Isn't the dental pulp a topic for Endodontics? Endodontics? topic for

Graduate Operative Dentistry Restorative Procedures and the Dental Pulp Dr. N. B. Cook

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N. B. Cook, DDS, MSD

Isn’t the dental pulp a Isn’t the dental pulp a topic fortopic for Endodontics?Endodontics?topic for topic for Endodontics?Endodontics?

“The treatment phase of restorative “The treatment phase of restorative

dentistry is or should be, more involved dentistry is or should be, more involved

than than endodonticsendodontics with the structure, with the structure,

function, tissue reactions, and potential function, tissue reactions, and potential

healing capacities of dentin and pulp Allhealing capacities of dentin and pulp Allhealing capacities of dentin and pulp. All healing capacities of dentin and pulp. All

caries prophylactic measures and caries prophylactic measures and

treatment phases of restorative dentistry treatment phases of restorative dentistry

should be considered ‘preventive should be considered ‘preventive

endodonticsendodontics.’”.’”MjMjör IA. Quint Int 2001ör IA. Quint Int 2001

EnamelEnamel

DentinDentin

PulpPulp

odontoblasticodontoblasticprocessprocess

Dentin Anatomy & Dentin Anatomy & PhysiologyPhysiologyPhysiologyPhysiology

DentinDentin

•• Derived from Derived from odontoblastsodontoblasts

•• Newest layer of dentin always onNewest layer of dentin always onNewest layer of dentin always on Newest layer of dentin always on pulpalpulpal surfacesurface

•• Formation continues throughout lifeFormation continues throughout life


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Primary DentinPrimary Dentin

•• Dentin forming initial shape of Dentin forming initial shape of toothtooth

•• In permanent teeth, completed In permanent teeth, completed 3 years after tooth eruption3 years after tooth eruption

Secondary DentinSecondary Dentin

•• Low rate deposition continuing after Low rate deposition continuing after primary dentin is formed. primary dentin is formed.

•• Different directional pattern from Different directional pattern from primary dentin, more irregularprimary dentin, more irregular

•• Forms on internal aspect of pulp Forms on internal aspect of pulp chamberchamber

Dentin MatrixDentin Matrix

•• Calcified PortionCalcified Portion

Uncalcified PortionUncalcified Portion•• Uncalcified PortionUncalcified Portion

Calcified PortionCalcified Portion•• Organic Organic -- mainly collagenmainly collagen

•• Inorganic Inorganic -- hydroxyapatitehydroxyapatite

•• WaterWaterEnamelEnamel

DentinDentin

PulpPulp

Uncalcified PortionUncalcified Portion

•• Dentinal tubulesDentinal tubules–– odontoblastic fibers (Tome’s)odontoblastic fibers (Tome’s)

fl idfl id–– fluidfluid EnamelEnamel

DentinDentin

PulpPulp

Distance from Distance from pulp(mm)pulp(mm)

Mean Number Mean Number of tubules of tubules

(1000/mm2)(1000/mm2)

Pulpal WallPulpal Wall0.10.1--0.50.50 60 6 1 01 0

4545434338380.60.6--1.01.0

1.11.1--1.51.51.61.6--2.02.02.12.1--2.52.52.62.6--3.03.03.13.1--3.53.5

383835353030232320201919

(Pathways of the Pulp, 6th ed.)


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Distance from Distance from pulp (mm) pulp (mm)

Mean Tubule Mean Tubule Diameter (Diameter (m)m)

Pulpal WallPulpal Wall0.10.1--0.50.50.60.6--1.01.0

2.52.51.91.91.61.6

1.11.1--1.51.51.61.6--2.02.02.12.1--2.52.52.62.6--3.03.03.13.1--3.53.5

1.21.21.11.10.90.90.80.80.80.8

(Pathways of the Pulp, 6th ed.)

EnamelEnamel

Dentin

PulpPulp AA BB

Dentin PermeabilityDentin Permeability

•• Movement of fluids through dentinMovement of fluids through dentin

•• Related to thickness of dentinRelated to thickness of dentinRelated to thickness of dentin, Related to thickness of dentin, and diameter and number of and diameter and number of tubulestubules

•• Pulpal fluid has slight positive Pulpal fluid has slight positive pressure pressure (5 (5 --20 mm Hg)20 mm Hg)

James K. Avery, University of Michigan, School of Dentistry, 1987


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Clinical ImplicationsClinical Implications

•• PermeabilityPermeability–– fluid flow (bonding)fluid flow (bonding)

–– access to pulp access to pulp (chemical & (chemical & bacterial)bacterial)

–– tooth sensitivity tooth sensitivity (hydrodynamic (hydrodynamic theory)theory)

Functions of the PulpFunctions of the Pulp

•• FormativeFormative

•• NutritiveNutritive

•• SensorySensory

•• ProtectiveProtective

Review in Chapter 1 (Summitt)Review in Chapter 1 (Summitt)

Pulpal ReactionPulpal Reaction

•• Inflammatory response to noxious Inflammatory response to noxious stimulistimuli–– Bacteria and endotoxinsBacteria and endotoxins

–– Physical, chemical, & thermal Physical, chemical, & thermal irritation from restorative proceduresirritation from restorative procedures

Stressed Pulp SyndromeStressed Pulp Syndrome

•• Pulp is stressed during every Pulp is stressed during every restorative episoderestorative episode

•• Stressful effects are additiveStressful effects are additive

•• Repeated insults decrease pulp’s Repeated insults decrease pulp’s ability to tolerate injury ability to tolerate injury

Effects of AgingEffects of Aging•• Young PulpsYoung Pulps

–– Highly cellular, low fiberHighly cellular, low fiber•• Old pulpsOld pulps

Increased fibrous componentIncreased fibrous component–– Increased fibrous componentIncreased fibrous component–– Low number of cellsLow number of cells–– Decreased nerve fibers and Decreased nerve fibers and

neuropeptidesneuropeptides

•• Therefore, reparative capability Therefore, reparative capability of older pulps is decreased.of older pulps is decreased.

Effects of AgingEffects of Aging

•• However;However;aged teeth are generally:aged teeth are generally:–– less sensitiveless sensitiveless sensitiveless sensitive

–– protected by sclerotic and protected by sclerotic and tertiary dentintertiary dentin

–– Low dentin permeabilityLow dentin permeability


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Pulpal Response to Pulpal Response to Dental ProceduresDental ProceduresDental ProceduresDental Procedures

Opportunities to Opportunities to the Pulpthe Pulp

•• Tooth PreparationTooth Preparation

T th R t tiT th R t ti

KillKillProtectProtect

•• Tooth RestorationTooth Restoration

Goal during restorative process:Goal during restorative process:

Maintain the health of the pulpMaintain the health of the pulp

Natural DefensesNatural Defenses

Remaining Dentin Thickness Remaining Dentin Thickness (RDT)(RDT)

•• Remaining dentin thicknessRemaining dentin thickness (prep to (prep to pulp)pulp) is single most important factor is single most important factor in protecting pulp from insultin protecting pulp from insult

•• 0.5mm reduces effect of toxins 75%0.5mm reduces effect of toxins 75%

•• 1.0mm reduces effect of toxins 90%1.0mm reduces effect of toxins 90%

•• 2.0+mm little pulpal reaction2.0+mm little pulpal reaction

Remaining Dentin ThicknessRemaining Dentin Thickness

•• Thicker dentin, better insulatorThicker dentin, better insulator

•• Thicker dentin better bufferThicker dentin better buffer•• Thicker dentin, better bufferThicker dentin, better buffer

•• Greater permeability in deep Greater permeability in deep prepspreps

Smear LayerSmear Layer


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Reparative Dentin Reparative Dentin (tertiary dentin)(tertiary dentin)

•• Response to moderate level Response to moderate level irritants:irritants: attrition, abrasion, erosion,attrition, abrasion, erosion,irritants: irritants: attrition, abrasion, erosion, attrition, abrasion, erosion, trauma, moderatetrauma, moderate--rate caries lesions, rate caries lesions, operative procedures, etc.operative procedures, etc.

•• Localized dentin deposit on Localized dentin deposit on wall of pulp cavitywall of pulp cavity

Reparative Dentin Reparative Dentin (tertiary dentin)(tertiary dentin)

•• Variable tubular structureVariable tubular structure“barrier effect”“barrier effect”

•• Low permeabilityLow permeability

•• 1 month to detect microscopically1 month to detect microscopically

•• 77--8 weeks to get 708 weeks to get 70m thicknessm thickness(Stanley)(Stanley)

Sclerotic DentinSclerotic Dentin

•• Mineral crystallization within Mineral crystallization within tubulestubules

•• Result of aging or mild irritationResult of aging or mild irritation

•• Progresses from DEJ toward pulpProgresses from DEJ toward pulp

DentinalDentinalTubuleTubule

PeritubularPeritubularDentinDentin

IntertubularIntertubularDentinDentin

The Dental Pulp during The Dental Pulp during Tooth PreparationTooth PreparationTooth PreparationTooth Preparation

Local AnestheticLocal Anesthetic

•• 2% Lido w/ 1:100K epi 2% Lido w/ 1:100K epi -- blood blood flow reduced (infiltration / IA flow reduced (infiltration / IA block)block)

•• pulpal blood flow ceases for 30 pulpal blood flow ceases for 30 min. with ligamental injectionmin. with ligamental injection


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Local AnestheticLocal Anesthetic

•• Direct relationship between length of Direct relationship between length of flow cessation and concentration of flow cessation and concentration of vasoconstrictor usedvasoconstrictor usedvasoconstrictor usedvasoconstrictor used

•• Prolonged reduction in oxygen Prolonged reduction in oxygen transport can alter pulpal response transport can alter pulpal response to injuryto injury

Thermal InjuryThermal Injury

•• is primary cause of is primary cause of pulpal damage during restorative pulpal damage during restorative proceduresprocedures

•• Deep prep worse than shallowDeep prep worse than shallow


•• Main pulpal damage in 1Main pulpal damage in 1--2mm 2mm radius of dentin being cutradius of dentin being cut

•• Tooth “blushing” during prep Tooth “blushing” during prep attributed to frictional heatattributed to frictional heat


•• 4 4 ooFF increase increase -- minimal minimal reactionreaction

•• 10 10 ooFF increase increase -- partial partial odontoblastodontoblast destruction, 15% of destruction, 15% of cases showed cases showed pulpalpulpal necrosisnecrosis


•• 20 20 ooFF increase increase -- complete complete odontoblasticodontoblastic destruction, destruction, 60% of cases did not recover60% of cases did not recover

•• 30 30 ooFF increase increase -- necrotic pulpnecrotic pulp

Instrumentation and Pulpal Instrumentation and Pulpal TemperaturesTemperatures

•• 18001800--10,000 rpm’s, no coolant 10,000 rpm’s, no coolant 55--2222 ooF increaseF increase55 22 22 F increaseF increase

•• 18001800--10,000 rpm’s, air coolant 10,000 rpm’s, air coolant 1 1 ooF increaseF increase


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Instrumentation and Pulpal Instrumentation and Pulpal TemperaturesTemperatures

•• 250,000250,000--300,000 rpm’s w/ air 300,000 rpm’s w/ air ,, , p, p44--7 7 ooF decreaseF decrease

•• 250,000250,000--300,000 rpm’s w/ water 300,000 rpm’s w/ water spray spray 88--9 9 ooF decreaseF decrease

InstrumentationInstrumentation•• Speed and type of coolantSpeed and type of coolant

InstrumentationInstrumentation•• Large vs. small bursLarge vs. small burs

InstrumentationInstrumentation•• Pressure on rotary instrumentsPressure on rotary instruments

Pressure applied has greater effect ontemperature than does rotational speed

Carbide vs. steel bursInstrumentationInstrumentation

•• Carbide bursCarbide burs–– better for cutting better for cutting ductileductile materials materials

such as dentin, metal alloys, such as dentin, metal alloys, amalgam removalamalgam removal

–– better for end cutting, intracoronal better for end cutting, intracoronal cavity preparationcavity preparation


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Diamond burs / stones

Diamonds produce more temperaturerise than do carbide burs

Crown PreparationCrown Preparation

•• Incidence of pulp necrosisIncidence of pulp necrosis–– full crown preparation 13.3%full crown preparation 13.3%

–– partial veneer restoration 5.1%partial veneer restoration 5.1%

–– unrestored control unrestored control 0.5%0.5%(Felton, 1989)(Felton, 1989)

InstrumentationInstrumentation

•• Diamond bursDiamond burs–– better for cutting better for cutting brittlebrittle materialsmaterials

(e.g. enamel, porcelain)(e.g. enamel, porcelain)

–– better for extrabetter for extra--coronal cavity coronal cavity preparation, beveling enamel preparation, beveling enamel margins, enameloplastymargins, enameloplasty

InstrumentationInstrumentation•• Pin placementPin placement

Other Potential Heat SourcesOther Potential Heat Sources

•• Light curing of resinsLight curing of resins 2.9 2.9 -- 7.87.8ooCC (Hannig, Dent Mater, 1999)(Hannig, Dent Mater, 1999)

•• Resin finishing & polishingResin finishing & polishingMax. 4000 rpms (dry), 10000 rpm’s (wet)Max. 4000 rpms (dry), 10000 rpm’s (wet)

(Briseno, Quintessence Int, 1995)(Briseno, Quintessence Int, 1995)

Other Potential Heat SourcesOther Potential Heat Sources

•• Amalgam polishingAmalgam polishing(Class V (Class V amalamal, rubber brownie point) 15000 , rubber brownie point) 15000

rpm’s, 60 rpm’s, 60 gmsgms force force pulpalpulpal damage in 15 damage in 15 ddsecondsseconds. . (Hatton, Am J Dent, 1994)(Hatton, Am J Dent, 1994)

Continuous polishing, high velocity Continuous polishing, high velocity pulpalpulpal temp temp increased more than 20increased more than 20ooC in 30 secondsC in 30 seconds..

(van (van AmerongenAmerongen, J , J ProsthetProsthet Dent, 1990)Dent, 1990)

•• Fabrication of Fabrication of provisionalsprovisionals


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ElectrosurgeryElectrosurgery•• ContactContact enamelenamel with probewith probe little to little to

no pulpal reactionno pulpal reaction

•• Contact Contact metallicmetallic restorationrestoration adverse and often severe reactionadverse and often severe reaction

–– More severe reaction with More severe reaction with contact contact time (>0.4sec) and time (>0.4sec) and dentin thickness dentin thickness between restoration and pulpbetween restoration and pulp

InstrumentationInstrumentation•• Hand InstrumentsHand Instruments

Desiccation of DentinDesiccation of Dentin

•• Rapid outward fluid movementRapid outward fluid movement

•• Continuous air drying can Continuous air drying can y gy gaspirate odontoblasts into tubulesaspirate odontoblasts into tubules

•• Dentin desiccation from air blasts Dentin desiccation from air blasts and cutting procedures has and cutting procedures has limited pulpal effectlimited pulpal effect

Desiccation of DentinDesiccation of Dentin

“Pulp“Pulp--friendly” Preppingfriendly” Prepping

•• Preserve tooth structurePreserve tooth structure

•• Adequate airAdequate air--water spraywater sprayqq p yp y

•• Light pressureLight pressure

•• Sharp bursSharp burs

•• Do not overdryDo not overdry

Pulpal Response to Pulpal Response to Restorative MaterialsRestorative MaterialsRestorative MaterialsRestorative Materials


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Commonly Used Cytotoxic Commonly Used Cytotoxic Clinical MaterialsClinical Materials

•• eugenoleugenol

•• formocresolformocresol

•• HEMAHEMA

•• BisBis--GMAGMA

•• glutaraldehydeglutaraldehyde •• UDMAUDMA

••StanleyStanley

••BrannstromBrannstrom

Dental MaterialsDental Materials

•• Acid etchingAcid etching



•• Bonding agentsBonding agents•• Bonding agentsBonding agents




•• DualDual--cure resin cementscure resin cements




•• DualDual--cure resin cementscure resin cements

•• Dental cementsDental cements


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•• Composite resinsComposite resins

•• Dental amalgamDental amalgam•• Dental amalgamDental amalgam

•• GoldGoldCox, et al. J Pros Dent, 1987;57(1):1-8.Cox, et al. Int J Periodontics Restorative Dent

1996;16(3):240-51.

Pulpal Response to Dental MaterialsPulpal Response to Dental Materials(summary)(summary)

•• Inflammatory reactions to dental Inflammatory reactions to dental materials tend to be mild and transitorymaterials tend to be mild and transitory

•• Significant pulpal responses occur more Significant pulpal responses occur more as the result of infiltration of bacteria or as the result of infiltration of bacteria or their toxins.their toxins.

Liners and BasesLiners and BasesClassification SystemClassification System

•• According toAccording to FunctionFunction―― SealersSealers―― LinersLiners―― BasesBases

ClassificationClassification

•• Cavity Sealers Cavity Sealers –– protective coating / barrier to protective coating / barrier to

leakageleakage

McCoy 1995McCoy 1995

(all leak)(all leak)

–– Applied to Applied to ALLALL WALLSWALLS•• Varnish:Varnish: natural gum or rosin in organic natural gum or rosin in organic

solvent (dentin permeability solvent (dentin permeability 69%)69%)

•• Resin Bonding System:Resin Bonding System: etch, hybrid etch, hybrid layer, bifunctional moleculelayer, bifunctional molecule

ClassificationClassification•• Cavity Liners Cavity Liners

–– thickness <0.5mmthickness <0.5mm

–– physical barrier or therapeutic effectphysical barrier or therapeutic effect


–– Usually only applied to dentin walls Usually only applied to dentin walls near pulpnear pulp

•• Calcium Hydroxide Calcium Hydroxide

•• Glass IonomerGlass Ionomer (Vitrebond, Lining LC)(Vitrebond, Lining LC)


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ClassificationClassification•• Cavity Bases Cavity Bases

–– Replace missing dentinReplace missing dentin

–– Used for build up and/or block outUsed for build up and/or block out


••Zinc OxideZinc Oxide--EugenolEugenol

••Zinc Phosphate Zinc Phosphate

••Glass IonomerGlass Ionomer

What to use and when?What to use and when?

PostPost--Op SensitivityOp Sensitivity

•• TheoriesTheories–– Theory of Thermal ShockTheory of Thermal ShockTheory of Thermal ShockTheory of Thermal Shock

(thermal diffusion)(thermal diffusion)

–– Theory of Pulpal HydrodynamicsTheory of Pulpal Hydrodynamics

Thermal DiffusivityThermal Diffusivity

•• Pure gold 119.0Pure gold 119.0

•• Amalgam 9.6Amalgam 9.6

•• Zn phos. 0.290Zn phos. 0.290

•• Compound 0.226Compound 0.226

•• Comp. resin 0.675Comp. resin 0.675

•• Porcelain 0.64Porcelain 0.64

•• Enamel 0.469Enamel 0.469

•• ZOE 0.389ZOE 0.389

•• GlC 0.198GlC 0.198

•• Dentin 0.183Dentin 0.183

•• Acrylic resin 0.123Acrylic resin 0.123

Craig RG. Restorative Dental Materials, 10th ed. 1997; Mosby.

Thermal DiffusionThermal Diffusion

Miller & Charbeneau. Miller & Charbeneau. Oper Dent Oper Dent 1984;9:1301984;9:130--5.5.

-- no need for base under resin compositeno need for base under resin composite

-- base should be 0.50 base should be 0.50 –– 0.75mm thick0.75mm thick

-- should have high modulus of elasticityshould have high modulus of elasticity

-- base thickness base thickness Fx resistance of amalFx resistance of amal

Thermal DiffusionThermal Diffusion

Trowbridge Trowbridge et. al.et. al. (1980) showed in 16 teeth (1980) showed in 16 teeth that pain fibers (Athat pain fibers (A--delta) are activated before delta) are activated before it was possible for the temperature change toit was possible for the temperature change toit was possible for the temperature change to it was possible for the temperature change to diffuse through dentin near the fibersdiffuse through dentin near the fibers


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rapid movement rapid movement of fluid in the of fluid in the dentinal tubules dentinal tubules

Hydrodynamic TheoryHydrodynamic Theory(Brannstrom et al.)(Brannstrom et al.)

results in results in deformation of deformation of the the mechanoreceptor mechanoreceptor nerve endingsnerve endings

Hydrodynamic TheoryHydrodynamic Theory

•• intrapulpal pressureintrapulpal pressure •• desiccationdesiccation

Causes of fluid movementCauses of fluid movement

•• coldcold

•• heatheat

•• osmotic gradientosmotic gradient

•• negative pressurenegative pressure

•• hydraulic pressurehydraulic pressure

•• mechanical mechanical instrumentationinstrumentation

Hydrodynamic TheoryHydrodynamic Theory

•• Most widely accepted explanation Most widely accepted explanation for tooth sensitivityfor tooth sensitivity

N t ll d li i l t i lN t ll d li i l t i l•• Numerous controlled clinical trials Numerous controlled clinical trials have failed to show decreased posthave failed to show decreased post--op sensitivity with resin bonding op sensitivity with resin bonding under amalgamsunder amalgams

•• 90 class 1 and class 2 amalgams90 class 1 and class 2 amalgams

•• Lesion depth:Lesion depth: equal numbers of lesions in equal numbers of lesions in outer, middle and inner third of dentinouter, middle and inner third of dentin

•• Test groups:Test groups:

Gordan, Gordan, et al.et al., Oper Dent 1999; 24:377, Oper Dent 1999; 24:377--8383

–– No linerNo liner

–– 2 coats Copalite2 coats Copalite

–– Dentin adhesive resin linerDentin adhesive resin liner

–– Resin modified glass ionomer linerResin modified glass ionomer liner

•• Patient complaints of sensitivityPatient complaints of sensitivity

•• Results:Results:

–– No clinical or statistically significant No clinical or statistically significant difference between lesion depth or difference between lesion depth or

Gordan, Gordan, et al.et al., Oper Dent 1999; 24:377, Oper Dent 1999; 24:377--8383

dentin treatment.dentin treatment.

–– When teeth were sensitive, copal When teeth were sensitive, copal varnish and resin lined teeth varnish and resin lined teeth remained sensitive longer than glass remained sensitive longer than glass ionomer or no liner teeth.ionomer or no liner teeth.

Sealers, Liners, & BasesSealers, Liners, & Bases

•• Under AmalgamUnder Amalgam

–– Generally no sealers,liners, or basesGenerally no sealers,liners, or basesy , ,y , ,

–– GI liner in deep areas close to pulpGI liner in deep areas close to pulp

–– If less than 0.5 mm dentin remaining If less than 0.5 mm dentin remaining (you can see pink through dentin),(you can see pink through dentin),Ca(OH)Ca(OH)22 (dycal) on deep area, cover (dycal) on deep area, cover with glass ionomer linerwith glass ionomer liner


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Initial vs. Replacement Initial vs. Replacement RestorationsRestorations Sealers, Liners, & BasesSealers, Liners, & Bases

•• Under Resin CompositeUnder Resin Composite–– Generally no liners or bases. Generally no liners or bases.

B di t i th lB di t i th lBonding agent is the sealer.Bonding agent is the sealer.

–– GI liner in deep areas close to pulpGI liner in deep areas close to pulp******

–– If less than 0.5 mm dentin remaining, If less than 0.5 mm dentin remaining, Ca(OH)Ca(OH)22 (dycal) on deep area, cover (dycal) on deep area, cover with glass ionomer linerwith glass ionomer liner

Sealers, Liners, & BasesSealers, Liners, & Bases

•• Under Resin Under Resin CompositeComposite (posterior)(posterior)Composite Composite (posterior)(posterior)

–– Some advocate flowable Some advocate flowable composite linercomposite liner

–– Prefer glass ionomer linerPrefer glass ionomer liner

Pulp ExposurePulp Exposure

•• Pulpal injury primarily due to Pulpal injury primarily due to bacterial contaminationbacterial contamination

•• Mechanical or carious Mechanical or carious exposure?exposure?

•• Rubber dam used?Rubber dam used?

Pulp CappingPulp Capping

•• Endodontic treatment designed to Endodontic treatment designed to maintain pulpal vitalitymaintain pulpal vitality

•• Formation of reparative dentin Formation of reparative dentin pp(dentin bridge)(dentin bridge)

Pulp Capping RequirementsPulp Capping Requirements

•• Pulp must be vital, no history of Pulp must be vital, no history of spontaneous painspontaneous pain

•• No lingering pain to cold/hot testingNo lingering pain to cold/hot testing•• No lingering pain to cold/hot testingNo lingering pain to cold/hot testing

•• No periradicular lesion on radiographNo periradicular lesion on radiograph


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Pulp Capping RequirementsPulp Capping Requirements

•• Must be able to place a wellMust be able to place a well--sealed sealed restorationrestoration

R bb d i l tiR bb d i l ti•• Rubber dam isolationRubber dam isolation

•• Consider how tooth is to be used in Consider how tooth is to be used in treatment plantreatment plan

Indirect Pulp CapsIndirect Pulp Caps

•• Indirect pulp cap is preferredIndirect pulp cap is preferred

–– Protective thickness of dentin remains Protective thickness of dentin remains over pulpover pulp

Because RDT is directly related toBecause RDT is directly related to–– Because RDT is directly related to Because RDT is directly related to odontoblast survival, reparative dentin odontoblast survival, reparative dentin formation is enhancedformation is enhanced

–– Less chance for infected debris to get Less chance for infected debris to get into the pulp causing inflammationinto the pulp causing inflammation

Indirect Pulp Cap ProcedureIndirect Pulp Cap Procedure

1.1. Anesthesia, Isolate with rubber damAnesthesia, Isolate with rubber dam

2.2. Prepare tooth for final restoration Prepare tooth for final restoration leaving demineralized dentin only leaving demineralized dentin only immediatel adjacent to p lpimmediatel adjacent to p lpimmediately adjacent to pulp.immediately adjacent to pulp.

3.3. Caries detecting dye?Caries detecting dye?

4.4. Carefully remove wet, soft carious Carefully remove wet, soft carious dentin. Leave dry, firm, leathery dentin.dentin. Leave dry, firm, leathery dentin.

Indirect Pulp Cap ProcedureIndirect Pulp Cap Procedure

5.5. Calcium hydroxide placed over Calcium hydroxide placed over remaining demineralized dentin. This is remaining demineralized dentin. This is always sealed with a glass ionomer always sealed with a glass ionomer liner.liner.

6.6. Place restoration.Place restoration.

7.7. Monitor pulp vitality.Monitor pulp vitality.

Direct Pulp CappingDirect Pulp Capping

•• Traditionally performed with Traditionally performed with Ca(OH)Ca(OH)22

R d i t t i l iR d i t t i l i•• Renewed interest in pulp capping Renewed interest in pulp capping using using MineralMineral TrioxideTrioxide AggregateAggregate(MTA) (MTA) (similar to Portland cement)(similar to Portland cement)

Direct Pulp CappingDirect Pulp Capping

•• Only works under ideal conditionsOnly works under ideal conditions

•• A bacteria free environment requiredA bacteria free environment required

•• Small mechanical exposure on otherwise Small mechanical exposure on otherwise h lth lh lth lhealthy pulphealthy pulp

•• Aged pulps have less healing capabilityAged pulps have less healing capability

•• Increased bleeding associated with Increased bleeding associated with increased likelihood of failure.increased likelihood of failure.


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Direct Pulp Cap ProcedureDirect Pulp Cap Procedure

•• Achieve Achieve hemostatishemostatis

•• Place calcium hydroxide (or MTA) over Place calcium hydroxide (or MTA) over exposureexposure

•• Seal calcium hydroxide (or MTA) with Seal calcium hydroxide (or MTA) with glass glass ionomerionomer linerliner

•• Placed wellPlaced well--sealed restorationsealed restoration

•• Monitor pulp vitalityMonitor pulp vitality

AA BB

•• Primary DentinPrimary Dentin

•• Secondary DentinSecondary Dentin

•• Tertiary DentinTertiary DentinTertiary DentinTertiary Dentin

•• Reparative DentinReparative Dentin

•• Sclerotic DentinSclerotic Dentin

During restorative procedures, During restorative procedures, what is the primary cause of what is the primary cause of

l l d ?l l d ?pulpal damage?pulpal damage?


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Which case is more likely to have postWhich case is more likely to have post--op op sensitivity following the placement of sensitivity following the placement of an amalgam restoration?an amalgam restoration?

a.a. Conservative MO amalgam on Conservative MO amalgam on previously unrestored tooth #3previously unrestored tooth #3previously unrestored tooth #3.previously unrestored tooth #3.

b.b. Large MODL amalgam replacing Large MODL amalgam replacing previous large amalgamprevious large amalgam

Documents

Isn't the dental pulp a topic for Endodontics? Endodontics? topic for