Pulp capping

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Sedative material placed over exposed or nearly exposed pulp 1) crown 2) root 3) restoration 4) pulp cap 5) pulp chamber Pulp cap.png
Sedative material placed over exposed or nearly exposed pulp 1) crown 2) root 3) restoration 4) pulp cap 5) pulp chamber
Pulpal dentin junction. 1) outside tooth/enamel 2) dentin tubule 3) dentin 4) odontoblastic process 5) predentin 6) odontoblast 7) capillaries 8) fibroblasts 9) nerve 10) artery/vein 11) cell-rich zone 12) cell-poor zone 13) pulp chamber Pulpal dentin junction.png
Pulpal dentin junction. 1) outside tooth/enamel 2) dentin tubule 3) dentin 4) odontoblastic process 5) predentin 6) odontoblast 7) capillaries 8) fibroblasts 9) nerve 10) artery/vein 11) cell-rich zone 12) cell-poor zone 13) pulp chamber

Pulp capping is a technique used in dental restorations to protect the dental pulp, after it has been exposed, or nearly exposed during a cavity preparation, from a traumatic injury, or by a deep cavity that reaches the center of the tooth, causing the pulp to die. [1] Exposure of the pulp causes pulpitis (an inflammation which can become irreversible, leading to pain and pulp necrosis, and necessitating either root canal treatment or extraction). [1] The ultimate goal of pulp capping or stepwise caries removal is to protect a healthy (or reversibly inflammed) dental pulp, and avoid the need for root canal therapy.

Contents

When dental caries is removed from a tooth, all or most of the infected and softened enamel and dentin are removed. This can lead to the pulp of the tooth either being exposed or nearly exposed. [1] To prevent the pulp from deteriorating when a dental restoration gets near the pulp, the dentist will place a small amount of a sedative dressing, such as calcium hydroxide or MTA. These materials protect the pulp from noxious agents (heat, cold, bacteria) and stimulate the cell-rich zone of the pulp to lay down a bridge of reparative dentin. Dentin formation usually starts within 30 days of the pulp capping (there can be a delay in onset of dentin formation if the odontoblasts of the pulp are injured during cavity removal) and is largely completed by 130 days. [2] : 491–494 

As of 2021, recent improvements in dressing materials have significantly increased the success rates of pulp capping teeth with cavities. [3]

Two different types of pulp cap are distinguished. In direct pulp capping, the protective dressing is placed directly over an exposed pulp; and in indirect pulp capping, a thin layer of softened dentin, that if removed would expose the pulp, is left in place and the protective dressing is placed on top. [4] A direct pulp cap is a one-stage procedure, whereas a stepwise caries removal is a two-stage procedure over about six months.

Direct

Success rates (% of teeth not needing more treatment) for the capping of pulp exposed by cavities, as of 2021 [3]
Protective material6 months1 year2-3 years4-5 years
Mineral trioxide aggregate 91%86%84%81%
Biodentine 91%86%86%[no data]
Calcium hydroxide 74%65%59%56%

This technique is used when a pulpal exposure or near-exposure occurs, either due to caries extending to the pulp chamber, or accidentally, during caries removal. It is only feasible if the exposure is made through uninfected dentin, and any pulpitis is reversible (that is, there is no recent history of spontaneous pain, indicating irreversible pulpitis) and a bacteria-tight seal can be applied. [4] [ needs update ]

Once the exposure is made, the tooth is isolated from saliva to prevent contamination by use of a dental dam, if it was not already in place. The tooth is then washed and dried, and the protective material placed, followed finally by a dental restoration which gives a bacteria-tight seal to prevent infection. [4]

Since pulp capping is not always successful in maintaining the vitality of the pulp, the dentist will usually keep the status of the tooth under review for about 1 year after the procedure. [4] Success rates (the chance that the tooth will be preserved) have risen with newer protective materials. [3]

Indication for Direct Pulp Capping

Indication for Direct Pulp Capping: [5]

Contraindication for Direct Pulp Capping

Contraindication for Direct Pulp Capping: [5]

Indirect

In 1938, Bodecker introduced the Stepwise Caries Excavation (SWE) Technique for treatment of teeth with deep caries for preservation of Pulp vitality. [6] This technique is used when most of the decay has been removed from a deep cavity, but some softened dentin and decay remains over the pulp chamber that if removed would expose the pulp and trigger irreversible pulpitis. Instead, the dentist intentionally leaves the softened dentin/decay in place, and uses a layer of protective temporary material which promotes remineralization of the softened dentin over the pulp and the laying down of new layers of tertiary dentin in the pulp chamber. The color of the carious lesion changes from light brown to dark brown, the consistency goes from soft and wet to hard and dry so that Streptococcus Mutans and Lactobacilli have been significantly reduced to a limited number or even zero viable organisms and the radiographs show no change or even a decrease in the radiolucent zone. [7] A temporary filling is used to keep the material in place, and about 6 months later, the cavity is re-opened and hopefully there is now enough sound dentin over the pulp (a "dentin bridge") that any residual softened dentin can be removed and a permanent filling can be placed. This method is also called "stepwise caries removal." [4] [8] The difficulty with this technique is estimating how rapid the carious process has been, how much tertiary dentine has been formed and knowing exactly when to stop excavating to avoid pulp exposure. [9]

Materials

The following materials have been studied as potential materials for direct pulp capping. However, calcium hydroxide and mineral trioxide aggregate (MTA) are the preferred material of choice in clinical practice due to their favourable outcome.

Zinc oxide eugenol

Zinc Oxide Eugenol (ZOE) is a commonly used material in dentistry. The use of ZOE as a pulp capping material remains controversial. This is due to Eugenol, being cytotoxic to the pulp are present in large quantity in this formulation. Also due to its nature of non-adhesive, it leads to poor coronal seal hence increases micro-leakage. Studies have demonstrated unfavourable results for ZOE when compared to calcium hydroxide as a direct pulp capping material as it causes pulpal necrosis. [10]

Glass and resin modified glass ionomer

Both Glass Ionomer (GI) and Resin Modified Glass Ionomer (RMGIC) has been widely used as a lining or base material for deep cavities where pulp is in close proximity. This is due to its superior properties of good biocompatibility and adhesive nature, providing coronal seal to prevent bacteria infiltration. However, they are not a material of choice for direct pulp capping. When the use of RMGIC and calcium hydroxide has been studied as direct pulp capping agents, RMGIC has demonstrated increase in chronic inflammation in pulpal tissues and lack of reparative dentine bridge formation. [10]

Adhesive system

Materials that fall under this category include 4-META-MMA-TBB adhesives and hybridizing dentine bonding agents. The idea of using adhesive materials for direct pulp capping has been explored two decades ago. Studies have demonstrated that it encourages bleeding due to its vasodilating properties hence impairing polymerisation of the material, affecting its ability to provide a coronal seal when used as a pulp capping agent. In addition, the material triggers chronic inflammation even without the presence of bacteria makes it an unfavourable condition for pulp healing to take place. Most importantly, its toxicity to human pulp cells once again makes it an unacceptable material of choice. [10]

Calcium hydroxide cement

Calcium hydroxide (CaOH) is an organo-metallic cement that was introduced into dentistry in the early twentieth century [11] and there have since been many advantages to this material described in much of the available literature. CaOH has a high antimicrobial activity which has been shown to be outstanding. [12] [13] In one experiment conducted by Stuart et al. (1991), bacteria-inoculated root canals of extracted human teeth were treated with CaOH for 1 hour against a control group with no treatment and the results yielded 64-100% reductions in all viable bacteria. [12] CaOH also has a high pH and high solubility, thus it readily leaches into the surrounding tissues. [14] This alkaline environment created around the cement has been suggested to give beneficial irritancy to pulpal tissues and stimulates dentine regeneration. One study further demonstrated that CaOH causes release of growth factors TGF-B1 and bioactive molecules from the dentine matrix which induces the formation of dentine bridges. [15]

CaOH does however have significant disadvantages. The set cement has low compressive strength and cannot withstand or support condensation of a restoration. [14] [16] It is thus good practice to place a stronger separate lining material (e.g. glass ionomer or resin-modified glass ionomer) over CaOH before packing the final restorative material. [10] CaOH cement is not adhesive to tooth tissues and thus does not provide a coronal seal. [10] In pulp perfusion studies, CaOH has shown to insufficiently seal all dentinal tubules, and presence of tunnel defects (patent communications within reparative dentine connecting pulp and exposure sites) indicate a potential for microleakage when CaOH is used. [14] [17] It is suggested that an adhesive coronal restoration be used above the CaOH lining to provide adequate coronal seal. Because of its many advantageous properties and long-standing success in clinical use, it has been used as a control material in multiple experiments with pulp capping agents over the years [18] [19] and is considered the gold standard dental material for direct pulp capping to date. [20]

Mineral trioxide aggregate

Mineral trioxide aggregate (MTA) is a recent development of the 1990s [21] initially as a root canal sealer but has seen increased interest in its use as a direct pulp capping material. [10] The material comprises a blend of tricalcium silicate, dicalcium silicate and tricalcium aluminate; bismuth oxide is added to give the cement radiopaque properties to aid radiological investigation. [21] MTA has been shown to produce CaOH as a hydration product [22] and maintains an extended duration of high pH in lab conditions. [23] Similar to CaOH, this alkalinity potentially provides beneficial irritancy and stimulates dentine repair and regeneration. [24] MTA has also demonstrated reliable and favourable healing outcomes on human teeth when used as a pulp cap on teeth diagnosed as nothing more severe than reversible pulpitis. [25] There is also less coronal microleakage of MTA in one experiment comparing it to amalgam [26] thus suggesting some tooth adhesion properties. MTA also comes in white and grey preparations [27] which may aid visual identification clinically. Disadvantages have also been described for MTA. Grey MTA preparations can potentially cause tooth discolouration. [10] MTA also takes a long time (up to 2 hours 45 minutes) to set completely [28] thus preventing immediate restoration placement without mechanical disruption of the underlying MTA. It has been suggested that a pulp capped with MTA should be temporised to allow for the complete setting of MTA, [10] and the patient to present at a second visit for placement of the permanent restoration. [25] MTA also has for difficult handling properties and is a very expensive material, thus is less cost effective as compared to CaOH. [10]

Although MTA shows great promise which is possibly attributed to its adhesive properties and ability to act as a source of CaOH release, [10] the available literature and experimental studies of MTA is limited due to its recency. Studies that compare pulp capping abilities of MTA to CaOH in human teeth yielded generally equal and similarly successful healing outcomes at a histological level from both materials. [29] [30]

Success rates

There have been several studies conducted on the success rates of direct and indirect pulp capping using a range of different materials. One study of indirect pulp capping recorded success rates of 98.3% and 95% using bioactive tricalcium silicate [Ca3SiO5]-based dentin substitute and light-activated calcium hydroxide [CA(OH)2]-based liner respectively. [31] These results show no significant difference, nor do the results from an indirect pulp capping experiment comparing calcium silicate cement (Biodentine) and glass ionomer cement, which had clinical success rates of 83.3%. [32] A further study testing medical Portland cement, Mineral Trioxide Aggregate (MTA) and calcium hydroxide in indirect pulp treatment found varying success rates of 73%-93%. This study concluded that indirect pulp capping had a success rate of 90.3% regardless of which material was used but stated that it is preferable to use non-resorbing materials where possible. [33]

Similar studies have been conducted of direct pulp capping, with one study comparing ProRoot Mineral Trioxide Aggregate (MTA) and Biodentine which found success rates of 92.6% and 96.4% respectively. [34] This study was conducted on 6-18 year old patients, while a comparable study conducted on mature permanent teeth found success rates of 84.6% using MTA and 92.3% using Biodentine. [35] Calcium hydroxide has also been tested on its use in indirect pulp capping and was found to have a success rate of 77.6%, compared to a success rate of 85.9% for MTA in another study. [36]

A systematic review attempted to compare success rates of direct pulp capping and indirect pulp capping and found that indirect pulp capping had a higher level of success but found a low quality of evidence in studies on direct pulp capping. [37] More research will be needed to provide a comprehensive answer.

See also

Related Research Articles

Dental products are specially fabricated materials, designed for use in dentistry. There are many different types of dental products, and their characteristics vary according to their intended purpose.

<span class="mw-page-title-main">Dentin</span> Calcified tissue of the body; one of the four major components of teeth

Dentin or dentine is a calcified tissue of the body and, along with enamel, cementum, and pulp, is one of the four major components of teeth. It is usually covered by enamel on the crown and cementum on the root and surrounds the entire pulp. By volume, 45% of dentin consists of the mineral hydroxyapatite, 33% is organic material, and 22% is water. Yellow in appearance, it greatly affects the color of a tooth due to the translucency of enamel. Dentin, which is less mineralized and less brittle than enamel, is necessary for the support of enamel. Dentin rates approximately 3 on the Mohs scale of mineral hardness. There are two main characteristics which distinguish dentin from enamel: firstly, dentin forms throughout life; secondly, dentin is sensitive and can become hypersensitive to changes in temperature due to the sensory function of odontoblasts, especially when enamel recedes and dentin channels become exposed.

<span class="mw-page-title-main">Pulp (tooth)</span> Part in the center of a tooth made up of living connective tissue and cells called odontoblasts

The pulp is the connective tissue, nerves, blood vessels, and odontoblasts that comprise the innermost layer of a tooth. The pulp's activity and signalling processes regulate its behaviour.

<span class="mw-page-title-main">Crown (dental restoration)</span> Dental prosthetic that recreates the visible portion of a tooth

In dentistry, a crown or a dental cap is a type of dental restoration that completely caps or encircles a tooth or dental implant. A crown may be needed when a large dental cavity threatens the health of a tooth. Some dentists will also finish root canal treatment by covering the exposed tooth with a crown. A crown is typically bonded to the tooth by dental cement. They can be made from various materials, which are usually fabricated using indirect methods. Crowns are used to improve the strength or appearance of teeth and to halt deterioration. While beneficial to dental health, the procedure and materials can be costly.

<span class="mw-page-title-main">Deciduous teeth</span> First set of teeth in diphyodonts

Deciduous teeth or primary teeth, also informally known as baby teeth, tothlings, milk teeth, or temporary teeth, are the first set of teeth in the growth and development of humans and other diphyodonts, which include most mammals but not elephants, kangaroos, or manatees, which are polyphyodonts. Deciduous teeth develop during the embryonic stage of development and erupt during infancy. They are usually lost and replaced by permanent teeth, but in the absence of their permanent replacements, they can remain functional for many years into adulthood.

Pulpitis is inflammation of dental pulp tissue. The pulp contains the blood vessels, the nerves, and connective tissue inside a tooth and provides the tooth's blood and nutrients. Pulpitis is mainly caused by bacterial infection which itself is a secondary development of caries. It manifests itself in the form of a toothache.

<span class="mw-page-title-main">Dentinogenesis imperfecta</span> Medical condition

Dentinogenesis imperfecta (DI) is a genetic disorder of tooth development. It is inherited in an autosomal dominant pattern, as a result of mutations on chromosome 4q21, in the dentine sialophosphoprotein gene (DSPP). It is one of the most frequently occurring autosomal dominant features in humans. Dentinogenesis imperfecta affects an estimated 1 in 6,000-8,000 people.

Dentin hypersensitivity is dental pain which is sharp in character and of short duration, arising from exposed dentin surfaces in response to stimuli, typically thermal, evaporative, tactile, osmotic, chemical or electrical; and which cannot be ascribed to any other dental disease.

Dens evaginatus is a rare odontogenic developmental anomaly that is found in teeth where the outer surface appears to form an extra bump or cusp.

<span class="mw-page-title-main">Dentin dysplasia</span> Medical condition

Dentin dysplasia (DD) is a rare genetic developmental disorder affecting dentine production of the teeth, commonly exhibiting an autosomal dominant inheritance that causes malformation of the root. It affects both primary and permanent dentitions in approximately 1 in every 100,000 patients. It is characterized by the presence of normal enamel but atypical dentin with abnormal pulpal morphology. Witkop in 1972 classified DD into two types which are Type I (DD-1) is the radicular type, and type II (DD-2) is the coronal type. DD-1 has been further divided into 4 different subtypes (DD-1a,1b,1c,1d) based on the radiographic features.

<span class="mw-page-title-main">Root canal treatment</span> Dental treatment

Root canal treatment is a treatment sequence for the infected pulp of a tooth which is intended to result in the elimination of infection and the protection of the decontaminated tooth from future microbial invasion. Root canals, and their associated pulp chamber, are the physical hollows within a tooth that are naturally inhabited by nerve tissue, blood vessels and other cellular entities. Together, these items constitute the dental pulp.

Mineral trioxide aggregate (MTA) is an alkaline, cementitious dental repair material. MTA is used for creating apical plugs during apexification, repairing root perforations during root canal therapy, and treating internal root resorption. It can be used for root-end filling material and as pulp capping material. It has better pulpotomy outcomes than calcium hydroxide or formocresol, and may be the best known material, as of 2018 data. For pulp capping, it has a success rate higher than calcium hydroxide, and indistinguishable from Biodentin.

<span class="mw-page-title-main">Pulpotomy</span>

Pulpotomy is a minimally invasive procedure performed in children on a primary tooth with extensive caries but without evidence of root pathology. The minimally invasive endodontic techniques of vital pulp therapy (VPT) are based on improved understanding of the capacity of pulp (nerve) tissues to heal and regenerate plus the availability of advanced endodontic materials. During caries removal, this results in a carious or mechanical pulp exposure (bleeding) from the cavity. During pulpotomy, the inflamed/diseased pulp tissue is removed from the coronal pulp chamber of the tooth leaving healthy pulp tissue which is dressed with a long-term clinically successful medicament that maintains the survival of the pulp and promotes repair. There are various types of medicament placed above the vital pulp such as Buckley's Solution of formocresol, ferric sulfate, calcium hydroxide or mineral trioxide aggregate (MTA). MTA is a more recent material used for pulpotomies with a high rate of success, better than formocresol or ferric sulfate. It is also recommended to be the preferred pulpotomy agent in the future. After the coronal pulp chamber is filled, the tooth is restored with a filling material that seals the tooth from microleakage, such as a stainless steel crown which is the most effective long-term restoration. However, if there is sufficient remaining supporting tooth structure, other filling materials such as amalgam or composite resin can provide a functional alternative when the primary tooth has a life span of two years or less. The medium- to long-term treatment outcomes of pulpotomy in symptomatic permanent teeth with caries, especially in young people, indicate that pulpotomy can be a potential alternative to root canal therapy (RCT).

Pulp necrosis is a clinical diagnostic category indicating the death of cells and tissues in the pulp chamber of a tooth with or without bacterial invasion. It is often the result of many cases of dental trauma, caries and irreversible pulpitis.

In dentistry, the smear layer is a layer found on root canal walls after root canal instrumentation. It consists of microcrystalline and organic particle debris. It was first described in 1975 and research has been performed since then to evaluate its importance in bacteria penetration into the dentinal tubules and its effects on endodontic treatment. More broadly, it is the organic layer found over all hard tooth surfaces.

<span class="mw-page-title-main">Pulp stone</span>

Pulp stones are nodular, calcified masses appearing in either or both the coronal and root portion of the pulp organ in teeth. Pulp stones are not painful unless they impinge on nerves.

The Hall Technique is a minimally-invasive treatment for decayed baby back (molar) teeth. Decay is sealed under preformed crowns, avoiding injections and drilling. It is one of a number of biologically orientated strategies for managing dental decay.

<span class="mw-page-title-main">Regenerative endodontics</span> Dental specialty

Regenerative endodontic procedures is defined as biologically based procedures designed to replace damaged structures such as dentin, root structures, and cells of the pulp-dentin complex. This new treatment modality aims to promote normal function of the pulp. It has become an alternative to heal apical periodontitis. Regenerative endodontics is the extension of root canal therapy. Conventional root canal therapy cleans and fills the pulp chamber with biologically inert material after destruction of the pulp due to dental caries, congenital deformity or trauma. Regenerative endodontics instead seeks to replace live tissue in the pulp chamber. The ultimate goal of regenerative endodontic procedures is to regenerate the tissues and the normal function of the dentin-pulp complex.

An Endodontic crown or endocrown is a single prostheses fabricated from reinforced ceramics, indicated for endodontically treated molar teeth that have significant loss of coronal structure. Endocrowns are formed from a monoblock containing the coronal portion invaded in the apical projection that fills the pulp chamber space, and possibly the root canal entrances; they have the advantage of removing lower amounts of sound tissue compared to other techniques, and with much lower chair time needed. They are luted to the tooth structure by an adhesive material. The ceramic can be milled using computer-aided techniques or molded under pressure. Endocrowns can be an alternative to conventional crown restorations.

Apexification is a method of dental treatment to induce a calcific barrier in a root with incomplete formation or open apex of a tooth with necrotic pulp. Pulpal involvement usually occurs as a consequence of trauma or caries involvement of young or immature permanent teeth. As a sequelae of untreated pulp involvement, loss of pulp vitality or necrotic pulp took place for the involved teeth.

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  34. ↑ Parinyaprom N, Nirunsittirat A, Chuveera P, Na Lampang S, Srisuwan T, Sastraruji T, Bua-On P, Simprasert S, Khoipanich I, Sutharaphan T, Theppimarn S, Ue-Srichai N, Tangtrakooljaroen W, Chompu-Inwai P (December 2017). "Outcomes of Direct Pulp Capping by Using Either ProRoot Mineral Trioxide Aggregate or Biodentine in Permanent Teeth with Carious Pulp Exposure in 6- to 18-Year-Old Patients: A Randomized Controlled Trial". Journal of Endodontics. 44 (3): 341–348. doi:10.1016/j.joen.2017.10.012. PMID   29275850. S2CID   3533472.
  35. ↑ Linu S, Lekshmi MS, Varunkumar VS, Sam Joseph VG (October 2017). "Treatment Outcome Following Direct Pulp Capping Using Bioceramic Materials in Mature Permanent Teeth with Carious Exposure: A Pilot Retrospective Study". Journal of Endodontics. 43 (10): 1635–1639. doi:10.1016/j.joen.2017.06.017. PMID   28807371.
  36. ↑ Çalışkan MK, Güneri P (January 2017). "Prognostic factors in direct pulp capping with mineral trioxide aggregate or calcium hydroxide: 2- to 6-year follow-up". Clinical Oral Investigations. 21 (1): 357–367. doi:10.1007/s00784-016-1798-z. PMID   27041110. S2CID   25369177.
  37. ↑ Coll JA, Seale NS, Vargas K, Marghalani AA, Al Shamali S, Graham L (January 2017). "Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-analysis". Pediatric Dentistry. 39 (1): 16–123. PMID   28292337.
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