Management of deep caries and pulp capping Dr. Eason Soo DDS (UKM), MDS Endo (Hong Kong) AdvDipEndodont (Hong Kong), M Endo RCS (Edinburgh)
Lecturer/Clinical Specialist in Endodontics Dept. of Operative Dentistry Faculty of Dentistry, UKM
Clinical case
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Learning outocmes: • • • • • • •
Describe the management of deep carious lesion
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Describe the process at the cellular level when the technique is implemented
• • •
Describe what is achieved at the end of the process
Describe the clinical investigation required for the management Describe the stepwise excavation / 2 stage excavation techniques Define direct and indirect pulp capping Discuss the indications for each technique Describe & perform the clinical procedures for each technique Able to manage pulp exposure and recognise when further intervention is required
List and discuss materials which can be used - previous and current Factors which influences success and failure for each procedures
Knowledge check • Translucent zone (TZ)
• Dark zone (DZ) • Body of the lesion (B)
• Surface zone (SZ)
Deep carious lesion • Pulp assessment • Poor correlation of symptoms with pulpal pathology !
• Transient low grade pain on eating sweet foods : ? early lesion in dentine, pulp normal
• Transient mild pain on hot & cold foods : ? deeper lesion in dentine, pulp normal
• More severe pain lasting/linger after the stimulas has gone : ? pulp pathology
Management of deep carious lesion – without exposing the pulp • Ideally, remove the whole lesion, leaving sound dentine as the base of the cavity – not always the case in daily practice!
• Soft mushy dentine MUST be removed completely • Possible to leave slight softening dentine (structurally intact) if high risk of exposure is anticipated – educated guess
• Indirect pulp capping is placed – remineralization of the
softened dentine & deposition of secondary dentine beneath the lesion
• Then restoration with your choice of dental material – maintaining long term seal is crucial !
• Alternative: Stepwise excavation
Stepwise excavation • Assessment, ? high risk of caries exposure • Remove only the peripheral caries & the majority of caries on the pulpal floor
• Place calcium hydroxide and restore with a well-sealed temporary restoration
• Re-exploration after 6-8 months, remove remaining caries
• The final excavation is often less invasive than expected, as a result of the altered dentinal changes gained during the treatment interval
• Thus, reduce incidence of pulpal exposure & preserving pulpal vitality
Management of deep carious lesion – with a pulp exposure • If the removal of
softened dentine results in an exposure, the whole lesion should be excavated immediately
• Pulpal contamination is most likely & infected dentine should not be left – consider direct pulp capping (pre-op assessment?) !
Treatment options for pulpal exposure: • Direct pulp capping • Pulpotomy, partial pulpotomy/Cvek’s pulpotomy
• Pulpectomy
Treatment options for painful conditions: • ? Wait & see • Temporary restoration • Replacement of restoration • Emergency exposure of the pulp: pulpotomy
• Pulpectomy
• Pulpectomy procedure should be carried out when a pulpal condition is deemed irreversible
• Pulp capping/partial pulpotomy procedure may be carried out when an exposed pulp is healthy or reversibly inflamed
• In a clinical conditions the cut-off point between
irreversibly inflammed and reversibly inflamed is often hard to identify
Cut-off point for pulpectomy !
Pulpal condition
Healthy
Reversibly Irreversibly inflamed inflamed
Direct pulp capping • Procedure in which a
dressing/lining (or restorative material) is placed into direct contact with exposed pulpal tissue
• Carried out following a carious or traumatic exposure
• Calcium hydroxide is
most commonly used
Direct pulp capping : clinical procedure • Remove any blood clot with a sharp excavator
• Establish haemostasis by applying
gentle pressure on the wound with a cotton pellet moistened with chlorhexidine, sterile saline or analgesic solution
• Renew the cotton pellet if necessary & wait for complete haemostasis
• Gently apply capping material e.g.
Ca(OH)2/MTA to the exposure site without firm pressure
• Cover the capping material with a hard-setting cement e.g. GIC
• Restore & seal the cavity with a restoration
Direct pulp capping – evaluation
• After 1 week, evaluate the presence or absence of symptoms • After 6 months, evaluate: • symptoms • reactions to thermal stimuli – ? absent, short, prolonged • sensitivity to EPT – ? positive / negative • Periapical radiograph changes • radiographically verified “bridge” formation • repeat aforementioned procedure at yearly interval • Based on clinical/radiographic findings, continue recalls or commence root canal treatment if indicated
Indirect pulp capping • Essentially where not all carious affected dentine has been
removed & involves placement of a dressing on the deepest dentine
• Some confusion in the literature : term to describe the
situation where stained, demineralized dentine is not removed & a Ca(OH)2 lining placed to stimulate tertiary dentine formation & kill any remaining bacteria
• Alternative term : Ca(OH)2 is used in a similar manner over soft, carious dentine (insufficient evidence, hence should not be performed !)
• see Stepwise excavation
Capping materials & healing patterns
Calcium hydroxide • setting & non-setting form • antimicrobial • high pH ~ 12.5, cauterize tissue & cause superficial necrosis (minor extend), predictable healing
• induce hard-tissue repair
Healing sequence with Ca(OH)2 capping • •
1 day after capping: superficial layer of tissue necrosis & inflammatory cell infiltrates
•
The inflammatory reaction is gradually reduced & a collagen-rich matrix is formed in close relation to the necrotic zone or directly adjacent to the capping material
• • •
In the following week, mineralization of the amorphous tissue start
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Common to have more regular-formed hard tissue contains cell inclusions & tunnel defects (permeable to noxious elements in the oral cavity or highly permeable to bacteria and their elements)
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Thus, less able than primary dentine to protect the pulp from such elements, risk of pulpal infection in the future if microleakage present
First few days thereafter: blood clots are resolved & the tissue is in a process of reorganization
First mineralized tissue is irregular & contains many cell inclusions More dentine-like tissue with tubule is formed with odontoblast-like tissue line the tissue
Calcific barrier
Reparative dentine formation
Other potential capping materials • Dentine bonding agent has been suggested
but its trigger pulpal inflammation and foreign body reaction agains displaced resin particles – should not be used !
• Mineral trioxide aggregate (MTA) : in favor • produce a tissue response similar to that of Ca(OH)2
• set very hard, bacterial tight seal, less risk of dissolution over time
Factors affecting success of direct pulp capping • Age : prognosis better in young then old individual, young teeth react favorably to microbiological & traumatic challenge
• Size & location : the larger the exposure, the less
likely is a successful outcome, exposure over 1 mm in Ø has a very poor prognosis; ?Occlusal, incisal or cervical portion have the similar outcome.
• Contamination with saliva : reduce success rate greatly from bacterial contamination
• Marginal leakage : any leakage can result in bacterial ingress and direct access to the pulp
Clinical case
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7 month review
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