ALTERNATIVES TO

ROUTINE
ENDODONTIC TREATMENT
BY
PROF. MAGED NEGM
• Alternative to routine endodontic
treatment are:

Vital pulp therapy.

Apexogenesis
&
Apexification.
• Requirements of an ideal material for vital
pulp therapy:

1-Stimulates reparative dentin formation.

2-Maintains pulp vitality.
3- Bactericidal or bacteriostatic.
4-Adheres to dentin.
5-Adheres to restorative materials.
6-Resists forces during restoration placement and during
lifetime of restoration.
.
7-Releases fluoride to prevent secondary caries.
8-Provides bacterial seal.
9-Radiopaque.
10-Sterile.

Researchers have not reached to an ideal

material that fulfills these requirements.
• Vital pulp therapy materials
• Calcium hydroxide (Ca (oH)2):
• Highly alkaline bactericidal +
stimulation of pulpal defense and repair.
• Advantages:
i-Bactericidal.
ii-Neutralizes the lactic acid excreted by
osteoclasts.
iii-Activates alkaline phosphatase enzyme
essential for hard tissue formation.
iv-Calcium ions integral part of the
immunological reaction of the tissues.
• Disadvantages:
i-Poor marginal adaptation.
ii-Dissolution and degradation beneath
restorations.
iii-Failure to provide long-term seal against
microleakage.
iv-Formation of defective dentinal bridges.
v-Induce internal calcification and canal
obliteration.
• Mineral Trioxide Aggregate (MTA):
• Composition:
• Tricalcium silicate, tricalcium aluminate,
tricalcium oxide, tetracalcium aluminoferrite,
silicate oxide, and bismuth oxide which is
added for radiopacity.
• MTA structure similar to Portland cement.
• MTA cement sets in presence of moisture
and blood.
• Advantages:

i- Biocompatible due to alkaline

pH,slow release of Ca ions and small particle
size .

ii- Forms a reactionary layer resembles

hydroxyapatite in structure.

iii-Allows cell attachment to its hydroxyappatite

layer.

iv- Non resorbable.

• v-Induces cell prolifreration which promotes
dentinal bridging.

• vi-Prevents microbial growth (bactericidal).

• vii-Strong bonding with adhesive restorations.

• viii-High compressive strength.

• ix-Superior marginal adaptation

• 1- VITAL PULP THERAPY

Indirect pulp capping.

Direct pulp capping.

Pulpotomy.
• INDIRECT PULP CAPPING:

• Definition:
A technique for avoiding pulp exposure in
treatment of teeth with deep caries.

• Objective:
• To activate the natural protective mechanisms
of the pulp against caries.
• Theory:

• In caries a layer of affected

demineralized dentin exists between infected
dentin and pulp.
• Upon removal of infected dentin the affected
dentin remineralizes.

Odontoblasts form reparative dentin.

• Indication:
• Complete removal of caries may cause pulp
exposure.
• Contraindications:
• Painful teeth.
• Evidence of pulp degeneration.
• Periapical affection.
• Technique:
• Careful diagnosis clinical, radiographic
and vitality testing.
• LA. and rubber dam application.
• Caries removal:

– Remove all caries except those overlying the pulp.

– Remove all caries at the cavity margins.
– A slow-speed large round carbide bur + coolant
removal of deep caries.
– A sharp spoon excavator removal of
caries at the cavo-surface margins.
– No soft carious dentin is left in the cavity.
• MTA is mixed (3:1 MTA : H2O) and carried with
hand instruments or MTA gun.
• MTA paste (wet sand consistency) is patted
down with small moist cotton pellet.
• A layer 1.5mm thick of MTA should cover the
floor of the cavity.
• A circumferential area of 1.5mm around the
cavity margins is kept uncovered.
• Fill the cavity with light-cure glass ionomer
restoration.
• Follow-up and prognosis:
• Clinical and radiographic follow-up and vitality
testing.
• Tooth is re-entered in 6-8 weeks and remaining
carious dentin is removed.
• Caries appears arrested and reparative dentin
formation will allow removal of last layer.
• Tooth should be asymptomatic, free from
periapical changes and normally responding to
vitality tests.
• Success varies from 75% to 95% depending on
proper case selection and treatment.
• DIRECT PULP CAPPING
• Definition:
• Application of a dressing to an exposed pulp to
preserve its vitality.
• Objective:
• To achieve a healthy pulp to initiate dentin
bridge formation & wall off the exposure site.
• Indication:
• Traumatic or carious exposure with no signs of
pulpitis or periapical pathosis.
• Contraindications:
• 1-Irreversible pulpitis.
• 2-Periapical pathosis.
• 3-Profuse bleeding at the exposure site.
• 4-Wide exposure site.
• 5-Periodontally affected teeth, which has
poor blood supply.
• 6-Teeth with pulp calcification.
• 7-Aging dental pulps.
• 8-Primary teeth.
• Technique:
• Similar to the indirect pulp capping technique.
• Recommendations:
• Peripheral caries is removed first before that
of the exposure site.
• Rinse cavity with saline or sterile distilled
water or 2% to 5% NaOcl.
• Bleeding is controlled with a cotton pellet
moistened with sterile saline.
• If bleeding continues for more than 10
minutes pulpotomy is considered.
• Follow up and prognosis:

• Clinical, radiographic evaluation and vitality

testing.
• The final restoration should provide perfect
marginal seal.
• Pulp vitality, clinical and radiographic
examinations at 1,3,6,12,months.
• Teeth should be asymptomatic, pulp maintains
its vitality with no signs of periapical pathosis.

• Successful pulp capping is recorded in

presence or absence of dentin bridge
formation.
• PULPOTOMY
• Definition:
• Partial or total amputation of coronal pulp
tissue, leaving intact the remaining vital pulp
tissues.
• Objective:
• To maintain vitality and health of the
remaining intact pulp tissues.
• Depth of tissue removal determined by
clinical judgement.
• All tissues judged to be inflamed should be
removed to place the dressing on healthy
uninflamed pulp tissues.
• Indications:
• Permanent teeth with vital pulp exposure.
• Primary teeth with vital pulp exposure.
• Contraindications:
• 1-Non restorable teeth.
• 2-Teeth with spontaneous pain.
• 3-Periapical or furcal pathosis.
• 4-Unbleeding exposed pulp.
• 5-Uncontrolled bleeding following
amputation.
• 6-Coronal or apical discharge.
• 7-A primary tooth prior to exfoliation.
• Types of pulpotomy:
• Partial (shallow) pulpotomy (Cvek technique):
• Removal of part of the pulp from pulp
chamber and covering the remaining part with
capping material.
• Full pulpotomy (cervical or total) :
• Total removal of coronal pulp tissues and
covering of healthy pulp tissues in the root
canal.
• Technique:
• Diagnosis, LA. & rubber dam application.
• Removal of the roof of the pulp chamber with
high speed round bur and water cooling.
• Removal of coronal pulp tissues or 1-2 mm
deep with low-speed round bur and coolant.
• This procedure was found to create the least
damage to the underlying tissues.
• Washing of the cavity with saline or
sterile distilled water.
• Dryness with sterile gauze gently placed on
the pulp stumps.
• To control hemorrhage a slightly
moistened cotton pellet is used under
pressure.
• Recommendations:
• Using dry cotton pellet for control of
hemorrhage is contraindicated.
• Cotton fibers will be incorporated into the
blood clot removal will renew bleeding.
• If hemorrhage continues it means
incomplete removal of inflamed tissues.
• In case of total pulpotomy pulp amputation
may be done with sharp spoon
excavator.
• A layer of MTA or Ca(oH)2 is placed over the
amputated pulp.

• A layer of polycarboxylate or glass ionomer

cement is placed over it.

• Access cavity is filled with hard restoration.

• Follow-up & prognosis:
• Prognosis is good as long as follow-up
shows:
• Absence of signs and symptoms.
• Absence of resorption either internal or
external.
• Patients are recalled after 1,3,6,12 months for
follow up.
• Primary teeth pulpotomy
( Formocresol pulpotomy)

• Indication:
• Pulp exposure in primary teeth in which
inflammation or infection is confined to the
coronal pulp.
• Contraindications:

1-Non restorable teeth.

2-Prior to tooth exfoliation.
3-Spontaneous toothache.
4-Unbleeding exposed pulp .
5-Uncontrolled bleeding following amputation.
6-Coronal or apical discharge.
7-Periapical or furcal pathosis.
• Technique:
• Diagnosis, LA & rubber dam application.
• Removal of the roof with high speed
round bur and copious water cooling.
• Removal of the coronal pulp by low speed
round bur & a coolant or sharp excavator.
• Washing with saline or sterile distilled water.
• Control of hemorrhage with lightly moistened
cotton pellet.
• Dryness with sterile gauze.
• A cotton pellet with either full – strength or
diluted formocresol placed 5 min.
• The cotton pellet is removed and a hard
setting ZOE base or ZO powder mixed with
formecresol is placed.
• Coronal permanent restoration.
• Permanent restoration of choice st. st. or
temp. crowns.
• Formocresol does not induce hard tissue
barrier formation.
• Signs of failure of formocresol pulpotomy:

• Internal or external resorption.

• Development of a fistula.
• Development of periapical or furcation
radiolucencies.
• Formocresol:

• Formocresol the most common pulpotomy

medicament used in pediatric dentistry.
• Composition:
• 19% formaldehyde
• 35% cresol
• 15% glycerine
• 31% water
• Cresol potentiates the effect of formaldehyde.
• Mode of action:
• Formocresol surface layer of coagulative
necrosis fixation of pulpal tissues.
• Fixation prevents cell autolysis, destroys
microorganisms and forms a harmless layer.
• Pulpal tissues respond by forming different zones:
1-At the contact area (highest conc.)
fixed and eosinophilic tissues.
2-Next zone poor cellular definition or
necrotic zone.
3-Broad zone chronic inflammatory cells
diffuse apically into normal pulp.
• Untoward systemic effects of formocresol:

• High conc. distributes to liver, heart,

spleen, kidneys, muscles and cerebral fluids.
• Teratogenic effects.

• Mutagenic and carcinogenic potentials.

• However, the debate still goes on regarding its

safety and use in dentistry.
 II.APEXOGENESIS & APEXIFICATION
APEXOGENESIS
• Definition:
Completion of root formation by the help of
vital pulp tissues.
• Objective:
• To maintain a healthy pulp in the root canals
to complete the root formation.
• Indication:
• Incompletely formed roots having vital healthy
pulp tissues.
• Contraindications:

• The same contraindications of pulpotomy.

• Technique:

• The same technique of pulpotomy.

• Follow-up and prognosis:

• Patient is recalled after 1,3,6,12,18&24

months.
• Prognosis is good in case of:

• Absence of signs and symptoms.

• Radiographic evidence of continued root
formation.
• APEXIFICATION
• Definition:
Stimulated root formation and apical closure
technique.
• Objective:
• To activate complete root formation and apical
closure.
• Indication:
• Loss of vitality of a tooth with incompletely
formed root apex.
• Contraindications:

• Severe periapical pathosis.

• Uncontrolled periodontal disease.
• Young patients with debilitating diseases.
• Diagnosis:
• History most of these cases are due to
trauma.
• Pain spontaneous pain denotes pulpal
involvement.
• Visual examination discoloration denotes
necrosis.
• Percussion sensitivity to percussion
denotes periapical inflammation.
• Mobility denotes bone or periodontal loss.
6-Radiographically radiolucency is
normal in maturing apex.

7-EPT. unreliable in maturing apex

8-Thermal tests more reliable.

• Technique:
• LA. & rubber dam application.
• Access cavity and tooth length determination.
• Cleaning and shaping with frequent irrigation
with NaOcl.
• Dry with paper points and seal with temp.
filling.
• When tooth is free from signs and symptoms
of infection reopen.
• Fill the canal with either Ca(oH)2 or
MTA stiff mixes.
• Apply the paste with Lentulo spiral,
amalgam carrier, special syringe or MTA gun.
• Gently pack the paste to the apex.
• Check radiographically and seal with a hard
restoration.
• Follow-up and prognosis:

• Usual time required for complete treatment

6-24 months.
• Periodical recall every 3 months.
• Root canals may need repacking during the
period of treatment.
• Clinical and radiographic evaluation are done
periodically.
• Indications of success:

• Radiographically root elongation and

apical closure.
• Clinically endo. file fails to penetrate
through the apex.
• Histologically repair forms by osteoid
or cementoid barriers.
• Post treatment obturation:
• Remove the medicament and clean the canal.
• Conventional root canal obturation is done.
• Employ the suitable technique for obturation such
as:
1-Custom made gutta percha.
2-Inverted cone.
3-Thermafil technique.
4-Thermoplasticized technique.
 GOOD
THANK YOU
LUCK