Pulp Capping Agents

© Ramaiah University of Applied Sciences
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Faculty of Dental Sciences
Presented by: Dr.Arbiya Anjum S
Moderated by: Dr. Shruthi Nagaraj
Pulp Capping Agents

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Contents
• Introduction
• Vital Pulp Therapy
• History
• Rationale
• Dentinogenic response to
injury
• Odontoblast differentiation
• Remaining Dentinal Thickness
• Outcome of VPT
• Indirect pulp capping
• Direct pulp capping
• Pulp capping agents with
advantages and disadvantages
of each
• Conclusion
• References

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Faculty of Dental Sciences©M. S. Ramaiah University of Applied Sciences
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Introduction
Vital Pulp Therapy – “Treatment initiated to preserve and maintain pulp tissue in a
healthy state, tissue that has been compromised by caries, trauma, or restorative
procedures”
Healing is a matter of time,but it is sometimes also a matter of opportunity -Hippocrates
Objective : To stimulate formation of reparative dentin to retain the tooth as functional unit

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Vital Pulp Therapy
1. Loss of vitality- loss of interdental sensory function
Non-vital tooth requires 2.5 times more load
->Increased susceptibility to fracture
Abdel Wahab MHA et al., J Dent Res 1985
2.Healthy pulp produces reparative, secondary & peritubular dentin
• Kakehashi et al –Presence of bacteria, exposed pulpal tissue in conventional rats is
partially necrotic by 8 days
• Completely necrotic with periradicular abscesses by 14 days
• 32 days - Intact dentinal bridge has developed with subjacent normal dental pulp tissue
Seltzer and bender

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HISTORY
1756 – Phillip
Ptaff
• Covered the
exposed pulp
with thin
convex shaped
gold foils
End of 18th century
– Fredrich Hirsch
• Treated carious
teeth by
cauterization
with a glowing
probe to
desensitize the
pulp
1883- Hunter
• recommended
covering an
exposure with a
mixture of
Sorghum
molasses and the
droppings of the
English sparrow
and claimed 98%
success rate
1848 - Robinson
• Treated exposed
pulp with
collodion and
morphine
followed by
restoration with
asbestos
Followed by the
use of disinfecting
materials for pulp
capping
Dammaschke, T., 2007. The history of direct pulp capping. Journal of the History of Dentistry, 56(1), pp.9-23.

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Bjørndal, L., 2008. Indirect pulp therapy and stepwise excavation. Journal of endodontics, 34(7), pp.S29-S33.
1956-Sowden : Carious
tissue removed, 1mm
Ca(OH)2 placed followed by
temporary restoration, re
entry after 2-3 weeks
1962-Law and
Lewis: Removed all
areas of carious
dentin, placed
Ca(OH)2 and
amalgam, re entry
after 6 months
1965- Eidelman:
All undermining
enamel is removed
to gain easy access
to carious dentin,
1mm of carious
dentin was left at
the pulpal wall, re
entry after 1 year
1977- Magnusson
and Sundell :
emphasized that
a soft thin layer
(residual caries)
was not removed
along the pulpal
wall ,ZnOE
cement placed, re
entry after 4-6
weeks

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Rationale
Bjorndal : To change the ecologic and metabolic balance within the biofilm and arrest caries
Mjor : Outer carious dentin is irreversible & denatured while the inner dentin has a
reversible & remineralizing ability
Cohen : The pre-dentin layer consists of GFs that would help form tertiary dentin thus IPT
can be performed
Stanley And Reeves : If the carious lesion is at a 1mm distance from the roof of the pulp,
regenerative capacity is maximum

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Dentinogenic Response To Injury
• Mild injury -Odontoblasts are stimulated to secrete a reactionary dentine matrix focally
at the pulp–dentine interface beneath the injury site
• Severe injury, odontoblast-like cells may differentiate from underlying pulpal cells
secreting a reparative dentine matrix
PRIMARY DENTIN
ODONTOBLASTS
PRIMARY DENTIN
SECONDARY DENTIN
ODONTOBLASTS
INJURY
PRIMARY DENTIN
TERTIARY DENTIN
D. Tziafas et al. / Journal of Dentistry
The rate of reparative dentin deposition has been shown to average 1.4um/day
The rate of reparative dentin formation decreases markedly after 48days

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Remaining Dentinal Thickness/ Effective Depth
• RDT is a key determinant of pulp survival after cavity preparation & avoiding pulp
exposure
Effective depth= Effective depth in radiograph x Actual thickness of enamel
Enamel thickness in radiograph

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Infected dentin
• Highly demineralized
• Unremineralizable collagen
• Superficial
• No 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 collagen
• Deeper
• Sensitive
• Does not stain
• Ultrastructure: intertubular dentin
• Partially demineralized, but apatitie crystals
bound like fringes to the Sound fibers with
distinct Cross bands and interbands
• Should be left remineralize

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The outcome of VPT depends on
• Age of the patient
•Size & location of the pulp exposure -> 1.0 mm
•Presence of dentinal chips- encourages dentin bridge formation, contamination leads
to inflammation
•Control of hemorrhage and plasma exudate- Marzouk, Van Huysen27 in 1966,
operative trauma may evoke very rapid changes in the dental pulp, leading to
permeation and leakage of plasma proteins out of the tubules to the cut dentinal
surface, inhibits wound healing
•Impaction and embolization of pulp-capping agents
•Pulp capping material
•Quality of the final restoration

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Pulp Capping – “The placement of a protective base or a liner on the pulpal and axial walls
of the cavity preparation to act as a protective barrier between the restorative material and
the tooth(AAPD)”
Pulp Capping
Direct Pulp
Capping
Indirect Pulp
Capping
Treatment of an exposed vital
pulp by sealing the pulpal
wound with a dental material
placed directly on a
mechanical/ traumatic
exposure to facilitate the
formation of reparative
dentin & maintenance of the
vital pulp
Glossary of endodontic terms
A procedure in which a
material is placed on a thin
partition of remaining carious
dentin that, if removed, might
expose the pulp in immature
permanent teeth
Glossary of endodontic terms

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Direct Pulp Capping
Healing after
direct pulp
capping
Secondary
odontoblast
Formation of
reparative
dentine
Regulation of
gene expression
Progenitor/stem
cells in the pulp
Angiogenetic
growth factors)
released from
the dentine
matrix
Growth factors
and bioactive
molecules (e.G
tgf-βs, bmps,
IGF,
Repair and regeneraation, IEJ 44, 889-906; 2011.
Yamamura – Tissue reactions to pulp capping with Ca(OH)2 in dog teeth :
Exudative stage (1–5 days)
Proliferative stage (3–7 days),
Osteodentin formative stage (5–14days), &
Tubular dentin formative stage (14 days and more)

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Indirect Pulp Capping
Objective : To protect the primary odontoblast and to promote reactionary dentin formation
Formation of
reactionary
dentine
Up –regulation
of gene activity
Primary
odontoblasts
Angiogenetic
growth factors)
released from
the dentine
matrix
Growth factors
and bioactive
molecules (E.G
tgf-βs, bmps,
IGF,

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Pulp Capping Agents
Ideal Requirements
• Stimulate reparative dentin formation
• Maintain pulpal vitality
• Release fluoride to prevent secondary
caries
• Bactericidal/Bacteriostatic
• Adhere to dentin, restorative material
• Resist forces during restoration
placement
• Must resist forces under restoration
during lifetime of restoration
• Sterile
• Radiopaque
• Provide bacterial seal

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Germicidal agent
Used in indirect pulp capping
After 24H 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→chronic inflammation ,abscess formation and liquefaction
Zinc oxide-eugenol
• Tronstad and Mjör stated that ZOE cement is more beneficial for inflamed and exposed pulp
• Glass and Zander, Hembree and Andrews, Watts, Holland et al., ZOE, in direct contact with the pulp
tissue, produced chronic inflammation, lack of calcific barrier, and end result is necrosis

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Corticosteroids And Antibiotics
• Hydrocortisone, Cleocin, cortisone, Ledermix, penicillin, neomycin and Keflin along with
calcium hydroxide – reduce or prevents pulp inflammation
• Gardner, et al., vancomycin + calcium hydroxide more effective than calcium hydroxide alone
and stimulated a more regular reparative dentin bridge
• Watts and Paterson - anti-inflammatory compounds should not be used in patients at risk
from bacteremia
• Reduces pulp inflammation
• Vanocmycin + Ca(OH)2 - more regular reparative dentin bridge
• Should not be used in patients at risk from bacteremia

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• Synthetic corticosteroid - topical application - dermatologic disorders and oral
vesiculoerosive lesions
• Proliferative effect on cells, such as skin fibroblasts and dental pulp cells
• Concentration-dependent; high concentrations inhibit mitotic activity
• 0.1–10 mmol/L stimulates extracellular matrix and hard tissue formation of human dental
pulp cells
• pH 10.57–11.72, higher than Dycal (9.80–10.86)
• Louwakulet al.-Pulp-capping Material Containing Fluocinolone Acetonide
Fluocinolone acetonide

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Polycarboxylate Cement
• McWalter, G et al., found that it lacks an antibacterial effect and calcific bridge formation
• Chemically bond to the tooth structure
• Lack of antibacterial effect
• Fail to stimulate calcific bridge formation

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• Bhaskar SH et al., and Heys DR et al - Isobutyl Cyanoacrylate(Berkman 1971) and Tricalcium
Phosphate Ceramic (Heller 1975)
Inert Materials
• Reduces pulp inflammation
• Stimulate dentin bridge formation
• None of these materials have been promoted to the dental profession
as a viable technique

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• Dick HM and Carmichael DJ - collagen fibers are less irritating than Ca (OH)2 and promotes
mineralisation but does not help in thick dentin bridge formation
Collagen
• Less irritating, promotes mineralization
• Does not help in thick dentin bridge formations

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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
Bonding Agents
• Miyakoshi et al.- 4-META-MMA-TBB adhesives and hybridizing dentin bonding agents-
superior adhesion to peripheral hard tissues and effective seal against micro leakage
• Hebling et al. (1999), Adhesive system (All bond 2) did not appear to allow any pulp
repair and does not appear to be indicated for pulp capping of human teeth

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• Superior adhesion to hard tissues
• Effective seal against microleakage
• Cytotoxic effect
• Absence of calcific bridge formation
• Application of an adhesive resin directly onto a site of pulp exposure, or to
a thin layer of dentin (> 0.5 mm), causes dilatation and congestion of blood
vessels as well as chronic inflammatory pulpal response
• Costa et al. (2003)- RMGIC or self-etching adhesive system- inflammatory pulpal response,
allowed pulpal healing characterized by cell-rich fibro dentin and tertiary dentin deposition

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• Alpha-tricalcium phosphate & Tetracalcium phosphate (4CP) set & convert to Hydroxyapatite
• Viable alternative because of its good biocompatibility, superior compressive strength and 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
Calcium phosphate Compounds
• Act as scaffold for newly formed mineralized tissue
• Mild inflammation with superficial necrosis of pulp

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• It is the most thermo dynamically stable of the synthetic calcium phosphate ceramics
• It has good biocompatibility with neutral pH -7.0
Hydroxyapatite
• Act as scaffold for the newly formed mineralized tissue
• Clinical trials are necessary to evaluate this material

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Calcium Hydroxide
• Considered as the ‘gold standard’ material in pulp capping
• Herman (1930) – Ca(OH)2 pulp capping,pH 12
• Dissolution and micro leakage of Ca(OH)2 with time
Sangwan, P., Sangwan, A., Duhan, J. and Rohilla, A., 2013. Tertiary dentinogenesis with calcium hydroxide: a review of proposed mechanisms. International
endodontic journal, 46(1), pp.3-19.

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• Sciaky and Pisanti in 1960 calcium ions present in the applied calcium hydroxide do not
become incorporated in the mineralized repaired tissue, which derives its mineral
content solely from the dental pulp
• Forman –Ca(OH)2 - initiator rather than a substrate
• Clinical success rates after direct pulp capping with Ca(OH)2 - 13% to 96%
Mente et al.Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: An Analysis of the Clinical
Treatment Outcome. JOE — Volume 36, Number 5, May 2010

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Glass & Zander – Effect of ca(oh)2
on the pulp
Immediately : Small necrotic
zone is seen, bordered by small
basophilic layer of calcium
protienate on pulp side
After 2 weeks : Basophilic zone
shows small areas of calcification
resembling osseous reparative
tissue. Few fibroblasts of pulp
emigrate to border of this area
After 4 weeks : Necrotic zone
disappears leaving an empty
space, basophilic layer
invaded by more & more
dystrophic calcified tissue
After 8 weeks : Layer of
0.1mm of dentin is formed &
basophilic layer is now
mineralized
After 6 months : Dentin bridge
reaches thickness of 0.3mm

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Stimulation of
reparative dentin bridge
High alkalinity,leads to enzyme
phosphatase activation, releasing
of inorganic phosphate from the
blood
Low cytotoxicity
Excellent antibacterial
properties
Accorinteet al. “Evaluation of Mineral Trioxide Aggregate and Calcium Hydroxide Cement as Pulp-capping Agents in Human Teeth”. JOE — Volume 34, Number 1, January 2008
Presence of tunnels in
dentin barrier
Extensive dentin
formation obliterating
the pulp chamber
High solubility in oral
fluids
Lack of adhesion and
degradation after acid
etching

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Mineral Trioxide Aggregate
•Developed in the 1990s by Torabinejad and his Coworkers, introduced to Endodontics by lee et al., 1990’s
Non-resorbable, ash-colored powder
•Superior marginal adaptation
•Structural resmeblence portland cement
•When cured in presence of calcium ions and tissue fluids, it forms a reactionary layer at the dentin
interface resembling hydroxyapatite in structure
•Sustained Alkaline ph, Slow release of calcium ions

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Action: It has ability to stimulate cytokine and interleukins release from blood cells, indicating
that it actively promotes formation of the calcific barrier
Advantages over Ca(OH)₂
1. Thicker dentinal bridge
2. Less inflammation
3. Less hyperemia
4. Less pulpal necrosis
5. Dentin bridge formation at faster rate

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Aeinehchi, M., Eslami, B., Ghanbariha, M. and Saffar, A.S., 2003. Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human
teeth: a preliminary report. International endodontic journal,36(3), pp.225-231.

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Aeinehchi, M., Eslami, B., Ghanbariha, M. and Saffar, A.S., 2003. Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth:
a preliminary report. International endodontic journal,36(3), pp.225-231.

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• Initial pH- 10.2, which increases to 12.5
• First few hours. Comp strength : 26.4 Mpa -24 hrs & 30.4 Mpa – 21 days
• Prevents microleakage over the vital pulp
• Promotes regeneration of the original tissues when placed in contact with the dental
pulp or periradicular tissues
Reaction with other dental materials: - GIC or composite resins

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• Myers K (1996) - MTA, similar to calcium hydroxide (CaOH2 ), induces formation of dentin
bridge
• Holland et al. (1999 - Tricalcium oxide content of MTA interacts with tissue fluids and form
CaOH2 , resulting in hard-tissue creation in a similar manner to that of CaOH2
)
• Faraco et al. (2001) -Dentin bridge formed with MTA is relatively faster, with good
structural integrity than with CaOH2
• Dominguez et al. (2003) and Tziafas (2002) - MTA stimulates reparative dentin formation
along with maintaining the integrity of the pulp
• Pitt Ford et al first to evaluate the performance of MTA for pulp capping in monkey’s teeth,
superior performance compared with calcium hydroxide
• Torabinejad et al, 1993, 1994 Excellent sealing ability & biocompatible

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• Farsi N, et al 2006 - Pulp capping with MTA is recommended for teeth with carious pulp
exposures specially immature teeth with high potential for healing
• Min et al, 2008 Superior in terms of dentin bridge formation during the early healing
process in human dental pulp
• Accornite et al, 2008 Heal the pulp tissue at a faster rate than CH cement in human teeth
• Nair PN et al, 2009 Easier to use , less pulpal inflammation and more predictable hard
tissue barrier formation than Dycal
• Till Dammaschke et al(2010) MTA showed similar results when compared with Ca(OH)2
within the first week after direct pulp capping

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MTA applied using
small ball applicator
over exposure
Remove excess
moisture with cotton
pellet
Apply small amount of
Dyract flow flowable
compomer to cover
MTA and light cured
Etch remaining cavity
walls with 34-37%
phosphoric acid gel, 15
seconds then rinse
Dry the cavity leaving
dentin moist. Apply
bonding agent and cure
Place composite to
complete the
restoration
One step pulp capping
Next appointment assess pulp vitality then follow-up every 3 to 6 months or as needed

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DPC with Mineral Trioxide aggregate using two visit format
•Tooth identified as
either reversible pulpitis/
healthy pulp
•Profound local
anesthesia
•Isolation with rubber
dam
•Caries detector dye
applied for 10 seconds
•Undermined enamel
removed with diamond,
carbide bur & spoon
excavator
•Disinfected with either
chlorhexidine/ NaOCl
•Cotton pellet moistened
in 3 to 6% NaOCl placed
against exposures for 1 to
10 mins
•MTA mixed placed on
pulp and all surrounding
dentin, atleast 1.5 mm
thick
•A custom fabricated
cotton pellet placed over
entire area of MTA
•Strong interim
restoration provided,
preferably an unbonded
composite material that
will facilitate removal
during second visit
•Second appointment
scheduled 5-10 days after
MTA placement
•Tooth is cold tested to
confirm continued normal
vitality
•LA> isolate> interim
material & cotton
removed> MTA checked &
adjusted> composite
placed
•Patient recalled after 6
weeks evaluated followed
by 6 – 12 months and
thereafter yearly basis

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Biodentine
• Calcium silicate based cement with dentin-like mechanical properties
• Tran et al., 2008 - Effective dentin substitute used as a coronal restoration material (IPC), but can also be placed
in contact with the pulp
• Goldberg et al., 2009., Shayegan et al., 2010 perfectly biocompatible & capable of inducing the apposition of
reactionary dentin by stimulating odontoblast activity & reparative dentin, by induction of cell differentiation
• Faster setting time - immediate crown restoration/ to make it directly intraorally “functional” without fear of
the material deteriorating
• Laurent P, Camps J et al., - significantly increased TGF- β1 secretion from pulp cells independently of the contact
surface compared to the increase by Ca(OH)2 & MTA
• Altunsoy M et al. 2015 Shear bond strength with resin composite is one of the highest among CSCs – 17MPa

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Powder - tricalcium silicate , dicalcium silicate, calcium carbonate, oxide filler, iron oxide shade,
zirconium oxide (contrast medium)
Liquid-calcium chloride - accelerator , hydrosoluble polymer - water reducing agent, water
• Hydration of tricalcium silicate- a hydrated calcium silicate gel and Ca(OH)2
• Unreacted tricalcium silicate grains are surrounded by hydrated calcium silicate gel
• Setting time-10-12min , Maturation- 2weeks
• Mixed in triturater , frequency 30s; 5 doses of powder & 1 dose of liquid in each capsule

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• In deep cavities of swine teeth, no bacterial staining or intense inflammatory reaction
• A continuous zone of mineralized matrix mostly of tubular structure
• A separate zone of osteotypic mineralized matrix
• SEM revealed fibrous structural morphology;
• Significantly increased rate of mineralized matrix at both 3 & 8 weeks - group without
Dycal base (Tzifi C et al. 2015)
• Koubi G et al. 2013 - Unique advantage of acting as temporary enamel substitute and
permanent dentine substitute
• Camilleri J et al. 2015 - Does not discolor even in the presence of NaOCl
• Valles M et al. 2015- Equal to control in color stability- even in O2 free environment & blood

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• Biocompatible
• Good antimicrobial activity
• Stimulate tertiary dentin formation
• Stronger mechanically, less soluble and produces tighter seals compared to Ca(OH)2
• Less setting time, good handling characteristics than MTA
• More long-term clinical studies are needed for a definitive evaluation of Biodentine

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Theracal
• Radio opaque , Light-curable pulp-capping material- tricalcium silicate particles in a
hydrophilic monomer provides significant calcium release making it a uniquely stable and
durable material as a liner or base
• Ability to provide free calcium ions could favour the formation of apatite and induce the
differentiation of odontoblasts with the formation of new dentin
• Insulator/barrier and protectant of the dental pulpal complex
M.G. Gandolfi et al., International Journal of Endodontics,2012
• Calcium - hydroxy apatite and secondary dentin bridge formation
• Indication- any pulpal exposures, i.e carious exposures, mechanical exposures or
exposures due to trauma

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Immediate placement & condensation
Gandolfi et al -Higher calcium-releasing ability & lower solubility than either ProRoot MTA or
Dycal
• Curability depth of 1.7 mm - avoid the risk of untimely dissolution
• Syringe material, eliminates need for mixing and handling procedures, as the cement is
applied directly onto the operative site and light cured for 20 s for up to 1-mm increments

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• Act as protectant of the dental pulpal complex
• Bond to deep moist dentin
• Used as a replacement for Ca(OH)2, glass ionomer, RMGI, IRM/ZOE and
other restorative materials
• Have strong physical properties,no solubility, high radiopacity
• It is opaque and “whitish” in color

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• Vij et al -2004:
• GIC temporization for 1-3 months, observed success of subsequent vital pulp therapy from
79% to 92 %
• Campbell et al-2007
• Used GICC as a diagnostic tool for 1-3 months, in symptomless radiographic exposure
teeth or ones with pain and questionable vitality – observed a 98% success in vital pulp
therapy
Vij, R., Coll, J.A., Shelton, P. and Farooq, N.S., 2004. Caries control and other variables associated with success of primary molar vital pulp therapy. Pediatric
Dentistry, 26(3), pp.214-220.
Glass Ionomer Cement/Resin Modified GIC
• Excellent bacterial seal and good biocompatibility
• Produces dentinal bridging, but irritates when it is placed directly onto sensitive pulpal
tissue

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• Excellent bacterial seal
• Fluoride release,coefficient of thermal expansion and modulus of
elasticity similar to dentin
• Bond to both enamel and dentin
• Good biocompatibility
• Chronic inflammation
• Lack of dentin bridge formation
• Poor physical properties, high solubility and slow setting rate
• RMGIC is more cytotoxic than conventional GIC, so it should not be
applied directly to the pulp tissue

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• Mercel et al in 1987,co2 laser for pulp capping in dog’s teeth
• To overcome the histological deficits of electrosurgery
• CO2 Laser , Argon Laser, Diode Laser, Erbium:Yttrium-Aluminum Garnet (Er.YAG)
• Pulp treatment based on its haemostatic, coagulative and sterilizing effects
• Neodymium-doped yttrium-aluminium-garnet laser emits an infrared beam at a wavelength
of 1064nm can be of therapeutic benefit for direct pulp capping and pulpotomy
• Yasuda Y, et al., effect of CO2 laser irradiation on mineralization in dental pulp cells in rats
,stimulated mineralization in dental pulp cells
Laser

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• Technique sensitive
• Causes thermal damage to pulp in high doses
• Formation of secondary dentin
• sterilization of targeted tissue
• Bactericidal effects

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• Biological modulators , able to promote cell proliferation and differentiation
• Promising materials , revive the expectations for regeneration of the exposed pulp
tissue, rather than devitalization
• Formation of osteodentin and tubular dentin, more homogenous reparative dentin
• Superior to calcium hydroxide in the mineralization inducing properties
• High concentration required, Half life- less
• Appropriate dose - avoid uncontrolled obliteration of pulp chamber
Growth factors

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• Osteogenic proteins (BMPs)- stimulate bone formation
• BMP belongs to super family TGF-β , potent modulator of tissue repair in different situations
• Lianjia et al., BMPs are responsible for dentinogenesis, inducing non differentiated
mesenchymal cells from the pulp to form odontoblast-like cells, obtaining osteodentin and
tubular dentin deposition
• PDGF (platelet-derived growth factor), IGF (insulin-like growth factor) and FGF (fibroblast
growth factor)

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• Fail to stimulate reparative dentin in inflamed pulp
• Delivery vechicles - potent effects at the pictogram level and appropriate
carriers will be required to facilitate their handling
• Immunological problems due to repeated implantation of active molecules
• Formation of osteodentin and tubular dentin, more homogeneous reparative
dentin
• Superior to Ca(OH)2 in the mineralization inducing properties
• Dentin bridge formation was equal to dycal after 28 days
• Only TGF-b1 induced reparative dentin formation

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Bioactive molecules
BSP & BMP
implanted in
the pulp
Recruitment of
cells bearing an
osteoblastic
phenotype
Produces a
mineralizing
extracellular
matrix
A tubular
Dentin dense
layer
• Bone Sialoprotein (BSP)
• Bone Morphogenetic Protein-7 (BMP-7), also termed Osteogenic Protein-1 (OP-1)
• Goldberg M et al., BSP - efficient bioactive molecule,induced homogeneous and well
mineralized reparative dentin
• Both BSP and BMP-7 were superior to calcium hydroxide in their mineralization inducing
properties
M. Goldberg et al ., Adv Dent Res August 2001

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• Induced homogeneous and well mineralized reparative dentin
• Superior to Ca(OH)2 in the mineralization inducing properties
• Further clinical studies are needed

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Emdogain (EMD)/Enamel Matrix Derivative
• Rich Amelogenin & Amelin biomaterial inducing a reparative process similar to normal
odontogenesis when placed in contact with pulp tissue
• MTA produced a better quality reparative hard tissue response with the adjunctive use of
Emdogain, when compared with the use of calcium hydroxide
Amelogenins form a matrix layer on the
surface
Contact to cells of the healthy part of the
dentin
The cells secrete natural and specific cytokines
and autokrine substances
Adduction and proliferation of mesenchymal
cells from the healthy part of the dentin
Attraction and differentiation of odontoblasts,
begin the formation of the matrix

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• Dissolved in propylene glycol alginate gel, BMP like molecules and BMP expressing cells,
promote odontoblast differentiation and reparative dentin formation
• Secreted from Hertwig’s epithelial root sheath during porcine tooth development, important
regulator of enamel mineralization and periodontal tissue formation
• Nakamura Y et al., amount of hard tissue formed in EMD treated teeth was more than twice
that of the calcium hydroxide treated control teeth
• Al-Hezaimi K -Calcium hydroxide, ProRoot White MTA and white Portland cement after EMD
application on the exposed pulp, MTA produced a better quality reparative hard tissue
response with the adjunctive use of EMD compared with calcium hydroxide

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• When applied on exposed pulps without the adjunctive use of a pulp
capping material was proven to be ineffective in producing a hard tissue
barrier because of its poor sealing qualities
• Clinical advantages of using EMD are unproven
• Promote odontoblast differentiation and reparative dentin formation
• Suppresses the inflammatory cytokine production
• Post operative symptoms were less

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Odontogenic Ameloblast Associated Protein (ODAM)
• Expressed in ameloblasts, odontoblasts, and pulpal cells, involved in ameloblast
maturation and enamel mineralization
• Yang IS et al., ODAM accelerates reactionary dentin formation close to the pulp exposure
area, thereby preserving normal odontoblasts in the remaining pulp
• Biocompatible
• Accelerates reactionary dentin formation
• Normal pulp tissue appearance without excessive tertiary dentin formation
and obliteration of the pulp cavity compared to MTA
• Further studies containing a larger number of samples and longer follow-
up assessments with various studies with higher primates should be followed

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Endo Sequence Root Repair Material
• Calcium silicates, monobasic calcium phosphate, zirconium oxide, tantalum oxide,
proprietary fillers and thickening agents
• Hirschman et al., compared Cytotoxicity of MTA-Angelus, Brasseler Endosequence Root
Repair Putty (ERRP), Dycal and Ultra-blend Plus (UBP)-(light curable Ca(OH)2) and concluded
that ERRP and UBP are less cytotoxic
• Antibacterial property
• Less cytotoxic than MTA, Dycal and light cure Ca(OH)2
• Bioactivity of the cells as well as ALP activity were decreased gradually
when exposed to ERRM

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• 81-96% triglyceride of ricinoleic acid, considered a natural polyol containing three hydroxyl
radicals
• Biomaterial for bone repair and regeneration after local bone damage
• Positive characteristics, excellent candidate for use in pulp capping
Castor Oil Bean Cement (COB)/Ricinus Communis Polyurethane(RCP)
• Good antibacterial Property
• Less inflammatory response
• Facilitates tissue healing
• Better sealing ability than MTA & GIC
• Good mechanical properties
• Bio inert rather than bioactive
• Further clinical trials are required

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• Heme oxygenase-1(HO) is the rate limiting enzyme in heme catabolism
• Odontoblasts and oxidatively stressed dental pulp cells express HO-1, indicates that the pulp
might respond to oxidative stress at the molecular level
• Simvastatin - improves the osteoblast function and suppresses osteoclast function, resulting
in enhanced bone formation
• Statin - induce angiogenesis and increase neuronal cells, indicating the possible effectiveness
in pulp regeneration along with dentin regeneration
• Anti-inflammatory effect in various tissues, so it is considered as an ideal active ingredient in
pulp capping material to accelerate reparative dentin formation
Enzymes

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• Play a cytoprotective role against proinflammatory cytokines and nitric oxide in
human pulp cells
• Prevent H2O2 induced cytotoxicity and oxidative stress in human dental pulp cells
• Induction of angiogenesis
• Improve the function of odontoblasts, thus leading to improved dentin formation
• Further in vitro and in vivo studies are required
• High concentration causes pulp tissue damage
• Careful evaluation is required before clinical application to determine the suitable
concentration when applied indirectly to a cavity or directly to pulp tissue

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• Resinous material collected by honey bees, traditional anti-infalmmatory and anti-bacterial
medicine for many centuries
• Flavonoids, phenolics, iron, zinc and other various aromatic compounds
• Used as indirect pulp capping paste when mixed with Zno powder ,similar effect as Zoe in
secondary dentin formation
• Direct capping- No pulp degeneration and formation of protective layer
• Parolia A, et al., compared propolis, MTA and Dycal histologically in human dental pulp and
concluded that Propolis and MTA showed similar bridge formation when,compared to Dycal
Propolis/Russian Penicillin

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Study showed that direct pulp capping in rats with
• Non-flavonoids Propolis- 1 w showed pulp inflammation, no dentine bridge formation a
long the follow up period
• Flavonoids -1w no evidence of inflammatory response
• 2 and 4w mild to moderate pulp inflammation
• 4W dentinal bridge formation
• Antioxidant, antibacterial, antifungal, antiviral and anti-inflammatory properties
• Superior bridge formation compared to Dycal, similar results to MTA
• Forms dental pulp collagen, reduces both pulp inflammation and degeneration
• Stimulate reparative dentin formation
• Showed mild / moderate inflammation after 2,4 weeks with partial dentinal bridge
formation

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• Dental pulp stem cells (DPSCs) and Stem cells from Human Exfoliated Deciduous Teeth (SHED)
,novel population of stem cells , capacity of self-renewel and multi lineage differentiation
• Nakamura S et al., compared the proliferation and stem cell marker of SHED, DSPCs and Bone
Marrow Derived Mesenchymal Stem Cells (BMMSCs), gene expression profile of DSPCs and
SHED were analyzed by using DNA microarray
• SHED -Higher proliferation rate than that of DSPCs and BMMSCs
Stem Cells
• Regeneration of dentin pulp complex
• SHED is superior to DPSCs
• Less economic
• Technique sensitive

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66Keys to Clinical Success with Pulp Capping: A Review of the Literature TJ Hilton
•Avoid exposing pulp,chances for tooth survival are excellent if the tooth is asymptomatic and well sealed, even if
residual caries remains
•Control hemorrhage with water, saline or sodium hypochlorite. Water and saline , most benign to the pulp;
sodium hypochlorite , best at controlling hemorrhage and disinfecting
•ZOE, GI/RMGI and adhesives are poor direct pulp-capping agents and should be avoided for this application
•MTA demonstrates comparable results to calcium hydroxide as a direct pulp cap agent in short-term data
•Calcium hydroxide “gold standard” for direct pulp capping, longest track record of clinical success, most cost-
effective and is likely effective component in MTA
•Provide a well-sealed restoration immediately after pulp capping, provide protection against ongoing leakage and
bacterial contamination that can compromise the success of the pulp cap

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• Knowledge of biology of caries, comprehension of technological advances and
conviction about improved restorative materials has initiated a pulp preservation
that indeed is a boon to the clinician and the patient
Conclusion

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• Ingle 5th edition, Cohen & Wiene
• Orban’s Oral histology & Embryology. 2004 mosby 11th edition.
• The dental pulp. 2000 Samuel seltzer & I.B.Bender 3rd edition
• Evaluation of clinical & Microbiological features of deep Carious lesions in primary molars, Buket ayna et al (J Dent Child 2003;70 15-18).
• Desinging new treatment strategies in vital pulp therapy, D. Tziafas et al, (J of dentistry 2000;28 77-92).
• Calcium hydroxide pastes : Classification and clinical indications, L.R.G. Fava et al, (INT. Endo J 1999; 32 257-282
• Formaldehyde in dentistry : A review for the millenium, Bradley Lewis (J Clin, Pediatr Dent 1998; 22(2) 167-177
• Er: YAG Laser Effects on Oral Hard and Soft Tissues, Ulrich Keller & Raimund Hibst (Lasers in Dentistry)
• Identification of Hard Tissue After Experimental Pulp Capping Using Dentin sialoprotein (DSP) as a marker (JOE, 2003 29(10) 646-650)
• Reparative dentin: affecting its deposition, Charles F. Cox et al (QI, 1992 23 257-270
• Pulp capping of dental pulp mechanically exposed to oral microflora: a 1-2 year observation of wound healing in the monkey. C.F.Cox et al ( J
of oral pathology 1985: 14 156-168).
• Pulpotomy therapy in primary teeth: new modalities for old rationales, Don M. Ranly.(Pediatric dentistry 1994 16(6) 403-408)
• Pulpal healing and dentinal bridge formation in an acidic environment. C.F.Cox et al ( QI 1993; 24 501-510)
.
References

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• Histopathologic study on Pulp response to single-bottle and self Etching adhesive systems VO Medina et al . (Operative dentistry 2002 27 330-
342).
• Direct pulp capping with bonding resin, without calcium hydroxide H.S. Cho et al (Int J of paed Dent 13(suppl 1 ): 5 -68
• Malkondu Ö, Kazandağ MK, Kazazoğlu E. A review on biodentine, a contemporary dentine replacement and repair material. BioMed research
international. 2014;2014
• Bjørndal, L., 2008. Indirect pulp therapy and stepwise excavation. Journal of endodontics, 34(7), pp.S29-S33
• Qureshi et al.Recent Advances in Pulp Capping Materials: An OverviewJ Clin Diagn Res. 2014 Jan; 8(1): 316–321
• Louwakulet al.Pulp-capping Material Containing Fluocinolone Acetonide,JOE
• Accorinteet al. “Evaluation of Mineral Trioxide Aggregate and Calcium Hydroxide Cement as Pulp-capping Agents in Human Teeth”. JOE —
Volume 34, Number 1, January 2008
• Dammaschke et al. A new bioactive cement for direct pulp capping. INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL. 2, NO. 2
• Patel et al. Preserving pulp vitality.Dental health.Volume 52 No 2 of 6 March 2013 Ardo et al.Histological analysis of rat dental pulp tissue
capped with propolis, J oral sci., 2005; 47:135-138

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