**Conservative Pulp Treatment**
**W/Prof. Paul V. Abbott AO**
---
**Conservative Pulp Treatment**
**Prof. Paul V. Abbott AO**
*BDSc, MDS, FRACDS(Endo), FPFA, FICD, FADI, FICD, FACD, FIADT*
Specialist Endodontist
Winthrop Professor of Clinical Dentistry
UWA Dental School
The University of Western Australia
---
**Some Treatment Dilemmas**
- **Pulp Exposures**
- → Trauma
- → Caries
- **When to do endodontic treatment?**
- **What are the alternatives?**
- **What materials should we use?**
---
*DMD 3rd Year - 2022*
*Page 1*
# **Conservative Pulp Treatment**
## **Some Treatment Dilemmas**
> [!info]
> The primary dilemma for clinicians is deciding between performing a root canal treatment or attempting a more conservative pulp-preserving procedure. This decision is influenced by a variety of factors related to the tooth, the injury, and the patient's restorative needs. The goal is to choose the treatment that offers the best long-term prognosis for the tooth.
- **Pulp Exposures**
- Trauma
- Caries
- **When to do endodontic treatment?**
- **What are the alternatives?**
- **What materials should we use?**
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
### **Some Treatment Dilemmas**
- **Pulp Exposures**
➔ Trauma
---
### **Pulp Exposures**
➔ Trauma
- **When to do endodontic treatment?**
- **Main factors to consider:**
➔ Diagnosis of pulp status
- Normal pulp
- Pulpitis - reversible or irreversible
- Necrosis - with or without infection
- Pulpless + infected
---
DMD 3rd Year - 2022
Page 2
## **Pulp Exposures from Trauma**
> [!info]
> A pulp exposed due to a complicated crown or crown-root fracture is typically normal, healthy tissue. The management of such an exposure depends on several critical factors.
### **Main factors to consider:**
- Diagnosis of pulp status
- Normal pulp
- Pulpitis - reversible or irreversible
- Necrosis - with or without infection
- Pulpless + infected
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Pulp Exposures**
→ Trauma
→ When to do endodontic treatment?
**Main factors to consider:**
→ Diagnosis of pulp status
→ Stage of root development
○ Fully developed
○ Incompletely developed
---
**Incompletely Developed Teeth**
**AIM:** Always wait for pulp revascularisation
- Allows further root development
- Improves long-term prognosis of tooth
---
DMD 3rd Year - 2022
Page 3
- Stage of root development
- Fully developed
- Incompletely developed
### **Incompletely Developed Teeth**
**AIM:** Always wait for pulp revascularisation
- Allows further root development
- Improves long-term prognosis of tooth
> [!example] Clinical Example
> A study by Cvek (1992) demonstrated a direct correlation between the stage of root development and the frequency of root fractures, with the most immature teeth being the most vulnerable. A case was presented where premature root canal treatment on two very immature avulsed incisors resulted in a poor outcome. While one tooth was partially saved, the other had to be extracted due to a lack of further root development, highlighting the critical importance of attempting to preserve the pulp in such cases.
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Factors Affecting Healing after Trauma**
**Stage of Root Development**
---
DMD 3rd Year - 2022
Page 4
![]()
Bar charts showing relationship between pulp revascularization and pulp length after replantation, and frequency of cervical root fractures in Ca(OH)₂ treated luxated incisors related to stage of root development.
### **Factors Affecting Healing after Trauma**
- **Stage of Root Development**
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
DMD 3rd Year - 2022
Page 5
![]()
Radiographic and intraoral images showing dental follow-up at referral, 18 months, and 2 years.
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
DMD 3rd Year - 2022
Page 6
- **Pulp Exposures**
- ➔ Trauma
- **When to do endodontic treatment?**
- **Main factors to consider:**
- ➔ Diagnosis of pulp status
- ➔ Stage of root development
- ➔ Other concurrent injuries
- ○ Luxation
- ○ Avulsion
- ○ etc
<img> P
- Other concurrent injuries
- Luxation
- Avulsion
- etc
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
### **Pulp Exposures**
→ **Trauma**
→ **When to do endodontic treatment?**
### **Main factors to consider:**
→ Diagnosis of pulp status
→ Stage of root development
→ Other concurrent injuries
→ **Size of exposure:**
○ **Small** -v- **Large**
→ **Time since exposure**
○ **Minutes** -v- **Days**
○ **Open for bacteria**
---
DMD 3rd Year - 2022
Page 7
- **Size of exposure:**
- **Small** -v- **Large**
- **Time since exposure**
- **Minutes** -v- **Days**
- **Open for bacteria**
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
**“Cvek Pulpotomy”**
*Table 1. Distribution of 125 permanent incisors with a complicated crown fracture and results 4 years after partial pulpotomy. Each* denotes one case of failure.*
| Size of the exposure (mm) | 1–8 | 9–30 | 31–100 | 101–2160 | Total |
|---------------------------|-----|------|--------|----------|-------|
| 0.5–1.0 | 25* | 22 | 3 | — | 60 |
| 1.1–2.0 | 21 | 10***| 5 | — | 40 |
| 2.1–3.0 | 8 | 6 | 1 | — | 16 |
| 3.1–4.0 | 5 | 1 | 2 | — | 9 |
| **Total** | 63 | 39 | 14 | 9 | 125 |
| **Immature** | 32 | 8 | 6 | — | 55 |
| **Mature** | 31 | 27 | 8 | 9 | 67 |
- **Results: 125 teeth - 6 failures - 95.2% success**
- **Not related to time of exposure: 1 hour - 90 days**
- **Not related to size of exposure: 0.5 - 4.0 mm**
---
**Pulp Exposures**
→ Trauma
→ **When to do endodontic treatment?**
**Main factors to consider:**
→ Diagnosis of pulp status
→ Stage of root development
→ Other concurrent injuries
→ Size of exposure
→ Time since exposure
→ Restorative dental needs
○ ? Post needed
DMD 3rd Year - 2022
Page 8
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
DMD 3rd Year - 2022
Page 9
- **Pulp Exposures**
→ Trauma
- When to do endodontic treatment?
- **Main factors to consider:**
+ Diagnosis of pulp status
+ Stage of root development
+ Other concurrent injuries
+ Size of exposure
+ Time since exposure
+ Restorative dental needs
![]()
Radiographic and intraoral images showing pulp exposures and associated dental trauma.
### **Comprehensive List of Factors for Consideration**
- Diagnosis of pulp status
- Stage of root development
- Other concurrent injuries
> [!warning]
> The presence of other injuries, such as luxation, significantly impacts pulp survival. The more severe the concurrent injury (e.g., intrusion, lateral luxation), the lower the chance of pulp survival, especially in teeth with closed apices.
- Size of exposure
- Time since exposure
- Restorative dental needs
- ? Post needed
> [!tip]
> For an immature tooth, a partial pulpectomy might be considered to allow for a post while preserving the apical pulp for further development.
**Conservative Pulp Treatment**
*W/Prof. Paul V. Abbott AO*
---
### **Pulp Exposures**
→ **Trauma**
- *When to do endodontic treatment?*
- *What are the alternatives?*
---
### **Pulp Exposures**
→ **Trauma**
- *When to do endodontic treatment?*
- *What are the alternatives?*
**Options:**
→ **Pulp Capping**
→ **Pulpotomy - Partial, Cervical**
→ **Pulpectomy - Partial**
---
*DMD 3rd Year - 2022*
*Page 10*
![]()
Two clinical images showing traumatized anterior teeth with visible pulp exposure.
![]()
Two clinical images showing traumatized anterior teeth with visible pulp exposure.
## **Alternatives to Endodontic Treatment for Pulp Exposures**
> [!info]
> When root canal treatment is not indicated, several conservative options are available. These procedures are fundamentally similar, differing mainly in the level to which pulp tissue is removed.
### **Options:**
- **Pulp Capping**
- **Pulpotomy - Partial, Cervical**
- ==**Partial Pulpotomy (Cvek Pulpotomy):** Removal of the superficial 2-3 mm of inflamed/contaminated pulp tissue.==
- ==**Full (Cervical) Pulpotomy:** Removal of the entire coronal pulp down to the cervical level, typically used in anterior teeth with extensive fractures.==
- **Pulpectomy - Partial**
- ==Removal of pulp tissue to a deeper level within the root canal, often to accommodate a post while preserving the apical pulp in an immature tooth.==
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
**Pulp Exposures**
➤ Trauma
▪ When to do endodontic treatment?
▪ What are the alternatives?
**Aims - to:**
▪ **Preserve the pulp**
➤ Especially incompletely developed teeth
▪ **Allow further root development**
➤ Improves long-term prognosis
• “Stronger tooth”
• more dentine
DMD 3rd Year - 2022
Page 11
![]()
Diagram illustrating Partial Pulpectomy, Cervical Pulpotomy, Partial Pulpotomy, and Direct Pulp Cap on a tooth cross-section.
### **Aims of Conservative Treatment**
- **Preserve the pulp**
- Especially incompletely developed teeth
- **Allow further root development**
- Improves long-term prognosis
- “Stronger tooth”
- more dentine
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Pulp Exposures**
→ Trauma
- When to do endodontic treatment?
- What are the alternatives?
**Main factor to consider:**
→ Diagnosis of pulp status
- Viable pulp
- Preferably no inflammation
- No necrosis or only surface necrosis at the site of exposure
---
**Healing Frequencies**
→ Exposed pulp after crown fractures
- Pulp Capping → 72 - 81 %
---
DMD 3rd Year - 2022
Page 12
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
**Healing Frequencies**
> *Exposed pulp after crown fractures*
- **Pulp Capping** → 72 - 81 %
- **Partial Pulpotomy (Cvek)** → 94 - 96 %
**Healing Frequencies**
> *Exposed pulp after crown fractures*
- **Pulp Capping** → 72 - 81 %
- **Partial Pulpotomy** → 94 - 96 %
- **Cervical Pulpotomy** → 72 - 79 %
DMD 3rd Year - 2022
Page 13
## **Healing Frequencies of Conservative Treatments**
*Exposed pulp after crown fractures*
- **Pulp Capping**
- ==Placing a material directly onto a small pulp exposure.==
→ 72 - 81 %
- **Partial Pulpotomy (Cvek)** → 94 - 96 %
- **Cervical Pulpotomy** → 72 - 79 %
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Healing Frequencies**
➤ **Exposed pulp after crown fractures**
- **Pulp Capping**
→ 72 - 81 %
- **Partial Pulpotomy**
→ 94 - 96 %
- **Cervical Pulpotomy**
→ 72 - 79 %
*Compare with reported success rates for endodontic treatment:*
**85 - 100%**
---
**Cvek Partial Pulpotomy Technique**
*From: Andreasen et al - 4th edn 2007, 285*
---
DMD 3rd Year - 2022
Page 14
![]()
*24 hours after pulp exposed*
*1 week after pulp exposed*
*Compare with reported success rates for endodontic treatment:*
**85 - 100%**
> [!success] Treatment of Choice
> Given the exceptionally high success rate of the partial pulpotomy (94-96%), it is arguably the treatment of choice when clinically feasible.
## **Cvek Partial Pulpotomy Technique**
*From: Andreasen et al - 4th edn 2007, 285*
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Cvek Partial Pulpotomy Technique**
*Used an abrasive high speed diamond bur with saline coolant*
---
**Cvek Partial Pulpotomy Technique**
*Abrasive diamond - had no tissue damage beyond the wound surface*
---
DMD 3rd Year - 2022
Page 15
- Used an abrasive high speed diamond bur with saline coolant
- Abrasive diamond - had no tissue damage beyond the wound surface
1. ==**Pulp Amputation:** Use a **high-speed diamond bur** with copious water spray to create an abrasive wound. A diamond bur minimizes collateral tissue damage compared to a carbide bur, which tends to tear the pulp. The pulp is removed to a depth of approximately 2 mm.==
2. ==**Hemostasis (Bleeding Control):** Place a cotton pellet moistened with sterile saline over the amputated pulp with gentle pressure for several minutes.==
3. ==**Assessment:** If bleeding stops, it indicates that the remaining pulp tissue is healthy. If bleeding persists, the tissue is still inflamed, and a little more pulp must be removed until hemostasis is achieved.==
4. ==**Pulp Capping:** Once bleeding is controlled, the chosen capping material is placed over the pulp stump.==
5. ==**Restoration:** A base of glass ionomer is typically placed over the capping agent, followed by a final composite resin restoration.==
> [!warning] Note
> It is **not necessary** to re-enter the tooth later to check for a dentine bridge. Success is determined by monitoring the tooth clinically (pulp sensibility tests) and radiographically (evidence of continued root development). A dentine bridge is a byproduct of healing, not a prerequisite for success, and re-entry causes unnecessary trauma.
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Cvek Partial Pulpotomy Technique**
- **Pulp Exposures**
➔ Trauma
- When to do endodontic treatment?
- **What are the alternatives?**
- **Main factors to consider:**
+ Diagnosis of pulp status
+ Stage of root development
+ Other concurrent injuries
+ Size of exposure
+ Time since exposure
+ Restorative dental needs
---
DMD 3rd Year - 2022
Page 16
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
### Pulp Exposures
→ **Trauma**
- When to do endodontic treatment?
- What are the alternatives?
- What materials should we use?
**CHOICES:**
- Calcium hydroxide
- **Corticosteroid / Antibiotic**
- Calcium Silicate-based Materials
---
### Pulp Capping / Pulpotomy Material
**Calcium Hydroxide**
---
DMD 3rd Year - 2022
Page 17
![]()
Image showing dental materials and tools for pulp capping/pulpotomy
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Pulp Capping / Pulpotomy Material**
**Calcium Hydroxide**
- Used for many years
- Long history with good success rates
- Considerable research
- Histological, clinical, radiographic, animals, humans, *in vivo*, *in vitro*, etc
- Consistent findings & results
---
- Typical healing response with Ca(OH)₂
*(Clarke 1970)*
---
DMD 3rd Year - 2022
Page 18
![]()
Diagram showing layers: Ca(OH)₂, DEBRIS, NECROSIS, LYSED BLOOD, DENSE ZONE, CALCIFICATION, PULP
### **Calcium Hydroxide**
- Used for many years
- Long history with good success rates
- Considerable research
- Histological, clinical, radiographic, animals, humans, *in vivo*, *in vitro*, etc
- Consistent findings & results
- ==A **hard-setting** formulation (e.g., Dycal, Life) must be used to provide a stable base for the final restoration.==
- ==The main limitation is the quality of the overlying restoration. If the seal fails, bacteria can colonize the necrotic zone created by the Ca(OH)₂ and lead to pulp infection.==
#### **Typical Healing Response with Ca(OH)₂**
*(Clarke 1970)*
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Typical healing response with Ca(OH)₂**
*(Cvek 1989)*
1 = Necrosis
2 = Calcified tissue
3 = Dentine bridge
---
**Pulp Capping / Pulpotomy Material**
**1963 - Schroeder: Ledermix Cement**
- **C-st: Triamcinolone** - 0.67 %
- **Ab: Demeclocycline** - 2.0 %
- **Calcium hydroxide** - 33.4 %
- **Zinc oxide** - 47.2 %
- **+ Eugenol** - 85% of the liquid
→ Hard-setting base
---
DMD 3rd Year - 2022
Page 19
### **Corticosteroid/Antibiotic Combinations (Ledermix Cement)**
*1963 - Schroeder: Ledermix Cement*
#### **Composition**
- **C-st: Triamcinolone** - 0.67 %
- **Ab: Demeclocycline** - 2.0 %
- **Calcium hydroxide** - 33.4 %
- **Zinc oxide** - 47.2 %
- **+ Eugenol** - 85% of the liquid
- Hard-setting base
> [!note]
> Essentially, it is a zinc oxide-eugenol (ZOE) cement fortified with calcium hydroxide, a corticosteroid, and an antibiotic.
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
**Ledermix cement**
- **Triamcinolone**
- Anti-inflammatory agent
→ 70% released by the end of day 1
→ Rest by end of day 3
(Hume & Kenney - JoE 1981)
- Triamcinolone - 0.67 %
- Calcium hydroxide - 33.4 %
- Zinc oxide-eugenol - 47.2 %
**Ledermix cement**
- **Triamcinolone**
- Anti-inflammatory agent
→ 70% released by the end of day 1
→ Rest by end of day 3
(Hume & Kenney - JoE 1981)
- **NO evidence that it causes necrosis without symptoms**
- Long held misconception about Ledermix cement
- Triamcinolone - 0.67 %
- Calcium hydroxide - 33.4 %
- Zinc oxide-eugenol - 47.2 %
DMD 3rd Year - 2022
Page 20
#### **Component Properties**
##### **Triamcinolone**
- Anti-inflammatory agent
- 70% released by the end of day 1
- Rest by end of day 3
(Hume & Kenney - JoE 1981)
- **NO evidence that it causes necrosis without symptoms**
- Long held misconception about Ledermix cement
> [!info] Debunking a Myth
> The lecture strongly refutes the historical misconception that Ledermix causes asymptomatic pulp necrosis. This belief stemmed from its inappropriate use in the 1960s and 70s on teeth with irreversible pulpitis. The pulp was destined to necrose regardless; the drug merely masked the symptoms temporarily. When used correctly on vital, reversibly inflamed pulps, it is a safe and effective material.
**Conservative Pulp Treatment**
**W/Prof. Paul V. Abbott AO**
---
**Ledermix cement**
**Triamcinolone**
- Anti-inflammatory agent
→ 70% released by the end of day 1
→ Rest by end of day 3
*(Hume & Kenney - JoE 1981)*
- **NO evidence that it causes necrosis without symptoms**
- Long held misconception about Ledermix cement
- Arose from inappropriate use, lack of diagnosis, poor understanding of the disease processes, poor understanding of the pharmacodynamics of the drug, misconception about corticosteroids, unrealistic expectations of the material, etc.
**Ledermix cement composition:**
- Triamcinolone - 0.67 %
- Calcium hydroxide - 33.4 %
- Zinc oxide-eugenol - 47.2 %
---
**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)*
---
**DMD 3rd Year - 2022**
**Page 21**
- Arose from inappropriate use, lack of diagnosis, poor understanding of the disease processes, poor understanding of the pharmacodynamics of the drug, misconception about corticosteroids, unrealistic expectations of the material, etc.
##### **Calcium hydroxide**
- Sedative and promotes dentine repair *(numerous studies)*
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
DMD 3rd Year - 2022
Page 22
---
**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 of Ledermix cement:**
- Triamcinolone - 0.67 %
- Calcium hydroxide - 33.4 %
- Zinc oxide-eugenol - 47.2 %
---
**Eugenol is released by progressive hydrolysis**
Hydrolysis occurs at:
- External surface (saliva)
- Cavity floor (dentinal fluid)
![]()
Diagram showing ZOE diffusion into pulp with concentration gradients (10⁻² M, 10⁻³ M, 10⁻⁴ M), labeled “Anti-bacterial” and “Reduces inflammation”
##### **Zinc oxide - Eugenol**
- ==The eugenol component is sedative and anti-inflammatory at low concentrations. The ZOE base also has antibacterial properties.==
- Anti-inflammatory and anti-bacterial
*(Hume 1984, 1986, 1987; Brannström 1979)*
#### **Release Mechanism**
- Eugenol is released by progressive hydrolysis
- Hydrolysis occurs at:
- External surface (saliva)
- Cavity floor (dentinal fluid)
**Conservative Pulp Treatment**
**W/Prof. Paul V. Abbott AO**
---
**Brännström et al J Prosthet Dent 1979**
**Brännström’s “upside down restorations”**
- Human teeth *in vivo*
---
DMD 3rd Year - 2022
Page 23
#### **Supporting Evidence: Brännström's Studies**
*Brännström et al J Prosthet Dent 1979*
*Brännström’s “upside down restorations”*
- Human teeth *in vivo*
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Brännström et al J Prosthet Dent 1979**
- Human teeth *in vivo*
- **Class V cavities**
- Restored
- Teeth extracted
- Examined histologically
---
**Brännström et al J Prosthet Dent 1979**
- Human teeth *in vivo*
- Class V cavities
- **Silicate restorations**
- No lining
- ? Acid effect on pulp
---
DMD 3rd Year - 2022
Page 24
- **Class V cavities**
- Restored
- Teeth extracted
- Examined histologically
- **Silicate restorations**
- No lining
- ? Acid effect on pulp
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
**DMD 3rd Year - 2022**
**Page 25**
---
**Brännström et al J Prosthet Dent 1979**
- Human teeth *in vivo*
- Class V cavities
- Silicate restorations
– No lining
? Acid effect on pulp
✗ Silicate alone
→ Pulp inflamed
→ Bacteria under restoration & in the tubules
**Brännström et al J Prosthet Dent 1979**
- Human teeth *in vivo*
- Class V cavities
- Silicate restorations
– No lining
? Acid effect on pulp
✓ ZO-E cover
→ No pulp inflammation
→ No bacteria seen
![]()
Diagram comparing silicate alone vs. ZO-E covered silicate restorations in Class V cavities, showing pulp inflammation and bacterial presence with silicate alone, and absence with ZO-E cover.
- **Results:**
- **Silicate alone**
- Pulp inflamed
- Bacteria under restoration & in the tubules
- **ZO-E cover**
- No pulp inflammation
- No bacteria seen
# Conservative Pulp Treatment
W/Prof. Paul V. Abbott AO
DMD 3rd Year - 2022
Page 26
## Brännström’s “upside down restorations”
> **ZO-E prevented entry of bacteria into the cavities**
> *Brännström et al J Prosthet Dent 1979*
---
## Ledermix cement
- **Triamcinolone** - 0.67 %
- **Calcium hydroxide** - 33.4 %
- **Zinc oxide-eugenol** - 47.2 %
### 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)*
- **Conclusion:**
- **ZO-E prevented entry of bacteria into the cavities**
*(Brännström et al J Prosthet Dent 1979)*
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
- **Typical healing response - Ledermix cement**
Schroeder & Triadan 1962; Schroeder 1968, 1972;
Barker & Ehrmann 1969; Barker & Lockett 1971, 1972;
Clarke 1971; Barker 1975; Robertson 1977; Ehrmann 1981; etc.
→ Normal pulp tissue in contact with the cement
→ No inflammatory cells
→ Occasionally a dentine bridge forms
→ Occasionally diffuse calcifications in the pulp
**Is a dentine bridge necessary ??**
**Is it a sign of successful treatment ??**
---
- **Typical healing response - Ledermix cement**
Robertson 1977
---
DMD 3rd Year - 2022
Page 27
#### **Typical Healing Response with Ledermix Cement**
*Schroeder & Triadan 1962; Schroeder 1968, 1972; Barker & Ehrmann 1969; Barker & Lockett 1971, 1972; Clarke 1971; Barker 1975; Robertson 1977; Ehrmann 1981; etc.*
- Normal pulp tissue in contact with the cement
- No inflammatory cells
- Occasionally a dentine bridge forms
- Occasionally diffuse calcifications in the pulp
**Is a dentine bridge necessary ??**
**Is it a sign of successful treatment ??
> [!success]
> Healing often occurs with **normal, non-inflamed pulp tissue** directly in contact with the cement. A dentine bridge is seen less frequently than with calcium hydroxide, and its absence does not indicate failure. Clinical cases demonstrate excellent long-term pulp survival and continued root development in immature teeth treated with Ledermix cement.
**
*Typical healing response - Ledermix cement (Robertson 1977)*
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Human Pulp Reactions to a Glucocorticosteroid-Antibiotic Compound**
Barker BC, Ehrmann EH. Aust Dent J 1969; 14: 104-19
---
**Ledermix Cement**
- indirect pulp cap
---
DMD 3rd Year - 2022
Page 28
**Human Pulp Reactions to a Glucocorticosteroid-Antibiotic Compound**
*Barker BC, Ehrmann EH. Aust Dent J 1969; 14: 104-19*
**Ledermix Cement**
- indirect pulp cap
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
**Ledermix Cement - Partial Pulpotomy**
*Tooth 11*
3 months
18 months
**Ledermix Cement - Partial Pulpotomy**
*Tooth 11*
1 mth
12 mths
2 yrs
3 yrs
DMD 3rd Year - 2022
Page 29
**Ledermix Cement - Partial Pulpotomy**
- *Tooth 11*
- 3 months
- 18 months
- *Tooth 11*
- 1 mth
- 12 mths
- 2 yrs
- 3 yrs
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Ledermix Cement - Cervical Pulpotomy**
*Pre-operative*
*6-months*
---
**Calcium Silicate-Based Materials**
- Examples:
- Mineral Trioxide Aggregate (MTA)
- Biodentine
---
DMD 3rd Year - 2022
Page 30
**Ledermix Cement - Cervical Pulpotomy**
- *Pre-operative*
- *6-months*
### **Calcium Silicate-Based Materials**
- Examples:
- Mineral Trioxide Aggregate (MTA)
- Biodentine
**Conservative Pulp Treatment**
**W/Prof. Paul V. Abbott AO**
---
**ProRoot™ - MTA**
**Mineral Trioxide Aggregate (MTA)**
**Components**
- **Powder**
→ Dicalcium silicate
→ Tricalcium silicate
→ Tricalcium aluminate
→ Bismuth oxide
→ Calcium sulphate dihydrate
→ Other trace elements
- **Liquid**
→ Sterile Water
---
**DMD 3rd Year - 2022**
**Page 31**
#### **ProRoot™ - Mineral Trioxide Aggregate (MTA)**
##### **Components**
- **Powder**
- Dicalcium silicate
- Tricalcium silicate
- Tricalcium aluminate
- Bismuth oxide
- Calcium sulphate dihydrate
- Other trace elements
> [!note]
> MTA is primarily composed of dicalcium silicate, tricalcium silicate, and tricalcium aluminate, which are the main components of **Portland cement**.
- **Liquid**
- Sterile Water
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Mineral Trioxide Aggregate (MTA)**
*Torabinejad & Chivian - JoE 1999*
Monkey incisor - Mechanical exposure
Direct Pulp Cap - With MTA
Hard tissue formation; No inflammation
---
**Mineral Trioxide Aggregate (MTA)**
- **Excellent mechanical properties**
- **But studies have not shown any advantage over Ca(OH)₂**
- **Disadvantages**
- **Difficult to handle the material**
→ Powder + sterile water - ratio critical
- **Very slow setting time** - at least 4 hours
- **Discolouration of the tooth**
→ Especially with the original grey version
→ But also with the later white version
○ Although less severe
---
DMD 3rd Year - 2022
Page 32
![]()
Microscopic image showing MTA, Dentine bridge, Dentine, and Pulp layers in a tooth section
##### **Properties and Performance**
*Torabinejad & Chivian - JoE 1999*
> [!warning] Caution
> While marketed as a
- Monkey incisor - Mechanical exposure
- Direct Pulp Cap - With MTA
- Hard tissue formation; No inflammation
- **Excellent mechanical properties**
- **But studies have not shown any advantage over Ca(OH)₂**
##### **Disadvantages**
- **Difficult to handle the material**
- Powder + sterile water - ratio critical
- ==It is difficult to handle, with a consistency similar to wet sand or concrete.==
- **Very slow setting time** - at least 4 hours
- ==This complicates the placement of an immediate final restoration.==
- **Discolouration of the tooth**
- Especially with the original grey version
- But also with the later white version
- ==This is a significant aesthetic concern for anterior teeth.==
- Although less severe
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Calcium Silicate-Based Materials**
- Examples:
- Mineral Trioxide Aggregate (MTA)
- **Biodentine**
---
**Biodentine**
- Components
- **Powder**
- Tricalcium silicate
- Calcium carbonate
- Zirconium oxide
- **Liquid**
- Calcium chloride
- *Accelerator*
- Water
---
DMD 3rd Year - 2022
Page 33
#### **Biodentine**
##### **Components**
- **Powder**
- Tricalcium silicate
- Calcium carbonate
- Zirconium oxide
- **Liquid**
- Calcium chloride
- *Accelerator*
- Water
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
---
**Biodentine**
- **Advantages**
- Easier to mix and handle than MTA
→ Capsule
- Faster setting time than MTA
→ 10-12 minutes
- Does not discolour the tooth
- Recommended as a “dentine replacement” material
- Can be used as a coronal restorative material
- Excellent mechanical properties
- Pulp cap: excellent pulp responses and dentine bridges
---
**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**
- Calcium Silicate-based Materials
---
DMD 3rd Year - 2022
Page 34
##### **Advantages**
- Easier to mix and handle than MTA
- Capsule
- Faster setting time than MTA
- 10-12 minutes
- Does not discolour the tooth
- Recommended as a “dentine replacement” material
- Can be used as a coronal restorative material
- Excellent mechanical properties
- Pulp cap: excellent pulp responses and dentine bridges
## **Summary of Treatment Dilemmas and Material Choices**
> [!abstract] Summary
> The lecture concludes that for traumatic pulp exposures in vital teeth, conservative pulp treatment is a highly successful alternative to root canal therapy. The choice of procedure depends on factors like root maturity and the extent of the fracture, with the **Cvek partial pulpotomy** showing the highest rates of success.
- **Pulp Exposures**
- Trauma
- Caries
- **When to do endodontic treatment?**
- **What are the alternatives?**
- **What materials should we use?**
### **CHOICES:**
- Calcium hydroxide
- **Corticosteroid / Antibiotic**
- Calcium Silicate-based Materials
**Conservative Pulp Treatment**
W/Prof. Paul V. Abbott AO
DMD 3rd Year - 2022
Page 35
![]()
Black rectangle placeholder, likely a missing or redacted figure.
# **Conservative Pulp Treatment**
> [!info]
> This lecture focuses on conservative pulp treatment, which aims to preserve the vitality of the dental pulp, particularly following traumatic injuries. It contrasts this with pulp exposures caused by caries, which will be discussed in a subsequent lecture. The key distinction is that a pulp exposed by trauma is generally a clinically normal, healthy pulp with a greater capacity for healing compared to a pulp that has been subjected to long-term irritation from caries.
W/Prof. Paul V. Abbott AO
## **Additional instructions**
This lecture contains lots of graphical figures and study results. For grahpical figures omit any mention unless it can be used to add context to the exsiting text. For academic studies, their results should be summarized into 1 or 2 key points maximum (as they often contain unneccessary informat).
[[O10A Conservative Pulp Treatment.pdf#page=1|O10A Conservative Pulp Treatment, p.1]]
[[O10A Conservative Pulp Treatment.pdf#page=2|O10A Conservative Pulp Treatment, p.2]]
[[O10A Conservative Pulp Treatment.pdf#page=3|O10A Conservative Pulp Treatment, p.3]]
[[O10A Conservative Pulp Treatment.pdf#page=4|O10A Conservative Pulp Treatment, p.4]]
[[O10A Conservative Pulp Treatment.pdf#page=5|O10A Conservative Pulp Treatment, p.5]]
[[O10A Conservative Pulp Treatment.pdf#page=6|O10A Conservative Pulp Treatment, p.6]]
[[O10A Conservative Pulp Treatment.pdf#page=7|O10A Conservative Pulp Treatment, p.7]]
[[O10A Conservative Pulp Treatment.pdf#page=8|O10A Conservative Pulp Treatment, p.8]]
[[O10A Conservative Pulp Treatment.pdf#page=9|O10A Conservative Pulp Treatment, p.9]]
[[O10A Conservative Pulp Treatment.pdf#page=10|O10A Conservative Pulp Treatment, p.10]]
[[O10A Conservative Pulp Treatment.pdf#page=11|O10A Conservative Pulp Treatment, p.11]]
[[O10A Conservative Pulp Treatment.pdf#page=12|O10A Conservative Pulp Treatment, p.12]]
[[O10A Conservative Pulp Treatment.pdf#page=13|O10A Conservative Pulp Treatment, p.13]]
[[O10A Conservative Pulp Treatment.pdf#page=14|O10A Conservative Pulp Treatment, p.14]]
[[O10A Conservative Pulp Treatment.pdf#page=15|O10A Conservative Pulp Treatment, p.15]]
[[O10A Conservative Pulp Treatment.pdf#page=16|O10A Conservative Pulp Treatment, p.16]]
[[O10A Conservative Pulp Treatment.pdf#page=17|O10A Conservative Pulp Treatment, p.17]]
[[O10A Conservative Pulp Treatment.pdf#page=18|O10A Conservative Pulp Treatment, p.18]]
[[O10A Conservative Pulp Treatment.pdf#page=19|O10A Conservative Pulp Treatment, p.19]]
[[O10A Conservative Pulp Treatment.pdf#page=20|O10A Conservative Pulp Treatment, p.20]]
[[O10A Conservative Pulp Treatment.pdf#page=21|O10A Conservative Pulp Treatment, p.21]]
[[O10A Conservative Pulp Treatment.pdf#page=22|O10A Conservative Pulp Treatment, p.22]]
[[O10A Conservative Pulp Treatment.pdf#page=23|O10A Conservative Pulp Treatment, p.23]]
[[O10A Conservative Pulp Treatment.pdf#page=24|O10A Conservative Pulp Treatment, p.24]]
[[O10A Conservative Pulp Treatment.pdf#page=25|O10A Conservative Pulp Treatment, p.25]]
[[O10A Conservative Pulp Treatment.pdf#page=26|O10A Conservative Pulp Treatment, p.26]]
[[O10A Conservative Pulp Treatment.pdf#page=27|O10A Conservative Pulp Treatment, p.27]]
[[O10A Conservative Pulp Treatment.pdf#page=28|O10A Conservative Pulp Treatment, p.28]]
[[O10A Conservative Pulp Treatment.pdf#page=29|O10A Conservative Pulp Treatment, p.29]]
[[O10A Conservative Pulp Treatment.pdf#page=30|O10A Conservative Pulp Treatment, p.30]]
[[O10A Conservative Pulp Treatment.pdf#page=31|O10A Conservative Pulp Treatment, p.31]]
[[O10A Conservative Pulp Treatment.pdf#page=32|O10A Conservative Pulp Treatment, p.32]]
[[O10A Conservative Pulp Treatment.pdf#page=33|O10A Conservative Pulp Treatment, p.33]]
[[O10A Conservative Pulp Treatment.pdf#page=34|O10A Conservative Pulp Treatment, p.34]]
[[O10A Conservative Pulp Treatment.pdf#page=35|O10A Conservative Pulp Treatment, p.35]]