Materials used in Pulp therapy

Contents : Materials used in pulpotomy. Materials used in pulp capping. Materials used in pulpotomy. Materials used in partial pulpotomy. Materials used in pulpectomy in permanent teeth. Material used in apexification. Materials used in root canal treatment.

-Consist of Zno. Powder & Eugenol liquid. -PH =7 -Slow resorption. 1- Material used in pulp capping:   1- Zno/E : -Consist of Zno. Powder & Eugenol liquid. -PH =7 -Slow resorption. -Success rate : 65-86 % -Used in indirect pulp capping Excellent seal. Antibacterial properties.

Suffer from interfacial failure upon amalgam condensation 2- Ca(OH)2 : -PH =12 Disadvantages : Suffer from interfacial failure upon amalgam condensation Fails to provide a long term seal against micro- leakage poor marginal adaptation to dentine does not exclusively stimulate reparative dentine formation

Disadvantage Ca(OH)2: follow- degrade and dissolve beneath restoration. produce a gap between the dentine interface when used with bonding resins. dentin bridge beneath calcium hydroxide are associated with tunnel defects. Ca(OH)2 +corticosteroids → improve tissue receptivity & markedly reduce the oedema and inflammation.

Effect : Ca(OH)2 Antibacterial Stimulate reparative dentine formation. Success rate in permanent teeth 44-95% - in vital pulp 75- 95%

Based on researcher stated that most of : -Postoperative sensitivity. 3- dentin bonding agent: Based on researcher stated that most of : -Postoperative sensitivity. -Thermal stimuli. -Pulp inflammatiom & pathosis. Mode of adhesion to dentine: - Several challenges are faced by clinician: Heterogenous strength of dentine. Smear layer. Dentine fluid in dential tubules.

Advantages: (dentin bonding agent). Decrease micro leakage. Antibacterial effect. Long term increase bond strength. No clinical discomfort.  

4-Growth factor Naturally: present in local wound healing environment. Function: enhance regeneration & reparative function BMP = ''Bone Morphogenetic Protein'' It is a protein bone extract, containing multiple factors that stimulate bone formation. Studies: application of BMP during pulpal healing induce reparative dentine formation & differentiation of adult pulp cells (odontoblasts). Has the ability to induce formation of both osteodentine & tubular dentine.

first BMP implanted in amputated pulp. Dissolved within 2 weeks. Mode of action : first BMP implanted in amputated pulp. Dissolved within 2 weeks. Stimulate mitosis of umc's which differentiate into osteodentinoblast. Osteodentinoblast lay down osteodentine matrix. Osteodentine matrix help in differentiation of odontoblaste. New reparative dentin in place of dissolved agent → super facial to & not at the extent of vital pulp tissue.

5-Mineral trioxide aggregate :(MTA) New biocompatible material with numerous applications in dentistry. Chemically: Powder '' Tricalcum (oxide- Silicate- Aluminate) + silicate oxide On hydration → colloidal gel of increase alkalinity (12.5) , setting time 3 hours. Properties & advantages: Osteo-conductive. Biocompatibility.

Comparisons: 1-MTA vs Ca(OH)2 → decrease inflammation & better increase dentine bridge formation.  2-MTA vs Portland cement: MTA =75% Portland cement + 20% Bismuth.O + 5%Gypsum. Identical in Macro structure & microstructure. Identical as pulp protective material. Identical in reparative dentine formation. 3-MTA vs GI (Ketac – endo sealer) : better biological properties in apexification.

Function: Drawbacks: Cost. Long setting time. Discoloration. Prevent bacterial micro leakage Biocompatible Promotes regeneration Due to: Excellent sealing Biocompatibility High alkalinity 12.5

Advantages: MTA. 1-Excellent, long lasting seal of ability due to Long setting time → decrease setting shrinkage. Decrease solubility. Ability to set even in moisture or blood. No dimensional changes on setting. 2-Antibacterial properties due to high PH. 3-Minimum micro leakage through long setting time, prevents setting shrinkage (slow setting).

4-Bio compatible, non-cytotoxic, tissue reaction with no inflammation. 5-Promote tissue regeneration. a) Repair of perforation b)Allow deposition of cementum when used as root end filling material after apexification. c)Promote regeneration of periodontal ligament. d)Can be used as R.C sealer. 6-Produce better apical barrier than Ca(OH)2.

- (MTA) Used in: pulp capping ''direct-indirect'', pulpotomy, apexification, apexiogenesis, root end filling material, root perforation.

6-Bio active glass : Composition: Ca oxide, sodium oxide, phosphors oxide, Si oxide. Properties: Biocompatible Antibacterial Chemical reaction: When contacts tissue fluids → series of chemical reactions occur→ Hydroxyl- Carbonate – Apetite (HCA) layer → attract osteoblasts→ mineralized tissues.

Applications: Bone repair. Pulp capping. Apexification. Apexogenesis. Dentine remineralization or mineralization. Draw backs: Expensive

Able to set and convert to hydroxyl apetite. 7-Ca-Ph compound ''CPdS'' Composition: 1-Alpha tri Ca Ph (ᾳ 3CP) 2-Tetra Ca Ph (4 Cp) Able to set and convert to hydroxyl apetite. Stimulate pulp to form hard tissue indirect contact to cells of pulp. Mechanism is not clear but may be due to biocompatibility or osteo conductive properties.  

8-High Mwt hyaluronic acid: Stimulate u.m.c's to form odontoblasts and form repair dentine. 9- Modified bioglass formula: Indication: direct capping material Funcation: a)Increase incidence of dentine bridge formation ''biocompatible'' 10-Co2 laser: Used in direct pulp capping Thermal effect of laser radiation → sterilization & scar formation at irradiation area → preserve pulp vitality by protecting it from bacterial invasion.

12-Propolis: 11-Ozon O3: Properties:   11-Ozon O3: Very Powerful oxidization agent, produce sterilization effect at site of application due to its antibacterial properties kill (99.9%) . 12-Propolis: Resinous material collected by honey bees and mixed with wax. Properties: -Anti bacterial, anti viral , anti fungal. -Anti inflammation & anti oxidation. Studies on pulp therapy: Propolis vs Ca(OH)2: 75% viability of PDL cells & fibroblasts vs 25% Ca(OH)2 Propolis vs MTA & Ca(OH)2 : dentine bridge formation. Propolis vs Ca(OH)2 & CMCP : no significant different in antibacterial effect against (EF &St.)

Material used in pulpotomy   Material used in pulpotomy  1-Ca(OH)2 - Not indicated in primary teeth: --Chronic pulp inflammation --Internal resorption Modification of Ca(OH)2 in pulpotomy: 1-Ca(OH)2 + Corticosteriod. -Increase tissue respectivity -Decrease oedema & inflammation. 2- Ca(OH)2 + 5% buffered glutardehyde sluation(PH= 8) alkaline a-anti- septic action b-sustained hemostatic effect

Formocresol: Action: Introduced (1904 by Buckley). Composition: 19% formaldehyde 19 ml 35% tricresol 35 ml 25% glycerin 25ml 21% water 21ml Action: 1-Formaldehyde Formocresol releases formaldehyde which diffuses through pulp tissues with the following actions: 1-Binds with cellular protein → pulp fixation→ prevent tissue autolysis 2-Bactericidal effect due to binding of formaldehyde with bacterial proteins. 3-Inactivates oxidative enzymes in pulp.

2-Tricresol Action: 1-Potentiates effect of formaldehyde on protein ''both bacterial & pulp tissue protein'' 2-Lipid solvent thus attacks lipoprotein of the bacterial cell membrane causing cell lysis

Modifications: Clinical evaluation of formocresol: 1:5 concentration Buckley's formocresol in primary teeth = 4% formaldehyde → success rate in primary teeth 90%, success rate in permanent teeth 71-100% → achieve desired cellular response + decrease cytotoxic Effects Modifications: 1- 1:5 conc. Buckley's formocresol, decrease cytotoxic effect & achieve desired cellular response. 2- Zno/E + formocresol, decrease diffusing → omission of formocresol from sub bone. 3- 1 minute application, least inflammatory response + tissue reaction .

-Decrease post operative systemic transportation. Why we do modifications ? -Decrease post operative systemic transportation. -Decrease effect of enamel hypoplasia. -Decrease toxicity. -Decrease mutagenicity. -Decrease carcinogenicity.

Variation in technique: 1-Time of application When compare 1 min application with 3 or 5 min → least inflammation response & tissue reaction. 2-Concentration from 19% to 4%. 3-Omission of & from sub-base, microscopical studies with Zno/E give identical result.

- Safe use of formocresol: 1-In the lowest concentration (1:5 dilution of Buckley's formocresol) 3 parts glycerin + 1 part distilled water = 4 parts diluents 4 parts diluents + 1 part formocresol = 1:5 concentration 2-For the least time (1 minute). 3-Eliminate its use from the filling material sub base. 4-The cotton pellet used should be dried before placing inside the pulp chamber. 5-Avoid inhalation through wearing of masks. 6-Avoid contact with tissues. 7-Usually keep in a tightly sealed containers.

Formocresol debate: Mutagenic. Genotoxic. Postoperative systemic transport. Carcinogenic. Immunotoxic.

Advantages over formocresol: 3-Gluteraldehyde: Concentration: 2% Success rate: 92-98% Action: Similar to formocresol, having 2 functional aldehyde groups which fix protein by affecting the free amino groups. Advantages over formocresol: Give more stable fixed tissues. Do not diffuse out of tooth. Decrease cytotoxic & antigenic. Decrease systemic absorbtion. Bactericidal. Short (instant) reaction time < 1 min. Unstable on storage.

4-Ferric sulphate: (Astringedent) - 15.5 % solution - Non aldehyde chemical Advantage: 1-No systemic absorbtion 3-Decrease inflammation 4-No toxicity 5-No internal resorption Success rate = diluted formocresol with less toxicity 97- 98%

Jojoba oil: Oil extracted from seeds ''El Tawil & El Dokky, 2009) Properties: Bio- compatible Anti- bacterial Anti-inflamatory Increase healing Jojoba oil vs formocresol : anti inflammatory property It is an alternative to formocresol

Other experimental materials   Other experimental materials Freeze dried bone: Superior to Ca(OH)2 → dentine bridge → preserve vitality of pulp & no or minimum inflammation response. Advantages: Quick Self- limiting hemostasis Good visibility No systemic effect

Co2 laser Disadvantage: Heat cause tissue distraction. Persistant inflammation (pulpal). Energy can't be isolated to surface root resorption. Co2 laser Heamostatic – coagulative – sterilization Increase healing & increase dentine bridge – preserve pulp vitality . N.B: Laser pulpotomy 1- Co2 laser 2-Argon laser 3-Diode laser

Materials used in pulpectomy for primary teeth Requirement: 1-Keep root free from infection ''antiseptic effect'' 2-Resorbed with same rate of primary root. 3-Excess beyond root apex → easily & quickly absorbed. 4-Harmless to the periapical tissues & permanent successor. 5-Radiopaque. 6-Doesn't discolor the tooth. 7-Should not shrink & be easily removed if necessary. 8-Fill the root canal and adhere to the walls of the canal.  

1-Zno/E 2-KRI iodoform paste: -Alone or with fixative (formocresol) -May cause chronic inflammation reaction & slow resorption of root over retention -Success rate 65-85%   2-KRI iodoform paste: -Zno + iodoform -Success rate 84-100% Advantages: -Anti-septic due to liberation of free iodine -Resorbed with some rate of primary teeth -Less irritant to tissue if over filled -Cytotoxic > Zno/E

3-Vitapex 4-Pulpdent -Ca(OH)2 + Iodoform → effective as KRI paste. -Resorbs at a slightly faster rate than that of the roots.   4-Pulpdent -Ca(OH)2 + methyl cellulose base. -Success rate 86.7% -Alkaline properties as local buffer. - Help in healing at periapical tissue. - Activate alkaline phosphatase for hard tissue formation.  5-Ledermix -Corticosteroid (1% triamcinolone) & antibiotic (3% chlortetracycline) -Bactericidal effect -Successful for traumatized permanent teeth.

Material used in apexification Ca(OH)2 -Success rate (74- 100%) -Apical barrier within 5-20 months -Replace ever 3 months’   BMP MTA -Best mineral trioxide aggregation.

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