DIRECT PULP CAPPING. It has been suggested that a pulp capped with MTA should be temporised to allow for the complete setting of MTA,[9] and the patient to present at a second visit for placement of the permanent restoration. MTA also comes in white and grey preparations[26] which may aid visual identification clinically. Conclusions Despite the success rate of indirect pulp Only age had a significant effect on the pulpal survival rate: the success rate was 90.9% in patients younger than 40 years and 73.8% in patients 40 years or older (P = .0480). [3] 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. This report included 22 operators and a total of 299 teeth. However, calcium hydroxide and mineral trioxide aggregate (MTA) are the preferred material of choice in clinical practice due to their favourable outcome. 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. Tronstad L, Mjör IA. A recent systematic review of vital pulp therapy in vital permanent teeth with cariously exposed pulps reviewed success rates of direct pulp capping.3 In this review the success rate of direct pulp capping was reported as >6 months-1 year, 87.5%; >1-2 … After 6 months, this result is put into perspective [68]. Aim Indirect pulp capping (IPC) is a treatment that preserves pulp vitality. These results show no significant difference, nor do the results from an indirect pulp capping experiment comparing calcium silicate cement (Biodentine) and gl… 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. 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. glass ionomer or resin-modified glass ionomer) over CaOH before packing the final restorative material. Van Hassel HJ. If the pulp appears infected or symptomatic, the dentist may decide a root canal is the best treatment option. 2009;35(8):1147-1151. (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. This technique is used when a pulpal exposure occurs, either due to caries extending to the pulp chamber, or accidentally, during caries removal. Indirect Pulp Capping: In this process, a thin layer of the soft dentin is left over the pulp, and a protective dressing is placed over the soft dentin. The idea of using adhesive materials for direct pulp capping has been explored two decades ago. Results: The success rate of direct capping was 80.1% after 1 … Also due to its nature of non-adhesive, it leads to poor coronal seal hence increases micro-leakage. It is only feasible if the exposure is made through non infected dentin and there is no recent history of spontaneous pain (i.e. When dental caries is removed from a tooth, all or most of the infected and softened enamel and dentin are removed. [23] 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. [20] MTA has been shown to produce CaOH as a hydration product[21] and maintains an extended duration of high pH in lab conditions. [11][12] In one experiment conducted by Stuart et al. Most importantly, its toxicity to human pulp cells once again makes it an unacceptable material of choice. RESULTS: The overall success rate was 100% in the absence of preoperative pain. This can lead to the pulp of the tooth either being exposed or nearly exposed which causes pulpitis (inflammation). ×�Û�\Ìü@/‘rıÕ’×è²®÷KËé¬ôÚ­ëßÈh9é Vz�ĞcÅ:ŒIY5÷ÅRQ ãÁ2t~òİ�Ÿ�×ÑvÕ>>ÿ×õ¢×q³ãs¥`ƒßSú:èV�`_äÉ5'–#Ox¹fG…÷;” Jµ˜ó¸ÒKYGq‰åõXG«SUš²Ïø.K+õAoÃ>ç¹T«iÉÚÍ–lÍõ„�ÒK@¢pj`{KÖ5îh.ξ|hŸ,u6îìóœëËvƒÇ³á�Z?ˆ}©›¼Po@¤ÚÅ×Y7Tw”»5¯dØÁ. 1 The caries surrounding the pulp is left in place to avoid pulp exposure and is covered with a biocompatible material. 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. This is due to its superior properties of good biocompatibility and adhesive nature, providing coronal seal to prevent bacteria infiltration. Capping of the inflamed pulp. This is a step wise procedure and a long procedure which takes about 6 months or more to complete. [28][29], There have been several studies conducted on the success rates of direct and indirect pulp capping using a range of different materials. 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. However, they are not a material of choice for direct pulp capping. Studies on indirect pulp capping had clinical success ranging from 73 to 97% after a follow-up period of 2 weeks to 11 years . Indirect pulp capping • procedure where the deepest layer of the remaining affected carious dentin is covered with layer of biocompatible material in order to prevent pulpal exposure and further trauma to pulp. Indirect pulp treatment: in vivo outcomes of an adhesive resin system vs calcium hydroxide for protection of the dentin-pulp complex. A direct pulp cap is done on permanent teeth when the removal of deep decay results in exposing the pulp. [ Links ] 8. 2006;31(2):68-71. Studies have demonstrated unfavourable results for ZOE when compared to calcium hydroxide as a direct pulp capping material as it causes pulpal necrosis. Clinically and radiographically, teeth treated with indirect pulp capping using MTA show higher success rates after 3 months compared to using a setting calcium salicylate cement (Dycal, Dentsply Sirona, Konstanz, Germany). [3] A direct pulp cap is a one-stage procedure, whereas a stepwise caries removal is a two-stage procedure over about six months. For vital pulp capping to be successful, the tooth should be asymptomatic or have minimal symptoms and the bleeding must be controlled. J Endod. [6] 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. 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. Retrospective studies have shown CH pulp capping to have a success rate of 30-85% over a period of 2-10 years (64) (65) (66) (67). [14], CaOH does however have significant disadvantages. This method is also called "stepwise caries removal. J Clin Pediatr Dent. 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. Other studies also support claims of Biodentine’s and MTA’s superiority over calcium hydroxide in terms of success rate in pulp capping procedures [107,108]. [34] 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.[35]. But success rates for pulpotomy decreases over time from 90% or more initially (6-12 months) to 70% or less after 3 years or more. They had pulp dressing by indirect pulp capping technique.Results: MTA dressing (indirect pulp capping technique) is associated with 55% of the success meanwhile the use of calcium hydroxide is associated with 60% succes rate. CaOH has a high antimicrobial activity which has been shown to be outstanding. [13][16] It is suggested that an adhesive coronal restoration be used above the CaOH lining to provide adequate coronal seal. Two different types of pulp cap are distinguished. 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.[8]. Pulp capping material should provide a suitable condition to encourage regeneration of the dentin-pulp complex; be able to induce differentiation of odontoblastlike cells; and be antibacterial, biocompatible, and nontoxic 8 . 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. Results of success, 6 and 12 months after indirect pulp therapy (in one or two sessions) of asymptomatic pulpitis in primary teeth. "Vital Pulp Capping: A Worthwhile Procedure (review)", "Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology", "Keys to Clinical Success with Pulp Capping: A Review of the Literature", "Restorative dentistry: Management of the deep carious lesion and the vital pulp dentine complex", "Keys to clinical success with pulp capping: a review of the literature", "Calcium hydroxide liners: a literature review", "Mineral trioxide aggregate: a review of the constituents and biological properties of the material", "Clinical and radiographic assessment of the efficacy of calcium silicate indirect pulp capping: a randomized controlled clinical trial",, Creative Commons Attribution-ShareAlike License, Immature/mature permanent teeth with simple restoration needs, Recent trauma less than 24hours exposure of pulp / mechanical trauma exposure (during restorative procedure), This page was last edited on 3 January 2021, at 04:13. the criteria for successfully conducted indirect pulp capping were evaluated. If the indirect pulp capping procedure has been accomplished properly, there is an amazingly high success rate. Figure 3: The final restoration, in this case resin-based composite, should be placed over the direct or indirect pulp cap in the normal manner as described in this article. Pulp Capping Treatent. 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. 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[17][18] and is considered the gold standard dental material for direct pulp capping to date. Direct pulp capping (DPC) and calcium hydroxide has been widely used with high success rates in young permanent teeth, but the results in primary teeth are less satisfactory [3,4]. A very recent multi-centre RCT of moderate quality observed better success rate for indirect pulp capping than stepwise excavation after an observation period of 3 years, 91% versus 69%. [9], 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. But more recently mineral trioxide aggregate (MTA) used as a primary molar medicament for pulpotomies reported a 97% success rate. Indirect pulp capping in the primary dentition: a four year follow-up study. Physiology of the human dental pulp. In the reported literature, the prognosis of direct pulp capping is unpredictable, with the lowest success rate in carious pulp exposures in the adult dentition. [32], 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. Another study reported that the success rate of DPC with BD is 90.9% in patients younger than 40 and 73.8% in patients 40 or older [ 109 ]. Pulp capping is a technique used in dental restorations to prevent the dental pulp from necrosis, after being exposed, or nearly exposed during a cavity preparation. [24] MTA also has for difficult handling properties and is a very expensive material, thus is less cost effective as compared to CaOH. Success expectations for indirect and direct pulp caps. Defined as a procedure in which the exposed vital pulp is covered with a protective dressing or base placed directly over the site of exposure in an attempt to preserve the pulp vitality. Factors affecting the outcomes of direct pulp capping using Biodentine. [33] 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. Grey MTA preparations can potentially cause tooth discolouration. The prognosis of pulp capping (both direct and indirect) varies with success rates ranging from 13 percent to 100 percent. Zinc Oxide Eugenol (ZOE) is a commonly used material in dentistry. [31] 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%. Indirect pulp capping in the primary dentition: a 4 year follow-up study. [9] CaOH cement is not adhesive to tooth tissues and thus does not provide a coronal seal. There have been several studies conducted on the success rates of direct and indirect pulp capping using a range of different materials. 12. However, when the preoperative pain was present, the … The mean initial residual dentine thickness was 0.23 mm, and increased by 0.121 mm with MTA and by 0.136 mm with calcium hydroxide at 3 months. Bogen et al 7 reported a high survival rate of 97.96% for pulp capping with mineral trioxide aggregate (MTA) in carious exposures. Objective: A retrospective study of the success rate of direct pulp capping (DPC) and indirect pulp capping (IPC) was carried out in children between 6–14 years-old, con-sidering separately primary caries or caries affecting teeth with molar incisor hypo-mineralization (MIH). Disadvantages have also been described for MTA. 11. The following materials have been studied as potential materials for direct pulp capping. Oral Surg Oral Med Oral Pathol. and practice of indirect pulp capping in primary teeth. 16. [24] There is also less coronal microleakage of MTA in one experiment comparing it to amalgam[25] thus suggesting some tooth adhesion properties. Table 1. Compend Contin Educ Dent. [9] 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. [9] 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. J Clin Pediatr Dent. [1] The ultimate goal of pulp capping or stepwise caries removal is to protect a healthy dental pulp and avoid the need for root canal therapy. Indirect pulp treatment is a procedure performed in a tooth with a deep carious lesion approximating the pulp but without signs or symptoms of pulp degeneration. (grossman) • without signs or symptoms of pulp degeneration. The teeth were observed up to 9 years with a first visit after 3 months followed by an annual routine visit. [9], Materials that fall under this category include 4-META-MMA-TBB adhesives and hybridizing dentine bonding agents. [11] CaOH also has a high pH and high solubility, thus it readily leaches into the surrounding tissues. The non-randomised study found a statistically significant difference in favour of indirect pulp capping for clinical and radiological success at 3 years but with high overall risk of bias. 10. 2002;24(3):241-8. [36] More research will be needed to provide a comprehensive answer. [9], Although MTA shows great promise which is possibly attributed to its adhesive properties and ability to act as a source of CaOH release,[9] the available literature and experimental studies of MTA is limited due to its recency. 9. Evidenced-based review of clinical studies on indirect pulp capping. The use of ZOE as a pulp capping material remains controversial. [13][15] It is thus good practice to place a stronger separate lining material (e.g. 1971;32(1):126-134. 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. Type of One Sided Exact Indirect Pulp Treatment (IPT) was a success in 95%. A three-year study of 44 carious exposed pulps capped with calcium hydroxide resulted in an 80% success rate.46 Thirty-four traumatically exposed teeth that experienced an approximately four-hour delay before calcium hydroxide pulp capping demonstrated 97% success when followed for periods of up to 17 years.90 To better elucidate the relative benefits of MTA versus calcium hydroxide for pulp … [9], Calcium hydroxide (CaOH) is an organo-metallic cement that was introduced into dentistry in the early twentieth century[10] and there have since been many advantages to this material described in much of the available literature. S�†zÊ‚>e˜w @¯’¿£0`mc}£0tOaaïQmĞPËšUv1¶c¡ :œ…¶Ñ‰¯@„Z§Ğ±Úk©Ë¢GŞS¶f©_Æ«BmQèÏ:­öœÆúsÙ¶Óî¸RğdkSZltLIإ蘒­vL54:S? No statistical significant difference between the groups was observed (P = 0.62). In this study, the success rate for Biodentine™ after 24 months became 77.8% due to the lower recall rate and for Fuji IX™ was 66.7%. [5] 10. Aim Indirect pulp capping (IPC) is a treatment that preserves pulp vitality. 2018; 39(3):182-189. Calcium hydroxide liners increased the success rate of IPT. Selection was based on caries to or deeper than half the distance to the pulp. 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. Pediatr Dent. Pulpitis, in turn, can become irreversible, leading to pain and pulp necrosis, and necessitating either root canal treatment or extraction. "[3][7] Several materials have been used for this procedure. Alex G. Direct and indirect pulp capping: a brief history, material innovations, and clinical case report. 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. FACTORS DETERMINING SUCCESS OF IPC. 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. As a dentist, you find that the decay is extensive and very close to the pulp (nerve) of the tooth. [13] This alkaline environment created around the cement has been suggested to give beneficial irritancy to pulpal tissues and stimulates dentine regeneration. In addition, the material triggers chronic inflammation even without the presence of bacteria makes it an unfavourable condition for pulp healing to take place. [19], Mineral trioxide aggregate (MTA) is a recent development of the 1990s[20] initially as a root canal sealer but has seen increased interest in its use as a direct pulp capping material. 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. [9] MTA also takes a long time (up to 2 hours 45 minutes) to set completely[27] thus preventing immediate restoration placement without mechanical disruption of the underlying MTA. Advertisement . This is due to Eugenol, being cytotoxic to the pulp are present in large quantity in this formulation. irreversible pulpitis) and a bacteria-tight seal can be applied. Direct pulp capping Indirect pulp capping 15. Remaining dentin thickness(0.5-2mm) Choice of indirect pulp capping agent. ... ease of use and success rate. An Indirect pulp cap is where, in a permanent tooth, most of the decay is removed. [3], Contraindication for Direct Pulp Capping:[4], In 1938, Bodecker introduced the Stepwise Caries Excavation (SWE) Technique for treatment of teeth with deep caries for preservation of Pulp vitality. Marchi JJ, de Araujo FB, Froner AM, et al. The set cement has low compressive strength and cannot withstand or support condensation of a restoration. The success rate is presented in percentage to the number of teeth treated in the group. ... success rate of the ProRoot MTA material was higher than those of TheraCal LC and Dycal (the success rates were 94.4%, 87.8% and 84.6 % respectively). [22] Similar to CaOH, this alkalinity potentially provides beneficial irritancy and stimulates dentine repair and regeneration. Marchi JJ, de Araujo FB, Fröner AM, Straffon LH, Nör JE. 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. Logistic regression was performed to identify significant clinical and demographical factors associated with the success of the indirect pulp capping. 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. In fact, it may be likely that if you did remove all of the decay, the pulp would be exposed by the infected decay thus resulting in the need for a root canal. In studies where dentists where were described the scenario of deep caries and given the option of removing all the affected dentin and exposing the pulp and doing a direct pulp cap, versus leaving some of the affected dentin and placing an indirect pulp cap, only 17% responded that they would stop and leave carious dentin behind. 16. 2006;31(2):68-71. [30] 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%. Direct Pulp Caps. At 6 months, the success rate was 89.6% with MTA, and remained steady at 73% with calcium hydroxide (P = 0.63). 11. 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. Results: After 48 months, Group-1 showed a success rate of 88.8% and Group-2 of 93%. The overall success rate was 82.6%.