Vital Pulp Therapy in

Permanent Teeth
Click to edit Master subtitle style

นศ.ทพ. สุรจ
ั ฉรา
ชัยราช
เลขทะเบียน
06/01/54 vital pulp 11
4813590108
Outline

n Introduction
n Requirements for a successful vital
pulp therapy
n Partial pulpotomy
n Full pulpotomy
n Pulp capping materials

06/01/54 vital pulp 22

Introduction

n Vital pulp therapy: a treatment that

promotes healing of the pulp tissue around
an exposure site (พัชนี ชูวีระ และคณะ, 2547)
n Aim:
¡ To treat reversible pulpal injury by
application of a protective dressing can
protect pulp from additional injury,
thereby facilitating healing and repair
(American Association of endodontics, 1981)

06/01/54 vital pulp 33

Introduction

n Immature permanent teeth:

¡ Maintain pulp vitality by eliminate
bacteria from the dentin-pulp complex
and establish an environment

¡ promote normal development of root

complex
(apexogenesis)
06/01/54 vital pulp 44
Requirements for a successful
vital pulp therapy

1. The pulp is not inflamed

2. Hemorrhage is properly controlled
3. A non-toxic capping material is applied
4. The capping material and restoration
have to seal out bacteria (bacterial-
tight seal)

Swift EJ et al ,
2003
06/01/54 vital pulp 55
Pulp therapy

Reversible Irreversible
pulpitis pulpitis or
necrotic pulp

Vital pulp Closed Open

therapy apex apex

Pulp
Root Root-end
capping
canal closure and
Or therapy obturation
06/01/54 vital pulp Torabinejad
66 et al
pulpotom , 2009
Pulp therapy

Reversible Indirect pulp

pulpitis capping
Direct pulp
capping
Vital pulp
therapy Pulpotomy
(Partial,
full pulpotomy)
Pulp
capping
Torabinejad et al
Or , 2009
06/01/54
pulpotom vital pulp 77
Pulpotomy

The surgical removal of coronal

portion of a vital
pulp as a mean of preserving
vitality of the

Torabinejad et al
, 2009
06/01/54 vital pulp 88
Partial pulpotomy

The surgical removal of a small

diseased of a
vital pulp as a mean of
preserving vitality of

Torabinejad et al
, 2009
06/01/54 vital pulp 99
n Indications:
1. Tooth with traumatic or mechanical or
carious exposures
2. Tooth has no history of spontaneous pain.

3. Tooth has acute minor pain that subsides

with analgesics.
4. Tooth has no discomfort to percussion, no
vestibular swelling and no mobility.
5. Radiographic examination showsFong normal
& Davis,
appearance
06/01/54 of periodontal
vital pulp attachment.
2001 Swift EJ
1010
et al , 2003
Partial pulpotomy
n Procedures

Swift EJ et al ,
2003
06/01/54 vital pulp 1111
Partial pulpotomy
n Recall
¡ Evaluation using EPT, thermal testing,
palpation and percussion tests at 3-4
weeks, 3 months, 6 months,
12 months, and every year thereafter
¡ Radiographs are needed to detect
presense of periapical radiolucencies and
for immature teeth, continued
development of the root
n Prognosis
Swift EJ et al ,
06/01/54 vital pulp 20031212
Full pulpotomy
The surgical removal of a entire
coronal pulp to
the level of canal orifice of a
vital pulp as a
mean of preserving vitality of

Torabinejad et al
, 2009
06/01/54 vital pulp 1313
Full pulpotomy

n Indications:
¡ Similar to those for a partial pulpotomy,
except that the pulp is likely to have
more extensive inflammation

Swift EJ et al ,
2003
06/01/54 vital pulp 1414
Full pulpotomy
n Procedures

similar to partial
Bacterial- pulpotomy
tight seal
Pulp capping except the entire
Normal pulp mass of coronal pulp
tissue is removed,
normally to canal
orifice
Swift EJ et al ,
2003
06/01/54 vital pulp 1515
Full pulpotomy

n Recall
¡ same intervals recommended for a tooth

treated with partial pulpotomy

n Prognosis
¡ A success rate of 90% at 6 months and

78% at 12 months

Swift EJ et al ,
2003
06/01/54 vital pulp 1616
Capping materials for
pulpotomy
n Calcium hydroxide
n Mineral trioxide aggregate

06/01/54 vital pulp 1717

Calcium hydroxide

n White, crystaline
n Dissociate into calcium ions and hydroxyl
ions (high
alkalinity, pH~12.5)
n Used in:
¡ As a paste: Dycal

¡ As a powder/liquid mixture

06/01/54 vital pulp 1818

Calcium hydroxide

n Mineralizationeffect
Antimicrobial
¡ Hydroxyl
Form dentin
ionsbridge
destroy
when
phospholipids
placed in
¡ contact with pulpal
High alkalinity breaktissue
down ionic bond of
bacterial protein
¡ Hydroxyl ions react with bacterial DNA

Witherspoon et
al , 2006
06/01/54 vital pulp 1919
Calcium hydroxide

n Disadvantages
¡ Inability to seal out bacteria
¡ Soften, disintegrate and dissolve overtime
¡ Tunnel defect in dentinal bridges

Swift EJ et al ,
2003
06/01/54 vital pulp 2020
Calcium hydroxide

n Outcomes
¡ Barthel et al, 2000: At 5 and 10 year

follow up, pulp capping of cariously

exposedd teeth result in a failure rate of
44.5% and 79.7%
¡ Teixeira et al, 2001: 41 teeth with carious

pulpal exposure treated pulpotomy and

Ca(OH)2 , healing rate 79%-87%
*** but the healing rate in teeth with et
Witherspoon
pre-existing pain~50% al , 2006
06/01/54 vital pulp 2121
Mineral Trioxide
Aggregate

n Composed of tricalcium silicate, tricalcium

aluminate, tricalcium oxide and silicate oxide

Hydration of
the powder
Colloidal
gel≤ 3 hrs
Solidifies
into hard
structure
06/01/54 vital pulp 2222
Mineral Trioxide
Aggregate

n Mineralization: Induce hard tissue

formation
¡ The process is not known
¡ Holland et al, 1999: theorized that
tricalcium oxide reacts with tissue fluids
to form Ca(OH)2 hard tissue
formation

Witherspoon et al, 2006 and

Witherspoon, 2008
06/01/54 vital pulp 2323
Mineral Trioxide
Aggregate

n Biocompatibility
n Antibacterial effect:
¡ Torabenejad et al, 1995: Antibacterial
effect on some facultative bacteria
¡ High ability to resist the penetration of
microorganism

Witherspoon et al, 2006 and

Witherspoon, 2008

06/01/54 vital pulpTorabenejad and2424

Pariroke, 2010
Mineral Trioxide
Aggregate

n Clinical outcome
¡ Barrieshi-Nusair et al, 2006: Very high
success rate when use MTA for partial
pulpotomy in carious exposed young
permanent first molar
¡ Witherspoon et al, 2006: Used MTA
pulpotomies to treat carious exposed
immature permanent teeth success
rate 92% Witherspoon DE,
2008
06/01/54 vital pulp 2525
Calcium Hydroxide Vs. Mineral
Trioxide Aggregate

n Qudeimat et al, 2007:

¡ Comparing success rate of partial

pulpotomies with treated cariously

exposed permanent by using Ca(OH)2 or
MTA

No statistically significant in the success

¡
Witherspoon DE,
rate between each group (Ca(OH)2 2008 =
06/01/54 vital pulp 2626
Calcium Hydroxide Vs. Mineral
Trioxide Aggregate

n Torabenejad et al, 1996 and Faraco et al,

2001:
¡ MTA has a greater ability to maintain the

integrity of pulp tissue than Ca(OH)2

n Torabenejad et al, 1996 and Aeinehchi et al,
2003:
¡ MTA induce thicker dentin bridge, less

inflammation, less hyperemia and pulpal

necrosis Witherspoon et al, 2006 and
Witherspoon, 2008
06/01/54 vital pulp 2727
Calcium Hydroxide Vs. Mineral
Trioxide Aggregate

n Chacko and Kurikose , 2006:

¡ MTA induce more homogenous and

continuous dentin bridge with less pulpal

inflammation than calcium hydroxide

Roberts HW et
al, 2008
06/01/54 vital pulp 2828
References

n พัชรี ชูวีระ และคณะ. การรักษาเนื้อเยื่อโพรงฟันแบบคงความมีชีวิต

ในฟันแท้ที่ผุทะลุโพรงฟัน (Vital pulp therapy in cariously
exposed permanent teeth) ชม.ทันตสาร. 2547; 25: 15-27
n Tziafas D et al. Designing new treatment strategies in vita
pulp tgerapy. Journal od dentistry. 2000; 28:77-92
n Witherspoon DE, Small JC, Harris GZ. Mineral trioxide
aggregate pulpotomies: a case series outcomes assessment. J
Am Dent Assoc. 2006;137:610–8.
n Roberts HW et al. Mineral trioxide aggregate material use in
endodontic treatment: A review of the literature. Dental
materials. 2008;24:149–164.
n Witherspoon DE. Vital pulp therapy with New materials: New
directions and treatment Perspectives-Permanent teeth. J
Endod. 2008; 34:25-28
n Swift EJ et al. Vital pulp therapy for the mature tooth-can it
work. Endodontic topics. 2003; 5: 49-56
n Horsted-Bindslev P and Lovschall H. Treatment outcome of
06/01/54 vital pulp 2929