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PULP CAP

PULP CAP. KAMLOOPS APRIL 14, 2012. RETROSPECTIVE STUDIES. 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.

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PULP CAP

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  1. PULP CAP KAMLOOPS APRIL 14, 2012

  2. RETROSPECTIVE STUDIES • 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

  3. RMGI Vitrebond Plus or GC Fuji Lining LC Indirect 40% Indirect 68% Calcium Hydroxide 28% Direct, 14% Indirect Bonding agent Direct 7% Indirect 5% Laser 2% Direct Gluteraldehyde Indirect 3% MTA 3% Direct Polycarboxylate – no mention Glass Ionomer – no mention English sparrow poop PULP CAP MATERIALS ?CR NEWS Jan 2010

  4. CR News Jan 2010 vol 3 issue 1 • CR respondents; success rates • 3 years: Direct 58%, Indirect 70% • 5 years: Direct 48%, Indirect 61%

  5. MTA • 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.

  6. MTA BOGAN PEDO FUKS PULP CAP SUCCESS RATES

  7. SUCCESSFUL PULP CAPS Inflammation management

  8. SUCCESSFUL PULP CAPS Inflammation management

  9. SUCCESSFUL PULP CAPS Inflammation management

  10. APICAL RADIOLUCENCY APICAL DETERIORATION -CONDENSING OSTEITIS THREADLIKE PULP PULP STONES PROBABLE FUTURE PULP OCCLUSION E.G. CLASS V RADIOGRAPHICLY EVIDENT CARIOUS INVASION OF PULP CHAMBER RADIOGRAPHIC CONTRAINDICATIONS

  11. DIAGNOSTIC CONTRAINDICATIONS = HISTORY OF ++ PAIN • APICAL TENDERNESS • SPONTANEOUS • LONG STANDING • NOCTURNAL • THROBBING • ENDURING • SICKENING • CONSTANT NEED OF MEDICATIONS

  12. OPERATIVE OBSERVATIONS CONTRAINDICATIONS AT EXPOSURE • EXUDATE – SEROUS • PUS • PROLONGED CLOTTING TIME > 5 MINS • >3MM EXPOSURE • EXPLORER INTO THE PULP (OPERATOR ERROR)

  13. SUCCESSFUL PULP CAPS Inflammation management

  14. FORMULA FOR CARIES DETECTOR • ACID RED 52 2% IN PROPYLENE GLYCOL • COMPOUNDING PHARMACY • $30 FOR 200 CC.= 5 YEARS’ SUPPLY ref

  15. CARIES DETECTOR - NO EFFECT ON BOND STRENGTH • El-Housseiny and Jamjoum, J Clin Pediat Dent 200 • Kazemi et al, Oper Dent 2002

  16. AFFECTED DENTIN INFECTEDDENTIN

  17. SETTING THE STAGE FOR PULPAL HEALING • EXPOSURE ZONE: • LOW/NIL BACTERIAL COUNT • CONTIGUOUS ZONE • BIOCOMPATIBLE AND CALCIGENIC AGENT • VISIBLE DELINEATION FOR FUTURE INTERVENTIONS • PERIPHERAL ZONE • SEAL (ZERO MICROLEAKAGE)

  18. TUBULES % AREA NUMBER/ MM2 DIAMETER PRESSURE NIL POSITIVE SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP DENTIN 10% 88% 20 K 58K 3u 1u

  19. SUCCESSFUL PULP CAPS Inflammation management

  20. LEAVING CARIES? • REFERENCE

  21. CR JAN 2010 • 2 APPLICATIONS • ONE MINUTE EACH ref

  22. CR News Jan 2010 vol 3 issue 1 • http://www.cliniciansreport.org/products/dental-reports/january-2010-volume-3-issue-1.php • Subscription required

  23. ENDODONTIC SILVER NITRATE IODINE FORMOCRESOL CA(OH)2 PULPAL HYPOCHLORITE - KANCA CHLORHEXEDINE-MANY OTHER INTRAORAL DISINFECTANTS ref

  24. CHLORHEXEDINE NO EFFECTON BOND STRENGTH • Santos et al, JOE, 2006 • Perdiao et , Am J Dent 1994

  25. WHAT ABOUT SURFACE DISINFECTANTS? • 70% ALCOHOL WITH PHENOLS • 70% ALCOHOL WITH CHX • ACCELERATED PEROXIDE • HYPOCHLORITE ref

  26. NaOCl • 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

  27. 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

  28. EDTA reverses effect of NaOCl • Doyle t al, JOE, 2006 • A final rinse with EDTA reversed the effects of NaOCl on bonding

  29. H2O2 reduces bond strength of DBAs • Erdemir et al JOE, 2004 • Nikaido et al, Am J Dent 1999

  30. Optim 33TB Sci Can One minute kill =10 Log -6 TB effective CR tested April 2007 Excellent surface cleaner Tissue compatible DEEP CARIES DISINFECTION

  31. WALFORD DEEP CARIES / EXPOSURE PROTOCOL • GET CLOSE • OPTIM 33TB ONE MINUTE • NO DETECTOR • CAREFUL ECAVATION • SLOW RPMS • SPOON • SMEAR CLEAR ONE MINUTE • REMOVE SMEAR LAYER • OPTIM 33 ONE MINUTE • PENETRATE TUBULES

  32. REMOVING SMEAR LAYER &PENETRATING TUBULES • EDTA • SmearClear (SybronEndo) • QMix (Tulsa/Dentsply) • Acid etch

  33. GET CLOSE: OPTIM 33TB ONE MINUTE NO DETECTOR CAREFUL ECAVATION SLOW RPMS SPOON SMEAR CLEAR ONE MINUTE REMOVE SMEAR LAYER OPTIM 33 ONE MINUTE PENETRATE TUBULES SMEAR CLEAR (as reducer) 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 WALFORD DEEP CARIES / EXPOSURE PROTOCOL

  34. MTA: SUPPLIER • CLINICAL RESEARCH DENTAL • LONDON ONTARIO • 1800 265 3444 • “MTA ANGELUS WHITE”

  35. MTA MECHANISM • 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/issue-8/729.html

  36. MTA MECHANISM • 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.

  37. MTA MENTE ET AL • 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

  38. Mente, DMD, et al J. Endo May 2010 • 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.

  39. SUCCESSFUL PULP CAPS Inflammation management

  40. RESIN BIOCOMPATIBILITY??? • 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 SeeWebsite: Home>MODXYZ> Biocompatibility ref

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