Pain control in operative dentistry

By Bezawork R.

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 Course out line
• Introduction

• Pulp-dentin Complex
• Pulp Nerve Supply
• Classification of nerve in dental pulp
• Pulp Irritants

• Pulp capping
• Factors affecting Pulp Capping success
• Recent materials used for pulp protection
• Lasers in pulp capping
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 Introduction
• The restoration and maintenance of dental health through
adequate restorative treatment in order to protect pulp function
is the main purpose of restorative dentistry
• The dental pulp is a soft connective tissue of mesenchymal origin
present within the pulp chamber and root canals of teeth
• It is not considered an external tissue, yet its exposure to external
stimuli is unceasing due to several factors that make the pulp
extremely sensitive to environment outside
• Protection of dentin-pulp complex is an important factor in pulp
vitality during operative procedures
• This involves the avoidance of thermal stimuli caused by
operative procedures, toxicity of restorative materials and
bacteria penetration

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 Pulp-dentin Complex
• The dentin and pulp must be considered as one organ because of
their intimate relationship between cellular tissue within dentin
and peripheral pulp tissue
• As long as dentin is covered peripherally by enamel on coronal
surfaces and cementum on radicular surfaces ,
• Dental pulp will remain healthy for life unless apical blood supply
is disrupted by excessive orthodontic forces or severe impact of
trauma
• Most pathological pulp conditions begin with removal of these
barriers via caries, fractures or abrasion
• Structure and response of dentin to injury are largely functions of
the odontoblasts and other cells in pulp but these cells are
dependent on dentin for their protection and their state of
differentiation
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 …cont’d
• Normal form and function of one cannot be maintained without
other
• Hence its obvious response of pulp to any restorative material will
be influenced by its surrounding dentin
• Therefore it is apparent that substances easily permeate dentin
permit thermal, osmotic, and chemical insults to act on the
pulpal constituents
• This involves stimulation of odontoblast in initial stages which
may proceed to inflammation finally which often lead to tissue
destruction
• Once dentin tubules are opened, molecules can permeate to pulp
easily that lead to dentin Sensitivity

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 Pulp Nerve Supply
• Dental pulp has an abundant supply of both sensory and
autonomic nerves
• Majority of the nerves are sensory
• The trigeminal ganglion supplies sensory innervations to the pulp
via maxillary and mandibular nerves
• Nerve fibres enter the teeth via apical foramen and arborize
coronally to form plexus of rakshow in subodondoblastic region of
pulp
• Coronal dentin is more densely innervated than radicular dentin

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 Pulp Response To Irritant

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 Pulp Irritants
• Bacterial irritants (Most common cause for pulpal irritation)
• Trauma (Tooth fracture, Luxation,Avulsion, Parafunctional habits
like bruxism
• Iatrogenic:
• i. during tooth preparation Heat production during cutting
procedures
• ii. Orthodontic movement of tooth iii
• Periodontal and periapical curettage iv. use of chemicals , v.
idiopathic

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 Iatrogenic
1. During cavity preparation
a. Heat production during cutting procedures
Pulp temperature + 11°C. → destructive reaction
 Pulpal temperature is critical and must not exceed normal values
in dental restorative procedures
 Clinical research has shown irreversible damage to pulp tissues at
level of 60% at 5.5°C and 100% at 11°C.

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 …cont’d
b) Pressure exerted
Pressure of hand or rotary instruments →Nuclear aspiration of
odontoblasts or nerve ending from pulp tissues into the dentinal
tubules →Disturb ododntoblast metabolism leading to their
complete degeneration and disintegration

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 …cont’d
 4.Uses of chemicals
 Temorary and permanent filling, bases, linears and use of alcoho l
that leads to pulpal injury to its cytotoxicity, acidity, heat formed
and marginal leakage

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 Direct pulp capping
• Direct pulp capping is placing a biocompatible material over the
exposed pulp to maintain vitality and promote healing
Purpose of direct pulp capping
• To maintain the vitality of the remaining pulp tissue
• To prevent root canal treatment
• To help conserve tooth structure
Indication
• Recent small mechanical exposure of pulp during (<24hrs)
• No or minimal bleeding at the exposure site

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 indirect pulp capping
 All caries are removed except the ones that lie adjacent to the
pulp
 Caries near the pulp is left in place to prevent pulp exposure and
preparation is enclosed with a biocompatible material
Indications
 1. Deep carious lesion near the pulp tissue but not involving it
 2. No mobility of tooth
 3. No history of spontaneous toothache
 4. No tenderness to percussion
 5. No radiographic evidence of pulp pathology
 6. No root resorption or radicular disease should be present
radiographically

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 Factors affecting Pulp Capping success
• 1) Age of the patient: Due to vascularity of the pulp, young
patients have greater potential for success than older ones Young
patient Old patient
• 2) Type of exposure: Mechanically done pulpal exposure has
better prognosis than exposure caused by caries, due to less
pulpal inflammation and deleterious effect of bacterial toxins on
the pulp
• 3) Size of the exposure: In large exposures, it is difficult to control
the hemorrhage and tissue seepage. Small pinpoint exposures are
easy to manage and have a greater potential for success
• 4) History of pain: If previously pain has not occurred in the tooth,
the potential for success is more

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 Bases

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Recent materials used for pulp protection

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 …cont’d
• Biodentine is new calcium silicate based restorative cement with
dentin like mechanical properties which can be used as a dentin
substitute on crown and roots similar to MTA
• It has a positive effect on vital pulp cells and stimulates tertiary
dentin formation
• Biodentine consist of powder and liquid
• The powder mainly contains tricalcium and dicalcium silicate(the
principal component of portland cement as well as calcium
carbonate, Zirconium dioxide serves as contrast medium
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 …cont’d
• The liquid consists oof calcium chloride which is used as setting
accelerator and water reducing agent in acqueous solution with
and admixture of polycarboxylate (a superplasticizing agent
• After validation of health it may be partially removed to place a
permanent composite material

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 Lasers in pulp capping
• Most recent studies report long term success rates close to 90%
for laser assisted pulp capping compared to a success rate of
about 60% with traditional methods
• The use of the Er.Cr:YSGG laser allows cavity preparation to be
completed with only one instrument in contrast to alternative use
of high and low speed rotary instruments and other laser
wavelengths (CO2,Nd:YAG and diode lasers) which cannot be
used for ablation of hard tissue
• CO2 and erbium lasers are more superficial in their interaction
with tissue than the diode and Nd:YAG wavelength which
penetrate more deeply and have greater capacity for scattering
• Coagulating effect of laser guarantees a dry operating area with
no bleeding and creation of zone necrosis that is more superficial
compared to chemical pulp capping agent
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 Any question??

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