Presentation Outline

Determination of Pulp status Indirect Pulp capping Direct Pulp capping Materials used for capping Related studies

Determining Pulp status

1. Visual and tactile examination of carious dentin and associated periodontium 2. Radiographic examination of
a. periradicular and furcation areas b. pulp canals c. periodontal space d. developing succedaneous teeth

3. History of spontaneous unprovoked pain 4. Pain from percussion 5. Pain from mastication 6. Degree of mobility 7. Palpation of surrounding soft tissues 8. Size, appearance, and amount of hemorrhage associated with pulp exposures

 Paediatric pulp therapy for primary and young permanent teeth involves the following techniques:
1. Indirect pulp capping 2. Direct pulp capping 3. Coronal pulpotomy 4. Pulpectomy

Hunter recommended covering an exposure with a mixture of sorghum molasses and the droppings of the English sparrow and claimed a 98% success rate.

1920 Hermann introduced calcium hydroxide

1938 - Teuscher & Zander introduced calcium hydroxide in the U.S.; they histologically confirmed complete dentinal bridging with healthy radicular pulp under calcium hydroxide dressings

Phillip Pfaff 1756 gold foils

Indirect Pulp Capping

Hugh M Kopel : is defined as the application of a medicament over a thin layer of remaining carious dentin, after deep excavation, with no exposure of the pulp. Stephen Cohen: 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

History of indirect pulp capping

Described by Pierre Fauchard John tomes 1859 it is better that a layer of discoloured dentin should be allowed to remain for the protection of the pulp rather than run the risk of sacrificing the tooth. In 1891, W.D Miller discussed various antiseptics that should be used for sterilizing dentin G.V Black (1908) felt that in the interest of specific dental practice, no decayed or softened material should be left in cavity preparation, whether or not the pulp was exposed.

Objectives of Indirect Pulp Capping

Eidelman 1965
Arresting the carious process Promoting dentin sclerosis Stimulating formation of tertiary dentin Remineralization of carious dentin

 Whitehead et al (1960) compared deep excavations in primary and permanent teeth. After all softened dentin had been removed from the cavity floor, they found that 51.5% of the permanent teeth were free from all signs of organisms, and a further 34% had only 1 to 20 infected dentinal tubules in any one section. Shovelton (1968) - Primary teeth however showed a much higher percentage of bacteria in the cavity floor after all softened dentin was removed Finding was supported by Seltzer and Bender

 INFERENCE
Complete clinical removal of carious dentin does not necessity ensue that all infected tubules have been indicated conversely, the presence of softened dentin does not necessarily indicate infection.

Remaining dentin thickness

Reeves and Stanley(1966) and Shovelton (1970) when the carious lesion proximity to the pulp was greater than 0.08mm (including reparative dentin when present) no significant disturbance occurred with in the pulp of permanent teeth. Rayner and Southam (1970) in studying carious primary teeth, found the mean depth of pulp inflammatory changes from bacterial dentin penetration to be 0.6mm in proximity to the pulp, with some changes occurring within 1.8mm pulp proximity

 Massler and Pawlak (1977) used the terms affected infected to describe pulp reaction to deep carious attack. Canby and Bernier (1936) concluded that the deeper layers of carious dentin tend to impede the bacteria invasion of the pulp because of the acid nature of the affected dentin.
1. A necrotic, soft, brown dentin outer layer, teeming with bacteria and not painful to remove 2. Firmer, discolored dentin layer with fewer bacteria but painful to remove, suggesting the presence of viable odontoblastic extensions from the pulp 3. Hard, discolored dentin deep layer with a minimal amount of bacterial inversion that is painful to instrumentation

Dentin Response to IPC

Sayegh (1968) found 3 distinct types of new dentin in response to indirect pulp capping (1) cellular fibrillar dentin at 2 months post treatment (2) presence of globular dentin during the first 3 months and (3) tubular dentin in a more uniformly mineralized pattern Sayegh - new dentin forms fastest in the teeth with the thinnest dentin remaining after cavity preparation. Longer treatment times enhanced dentin formation.

Indications of IPC
History Mild pain associated with eating Negative history of spontaneous extreme pain Radiographic examination Normal lamina dura and PDL space No radiolucency in the bone around the apices of roots or in furcation. Clinical examination Deep carious lesion, close to but not involving pulp in vital primary or young permanent teeth No mobility When pulp inflammation is nominal and there is a definite layer of affected dentin after removal of infected dentin

Contraindications of IPC
History Sharp penetrating pulpalgia indicating acute pulpal inflammation Prolonged night pain Radiographic examination Definite pulp exposure Interrupted or broken lamina dura Radiolucency about the apices of roots Clinical examination Swelling Fistula Tenderness to percussion. Pathological mobility Discoloration of tooth

Technique
Two appointment technique Single appointment technique
second entry subjects the pulp to potential risk of exposure owing to over zealous excavation

Reentry decided based on remaining dentin thickness and patient symptoms after cavity preparation

Evaluation of therapy
Law and Lewis (1964) reported irritational dentin formation an active odontoblastic layer an intact zone of Weil slightly hyperactive pulp with the presence of some inflammatory cells

 Tostenson et al (1982) demonstrated slight to moderate inflammation when ZOE was used in deep unlined cavities that were less than 0.5mm to the pulp itself. Nordstrom et al (1982) reported that carious dentin, wiped with a 10% selection of strannous fluoride for 5 minutes covered with ZOE, can be remineralised. King et al (1965);Aponte et al (1966); Parikh et al (1963) - residual layer of carious dentin left can be sterilized with either ZOE cement or Ca(OH)2. Sawush (1982) evaluated Ca(OH)2 liners for indirect pulp capping for primary and young permanent teeth. After periods varying from 3 - 21 months, he concluded that Dycal was a highly effective agent.

Direct Pulp Capping

Hugh M Kopel : involves the placement of a biocompatible agent on healthy pulp tissue that has been inadvertently exposed from caries excavation or traumatic injury. D B Kennedy et al: Direct pulp capping is the placement of material over an exposed vital pulp. Jon T Kapala: Direct pulp capping involves the application of the medicament, dressing or dental material to the exposed pulp as an attempt to preserve its vitality. Ulla Schroder: Direct pulp capping means covering the exposed healthy pulp with a medicament, preferably calcium hydroxide, without any surgical intervention.

Objective Seal the pulp against bacterial leakage Encourage the pulp to wall of the exposure site by initiating a dentin bridge Maintain the vitality of the underlying pulp tissue regions

Indications of Direct Pulp Capping

pinpoint mechanical exposures that are surrounded with sound dentin. The exposed pulp tissue should be bright red in colour and have a slight hemorrhage that is easily controlled with dry cotton pellets applied with minimal pressure. Frigoletto 1973 - exposures less than 1mm Stanley 1998 - size of the exposure is less significant than the quality of the capping technique in avoiding contamination and mechanical trauma to the exposure site and careful application of the medicament to hemostatically controlled pulp tissue

Contraindications of DPC
Spontaneous and nocturnal tooth aches Excessive tooth mobility Thickening of the periodontal ligament Radiographic evidence of furcal or periradicular degeneration Uncontrollable hemorrhage at the time of exposure Purulent or serious exudates from the exposure

Clinical Success of DPC

Salient features of a clinically successful direct pulp capping treatment (with or without bridging) (1) maintenance of pulp vitality (2) absence of sensitivity or pain (3) minimal pulp inflammatory responses (4) absence of radiographic signs of dystrophic changes.

Clinical Success in Primary Teeth

Kennedy & Kapala - high cellular context of pulp tissue are responsible for direct pulp capping failures in primary teeth, undifferentiated mesenchymal cells may give rise to odontoclastic cells in response to either the caries process or the pulp capping material, resulting in internal resorption. Starkey - high degree of success with direct pulp capping in primary teeth

Clinical Success in Permanent Teeth

Dentin bridge formation not necessary Weiss & Bjorvatn -healthy pulp can exist beneath a direct pulp cap even in the absence of a dentinal bridge. Seltzer and Bender and Langeland et al have shown that a dentin bridge is not as complete as it appears, which can ultimately lead to untoward pulp reactions. Cox and Subay found that 89% of bridges formed in response to calcium hydroxide direct pulp and caps demonstrated tunnel defects, which allowed access of microleakage products beneath 41% of all bridges formed in the sample.

Treatment Considerations
Debridement Kalins & Frisbee - necrotic and infected dentin chips are invariably pushed into the exposed pulp during the last stages of caries removal. Remove peripheral masses of carious dentin before beginning the excavation where an exposure may occur. When an exposure occurs, the area should be irrigated with nonirritating solutions such as normal saline to keep the pulp moist

Hemorrhage and Clotting Hemorrhage at the exposure site can be controlled with cotton pellet pressure. A blood clot must not be allowed to from after the cessation of hemorrhage from the exposure site as it will impede pulpal healing. Capping material must directly contact pulp tissue to exact a reparative dentin bridge response

Exposure enlargement (1) Removes inflamed and/or infected tissue in the exposed area (2) Facilitates removal of carious and non carious debris, particularly dentin chips (3) Ensures intimate contact of the capping medicament with healthy pulp tissue below the exposure site.

Bacterial contamination Cox et al - pulp healing is more dependent on the capacity of the capping material to prevent bacterial microleakage rather than the specific properties of the material itself. Watts and Paterson - Bacterial microleakage under various restorations causes pulpal damage in deep lesions, not the toxic properties of the cavity liners and/or restorative materials

Medicaments and Materials

Ca(OH)2 ZnOE Dentin Bonding Agents Glass Ionomer Antibiotics
Antioxidants Growth Factors Enzymes Cyanoacrylates

Corticosteroids
Polycarboxylate cement Tri / Tetracalcium Phosphate Dentin Shavings MTA Collagen

Calcium Hydroxide
Introduced by Herman in 1920 Action on tissue
Elevated pH activates alkaline phosphatase Tissue adjacent to calcium hydroxide undergoes coagulative ecrosis (Schroeders layer of Firm Necrosis, Stanleys mummified zone)

Induces cytodifferentiation Neutralizes lactic acid

Should be pure, fresh & without non irritating additives Reacts with atmospheric CO2
Ca(OH)2 + CO2 Ca(CO3)2 + Ca(Co3)2 Emboli Phosphoric acid / silicates

OH Neutralizes Acid

Ca 2+ Capillary permeability

Optimum Ph for pyrophosphate activity

Serum Flow

Ca 2+ dependent pyrophosphate

Inhibitory pyrophosphate

Uncontrolled mineralization

 Sciaky and Pisanti ; Attalla and Noujaim calcium ions from the capping material were not involved in the bridge formation. Stark et al calcium ions from the capping medicament do enter into bridge formation

 Seltzer and Bender identified the osteogenic potential of Ca(OH)2. It is capable of inducing calcific metamorphosis, resulting in obliteration of the pulp chamber and root canals. Lim and Kirk - obliteration of the pulp chamber and root canals and internal resorption is not a major concern for pulp capping.

Advantages
Bacteriostatic bactericidal Healing & Repair Stimulates Fibroblasts Stimulates Enzyme systems Stops internal resorption Obturates open tubules Ideal intracanal medication Inexpensive & easy to use

Disdvantages No adherence to dentin Recurrent caries if lost Cavosurface microleakage

Zinc oxide eugenol

Used as an indirect pulp capping agent Glass and Zander - ZOE, in direct contact with the pulp tissue, produced chronic inflammation, a lack of calcific barrier, and an end result of necrosis. Sveen reported 87% success with the capping of primary teeth with ZOE in ideal situations of pulp exposure Tronstad and Mjr - compared ZOE with calcium hydroxide, found ZOE more beneficial for inflamed, exposed pulps and felt that the production of a calcific bridge is not necessary if the pulp is free of inflammation following treatment

Dentin Bonding Agents

Formation of hybrid layer provides adequate sealing
Resin covering prevents displacement of composite into pulp chamber. Primer, adhesive work in wet environment

Prevents dehydration injury

 Cox et al - pulps sealed with 4-META showed reparative dentin deposition without subjacent pulp pathosis Stanley - acid conditioning agents can harm the pulp when placed in direct contact with exposed tissues. Araujo et al Bacterial penetration occurred in 50% of treated teeth.

 Persistence of chronic inflammation with a foreign body response in the form of resin globules imbedded within the exposed pulp tissue that were surrounded by pulpal macrophages. Further long term evidence and histologic evaluation are needed for bonding agents to be used as capping agents Katoh et al - improved direct pulp-capping results with dentin bonding agents when they were used in conjunction with calcium hydroxide

Corticosteroids and Antibiotics

Introduced by Brosch JW in 1966 Gardner et al - vancomycin, in combination with calcium hydroxide, was somewhat more effective than calcium hydroxide used alone and stimulated a more regular reparative dentin bridge They were found only to preserve chronic inflammation and/or reduce reparative dentin Neomycin and hydrocortisone, Ledermix are examples Can also induce hypersensitivity reactions

Polycarboxylate cements
Suggested as a direct capping material Lack of antibacterial effect and did not stimulate calcific bridging Negm et al placed Ca(OH)2 and ZnOE into a 42% aqueous polyacrylic acid and used this combination for direct pulp exposure in patients from 10-45 years of age. This mixture showed faster dentin bridging over the exposures in 88-91% of the patients when compared to Dycal as the control.

Inert Materials
Tri calcium Phosphate
Bhasker 1971 - Stimulates bone formation Boone 1979 though induces dentin formation; pulps of teeth exposed to it were inflamed due to bacterial contamination

Cyanoacrylates
Used as a pulp capping agent with apparent success. Butyl form well tolerated than others Hemostatic bacteriostatic property The pulp tissue adjacent to it retains vitality & shows less inflammation. Dentin formation is inhibited

Collagen
Known to influence mineralization Dick and Carmichael - placed modified wet collagen sponges with reduced antigenecity in pulp exposed teeth. Less irritating than Ca(OH)2, and with minimal dentin bridging in 8 weeks Collagen was not as effective in promoting a dentin bridge as was Ca(OH)2.

MTA
Introduced by Torabinejad in 1993

More dentinal bridging less time Lesser inflammation quicker dentin deposition than Ca(OH)2 Highly biocompatible
Hydrophilic

Alkaline pH (12) promotes dentinogenesis (Thomas et al 1992)

Calcium tetra phosphate

Chaung et al. - histologically compared calcium phosphate cement with calcium hydroxide as a direct pulp-capping agent. Calcium phosphate cement - a viable alternative because of
(1) its more neutral pH resulting in less localized tissue destruction (2) its superior compressive strength (3) its transformation into hydroxyapatite over time

Yoshimine et al - In contrast to calcium hydroxide, tetracalcium phosphate cement induced bridge formation with no superficial tissue necrosis and significant absence of pulp inflammation

Dentin Shavings
Sterilized Autogenic / allogenic Shavings (As DPC agent) Seeding agents for reparative dentin (Bang 1972)

Hard tissue formation caused by non collagenous portion of the matrix. (Bang 1981)

Growth factors
BMP - discovered by Urist in 1965

BMP Stimulates synthesis of Collagen & Proteoglycans during odontogenesis

TGFB1 & TGFB2 - Regulates cells differentiation. Recombinant osteogenic protein 1 in a collagen matrix - suitable for direct pulp capping

Enzymes
Alkaline phosphatase stimulates differentiation of pulp cells into odontoblasts elaboration of dentin matrix

Acid phosphatase no such result

Chondroitin Sulfate induces heterotrophic bone formation in rats (Moss 1960) - no such Result when used in humans by Seltzer.

Emdogain

Guven 2011 EMD when used in conjunction with MTA, dycal and Gic increased their biocompatibility

Carisolv
Chemo mechanical caries removal method Bulut 2004 - Shows irregular mass of reparative dentin on pulpal walls near exposure site

No hard tissue bridging seen - when used alone

Hard tissue bridging seen when used with Ca(OH) 2 Causes coagulative necrosis up to 150 micro mm from exposure site due to alkaline hydrolysis caused by its high pH

Lasers
Andreas Meritz 1998 first evaluated the effect of laser on direct pulp capping and reported a success rate of 89% CO2 laser as DPC at Lower Energy levels followed by Ca(OH)2 dressing:
Vitality maintained 89% cases (CaOH2 alone 68%)

Nd YAG laser as IPC agent:

Decreases the permeability fo dentin ablation, melting, resolidification

Doesnt cause pulpal damage.

Biodentine
Dammaschke - Biodentine is a new bioactive cement with dentin-like mechanical properties, which can be used as a dentin substitute on crowns and roots. It has a positive effect on vital pulp cells and stimulates tertiary dentin formation. In direct contact with vital pulp tissue it also promotes the formation of reparative dentin

Haghoo 2007 - evaluated the histological pulp responses of Calcium hydroxide and Bioactive glass placed directly on exposed pulp tissues. 20 extracted teeth divided into 2 groups
All teeth in calcium hydroxide group showed inflammation. 7 teeth showed internal resorption Bioactive glass group did not show any internal resorption Bioactive glass appears to be superior to Calcium hydroxide as a pulp capping agent in primary teeth

 Loukuwal 2011 investigated the release of

fluocinolone acetonide from an experimental pulp capping material containing fluocinolone acetonide (PCFA) and compare some physical and mechanical properties with Dycal The PCFA is a hard-setting calcium hydroxide cement composed of 50 mmol/L fluocinolone acetonide.. The pH, setting time, and acid soluble arsenic content of PCFA were significantly higher than those of Dycal. The compressive strength and disintegration of PCFA were comparable to control. PCFA may be considered as an alternative in pulp capping of inflamed dental pulp tissue.

References
Endodontics 5th edition Ingle Pathways of Pulp 9th edition Cohen Grossmans Endodontic Practice 12th edition Dentistry for the child and adolescent. 9th edition McDonald Sturdevants Operative Dentistry 4th edition Textbook of Endodontology Gunner Bergenholtz Textbook of Pediatric Dentistry Nikhil Marwah