SEMINAR

1. PULP CAPPING AND PULP CAPPING
AGENTS
Presented by
KARUNA SHARMA

2. Pulp therapies in primary molars

3. Objectives
Esthetics
Masticaton
Speech
Psychology
Preservation
of the arch
space
Growth of
Skeletal &
Dental
complex(Bar
nett,1985)
Effects on
succedenous
tooth
(Whine,
1981)

4. Title
Indirect Pulp Capping
Direct Pulp Capping
Pulpotomy
Pulpectomy
Classification of pulp therapy
procedures in primary teeth
Conservative procedures
Radical procedures
Weine.Endodontic therapy 6th Edition.Mosby Publication.

5. Title
Protective liner
Indirect Pulp Capping
Direct Pulp Capping Pulpotomy
Pulpotomy
pulpectomy
Pulpectomy
Classification of pulp therapy
procedures in primary teeth
Vital pulp therapy for primary teeth
diagnosed with a normal pulp or
reversible pulpitis
Nonvital pulp treatment for primary
teeth diagnosed with irreversible pulpitis
or necrotic pulp
Clinical guidelines on pulp therapy for primary and young permanent
molars AAPD 2009

6. Protective liner

7. Protective liner
Itota T, Nakabo S, Torii Y, Narukami T, Doi J, Yoshiyama M. Effect of fluoride-releasing
liner on demineralized dentin. Quintessence Int 2006;37(4):297-303.
Weiner RS, Weiner LK, Kugel G. Teaching the use of bases and liners: A survey of
North American dental schools. J Am Dent Assoc 1996;127(11):1640-5.
A protective liner is a thinly-applied liquid placed on
the pulpal surface of a deep cavity preparation,
covering exposed dentin tubules, to act as a
protective barrier between the restorative material
or cement and the pulp. Placement of a thin
protective liner such as calcium hydroxide, dentin
bonding agent, or glass ionomer cement is at the
discretion of the clinician.

8. Protective liner
Indications
In a tooth with a normal pulp, when all caries is
removed for a restoration, a protective liner may
be placed in the deep areas of the preparation to
minimize injury to the pulp, promote pulp tissue
healing, and/or minimize postoperative
sensitivity.

9. Objectives
• The placement of a liner in a deep area of
the preparation is utilized to preserve the
tooth’s vitality, promote pulp tissue
healing and tertiary dentin formation, and
minimize bacterial microleakage.
• Adverse post-treatment clinical signs or
symptoms such as sensitivity, pain, or
swelling should not occur.

10. Pulp Capping

11. Indirect Pulp Capping

12. Indirect Pulp Capping
Definition
Objectives
Mechanism
Indications
Contraindications
Materials
Techniques
Success of Indirect pulp capping

13. Definition

14. “It is defined as procedure wherein small
amount of carious dentin is retained in
deep areas of the cavity to avoid pulp
exposure, followed by placement of a
suitable medicament and restorative
material that seals off the carious dentin
and encourages pulp recovery”
-Ingle
Definition
John I Ingle Leif K Bakland Endodontics, Fifth Edition

15. “It is defined as application of a suitable
medicament over a thin layer of
remaining carious dentin(affected dentin),
after deep excavation of infected dentin
without exposure to the pulp”
-Mathewson,1995

16. Objectives (AAPD)
Tooth vitality should be preserved
Restorative material should seal the
involved dentin completely
No post-treatment senstivity, pain &
swelling
No harm to the succedenous tooth

17. Title
Removal of the carious dentin
Remaining carious dentin is covered with
biocompatible material
Physiologic remineralisation can occur only if the
affected dentin contains sound collagen fibers and
living odontoblastic processes
Sound collagen fibres – base to appatite crystals
Living odontoblastic processes supply calcium
phosphate from vital pulp for remineralisation
Mechanism

18. Reparative dentin
Highest amount of
dentin formed during
first month
(Traubman 1967).
New dentin
formation faster –
Primary teeth ↑
than permanent teeth
Males > females
The rate of
reparative dentin
formation is 1.4
micron per day.

19. A- Soft necrotic
B- Firm, semi soft
C-Hard, discolored
Kopel, 1976

20. A-
B-
C-
Fusyama, 1979
Infected
layer
Affected layer

21. INFECTED LAYER AFFECTED LAYER
Highly demineralized
Superficial layer
Lacking sensation
Stained by 0.5% fuschin
in propylene glycol
Intertubular dentin
greatly demineralized
Deteriorated collagen
fibers
Unmineralizable
Intermediately
demineralised
Deeper layer
Sensitive
Does not stain
Partially demineralized
Sound collagen cross
linkage
Remineralizable
21

22. Indications &
Contra-indications

23. Indications (Kopel HM, 1985)
History
• Tolerable dull
pain with mild
discomfort from
chemical and
thermal stimuli
• No history of
spontaneous pain
Clinical
examination
• Large carious lesion
without any frank
pulpal exposure
• Positive response to
electric pulp
sensitivity, thermal
stimulation and test
cavity
• Normal appearance
of adjacent gingiva
• Normal to
percussion
Radiographic
examination
• Large carious lesion
in close proximity
to the pulp
• Normal lamina dura
• Normal periodontal
ligament space
• No periapical
radiolucency
John I Ingle Leif K Bakland Endodontics, Fifth Edition

24. Contraindications
History
• Sharp,
penetrating pain
• Prolonged
spontaneous pain,
particularly at
night
Clinical
examination
• Excessive tooth
mobility
• Parulis in the gingiva
• Discoloration.
Radiographic
examination
• Large carious lesion
with apparent pulp
exposure
• Interrupted lamina
dura
• Widened periodontal
ligament space
• Radiolucency at the
furcation areas.
John I Ingle Leif K Bakland Endodontics, Fifth Edition

25. Techniques

26. Title Techniques
Two appointment
technique
One appointment
technique
John I Ingle Leif K Bakland Endodontics, Fifth Edition

27. Title
Two appointment technique
(First sitting)
Carious peripheral dentin should be removed by sharp spoon
excavator
Stop the excavation as soon as firm resistance of sound dentin is
felt
Administer local anesthesia and isolate with a rubber dam.
Establish cavity outline with a high speed hand piece.
Remove the majority of soft, necrotic, infected dentin with a large
round bur in a slow speed hand piece without exposing the pulp.
.
Cover the remaining affected dentin with a hard setting
calcium hydroxide dressing.
Fill or base the remainder of the cavity with a reinforced ZOE
cement and Do not disturb this sealed cavity for 6 to 8 weeks.

29. 1st Appointment

30. Title
Two appointment technique
(Second sitting)
Between the appointments history must be negative and
temporary restoration should be intact.
Bitewing radiographs of the treated tooth should be assessed for
the presence of reparative dentin
The remaining affected carious dentin should appear dehydrated and
"flaky“,The area around the potential exposure should appear whitish and
may be soft, this is "predentin".
The cavity preparation should be irrigated and gently dried.
Carefully remove all temporary filling material, especially the calcium
hydroxide dressing over deep portions of the cavity floor.
.
Cover the entire floor with a hard setting calcium
hydroxide dressing.
A base should be placed with a reinforced ZOE or glass ionomer
cement, and tooth should receive a final restoration.

31. 2nd Appointment

32. 1st Appointment
2nd Appointment

33. After 1st
Appointment
After 2nd
Appointment

34. Protective base
Calcium
hydroxide
Restoration

35. Title
Indications
Poor patient cooperation
Inability to remove carious dentin in
the first appointment
Disadvantages
According to Leng et al (1980) The
re-entry and re-excavation may
potentially increase the chances of
pulp exposure.
Two appointment technique

36. TitleTwo appointment technique
Current literature indicates that there is
inconclusive evidence that it is necessary
to reenter the tooth to remove the
residual caries.

37. These investigators suggested that reentry
to remove the residual minimal carious
dentin after capping with calcium hydroxide
may not be necessary if the final
restoration maintains a seal and the tooth is
asymptomatic.
One appointment technique

38. TitleOne appointment technique
Carious peripheral dentin should be removed by sharp spoon
excavator
Stop the excavation as soon as firm resistance of sound dentin
is felt
Administer local anesthesia and isolate with a rubber dam.
Establish cavity outline with a high speed hand piece.
Remove the majority of soft, necrotic, infected dentin with a large
round bur in a slow speed hand piece without exposing the pulp.
.
Cover the remaining affected dentin with a hard setting
calcium hydroxide dressing.
A base should be placed with a reinforced ZOE or glass ionomer
cement, and tooth should receive a final restoration.

39. One Appointment
technique

40. Conventional
materials..

41. Title
Calcium Hydroxide
Zinc oxide Eugenol
Materials

42. Title
Dentin bonding agents
(Falster CA et al 2002)
Resin modified glass
ionomer (Farooq 2000)
Light cured composites
(Lado & Stanley 1987)
Materials

43. Title Materials
Light cured composites

44. Title Materials
Dentin bonding
agents
J.J. Marchi .Analysis of Primary Tooth Dentin After Indirect Pulp Capping. Journal
of Dentistry for Children-75:3, 2008

45. Title Materials
Resin modified glass
ionomer
J.J. Marchi .Analysis of Primary Tooth Dentin After Indirect Pulp Capping. Journal
of Dentistry for Children-75:3, 2008

46. Recent
Advancements..

47. TitleNew Materials..
Emdogain

48. TitleNew Materials..
Insulin-like growth
factor I

49. Evaluation of
Therapy

50. In histological sections
4 histological layers:
Carious decalcified
dentin
Rhythmic layers of
irregular reparative
dentin
Regular tubular
dentin
Normal pulp with a
slight increase in
fibrous element.

51. Success of I.P.C

52. Intact restoration
Negative history of
pain.
No radiographic evidence of
abnormal root resorption.
No radiological evidence of
radicular disease.
Success of Indirect pulp capping

53. Indirect pulp capping
Indirect pulp capping has been shown
to have a higher success rate than
pulpotomy in long term studies.
It also allows for a normal exfoliation
time.
Therefore, indirect pulp treatment is
preferable to a pulpotomy when the pulp
is normal or has a diagnosis of reversible
pulpitis.

54. Direct Pulp Capping

55. Direct Pulp Capping
Definition
Studies
Objectives
Indications
Contraindications
Materials
Techniques
Success of direct pulp capping

56. Title
“Direct pulp capping is the
placement of a biocompatible
agent on the healthy pulp
tissue that has been
inadvertently exposed from
caries excavation or traumatic
injury.” -Fuks (1988)
Definition
John I Ingle Leif K Bakland Endodontics,
Fifth Edition

57. TitleGuidelines (AAPD)
Guidelines developed by the
American Academy of Pediatric
Dentistry (AAPD) recommend that
direct pulp capping should be reserved
for small mechanical or traumatic
exposures in primary teeth.

58. Title
Maintain the vitality of
underlying pulp tissue
regions.
Encourage the pulp to
wall off the exposure
site by initiating a
dentin bridge.
To seal the pulp
against bacterial
leakage
Objectives
John I Ingle Leif K Bakland
Endodontics, Fifth Edition

59. Indications (Kopel HM, 1985)
History
• Mild discomfort
from chemical
and thermal
stimuli
• Absence of
spontaneous pain
Clinical
examination
• “Pinpoint”mechanical
exposures
• The exposed pulp tissue
should be bright red in
color
Radiographic
examination
• Large carious lesion
in close proximity
to the pulp
• Normal lamina dura
• Normal periodontal
ligament space
• No periapical
radiolucency
John I Ingle Leif K Bakland Endodontics, Fifth Edition

60. Contraindications
History
• Sharp,
penetrating pain
that persists
after withdrawing
stimulus
• Prolonged
spontaneous pain,
particularly at
night
Clinical
examination
• Large pulp exposure
• Excessive tooth
mobility
• Purulis in the gingiva
• Non responsiveness
to pulp testing
techniques.
Radiographic
examination
• Large carious pulp
exposure
• Interrupted or broken
lamina dura
• Widened periodontal
ligament space
• Radiolucency at the
root apices or
furcation areas.

61. Title Technique
It is prudent to remove peripheral
masses of carious dentin before beginning the
excavation where an exposure may occur.
The area should be appropriately
irrigated with non irritating solutions such as
normal saline to keep the pulp moist.
Kalins, Frisbee, Delgado et al
DEBRIDEMENT
Kopel HM. Cosiderations of Direct pulp capping
agents in Primary teeth: A Review. J Dent Children.

62. Title Technique
BLEEDING & CLOTTING
Hemorrhage at the exposure site can be controlled with cotton
pellet pressure.
A biocompatible material is placed directly in contact with pulp
tissue

63. Title Technique
Exposure enlargement
Frigoletto noted that small exposures & good
blood supply provide the best healing potential.
There have been recommendations that the
exposure site must be enlarged.
(Cvek & zilberman, 1980)
Kopel HM. Considerations of Direct pulp capping
agents in Primary teeth: A Review. J Dent Children.

64. fast setting ZOE cement to achieve a hermetic seal and lastly placing
final restoration (SS crown)
Placing a hard set CaOH material over the exposure
Hemostasis with NaOCl
Flushing out dentinal debris with mild solutions
Excavate the caries
Administer local anesthesia and isolate with a rubber dam.
Technique

65. Title

66. Protective base
Calcium
hydroxide
Restoration

67. • Beveridge and Brown demonstrated that cold
stimuli could decrease intrapulpal pressure by
28 mm Hg.
• This was considered to be a direct result of
the vasoconstriction of the pulpal blood
vessels in response to the cold stimulus.

68. • In the hydrodynamic theory, Brannstrom
postulated that the capillary action of fluid in
the dentinal tubules resulted in the
transmission of pain between the tubules and
vital pulp tissue in the more apical portions of
the pulp chamber and root canal system,even
though there was necrotic tissue or
hemorrhage in the intervening area.

69. • This would seem to account for the sensitivity
to tactile stimuli and changes in temperature,
even though a large portion of the coronal
pulp might be necrotic.
• The coefficient of expansion of dentin fluid is
estimated to be approximately ten times
greater than that of the tubule wall.
• Cooling of dentin would result in a contraction
of the tubules’ contents with a resultant flow
of the fluid away from the pulpal tissues.

70. • During acute inflammation, there is an
accumulation of polymorphonuclear
neutrophils and dilatation of capillaries which
allows plasma proteins to escape into
connective tissue spaces.
• The resultant edema could cause pressure on
the pulpal and/or periapical nerve fibers and
elicit a painful response.
• Van Hassell found that in human teeth the
intrapulpal pressure could increase an average
of 15 mm Hg in an area of local inflammation.

71. • The application of a cold stimulus could, in
turn, result in contraction of the dentinal
fluid and decrease the pressure within the
pulp, yielding a rapid transient reduction of
pain.

72. Pulp capping agents..

73. INTRODUCTION
Historically, the first pulp capping procedure
was performed in 1756, by the Phillip pfaff,
who packed a small piece of gold over an
exposed vital pulp to promote healing.
However, the success of the pulp capping
procedure greatly depends upon the
circumstances under which it is performed
and the prognosis depends upon the age, type,
site and size of pulp exposure.

74. PROPERTIES
 Stimulate reparative dentin formation
 Maintain pulpal vitality
 Release fluoride to prevent secondary caries
 Bactericidal or bacteriostatic
 Adhere to dentin
 Adhere to restorative material
 Resist forces during restoration placement
and during the life of restoration.
 Sterile
 Radiopaque
 Provide bacterial seal

75. PULP CAPPING AGENTS
1. Ca (OH)2(1960’s)
2. Zinc oxide eugenol cement (1960-70’s)
3. Corticosteroids and antibiotics (1970’s)
4. Polycarboxylate cement (1970’s)
5. Inert materials (1970’s)(Isobutyl
cyanoacrylate and Tri calcium phosphate
ceramic)
6. Collagen(1980)

76. PULP CAPPING AGENTS
7.Bonding agents(1995) 4-META-MMA-TBB
adhesives and hybridizing dentin bonding
agents
8.Lasers (1995-2010) CO2 Nd: YAG
9.Mineral trioxide aggregate (1996-2008)
10.Growthfactors(1900-2007)Bone
Morphogenic Protein (BMP 2,4,7)
11.Emdogain(2001-2011)

77. Calcium Hyroxide
• Calcium hydroxide (Ca (OH) 2) was
introduced to the dental profession in 1921
by Hermann and has been considered the
“gold standard” of direct pulp capping
materials for several decades, against
which new materials should be, tested

78. MECHANISM OF
ACTION OF
CALCIUM
HYDROXIDE

79. Calcium hydroxide has the unique potential
to induce mineralization even in tissues that
have not been programmed to mineralize.

80. Sciaky and Pisanti in 1960 observed that
calcium hydroxide do not become
incorporated in the mineralized repaired
tissue, which derives its mineral content
solely from the dental pulp,through blood
supply.

81. CaOH
Ca ions
Reduced capillary
permeability
Reduced serum flow
Reduced levels of inhibitory
pyrophosphate
mineralization
Hydroxyl ions
Neutralizes acid produced
by osteoclasts
Optimum ph for
pyrophosphate activity
Increased levels of calcium ion
dependent pyrophosphatase

82. Zinc Oxide Eugenol (ZOE) Cement
• Tronstad and Mjör stated that ZOE cement
is more beneficial for inflamed and exposed
pulp.
• However in the literature Glass and
Zander, Hembree and Andrews, Watts,
Holland et al., found that ZOE, in direct
contact with the pulp tissue, produced
chronic inflammation, lack of calcific
barrier, and end result is necrosis.

83. Title
These agents include Neomycin and
Hydrocortisone, Cleocin, Cortisone,
Ledermix, Penicillin and Keflin.
Corticosteroids & Antibiotics

84. Title
Reduces pulp inflammation
Vanocmycin + Ca(OH)2 stimulated a
more regular reparative dentin bridge.
Corticosteroids & Antibiotics

85. TitlePolycarboxylate cements
Kopel HM. Cosiderations of Direct pulp capping
agents in Primary teeth: A Review. J Dent Children.
 bonds to the tooth structure
McWalter, G et al., found that it lacks an
antibacterial effect and calcific bridge formation .

86. TitleHybridizing bonding agents
J.J. Marchi .Analysis of Primary Tooth Dentin After Indirect Pulp Capping.
Journal of Dentistry for Children-75:3, 2008

87. Title
Miyakoshi et al have shown the effectiveness of 4-
META-MMA-TBB in obtaining an effective biologic
seal. Pulp showed reparative dentin deposition
without pulp pathosis.
Heitman and Unterbrink studied a GLUTARALDEHYDE
containing Dentin bonding agent. All teeth were
vital after 6 month post operative period.
Hybridizing bonding agents
J.J. Marchi .Analysis of Primary Tooth Dentin After Indirect Pulp Capping.
Journal of Dentistry for Children-75:3, 2008

88. Title
Have cytotoxic effect
Absence of calcific bridge formation
In vivo studies have demonstrated that the
application of an adhesive resin directly onto a
site of pulp exposure, or to a thin layer of
dentin (less than 0.5 mm), causes dilatation and
congestion of blood vessels as well as chronic
inflammatory pulpal response
Hybridizing bonding agents
J.J. Marchi .Analysis of Primary Tooth Dentin After Indirect Pulp Capping.
Journal of Dentistry for Children-75:3, 2008

89. TitleCollagen Fibers
Carmichael DJ reported that
collagen fibers are less
irritating than Ca (OH)2 and
promotes mineralisation but
does not help in thick dentin
bridge formation
Fuks et al found dentin bridge
after 2 months in 73% cases.

90. Title
Materials like Iso-butyl Cyanoacrylate and
Tri- Calcium Phosphate ceramic have been
used as pulp capping agents.
Reduces pulp inflammation
Stimulate dentin bridge formation
Inert Materials

91. Title
None of these materials have been
promoted to the dental profession as a
viable technique
Inert Materials

92. Title
M.T.A
Bone Morphogenic Proteins
(B.M.P)
Cell Inductive Agents

93. MTA (Mineral Trioxide Aggregate)
Torabinejad centered his research in the
development of MTA at the loma linda
university, California in 1995.

94. Composition
Tricalcium silicate
Dicalcium silicate
Tricalcium aluminate
Tetracalcium aluminoferrite
Bismuth oxide
Traces of silica

95. • exists in both white and gray form
• difference between the two forms is
thelack of iron in the tetracalcium
aluminoferrite in the white version.
• Can be used for root end fillings
perforation repair,pulpotomy and
apexification treatment.

96. Title
MTA (Mineral Trioxide Aggregate)
Pitts et al (1996) & Sluyk et al (1998)
It allows some micro leakage but superior sealing ability to
amalgam, ZnOE / IRM
- superior to CH in animal models (Torabinejab M et al, 1999
&Junn D.J et al, 1998)
Cell Inductive Agents

97. TitleTitle
Major Advantages:
 Excellent sealing ability
 Good Compressive Strength
 Good Biocompatibility
 Pitt Ford et al documented
Superior bridge formation and
preservation of pulp vitality
with MTA when compared with
Ca(OH)2
Cell Inductive Agents

98. TitleTitle
Major Advantages:
 has significant antimicrobial property
 Hydrophilic
 Is alkaline(12.5) and may induce
dentinogenesis.
 The presence of blood has little impact on
the degree of leakage of MTA.
 Thus it can be used as an alternative to
calcium hydroxide in both direct pulp
capping and pulpotomy preocedures.
Cell Inductive Agents

99. TitleTitle
Bone morphogenic protein (BMP)
BMP belongs to super family transforming
growth factor beta (TGF-b).
-
TGF b is a potent modulator of tissue repair
in different situations. BMP-2, 4, and 7
plays a role in the differentiation of adult
pulp cells into odontoblasts during pulpal
healing.
Cell Inductive Agents
Kopel HM. Cosiderations of Direct
pulp capping agents in Primary
teeth: A Review. J Dent Children.

100. TitleTitle
-
Urist (1965), observed demineralized bone
matrix could stimulate new bone formation
when implanted to ectopic sites (muscles)
demineralized dentin – from both bone &
dentin
- Soren J et al (1997), dentin formation by
recombinant human osteogenic protien-1.
Cell Inductive Agents
Kopel HM. Cosiderations of Direct
pulp capping agents in Primary
teeth: A Review. J Dent Children.

101. Recombinant Insulin Like
Growth Factor-I
Lovschall H, et al., evaluated
recombinant insulin like growth
factor-I (rhIGF-I) in rat molars
and concluded that dentin bridge
formation was equal to dycal
after 28 days.
TitleTitleCell Inductive Agents

102. TitleTitle Emdogain

103. • EMD is enamel matrix derivative
secreted from Hertwig’s epithelial root
sheath during porcine tooth
development.
• It is an important regulator of enamel
mineralization and plays an important
role during periodontal tissue formation.

104. TitleTitleNew Materials..
Emdogain
“Amelogenin” &
“Amelin”
Stimulates dental stem cells
for regeneration of
periodontium
Rangel AG et al. Direct Pulp capping in Primary Molars
with Enamel Matrix derivative. JCPD 2009.34(1).9-12.

105. • It stimulates the regeneration of acellular
cementum, periodontal ligaments, and
alveolar bone.
• Nakamura Y et al., concluded that amount
of hard tissue formed in EMD treated
teeth was more than twice that of the
calcium hydroxide treated control teeth

106. • Al-Hezaimi K evaluated 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

107. • Melcer et al., suggested between the years
1985 and 1987 that the carbon dioxide
(CO2) (1W) laser used for direct pulp
capping .
• Yasuda Y, et al., did a study to examine
the effect of CO2 laser irradiation on
mineralization in dental pulp cells in rats
and the results suggested that CO2 laser
irradiation stimulated mineralization in
dental pulp cells .
Laser

108. • 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 in clinical
practice

109. TitleTitle
Orban’s Oral Histology & Embryology 11th Edition.
Grossman’s Endodontic Practice twelfth edition
Text book of pediatric dentistry Nikhil Marwah 2nd edition
Guidelines on pulp therapy for primary and immature permanent
teeth AAPD
Antonio Nancy.Tencate’s Oral Histology.6th Edition.
Kopel HM. Cosiderations of Direct pulp capping agents in Primary
teeth: A Review. J Dent Children.
Rangel AG et al. Direct Pulp capping in Primary Molars with Enamel
Matrix derivative. JCPD 2009.34(1).9-12.
John I Ingle Leif K Bakland Endodontics, Fifth Edition
References

110. Thank You