keep doing traditionnaly... as far it may be the safer option!

Currently there is unfourtunately little regards for pulps.....

Vitrebond by 3M is a fluoride releasing glass ionomer. This makes a good bas/liner for preparations that are deep, or close to the nerve. Dycal is a calcium hydroxide liner that works as well. Vitrebond is nice because of the fluoride releasing property. This should help with sensitivity. This can be used as an indirect pulp cap, if deep and not pulp exposure is noted, or as a direct pulp cap if there is a slight exposure of the pulp horn. If used as a direct pulp cap, the patient may ultimately neet root canal therapy if they become symptomatic.If the preparation is shallow it may not be necessary to use a base/liner, but that is the practitioner's choice. Cold sensitivity is not uncommon with resin composite fillings, but it should subside within weeks, possibly a couple months. Hope that helps.

There is little evidence that any liners provide significant benefit. In terms of an exposure, the best solution after a localised pulpotomy is to employ a bio-active material such as MTA or Biodentine. Glass ionomer and calcium hydroxide are irritants to pulpal tissue. Atraumatic and progressive caries removal is the over arching approach, rather than removing caries to 'almost' the pulp, and then wanting to place a a barrier. Hope this helps!

I agree completely with James Field  : "....Atraumatic and progressive caries removal is the over arching approach, rather than removing caries to 'almost' the pulp..."

The best procedures are those driven to let the tooth help himself .... pulpcells belongs to the   high sophisticate tissues   and display extreme living potential. 

james

you are right in saying that CalciumHydroide is an irrtant to pulp. In Pathology we are taught that inflammation and repair go together.  Don't you think  irritation sets up inflammation in the pulp tissue which subsequently heals the it.

When the cavity is shallow, lining is not necessary as thick dentin is the best protective layer to the pulp.

When the cavity is close to the pulp without pulp exposure, I would suggest to apply calcium hydroxide or vitrobond liner. 

when there is pulp exposure, the lining material of choice is MTA but it is expensive material. The alternative is to use CaOH lining followed by Vitrobond  to ensure a good seal and then good temporary material or even better to place a permanent restoration.

Regards

Zakereyya

That sounds ok. Thank you for this piece of info

I  agree with James.  Literature also stated that MTA or Biodentine can be used,

The most important thing is a proper diagnosis to no use irrationally each procedure.

 Dear Dr Mirza

There must be a balance between advantages and disadvantages of chemicals used over the bottom of the cavity in restorative dentistry.

My policy is as follows:

if 1 or 2 mm of tooth structure is prepared no protection is needed.

if the depth of cavity is more than 2 mm a thin layer of dycal covered by a base compatible with a live tooth such as Glass Ionomer are needed. Over them 2 layer of varnish is applied and amalgam is placed in the cavity.

In the case of composite filling, no varnish is indicated.

Dear Dr Alireza

Yes it seems to be a logical approach to be emphasized to undergraduate dental students to follow. But I think still it requires some research to work on the depth of the cavity. Don't you think so?

wel the literature is clear on this. If you look at Kanca's work in the 90's, the problem is not the depth but getting a good seal.. This is true of any pulp issues so the problem is not the material or the depth.  With composites, you get a great seal. No need for a base (yuk) or a liner (yuk yuk) and where I was trained in the 70's , we never placed a liner or base. Last time i did was in 76 when I graduated.

Forget Dycal. Inferior material at best. Does not do what 'they' they do.  IRM or ZOE? toxic to the pulp [see Harold Stanley in the '70's and late 90's; see Law et al from Unv of WA].

To get away from doing Civil War Dentistry, if doing a composite, don't need one even if you are .1 mm from the pulp.  Adhesive blocks tubules in case of any leakage which you would not get any way by bonding with composite.

We teach if you really reallyl really want to sleep better, use a GIC. Won't kill the patient but also won't help them either.  You get a great seal too with it, esp if you use the mandatory conditioner which is a mild poly acrylic acid. BOnds better and get a great seal. But you get one anyway just placing it without conditioning.

In summary, gone are the days of a base and liner. In fact, if you look at the latest info, if it was that deep to begin with, why not do an indirect pulp cap, don't go as deep, place a GIC ,then final restoration. See the AAPD Reference Manual 2014/2015 on this. [American Academy of Pediatric Dentistry]. IPC way to go. No need to take all caries out anymore. Research is clear on this.  I direct you to:

pediatricdentistryfuture.org = great videos on getting out of the old mindset.

For a good review article, see Ranley, about 1996 or 1997.  Lots of the stuff we were taught were passed down over the centruries with NO research to back them up .  They just reached back in 1905 for the closest thing on the table.  Thank God we have better materials.

Hope I helped. Comes up all the time with our dental students.

Lance

Lance Kisby DMD, FASDC, FAAPD, MAGD

i agree with explanation given by Lance Kisy

i also concur with Lance Kisby. thank you for the summary Lance

The recent concept in this regard in the "stepwise caries excavation" -much similar to indirect pulp capping with CaOH.

We are here discussing standardized and recommended techniques for protecting the pulp before placing a definitive restoration.

Dental clinicians have to take different dimensions into consideration while drawing the suitable treatment plan for their patients. Yes step-wise caries excavation is recommended. However, it may involve a number of visits to the dentist and added cost accordingly. 

Regardless of what technique we use, the prime object of any technique is to remove most of the carious lesion if not all of it, and give time and suitable environment for secondary dentin formation which gives healthy protection to the pulp.

I totally agree with Lance Kisby, but the 1st line in the 2nd paragraph of the comment it was written(forget dycal); what about the use of MTA,  BIODENTINE and CEM cement?

Nice to see your answer. Actually, the depth has nothing to do with survival of the pulp. For example, leaving caries behind in Indirect Pulp Caps (IPC), thus very deep preps are done, as close as .25 mm from the pulp has shown to have a better success rate than pulpotomies in primary teeth. The issue is getting a good seal so no oral bacteria gets on thru to below ANY restoration.  We teach our dental students to do IPCs. I personally have not done a pulpotomy in about 8-10 years andwith better and greater success.

See:

Indirect pulp treatment: in vivo outcomes

of an adhesive resin system vs calcium hydroxide

for protection of the dentin-pulp complex Pediatr Dent 24:241-248, 2002

See:

TJ Hilton

Keys to Clinical Success with Pulp Capping: A Review of the

Literature Oper Dent. 2009 ; 34(5): 615–625.

Here is an excerpt from that article:

Removal of caries is one of the most basic activities in dentistry. When caries is deep, everyrestorative dentist is faced with the question of the best way to proceed: is it better to removeall caries regardless of pulpal consequences, or stop and not expose the pulp? Whenpractitioners in a dental PBRN were given a hypothetical scenario that involved thisquestion, only 17% responded that they would stop, leave the remaining caries in place andrestore the tooth.32 This procedure, where caries is allowed to remain adjacent to a vital pulprather than risk pulp exposure, covered with a cavity sealer or liner and restored, is termedan indirect pulp cap. The evidence regarding indirect pulp capping stands in contrast to theresponse of practitioners, however. Several studies show restored teeth with partial cariesremoval have equal success compared to restored teeth with complete caries removal.33–35A number of studies have evaluated the fate of caries lesions in which partial caries removalwas done. Typically, an initial clinical and microbiological assessment of the caries lesion iscarried out, partial caries removal is accomplished and a sealer or liner and restoration isplaced for a period of 4–12 months before the tooth is re-entered and reassessed. Invariably,these studies find that the lesion color has changed from light brown to dark brown; theconsistency goes from soft and wet to hard and dry,s mutans and lacto-bacilli have beensignificantly reduced to a limited number or even zero viable organisms, and the radiographsshow either no change or even a decrease in the radiolucent zone. The type of liner is less important to success than the placement of a well-sealed restoration.20,34,36–41 In addition,partial caries removal significantly reduces the chance of pulp exposure during cariesexcavation.22,42 These findings are confirmed by two thorough systematic reviews thatconcluded the following: partial caries removal reduced the risk of pulp exposure by 98%compared to complete caries excavation in teeth with deep caries; there is no evidence thatpartial caries removal is detrimental in terms of signs, symptoms, pulpitis occurrence orrestoration longevity; there is substantial evidence that complete caries removal is notneeded for success provided the restoration is well sealed.24,43

Darwn:

Good point.

Kanca and others including even Christensen, have shown that you don't need a base. that was my point even made by Kanca 20+ yrs ago.  We tend to do things because someone told them and that person told them who was told by someone else. I think a lot of this base issues is coming from a generation of those using Dycal (i have to wash my mouth out with soap every time i say it.. ha ha) and have just taken that technique and appliled it to present day materials.  Post op pain from deep preps comes from bacterial leakage.  I tell my Pedo residents and dental students, if the cry and whine about not putting in a base like GIC, I finally say: 'OK if it will make you sleep better at night. You won't hurt the patient but you will also not make them any better.

Yes, MTA and BIodentine are great and the standard of care for pulpotomies.

But...........why do a pulpotomy if you can get better results with and IPC!

IN fact, the success rate of an IPC is close to 90%.  A pulpotomy done due to caries exposure has a success rate, on a good day, of about 30%. Pulpotomy done due to iatrogenic exposure is about 75%. So, it is not the material per se but the way of doing the procedure.  An IPC is shorter time in the chair, reduces cost, and makes everyone happy now that you did a more conservative procedure.

See also:

1. Pulpotomy therapy in primary teeth: newm odalities for old rationales

Don M. Ranly, DDS, PhD

Pediatric Dentistry: November/December 1r9 94- Volume 16, Number6

2.

Indirect Pulp Capping and Primary Teeth: Is the Primary Tooth Pulpotomy

Out of Date?

James A. Coll

Journal of Endodontics

July 2008, Volume 34, Number 7S

I agree with COll.  The pulpotomy is way way outdated.  Time to move into the 21st Centruy. HA HA

I hope this helps.

Thanks for the comments.

Lance

Lance Kisby DMD, FASDC, FAAPD, MAGD

Prog. Dir Pediatric Dentistry Residency

A.I. DuPont Hospital for Children.

Oh, one last thing:

Stepwise excation is no longer done here at all. We have taught for 8 yrs do all in 1 visit.

Trope, Coll, and Seale have all said you can do the procedure (IPC) in 1 visit. ANd restosr then or later. Up to you.

Thanks

Lance

CALCIUM HYDROXIDE AND GLASS IONOMER CAVITY LINER

Mona

Good question.

I was trained in Pedo in the 70's and we stopped using Dycal in 1976 when I started my program.  Dycal does not give good compressive strength nor does it give a great seal at all.  At a recent AAPD (American Academy of Pediatric Dentistry) and AAE (American Academy of Endontics) joint 2 day meeting, in 2012,  no one talked about Dycal. On a good day, it is a bad material. Better materials are GIC if one really wants to do a base.  GIC gives a great seal.  At the annual meeting noted above, qith 900 pedo, endo, faculty and grad students, and the meeting topic was "Current State of Pulp Therapy" and the proceedings from that meeting would be in the journal Pedi Dent in the spring of 2013, about month March, April, or May.  Everyone who lectures has to write an article on their talk.

CaOH under GIC is redundant and counterproductive. One is placing a hard compressive strength materiral (GIC) on a softer one (Dycal).  The rate of reparative dentin is constant and is not determined by the use of Dycal.  Beagle studies in the 70's showed the Ca used in the formation of reparative dentin DOES NOT come from Dycal but systemically.

Hey, just another point here. I lecture nationally for the last 15 yrs and my all day and half-day  topic is: "Updates in Pediatric Dentistry: Treating Tiny Tots to Teens."

If any of you want me to speak at as an all day dental CME course, let me know.

I hope I helped.  Given EBD (evidence based dentistry), thank God we now have what i think are easier and simpler and faster techniques for treating our child patients.

See ya

Lance

Lance gives the science behind his answer, I will just give you an answer that has worked for me for over the last fifteen years.  I only use resins, composites or porcelain restorations, no mercury poisoning of my patients.  For routine restorations, I utilized Adpher Prompt L pop an ecthent and then an adhesive that is place in one step.  The key is let it set up for 15 seconds and then apply the appropriate curing light for 20 seconds.  (Get your curing light strength checked every six months of use.)

If it is very deep, I will place BIODENTINE a product that encourages secondary dentin to grow.  I have been successful placing this product over  very small exposed nerve.

I can leave the product and then place a resin over this material after it is set and watch the tooth closely.

Lance Kisby. Thanks for your answers. Do you suggest indirect pulp caps for non-primary teeth over base/liner as well?

In deep cavities, the most important issue is good isolation and good sealing material to give the pulp the opportunity to form the 2ry dentine to protect itself, and the gold standard material for pulp capping right now is mineral trioxide aggregate (MTA), also Biodentine is under study, then you could use any base material.

While in shallow cavities, I prefer GIC as a base with no need for a liner.