Pulp Protection- 2

Dr. Islam Aboubaker

• Introduction
• One of the main goal of operative dentistry is to
preserve the health of dental pulp.
• Introduction
• One of the main goal of operative dentistry is to preserve the
health of dental pulp. Normal pulp is a coherent soft tissue,
dependent on its normal hard dentin shell for protection and
hence, once exposed, extremely sensitive to contact and
temperature .
• Pulp can get irritated by various restorative materials and dental
procedures. To protect the pulp from various irritants, various
pulp protective agents are used.
PULPAL IRRITANTS
• Bacterial irritants:
• Most common cause for pulpal irritation are bacteria or their products which may enter pulp by caries
accidental exposure, fracture extension of infection from gingival sulcus, periodontal pocket and
anachoresis.
• Traumatic:
• Acute trauma like fracture, luxation or avulsion of tooth
• Chronic trauma including parafunctional habits like bruxism.
• Iatrogenic:
• Thermal changes generated during cutting and restorative procedures, bleaching, microleakage occurring
along the restorations, electrosurgical procedures, laser beam, etc.
• Orthodontic movement
• Periodontal curettage
• Periapical curettage
• Idiopathic:
• Aging
• Resorption: Internal or external.
Effect Of Dental Caries On Pulp
• Following defense reactions take place in a carious tooth to protect the pulp:
• Formation of reparative dentin:
• Rate of reparative dentin formation is inversely related to rate of carious attack.
• Faster the caries attack, lesser is the reparative dentin formation.
• Dentinal sclerosis, i.e. reduction in permeability of dentin by narrowing of dentinal tubules:
Effect Of Tooth Preparation On Pulp
• Pressure
• Pressure of instrumentation causes aspiration of odontoblasts or nerve endings from pulp tissues into the
dentinal tubules.
• This disturbs the metabolism of odontoblasts leading to their complete degeneration and disintegration.
• Heat Production
▪ RPM.
▪ Pressure.
▪ Surface area of contact.
▪ Desiccation.
• Vibrations
• Higher the amplitude, more destructive is the pulp response.
• Remaining Dentin Thickness (RDT)
• In human teeth, dentin is approximately 3 mm thick
• Dentin permeability increases with decreasing RDT
• RDT of 2 mm or more, effectively precludes restorative damage
to the pulp
• At RDT of 0.75 mm, effects of bacterial invasion are seen
• When RDT is 0.25 mm, odontoblastic cell death is seen.
▪ Generally, 2 mm of dentin thickness between floor of the tooth preparation and the pulp will
provide an adequate insulting barrier against irritants. As dentin thickness decreases, the pulpal
response increases.
▪ Speed of Rotation
• Ultra high-speed should be used for removal of enamel and superficial dentin. A speed of 3,000 to
30,000 rpm without coolant can cause pulpal damage.
• Nature of Cutting Instrument
• Use of worn off and dull instruments can cause vibration and reduced cutting efficiency.
• Their use encourages the clinician to apply excessive operating pressure, which results in
increased temperature.
• This can result in thermal injury to pulp.
 Effect Of Chemical Irritants On Pulp
• Factors Influencing the Effect of Restorative Materials on Pulp
• Acidity
• Absorption of water from dentin during setting
• Heat generated during setting
• Poor marginal adaptation leads to bacterial penetration
• Cytotoxicity of material.
Pulp Protection Procedures
• Pulp Needs Protection Against Various Irritants as the Following :
• Thermal protection against temperature changes
• Electrical protection against galvanic currents
• Mechanical protection during various restorative procedures
• Chemical protection from toxic components
• Protection from microleakage interface between tooth and the restoration
• Pulp Protection in Shallow and Moderate Carious Lesions
• In a moderate carious lesion, caries penetrates the enamel and may involve
one half of the dentin, but not to the extent of endangering the pulp. In these
cases, to protect the pulp, liner is applied to cover the axial and/or pulpal
wall. Then, base is placed over the liner. After the base material hardens,
permanent restoration is done.
• Pulp Protection in Deep Carious Lesions
• In deep carious lesion, caries can reach very near or up to the pulp, so
treatment of deep carious lesion requires precautions.
• Indirect Pulp Capping
• Indirect pulp capping is a procedure performed in a tooth with deep carious
lesion adjacent to the pulp. In this procedure, all infected carious dentin is
removed leaving behind the softened carious dentin adjacent to pulp.
Caries near the pulp is left in place to avoid pulp exposure and preparation
is covered with a biocompatible material.
• Indications for Indirect Pulp Capping
• Deep carious lesion near the pulp tissue but not involving it
• No mobility of tooth
• No history of spontaneous toothache
• No tenderness to percussion
• No radiographic evidence of pulp pathology
• No root resorption or radicular disease should be present radiographically
• Contraindications
• Presence of pulp exposure
• Radiographic evidence of pulp pathology
• History of spontaneous toothache
• Tooth sensitive to percussion
• Mobility present
• Root resorption or radicular disease is present radiographically.
• Clinical technique
• Band the tooth if tooth is grossly decayed
• Anesthetize the tooth
• Apply rubber dam to isolate the tooth
• Remove soft caries either with spoon excavator or round bur
• A thin layer of dentin and some amount of caries is left to avoid exposure
• Place calcium hydroxide paste on the exposed dentin
• Cover the calcium hydroxide with zinco xide eugenol base
• Tooth should be evaluated after 6 to 8 weeks
• After 2 to 3 months, remove the cement and evaluate the tooth
preparation. If due to remineralization and/or formation of
secondary dentin, the soft dentin has become hard, then remove
any residual soft debris and then finally give protective cement
base and place the permanent restorative material.
• Success of indirect pulp capping depends on the age of the
patient, size of the exposure, restorative procedure and evidence
of pulp vitality. In young patients, the potential for success is more
due to large volume of pulp tissue and abundant vascularity.
• Direct Pulp Capping
• Direct pulp capping procedure involves the placement of
biocompatible material over the site of pulp exposure to maintain
vitality and promote healing.
• Indications
• Small mechanical exposure of pulp during:
• Tooth preparation
• Traumatic injury.
• No or minimal bleeding at the exposure site.
• Contraindications
• Wide pulp exposure
• Radiographic evidence of pulp pathology
• History of spontaneous pain
• Presence of bleeding at exposure site.
▪ Clinical procedure
• Isolate the tooth with rubber dam
• When vital and healthy pulp is exposed, check the fresh bleeding at
exposure site
• Clean the area with distilled water or saline solution and then dry it with a
cotton pellet
• Apply calcium hydroxide (preferably Dycal) over the exposed area
• Give interim restoration such as zinc oxide eugenol for 6 to 8 weeks
• After 2 to 3 months, remove the cement very gently 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. If favorable prognosis is not there, pulpotomy or pulpectomy is
done.
• Factors affecting success of direct pulp capping:
• Age of the patient
• Type of exposure
• Size of the exposure
• History of pain
Materials Used For Pulp Protection
• Classification of Pulp Protective Agents
1. Cavity sealers
• Varnish
• Resin bonding agents
2. Liners
3. Bases
1. Materials used as Varnish
I. Varnish
• Varnish is an organic copal or resin gum suspended in solutions of ether or
chloroform. When applied on the tooth surface the organic solvent evaporates
leaving behind a protective film.
• Indications for use of varnish
• To seal the dentinal tubules
• To act as barrier to protect the tooth from chemical irritants from cements
• To reduce microleakage around restorations.
II. Resin Bonding Agents
• An adhesive sealer is commonly used under composite restorations.
2. Materials used as Liners
I. Zinc oxide eugenol liners
• It should not be used under composite restorations as it inhibits
polymerization of bonding agent and composite.
II. Calcium hydroxide
•It stimulates reparative dentin formation
• It forms a mechanical barrier, when applied to dentin.
• Because of high pH, it neutralizes acidity of silicate and zinc phosphate
cements
• Biocompatible in nature
• Bactericidal in nature.
• Limitations:
• Low strength
• High solubility
III. Flowable composites
• They are primarily used under composite restorations.
• Advantages
• Adaptation to preparation walls because of their flow
• Placement ease
• Esthetic
• Consistency.
IV. Glass ionomer cements (GIC):
• Advantages
• Bond to tooth structure
• Anticariogenic
• Act as a thermal barrier
• Easy to use.
V. Light-cured resin-modified glass ionomers (RMGIs)
• RMGI materials have a dual-setting reaction—a light-activated,
methacrylate crosslinking reaction and a slower, delayed, acid-
base reaction that gives RMGIs an additional period of maximum
flexibility to absorb stress from the adjacent shrinking composite.
2. Bases
• Bases are used as pulp protective materials since they provide
thermal insulation, encourage recovery of injured pulp from
thermal, mechanical or chemical trauma, galvanic shock and
microleakage .
• Bases should have sufficient strength so as to withstand forces of
mastication and condensation of permanent restorations.
3. Materials used as bases
I. Zinc oxide eugenol
II. Zinc phosphate cement
• Reduces the thermal conductivity of metallic restorations
• Blocks undercuts in the preparation wall in case of cast restorations.
III. Polycarboxylate cement
• Chemically bonds to tooth .
• Antibacterial properties
• Well tolerated by the pulp
IV. Glass ionomer cement
• Anticariogenic property
• Chemical bond to tooth
• Well tolerated by the pulp.
Types of Shallow (RDT Moderately deep Deep
restoration > 2.0 mm) (RDT > 0.5– (RDT < 0.5 mm)
2 mm)
Silver Varnish Base, e.g. zinc Calcium hydroxide
amalgam phosphate, zinc as sub-base
polycarboxylate covered with base
Glass Not required Not required Calcium hydroxide
ionomer as liner
cement
Composite Dentin Dentin bonding Calcium hydroxide
resins bonding agent as liner followed
agent by glass ionomer
as base
Cast gold Base Calcium hydroxide
restorations as liner with base
over it
The end