Pulpitis management:
direct and indirect pulp capping, vital
amputation.
Electrosurgery and laser surgery for
pulpotomy.
Topic 5
Treatment strategy Diagnosis
Indirect pulp capping ”reversible pulpitis”
bacteria near but not inside pulp chamber
Long-lasting pain after cold, no acute pain in anamnesis.
Deep cavity, pulp is not exposed, pain on probing. Electric test 10-20 mA.
Direct pulp capping ”reversible pulpitis”
bacteria near but not inside pulp chamber
Long-lasting pain after cold, no acute pain in anamnesis.
Deep cavity with exposed pulp (traumatic exposure or exposure during prepation),
pain on probing.
Electric test 10-20 mA.
Pulp amputation ”Acute partial irreversible pulpitis”, ”limited [partial] pulpitis”
superficial pulp infection
Long-lasting pain after cold or spontaneous pain without irradiation; no acute pain in
anamnesis.
Deep cavity with exposed pulp (traumatic exposure or exposure during
prepation)/not exposed pulp, pain on probing.
Electric test 20-40 mA.
More often in pediatric and geriatric dentistry.
Pulp extirpation Any form of irreversible pulpitis
Bacteria penetrate into the root canals
Long-lasting pain from hot, spontaneous irradiated pain.
Deep cavity with exposed/not exposed pulp, pain on probing.
Electric test more the 40 mA.
Vital pulp therapy
Aim - maintenance of pulp vitality (of the whole pulp, or of
its part)
Invasiveness depends on the clinician’s assessment of the
extent of contamination and pulpal inflammation
cold or electrical pulp testing (EPT)
careful inspection of the residual healthy tissue: continued
bleeding despite application of mild pressure by an operator is
interpreted as pulp that is too severely inflamed to be directly
capped.
In this case more of the pulp tissue must be removed until its
healthy appearance is observed and hemostasis is achieved
Vital pulp
therapy
Capping
Pulpotomies
procedures
Indirect Pulp Direct Pulp Pulp Chamber Partial
Capping Capping Pulpotomy Pulpotomy
Reversible pulpitis management
Anaesthesia
Isolation
Careful cavity preparation
Use of bioactive liners (direct/indirect pulp capping)
Temporary GIC restoration
Monitoring for 3-6 months
Permanent restoration
Indirect pulp capping
Pulp Bioactive
material
Indirect pulp capping
• reversible pulpitis caused by caries or
uncomplicated crown fractures (without pulp
exposure)
• if possible, the pulp tissue should not be
violated
• cavity preparations with residual dentin
thickness of at least 0.5 mm from the pulp
could be successfully capped with a bioactive
material, resulting in the desirable formation
of reactionary dentin, particularly in young
patients
• bioactive material does not directly contact
the pulp, but its bioactive components and
high pH can neutralize bacteria and directly
stimulate odontoblasts to produce reactionary
tertiary dentin in the site of injury
Rotary instruments for deep cavity preparation
Manual instruments for carious dentine excavation
Calcium hydroxide liners
Aqueous suspension varnish Composite resin
Cement
Topical calcium hydroxide placement
Linear calcium hydroxide placement
Stepwise caries excavation
Stepwise caries excavation
• there is evidence that residual softened dentin can be capped,
still resulting in tertiary dentin and arrested progression of
the disease
• partial caries removal approach can be accomplished in one
visit or may be followed by additional visits for excavation
followed by capping, called step-wise caries excavation
• clinicians need to maintain a close follow-up to ensure that
these biological goals are being achieved and that the pulp
remains vital and the patient asymptomatic
Direct pulp capping
Direct pulp capping
pulp exposure from caries, trauma or tooth preparation leads to reversible
inflammation which can be managed with direct pulp capping
material is placed directly over the exposed pulp tissue to promote pulp
healing and generate reparative dentin
Success of direct pulp capping
state of the pulp (healthy or inflamed)
complete/incomplete root formation (blood supply)
biocompatible pulp capping agent that stimulates the
formation of reparative dentin
prevention of bacterial ingress by the placement of a
well-sealed restoration
Direct pulp capping: materials
Mineral trioxide aggregate (MTA)
Ca(OH)2 aqueous suspension
Biodentin
Calcium hydroxide = Ca(OH)2
• one of the oldest and most widely used medicaments for
vital pulp therapy
• excellent antibacterial properties, high (alkaline) pH
• low-grade pulpal irritation induced by Ca(OH)2 is
important for dentinal bridge formation
Calcium hydroxide paste
produces an inflammatory
response that stimulates
dentinal bridge formation
Calcium hydroxide = Ca(OH)2
antibacterial properties, that minimize or eliminate bacterial
penetration to the pulp
high pH causes irritation of the pulp tissue, which stimulates
repair
calcium hydroxide is known to solubilize bioactive proteins
from dentin, this potentiating pulp repair
self-cure formulations are highly soluble and are subject to
dissolution over time
no adhesive qualities and poor seal
MTA
• Contains tricalcium silicate, dicalcium silicate, tricalcium
aluminate, tetracalcium aluminoferrite, calcium sulfate,
and bismuth oxide.
• there are two types of MTA: grey and white and the
difference is in the presence of iron in the former which
further forms the tetracalciumalumino-ferrite phase
MTA
the advantages and potential mechanisms of action for MTA are
similar to calcium hydroxide, including its antibacterial and
biocompatibility properties, high pH, radiopacity and its ability to aid
in the release of bioactive dentin matrix proteins
provides some seal to tooth structure
more predictable hard tissue barrier formation in comparison to
calcium hydroxide
high solubility, demonstrating 24% loss after 78 days of storage in
water
poor handling characteristics
presence of iron in the grey MTA formulation may cause tooth
discoloration (white MTA can be used)
prolonged setting time of approximately 2 hours and 45 minutes
(two-step procedure, with a temporary restoration to allow the MTA
to set; or using a quick-setting liner to protect the MTA)
expensive
Biodentin
• a new tricalcium silicate-based cement material
introduced in 2009
• available in the form of a capsule containing the ideal
ratio of its powder and liquid
Biodentin
biocompatible
good antimicrobial activity.
stimulate tertiary dentin formation
stronger mechanically, less soluble and produces tighter
seals compared to Ca(OH)2
less setting time, better handling characteristics than that
of MTA
more soluble than MTA
clinical studies are needed for a definitive evaluation of
Biodentine
Direct pulp capping (ProRoot)
Pulpotomy (pulp amputation)
Pulpotomy
• If the exposure is large or seriously contaminated, it may
require the removal of the
• superficial layer of the diseased pulp (partial pulpotomy)
• entire coronal pulp to the level of the root canal orifice (pulp
chamber pulpotomy)
• Most commonly applied in teeth with incomplete root
maturation
Pulpotomy
Carious cavity preparation
Endodontic access preparation
Coronal pulp amputation (diamond bur at high speed)
Hemostasis
Pulp chamber careful irrigation with antiseptic solution
Liner application
Temporary GIC restoration
Monitoring for 3-6, permanent restoration
Monitoring at 12 months, followed by annual evaluations
for the first 4 years
Pulp vitality tests are not usually helpful in the pulpotomy-treated tooth.
Clinical success is judged by the absence of any clinical or radiographic signs of pathosis.
Pulpotomy
Bioactive material and
Haemostasis
temporary restoration
Pulpotomy: materials
• Mineral trioxide aggregate (MTA), Biodentin
• Ca(OH)2 – aqueous suspension
• Pulpotec (Iodoform, Polyoxymethylene, Phenol,
Guaiacol, Formaldehyde, Dexamethasone Acetate)
Alternatives
Laser pulpotomy
Elecrosurgery for pulpotomy
Advantage: easier control of haemorrhage
More clinical studies are needed
Electrosurgery
• diathermy is a transformation of electrical energy of alternating current (AC)
with high frequency in vital tissues into heat
• electrocoagulation occurs when tissue is heated below the boiling point and
undergoes thermal denaturation
• electrosection occurs when sudden increase in tissue temperature above
boiling point results in rapid explosive vaporization of the water content in
the tissue adjacent to the electrode, leading to tissue fragmentation and
cutting
• During diathermy, only the biological tissues containing liquid get heated. The
tissues get heated locally only in the place of direct contact with the
electrode. Metallic electrode does not get heated
Electrosurgical pulpotomy
Anaesthesia
Endodontic access
Electrode tip is positioned slightly
above the pulp tissue but close
enough for electrical arcing to occur
(about 1 mm above the tissue)
The current is applied for 1 to 2
seconds over each pulpal stump. This
procedure was repeated up to three
times on each pulpal orifice, until
brown appearance was observed in
the tissue
Restoration
Laser pulpotomy
Anaesthesia
Endodontic access
Coronal pulp is removed with a
sharp excavator
Haemostasis obtained
The entrances to the root canals is
irradiated with a laser to disinfect
and coagulate the pulp
Restoration
Laser pulpotomy
Mandibular first and second primary molars 36 months after pulpotomy with MTA.
Pulp canal obliteration is evident in the distal root of the second molar;
both procedures were rated as successful.
Complications after direct placement
of bioactive materials
Irreversible pulpitis and pulp necrosis
Pulp chamber obliteration with reparative dentine
Internal root resorption
General considerations
• Avoid exposing the pulp. The chances for tooth survival are excellent
if the tooth is asymptomatic and well sealed, even if residual caries
remains.
• Control hemorrhage with water, saline or sodium hypochlorite.
Water and saline are the most benign to the pulp; sodium
hypochlorite is best at controlling hemorrhage and disinfecting.
• ZOE, GIC/RMGIC and adhesives are poor direct pulp-capping agents
and should be avoided for this application.
• MTA demonstrates comparable results to calcium hydroxide as a
direct pulp cap agent in short-term data.
• Calcium hydroxide remains the “gold standard” for direct pulp
capping. It has the longest track record of clinical success, is the most
cost-effective and is the likely effective component in MTA.
• Provide a well-sealed restoration immediately after pulp capping.
This will provide protection against ongoing leakage and bacterial
contamination that can compromise the success of the pulp cap.
Hilton TJ. Keys to clinical success with pulp capping: a review of the literature. Oper Dent. 2009;34(5):615-625. doi:10.2341/09-132-0
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