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1
Greatest challenges to the integrity
of the developing tooth
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Primary goal
Maintain pulp vitality
Normal tooth development
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History
• 1746 - Philip Pfaff a dentist to King Frederick of Prussia first mentioned capping an
exposed pulp before inserting a filling
• 1800’s, - clinicians utilized metal-caps covered with chlora-percha as a temporary
“stopping” agent to clinically treat an exposed pulp
• 1826 - Koecker recommended that an exposed pulp be cauterized with a red-hot
wire before covering with gold leaf and the cavity filled with gold
• 1900- Jack gave the name “direct pulp capping”, came from the clinical placement
of small metal caps over an exposed pulp
• 1920 – Hermann – Ca(OH)2
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Key responses of the dentin-pulp to caries / injury
Tertiary dentin 5
Reactionary dentinogenesis
Caries
Odontoblasts
Dentin
Tertiary, reactionary dentin laid
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Reparative dentinogenesis
Tertiary,
reparative dentin
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• RDT is a key determinant of pulp survival after cavity preparation & avoiding pulp
exposure has been considered advantageous.Int Endod J 41:389, 2008.
Remaining Dentinal Thickness/ Effective Depth
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1. Visual & tactile examination of carious dentin and associated periodontium
2. Radiographic examination
3. History of spontaneous unprovoked pain
4. Pain from percussion
5. Pain from mastication
6. Degree of mobility
7. Palpation of surrounding soft tissues
8. Size, appearance & amount of hemorrhage associated with pulp exposures
Endodontics : Ingle 5th edi10
Determining the pulpal status of cariously involved teeth involves the following:
- Type of injury
- age of the pt
- size & location of the pulp exposure
- bacterial contamination
- pulp capping material &
- quality of the final restoration
The outcome of VPT depends on:
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Vital pulp therapy
Indirect pulp capping
Direct pulp capping
Pulpotomy
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• To arrest the carious process,
• Provide conditions conducive to the formation of reactionary
dentin, and
• Promote remineralization of the altered dentin that was left.
• Promote pulpal healing & preserve/maintain the vitality of the pulp.
Indirect pulp capping
Definition: IPC is a procedure wherein the deepest layer of the remaining
affected carious dentin is covered with a layer of biocompatible material in order
to prevent pulpal exposure & further trauma to the pulp.
Aims of indirect pulp capping :
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• When pulpal inflammation has been judged to be minimal & complete removal of
caries would cause pulp exposure.
• Mild pain associated with eating.
• Negative history of spontaneous, extreme pain.
• When there is a definite layer of affected dentin after removal of infected dentin.
• Deep carious lesion, which are close to, but not involving pulp in vital primary or young
permanent teeth
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• Any signs of pulpal or periapical pathology.
• Soft leathery dentin covering a very large area of the cavity, in a non restorable tooth.
• Sharp, penetrating pulpalgia
• Prolonged night pain.
• Mobility of the tooth.
• Discoloration of the tooth.
• Definite pulp exposure.
• Interrupted or broken lamina dura.
• Radiolucency about the apices of the roots16
• Hard setting Ca(OH)2
• ZOE
• GIC (Glass ionomer caries control approach)
• Resin modified glass ionomer
• Bonded composite
• MTA
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• IPC studies show success rates of 90% or greater over time with differing
techniques and medicaments.
J Endod Vol 34, No 7S, July 2008
IPT medicaments Success
(%)
Time (mo) Sample
(N)
Nirschl and Avery
1983
Calcium hydroxide 94 6 33
Al-Zayer et al. 2003 Calcium hydroxide 95 14 (median) 187
Vij et al. 2004 Glass ionomer 94 40 108
Farooqet al. 2000 Glass ionomer 93 50 55
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• To manage lesions in primary molars (that are
symptom free and free from radiographic signs of
periradicular pathology) by cementing a preformed
metal (stainless steel) crown in place without local
anaesthesia, tooth preparation, or any attempt at
caries removal.
Innes NP, Stirrups DR, Evans DJ, Hall N, Leggate M: A novel technique
using preformed metal crowns for managing carious primary molars in
general practice–a retrospective analysis. Br Dent J 200:451, 2006
• After a review period of 2 years, comparing the
teeth managed using Hall preformed metal
(stainless steel) crowns with conventional
restorations, the “Hall crowns” showed better
treatment outcomes for both pulpal health and
restoration longevity.
Innes NP, Evans JP, Stirrups DR: The Hall technique; a randomized
controlled clinical trial of a novel method of managing carious primary
molars in general dental practice: acceptability of the technique and
outcomes at 23 months. BMC Oral Health 7:18, 2007. 19
• Two appointment technique
• One appointment technique
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• Researchers continue to investigate the role of antimicrobial treatments,
including
• Ozone fumigation, Eur J Oral Sci 114:349, 2006
• Photo-activated disinfection (PAD), and
• Antimicrobial resins in sterilizing deep layers of affected dentin & creating the
conditions for arresting and remineralisation.
Int Endod J 40:58, 2007.
• Considerable interest has also focused on the active upregulation of reactionary
dentinogenesis by applying bioactive agents such as the TGF-β family of
molecules to the depths of cavity preparations.Caries Res 38:314, 2004.
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Guideline on Restorative Dentistry
Recommendations
1. There is evidence from randomized controlled trails and systematic reviews that
incomplete caries excavation in primary and permanent teeth with normal
pulps or reversible pulpitis, either partial (one step) or stepwise (two step)
excavation, results in fewer pulp exposures and fewer signs and symptoms of
pulpal disease than complete excavation.
2. There is evidence that partial excavation (one step) followed by placement of
final restoration leads to higher success in maintaining pulp vitality in
permanent teeth than stepwise (two-step) excavation.
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American Academy of Pediatric Dentistry (AAPD) & American Association of Endodontists (AAE)
2014
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Def: 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.
Oral Surg 1972;34:477.
Objective: To seal the pulp against bacterial leakage,
encourage the pulp to wall off the exposure site by initiating a dentin
bridge, and maintain the vitality of the underlying pulp tissue regions.
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1. Small pin point mechanical exposures of diameter < 1.0mm
2. Pulp exposed without previous symptoms of pulpitis.
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(1) Spontaneous & nocturnal toothaches.
(2) Excessive tooth mobility.
(3) Thickening of the PDL.
(4) Radiographic evidence of furcal or periradicular degeneration.
(5) Uncontrollable hemorrhage at the time of exposure, and
(6) purulent or serous exudate from the exposure.
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• Ca(OH)2
• ZOE
• Corticosteroids & Antibiotics
• Polycarboxylate cements
• Collagen fibers
• Formocresol
• Bonding agents
• MTA
• Biodentine
• Calcium enriched mixture
• Bioactive glass
• Enamel matrix derivates
• Bioactive molecules
• Miscellaneous
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Calcium Hydroxide - gold standard
Hermann (1920) - introduced the use of
CaOH2 as a clinical procedure to stimulate pulp
healing and dentin bridge formation.
Mechanism:
enzyme alkaline
phosphatase
CH – high alkaline medium
Coagulation necrosis of the surface of the
pulp
Inorganic phosphate and calcium from the
blood (Pisanti & Sciaky 1964)
Precipitation of calcium
phosphate
Disadvantages of Ca(OH)2
Presence of tunnel defects in dentin barrier.
Extensive dentin formation.
High solubility in oral fluids.
Lack of adhesion & degradation after acid etching.
Asgary et al, 2008,
Cox et al, 1985,
Pitt ford, Roberts 1991
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• Pulp capping with MTA is recommended for teeth with carious pulp exposures specially immature teeth
with high potential for healing.
Farsi N, et al 2006
• MTA is superior in terms of dentin bridge formation during the early healing process in human dental
pulp.
Min et al, 2008
• MTA seemed to heal the pulp tissue at a faster rate than CH cement in human teeth.
Accornite et al, 2008
• MTA was clinically easier to use as a direct pulp capping agent and resulted in less pulpal inflammation
and more predictable hard tissue barrier formation than Dycal.
Nair PN et al, 2009
• It has excellent sealing ability.Torabinejad et al, 1993, 1994, Bates et al, 1996, Fischer et al, 1998, Wu et al, 1998.
• Biocompatibility. Kettering & Torabinejad 1995, Torabinejad et al, 1997, 1998, Holland et al, 1999, Mitchell et al, 1999, Keiser et al,
2000
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Mechanism………………………
Calcium oxide present in MTA + tissue fluids calcium hydroxide
calcite crystals
attract fibronectin, which is responsible for cellular
adhesion and differentiation
(“Holland et al 1999”)
Calcium ions released from MTA + phosphate in tissue fluid hydroxapatite
initial deep caries and immature apices
Five-minute application of 5.25% sodium hypochlorite
hemostasis, on two 1.5- to 2.0-mm exposures
Pulpal exposure
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Radiograph of molar with MTA after
initial visit
Radiograph taken at the 5.5-year recall
appointment showing permanent
restoration and evidence of complete
root formation.
(From Bogen G, Kim JS, Bakland LK: Direct pulp capping with mineral trioxide
aggregate. An observational study. J Am Dent Assoc 139:305-315, 2008. 34
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• On the biological level, it is perfectly biocompatible & capable of inducing the apposition of reactionary
dentin by stimulating odontoblast activity & reparative dentin, by induction of cell differentiation .
Laurent et al., 2008.,
Goldberg et al., 2009.,
Shayegan et al., 2010
• It is an effective dentin substitute that can be used as a coronal restoration material (for indirect pulp
capping), but can also be placed in contact with the pulp.
• Its faster setting time allows either immediate crown restoration, or to make it directly intraorally
“functional” without fear of the material deteriorating.
Tran et al., 2008
• Biodentine™ significantly increased TGF- β1 secretion from pulp cells independently of the contact
surface compared to the increase by Ca(OH)2 & MTA.
Laurent P, Camps J, About I: Int Endod J; May 2012, Vol. 45 Issue 5, p439-448.
Clinical view Distal pulp horn involvement
After removal of restoration Biodentine placement
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Post--‐operative clinical view Post‐operative X‐ray follow‐up image
Ceramic onlay, final restoration
after 2 monthsPost ‐operative X‐ray follow‐up image
Courtsey: Dr. Lucile Goupy
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• Antibacterial effect comparable to CH & superior to MTA
Asgary S, Kamrani FA 2008
• Sealing ability similar to MTA
Asgary S, Eghbal MJ, Parirokh M 2008
• Biologic response of pulp to MTA & CEM cement - similar in dogs’ teeth.
Asgary S et al, 2008
• CEM cement provides an endogenous source of calcium & phosphate ions that accelerates
hydroxyapatite (HA) crystal formation as a second-seal on its surface even in normal saline storage
media.
Aust Endod J 2009;35:147–52.
• Set form of CEM cement is similar to dentin.
J Endod 2009;35:243–50.
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• Hench – 1969
• Bioglass® 45S5 45wt% SiO2, 24.5wt% Na2O & CaO, and 6wt% P2O5.
• React with aqueous solutions & produce a carbonated apatite layer.
• BAG can be the material of choice for pulp capping & periapical bone healing because it is
biocompatible & has antibacterial property.
Schepers et al, 1991
• BAG produce Less inflammation, dentin bridge formation & no internal resorption, necrosis or abscess
compared to Ca(OH)2
Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2007)39
dentin
• Enamel Matrix Derivative (EMD) is a rich Amelogenin & Amelin biomaterial that has been
demonstrated to induce a reparative process similar to normal odontogenesis when placed in
contact with pulp tissue.
• MTA produced a better quality reparative hard tissue response with the adjunctive use of Emdogain,
when compared with the use of calcium hydroxide.J Endod 35 , Pages 667-672, May 2011
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Amelogenins form a matrix layer on the surface.
Contact to cells of the healthy part of the dentin
The cells secrete natural and specific cytokines and autokrinesubstances, which promote the required proliferation
Adduction and proliferation of mesenchymal cells from the healthy part of the dentin
Attraction and differentiation of odontoblasts, begin the formation of the matrix
• Consists of Calcium silicates, Monobasic calcium phosphate, zirconium oxide, tantalum oxide
• Hirschman et al compared Cytotoxicity of MTA-Angelus, Brasseler Endosequence Root Repair
Putty (ERRP), Dycal & Ultra-blend Plus (UBP)-(light curable Ca(OH)2 & concluded that ERRP &
UBP are less cytotoxic
J Endod 2012
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• Light-cured resin-modified calcium silicate pulp protectant
• Immediate placement & condensation.
• TheraCal displayed higher calcium-releasing ability & lower solubility than either ProRoot
MTA or Dycal.
• The capability of TheraCal to be cured to a depth of 1.7 mm may avoid the risk of untimely
dissolution.
Int Endod J , 45: 571–579, June 2012.
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1. Bone Sialoprotein (BSP)
2. Bone Morphogenetic Protein-7 (BMP-7), also termed Osteogenic Protein-1 (OP-1)
“M. Goldberg et al - Adv Dent Res August 2001”
Bioactive molecules
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BSP & BMP
implanted in the pulp
recruitment of cells bearing an osteoblastic phenotype
(i.e which differentiate into osteoblast like cells )
Atubular Dentin dense layer.
Produces a mineralizing extracellular matrix.
Miscellaneous
• TGF-b1
Enhances reparative dentin formation
Hu et al - J Endod. 1998
• Recombinant Insulin Like Growth Factor-I
rhIGF-I in rat molars resulted dentin bridge formation equal to dycal
after 28 daysLovschall H, et al - J Endod. 2008
• Odontogenic Ameloblast Associated Protein (ODAM)
rODAM accelerates reactionary dentin formation close to the pulp exposure area,
thereby preserving normal odontoblasts in the remaining pulp
Yang IS et al - J Endod. 2010
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Def: “amputation of the affected or infected coronal portion of the dental pulp,
preserving the vitality & function of all or part of the remaining radicular
pulp”.
AAPD guidelines 2014
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• Caries removal results in pulp exposure in a primary tooth with a normal pulp or
reversible pulpitis or after a traumatic pulp exposure.
• Radicular tissue is judged to be vital without suppuration, purulence, necrosis, or
• Excessive hemorrhage that cannot be controlled by a damp cotton pellet after several
minutes,
• No radiographic signs of infection or pathologic re-sorption.
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• Resorption exceeding >1/3rd of the root length
• Nonrestorable tooth crown
• Highly viscous, sluggish, or absent hemorrhage at the radicular canal orifices
• Marked tenderness to percussion
• Mobility with locally aggravated gingivitis associated with partial or total radicular pulp necrosis
• Radiolucency in the furcal or periradicular areas
• Persistent toothaches & coronal pus
According to Mejare:
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CLASSIFICATION
Amount of pulpal tissue involved
Cervical / Complete Pulpotomy
Partial pulpotomy [Cvek’s pulpotomy]
Type of medicament employed
Grossman’s Endodontic Practice 12th Edition
CLASSIFICATION
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Pedodontics – Shobha Tandon 2nd Edition
Types Other name Features Examples
Devitalization
Preservation
Regeneration
Mummification, cauterization
Minimal devitalization, noninductive
Inductive, reparative
It is intended to destroy or mummify the vital tissue.
This implies maintaining the maximum vital tissue,with no induction of reparative dentin.
This has formation of dentin bridge.
Single sittingFormocresolElectrosurgeryLaser Two stageGysi triopasteEaslick’s formaldehydeParaform devitalizing paste
ZnO EugenolGlutaraldehydeFerric sulphate
Ca(OH)2 Bone morphogenic proteinMineral trioxide aggregateEnriched collagenFreezed dried bone Osteogenic protein
Agents for pulpotomy
Pharmacotherapeutic
Formocresol
Glutaraldehyde
Calcium hydroxide
Collagen
Ferric sulfate
CaPo4 cement
Hydroxyapatite
BMP 2 & 4
Freeze dried bone
MTA
CEM
Biodentine
Non-pharmacologic
Electro surgery
Lasers
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MTA & Formocresol
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JOE—Volume 34, Number 7, July 2008
Ferric sulphate & Formocresol
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JOE—Volume 34, Number 7, July 2008
CH & FC
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JOE—Volume 34, Number 7, July 2008
Laser vs FC
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Clinical (%) Radiograhic (%)
Nd:YAG laser 97 94
FC 85 78
• The permanent successors of the laser-treated teeth erupted without any
complications.
J Endod, 2006: 32:404-7
NaOCl vs FS
Vargas et al, 2006
Paediatr Dent 2006, 28: 511-7
Duration Ferric sulphate NaOCl
Clinical
success
Radiographic
success
Clinical
success
Radiographic
success
At 6 months 100% 68% 100% 91%
At 12 months 85% 62% 100% 79%
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• Case reports showing successful pulpotomy with MTA
JADA, Vol. 137 May 2006
18 month
19 month
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Case report showing successful pulpotomy with
CEM cement in permanent molar with irreversible
pulpitis & condensing apical periodontitis:
Saeed Asgary. J Conser Dent 2011, 14: 90-93
6 months
1 year 2 years
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