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Copy of indirect pulp capping

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on 8 December 2012

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Transcript of Copy of indirect pulp capping

to the pulp? Bacteria and/or their toxins What are the requirements for ideal pulp capping agent ? The pulp capping agent ;

Biologically compatible
Stimulating the formation of reparative dentin.
Highly impermeable Preventing bacteria from the dental pulp .
Has anti- bacterial effect. Glass Ionomer (GI)/Resin-Modifed Glass Ionomer (RMGI) GI has the ability to chemically bond to tooth structure
Provides an excellent bacterial seal
Shows good biocompatibility when used in close approximation but not in direct contact with the pulp.
It can prevent the diffusion of toxic materials through dentin to the pulp. The self-etching system is an adhesive system based on a current bonding strategy using non rinsing, acidic, and polymerizable monomers on dentin and enamel simultaneously . Zinc Oxide Eugenol (ZOE) Zinc oxide eugenol (ZOE) material has been available since the late 1800s and is considered to be the least irritating of all dental materials.
Approximately of pH 7
have a sedative effect on the pulp
ZOE inhibits bacterial cell metabolism
low incidence of postoperative sensitivity
ZOE provides an excellent
initial seal at the restoration-tooth
interface, despite the fact that
it does not adhere to tooth structure. However ! Eugenol is highly cytotoxic.

ZOE demonstrates high interfacial leakage.
it is anticipated that the effectiveness of ZOE in excluding bacteria is reduced the longer it is in place in the mouth. However! Indirect pulp capping employing a RMGIC,has been evaluated in two studies;
one reported acceptable pulpal response
the other described a less favorable pulpal reaction .
Several studies on cultured cells have shown that the light activated glass ionomer cements exhibit poor biocompatibility and greater cytotoxicity than the conventional ones Mineral Trioxide Aggregate (MTA) (MTA) has generated considerable interest as a direct and indirect pulp capping agent in recent years.

MTA is considered a silicate cement rather than an oxide mixture, and so its biocompatibility is due to its reaction products.

Interestingly, the primary reaction product of MTA with water is calcium hydroxide. However The presence of iron and bismuth oxide in the MTA formulation may darken the tooth.
The handling characteristics of the powder-liquid MTA are very different from the typical pastepaste formulations of calcium hydroxide
prolonged setting time of approximately 2 hours and 45 minutes.
MTA has shown solubility.
MTA is very expensive. The inclusion of antibacterial components in the self-etching system has also been attempted using several methods.
Imazato et al. identified the bactericidal effect of the primer incorporating the antibacterial monomer methacryloyloxydodecylpyridinium bromide (MDPB) against bacteria in carious lesions resulted in little or no pulpal inflammation for all periods tested What are the materials suitable for this technique? Research since the mid-1970s has indicated that the pulp can tolerate a variety of restorative materials if bacteria and/or their toxins can be excluded from the pulp. Therefore, one of the crucial principles, is that
the key to pulp survival after capping is a well-sealed restoration. However! It must be kept in mind that pulp will react to a noxious stimulus
with an
inflammatory response. calcium hydroxide Gold stander why? stimulate sclerotic and reparative dentin formation
Protecting the pulp against thermal stimuli
Antibacterial action Advantages of MTA Many of the advantages and potential mechanisms of action are similar to calcium hydroxide including:
Its antibacterial
Biocompatibility properties
High pH
It is ability to aid in the release of bioactive dentin matrix proteins. Silver Diamine Fluoride:
A Caries “Silver-Fluoride Bullet” SDF is cariostatic agent . Recent reports of its effect in deciduous teeth follow classic studies which had reported its utility in the treatment and prevention of caries in these teeth
SDF increased calcium, phosphate and fluoride ions in caries affected dentin, the highest being fluoride ions. If mircroleakage is prevented, and bacteria are controlled outside the pulp, the pulp may recover by itself and the pulp capping treatment may obtain a good result. The main purpose of restorative dentistry is to restore and maintain tooth health by an adequate restorative treatment in order to protect and re-establish pulp function The protection of the dentin-pulp complex consists of
the application of one or more layers of specific material
between the restorative material and dental tissue to avoid
additional challenge to the pulp tissue
and recover pulp vitality However! The hard-setting calcium hydroxide medication:
Don't prevent microleakage fully.
The dentin bridge formed by Ca(OH)2 is porous, with numerous tunnel defects.
After 1–2 years, the Ca(OH)2 dressing dissolves so ,clinically, it is not an effective long-term seal . Remineralizing potential of Silver-diamine-fluoride and Glass-ionomer-type-VII on carious dentin in-vivo Aims: To evaluate two high fluoride releasing materials: Silver diamine fluoride (SDF) and Glass-ionomer cement-Type VII(GIC-VII) as potential indirect pulp capping materials (IPC) as compared to calcium hydroxide.
Conclusion: Both SDF and GIC-type VII can be potential IPC materials.  The study needs to be expanded to include larger number of cases with longer follow up periods. The type of liner is less
important to success than the placement of a well-sealed restoration. There is no evidence that
partial caries removal is detrimental in terms of signs, symptoms, pulpitis occurrence or restoration longevity; there is substantial evidence that complete caries removal is not needed for success provided that
the restoration is well sealed.
24,43,20,34,36–41 Toxicity from dental materials Introduction of self etch system as pulp capping agent Technique Local Anaesthesia and Rubber dam were placed as a routine in many studies discussing this technique.

Gruythuysen et al., 2010
Kotsanos and Arizos, 2011

In apprehensive and very young patients with low caries risk this technique can be done without local anaesthesia & rubber dam

In some techniques as ART, local anesthesia and rubber dam are avoided. Start spark Carious Dentine... when to stop?
It is possible to identify three dentinal layers:

1. Necrotic, soft, brown dentin, teeming with bacteria and not painful to remove.

2. Firm but still softened, discolored dentin with fewer bacteria, but painful to remove, suggesting the presence of viable odontoblastic extensions from the pulp

3. Sound dentin, a discolored area, presumably with a minimal amount of bacterial invasion and painful to instrumentation Dental Caries So, remove:
Irreversibly denaturated
Non-remineralizable dentin

To allow:
Remineralization of demineralized affected
dentin Armamentarium Conventional Caries Detection Dies Polymer Bur = Smart Bur Chemico-mechanical Methods Papacarie Carisolve Fluorescence-Aided Caries Excavation (FACE) PowerDrive
A Multifunctional Electronic Instrument! Specially-designed tips for treatment with Carisolv™ A microprocessor is used to control the torque
with high precision We still have more..! "PAD"

Photo Activated Disinfection Healozone Complete caries removal Total removal of caries biomass This will inhibit lesion progression Least amount of cariogenic bacteria.

However, These bacteria are viable and are able to proliferate.

But, It dramatically decrease after sealing the cavity

Lula et al., 2009 2-steps Partial Caries Removal

= Stepwise Excavation

=Partial removal of caries as provisional ttt Carful caries removal Leaving a thin layer of carious dentine overthe pulp


Leaving more carious tissue on the pulp floor which is "currently recommended"


A provisional restoration is put and then re-opened 6-8 months to:
1- Remove residual carious dentine.
2- Evaluate formation of tertiary dentine.
Finally the tooth can be restored with the suitable final restoration.

Bjørndal and Kidd, 2005; Bjørndal 2008; Ribeiro, 2012 Rationale for the partial removal of carious tissue in primary teeth.

(Ribeiro et al 2012) Deep Cavity... Or Pulp exposure... This will decrease risk of pulpal exposure during caries removal but, it may occure during re-entry

Ricketts et al., 2006 Microbial colonization level after 3-6 monthes after sealing: as complete caries removal

Lula et al., 2009 Carious process arrest

Pinto et al., 2006; Franzon et al., 2007 Partial Caries removal Carful removal of most but not all carious dentine on the pulp floor. and then final restoration is directly placed.
Ribeiro et al., 2012 1 step
(Partial removal of caries as a definitive ttt) Partial caries removal Gradual Caries Arrest

Soft Hard
Light yellow Dark brown

Caries progression

Ribeiro et al., 1999 ; Ricketts et al., 2006 ; Thompson et al., 2008 ; Casagrandeet et al, 2009 Many In-vitro studies revealed:

Tissue re-organization.
Increase in carious tissue micro-hardness.
Increased calcium content in the carious tissue.

Massara et al., 2002 ; Wambier et al., 2007;
Juliana et al., 2008 WOW..! What about bacteria? Double click to crop it if necessary (cc) photo by Metro Centric on Flickr (cc) photo by Franco Folini on Flickr (cc) photo by jimmyharris on Flickr (cc) photo by Metro Centric on Flickr Double click to crop it if necessary (cc) photo by Metro Centric on Flickr (cc) photo by Franco Folini on Flickr (cc) photo by jimmyharris on Flickr (cc) photo by Metro Centric on Flickr Double click to crop it if necessary (cc) photo by Metro Centric on Flickr (cc) photo by Franco Folini on Flickr (cc) photo by jimmyharris on Flickr (cc) photo by Metro Centric on Flickr A team work debate In The Cross Roads For Changing Concepts Why to shift the concept??? For a million years Pulpotomy has been advocated as the treatment of choice for treating Primary teeth with deep caries because of: Vital Pulp Therapy Paradigm Shift Of Concept
1. Preservation of the tooth structure
& pulp vitality
"Minimal Invasive Dentistry" Paradigm Shift Of Concept 2. Early exfoliation of teeth treated
with pulpotomy Paradigm Shift Of
Concept 3. Success Rate Case Selection Evidence Based
Paradigm Shift
of Concept History Clinical Examination Radiographic Examination NO
Sinus or fistula NO
Mobility NO
Discoloration of
the tooth No NO No Paradigm Shift Of
Concept Paradigm Shift Of
Concept 6.Lower possibility of affecting permanent successor Indirect Pulp Capping "A procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin." Paradigm Shift Of
Concept Indirect Pulp Therapy Early Normal 0% 100% The study also concluded that the early range was 6 months or more for the FP-treated teeth Dr. Farouq, Dr. Coll, Dr. Kuwabara, Dr. Shelton
Pediatric Dentistry, 2000. 93% Immediate success The overall success rate was based on combining radiographic and clinical findings. All clinical failures exhibited radiographic
failures, but not all radiographic failures
had clinical signs or symptoms. Long-term success Dr. Coll
Pediatric Dentistry, 2008 ZA Kurji, MJ Sigal, P Andrews, K Titley, G Kulkarni
Faculty of Dentistry, University of Toronto Outcomes of a Modified Pulpotomy Technique Objectives To assess the clinical and radiographic outcomes of a one minute application of full strength Buckley’s formocresol and concurrent hemostasis with the medicated cotton pledget, in human primary teeth To evaluate the relationship between formocresol pulpotomies on primary teeth and enamel defects on their permanent successors To examine the effect of formocresol pulpotomies on the timing of exfoliation of the treated teeth Results Clinical Radiographic Exfoliation Successor Clinical The sample comprised 557 treated teeth

4 out of the 557 failed 99.3% Radiographic 89.8% Exfoliation Successor Five premolars that succeeded pulpotomized primary molars presented with surface enamel defects and or positional alterations 28.8% 2.6% Conclusion One-minute formocresol pulpotomy technique results in 94.5% combined clinical and radiographic success rates with minimal adverse effects on succedaneous teeth or on exfoliation times . Good Intercuspation
The Corner-stones in IPC
are The perfect coronal
hermetic seal The proper case selection Recent Studies have shown that perfect coronal seal prevents the entrance of nutrients and formation of acidic media suitable for bacterial growth.

Resulting in making the bacteria dormant and subsequent death (Clin Oral Invest 2008).

King and associates, Found that the residual layer of carious dentine,left in the IPC could be changed to sclerotic or hyper calcified dentine. The perfect coronal hermetic seal Provoked Pain Not spontaneous Clinical
Examination Vital The cases are selected according to Case history Clinical
examination Radiographic
examination 3 - 4 years >90% Hazards of formocresol as a potential carcinogen and mutagen upon the general health Hazards nasopharyngeal
cancer increase in white blood cell chromosomal abnormalities mutagenic Dr. Farouq, Dr. Coll, Dr. Kuwabara, Dr. Shelton
Pediatric Dentistry, 2000. Immediate success 74% Long-term success Dr. Coll
Pediatric Dentistry, 2008 6 - 12 months 90% 3 - 4 years 70% Dr. Coll
Pediatric Dentistry, 2008 FP >35% IPT 0% A connection has been found between the use of formocresol in pulpotomies and the occurrence of enamel hypoplasia in the permanent successor Recent biological studies (3 RCT's one of which with a 10-year follow-up) demonstrate that cariogenic bacteria once isolated from the source of nutrition by a restoration of sufficient integrity either die or remain dormant presenting no risk to the pulp. Foley J, Evans D, Blackwell A., 2004 Formocresol Pulpotomy (FP) Indirect Pulp Therapy IPT FP Case selection we need to diagnose cases of REVERSIBLE PULPITIS which are suitable for either FP or IPC . CASE SELECTION While cases of sharp penetrating pain or prolonged night pain indicating IRREVERSIBLE PULPITIS need pulpectomy of the tooth. Loss of
lamina dura widening of
PL space R.L about the
apices of the roots
or in the furcation Pulpotomy "Pulpotomy is defined as the amputation of damaged and inflammed vital pulp from the coronal chamber followed by placement of a medicament over the radicular pulp stumps to stimulate repair, fixation or mummification of the remaining vital radicular pulp." High Success Rate Easiness of treatment Single-step Technique Cheap Dr. Farouq, Dr. Coll, Dr. Kuwabara, Dr. Shelton
Pediatric Dentistry, 2000. Complete Partial 1- Step Over 1 year follow up Clinical

Radiographic = Over 5 years follow up Clinical & Radiographic Ribeiro et al., 1999; Casagrand et al., 2009 Satisfactory However, Reduction in the number of viable microorganisms.

Massara et al., 2002; Pinto et al.,2006; Wambier et al., 2007; Orhan et al., 2008; Duque et al., 2009; Lula et al., 2009 Bacterial adaptation to be not able to contiue caries process due to drastic reduction in nutrients & blockage of communication with the biofilm on the tooth surface

Kidd, 2004
Complete bacterial elimination S.mutans and Lactobacilli was found to be eliminated within 3-6 monthes after cavity sealing

Wabbier et al.,2007; Douque et al., 2009;
Lula et al., 2009 What about bacteria?! Caline et al., 2002 Caline et al., 2002
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