Bioconservative therapies
Bioconservative therapies
1-Introduction:
The pulp is a unique tissue capable of adapting and responding to any aggression. The primary role of the pulp is to secrete dentin. The pulp has the ability to restart the production of scar dentin at any time, in order to distance itself and protect itself from external aggressions.
Living pulp in good condition is able to heal after aggression. Healthy living pulp is the best barrier against microbial invasion.
Keeping pulped teeth in good condition helps to limit the structural and biological changes that weaken the dental organ, to maintain the defense functions that oppose bacterial penetration, and finally to preserve the healing potential of the pulp.
A tooth that has lost its pulp is more mechanically fragile; the risk of fracture/crack is therefore greater. Also, the risk of infection is increased because the anti-infectious, anti-inflammatory and immune elements provided by the pulp are no longer present.
In the era of minimally invasive dentistry, it is necessary to maintain pulp vitality as much as possible in order to promote longer preservation of teeth on the arch.
2-Definition of dentinogenic therapy:
Dentinogen is the name given to all bioconservative therapies relating to the pulp-dentin complex, with the aim of restoring the inflamed pulp to a normal structure and a healthy life so that its natural functions, in particular dentinogenesis, can once again be carried out regularly.
3-Limit:
Diagnosis: The first limit to the vital preservation of the pulp is obviously the assurance that it is alive. The so-called pulp sensitivity tests are well codified, and their interpretation is generally not difficult. However, the conclusion must be cautious, in fact, the lack of rigor in the development of the diagnosis is a first limit to the preservation of pulp vitality.
4-Bioconservative therapies:
4-1-Etiological therapies : These consist of eliminating the direct or indirect causes of pulp disorders. Pulp lesions are almost always the result of a loss of calcified tissue of carious, traumatic or iatrogenic origin. The opening of the canaliculi, or the indirect exposure of the pulp, allows the penetration of bacteria or their toxins into the pulp.
4-2-Medical therapies:
These are biopreservative treatments which are HAIRDRESSING. There are three types:
A- Dentino-pulp capping or dentin capping : at a distance from the pulp, aims to promote dentin sclerosis.
B- Biological or natural capping (indirect pulp), is indicated near the pulp in the presence of a layer of non-infected demineralized dentin, preserved in order to protect the pulp; the objective being to promote the remineralization of the dentin and the formation of a calcified barrier.
Bioconservative therapies
C- Direct pulp capping : applied to a denuded pulp horn or after pulpotomy; its objective is to promote the formation of a dentin bridge.
Bioconservative therapies
4-3-Functional therapies : These generally require the use of plastic and/or cast reconstruction materials in order to achieve the objective of hermeticity, sealing and maintaining or restoring the function of the tooth in the entire masticatory system.
5-Interest in keeping a pulp alive:
Why should we try to keep the pulp alive?
The answer comes from a brief review of pulp biology and the relevance of its various functions:
Dentinogenesis : occurs during tooth formation, then at a slower rate, throughout life, the tooth becomes increasingly calcified, offering greater resistance to carious destruction. Early pulp loss stops root formation.
The existence of transdental hydro-ionic exchanges:
The colloidal quality of the fundamental substance of the mineralized tissues of enamel and especially of dentin, hence translucency, maintenance of color, better mechanical resistance of hard tissues.
The contribution to the pulp of all the anti-infectious, anti-inflammatory and immune elements : THE GREAT DANGER OF DEPULPATION IS infection. The pulp is the best barrier against microbial infiltration between the periapical inner world and the salivary outer world.
The living tooth is sensitive : Sensitivity, whose proprioceptive role is quite limited, constitutes on the other hand a factor of limitation of the evolution of pathologies, by constituting an alarm for the patient thus incited to seek treatment.
6-General indications:
Dentinogenic therapies are therefore indicated on:
– Pulpo-dentin damage.
-Reversible (curable) pulpitis.
7-Contraindications:
On the other hand, dentinogenic therapies are contraindicated in cases of:
– Irreversible total pulpitis
– Chronic open pulpitis
– Patients with general illnesses such as diabetes
– Elderly subjects where the pulp assessment is almost zero
– Technical requirements when the tooth is severely damaged requiring coronal or corono-radicular anchors for its reconstruction
8-DENTINOPULPARY PROTECTION MATERIALS:
-BIOLOGICAL PROPERTIES:
- Biocompatible with the pulp-dentin complex
- Non-toxic, non-allergenic
- Anti-inflammatory
- Anti-infectious properties
- Induce dentinogenesis
PHYSICO-CHEMICAL PROPERTIES:
- Do not induce tooth staining
- Adhere to dentin surfaces
- Waterproof
- Mechanical resistance to pressure
- Radio opaque
- Easy handling
ZINC OXIDE-EUGENOL CEMENT:
POWDER:
Zinc oxide 69%
Rosin
Zinc stearate 1%
Zinc acetate 0.7%
LIQUID :
Eugenol (85%)
(Clove essence + olive oil)
Properties:
- The thickness of the film must be sufficient to protect the pulp against thermal aggression.
- Setting time between 4 to 10 minutes
- A dentinogenic power
- Their pH is between 7 and 8, the phenol function and free eugenol are responsible for the bacteriostatic action. The sedative action is due to the calming phenol function.
- However, eugenol blocks the polymerization of macromolecules; therefore, they are contraindicated under light-curing composites and CVIs. Plus they abrade very quickly.
Calcium hydroxide:
Calcium hydroxide, also called hydrated lime or slaked lime, is a fine, odorless white powder with the chemical formula Ca(OH)2. Its molecular weight is 74.08 g/mol.
In an aqueous environment, calcium hydroxide dissociates into calcium ions Ca²+ and hydroxyls OH-.
This ionic dissociation is responsible for the main actions of calcium hydroxide on living tissues, including the induction of hard tissue deposition and the antibacterial effect.
CaO +H20 Ca(OH)2
Bioconservative therapies
Properties :
- Alkaline pH around 12.5
- Working time 3 to 5 minutes
- Setting time varies between 3 and 5 minutes
- Poorly soluble in water and tissue fluids
- Low thermal conductivity
- Film thickness between 1.5 and 2 mm
- Low compressive strength
- Same radiopacity as dentin
- Poor adhesion and sealing
- Absorbable over time
- Biocompatible
- Bactericidal power
- Anti-inflammatory action
- Antihemorrhagic action
- Bioactivity (dentinogenetic induction)
Glass ionomer cement:
Composition:
The powder is a mixture of silicate and alumina, while the liquid is a 50% aqueous solution of polyacrylic acid. In addition, they contain fluorine (fluorides). Example: Ketac Silver® (ESPE).
Light-curing CVIs contain 20% polymethyl methacrylate (resin). They are resistant and harden quickly.
Properties:
They play an important role in preventing bacterial proliferation.
They have insufficient mechanical properties, they are not very resistant to wear, their handling time is too short, photopolymerizing glass ionomers make it possible to get around this drawback.
They release fluoride thanks to the fluoride ions they contain, which play a role in preventing tooth decay.
They are biocompatible and it is however recommended to use calcium hydroxide if the cavity is close to the pulp.
MINERAL CEMENTS (based on calcium silicate):
MTA: is a material derived from Portland cement, i.e. a cement used in construction. Its composition is therefore very similar to that of Portland cement. The main components of MTA powder (ProRoot® MTA) are detailed in the table below:
Taking reaction:
MTA is a hydrophilic material that requires the presence of moisture to set. Thus, sufficient moisture is required during the hydration process to allow the material to harden.
When performing direct pulp capping, it is advisable to place a damp cotton ball in contact with the MTA, and leave it in between sessions to ensure its hold.
Properties:
- Long setting time 2 hours 45 minutes or even a week
- Alkaline pH 12.5
- Low compressive strength
- radiopacity due to the addition of bismuth oxide
- Good sealing and marginal adaptation
- Excellent biocompatibility
- Good anti-inflammatory action
- Antimicrobial action
- Excellent antifungal effect
- Bioactivity (pulp repair)
Bioconservative therapies
Biodentine:
Biodentine® is a bioactive cement recently presented at the French Dental Association congress in November 2010. This material was developed by the Research and Development (R&D) department of the Septodont company (Saint-Maur-des-Fossés, France). It is the result of a new technology aimed at micronizing Portland cements used in construction: “Active Biosilicate Technology”. Biodentine® is thus made up of the main component of Portland cement: tricalcium silicate. It is now marketed by Septodont laboratories.
Presentation:
Bioconservative therapies
Properties:
- Its properties are close to those of natural dentin (modulus of elasticity, compressive strength, hardness)
- Setting time between 9 and 12 minutes
- Sensitive to moisture while setting
- Good mechanical resistance, no porosity
- Good compressive strength
- radiopacity due to zirconium oxide
- Excellent sealing
- Good marginal adaptation
- Excellent biocompatibility
- Antimicrobial action
- Bioactivity (dentinogenetic induction)
Bioconservative therapies
9-Conclusion:
Dentin therapies not only preserve teeth but also keep their pulps alive.
However, to keep the pulp alive it is necessary:
-Make the diagnosis correctly
-Take into account the biological assessment
-And a certain number of technical requirements, in particular those linked to the reconstruction of the tooth.
The indication and prognosis of dentinogenic therapy depend essentially on the state of the pulp, but also on the quality of the loss of dentin substance: open wound or not, penetrating or not, carious or not, hence the interest in considering all these facts so that the practitioner can make his choice.
Bioconservative therapies
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