Adjunctive Endodontic Treatment

Hey everyone Ryan here and welcome back to our series on endodontics like all my
videos I'm gonna be focusing only on the highest seal topics and this is actually the last video in
our series before our bonus video with those practice questions that'll be modelled after actual
board exam questions and cover all of the videos all the topics we've talked about within them.
So in this last video we're going to talk about adjunctive endodontic therapies that we
didn't get a chance to cover in the previous videos and we're gonna focus primarily on vital pulp
therapy, and what that's all about. but first I wanted to talk a little bit about two materials that are
used routinely in endodontics and particularly in the realm of vital pulp therapy.
So the first one is calcium hydroxide which we've talked about in the previous videos but
I just wanted to reintroduce it and some of the major concepts that come along with it. So
calcium hydroxide stimulates secondary odontoblasts to repair with dentin bridge formation and.
So back from our very first video in this series we talked about these things called
undifferentiated mesenchymal cells​, and they can sort of become different cells depending
on what they're being asked to do they're kind of like ​stem cells​. and calcium hydroxide can
stimulate those cells to become secondary odontoblasts which then are in turn stimulated to
form tertiary dentin and that tertiary dentin or this dental bridge is a barrier that can protect the
pulp. So that's basically how a calcium hydroxide works and it does. So by having a very high
pH a very basic pH of around 12.5 which both cauterizes the tissue irritates to these cells and
also kills bacteria.
And the other material is mineral trioxide aggregate or more commonly referred to as
MTA and this material does something a little bit stimulates cementoblasts to produce hard
tissue. So the other one is calcium hydroxide is targeting odontoblasts or secondary dontoh
lasts to make dentin whereas this one is targeting cementoblasts. So you again produce hard
tissue. So is as the name suggests it's an aggregate of three minerals and those are calcium
silicon and aluminum and. So it contains basically a cement with a combination of these three
minerals and it consists of hydrophilic particles of calcium phosphate and calcium oxide and
different combinations of those things. So the only downsides to this material is that it has a long
setting time of about three hours, and it contains this thing called bismuth oxide, and the
bismuth oxide is at a pacifier which is helpful. It basically means it allows you to detect it on an
x-ray they'll show up as being radiopaque but this material can leak and stain the tooth. So not
great for anterior teeth but otherwise this is really a superior product to calcium hydroxide in
almost every regard, and there are really three things that it does very very well. First it seals
really well because it sets in the presence of moisture. So it doesn't dissolve in saliva. So
isolation isn't really that big of an issue antimicrobial, yes calcium hydroxide also does this and
it's non resorbable, whereas calcium hydroxide is very resorbable this is both non resorbable
and biocompatible. it's basically like sand you can think of it. So again it's a great sealing agent

Tự học Tiếng Anh RHM

• ​Mobile: 0385552654 
• ​Email: t​ uhoctienganhrhm@gmail.com
• ​Page: ​https://www.facebook.com/tuhoctienganhrhm2020/ 
does that really really well. So for MTA you can remember the three-three and I'll point those out
the three-three consist of three minerals it has a three hour setting time and there are three
things that make it very very useful. So those are your three threes to remember for mineral
trioxide aggregate

All right and. So now we can talk about vital pulp therapies. So vital pulp therapy
includes those treatment options for a pulp that is vital and you want to maintain vitality but
there's some sort of disease or some sort of pulp exposure or something that's currently
troubling the pulp but it's still vital and we want to maintain its vitality.
So in bold are all of the vital pulp therapies and the rest are you can think of them like
non-vital pulp therapies. So this is a pretty comprehensive list of treatment options for
endodontic problems and of course I always like to abbreviate where I can and where it helps.
So I've included those as well on the right. So if those pulp up and other videos or later in this
video you kind of know what I'm referring to alright.

So our first one is an indirect pulp cap. So this is where we would use calcium hydroxide
or a resin-modified glass ionomer restorative material and it's placed on a thin partition of
remaining dentin that if removed might expose the healthy pulp and in all these treatment
options I will have underlined the status of the pulp when performing this certain treatment and.
So an indication for it would be deep caries that's approximating the pulp. So you go to remove
the caries, get the sound to structure axially and on the sides of your prep and you're getting
pretty close to the pulp tissue and. So if we still had some caries that if we were to remove them
might expose the pulp, we could like to actually leave that carries dent in there and place this
indirect pulp cap, it's not touching the pulp but it's very very close, certainly less than a
millimeter away and. So this indirect pulp cap would be composed (of one) or maybe you have
calcium hydroxide lining ​the bottom of it, and then resume if I glass ionomer over the top of it,
because remember calcium hydroxide is very resorbable and will dissolve in saliva. So we can
protect it with something that won't. So like a resin-modified glass ionomer. So that's an
example of an indirect pulp cap.

And of course we have a direct pulp cap, where you have the calcium hydroxide placed
directly on an otherwise healthy pulp exposure. So now we've gotten to the point where the pulp
is exposed and we want to make sure we can cover it. So as promised, this is a review from the
last video where direct pulp cap ​is a treatment of choice ​if a tooth is fractured, and a pulp
exposure occurred less than 24 hours ago. So we want to try to save that pulp tissue as much
as possible by directly capping it or covering it with this calcium hydroxide material that we just
talked about. So it can also be used for a caries or mechanical exposure that's less than 2

Tự học Tiếng Anh RHM

• ​Mobile: 0385552654 
• ​Email: t​ uhoctienganhrhm@gmail.com
• ​Page: ​https://www.facebook.com/tuhoctienganhrhm2020/ 
millimeters, you know across and. So this would be we're in the indirect pulp cap scenario and
we go a little bit too deep and we have a little pinpoint pulp exposure and. So a direct pulp cap
would be a nice option to try to save the pulp there and a hard tissue barrier will hopefully form
within six weeks. So when we were talking about calcium hydroxide again that's stimulating
those secondary odontoblasts to make that dentinal bridge to physically protect the pulp with a
barrier. So that's what we're hoping to happen from this direct pulp cap.
So this is actually a less favorable prognosis than the indirect pulp cap, because instead
of maintaining a thin partition of dentin we are relying on those secondary odontoblasts to
respond and create to tertiary dentin bridge. So in other words, we're right up against the pulp
here. So you can think the deeper you are, the worse your prognosis will likely be.
All right and next we have the Cvek pulpotomy which is a little bit difficult to find a good
picture for this one but this is otherwise known as a partial pulpotomy or a shallow pulpotomy,
and it involves the removal of a small portion of coronal diseased pulp. So here in this picture
we have this little portion of infected pulp tissue and say we were removing this deep carious
lesion and those bacteria and their byproducts have infiltrated the pulp tissue and that's really
inflamed and really bothered and we can tell that by say very profuse bleeding or heme that is
coming from this pulp exposure and. So we want to remove that. We don't want to leave that
there it's a little bit too far gone to, just try to indirect or direct pulp cap over that. This could also
result from a traumatic exposure or this could also be the process you want to go through for a
traumatic exposure that's been more than 24 hours. You know a situation where the pulp has
been exposed to the elements a little bit too long and is starting to become bothered and
diseased. you want to remove a very little bit of that pulp that has been exposed. and again if
we have a caries or mechanical exposure that's larger than two millimeters across, well, this is a
situation where it's just not feasible to do a direct pulp cap, and the risk of failure outweighs the
potential benefit. So we would elect to do a Cvek pulpotomy and then cover it from there.

Now the next stage in terms of a more involved procedure would be a full pulpotomy
and. So this is the removal of coronal diseased pulp. So for pulpotomy just remember it's only
the coronal pulp tissue that's being removed, the pulp of the crown part of the tooth. So this
would be something you would do as I mentioned in the last video for a traumatic exposure
that's been more than 72 hours. So now we're too far gone for the direct pulp cap or too far
gone even for this Cvek pulpotomy, we have to do a full pulpotomy and remove the entire
coronal pulp. Now for primary teeth this would be something you'd want to do for a vital and
restorable primary tooth with a pulp exposure as ideal for that tooth to have no symptoms. So
you prefer for that primary tooth to be asymptomatic, and for primary teeth, really the vast
majority of pulpotomy are done for primary teeth in this way in order to save them as their
function which is a space maintainer. So this picture illustrates a classic pulpotomy for primary
tooth and (you would place) you would remove that coronal pulp tissue you'd have this

Tự học Tiếng Anh RHM

• ​Mobile: 0385552654 
• ​Email: t​ uhoctienganhrhm@gmail.com
• ​Page: ​https://www.facebook.com/tuhoctienganhrhm2020/ 
formocresol you'd place form a priest all right over the orifices to the pulp canals and it place it
with a cotton pellet, and there's this area of fixation that occurs where the pulp directly contacts
the formocresol and that made a comment which I will talk about in the next slide renders it
resistant to enzymatic breakdown, and under this area is an area of coagulation necrosis and.
So that's where the pulp tissue will unfortunately die but hopefully there's still some vital tissue
left in the apical part of the pulp canals. So that tooth can technically maintain some vitality and
then over that, we put a zinc oxide eugenol core build-up and a stainless steel crown over the
top of that. So that's a very classic primary tooth pulpotomy. and both Cvek and regular
pulpotomy are not be indicated for mature permanent teeth because they may induce
undesirable calcification and the pulp canals.
All right. So there is this certain type of form of crystal called Buckley's formocresol
which could be tested on the exam and it's the one that we would use for those pulpotomy x' to
fixate the or quote-unquote fixate the pulp. So it contains 19% formaldehyde and 35% cresol
and that's how it gets its name formo from formaldehyde, cresol all from cresol, and then 15%
glycerine, the rest is a water base and for me for my cresol is both a bactericidal agent it kills
bacteria and it's also a quote-unquote fixative, basically it fixes the pulp tissue devitalizes it in
that little fixation zone and makes it resistant to enzymatic breakdown. And it's been used for
many years but still remains controversial because it's very toxic, but if used in the correct
dilutions for no longer than as necessary, the risk of any mutagenesis and cancer or otherwise
is inconsequential.

Alright and the next one we're going to talk about is pulpectomy and you can kind of
think of it like the root canal of the root canal treatment without the gutta-percha operation step,
and instead placing a creamy zinc oxide eugenol fill. So the pulpectomy involves removal of
coronal and radicular dead or dying pulp tissue. So the pulpotomy, you only root remove
coronal, pulpectomy you take all the pulp out, you remove both the coronal and the radicular
part of the pulp tissue. So this is no longer vital pulp therapy because while we're removing all
the pulp and there's nothing left. So the pulp will be diagnosed back in our second video of the
series this would become a previously treated pulp it wouldn't be vital it wouldn't be necrotic it
just wouldn't have a pulp anymore because we treated it.
And again this is often used as temporary pain relief on teeth with irreversible pulpitis
until a full root canal can be done. but again it's really reserved for primary teeth and it would be
for a non vital and restorable primary teeth with a pulp exposure, and for those primary teeth it's
just best that they're asymptomatic to have the best chance of success. So really pulpectomy,
you're either you have a patient who comes in for urgent care is in a lot of pain, you just do this
as a temporary measure until you can do the full root canal treatment with the gutta-percha, or
you have a pediatric patient with a non-vital and restorable primary teeth with an asymptomatic
pulp exposure. So those are your two kind of certain two different scenarios where you'd be

Tự học Tiếng Anh RHM

• ​Mobile: 0385552654 
• ​Email: t​ uhoctienganhrhm@gmail.com
• ​Page: ​https://www.facebook.com/tuhoctienganhrhm2020/ 
doing a pulpectomy procedure. and again it's similar to the pulpotomy you'd have zinc oxide
eugenol and the crown but you'd be using calcium hydroxide in the root this time. So no need
for a formocresol because we're not leaving any pulp, no need for any of this like fixation zone
or coagulation at cursus because again. we're removing the entire pulp with a pulpectomy and
we're using this calcium hydroxide because what we're gonna take advantage of the fact that it's
resorbable because if we're using this in a primary tooth we want the underlying permanent
tooth to be able to erupt normally and for that calcium hydroxide to be resorbed. So it's a great
material to be used in that scenario.

All right and then we have the the classic extraction and. So this would be another option
removal of a tooth with a dead or dying pulp and for primary teeth this would be really for
something that's non restorable. So we can't put a crown on it just not savable then we really
have no other option than to extract it and try to maintain that space with some other measure.
We also would option to do an extraction over a pulpectomy for a primary first molar and
this is kind of a generalization but certainly can be tested on the board exam because primary
first molars have lots of accessory canals and they're very challenging to perform a successful
pulpectomy on. So in those scenarios or the pulp anatomy is just very complex not likely again
the risk of having failure outweighs the potential benefit of doing it such as best. So sometimes
extract those primary first molars, not try to save them.

Also if the tooth is exhibiting some root resorption it's symptomatic the patient's being
bothered by it apple pectin ii may not fix the problem. So really we should help to extract that
tooth. So these things are really really important when considering treatment options for a
primary tooth if you're gonna go the pulp ectomy or the pulpotomy route versus extracting that
tooth. So I definitely be familiar with these facts why you would do an extraction in this case all
right and then we have the classic root canal treatment again the pulp can be diseased or dead
when you're opting to do this procedure and again maybe a little over a generalization but it's
basically a pulp ectomy where we remove all the pulp from both the coronal and radicular
segments and you clean it you shape the canals and then you fill it with that gutta percha or
other operation material and. So I've talked about this a lot in my third video of the series. So if
you haven't watched that one go check that out alright and now we have two things two
treatments that I listed in our comprehensive list of n atomic therapies that are a little bit
confusing and. So I definitely want to focus on these next two and I hopefully will be able to
clarify any confusion for these two procedures. So a peck. So genisys literally means formation
of you say the apex or we could say the root. So root formation let's say that's what apex of
Genesis is trying to do and. So a peck. So Genesis is maintaining pulp vitality in order to
stimulate root development and allow the body to make a stronger root. So this is a vital pulp
therapy we have a pulp that is vital it's healthy or diseased but it is vital and we're going to try to

Tự học Tiếng Anh RHM

• ​Mobile: 0385552654 
• ​Email: t​ uhoctienganhrhm@gmail.com
• ​Page: ​https://www.facebook.com/tuhoctienganhrhm2020/ 
maintain that vitality in order for the root to finish developing. So we're going to use something
like calcium hydroxide or MTA one of those two materials we talked about at the start of the
video and here's the thing that really really helped me figure this out epic. So Genesis
technically includes any indirect pulp cap, direct pulp cap, speck pulpotomy or full pulpotomy
performed in an immature permanent tooth basically all of the vital pulp therapies.
We've talked about thus far when they are performed on an immature permanent tooth
where the root is still developing; this is when we can technically refer to it as apexogenesis
because the whole point of it is seeking to stimulate continued root development for a nice
strong sturdy root. So we have a tooth like this where the root has not completed development
the apex is wide open we have some kind of pulp exposure and then depending on all those
factors we talked about we can decide which one of the four of these, we want to do once, we
now, this next picture doesn't show the restoration but say this was restored somehow and we
want to get this result where the root can still finish developing and we get a nice strong sturdy
root and that's a great great result. So say for this one we had a pulp exposure less than 24
hours ago we want to do direct pulp cap and that would be direct pulp cap plus apexogenesis
because that is our goal here. we want to make sure the root can finish developing and this is
contraindicated in avulsed non restorable severe horizontal root fracture and necrotic teeth. So
that's apexogenesis.

and the other one is apexification, and this one is not a vital pulp therapy because the
tooth is not alive that the tooth does not have a vital pulp and. So this one is not about allowing
the root to finish developing but rather some way to close off that root to attain root and closure
and. So apexification would be dis-infection of the root canal followed by induction of an
acceptable apical barrier in order to block off that end of the root that just not has not finished
developing it and. So again we would option to use either those two materials calcium hydroxide
or MTA placed at the base of the canal after the dead or dying pulp is entirely removed and. So
like we had our and red font here, our parallel, between vital pulp therapies, performed on an
immature permanent tooth. apexification is a pulpectomy performed in an immature permanent
teeth. So again these two apex treatments think about an immature permanent tooth where the
root has not finished developing it and the pulpectomy is performed in this scenario in order not
to allow that the root to finished formation because that is, unfortunately, out of the window, but
we can at least form an apical barrier to prevent retrograde infection to prevent the spread of
disease by ​sealing off the apex​. So those two things hopefully that really clarifies things for you
that apexogenesis and a pexification are referring exclusively to immature permanent teeth and
doing either vital or non vital pulp therapy to try to heal heal up or ​seal off the apex​.

Tự học Tiếng Anh RHM

• ​Mobile: 0385552654 
• ​Email: t​ uhoctienganhrhm@gmail.com
• ​Page: ​https://www.facebook.com/tuhoctienganhrhm2020/