vital pulp treatment indirect pulp capping direct pulp capping materials radiographic examination Done by Weam Mahmoud Faroun

1. Direct
&
Indirect pulp capping
Done by Weam faroun

2. PULP
• is defined as soft
tissue forming
inner structure of
tooth and
containing nerve
and blood vessel ,
also called as tooth
pulp.

3. • designed to preserve and maintain pulpal
health in teeth that have been exposed to
trauma, caries, restorative procedures, and
anatomic anomalies
Vital pulp therapy

4. Vital pulp therapy
• All these procedures involve removal of local
irritant and placement of protective material
directly or indirectly over the pulp

5. • Common objective is to induce a physical
protective barrier over pulp to maintain its
vitality and function.
• (to initiate the formation of tertiary
reparative dentin or calcific bridge
formation.))

6. • This procedure is essential for the immature
permanent teeth where root development
may be incomplete

7. Out comes
depend on

8. recognized that outcomes for vital pulp
therapy can vary, depending on:
1. The age of the patient,
2. Extent of bacterial contamination,
3. Degree of pulp inflammation.
4. Perhaps of greater importance may be
the choice of pulp capping material
5. The quality of the permanent restoration

9. • intraoral radiographs of the involved tooth
must be taken to evaluate accurately the
extent of root formation and periradicular
or furcation changes associated with the
periodontal ligament and supporting bone

10. • In young permanent teeth, the stage of
root development directly influences the
diagnosis and treatment options. Because
the faciolingual dimension of most
immature roots is greater than the
mesiodistal dimension, apical closure may
be difficult to determine radiographically.

11. • Before arriving at treatment decisions, the
clinician should carefully assess all available
information;
1. The medical history
2. Patient report
3. Radiographic evidence,
4. Clinical evaluation, and vitality (cold) testing are
recommended.
5. Periodontal probing,
6. Mobility assessment,
7. The presence of any localized swelling or sinus
tracts should be recorded during the evaluation
8. Radiographs, including bite wings and
periapical views, should be evaluated for
:periapical and furcation pathosis, resorptive
defects, and pulpal calcification resulting from
trauma or previous restorations.

12. • Clinical evidence indicates that cold
testing with carbon dioxide ice is a
more reliable prognosticator of pulp
status in immature permanent teeth
than electronic testing devices.

13. Teeth that have a history of trauma or previous
restorations or that display pulpal calcification
have a poorer prognosis than teeth showing
only initial caries.
 In the selection of a specific vital pulp
treatment, it is important to consider the
remaining tooth structure and future restorative
plan.
In patients with uncontrolled caries or extensive
loss of coronal structure, in which full coverage
is indicated, pulpotomy rather than pulp capping
is recommended

14. Direct pulp
capping Indirect pulp
capping

15. Indirect pulp capping
• procedure where the deepest layer of the
remaining affected carious dentin is covered
with layer of biocompatible material in order
to prevent pulpal exposure and further
trauma to pulp. (grossman)
• without signs or symptoms of pulp
degeneration.

17. Objective
to preserve the vitality of the pulp by
completely removing the carious infected
dentin
followed by placement of material that
would enable the affected dentin to
remineralize by stimulating the underlying
odontoblasts to form tertiary dentin.

18. do we do
Indirect
pulp
capping
When
Why

19. • When disinfection of residual affected dentin
is accomplished, with a cavity close to pulp
but not penetrating it, and no existing sign of
pulpal inflammation.
• It eliminates the need for more difficult pulp
therapy by arresting the carious process and
allowing the pulp reparative process to occur.
• Patient comfort is immediate.
• Rampant dental caries is ceased when all
carious teeth are treated.

20. Diagnosis
Radiographic
examination
Clinical
examination
History

22. m

23. Clinical procedure
• Can be performed as single or two-step approach.
• First appointment:
- Anesthetize and isolate with rubber dam.
- Using low speed hand-piece with large round burs to
remove the superficial debris and majority of the soft
infected dentin without exposing the pulp.
- - Deepest layer of affected dentin is covered with a
hardsetting calcium hydroxide, and sealed with an
overlying base of reinforced zinc-oxide eugenol
(temporary filling).

24. -The cavity is then not disturbed for 6-8 weeks.
*Second appointment:
- Radiograph is obtained to check pulpal integrity,
and tertiary dentin formation.
- Remove the temporary filling, and check that the
deep brownish red color of affected dentin has
changed to lighter brownish gray color and
harder in nature.
- If there is need to extend or re-do the calcium
hydroxide liner.
- Placement of final restoration, assuming there no
evidence of pulpal irritation.

27. Direct pulp capping
• It is defined as the procedure in which the
exposed vital pulp is covered with a protective
dressing or base placed directly over the site
of exposure in an attempt to preserve pulpal
vitality.

29. • Indications
• Iatrogenic mechanical exposure of the pulp in an
asymptomatic vital tooth with sound dentin at the periphery
• Small carious exposures in an asymptomatic permanent
tooth with an incomplete root formation
• Radiographically there should no thickening of PDL space
and no evidence periradicular lesion.

32. Contraindications
- In cases of carious exposures of primary teeth.
- Large carious exposures in symptomatic
permanent teeth.
- Factors affecting prognosis of direct pulp
capping:
*Size of exposure.
*Area of exposure.
*Micro leakage.
• Source of exposure (Carious vs Mechanical).
• * Treatment plan.

33. CI

34. How to detect mechanical pulp
exposure
• - Heat: using a rotary instrument in close
proximity to the pulp with out the use of water
coolant might lead to over heating the pulp and
hence cause pulpal damage.
• - Pressure: exerting large amount of pressure on
a thin pulp floor might cause exposure of the
pulp.
• - Damage to the pulp tissue while cleaning cavity.
• Hemorrhage: seeping of blood from the cavity
floor is an indication of pup exposure

35. Clinical procedure
• Clean the cavity with chlorhexidine solution.
• First appointment:
• Anesthetize and isolate with rubber dam.
• Rinse with anesthetic or sterile saline.
• using a sterile cotton pellet control the bleeding.
• Mix the capping agent & apply it to exposure
site.
• Temporize and observe for 5-10 days

37. Pulp capping Material
• 1- Calcium Hydroxide Ca(OH)2.
• 2- Mineral Trioxide Aggregate MTA.
• 3- Tri-calcium phosphate.
• 4- Bioaggregate.
• 5- Biodentin
• 6- Bonding systems.

38. Ideal properties of a pulp capping
agent - Maintain pulp vitality.
• - Stimulate reparative dentin formation.
• - Bactericidal or bacteriostatic, able to provide
bacterial seal.
• - Adhere well to dentin and restorative material.
• - Resist the forces under restoration for lifetime.
• - Sterile.
• - Radio opaque.

39. Calcium Hydroxide:
• - Its the most common direct-pulp capping
agent.
• - Antibacterial and disinfects the superficial
pulp.
• - Has a high PH about 12.5.
• e.x of calcium hydroxide products are Dycal,
Pulpdent.

41. The drawbacks of CH include:
A. weak marginal adaptation to dentin,
B. degradation and dissolution over time
C. primary tooth resorption
* Histologically, CH demonstrates cytotoxicity
in cell cultures and has been shown to
induce pulp cell apoptosis

42. Mineral Trioxide Aggregate (MTA):
• Composed of :
• - Tricalcium silicate.
• - Dicalcium silicate.
• - Tricalcium aluminate.
• - Tricalcium alumino ferrite.
• - Bismuth oxide.
• - Traces of free crystalline silica.
• - Other traces constituents included calcium
oxide, free magnesium oxide, potassium and
sodium sulphate compounds.

43. Properties of MTA
• - Low or no solubility.
• - PH value after mixing is 10.2 and rises to 12.5
after 3 hours.
• - Antibacterial effect.
• - Induces pulpal cell proliferation.
• - Stimulation of mineralized tissue formation.

44. • MTA activates the migration of progenitor
cells from the central pulp to the injury site
and promotes their proliferation and
differentiation into odontoblast-like cells
without inducing pulp cell apoptosis.

46. • Advantages of MTA over CH:
• - Rapid cell growth promotion in vitro.
• - Greater ability to maintain the integrity of
pulp tissue
• - Thicker dentinal bridge, less inflammation,
less hyperemia and less pulpal necrosis.
• - Induce the formation of dentin bridge at a
faster rate.
• - High ability to resist the penetration of
microorganisms Disadvantages of MTA over
CH: - Limited antibacterial effect.

47. Tri-calcium phosphate
• - Bone regeneration procedures (promotes
effects on hard tissue formation by
osteoblasts)
• - Studies showed that dentinal bridge
formation does take place, by direct
apposition, on the pulpal wall.

48. Bio-Aggregate
- It is a root canal repair material composed of
bio-ceramic nano-particles.
- Indicated as: repair of root perforation repair
of root resorption apexification pulp capping

49. Biodentine
• Composed of : Powder Tri-calcium silicate
(C3S) main core material. Di-calcium silicate
(C2S) second core material. Calcium carbonate
and oxide filler. Iron oxide shade. Zirconium
oxide radiopacifier.

50. Bonding systems
- Sealing potential of resin adhesive systems might
lead to direct pulp capping.
Advantages over CH:
- Less porous dentinal bridges = better seal against
bacterial leakage.
- Less pulpal inflammation.
- Disadvantages over CH: - Lower success rates
especially with inflamed pulp.
- - Lack the inherent hemostatic and bactericidal
properties

51. THE PERMANENT RESTORATION
• The placement and quality of the permanent
restoration can be crucial to the long-term
maintenance of pulp vitality and may be more
significant than the actual pulp treatment
• The aim of the final restoration is to
complement the sealing ability of the pulp
capping material and effectively defined the
pulp from further microbial challenges

52. • The incorporation of adhesive restorative
materials as definitive final restorations
minimizes tooth reduction, encourages
anatomic preservation, and thus provides
better pulpal protection and repair potential
• Permanent restorations for pulp capped
permanent teeth can include composite resins,
bonded or unbonded amalgam restorations,
and cuspal coverage restorations. However, the
more conservative the restorative treatment,
the greater the probability of pulp survival.

53. POSTOPERATIVE FOLLOW-UP AND
RECALL
• After treatment completion, the pulp status
must be assessed periodically to ensure
• 1. continued pulp vitality
• 2. normal function,
• 3. apical closure immature teeth.
• Radiographic evaluation and cold testing
most accurately assess continued pulp health
and are excellent predicators for measuring
survival rates

54. • Recalls can address postoperative sensitivity,
pulpal degeneration or necrosis, and
indications for more extensive endodontic
care, such as pulpectomy and root canal
treatment Radiographic and clinical review
also allows detection of emerging
complications, including recurrent caries,
poor hygiene, restoration failures, cuspal
fractures, and other potentially adverse
conditions

55. • may be preferable to establish recall rates
individually, based on
A. patient need,
B. symptomatology,
C. the caries index,
D. periodontal status,
E. and craniofacial development assessment in
younger patients.

56. Thank You