|
Dentsply
Asia is proud to be associated with many prominent
renowned clinicians and academic researchers
from all over the world. We invite their input
and sharing of clinical experiences with our
readers and those who regularly visit our
website.
The
most recent website update in June features
the clinical experience of Dr. Lou Graham
and his group of clinical associates in
Chicago on the use of Pro-Root in Pulp Capping.
We are very pleased to bring this new information
to you. We also welcome additional input
from other clinicians in the use of Dentsply
products and innovative techniques.
Direct
Pulp Capping
By Dr. Lou
Graham, Chicago, Illinois, May 2003
The
Tooth
- Dentin
and the Pulp are living tissues sealed
by enamel and cementum.
- Over
one's life, secondary dentin is secreted
at a low rate decreasing the pulpal volume.
- Injurious
activities cause the dentin/pulp complex
to secrete tertiary dentin.
- Hebling
(1999) along with others have shown that
with deeper lesions, resin bonding agents
place on the cavity floor, may diffuse
across dentin and reach the pulp, triggering
local inflammatory reactions or enhance
existing inflammation
- Remaining
Dentinal Thickness (RDT) has been shown
to be a major determinant of the severity
of damages caused in the pulp after restorative
procedures with adhesive systems (Gwinnett
and Tay, 1998 and Costa 2000). This is
one specific reason why I believe in basing
out deep restorations.
- About's
in vivo study (2001) showed the RDT was
the most important feature in final pulpal
outcomes.
- Jo
Camp's study (2000) showed the bacterial
remaining in the cavity to be the primary
issue followed by RDT.
- Treatment
near pulpal exposures should thus avoid
resin based treatments and incorporate
bases that have antibacterial properties.
Be cautions, because some glass ionomers
can also cause inflammatory reactions.
Essential features to Successful Pulp Capping
- Self
healing capacity of the pulp
- Absence
of bacteria
- Proper
hemorrhage control
ProRoot MTA - Root Canal Repair Material
Figure
1: ProRoot MTA from Dentsply Tulsa
Research
on Sealability showed that MTA provides
a better apical seal as root-end filling
material than amalgam, IRM, and Super EBA
(Fisher, E. et al., JOE Vol 24 (3), March
1998, pp 176-179)
Benefits
- Allows
normal healing response
- Allows
formation of new cementum
- Allows
formation of new dentin
- Least
leakage
Uses
- Pulp
Capping
- Pulpotomy
- Furcation
Perforation
- Extra-Radicular
perforation repair
- Apexification
- Surgical
root repair
- Internal
resorption repair
Figure
4 |
Figure
5 |
Figure
6 |
Figure
7 |
Usage
Notes
- Thoroughly
disinfect the area
- I
utilize Sodium Hypochlorite x 1 minute
(not too wet)
- I
utilize Superoxyl (not too wet) to stop
any hemorrhage for 1 minute
- I
actually open up minor exposures so I
can pack in the material with 1/4 round
bur
Mixing
- Open
a single pouch
- Instructions
recommend a full pouch, I can recommend
a half pouch and seal the material in
a dark container.
- Mix
with the water ampule (sterile water)
provided and get to a creamy consistency
- I
place with a perio-probe and condense
with a condenser. I use a micro-brush
to remove excess moisture
- Approximately
5 - 15 minutes' working time and 4 - 6
hours' setting time.
Figure
8: Following the instructions will
provide you with a material wth a
creamy consistency. |
Clinical
Experiences
- Pulp
Cap asymptomatic teeth
- Transient
cold sensitivity is not a contraindication
- 62
vital pulp caps in our group in 3 years
have been carried out
- 52
patients have continued post op follow-ups
- 2
have required endo (both patients did
not have a rubber dam on due to circumstances)
Size of Exposure
- The
size of the exposure can be 0.5 mm (the
tip size of a perio probe) to 4 mm with
the same success
- Pin
point exposures may
not
be exposed to enough material to create
tertiary dentin
Figure
9: Patient came in with an asymptomatic
upper bicuspid, for replacement of an
old amalgam with leaking margins. Patient
foretold of proximity to the nerve and
had a 45 minute appointment. Exposure
of buccal pulp horn. |
Figure
10: Placement of superoxyl pellet followed
by sodium hypochloride pellet, not heavily
soaked, placed on the exposure for 60
seconds each. This is the weak link
in therapy. CO2
laser therapy works by evaporating the
coronal tissue, sterilizes the area,
coagulates the area and carbonizes the
wound (scab). |
Laser
Therapy
- The
CO2 laser showed
a 89% success versus a 68% success versus
Ca(OH)2 therapy
- The
following up was up through 1 year
- 100
direct asymptomatic pulp caps in each
group
- Size
of the lesions was 0.1 mm to 1.5 mm and
obviously as stated this can affect success
- Ca(OH)2
was placed over the pulp cap
Figure
11 |
Figure
12: Placement of ProRoot over the non-bleeding
exposure. Utilizing the tip of the periodontal
probe to place the material and a microbrush
to absorb excess moisture. Wait 5-10
minutes for initial set. |
|
Figure
13
|
Figure
14
|
|
Figure
15: Patient returned 2 weeks later
with an asymptomatic tooth. Temporary
was removed, tublicid was used to
cleanse the preparation and remove
excess material. Sectional matrix
band, etched and bonded, hybrid layer
shown.
|
Figure
16
|
|
Figure
17
|
Figure
18: Patient presented for 1.5 hour
appointment to replace carious old
amalgams on numbers 14 and 15. Patient
understood the depth of the previous
restorations and the potential for
root canal treatment.
|
|
Figure
19
|
Figure
20: 15 minutes after place- ment,
the material has its preliminary set.
|
|
Figure
21
|
Figure
22: A resin modified glass ionomer
cement, Vitrebond, was placed over
the area, excess removed and then
the restoration was etched and bonded.
|
|
Figure
23
|
Figure
24
|
|
Figure
25: Upper 2nd molar was pulp capped
12 weeks prior to final impression
for gold onlay.
|
Figure
26: Final restoration seated into
place. The old amalgams could have
been replaced at the time of the restoration
but the decision was to leave the
remaining ridge and can always be
restored with a conservative bonded
restoration.
|
-END-
|
 |
|
