PULP PROTECTIVE

MEASURES

Dr.Mandari G J
PULP PROTECTIVE MEASURES cont….

1. INDIRECT PULP CAPING

 Indications
i) Tooth is asymptomatic
ii) Periodic discomfort caused by food
pack
iii) There is no pulp exposure.
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Technique
1. Give proper local anesthesia.
2. Isolate the carious tooth.
3. Remove caries in the enamel and make a proper cavity.
4. Remove caries in the dentine using a round bur inserted in a
low speed hand-piece.
5. When deep in the dentine use a fuschin dye to distinguish the
infected dentine from the non-infected dentine. The infected
dentine will get discolored.
6. The infected dentine is also sensitive when attempts are made
to remove it while the non-infected is not.
7. Remove only the infected dentine.
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8. Cover the non-infected inner dentine with a liner such as

CaOH (Dycal or Life) or ledermix (CaOH + steroid +
antibiotic).
9. Place a base such as Zinc oxide on top of the liner.
10. Finally place a Temporary restoration.
11. After 6-8 weeks give a L.A to the tooth and open the tooth.
12. Check the remaining dentine that should now be hardened to
various degrees i.e. re-mineralized (seen as a radio-opaque
zone on the X-ray picture).
13. Remove any the soft debris by means of an excavator. Place
a base. Place a final Permanent filling.
NOTE:
- This is called a two appointment technique
- Materials: CaOH or Zinc Oxide Eugenol.
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2.DIRECT PULP CAPING

 Indications
i) Pulp exposure due to trauma or operative
mismanagement.
ii) Pulp exposure of not more than 24 hrs
ii) Clean site of exposure.

NB:Size of exposure does not influence prognosis of

direct pulp capping. i.e. it can be a big exposure
and succeed (Tronstad pg 87) i.e. form a dentine
bridge.
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 Advanced age is not a contraindication to direct

pulp capping. However, with age the capacity of the
pulp cells to form dentinal bridge is reduced.
Therefore only in rare incidences will the procedure
succeed.(Tronstad pg 87).
 Because of this, it is better to do pulpectomy unless
when the morphology of the tooth does not allow.
That is pulp capping to be reserved for young
permanent teeth and deciduous (for indirect
caping).
 Success in treating exposure at the cervical region
is the same as pulp horn exposure (Tronstad pg 87)
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Failure of pulp caping of young permanent teeth

 10-20% (Tronstad pg 87).
 These failures maybe noted after 2-3 yrs or even more.
Therefore follow-up to be 3,6, 12 months later, and then once
a year as deemed necessary (Tronstad pg 87).

Failure of pulp caping is indicated by:

 Clinical symptoms- pain, swelling etc
 Radiologically : (Tronstad pg 87)
 Constricted/obliterated root canal (sign of chr. Inflamation)
 Widened root canal- sign that the pulp has become necrotic,
hence no dentine is formed around the root canal walls.
PULP PROTECTIVE MEASURES cont….

Techniques
1. Clean and dry the tooth
2. Control the bleeding at the site by irrigating with normal
saline and compress the area with cotton pellets.
3. Mix calcium hydroxide powder with normal saline.
4. Place a thin layer of the mix over the entire pulpal floor.
5. Place a base of Zinc oxide eugenol on top of calcium
hydroxide. This should form a tight seal against bacteria.
6. Place a permanent filling.
7. Monitor the progress i.e
8. Thermal tests for pulp vitality.
9. Radiographic pictures
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 To compare the width of the canal with that

of the contralateral tooth. If the width has
reduced it is a sign of chronic inflammation
within the pulp.
 If the width has increased it is a sign of
death of the pulp which makes it impossible
to form dentine along the walls.
 To monitor any radioluscencies around the
apex. This as well is a sign of failure of the
procedure
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NOTE:
 Dentinal bridge forms after around eight weeks. Sometimes it
may take longer. Therefore it is good to monitor the tooth
even after 8 weeks ie even after 2 years.Failure may occur
i.e pain e.t.c may be noted even after the bridge had formed
after 8 weeks.
 Zinc oxide Eugenol cement has been unsuccessful for direct
pulp caping because of it's high concentration of eugenol
which affects directly the odontoblasts. However it is
successful during direct pulp caping.
 Under favorable circumstances the pulp responds by laying
down reparative dentine in a form of a dentinal bridge. This is
done by mitosis of Fibroblast cells and undiferentiated
mesenchyma cells to form new odontoblast cells
responsible for formation of the thew dentine.
PULP PROTECTIVE MEASURES cont….

 Direct pulp caping fails in most of the deciduous

teeth because of the fast spread of infection in the
pulp chamber. Therefore direct pulp caping should
not be done to deciduous teeth. Instead pulpotomy
should be done.
 In case the pulp perforation is due to dental caries,
pulp caping should not be done. Instead pulpotomy
should be the choice of treatment.
 The success rate of direct pulp caping in young
non-inflamed permanent teeth is around
80- 90%.(Tronstad). In inflamed teeth it is 30-40%.
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Pulp caping of inflamed/carious teeth

i) Local necrosis will form at the
exposure site
ii) Hence dentine bridge will not be able
to form.