PULP CAPPING

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
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 Clinical
Deep carious lesion,
examination
Mild pain associated close to but not
with eating involving pulp in vital
Negative history of primary or young
permanent teeth
spontaneous extreme
pain No mobility
Radiographic examination When pulp
inflammation is
Normal lamina dura and
nominal and there is a
PDL space
definite layer of
No radiolucency in the
affected dentin after
bone around the apices
removal of infected
of roots or in furcation.
dentin
Contraindications of IPC
History Clinical examination
Sharp penetrating
pulpalgia indicating
acute pulpal Swelling
inflammation Fistula
Prolonged night pain Tenderness to
Radiographic examination
percussion.
Definite pulp exposure Pathological mobility
Interrupted or broken Discoloration of tooth
lamina dura
Radiolucency about the
apices of roots
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 Antioxidants
ZnOE Growth Factors
Dentin Bonding Agents Enzymes
Glass Ionomer Cyanoacrylates
Antibiotics
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 + Phosphoric acid / silicates Emboli
 OH -
Ca 2+

Neutralizes Acid Capillary permeability

Optimum Ph for
pyrophosphate Serum Flow
activity

Ca 2+ Inhibitory
dependent pyrophosphate
pyrophospha
te
Uncontrolled
mineralizatio
n
 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 Disdvantages
Bacteriostatic bactericidal
Healing & Repair
Stimulates Fibroblasts No adherence to dentin
Stimulates Enzyme systems Recurrent caries if lost
Stops internal resorption Cavosurface microleakage
Obturates open tubules
Ideal intracanal medication
Inexpensive & easy to use
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
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 12 th edition
Dentistry for the child and adolescent. 9 th
edition McDonald
Sturdevants Operative Dentistry 4 th edition
Textbook of Endodontology Gunner
Bergenholtz
Textbook of Pediatric Dentistry Nikhil
Marwah