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Vital Pulp Therapy
Dr. ARAVINDHAN A,
JR-2,
Dept. of Paediatric & Preventive Dentistry
Introduction
 Vital pulp therapy is the treatment initiated on an exposed pulp to
repair and maintain the pulp vitality.
...
contents
 Indirect pulp capping
 Direct pulp capping
 Pulpotomy
 Apexogenesis
Indirect pulp capping
 Definition:
“a procedure wherein small amounts of
carious dentin is retained in deep areas of
cavi...
Objectives of indirect pulp
capping: (Eidelman-1965)
 Arresting the carious process
 Promoting dentin sclerosis
 Stimul...
Rationale of IPC
Indication contraindication
Mild pain while eating Spontaneous pain
Deep carious lesion with no
pulpal involvement
Pulpo p...
Procedure
Single appointment
procedure
Two appointment
procedure
Under LA and rubber dam
Removal of infected
dentin
Site i...
 Indirect pulp capping agent
Titanium
dioxide in
glycol
salicylateCa(OH)2 and
ZnO in ethyl
toluene
sulfonamide
Method of ...
Sequalae of IPC
 1. cellular fibrillar dentin – first 2 months
 2. globular dentin- 3 months
 3. tubular dentin- after ...
Pulp response to high fluoride releasing glass
ionomer, silver diamine fluoride, and calcium
hydroxide used for indirect p...
Direct pulp capping
 “Placement of medicament
or non medicated material on
a pulp that has been exposed in
course of exca...
Creation of new dentin in the area of the
exposure and subsequent healing of the pulp
Indications
-Small mechanical exposure
-True pin point exposure
-Exposure with bright red hemorrhage
-Asymptomatic vital
p...
Technique
Rubber dam isolation
Cavity should be irrigated with saline, chloramine T, or distilled water
Arresting of hemor...
Histological changes after DPC
24 hrs
• Necrotic zone adjacent to Ca(OH)2 is separated from healthy
pulp tissue
7 days
• I...
Histological evaluation of hard tissue formation after direct pulp capping with
a fast-setting mineral trioxide aggregate ...
Limitations of direct pulp capping in
primary tooth
 Internal resorption
 High cellular content
 Faster inflammatory re...
Materials used for direct
pulp capping
 Calcium hydroxide
 Corticosteroids and antibiotics:
neomycin and hydrocortisone ...
 Direct bonding
 Denatured albumin ( Berkman, 1971)
 MTA
 Bone Morphogenic Protein
 Laser
(laser assisted direct pulp...
Pulpotomy
 “Amputation of the affected or infected coronal
portion of the dental pulp, preserving the vitality &
function...
 Objectives:
1. removal of inflammed/ infected coronal pulp
2. preserving the vitality of the pulp
3. Maintain the integr...
Criteria for case selection
 Teeth with deep carious lesion
 Restorable tooth
 No signs of periapical lesion, abscess,
...
Formocresol pulpotomy/ single stage
pulpotomy
 Introduced by Buckley (1904).
 Sweet(1930)- multivisit pulpotomy
 Doyle(...
 Mechanism of action: it prevents tissue
autolysis by bonding to the proteins.
 Composition:
 Cresol- 35%
 Glycerol- 1...
Procedure
LA and isolation with rubber dam
Removal of all caries and roof of pulp
chamber
Sharp spoon excavator to scoop o...
Histological changes after
formocresol pulpotomy
immediate
• Pulp become fibrous and acidophilic
7-14 days
• Broad eosinop...
Comparative evaluation of formocresol and mineral trioxide
aggregate as pulpotomy agents in deciduous teeth-
Daya srinivas...
Concerns about formocresol
 Toxicity:
Lewis(1981)- cytotoxic, mutagenic and
carcinogenic in animals.
“over 3000 pulpotomi...
 Mutagenicity and cytotoxicity:
formaldehyde denatures nucleic acids
Formation of methylol compounds
Genetic biosynthesis...
Modified formocresol
pulpotomy
 Trask (1972)
 Used in tooth that have to be retained for a
short period of time only
 T...
Two visit devitalisation
pulpotomy
 Fixation of entire coronal and radicular
pulp tissue by paraformaldehyde in two
visit...
Materials used for 2 visit
pulpotomy
Gysi trio paste Easlicks paraformaldehyde
paste
Paraform devitalising
paste
tricresol...
Procedure
LA & isolation
Caries removal &
enlarge the cavity
with round bur
Paraformaldehyde
paste placement and
tempotary...
Gluteraldehyde pulpotomy
 Kopel-1979
 Mechanism:
-rapid surface fixation of pulpal tissue.
-blends into vital normal api...
Adavntages over formocresol…
 1.superior fixation by protein cross linkage.
 2. excellent antimicrobial.
 3. less necro...
Ferric sulphate pulpotomy
 Method of application is similar to formocresol
pulpomy.
 15.5% concentration of solution is ...
Laser pulpotomy
 Ebimara-1985 used Nd-YAG laser in
pulpotomy at 20Hz.
Coronal pulp is removed with spoon
excavator
Laser ...
“Postoperative assessment of diode laser zinc oxide eugenol and
mineral trioxide aggregate pulpotomy procedures in childre...
Cvek pulpotomy
 Partial pulpotomy/ calcium hydroxide
pulpotomy
 Mejare & cvek-1978
 Indicated in young permanent tooth
...
All carious tooth structure is removed
Part of coronal pulp is removed
Ca(OH)2 is applied
Temporary
restoration
Asymptomat...
Non vital pulpotomy
 Mortal pulpotomy
 Non vital tooth should be treated with pulpectomy,
but sometimes it is impractica...
Current concepts in pulpotomy…
 MTA pulpotomy
 Portland cement
 Nano hydroxy apatite and BMP
 Calcium enriched mixture...
-Journal of conservative dentistry,(2015)
Apexogenesis
 It is defined as “the treatment
of a vital pulp by capping or
pulpotomy in order to permit
continued growth...
Procedure
LA & isolation
Removal of carious tooth structure
Removal of coronal pulp and control
of hemorrhage
Ca(OH)2 is p...
-PJ Van der vyver et al., SADJ (2018)
Thank you!
Vital pulp therapy
Vital pulp therapy
Vital pulp therapy
Vital pulp therapy
Vital pulp therapy
Vital pulp therapy
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/dr.aravind-odontopediatrician/ topic discusses about management of pulpal pathoses while maintaining the vitality in primary& young permanent teeth.

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Vital pulp therapy

  1. 1. Vital Pulp Therapy Dr. ARAVINDHAN A, JR-2, Dept. of Paediatric & Preventive Dentistry
  2. 2. Introduction  Vital pulp therapy is the treatment initiated on an exposed pulp to repair and maintain the pulp vitality. - Grossman  Pulpal exposure by mechanical or bacterial means leading to direct communication between pulp and external environment.  Conservation of tooth in a healthy state.  Preservation of arch space.  Enhances esthetics and function.  Prevents peri radicular infection and its sequalae.
  3. 3. contents  Indirect pulp capping  Direct pulp capping  Pulpotomy  Apexogenesis
  4. 4. Indirect pulp capping  Definition: “a procedure wherein small amounts of carious dentin is retained in deep areas of cavity to avoid exposure of pulp, followed by placement of suitable medicament and restorative material that seals off the carious dentin and encourages pulp recovery” -Ingle
  5. 5. Objectives of indirect pulp capping: (Eidelman-1965)  Arresting the carious process  Promoting dentin sclerosis  Stimulating the formation of tertiary dentin  Remineralisation of carious dentin. A successful vital pulp treatment requires, 1. a good sealant against bacteria, 2. no severe inflammatory reactions, 3. and stable haemodynamic within the pulp. - R. Vij, J. A. Coll, P. Shelton, and N. S. Farooq, “Caries control and other variables associated with success of primary molar vital pulp therapy,” Pediatric Dentistry, vol. 26, no. 3, pp. 214– 220, 2004.
  6. 6. Rationale of IPC
  7. 7. Indication contraindication Mild pain while eating Spontaneous pain Deep carious lesion with no pulpal involvement Pulpo periapical invlovement Normal periodontium, gingiva and no mobility Mobility ,abscess/ fistula .
  8. 8. Procedure Single appointment procedure Two appointment procedure Under LA and rubber dam Removal of infected dentin Site is covered with Ca(OH)2 Remainder cavity is filled with suitable restorative material 2nd appointment is given after 6-8 weeks of placement of Ca(OH)2 Re entry of the cavity Removal of caries if needed Placement of Ca(OH)2 Restoration of the cavity
  9. 9.  Indirect pulp capping agent Titanium dioxide in glycol salicylateCa(OH)2 and ZnO in ethyl toluene sulfonamide Method of application Blunt probe Mixing pad
  10. 10. Sequalae of IPC  1. cellular fibrillar dentin – first 2 months  2. globular dentin- 3 months  3. tubular dentin- after 3 months (0.1 mm) Step wise excavation technique -Re entry of the cavity is done at various intervals -After Superficial carious lesion is excavated, suitable interim restoration is done depends on treatment interval (ranges between 6-8 months) Bjorndal L et al., Indirect pulp therapy and step wise excavation. J Endod.2008
  11. 11. Pulp response to high fluoride releasing glass ionomer, silver diamine fluoride, and calcium hydroxide used for indirect pulp treatment: An in- vivo comparative study- Logani A et al.,JCCD (2015).
  12. 12. Direct pulp capping  “Placement of medicament or non medicated material on a pulp that has been exposed in course of excavating the last portions of deep dentinal caries or as a result of trauma.”-Kopel (1992)  “Procedure in which the exposed vital pulp is covered with a protective dressing or base placed directly over the site of exposure in an attempt to preserve pulpal vitality.”- Grossman.
  13. 13. Creation of new dentin in the area of the exposure and subsequent healing of the pulp
  14. 14. Indications -Small mechanical exposure -True pin point exposure -Exposure with bright red hemorrhage -Asymptomatic vital primary/permanent tooth contraindications -Spontaneous pain -Tooth mobility -Uncontrollable bleeding at exposure site -External/internal resorption
  15. 15. Technique Rubber dam isolation Cavity should be irrigated with saline, chloramine T, or distilled water Arresting of hemorrhage with sterile cotton pellets in light pressure Passive placement of pulp capping agent Temporary restoration Final restoration of evaluating the success of DPC clinically/ radiologically.
  16. 16. Histological changes after DPC 24 hrs • Necrotic zone adjacent to Ca(OH)2 is separated from healthy pulp tissue 7 days • Increase in cellular and fibroblastic activity 14 days • Disappearance of necrotic zone • Formation of partly calcified fibrous tissue 28 days • Zone of new dentin -GLASS &ZANDER (1949)
  17. 17. Histological evaluation of hard tissue formation after direct pulp capping with a fast-setting mineral trioxide aggregate (RetroMTA) in humans- Till Dammaschke et al.,JCOI (2019).
  18. 18. Limitations of direct pulp capping in primary tooth  Internal resorption  High cellular content  Faster inflammatory response  Poor localisation of infection.
  19. 19. Materials used for direct pulp capping  Calcium hydroxide  Corticosteroids and antibiotics: neomycin and hydrocortisone ( Brosch,1966) ledermix ( Ca(OH)2 and prednisolone). penicillin/ vancomycin with Ca(OH)2.  Inert materials:  isobutyl cyanoacrylate  tricalcium phosphate ceramic  Collagen fibres  4- META adhesives
  20. 20.  Direct bonding  Denatured albumin ( Berkman, 1971)  MTA  Bone Morphogenic Protein  Laser (laser assisted direct pulp capping has 89% success rate ,1998)
  21. 21. Pulpotomy  “Amputation of the affected or infected coronal portion of the dental pulp, preserving the vitality & function of all or part of the remaining radicular pulp”- AAPD-1998. VITAL NON- VITAL •Devitalisation •preservation •regeneration •Mortal pulpotomy
  22. 22.  Objectives: 1. removal of inflammed/ infected coronal pulp 2. preserving the vitality of the pulp 3. Maintain the integrity of tge arch Indications contraindicatons Mechanical pulp exposure in primary teeth Persistent tooth ache No sinus / fistula Presence of furcal/periapical infection Presence of atleast 2/3rd root External /internal resorption/physiological resorption of more than 1/3rd of root Controllable Hemorrhage from the exposure site Uncontrollable sluggish hemorrhage No peri radicular pathology Mobilty of tooth
  23. 23. Criteria for case selection  Teeth with deep carious lesion  Restorable tooth  No signs of periapical lesion, abscess, fistula  No internal/ external resorption  Hemorrhage should be arrested within 5 minutes from the amputated pulp stumps. - Heilig J et al.,(1984) & Waterhouse et al., (2000).
  24. 24. Formocresol pulpotomy/ single stage pulpotomy  Introduced by Buckley (1904).  Sweet(1930)- multivisit pulpotomy  Doyle(1962)- two sitting procedure  Spedding(1965)- 5 minutes protocol  Venham(1967)- 15 seconds procedure -Current concept used 4 minutes application time.
  25. 25.  Mechanism of action: it prevents tissue autolysis by bonding to the proteins.  Composition:  Cresol- 35%  Glycerol- 15%  Formaldehyde- 19%  Water- 31%
  26. 26. Procedure LA and isolation with rubber dam Removal of all caries and roof of pulp chamber Sharp spoon excavator to scoop out coronal pulp Application of formocresol for 4 minutes with cotton pellet Temporary restoration and replacement of permanent restoration after 1 week
  27. 27. Histological changes after formocresol pulpotomy immediate • Pulp become fibrous and acidophilic 7-14 days • Broad eosinophilic zone of fixation • Pale staining zone of atrophy with poor cellular definition • Broad zone of inflammation extending into vital pulp apically 1 yr • Progressive apical movement of these zones. • Only acidophilic zone left after 1 year
  28. 28. Comparative evaluation of formocresol and mineral trioxide aggregate as pulpotomy agents in deciduous teeth- Daya srinivasan et al., IJDR (2011).
  29. 29. Concerns about formocresol  Toxicity: Lewis(1981)- cytotoxic, mutagenic and carcinogenic in animals. “over 3000 pulpotomies must be done in an individual to reach the toxic level of formocresol”.- Ranly.  Systemic distribution: formocresol was found in PDL, bone, dentine, and urine- Myers (1978).  Antigenocity: immunogenicity is found with fromocresol- Thoden valzen (1977).
  30. 30.  Mutagenicity and cytotoxicity: formaldehyde denatures nucleic acids Formation of methylol compounds Genetic biosynthesis blockade (interaction with DNA & RNA) - Nongentini,1980. “formaldehyde is not a potent human carcinogen under conditions of low exposure” - Milnes et al., persuasive evidence that formocresol use in pediatric dentistry is safe. J Can Den Assoc.2006
  31. 31. Modified formocresol pulpotomy  Trask (1972)  Used in tooth that have to be retained for a short period of time only  Technique is identical to primary tooth only but formocresol, soaked cotton pellet was kept inside the permanent tooth.
  32. 32. Two visit devitalisation pulpotomy  Fixation of entire coronal and radicular pulp tissue by paraformaldehyde in two visits. Indications:  1. sluggish bleeding at the ampuatation site that is difficult to control.  2.pus in the chamber but none at the amputation site Contraindications: 1. tooth with necrotic pulp.  2. non restorable tooth.
  33. 33. Materials used for 2 visit pulpotomy Gysi trio paste Easlicks paraformaldehyde paste Paraform devitalising paste tricresol paraformaldehyde paraformaldehyde cresol Procaine base lignocaine ZOE Powdered asbestos Propylene glycol glycerin Petroleum jelly carbowax paraformaldehyde Carmine to color
  34. 34. Procedure LA & isolation Caries removal & enlarge the cavity with round bur Paraformaldehyde paste placement and tempotary restoration Removal of the old cotton pellet Pulpal remnants are removed restoration 1st visit 2nd visit After 1-2 weeks - Nikhil Marwah, 4th edition
  35. 35. Gluteraldehyde pulpotomy  Kopel-1979  Mechanism: -rapid surface fixation of pulpal tissue. -blends into vital normal apical tissue. -fixed tissue is replaced by dense collagenous tissue with time. - 2% gluteraldehyde is applied for 1-3 minutes over the ampuated pulp. (garcia & godoy ,1986)
  36. 36. Adavntages over formocresol…  1.superior fixation by protein cross linkage.  2. excellent antimicrobial.  3. less necrosis of pulp  4. doesn’t perfuse through apex.  5. less mutagenicity and antigenicity.
  37. 37. Ferric sulphate pulpotomy  Method of application is similar to formocresol pulpomy.  15.5% concentration of solution is applied for 15 seconds.  Mechanism: agglutination of blood proteins results from the reaction of blood with both ferric and sulphate ions. -agglutinated proteins form plugs to occlude capillary orifice.  Minimises the chance of internal resorption. “Controlled clinical studies have been critically reviewed, and mineral trioxide aggregate and ferric sulfate have been considered appropriate alternatives to formocresol for pulpotomies in primary teeth with
  38. 38. Laser pulpotomy  Ebimara-1985 used Nd-YAG laser in pulpotomy at 20Hz. Coronal pulp is removed with spoon excavator Laser is applied at pulp stumps for not more than 2-3 minutes restoration Diode laser 810 nm 3W power Non contact mode Continuous wave
  39. 39. “Postoperative assessment of diode laser zinc oxide eugenol and mineral trioxide aggregate pulpotomy procedures in children: A comparative clinical study”- Pratima I et al., JISPPD (2018).
  40. 40. Cvek pulpotomy  Partial pulpotomy/ calcium hydroxide pulpotomy  Mejare & cvek-1978  Indicated in young permanent tooth where the radicular pulp is judged vital by clinical/ radiological criteria and root formation is incomplete.  According to American Academy of Pediatric Dentistry (AAPD) guidelines, partial pulpotomy for traumatic exposures is a procedure, in which the inflamed pulp tissue beneath an exposure is removed to a depth of 1-3 mm or more to reach the deeper healthy tissue.
  41. 41. All carious tooth structure is removed Part of coronal pulp is removed Ca(OH)2 is applied Temporary restoration Asymptomatic during recall Permanent restoration
  42. 42. Non vital pulpotomy  Mortal pulpotomy  Non vital tooth should be treated with pulpectomy, but sometimes it is impracticable due to non negotiable root canals. Mortal pulpotomy is done in such patients.  Beechwood cresol is used in this procedure.  If the tooth is asymptomatic after 1-2 weeks , definite restoration is given.
  43. 43. Current concepts in pulpotomy…  MTA pulpotomy  Portland cement  Nano hydroxy apatite and BMP  Calcium enriched mixture  Allium sativum oil  Lyophilised freeze dried platelet with calcium hydroxide.  Enamel matrix derivative  Propolis  Ankaferd blood stopper  Platelet rich plasma  Pulpotec  Calcium phosphate cement  Biodentine
  44. 44. -Journal of conservative dentistry,(2015)
  45. 45. Apexogenesis  It is defined as “the treatment of a vital pulp by capping or pulpotomy in order to permit continued growth of the root and closure of the open apex”.  Rationale: maintanence of integrity of the radicular pulp tissue to allow for continued growth.
  46. 46. Procedure LA & isolation Removal of carious tooth structure Removal of coronal pulp and control of hemorrhage Ca(OH)2 is placed over the pulp stumps Periodic follow up to check the root development
  47. 47. -PJ Van der vyver et al., SADJ (2018)
  48. 48. Thank you!
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/dr.aravind-odontopediatrician/ topic discusses about management of pulpal pathoses while maintaining the vitality in primary& young permanent teeth.

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