Vital Pulp Therapy

Dr Abeer A Elhakim Elgendy

Lecturer of Endodontic
Ain Shams University
 ?What
All measures that protect the
vitality before its irreversibly
damaged.
Why, When,
???How
 Why I need to preserve
?pulp vitality
:Pulp is responsible for
. Formation of reparative dentin-1
. Resilience and toughness of dentin-2
.Vital tooth show proprioceptive response-3
Continued root development in immature permanent-4
(. teeth (open apex
 Why I need vital pulp
therapy to treat Immature
?teeth
:problems 2

Need for complete root

formation

Open apex
 Absence of apical constriction
 Apicalpart of canal is wider than
coronal part
 High possibility of hypochlorite
accident.
 Why?

Caries in deciduous
teeth
 ?When
Indication for vital pulp
therapy:
1. Teeth with open apex.
2. Primary teeth.
3. Teeth that would be
difficult to perform root
canal ttt.
4. Teeth involved in simple
restoration.
 ?When
Contraindication for vital pulp
therapy:
1. Teeth involved in a complex
restoration .
2. Teeth in which the root
canal space is needed to
hold a post and core.
3. Teeth involved in a complex
periodontal therapy.
Criteria must be fulfilled to
undergo vital pulp therapy
1. Pulp is asymptomatic or show
symptoms of reversible pulpitis.

2. Pulp vitality test show normal positive

response.

3. Radiographic examination show no

signs of periapical inflammation
 Success of vital pulp
therapy
1. Removal of noxious stimulus.
2. Stimulation of specific
dentinogenic response
3. Prevention of future
microleakage, and dentin-pulp
complex damage.
4. Type of exposure either
traumatic or pathologic.
 Treatment alternatives
1.Pulp capping
Indirect
direct

2. Plupotomy
 How to decide which
?procedure is needed
:Procedure selection dep. on
.Tooth is primary or permanent-1
.Tooth is mature or immature-2
.Pulp is vital or not-3
.Bleeding control-4
.Exposure is traumatic or pathologic-5
.Size of exp-6
Prescence of aseptic conditions. (rubber-7
(dam
Involvment of tooth in complex restoration-8
 Pulp capping

A procedure in which an exposed

or nearly exposed pulp is
covered with a protective
dressing that protects it from
additional injury and permits
healing and repair
 Pulp capping

Direct Indirect
 Indirect pulp capping
A mean of protecting an injured pulp.
 Materials used in pulp
capping
calcium hydroxide-1
:A-Usage
In both direct and indirect pulp
capping
:B-Effect on pulp
necrosis of adjacent pulp tissue-
.stimulate dentin bridge formation-
Mechanism of action-
Experiments carried with radioactive
calcium show that calcium ions used for
dentin bridge formation come from blood
.and not from CAH
It was suggested that its action
A-alkaline ph 12
.B-low grade irritation to pulp
Disadvantages
.complet Canal calcification-1
.Int resorption-2
Deficient physical properties might-3
lead to microleakage
Resulted dentin bridge is thought to-4
.be incomplete
:ZNO-E-2
.Its usage is controversial-
.No dentin bridge is formed
Pulp tissue adjacent to it show mass of
red blood cells and PMNL, with
underlying tissue show zone of
.fibrosis and infl. cells
ANTIBIOTICS-3
Eliminate infection
CORTICOSTEROIDES-4
.Decrease inflamn
:Isobutyl cyanoacrylate-5
.Hemostatic, bacteriostatic
:Tricalcium phosphate-6
.Show dentin bridge formation
:adhesive resins-7
Are recently used for direct pulp capping due to it Provide
.better seal than CAH
(:MTA(mineral trioxide aggregate-8
It is a biocompatible material used in
.direct pulp capping
It was detected to induce dentin bridge
formation…so is recommended in
DIRECT pulp capping procedure and
.many other usages
Mechanism of action of
:MTA
MTA act by up-regulation of bone
morphogenic protein which is
responsible for bone, collagen
formation and help pulp cells to
differentiate into odontoblasts.
 Clinical case showing dentin
bridge formation in direct pulp
:capping using MTA
:Procedure
(.diag,anaesth.,isoln(RUBBER DAM-1
all caries removed, except in case of-2
.ind. pulp capping
.swab cavity with antiseptic agent-3
apply CAH over cavity floor in case of-4
ind.pc
.And over pulp in case of direct pc
cover CAH with ZNO-E-5
.seal cavity with permanent restoration-6
.follow up the case-7
 Success of pulp capping
:depends on
.size of exp-1
In case of direct pulp capping…not more
.than 1mm
.type of exp-2
Traumatic not pathologic
.bleeding controlled-3
Note.. it was discov. That pulpal
contamination by oral env. for 24 hrs has
little or no effect on pulpal and hard
.tissue contamination
 How to judge success of
?pulp capping
1. tooth has vital pulp and dentin
bridge formation within 75 to 90
days.
2. absence of pain.
3. absence of any signs of pulpal or
periapical lesions.
4. completion of root dev. (in case of
immat. teeth).
 Failure of pulp capping
:Detected clinically in form of
.continous pain-1
.abscess formation-2
.periapical radiolucency can be detected in RG-3
.internal resorption can be detected in RG-4
:Causes
(.non-sterile procedure (absc. of rubber dam-1
.bacterial microinfilteration-2
:This is due to
.contam.of pulp prior to or during cav.preprn-1
.improper seal of cavity-2
.improper case selection-3
 Pulpotomy
Definition:
The surgical amputation of the coronal portion of an exposed
vital pulp, usually as a mean of preserving the vitality of the
remaining radicular portion.

Indication:
1. Immature teeth with exposed pulp.
2. Primary teeth.
3. Emergency treatment in posterior teeth.
Contraindication:

Tenderness to percussion or
1.
palpation.
2. Swelling or fistula.
3. Mobility.
4.Non-restorable teeth.
5.Prefuse hemorrhage.
6.Necrotic pulp.
7.Spontaneous pain.
Materials used:
1.Calcium hydroxide:
(The most common dressing used)
it is anti bacterial-1
high ph 12.5 which cause liquefaction-2
.necrosis in super facial layer
cause coagulative necrosis at junction of- 3
necrotic and vital tissue cause mild
.irritation to the pulp
mild irritation lead to inf response in-4
absence of bacteria will heal with a hard
tissue barrier

disadvantage
Not seal fractured surface )an additional material must be used
.to ensure complete sealing of pulp
 Formocresol.
• composition
cresol 35%-1
formalin 19%-2
in aquous glycerin-3

• formocresol Toxicity.
There is possible spread to distant sites )it is found that 5 minutes
exposure of pulpal tissue to FC result in systemic absorption of
about 1% of the dose

Plus:
its allergenicity, carcinogenicity
and mutagenicity
Actions:
)Three zones in radicular pulp (
1. Fixation zone

2. Coagulation necrosis

3. Vital tissue
 steps
1. Remove the roof of the
pulp chamber

2. Remove the coronal

portion of vital pulp

3. Control hemorrhage

4.Place a cotton pellet

dampened with
formocresol for five
minutes
2. Pulpotomy in young permanent
)apexogenesis(:
Diagnosis
a. Clinical diagnosis:
• No abscess, no fistula
• No mobility
• Large carious
• Mechanical or traumatic exposure
b. Radiographic diagnosis:
• incomplete root development
• pulp exposure
• normal bone structure
• no internal or external root resorption
 procedure for Ca)OH(2pulpotomy:

1. Anesthesia

2. Rubber dam application

3. Caries removal & access preparation

4. Amputation of the coronal pulp tissue

using sharp spoon excavator or large

diamond stone
 5. Pulp champer is flushed with sterile water or saline
6. Hemorrhage control either by saline or NaOCl

7. A layer of Ca)OH(2 preparation is placed against

the amputated pulp stump

8. Mix of ZnOE over Ca)OH(2

9. All cavity sealed with filling material

Prognosis :
•Patient recalled at 1& 3 & 6 months intervals for
radiographic examination
a. Successful cases:
1. x-ray shows complete root formation & calcific barrier
2. no pain or swelling
3. pulp retain its vitality

b.Unsuccessful cases:
1.failure of root development
2. pain & swelling
3. radiographic radiolucency
Prognosis of pulpotomy:

1- Size of the exposure

2-Exposure to saliva

3- Microleakage

4- Systemic factors
• If all trails are failed to retain pulp vitality

???What is the solution

• Endodontic mangement of immature non vital teeth

conventional ttt-1 surgical ttt-2

 Surgical method
(Apical resection )apicectomy
•Def : is the cutting of apical part
of the root after root canal is
cleaned ,shaped & obturated

•as the greatest width of the canal

is at the apex so no way to clean
&seal the canal successfully at
apex with any thing except
anapical approach
Disadvantages

aggressive technique-1

the root is left with thin dentinal wall-2

& unfavorable crown \root ratio

 Conventional ttt
.barrier technique & immediate obturation-1
In which amaterial is packed into the apical 2 -4 mm of
blunder buss canal to act as abarrier against which gutta
percha is condensed

•Material used
tri calcium phosphate-1
Athick mix is made &packed into the apical 2 mm of the canal
against which gutta percha is condensed in one visit with help
of radiographs
dentin chips-2
collagen&hydroxy appatite gel-3
MTA-4
 M T A & abarrier technique
.Procedure
root canal is cleaned &-1
.shaped
medicated with Ca)OH(2 for-2
.1 week
on reentry into the canal it- 3
irrigate with NaOCl then
.dried
aplug of MTA is packed-4
.into the apical end
moist cotton pellet is- 5
inserted against MTA.&
.access is sealed for 4-6 hrs
.then canal is obturated- 6
 apexification- 2
Def: induction of apical closure of an immature tooth in which pulp is
.non vital

.Materials used
calcium hydroxide-1
.calcium hydroxide. & camphorated mono chloro phenol-2
MTA-3
 Diagnosis

clinical Radiographic
1. History )as trauma is the most •Is complicated
common cause of pulp necrosis because of the
2. Pulp vitality tests not provide normal
reliable information due to open radiolucency
apex
present at the apex
3. Presence of pain with percussion, as the root develop
mobility or discoloration of crown
are indication of pulp necrosis
 Procedure for apexification
Ca)OH(2
First appointment
.tooth isolation rubber dam application-1
.access preparation &tooth length determination-2
.thorough cl&sh with irrigation using naocl or saline-3
root canal is dried with sterile paper point &partially medicated-4
.withCMCP
.the cavity is sealed with temporary cement- 5
•Second appointment )1-2 week later(

.tooth isolation &removal of temporary dressing-1

.thorough irrigation of the root canal &proper dryness-2

place thick mix of Ca)OH(2 &CMCP as apical as possible inside-3

root canal

place sterile cotton pellet in the pulp chamber & seal the-4
.access cavity& final restoration

follow up the case where the pt should be recalled after 6-5

.months for radiographic examination
Prognosis :

•Time needed for apexification is about 6 to

24 months.

•Factors may lead to increase the time :

1. Presence of radiolucent lesion
2. Interappointment symptoms
3. lose of external seal with reinfection of the canal
•Radiographic examination of the apexified
tooth may be:
1.Apical closure with closure of canal
2. Apical closure without change in the canal space
3. No radiographic change is present but clinically a definite
apical stop can be probed at the apex
4.Radiographic evidence of a calcified material at or near the
apex
5. No radiographic change with evidence of periapical
pathosis

•Histology of apexification with Ca)OH(2:

the calcified material that form over the apical foramen
has been histologically identified as an osteoid )bone
like( or cementoid )cementum like( material.