Pulpotomies for Irreversible Pulpitis? The Rise of Vital Pulp Therapy – PDP133

Jaz’s Introduction:
And this episode really challenges our beliefs that we hold in terms of what requires a root canal treatment, ie we were trained that irreversible pulpitis equals pulpectomy, which is a root canal right? Now, that’s what I was taught to. But what is happening now in endodontics, is brilliant. And Georg explains it really well, with his lovely German accent, we go over the fact that nowadays, whenever a patient comes to Georg, with irreversible pulpitis , that you know, severe throbbing ache, it does not mean root canal for him anymore, it means a PULPOTOMY OF THE PERMANENT TOOTH, it means a pulpotomy of a vital permanent tooth, which then hopefully, will preserve that radicular pulpal tissue, and therefore, the patient will not require a root canal treatment anymore. So, it’s pretty different.

Now, maybe you’re already seasoned in this, maybe you’ve already using MTAs, and whatnot. And that’s amazing. Good for you. But for a lot of dentists, I imagine this is like, wait, what do you what do you mean, we don’t have to do I commit to a root canal anymore like we can, we can actually do a pulpotomy for an adult, let alone one that we have diagnosed as, quote unquote, ‘irreversible pulpitis’, which actually Georg argues, is a poor term. Welcome, Protruserati. I’m Jaz Gulati, I’m your host. And if you’re new to the podcast, welcome. It’s great to have you. If you’re a veteran, and you’ve been with me for many years, it’s always a pleasure to have you.

This one’s a really cool episode, I didn’t think before I recorded it, that I’ll be having so many moments of laughter with our guests, Georg Benjamin, who was not a specialist in Germany, he is pretty much limited to endodontics. And he’s been following vital pulp therapy or pulpotomy of vital adult teeth for a long while now. And he’s got some great views on it. And if you listen to the end, we say some very controversial things about certain groups in dentistry. So, I apologize to my friends by offended you. It was all a little bit unjust but a little bit serious at the same time.

The Protrusive Dental Pearl 
The Protrusive Dental Pearl I have for you today is and I’m really hoping I haven’t shared this one with you already before, but it is how do you test for OBJECTIVE ANESTHESIA? So, as you know, guys, I’m a big fan of buccal articaine infiltrations, for lower first molars and even lower second molars, if I’m doing a root canal, or a crown or a large restoration, I am no longer reaching for an ID block, I am doing a buccal infiltration with articaine. I’ve got a video on YouTube showing exactly how I do it. And I get about 90% success rate with this. And I say there’s easy patients and then there’s difficult patients, the difficult ones being the thick bone and whatnot. And yeah, probably successes 80% with those guys, but more normal anatomy than I’m probably getting 95%. So, if you balance it out, it’s about 80- 90% success rate. And so, one thing I started to do to really make sure my patient is super numb is instead of subjective, instead of asking the patient, are you feeling quite numb, is that is that really numb, it’s much better to be objective.

So, I get some endo frost, so minus 50 degrees on a cotton pellet. And I put it on tweezers, and I press it onto the tooth. And I leave it there for about 10 seconds. And hopefully the patient will feel nothing at all. Now that for me, gives me so much more assurance that that tooth doesn’t require a supplemental anesthetic. It does not require an inferior alveolar nerve block. And that’s worked really well for me. So, in those times where I put the coal on, and after about six seconds, they say you know, I just feel a little bit, either give a little bit more articaine into the gingival tissues, subperiosteal region, or I might even in a tricky patient, give it an ID block at that stage. So, it really helps me in my decision making.

So, next time you’re not sure, do a objective test by putting endo frost on the tooth and just seeing the response before you start your therapy. Now by this point, usually I already have rubberdam on as the last thing I do before I then continue my treatment because most of times, they won’t feel the end of frost anymore. This episode is brought to you by Enlighten Smiles, the good guys Payman Langroudi et al who support this podcast so dearly. Thanks so much. I love using Enlighten Whitening, I’m getting great results. My patients, they got some awesome trays, and their gel is always fresh. And of course, if you want some training, you have to check out the one-hour webinar that Payman does, as always is in the link section. It’s also on the YouTube for the freemium version. And if you’ve not already downloaded the app, the Protrusive app, oh my god, we’re getting so much traction. We’re getting so much good vibes on the community section and the exclusive content is just gonna blow your mind. The amount of things I’ve got planned for it. It’s gonna be amazing. So, if you haven’t downloaded Protrusive app yet, what are you waiting for? Download it. Let’s join Georg Benjamin to discuss vital pulp therapy aka pulpotomy for adult teeth, no more irreversible pulpitis. Georg Benjamin. Welcome to the Protrusive Dental Podcast. How are you, my friend?

[Georg] 
Oh, I’m fine. Great to finally be on a different podcast as well.

[Jaz]
Well, it’s for those who don’t know, Georg is a host of his podcasts was mostly in German, I believe. Tell us, you’ve been podcasting way longer than I have. Tell us about your podcast and in Germany and what kind of topics do you cover?

[Georg] 
Basically, I started podcasts in 2016, which is now basically ages ago, and actually, I remember in 2018, everybody in the podcast environment was talking about, oh, which podcast peak, it’s over now. It won’t rise anymore. And I was basically inspired by the dental hacks podcast, basically, the American podcast, which is now very dental podcast, they kind of split up, but I’ll admit they’re still doing it. And I was kind of surprised how Americans talk openly on their podcast, about certain things like, oh, well, I got everyone in my team, an iPad. I mean, they’re just a $1,000. So, I got 10.

[Jaz] 
Sounds like a very American thing so.

[Georg] 
Things you would never hear on a German podcast, it was like, Yeah, talk to my text advisor. And afterward, we found a way to make it work. Yeah. Well, at least my podcast is called SaureZähne Dental Podcast, actually, the name wasn’t very SEO, anything. We just started started enjoying the dental hex and started our own podcast. And actually, we were the first German dental podcast for our dentists. And it was really good networking too. I mean, who should I tell you that I saw how you grow with your podcast. You know, you even have an app, which is really great. And it’s the networking part is so good. I just can encourage everyone to start a podcast. Today, there are so many podcasts on how to start it and how to present yourself. I started just without anything. I just started about a name at first and started recording. It was so much fun, I can really recommend to everyone.

[Jaz] 
Amazing for those who who want to listen to a German Dental Podcast, check out yours. I can’t even pronounce it. But it you know, it’s amazing that you are so dedicated and I’m sure every dentist in Germany probably knows your podcast today would do this in English guys. Don’t worry, be reassured. We’re gonna do an English podcast today on vital pulp therapy as you in our preamble, our pre chat you described as vital pulpotomy for adults, because dentists are more likely to be like, ‘Oh, okay, I can visualize what that means.’ So before we get into that, just tell us a bit more about yourself. Are you limited to endodontics? Are you an endodontist? Or do you just love endodontics?

[Georg]
It’s very interesting. Basically, in UK terms, I’m a general dentist. But I spent most of my time with endodontics. That means now I recently opened my office, I have scope CBTC. So, everything you need today, for endodontics. But actually, when I graduated in 2010, I basically didn’t have any or when I heard this term pulpotomy of teeth, I was only thinking about milk teeth, and never heard about anything else. It was really interesting. When I was a young dentist at my first dental job, I was in an office in a rural area close to Berlin. But they were like two dental offices in a town of 10,000 people, and very well, really bad. So many patients, it was crazy. I mean, after two weeks, all my afternoons are already fully booked. But it’s like the best start for young dentist. And we had an interesting approach to pain treatment, if someone came in refer a reversible pulpitis. And the pain treatment was basic, very simple, because we didn’t have a lot of time, it was a full pulpotomy.

And we basically just placed a cotton pellet on it with a Ledermix, which is like an antibiotic steroid mix, which is very popular in Germany and covered at Cavit. And we call the patients on the next day just to see if they’re fine if we should need to root canal treatment, or if the whole thing bought us time. Actually, it surprised myself a lot, how much times it’s actually gave us and when we started to do the root canals later on. It was quite useful, but pulp was still vital and the root canals. And it was basically we had to do anesthesia, rubberdam, of course, and it was pretty much standard endo. And I was always chatting with my boss back then. It was Dennis. ‘Dennis, how come this pulp cells and they are still vital even it’s I know. How come we can’t place anything on it like MTA. So we don’t need to do the endodontic treatment. And you know back when it was like if it’s irreversible pulpitis it’s no way out completely. It’s a one-way street.

[Jaz] 
Which you know that everyone who’s listening so far. I mean, not everyone but I’d say 98% of the colleagues, the Protruserati listening right now probably think the same as what I thought as well, which is when you diagnose irreversible pulpitis, that’s it. I mean, that’s the end of the line for the tooth. It needs a root canal if it’s even possible, right?

[Georg] 
Yeah. And basically, maybe the terminology is wrong. Not saying but it’s not very easy terminology. If it’s irreversible, we don’t have to do it. If it’s a reversible, we have to do it. But if it would be have a different name and wouldn’t have the name I will suppose that it’s a one way street, we might think different. But let’s be honest, it’s very easy diagnostic tool to say. That’s the street we take here. That’s the street, we take there, and fine. And basically, I did some endodontic continuous education. And I met Martin Trope who basically showed us a really nice study from a guy called Mr. Bowden from the US an endodontist, who basically treated young molars of young children basically, with full removal of decay. But he called the direct pulp capping with MTA.

But basically, when I look at the clinical picture, it was basically a partial pulpotomy because you really removed all the decay nichts apart a couple of times, just placed MTA on it. And it worked. And the thing is, you know, okay, it’s one study, let’s see, but this recall rate was 97%. Yeah, it’s like enormous. Martin Trope was joking, but private detective was hired to get this week away. Unfortunately, Georg couldn’t attend the last German endodontic Society Meeting due to some restrictions, because I wanted to ask him that. But with these results in mind, I kind of started in a different office where it’s getting more and more endodontic focus to treat these cases. And I remember one case, where basically everything went wrong, Jaz, seriously, everything. Yeah, it was a deep cavity assault on the x-ray before I basically knew that. Some partial pulpotomy is better than the direct pulp cap due to the literature, which is outwear on these topics. And I did a partial pulpotomy places-

[Jaz]
Before you progressed with this course, let’s paint a picture, how old was the patient? And what was your pulpal diagnosis before you started?

[Georg] 
Yeah, basically, the patient was maybe in the mid-30s and adults. My diagnosis was basically in reversible pulpitis because the patient didn’t get any pain. And-

[Jaz] 
I want clarity, reversible or irreversible. I couldn’t hear it.

[Georg] 
It was reversible pulpitis .

[Jaz] 
Reversible, okay.

[Georg] 
Just imagine, you see deep caries close to the pulp, and you’d be like, okay, the tooth is vital. The patient doesn’t have a lot of pain, but we need to treat it, it’s pretty sure. And basically, entered the tooth, did a partial pulpotomy, placed my MTA. And back then I basically had a two-step approach for the first place the MTA, did a temporary filling, and we call the patient to see if the MTA has set. And when I was placing the temporary refilling, which was Cavit at this time, I basically suddenly saw how the blood from the pulp came out. And we’ll say okay, this will not gonna work at all, because I’m out of time, I can’t do anything anymore. It is how it is.

And maybe she will be there as a pain patient the next day, but she didn’t come at all. And you know, if the patient doesn’t come up, you basically already know what happens. You went somewhere else in Berlin at least. But basically, the patient came back, I think a month later because the temporary filling fall off. And basically, the MTA and it was hard. And since this was a partial pulpotomy I could do my cold test and to correct normal. And I just placed my composite on it. And that’s it. And then, I kind of realized maybe I didn’t trust the pulp too much things.

[Jaz] 
You didn’t have faith?

[Georg] 
I didn’t have faith at all with a pulp. I mean, I kind of like-

[Jaz] 
Like most of us, right? Especially if it’s caries, like, you know, you’re gonna think okay, ‘Mr. Smith, you need to have a root canal treatment for sure.’ So, I don’t think that’s surprising. I think most of us would, I think there’s a real paradigm shift for us.

[Georg] 
Yeah, it’s a paradigm shift. And actually, now there’s new literature out of which it makes it easier back then, it was eight years ago. This is how we noticed that we are actually old, Jaz. But you know back then, whenever you had such a treatment, you should always say it was reversible pulpitis because still wasn’t really allowed in a irreversible way, kind of you know, but the interesting part is, actually there’s this term called Vital Pulp Therapy. And it’s actually sometimes a bit misleading because vital pulp to me could mean anything, it could be in an indirect pulp cap, a direct pulp cap, partial pulpotomy, full pulpotomy. In the last e-meeting. I even learned the term mini pulpotomy, which is interesting. But I like this term. It’s from a British guy I forgot to sorry. And basically, I’ll focus pretty much on the pulpotomy part because it’s the more interesting part.

[Jaz] 
Okay, before we get to that, Georg I just wanted like back to that case that you mentioned that lady who had this positive experience where you thought that okay, she’s gonna come back in pain or it’s gonna go necrotic and it was fine. Eight years on now. Do you still see this lady? Have you seen her? Is everything still, okay?

[Georg] 
Actually, with this woman I didn’t saw her again. I saw her husband. But she also had like a really bad root canal to the teeth, which needed treatment. And she didn’t like my fee behind it. So, she never came back. But I know that she was fine for quite some years. But I started recalling and documented these cases after that, actually, because it has gotten a bit more interesting.

[Jaz] 
And with that case, for the younger dentists listening which everyone actually, when you had that deep caries, which you knew was close to the pulp, but your diagnosis was that you know, it was still reversible pulpitis at that stage. There wasn’t signs of deep throbbing pain, keeping awake at night, nothing like that. Why did you not consider just removing as much caries as possible, but leaving some caries over the pulp and just restoring like that? Do you not think that perhaps dentin could have been the best insulator, the best base, in that case, the best lining if you’d like.

[Georg] 
Oh, you’re touching a really topic, which are feeling really strongly about it, I would like to put it in the end of the podcast, because-

[Jaz] 
We’ll find out. Stay tuned until the end, we will find out why Georg prefers to actually go into the pulp in that case and do a pulpotomy which leads us nicely to what you were just going to explain.

[Georg]
So, let’s focus a bit on the pulpotomy part because it’s quite interesting. First of all, basically pulpotomy started more or less in traumatize tooth. And therefore, we have a lot of really good literature about pulpotomy and permanent tooth, you just say, chipped, central incisor, the pulp is exposed. And we basically know from literature, even if this young patient is running around with this open tooth for a week or so. But we just need to remove two millimeters of the vital pulp. And it still will work. Yeah. Which is surprising because the pulp has an immune system, and therefore it’s fine. Of course, we have probably cases where it doesn’t work. But spec showed that in his enamel studies, that it worked and even like later on with his patients, and which is interesting. And this pulpotomy has a high success rate. But let’s be honest, it’s all young patients on traumatize teeth, no caries, of course, it works very good. So, what’s with the teeth we see in our office and interesting there’s like study from Iran, actually. But they did a multi-central study with full pulpotomy in permanent teeth and compare that to a root canal treatment. And actually, the results were comparable.

But we have to be careful when we’re this study. Because you can also always make studies and kind of get the same result if you don’t read them well. And I’ve never been to university and never, of course I’ve been to uni. I’ve never worked at university. I’m really not good to literature, Jaz.

So it’s the first time I didn’t see it. But actually, in this study, which is was quite good. The RCT group just brings sterile water. And you know, in vital case it probably works, but not as good as maybe a stronger disinfectant like sodium hypochlorite. So-

[Jaz] 
Okay.

[Georg] 
So, the results are pretty much the same.

[Jaz] 
So, for the actual root canal therapy prior to the obturation for this RCT group, they chose to use sterile water. And-

[Georg] 
Yes, that’s it.

[Jaz] 
But we know, let’s talk. That’s not even the gold standard, we know that we should be using sodium hypochlorite. So, why would you do that for a study? Surely, that’s negligent?

[George] 
Yeah, you could do it. I wouldn’t go so far to and maybe they wanted to have the RCT group to be a bit less successful, but they both more or less get 80% success, and which is actually 80% percent success. If you just look at by the vital pulp therapy group, multicentric, a lot of different dentists is quite good actually. When you look at the molar, it’s much easier to do a full pulpotomy and a molar, play some MTA and restore the tooth right away than to do a root canal treatment, but I always have to advocate if people are now saying, ‘Well, it’s an alternative to an RCT. No, actually it’s a more predictable pulp cap. I would say pulpotomy is more predictive and a pulp cap. But let’s be honest, a lot of people out there and I have done the same, came from the university, done a pulp cap and it went horribly wrong. That’s a patient-

[Jaz] 
For students, just for student listening young dentists, vital pulp cap just recap. Direct pulp cap, indirect pulp cap, what is the difference? Just describe what kind of materials you would use in each scenario.

[Georg]
Let’s say you just removed an old insufficient restoration, maybe an old GSE amalgam whatever, and you accidentally see that vessel open pulp. Yeah, or maybe you nicked it. And basically, in this case, I would just like use calcium silicate cement that could be an MTA could be biodentin, could be whatever and rinse it a bit with sodium hypochlorite usually I use 2%. Some people suggest 3%. Some say I always use 5% because it’s the only thing I have to offer, doesn’t matter in my eyes. And basically if it’s like, doesn’t have a lot of symptoms before, it probably is fine. Yeah, I probably best-

[Jaz] 
And that’s a direct pulp cap, right? And then you know what it when I trained we were using dycal.

[Georg] 
Yeah, dycal was actually quite bad idea, because it-

[Jaz] 
Of course.

[Georg] 
There’s literature that dycal, carelife, self-setting calcium hydroxide products work less successful when freshly mixed calcium hydroxide. It’s quite surprising. But I was taught that in university because already back then everybody should know it from literature. And basically, it’s better to use a freshly mixed calcium hydroxide and two places on the pulp. If you come up with it, I basically use MTA because due to my endodontic background or endodontic 70s. I think it’s cooler. But if you look at the literature, they are both are great. Maybe it’s a cotton product that resolves.

Yeah, we see that sometimes old pulp caps, but the pulp is still vital. And sometimes in this scenario with the direct pulp cap, I tend to avoid it by doing something I would call now learn that term. It’s called mini pulpotomy. Because before I come to the mini pulpotomy, because I noticed I did some pulp caps with really cool materials. They’re called Bioceramics effing unfair still went wrong. And then noticed that sometimes even it’s just a small pulp exposure. And the bleeding stops by itself, which is basically by the book, the best indication sign.

[Jaz] 
It’s a good sign.

[Georg] 
Yeah, it’s a good sign. Actually, I now with my experience in vital pulpotomy or pulpotomy, I rather see the pulp bleeding, and look for it, I would just like freshen up it with the diamond burs at high speed. Just don’t remove anything, just touch it two, three times, see, okay, it’s really bleeding. Because I noticed sometimes that there’s some blood in the pulp chamber, which kind of finds its way but when it stopped when you open it, you really don’t see a lot of really nice vital pulp tissue. And remember that story when I come back to the decay part. So, but first, I hope I don’t jump around too much the indirect pulp cap.

[Jaz] 
Yes.

[Georg]
I also already told you at this podcast, that I like to remove all the decay even if it’s an hour Cochrane Review, which basically states that I’m basically dentin Bavarian, who removes too much dentin. That’s fine. Yeah, in cases where I have deep caries. And I really thought I would expose the pulps but I don’t. Even if I removed everything, sandblasts everything. Then I will do following, still use sodium hypochlorine like to clean something. Yeah, because-

[Jaz] 
So, you’re basically killing the cavity even though you don’t have exposure?

[Georg] 
Yeah, you know, we cleaned the cavity, because we have one study from Michael Sander, who basically did vets and even in an indirect pulp cap, a successful rate was much better when without, which was interesting. In my logic, it’s quite logic. And then I will just pass again, calcium silicate cement, this can’t go pretty fast as the biodentin. Just cover the dentin, close to the pulp, not everything. And basically covered with self-etching flow. Because I’m really lazy. I don’t really like to wait for the biodentin to set. In my hands, it works very good. Some people like to wait 12 minutes until it sets, that’s fine. Some people even do the two visits, which is fine and do a cut back. For those indications, a metric is really a good choice. And that’s it for indirect pulp cap.

[Georg]
Yeah, let’s now go to the real pulpotomy part. And now’s the interesting part that you have someone coming to you could be an young patient or patient with a big decay. And of course he has pain, maybe even at night. And I always say, of course he has pain. I mean, if you have like Swiss cheese, very close to the pulp and you feel everything. Of course, the pulp is irritated. And so the question is always, how much is the pulp irritated? So, of course I do my pulp testing, I do an x-ray to kind of see if there’s no lesion on the x-ray. Although we have to kind of say if it’s a huge lesion, we probably say that’s a necrotic and our cold test was basically a false positive. But if it’s like really, really tiny one, I wouldn’t give it too much of a thought actually, yeah.

[Jaz] 
CBCT maybe if you’re, in that would you consider that?

[Georg] 
I have a CBCT. Actually in this case, I wouldn’t consider it because now I strongly believe it’s a vital pulp therapy now and then confident, but I handled the root canal treatment, I really like to consider it. But it’s a case by case decision. But the past, I went more and more for the pro CBCT. Because it gives me a lot of information I need. But for example, these cases, you see maybe something on one root, which is like an enlargement, not to be lesion. And when you kind of take out your measuring tool and measure, it’s more than one half millimeter. Because if it’s more one half millimeter, referred, it’s probably more likely to be lesion. If it’s less than half a millimeter, it’s probably not a lesion. Yeah. But so rule of thumb, I heard somewhere, I can’t credit anyone, but it was a great tip. I got but usually in this vital case, ideally, if I would do CBCT in this case, I probably would expect I don’t see a lot of it. So, since I wouldn’t probably not to wear root canal treatment since I don’t see anything, it doesn’t really bring anyone a benefit. But remember just in case, and everybody who’s a dentist knows that. This one will be a no for sure. Because it’s such a big caries. And I don’t have to point out if it’s molar or premolar or whatever.

You just know that feeling. And in some cases, even you think about which posts I’m going to place or whatever. And it’s interesting when you enter these cases, these really deep caries we see in the dental practice, I considered my first choice of treatments always a full pulpotomy. If it’s really, even me if it’s pain, we don’t bother around with partial pulpotomy, due to pain management reasons, actually.

Because, of course, if you would be a patient and you accidentally, it would have like hidden caries nobody saw with all the technique we have, I would probably consider in your case of partial pulpotomy, knowing that we have an full pulpotomy as the second option as well. Because your patient, which is a dentist and we both know what we’re doing.

[Jaz]
But you know, one thing before you then maybe continue is coming on to the difference between the mini, the partial, and the full pulpotomy. It seems like you know, for me, the pulp chamber and a molar sometimes is very, very small. So I mean, what is really in millimeters difference between and the protocol, I guess between a mini, a partial, and a full? For me, it’s just you’re tickling the pulp chamber, you’re going to make it bleed, and then you’re going to put your MTA on top. So, I’m surprised that there’s three classifications of nicking the pulp chamber.

[Georg] 
Actually, there’s a really interesting German PhD thesis that she found more. But let’s say the mini pulpotomy is really easy. You just have a pulp, you just push the burs really gently on it. And you know, it’s-

[Jaz] 
How big of a bur? Because this is important, you know how they used to say like, ‘Oh, if it’s like a half a millimeter exposure or etc.’

[Georg] 
Yeah, okay, I know what you mean. Basically, I have Komet bur, which is a ball, which will really long shaft. And basically, I think, a millimeter in diameter. And I have also a bear cut which one is always sterilized for this kind of process. Because I just don’t want to use a bur, just used for excavation, where efforts they will kit I take out you can argue that it probably doesn’t matter. But that’s a different discussion. And referred, I would do mini pulpotomy and the partial pulpotomy. And by partial, my ideas to take two millimeters away. But now it really depends on the molar, for example, from which angle do you look at, from the occlusal? Or from the lateral?

And from the lateral, it’s quite hard to distinguish sometimes. And there’s interesting studies about pulp caps about pulp expose on the occlusal and pulp caps on the lateral. And of course, on occlusal I our work better. And I would say we probably can transfer this knowledge to the pulpotomy as well. But it’s harder to do partial pulpotomy if you just nick a pulp horn and kind of remove it. And so you don’t know, did I do a full pulpotomy on one root of smaller and the partial pulpotomy of the other one. And to make it short, if a doubt, go for full pulpotomy. What is full pulpotomy? You just go until the root canal entries.

[Jaz] 
Like the orifice, a bit literally like the canal orifice?

[Georg] 
Yeah, pretty much. That’s the full pulpotomy. You basically take the whole pulp chamber away. And actually it sometimes makes bleeding control quite easier than the partial pulpotomy because you just have some root canal orifice where it’s bleeding and you can kind of just use your sodium hypochlorite, which is my first choice. Sometimes I even use sterilized cotton, the foam pellets to put some gentle pressure.

[Jaz] 
And one thing that maybe someone may not appreciate and I’m just thinking out loud here is if you’re trying to stay within the pulp chamber and not actually damage the pulp tissue in the canals, it’s fair to say that with you’re hypochlorite, you’re definitely making sure that you’re definitely staying within the pulpotomy. You’re not forcing any hypochlorite into the canals, is that an important part of protocol?

[Georg] 
Actually, it’s important that we don’t put our syringe like an endodontic treatment and place it directly into canals. But actually, it’s a typical question you’re pointing out, Jaz. Because a lot of people are afraid, will sodium hypochloride destroys a pulp? And basically, just say, ‘Did you ever get a sodium hypochlorite on your skin?’ Yeah. And the question is some say yes, some are ‘What’s happened?’ Well, it burnt a bit. But did it went through your hand? No. And actually, it lower concentration that used to be in the First World War, instead of infection agent for open wounds. And so, of course, the sodium hypochlorite can disolve necrotic and vital tissues, but that’s good news. It’s basically doing parts of your pulpotomy for you, but in a chemical way. And that’s why it’s like the best thing you have here.

[Georg]
And now we have to talk about bleeding time, because that’s the most obvious question when it comes after it. And it’s really interesting when you look at the literature, and we have now recommendations from the German Endodontic Society from the ESE. And it’s great when we have, for example, Dominica, where we could wait two minutes, and then he goes on with this partial pulpotomy, wait two minutes again, until he reached the full pulpotomy. But Dominican Country is really great. And Mayan, but he has a lot of time and patience.

[Jaz] 
Yeah, but what are you waiting for? Like if you enter the pulp chamber, and then you just wait two minutes to let it bleed out?

[Georg] 
Yeah, basically, you place, your sodium hypocholride and wait for the bleeding to stop. Basically, actually, in the ESE paper, you are allowed to wait for five minutes, for example, first to a partial pulpotomy wait five minutes, bleeding is still there, when you do a full pulpotomy wait five minutes. And if it’s still bleeding too hard, you basically go for root canal treatment. And that’s actually a recommendation, which is for every general practitioner out their fight gods, but we have to think that it’s just a recommendation. It’s not a law, we have no science supporting this bleeding time. And, of course, there will be now someone on university under endodontic department who wants to kill me for that statement. But that’s fine.

Actually, I love having discussion with my German endodontic department because I say and have some minor literature to prove it. But the bleeding time doesn’t really matter. But that’s just my science opinion. But it’s okay to have it. Because I noticed that sometimes there are also other bleeding control agents out there, which don’t have any signs of doing so I don’t mention that. But if we just look at milk teeth, they basically use ferric sulfate that works great. Yeah. Could you use ferric sulfate in a permanent molar? Yeah, probably you can. Is your science on it? No. Pretty easy. So, I basically come to guessing and some people are afraid that we are hiding some symptoms which are inside the pulp and which costs pain. But let’s be honest, if the patient has still has pain after full pulpotomy, you do a root canal treatment.

And that’s it. Did you lose anything? No, you have a nice pre-endodontic build up? Probably? Is it hard to drill through MTA? No, it’s quite easy. Because MTA is like under filling out an amalgam. You really say ‘Yes, great. It’s so easy to remove. It’s not tooth colored composite, or GIC, which is template so easy to remove.’ So go for it.

[Jaz]
But a real-world issue here, Georg, is then is fee discussing, you know, setting your fees for the patient and extra time that’s going to take to then need that and then you need to have a patient on board that, okay, we’re trying this. If it doesn’t work, then you need to pay for the root canal treatment. And then he just needs additional procedure and having a patient on board that, you know, had you just had the root canal treatment, you’d be out of pain. Now, It’s a shame that you don’t have a pulp anymore. But we’ve been doing it for many years.

[Georg] 
I know what you mean, actually, in the beginning it’s quite easy. You just present two plans. One is pulpotomy and one is root canal treatment. We don’t know yet what will happen. Probably if we have time to plan that, you say pulpotomy is one appointment where it’s just maybe half the price. And root canal treatment is two appointments. So, it’s double the price It’s logic.  And basically, the people are crazy, always on your side. If you say we try to avoid what kind of treatment or I don’t like it, I told you, but I don’t like it to point it out as an alternative to what kind of treatment but for example, it could be a false positive, so there’s no pulp inside. That’s just the necrotic, of course, you have to do a root canal, pretty much, pretty easy. And so for the beginning, it’s actually quite good to do it. Actually in Germany, we have the problem that our health insurance billing system doesn’t really have this pulpotomy position for permanent teeth. For milk teeth, they have. So it’s kind of, you have to be a bit creative. Unfortunately.

[Jaz] 
We know what that likes in the UK we know how to be creative in our systems.

[Georg] 
But basically how it works. Just because you’re from UK, Jaz. So, a guy from the UK said it also too easy meeting he waits for 10 minutes.

[Jaz]
Oh, my goodness. Okay. He must have been in private endodontist. Not a health board. Yeah, nothing insurance base there. So, that that makes sense. I mean, there’s so many questions going on my mind now. So, you’ve described the mini pulpotomy, your sink the bur through a little bit, let’s say a millimeter. Partial is up to two millimeters that you go into the pulp chamber and full is you reached the canal orifice. One thing I want to know now is still that decision making.

So, what I’m hearing I’m guessing Georg for you is that irreversible pulpitis. I’ve been awake all night in pain, I need to put a cold bottle next to my tooth to get out of pain. That classic irreversible pulpitis. You’re suggesting to me that you will still try to assess the bleeding time and potentially go down the route of pulpotomy. In this day and age, 2022 Qatar World Cup coming up. And you’re saying that now you’ve shifted away from okay, there’s two things RCT to, actually, I’m going to go for pulpotomy. Am I hearing you right?

[Georg] 
Yes. But there’s also a little but. For example-

[Jaz] 
Let’s see the nuances.

[Georg] 
So, for example, if you now have a businessman who will be at the World Cup in Qatar next week. It’s a different patient management in this case. I would say, look, I would strongly believes this will work. But it could be but emergency dentist in Qatar says that I’m the worst dentist of the planet, because I started the RCT and did not finish it. So, and it really depends on for example, now I’m more or less don’t have my own patients anymore. I have I get referrals. So it makes it a bit more complicated as well. So, let’s say the next 14 days he’s in town, and would be fine, if it were something I would probably go for pulpotomy.

The younger they are, I tend to more say pulpotomy is my first and only choice, because it just makes sense in my eyes because I did a lot of the treatment of teeth, broken canals, broken instruments, and I know how many things can go wrong and I break even instruments of course, yeah. So, it’s for my logic, my first choice. And if you have your first patients where you’re doing it, always do a full pulpotomy. Dentist always wanted to do a partial pulpotomy in their first case, always do a full pulpotomy. Just trust me. I talked to really cool people like Ness retire from John who did research on it. And she even said, which is something scientific. The full pulpotomy tends to be a clinical better than the partial one.

[Jaz] 
Then, why not always do a full pulpotomy? It’s only like a millimeter, two millimeter extra pulp tissue. Let’s just go for it.

[Georg] 
Yeah, I mean, there is a partial pulpotomy which has some advantages. And one big advantage is that you can do a cold test later on to see if the tooth reacts to it. But full pulpotomy, you can’t do a cold test because-

[Jaz] 
I didn’t know that.

[Georg] 
Pulp chambers for and that’s really drawback, but it’s still safe for your first case, guys remember me saying that. Go for a full pulpotomy. I know where people sending me x-ray. I did a partial because I was afraid. Okay, do full pulpotomy before. Okay. Firstly, then get experience. And that’s fine.

[Jaz] 
All I’m thinking Georg is the next time your uncle, your brother, your father, your mother, your nurse, your receptionist, your neighbor has signs of irreversible pulpitis or that very deep caries that you just know it’s going to be an issue, then perhaps your first full pulpotomy should be on this kind of patient.

[Georg]
Yeah. And actually, right now, I wouldn’t have any problems to do it on any family member on any staff member to do full pulpotomy. Because I now have the confidence. But we talk about failures as well. Because without talking about failures, it would be very misleading this podcast. Yes. Yes. Basically, you can basic distinction between early and late failures. Yeah. First of all, how high is the possibility that the patient will be better on the next day and still have pain? I can tell you, that’s a pulpotomy as a pain treatment works in 91%. Well, as a pulp ectomy will work at 99%, and from an emergency dentist point of view, and you had to do a podcast recently, I think.

[Jaz] 
Yes, yes, we did. With Sanj Bhanderi.

[Georg] 
Yeah. Was a great one.

[Jaz] 
I’m sure you would have done.

[Georg] 
Yeah. And for those 8% more success, how much time do you spend? So, I can tell you whether it’s pretty much less likely that the patient will show up the next day and have pain.

[Jaz] 
So, the lesson there really is if your main occupation is an emergency dentist who does not have the privilege and the pleasure of following up your patients and you’re delivering a service and that services, get this patient out of pain and keep them out of pain, then perhaps in your setting, in your environment, you should stick to pulpectomy Is that a fair statement?

[Georg] 
Depends from how many patients in a waiting room. Actually, it’s during the corona pandemic, yes. And Garrett even suggested from his time in Lebanon, to just place dexamethasone, just to injection with dexamethasone close to the pulp, just doing this filtration. That’s the best word. And it will resolve the pain.

[Jaz] 
Like intrapulpal?

[Georg] 
No, no, it’s just like an regular-

[Jaz] 
Like a buccal infiltration.

[Georg] 
Buccal infiltration.

[Jaz] 
Okay.

[Georg] 
Yeah. And he’s suggested with a braided wet back, when was Lebanon. And maybe now it’s beginning of the Corona, because everybody was afraid of aerosols, that should be a treatment option we got considered. So if you have really a lot of patients, you basically have to take the one with the past coming out, he’s your first choice, everyone can get injection. If you have a lot of patients more or less, no severe swellings, I would go to full pulpotomy with everyone and just play some temporary filling on it, and it will work quite good. And of course, if we have such cases where the bleeding is so extensive from the canals, no matter what you do, it won’t stop these cases, you do a pulpectomy. Of course, yeah. Because you can’t really tell them even in emergency but bleeding out of the tooth is normal.

[Jaz]
But well, it is true. But early failure, you said was the next day pulpectomy 99%, out of pain pulpotomy 91% out of pain. And then so if someone comes in with an early failure, does that mean they now advanced to stage two, which is the pulpectomy is that what happens?

[Georg] 
Basically, after full pulpectomy. It’s pretty easy. Actually, interesting with my failures, it’s actually you have a gender part in it lots of more female patients have an early failure. Which is interesting. And usually, the early failures in the first seven days, yeah, even like now tennis to hot drinks are still cold after full pulpotomy if you feel something cold. That’s something wrong. You can basically say, okay, maybe that’s a real recession. It’s a palatal route, and where you can kind of get some signals.

That could explain it. But after full pulpotomy, you don’t feel any cold. And so if I still feel something, it’s kind of odd. Really, I would say in the first seven days, it can happen. Yeah. Remember the 80% success from the Iran study? And I think we can relate for very good, very good, but it’s not like that every fifth patient will be visit you next week and have pain, because we have also late failures, but somehow to get necrotic. Or, yeah, basically, they get necrotic somehow.

[Jaz]
Well, the interesting thing here, and the dilemma we have is that if we start in the in the future, because look, Georg as much as we’d love for everyone to pulpotomy. And I think this episode is gonna go a long way, hopefully, to start making dentists think about this. And so that’s what I love about speaking to people like you generating new ideas, not even very new, like relatively new, because we know the lecture is now getting out there, which is amazing.

And we’re sharing these new protocols and ideas. But the dilemmas it poses are also new, which is the whole thing about cuspal coverage, if the patient now needs to spend additional, I don’t know, 900,000 pounds, 1000 euros, because to be able to get to a point where the tooth potentially needs a pulpotomy, it’s the same thing as it potentially needs pulpectomy. It’s got a huge amalgam of fracture, it needs cuspal coverage. And then the extra dimension of doubt that you have now is should I put a crown on?

What if two years later we had to then drill to the crown and do an RCT? Which is the same dilemma we have, and we have deep caries, right? So, this is another layer of complexity.

[Georg] 
Yeah, but in my hands, actually, the full pulpotomy makes things simpler because we don’t have nose guessing. Spheres, deeper divorce leavings decay. Okay, how was the pulp studies anyway? We don’t know where it. And with the pulpotomy, we have one advantage we saw was it vital? Was it necrotic? Or didn’t look well? Actually, it’s really hard. There’s not really a good book about how the healthy pulp and a lot of picture of healthy and unhealthy pulps which it really comes down to experience and I even myself say something on it. Yeah.

And for example, you just mentioned your staff member I just had a staff member opened up the pulp and there was a small moment where I said OKAY, it just exposes the pulps a bit. I just do a mini pulpy and we’ll be done it was great. But it was like no, she had pain. I go for pulpotomy, and they looked at the path and you don’t use could see the pulp but was not really bleeding very good. So, I did the full path to me it still was not being very how I saw some bleeding I was like, oh okay. I still went for the biodentin on top, placed my filling but said okay, let’s look. Next seven days and you know the seven days Oh, over she still have some symptoms on hot. So, I say no, we have to probably do adversities pretty sure after seven days if it’s a pain has not gone up seven days. It’s quite good sign. I mean, she has a short distance to the dentist’s differentiates at work and experience fame. So, when the next

[Jaz] 
When the next patient cancels, she’s the one in the chair.

[Georg] 
Usually, the last patient of the day or something like that. We always find a way. And therefore when you kind of have a look at the pulp and you kind of still don’t feel really comfortable, it’s probably not working.

[Jaz]
And what is the unhealthy pulp look like? Like a vital but unhealthy pulp that gives you that feeling in your stomach, that’s not going to work for them less experience. Because look, think about it, Georg, we are used to a living less way less experienced then we are used to opening up the pulp chamber with one motive; kill, kill, kill. We don’t even probably look at the we just go through the bleeding, we stick some hypochlorite right in the canal and we put the pressure inside. We don’t even look pause and see. What is the health status? What is this pulp looking like today? So you need to enlighten us.

[Georg] 
Yeah, it’s very difficult to tell. But even when I look at Dominica, we could use studies where he did a lot of pictures of really nice pulp and say, and she says that’s unhealthy, but suffering like, oh, wow. And there are some things where you can say the color methods, if it’s really pinkish, and it’s probably it, if it’s more brownish or leathery, let’s say this one, it’s probably nothing. And sometimes I mean, you can just pop the pulp and if it feels like it’s one block of very liquid, it’s probably not working. And I even had one case where I did want it to do kind of some pulpotomy at the central incisor and just rinsed it a bit.

And suddenly the whole pulp was in the vacuum sucked away. And I was like, okay, probably that was not unhealthy pulp. Pretty easy. But it also has a case with a young patient, where I had on the referral sheet, root canal treatment to ferrule, and I looked inside, it was a healthy pulp. Apparently, the pulp kind of went away, did put two people by the file, which was interesting. And so I don’t have the answer for you, unfortunately. Yeah, but my answer so I like bleeding pulp, if it’s bleeding, and it stops its-

[Jaz] 
What if it’s that term, hyperemia? You know, we always see that the patient in pain comes in, and it’s just flooding in blood. Is that encouraging for you, as someone who’s not looking it as a pulpotomy?

[Georg] 
Let’s say it’s this way, if it’s really hyperemic, you probably have no chance, because you would need a really strong leading control agent, or even something where you just close your eyes place MTA on a cupboard, or is probably not gonna work. I wouldn’t say never. But it’s not that-

[Jaz] 
Okay, good to know that if it’s too much bleeding, it’s hyperemia, go with your gut, and then that is an unhealthy pulp.

[Georg]
That’s why I basically like the time of the five minutes, which is basically I don’t want to say it’s literally have to stick to it. Because some people are very dogmatic about what’s in the literature. It’s a recommendation without any proof. And but I like it and I would say if it’s still bleeding very hard after five minutes, you left sodium hypochlorite on it. It’s probably your restorative material will not work. Yeah, but I also found that some MTAs work better than the other. It’s just interesting. And since people are always asked me for products, biodentin has the best literature from Zepto don’t outwear so it’s my first choice when I have for example, a really young kids, which has a bleeding it’s a little bit itchy. Yeah, that’s the best way to describe it. But I still want to keep it. Sometimes tend to use material from CERKAMED, Polish company, BIO MTA+, because it’s bit better-

[Jaz] 
That’s a cool name. Bio MTA plus a second every single good thing endodontics BIO MTA+, and just that’s the best product name there is in endodontic surely.

[Georg] 
Second mate, is a nice company, they’re not good at research.

[Jaz] 
The real wet fingers dentists of the world.

[Georg] 
Basically, it’s for surrounded by wet finger dentists. And but it works good in situations where the pulp bleeding is a bit bitchy. The other materials which are also very interesting because ultradent and just released, MTAFlow White, and the material has like an agent in the liquid, which is less problematic when washing away and wash away fluid can longer-

[Jaz] 
So, less water soluble?

[Georg] 
We have, who knows. Actually, just that company told me that it’s something which is very, very common in the concrete industry but only to people in the dental industry habits and other products. Then there’s also products from Angelus MTA REPAIR HP. It’s also quite good. And I tell you why it’s important that we have some different materials because we didn’t talk about one thing which is tooth discoloration because some MTAs even the classic approved MTA have some radiopaque and acids, which when it’s combined with sodium heparin, discolors. And they have different concentration for example, second one has also this radiopaque and bear.

So, I would rather use it at a molar and tell the patient that’s a tooth might discolor that won’t turn black, don’t worry, but it will appear more grayish. And if it’s a first premolar, you’ll see it. And then we also have to take in consideration that in every manual you take out and buried and in better say, as I only placed it on basically on the non-bleeding pulp. And the reason is when even like when materials come in contact with Bloods, which I suppose not discoloring. Of course, if there’s too much blood with iron inside, it will discolor Yeah, it’s very natural. So that’s also reason to spend a bit more time in controlling the pulp and that’s why it’s a pulpal bleeding. And that’s why I’m not a fan of this five minutes in vets situation.

[Jaz]
Well, we have to now wrap up and talk about okay, why is it that you’re so anti-leaving some caries weight where you can get a good bond? Because your peripheral seal will be good, you know, the seal is a deal and when a kid so why not leave caries dentin as your base?

[Georg] 
Yeah, I mean, I tried to make it short. Basically, it’s the concept is very good. And I liked it at the beginning a lot and did it a lot, even with this deep caries one and I got failures, failures, well, I’d say I would have done a pulpotomy. versus refill so on, it’s a good idea. But let’s be honest, if you think about it, that the ceiling sounds better than it is even like a healthy tooth bacterias crossing, it’s the whole time it’s not sealed in the way because we don’t have sterile and violent at the mouth. And the basic is carriers model everyone is talking about as maybe a flower model, if you take aways in a tuition vans, and when nothing will happen.

[Jaz]
It’s a disease of the surface, as you said.

[Georg]
And it’s a simplified model. And it’s really easy to understand, and it’s far completely okay. But you have to always say it’s a simplified model, who says where we are not some backs in the decay, who don’t need sugar, they just live on pulpal fluids. So, this box is really simplified. Now, I, myself doing the same thing, but I have a friend from the University of Munster Germany, who can say at a much more convenient way. Actually, we have a German podcast on it. But-

[Jaz]
Very good.

[Georg]
But he basically says we are some bacterias who are irritating the pulp and you know, functioning and one of the advisors of the seal is a deal theory, which he stood on grade z is research says come on, it’s just of course the pulp is irritated. It’s what’s the deal about it. But I would say clinically speaking, I tried it. In some cases, I’d even still do it. For example, in cases where we have a lower molars. And really cervical dentin cariers widened the distal, where, you know, if I would do it directly, I would destroy a lot of tooth in these cases, I would just try to push some GIC inside and monitor it. And, of course, there are some patients where it makes sense to use this approach. But it really also depends on your personal setting where you work in. And for example, if I have the time, if I have rubber dam magnification, of course I can remove more. And look if there’s a pulp, and we have a success rate of a vital pulp treatment of the Pulpotomy, which is so good. I would even say-

[Jaz]
That’s 80%, right? We’re talking about 80%. Right?

[Georg]
80% Actually, if you look to literature, it’s the lowest

[Jaz]
And how many years are we talking? Five years? 10 years, what do we have?

[Georg]
We don’t have 10 years we have five year max, that’s a pretty basically. And that’s why now the Cochrane Reviews favors leaving of the decay. I say it on purpose leaving of the decay. And anyways, if you have have, like, a new rule area where not a lot of dentists, it’s a good concept. Let’s be honest, and so whole technique with children. Really good concept. Yeah, let’s be honest. But the success rate of this treatment, after the beyond our study, whatever, it’s not so good. If you just look at the numbers, it’s mainly 60%. We have had really strict success criterias if it’s not working on the cold test anymore, where basically you said that’s the failure, but it’s really strict. But if you look at other studies, newer studies 90 percentage area with the success waist, and we don’t-

[Jaz]
Vital pulpotomy once again.

[Georg]
For me, irreversible pulpitis, everything you want permanent teeth. And that’s a lot and then you basically think last beyond our heads 11% success with partial pulpotomy. And you basically, ask yourself, what did they do wrong? And it’s not written in a study. And it’s not a criticism. I mean, it’s a great study in the evidence is much higher than everything else. But we don’t have any comparison studies. And of course, everyone in university, ‘Oh just do a randomized control trial.’ I don’t know how to do a randomized trial. It’s kind of even, like when you think about it, I would like to do a randomized trial, but I don’t believe in selective caries removal.

So, I should do something I’m not believing in, guess the results! Probably it will turn out better than my vital pulpotomy. And that’s something because I’m just biased. Even with like, a lot of centers, you will get basically, this result, either one is trained in the vital pulp therapy on the selective cariers removal. And I don’t condemn myself, but I for myself, from my experience with my failures by the pulpotomy, and selective caries decided, I don’t want to do selective cariers removal anymore. And I hope I am not will be like so. You noticed all dents like in the early days, we did all this review with all the carriers. And it works much better when you’re selective approach.

And, you know, I’m not sure about this. And I’m not following up on my cases to really know how my success rate, and my weaker rate would be really bad. But that’s a problem in all dentistry. And it really depends. Now, I’m basically in private office, I have time to place my rubber dam treatment plan. Of course, it will work in my hands quite good. And let’s be honest, if I would believe and select cavity, these cases would all work very good as well. Yeah. So, I don’t like this dogmatic approach a while. There are some reasons to look at the pulp and see if it’s vital. Like I’m just kidding. Yeah, but it’s nothing I would say to vet or vet. But for us in the practice, and I worked in a rural race, just remember the tooth with a deep caries, and so we’ll be ended for sure. And I don’t really have time, Z has good cases to start. Because you don’t have anything to lose. And it’s not an experiment. I really hate about experiments. Sometimes you’re doing experience.

It’s nothing new. It’s probably even older than spec. I think, even like before the First World War, some people were doing research on it. And it was just forgotten knowledge. I mean, even selective caries removal is nothing new vessel really nice this article about it from the 50s where we extracted first molar of children and kind of compared selective carious removal and they use the full caries removal, new metrical calcium hydroxide back then the MTA of that time. So we’ll come in waves and just to complete it, I’m not dogmatic of any way. And I would really be happy to see some literature that I know is a functioning group and Berlin is working on it, I would say, there’s not a perfect study you can design to really convince everyone due to the bias, and-

[Jaz]
I mean, yeah, clinical dentistry is played with this issue of not having amazing evidence when you compared to other fields. So, this is what we have to accept. So, there’s still a lot to be discovered in terms of what are the best definitive protocols. So, I very much appreciate that. And let’s not be dogmatic, and it’s one of my favorite things. There’s no place for dogmas on this podcast. And I thank you very much for giving your time to discuss this. You’ve opened my mind, Georg, because you know, to think that irreversible pulpitis does not equal RCT anymore, does not equal pulpectomy. anymore, is very fascinating. And I’m very much my background in training is never exposed. That’s just like, ingrained in me never expose. But really, and I’m open to listening to you and then finding out more, which is in some cases, actually, there is a place for pulpotomy in the adult tooth, which has been carious and the dubious pulpal status.

So, I think what we’ve done is open everyone’s mind, what do you think is the next step? Because I don’t expect for intelligent dentists listen to this one podcast episode, and then just start cracking on and guessing how much MTA they need. I do feel that perhaps there’s some training that’s merited? Where does one get some training and some knowledge? And also, one more thing actually, is, if I’m working with an endodontist in the practice, and before I started sending him cases or advising him, you really need to have an endodontist who is on board with you. Right? And I think that sort of team approach, it is really important to have that open line of conversation with your endodontist.

[Georg]
Yeah, I was at ease, you don’t find any endodontic conference from now on probably ’til the next 10 years, which is not talking about vital pulpotomy. It’s the hottest topic of office. No, I wouldn’t say so of this decade for sure. Because now the AAE had a position statement and the ESE.

And basically, we were just waiting for 10 years data and there’s like something like a little fight between the cariologist and the endodontist. And so cariologist will win because they’re much more, that’s fine. To get your endodontist on board, it’s a really cool idea. Janet, basically tell them, you basically just do the root canal. And he’s just doing what is on the first sheet. Because that’s a different topic as well. Actually, I have an old lecture at Dentinal Tubules with to show a couple of years ago, actually, just when we started talking, I thought I really have to talk to Drew to update it.

Because some of the things I say I would frame them differently now, which is fine. The answer is, you see how it’s Bob’s. And I’m pretty sure there’s training out there. But most of the time, people think it’s so specific, probably no one is interested. And actually, a view if you call it pulpotomy of permanent teeth, every dentist understands it, it sounds something new. And just start your cases, document it and you can do some local lectures for sure.

[Jaz]
Well, what I appreciate is we’re not trying to make something more complex, because I’m not going to name any names here, Georg, but there are some sub specialities let’s call them all disciplines, new disciplines of dentistry emerging, which I think are trying to complicate dentistry, and they’re giving new names and new acronyms to things which is already in the on the old textbooks. I think, you know what I mean. And I like-

[Georg]
It’s just biomimetic.

[Jaz]
I got so many biomimetic friends and guys, like don’t get any offense, right? They’re great. And you gotta love what you do. But when did we stop calling it adhesive dentistry and just change it to biometric? I don’t know when that happens. But yeah, what you’re doing Georgie, I appreciate that, that you’re saying that, ‘Oh, no, it’s not vital pulp therapy.’ Why don’t we call it a pulpotomy of vital teeth

[Georg]
Pulpotomy of vital teeth and one thing, biomimetic dentists are afraid of the pulp I don’t know why, but they’re afraid, I would say but it’s basically due Tuesday based in the US, they have to refer I think to the dentist and they lose money on it. Just really a simplification-

[Jaz]
Very cynical, but yes.

[Georg]
Therefore, they want to tend to have anything inside and then therefore this concept of selective caries removal works very good for me. I’m personally, I’m not afraid of the pulp. Not at all.

You don’t need to be if you see the pulp, just refresh it a bit. If it’s bleeding to hard remove a bit more, if it’s still bleeding to hard, remove the whole pulp chamber. And when you have RCT, which don’t have to do if you don’t want to do RCT, just stop there after the full pulpotomy and place some ledermix pellets.

 So, your endodontist will love you for that. And the patient won’t hate you because they basically out of pain. So, everything’s fine. You don’t need to be afraid of anything of not exposing. And there’s one German study where we’re exposed to pulp and that really bad results. And when you look at the studies, treatment was done by dental students. They used carelife and dycal things which don’t work.

Plus replaced the temporary filling on it a GIC, which is regularly a good material, unless you have exposed pulp, when it will be a success after six months. And you basically can wait for, it will be not a success. It will be failure after six months, because the backs are going downward, and you’re gonna love to kill the open pulp. And that’s pretty easy. So you find today, literature for anything, but you don’t need to be afraid of the pulp.

[Jaz]
Guys no longer are we afraid of the pulp. I certainly won’t be. Georg thanks so much for giving our time, really appreciate it. Check out SaureZähne. Hope I said it correctly. We’ll put the link on and again, thank you so much and good luck to Germany advocate a Qatar. I’ll be rooting Amrita, I’m cheering three teams, England, but today I paid five pounds in the sweepstake at work, and I got Argentina, and I got I paid another five pounds and I got Spain. So, my three teams are England, Argentina, Spain, and if I win, I win 150 pounds, and I will treat the entire staff to pizza. So, that’s the plan.

[Georg]
That’s a good plan.

Jaz’s Outro:
Thank you so much. Oh, there we have it guys. Look, I’m really sorry if I offended anyone towards the end. I’ve got some really great friends who are Biomimetic Dentists like Germàn. Germàn, I know you listen to this. Thanks so much. Look, you know, I don’t like to offend anyone. And I really mean it a bit tongue in cheek. I mean, it as a jest. But what we’re trying to say. I mean, Georg meant was that sometimes we need to simplify things and not complicate it. And I think what Georg suggested was that biomimetic dentists are afraid of the pulp. We know that’s not true. We know you’re trying to preserve the pulp as much as possible. And I get it and that’s awesome. So, love to all, respect to all, let’s listen to everyone, but do what feels right to you. So guys, don’t just jump in and do a vital pulp therapy, aka pulpotomy. Maybe read a little bit more around the subject and then commit to it but at least it has given you a reason not to be afraid of the pulp anymore. Thank you so much for listening all the way to the end. Claim your one hour plus CPD by answering a few questions below if you’re watching on Protrusive Premium. Thanks as ever for joining us today.