1. Recent Concepts in Vital pulp therapy
6/17/2013 1YES YES WHY

2. Dr. Sarjeev Singh Yadav
Professor & HOD
Dept. of Conservative dentistry and Endodontics
Govt. Dental College and Hospital
6/17/2013 2YES YES WHY

3. Greatest challenges to the integrity
of the developing tooth
6/17/2013 3YES YES WHY

4. Abnormal root development
Impact on long-term prognosis for
tooth retention
6/17/2013 4YES YES WHY

5. Primary goal
Maintain pulp vitality
Normal tooth development occurs
Promotes healing by regeneration rather
than repair
6/17/2013 5YES YES WHY

6. The Pulp-Dentin Complex in Primary and
Young Permanent Teeth
Deep dentin is more porous than superficial dentin.
Normally in primary and young permanent teeth, the
dentin is thinner and more porous than in their mature
permanent counterparts.
The pulps of primary and immature permanent teeth are
at special risk from deep carious lesions, deep cavities,
and traumatic injuries.
Key Points of Clinical Relevance:
6/17/2013 6YES YES WHY

7. Superficial dentin
Deep dentin
6/17/2013 7YES YES WHY

8. Sensory innervations to the pulp does not mature until
the late stages of root formation; pulp testing may
therefore be inconclusive in immature teeth.
Young, well-perfused pulps have enormous reparative
capacity in the face of injury.
The Pulp-Dentin Complex in Primary and
Young Permanent Teeth
6/17/2013 8YES YES WHY

9. Key responses of the dentin-pulp to caries / injury
Tertiary dentin6/17/2013 9YES YES WHY

10. Reactionary dentinogenesis
Caries
Odontoblasts
Dentin
Tertiary, reactionary dentin laid
down by primary odontoblasts
as they retreat from injury
6/17/2013 10YES YES WHY

11. Reparative dentinogenesis
Tertiary,
reparative dentin
Deep dentin injury kills
primary odontoblasts and
stimulates recruitment of
replacements from
the cell-rich layer
New
odontoblast-like
cells migrate to
the wound
6/17/2013 11YES YES WHY

12. 6/17/2013 12YES YES WHY

13. 6/17/2013 13YES YES WHY

14. • A correct diagnosis of pulp conditions in primary and
young permanent teeth is important for treatment
planning.
• McDonald and Avery have outlined several diagnostic
aids in selecting teeth for vital pulp therapy.
• Eidelman et al and Prophet and Miller have
emphasized that no single diagnostic means can be relied
on for determining a diagnosis of pulp conditions.
• A suggested outline for determining the pulpal status of
cariously involved teeth in children involves the following:
6/17/2013 14YES YES WHY

15. 1. Visual and tactile examination of carious dentin and
associated periodontium
2. Radiographic examination of
a. periradicular and furcation areas
b. pulp canals
c. periodontal space
d. developing succedaneous teeth
3. History of spontaneous unprovoked pain
4. Pain from percussion
5. Pain from mastication
6. Degree of mobility
7. Palpation of surrounding soft tissues
8. Size, appearance, and amount of hemorrhage
associated with pulp exposures
Endodontics : Ingle 5th edi
6/17/2013 15YES YES WHY

16. Electric pulp tests are not valid in primary teeth.
Andreasen et al. Textbook and color atlas of traumatic
injuries to the teeth. 4th ed, 2007
Thermal tests are usually not conducted on primary teeth
because of their unreliability.
Cohen S, Hargreaves K : 9th ed. 2006:822– 82.
Numerous studies have reported the unreliability of electric
pulp tests in permanent teeth with open and developing
apices.
J Dent Child 1978;45:199 –202.
J Endod 1986;12:301–5.
Aust Dent J 1977;22:272–9.
6/17/2013 16YES YES WHY

17. Laser Doppler flowmetry might be of greater help in
determining vitality.
Endod Dent Traumatol 1999;15:284 –90.
Dent Traumatol 2001;17:63–70
Endod Top 2003;5:12–25.
6/17/2013 17YES YES WHY

18. - Type of injury
- age of the pt
- size & location of the pulp exposure
- bacterial contamination
- pulp capping material &
- quality of the final restoration
The outcome of VPT depends on:
6/17/2013 18YES YES WHY

19. 1. Indirect pulp capping
2. Direct pulp capping
3. Coronal pulpotomy
Vital pulp therapy for primary and young
permanent teeth involves the following techniques:
6/17/2013 19YES YES WHY

20. 6/17/2013 20YES YES WHY

21. • to arrest the carious process,
• provide conditions conducive to the formation of
reactionary dentin, and
• promote remineralization of the altered dentin that was
left.
• This in turn is expected to promote pulpal healing and
preserve/maintain the vitality of the pulp.
Def: The application of a medicament over a thin layer of
remaining carious dentin, after deep excavation,
with no exposure of the pulp.
The aims of indirect pulp capping is:
6/17/2013 21YES YES WHY

22. 1. History
a. Mild discomfort from chemical and thermal stimuli
b. Absence of spontaneous pain
2. Clinical examination
a. Large carious lesion
b. Absence of lymphadenopathy
c. Normal appearance of adjacent gingiva
d. Normal colour of tooth
3. Radiographic examination
a. Large carious lesion in close proximity to the pulp
b. Normal lamina dura
c. Normal periodontal ligament space
d. No interradicular or periapical radiolucency
6/17/2013 22YES YES WHY

23. 1. History
a. Sharp, penetrating pain persisting after withdrawing
stimulus
b. Prolonged spontaneous pain, particularly at night
2. Clinical examination
a. Excessive tooth mobility
b. Parulis in the gingiva approximating the roots of the tooth
c. Tooth discoloration
d. Non responsiveness to pulp testing techniques
3. Radiographic examination
a. Large carious lesion with apparent pulp exposure
b. Interrupted or broken lamina dura
c. Widened periodontal ligament space
d. Radiolucency at the root apices or furcation areas6/17/2013 23YES YES WHY

24. • Two appointment technique
• One appointment technique
6/17/2013 24YES YES WHY

25. Hard setting Ca(OH)2
ZOE
GIC (Glass ionomer caries control approach)
Resin modified glass ionomer
Bonded composite
MTA
6/17/2013 25YES YES WHY

26. • IPC studies show success rates of 90% or greater over time
with differing techniques and medicaments.
J Endod Vol 34, No 7S, July 2008
IPT medicaments Success
(%)
Time (mo) Sample
(N)
Nirschl and Avery
1983
Calcium hydroxide 94 6 33
Al-Zayer et al.
2003
Calcium hydroxide 95 14
(median)
187
Vij et al. 2004 Glass ionomer 94 40 108
Farooqet al. 2000 Glass ionomer 93 50 55
6/17/2013 26YES YES WHY

27. • To manage lesions in primary molars (that are symptom
free and free from radiographic signs of periradicular
pathology) by cementing a preformed metal (stainless
steel) crown in place without local anaesthesia, tooth
preparation, or any attempt at caries removal.
Innes NP, Stirrups DR, Evans DJ, Hall N, Leggate M: A novel technique
using preformed metal crowns for managing carious primary molars in
general practice–a retrospective analysis. Br Dent J 200:451, 2006
6/17/2013 27YES YES WHY

28. • The Hall technique was preferred to conventional
restorations by the majority of children, guardians, and
clinicians.
• After a review period of 2 years, comparing the teeth
managed using Hall preformed metal (stainless steel)
crowns with conventional restorations, the “Hall crowns”
showed better treatment outcomes for both pulpal health
and restoration longevity.
Innes NP, Evans JP, Stirrups DR: The Hall technique; a randomized
controlled clinical trial of a novel method of managing carious primary
molars in general dental practice: acceptability of the technique and
outcomes at 23 months. BMC Oral Health 7:18, 2007.
6/17/2013 28YES YES WHY

29. • The pulps of young permanent teeth are at risk of
breakdown following traumatic injuries, dental caries, and
restorative dentistry.
• There is good evidence that RDT is a key determinant of
pulp survival after cavity preparation, and avoiding pulp
exposure has been considered advantageous.
Int Endod J 41:389, 2008.
• The management of deep caries by partial and serial
excavation has gained considerable support in recent
years, reducing the risks of pulp exposure and harnessing
the natural defences of the pulp in laying down protective
tertiary (reactionary) dentin.
J Endod 34(7S):S29, 2008.
In YOUNG PERMANENT TEETH..
6/17/2013 29YES YES WHY

30. • Researchers continue to investigate the role of antimicrobial
treatments, including
• ozone fumigation, Eur J Oral Sci 114:349, 2006
• photo-activated disinfection (PAD), and
• antimicrobial resins in sterilizing deep layers of affected
dentin and creating the conditions for arrest and
remineralisation.
Int Endod J 40:58, 2007.
• Considerable interest has also focused on the active
upregulation of reactionary dentinogenesis by applying
bioactive agents such as the TGF-β family of molecules to
the depths of cavity preparations.
Caries Res 38:314, 2004.
6/17/2013 30YES YES WHY

31. 6/17/2013 31YES YES WHY

32. Def: Direct pulp capping involves
the placement of a biocompatible
agent on healthy pulp tissue that
has been inadvertently exposed
from caries excavation or
traumatic injury.
Oral Surg 1972;34:477.
Objective: is to seal the pulp against bacterial leakage,
encourage the pulp to wall off the exposure site by
initiating a dentin bridge, and maintain the vitality
of the underlying pulp tissue regions.
6/17/2013 32YES YES WHY

33. • Vital pulp therapy has a high success rate if the
following conditions are met:
(1) The pulp is not inflamed;
(2) Hemorrhage is properly controlled;
(3) A non-toxic capping material is applied; and
(4) The capping material and restoration seal out
bacteria.
6/17/2013 33YES YES WHY

34. 1. Small pin point mechanical exposures of diameter
< 1.0mm
2. Pulp exposed without previous symptoms of pulpitis.
6/17/2013 34YES YES WHY

35. (1) Spontaneous and nocturnal toothaches.
(2) Excessive tooth mobility.
(3) Thickening of the PDL.
(4) Radiographic evidence of furcal or periradicular
degeneration.
(5) Uncontrollable hemorrhage at the time of exposure, and
(6) purulent or serous exudate from the exposure.
6/17/2013 35YES YES WHY

36. (1) Maintenance of pulp vitality,
(2) Absence of sensitivity or pain,
(3) Minimal pulp inflammatory responses, and
(4) Absence of radiographic signs of dystrophic changes.
Salient features of a clinically successful DPC (with or
without bridging) are:
6/17/2013 36YES YES WHY

37. • The first method of capping exposed pulps, using gold
foils was described by Pfaff in 1756. Thereafter,
numerous agents for direct pulp capping have been
recommended. (Dammaschke T 2008)
6/17/2013 37YES YES WHY

38. • Ca(OH)2
• ZOE
• Corticosteroids and
antibiotics
• Polycarboxylate
cements
• Inert materials
• Collagen fibers
• Formocresol
• Bonding agents
• Cell Inductive agents
• Hydroxyapatite
• Bioactive glass
• MTA
• Calcium phosphate cement
• Calcium enriched mixture
• Lasers
• Biodentine
• Emdogain
6/17/2013 38YES YES WHY

39. • Calcium hydroxide (CH) or calcium hydroxide compounds
have, for many years, been the material of choice.
• But calcium hydroxide and most calcium hydroxide
cements are liable to dissolution, dentin bridge formation
beneath CH has tunnel defects and, in cases of
microleakage around restorations, bacteria may gain
access to the exposure site.
Asgary et al, 2008, Cox et al, 1985, Pitt ford, Roberts 1991
• Therefore, much research has been devoted to generate
alternative materials.6/17/2013 39YES YES WHY

40. • Self-etching adhesive and calcium hydroxide on
human pulp tissue:
• The clearfil SE ability to induce reparative dentin was
significantly weaker than Dycal.
Lu et al, 2008
• Direct pulp capping in dogs teeth with self-etching
adhesive system did not allow pulp tissue repair and failed
histopathologically in 100% of the cases.
da Silva La et al, 2009
6/17/2013 40YES YES WHY

41. • Tri-calcium phosphate based cement:
• Dentin bridge formation was observed on exposed pulps
of rats with no evidence of necrosis or marked
inflammation.
Yoshimine and Maeda, 1995
• Tricalcium phosphate was most active when used in
combination with CH.
Yoshiba K, Yoshiba N, Iwaku M, 1994
6/17/2013 41YES YES WHY

42. • Adhesive resin-based composite:
• The globules of resin can migrate into the pulp tissue and
stimulate inflammation.
Kitasako et al, 1999
• In addition, polymerization shrinkage during the
placement of these materials can create marginal gaps
to permit bacterial leakage to occur.
Pashley, 1996
6/17/2013 42YES YES WHY

43. • Calcium hydroxide combined with Vancomyin:
• The combination of CH with vancomycin in monkeys was
somewhat more successful in stimulating regular
reparative dentin bridges.
Gardner et al, 1971
6/17/2013 43YES YES WHY

44. 6/17/2013 44YES YES WHY

45. • The disadvantages of CH:
• The presence of tunnel defects in dentin barrier.
• Extensive dentin formation.
• High solubility in oral fluids.
• Lack of adhesion and degradation afer acid etching.
6/17/2013 45YES YES WHY

46. • It was introduced in 1993 by Torabinejad.
• Pitt Ford et al, 1996 were the first to evaluate the
performance of MTA for pulp capping in monkey’s teeth.
• Pulp capping with MTA is recommended for teeth with
carious pulp exposures specially immature teeth with
high potential for healing.
Farsi N, et al 2006
6/17/2013 46YES YES WHY

47. • MTA is superior in terms of dentin bridge formation
during the early healing process in human dental pulp.
Min et al, 2008
• MTA seemed to heal the pulp tissue at a faster rate than
CH cement in human teeth.
Accornite et al, 2008
• MTA was clinically easier to use as a direct pulp capping
agent and resulted in less pulpal inflammation and more
predictable hard tissue barrier formation than Dycal.
Nair PN et al, 2009
6/17/2013 47YES YES WHY

48. • It has excellent sealing ability.
Torabinejad et al, 1993, 1994, Bates et al, 1996,
Fischer et al, 1998, Wu et al, 1998.
• Biocompatibility.
Kettering & Torabinejad 1995, Torabinejad et al,
1997, 1998, Holland et al, 1999, Mitchell et al, 1999,
Keiser et al, 2000
6/17/2013 48YES YES WHY

49. initial deep caries and immature apices
Five-minute application of 5.25% sodium hypochlorite
hemostasis, on two 1.5- to 2.0-mm exposures
Pulpal exposure
6/17/2013 49YES YES WHY

50. Radiograph of molar with MTA after
initial visit
Radiograph taken at the 5.5-year recall
appointment showing permanent
restoration and evidence of complete
root formation.
(From Bogen G, Kim JS, Bakland LK: Direct pulp capping with mineral trioxide
aggregate. An observational study. J Am Dent Assoc 139:305-315, 2008.6/17/2013 50YES YES WHY

51. • Biodentine™ consists of a powder in a capsule and liquid in
a pipette.
• The powder mainly contains tricalcium and dicalcium
silicate, the principal component of Portland cement and
MTA, as well as calcium carbonate.
• Zirconium dioxide serves as contrast medium.
• The liquid consists of calcium chloride in an aqueous
solution with an admixture of modified polycarboxylate.
• The powder is mixed with the liquid in a capsule in a
triturator for 30 sec.
• Once mixed, Biodentine™ sets in about 12 to 15 Min.
• During the setting of the cement calcium hydroxide is
formed.6/17/2013 51YES YES WHY

52. • On the biological level, it is perfectly biocompatible
(Laurent et al., 2008) and capable of inducing the apposition
of reactionary dentin by stimulating odontoblast activity
(Goldberg et al., 2009) and reparative dentin, by induction of
cell differentiation (Shayegan et al., 2010).
• It is in effect a dentin substitute that can be used as a
coronal restoration material (for indirect pulp capping), but
can also be placed in contact with the pulp.
• Its faster setting time allows either immediate crown
restoration (Tran et al., 2008), or to make it directly
intraorally “functional” without fear of the material
deteriorating.
6/17/2013 52YES YES WHY

53. Clinical view Distal pulp horn involvement
After removal of restoration Biodentine placement
6/17/2013 53YES YES WHY

54. Post--‐operative clinical view Post‐operative X‐ray follow‐up image
Ceramic onlay, final restoration
after 2 months
Post ‐operative X‐ray follow‐up image
- Dr. Lucile Goupy6/17/2013 54YES YES WHY

55. • Biodentine, Ca(OH)2, MTA and Xeno III:
• Biodentine™ induced mineralized foci formation early
after its application. The mineralization appeared under
the form of osteodentine and expressed markers of
odontoblasts.
• Biodentine™ significantly increased TGF- β1 secretion
from pulp cells ( P < 0.03) independently of the contact
surface increase. This increase was also observed with
calcium hydroxide and MTA, but not with the resinous
Xeno®III.
Laurent P, Camps J, About I: Int Endod J; May 2012, Vol. 45 Issue
5, p439-448.
6/17/2013 55YES YES WHY

56. • Calcium enriched mixture (CEM) cement is a new
endodontic cement with similar clinical applications as MTA
but different chemical composition.
J Endod 2008;34:990–3, J Endod 2009;35:243–50.
• CEM cement has antibacterial effect comparable to CH
and superior to MTA (Asgary S, Kamrani FA 2008) and sealing
ability similar to MTA (Asgary S, Eghbal MJ, Parirokh M 2008).
• The biologic response of the pulpal tissue to MTA and
CEM cement has been shown to be similar in dogs’ teeth.
Asgary S et al, 2008
6/17/2013 56YES YES WHY

57. • In addition, Asgary and Ehsani showed in a case series
study that CEM cement has favourable clinical success in
pulp capping of permanent molars with irreversible pulpitis.
J Conserv Dent 2009;12:31–6.
• It has been shown that CEM cement provides an
endogenous source of calcium and phosphate ions that
accelerates hydroxyapatite (HA) crystal formation as a
second-seal on its surface even in normal saline storage
media.
Aust Endod J 2009;35:147–52.
• The composition of the set form of CEM cement is similar
to dentin.
J Endod 2009;35:243–50.
6/17/2013 57YES YES WHY

58. • Bioactive glass is often used as a filler material for repair of
dental bone defects.
• They react with aqueous solutions and produce a
carbonated apatite layer.
• BAG is biocompatible and can bind to the bone.
• BAG can be the material of choice for pulp capping and
periapical bone healing because it is biocompatible and
has antibacterial property.
Schepers et al, 19916/17/2013 58YES YES WHY

59. • Bioactive glass and calcium hydroxide in primary
molars:
• Less inflammation, dentin bridge formation and no internal
resorption, necrosis or abscess in BAG group.
Journal of Dentistry, Tehran University of Medical Sciences, Tehran,
Iran (2007; Vol: 4, No.4)
Pulpal response CH BAG
Mild inflammation 2 0
Mild inflammation 5 2
Severe inflammation 3 1
Internal resorption 6 0
Abscess 5 0
Necrosis 0 0
Dentinal bridge 7 2
6/17/2013 59YES YES WHY

60. • Novamin® compared with calcium hydroxide as
a pulp-capping agent:
• Novamin® showed less or no inflammation when
compared to Ca(OH)2.
• There was no presence of bacteria on any sample for
both NovaMin® and Ca(OH)2 groups.
Bioceramics: Volume 8, 1995. 512 pg
6/17/2013 60YES YES WHY

61. • ODAM has been shown to be specifically expressed in
ameloblasts and odontoblasts and has been suggested to
play a role in the mineralization of the enamel, possibly
through the regulation of matrix metalloproteinase
20. However, its function in dentin is not clear.
White MTA and rODMA comparison on formation of
reactionary dentine formation:
• rODAM accelerates reactionary dentin formation close to
the pulp exposure area, thereby preserving normal
odontoblasts in the remaining pulp.
J Endod; Dec 2010, Vol. 36 Issue 12, p1956-1962.6/17/2013 61YES YES WHY

62. • Enamel Matrix Derivative (EMD) is a rich amelogenin and
amelin biomaterial that has been demonstrated to induce
a reparative process similar to normal odontogenesis
when placed in contact with pulp tissue.
• Numerous in vivo and in vitro studies, as well as clinical
trials, have shown that EMD is clinically useful in
promoting periodontal regeneration.
Esposito M et al 2003
• Several studies have also shown its promising effect in
direct pulp capping.
6/17/2013 62YES YES WHY

63. • Histological evaluation of EMD as a pulpotomy
agent in primary teeth:
Pediatric Dent 2007 Nov-Dec;29(6):475-9.
Extraction of
primary
canines
Histology of pulp
after 1 week surface was lined by a thin, nearly continuous
cellular layer. Generalized congestion was
accompanied by an increase in angiogenesis
after 2 weeks small islands of dentin-like tissue at different
stages of mineralization.
after 6 months coalescing islands of dentin-like tissue trying to
bridge the full width of the coronal pulp at the
interface between the wounded and unharmed
pulp tissue below the amputation site.
6/17/2013 63YES YES WHY

64. • A Hybrid Approach to Direct Pulp Capping by
Using Emdogain with a Capping Material:
• Calcium hydroxide, ProRoot White MTA, white Portland
cement were used after Emdogain application on the
exposed pulp.
• MTA produced a better quality reparative hard tissue
response with the adjunctive use of Emdogain, when
compared with the use of calcium hydroxide.
J Endod 35 , Pages 667-672, May 2011
6/17/2013 64YES YES WHY

65. • Comparison of histologic healing processes with
either tetracalcium phosphate cement or calcium
hydroxide cement to the exposed pulp of the rat
maxillary incisors:
• In teeth applied with Ca(OH)2, necrotic tissue was present
beneath the cement before new hard tissue formed.
• In contrast, tetracalcium phosphate cement elicited a
dentine bridge formation with no evidence of either
intervening tissue necrosis or marked inflammation.
6/17/2013 65YES YES WHY

66. • Furthermore on ultrastructural examination the newly
formed hard tissue was in direct contact with the material.
• This study suggests that 4CP cement possesses a
biocompatible property, which indicates its potential for
use as a direct pulp-capping agent.
Yoshimine Y, Maeda K, 1995
6/17/2013 66YES YES WHY

67. • Brasseler USA (Savannah, GA) has formulated a
bioceramic material for root repair needs. Currently there
is limited research on the Endosequence Root Repair
Material (ERRM).
• It has mainly been evaluated for use as a root-end filling
material.
• Its properties include exceptional stability, high
mechanical bond strength, high pH, radiopaque, and
hydrophilic setting properties, and it is premixed.
J Endod 2011;37:372–5.
6/17/2013 67YES YES WHY

68. • MTA-Angelus, Brasseler Endosequence Root Repair Putty
(ERRP) , Dycal and Ultra-blend Plus (UBP):
• MTA-Angelus, (ERRP) , and Ultra-blend Plus had
statistically similar adult human dermal fibroblast
cytotoxicity levels.
• Relative to the negative control, only Dycal was shown to
have a statistically significant cytotoxic effect on adult
human dermal fibroblasts at all tested intervals.
• ERRM and UBP did not negatively influence cell survival.
Hirschman et al, J Endod 2012; 1–4 (Article in press)
6/17/2013 68YES YES WHY

69. • TheraCal LC is a light-cured resin-modified calcium
silicate pulp protectant / liner designed to perform as a
barrier and to protect the dentin-pulp complex.
• The light-cured set permits the practitioner immediate
placement and condensation of the restorative material.
• TheraCal is indicated in both indirect and pulp capping
procedures.
6/17/2013 69YES YES WHY

70. • Comparison of chemical-physical properties of
TheraCal, ProRoot MTA and Dycal:
• TheraCal displayed higher calcium-releasing ability and
lower solubility than either ProRoot MTA or Dycal.
• The capability of TheraCal to be cured to a depth of
1.7 mm may avoid the risk of untimely dissolution.
• These properties offer major advantages in direct pulp-
capping treatments.
Int Endod J , 45: 571–579, June 2012.
6/17/2013 70YES YES WHY

71. 6/17/2013 71YES YES WHY

72. Def: “amputation of the affected or infected coronal portion
of the dental pulp, preserving the vitality and function
of all or part of the remaining radicular pulp”.
AAPD guidelines 2003-2004
• Outcome of the treatment – influenced by type, conc &
time of tissue contact of the medicament.
6/17/2013 72YES YES WHY

73. • clinical and radiographic signs of radicular pulp vitality,
• absence of pathologic change,
• restorability, and
• at least two-thirds remaining root length.
• young permanent teeth with incompletely formed apices
and cariously exposed pulps.
6/17/2013 73YES YES WHY

74. (1) root resorption exceeding >1/3rd of the root length
(2) Nonrestorable tooth crown
(3) highly viscous, sluggish, or absent hemorrhage at the
radicular canal orifices
(4) marked tenderness to percussion
(5) mobility with locally aggravated gingivitis associated
with partial or total radicular pulp necrosis
(6) radiolucency in the furcal or periradicular areas
(7) persistent toothaches & coronal pus
According to Mejare:
6/17/2013 74YES YES WHY

75. - Vitality of the majority of the radicular pulp
- No prolonged adverse clinical signs or symptoms,
such as prolonged sensitivity, pain, or swelling
- No radiographic evidence of internal resorption
- No breakdown of periradicular tissue
- No harm to succedaneous teeth
- Pulp canal obliteration (abnormal calcification)
Evidence of success in therapy includes the following:
6/17/2013 75YES YES WHY

76. Agents for
pulpotomy
Pharmacotherapeutic
Formocresol
Glutaraldehyde
Calcium hydroxide
Collagen
Ferric sulfate
CaPo4 cement
Hydroxyapatite
BMP 2 & 4
Freeze dried bone
MTA
CEM
Biodentine
Non-
pharmacologic
Electro surgery
Lasers6/17/2013 76YES YES WHY

77. • Most popular – Formocresol
- because of its ease in use and
- excellent clinical success.
but concerns  systemic distribution
potential for toxicity
allergenicity
carcinogenicity and
mutagenicity
6/17/2013 77YES YES WHY

78. • Studies Directly Comparing MTA and Formocresol
6/17/2013 78YES YES WHY

79. • Studies Comparing Directly Ferric sulphate and
Formocresol
6/17/2013 79YES YES WHY

80. • Studies Directly Comparing CH and FC
6/17/2013 80YES YES WHY

81. • This clinical study compared the effects of Nd:YAG laser
pulpotomy with FC on human primary teeth.
• In the Nd:YAG laser group, clinical success was achieved
in 66 of 68 teeth (97%), and 94% were radiographically
successful.
• In the control group, 85% and 78% achieved clinical and
radiographic success, respectively.
• The success rate of the Nd:YAG laser was significantly
higher than that of the FC pulpotomy.
• The permanent successors of the laser-treated teeth
erupted without any complications.
J Endod, 2006: 32:404-7
• Study Comparing Laser With FC:
6/17/2013 81YES YES WHY

82. • Study Comparing Sodium Hypochlorite With FS:
Vargas etal, 2006
• The authors concluded that preliminary evidence showed
that NaOCl can be used successfully as a pulpotomy
medicament.
Paediatr Dent 2006, 28: 511-7
Duration Ferric sulphate NaOCl
Clinical
success
Radiographic
success
Clinical
success
Radiographic
success
At 6 months 100% 68% 100% 91%
At 12 months 85% 62% 100% 79%
6/17/2013 82YES YES WHY

83. • Case reports showing successful pulpotomy with MTA
JADA, Vol. 137 May 2006
18 month
19 month
6/17/2013 83YES YES WHY

84. • Case report showing successful pulpotomy with
CEM cement in permanent molar with irreversible
pulpitis and condensing apical periodontitis:
Saeed Asgary. J Conser Dent 2011, 14: 90-93
6 months
1 year 2 years
6/17/2013 84YES YES WHY

85. 6/17/2013 85YES YES WHY

86. • During the last 10–15 years, there has been a tremendous
increase in our clinical “tools” (ie, materials, instruments,
and medications) and knowledge from the trauma and
tissue engineering fields that can be applied to
regeneration of a functional pulp-dentin complex.
• In addition, recent case reports indicate that biologically
based endodontic therapies can result in continued root
development, increased dentinal wall thickness, and apical
closure when treating cases of necrotic immature
permanent teeth.
6/17/2013 86YES YES WHY

87. • Several groups recently have published preclinical research
or case reports that offer a biologically based alternative to
conventional endodontic treatment of these complex clinical
cases.
6/17/2013 87YES YES WHY

88. 6/17/2013 88YES YES WHY

89. J Conser Dent 2012, 15: 97-1036/17/2013 89YES YES WHY

90. 6/17/2013 90YES YES WHY

91. • The pulp-capping agents used, and not the procedure
itself, has been the subject of controversy among
researchers.
• Development of new capping materials for delivery of
exogenous signaling molecules offers exciting
opportunities for the future.
• However, a number of critical considerations, such as
the dose-response effects, the nature of the delivery
system, half-life of the molecules, their possible side-
effects and long term clinical studies need to be
addressed before any introduction of new treatment
modalities into clinical practice.
6/17/2013 91YES YES WHY

92. 6/17/2013 92YES YES WHY