Pulp capping and pulp capping agents

SEMINAR

1. PULP CAPPING AND PULP CAPPING AGENTS Presented by KARUNA SHARMA

2. Pulp therapies in primary molars

3. Objectives Esthetics Masticaton Speech Psychology Preservation of the arch space Growth of Skeletal & Dental complex (Barnett,1985) Effects on succedenous tooth (Whine, 1981)

4. Title Indirect Pulp Capping Direct Pulp Capping Pulpotomy Pulpectomy Classification of pulp therapy procedures in primary teeth Conservative procedures Radical procedures Weine.Endodontic therapy 6 th Edition.Mosby Publication.

5. Title Protective liner Indirect Pulp Capping Direct Pulp Capping Pulpotomy Pulpotomy pulpectomy Pulpectomy Classification of pulp therapy procedures in primary teeth Vital pulp therapy for primary teeth diagnosed with a normal pulp or reversible pulpitis Nonvital pulp treatment for primary teeth diagnosed with irreversible pulpitis or necrotic pulp Clinical guidelines on pulp therapy for primary and young permanent molars AAPD 2009

6. Protective liner

7. Protective liner Itota T, Nakabo S, Torii Y, Narukami T, Doi J, Yoshiyama M. Effect of fluoride-releasing liner on demineralized dentin. Quintessence Int 2006;37(4):297-303. Weiner RS, Weiner LK, Kugel G. Teaching the use of bases and liners: A survey of North American dental schools. J Am Dent Assoc 1996;127(11):1640-5.

8. Protective liner Indications In a tooth with a normal pulp, when all caries is removed for a restoration, a protective liner may be placed in the deep areas of the preparation to minimize injury to the pulp, promote pulp tissue healing, and/or minimize postoperative sensitivity.

9. Objectives The placement of a liner in a deep area of the preparation is utilized to preserve the tooth’s vitality, promote pulp tissue healing and tertiary dentin formation, and minimize bacterial microleakage . Adverse post-treatment clinical signs or symptoms such as sensitivity, pain, or swelling should not occur.

10. Pulp Capping

11. Indirect Pulp Capping

12. Indirect Pulp Capping Definition Objectives Mechanism Indications Contraindications Materials Techniques Success of Indirect pulp capping

13. Definition

14. “It is defined as procedure wherein small amount of carious dentin is retained in deep areas of the cavity to avoid pulp exposure, followed by placement of a suitable medicament and restorative material that seals off the carious dentin and encourages pulp recovery” -Ingle Definition John I Ingle Leif K Bakland Endodontics , Fifth Edition

15. “It is defined as application of a suitable medicament over a thin layer of remaining carious dentin(affected dentin), after deep excavation of infected dentin without exposure to the pulp” -Mathewson,1995

16. Objectives (AAPD) Tooth vitality should be preserved Restorative material should seal the involved dentin completely No post-treatment senstivity , pain & swelling No harm to the succedenous tooth

17. Title Mechanism

18. Reparative dentin Highest amount of dentin formed during first month ( Traubman 1967). New dentin formation faster – Primary teeth ↑ than permanent teeth Males > females The rate of reparative dentin formation is 1.4 micron per day.

19. A - Soft necrotic B - Firm, semi soft C -Hard, discolored Kopel , 1976

20. A - B - C - Fusyama , 1979 Infected layer Affected layer

21. Infected Layer Affected layer Highly demineralized Superficial layer Lacking sensation Stained by 0.5% fuschin in propylene glycol Intertubular dentin greatly demineralized Deteriorated collagen fibers Unmineralizable Intermediately demineralised Deeper layer Sensitive Does not stain Partially demineralized Sound collagen cross linkage Remineralizable 21

22. Indications & Contra-indications

23. Indications ( Kopel HM, 1985) John I Ingle Leif K Bakland Endodontics , Fifth Edition

24. Contraindications John I Ingle Leif K Bakland Endodontics , Fifth Edition

25. Techniques

26. Title Techniques Two appointment technique One appointment technique John I Ingle Leif K Bakland Endodontics , Fifth Edition

27. Title Two appointment technique (First sitting ) Carious peripheral dentin should be removed by sharp spoon excavator Stop the excavation as soon as firm resistance of sound dentin is felt Administer local anesthesia and isolate with a rubber dam. Establish cavity outline with a high speed hand piece . Remove the majority of soft , necrotic, infected dentin with a large round bur in a slow speed hand piece without exposing the pulp. . Cover the remaining affected dentin with a hard setting calcium hydroxide dressing . Fill or base the remainder of the cavity with a reinforced ZOE cement and Do not disturb this sealed cavity for 6 to 8 weeks.

28. 1 st Appointment

29. Title Two appointment technique (Second sitting ) Between the appointments history must be negative and temporary restoration should be intact. Bitewing radiographs of the treated tooth should be assessed for the presence of reparative dentin The remaining affected carious dentin should appear dehydrated and " flaky“, The area around the potential exposure should appear whitish and may be soft, this is " predentin ". The cavity preparation should be irrigated and gently dried. Carefully remove all temporary filling material , especially the calcium hydroxide dressing over deep portions of the cavity floor. . Cover the entire floor with a hard setting calcium hydroxide dressing. A base should be placed with a reinforced ZOE or glass ionomer cement, and tooth should receive a final restoration.

30. 2 nd Appointment

31. 1 st Appointment 2 nd Appointment

32. After 1 st Appointment After 2 nd Appointment

33. Protective base Calcium hydroxide Restoration

34. Title Indications Poor patient cooperation Inability to remove carious dentin in the first appointment Disadvantages According to Leng et al (1980) The re-entry and re-excavation may potentially increase the chances of pulp exposure. Two appointment technique

35. Title Two appointment technique Current literature indicates that there is inconclusive evidence that it is necessary to reenter the tooth to remove the residual caries.

36. These investigators suggested that reentry 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. One appointment technique

37. Title One appointment technique Carious peripheral dentin should be removed by sharp spoon excavator Stop the excavation as soon as firm resistance of sound dentin is felt Administer local anesthesia and isolate with a rubber dam. Establish cavity outline with a high speed hand piece . Remove the majority of soft , necrotic, infected dentin with a large round bur in a slow speed hand piece without exposing the pulp. . Cover the remaining affected dentin with a hard setting calcium hydroxide dressing . A base should be placed with a reinforced ZOE or glass ionomer cement, and tooth should receive a final restoration.

38. One Appointment technique

39. Conventional materials ..

40. Title Calcium Hydroxide Zinc oxide Eugenol Materials

41. Title Dentin bonding agents (Falster CA et al 2002) Resin modified glass ionomer ( Farooq 2000) Light cured composites ( Lado & Stanley 1987) Materials

42. Title Materials Light cured composites

43. Title Materials Dentin bonding agents J.J. Marchi . Analysis of Primary Tooth Dentin After Indirect Pulp Capping. Journal of Dentistry for Children-75:3, 2008

44. Title Materials Resin modified glass ionomer J.J. Marchi . Analysis of Primary Tooth Dentin After Indirect Pulp Capping. Journal of Dentistry for Children-75:3, 2008

45. Recent Advancements ..

46. Title New Materials .. Emdogain

47. Title New Materials .. Insulin-like growth factor I

48. Evaluation of Therapy

49. In histological sections 4 histological layers: Carious decalcified dentin Rhythmic layers of irregular reparative dentin Regular tubular dentin Normal pulp with a slight increase in fibrous element.

50. Success of I.P.C

51. Intact restoration Negative history of pain. No radiographic evidence of abnormal root resorption . No radiological evidence of radicular disease. Success of Indirect pulp capping

52. Indirect pulp capping Indirect pulp capping has been shown to have a higher success rate than pulpotomy in long term studies. It also allows for a normal exfoliation time. Therefore, indirect pulp treatment is preferable to a pulpotomy when the pulp is normal or has a diagnosis of reversible pulpitis .

53. Direct Pulp Capping

54. Direct Pulp Capping Definition Studies Objectives Indications Contraindications Materials Techniques Success of direct pulp capping

55. Title “Direct pulp capping is the placement of a biocompatible agent on the healthy pulp tissue that has been inadvertently exposed from caries excavation or traumatic injury.” - Fuks (1988) Definition John I Ingle Leif K Bakland Endodontics , Fifth Edition

56. Title Guidelines (AAPD) Guidelines developed by the American Academy of Pediatric Dentistry (AAPD) recommend that direct pulp capping should be reserved for small mechanical or traumatic exposures in primary teeth.

57. Title Objectives John I Ingle Leif K Bakland Endodontics , Fifth Edition

58. Indications ( Kopel HM, 1985) John I Ingle Leif K Bakland Endodontics , Fifth Edition

59. Contraindications

60. Title Technique It is prudent to remove peripheral masses of carious dentin before beginning the excavation where an exposure may occur. The area should be appropriately irrigated with non irritating solutions such as normal saline to keep the pulp moist. Kalins , Frisbee, Delgado et al DEBRIDEMENT Kopel HM. Cosiderations of Direct pulp capping agents in Primary teeth: A Review. J Dent Children.

61. Title Technique BLEEDING & CLOTTING Hemorrhage at the exposure site can be controlled with cotton pellet pressure. A biocompatible material is placed directly in contact with pulp tissue

62. Title Technique Exposure enlargement Frigoletto noted that small exposures & good blood supply provide the best healing potential. There have been recommendations that the exposure site must be enlarged. ( Cvek & zilberman , 1980) Kopel HM. Considerations of Direct pulp capping agents in Primary teeth: A Review. J Dent Children.

63. Technique

64. Title

65. Protective base Calcium hydroxide Restoration

66. Beveridge and Brown demonstrated that cold stimuli could decrease intrapulpal pressure by 28 mm Hg. This was considered to be a direct result of the vasoconstriction of the pulpal blood vessels in response to the cold stimulus.

67. In the hydrodynamic theory, Brannstrom postulated that the capillary action of fluid in the dentinal tubules resulted in the transmission of pain between the tubules and vital pulp tissue in the more apical portions of the pulp chamber and root canal system,even though there was necrotic tissue or hemorrhage in the intervening area.

68. This would seem to account for the sensitivity to tactile stimuli and changes in temperature, even though a large portion of the coronal pulp might be necrotic. The coefficient of expansion of dentin fluid is estimated to be approximately ten times greater than that of the tubule wall. Cooling of dentin would result in a contraction of the tubules’ contents with a resultant flow of the fluid away from the pulpal tissues.

69. During acute inflammation, there is an accumulation of polymorphonuclear neutrophils and dilatation of capillaries which allows plasma proteins to escape into connective tissue spaces. The resultant edema could cause pressure on the pulpal and/or periapical nerve fibers and elicit a painful response. Van Hassell found that in human teeth the intrapulpal pressure could increase an average of 15 mm Hg in an area of local inflammation.

70. The application of a cold stimulus could, in turn, result in contraction of the dentinal fluid and decrease the pressure within the pulp, yielding a rapid transient reduction of pain.

71. Pulp capping agents ..

72. INTRODUCTION Historically, the first pulp capping procedure was performed in 1756, by the Phillip pfaff , who packed a small piece of gold over an exposed vital pulp to promote healing. However, the success of the pulp capping procedure greatly depends upon the circumstances under which it is performed and the prognosis depends upon the age, type, site and size of pulp exposure.

73. PROPERTIES Stimulate reparative dentin formation Maintain pulpal vitality Release fluoride to prevent secondary caries Bactericidal or bacteriostatic Adhere to dentin Adhere to restorative material Resist forces during restoration placement and during the life of restoration. Sterile Radiopaque Provide bacterial seal

74. PULP CAPPING AGENTS Ca (OH)2(1960’s) Zinc oxide eugenol cement (1960-70’s) Corticosteroids and antibiotics (1970’s) Polycarboxylate cement (1970’s) Inert materials (1970’s)(Isobutyl cyanoacrylate and Tri calcium phosphate ceramic) 6. Collagen(1980)

75. PULP CAPPING AGENTS 7. Bonding agents(1995) 4-META-MMA-TBB adhesives and hybridizing dentin bonding agents 8.Lasers (1995-2010) CO2 Nd : YAG 9.Mineral trioxide aggregate (1996-2008) 10.Growthfactors(1900-2007)Bone Morphogenic Protein (BMP 2,4,7) 11.Emdogain(2001-2011)

76. Calcium Hyroxide Calcium hydroxide (Ca (OH) 2 ) was introduced to the dental profession in 1921 by Hermann and has been considered the “gold standard” of direct pulp capping materials for several decades, against which new materials should be, tested

77. MECHANISM OF ACTION OF CALCIUM HYDROXIDE

78. Calcium hydroxide has the unique potential to induce mineralization even in tissues that have not been programmed to mineralize.

79. Sciaky and Pisanti in 1960 observed that calcium hydroxide do not become incorporated in the mineralized repaired tissue, which derives its mineral content solely from the dental pulp,through blood supply.

80. Zinc Oxide Eugenol (ZOE) Cement Tronstad and Mjör stated that ZOE cement is more beneficial for inflamed and exposed pulp. However in the literature Glass and Zander , Hembree and Andrews, Watts, Holland et al., found that ZOE, in direct contact with the pulp tissue, produced chronic inflammation, lack of calcific barrier, and end result is necrosis .

81. Title These agents include Neomycin and Hydrocortisone, Cleocin , Cortisone, Ledermix , Penicillin and Keflin . Corticosteroids & Antibiotics

82. Title Reduces pulp inflammation Vanocmycin + Ca(OH)2 stimulated a more regular reparative dentin bridge. Corticosteroids & Antibiotics

83. Title Polycarboxylate cements Kopel HM. Cosiderations of Direct pulp capping agents in Primary teeth: A Review. J Dent Children. bonds to the tooth structure McWalter , G et al., found that it lacks an antibacterial effect and calcific bridge formation .

84. Title Hybridizing bonding agents J.J. Marchi . Analysis of Primary Tooth Dentin After Indirect Pulp Capping. Journal of Dentistry for Children-75:3, 2008

85. Title Miyakoshi et al have shown the effectiveness of 4-META-MMA-TBB in obtaining an effective biologic seal. Pulp showed reparative dentin deposition without pulp pathosis. Heitman and Unterbrink studied a GLUTARALDEHYDE containing Dentin bonding agent. All teeth were vital after 6 month post operative period. Hybridizing bonding agents J.J. Marchi . Analysis of Primary Tooth Dentin After Indirect Pulp Capping. Journal of Dentistry for Children-75:3, 2008

86. Title Have cytotoxic effect Absence of calcific bridge formation In vivo studies have demonstrated that the application of an adhesive resin directly onto a site of pulp exposure, or to a thin layer of dentin (less than 0.5 mm), causes dilatation and congestion of blood vessels as well as chronic inflammatory pulpal response Hybridizing bonding agents J.J. Marchi . Analysis of Primary Tooth Dentin After Indirect Pulp Capping. Journal of Dentistry for Children-75:3, 2008

87. Title Collagen Fibers Carmichael DJ reported that collagen fibers are less irritating than Ca (OH)2 and promotes mineralisation but does not help in thick dentin bridge formation Fuks et al found dentin bridge after 2 months in 73% cases.

88. Title Materials like Iso -butyl Cyanoacrylate and Tri- Calcium Phosphate ceramic have been used as pulp capping agents. Reduces pulp inflammation Stimulate dentin bridge formation Inert Materials

89. Title None of these materials have been promoted to the dental profession as a viable technique Inert Materials

90. Title M.T.A Bone Morphogenic Proteins (B.M.P) Cell Inductive Agents

91. MTA (Mineral Trioxide Aggregate) Torabinejad centered his research in the development of MTA at the loma linda university, California in 1995.

92. Composition Tricalcium silicate Dicalcium silicate Tricalcium aluminate Tetracalcium aluminoferrite Bismuth oxide Traces of silica

93. exists in both white and gray form difference between the two forms is thelack of iron in the tetracalcium aluminoferrite in the white version. Can be used for root end fillings perforation repair,pulpotomy and apexification treatment.

94. Title MTA (Mineral Trioxide Aggregate) Pitts et al (1996) & Sluyk et al (1998) It allows some micro leakage but superior sealing ability to amalgam, ZnOE / IRM - superior to CH in animal models ( Torabinejab M et al, 1999 & Junn D.J et al, 1998) Cell Inductive Agents

95. Title Title Major Advantages : Excellent sealing ability Good Compressive Strength Good Biocompatibility Pitt Ford et al documented Superior bridge formation and preservation of pulp vitality with MTA when compared with Ca(OH) 2 Cell Inductive Agents

96. Title Title Major Advantages : has significant antimicrobial property Hydrophilic Is alkaline (12.5) and may induce dentinogenesis . The presence of blood has little impact on the degree of leakage of MTA. Thus it can be used as an alternative to calcium hydroxide in both direct pulp capping and pulpotomy preocedures . Cell Inductive Agents

97. Title Title Bone morphogenic protein (BMP) BMP belongs to super family transforming growth factor beta (TGF-b). - TGF b is a potent modulator of tissue repair in different situations. BMP-2, 4, and 7 plays a role in the differentiation of adult pulp cells into odontoblasts during pulpal healing. Cell Inductive Agents Bo Kopel HM. Cosiderations of Direct pulp capping agents in Primary teeth: A Review. J Dent Children.

98. Title Title - Urist (1965), observed demineralized bone matrix could stimulate new bone formation when implanted to ectopic sites (muscles) demineralized dentin – from both bone & dentin - Soren J et al (1997), dentin formation by recombinant human osteogenic protien-1. Cell Inductive Agents Bo Kopel HM. Cosiderations of Direct pulp capping agents in Primary teeth: A Review. J Dent Children.

99. Recombinant Insulin Like Growth Factor-I Lovschall H, et al., evaluated recombinant insulin like growth factor-I ( rhIGF -I) in rat molars and concluded that dentin bridge formation was equal to dycal after 28 days. Title Title Cell Inductive Agents Bo

100. Title Title Emdogain

101. EMD is enamel matrix derivative secreted from Hertwig’s epithelial root sheath during porcine tooth development. It is an important regulator of enamel mineralization and plays an important role during periodontal tissue formation.

102. Title Title New Materials .. Emdogain “ Amelogenin ” & “ Amelin ” Stimulates dental stem cells for regeneration of periodontium Rangel AG et al. Direct Pulp capping in Primary Molars with Enamel Matrix derivative. JCPD 2009.34(1).9-12.

103. It stimulates the regeneration of acellular cementum , periodontal ligaments, and alveolar bone. Nakamura Y et al., concluded that amount of hard tissue formed in EMD treated teeth was more than twice that of the calcium hydroxide treated control teeth

104. Al- Hezaimi K evaluated Calcium hydroxide, ProRoot White MTA and white Portland cement after EMD application on the exposed pulp. MTA produced a better quality reparative hard tissue response with the adjunctive use of EMD compared with calcium hydroxide

105. Melcer et al., suggested between the years 1985 and 1987 that the carbon dioxide (CO2) (1W) laser used for direct pulp capping . Yasuda Y, et al., did a study to examine the effect of CO2 laser irradiation on mineralization in dental pulp cells in rats and the results suggested that CO2 laser irradiation stimulated mineralization in dental pulp cells . Laser

106. Neodymium-doped yttrium- aluminium -garnet laser emits an infrared beam at a wavelength of 1064nm can be of therapeutic benefit for direct pulp capping and pulpotomy in clinical practice

107. Title Title Orban’s Oral Histology & Embryology 11th Edition. Grossman’s Endodontic Practice twelfth edition Text book of pediatric dentistry Nikhil Marwah 2 nd edition Guidelines on pulp therapy for primary and immature permanent teeth AAPD Antonio Nancy.Tencate’s Oral Histology.6 th Edition. Kopel HM. Cosiderations of Direct pulp capping agents in Primary teeth: A Review. J Dent Children. Rangel AG et al. Direct Pulp capping in Primary Molars with Enamel Matrix derivative. JCPD 2009.34(1).9-12. John I Ingle Leif K Bakland Endodontics , Fifth Edition References

108. Thank You