INTRODUCTION

INDIRECT PULP CAPPING

Definition & historical review

Rationale

Objectives

Response to treatment

Procedure for IPC

Medicament of choice

Clinical studies

DIRECT PULP CAPPING

Definition

Objectives

Indications & contraindications

Treatment considerations

Medications & materials

Clinical studies

PULPOTOMY

Introduction

Definition

History & development

Indications & contraindications

Classification

Formocresol pulpotomy

Calcium hydroxide pulpotomy

Other materials

Non –pharmacologic pulpotomy techniques

Electro-surgery
 Lasers

Clinical studies

) APEXOGENESIS

Definition

Indications & contraindications

Treatment of vital teeth with open apices

Pulpotomy

Partial or Cvek pulpotomy

Clinical studies

New biological approaches to vital pulp therapy

Bone morphogenic protein molecules

Transdentinal treatment

Conclusion

Dental caries - & Pulp dentin complex reactions

Ist Pulp – dentin complex reactions

Branstorm & Lind (1965)- in chronic inflammatory cells when lesions

apparently confined to enamel

Others – reactions occur only when caries extends into dentin

Fuzayama – relationship b/w dentine softening , discoloration &

bacterial infection
 Softening Discoloration Bacterial infection

Reduce the permeability of dentine deposition of apatite & whitlockite crytsals dentine tubule
sclerosis

Addition to this tertiary dentine may also be laid down

Odontoprogentior cells from adjacent cell rich layer – Production of

reparative dentine

Depending on severity – can be irregular with cellular inclusions or

less agressive – resemble normal tubular dentine

Reeves & Stanley – Showed that if the advancing front of the lesion was

greater than 0.8mm from the pulp - no significant

 disturbance occured

Shovelton – Occurs only when the lesion was with in 0.25 mm –0.3mm

of the pulp that hypermia & pulpitis occur

• Summary of human pulp responses to the remaining dentin thickness of cavity preparations
 • Pulp injury & repair activity decreased as the remaining dentin thickness increases

• 13(6):509-520 (2002) Crit Rev Oral Biol Med 509

• Classification of techniques for the treatment of carious dentin

Techniques Instruments, Principles Advantages Disadvantages Conclusion

materials

1 Excavation techniques

Manual Sharp hand Mechanical removal -Long-term High pressure Accepted procedure
excavation excavator of softened dentin causes pain
observations especially in pedodontics an

-Adequate tissue removal anxious patients

-Over-excavation is
unlikely

Rotary Low-speed contra Mechanical removal Long-term - Aversive for Widely accepted
excavation of softened dentin
angled handpieces Observations patients gold standard

with Efficient - Over Preparation

electromotors
  of tissues
or turbines .
- Possible -ve
Round carbon- effects on pulp
steel burs
Techniques Instruments, Advantages Dis Conclusion
materials Principles
advantages

Controlled Torque Selective caries Questionable Hardness of Experimental

selective rotary controlled removal due to dentin varies
excavation (step) motors differences in
(Endostepper, hardness
Brasseler), between healthy
Carisolv and carious
Drive, dentin
MediTeam)

Polymer burs Selective caries Questionable Hardness of not convincing

(Smart Prep, removal due to dentin varies
SS White) differences in
hardness b/w
healthy and
carious dentin

Fluorescence- Exciting carious -On-time feedback Excavation hasInteresting

aided caries dentin with during excavation to be
excavation violet blue light technique with clin
(FACE) causes visible -Quality control of visually
potential, however
orange-red excavation   observed
fluorescence, through limited clinical
allowing a 530 nm data
identification of highpass filter
residual carious
dentin

Techniques Instruments, Principles Advantages Disadvantages Conclusion

materials
Air Air pressure device Mechanical Selective caries Unclear completeness Experimental
abrasion, abrasion removal is principally of
air Abrasive powder possible
polishing excavation Limited
(aluminium oxide, scientific data
resin, hydroxyapatite,
salts)

Chemo- Carisolv(MediTeam)so Mechanical Adequate tissue Less effective than Limited clinical indications
mechanical dium hypochlorite removal of removal Less pain rotary
excavation solution applied with chemically alteredSafe
modified dull hand or or solved instrumentation
rotary excavators (time consuming)
Carious dentine

Enzymatic Exp. Enzyme Mix Proteolytic Enzymes are highly No clinical studies Experimental
digestion   enzymatic selective Promising in
Collagenase ,Pronase digestion of vitro results  
  collagen

Photo Laser: CO 2 , Selective ablation Self-controlled Expensive Time Experimental

of carious dentin selective excavation consuming
ablation Nd-YAG, Er:YAG   Poor cost/ effectiveness ratio
(Laser) Thermal side effects  

Techniques Instruments, Principles Advantages Disadvantages Conclusion

materials
 2 Disinfection techniques

Ozone treatment Ozone generator O 3 gas disinfects Efficient method: •  Only limited data for other Clinically effecti
(HealOzone, effectively due to disinfection time less defects than primary root
KaVo) oxidizing properties than caries lesions •  Depth of for primary root
Controlled handpiece disinfection within carious
with rubber cup ensures 60 s dentin not yet determined caries lesions • 
safe application Promising result
Probably limited need
for enamel preparation
for other indicati

but more researc

is still needed

Photodynamic Photoactivated Disinfection with low •  Effective non- •  Effect is limited by dentin •  Promising
therapy disinfection (PAD, energy laser in invasive disinfection thickness  
Denfotex):   combination with method technique, but
photosensitizers
limited clinical

studies

Techniques Instruments, materials Principles Advantages Disadvantages Conclusion

Antibacterial AgNO 3 Impregnation •  Ease of use •  No •  AgNO 3 : Biocompatibility, •  Adjunct, but
therapy Disinfection of dentin special device discoloration •  Effectiveness
Fluorides: SnF 2 , and/or smear layer necessary with respect to prevention of no substitute of
carious progression is not yet
Silverdiamine-F - , convincingly proven excavation
Amine-

F - Chlorhexidine • 
Ca(OH) 2

•  Antibiotics:  Impregnation Step- •  Less probability •  Two appointments •  Promising

Tetracycline- wise excavation: of pulp damage or obligatory •  Patient´s
preparations antibacterial therapy opening compliance necessary technique, esp.
(Ledermix, Riemser) and temporary
followed by re-entry •  Ease of use in in pedodontics,
and final restoration dental emergency
situations but limited

clinical studies

Techniques Instruments, materials Principles Advantages Disadvantages Conclusion

3 Sealing techniques

Fluoride- ART: Atraumatic  Fluorides might Antibacterial Dentin sealing abilities are Proposed for
releasing Restorative Technique: prevent caries restorative material limited
materials hand excavators and progression or is thought to limit developing
glass ionomer cements secondary caries caries attack due to Limited data in high risk
fluoride release situations countries

•  Limited

political &

professional

acceptance
Dentin Functional hydrophilic •  Sealing dentin and/or•  Limited •  Adhesion to caries-affected   Promising, but
adhesives monomer systems restoration margins excavation dentin is less than ideal • 
developed for dentin hinders nutrition necessary •  Tolerable amount of residual still
adhesion transport to bacteria Efficient clinical bacteria has to be determined
left after excavation procedure experimental

technique

Techniques Instruments, materials Principles Advantages Disadvantages Conclusion

Antibacterial Dentin adhesives Combination of sealingMaterials claim to •  Antibacterial effect of Promising in

resin containing Chorhexidine and antibacterial effect be forgiving even materials without antibacterial
materials •  Triclosan (Seal under less than release is unclear vitro results, but
&Protect, Dentsply) ideal conditions
limited clinical

studies
 GOALS OF PULP THERAPY

Primary objective of pulp treatment is to

Allow a tooth to remain in the oral cavity in a non-pathological state.

To maintain the arch length and tooth space

To restore a tooth to its functionally efficient form.

To prevent the development of aberrant habits & speech abnormality

To maintain esthetics and thereby prevent any psychological trauma.

VITAL PULP THERAPY

INDICATIONS

Normal radiographic appearance

Absence of sensitivity to percussion

No abnormal response to thermal stimuli

Lack of evidence of hemorrhage

No evidence of foul odor

CONTRAINDICATION

Partial or complete degenerative changes - i.e purulent drainage, necrotic debris in canal, prolonged pain to
thermal stimuli, throbbing toothache, periapical radiolucency

Indirect pulp capping

DEFINITION

A procedure where by caries is excavated in a stepwise fashion in order to prevent iatrogenic pulpal
exposure . Gunnar Bergenholtz
 Deepest layer of the remaining carious dentin is covered with a biocompatible material to prevent pulp
exposure & additional trauma to the tooth Stephen Cohen

• Application of a medicament over a thin layer of remaining carious dentin, after deep excavation, with no
exposure of the pulp JOHN [Link]

Placement of sedative dressing over residual hard carious dentine in an attempt to allow reparative dentine
to be formed within the pulp chamber Harty’s

HISTORICAL REVIEW

Concept of IPC - I st described by Pierre Fauchard

John Tomes in the mid-18th century - recommended that all caries should not be removed in deep, sensitive
cavities “for fear of exposing the nerve and making the cure worse than the disease.”

John Tomes, in his mid- 19th century textbook, stated,

“It is better that a layer of discolored dentin should be allowed to remain for the protection of the pulp
rather than run the risk of sacrificing the tooth

1891, W. D. Miller - various “antiseptics”should be used for sterilizing dentin.

G.V. Black - no decayed or softened material should be left in a cavity preparation, whether or not the pulp
was exposed.

RATIONALE

Decalcification of the dentin precedes bacterial invasion within the dentin.

Fusayama and colleagues

Acute caries - dentin discoloration occurred far in advance of the

microorganisms,

2 mm of softened or discolored dentin was not infected.

In a later study,
 Outer layer is irreversibly denatured, infected, & incapable of being remineralized

& should be removed.

Inner carious layer is reversibly denatured, not infected, & capable of being

remineralized & should be preserved.

2 layers can be differentiated clinically by a solution of basic fuchsin

Whitehead compared deep excavations in primary & permanent teeth.

Permanent teeth.

51.5% permanent teeth- free from all signs of organisms,

a further 34% had only 1 to 20 infected dentinal tubules .

Primary teeth showed a much higher % of bacteria in the cavity floor

Supported by Shovelton ,Seltzer & Bender

Massler and Pawlak - “affected” and“infected”

3 dentinal layers in active caries

(1) A necrotic, soft, brown dentin outer layer, teeming with bacteria & not painful to remove

(2) A firmer, discolored dentin layer with fewer bacteria but painful to remove, suggesting the presence of viable
odontoblastic extensions from the pulp

(3) A hard, discolored dentin deep layer with a minimal amount of bacterial

invasion that is painful to instrumentation.

• RATIONALE

Promote dentinal sclerosis

Reparative dentin formation

Remineralization of affected dentin while preserving pulp vitality leads to -- Arrest the carious process

Infected Dentin Affected Dentin

Highly demineralized Intermediately demineralized

Unremineralized Remineralized
Superficial layer Deeper layer

Lacks sensation Sensitive

Stained by Caries detector dye Does not stain

Ultrastructure: Intertubular dentin Ultrastructure: Inter-tubular dentin partially demineralized, but

greatly demineralized, with irregularly appetite crystals bound like fringes to the sound dentin
scattered crystals.

Presence of deteriorated collagen fibers Collagen fibers with distinct cross bands and interbands.
that have only indistinct cross bands
and no interbands.

Should be excavated Should be left to remineralize.

OBJECTIVES

History

No recurring (or )

spontaneous pain

No swelling

Preoperative assessment

Normal vitality test

Not tender to percussion

No radiographic evidence of periradicular pathology

young patient

Radiographically obvious pulp chamber & root canal

INDICATIONS
History

Mild discomfort from chemical & thermal stimuli

Negative h/o spontaneous pain

O/E

Large carious lesion

Absence of lymphadenopathy

Normal color of gingiva & tooth

R/F

Large carious lesion in close proximity of the pulp

Normal lamina dura & PDL space

No interradicular or periradicular radiolucency

• CONTRAINDICATIONS

History

Sharp penetrating pain that persists after withdarwing stimulus

Prolonged spontaneous pain ,particularly at night

O/E

Excessive tooth mobility

Discolored

Nonresponsiveness to pulp testing techniques

R/E

Large carious lesion with apparent pulp exposure

Widened PDL space & interrupted or broken lamina dura

Radiolucency at the root apices or furcation areas

Diagnosis of the type of caries influences the treatment planning for IPC

Active lesion

Outer layers of decay - most of the caries-related organisms

Deeper decalcified layers fairly free of bacteria.

 Arrested lesion

Surface layers - not always contaminated, especially where the surface is

hard & leathery.

Deepest layers - quite sclerotic & free of microorganisms.- Even more resistant to decomposition by
acids & proteolysis .

Two-Appointment Technique (First Sitting)

1. Administer local anesthesia and isolate with a rubber dam.

2. 2. Establish cavity outline with a high-speed handpiece.

3. 3. Remove the majority of soft, necrotic, infected dentin with a large round bur (# 6 - 1.8mm or # 8-2.3
mm ) in a slow-speed handpiece without exposing the pulp.

4. 4. Remove peripheral carious dentin with sharp spoon excavators. Irrigate the cavity and dry with cotton
pellets.

5. Cover the remaining affected dentin with a hard-setting calcium hydroxide dressing.

6. 6. Fill or base the remainder of the cavity with a reinforced ZOE cement or a glass-ionomer cement to
achieve a good seal.

7. 7. Do not disturb this sealed cavity for 6 to 8 weeks. It may be necessary to use amalgam, composite resin,
or a stainless steel crown as a final restoration to maintain this seal.

Two-Appointment Technique (Second Sitting, 6 to 8 Weeks Later).

If the tooth has been asymptomatic, the surrounding soft tissues are free from swelling, and the
temporary filling is intact, the second step can be performed:

1. Bitewing radiographs of the treated tooth should be assessed for the presence of reparative dentin.

2. Again use local anesthesia and rubber dam isolation.

3. Carefully remove all temporary filling material, especially the calcium hydroxide dressing over the
deep portions of the cavity floor.

4. The remaining affected carious dentin should appear dehydrated and “flaky” and should be easily
removed. The area around the potential exposure
 should appear whitish and may be soft; this is “predentin.”Do not disturb!

5. The cavity preparation should be irrigated and gently dried.

6. Cover the entire floor with a hard-setting calcium hydroxide dressing.

7. A base should be placed with a reinforced ZOE or glass ionomer cement, and the tooth should
receive a final restoration

Adv of Stepwise excavation

Removing carious biomass

Sealing remaining caries from extrinsic substrate

Caries – become less active

Allows time for pulp dentin complex – regular tubular tertiary dentin

Less likelohood of pulpal exposure

Why re-enter

Success of this technique depend on – intergrity of restoration & seal

Following caries seal dentin becomes dry ,harder & darker - shrinkage of tissue - void beneath the
restoration .

Mertz –Fairhuret et al – interaval b/w Ist & II nd - 6- 12 months ( not critical )

Randomized controlled study – compared conventional vs stepwise

Step wise – fewer teeth exposed pulps – 17.5%

Conventional – More no of teeth exposed pulps – 40%

Based on animal studies – Bergenholtz – healing cappacity of pulp could be substantial once the irritating
agents are removed .

Step wise excavation - results of > 90% clinical success rate

 One-Appointment Technique

Success rates of IPC with Ca(OH) 2 ranging from 73 to 98%

Potential risk of exposure owing to overzealous re-excavation.

Leung et al & Fairbourn significant of bacteria in deep carious lesions after being covered with Ca(OH) 2
or a modified ZOE for periods ranging from 1 to 15 months.

. These investigators suggested that re-entry 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

After cavity preparation, if all carious dentin was removed except the portion that would expose the pulp,

Conversely, if the clinician had to leave considerably more carious dentin owing to patient symptoms, re-entry
would be advised to confirm reparative dentin and pulp exposure status. If a pulp exposure occurs during re-entry,
a more invasive vital pulp therapy technique such as direct pulp capping or pulpotomy would be indicated. Tooth
selection for one-appointment indirect pulp capping must be based on clinical judgment and experience with many
cases in addition to the previously mentioned criteria.

Deepest layer of remaining carious dentin is covered with a dressing ,usually ZnOE or Ca(OH) 2

3 techniques are commonly employed

1) Thin layer of Ca(OH)2 - over the area of exposure & thick layer of ZnOE
 2) Thin layer of ZnOE - over the area of exposure & thick layer of ZnOE

3) Dressing of Ca(OH)2 paste with or without ZnOE

• CALCIUM HYDROXIDE

Ist used – Hermann – 1920

Actions

Prtotective barrier for pulp tissue

Blocking patent dentin tubules

Neutralizing the attack of inorganic acids & their leached products

When placed over vital pulp exposure – stimulates formation of reparative dentin

Laws & Lewis – effect of Ca(OH)2 in deep carious dentin ( after 2years) ---

76% of all primary & permanent teeth were clinically & radiographically sound

Hawis & Dimaggio – only 3% failures in primary & permanent teeth

Held – wydler – Permanent teeth - Ca(OH) 2 (630 days )----

- 61 % showed normal pulp tissue with out any sign of inflammation

Farooq (2000)

IPC & formocresol pulpotomy used to treat deep caries with IPC having 93 % success compare to
formocresol pulpotomy with 75%.

Al-Zayer ( 2003)

Success of IPC 95% in deeply caries primary posterior teeth.

• ZINC OXIDE EUGENOL

Powder – Zno , Zn stearate , Zn acetate & rosin

Liquid - Purified eugenol or oil of clove ,small amount of vegetable or

 mineral oil as diluents & alcohol ,acetic acid & water

pH– close to 7

Compressive strength – 100 – 2000 psi

Reinforced ZnOE

1) Powder – 10 % - 40% finely divided natural or synthetic resin – increased Strength , & decreased
Solubility

2) EBA category

Powder – quartz ,alumina or rosin added to Zno

Liquid – EBA is added

Higher solubility but a lower shrinkage on setting

Held-Wydler (covered with ZnOE)

Demonstrated irritational dentin & Pulp tissue was either completely normal or mildly inflamed over a period of
34 to 630 days.

In the histologic sections, 4 layers could be demonstrated

(1) Carious decalcified dentin,

(2) Rhythmic layers of irregular reparative dentin,

(3) Regular tubular dentin,

(4) Normal pulp with a slight in fibrous elements.

Torstenson et al.

Slight to moderate inflammation when ZnOE was used in deep unlined cavities that were less than 0.5 mm to the
pulp itself.

A thin mix of ZnOE significantly reduces intradental nerve activity when placed in a deep cavity preparation in cats
teeth

Provides a good biological seal - & its antimicrobial properties enable it to suppress bacterial growth thus reducing
formation of toxic metabolites that result in pulpal inflammation

Walton Torabinejad

ZnOE pH is approximately 7 at the time of they are inserted into the tooth.
 ZnOE cement is one of the least irritating of all dental material and provides excellant seal against leakage

ANUSAVICE

ZnOE - sealing and obtundant properties, which reduce pulp symptoms.

Ca(OH)2 - ability to stimulate a more rapid formation of reparative dentin.

Stanley

It makes no difference which is used because neither is in direct contact with pulp tissue & dentin thickness
was observed to occur beneath deep lesions treated with both agents.

In case of an undetected microscopic pulp exposure during caries excavation, Ca(OH) 2 will better stimulate a
dentinal bridge.

Lado and Stanley

Light-cured Ca(OH)2 compounds were equally effective in inhibiting growth of organisms commonly found
at the base of cavity preparations.

Nordstrom and colleagues

Carious dentin, wiped with a 10% solution of stannous fluoride for 5 minutes and covered with ZnOE, can
be remineralized.

No particular difference was found in failure rates of teeth treated with calcium hydroxide and those treated
with stannous fluoride.

CAVIT

Good sealing – due to linear expansion ( Widermann et al )

Create - - ve pressure – causes pain

GIC – antimicrobial & remineralization effects

Atraumatic restorative treatment – a form of indirect pulp treatment

GLASS IONOMER CEMENT

If the RDT is less than 0.5mm ,it may be necessary to protect dentin surface from direct contact with unset glass-
ionomer materials by using a calcium hydroxide liner Sturdevant
 An unhealthy reparative reaction has been reported in the P-D organ of teeth restored with this material
having an effective depth as low as 0.5-1mm

In extremely deep lesions with less than 1mm effective depth , it is advisable to apply a base of calcim
hydroxide cement

[Link]

Controversial

Placing an acid – etched , bonded composite directly over the remaining affected dentin & deep areas of
excavation

Seal the the tooth against microleakage of bacteria .

Other investigators found a significant loss of bond strength to human carious dentin when compared to
normal dentin

BIOACTIVE MOLECULES

Enamel matrix protein (Emdogain)

TGF-beta

Have been used experimentally to stimulate tertiary dentin formation & decrease dentin permeability but
are not yet in use clinically

LASERS

Deep & hypersensitives cavities – IPC considered

Reduction in permeability of the dentin – sealing the dentinal tubules

Nd : YAG & 9.6µm CO2 lasers can be used

9.6µm CO2 lasers – well absorbed by the hydroxyapatite of enamel & dentin causing tissue ablation , melting and
resolidification – did not cause any noticeable damage to the pulpal tissue .

WHITE et al

Use of pulsed Nd :YAG laser with an energy level of below 1w , a 10 –Hz repetition rate – 10 second over
all exposure time – not significantly elevate the intrapulpal temperature
CO2 laser has high affinity for water and hydroxyapatite thus it can be used for removal of caries and cutting dentin
with coolant .

Ho ;YAG laser has a high affinity to water but not to tooth structure ,thus it is used primarily for soft tissue injury

Nd;YAG laser has high affinity for water and pigmented tissues and offers good hemostasis , thus it can be used
exclusively in surgery

FINAL RESTORATION

Stanley et al – formation of reparative dentin is a slow healing response of dental pulp to trauma & seldom begins in
less than 30 days ( with a subsequent average daily deposition of 1.5 µm )

After 3 months a layer of approximately 100 µm or 0,1mm can be expected .

Nygaard – ostby – advocates complete removal of all carious dentin before a permanent restoration is placed

RESPONSE TO TREATMENT

RESPONSE TO TREATMENT

(1) Cellular fibrillar dentin at 2 months post-treatment,

(2) Presence of globular dentin during the first 3 months,

(3 )Tubular dentin in a more uniformly mineralized pattern.

Conclusion

New dentin forms fastest in teeth with the thinnest dentin remaining after cavity preparation.

Longer treatment times enhanced dentin formation.

SUCCESSFUL INDIRECT THERAPY

Healing of pulp is evidentce by the formation of layers of reparative dentin under the affected tubules

Massler believes that optimal healing occurs

Amount of pulp dentin at the pulp end = dentin lost from the surface at the DEJ

Regular tubular dentin is formed rather than irregular dentin or osteodentin

When the body of pulp shows only a slight inflammatory reaction that leads to healing rather than to a
severe chronic destructive diseases .
DIRECT PULP CAPPING

Definition

Application of a material directly on to pulp tissues which has been exposed as a result of cavity preparation or by
traumatic injury – aims to encourage formation of an irritation dentin bridge below the exposure & to maintain pulp
vitality – Harty’s

Is a procedure in which ‘a dental material is placed over an exposed or nearly exposed pulp to encourage the
formation of irritation dentin at the site of injury’

American Association of Endodontics

Direct pulp capping involves the placement of a biocompatible agent on healthy pulp tissue that has been
inadvertently exposed from caries excavation or traumatic injury - JOHN .I. INGLE

Involve the application of a medicament , dressing or dental material to the exposed pulp in an attempt to preserve
the pulp vitality . - Stephen Cohen

INDICATIONS

Exposed pulp should be bright red in colour

 Bleeding – minimal – stop soon after exposure

Diameter of exposure – less than 1mm

Non carious exposures

No thickening of PDL space

No evidence of periradicular lesion

CONTRAINDICATIONS

Severe Tooth ache at night

Spontaneous pain

Excessive tooth mobility

Thickening of PDL space

Radiographic evidence of furcal or periradicular degeneration

Excessive hemorrhage

Purulent or serous exudate from the exposure site

CLINICAL SCENARIOS

Any direct exposure of the pulp – destructive inflammatory break down

Pulp wound has littale seal healing capacity unless properly treated .In contrast to skin & mucosal tissues where
cuts or wounds normally heal with in short period of time , the pulp has no epethelia that can bridge the defect .-
means even a small exposure may permit the bacterial flora of the oral cavity with the potential too cause
destructive & irreversible (non-healing )inflammatory condition .

CRITERIA ESSENTIAL FOR A SUCCESSFUL DIRECT PULP CAPPING

 Assessment of the preoperative condition of the pulp
2 conditions that are used to guide the clinician

1) The presence and character of painful pulpal symptoms

2) The presence and type of pulpal exposure

No objective means available – by which true condition of the pulp can be decided

Pain symptoms associated with a pulpal inflammatory lesion

Increased sensitivity elicited by exposure to cold drinks , food and air or touch of an exposed dentine surface are
early signs of pulpal inflammation .not suggestive of an advanced lesions .Such symptoms may emerge shortly after
the procedure but often subside along with recovery of the tissue

Short intermittent periods of lingering pain (second sto minutes ) by exposure to cold drinks , food and air may be
signs of a pulpal inflammatory lesion in progress . Nevertheless such symptoms may prevail for long periods of
time ( months ,years ) without resulting in pulpal necrosis .

Longstanding ( hours ) svere pain , spontaneous or intermittently provoked by external stimuli , including hot food
and drinks , is an alarming sign suggestive of an irreversible (non –healing ) pulpal condition
 Size, appearance & amount of hemorrhage associated with carious pulp exposures

Frigoletto

Small exposures (less than 1mm )& a good blood supply – best healing

Stanley

Size of exposure is less important than the quality of capping technique

Color and amount of blood

Light red blood & easily arrested - limited to the coronal pulp.

Profuse hemorrhage of deep red blood - extending into the root canals

Less successful in patients displaying painful symptom than in patients without pain at the time of treatment
.

Conclusion

Clinical & radiographical signs are less than decisive diagnostic measures to determine the spread of pulpal
inflammation in a given case and yet they are the only signs currently available for diagnosis .
 FACTORS OF IMPORTANCE FOR SUCCESSFUL OUTCOME

Decreased success rate has been shown when dentin fragments are forced into these underlying pulp tissue
.inflammatory reaction and formation of dentin matrix are stimulated around these dentin chips .in addition
microorganisms may be forced into the tissue .The resulting inflammatory reaction can be so serve as to cause
failure .

Larger the area of carious exposure the poorer the prognosis for pulp capping .with a larger exposure
more pulpal tissue is inflamed and there is a greater chance for contamination by microorganisms .There is also
greater chance from crushing of tissues and hemorrhage , causing a more severe inflammation .

However when exposure occurs as a result of traumatic or mechanical injury to a healthy pulp the size of the
exposure does not influence healing .

Location of pulp exposure may be an important consideration in the prognosis .if the exposure is on the axial wall
and the remaining pulp tissue coronal to the exposure site is deprived of its blood supply , it will undergo necrosis
.in such cases pulpotomy or pulpectomy should be performed rather than a pulp cap

Age Prognosis – Young > Old individuals

Horsted et al – Pulp survival 5 years after pulp capping

 70% - for 50- 80 years old

85% - for 30-50 year old

92% - for 10 -30 years old

Increase in fibrous & calcific deposits and a reducing in pulpal volume may be observed in older pulps . With age
the fibroblast proliferations obseserved in older pulps . With age the fibroblst proliferation observed in the teeth of
young animanls is significantly reduced

Teeth with calcifications of root canals and pulp chamber are not candidates for pulp capping procedures .

These calcifications indicate previous inflammatiory response or trauma and render the pulp less responsive to vital
therapy .

CLINICAL PROCEDURE

Remove any blood clot with a sharp spoon excavator in the case of time lag b/w exposure & treatment

Establish hemostasis by applying gentle pressure on the wound

with a cotton pellet moistened with chlorhexidine ,Sterile saline or

analgesic solution.

Renew the cotton pellet if necessary & wait for complete hemostasis .

3 Gently apply capping material to the wound without firm pressure

4 Cover the wound dressing with a hard setting cement such as a glass ionomer cement

5 Restore and seal the cavity with a restoration

6 After 1 week evaluate the presence or absence of symptoms

7 After 6 months evaluate

Symptoms

Reactions to thermal stimuli - absent ,short ,prolonged

Sensitivity to electric pulp testing - +ve / -ve

Periapical radiographic changes

Radiographically verified ‘bridge’ formation

Based on the findings , continue recall or do root canal treatment

8 Repeat (7) at yearly intervals

 TREATMENT CONSIDERATIONS

DEBRIDEMENT

Bacterial Contamination

Watts and Patersonand Cox

Bacterial microleakage under various restorations causes pulpal damage in deep lesions.

Success - dependent on prevention of microleakage by an adequate seal.

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.
 C
LINICAL SUCCESS

The salient features of a clinically successful direct pulpcapping

treatment (with or without bridging) are

Maintenance of pulp vitality,

Absence of sensitivity or pain,

Minimal pulp inflammatory responses, and

Absence of radiographic signs of dystrophic changes.

PERMANNET TEETH
PRIMARY TEETH

Kennedy and Kapala

High cellular content of pulp tissue

Undifferentiated mesenchymal cells - odontoclastic cells in response to either the caries process or the
pulp-capping material - internal resorption.

Should be reserved for teeth with mechanical exposures or in older children in cases in which the teeth will
exfoliate within 1 or 2 years .

PARTIAL PULPOTOMY /CVEK PULPOTOMY

Cvek et al found that the time b/w the accident & treatment was not critical as long as the superficially inflamed
pulp tissue was removed before capping .The size of bearing had no bearing on success or failure

INDICATIONS

Wounds that have been exposed to microbial challenges for a period of time

( more than 24 hrs)

Large carious exposure Some pulp tissue is removed at the exposure site to a depth of 1-2 mm
Clinical procedure

• Preparation should be carried out 1-2 mm deep with an end- cutting diamond bur in an air turbine under
copious water irrigation in order to reduce the trauma on the tissue

Adv

• Removes the superficial & potentially infected layer of the pulp

• Some surrounding dentin is removed as well which creates well defined space for placement of capping
materials .

PARTIAL PULPOTOMY /CVEK PULPOTOMY

CAPPING MATERIALS

Lufkin (1938)

Suggests that Philip Pfaff (1746) a dentist to King Frederick of Prussia

I st mentioned capping an exposed pulp before inserting a filling

Late 1800’s,
Utilized metal-caps covered with chlora-percha as a temporary “stopping”

agent to clinically treat an exposed pulp .

1826- Koecker

Cauterized with red hot wire before covering with gold leaf

Others – with Opium , Camphor , or aromatic oils of clove

1874 – Hirschfield

Stamp paper moistened with carbolic

Johnston (1884)

Use of iodoform cement containing carbolic, eugenol, portion of the

cavity with guttapercha, carrying it over the metal

1898 – Hopewell smith

Exposed aseptic pulp has capable of healing

CAPPING MATERIALS

Calcium hydroxide

ZnOE

Dentin bonding agents

4- Meta adhesives

Formocresol

Corticosteroids
Isobutyl cyanoacrylate

Antibiotics

Polycarboxylate cement & GIC

Resorbable tricalcium phosphate ceramic

Calcitonin

Chondroitin sulfate

Sodium hyaluronate

Collagen

Denatured albumin ( Protein )

Barium & strontium hydroxide

Freeze dried platelet derivatives

Bone morphogenic protein

Calcium phosphate cement

MTA

Dentin shavings

Enzymes

Lasers

Emdogain

CALCIUM HYDROXIDE
Schroder and Granath

3 layered necrosis – with in a hour

With a zone of coagulative necrosis demarcating against vital tissue

Yamamura

Exudative stage (1–5 days)

Proliferative stage (3–7 days),

Osteodentin formative stage (5–14days), &

Tubular dentin formative stage (14 days and more)

Ca(OH)2 pastes vs Hard-set Ca(OH)2 cements

Set quickly & hard for lining cavities and pulp capping.

“Necrobiotic” and inflammatory zones are minimal,

Dentin bridges form directly under thes compounds

Antibacterial properties & physical strength to support amalgam condensation have been shown for the
hard-set Ca(OH)2 cements.

Stanley and Pameijer and Seale and Stanley,

Ca(OH)2 product cured by visible light, maintained all of the characteristics of healing and bridge
formation equivalent to the original self-curing Dycal.

Lado, ( bacterial inhibition )

Light-cured products= Self-setting Ca(OH) 2 cements

ROLE OF CALCIUM

For cell proliferation ,blood coagulation & mineralisation

Pisanti & Sciaky – calcium taking part in the mineralization of the barrier came from tissues & not from
medicament

Holland et .al – same results

Stark et .al – Used radioactuve Calcium hydroxide

BENEFICIAL EFFECTS OF Ca(OH)2

Chemical injury caused by hydroxyl ions

Tolerance of ca+2 ions by the tissues

Antimicrobial – because of high pH

The firm , limiting necrosis against the vital tissues

Causes slight irritation of the pulp & stimulates the pulpal cells to defense & repair

ADVANTAGES DISADVANTAGES

Initially bactericidal then bacteriostati Does not exclusively stimulate dentinogenesis.

Promotes healing and repair Does exclusively stimulate reparative dentin.

High pH stimulates fibroblasts. Associated with primary tooth resorption.

Neutralizes low pH of acids. Does not adhere to the dentin or resin restoration

Blocking patent dentin tubules. May degrade during acid etching.

Inexpensive and easy to use. Degrades upon tooth flexure.

Marginal failure with amalgam condensation.

Effect of Ca(OH)2 on inflamed pulp tissue

 • CONCLUSI
ON

Therapeutic use of Ca(OH)2 should be restricted to conditions where the residual pulp tissue is judged to be with out
chronic inflammation , since Ca(OH) 2 has not been shown to have any beneficial effect on chronically inflammed
pulp tissue

ZINC OXIDE EUGENOL

Humes review

ZOE seals and exclude dietary substrate from cariogenic microorganisms , reducing their metabolism -
both the tendency of the lesion to spread & inward diffusion of toxic end products

In pulp adjacent to intact dentin beneath ZOE ,a conc of eugenol at or less than 10 -4 mol / l can be expected
for at least 10 weeks after ZOE placement .

sensory nerve activity , blood flow and clearance of toxins , and prostaglandins synthesis and
inflammation , while not harming pulp cells

In addtion low thermal conductivity of ZOE its effectiveness as a barrier against chemical diffusion will
other insults to the pulp .

Glass , Zender & Seelig –

Produced chronic inflammation ,abscess & liquefaction process

No secondary bridging

Weiss & Bjorvatn

Negligible necrosis of the pulp in direct contact with ZnOE

Probably a layer of dentin chips

No apparent difference in the pulp reaction of primary & permanent teeth

Hess

10% success with ZnOE

90% success with Ca(OH)2

CONCLUSION

ZnOE has been an unsuccessful pulp – capping material

When ZnOE is used as a base – it improves the quality of dentin bridge

DENTINE BONDING AGENTS

Brännström and colleagues

Pulp possesses an inherent capacity to heal, in the absence of bacterial inflammation

Cox and colleagues

Ist to demonstrate histological evidence of pulp healing &dentin

bridge formation against an auto cured adhesive system(1987)

White et al. (1994)

Mechanical pulp exposures were direct capped with a IV th generation adhesive system .It leads to Soft tissue
healing & dentin bridge formation directly adjacent to the adhesive resin interface .

exposed pulp possesses an inherent capacity for healing through cell reorganization and bridge formation when a
proper biologic seal is provided and maintained against leakage of oral contaminants.

A successful pulp cap has a vital pulp and a dentin bridge within 75 to 90 days.

hemostasis must be obtained. The exposure site is then covered with a non-setting calcium hydroxide paste (e.g.,
Pulpdent, Pulpdent Corp. of America, Brookline, Mass.) and the cavity preparation completed. Following
disinfection of the cavity, the enamel and dentin are etched with 32% phosphoric acid for 15 seconds. The acid and
calcium hydroxide are rinsed off and the preparation is lightly dried. The entire preparation , including enamel,
dentin and pulpal tissue , is treated with a dentin bonding system

Following placement of several layers of the hydrophilic primer, a thin layer of the adhesive resin is painted onto
the enamel, dentin and pulpal tissue and light cured. A second layer of unfilled resin is applied, and a thin layer of
resin-modified glass ionomer is also applied over and around the exposure site to mechanically protect the
perforation from intrusion of the restorative material during packing or condensation. These layers are also light
cured
 Acids themselves do not kill pulp tissue when placed and rinsed within the normal few seconds of clinical
placement.

Hemorrhage control is most important before placing an adhesive system onto the dentin pulp interface.

Equally important is the removal of any contaminating biofilm from blood and consider the variables which
lead to success or failure.

4- META adhesives
COX et al - 4-methacryloxy ethyl trimellitate anhydrite
DISADV
 Does not necessarily result in a permanent bacterial sealing of the cavity & bridging of the wound
area
Pulpal inflammation & foreign body reaction against displaced resin particles have been
described
OPPONENTS OF Ca(OH)2
Does not adhere to dentin & will not adhere to bonding resin composite
Ca(OH)2 bases – under resin restoration - tended to pullaway from the cavity surface during
polymerization – leaving gap b/w Ca(OH)2 & dentin
Cox & others
High rate of multiple tunnel defects in dentin bridges
Long therapeutic effect of Ca(OH)2 in serious doubt
A very small exposure & essentially a near exposure ,cant’t be treated with Ca(OH)2,
OPPONENTS OF TOTAL ETCH TECHNIQUE
 40% loss of pulp vitality over aperiod of 75 days
 Of the remaining surviving pulp , only 53% even attempted bridge formation
Proponents of this technique
Germ-free studies have shown that pulp heals rapidly even when bonding agents are placed directly on
pulpal tissue.
CONCLUSION
Although both techniques can achieve successful vital pulp caps , Ca(OH)2 technique has demonstrated its
success over a longer period of time

FORMOCRESOL
Because of the clinical success of formocresol when used in primary pulp therapy such as pulpotomies
and pulpectomies, several investigators have been intrigued by the possibility of its use as a medicament
in direct pulp-capping therapy.
Arnold
applied full-strength formocresol for 2 minutes over enlarged pulp exposures in primary teeth and found a
97% clinical “success” after 6 months.
Ibrahim et al. reported
absence of inflammation along with dentin bridging in 15 experimental teeth when exposures were
medicated with formocresol for 5 minutes and capped with a mixture of formocresol and ZOE cement.
More recently, Garcia-Godoy
obtained a 96% clinical and radiographic success rate in human exposed primary molars when capped
with a paste of one-fifth diluted formocresol mixed with a ZOE paste and covered with a reinforced ZOE
cement.

CORTICOSTEROIDS & ANTIBIOTICS

inflammation which is defensive mechanism of the body , presents some peculiarities in the dental pulp
.Enclosed within the unyielding walls of dentin the pulp cannot react in the same way as other body
tissues to the pressure of inflammatory exudate and may succumb as a result os strngulation of the apical
vessels .therefore vitality of the pulp may be preserved is the inflammation could be controlled in the
early stages

Borsch
Primary teeth > permanent teeth
( calcium phosphate , neomycin & hydrocortisone )
Both in carious & non carious primary teeth > permanent teeth

Ledermix Antibiotic & Steroid

Synthetic glucocorticosteroid +Ledermycin (Dimethyl chlorotetracycline )– mixed with Ca(OH)2 & ZnOE
Antibiotic – kill microorganisms
Steriod – reduce pulpal inflammation – reduce pain
 ISOBUTYL CYANOACRYLATE
Excellent hemostatic agent + reparative dentin bridge stimulator
Advantages
Hemostatic & bacteriostatic properties – less inflammation than calcium hydroxide
Disadv
• Does not produce a continuous barrier of a reaparative dentin
• Cytotoxic effect on mammalian cells
• Cytotoxic when freshly polymerized
DENATURED ALBUMIN

• Become a matrix for calcification – chances of biologic obliterartion

• Also absorb blood & exudate from the pulp – eliminating undesirable increase in pressure
Molven
• Showed no clinical symptoms
Histologically – no hard tissue barrier or fibrous capsule
• Conclusion
• Can’t be recommended as a capping material
COLLAGEN BIORESORBABLE MEMBARANE
Advantages
• Ease of placement & post operative maintenance
• Eliminating second generation material
Bimstein & shoshan
Pulp of treated teeth remained vital & histologically similar to the pulp of intact teeth
A thin newly created dentin bridge was found
Fuks et al –
Obtained same results
Rutheford et al
Human osteogenic protein as a DPC + collagen matrix (carrier)
Human osteogenic protein – good characterstics as DPC
Collagen matrix – itself didnot initiate mineralization (or) creation of dentin bridge
Cox et al 1987
Stimulatory chemical factor is neccessary
Bimstein ,shoshan & Fuks
used an enriched collagen solution
Invitro – capacity to initiate mineralization
Invivo - ?
CONCLUSION
Although a highly biocompatible material, is not a suitable means for direct pulp capping.

Nanocrystalline Tetracalcium Phosphate Cement

Composition - & mechanism of setting
Tetracalcium phosphate & Di- calcium phosphate
Yoshimine et al.
Ability to be gradually converted into hydroxyapatite over time.
No superficial tissue necrosis and significant absence of pulp inflammation.
CALCIUM PHOSPHATE CEMENT
Tetracalcium phosphate and dicalcium phosphate, which react in an aqueous environment to form
hydroxyapatite,
Chaung et al.
histologically compared
calcium phosphate cement = calcium hydroxide
More neutral pH resulting in less localized tissue destruction
Superior compressive strength
Its transformation into hydroxyapatite crystals over time
DiaRoot® BioAggregate
DiaRoot BioAggregate Root Canal Repair Material is a biocompatible pure white powder
composed of ceramic nano-particles. Upon mixing DiaRoot with BioA Liquid, the hydrophilic
BioAggregate Powder promotes cementogenesis and forms a hermetic seal inside the root canal.
Its effectiveness to clinically block off bacterial infection,

PREMIXED CALCIUM HYDROXIDE PASTE CONTAINING IODOFORM

Improves radioopacity
Adds an antibacterial properties
Polycarboxylate cements

Good sealing properties

Showed lack of antibacterial properties

Didnot stimulate calicific bridging

Glass Ionomer Cement

Antibacterial cement

Stable long term ionic bonding – prevents microleakage

 Assist remineralization of inner carious dentin

DENTIN SHAVINGS

BIO ACTIVE MATERIALS

Controls differentiation of cell types
Ex BMP & TGF-B
BMP – stimulates synthesis of collagen & proteoglycans
during odontogenesis
TGFB1 & TGFB2 - Regulates pulp differentiation

ENZYMES
Alkaline phosphatase
Stimulates pulp cells into odontoblasts – elaboration of dentin matrix
Acid phosphatase
No such results
Chondroitin sulphate
 Heterophilic bone formation in rats
No such results in humans – by Seltzer

EMDOGAIN
growth or differentiation factors have been used as a pulp capping material on pulp exposures in animals have
shown interesting results

Amelogenin and amelin are proteins that have been suggested to participate in the final differentiation of
odontoblasts and subsequent dentine formation during dentinogenesis
An amelogenin-rich fraction of porcine enamel matrix derivative (EMD) that also contains amelin has
been used in patients with severe periodontitis to induce cementogenesis as the EMD induces processes
that seem to imitate normal odontogenesis
Emdogain Gel (Biora AB,Malmo¨ , Sweden) is a commercial product containing EMD used in the
treatment of periodontal disease. Studies in miniature pig, where this product has been tested as a pulp
capping material, demonstrated the potential of EMD to induce hard tissue after experimental pulp
exposures (Nakamura)
Enamel matrix derivative (EMD) in a propylene glycol alginate (PGA-Gel) vehicle,
Used for treatment of PDl diseases.
When compared to Ca(OH)2: lesser post op. symptoms ncreased Inflammatory reaction.

Pattern of Hard tissue formation

Ca(OH)2 – bridge formation occurred
Emdogain – hard tissue formed not only along the exposed dentin surface + patches in the
adjacent pulp tissue
Reason for Increased inflammation
Microbial invasion through the leakage around temporary restoration.
Microbial invasion – more with emdogain gel than Ca(OH)2
Reason for Hard Tissue formation
Emdogain from PGA vehicle gets precipitated when acidity is neutralized & temperature is increased (Ex.
by tissue fluids)
Precipitate is apparent as hard tissue on the radiograph
Conclusion

Post operative symptoms were less

induced greater amounts of hard tissue in a markedly diffrent pattern compared with the teeth
treated with Ca(OH)2 .
However the operative procedures and the formation with EMD in a PGA vehicle do not seem to
be effective for the formation of a hard tissue barrier and as a consequence for dental pulp capping
MINERAL TRIOXIDE AGGREGATE

1993 – Torabinejad & colleagues

1998 – FDA approval
Available - Pro root gray or Pro root white MTA.
White pro root - aesthetic improvement over the original material for the placement in anterior
teeth.
ProRoot™ MTA
(Portland Cement – 75%)

Tricalcium Silicate
Dicalcium Silicate
Tricalcium Aluminate
Tetracalcium Alumino ferrite
Calcium carbonate
Calcium sulfate
Bismuth Oxide – 20%
Calcium Sulfate Dihydrate (gypsum) – 5%
White MTA
Similar to that of Gray MTA ( Portland cement ) but lacks tetracalcium alumino ferrite

Jacob Saidon et al
Conducted a study to compare the cytotoxic effect MTA and portland cement and Concluded that MTA
and Portland cement show comparative biocompatibility
MTA –Angelus
80% - Portland cement
20% - Bismuth oxide
pH & calcium ions release for MTA –Angelus is higher than ProRoot MTA
PROPERTIES OF MTA
5 minutes working time
4 to 6 hours set time
Cover mixture with moist gauze pad to fasten the setting reaction and decrease setting time
Biocompatible.
Available in powder form.
Sets in the presence of moisture.
MTA
In Favour
Excellent Results (Torabinajad et al)
More dentinal bridging – less time – less inflammation – quicker dentin deposition than Ca(OH)2
Highly biocompatible
Hydrophilic
Alkaline pH (12) – promotes dentinogenesis (Thomas et al – 1992)
Good marginal & sealing ability

Against
Takes 3-4 hours to set
Difficult to manipulate
Expensive
MECHANISM OF ACTION
 PULPAL REACTIONS

Cox C.F et al
Healing of dental pulp exposure is not dependent on the pulp capping material , but is related to
the capacity of theses materials to prevent bacterial leakage
Hence dentinogenic effect of MTA is because of its
Sealing ability
Biocompatability
Alkalinity

MTA as a pulp – capping material

MTA – 5/6 – no pulpal inflammation
- 6/6 – complete dentin bridge
Ca(OH)2 – 6/6 –pulpal inflammation
- 2/6 – bridge formation
H/S – complete bridge in MTA – No tunnel defects
Ca (OH)2 - Tunnel defects in dentin bridge
LASERS
Melcer et al CO2 laser –
New mineralized dentin formation with out cellular modification of pulp tissue

Shoji et al - CO2 laser

Using 3,10,30 & 60 W – Charrring ,coagulation necrosis & degeneration of the odontoblastic layer
occurred although no damage was detected in the radicular portion of the pulp .

Moritz et al (1998)
CO2 lasers – energy level of 1w at 0.1 sec exposure time with 1 sec exposure pulse interval &
Ca(OH)2 dressing gives
Vitality maintained – 89% cases
Ca(OH)2 alone – 68%
• Clinical study of DPC applied to carious exposed pulp
Success rate 81.8%
Degree of bleeding – indicative for prognosis
 Length of time necessary for adequate post operative follow up – 21 months
DENTIN SHAVINGS

DENTINE BONDING AGENTS

Acids themselves do not kill pulp tissue when placed and rinsed within the normal few seconds of
clinical placement.
Hemorrhage control is most important before placing an adhesive system onto the dentin pulp
interface.
Equally important is the removal of any contaminating biofilm from blood and consider the
variables which lead to success or failure.
VITAL PULPOTOMY
Definition
History & development
Indications & contraindications
Classification
Formocresol Pulpotomy
Calcium hydroxide Pulpotomy
Other materials
Summary & conclusions

Definition
D. B. Kennedy
Procedures involving removal of vital, partially inflamed coronal pulp tissue and placing a dressing
over the amputed pulp stumps and then placing the final restoration.
Ingle & Bakland
 Surgical removal (Amputation) of the entire coronal pulp, leaving intact the vital tissues in the
canals. A suitable medicament or dressing is then placed over the remaining tissue in an attempt to
promote healing and retention of this vital tissue.

Anlow &, Rock 1993

Procedure in which the entire coronal pulp is removed with the aim of removing all infected pulp
tissue, the radicular pulp is treated in different ways, according to the technique employed.
Fadavi & anderson 1989 … Istuse of Freeze Dried Bone

Davis & Furtado 1991 … Ist to use ferric sulphate as a pulpotomy agent.
 Favo 1996 … Ist to report success with MTA as a pulpotomy agent

INDICATIONS
The tooth is free of Radicular pulpitis
Pain if present is neither persistent nor spontaneous
The tooth is restorable
The tooth possesses at least 2/3rd of its root length
There is no evidence of internal root resorption
There is no inter Radicular bone loss
No abscess or fistula
The hemorrhage from amputated site is pale red & easy to control.

young permanent teeth – incompletely formed apices & cario pulps

CONTRAINDICATIONS

Spontaneous pain - pain at night.

Swelling
Fistula
Tenderness on Percussion
Pathological mobility
Root resorption exceeds more than 1/3 rd of root length - (Mejare)
Evidence of periapical or furcal pathosis
Internal root resorption

Pulp Calcifications
Pathological external root resorption
Pus/serous exudates at the exposure site.
Inability to control hemorrhage after a coronal pulp amputation
A pulp that does not hemorrhage

RATIONALE OF PULPOTOMY
 Radicular pulp tissue is healthy or is capable of healing after surgical
amputation of the affected or infected coronal pulp .
Fuks and Elderman -
1991

CLASSIFICATION
DEVITALIZATION
Single sitting : Formocresol
Electro surgery
Laser

Two stage : Gysi Triopaste

Easlick’s Formaldehyde
Paraform devitalizing paste

Ranly classified
Devitalization
Formocresol, Glutaraldehyde, Electrocoagulation
Preservation
Ferric sulphate, Calcium hydroxide, MTA ,Laser
Remineralization
Indirect Pulp Thearpy, Bone morphogenic protein, Collagen
Level of procedure
- High or Partial pulpotomy
- Low or Cervical pulpotomy
Method of removal of pulp tissue
- Surgical : Using burs, spoon excavators
-Therapeutic : Formocresol
On the number of sittings taken
- Single visit : Full strength formocresol
Electrosurgery
Laser
- Two visit : 1:5 dilution formocresol (Easlik’s)
Gysi Triopaste
Paraformaldehyde devitalizing paste
Dentition involved
- Primary
- Young permanent
- Permanent
CATEGORIES OF MEDICAMENT
FIXATIVES
Formcoresol , Glutaraldehyde
COAGULANTS
Ferric sulfate , Aluminium chloride , Epinephrine
MINERALIZING AND OR BACTERIOSTATIC AGENTS
Calcium hydroxide , Tricalcium phosphate
PALLIATIVE SEALERS
ZnOE
OBTURATORS
MTA
ANTIBIOTICS . ANTIMICROBIALS
Erythromycin ,others
TISSUE HEALING AGENTS
Collagen ,BMP
GLUCOOCRTICOIDS
 Corticosteroids
Medicaments of combination
VITAPEX
Iodoform , Calcium hydroxide
MAISTO’s PASTE
Iodoform , Parachlorophenol , Camphor /menthol
LEDERMIX
Dimethylchlorotetracycline ,Triamcinolone

FORMOCRESOL PULPOTOMY
• Introduced in 1904 – Buckley
• Formocresol pulpotomy – by sweet in 1930
• 1955 – Sweet claimed 97% clinical success
•

SINGLE VISIT FORMOCRESOL PULPOTOMY

(VITAL PRIMARY TEETH)
INDICATIONS
Mechanical exposures in vital primary teeth.
A vital carious exposure in an asyrnptomatic primary teeth.
An iatrogenic exposurc under proper isolation
Advocated by sweet in 1930.
1. Arrange instruments & necessary materials
2. Anesthetize tooth to be operated
3. Isolation with rubber dam
4. Cavity preparation
a. For high speed, recommended burs are pear shaped diamond 525 & pear shaped tungsten carbide
330
 b. For low speed round steel or tungsten carbide bur no ½ or 1.
c. Keep the bur at established level - all the caries on floor & lateral walls of cavity
Clear all remaining caries before removing the caries adjacent to the pulp
Remove roof of pulp chamber using fissure bur no 2 or round bur (ANLAW and ROCK -1993 )
Remove coronal pulp with an sharp excavator or with large round bur at low speed ( Kennedy D.B 1986 )
Amputate pulp stumps with large round bur at low speed
Selected instrument should be larger in diameter than the root canal orifice to avert radicular pulp insult .
Running the bur counter clockwise may deter disengaging pulp from the root canal
The coronal pulp should be extirpated in toto .
Take care to avoid perforation

Wash and dry the cavity:

The prepared cavity should be square is shape with all the walls perpendicular to the floor.
There should not be any undercut. Post amputation bleeding is controlled by moistening the cotton pellet
with non-irritating solution such as saline or water and placing them over amputed stumps for three to five
minutes.
The tooth may be considered suitable for single visit pulpotomy only if hemorrhage is arrested naturally.
The cavity is wasted and dried with cotton pallet.

Remove excess Medication.

Moistened cotton pe;;et of formocresol over pulp stumps 3 mins
Remove cotton pellet and confirm pulp fixation, by the “black eye” appearance of the pulp stumps
Place a cotton pellet with formocresol for 5 minutes in the pulp chamber

H – fill the pulp chamber with a thick mixture of Zinc oxide

Application of formocresol:
Dip a cotton pellet in formocresol solution. Remove the excess by squeezing with the cotton and place it
in a cavity covering the radicular pulp for 5 minutes. (ANLAW AND ROCK -1993)
Apply antiseptic dressing:
When the cotton pellet of formocresol is removed, the pulp stumps will be darker in colour. Stumps are
then covered with ZNOE mix to which formocresol is added .
Inclusion of formocresol with ZnOE is not critical (BEAVER and KOPEL – 1996) .KELY and
GOLDMAN 1991 strongly objected the use of formocresol in the subbase . (ANLAW AND ROCK
-1993) – but this procedure affords the clinical assurance that the pulp stumps receive maximum
formocresol in influence
Restore the tooth: Place quick setting cement base before restoring tooth with stainless steel crown
A stainless steel crown is the ideal restoration for a pulpotomised tooth ANLAW AND ROCK 1993

One appointment procedure

Roof of the pulp chamber and coronal pulp removed . Cotton pellet with formocresol in place for 5 min
Successful formocresol pulpotomy 1 year following treatment
• TWO VISIT PULPOTOMY
• Less emphasis is placed on the type of preoperative pain and on the pulpal hemorrhage at the
exposure site
• One recommended approach to the treatment of vital primary teeth with inflammation extending
into the radicular filaments
• TECHNIQUE
Necrotic pulp tissue is removed & the infected radicular pulp is then treated with creosote ( a mixture of
cresol , guaicol and other phenols ) is used (Hobson – 1970)
Others
Formocresol ( Droter – 1963 )
Camphorated monochlorphenol (ANLAW and ROCK 1993 )
Inter appointemnt span – 3 days to 3 weeks
( 3 weeks beneficial – Berger J.E -1965

Formocresol ( Buckley’s formula )

Formocresol is a solution of
Formalin -19%
 Cresol - 35%
Glycerin - 15%
Water - Rest
( Tricresol is effective against gram-positive & gram negative bacteria. Because it is based upon the
phenol molecule the Tricresol paralyses the sensory nerve endings; thus, giving it analgesic properties
The glycerine is added to prevent polymerization of formocresol to Para formaldehyde . The presence of
Para formaldehyde causes clouding of the solution.
Tri Cresol – Coal derivatives
Mixture of 3 isomeric forms of cresol.
Glycerin used a vehicle- shows equal toxic effect on the tissue cultures, pulp fibroblast cell death)

IMPORTANT CONSIDERATIONS
1- minute application of formocresol is adequate to produce the desired results.
Doyle et al (1960) used 2 visit or 7 day pulpotomy in cases where hemorrhage control is a problem
Berger (1963) used a one – appointment method with a 5 min application of formocresol -
followed by a ZnOE base with formocresol added to the eugenol.
Redig (1968) compared the two methods in 209 children. He found little clinical and radiographic
difference in the teeth after 18 months.
Garcia godoy (1982) found that 1-min application of full conc formocresol produced less
inflammation than 3 or 5 min application

Loss et al 1973 –
20% dilution of formocresol was a effective cytostatic agent as full strength - Similar metabolic
cell changes but greater and early recovery.
20% dilution causes the least histologic damage

Morawa et al (1975) evaluated clinically the use of a 20% dilution of formocresol. They suggested that
some of the histopathology and subsequent clinical failure could be reduced by use of 20% concentration
METHOD
Dilute 3 part glycerine (90ml) + 1 part (34ml) Distilled sterile water: mix well

Add 1 part formocresol (30ml) to 4 part diluent 30ml : 150ml

1: 5 – 20% formocresol.

Fuks and Bimstein (1981) and hicks et al (1986) found that formocresol pulpotomies on primary molar
resulted in accelerated rate of resorption for 45% to 56% when compared to their antimeres. The cause of
early resorption was speculated to be the chronic inflammatory reaction caused by formocresol seeded
into surrounding periodontal tissues
BIOMECHANICAL REACTIONS OF FORMOCRESOL
Formaldehyde s well known cytogenic and mutagenic effects therefore can be explained by its ability to
dentature nucleic acids by forming methylol derivative and methylene cross links that might render the
genetic machinery inoperative
Binding of alcoholic groups in carbihydrates with formaldehyde has not been established .common lipids
also donot appear to have any functional groups that react with formaldehyde
Formocresol treatment can irreversibly damage the protein portion of enzymes , genetic material ,
membranes and connective tissue
It also can affect directly with protein synthesis and cell reproduction by interacting with DNA and RNA
eventually disrupt the lipid component of the membrane .It is therefore readily understandable why this
medicament accomplishes the profound cytological effects evidenced .
Cytotoxicity
Permanent tooth hypoplasia
Roland [Link] et al (1977) -
hypoplastic facial surfaces in the permanent teeth
Systemic distribution
David A. Myers et al (1978) and
Edna L. Pashley et al (1980) –
Rhesus monkeys, 14c- formaldehyde - absorbed into the systemic circulation
Block et al (1983) used 14c labeled
formocresol in dogs
 Presence in liver, kidney, lymph nodes and blood circulation.
ANTIGENECITY
Due to the conversion of autologus tissue to foreign body after fixation.
This elicits a predominantly T-Cell immune response
(VAN VELEN ET AL 1977)
MUTAGENECITY & CARCINOGENICITY

• `
DEVITALIZATION

Glutaraldehyde
Proposed as pulp tissue fixative by Gravenmade in 1975.
It is a dialdehyde compound
Excellent disinfectant
Active against both vegetative & spore form of bacteria
Used as 2% solution
Ranly et al -4% buffered glutaraldehyde with a 4 min application time or 8% for 2 min
• PROPERTY OF MATERIAL
Better fixative than formocresol
Limited shelf life
Cross linking ability superior to formocresol
 Systemic effect ,cytotoxicity and mutagencity reported similar to formocresol
Use of buffered glutaraldehyde applied for five minutes over pulp tissue of
primary teeth to achieve the fixative effect.
ADVANTAGES
Limited diffusion from tooth structure into adjacent tissue
Binding with protein tissue is irreversible.
There is less pulpal irritation because of less apical diffusion.
Cold, buffered,2% Gluteraldehyde is most stable
• CLINICAL STUDIES
98% success rate reported after follow up for 19-42 months for 1-3 minutes application.
Garcia-godoy(1986)
Success rate of 94.3% over six months that decreased to 82%
Fuks et al(1986)
FORMOCRESOL
Reactions are reversible
Has smaller molecues that penentrates apical foramen
Requires a long reaction and an excess solution to fix tissue

GLUTARALDEHYDE

Reactions are irreversible

Has larger molecules that does not penetrates
Fixes tissue instantly and excess of solution is unnecessary
 • CONCLUSION
With similar toxic effect to formocresol
No strong evidence of improved success rate.
Not accepted as appropriate alternative to formocresol.
• Before Clearfil Protect Bond, the main objectiveof adhesive systems was to provide adhesion b/w the tooth
structure & the restorative material.

• With the introduction of self-etching systems, the objective expanded to include the elimination of
postoperative sensitivity.

• Now with Clearfil Protect Bond, a new class of adhesive, two other functions are provided, antibacterial
cavity-cleansing and fluoride release. - MDPB ( Methacryloloxy decyl pyridyrenium bromide)

• Cox et al (2003) has reported in 6 month study , that restoring an exposed pulp with an antimicrobial
adhesive and composite resin presented several constant reproducible results

• Permanent Tooth Pulpotomy

Indications & Contraindications
Recommended pulpotomy agent for carious & traumatic exposures in young permanent teeth,
particularly with incomplete apical closure
Following the closure of the apex - conventional root canal obturation be accomplished to avoid the
potential long-term outcome of root canal calcification.
 CALCIUM HYDROXIDE

3 identifiable histologic zones under the Ca(OH)2 in 4 to 9 days

Coagulation necrosis,
Deep-staining basophilic areas with varied osteodentin
Relatively normal pulp tissue, slightly hyperemic, underlying an
odontoblastic layer
 Ca(OH)2 does not adhere to dentine and lacks the ability to seal.

Tunnel defect under the in dentine bridges under Ca(OH)2 dressing can act as pathway for micro leakage
Cox et al 1985
This material has tendency to dissolve over time.
schuur [Link] 2000
Blood clot on the wound surface can interfere with healing by producing inflammation and necrosis
Schroder 1978

There are significant success with Ca(OH)2 in commercial preparation such as pulpdent and dycal.
The Difference in pulp response is attributed to their lower pH
 Studies have shown more consistent bridging with pulpdent than other type of calcium
hydroxide.
( Phaneuf et al. 1968)
 At present Ca(OH)2 pulpotomy technique can not be generally recommended for primary
teeth due to low success rate.

Formocresol Calcium hydroxide

Tissue fixation is evident Calcific bridge formation

Potent germicidal Some germicidal activity

vital tissue remains at apex Vital pulp remains

Clinical success 95% after two years. Internal resorption is a common problem even underneath radio
graphically adequate bridging.

Histological success 70% after two years. Clinical success 65% ,histological success 30%.

Some evidence of increased enamel defects on the In permanent teeth the bridging make subsequent endodontic treatm
permanent successors. more difficult.

• ASTRINGENTS
Schröder & Granath - Pulpal hemorrhage control is critical for pulpotomy success.
Kouri et al.

compared formocresol pulpotomies in primary teeth using epinephrine vs sterile water and cotton pellets
for hemorrhage control.

After 6- week to 3-month post-treatment periods, histologic& electron microscopic evidence of healing
was similar for both groups.

Bleeding times for the epinephrine-treated pulps were 50 seconds versus 251 seconds for the sterile water–
treated pulps.

Less extravasated blood occurred with the epinephrine-treated pulps and was limited to the amputation site.
No clinical or radiographic failures occurred for either group.

Helig et al. compared aluminum chloride vs sterile water in achieving hemostasis prior to medicament
placement in calcium hydroxide pulpotomies for primary teeth in humans.
 They found a 25% radiographic failure rate in the sterile water group vs no radiographic failures with the
aluminum chloride group after 9 months.

Landau & Johnsen in 1988

Ferric sulphate was carried out in monkey teeth to investigate usage prior to the placement of Ca(OH) 2 over
amputated pulps

Landau and Johnson

More favorable pulpal response to a 15.5% ferric sulfate solution than Ca(OH) 2

in primate pulpotomies after 60 days

Fei et al.

Success rate 96.3% - Ferric sulfate pulpotomies

77.8%- Diluted formocresol pulpotomies in humans after 12 months.

Fuks et al.

Success rate 92.7% - Ferric sulfate

83.8% - Diluted formocresol in primary tooth pulpotomies after

a mean post-treatment time of 20.5 months.

 MINERAL TRIOXIDE AGGREGATE

MTA has ability to stimulate cytokine release from bone cells indicating it actively promotes hard tissue
formation

Koh et al (1995).

MTA was proposed as suitable alternative to formocresol in primary teeth

Eidelman & co - workers (2001).

A lack of internal resorption in above studies in teeth treated with MTA

Gray MTA White MTA Formocresol

Dentin brdige formation Dentin brdige formation Dentin brdige formation

Normal pulp architecture Inflammatory cells & areas of necrosis Significant pulp destruction

Intact & continuous odontoblastic More pulp calcification Internal root resorption
layer
Less secondary dentin deposited in
root canals

Zinc oxide – eugenol cement

Corticosteroids – Ledermycin

Collagen fiber

Bone morphogenic proteins

Enamel matrix proteins

Freeze dried bone

ELECTROSURGERY & LASER

• Advantages

Quick & efficient

Self-limiting

Good hemostasis

Good visibility of the field

No systemic effects

Sterilization at the site of application.

• ELECTROSURGERY
 1982 - Anderman described electrosurgical pulpotomy

• Non pharmacological, haemostatic technique used for amputation of the inflamed coronal pulp prior to
placing a lining material.

• It is described as a time efficient method that is relatively free from post operative complication.

• MECHANISM

• The procedure carbonizes and denatures the pulp tissue, produces a layer of coagulative necrosis which act
as barrier b/w the lining base material placed and the healthy radicular tissue beneath.

• TECHNIQUE

• Steps in electrosurgeical pulpotomy technique are basically same as those of the formocresol technique
through the removal of the coronal pulp tissue .

• Large sterile cotton pellets are placed in contact with the pulp , and pressure is applied to obtain hemostasis
The Hyfrecator plus 7-797 is set at 40% power ( high at 12 w) and the the 705-A dental electrode is used to
deliver the electrical arc .

• The cotton pellet are quickly removed , and the electrode is placed 1 to 2mm above the pulp stump .

• The electric arc is allowed to bridge the gap to the pulp stump for 1 sec , followed by a cool- down period
of 5 seconds thus heat and electrical transfer are minimized by keeping the electrode as far as away from the
pulpal stump and tooth structure as possible while still allowing electrical arc to occur .

• Is necessary this procedure may be repeated for the next pulpal stump .when the procedure properly
performed the pulapl stumps appear dry and completely blackend .

• The chamber is filled with ZOE and Ca(OH)2 as the dressing .the toooth should be restored with an SS
crown .

Ruemping et al. histologically

compared electrosurgery with formocresol in pulpotomy techniques for primate primary and young permanent

teeth.

After an 8-week post-treatment period, the histologic appearance for both groups was similar, with no evidence of
pulp necrosis or abscess formation.

Electrosurgery group, secondary dentin was deposited along the lateral

canal walls, and the apical two-thirds of the pulp revealed a slightly fibrotic to normal appearance.

Shaw et al. compared, after 6 months, the histologic

effects of electrosurgery with formocresol on the radicular

pulp. similar success rates of 80% for the formocresol and 84% for the electrosurgical groups according to their
histologic criteria.

Mark and Dean reported a very high success rate with the technique .It is difficult to explain why burned tissue is
tolerated by the vital pul tissue .

Shulman et al.

Histologically compared electrosurgery, formocresol, & electrosurgery plus

formocresol in primate pulpotomies.

More periradicular & furcal pathologic change after 65 days in the –Electrosurgery

Combining 2 techniques of electrosurgery & formocresol produced no better results

Sheller and Morton

Varying degrees of inflammation, edema, & necrosis were seen at all time periods .

Reparative dentin formation - along the lateral aspect of the radicular canal walls but not across the amputation site.

Conclusion

Results did not support the concept of electrosurgery being less harmful to pulp tissue than conventional
pharmacotherapeutic techniques.

• LASER

Use in pulpotomies was first published in 1985

Shoji et al – No detectable change in the radicular partion of the pulp

Wilder – smith and Dang et al found that secondary dentin was formed and a regular odontoblst layer was
present .

Jukic et al – laser irradiation caused carbonisation , necrosis , inflammatory infiltration , oedema and
hemorrhage in pulpal tissues .
• Evidence of success in therapy includes

Vitality of majority of the radicular pulp

No prolonged adverse clinical signs or symptoms such as prolonged sensitivity ,pain or swelling

No radiographic evidence of internal resorption reaching the alveolar bone

No breakdown of periradicular tissues

No harm to succedaneous teeth

Pulp canal obliteration ( abnormal calcification ) - Not consider a failure

TRANSDENTINAL TREATMENT

Stepwise excavation procedure , where Ca(OH) 2 is used to induce reparative dentine is an example of
transdentinal treatment

Use of biological agents to control pulp response through an existing layer of dentine would provide extra
protection from external irritants

Reduced permeability of this reparative dentine provides an additional protection of the pulp from thermal
and mechanical challenges

A controlled amount of reparative dentine immediately following extensive dentine loss wothout pulp
exposure would be a desirable clinical goal
 • Pulpotomy medicaments :conclusions

• Ferric sulphate , MTA and IPT appear to be promising to the single visit formocresol for cariously exposed
vital primary teeth .

• Ferric sulphae use is arguably technique – sensitive and MTA has cost implications .

• Use of laser and electrosurgery is not routine in all dental settings and may not be readily available

• APEXOGENESIS

Apexogenesis Apexification

Physiological process of root development in vital Inducing the development of root apex in an immature pulpless tooth by a
infected teeth formation of osteocementum or other bone like tissue

Normal pulp tissue with minimal inflamation is In cases where there is no normal pulp tissue i.e where the pulp has
present undergone irreversible pulpal necrosis

1 Direct pulp capping

2 Pulpotomy

Normal root end development Normal root end development takes place rarely ,More commonly calcific
barrier is formed clinically , on a radiograph or both
APEXOGENESIS

•
INDICATIONS

The tooth is free of radicular pulpitis

Pain if present is neither persistent nor spontaneous

The tooth is restorable

The tooth possesses at least 2/3rd of its root length

There is no evidence of internal root resorption

There is no inter Radicular bone loss

No abscess or fistulae

The hemorrhage from amputed site is pale red & easy to control.

Spontaneous pain – at night

Swelling
Fistula

Tenderness to percussion

Pathological mobility

External/Internal root resorption

Periapical or interradicular radiolucency

Pulp calcification

Pathological external root resorption

Pus or serous exudates at the exposure site

Uncontrolled hemorrhage from amputed pulp stumps.