Question: If we have a mechanical pulp exposure, shall we go for a root canal or should we try to rely on bioactive materials?

Question: If we have a mechanical pulp exposure, shall we go for a root canal or should we try to rely on bioactive materials?

The big question is if we have a mechanical pulp exposure, shall we go for a root canal or should we try to rely on bioactive materials? In this case I used Theracal LC.

Oscar Vargas Fdz: Too risky it depends in case selection!!!!

Salvatore Sauro: ……………and it worked?

Delfín Barquero Barquero: Just did it. 20 min ago.

Salvatore Sauro: really??………..well I am 99% sure it will work!!! 😉

Rolando Nunez: It depends on the clinical assessment. If possible, let’s try to save the tooth. Nice pic Del!!!

Rolando Nunez: I wouldn’t say risky. Root canal is the safe route. Preserving pulp, now there is a challenge !!!

Oscar Vargas Fdz: Sure I am agree that preserving pulp is the safest way! And clinical and Patient assesment is a key factor!

Rolando Nunez: Agreed.

Liviu Steier: Great question indeed. Asking myself in regards of further preliminary steps to application of the MTA like materials not mentioned so far!

Delfín Barquero Barquero: To make this discussion richer lets make a list of aspects to evaluate to decide if this is a good approach.

Delfín Barquero Barquero: 1.Rubber dam before the removal of old restorations.

Liviu Steier:

Liviu Steier: Great start so far….and…..??????

Delfín Barquero Barquero: Lets do it together!

Liviu Steier: OK!

Delfín Barquero Barquero: 2. Should be mechanical injury and not bacterial injury.

Liviu Steier: Not sure about that!!!

Liviu Steier: Would start with diagnostics!

Liviu Steier: Is sensitivity test the right diagnostic tool?

Liviu Steier: How about Laser Doppler?

Delfín Barquero Barquero: dont know the technique.

Liviu Steier: The only approach to really understand and appraise the estate of the pulp!

Delfín Barquero Barquero: I would love to know about it!!!

Liviu Steier: Int Endod J. 2009 Jun;42(6):476-90.Laser Doppler flowmetry in endodontics: a review.Jafarzadeh H.

Carolina Ballestero Jamienson: It’s a possible way but not fairly available for everyone

Liviu Steier: It would be interesting to learn the difference between the two, isn t it?

Liviu Steier: Ok…whats next?

Delfín Barquero Barquero: Some studies have shown that a tooth is more likely to survive direct pulp capping if the initial exposure is due to mechanical reasons rather than caries. Long term clinical assessment of direct pulp capping. Thomas J Hilton, DMD, MS, Alumni Centennial Professor in Operative Dentistry, Oregon Health & Science University, School of Dentistry, Department of Restorative Dentistry, Portland, OR, USA

Liviu Steier: Yes, but today we may be in the position to help better than back in 1981, aren t we?

Delfín Barquero Barquero: ohhhhh yesss

Delfín Barquero Barquero: Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MAJ Am Dent Assoc. 2006 Dec; 137(12):1699-705.

Liviu Steier: Sure but material and methods does not mirror utilization of all adequate criteria we intend to add together here.

Delfín Barquero Barquero: Baume LJ, Holz JInt Dent J. 1981 Dec; 31(4):251-60.

Delfín Barquero Barquero: 3. No clinical or radiographic signs of pathology.

Liviu Steier: At which estate of the disease will radiography indicate pathology?

Delfín Barquero Barquero: When its too late…

Delfín Barquero Barquero: Im recalling what I was taught in school. Not all of them apply in 2016…

Delfín Barquero Barquero:

Delfín Barquero Barquero:

Salvatore Sauro: This sounds interesting !!!

Carolina Ballestero Jamienson: We have one at the UCR Delfin but not yet reliable … Technique sensitive

Delfín Barquero Barquero: Not a daily practice issue

Delfín Barquero Barquero:

Delfín Barquero Barquero: Thank you Liviu Steier

Liviu Steier: You are welcome! …but we did not come to an end with the list I am afraid….

Delfín Barquero Barquero: no doc… I need help!!!

Delfín Barquero Barquero: From a clinical point of view my criteria will be:

Delfín Barquero Barquero: 1. No current pathology

Delfín Barquero Barquero: 2. No bacterial contamination ( not sure if this can be accomplished 100%)

Liviu Steier: Presuming you exactly own the knowledge regarding the estate of the inflammatory process…any suggestion?

Delfín Barquero Barquero: I think we can only determine inflamation histologically. Clinically I dont think so.

Delfín Barquero Barquero: Therefore, I think we need to try to keep the tooth away from root canal therapy.

Delfín Barquero Barquero: 3. No contamination from oral fluids

Delfín Barquero Barquero: Good rubber dam isolation

Delfín Barquero Barquero: A real bioactive material

Liviu Steier: Absolut correct …and how about disinfection?

Liviu Steier: Clin Oral Investig. 2016 Apr 2. Different materials for direct pulp capping: systematic review and meta-analysis and trial sequential analysis.Schwendicke F, Brouwer F, Schwendicke A, Paris S.

Liviu Steier: …and how about this? Aust Endod J. 2013 Dec;39(3):171-5. doi: 10.1111/j.1747-4477.2012.00357.x. Epub 2012 May 29.Efficacy of the enamel matrix derivative in direct pulp capping procedures: a systematic review.Al-Hezaimi K1, Javed F, Al-Fouzan K, Tay F.

Delfín Barquero Barquero:

Delfín Barquero Barquero:

Delfín Barquero Barquero:

Delfín Barquero Barquero: Is it favourable to use CHX over the exposure?

Liviu Steier: Afraid not! Int J Mol Med. 2016 Jun;37(6):1594-600. Clinical implications of the growth-suppressive effects of chlorhexidine at low and high concentrations on human gingival fibroblasts and changes in morphology.Wyganowska-Swiatkowska M, Kotwicka M, Urbaniak P, Nowak A, Skrzypczak-Jankun E, Jankun J.

Liviu Steier: There is a wide variety of better solutions for desinfection

Pancho Lopez: Me gusta lavar con lechada de hidroxico de calcio, antes de aplicar el material en igual de CHX

Silvia Gonzalez Fernandez: Liviu Steier what would you consider to be the best?

Liviu Steier: Silvia Gonzalez Fernandez Hello! From case to case different but the following is in my armamentarium: PAD, Ozone, Enamelmatrixprotein and PRGF. The decision making process is extensive but valid.

Hamdi Hosni: I rely more on the caries removal method; enzyme-based CMCR method can provide a good solution to the remaining CID…/265379485_Viability_of…

Viability of Intratubular Bacteria after Chemomechanical Caries Removal

Salvatore Sauro: I like that!!!!

Shaikh Abdul Wahid: interesting … does it mean that in deep caries lesion where i am anticipating pulp exposure during mechanical debridement a prior rinse of sodium hypochlorite will be good for intratubular disinfection.. and thereby making dpc more predictable.

Hamdi Hosni: Yup. It follows PCR concept , kindly have a look in these series of publications..hope to be useful

Hamdi Hosni:…/280683309_Caries…

Caries Management: A Journey between Black’s principals and…

Hamdi Hosni:…/264792426_Current_update…

Current update of chemomechanical caries removal…

Shaikh Abdul Wahid: shukran brother

Hamdi Hosni:…/272835642_Effect_of…

Effect of silver diamine fluoride and potassium iodide on residual bacteria in dentinal tubules

John Comisi: Coming in late in this discussion (sorry). I would like to know why we have a mechanical exposure in he first place? That can be avoided, in my opinion, in many cases by as Tore and I mentioned in the other endo thread to remove as much of the “infected” dentin and leave the affected dentin. But since we have a mechanical exposure, was the exposure showing bright red bleeding? If so, then Theracal LC, MTA, BioDentin and even calcium hydroxide could be placed (although you would need a base with that to help with the compressive forces) and I would believe the tooth could respond favorably.

Delfín Barquero Barquero: No bleeding at all doc

John Comisi: hmmmm…. and there the pulp was exposed?

Delfín Barquero Barquero: It looked the way it is in the photo doc. What do you think?

John Comisi: The photo has a lot of moisture present. I see some light red, so the pulp may be “vital” but hmmmm.

John Comisi: I would be happier and more confident if there was more “red”.

Delfín Barquero Barquero:

John Comisi: Ok, that helps. Then the direction you have taken has a good chance of succeeding.

Delfín Barquero Barquero: FIUSHHHH

Delfín Barquero Barquero:

Richard Trushkowsky: I agree with Dr Comsi Voco also has good material fill with Activate or similar

Salvatore Sauro: Voco is a very good company!!!! With excellent products!!!

Delfín Barquero Barquero: Thank you Richard Trushkowsky Activa from Puldent may be also a way to go. Hope to get it soon in Costa Rica.

Valeri Stefanov: my approach in such cases – cover the pulp lesion with very thing layer of bc sealer, thus ensuring the pulp tissues are in contact with pure bc only.(Teracal has resin inside) Cover the thin layer of bc with resin liner containing hydroxylapatite – Lime-Lite (Pulpdent USA ) and restore in single visit with ACTIVA :-). One may use any other restorative material, too ofc.

Salvatore Sauro: Nice approach

Valeri Stefanov: and it works 🙂

Salvatore Sauro: Valeri Stefanov indeed! 🙂

Valeri Stefanov: same approach can be used in cases of very deep caries, too. Rinsing the cavity with CHX or Octenisept , followed by saline prior to placing bc sealer, helps with additional disinfection 😉

Kozo Yoshino: I used too

Salvatore Sauro: Nice!!!

John Comisi: Terrific!

Carolina Ballestero Jamienson: I would go with you on this! if you have proper Rubber dam isolation, occlusal site, non symptomatic, no signs of pathology! More cost effective and you can rely that your pulp diagnosis tends in its vast mayority to correlate to histological conditions! Case selection is important! Young patients occlusal exposure rather than older patients with proximal exposures

Carolina Ballestero Jamienson:

Carolina Ballestero Jamienson: Case selection …

Carolina Ballestero Jamienson: Histology vs clinical diagnosis

Carolina Ballestero Jamienson:

Salvatore Sauro: Very interesting Carolina

Delfín Barquero Barquero: One of thenbest costarican endodontist. Salvatore Sauro

Carolina Ballestero Jamienson: Thanks my friend! For the compliment!

Salvatore Sauro: I am sure she is 🙂

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