VITAL PULP

THERAPY TECHNIQUE

NGUYỄN CÔNG NĂNG

NGUYỄN MINH HIỀN

LÊ ĐỨC ANH
Indirect Pulp
Therapy
(Indirect Pulp
Capping)
I. Definition

▪Indirect pulp therapy (IPT) is a treatment is to seal and arrest caries,

avoid pulp exposure, and maintain pulpal vitality
II. Principle

▪IPT is a procedure performed in a tooth with a deep caries lesion

approximating the pulp champer. Indirect pulp treatment is a
procedure that leaves the deepest caries adjacent to the pulp
champer undisturbed in an effort to avoid a pulp exposure. This
caries-affected dentin is covered with a biocompatible material to
produce a biological seal
III. Mechanism

▪Seal and arrest caries

▪Stimulate remaining carious to heal and repair
▪Reparative dentin to form to protect the pulp
 IV. Indications

▪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

▪History has prolonged spontaneous pain

▪Sharp, penetrating pain when simulate in clinical examination
▪Excessive tooth mobility
▪Tooth discoloration
▪Radiographic examination:
▪ Large carious lesion with apparent pulp exposure
▪ Radiolucency at the root apices or furcation areas.
VI. Material

▪The restorative material should seal completely the involved dentin

from the oral environment. The tooth’s vitality should be preserved.
No post-treatment signs or symptoms such as sensitivity, pain, or
swelling should be evident. There should be no harm to the
succedaneous tooth
 VI. Material

▪Ca(OH)2 has been a gold standard for pulp

capping and is being used since its use was
first described by Zander in 1939. Commercial
available as Liner.
▪It allows the formation of a reparative dentin
through cellular differentiation, extracellular
matrix secretion, and subsequent
mineralization
▪Ca(OH)2 has a high pH and induces reparative
dentin, it has disadvantages of high solubility,
inadequate seal, and low compressive
strength
 VI. Material

▪Due to these properties, reinforced ZOE

(Eugenolate) should be placed over Ca(OH)2
to ensure a seal against microleakage

Now we have various newer materials for

Indirect Pulp Capping including mineral
trioxide aggregate (MTA), biodentine and
different bioceramic materials
 VII. Technical

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

Success rate varies from 75 - 100%

Using glass ionomer cement (GIC) as a one-step procedure with

liner for IPT and cementing the stainless-steel crown. Glass
ionomer offers additional beneficial properties of an antimicrobial
effect on mutans streptococci and a good seal, reducing bacterial
microflora due to reduction in nutrients. Vitrebond, a resin-
modified glass ionomer, is commonly used.

Bowen reported that IPT studies consistently found success rates

of over 90% with CaOH and glass ionomer.
Direct Pulp
Capping
I. Definition

▪Direct myelography is to cover the open pulp with biocompatible

materials to ensure the survival of the pulp and promote the healing
process.
▪When there is a small pulp opening due to mechanical action of the
preparation of the filling or trauma, the exposed pulp may be
exposed to a suitable protector to maintain the survival of the pulp
tissue.
 I. Definition

▪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

▪Exposed pulp caused by dentist (< lmm, not infected) or trauma,

teeth in stage 1.
▪No or minimal bleeding at the pulpal opening.
III. Contraindications

▪Teeth in stages 2 and 3.

▪Depending on openness due to caries (Seltzer and Bender 1975).
▪Having symptoms of pulp disease: showing pulp disease on X-ray
film
▪There is a history of intermittent toothache, bleeding at the opening
of the pulp.
▪Wide cleft.
IV. Material

▪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

Less favorable for baby teeth.

Progression: marrow necrosis and other complications.

Currently, direct root canal therapy is considered as an exception

treatment, rarely indicated for carious lesions in the primary dental arch.
Temporary filling with ZOE, l.R.M (Quick-hardening Eugenolate), C.V.I
(ciment verre ionomere), ... within 6-8 weeks. Compaction must be avoided
when placing the material.
Permanent filling.

Clinical and radiological monitoring.

Pulpotomy
 I. Definition

▪The removal of the coronal portion of the

pulp is an accepted procedure for treating
both primary and permanent teeth with
carious pulp exposures. The justification for
this procedure is that the coronal pulp tissue,
which is adjacent to the carious exposure,
usually contains microorganisms and shows
evidence of inflammation and degenerative
change. The abnormal tissue can be
removed, and the healing can be allowed to
take place at the entrance of the pulp canal
in an area of essentially normal pulp.
II. Indications

Inflammation of coronal pulp

Coronal pulp exposure in cracked tooth

External root resorption.

Pulp exposure untreatable with direct pulp cap, stage 2 or 3

of primary tooth
III. Contraindications

Contraindications  The patient has a chronic illness

 Tooth is severely mobile
in clinical  Pain on percussion
evaluation:  Gingivitis

 Tooth with mechanical or carious perforation of the

floor of the pulp chamber
Contraindications  Damaged apical foramen
in radiography:  Tooth close to natural exfoliation
 Evidence of internal resorbtion
 IV. Pulpotomy procedure

 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

Standards of material used to cover

the remaining pulp tissue:
• Disinfectant
• Not damaging the pulp and vicinity structure
• Induce pulp regeneration
• Not affecting tooth natural exfoliation
 V. Material

Mineral trioxide aggregate (MTA)

• MTA is a mixture of tricalcium silicate, bismuth oxide,
dicalcium silicate, tricalcium aluminate and calcium
sulphate. It is chemically similar to standard cement
mix. MTA powder reacts water to form a paste, which is
highly alkaline (pH = 13) during the setting phase, then
sets to form an inert mass..
• The MTA powder is mixed with water immediately prior
to use. The resultant paste is applied to the pulpotomy
site using a proprietary carrier or a plastic instrument
and is left in situ to set. It is covered with a suitable
base material prior to restoration of the tooth. The
paste should only be applied after haemostasis has
been obtained. Exposure to MTA dust can cause
respiratory irritation, ocular damage, and skin irritation.
 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 is available in the form of a capsule containing the ideal ratio of

its powder and liquid. The composition of powder is given in:
Powder Percentage

Tricalcium silicate (3CaO.SiO2) (main core material) 80.1

Dicalcium silicate (2CaO.SiO2) (second core material)  

Calcium carbonate (CaCO2)(filler) 14.9

Zirconium Oxide (ZrO2) (radioopacifier) 5

Iron oxide(colouring agent)  

 V. Material

Biodentine

The working time of Biodentine and MTA is given in:

Porosity
Material Initial setting time Final setting time characteristics
(minutes) (minutes) {density(g/cm3)}

MTA  70 175 1.182

Biodentine 6 10.1 2.260

 V. Material

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  

manoeuvrability and economical Dentin substitute   X

Root canal filling and apex closure   X
factors fall in favour of Biodentine.
 V. Material

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