FROM: Mohamad Jalloul

To: Dr Fadel Khaled

ASSIGNMENT
ENDO 424
201900041
Effect of Materials on dental pulp
Dental decay begins when bacteria in tooth plaque, most often streptococcus mutans and lactobacillus,
make acids. It causes inorganic demineralization. component of tooth and also by enzymatic reaction of
organic fraction. Caries is the most prevalent reason for tooth restoration. The aims of restoration are to
return teeth to a healthy, functional, and aesthetically pleasing state, as well as to prevent caries from
recurring. The materials utilized to repair the tooth might induce mild to severe pulpal responses.
Composite, glass ionomer cement, and amalgam are the most often utilized permanent restorative
materials.

Zinc phosphate
Because of its acidic nature, zinc phosphate cement may result in significant pulpal injury. When the
cement is used in deep cavity preparations, the toxicity increases. Zinc phosphate cement should not be
utilized in deep cavities without an intervening liner of zinc oxide eugenol or calcium hydroxide. To
reduce pulp irritation and marginal leakage, thick mixtures should be employed.

To reduce pulp irritation and marginal leakage, thick mixtures should be employed. Pulp may be
influenced by material components, exothermic heat emitted during cement setting, and marginal
leakage that allows irritants from saliva to enter. The pulpal damage is caused mostly by marginal
leakage rather than harmful chemical characteristics.

Zinc carboxylate cement

It comprises modified zinc oxide powder and a polyacrylic acid aqueous solution. It has antimicrobial
qualities and chemically binds to enamel and dentin. It is well tolerated by the pulp and, in this regard, is
basically equal to zinc oxide eugenol cement.

Amalgam

Amalgam is often regarded as one of the least irritating filling materials. Even if no varnish is used, a
marginal seal forms between the tooth and the restoration within a few weeks due to the corrosion
products. Because of its high heat conductivity, it causes pain. As a result, liners or bases are required to
offer thermal insulation. In deep cavities, it may induce mild to severe inflammation, suppression of
reparative dentin development due to odontoblast destruction, toxicity in high copper alloys, and
postoperative heat sensitivity due to high thermal conductivity.

Zinc Oxide Eugenol

It chemically irritates the pulp at greater concentrations. The pulp reacts poorly to the drilling
stimulation, becoming highly irritated and precipitating a disease known as acute or chronic pulpitis.
This disorder typically causes significant chronic tooth sensitivity or true pain, which can only be cured
with root canal treatment. The use of a "temporary" ZOE for a few to several days prior to the final filling
frequently reduces sensitivity or pain and, as a result, usually eliminates the need for the costly and
time-consuming root canal surgery. Heat travels through the restoration or surrounding micro-leakage;
if the released heat is about 113 degrees Fahrenheit, it creates pulpal inflammation; if it is around 130
degrees Fahrenheit, it causes irreversible pulpal damage.
GIC
As restorative materials, GICs have disadvantages due to their susceptibility to dehydration and poor
physical qualities such as high solubility and slow setting rate. It has anticariogenic effects and is
tolerated well by the pulp. Toxicity decreases as setting time increases.

A research found that high fluoride releasing materials (Silver Diamine Fluoride) and Type VII GIC did not
cause pulp inflammation/necrosis. They are capable of inducing tertiary dentin. Based on these
characteristics, they can be recommended as indirect pulp treatment materials for deep cavity
management.

Calcium hydroxide
When calcium hydroxide is employed as a pulp-capping agent or is
deposited in the root canal in contact with healthy pulpal or
periodontal tissue, a calcified barrier can form. A superficial layer
of necrosis occurs in the pulp to a depth of up to 2 mm due to the
material's high pH of up to 12.5. Beyond this layer, only a
moderate inflammatory reaction is observed, assuming that the
operative field was bacteria-free when the material was applied.
It is possible that a hard tissue barrier will develop as a result of
this procedure.

Techniques and Materials for Pulp protection

When the pulp is exposed in preparations, it must be protected to avoid discomfort, infection, and
ultimately tooth loss. Pulp capping, which includes sealing materials over the exposed area to protect
the pulp, might be beneficial. There are several pulp capping alternatives for restorations. We take a
deeper look at some of them, as well as some of the younger players in the sector, who can perform this
critical duty in your restorations.

When the pulp is clearly exposed (vital pulp exposure) as a result of caries, trauma, or an iatrogenic
insult, such as unintentional exposure during tooth preparation or caries treatment, direct pulp capping
is employed. Indirect pulp capping is commonly employed in deep cavity preparations, with or without
residual caries, that are near to the pulp but have little apparent exposure.

A- Indirect Pulp Capping: Two-Stage Approach

Using two-stage or progressive caries removal procedures, all

carious dentin is normally removed from the cavity
preparation's walls and dentino-enamel junction. If removal
would result in pulp exposure, a layer of deep carious dentin,
which is generally discolored but hard, may be left on the
preparation's floor. Typically, a liner such as calcium hydroxide is
applied first, followed by an interim repair such as zinc oxide
and eugenol or glass ionomer.

The placement of a well-sealing provisional restoration for

several months, which isolates any remaining caries and
bacteria from the oral environment, is critical with this
technique. In fact, several studies suggest that providing a seal
and entombment of residual bacteria to arrest caries progression is more important than any specific
base or liner placed initially in terms of caries arrestment and dentin remineralization.

While materials and techniques differ, the provisional is normally removed, any residual cavities is
removed to hard tissue, and a final restoration is put. The aim is that some degree of dentin
remineralization happened during the time period between the first and second visits, as well as the
creation of reparative dentin and dentin bridging, allowing for residual caries removal during the second
session without exposing the pulp. A lot of dentists are uncomfortable leaving residual caries in cavity
preparations and want to remove all caries at the first session, even if it means risking pulp exposure.
According to a recent study, when correcting deep carious lesions, the great majority of questioned
dentists preferred total carious excision to hard dentin at the initial session, even if it meant risking pulp
exposure.

B- Indirect Pulp Capping: One-Step Approach

Typically, all or most of the caries is removed during the initial appointment, some type of indirect pulp
capping material is placed in close proximity to but not direct contact with the pulp, and the final
restoration is placed, all during the same appointment. One common technique is to remove only the
infected dentin while leaving the affected dentin in place.

Typically, the damaged dentin is covered with a base or liner in the expectation that it may remineralize
and create firm bacteria-free dentin over time. While this appears acceptable in theory, the actual
reality is that distinguishing between infected and impacted dentin may be quite difficult. Caries
detecting solutions that, in theory, stain just the denatured collagen of diseased dentin may be valuable
adjuncts in this respect, but their accuracy is debatable, and it is unlikely that they signal with
confidence whether or not all active caries has been eliminated.
The author likes to examine the caries state of the dentin during cavity excavation and preparation by
using judicious use of caries detecting solutions in combination with careful and extensive use of tactile
and visual criteria. Dentists should also be aware that bonding directly to deep caries-affected dentin is
more difficult than bonding to normal dentin because caries-affected dentin has distinct morphological,
chemical, and physical properties. Many dentists prefer to employ a foundation or liner in deep cavity
preparations before using an adhesive technique and placing the final restoration.

When dealing with deep caries-affected dentin, one procedure

that has worked successfully for the author is to first disinfect
the substrate using a 2% aqueous solution of chlorhexidine
digluconate, followed by the installation of an RMGI liner. The
RMGI liner is applied in a thin layer (1 mm) before the dentin
bonding agent and composite restorative are applied.

RMGI liners provide a number of advantages, including excellent

adhesive and sealing capabilities due to micromechanical and
chemical interactions with dentin. They are easy to mix and put,
have substantial antibacterial qualities, are low in solubility, and have a good modulus of elasticity and
coefficient of thermal expansion and contraction (similar to dentin). Furthermore, RMGI liners have
been found in several tests to aid in the reduction of gap development and microleakage. While there is
scientific and anecdotal evidence to support the use of RMGI liners in close proximity to (but not direct
contact with) pulp, the use of RMGI liners as direct pulp capping agents is typically discouraged in the
literature.

C- Direct Pulp Capping

Typically, the process entails stopping any pulpal bleeding and

then covering and sealing exposed pulp tissue in some way to
protect its health, function, and viability. Calcium hydroxide has
long been regarded as the "gold standard" and is the most often
utilized substance in this respect. This is due in part to its
capacity to dissociate into calcium and hydroxyl ions, its high pH,
antibacterial qualities, and its ability to encourage odontoblasts
and other pulp cells to create reparative dentin in a variety of
ways. Calcium hydroxide's high pH has also been linked to
superficial coagulation necrosis when it comes into touch with
the pulp, according to research. This promotes mineralized
tissue and dentin bridge development while also providing some
hemostasis.

Although calcium hydroxide direct pulp caps are occasionally successful, they have substantial
drawbacks such as a lack of intrinsic adhesive and sealing qualities, poor physical characteristics, and
breakdown over time. Furthermore, some research indicates that the dentin bridge created beneath
calcium hydroxide pulp caps has many "tunnel" flaws and porosities.

While it has long been assumed that calcium hydroxide possesses antibacterial characteristics, at least
one study calls this notion into doubt. Long-term clinical investigations reveal that success rates with
calcium hydroxide pulp caps on carious exposures are very varied, unexpected, and frequently failed. It
makes sense to develop and test direct pulp capping medications that address some of the inadequacies
of calcium hydroxide while also having the potential to give more consistent and predictable therapeutic
effects.
MTA and MTA/Hybrid Materials

While the chemical reactions that occur when MTA is combined

with water are highly complicated and beyond the scope of this
page, the major reactants of MTA break down into a variety of
reaction products, including the well-known calcium hydroxide.
The dissociation of calcium hydroxide into hydroxyl ions results
in a high pH local environment. Unlike normal calcium
hydroxide, which loses solubility over time, this agglomeration
of reaction products retains its physical integrity long after
placement.

MTA has various beneficial properties in addition to its low solubility, including strong biocompatibility,
bioactivity, hydrophilicity, radiopacity, less toxicity than calcium hydroxide, and good sealing ability.
MTA has been demonstrated to stimulate periodontal ligament, tooth pulp, and peri-radicular tissue
regeneration. As with calcium hydroxide, there is some debate in the literature on MTA's antibacterial
properties.

MTA was first created for endodontic uses, such as a root end sealer and for sealing unintentional
furcation and root canal perforations, but its potential usage as a direct pulp capping agent was
immediately identified. When MTA and calcium hydroxide are compared head to head in direct pulp
capping investigations, there is a growing body of scientific information, including controlled clinical
research, that shows MTA has superior clinical results and histologic responses than calcium hydroxide.
While research suggests that MTA is a viable, and maybe superior, choice than calcium hydroxide for
direct pulp capping operations, typical powder/liquid MTA formulations have substantial limitations and
are not employed in most dental practices.

Traditional MTA formulations require extended setting periods (usually 2 to 4 hours), with one research
revealing that the MTA formulation tested was still not set after 6 hours under simulated intraoral
circumstances. Some modified MTA formulations contain hydration promoters such as citric acid, lactic
acid, calcium chloride, and calcium lactate gluconate. This, along with the incorporation of the powder
and liquid components into triturable capsules (ie, Biodentine), manipulation of particle sizes and
powder/liquid ratios, and other modifications, has significantly reduced the setting time of some MTA
formulations to a much more clinically manageable, albeit still lengthy, 10 to 15 minutes.
MTA-based resin-modified materials that cure on demand by
light polymerization may be an appealing option since the
ability to cure fast provides a substantial therapeutic benefit.
One critical concern for such a hybrid product is whether the
introduction of light-curable resin components and chemistry
into an MTA matrix will jeopardize the MTA's bioactive
capabilities and desired features. While promising studies and
anecdotal data support such a product, further study is needed
to properly address this critical issue.

Difference between primary and

permanent teeth pulpotomy
Primary Teeth
When caries removal leads in pulp exposure in a tooth with normal pulp or reversible pulpitis, or after
traumatic pulp exposure, and there is no radiographic indication of infection or pathologic resorption, a
pulpotomy is done. The coronal pulp is severed, pulpal bleeding is managed, and the remaining vital
radicular pulp tissue surface is treated with a clinically effective long-term medication. Only MTA and
formocresol are advised as the preferred medicaments for teeth intended to be kept for 24 months or
longer. Other materials or processes with conditional recommendations include ferric sulfate, lasers,
sodium hypochlorite, and tricalcium silicate.

Following the filling of the coronal pulp chamber with an appropriate foundation, the tooth is rebuilt
with a restoration that protects the tooth from microleakage. When the original tooth has a life lifetime
of two years or fewer and there is adequate supporting enamel left, amalgam or composite resin can
give a viable substitute. A stainless steel crown, on the other hand, is the repair of choice for
multisurface lesions.

Indication: When caries removal leads in pulp exposure in a primary tooth with a normal pulp or
reversible pulpitis, or after traumatic pulp exposure, and there are no radiographic symptoms of
infection or pathologic resorption, the pulpotomy surgery is appropriate. When the coronal tissue is
removed, the remaining radicular tissue must be deemed vital in the absence of suppuration, purulence,
necrosis, or severe bleeding that cannot be managed by a cotton pellet after several minutes.
Objectives: The radicular pulp should remain asymptomatic, with no indications or symptoms of
sensitivity, discomfort, or edema. Postoperative radiological evidence of pathologic external root
resorption should be absent. Internal root resorption has the potential to be self-limiting and stable. If
the perforation causes loss of supporting bone and/or clinical symptoms of infection and inflammation,
the doctor should remove the damaged tooth. The sucedaneous tooth should be unharmed.

Immature permanent teeth

Partial pulpotomy for carious exposures

For carious exposures, a partial pulpotomy is performed. The partial pulpotomy for carious exposures is
a technique that removes the inflammatory pulp tissue underneath an exposure to a depth of one to
three millimeters or deeper in order to reach healthy pulp tissue. Before covering the wound with
calcium hydroxide or MTA, the bleeding must be stopped using a bacteriocidal agent such as sodium
hypochlorite or chlorhexidine. While calcium hydroxide has been shown to be effective over time, MTA
results in more predictable dentin bridging and pulp health.

Indication: In a young permanent tooth with a carious pulp exposure, a partial pulpotomy is advised to
halt the pulp bleeding within several minutes. The tooth must be vital, with a normal pulp or reversible
pulpitis diagnosis.

Objectives: After a partial pulpotomy, the remaining pulp should be vital. There should be no negative
clinical indications or symptoms including sensitivity, discomfort, or edema. There should be no
postoperative radiographic evidence of internal or external resorption, aberrant canal calcification, or
periapical radiolucency. Teeth with immature roots should continue to grow normally and apexogenesis.

Partial pulpotomy for traumatic exposures (Cvek pulpotomy)

The partial pulpotomy for traumatic exposures is a treatment that removes the inflamed pulp tissue
underneath a four millimeter or less exposure to a depth of one to three millimeters or more in order to
reach the deeper healthy tissue. While the research suggests that a Cvek pulpotomy can be performed
up to nine days after initial exposure, there is no information on tooth outcomes with longer wait times.
Irrigants such as sodium hypochlorite or chlorhexidine are used to reduce the bleeding, and the wound
is subsequently coated with calcium hydroxide or MTA. MTA might darken your teeth. The qualities of
the two variants (light and gray) have been demonstrated to be identical.

While calcium hydroxide has been shown to be effective over time, MTA results in more predictable
dentin bridging and pulp health. The exposed and
surrounding dentin should be covered with MTA (at
least 1.5 millimeters thick), followed by a layer of light-
cured resin-modified glass ionomer. A restoration is
implanted to protect the tooth against microleakage.

Indication: This pulpotomy is recommended for a vital,

traumatized, young permanent tooth, particularly one
with an incompletely developed apex.

Objectives: After a partial pulpotomy, the remaining pulp should be vital. There should be no negative
clinical indications or symptoms such as sensitivity, discomfort, or edema. There should be no
postoperative radiographic evidence of internal or external resorption, aberrant canal calcification, or
periapical radiolucency. Teeth with immature roots should continue to grow normally and exhibit
apexogenesis.

Complete Pulpotomy

A complete or conventional pulpotomy involves the surgical removal of the coronal vital pulp tissue,
followed by the implantation of a biologically appropriate substance in the pulp chamber and tooth
restoration.6

MTA and tricalcium silicate outperform calcium hydroxide in terms of long-term seal and reparative
dentin development, resulting in a better success rate.
Indication: In immature permanent teeth with cariously exposed pulp, a thorough pulpotomy is advised
as an interim surgery to facilitate continuing root formation (apexogenesis). It may also be used as an
emergency technique to provide temporary relief from symptoms before a definitive root canal
treatment can be completed.

Objectives: In a living permanent tooth, a full pulpotomy treatment is performed to maintain the life of
the remaining radicular pulp. The goal is to avoid adverse clinical signs and symptoms, obtain
radiographic evidence of adequate root development for endodontic treatment, prevent breakdown of
periradicular tissues, and avoid resorptive defects or accelerated canal calcification as determined by
periodic radiographic evaluation.6
References
- Response of pulp towards various dental restorations - IJSR. (n.d.). Retrieved April 18, 2023, from
https://www.ijsr.net/archive/v6i5/ART20173781.pdf

- Direct and indirect pulp capping: A brief history ... - michigan dental. (n.d.). Retrieved
April 18, 2023, from
https://www.michigandental.org/Portals/pro/Annual%20Session/2019/Handouts/Friday/A
lex%20-%20Direct%20Pulp%20Capping%202018.pdf
- Different ways to protect dental pulp. Dental Products Report. (n.d.). Retrieved April 18,
2023, from https://www.dentalproductsreport.com/view/different-ways-to-protect-dental-
pulp
- Pulp therapy for primary and immature permanent teeth - AAPD. (n.d.). Retrieved April
18, 2023, from https://www.aapd.org/media/Policies_Guidelines/BP_PulpTherapy.pdf