sharefah abdulwahab
431808506
PULP CAPPING
Pulp capping is a process of placing a specialized agent in contact with or
in close proximity to the pulp with the intention of encouraging formation
of new dentin (secondary dentin) and promote the healing of the pulp.
indirect pulp capping
This describes the placement of a dressing over
residual hard carious dentine in an attempt to
stimulate secondary dentine formation within the
pulp chamber
indications
•Deep carious lesion, which is close to, but not
involving the pulp in vital primary or young
permanent teeth.
•Pulpal inflammation adjudged to be minimal.
•There is a definite layer of affected dentin after
removal of infected dentine and complete removal
of caries would cause pulp exposure.
•Mild pain associated with eating.
•No history of spontaneous toothache
•No tenderness to percussion
•No abnormal mobility
•No radiographic evidence of radicular disease
•No internal or external root resorption detectable
radiographically
Contraindications
•Sharp, penetrating pulpalgia indicating acute pulpal
inflammation.
•Prolonged night pain
•Discoloration of the tooth.
•Mobility of the tooth.
•Negative reaction of electric pulp testing
Soft leathery dentine covering a very large area of
the cavity, in a non restorable tooth.
•Definite pulp exposure.
•Any signs of pulpal or periapical pathology.
•Interrupted or broken lamina dura
Materials
Dressing materials should promote pulp tissue
healing and tertiary dentine formation, and
minimize microleakage
.
•Traditional materials
: Calcium hydroxide, ZnO
eugenol
•New materials:
Composite resin and glass
ionomer cements.
calcium hydroxide
The greatest benefit of Calcium hydroxide is the
stimulation of reparative dentin bridge. This is due
to its high alkalinity, which leads to enzyme
phosphatase being activated resulting in the release
of inorganic phosphate from the blood (calcium
phosphate)It also has an antibacterial action. Its high alkalinity (pH of 9.0
to 10.0) results in the destruction of
bacteria cell wall.
•A set back of the potential for internal resorption
after pulp exposure and capping with calcium
hydroxide
.
Technique
•Use local anesthesia and isolation with rubber dam.
•Establish cavity outline with high speed hand piece
•Remove the superficial debris and majority of the
soft necrotic dentine with slow speed hand piece
using large round bur
•Stop the excavation as soon as the firm resistance
of sound dentine is felt.
•Carious dentine is removed with a sharp spoon
excavatorCavity flushed with saline and dried with cotton
pellet.
•Cover site with calcium hydroxide.
•Remainder cavity is filled with reinforced ZOE and
amalgam
Direct Pulp Capping
INDICATIONS
1. Light red bleeding from the exposure site that can be controlled by
cotton pellet.
2. Traumatic exposures in a dry, clean field, which report to the dental
office within 24 hours.
3. Mechanical exposures less than I sq mm, surrounded by clear dentin in
an asymptomatic vital deciduous tooth. 4. Mechanical or carious
exposures less than 1 sq mm in an asymptomatic vital young permanent
tooth.
5.Small pulp exposures produced during cavity preparation i.e. pin point
exposure surrounded by sound dentin.
6. When the tooth is not painful, with the exception of discomfort caused
by FOOD intake. 7. Minimal or no bleeding from the exposure site.
CONTRAINDICATIONS
1. Large pulp exposures.
2. Presence of caries surrounding the exposure site.
3. Excessive bleeding indicates hyperemia or pulpal inflammation.
4. Pain at night.
5. Spontaneous pain.
6. Tooth MOBILITY.
7. Thickening of periodontal membrane
8. Intraradicular radiolucency
9. Purulent or serous exudates
10. Swelling
11. Fistula
12. Root resorption
13. Pulpal calcification
TECHNIQUE OF DIRECT PULP CAPPING
Rubber dam provides only means of working in a sterile environment, so
it has to be used. ↓ Once an exposure is encountered, further
manipulation of pulp is avoided. ↓ Cavity should be irrigated with saline,
chloramines T or distilled water. ↓ Hemorrhage is arrested with light
pressure from sterile cotton pellets. ↓ Place the pulp capping material,
on the exposed pulp with application of minimal pressure so as to avoid
forcing the material into pulp chamber. ↓ Place temporary restoration.
↓ Final restoration is done after determining the success of pulp capping
which is done by determination of dentinal bridge, maintenance of pulp
.vitality, lack of pain and minimal inflammatory response
MEDICATIONS AND MATERIAL USED FOR PULP CAPPING
Ca(OH) 2 : The greatest benefit of Ca(OH)2 is the stimulation of
reparative dentin bridge, due to a high alkalinity, which leads to enzyme
phosphatase being activated and thus releasing of inorganic phosphate
from the blood (calcium phosphate) leading to formation or dentinal
bridge. It also has an antibacterial action. When calcium hydroxide is
applied directly to pulp tissue, there is necrosis of the adjacent pulp
tissue and inflammation of the contiguous tissue. Compounds of similar
alkalinity cause liquefaction necrosis when applied to pulp tissue. Internal
resorption may occur after pulp exposure and capping with calcium
hydroxide. Calcium from Dentin Bridge comes from the blood stream.
The action of calcium hydroxide to form Dentin Bridge appears to be a
result of low grade irritation in the underlying pulpal tissue after
)application.
Corticosteroids and antibiotics: BROSCH J.W introduced this combination
in 1966. These agents include Neomycin and hydrocortisone; Ledermix
(Ca (OH) 2 and prednisolone), Penicillin or Vancomycin with Ca (OH) 2.
Inert materials: Isobutyl Cynoacrylate and Tricalcium phosphate ceramic.
Collagen fibers: Collagen fibers influence mineralization and are less
irritant than Ca (OH) 2 with dentin bridge formation in 8 weeks. 4-META
adhesive: The main advantage of 4-META adhesive is that it can soak into
the pulp, polymerize there and form a hybrid layer with the pulp thereby
providing adequate sealing Direct bonding: Recent advances in total etch
direct bonding have evoked an interest in application for pulp therapy.
Here polygenic film can be layered over an exposure site without
displacing pulp tissue and onto surrounding dentin where it penetrates
the tubules.
Isobutyl cyanoacrylate: It is an excellent pulp capping agent because of its
haemostatic and bacteriostatic properties; at the same time it causes less
inflammation than calcium hydroxide. But it can not be regarded as an
adequate therapeutic alternative to calcium hydroxide since it does not
produce a continuous barrier of a reparative dentin following application
of the exposed pulp tissue. Disadvantage is that it is cytotoxic when
freshly polymerized. Denaturated albumin: This protein has calcium
binding properties. If a pulp exposure is capped with a protein, the
protein may become a matrix for calcifation, thereby increasing the
chances of biologic obliteration. Laser: ANDREAS MERITZ 1n 1998
evaluated the effect of direct pulp capping. Bone morphogenic protein
(BMP): The demineralized bone matrix could stimulate new bone
formation when implanted to ectopic sites such as muscles. The
implications for pulp therapy are immense as it is capable of inducing
reparative dentin.
Properties: 1. It is biocompatible material and its sealing ability is better
than that of amalgam or ZOE.
2. Initial pH is 10.2and set pH is 12.5.
3. The setting time of cement is 4 hours.
4. The compressive strength is 70 MPA, which is comparable to that of
IRM. 5. Low cytotoxity- it presents with minimal inflammation if extended
beyond the apex. Action: It has ability to stimulate cytokine and
interleukins release from blood cells, indicating that it actively promotes
Mineral trioxide aggregate (MTA): TORABINEJAB described the physical
and chemical properties of MTA in 1995. it is ash colored powder made
primarily of fine hydrophilic particles of tricalcium aluminates, tricalcium
silicate, silicate oxide, tricalcium oxide and bismuth oxide is added for
radio-opacity. When compared with calcium hydroxide, MTA produced
significantly more dentinal bridging in shorter period of time with
significantly less inflammation. Dentin deposition has began earlier with
MTA. The disadvantage of this technique is that 3 to 4 hours is needed for
setting of MTA after placement. The procedure involves placing MTA
directly over the exposure site and sealing the tooth temporarily to allow
the cement to harden. The tooth is later reentered and permanently
sealed over the set MTA with an etched, dentin bonding agent and
composite resin to prevent future bacterial micro leakage. hard tissue
formation
References
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