PULP CAPPING

Submitted by:Shekhar kumar mandalBDS IVRoll no:26

SUBMITTED TO:Dr. Deepika KapoorDepartment of Pedodontics and Preventive DentistryCollege of Medical Sciences, Bharatpur, Nepal

1. INTRODUCTION2. TREATMENT MODALITIES3. TYPES OF PULP CAPPING4. INDIRECT PULP CAPPING5. PATENT DENTIN MEASURING DEVICE6. DIRECT PULP CAPPING7. FEATURES OF SUCCESSFUL PULP CAPPING8. PULP CAPPING AGENTS9. CONCLUSION10.REFERENCES

Contents

PULP is defined as soft tissue forming inner structure of tooth and containing nerve and blood vessel , also called as tooth pulp.

The dental pulp occupies the center of each tooth and shapes itself to a maturation of the tooth .

INTRODUCTION

TREATMENT MODALITIES PULP TREATMENT

CONSERVATIVE RADICAL1. Protective base 1. Pulpectomy 2. Indirect pulp therapy 2. Root filling3. Direct pulp therapy4. Pulpotomy

Pulp capping is a

technique used in

dental restorations to

prevent the dental pulp

from dying, after being

exposed, or nearly

exposed during a cavity

preparation

PULP CAPPING

FIG: Exposed or nearly exposed pulp 1) Crown 2) Root 3) Restoration 4) PULP CAPPING 5) Pulp chamber

PULP CAPPING TECHNIQUES

INDIRECT PULP CAPPING

DIRECT PULP CAPPING

INDIRECT PULP CAPPING

Indirect pulp treatment is defined as the procedure in which the non-

remineralisable carious tissue is removed and a thin layer of caries is left at

the deepest sites of the cavity preparation where complete caries removal

would result in pulp exposure.{ AAPD}

“A procedure where the deepest layer of the remaining affected carious

dentin is covered with a layer of biocompatible material in order to prevent

pulpal exposure and further trauma to pulp”. {Grossman}

“Indirect pulp therapy is a technique for avoiding pulp exposure in the

treatment of teeth with deep carious lesions in which there exists no clinical

evidence of pulpal degeneration or periapical disease.” {Cohen}

“A procedure in which only gross caries is removed from the lesion and cavity

is sealed for a time with a biocompatible material.” {Mc Donald}

DEFINITION

Historically, the indirect pulp-capping (IPC) procedure was advocated more than 200 years ago as a conservative pulp therapy.

Ripp reported that Fauchard, in 1746, advocated a conservative treatment of extensively carious teeth.He recommended the retention of some caries because, if the caries were completely removed, a pulp exposure would occur.

The term indirect pulp capping (IPC) was recently replaced by the term Indirect pulp treatment (IPT; American Academy of Pediatric Dentistry Reference Manual)

History

To arrest the carious process,

To provide conditions

conducive to the formation of

reactionary dentin, To promote remineralization of

the carious dentin that was

left. To Promote dentin sclerosis,

this in turn is expected to

promote pulpal healing and

preserve/maintain the vitality

of the pulp.

AIMS

& OBJECTIVES

History

Mild discomfort from chemical and thermal stimuli

Absence of spontaneous pain

INDICATIONS

Large carious lesion

Absence of lymphadenopathy

Normal appearance of adjacent gingiva

Normal colour of tooth

Clinical examination

Large carious lesion in close proximity to the pulp

Normal lamina dura

Normal periodontal ligament space

No interradicular or periapical radiolucency

Radiographic examination

CONTRAINDICATIONS

Sharp, penetrating pain persisting after withdrawing stimulus

Prolonged spontaneous pain, particularly at night

History

Excessive tooth mobility

Soft leathery dentin covering a very large area of

the cavity, in a non restorable tooth

Parulis in the gingiva

approximating the roots of the

tooth

Tooth discoloration

Non responsiveness to pulp testing

techniques

Clinical examination

Radiographic examination

Large carious lesion with apparent pulp exposure

Interrupted or broken lamina dura

Widened periodontal ligament space

Radiolucency at the root apices or furcation areas

It is based on the theory that a zone of affected, demineralized dentin exist between the outer infected layer of dentine and the pulp.

When the infected dentine is removed, the affected dentine can remineralize and the odontoblasts form reparative dentine, thus avoiding pulp exposure

BASIC PRINCIPLE OF IPC

Two Appointment TechniquesSingle Appointment TechniqueTECHNIQUE OF IPC

Indirect Pulp Capping Procedure

Two Appointment

Technique

First appointment • Tooth is isolated with a

rubber dam • The gross caries is removed with a large

round bur (6 or 8) or sharp spoon exclavator .Care must be taken removing the caries to prevent exposure of pulp .Care must be taken to eliminate all the caries at the DEJ . Because of its closeness to the surface caries left in the areas will likely cause failure .

•The remaining thin layer of caries is covered with a radiopaque biocompatible base material and sealed with a durable interim restoration

•Wait for 6-8 weeks.•During this time the caries process in the deeper layer is arrested.

.

Second Appointment (6-8 wks)•If the tooth is asymptomatic, the surrounding soft tissues are free from swelling and the temporary filling is intact , the bitewing radiograph at the treated tooth should be taken for the presence of reparative dentin .

•Carefully remove all the temporary filling material , especially base over the deep portion of the cavity floor.The remaining affected carious dentin should appear dehydrated and flaky and should be easily removed

• The cavity preparation should be irrigated and gently dried.

• Cover entire floor with Hard setting Ca(OH)2 dressing

•Base should be placed with reinforced GIC or ZOE•Final restoration with composite or Amalgam

Avoid unintentional pulp exposure

Dentist get chance to assess reaction of tooth and caries activity

Helps to remove slowly progressing lesion

Final excavation of caries is safer in second sitting.

Advantages of two appointment technique

Indirect Pulp capping Procedure

Electronically measures the thickness of dentin layer above the pulp chamber during crown preparation with a simple touch of probe

GREEN LIGHT:safe zone ORANGE LIGHT:limit of safe

zone RED LIGHT:danger of

penetration through dentin.

PATENT DENTIN MEASURING DEVICE

Remaining dentin thickness(0.5-2mm)

Choice of indirect pulp capping agent

FACTORS AFFECTING SUCCESS OF IPC

First 30 days •1/5th Tubular dentin is formed

First 2 months •Cellular fibrillar dentin is formed

Third month •Globular dentin is formed

More than 3 months •0.1mm Tubular dentin is formed

Outcomes

3 distinct types of new dentin formation takes place:

Infected Dentin▪Highly demineralized▪Unremineralizable▪Superficial layer▪Lacking sensation▪Stained by 0.5% fuschin or i.e. 1.0% acid red solution▪Ultrastructure- intertubular dentin greately demineralized, with irregular scattered crystals. Presence of deteriorated collagen fibers

that have only distinct cross bands and no interbands.

▪Should be excavated

Affected Dentin Intermediately demineralized Remineralizable Deeper layer Sensitive Does not stain

Ultrasyructure: intertubular dentin partially demineralized, but apatitie crystals bound like fringes

Sound collagen fibers with distinct cross bands and interbands.

Should be left remineralized.

Difference between affected and infected dentin

DIRECT PULP CAPPING

DEFINITION

It is the protection of a pulp exposed by traumatic fracture or in the course of excavating deep dentinal caries. Protection is provided by placing a medicated or nonmedicated material in direct contact with the pulp tissues to promote a reparative reaction.[Ingle]

It is the placement of a calcium hydroxide preparation on a small (pinpoint) pulpal exposure. [Mathewson]

It consists merely of placing a layer of protective material over the site of the exposed pulp prior to restoring the tooth.[Finn]

HISTORY

HISTORY contd…

Encouragement of young , healthy pulps to initiate a dentin bridge, thus walling of the exposure site

RATIONALE

OBJECTIVESa) preservation of vitality of the radicular pulp.b) relief of pain in patients with acute pulpagia.c) ensuring the continuity of normal apexogenesis in immature permanent teeth

Accidental pin point exposure of pulp when excavating deep caries, less than 1 sq. mm. surrounded by clean dentin for (<24hours)

Traumatic fracture of tooth(<24 hours) with pin point exposure

Iatrogenic exposure during cavity preparation & crown preparation

INDICATIONS

Bleed if touched but not excessively and controlled easily with cotton pellet

Normal vitality tests without tender to percussion

No radiographic evidence of periradicular pathology

Young patient

History of severe spontaneous tooth aches at night

Excessive tooth mobility

Periodontal ligament thickening

Intraradicular radiolucency

Excessive bleeding at exposure site

Purulent , serous exudate from exposure

External or internal resorption

Swelling and fistula with associated tooth

CONTRAINDICATIONS

Why DPC is Contraindicated In Primary Teeth???

Localization of infection & inflammation in primary teeth is poorer than in permanent teeth. [Mc Donalds,1956]

Incidence of reparative dentin formation in primary teeth is more extensive than permanent Teeth. [Sayegh , 1968]

Primary pulp contain high cellular content which might be responsible for failures. Primary pulp responds more rapidly to the effects of dentinal caries then the perm. Teeth. [Rayner & Southam, 1979]

Undifferentiated mesenchymal cells may differentiate into osteoclasts in response to caries or pulp capping material which could lead to internal resorption. [Kennedy,1985]

Primary Pulp are more closer to outer enamel surface & are rapidly infected by the carious lesion. Once exposed pulpal inflammation is so involved that the DPC proves unfavorable. [Kennedy & Kopel,1985]

Increased resorption in primary teeth is because already root resorption is in progress. [Stanley, 1985]

Wide apical foramina in pri. teeth leads to abundant blood supply which results in more typical and faster inflammation response to irritation than in permanent teeth. [Kopel,1992]

Acc. To finn, in primary teeth pulp capping is best carried out in teeth where dental pulp has been mechanically exposed.

Pulp capping not recommended. Internal resorption or acute dentoalveolar abscess may result . [Pinkham]

Rubber Dam placement

Deep carious dentin

excavation:inhibit infected matter from entering

pulp. Necrotic & infected dentin

chips will invariably be

pushed into the exposed pulp

during last stages of caries removal. Bleeding

controlled with sterile cotton wool

(blast of air not used).No

instruments should be inserted into exposure site.

Layer of hard setting calcium flowed IRM

and a permanent restoration. In small teeth, Ca(OH)2 can act as base. Blood clot-not allowed to

be formed after cessation of bleeding from exposure as it

impedes pulpal healing. Kopel,1992

a more adequate seal of pulp capping is needed (Stainless steel crown -best).

TECHNIQUE OF DIRECT PULP CAPPING

SALIENT FEATURES OF SUCCESSFUL DPC

Dentin bridging

Maintenance of pulp vitality

Lack of undue sensitivity or pain

Minimum pulpal inflammation response

Ability of pulp to maintain itself without progressive

degenerationLack of internal resorption and/ or interradicular

pathosis

In Accordance with Kennedy & Kopel (1985):

FACTORS AFFECTING PROGNOSIS OF DIRECT PULP CAPPING

PULP CAPPING AGENTS

IDEAL REQUIREMENTSIdeal dressing material for pulp therapy in primary teeth does not

exist, but the material should be:

1. Bactericidal2. Biocompatible3. Harmless to the pulp, surrounding structures and the

permanent tooth germ.4. Promote healing5. Not interfere with physiologic process of resorption.

Calcium hydroxide Zinc oxide eugenol cementCorticosteroids and

antibioticsPolycarboxylate

cementIsobutyl

cyanoacrylate and tri calcium

phosphate ceramic

Collagen

Bonding Agents

Calcium phosphate

HydroxyapatiteMineral trioxide aggregate

GIC/RMGIC

Lasers

MTA 1-Calcium

Growth factors

Odontogenic ameloblast

associated protein

Endo sequence root repair material

Castor oil bean cement

Thera Cal

VARIOUS PULP CAPPING AGENT

It is a colorless crystal or white powder prepared by reacting calcium oxide with water.

The use of calcium hydroxide in endodontics was introduced by Hermann in between 1920-1930.

Calcium hydroxide was most favored as a pulpotomy agent in the 1940s and mid- 1950s.

“Calcium hydroxide has the ability to form reparative dentin formation”,this rationale was introduced by Teuscher and Zander in 1938.

Lim and Kirk, in an extensive review of direct pulp capping literature, found little support for pulp obliteration and internal resorption being a major complication of pulp capping

Estrela et al. summarized the antibacterial properties of calcium hydroxide.

CALCIUM HYDROXIDE

ADVANTAGESReparative dentin formation Antibacterial action Pulp protection The tissue-dissolving property Newer preparation shows Improved strength, essentially no solubility in acid, and minimal solubility in water and control the over working time

DISADVANTAGES Pulp obliteration Internal resorption Lack of adhesion to hard tissues Microleakage Short working time of self cured preparation

Base paste –Glycol salicylate-40%-reacts with calcium hydroxide and ZnO Titanium dioxide-Inert fillers Calcium tungstate - FillersBarium sulphate-provide radioopacity

Catalyst paste Calcium hydroxide-50%-principal reactive ingredient Zinc oxide-10% Zinc stearate-0.55%-accelerator Sulphonamide-39.5%-oily compound acts as carrier.

COMPOSITION

•AVAILABLE AS a)Pulpdent b)Hydrex : two paste system c)Dycal.

MECHANISM OF ACTION

D: After 8 weeks

A: After 24 hoursB: After 2-3 weeks

C: After 4-5 weeks

Three distinct zone can be visualised: I. Zone of obliteration (early changes: area of superficial debris)II. Zone of coagulation necrosis (Schroeder’s layer of “firm necrosis”,

Stanley’s “mummified zone”)III. Line of demarcation

HISTOLOGY OF HEALING AFTER PULP CAPPING WITH Ca(OH)2

Zone of obliterationEarly changes: area of superficial debrisDrug’s caustic effectTissue in immediate contact becomes deranged and distorted.This Zone consists of-

i. Debrisii. Dentinal fragmentsiii. Blood clotiv. Blood pigmentv. Calcium hydroxide

particles

Zone of coagulation necrosis Weaker chemical reaction from 1st zone reaches the subjacent , more apical tissues & results in this zone of coagulation & necrosis.Thickness- 0.3-0.7 mm (Acc. to Craig: 1mm thick)Represents devitalised tissue without complete obliteration of its structural architectureCellular details-greatly diminishedCapillaries outlines, nerve bundles & pyknotic nuclei can be recognized.Stimulates subjacent vital pulpVascular changes occur

Line of demarcationDevelops between Zone of coagulation necrosis and vital tissuesThis zone results from reaction of Calcium hydroxide with the tissue protein to form proteinate globules.

It is a new remarkable biocompatible material with exciting clinical applications pioneered by Dr. Mahmoud Torabinejad, Loma Linda University, in 1993COMPOSITION

MTA is a mechanical mixture of 3 powder ingredients: • Portland cement (75%) • Bismuth oxide (20%) • Gypsum (5%)

Composition includes :• Tricalcium silicate • Dicalcium silicate • Tricalcium aluminate • Tetracalcium aluminoferrite • Calcium sulfate • Bismuth oxide (provides radio-opacity)

MINERAL TRIOXIDE AGGREGATE[MTA]

CONTRAINDIACTIONIrreversible pulpitis

INDICATION•To preserve pulp vitality • Prevent pathological changes in the periradicular tissues • Mechanical pulp exposures • Carious pulp exposures with immature apices.

PROPERTIES OF MTA•Mixing MTA: Powder: Water = 3: 1Glass SLABor paper slab used•SETTING TIME: Hydration of MTA powder results in a colloidal gel that solidifies to a hard structure in 3~ 4 hrs which has a long setting time with less shrinkage.•pH=12.5

ADVANTAGES• Antimicrobial Activity • Prevents MicroLeakage over vital pulp• Cementoconductive• Non toxic and Non-mutagenic • Cell adherence & growth • Alkaline phosphotase/ osteocalcin • Interleukin production • Periodontal ligament attachment to cementum growth• Dentinal bridge formation

DISADVANTAGES• More difficult to manipulate• Longer setting time

CLINICAL APPLICATION OF MTA

• Direct Pulp Capping • Apical plug • Root End Filling • Perforation Repair • Furcation involvment • Resorptive Defects • Immature apices (apexogenesis/ Apexification)

Ca(OH)2 MTAHard tissue formation Not much Root end induction

Calcific bridge Not continuous Continuous with dentin

Biocompatibility Low High

Degree of Inflammation Low High

Sets Not Hard Hard

pH High High

Solubility Partially disolve Less soluble

Permeable to fluids Non permeable

Viscosity Poor Good

Application Not easy to apply in RC Easy

Resorption Rate vary with density Non-resorbable

Appical barrier formation Change rate/ initial narrow appical width

Less/wide

Patient follow up More Less

Treatment Delay shortens

Germicidal agent

Used in indirect pulp capping due to its

This gives the pulp the chance for healing & regeneration

Direct contact →chronic inflammatiom ,abscess formation and liquefaction necrosis.

After 24Hr of capping →a mass of red blood cells &PNLs. Demarcated from the underlying tissue by zone of fibrin and inflammatory cells.

After 2W of capping → pulp degeneration &chronic inflammation extends deep to the apex.

ZINC OXIDE-EUGENOL

Palliative affectExcellent initial sealKills bacteria present in carious lesionsSo arrests the caries process

Different studies were led on laser energy to overcome the histological deficits of electrosurgery.

Used in Direct pulp capping & pulpotomy.

Co2 Laser , Argon Laser, Diode Laser, Erbium:Yttrium-Aluminum Garnet (Er.YAG).

Laser radiation has been proposed for pulp treatment based on its haemostatic, coagulative and sterilizing effects.

Laser irradiation creates a superficial zone of coagulation necrosis that remains compatible with the underlying tissue and isolate pulp from effects of the subbase. Mortiz et al., reported that the thermal effects of laser radiation caused sterilization and scar formation in the irradiated area, which in turn preserves the pulp from bacterial invasion.

LASER

Alpha-tricalcium phosphate & Tetracalcium phosphate (4CP) set & convert to hydroxyapatite.

Stimulate the pulp to form hard tissue.

No finding of necrotic pulp tissue in direct contact with 4CP cement compared to calcium hydroxide slight acidity after mixing

4CP cement has mechanical strengths so it could be used as so called “dentin substitute”. Pulp capping agent

lining material

Calcium phosphate Compounds

There were suggested as direct pulp capping and pulpotomy agents with the introduction of adhesive dentistry in both primary and permanent dentition.

Adhesive material forms:- A complete marginal seal- Prevents bacterial intrusion - Allowed pulp repair, characterized by a new odontoblast cell

layer underlying the dentin bridge formation.

Many studies have indicated that composite & resin-modified glass-ionomer are compatible with pulp tissue.

Adhesive Liners

Propolis, a resinous material collected by honey bees, has been used as a traditional anti-infalmmatory and anti-bacterial medicine for many centuries.

Used as indirect pulp capping paste when mixed with ZnO powder and this showed similar effect of ZnO and Eugenol as secondary dentin formation.

In direct capping with this paste showed no pulp . degeneration and formation of protective layer.

Propolis

OTHER MATERIALS USED AS PULP CAPPING AGENT….PULP CAPPING AGENT ADVANTAGES DISADVANTAGES

Zinc oxide eugenol cement. 1)Reduces inflammation. 1) Lack of calcific bridge formation.2) Releases eugenol in high

concentration which is cytotoxic.3) Demonstrates interfacial

leakage.

Corticosteroids and antibiotics. 1) Reduces pulp inflammation.2) Vanomycin and calcium hydroxide

stimulated a more regular reparative dentin.

1) Should not be used in patients with risk from bacteremia.

Polycarboxylate cement. 1)Chemically bond to tooth structure. 1) Lack of antibacterial effect.2) Fail to stimulate calcific bridge

formation.Inert materials( Isobutyl cyanoacrylate and tri calcium phosphate ceramic)

1) Reduces pulp inflammation.2) Stimulate dentin bridge formation.

1) NONE of these materials have been promoted in dentist profession as a viable technique

Collagen 1) Less irritating than calcium hydroxide and promotes mineralization.

1) Does not help in thick dentin bridge formation.

Bonding Agents 1) Superior adhesion to hard tissues.2) Effective seal against micro leakage.

1) Has cytotoxic effect.2) Absence of calcific bridge formation.

RS

PULP CAPPING AGENT

ADVANTAGES DISADVANTAGES.

Calcium phosphate. 1) Helps in bridge formation with no superficial tissue necrosis.

2) Significant absence of pulp inflammation.3) Good physical properties.

1) Clinical trials are necessary to evaluate this material.

Hydroxyapatite. 1) Biocompatible.2) Act as a scaffold for the newly formed

mineralized tissue.

1) Mild inflammation with superficial necrosis of pulp.

Carbon dioxide lasers 1) Formation of secondary dentin.2) Bactericidal effects.

1) Technique sensitive.2) Causes thermal damage to pulp at

high doses.

Glass ionomer/ Resin modified glass ionomer.

1) Excellent bacterial seal.2) Fluoride release, coeffient of thermal

expansion and modulus of elasticity similar to dentin.

3) Good biocompatibility.

1) Cause chronic inflammation.2) Lack of dentin bridge formation.3) Cytotoxic when in direct cell contact.4) High solubility and slow setting rate.

MTA 1-Calcium 1) Helps in dentin bridge formation without formation of necrotic layer.

2) Shear bond strength is higher than conventional GIC and similar to RMGIC.

1) Presence of 10% calcium hydroxide interferes with complete curing of the material, residual monomers causes cytotoxicity.

Growth factors. 1) Formation of osteodentin and tubular dentin.

2) Formation of more homogenous reparative dentin

3) Superior to calcium hydroxide in the mineralization inducing properties.

1) High concentration is required.2) Half life is less.3) Appropriate dose response is required

to avoid uncontrolled obliteration of pulp chamber.

PULP CAPPING AGENT

ADVANTAGES. DISADVANTAGES.

Odontogenic ameloblast associated protein.

1) Biocompatible.2) Accelerates reactionary dentin

formation.3) Normal pulp tissue appearance

without excessive tertiary dentin formation and obliteration of the pulp cavity compared to MTA

1) Till now only invitro studies were conducted.

2) Further studies regarding this material is required.

Endo sequence root repair material

1) Antibacterial property.2) Less cytotoxic than MTA, Dycal and

light cure calcium hydroxide.

1) Bioactivity of the cells were decreased gradually when exposed to this material.

Castor oil bean cement.

1) Good antibacterial property.2) Less cytotoxic.3) Good mechanical properties.4) Facilitates tissue healing.5) Better sealing ability than MTA and

GIC.6) Less cost.

1) Bio inert rather than bioactive.2) More clinical trials are

required.

Thera Cal. 1) Act as protectant of the dental pulp complex.

2) Has strong physical properties, no solubility, high radiopacity.

3) TheraCal exhibited higher calcium releasing ability than MTA or Dycal.

1) It is opaque and whitish in color and it should be kept thin so as not to show through composite material that are very translucent affecting final restoration shading.

Pulp capping is a procedure that maintains pulp vitality and function, promotes healing/repair, prevents breakdown of peri radicular supporting tissues, and promotes formation of secondary dentin Direct pulp capping is a procedure used in asymptomatic teeth with deep caries reaching upto pulp. It is another method than Indirect pulp capping to treat deep caries but it is not a preferred method in children as success rate is very low, like indirect pulp capping in this also a suitable medicament is placed to induce dentin bridge formation

CONCLUSION

Teacher’s Note Textbook of Pedodontics 2e, - Shobha Tandon Principle and practice of pedodontics, 3e, Aarti Rao Textbook of Pedodontics, 3e, Nikhil Marwah Dentisry on Child and Adloscence, Mc Donald Text book of Endodontics, Grossman Pathway of Pulp 9e,Cohen Stewart DJ and Kramer IRH. Effects of calcium hydroxide on the unexposed pulp,

J. Dent Suneda YT et al . A histopathological study of direct pulp capping with adhesive

resins Teethanime.com/pulp Peter. Murray et al. Analysis of pulpal reactions to restorative procedures,

materials, pulp capping, and future therapies crit rev oral biol med509-13:520 2002

REFERENCES