CARIES PATOLOGI – VAD HÄNDAR I
TANDEN OCH PULPAN?
Lars Bjørndal DDS, PHD, DR. ODONT Section of
Cariology and Endodontics, University of Copenhagen labj@sund.ku.dk
Treatment concepts
AD 3.
1. There are many different treatment options for the same carious lesion: We need more consensus!
At the moment the caries penetrations depths are
not clearly related to one specific treatment
approach
HOW WOULD YOU TREAT A DEEP
CARIES LESION WHEN EXPECTING
A PULP EXPOSURE ?
Partial excavation Complete excavation Endodontic treatment
Oen et al. 2007 Gen Dent
Responds from practitioners in a Network survey
The goal should be to define specific treatment
modalities for each lesion stage!
Bjørndal et al 2010, EJOS
In case of carious
exposure in deep caries:
Direct pulp capping
versus Partial Pulpotomy
Pulp
Ketac Molar Dycal
Direct capping
Pulp Ketac Molar
Dycal
Partial Pulpotomy
Let ´ ´ ´ ´ s define the deep lesions by
the x-ray
Deep Caries:
Penetrating ¾ into the
dentine but still with a
well-defined dentine
towards the pulp
Extreme deep caries:
Penetrating through
the entire thickness of
the dentine
The outcome of all patients
involved in the excavation trial !
Unexposed
deep
caries lesions
Pulp survival
rate:
88.8%
Cariously
exposed
pulps
Pulp survival
rate:
32.8%
Area of Cariology and Endodontics
Direct pulp capping versus
partial pulpotomy
Pulp Capping Trial N = 58
Treatment visit: Direct Pulp Capping N = 27
1. month control visit N = 25
At 1-yr follow-up N = 9 Pain N = 11 Lost N = 5
Pain N = 2
Treatment visit: Partial Pulpotomy
N = 31
1. month control visit N = 26
At 1-yr follow-up N = 13 Pain N = 11 Lost N = 1AP N = 1
Pain N = 2
Haemostasis N = 2 Lost N = 1
A lot of pain !
Area of Cariology and Endodontics
• Direct pulp caps
•Class I (accident, ie
pulp exposure in
normal dentine)
•Class II (Intended ie
carious dentine)
A suggested classification of
DPC:
• Direct pulp caps
•Class I (accident, ie
pulp exposure in
normal dentine)
• Class II (Intended ie carious
dentine)
A suggested classification of
DPC:
• The exposure has occurred
following trauma, preperation,
or as an accidential
exposure of normal
dentine during
excavation of caries
Direct pulp capping
Class I
In other words the caries lesions are not
deep nor extreme deep
X X
• The exposure has occurred following
trauma preperation or as an accident
during excavation of caries
• The pulp is judged to be
clinical healthy
Direct pulp capping
Class I
What is a healthy pulp in clinical terms
• It is vital
• The patient is without subjective pain
• Hemostasis can be expected
Direct pulp capping (Class I)
• The cavity and the pulp exposure are gently flushed with saline in order to remove detritus and to establish a clean non-bleeding pulp wound
• Direct flush at the exposure should be avoided
• Firm pressure with a cotton pellet should be avoided as the removal tends to reactivate bleeding
• Hemostasis should be reach within 5 min.
Direct pulp capping (Class I)
• Pulp capping agent is applied at the exposure site and in contact with the tissue (ex. calcium hydroxide containing base material or MTA) followed by an additional restoration
• A permanent restoration is placed immediately or within a few days in order to prevent secondary bacterial infection
In short accepting the condition for
case selection for the so-called
Class I CAP –
The prognosis is traditionally
expected to be good !
It is very rare that we get information
about the depth of the caries lesions in
clinical studies reporting vital pulp
therapies!
………. is the pulp exposure
performed in sound dentine
or is it carried out within
carious dentine during
treatment of deep /
extreme deep caries
• Direct pulp caps
• Class I (accident, ie pulp
exposure in normal dentine)
•Class II (Intended
ie carious dentine)
A suggested classification of
DPC:
• The pulp exposure is not an
accident
• Stringent protocol using
magnification, caries
detector, high conc. of sodium
hypoclorite and MTA –like
cement
• Deep or Extreme deep caries
(Caries reaching the pulp)
Direct pulp capping
Class II (ad modem Bogen)
J Am Dent Assoc.2008 Mar;139(3):305-15; quiz 305-15. Direct pulp capping with mineral trioxide aggregate: an observational study.
Bogen G, Kim JS, Bakland LK.
Courtesy G . Bogen
• Initial and follow-up states
• Likelihood of teeth transitioning to next health state
• 6 months simulation cycles
• Sequence of events constructed according to current evidence
The Markow model:
• Deeply carious molar with a sensible, nonsymptomatic (ie painless) pulp being exposed during caries excavation
• NO discrimination between carious exposures and
‘accidential’ (sound dentine) exposures
• DPC were restored either by Calcium hydroxid or MTA followed by direct restoration
• RCT (vital pulpectomy) followed by cast coronal restoration
• Caries lesion involved both approximal and occlusal caries
COST BENFITE ANALYSES:
The assumptions for the simulated scenario
using a Markow model:
• Optimal scenario:
• Younger pt (< 40 yrs) occlusal exposure sites in posterior teeth
• Less effective and more costly
scenario:
• Older patients (> 40 yrs) approximal sites in anterior teeth. In particular the time until follow-up treatments was short leading to early need of RCT
Results from the simulation scenario:
Schwendicke & Stolpe 2014 JOE
State transition diagram simulating the lifetime of a tooth
with an exposed, sensible, non-symptomatic pulp
Schwendicke & Stolpe. J Endod 2014
• Optimal scenario:
• Younger pt (< 40 yrs) occlusal exposure sites in posterior teeth
• Less effective and more costly
scenario:
• Older patients (> 40 yrs) approximal sites in anterior teeth. In particular the time until follow-up treatments was short leading to early need of RCT
Results from the simulation scenario:
Schwendicke & Stolpe 2014 JOE
Of course many limitations within a simulating
environment:
• Can’t integrate all clinical parameters
• Does not account for cost caused by pain and loss of patient time
Direct pulp capping versus
partial pulpotomy
Pulp Capping Trial N = 58
Treatment visit: Direct Pulp Capping N = 27
1. month control visit N = 25
At 1-yr follow-up N = 9 Pain N = 11 Lost N = 5
Pain N = 2
Treatment visit: Partial Pulpotomy
N = 31
1. month control visit N = 26
At 1-yr follow-up N = 13 Pain N = 11 Lost N = 1AP N = 1
Pain N = 2
Haemostasis N = 2 Lost N = 1
A lot of pain !
Area of Cariology and Endodontics
Of course many limitations within a simulating
environment:
• Can’t integrate all clinical parameters
• Does not account for cost caused by pain and loss of patient time
• Prof. experience
• The data building up the the simulation is from the start not the high level evidence data!
• Attitudes toward various treatments
• Exposure in sound or carious dentine (unknown)
Of course many limitations within a simulating
environment:
• Can’t integrate all clinical parameters
• Does not account for cost caused by pain and loss of patient time
• Prof. experience
• The data building up the the simulation is from the start not the high level evidence data!
• Attitudes toward various treatments
• Exposure in sound or carious dentine (unknown)
• The general lack of being able to estimate pulp inflammation
• The health care system varies
• Optimal DPC scenario:
• Younger pt (< 40 yrs) occlusal exposure sites in posterior teeth
• Less effective and more costly
DPC scenario:
• Older patients (> 40 yrs) approximal sites in anterior teeth. In particular the time until follow-up treatments was short leading to early need of RCT
Results from the simulation scenario:
Schwendicke & Stolpe 2014 JOE
The goal would be to define specific treatment
modalities for each lesion stage!
DPC Class I
DPC Class II or RCT
Deep/ Extreme deep
