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Analysis of Pulpal Reactions to Restorative Procedures, Materials, Pulp Capping, and Future Therapies
Peter E. Murray, L. Jack Windsor, Thomas W. Smyth, Abeer A. Hafez and Charles F. Cox
CROBM 2002 13: 509
DOI: 10.1177/154411130201300607
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Thomas W. Smyth
Department of Dentistry, St. Francis Hospital and Medical Center, Hartford, CT 06105
Abeer A. Hafez
School of Dentistry, University of Southern California, Los Angeles, CA 90089-0641
Charles F. Cox
Department of Restorative Dentistry, School of Dentistry, University of California at Los Angeles, Los Angeles, CA 90095-1668
ABSTRACT: Every year, despite the effectiveness of preventive dentistry and dental health care, 290 million fillings are
placed each year in the United States; two-thirds of these involve the replacement of failed restorations. Improvements in
the success of restorative treatments may be possible if caries management strategies, selection of restorative materials,
and their proper use to avoid post-operative complications were investigated from a biological perspective. Consequently,
this review will examine pulp injury and healing reactions to different restorative variables. The application of tissue engi-
neering approaches to restorative dentistry will require the transplantation, replacement, or regeneration of cells, and/or
stimulation of mineralized tissue formation. This might solve major dental problems, by remineralizing caries lesions, vac-
cinating against caries and oral diseases, and restoring injured or replacing lost teeth. However, until these therapies can
be introduced clinically, the avoidance of post-operative complications with conventional therapies requires attention to
numerous aspects of treatment highlighted in this review.
Key words. Cavity preparation, cavity restoration, dental materials, growth factors, inflammation, bacterial microleakage.
(I) Introduction Burke et al., 1999). In the United States, it is estimated that, of
290 million restorations, 200 million are replacements for failed
T he regeneration or replacement of oral tissues affected by
inherited disorders, trauma, and neoplastic or infectious
diseases is expected to solve many dental problems. Within
restorations (Arnst and Carey, 1998). Currently, a high propor-
tion of these teeth develop symptoms requiring endodontic
the next 25 years, unparalleled advances in restorative den- treatment (Zöllner and Gaengler, 2000), and millions of teeth
tistry are set to take place with the availability of artificial are extracted, with 1.5 million US restorations requiring root
teeth, bone, organs, and oral tissues (Baum and Mooney, 2000; canal therapy (NIDCR, 2002). This rate of treatment failure sug-
Baum et al. 2002), as well as the ability of growth factors to gests that current restorative regimes are not yet optimized and
stimulate dental repair (Murray and Smith, 2002), regenerate have a potential for improvement. Often, clinical experience or
lost tissues (Becker, 1994; Smith et al., 2002), produce vaccina- empirical evidence is used to diagnose dental problems requir-
tions against viruses (Baum and O'Connell, 1995), and geneti- ing treatment, because scientific evidence is lacking (Mjör,
cally alter disease pathogens to help eradicate caries and peri- 2001a). Therefore, it is necessary to evaluate the biological
odontitis (Hillman et al., 2000). Patient demand for tissue engi- changes taking place in teeth to help optimize current treat-
neering therapy is staggering in both scope and cost. Each ment regimens, and to use, stimulate, or augment natural
year, $400 billion is spent treating Americans suffering some regenerative processes to accomplish therapy by tissue engi-
type of tissue loss or end-stage organ failure. This includes neering. Avoidance of tooth-healing complications requires
20,000 organ transplants, 500,000 joint replacements, and mil- examination of surgical trauma and injuries caused by a failure
lions of dental and oral craniofacial procedures, ranging from to use materials and procedures congruent with the natural
tooth restorations to major reconstruction of facial soft and regenerative activity of teeth (Murray et al., 2000a). There is lim-
mineralized tissues (National Institute of Dental and ited information regarding sources of pulp injury, healing
Craniofacial Research [NIDCR], 2002). defects, bacterial leakage, and pulp inflammation, although
Two-thirds of all restorative dentistry involves the replace- these factors often create healing problems. Consequently, this
ment of failed restorations (Maupome and Sheiham, 1998; review will investigate those aspects of restorative dentistry
Common current Seal fissure or Excavate caries Stepwise excavation Pulp capping, Remove injured tissue
restorative therapy excavate caries and apply of caries lesion, endodontic treatment, and place implant
and apply restorative materials. or pulp capping or tooth extraction or prosthetic teeth.
restorative materials.
Likely objective of Alter oral bacterial Stimulate pulp-dentin Regenerate lost Implant progenitor Use progenitor cells
tissue engineering DNA to arrest healing with tissues and cells to regenerate and growth factors
in restorative and prevent growth factors. dentin repair lost tissue and tooth in 3-dimensional
therapy subsequentenamel with growth factors. mineralized structure. tissue culture to
and dentin caries harvest artificial teeth
demineralization. for implantation.