Clinical Endodontics Fifth Year

1. VITAL PULP THERAPY

2. Physical / Chemical / Thermal injuries
Dental Caries
Pulpal Irritation
Inflammation
Reversible
Irreversible
Vital Pulp Therapy
Repair
Pulp Necrosis

3. Vital pulp therapy is defined as a treatment initiated to
preserve and maintain pulp tissue in a healthy state
→
tissue that has been compromised by caries, trauma or
restorative procedures.

4. OBJECTIVE
REPARATIVE
→
DENTIN
STIMULATE THE FORMATION OF
TO
RETAIN
THE
TOOTH
AS
FUNCTIONAL UNIT
VITAL PULP THERAPY
→
Capacity of the pulp for
repair in the absence of microbial contamination
A

5. Outcome of Vital Pulp Therapy will depend on:
 Age of the patient
 Size of the pulp chamber
 Bacterial contamination
 The pulp capping material
 Quality of final restoration

6. Most important aspects for the Vital Pulp Therapy are
 Diagnosis of pulpal condition
 Case selection

8. According to the American Academy of Pediatric Dentistry:
“ Teeth exhibiting provoked pain of short duration, that is
relieved upon the removal of the stimulus, with analgesics,
or by brushing , without signs and symptoms of irreversible
pulpitis are candidates for Vital pulp Therapy

9. Primary Goals
of
Vital Pulp Therapy
 Dentin bridge formation
 Continuation of root development
:

10. STIMULATION
UNDIFFERENTIATED MESENCHYMAL CELLS
PRE EXISTING ODONTOBLASTS
ODONTOBLAST LIKE CELLS
REPARATIVE DENTIN
REACTIONARY DENTIN
TERTIARY DENTIN
DENTINAL BRIDGE

11. VITAL PULP THERAPY
 Includes:
 Indirect Pulp Capping
 Direct Pulp Capping
 Pulpotomy
 Apexification

12. INDIRECT PULP CAPPING
A procedure in which a material is placed on a thin partition of
remaining carious dentin, that if removed, may expose the pulp
 Indirect pulp capping – stepwise excavation of caries
 Indirect pulp capping without re-entry and further excavation

13. Stepwise excavation of caries :
Technique in which caries is removed in increments in two or
three appointments over a few months to a year rather than
removing the caries in one sitting [ in deep carious lesions ]
Each time caries is removed
Glass ionomer base is placed
which may contribute to mineralization, followed by a well
sealing temporary restoration

14. 
The deeper
affected but not infected dentin may
remineralize and tertiary dentin may form
 Case selection :
No signs or symptoms of irreversible pulpitis
 Periodic follow up
•
Radiographs and
•
Pulp testing

15. TECHNIQUE
 Local Anesthesia
 Rubber dam isolation to keep bacterial count as low
as possible
 Removal of as much caries as leaving a thin layer
of affected dentin to permit placement of a
temporary restoration
 Large round bur less likely to cause accidental
exposure than spoon excavator

16.  Place a layer of Glass ionomer [or calcium hydroxide]
and restore the tooth with a provisional restoration
 The seal provided by the restoration is very important
 After 1-2 months remove the restoration and excavate
the remaining caries.
 If any exposure then – direct pulp capping
Pulpotomy
pulpectomy
If no exposure - permanent restoration

17. Indirect pulp capping without re-entry and further
excavation
This is similar to stepwise excavation but differs in the
sense that the innermost layer of
carious dentin is
deliberately and permanently left behind

18. DIRECT PULP CAPPING:
The treatment of an exposed vital pulp by sealing the
pulpal wound with a dental material placed directly on the
exposure site to facilitate the formation of reparative
dentin and maintenance of the vital pulp
Exposure of the pulp may be due to
 Traumatic exposure
 Mechanical exposure
 Caries removal

19.  Success rate for Mechanical exposure > Carious exposures
Materials commonly used
•
•
MTA [Mineral Trioxide Aggregate]
Calcium hydroxide
 These materials should be covered by a permanent
restoration with a good marginal seal

20. Success of Direct pulp capping depends on
Size of exposure
Presence of good isolation
Condition of the pulp
Absence of symptoms
Age of the patient
Restorative material used

23. PULPOTOMY
The pulpotomy procedure involves removing only part of the
pulp, eliminating tissue that has inflammatory or degenerative
changes and leaving intact the underlying healthy pulp tissue
The surgical amputation of the coronal portion of an exposed
pulp to protect and preserve the remaining radicular pulp’s
vitality and function

25. Indications:
 Exposed vital pulps in carious primary teeth
 Exposed
permanent
vital
pulps
teeth
(to
in
carious
allow
immature
continued
root
development prior to NSRCT)
 Traumatically exposed primary or permanent teeth
[mature or immature]
 As an emergency procedure prior to NSRCT

26. Prognosis for traumatic/mechanical exposures
exposures
Case selection
-Vital pulp
-Reversible pulpitis
-No symptoms of irreversible pulpitis
> carious

27. Steps:
 All the carious dentin and pulp to the level of radicular
pulp are removed
- level of CEJ in anteriors
- level of canal orifices in posteriors
 Bleeding from the pulp stump is controlled with moist
cotton pellets and gentle pressure
 The chamber is rinsed with Sodium hypochloride
 The severed pulp is capped with
-
Calcium hydroxide
-
MTA

28.  This is then covered with Glass ionomer and the tooth is
restored with a restoration that seals completely
 Follow up
•
No signs of irreversible pulpitis
•
No radiographic signs of
o
internal resorption
o
external resorption
o
calcification
o
periapical radioluscency

29. CVEK PULPOTOMY / PARTIAL PULPOTOMY:
The surgical removal of a small portion of the coronal portion
of a vital pulp as a means of preserving the remaining coronal
and radicular pulp.

30. OPEN APEX
 An open apex is the developing root of an immature tooth
until apical closure occurs .
 Apical closure occurs 2-3 yrs after tooth eruption
 Any injury to the pulp at this stage will stop the closure of
the apex
 Such a tooth will have short , thin walls at the apical
portion of the root

32.  Open apex can also be caused by extensive resorption of
a previously mature apex after orthodontic treatment or
severe periapical inflammation

33. Diagnosis and assessment:
 History
 Subjective symptoms
 Diagnostic tests
 Radio graphs
A radiolucent area usually surrounds the apex of an
immature root with a healthy pulp

34. OPEN APEX
VITAL PULP
APEXOGENESIS
NON VITAL PULP
APEXIFICATION

35. APEXOGENESIS
A
Vital Pulp Therapy procedure performed to encourage
continued physiologic development and formation of the root
end.
Since the main objective is to maintain the vitality of the
radicular pulp the pulp must be vital and capable of repair

36. Trauma / mechanical exposure / Caries
 Small exposure
-
Pulp capping
 Large exposures - Cvek pulpotomy
Pulpotomy

37. Technique:
1. Anesthesia and rubber dam isolation
2. The inflamed pulp tissue is removed using a sharp round
bur in a high speed hand piece with water coolant for
superficial 2-3mm of pulp amputaion [Cvek pulpotomy]
3. Or removal of the entire pulp to the level of the canal
orifices using a large Spoon excavator
4. Hemorrhage is controlled by pressure on a cotton pellet
moistened with saline.
[ failure to achieve hemorrhage indicates pulpal inflammation]

38. The exposed pulp is rinsed with 2.5% sodium hypochlorite
MTA
or
hard set calcium hydroxide is placed over the
amputated pulp.
MTA is prepared by mixing MTA powder with saline in the
ratio of 3:1 on a glass slab. The mixture is placed on
the exposed pulp and patted with a moist cotton
pellet.
MTA sets in the presence of moisture. Wet cotton
pellet is placed over MTA and the tooth is restored.

39. The patient is then put on a periodic recall for 1-2yrs at
every 6 month interval.
Commonly encountered
•
Calcific metamorphosis
•
Internal resorption
In such cases NSRCT initiated.

41. APEXIFICATION
Induction of a calcific barrier or creation of an artificial barrier
across an open apex
Technique:
Local anesthesia and Rubber Dam isolation
Access cavity preparation and extirpation of the pulp
Working length is established slightly short of the apex [to
prevent injury to apical tissues]
Instrumentation and copius irrigation
Drying the canal and introducing MTA into the canal

42.  Packing MTA using endodontic pluggers or special
system like MAP SYSTEM [Micro Apical placement]
 MTA acts as an artificial barrier against which Gutta
percha can be condensed.
 Calcium hydroxide produces a biologic barrier but takes
longer time.

44. TISSUE ENGINEERING :
Science of design and manufacturing of new tissues to
replace tissues lost to disease or trauma.
It involves three key elements
1. Stem cells/ progenitor cells
2. Signals or morphogens that induce morphogenesis
3. A scaffold that provides a 3D microenvironment for cell
growth and environment

45. Tissue Regeneration
Bone morphogenetic protein
scaffold
Undifferentiated
mesenchymal cells
Odontoblasts

46. 1. The bone morphogenetic proteins are directly
applied over the exposed amputated pulp
2. Ex-vivo -
stem/progenitor cells are isolated from
the pulp and differentiated into odontoblasts with
recombinant BMP and BMP genes. These
odontoblasts are autogenously transplanted into the
exposed pulp.

47. Other techniques:
Revascularization
Retrograde MTA