FifthYear

Endodontics

Vital Pulp Therapy

One of the most important issues in Vital pulp therapy (VPT) is the status of the pulp tissue.
The traditional school of thought is that VPT should only be carried out in teeth with signs
and symptoms of reversible pulpitis. The problem is how we can accurately assess the status
of the pulp. The clinical signs and symptoms such as sensibility and pain testing do not
.precisely reflect the pulp condition

The degree of pulpal bleeding may be a better indicator of pulpal inflammatory status.

Increased bleeding on exposure site that is difficult to stop, suggest that the inflammatory
response extends deeper into the pulp tissue and the treatment procedure should be
.modified, for example by shifting from direct pulp cap to partial pulpotomy

Additionally, other factors may affect the success of VPT. The presence of an
adequate  blood supply is required for the maintenance of the pulp vitality. In addition, the
presence of a healthy periodontium is necessary for success of VPT, and teeth with moderate
.to severe periodontal disease are not suitable candidates for the treatment

Suitable candidates for VPT include teeth in which an appropriate coronal seal can be

provided. The prognosis of VPT is significantly reduced in cases with inadequate coronal seal
.and subsequent bacterial microleakage

Control of hemorrhage is also necessary for the success of VPT. Various options are available
for the achievement of pulp hemostasis such as mechanical pressure using a sterile cotton
pellet which may be soaked in sterile water or saline. In addition, disinfection protocols
should be also followed as a main principle. Sodium hypochlorite (NaOCl) has been
suggested as an agent in VPT that can control hemorrhage, remove the coagulum and dentin
chips, disinfect the cavity interface, and aid in formation of dentinal bridge. Another
important factor in the success of VPT is a suitable dressing material. Pulp covering material
.should be biocompatible, noncytotoxic, and antibacterial

:Indications for vital pulp therapy

Teeth with incomplete Root development          ·

Primary teeth         ·

Healthy pulpal condition with minimal hemorrhage on exposure          ·

:Contra indications for vital pulp therapy

Infected, Inflamed pulp         ·

Teeth involved in complex prosthesis (Bridge)          ·

Teeth in which the root canal space is needed to hold a post and core          ·

Teeth involved in complex periodontal therapy          ·

:Techniques of Vital Pulp Therapy

:Pulp Capping-

Indirect

Direct

Pulpotomy-

Partial (Cvek)

Full

Pulp Regeneration-

Indirect pulp capping (IPC)

Indirect pulp capping (IPC) is defined as a procedure in which carious dentin closest to the
pulp, is preserved to avoid pulp exposure and is covered with a biocompatible material.
.Success rate with a healthy pulp is about 90%

Traditionally, Calcium hydroxide (CH) has been the material of choice in indirect pulp capping
because of its alkaline pH and biocompatible properties that induces pulpo-dentin
remineralization. However, since concerns exist regarding its long-term solubility and lack of
adhesion to dentin , some adhesive materials such as resin modified glass ionomer cements
(RM-GIC) have been also suggested. Recently, mineral trioxide aggregate (MTA) has been
.used as a lining material and was found better compared with CH

Direct pulp capping

Direct pulp capping (DPC) is defined as the treatment of a mechanical or traumatic vital pulp
exposure by sealing the pulpal wound with a biomaterial placed directly on exposed pulp to
facilitate formation of reparative dentin and maintenance of the vital pulp
Success rate: 70% at best  (range from 30% to 70% according to studies)

Beside the use of rubber dam and aseptic treatment condition the cavity should be restored
immediately with a bacteria-tight restoration. MTA can be placed directly on the pulp
.followed by Composite on top of it

.Direct pulp capping has the highest failure rate of all vital pulp therapy procedures

Pulpotomy

.Pulpotomy is carried out with two treatment approaches: Partial and full pulpotomy

Partial pulpotomy

Partial or Cvek pulpotomy is defined as “the surgical removal of a small portion of the
coronal pulp tissue to preserve the remaining coronal and radicular pulp”. The inflamed
.tissue is removed to the level of healthy coronal pulp tissue

Partial pulpotomy is indicated in a small pulp exposure in which the pulpal bleeding is
controlled in 2 min. Bleeding must not exceed 5 minutes. A cotton moistened with Naocl is
used to stop the bleeding. This step is of extreme importance to assess the level of pulpal
inflammation. The coronal 3mm of the inflamed pulp are removed by a high speed bur with
a coolant or an excavator & the capping material (MTA or Bioceramics or Biodentin) are
.placed

Tooth responsiveness to electric pulp tests has been reported in many cases of partial
.pulpotomy because of preserving the vitality of coronal pulp tissue

Partial pulpotomy has some advantages compared to direct pulp capping such as: removal of
the superficially inflamed pulp tissue and providing space for the dressing material which
.gives the opportunity to seal the cavity

The reported success rate for partial pulpotomy is 90%, with predictable results if done
.correctly

It can be performed in permenant teeth with fully formed or incompletely formed roots.
Pulp testing must be done regularly on follow up visits along with radiographs to make sure
.that the pulp condition remains healthy

Full pulpotomy

This procedure is defined as “the surgical removal of the entire coronal portion of the vital
pulp to preserve the vitality of the remaining radicular portion”. This treatment approach is
indicated when it is predicted that the inflammation of the pulp tissue has extended to deep
levels of the coronal pulp. After the removal of the coronal pulp, hemostasis must be
.achieved and a (bio) material is placed over the remaining pulp tissue
Full pulpotomy is performed only in deciduous teeth and permanent teeth with
incompletely formed roots. After root development regular root canal treatment is
performed. It can be done also as an emergency visit in permenant teeth when the operator
.has no time to complete the cleaning and shaping

Dressing materials (pulp covering agents)

Calcium hydroxide

Some advantages of CH are antimicrobial characteristics owing to its high alkaline pH and
.the irritation of pulp tissue that stimulates pulpal defense and repair

However CH can degrade and dissolve beneath restorations. The disintegration of CH under
restorations is associated with porosity in the dentinal bridge which can provide a pathway
.for microleakage. Thus recently CH is not advocated to be used in VPT scenarios

Resin modified glass ionomers (RMGIs)

RMGIs have been successful as an indirect pulp capping agent even in cavities with minimal
remaining dentin thickness. This may be due to their capacity to bond to the dentin.
Contrary to these useful properties, poor responses have been reported in direct pulp
capping of human teeth with RMGIs. Pulp tissues that were capped with RMGIS exhibited
moderate to intense inflammatory responses. Thus, the application of RMGIs directly on the
.pulp tissue is not recommended

Adhesive resins

Recently available composites & self-etching adhesive systems as pulp capping material
resulted in unresolved inflammatory responses and minimal pulp tissue repair .Many of the
resin components in dentin adhesives promote bleeding after hemostasis has been achieved
with hemostatic agents. It seems that the adhesive resins are unacceptable as pulp capping
.agents

Mineral trioxide aggregate

Dental pulp cells demonstrated in direct contact with MTA showed a faster and more
predictable formation of dentinal bridge and more effective pulpal repair. Histologically, the
calcified bridge formed in contact with MTA is thicker with less pulpal inflammation
compared to CH. With respect to its success rate, MTA provided a superior performance
.compared with CH

Bioceramics
Recently, Bioceramic pastes, BioAggregate, Biodentin  and many other bioceramic-based
products have been introduced which can be used with the same applications as MTA and
.with a superior performance compared to CH

:Pulp Regeneration

.Regeneration of a new vital tissue in an empty & disinfected root canal space

:Case Selection

Tooth with Vital inflamed or Necrotic pulp -

Immature (open) apex -

Young Patients (7-12 years) -

Permenant teeth & Adult Patients (Case reports) **

Clinical Steps: (American Association of Endodontics Guidelines)

First visit.1

Second visit.2

”First visit “Disinfection.1

.Local anesthesia, rubber dam isolation, access & W.L        ·

.Irrigation with 20ml NaOCl (needle with closed end and side-vents)        ·
Lower concentrations of NaOCl are advised [1.5% NaOCl (20mL/canal, 5 min), with irrigating
needle positioned about 1 mm from root end, to minimize cytotoxicity to stem cells in the
.apical tissues. Avoid Chlorohexidine irrigants as they kill stem cells

Ca(oH)2 or low conc. of triple antibiotic paste: mix 1:1:1 ciprofloxacin: metronidazole:
.minocycline to a final   concentration of 0.1-1.0 mg/ml

Double antibiotic paste without minocycline paste or substitution of minocycline with         •
clindamycin;or amoxicillin

Deliver via syringe        •

.3-4mm of a temporary filling         •

.Dismiss patient for 1-4 weeks        •

:Second Visit .2

)weeks after 1 st visit 1-4(

Anesthesia with 3% mepivacaine without vasoconstrictor (to allow bleeding)         •

Irrigation with 20ml of 17% EDTA for 2 minutes ( to remove the medicament and allow         •
production of growth factors from dentine)

Create bleeding into canal system by over-instrumenting (endo file, endo explorer)         •
(induce by rotating a pre-curved K-file at 2 mm past the apical foramen (apical papilla) An
alternative to creating  a blood clot is the use of platelet-rich plasma (PRP), platelet rich
fibrin (PRF). PRP and PRF are better than the clot because it was found that the RBCs in the
.blood clot scaffold created degenerate by time

Place white MTA as capping material 3-4 mm of the Coronal root canal         •

A 3–4 mm layer of glass ionomer or RMGI, followed by composite          •

In cases of Vital Inflamed pulp the regeneration procedure can be finished in a single visit
.(No Intracanal Medicament used)
Follow Up

:Clinical and Radiographic exam        •

No pain, soft tissue swelling or sinus tract (often observed between first and second          •
.appointments)

Resolution of apical radiolucency (often observed 6-12 months after treatment)          •

Increased width of root walls (this is generally observed before apparent increase in           •
.root length and often occurs 12-24 months after treatment)

Increased root length        •

Positive Pulp vitality test response        •

Thus the patient must be seen after 3 months then 6 months then 1 year then yearly for a
.period of 5 years

:The degree of Success of Regeneration -

.Primary goal: The elimination of symptoms and the evidence of bony healing        ·

Secondary goal: Increased root wall thickness and/or increased root length        ·

Tertiary goal: Positive response to vitality testing (which if achieved, could indicate a        ·
more organized vital pulp tissue)

.If the primary and secondary goals are achieved then the case is considered successful

:Success rate of regeneration-

.Studies place the success rate of regeneration in a range from 90% to 100%

.Of course a 100% is not attainable, it’s just a range

:Key Elements for Pulp Regeneration

:Scaffolds
Blood clot, Platelet Rich Plasma (PRP), Platelet Rich Fibrin (PRF), Natural polymers as
.collagen or Synthetic polymers as poly glycolic acid and hydrogels

The scaffold acts as a matrix that holds the stem cells and allows the travel of growth factors
for stimulation of the stem cells. The scaffold should be easily applied and shouldn’t induce a
.foreign body reaction

:Stem Cells

SCAP (Stem cells of apical papilla)

PLSC (Periodontal Ligament stem Cells)

DPSC (Dental pulp stem cells)

BMSC ( Bone Marrow Stem Cells)

iPAPC (inflammatory progenitor apical periodontitis cells)

SCAP has the highest content of stem cells from all other sources and they have a greater
.regenerative potential

:Growth Factors

Vascular Endothelial Growth Factors, Neural Growth Factors, Dentine Morphogenic Protein,
.Transforming growth factor

Human dentine is rich in growth factors which can be expressed through using a chelating
.agent as EDTA in the regenerative protocol