13 Repair of Pulpal Lnjury With Dental Materials

Chapter
Repair of Pulpal Injury

with Dental Materials 13
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
Harold E. Goodis, DDS

Sally Marshall, PhD
Franklin R. Tay, BDSc (Hons), PhD
Grayson W. Marshall, Jr, DDS, MPH, PhD
Vital pulp therapy includes direct and indirect pulp The effects of dental materials on the dental
capping, pulpotomy, and other therapies that mini- pulp have fascinated investigators since teeth were
mize pulpal injury by protecting the pulp from the first subjected to restorative procedures. From the
toxic effects of chemical, bacterial, mechanical, or time that caries was thought of as being caused by
thermal insult.1 Vital pulp therapy therefore is aimed “worms,”4 many materials have been suggested not
at treating reversible pulpal injuries by sealing the only to replace lost or prepared tooth structure but,
pulp and stimulating the formation of tertiary den- more importantly, to protect and preserve the vitality
tin.2 Pathologic stimuli that can induce reversible of the dental pulp. This innate repair system is influ-
pulpitis include attrition, erosion, caries, restoration enced by the clinician’s choice of material and tech-
procedures, and restoration placement.3 nique and other factors influencing case selection.
This chapter first explores the factors that affect the The dental pulp, when exposed by caries or mechani-
success of vital pulp therapy and then specifically dis- cal, chemical, or physical trauma, may respond favor-
Copyright @ 2012. International Quintessence Publishing Group.
cusses calcium hydroxide (Ca[OH]2) treatment, which ably to application of a variety of materials used in
is compared with treatments that use other materials pulp capping procedures.5 Many studies have con-
developed and evaluated for vital pulp therapy. firmed the formation of hard tissue over the site of
The dental pulp is vulnerable to injury for three the exposure (see section on calcium hydroxide). The
reasons: (1) It is a relatively large volume of tissue dental pulp thus can be said to demonstrate an intrin-
with a relatively small volume of blood supply; (2) sic capacity to heal.
it is a terminal circulation with few, if any, collateral However, in the clinical situation, where a pulpal
vessels; and (3) it is confined in calcified tissue walls exposure leads to long-term irritation and inflamma-
(dentin). Therefore, the pulp is considered a low- tion at the exposure site, the outcome of hard tissue
compliance system that does not tolerate injury eas- formation is not predictable.5 Some factors relating
ily. Nevertheless, the dental pulp has the capacity to pulpal defensive reactions and healing after cap-
to heal itself. Like many other tissue systems in the ping procedures are understood, but the mecha-
body, the dental pulp can answer an adverse stimu- nisms of other factors are less well known, including
lus with an immune response that allows the dental those that regulate the inflammatory response and
pulp to protect itself and survive. This capacity may possible resultant necrosis. Improved understand-
depend on age because the volume of the coronal ing of the regulation of healing and wound closure
pulp and root canal system decreases with age. (hard tissue formation) may allow the development
EBSCO : eBook Academic Collection (EBSCOhost) - printed on 5/9/2018 4:33 PM via UNIVERSIDAD DEL BOSQUE
301
AN: 811795 ; Tay, Franklin R., Seltzer, Samuel, Hargreaves, Kenneth M., Goodis, Harold E..; Seltzer and Bender's Dental Pulp
Account: s9777129.main.ehost
13 Repair of Pulpal Injury with Dental Materials
Fig 13-3 Dental pulp 7

days after pulpal exposure in
germ-free rats. The dental pulp
remains vital even though food
debris has been impacted into
the exposure site and pulp tis-
sue (H&E stain; original mag-
nification ×340). (Reprinted

from Kakehashi et al6 with
permission.)
Fig 13-4 Dental pulp 32

days after pulpal exposure
in germ-free rats. Note the
formation of a dentin bridge
Fig 13-1 Dental pulp 8 days after Fig 13-2 Dental pulp 14 days
across the exposure with
pulpal exposure in conventional rats. after pulpal exposure in convention-
vital and uninflamed dental
Note the necrotic and vital pulp tis- al rats. Note the complete necrosis
pulp beneath the bridge (H&E
sue juxtaposed in the root canal of the dental pulp with the devel-
stain; original magnification
system (hematoxylin-eosin [H&E] opment of a periradicular abscess
×3,100). (Reprinted from
stain; original magnification ×100). (H&E stain; original magnification
Kakehashi et al6 with permis-
(Reprinted from Kakehashi et al 6 ×40). (Reprinted from Kakehashi et
sion.)
with permission.) al6 with permission.)
of improved treatment procedures, leading to more • The potential for a medicament, a material, or a
predictable outcomes. combination of both to obdurate a pulpal expo-
The clinician should understand how restorative sure and allow the pulp to recover its natural form,
materials aid in the recovery of the pulp tissue in the function, and vitality
face of reversible and irreversible tissue changes that
threaten its vitality (see also chapters 14 and 15). In
order to anticipate the reaction of the dental pulp
to various materials and to the preparations for their Influence of Bacteria on Pulpal
placement, the clinician must investigate and under- Healing
stand:
• The ability of the available materials to stimulate The classic studies of Kakehashi et al6 clearly showed
tissue repair the pathologic role of bacteria in pulpal exposures.
• The methods used to test the materials, both in In the presence of bacteria, exposed rat pulp tis-
the laboratory (in vitro) and the clinic (in vivo) sue is partially necrotic by 8 days (Fig 13-1) and
• The ability of the materials to seal the interface completely necrotic with formation of periradicular
between the margin of the preparation and the abscesses by 14 days (Fig 13-2). This response is not
margin of the restorative material seen in germ-free animals with pulpal exposures.
• The role of microorganisms (bacteria) in pulpal Figure 13-3 shows the dental pulp at 7 days after
disease exposure in germ-free animals; although food debris
• The potential for tooth preparation procedures to has been impacted in the dental pulp, the tissue
cause pulpal disease appears normal. By 32 days after pulpal exposure
• The effects of mechanical or pathologic exposures in germ-free rats, an intact dentin bridge has devel-
that allow contact of pulp tissue with the oral envi- oped with normal dental pulp tissue beneath the
ronment as well as restorative materials newly formed dentin (Fig 13-4). Thus, bacterial infec-
302
Influence of Bacteria on Pulpal Healing
tion of dental pulp constitutes a critical etiologic lectively, these studies illustrate that the duration of
factor for pulpal necrosis (see also chapter 10). Vital contamination remains an important yet controver-
pulp therapy therefore must include materials and sial factor in terms of successful pulp capping.
methods that reduce or eliminate bacteria.
This is an important consideration because suc-
Bacterial microleakage versus
cess in direct pulp capping procedures is not pre-

dictable. There are conflicting studies concerning material toxicity
the procedures and materials that offer the greatest
chances for success with pulp capping. A pioneer- A second issue in pulpal healing is the relative
ing study7 described the placement of phenol at the importance of bacterial microleakage and material
site of pulpal exposure prior to the pulp capping toxicity. Various materials differ in these properties;
procedure. The study also examined the direct use some (eg, zinc oxide–eugenol) show greater abil-
of either Ca(OH)2 or zinc oxide–eugenol at the site of ity to prevent microleakage, while others (eg, zinc
exposure with prior use of phenol. Healing occurred phosphate cement) were thought to show greater
when Ca(OH)2 was used as the capping material but tissue toxicity. Early research focused on the tissue
not when zinc oxide–eugenol was used. Phenol nei- toxicity of materials, but in 1971 Brännström and
ther interfered with nor enhanced pulpal healing. An Nyborg14 demonstrated that infection caused by the
important principle to remember is that pulpal heal- microleakage of microorganisms around the restora-
ing occurs in an environment free from the presence tion provided the greatest threat to pulpal health.15
of microorganisms. Other investigators16–18 have suggested that pulpal
Two issues modify pulpal healing and therefore devitalization following a restorative procedure is
must be considered in the development of guide- likely to result from the combined effect of bacteria,
lines for vital pulp therapy: (1) How does the dura- the mechanical injury induced during cutting of the
tion of pulpal exposure to the oral environment tooth substance, the extent and depth of the cav-
modify the success of pulp capping procedures? (2) ity preparation, and the toxicity of the restorative
What is the relative importance of the capacity of a materials (see also chapter 14). However, bacteria
material to seal against bacterial invasion compared are believed to be the main factor. Pulpal mecha-
to its cytotoxicity? nisms proposed to reduce bacterial invasion include
increased outward flow of dentinal fluid (see also
chapter 4), emigration of neutrophils into dentinal
Duration of pulpal exposure tubules, and the sequestering of toxic substances (of
either restorative or bacterial origin) by their binding
The duration of pulpal contamination is an important to dentin.18
factor in the success of pulp capping procedures. Taken together, these studies indicate that both
Many clinicians believe that only uncontaminated bacteria and material toxicity contribute to the
pulpal exposures should be treated and that longer development of pulpal pathosis. An obvious rela-
periods of contamination by oral microorganisms tionship has been established between the pres-
and debris reduce the chance of success.8–11 This ence of microorganisms and the degree of pulpal
view is reinforced by results from animal studies that response.6,10 In an excellent review, Bergenholtz18
indicate that the success of Ca(OH)2 pulp capping is indicated that even a thin wall of primary dentin, if
reduced from 93% to 56% when microbial contami- intact, often prevents the deleterious effects of both
nation is extended from 1 hour to 7 days.11 However, toxic materials and bacterial leakage. The biocom-
clinical studies in younger patients have shown that patibility of materials is directly affected by bacterial
the superficial pulp is resistant to bacterial invasion contamination (eg, leakage) as well as their intrinsic
and that partial pulpotomy with Ca(OH)2 dressing toxicity (eg, effects of constituents such as acids and
can provide a 93% radiographic success rate at a components such as catalysts and photoinitiators).
mean follow-up of more than 4.5 years.12,13 In these Therefore, both the sealing ability and the toxicity
studies, treatment of pulp that was exposed for up of the material are important factors in predicting
to 3 months had success rates similar to those asso- pulpal responses to vital pulp therapy.18,19
ciated with exposures of a shorter duration.12 Col-
303
a b c d
Fig 13-5 (a) Mandibular left second molar of a 17-year-old girl. Caries excavation resulted in exposure of mesiobuccal and distolingual pulp horns. After control of
hemorrhage, pulp capping was performed with Dycal (Dentsply Caulk) and followed by the placement of a light-cured resin-modified glass-ionomer liner (Vitrebond).
The cavity was restored with resin composite. (b) The patient presented 19 months later with fracture of the distal marginal ridge. No symptoms were present. The tooth
responded normally to pulp tests. Radiographically, the margin of the fracture was close to the periodontal bone. After different treatment options were discussed, the
tooth was extracted to allow eruption of the third molar. (c) The tooth was processed for light microscopy for serial sectioning. This section represents the one that passed
through the mesiobuccal exposure site. A calcified barrier is present and dentin chips (arrow) are embedded within the barrier. Ca(OH)2 remnants (open arrow) are pres-
ent on top of the calcified tissue, which exhibits tubular characteristics. The pulp tissue is uninflamed and appears detached from the hard tissue because of hemorrhage
(solid arrowheads) that resulted from a crack created during extraction (H&E stain; original magnification ×50). (d) Higher magnification of the area indicated by the
arrow in (c). The dentin chip (asterisk) is completely surrounded by an amorphous eosinophilic calcified mass. In addition, Ca(OH)2 remnants (arrow) that were previously
pushed into the exposed pulp are trapped within the calcified mass (H&E stain; original magnification ×400). (Courtesy of Dr Domenico Ricucci, Rome, Italy.)
Factors That Influence the Presence of dentin chips

Outcome of Pulp Capping and Pulpal exposures are often contaminated with dentin
Repair chips, or debris, resulting from the use of rotating
instruments in caries removal and tooth prepara-
tion procedures (Fig 13-5). The question of whether
Size of pulpal exposure these dentin chips promote or retard healing remains
controversial. Some researchers believe that dentin
Several studies suggest that the size of the pulpal chips encourage the formation of a dentin bridge.23–25
exposure may influence case selection. Many den- However, if dentin chips are forced into the deeper
tists believe that for pulp capping to be successful coronal pulp tissue by a rotating instrument, they may
the exposure must be less than 1.0 mm in its major produce a pulpitis with abscess formation, especially
dimension and the patient must be young.20,21 Pulpal if contaminated with oral microflora. One study found
exposures that are too large may have greater risk of that unintentional deep impaction of the medicament
adversely reacting to microleakage and may be very and dentin chips in primary teeth led to an increased
difficult to restore. However, partial pulpotomies inflammatory response.26
after traumatic crown fractures have been shown Ideally, any capping agent should be placed
to produce a 96% success rate with an average gently on the exposed pulp surface and not in the
31-month follow-up, even for pulpal exposures rang- deeper pulp tissue because deep impaction of par-
ing from 0.5 to 4.0 mm in size.12 Thus, the size of the ticles of the pulp capping material can also reduce
exposure, within this range, does not appear to be the success of dentin bridge formation and healing.
a major factor in the success of vital pulp therapy. Control or limitation of impaction is a clinical chal-
Similar success rates were observed in teeth with lenge and one that is not always achieved (see Fig
immature and mature roots.12,21,22 13-5). Studies have shown that particles of certain
Ca(OH)2 formulations can be phagocytosed. Par-
304
Factors That Influence the Outcome of Pulp Capping and Repair
ticles that are no longer chemically active can be halt hemorrhage and allow capping materials to be
retained indefinitely in macrophages and giant cells placed in a relatively dry environment. Sodium hypo-
in the healed area beneath the bridge and adjacent chlorite (NaOCl) has been suggested to remove the
normal areas.21 coagulum, control hemorrhage, remove dentin chips,
One study used a cell culture model system and aid formation of a dentin bridge.34
to evaluate the ability of Ca(OH)2 to alter macro- In one study, Class V cavities (n = 90) with
phage function.27 Inflammatory macrophages were mechanical pulpal exposures were prepared in adult
obtained from rats, and substrate adherence capaci- monkey teeth. Hemorrhage was controlled with a
ty assays indicated that Ca(OH)2 decreased substrate 3% solution of NaOCl.35 All-Bond 2 (Bisco Dental;
adherence in a time- and dose-dependent manner. n = 22), One-Step and Resinomer (Bisco Dental;
Thus, Ca(OH)2 inhibited macrophage function and n = 26), and Ca(OH)2 and amalgam (n = 42 posi-
reduced inflammatory reactions when used in direct tive controls) were used as pulp capping agents.
pulp capping and pulpotomy procedures. This may The pulp tissue was examined at 7, 27, and 90 days.
explain, at least in part, the mineralized tissue induc- Eighty-six percent of pulps irrigated with NaOCl
tion property of the agent. prior to adhesive placement showed normal soft tis-
In another study, an adhesive system applied sue reorganization and dentin bridge formation.
to exposed human pulp tissue caused large areas In another study, several hemostatic agents were
of neutrophil infiltration and death of odonto- used when Class II preparations were placed in
blasts.28 The inflammatory infiltrate was subsequently 25 human teeth scheduled for removal for ortho-
replaced with fibroblasts, macrophages, and giant dontic reasons.36 Teeth capped with an adhesive
cells in the coronal pulp tissue; this response inhib- system after hemorrhage control with saline, ferric
its pulp repair and dentin bridging. Together, these sulfate, 2.5% NaOCl, and a Ca(OH)2 solution showed
studies suggest that the sealing ability of the agent, a tissue response that varied from acute inflamma-
the method of placement (eg, minimizing the impaction to necrosis and no dentin bridge formation.
tion of pulp capping agents in dental pulp), and the The group with saline rinses to control hemorrhage
chemical nature of the pulp capping material are all and Ca(OH) 2 as a capping agent demonstrated
critical factors in pulpal healing. bridge formation. In a subsequent study that utilized
Ca(OH)2 instead of a dentin adhesive as the pulp
capping agent,37 the authors also observed that the
Hemostatic control of hemorrhage and use of saline as a hemostatic agent resulted in sig-
plasma exudate nificantly better pulpal response and dentin bridge
formation than did the use of 2.5% NaOCl.
The need for hemorrhage control was first investi- Saline (n = 14), 5.25% NaOCl (n = 16), and
gated by Marzouk and Van Huysen29 in 1966, and 2% chlorhexidine digluconate (n = 15) were used
others have since confirmed its necessity.30–32 Chiego33 for hemorrhage control in another study, 38 and
has suggested that operative trauma may evoke very the exposures were covered with a hard Ca(OH)2
rapid changes in the dental pulp, leading to per- cement. The results demonstrated that the three
meation and leakage of plasma proteins out of the hemostatic agents did not impede the healing pro-
tubules to the cut dentin surface. Such leakage could cess of the dental pulp to Ca(OH)2 capping. It is
inhibit wound healing (ie, dentin bridge formation). apparent that more work is needed to better define
Hemorrhage of exposed dental pulp tissue is in the use of these agents prior to capping, especially
part due to the inflammatory response of the pulp to when they will be used in combination with other
bacteria and their by-products from carious dentin. materials, such as mineral trioxide aggregate (MTA),
The trauma of caries removal leading to the exposure now suggested for these procedures.
may increase the amount of bleeding encountered. The development of pulpal edema can have sev-
It is apparent from several studies that the materi- eral deleterious effects, including extrusion of pulp
als placed against a bleeding pulp will not lead to tissue, dislodgment of the pulp capping material,
subsequent tertiary dentin formation and bridging loss of an effective seal against bacterial invasion,
and may not lead to maintenance of vital pulp tissue development of a chronic inflammatory infiltrate,
(see next section). Studies have examined the use and inhibition of tertiary dentin formation. Accord-
of hemostatic agents placed over the exposure to ingly, the use of a hemostatic agent may be recom-
305
Fig 13-6 Emboli (E) of Ca(OH)2 Fig 13-7 Pulpal response to a

(Prisma VLC Dycal [Dentsply]) Ca(OH)2 saline paste at 7 days.
in numerous blood vessels far Note the thickness of the mum-
removed from the exposure sur- mified zone (MZ). The arrow
face (H&E stain; original magni- denotes the line of demarcation
fication ×480). (Reprinted from between the mummified zone
Stanley and Pameijer39 with per- and the dental pulp. A new layer
E
mission.) of odontoblast-like cells is form-
ing subjacent to the mummified
zone (H&E stain; original mag-
nification ×80). (Reprinted from
Turner et al26 with permission.)
Fig 13-8 Example of a porous den- Fig 13-9 Example of a high-quality,

tin bridge created in human pulp tis- dense dentin bridge in human pulp tis-
sue that was mechanically exposed sue that was mechanically exposed and
and capped with Dycal for a 30-day capped with Dycal for a 90-day period.
period. A partial hard tissue barrier New odontoblasts (odontoblast-like cells
(open arrowhead) was present under- [arrow]) were present underlying the com-
lying the capping agent (solid arrow). plete hard tissue barrier. The subjacent
Additional reparative tertiary dentin pulp tissue exhibits normal histologic fea-
had been formed adjacent to the site tures (H&E stain; original magnification
of pulpal exposure (open arrow). A ×32). (Courtesy of Drs Carlos Alberto de
mild inflammatory pulpal response is Souza Costa and Josimeri Hebling, São
present immediately below the pulp Paulo, Brazil.)
capping site (pointer). The subjacent
pulp tissue exhibits normal histologic
characteristics with no inflammatory
response (asterisk) (H&E stain; origi-
nal magnification ×32). (Courtesy of
Drs Carlos Alberto de Souza Costa and Josimeri Hebling, São Paulo, Brazil.)
mended in the future for all vital pulp procedures. pulpal blood flow, which may lead to delayed or
Ideally, clotting of the capillaries within the subjacent inadequate healing.

pulp tissue should occur.21
The presence of open or cut vessels can carry
capping material particles into the deeper pulp Quality of the dentin bridge
tissue. In a large mechanical exposure, especially
one resulting from a traumatic injury or following a If dentin bridge formation is essential to the success
pulpotomy, many vessels may be dilated or trans- of pulp capping procedures, then the presence and
sected. Sometimes particles of the capping mate- quality of the dentin bridge are important prognos-
rial may enter these vessels and travel until lodged tic factors for clinical success. A dentin bridge will
in the vessel as it diminishes in size near the apical form with appropriate Ca(OH)2 treatment, permit-
portion of the root canal (Fig 13-6). At these sites, ting intimate contact with remaining pulp tissue
the chemical or caustic effects of agents such as the (Fig 13-7). Although the integrity of a dentin bridge
fresh particles of Ca(OH)2 (if still chemically active may be suspect (see also chapter 2), it neverthe-
and especially if from high-pH formulations) produce less serves as a physical barrier to protect the pulp.
perivascular foci of mummification and inflammation. Figure 13-8 shows a thin, porous dentin bridge that
If the particles are from low-pH Ca(OH)2 formula- formed in 4 weeks. Figure 13-9 represents an exam-
tions, they merely block the vessels and decrease ple of a thick, dense bridge that formed over a peri-
306
a b c d
e f g h
Fig 13-10 (a) Radiograph of a mandibular molar of a 26-year-old man showing deep occlusal caries. The patient was asymptomatic, and sensitivity tests yielded nor-
mal responses. (b) During caries removal, a large exposure of the lingual pulp horn was produced. (c) Following hemorrhage control, pulp capping was performed with
Ca(OH)2 powder. (d) The powder and the remaining dentin were covered with Dycal. The cavity was restored with IRM (Dentsply Caulk). (e) The patient never returned for
the final restoration. He presented after 2 years 4 months with acute pericoronitis. The restorative material was in good clinical condition with little marginal deteriora-
tion. The tooth responded normally to sensitivity tests. A radiograph showed normal periapical conditions. (f) The patient decided to have the tooth extracted. Restorative
materials were removed after extraction and a hard tissue barrier was present in the previous exposure site. (g) The tooth was processed histologically. Sections were
taken on a mesiodistal plane passing through the exposure site. An irregular barrier is present covering the defect (H&E stain; original magnification ×25). (h) Detail of
the calcified tissue in (g). The calcified barrier shows tunnel defects containing necrotic tissue (open arrowheads). These spaces provide pathways for bacterial leakage.
The calcified tissue mass does not resemble dentin in that it does not have dentinal tubules. In addition, no odontoblasts are seen underlying the calcified tissue while
they form a normal layer on the adjacent mesial root canal wall. The pulp tissue beneath the barrier is uninflamed (H&E stain; original magnification ×100). (Reproduced
and modified from Ricucci40 with permission.)
od of 90 days. Thus, dentin bridges may continue mating the exposure site and create an impen-
to form over time, and most pulps survive despite etrable hybrid layer that prevents subsequent
the presence of a porous dentin bridge21 (Fig 13-10). microleakage when followed by placement of a
However, incomplete dentin bridges may occasion- permanent restoration.

ally result in the breach of the physiologic seal, bac- This theory is no longer acceptable in light of
terial ingress, formation of microabscesses, and per- more recent findings on the adverse effects of direct
sistent inflammation adjacent to the exposed part of resin pulp capping. Rather, the results of preliminary
the dentin bridge (Fig 13-11). studies have indicated that the application of adhe-
Additional studies have shown that exposed sive systems in direct contact with healthy pulp tis-
pulps survive even in the absence of dentin bridg- sues does not result in the expression of proteins or
es. The theory is that acid etching and bonding signals that are essential for pulp repair,41 that is, sig-
techniques adequately seal the exposure sites from naling molecules that replace the original ectomes-
bacterial invasion so that the inflammatory pulpal enchymal signals necessary for inducing odontogen-
response to bacteria or their by-products does not esis (see chapter 2). For example, MTA also provides
occur, obviating the need for a dentin bridge. This a good seal but produces dentin bridges,42 probably
theory is based on the observation that the newer due to its ability to dissolve bioactive dentin matrix
dentin bonding agents can prevent recontamina- components43 and the activation of transcription fac-
tion of the exposed pulpal surface by forming a seal tors44 (see chapter 1) that act as signaling molecules
that protects against bacterial invasion. The bonding for pulp repair.
agent will penetrate the dentinal tubules approxi-
307
a b c d
e f g h
Fig 13-11 Molar of a 32-year-old man who presented with pain on mastication, lingering sensitivity to cold stimuli, and episodes of spontaneous pain. (a) A radio-
graph showed deep occlusal caries approximating the mesial pulp horns. (b) Caries excavation resulted in exposure of the mesiolingual pulp horn. Pulp capping was
performed with Ca(OH)2 powder followed by Dycal. The cavity was restored with IRM, and the patient was asked to return after 3 months. (c) The patient presented after
7 months because of severe, spontaneous pain. The radiograph did not show periapical changes. (d) A decision was made to examine the cavity floor. After removal of all
the restorative materials, calcified tissue was seen at the site of the previous exposure, but a sharp probe could penetrate into the subjacent pulp. Probing did not provoke
bleeding. The patient did not accept any further treatment and requested extraction. (e) Histologic section passing through the exposure site. The overview confirms the
incompleteness of the calcified barrier and an abscess in the mesial pulp horn (H&E stain; original magnification ×16). (f) Proximal section. Note the transition between
the abscess and the relatively normal pulp tissue (Taylor’s modified Brown & Brenn stain; original magnification ×16). (g) Higher magnification of the area from the
mesial wall indicated by the arrowhead in (f). Bacteria are present within the dentinal tubules (Taylor’s modified Brown & Brenn stain; original magnification ×1,000).
(h) Higher magnification from the inflamed area under the perforation showing the cellular aspect of acute inflammation. The lumen of a vessel is congested with eryth-
rocytes and polymorphonuclear leukocytes. An elongated inflammatory cell is visible; its cytoplasm adheres to the vessel wall in the process of transmigration through
the endothelial cell or cell junction. Outside the vessel, the cytoplasm of a cell is filled with phagocytosed foreign bodies that appear to be bacterial fragments (arrows)
(Taylor’s modified Brown & Brenn stain; original magnification ×1,000). (Modified from Ricucci40 with permission.)
Calcium hydroxide treatment tive characteristic has triggered efforts to find a for-
mula that can stimulate reparative dentin bridging

From a historical perspective, the introduction of without inducing this caustic effect.
Ca(OH)2 products played an important role in the Numerous studies have shown that Ca(OH)2 is
development of vital pulp therapy. The first materials capable of promoting the formation of reparative
to show promise as pulp capping agents were den- dentin at the junction between the caustic zone
tin chips and pastes utilizing Ca(OH)2.45–47 Numerous and vital tissue in human subjects. 53,54 The caus-
later studies have demonstrated dentin bridge for- tic actions of the high-pH formulations of Ca(OH)2
mation in 50% to 87% of teeth treated with various reduce the size of the subjacent dental pulp by up to
Ca(OH) 2 formulations. 11,48–52 However, despite its 0.7 mm; the thickness of the resulting dentin bridge
long history, the use of Ca(OH)2 in vital pulp therapy also reduces the pulp size.55 In contrast, the low-pH
remains controversial. formulations of Ca(OH)2 have only a minor effect
Part of this controversy concerns the caustic because only the thickness of the dentin bridge
actions of Ca(OH)2. When applied to dental pulp in reduces the bulk of the remaining vital pulp tissue.56
the pure state, rather than functioning merely as a One advantage of Ca(OH)2 is its antimicrobial
biologic dressing, Ca(OH)2 actually destroys a cer- characteristics. Classic studies have demonstrat-
tain amount of pulp tissue. Because Ca(OH)2 is also ed that bacteria represent the primary etiologic
extremely toxic to cells in tissue culture, this destruc- agent of pulpal necrosis6,10 (see Figs 13-1 to 13-4),
308
a b c d
Fig 13-12 Mixed pulpal response to Dycal capping after 3 months of observation. (a) A distal macrophotographic view of the mesial half of a maxillary right third
molar shows the remnants of the restorative and capping material (CP) as a white plug in the cavity preparation and pulp chamber. (b) This photomicrograph is a seg-
ment of a histologic section of the specimen in (a). Note the cavity opening into the pulp chamber and remnants of the capping material (CP). (c) Higher magnification of
the rectangular area demarcated in (b). The distinct but incomplete hard tissue bridge (BR) reveals gaps on either side. (d) Higher magnification of the rectangular area
demarcated in (c). An infiltrate of chronic inflammatory cells (IC) is visible in the gap (periodic acid–Schiff and methylene blue–azure II stains; original magnification ×6,
×18, ×46, and ×120, respectively). (Reproduced from Nair et al63 with permission.)
suggesting that antimicrobial properties may con- complete bridging and increasing thickness over
fer therapeutic advantages. In one study, canine longer posttreatment periods. Cross sections of
pulps were exposed to Streptococcus sanguinis pulps treated for more than 6 weeks demonstrated
for 2 days prior to placement of Ca(OH)2; none- a superior amorphous layer of tissue debris and
theless, thick dentin bridges formed 10 weeks Ca(OH)2, a middle layer of a coarse meshwork of
later.49 In a primate study with a 1- to 2-year fol- fibers identified as fibrodentin, and an inner layer
low-up, Ca(OH) 2 -induced dentin bridge forma- showing tubular osteodentin. In a later study using
tion occurred in 78 (85%) of 91 exposed and con- microradiographic techniques, the same three lay-
taminated dental pulps, while 10% of the pulps ers in the dentin bridge were observed; the middle
in the study sample became necrotic. 52 Well- tubular layer exhibited the highest mineral content.61
controlled clinical trials evaluating this effect are Another study comparing the hard tissue barrier
usually not possible because it would be necessary formed following short-term applications of either
to contaminate the pulps of human subjects. cyanoacrylate or Ca(OH)2 in pulpotomized monkey
Another advantage of Ca(OH)2 is its ability to teeth showed that Ca(OH)2 increased the incidence
extract, from mineralized dentin, “fossilized” growth of a continuous dentin barrier below the level of the
factors and bioactive dentin matrix components original wound. The condition of the pulp was nega-
that induce dentin regeneration at the site of pulpal tively affected by the presence of bacteria and posi-
exposure.57 More recently, it has been shown that tively influenced by high continuity of the hard tis-
calcium ions released from Ca(OH)2 stimulate fibro- sue, and results suggested that low-grade irritation
nectin synthesis by dental pulp cells, which in turn was responsible for hard tissue barrier formation.62
may induce the differentiation of pulp progenitor However, other studies have reported porosity in
cells into mineralized tissue-producing phenotypes.58 Ca(OH)2-induced dentin bridges, and the term tun-
Other studies have evaluated the ultrastructure neling has been used to describe incomplete dentin
of Ca(OH)2-induced dentin bridges to determine bridge formation (Fig 13-12). A summary of several
whether the structure was permeable and yet still primate studies involving direct pulp capping with
provided satisfactory pulpal protection.59 Scanning Ca(OH)2 reported a number of inflamed and infected
electron microscopy was employed to evaluate den- pulps after a follow-up period of 1 to 2 years.64 The
tin bridges formed 4 to 15 weeks after pulp capping authors proposed that these findings resulted from
of deliberately exposed human premolars and third deterioration of the overlying restorations and subse-
molars (teeth scheduled for removal for orthodontic quent migration of microorganisms through tunnels
reasons) with a Ca(OH)2 paste.60 Results suggested within the dentin bridges. Of 192 dentin bridges in
309
primate teeth, 172 (90%) contained tunnel defects. to unravel the molecular biologic responses of pulp
The authors also questioned the long-term efficacy of cells and their responses to injury and pulp thera-
commercially available Ca(OH)2 bases, particularly in py. This approach holds great promise, but no clear
light of the potential for microleakage.64 guidelines have been developed at this point because
of the complexities involved. Semiquantitative reverse
transcription polymerase chain reaction analysis con-

firmed that markers preferentially expressed in odon-
Molecular Responses to toblasts, namely dentin sialophosphoprotein (DSPP)
Pulpal Exposure and nestin, amplified more readily from the extract-
ed pulp-odontoblast complex than from pulp tissue
alone. In addition, analysis characterizing the expres-
Vital pulp therapy attempts to maintain pulpal vital- sion of members of the transforming growth factor
ity and function and restore normal tissue architec- (TGF) and bone morphogenetic protein (BMP) fami-
ture subsequent to the pulp capping procedure.65 lies and their receptors indicated that these genes,
For a successful outcome, the healing response which were expressed by healthy odontoblasts, were
must have the following three characteristics: (1) upregulated in both pulpal cells and odontoblasts
rapid formation of hard tissue to protect the pulp in response to pulpal injury.69 Certain inflammatory
from other stimuli (oral bacteria); (2) formation of a and antimicrobial peptides produced by neutrophils,
barrier that prevents secondary pulp infections; and such as macrophage inflammatory protein-3α and
(3) induction of hard tissue formation at the pulp- β-defensin-2, have the ability to stimulate odontoblast
material interface, not within the pulp itself, to avoid differentiation via upregulation of DSPP gene expres-
obliteration of the pulp. These characteristics repre- sion.70
sent the desirable healing process that should occur The pulp contains progenitor cells that can dif-
when any substance is applied directly to the pulpal ferentiate into odontoblast-like cells in the event the
exposure site that is capable of stimulating dentino- original odontoblasts are so severely injured that
genesis.66 they undergo necrosis. Recombinant human BMP-2
Despite the successful use of Ca(OH)2 as a pulp promoted the differentiation of human pulp cells into
capping agent for 60 years,7 predictable outcomes odontoblasts71 but did not affect cell proliferation. A
remain a problem. For example, a retrospective study study aimed at identification of the changes in gene-
that examined Ca(OH)2 pulp capping of carious expo- expression profiles in the dental pulp under caries
sures in 123 teeth revealed that 45% failed in the lesions identified 445 genes with twofold or greater
5-year group and 80% failed in the 10-year group.67 differences in expression levels; 85 genes were more
In that study, the placement of a definitive restora- abundant in healthy pulp tissue, while 360 were more
tion within the first 2 days after pulpal exposure was abundant in diseased tissue. Real-time polymerase
found to contribute significantly to the survival rate chain reaction analyses of adrenomedullin and den-
of those teeth. A more recent study that examined tin matrix protein 1 showed increased expression of
the treatment outcomes of 248 teeth that had under- adrenomedullin in neutrophils activated by bacterial
gone direct pulp capping with Ca(OH)2 for 0.4 to 16.6 products, while dentin matrix protein 1 was expressed
years showed that the overall survival rate was 76.5% by cells in healthy pulp tissue.72
after 1.3 years.68 In that study, the pulps of 60-year-old Evolutionarily conserved pathways such as Notch
patients showed a less favorable outcome than did signaling control the developmental fate of multipo-
the pulps of patients younger than 40 years. Also, the tent stem cells into functional cell types (see chapter
likelihood that a tooth would become nonvital after 1). In a study of adult rats, in situ hybridization of
direct pulp capping was higher within the first 5 years exposed maxillary first molars that were pulp capped
after treatment than it was more than 5 years after with Ca(OH)2 revealed an increased expression of
treatment. Notch 1 signaling genes on day 1 that decreased on
Apart from the contribution of microbial leakage to day 3. Notch 2 expression increased in areas of tis-
the failure of direct pulp capping, another important sue surrounding coronal odontoblasts, while Notch
issue is likely to be the lack of appropriate stimulating 3 expression increased in areas of perivascular cells.
factors for dentin formation. Researchers have begun These results indicated that Notch signaling is acti-
310
Comparison of Ca(OH)2 and Other Materials for Vital Pulp Therapy
vated in the dental pulp in response to injury and is availability of materials, medicaments, and delivery
associated with differentiation of pulpal stem cells techniques, perhaps applied based on a controlled-
into perivascular cells and odontoblast-like cells.73 release approach, that will ultimately address the
Apoptosis (programmed cell death) is associ- clinical problem of pulpal exposure (see chapter 2).
ated with wound healing and regeneration of tis-
sue. Examination of the effects of heat stress on

a clonal dental pulp cell line (RPC-C2A cells) was
carried out by exposing the cells to heat stress of Comparison of Ca(OH)2 and
43°C for 45 minutes. Apoptosis was induced in some
cells, but other cells remained alive and acted as
Other Materials for Vital Pulp
scavenger-like cells and engulfed apoptotic cells.74 Therapy
This suggests a possible pathway for partial healing
of pulpal wounds created by heat generated dur-
ing cavity preparations. In another study, primary Studies utilizing Ca(OH)2 as the sole pulp capping
pulp cells and dental pulp stem cells were cultivated agent appear to be of little interest to investiga-
and exposed to heat shock between 37°C and 45°C tors today, leading to newer studies comparing it
for 5- to 10-second durations. Thermal stimulations to other materials. Researchers have investigated
enhanced leukotriene B4 (LTB4) synthesis for both the concept that the pulp capping agent itself can
cell cultures at all temperatures.75 The arachidon- serve as the equivalent of a reparative dentin bridge,
ic acid mediator LTB4 has the capacity to induce thereby reducing the loss of remaining vital pulp
inflammatory reactions and sensitize nociceptive tissue.56 This theory has been previously tested with
nerve endings (see chapter 11). The study demon- dentin chips,23 synthetic hydroxyapatite,77,78 and Bio-
strated that pulp cells have the capability to synthe- glass (US Biomaterials).79,80 The results of these ear-
size LTB4 in response to minor temperature changes lier studies, in general, indicated that the tested
and that the generation of this inflammatory media- materials demonstrated limited pulp repair. Healing
tor may inhibit wound healing after cavity prepara- was consistently hampered by continuing inflam-
tions and pulpal exposures. matory responses with little, if any, tertiary dentin
Extracellular matrix proteins such as fibronectin formation. Conversely, the Ca(OH)2 control groups
and tenascin are important for cell adhesion dur- demonstrated formation of tertiary dentin without
ing the early stages of wound healing. Ca(OH)2 was significant inflammatory responses.
placed over intentional exposures in third molars and Many studies, beginning in the mid-1990s, have
covered with zinc oxide–eugenol cement. Teeth were involved the use of glass ionomers (GIs) and dentin
removed at times between 1 and 30 days. Immuno- adhesives as direct pulp capping agents. In general,
histochemical analysis showed increased expression results support the following statements:
of both glycoproteins, indicating their role in the heal-

ing of dental pulpal exposures.76 • B oth systems may work well when there is no
Although the information presented by the pulpal exposure and there is at least a minimum
aforementioned studies appears disconnected, the amount of remaining dentinal thickness.
results serve to illustrate the complexity of the pro- • In direct exposures, results remain controversial at
cesses involved in pulpal wound healing and repair this time.
at the gene-expression and protein-transcription • If there is bacterial microleakage, vital pulp thera-
levels following pulpal exposure and direct pulp py will fail, whereas Ca(OH)2 is sufficiently bacteri-
capping. Much more work will be required to under- cidal and usually leads to dentin bridge formation.
stand these molecular events before they can be
incorporated into predictable pulp therapy tech- More recently, there has also been great interest
niques for restoring the dental pulp to its prein- in the use of MTA for direct pulp capping and vital
jury form and function. Nevertheless, with the recent pulp therapy. These newer materials are reviewed in
advances in molecular biology and pulpal regen- the following sections.
eration research, it is possible to envision the future
311
Fig 13-13 Histo- Fig 13-14 Histologic section of a

logic section of a non- nonhuman primate pulpal exposure that
human primate expo- was treated with 5% NaOCl for 30 sec-
sure that was capped onds to remove operative debris and
directly with Resino- control hemorrhage. The exposure was
mer for 27 days. A new capped with resin for 7 days. No clot,
(pink-stained) dentin coagulum, or operative debris is present.
bridge is seen directly The pulp has migrated to the clear inter-
at the material interface on the left, which was previously
face. New odontoblas- filled with resin. There is only a minimal
toid cells are located presence of inflammatory cells. Odonto-
along thicker portions blasts are present along the remaining
of the new dentin. Some operative debris chips remain in the lower left of the dentin, and a very thin zone of reaction-
pulp. A thin, light, pink-stained mass of reparative dentin (mid-right) is seen at ary dentin has formed (H&E stain; origi-
the pulp-dentin interface of the cavity wall. The deeper pulp is normal with no nal magnification ×50). (Courtesy of Dr
resin particles. No Ca(OH)2 was employed in this procedure (H&E stain; original Charlie Cox, Birmingham, AL.)
magnification ×125). (Courtesy of Dr Charlie Cox, Birmingham, AL.)
Resin-modified glass ionomers erate to intense inflammatory pulpal responses,

including large necrotic zones, lack of dentin bridge
Pulpal responses to indirect pulp capping of deep formation, and impaired healing.88 Thus, RMGIs do
dentin and caries lesions with GIs and resin-modified not appear to be appropriate materials for direct
glass ionomers (RMGIs) are covered in chapter 14. pulp capping in human teeth.
RMGIs have been used as definitive restorative
materials to decrease microleakage because of their
capacity to bond to the tooth structure81 and their Dentin adhesives
antimicrobial effects.82
Although they have been successful as indirect A number of usage and clinical studies in the late
pulp capping agents even in cavities with minimal 1990s and early 2000s have reported that exposed
remaining dentinal thickness, 83,84 the histopatho- nonhuman and human dental pulps and periradicu-
logic responses to RMGIs as direct pulp capping lar tissues will heal when capped with etch-and-rinse
agents remain controversial because there are very dentin adhesives89–92 (Figs 13-13 and 13-14). Most of
few human clinical studies available that involve the adhesive usage studies from that era reported
the application of GI systems directly to exposed a lack of bacterial staining along the cavity walls or
pulps.85 An earlier primate study that involved the within the pulp at long-term intervals. These results
placement of an RMGI as a direct pulp capping were confirmed in a subsequent long-term primate
material failed to demonstrate any sign of dentin study showing that direct pulp capping with dentin
bridge formation.86 A subsequent long-term primate adhesives achieved significantly better results than
study showed that the use of an RMGI (Vitrebond, did the use of Ca(OH) 2 as a direct pulp capping
3M ESPE) as a direct pulp capping agent for more agent. 87 The collective biologic assessment sug-
than 2 years resulted not only in dentin bridge for- gested that most adhesives are biologically com-
mation but also in less bacterial leakage, fewer tun- patible when placed directly on exposed vital pulp
nel defects within dentin bridges, and less pulpal tissue and are comparable to or even better than
inflammation than did the use of Ca(OH)2 as a pulp Ca(OH)2 controls.
capping agent.87 Opposing results, however, were demonstrated
Contrary to these favorable responses reported in other studies. The pulp horns of 51 sound human
with the use of RMGIs in primates, poor responses premolars were gently exposed (exposures irrigated
have been reported in human teeth. Human teeth with sterile saline) and capped with either an adhesive
with intentional mechanical exposures that were resin or Ca(OH)2.93 In the short term, the adhesive-
capped with Vitrebond were found to exhibit mod- treated teeth exhibited dilated, congested vessels
312
with a moderate inflammatory response that includ-

ed blanching of pulp cell nuclei. Long-term results
revealed no evidence of healing or dentin bridge
formation and the presence of a persistent inflam-
matory response; microabscesses were associated
with bacterial infiltration (Fig 13-15). With time, mac-

rophages and giant cells engulfed resinous materials
that had been displaced into the pulp space. Con-
versely, pulps capped with Ca(OH)2 showed an initial
organization of elongated pulp cells beneath coagu-
lation necrosis, eventual pulp repair, and complete
dentin bridging. a b
Other studies indicate that adhesives allow
Fig 13-15 Unlike nonhuman primate exposures, mechanical exposures per-
greater bacterial penetration and cytotoxic effects
formed on noncarious human teeth have demonstrated unacceptable results fol-
than those observed with Ca(OH)294,95 and that light- lowing pulp capping with dentin adhesives. (a) A mechanical exposure that was
cured resins should be avoided for direct pulp cap- capped with Single Bond (3M ESPE) for 90 days reveals no sign of dentin bridge
ping.96 Adhesive systems placed in direct contact with formation; a persistent, moderately intense inflammatory infiltrate (asterisk); and
microabscess formation (open arrowheads) (Masson trichrome stain; original
mechanically exposed pulp in healthy dog teeth did magnification ×10). (b) Higher magnification shows congested blood vessels
not lead to acceptable repair.96 Compared with dentin (arrow) in the inflamed part of the pulp and delayed healing of the adjacent
adhesives, Ca(OH)2 remains the agent of choice for pulp tissues (Masson trichrome stain; original magnification ×20).
mechanically exposed human dental pulp.97 Similar
conclusions have been reached about the use of the
recently available self-etching adhesive systems for
direct pulp capping. Intense, unresolved inflammatory
responses and minimal pulp tissue repair were unani- materials. However, delayed healing is frequently
mously reported in those studies.98–101 observed even after the creation of an intact resinous
Furthermore, many of the resin components seal over the exposed pulp. Recent studies have fur-
employed in etch-and-rinse and self-etching dentin ther indicated that this resinous seal is not as durable
adhesives are vasorelaxants.102–104 These resin com- as it was previously conjectured105 and that the resin-
ponents promote bleeding and impair healing when dentin bonds degrade over time (see chapter 14).
placed directly on exposed pulps after hemosta-
sis has been successfully achieved with hemostatic
agents. The accompanying plasma extravasation may Mineral trioxide aggregate
also compromise polymerization of the dentin adhe-
sives, resulting in increased cytotoxicity to the dental While Ca(OH)2 has been the material of choice in
pulp. deep cavities and exposed pulps, MTA, a more
It is apparent from the more recently available recently developed Portland cement–based material,
data that dentin adhesives are unacceptable and has gained great popularity. This material was first
contraindicated as direct pulp capping agents. The suggested as the material of choice for correcting
critical issue that argues against the use of adhesive procedural errors (canal system perforations and
resin pulp capping procedures is not the presence apical root stripping) that occurred during cleaning
or absence of a hard tissue barrier but the persis- and shaping procedures in endodontic therapy. The
tence of fairly intense inflammation and foreign material is often used in apicoectomy procedures
body reactions that frequently accompany the appli- as a root end filling material. In both instances, the
cation of such procedures. material has been shown to be tissue compatible,
The necessity of a physiologic hard tissue barrier is encouraging the formation of new cementum-like
debatable because it is not totally impervious to bac- hard tissue with restoration of the periodontal liga-
terial invasion in the presence of tunnel defects.64,83 ment, and is considered to have significant osteo-
This physiologic barrier may well be replaced by a genic potential.
synthetic, noncytotoxic hard barrier in the event that MTA has now taken its place with Ca(OH)2 as a
an intact, durable seal is established with resinous material of choice in direct pulp capping procedures,
313
and investigations into its ability to act in a manner amalgam or stainless steel crowns and assessed
compatible with formation of dentin bridges and radiographically and clinically over a 24-month
retention of pulpal vitality have been encouraging, period.110 Twenty-two teeth showed no radiographic
especially in the area of dentinogenesis. MTA has sign of disease and responded to clinical vitality test-
been compared to bioactive glass, ferric sulfate, and ing. The remainder did not respond to testing but
formocresol as a pulpotomy agent in rats.106 After 80 appeared normal radiographically. Again, proper
rat maxillary first molars were exposed, pulpotomies controls were omitted in this study.
were performed and capped with one of the materi- White ProRoot MTA (Dentstply Tulsa Dental) was
als. Histologic sections after 2 weeks showed that compared to hard-setting Ca(OH)2 (Dycal) for capping
some MTA specimens displayed acute inflammatory procedures (n = 24 for each group). A light-cured
responses with evidence of macrophages in the radic- copolymer was placed over the pulp capping mate-
ular pulp. Dentin bridge formation and normal pulp rial, and a resin composite adhesive was used to
biology was a finding at both 2 weeks and 4 weeks. restore the teeth.111 The teeth were removed at 7, 30,
Ferric sulfate resulted in moderate pulpal inflamma- or 136 days and evaluated histologically. Findings at
tion with widespread coronal necrosis. Formocresol 136 days showed that 20 teeth capped with MTA and
resulted in zones of atrophy, inflammation, and fibro- 18 teeth capped with Ca(OH)2 had developed a den-
sis, and there was evidence of calcification in some tin bridge. No significant differences were found for
samples. Bioactive glass induced inflammation at 2 superficial or deep inflammatory cellular responses at
weeks, but it was resolved at 4 weeks. any of the time periods. Another study compared the
MTA was compared with Ca(OH)2 in young per- same two materials, again using young permanent
manent teeth undergoing apexogenesis (coronal first molars. MTA and Ca(OH)2 were judged to have
pulpotomy, retention of root system vital pulp tissue, comparable success rates.112
and immature root formation).107 Two of 14 teeth in A more recent randomized clinical trial com-
the Ca(OH)2 group failed because of pain and swell- pared the pulpal responses to iatrogenic pulpoto-
ing, while all in the MTA group appeared to be suc- my performed in healthy human teeth using MTA
cessfully treated. Calcific metamorphosis (mineral- or Dycal.63 Pulpal wounds treated with MTA were
ized tissue extension from the exposure site into the mostly free from inflammation after 1 week (Fig
body of the pulp) was a radiographic finding in two 13-16) and became covered with a compact hard tis-
teeth treated with Ca(OH)2 and four teeth treated sue barrier within 3 months following capping (Fig
with MTA. When MTA and Ca(OH)2 were compared 13-17). The control teeth treated with Dycal revealed
in direct pulp capping procedures in dog teeth,108 distinctly less consistent formation of a hard tissue
MTA presented a higher success rate than Ca(OH)2, barrier that had numerous tunnel defects. The pres-
with a lower occurrence of infection and pulpal ence of pulpal inflammation up to 3 months after
necrosis. No report was made concerning the loss of capping was identified as a common feature in the
provisional restorations in any of the test teeth. Dycal specimens (see Fig 13-12).
In some areas of the world, carious pulpal expo- A similar study performed on intentional-
sures of young permanent first molars are relatively ly exposed immature human permanent premo-
common, leading to the use of MTA in large popula- lars also showed that slightly better results were
tions of young patients. Thus, 30 young permanent achieved with white MTA than with Ca(OH) 2 in
asymptomatic first molars were pulp capped with regard to the number of teeth that demonstrated
MTA. The teeth were assessed clinically with pulpal definitive dentin bridge formation.113 In a random-
sensitivity testing and periodic radiographic obser- ized controlled prospective study, no differences
vation, but no apparent controls were used. At 24 were identified in the histologic responses to pulp
months, both the sensitivity and radiographic evalu- capping between two commercially available gray
ations showed a 93% success rate.109 MTA formulations, MTA-Angelus (Angelus Soluções
A similar study was conducted in 23 patients Odontológicas) and ProRoot MTA.114 Analysis indi-
with carious exposures in 31 permanent first molars cated that 94% of the human teeth capped with
in patients 7 to 13 years of age. Pulpotomies were MTA-Angelus and 88% of those capped with Pro-
performed, and MTA was placed against the wound Root MTA exhibited total or partial dentin bridge
and covered with a GI. The teeth were restored with formation. Collectively, the results of all these stud-
314
a b c d
Fig 13-16 Pulpal response to MTA capping after 1 week of observation. (a) Distal macrophotographic view of the cut face of the mesial half of a maxillary left third
molar with remnants of the restorative and capping (CP) material (white plug in the cavity preparation and pulp chamber). (b) This photomicrograph represents part of
a histologic section of the specimen in (a). Note the cavity opening into the pulp chamber, remnants of the capping material (CP), and healthy remaining pulp (PU). (c
and d) Higher magnifications of the rectangular areas demarcated in (b) and (c), respectively. The interface (arrowheads) of the pulp (PU) and cap (CP) shows fibrous
encapsulation. Note the absence of pulpal inflammation (periodic acid–Schiff and methylene blue–azure II stains; original magnification ×7, ×18, ×90, and ×220,
respectively). (Reproduced from Nair et al63 with permission.)
BR
PU
1 mm
a b 2 mm c
Fig 13-17 Pulpal response to MTA capping after

3 months of observation. (a) Distal macrophoto-
graphic view of the mesial half of a maxillary left
third molar shows the remnants of the restorative
and capping material (CP) and a distinct hard tissue
bridge (BR) across the exposed pulp (PU). (b and
c) These photomicrographs are part of a histologic
section of the specimen in (a). Note the mineral-
ized hard tissue barrier (BR) stretching across the
full length of the exposed pulp (PU). (d) Higher
magnification of the rectangular area demarcated in d 0.5 mm e 100 μm
(c). (e) Higher magnification of the rectangular area
demarcated in (d). Note the cuboidal pulpal cells (arrowheads) lining the bridge (BR) and the absence of pulpal inflammation (methylene blue–azure II stains; original
magnification ×6, ×8, ×23, and ×200, respectively). (Reproduced from Nair et al63 with permission.)
ies indicate that MTA is as successful as or even opmental processes in response to cellular signaling
more successful than Ca(OH)2 in vital pulp therapy mechanisms. These strategies involve selective acti-
procedures.115,116 vation of genes and other proteins that are neces-
sary in dentinogenesis and may allow translation of
findings from laboratory biomedical research into
Experimental bioactive molecule– clinical practice. Investigations of these bioactive
containing materials substances, while still in their infancy, include the
roles of stem cells and genetic recruitment. This
Ca(OH)2 causes inflammatory responses in pulp tis- section examines studies that have employed bioac-
sue that may induce dentin bridge formation and tive molecules in experimental direct pulp capping
pulpal healing if the restoration is sealed. Despite procedures. Understanding the fundamental mecha-
the controversial nature of this idea,117 the last sev- nisms of biomineralization is of broad biologic inter-
eral years have seen a change in thinking from est, and it is envisaged that such mechanisms will
attempting to induce pulp repair through irritation eventually be used clinically to effect pulp repair and
to the use of substances that mimic normal devel- healing.
315
To evaluate the effects of bioactive molecules in nerve growth factor released from the pulp. Tooth
pulpal wound healing, cavities were prepared and slices were immersed in either one of the two mol-
pulp tissues exposed in maxillary rat molars.118 Com- ecules and cultured at 4 and 7 days. Binding sites for
parisons were made between (1) dentin and preden- the two molecules were detected on odontoblasts,
tin shavings implanted in the pulpal exposure and suggesting that odontoblasts respond to factors
evaluated at 8, 14, and 28 days; (2) a carrier without expressed from dentin and pulp during tissue repair.
bioactive substances; (3) Ca(OH)2; (4) bone sialopro- During odontogenesis, amelogenins from pre-
tein (BSP); (5) different concentrations of BMP-7 and ameloblasts are translocated to differentiating odon-
osteogenic protein 1; and (6) N-acetyl cysteine, an toblasts in the dental papilla. The effect of enamel
antioxidant that prevents glutathione depletion. Of matrix derivative (eg, Emdogain gel in propylene-
the first four agents examined after 28 days, BSP was glycol alginate, Biora AB) on the healing of pulpal
the most efficient and induced homogenous and wounds was examined by placement of the mol-
well-mineralized reparative dentin. BMP-7 induced ecule through Class V preparations and pulpal expo-
formation of reparative osteodentin coronally and sures in premolars of miniature swine.123 Contralat-
homogenous mineralized structure in the root canal. eral teeth were used as controls, and all preparations
These findings indicate that the coronal and radicular were sealed with GI. At 2- and 4-week intervals,
parts of the pulp bear their own specificity. BSP and the teeth were harvested and subjected to histo-
BMP-7 were superior to Ca(OH)2, presenting larger logic analysis. The teeth treated with enamel matrix
areas of mineralization with fewer pulp tissue inclu- derivative displayed large amounts of newly formed
sions. The mineralization process appeared to take dentin-like tissue; associated formative cells outlined
place by mechanisms that involved recruitment of the pulpal wound and separated the wound area
cells that differentiated into osteoblasts, producing from the underlying pulp tissue. Inflammatory cells
a mineralized extracellular matrix. Reparative dentin were present in the exposure area but not subjacent
formation was also induced by N-acetyl cysteine. to the newly formed hard tissue. The amount of new
The results of this study have been far-reaching tissue was more than twice that found in Ca(OH)2-
in providing new avenues for direct pulp capping treated controls.
treatment. Nevertheless, a healthy pulp model was Porcine enamel matrix was found to weakly
employed in the study.118 This underestimated the enhance the formation of both reparative dentin and
potential difficulties encountered with the use of dentin bridges during wound healing of amputated
bioactive molecules for reparative dentinogenesis rat molar pulp.124 A 23–amino acid peptide derived
in inflamed dental pulps. Ferret dental pulps with from matrix extracellular phosphoglycoprotein, Den-
inflammation induced by the use of lipopolysac- tonin (Acologix), was used successfully to stimulate
charides responded differently to exogenous BMP-7 dental pulp stem cell proliferation and/or differentia-
and did not exhibit reparative dentinogenesis.119 tion.125 Dentonin primarily affects the initial cascade
Smith et al120 adopted a different approach by of events leading to pulpal healing.126

using growth factors based on the TGF-β family. However, application of bioactive molecules that
These bioactive molecules have been shown to is intended to stimulate repair of the exposed pulp
signal cellular events leading to reactionary and could result in eventual mineralization and occlu-
reparative tertiary dentinogenesis. They may be sion (closure) of the entire pulp canal system. 127
released during active caries or other pulpal injuries This event has been shown to occur with the use of
and through subsequent tooth preparation proce- BSP, BMP-7, Dentonin, and two small amelogenin
dures. Thus, this approach supports the regenera- gene splice products (A+4 and A–4). These splice
tive potential of inflamed pulps and has led to more variants cause proliferation and cell recruitment
biologic approaches to clinical treatment of dental toward an odonto-osteogenic phenotype. 128 The
disease. same researchers implanted the gene splice prod-
Smith121 reiterated his belief that growth factors ucts in the mucosa of the cheeks in mice. Immuno-
are key mediators in health and disease. Magloire et histochemical analysis at 3, 8, and 30 days revealed
al122 considered two major growth factors that may expression of osteochondrogenic markers.129
be implicated in the control of odontoblast activ- Goldberg et al130 summarized what is known and/
ity: TGF-β1 released from demineralized dentin and or assumed concerning the biologic mechanisms
316
Indirect Pulp Treatment
of bioactive molecule therapies. It is generally lesions may not be possible. A review of the events
believed that the repair of dental pulp by implanta- occurring during development of caries is necessary
tion of bioactive molecules implies a cascade of four to understand the histopathologic events involved in
steps: moderate inflammation, commitment of adult indirect pulp capping (see also chapter 14).
reserve stem cells, their proliferation, and their ter- In 1969, Keyes136 described three factors essential
minal differentiation.131,132 The link between the initial to the etiology of caries: (1) a susceptible host, (2)
inflammation and cell commitment is not yet well cariogenic microflora, and (3) a suitable substrate.
established but appears to be a potential key factor For caries to occur or progress, all factors must inter-
in the reparative process. Either the release of cyto- act simultaneously. It has been hypothesized that if
kines in response to inflammatory events activates the source of nutrition for the cariogenic bacteria
resident stem (progenitor) cells, or inflammatory could be eliminated, the organisms would die, thus
cells or pulp fibroblasts undergo a phenotypic con- arresting the caries process.
version into osteoblast/odontoblast–like progenitors Caries penetrates dentin at an average rate of
implicated in reparative dentin formation. Activation approximately 1 mm every 6 months.137 In untreated
of antigen-presenting dendritic cells by mild inflam- carious teeth, the relationship of bacterial penetra-
matory processes may also promote osteoblast/ tion to pulpal pathosis is quite predictable. The
odontoblast–like differentiation and expression of intensity of the pulpal response to bacterial penetra-
the bioactive molecules implicated in mineralization. tion of dentin is substantial, regardless of whether
Recognition of bacteria by toll-like odontoblast and the penetration is 3 mm or 1 mm from the pulp.
fibroblast membrane receptors (see also chapter However, when the bacterial penetration comes
11) triggers an inflammatory and immune response within 0.75 mm of the pulp or when the bacteria
within the pulp tissue that will also modulate the invade previously formed reparative dentin, the
repair process. degree of pulpal disease becomes extreme and,
In summary, dentin contains many peptides and most likely, irreversible. In other words, although the
signaling molecules within a mineralized matrix. practitioner cannot evaluate this measurement clini-
These molecules are released in response to pulpal cally, the pulp remains reasonably intact if there is at
injury.133 They include many of the same molecules least 0.75 mm of intact, bacteria-free dentin between
that are expressed during embryonic tooth develop- the caries lesion and the pulp.
ment and are again expressed in dental tissues in The reason for this abrupt change in the inten-
response to pathologic conditions.134 The pulpoden- sity of the response in the last millimeter is that
tin complex demonstrates great regenerative poten- before the bacteria reach the pulp, their by-products
tial in response to injury and contains a population (enzymes, toxins, and organic acids) can penetrate
of multipotent mesenchymal progenitor cells (dental the remaining tubular distance and cause pulpitis.
pulp stem cells) that can be recruited to produce In addition, the number of tubules per unit area and
new hard tissue. Therefore, these substances will the tubule diameter increase closer to the pulp,138
generate new, biologically based approaches to providing an easier path for penetration. If all of
pulpal healing.135 These approaches hold the prom- the caries is removed except for the last deep layer
ise of leading to more predictable solutions to the overlying some intact, relatively bacteria-free pri-
vexing and unpredictable problem of direct capping mary, secondary, or tertiary/reparative dentin, then
of the dental pulp. the bulk of the lactic acid–producing complex is
eliminated.
When the inflammation that previously prevented
the continual formation of tertiary dentin has been
Indirect Pulp Treatment eliminated, tertiary dentin can be formed by either
the reactionary mechanism (via surviving postmi-
totic odontoblasts) or the reparative mechanism
Although not a new concept, indirect pulp treatment (see chapter 2). The few persisting cariogenic organ-
continues to elicit a great deal of controversy. Many isms that may filter through the remaining dentin
clinicians believe that the pulp may be so diseased are phagocytosed by neutrophils in the rejuvenated
beneath caries lesions that resolution of established pulp tissues. The process has shifted from favoring
317
the caries lesion and a gradually dying pulp to one tion of bonds created by dentin adhesives in caries-
that favors the potential for complete resolution affected dentin.144
of the pulpal lesions, unless abscess formation has Another approach to caries control has gained
occurred. relatively wide acceptance in underdeveloped parts
In an indirect pulp treatment procedure, debride- of the world. In the atraumatic restorative technique,
ment of the carious layers in a manner that minimiz- severe caries is removed with hand instruments and
es mechanical trauma is the first step toward pulpal the cavity is restored with a GI restoration. Although
recovery. Application of zinc oxide–eugenol, which not technically an indirect pulp capping procedure,
is antibacterial and of low pulpal toxicity if there is the atraumatic restorative technique may accomplish
a layer of intact dentin, reduces the bacterial threat. the same objective. Clinical trials have shown the
Its ability to seal the tooth from further ingress of success of this method, particularly in large Class I
bacteria is an important property. Another argument restorations, which is comparable to or better than
for its use is the possibility that the partially decalci- the success rates for traditional restorative proce-
fied dentin would remineralize after bacteria are dures for periods up to several years.145–147 A study
deprived of a substrate, with a subsequent return to in older adults, in whom Class V preparations were
normal tissue pH.139 placed on root surfaces, found no differences in
An alternative method is to place resin compos- survival rates between conventional and atraumatic
ite systems directly on carious dentin or on pulp tis- restorative procedures at 12-month examinations.148
sue beneath deep cavity preparations, as previously A 10-year clinical trial compared the marginal
stated. The success of these materials depends on integrity of three types of restorative preparations:
two factors: (1) the ability of the pulp to respond to (1) a conventional Class I preparation extended for
materials put in contact with or in close proximity to prevention into noncarious fissures, with removal of
it and (2) the ability of the restorative material to seal all caries and placement of an amalgam restoration;
the interface between it and the preparation (hence (2) a more conservative preparation, with removal of
the terms total etch and total seal).105 Most reports all caries, restoration with amalgam, and use of pit
of successful total seal appear to be empirical and/ and fissure sealant; and (3) preparation of a 45- to
or anecdotal; therefore, more work is necessary to 60-degree bevel in the enamel surrounding a frankly
make valid determinations.18 Some studies137,140 sup- cavitated caries lesion; the deep soft portions of the
port the occurrence of at least some of these condi- caries remained untouched. The lesion extended
tions. no deeper than halfway into dentin between the
However, other studies have shown that resin- dentinoenamel junction and the pulp chamber, and
dentin bonds created in vivo are susceptible to resin-based composite was used.137 At the 10-year
degradation by endogenous, dentin matrix–bound follow-up period, open margins were found on 8%
matrix metalloproteinases (MMP-2, -3, -8 and -9) of the resin-based composite restorations, 9% of
that are activated during the application of mildly the sealed amalgam restorations, and 29% of the
acidic dentin adhesives.141,142 As complete infiltra- unsealed amalgam restorations. However, the most
tion of caries-affected dentin by both etch-and-rinse important result was that the caries lesions beneath
and self-etching adhesives has never been demon- the sealed resin-based composite restorations
strated, the loss of bond integrity caused by deg- ceased to progress. Not one pulp became nonvital
radation of resin-sparse, water-rich collagen fibrils in the 10-year study. These results have contributed
within the bonded caries-affected dentin jeopardizes to a new understanding of the caries process and
the long-term seal of the resin-dentin interface. the value of indirect pulp capping.
More recently, cysteine cathepsins have also been A review of the literature indicates that the major-
reported in intact dentin but were more abundantly ity of the most recent studies are dedicated to pre-
(approximately tenfold) identified from carious den- serving the primary dentition (and permanent first
tin.143 Similar to MMPs, cysteine cathepsins may be molars in preteenagers) and maintaining proper spac-
activated in mildly acidic environments. Acid activa- ing for the eventual loss of these teeth to their per-
tion of dentin-bound cathepsins may further result manent successors. Studies dedicated to the latter
in activation of matrix-bound MMPs. Taken together, were carried out, for the most part, in primary molars,
salivary MMPs, dentin matrix–bound MMPs, and which tended to be the last primary teeth lost.149,150
cysteine cathepsins may contribute to the degrada-
318
References
Stepwise excavation of caries lesions in the per- so that judgments can be made about the need
manent dentition involves initial removal of gross for direct and indirect pulp capping, pulpotomy or
caries and subsequent placement of a material that pulpectomy, diagnoses of reversible versus irrevers-
is used in an attempt to remineralize the remaining ible symptoms, and the presence of radiographic
caries lesion to prevent a direct carious pulpal expo- evidence of periradicular changes.
sure. At a later time (6 months to a year), the previ-

ously placed restoration and indirect capping mate-
rial are removed with the expectation of finding a
sterile, hard, mineralized tissue that can be left with Conclusion
the expectation that caries will not invade the coro-
nal pulp. When incomplete caries excavation was
performed in 32 teeth with deep caries lesions,151 To improve the success rate of vital pulp therapy, a
changes found on reentry were subjected to radio- concerted effort must be made on the part of pulp
graphic density assessments by digital image sub- biologists, dental researchers, and clinicians to recog-
traction. At reentry, the dentin was dry and hard in nize the progress that has been achieved in vital pulp
80% of the teeth, and there were statistically signifi- therapy and to incorporate the latest available infor-
cant increases in radiographic density. mation into practice and clinical training. A review of
However, in vitro studies of severely carious teeth the treatment techniques and other considerations
found that clinical observations of dentin color chang- associated with removing all caries (leading to an
es and increases in mineral in the remaining carious exposure) or retaining a layer of carious dentin (indi-
dentin do not always represent a change in the bac- rect procedures) presents the dilemma most clinicians
terial content.152 While the microbiologic bioburden face in deciding how to treat these lesions. Continued
may be reduced, it is still in place. These studies must research and clinical trials are needed to develop
be carried out over a longer time period to ensure the appropriate case selection guidelines, treatment
that remaining caries-causing microorganisms are not approaches, and materials needed to maximize clini-
present to cause further tooth breakdown. cal success. Significant advances in the understanding
Chlorhexidine has been suggested as a cavity of the molecular basis of the pulpal healing response
varnish. Compared with a 1% thymol–containing var- are currently underway and should lead to significant
nish and demeclocycline hydrocortisone ointment, new, biologically based pulp therapies.
chlorhexidine varnish was less effective in reducing
the total anaerobic microorganisms associated with
carious dentin.153 In another study, the antimicrobial
effect of chlorhexidine was more effective when it References
was combined with a GI.154
Collectively, these studies indicate that microbio-

logic bioloads are reduced during stepwise excava- 1. Rutherford B, Fitzgerald M. A new biological approach to vital pulp thera-
py. Crit Rev Oral Biol Med 1995;6:218–229.
tion procedures and the remaining carious dentin 2. Tziafas D, Smith AJ, Lesot H. Designing new treatment strategies in vital
becomes darker, harder, and drier, allowing for further pulp therapy. J Dent 2000;28:77–92.
3. Burke FM, Samarawickrama DY. Progressive changes in the pulpo-dentinal
removal of carious tooth structure if deemed neces- complex and their clinical consequences. Gerodontology 1995;12:57–66.
sary at a subsequent visit. The final excavation has 4. Gerabek WE. The tooth worm: Historical aspects of a popular medical
two aims: (1) to verify the arrest of the caries process belief. Clin Oral Investig 1999;3:1–6.
5. Tjäderhane L. The mechanism of pulpal wound healing. Aust Endod J
and (2) to remove a darker, harder dentin when nec- 2002;28:68–74.
essary.155 However, a meta-analysis recently conduct- 6. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of
ed for the Cochrane Database156 led to the following dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral
Med Oral Pathol 1965;20:340–349.
conclusions: First, there were too few studies that 7. Zander HA, Glass RL. The healing of phenolized pulp exposure. Oral Surg
could be included in the review because of the many Oral Med Oral Pathol 1949;2:803–810.
8. Masterton JB. Inherent healing potential of the dental pulp. Br Dent J
different variables found in the studies. Second, the
1966;120:430–436.
findings of the studies reviewed did not suggest 9. Torneck CD, Moe H, Howley TP. The effect of calcium hydroxide on porcine
that any significant changes should be made from pulp fibroblasts in vitro. J Endod 1983;9:131–136.
10. Kakehashi S, Stanley HR, Fitzgerald R. The exposed germ-free pulp: Effects
accepted conventional practice procedures. The of topical corticosteroid medication and restoration. Oral Surg Oral Med
reader is encouraged to review the entire report Oral Pathol 1969;27:60–67.
319
11. Cox CF, Bergenholtz G, Fitzgerald M, Heys DR, Avery JK, Baker JA. Capping 36. Accorinte Mde L, Loguercio AD, Reis A, Muench A, de Araújo VC. Response
of the dental pulp mechanically exposed to the oral microflora—A 5-week of human pulp capped with a bonding agent after bleeding control with
observation of wound healing in the monkey. J Oral Pathol 1982;11:327– hemostatic agents. Oper Dent 2005;30:147–155.
339. 37. Accorinte Mde L, Loguercio AD, Reis A, Holland R. Effects of hemostatic
12. Cvek M. A clinical report on partial pulpotomy and capping with calcium agents on the histomorphologic response of human dental pulp capped
hydroxide in permanent incisors with complicated crown fracture. J Endod with calcium hydroxide. Quintessence Int 2007;38:843–852.
1978;4:232–237. 38. Silva AF, Tarquinio SB, Demarco FF, Piva E, Rivero ER. The influence of hae-
13. Mejàre I, Cvek M. Partial pulpotomy in young permanent teeth with deep mostatic agents on healing of healthy human dental pulp tissue capped
carious lesions. Endod Dent Traumatol 1993;9:238–242. with calcium hydroxide. Int Endod J 2006;39:309–316.
14. Brännström M, Nyborg H. The presence of bacteria in cavities filled with 39. Stanley HR, Pameijer CH. Pulp capping with a new visible light-curing
silicate cement and composite resin materials. Sven Tandlak Tidskr 1971; calcium hydroxide composition (Prisma VLC Dycal). Oper Dent 1985;10:
64:149–155. 156–163.
15. Brännström M, Vojinovic O. Response of the dental pulp to invasion of bac- 40. Ricucci D. Patologia e Clinica Endodontica. Testo/Atlante. Bologna: Edizioni
teria around three filling materials. ASDC J Dent Child 1976;43:83–89. Martina, 2009.
16. Bergenholtz G, Cox CE, Loesche WJ, Syed SA. Bacterial leakage around 41. Fernandes AM, Silva GA, Lopes N Jr, Napimoga MH, Benatti BB, Alves JB.
dental restorations: Its effect on the dental pulp. J Oral Pathol 1982;11: Direct capping of human pulps with a dentin bonding system and calcium
439–450. hydroxide: An immunohistochemical analysis. Oral Surg Oral Med Oral
17. Stanley HA. The relationship of bacterial penetration and pulpal lesions. Pathol Oral Radiol Endod 2008;105:385–390.
In: Anusavice KJ (ed). Quality Evaluation of Dental Restorations: Criteria 42. Simon S, Cooper P, Smith A, Picard B, Ifi CN, Berdal A. Evaluation of a
for Placement and Replacement [Proceedings of the International Sympo- new laboratory model for pulp healing: Preliminary study. Int Endod J
sium on Criteria for Placement and Replacement of Dental Restorations, 2008;41:781–790.
19–21 October 1987, Lake Buena Vista, Florida]. Chicago: Quintessence, 43. Tomson PL, Grover LM, Lumley PJ, Sloan AJ, Smith AJ, Cooper PR. Dissolu-
1989:303–323. tion of bio-active dentine matrix components by mineral trioxide aggre-
18. Bergenholtz G. Evidence for bacterial causation of adverse pulpal respons- gate. J Dent 2007;35:636–642.
es in resin-based dental restorations. Crit Rev Oral Biol Med 2000;11: 44. Perinpanayagam H, Al-Rabeah E. Osteoblasts interact with MTA surfaces
467–480. and express Runx2. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
19. Costa CA, Hebling J, Hanks CT. Current status of pulp capping with dentin 2009;107:590–596.
adhesive systems: A review. Dent Mater 2000;16:188–197. 45. Hermann BW. Kalziumhydroxid als mittel zum behandeln und füllen von
20. Isermann GT, Kaminski EJ. Pulpal response to minimal exposure in pres- Zahnwurzelkanälen [thesis]. Würzburg, Germany: Würzburg University,
ence of bacteria and Dycal. J Endod 1979;5:322–327. 1920.
21. Cvek M, Cleaton-Jones PE, Austin JC, Andreasen JO. Pulp reactions to 46. Zander HA. Reaction of the pulp to calcium hydroxide. J Dent Res 1939;18:
exposure after experimental crown fractures or grinding in adult monkeys. 373–379.
J Endod 1982;8:391–397. 47. Glass RL, Zander HA. Pulp healing. J Dent Res 1949;28:97–107.
22. Bianco L, Cohen S. Treatment of crown fractures with exposed pulps. J Calif 48. Pitt Ford TR. Pulpal response to Procal for capping exposures in dog’s
Dent Assoc 2002;30:419–425. teeth. J Br Endod Soc 1979;12:67–72.
23. Obersztyn A, Jedrzejczyk J, Smiechowska W. Application of lyophilized den- 49. Pitt Ford TR. Pulpal response to a calcium hydroxide material for capping
tin chips, mixed with prednisolone and neomycin, on infected rat incisor exposures. Oral Surg Oral Med Oral Pathol 1985;59:194–197.
pulp. J Dent Res 1968;47:374–380. 50. Brännström M, Nyborg H, Strömberg T. Experiments with pulp capping.
24. Hørsted P, El Attar K, Langeland K. Capping of monkey pulps with Dycal Oral Surg Oral Med Oral Pathol 1979;48:347–352.
and a Ca-eugenol cement. Oral Surg Oral Med Oral Pathol 1981;52:531– 51. Heys DR, Cox CF, Heys RJ, Avery JK. Histological considerations of direct
553. pulp capping agents. J Dent Res 1981;60:1371–1379.
25. Kitasako Y, Shibata S, Pereira PN, Tagami J. Short-term dentin bridging of 52. Cox CF, Bergenholtz G, Heys DR, Syed SA, Fitzgerald M, Heys RJ. Pulp cap-
mechanically-exposed pulps capped with adhesive resin systems. Oper ping of dental pulp mechanically exposed to oral microflora: A 1-2 year
Dent 2000;25:155–162. observation of wound healing in the monkey. J Oral Pathol 1985;14:156–
26. Turner C, Courts FJ, Stanley HR. A histological comparison of direct pulp 168.
capping agents in primary canines. ASDC J Dent Child 1987;54:423–428. 53. Lu Y, Liu T, Li H, Pi G. Histological evaluation of direct pulp capping with
27. Segura JJ, Llamas R, Rubio-Manzanares AJ, Jimenez-Planas A, Guerrero a self-etching adhesive and calcium hydroxide on human pulp tissue. Int
JM, Calvo JR. Calcium hydroxide inhibits substrate adherence capacity of Endod J 2008;41:643–650.
macrophages. J Endod 1997;23:444–447. 54. Kiatwateeratana T, Kintarak S, Piwat S, Chankanka O, Kamaolmatyakul
28. Hebling J, Giro EM, Costa CA. Biocompatibility of an adhesive system S, Thearmontree A. Partial pulpotomy on caries-free teeth using enamel
applied to exposed human dental pulp. J Endod 1999;25:676–682. matrix derivative or calcium hydroxide: A randomized controlled trial. Int
29. Marzouk MA, Van Huysen G. Pulp exposure without hemorrhage. J Dent Endod J 2009;42:584–592.
Res 1966;45:405. 55. Heide S. The effect of pulp capping and pulpotomy on hard tissue bridges
30. Heys DR, Heys RJ, Cox CF, Avery JK. The response of four calcium hydrox- of contaminated pulps. Int Endod J 1991;24:126–134.
ides on monkey pulps. J Oral Pathol 1980;9:372–379. 56. Stanley HR. Criteria for standardizing and increasing credibility of direct
31. Heilig J, Yates J, Siskin M, McKnight J, Turner J. Calcium hydroxide pulpoto- pulp capping studies. Am J Dent 1998;11(special issue):S17–S34.
my for primary teeth: A clinical study. J Am Dent Assoc 1984;108:775–778. 57. Graham L, Cooper PR, Cassidy N, Nor JE, Sloan AJ, Smith AJ. The effect of
32. Mjör IA, Dahl E, Cox CF. Healing of pulp exposures: An ultrastructural study. calcium hydroxide on solubilisation of bio-active dentine matrix compo-
J Oral Pathol Med 1991;20:496–501. nents. Biomaterials 2006;27:2865–2873.
33. Chiego DJ Jr. An ultrastructural and autoradiographic analysis of primary 58. Mizuno M, Banzai Y. Calcium ion release from calcium hydroxide stimulat-
and replacement odontoblasts following cavity preparation and wound ed fibronectin gene expression in dental pulp cells and the differentiation
healing in the rat molar. Proc Finn Dent Soc 1992;88(suppl 1):243–256. of dental pulp cells to mineralized tissue forming cells by fibronectin. Int
34. Demir T, Cehreli ZC. Clinical and radiographic evaluation of adhesive pulp Endod J 2008;41:933–938.
capping in primary molars following hemostasis with 1.25% sodium hypo- 59. Holland R, de Souza V, de Mello W, Nery MJ, Bernabe PF, Otoboni Filho JA.
chlorite: 2-year results. Am J Dent 2007;20:182–188. Permeability of the hard tissue bridge formed after pulpotomy with calcium
35. Hafez AA, Cox CF, Tarim B, Otsuki M, Akimoto N. An in vivo evaluation of hydroxide: A histologic study. J Am Dent Assoc 1979;99:472–475.
hemorrhage control using sodium hypochlorite and direct capping with a 60. Franz FE, Holz J, Baume LJ. Ultrastructure (SEM) of dentine bridging in the
one- or two- component adhesive system in exposed nonhuman primate human dental pulp. J Biol Buccale 1984;12:239–246.
pulps. Quintessence Int 2002;33:261–272.
320
References
61. Franz FE, Holz J, Baume LJ. Microradiographic assessment of neodentinal 84. Costa CA, Giro EM, do Nascimento AB, Teixeira HM, Hebling J. Short-term
bridging following direct pulp capping in human teeth. J Endod 1985;11: evaluation of the pulpo-dentin complex response to a resin-modified glass-
6–10. ionomer cement and a bonding agent applied in deep cavities. Dent Mater
62. Cvek M, Granath L, Cleaton-Jones P, Austin J. Hard tissue barrier forma- 2003;19:739–746.
tion in pulpotomized monkey teeth capped with cyanoacrylate or calcium 85. Sidhu SK. Clinical evaluations of resin-modified glass-ionomer restorations.
hydroxide for 10 and 60 minutes. J Dent Res 1987;66:1166–1174. Dent Mater 2010;26:7–12.
63. Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural 86. Hafez AA, Kopel HM, Cox CF. Pulpotomy reconsidered: Application of an
and quantitative investigations on the response of healthy human pulps adhesive system to pulpotomized permanent primate pulps. Quintessence
to experimental capping with mineral trioxide aggregate: A randomized Int 2000;31:579–589.
controlled trial. Int Endod J 2008;41:128–150. 87. Murray PE, García-Godoy F. The incidence of pulp healing defects with
64. Cox CF, Sübay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in den- direct capping materials. Am J Dent 2006;19:171–177.
tin bridges: Their formation following direct pulp capping. Oper Dent 88. do Nascimento AB, Fontana UF, Teixeria HM, Costa CA. Biocompatibility of
1996;21:4–11. a resin-modified glass-ionomer cement applied as pulp capping in human
65. Rutherford RB, Wahle J, Tucker M, Rueger D, Charette M. Induction of teeth. Am J Dent 2000;13:28–34.
reparative dentine formation in monkeys by recombinant human osteo- 89. Otsuki M, Tagami J, Kanca J III, Akimoto N, Cox CF. Histologic evaluation of
genic protein-1. Arch Oral Biol 1993;38:571–576. two Bisco adhesive systems on exposed pulps. J Dent Res 1997;76:78.
66. Ziafras D, Belibasakis G, Veis A, Papadimitriou S. Dentin regeneration in 90. Olmez A, Oztaş N, Başak F, Sabuncuoğlu B. A histopathologic study of
vital pulp therapy: Design principles. Adv Dent Res 2001;15:96–100. direct pulp-capping with adhesive resins. Oral Surg Oral Med Oral Pathol
67. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping of carious Oral Radiol Endod 1998;86:98–103.
exposures: Treatment outcome after 5 and 10 years: A retrospective study. 91. Maeda H, Hashiguchi I, Nakamuta H, Toriya Y, Wada N, Akamine A. Histo-
J Endod 2000;26:525–528. logical study of periapical tissue healing in the rat molar after retrofilling
68. Dammaschke T, Leidinger J, Schäfer E. Long-term evaluation of direct pulp with various materials. J Endod 1999;25:38–42.
capping–treatment outcomes over an average period of 6.1 years. Clin 92. Kitasako Y, Inokishi S, Tagami J. Effects of direct resin pulp capping tech-
Oral Investig 2010;14:559–567. niques on short-term response of mechanically exposed pulps. J Dent
69. McLachlan JL, Smith AJ, Sloan AJ, Cooper PR. Gene expression analysis in 1999;27:257–263.
cells of the dentine-pulp complex in healthy and carious teeth. Arch Oral 93. Pereira JC, Segala AD, Costa CA. Human pulpal response to direct pulp
Biol 2003;48:273–283. capping with an adhesive system. Am J Dent 2000;13:139–147.
70. S hiba H, Mouri Y, Komatsuzawa H, et al. Macrophage inflammato- 94. Demarco FF, Tarquínio SB, Jaeger MM, de Araújo VC, Matson E. Pulp
ry protein-3α and β-defensin-2 stimulate dentin sialophosphoprotein response and cytotoxicity evaluation of two dentin bonding agents. Quin-
gene expression in human pulp cells. Biochem Biophys Res Commun tessence Int 2001;32:211–220.
2003;306:867–871. 95. Accorinte Mde L, Loguercio AD, Reis A, Muench A, de Araújo VC. Adverse
71. Saito T, Ogawa M, Hata Y, Bessho K. Acceleration effect of human recombi- effects of human pulps after direct pulp capping with the different
nant bone morphogenetic protein-2 on differentiation of human pulp cells components from a total-etch, three-step adhesive system. Dent Mater
into odontoblasts. J Endod 2004;30:205–208. 2005;21:599–607.
72. McLachlan JL, Smith AJ, Bujalska IJ, Cooper PR. Gene expression profiling 96. Koliniotou-Koumpia E, Tziafas D. Pulpal responses following direct pulp
of pulpal tissue reveals the molecular complexity of dental caries. Biochim capping of healthy dog teeth with dentine adhesive systems. J Dent
Biophys Acta 2005;741:271–281. 2005;33:639–647.
73. Løvschall H, Tummers M, Thesleff I, Füchtbauer EM, Poulsen K. Activation of 97. Silva GA, Lanza LD, Lopes-Júnior N, Moreira A, Alves JB. Direct pulp cap-
the Notch signaling pathway in response to pulp capping of rat molars. Eur ping with a dentin bonding system in human teeth: A clinical and histologi-
J Oral Sci 2005;113:312–317. cal evaluation. Oper Dent 2006;31:297–307.
74. Kitamura C, Nishihara T, Ueno Y, Nagayoshi M, Kasugai S, Terashita M. 98. de Souza Costa CA, Lopes do Nascimento AB, Teixeira HM, Fontana UF.
Thermotolerance of pulp cells and phagocytosis of apoptotic pulp cells by Response of human pulps capped with a self-etching adhesive system.
surviving pulp cells following heat stress. J Cell Biochem 2005;94:826– Dent Mater 2001;17:230–240.
834. 99. A ccorinte ML, Loguercio AD, Reis A, Costa CA. Response of human
75. Eberhard J, Zahl A, Dommisch H, Winter J, Acil Y, Jepsen S. Heat shock pulps capped with different self-etch adhesive systems. Clin Oral Investig
induces the synthesis of the inflammatory mediator leukotriene B 4 in 2008;12:119–127.
human pulp cells. Int Endod J 2005;38:882–888. 100. Cui C, Zhou X, Chen X, Fan M, Bian Z, Chen Z. The adverse effect of self-
76. Piva E, Tarquínio SB, Demarco FF, Silva AF, de Araújo VC. Immunohisto- etching adhesive systems on dental pulp after direct pulp capping. Quin-
chemical expression of fibronectin and tenascin after direct pulp capping tessence Int 2009;40:e26–e34.
with calcium hydroxide. Oral Surg Oral Med Pathol Oral Radiol Endod 101. da Silva LA, de Freitas AC, de Carvalho FK, de Queiroz AM, Nelson-Filho
2006;102:e66–e71. P, Porto-Neto ST. Direct pulp capping with a self-etching adhesive system:
77. Frank RM, Wiedemann P, Hemmerle J, Freymann M. Pulp capping with Histopathologic evaluation in dogs’ teeth. Oral Surg Oral Med Oral Pathol
synthetic hydroxyapatite in human premolars. J Appl Biomater 1991;2: Oral Radiol Endod 2009;108:e34–e40.
243–250. 102. Maddux WF, Abebe W, Schuster GS, Mozaffari MS. Effects of dental resin
78. Hayashi Y, Imai M, Yanagiguchi K, Viloria IL, Ikeda T. Hydroxyapatite applied components on vascular reactivity. J Biomed Mater Res 2002;61:572–580.
as direct pulp capping medicine substitutes for osteodentin. J Endod 103. Abebe W, Pashley DH, Rueggeberg FA. Vasorelaxant effect of resin-based,
1999;25:225–229. single-bottle dentin bonding systems. J Endod 2005;31:194–197.
79. Oguntebi BR, Clark A, Wilson J. Pulp capping with Bioglass and autologous 104. Başak F, Vural IM, Kaya E, et al. Vasorelaxant effect of a self-etch adhesive
demineralized dentin in miniature swine. J Dent Res 1993;72:484–489. system through calcium antagonistic action. J Endod 2008;34:1202–1206.
80. Stanley HR, Clark AE, Pameijer CH, Louw NP. Pulp capping with a modified 105. Bertolotti R. Total etch, total seal, total success. Dent Dimens 1990;23:
Bioglass formula (#A68-modified). Am J Dent 2001;14:227–232. 3–4,10–11.
81. Sidhu SK, Watson TF. Resin-modified glass ionomer materials. A status 106. Salako N, Joseph B, Ritwik P, Salonen J, John P, Junaid TA. Comparison of
report for the American Journal of Dentistry. Am J Dent 1995;8:59–67. bioactive glass, mineral trioxide aggregate, ferric sulfate, and formocresol
82. D uque C, Negrini Tde C, Hebling J, Spolidorio DM. Inhibitory activ- as pulpotomy agents in rat molar. Dent Traumatol 2003;19:314–320.
ity of glass-ionomer cements on cariogenic bacteria. Oper Dent 2005;30: 107. El-Meligy OA, Avery DR. Comparison of mineral trioxide aggregate and
636–640. calcium hydroxide as pulpotomy agents in young permanent teeth (apexo-
83. Murray PE, Windsor LJ, Smyth TW, Hafez AA, Cox CF. Analysis of pulpal genesis). Pediatr Dent 2006;28:399–404.
reactions to restorative procedures, materials, pulp capping, and future
therapies. Crit Rev Oral Biol Med 2002;13:509–520.
321
108. Briso AL, Rahal V, Mestrener SR, Dezan Junior E. Biological response 131. Goldberg M, Lacerda-Pinheiro S, Priam F, et al. Matricellular molecules and
of pulps submitted to different capping materials. Braz Oral Res odontoblast progenitors as tools for dentin repair and regeneration. Clin
2006;20:219–225. Oral Investig 2008;12:109–112.
109. Farsi N, Alamoudi N, Balto K, Al Mushayt A. Clinical assessment of mineral 132. Goldberg M, Farges JC, Lacerda-Pinheiro S, et al. Inflammatory and immu-
trioxide aggregate (MTA) as direct pulp capping in young permanent teeth. nological aspects of dental pulp repair. Pharmacol Res 2008;58:137–147.
Clin Pediatr Dent 2006;31:72–76. 133. Silva TA, Rosa AL, Lara VS. Dentin matrix proteins and soluble factors:
110. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study of mineral Intrinsic regulatory signals for healing and resorption of dental and peri-
trioxide aggregate for partial pulpotomy in cariously exposed permanent odontal tissues. Oral Dis 2004;10:63–74.
teeth. J Endod 2006;32:731–735. 134. About I, Mitsiadis TA. Molecular aspects of tooth pathogenesis and repair:
111. Iwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, Jefferies S. In vivo and in vitro models. Adv Dent Res 2001;15:59–62.
Clinical and histological evaluation of white ProRoot MTA in direct pulp 135. Sloan AJ, Smith AJ. Stem cells and the dental pulp: Potential roles in den-
capping. Am J Dent 2006;19:85–90. tine regeneration and repair. Oral Dis 2007;13:151–157.
112. Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium hydroxide vs min- 136. Keyes PH. Present and future measures for dental caries control. J Am Dent
eral trioxide aggregates for partial pulpotomy of permanent molars with Assoc 1969;79:1395–1404.
deep caries. Eur Arch Paediatr Dent 2007;8:99–104. 137. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM. Ultra-
113. Sawicki L, Pameijer CH, Emerich K, Adamowicz-Klepalska B. Histologi- conservative and cariostatic sealed restorations: Results at 10 years. J Am
cal evaluation of mineral trioxide aggregate and calcium hydroxide in Dent Assoc 1998;129:55–66.
direct pulp capping of human immature permanent teeth. Am J Dent 138. Marshall GW Jr, Marshall SJ, Kinney JH, Balooch M. The dentin substrate:
2008;21:262–266. Structure and properties related to bonding. J Dent 1997;25:441–458.
114. Accorinte ML, Loguercio AD, Reis A, et al. Evaluation of two mineral tri- 139. Cox CF, Hafez AA, Akimoto N, Otsuki M, Suzuki S, Tarim B. Biocompatibil-
oxide aggregate compounds as pulp-capping agents in human teeth. Int ity of primer, adhesive and resin composite systems on non-exposed and
Endod J 2009;42:122–128. exposed pulps on non-human primate teeth. Am J Dent 1998;11(special
115. Witherspoon DE. Vital pulp therapy with new materials: New direc- issue):S55–S63.
tions and treatment perspectives—Permanent teeth. J Endod 2008;34(7 140. Tarim B, Hafez AA, Cox CF. Pulpal response to a resin-modified glass-
suppl):S25–S28. ionomer material on nonexposed and exposed monkey pulps. Quintessence
116. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide Int 1998;29:535–542.
aggregate: An observational study. J Am Dent Assoc 2008;139:305–315. 141. Hebling J, Pashley DH, Tjäderhane L, Tay FR. Chlorhexidine arrests subclini-
117. Bergenholtz G. Advances since the paper by Zander and Glass (1949) on cal degradation of dentin hybrid layers in vivo. J Dent Res 2005;84:741–
the pursuit of healing methods for pulpal exposures: Historical perspec- 746.
tives. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100(2 142. Carrilho MR, Geraldeli S, Tay FR, et al. In vivo preservation of the hybrid
suppl):S102–S108. layer by chlorhexidine. J Dent Res 2007;86:529–533.
118. Goldberg M, Six N, Decup F, et al. Application of bioactive molecules in 143. Nascimento FD, Minciotti CL, Geraldeli S, et al. Cysteine cathepsins in
pulp-capping situations. Adv Dent Res 2001;15:91–95. human carious dentin. J Dent Res 2011;90:506–511.
119. Rutherford RB, Gu K. Treatment of inflamed ferret dental pulps with 144. Liu Y, Tjäderhane L, Breschi L, et al. Limitations in bonding to dentin
recombinant bone morphogenetic protein-7. Eur J Oral Sci 2000;108: and experimental strategies to prevent bond degradation. J Dent Res
202–206. 2011;90:953–968.
120. Smith AJ, Murray PE, Sloan AJ, Matthews JB, Zhao S. Trans-dentinal stimu- 145. Smales RJ, Fang DT. In vitro effectiveness of hand excavation of caries
lation of tertiary dentinogenesis. Adv Dent Res 2001;5:51–54. with the ART technique. Atraumatic restorative treatment. Caries Res
121. Smith AJ. Vitality of the dentin-pulp complex in health and disease: Growth 1999;33:437–40.
factors as key mediators. J Dent Educ 2003;67:678–689. 146. Smales RJ, Yip HK. The atraumatic restorative treatment (ART) approach for
122. Magloire H, Romeas A, Melin M, Couble ML, Bleicher F, Farges JC. Molecu- the management of dental caries. Quintessence Int 2002;33:427–32.
lar regulation of odontoblast activity under dentin injury. Adv Dent Res 147. Wang L, Lopes LG, Bresciani E, Lauris JR, Mondelli RF, Navarro MF. Evalu-
2001;15:46–50. ation of Class I ART restorations in Brazilian school children: Three-year
123. Nakamura Y, Hammarström L, Lundberg E, et al. Enamel matrix deriva- results. Spec Care Dentist 2004;24:28–33.
tive promotes reparative processes in the dental pulp. Adv Dent Res 148. Lo EC, Luo Y, Tan HP, Dyson JE, Corbett EF. ART and conventional root res-
2001;15:105–107. torations in elders after 12 months. J Dent Res 2007;85:929–932.
124. Igarashi R, Sahara T, Shimizu-Ishiura M, Sasaki T. Porcine enamel matrix 149. Marchi JJ, Froner AM, Alves HL, Bergmann CP, Araújo FB. Analysis of
derivative enhances the formation of reparative dentine and dentine primary tooth dentin after indirect pulp capping. J Dent Child (Chic)
bridges during wound healing of amputated rat molars. J Electron Microsc 2008;75:295–300.
(Tokyo) 2003;52:227–236. 150. Casagrande L, Falster CA, Di Hipolito V, et al. Effect of adhesive restora-
125. Liu H, Li W, Gao C, Kumagai Y, Blacher RW, DenBesten PK. Dentonin, a tions over incomplete dentin caries removal: 5-year follow-up study in
fragment of MEPE, enhanced dental pulp stem cell proliferation. J Dent Res primary teeth. J Dent Child (Chic) 2009;76:117–122.
2004;83:496–496 151. Maltz M, de Oliveira EF, Fontanella V, Bianchi R. A clinical, microbio-
126. Six N, Septier D, Chaussain-Miller C, Blacher R, DenBesten P, Goldberg M. logic, and radiographic study of deep caries lesions after incomplete caries
Dentonin, a MEPE fragment, initiates pulp-healing response to injury. J removal. Quintessence Int 2002;33:151–159.
Dent Res 2007;86:780–785. 152. Bönecker M, Toi C, Cleaton-Jones P. Mutans streptococci and lactobacilli
127. Goldberg M, Lacerda-Pinheiro S, Jegat N, et al. The impact of bioactive in carious dentin before and after atraumatic restorative treatment. J Dent
molecules to stimulate tooth repair and regeneration as part of restorative 2003;31:423–428.
dentistry. Dent Clin North Am 2006;50:277–298. 153. Wicht MJ, Haak R, Schütt-Gerowitt H, Kneist S, Noack MJ. Suppression of
128. Lacerda-Pinheiro S, Jegat N, Septier D, et al. Early in vivo and in vitro caries-related microorganisms in dentin lesions after short-term chlorhexi-
effects of amelogenin gene splice products on pulp cells. Eur J Oral Sci dine or antibiotic treatment. Caries Res 2004;38:436–441.
2006;114(suppl 1):232–238. 154. Frencken JE, Imazato S, Toi C, et al. Antibacterial effect of chlorhexi-
129. Lacerda-Pinheiro S, Septier D, Tompkins K, Veis A, Goldberg M, Chardin H. dine-containing glass ionomer cement in vivo: A pilot study. Caries Res
Amelogenin gene splice products A+4 and A-4 implanted in soft tissue 2007;41:102–107.
determine the reorientation of CD45-positive cells to an osteo-chondro- 155. Bjørnal L, Kidd EA. The treatment of deep dentine caries lesions. Dent
genic lineage. Biomed Mater Res A 2006;79:1015–1022. Update 2005;32:402–4,407–10,413.
130. Goldberg M, Six N, Decup F, et al. Bioactive molecules and the future of 156. Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp manage-
pulp therapy. Am J Dent 2003;16:66–76. ment for caries in adults: Maintaining pulp vitality. Cochrane Database Sys
Rev 2007;(2):CD004484.
322

13 Repair of Pulpal Lnjury With Dental Materials

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

13 Repair of Pulpal Lnjury With Dental Materials

Uploaded by

Copyright:

Available Formats

Chapter

Repair of Pulpal Injury

Harold E. Goodis, DDS

Fig 13-3 Dental pulp 7

nification ×340). (Reprinted

Fig 13-4 Dental pulp 32

cess in direct pulp capping procedures is not pre-

Factors That Influence the Presence of dentin chips

Fig 13-6 Emboli (E) of Ca(OH)2 Fig 13-7 Pulpal response to a

Fig 13-8 Example of a porous den- Fig 13-9 Example of a high-quality,

Ideally, clotting of the capillaries within the subjacent inadequate healing.

However, incomplete dentin bridges may occasion- permanent restoration.

mula that can stimulate reparative dentin bridging

transcription polymerase chain reaction analysis con-

sue. Examination of the effects of heat stress on

of both glycoproteins, indicating their role in the heal-

Fig 13-13 Histo- Fig 13-14 Histologic section of a

Resin-modified glass ionomers erate to intense inflammatory pulpal responses,

with a moderate inflammatory response that includ-

with bacterial infiltration (Fig 13-15). With time, mac-

Fig 13-17 Pulpal response to MTA capping after

Smith et al120 adopted a different approach by of events leading to pulpal healing.126

sure. At a later time (6 months to a year), the previ-

Collectively, these studies indicate that microbio-

You might also like