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Today we are going to talk about pulp capping and preventive endodontics, this lecture is important in the final exam.

The dental pulp


Dental pulp can be defined as soft mesenchymal connective tissue that occupies the pulp cavity in the tooth (in the center of the tooth). It's enclosed by dentine all around whether it was in the coronal part or in the radicular part, so you can imagine that the dental pulp will be like this in 3 dimensions.

Pulp horns are usually underneath the cusp tips, this should help you in identification of the location of the canal (I think the Dr means the orifice), and help you about the possibility of pulp exposure while preparing the cavity. In young teeth the pulp is higher than in older ones, because of the formation of secondary dentine.

The functions of the pulp


1234Nutrition. Defense. Sensation. Formation.

Histology of the pulp


We have primary dentine and secondary dentine. The primary dentine is the dentine that is formed when the tooth is still forming (before closure of the apex), secondary dentine is formed after root formation is complete, and it's deposited by microns throughout your life. Tertiary dentine is formed when there is an insult or injury to the tooth; it can be reactionary or reparative. I think you remember for the histology that we have something called predintin, which is the unmineralised layer of dentin.

So the odontoblasts cell bodies are within the pulp and the process are within the dentin. If you take a cross section of the tooth you'll see the following:

First you have projection of the pulp into the cusp which equals pulp horns, then you the pulp chamber which is located in the coronal part, and then you have the radicular which is located in the root, sometime we have lateral canal and accessory canals and then we have the apical foramen (which is the opening of the pulp to the apex of the tooth).

So if we took this part of the tooth and we magnify it we'll have the body of odontoblasts, odontoblastic process, dentinal tubules and fluid and the dentin layer.

The blood and nerve supply


We have the main external carotid which gives the inferior and superior alveolar (Extra info: the inferior alveolar and the posterior superior alveolar and the middle superior alveolar are braches of
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the maxillary artery, while the anterior superior alveolar is a branch of the infraorbital artery, both of them (the maxillary and the infraorbital) comes from the external carotid). There is a high blood pressure inside pulp. The neurovascular bundle inters the tooth through the apical foramen.

The contents of the pulp


1- Cells: odontoblasts, fibroblasts, WBCs and undifferentiated mesenchymal cells inside the pulp (this one is important). 2- Fibrous matrix: collagen and reticular fibers. 3- Ground substance matrix: medium to transport nutrient and debris in and out of the cells.

We have dentin then immediately predintin then immediately odontoblasts, the predintin will be calcified to dentin.

Under the odontoblasts we have the cell free zone (CFZ) then the cell rich zone (CRZ) then the pulp core. These are important because when injury takes place you have to memorize them to know how the process is going on. So we have the odontoblastic layer on the pulpal wall (body of the odontoblasts) which forms the secondary dentin, in the cell free zone we have few cells that's why we don't have much innervations, then the cell rich zone which have more innervations because there are more cells (and they need

nutrients!!), then the pulp core which is the center of the pulp, it resembles the cell rich zone, it's just in the core.

Pulp irritation
Things that can cause pulp irritation can be divided into 4 categories: 1- Microbial: bacteria inside the tooth, which maybe newly introduced or dormant, that's why it's very important to keep very good moisture control during your work to prevent bacterial contamination. 2- Chemical: can be dental materials (amalgam, composite resin, any cement or lining material you use, acid etch sometimes, phenol, eugenol or silver nitrate) or anti-bacterial agents. 3- Thermal. 4- Mechanical: mechanical and thermal are inter-related, and you often do that in the clinic, you have to pay attention to these things: the heat produced during cavity preparation from the handpiece, the depth of the cavity (you should be conservative, dont go deep, just follow the caries, the soft dentin and leave the hard one), to avoid heat buildup you have to pay attention to the speed of rotation, the water coolant and the burs should be sharp and clean. If you have pulp exposure the first thing to do is to maintain very good isolation. Sometimes the pulp exposure is related to inserting of pins (which are used to retain large amalgam fillings). Pulp exposure can be iatrogenic or pathological, pathological you have nothing to do with it, it happens because the caries extension was very deep or it could be due to trauma (fracture and exposure). The mechanical trauma can be acute or chronic: The acute which can be coronal or root fracture, and can be luxation where the tooth moves only inside the bone. The chronic can be from parafunctional habits or tooth wear, an example of parafunctional habits is chewing gum!! It might not cause trauma to the tooth trauma but it may cause it to the TMJ.

Pulp response to injury


Can be mild injury or severe injury, when we have mild injury the odontoblasts are not injured or not irreversibly damaged, so they can continue secretion of the tertiary dentin which is regenerative (or reactionary) type we talked about and deposit it around the pulp and protect it. In case you have severe injury (and we are talking about pulp exposure) these odontoblasts are irreversible damaged now and they can't continue to function and most probably they die, so we need a repair type of tertiary dentin, in mild injury it was a regenerative (or reactionary) type, here it's different because there is recruitment of new cells (undifferentiated cells that we
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talked about) these differentiate into odontoblasts and they start secreting reteriary (I think the Dr. means reparative) dentin. It's important for us clinically, the remaining dentin thickness is important because as we go deeper we are exposing the odontoblasts to a higher risk of injury especially irreversibly, so don't go so deep because sometimes you are following stains! You have to leave it (leave the hard dentin). Repair is an inflammatory response! We need the inflammation! We need the signals and the molecules and the factors in this process because they are important, but it should be balanced! If inflammation is too much beyond the needed level we have uncontrolled process, in which the inflammation won't be repair process anymore, it's going to be a destructive process, so it should be balanced.

Treatment modalities
If this happen in the clinic we have 3 vital techniques: 1- Indirect pulp capping. 2- Direct pulp capping. 3- Pulpotomy. These techniques are vital because they are conservative, it preserve vitality and the function of the pulp, we are helping the tooth to repair itself and hence the longevity of the tooth and the final restoration.

Pulp capping
It's placing of a specialized material or lining in contact with the pulp or very close to it to promote the healing, relieve the inflammation and encourage formation of new dentin. Examples of materials used in pulp capping: calcium hydroxide and MTA. In direct pulp capping you have pinpoint pulp exposure, you directly apply material on it and then another lining material or base and then you place the final restorations. So what are the indications of pulp capping? 1- Immature permanent tooth or if you have a mature tooth with minimal or simple restorative treatment, you'll go to cap it and then place a permanent simple restoration (no need for crown or onlay). 2- When you have little bleeding at the exposure site, if there is no bleeding at all you start suspecting necrosis that's why it's important to take the history from the patient, the nature of the pain, the duration, these will give you an idea if the tooth vital or necrotic or irreversibly inflamed, so if the symptoms are favorable and you have a tiny exposure with minimal bleeding you can go with direct pulp capping.

3- If there is adequate coronal restoration and you are going directly for a permanent restoration, for example if you have a small class IV you can restore it simply because it's not a badly broken crown. Contraindication on the other hand: 1- If you have symptoms that indicate irreversible pulpitis or necrosis of the pulp. 2- If there is swelling or pus, definitely you don't go for direct pulp capping, maybe when you are working on a molar the mesial side will have a clean exposure with minimal bleeding while the distal root is severely inflamed and necrotic and have periapical lesion, so we may face this in multi-rooted teeth, so you still can go for direct pulp capping, you have to go for RCT! (The Dr said this in 24:44 in the record!).

(I didn't attend the lecture and the slides were not available when I prepared the script but I guess this picture resembles the one that the Dr talked about in the lecture). 3- If you see this in the clinic what do you do? You should ask about history of trauma, you take a radiograph and you do the vitality test and even if you have a minute exposure you go for RCT. 4- The Dr presented a picture and commented about it: If you have a large exposure with no bleeding you suspect necrosis, here you don't have large uncontrolled bleeding, you have a large area with shadow of the pulp but if you can see that you have multiple carious lesions, so in a patient with poor oral hygiene you might go for root canal treatment rather than direct pulp capping, so oral hygiene is significant. 5- Sometimes you have a case where half of the tooth is missing, it needs crown or onlay (most probably it needs cuspal coverage, so in this case we might go for something called elective endodontic treatment, we electively do RCT to use the coronal or the radicular part to retain the restoration, if you are going to do simple restoration in such case it won't last. 6- If you have pulp stones or calcification it's going to be difficult to do pulp capping, because if we do this we are stimulating tertiary dentin, so the pulp is already receding and you are inducing tertiary dentin formation so it's going to be occluded totally, and eventually

you are going to lose vitality and going to be impossible to do RCT so you have to keep this in mind, in such cases we should refer the case to specialist. If you don't have enough tooth structure to retain the restoration, or if caries level is beneath the gingiva you have to go for RCT or extraction.

Variable affecting pulp repair


1- The most significant variable when you have pulp repair when is the bacterial microleakage, that's why it's important if you have direct pulp exposure or you are close to the pulp you maintain very good isolation. 2- Odontoblast cell layer (The layer underneath) because this is the source of the tertiary dentin. 3- Operative debris and the dentin bridge formation, we don't want operative debris. 4- Volume of the capping material: it shouldn't be tiny and shouldn't be overfilling the cavity; you only need the amount that covers the part that is exposed. 5- Tunnel defect: we have the newly formed layer of dentin and it's called dentin bridge, sometimes this bridge which is protecting the pulp space has defects, where there are spaces between the newly formed dentin, if we have this then we have compromised isolation and we are exposing the tooth to bacterial microleakage which will lead to poor prognosis.

So , if you imagine that Odontoblast are( sorry I cant hear the word exactly at 29:0229:04 ) this is the tertiary dentin particles for example ( formed layer by layer ) , and this is the dentine bridge , if you can see here , there is a space here , this is the tunnel defect , if we have this space here , we will increase the chance for bacterial microleakage inside the pulp , it will compromise our treatment . So , good material , Good isolation you will have good bridge

This picture may help you

* The Odontoblast-like cells are important , and this bring us back to the thickness of the dentine layer . * All of these reduce the post-operative complications like when you do direct pulp capping and you are giving instruction to the patient {e.g : you might feel pain or sensitivity }

The factors that reduce these complications : (which is the failure of the treatment) :
#1) The Odontoblast-like cell layer : [ the thickness of the remaining dentin ]. #2) Time : the more time you give it to the patient , there will be more formation of tertiary dentine and thicker bridge , and good time will lead to subside . #3) Debris : when you are working an operative work you are reducing debris , these debris might be infected , might be carious dentine that you are creating , the debris will go inside and diffuse through the dentinal tubules inside the pulp , it will penetrate the pulp depending on the remaining thickness ( V.I.Factor ) .

So, if you are minimizing your operative debris + using LOW SPEED HAND PIECE when you are very closed to the pulp + maintaining very good isolation , You are reducing the post-operative complications and increasing the success of your work .

END of part one Done by: Ammar aldawoodyeh