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Introduction
1. Pulp : A peculiar tissue
2. Skepticism towards vital pulp therapy
3. Present concept
4. Preserving tooth vitality.
5. Development of tooth
Bell stage in detail
Odontoblast
Formation of enamel - dentin complex
Types of dentin
1. Primary dentin
2. Secondary dentin
3. Circum-pulpal dentin
4. Intertubular dentin
5. Peritubular dentin
6. Reactionary dentin
7. Reparative dentin
Types of reparative dentin
Blood supply of teeth
Venous drainage of teeth
Lymphatic drainage
Nerve supply and pain perception
Materials of importance
Calcium hydroxide
Mineral Trioxide Aggregate (MTA) / Portland
cement (PC)
Bone Morphogenic Proteins (BMP)
Remaining dentin thickness and its importance
Indirect pulp capping
Definition
Rationale
Case selection
Caries excavation
Mechanical - Rotary and non rotary
Chemomechanical - Carisolv
Photoablation - Laser
Difference between infected and affected
dentin
Procedure
Choice of capping agent
Calcium hydroxide
Dentin adhesives
Pre-requisites
Rationale
Effectiveness
Biological testing
Controversies
Remaining dentin thickness
Quality and durability of bond
Glass ionomer cement
Re-entry?
Direct pulp capping
Case selection
Factors determining success
Control of haemorrhage and pre-treatment
Materials used
Laser
Calcium hydroxide
Dentin bonding agents
Mineral trioxide aggregate
Collagen
Antoxidants
Growth factors
Pulpotomy
Definition
Partial
Complete
Indications
Procedure
Materials used
Calcium hydroxide
Dentin adhesives
BMP
Re-entry?
Molecular biology
Designing new strategies in vital pulp therapy
Summary and conclusion
INTRODUCTION
Why preserve?
1. Loss of vitality – loss of intradental sensory function
Registration of masticatory load:
BMP 2
92
%
59% BMP 5
BMP 4
BMP 6
82
% BMP 7
BMP 8
BMP 9
BMP 3
Bone Morphogenetic Protein Receptors
SIGMA-ALDRICH
THE IMPORTANCE OF REMAINING DENTINE THICKNESS
UNDERLYING CAVITY PREPARATIONS IN MODIFYING PULP
RESPONSES TO DENTAL METERIALS.
STANLEY 1975
Definition
“A procedure where in a small amount of carious
dentin is retained in deep areas of cavity preparation to
avoid exposure of the pulp and placement of a
medicament to seal the dentin, and encourage pulp
recovery.”
Radiography : Absence of –
Periodontal ligament
thickening
Periapical rarefaction
PROCEDURE
Caries removal
Placement of indirect pulp capping agent
Final restoration
Carries excavation
a) Mechanical
Rotary- High and low speed
a. Biocompatible
b. Provide biological seal
c. Prevent bacterial micro leakage
Ca (OH)2
Charles F. Cox
Dentin Adhesives
Pre-requisites:
S.E.P.’s
a) Reduces polymerization
b) Reduces bond strength
c) Therefore integrity of Bond - ?
Indirect pulp capping
Conventional
Ca (OH)2 or ZOE
- Time tested
- Considerable degree of success
- Long term studies available
- Certain limitations
Re-entry necessary:
Re-entry and stepwise excavation suggested (Pittford)
DIRECT VITAL PULP THERAPY
“An exposed pulp is doomed organ” – Rebel
Research ongoing to disprove this axiom – Stanely Cox
and others
Doomed organ ---------- “Hope & Recovery”
Effects:
•Sterilizes exposed pulp and surrounding dentin
•Scar formation owing to thermal effect
•Both above – preserve pulp from bacterial
invasion and help efficiently control hemorrhage
•Direct stimulation of dentinogenesis.
Healing – Ca (OH)2
High pH Material
Zone of obliteration followed by
Zone of coagulation necrosis
Mummification
1. Dentin bridge – forms below the necrotic zone and
pulp void is formed when necrotic zone resorbs
subsequently.
Low Ph material
Rationale:
1. Cohesive hybridization – seal against bacterial
invasion
2. Resinous film layered over wet pulp without
damaging or displacing pulp tissue
3. Primer and adhesive work in wet environment –
reduces potential for dehydration injury
4. Resinous covering effectively prevent displacement
of composite resin into pulp chamber
Pulpal healing following direct pulp capping views
Formation of dentin bridge in primates – although
thickness of dentin bridge was less compared to
calcium hydroxide
Akimoto, Cox et al
Noticed tunnel defects in dentin bridge (79%) due to
presence of vascular channels below the bridging
interface.
Yet, no inflammation since the cavity is adequately
sealed by adhesive – Cox et al.
Dentin bridge formation after adhesive pulp capping –
D.H.Pashley.
Pulp has a high tolerance for acidic conditioners –
Snuggs.
Acid etching of exposed pulp does not produce pulpal
inflammation - Brannstrom.
Pulpal reactions following capping – unfavorable
views
Dentin adhesives may be cytotoxic –
Resin monomers – immunosuppression of pulpal
immunocompentent cells, decreased resistacne to
infectious agents -- increased susceptibility of pulp to
bacterial attack – (Luster et. al.)
Globules of resin monomers in pulp cause foreign
body reaction – (Hussey et. al.)
Advantages:
Highly biocompatible with living tissues
Hydrophillic – sets hard in presence of water
Alkaline (pH 12) – may induce dentinogenesis like
Ca (OH)2 – (Thomas &R.Pittford et. al.)
Collagen:
Advantages: induces dentinogenesis with out pulpal
necrosis
Mechanism
• Collagen fibrils catalyses calcium phosphate
crystallization from physiologic concentration of Ca
and PO4 ions
• 3 dimensional collagen net work is formed
Can be used as frame work for healing
process.
Advantages
1. Hydroxyapatite layer – used as scaffolding for newly
forming mineralized tissue.
2. Wound healing is more desirable than that of
Ca(OH)2
Antoxidants (Catalase)
Mechanism:
a)Free radicals generated during normal oxidative
mechanism --- begin inflammatory process.
Partial pulpotomy
Introduced by Cvek, differs from Sweet’s pulpotomy in
that, only a portion of the coronal pulp, (Superficial
layers – just sufficient depth to reach the tissue that is
free of inflammation) is removed before placing a
medicament.
Indications:
Pulp amputation
Hemorrhage control
Placement of medicament
Final restoration
PARTIAL
PULPOTOMY
COMPLETE
PULPOTOMY
1- Completely
remove caries.
2- Open pulp
chamber by
completely
removing the
roof with 330 high
speed bur.
3- Remove pulp from
pulp chamber with
a sharp curette or
a large round low-
speed bur or a 330
high speed bur.
4- Stop bleeding by
applying a moist
cotton pellet in the
pulp chamber for 3
minutes
5- Place a cotton
pellet with
formocresol for 5
minutes in the
pulp chamber.
6- Remove cotton
pellet and
confirm pulp
fixation, by the
“black eye”
appearance of “Black eye”
the pulp stumps .
7- Fill the pulp chamber
with ZOE-eugenol
Pulp amputation
• Sharp spoon excavator
• Large rotating round bur in slow speed.
• Diamond drill – High speed
• Electro surgery
• Lasers
Control of hemorrhage :
a. Pressure application with moist cotton pellet
b. Haemostatic agent e.g. – aluminum chloride, gel
foam, sodium hypochlorite – good results with
additional advantages
c. Electro surgery
d. Laser energy
i. Blood less tissue incision
ii. Sterilization of pulp, promotes healing
iii. Scarring
Choice of pulpotomy agent
Calcium hydroxide
Formocresol
Gluteraldehyde
Dentin adhesives
Light cure glass ionomers
Collagen, cyanoacrylates
B.M.P’s etc.
Calcium hydroxide: traditionally used over many
decades with considerable degree of success.
Limitations:
May precipitate dystrophic calcification,
complicating pulp space therapy later.
Dentin adhesives as pulpotomy agent
Advantages
Predictably induces sound dentin bridges
leaving radicular tissue completely enclosed in
healthy dentin.
Need for pulp space therapy after pulpotomy
eliminated.
If successful
Vital pulp therapy will acquire more importance
in preventive endodontics.
Pulpotomy – permanent treatment procedure
even in mature teeth.
RECENT CONCEPTS – MOLECULAR
BIOLOGY
MILD INJURY:
PRIMARY DENTIN
ODONTOBLASTS
ODONTOBLAST SECRETORY ACTIVITY
PRIMARY DENTIN
PHYSIOLOGICAL
SECONDARY DENTIN
ODONTOBLASTS
ODONTOBLAST SECRETORY ACTIVITY
INJURY
PRIMARY DENTIN
TERTIARY DENTIN
SEVERE INJURY:
Injury
Primary
dentin
Tertiary
dentin
MOLECULAR AND CELLULAR UNDERSTANDING OF
ODONTO BLAST DIFFERENTIATION :
Differentiation of tooth germ is triggered by various molecular
signals.
.Molecular signals are responsible for the cytodifferentiation of
Dental papilla
IMPORTANCE OF MATRIX
SUB-STRATUM
• The presence of an
Endogenous
insoluble substrate signalling
molecules
odontoblast like
Fibrodentin formed as an intermediate
cells seems to be
matrix zone during the wound healing
of critical
process has been suggested to
importance during
represent the stereotypic requirement
reparative for initiation of reparative dentin
dentinogenesis. formation.
Differentiation of odontoblast like cells in pulp capping situations
has been observed when healing processes occur in contact
with a collagenous matrix formed as a response of vital pulp
tissue to superficial necrosis or with some calcium hydroxide
containing cements.
Calcium hydroxide
Firm zone of
tissue reaction
binding
Endogenous
signalling
Pulpal progenitor cell molecules
Odontoblast – like cell
• The role of these surfaces in the mechanisms,
which control odontoblast like cell differentiation,
has not been adequately investigated.
Controversial
Seltzer and Bender
• Routine re-entry not necessary
• Follow proper technique with utmost care to avoid
microbial contamination – progressive calcification
is infrequent sequelae.
• Periodic recall will suffice – Cohen C. Burns
Conclusion
Ultimate goal of Vital Pulp Therapy is to maintain the
vitality and function of pulp dentin complex.
Natural defense mechanism of pulp have been
fully recognized.
Healing and recuperation of pulp largely
depends on providing an irritation free environment.
Varieties of materials are tested for V.P.T. with
variable degree of success – therefore dentin
bridge formation does not seem to be material
specific.
Do not employ procedures and materials, which
will over power pulpal defenses and push the pulp
beyond a point of no return.
“Do the right thing at the right time –the right
way for the right patient – to get the best
possible results”
List of references
1. Orban’s Oral histology & Embryology. 2004 mosby 11th edition.
2. The dental pulp. 2000 Samuel seltzer & I.B.Bender 3rd edition
3. Tissue engineering (qb) 1999. Samuel E lynch, Robert J Genco & Robert E
Marx.
4. Evaluation of clinical & Microbiological features of deep Carious lesions in
primary molars, Buket ayna et al (J Dent Child 2003;70 15-18).
5. Desinging new treatment strategies in vital pulp therapy, D. Tziafas et al, (J
of dentistry 2000;28 77-92).
6. Calcium hydroxide pastes : Classification and clinical indications, L.R.G.
Fava et al, (INT. Endo J 1999; 32 257-282
7. Formaldehyde in dentistry : A review for the millenium, Bradley Lewis (J Clin,
Pediatr Dent 1998; 22(2) 167-177
8. Er: YAG Laser Effects on Oral Hard and Soft Tissues, Ulrich Keller &
Raimund Hibst (Lasers in Dentistry)
9. Identification of Hard Tissue After Experimental Pulp Capping Using Dentin
sialoprotein (DSP) as a marker (JOE, 2003 29(10) 646-650)
10.Reparative dentin: affecting its deposition, Charles F. Cox et al (QI, 1992 23
257-270
11.Pulp capping of dental pulp mechanically exposed to oral microflora: a 1-2
year observation of wound healing in the monkey. C.F.Cox et al ( J of oral
pathology 1985: 14 156-168).
12.Pulpotomy therapy in primary teeth: new modalities for old rationales, Don
M. Ranly.(Pediatric dentistry 1994 16(6) 403-408)
13.Pulpal healing and dentinal bridge formation in an acidic environment.
C.F.Cox et al ( QI 1993; 24 501-510)
14.Histopathologic study on Pulp response to single-bottle and self Etching
adhesive systems VO Medina et al . (Operative dentistry 2002 27 330-342).
15.Direct pulp capping with bonding resin, without calcium hydroxide H.S. Cho
et al (Int J of paed Dent 13(suppl 1 ): 5 -68