1. Prepared By: Abeer Al-Mahdi 2009 Pulp Biology 510 RDS King Saud University, Endodontic Postgraduate College of dentistry Supervised by Prof. Saad Al-Nazhan

2. The Contents: ☻ Vital pulp therapy. ☻ Direct pulp capping. ☻ The success and evaluation criteria. ☻ Materials used for DPC. ☻ MTA and Calcium hydroxide.

3. It is one of the treatment options in cases of inflamed pulps in primary and young permanent teeth. The studies showed high success rate of vital pulp therapies compared with conventional root canal treatment or the success rate was comparable to that of RCT.

4.  It involves application of a medicament, dressing, or dental material to the exposed pulp in an attempt to preserve its vitality.

5.  Primary carious pulp exposures  Permanent teeth with history of spontaneous pain.  Radiographic evidence of pulpal or periapical pathosis.  Calcification of pulp chamber or root canals.  Excessive hemorrhage at the exposure site, or exposures with purulent or serous exudates

6.  37% in cases of exposed pulps after 5 yrs and 13% after 10 yrs (Barthel et al., 2000).  Recent long-term clinical studies indicate that direct pulp capping can produce success rates of between 80% and 90%.

7. Clinical criteria Radiographic criteria Biological criteria

8. The biological properties: 1-Insure intimate sealing against the bacterial microleakage:  Kakehashi et al 1965, found that normal pulp wound healing was observed in germ-free rats, indicating that the presence or absence of microbial flora is the major determinant in healing of exposed reodent pulps. 2-Inert and biocompatible.

9. 3-Promote the dentin bridge formation at the area of exposure: The secretion of dentin bridges can be influenced by pulp-capping materials, degree of mechanical injury, and the creation of dentin debris during operative procedures (Murray et al., 2002).

10. What are the available materials?  The first method of capping exposed pulps, using gold foils, was described by Pfaff in 1756. Thereafter, numerous agents for direct pulp capping have been recommended.. (Dammaschke T.2008)Dammaschke T

12. Self-etching adhesive and calcium hydroxide on human pulp tissue:  The clearfil SB ability to induce reparative dentine was significantly weaker than Dycal. (Lu et al, 2008)  Direct pulp capping in doges teeth with the self-etching adhesive system did not allow pulp tissue repair and failed histopathologically in 100% of the cases. (da Silva La,et al, 2009)

13. Tetra-calcium phosphate-based cement: dentin bridge formation was observed on exposed pulps of rats with no evidence of necrosis or marked inflammation. ( Yoshimine and Maeda, 1995)

14. Adhesive resin- based composite:  The globules of resin can migrate into pulp tissue and stimulate inflammation (Kitasako,et al.,1999).  In addition, polymerization shrinkage during the placement of these materials can create marginal gaps to permit bacterial leakage to occur (Pashley, 1996).

15. Calcium hydroxide combined with Vancomycin: The combination of calcium hydroxide with vancomycin in monkeys was somewhat more successful in stimulating regular reparative dentin bridges. ( Gardner, et al 1971)

17. The disadvantages of Ca(OH)2: The presence of tunnels in dentin barrier Extensive dentin formation. High solubility in oral fluids. Lack of adhesion and degradation after acid etching

18.  It was introduced in 1993 by Torabinejad.  Pitt Ford et al, 1996 were the first to evaluate the performance of MTA for pulp capping in monkey's teeth.  Pulp capping with MTA is recommended for teeth with carious pulp exposures specially immature teeth with high potential for healing( Farsi N, et al 2006 )  It was introduced in 1993 by Torabinejad.  Pitt Ford et al, 1996 were the first to evaluate the performance of MTA for pulp capping in monkey's teeth.  Pulp capping with MTA is recommended for teeth with carious pulp exposures specially immature teeth with high potential for healing( Farsi N, et al 2006 )

19.  MTA is superior in terms of dentin bridge formation during the early wound healing process in human dental pulp. (Min, et al 2008)  MTA seemed to heal the pulp tissue at a faster rate than Ca(OH)2 cement in human teeth. (Accorinte, et al 2008)  MTA was clinically easier to use as a direct pulp-capping agent and resulted in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal. (Nair PN, et al 2009)  MTA is superior in terms of dentin bridge formation during the early wound healing process in human dental pulp. (Min, et al 2008)  MTA seemed to heal the pulp tissue at a faster rate than Ca(OH)2 cement in human teeth. (Accorinte, et al 2008)  MTA was clinically easier to use as a direct pulp-capping agent and resulted in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal. (Nair PN, et al 2009)

21. Its excellent sealing ability (Torabinejad et al. 1993. 1994. Bates et al. 1996. Fischer et al. 1998,Wu et al.1998). Biocompatibility (Kettering & Torabinejad 1995, Torabinejad et al1997.1998, Holland et al. 999, Mitchell el al. 1999, Keiser et al. 2000). Its excellent sealing ability (Torabinejad et al. 1993. 1994. Bates et al. 1996. Fischer et al. 1998,Wu et al.1998). Biocompatibility (Kettering & Torabinejad 1995, Torabinejad et al1997.1998, Holland et al. 999, Mitchell el al. 1999, Keiser et al. 2000).

22. A view of the pulp cap area of a 2-month sample capped with MTA, (1) MTA; (2) dentinal bridge; (3) pulp; (4) calcification. 1 2 3 4

23. A view of the pulp cap area of a 3-month sample capped with MTA, (1) MTA; (2) dentinal bridge; (3) odontoblasts 1 2 3

24. A view of the pulp cap area of a 3-month sample capped with calciumhydroxide, (1) Calcium hydroxide; (2) pulp. A few vessels can be seen (arrows) indicating mild hyperaemia 2 1

25. A view of the pulp-cap area of a 3-month sample capped with calciumhydroxide, (1) calcium hydroxide; (2)dentine-like structures; (3) pulp. Polymorphonuclear leucocytes dominate the superficial layers (top), whereas lymphocytes are more frequently dispersed in the deeper parts (bottom).Mild hyperaemia is also present (arrows). 3 2 1

26. White MTA and Gray MTA  Both types produce similar inflammatory cellular response in short and long term periods (Vasoughhosseini et al,2008)  The main difference is the color.