TREATING THE VITAL TOOTH APEXOGENESIS

1. Submitted by:
Shekhar kumar mandal
BDS IV
Roll no:26
SUBMITTED TO:
Dr. Deepika Kapoor
Department of Pedodontics and
Preventive Dentistry
College of Medical Sciences,
Bharatpur, Nepal

2. 1. INTRODUCTION
2. TREATMENT MODALITIES
3. TYPES OF PULP CAPPING
4. INDIRECT PULP CAPPING
5. PATENT DENTIN MEASURING DEVICE
6. DIRECT PULP CAPPING
7. FEATURES OF SUCCESSFUL PULP CAPPING
8. PULP CAPPING AGENTS
9. CONCLUSION
10.REFERENCES

3.  PULP is defined as soft
tissue forming inner
structure of tooth and
containing nerve and blood
vessel , also called as tooth
pulp.
The dental pulp occupies the
center of each tooth and
shapes itself to a maturation
of the tooth .

4. PULP TREATMENT
CONSERVATIVE RADICAL
1. Protective base 1. Pulpectomy
2. Indirect pulp therapy 2. Root filling
3. Direct pulp therapy
4. Pulpotomy

5. FIG: Exposed or nearly
exposed pulp
1) Crown
2) Root
3) Restoration
4) PULP CAPPING
5) Pulp chamber

6. PULP CAPPING TECHNIQUES
INDIRECT PULP
CAPPING
DIRECT PULP
CAPPING

11. History
 Mild discomfort from
chemical and thermal
stimuli
 Absence of spontaneous
pain

12.  Large carious lesion
 Absence of lymphadenopathy
 Normal appearance of adjacent
gingiva
 Normal colour of tooth
Clinical examination

13.  Large carious lesion in
close proximity to the
pulp
 Normal lamina dura
 Normal periodontal
ligament space
 No interradicular or
periapical radiolucency

14. CONTRAINDICATIONS

17. Large carious lesion with apparent
pulp exposure
Interrupted or broken lamina dura
Widened periodontal ligament space
Radiolucency at the root apices or furcation areas

19. Indirect Pulp Capping Procedure

20. Two Appointment
Technique

21. First appointment
• Tooth is isolated with a rubber dam
• The gross caries is removed with a large round bur (6 or
8) or sharp spoon exclavator .Care must be taken
removing the caries to prevent exposure of pulp .Care
must be taken to eliminate all the caries at the DEJ .
Because of its closeness to the surface caries left in the
areas will likely cause failure .
• The remaining thin layer of caries is covered
with a radiopaque biocompatible base
material and sealed with a durable interim
restoration
• Wait for 6-8 weeks.
• During this time the caries process
in the deeper layer is arrested.

22. .
• If the tooth is asymptomatic, the surrounding
soft tissues are free from swelling and the
temporary filling is intact , the bitewing
radiograph at the treated tooth should be taken
for the presence of reparative dentin .
• Carefully remove all the temporary filling material ,
especially base over the deep portion of the cavity
floor.The remaining affected carious dentin should
appear dehydrated and flaky and should be easily
removed
•The cavity preparation should be irrigated and gently dried.
•Cover entire floor with Hard setting Ca(OH)2 dressing
• Base should be placed with reinforced GIC or ZOE
• Final restoration with composite or Amalgam

24. Avoid unintentional pulp exposure
Dentist get chance to assess reaction of tooth and
caries activity
Helps to remove slowly progressing lesion
Final excavation of caries is safer in second sitting.

25. ONE APPOINTMENT
TECHNIQUE

26. If the tooth remains asymptomatic there is no need for reentry.
The removal of bacteria and substrate together with an effective seal of restoration
provides the means whereby the pulp can recover the laying down secondary dentin .
Assure retention and sealing of temporary restoration
A protective radiopaque biocompatible base material must be placed prior to
temporary restoration
Remove all the soft moist and leathery texture of dentin
The DEJ must be free from all softened material and stain even if the stain is firm .
All margins are left adequately supported and peripheral caries is removed with a
large round bur .
The tooth is isolated with rubber dam ,the cavity outline form is made .

27. Indirect Pulp capping Procedure

28.  Electronically measures the
thickness of dentin layer above
the pulp chamber during crown
preparation with a simple touch
of probe
 GREEN LIGHT:safe zone
 ORANGE LIGHT:limit of safe
zone
 RED LIGHT:danger of
penetration through dentin.

29. Remaining dentin thickness(0.5-2mm)
Choice of indirect pulp capping agent

30. First 30 days
•1/5th Tubular dentin is formed
First 2
months
•Cellular fibrillar dentin is formed
Third
month
•Globular dentin is formed
More than
3 months
•0.1mm Tubular dentin is formed

31. Infected Dentin
▪Highly demineralized
▪Unremineralizable
▪Superficial layer
▪Lacking sensation
▪Stained by 0.5% fuschin or i.e. 1.0% acid
red solution
▪Ultrastructure- intertubular dentin
greately demineralized, with irregular
scattered crystals.
 Presence of deteriorated collagen fibers
that have only distinct cross bands and
no interbands.
▪Should be excavated
Affected Dentin
 Intermediately demineralized
 Remineralizable
 Deeper layer
 Sensitive
 Does not stain
 Ultrasyructure: intertubular dentin
partially demineralized, but
apatitie crystals bound like fringes
 Sound collagen fibers with distinct
cross bands and interbands.
 Should be left remineralized.
Difference between affected and infected dentin

34. One year later, Rebel performed the first animal experiments with disastrous results, so he regarded the
exposed pulp as a doomed organ.
The first scientific clinical study to compare different capping materials was made by Dätwyler in 1921,
whereupon zinc oxide-eugenol showed the best results.
Hunter(1883) suggested 1st pulp capping materials. He recommended covering an exposure with a mixture
of Sorghum molasses and the droppings of the English sparrow and claimed 98% success rate
Until the end of the 19th century, most materials were used empirically with the idea that the pulp tissue
must be irritated by etching or cauterization to heal.
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.

35. Placement of a medicated or a nonmedicated material on a pulp that
has been exposed in the course of preparing a cavity in a carious
tooth or as the result of trauma.[Kopel, 1997]
Since then, calcium hydroxide has been recommended by several
authors for direct pulp capping, but it took until the middle of 20th
century until it was regarded as the standard of care.
In 1920 Hermann, introduced calcium hydroxide for root canal fillings.
Between 1928 and 1930 he studied the reaction of vital pulp tissue to
calcium hydroxide to prove that it was a biocompatible material.

36. Encouragement of young , healthy pulps to initiate a
dentin bridge, thus walling of the exposure site
OBJECTIVES
a) preservation of vitality of the radicular pulp.
b) relief of pain in patients with acute pulpagia.
c) ensuring the continuity of normal apexogenesis in immature
permanent teeth

37. Accidental pin point exposure of pulp when
excavating deep caries, less than 1 sq. mm.
surrounded by clean dentin for (<24hours)
Traumatic fracture of tooth(<24 hours) with
pin point exposure
Iatrogenic exposure during cavity
preparation & crown preparation

38. Bleed if touched but not excessively and
controlled easily with cotton pellet
Normal vitality tests without tender to
percussion
No radiographic evidence of periradicular
pathology
Young patient

39. History of severe spontaneous tooth aches at night
Excessive tooth mobility
Periodontal ligament thickening
Intraradicular radiolucency
Excessive bleeding at exposure site
Purulent , serous exudate from exposure
External or internal resorption
Swelling and fistula with associated tooth

40. Localization of infection & inflammation in primary teeth is poorer than
in permanent teeth. [Mc Donalds,1956]
Incidence of reparative dentin formation in primary teeth is more
extensive than permanent Teeth. [Sayegh , 1968]
Primary pulp contain high cellular content which might be responsible
for failures. Primary pulp responds more rapidly to the effects of
dentinal caries then the perm. Teeth. [Rayner & Southam, 1979]
Undifferentiated mesenchymal cells may differentiate into osteoclasts
in response to caries or pulp capping material which could lead to
internal resorption. [Kennedy,1985]

41. Primary Pulp are more closer to outer enamel surface & are rapidly
infected by the carious lesion. Once exposed pulpal inflammation is so
involved that the DPC proves unfavorable. [Kennedy & Kopel,1985]
Increased resorption in primary teeth is because already root resorption
is in progress. [Stanley, 1985]
Wide apical foramina in pri. teeth leads to abundant blood supply which
results in more typical and faster inflammation response to irritation than
in permanent teeth. [Kopel,1992]
Acc. To finn, in primary teeth pulp capping is best carried out in teeth
where dental pulp has been mechanically exposed.
Pulp capping not recommended. Internal resorption or acute
dentoalveolar abscess may result . [Pinkham]

42. Rubber Dam placement
Deep carious dentin
excavation:inhibit infected matter
from entering pulp. Necrotic &
infected dentin chips will invariably be
pushed into the exposed pulp during
last stages of caries removal.
Bleeding controlled with sterile cotton
wool (blast of air not used).No
instruments should be inserted into
exposure site.
Layer of hard setting calcium flowed IRM
and a permanent restoration. In small teeth,
Ca(OH)2 can act as base. Blood clot-not
allowed to be formed after cessation of
bleeding from exposure as it impedes pulpal
healing. Kopel,1992 a more adequate seal of
pulp capping is needed (Stainless steel crown
-best).

43. Dentin bridging
Maintenance of pulp vitality
Lack of undue sensitivity or pain
Minimum pulpal inflammation response
Ability of pulp to maintain itself without progressive degeneration
Lack of internal resorption and/ or interradicular pathosis
In Accordance with Kennedy & Kopel (1985):

46. IDEAL REQUIREMENTS
Ideal dressing material for pulp therapy in primary teeth does not
exist, but the material should be:
1. Bactericidal
2. Biocompatible
3. Harmless to the pulp, surrounding structures and the
permanent tooth germ.
4. Promote healing
5. Not interfere with physiologic process of resorption.

47. Calcium hydroxide
Zinc oxide eugenol cement
Corticosteroids and antibiotics
Polycarboxylate cement
Isobutyl cyanoacrylate and tri
calcium phosphate ceramic
Collagen
Bonding Agents
Calcium phosphate
Hydroxyapatite
Mineral trioxide aggregate
GIC/RMGIC
Lasers
MTA 1-Calcium
Growth factors
Odontogenic ameloblast
associated protein
Endo sequence root repair material
Castor oil bean cement
Thera Cal

48.  It is a colorless crystal or white powder
prepared by reacting calcium oxide with water.
 The use of calcium hydroxide in endodontics was introduced by
Hermann in between 1920-1930.
 Calcium hydroxide was most favored as a pulpotomy agent in the
1940s and mid- 1950s.
 “Calcium hydroxide has the ability to form reparative dentin form
ation”,this rationale was introduced by Teuscher and Zander
in 1938.
 Lim and Kirk, in an extensive review of direct pulp capping
literature, found little support for pulp obliteration and
internal resorption being a major complication of pulp
capping
 Estrela et al. summarized the antibacterial properties of
calcium hydroxide.

49. ADVANTAGES
Reparative dentin formation
Antibacterial action
Pulp protection
The tissue-dissolving property
Newer preparation shows Improved
strength, essentially no solubility in acid, and
minimal solubility in water and control the
over working time
DISADVANTAGES
Pulp obliteration
Internal resorption
Lack of adhesion to hard tissues
Microleakage
Short working time of self cured
preparation
Base paste –
Glycol salicylate-40%-reacts with
calcium hydroxide and ZnO
Titanium dioxide-Inert fillers
Calcium tungstate - Fillers
Barium sulphate-provide radioopacity
Catalyst paste
Calcium hydroxide-50%-principal
reactive ingredient
Zinc oxide-10%
Zinc stearate-0.55%-accelerator
Sulphonamide-39.5%-oily
compound acts as carrier.
COMPOSITION
•AVAILABLE AS
a)Pulpdent b)Hydrex : two paste system c)Dycal.

50. D: After 8 weeks
A: After 24 hours
B: After 2-3 weeks
C: After 4-5 weeks

51. Three distinct zone can be visualised:
I. Zone of obliteration (early changes: area of superficial debris)
II. Zone of coagulation necrosis (Schroeder’s layer of “firm necrosis”,
Stanley’s “mummified zone”)
III. Line of demarcation
Zone of obliteration
Early changes: area of
superficial debris
Drug’s caustic effect
Tissue in immediate contact
becomes deranged and
distorted.
This Zone consists of-
i. Debris
ii. Dentinal fragments
iii. Blood clot
iv. Blood pigment
v. Calcium hydroxide
particles
Zone of coagulation necrosis
Weaker chemical reaction from 1st
zone reaches the subjacent , more
apical tissues & results in this zone of
coagulation & necrosis.
Thickness- 0.3-0.7 mm (Acc. to
Craig: 1mm thick)
Represents devitalised tissue
without complete obliteration of its
structural architecture
Cellular details-greatly diminished
Capillaries outlines, nerve bundles
& pyknotic nuclei can be recognized.
Stimulates subjacent vital pulp
Vascular changes occur
Line of demarcation
Develops between Zone
of coagulation necrosis
and vital tissues
This zone results from
reaction of Calcium
hydroxide with the
tissue protein to form
proteinate globules.

52. It is a new remarkable biocompatible material with exciting clinical
applications pioneered by Dr. Mahmoud Torabinejad, Loma
Linda University, in 1993
COMPOSITION
MTA is a mechanical mixture of 3 powder ingredients:
• Portland cement (75%)
• Bismuth oxide (20%)
• Gypsum (5%)
Composition includes :
• Tricalcium silicate
• Dicalcium silicate
• Tricalcium aluminate
• Tetracalcium aluminoferrite
• Calcium sulfate
• Bismuth oxide (provides radio-opacity)

53. CONTRAINDIACTION
Irreversible pulpitis
INDICATION
•To preserve pulp vitality
• Prevent pathological changes in the
periradicular tissues
• Mechanical pulp exposures
• Carious pulp exposures with
immature apices.
PROPERTIES OF MTA
•Mixing MTA:
Powder: Water = 3: 1
Glass SLABor paper slab used
•SETTING TIME:
Hydration of MTA powder results in a
colloidal gel that solidifies to a hard
structure in 3~ 4 hrs which has a long
setting time with less shrinkage.
•pH=12.5
ADVANTAGES
• Antimicrobial Activity
• Prevents MicroLeakage over vital pulp
• Cementoconductive
• Non toxic and Non-mutagenic
• Cell adherence & growth
• Alkaline phosphotase/ osteocalcin
• Interleukin production
• Periodontal ligament attachment to
cementum growth
• Dentinal bridge formation
DISADVANTAGES
• More difficult to manipulate
• Longer setting time

54. • Direct Pulp Capping
• Apical plug
• Root End Filling
• Perforation Repair
• Furcation involvment
• Resorptive Defects
• Immature apices
(apexogenesis/ Apexification)

55. Ca(OH)2 MTA
Hard tissue formation Not much Root end induction
Calcific bridge Not continuous Continuous with dentin
Biocompatibility Low High
Degree of Inflammation Low High
Sets Not Hard Hard
pH High High
Solubility Partially disolve Less soluble
Permeable to fluids Non permeable
Viscosity Poor Good
Application Not easy to apply in RC Easy
Resorption Rate vary with density Non-resorbable
Appical barrier formation Change rate/ initial narrow
appical width
Less/wide
Patient follow up More Less
Treatment Delay shortens

56.  Germicidal agent
 Used in indirect pulp capping due to its
 This gives the pulp the chance for
healing & regeneration
 Direct contact →chronic inflammatiom ,abscess formation and
liquefaction necrosis.
 After 24Hr of capping →a mass of red blood cells &PNLs. Demarcated
from the underlying tissue by zone of fibrin and inflammatory cells.
 After 2W of capping → pulp degeneration &chronic inflammation
extends deep to the apex.
Palliative affect
Excellent initial seal
Kills bacteria present in
carious lesions
So arrests the caries process

57.  Different studies were led on laser energy
to overcome the histological deficits of electrosurgery.
 Used in Direct pulp capping & pulpotomy.
 Co2 Laser , Argon Laser, Diode Laser, Erbium:Yttrium-Aluminum Garnet (Er.YAG).
 Laser radiation has been proposed for pulp treatment based on its haemostatic,
coagulative and sterilizing effects.
 Laser irradiation creates a superficial zone of coagulation necrosis that remains
compatible with the underlying tissue and isolate pulp from effects of the subbase.
Mortiz et al., reported that the thermal effects of laser radiation caused
sterilization and scar formation in the irradiated area, which in turn preserves the
pulp from bacterial invasion.

58.  Alpha-tricalcium phosphate & Tetracalcium phosphate (4CP)
set & convert to hydroxyapatite.
 Stimulate the pulp to form hard tissue.
 No finding of necrotic pulp tissue in direct contact with 4CP
cement compared to calcium hydroxide slight acidity after
mixing
 4CP cement has mechanical strengths so it could be used as
so called “dentin substitute”. Pulp capping agent
lining material

59.  There were suggested as direct pulp capping and pulpotomy
agents with the introduction of adhesive dentistry in both
primary and permanent dentition.
 Adhesive material forms:
- A complete marginal seal
- Prevents bacterial intrusion
- Allowed pulp repair, characterized by a new odontoblast cell
layer underlying the dentin bridge formation.
 Many studies have indicated that composite & resin-modified
glass-ionomer are compatible with pulp tissue.

60.  Propolis, a resinous material collected by
honey bees, has been used as a traditional anti-infalmmatory
and anti-bacterial medicine for many centuries.
 Used as indirect pulp capping paste when mixed with ZnO
powder and this showed similar effect of ZnO and Eugenol as
secondary dentin formation.
 In direct capping with this paste showed no pulp
. degeneration and formation of protective layer.

62. PULP CAPPING AGENT ADVANTAGES DISADVANTAGES
Zinc oxide eugenol cement. 1)Reduces inflammation. 1) Lack of calcific bridge
formation.
2) Releases eugenol in high
concentration which is
cytotoxic.
3) Demonstrates interfacial
leakage.
Corticosteroids and
antibiotics.
1) Reduces pulp inflammation.
2) Vanomycin and calcium hydroxide
stimulated a more regular reparative
dentin.
1) Should not be used in patients
with risk from bacteremia.
Polycarboxylate cement. 1)Chemically bond to tooth structure. 1) Lack of antibacterial effect.
2) Fail to stimulate calcific bridge
formation.
Inert materials( Isobutyl
cyanoacrylate and tri
calcium phosphate ceramic)
1) Reduces pulp inflammation.
2) Stimulate dentin bridge formation.
1) NONE of these materials have
been promoted in dentist
profession as a viable technique
Collagen 1) Less irritating than calcium hydroxide
and promotes mineralization.
1) Does not help in thick dentin
bridge formation.
Bonding Agents 1) Superior adhesion to hard tissues.
2) Effective seal against micro leakage.
1) Has cytotoxic effect.
2) Absence of calcific bridge
formation.

63. PULP CAPPING
AGENT
ADVANTAGES DISADVANTAGES.
Calcium phosphate. 1) Helps in bridge formation with no
superficial tissue necrosis.
2) Significant absence of pulp
inflammation.
3) Good physical properties.
1) Clinical trials are necessary to
evaluate this material.
Hydroxyapatite. 1) Biocompatible.
2) Act as a scaffold for the newly formed
mineralized tissue.
1) Mild inflammation with superficial
necrosis of pulp.
Carbon dioxide lasers 1) Formation of secondary dentin.
2) Bactericidal effects.
1) Technique sensitive.
2) Causes thermal damage to pulp at
high doses.
Glass ionomer/ Resin
modified glass
ionomer.
1) Excellent bacterial seal.
2) Fluoride release, coeffient of thermal
expansion and modulus of elasticity
similar to dentin.
3) Good biocompatibility.
1) Cause chronic inflammation.
2) Lack of dentin bridge formation.
3) Cytotoxic when in direct cell
contact.
4) High solubility and slow setting
rate.
MTA 1-Calcium 1) Helps in dentin bridge formation
without formation of necrotic layer.
2) Shear bond strength is higher than
conventional GIC and similar to RMGIC.
1) Presence of 10% calcium hydroxide
interferes with complete curing of the
material, residual monomers causes
cytotoxicity.
Growth factors. 1) Formation of osteodentin and tubular
dentin.
2) Formation of more homogenous
reparative dentin
3) Superior to calcium hydroxide in the
mineralization inducing properties.
1) High concentration is required.
2) Half life is less.
3) Appropriate dose response is
required to avoid uncontrolled
obliteration of pulp chamber.

64. PULP CAPPING
AGENT
ADVANTAGES. DISADVANTAGES.
Odontogenic
ameloblast
associated
protein.
1) Biocompatible.
2) Accelerates reactionary dentin
formation.
3) Normal pulp tissue appearance
without excessive tertiary dentin
formation and obliteration of the
pulp cavity compared to MTA
1) Till now only invitro studies
were conducted.
2) Further studies regarding
this material is required.
Endo sequence
root repair
material
1) Antibacterial property.
2) Less cytotoxic than MTA, Dycal and
light cure calcium hydroxide.
1) Bioactivity of the cells were
decreased gradually when
exposed to this material.
Castor oil bean
cement.
1) Good antibacterial property.
2) Less cytotoxic.
3) Good mechanical properties.
4) Facilitates tissue healing.
5) Better sealing ability than MTA and
GIC.
6) Less cost.
1) Bio inert rather than
bioactive.
2) More clinical trials are
required.
Thera Cal. 1) Act as protectant of the dental pulp
complex.
2) Has strong physical properties, no
solubility, high radiopacity.
3) TheraCal exhibited higher calcium
1) It is opaque and whitish in
color and it should be kept thin
so as not to show through
composite material that are
very translucent affecting final

65. Pulp capping is a procedure that maintains pulp vitality
and function, promotes healing/repair, prevents
breakdown of peri radicular supporting tissues, and
promotes formation of secondary dentin
Direct pulp capping is a procedure used in asymptomatic
teeth with deep caries reaching upto pulp. It is another
method than Indirect pulp capping to treat deep caries
but it is not a preferred method in children as success
rate is very low, like indirect pulp capping in this also a
suitable medicament is placed to induce dentin bridge
formation

66.  Teacher’s Note
 Textbook of Pedodontics 2e, - Shobha Tandon
 Principle and practice of pedodontics, 3e, Aarti Rao
 Textbook of Pedodontics, 3e, Nikhil Marwah
 Dentisry on Child and Adloscence, Mc Donald
 Text book of Endodontics, Grossman
 Pathway of Pulp 9e,Cohen
 Stewart DJ and Kramer IRH. Effects of calcium hydroxide on the
unexposed pulp, J. Dent
 Suneda YT et al . A histopathological study of direct pulp capping with
adhesive resins
 Teethanime.com/pulp
 Peter. Murray et al. Analysis of pulpal reactions to restorative
procedures, materials, pulp capping, and future therapies crit rev oral
biol med 509-13:5202002