Download Indications for Vital Pulp Therapy

Current concepts of pulp protection
Dental pulp consists of vascular connective tissue contained within the rigid
dentin walls. It is the principle source of pain within the mouth and also a
major site of attention in endodontics and restorative treatment.
Vital pulp therapy is broadly defined as treatment initiated to preserve and
maintain pulp tissue in a healthy state, tissue that has been compromised by
caries, trauma, or restorative procedures. The objective is to stimulate the
formation of reparative dentin to retain the tooth as a functional unit. This is
particularly important in the young adult tooth, where apical root
development may be incomplete.
Indications for Vital Pulp Therapy
Vital pulp therapy is indicated whenever the remaining pulp exhibits
reversible pulpitis and can be selectively induced to produce a reparative
barrier that protects the tissue from microbial challenges.
Vital Pulp Therapy Materials
Ideal requirement of pulp capping material, may include the following
characteristics:
1. Stimulate reparative dentin formation
2. Maintain pulpal vitality
3. Release fluoride to prevent secondary caries
4. Bactericidal or bacteriostatic
5. Adhere to dentin
6. Adhere to restorative material
7. Resist forces during restoration placement
8. Must resist forces under restoration during lifetime of restoration
9. Sterile
10.Radiopaque
11.Provide bacterial seal
The materials most commonly used are:
CALCIUM HYDROXIDE
This material, long considered the ‘‘benchmark’’ for vital pulp therapy
materials, has been shown to have some desirable properties, but long term
study outcomes have been variable. Beneficial characteristics include a
bactericidal component owing to its high alkaline pH and the irritation of
pulp tissue that stimulates pulpal defense and repair. Although calcium
hydroxide has been shown to be clinically effective over time, it produces a
superficial layer of coagulation necrosis. The low-grade irritation of this
layer induces the formation of a hard tissue barrier. Conversely, calcium
hydroxide Ca(OH)2 has been shown to be cytotoxic in cell cultures, does not
exclusively stimulate reparative dentin formation, shows poor marginal
adaptation to dentin, it can degrade and dissolve beneath restorations, and it
can also suffer interfacial failure upon amalgam condensation, the material
fails to provide a long-term seal against microleakage when used as a pulp
capping agent which can provide microorganisms with a pathway for
penetration into pulpal tissue.
MINERAL TRIOXIDE AGGREGATE (MTA)
MTA was introduced to endodontics by Lee et al. in the early 1990s. This
bioactive silicate cement was originally composed of tricalcium silicate,
tricalcium aluminate, tricalcium oxide, silicate oxide, and other mineral
oxides. Originally a gray powder, white MTA was produced for esthetic
reasons.
Comparison of dentin bridge formation using mineral trioxide aggregate (MTA) or calcium
hydroxide in dog pulps.A,After 1 week, a noticeable bridge has formed subjacent to MTA.B,A
comparable bridge under calcium hydroxide after 2 weeks.C,A 4-week specimen with MTA
shows excellent bridge formation.D,Consistently, the bridge formation under calcium hydroxide
lagged behind MTA; an example of bridge formation under calcium hydroxide after 8 weeks. CH
= calcium hydroxide; DB = dentin bridge; MTA = mineral trioxide aggregate.
The cement exhibits many favorable characteristics, which make it a superior
material when used as a direct pulp capping material in adult teeth or as an
agent in partial or complete pulpotomy in primary teeth:
1. MTA, unlike calcium hydroxide, has been shown to induce a hard
tissue barrier without inflammation.
2. It set in the presence of blood and moisture.
3. It exhibits a superior marginal adaptation and is nonabsorbabale,
4. When it cures in the presence of calcium ions and tissue fluids, it
forms a reactionary layer at the dentin interface resembling
hydroxyapatite in structure.
5. Biocompatible characteristics include a sustained alkaline pH after
curing, small particle size, and a slow release of calcium ions.
6. MTA induces pulpal cell proliferation, and promotes hard tissue
formation.
The high alkalinity of MTA and its calcium release and sustained pH
at 12.5 is most likely responsible for preventing any further microbial
growth of residual microorganisms left after caries excavation. The
high pH also extracts growth factors from adjacent dentin thought to
be responsible for promoting dentinal bridging.
Indications:
Examples of MTA material
BIODENTINE
Biodentine is a calcium-silicate based material that has drawn attention in
recent years and has been advocated to be used in various clinical
applications, such as root perforations, apexification, resorptions, retrograde
fillings, pulp capping procedures, and dentine replacement. Calcium silicate
based materials have gained popularity in recent years due to their
resemblance to mineral trioxide aggregate (MTA) and their applicability in
cases where MTA is indicated. This material “Biodentine” became
commercially available in 2009 by Septodont company.
Indications:
Biodentine™ is a material offering bioactivity and outstanding sealing
properties to fully replace dentine, both in the crown and in the root with
unique benefits:
1 - Preservation of pulp vitality:
 Absence of post-operative sensitivity: high biocompatibility reducing the
risk of pulp or tissue reaction
• Bioactive: remineralisation of dentine for unique pulp healing properties
• Formation of reactionary dentine and dentine bridges
• Pulp healing promotion after pulp exposure: reversible pulpitis, trauma or
iatrogenic exposure
2 - Prevention of clinical failures:
• Long lasting sealing properties: mineral tags in the dentine tubules
combined with high dimensional stability over time
• Less risk of bacterial percolation: outstanding microleakage resistance
• Absence of post-operative sensitivity: no shrinkage
• No conditioning or bonding: natural mechanical anchorage in dentine
tubules
3 - Ultimate dentine substitute: Biodentin can replace dentin with the
same mechanical properties.
• Easy handling for optimised clinical use
• Superior radiopacity for clear short and long term follow-up
• Comparable to human dentine: similar mechanical behaviour
LASERS
The word LASER is an acronym for Light Amplification by Stimulated
Emission of Radiation. Laser was first introduced by Maiman in 1960, after
which it was used in many field of medicine and dentistry. Lasers can be
used nearly in all fields of dentistry. The most frequently used lasers in
dentistry, either for basic research or clinical application, are the Carbon
dioxide (CO2), the Er:YAG (Erbium-Yttrium- Aluminum - Garnet) and
the Er,Cr:YSGG (Erbium-Chromium-Yttrium-ScandiumGallium-Garnet) ,
Holmium yttrium-aluminium garnet laser (Ho:YAG), Neodymium yettrium
aluminum garnet (Nd:YAG) laser, the Diodes, Argon laser(Ar), and the
Excimer lasers.
Laser can be used for direct and indirect pulp capping with the following
advantages:
1-Unlike mechanical instrumentation, the erbium laser produces minimal
temperature increase because the tooth is air/water-cooled, while being
bactericidal and productive of hemostasis. And may even decrease when
working with water spray cooling.
2-The laser does not produce dentinal chips like rotary instruments, thus
minimizing the chances of bacterial recontamination
3-There is no mechanical insult to the nerve, such as vibration, smearing or
heat, which is the case when using drills. The infected dentine is thus
removed completely
4- laser supported direct pulp capping has proven effectiveness by its
capacity to stimulate reparative dentine formation by pulp cells
5- The laser minimizes the formation of hematoma between the pulp tissue
and the calcium hydroxide dressing allowing a close contact between the
dressing and the exposed pulp.
6-pain reduction
7- The use of the Erbium lasers laser allows cavity preparation to be
completed with only one instrument, in contrast to the alternate use of highand low-speed rotary instruments