Vital pulp therapy aims to maintain pulp vitality by removing irritants and placing protective materials over exposed pulp. Indirect pulp capping covers deep caries with a biocompatible material to stimulate tertiary dentin formation and arrest decay. Direct pulp capping places protective dressings directly over pulp exposures to induce reparative dentin bridges. Calcium hydroxide and mineral trioxide aggregate are commonly used capping agents. Apexification forms apical barriers in open-apexed teeth while pulpotomy removes coronal pulp to preserve radicular vitality. Gentle techniques and accurate diagnoses are important for predictable outcomes of vital pulp therapies.

1. VITAL PULP THERAPY
- BY
MAHAK RALLI
ROLL NO. 42
IV/I

2. INTRODUCTION
• Hard tissue covering of tooth structure
provides protective armour to
sensitive pulpal tissues from external
insults.
• Carious and non carious diseases
result in progressive destruction of
these hard tissues rendering the pulp
tissue more and more vulnerable.

3. WHAT IS VITAL PULP THERAPY?
• Vital pulp therapy is the treatment
initiated on an exposed pulp to repair and
maintain the pulp vitality.
• All these procedures involve removal of
local irritant and placement of protective
material directly or indirectly over the
pulp.
• Common objective is to induce a physical
protective barrier over pulp to maintain its
vitality and function.

4. GOALS
• Treat reversible pulpal injuries.
• Neutralization of any existing pulpal
contamination.
• Prevention of further contamination
(microleakage)

5. INDIRECT PULP CAPPING
• DEFINITION:
Indirect pulp capping is defined as a
procedure wherein 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.

6. OBJECTIVE OF INDIRECT PULP CAPPING
• The ultimate objective is to preserve
the vitality of the pulp by completely
removing the carious infected dentin
followed by placement of material
that would enable the affected dentin
to remineralise by stimulating the
underlying odontoblasts to form
tertiary dentin.

7. RATIONALE OF INDIRECT PULP CAPPING
• Disinfection of residual affected
dentin is more readily accomplished.
• It eliminates the need for more
difficult pulp therapy by arresting the
carious process and allowing the pulp
reparative process to occur.
• Patient comfort is immediate.

8. CLINICAL PROCEDURE
• Performed as single or two-step approach.
• TREATMENT OUTCOME DEPENDS ON :
1. Remaining dentin thickness
2. Choice of indirect pulp capping agent

9. FIRST APPOINTMENT
• Use of local anesthesia and isolate with rubber
dam.
• A slow speed hand-piece with burs is used to
remove the superficial debris and majority of the
soft infected dentin without exposing the pulp.
• Deepest layer of infected dentin is covered with a
hard-setting calcium hydroxide preparation, and
sealed with an overlying base of reinforced zinc-
oxide eugenol preparation.
• This sealed cavity is not disturbed for 6-8 weeks.

10. SECOND APPPOINTMENT
• A bitewing radiograph of treated tooth is obtained.
• Use local anesthesia and isolate with rubber dam.
• The previous remaining soft, deep brownish red
colour affected dentin will have changed lighter
brownish grey colour and most importantly harder
in nature.
• The entire floor is covered with calcium hydroxide
preparation.
• When clinical and radiographic findings are
negative, the final restoration is placed.

12. DIRECT PULP CAPPING
• DEFINITION :
Its defined as the procedure in which the
exposed vital pulp is covered with a
protective dressing or base placed directly
over the site of exposure in an attempt to
preserve the pulpal vitality.

13. INDICATIONS
• Iatrogenic mechanical exposure of pulp in
an asymptomatic vital tooth with sound
dentin at the periphery
• Small carious exposures in an
asymptomatic permanent tooth with an
incomplete root formation.
• Radiographically there should be no
thickening of PDL space and no evidence
of peri-radicular lesion.

14. CONTRAINDICATIONS
• In cases of carious exposures of
primary tooth.
• Large carious exposures in
symptomatic permanent tooth

15. FACTORS AFFECTING PROGNOSIS OF
DIRECT PULP CAPPING

18. PPROPERTIES OF PULP CAPPING
AGENTS

19. CALCIUM HYDROXIDE
• In 1920, a new era in the treatment of exposed
pulp began when Hermann introduced a calcium
hydroxide mixture that induced the bridging of
the exposed pulp with reparative dentin
• The examples : Pulpdent
paste and Dycal

20. MECHANISM OF ACTION

21. HEALING WITH CALCIUM HYDROXIDE
• Zone of obliteration
• Zone of coagulation necrosis
• Zone of dentin bridge formation
• Line of demarcation

23. ZONE OF OBLITERATION
• Pulp tissue immediately in contact to
calcium hydroxide is usually completely
deranged and distorted because of the
caustic effect of the drug.
• This zone consists of debris, dentinal
fragments, hemorrhage, blood clot, blood
pigment and particles of calcium hydroxide.
• This zone is a result of high conc of hydroxyl
ions and high pressure od medicament
application.

24. ZONE OF COAGULATION NECROSIS
• A weaker chemical effect reaches the
subjacent, more apical tissues and results
in a zone of coagulation necrosis and
thrombosis
• Also called Schroeder’s layer of “firm
necrosis” and Stanley’s “mummified zone”

25. ZONE OF DENTINE BRIDGE FORMATION
• Area of mineralization initiated by calcium
hydroxide
• No structural configuration is seen in the
mineralised dentine initiated by calcium
hydroxide
• Zone ranges from 0.3-0.7mm in thickness

26. LINE OF DEMARCATION
• A line of demarcation between the
deepest level and subjacent vital pulp
tissue
• It is believed to be resulted from the
reaction of calcium hydroxide with
tissue protein to form proteinate
globules

27. MINERAL TRIOXIDE AGGREGATE
• COMPOSTION
1. Tricalcium silicate
2. Dicalcium silicate
3. Tricalcium aluminate
4. Tetracalcium alumino ferrite
5. Bismuth oxide
6. Traces of free crystalline silica
7. Other trace constituents include calcium oxide,
free magnesium oxide, potassium and sodium
sulphate compounds

28. SETTING REACTION OF MTA

29. ADVANTAGES OF MTA
• Produces more dentinal bridging with superior
structural integrity than calcium hydroxide in a
shorter span
• Better resistance to bacterial penetration
• Highly biocompatible
• Set MTA is alkaline and may induce
dentinogenesis
• Hydrophilic
• Significant antimicrobial activity
• Presence of blood has little impact on the degree
of leakage of MTA

30. TECHNIQUES OF DIRECT PULPCAPPING

31. BIODENTINE
• A calcium silicate-based material used for repair
of perforations and resorption, apexification and
root-end fillings
• Can also be used in class II fillings as temp
restoration
• COMPOSITION
Powder Liquid
-Tricalcium silicate -calcium chloride in
-Dicalcium silicate aqueous solution
with
-Calcium carbonate an admixture of
-Zirconium dioxide polycarboxylate

32. SETTING REACTION
• Powder is dispensed in a capsule that is mixed
with liquid in a triturator for 30 seconds
• Hydration of tricalcium silicate produces a
hydrated calcium silicate gel and calcium
hydroxide
• Unreacted tricalcium silicate grains are
surrounded by layers of calcium silicate
hydrated gel, which are relatively impermeable
to water, thereby slowing the effects of further
reaction
• Setting time is 10 mins

33. ADVANTAGES
• Pulp capping and to bulk fill the cavity
• Does not stain the tooth
• Excellent radiopacity
• No need for d=surface preparation or
tedious bonding due to micr0-mechanical
anchorage
• Higher compressive strength than
dentine, promotes pulp healing and
preserves the pulp
• Microleakage resistance is enhanced

34. APEXIFICATION
• Definition : Its defined as a method to induce a
calcific barrier across an open apex of an
immature, pulpless tooth.
• Objective : The aim of apexification is to induce
either closure of the open apical third of the root
canal or the formation of an apical “calcific
barrier” against which obturation can be
achieved.

35. PULPOTOMY
• Its defined as a procedure in which a portion of
exposed vital pulp is surgically removed as a
means of preserving the vitality and function of
the remaining radicular portion. The procedure
is similar in concept to direct pulp capping
except in the amount and extent of pulp tissue
removal.

36. OBJECTIVES
• Preservation of vitality of radicular pulp
• Relief of pain in patients with acute
pulpalgia and inflammatory changes in the
tissue
• Ensuring the continuation of normal
apexogenesis in immature permanent
teeth by retaining the vitality of pulp

37. CONCLUSION
• Diseases affecting the hard tissues of the tooth
as well as most operative procedures are
traumatic to the pulp
• Though the pulp has remarkable recuperative
powers all efforts must be made to minimise
insults to it
• Hence a gentle approach to cavity preparation
and restoration should be employed
• An accurate diagnosis of the pulpal status and
case selection plays a major role in the
predictable outcome of vital pulp therapy
procedures