Jorge Perdigo, DMD, MS, PhD

OPERATIVE DENTISTRY
Paracelsius (1493-1541)

www.jorgeperdigao.com

PULP CAPPING

Composition

State-of-the art

(Vol %)

The research data on pulp capping is at times

inadequate, confusing, misleading or even
incorrect and diminishes the confidence of the
practitioner in performing pulp capping.

mineral
water
organic

Stanley, AJD, 1998

After D. H. Pashley

Perdigao, 2005

 Neutralizes acids - potent buffer mechanism

Tubular fluid under constant outward pulpal pressure
Anatomical area of dentinal tubule > functional area

In 1756, Pfaff, the dentist of the King of

Prussia, applied a cap of lead foil to the
exposed pulp, thus the term capping

...There is enough evidence to cast serious

doubts on the acid theory of pulp irritation
under silicate fillings. There is another
explanation of this phenomenon...

Crowell WS (1927): J Am Dent Assoc 14:1038-1048

Remaining dentin thickness (RDT)

This study observed the pathologic changes resulting from
untreated pulp exposures in germ-free rats as compared with
conventional rats with a normally complex microflora.

Bacterial leakage
Toxic components of dental materials
Cavity desiccation

The results, even in face of gross food impaction, indicate that

the presence or absence of a microbial flora is the major
determinant in the healing of exposed pulps.

Threaded pins
Temperature increase (no water refrigeration)
Pressure and speed of handpiece

Kakehashi S, Stanley HR, Fitzgerald RJ (1965): Oral

Surgery, Oral Medicine & Oral Pathology 20:340-349.

Remaining Dentin Thickness

Remaining Dentin Thickness

Cavity depth (remaining dentin thickness or RDT) was the major
factor in odontoblast response and in dentin formation.

The most important cavity preparation variable is the

remaining dentin thickness (RDT). Odontoblast injury
increases as the cavity RDT decreases

Below 0.25 mm the number of odontoblasts

decreases by 23%, and minimal reactionary dentin
repair is observed.

About et al. (2001). J Dent 29:109-117

Deeper cavities suppressed odontoblasts with less subsequent

dentin formation at all time periods.
Base materials had little effect on odontoblast activity or on the
rate of dentin formation. An exception was in deep cavities, with
Ca(OH)2 showing more label.

Lee SJ, Walton RE, Osborne JW. Pulp response to bases and cavity
depths. Am J Dent 1992; 5:64-68.

Bacterial Leakage
Toxicity of Dental Materials
...The result of the present study demonstrated that dental
materials such as silicate cement, zinc phosphate, amalgam,
and composites, when surface-sealed, are well accepted by
the dental pulp tissue and do not impair or negatively affect
pulpal wound healing on a short-term basis ...

Pulp exposure + restoration

ZOE
Skodegal & Eriksen, 1976

Cox et al., 1987, JPD

Pulp exposure + restoration +

surface seal with ZOE

Cox et al., 1987

Research in monkeys

Bacterial Leakage
Toxicity of Dental Materials
...In the presence of bacterial colonization at the
restoration interface, severe inflammatory involvement and
pulp tissue breakdown were seen. This observation
indicates that chemical toxic factors such as acid and
components of the restorative materials per se are less
significant in causing pulpal injury than bacterial leakage
around the restoration margins...

Unpolymerized composite resulted in significant

toxicity of pulp cells
Composite cured with high-intensity lights resulted in
significant toxicity

Cox et al., 1987, JPD

Longer curing time with lower intensity lights resulted

in less toxicity

Pressure and Speed of Handpiece

Handpiece speed (rpms) varied from 7000-15,000 rpms and

applied pressure from 20-60 gr force.
Increases in either speed or pressure can produce significant
intrapulpal temperature increases over these ranges.
Doubling either one produces a 50% temperature increase
during finishing.

Two Current Strategies

Hatton JF, Holtzmann DJ, Ferrillo PJ Jr, Stewart GP. Effect of handpiece
pressure and speed on intrapulpal temperature rise. Am J Dent 1994; 7:108-110.

PULP CAPPING

Deep dentin or mechanical exposure

PULP CAPPING
Two strategies

1. Pulp capping with acid and adhesive

Pulp capping with acid and adhesive?
OR
Pulp capping with calcium hydroxide?

Calcium hydroxide should NEVER be used to

cap exposed pulps because
the dentin bridges that form underneath the calcium
hydroxide contain empty tunnels therefore fail to provide a
hermetic seal to the underlying pulp against bacteria

Cox et al., 1996. Oper Dent 21:4-11

PULP CAPPING
Two strategies

2. Pulp capping with calcium hydroxyde

Calcium hydroxide should ALWAYS be used to

cap exposed pulps because
CaOH2 does not make the tunnels. Tunnels are a result of the
degree of trauma to the pulp created by the mechanical
exposure. The size and number of vessels injured determine the
number of tunnels formed..

Strategy #1 - Calcium hydroxide should NEVER be

used to cap exposed pulps because

Stanley & Pameijer (1997). Oper Dent 22:1-3

Direct Pulp Capping

Acid + Adhesive?
Deep dentin - RDT < 0.5 mm
The results observed in animal teeth cannot be directly
extrapolated to human clinical conditions.
Persistent inflammatory reactions as well as delay in pulpal
healing and failure of dentin bridging were seen in human
pulps capped with bonding agents.
Souza Costa et al. (2000). Current status of pulp capping with dentin
adhesive systems: a review. Dent Mater 16:188-197

PULP CAPPING
Deep dentin - RDT < 0.5 mm
At 7 days, with All Bond 2 capping, there was a large area of neutrophilic
infiltrate underlying the pulp capping material, and the death of adjacent
odontoblasts. With time, the neutrophilic reaction was replaced by
fibroblastic proliferation with macrophages and giant cells surrounding
globules of resin scattered in the coronal pulp.

The persistent inflammatory reaction and hyaline alteration

of extracellular matrix inhibited complete pulp repair or
dentin bridging.
Hebling et al. (1999). Biocompatibility of an adhesive system applied to
exposed human dental pulp. J Endod 25:676-82.

Results from animal pulp studies cannot be

extrapolated to humans
Prime &Bond 2.1 facilitates pulp healing and dentin
formation in sheep teeth but in human teeth it was not as
successful as Ca(OH)2 as a pulp capping agent

Ersin NK, Eronat N. The comparison of a dentin adhesive with Ca(OH)2 as the pulp-capping
agent on the exposed pulps of human and sheep teeth. Quintessence Int 2005;36:271-280

DIRECT PULP CAPPING

Calcium Hydroxide

Strategy #2 - Calcium hydroxide should ALWAYS be

used to cap exposed pulps because

DIRECT PULP CAPPING

Calcium Hydroxide

Deep dentin - RDT < 0.5 mm

The adhesive released resin particulates into the pulp
space, triggering a persistent inflammatory response that
inhibited pulp repair.
Calcium hydroxide remains the pulp capping agent of
choice.
Souza Costa et al. (2001). Response of human pulps capped with a selfetching adhesive system. Dent Mater 17:230-240.

The dentin adhesive did not allow any pulp repair and is not
indicated for direct pulp capping of human teeth.
In contrast, at 7 days, the pulp tissue capped with calcium
hydroxide exhibited odontoblast-like cells organized
underneath coagulation necrosis.
Pulp repair evolved into apparent complete dentin bridge
formation at 60 days.
Hebling et al. (1999). Biocompatibility of an adhesive system applied to
exposed human dental pulp. J Endod 25:676-82.

NO
Cavity preparation is in superficial or in middle
dentin (>0.5 mm from the pulp)

YES
A. Cavity preparation is deep dentin (0.5 mm
from the pulp)
B. There is a non-carious mechanical exposure
on a tooth without symptoms of irreversible
pulpitis

Mechanical exposure (non-carious dentin)

OR
Deep preparation < 0.5 mm from pulp
Cap exposure with Ca (OH)2 cement
Cover Ca (OH)2 and adjacent dentin with a resinmodified GIC base (do NOT cover all the dentin surface)
Proceed with definitive restoration
Evaluate at each recall.

Why is it not recommended in superficial preparations?

Does not have any therapeutic effect in superficial dentin

Fairly weak mechanical properties
Easily dissolved by phosphoric acid
Prevents contact of the adhesive with dentin
If the adhesive penetrates underneath the Ca(OH)2
Adhesive will not polymerize.

...Dycal has a low compressive strength; it is

significantly weaker at 90 days than at 24
hours...
compared to Fuji Lining LC, Ketac Bond, Timeline, Vitrebond, VLC
Dycal e XR-Ionomer

Lewis et al. (1992). Mechanical properties of dental base materials. Am J Dent 5:69-72.

Mechanical exposure
(with residual carious dentin)

Start root canal treatment (success is higher when

RCT is performed immediately)

...68 amalgam restorations from less than 1

year to 5 years with Dycal as base. The base
was present in all the teeth, but softened in
70.6% of them. In 50% of the restorations
with less than 1 year, the base was
softened...

If RCT cannot be performed in the same

appointment:
Pulpotomy
Sterile cotton pellet or cotton pellet with eugenol
in the chamber
Temporary restoration with reinforced ZOE
Refer to Endodontics

Pereira et al. (1990): Clinical evaluation of Dycal under amalgam restorations.

Am J Dent 3:67-70.

Avoid cavity desiccation

Avoid pins
Use materials backed with scientific
evidence of success rather than
anecdotal testimonials.

Avoid deep cavity preparations

Work with absolute isolation
Margins in enamel - composites do not
prevent microleakage around dentin
margins
Abundant water refrigeration