**Conservative Pulp Treatment - II**
**Prof. Paul V. Abbott AO**
BDSc, MDS, FRACDS(Endo), FPFA, FICD, FIADT
*Specialist Endodontist*
*Winthrop Professor of Clinical Dentistry*
*UWA Dental School*
*The University of Western Australia*
![]()
UWA Dental School logo and Oral Health Centre logo
# **Conservative Pulp Treatment - II**
**Prof. Paul V. Abbott AO**
BDSc, MDS, FRACDS(Endo), FPFA, FICD, FIADT
*Specialist Endodontist*
*Winthrop Professor of Clinical Dentistry*
*UWA Dental School*
*The University of Western Australia*
> [!NOTE]
> This lecture focuses on the management of pulp exposures in teeth affected by caries, which presents a different challenge compared to traumatic exposures. A pulp compromised by long-standing caries is less likely to recover than a clinically normal pulp in a trauma case. The core of the lecture revolves around the diagnostic dilemmas, treatment options, key clinical studies, and materials used in conservative pulp therapy for carious teeth.
# Some Treatment Dilemmas
- **Pulp Exposures**
- → Trauma
- → Caries
- **When to do endodontic treatment?**
# **Some Treatment Dilemmas**
- **Pulp Exposures**
- → Trauma
- → Caries
- **When to do endodontic treatment?**
- ➤ Irreversible pulpitis
- ➤ Pulp necrosis + infection
- ➤ Pulpless + infected
- **Must consider: Apexification**
- ◆ If open apices in immature teeth
![]()
Radiograph showing teeth with open apices
## **Pulp Exposures**
> [!NOTE]
> The primary dilemma is deciding between root canal treatment and conservative pulp therapy for a tooth with a carious pulp exposure. This decision is entirely dependent on an accurate diagnosis of the pulp's condition.
- Caused by:
- Trauma
- Caries
## **Key Questions & Considerations**
> [!NOTE]
> A correct diagnosis is paramount and requires a thorough:
> - Patient history
> - Clinical examination
> - Radiographs
> - Pulp sensibility tests
- When to do endodontic treatment?
- Irreversible pulpitis
- Pulp necrosis + infection
- Pulpless + infected
- What are the alternatives?
- What materials should we use?
- Must consider: Apexification
- If open apices in immature teeth
## **Treatment Options**
> [!NOTE]
> For cases of reversible pulpitis or a relatively healthy pulp, the conservative options are similar to those for traumatic exposures, but the compromised state of the pulp affects the prognosis.
- Pulp Capping
- Pulpotomy - Partial, Cervical
- Pulpectomy - Partial
- ==(rarely used in these situations, but may be considered for very immature teeth to promote root development)==
**Apexification - Lower First Molar**
Pre-operative
![]()
Radiograph of a lower first molar showing pre-operative condition.
# **Case Study: Apexification - Lower First Molar**
## **Pre-operative**
- ==**Tooth:** Immature lower first molar with considerable caries under a failing restoration.==
- ==**Radiograph:** Shows wide-open apical foramina on both roots and a periapical radiolucency.==
**8 mths - Ca(OH)₂**
## **8 months - Ca(OH)₂**
- ==**Procedure:** After cleaning and shaping the canals (being careful of the open apices), the tooth was dressed with calcium hydroxide (Ca(OH)₂).==
- ==**Observation:** Healing is progressing, but slowly. The radiograph shows that the Ca(OH)₂ paste has partially washed out, highlighting the need for regular changes.==
- ==**Protocol:** It is advocated to change the Ca(OH)₂ dressing every three months to ensure its continued efficacy and to reassess the tooth.==
**18 mths - Ca(OH)₂**
## **18 months - Ca(OH)₂**
- ==**Observation:** Significant periapical bone repair is evident.==
- ==**Clinical Test:** A hard tissue barrier at the apex is confirmed by gently probing with a fine paper point, which comes to a
![]()
Dental radiograph labeled "RCF 2 yrs" showing root canal filling and tooth structure after 2 years
**Recall 2.5 yrs**
![]()
Dental radiograph showing a tooth with a large restoration and two smaller inset images labeled "Recall 2.5 yrs"
## **Recall 2.5 yrs**
- ==**Outcome:** The root canal filling was completed. The gutta-percha appears short of the radiographic apex, but this is because a hard tissue barrier formed at that level, followed by some further root development.==
- ==**Conclusion:** The tooth is stable and has been successfully restored. The case history is crucial to correctly interpret the final radiograph.==
**Some Treatment Dilemmas**
◆ **Pulp Exposures**
→ Trauma
→ Caries
■ *When to do endodontic treatment?*
■ *What are the alternatives?*
◆ **Options:**
→ Pulp Capping
→ Pulpotomy - Partial, Cervical
→ Pulpectomy - Partial
**Pulpotomy of carious vital teeth with periapical involvement**
Çalışkan MK
*Int Endod J* 1995; 28: 172 - 6.
# **Study: Pulpotomy of Carious Vital Teeth with Periapical Involvement**
Çalışkan MK
*Int Endod J* 1995; 28: 172 - 6.
**Method**
- **26 permanent molars**
- *20 lowers, 6 uppers*
- **Inflamed pulps with carious exposures**
- **Periapical involvement**
- *Radiolucency or radiopacity*
Çalışkan 1995
## **Method**
- **26 permanent molars**
- 20 lowers, 6 uppers
- **Inflamed pulps with carious exposures**
- **Periapical involvement**
- Radiolucency or radiopacity
- ==**Diagnosis:** The pulps were considered to have reversible pulpitis.==
**Method**
- 26 permanent molars
- 20 lowers, 6 uppers
- Inflamed pulps with carious exposures
- Periapical involvement
- Radiolucency or radiopacity
- Aged 10 - 24 years
- Followed for 16 - 72 months
- Clinically - examination and re-entered teeth
- Electric pulp test
- Radiographs
Çalışkan 1995
- **Aged 10 - 24 years**
- **Followed for 16 - 72 months**
- Clinically - examination and re-entered teeth
- Electric pulp test
- Radiographs
**Atraumatic Technique**
- Citanest - no vasoconstrictor
- Rubber dam isolation
- Pulp amputation with high speed diamond + sterile saline spray
- Saline + pressure for haemorrhage control
- Calcium hydroxide + distilled water
- ZnO-E and amalgam restoration
Çalışkan 1995
## **Atraumatic Technique**
- Citanest - no vasoconstrictor
- Rubber dam isolation
- Pulp amputation with high speed diamond + sterile saline spray
- Saline + pressure for haemorrhage control
- Calcium hydroxide + distilled water
- ZnO-E and amalgam restoration
**Results**
- **Overall - 92.3 % favourable**
*(n = 26 teeth)*
- **No cases with -**
- Internal resorption
- Pulp canal calcification
- Recurrence of periapical involvement
→ During time of follow-up (up to 6 years)
**Çalışkan 1995**
## **Results**
- **Overall - 92.3 % favourable**
- (n = 26 teeth)
- **No cases with:**
- Internal resorption
- Pulp canal calcification
- Recurrence of periapical involvement
- → During time of follow-up (up to 6 years)
**Results**
- **Overall - 92.3 % favourable**
- **Radiographically -**
- 21 teeth: radiolucencies disappeared
- 3 teeth: radiopacities healed
Çalışkan 1995
- **Radiographically:**
- 21 teeth: radiolucencies disappeared
- 3 teeth: radiopacities healed
**Results**
- **Overall - 92.3 % favourable**
- **Radiographically -**
- 21 teeth: radiolucencies disappeared
- 3 teeth: radiopacities healed
- **Clinically - 24 teeth re-entered after 6-9 mths**
- All had a dentine bridge
- All responded to electric pulp tests
Çalışkan 1995
- **Clinically - 24 teeth re-entered after 6-9 mths:**
- All had a dentine bridge
- All responded to electric pulp tests
# Results
- **Overall - 92.3 % favourable**
- **Radiographically -**
- 21 teeth: radiolucencies disappeared
- 3 teeth: radiopacities healed
- **Clinically - 24 teeth re-entered after 6-9 mths**
- All had a dentine bridge
- All responded to electric pulp tests
- **Unfavourable outcomes - 2 teeth**
- After 2 weeks and 6 weeks
→ Treated endodontically
Çalişkan 1995
- **Unfavourable outcomes - 2 teeth**
- After 2 weeks and 6 weeks
- Treated endodontically
![]()
Radiographic comparison of a dental procedure: Pre-operative view and 3-year follow-up, labeled Fig. 1, with citation "Çalişkan 1995".
**Fig. 2**
**Pre-op**
**4 Years**
Çalışkan 1995
### **Fig. 2**
- **Pre-op**
- **4 Years**
**Fig. 3**
**Pre-op**
**5 Years**
Çalışkan 1995
### **Fig. 3**
- **Pre-op**
- **5 Years**
> [!NOTE]
> These radiographs provided strong evidence that a periapical lesion does not always signify an infected, necrotic pulp.
**Other Cases Reported**
- Moore 1967
- Sapone 1976
- Jordan *et al* 1978
- Foreman 1980
- Moule & Oswald 1983
- Çalişkan 1993
- Çalişkan & Sepetçíoğlu 1993
**Çalişkan 1995**
## **Other Cases Reported**
- Moore 1967
- Sapone 1976
- Jordan *et al* 1978
- Foreman 1980
- Moule & Oswald 1983
- Çalişkan 1993
- Çalişkan & Sepetçíoğlu 1993
> [!NOTE]
> The lecturer notes that while other studies had shown similar results, the Çalışkan study was particularly influential due to its sample size and clear documentation.
**Factors Affecting Outcome**
- Original state of pulp
- Atraumatic technique
- Use of vasoconstrictor
- Extra-pulpal blood clot
- Material used on pulp
- Restorative material used
Çalışkan 1995
## **Factors Affecting Outcome**
- Original state of pulp
- Atraumatic technique
- Use of vasoconstrictor
- Extra-pulpal blood clot
- Material used on pulp
- Restorative material used
- ==**The quality and seal of the final restoration** is a critical factor in preventing bacterial leakage.==
- ==The amount of remaining tooth structure to support the restoration.==
**Major Problem**
- **Diagnosis:**
- **Difficult to distinguish between reversible and irreversible pulpitis**
- History provided by young patients may not be very accurate
Çalışkan 1995
## **Major Problem: Diagnosis**
- **Difficult to distinguish between reversible and irreversible pulpitis**
> [!NOTE] Lecturer's Counterpoint
> While Çalışkan noted this difficulty, the lecturer argues that with good questioning and thorough testing, the distinction is usually not that difficult. Furthermore, the old belief of a poor correlation between clinical and histological diagnoses has been disproven by more recent research (e.g., Ricucci), which shows a high correlation.
- History provided by young patients may not be very accurate
**Major Problem**
- **Diagnosis:**
- **Difficult to distinguish between reversible and irreversible pulpitis**
- History provided by young patients may not be very accurate
- Responses to pulp sensibility tests vary between individuals
- Lack of correlation between clinical findings and the histological state of the pulp
Çalışkan 1995
- Responses to pulp sensibility tests vary between individuals
- Lack of correlation between clinical findings and the histological state of the pulp
**Consider:**
- Chronic pulp inflammation may be limited to the coronal pulp while the apical pulp may still be normal
- Spouge 1973, Grossman 1976, Walton et al 1985, Smulsen & Sieraski 1989
Çalışkan 1995
## **Histological Considerations**
- Chronic pulp inflammation may be limited to the coronal pulp while the apical pulp may still be normal
- Spouge 1973, Grossman 1976, Walton et al 1985, Smulsen & Sieraski 1989
**Consider:**
- Chronic pulp inflammation may be limited to the coronal pulp while the apical pulp may still be normal
- Spouge 1973, Grossman 1976, Walton et al 1985, Smulsen & Sieraski 1989
- Chronic pulpitis with periapical involvement often exhibits normal pulp apically
- Jordan et al 1976, Russo et al 1982, Bender & Mori 1985, Smulsen & Sieraski 1989
Çalışkan 1995
- Chronic pulpitis with periapical involvement often exhibits normal pulp apically
- Jordan et al 1976, Russo et al 1982, Bender & Mori 1985, Smulsen & Sieraski 1989
**Consider:**
- Histological studies show periapical pathosis is not necessarily associated with total pulp necrosis and infection
- **Mitchell & Tarplee 1960, Langeland 1981**
**Çalişkan 1995**
- Histological studies show periapical pathosis is not necessarily associated with total pulp necrosis and infection
- **Mitchell & Tarplee 1960, Langeland 1981**
**Consider:**
- Histological studies show periapical pathosis is not necessarily associated with total pulp necrosis and infection
- *Mitchell & Tarplee 1960, Langeland 1981*
- Some teeth with periapical radiolucencies and normal pulps had only a few inflammatory cells in the apical portion of the pulp
- *Russo et al 1982*
**Çalışkan 1995**
- Some teeth with periapical radiolucencies and normal pulps had only a few inflammatory cells in the apical portion of the pulp
- *Russo et al 1982*
> [!SUCCESS] Key Takeaway
> A periapical radiolucency can be an extension of the inflammatory process from a vital pulp; it does not automatically mean the pulp is necrotic and infected.
**Conclusions**
- Clinical observations of many previous studies have been confirmed
- **The indications for conservative pulp therapy may be greater than previously thought**
- Benefits to the community
- More conservative of tooth structure
- More long term options for the tooth
- Less expensive
- Less time, etc.
Çalışkan 1995
## **Conclusions from Çalışkan (1995)**
- Clinical observations of many previous studies have been confirmed
- **The indications for conservative pulp therapy may be greater than previously thought**
- Benefits to the community
- More conservative of tooth structure
- More long term options for the tooth
- Less expensive
- Less time, etc.
**Conservative Pulp Therapy**
- **Favourable outcome rates between 80 - 96%**
- Cvek 1978
- Haskell et al 1978
- Hørsted et al 1985
- Lim & Kirk 1987
- Stanley 1989
- Çalişkan & Sabah 1992
- Çalişkan 1993
- **Compare with reported rates for favourable outcome of endodontic treatment: 80 - 100%**
- Çalişkan 1995
# **Comparing Treatment Outcomes**
## **Conservative Pulp Therapy**
- **Favourable outcome rates between 80 - 96%**
- Cvek 1978
- Haskell et al 1978
- Hørsted et al 1985
- Lim & Kirk 1987
- Stanley 1989
- Çalişkan & Sabah 1992
- Çalişkan 1993
## **Endodontic Treatment**
- **Compare with reported rates for favourable outcome of endodontic treatment: 80 - 100%**
> [!SUCCESS] Conclusion
> Given the similar success rates, conservative pulp therapy should be the preferred first choice when the diagnosis is appropriate. If it fails, it simply confirms the need for root canal treatment.
**Major Problems**
◆ **Diagnosis**
- Difficult to distinguish between reversible and irreversible pulpitis
◆ **Dentists**
- Existing attitudes and approaches to treatment
- Poor understanding of pulp disease
- Poor understanding of treatment modalities
- Poor understanding of materials
- Often financial considerations dominate the decision making processes
± **Both ways !!**
# **Major Problems in Pulp Therapy**
## **Diagnosis**
- Difficult to distinguish between reversible and irreversible pulpitis
- ==It is also possible, though rare, for the treatment procedure itself to convert a reversible pulpitis into an irreversible one.==
## **Dentist-Related Factors**
- Existing attitudes and approaches to treatment
- ==Outdated beliefs or unfamiliarity with current materials and techniques can lead dentists to default to root canal treatment.==
- Poor understanding of pulp disease
- Poor understanding of treatment modalities
- Poor understanding of materials
- Often financial considerations dominate the decision making processes
- ==Dentists may prefer more expensive treatments, or patients may opt for cheaper ones, sometimes influencing the clinical decision.==
- ± **Both ways !!**
# Some Treatment Dilemmas
- **Pulp Exposures**
- → Trauma
- → Caries
- When to do endodontic treatment?
- What are the alternatives?
- **What materials should we use?**
**CHOICES:**
- Calcium hydroxide
- **Corticosteroid / Antibiotic**
- MTA - Mineral Trioxide Aggregate
# **Materials for Pulp Treatment**
## **Choices**
- Calcium hydroxide
- **Corticosteroid / Antibiotic**
- MTA - Mineral Trioxide Aggregate
**Calcium Hydroxide**
- **Very commonly used material**
- *Well researched and supported*
- **But usually leads to:**
- *Pulp canal calcification, or*
- *Diffuse calcifications throughout the root canal*
→ **Both make future endodontic treatment very difficult, or even impossible**
## **Calcium Hydroxide**
- **Very commonly used material**
- *Well researched and supported*
- **But usually leads to:**
- *Pulp canal calcification, or*
- *Diffuse calcifications throughout the root canal*
- → **Both make future endodontic treatment very difficult, or even impossible**
- ==The dentine bridge it forms can have
- **Typical healing response with Ca(OH)₂**
*(Clarke 1970)*
![]()
Diagram showing layers from top to bottom:
- Ca(OH)₂
- DEBRIS (with red asterisk)
- NECROSIS
- LYSED BLOOD
- DENSE ZONE
- CALCIFICATION
- PULP
### **Healing Response with Ca(OH)₂**
- Typical healing response with Ca(OH)₂
- *(Clarke 1970)*
**Recommendation**
- Success may be increased by using an anti-inflammatory dressing followed by calcium hydroxide
- **Russo et al 1982**
## **Recommendation: Anti-Inflammatory Dressing**
- Success may be increased by using an anti-inflammatory dressing followed by calcium hydroxide
- **Russo et al 1982**
**Recommendation**
- Success may be increased by using an anti-inflammatory dressing followed by calcium hydroxide
- *Russo et al 1982*
- Ledermix cement:
- Triamcinolone - 0.67 %
- Calcium hydroxide - 33.4 %
- Zinc oxide-eugenol - 47.2 %
- Keeps options open for future treatment - if required
- **Ledermix cement:**
- Triamcinolone - 0.67 %
- Calcium hydroxide - 33.4 %
- Zinc oxide-eugenol - 47.2 %
- Keeps options open for future treatment - if required
**Ledermix cement**
**Triamcinolone**
- Anti-inflammatory agent
- 70% released by the end of day 1
- Rest by end of day 3 (Hume & Kenney - JoE 1981)
**Calcium hydroxide**
- Sedative and promotes dentine repair (numerous studies)
**Zinc oxide - Eugenol**
- Anti-inflammatory and anti-bacterial (Hume 1984, 1986, 1987; Brannström 1979)
Composition:
- Triamcinolone - 0.67 %
- Calcium hydroxide - 33.4 %
- Zinc oxide-eugenol - 47.2 %
## **Ledermix Cement**
> [!NOTE]
> This material was developed by Schroeder to combine an anti-inflammatory agent with a hard-setting base in a single application.
### **Composition & Properties**
> [!INFO] Therapeutic Effects
> Ledermix cement provides multiple therapeutic effects:
> - **Short-term anti-inflammatory effect:** From the corticosteroid **triamcinolone**.
> - **Longer-term reparative effect:** From **calcium hydroxide**.
> - **Obtundent/Antimicrobial effect:** From **eugenol** in the ZOE base.
- **Triamcinolone**
- Anti-inflammatory agent
- 70% released by the end of day 1
- Rest by end of day 3 (Hume & Kenney - JoE 1981)
- **Calcium hydroxide**
- Sedative and promotes dentine repair (numerous studies)
- **Zinc oxide - Eugenol**
- Anti-inflammatory and anti-bacterial (Hume 1984, 1986, 1987; Brannström 1979)
### **Full Composition**
- Triamcinolone - 0.67 %
- Calcium hydroxide - 33.4 %
- Zinc oxide-eugenol - 47.2 %
- **Typical healing response - Ledermix cement**
Robertson 1977
### **Healing Response with Ledermix Cement**
- ==**Normal Pulp (e.g., trauma):** Heals with normal, inflammation-free pulp tissue.==
- ==**Carious/Compromised Pulp:** Healing is slightly different, often showing some dentine bridge formation and/or diffuse calcifications throughout the pulp space.==
- Typical healing response - Ledermix cement
- Robertson 1977
**Ledermix Cement**
- *indirect pulp cap*
![]()
Microscopic images showing dental tissue response to Ledermix Cement application, with labeled sections indicating pulp and surrounding structures.
### **Ledermix Cement Application**
> [!EXAMPLE] Case Example
> A case of an indirect pulp cap on a dental student was presented. The tooth was later extracted for orthodontic reasons, and histology showed a completely normal, inflammation-free pulp, demonstrating the material's effectiveness.
- *indirect pulp cap*
![]()
Diagram showing a tooth with a green arrow pointing to the pulp chamber, alongside packaging for "PRO ROOT MTA" root canal repair material.
**Clinical, radiographic and histological analysis of the effects of MTA used in direct pulp capping and pulpotomies of primary teeth**
**Caicedo R, Abbott PV, Alongi DJ, Alarcon MY.**
*Aust Dent J 2006; 51: 297-305.*
# **Study: MTA in Direct Pulp Capping and Pulpotomies**
**Clinical, radiographic and histological analysis of the effects of MTA used in direct pulp capping and pulpotomies of primary teeth**
*Caicedo R, Abbott PV, Alongi DJ, Alarcon MY.*
*Aust Dent J 2006; 51: 297-305.*
**Pulp Treatment with ProRoot™ (MTA)**
![]()
Two dental images showing teeth during pulp treatment with ProRoot MTA material, alongside a product label for ProRoot MTA.
## **Pulp Treatment with ProRoot™ (MTA)**
- ==**Major Disadvantages:**==
- ==**Very long setting time (approx. 4 hours)**, making it clinically impractical for single-visit procedures.==
- ==Potential for **tooth discoloration**, especially in anterior teeth.==
- ==**Procedure:** Due to the long setting time, a temporary restoration must be placed over the MTA, requiring a second appointment for the final restoration.==
**Pulp Treatment with ProRoot™ (MTA)**
![]()
Two clinical images showing teeth during pulp treatment with ProRoot MTA, one displaying the material being placed and the other showing the filled tooth. A small product label for ProRoot MTA is also visible.
**Pulp Treatment with ProRoot™ (MTA)**
![]()
Three clinical images showing dental procedures involving ProRoot MTA application on teeth, with one image displaying a product label for ProRoot MTA.
**Pulp Treatment with ProRoot™ (MTA)**
![]()
Three dental radiographs labeled "Pre-op", "1 mth", and "3 mths" showing progression after ProRoot MTA treatment, with a product box image of ProRoot MTA below.
**Direct Pulp Cap with ProRoot™ (MTA)**
**Hard tissue formation; No inflammation**
![]()
Microscopic images showing hard tissue formation with ProRoot MTA, labeled with D, P, Ca, Vs, and 200X magnification. A small product image of ProRoot MTA is also visible.
### **Direct Pulp Cap with ProRoot™ (MTA) - Outcome 1**
- **Hard tissue formation; No inflammation**
**Direct Pulp Cap with ProRoot™ (MTA)**
**Hard tissue formation;
Chronic inflammation; Micro-abscess**
![]()
Microscopic image showing MTA application with labeled areas: Ca, Mi.Ab, Lin.C, D, P at 40x magnification.
### **Direct Pulp Cap with ProRoot™ (MTA) - Outcome 2**
- **Hard tissue formation;**
- **Chronic inflammation; Micro-abscess**
**Pulpotomy with ProRoot™ (MTA)**
**Hard tissue formation; No inflammation**
![]()
Microscopic images showing hard tissue formation and no inflammation after pulpotomy with ProRoot MTA, labeled with Ca, D, P, Vs, and magnifications (40X, 200X).
### **Pulpotomy with ProRoot™ (MTA) - Outcome 1**
- **Hard tissue formation; No inflammation**
**Pulpotomy with ProRoot™ (MTA)**
**Intra-pulpal calcifications; Some chronic inflammation**
![]()
Microscopic images showing pulp tissue at 100X and 400X magnification with labeled features (D, C, Lin, Ca.P, P) and a ProRoot MTA product box.
### **Pulpotomy with ProRoot™ (MTA) - Outcome 2**
- **Intra-pulpal calcifications; Some chronic inflammation**
- ==These calcifications could significantly complicate any future root canal treatment.==
- **84 first permanent molars**
- **Reversible pulpitis**
- **Carious pulp exposures**
- **Patients aged 7 – 10 years old**
# **Study: MTA vs. Ca(OH)₂ Partial Pulpotomies**
## **Method**
- **84 first permanent molars**
- **Reversible pulpitis**
- **Carious pulp exposures**
- **Patients aged 7 – 10 years old**
**MTA –v– Ca(OH)₂ Partial Pulpotomies**
- **Cvek partial pulpotomy**
- Rubber dam, aseptic technique used
- Ca(OH)₂ (Dycal) or MTA placed on pulp
- Then Vitremer and amalgam
- Reviewed for 2 years
![]()
Clinical images showing pulpotomy site and reference article
- **Cvek partial pulpotomy**
- Rubber dam, aseptic technique used
- Ca(OH)₂ (Dycal) or MTA placed on pulp
- Then Vitremer and amalgam
- Reviewed for 2 years
**MTA -v- Ca(OH)₂ Partial Pulpotomies**
- More unfavourable outcomes when pulp exposure > 5 mm
- Median survival time: 24 months
- No difference between Ca(OH)₂ and MTA
![]()
Pre-op and 2 Yr RC radiographs comparison
## **Results**
- More unfavourable outcomes when pulp exposure > 5 mm
- ==This contrasts with trauma cases, where exposure size is not a significant factor.==
- Median survival time: 24 months
- No difference between Ca(OH)₂ and MTA
> [!CONCLUSION]
> The primary difference between the materials is the poor handling and very slow setting time of MTA, making it clinically less practical.
# Some Treatment Dilemmas
- **Pulp Exposures**
- → **Trauma**
- → **Caries**
- When to do endodontic treatment?
- What are the alternatives?
- **What materials should we use?**
**CHOICES:**
- Calcium hydroxide
- **Corticosteroid / Antibiotic**
- **MTA - Mineral Trioxide Aggregate**
# **Summary: Treatment Dilemmas & Material Choices**
- **Pulp Exposures**
- → **Trauma**
- → **Caries**
- **Key Questions**
- When to do endodontic treatment?
- What are the alternatives?
- ==When is Conservative Pulp Treatment an option?==
- ==A clinically
- **What materials should we use?**
- **CHOICES:**
- Calcium hydroxide
- **Corticosteroid / Antibiotic**
- **MTA - Mineral Trioxide Aggregate**
> [!TIP] The Final Restoration is Key
> After achieving a correct diagnosis, the single most important factor for long-term success is the **quality of the final restoration** and its ability to provide a long-term seal against bacterial leakage. The amount of remaining tooth structure is also critical.
> [!NOTE] Material Choice
> The choice of pulp-capping material plays a role, particularly in the immediate post-operative period. The lecturer's preference is **Ledermix cement** due to its beneficial combination of anti-inflammatory, reparative, and hard-setting properties.
> [!INFO] Prognosis Considerations
> The healing response and outcomes differ between traumatic exposures (normal pulp) and carious exposures (compromised pulp). Most animal research is on normal pulps, making clinical studies on carious teeth, like Çalışkan's, invaluable.
> [!SUCCESS] Final Recommendation
> Conservative pulp treatment is a highly effective and desirable procedure. It should be considered for any tooth without irreversible pulp disease, especially in immature teeth where continued root development is the goal.
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