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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