Practical vital pulp treatment: MTA or calcium hydroxide?

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1 Practical vital pulp treatment: MTA or calcium hydroxide? Hal Duncan, Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Ireland NVvE Voorjaarscongres, 2 nd April 2016

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5 Early memories and the Alan Rough effect

6 Saturday morning s pulpal agenda Briefly discuss 4 pulp issues 1. Why keep the pulp? 2. What tissue(s) are we really dealing with? 3. Practical vital pulp treatment 4. Material choice and histological response

7 1. Why maintain the pulp? 100% clinical and 97.5% radiographic success during the first year, and 92.7% success at 3 years. Survival rate at 24 months was estimated to be 82% for carious exposures.

8 The alternative

9 Majority of RCT of poor technical quality Cross-sectional studies The percentage of root filled teeth with AP was 38.3%. AP was significantly more frequently found in root treated, compared with non-root treated, teeth (p <0.001). In 44.3% of the cases, the technical quality of the root canal filling was inadequate. Chong et al. 2014

10 The Alan restorative Rough effect cycle

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12 Clinical decision-making 2 clinical scenarios (Frisk et al. 2013) Case year old patient had a deep carious lesion in tooth 36 Case year old patient had a deep carious lesion in tooth 14. The participants were asked to nominate their treatment of choice: - pulp capping, partial pulpotomy or pulpectomy. Case per cent of the respondents selected pulpectomy Case per cent pulpectomy Female dentists and age group years were predictive of selection of less invasive treatment options. Conclusions: However, Swedish dentists are recommended to elect pulpectomy prior to pulp capping/partial pulpotomy in a cariously exposed pulp in adults.

13 2. What tissues are we dealing with?

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15

16 From Galler et al. 2014

17 Caries: Pulp irritation, antigen recognition by odontoblasts, initially reversible inflammation which drives reparative response. Duncan et al. 2016

18 3. Practical vital pulp treatment What do clinicians need to know? Is the type of exposure significant? Is the size of the exposure significant? Is the age of the patient significant? Is the level of pulpal bleeding significant? Is the material used significant? Is the technique significant? Is the pulp exposure time prior to treatment significant?

19 What are our limitations in diagnosis? Pain history Clinical and radiographic examination Cone beam CT Vitality/sensibility testing Clinical experience Diagnostic challenges

20 Diagnostic challenges How predictable is this assessment? Signs and symptoms offer clues but may mislead Histopathological state of the pulp, traditionally not related to clinical symptoms (Seltzer et al. 1965; Dummer et al. 1980) No symptoms associated with irreversible pulpitis in 14-60% of cases Silent pulp death (Michaelson & Holland 2002, Flores et al. 2007, Fuks et al. 1982)

21 Diagnostic challenges Can we clinically assess pulpal inflammation? Matsuo et al. 1996

22 JOURNAL OF CBCT Results: Methods: Clinical PA radiographs signs and symptoms and CBCT scans suggestive were taken of irreversible of 138 teeth pulpitis in 130 were patients established diagnosed in 44/52 with teeth irreversible and periapical pulpitis. rarefaction was present in 14 teeth. Results: A comparison of the 307 paired roots revealed that AP lesions were present in 10 (3.3%) and Immediate absent in 297 failure (96.7%) occurred pairs of in one roots tooth. when Overall assessed 100% with clinical PA radiography. and 97.5% When radiographic the same success 307 sets during of the roots first were year, assessed and 92.7% with success CBCT scans, at 3 years. AP lesions were present in 42 (13.7%) and absent in 265 (86.3%) paired roots (P <.05). All Conclusions: cases with The periapical present rarefaction study highlights were associated the advantages with improvement of using CBCT in for the detecting periapical AP index lesions, (PAI) score. especially in teeth with symptomatic irreversible pulpitis.

23 Clinical considerations Perforation of the pulp chamber or not? Stepwise excavation Ca(OH) 2 [Dycal] and GI Or direct removal of all caries Cavities re-entered at 8-12 weeks Statistically superior success rate at 1 year stepwise excavation (74%) rather than complete removal (63%) Also fewer exposures

24 Is the type of exposure significant? Traumatic/iatrogenic Carious Clinical considerations 2 days no drop in success, up to 90 days some successful Cvek 1978 Prognostic factors? Pulpal state/symptomatology Bleeding Careful technique

25 What is reported outcome of vital pulp treatment in carious teeth? Barthel et al (Ca(OH) 2 5 years 37%, 10 years 13%) Witherspoon et al (average 19 months: MTA 79%, claimed 90%) Farsi et al (average 1 year: MTA 93.3%) Barrieshi-Nusair & Qudeimat 2006 (2 years: MTA 90%+) Bogen et al (up to 9 years: MTA 97%) Qudeimat et al (average 3 years: Ca(OH) 2 91%, MTA 93%) Mente et al (1-3 years: Ca(OH) 2 60%, MTA 78%) Bjorndal et al (>1 year: Ca(OH) %) Why so low? 1. Mild-moderate pain in pulp exposure group (not further defined) 2. Teeth included if bleeding arrested within 5 minutes 3. Only teeth in which caries excavation during stepwise or complete removal led to exposure

26 Patient-orientated outcome Will it last me a lifetime? How likely is this to work? How much will it cost? Will there be any further costs?

27 Recent literature in vital pulp treatment? Methods: Method: Clinical/radiographic teeth 95 (aged consecutive outcomes years) teeth with categorized of reversible signs 229 indicative teeth as pulpitis (mean normal/reversible of irreversible 42 and months). carious pulpitis Carious pulpitis and or and exposures carious irreversible mechanical pulpwere exposures. pulpitis randomly were divided treated processed into with2 histologically. groups full coronal pulpotomy. Results: Success rates 80.5% MTA and Results: 59% Conclusions: in the Normal/reversible CH Partial group. Full pulpotomy pulpitis in 96.6% young clinical patients using histological with MTA reversible resulted match, pulpitis, inwhile favourable 84.4% either irreversible Conclusions: using treatmentmta outcomes pulpitis The or results for Dycal, of upthis toresulted 2study years. All in indicate favourable successful that up treatment MTA to 73.6 provides months. outcomes better for longterm 2 years. results 1after MTA/ direct Classification 2 CH pulp lost capping all of others pulp up to Conclusions: conditions compared survived. Radiographically The with hasincidence CH. highard Placing chances of tissue a permanent unfavourable of guiding bridge the restoration outcome formed correct in tended 57% immediately therapy of cases. toin be the after higher large direct majority in pulp teeth of capping with cases. pulp is recommended. exposure areas larger than 5mm 2. (icc

28 Immediately restore, inform and review Pulp cap, partial or full pulpotomy?

29 Materials What materials are used? Calcium hydroxide Mineral Trioxide Aggregate (MTA) Resin-based-composite Ledermix Biodentine Experimental

30 How significant is the material? Randomised controlled human pulp capping trial comparing MTA and Ca(OH) 2 [Dycal]

31 MTA: 1 week

32 Dycal: 1 week

33 MTA: 3 months

34 Dycal: 3 months

35 Study conclusions MTA is clinically easier to use as a direct pulp capping agent and results in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal. Therefore, MTA or equivalent products should be the material of choice for direct pulp capping procedures instead of hard setting calcium hydroxide products.

36 Smith et al. 2016

37 Nair et al. 2008

38 .the so formed hard tissue lacks the tubular features characteristic of genuine dentine. Rather, this process represents a repair process that produces calcified scar tissue by pulpal fibroblasts (Ricucci et al. 2014)

39 What are the limitations of current restorative treatments? Cox et al Nair et al. 2008

40 Current material limitations There were not any recently used endodontic materials that would not induce at least measurable colour changes. For a wide range of materials currently available on the market there is only scarce or no evidence available on their staining ability. (Krastl et al. 2012)

41 We as dentists have to aim to reduce intervention as much as possible To conclude Regenerative biological-based therapies are less invasive and should be a focus a future research in this area Current material choice should be based around calcium silicate cements, however, new targeted materials should be developed In order for regenerative dental solutions to translate to the high street they need to be cost-effective, practical and predictable These therapies will not improve patient experience, unless high quality laboratory and clinical research is completed

42 What are the potential solutions?

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