Influence of the restoration

after pulpotomy on the

strength of electrical
stimulus reaching the pulp
space: An in vitro
investigation
Aakanksha Chopra, Sidhartha Sharma, Vijay Kumar, Amrita Chawla, Suman Jain , Ajay
Logani JOURNAL OF CONSERVATIVE
DENTISTRY YEAR:2023
 THE VITAL PULP
The dental pulp is a highly vascular tissue that has the unique distinction of
being encased within a rigid chamber composed of dentin, cementum, and
enamel.
The tissue provides several important functions, including immune cell
defense, dentinogenesis, calcified barrier formation, nutrition.
GOAL ----------> Reparative dentin bridge formation
 VITAL PULP THERAPY
Vital pulp therapy is advanced treatment devised to conserve, protect, and maintain
a healthy pulp.
VPT encompasses indirect pulp capping, direct pulp capping, and pulpotomy
(partial or full) procedures.
According to the American Academy of Pediatric Dentistry, “Teeth exhibiting
provoked pain of short duration, that is relieved, upon the removal of the stimulus,
with analgesics, without signs and symptoms of irreversible pulpitis, have a
clinical diagnosis of reversible pulpitis and are candidates for vital pulp therapy.”
 Pulpectomy
• A pulpectomy is the process of removing all of the nerves within the tooth
and cleaning out the infection. Root canal treatment takes this a step
further by filling the emptied and sterilized canals with a sealing material,
as explained by the AAPD.
 PULPOTOMY
Pulpotomy is a more invasive procedure defined as “the removal of the
coronal portion of a vital pulp as a means of preserving the vitality of the
remaining radicular portion. It may be performed as an emergency
procedure for temporary relief of symptoms or therapeutic measure, as in
the instance of a Cvek pulpotomy.”
Indicated whenever the remaining pulp exhibits reversible pulpitis.
 TYPES OF PULPOTOMY

PARTIAL COMPLETE
PULPOTOMY PULPOTOMY

• The removal of a small portion The removal of the coronal

of the vital coronal pulp as a portion of the vital pulp as a
means of preserving the means of preserving the vitality of
remaining coronal and the remaining radicular portion.
radicular pulp tissues.
 MATERIALS FOR VITAL PULP THERAPY
The ideal pulp capping material should  Resist forces during restoration
be sterile and display the following placement
characteristics:  Resist forces under the restoration
 Stimulate hard tissue repair during its lifetime
 Maintain pulpal vitality  Be radiopaque
 Should be bactericidal or  Provide a bacteria-tight seal.
bacteriostatic
 Adhere to dentin
 Adhere to restorative material
 Pulpotomy

Vital Non Vital

Devitalization Mortal Pulpotomy

Preservation

Regeneration
 CALCIUM HYDROXIDE
1. An initial high alkaline ph, which is responsible for stimulating
fibroblasts and enzyme systems.
2. Neutralizes the low pH of acids, shows antibacterial properties, and
promotes pulp tissue defense mechanisms and repair.
3. The drawbacks of CH include weak marginal adaptation to dentin,
degradation and dissolution over time.
 Mineral Trioxide Aggregate (MTA)
• Mineral trioxide aggregate was introduced as a pulp capping material by Torabinejad and
associates in the mid-1990s.
• Exhibits favorable physiochemical characteristics that stimulate reparative dentinogenesis
by recruitment and activation of hard tissue–forming cells, contributing to matrix
formation and mineralization.
• Calcium hydroxide and calcium silicate hydrate, the principal by-products formed during
hydration of mixed MTA, contribute to a sustained alkaline pH.
• During the setting process, the gradual release of calcium ions encourages reparative
barrier formation by promoting signaling molecules, such as vascular endothelial growth
factor (VEGF), macrophage colony-stimulating factor (MCSF), TGFβ, and interleukins
IL-1β and IL-1α.
PRESENT STUDY
The present in vitro study was designed to evaluate the influence of
coronal restoration after pulpotomy on the strength of electrical
stimulus reaching the radicular pulp using an EPT.
A total of 10 single-rooted human mandibular premolar teeth.
Three millimeters of the apical root end were resected
Tissue was removed from the pulp chamber and root canal space
through retrograde instrumentation and copious irrigation with 3%
NaOCl.
An electroconductive gel (np-1, nissin dental products inc., Kyoto,
japan) was used to replace the pulp tissue.
 Study model preparation

• A dental model for electronic apex locator training

(CON1002 Series, Nissin Dental Products Inc., Kyoto,
Japan) was selected, and the right mandibular first
premolar was removed. The root canal space and the
socket were filled with electroconductive gel. The tooth
was secured in the socket using sticky wax.
 Electric stimulus measurement
 A Powerlab device (DAQ, Data Acquisition Hardware Device, AD
instrument Ltd, Sydney, Australia) was used.
 The cathode probe of Powerlab was covered with an insulating sleeve
with only a 2 mm tip exposed and inserted into the pulp space through
the opening on the lingual aspect.
 Anode was coupled to the EPT handpiece
 The EPT probe was coated with conducting media (K-Y Jelly,
Reckitt Benckiser) and placed at the middle third of the buccal
tooth surface.

 The pulsating electric stimulation rate of the EPT was set at 5

to facilitate readings in a clinical scenario.
 Simulated pulpotomy
Access opening was performed with the help of a round diamond bur under water
spray, and the pulp space was again flushed with 3% naocl to remove any residual
tissue or gel.
A collagen sponge was placed inside the root canal up to the level of the
cementoenamel junction.
A 2-mm thick MTA was placed over the collagen sponge and gently condensed to
simulate the placement of the pulpotomy agent
Moist cotton pellet was placed on the MTA
 A layer of resin-modified glass ionomer cement was placed over MTA and light-cured for
20 s. The teeth were restored with restorative composite resin and further incubated for 24
h under 100% humidity and at the room temperature to allow the complete set of coronal
restoration.

 The root canal space was filled with electroconductive gel and the experimental setup was
re-established.

 The EPT probe was contacted at the middle third of the crown on the buccal surfaces, and
measurements of the electrical stimulus from EPT transferred to the pulp chamber were
recorded on the labchart.

 The pre- and post-pulpotomy electrical stimulus measurements (in voltage) at EPT
reading 40 were recorded three times per tooth, and the EPT was allowed to return to 0
before each reading.
The radiograph demonstrates the level and thickness of the pulp
capping agent, coronal restoration and location of the lingual hole for
placement of the Powerlab electrode probe.
 RESULTS

• There was a statistically significant difference (P = 0.

038) between the pre-and post pulpotomy tooth
samples for the strength of electrical stimulus reaching
pulp space, and the values were diminished after the
placement of pulpotomy agent and coronal restoration
when compared with an intact tooth.
 DISCUSSION
The outcome of pulpotomy depends upon the reparative
potential of residual radicular pulp and the asepsis followed
during the clinical procedure.
The occurrence of spontaneous, intense, or continuous pain in a
pulpotomized tooth during a period of 2 months postoperatively
constitutes an acute adverse event.
A significant difference was observed in the cumulative voltage
reaching pulp space from 0 to 40, the values were significantly
reduced (P = 0.038) after placement of pulpotomy agent and coronal
restoration when compared with an intact tooth.

Can be attributed to the weak electrical conductance of composite

resin used as coronal restorative material which can attenuate the
magnitude of current reaching the radicular pulp space.
 CONCLUSION
The electrical stimulus from the electric pulp tester reaches the
radicular pulp space despite the presence of restoration and pulp
capping agent but the stimulus strength is significantly reduced.
The EPT can be used for the assessment of pulp sensibility after
full pulpotomy. When compared to the contra-lateral control
teeth, it is anticipated that the pulpotomized teeth will respond at
greater EPT readings.
THANK YOU
Calcium Silicate–Based Cements (CSCs)
• CSCs have demonstrated physiochemical and bio-inductive properties
comparable to those of MTA.

BioAggregate BioDentine EndocemMTA

Endosequence
 Main components of MTA and the new CSCs are tricalcium silicate and
dicalcium silicate, major components of Portland cement.
 Hydraulic tricalcium silicates promote reparative barrier formation by up-
regulation of transcription factors after gaining immediate strength on
hydration
 TECHNIQUES FOR GENERATING
REPARATIVE BRIDGES
Direct Pulp Capping
Indirect Pulp Capping
Pulpotomy
Partial Pulpotomy