Direct pulp capping Delivered by: Dr. Rajeev Kumar Singh
Direct Pulp Capping
Indications Small pinpoint mechanical exposure of < 1 mm diameter Recent traumatic (<24 h) pulp exposure
contra-Indications Spontaneous pain/ Nocturnal pain X Thickening of PDL Uncontrollable hemorrhage at the time of exposure X Excessive tooth mobility Purulent or serous exudate from the exposure X Furcation/periapical radiolucency
objectives of dpc Seal the pulp against bacterial leakage Maintain the vitality of the underlying pulp tissue Encourage the pulp to wall off the exposure site by initiating a dentin bridge
success of dpc Non inflamed pulp Nice sealing of capping material & restoration HIGH SUCCESS RATE Application of a non toxic capping material Hemorrhage properly controlled
Procedure of dpc Once an exposure is encountered, further manipulation of pulp is avoided Cavity should be irrigated with saline or distilled water or chlorhexidine 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 pulp of capping which is done by determination of dentinal bridge, maintenance of pulp vitality and lack of pain.
Procedure in brief A radiopaque capping material is placed directly onto the surface of vital pulp tissue at the site of the pulp exposure followed by a base The final restoration is placed over the base The status of the pulp and peri-radicular tissues should be assessed through periodic recall examinations.
silent feature of clinically successful dpc Maintenance of pulp vitality Absence of sensitivity or pain Minimal pulp inflammatory responses Absence of radiographic signs of dystrophic changes Teeth with immature roots should show continued root development and apexogenesis
Decision of doing DPC Exposure permits the capping material to make direct contact with the vital pulp tissue Patient has been fully informed that endodontic treatment may be indicated in the future
Enzymes & matrix components Zinc Oxide Eugenol Calcium Hydroxide Collagen Growth Factors Glass ionomers cement Isobutyl cyanoacrylate Bio dentine Resin Bonding agents Laser Bone morphogenic protein Alpha-Tricalcium Phosphate Bio aggregates Theracal Corticosteroids & antibiotics Mineral Trioxide Aggregate (MTA) Various materials used for DPC
Calcium hydroxide Ca(OH)2 Originally introduced by Herman in 1930 as a pulp-capping agent It is the most commonly used dressing for treatment of the vital pulp
Mechanism of action of Ca(OH)2 A calcified barrier may be induced when calcium hydroxide is used as a pulp-capping agent or placed in the root canal in contact with healthy pulpal or periodontal tissue.
Because of the high p. H of the material, up to 12. 5, a superficial layer of necrosis occurs in the pulp to a depth of up to 2 mm. Beyond this layer only a mild inflammatory response is seen, and providing the operating field was kept free of bacteria when the material was placed, a hard tissue barrier may be formed.
The hydroxyl group is considered to be the most important component of calcium hydroxide as it provides an alkaline environment which encourages repair and active calcification. The alkaline p. H induced not only neutralizes lactic acid from the osteoclasts, thus preventing a dissolution of the mineral components of dentine, but could also activate alkaline phosphatases which play an important role in hard tissue formation. The calcified material which is produced appears to be the product of both odontoblasts and connective tissue cells and may be termed osteodentine. The barrier, which is composed of osteodentine, is not always complete and is porous.
Mineral Trioxide Aggregate or MTA) was developed for use as a dental root repair material by Dr. Mahmoud Torabinejad MTA is used for creating an apical plug during apexification, repairing root perforations during root canal therapy and treating internal root resorption and can be used as both a root-end filling material and pulp-capping material.
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
Properties • Low or no solubility • PH value 10. 2 after mixing and rises to 12. 5 after 3 hours • Antibacterial effect • Induces pulpal cell proliferation • Stimulation of mineralized tissue formation
Bio dentine was developed by Septodent. It is a calcium-silicate based formulation which is suitable as a dentin replacement material whenever origin dentin is damaged.
Thera. Cal LC Thera. Cal Lc is a light cured, resin modified calcium silicate filled liner. It performs as an insulator/barrier and protectant of the dental pulp complex.
Bioaggregate is a root canal repair material which is composed of ceramic nano particles. It promotes cementogenesis and forms a hermetic seal inside the root canal.
DPC in Primary teeth ? ? Reasons of failure High cellular content of pulp tissue Undifferentiated mesenchymal cells may give rise to odontoclasts, which may cause internal resorption Faster inflammatory response Poor localization of infection
Indirect pulp capping Direct pulp capping Indication Ø Ideally, used when pulpal inflammation has been judged to be minimal and complete removal of caries would cause a pulp exposure Ø Small mechanical exposure less than 1 mm which is surrounded by sound dentin Ø Light red bleeding from the exposure site that can be controlled by cotton pellet Ø Traumatic exposure in a dry, clean field, which report to the dental office within 24 hrs Contraindication Ø Any signs of pulpal or periapical pathology Ø Soft leathery dentin covering a very large area of the cavity, in a non restorable tooth Contraindication Ø Ø Ø Ø Pain at night Spontaneous pain Tooth mobility Thickening of PDL Intra radicular radiolucency Excess bleeding at the exposure site Purulent or serious exudate
Summery Calcium hydroxide remains the “gold standard” for direct pulp capping. It has the longest track record of clinical success and is the most cost-effective of all materials. MTA demonstrates comparable results to calcium hydroxide as a direct pulp capping agent in short-term data. Zinc oxide and eugenol formulations, glass ionomers, resinmodified glass ionomers and adhesives are poor direct pulp capping agents and should be avoided for this use.
Summery DPC has been found to be less successful in primary teeth than IPC or coronal pulpotomy. DPC tends to be more successful in young permanent teeth.