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本书版权归John Wiley & Sons Inc.所有
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Vital Pulp Treatment
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Vital Pulp Treatment
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Edited by
Henry F. Duncan
Ikhlas A. El-Karim
Clinical Professor and Consultant in Restorative Dentistry School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
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This edition first published 2024
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© 2024John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/ permissions.
The right of Henry F. Duncan and Ikhlas A. El-Karim to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
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Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging- in- Publication Data
Names: Duncan, Henry, 1971- editor. | El-Karim, Ikhlas A., editor. Title: Vital pulp treatment / edited by Henry F. Duncan, Ikhlas A.
El-Karim. Description: Hoboken, NJ : Wiley-Blackwell, 2024. | Includes index. Identifiers: LCCN 2023043780 (print) | LCCN 2023043781 (ebook) |
ISBN 9781119930389 (hardback) | ISBN 9781119930396 (adobe pdf) |
ISBN 9781119930402 (epub) Subjects: MESH: Dental Pulp Diseases–therapy Classification: LCC RK351 (print) | LCC RK351 (ebook) | NLM WU 230 | DDC
617.6/342–dc23/eng/20231107 LC record available at https://lccn.loc.gov/2023043780 LC ebook record available at https://lccn.loc.gov/2023043781
Cover Design: Wiley Cover Images: © Henry Duncan
Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India
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Contents
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List of Contributors x Foreword Preface
1 TheImportanceofMaintainingPulpVitality 1
Bruno Cavalcanti and Daniel Chiego, Jr.
Introduction  1 Dental Pulp Development  1
Stem Cell Reserve andHealing/Regeneration Potential ofthe Dental Pulp  6 Pulp Vascularization andits Clinical Implications  6 Pulp Innervation andits Contribution toPhysiologic Changes  9 Pulp Response toRestorative Processes  11 Pulp Vitality andInflammation  12 Mechanisms ofPulp Repair  12 Conclusions  14 References  15
xii
xiv
Cell Signalling andDental Pulp Development  2 The Role ofthe Apical Papilla  5
v
2 BiologicalBasisforVitalPulpTreatment 20
Fionnuala T. Lundy, Lara T. Friedlander, and Paul R. Cooper
Dental Pulp– Structure and Function  20
Development andAnatomy ofthe Dental Pulp  20 Cells ofthe Dental Pulp  21 Odontoblasts  21 Fibroblasts  22 Stem Cells  22 Immune Cells  23 ECM  23 Nerves  24 Vasculature  24 Ageing  24
Healing Capability ofthe Dental Pulp  25
Molecular andCellular Regulatory Processes inTertiary Dentinogenesis  26
Bioactive Molecules  26
Cellular Responses  27 Immune-Inflammatory Response inDentine-Pulp  Repair– ADouble-Edged Sword  27
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Contentsvi
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Immunological Response inthe Dental Pulp  28 Diagnostics forPulpal Disease  32 Future Vital Pulp Treatments  33 References  35
3 PulpalDiagnosis 47
Johnah C. Galicia and Asma A. Khan
Introduction  47 Diagnoses ofPulpal Status andTheir Associated Diagnostic Terminologies  48 The Diagnostic Process  48
Pain History  49 Pulp Sensitivity/Sensibility Testing  50 Diagnostic Accuracy ofSensibility Tests  50 Other Diagnostic Tests  51
Radiographic Examination  51 Preoperative Diagnosis versus Direct Observation  51 Clinical toMolecular Diagnostic Tests: Possibilities andChallenges  52 Conclusion  55 References  55
4 VitalPulpTreatmentModalities:TheManagementofDeepCariesUsingSelectiveand
Non-SelectiveRemovalofCariousTissue,StepwiseExcavationandIndirectPulpCapping 59
Helena Fransson and Lars Bjørndal
Introduction  59 Vital Pulp Treatment Modalities Aiming Not toExpose thePulp  60 Indications– APragmatic Subdivision ofExtensive Carious Lesions  60
Caries Profunda 1  62
Caries Profunda 2  62
Caries Profunda 3  63 Understanding Caries Pathology– AReason to‘Dare’ Leaving Carious Dentine Behind  64
The Non-cavitated Enamel-Dentine Lesion  64
The Approximal andOcclusal Cavitated Carious Lesion  65
Cavitated Deep andExtremely Deep Carious Lesions  66
Consequences ofChanging theCariogenic Ecosystem– Knowhow forLess Invasive 
Treatments  67
Formation ofIntra-Pulpal Cartilage-Like andHyperplastic Tissue inthe Pulp  68
Intra-Pulpal Mineralized Tissue– ASign ofPulp Pathology andAvoidance ofNon-
exposing Treatments?  68 Outcomes  68
Reported Outcome fromClinical Studies  72
Monitoring  74 Evidence-based andConsensus Recommendations  75 Epidemiology ofCurrent Practice  76
How Often Is Stepwise Excavation Performed?  76 Future  77 References  79
5 VitalPulpTreatmentModalities:DirectPulpCapping 84
Till Dammaschke
Is Exposing thePulp aProblem? AnIntroduction  84
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Management ofTraumatic andIatrogenic Pulp Exposures  85
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Indications forDirect Pulp Capping  86 Factors Affecting theOutcomes ofDirect Pulp Capping  87
Patient Age  87 Exposure Size  89 Location ofthe Pulp Exposure  89 Microorganisms  90 Caries Excavation  90 Haemostasis andCavity Disinfection  91 Selection ofthe Pulp Capping Material  92
Definitive Restoration  94 Contraindications forDirect Pulp Capping  95 Evidence-based Outcomes ofDirect Pulp Capping  98
Outcome ofDirect Pulp Capping After Deep Caries Excavation  98
Outcome ofDirect Pulp Capping After Dental Trauma  99 Future Developments inDirect Pulp Capping  99 Conclusions  100 References  101
6 VitalPulpTreatmentModalities:Pulpotomy–PartialandComplete 108
Roberto Careddu, Mark Lappin, Henry F. Duncan, and Ikhlas A. El-Karim
Introduction  108 Definitions  109 Indications  109
Definitive Treatment forAsymptomatic Cariously Exposed Pulp  109
Definitive Treatment forSymptomatic Irreversible Pulpitis  110
Definitive Treatment forTraumatically Exposed Pulp  111
Other Indications  112 Contraindications  112 The Procedure  113
Aseptic Operatory Field  113
Magnification andCaries Detection  114
Bleeding Control andAntibacterial Lavage  114
Capping Materials  115 Clinical Protocol  118
Armamentarium  118
Assessment andAnaesthesia  118
Pre-VPT Preparatory Procedures  120
Caries Removal  121
Pulp Tissue Removal (Pulpotomy)  121 Achieving Haemostasis  123
Placement ofthe Pulp Capping Material  124
Placement ofFinal Restoration  126 Outcomes ofPulpotomy  126
Which Outcome toAssess?  126
When andHow Outcomes Are Assessed?  127
Factors That May Influence theOutcomes of Pulpotomy  127 Conclusions  127 References  127
Contents vii
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Contentsviii
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7 VitalPulpTreatment–MaterialSelection 133
Renan Dal-Fabbro, Isaac J. de Souza Araújo, and Marco C. Bottino
Introduction  133 Native Pulp Conditions  136 Pulp Response toTraumatic or Carious Injuries  136 Decision-making forPulp Exposures  138 Historical Background on VPT Materials and Their Influence on Success  139 Current Gold Standard and Limitations of VPT Materials  141 Biology ofthe Tissue Response andMechanisms ofRepair– Matrix Proteins, Signalling  Molecules andPathways  143 Opportunities and Next-generation VPT Materials  144 Acknowledgements  148 References  148
8 VitalPulpTreatmentforTraumaticDentalInjuries 154
Bill Kahler and Giampiero Rossi-Fedele
Introduction  154 Traumatic Dental Injuries  154 Diagnosing thePulp Condition  155 Direct Pulp Capping andPulpotomies forManaging Traumatised Teeth  156 What is theEvidence forthe Preferred Treatment Choice?  156 Factors that Affect Outcomes of VPT in TDI  160
Restorations  160 Mobility  160 Delay inTreatment  161 Size ofPulp Exposure  163 Stage ofRoot Development  164 Material Choice for CCFs  165 Time Taken toAchieve Haemostasis  166 Time or Patient Limited Options  166 Initial Pulp Cap Followed by aLater Partial Pulpotomy  167
Complications from VPT in Traumatised Teeth  167
Pulp Canal Calcification  167 Discolouration  170
Resorption  171 Oral Health-Related Quality of Life  172 Differences Between Trauma andCaries Management  172 Complicated Crown Fracture withLuxation andComplex Injuries  174 Clinical Protocols forDirect Pulp Capping andPulpotomy  177
Pulpotomy  177
Direct Pulp Capping  177
Follow-up Protocol  177 Future Directions  178 References  178
9 RegenerativeEndodontics 185
Matthias Widbiller and Kerstin M. Galler
Introduction  185 Biological andMechanical Goals ofPulp Regeneration  186
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Historical Development ofRegenerative Endodontics  187
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Revitalization  188
Indications andContraindications  189 Clinical Protocol  189 Follow-Up  191 Outcome Measures  191 Clinical Outcome  192 Revitalization ofMature Teeth  193 Biological Result  193
Endodontic Tissue Engineering  195
Classification  195
Autologous Platelet Products  196 Conclusion  196 References  196
10 OutcomeofVitalPulpTreatmentandRegenerativeEndodontics 201
Siobhan Cushley, Emi Shimizu, Yoshifumi Kobayashi, andVenkateshbabuNagendrababu
Introduction  201 Outcomes Reporting in VPT  202
Success  202
Pain  202
Timing ofMeasurement ofPain  204
Sensibility/Vitality ofPulp  204
Timing ofSensibility Testing  205
Absence ofApical Periodontitis, Root Resorption and, inthe Case ofImmature Teeth, 
Continued Root Development  205
Timing ofRadiographic Assessment  205
Other Outcomes Reported inVPT Studies  206
Quality ofthe Definitive Restoration  207
Survival  207
Histopathological Outcomes  207
Formation ofHard Tissue Barrier  208
Oral Health-Related Quality ofLife  208
Composite Outcomes  208 Stakeholder Considerations inOutcome Reporting  209 Pulp Revitalization asa Regenerative Endodontic Therapy  209
Outcomes andOutcome Measures  209
Success/Survival  209 Radiographic Measurement ofOutcomes  210 Pain  211 Tooth Function  211 Seek Emergency Treatment  211 Adverse Effects  211 Follow-Up andOptimal Timing forReporting Outcomes  211 Improvement ofCurrent RET by Assessing OHRQoL  212
References  213
Contents ix
Index 218
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