PULP CAPPING AGENTS

RAJANA RAGHUNATHPG STUDENTDEPT. OF CONS & ENDOKVG DENTAL COLLEGE & HOSPITAL

Never must the physician say the disease is incurable. By that admission he denies God, our Creator; He doubts Nature with her profuseness of hidden powers and mysteries. —Paracelsus

CONTENTS Introduction Indirect pulp capping Direct pulp capping Historical review Pulp capping agents Conclusion References

Calcium hydroxide

Zinc oxide Eugenol

GIC

MTA

Biodentine

Emdogain

Lazer

Enzymes

Growth factors

Isobutyl Cyanoacrylate

Stem cells

Theracal

Polycaboxylate cement

Fluocinolone acetonide

INTRODUCTION Pulp protection is the term coined by AAPD which recommends the placement of a

protective base or a liner on the pulpal and axial walls of the cavity preparation to act as a protective barrier between the restorative material and the tooth

Pulp treatment modality can be classified to 2 categories-

A- conservative Treatment-Which aims at maintaining pulp vitality,include1. Protective base.2. Indirect pulp treatment.3. Direct pulp capping.4. Pulpotomy.

B-Radical treatment-consisting of pulpectomy and root filling

INDIRECT PULP CAPPING-

It is defined by Ingle as a procedure where in small amount of carious dentin is retained in deep areas of cavity to avoid exposure of pulp, followed by placement of a suitable medicament and restorative material that seals off the carious dentin and encourages pulp recovery.

A radiopaque base is placed over the remaining affected dentin to stimulate healing and repair. The tooth is then restored with a material that seals the involved dentin from the oral environment.

Indication permanent teeth diagnosed with normal pulp with no signs or symptoms of pulpitis

Contra-indication Large pulp exposure, non-restorable

tooth or tooth with low prognosis.

Infected dentin Affected dentinHighly demineralized▪Unremineralizable▪Superficial layer▪Lacking sensation▪Stained by 0.5% fuschin or i.e. 1.0% acid red solution

Ultrastructure: intertubular dentin greately demineralized, with irregular scattered crystals.Presence of deteriorated collagen fibers that have only distinct cross bands and no interbands.▪Should be excavated

Intermediately demineralized ▪Remineralizable collagen ▪Deeper layer ▪Sensitive ▪Does not stain

Ultrastructure: intertubular dentinPartially demineralized, but apatitie crystals bound like fringes to the Sound fibers with distinct Cross bands and interbands. ▪Should be left remineralize.

In a prepared cavity, remaining dentine thickness of more than 0.5 mm is ideal for avoiding pulpal inflammation

Reactionary dentine forms when remaining dentine thickness is 2.5- 0.01 mm due to presence of a layer of surviving odontoblasts in the area, whereas reparative dentine is formed following pulp exposure.

Very deep cavities greatly reduce the number of surviving odontoblasts and hence none remain to secrete tertiary dentine. Remaining dentine thickness not only influences vitality of the underlying pulp tissue but also determines the repair response.

In light of the knowledge of the importance of remaining dentine thickness, it is essential that sound dentine is never removed in order to accommodate for a lining, base or sealer material.

Direct Pulp Capping

The procedure in which the small exposure of the pulp ,encountered during cavity preparation or following a traumatic injury or due to caries, with a sound surrounding dentin ,is dressed with an appropriate biocompatible radio-opaque base in contact with the exposed pulp tissue prior to placing a restoration is termed as a direct pulp capping.

Objectives

The vitality of tooth should

be maintained.

No prolonged post-treatment

signs or symptoms of

sensitivity, pain or swelling should be evident.

Pulp healing and tertiary

dentin formation

should result.

There should be no

pathologic changes.

To create new dentin in the area of the

exposure and subsequent

healing of pulp

Indication Small mechanical exposures less than 1 mm which is surrounded by sound dentin.

Light red bleeding from the exposure site that can be controlled by cotton pellet.

Traumatic exposures in a dry ,clean field ,which report to the dental office within 24 hrs.

Contra-indication

Pain at night

Spontaneous pain

Tooth mobility

Thickening of periodontal membrane

Intraradicular radiolucency

Excess bleeding at the exposure site

Purulent or serous exudates

Historically, the first pulp capping procedure was performed in 1756, by the Phillip Pfaff, who packed a small piece of gold over an exposed vital pulp to promote healing.

A controversy has existed within dentistry as to what is more detrimental to the pulp: toxicity from dental materials or bacteria and/or their toxins. For many years, even decades, practitioners believed that some restorative materials “killed” pulps due to their inherent toxic properties. However, research since the mid-1970s has indicated that the pulp can tolerate a variety of restorative materials if bacteria and/or their toxins can be excluded from the pulp

Orban described the histopathology of the pulp and concluded that the cells of the pulp were the same as those of loose connective tissue. He believed these cells could differentiate and healing could occur in the dental pulp. In subsequent years much experimentation has taken place, with advocates both for and against pulp-capping and pulpotomy procedures

Because of the normal aging of the dental pulp, chances of successful pulp capping diminish with age. Increases in fibrous and calcific deposits and a reduction in pulpal volume may be observed in older pulps. With age the fibroblast proliferation observed in the teeth of young animals is significantly reduced.

Teeth with calcifications of the pulp chamber and root canals are not candidates for pulp-capping procedures. These calcifications are indicative of previous inflammatory responses or trauma and render the pulp less responsive to vital therapy

These long-standing inflammations with circulatory disturbances are frequently accompanied by apposition and resorption of the canal walls and calcification in the pulp. The inflammation, calcification, apposition, and resorption may increase under pulp caps, regardless of which material is used as the pulp-capping agent

According to Seltzer and Bender pulp capping should be discouraged for carious pulp exposures since microorganisms and inflammation are invariably associated.

Macroscopic examination of such exposures is difficult, and areas of liquefaction necrosis may be overlooked.

Location of the pulp exposures is an important consideration in the prognosis. If the exposure occurs on the axial wall of the pulp, with pulp tissue coronal to the exposure site, this tissue may be deprived of its blood supply and undergo necrosis, causing a failure. Then a RCT should be performed rather than a pulp cap.

Ideal Requirements

As suggested by Cohen and Combe

Zinc oxide-eugenol Germicidal agent

Used in indirect pulp capping due to its

This gives the pulp the chance for healing & regeneration

Direct contact After 24H of capping →a mass of red blood cells & PNLs. Demarcated from the

underlying tissue by zone of fibrin and inflammatory cells. After 2W of capping → pulp degeneration & chronic inflammation extends deep to the

apex. →chronic inflammation ,abscess formation and liquefaction necrosis.

Palliative affectExcellent initial sealKills bacteria present in carious lesionsSo arrests the caries process

Adhesive Liners A complete marginal seal Prevents bacterial intrusion Allowed pulp repair, characterized by a new odontoblast cell layer underlying the

dentin bridge formation.

Many studies have indicated that composite & resin-modified glass-ionomer are compatible with pulp tissue

According to Miyakoshi et al., 4-META adhesives and hybridizing dentin bonding agents provide superior adhesion to peripheral hard tissues and effective seal against micro leakage. But they have poor outcome due to its cytotoxic effect and absence of calcific bridge formation

Qureshi et al. Recent Advances in Pulp Capping Materials: An OverviewJ Clin Diagn Res. 2014 Jan; 8(1): 316–321.

The success of adhesive dentistry is dependent on etching the enamel and dentin. When phosphoric acid was used as an etching agent, in teeth with pulp exposures, it did not demonstrate pronounced inflammatory nor necrotic changes.

However Hebling et al. (1999), reported in their study that the (all bond 2) adhesive system did not appear to allow any pulp repair and does not appear to be indicated for pulp capping of human teeth

Costa et al. (2003), evaluated the response of pulps of rats capped with resin-modified glass-ionomer cement or self-etching adhesive system. Despite some inflammatory pulpal response, both experimental pulp-capping agents allowed pulpal healing characterized by cell-rich fibro dentin and tertiary dentin deposition

Glass Ionomer (GI) /Resin-Modifed Glass Ionomer (RMGI)

While not as cytotoxic as ZOE, GI/RMGI is also cytotoxic when in direct cell contact. Glass ionomer also provides an excellent bacterial seal and shows good

biocompatibility when used in close approximation but not in direct contact with the pulp

Fluoride release, coefficient of thermal expansion and modulus of elasticity similar to dentin.

Lack of dentin bridge formation. High solubility and slow setting rate. RMGIC as direct pulp capping agent exhibited chronic inflammation and lack of dentin

bridge formation; whereas the calcium hydroxide control groups showed significantly better pulpal healing

RDT- 0.5 – 0.25um – Ca(OH)2 & Composite shows faster deposition of tertiary dentin than GIC

Exposed pulps in non carious tooth – microleakage less than half that of Ca(OH)2

Calcium Hydroxide Many studies indicated that calcium hydroxide and calcium hydroxide compounds

are the gold standard in human teeth, against which new materials should be tested.

However, several disadvantages have been listed with the use of calcium hydroxide material. Presence of tunnels in dentin barrier, extensive dentin formation obliterating the pulp chamber, high solubility in oral fluids, and lack of adhesion and degradation after acid etching are some of the limitations reported

Accorinteet al. “Evaluation of Mineral Trioxide Aggregate and Calcium Hydroxide Cement as Pulp-capping Agents in Human Teeth”. JOE — Volume 34, Number 1, January 2008

Herman (1930) – Ca(OH)2 pulp capping 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.

When calcium hydroxide is applied directly to pulp tissue, there is necrosis of the

adjacent pulp tissue and inflammation of the contiguous tissue. Excellent antibacterial properties. Low cytotoxicity.

Mechanism of action Unique potential to induce mineralization Sciaky and Pisanti in 1960 observed that calcium ions present in the applied

calcium hydroxide do not become incorporated in the mineralized repaired tissue, which derives its mineral content solely from the dental pulp.

Forman observed that calcium hydroxide is an initiator rather than a substrate for repair

Hard setting calcium hydroxide preparations are recommended, as these cements release fewer hydroxyl ions than pure calcium hydroxide and are gentle to pulp

Hydroxyl Ions

Neutralizes acid produced by osteoclasts

Optimum pH for pyrophoshatase

activity

Inc levels of Ca ion- dependent

pyrophosphatase

Mineralization

Reduced levels of inhibitory

pyrphoshatase

Reduced serum flow

Reduced capillary

permeability

Calcium ions

Calcium Hydroxide

Advantages Disadvantages

Initially bactericidal then bacteriostatic Promotes healing and repair High pH stimulates fibroblasts Neutralizes low pH of acids Stops internal resorption Particles may obturate open tubules

• Does not exclusively stimulate dentinogenesis• Does not exclusively stimulate reparative dentin• Associated with primary tooth resorption• May dissolve after one year with cavosurface

dissolution• May degrade acid etching• Degrades upon tooth flexure • Marginal failure with amalgam condensation• Does not adhere to the dentin or resin restoration

Healing Zone of obliteration- pulp tissue in cantact, completely deranged & distorted. Zone of coagulation necrosis- takes the brunt of calcium hydroxide chemical

thrust. Schroder’s layer of firm necrosis and Stanley’s mummified zone Zone of dentin bridge formation- no distinct configuration. 0.3-0.7mm Line of demarcation btwn deepest level and subjacent vital pulp tissue. Glass and

Zander- calcium hydroxide with protein to form proteniate globulates.

Poor bonding to dentin, material resorption and mechanical instability are among them. As a result, calcium hydroxide does not prevent microleakage in the long run. The porosities (‘tunnel defects’) of the newly formed hard tissue may act as a portal of entry for microorganisms. These may cause secondary inflammation of the pulp tissue and are thought to be responsible for failed maintenance of tooth vitality. In addition, the high pH (12.5) of calcium hydroxide suspensions causes liquefaction necrosis at the surface of the pulp tissue

The 3 main available products are : Pulpdent, Dycal and Hydrex (MPC)

Dammaschke et al. A new bioactive cement for direct pulp capping. INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL. 2, NO. 2

Clinical success rates after direct pulp capping with Ca(OH)2 or with Ca(OH)2 compounds have been evaluated in different studies , and today this material is regarded as the gold standard.

The spectrum of success rates ranges from 13% to 96% . The difference in these rates is attributed to different potential prognostic factors that can influence the outcome of direct pulp capping such as length of follow-up, type of pulp exposure (carious or mechanical), presence of an extrapulpal blood clot between the pulp and the capping material, the area of pulp to which the capping material was applied, time elapsed to placement of a definitive restoration of the pulp-capped tooth, type of Ca(OH)2 used, presence or absence of infection as well as the age of the patients

Mente et al.Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: An Analysis of the Clinical Treatment Outcome. JOE — Volume 36, Number 5, May 2010

Mineral Trioxide Aggregate (MTA) In recent years a new cement (mineral trioxide aggregate [MTA]), developed in the 1990s

by Torabinejad and his coworkers at Loma Linda University (California), has become available as a root canal repair material and for direct pulp capping.

During the setting process, MTA has an initial pH of 10.2, which increases to up to 12.5 during the first few hours. Comp strength : 26.4 Mpa -24 hrs & 30.4 Mpa – 21 days.

MTA is a non-resorbable, ash-colored powder made primarily of fine hydrophilic particles of tricalcium aluminate, tricalcium silicate, silicate oxide, and tricalcium oxide. Prevents microleakage over the vital pulp Biocompatible Promotes regeneration of the original tissues when it is placed in contact with the dental

pulp or periradicular tissues. MTA has the ability to stimulate cytokine release from bone cells promotes hard tissue

formation.

It is a technique-sensitive material. When the material is in contact with moisture it becomes a colloid gel, it sets in approximately 3-4 hours, and bismuth oxide has been added for radiopacity

Initially, MTA was used in endodontics to seal off all pathways of communication between the root canal system and the external surface of the tooth

Pitt Ford et al. were the first to evaluate the performance of MTA for pulp capping in monkey’s teeth, and they demonstrated superior performance of MTA compared with calcium hydroxide

MTA powder

Hydration (in the presence of water/blood)

Calcium silicate hydrogel Ca(OH)2

3-4 hours

Porous gel soldifies to a hard increase in pH to 12.5Crystalline structure

According to Seux et al. , after contact with pulp tissue, MTA presents some structures that are similar to calcite crystals found in calcium hydroxide. They attract fibronectin, which is generally responsible for cellular adhesion and differentiation, as do calcium hydroxide.

According to Faraco and Holland, the presence of necrotic tissue nearest to the hard tissue bridge suggests that MTA, similar to calcium hydroxide, initially causes necrosis by coagulation in contact with pulp connective tissue. This reaction might occur because of the high alkalinity of the product, whose pH is near to 9 –10 .

Recently, Min et al. compared the cellular effects of Portland cement (the base of MTA) with other materials, including calcium hydroxide cement, on cultured human pulp cells. The results suggested that Portland cement is biocompatible and allows the expression of mineralization-related genes on cultured human pulp cells. These genes are responsible for inductive process on hard tissue bridge formation with MTA cement

Studies on pulp capping of carious-exposed permanent teeth with MTA have reported high success rates, which ranged from 93%–98%

In a clinical trial, a lower success rate of 56.2% was reported after direct pulp capping with MTA . However, no attempt was made to fully remove carious dentin as soon as pulpal bleeding was observed. The success of vital pulp therapy may depend on the complete removal of all disintegrated tissue

Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: an observational study. J Am Dent Assoc 2008;139:305–15.

Miles JP, Gluskin AH, Chambers D, Peters OA. Pulp capping with mineral trioxide aggregate (MTA): a retrospective analysis of carious pulp exposures treated by undergraduate dental students. Oper Dent 2010;35:20–8.

Marques et al.Outcome of Direct Pulp Capping with Mineral Trioxide Aggregate: A Prospective Study.JOE

Biodentine® (Septodont, Saint-Maur-des-Fosses, France) is a new generation material based on calcium silicate synthesized by bioactive technology

Biodentine stimulates release of TGF-β from pulpal cells, stimulating reparative dentin formation in a very short period of time. Particular growth factors from the TGF-ß family have the ability to initiate odontoblast differentiation and hence produce tertiary dentine by cell signalling

Popović Bajić M. et al. Direct Pulp Capping Using Biodentine.Serbian Dental Journal, vol. 61, No 2, 2014

Consists of a powder in a capsule and liquid in a pipette. The powder mainly contains tricalcium and dicalcium silicate - the principal

component of portland cement - as well as calcium carbonate. Zirconium dioxide serves as contrast medium.

The liquid consists of calcium chloride in aqueous solution with an admixture of polycarboxylate. The powder is mixed with the liquid in a capsule in the triturator for 30 seconds.

Hydration of tricalcium silicate- a hydrated calcium silicate gel and Ca(OH)2. The unreacted tricalcium silicate grains are surrounded by hydrated calcium

silicate gel, Once mixed, biodentine™ sets in approximately 10-12 minutes. The consistency of biodentine is similar to that of phosphate cement.

An experiment of damaged pulp fibroblasts was conducted to test for bioactivity. Of all the materials tested, only ProRoot® MTA and Biodentine™ were able to stimulate the formation of tertiary dentine. Both displayed presence of enhanced levels of TGF-ß. Biodentine™ also showed presence of other growth hormones (in addition to TGF-ß) which contribute to the formation of dentine bridges

About, I. (2011). Effets des matériaux bioactifs Biodentine TM et Calcipulpe® sur les étapes. London, UK: Septodent UK- R&D Department.

Another study of indirect pulp capping on rat molars concluded that Biodentine™ was able to stimulate (thick and dense) reactionary dentine formation, which stopped after about three months when a sufficient dentine barrier was formed. Studies conducted to test Biodentine™ for application as a direct pulp capping agent and for pulpotomy showed that it was well tolerated even when in direct contact with the pulp. It was even suggested that the quality of dentine bridges formed were better than those formed by calcium hydroxide alone

Patel et al. Preserving pulp vitality.Dental health.Volume 52 No 2 of 6 March 2013

Biodentine™ is both a dentin substitute base and a cement for maintaining pulp vitality and stimulating hard tissue formation, i.e. the formation of reactive or reparative (tertiary) dentin

Used for pulp capping, the material offers certain advantages over calcium hydroxide: It is stronger mechanically, less soluble and produces tighter seals.

Three major disadvantages of calcium hydroxide, notably material resorption, mechanical instability and the resultant failure of preventing microleakages are therefore avoided.

Compared to other materials such as Mineral Trioxide Aggregate, Biodentine™ handles easily and needs much less time for setting. Unlike other Portland cement-based products, it is sufficiently stable to be used for both for pulp protection and temporary fillings.

Dammaschke et al. A new bioactive cement for direct pulp capping. INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL. 2, NO. 2

Isobutyl Cyanoacrylate Cyanoacrylate is an adhesive that results from the chemical reaction between

formaldehyde and the esters of cyanoacetate 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.

Bhaskar SH et al., and Heys DR et al., investigated isobutyl cyanoacrylate and tricalcium phosphate ceramic as direct pulp capping materials. Although pulpal response in the form of reduced inflammation and unpredictable dentin bridging were found, but none of these materials have been promoted to the dental profession as a viable technique

Denaturated albumin:

This protein has calcium binding properties. If a pulp exposure is capped with a protein, the protein may become a matrix for calcification, thereby increasing the chances of biologic obliteration.

Laser

To overcome the histological deficits of electrosurgery. CO2 Laser , Argon Laser, Diode Laser, Erbium:Yttrium-Aluminum Garnet (Er.YAG). Laser radiation has been proposed for pulp treatment based on its haemostatic,

coagulative and sterilizing effects. Yasuda Y, et al., did a study to examine the effect of CO2 laser irradiation on

mineralization in dental pulp cells in rats and the results suggested that CO2 laser irradiation stimulated mineralization in dental pulp cells.

Advantages

Better clinical, radiographic, and histological results after using of laser for pulpotomy in primary teeth.

Patient did not present any pain or discomfort and no analgesic was needed in Diode laser pulpotomies.

Disadvantages The high cost.

Growth factors

Growth factors are biological modulators that are able to promote cell proliferation and differentiation.

It is considered that the biological modulators will be the promising materials that will revive the expectations for regeneration of the exposed pulp tissue, rather than, devitalization.

Formation of osteodentin and tubular dentin.Formation of more homogenous reparative dentinSuperior to calcium hydroxide in the mineralization inducing properties.High concentration is required.Half life is less.Appropriate dose response is required to avoid uncontrolled obliteration of pulp chamber.

Osteogenic proteins, such as bone morphogenetic proteins (BMPs), which are protein bone extract containing multiple factors that stimulate bone formation.

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

BMP belongs to super family transforming growth factor beta (TGF-β). TGF β is a potent modulator of tissue repair in different situations..

Lianjia et al., found that BMPs are responsible for dentinogenesis, inducing non differentiated mesenchymal cells from the pulp to form odontoblast-like cells, obtaining osteodentin and tubular dentin deposition, when used as direct protectors

Other osteogenically active growth factors that have been identified are PDGF (platelet-derived growth factor),IGF (insulin-like growth factor) and FGF (fibroblast growth factor).

Calcium phosphate Compounds Alpha-tricalcium phosphate & Tetracalcium phosphate (4CP) set & convert to

hydroxyapatite. Calcium phosphate cement was suggested as viable alternative because of its

good biocompatibility, superior compressive strength and its transformation into hydroxyapatite over time.

Yoshimine et al., demonstrated that in contrast to calcium hydroxide, tetracalcium phosphate cement induced bridge formation with no superficial tissue necrosis and significant absence of pulp inflammation

4CP cement has mechanical strengths so it could be used as so called “dentin substitute”.

Hydroxyapatite.

Biocompatible. Act as a scaffold for the newly formed mineralized tissue. Mild inflammation with superficial necrosis of pulp. It is the most thermo dynamically stable of the synthetic calcium phosphate

ceramics. It has good biocompatibility with neutral pH -7.0.

Modified Bioglass Formula (MBF) Stanly et al. (2001) reported that MBF#68 used as direct pulp capping agent

showed 1- no evidence of mummification 2- high incidence of properly positioned dentine bridge. At 2 weeks, inflammatory changes in the pulp. 4 weeks, some samples showed

normal pulp histology, with evidence of vasodilation.

Enzymes

Heme oxygenase-1(HO) is the rate limiting enzyme in heme catabolism. Odontoblasts and oxidatively stressed dental pulp cells express HO-1, indicates that the pulp might respond to oxidative stress at the molecular level.

Simvastatin improves the osteoblast function and suppresses osteoclast function, resulting in enhanced bone formation.

Statin is known to induce angiogenesis and increase neuronal cells, indicating the possible effectiveness of statin in pulp regeneration along with dentin regeneration. It has an anti-inflammatory effect in various tissues, so it is considered as an ideal active ingredient in pulp capping material to accelerate reparative dentin formation

Propolis Propolis, a resinous material collected by honey bees, has been used as a traditional

anti-infalmmatory and anti-bacterial medicine for many centuries.

Used as indirect pulp capping paste when mixed with Zno powder and this showed similar effect of Zno and eugenol as secondry dentin formation.

In direct capping with this paste showed no pulp degeneration and formation of protective layer

It contains flavonoids, phenolics, iron, zinc and other various aromatic compounds .

Parolia A, et al., compared propolis, MTA and Dycal histologically in human dental pulp and concluded that Propolis and MTA showed similar bridge formation when compared to Dycal

Study showed that direct pulp capping in rats with Non-flavonoids Propolis at 1 w showed pulp inflammation, no dentine bridge

formation a long the follow up period.

- Flavonoids at 1w no evidence of inflammatory response.

At 2 and 4w mild to moderate pulp inflammation was evident.

In week 4 dentinal bridge formation was detected.

Ardo et al.Histological analysis of rat dental pulp tissue capped with propolis, J oral sci., 2005; 47:135-138

Corticosteroids and antibiotics.

Corticosteroids like hydrocortisone, Cleocin, cortisone, Ledermix, penicillin, neomycin and along with calcium hydroxide was used for pulp capping with the thought of reducing or preventing pulp inflammation.

Gardner, et al., found that vancomycin, in combination with calcium hydroxide was somewhat more effective than calcium hydroxide used alone and stimulated a more regular reparative dentin bridge.

Watts and Paterson cautioned that anti-inflammatory compounds should not be used in patients at risk from bacteremia

Qureshi et al.Recent Advances in Pulp Capping Materials: An OverviewJ Clin Diagn Res. 2014 Jan; 8(1): 316–321.

Polycarboxylate cement.

Chemically bond to tooth structure. Lack of antibacterial effect. Fail to stimulate calcific bridge formation.

McWalter, G et al., found that it lacks an antibacterial effect and calcific bridge formation

Fluocinolone acetonide Fluocinolone acetonide (FA) is a synthetic corticosteroid commonly used for topical

application in the management of dermatologic disorders and oral vesiculoerosive lesions.

Interestingly, a wide range of concentrations of FA have a proliferative effect on some types of cells, such as skin fibroblasts and dental pulp cells. This effect is concentration-dependent; high concentrations inhibit mitotic activity, but low concentrations slightly increase the activity.

A specific range of concentrations (0.1–10 mmol/L) of FA also stimulates the extracellular matrix and hard tissue formation of human dental pulp cells

The pH of PCFA is about 10.57–11.72, which is higher than that of Dycal (9.80–10.86), but may be comparable to that of MTA (10.2–12.5)

Louwakulet al.Pulp-capping Material Containing Fluocinolone Acetonide,JOE

Although PCFA is not an ideal pulp-capping material, it acts like a type of drug delivery system, which slowly releases FA and the hydroxyl ions. Its physical and mechanical properties are similar to those of Dycal, except for higher pH and longer setting time.

Thus, PCFA may have the same problems as the other calcium hydroxide pulp-capping materials (ie, sealing ability, dissolution) when used during a long period of time

Stem Cells

Dental pulp stem cells (DPSCs) and Stem cells from Human Exfoliated Deciduous Teeth (SHED) have been identified as a novel population of stem cells that have the capacity of self-renewel and multi lineage differentiation.

Nakamura S et al., used mesenchymal stem cells for clinical application in tissue engineering and regenerative medicine. In this study, they compared the proliferation and stem cell marker of SHED, DSPCs and Bone Marrow Derived Mesenchymal Stem Cells (BMMSCs). In addition, gene expression profile of DSPCs and SHED were analyzed by using DNA microarray. They concluded that SHED has got significantly higher proliferation rate than that of DSPCs and BMMSCs and this could be a desirable option as a cell source for therapeutic applications

Emdogain (EMD)

EMD is enamel matrix derivative secreted from Hertwig’s epithelial root sheath during porcine tooth development. It is an important regulator of enamel mineralization and plays an important role during periodontal tissue formation. It stimulates the regeneration of acellular cementum, periodontal ligaments, and alveolar bone.

EMD contains BMP like molecules and BMP expressing cells. BMP like molecules in EMD promote odontoblast differentiation and reparative dentin formation.

Nakamura Y et al., concluded that amount of hard tissue formed in EMD treated teeth was more than twice that of the calcium hydroxide treated control teeth .

Al-Hezaimi K evaluated Calcium hydroxide, ProRoot White MTA and white Portland cement after EMD application on the exposed pulp. MTA produced a better quality reparative hard tissue response with the adjunctive use of EMD compared with calcium hydroxide

Theracal

TheraCal LC 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. TheraCal LC performs as an insulator/barrier and protectant of the dental pulpal complex.

The proprietary formulation of TheraCal LC consists of 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. Calcium release stimulates hydroxy apatite and secondary dentin bridge formation. TheraCal LC may be placed directly on pulpal exposures after hemostasis is obtained. It is indicated for any pulpal exposures, including carious exposures, mechanical exposures or exposures due to trauma.

Gandolfi et al., compared chemico physical properties of TheraCal, ProRoot MTA and Dycal and concluded that TheraCal displayed higher calcium releasing ability and lower solubility than either ProRoot MTA or Dycal.

The capability of TheraCal to be cured to a depth of 1.7 mm may avoid the risk of untimely dissolution. These properties offer major advantages in direct pulp capping treatments

Conclusion Emphasis has shifted from the “doomed” organ concept of an exposed pulp to one

of hope and recovery. The era of vital-pulp therapy has been greatly enhanced with the introduction of various pulp capping materials.

There are many arguments about the best medicaments suitable for this role and their long term advantages and disadvantages. Pulp capping is a conservative dental treatment due to the regenerative nature of the dentine-pulp complex and its ability to secrete tertiary dentine.

The best root canal ‘filling’ is healthy pulp tissue and it cannot be assumed that all damaged pulp must be extirpated or that all pulp conservation procedures are unsatisfactory.

Clarity on the biology of caries, comprehension of technological advances and conviction about improved restorative materials has initiated a pulp preservation that indeed is a boon to the clinician and the patient.

References Grossman’s Endodontic practice 13 ed Phillip’s science of dental materials: 11 ed Craig’s restorative dental materials 13 ed Ingle’s Endodntics 6 ed Shobha Tandon’s textbook of Pedodontics Qureshi et al.Recent Advances in Pulp Capping Materials: An OverviewJ Clin Diagn Res.

2014 Jan; 8(1): 316–321 Louwakulet al.Pulp-capping Material Containing Fluocinolone Acetonide,JOE Accorinteet al. “Evaluation of Mineral Trioxide Aggregate and Calcium Hydroxide Cement

as Pulp-capping Agents in Human Teeth”. JOE — Volume 34, Number 1, January 2008 Dammaschke et al. A new bioactive cement for direct pulp capping. INTERNATIONAL

DENTISTRY – AFRICAN EDITION VOL. 2, NO. 2 Patel et al. Preserving pulp vitality.Dental health.Volume 52 No 2 of 6 March 2013 Ardo et al.Histological analysis of rat dental pulp tissue capped with propolis, J oral sci.,

2005; 47:135-138