INTRODUCTION

&
Pulp Capping
 Contents

• Introduction • Indications

• Sequence of diagnostic events • Contraindications

• Diagnostic tests • Procedures

• Indirect and direct pulp capping • Pulp capping agents

• Definition and objectives • Conclusion

• References
 Introduction

• Diagnosis is the art and science of detecting…….

• No appropriate treatment recommendation can be made…..

• Planned, methodical, and systematic approach to this

investigatory process is crucial.
 Process of diagnosis
The patient tells the clinician why the patient is
seeking advice

The clinician questions the patient about the

symptoms & history that led to the visit

The clinician performs objective clinical tests

The clinician correlates the objective findings with

subjective details & creates a tentative differential
diagnosis

The clinician formulates a definitive diagnosis

 Chief Complaint
• Reasons patient give for consulting with a clinician…..

• Determine - chronology of events

• Properly documented, using patient’s own words

 Medical history

• Responsibility of clinician

• Base line vital signs :

Blood pressure
Pulse rate
Temperature
• The clinician should evaluate a patient’s response to health
questionnaire from 2 perspectives:

Altering the
that have oral
manner in
manifestations
which dental Medical
or mimic dental
care will be conditions
pathosis
provided
 Tuberculosis- lymph node enlargement-

Lymphomas-

Immunocompromised patients-
,drug allergies /allergies to dental products-
Anemia and leukemia- paresthesia-
prosthesis, or organ transplants-
,Medications- negatively interact with local anesthetics-
Sickle cell anemia, multiple myeloma-
.analgesics, antibiotics
Radiation therapy-

Neuralgia,referred pain-

Acute maxillary sinusitis-

 Dental history

Localization: can you point out the offending tooth?

Commencement: when did the symptoms first occur?
- may be spontaneous in nature,
- may be due to trauma,
- while biting on hard objects.
Intensity: how intense is the pain?
Provocation and relief of pain:
Duration:
Provoked pain that ceases
after removal of the
causative stimulation Spontaneous pain is a
-reversible constant or throbbing
pain that occurs without
- thermal, chemical, and stimulation or continues
mechanical irritants, deep long after the causative
caries, faulty restorations, factor has been
primary tooth- exfoliation, removed.
or erupting permanent
tooth.
 Extra Oral Examination
• Observe patients as they enter the operatory.
• Facial asymmetry
• Visual and palpation- localized or diffuse, firm or
fluctuant swelling
• Bilateral swellings
• Lymph node palpation
• Extra oral facial swelling of odontogenic origin
• Typically endodontic etiology
Subtle visual changes

Loss of nasolabial fold

:Space infections

Canine space-

Buccal space-

Submental/submandibular space-
• Sinus tract- extraoral opening
• Scar formation- extraoral stoma
 Intraoral Examination
SOFT TISSUE EXAMINATION:
• Gingiva and mucosa
• Retraction
• Abnormalities in colour and texture
• Raised lesions
• Ulcerations
• Biopsy?
 Intraoral swelling:

• Visualise
• Palpate
-- diffuse or localized
-- firm or fluctuant
-- location
• Determine etiology- endo/ perio/endo-perio/non
odontogenic
 Examples of intraoral swellings:

Palatal swelling- usually-maxillary lateral incisors-

distally/palatally deviated roots-50%

Posterior palate- maxillary molars-palatal root

Sublingual space- bilateral extension with elevation of

tongue
Parapharyngeal space
Intraoral sinus tracts:

• Chronic endo infection drains via

intraoral communication -sinus tract (stoma)
• Extraoral communication- fistula

• Heal when etiology is removed.

Palpation:

• Soft tissue swelling

• Bony expansions
• Compare with adjacent and contralateral tissues
• Subjective finding- unusual sensitivity
Hard Tissue Examination

• Severe dental decay, defective or missing restorations and

draining parulis might indicate pulpal involvement
Percussion:
• Correlate with chief complaint
• Indication of inflammation in periodontal ligament
• Proprioceptors in pdl space- localization

Vertical percussion Horizontal percussion

Before percussion test:
• Tell the patient what will happen during the test
• Anxiety of patient due to acute symptoms
• Test contralateral teeth as a control
• Initial- gentle finger pressure
- no response- blunt end of instrument
- first occlusal- no response- facial –lingual aspects

• Any hightened response- repeat- determine accuracy and

reproducibility
Mobility:

• Compromise of pdl attachment

Classification - mobility
• Grade I: Noticeable moment of the tooth in its socket
• Grade II: Movement of a tooth within a range of 1mm
• Grade III: Movement of a tooth greater than 1mm or when the
tooth can be depressed

Tooth mobility might be present normally because of physiologic

.resorption and many pulpally involved teeth have no mobility
Pulp tests
• Why?

• failure of immature teeth to respond

• children perceive the vitality testing methods as unpleasant
stimuli

• lack of development of the plexus of Raschkow in the pulp-

dentin complex
Mechanical tests for pulp vitality include:

probing or blowing air: hydrodynamic pressure changes in the

dentinal tubules
test cavity test: heat from the bur
anesthetic test : pain should disappear
occlusal pressure test: pain -experienced -biting force is released
 Thermal Tests

Thermal Testing - assess the vitality of the pulp identify the

offending tooth correctly in situations where the patient is
unable to locate the source of the pain
Heat Testing
Response to thermal tests
• No response – Non vital pulp
• Mild to moderate pain – Normal pulp.

• Strong – momentary painful response that subsides within

1-2 sec after the removal of stimulus – Reversible pulpitis.

• Moderate to strong painful response - lingers for several

seconds to longer after the stimulus has been removed –
irreversible pulpitis.
 Limitations of heat test
• Anxiety of the child.
• The heat might damage the pulp
• If the child is uncooperative -injury to the
soft tissue.
 Causes Of False Positives/Negative

1. Calcified canals

2. Immature apex – usually seen in young patients

3. Trauma

4. Premedication of the patient – pulp sedated

Cold Testing

• A response to cold indicates a vital pulp

• A stream of cold air, ethyl chloride spray, CO2 snow or dry ice.
• This was devised by Ehrmann

Fuss et al, 1986- in an invivo study comparing tooth vitality, produced a

positive vitality response of 98.7% with Di chloro – Difluro – Methane
(DDM) and 97.4 % with CO2 snow.
• In pediatric patients, application of CO2 snow produces a low
intrapulpal pressure and is far more effective and reliable
even in immature tooth.
Electric Pulp Tests (EPT)

• Electric pulp tester uses electric excitation to stimulate the A-

delta sensory fibers with in the pulp.

• The electric pulp test fails to provide any information about the
vascular supply to the pulp, which is the true determinate of pulp
vitality.
• Ideal features of a pulp vitality tester

• Assesses pulp blood flow

• Objective measurements

• Free from error

• Effective for heavily restored teeth

• Effective when the pulp size is reduced

• Quick and easy to use

• Inexpensive
False Negative Results

 Premedication with drugs

 Immature teeth – recently erupted teeth

 Individual patients with atrophied pulps.

 High pains thresholds

 Increased reparative dentin formation or in fibrotic pulp

 Recently traumatized teeth.

False-positive response

• When electrode contacts the gingiva

• liquefaction necrosis
• failure to isolate and dry the teeth properly
• multirooted teeth where the pulp may be vital in
one or more root canals.
EPT- limitations

• relationship between odontoblasts and nerve fibers of the

pulp has yet to develop

• lack of development of Raschkow plexus

• nerve fibers are the last to develop and first to degenerate

Advanced Pulpal Diagnostic Aids

Laser Doppler flowmetry

Xeroradiography
Pulse oximetry Digital imaging
Dualwave spectrophotometry Subtraction radiography
.Computed tomography
Plethysmography

Liquid crystal testing

Electronic thermography

Ultrasonic imaging
 Laser Doppler Flowmetry

• The principle of LDF is based on the detection of movement of

blood cells in the pulpal blood vessels - which thus gives a true
picture regarding pulp vitality.
• The back scattered light has 2 components

 Light back-scattered from static tissue which has the same

frequency as the light going in is not shifted

 The other component is the Doppler shifted light with a

different frequency
Advantages of LDF:
• Non-invasive
• Simple to apply
• Provides a continuous record
• Useful to demonstrate establishment of vitality of
untreated teeth.

Disadvantages:
• Impossible to calibrate the readings in absolute units.
• Output may not be linearly related to blood flow.
 Pulse Oximetry

• Silicon photo detector diode is placed on the opposing surfaces

of the tooth, which is connected to a microprocessor.

• Gingival third - disturbances from gingival circulation or any

gingival trauma or bleeding will interfere with the readings.
 Advantages

• Effective and objective method to evaluate pulp vitality

• Useful in cases of traumatic injuries where the blood

supply remains intact but nerve supply is damaged

• Pulpal circulation can be detected independent of gingival

circulation
 Assessment Of Pulp Oxygen Saturation Levels By Pulse Oximetry For Pulpal
Diseases –A Diagnostic Study
Anusha Bander, Madhusudhana Koppolu et al

Journal of Clinical and Diagnostic Research. 2017 Sep, Vol-11(9): ZC36-ZC39

Aim: The aim of the study was to analyse oxygen saturation levels of different
pulpally inflamed teeth by using pulse oximetry.

• Materials and Methods: Hundred patients were included in the study and
categorized into five groups based on pulpal status of the test tooth by using
heat test and cold test.
• The mean oxygen saturation levels of RP, IP, PN, PC and NC were 85.4%,
81.6%, 70.7%, 94.6% and 0 respectively.

• There was significant difference in the oxygen saturation levels between all
the groups. Pulse oximeter is an effective tool in diagnosing different pulpal
pathologies especially PN which was interpreted inaccurately by thermal tests.
 Dyes
• Staining of fractured teeth with a dye such as methylene blue
dye

• Application of dye directly on tooth to identify fracture

• Chewing a disclosing tablet can also identify cracked tooth

 Transillumination
• Helps to identify vertical crown fracture
• Produces light and dark shadows at fracture site
• A crack will block and reflect the light when transilluminated
 Radiographs
Pre-operative radiograph
• Deep caries
• Large restorations
• Peri apical radiolucency
• Widening of PDL
• Resorption
• Pulp stones
• Root fractures
Radiographic examination:
a. peri-radicular and furcation areas
b. pulp canals
c. periodontal space
d. developing succedaneous teeth
 Treatment Of Deep Carious Lesions

• Indirect pulp capping

• Direct pulp capping

Objectives of pulp therapy:

• Conservation of tooth – healthy, functional state
• Preservation of arch space
• Enhance esthetics, mastication
• Prevention of deleterious effects on succedaneous tooth &
periapical tissues
 Treatment Modalities

• Pulp therapy for primary and young permanent

teeth involves the following techniques

• 1. Indirect pulp capping

Vital pulp
• 2. Direct pulp capping therapy

• 3. Coronal pulpotomy

• 4. Pulpectomy
 Indirect Pulp Capping

Ingle: “A procedure where in small amount of carious dentin is retained in deep caries of
cavity to avoid exposure of pulp, followed by placement of suitable medicament and
restorative material that seals off the carious dentin and encourages pulp recovery

Cohen: “It is a technique for avoiding pulp exposure in the treatment of teeth with deep
carious lesions in which there exists no clinical evidence of pulpal degeneration or
periapical disease.”
Treatment objectives:
• arrest caries progression

• provide conditions conducive to the formation of

reactionary dentin
• stimulate the pulp to generate reparative dentin.

• preservation of the vitality of the non exposed pulp.

 History
• The concept of IPC was first described by Pierre Fauchard in 1746-
recommended that all caries should not be removed in deep, sensitive
cavities “for fear of exposing the nerve and making the cure worse than
the disease”.

• John Tomes -“It is better that a layer of discoloured dentin should be

allowed to remain for the protection of the pulp rather than the risk of
sacrificing the tooth.”
Fusayama (1966):
a) outer layer / infected dentin
b) inner layer / affected dentin

Kopel (1976) identified three distinct layers in active caries:

1. Necrotic, soft, brown dentin

2. Firm but softened dentin(leathery), painful to

3. Hard, slightly discolored, sound dentin containing few bacteria

 Infected Vs Affected dentin

Infected Dentin Affected Dentin

Unremineralized Remineralized
Lacks sensation Sensitive
Stained by Caries detector dye Does not stain

Ultrastructure: Intertubular dentin Ultrastructure: Inter-tubular dentin

greatly demineralized, with partially demineralized, but apatite
irregularly scattered crystals crystals bound like fringes to the
sound dentin
Presence of deteriorated collagen Collagen fibers with distinct cross
fibers bands and interbands

Should be excavated Should be left to remineralize.

 INDICATIONS

History:
-Mild discomfort from chemical & thermal stimuli
-Negative h/o spontaneous pain
Clinical examination:
- Large carious lesion
-Absence of lymphadenopathy
- Normal color of gingiva & tooth
R/F:
- Large carious lesion in close proximity of the pulp
- Normal lamina dura & PDL space
- No interradicular or periradicular radiolucency
Contraindications
History
-Sharp penetrating pain that persists after withdrawing stimulus
-Prolonged spontaneous pain ,particularly at night
O/E
-Excessive tooth mobility
-Discolored
-Non responsiveness to pulp testing techniques
R/E
-Large carious lesion with apparent pulp exposure
-Widened PDL space & interrupted or broken lamina dura
-Radiolucency at the root apices or furcation areas
Two-appointment Technique
(First Sitting)
Two-appointment Technique
(2nd Sitting, 6 to 8 Weeks Later)
Advantages

1. Avoid unintentional pulp exposure

2. Dentist get chance to assess reaction of tooth and caries activity

3. Helps to remove slowly progressing lesion

4. Final excavation of caries is safer in second sitting.

One - Appointment Technique
 Guideline on Pulp Therapy for Primary and Immature Permanent
Teeth 2014:AAPD

• Current literature indicates

• As long as the tooth remains sealed from bacterial contamination,

the prognosis is good for caries to arrest and reparative dentin to
form to protect the pulp.

• Indirect pulp capping has been shown to have a higher success

rate than pulpotomy in long term studies. It also allows for a
normal exfoliation time.
3 distinct types of new dentin formation takes place: sayegh
(1968)

First 30 days
1/5th Tubular dentin is formed

First 2
Cellular fibrillar dentin is formed
months

Third
Globular dentin is formed
month

More than 0.1mm Tubular dentin is formed- uniform

3 months mineralized dentin
Farooq NS, Coll JA, Kuwabara A, Shelton P (2000)
The success rate of IPC for permanent teeth - 74 to 99%
In primary teeth as well, with success rates - 93 to 96 %

Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB (2003)

The success rate of IPC in primary teeth has been shown to increase
seven-fold if the final restoration is a stainless steel crown
 References

 John I Ingle. Text book of endodontics,5th edition,Elsevier,2003.

 Fundamentals of pediatric dentistry – [Link]
 Pathways of pulp – Cohen & Burn

 Grossman’s endodontic practice,12th edition, Lippincott Williams & Wilkins

2010.
 Adv. Dent. Res. 2001; 15; 96
 British dental journal, volume 191, no. 11, december 8 2001

 Stewart RE, Barber TK. Pediatric dentistry. Scientific Foundations and Clinical

Practice. St. Louis: [Link]; 1982.

 McDonald RE, Avery DR, Dean JA. Dentistry for the child and adolescent. 9 th ed.
Haryana: Elsevier; 2011.

 Asma Q, Soujanya E, Nanda K, Pratap K,Sambashiva R. A Recent Advances in Pulp

Capping Materials: An [Link]. 2014 ;8(1): 316-21.

 Qureshi et al. Recent Advances in Pulp Capping Materials: An OverviewJ Clin Diagn
Res. 2014 Jan; 8(1): 316–321

 Accorinteet al. “Evaluation of Mineral Trioxide Aggregate and Calcium Hydroxide

Cement as Pulp-capping Agents in Human Teeth”. JOE — Volume 34, Number 1,
January 2008