pulp treatment modalities

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pedontic endodontics..pulp capping,pulpotomy,pulpectomy,apexification,apexogenesis

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PULP TREATMENT MODALITIES:

PULP TREATMENT MODALITIES By, Mythreyee Thakur.

TREATMENT MODALITIES:

TREATMENT MODALITIES PULP TREATMENT CONSERVATIVE RADICAL Protective base Pulpectomy Indirect pulp therapy Root filling Direct pupl therapy pulpotomy

PULP PROTECTION:

PULP PROTECTION AAPD coined this term It recommends placement of a protective base liner on the pulpal and axial walls of cavity prepared to act as protective barrier between restoration and tooth.

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INDICATIONS: Floor of cavity should not be infected In deep cavity preparations MATERIALS: GIC Resin modified GIC DBA

INDIRECT PULP CAPPING THERAPY:

INDIRECT PULP CAPPING THERAPY ‘ ’The procedure involving a tooth with a deep carious lesion where carious dentin removal is left incomplete and the decay process is treated with a biocompatible material for sometime in order to avoid pulp tissue exposure .’’

INDICATIONS AND CONTRAINDICATIONS:

INDICATIONS AND CONTRAINDICATIONS When pulp inflammation is minimal and complete removal of caries would cause pulp exposure. Any signs of pulpal or periapical pathology Non restorable tooth

PROCEDURE:

PROCEDURE Tooth is anesthetized and isolated. All the caries except that immediately over the pulp is removed.(use a large round bur at low speed) A zone of AFFECTED demineralized dentin is left behind A sedative dressing of ZOE or calcium hydroxide is placed

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Restore with ZOE or amalgam. Formation of REPARATIVE DENTIN beneath the caries.(1.4microns/day) The tooth is reentered after 6-8 weeks and the remaining caries is excavated.

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Permanent Tooth restoration along with pulp protection with base placement is done

PATENTED DENTIN MEASURING DEVICE:

PATENTED DENTIN MEASURING DEVICE Electronically measures the thickness of dentin layer above the pulp chamber during crown preparation with a simple touch of probe GREEN LIGHT:safe zone ORANGE LIGHT:limit of safe zone RED LIGHT:danger of penetration through dentin.

PREPOMETER:

PREPOMETER

DIRECT PULP CAPPING:

DIRECT PULP CAPPING DEFINITION: The procedure in which small exposure of the pulp which is encountered During cavity preparation Following a traumatic injury Due to caries,with a sound surrounding dentin,is dressed with an appropriate biocompatible radioopaque base in contact with the exposed pulp tissue prior to placing a restoration .

LIMITATIONS IN PRIMARY TEETH:

LIMITATIONS IN PRIMARY TEETH Abundant blood supply and a consequent faster inflammatory response. Internal resorption Calcification Chronic pulp inflammation Necrosis Intra radicular involvement

Indications and Contraindications:

Indications and Contraindications Small mechanical exposure less than 1mm,surrounded by sound dentin. Bleeding from the exposure site can be controlled easily. Traumatic exposured in a dry clean field(within 24hrs) Pain at night. Spontaneous pain Tooth mobility Thickening of periodontal ligament Inta radicular radiolucency Excess bleeding Purulent or serous exudate

STAINING CARIOUS LESIONS:

STAINING CARIOUS LESIONS Proposed by FUSAYAMA to allow differentiation between infected and affected dentin. Infected dentin gets stained. Ex-Cari-D test, Caries Detector, Caries Finder, Sable Seek.

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Location of pulp exposure is important. Pushing of dentin chips and microorganisms into the pulp should be avoided.

PROCEDURE:

PROCEDURE CALCIUM HYDROXIDE TECHNIQUE Hemostasis Disinfect cavity Calcium hydroxide resin mod. GIC IRM DBS restotation DENTIN BONDING SYSTEM Hemostasis Disinfect cavity Bonding agent Adhesive restoration

CALPLUS:

CALPLUS

FEATURES OF SUCCESSFUL PULP CAPPING:

FEATURES OF SUCCESSFUL PULP CAPPING Maintenance of pulp vitality. Lack of undue sensitivity or pain. Minimal inflammatory response. Lack of internal resorption and intra radicular pathosis.

PULP CAPPING AGENTS:

PULP CAPPING AGENTS Calcium hydroxide is the material of choice. Herman in 1930 1 st introduced Ca(OH)2 for pulp capping. Ca(OH)2 causes necrosis of adjacent pulp tissue and inflammation of contiguous tissue. Dentin bridge formation accurs at the junction of necrotic and inflammed tissue.

Advantages and Disadvantages:

Advantages and Disadvantages Initially bactericidal then bacterostatic. Promotes healing and repair High pH stimulates fibroblasts Neutralization of acids Stops internal resorption Inexpensive and easy to use Particles may obturate open tubules Doesn’t exclusively stimulate Dentinogenesis May dissolve after 1yr May degrade during acid etching and tooth flexure Marginal failure with amalgam condensation Doesn’t adhere to dentin or resin restoration

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Three main calcium hydroxide products- Pulpdent paste:52.5% calcium hydroxide suspended in aq.methyl cellulose sol. Hydrex is a two paste system-calcium hydroxide,barium sulfate,titanium dioxide and a selected resin. Dycal.

ISOBUTYL CYANOACRYLATE:

ISOBUTYL CYANOACRYLATE Hemostatic and bacteriostatic properties. Less inflammation than calcium hydroxide Doesn’t produce continuous barrier of reparative dentin.

RESIN BONDING AGENTS:

RESIN BONDING AGENTS Suggested as means to achieve a hermetic seal at the dentin/pulpal interface by means of resinous‘’hybrid’’ layer. 4-methacryloxyethyl trimellitate anhydride(4-META) can be used on exposed pulp.

LASER:

LASER Andreas Moritz in 1998 evaluated the effect of Co2 laser on direct pulp capping. Success rate-89%

PROPOLIS:

PROPOLIS Recently used material. Equally effective as calcium hydroxide. Sabir et al (2005) conducted experiments.

OTHER MATERIALS:

OTHER MATERIALS Antibiotics Corticosteroids Dentin Albumin Poly carboxylate cements

3rd Molar in ‘’SEERSHASANAM’’:

3 rd Molar in ‘’SEERSHASANAM’’

PULPOTOMY:

PULPOTOMY DEFINITION: It can be defined as the complete removal of the coronal portion of dental pulp,followed by placement of a suitable dressing or medicament that will promote healing and preserve vitality of the tooth.(finn,1959)

PULPOTOMY:

PULPOTOMY VITAL PULPOTOMY DEVITALIZATION: Single sitting: Formocresol Electrosurgery Laser Two stage: Gysi triopaste Easlick’s formaldehyde Paraform devitalising paste PRESERVATION: Glutaraldehyde Ferric sulphate MTA REGENERATION: Bone morphogenetic protein. NON VITAL PULPOTOMY Beechwood cresol. Formocresol

Indications and Contraindications :

Indications and Contraindications Vital tooth No spontaneous nor persisting pain Tooth is restorable Tooth which possesses 2/3 rd of its root length Hemorrhage-pale red Primary tooth preffered to a space maintainer. Internal resorption Inter radicular bone loss Abscess or fistula in relation to teeth Calcific globules in pulp chamber Caries penetating to floor of pulp chamber Tooth close to natural exfoliation

DIAGNOSTIC CONSIDERATIONS:

DIAGNOSTIC CONSIDERATIONS Inflammation should be confined to the coronal pulp for a successful PROGNOSIS. Radiographic interpretation- Extent of carious lesion Status of lamina dura Abnormal resorptive processes

READY?? :

READY?? 

DEVITALIZATON(SINGLE SETTING):

DEVITALIZATON(SINGLE SETTING) FORMOCRESOL PULPOTOMY TECHNIQUE: 1 st advocated by SWEET. formocresol is a solution of- 19% formaldehyde, 35% cresol, In a vehicle of 15%glycerine and water.

MECHANISM OF ACTION:

MECHANISM OF ACTION It prevents tissue autolysis by bonding to protein. This is a reversible process with out change in overall structure of proteins. IARC in june 2004 classified formocresol as CARCINOGENIC.

PROCEDURE:

PROCEDURE Tooth anesthetized and isolated with rubber dam. All remaining dental caries should be removed and overhanging enamel should be planed. Entire roof of pulp chamber should be removed with bur. Amputate coronal pulp with spoon excavator. Irrigate pulp chamber.

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Moist cotton pellets should be placed until a clot forms. Haemorrhage controls readily-safe to proceed. Pulp chamber is dried with a sterile cotton pellet. Place a cotton moistened with 1:5 conc of buckley’s formocresol for 5min. Pellet is removed and pulp chamber is again dried with new pellet.

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Thick paste of ZOE is placed over pulp stump Zinc polycarboxylate cement is placed. Tooth restored with stainless steel crown.

DEVITALIZATION PULPOTOMY(TWO STAGE):

DEVITALIZATION PULPOTOMY(TWO STAGE) Paraformaldehyde is used to fix the entire coronal and radicular pulp. Agents used- Gysi trio paste Easlick’s paraformaldehyde paste Paraform devitalizing paste.

TECHNIQUE:

TECHNIQUE 1 st appointment: STEP 1: Preparation of instruments and materials Isolation of the affected teeth with rubber dam Preparation of the cavity Excavation of deep carious dentin

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STEP 2: When pulp exposure is encountered,ensure it is free of debris Enlarge with round bur Prepare a cotton pellet to cover the exposure. Incorporate paraformaldehyde paste into the pellet Seal the tooth for 1 to 2 weeks. Formaldehyde gas-fixes tissues

SECOND APPOINTMENT:

SECOND APPOINTMENT Pulpotomy is carried out under LA. Roof of pulp chamber removed and cleaned,dried. Pulp chamber is filled with antiseptic paste and tooth is restored. If pulp found vital-repeat the dressing for one more week

ELECTROSURGICAL PULPOTOMY:

ELECTROSURGICAL PULPOTOMY Electocautery carbonizes and heat denatures the pulp and bacterial contamination Disadvantage: Contaminated pulp tissue doesn’t allow adequate current penetration.

LASER PULPOTOMY:

LASER PULPOTOMY Non pharmacologic hemostatic technique for the pulpotomy procedure. Jeng-fen Liiu in 1999 studied the effect of Nd:YAG laser for pulpotomy in primary teeth and noted 100% success.

ONE MINUTE PULPOTOMY:

ONE MINUTE PULPOTOMY Garcia Godoy,Novakovic,Carvajal have suggested shorter application time(1 min). Equally effective.

PARIAL PULPOTOMY:

PARIAL PULPOTOMY Cvek pulpotomy Done for the traumatic exposures of pulp in which inflamed pulp tissue is removed to a depth of 1 to 3mm. Sealed with calcium hydroxide or MTA

PRESERVATION:

PRESERVATION Chemicals which induce minimal insult to tissues are used. They help to conserve vitality of radicular pulp Gluteraldehyde and Ferric sulfate are used.

GLUTARALDEHYDE:

GLUTARALDEHYDE Introduced by Kopel in 1979. Superior to formocresol in view of its- Superior fixative properties Self limiting penetration Low antigenicity Low toxicity Elimination of cresol.

PROPERTIES:

PROPERTIES Better and non reversible fixation of tissues. Excellent antimicrobial Pulp tissue remains vital Clinical success 98-100% Less dystrophic calcification Less pulpal necrosis Application in 2-5%conc safe for clinical success

FERRIC SULFATE:

FERRIC SULFATE Non aldehyde hemostatic compound which prevents problems encountered with clot formation and thereby minimizes inflammation and internal resorption. Forms metal protein clot and this acts as a barrier to irritating components of the sub base.

PROPERTIES:

PROPERTIES 100% clinical success 97.2% radiographic success Pulpal response favourable No systemic or local side effects

REGENERATION:

REGENERATION In this technique reparative dentin formation by pulpotomy agent occurs. BMP’s are osteogenic proteins which form a part of TGF-beta. They are implicated in- Cell differentiation Tissue morphogenesis Regeneration and repair.

PowerPoint Presentation:

Domingue AT in 2003 stated that MTA(mineral trioxide aggregate) forms crystals of calcium oxide in an amorphous structure of:33%Ca,49%P04,2%C,3%Cl,6%Si. This new era was found when Urist in 1965 concluded that bone contains a factor capable of AUTO INDUCTION called as BMP(bone morphogenic protein). Recombinant human BMP-2 and BMP-4 induce differentiation of adult pulp cell into odontoblast.

MORTAL PULPOTOMY:

MORTAL PULPOTOMY Non vital tooth. Pulpectomy of primary 1 st molar may sometimes be difficult due to non negotiable canals,limited patient cooperation.

TWO STAGES:

TWO STAGES 1 st appointment:necrotic coronal pulp removed. Irrigated and dried Place a cotton pellet dipped in Beechwood Cresol over Radicular pulp. Seal with Temporary cement for 1 or 2 weeks.

Second appointment:

Second appointment Remove temporary dressing. Note for resolution of signs and symptoms Then fill pulp chamber with antiseptic solution Restore with stainless steel crown.

PULPECTOMY:

PULPECTOMY Pulpectomy involves removal of the roof and contents of pulp chamber in order to gain access to the root canals which are debrided,enlarged and disinfected. Canals are filled with RESORBABLE MATERIALS.

OBJECTIVES:

OBJECTIVES Infectious process should resolve Radiographic evidence of successful filling Treatment should allow reosrption of primary root structures and filling materials at appropriate time No post treatment pain,swelling or sensitivity No radiographic evidence of further break down of supporting tissue No internal or external resorption.

Indications and Contraindications:

Indications and Contraindications Stratergically imp tooth Irreversible pulpitis Minimal periapical changes Atleast 2/3 rd of root length available Internal resorption with out any obvious perforation Excessive mobility Non restorable tooth Underlying DC or follicular cyst Less than 2/3 rd of root length Perforation of pulpal floor Medically compromised children

TECHNIQUE:

TECHNIQUE ACCESS OPENING FOR PULPECTOMY OF PRIMARY TEETH First part of treatment also known as ENDODONTIC ENTRY Two phases-CORONAL phase,RADICULAR phase.

RULES FOR PROPER ACCESS PREPARATION:

RULES FOR PROPER ACCESS PREPARATION Endodontic Dogma:’’careful cavity preparation and root canal obturation are the key stones to successful root canal therapy.’’ Objective of entry-gain direct access to apical foramena. Internal anatomy of the tooth under treatment must be determined. Access cavity preparations are not guided by topography of ooclusal grooves,pits and fissures

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4.Endodontic entries are prepared always through the occlusal or the lingual surface. 5.Unsupported cusps of the posterior teeth must be reduced to avoid weakening of tooth structure.

THREE FACTORS OF INTERNAL ANATOMY :

THREE FACTORS OF INTERNAL ANATOMY SIZE OF PULP CHAMBER Young patients have large pulp chambers and root canals-so they require large Instruments and Filling materials.

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SHAPE OF PULP CHAMBER: The finished outline form should accurately reflect the shape of the Pulp chamber.

NUMBER,POSITION AND CURVATURE OF THE ROOT CANALS:

NUMBER,POSITION AND CURVATURE OF THE ROOT CANALS PRIMARY ANTERIORS Teeth no.of roots shape accessory c Max.In 1 Round Rare Man.In 1;2 in<10%flat M n D Occasional Max n 1 Rounded Mand . Cn shape Rare

PRIMARY MOLARS:

PRIMARY MOLARS Teeth no.of roots shape accessorycanals Max.1 st 2 to 4 Round(p) 75%mesio-facial root bifurcation Max.2 nd 2 to 5 exterior 85% to 95% root shape mesiofacial root bifurcation.

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Teeth no.of canal s shape accessory canals Mand.1 st 2 to 4 roughly 75%(m)25%(d) external contain 2canals root Man . 2 nd 2 to 5 anatomy 85%(m)25%(d) conatin 2canals

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Access opening for primary anterior teeth is through the lingual surface-except max.primary incisors due to the problem of discolouration. Facial approach followed by acid etch composite restoration is recommended.

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Access opening for posterior primary root canals is mostly same as that for permanent teeth. Important differences- Bulbous shape of crowns Depth necessary to peretrate pulp chamber is less Occlusal surface to pulp floor distance is less

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Entire roof of the pulp chamber is removed with a bur. Canal cleaning and shaping: ISOLATION:best method is use of Rubber dam.(Barnum) DEBRIDEMENT:canal cleaning and shaping. The main objective of chemico-mechanical preparation of primary tooth is debridement.

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Relative pulpectomy:due to tortuous course of root canal coupled with the numerous accessory canals,complete removal of pulp in primary teeth is often difficult. Selective filling:resorption,slender roots with thin apical ends may predispose the tooth to a root fracture.thus selective filling of canals should be followed.

WORKING LENGTH:

WORKING LENGTH Working length be shortened,2-3mm short of the radiographic root length. ELECTRONIC APEX LOCATOR for working length determination.

APEX LOCATOR (Root ZX):

APEX LOCATOR (Root ZX) It is a third generation electronic apex locator manufactured by J.Morita Corp. Consists of LCD monitor,a file holder tip and a contrary electrode to complete the circuit. Working principle of Root ZX: Meter in the display indicates position of file tip. As file approaches the apex,the audible alarm will beep slowly,meter reaches 2

APEX LOCATOR:

APEX LOCATOR

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Apical constriction-0.5 on meter,sound of alarm will change,image of root canal will start flashing. Major foramen-meter reading 0,alarmwill give single sustained beep,word APEX will flash.

OPERATOR INSTRUCTIONS:

OPERATOR INSTRUCTIONS Length of filling material is calculated by- Subtracting 0.5-1.0mm from the working length indicated by 0.5 reading on the meter. Instrument should be gently curved to help negotiate the canals. Canals are enlarged several file sizes past the 1 st file. Since many of pulpal ramifications cannot be reached mechanically,chemical debridement with sodium hypochlorite to digest organic debris should be done.

ROTARY INSTRUMENTS :

ROTARY INSTRUMENTS Rotary ni-ti files are specially designed to provide superior flexibility and unmatched efficiency. Can be attached to a hand piece.

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If iflammation is beyond the coronal pulp with only interradicula but no periapical radiolucency-single visit pulpectomy is done. If pulp is necrotic with periapical involvement,filling is done at subsequent appointement.

Ni-Ti FILES:

Ni-Ti FILES

Advantages and Disadvantages:

Advantages and Disadvantages More consistent dense fill due to uniform debridement. Greater apical enlargement Prevent apical exposure Provide better shape Reduce instrumentation time Skill required Resorption may be a problem Breakage of files in the canal. Repeated use increases risk of fracture.

FILLING OF PRIMARY ROOT CANALS:

FILLING OF PRIMARY ROOT CANALS IDEAL REQUIREMENTS: Should resorb at the same rate as primary roots. Should be harmless Should have stable disinfecting power Ease of use Should not shrink Insoluble in water Radio opaque,not discolour teeth.

ZOE paste:

ZOE paste Most commonly used. Camp in 1984 introduced endodontic pressure syringe. Disadvantages: Overfilling causes Foreign body reaction Difference in rate of resorption from that of tooth root. Success rate 65%

IODOFORM PASTE:

IODOFORM PASTE KRI paste : Iodoform 80.8%,camphor 4.86%,parachlorophenol 2.025%,menthol 1.215% Advantages: Resorbs rapidly Extruded paste in periapical tissue is replaced with normal tissue. Bactericidal potential Can be removed if re treatment is required Success rate 84%

CALCIUM HYDROXIDE:

CALCIUM HYDROXIDE Calcium hydroxide and iodoform mixture-Vitapex,Neo Dental Chemical Products Co;Tokyo,has been published by Fuchino and Nishino in 1980. Properties: Non toxic Easy to apply Resorbs at slightly faster rate than root Radio opaque 100% success rate.

ENDOFLAS:

ENDOFLAS Composition: Zno-56.5%,Barium sulphate 1.63%,Iodoform 40.6%,Calcium hydroxide 1.07%,Eugenol Pentachlorophenol. Microleakage should be prevented. 70% success rate.

OBTURATION TECHNIQUES:

OBTURATION TECHNIQUES Larger canals can be filled with the thin mix coating the walls of the canal with reamer in ANTICLOCL WISE direction and then with a thicker mix. Lentulo spiral mounted on a micromotor hand piece.96-92% success rate. Endodontic pressure syringe-ZOE,Vitapex

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After obturation,temporary cement is filled in pulp chamber. Then restoration with stainless steel crown.

FOLLOW UP:

FOLLOW UP Rate of success-high Primary tooth should be free form pathosis,pain,firm in alveolus and resorb normally. Over retention may be a problem.

Whom do u like to have on ur Tooth??:

Whom do u like to have on ur Tooth??

HELLO!!!!:

HELLO!!!! ONCE AGAIN :p

MTA:

MTA MTA(Mineral Trioxide Aggregate)is a new material. 1 st described in Dental literature in 1993 by Torabinejad for repair of lateral root perforations.

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Developed in the LOMA LINDA university in 1990’s as ROOT END FILLING MATERIAL.

Advantages over Ca(oH)2:

Advantages over Ca(oH)2 Thicker dentinal bridge Less inflammation Less hyperemia Less pulpal necrosis Dentin bridge formation at faster rate

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APPLICATIONS: Root end fillings DPC Apexification pulpotomy perforation repairs

COMPOSITION:

COMPOSITION Tricalcium silicate Dicalcium silicate Tricalcium aluminate Calcium sulphate dehydrate Bismuth oxide

PROPERTIES:

PROPERTIES pH is 12.5 Setting strength similar to IRM Non cytotoxic Long term success in primary tooth pulpotomy Biocompatible Provides agood seal Promotes hard tissue formation Takes lesser time for biological barrier formation than Ca(OH)2.

MINERALIZATION:

MINERALIZATION Hydration of MTA(neutral phosphate buffer saline sol) Two separate reactions. Tricalcium aluminate+water(caso4)=ETTRINGITE.

PowerPoint Presentation:

Tricalcium silicate,dicalcium silicate+water=calcium silicate hydrate+Ca(oH)2. Ca(oH)2 leaches Ca Reacts with tissue fluid forming HYDROXYAPETITE.(physicochemical basis for biologic properties)

Antimicrobial effect:

Antimicrobial effect Less antibacterial than calcium hydroxide. More resitant to microbial leakage. Why??

procedure:

procedure Standard pulpotomy Hemostasis by sodium hypochlorite 2mm thick layer of MTA applied

LIMITATIONS:

LIMITATIONS Cost Problems of storage.??

Conclusion:

Conclusion MTA can be used as a substitution for Ca(oH)2 in pulpotomy-further research however is needed!!!

Thank u 4 ur patient listening :

Thank u 4 ur patient listening 

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