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THERAPY TECHNIQUE
LÊ ĐỨC ANH
Indirect Pulp
Therapy
(Indirect Pulp
Capping)
I. Definition
▪Indirect Pulp Therapy (IPT) is indicated for asymptomatic primary molars with deep caries
approaching the pulp (distance dentin-pulp >1,5mm)
▪Absence of spontaneous pain
▪Percussion elicits no pain, and there is no pathologic mobility
▪When judged the pulp by clinical and radiographic criteria, a primary tooth with deep caries that
exhibits no pulpitis or with reversible pulpitis when the deepest carious dentin is not removed to
avoid a pulp exposure
▪Radiographic examination reveals caries close to the pulp, absence of periapical or furcation
radiolucencies, and absence of internal or external root resorption.
▪Radiographic examination reveals that absence of periapical or furcation radiolucencies, and
absence of internal or external root resorption.
V. Contraindications
Step 7:
Step 3: Remaining
Isolate a Step 5: affected
Step 1: Step 4: Step 8:
Step 2: teeth from Disinfect by Step 6: dentin
Radiographic Removal of Restoration
Anesthesia the overal Chlorhexedin Drying tooth covered with
examination caries dentin of crowns
environment e calcium
al hydroxide
and Zoe
VIII. Prognosis
▪Animal experiments have demonstrated that local pulpitis is reversible if irritants are removed,
even if dentin caries is still progressing. The cause of recovery is due to decreased permeability of
sclerotic dentin and secondary dentin.
▪In the past, direct pulp occlusion had a very low success rate in primary teeth because the
outcome was often unpredictable. Kenneky and Kapala suggested that this failure may be due to
the high cell count in the pulp tissue of primary teeth. Undifferentiated mesenchymal cells can
differentiate into osteoclasts that cause resorption (the main sign of failure due to direct pulp
cover) or even acute alveolar abscesses. However, in a review of root canal treatments in
deciduous teeth, Iman Parisay concluded that direct root canal therapy in exposed caries has
brought promising successful results (over 90 years). %) in randomized clinical trials using novel
biomaterials. This may provide a promising opportunity for direct root canal therapy of primary
teeth in the future.
II. Indications
▪The ideal material for covering the pulp should be biocompatible with
the pulp tissue, stimulate the formation of a calcium barrier to protect the
pulp, and have antibacterial properties. The most commonly used
material is calcium hydroxide because of its antiseptic and dentinogenic
properties.
IV. Material
▪- Mechanism of action of Ca(OH)2: after myeloscopy, a necrotic area is rapidly formed under the
Ca(OH)2 layer, separated from healthy marrow tissue by an basophilic region containing calcium
proteinates. . Within 2 weeks, a thick layer of fibrous tissue develops just below the basophilic zone,
under which is a layer of cells that look like odontoblasts. This calcified barrier, or dentin bridge, is
related to the dentin-forming cell barrier, which is derived from undifferentiated mesenchymal cells in
the pulp. The mechanism that stimulates the formation of dentin bridges is not clear, Ca(OH)2 does
not combine with adjacent dentin bridges, but only produces reactive dentin when in direct contact
with pulp tissue. This effect does not occur in the case of indirect pulp cover. The disadvantage of
Ca(OH)2 is long-term instability, easy to digest, creating space for bacteria to invade marrow tissue.
Currently, many materials with similar and superior properties to Ca(OH)2 such as MTA, biodentine are
increasingly widely used and have a high success rate, however, with baby teeth, caution should be
exercised in lead. plan to cover the pulp directly or take the pulp chamber.
V. Technical
Step 7:
Step 3:
Remaining
Isolate a Step 5:
Step 1: Step 4: affected
Step 2: teeth from Disinfect by Step 6:
Radiographic Removal of dentin
Anesthesia the overal Chlorhexedin Drying tooth
examination caries dentin covered with
environment e
calcium
al
hydroxide
VI. Prognosis
Cream or topical anesthetic will be applied to the gums to numb the area. Once the gums are numb, the
local anesthetic will be administered.
A rubber dam will then be placed to isolate the tooth and reduce saliva moisture.
Remove caries and gain access with round bur and high speed handpiece
Pulpal extension using Endo-Z bur
Remove the infected material within the tooth’s crown using a different round bur used in gaining access
Clean the area using NaOCl
Stop bleeding with cotton pellet
Cover the remaining pulp tissue using formocresol or MTA…
The chamber will then be filled with zinc oxide- eugenol cement
The tooth is then covered with a crown.
V. Material
Biodentine
• Biodentine has been recently introduced
as the “the first all-in-one, bioactive and
biocompatible material for damaged
dentin replacement”. Manufacturers
claim that Biodentine has noticeably
shorter setting time in contrast to other
silicate cements such as Mineral Trioxide
Aggregate (MTA) and also has better
mechanical and handling properties
V. Material
Biodentine
Biodentine
Biodentine
• The density and the porosity determines the amount of leakage and outcome of the treatment
because greater pore diameter => larger leakage =>compromised hermetic seal
• Flexural strength of any dental material is an important factor as it decreases the risk of fracture in
clinical use. Walker MP et al., found that the flexural strength of MTA was 14.27 MPa when
specimens were exposed to two-sided moisture after 24th hour of setting time [18]. However, the
flexural strength of Biodentine recorded after two hours, has been found to be 34 MPa
• The compressive strength of the MTA increases 100 MPa in the first hour and 200 MPa at 24th
hour and it continues to improve with time over several days until reaching 300 MPa after one
month, which is comparable to the compressive strength of natural dentine i.e 297 MPa. A study
conducted by Grech L et al., showed that Biodentine had highest compressive strength when
compared to other tested materials due to low water/cement ratio used in Biodentine
V. Material
Biodentine
Clinical Implications Clinical applications MTA Biodentine
Pulp capping X X
Pulpotomy X X
Perforation repair (Furcal or root) X X
Due to lack of long-term observational
studies, it is difficult to infer concretely Root end filling X X
that which material out of MTA and Root canal filling X X
Biodentine is superior, however, Resorption X
Formocresol
• Formocresol has been used in
pulpotomy procedures of the
primary teeth since 80 years.
• Formocresol is both a bactericidal
and devitalizing agent.
• Formaldehyde, which is a primary
component in formocresol, is a
hazardous substance.
V. Material
ZOE (Eugenolate)
• ZOE is a nontoxic material for
pulpal cells and possess
antimicrobial as well as anti-
inflammatory properties.
• It also has local anesthetic or
soothing effect on the dental
pulp.
V. Material
Calcium hydroxide
• Calcium hydroxide is a highly alkaline
(pH 12) material that has bactericidal
effect and has the potential to enhance
reparative dentin (dentin bridge)
formation.
• However, it also leads to superficial
necrosis of the pulp tissue in contact
with the medication and has been shown
to be toxic to cells in tissue culture.
V. Material
Ferric sulfate
• Ferric sulfate is used to arrest pulpal
bleeding by forming a sealing membrane
through the agglutination of the blood
proteins with ferric and sulfate ions.
• The metal-protein clot at the surface of the
pulp may act as a barrier to external
irritants.
• Most importantly, ferric sulfate causes
minimal devitalization and subsequent
preservation of the pulp tissue.
VIDEO