Goodluck Everyone

1. Pulp
Protection
Restoring the Tooth’s own
heartbeat
Presented By: Ghida Lawand
Hind Tabbal
Lara Habli

2. Outline:
Pulp Irritants
Protection in shallow and moderate cavities
Pulp protection in deep cavities
Indirect pulp capping
direct pulp capping
Materials used for pulp protection
New Materials and mesthods to protect pulp

3. The dental pulp is a soft
connective tissue of mesenchymal
origin present within the pulp
chamber and root canals of teeth.
It is not considered an external
tissue, yet its exposure to external
stimuli is unceasing due to several
factors that make the pulp
extremely sensitive to environment
outside.
We have to protect it from any type of irritant

4. Pulpal irritants
A) Bacterial irritants
(Most common cause for
pulpal irritation)
B) Traumatic
1-Caries
Tooth fracture
Luxation
Avulsion
Parafunctional
habits like bruxism
2- Periodontal
pocket and abscess
1-Acute trauma 2- Chronic
Trauma

5. C) Iatrogenic:
1. During tooth preparation
a) Heat production during cutting procedures:
Pulp temperature 11°F Destructive reaction
Revolution per minute (RPM) of the bur: As RPM increases,heat production
increases. Speed must not exceed 3,000 rpm.
Pressure: It is directly proportional to heat generation.
Surface area of contact: The more the contact between the tooth structure and
revolving tool, the more is the heat generation

6. Excessive heat generation leads to change in
dentin color due to vascular stasis and
hemorrage in the subodontoblastic vascular
plexus present in the pulp

7. b) Pressure exerted:
Pressure of hand or rotary instruments Nuclear aspiration of odontoblasts
or nerve endings from pulp tissues into the dentinal tubulesDisturb
odontoblasts metabolism leading to their complete degeneration and
disintegration.
c) Remaining Dentin Thickness (RDT)

8. 2. Orthodontic movement
3. Periodontal and periapical curettage

9. 4. Use of chemicals
Temporary & permanent fillings, bases, liners, and use of alcohol
that leads to pulpal injury due to its cytotoxicity, acidity, heat
formed and marginal leakage
Chemical irritants applied to dentin can result in
damage and disorganization in the subadjacent pulp

10. D- Idiopathic
Resorption
Aging
Internal External

11. Because of these various irritants
pulp needs protection…

13. Conventional methods
Direct pulp capping is placing a
biocompatible material over the
exposed pulp to maintain
vitality and promote healing.
Direct Pulp Capping
WHY?
1) To maintain the vitality of the remaining pulp tissue
2) To prevent root canal treatment
3) To help conserve tooth structure

14. Indications
Recent small mechanical exposure of
pulp during (< 24 hours):
a) Tooth preparation
b) Traumatic injury.
No or minimal bleeding at the
exposure site.

15. Contraindications
Wide pulp exposure
Pre-operative
history of
Spontaneous
pain
Presence of bleeding at
exposure site
Radiograph doesn’t
show any pulp pathology

16. Clinical Procedure
3.When vital & healthy
pulp is exposed, check
fresh bleeding
2. Isolate the tooth
with rubber dam
1. Administer local
anesthesia
4. Clean the area with
saline solution
5. Dry it with a
cotton pellet
6. Apply calcium hydroxide
(preferably Dycal) over the
exposed area

17. 7. Give interim
restoration such as
zinc oxide eugenol
for 6 to 8 weeks
b) If not pulpotomy or
pulpectomy is requested
a) Remove the cement
to inspect the exposure
site. If secondary dentin
formation takes place
over the exposed site
restore the tooth
permanently with
protective cement base
and restorative material.

18. In indirect pulp capping, all caries are removed
except the ones that lie adjacent to the pulp.
Caries near the pulp is left in place to prevent
pulp exposure and preparation is enclosed with a
biocompatible material.
Indirect Pulp Capping

19. Indications
1. Deep carious lesion near the pulp tissue but not involving it
2. No mobility of tooth
3. No history of spontaneous toothache
4. No tenderness to percussion
5. No radiographic evidence of pulp pathology
6. No root resorption or radicular disease should be present
radiographically.
Root resorption

20. Clinical Procedure
It’s the same procedure as the direct pulp capping except that the
pulp is not exposed. A thin layer of dentin and some amount of
caries is left to avoid exposure.
Placement of calcuim hydroxide and zinc
oxide eugenol dressing after excavation
of soft caries

21. Factors affecting Pulp Capping success
1) Age of the patient: Due to vascularity of the pulp, young patients have
greater potential for success than older ones
Young patient Old patient
2) Type of exposure: Mechanically done pulpal exposure has better prognosis than
exposure caused by caries, due to less pulpal inflammation and deleterious effect of
bacterial toxins on the pulp

22. 3) Size of the exposure: In large exposures, it is difficult to control the
hemorrhage and tissue seepage. Small pinpoint exposures are easy to
manage and have a greater potential for success
4) History of pain: If previously pain has not occurred in the tooth, the
potential for success is more

23. Recent methods
Laser in pulp capping
Mechanism:
CO2 laser emits an
infrared beam
Stimulates mineralization
in dental pulp cells
Therapeutic
benefit for direct
pulp capping
and pulpotomy
in clinical
practice

24. Conventional Materials
Materials used for Pulp Protection
Recent Materials
Varnish Base Sealer Liner
1) Zinc oxide eugenol liners
2) Calcium hydroxide
3) Flowable composites
4) Glass ionomers
1) Zinc Oxide Eugenol
2) Zinc phosphate cement
3) Polycarboxylate cement
4) Glass ionomer cement
Growth
Factors
Cements Stem
Cells
Enzymes

25. Ether or
chloroform
Organic
copalResin
gum
Solvent
evaporates
Definition:
It is an organic copal or resin gum
suspended in solutions of ether or
chloroform.
When we put it on the tooth surface the
organic solvent evaporates leaving a
protective film
Two coats of varnish should be applied
using a small cotton pellet to ensure
sufficient wetting of cavity walls
A) Varnish

26. Indications
To seal the dentinal tubules
Dentinal
tubules
Open Dentinal
tubules
Sealing dentinal
tubules with varnish
Dentinal tubules
blocked by varnish
2. Protects the tooth from
chemical irritants from cements
 reducing postoperative pain
3. Reduces microleakage
around restorations
1. Prevents discoloration of tooth
with an amalgam restoration by
preventing migration of ions into
the dentin

27. Under Composite
Resin
Varnishes dissolve in the
monomer of the resin &
also interfere with their
polymerization of resins
With Glass Ionomer
Restorations
It interferes the bonding
of tooth to these cements
Contraindications

28. B) Sealer
Indications
• To seal dentinal tubules
• To treat dentin hypersensitivity.
An adhesive sealer is commonly
used under indirect restorations.
For application, cotton tip
applicator is used to apply sealer
on all areas of exposed dentin.
C) Liners
• Fluid materials that can adapt more
readily to all aspects of a tooth
preparation
• Used to create a uniform, even
surface that aids in adaptation of
more viscous filling materials
(amalgams, composites)
• Do not have sufficient thickness,
hardness and strength  not used
alone in deep preparations
1. Protect pulp from chemical irritants
by sealing ability
2. Stimulate formation of reparative
dentin.
Indications

30. 1. Zinc oxide eugenol liners
• Used to alleviate pain from mild-to-
moderate inflammation of pulp.
 In low concentration  it acts as
obtundant
 In high concentration  it acts as
chemical irritant
Contraindication:
It inhibits polymerization  Should not be used under bonding
agents & composite restorations

31. 2- Calcium hydroxide
Most common agent considered as the
“gold standard” of direct pulp capping
materials against which new materials
should be tested
Advantages:
1. Causes dentin mineralization by activating the enzyme ATPase
2. Stimulates reparative dentin formation
3. Biocompatible
4. High pH (12.5)  neutralizes acidity of silicate and zinc phosphate
cements
Disadvantages:
1. Low strength
2. High solubility Dissolves rapidlyUsed over small areas requiring pulp
protection / Applying glass ionomer or zinc phosphate base to prevent its
dissolution.

32. When it dissociates:

33. 3- Flowable composites
Composites with a lower
amount of filler  more fluid
consistency, less strength and
lower modulus

34. 4- Glass ionomers
Renewable source of
fluoride under
restorations
Reduce the
incidence of
caries
Fluoride
Glass ionomer cements (GIC):
 Bond to tooth structure
 Act as a thermal barrier
 Ability to bond in a moist environment
 Easy to use.
 Anticariogenic.

35. Light-cured resin-modified glass
ionomers (RMGIs)
 Provide good adhesion to both tooth
structure and restorative materials
 High strength
 Flexible (low modulus of elasticity)
 Dual-setting reaction:
1) Light-activated, methacrylate
crosslinking reaction
2) Slower, delayed, acid-base
reaction
Which gives RMGIs an additional
period of maximum flexibility to absorb
stress from the adjacent shrinking
composite.

36. Classification of bases
Protective
bases
Sedative bases Insulating bases
They protect the
pulp before
restoration is
placed
They help in calming the pulp
which has been irritated by
mechanical, chemical or
other means
They protect the
tooth from thermal
shock.
D) Bases
Bases should have sufficient strength so that they can withstand
forces of mastication and condensation of permanent
restorations.

37.  Excellent
sealing quality.
 Bacteriostatic
in nature.
 Anodyne
effect.
Reduces the thermal
conductivity of
metallic restorations
Blocks undercuts in
the preparation wall
in case of cast
restorations.
 Chemically
bonds to tooth
 Antibacterial
properties
 Fluoride release
 Anticariogenic
property
 Chemical
bond to tooth
 Well tolerated
by the pulp.
Materials used as bases
Zinc oxide
eugenol
Zinc phosphate
cement
Polycarboylate
cement
Glass ionomer
cement

38. Pulp Protection according with depth of tooth
preparation

39. Recent Materials used for Pulp Protection

40. Biodentin
Biodentine is a calcium-silicate based material, it has been used in various
clinical applications:
Advantages:
 Biocompatible so no pulp inflammatory
responses
 Can be used wherever dentin is damaged
 Outstanding sealing properties
 Used as base or liner under composite
restorations
 Adequate compressive and flexural strength
 Creates faster dentin bridges
 Better properties than glass ionomer and
calcium hydroxide
 Radio opacity for following up

42. (a & b) Pre-operative photograph showing in 11 with pulp exposure
(c) Preoperative radiograph
(d and e) A 3mm layer of Biodentine located over the uncovered pulp
(f) Immediate post-operative radiograph showing 3mm barrier of Biodentine
(g) Post-operative radiograph after 18 months showing a well-formed radio-
opaque barrier
(h) Post-operative recall photograph after 18 months
Clinical Procedure:

43. Dental pulp engineering and regeneration

44. Mineral Trioxide Aggregate (MTA)
1) Characteristics:
 Non-toxic material
 Low or no solubility
 Stimulate reparative dentin development
by a normal defending process of an
early pulpal wound healing (evidence
was the presence of odontoblast like
cells)
 Minimal inflammation at early healing
stage
2) Composition:
a. Tricalcium silicate
b. Tricalcium aluminate
c. Tricalcium oxide
d. Silicate oxide

45. 3) Manipulation:
Mixed with sterile water in a 3:1 powder to liquid ratio
Setting time: MTA sets in 5 minutes
4) How does MTA work?
Tricalcium
oxide
Tissue fluids
Calcium
hydroxide
Hard tissue
formation

46. 5) Clinical procedure
a) Radiograph before performing the operative procedure
b) A Photograph that shows the uncovered pulp tissue
c) Photograph showing settlement of MTA above the pulp tissue
d) Radiograph after restoring the tooth permenantly
e) Six months follow up radiograph

47. Why is MTA better than Calcium Hydroxide?
MTA Calcium hydroxide
VS.
1. Rapid cell growth promotion in vitro
2. Greater ability to maintain the integrity of pulp tissue
3. Thicker and rapidly formed dentinal bridge
4. Less hyperemia
5. Lower level of necrosis

48. Caster Oil Bean (COB) Cement
Histological sections
comparing the rate of
regeneration between
calcium hydroxide and
COB indicating that the
regeneration is faster with
COB
The castor oil bean (COB) (Ricinus communis) is a polyester formed by an amino radical
which was initially developed as a biomaterial for bone repair and regeneration after local
bone injury.
Advantages:
Confers bactericidal effect
Has biocompatibility with living tissues.
It has great potential to facilitate tissue
healing
Excellent structural properties,
Low cost
Good physicochemical properties

49. Thercal
2) Composition:
Tricalcium silicate particles in a hydrophilic monomer that provides significant
calcium release making it a uniquely stable and durable material as a liner or base.
3) Mechanism:
Calcium release stimulates hydroxyapatite and secondary dentin bridge formation
4) Indications:
Any pulpal exposures (carious exposures, mechanical exposures or traumatic
exposures )
1) Characteristics:
TheraCal is a light cured, resin modified
calcium silicate filled liner designed for use in
direct and indirect pulp capping, as a protective
base/liner under composites, amalgams,
cements, and other base materials.

50. Clinical Procedure

51. Why is Thercal better than MTA & Calcium Hydroxide?
MTA Calcium hydroxideThercal
VS.
 Higher calcium releasing ability
 Lower solubility than either MTA or Calcium Hydroxide due to
the capability of TheraCal to be cured to a depth of 1.7 mm
which avoids the risk of dissolution.

52. Clarity on the biology of caries, comprehension of technological advances
and conviction about enhanced restorative products has initiated pulp
preservation that indeed is a benefit to the clinician and the patient.
Science is a mystery that we won’t ever stop trying to reveal
its secrets so what’s the next material we’ll discover?

53. References:
- N. G. (2015). Textbook of Operative Dentistry (3rd
ed.). London: The Health Sciences Publisher page 213-
223
- A. (2014, January 12). Recent Advances in Pulp
Capping Materials: An Overview. Retrieved January 8,
2014
-M. (n.d.). High-Tech Pulp Capping Using Laser and
CAD/CAM.

54. Thank You