Protecting the Pulp,

Preserving the Apex

Dr. musa mohammedtom musa
B.d.s, Mfdrcsi, MSc clinical restorative
dentistry, implant Diploma BAIRD
Academy
LEARNING OBJECTIVES

After reading lecture, the student should be

able to:
1. Describe pulp protection and pulp therapy.
2. Describe the reparative mechanisms of the
pulp.
3. Describe the effect of dental procedures and
materials on the pulp.
LEARNING OBJECTIVES

4. Appreciate the significance of

microleakage and smear layer on pulp
response.
5. Describe the indications for and
procedures for vital pulp therapy.
6. Discuss the effects of pulpal injury in
teeth with developing roots.
LEARNING OBJECTIVES

7. Describe the techniques for vital pulp

therapy (apexogenesis) and root-end
closure (apexifi cation).
DEFINITIONS
Endodontology is concerned with the
study of the form, function and health of,
injuries to and diseases of the dental pulp
and periradicular region, their prevention
and treatment; being apical periodontitis,
caused by infection (ESE 2006)
DEFINITIONS
Pulp cap
Treatment of an exposed vital pulp in which
the pulpal wound is sealed with a dental
material, such as calcium hydroxide or MTA,
to facilitate the formation of reparative
dentin and maintenance of a vital pulp.
DEFINITIONS
Direct pulp cap
A dental material placed directly on a
mechanical or traumatic vital pulp exposure.
Step-wise caries excavation
A material is placed on a thin partition of
remaining carious dentin that if removed
might accidentally expose the pulp (for
immature permanent teeth).
DEFINITIONS
Pulpectomy (pulp extirpation)
The complete surgical removal of the vital
pulp.
Pulpotomy (pulp amputation)
The surgical removal of the coronal portion
of a vital pulp as a means of preserving
vitality of the remaining radicular portion.
DEFINITIONS
Partial pulpotomy (shallow pulpotomy;
Cvek pulpotomy)
The surgical removal of a small diseased
portion of vital pulp as a means of
preserving the remaining coronal and
radicular pulp tissues.
DEFINITIONS
Apexification
Inducing a calcified or artificial barrier in a
root with an open apex or the continued
apical development of an incompletely
formed root in teeth with a necrotic pulp.
DEFINITIONS
Apexogenesis
A vital pulp therapy procedure performed
to enable continued physiologic
development and formation of the root end.
DEFINITIONS
Pulp Protection
The principal threat to the health of the
dental pulp is dental caries.
The second is the treatment of dental
caries.
Heat generation and desiccation during
cavity preparation, the toxicity of restorative
materials, and, most significantly, the leakage
of bacteria and their products at the
margins of restorations.
DEFINITIONS
Pulp Protection
This damage can convert a reversible
pulpitis into an irreversible pulpitis. In
consideration of this, operative dentistry
can be considered “preventive” or
“interceptive” endodontics.
DEFINITIONS
Pulp Protection
Restorative procedures should be designed
not only to restore the mechanical integrity
and appearance of the tooth but also to
avoid further harm.
DEFINITIONS
Pulp Therapy
When the dental pulp is mechanically
exposed by trauma or during cavity
preparation, it may by appropriate treatment
be possible to maintain pulp vitality and
avoid root canal treatment.
IATROGENIC EFFECTS ON
THE DENTAL PULP
Local Anesthesia
Cavity/Crown Preparation Heat
Cavity Depth/Remaining Dentin Thickness
Dentin permeability increases exponentially
with increasing cavity depth, as both
diameter and density of dentinal tubules
increase with cavity depth
IATROGENIC EFFECTS ON
THE DENTAL PULP
Cavity Drying and Cleaning
A prolonged blast of compressed air aimed
onto freshly exposed vital dentin will cause
a rapid outward movement of fluid in patent
dentinal tubules.
IATROGENIC EFFECTS ON
THE DENTAL PULP
Etching Dentin/Smear Layer Removal
Complete dissolution of the smear layer
opens the dentinal tubules, significantly
increasing the permeability of dentin.
If the dentin is left unsealed, the diffusion of
irritants to the pulp may intensify and
prolong the severity of pulpal reactions.
IATROGENIC EFFECTS ON
THE DENTAL PULP
Pins
Pins used to retain amalgam require
caution; it is preferable to use other, safer
means of retention. Pulp damage may result
from pinhole preparation or pin placement.
IATROGENIC EFFECTS ON
THE DENTAL PULP
Impressions, Temporary Crowns, and
Cementation
Rubber base and hydrocolloid materials do
not injure the pulp. Modeling compound
may be damaging as a result of the
combination of heat and pressure.
Temperatures of up to 52° C have been
recorded in the pulp during impression
taking with modeling compound.
IATROGENIC EFFECTS ON
THE DENTAL PULP
Polishing Restorations
Polishing with rubber wheels, points, or
cups should be at low speeds using
intermittent pressure and a coolant.
Removing Old Metallic Restorations
Postrestorative Hypersensitivity
IATROGENIC EFFECTS ON
THE DENTAL PULP
Dental Materials Microleakage
The most important characteristic of any
restorative material in determining its effect
on the pulp is its ability to form a seal that
prevents the leakage of bacteria and their
products onto dentin and then into the
pulp.
IATROGENIC EFFECTS ON
THE DENTAL PULP
Orthodontic Tooth Movement
The heavy forces used to reposition
impacted canines frequently lead to pulp
necrosis or calcific metamorphosis.
Vital Tooth Bleaching
Overnight external bleaching of anterior
teeth with 10% carbamide peroxide causes
mild pulpitis, which is reversed within 2
weeks.
PROTECTING THE PULP
FROM THE EFFECT OF
MATERIALS
Cavity Varnishes, Liners, and Bases
“Insulating” Effect of Bases
thick cement bases are no more effective
than just a thin layer of varnish in preventing
thermal sensitivity, indicating that
postrestorative sensitivity is at least partly a
result of microleakage
VITAL PULP THERAPIES
Maintaining an intact healthy pulp is
preferable to root canal treatment or other
endodontic procedures that are complex,
expensive, and time consuming.
 VITAL PULP THERAPIES
Removal of Dental Caries
Caries is a localized, progressive destruction of
tooth structure and the most common cause of
pulp disease.
 VITAL PULP THERAPIES
Capping the Vital Pulp
Step-Wise Excavation of Caries
Direct Pulp Cap
Pulpotomy
 THE OPEN APEX
An open apex is in the developing root of
immature teeth until apical closure occurs, which
is approximately 3 years after eruption.
if the pulp becomes necrotic before root
growth is complete, dentin formation ceases and
root development is arrested.
 THE OPEN APEX
Apexogenesis
Apexogenesis is defined as a vital pulp therapy
procedure performed to encourage continued
physiologic development and formation of the
root end.
 THE OPEN APEX
Apexogenesis
Technique
1. Anesthesia is obtained, and the rubber dam
placed.
2. The inflamed pulp tissue is removed. This may
involve removal of the most superficial 2 to 4
mm of pulp
 THE OPEN APEX
Apexogenesis
Technique
3. Hemorrhage is controlled by pressure on a
cotton pellet moistened with saline.
4. The exposed pulp is rinsed with 2.5% sodium
hypochlorite.
5. A material is placed over the amputated pulp.
MTA is the preferred material, although historically
hard-set calcium hydroxide has been widely used.
 THE OPEN APEX
Apexification
Apexification is the induction of a calcific barrier
(or the creation of an artificial barrier) across an
open apex.
Apexification involves removal of the necrotic
pulp followed by debridement of the canal and
placement of an antimicrobial medicament like
caoH, MTA or biodentin.
Thank You