Vital pulp therapy and regenerative
procedures in endodontics
Minimally invasive endodontics
(Endolight)
• Dentin is a bioactive substance (vital tissue with cells -
odontoblasts)
- complex dentin and pulp – endodont
- reparative and regenerative potential (sclerosis,
reparative dentine)
- diferenciation of new odontoblasts
- growth factors in dentine that are releasing during
carious demineralization can have positive effect on
reparation and regeneration of dental pulp
- pulp vitality can be kept also in case of irreversible
pulpitis
Correlation between clinical picture
and histological finding in dental pulp
• Traditional concept
- There is very small accordance between
clinical symptoms and histological finding in
dental pulp(Seltzer a Bender 1963;Garfunkel a
spol. 1973).
• Contemporary concept
- There is quite good accordance between
clinical symptoms and histological finding in
dental pulp (Ricucci a spol. 2014).
Clinical x histological finding
• In cases of irreversible pulpitis are
pathological changes in coronal part of dental
pulp.
• Dental pulp in the root canal can be
conserved.
Benefits of minimally invasive
approach
• Healing potential and defense mechanism of
dental pulp can be kept.
• Simple procedures – less risk of complication
due to difficult morphology of the root canal
system.
• Less painful
• Lower costs
Classification of pulpitis
Hashem 2015
• Mild reversible pulpitis MRP
- Sensitivity on cold, hot and sweet stimuli
Persistence 15 – 20 s,regress spontaneously
• Severe reversible pulpitis SRP
- Sensitivity on cold, hot and sweet stimuli
- Persists several minutes, analgetics could be necessary
• Ireversible pulpitis IP
- Spontaneous pain, sharp, throbbing,after lying down
- Pain on percussion
New clasification and guidelines for
the therapy
• Initial pulpitis
Increased but not prolongated pain on cold,
absence of spontaneous pain.
Histologically: hyperaemia
Therapy:
Indirect pulp therapy –IPT.
Mostly Indirect pulp capping
New clasification and guidelines for
the therapy
• Mild pulpitis
- Increased reaction on cold, hor and sweet
stimuli, prolongated max 20s, spontaneous
regression.
- Histologically: inflammation of the coronal
part of dental pulp.
Terapy: IPT – indirect pulp therapy.
Mostly intermittent excavation
New clasification and guidelines for
the therapy
• Moderate pulpitis
Clear symptoms, strong pain, very prolongated
reaction on cold, hot (minutes), possible pain on
percussion, spontaneous pain, analgetics have
only partiqal effect.
Histologically: Extensive inflammation affecting
the coronal pulp completely
Thrapie: Coronal pulpotomy –partial/complete
New clasification and guidelines for
the therapy
• Severe pulpitis
Haevy spontaneous pain, very strong pain on
stimuli, sharp, throbbing, strong pain after lying
down, pain on percussion and
Histologically:
Extensive inflammation in dental pulp,
spreading probably into root canal .
Terapie: Deep pulpotomy or pulpectomy
Therapeutic procedures
• Indirect pulp capping
Caries next to dental pulp (caries pulpae
proxima). Carious dentin is possible to remove
almost completely. Decay is deep in small
region. Appr 1 mm2 carious dentin can be left.
Kalciumhydroxide cement,permanent filling
Alternativs: MTA, Biodentine
Formation of tertiary dentine.
Therapeutic procedures
• Intermitent excavation
Large dental caries spreading towards dental
pulp. Big amount of carious dentine.
Hogh risk of perforation
Suspension of calcium hydroxide, temporary
filling for 6 weeks.
Dessication of soft dentine, formation of tertiary
dentine.
lroubalikova@gmail.com 13
Intermitentní exkavace Pulpotomie
14
Nepřímé překrytí materiálem Biodentine
Therapeutic procedures
• Direct pulp capping
• Treatment of small perforation after preparation
or traumatic dental injury in non carious dentine.
Immediately ( 2 – 3hours).
Suspension of calcium hydroxide hydroxidu
vápenatého, calcium hydroxide cement, permanent
filling.
Alternatives: MTA, Biodentine aj.
Dentin bridge formation
Therapeutic procedures;
Pulpotomy
- Coronal
✓Partial ( removal cca 2 mm of dental pulp)
✓Total (removal dental pulp from the pulp
chamber completely)
✓Deep (removal of dental pulp to the root canal
cca 4 mm of dental pulp apically can be left)
Pulpotomy
• Aseptic approach
• Excavation of soft dentine
• Opening of the pulp chamber with sterile bur
or diamond)
Stopping bleeding (2,5% sodium hypochlorite)
Capping using calcium hydroxide or bioactive
cement, permanent filling.
Dentine bridge
Pulpotomy - indication
• Traumatic dental injury – opening of the pulp
chamber - bigger perforation or longer time after
the injury(more than 2 -3 hours)
• Perforation in carious dentine
• Reversible pulpitis
It is necessary to consider
- Age of the patient
- Aseptic approach
Fracture Pulpotomy Calcification, resorption
Apexification
• Permanent teeth with widely open root canal
(immature teeth)
• Calcium hydroxide – temporary root canal filling
Approximately 1 year
- MTA plug
- Combination
MTA x CH comparable results, MTA – hard barrier.
Apexifiction
Disadvantages
Root canal walls remain thin
Risk of the fracture
Time consuming procedure
The tooth usually does not complete the
development
Benefit
Undemanding on equipment
Predictable result
Technique of MTA plug
• High % success -95%. Elongation of root for appr. 6%.
• Disadvantage: highre price and difficult manipulation with
MTA.
lroubalikova@gmail.com 23
MTA plug in the tooth with widela open apex
Regenerative endodontics
Tissue engineering
Growth
factors
Scaffold
Stem cells
Tissue engineering
Regenerative procedure
• Revascularisation, maturogenesis,
revitalisation.
• Nygaard a Ostby 1960 – Observation of
coagulum – ingrowth of fibrotic tissue into the
coagulum, production of cellular cement.
Stem cells
• Multipotential mesenchymal cells,
perivascular - small areas (nikes):
Stem cells
• Apical papilla
• Dental pulp
• Bone marrow
• Periapical inflammation
• Radicular cyst
Growth factors
• Polypeptides or proteines, they bind on
receptors of cells. Local effect
• During dentinogenesis these factors are
produced by odontoblasts and are
incorporated into collagen matrix. These
fractors release during demineralization
(decay, etching) and have influence on tertiary
dentin formation.
Growth factors
• Transforming growth factor beta-1, TGF-β1)
Antiinflammatory effect, accelerates healing,
produced by odontoblasts.
• Basic fibroblast growth factor, bFGF nebo
FGF-2)
Stimululates angiogenesis and induces
differentiation of mesenchymal cells.
• Vascular endotelial growth factor (VEGF)
Angiogenesis, new vessels formation
• Bone morphogenetic proteins, BMP)
BMP osteoinductive and chondrogenic effect.
• Platelet-derived growth factor, PDGF)
Scaffold
• Physical-chemical a biological 3D
microenvironment, where the celle can
multiplay, differenciate and migrate. Transport
of nutrients, oxygen and metabolits. It should
be replaced with regenarated tissue.
Coagulum
• Bleeding into the root canal
• Coagulum – scaffold (fibrin, fibronectin,
growth factors).
• Coagulum must mature – 15 min.
• Alternative rich platelet plasma.
Decontamintion of the root canal
systém - irrigation
• Sodium hypochlorite (1,5%)
- Antimicrobial effekt
- Dissolving of biofilm.
- Chlorhexidin
Bimnding to collagen fibers, this binding
decreases its effect, the survival of stem cells
decreases.
Irrigation
• EDTA
Chelator – effect on inorganic part of hard dental
tissues.
- Removal of inorganic part of the smear layer
- Exposure of collagen fibers and releasing growth
factors
- Inactivation of sodium hypochlorite
- Better adhesion of stem cells of apical papila,
enhanced migration, adhesion and differentiation
of stem cells from dental pulp.
Protection of the coagulum
• Antibiotic pastes
- Minocyklin
- Metronidazol
- Ciprofloxacin
- Amoxicilin
- Cefaclor
- Rifampicin
One- two-three component pasts
Calcium hydroxide
• Ability od dissolution of hard dental tissues
and expose collagen fibers with growth factors
Clinical procedure
1. visit
Launch od endo treatment, establishment of WL,
temporary root canal filling, atb paste or calcium
hydroxide, irrigation NaOCVL 1,5%. Teflon,
temporary filling.
2. visit
Irrigation 17% EDTA, saline solution, induction of
bleeding, stabilization of coagulum. Calciumsilicate
cement, permanent filling(GIC+flow composite)
Indication
• Pewrmanent teeth eith widela open root canal –
alternative to apexification.
Benefit: achievement vital tissue in the toor canal
systém, possibility of growth of the root.
Problems
Technologically difficult
Excellent compliance
Complications: discoloration, calcifiation,
reinfektion, short root.
Materials
Portland cement - MTA
• Ca3Si Calcium trisilicate
• Ca2Si Calcium disilicate
• Ca3Al Calcium aluminate
• Ca4AlFe Calcium aluminoferrite
• CaSO4 Calcium sulphate
• BiO3 Bismuth trioxide
+
Water
lroubalikova@gmail.com 41
Portland cement - MTA
• Pulp capping
• Pulpotomy
• Apexification (no multiple visit)
• Endodontic repair material
• Surgical endodontics
lroubalikova@gmail.com 42
Active biosilicate technology tm
Septodont
Active Biosilicate Technology™ is a proprietary
technology developed according to state-of-the-art
pharmaceutical background applied to the high
temperate ceramic mineral chemistry.
lroubalikova@gmail.com 43
Biodentine - composition
• Powder
Ca3SiO5 (tricalcium silicate C3S) Main core material
Ca2SiO5 (dicalcium silicate C2S) Second core material
CaCO3 (calcium carbonate) Filler
CaO (calcium oxide) Filler
Fe2O3 (iron dioxide) Shade
ZrO2 (zirconium dioxide) Radiopacifier
• Liquid
CaCl2 . 2 H2O Accelerator
Hydrosoluble polymer Water reducing agent
Water
lroubalikova@gmail.com 44
Biodentine – setting reaction
• 2(3CaO.SiO2) + 6H2O 3CaO.2SiO2.3H2O + 3Ca(OH)2
C3S CSH
CSH
C3S
C3S
CSH CSHCa(OH)2
C3SC3S
Ca(OH)2
Ca(OH)2
Ca(OH)2
C3S
C3S
H2O
H2O
H2O
H2O
H2O
H2O
lroubalikova@gmail.com 45
The hardening process results from of the formation of crystals that
are deposited in a supersaturated solution.
Setting time: 9 -12 min.
lroubalikova@gmail.com 46
Bioactivity - angiogenesis
The concentration level of TGF-β1 was enhanced by both
ProRoot® MTA and Biodentine™. Moreover, VEGF and FGF-2
were enhanced in presence of Biodentine™.
Biodentine™ is able to stimulate
angiogenesis, in order to
heal pulp fibroblasts.
lroubalikova@gmail.com 47
Bioactivity – indirect pulp capping
Biodentine™ was able to stimulate a reactionary dentine which is a
naturalbarrier against bacterial invasions. The reactionary dentine
formation stabilises at 3 months, indicating that the stimulation process is
stopped when a sufficient dentine barrier is formed.
Rat model.
Goldberg 2009
lroubalikova@gmail.com 48
Bioactivity – direct pulp capping and
pulpotomy
Biodentine™ is a suitable material for pulpotomy
Pig model.
and direct pulp capping
12 weeks
12 weeks
Biodentin is at least equivalent MTA, better than the others
lroubalikova@gmail.com 49
Overall bioactivity
• Biodentin was well tolerated. Moreover, Biodentine™ was able to
promote mineralisation, generating a reactionary dentine as well as a
dense dentine bridge. These phenomena illustrate the great potential
for Biodentine™ to be in contact to the pulp, by demonstrating its
bioactivity in several indications.
As a conclusion, Biodentine™ is
bioactive.
lroubalikova@gmail.com 50
lroubalikova@gmail.com 51
lroubalikova@gmail.com 52
lroubalikova@gmail.com 53
lroubalikova@gmail.com 54
Indications
• Pulp capping
• Pulpotomy
• Perforation of the root
• Resorption
• Open apex (immature teeth, a
stp.apicoectomy) – apical plug
• Revitalisation
lroubalikova@gmail.com 56
lroubalikova@gmail.com 57
58
Perforation
lroubalikova@gmail.com 59
Apical plug
Apexification and apical plug