Pulp capping is a technique used in dental restorations to prevent dental pulp from necrosis, after exposure, or nearly exposure during cavity preparation. When dental caries is removed from the tooth, all or most of the infected and softened enamel and dentin are removed. This can cause either affected or near-affected dental pulp causing pulpitis (inflammation). Pulpitis, in turn, can become irreversible, causing pain and pulp necrosis, and requires root canal treatment or extraction. The main purpose of pulp capping or stepwise caries removal is to protect healthy pulp and avoid the need for root canal therapy.
To prevent the pulp from worsening when dental restorations approach the pulp, the dentist will place a bit of a tranquilizer, such as calcium hydroxide or MTA. These materials protect the pulp from harmful agents (heat, cold, bacteria) and stimulate pulp-rich zone cells to place reparative dentine bridges. Dentin formation usually begins within 30 days of capping of the pulp (delay can occur in the onset of dentin formation if pulp odontoblasts are injured during cavity removal) and most are completed by 130 days.
Two different types of pulp lids are differentiated. In direct pulp capping , the protective pads are placed directly above the open pulp; and in indirect pulp capping, a softened dentine film which, when exposed, exposes the pulp, is left in place and a protective dressing is placed on top. The direct pulp cap is a one-step procedure, while the gradual elimination of caries is a two-stage procedure for about six months.
Video Pulp capping
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This technique is used when pulp exposure occurs, either because the caries extends into the pulp chamber, or unintentionally, during caries removal. This is only feasible if the exposure is done through non-infected dentin and no history of spontaneous pain (ie irreversible pulpitis) and bacteria-tight seal can be applied. After exposure, the teeth are isolated from saliva to prevent contamination by using a dental dam, if not already in place. The teeth are then washed and dried, and the protective material is placed, followed ultimately by dental restorations that provide a bacteria-resistant seal to prevent infection. Since pulp capping does not always succeed in maintaining the vitality of the pulp, the dentist will usually maintain the status of the tooth being examined for about 1 year after the procedure.
Indications for Direct Pulp Capping
- Teeth permanently immature/adults with simple recovery needs
- Recent trauma less than 24 hours exposure to pulp/exposure to mechanical trauma (during restorative procedures)
- Minimum or no bleeding on exposure site
- Normal sensitivity test
- Not soft on percussion
- No periradicular pathology
- Young patients
Maps Pulp capping
Contraindication to Direct Pulp Capping
- Systemic disease involvement
- Primary teeth
- Signs and symptoms of inflammation
- Pre-operative tooth sensitivity
- Big pulp exposure
- Uncontrolled bleeding from the pulp
- Teeth that can not be restored
- Older patient
Indirect
In 1938, Bodecker introduced the Stepwise Stepwise Fattening Technique (SWE) for dental treatment with deep caries to maintain the vitality of Pulp. This technique is used when most of the decomposition has been removed from the deep cavity, but some dentin and decay are softened above the pulp chamber which if exposed will expose the pulp and trigger irreversible pulpitis. Instead, the dentist deliberately leaves dentin dentin in place, and uses a protective film layer that promotes dentin remineralization that softens above the pulp and the accumulation of a new layer of tertiary dentine in the pulp chamber. The color of the carious lesion changed from light brown to dark brown, the consistency changed from soft and wet to hard and dry so that Streptococcus mutans and Lactobacilli had significantly reduced to a limited number or even zero viable organisms and the radiograph showed no change. or even a decrease in the radiolucent zone. Temporary filling is used to keep the material in place, and about 6 months later, the cavity reopens and hopefully there is enough dentin sound above the pulp (dentin bridge) that any residual softened dentine can be removed. and permanent filling can be placed. This method is also called "gradual caries removal." The difficulty with this technique is to estimate how fast the caries process is, how many tertiary dentine have formed and know when exactly to stop digging to avoid pulp exposure.
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 ingredients selected in clinical practice because of favorable outcomes.
Zinc oxide eugenol
Zinc Oxide Eugenol (ZOE) is an ingredient commonly used in dentistry. The use of ZOE as a capping pulp material is controversial. This is due to Eugenol, since the cytotoxicity of the pulp is present in large quantities in this formulation. Also because of its non-adhesive properties, it leads to poor coronal seals thereby increasing the micro leakage. Studies have shown poor results for ZOE when compared with calcium hydroxide as a direct pulp capping material because it causes pulp necrosis.
Glass and resin of modified glass ionomer
Both Glass Ionomer (GI) and Resin Modified Glass Ionomer (RMGIC) have been widely used as layers or basic materials for deep cavities in which the pulps are in close proximity. This is due to the superior properties of good biocompatibility and adhesive properties, providing a coronal seal to prevent bacterial infiltration. However, they are not the material of choice for direct pulp restriction. When the use of RMGIC and calcium hydroxide has been studied as a direct pulp capping agent, RMGIC has shown an increase in chronic inflammation in pulp tissue and a lack of reparative dentin bridge formation.
Adhesive System
Materials included in this category include 4-META-MMA-TBB adhesives and hybridization of dentin bonding agents. The idea of ​​using an adhesive for direct pulp capping has been explored two decades ago. Studies have shown that it encourages bleeding due to the nature of vasodilation thus disrupting the polymerization of the material, affecting its ability to provide coronal seals when used as pulp capping agents. In addition, the ingredients trigger chronic inflammation even in the absence of bacteria makes it an unfavorable condition for pulp healing to take place. Most importantly, its toxicity to human pulp cells once again makes it an unacceptable ingredient of choice.
Calcium hydroxide cement
Calcium hydroxide (CaOH) is an organo-metal cement that was introduced into dentistry in the early 20th century and since then there have been many advantages to this material that are described in many of the available literatures. CaOH has high antimicrobial activity that has proven to be remarkable. In one experiment conducted by Stuart et al. (1991), inoculated bacterial root canals from extracted human teeth were treated with CaOH for 1 h to the control group without treatment and the results resulted in a 64-100% reduction in all living bacteria. CaOH also has a high pH and high solubility, so it is easily absorbed into the surrounding tissue. This alkaline environment created around cement has been suggested to provide favorable irritation to the pulp tissue and to stimulate dentine regeneration. One further study showed that CaOH caused release of growth factor of TGF-B1 and bioactive molecule from dentin matrix induced dentin bridge formation.
However, CaOH has significant losses. The cement set has a low compressive strength and can not resist or support the restoration condensation. Therefore, it is a good practice to place a stronger separate lining material (eg glass ions or resin modified glass ionizers) above CaOH before packing the final restorative material. CaOH cement does not adhesive to dental tissue and thus does not provide a coronal seal. In the pulp perfusion study, CaOH has shown insufficient all dentin tubules, and the presence of tunnel defects (patent communication in the reparative dentin connecting the pulp and exposure site) shows the potential for micro leakage when CaOH is used. It is recommended that coronal glue restoration be used above the CaOH layer to provide adequate coronal seal. Due to its many advantages and long-term success in clinical use, it has been used as a control material in several experiments with pulp capping agents for many years and is considered the standard gold dental material for direct pulp capping to date.
Aggregate trioxide minerals
The mineral trioxide aggregate (MTA) is the latest development in the 1990s that originally served as a root canal sealer but has seen an increase in interest in its use as a direct pulp pulp material. The material comprises a mixture of tricalcium silicate, silicone silicone and tricalcium aluminum; bismuth oxide is added to provide the properties of cement radiopaque to assist in radiological investigation. MTA has been shown to produce CaOH as a hydration product and maintain long duration of high pH under laboratory conditions. Similar to CaOH, this alkalinity potentially provides favorable irritation and stimulates dentine repair and regeneration. MTA has also shown reliable and beneficial healing results in human teeth when used as pulp caps on teeth that are diagnosed no worse than reversible pulpitis. There is also a less coronal microleakage of MTA in one trial comparing it with amalgam thus suggesting some adhesion properties of the tooth. MTA is also present in white and gray preparations that can help clinical visual identification. Losses have also been described for MTA. The preparation of gray MTA has the potential to cause tooth discoloration. MTA also takes a long time (up to 2 hours 45 minutes) to fully regulate so as to prevent the placement of the restoration immediately without the mechanical disturbance of the underlying MTA. It has been suggested that the slurry covered with MTA should be temporis to allow for the complete setting of the MTA, and the patient to be present at the second visit for permanent restoration placement. MTA also has a difficult handling properties and is a very expensive material, making it less effective than CaOH.
Although the MTA shows great promise that may be attributed to adhesive properties and its ability to act as a source of CaOH release, the available literature and MTA experimental studies are limited due to its absolute. A study comparing the capability of pulp capping from MTA to CaOH in human teeth yielded similar and successful healing results at the histologic level of both materials.
Success rate
There have been several studies conducted on the success rate of direct and indirect pulp capping using a variety of different materials. One study of indirect pulp pulp recorded a success rate of 98.3% and 95% using a silicone-based substitute bioactive tricalcium silicate [Ca3SiO5] and light-activated [CA (OH) 2) calcium-hydroxide respectively. These results show no significant difference, as well as the results of indirect pulp capping experiments comparing calcium silicate cement (Biodentine) and glass ionomer cement, which has a clinical success rate of 83.3%. A further study tested Portland medical cement, Trioxide Aggregate Minerals (MTA) and calcium hydroxide in indirect pulp treatment found various success rates of 73% -93%. The study concluded that indirect pulp capping had a 90.3% success rate regardless of the material used but stated that it is better to use non-resorbing materials whenever possible.
Similar studies have been conducted on direct pulp, with one study comparing ProRoot Minerals Trioxide Aggregate (MTA) and Biodentine which found a success rate of 92.6% and 96.4% respectively. The study was conducted in patients aged 6-18 years, while comparable studies conducted on mature permanent teeth found a success rate of 84.6% using MTA and 92.3% using Biodentine. 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 with an 85.9% success rate for MTA in other studies.
A systematic review attempted to compare the success rate of direct pulp capping and indirect pulse capping and found that indirect pulp capping had a higher success rate but found low-quality evidence in the study of direct pulp capping. More research will be needed to provide a comprehensive answer.
See also
- Pulpotomi
References
Source of the article : Wikipedia
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