PULP CAPPING

MATERIALS
 IDEAL REQUIREMENTS
Ideal dressing material for pulp therapy in primary teeth does not
exist, but the material should be:

1. Bactericidal
2. Biocompatible
3. Harmless to the pulp, surrounding structures and the
permanent tooth germ.
4. Promote healing
5. Not interfere with physiologic process of resorption.
 VARIOUS PULP CAPPING AGENT
Calcium hydroxide
Thera Cal Zinc oxide eugenol cement
Castor oil bean cement Corticosteroids and antibiotics
Endo sequence root repair material Polycarboxylate cement
Odontogenic ameloblast Isobutyl cyanoacrylate and tri
associated protein calcium phosphate ceramic

Growth factors Collagen

MTA 1-Calcium Bonding Agents

Lasers Calcium phosphate

GIC/RMGIC Hydroxyapatite
Mineral trioxide aggregate
 CALCIUM HYDROXIDE
 It is a colorless crystal or white powder prepared by
reacting calcium oxide with water.
 The use of calcium hydroxide in  endodontics was introduced by
 Hermann  in between 1920-1930.
 Calcium hydroxide was most favored as a 
pulpotomy agent in the 1940s and mid- 1950s.
 “Calcium hydroxide has the ability to form reparative dentin 
formation”,this  rationale    was  introduced  by  Teuscher  and  Zander
 in 1938.
 Lim and Kirk, in an extensive review of direct pulp capping 
literature,  found  little  support  for  pulp  obliteration and internal 
resorption  being  a  major  complication  of  pulp  capping
 Estrela  et  al.  summarized  the  antibacterial  properties  of 
calcium  hydroxide.
ADVANTAGES DISADVANTAGES
Reparative dentin formation Pulp obliteration
Antibacterial action Internal resorption
Pulp protection Lack of adhesion to hard tissues
The tissue-dissolving property Microleakage
Newer preparation shows Improved Short working time of self cured
strength, essentially no solubility in acid, and preparation
minimal solubility in water and control the
over working time 

COMPOSITION
Base paste – Catalyst paste
Glycol salicylate-40%-reacts with Calcium hydroxide-50%-principal
calcium hydroxide and ZnO reactive ingredient
Titanium dioxide-Inert fillers Zinc oxide-10%
Calcium tungstate - Fillers Zinc stearate-0.55%-accelerator
Barium sulphate-provide radioopacity Sulphonamide-39.5%-oily
compound acts as carrier. 
•AVAILABLE AS
a)Pulpdent b)Hydrex : two paste system c)Dycal.
MECHANISM OF ACTION

A: After 24 hours
B: After 2-3 weeks

C: After 4-5 weeks D: After 8 weeks

 HISTOLOGY OF HEALING AFTER PULP CAPPING WITH Ca(OH)2
Three distinct zone can be visualised:
I. Zone of obliteration (early changes: area of superficial debris)
II. Zone of coagulation necrosis (Schroeder’s layer of “firm necrosis”,
Stanley’s “mummified zone”)
III. Line of demarcation
Zone of obliteration Zone of coagulation necrosis Line of demarcation
Early changes: area of Weaker chemical reaction from 1st Develops between Zone
superficial debris zone reaches the subjacent , more of coagulation necrosis
Drug’s caustic effect apical tissues & results in this zone of and vital tissues
Tissue in immediate contact coagulation & necrosis. This zone results from
becomes deranged and Thickness- 0.3-0.7 mm (Acc. to reaction of Calcium
distorted. Craig: 1mm thick) hydroxide with the
This Zone consists of- Represents devitalised tissue tissue protein to form
i. Debris without complete obliteration of its proteinate globules.
ii. Dentinal fragments structural architecture
iii. Blood clot Cellular details-greatly diminished
iv. Blood pigment Capillaries outlines, nerve bundles
v. Calcium hydroxide & pyknotic nuclei can be recognized.
particles Stimulates subjacent vital pulp
Vascular changes occur
MINERAL TRIOXIDE AGGREGATE[MTA]
It is a new remarkable biocompatible material with exciting clinical applications
pioneered by Dr. Mahmoud Torabinejad, Loma Linda University, in
1993
COMPOSITION
MTA is a mechanical mixture of 3 powder ingredients:
• Portland cement (75%)
• Bismuth oxide (20%)
• Gypsum (5%)
Composition includes :
• Tricalcium silicate
• Dicalcium silicate
• Tricalcium aluminate
• Tetracalcium aluminoferrite
• Calcium sulfate
• Bismuth oxide (provides radio-opacity)
PROPERTIES OF MTA ADVANTAGES
•Mixing MTA: • Antimicrobial Activity
Powder: Water = 3: 1 • Prevents MicroLeakage over vital pulp
Glass SLABor paper slab used
• Cementoconductive
•SETTING TIME:
Hydration of MTA powder results in a • Non toxic and Non-mutagenic
colloidal gel that solidifies to a hard • Cell adherence & growth
structure in 3~ 4 hrs which has a long • Alkaline phosphotase/ osteocalcin
setting time with less shrinkage. • Interleukin production
•pH=12.5 • Periodontal ligament attachment to
INDICATION cementum growth
•To preserve pulp vitality • Dentinal bridge formation
• Prevent pathological changes in the
periradicular tissues
• Mechanical pulp exposures
• Carious pulp exposures with
immature apices. DISADVANTAGES
• More difficult to manipulate
CONTRAINDIACTION • Longer setting time 
Irreversible pulpitis
CLINICAL APPLICATION OF MTA
• Direct Pulp Capping
• Apical plug
• Root End Filling
• Perforation Repair
• Furcation involvment
• Resorptive Defects
• Immature apices
(apexogenesis/ Apexification)
 Ca(OH)2 MTA
Hard tissue formation Not much Root end induction
Calcific bridge Not continuous Continuous with dentin
Biocompatibility Low High
Degree of Inflammation Low High
Sets Not Hard Hard
pH High High
Solubility Partially disolve Less soluble
Permeable to fluids Non permeable
Viscosity Poor Good
Application Not easy to apply in RC Easy
Resorption Rate vary with density Non-resorbable
Appical barrier formation Change rate/ initial narrow Less/wide
appical width

Patient follow up More Less

Treatment Delay shortens
 ZINC OXIDE-EUGENOL

 Germicidal agent
 Used in indirect pulp capping due to its Palliative affect
Excellent initial seal
Kills bacteria present in
This gives the pulp the chance for
carious lesions
healing & regeneration So arrests the caries process

 Direct contact →chronic inflammatiom ,abscess formation and

liquefaction necrosis.
 After 24Hr 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.
 LASER
 Different studies were led on laser energy
to overcome the histological deficits of electrosurgery.

 Used in Direct pulp capping & pulpotomy.

 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.
 Laser irradiation creates a superficial zone of coagulation necrosis that remains
compatible with the underlying tissue and isolate pulp from effects of the subbase.
Mortiz et al., reported that the thermal effects of laser radiation caused sterilization
and scar formation in the irradiated area, which in turn preserves the pulp from
bacterial invasion.
 Calcium phosphate Compounds
 Alpha-tricalcium phosphate & Tetracalcium phosphate (4CP)
set & convert to hydroxyapatite.

 Stimulate the pulp to form hard tissue.

 No finding of necrotic pulp tissue in direct contact with 4CP

cement compared to calcium hydroxide slight acidity after
mixing

 4CP cement has mechanical strengths so it could be used as

so called “dentin substitute”. Pulp capping agent
lining material
 Adhesive Liners
 There were suggested as direct pulp capping and pulpotomy
agents with the introduction of adhesive dentistry in both
primary and permanent dentition.

 Adhesive material forms:

 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.
 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
secondary dentin formation.

 In direct capping with this paste showed no pulp

. degeneration and formation of protective layer.
OTHER MATERIALS USED AS PULP CAPPING AGENT….
PULP CAPPING AGENT ADVANTAGES DISADVANTAGES

Zinc oxide eugenol cement. 1)Reduces inflammation. 1) Lack of calcific bridge

formation.
2) Releases eugenol in high
concentration which is
cytotoxic.
3) Demonstrates interfacial
leakage.

Corticosteroids and 1) Reduces pulp inflammation. 1) Should not be used in patients

antibiotics. 2) Vanomycin and calcium hydroxide with risk from bacteremia.
stimulated a more regular reparative
dentin.

Polycarboxylate cement. 1)Chemically bond to tooth structure. 1) Lack of antibacterial effect.

2) Fail to stimulate calcific bridge
formation.

Inert materials( Isobutyl 1) Reduces pulp inflammation. 1) NONE of these materials have
cyanoacrylate and tri 2) Stimulate dentin bridge formation. been promoted in dentist
calcium phosphate ceramic) profession as a viable technique

Collagen 1) Less irritating than calcium hydroxide 1) Does not help in thick dentin
and promotes mineralization. bridge formation.

Bonding Agents 1) Superior adhesion to hard tissues. 1) Has cytotoxic effect.

2) Effective seal against micro leakage. 2) Absence of calcific bridge
PULP CAPPING ADVANTAGES DISADVANTAGES.
AGENT
Calcium phosphate. 1) Helps in bridge formation with no 1) Clinical trials are necessary to
superficial tissue necrosis. evaluate this material.
2) Significant absence of pulp
inflammation.
3) Good physical properties.

Hydroxyapatite. 1) Biocompatible. 1) Mild inflammation with superficial

2) Act as a scaffold for the newly formed necrosis of pulp.
mineralized tissue.

Carbon dioxide lasers 1) Formation of secondary dentin. 1) Technique sensitive.

2) Bactericidal effects.
RS
2) Causes thermal damage to pulp at
high doses.

Glass ionomer/ Resin 1) Excellent bacterial seal. 1) Cause chronic inflammation.

modified glass 2) Fluoride release, coeffient of thermal 2) Lack of dentin bridge formation.
ionomer. expansion and modulus of elasticity 3) Cytotoxic when in direct cell
similar to dentin. contact.
3) Good biocompatibility. 4) High solubility and slow setting
rate.

MTA 1-Calcium 1) Helps in dentin bridge formation without 1) Presence of 10% calcium hydroxide
formation of necrotic layer. interferes with complete curing of the
2) Shear bond strength is higher than material, residual monomers causes
conventional GIC and similar to RMGIC. cytotoxicity.

Growth factors. 1) Formation of osteodentin and tubular 1) High concentration is required.

dentin. 2) Half life is less.
2) Formation of more homogenous 3) Appropriate dose response is
PULP CAPPING ADVANTAGES. DISADVANTAGES.
AGENT

Odontogenic 1) Biocompatible. 1) Till now only invitro studies

ameloblast 2) Accelerates reactionary dentin were conducted.
associated formation. 2) Further studies regarding
protein. 3) Normal pulp tissue appearance this material is required.
without excessive tertiary dentin
formation and obliteration of the
pulp cavity compared to MTA

Endo sequence 1) Antibacterial property. 1) Bioactivity of the cells were

root repair 2) Less cytotoxic than MTA, Dycal and decreased gradually when
material light cure calcium hydroxide. exposed to this material.

Castor oil bean 1) Good antibacterial property. 1) Bio inert rather than
cement. 2) Less cytotoxic. bioactive.
3) Good mechanical properties. 2) More clinical trials are
4) Facilitates tissue healing. required.
5) Better sealing ability than MTA and
GIC.
6) Less cost.
Thera Cal. 1) Act as protectant of the dental pulp 1) It is opaque and whitish in
complex. color and it should be kept thin
CONCLUSION
Pulp capping is a procedure that maintains pulp vitality
and function, promotes healing/repair, prevents
breakdown of peri radicular supporting tissues, and
promotes formation of secondary dentin
Direct pulp capping is a procedure used in asymptomatic
teeth with deep caries reaching upto pulp. It is another
method than Indirect pulp capping to treat deep caries
but it is not a preferred method in children as success
rate is very low, like indirect pulp capping in this also a
suitable medicament is placed to induce dentin bridge
formation