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PULP CAP

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PULP CAP

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  1. PULP CAP FEBRUARY 2013 COMPRESSED VERSION

  2. MTA THERAPIES • Root canal therapy • Perforation repair • Apicoectomy • Indirect Pulp cap (Pink Dentin) • Direct pulp cap (Direct Exposure) • Pulpotomy (Coronal extirpation) • Pulpectomy (Coronal and radicular extirpation) • Adult and pedodontic

  3. WHAT IS MTA • CALCIUM SILICATE • GYPSUM, PLASTER OF PARIS • DICALCIUM SILICATE • MAIN CONSTITUENT IN PORTLAND CEMENT • TRICALCIUM ALUMINATE (MINOR) • BIMUTH OXIDE ( 20%) FOR RADIOPACITY

  4. Healthy patient seal Recoverable pulp Histological repair Flawless caries removal Disinfection SUCCESSFUL PULP CAPS Inflammation management

  5. 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

  6. 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

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

  8. 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 nineyears, 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.

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

  10. Healthy patient seal Recoverable pulp Histological repair Flawless caries removal Disinfection SUCCESSFUL PULP CAPS Inflammation management

  11. Healthy patient Recoverable pulp seal Flawless caries removal Histological repair Disinfection SUCCESSFUL PULP CAPS Inflammation management

  12. Healthy patient seal Recoverable pulp Histological repair Flawless caries removal Disinfection SUCCESSFUL PULP CAPS Inflammation management

  13. 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

  14. DIAGNOSTIC CONTRAINDICATIONS • APICAL TENDERNESS • SPONTANEOUS • LONG STANDING • NOCTURNAL • THROBBING • ENDURING • SICKENING • CONSTANT NEED OF MEDICATIONS

  15. OPERATIVE CONTRAINDICATIONS • EXUDATE – SEROUS • PUS • PROLONGED CLOTTING TIME > 5 MINS • >3MM EXPOSURE • GROSS CARIES INTRODUCTION INTO PULP CHAMBER • EXPLORER INTO THE PULP (OPERATOR ERROR)

  16. Healthy patient seal Recoverable pulp Histological repair Flawless caries removal Disinfection SUCCESSFUL PULP CAPS Inflammation management

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

  18. CARIES DETECTOR - NO EFFECT ON BOND STRENGTH • El-Housseiny and Jamjoum, J ClinPediat Dent 2000 • Kazemi et al, Oper Dent 2002

  19. AFFECTED DENTIN INFECTEDDENTIN

  20. 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 • PERFECT SEAL (ZERO (ZERO ZERO MICROLEAKAGE)

  21. TUBULES % AREA NUMBER/ MM2 DIAMETER PRESSURE NIL POSITIVE!!! SE BONDS LESS EFFECTIVE THAN ETCH AND RINSE IN DEEP DENTIN 10% 90% 20 K 60K 3u 1u

  22. Healthy patient seal Recoverable pulp Histological repair Flawless caries removal Disinfection SUCCESSFUL PULP CAPS Inflammation management

  23. LEAVING CARIES? JOE — Volume 36, Number 9, September 2010 Long-term Survival of Indirect Pulp Treatment Performed in Primary and Permanent Teeth with Clinically Diagnosed Deep Carious Lesions Rene´ Gruythuysen, DDS, PhD, Guus van Strijp, DDS, PhD, and Min-Kai Wu, MSD, PhDE

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

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

  26. ENDODONTIC SILVER NITRATE IODINE FORMOCRESOL CA(OH)2 PULPAL HYPOCHLORITE - KANCA CHLORHEXEDINE-MANY POTENTIAL DISINFECTANTS ref

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

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

  29. 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

  30. REVERSING NaOCl EFFECTS ON DBAS A reducing agent, such as ascorbic acid, or sodium ascorbate, reverses 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 original bond strength

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

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

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

  34. DISINFECTION PRIOR TO EXPOSURE • GET CLOSE WITH DETECTOR • OPTIM 33TB ONE MINUTE • NO DETECTOR • FINAL EXCAVATION • SLOW RPMS • SPOON • ACID ETCH 10 SECONDS/RINSE • REMOVE SMEAR LAYER • OPTIM 33 ONE MINUTE • PENETRATE TUBULES

  35. OPTIONS FOR REMOVING SMEAR LAYER &PENETRATING TUBULES • EDTA 14% • SmearClear (SybronEndo) • 17%EDTA ,surfactant • QMix (Tulsa/Dentsply) • CHX digluconate, <15% EDTA, surfactant • Phosphoric Acid etch • Citric acid

  36. FINAL EXCAVATION; EXPOSE if still carious MTA DIRECT CAP IMMEDIATE OVERSEAL WITH UNMODIFIED GLASS IONOMER (LUTING CEMENT) ALLOW GI TO SET (APPROX 4 MINS) EDTA TO RESTORE BONDABILITY PA ETCH/RINSE/DRY PRIME/DRY+ BOND/THIN/EVAPORATE SEAL CAP PERIMETER FLOWABLE/CURE SEAL REMAINING DENTIN AND GINGIVAL MARGIN WITH FLOWABLE AND CURE RESTORE WITH FINAL RESIN FOLLOWING LOW CONTRACTION STRESS PRINCIPLES , IE, INCREMENTING FINISH AND ARTICULATE METICULOUSLY CAPPING THE EXPOSURE:CAP, SEAL CAP WITH RESIN, RESTORE

  37. 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

  38. 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.