Vital Pulp Therapy: Why It Matters

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Vital pulp therapy has become a hot topic in dentistry. Current treatments have the potential to conserve natural tooth structure, minimize patient discomfort, and improve dentist's confidence when placing deep restorations. Today, we'll be discussing pulp capping and options for materials, including bioceramics. Our guest is Dr. Lauren Kuhn, an endodontist and part-time university professor at the University of Minnesota School of Dentistry. She is a key opinion leader in the field of endodontics, has written articles in various publications, and presented CE lectures that have been viewed by thousands of dentists nationwide. So we're very honored to have Dr. Kuhn on our show. Dr. Kuhn, it's a pleasure to have you on Dental Talk. Thank you so much, Phil. I'm happy to be here. Yeah. And you being an endodontist and me being a retired endodontist, that's kind of fun because I don't interview too many endodontists lately. I haven't lately. So it's always nice to have someone on. You also, you went to Harvard dental school or endo school, endo program? For dental school. I did my endo residency in South Carolina at the Medical University of South Carolina. Okay. And you all, were you not a Miss America pageant contestant? I was. I was fourth runner-up to Miss America in September 2014. So that was pretty exciting. I like to joke that, you know, before I became a root canal specialist, the opposite of what people are, you know, hoping to do with their time and the type of people they'd want to see. I used to... um you know be a beauty queen so that was that was exciting back in the day yeah those those are two opposite ends of the spectrum as far as yes who you want to go to yes but but i guess i listen it can hurt your endodontic practice being oh thank you yeah i'm sure it doesn't hurt but again we're happy to have you so let's start with a pretty simple question just to help us clear things up before we get too deep into it can you differentiate for our audience the difference between a vital pulp exposure versus an exposure that involves an infected pulp yes so pulp exposures of course occur either mechanically or due to caries reaching the pulp so they've made it through the enamel through the dentin and they have now reached the pulp when we expose the pulp it's essentially the core of the tooth if a tooth is vital that doesn't necessarily mean it's normal or healthy but If it's vital, it means that it has blood flow. So a vital pulp tends to be pink or if it's very inflamed, it'll be red. It has blood flow. An infected tooth or a necrotic tooth. tends to have either nothing in the pulp it's essentially an empty space where there used to be nerves and blood vessels or it could be filled with a purulent exudate which might be white or yellow in color so when you have a vital pulp exposure you should be seeing something that is either pink or red that would symbolize the fact that there is blood flow in the tooth right well said so and for the purpose of this podcast based on the title of it which everybody probably read already vital pulp therapy, why it matters. So we're talking about teeth that are vital, that have a pulp exposure, most likely mechanical. It could even be to a traumatic injury. But the bottom line is the tooth is not necrotic. It's not perillin. It doesn't have any swelling necessarily apically, and it's probably not positive to percussion, more sensitive, if anything, too hot and cold, right? That's really what we're looking at. If we do determine that it is in fact a vital pulp, why is this relevant to a gp first of all these types of cases come up all the time so all of us whether we are endodontists or general dentists all of us have heard from patients i never had pain until my dentist went and filled that cavity i never had a problem now i need a root canal you know he or she must have done something wrong so long story short patients don't know necessarily the health of their dentition they don't necessarily know a lot about the treatments we're performing they just know if it hurts and they know if it's expensive so if you have a vital pulp exposure and if you can obtain hemostasis and perform vital pulp therapy according to guidelines again you don't have a hyperemic pulp that is like a volcano of red liquid blood okay you don't have that you have something that is vital and you're able to obtain hemostasis you may be able to place a direct pulp cap with a material that is likely to induce a dentin bridge and is likely to have less post-operative pain and it also allows your patients to save time and money because if you are able to place a direct pulp cap by performing vital pulp therapy, you have freed up some of the patient's time and money. So their precious resources to be able to invest in their other teeth. So instead of sinking three or $4,000 into one tooth for an essentially elective or avoidable root canal and crown, maybe, maybe you can place a direct pulp cap and a direct restoration, maybe a composite same day. And then you can, help the patient to avoid post-op pain and invest their time and money into their other teeth so that they're not sinking everything into one tooth just because it had a deep cavity. Yeah. And that makes total sense. And the key thing is the success rate using the materials that are available today is quite high. Is it not on pulp capping? It is high. And in dental school, even when I was in dental school, not that long ago, the success rates weren't, as high because a lot of times calcium hydroxide or other more traditional materials were being used and so it wasn't really promoted to perform vital pulp therapy. If you had a pulp exposure the patient needs a root canal. Nowadays we're finding out that that root canal might be avoidable in some cases and if you can place a direct pulp cap with appropriate circumstances especially then using a bioceramic. it's highly likely to be successful. Yeah. And it's important to communicate well with your patient when you do have a vital pulp exposure, right? You want to let them know, here's what we're doing. Here's what we could be preventing. And you might experience some discomfort going forward. Okay. Then we have nothing to lose. We can then proceed with endodontic therapy. But in the meantime, we could obviate the need for endodontic therapy, saving you the time, the money. And I don't want to say the discomfort because we're both endodontists. We know that. root canal could be done quite comfortably. But the patient has innate fears about root canal. So we could take that off the table if we can get this to be successful. So let's talk about bleeding. We have a vital pulp exposure. It's essentially mechanical. What are your recommendations for obtaining hemostasis when pulpal bleeding is present? So if there is bleeding, I like to use a cotton pellet with sodium hypochlorite on the pellet. So I will take bleach. put it on a cotton pellet, and I will very gently dab the pulp. And it depends on how much bleeding there is. I mean, if it is hemorrhaging, I'm going to put a decent amount of pressure on it. If it is not hemorrhaging and it's just slightly bleeding, of course, if you were to imagine nicking your gingiva, that's going to bleed as well. So it doesn't necessarily mean that there's something irreversibly inflamed about this. You have exposed the pulp. Of course, it's going to bleed a little bit. But I will... put pressure depending on how much bleeding I see with a sodium hypochlorite soaked cotton pellet and then afterward I very gently air dry I'm not trying to hit the pulp with a lot of air but I want to slowly evaporate off the sodium hypochlorite if you can't obtain hemostasis within up to 10 minutes The pulp is probably irreversibly inflamed and it might be appropriate to proceed with endodontic treatment and full extirpation of the pulp. Right. Now, if you get a pulp exposure vital that's not bleeding at all, can we use like 2% chlorhexidine instead of sodium hypochloride, which I guess is normally 3%? Yes, you could. You could use chlorhexidine on the pulp. Either way, whether it's bleeding or not, if you get a pulp exposure with just almost no bleeding, you'll still use sodium hypochloride. Yes, I will. And part of that also is I want to eradicate the bacteria in the area. And as I'm prepping and I think there might be a pulp exposure, I actually cleanse the prep and my burr with sodium hypochlorite so that when my exposure does occur, I'm hoping that it is in a moderately clean environment. But yes, I'll cleanse the prep with sodium hypochlorite. I haven't been using chlorhexidine recently. However, I know some clinicians like it because not only is it antimicrobial, but it could improve the bonding of some. adhesive dental materials. So if that's the case, yes, you could use chlorhexamine. Yeah. So tell us about the bioceramic materials that are out there, the promising materials that really do have some biomimetic effects on the dentinal area where there's the exposure. And if you can walk us through the process, like what do you do after you've finished the hemostasis process? What's next? Okay. Vital pulp therapy agents nowadays, including bioceramics, like you mentioned, I tend to use biodenton more often in practice, and I like it because it's easy to manipulate. When you use one of these bioceramic agents, the idea is that it is a dentin substitute. So for example, with biodenton, that's why they... named it that it's biodenton it's a um it's supposed to be a biologically compatible dentin substitute so these bioceramic pulp capping agents are being put directly on the pulp and you only need about a millimeter to two thickness so you don't need um you don't need a massive quantity but you're putting it over the pulp to essentially cover the pulp and act again as a dentin substitute it has a high ph all of these bioceramic pulp capping agents do have a high pH so they're antimicrobial but they also are calcium silicate based and they are biocompatible so the pulpal fibroblasts don't consider bioceramic materials to be cytotoxic. So what I do after I have obtained my hemostasis is I, like I said, just very gently air dry. I test the air on my glove first. You know how sometimes you push the button on the air water syringe and it's like you're creating a hurricane. I just very gently push on it and then I bring it to the tooth. Okay. So I'm just trying to gently evaporate off my sodium hypochlorite that I use to obtain hemostasis on a clean field. Then I place my bioceramic. So in my case, I like to use biodentin. Place that on there and I let it set for a few minutes. Biodentin takes 12 minutes to fully set. Regardless of what material you're using, though, you will want to put some type of a barrier over the top of that. So I essentially place a button of bioceramic directly on the pulp and slightly over some healthy dentin circumferentially. And then I put basically a liner over the top of that. You'd use a resin-modified glass omelette? Generally. So yeah, I tend to use like Vitribond or Fuji. There are a few different formulations, some of which are syringeable, others you have to apply with like a kind of like a Dical carrier with another instrument. But anyway, I put some type of a... resin-modified glass cyanomer over the top of the biodentin or other bioceramic material. Circumferentially, again, I want it to be just slightly, you know, covering slightly more dentin. And then I'm able to proceed with selective etch of the enamel and then bonding and permanently restoring with a direct restoration. Right. And you would use a permanent composite on top of that or a core buildup. So the days of temporizing or monitoring for symptoms, before going to more of a permanent composite, are they over now? Is that something you don't do? Yes. Yes. Yes. So the American Association of Endodontists does not recommend monitoring and placing a temporary restoration because success rates are higher and bioceramic materials have high success rates and less post-operative pain. They do recommend placing a permanent restoration because the benefits of having it permanently sealed and preventing bacterial leakage from getting in there and contaminating that clean, vital pulp, those benefits of placing that direct restoration and minimizing that leakage outweigh the cost of placing that composite. So a lot of clinicians are concerned if I place a composite and then now this needs something else, I've just charged the patient for this composite. Okay, well, you know, maybe in some cases you may choose to negotiate and do something that seems fair to you. That's fine. But the American Association of Endodontists, and I agree with it, recommend placing something permanent when the pulp exposure and pulp capping occur, and that's to prevent bacterial leakage. However, if you're one of these people that still really doesn't like that idea and you really, really want to monitor and you just don't want to restore it that day, biodentin can actually be used as a bulk fill. So you could bulk fill the entire MO, DO, MOD, whatever this prep is. You could bulk fill it with biodentin. Again, it's a dentin substitute. And then you can shape it however you would like it to be shaped. And then as long as the area is permanently restored and, you know, restorations are enamel substitutes, right? As long as this area is permanently restored within six months, it should be fine. So AAE says just go ahead and place your permanent restoration. But if you're still really hesitant about that, you could bulk fill with biodenton and then monitor. What about the waiting period for a permanent crown? Would you wait until? six weeks or so to make sure the patient's asymptomatic? Or would that not affect even your scheduling for placing a final crown? So I think this is very clinician based. So obviously what we're doing is practice, right? And every person and every tooth is going to be a little bit different. And we try to predict the future, but we can't always be right. So what I have done traditionally when I perform vital pulp therapy is I have patients come for a three month check. So I lighten the occlusion. I place the permanent restoration. I have them come for a three -month check. And I will say if a patient had PDL widening apically, so inflammation had actually reached the apices, a lot of times that is fully resolved by the three-month mark. They are not having symptoms. Then I feel very confident to tell the referring dentist, go ahead and put a crown on this. I think it's unlikely that it's going to need a root canal. But I would say probably six weeks would also be adequate. done three months just as a personal preference. And as far as the biodentine material, how it's applied, can you go over quickly how that's done? I believe it comes in a capsule. You open the capsule, add a couple of drops of liquid, drop it into a triturator. And then how do you... it to the tooth do you use a like an amalgam condenser or something from the past i know that's like an archaic tool yeah caveman days does anybody know what that is even triturators i mean you have to go on ebay to find those these days um yeah but it does have to be triturated which is kind of an old way to do things but there's a reason for it yeah So trituration obviously allows it to be mixed more effectively and fully. So yes, it should be triturated. An off-label usage of the material would be to hand mix it. So if someone were in a pinch, they could do that. However, that is an off-label usage. So if you find yourself in a pinch with no triturator, it may be acceptable as long as you recognize that it's off-label usage, you could hand mix. And I believe that the... the strength of the biodenton in megapascals is a little bit lower when it's hand mixed. However, the biocompatibility shouldn't be changed from my perspective. So yes, titration is ideal. Hand mixing would be an off-label usage. The way that I put it into the tooth, there are a million ways. So you could use an amalgam carrier if you wanted to. You could use an MTA carrier if you wanted to. Sometimes I'll use a spoon or I'll use a Glick. Sometimes I'll even use a plugger and it doesn't have to be pretty when it's going in. You can have a very small amount. Think of it almost like wet sand. You have a very small amount and you just gently lay it on the pulp. You're not trying to compact it and push it and traumatize the pulp. You want to just let it sit there and then let it flow gently over the top in a way like. other flowable materials we use, like flowable composite. You're not trying to push, you're trying to just let it flow and fill in gaps. So I will put, you know, whatever I feel like using that day, spoon, glick, or a plugger, I will place small increments until I have the thickness that I want, usually about a millimeter to a millimeter and a half. And then I will, after I let it set for just a couple of minutes, it has an initial setting. about six minutes i'll take a spoon and i'll remove any excess so especially when you're using it in the maxilla yeah you might get a little bit on the enamel or you might get some at the dej that's not where you're aiming to have it that's fine you can remove it with a spoon blow a tiny bit of air and then pretty soon afterward i'll place my resin modified glass ionomer liner and then move forward with my selective edge bond and restoration yep right so once you place your RMGI, you can light cure that. And then on top of that, you can put your permanent composite. Now, if the material is a little bit too thick, when you're using the biodentine, you can add a couple of drops of liquid that comes with the system to tamp it down a little bit to make it flow better. Is that something? Because I've heard that from other dentists. Yeah, you could do that. I mean, imagine mixing MTA for those who have used MTA or even for sealers that are being mixed. BioRoot or C-S from Septidont or other sealers, you know, even zinc oxide eugenol that had been used traditionally. If you don't like the consistency, you could add a little bit of liquid. Right. Okay. So these bioceramic materials are really promising materials restoratively, not only for vital pulp therapy. What are some of the other applications in your mind that a general dentist should be aware of using materials like biodentine? So bioceramic materials, including biodenton, they could be used for many, many purposes. So they can be used just generally as a densin substitute. They can be used as a surgical retrofilling. So if you're performing an apicoectomy, I know these are mostly done by endodontists. myself or like you, but if you are performing apicoectomies or other surgeries that require a retrofilling that's not in contact with a toothbrush, so something that is apical to the CEJ and you want to have attachment of PDL cells to it, you could place bioceramic as your retrofilling material. It can also be used for perforation repairs. There are a lot of uses. And resorption, small resorption, lesions, external resorption, probably if you can get to it and so forth. Yeah. If you can get to it. Right. Yeah. So that's been very helpful. And Dr. Kuhn, you did a webinar for Viva Learning. That's on vivalearning.com. And it does address a lot of these topics in the area of vital pulp therapy using bioceramics and other things you talked about, which was a very good webinar. So I'm talking to my audience now. Please check into that. You can go to vivalearning.com, type in Kuhn, K-U-H-N, which is Dr. Kuhn's last name, and you'll see her webinar. So you can watch a good one hour program on and get more details on all of this stuff. In the meantime, I think you gave us some great insight. Very, very good information, Dr. Kuhn. And we really appreciate you being on the show and we hope to have you on again soon. Thank you so much, Phil.