BDS11144 Treatment of Immature Non-Vital teeth and Vital Pulp Therapy.pdf

Tooth Physical/Chemical/Traumatic injuries Dental Caries Pulp Irritation Inflammation Reversible Irreversible Repair (vital Pulp Therapy) Pulp Necrosis It is the treatment initiated to preserve and maintain pulp tissue in a healthy state The main objective is to stimulate the formation of reparative...

Tooth Physical/Chemical/Traumatic injuries Dental Caries Pulp Irritation Inflammation Reversible Irreversible Repair (vital Pulp Therapy) Pulp Necrosis It is the treatment initiated to preserve and maintain pulp tissue in a healthy state The main objective is to stimulate the formation of reparative dentin to retain the tooth as functional unit Continued root development in immature permanent teeth (open apex). Better proprioception 1- Blunderbuss The walls of the canal are divergent and flaring, more especially in the buccolingual direction. The apex is funnel shaped and typically wider than the coronal aspects of the canal. 2- Non-blunderbuss (tubular) The walls of the canal may be parallel to slightly convergent as the canal exist the root. The apex, therefore can be broad (cylinder shaped) or tapered (convergent). 1. No apical constriction : no barrier for stopping the root filling material. 2. Dentinal walls are very thin : liable to fracture. 3. Canal is often wider apical than coronal: The infected root canal cannot be disinfected with the standard endodontic files. 4. Compromised crown root ratio Aspects of Vital Pulp Therapy Proper Diagnosis Case Selection According to the American Dental Association of Pediatric Dentistry Teeth exhibiting provoked pain of short duration, that is relieved upon the removal of the stimulus, with analgesics, or without signs and symptoms of irreversible pulpitis are candidates for Vital pulp Therapy Young permanent tooth Non- vital Vital Continous root formation Preserve vitality (Apexogenesis) Apical closure Disinfection (Apexification) Revascularization MTA Apical Plug Stem cell Pulp Capping Indirect Direct Pulpotomy Partial (Cvek) Total Scaffold Growth factors APEXOGENESIS: A Vital Pulp Therapy procedure performed to encourage continued physiologic development and formation of the root end to maintain the vitality of the radicular pulp APEXIFICATION: Induction of a calcific barrier or creation of an artificial barrier across an open apex A. Management of VITAL Immature tooth Definition Indications and Contraindications Theory Technique Criteria for success Tooth is asymptomatic or showing signs of reversible pulpitis Young age, Immature permanent teeth with open apex Indications Teeth with deep caries but not badly mutilated Mechanical exposures and traumatic injuries Difficulty to perform root canal treatment Teeth with irreversible pulpitis Contraindications Badly mutilated teeth Periodontally affected teeth Pathologic exposures or when complete aseptic conditions cannot be obtained It is a procedure performed in a tooth with deep carious lesion adjacent to the pulp, with NO signs of pulp exposure outer infected layer of dentin zone of affected demineralized dentin exists When the infected layer is removed, the affected dentin can remineralize and odontoblasts form reparative dentin avoiding exposure. Stepwise Excavation (Reentry technique) Single Entry Excavation (Partial caries removal ) Anesthetize the tooth. Apply the rubber dam to isolate the tooth. Remove the soft caries either with spoon excavator or round bur. A thin layer of dentin and some amount of caries are left to avoid exposure. Place calcium hydroxide paste on the remaining carious dentin. Cover the calcium hydroxide with zinc oxide eugenol and Final restoration 1-When the tooth is re-entered the caries appears to be arrested. 2- The color changes from deep red to light gray or brown 3- the texture changes from spongy and wet to hard and dehydrated. Clinically Radiographically Histologically "Treatment of an exposed vital pulp by sealing the pulpal wound with a dental material placed directly on a mechanical or traumatic exposure to facilitate the formation of reparative dentin and maintenance of a vital pulp and promote healing of the pulp" Objective : The procedure activates a healthy pulp to initiate a dentin bridge to wall off the exposure site. Indications Contraindications Small mechanical exposure of the pulp during cavity preparation or traumatic injury. Teeth with pinpoint carious exposure surrounded with sound dentin. Absence of signs of irreversible pulpal or periapical disease. Wide pulp exposure History of spontaneous pain. Increased bleeding at the exposure site. Teeth with periapical pathosis or the presence of fistula. Teeth with calcification Normal aging of the dental pulp Periodontally affected teeth Anesthetize the patient A rubber dam applied The gross caries can be removed with either a sharp Spoon excavator or a large, round, slow-speed carbide bur. pulp is approached the cavity is flushed with. NaOCl Hemostasis and dryness Apply the pulp capping material , then the final restoration During Pulp capping procedure it is of prime importance to control pulp bleeding prior to placing the pulp cap agent. Bleeding is normally controlled by placing a cotton pellet soaked in a solution on the exposed pulp. This is likely a result of two reasons: I. Increased bleeding can be indicative of a greater degree of inflammation in the pulp II. The moisture and contamination of dentin adjacent to the exposure site due to bleeding can make it more difficult to obtain an adequate seal that will prevent subsequent bacterial exposure. Requirements for an ideal material: 1. Stimulate reparative dentin formation. 2. Maintain pulp vitality, 3. Release fluoride to prevent secondary caries. 4. Bactericidal or bacteriostatic. 5. Adhere to dentin and provide bacterial seal. 6. Adhere to restorative material. 7. Resist forces during restoration placement and afterwards during the lifetime of the restoration. 8. Radiopaque. 1.Zinc Oxide and Eugenol. 2.Adhesive Resins 3.Glass Ionomers and RMGI. 4.Calcium Hydroxide 5.Mineral Trioxide Aggregate. 6.Biodentine 1. Zinc Oxide and Eugenol: Its use for direct pulp capping is questionable because: Eugenol is highly cytotoxic and properties drop dramatically with time ZOE demonstrates high interfacial leakage. 2. Adhesive Systems: Showed poor outcomes cytotoxic effects on pulp cells. NO adequate seal Increased moisture 3.Glass Ionomers / Resin Modified Glass Ionomers: chemically bond to tooth structure, excellent bacterial seal, and good biocompatibility when used in close approximation to the pulp BUT, GI/RMGI is cytotoxic when in direct cell contact. Theory of Action Calcium would diffuse from a CaOH dressing into the pulp and participate in the formation of reparative dentin. (wrong theory) However, Source of calcium in dentinal bridge comes from blood stream. Its high alkaline pH giving it excellent antibacterial properties. It activates alkaline phosphatase enzymes which play an important role in hard tissue formation. Advantages of CaOH High antibacterial action Stimulate pulp repair by release of bioactive molecules Disadvantages of CaOH Highly soluble and subject to dissolution over time causes microleakage beneath the restoration. No inherent adhesive qualities. Suffer from interfacial failure upon amalgam condensation. Tunnel defects in the formed dentin bridge. The pulp remains chronically inflamed or becomes necrotic. Complete dentin mineralization of the remaining pulp tissue occludes the canals Unset MTA is primarily calcium oxide in the from of Tricalcium silicate, Dicalcium silicate Tricalcium aluminate. Bismuth oxide is added for radiopacity. Biocompatiblity Formation of dentine bridge Superior sealing. Advantages Disadvantages The presence of iron in the grey MTA formulation may darken the tooth. The prolonged setting time of approximately 2 hours and 45 minutes. The handling characteristics of the powder/liquid MTA are very different from the typical paste/paste formulations of calcium hydroxide expensive. Advantages Setting time is much shorter than MTA (12 min compared to 2h:45 min). High mechanical strength, which is similar to Glass ionomers. It is encapsulated, and thus easier to handle. Leakage resistance and mechanical strength will improve over the first weeks after placement. Formation of Dentin Bridge was suggested to be the main sign of success of pulp capping, however most studies showed that the pulp retains its vitality despite absence of dentin bridge. Features for successful pulp capping include: 1. Pulp retains its vitality 2. Absence of pain 3. Absence of signs of pulp and per-apical pathosis 4. Completion of root development in case of immature teeth. It refers to amputation of the vital inflamed pulp from the coronal chamber followed by medicament placement over the radicular pulp stump, to fix or stimulate repair of the remaining vital pulp tissue Objectives of Pulpotomy 1. Preserve the vitality of the pulp. 2. Promote apexogenesis. 3. Provide pain relief in case of acute pulpitis(emergency ttt). INDICATIONS CONTRAINDICATIONS Vital tooth with healthy periodontium. Pain, if present not spontaneous nor persists after removal of the stimulus. Tooth which is restorable. Hemorrhage from the amputation site is pale red & easy to control. As an emergency treatment in posterior teeth where total pulp extirpation is difficult. Evidence of internal resorption. Presence of inter-radicular bone loss. Abscess, fistula in relation to teeth. Radiographic sign of calcific globules in pulp chamber. Caries penetrating the floor of pulp chamber. Patients with poor healing power According to Level of Amputation According to dentition According to capping material According to method of Amputation Partial Pulpotomy (Cvek) Deciduous Calcium Hydroxide Bur Total Pulpotomy Permanent open apex MTA Spoon excavator Permanent mature teeth Formocresol Glutaraldehyde Partial pulpotomy (CVEK Pulpotomy): surgical removal of a small part of the coronal portion of a vital pulp as means of preserving the remaining coronal and radicular pulp. Inflamed tissue is removed to expose deeper healthy coronal pulpal tissue. Total pulpotomy: surgical removal of all the coronal portion of a vital pulp as a means of preserving the vitality of the remaining radicular portion, after that a material is placed over the canal orifices. Ca (OH)2 Mineral trioxide aggregate (MTA). Absence of any clinical or radiographic sign of pathosis. The presence of continued root development in young permanent teeth with incomplete roots. Unlike Ca(OH)2 pulpotomy with formocresol no dentin bridge occurs. 1. Size of exposure The larger the size of exposure, the more damage to pulp tissue, Less prognosis 2. Systemic factors Pt suffering from anemia Liver ds Malnutrition Diabetes Bad candidates for Pulpotomy ,,,, ↓ healing power 3.Exposure to saliva Increasing the pulp exposed increasing chances for contamination, less prognosis 4.Microleakage Salivary contamination, less chances for healing and repair, less prognosis The time taken for apexogenesis after pulpotomy ranges between 1 to 2 years depending primarily upon the extent of root development at the time of pulpotomy procedure. The patient should be recalled at a minimum of 3-month intervals to check: 12- Vitality of the pulp. Extent of apical maturation. N.B An absence of symptoms does not necessarily reflects the true state of the pulp. B. Management of NON VITAL Immature tooth Diagnosis of pulpal necrosis in a tooth with an incompletely formed apex is often difficult; the electronic pulp tester rarely provides meaningful data, and thermal tests often give equivocal or false results in young children and traumatized teeth. The presence of acute or chronic pain, percussion sensitivity, mobility, coronal discoloration, or a discharging sinus may be helpful guides, whereas radiographic diagnosis can be complicated by the normal radiolucencies appearing at the apices of developing teeth. Comparison of root formation with contralateral teeth should always be 1- Obturation without induction of apical closure using Inverted cone technique Tailor made technique. 2- Apexfication: CaOH Apexification 3- MTA (Artificial Apical Barrier). 4- Regenerative endodontics. Tailor-made gutta-percha Roll Inverted Cone technique Disadvantages Leakage. Poor adaptation. Thin dentinal walls is left. Needs more coronal flaring for manipulation. Shrinking of gutta-percha. Apexification or root end closure is a non surgical approach, whereby a non vital immature permanent tooth which has lost the capacity for further root development is induced to from a calcified barrier at the root terminus. Unlike pulp capping, pulpotomy or apexogenesis, apexification will at best induce root end closure by formation of a biological calcific barrier Advantages of calcium hydroxide Initially bactericidal then bacteriostatic. Promotes healing and repair. High pH stimulates fibroblasts Neutralizes low PH of acids Stops internal resorption Inexpensive and easy to use Disadvantages of calcium hydroxide Open apex takes a long time to close. Decreases fracture resistance of thin dentinal walls. Canals may be completely calcified Access opening, and length determination by radiograph Irrigation with NaOCl throughout debridement Dry the canal, apply intracanal medicament and put temporary filling. Rubber dam applied CaOH paste delivered into the dried canal. Tooth sealed Patient is recalled every 3 months. Change CaOH Check for calcific barrier Follow up for 9-24 months The radiographic examination of the apexified tooth may reveal one of the following five conditions: 1- No radiographic change is apparent but clinically, a definite apical stop can be probed at the apex. 2- Radiographic evidence of a calcified material at or near the apex. 3- Apical closure without any change in the canal space. 4- Apical closure with closure of the canal space. 5- No radiographic change is apparent with evidence of development of periapical pathosis. Restoration should be designed to strengthen the tooth. Gutta-percha should be removed below the alveolar crest. The dentin is acid etched and composite resin is applied. Placement of posts in such cases should be avoided.    The creation of hard tissue barrier using calcium hydroxide could take from 3 to 18 months MTA has been used to create a hard tissue barrier quickly after disinfection of the canal. Calcium Sulphate can be pushed through the apex to provide a resorbable extraradicular barrier against which MTA can be packed.  MTA is mixed and placed into apical 3 mm.  Final Restoration is applied. Re-establishment of the vitality in a non-vital tooth to allow repair and regeneration of tissues. 1ST VISIT Disinfection Naocl + EDTA 2ND VISIT Mixture Antibiotic s Access cavity sealed Reirrigate Initiate bleeding MTA bacterial tight seal Composit e resin The three key ingredients for tissue engineering are 3S Tissue engineering with the triad of dental pulp progenitor/stem cells, morphogens, and scaffolds may provide a useful alternative method for pulp capping and root canal treatment * Signals for morphogenesis [bone morphogenic protein BMP or BMP gene] including growth and differentiation factors * Stem cells or progenitor cells to respond to morphogenesis * Scaffold of extra cellular matrix Young permanent tooth Non- vital Vital Continuous root formation Preserve vitality (Apexogenesis) Apical closure Disinfection (Apexification) Revascularization MTA Apical Plug Stem cell Pulp Capping Indirect Direct Pulpotomy Partial (Cvek) Total Scaffold Growth factors Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. (chapter 24) Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. (chapter 21) Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. (chapter 6) Clinical endodontics, 3rd edition, 2009, Leif Tronstad. (chapters 5 and 6)