Vital Pulp Therapy Endodontic Topics 2002, vol. 2, 24-34

The mechanisms involved in wound healing of pulpal tissue (1) Inflammation (2) CaOH effects (3) Reparative Dentinogenesis (4) Stem Cells (5) Growth Factors

Indirect Pulp Capping

Indications for treatment: Indirect pulp capping is indicted on permanent teeth with immature apices if ALL the following conditions exist:

1 Tooth has a deep carious lesion that is considered likely to result in pulp exposure during excavation

2 No history of subjective pretreatment symptoms

3 Pretreatment radiographs should exclude periradicular pathosis

4 Patient has been fully informed that endodontic treatment may be indicated in the future.

Procedure: Two treatment visits, 6 to 8 months apart. 1st visit; caries biomass is excavated leaving affected dentin adjacent to the pulp. CaOH or MTA is placed over the dentin followed by a base, and the tooth is soundly restored. 2nd visit: the restorative material and the residual caries mass is removed and the tooth restored.

Objectives: (1) to maintain vitality of pulp. (2) Obtain radiographic evidence of root development (3) prevent resorptive defects or accelerated canal calcification as determined by periodic radiographic evaluation. CONT’D▼

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Direct Pulp Capping

Indications for treatment: Direct pulp capping is indicated when all the following clinical conditions exist:

1. Mechanical exposure of a clinically vital and asymptomatic pulp occurs.

2. Bleeding is controlled at the exposure site

3. Exposure permits the capping material to make direct contact with the vital pulp tissue

4. Exposure occurs when tooth is under rubber dam isolation

5. Adequate seal of the coronal restoration can be maintained Patient has been fully informed that endodontic treatment may be indicated in the future

Procedure: A radiopaque capping material is place directly over the surface of vital pulp tissue at the site of the pulp exposure followed by a base. The final restoration is placed over the base. The status of the pulp and periradicular tissues should be assessed through periodic recall exams.

Objective: Try to maintain healthy pulp

Literature support: 80 to 95% success in teeth with no sign of irreversible pulpitis

Haskell, Stanley, -1978 Direct pulp capping treatment: a long term-term follow-upBaume, 1981 - Long term clinical assessment of direct pulp cappingHØrsted, 1985 – A retrospective study of dirct pulp capping with CaOH compounds.

Dentin Bonding agents are NOT as good as CaOH

De Souza, 2001 – Response of human pulps capped with a self-etching adhesive system

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Pulpotomy

Indications for treatment: A pulpotomy may be indicted if ANY of the following clinical conditions exist:

1. Exposed vital pulps or irreversible pulpitis of primary teeth. Primary teeth with insufficient root structure, internal resorption, furcal perforation or periradicular pathosis that may jeopardize the permanent successor are not indicated for pulpotomy procedures

2. As an emergency procedure in permanent teeth until root canal treatment can be accomplished

3. As an interim procedure for permanent teeth with immature root formation to allow continued root development. (apexogenisis)

Procedure: Pulpotomy is the surgical removal of the coronal portion of vital pulp tissue. A biologically acceptable material is placed in the pulp chamber, and the tooth is restored.

Objectives: (1) Obtain sufficient root development for endodontic treatment. An increase in root length may be evident(2) To prevent resorptive defects or accelerated canal calcification as determined by periodic x-rays (3) to prevent breakdown of the periradicular supporting tissues (4) to prevent adverse clinical signs of symptoms.

Literature support: 95% success after direct pulp capping and partial or total pulpotomy

Zilberman, 1989 – Partial pulpotomy in carious permanent molarsMejare, Cvek, 1993 – Partial pulpotomy in young permanent teeth with deep carious lesionsCaliskan, 1995 – Pulpotomy of carious vital teeth with periapical involvementNostrat, 1998 Reparative hard tissue formation following CaOH application after partial pulpotomy in cariously exposed pulps of permanent teeth Cont’dCvek ,1978 - A clinical report on partial pulpotomy and capping with CaOH in permanent incisors with complicated crown fracture 96% success, 3 to 15 year follow-up

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