Direct Pulp Capping: A recent update

Lebanese University –School of Dentistry

Department of Restorative and Aesthetic Dentistry

Dr S.Artine

Dr P.Hajjar

Dr S. Mouawad

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I- What is direct pulp capping?

Placement of a protective dressing directly over the

exposed pulp

Pulp exposed

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No need for RCT

Why?

Saves the tooth and

Preserves vitality

Conservative treatment

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o Healing/ Repair.

o Pulp’s vitality and function.

o Normal responsiveness to

electrical and thermal pulp tests.

o Preventing breakdown of the

peri-radicular supporting tissue.

oFormation of secondary dentine.

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1756, Pfaff

1826, Koecker

1921, Dätwyler

1930, Hermann

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•Immature permanent teeth or

mature permanent teeth with

simple restorative needs.

II- Indications of direct pulp capping

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Small pinpoint pulp exposure=1mm

•Recent traumatic (<24 h)/Mechanical pulp

exposure

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•Little or no bleeding at the exposure site

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•NO PULP

VITALITY

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•No pulp calcification

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•Adequate coronal restoration can be made

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•Systematic diseases: diabetes, cancer…

III-Contraindications

•Inflammatory signs/ symptoms 13

•primary teeth root resorption

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•Pre-operative

tooth sensitivity

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•Large

pulp exposures

•Uncontrolled

bleeding

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•Non-restorable tooth

or restorable with low

prognostic

Dentin Bridge

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IV- Pulp capping materials

•Calcium Hydroxide Ca(OH)2

•Mineral Trioxide Aggregate MTA

•Tri-calcium phosphate

•Bioaggregate

•Biodentine

•Bonding Systems

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•The most common direct

pulp-capping agent

•Antibacterial and

disinfects the superficial

pulp

•High pH (about 12.5)

Pure Calcium

hydroxide

Calcium hydroxide Ca(OH)2:

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How does Ca(OH)2 work??

•Liquefaction necrosis of the superficial pulp

•Neutralization of toxicity in deeper layers

•Coagulative necrosis…Irritation of adjacent

pulp

•Minor inflammation response… Hard tissue

barrier

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•Pure calcium hydroxide are more

caustic than Hard-setting calcium

hydroxide pastes (Dycal, Life,…)

but both have been shown to

initiate the same type of healing

Properties:

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• Dentin bridges beneath calcium

hydroxide pulp caps contain ‘tunnel

defects’, therefore an additional

base material is necessary to seal the

exposed pulp from the external

environment.

•Calcium hydroxide materials tend to soften, disintegrate,

and dissolve over time.

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Mineral Trioxide Aggregate or MTA:

ProRoot To seal communications between

the root canal system and the

external tooth surface at all

levels and recently indicated in

pulp treatment as direct pulp

capping.

Dr M.Torabinejad

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Composition:

•Tricalcium silicate

•Tricalcium aluminate

•Tricalcium oxide

•Silicate oxide

Mixed with sterile water in a 3:1 powder-to-liquid ratio,

MTA sets in 5 minutes

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Application of MTA

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•Low or no solubility

•PH value10.2 after mixing and rises to 12.5 after 3 hours

•Antibacterial effect

•Induces pulpal cell proliferation

•Stimulation of mineralized tissue formation

(Mineral Trioxide Aggregate: A Comprehensive LiteratureReview—Part I: Chemical, Physical, and Antibacteria lProperties)

(Direct pulp capping with mineral trioxide aggregateJ Am Dent Assoc 2008;139;305-315)

(MTA AND CALCIUM HYDROXIDE FOR PULP CAPPINGJ Appl Oral Sci 2005; 13(2): 126-30)

Properties:

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Process not yet known

Tri-calcium oxide + tissue fluids = calcium hydroxide

Hard-tissue formation

How does MTA work??

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•Rapid cell growth promotion in vitro

•Greater ability to maintain the integrity of pulp tissue

•Thicker dentinal bridge, less inflammation, less

hyperemia and less pulpal necrosis

•Induce the formation of a dentin bridge at a faster rate

•High ability to resist the penetration of microorganisms

•Limited antibacterial effect

(Mineral trioxide aggregate pulpotomies A case series outcomes assessment J Am Dent Assoc 2006;137;610-618)

MTA v/s calcium hydroxide

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Tri-calcium phosphate:

- Bone regeneration procedures (promotes effects on

hard tissue formation by osteoblasts)

- Studies (by Heller) showed that dentinal bridge

formation does take place, by direct apposition, on the

pulpal wall

The bridge:

•Contiguous

•Thick

•Minimal pulpal inflammation

•Odontoblasts directly under and in contact with the

bridge

Use of a Resorbable Ceramic (SYNTHOS) in Direct Pulp-Capping Driskell, T., Heller, A., and Koenigs, J., The Ohio State

University,Columbus 1974

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Bio-Aggregate

Indicated as:

• Repair of Root Perforation

• Repair of Root Resorption

• Apexification

• Pulp Capping

Bio-Aggregate is a root canal

repair material composed of

bio-ceramic nano-particles

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Pure white powder and liquid mixed together to form

a thick paste-like mixture.

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VS

MTA and Bio-Aggregate show

similar chemical composition with

some differences

Tantalum oxide Bismuth oxide

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Biodentine™ :

Active Biosilicate

Technology™ /calcium

Silicate based cement

Dentin substitute from Septodont Saint

Maur-des Fossés, France

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Indications:

•Endodontic indications (repair of perforations or

resorptions, apexification, root-end filling)

•Permanent dentine substitute and temporary enamel

substitute

•Restoration of deep or large crown carious lesions

•Direct pulp capping in adults presenting healthy pulp

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Formulation:

Powder

Tri-calcium Silicate (C3S) Main core material

Di-calcium Silicate (C2S) Second core material

Calcium Carbonate and Oxide Filler

Iron Oxide Shade

Zirconium Oxide Radiopacifier

Liquid

Calcium chloride Accelerator

Hydrosoluble polymer Water reducing agent

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Clinical Case

After 3 months: Final filling

BIODENTINE™ A NEW BIOACTIVE CEMENT FOR DIRECT PULP CAPPING Till Dammaschke, assistant

professor, DDM Department of Operative Dentistry Waldeyerstr. 30 48149 Münster Germany

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Other:

Bonding systems =

Sealing potential of resin adhesive systems

direct pulp capping

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Resin adhesives Vs calcium hydroxide

•Less porous dentinal bridges = Better seal against bacterial

leakage

•Less pulpal inflammation

•Less successful (Pameijer and Stanley: ‘disastrous effects’

causing hemorrhage that was difficult to control)

•Less success rates with inflamed pulps (lack the inherent

haemostatic and bactericidal properties)

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CH

•Stimulating sclerotic and reparative dentin formation due to

release some proteins and growth factors

•Protecting the pulp against thermal stimuli and antibacterial

action

•Inducing pulp tissue to form a mineralized barrier

•Biological and therapeutic potential (Material of choice)

V- Biocompatibility & Cytotoxicity of pulp

capping materials

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MTA

•Abedi et al. (1996) MTA: less inflammation

•Pitt Ford et al. (1996): dentine bridge formation in all pulps

capped with MTA and no inflammation except in one sample

•MTA: excellent sealing ability (Torabinejad et al. 1993, 1994,

Bates et al. 1996, Fischer et al. 1998, Wu et al.1998)

• Excellent biocompatibility (Kettering & Torabinejad1995,

Torabinejad et al.1997, 1998, Holland et al. 1999, Mitchell et al.

1999, Keiser et al. 2000). Supposedly due to CH and

Hydroxyapatite formation

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1- Anesthesia

2- Rubber dam

VI- Techniques of direct pulp capping

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3- Chlorhexidine solution

4- Rinse with anesthetic or sterile saline

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5- sterile cotton

pellet to control

bleeding

6-Mix capping agent

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7- Apply to exposure site

8- Base/liner then restore

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VII- Temporary or Permanent Filling?

What’s the best choice?

A permanent restoration seals the margin more

effectively than does a temporary restoration, thus

preventing or reducing the microleakage.

(Ahmad S. Al-Hiyasat, Kefah M. Barrieshi-Nusair,Mohammad A. Al-Omari: The radiographic outcomes of direct pulp-capping procedures performed by dental students A retrospective study)

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The best Permanent filling process consists of

covering the pulp capping material with a RMGIC

followed by a hermetic composite resin

restoration to prevent bacterial leakage and

recontamination of the exposed area.

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VIII- Prognosis of direct pulp capping:

Success rates range from 13% to 98% in one to 10 years retrospective

studies:

• Armstrong and Hoffman: 97.8% success rate after 1.5 years.

• Fitzgerald and Heys: 79% success rate after one year.

• Haskell and colleagues: success rate of 87.2% after five years.

• Barthel and colleagues: success rate of 37% after five years and 13%

after 10 years for 123 pulp-capping procedures performed by dental

students.

• Baume and Holz: The operator’s skill seems to be one factor that

influences the outcome of pulp-capping procedures

(Baume LJ, Holz J. Long term clinical assessment of direct pulp capping. Int Dent J 1981;31(4):251-60)

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Not Significant Significant

Age Sex Tooth Location Tooth Position

Type of Exposure Type of Restoration Class of Restoration

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Age of patient

Sex of patient

Tooth location

Tooth position

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Mechanical exposure: Direct pulp capping + permanent restoration

to conserve the vital pulp.

Carious exposure: Avoid Pulp capping & opt for endodontic

therapy.

1. Type of Exposure:

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An hermetic seal against bacterial infiltration is a must to guarantee the success

of the pulp treatment.

2. Type of Restoration:

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The prevention or reduction in the microleakage reflects the higher success rate of

pulp capping in Class I restorations relative to that in the Class II, III, IV and V

and MOD restorations

3. Class of Restoration:

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Periapical radiolucency and need for RCT

Need for extraction

Good to know: time devoted to the teaching of vital-pulp

therapy to undergraduate students < teaching of formal

endodontic treatments

Failure

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1. Calcium Hydroxide:

•At the 7th day, the pulp tissue capped with Calcium

Hydroxide exhibited:

o Odontoblast-like cells organized underneath

o A zone of coagulation necrosis

• Pulp repair and apparent complete dentin bridge

formation after 60 days.

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2. MTA® (Mineral Trioxide Aggregate):

• A comparative study of WMTA (White MTA) and

Calcium Hydroxide concluded that at the 136th recall

day:

o 23 teeth of 23 Capped with WMTA, were clinically

diagnosed as successful

as well as

o 22 teeth of 23 of the Calcium Hydroxide group.

(Iwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, Jeffries S. Clinical and histological evaluation of white ProRoot MTA

in direct pulp capping. Am J Dent. 2006;19:85-90)

100%

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3. Biodentine® (Tri-Calcium Silicate)

Applied in 116 patients with at least one year follow-up. It’s

very well tolerated and can be used as cavity lining with a

permanent composite restoration.

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Success Rates

1. Type of Exposure

92.2% Mechanical

33.3% Carious

2. Type of Restoration

80.8% Permanent

47.3% Temporary

3.Class of Restoration

83.8% Cl I O

28.6% Cl II MOD

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IX- New perspectives and future trends:

• Other innovative technical advances include the use of:

• Lasers

• Ozone technology

• Bioactive agents

that induce and stimulate pulpal defenses

•Gene-enhanced Tissue Engineering

•Dental Pulp Stem Cell Therapy:

o Potential to improve on conventional pulp-capping with calcium

hydroxide or other artificial materials.

o Ex vivo cell therapy may have an advantage and might result in

copious amounts of reparative dentin formation.

o Skin fibroblasts transduced with BMP7-adenovirus induce reparative

dentin formation (Rutherford, 2001)

o Techniques have to be established and optimized before cell therapy

with BMP2 can become a clinical reality for caries and endodontic

therapy.

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THANK

YOU