caries: definition, treatment, pulp capping, zinc oxide eugenol,glass ionomer cement, adhesive system, biodentine, calcium hydroxide cement, MTA

1. TREATMENT OF
DENTAL CARIES
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2. INTRODUCTION
Caries prevalence remains high throughout the world, with the burden of
disease increasingly affecting older and socially disadvantaged groups in
Western cultures. If left untreated, caries will advance through dentine
stimulating pulpitis and eventually pulp infection and necrosis; however, if
conservatively managed pulpal recovery occurs even in deep carious
lesions.

3. OVERVIEW
Traditionally, deep caries management was destructive with non‐selective (complete) removal of all carious dentine; however, the
promotion of minimally invasive biologically based treatment strategies has advocated for selective (partial) caries removal and a
reduced risk of pulp exposure.
Selective caries removal strategies can be, one‐visit as indirect pulp treatment or two‐visit, using a stepwise approach.
Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy and the
re‐emergence of vital pulp treatment (VPT) techniques such as partial and complete pulpotomy.
These changes stem from an improved understanding of the pulp‐dentine complex's defensive and reparative response to irritation, with
harnessing the release of bioactive dentine‐matrix‐components and careful handling of the damaged tissue considered critical.
Notably, the development of new pulp capping materials such as mineral‐trioxide‐aggregate, which although not an ideal material, has
resulted in more predictable treatments from both a histological and clinical perspective.

4. DENTAL PULP
Dental pulp is an unmineralized oral
tissue composed of soft connective
tissue, vascular, lymphatic and
nervous elements that occupies the
central pulp cavity of each tooth. Pulp
has a soft, gelatinous consistency.

5. Dental pulp of 13 year subject's tooth after vertical split of
tooth into two equal halves

6. VITAL PULP THERAPY
designed to preserve and maintain pulpal health in teeth that have been exposed to trauma,
caries, restorative procedures, and anatomic anomalies.
All these procedures involve removal of local irritant and placement of protective material directly
or indirectly over the pulp.
Common objective is to induce a physical protective barrier over pulp to maintain its vitality and
function.==>to initiate the formation of tertiary reparative dentin or calcific bridge formation.

7. TERTIARY DENTIN
Tertiary dentin. Tertiary dentin (including reparative dentin or
sclerotic dentin) forms as a reaction to stimulation, including
caries, wear and fractures. ... This form of dentine can be
easily distinguished on the surface of a tooth, and is much
darker in appearance compared to primary dentine.

8. PULP CAPPING- WHAT IS IT?
• 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.
• 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 which causes pulpitis (inflammation).
• Pulpitis, in turn, can become irreversible, leading to pain and pulp necrosis, and
necessitating either root canal treatment or extraction.
• 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!

9. PULP CAPPING- HOW?
• 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 and is largely completed by 130 days.
• Two different types of pulp cap are distinguished. Indirect 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.
• A direct pulp cap is a one-stage procedure, whereas a stepwise caries removal is a two-stage
procedure over about six months.

10. WHEN IS NOT RECOMMENDED?
Teeth that have a history of trauma or previous restorations or that display pulpal
calcification have a poorer prognosis than teeth showing only initial caries.
In the selection of a specific vital pulp treatment, it is important to consider the
remaining tooth structure and future restorative plan.
In patients with uncontrolled caries or extensive loss of coronal structure, in which full
coverage is indicated, pulpotomy rather than pulp capping is recommended.

11. DIRECT PULP CAPPING
It is defined as the 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 pulpal vitality.
This technique is used when a pulpal 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 non infected dentin and there is no recent history of spontaneous pain (i.e. irreversible pulpitis)
and a bacteria-tight seal can be applied.
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.
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.

13. INDICATION FOR DIRECT PULP
CAPPING
Immature/mature permanent teeth with simple restoration needs
Recent trauma less than 24hours exposure of pulp / mechanical trauma exposure (during restorative procedure)
Minimal or no bleeding at exposure site
Normal sensibility test
Not tender to percussion
No periradicular pathology
Young patient

14. CONTRAINDICATION FOR DIRECT
PULP CAPPING
Systemic disease involvement
Primary teeth
Inflammatory signs and symptoms
Pre-operative tooth sensitivity
Large pulpal exposure
Uncontrollable bleeding from the pulp
Non-restorable tooth
Elderly patient

15. HOW TO DETECT MECHANICAL PULP
EXPOSURE
- Heat: using a rotary instrument in close proximity to the pulp with out the use of water coolant might lead to over
heating the pulp and hence cause pulpal damage.
- Pressure: exerting large amount of pressure on a thin pulp floor might cause exposure of the pulp.
- Damage to the pulp tissue while cleaning cavity.
- Hemorrhage: seeping of blood from the cavity floor is an indication of pup exposure

16. CLINICAL PROCEDURE
Clean the cavity with chlorhexidine solution.
Anesthetize and isolate with rubber dam.
Rinse with anesthetic or sterile saline.
using a sterile cotton pellet control the bleeding.
Mix the capping agent & apply it to exposure site.
Temporize and observe for 5-10 days
https://www.youtube.com/watch?v=GAwvzmP56iM

17. DIRECT PULP CAPPING WITH
BIODENTIN ON 46

18. INDIRECT PULP CAPPING
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.
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.„
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.

20. 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.
1. Calcium Hydroxide Ca(OH)2.
2. Zinc oxide eugenol
3. Glass and resin modified glass ionomer
4. Adhesive system
5. Mineral trioxide aggregate -MTA

21. 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.

22. 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.
• 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.

23. 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.

24. MINERAL TRIOXIDE AGGREGATE -MTA
• 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.
• MTA has been shown to produce CaOH as a hydration product and maintains an extended duration of high pH in lab conditions.
• Similar to CaOH, this alkalinity potentially provides beneficial irritancy and stimulates dentine repair and regeneration.
• 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.
• There is also less coronal microleakage of MTA in one experiment comparing it to amalgam thus suggesting some tooth adhesion
properties. MTA also comes in white and grey preparations which may aid visual identification clinically.
• Disadvantages have also been described for MTA. Grey MTA preparations can potentially cause tooth discolouration.
• MTA also takes a long time (up to 2 hours 45 minutes) to set completely 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, and the patient to present at a second visit for placement of the permanent restoration.
• MTA also has for difficult handling properties and is a very expensive material, thus is less cost effective as compared to CaOH.
• Although MTA shows great promise which is possibly attributed to its adhesive properties and ability to act as a source of CaOH
release, 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.

26. BIODENTINE
• Recently, various calcium silicate based products have been launched to the market,
one of these is Biodentine;Biodentine is a new tricalcium silicate (Ca3SiO5) based
inorganic restorative commercial cement and advertised as ‘bioactive dentine
substitute’.
• This material is claimed to possess better physical and biological properties compared
to other tricalcium silicate cements such as mineral trioxide aggregate (MTA) and
Bioaggregate.
• Its main mechanism of action is based on stimulating the production of reactionary or
tertiary dentin by contact with vital pulp tissue. In addition, Biodentine has excellent
sealing capacity and outstanding chemical and physical stability. Biodentine provides a
bacteria-proof hermetic seal and can therefore be used in a variety of endodontic
treatments to preserve pulp vitality.

27. BIODENTINE
A product that is designated as a dentin substitute should, however, meet certain demands. These include:
• stability and dimensional accuracy
• biocompatibility
• radiopacity
• imperviousness to fluids/moisture
• simple and uncomplicated handling
• stimulation of production of new hard tissue
• antibacterial properties
• insolubility
• no signs of absorption
• ensuring of a tight and durable seal; preferably by a molecular bond

29. CALCIUM HYDROXIDE CEMENT
• Calcium hydroxide (CaOH) is an organo-metallic cement.
• CaOH has a high antimicrobial activity.
• CaOH also has a high pH and high solubility, thus it readily leaches into the surrounding tissues. This alkaline
environment created around the cement give beneficial irritancy to pulpal tissues and stimulates dentine
regeneration. CaOH causes release of growth factors TGF-B1 and bioactive molecules from the dentine
matrix which induces the formation of dentine bridges.
• CaOH have significant disadvantages- the set cement has low compressive strength and cannot withstand or
support condensation of a restorationis thus good practice to place a stronger separate lining material (e.g.
glass ionomer or resin-. It modified glass ionomer) over CaOH before packing the final restorative material.
• CaOH cement is not adhesive to tooth tissues and thus does not provide a coronal seal. 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. 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 and is considered the gold
standard dental material for direct pulp capping to date.

31. CALCIUM HYDROXIDE CEMENT- ROLE
Calcium hydroxide has a hard tissue inducing effect.
It is a powder, that can be mixed with a physiological saline to a paste. The paste is highly alkaline with a pH 12.5 and its application to
the pulp results in necrosis of the part of coronal pulp tissue shows no or only a milled inflammatory reaction.
Analyzing the pH and the concentration of calcium ions in the periapical area, it is obvious that at least 2 weeks are necessary for calcium
hydroxide bactericide activity.
Calcium hydroxide retains its anti-bacterial properties for about two months when placed under a restoration, after which it degrades to
calcium oxide and other less effective calcium salts.
All calcium hydroxide preparations have a limited shelf life as they eventually turn into calcium oxide. Calcium hydroxide can be used as
linings, for indirect and direct pulp cupping, root dressing, root canal sealant, apical closure.
The vehicles play a supportive role, giving pastes chemical characteristics such as dissociation and diffusion as well as favoring the correct
filling of the root canal which are decisive factors for antimicrobial potential and tissue healing.
The mechanism of action of calcium hydroxide on tissues, inducing the deposition of mineralized tissue, is an extremely important aspect
for the indication of calcium hydroxide, because it demonstrates biological compatibility of calcium hydroxide.

32. SOURCES
• https://www.researchgate.net/publication/332428590_Management_of_Deep_Caries_an
d_the_Exposed_Pulp
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856472/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2692285/
• https://en.wikipedia.org/wiki/Pulp_capping#Materials
• https://en.wikipedia.org/wiki/Pulpitis
• https://www.slideshare.net/weamfaroun/direct-and-indirect-pulp-capping-123652867
• https://www.slideshare.net/drhashimmoeen/biodentine-47212644

33. THANK YOU!