Karthikeson P.S et al /J. Pharm. Sci. & Res. Vol.

8(6), 2016, 525-527

Pulp Capping Agents-A Review

Karthikeson P.S Jayalakshmi S
I year BDS Student, Conservative Dentistry,
Saveetha Dental College and Hospitals, Saveetha Dental College and Hospitals,
No.162.P.H.Road,Chennai-600077. No.162.P.H.Road,Chennai-600077.

Abstract::
Aim and Objective:
This review focuses on describing the various dentin bridge forming direct pulp capping agent .

Background:
Pulp capping agents are used in dental restorations to prevent the dental pulp from dying, after being exposed, or nearly
exposed due to a mechanical exposure. Some commonly used pulp capping agents include Calcium Hydroxide,
Zinc Oxide Eugenol (ZOE) Cement,Corticosteroids and Antibiotics,Collagen,Polycarboxylate cement,Calcium phosphate etc.

Reason:
The success of the pulp capping procedure greatly depends upon the circumstances under which it is performed and the
prognosis depends upon the age, type, site and size of pulp exposure. In addition to this the pulp capping material should have
the following ideal properties like
* Stimulate reparative dentin formation
* Maintain pulpal vitality
* Release fluoride to prevent secondary caries
* Bactericidal or bacteriostatic
* Adhere to dentin
This review helps to know the various pulp capping agents which can form dentin bridge .
Keywords: dentin bridge, dental caries, pulp capping , pulpitis

INTRODUCTION: this becomes successful, this procedure suggests the need

Historically, the first pulp capping procedure was for more invasive, more extensive and more expensive
performed in 1756, by the Phillip pfaff, who packed a small treatment.A number of factors have been shown to have an
piece of gold over an exposed vital pulp to promote impact on direct pulp cap success.A number of materials
healing. However, the success of the pulp capping have been suggested for use in direct pulp capping. [6]
procedure greatly depends upon the circumstances under Some of the pulp capping materials form dentin bridge and
which it is performed and the prognosis depends upon the some materials don't form dentin bridge.
age, type, site and size of pulp exposure.[1] In this review, pulp capping agents forming dentin bridge is
The consequences of pulp exposure from caries, trauma or discussed briefly.
tooth preparation misadventure can be severe, with pain
and infection the result. The morbidity associated with Significance of pulp capping agents forming dentin
treating pulp exposures is consequential, often requiring bridge:
either extraction or root canal therapy.[2]Both the loss of the Dentin bridge is defined as a deposit of reparative dentin or
tooth and its replacement, or endodontic treatment and other calcific substances that forms across and resells
tooth restoration, involve multiple appointments and exposed tooth pulp tissue. [7] Dentin is formed usually after
considerable expense. An alternative procedure to 30 days of pulp capping. Direct pulp capping agents like
extraction or endodontic therapy is pulp capping, in which calcium hydroxide and MTA help in thick dentin bridge
a medicament is placed directly over the exposed pulp formation. [8]These materials are well known for its
(direct pulp cap), or a cavity liner or sealer is placed over antimicrobial properties. Indirect pulp capping agents don't
residual caries (indirect pulp cap) in an attempt to maintain form think dentin bridge.
pulp vitality and avoid the more extensive treatment Hence for most of the patients, dentin bridge forming pulp
dictated by extraction or endodontic therapy.[3] capping agents is used.Some of the pulp capping agents
forming dentin bridge is discussed below.
DIRECT PULP CAPPING:
The pulp of a tooth can be exposed due to several causes: Dentin bridge forming pulp capping agents:
caries, trauma or mechanical reasons, the latter typically 1.Calcium Hydroxide Ca(OH)2
due to a misadventure during tooth preparation. [4]The 2.Mineral Trioxide Aggregate MTA
direct pulp cap, in which a material is placed directly over 3.Calcium phosphate
the exposed pulp tissue, has been suggested as a way to 4.Hydroxyapatite
promote pulp healing and generate reparative dentin. [5]If 5.Biodentine

525
 Karthikeson P.S et al /J. Pharm. Sci. & Res. Vol. 8(6), 2016, 525-527

1.Calcium Hydroxide Ca(OH)2: 3.Calcium phosphate:

Calcium hydroxide is a gold standard of direct pulp Calcium phosphate is another pulp capping agent which
material discovered in 1929. came into practice in the year 1900’s.[28]
One study found a 100% reduction in microorganisms Its advantages are ,it helps in forming dentin bridge without
associated with pulp infections after one-hour contact with any tissue necrosis.It has good physical properties.Also the
calcium hydroxide. [9] Most importantly, calcium hydroxide absence of pulp inflammation is seen compared to calcium
has a long term track record of clinical success as a direct hydroxide Ca(OH)2.[28]
pulp-capping agent in periods of up to 10 years. Release of calcium ions is the key factor for a successful
Calcium hydroxide is believed to effect pulp repair by one pulp capping because of action of calcium on
or more of several mechanisms of action. It has believed differentiation,proliferation and mineralisation of pulp
that hydroxide’s high pH causes irritation of the pulp tissue, cells.
which stimulates repair via some unknown mechanism .[10] But calcium phosphate is not commonly used till
In recent years, this “unknown mechanism” may have been now.Because more clinical trials are necessary to evaluate
explained by the release of bioactive molecules. [11] It is the material.
known that a variety of proteins are incorporated into the
dentin matrix during dentinogenesis. Of particular 4.Hydroxyapatite:
importance to the topic of pulp capping is that at least two It is the most thermo dynamically stable of the synthetic
of these proteins, Bone Morphogenic Protein (BMP) and calcium phosphate ceramics.
Transforming Growth Factor-Beta One (TBF-β1), have Hydroxyapatite is a ceramic biomaterial, biocompatible,
demonstrated the ability to stimulate pulp repair. [12] osteoconductor and classified as a ceramic composed of
The advantages of calcium hydroxide are,it has excellent calcium phosphate crystals that are similar to the mineral
antibacterial properties to eliminate bacterial penetration to portion of the bone tissue. It acts as a frame for bone tissue
the pulp.Induction of mineralization is seen in calcium growth and has been indicated for filling bone cavities.[29]
hydroxide.[13] Cytotoxicity is low in calcium hydroxide.[14] Hydroxyapatite is not indicated for pulp protection of
However it has some disadvantages also.It is highly soluble human teeth because the formation of a dentine bridge has
in highly soluble in oral fluids.It lacks adhesion.[15] Due to not been observed.However, its combination with other
high extensive dentin formation property,it obliterates the biomaterials is being amply used.
pulp chamber.It easily degrades after acid etching.Calcium The association of collagen and hydroxyapatite has been
hydroxide is lost due to dissolution over time.[16],[17] Risk of indicated as a collagenic biocompatible biomaterial. [30]
pulp inflammation is more in calcium hydroxide Tunnel It has been evaluated in laboratory animals and in humans
defect is more common in calcium hydroxide where tunnels and indicated for pulp coverage, filling of surgical cavities
are formed in reparative dentin however the quality of in bone defects,guided tissue regeneration and as a fixing
reparative dentin improves as the bridge gets thicker.[15] agent for ceramic particles.[30]
It has good biocompatibility with neutral pH -7.0. It can be
2.Mineral Trioxide Aggregate MTA: used as scaffolding for the newly formed mineralised tissue
Mineral Trioxide Aggregate (MTA) has been emerging as a However there is mild inflammation with necrosis of pulp.
good direct pulp capping agent in recent years.[18]
Unset MTA is primarily calcium oxide in the form of 5.Biodentine:
tricalcium silicate, dicalcium silicate and tricalcium Biodentine is a new tricalcium silicate(Ca3Si05) based
aluminate.[19]Bismuth oxide is added for inorganic restorative commercial cement and advertised as
radiopacity.Basically calcium hydroxide is the combination bioactive dentin substitute.[31]
of water and Mineral Trioxide Aggregate (MTA).[20],[21] It possess good physical and biological properties
However MTA is used more common next to calcium compared to MTA and bioaggregate.In powder form,its
hydroxide due to its good compatibility,less pulpal composition will be tricalcium silicate,dicalcium
inflammation,radiopacity and antibacterial property [22] silicate,calcium carbonate,zirconium oxide and iron
Moreover it releases bioactive dentin matrix proteins.It has oxide.Its nature can be easily explained as it causes early
more predictable hard tissue barrier formation compared to mineralization by release of TGF- β1 from pulpal cells to
calcium hydroxide.It has high solubility like calcium encourage pulp healing and by odentoblastic stimulation
hydroxide which is a disadvantage.[23] for dentin bridge formation to protect the pulp.
Most of the dentists don't prefer to buy MTA since it is Mineralisation occurs in the form of osteodentine that
highly expensive.[24]Also some disadvantages are its poor forms the reparative dentine.Remineralisation of
handling characteristics,setting time is long.There are two dentine,pulp healing,preserving pulp vitality,better
versions of MTA-grey and blue.[25],[26] Grey MTA is due to handling characteristics,reduced setting time are the
addition of iron.Grey MTA causes tooth advantages of biodentine.
discolouration.[26],[27] However there are some disadvantages.
Apical barrier formation with MTA can be achieved in one More long term and clinical studies alike calcium
visit unlike in calcium hydroxide apexification which takes phosphate are needed for a definitive evaluation of
around 6 to 9 months for the apical barrier to form. Biodentin.[31]

526
 Karthikeson P.S et al /J. Pharm. Sci. & Res. Vol. 8(6), 2016, 525-527

CONCLUSION: [15] Cox C, Subay R, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in
dentin bridges: Their formation following direct pulp capping.
When you hear the word "endondontics," you probably Operative Dentistry 1996;21(1):4–11. [PubMed: 8957909]
think of a root canal. But endodontic treatment entails [16] Ulmansky M, Sela J, Sela M. Scanning electron microscopy of
treating any disease of the tooth's pulp, and endodontists calcium hydroxide induced bridges. Journal of Oral Pathology
practice several techniques to save teeth.[32] One such 1972;1:244–248. [PubMed: 4199102]
[17] Graham L, Cooper P, Cassidy N, Nor J, Sloan A, Smith A. The
example is pulp capping, which is used to keep tooth decay effect of calcium hydroxide on solubilisation of bio-active dentine
from attacking the tooth's pulp chamber. matrix components. Journal of Biomaterials 2006;27:2865– 2873.
Pulp capping agent provide a well-sealed restoration [18] Torabinejad, M.; White, D. US Patent 5,769,638.
immediately after pulp capping. This will provide [19]. Camilleri J, Pitt Ford T. Mineral trioxide aggregate: A review of the
constituents and biological properties of the material. International
protection against ongoing leakage and bacterial Endodontics Journal 2006;39:747–754.
contamination that can compromise the success of the pulp [20] Fridland M, Rosado R. Mineral Trioxide aggregate (MTA) solubility
cap.This review provides evidence-based recommendations and porosity with different water-to-powder ratios. Journal of
to guide clinicians in their decision-making process when Endodontics 2003;29(12):814–817. [PubMed: 14686812]
[21] Fridland M, Rosado R. MTA solubility: A long-term study. Journal
they encounter a situation requiring pulp capping.This of Endodontics 2005;31(5): 376–379. [PubMed: 15851933]
review mainly describes about she dentin bridge forming [22] Camilleri J, Montesin FE, Di Silvio L, Pitt Ford TR. The chemical
pulp capping agents.[33] constitution and biocompatibility of accelerated Portland cement for
endodontic use. International Endodontics Journal 2005;38:834–842.
[23] Islam I, Kheng Chng H, Jin Yap A. Comparison of the physical and
REFERENCES: mechanical properties of MTA and Portland cement. Journal of
[1] Cohen BD, Combe EC. Development of new adhesive pulp capping
Endodontics 2006;32(3):193–197. [PubMed: 16500224]
materials. Dent Update. 1994; 21(2):57-62.
[24] Aeinehchi M, Eslami B, Ghanbariha M, Saffar A. Mineral trioxide
[2] Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp
aggregate (MTA) and calcium hydroxide as pulp-capping agents in
management for caries in adults: Maintaining pulp vitality Art No:
human teeth: A preliminary report. International Endodontics
CD004484. The Cochrane Database of Systematic Reviews. 2007;
Journal 2002;36:225–231.
(Issue 2) DOI: 10.1002/14651858.CD004484 pub 2.
[25] Tomson P, Grover L, Lumley P, Sloan A, Smith A, Cooper P.
[3] Accorinte M, Loguercio A, Reis A, de Souza Costa C. Response of
Dissolution of bio-active dentine matrix components by mineral
human pulps capped with different self-etch adhesive systems.
trioxide aggregate. Journal of Dentistry 2007;35:636–642. [PubMed:
Clinical Oral Investigations 2008;12:119–127. [PubMed: 18027004]
17566626]
[4] Murray PE, Windsor LJ, Smyth TW, Hafez AA, Cox CF. Analysis
[26] Song J, Mante F, Romanow W, Kim S. Chemical analysis of powder
of pulpal reactions to restorative procedures, materials, pulp capping,
and set forms of Portland cement, gray ProRoot MTA, white
and future therapies. Critical Reviews in Oral Biology & Medicine
ProRoot MTA, and gray MTA-Angelus. Oral Surgery, Oral
2002;13(6):509–520. [PubMed: 12499243]
Medicine, Oral Pathology, Oral Radiology, and Endodontics
[5] Baume L, Holz J. Long-term clinical assessment of direct pulp
2006;102:809–815.
capping. International Dental Journal 1981;31(4):251–260.
[27] Camilleri J. Characterization of hydration products of mineral
[PubMed: 7030965]
trioxide aggregate. International Endodontics Journal 2008;41:408–
[6] Olmez A, Oztas N, Basak F, Sabuncuoglu B. A histopathologic
417.
study of direct pulp-capping with adhesive resins. Oral Surgery, Oral
[28] Yoshimine Y, Maeda K. Histologic evaluation of tetracalcium
Medicine, Oral Pathology, Oral Radiology, and Endodontics
phosphate-based cement as a direct pulp-capping agent. Oral Surg
1998;86:98–103.
Oral Med Oral Pathol Oral Radiol Endod.1995; 79(3): 351-8.
[7] Pinto, Shelon Cristina S., Márcia T. Pochapski, Denise S. Wambier,
[29] Hayashi Y, Imai M, Yanagiguchi K, Viloria IL, Ikeda T.
Gibson L. Pilatti, and Fábio A. Santos. "In Vitro and in Vivo
Hydroxyapatite applied as direct pulp capping medicine substitutes
Analyses of the Effects of Desensitizing Agents on Dentin
for osteodentin. J Endod. 1999; 25(4): 225-9.
Permeability and Dentinal Tubule Occlusion." J Oral Sci Journal of
[30] Silva, Léa Assed Bezerra Da, Mario Roberto Leonardo, Paulo
Oral Science 52.1 (2010): 23-32. Web.
Nelson-Filho, Alexandra Sárzyla Medeiros, and Marcos Antonio
[8] Oguntebi, Bamiduro R., Timothy Heaven, Arthur E. Clark, and
Rossi. "Pulp Response of Anionic Lyophilized Collagen Matrix with
Frank E. Pink. "Quantitative Assessment of Dentin Bridge
or without Hydroxyapatite after Pulpotomy in Dog's Teeth." Mat.
Formation following Pulp-capping in Miniature Swine." Journal of
Res. Materials Research 9.2 (2006): 175-80. Web.
Endodontics 21.2 (1995): 79-82. Web.
[31] Laurent P, Camps J, de Méo M, Déjou J, About I. Induction of speci
[9] Stuart K, Miller C, Brown C Jr, Newton C. The comparative
c cell resonses to a Ca3SiO5-based posterior restorative material.
antimicrobial effect of calcium hydroxide. Oral Surgery, Oral
Dent Mater. 2008; 24(11):1486-94.
Medicine, Oral Pathology, Oral Radiology, and Endodontics
[32] Qureshi, Asma. "Recent Advances in Pulp Capping Materials: An
1991;72:101–104.
Overview." Jcdr Journal Of Clinical And Diagnostic Research
[10] Prosser H, Groffman D, Wilson D. The effect of composition on the
(2014). Web.
erosion properties of calcium hydroxide cements. Journal of Dental
[33] Hilton, T. J. "Keys to Clinical Success with Pulp Capping: A Review
Research 1982;61(12):1431–1435. [PubMed: 6960048]
of the Literature." Operative Dentistry 34.5 (2009): 615-25. Web.
[11] Duque C, Hebling J, Smith A, Giro M, Freitas M, de Souza Costa C.
Reactionary dentinogenesis after applying restorative materials and
bioactive dentin matrix molecules as liners in deep cavities prepared
in non-human primate teeth. Journal of Oral Rehabilitation
2006;33:452–461. [PubMed: 16671993]
[12] Weibo Zhang X, Walboomers F, Jansen J. The formation of tertiary
dentin after pulp capping with a calcium phosphate cement, loaded
with PLGA microparticles containing TGF-β1. Journal of
Biomedical Materials Research Part A. 2007 Published online: 13
Aug 2007.
[13] Ferracane, J. Materials in Dentistry, Principles and Applications. 2nd
ed. Philadelphia: Lippincott, Williams & Wilkins; 2001. p. 63-64.
[14] Kitasako Y, Ikeda M, Tagami J. Pulpal responses to bacterial
contamination following dentin bridging beneath hard-setting
calcium hydroxide and self-etching adhesive resin system. Dental
Traumatology 2008;24:201–206. [PubMed: 18352925]

527