1. Direct Pulp Capping:
A recent update
Lebanese University –School of Dentistry
Department of Restorative and Aesthetic Dentistry
Dr S.Artine
Dr P.Hajjar
Dr S. Mouawad

2. I- What is direct pulp capping?
Placement of a protective dressing directly over the
exposed pulp
Pulp exposed
2

3. Why?
Saves the tooth and
Preserves vitality
Conservative treatment
No need for RCT
3

4. o Healing/ Repair.
o Pulp’s vitality and function.
o Normal responsiveness to
electrical and thermal pulp tests.
o Preventing breakdown of the
peri-radicular supporting tissue.
oFormation of secondary dentine.
4

5. 1930,
Hermann
1921,
Dätwyler
1826,
Koecker
1756,
Pfaff
5

6. II- Indications of direct pulp capping
•Immature permanent teeth or
mature permanent teeth with
simple restorative needs.
6

7. •Recent traumatic (<24 h)/Mechanical pulp
exposure
Small pinpoint pulp exposure=1mm
7

8. •Little or no bleeding at the exposure site
8

9. •NO PULP
VITALITY
9

10. •No pulp calcification
10

11. •Adequate coronal restoration can be made
11

12. III-Contraindications
•Systematic diseases: diabetes, cancer…
12

13. •primary teeth root resorption
•Inflammatory signs/ symptoms 13

14. •Pre-operative
tooth sensitivity
14

15. •Large
pulp exposures
•Uncontrolled
bleeding
15

16. •Non-restorable tooth
or restorable with low
prognostic
Dentin Bridge
16

17. IV- Pulp capping materials
•Calcium Hydroxide Ca(OH)2
•Mineral Trioxide Aggregate MTA
•Tri-calcium phosphate
•Bioaggregate
•Biodentine
•Bonding Systems
17

18. Calcium hydroxide Ca(OH)2:
•The most common direct
pulp-capping agent
•Antibacterial and
disinfects the superficial
pulp
•High pH (about 12.5)
Pure Calcium
hydroxide
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19. How does Ca(OH)2 work??
•Liquefaction necrosis of the superficial pulp
•Neutralization of toxicity in deeper layers
•Coagulative necrosis…Irritation of adjacent
pulp
•Minor inflammation response… Hard tissue
barrier
19

20. Properties:
•Pure calcium hydroxide are more
caustic than Hard-setting calcium
hydroxide pastes (Dycal, Life,…)
but both have been shown to
initiate the same type of healing
20

21. • Dentin bridges beneath calcium
hydroxide pulp caps contain ‘tunnel
defects’, therefore an additional
base material is necessary to seal the
exposed pulp from the external
environment.
•Calcium hydroxide materials tend to soften, disintegrate,
and dissolve over time.
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22. Mineral Trioxide Aggregate or MTA:
ProRoot
To seal communications between
the root canal system and the
external tooth surface at all
levels and recently indicated in
pulp treatment as direct pulp
capping.
Dr M.Torabinejad
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23. Composition:
•Tricalcium silicate
•Tricalcium aluminate
•Tricalcium oxide
•Silicate oxide
Mixed with sterile water in a 3:1 powder-to-liquid ratio,
MTA sets in 5 minutes
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24. Application of MTA
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25. Properties:
•Low or no solubility
•PH value10.2 after mixing and rises to 12.5 after 3 hours
•Antibacterial effect
•Induces pulpal cell proliferation
•Stimulation of mineralized tissue formation
(Mineral Trioxide Aggregate: A Comprehensive LiteratureReview—Part I: Chemical, Physical, and Antibacteria lProperties) 25
(Direct pulp capping with mineral trioxide aggregateJ Am Dent Assoc 2008;139;305-315)
(MTA AND CALCIUM HYDROXIDE FOR PULP CAPPINGJ Appl Oral Sci 2005; 13(2): 126-30)

26. How does MTA work??
Process not yet known
Tri-calcium oxide + tissue fluids = calcium hydroxide
Hard-tissue formation
26

27. MTA v/s calcium hydroxide
•Rapid cell growth promotion in vitro
•Greater ability to maintain the integrity of pulp tissue
•Thicker dentinal bridge, less inflammation, less
hyperemia and less pulpal necrosis
•Induce the formation of a dentin bridge at a faster rate
•High ability to resist the penetration of microorganisms
•Limited antibacterial effect
27
(Mineral trioxide aggregate pulpotomies A case series outcomes assessment J Am Dent Assoc 2006;137;610-618)

28. Tri-calcium phosphate:
- Bone regeneration procedures (promotes effects on
hard tissue formation by osteoblasts)
- Studies (by Heller) showed that dentinal bridge
formation does take place, by direct apposition, on the
pulpal wall
The bridge:
•Contiguous
•Thick
•Minimal pulpal inflammation
•Odontoblasts directly under and in contact with the
bridge
28
Use of a Resorbable Ceramic (SYNTHOS) in Direct Pulp-Capping Driskell, T., Heller, A., and Koenigs, J., The Ohio State
University,Columbus 1974

29. Bio-Aggregate
Bio-Aggregate is a root canal
repair material composed of
bio-ceramic nano-particles
Indicated as:
• Repair of Root Perforation
• Repair of Root Resorption
• Apexification
• Pulp Capping
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30. Pure white powder and liquid mixed together to form
a thick paste-like mixture.
30

31. MTA and Bio-Aggregate show
similar chemical composition with
some differences
VS
Tantalum oxide Bismuth oxide
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32. Biodentine™ :
Active Biosilicate
Technology™ /calcium
Silicate based cement
Dentin substitute from Septodont Saint
Maur-des Fossés, France
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33. Indications:
•Endodontic indications (repair of perforations or
resorptions, apexification, root-end filling)
•Permanent dentine substitute and temporary enamel
substitute
•Restoration of deep or large crown carious lesions
•Direct pulp capping in adults presenting healthy pulp
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34. Formulation:
Powder
Tri-calcium Silicate (C3S) Main core material
Di-calcium Silicate (C2S) Second core material
Calcium Carbonate and Oxide Filler
Iron Oxide Shade
Zirconium Oxide Radiopacifier
Liquid
Calcium chloride Accelerator
Hydrosoluble polymer Water reducing agent
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35. Clinical Case
After 3 months: Final filling
35
BIODENTINE™ A NEW BIOACTIVE CEMENT FOR DIRECT PULP CAPPING Till Dammaschke, assistant
professor, DDM Department of Operative Dentistry Waldeyerstr. 30 48149 Münster Germany

36. Other:
Bonding systems =
Sealing potential of resin adhesive systems
direct pulp capping
36

37. Resin adhesives Vs calcium hydroxide
•Less porous dentinal bridges = Better seal against bacterial
leakage
•Less pulpal inflammation
•Less successful (Pameijer and Stanley: ‘disastrous effects’
causing hemorrhage that was difficult to control)
•Less success rates with inflamed pulps (lack the inherent
haemostatic and bactericidal properties)
37

38. V- Biocompatibility & Cytotoxicity of pulp
capping materials
CH
•Stimulating sclerotic and reparative dentin formation due to
release some proteins and growth factors
•Protecting the pulp against thermal stimuli and antibacterial
action
•Inducing pulp tissue to form a mineralized barrier
•Biological and therapeutic potential (Material of choice)
38

39. MTA
•Abedi et al. (1996) MTA: less inflammation
•Pitt Ford et al. (1996): dentine bridge formation in all pulps
capped with MTA and no inflammation except in one sample
•MTA: excellent sealing ability (Torabinejad et al. 1993, 1994,
Bates et al. 1996, Fischer et al. 1998, Wu et al.1998)
• Excellent biocompatibility (Kettering & Torabinejad1995,
Torabinejad et al.1997, 1998, Holland et al. 1999, Mitchell et al.
1999, Keiser et al. 2000). Supposedly due to CH and
Hydroxyapatite formation
39

40. VI- Techniques of direct pulp capping
1- Anesthesia
2- Rubber dam
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41. 3- Chlorhexidine solution
4- Rinse with anesthetic or sterile saline
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42. 5- sterile cotton
pellet to control
bleeding
6-Mix capping agent
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43. 7- Apply to exposure site
8- Base/liner then restore
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44. 44

45. VII- Temporary or Permanent Filling?
What’s the best choice?
A permanent restoration seals the margin more
effectively than does a temporary restoration, thus
preventing or reducing the microleakage.
45
(Ahmad S. Al-Hiyasat, Kefah M. Barrieshi-Nusair,Mohammad A. Al-Omari: The radiographic outcomes of direct pulp-capping
procedures performed by dental students A retrospective study)

46. The best Permanent filling process consists of
covering the pulp capping material with a RMGIC
followed by a hermetic composite resin
restoration to prevent bacterial leakage and
recontamination of the exposed area.
46

47. VIII- Prognosis of direct pulp capping:
Success rates range from 13% to 98% in one to 10 years retrospective
studies:
• Armstrong and Hoffman: 97.8% success rate after 1.5 years.
• Fitzgerald and Heys: 79% success rate after one year.
• Haskell and colleagues: success rate of 87.2% after five years.
• Barthel and colleagues: success rate of 37% after five years and 13%
after 10 years for 123 pulp-capping procedures performed by dental
students.
• Baume and Holz: The operator’s skill seems to be one factor that
influences the outcome of pulp-capping procedures
47
(Baume LJ, Holz J. Long term clinical assessment of direct pulp capping. Int Dent J 1981;31(4):251-60)

48. Not Significant Significant
 Age
 Type of Exposure
 Sex
 Type of Restoration
 Tooth Location
 Class of Restoration
 Tooth Position
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49. Age of patient
Sex of patient
Tooth location
Tooth position
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50. 1. Type of Exposure:
Mechanical exposure: Direct pulp capping + permanent restoration
to conserve the vital pulp.
Carious exposure: Avoid Pulp capping & opt for endodontic
therapy.
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51. 2. Type of Restoration:
An hermetic seal against bacterial infiltration is a must to guarantee the success
of the pulp treatment.
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52. 3. Class of Restoration:
The prevention or reduction in the microleakage reflects the higher success rate of
pulp capping in Class I restorations relative to that in the Class II, III, IV and V
and MOD restorations
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53. Periapical radiolucency and need for RCT
Need for extraction Failure
Good to know: time devoted to the teaching of vital-pulp
therapy to undergraduate students < teaching of formal
endodontic treatments 53

54. 1. Calcium Hydroxide:
•At the 7th day, the pulp tissue capped with Calcium
Hydroxide exhibited:
o Odontoblast-like cells organized underneath
o A zone of coagulation necrosis
• Pulp repair and apparent complete dentin bridge
formation after 60 days.
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55. 2. MTA® (Mineral Trioxide Aggregate):
• A comparative study of WMTA (White MTA) and
Calcium Hydroxide concluded that at the 136th recall
day:
o 23 teeth of 23 Capped with WMTA, were clinically
diagnosed as successful
100%
as well as
o 22 teeth of 23 of the Calcium Hydroxide group.
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(Iwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, Jeffries S. Clinical and histological evaluation of white ProRoot MTA
in direct pulp capping. Am J Dent. 2006;19:85-90)

56. 3. Biodentine® (Tri-Calcium Silicate)
Applied in 116 patients with at least one year follow-up. It’s
very well tolerated and can be used as cavity lining with a
permanent composite restoration.
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57. Success Rates
92.2% Mechanical
1. Type of Exposure
33.3% Carious
80.8% Permanent
2. Type of Restoration
47.3% Temporary
83.8% Cl I O
3.Class of Restoration
28.6% Cl II MOD
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58. IX- New perspectives and future trends:
• Other innovative technical advances include the use of:
• Lasers
• Ozone technology
• Bioactive agents
that induce and stimulate pulpal defenses
•Gene-enhanced Tissue Engineering
•Dental Pulp Stem Cell Therapy:
o Potential to improve on conventional pulp-capping with calcium
hydroxide or other artificial materials.
o Ex vivo cell therapy may have an advantage and might result in
copious amounts of reparative dentin formation.
o Skin fibroblasts transduced with BMP7-adenovirus induce reparative
dentin formation (Rutherford, 2001)
o Techniques have to be established and optimized before cell therapy
with BMP2 can become a clinical reality for caries and endodontic
therapy.
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59. THANK
YOU
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