Pulp capping agents

PULP CAPPING
AGENTS
RAJANA RAGHUNATH
PG STUDENT
DEPT. OF CONS & ENDO
KVG DENTAL COLLEGE & HOSPITAL
Never must the physician say the disease is
incurable. By that admission he denies God, our
Creator; He doubts Nature with her profuseness of
hidden powers and mysteries.
—Paracelsus

CONTENTS
 Introduction
 Indirect pulp capping
 Direct pulp capping
 Historical review
 Pulp capping agents
 Conclusion
 References
Calcium
hydroxide
Zinc oxide
Eugenol
GIC
MTA
Biodentine
Emdogain
Lazer
Enzymes
Growth factors
Isobutyl
Cyanoacrylate
Stem cells
Theracal
Polycaboxylate
cement
Fluocinolone
acetonide

INTRODUCTION
 Pulp protection is the term coined by AAPD which recommends the placement of a
protective base or a liner on the pulpal and axial walls of the cavity preparation to act
as a protective barrier between the restorative material and the tooth
 Pulp treatment modality can be classified to 2 categories-
A- conservative Treatment-Which aims at maintaining pulp vitality,include
1. Protective base.
2. Indirect pulp treatment.
3. Direct pulp capping.
4. Pulpotomy.
B-Radical treatment-consisting of pulpectomy and root filling

INDIRECT PULP CAPPING-
 It is defined by Ingle as a procedure where in small amount of carious dentin is
retained in deep areas of cavity to avoid exposure of pulp, followed by placement
of a suitable medicament and restorative material that seals off the carious dentin
and encourages pulp recovery.
 A radiopaque base is placed over the remaining affected dentin to stimulate
healing and repair. The tooth is then restored with a material that seals the involved
dentin from the oral environment.

Infected dentin Affected dentin
Highly demineralized
▪Unremineralizable
▪Superficial layer
▪Lacking sensation
▪Stained by 0.5% fuschin or i.e. 1.0%
acid red solution
Ultrastructure: intertubular dentin
greately demineralized, with irregular
scattered crystals.
Presence of deteriorated collagen
fibers that have only distinct cross
bands and no interbands.
▪Should be excavated
Intermediately demineralized
▪Remineralizable collagen
▪Deeper layer
▪Sensitive
▪Does not stain
Ultrastructure: intertubular dentin
Partially demineralized, but apatitie
crystals bound like fringes to
the Sound fibers with distinct
Cross bands and interbands.
▪Should be left remineralize.

 In a prepared cavity, remaining dentine thickness of more than 0.5 mm is ideal for
avoiding pulpal inflammation
 Reactionary dentine forms when remaining dentine thickness is 2.5- 0.01 mm due
to presence of a layer of surviving odontoblasts in the area, whereas reparative
dentine is formed following pulp exposure.
 Very deep cavities greatly reduce the number of surviving odontoblasts and hence
none remain to secrete tertiary dentine. Remaining dentine thickness not only
influences vitality of the underlying pulp tissue but also determines the repair
response.
 In light of the knowledge of the importance of remaining dentine thickness, it is
essential that sound dentine is never removed in order to accommodate for a
lining, base or sealer material.

Direct Pulp Capping
 The procedure in which the small exposure of the pulp ,encountered during cavity
preparation or following a traumatic injury or due to caries, with a sound
surrounding dentin ,is dressed with an appropriate biocompatible radio-opaque
base in contact with the exposed pulp tissue prior to placing a restoration is termed
as a direct pulp capping.

Objectives
The vitality of
tooth should
be maintained.
No prolonged
post-treatment
signs or
symptoms of
sensitivity, pain
or swelling
should be
evident.
Pulp healing
and tertiary
dentin
formation
should result.
There should
be no
pathologic
changes.
To create new
dentin in the
area of the
exposure and
subsequent
healing of pulp

Indication Small mechanical exposures less than 1 mm which is surrounded by
sound dentin.
Light red bleeding from the exposure site that can be controlled by cotton
pellet.
Traumatic exposures in a dry ,clean field ,which report to the dental office
within 24 hrs.
Contra-
indication
Pain at night
Spontaneous pain
Tooth mobility
Thickening of periodontal membrane
Intraradicular radiolucency
Excess bleeding at the exposure site
Purulent or serous exudates

 Historically, the first pulp capping procedure was performed in 1756, by the Phillip
Pfaff, who packed a small piece of gold over an exposed vital pulp to promote
healing.
 A controversy has existed within dentistry as to what is more detrimental to the
pulp: toxicity from dental materials or bacteria and/or their toxins. For many years,
even decades, practitioners believed that some restorative materials “killed” pulps
due to their inherent toxic properties. However, research since the mid-1970s has
indicated that the pulp can tolerate a variety of restorative materials if bacteria
and/or their toxins can be excluded from the pulp

 Orban described the histopathology of the pulp and concluded that the cells of the
pulp were the same as those of loose connective tissue. He believed these cells
could differentiate and healing could occur in the dental pulp. In subsequent years
much experimentation has taken place, with advocates both for and against pulp-
capping and pulpotomy procedures
 Because of the normal aging of the dental pulp, chances of successful pulp
capping diminish with age. Increases in fibrous and calcific deposits and a
reduction in pulpal volume may be observed in older pulps. With age the fibroblast
proliferation observed in the teeth of young animals is significantly reduced.

 Teeth with calcifications of the pulp chamber and root canals are not candidates for
pulp-capping procedures. These calcifications are indicative of previous
inflammatory responses or trauma and render the pulp less responsive to vital
therapy
 These long-standing inflammations with circulatory disturbances are frequently
accompanied by apposition and resorption of the canal walls and calcification in
the pulp. The inflammation, calcification, apposition, and resorption may increase
under pulp caps, regardless of which material is used as the pulp-capping agent

 According to Seltzer and Bender pulp capping should be discouraged for carious
pulp exposures since microorganisms and inflammation are invariably associated.
 Macroscopic examination of such exposures is difficult, and areas of liquefaction
necrosis may be overlooked.
 Location of the pulp exposures is an important consideration in the prognosis. If the
exposure occurs on the axial wall of the pulp, with pulp tissue coronal to the
exposure site, this tissue may be deprived of its blood supply and undergo
necrosis, causing a failure. Then a RCT should be performed rather than a pulp
cap.

Ideal
Requirements
 As suggested by Cohen and Combe

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

Adhesive Liners
 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
 According to Miyakoshi et al., 4-META adhesives and hybridizing dentin bonding
agents provide superior adhesion to peripheral hard tissues and effective seal
against micro leakage. But they have poor outcome due to its cytotoxic effect and
absence of calcific bridge formation
Qureshi et al. Recent Advances in Pulp Capping Materials: An OverviewJ Clin Diagn Res. 2014 Jan; 8(1): 316–321.

 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.
 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
 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

Glass Ionomer (GI) /
Resin-Modifed Glass Ionomer (RMGI)
 While not as cytotoxic as ZOE, GI/RMGI is also cytotoxic when in direct cell contact.
 Glass ionomer also provides an excellent bacterial seal and shows good
biocompatibility when used in close approximation but not in direct contact with the
pulp
 Fluoride release, coefficient of thermal expansion and modulus of elasticity similar to
dentin.
 Lack of dentin bridge formation.
 High solubility and slow setting rate.
 RMGIC as direct pulp capping agent exhibited chronic inflammation and lack of dentin
bridge formation; whereas the calcium hydroxide control groups showed significantly
better pulpal healing

 RDT- 0.5 – 0.25um – Ca(OH)2 & Composite shows faster deposition of tertiary
dentin than GIC
 Exposed pulps in non carious tooth – microleakage less than half that of Ca(OH)2

Calcium Hydroxide
 Many studies indicated that calcium hydroxide and calcium hydroxide compounds
are the gold standard in human teeth, against which new materials should be
tested.
 However, several disadvantages have been listed with the use of calcium
hydroxide material. Presence of tunnels in dentin barrier, extensive dentin
formation obliterating the pulp chamber, high solubility in oral fluids, and lack of
adhesion and degradation after acid etching are some of the limitations reported
Accorinteet al. “Evaluation of Mineral Trioxide Aggregate and Calcium Hydroxide Cement as Pulp-capping Agents in
Human Teeth”. JOE — Volume 34, Number 1, January 2008

 Herman (1930) – Ca(OH)2 pulp capping
 The greatest benefit of Ca(OH)2 is the stimulation of reparative dentin bridge, due
to a high alkalinity, which leads to enzyme phosphatase being activated and thus
releasing of inorganic phosphate from the blood (calcium phosphate) leading to
formation or dentinal bridge.
 When calcium hydroxide is applied directly to pulp tissue, there is necrosis of the
adjacent pulp tissue and inflammation of the contiguous tissue.
 Excellent antibacterial properties.
 Low cytotoxicity.

Mechanism of action
 Unique potential to induce mineralization
 Sciaky and Pisanti in 1960 observed that calcium ions present in the applied
calcium hydroxide do not become incorporated in the mineralized repaired tissue,
which derives its mineral content solely from the dental pulp.
 Forman observed that calcium hydroxide is an initiator rather than a substrate for
repair
 Hard setting calcium hydroxide preparations are recommended, as these cements
release fewer hydroxyl ions than pure calcium hydroxide and are gentle to pulp

Hydroxyl
Ions
Neutralizes
acid produced
by osteoclasts
Optimum pH for
pyrophoshatase
activity
Inc levels of Ca
ion- dependent
pyrophosphatase
Mineralization
Reduced levels
of inhibitory
pyrphoshatase
Reduced
serum flow
Reduced
capillary
permeability
Calcium
ions
Calcium Hydroxide

Advantages Disadvantages
 Initially bactericidal then bacteriostatic
 Promotes healing and repair
 High pH stimulates fibroblasts
 Neutralizes low pH of acids
 Stops internal resorption
 Particles may obturate open tubules
• Does not exclusively stimulate dentinogenesis
• Does not exclusively stimulate reparative dentin
• Associated with primary tooth resorption
• May dissolve after one year with cavosurface
dissolution
• May degrade acid etching
• Degrades upon tooth flexure
• Marginal failure with amalgam condensation
• Does not adhere to the dentin or resin restoration

Healing
 Zone of obliteration- pulp tissue in cantact, completely deranged & distorted.
 Zone of coagulation necrosis- takes the brunt of calcium hydroxide chemical thrust.
Schroder’s layer of firm necrosis and Stanley’s mummified zone
 Zone of dentin bridge formation- no distinct configuration. 0.3-0.7mm
 Line of demarcation btwn deepest level and subjacent vital pulp tissue. Glass and
Zander- calcium hydroxide with protein to form proteniate globulates.

 Poor bonding to dentin, material resorption and mechanical instability are among
them. As a result, calcium hydroxide does not prevent microleakage in the long
run. The porosities (‘tunnel defects’) of the newly formed hard tissue may act as a
portal of entry for microorganisms. These may cause secondary inflammation of
the pulp tissue and are thought to be responsible for failed maintenance of tooth
vitality. In addition, the high pH (12.5) of calcium hydroxide suspensions causes
liquefaction necrosis at the surface of the pulp tissue
 The 3 main available products are : Pulpdent, Dycal and Hydrex (MPC)
Dammaschke et al. A new bioactive cement for direct pulp capping.
INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL. 2, NO. 2

 Clinical success rates after direct pulp capping with Ca(OH)2 or with Ca(OH)2
compounds have been evaluated in different studies , and today this material is
regarded as the gold standard.
 The spectrum of success rates ranges from 13% to 96% . The difference in these
rates is attributed to different potential prognostic factors that can influence the
outcome of direct pulp capping such as length of follow-up, type of pulp exposure
(carious or mechanical), presence of an extrapulpal blood clot between the pulp
and the capping material, the area of pulp to which the capping material was
applied, time elapsed to placement of a definitive restoration of the pulp-capped
tooth, type of Ca(OH)2 used, presence or absence of infection as well as the age of
the patients
Mente et al.Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: An Analysis of the Clinical
Treatment Outcome. JOE — Volume 36, Number 5, May 2010

Mineral Trioxide Aggregate
(MTA)
 In recent years a new cement (mineral trioxide aggregate [MTA]), developed in the
1990s by Torabinejad and his coworkers at Loma Linda University (California), has
become available as a root canal repair material and for direct pulp capping.
 During the setting process, MTA has an initial pH of 10.2, which increases to up to 12.5
during the first few hours. Comp strength : 26.4 Mpa -24 hrs & 30.4 Mpa – 21 days.
 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.

 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

 Initially, MTA was used in endodontics to seal off all pathways of communication
between the root canal system and the external surface of the tooth
 Pitt Ford et al. were the first to evaluate the performance of MTA for pulp capping
in monkey’s teeth, and they demonstrated superior performance of MTA compared
with calcium hydroxide

MTA powder
Hydration (in the presence of water/blood)
Calcium silicate hydrogel Ca(OH)2
3-4 hours
Porous gel soldifies to a hard increase in pH to 12.5
Crystalline structure

 According to Seux et al. , after contact with pulp tissue, MTA presents some
structures that are similar to calcite crystals found in calcium hydroxide. They
attract fibronectin, which is generally responsible for cellular adhesion and
differentiation, as do calcium hydroxide.
 According to Faraco and Holland, the presence of necrotic tissue nearest to the
hard tissue bridge suggests that MTA, similar to calcium hydroxide, initially causes
necrosis by coagulation in contact with pulp connective tissue. This reaction might
occur because of the high alkalinity of the product, whose pH is near to 9 –10 .
 Recently, Min et al. compared the cellular effects of Portland cement (the base of
MTA) with other materials, including calcium hydroxide cement, on cultured human
pulp cells. The results suggested that Portland cement is biocompatible and allows
the expression of mineralization-related genes on cultured human pulp cells. These
genes are responsible for inductive process on hard tissue bridge formation with
MTA cement

 Studies on pulp capping of carious-exposed permanent teeth with MTA have
reported high success rates, which ranged from 93%–98%
 In a clinical trial, a lower success rate of 56.2% was reported after direct pulp
capping with MTA . However, no attempt was made to fully remove carious dentin
as soon as pulpal bleeding was observed. The success of vital pulp therapy may
depend on the complete removal of all disintegrated tissue
Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: an observational
study. J Am Dent Assoc 2008;139:305–15.
Miles JP, Gluskin AH, Chambers D, Peters OA. Pulp capping with mineral trioxide aggregate (MTA): a retrospective
analysis of carious pulp exposures treated by undergraduate dental students. Oper Dent 2010;35:20–8.

Marques et al.Outcome of Direct Pulp Capping with Mineral Trioxide Aggregate: A Prospective Study.JOE

 Biodentine® (Septodont, Saint-Maur-des-Fosses, France) is a new generation
material based on calcium silicate synthesized by bioactive technology
 Biodentine stimulates release of TGF-β from pulpal cells, stimulating reparative
dentin formation in a very short period of time. Particular growth factors from the
TGF-ß family have the ability to initiate odontoblast differentiation and hence
produce tertiary dentine by cell signalling
Popović Bajić M. et al. Direct Pulp Capping Using Biodentine.Serbian Dental Journal, vol. 61, No 2, 2014

 Consists of a powder in a capsule and liquid in a pipette.
 The powder mainly contains tricalcium and dicalcium silicate - the principal
component of portland cement - as well as calcium carbonate. Zirconium dioxide
serves as contrast medium.
 The liquid consists of calcium chloride in aqueous solution with an admixture of
polycarboxylate. The powder is mixed with the liquid in a capsule in the triturator
for 30 seconds.
 Hydration of tricalcium silicate- a hydrated calcium silicate gel and Ca(OH)2.
 The unreacted tricalcium silicate grains are surrounded by hydrated calcium
silicate gel,
 Once mixed, biodentine™ sets in approximately 10-12 minutes.
 The consistency of biodentine is similar to that of phosphate cement.

 An experiment of damaged pulp fibroblasts was conducted to test for bioactivity.
Of all the materials tested, only ProRoot® MTA and Biodentine™ were able to
stimulate the formation of tertiary dentine. Both displayed presence of enhanced
levels of TGF-ß. Biodentine™ also showed presence of other growth hormones (in
addition to TGF-ß) which contribute to the formation of dentine bridges
About, I. (2011). Effets des matériaux bioactifs Biodentine TM et Calcipulpe® sur les étapes. London, UK: Septodent
UK- R&D Department.

 Another study of indirect pulp capping on rat molars concluded that Biodentine™
was able to stimulate (thick and dense) reactionary dentine formation, which
stopped after about three months when a sufficient dentine barrier was formed.
Studies conducted to test Biodentine™ for application as a direct pulp capping
agent and for pulpotomy showed that it was well tolerated even when in direct
contact with the pulp. It was even suggested that the quality of dentine bridges
formed were better than those formed by calcium hydroxide alone
Patel et al. Preserving pulp vitality.Dental health.Volume 52 No 2 of 6 March 2013

 Biodentine™ is both a dentin substitute base and a cement for maintaining pulp
vitality and stimulating hard tissue formation, i.e. the formation of reactive or
reparative (tertiary) dentin

 Used for pulp capping, the material offers certain advantages over calcium
hydroxide: It is stronger mechanically, less soluble and produces tighter seals.
 Three major disadvantages of calcium hydroxide, notably material resorption,
mechanical instability and the resultant failure of preventing microleakages are
therefore avoided.
 Compared to other materials such as Mineral Trioxide Aggregate, Biodentine™
handles easily and needs much less time for setting. Unlike other Portland cement-
based products, it is sufficiently stable to be used for both for pulp protection and
temporary fillings.
Dammaschke et al. A new bioactive cement for direct pulp capping. INTERNATIONAL DENTISTRY – AFRICAN
EDITION VOL. 2, NO. 2

Isobutyl Cyanoacrylate
 Cyanoacrylate is an adhesive that results from the chemical reaction between
formaldehyde and the esters of cyanoacetate
 It is an excellent pulp capping agent because of its haemostatic and bacteriostatic
properties; at the same time it causes less inflammation than calcium hydroxide.
 But it can not be regarded as an adequate therapeutic alternative to calcium
hydroxide since it does not produce a continuous barrier of a reparative dentin
following application of the exposed pulp tissue.
 Bhaskar SH et al., and Heys DR et al., investigated isobutyl cyanoacrylate and
tricalcium phosphate ceramic as direct pulp capping materials. Although pulpal
response in the form of reduced inflammation and unpredictable dentin bridging
were found, but none of these materials have been promoted to the dental
profession as a viable technique

Denaturated albumin:
 This protein has calcium binding properties. If a pulp exposure is capped with a
protein, the protein may become a matrix for calcification, thereby increasing the
chances of biologic obliteration.

Laser
 To overcome the histological deficits of electrosurgery.
 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.
 Yasuda Y, et al., did a study to examine the effect of CO2 laser irradiation on
mineralization in dental pulp cells in rats and the results suggested that CO2 laser
irradiation stimulated mineralization in dental pulp cells.

Advantages
 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.

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.
Formation of osteodentin and tubular dentin.
Formation of more homogenous reparative dentin
Superior to calcium hydroxide in the mineralization inducing properties.
High concentration is required.
Half life is less.
Appropriate dose response is required to avoid uncontrolled obliteration of pulp
chamber.

 Osteogenic proteins, such as bone morphogenetic proteins (BMPs), which are protein
bone extract containing multiple factors that stimulate bone formation.
 The demineralized bone matrix could stimulate new bone formation when implanted to
ectopic sites such as muscles.
 The implications for pulp therapy are immense as it is capable of inducing reparative
dentin
 BMP belongs to super family transforming growth factor beta (TGF-β). TGF β is a potent
modulator of tissue repair in different situations..
 Lianjia et al., found that BMPs are responsible for dentinogenesis, inducing non
differentiated mesenchymal cells from the pulp to form odontoblast-like cells, obtaining
osteodentin and tubular dentin deposition, when used as direct protectors
 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).

Calcium phosphate Compounds
 Alpha-tricalcium phosphate & Tetracalcium phosphate (4CP) set & convert to
hydroxyapatite.
 Calcium phosphate cement was suggested as viable alternative because of its
good biocompatibility, superior compressive strength and its transformation into
hydroxyapatite over time.
 Yoshimine et al., demonstrated that in contrast to calcium hydroxide, tetracalcium
phosphate cement induced bridge formation with no superficial tissue necrosis and
significant absence of pulp inflammation
 4CP cement has mechanical strengths so it could be used as so called “dentin
substitute”.

Hydroxyapatite.
 Biocompatible.
 Act as a scaffold for the newly formed mineralized tissue.
 Mild inflammation with superficial necrosis of pulp.
 It is the most thermo dynamically stable of the synthetic calcium phosphate
ceramics. It has good biocompatibility with neutral pH -7.0.

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

Enzymes
 Heme oxygenase-1(HO) is the rate limiting enzyme in heme catabolism.
Odontoblasts and oxidatively stressed dental pulp cells express HO-1, indicates
that the pulp might respond to oxidative stress at the molecular level.
 Simvastatin improves the osteoblast function and suppresses osteoclast function,
resulting in enhanced bone formation.
 Statin is known to induce angiogenesis and increase neuronal cells, indicating the
possible effectiveness of statin in pulp regeneration along with dentin regeneration.
It has an anti-inflammatory effect in various tissues, so it is considered as an ideal
active ingredient in pulp capping material to accelerate reparative dentin formation

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
 It contains flavonoids, phenolics, iron, zinc and other various aromatic compounds .
 Parolia A, et al., compared propolis, MTA and Dycal histologically in human dental
pulp and concluded that Propolis and MTA showed similar bridge formation when
compared to Dycal

 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.
Ardo et al.Histological analysis of rat dental pulp tissue capped with propolis, J oral sci., 2005; 47:135-138

Corticosteroids and antibiotics.
 Corticosteroids like hydrocortisone, Cleocin, cortisone, Ledermix, penicillin,
neomycin and along with calcium hydroxide was used for pulp capping with the
thought of reducing or preventing pulp inflammation.
 Gardner, et al., found that vancomycin, in combination with calcium hydroxide was
somewhat more effective than calcium hydroxide used alone and stimulated a
more regular reparative dentin bridge.
 Watts and Paterson cautioned that anti-inflammatory compounds should not be
used in patients at risk from bacteremia
Qureshi et al.Recent Advances in Pulp Capping Materials: An OverviewJ Clin Diagn Res. 2014 Jan; 8(1): 316–321.

Polycarboxylate cement.
 Chemically bond to tooth structure.
 Lack of antibacterial effect.
 Fail to stimulate calcific bridge formation.
 McWalter, G et al., found that it lacks an antibacterial effect and calcific bridge
formation

Fluocinolone acetonide
 Fluocinolone acetonide (FA) is a synthetic corticosteroid commonly used for topical
application in the management of dermatologic disorders and oral vesiculoerosive
lesions.
 Interestingly, a wide range of concentrations of FA have a proliferative effect on
some types of cells, such as skin fibroblasts and dental pulp cells. This effect is
concentration-dependent; high concentrations inhibit mitotic activity, but low
concentrations slightly increase the activity.
 A specific range of concentrations (0.1–10 mmol/L) of FA also stimulates the
extracellular matrix and hard tissue formation of human dental pulp cells
 The pH of PCFA is about 10.57–11.72, which is higher than that of Dycal (9.80–
10.86), but may be comparable to that of MTA (10.2–12.5)
Louwakulet al.Pulp-capping Material Containing Fluocinolone Acetonide,JOE

 Although PCFA is not an ideal pulp-capping material, it acts like a type of drug
delivery system, which slowly releases FA and the hydroxyl ions. Its physical and
mechanical properties are similar to those of Dycal, except for higher pH and
longer setting time.
 Thus, PCFA may have the same problems as the other calcium hydroxide pulp-
capping materials (ie, sealing ability, dissolution) when used during a long period of
time

Stem Cells
 Dental pulp stem cells (DPSCs) and Stem cells from Human Exfoliated Deciduous
Teeth (SHED) have been identified as a novel population of stem cells that have
the capacity of self-renewel and multi lineage differentiation.
 Nakamura S et al., used mesenchymal stem cells for clinical application in tissue
engineering and regenerative medicine. In this study, they compared the
proliferation and stem cell marker of SHED, DSPCs and Bone Marrow Derived
Mesenchymal Stem Cells (BMMSCs). In addition, gene expression profile of
DSPCs and SHED were analyzed by using DNA microarray. They concluded that
SHED has got significantly higher proliferation rate than that of DSPCs and
BMMSCs and this could be a desirable option as a cell source for therapeutic
applications

Emdogain (EMD)
 EMD is enamel matrix derivative secreted from Hertwig’s epithelial root sheath during
porcine tooth development. It is an important regulator of enamel mineralization and
plays an important role during periodontal tissue formation. It stimulates the
regeneration of acellular cementum, periodontal ligaments, and alveolar bone.
 EMD contains BMP like molecules and BMP expressing cells. BMP like molecules in
EMD promote odontoblast differentiation and reparative dentin formation.
 Nakamura Y et al., concluded that amount of hard tissue formed in EMD treated teeth
was more than twice that of the calcium hydroxide treated control teeth .
 Al-Hezaimi K evaluated Calcium hydroxide, ProRoot White MTA and white Portland
cement after EMD application on the exposed pulp. MTA produced a better quality
reparative hard tissue response with the adjunctive use of EMD compared with calcium
hydroxide

Theracal
 TheraCal LC is a light cured, resin modified calcium silicate filled liner designed for
use in direct and indirect pulp capping, as a protective base/liner under
composites, amalgams, cements, and other base materials. TheraCal LC performs
as an insulator/barrier and protectant of the dental pulpal complex.
 The proprietary formulation of TheraCal LC consists of tricalcium silicate particles
in a hydrophilic monomer that provides significant calcium release making it a
uniquely stable and durable material as a liner or base. Calcium release stimulates
hydroxy apatite and secondary dentin bridge formation. TheraCal LC may be
placed directly on pulpal exposures after hemostasis is obtained. It is indicated for
any pulpal exposures, including carious exposures, mechanical exposures or
exposures due to trauma.

 Gandolfi et al., compared chemico physical properties of TheraCal, ProRoot MTA
and Dycal and concluded that TheraCal displayed higher calcium releasing ability
and lower solubility than either ProRoot MTA or Dycal.
 The capability of TheraCal to be cured to a depth of 1.7 mm may avoid the risk of
untimely dissolution. These properties offer major advantages in direct pulp
capping treatments

Conclusion
 Emphasis has shifted from the “doomed” organ concept of an exposed pulp to one
of hope and recovery. The era of vital-pulp therapy has been greatly enhanced with
the introduction of various pulp capping materials.
 There are many arguments about the best medicaments suitable for this role and
their long term advantages and disadvantages. Pulp capping is a conservative
dental treatment due to the regenerative nature of the dentine-pulp complex and its
ability to secrete tertiary dentine.

 The best root canal ‘filling’ is healthy pulp tissue and it cannot be assumed that all
damaged pulp must be extirpated or that all pulp conservation procedures are
unsatisfactory.
 Clarity on the biology of caries, comprehension of technological advances and
conviction about improved restorative materials has initiated a pulp preservation
that indeed is a boon to the clinician and the patient.

References
 Grossman’s Endodontic practice 13 ed
 Phillip’s science of dental materials: 11 ed
 Craig’s restorative dental materials 13 ed
 Ingle’s Endodntics 6 ed
 Shobha Tandon’s textbook of Pedodontics
 Qureshi et al.Recent Advances in Pulp Capping Materials: An OverviewJ Clin Diagn
Res. 2014 Jan; 8(1): 316–321
 Louwakulet al.Pulp-capping Material Containing Fluocinolone Acetonide,JOE
 Accorinteet al. “Evaluation of Mineral Trioxide Aggregate and Calcium Hydroxide
Cement as Pulp-capping Agents in Human Teeth”. JOE — Volume 34, Number 1,
January 2008
 Dammaschke et al. A new bioactive cement for direct pulp capping. INTERNATIONAL
DENTISTRY – AFRICAN EDITION VOL. 2, NO. 2
 Patel et al. Preserving pulp vitality.Dental health.Volume 52 No 2 of 6 March 2013
 Ardo et al.Histological analysis of rat dental pulp tissue capped with propolis, J oral
sci., 2005; 47:135-138

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