2. Presented By
Reham Mohamed Ali

3. Objectives of pulp treatment
Types of Pulp Treatment
Requirements of pulp capping materi
Various capping materials and their r

4. Objectives of pulp treatment
Maintaining the integrity and health of the teeth and
their supporting tissues.
Maintaining the vitality of the exposed pulp or on a
thin residual layer soft dentin.
Pulp autolysis, however, can be stabilized, or pulp can
be eliminated without compromising the function of
the tooth.

5. -Different types of pulp ttt. have been recommended for
primary teeth. They can be classified into two
categories:
Conservative Treatment (normal pulp or
reversible pulpities)
Protective Base
(Indirect and direct) pulp capping
 Pulpotomy
Radical Treatment (irreversible pulpities or
necrotic pulp)
partial pulpectomy
Pulpectomy, and nonvital pulpotomy.

6. Requirements of pulp capping materials
Ideal dressing material for pulp therapy in primary
teeth does not exist, but the material should be:
Bactericidal
Biocompatible
Harmless to the pulp, surrounding structures and the
permanent tooth germ.
Promote healing
Not interfere with physiologic process of resorption.

7. Reaction of the pulp to
various capping materials
(Indirect and Direct)

8. Zinc oxide-eugenol
Germicidal agent
Palliative affect
Used in indirect pulp capping due to its Excellent initial seal
Kills bacteria present in
This gives the pulp the chance for carious lesions
healing & regeneration So arrests the caries process
Direct contact →chronic inflammatiom ,abscess formation and
liquefaction necrosis.
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.

9. Calcium Hydroxide
 It presents two fundamental enzyme properties;
- The inhibition of bacterial enzymes (antimicrobial effect).
-Activation of tissue enzymes such as alkaline phosphatase
(mineralizing effect).
 Calcium hydroxide (Ca(OH)2) encourages the formation of dentinal
bridges.
 Used in direct pulp capping and pulpotomy procedures in
permenant teeth.
 Due to its extreme alkalinity (pH of 12),
-that frequently causes necrosis,
-acute or chronic inflammation and
-dystrophic calcification in the pulp tissue,
it is not recommended for direct pulp capping
nor pulpotomies in primary dentition. Except in phase Ι.

10. Histological picture
The calcified barrier is done as follow:
Superficial necrosis.
Deeply staining zone
Area of fibrous tissue.
Odontoblasts like cells.
One month→ a calcified bridge appears in X-ray film.
Next 12 m increase in thickness.
Pulp beneath the calcified bridge remains vital & free
from inflammation.

11. Antibiotics and corticosteriods
in combination with calcium hydroxide
-These drugs were more successful in stimulating regular
reparative dentine bridges than calcium hydroxide alone.
However this work has not been expanded.
Combination between tricalcium
phosphate with calcium hydroxide
-Produce maximum reparative dentine.

12. Adhesive Liners
There were suggested as direct pulp capping and
pulpotomy agents with the introduction of adhesive
dentistry in both primary and permanent dentition.
Adhesive material forms
- 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.

13. 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.
Thin dentine bridges were seen in some of the extracted
teeth
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.

14. 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.

15. Mineral Trioxide Aggregate
(MTA)
Was approved for human usage by the FDA.
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.

16. Has numerous applications in dentistry.
pulp capping pulpotomy
root filling material
fill wide open apices in immature teeth
repair perforations and root fractures
retrograde root filling material.
Very effective in apexification compared to any other
procedure
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.

17. MTA has been used in pulp capping procedures and
demonstrate remarkable success compared to calcium
hydroxide.
MTA pulpotomies consistently produced dentine bridge
formation and maintained normal pulp histological
appearance over 2- and 4-week observation periods. After
6 months pulpotomy with MTA resulted in the formation
of calcified tissue that completely bridged the exposure
site.
The pulp C.T. presented characteristics of normality and a
small segment of cells adhered to the mineralized mass.
MTA showed clinical, radiographic and histologic success
as a dressing material following pulpotomy in primary
teeth compared to bioactive glass, ferric sulfate, and
formocresol.

18. Laser
Different studies were led on laser energy
to overcome the histological deficits of electrosurgery.
Used in Direct pulp capping & pulpotomy.
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.

19. Advantages
examination at 12 months demonstrated that teeth
remained vital after using CO2 laser in direct pulp
capping, corresponding to a success rate of 89%.
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.

20. Histological picture
Laser irradiation creates a superficial zone of coagulation
necrosis that remains compatible with the underlying tissue
and isolate pulp from effects of the subbase. Mortiz et al.,
reported that the thermal effects of laser radiation caused
sterilization and scar formation in the irradiated area,
which in turn preserves the pulp from bacterial invasion.
Using CO2 laser on exposed pulps reported no histological
damage to radicular pulp tissue.
A study in (2001) demonstrated that YAG laser used in direct
pulp capping had good healing capacity with dentin bridge
formation.
Argon laser pulpotomies in primary teeth reported that after
sixty days, favorable responses of healing and repair in pulps.

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

22. Based on recent evidence that bone and dentin
contain bone morphogenetic activity, the application
of this growth factor (BMP) during pulpal healing has
been proposed to induce reparative dentin formation.
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).
TGF beta (transforming growth factor beta)

23. Histological picture
It was observed that, the application of BMP on exposed
pulp is dissolved within two weeks stimulates mitosis of
the adjcent cells differentiate into osteodentinoblasts
lay down osteodentin matrix differentiation of
odontoblasts. were capable of inducing dentin formation.
At two months the pulps were covered with tubular
dentin at the pulp tissue side.

24. Studies in (2002), reported that implanted
- bone sialoprotein (BSP)
-bone morphogenic protein-7
-and chondrogenic inducing agents (CIA)
in amputated coronal pulp caused
-formation of reparative dentin closing the pulpal wound
(CIA),
-or filled the mesial part of the coronal pulp (BSP),
-or filled totally the pulp located in the root canal (BMP-7)
However, further research is desired.

25. Calcium phosphate Compounds
Alpha-tricalcium phosphate & Tetracalcium phosphate
(4CP) set & convert to hydroxyapatite.
Stimulate the pulp to form hard tissue.
No finding of necrotic pulp tissue in direct contact with
4CP cement compared to calcium hydroxide slight
acidity after mixing
4CP cement has mechanical strengths so it could be used
as so called “dentin substitute”. Pulp capping agent
lining material

26. (MBF) Modified Bioglass Formula
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.
Another study showed:
At 2 weeks, inflammatory changes in the pulp.
4 weeks, some samples showed normal pulp
histology, with evidence of vasodilation.

27. High molecular-weight hyaluronic
acid
It can provide an environment suitable for reparative
dentine formation through mesenchymal cell
differentiation during healing of the amputated dental
pulp.
2 days after applicaton, wound surfaces were covered with
blood and fibrin clots and inflammatory cells.
At 1 week, differentiation of fibroblastic and odontoblast-
like cells was observed beneath the wound layer: and
odontoblast-like cells produced globular calcified nodules.
At 2 weeks, a layer of reparative dentine had been.
Between 30 and 60 days, the formation of reparative
dentine had extended throughout the pulp chamber.

28. 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.

29. Another 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.

30. Reaction according to the
pulpotomy Technique
Devitalization:
based on fixation (destroy) of the radicular pulp tissue
“Formocresol, Electrosurgery and Laser”.
Preservation:
intended to only minimally insult the pulpal tissue,
without initiating an inductive process.
“Glutaraldehyde and Ferric Sulfate”
Regeneration:
Based on induction of reparative dentin formation by
the pulp agent “Calcium Hydroxide , Adhesive Liners,
MTA, portland cement, EMD and other experimental
materials.

33. Formocresol
The most widely used dental medicament
in spite of the introduction of new capping materials.
Introduced by Buckley in 1904, as a suppressant and
mummifying agent.
35% Cresol, 19% Formalin in a vehicle of glycerin and
distilled water.
1/5 dilution produces equivalent results as full strength
Formocresol acts by direct contact releasing formaldehyde
which combines to cellular protein & fixes the pulp tissue
Formocresol pulpoptomy technique was advocated by
Sweet in the 1930, clinical and radiographic success rates
of 98% have been reported.

34. Disadvantage:
The International Agency for Research on Cancer (IARC)
classified formaldehyde as carcinogenic to humans in June
(2004).
-causes nasopharyngeal cancers in humans
-nasal & paranasal sinuses cancers -leukemia.
Cause necrosis and sloughing If it touches the gingiva.
Correlation between enamel defects in succedaneous teeth
and formocresol pulpotomies performed on the primary
dentition, such as
-increase in the prevalence of hypoplastic and/or
hypomineralization defects.
-increased prevalence in positional alteration of the
succedaneous teeth.
This makes it very important for the profession to look for
viable alternatives to Formocresol.

35. Histological picture
After exposure of pulp to formocresol for periods of 7 to 14 days
three distinct zone become evident:
 Fixation of the pulp tissue adjacent to formocresol
application sight (broad acidophilic zone)
 The middle third showed loss of cellular integrity which,
alters the blood flow resulting in areas of ischemia (Atrophy).
 Middle to apical third showed an ingrowth of granulation
tissue and broad zone of inflammatroy cells.
In 2003, studies reported that fibrosis was more extensive at
4 weeks with evidence of calcification in certain samples.

36. Electrosurgy
Considered as non-chemical devitalization of the
pulp tissue.
A technique in which the cutting effect performed
without crushing of the tissue cells, hence minimal
tissue destruction occur.

37. Advantages
It can be performed quickly
No drugs involved that may produce undesirable systemic
effects.
No clinical and radiographical differences in the success
rate between the electrosurgical and formocresol
techniques.
Contraindication:
All general contraindication to surgery
Within 15 feet of demand type cardiac pacemakers
Near flammable anesthetic agent
Around implants
In irradiated pts..

38. Histological picture
layer of coagulation necrosis provides a barrier between
healthy radicular tissue and the base material placed in
the pulp chamber.
fibrosis with acute and chronic inflammatory cells.
Reparative dentin was detected four and six weeks post-
treatment.
No internal root resorption, periapical involvement was
observed after four weeks.
Many studies concluded that pulpotomized primary teeth
treated by electrosurgery exhibited less histopathological
reaction than treated by formocresol pulpotomy.

40. Glutaraldehyde
An excellent bactericidal agent and seems to offer
some advantages compared with formocresol in the
following ways:
1.Formaldehyde reactions are reversible,
gluteraldehyde reactions are not.
2. Formald. is a small molecule, penetrates the apical
foramen
gluteraldehyde is a large molecule that does not.
3. Formald. long reaction time, excess of solution to fix
tissue,
gluteraldehyde fixes tissue instantly, excess is
unnecessary.

41. Histological picture
When placed over vital pulp tissue produces zone of
superficial fixation that doesn’t migrate apically with very
little underlying inflammation.
The vitality of the remaining pulp is maintained.
However the clinical success rates with glutaraldehyde
have ranged widely, due to superficial fixation that may
result in insufficient depth of antibacterial action causing
a deep zone of chronic cell injury.
It has also been observed that inadequate fixation leaves a
deficient barrier to sub-base irritation, resulting in
internal resorption.

42. Ferric Sulfate
Ferric sulfate nonaldehyde agent
controls hemorrhage without clot formation.
Agglutinates blood protiens (produces hemostasis at pulp
stumps by chemically sealing cut blood vessels).
It is available in a 15.5% solution under the trade name of
Astringedent.
Advantages
low toxicity and no systemic side effects.
Clinical and radiographical evaluation have reported
favourable responses compared to those noted with
formocresol and calcium hydroxide.

43. Histological picture
Preventing clot formation might minimize the
chances for chronic inflammation.
However a study in 2004 showed that Ferric sulfate
showed moderate inflammation of pulp with
widespread necrosis in coronal pulp at 2 and 4 weeks.

45. The dental pulp is a highly vascular and innervated
connective tissue, which is capable of healing by
producing reparative dentin and/or dentin bridges in
response to various stimuli and surgical exposure.
The rationale for regeneration is the induction of
reparative dentin formation by the pulpotomy agent.

46. ( Portland cement (PC
PC differs from MTA by the absence of bismuth ions and
the presence of potassium ions.
Both materials have comparable antibacterial activity and
almost identical properties macroscopically,
microscopically and by X-ray diffraction analysis.
Similar clinical and radiographic effectiveness of PC and
MTA as pulpotomy dressing agents.
An inexpensive material.
Save

47. PC and MTA have similar effect on pulpal cells and
formation of dentin bridge when used for direct pulp
capping or pulpotomy.
Dentin bridge may be due to its mechanisms of action.
Calcium oxide + water calcium hydroxide
The reaction of the Ca from calcium hydroxide with the
carbon dioxide from the pulp tissue produces calcite
crystals.
Then, a rich extracellular network of fibronectin in close
contact with these crystals can be observed
(initiating step in the formation of a hard tissue barrier).
Moreover, PC has an excellent sealing ability and fast
setting, thus preventing the diffusion of the material into
the tissues, and reducing microleakage during the pulp
healing period.

48. Preoperative periapical radiograph of the mandibular 3-month follow-up periapical radiograph suggesting the
left primary molars of a 6-year old girl, which presented initial formation of a dentin bridge immediately below
extensive caries lesions and no signs of periapical lesion. the Portland cement in the distal root (arrow) of the
Absence of the mandibular left permanent second pulpotomized mandibular left second molar and
premolar was observed absence of periapical lesion in both pulpotomized
mandibular left primary molars
6-month follow-up periapical radiograph suggesting the 12-month follow-up periapical radiograph suggesting the
presence of the dentin bridge immediately below the initial radicular pulp obliteration
Portland cement in the distal root (arrow) of the
pulpotomized mandibular left second molar

49. Histologically
After 120 days, the pulp wounds healed with hard tissue
formation of considerable thickness.
The coronary third of the root canals were completely
closed by a newly formed homogeneous mineralized
tissue.
A basophilic-like mass constituting the remnants of the
pulp capping materials could be seen covering the newly
formed dentin.
The pulp tissue was normal and free of inflammatory cells.
No tissue necrosis was noticed.
Presence of macrophages was also observed in some cases.

50. Enamel Matrix Derivative
Enamel matrix derivative (EMD), obtained from
embryonic enamel of amelogenin.
EMD commercially presented as EMDOGAIN® which
has been successfully employed to incite natural
cementogenesis to restore a fully functional
periodontal ligament, cementum and alveolar bone in
patients with advanced peridontitis.

51. After 6 months, using formocresol (FC) and (EMD) the
clinical success rates for the FC and EMD groups was not
statistically significant. However, the radiographic success
rates for the FC and EMD groups showed a statistical
significance between the two groups at 6 months.
Periapical radiographs showing lower 2nd primary molars of
the same patient treated with formocresol (figure1) and
Emdogain® (figure2).
(Figure 1): (Figure 2):
At 6 months furcation radiolucency At 6 months no radiographic changes
periapical radiolucency
internal resorption

52. The histopathological response of dental pulp tissue
to EMD used in pulpotomized teeth showed that
(2001,2003):
-The pulp wound showed features of classic wound healing.
-Subjacent to the healing wound, a bridge of new hard tissue
(tertiary dentin) was formed, sealing off the wound from
the healthy pulp tissue.
-The pulp tissue subjacent to this new hard tissue was
invariably free of all signs of inflammation. Moreover, a
layer of odontoblast-like cells had formed, abutting the
newly formed mineralized tissue.
-Furthermore, it was also reported that growth of some
bacteria including Streptococcus mutans, is inhibited by
the presence of EMD.

53. -After twelve weeks, EMD demonstrated extensive
amounts of hard tissue formed. Moreover, postoperative
symptoms were less frequent.
-These results offers preliminary evidence that EMD is a
promising material which may be as successful, or more
so, than other pulpotomy agents

54. Other Experimental Capping
materials
Enriched Collagen Solution (ECS)
Using of ECS as a Pulp Dressing in pulpotomies showed that:
-80% of the ECS- treated teeth had vital pulps,
-73% dentine bridges were present and
-more than half of the ECS-treated teeth showed no pulpal
inflammation after two months.

55. Freeze-Dried Bone (FDB)
(Pediatric Dentistry.2004)
-Histological findings of pulpotomized teeth using FDB
showed histological findings very similar to calcium-
hydroxide.
-At 3 m Complete or partial calcific barrier was evident
directly below treatment site.
-Normal appearing odontoblastic cells were noted below the
calcific barrier.
-The apical third was vital with an occasional chronic
inflammatory cell visible.

56. Ethyl-cyanoacrylate
Present adhesive, haemostatic and bacteriostatic
properties.
Induce more rapid tissue repair.
Cyanoacrylate is an adhesive that results from the
chemical reaction between formaldehyde and the esters of
cyanoacetate.
These products have been used in neurosurgery,
gastrointestinal tract surgery and in oral and maxillofacial
surgery.
In dentistry, observation of a hard tissue barrier in
monkey dental pulp covered with Isobutyl cyanoacrylate.

57. Teeth capped with ethyl-cyanoacrylate for 30 days
showed:
- Formation of a continuous hard tissue barrier at the level
of pulpal amputation
-These hard tissue barriers consisted of a bone-like layer at
the surface and an underlying layer of dentin-like tissue.
- No necrotic tissue between the barrier and the ethyl-
cyanoacrylate.
- The pulpal aspect, underneath the barrier, showed signs of
vitality with the presence of a chronic inflammatory
process. The inflammatory response was considered to be
moderate in this area.
- The other two-thirds of the pulpal tissue were free of
inflammation.

58. OZONE
• A gas containing three oxygen atoms per molecule. Ozone
is a very powerful oxidizing agent and is formed when
oxygen or air is subjected to electric discharge.
The disinfection power of ozone makes the use of ozone
in dentistry a very good alternative to standard antiseptics.
Dissolved ozone in water and ozonated oils were and are
still commonly used in different fields of dentistry.
ozonated water can be used as a disinfectant and irrigant
(HealOzone have the ability of pulp tissue dissolution in
bovine teeth).

59.  It is also postulated that ozone will penetrate through the
apical foramen, and enter into the surrounding and
supportive bone tissue. The effect of ozone on these
tissues will be to encourage healing and regeneration
(Bioregulator).
With the development of a footpedal-activated dental
handpiece with a suction feature, O3 gas can now be used
safely in situations.

60. Stem cell delivery
A number of recent studies have demonstrated that stem
cells, of both dental and non-dental origin, are capable of
inducing odontogenesis and regenerating dentin.
Deciduous teeth contain a population of more immature
multipotent stem cells ("stem cells from human exfoliated
deciduous teeth"; SHED), that are capable of forming
dentin-like structures but not a complete dentin-pulp
complex.
A study in 2004, recommended that Ex vivo cell therapy
may have an advantage, in that the cultured tissue
stem/progenitor cells can be implanted after
differentiation into odontoblasts and might result in
copious amounts of reparative dentin formation.

61. Radical Treatment
(irreversible pulpities or
( necrotic pulp

62. Zinc oxide-eugenol and iodoform
(KRI Paste)

63. Calcium Hydroxide and iodoform
(Vitapex, Diapex or Metapex)
- There are Favorable reports about their
successful use in infected primary teeth
Pulpdent
In the year 2000 Mani et al. used calcium hydroxide paste in a
methyl cellulose base as a root canal filling material in primary
teeth of children.
A success rate of 86.7 percent was reported . The authors
suggested that the alkaline property of the material
- helps in healing of periapical lesions by acting as a local buffer ,
- activating the alkaline phosphates activity, which is important
for hard tissue formation.

64. Conclusion
Ferric sulphate, MTA and Indirect pulp capping
appear to be promising alternatives to formocresol
pulpotomy for cariously exposed vital primary molars.
Many investigators indicated that the healing of
dental pulp exposures is not dependent on the pulp-
capping material, but is related to the capacity of
these materials to prevent bacterial leakage.

65. References
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pulps submitted to different capping materials. Braz Oral Res.,
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 Saeed Asgary et al.SEM evaluation of pulp reaction to different pulp
capping materials in dog’s teeth. IEJ., 2006; 1:117-123.
 Peter. Murray & Franklin Garcia-Godoy.The incidence of pulp healing
defects with direct capping materials. Amr J of Dent., 2006; 19:171-177.
 Peter. Murray et al. Analysis of pulpal reactions to restorative
procedures, materials, pulp capping, and future therapies crit rev oral
biol med509-13:520 2002
 Ardo Sabir et al.Histological analysis of rat dental pulp tissue capped with
propolis, J oral sci., 2005; 47:135-138.
 Taisa Regina et al. pulpotomies with portland cement in human primary
molars, J Oral Sci., 2009;17:66-69.
 Jumana Sabbarini. Alternative Interventions to Formocresol as a Pulpotomy
Medicament in Primary Dentition: Smile Dent J.,2010