INTRODUCTION:

During the last 200yrs there have been many changes in the rationale governing the treatment of dental pulp. Question concerning which technique gives the highest % of

success. It is essential to have thorough understandings of the

compatibility of the material, its physiological response, and the

histological changes that takes place during and after the use of
medicaments

HISTORY

Mid 18th century - Pierre Fauchard

Mid 19th century - John Tomes Layer of discolored dentin (indirect)

1756 Philip Ptaff golf leaf (direct pulp capping)

1850 Principles of indirect pulp capping Foster 1860 Taft mixture of sorghum molasses/sparrow 1866 Atkinson - Creosote 1891 W.D. Miller Antiseptics 1930 Teucner New era 1980 Calcium phosphate cement 1990 Dentin bonding agent 1993 Mineral trioxide aggregate

Zones of early enamel caries: I Translucent: More porous (1% pore volume/0.1% normal enamel) 1.2% mineral loss II Dark zone: Positive more porous (2-4%) 6% mineral loss III Body of lesion: 5% in periphery & 25% center 25% mineral loss IV: Surface zone: Unaffected (20-100m) 10% mineral loss

Zones of dentinal caries:

I Normal dentin: No bacteria II Sub-transparent dentin: Demineralization of intertubular crystals odontoblastic process are damaged III Transparent dentin: Softer IV Turbid dentin: Bacterial invasion widening & destruction of

tubules little mineral denatured collagen

V Infected dentin: Decomposed dentin

Infected dentin

Affected dentin

Highly deminerlized Unremineralizable Superficial layer Lacking sensation Can be stained Should be excavated

Less Remineralizable Deeper Sensitive Does not stain Left behind

DIRECT PULP CAPPING Application of a medicament to exposed pulp to preserve the vitality

1. Pinpoint sound dentin no hemorrhage - mild infl. repaired

2. Pinpoint sound dentin drop of blood mild infl.

3. Infected dentin considerable site far doubtful

4. Profuse greater infl. very doubtful 5. Infl. Pus/fluid destruction not indicated

Indications:

No H/O pain. Exposure size < 4 mm No observable hemorrhage

Clean uncontaminated field

Dentin at periphery is repairable No pathologic changes Contraindications: Severe toothache Tooth mobility

Excess hemorrhage
Purulent discharge Radiographic changes

Direct Pulp Capping

INDIRECT PULP CAPPING Gross caries is removed and the cavity is sealed with a biocompatible material Pulp inflammation is minimal complete removal of caries would cause an exposure

Indication:

Contraindication:

Severe toothache Tooth mobility Purulent discharge Radiographic changes

Indirect Pulp Capping

Objectives:

Seal completely

Vitality.
No prolonged post-treatment Pulp healing & tertiary dentin No pathological changes.

Failures:
Degree of trauma Sealing pressure

Low threshold of host resistance

Presence of microorganisms Failure of an aseptic technique

Ivory

Quill

Gold-beaters skin Canada balsam Oxychloride Asbestos

Oiled skin Gutta percha

Paper Plaster of paris Lactophosphate of lime

Oxyphosphate Oxyxulphate of zinc cement

Calcium hydroxide Pulp Caps Celluloid Dome

Zinc phosphate
Zinc oxide eugenol Zinc polycarboxylate Glass ionomer

Calcium phosphate

Freezed dried bone

MTA

Bone cement
Demineralized dentin matrix Dentin chips Bioactive glass Collagen matrix

Zinc phosphate cement

Most irritating (acidity / exothermic) - Solubility (0.06%), pH 3.5 (neutral) ED >2.5 mm Healthy reparative, but occ. unhealthy

ED 1.5 - 2.5 mm Unhealthy reparative, sometimes destruction

ED <1.5 mm destruction of pulp tissue

Zinc oxide eugenol: - Least irritating (eugenol / impurities) - Solubility (0.4%), pH 6.6-8 - Obtudent (sedative) 1. Pulp is healthy, site is controlled microbially & reparable

Limited Fibrous tissue Matrix formation Mineralization Bridging

Propagate Pulp/root canal Necrosis (slow/symptomless)

Firbosis No bridge

Acute infl. Necrosis

2. Acute inflammation bridging is unlikely to occur

3. Dentin chips fibrous bridging. (nucleation) 4. Impingement (force, thin matrix) interfere healing.

Zinc polycarboxylate
- minimally irritant - Solubility (0.6%), pH 3-4 (5-6)

ED >1mm = healthy reparative dentin

ED <1mm = Unhealthy / frequently destruction

BORISSOV 2003 5% potassium nitrate (anti-inflammatory effect of alkaline medium) reparative dentin.

Glass ionomer cement - irritant ED > 1.5 mm = healthy dentin ED 0.5 1 mm = unhealthy dentin

ED < 0.5 mm = destruction

Cyanoacrylate cements

- Composite-type polymers
- methyl, ethyl, n-butyl or isobutyl cyanoacrylate Rapid hemostasis, biocompatible & reparative dentin formation without necrotic zone. (Berkman & Bhasker et al, 1971) On degradation low-grade degeneration cellular layer chemical

equilibrium attract calcium - mineralization

Spray form Fine drop of liquid

Additive in capping material:

Diff. Substance to reduce infl./eliminate infection

Corticosteriods:

Degenerative changes interfere hard tissue

(Hansen, 1963, Everett 1969, Barker 1969, Mitchell 1970, Soto-Feine 1982)

Antibiotics: Little information on topical application (cytotoxic/hypersensitivity)

[Tetracycline, neomycin, penicillin, vancomycin
Obersztyn 1968, Baker 1969, Gardner 1971, Page 1973, Bergenholtz 1977]

Antiseptics: Cytotoxcity
(Dankert 1976, Martin 1978, Kopel 1980, Cunningham 1982)

Calcium Hydroxide
In 1920, Herman - irritant (alkalinity) - Solubility (0.4-7.8%), pH 9.2-11.7 ED > 1mm = healthy reparative dentin ED < 1mm = unhealthy reparative dentin Direct Contact 1. Zone of obliteration (compressed tissue) debris, dentinal fragment, hemorrhage, blood clots, Ca(OH). 2. Zone of edema 3. Zone of coagulative necrosis(mummifying) -

24-hours

4-5 weeks

2-months

2-3 weeks

Ca(OH)2 Ca2+ Reduced capillary permeability Reduced serum flow Reduced level of inhibitory pyrophosphate OHNeutralize acid -osteoblast Pyrophosphates activity (pH) Increased Ca2+ dependent pyrophosphate

Uncontrolled mineralization

Advantages:
Bactericidal & bacteriostatic Promote healing & repair

pH fibroblasts
Inexpensive and easy to use

Disadvantages:
Does not exclusively dentinogenesis/reparative dentin Degrade during acid etching Do not adhere to dentin / resin restoration Solubility

Settable calcium hydroxide:

Dycal Hydrex

Reolit
Life Nu-Cap Dycal VLC Reocap

Procal

Water-Based Calcium Hydroxide Direct pulp-capping Radiopaque 63% Ca(oH)2 "Save cap"
Self-Curing Calcium Hydroxide Indirect pulp capping 25 % Ca(oH)2

Light-Curing Calcium Hydroxide Cures in 30 seconds Compressive strength (135 MPa)

COX et al capacity of the capping agents to provide a biologic

seal against immediate & long-term bacterial microleakage along the entire tooth surface

Hybridization of dentin Superior ability to adhere to both demineralized enamel and dentin Inoue et al, 1992 excellent pulp healing Katoh et al, 1993 good healing with adhesive resin Miyakoshi et al, 1994 protective layer on the pulpal surface

Jontell et al, 1995 immunosuppression -pulpal immunocompetent cells

Tsuneda et al, 1995 histopathologic best healing(absence infl.)

Mijakoshi et al 4-META-MMB-TBB effective biological seal

Ability to seal the exposure site from bacterial microleakage

 Cytotoxic pulpal inflammation Leachable nonpolymerized monomers Accumulation of DBA fragments

In vitro/ In vivo components are cytotoxic to pulp cells (fibroblast) Current adhesives (SEP) suitable property lack of diffusion of resin globules (DT) may be useful and safe

While bonding system have greatly improved sealing

ability in recent years, there is a clear evidence that even with the best bonding system, there is microleakage of bacteria around the restoration Need long-term clinical performance

MTYA1-Ca (resinous agent)

Powder: Microfiller 89% 10%

Calcium hydroxide

Benzyl peroxide (catalyst)

1%BPO

Liquid:

Triethylene glycol dimethacrylate Glyceryl methacrylate 30%GM

67.5%(3G)

Methacryloyl tyrosine amide(MTYA) adhesive

Dimethyaminoethylmethacrylate (initiator) DMAEMA

Camphoroqiunone ( catalyst)

 Powder:Liquid = 3:5
MTYA good adhesion (adhesive monomer) Triethylene glycol dimethacrylate Mechanical prop

Glyceryl methacrylate bond strength

MTYA1-Ca good physical properties. Potential to be used as a direct pulp capping agent
Niinuma et al,1999

Calcium phosphate cements (1980) Ca:P Octacalcium phosphate, (Ca4H(PO4)3)3H2O 1.33

Tricalcium phosphate, (Ca3(PO4)2)

Calcium hydroxyapatite, (Ca5(OH)(PO4)3) Dicalcium phosphate dihydrate, (CaHPO4 2H2O) Nucleation/growth amorphous

1.50
1.67 1.0

solid crystalline HAP

Further investigations explain how exactly contribute RD formations

Bioactive glass Amorphous non-crystalline ionic release

Silica 45.0%

Sodium 24.5% Phosphorus 6.0%

Calcium 24.5%

Negative charge, - attract building blocks Grainy particles Porous Framework of hydroxy-carbonate -apatite crystals - trapping & bonding building blocks

MTA
Fine hydrophilic particles Tricalcium silicate - Tricalcium aluminate - Tricalcium oxide - Silicate oxide Hydration colloidal gel - < 4 hours pH 10.2 to 12.5 Resistant to marginal leakage Allows normal healing response Set in the presence of moisture Reduces bacterial migration

 Open a single pouch Mix with the water ampule (sterile water) provided to a creamy consistency Condense with a condenser Approximately 5 - 15 minutes' working time and 4 - 6 hours' setting time Action: Stimulate cytokine release hard tissue formation

Dentinogenesis sealing ability, biocompatibility & alkalinity

Portland Cement
Ingredients in common with MTA, (calcium phosphate, calcium oxide, & silica.) MTA - bismuth oxide (radiopacity), - absent PC Induce dentin bridge - excellent sealing, fast ST 5 minutes.

BONE CEMENT
Powder - (polymethyl) methacrylate polymer, methyl methacrylate styrene copolymer & barium sulphate Liquid - methylmethacrylate monomer. Antibiotics - 2% weight by weight (gentamicin sulphate) Advantage: Moist environment.

Gary Mathew Holt & Thom C Dumsha - dye leakage In vitro bacteriological study by High et al - bacteriocidal

An ideal repair material is one that will support osteogenesis and

cementogenesis and biocompatible, non toxic, non carcinogenic, easily

obtainable, convenient to use, biodegradable. No such ideal material

has yet been identified

LASER First laser use in endodontics Weichman & Johnson, 1971 CO2 Argon Nd YAG Er. YAG Immense heat & power sterilizes scar formation preserve pulp from bacterial invasion Blood extravasation gradual organization hard tissue formation Melcer et al, 1987 exposed pulp tissue (CO2) hemostasis Ebihara et al, 1992 Nd:YAG 89% success Moritz et al, 1998 CO2 direct pulp capping

 Sekine et al No reparative dentin formation (28 days)

Wigdor et al No reparative dentin after 4 days (CO2 laser)

Tankano et al - Reparative dentin (Er.YAG)

With the development of thinner, more flexible and durable laser fibers, laser application in endodontics will increase, but acceptance of this technology by clinicians has remained limited

Two concepts

Mechanical concepts

Biological properties

Disappearing

Bioactive molecules

Bioactive molecules: Materials that induce a specific biological activity in the body With the development of tissue engineering, a new era that will lead to modifications in daily practice in the near future

Bioengineered reconstruction, regeneration four components

Undifferentiated / STEM cells - repair site cells prog. specifically tissue

3D-ECM
- Specific possess intrinsic mineralizing prop Signaling molecules - cytokines, growth factors, hormones Carrier - important factor, scaffold

DSPP

DPP

DSP

- nucleator for mineralization

- dentin mineralization Dentin matrix protein (DMP-1)

Bone sialoprotein I (osteopontin)

Bone sialoprotein II

Bone sialoprotein

TGF-
BMP-7 / OP1 IGF I & II

 Rutherford et al - hOP-1/ bovine type-1 collagen, sterile saline, reparative dentine

Nakashima - BMP-2 & BMP4 - dentin formation

Hu et al - (i.e.EGF, FGF, IGFII, PDGF-BB, and TGF-) TGF-1 = enhanced reparative dentin

Six et al - the effect of dose-dependent BMP-7 - collagen pellets containing 1, 3 or 10 g = No difference

BMP-7/OP-1

Enamel matrix (EMD) induces hard tissue formation in the pulp and that it may be a suitable capping agent.

EmdogainGel consists of EMD in propylene glycol alginate.

Two vials - a vehicle solution and freeze dried enamel matrix proteins (amelogenin fraction). When mixed, they create a viscous,

easy to use,
syringable gel

Treatment of dentine matrix with various cavity conditioning

agents -solubilize TGF-b1

EDTA was the most effective agent Calcium hydroxide is also able to solubilise TGFb-1 from dentine matrix

Questions concerning the application of these biological modulators:

1. Development & classification of biological modulators.

2. Interaction - artificial barriers, biological modulators, & restorative materials. 3. Effects - status (i.e. normal, inflamed or infected). Most of the research - vital, non-inflamed

4. The effect of aging on pulpal response.

5. The delivery vehicle used for the molecules. 6. The dose response effects of the molecules. 7. The half-life of the molecules. 8. Immunological problems due to repeated implantation

Reparative Dentin Formation by Ultrasound-Mediated Gene Delivery of Growth/Differentiation Factor 11 BMPs - Odontogenic differentiation. Gene therapy - induce reparative dentin. Gene transfer (Gdf11)/Bmp11 plasmid DNA into dental pulp stem cells by sonoporation & stimulated by ultrasound (1 MHz, 0.5 W/cm2, 30 sec) - stimulated a large amount of reparative dentin formation on the amputated dental pulp in canine teeth in vivo. Gdf11 cDNA plasmid - by sonoporation in vitro, induced Dsp (marker for odontoblasts.) Thus, the result suggested the possible use of BMP using ultrasound-mediated gene therapy for endodontic treatment.

 Endodontic & restorative challenge

Debridement & obturation impossible

APEXIFICATION
Process of creating an environment with in the root canal & periapical tissue after pulp death that allows a calcified barrier to form across the open apex.

Indication: Immature tooth with pulp necrosis.

Contraindication:

- Root # - Replacement resorption

- Very short roots.

Objective: Calcified barrier / artificial barrier

 Nygaard-Ostby Lacerate the apical tissue cementum-like tissue Elimination of residues/bacteria stimulate the radicular formation not necessary chemical stimulator cementum Baouchon et al Walkoffpaste Kaiser at al Calcium hydroxide (1956) Frank - Published

TECHNIQUE: Anesthesia and Rubber Dam Isolation

Bigger Access Cavity

MATERIALS Ca(OH)2 MTA Tricalcium Phosphate EWL Hypochlorite Ultrasonic Devices Recommended Ca(OH)2

Permanent filling
4-6 week, 3rd, 6th,& 24 month recall

 Duration of treatment
Marginal adaptability Sealing ability One Visit Apexification

1. 2. 3. 4. 5.

Good sealing ability Marginal adaptation Biocompatible Used in moisture presence Speed of completion of therapy

MTA Angelus

Composition
SiO2, K2O, Al2O3, Na2O, Fe2O3, SO3, CaO, Bi2O3, MgO and insoluble residues of CaO, KSO4, NaSO4 and crystalline silica. ST - Gel - in 10 -15 minutes.

Success:

Absence of signs / symptoms Calcified barrier

Failure:

Bacterial contamination (seal / debridement) Infected necrotic material

Undetected root #

Conclusion:
The last decade has proved to be an exciting time for pulp

biology & has led to rapid advances in repair of this tissue. At the start
of a new millennium, the use of biological molecules for the

development of novel treatment modalities is in sight.

These approaches have potential applications in unexposed as

well as in exposed pulp situations for the restoration of the structural

integrity of the dentin wall by reparative dentinogenesis