PULP CAP
FEBRUARY 2013
COMPRESSED
VERSION
MTA THERAPIES
• Root canal therapy
– Perforation repair
– Apicoectomy
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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
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
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%
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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%
100
90
80
70
60
50
40
30
20
10
0
DIRECT
INDIRECT
BOGAN
FUKS
BARTHEL
3
5
10
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”
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
SUCCESSFUL PULP CAPS
Healthy patient
Recoverable pulp
Inflammation
management
seal
Histological repair
Flawless caries
removal
Disinfection
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
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
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APICAL TENDERNESS
SPONTANEOUS
LONG STANDING
NOCTURNAL
THROBBING
ENDURING
SICKENING
CONSTANT NEED OF MEDICATIONS
OPERATIVE CONTRAINDICATIONS
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EXUDATE – SEROUS
PUS
PROLONGED CLOTTING TIME > 5 MINS
>3MM EXPOSURE
GROSS CARIES INTRODUCTION INTO PULP
CHAMBER
• EXPLORER INTO THE PULP (OPERATOR ERROR)
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
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
MICROLEAKAGE)
(ZERO (ZERO ZERO
• TUBULES
% AREA
90%
10%
• NUMBER/ MM2
20 K
60K
• DIAMETER
• PRESSURE
NIL
1u
3u
POSITIVE!!!
• SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP DENTIN
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
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 Lesions
Rene´ Gruythuysen, DDS, PhD, Guus van Strijp, DDS, PhD, and Min-Kai Wu,
MSD, PhDE
CR
JAN 2010
2 APPLICATIONS
ONE MINUTE EACH
ref
• CR News Jan 2010 vol 3 issue 1
• http://www.cliniciansreport.org/products/den
tal-reports/january-2010-volume-3-issue1.php
• Subscription required
POTENTIAL DISINFECTANTS
• ENDODONTIC
• PULPAL
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• HYPOCHLORITE KANCA
• CHLORHEXEDINE-MANY
SILVER NITRATE
IODINE
FORMOCRESOL
CA(OH)2
ref
CHLORHEXEDINE NO EFFECT
ON BOND STRENGTH
• Santos et al, JOE, 2006
• Perdiao et , Am J Dent 1994
WHAT ABOUT SURFACE DISINFECTANTS?
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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, 2001
Lai et al, J Dent Res, 2001
Yiu et al, J Dent Res, 2002
Weston 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
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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
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EDTA 14%
SmearClear (SybronEndo)
– 17%EDTA ,surfactant
•
QMix (Tulsa/Dentsply)
–
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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/issue8/729.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
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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.
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
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 lightcuring 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.
NEW - BIODENTINE
•
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SEPTODONT
$17 PER APPLICATION
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IS MEANT TO BE A COMPLETE TEMPORARY
FILLING
• STICKY HANDLING
• INDEPENDENT REVIEW YET TO BE SEEN
Theracal- Bisco
PEDODONTIC PULPOTOMY
SUCCESSFUL PULP CAPS
Healthy patient
Inflammation
management
Recoverable pulp
Seal
Flawless caries
removal
Histological repair
Disinfection
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
SUCCESSFUL PULP CAPS
Healthy patient
Recoverable pulp
Histological repair
Inflammation
management
Flawless caries
removal
seal
Disinfection
INFLAMMATION MANAGEMNT
• MEDICATION
• COMMUNICATION
– Disciplined use of
1. Cautious prognosis
Ibuprofen 400 mg for 24
2. “Call me I want to
hours q4h 6 tabs
know”
– Instruct to use regardless
3. Next day follow-up call
if painful or not
11 am
• Alternative for NSAIDintolerant patients:
4. Not that night!
dexamethasone
5. Inform that success
may be temporary
THE END