Download ref - Peter Walford Dentistry

PULP CAP
KAMLOOPS
APRIL 14, 2012
RETROSPECTIVE STUDIES
1.
2.
3.
Bogan G et al JADA 2008:39 (3) 305-315
97%
Fuks AB, Pediatr Dent 1982,4: 240-244
81% success on permanent incisors
Barthel CR ,J Endod 2000; 26: 525-528
37% @ 5 years, 13% @10 years
PULP CAP MATERIALS ?
CR NEWS Jan 2010
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RMGI Vitrebond Plus or
GC Fuji Lining LC
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Calcium Hydroxide
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Indirect 40%
Indirect 68%
28% Direct,
14% Indirect
Bonding agent
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Direct 7%
Indirect 5%
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Laser 2% Direct
Gluteraldehyde Indirect
3%
MTA 3% Direct
Polycarboxylate – no
mention
Glass Ionomer – no
mention
English sparrow poop
CR News Jan 2010 vol 3 issue 1
1.
CR respondents;
success rates
1.
2.
3 years: Direct 58%,
Indirect 70%
5 years: Direct 48%,
Indirect 61%
100
90
80
70
60
50
40
30
20
10
0
DIRECT
INDIRECT
BOGAN
FUKS
BARTHEL
3
5
10
MTA
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Bogan G et al JADA 2008:39 (3) 305-315
Direct pulp capping with Mineral Trioxide
aggregate – an Observational Study.
Over an observation period of nine years,
the authors followed 49 of 53 teeth and
found that 97.96% percent had favorable
outcomes on the basis of radiographic
appearance, subjective symptoms and
cold testing.
PEDO
FUKS
100
90
80
70
60
50
40
30
20
10
0
MTA
BOGAN
Barthel
Fuks
CRA indirect
CRA direct
Bogan
PULP CAP SUCCESS RATES
70
60
50
RMGI
CA(OH)2
GLUT
BOND
MTA
40
30
20
10
0
INDIRECT
DIRECT
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
SUCCESSFUL PULP CAPS
Healthy patient
Recoverable pulp
Inflammation
management
seal
Histological repair
Flawless caries
removal
Disinfection
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
RADIOGRAPHIC
CONTRAINDICATIONS
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APICAL
RADIOLUCENCY
APICAL
DETERIORATION CONDENSING
OSTEITIS
THREADLIKE PULP
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PULP STONES
PROBABLE
FUTURE PULP
OCCLUSION E.G.
CLASS V
RADIOGRAPHICLY
EVIDENT CARIOUS
INVASION OF PULP
CHAMBER
DIAGNOSTIC
CONTRAINDICATIONS =
HISTORY OF ++ PAIN
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APICAL TENDERNESS
SPONTANEOUS
LONG STANDING
NOCTURNAL
THROBBING
ENDURING
SICKENING
CONSTANT NEED OF MEDICATIONS
OPERATIVE OBSERVATIONS
CONTRAINDICATIONS AT
EXPOSURE
EXUDATE – SEROUS
 PUS
 PROLONGED CLOTTING TIME > 5
MINS
 >3MM EXPOSURE
 EXPLORER INTO THE PULP
(OPERATOR ERROR)
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SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
FORMULA FOR CARIES DETECTOR
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ACID RED 52 2% IN PROPYLENE GLYCOL
COMPOUNDING PHARMACY
$30 FOR 200 CC.= 5 YEARS’ SUPPLY
ref
CARIES DETECTOR - NO EFFECT
ON BOND STRENGTH
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El-Housseiny and Jamjoum, J Clin Pediat
Dent 200
Kazemi et al, Oper Dent 2002
AFFECTED DENTIN
INFECTED DENTIN
SETTING THE STAGE FOR PULPAL
HEALING
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EXPOSURE ZONE:
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CONTIGUOUS ZONE
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LOW/NIL BACTERIAL COUNT
BIOCOMPATIBLE AND
CALCIGENIC AGENT
VISIBLE DELINEATION FOR
FUTURE INTERVENTIONS
PERIPHERAL ZONE
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SEAL (ZERO MICROLEAKAGE)
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TUBULES
% AREA
88%
10%
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20 K
NUMBER/ MM2
58K
3u
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DIAMETER
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PRESSURE
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SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP
1u
NIL
POSITIVE
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
LEAVING CARIES?
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REFERENCE
CR
JAN 2010
2 APPLICATIONS
ONE MINUTE EACH
ref
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CR News Jan 2010 vol 3 issue 1
http://www.cliniciansreport.org/products/d
ental-reports/january-2010-volume-3issue-1.php
Subscription required
OTHER INTRAORAL
DISINFECTANTS
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ENDODONTIC
SILVER NITRATE
IODINE
FORMOCRESOL
CA(OH)2
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ref
PULPAL
HYPOCHLORITE KANCA
CHLORHEXEDINEMANY
CHLORHEXEDINE NO EFFECT
ON BOND STRENGTH
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Santos et al, JOE, 2006
Perdiao et , Am J Dent 1994
WHAT ABOUT SURFACE
DISINFECTANTS?
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70% ALCOHOL WITH PHENOLS
70% ALCOHOL WITH CHX
ACCELERATED PEROXIDE
HYPOCHLORITE
ref
NaOCl
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IS A STRONG OXIDIZING AGENT
REDUCES BOND STRENGTH OF DENTIN
BONDING AGENTS
Ari et al, JOE, 2003
Erdemir et al, JOE, 2004
Santos eta l JOE, 2006
Lai et al, J Deny Res 2001
REVERSING NaOCl EFFECTS ON
DBAS
A reducing agent, such as ascorbic acid, or sodium
ascorbate, can reverse the effect of NaOCl on
bonding strength
Morris et al, JOE, 2001
Lai et al, J Dent Res, 2001
Yiu et al, J Dent Res, 2002
Weston et al JOE, 2007: 10% Na ascorbate for 1
min restored the origonal bond strenghts
EDTA reverses effect of NaOCl
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Doyle t al, JOE, 2006
A final rinse with EDTA reversed the
effects of NaOCl on bonding
H2O2 reduces bond strength of
DBAs
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Erdemir et al JOE, 2004
Nikaido et al, Am J Dent 1999
DEEP CARIES DISINFECTION
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Optim 33TB Sci Can
One minute kill
=10 Log -6
TB effective
CR tested April 2007
Excellent surface
cleaner
Tissue compatible
WALFORD DEEP CARIES /
EXPOSURE PROTOCOL
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GET CLOSE
OPTIM 33TB ONE MINUTE
NO DETECTOR
CAREFUL ECAVATION
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SMEAR CLEAR ONE MINUTE
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SLOW RPMS
SPOON
REMOVE SMEAR LAYER
OPTIM 33 ONE MINUTE
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PENETRATE TUBULES
REMOVING SMEAR LAYER &
PENETRATING TUBULES
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EDTA
SmearClear (SybronEndo)
QMix (Tulsa/Dentsply)
Acid etch
WALFORD DEEP CARIES /
EXPOSURE PROTOCOL
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GET CLOSE: OPTIM 33TB
ONE MINUTE
NO DETECTOR
CAREFUL ECAVATION
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SMEAR CLEAR ONE
MINUTE
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REMOVE SMEAR LAYER
OPTIM 33 ONE MINUTE
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SLOW RPMS
SPOON
PENETRATE TUBULES
SMEAR CLEAR (as
reducer)
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EXPOSE if still carious
MTA DIRECT CAP
OVERSEAL WITH GLASS
IONOMER or CA(OH)2
ALLOW TO SET
ETCH PRIME BOND
OVERSEAL
FLOWABLE/CURE
FLOWABLE /CURE
RESTORE FOLLOWING
LOW CONTRACTION
STRESS PRINCIPLES
MTA: SUPPLIER
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CLINICAL RESEARCH DENTAL
LONDON ONTARIO
1800 265 3444
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“MTA ANGELUS WHITE”
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MTA MECHANISM
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Silviera CMM et al. Repair of Furcal
Perforation with Mineral Trioxide
Aggregate: Long-Term Follow-Up of
2 Cases JCDA October 2008 Vol 74 #8
729-732
http://www.cda-adc.ca/jcda/vol-74/issue8/729.html
MTA MECHANISM
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Saidon J et al. OSOMOPOR Endod
2003:95:483-489 “Cell and tissue
reactions to mineral trioxide
aggregate (MTA) and Portland
cement.”
MTA and Portland cement show
comparative biocompatibility when
evaluated in vitro and in vivo. The
Portland cement was sterilized by
ethylene oxide.
MTA MENTE ET AL
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Johannes Mente, DMD, et al J. Endo May
2010 806-814
Mineral Trioxide Aggregate or Calcium
Hydroxide Direct Pulp Capping: An
Analysis of the Clinical Treatment Outcome
5 years, 167 teeth
78% success MTA, 60% Ca(OH)2
i.e. Twice as much failure with Ca(OH)2
Mente, DMD, et al J. Endo May
2010
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Dentin bridge formation with MTA seems to be more homogenous (fewer
tunnel defects) and more localized than that formed with Ca(OH)2 (20–24).
caries was excavated from the cavity walls.
Near to the pulp, except for one carious spot, the removal of which resulted
in exposure of the pulp, the cavities were routinely disinfected with 0.12%
chlorhexidine solution (Glaxo Smith Kline GmbH, Buhl, Germany).
Resolution of bleeding from the exposed pulp in less than 5minutes was
considered to be indicative of reversible inflammation
The MTA pulp cap was overlaid with a thin protective layer of resin modified
glass ionomer cement (Vitrebond; 3M Espe)
The reduction in clinical success if a direct pulp capping is not followed
immediately with permanent restoration has been shown in other clinical
studies (11, 12)
The longer the follow-up period, the more evident the trend became to a
decline in the success rate of the teeth in the Ca(OH)2 group compared
with the MTA group.
SUCCESSFUL PULP CAPS
Healthy patient
seal
Recoverable pulp
Inflammation
management
Flawless caries
removal
Histological repair
Disinfection
RESIN BIOCOMPATIBILITY???
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Volk,J, Engelmann,J.,Leyhausen,G.,Geurtsen,W.
Dental Materials 2006 22:499-505
Effects of three resin monomers on the cellular
glutathione concentration of cultured human
fibroblasts
See Website: Home>MODXYZ> Biocompatibility
ref
DYRACT AND DYRACT-CEM AND
VITREBOND
J Dent Res. 1998 Dec;77(12):2012-9.
Residual monomer/additive release and variability in cytotoxicity of
light-curing glass-ionomer cements and compomers. Geurtsen W,
Spahl W, Leyhausen G. Severe cytotoxic effects were observed in
response to both of these materials
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Mutat Res. 1996 Jul 5;368(3-4):181-94.
Genotoxicity of dental materials. Heil J, Reifferscheid G, Waldmann
P, Leyhausen G, Geurtsen W. Genotoxic effects were found for
Vitrebond and AH 26 (since upgraded to AH26 Plus)
GLASS IONOMER
BIOCOMPATIBILITY
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Biomaterials. 1998 Mar;19(6):559-64.
Biocompatibility of various light-curing and
one conventional glass-ionomer cement.
Leyhausen G, Abtahi M, Karbakhsch M,
Sapotnick A, Geurtsen W.
Two GIs was found to be very
biocompatible, while Vitrebond was found
to be cytotoxic.
MTA THERAPIES
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Indirect Pulp cap (Pink Dentin)
Direct pulp cap (Direct Exposure)
Pulpotomy (Coronal extirpation)
Pulpectomy (Coronal and radicular
extirpation)
Root canal therapy
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Perforation repair
Apicoectomy
NEW - BIODENTINE
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SEPTODONT
$17 PER APPLICATION
REQUIRES TRITURATOR
IS MEANT TO BE A COMPLETE
TEMPORARY FILLING
STICKY HANDLING
INDEPENDENT REVIEW YET TO BE SEEN
PEDODONTIC PULPOTOMY
SUCCESSFUL PULP CAPS
Healthy patient
Inflammation
management
Recoverable pulp
Seal
Flawless caries
removal
Histological repair
Disinfection
SEALING THE PULP CAP
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IMMEDIATE RESTORATION improves
prognosis 30% (Mente et al)
PROTECT THE CAP from shrinkage
FINAL RESTORATION with low sensitivity
technique
CAREFUL OCCLUSION
CAREFUL AND ACCURATE
OCCLUSION
SUCCESSFUL PULP CAPS
Healthy patient
Recoverable pulp
Histological repair
Inflammation
management
Flawless caries
removal
seal
Disinfection
INFLAMMATION MANAGEMNT
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MEDICATION
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Disciplined use of
Ibuprofen 400 mg for
24 hours q4h 6 tabs
Instruct to use
regardless if painful or
not
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1.
2.
3.
4.
5.
COMMUNICATION
Cautious prognosis
“Call me I want to
know”
Next day follow-up
call 11 am
Not that night!
Inform that success
may be temporary
THE END