Direct pulp capping

it will provide u a detail description about direct pulp capping treatment,its indication ,contraindication,methods and materials used,techniqes,advantage and disadvantage and its limitation on primary teeth

1. DON’T KILL THE PULP DIRECT PULP CAPPING IS HERE N.MOHAMED RAHMAN KHAN BDS -CRRI

2. INTRODUCTION Pulp is defined as soft tissue forming inner structure of tooth and containing nerve and blood vessel , also called as tooth pulp . The primary objective of pulp treatment of an affected tooth is to maintain the integrity and health of oral tissues.

3. PULP THERAPY VITAL PULP THERAPY NON-VITAL PULP THERAPY Apexogenesis Pulpotomy Pulpectomy pulp capping -direct -indirect Apexification Pulpectomy Non-vital Pulpotomy

4. PULP CAPPING Pulp capping is a technique used in dental restoration to prevent the dental pulp from dying after being exposed or nearly exposed during a cavity preparation Maintaining the vitality of the pulp and thus the integrity of the tooth

5. Direct pulp capping Indirect pulp capping

6. DIRECT PULP CAPPING DEFINITION: It is the protection of a pulp exposed by traumatic fracture or in the course of excavating deep dentinal caries . Protection is provided by placing a medicated or non-medicated material in direct contact with the pulp tissues to promote a reparative reaction.

7. RATIONALE: Encouragement of young, healthy pulps to initiate a dentin bridge, thus walling of the exposure site.

8. OBJECTIVES: Preservation of vitality of radicular pulp No post treatment signs and symptoms like swelling ,pain or sensitivity Ensuring the continuity of the normal apexogenesis in immature permanent teeth Pulp healing and tertiary dentin formation should result There should be no pathological change

9. INDICATIONS Accidental pin point exposure of the pulp when excavating deep caries ,less than 1 sq.mm. surrounded by clean dentin [<24 hrs] Traumatic fracture of tooth[<24 hrs] with pin point exposure. Iatrogenic exposure during cavity preparation & crown preparation

10. Asymtomatic teeth Bleed if touched but not excessively and controlled easily with cotton pellet Normal vitality test without tender to percussion No radiographic evidence of peri-radicular pathology Young patients

11. CONTRA-INDICATIONS Large pulp exposure History of spontaneous tooth pain pain at nights Presence of caries surrounding the teeth Excessive tooth mobility Periodontal ligament thickening Intra- radicular radiolucency

12. Excessive bleeding at exposure site Purulent , serous exuade from exposure External or internal resorption Swelling fistula with associated tooth. Root resorption Pulpal calcification

13. TREATMENT CONSIDERATION Debridement: Necrotic and infected dentin chips should be removed else they will invariably pushed into the exposed pulp during last stages of caries removal and impede healing and increase pulpal inflammation.

14. Pulp capping procedure In the first appointment: Anesthesia and apply rubber dam At, the exposure site ,any further manipulation is avoided ;only irrigate with saline or distilled water Bleeding is stopped by applying minimal pressure with cotton pellet

15. Place calcium hydroxide or MTA at exposure .if you use dMTA , then place wet cotton over it Place temporary filling material and recall after 6-8 weeks .

16. Pulp capping procedure In the second appointment : If patient was asymptomatic ; No pain Pulp vitality tests positive No radiographic changes Formation of dentinal bridge on radiograph In that case , remove temporary filling and cotton and replace with final restoration

17. SALIENT FEATURES OF SUCCESSFUL DPC Dentine briding Maintenance of pulp vitality lack of undue sensitivity or pain Minimum pulpal inflammation response Ability of pulp to maintain itself without progressive degeneration Lack of internal resorption and interradicular pathosis

18. Pulp capping agents Calcium hydroxide paste MTA(mineral trioxide aggregate) Isobutyl cyanoacrylate Laser Denaturated albumin

19. CALCIUM HYDROXIDE[ca( O H)2] When calcium hydroxide is applied directly to the pulpal tissue, there is necrosis of the adjacent pulp tissue and inflammation of the contiguous tissue. Compound of similar alkanity cause liquefication necrosis when applied to pulpal tissue The action of calcium hydroxide in the form of dentin bridge to be result of low grade irritation in the underlying pulpal tissue the after application

20. The greatest benefit of ca[0H]2 is the stimulation of reparative dentin bridge due to a high alkanity of ca[OH]2 which leads to enzyme phosphatase being activated releasing of inorganic phosphate from the blood [calcium phosphate] leading to formation of dentinal bridge It also has a anti-bacterial property

21. Isobutyl cyanoacrylate : it is an excellent pulp capping agent because of its haemostatic and bacteriostatic properties Less inflammation than calcium hydroxide Disadvantage: cytotoxic when freshly applied Denaturated albumin: This protein has calcium binding properties .if a pulp is capped with a protein , the protein may became a matrix for calcification , threby increasing the chance of biological obliteration

22. Mineral trioxide aggregate (MTA): it is the ash coloured powder made primarily of fine hydrophillic particles Tricalcium aluminates Tricalcium silicates Silicate oxide Tricalcium oxide and Bismuth oxide When compared with ca(OH)2 ,MTA produced significantly more dentinal bridging in shorter period of time with significantly less inflammation Dentin deposition has began earlier with MTA

23. Disadvantage: 3 to 4 hours is needed for setting of MTA after placement . Procedure:

24. Procedure: It involve placing MTA directly over the exposure site and sealing the tooth temporarily with to allow the tooth to be harden Tooth later re-entered and GIC is permanently sealed over the set MTA . And etched, denin bonding agent and composite resin to prevent future bacterial micro-leakage

25. Advantage over ca( oH )2: Thicker dentinal bridge Less inflammation Less hyperemia Less pulpal necrosis Dentin bridge formation at faster rate

26. FACTORS INFLUENSING PROGNOSIS OF DIRECT PULP CAPPING

27. IS THERE LIMITATIONS FOR DIRECT PULP CAPPING IN PRIMARY TEETH

28. Primary and permanent teeth responds differantly to trauma, bacterial invasion , irritation,medication etc. Reason for it: L ocalisation of infection and inflammation in primary teeth is poorer than in permanent teeth

29. Primary pulp more closer to outer enamel surface and are rapidly infected by caries lesion on abundent Wide apical foramina in primary teeth leads to abundant blood supply which make DPC unfavourable

30. Higher cellular content in primary pulp which might be reponsible for failures caries or pulp capping material may stimulate Undifferatiated mesenchymal cells to differantiate into osteoclasts w hich could lead to internal resorption

31. Internal resorption , calcification ,chronic inflammation and interradicular involvement worsen the success rate of DPC in primary teeth Whereas , Formocresol pulpotomy exhibits higher rates of success than calcium hydroxide pulp capping in primary teeth

32. CONCLUSION Direct pulp capping is a procedure used in asymptomatic teeth with deep caries reaching upto pulp On placing a suitable medicament , it is the best method that maintain pulp vitality and function ,promotes healing ,prevent breakdown of peri-radicular supporting tissues and induce dentin bridge formation in permanent teeth . Pulpotomy is better than pulp capping in primary teeth (mechanically or caries exposure ). Whereas, direct pulp capping can be applied for non carious traumatic exposure in primary teeth

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