PULP PROTECTION

Pulp is a soft, delicate specialized connective tissue located in the central

portion of each tooth containing thin walled blood vessel and nerve
endings enclosed within dentin.

Causes:

The reason for using liner or base is to protect the pulp or to aid pulpal
recovery or both. Pulpal irritation that occurs during or after operative
procedures may result from:

 Heat generated by rotary instruments.

 Some ingredients of various materials.
 Thermal changes conducted through restorative material.
 Galvanic shock.
 Forces transmitted through materials to the dentin.
 Ingress of noxious products and bacteria through micro leakage.

 Effective Depth/Remaining Dentin Thickness:

Minimum thickness of dentin separating pulpal tissue from carious

lesions. It is of three types:
1. Shallow type(> or = 2mm of RDT)

In a shallow tooth excavation (which includes > or = 2mm of RDT),

pulpal protection other than in terms of chemical protection is not
necessary.

 For an amalgam restoration, the preparation is coated with two thin

coats of varnish or a single coat of dentin sealer or a dentin bonding
system and then restored. In most cases, dentin sealer is material of
choice.
 For a composite restoration, the preparation is treated with a
bonding system (etched, primed, coated bonding agent) and then
restored.

2. Moderately deep preparation (0.5-2mm of RDT)

 In a moderately deep toothexcavation for amalgam application of
base only at that site using light cured resin modified glass
ionomer.
 Traditionally, zinc phosphate cement and polycarbo
xylate cement were preferred bases under amalgam restorations.
However light cured resin modified glass ionomers are
recommended.
 In a composite tooth preparation, eugenol has potential to prevent
polymerization of layers of bonding agent or composite in contact
with it.Resin modified glass ionomer is used as a base if indicated.

3. Very deep preparation (<0.5MM of rdt)

 Ifthe RDT is very small or if pulp exposure is potential problem,
calcium hydroxide is used to stimulate reparative dentin formation.
A thickness of 0.5-1mm of set calcium hydroxide is sufficient to
treat a near or actual pulp exposure.
 light cured resin modified glass ionomer base should be applied
over already placed calcium hydroxide liner.
 Shallow Moderate Deep excavation(RDT < 0.5mm)
excavation(RDT excavation(RDT 0.5-
>2mm) 2mm)

Amalgam No/no/sealer No / base/sealer Dycal/ base

Composite No/no/dentin No/no/dentin bonding Dycal/no/dentin

bonding system system
Bonding system

Gold, No/no/cement No/base/cement Dycal/base/cement

Inlay,Onlay

Ceramics No/no/dentin No/no/dentin bonding Dycal/no/dentin bonding

bonding system, system, composite system, composite cement
composite cement cement

Cavity LINER:
Cavity liner are relatively thin layer of materials used primarily to
provide a barrier to protect the dentin. They can be classified as:-

1. Thin film liners(1-50µm)

a. Solution liners ( 2-5µmetre)eg cavity varnish
 b. Suspension liners(20-25 µmeter) eg zinc oxide (type IV)&
calcium hydroxide
2. Thick liners(200-1000µmeter)
a. GIC {type III}

Functions of suspension liner (ZnoE and Ca(OH) 2)

 Electrical insulation under metallic restoration

 Chemical protection of pulp from residual reactants diffusing
out of restoration
 physical barrier to ingress of bacteria/bacterial products
 Therapeutic effect of calcium hydroxide. It helps in formation of
reparative dentin, so used as pulp medicament.
 Zinc oxide eugenol has anodyne effect so used as an obtundant
in case of mild to moderate inflammation of pulp
 To prevent oral fluids that may penetrate leaky restorations
from reaching the pulp through the dentin.

Cavity varnish or solution liner

Cavity varnish is a solution of natural (copal) or synthetic (nitrated)
cellulose resin dissolved in an organic solvent such as alcohol, acetone,
and benzene. Some varnishes also contain medicinal agents such as
eugenol, thymol and fluorides.

When applied to cavity walls, organic solvents evaporate leaving a thin resin film
that serves as barrier between the restoration and the dentinal tubules

It is available as liquid in dark colored bottles.

Film thickness varies from 2- 400 µm.

It can be applied using a brush, wire loop or a small pledget of cotton. Several
thin layers are applied. Each layer is allowed to dry before applying the next one.
The main objective is to get uniform and continuous coating.

 FUNCTIONS: Varnish seals the margins of newly placed amalgam

restorations, thereby reducing postoperative sensitivity.
 It also prevents the penetration of corrosion products into the tubules
from amalgam restoration thus preventing tooth discoloration.
 It reduces the passage of irritants into the dentinal tubules from the
overlying restoration or base. E.g. silicate.
 Varnish may be applied on the surface of metallic restoration as a
temporary protection in cases of galvanic shock.
 In cases where electro surgery is to be done adjacent to metallic
restorations, varnish applied over the metallic restorations serves as
a temporary electrical insulator.
 Fluoride containing varnishes release fluoride.
 It also acts as a chemical insulator by preventing the acids from the
cements such as zinc phosphate from leaching into the tubules.
 A coating of varnish over freshly placed GIC prevents its dehydration
or over hydration from oral fluids.

Disadvantages:

 Varnish should not be used under composite resin as it interferes

with polymerization.
 It is also contraindicated under GIC and polycarboxylates as it
interferes with the chemical bond and fluoride release.

PRECAUTIONS

 Bottle tightly capped after use to prevent loss due to evaporation.

 Should be applied in a thin consistency
 Should not be left on margins of restoration as it interferes in
finishing of restoration
  For silicate cements applied only on dentin and not on enamel as
it inhibits the uptake of fluoride by enamel.

SUSPENSION LINERS:

Suspension liners containing calcium hydroxide or zinc oxide (type IV)

are used for pulp protection under restorations.

 Calcium hydroxide-based liners:

These are suspensions of calcium hydroxide in an organic liquid such as

methyl ethyl alcohol or in an aqueous solution of methyl cellulose.
Fluoride compounds have also been incorporated in some liners.

Since the supply of calcium ions encourages the formation of reparative

dentin, calcium hydroxide is the preferred liner in cavities (indirect pulp
capping) and in contact with living tissues (direct pulp capping).

 Light cured calcium hydroxide liner:

Calcium hydroxide liners are also available as single-paste systems; the

setting occurs by light curing. This liner consists of urethane dimethyl
acrylate (UDMA) resin matrix in which calcium hydroxide and barium
sulfate are incorporated. It also contains hydroxyethylmethacrylate
(HEMA) and a light activator-initiator system.

Calcium hydroxide liners are commercially available as two-paste

systems, DYCAL (DENTSPLY), and single paste systems, CALCIMOL LC
(Voco) and Septocol LC (Septodont).

MECHANISM OF CALCIUM HYDROXIDE:

 Calcium hydroxide stimulates the formation of reparative dentin due

to its alkalinity and antibacterial effect. Its biological properties are
achieved by its dissociation into calcium and hydroxyl ions.
˙
Ca (OH ) 2→ Ca2+¿+OH −¿¿ ¿

The action of these ions on vital tissues and bacteria generates the
induction of hard tissue deposition and the antibacterial effect.
Calcified barrier is formed by Ca (OH) 2,when it is in contact with
healthy pulpal(pulp capping) or periodontal tissue(apexification). The
high pH of the material (up to 12.5) leads to the formation of superficial
layer of necrosis in the pulp upto depth of 2mm and a layer of mild
inflammation. Calcium hydroxide dissociates into the calcium and
hydroxyl ions. The calcium ions that form the barrier are derived
entirely from the bloodstream and not from the Ca (OH) 2. Calcium ions
may activate the calcium-dependent adenosine triphosphate reaction
associated with hard tissue formation. The hydroxyl ion provides the
alkaline pH that neutralizes lactic acid, thus preventing dissolution of
mineral components of dentin and also activates alkaline phosphatases
which play an important role in hard tissue formation.

APPLICATIONS OF CALCIUM HYDROXIDE:

1. Conservative procedure
a. Pulp Capping
i. Direct
ii. Indirect
2. Endodontics
a. Pulpotomy
b. Apexification
c. Management of resorption
d. Management of traumatized teeth
e. Intracanal medicament
f. Endodontic sealer
3. Pediatric dentistry
a. Pediatric obturation material.

Zinc oxide liners:

They are available as two-paste systems. They are conventional ZOE

without any modifications, the pastes containing zinc oxide and eugenol
with inert oils and fillers, respectively. When used in deep cavities, they
have an obtundent or sedative effect on the pulp. The setting reaction is
accelerated by moisture and increased temperature.
 Disadvantages:

 Zinc oxide liners are weak and rigid as compared to calcium

hydroxide liner.
 They are not used under composite restoration, since eugenol
inhibits the polymerization reaction. There is no secondary dentin
formation.

 Glass ionomer cement:

The material is used as a liner and a base primarily because of its highly
desirable properties like fluoride release and chemical adhesion to
tooth structure.

It may be placed in moderate to deep cavities. It has good

biocompatibility with the pulp and good strength. It is used as a liner
under amalgam, cast gold and composite restorations. Resin-modified
glass ionomer liners are more compatible with composite restorations.

CAVITY BASES:
Bases (cement bases 0.5 -0.75mm) are used to provide thermal
protection for pulp and to supplement mechanical support for the
restoration by distributing local stresses from the restoration across
underlying dentinal surface.

Low ZOE, calcium Generally Calcium

strength hydroxide used under hydroxide
bases: temporary/ used as a
BASES ARE
Interim sub-base CLASSIFIED AS:
Restoration
High GIC, reinforced Used under Only some
ZOE, zinc Direct and bases are
strength phosphate, indirect indicated
bases: Zinc metallic under
polycarboxylate restoration composite
resin, e.g.
GIC
Uses and indications of bases are as follows:
 To protect pulp against thermal injury, galvanic/electrical
shock, and chemical irritation, e.g. Zincphosphate and ZOE
cements under metallic restorations.
 To withstand the forces of condensation of the restorative
material and act as shock absorbers, e.g. zinc phosphate
cement under amalgam restoration.
 To substitute dentin in deep cavities, e.g. all high strength
bases.

Clinical considerations:
 The base should be 0.5-0.75mm thick. Very thick base compromise
the bulk of restoration and increase the potential for fracture of
restoration.
 It is not recommended to remove sound tooth structure in order to
provide space for base. Conserving sound tooth structure will
enhance restorative support and provide pulpal protection.
 Bases are applied only on internal walls of cavity preparation to
prevent dissolution by saliva.

SANDWICH TECHNIQUE:

The “sandwich” technique was developed by McLean to combine the

beneficial properties of glass ionomer cement and composite resins.

Presently it is called laminate or bilayered technique.

The technique can be employed clinically with large Class III, Class IV,
Class V, Class I and Class II with composite resins.

CLINICAL STEPS:

 After cavity preparation, condition the cavity to develop good

adhesion with glass ionomer.

 A fast setting type III glass ionomer cement is used to replace the lost
dentin in sufficient bulk (1-2mm). Either auto cured or resin-modified
glass ionomer cement may be used. The glass ionomer can also be
placed in cavities extending subgingivally.

 Once it has set, cut back to expose the enamel margins and to allow
enough bulk for composite resins.

 Etch the enamel and auto cured glass ionomer cements for 15 seconds
using phosphoric acid. This will improve the micromechanical bond
to composite resins. Etching is not necessary for resin-modified glass
ionomer cements. When they are used, etch the enamel alone for 15
seconds.

 Wash and gently dry

 Apply a thin coat of a low viscosity enamel bonding agent on the

enamel and glass ionomer base and light cure for 20 seconds
 Proceed with composite resin buildup.

ADVANTAGES:

 Favorable pulpal response due to biocompatibility of glass

ionomer cement.

1. Ion – exchange adhesion of glass ionomer to dentin prevents micro

leakage.

2. Fluoride release from glass ionomer cement minimizes recurrent

caries.

3. Excellent subgingival response.

4. By minimizing the bulk of composite resin, polymerization shrinkage

of the resin is reduced.

5. Better strength, finish and esthetics of the overlying composite resin.

DISADVANTAGES: It is time consuming and technique sensitive.

PULP CAPPING:
Pulp capping implies placing the dressing directly onto the pulp
exposure.

It is of two types:

1. Indirect pulp capping

2. Direct pulp capping

Indirect pulp capping therapy:

The procedure involving a tooth with a deep carious lesion where

carious dentin removal is left incomplete, and a decay process is treated
with a biocompatible material for some time in order to avoid pulp
exposure.

Direct pulp capping therapy:

The procedure in which small exposure of pulp which is encountered

 During cavity preparation

 Following a traumatic injury
 Due to caries with a sound surrounding dentin is dressed with an
appropriate biocompatible radiopaque base in contact with
exposed pulp tissue prior to placing restoration.

Indirect pulp capping:

In deep carious lesions, the caries in dentin may be close to the pulp.
Normally all carious dentin should be removed before placement of
restoration. But in those conditions where complete removal of all the
softened carious dentin may result in pulp exposure, the deepest layer
(approx. 0.5mm from the pulp) may be intentionally left behind and
protected with an indirect pulp capping agent.
Indirect pulp capping is deliberate retention of softened carious dentin
near the pulp and medication of the remaining dention with calcium
hydroxide.

The rationale behind this procedure is that calcium hydroxide being

alkaline in nature can eliminate the remaining bacteria and render the
residual carious dentin sterile. Placement of well-sealed interim
restoration such as reinforced glass ionomer cement or reinforced zinc
oxide eugenol over calcium hydroxide liner will deny the remaining
bacteria nutrients for further acid production and arrest the carious
lesion.

Direct pulp capping:

It is a technique for treating an exposed pulp with a material that seals
the exposure site and promotes reparative dentin formation.

Certain criteria may be followed for successful direct pulp capping:

1. The tooth may be asymptomatic before the exposure-no spontaneous

pain, or abnormal response to thermal stimuli.
2. The size of the exposure must be small-less than 0.5mm in diameter.
3. Hemorrhage from the exposed pulp must be easy to control.
4. The area of the exposure must be uncontaminated by saliva or
gingival fluids.
Calcium hydroxide has been used as material of choice for direct pulp
capping. It stimulates the formation of dentin bridge over the exposure
provided a sealed interim restoration such as glass ionomer cement is
placed over it.

However it has several disadvantages:

 It does not provide a good seal.

 It disintegrates over time.
 The dentin bridge formed under calcium hydroxide has tunnel
effects that allow bacterial penetration.
 INDICATIONS:

 INDIRECT PULP  DIRECT PULP CAPPING

CAPPING
 Ideally used when  Small mechanical exposure less
pulpal than 1 mm which is surrounded by
inflammation has sound dentin.
been judged to be  Light red bleeding from the
minimal and exposure site that can be
complete removal controlled by cotton pellet.
of caries would  Traumatic exposures in a dry,
cause a pulp clean field, which report to the
exposure. dental office within 24 hours.
CONTRAINDICATIONS
DIRECT PULP
INDIRECT PULP CAPPING CAPPING

 Any signs of pulpal or  Pain at night

periapical pathology.  Spontaneous pain
 Soft leathery dentin  Tooth mobility
covering a very large area  Intraradicular
of the cavity, in a non- radiolucency Presently, mineral
restorable tooth  Thickening of trioxide aggregate
periodontal membrane (MTA)bioactive silicate
 Purulent or serous cement is widely used as
exudate a direct pulp capping
agent. It was developed
by DrTorabinejad at Loma Linda University in 1992. It is available in
grey and white colors. It is composed of tricalcium silicate, dicalcium
silicate and traces of magnesium hydroxide, sodium sulfate and
potassium sulfate. Bismuth oxide is added to impart radiopacity. Tetra
calcium alumino ferrite is present in grey MTA and absent in white MTA.

Properties:
1. It has a pH of 12.5 (when set) similar to Ca (OH) 2.
 2. Setting time is 2 hours 45 minutes.
3. It has a hard setting non-resorbable surface.
4. Compressive strength 40 Mpa after setting and 70 Mpa after 21
days.
5. It sets in moist environment (hydrophilic).
6. It has low solubility.
7. It shows resistance to micro leakage.
8. Reduces bacterial migration.
9. Biocompatible with periradicular tissues.
10. Also known as PORTLAND CEMENT except for addition of
bismuth oxide which is added for modifying its setting properties.

Commercial name: PROROOT

Manipulation:

Liquid and powder mixed to putty consistency since it is loose

granular aggregate, it doesn’t stick very well to any instrument.

It can be carried to cavity in messing gun, amalgam carrier or

specially designed carrier. Once placed, compacted with burnisher
and micro plugger than a small damp cotton pellet is used to gently
clean any excess MTA from cavity.

It has advantages like:

 Highly biocompatible
 Sets in the presence of moisture and acts as an excellent seal over the
exposed pulp.
 Promotes faster and thicker dentin bridge formation without any
tunnel defects.
 Normal healing response without inflammation.
 Least toxic
 bacteriostatic
Disadvantages of MTA:
 Prolonged setting time.
 Difficult handling characteristics.
 Costly
 Long setting time

INDICATIONS:
1. Pulp capping
2. Apical plug- apexification and apexogenesis
3. For repair of root perforation
4. For repair of root resorption
5. As a root end filling material

PRECAUTIONS:
1. Keep in closed container to avoid moisture.
2. Stored in dry area
3. Placed immediately after mixing to prevent dehydration
4. Too much or too little liquid will reduce strength of cement
5. Setting time 3-4 hours but working time 5 minutes.

DIRECT PULP CAPPING

BIODENTINE:
 Designed as dentin replacement material.
 Commercially available in 2009 (SEPTODENT).
 Calcium silicate based material.

COMPOSITION:

POWDER-

 Tricalcium silicate (core material)

 Dicalcium silicate (core material)
 Calcium carbonate
 Oxide
 Ion oxide
 Zirconium oxide (radio opacifier)

LIQUID-

 Calcium chloride (acts as an accelerator)

 Hydrosoluble polymer (acts as water reducing agent)

Setting time :9-12 minutes

 Adequate compressive strength so used in vital pulp therapies

 Deposition of substances such as hydroxyapatite on material
surface when in contact with synthetic tissue fluid.

USES:
 Root perforation
 Apexification
 Resorption
 Retrograde fillings
 Pulp capping procedures
 Dentin replacement