Pulp Protection

INTRODUCTION
One of the main goal of operative dentistry is to preserve the health of dental pulp.
Normal pulp is a coherent soft tissue, dependent on its normal hard dentin shell for protection and
hence, once exposed, extremely sensitive to contact and temperature .
Pulp can get irritated by various restorative materials and dental procedures.
To protect the pulp from various irritants, various pulp protective agents are used.

PULPAL IRRITANTS
•Bacterial irritants:
Most common cause for pulpal irritation are bacteria or their products which may enter pulp by
caries , accidental exposure, fracture, extension of infection from gingival sulcus, periodontal
pocket and anachoresis.
•Traumatic:
– Acute trauma like fracture, luxation or avulsion of tooth
– Chronic trauma including parafunctional habits like bruxism.
•Iatrogenic:
– Thermal changes generated during cutting and restorative procedures, bleaching, etc.
– Orthodontic movement
– Periodontal curettage
– Periapical curettage
•Idiopathic:
– Aging
– Resorption: Internal or external.

EFFECT OF DENTAL CARIES ON PULP

Following defence reactions take place in a carious tooth to protect the pulp:
•Formation of reparative dentin:
Rate of reparative dentin formation is inversely related to rate of carious attack.
Faster the caries attack, lesser is the reparative dentin formation.
•Dentinal sclerosis:
In dentin sclerosis the dentinal tubules are partially or fully filled with mineral deposits, thus
reduce the permeability of dentin .
Therefore, dentinal sclerosis act as a barrier for the ingress of bacteria and their product.

EFFECT OF TOOTH PREPARATION ON PULP
1- Pressure :
Pressure of instrumentation causes aspiration of odontoblasts or nerve endings from pulp tissues
into the dentinal tubules.
This disturbs the metabolism of odontoblasts leading to their complete degeneration and
disintegration.
2- Heat Production
If pulp temperature is elevated by 11°F, destructive reaction will occur even in a normal, vital
periodontal organ.
“Heat” is a function of;

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•RPM, i.e. more the RPM greater is the heat production.
•Pressure: It is directly proportional to heat generation.
•Surface area of contact: More is the contact between tooth structure and revolving tool, greater
is the heat generation.
•Desiccation: Desiccation causes aspiration of odonto blasts into tubules. Subsequent
disturbances in their metabolism may lead to the complete degeneration of odontoblasts.
3- Vibrations :
Vibrations are measured by their amplitude or their frequency (the number/unit time).
Vibrations are an indication of eccentricity in rotary instruments.
Higher the amplitude, more destructive is the pulp response.
4- Remaining Dentin Thickness (RDT) :
(RDT) : Is the dentin present between floor of the tooth preparation and pulp chamber.
Generally, 2 mm of dentin thickness between floor of the tooth preparation and the pulp will
provide an adequate insulting barrier against irritants .
As dentin thickness decreases, the pulpal response increases.
5- Speed of Rotation :
Ultra highspeed should be used for removal of enamel and superficial dentin.
A speed of 3,000 to 30,000 rpm without coolant can cause pulpal damage.
6- Nature of Cutting Instrument :
Use of worn off and dull instruments can cause vibration and reduced cutting efficiency.
Their use encourages the clinician to apply excessive operating pressure, which results in increased
temperature.
This can result in thermal injury to pulp.

EFFECT OF CHEMICAL IRRITANTS ON PULP
Properties of a material that could cause pulpal injury are its :
• cytotoxic nature
• acidity
• heat evolved during setting
• marginal leakage

PULP PROTECTION PROCEDURES:
Pulp Needs Protection Against Various Irritants as the Following :
•Thermal protection against temperature changes
•Electrical protection against galvanic currents
•Mechanical protection during various restorative Procedures
•Chemical protection from toxic components
•Protection from microleakage interface between tooth and the restoration.

1/ Pulp Protection in Shallow and Moderate Carious Lesions
In a moderate carious lesion, caries penetrates the enamel and may involve one half of the dentin,
but not to the extent of endangering the pulp.
In these cases, to protect the pulp, liner is applied to cover the axial and/or pulpal wall.
Then, base is placed over the liner.
After the base material hardens, permanent restoration is done .

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 2/ Pulp Protection in Deep Carious Lesions
In deep carious lesion, caries can reach very near or up to the pulp, so treatment of deep carious
lesion requires precautions because of postoperative pulpal response.
Depending upon the condition, following methods for pulpal protection are employed.
A/ Indirect Pulp Capping
Indirect pulp capping is a procedure performed in a tooth with deep carious lesion adjacent to the
pulp .
In this procedure, all infected carious dentin is removed leaving behind the softened carious dentin
adjacent to pulp.
Caries near the pulp is left in place to avoid pulp exposure and preparation is covered with a
biocompatible material.
Indications
•Deep carious lesion near the pulp tissue but not involving it
•No mobility of tooth
•No history of spontaneous toothache
•No tenderness to percussion
•No radiographic evidence of pulp pathology
•No root resorption or radicular disease should be present radiographically.
Contraindications
•Presence of pulp exposure
•Radiographic evidence of pulp pathology
•History of spontaneous toothache
•Tooth sensitive to percussion
•Mobility present
•Root resorption or radicular disease is present radiographically.
Clinical technique
•Band the tooth if tooth is grossly decayed
•Anesthetize the tooth
•Apply rubber dam to isolate the tooth
•Remove soft caries either with spoon excavator or round bur
•A thin layer of dentin and some amount of caries is leftto avoid exposure
•Place calcium hydroxide paste on the exposed dentin
•Cover the calcium hydroxide with zinc oxide eugenol base
•If restoration is to be given for alonger time, then amalgam restoration should be given
•Tooth should be evaluated after 6 to 8 weeks
•After 2 to 3months ,remove the cement and evaluate the tooth preparation. If due to
remineralization and/or formation of secondary dentin, the soft dentin has become hard, then
remove any residual soft debris and then finally give protective cement base and place the
permanent restorative material.

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B/ Direct Pulp Capping
Direct pulp capping procedure involves the placement of biocompatible material over the site of
pulp exposure to maintain vitality and promote healing.
When a small mechanical exposure of pulp occurs during tooth preparation or following a trauma,
an appropriate protective base should be placed in contact with the exposed pulp tissue so as
to maintain the vitality of the remaining pulp tissue .
Indications
•Small mechanical exposure of pulp during
1. Tooth preparation
– Traumatic injury.
•No or minimal bleeding at the exposure site.
Contraindications
•Wide pulp exposure
•Radiographic evidence of pulp pathology
•History of spontaneous pain
• Presence of bleeding at exposure site.
Clinical procedure
•Administer local anesthesia
•Isolate the tooth with rubber dam
•When vital and healthy pulp is exposed, check the fresh bleeding at exposure site
•Clean the area with distilled water or saline solution and then dry it with a cotton pellet
•Apply calcium hydroxide(prefer ably Dycal) over the exposed area
•Give interim restoration such as zinc oxide eugenol for 6 to 8 weeks
•After 2 to 3 months, remove the cement very gently to inspect the exposure site. If secondary
dentin formation takes place over the exposed site, restore the tooth permanently with protective
cement base and restorative material. If favorable prognosis is not there, pulpotomy or pulpectomy
is done.

MATERIALS USED FOR PULP PROTECTION

These materials help to:

• Insulate the pulp
• Protect the pulp in case of deep carious lesion
• Act as barriers to microleakage
• Prevent bacteria and toxins from affecting the pulp.

Classification of Pulp Protective Agents

1. Cavity sealers
• Varnish
• Resin bonding agents
2. Liners
3. Bases

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(1) Cavity sealers :
(A) Varnish
Varnish is an organic copal or resin gum suspended in solutions of ether or chloroform.
When applied on the tooth surface the organic solvent evaporates leaving behind a protective film.
Two coats of varnish are applied using a small cotton pellet for sufficient wetting of cavity walls.
Indications for use of varnish
• To seal the dentinal tubules
• To act as barrier to protect the tooth from chemical irritants from cements
• To reduce microleakage around restorations.

Contraindications
• Use of varnish is contraindicated under glass ionomers as it interferes the bonding of tooth to
these cements
• With restorative resins varnish is not used because the varnish liners dissolve in the monomer of
the resin and it also interfere the polymerization of resins.

(B) Resin Bonding Agents

An adhesive sealer is commonly used under composite restorations .
For application, cotton tip applicator is used to apply sealer on all areas of exposed dentin.
Indications
• To seal dentinal tubules
• To treat dentin hypersensitivity.

(2) Liners :
Liners are typically fluid materials that, because of their rheology, can adapt more readily to all
aspects of a tooth preparation.
They can be used to create a uniform, even surface that aids in adaptation of more viscous filling
materials such as amalgams or composites.
Liners usually do not have sufficient thickness, hardness and strength to be used alone in the deep
preparation.
Indications of use of liners:
• To protect pulp from chemical irritants by sealing ability
• To stimulate formation of reparative dentin.

Materials used as Liners:
(A) Zinc oxide eugenol liners:
• Eugenol is used to alleviate pain from mild-to-moderate inflammation of pulp.
• In low concentration, it acts as obtundant.
• In high concentration, it acts as chemical irritant.
• It should not be used under composite restorations as it inhibits polymerization of bonding agent
and composite.

(B) Calcium hydroxide:

• It stimulates reparative dentin formation

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• It forms a mechanical barrier, when applied to dentin.
• Because of high pH, it neutralizes acidity of silicate and zinc phosphate cements
• Biocompatible in nature
• Bactericidal in nature.
Limitations:
• Low strength
• High solubility

( C) Flowable composites:
They are primarily used under composite restorations and in crown and bridge preparations to
block out undercuts prior to impression taking.
Advantages :
• Adaptation to preparation walls because of their flow
• Placement ease
• Esthetic
• Consistency.
Disadvantages
• Technique sensitive
• Requires maintenance of contamination free field
• Polymerization shrinkage can result in gap formation at resin-tooth interface.

(D) Glass ionomer cements (GIC):

• Bond to tooth structure
• Anticariogenic
• Act as a thermal barrier
• Easy to use.

(E) Light-cured resin-modified glass ionomers (RMGIs):
RMGI materials have a dual-setting reaction—a light-activated, methacrylate crosslinking reaction
and a slower, delayed, acid-base reaction that gives RMGIs an additional period of maximum
flexibility to absorb stress from the adjacent shrinking composite.

(3) Bases :
Bases are used as pulp protective materials since they provide thermal insulation, encourage
recovery of injured pulp from thermal, mechanical or chemical trauma, galvanic shock and
microleakage.
Bases should have sufficient strength so as to withstand forces of mastication and condensation of
permanent restorations.

Classification
• Protective bases: They protect the pulp before restoration is placed
• Sedative bases: They help in soothing the pulp which has been irritated by mechanical, chemical
or other means
• Insulating bases: They protect the tooth from thermal shock.

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Materials Used as Bases :
(A) Zinc oxide eugenol :
• Excellent sealing quality.
• Bacteriostatic in nature.
• Anodyne effect.

(B) Zinc phosphate cement :
• Reduces the thermal conductivity of metallic restorations
• Blocks undercuts in the preparation wall in case of cast restorations.


(C) Polycarboxylate cement :
• Chemically bonds to tooth
• Antibacterial properties
• Well tolerated by the pulp
• Varnish should not be used with polycarboxylate cement because it would neutralize the
adhesion potential of the cement.

(D) Glass ionomer cement :
• Anticariogenic property
• Chemical bond to tooth
• Well tolerated by the pulp

PREVENTION OF PULPAL DAMAGE DUE TO OPERATIVE PROCEDURE
To preserve the integrity of the pulp, the dentist should observe certain precautions while rendering
treatment:
• Excessive force should not be applied during insertion of Restoration
• Restorative materials should be selected carefully, considering the physical and biological
properties of the material
• Excessive heat production should be avoided while polishing procedures
• Avoid application of irritating chemicals to freshly cut dentin
• Use varnish or base before insertion of restoration .
• Patient should be called on recall basis for periodic evaluation of status of the pulp.