Vital pulp therapy Flashcards
Deep caries?
inner 1/4 dentine affected
Zone of hard dentine over the pulp
Risk of pulpal exposure
Extremely deep caries?
penetrates entire thickness of dentine
Pulpal exposure unavoidable
Extremely deep caries
Deep caries
Caries activity?
Light yellow
Actively progressing
Scoop out with spoon excavator
Caries activity?
Light brown
Slowly progressing
Scoop out with spoon excavator
Caries activity?
Dark brown
Slowly progressing/arrested
Reparative dentinogensis after pulpal exposure?
What is vital pulp tx?
to maintain health of all or part of the pulp
Indirect pulp cap?
single stage caries removal to hard dentine
Biomaterial placement over thin layer of remaining dentine
Selective various tissue removal?
selective to soft of firm dentine on pulpal wall
Biomaterial placement on pulpal wall of cavity
Direct pulp cap?
class I - no pre-operative deep caries I.e. pulpal exposure due to trauma or iatrogenic damage
Class II - carious exposure, disinfectant and calcium silicate cement used
Partial pulpotomy?
removal of a small portion of coronal pulp
Placement of biomaterial and restoration
Full pulpotomy?
removal of all coronal pulp Placement
Placement of biomaterial and restoration
What to use for class I pulp cap?
calcium hydroxide
Indications for class I pulp cap?
complicated traumatic fracture, which involves a superficial exposure of the pulp or after an accidental perforation
Clinically pulp considered vital
Small exposure - coronal third of pulp chamber
Class II pulp cap?
Pre operative presence of deep carious lesion
Symptoms may be present but not indicative of irreversible pulpitis
What is biodentine?
calcium trisilicate cement
When is direct pulp capping most cost-effective?
younger patients (under 40)
When is pulp calling unsuccessful?
haemostasis difficult to achieve
Can you do a partial pulpotomy for management of irreversible pulpitis?
Controversial
Remember to clean peripheries before going deeper
What do you irrigate with?
sodium hypochlorite
Use cotton pellets and apply pressure to achieve haemostasis
Technique for a pulpotomy?
- Informed consent - pros and cons
- Local anaesthesia
- Rubber dam
- Remove damaged pulpal tissue
- Microbial control 1-3% NaOCl
- Haemostasis
- Placement hydraulic calcium trisilicate cement (biodentine)
- Temporise (GIC)
- Definative coronal restoration
- Follow-up for upto 4 years
Case selection VPT?
pulp must be vital
Younger or
Occlusal lesions
Traumatic lesions
No/minimal symptoms
All associated with better results
When is VPT controversial?
management of irreversible pulpitis
Properties of calcium silicate cements?
- Hydraulic (requires water to set) / hydrophilic
- Non-resorbable
- Biocompatible
- Bioactive
Favours regeneration of the pulp, bone, cementum and PDL
How long does biodentine take to set?
12 mins
No light cure
No etch
What dentine do bioceramics encourage?
Stimulate ondontoblasts to form tertiary dentine
Do bioceramics cause host response?
Little or no host response when touches vital tissues
Similar but better than calcium hydroxide
Advantages of bioceramics?
Hydraulic setting reactions mean that they are hydrophilic with excellent ability
to seal in moist areas, uninhibited by blood
* Little or no host response when touches vital tissues – similar but better than
calcium hydroxide
* Collagen fibres can integrate with the material
* When used for pulp capping this stimulation of odontoblasts encourages the
formation of tertiary dentine
* Regeneration of cementum & PDL also possible
* Useful in many endodontic situations incl. retrograde apical filling material, internal / external perforation repair, internal / external tooth resorption, pulp capping, apexification, apexogenesis,
orthograde sealant with GP
Example of hydraulic calcium silicate cements?
MTA
Biodentine (septodont)
Properties of MTA?
- pH 12.5 therefore antimicrobial
- Good dimensional stability, non-absorbent when set
- Compressive strength develops slowly over 28 days to reach approx. 50MPa
(equivalent to zinc oxide eugenol cement, less than dentine at ~290MPa) - Required to be placed in at least 2mm thickness to enable adequate compressive
strength - Little or no marginal leakage in dye leakage studies
- Expands in moist environments - advantageous in adapting material to walls of
the tooth apically and in perforations - Denatures collagen so increases brittleness of adjacent dentine
Disadvantages of MTA?
- Difficult to manipulate
- Takes time to set (when used in orthograde situations a future apt for definitive restoration
necessary) - Can be washed out when rinsed
- Difficult to take a check PA prior to closure (as advocated in RCS/BES
Periradicular surgery guidelines 2020) - Causes increased brittleness of adjacent dentine
- Bismuth oxide causes darkening of tooth structure, particularly
of it comes into contact with sodium hypochlorite - Expensive
Properties of biodentine?
- Automix – easier with assured composition
- If placed incorrectly can be washed out prior to setting.
- Insoluable once set.
- Ability to seal similar to other calcium silicate materials, equivocal whether better or
worse than GIC. - Compressive strength similar to dentine, micro hardness outperforms bioaggregate,
IRM, GIC and RMGIC. - Push out bond strength as good as MTA, unaffected by blood contamination.
- Like MTA - definitive restoration should only be placed after 2 weeks when the biodentine is fully set.
- Biocompatible, studies to date show biocompatibility and bioactivity comparable to that of the gold standard MTA. Dentine bridge formation and hydroxyapetite crystals forming at interface.
