replacements fromthe cell-rich layer

New odontoblast-like cells migrate to

the wound

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Recent concepts in Vital Pulp Therapy04/11/2023 12YES YES WHY

CASE SELECTION

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• A correct diagnosis of pulp conditions in primary and young permanent teeth is important for treatment planning.

• McDonald and Avery have outlined several diagnostic aids in selecting teeth for vital pulp therapy.

• Eidelman et al and Prophet and Miller have emphasized that no single diagnostic means can be relied on for determining a diagnosis of pulp conditions.

• A suggested outline for determining the pulpal status of cariously involved teeth in children involves the following:

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1. Visual and tactile examination of carious dentin and associated periodontium2. Radiographic examination of a. periradicular and furcation areas b. pulp canals c. periodontal space d. developing succedaneous teeth3. History of spontaneous unprovoked pain4. Pain from percussion5. Pain from mastication6. Degree of mobility7. Palpation of surrounding soft tissues8. Size, appearance, and amount of hemorrhage associated

with pulp exposures

Endodontics : Ingle 5th edi04/11/2023 15YES YES WHY

Electric pulp tests are not valid in primary teeth.

Andreasen et al. Textbook and color atlas of traumaticinjuries to the teeth. 4th ed, 2007

Thermal tests are usually not conducted on primary teeth because of their unreliability.

Cohen S, Hargreaves K : 9th ed. 2006:822– 82.

Numerous studies have reported the unreliability of electric pulp tests in permanent teeth with open and developing apices.

J Dent Child 1978;45:199 –202.J Endod 1986;12:301–5.

Aust Dent J 1977;22:272–9.

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Laser Doppler flowmetry might be of greater help in determining vitality.

Endod Dent Traumatol 1999;15:284 –90. Dent Traumatol 2001;17:63–70

Endod Top 2003;5:12–25.

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- Type of injury

- age of the pt

- size & location of the pulp exposure

- bacterial contamination

- pulp capping material &

- quality of the final restoration

The outcome of VPT depends on:

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1. Indirect pulp capping 2. Direct pulp capping 3. Coronal pulpotomy

Vital pulp therapy for primary and young permanent teeth involves the following techniques:

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Indirect pulp capping

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• to arrest the carious process, • provide conditions conducive to the formation of

reactionary dentin, and • promote remineralization of the altered dentin that was left. • This in turn is expected to promote pulpal healing and

preserve/maintain the vitality of the pulp.

Def: The application of a medicament over a thin layer of remaining carious dentin, after deep excavation, with no exposure of the pulp.

The aims of indirect pulp capping is:

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INDICATIONS

1. History a. Mild discomfort from chemical and thermal stimuli b. Absence of spontaneous pain 2. Clinical examination a. Large carious lesion b. Absence of lymphadenopathy c. Normal appearance of adjacent gingiva d. Normal colour of tooth 3. Radiographic examination a. Large carious lesion in close proximity to the pulp b. Normal lamina dura c. Normal periodontal ligament space d. No interradicular or periapical radiolucency04/11/2023 22YES YES WHY

CONTRAINDICATION

S 1. History a. Sharp, penetrating pain persisting after withdrawing stimulus b. Prolonged spontaneous pain, particularly at night 2. Clinical examination a. Excessive tooth mobility b. Parulis in the gingiva approximating the roots of the tooth c. Tooth discoloration d. Non responsiveness to pulp testing techniques 3. Radiographic examination a. Large carious lesion with apparent pulp exposure b. Interrupted or broken lamina dura c. Widened periodontal ligament space d. Radiolucency at the root apices or furcation areas04/11/2023 23YES YES WHY

• Two appointment technique

• One appointment technique

TECHNIQUE

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What materials are used?

Hard setting Ca(OH)2

ZOE

GIC (Glass ionomer caries control approach)

Resin modified glass ionomer

Bonded composite

MTA

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• IPC studies show success rates of 90% or greater over time with differing techniques and medicaments.

J Endod Vol 34, No 7S, July 2008

IPT medicaments Success (%)

Time (mo)

Sample (N)

Nirschl and Avery 1983

Calcium hydroxide 94 6 33

Al-Zayer et al. 2003

Calcium hydroxide 95 14 (median)

187

Vij et al. 2004 Glass ionomer 94 40 108

Farooqet al. 2000 Glass ionomer 93 50 55

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• To manage lesions in primary molars (that are symptom free and free from radiographic signs of periradicular pathology) by cementing a preformed metal (stainless steel) crown in place without local anaesthesia, tooth preparation, or any attempt at caries removal.

Innes NP, Stirrups DR, Evans DJ, Hall N, Leggate M: A novel technique using preformed metal crowns for managing carious primary molars in general practice–a retrospective analysis. Br Dent J 200:451, 2006

The Hall Technique

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• The Hall technique was preferred to conventional restorations by the majority of children, guardians, and clinicians.

• After a review period of 2 years, comparing the teeth managed using Hall preformed metal (stainless steel) crowns with conventional restorations, the “Hall crowns” showed better treatment outcomes for both pulpal health and restoration longevity.

Innes NP, Evans JP, Stirrups DR: The Hall technique; a randomized controlled clinical trial of a novel method of managing carious primary molars in general dental practice: acceptability of the technique and outcomes at 23 months. BMC Oral Health 7:18, 2007.

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• The pulps of young permanent teeth are at risk of breakdown following traumatic injuries, dental caries, and restorative dentistry.

• There is good evidence that RDT is a key determinant of pulp survival after cavity preparation, and avoiding pulp exposure has been considered advantageous.

Int Endod J 41:389, 2008.

• The management of deep caries by partial and serial excavation has gained considerable support in recent years, reducing the risks of pulp exposure and harnessing the natural defences of the pulp in laying down protective tertiary (reactionary) dentin.

J Endod 34(7S):S29, 2008.

In YOUNG PERMANENT TEETH..

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• Researchers continue to investigate the role of antimicrobial treatments, including

• ozone fumigation, Eur J Oral Sci 114:349, 2006

• photo-activated disinfection (PAD), and• antimicrobial resins in sterilizing deep layers of affected

dentin and creating the conditions for arrest and remineralisation.

Int Endod J 40:58, 2007.

• Considerable interest has also focused on the active upregulation of reactionary dentinogenesis by applying bioactive agents such as the TGF-β family of molecules to the depths of cavity preparations.

Caries Res 38:314, 2004.

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Direct pulp capping

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Def: Direct pulp capping involves the placement of a biocompatible agent on healthy pulp tissue that has been inadvertently exposed from caries excavation or traumatic injury.

Oral Surg 1972;34:477.

Objective: is to seal the pulp against bacterial leakage, encourage the pulp to wall off the exposure site by initiating a dentin bridge, and maintain the vitality of the underlying pulp tissue regions.

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• Vital pulp therapy has a high success rate if the following conditions are met:

(1) The pulp is not inflamed;

(2) Hemorrhage is properly controlled;

(3) A non-toxic capping material is applied; and

(4) The capping material and restoration seal out bacteria.

Requirements for a successful vital pulp therapy:

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1. Small pin point mechanical exposures of diameter

< 1.0mm

2. Pulp exposed without previous symptoms of pulpitis.

INDICATIONS

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CONTRAINDICATIONS

(1) Spontaneous and nocturnal toothaches. (2) Excessive tooth mobility. (3) Thickening of the PDL. (4) Radiographic evidence of furcal or periradicular degeneration. (5) Uncontrollable hemorrhage at the time of exposure, and (6) purulent or serous exudate from the exposure.

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CLINICAL SUCCESS

(1) Maintenance of pulp vitality,

(2) Absence of sensitivity or pain,

(3) Minimal pulp inflammatory responses, and

(4) Absence of radiographic signs of dystrophic changes.

Salient features of a clinically successful DPC (with or without bridging) are:

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WHAT ARE THE MATERIALS AVAILABLE..?

• 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. (Dammaschke T 2008)

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• Ca(OH)2

• ZOE• Corticosteroids and

antibiotics• Polycarboxylate cements• Inert materials• Collagen fibers• Formocresol • Bonding agents

• Cell Inductive agents• Hydroxyapatite• Bioactive glass• MTA• Calcium phosphate

cement• Calcium enriched mixture• Lasers• Biodentine• Emdogain

PULP CAPPING AGENTS

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Which material is biocompatible to be used

• Calcium hydroxide (CH) or calcium hydroxide compounds have, for many years, been the material of choice.

• But calcium hydroxide and most calcium hydroxide cements are liable to dissolution, dentin bridge formation beneath CH has tunnel defects and, in cases of microleakage around restorations, bacteria may gain access to the exposure site.

Asgary et al, 2008, Cox et al, 1985, Pitt ford, Roberts 1991

• Therefore, much research has been devoted to generate alternative materials.04/11/2023 39YES YES WHY

• Self-etching adhesive and calcium hydroxide on human pulp tissue:

• The clearfil SE ability to induce reparative dentin was significantly weaker than Dycal.

Lu et al, 2008

• Direct pulp capping in dogs teeth with self-etching adhesive system did not allow pulp tissue repair and failed histopathologically in 100% of the cases.

da Silva La et al, 2009

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• Tri-calcium phosphate based cement:

• Dentin bridge formation was observed on exposed pulps of rats with no evidence of necrosis or marked inflammation.

Yoshimine and Maeda, 1995

• Tricalcium phosphate was most active when used in combination with CH.

Yoshiba K, Yoshiba N, Iwaku M, 1994

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• Adhesive resin-based composite:

• The globules of resin can migrate into the pulp tissue and stimulate inflammation.

Kitasako et al, 1999

• In addition, polymerization shrinkage during the placement of these materials can create marginal gaps to permit bacterial leakage to occur.

Pashley, 1996

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• Calcium hydroxide combined with Vancomyin:

• The combination of CH with vancomycin in monkeys was somewhat more successful in stimulating regular reparative dentin bridges.

Gardner et al, 1971

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MTA or

Calcium hydroxide

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• The disadvantages of CH:

• The presence of tunnel defects in dentin barrier.• Extensive dentin formation.• High solubility in oral fluids.• Lack of adhesion and degradation afer acid etching.

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Mineral trioxide aggregate (MTA)

• It was introduced in 1993 by Torabinejad.

• Pitt Ford et al, 1996 were the first to evaluate the performance of MTA for pulp capping in monkey’s teeth.

• Pulp capping with MTA is recommended for teeth with carious pulp exposures specially immature teeth with high potential for healing.

Farsi N, et al 2006

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• MTA is superior in terms of dentin bridge formation during the early healing process in human dental pulp.

Min et al, 2008

• MTA seemed to heal the pulp tissue at a faster rate than CH cement in human teeth.

Accornite et al, 2008

• MTA was clinically easier to use as a direct pulp capping agent and resulted in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal.

Nair PN et al, 2009

MTA

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• It has excellent sealing ability. Torabinejad et al, 1993, 1994, Bates et al, 1996, Fischer

et al, 1998, Wu et al, 1998.

• Biocompatibility. Kettering & Torabinejad 1995, Torabinejad et al, 1997,

1998, Holland et al, 1999, Mitchell et al, 1999, Keiser et al, 2000

MTA

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Technique

initial deep caries and immature apices

Five-minute application of 5.25% sodium hypochloritehemostasis, on two 1.5- to 2.0-mm exposures

Pulpal exposure

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Radiograph of molar with MTA after initial visit

Radiograph taken at the 5.5-year recall appointment showing permanent

restoration and evidence of complete root formation.

(From Bogen G, Kim JS, Bakland LK: Direct pulp capping with mineral trioxide aggregate. An observational study. J Am Dent Assoc 139:305-315, 2008.04/11/2023 50YES YES WHY

Biodentine• Biodentine™ consists of a powder in a capsule and liquid in

a pipette. • The powder mainly contains tricalcium and dicalcium

silicate, the principal component of Portland cement and MTA, as well as calcium carbonate.

• Zirconium dioxide serves as contrast medium. • The liquid consists of calcium chloride in an aqueous

solution with an admixture of modified polycarboxylate.• The powder is mixed with the liquid in a capsule in a

triturator for 30 sec.• Once mixed, Biodentine™ sets in about 12 to 15 Min.• During the setting of the cement calcium hydroxide is

formed.04/11/2023 51YES YES WHY

• On the biological level, it is perfectly biocompatible

(Laurent et al., 2008) and capable of inducing the apposition of reactionary dentin by stimulating odontoblast activity

(Goldberg et al., 2009) and reparative dentin, by induction of cell differentiation (Shayegan et al., 2010).

• It is in effect a dentin substitute that can be used as a coronal restoration material (for indirect pulp capping), but can also be placed in contact with the pulp.

• Its faster setting time allows either immediate crown restoration (Tran et al., 2008), or to make it directly intraorally “functional” without fear of the material deteriorating.

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Technique

Clinical view Distal pulp horn involvement

After removal of restoration Biodentine placement04/11/2023 53YES YES WHY

Post--‐operative clinical view Post‐operative X‐ray follow‐up image

Ceramic onlay, final restoration after 2 months

Post ‐operative X‐ray follow‐up image

- Dr. Lucile Goupy04/11/2023 54YES YES WHY

• Biodentine, Ca(OH)2, MTA and Xeno III:

• Biodentine™ induced mineralized foci formation early after its application. The mineralization appeared under the form of osteodentine and expressed markers of odontoblasts.

• Biodentine™ significantly increased TGF- β1 secretion from pulp cells ( P < 0.03) independently of the contact surface increase. This increase was also observed with calcium hydroxide and MTA, but not with the resinous Xeno®III.

Laurent P, Camps J, About I: Int Endod J; May 2012, Vol. 45 Issue 5, p439-448.

04/11/2023 55YES YES WHY

Calcium enriched cement

• Calcium enriched mixture (CEM) cement is a new endodontic cement with similar clinical applications as MTA but different chemical composition.

J Endod 2008;34:990–3, J Endod 2009;35:243–50.

• CEM cement has antibacterial effect comparable to CH and superior to MTA (Asgary S, Kamrani FA 2008) and sealing ability similar to MTA (Asgary S, Eghbal MJ, Parirokh M 2008).

• The biologic response of the pulpal tissue to MTA and CEM cement has been shown to be similar in dogs’ teeth.

Asgary S et al, 200804/11/2023 56YES YES WHY

• In addition, Asgary and Ehsani showed in a case series study that CEM cement has favourable clinical success in pulp capping of permanent molars with irreversible pulpitis.

J Conserv Dent 2009;12:31–6.

• It has been shown that CEM cement provides an endogenous source of calcium and phosphate ions that accelerates hydroxyapatite (HA) crystal formation as a second-seal on its surface even in normal saline storage media.

Aust Endod J 2009;35:147–52.

• The composition of the set form of CEM cement is similar to dentin.

J Endod 2009;35:243–50.

04/11/2023 57YES YES WHY

Bioactive glass (BAG)

• Bioactive glass is often used as a filler material for repair of dental bone defects.

• They react with aqueous solutions and produce a carbonated apatite layer.

• BAG is biocompatible and can bind to the bone.

• BAG can be the material of choice for pulp capping and periapical bone healing because it is biocompatible and has antibacterial property.

Schepers et al, 199104/11/2023 58YES YES WHY

• Bioactive glass and calcium hydroxide in primary molars:

• Less inflammation, dentin bridge formation and no internal resorption, necrosis or abscess in BAG group.

Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2007; Vol: 4, No.4)

Pulpal response CH BAGMild inflammation 2 0

Mild inflammation 5 2

Severe inflammation 3 1

Internal resorption 6 0

Abscess 5 0

Necrosis 0 0

Dentinal bridge 7 2

04/11/2023 59YES YES WHY

Bioactive ceramic (Novamin)

• Novamin® compared with calcium hydroxide as a pulp-capping agent:

• Novamin® showed less or no inflammation when compared to Ca(OH)2.

• There was no presence of bacteria on any sample for both NovaMin® and Ca(OH)2 groups.

Bioceramics: Volume 8, 1995. 512 pg

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• ODAM has been shown to be specifically expressed in ameloblasts and odontoblasts and has been suggested to play a role in the mineralization of the enamel, possibly through the regulation of matrix metalloproteinase 20.  However, its function in dentin is not clear. 

White MTA and rODMA comparison on formation of reactionary dentine formation:

• rODAM accelerates reactionary dentin formation close to the pulp exposure area, thereby preserving normal odontoblasts in the remaining pulp.

J Endod; Dec 2010, Vol. 36 Issue 12, p1956-1962.

Odontogenic ameloblast-associated protein (ODAM)

04/11/2023 61YES YES WHY

Emdogain

• Enamel Matrix Derivative (EMD) is a rich amelogenin and amelin biomaterial that has been demonstrated to induce a reparative process similar to normal odontogenesis when placed in contact with pulp tissue.

• Numerous in vivo and in vitro studies, as well as clinical trials, have shown that EMD is clinically useful in promoting periodontal regeneration.

Esposito M et al 2003

• Several studies have also shown its promising effect in direct pulp capping.

04/11/2023 62YES YES WHY

• Histological evaluation of EMD as a pulpotomy agent in primary teeth:

Pediatric Dent 2007 Nov-Dec;29(6):475-9.

Extraction of primary canines

Histology of pulp

after 1 week surface was lined by a thin, nearly continuous cellular layer. Generalized congestion was accompanied by an increase in angiogenesis

after 2 weeks small islands of dentin-like tissue at different stages of mineralization.

after 6 months coalescing islands of dentin-like tissue trying to bridge the full width of the coronal pulp at the interface between the wounded and unharmed pulp tissue below the amputation site.

04/11/2023 63YES YES WHY

• A Hybrid Approach to Direct Pulp Capping by Using Emdogain with a Capping Material:

• Calcium hydroxide, ProRoot White MTA, white Portland cement were used after Emdogain application on the exposed pulp.

• MTA produced a better quality reparative hard tissue response with the adjunctive use of Emdogain, when compared with the use of calcium hydroxide.

J Endod 35 , Pages 667-672, May 2011

04/11/2023 64YES YES WHY

Tetracalcium phosphate-based cement

• Comparison of histologic healing processes with either tetracalcium phosphate cement or calcium hydroxide cement to the exposed pulp of the rat maxillary incisors:

• In teeth applied with Ca(OH)2, necrotic tissue was present beneath the cement before new hard tissue formed.

• In contrast, tetracalcium phosphate cement elicited a dentine bridge formation with no evidence of either intervening tissue necrosis or marked inflammation.

04/11/2023 65YES YES WHY

• Furthermore on ultrastructural examination the newly formed hard tissue was in direct contact with the material.

• This study suggests that 4CP cement possesses a biocompatible property, which indicates its potential for use as a direct pulp-capping agent.

Yoshimine Y, Maeda K, 1995

04/11/2023 66YES YES WHY

New Bioceramic Root Repair Putty

• Brasseler USA (Savannah, GA) has formulated a bioceramic material for root repair needs. Currently there is limited research on the Endosequence Root Repair Material (ERRM).

• It has mainly been evaluated for use as a root-end filling material.

• Its properties include exceptional stability, high mechanical bond strength, high pH, radiopaque, and hydrophilic setting properties, and it is premixed.

J Endod 2011;37:372–5.04/11/2023 67YES YES WHY

• MTA-Angelus, Brasseler Endosequence Root Repair Putty (ERRP) , Dycal and Ultra-blend Plus (UBP):

• MTA-Angelus, (ERRP) , and Ultra-blend Plus had statistically similar adult human dermal fibroblast cytotoxicity levels.

• Relative to the negative control, only Dycal was shown to have a statistically significant cytotoxic effect on adult human dermal fibroblasts at all tested intervals.

• ERRM and UBP did not negatively influence cell survival.Hirschman et al, J Endod 2012; 1–4 (Article in press)

04/11/2023 68YES YES WHY

Theracal

• TheraCal LC is a light-cured resin-modified calcium silicate pulp protectant / liner designed to perform as a barrier and to protect the dentin-pulp complex.

• The light-cured set permits the practitioner immediate placement and condensation of the restorative material.

• TheraCal is indicated in both indirect and pulp capping procedures.

04/11/2023 69YES YES WHY

• Comparison of chemical-physical properties of TheraCal, ProRoot MTA and Dycal:

• TheraCal displayed higher calcium-releasing ability and lower solubility than either ProRoot MTA or Dycal.

• The capability of TheraCal to be cured to a depth of 1.7 mm may avoid the risk of untimely dissolution.

• These properties offer major advantages in direct pulp-capping treatments.

Int Endod J , 45: 571–579, June 2012.

04/11/2023 70YES YES WHY

Pulpotomy

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Def: “amputation of the affected or infected coronal portion

of the dental pulp, preserving the vitality and function

of all or part of the remaining radicular pulp”.

AAPD guidelines 2003-2004

• Outcome of the treatment – influenced by type, conc & time of tissue contact of the medicament.

04/11/2023 72YES YES WHY

Indications

• clinical and radiographic signs of radicular pulp vitality, • absence of pathologic change, • restorability, and • at least two-thirds remaining root length.• young permanent teeth with incompletely formed apices

and cariously exposed pulps.

04/11/2023 73YES YES WHY

Contraindications

(1) root resorption exceeding >1/3rd of the root length (2) Nonrestorable tooth crown (3) highly viscous, sluggish, or absent hemorrhage at the radicular canal orifices (4) marked tenderness to percussion (5) mobility with locally aggravated gingivitis associated with partial or total radicular pulp necrosis (6) radiolucency in the furcal or periradicular areas (7) persistent toothaches & coronal pus

According to Mejare:

04/11/2023 74YES YES WHY

- Vitality of the majority of the radicular pulp

- No prolonged adverse clinical signs or symptoms, such as prolonged sensitivity, pain, or swelling

- No radiographic evidence of internal resorption

- No breakdown of periradicular tissue

- No harm to succedaneous teeth

- Pulp canal obliteration (abnormal calcification)

Evidence of success in therapy includes the following:

04/11/2023 75YES YES WHY

Agents for pulpotomy

Pharmacotherapeutic

Formocresol

Glutaraldehyde

Calcium hydroxide

Collagen

Ferric sulfate

CaPo4 cement

Hydroxyapatite

BMP 2 & 4

Freeze dried bone

MTA

CEM

Biodentine

Non-pharmacologic

Electro surgery

Lasers04/11/2023 76YES YES WHY

• Most popular – Formocresol - because of its ease in use and - excellent clinical success.

but concerns systemic distribution potential for toxicity allergenicity carcinogenicity and mutagenicity

04/11/2023 77YES YES WHY

• Studies Directly Comparing MTA and Formocresol

04/11/2023 78YES YES WHY

• Studies Comparing Directly Ferric sulphate and Formocresol

04/11/2023 79YES YES WHY

• Studies Directly Comparing CH and FC

04/11/2023 80YES YES WHY

• This clinical study compared the effects of Nd:YAG laser pulpotomy with FC on human primary teeth.

• In the Nd:YAG laser group, clinical success was achieved in 66 of 68 teeth (97%), and 94% were radiographically successful.

• In the control group, 85% and 78% achieved clinical and radiographic success, respectively.

• The success rate of the Nd:YAG laser was significantly higher than that of the FC pulpotomy.

• The permanent successors of the laser-treated teeth erupted without any complications.

J Endod, 2006: 32:404-7

• Study Comparing Laser With FC:

04/11/2023 81YES YES WHY

• Study Comparing Sodium Hypochlorite With FS:

Vargas etal, 2006

• The authors concluded that preliminary evidence showed that NaOCl can be used successfully as a pulpotomy medicament.

Paediatr Dent 2006, 28: 511-7

Duration Ferric sulphate NaOCl

Clinical success

Radiographic success

Clinical success

Radiographic success

At 6 months 100% 68% 100% 91%

At 12 months 85% 62% 100% 79%

04/11/2023 82YES YES WHY

• Case reports showing successful pulpotomy with MTA

JADA, Vol. 137 May 2006

18 month

19 month

04/11/2023 83YES YES WHY

• Case report showing successful pulpotomy with CEM cement in permanent molar with irreversible pulpitis and condensing apical periodontitis:

Saeed Asgary. J Conser Dent 2011, 14: 90-93

6 months

1 year 2 years

04/11/2023 84YES YES WHY

Regenerative procedures

04/11/2023 85YES YES WHY

• During the last 10–15 years, there has been a tremendous increase in our clinical “tools” (ie, materials, instruments, and medications) and knowledge from the trauma and tissue engineering fields that can be applied to regeneration of a functional pulp-dentin complex.

• In addition, recent case reports indicate that biologically based endodontic therapies can result in continued root development, increased dentinal wall thickness, and apical closure when treating cases of necrotic immature permanent teeth.

04/11/2023 86YES YES WHY

• Several groups recently have published preclinical research or case reports that offer a biologically based alternative to conventional endodontic treatment of these complex clinical cases.

04/11/2023 87YES YES WHY

04/11/2023 88YES YES WHY

J Conser Dent 2012, 15: 97-10304/11/2023 89YES YES WHY

Conclusion

04/11/2023 90YES YES WHY

• The pulp-capping agents used, and not the procedure itself, has been the subject of controversy among researchers.

• Development of new capping materials for delivery of exogenous signaling molecules offers exciting opportunities for the future.

• However, a number of critical considerations, such as the dose-response effects, the nature of the delivery system, half-life of the molecules, their possible side-effects and long term clinical studies need to be addressed before any introduction of new treatment modalities into clinical practice.

04/11/2023 91YES YES WHY

04/11/2023 92YES YES WHY