Deep caries management /certified fixed orthodontic courses by Indian dental academy

MANAGEMENT
OF
DEEP CARIES

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com

Three vital techniques:
• Indirect pulp capping

• Direct pulp capping

• Coronal pulpotomy


. Vital pulp therapy aims to treat reversible pulpal injury
and maintain pulp vitality and function. It includes two
therapeutic approaches: indirect pulp capping in cases of
deep dentinal cavities and direct pulp
capping/pulpotomy in cases of pulp exposures.
Successful outcome for vital pulp therapy is very
dependent on the type and location of injury, age of the
tooth, treatment modality (capping material) and
integrity of the cavity restoration
[ Mjör, 2002; Horsted-Bindslev and Bergenholtz,2003].


 Whilst the biological processes
directed by the treatment strategy have
received much attention during the last
four decades, controversy still exists
regarding the biological basis of the
mechanism by which the capping
material regulates healing and repair of
the pulp in vital pulp therapy

 [Nyborg, 1955; Fitzgerald, 1979; Cox et al., 1985; Horsted et al.,
1985; Schroder, 1985; Cvek et al.,1987; Stanley, 1989; Mjör et al.,
1991]

INDIRECT
PLUP CAPPING


 Indirect pulp capping sometimes called
the rest treatment.

 It is a procedure in which only the gross caries is
removed from the lesion and the cavity is sealed for a
time with a bactericidal agent.

 This procedure is more successful in
permanent teeth as bacterial contamination
is less in infected dentin compare to
primary dentition.

☻IPC is based on the theory that a zone of
affected demineralised dentin exist between the
outer infected layer of the dentin and pulp.
Affected dentin is an inner layer of uninfected carious
dentin which is vital and sensitive, not infused with bacteria, and
may be somewhat softened and demineralized, but which is
capable of remineralizing

☻ Removal of infected dentin and effectively sealing
them off from their source of substrate a
favorable environment is created.
Infected dentin is an outer layer of infected carious dentin
which is soft, discolored, nonvital, nonsensitive and cannot
remineralize.

Following which firstly remineralisation of
remaining decalcified dentin will occur and
secondly secondary dentin pulpal to carious
lesion is initiated.

 Secondary deposits contain less calcium, phosphorous,
and collagenous matrix per unit volume than the primary
dentine.
 Secondary dentin is less mineralized


What causes secondary dentin?
Generally, the answer is irritation.
Secondary dentin is dentin that is formed throughout
the pulp chamber and pulp canal from the time of
eruption
It's sort of like callous formation on skin.
If the irritation is serious enough inflammation occurs.
If the case ,secondary dentin is laid down by
odontoblasts in the layer of the pulp immediately
adjacent to the dentin lining the canal or pulp chamber.
Sources of that irritation are usually heat, cold, occlusal
pressures and the aging process

Indications

Symptom free

No radiological evidence
of pathosis

Pain history – no extremes. May be
associated with eating, sometimes dull

Clinical examination.
 No gingival Pathological condition
 No mobility and large carious Lesion.

Radiographic examination
 Probable carious exposure
 Normal periodontal tissue

Procedure
The tooth is anesthetized and isolated with rubber dam.

Gross caries is removed using large round bur or sharp
spoon excavator.

 High speed rotary instrumentation is
contraindicated as tactile sensation is lost.
 For judging the affected dentin and infected
dentin the colour difference between the two
is not a reliable index.

Caries overlying the pulp alone is left. All caries at
DEJ is removed. Undermined enamel can be left as it
helps in retention of temporary restoration.
↓
The base of cavity dried and bactericidal dressing of
calcium hydroxide or Zinc Oxide eugenol placed.
Both the materials will contribute insulating protection to
the pulp at a thickness of 5 mm or more and provide pulpal
protection from pressure of amalgam condensation forces
at a thickness of 1 to 1.5mm or more.

If pulp exposure is suspected CH is the choice. A
radiography is taken

 This is followed by interim dressing of thick
ZOE or Zincpolycarboxylate or amalgam.

 Preformed stainless steel band can support
interim restoration.
 Patient is recalled after 4-6 weeks if capping
materials is CH or 6 to 8 weeks if it is ZOE.
 The radiographic evidence is evident only after
10 to 12 weeks though rehardening occurs in 6
to 8 weeks.

Caries-Detector Dyes
How Accurate and Useful Are They?
Commercially available caries-detector dyes are purported to aid the dentist in differentiation of infected dentin, yet
research has established that these dyes are not specific for infected dentin.

They are non-specific protein dyes that stain the organic
matrix of less mineralized dentin, including normal
circumpulpal dentin and sound dentin in the area of the
amelo-dentinal junction.

A considerable body of evidence indicates that
conventional tactile and optical criteria provide
satisfactory assessment of caries status during cavity
preparation. There is reason for concern that subsequent
use of a caries-detector dye would result in unnecessary
removal of sound tooth structure. operative treatment.

The use of caries-detector dyes has also been suggested as a
diagnostic aid for occlusal caries.

Although diagnosis of carious dentin beneath apparently
sound enamel can be challenging, there is a lack of
substantive evidence supporting the use of dyes for this
purpose and false positives are a significant concern.

Careful visual inspection combined with bitewing
radiographic diagnosis has been shown to be the most
reliable diagnostic method for the presence of infected
dentin requiring

Commercial products
 SNOOP(Pulpdent) is a propylene glycol based caries
detector
 Carisolv(Omega trading) is a chemo-
mechanical method for non-invasive caries removal.
Τhe method comprises two parts :
1) a two component gel designed to soften carious
dentine and
2) the special hand instruments needed to remove this
softened tissue
without damaging adjacent healthy tissue

 Composition of
Carisolv Gel :
Sodium hypochlorite
solution 0,5%, ALT-
K, glutamic acid,
leucine, lysine,
sodium chloride,
erythrocin (E127B),
CMC 200-800 cps,
purified water,
sodium hydroxide,
pH 11. www.indiandentalacademy.com

± ReEntry
The tooth is anacsthetized, CH and the
remaining caries removed and may reveal a
sound base without exposure. The colour will
have changed from deep red rose to light gray or
brown.
↓
A liner material containing CH is applied
and cavity prepared and restored in
conventional way.

 The rate of reparative dentin deposition has been
shown by Stanley et al (1996) to average 1.4µm /
day following cavity preparation. It is fastest in
the first month.
 Controversy exist concerning the basing
materials. One group supports that CH must be
in direct contact with pulpal tissue to form
reparative dentin.
 Another group says that CH is soluble and hence
is transmitted by the fluid in the dentinal tubules
to the pulp & form reparative dentin.

MATERIALS USED
 Calcium Hydroxide
 Zinc Oxide Eugenol

 Glass ionomer


Calcium Hydroxide

 It is used for vital pulp therapy (direct and indirect pulp
capping, pulpotomy apexogenesis) root amputation and
apexification.
 It serves as blocking patent dentin tubules, neutralizing
the attack of inorganic and their leaching products from
certain cements.
 The caustic action associated with its high PH (11-13)
induces superficial necrosis and is assumed to be
responsible for reparative dentin formation.


 Sowden (1956) had reported the
recalcification of dentin
following dressing with calcium
hydroxide in IPC

 Law and Lewis (1961) is also
worked with calcium Hydroxide
and reported success.

Cacium Hydroxide, used in IPC appears to arrest
the lesion (Smirrow – 1989) sterilize the residual
deep layer of caries (King J.B., Crow ford J.J 1965)
remineralise the caries dentin (Kerkove et al 1965 & Law D.B.
et al – 1961).

The main CH products available now are
Pulpdent

Dycal

Hydrex.


Pulpdent is 55% CH suspended in
aqueous ethyl cellulose solution.
Pulpdent is most capable for early
bridge formation as found out by Berk
& Stanley (1979)
The bridge formed is readily visualized
radiographically as degenerated
necrotic zone separates the CH layer
from bridge.

Dycal was
introduced in 1962
and its is 2 paste
CH compound.

Base containing TiO2 in glycol salicylate with a
pigment and catalyst containing CH and Zinc
oxide ethyl toluene sulfonamide.
The calcified bridge forms directly against the CH
hence difficult to observe radiographically.

 Hydrex is a 2 paste – non essential oil, CH, Ba
S04, Ti2 and a selected lesion.

 Bridging occurs at CH pulp interface with out
induction of visible coagulated necrotic layer
because of lower PH


 Sufficient Hydroxyl concentration still exist for
stimulating the differentiation of odontoblast to
produce high quality of dentinal bridge.
 Sciaky & Pisanti (1960) performed
autoradiography with Ca to demonstrate that
the Ca to form to bride does not come from
CH dressing as first proposed by Zander (1939)
but is probably derived from pulp tissue.


Calcitonin in direct and indirect
pulp capping
 Calcitonin, the hormone produced by C cells of
the thyroid playing a great role in calcium
homeostasis, was used for direct and indirect
pulp capping .
 The usefulness of calcitonin for biological
treatment of pulp is unquestionable.

Czas Stomatol. 1990 Aug;43(8):441-6

 Jn 1963 Sawusch (1963) reported
Dycal was slightly superior to other as
it adapted to cavity wall with fairly
tight seal and had characteristic of
sedative.
 Sometimes particles of capping material may
enter the vascular channels and travel as emboli
and gets lodged deeper in pulp tissue causing
perivasular foci of coagulation necrosis.
 If too many emboli phenomenon occur the foci
may coalesce and cause destruction of pulp.

Zinc Oxide Eugenol
 The unmodified ZOE have uncalcined ZNO
small amount of Zinc stearate.
 Zinc acetate and rosin. Eugenol is 85%
(Eugenol – 4 ally 1 – 2 methoxy phenol).


 Cavit a modified form of ZOE, has been
suggested in IPC because of its good sealing
capability but its strength is half of ZOE.
 Because of water absorption it created a negative
pressure which caused odontoblast to be
aspirated into dentinal tubules and caused pain.
 Hence Cavit should be spatulated with H2O or
cavity should be moistened with eugenol prior
insertion.

Glass ionomer cements
In general, glass ionomer cements are
classified into three main categories:
Conventional- first introduced in 1972 by
Wilson and Kent

Metal-reinforced- 1977.

Resin-modified -
www.indiandentalacademy.com 1992

 Glass ionomer cement caused a greater
inflammatory response than zinc-oxide eugenol
cement, the inflammation resolved
spontaneously with no increase in reparative
dentin formation
 In an in vitro study, freshly mixed conventional
glass ionomer cement was found to be cytotoxic,
but the set cement had no effect on cell cultures

 More recently, Snugs and others have even
demonstrated dentin bridging in monkey teeth
where mechanical exposures in otherwise
healthy pulps were capped with a glass ionomer
liner.

 Therefore, lining is normally not necessary under
conventional glass ionomer restorations when
there is no pulpal exposure.
 Mount G. Making the most of glass ionomer cements. Dent
Update 1991; 18:276-9.

 Concern has been raised regarding the biocompatibility
of resin-modified materials since they contain
unsaturated groups. A cell culture study revealed poor
biocompatibility of a resin-modified liner.
 In contrast, Cox and others showed that a resin-
modified glass ionomer cement did not impair pulp
healing when placed on exposed pulps.
 As a result of this uncertainty, use of resin-modified
materials in deep unlined cavities is probably not
advisable.
 Sidhu SK, Watson TF. Resin-modified glass ionomer materials. A status
report for the American Journal of Dentistry. Am J Dent 1995; 8:59-67 .


DIRECT PULP CAPPING


 Researchers have demonstrated that exposed
pulps will heal and form reparative dentin. It is
realized now that the variable prognosis of vital
pulp capping is predominately a restorative issue.
 Vital pulp capping is the dressing of an exposed
pulp with the aim of maintaining pulp vitality
 DPC involves the application of a medicament
or dressing to exposed pulp in an attempt to
preserve the vitality.
 The criteria for success is formation of dentin
bridge (unbroken)

 Throughout the life of a tooth, vital pulp tissue
contributes to the production of secondary
dentin, peritubular dentin (sclerosis) and
reparative dentin in response to biologic and
pathologic stimuli.
 The pulp tissue , with its circulation extending
into the tubular dentin , keeps the dentin moist,
which in turn ensures that the dentin maintains
its resilience and toughness.


Major advances in the practice of vital pulp capping
have been made, and the emphasis has shifted
from the "doomed organ" concept of an exposed
pulp to one of hope and recovery.

Long-term assessments of vital pulp caps with
calcium hydroxide have shown very high success
rates.

Stanley HR. Pulp capping: conserving the dental pulp , can it
be done? Is it worth it? Oral Surg Oral Med Oral Pathol
1989; 68:628-39.

Studies have demonstrated that the
exposed pulp possesses an inherent
capacity for healing through cell
reorganization and bridge formation
when a proper biologic seal is provided
and maintained against leakage of oral
contaminants.
. Stanley HR. Pulp capping: conserving the dental pulp , can it be done? Is it worth it? Oral Surg
Oral Med Oral Pathol 1989; 68:628-39.
. Cox CF. Biocompatability of dental materials in the absence of bacterial infection. Oper Dent
1987; 12:146-52.
Cox CF. Microleakage related to restorative procedures. Proceedings of the Finnish Dental
Society; 1992.
. Baume U, Holz J. Long term clinical assessment of direct pulp capping. Int Dent J 1981; 31:251-
60.

Direct pulp capping should be used only on a
vital pulp that has been accidentally injured and
shows no other symptoms.

Direct pulp capping should not be performed on
a pulp that has been exposed as a result of
penetrating caries.

A successful pulp cap has a vital pulp and a
dentin bridge within 75 to 90 days.

Indication
1. Absence of history of pain

2. The exposure is small less than( 5mrn
in diameter).
If the exposure is a result of operators’ error (mechanical plup
exposure) DPC is more successful.
Carious pulpal exposure has lesser success because of presence
of microorganism.


No observable hemorrhage or the hemorrhage from
exposure site is easily controlled.

It is also important in control any excessive oozing of
serum of plasma that occupies, fills or create a space is
subjected to secondary infection which can lead to loss
of vitality.

The excessive blood clot or thick fibropurulent
membrane favours organization and differentiation of
fibroblast & odontoblast to create ectopic reparative
dentin formation i.e. in the cavity preparation rather
that exposure site.

Exposure occurred in clean
uncontaminated field hence the importance
of rubber dam.
Invasion of pulp relatively atraumatic with
minimal physical irritation to pulp tissue.
Dentin at periphery is repairable.
Exposure site not at a constricted or
potentially constricting area in pulp
chamber or root canal system.

 DPC has higher rate of failure in primary
dentition as they have faster response to caries
and resultant pulpal inflammation is faster.
 DPC is reserved only for mechanical exposure is
primary dentition.
 Disagreement also exist concerning DPC and
pulpotomy as permanent procedure in mature
secondary teeth but it is accepted for permanent
teeth with incompletely formed root with
exposed pulp as it favours apexogenesis.

 Teeth with calcification of pulp
chamber are also not candidate for
direct pulp capping as they are
indicative of previous inflammatory
process.
 Periodontal involved teeth are poor
risk because of diminished blood
supply.


MATERIALS USED/ATTEMPTED
CH Zinc oxide eugenol

Formocresol Tri calcium phoshate

Corticosteroid
Iso butyl cyanoacrylate
4 META Adhesives Ortho saminoseridine
Collagen Light cured CH

Chondroitin SO4 Laser

Sodium hyaluronate Enamel Matrix

Derivatives(EMD)
Antibiotics
MTA
Polycorboxylate cement
Denatured albumin

Calcium hydroxide

The opponents of calcium hydroxide claim
that it does not exclusively stimulate
sclerotic dentin formation, dentinogenesis,
reparative dentin formation or dentin
bridge formation.

 Cox CF, Suzuki S. Re-evaluating pulp protection: calcium hydroxide liners vs. cohesive hybridization. JADA
1994; 125:823-31.


They also claim that it may dissolve after one year, that
acids will degrade the interface during etching, and that
calcium hydroxide does not adhere to dentin and will
not adhere to bonding resin composite systems

One study(1996) found that calcium hydroxide bases
under resin composite restorations tended to pull away
from the cavity surface during resin polymerization,
leaving a gap between the calcium hydroxide and dentin

 Goracci G, Mon G. Scanning electron microsocpic evaluation of resin-dentin and calcium
hydroxide-dentin interface with resin composite restorations. Quintessence Int 1996; 27:129-35


Cox and others found a high rate of
multiple tunnel defects (89%) in dentin
bridges under calcium hydroxide. This high
rate of defects, they suggest, places the
long-term therapeutic effect of calcium
hydroxide in serious doubt. They also
suggest that calcium hydroxide
disintegrates and is lost over a period of
time.

 Cox CF, Subay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in dentin bridges: their formation following
direct pulp capping. Oper Dent 1996; 21:4-11


Zinc oxide eugenol
 Glass and Zander discount the use of ZOE as capping
agent in direct contact with pulp as chronic
inflammation ensure.
 No secondary dentin bridge occurred but pulp
remained vital.
 Hence when using ZOE sound dentin shaving are cut
from surrounding walls and deposited before placement
of creamy mix of unmodified ZOE.


Formocresol
 Ibrahim et al (1970) reported absence
of inflammation or dentin bridging in
15 teeth using formocresol mixed
ZOE.
 A histopathologic study of the effects of formocresol in pulp
capping of permanent teeth.
Egypt Dent J. 1970 Jul;16(3):219-34


Tri calcium phosphate
Heller et al (1975) used restorable
Tri calcium phosphate ceramic for
DPC and found a direct
appositional dental bridge
formation in monkeys. Longer
terms study are needed on human
teeth.

Formation of a dentinal bridge appears to be predictable.
The bridge is contiguous and thick, pulpal inflammation
is minimal, and odontoblasts are observed directly
under and in contact with the bridge.

The ceramic form of tricalcium phosphate appears to
enhance the formation of a dentinal bridge in contrast
with the calcium hydroxide that was used on the
control.

Direct Pulp Capping of Permanent Teeth in Primates using a Resorbable Form of
Tricalcium Phosphate Ceramic Journal of endodontics,volume1,number3

(Sawusch – 1982). Tri Calcium phosphate
ceramic – this material exhibited no hard
tissue barrier and had mild inflammation.

There was absence of pathological sequelae
such as internal resorption.


Ortho saminoseridine
 Sapone (1982) placed Ortho
saminoseridine on bleeding pulp
for 5 min followed by a mixture of
65% CH & 35% BaS04 and
reported 95% success.


Corticosteroid
On applying Corticosteroid, only the pain
disappears. It only preserves chronic
inflammation.
Germuth et al (1952) & Minkin (1953)
reported increased susceptibility to
infection and spread of existing infection
including bacterimia and septicemia result
of antiphysiologic effect of Corticosterioid.

Topically applied corticosteroids cause
degenerative changes in the tissue and reduce
the pulpal ability to form a hard tissue barrier
in the presence of calcium hydroxide
Flumetazone has a general excellent effect
towards rapid elimination of trauma-induced
oedema in animals.

 Effects of Flumetazone on Exposed Dental Pulp of DogsI.
CAPÍK, V. LEDECK¯, A. ·EVâÍK 2002


Paterson RC (1977) & Lakshmanan
CD (1972) evalauated the effect of
CORTICOSTEROIDS in pulp
capping and reported low success rate

Mondo Odontostomatol. 1977 Jul-Aug;19(4):52-9.

The evaluation of a corticosteroid antibiotic agent in pulp capping.
J Br Endod Soc. 1972 Summer;6(2):24-34.



Iso butyl cyanoacrylate
It is proved to be an excellent hemostatic agent as
well as a reparative dentin bridge stimulator as
reported by Berkman et al (1971) and Bhasker et
al (1969)
.
It provides an adequate seal that permits regeneration
Pulp inflammatory response is minimal.

No Zone of necrosis was shown.

Human pulp capping with isobutyl cyanoacrylate JDent Res. 1972 Jan-Feb;51(1):58-61
Bhaskar SN, Beasley JD, Ward JP, Cutright DE.


Micro abscess which are more
common in CH treated teeth also
were fewer.

It also inhibits growth of certain
microorganism. (Spanberg & et al
1974)..

Denatured albumin
Molven (1970) used denatured albumin
as it has calcium binding properties but
found that it cannot be sued as a
capping material as no dentine bridge
was observed

Oral Surg Oral Med Oral Pathol. 1970
Sep;30(3):413-24.


Antibiotics
Antibiotic like neomycin, penicillin, keflin were
used with corticosteroids. But they were found
only to preserve chronic inflammation.
The low rate of satisfactory responses of
pulps capped with Keflin, as used,
precludes its use of pulp capping.

Long-term study of pulp capping in monkeys with three agents J Am Dent
Assoc. 1976 Jul;93(1):105-10 (McWalter GM, el-Kafrawy AH, Mitchell DF.
)


Polycorboxylate cement
Polycorboxylate cement – though suggested as DPC
material, lacked an antibacterial effect and did not
stimulate calcific bridging in pulp .

Durelon is not recommended for pulp capping
since the material apparently lacks an
antibacterial effect and does not stimulate
reparative dentinogenesis at the exposure site.

Long-term study of pulp capping in monkeys with three agents J Am Dent
Assoc. 1976 Jul;93(1):105-10 (McWalter GM, el-Kafrawy AH, Mitchell DF
.)

Light cured calcium hydroxide
Light cured CH pulp capping products used as a liner
showed all characteristic of healing and bridge
formation (Stanley and Parmeijer (1995).

The success rate for DPC was 70 percent.
IPC had a success rate of 85 percent
Because of the improved physical properties, VLC-
Dycal was evaluated in a clinical trial for biological
properties and proved to be a useful cavity liner for
young permanent teeth( ASDC J Dent Child. 1991 Mar-Apr;58(2):124-8.
Straffon LH, Corpron RL, Bruner FW, Daprai F. )


The pulpal response to mechanical exposure and
capping either immediately or after 24 hours was
investigated in 64 teeth of four cynomolgus
monkeys with the use of Dycal, VLC Dycal, or
Prisma-Bond.
Dentine bridges were present in almost all teeth
filled with Dycal or VLC Dycal, and pulpal
inflammation was observed in only one tooth
that showed evidence of infection

.
(Immediate and delayed direct pulp capping with the use of a new visible light-cured calcium
hydroxide preparation Pitt Ford TR, Roberts GJ. Oral Surg Oral Med Oral Pathol. 1991
Mar;71(3):338-42.)


4 META Adhesives
 Miakoshi (1993) showed that this material could soak in
to the pulp, polymerize there and form hybrid layer with
pulp.
 COX (1993) demonstrated reparative dentin deposition
without subjacent pulp pathosis. This may well lead to
future pulp capping material.
 Capping agents may have an effect on pulp apoptosis
and that 4MMT may actively induce apoptosis during
pulp wound healing
 The distribution pattern of apoptotic cells was more
broadly spread, and the number of apoptotic cells was
significantly larger
 J Endod. 2003 Jan;29(1):41-3.

Obersztyn (1966) Rowe A.H.
(1967) used collagen,
chondroitin SO4, sodium
hyaluronate. The first
material gave good result.


Collagen
 Dick HM (1980)studied Reconstituted antigen-
poor collagen preparations as potential pulp-
capping agents
 Wet collagen sponge and wet collagen fabric are
better tolerated as pulp capping materials than dry
collagen sponge or dry collagen fabric.
 Dentin bridge formation seems to occur only
when an area of surface necrosis subsequently
undergoes dystrophic calcification
J Endod. 1980 Jul;6(7):641-4.


Chondroitin SO4
 The word chondrotin comes from the root
chondro- which means a word related to
cartilage. The full word, chondrotin has a
complex chemical definition, but let’s leave it
here that when you add some of this material to
your "calcium" formula, the matrix becomes
more capable of attracting and holding the
hunks of calcium.

Sodium hyaluronate
 . Sodium hyaluronate is similar to synovial fluid,
a substance that occurs naturally in the joints.
Synovial fluid acts as a lubricant and shock
absorber
 Sodium hyaluronate is injected into the knee
joints for the treatment of pain in individuals
with osteoarthritis


Laser
 Moritz et al 1996 & 1998 have shown favourable result in DPC
using continues wave and superpulsed mode CO2 laser.

 A study was conducted on the effects of CO2 laser irradiation on
the dental pulp

 Among the conditions examined, an output of 60 W and an
irradiation period of 0.5 s produced the most favorable border
between normal and necrotic tissues. No detectable damage was
observed in the radicular portions of pulps that were irradiated
 Histopathological Changes in Dental Pulps Irradiated by CO2 Laser: A Preliminary Report on
Laser Pulpotomy
Shigeru Shoji, Masanori Nakamura, and Hiroshi Horiuchi september1985,vol 11,number 9


 The laser and Vitrebond direct pulp cap
produces a significantly more predictable pulpal
response after the first 6 months than the Dycal
direct pulp cap. The survival rate of teeth treated
with the laser and Vitrebond direct pulp cap is
significantly greater than those treated with the
Dycal direct pulp cap over intervals of 9 to 54
months

Dycal versus Nd:YAG laser and Vitrebond for direct pulp capping in permanent teeth.
Santucci PJ.

.
J Clin Laser Med Surg. 1999 Apr;17(2):69-75


 Lou Graham (2003)The CO2 laser showed a
89% success versus a 68% success versus
Ca(OH)2 therapy

 The use of lasers in treating carious lesions has
become more common and provides certain
major advantages where the vitality of the pulp
is concerned
 Direct Pulp Capping Using an Er, Cr:YSGG
Laser
Blanken, Jan Walter
J Oral Laser Applications 5 (2005), No 2

 Complete but thin dentin bridges and no
inflammation were observed after 90 days
 CO2 laser irradiation and/or capping with
Clearfil Megabond could result in pulp healing
that is similar to CaOH capped teeth.

 Histopathologic Responses to CO2 Laser and Two-step Adhesive System M.
SHIRONO, T. EBIHARA, and Y. KATOH ,

Enamel Matrix
Derivative (EMD)


During odontogenesis,
amelogenins from the
preameloblasts are translocated to
differentiating odontoblast in the
dental papilla, suggesting that
amelogenins may be associated
with odontoblast changes during
development

Enamel matrix derivative exerts a considerable
influence on odontoblasts and endothelial cells
of capillaries in dental pulp tissue.

Enamel matrix derivative used as a pulp capping
material may play a role in the calcification of
dental pulp tissue.


 In the EMD-treated teeth, substantial amounts
of dentine-like tissue formation consistently led
to a complete hard-tissue bridging of the defects.
 The onset of hard tissue formation could be
observed after 2 weeks and was located only on
the pulpal wound. More limited dentine
formation was also observed in Dycal-treated
teeth.

Nakamura Y
The induction of reparative dentine by enamel proteins--- (2003)


However, in these teeth the new hard
tissue formed at the expense of pulp
chamber width, causing narrowing of root
canals.
The total amount of reparative dentine
formed in the EMD-treated teeth was
higher P<0.005) than in the Dycal-treated
specimens
Nakamura Y


The potential of EMD as a biologically active
pulp-dressing agent that specifically induces
pulpal wound healing and dentine formation in
the pulpotomized teeth without affecting the
normal function of the remaining pulp.

Nakamura Y


 In the EMD-treated teeth, large amounts of
newly formed dentin-like hard tissue with
associated formative cells outlined the pulpal
wound separating the cavity area from the
remaining pulp tissue. Inflammatory cells were
present in the wound area but not subjacent to
the newly formed hard tissue.

Adv Dent Res. 2001 Aug;15:105-7


Morphometric analysis showed that the amount
of hard tissue formed in EMD-treated teeth was
more than twice that of the calcium-hydroxide-
treated control teeth (p < 0.001), suggesting that
EMD is capable of promoting reparative
processes in the wounded pulp more strongly
than is calcium hydroxide.

Adv Dent Res. 2001 Aug;15:105-7


 Enamel matrix derivative exerts a considerable
influence on odontoblasts and endothelial cells of
capillaries in dental pulp tissue. These results imply that
enamel matrix derivative used as a pulp capping
material may play a role in the calcification of dental
pulp tissue.

Histopathological study of dental pulp tissue capped with enamel
matrix derivative -J Endod. 2003 Mar;29(3):176-9.

 Postoperative symptoms were less frequent in
the EMDgel-treated than in the calcium
hydroxide-treated teeth, especially during the
first six weeks.
 In the EMDgel-treated teeth, new tissue partly
filled the space initially occupied by the gel and
hard tissue was formed alongside the exposed
dentine surfaces and in patches in the adjacent
pulp tissue. EMD was detected in the areas
where new hard tissue had been formed.
Dental pulp capping: effect of Emdogain Gel on experimentally exposed human
pulps -Int Endod J. 2005 Mar;38(3):186-94.

 The wound area of the EMDgel-treated teeth
exhibited inflammation in the majority of the
teeth whereas less inflammation was seen in the
calcium hydroxide-treated teeth where the hard
tissue was formed as a bridge.
 In the EMDgel-treated teeth, postoperative
symptoms were less frequent and the amount
and pattern of hard tissue formation were
markedly different than in the teeth treated with
calcium hydroxide.
Dental pulp capping: effect of Emdogain Gel on experimentally exposed human
pulps -Int Endod J. 2005 Mar;38(3):186-94.


 However, the operative procedure and the
formulation with EMD in a PGA vehicle do not
seem to be effective for the formation of a hard
tissue barrier.
 Emdogain Gel (Biora AB, Malmo, Sweden),
consisting of a enamel matrix derivative (EMD)
in a propylene glycol alginate (PGA) vehicle,

Dental pulp capping: effect of Emdogain Gel on experimentally exposed human pulps -Int Endod J. 2005
Mar;38(3):186-94.


Mineral Trioxide
Aggregate (MTA)


GREY &WHITE MTA
 Electron probe microanalysis results indicated that lime
(CaO), silica (SiO2), and bismuth oxide (Bi2O3) were
the dominant compounds in each case
 And were present at comparable levels in either of the
types of mineral trioxide aggregate analyzed. It was
concluded that the most significant differences
observed were between the measured concentrations of
Al2O3 (+122%), MgO (+130%), and especially FeO
(+1000%) when gray mineral trioxide aggregate was
compared with white mineral trioxide aggregate.
 Chemical Differences Between White and Gray Mineral Trioxide Aggregate .
Journal of Endodontics. 31(2):101-103, February 2005.
Asgary, Saeed DDS, MSc; Parirokh, Masoud DDS, MSc; Eghbal, Mohammad Jafar DDS, MSc; Brink, Frank BAppSc,
MSc www.indiandentalacademy.com

 Mineral Troxide Aggregate (MTA) is a sealing agent
that has been developed to close communication
between the pulp canal system and external surfaces of
the teeth The material has been well studied in
experiments that showed good sealing ability and bio-
compatibility.
 It has been successfully used to close iatrogenic
perforations of furcations, as retrograde filling of root
ends and for orthograde filling of root canals.

 MTA has the same chemical properties as Portland
cement except that MTA also has bismuth to give it a
more opaque look in a radiograph.


 MTA can be used as a pulp capping material in
vital mechanical exposure or in primary tooth
pulpotomy.
 Ford et al (October 1996) found that pulps
capped with MTA had no pulpal inflammation
after five months in five of six samples and all
six pulps in this group had a complete dentin
bridge formation.
 In contrast, all the pulps capped with Ca(OH)2
showed pulpal inflammation, and bridge
formation occurred in only two samples.

 Eidelman, Holan, and Fuks (January 2001) did a
study to compare the effect of MTA with that of
formocresol as pulp-dressing agents in
pulpotomized primary molars with carious pulp
exposure. They found that none of the MTA-
treated teeth showed any clinical or radiographic
pathology at a 17-month recall.


 MTA did not induce apoptosis

 MTA induced proliferation, and not apoptosis, of pulp
cells in vitro

 These findings suggest a potential mechanism to
explain the regenerative effect observed in the dentin-
pulp complex when MTA was used for direct pulp
capping.

 Effect of ProRoot MTA on Pulp Cell Apoptosis and Proliferation In Vitro.
Journal of Endodontics. 31(5):387-391, May 2005.
.
Moghaddame-Jafari, Sasan; Mantellini, Maria G.; Botero, Tatiana M.; McDonald, Neville J.; Nor, Jacques E


 Histological evaluation demonstrated
less inflammation, hyperaemia and
necrosis plus thicker dentinal bridge
and more frequent odontoblastic layer
formation with MTA than calcium
hydroxide.
 MTA and calcium hydroxide as pulp-capping agents in human teeth: a preliminary report.
Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS Int Endod J. 2003 Mar;36(3):225-

31


GREY &WHITE MTA
 Gray MTA setting time was lower than that of
white MTA.
 According to Holland et al. (2002), the
mechanism of action of white MTA is very
similar to that reported for gray MTA
 Granulations birefringent to polarized light at
the opening of dentin tubes filled with white
MTA.
 These granulations were similar to the calcite
crystals observed with calcium hydroxide.

 MTA has no calcium hydroxide, but rather calcium
oxide that could react with tissue fluids to form calcium
hydroxide.
 Next to these granulations, there was a deposit of von
Kossa-positive hard tissue that resembled a mineralized
bridge.
 The mechanism of action of white MTA were very
similar to that reported for gray MTA .
 Considering these results, we believe that the white
MTA may be considered to be an effective pulp
capping material.

Braz. Dent. J. vol.15 no.2 Ribeirão Preto 2004


 Mineral Trioxide Aggregate (MTA) is a new
material approved by the FDA for use in pulpal
therapy. MTA has been reported to have
superior biocompatibility and sealing ability and
is less cytotoxic than other materials currently
used in pulpal therapy

 Schmitt, D., J. Lee, and G. Bogen, Multifaceted use of ProRoot
MTA root canal repair material. Pediatr Dent, 2001. 23(4): p. 326-
30.


Procedure
After anaesthetizing and isolation, undermined enamel
and unsound dentin is removed.
↓
The cavity floor and exposure site is washed gently with
sterile water and dried with cotton pellet.
The basing material is prepared and placed directly over
exposure site.
↓
Permanent restoration is then placed.
↓
Patient is recalled after 6 to 8 weeks for CH and 8 to 9
weeks if unmodified ZOE is used.

Although both techniques can achieve
successful vital pulp caps, the calcium hydroxide
technique has demonstrated its success over a
longer period of time.
Which technique offers the better prognosis
awaits the results of many more long-term
studies.


 Failures of pulp capping could be due to
microbial contamination
 dentinal debris and

 lack of peripheral seal apart from operators

 inability to perform proper surgical
procedures.


PULPOTOMY


 Partial pulpotomy (Cvek technique) (1978). This
consisted of amputation of only 1 to 2mm of
exposed pulp and then placement CH. This is
also called as pulp curettage.


 It is defined as the surgical excision of the
coronal portion of a vital pulp.
 Thereby vitality of radicular pulp is maintained
by the placement of medication at the
amputated area.
 Pulpotomy is accepted procedure for both
primary & permanent teeth with carious
exposure..

 The goal of an ideal pulpotomy in primary teeth
are to maintain arch length preserve masticatory
function and remove infection and chronic
inflammation from oral cavity


 The justification of this procedure is that the
coronal pulp tissue adjacent to carious exposure,
contains microorganism & inflammatory
changes.
 This abnormal tissue is removed & healing
allowed to take place at entrance of pulp canal.
 Traditionally the term pulpotomy has implied
removal of pulp tissue to the cervical line.
However the depth to which the tissue is
removed is determined by clinical judgment.


Indication

 History of patient
 Carious tooth with neither spontaneous nor
persistent pain.
 Immediate trauma with history of occurrence
within one hour without bleeding from tooth.
 Complaint of slight pain on taking hot and
cold which is not persistent.


Clinical Examination
 Deep carious lesion which is restorable.
 Fracture of tooth where the fracture line is near to pulp
horn.
 Absence of mobility, gingival pathology and fistulous
tract.
 If exposure is recent one the hemorrhage from the site
of amputation is pale red & easy to control.
 The size of exposure not more than 1.2mm.
 Tooth is vital.


Radiological

 Tooth has at least two third of root.
 No evidence of external & internal root
resorption.
 Carious lesion very near to pulp.
 Tortuous and ribbon shaped root canals.


CONTRAINDICATION

Teeth with
1. Spontaneous pain
2. Mobile
3. Tenderness to percussion
4. Pulp calcification


Therapeutic approaches to
pulpotomy
 Uses CH over amputated pulp
The CH pulpotomy is predicated on the healing of pulp
stumps under a dentin bridge where as formocresol
pulpotomy is predicated on sterilization of the
subjacent tissue.
 Uses formocresol
Dannerberg (1974) said that the mummified pulp under
formocresol is inert, fixed and incapable of bacterial or
autolytic breakdown.

Procedure
After anesthetization and isolation remaining dental caries is removed with slow
speed round bur.
↓
The entire roof of pulp chamber is removed with a fissure bur in
high speed hand piece.
↓
After unroofing, amputate the coronal pulp using sterile round bur
or a sterile sharp discoid spoon excavator.
↓
The pulp tissue should be cleanly excised with no tags of tissues.

(In 1998 Winter has suggested a conservative approach where in dentinal roof of pulp
chamber is preserved thus obtaining an important reinforcement of the tooth )


Haemostasis is obtained in radicular pulp by exerting pressure
with sterile cotton pellets.
↓
After post amputation the blood clot is formed after the use
of saline moistened cotton pellet to if radicular pulp is
healthy.
↓
If bleeding continues pulp stump are exposed to air for few
minutes and even then bleeding persists it indicates
inflamed radicular pulp tissue also.
↓
Therefore plain anaesthetic solution is used so as not to mask
the diagnosis.

INDICATIONS FOR CH
PULPOTOMY
 CH pulpotomy is recommended for permanent
teeth with immature root development but with
healthy pulp tissue in root canals.
 It is also indicated for a permanent tooth with a
pulp exposure resulting form crown fracture
when trauma has produced root fracture also.
 The technique is completed in single
appointment.

 After the amputation procedure as described and
control of hemorrhage the CH capping material is
placed to provide adequate seal and then the tooth
is prepared for full coverage.
 Polycarboxylate cement can also be used as a cavity sealing
material instead of ZOE.
 Successfully treated tooth should have after 1 year a
normal periodontal ligament and lamina dura,
radiographic evidence of calcific bridge and no
readiographic evidence of internal resorption or
pathologic resorption. Thus its use can cause
apicogencsis of young permanent tooth.

 The formocresol pulpotomy is recommended
for the primary dentition.
 The use of CH in primary dentition causes
internal resorption which may be due to over
stimulation of primary pulp causing mateplasia
in the pulp tissue leading to odontoclast
formation.


Formocresol pulpotomy is done in 2
methods.
 One appointment pulpotomy
 Two appointment pulpotomy

Formocresol used has
 Cresol – 35%
 Formalin 19%
 Glycerin and water.


One appointment pulpotomy
The orifice of root canals are covered by cotton
pellet moistened in formocresol solution for 1
minute.
↓
The cotton pellet should be compressed between
two layers of gauze sponge to remove excess.
↓
After removal of the cotton pellet, ZOE base is
placed.

 Alternatively diluted formocresol into ZOE
dressing can be placed instead of moistered
formocresol pellet followed by ZnPO4 cement
& silver amalgam. If silver amalgam is not
possible a stainless steel crown is placed.
 Periodic checkup at 6 weeks, 12 weeks and six
months is made where tooth is clinically and
radiologically assessed.
 Clinical evaluation includes history of pain,
tenderness on percussion & mobility. Vitality is
assessed with pulp tester.

Two appointment pulpotomy.
Indication:
 where there is sluggish bleeding at amputation
site or profuse, uncontrollable bleeding
 pus or infection in the chamber only and not at
amputation site
 when shorter appointments are necessary when
there is problem in patient management.


Procedure:
The procedure is same for 1 appointment except for
few steps.
 The cotton pellet moistened with formocresol is sealed
into the chamber for 5 to 7 days instead of taking out
within one min., above it temporary filling is placed.
 At second visit it is replaced with ZOE followed ZnP04
cement and amalgam.
 Emerson (1959) reported that five minute application
of formocresol resulted in surface fixation or normal
tissue whereas an application sealed in for 3 days
produced calcific degeneration.
 Hence formocresol pulpotomy may be classified as vital
or non vital depending on duration of formocresol
application.

 Maste rand Mansukhiani in 1959 found 3
distinctive zones in pulp after placement of
formocresol within 7 to 14 days
1) broad eosinoptic zone of fixation
2) a broad pale staining zone with poor
cellular definition
3) a zone of inflammation diffusing apically
into normal tissue.

 Formocresol is known to have carcinogenic effect.
 Alternative to formocresol, 2% gultheraldehyde can be
used for pulpotomies in primary teeth as suggested by
Kopel and his colleague in 1980.
 They found that there is a initial zone of fixation
adjacent to the dressing that did not proceed apically.
 The tissue adjoining the fixed zone and down to the
apex had cellular detail of normal pulp
 Gluteraldehyde is less antigenic.

MATERIALS USED/ATTEMPTED

Calcium Hydroxide
Formocresol
Gluteraldehyde
MTA
Toverud's paste
N2
Ferric sulfate
Laser
Electrosurgery
Recombinant human insulin-like growth factor I (rhIGF-I)


Calcium Hydroxide
 Calcium hydroxide, a regenerative pulpotomy agent, has
been reported to be a failure in primary teeth due to
higher incidence of the development of chronic pulpal
inflammation and internal resorption
 (Evaluation of deciduous teeth treated by pulpotomyand calcium hydroxide J Am Dent Assoc 1955;
50: 34 40 A comparative Evaluation of Two Pulpotomy Agents in Primary Molars 10. Magnusson B.: Therapeutic
pulpotomy in primary molarclinical and histologic follow up. Odontol Revy 1970; 21: 415-431).

 However, recent studies have reported a favorable
result for calcium hydroxide by controlling the variables
of treatment such as pulpotomy technique, strict
selection criteria, etc
 .( Br DentJ 2000; 188: 32-36. J Am Dent Assoc 1984; 108: 775-778 , J Am Dent Assoc 1984; 108: 775-778 ,
Br DentJ 2000; 188: 32-36)

.

Recent advances in the field of bone and dentin
formation have opened new vistas for pulp
therapy. Bone morphogenetic proteins (BMPs)
and Growth factor [such as transforming growth
factor (TGF), platelet derived growth factor
(PDGF),insulin growth factor (IGF)] derived from
platelet have generated considerable interest
during the last few years..
Int. J. Periodont Rest Dent 1996; 16: 8-19., Int. J Periodont Rest Dent 2002; 22: 45-53
.


Lyophilized Freeze Dried Platelet Derived
Preparation with Calcium Hydroxide

Lyophilized freeze dried platelet derived preparation
showed a 100% success rate, as all these teeth were
asymptomatic and not showing any signs of pulpal
degeneration clinically and radiographically
 Animal and human invivo and invitro studies have
shown that these proteins stimulates differentiated cell
of pulp to differentiate into odontoblast to deposit a
layer ofdentin (S.G.Damle 2004)


Formocresol
Sweet popularized the formocresol pulpotomy
technique in the 1930's and clinical and radiographic
success rates of 98% have been reported.
 The primary concern regarding the use of formocresol
is related to its toxicity and possible bloodborne spread
to distant sites.
 Meyers, et al, demonstrated this phenomenon in a study
of rhesus monkeys that found that a five-minute
exposure of pulpal tissue to 14C-formocresol resulted
in the systemic absorption of approximately 1% of the
dose
 Formocresol, a devitalizing agent has been reported to
be carcinogenic and mutagenic

Gluteraldehyde
Glutaraldehyde, a preservative agent has been
proposed as an alternative to formocresol, that
results in inadequate fixation and leaves a
deficient barrier to sub base irritation, resulting
to internal resorption
.
Sharon D. H, SueSeale N., Quintero M. and Guo L. Y: Effect of glutaraldehyde
pulpotomy treatment on pulpal enzymes.Pediatr Dent 1993; 15: 337-342.
. Kopel M. H., Bernick S., Zachrisson E. and Deromero S. A.:
The effect of glutaraldehyde on primary pulp tissue following
coronal amputation: an in vivo histologic study. J Dent Child
1980; 47: 425-430.

It would appear that glutaraldehyde
may offer distinct advantages over
formocresol, in the treatment of
cariously exposed primary and young
permanent teeth.

In particular, due to its chemical
structure, it is more active in fixing the
surface tissues and is more rapidly
limited in its depth of penetration
through these tissues.

Glutaraldehyde does not exhibit as
significant an ability to induce the total
loss of vitality, in the radicular pulp
tissues.
The progression of formocresol treated
pulps to apparent fibrotic replacement
via granulation-tissue ingrowth,
through the apex, does not occur with
the glutaraldehyde-treated pulp tissues.

There may, however, be a slow progression of
fibrotic replacement of the glutaraldehyde fixed
tissue, in the coronal portion of the radicular
pulp.
Perhaps most importantly it would seem that
since the glutaraldehyde does not perfuse the
tissues to the apex, it will not demonstrate
systemic distribution and other extradental
phenomena, as have been identified with the use
of formocresol
Glutaraldehyde: an alternative to formocresol for vital pulp therapy.Davis MJ, Myers R,
Switkes MD. ASDC J Dent Child. 1982 May-Jun;49(3):176-80

Mechasism of fixation
Lactic dehydrogenase, a respiratory enzyme, was
sharply affected by 0.5 percent and one percent
glutaraldehyde and a 1:5 dilution of formocresol,
exhibiting 7-, 71-, and 40-fold decreases in activity,
respectively. Alkaline phosphatase was much less
responsive to these same agents, giving only 4.5-, 17-,
and 2.5-fold reductions after treatment, respectively.
These findings support histochemical studies which
have suggested the sensitivity of respiratory enzymes of
the pulp to fixative medicaments

The effect of formocresol and glutaraldehyde on certain enzymes in bovine dental pulp.
Cunningham KW, Lazzari EP, Ranly DM.Oral Surg Oral Med Oral Pathol. 1982 Jul;54(1):100-3.
KW, EP, DM.Oral


Mummification
Dental pulp mummification a
technique of producing dry gangrene
of the pulp by means of
drugs, in which the dental pulp dries
and shrivels


 The primary reaction of formaldehyde is with the
functional groups which are nucleophillic.
 These may be found in various anion – acid side chains
of proteins and the amino group of nucleic acids.
 Thus formaldehyde serves as an addictive, non-
coagulative fixative and as a bactericide.
 Also suggested that, a hemi – acetal, formed between
formaldehyde and cresol would diffuse through the
tissues less rapidly which might explain the reduction in
the irritating preparation.

Buckley’s formula of formocresol

Formation : 19ml
Cresol : 35ml
Glycerin : 25ml
Water : 21ml

The action of glycerin is to decrease the polymerization of
paraformaldehyde, which causes clouding in the
solution as it was observed by Stephen in 1971.

GLUTARALDEHYDE
 Glutaraldehyde is a bactericide and a tissue fixative.
 It is an apliphatic dialdehyde.
 It forms direct intermolecular links between
adjacent protein chasing and underlines its
properties as a tissue fixative.
 Similarly the cross linking of the proteins or micro-
orgainsms accounts for its powerful antiseptic
action.
 As it cross links very fast, it does not diffuse
through the periapical tissues.

 In 1995 Waly NG suggested the used
of CH – gluteradelyed for pulpotomy
and reported 100% success in
comparison to 80% success when CH
was used alone.

Toverud's paste
 Sveen OB(1970) studied Toverud's paste as
Pulpotomy medicament in Primary molar
teeth


N2
 PROMINENT TOXICOLOGIST CONFIRMS
N2 IS SAFE!
 Dr. Brent, who is associate professor of Medicine,
Surgery and Pediatrics at the University of
Colorado Health Science Center, testified that
given the extremely small amounts of material
(N2) used in endodontic therapy, a prior dose
response makes any systemic illness from this
treatment implausible


 "I would say that given the many, many years of use of
this material, given the large number of people that have
been treated with it, given the fact that there hasn't been a
single report in the scientific literature of a systemic effect
attributed to Sargenti paste, given the scientific
implausibility, given the small amounts of formaldehyde
and lead that somebody would be exposed to from such a
Sargenti paste, I would say that it would just be a waste
of time to look for systemic effects. It can't happen."

Dr. Brent (1988)

 N2 earlier formulations had lead oxide and mercury,
newer formulations do not .
 The reaction is coagulative necrosis and reaches
maximum in 3 days.

 Blood-lead levels after root canal treatment with N2
cement were elevated when compared to preoperative
controls. Lead 210 was incorporated into the leadfree
N2 cement to identify the source of lead. Analyses of
blood samples for 210Pb indicated that the lead
originated from the filling material.
 September 1975, Volume 1, Number 9Shapiro, Iaquinta, Mitchell and
Grossman


Ferric sulfate
ferric sulfate or iron (III) sulfate, chemical
compound, Fe 2 (SO 4 ) 3 , a yellow rhombic
crystalline hygroscopic water-soluble salt that
decomposes when heated to a temperature of
480°C. The enneahydrate, Fe 2 (SO 4 ) 3 ·9H 2
O, is a deliquescent rhombic crystalline salt that occurs
in nature as the mineral coquimbite. It is used as a
mordant in dyeing, as a coagulant for industrial wastes
in pickling baths for aluminum and steel, and in pigments

Ferric sulphate has been proposed as a substitute to
formocresol, and the success rates were comparable to
those of formocresol.
 FS has been used as a hemostatic agent for crown and
bridge impressions [Fisc her, 1987].
 Even though the mechanism of the haemostatic action
of FS is still debated, it seems that agglutination of
blood proteins results from the reaction of blood with
ferric and sulphate ions with the acidic pH of the
solution.
 The agglutinated proteins form plugs that occlude the
capillary orifices [Lemon et al., 1993].

 The use of FS was recommel on the grounds that it
may prevent problems arising from clot formation after
the removal of the coronal pulp. It may also minimize
the chances for inflammation and internal resorption
that, according to Schroder [1978], was an important
factor for the failure of pulpotomies with calcium
hydroxide.
 A histological study on baboon teeth produced pulp
responses utilizing ferric sulfate that compared
favorably to formocresol pulpotomies.
 Ferric sulfate also demonstrated as good or better
clinical and radiographic success in human clinical trials.

The most common pathologic finding for FS
pulpotomy-treated incisors was widened
periodontal ligament space (in 67% of FS-
treated incisors but only 18% of RCT incisors).
Internal resorption was observed in 17% of FS-
treated incisors, and was sufficiently severe in
some incisors to be rated unacceptable.

Outcomes of Vital Primary Incisor Ferric Sulfate Pulpotomy and Root Canal
Therapy J Can Dent Assoc 2004; 70(1):34–8

Laser
Laser therapy is a non-pharmacologic hemostatic
technique for pulpotomy procedure. But research on
laser therapy for primary tooth pulpotomy is sparse .

Success rate of Nd:YAG laser pulpotomy was higher
than formocresol pulpotomy. The permanent
successors of the laser treated group erupted without
any complications. Therefore, Nd:YAG laser
pulpotomy can be considered for use as pulpotomy
technique in clinical practice.

Nd:YAG laser pulpotomy of human primary teeth International Congress Series
Volume 1248 , May 2003, Pages 251-256Jengfen Liu


 At 1 week after treatment, no inflammation or resorption was
observed in any cases in the control or 34 mJ/pulse-irradiated
groups. However, moderate to severe inflammation was
observed in 9 of 10 cases (90%) in the 68 and 102 mJ/pulse-
irradiated groups.
 Effects on pulp tissues during a pulpotomy procedure
by Er:YAG laser irradiation are minimal, if appropriate
parameters are selected, and this is a potential therapy
for pulpotomy of human teeth.
Journal of Clinical Laser Medicine & Surgery
Histopathological Changes in Dental Pulp Irradiated by Er:YAG Laser:
A Preliminary Report on Laser Pulpotomy Dec 2003, Vol. 21, No. 6: 345-
350


Electrosurgery
 Ruemping et al (1983) found Electrosurgery
pulpotomy gave favourable tissue response
 Shulmen et al (1987) gave a negative result.
 Another form of Electrosurgery is
Electrofulguration which need further histologic
investigation.


 Daniel W. Shaw (1987)Pulps of the treated teeth
were evaluated histologically for the presence of
inflammation, fibrosis, necrosis, resorption, and
reparative dentin formation.
 Results indicated that the electrosurgery
pulpotomy technique produced a tissue response
comparable to that induced with the
conventional formocresol pulpotmy technique


Recombinant human insulin-like
growth factor I (rhIGF-I)
 The pulp was covered with one dose of sterile 4%
methylcellulose gel containing either 400 ng rhIGF-I or
saline in contralateral controls. The exposure site was
closed with sterile Teflon membrane, and the cavity was
filled with IRM cement.
 The reparative dentin response to capping with rhIGF-
I was similar to that after the use of Dycal.

 Pulp-capping with recombinant human insulin-like growth factor I (rhIGF-I) in rat
molars Advances in Dental Research, Vol 15, Issue 1, 108-112


Therapeutic Regulation of Tertiary
Dentinogenesis: Existing Knowledge and
Future Perspectives for Research
 The ability of the pulp-dentin complex to respond to
therapeutic applications by specific cellular processes
and hard tissue formation has long been recognized.
 Current researchs has provided insights into the basic
molecular events underlying dental tissue repair,
induction of tertiary dentin formation, competence of
the responsive cells and how these phenomena could
be integrated into the clinical approach to the problem
of vital pulp therapy
 [Lesot et al., 1994; Smith et al., 1995; Rutherford, 1999; Tziafas
et al., 2000].

Application of biologically active growth and
morphogenetic factors and extracellular matrix
molecules as capping materials resulted in hard
tissue formation.
Bone morphogenetic proteins (BMP), such as
BMP-2, BMP-4 and BMP-7 (osteogenic protein-
1), induced formation of osteodentin in large
amounts followed by tubular reparative dentin
[Nakashima, 1994a, b; Rutherford et al., 1993;
Jepsen et al., 1997].
Capping experiments with insulin-like growth
factor-I have demonstrated complete dentinal
bridging and occasionally tubular reparative
dentin formation [Lovschall et al., 2001]

Transdentinal Stimulation of
Reactionary Dentinogenesis
 The aim of a regenerative
treatment strategy in the case
of mild dentinal injuries is to
stimulate localized peritubular
dentin formation and to provide
a regional and time-limited
effect on surviving
odontoblasts, in order to up-
regulate their biosynthetic
activity

Transdentinal Stimulation of Reparative
Dentinogenesis
 The ultimate goal of a regenerative
treatment strategy is to favour the
biological activity of dentin matrix,
which in an appropriate pulpal
environment is able to trigger
differentiation of new odontoblastlike
cells replacing lost primary
odontoblasts. result in differentiation
of odontoblast-like cells for
replacement of the lost odontoblasts
and a time-limited formation of
reparative dentin corresponding to the
involved area.

Direct Induction of Reparative
Dentinogenesis
 The ultimate goal of a regenerative
treatment strategy is to induce
differentiation of odontoblast-like
cells at the pulp-capping material
interface and to up-regulate the
biosynthetic activity of primary
odontoblasts around the pulpal
exposure to reconstitute the lost
continuum


Conclusion
 For unknown reasons, the pulp-capping agent used,
and not the procedure itself, has been the subject of
controversy among researchers
 Development of new capping materials for delivery of
exogenous signaling molecules offers exciting
opportunities for the future. However, a number of
critical considerations, such as the dose-response
effects, the nature of the delivery system, half-life of the
molecules and their possible side-effects need to be
addressed before any introduction of new treatment
modalities into clinical practice.

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