Conservative Treatment of Pulp Tissue

Dentistry and Oral Sciences
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Francine Benetti Faria
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Conservative Treatment of
Pulp Tissue: Indications,
Materials and Techniques
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I dedicate this book to my greatest partner, my husband,
who is a great supporter of my work, and to my parents
for their constant support.
Contents
Preface ........................................................................................... ix
Acknowledgments ....................................................................................... xi
Chapter 1 Pulp Biology – Structure and Function ...........................1
Isabella Faria da Cunha Peixoto,
Sylvia Cury Coste, Thiago César da Silva Lima
and Juliana Vilela Bastos
Chapter 2 Etiology of Pulp Alterations............................................21
Leticia Cabrera Capalbo, Renan Dal Fabbro,
Carlos Roberto Emerenciano Bueno
and Leopoldo Cosme-Silva
Chapter 3 Conservative Treatment of Pulp Tissue:
What Is Its Importance? .................................................41
Alexandre Henrique dos Reis-Prado,
Gabriel Pereira Nunes, Mariana Viana Donato,
and Francine Benetti
Chapter 4 Behaviour Guidance of Young Patients in
Dental Treatment.............................................................53
Valéria Silveira Coelho,
Letícia Fernanda Moreira-Santos
and Joana Ramos-Jorge
Chapter 5 Management of Deep Carious Lesion in Dentin ...........85
Hebertt Gonzaga dos Santos Chaves,
Isabella Figueiredo Assis Macedo,
Barbara Figueiredo, Francine Benetti
and Paulo Carvalho Tobias Duarte
viii Contents
Chapter 6 Treatment of Pulpal Exposures in Vital Teeth ...........103

Hebertt Gonzaga dos Santos Chaves,
Isabella Figueiredo Assis Macedo,
Barbara Figueiredo, Francine Benetti
and Paulo Carvalho Tobias Duarte
Chapter 7 Regenerative Endodontics ............................................127
Alexandre Henrique dos Reis-Prado,
Sabrina de Castro Oliveira,
Lara Cancella de Arantes, Juliana Goto
and Francine Benetti
Chapter 8 Biomaterials Used in the Conservative
Treatment of Pulp Tissue ..............................................161
Carlos Roberto Emerenciano Bueno,
Marina Tolomei Sandoval Cury,
Ana Maria Veiga Vasques,
Ana Cláudia Rodrigues Silva
and Leopoldo Cosme-Silva
About the Editor .......................................................................................189
List of Contributors ..................................................................................191
Index .........................................................................................193
Preface
Dental pulp is a loose, vascularized connective tissue located within the walls
of dentin. This tissue plays an important role in tooth longevity, whose
functions are formative, sensitive, nourishing and defensive. Pulp exposure
can be caused by several factors, such as a carious lesion or tooth fracture,
leading to inflammation of the pulp tissue, which can result in necrosis if
intervention is not performed quickly. Conservative treatments may be
indicated when removal of the carious lesion results in pulp exposure in a
young primary or permanent tooth, with normal pulp or reversible pulpitis, or
after accidental pulp exposure. The affected tissue is amputated and the
remaining pulp is considered vital when there is no suppuration or excessive
bleeding, and when there are no radiographic signs of infection or periapical
pathological resorption. The benefit of keeping the remaining pulp tissue is
extremely important in young teeth, as it retains all of the tooth's
proprioceptive functionality. Regenerative endodontic procedures, on the
other hand, have gained popularity among clinicians. Pulp revascularization
consists of restoring sensory, immunological and defensive properties of the
pulp-dentin complex, based on tissue engineering principles. Although
different protocols are discussed in the literature, there is no standard for
performing the revascularization technique. The ideal procedure would be one
that, based on microbiological and immunological principles, indicates the
standard irrigant and intracanal medication that is capable of removing and
inhibiting microbial growth and making the root environment conducive to
repopulation by stem cells. The property of inducing the formation of
mineralized tissue gives a material its bioactivity, and makes it favorable for
use in endodontics, where the repair of pulp tissue and formation of tertiary
dentin are aimed. Thus, this book addresses the physiology and pathology of
the pulp tissue, in order to communicate the importance, indications and
techniques of conservative treatments to be performed, especially in young
patients, as well as the most suitable biomaterials.
Acknowledgments
I am grateful to everyone who contributed to the success of this book. I know

that everyone worked with commitment and affection to provide the best
content. All chapters were worked on from a scientific basis, with the objective
of helping clinicians, graduate students, and undergraduate students with the
conservative treatment of pulp tissue. I also thank Raquel Carvalhaes de Paiva
Oliveira Guimarães, who provided the cover image for this book.
Chapter 1
Pulp Biology – Structure and Function
Isabella Faria da Cunha Peixoto, Sylvia Cury Coste,

Thiago César da Silva Lima and Juliana Vilela Bastos
Restorative Dentistry Department, School of Dentistry, Universidade
Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
Abstract
The dental pulp is the loose connective tissue that occupies the pulp
cavity in the core of each tooth. Anatomically, the dental pulp can be
divided into coronal and radicular pulp. The radicular pulp communicates
with surrounding periodontal tissue at the apical foramen, where vessels
and nerves enter and leave the tooth, providing vitality to the tooth organ.
Although the dental pulp contains components common to all connective
tissues, it has the unique characteristic of being enclosed in a rigid
framework of dentin—an avascular mineralized connective tissue.
Despite being distinct tissues, mature dentin and pulp share a common
embryonic origin and are structurally and functionally coupled. This
close association results in a reciprocal influence of both tissues
throughout the life of the vital tooth, from which the concept of a pulp-
dentin complex (PD complex) originated. Therefore, adequate
knowledge about the development and the morphological and functional
characteristics of the PD complex as a whole is fundamental to
understanding the biological basis for its responses to external damage,
as well as to better substantiate future regenerative approaches.
Keywords: dental pulp, pulp physiology, cell biology, tissues, dentistry.

Corresponding Author’s Email: bebelpeixoto@hotmail.com.
In: Conservative Treatment of Pulp Tissue

Editor: Francine Benetti Faria
ISBN: 978-1-68507-987-1
© 2022 Nova Science Publishers, Inc.
2 I. F. da Cunha Peixoto, S. C. Coste, T. C. da Silva Lima et al.
1. Introduction
Tooth development is initiated during embryogenesis and proceeds in multiple

phases until adolescence, with the emergence of permanent teeth. Dental tissue
formation is characterized by the interaction between the epithelium, derived
from the embryonic endoderm, and the ectomesenchyme, derived from the
neural crest. The development of the dental pulp begins in the eighth week of
embryonic life with the proliferation and condensation of the mesenchymal
cells around the placodal thickenings of the oral epithelium along the dental
lamina, called enamel organs.
The epithelial components are separated from the adjacent mesenchyme
by a basement membrane, where the signals from epithelium to mesenchyme
are delivered, and vice versa. This signaling is essential for tooth development,
which is evidenced by the fact that the oral mesenchyme separated from the
oral epithelium fails to form teeth (Mina & Kollar, 1987). During tooth
morphogenesis, odontogenic ectomesenchyme gives rise to two cell lineages:
(1) cells of the dental papilla, surrounded by the inner enamel epithelium, and
(2) dental follicle cells, which form the lining cell layer around the entire tooth
germ.
Together, the enamel organ surrounded by the ectomesenchyme forms the
tooth germ that undergoes different morphological stages starting as a bud,
moving to the cap, and then the bell stage. At the cap and bell stages, areas of
cell condensation in the central area of the inner enamel epithelium, the enamel
knots, function as signaling centers for the morphogenesis of the tooth crown
through the expression of Sonic hedgehog (Shh), bone morphogenetic proteins
(BMPs), and fibroblast growth factors (Thesleff, 2003). In the cap stage, the
cells located at the periphery of the dental papilla begin morphological and
histological differentiation, becoming pre-odontoblasts, followed by a polarity
inversion of adjacent cells from the internal epithelium of the enamel organ,
which go on to form pre-ameloblasts. At the bell stage, odontoblasts complete
their differentiation and deposit the first layer of dentin, the mantle dentin,
leading to the final differentiation of ameloblasts, which synthesize and
secrete the organic matrix of enamel (Figure 2A) (Hu et al., 2005; Tziafas &
Kodona, 2010; Zohrabian et al., 2015; Baranova et al., 2020). Several
products, such as growth factors, transcription factors, adhesion molecules,
integrins, and extracellular matrix elements, participate in the epithelium-
ectomesenchyme interactions throughout odontogenesis. The formation of
dentin is centripetal, occurring from the outside to the inside of the tooth germ,
while enamel deposition is centrifugal, occurring from the inside out.
Pulp Biology 3
Figure 1. Dental pulp structure and components. (A) Pulp vessels and nerves
communicate with periodontal tissues at the apical foramen (blue arrow). (B)
Histological aspect of pulp-dentin complex and pulp zones. De, dentin; PD,
predentin; O, odontoblastic layer; CF, subodontoblastic cell-free zone; CR, cell-rich
zone; PC, pulp core. (Courtesy of Professor Francine Benetti) (C) Dental pulp cells.
o, odontoblasts; f, fibroblasts; e, endothelial cells; sc, stem cells. (D) Smaller vessels
leave the central pulp arterioles and pass toward the peripheral pulp, where they form
an extensive capillary network. (E) Aδ-fibres (red arrows) are located in the
periphery of the pulp at the sub-odontoblastic and odontoblastic layer, predentin, and
within dentinal tubules. C-fibers (green arrows) are located deeper in the pulp, most
likely extending from the Raschkow plexus into the cell-rich zone and central region
of the pulp. (F) Different aspects of the odontoblast body cell according to the
secretory activity: (a) secretory odontoblasts during tooth formation; (b) young and
(c) adult mature odontoblasts responsible for secondary and reactional dentin
formation; (d) old odontoblast with reduced cell size and flattened shape. (Adapted
from Couve et al., 2013).
At the end of the crown phase, the differentiation events reach the cervical
region, when the inner and outer epithelia of the enamel organ join to form the
cervical loop (Figure 2B). This epithelial dual-layer gives rise to Hertwig’s
epithelial root sheath (HERS), which continues to proliferate to form the tooth
root, simultaneously with the beginning of the tooth-eruption process
(Bosshardt & Nanci, 2003; Kawashima & Okiji, 2016). Similar to the process
of crown formation, peripheric cells from the dental papilla differentiate into
odontoblasts and deposit the first dentin matrix, the mantle dentin.
Subsequently, the inner epithelial layer of HERS secretes a material that
contains enamel matrix proteins that will form the intermediate cement
together with the mantle dentin. Immediately thereafter, HERS degenerates

and is fenestrated by the follicular cells, which will originate cementoblasts
after coming into contact with the root surface. As the epithelial sheath is
fragmented, discrete aggregates of epithelial cells called Malassez epithelial
rests are observed in the surrounding tissue. Simultaneously, the cells in the
outer region of the follicle differentiate into osteoblasts, which will form the
alveolar bone, and the cells in the central region of HERS remain intact at the
root end until development is complete (Figure 2C) (Kawashima & Okiji,
2016; Hu et al., 2005).
Figure 2. Tooth development. (A) Stages of tooth development in humans: (I) bud,
(II) cap, and (III) bell. (B) At the end of the crown phase, the inner and outer
epithelia of the enamel organ join to form the cervical loop and the (C) Hertwig’s
epithelial root sheath (HERS), which continues to proliferate to form the tooth root.
(D) Detail of the asymmetric division of progenitor cells from papilla, which will
originate fully differentiated odontoblasts (O) and post-mitotic committed cells that
remain in the inner zone of the odontoblastic layer (SC).
2. Morphology
Histologically, the dental pulp has an appearance similar to mucoid mature

connective tissue containing nerves, vessels, and cells surrounded by a
network of loosely arranged collagen fibers and abundant ground substance.
The dental pulp is organized into four well-defined zones. First, the pulp
periphery is circumscribed by a specialized odontogenic layer composed of
Pulp Biology 5
odontoblasts. Subjacent to the odontoblastic layer, there is a cell-free zone

(Weil’s zone) with numerous bundles of reticular fibres (Korff’s fibres),
together with a dense net of capillaries loops and a plexus of free end nerve
fibres (Raschkow plexus). Under the cell-free zone, there is a cell-rich zone
containing mainly fibroblasts and undifferentiated mesenchymal cells that join
together to form a network. The central portion of the pulp tissue consists of
larger bundles of vessels, nerves, and collagen fibres (Figure 1A, 1B, 1D).
2.1. Pulp Cells
Dental pulp contains different types of cells, including odontoblasts,

fibroblasts, inflammatory and immunocompetent cells, endothelial cells, and
an expressive population of mesenchymal stem cells (Figure 1C).
2.1.1. Odontoblasts
Odontoblasts are highly specialized post-mitotic cells, derived from the
ectomesenchymal cells that migrate from the neural crest to form the dental
papilla during the early stages of tooth formation. They align along the
periphery of the dental pulp, where they form predentin and dentin by
secreting their collagenous and non-collagenous organic matrix components
and control the mineralization process. After differentiation, odontoblasts are
long-life stable cells that are not normally replaced, assuming distinct aspects
according to their dentin-secretory activity. During active dentin formation,
the odontoblast is a columnar polarized cell with a basally located nucleus and
well-developed synthetizing organelles, including the endoplasmic reticulum
and Golgi complex, and numerous mitochondria and vesicles. As dentin
synthesis diminishes, odontoblasts become progressively shorter with a
decreased number of organelles (Figure 1F). Furthermore, evidence suggests
that odontoblasts maintain an active autophagic-lysosomal system for the
turnover and degradation of cellular components, ensuring cell organization
and functionality for decades (Couve & Schmachtenberg, 2011).
The cellular bodies of odontoblasts are organized at the pulp-dentin
interface in the form of a continuous palisade, laterally attached by numerous
adherens junctions and firmly jointed to the predentin through well-developed
distal junctional complexes (Sasaki & Garant, 1996). These membrane
junctions are responsible for their fixation, polarization, and cell
communication, resulting in the formation of a kind of a functional syncytium
(Couve, 1986; Arana-Chavez & Massa, 2004; Couve et al., 2013).
As odontoblasts form dentin, their cellular bodies move centripetally

toward the pulp, leaving cytoplasmatic extensions in the inner part of dentin,
and originating parallel tubules that run from the dentin-enamel junction to the
pulp. The odontoblast process is the secretory pole of the cell, containing
numerous vesicles of various sizes. The most prevalent organelles are
microtubules and microfilaments, which are involved in cytoplasmatic
extension, transport of materials, and the provision of a structural framework.
Occasionally, mitochondria can be found in the initial portion of the process,
near the predentin (Figure 7) (Holland, 1985; Sasaki & Grant, 1996).
2.1.2. Fibroblasts
Fibroblasts are the most abundant cells in the pulp and are distributed
throughout the tissue, although they are particularly abundant in the cell-rich
zone of the coronal pulp. Their main function is to synthesize and remodel the
extracellular matrix of the pulp. In addition to acting on tissue structure,
fibroblasts play an important role in tissue regeneration, with a pivotal role in
pulp homeostasis. They can secrete soluble factors in response to biochemical
stimuli, such as growth factors, chemokines, and cytokines (Goldberg et al.,
2008). Pulp fibroblasts are also considered tissue sentinels, capable of
detecting microbial invasion, and are able to drive macrophage differentiation
into pro-inflammatory (M1) or anti-inflammatory (M2) lineages. Such
differentiation has a dual role. On the one hand, it is essential for the
elimination of cariogenic pathogens and the protection of pulp tissue, due to
the high phagocytic capacity of these cells (M1). At the same time, it has been
demonstrated that adjacent fibroblasts, which are not in direct contact with
pathogens, induce the differentiation of anti-inflammatory cells (M2),
controlling the damage to the pulp tissue (Tsai et al., 2021; Le Fournis et al.,
2021).
2.1.3. Dental Pulp Stem Cells

The dental pulp of postnatal human deciduous or permanent teeth harbors a
unique source of mesenchymal stem cells, generically called human dental
pulp stem cells (hDPSC). These were first described in impacted third molars
by the pioneering work of Gronthos et al., (2000; 2002). Since then, they are
of increasing interest, as the most prominent source of adult mesenchymal
stem cells. They have been shown to maintain self-renewal and clonogenic
characteristics and proliferative capacities, as well as multipotent
differentiation capabilities (e.g., dentinogenic, osteogenic, chondrogenic,
adipogenic, myogenic, neurogenic, hepatogenic, and angiogenic lineages). In
Pulp Biology 7
addition to their proliferative and differentiation characteristics, hDPSCs have

been demonstrated to possess potent immunomodulatory and anti-
inflammatory properties (Kok et al., 2022). Human DPSCs are mainly
ectomesenchymal-derived stem cells, originating during embryonic tooth
development from migrating cranial neural crest cells. It has been suggested
that they remain quiescent within their stem cell niche microenvironments
subjacent to the odontoblastic layer, within the cell-rich zone, and from
perivascular regions associated with the pulpal vasculature (Figure 1C). These
pulp stem cells contribute to postnatal tissue homeostasis through their
differentiation into newly formed odontoblast-like cells or via the restoration
of the composition of pulpal fibroblasts (Shi & Gronthos, 2003; Sui et al.,
2018). Progenitor cells of odontoblasts originate from the commitment of
peripheral cells from the dental papilla to the odontoblast lineage. These cells
undergo asymmetric division, where one daughter cell differentiates into a
secretory odontoblast and the other daughter cell remains undifferentiated and
remains in the inner zone of the odontoblastic layer. These post-mitotic cells
are competent to become odontoblasts and, along with the dentin matrix itself,
are responsible for the reparative processes observed following severe injury
of odontoblasts (Figure 2D). Undifferentiated mesenchymal stem cells, whose
appearance is similar to small young fibroblasts, are found in the cell-rich zone
and related to blood vessels in the pulp core. They can continuously produce
unaltered daughter cells, and can differentiate into connective tissue cells, such
as odontoblasts and fibroblasts, as well as into multiple lineages of
mesenchymal tissues, such as osteogenic, adipogenic, and myogenic cells
(Basson et al., 2018).
2.1.4. Inflammatory and Immunocompetent Pulp Cells

Healthy pulp tissue has resident immune cells, although they account for less
than 1% of the total cell population. Granulocytes and neutrophils are the most
numerous, followed by lymphocytes, monocytes, and dendritic cells. Minor
subpopulations of natural killer, B cells, and regulatory T cells (Tregs) are also
found. In general, these cells are antigen-presenting cells, capable of
recognizing a wide variety of exogenous antigens. Together with odontoblasts
and pulp fibroblasts, these leukocytes act as sentinels on healthy tissue,
examining the environment around them to detect invading pathogens. Once
they come into contact with a pathogen, their numbers increase, giving rise to
localized protective inflammation while leukocytes from the circulatory
system are recruited to migrate to the site of infection. Then, neutrophils and
macrophages progressively infiltrate the pulp tissue as the carious disease

progresses (Izumi et al., 1995; Farges et al., 2015; Duncan et al., 2020).
2.2. Extracellular Components
The extracellular components are a major constituent of connective tissues,

including fibrillar proteins and ground substance, which form the extracellular
matrix (ECM). The ECM plays a bioactive role in cellular behaviour,
influencing development, proliferation, migration, and function, in addition to
providing the structure for tissues (Linde, 1985; Abrahamson, 1986;
Nikoloudaki, 2021). Approximately 34% of the ECM proteins are collagen,
with types I and III being the most predominant (56.4% and 41%,
respectively). Collagen types V, VI, and elastin are also observed. Collagen
and elastin perform important structural functions, stabilising the pulp tissue
and conferring its elasticity (Shuttleworth et al., 1992; Goldberg & Lasfargues,
1995; Abrahão et al., 2006). Among the non-collagenous proteins, fibronectin
is a glycoprotein distributed throughout the pulp, responsible for cell adhesion
to the matrix. Dentin sialoprotein (DSP) and osteopontin (OPN) are also found
as biochemical mediators, which are mainly linked to the initial formative
processes of mineralized tissues. The ground substance of the dental pulp is
mainly composed of proteoglycans, such as chondroitin, dermatan sulphate,
and hyaluronic acid (Smith et al., 1995; Sodek et al., 2000; Guo et al., 2014;
Li et al., 2017).
2.3. The Pulp Vascular System
The dental pulp has a well-developed vascular system that is responsible for
the supply of nutrients and waste removal, as well as actively participating
during the inflammatory response of the pulp and subsequent regeneration.
Pulp vascularization has unique anatomic and functional characteristics due to
being located in an low-compliance environment surrounded by inextensible
rigid dentin walls. In addition, afferent and efferent vessels only have access
through the apical foramen (Kramer, 1960; Vongsavan & Matthews, 1992).
2.3.1. Blood Vessels

Dental pulp derives its vascular supply from small arteries or arterioles,
branches of the inferior alveolar artery, the superior posterior alveolar, and the
Pulp Biology 9
infraorbital arteries. Arterioles with a diameter of 10 µm or less pass through

the apical foramen and/or foramina along with nerve bundles, then travel
towards the crown through the central portion of the root pulp. At all levels,
the smaller vessels leave the central pulp arterioles and pass toward the
peripheral pulp, where they form an extensive capillary network. Along this
path, they emit lateral ramifications in the odontoblastic layer, forming the
capillary plexus, as well as in the subodontoblastic layer, giving rise to a
network of capillaries that supplies the odontoblasts with a rich source of
nutrients (Figure 1D) (Koling & Rask-Andersen, 1983; Gazelius et al., 1986;
Takahashi, Kishi & Kim, 1982; Kishi, Shimozato & Takahashi, 1989).
The capillaries drain into venules that fuse to form the central pulp
venules, which run parallel to the arterioles, exiting through the apical foramen
to drain posteriorly into the maxillary vein. Pulp venules have thin walls, and
the muscular layer is discontinuous, which facilitates the movement of fluid
in and out of the vessels (Harris & Griffi, 1971; Kishi, Shimozato, &
Takahashi, 1989).
2.3.2. Lymphatic Vessels

The presence of lymphatic vessels in the dental pulp remains controversial
because it is quite difficult to clearly distinguish lymphatic vessels from small
blood vessels. There is evidence that lymphangiogenesis occurs in the dental
pulp in response to injury during the pulp inflammatory response to assist in
removing inflammatory exudate and transudate, as well as cellular debris.
Lymphatic capillaries have been described in the pulp chamber and apical
area, from where they flow through the apical foramen and lateral canals to
drain into regional lymph nodes – submental, submandibular, or cervical.
Considering that the development of lymphatic vessels from existing ones can
only be possible when lymphatic vessels are present, it can be concluded that
healthy teeth have a lymphatic system. However, the pulp lymphatic system
is much less developed compared to other tissues of the body (Wisniewska et
al., 2021).
2.3.3. Pulp Blood Flow

The dental pulp is an intensely vascularized tissue, with an average capillary
density of approximately 1400/mm², which is higher than in many other
tissues in the body. Pulp blood flow is 40-50 ml/min/100 g tissue, comparable
to blood flow in the brain and liver, and is much greater than the flow to other
organs, such as skin and muscle at rest. This flow is not uniform throughout
the pulp tissue, being greater at the pulp periphery and decreasing towards the
central areas of the pulp. There is also a significant difference between pulpal
blood flow in the coronal and radicular pulp, with the coronal pulp being
almost twice that of the radicular pulp (Matthews & Vongsavan, 1994;
Vongsavan & Matthews, 1992; Haug & Heyeras, 2006; Kim, 1985). The
purpose of the relatively high blood flow in the coronal pulp is to provide the
pulp cells, especially the odontoblasts, with nutrients and oxygen, as well as
provide an exit route for tissue metabolic waste. Oxygen, nutrients, and waste
are exchanged in capillaries by diffusion. Pulp microcirculation also acts to
maintain intraluminal pressure within the pulp vasculature in harmony with
pulp tissue pressure (Orchardson & Cadden, 2001).
Pulp blood supply is regulated by the precapillary sphincters and their
sympathetic innervation. The stimulation of sympathetic vasoconstrictor
nerves reduces pulp blood flow, an effect mediated by α-adrenoreceptors.
However, during inflammation, dental sensory receptors are strongly affected
by the activation of the sympathetic nerves and release vasoactive
neuropeptides, leading to an increase in pulpal blood flow. Thus, the
microcirculation of pulp after injury results from the interaction between local
and remote vascular controls (Matthews & Vongsavan, 1994; Olgart, Edwall
& Gazelius, 1991; Takahashi, Kishi & Kim, 1982; Kishi, Shimozato &
Takahashi, 1989; Vongsavan & Matthews, 1992).
2.4. Pulp Innervation
The dental pulp is a peripheral end-organ that is densely innervated by mixed

sensory afferent fibers from the trigeminal nerve and sympathetic fibers
originating from the cervical sympathetic ganglion. Axons from both types of
fibers enter the radicular pulp through the apical foramen and accessory canals
forming large nerve bundles with the pulp vessels that are surrounded by a
collagen sheath. The primary function of sensory nerves is the transmission of
afferent stimulus from the pulp to the central nervous system, while
sympathetic nerves are involved in the control of pulpal blood flow. However,
there is an interplay between these functions in pulpal homeostasis and during
a defensive response to injury. Such interactions directly affect the secretion
of neuropeptides, the density of dental innervation, hemorregulation, and the
modulation of the immune response (Närhi, 1898; Zhan et al., 2021).
Pulp Biology 11
2.4.1. Sensory Innervation

The majority of nerves entering the teeth are sensory axons, most of which are
unmyelinated C-fibres (about 80%), together with thinly myelinated fibres
(Aδ-fibres) and very small amount of thickly myelinated fibres (Aβ-fibres)
(Nair & Shoroeder, 1995). As they progress through the radicular pulp, they
separate from the blood vessels, emitting few branches towards the pulp
periphery and branching extensively in the coronal pulp to form a complex
nociceptive network in the subodontoblastic layer, known as the Raschkow
plexus. Although presenting different diameters, conduction velocity, and
functions, all of these sensory fibers are specialized polymodal nociceptive
fibers and are crucial for the detection of noxious stimuli and the activation of
pain perception. They also play a critical role in modulating the production of
neuropeptides via the immune response, which mediates neurogenic
inflammation. Within the Raschkow plexus, glial Schwann cells also integrate
the neural network, providing trophic support and participating in nerve
regeneration to preserve sensory function (Couve & Schmachtenberg, 2018).
The majority of Aδ-fibres are located in the periphery of the pulp, from
where they lose their myelin and project nerve endings into the odontoblastic
layer, predentin, and within dentinal tubules, particularly in the region of the
pulp horns. These nerve endings are rarer in the radicular dentin tubules,
tending to be smaller and not extending beyond predentin. They have a fast
conduction speed and a low stimulation threshold, being responsible for the
sensitivity of dentine, generating a short, sharp, and stabbing pain. Aβ-fibres
belong to the same functional group of Aδ-fibres but have been reported to be
stimulated at a lower electrical threshold, being responsible for prepain
sensations. On the contrary, C-fibres are located deeper in the pulp, most likely
extending from the Raschkow plexus into the cell-rich zone and central region
of the pulp. They have a low conduction velocity and a higher excitation
threshold, causing slow, diffuse, and durable pain that turns into burning pain
as the intensity of the pain stimulus increases. C-fibres are also more resistant
to hypoxia than the A-fibres (Figure 1E) (Närhi et al., 1992; Jain & Gupta,
2013).
2.4.2. Sympathetic Innervation

Sympathetic fibers comprise only a small proportion of the total dental pulp
nerve supply, representing no more than 10% of the nerve fibers entering fully
developed teeth (Fehér et al., 1977). Postganglionic sympathetic nerve fibres
join the trigeminal ganglion of Gasser and run together with the maxillary and
mandibular division of the trigeminal nerve, both entering the dental pulp via
the apical foramen as large bundles. Sympathetic fibres usually form a plexus
around the blood vessels and are more numerous in the radicular especially in
the central part of the pulp, not reaching the odontoblastic and
subodontoblastic zones (Uddman et al., 1998).
In addition to their well-established role in regulating pulpal blood flow,
it has been shown that sympathetic innervation directly participates in the
modulation of the immune-inflammatory response of the dental pulp (Haug &
Heyeraas, 2006).
3. Pulp Physiology and Functions
The primary functions of the pulp are the induction and formation of the tooth
organ. In addition, the dental pulp also plays nutritive, sensory (protective),
and defensive/reparative roles.
3.1. Inductive Function
The very first function of the pulp is the induction of tooth formation. Very
early during tooth development, this induction takes place through the cross-
talk between the inner enamel epithelium and ecto-mesenchymal cells located
at the periphery of the dental papilla, originating from migrating neural crest
cells. This mutual induction is also mediated by local signalling from the
basement membrane and results in differentiation of both odontoblasts and
ameloblasts, which go on to form dentin and enamel, respectively. The dental
pulp maintains the ability to create new odontoblasts throughout its lifespan
due to the presence of dental pulp stem cells (DPSCs).
3.2. Formative and Reparative Function
Odontoblasts maintain predentin and dentin apposition throughout the whole

life of a vital tooth. The term “primary dentin” has been widely accepted for
the regular orthodentin, formed during tooth development by secretory
odontoblasts that have a well-developed secretory machine, producing dentin
at a high rate (4–8 μm/day) and forming the bulk of the tooth. After tooth
eruption and the completion of root formation, mature and radicular
Pulp Biology 13
odontoblasts preserve their secretory ability but undergo marked changes,

reducing their secretory machine and decreasing dentin deposition to a rate of
0.5 μm per day. Such dentin is referred to as “secondary dentin,” which has a
tubular structure in continuity with that of the primary dentin and the same
ratio of mineral to organic material of primary dentin (Couve et al., 2013).
During primary odontogenesis, the polarized arrangement and
morphological change of odontoblasts is a fundamental step for tubular dentin
formation. This ensures the formation of tubular dentin and subsequently
enables the existence of dentinal fluid and neural fibres within the dentinal
tubules. This tubular pattern makes dentin permeable, a key feature to support
the physiology of the PD complex either under normal conditions or in
response to an injury. In dentin regeneration, a similar transition of
odontoblasts is eagerly desired since the reconstruction of the tubular
microstructure represents a major challenge in the development of novel
dentin regeneration strategies (Chang et al., 2019).
Vital pulps have a relatively high interstitial tissue fluid pressure, which
results in a pressure gradient that pushes a transudate of extracellular fluid
from the inner layers of the pulp towards the outside throughout the dentin
tubules. This fluid is known as dentinal fluid and is rich in macro-molecules,
immunoglobulins, and inorganic material. This flow of fluids and solutes
(including nutrients) between the pulp and the dentinal tubules is regulated by
the tight junctions between odontoblasts, which constitute a selectively
permeable barrier (Mjör et al., 2001). The presence of fluid within the dentinal
tubules is implicated in several aspects of the physiology of the PD complex.
First, it confers elasticity to dentin, working like a hydraulic damper,
increasing the mechanical resistance of vital tooth to masticatory forces and
injuries. The circulation of dentinal fluid is also responsible for supplying
dentin with nutrients and structural materials. The flow of dentinal fluid is
thought to be the first line of pulp defence since it hampers the progression of
foreign bodies through dentinal tubules towards the pulp.
Dentinal tubules are concentrically surrounded by dense
hypermineralized dentin, the peritubular dentin, formed differently, through
the deposition of an amorphous matrix, and secreted by the odontoblast
process. It remains unclear whether odontoblasts also participate in the
mineralization phase or whether this occurs through the precipitation of
inorganic material from the dentin fluid. This continued deposition of
peritubular dentin leads to the gradual obliteration of dentin tubules with age,
and may be accelerated in response to injuries forming the sclerotic dentin
(Kabartai et al., 2015).
Additional dentine can also be formed in response to external stimuli

(caries, abrasion, attrition, erosion, and the managing and filling of cavities),
generally known as “tertiary dentin.” Tertiary dentin is classified into
reactionary and reparative dentin. Reactionary dentin is formed by pre-
existing odontoblasts and has biochemical and structural similarities to
primary and secondary dentin, although more poorly organized, with irregular
dentinal tubules embedded in the dentin matrix (Bleicher, 2014). It has been
suggested that bioactive molecules, such as TGFb, FGF2, PDGF, and VEGF,
that were entrapped in the organic dentin matrix are liberated after the
dissolution of the mineral components of dentin and re-activate quiescent
odontoblasts by upregulating specific gene expression and inducing
reactionary dentin synthesis (Yu & Klein, 2020).
On the other hand, a more severe injury can cause the death of local
odontoblasts and the recruitment of progenitor cells that differentiate into new
odontoblast-like cells that produce the reparative dentin. The organization and
composition of the reparative dentin reflect the origin of the progenitor cell:
the morphology can range from organized tubular dentin to more irregular
fibrodentin or osteodentin, with the inclusion of cells and connective tissue. If
damage to the pulp is severe and it is exposed to direct pathological factors,
the dentin must first be formed by fibroblasts and has a non-tubular structure,
resulting in the formation of a dentin bridge (Yu & Klein, 2020).
3.3. Sensorial and Defensive Function
Dentin sensitivity is based on the stimulation of the plexus of nerve terminals

arranged at the dentin-pulp interface, where odontoblasts and nerve fibers
interact in a still incompletely understood sensory transduction pathway for
dentinal pain. Currently, three non-mutually excluding theories have been
proposed to explain sensory transduction in the PD complex (Chung et al.,
2013). The neural theory proposes the transduction of thermal and mechanical
stimuli through nerve terminals present in dentinal tubules. The stimulation of
nociceptive fibres located within the dentin tubules, in the predentin,
odontoblastic, and subodontoblastic layer caused by abrupt changes in the
dentinal fluid flow through the tubules is the physiologic basis for the
hydrodynamic theory of dentinal pain (Brannstrom, 1986). In the third theory,
odontoblasts have been suggested to function as direct transducers of thermal,
mechanical, and chemical stimuli, transmitting sensory information to afferent
nerve endings. This assumption is based on current evidence demonstrating
Pulp Biology 15
the expression of transient-potential receptors and acid-sensing ion channels

in odontoblasts (Solé-Magdalena et al., 2018). Whatever the precise
contribution of odontoblasts to sensory transduction, they have been referred
to as relevant factors during dentin stimulation according to their strategic
location at the dentin-pulp interface.
Because odontoblasts are located in the outermost layer of the dental pulp,
they form a natural barrier and are the first cells to recognize pathogens and
sense external irritations. They have been demonstrated to express pattern
recognition receptors (PRRs), such as Toll-like receptors and NODs, which
are commonly expressed by immune-inflammatory cells. The activation of
these receptors stimulates the early production of chemokines and cytokines,
initiating an inflammatory response (Staquet et al., 2011; Galler et al., 2021).
3.4. Age-Related Changes
Pulp space diminishes through life by the deposition of secondary dentin,

which is formed around the whole periphery of the pulp chamber during the
whole life of a vital tooth. There is a greater deposition of secondary dentin in
the roof and floor in response to masticatory stimulus, leading to an
asymmetrical reduction in its size and the shape of the pulp chamber, which is
converted from a large rectangular space to a flat disc in the pulp space, and
further reduced by tertiary reactionary and reparative dentine, which are
deposited locally in response to injury. The formation of dystrophic pulp
calcifications (DPC) also contribute to the decrease in the pulp chamber
volume. DPC can be formed centrifugally in layers (pulp stones) and is
predominantly found in the crown pulp, eventually filling the whole pulp
chamber. In the radicular pulp, these calcifications assume a diffuse shape and
are mainly associated with the collagen sheaths of larger neuro-vascular
bundles (Goga et al., 2008; Palatyńska-Ulatowska et al., 2021).
In addition to the reduction of the pulp chamber volume, there is a
significant reduction of the diameter of dentinal tubules due to the continued
deposition of peritubular dentin, leading to the gradual obliteration of tubules
and the formation of the sclerotic dentin. This process may be further
accelerated in response to injuries. The reduced pulp sensibility in elderly
patients can be attributed to age-related sclerotic dentine tubules, which
diminish dentinal fluid flow. In addition, older patients have a thicker layer of
dentin, which the stimulus must cross to reach the dental pulp, in addition to
fewer and mineralized nerve branches, leading to weaker and delayed

responses to sensory stimulus (Maeda, 2020).
Space restriction of the pulp cavity is followed by a gradual decrease in
the number of blood and lymphatic vessels, associated nerves, and an overall
reduction of cellular components. This process seems to be driven by the low
expression of genes encoding for transcription regulators and the high
expression of genes involved in apoptotic processes (Tranasi et al., 2009). At
the same time, fibrous tissue accumulation occurs to the point where almost
nothing remains except for the fibrous tissue. This process is termed fibrous
degeneration or pulp atrophy. In addition to pulp fibrosis,
glycosaminoglycans, such as chondroitin sulphate, dermatan sulphate, and
keratan sulfate, are also present. In terms of proteins associated with
glycosaminoglycans, these can be identified in a gel-like matrix or the
intercellular ground substance as decorin, biglycan, lumican, and versican, in
contrast to hyaluronic acid, which is reduced with advancing age (Carvalho &
Lussi, 2017; Couve & Schmachtenberg, 2018; Maeda, 2020).
Conclusion
It is observed that the pulp tissue is a connective tissue with specific

particularities, such as the presence of a highly specialized cell type, the
odontoblasts, and the fact that it is contained in rigid dentin walls.
Furthermore, the pulp tissue is physiologically, anatomically and biologically
related in an intimate way with the dentin, thus forming the pulp-dentin
complex. This first chapter explained from embryogenesis to all the
characteristics of pulp tissue, serving as an important basis for reading the
other chapters.
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Chapter 2
Etiology of Pulp Alterations
Leticia Cabrera Capalbo1, Renan Dal Fabbro2,

Carlos Roberto Emerenciano Bueno3
and Leopoldo Cosme-Silva4,*
1
Department of Preventive and Restorative Dentistry, School of Dentistry,
São Paulo State University (UNESP), Araçatuba, Brazil
2
Department of Cariology, Restorative Sciences and Endodontics,
University of Michigan, Ann Arbor, Michigan, USA
3
Department of Endodontics, State University of Northern Paraná (UENP),
School of Dentistry, Jacarezinho, PR, Brazil
4
Department of Restorative Dentistry, School of Dentistry, Federal University of
Alagoas (UFAL), Alagoas, Brazil
Abstract
The dental pulp and periodontal tissues can be affected by pathological

alterations, especially inflammatory and infectious etiology. Aggression
to the pulp and the apical and periodontal ligament can be biological,
physical (thermal or mechanical), or chemical and dental caries is the
most common cause of pulp exposure. These factors, countered by host
defenses, can increase an inflammatory response. If the inflammatory
response fails to significantly reduce the intensity the process advances
and exacerbates causing pulp diseases such as Irreversible pulpitis and
pulp necrosis.
Keywords: dental pulp diseases, inflammation, tissue response
Corresponding Author’s Email: leopoldocosme@gmail.com.

*

ISBN: 978-1-68507-987-1
22 L. Cabrera Capalbo, R. Dal Fabbro, C. Roberto Emerenciano Bueno et al.
1. Introduction
The dental pulp and periodontacl tissues can be affected by pathological

alterations, especially inflammatory and infectious etiology. The primary
response of the dental pulp and periodontal tissues to injury stimuli is
inflammation. Inflammation intensity can vary according to the type of
aggression and its power. Often, when persistent aggression is not t resolved
by the mobilization of nonspecific host defense mechanisms, a chronic process
is installed, characterized by a specific character's participation in the adaptive
immune response. In this case, if the immune response cannot eliminate the
offending agent, it manages to control it, confining it to the site of aggression.
In the persistence of the aggressive stimulus, the host's defense responses,
specific or nonspecific, can generate tissue damage. In the case of pulp and
periodontal diseases, tissue destruction caused by the host's defenses in
response to persistent aggression seems significant than the direct effects
provided by the microorganisms. However, these are the main triggering
agents of the entire phenomenon (Siqueira & Rôças, 2011).
Aggression to the pulp and the apical and periodontal ligament can be
biological, physical (thermal or mechanical), or chemical. Although physical
and chemical aggressions can induce pulpal and periodontal inflammation,
these types of lesions are usually transitional. Therefore, in this case,
inflammation develops but does not persist. Microorganisms, in turn, represent
biological aggression that is often persistent, thus leading to an inflammatory
response that is also long-standing. For this reason, microorganisms are
essential for developing and perpetuating pulp and periradicular pathologies
(Bergenholtz, 1990; Cox et al., 1987; Kakehashi et al., 1965; Sundqvist, 1976).
In periodontal tissues, the inflammatory response limits the spread of infection
to bone and other sites in the body. Periodontal injury is usually characterized
by bone resorption, allowing the bone to retreat from the infected area and
strategically replaced with inflamed tissue.
2. Microorganisms and Pulp Pathology
2.1. Pathways of Dental Pulp Infection
Under normal conditions, tooth enamel and cementum protect and isolate
dentin and dental pulp against oral microorganism’s aggression. However, in
Etiology of Pulp Alterations 23
situations where this protection is lost (e.g., dental caries, trauma, or

unsatisfactory restorative procedures), a potential for microbial contamination
of the pulp tissue with the consequent installation of an infectious process is
created (Siqueira & Rôças, 2011). Bacteria's main pathways to gain dental
pulp are direct pulp exposure, dentinal tubules, and periodontal disease.
2.1.1. Pulp Exposure

Dental caries is the most common cause of pulp exposure. When carious
lesions destroy a considerable enamel and dentin thickness, the pulp is directly
exposed to microorganisms and their products, both in saliva and carious
lesions. A vast number of bacterial species go on to colonize exposed pulp’s
surface. In response, the dental pulp becomes inflamed. Whether the pulp
tissue will remain inflamed for an extended period or succumb will depend on
factors such as the number and virulence of microorganisms, host resistance,
microcirculation status, and drainage degree of the edema generated during
inflammation (Siqueira & Rôças, 2011).
As the bacterial density and species increase due to exposure, the dental
pulp is affected by higher concentrations of toxic bacterial products. In this
sense, the portion of the tissue in direct contact with the aggressor agent
undergoes severe inflammatory changes, culminating in its necrosis. This area
of necrotic tissue does not offer any resistance to bacterial invasion. Once
bacteria advance in the pulp towards the apical region, the aggression focuses
on the underlying tissue portion. This will go through the same phenomena
already described, suffering necrosis. The processes of bacterial aggression,
pulp inflammation, pulp necrosis, and bacterial invasion gradually advance
through the pulp in an apical direction (Ingle et al., 2008).
Dental pulp can also become exposed after trauma or by iatrogenic
procedures. A vital, healthy pulp exposed by trauma is resistant to bacterial
invasion, which happens slowly (Ingle et al., 2008). A dental pulp exposed by
trauma and remained in contact with the oral cavity microbiota for
approximately 48 hours can recover using direct capping. Suppose the period
in which the pulp remained exposed to the oral environment exceeds 48 hours.
In that case, the superficial portion of the pulp should be considered infected,
requiring more invasive treatment, such as pulpotomy or endodontic treatment
(biopulpectomy).
Iatrogenic pulp exposure does not lead to significant problems if it occurs
aseptically, which is rare. However, suppose there is contamination by saliva
or the instrument that promotes exposure (e.g., drills used to remove caries
and, therefore, contaminated). In that case, the pulp response will depend on
the number and virulence of the microorganisms, pulp condition, treatment,

and restorative measures to be instituted Ingle et al., 2008).
2.1.2. Dentin Tubules

Dentinal tubules run along all dentin lengths, from the dentin-pulp junction
(DPJ) to the dentino-enamel (DEJ) or dentino-cemental (DCJ) junctions.
These tubules occupy 20% to 30% of the dentin volume and present a conical
conformation, with a larger diameter close to the pulp, close to the DPJ. Dentin
tubules are also more numerous in the DPJ and, as it moves away from the
pulp towards the outer layers, tubular density decreases, and in the DEJ, it can
occupy 1% of the total area (Fristad & Berggreen, 2011).
However, bacteria do not easily invade dentin tubules in a normal/vital
pulp (Love & Jenkinson, 2002; Nagaoka et al., 1995). The presence of
odontoblastic processes, collagen fibers, lamina dura, and dentinal fluid in
tubules of vital dentin can delay intratubular invasion by microorganisms. In
addition, to these, other factors such as dentin sclerosis, reparative dentin,
smear layer, and deposition of plasma proteins, such as fibrinogen, in the
tubular walls may limit or prevent bacterial advancement through dentin
tubules. Antibodies and components of the dentinal fluid complement system
may also help contain the bacterial invasion. (Okamura et al., 1979, 1980). In
turn, dentin tubules of endodontically treated teeth or necrotic pulp are easily
invaded by bacteria. (Okamura et al., 1980), since all these main protection
mechanisms against bacterial infiltration no longer exist.
Dentin lesions involve demineralization by an acidogenic microbiota and
further degradation of the exposed organic matrix by proteolytic bacteria.
Thus, a succession of microbial populations can occur during the formation
and progression of dentin caries. The most prevalent microbiota that colonizes
deep dentin caries is anaerobic bacteria (Edwardsson, 1974; Lima et al., 2011).
Most of the time, bacteria do not reach dental pulp through tubules until the
carious process has destroyed the dentin tissue and left a small remaining
thickness of the tissue separating it from the pulp (Ørstavik, 2019). However,
even before bacteria reach the pulp directly, their products, such as enzymes,
toxins, fatty acids, sulfur compounds, and ammonia, diffuse through the
dentinal fluid, reaching the pulp (Khabbaz et al., 2000; Nissan et al., 1995).
Diffusion of bacterial products through dentin induces inflammatory
changes in the dental pulp. The microcirculation can rapidly dilute and drain
these bacterial products in a healthy young pulp, preventing them from
accumulating in the tissue underlying the tubules affected by dental caries.
However, in deep carious lesions, the concentration of toxic bacterial products
can exceed this drainage capacity of the microcirculation, especially if the

inflammatory process alters it. Thus, the intensity of the pulpal inflammatory
response under a dent in caries area will depend on the balance between
bacterial products reaching the pulp and the capacity of the pulp to drain. This
relationship can be influenced by microbial virulence, the concentration of
bacterial products in the pulp, duration of the aggression, and pulp health
status. If the tooth is treated by removing the carious lesion and placing a
suitable filling, the inflammation will usually subside, and the pulp will be
normal again (Khabbaz et al., 2000).
2.1.3. Periodontal Disease

During periodontal disease, bacteria and their products present in the biofilm
inside the periodontal pocket may gain access to the pulp via lateral foramina
associated with canal ramifications, dentin tubules, and apical foramen. The
exposure of lateral foramina and dentin tubules to the bacteria that compose
the periodontal biofilm does not seem to induce significant changes in dental
pulp, as long as it is vital. However, there is strong evidence that the complete
disintegration of the pulp tissue, characterized by necrosis, only occurs when
the periodontal disease reaches the apical foramen (Langeland et al., 1974). In
these cases, the main vascular and nerve bundle that penetrates through the
apical foramen can be injured by periodontal biofilm, resulting in pulp
necrosis. Thus, bacterial invasion through the foramen is facilitated since the
pulp can no longer fight it.
2.2. Dental Caries
Dental caries is the most common cause of aggression in the dentin-pulp

complex. Once dentin is exposed due to enamel or cementum destruction by
dental caries, dentin tubules can act as channels for the diffusion of bacterial
products to the pulp. Among the several ways in which dental caries can be
classified, in this chapter, we will approach its classification based on its rate
of progression, and this directly affects how the dentin-pulp complex will react
(Fouad & Levin, 2011; Pashley, 1996; Patel & Barnes, 2013).
2.2.1. Acute Caries

Acute dentin caries is clinically present with a light color, ranging from yellow
to golden brown, with a soft, friable consistency and a necrotic appearance
(Bjørndal & Mjör, 2001). As the destructive character is more evident in these
cases, a painful sensitivity accompanies this destruction, being quite

significant with the ingestion of sweets, cold, and acidic drinks.
Faced with various aggressions to the pulp-dentin complex, odontoblasts
can react in different ways, which, histologically, are observed with the
formation of sclerosed, opaque, and reparative dentin. In acute caries, sclerotic
dentin is practically not formed due to the rapid destruction of healthy dental
tissues (Stanley et al., 1983). In turn, odontoblasts defend themselves by
retracting their processes and emptying the tubules.
In rapidly progressing caries, the affected enamel and dentin may be
destroyed quickly, resulting in changes in the predentin region, with
subsequent destruction of odontoblasts (Bjørndal & Darvann, 1999). The
underlying pulp tissue will react to the transmission of the microbial product
from the dentinal tubules, releasing or activating mediators from defense cells,
thus initiating the inflammatory process and leading to the reversible or
irreversible stages of pulpitis, which may or may not be associated with
sensitivity or pain (Bjørndal & Mjör, 2001).
After odontoblasts’ destruction, dental pulp defends itself by forming
reparative dentin with a tubular pattern. In general, this reparative dentin is
secreted by new odontoblasts differentiated from the undifferentiated
ectomesenchymal cells in the pulp in the sub-odontoblastic layer (Klinge,
2001; Marshall et al., 2001; Murray et al., 2000; Smith et al., 1994).
2.2.2. Chronic Caries

Unlike acute caries, chronic caries have a dark surface and hardened
consistency. Lesion progress is slow and intermittent; dentin beneath the
surface is painless, sclerotic, and pigmented. Its dark color is due to the
presence of bacterial products, products of proteolysis, as well as products
from the oral environment, such as food (Bjørndal & Mjör, 2001; Sarnat &
Massler, 1965).
The chronic nature of this caries promotes the formation of sclerotic
dentin, with an accelerated deposition of peritubular dentin, obliterating the
dentinal tubules and leading to a reduction in dentin permeability (Marshall et
al., 2001). In addition to the sclerotic dentin present on the carious lesion
surface, histologically, the dentin pulp complex defends itself from chronic
aggressions by forming reparative dentin (Bjørndal & Darvann, 1999;
Bjørndal & Mjör, 2001). The more accentuated the aggression, the faster and
more irregular the deposition of reparative dentin will be. However, this dentin
is deposited more slowly in chronic caries, presenting a more regular tubular
pattern, absenting cells within its matrix. The cells that will form this dentin
are the odontoblasts, which, usually undamaged, can secrete this protective
barrier (Klinge, 2001; Marshall et al., 2001; Murray et al., 2000; Smith et al.,
1994). Dentin sclerosis and other reactional phenomena are an attempt to delay
the progress of caries, with sclerosis being the first microscopic aspect
established in dentin caries (Kidd & Fejerskov, 2004).
2.3. Dental Trauma
After dental caries, traumatic impact injuries involving teeth represent the
most significant cause of injury to the pulp and periapical tissues.
Epidemiological studies indicate that the highest incidence of dental trauma
occurs in male patients (34 to 52% more than female patients), with 90% of
cases occurring before 20 years of age (Petti et al., 2018). The maxillary
central incisors are the teeth most susceptible to traumatic injuries, around
80% of the affected teeth (Bastone et al., 2000; Lam, 2016).
Different traumatic agents are known, but those most frequently are
represented by car accidentsfalls, fights, and games (skates, bicycles,
skateboards) (Bastone et al., 2000; Lam, 2016; Petti et al., 2018; Skaare &
Jacobsen, 2003). The intensity of the traumatic agent is a critical factor, as the
damage can involve the enamel, dentin, dental pulp, root, and periapex. The
most common fractures associated with dental trauma affect only enamel or
enamel and dentin without pulp exposure. Risk factors must be considered,
such as increased overjet and inadequate lip protection (da Silva et al., 2021).
When affected, the extent of pulp involvement may vary depending on the
type of trauma. Dental injury can lead to bacterial invasion through dentin
tubules in uncomplicated coronary fractures or direct pulp exposure in
complicated coronary or crown-root fractures. In addition, dental pulp may
also be exposed to the periodontal ligament following disruption of the
neurovascular supply, which may occur at the apical foramen in dislocation
injuries or at the level of a root fracture. These two trauma scenarios can also
occur concomitantly in crown fracture with luxation cases. Traumatic injuries
have a direct impact on pulp responses, ranging from localized or generalized
tertiary dentin formation, pulp revascularization, and pulp canal calcification,
to chronic pulp inflammation, internal root resorption, as well as pulp necrosis
and subsequent infection of the root canal system (Yu & Abbott, 2016).
In addition, the dental pulp can also be damaged during deep cavity
preparations or in dental caries removal without adequate refrigeration and
due to the use of compressed air to dry the cavity. The heat generated by the
drill and friction are aggressive agents in these first two situations. Other
situations that can be sources of trauma to teeth are orthodontic movement
with excessive forces, occlusal trauma, and surgical manipulation of deeper
periodontal tissues, which can also compromise the health of the dental pulp
(Yu & Abbott, 2016).
3. Defense Mechanisms of the Dentin-Pulp Complex
The intensity of bacterial aggression depends on the number of pathogenic

bacteria and their virulence. These factors, countered by host defenses, can
increase an acute inflammatory response (acute apical periodontitis or acute
periradicular abscess) or a chronic response (chronic apical periodontitis or
chronic periradicular abscess) (Siqueira Junior & Dantas, 2000).
Host defenses against infection are represented by innate immunity and
adaptive immunity (Siqueira Junior & Dantas, 2000; Stashenko, 1990;
Torabinejad, 1994). The innate immune response is the first line of defense
and can be subdivided into two phases. The initial phase is immediate and can
be considered a pre-inflammatory response. After tissue invasion, bacteria are
immediately countered by tissue-resident macrophages and the complement
system is activated by the alternative and lectin pathway. The encounter of
bacteria with these host defense mechanisms triggers the production and
release of chemical mediators of inflammation, which induce vascular changes
and recruit more defense cells and molecules to the injury site. Therefore,
acute inflammation with all its vascular and cellular elements develops in
response to bacteria not eliminated by immediate innate mechanisms. This
leads to acute (or symptomatic) apical periodontitis (Siqueira Junior & Dantas,
2000).
Suppose the inflammatory response fails to significantly reduce the
intensity of the aggression from the root canal. In that case, the process
advances and exacerbates, evolving to inflammation characterized by purulent
exudation (pus), completing the formation of an acute periapical abscess. As
the acute response can only reduce the injury intensity but not eliminate the
source of infection located in the necrotic root canal, the inflammatory process
becomes chronic. Chronic inflammation contains elements of the adaptive
immune response repair process. This condition is known as chronic (or
asymptomatic) apical periodontitis. The chronic inflammatory response can,
in many cases, be initiated even without a previous acute episode. This occurs
when bacterial aggression has a low intensity from the beginning, as in chronic
carious processes (Siqueira Junior & Dantas, 2000).
Since dental caries lead to dentin exposure due to enamel or cementum
destruction, the dentin tubules can act as channels for the diffusion of bacterial
products to the pulp. By biological continuity, dentin and pulp respond to the
bacterial stimulus of caries basically through three main mechanisms (Fouad
& Levin, 2011; Pashley, 1996; Patel & Barnes, 2013):
(a) Dentin permeability reduction.

(b) Tertiary dentin formation.
(c) Immune response and initial inflammation.
The first two reactions involve dentin and reinforce barriers against
bacterial invasion, providing additional protection to the pulp. All three
reactions can develop simultaneously and present an intensity directly
proportional to the power of the aggression caused by the advancement of the
carious process. As caries can progress rapidly or slowly or even become
inactive, the reaction of the pulp-dentin complex will vary according to each
situation (Fouad & Levin, 2011; Pashley, 1996; Patel & Barnes, 2013).
3.1. Dentin Permeability Reduction
The reduction of dentin permeability is an important defense mechanism

against bacterial advances toward the pulp. In teeth with vital pulp, the
outward movement of dentinal fluid and vital tubular content influence dentin
permeability and may delay the intratubular bacterial invasion. In addition, the
dental pulp can make the exposed dentin even less permeable by increasing
the outflow of fluids, inducing tubules coating with plasma proteins, and the
deposition of sclerosed dentin. Host defense molecules, such as antibodies and
components of the complement system, may be present in the dentinal fluid of
vital teeth and help protect against bacterial invasion deep into the dentin
(Ackermans et al., 1981; Okamura et al., 1979). Dentin sclerosis is a critical
factor contributingto reduced permeability, and it has been reported to happen
in about 95% of teeth affected by dental caries (Stanley et al., 1983).
3.2. Tertiary Dentin Formation
Another important mechanism of pulp protection against caries bacteria

invasion tertiary dentin formation. This mechanism can be considered a way
for the pulp to retreat in response to advancing a dentin carious lesion,
delaying dental pulp exposure. Tertiary dentin can be reactional or reparative.
Bacteria in the carious process produce acids that demineralize the dentin and
cause the consequent release of bioactive molecules previously isolated in the
dentin matrix. Many of these bioactive molecules are growth factors that can
stimulate tertiary dentin formation (Cooper et al., 2010).
Reactive dentin is often formed beneath superficial or slowly progressing
caries. Released bacterial products induce a focal increase in matrix
production by odontoblasts, resulting in the formation of reactive dentin
(Cooper et al., 2010). However, more advanced and aggressive carious lesions
can cause the underlying odontoblasts to die. Tubules devoid of odontoblastic
cell processes are called dead tracts. Dental pulp reacts by depositing
reparative dentin in the area adjacent to the affected dentin, thus sealing the
pulpal portion of the dead tracts, which are highly permeable. Therefore, while
reactional dentin is produced by primary, original, and surviving odontoblasts
(which increase dentin formation in response to a relatively mild/moderate
irritant stimulus), reparative dentin, in turn, is produced by newly formed
odontoblast-like cells, newly formed and originated from undifferentiated
mesenchymal stem cells, in response to a more severe irritant stimulus that
resulted in the death of primary odontoblasts (Cooper et al., 2010). The
amount of tertiary dentin formed in response to slowly progressing chronic
carious lesions is more significant than that produced in cases of rapidly
progressing caries.
3.3. Immune Response and Initial Inflammation
Dental pulp responds to tissue injury through inflammation like any other
connective tissue in the bodyCaries biofilm bacteria represent the most
common source of antigens and aggression to the pulp. Pulp inflammation
develops as a low-intensity response to bacteria and their products in carious
lesions long before the pulp becomes directly exposed and infected (Siqueira
Junior & Dantas, 2000).
Some inflammatory changes are observed in the pulp region underlying
the affected tubules as soon as the carious process destroys tooth enamel and
reaches the underlying dentin. These changes are induced by bacterial

products released by caries biofilm diluted in the dentinal fluid and travel
along the entire tubular length until reaching the pulp causing an inflammatory
response (Staquet et al., 2008).
Initial pulp inflammation in response to caries involves the focal
accumulation of chronic inflammatory cells beneath the affected dentin.
Odontoblasts play an essential role in the initial response. Because they are
the most peripherally located cells in the pulp, odontoblasts are the first to
contact bacterial products and the bioactive components of the dentin matrix
released during demineralization. Odontoblasts can recognize bacterial
products and release pro-inflammatory molecules that recruit dendritic cells
(and later other defense cells) to the pulp region underlying the affected dentin
(Hahn & Liewehr, 2007; Staquet et al., 2008). Dendritic cells and pulp
macrophages actively participate in the process not only because they also
produce pro-inflammatory cytokines but because they capture antigens and
take them to lymph nodes to present them to lymphocytes. As caries progress
towards the pulp, the density of the chronic inflammatory infiltrate in the pulp
tissue increases.
Rich pulp innervation can influence the immune response through
neurogenic inflammation (Hahn & Liewehr, 2007). In this type of
inflammation, afferent neurons respond to bacterial products by releasing
neuropeptides, which are mediators that can attract host defense cells and
induce vascular changes characteristic of the inflammation process (Fristad et
al., 2007). Pulp inflammation extension in response to dental caries depends
on the depth of intratubular bacterial invasion, bacterial virulence, duration of
the disease process, and the degree to which dentin permeability has been
reduced. Although the inflammatory reaction develops early in response to
superficial caries and bacterial cells can be seen invading the dentinal tubules
to some extent, the pulp tissue is usually not infected if the pulp remains vital
or the layer of dentin remaining below the carious lesion is not very thin.
Bacteria can reach the pulp through tubules, even before actual pulp exposure
(Hoshino et al., 1992), but irreversible damage to dental pulp is not expected
to be caused. It is conceivable that the vital pulp can eliminate bacteria and
remove or inactivate bacterial products that arrive through the tubules.
Therefore, dental pulp under a carious lesion rarely undergoes significant
deleterious changes due to inflammation (e.g., abscess formation and
necrosis), while dental caries is confined to dentin (Bjørndal & Mjör, 2001).
In these cases, pulp inflammation (pulpitis) is often considered reversible;
once dental caries is removed or inactive, tissue repair occurs, and pulp returns
to a normal state. Caries removal and appropriate clinical treatment will

generally resolve the inflammatory reaction, reduce the levels of defense cells
and pro-inflammatory mediators, and prepare the environment to favor tissue
repair (Cooper et al., 2010).
4. Pulp Diseases
Endodontics diagnosis cannot be obtained from single isolated information,

resulting from a series of data from the patient himself (main complaint) and
the dental history and clinical (pulp, periradicular, periodontal probing) and
radiographic tests (Durack & Patel, 2012). Knowing the characteristics of a
standard pulp is very important for the clinical diagnosis since a clinically
normal pulp shows a mild and transient response to the thermal test, lasting no
more than one to two seconds after the stimulus is removed. Thus, a conclusive
diagnosis cannot be reached without comparing the tooth in question with
adjacent and contralateral teeth. Also, it is best to test a healthy tooth first so
that the patient is familiar with the experience of a normal response to the tests.
As mentioned before, dental injuries can lead to pulp pathologies, which will
be discussed further below (Pashley, 1996).
4.1. Reversible Pulpitis
In an initial phase, it is a slight inflammatory change in dental pulp, in which

tissue repair occurs as the injury is removed. In response to a deep carious
lesion that has not yet caused pulp exposure, pulpal blood vessels dilate, a
condition known histologically as hyperemia. Prolonged vasodilation
predisposes to edema due to increased capillary pressure and vascular
permeability. The hyperemic response in a localized pulp area may be
accompanied by a mild to moderate infiltrate of inflammatory cells (Siqueira
Junior & Dantas, 2000).
Reversible pulpitis is usually asymptomatic. However, the patient may
complain of acute, rapid, localized, and fleeting pain in response to certain
stimuli. This pain subsides immediately or a few seconds after removing the
stimulus (Närhi, 1990; Trowbridge, 1985). There is no spontaneous pain at
this stage of the pulp inflammatory process. However, dentin can be in a
hypersensitivity state. This causes mild stimuli (such as cold) that do not
usually evoke pain, to evoke it (Olgart, 1986; Panopoulos et al., 1983).
By clinical visual examination, extensive restoration or carious lesions
will usually be detected without pulp exposure. However, it should be noted
that in some cases, even before the pulp is exposed, irreversible pulpitis may
develop. Thermal tests should be applied to aid in the diagnosis. In heat
stimulus, the patient may complain of delayed pain at the initial application
(as observed in pulp normality cases), or the patient may report acute and
immediate pain, which soon goes away after stimulus removal. When
submitted to the cold test, the patient may report sharp, rapid, and localized
pain, which passes soon or a few seconds after simulating source removal,
similar to that observed in a normal pulp. Usually, dentin is more sensitive to
cold than to heat (Petersson et al., 1999).
In addition to thermal tests, an electrical test can also be applied. The
patient may report a tingling or burning sensation, usually equal to or slightly
less than a healthy tooth. The cavity test is of great value for teeth with
extensive restorations, which may not react to other tests, and dentin
stimulation through drills, exploring probe, or dentin spoon will lead to pain
in cases of pulp vitality. All the tests mentioned are subject to false-positive
results (positive response from a necrotic pulp) and false-negative results
(negative response from a vital pulp) (Petersson et al., 1999).
Percussion and palpation tests are negative in cases of reversible pulpitis
since there is no involvement of the periapical/periodontal tissues.
Radiographically, carious lesions or extensive restorations are verified close
to the pulp chamber. It is often risky to say whether the pulp has been exposed
using radiographs alone. For example, caries or buccal/lingual restorations
may overlap the pulp chamber on radiography, giving a false impression that
they have reached the pulp (Siqueira & Rôças, 2011).
Reversible pulpitis treatment removes the carious lesion or defective
restoration (or extensive) and applies a dressing with analgesic and anti-
inflammatory properties. The patient is rescheduled for at least seven days
later, when the case must be reassessed, considering the possibility of
definitively restoring the tooth (Siqueira & Rôças, 2011).
4.2. Irreversible Pulpitis
Pulp inflammation may become moderate to severe if the injury persists or

increases, which characterizes irreversible pulpitis. When the dental pulp is
exposed, an area of direct contact with caries microorganisms is established.

Combat then begins in an attempt to eliminate the aggressor agent. However,
in most cases, because of the anatomical characteristics of the pulp, it can
undergo irreversible changes, characterized by severe inflammation (Siqueira
Junior & Dantas, 2000). At this stage, removing irritants is no longer sufficient
to reverse the condition, requiring intervention directly in the pulp. Affected
by an irreversible inflammatory process, the pulp invariably progresses to
necrosis, which can occur slowly or quickly. If this exposure area is sealed or
obstructed, necrosis will progress wholly and rapidly, with consequent
development of periapical pathology. It is also important to emphasize that, in
some cases, irreversible pulpitis can be installed even without exposure of the
pulp to the oral cavity (Siqueira & Rôças, 2011).
The tissue area in contact with the contaminant agent undergoes a series
of pathophysiological phenomena dictated by the anatomical characteristics of
the pulp. The inflammatory response then becomes more pronounced. As a
result of the prolonged and marked increase in vascular permeability, there is
a significant increase in tissue hydrostatic pressure. This causes the throbbing,
excruciating, slow, spontaneous pain representative of irreversible pulpitis. In
advanced stages of pulp inflammation, the pulp only responds to high
electrical test currents and does not respond positively to the cold thermal test.
When heat is applied, the pain is exacerbated. This is because heat causes
vasodilation, increasing tissue pressure. On the other hand, a cold can relieve
symptoms, thanks to its vasoconstrictor or anesthetic effect (Vongsavan &
Matthews, 1992).
Most patients who are affected by irreversible pulpitis do not complain of
pain. For this reason, pain in irreversible pulpitis can be considered the
exception rather than the rule. Few patients report a previous episode of pain.
The absence of symptoms of irreversible pulpitis is probably due to pulp
exposure, which allows the drainage of inflammatory exudate and the release
of analgesic substances in the inflamed region. In addition, the pain
phenomenon is highly influenced by psychological factors and somatic ones
(Ciucchi et al., 1995). Thus, many patients with acute pulp inflammation may
not complain of pain symptoms.
When present, pain associated with acute inflammation of the pulp, in
intermediate stages, can be provoked, sharp, localized, and persists for an
extended time after the stimulus is removed (Ciucchi et al., 1995). The patient
usually reports using analgesics, which may or may not be effective in
relieving symptoms. In more advanced cases of acute pulpal inflammation, the
pain reported by the patient may be throbbing, excruciating, continuous, and
spontaneous. The use of common analgesics by the patient is usually

ineffective in overcoming the symptoms (Siqueira & Rôças, 2011).
Radiographically, carious lesions and extensive restorations can be
detected, usually suggesting pulp exposure. The periodontal ligament space is
normal or sometimes slightly thickened. Clinical-visual examination usually
shows the presence of carious lesions or extensive restorations. Once removed,
in most cases, pulp exposure is observed. This observation is fundamental to
establishing the diagnosis of irreversible pulpitis. However, the professional
must knowthat pulp exposure is not essential to establish an irreversible
pulpitis diagnosis (Siqueira & Rôças, 2011). If the cause of exposure is
microbial, due to dental caries, it is considered that the pulp is irreversibly
inflamed, requiring invasive treatment, represented by pulpotomy or
endodontic treatment. However, in cases of recent traumatic exposures
(maximum of 48 hours) or aseptic iatrogenic exposures, pulp inflammation
can be reversible, and the tissue can be saved by direct capping since there has
not yet been enough time for massive colonization and bacterial invasion of
the exposed pulp surface (Ingle et al., 2008). On the other hand, even if pulp
inflammation is not observed, but the patient complains of excruciating,
spontaneous, pulsating, and continuous pain, there are strong indications that
the pulp tissue is irreversibly inflamed conventional endodontic treatment is
indicated (Siqueira Junior & Dantas, 2000).
4.3. Pulp Necrosis
In short, a pulp attacked by bacteria becomes inflamed. Inflammation can be

acute and chronic, depending on several factors, and if the injury agent is not
eliminated, it will invariably progress to tissue necrosis. Necrosis is
characterized by the sum of morphological changes accompanyingcell death
in a tissue (Siqueira Junior & Dantas, 2000). Depending on the cause, pulp
necrosis can be classified as:
(a) Liquefactive necrosis: common in areas infected by bacteria. It results

from hydrolytic enzymes of bacterial and endogenous origin
(neutrophils), which promote tissue destruction.
(b) Coagulative necrosis: usually caused by a traumatic injury, with
interruption of the pulp blood supply due to the rupture of the
vascular-nervous bundle that penetrates through the apical foramen,
causing tissue ischemia. Although the nucleus is lost, cell
morphology is generally maintained despite death. This necrosis

model results from extensive protein denaturation of structural
proteins and autolytic enzymes, preventing proteolysis and total cell
destruction.
(c) Gangrenous necrosis: when tissue that has undergone coagulation
necrosis is invaded by bacteria that promote liquefaction. It occurs in
traumatized teeth whose pulps have suffered necrosis from aseptic
coagulation and later become infected. Coagulative and liquefactive
models coexist in pulp gangrene.
Pulp necrosis is usually asymptomatic, and the patient may report a

previous pain episode. However, depending on the status of the periodontal
tissues, pain may be present, as in cases of acute apical periodontitis or acute
periapical abscess (Siqueira Junior & Dantas, 2000).
Clinical-visual examination detects the presence of caries and extensive
restorations that have reached the dental pulp. In other situations, when the
cause of necrosis is traumatic, the dental crown may be sound. Pulp necrosis
can also promote the darkening of the crown (Siqueira & Rôças, 2011).
Thermal and electrical pulp tests are usually negative. However, there are
rare situations in which the patient may be sensitive to heat and high electrical
currents (false positive). The cold test is one of the most reliable for
determining pulp necrosis as a cavity test (results are always negative)
(Petersson et al., 1999). To palpation and percussion, responses can be positive
or negative, depending on the condition of the periodontal tissues (Siqueira &
Rôças, 2011).
Radiographically, it is possible to observe the presence of carious lesions,
fractured crowns, and extensive restorations. If the cause of necrosis was
traumatic, the dental crown may appear sound or with small restorations.
Periodontal ligament space may be normal, thickened, or a periapical lesion
characterized by bone resorption may be observed (Siqueira & Rôças, 2011).
The treatment of pulp necrosis consists of removing all necrotic and possibly
infected tissue, applying the intracanal medication, and filling root canals.
Conclusion
This chapter addressed the main aggressors of pulp tissue, and the pulp
response mechanism against these aggressors. It is noteworthy that the
diagnostic stage for treatment is a complex stage, which involves a lot of
attention and knowledge of the physiology, biology and pathology of the

dental pulp, as well as an attentive anamnesis in the initial conversation with
the patient. Knowing the causes of pulp pathologies, the next chapters will
address the conservative treatment of these pathologies.
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Chapter 3
Conservative Treatment of Pulp Tissue:

What Is Its Importance?
Alexandre Henrique dos Reis-Prado1,*,

Gabriel Pereira Nunes2, Mariana Viana Donato1,
Carlos Roberto Emerenciano Bueno2,3
and Francine Benetti1
1
Department of Restorative Dentistry, Universidade Federal de Minas Gerais
(UFMG), School of Dentistry, Belo Horizonte, Minas Gerais, Brazil
2
Department of Endodontics, São Paulo State University (UNESP),
School of Dentistry, Araçatuba, São Paulo, Brazil
3
Department of Endodontics, State University of Northern Paraná (UENP),
School of Dentistry, Jacarezinho, PR, Brazil
Abstract
Tooth loss enables the occurrence of various comorbidities and social

well-being problems, such as aesthetic and phonetics issues, which may
impact the quality of life, especially among children and young people.
According to the Centers for Disease Control and Prevention, lower-
income areas are most affected with the highest number of decayed,
missing, or filled permanent teeth. However, knowledge and awareness
regarding the importance of the preservation of pulp tissue and dental
integrity have increased in dentistry. Conservative or vital pulp therapy
is a biologically based procedure, less invasive, and more economic
alternative to conventional endodontic treatment. Despite showing high
success rates when properly indicated, this approach can preserve pulp
Corresponding Author’s Email: alexandreprado@ufmg.br.

*

ISBN: 978-1-68507-987-1
42 A. H. dos Reis-Prado, G. Pereira Nunes, M. Viana Donato et al.
vitality and allow continued root development under favorable biological

conditions after caries, dental trauma, or iatrogenic procedures. From a
biological and clinical standpoint, conservative pulp treatment is capable
of reducing the endodontic treatment time and improving the long-term
prognosis for tooth survival, especially in those areas that suffer from
oral health services precariousness.
Keywords: conservative treatment; dental pulp; Endodontics; oral health;

therapeutic use
1. Introduction
Oral diseases have been a major health issue in various countries, causing pain,
discomfort, and even death among individuals. Good oral health and the
achievement of good systemic health status have demonstrated a substantial
and inseparable correlation over the years (Seymour 2007, Astolphi et al.
2013, Reissmann et al. 2013, Kaufman et al. 2014, Lee et al. 2019). Moreover,
oral health conditions may share common risk factors with systemic disorders
and lead to the occurrence of noncommunicable diseases.
Tooth loss is considered a consequence of the most prevalent oral
diseases, and probably the most important proxy of oral health (Hujoel &
DeRouen 1995), particularly in lower-income areas with lower education
where increased means of decayed, missing, or filled permanent teeth (DMFT)
are observed among children and adolescents (Centers for Disease Control and
Prevention [CDC] 2014). In 2009, a Brazilian oral health survey reported a
tooth loss prevalence of 8.9% among a population from 15 to 19 years old (SB
Brazil 2012), which might affect daily activities and negatively impact their
quality of life.
Different variables are important determinants of oral health conditions
and perceptions between children and adolescents, such as biology, lifestyle,
and social environment (Maida et al. 2015). Poor oral health has been closely
linked to individuals’ self-esteem and social well-being due to its aesthetic and
phonetics implications (Musacchio et al., 2021), particularly during childhood
and young adulthood. For instance, the negative impact of traumatic dental
injuries (TDI) on oral health-related quality of life among children (Abanto et
al. 2015) and adolescents (Bendo et al. 2014) has been already described.
Additionally, tooth loss has been associated with various comorbidities,
such as cognitive impairment (Grabe et al. 2009), respiratory disease, and
Conservative Treatment of Pulp Tissue 43
cardiovascular diseases (Henke et al. 2016, Lee et al. 2019), in addition to

negatively affecting taste and digestive process due to compromising the
ability to chew. Thus, oral health problems, especially oral inflammation and
chronic infections, are common conditions that lead to medically
compromised patients.
Caries and TDI remain some of the most prevalent oral disorders of
childhood, mainly in low- and middle-income countries due to unfavorable
socioeconomic conditions, inadequate exposure to fluoride, poor access to
dental services, and unequal distribution of dentists. However, non-treated
microbial-induced pulpal and periapical inflammation, mainly in dental caries,
is still considered the most prevalent condition for tooth loss (Yong & Cathro
2021). Nevertheless, most of these oral disorders are largely preventable and
show satisfactory results if treated in their early stages.
The clinical symptoms are relevant in predicting dental pulpal conditions,
and consequently, indicating the choice of therapeutic intervention. For
example, caries and TDI are largely related to damage to the pulp-dentin
complex, mainly among young patients with immature permanent teeth. In
these cases, the inflammatory reaction in the pulp tissue provoked by these
oral diseases can be fully reversible if treated during the early stages.
Nevertheless, without appropriate treatment, the stimulus tends to progress to
an irreversible state of inflammation. Traditionally, oral health professionals
sacrifice the dental pulp and perform a conventional endodontic treatment to
prevent further bacterial spreading (Galler 2016). However, an increasing
trend toward tooth preservation and improvement of outcomes through
conservative treatment approaches has become increasingly widespread.
In general, dental services face a great challenge in public health, as it is
being inserted into a new context, with new practices and paradigms. Many
countries have a large part of the population with precarious financial
conditions and face difficulties in ensuring full access to health services,
especially oral health services (Wells et al. 2019). Health systems should be
prepared to offer the best possible dental care to the population so that patients
can have affordable and promising therapeutic alternatives. In this context,
less invasive treatments are a very interesting alternative for teeth with deep
carious lesions or TDI, which have pulp vitality and can be recovered without
the need for radical endodontic treatment (Lin et al. 2021).
In dentistry and other health sciences, tissue preservation became a
principle that began to be studied at the end of the 20th century, and it is related
to the application of minimally invasive procedures in the clinical setting. For
instance, the evolution of the research, biomaterials, and technologies,
especially in endodontics, has provided changes in the treatment of deep

carious lesions and/or necrotic teeth. Hence, conventional root canal treatment
and tooth extraction has been evolving toward the preservation of pulp tissue
and dental integrity.
The maintenance of pulp vitality could provide host defense mechanisms
against injury and reparative responses, such as nociception, immune-
inflammatory response, and hard tissue deposition (Farges et al. 2015, Galler
et al. 2016), being these physiologic mechanisms particularly important in
young individuals with incomplete root formation. In addition, low-cost dental
procedures can increase the chance of affording treatment and, consequently,
preserve the tooth in low-income individuals.
2. Conservative Endodontics and Clinical Considerations
Conservative or vital pulp therapy aims at preserving the vitally of the pulp
tissue, and consequently, regenerating the integrity of the pulp-dentin complex
by promoting soft and hard tissue regeneration after caries, TDI, or iatrogenic
procedures (Zhang & Yelick 2010, Hanna et al. 2020, Yong & Cathro 2021).
Although the etiological factor may impact the outcomes in teeth submitted to
conservative pulp therapy, the success rates of exposed pulps due to tooth
decayed and iatrogenic exposures were 87.5%–95.4% and 70%–98%,
respectively (Ghoddusi et al. 2014). These similar results demonstrate that
other variables may influence more the success of treatment rather than the
cause of pulpal exposure.
Conservative pulp therapy was originally divided into indirect and direct
pulp capping (AAE 2019). Partial pulpotomy and complete pulpotomy have
been also described as a less invasive alternative for the treatment of carious
exposure in deep lesions (ESE 2019). According to the European Society of
Endodontology (ESE), indirect pulp capping is an expectant procedure that
aims to partially remove decayed dentin in an attempt to avoid exposing the
pulp by placing a biocompatible material over the remaining sound or slightly
softened dentin layer (ESE 2006). This procedure has a high survival rate (over
90%) for permanent teeth, showing clinical signs of normality (Gurcan &
Seymen 2019, Llena et al. 2021). In primary teeth, a success rate of 99.4% and
a median survival of 15.98 ± 0.80 months were reported (Llena et al. 2021).
Regarding direct pulp capping, this treatment consists in covering the site
pulpal exposure with calcium hydroxide or biocompatible materials to induce
tissue healing and promote a hard-tissue barrier formation (dentin bridge) to
protect pulp vitality (ESE 2006, Cushley et al. 2021). This treatment shows a
favorable success rate, especially among children and young patients (Brodén
et al. 2016). However, for a long time, there were inconsistent reports about
the success rates of this procedure, since studies showed high percentages of
failure for direct capping, about 60% (Stanley 1998). Lack of interest in the
appropriate indications/protocols, and lack of knowledge of the biology of the
pulp-dentin complex may negatively influence the success of conservative
treatment. These factors are related to errors in diagnosis and planning, leading
to premature loss of pulp vitality and the weakening of the tooth structure.
Another well-known conservative treatment of dental pulp is pulpotomy.
Overall, pulpotomy is a less invasive option than root canal treatment,
showing high success rates in exposed pulps, mainly with the diagnosis of
reversible pulpitis (Alqaderi et al. 2016, Cushley et al. 2019). This approach
aims to remove the possibly contaminated coronary pulp and place a
protective biocompatible material over remnant healthy tissue. The
biomaterial layer is placed at the entrance of the root canals to preserve the
vitality of the pulp remnant, promote repair, and maintain function (ESE 2006,
Lin et al. 2021).
Traditionally, irreversible pulpits have been treated with conventional
root canal treatment for many years. Nevertheless, as new insights in pulp
biology have been gained attention, studies on vital pulp therapy have now
provided options for investigating new biologically based procedures
designed to replace damaged structures, such as dentin, root structures, and
cells of pulp-dentin complex (Hargreaves et al. 2013, Wolters et al. 2017).
Then, regenerative endodontics has become a growing field in tissue
engineering with promisor results. This treatment aims at preserving the
vitality of the affected tooth and promoting continued root development due
to soft and hard tissue regeneration, respectively (Galler et al. 2016, Kim et al.
2018).
Despite the positive outcomes of those conservative pulp therapies, long-
term failures have been documented and they may be associated with coronal
leakage and incorrect clinical indications. Despite the current understanding
of pulpal repair mechanisms, new biomaterials, and techniques, complete
caries removal remains a common practice in the management of deep caries
by clinicians (Stangvaltaite et al. 2013, Schwendicke et al. 2017), rather than
selective caries removal as a less invasive alternative (Bjørndal et al. 2019,
Cushley et al. 2021). This attitude has been mostly guided by prior experience
and familiarity (Schwendicke et al. 2017).
Hence, selecting the most appropriate therapies based on pulp status, and
monitoring patients’ progress may help clinicians to understand the magnitude
of benefits that come with the treatment of pulp tissue conditions, and then
preserve and promote the continued development of the tooth structure.
3. Promissor Outcomes in Conservative Pulp Therapy
As previously described, it has been commonly thought that permanent teeth

with signs and symptoms of irreversible pulpitis should be treated with root
canal treatment or extraction. Despite the success rates of conventional
endodontic therapy, many investigations have recently shifted their focus to
the preservation of vital pulp tissues, which could reduce the endodontic
treatment time and improve the long-term prognosis for tooth
retention/function (Wolters et al. 2017).
Pain is the main subjective symptom for which most patients seek
endodontic treatment (Nunes et al. 2021). Thus, the resolution of this symptom
is also related to the success of the endodontic treatment. Galani et al., (2017)
established a comparative relationship between postoperative pain and success
rate after pulpotomy and root canal treatment in cariously exposed permanent
molars. Although the authors found no significant differences in the success
rate after an 18-month follow-up, postoperative pain scores were significantly
lower for the pulpotomy group, indicating the presence of greater symptomatic
relief in this group. Similarly, more pain relief and radiographic success were
observed after pulpotomy compared to conventional endodontic treatment in
9- to 65-year-old patients with irreversible pulpitis, indicating that age may
not have a substantial effect on the treatment outcomes (Asgary et al. 2013).
However, further understanding of the processes of inflammation, repair, and
materials’ interaction is necessary to also understand the impact of pulp
condition on the success of the conservative therapy.
Despite these interesting data, a correct diagnosis of pulp condition is
necessary to ensure the success of the minimally invasive treatment,
considering its indications and limitations. Moreover, an important variable in
the success of conservative treatments is the patient age. Younger pulp tissue
has been associated with greater healing potential due to the increased capacity
of response of the odontoblastic cells (Stanley et al. 1983, Tziafas 2019).
Despite a favored biological response in these subjects, a long-term follow-up
after a conservative pulp treatment is crucial to estimate the success of
treatment in older patients.
A clinical study found 4 times higher 12-month success in preserving pulp

sensibility and periapical health using a minimally invasive protocol for caries
removal compared to non-selective caries removal on the management of deep
caries (Ali et al. 2018). The success of these conservative approaches relies on
several factors. For example, the amount of infected tissue/state of pulp
inflammation, size and time of the lesion, etiology factor, biofilm control,
presence of adequate blood supply, healthy periodontium, materials used, and
the possibility of good coronal restoration (Ghoddusi et al. 2014, Hanna et al.
2020).
In addition to being a more economic alternative of treatment for both
patient and dentist, conservative pulp therapies offer other advantages to
health care, as follows: reduction of pain and discomfort for the patient;
preservation of pulp tissue viability and hard tissue structure; and long-term
tooth survival and retention of a functional tooth (Yazdani et al. 2014, Wolters
et al. 2017, Morotoni et al. 2019). Some approaches may also form a dentinal
bridge to protect the remaining vital tissue from future irritants (Mousavi et al.
2016).
In contrast to root canal treatment, conservative treatment maintains pulp
integrity and allows immature teeth with incomplete root formation to
continue their development within favorable biological conditions (Murray
2018). Conservative treatments are also easier techniques to perform than
conventional endodontic treatment, presenting high success rates when well
indicated and performed (Galani et al. 2017, Lin et al. 2021, Llena et al. 2021).
On the other hand, some consequences of a non-vital tooth are a reduction in
resistance to external stimuli due to complete loss of perception and immune
functions, and the possibility to become more brittle due to loss of metabolic
capacity (Bergenholtz et al. 2009).
Furthermore, success is more predictable when the immune host defenses
are present. The decision to preserve the vitality of the teeth is always valid
and might be considered. Then, total loss of sensation when reinfection occurs
can allow tooth decay to progress leading to failure of root treatment.
Additionally, tooth loss is considered a type of mutilation. The impact of this
condition on quality of life is related to a negative influence on chewing,
speaking, and swallowing; in addition to harming systemic health and
aesthetics (Grabe et al. 2009, Henke et al. 2016, Wells et al. 2019, Sessle 2019,
Lee et al. 2019). Thus, the decision to preserve the vitality of the teeth might
always be considered. Moreover, a growing body of evidence and the
advances in biomaterials, systems of diagnosis, and tissue engineering
strategies in dentistry, clinicians are continually encouraged to change their
routine practice and make minimally invasive approaches a more frequent

treatment option.
Conclusion
Due to the emerging need for minimally invasive approaches in Dentistry,

preservation of pulp vitality and tooth structure, and the promotion of
biologically based strategies management have become important goals.
Conservative pulp therapies are considered to be economic and minimally
invasive approaches with promisor results, especially in low-income children
and young patients with special healthcare needs and poor oral health. From a
biological perspective, these alternatives of treatment may also provide
preservation of pulp tissue viability and immunological functions, hard tissue
formation, and increased tooth survival. In this chapter, we present the benefits
of choosing conservative pulp treatment rather than conventional endodontic
approaches, in which successful outcomes are mostly achieved by an accurate
diagnosis, mainly considering the pulp status and age of the tooth, besides the
patient’s motivation. Moreover, the authors hope that with the advances in
biomaterials, systems of diagnosis, and tissue engineering strategies, the
implantation of minimally invasive treatment strategies may become more
popular among clinicians.
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Chapter 4
Behaviour Guidance of
Young Patients in Dental Treatment
Valéria Silveira Coelho,

and Joana Ramos-Jorge*
Department of Pediatric Dentistry,
Universidade Federal de Minas Gerais (UFMG),
School of Dentistry, Belo Horizonte, Minas Gerais, Brazil
Abstract
Behaviour is a complex and multifactorial phenomenon. There are some

predictors of young patients’ behaviour undergoing dental treatment,
such as: dental fear and dental anxiety, cognitive development, family
characteristics, previous negative dental experiences, complexity of
procedures and child temperament. These predictors must be known by
the dentist for treatment planning and for counseling caregivers, which
contributes to the reduction of children´s dental anxiety. Thus, the
assessment of the behaviour presented by the patient during the dental
appointments allows the clinician to evaluate the patient’s attitudes
towards more or less complex treatments and the effectiveness of the
adopted techniques. The behavioural guidance techniques can be divided
into non-pharmacological techniques (distraction, talk-show-do, direct
observation, desensitization, memory restructuring and voice control)
and advanced techniques (protective stabilization and pharmacological
techniques). The choice or association of techniques depends on the
behaviour predictors and the dentist’s sensitivity. Particularities related
Corresponding Author’s Email: joanaramosjorge@gmail.com.

*

ISBN: 978-1-68507-987-1
54 V. Silveira Coelho, L. F. Moreira-Santos and J. Ramos-Jorge
to endodontic treatment such as use of local anesthesia and rubber can

act as aggravating factors to an inappropriate behaviour. The dentist’s
skills to guide children’s behaviour in the dental environment can
promote a good relationship with children and their caregivers,
contributing to a more positive behaviour and better treatment outcome.
Keywords: child behavior, behaviour control, pediatric dentistry, dental

environment
1. Introduction
Child dental care requires professionals who rigorously master the technique
of procedures and have the ability to establish a relationship of trust with the
patient (Klatchoian & Toledo 2012). The clinician must be prepared to identify
psychosocial factors inherent to child development, such as personality traits,
temperament, social and cognitive aspects (Axberg, Johansson Hanse &
Broberg 2008, Cademartori et al. 2020). These factors are related to the
behaviour guidance in the dental treatment of young patients, which influences
the quality of dental care, and consequently contributes to the treatment
success (Lia & Costa 2019).
Figure 1. Multifactorial and interactive context in which the children are inserted.
Behaviour Guidance of Young Patients in Dental Treatment 55
The literature shows that the professional-patient relationship is also

influenced by other factors that make up the multifactorial and interactive
context in which the child is inserted. In this context, parenting styles,
expectations and attitudes of modern parents and society have influenced the
use of behavioural guidance techniques, such as the preference for
communicative and pharmacological techniques (Oliver & Manton 2015)
(Figure 1).
It is known that there is no completely accurate assessment method to
predict children’s behaviour during dental treatment (Klatchoian & Toledo
2012), however several studies have identified some predictors, such as dental
fear, anxiety, cognitive development, family characteristics, complexity of
procedures and child’s negative temperament in previous experience (Ramos-
Jorge et al. 2013, Axberg, Johansson Hanse & Broberg 2008, Cademartori et
al. 2020). Thus, it is important to include questions related to dental and
medical history in the anamnesis in order to guide the choice of behavioural
guidance techniques according to the particularities of each child, promoting
a more positive initial contact between the clinician and the patient (Ramos-
Jorge et al. 2006).
The reader may consider that, as it is a book on conservative treatment of
pulp tissue, this chapter will address specific techniques for managing child
behaviour for endodontic procedures. However, behavioural guidance
techniques are used in the clinical practice of Pediatric Dentistry in different
clinical situations, and can be divided into non-pharmacological techniques
(distraction, talk-show-do, direct observation, desensitization, memory
restructuring and voice control) and advanced techniques (protective
stabilization and pharmacological techniques). This chapter will present and
discuss predictors of child behaviour, guidelines for parents/caregivers,
methods of assessing pain and child behaviour, as well as to non-
pharmacological and advanced techniques and particularities of endodontic
treatments.
2. Predictors of Child Behaviour
Some factors can influence the young patient’s ability to tolerate dental
procedures such as: cognitive level, previous negative experiences,
temperament, level of fear and anxiety and their relationship with parents
(Axberg, Johansson Hanse & Broberg 2008). Other factors intrinsic to dental
care, such as the severity of the problem, the complexity of the procedure and
the duration of the appointment can also generate behavioural changes

(Cademartori et al. 2020). Knowing these predictors can help the dentist to
assess the expected reactions and prepare for care in an individualized way,
adapting the techniques used to manage the patient’s behaviour.
2.1. Dental Fear and Dental Anxiety
In general, endodontic treatments are related to dental pain, as they are often
indicated due to the presence of severe dental caries or dental trauma
(Cademartori et al. 2020). Pain and fear have a bidirectional relationship and
share physiological factors (Vasiliki et al. 2016, Cademartori et al. 2017). A
higher level of anxiety has been associated with greater sensitivity to
nociceptive stimulation and greater acute pain (Van Wijk & Hoogstraten
2009). But it has also been reported that in treatments in which pain is
experienced, there is an increase in the level of anxiety at subsequent dental
visits (Versloot, Veerkamp, Hoogstraten 2008, Ramos-Jorge et al. 2013).
Dental fear has also been considered as a cumulative factor over time
(Tickle et al. 2009). Fearful children are 4.5 times more likely to present
destructive coping behaviour and, thus, tend not to collaborate with the dentist
(Crego et al. 2015). Therefore, procedures in which little or no pain is felt by
the patient should be recommended through the use of adequate local
anesthesia associated with behavioural guidance techniques to control anxiety.
An improvement in the relationship between paediatric dentists and their
young patients can increase the quality of dental care and, consequently,
reduce the fear and stress of dental treatment that can extend into adulthood
(Ramos-Jorge et al. 2006).
2.2. Cognitive Development of the Young Patient
The clinician must adapt vocabulary and behaviour guidance according to the
child’s age and ability to understand (AAPD 2020). For this, it is necessary to
understand that there are common and specific desires, fears and expectations
for each age group (Klatchioan & Toledo 2012). The age of the child was a
determining factor for changes in the level of anxiety. Dental anxiety is
typically most severe in younger individuals and anxiety levels improve with
age (Lima et al. 2020). The young patient who will undergo endodontic
treatment of permanent teeth is likely between 6 and 12 years of age.
Younger children (6 and 7 years old) experience intense physical and

mental growth and increased attention and motor skills. As they already attend
school, there is an increase in sociability. In the cognitive dimension, these
children are very curious, therefore, they ask a lot of questions, and they can
get frustrated when their need to know is not satisfied. They are interested in
play and games and feel the need to be admired (Klatchioan & Toledo 2012).
In older children (8 to 12 years old), growth slows down until the changes
that will occur at puberty at the end of this period. They have greater cognitive
ability, better understanding of their surroundings, and better perception of
fearful situations; therefore, they are less likely to develop anxiety (Klatchioan
& Toledo 2012).
It is important to emphasize that child development can follow a sequence,
but it is individual for each patient. The variability in development can be
related to genetic and hereditary factors, the environment in which the child
lives and how he/she adapts to it. Therefore, the patient and the context in
which he/she is inserted must be considered to plan and conduct the treatment,
respecting the capacities and limitations of each one
2.3. Influence of Parents/Caregivers on Child Behaviour
Maternal dental anxiety is an important predictor of child behaviour (Kramer

et al. 2020). Patients whose parents are highly anxious are 2.6 times more
likely to have high dental anxiety (Soares et al. 2017), and these children tend
to exhibit uncooperative behaviour during dental treatment (Crego et al. 2015,
Vasiliki et al. 2016, Cademartori et al. 2017, Kramer et al. 2020). In addition,
parenting practices impact children’s acquisition of coping skills and stress
tolerance (Spencer, Thanh, Louise, 2013).
Parenting style is a set of attitudes, beliefs and behaviours used by parents
to raise children (Darling & Steinberg 1993). Different parenting styles can
mean different types of behaviour in the dental office. Permissive parents are
those who set few limits and submit to their children’s demands, avoid
confrontations and always tend to spoil them. These children tend to behave
negatively in the dental office, probably because parents provide comfort
rather than discipline (Allen, Hutfless, Larzelere 2003). Authoritarian parents
exercise control but show less affection, presumably have children who have
fewer behavioural problems but who are less proactive and sociable (Janssen
2015). Children of authoritarian parents generally exhibit positive behaviour
in the dental office (Aunola & Nurmi 2005).
It is necessary to consider the change in parenting style over the years,

today it is very common for parents to show affection and high control at the
same time, which can be classified as authoritative parents. These parents
listen to their children, allow autonomy and encourage independence, explain
situations with reasons rather than demanding blind obedience. And they use
positive discipline rather than punitive, forceful measures. As a result, the
children of these parents are independent, self-sufficient, explore new
environments without fear, develop emotional control and self-control (Tsoi
et al. 2018). Some studies have shown that children who exhibit more positive
behaviours tend to be associated with authoritative parenting styles compared
to those who have authoritarian or permissive parenting styles (Howenstein et
al. 2015, Aminabadi et al. 2015). In addition, children who required advanced
behaviour guidance techniques for restorative care tended to have permissive
and authoritarian parents (Aminabadi & Farahani 2008).
Possibly, the conceptual change in behavioural guidance behaviouris
driven, in part, by the evolution of parenting styles. In some respects, it is
possible that the effectiveness of non-pharmacologic behavioural guidance
strategies may be affected by a child’s limited behavioural capacity and a
lower willingness on the part of the parents to expect their child to cooperate
(Axberg, Hanse, Broberg 2008).
2.4. Previous Negative Experiences
Regardless of the order of dental appointments, children who underwent

invasive procedures or had a previous negative dental experience were more
likely to be uncooperative during dental treatment (Cademartori et al. 2017,
Mitchual et al. 2017). Although routine dental procedures are usually painless,
dental treatment is often reported as a painful experience and invasive
treatments are perceived as involving pain or requiring pain relief (Tickle et
al. 2012). Pain during the appointment can influence the presence of dental
fear and, consequently, the child’s behaviour in the office (Van Wijk &
Hoogstraten 2009). Anxious individuals tend to experience more pain and
their experience of pain lasts longer than less anxious ones (Van Wijk &
Hoogstraten, 2009). In addition, children who have experienced pain report
higher levels of dental fear/anxiety (Versloot et al. 2004).
It is possible that different factors related to the type of care, including the
patient’s psychological approach and the dentist’s technical preparation,
influence how past experiences affect children’s behaviour in future visits to
the dentist (Cademartori et al. 2017). Children who are more anxious about
the dental environment reported the presence of sharp instruments during
dental care, strange sensations regarding the use of instruments inside the
mouth and unusual tastes during dental treatment, such as unpleasant sensory
experiences and a specific anxiety related to dental local anesthetic injections
(Morgan et al. 2017).
The absence of a history of dental visits is also associated with negative
behaviours during the dental appointment, which means that children who
have never been to the dentist are more likely to have a bad behaviour than
children who have been to the dentist (Kramer et al. 2020). When a child lies
down in the dental chair and is examined, he/she must deal directly with
unknown people and events, which can result in uncooperative behaviour
(Venham & Gaulin-Kremer 1979). On the other hand, a positive experience
with the dentist is associated with less anxiety, reducing fear of pain and
improving the child’s oral health-related quality of life (Lima et al. 2021,
Goettems et al. 2017). This information reveals the importance of the child’s
first contacts with the dentist and contributes to the preparation and advice
prior to the dental appointment to improve the child’s behaviour. Experience
gained during previous dental visits can help the child recognize non-
threatening aspects of dental visits and deal with stressful dental procedures,
decreasing negative reactions over time (Hembrecht et al. 2013).
2.5. Complexity of Dental Treatment
The complexity of dental treatment negatively affects the child’s behaviour,

regardless of the order of dental visit, which demonstrates that even with the
child’s familiarization with dental environment, behaviour can be affected by
both psychological and clinical characteristics (Cademartori et al. 2020).
Dental pain is still one of the main reasons for dental visits, often requiring
more invasive treatments, such as tooth extraction and endodontic treatment.
The complexity of the treatment performed is directly associated with the
child’s uncooperative behaviour in the dental setting, especially the use of
local anesthesia, which is strongly associated with the child’s negative
behaviour (Cademartori et al. 2017). Although behavioural problems are
caused by the procedure itself, feelings as dental fear/anxiety may arise during
the use of local anaesthesia to avoid pain during the procedure and exacerbate
the child’s negative reactions face to dental care (Vasiliki et al. 2016). Even
children with low anxiety may experience worsening behaviour when
anesthetized. This misbehaviour is demonstrated through more muscle

tension, more yelling or crying, and verbal protest (Hembrecht et al. 2013).
Dentists must be aware of changes in patient behaviour (e.g., facial
expressions, crying, complaints, and body movement during treatment), and
be able to recognize pain in children (Daher et al. 2015).
There is evidence that dental anxiety levels decrease over time regardless
of the dental procedure, even when emergency treatments are performed in
children with toothache at the first dental visit (Ramos-Jorge et al. 2013).
However, the complexity of dental treatment seems to play an important role
in the acquisition of fear/anxiety (Cademartori et al. 2020). Children with
history of one or more extractions are twice as likely to have anxiety compared
to other children (Tickle et al. 2009). Even in children who did not report
dental fear, the complexity of the treatment had a significant and negative
influence on their behaviour (Cademartori et al. 2020).
There is also some evidence on the relationship between the duration of
treatment and children’s behaviour at the dental appointment (Jamali et al.
2018). Supposedly, the longer the consultation, the more negatively the child
behaves (Jamali et al. 2018). However, further studies are needed to assess the
influence of this clinical aspect on the behaviour of young patients.
2.6. Child Temperament
Temperament is the “how” of behaviour, a “behavioural style,” or the

characteristic way a child experiences and responds to the environment.
Temperament can be categorized into five characteristics: negative
emotionality, impulsiveness, activity, sociability, and shyness (Klingberg &
Broberg 1998, Rothbart et al. 2001). Negative emotionality is defined as
hiding, fear, anger, tantrums, and crying. Activity is characterized by vigor
and rhythm or by the total production of energy. Sociability is the tendency to
prefer the presence of others rather than being alone. Shyness is the
characteristic of being slow to warm up in novel social situations (Klingberg
& Broberg 1998). Impulsiveness is defined as the speed of onset of response
(Rothbart et al. 2001).
The negative emotionality characteristic has been reported as the most
predictive value of dental behaviour guidance problems (Gustafsson et al.
2010, Tsoi et al. 2018). Children who rated higher on the emotionality scale
tend to exhibit a negative behaviour. Recognizing the temperament
characteristics and the reality of the child can help to establish the appropriate
form of intervention in the behaviour (Tsoi et al. 2018).
Child behaviour is a complex and multifactorial phenomenon.
Longitudinal assessments considering several behavioural predictors are
essential to identify whether non-collaborative behaviour reflects child’s
aversion to dental care or inherent to his/her temperament (Aminabadi et al.
2011, Cademartori et al. 2017). The focus behaviour should be on the
multidimensional assessment of the patient, including emotional, behavioural,
cognitive and physiological components and response systems (AAPD 2020).
3. Guidelines for Parents/Caregivers Prior to the Appointment
Parents do not want their children to face situations that could cause
discomfort and, in this sense, the mother’s anxiety can affect the child’s
behaviour in the dental environment (Kramer et al. 2020). Here is a strong
association between a higher maternal anxiety and a negative influence in
child dental fear, anxiety and behaviour (Gustafsson et al. 2010, Goettems et
al. 2011). Therefore, careful preparation with prior counseling to
parents/caregivers in order to reduce anxiety is necessary, which could
contribute to reduce fear and anxiety in their children (Popescu et al. 2014,
Xia et al. 2011).
The clinician may suggest ideas to prepare the preschooler for the first
visit, such as the parent/guardian reading a story about going to the dentist,
using a reclining chair at home for the child to experience the sensation of the
chair moving backward, and using a battery-powered spin brush. Immediately
before the visit is important to remind families what to expect and facilitate
communication (AAPD 2020).
The office’s non-clinical staff play an important role in guiding behaviour.
The scheduler or receptionist will often be the first contact with a potential
patient and family, either by internet or a phone conversation, and will also
assist the family upon arrival at the office. The tone of communication should
always be welcoming and should actively engage with the patient and family
to determine their main concerns, chief complaint, and any special care or
cultural/linguistic needs. Appointment times should be determined according
to the patient’s age, presence of a special health need, need for sedation,
distance between home and office, duration of appointment, most feasible time
of day (AAPD 2020).
The care and the way in which the child is received in practice in the first
and subsequent visits is important. A child-friendly reception area (eg, age-
appropriate toys and games) can provide distraction and comfort for young
patients. These first impressions can influence future behaviours.
4. Behaviour Assessment
The assessment of the behaviour presented by the patient during the dental
appointments allows the clinician to evaluate the patient’s attitudes towards
treatments of different levels of complexity and the effectiveness of the
techniques used (Sivakumar & Gurunathan 2019). Among the methods
available to record the behaviour of young patients, the Frankl behavioural
rating scale is often considered the gold standard, mainly due to its wide use
and acceptance in pediatric dentistry research (Frankl et al. 1962, Ramos-Jorge
et al. 2006, Sivakumar & Gurunathan 2019). This scale classify the observed
behaviour into four categories, ranging from definitely positive to definitely
negative (Table 1).
Table 1. The Frankl behavioural rating scale

(Frankl et al. 1962)
Definitely Refusal of treatment, forceful crying, fearfulness, any

negative other overt evidence of extreme negativism.
Reluctance to accept treatment, uncooperativeness, some
Negative
evidence of negative attitude but not pronounced.
Acceptance of treatment, cautious behaviour at times,
willingness to comply with the dentist, at times with
Positive
reservation, but patient follows the dentist’s directions
cooperatively.
Definitely Good rapport with the dentist, interest in the dental
positive procedures, laughter and enjoyment.
5. Informed Consent
Decisions regarding the use of behaviour guidance techniques must involve

the dentist, the parents and, if appropriate, the child (AAPD 2021). With the
exception of communicative management, a basic element of communication,
all other behavioural guidance techniques require an informed consent. Thus,

it is necessary to obtain an informed consent before the treatment, signed by
both the parents or caregivers and the clinician. However, a signature on the
consent does not constitute an informed consent (AAPD 2021). The healthcare
professional must provide relevant information about patient’s diagnosis and
treatment needs so that the parents can make a voluntary decision to accept or
refuse treatment. The parents must be informed about the potential
benefits/risks and any alternatives to the treatment proposed (ADA Division
of Legal Affairs 2010). If the parent refuses the proposed treatment, an
informed refusal form should be signed by the parent and filed in the patient’s
record (AAPD 2021).
6. Pain Assessment in Young Patients
Clinical decision-making regarding endodontic procedures should consider

the patient’s pain history, allowing the clinician to establish the diagnosis
based on the health status of the pulp tissue (normal, reversible pulpitis,
irreversible pulpitis, or necrosis) and to choose the most appropriate treatment
(conservative or not) (AAPD 2021).
Pain is always subjective, so its severity must be evaluated individually
(AAPD 2021). Pain assessment in young patients can be done following three
steps (Manworren & Stinson 2016). The first step is to record the pain history.
Thus, the patient/parents should be asked about pain onset, triggering factors,
region or location, time or duration, relief and spontaneity, medication use,
and impact on daily activities (McGrath & Unruh 2013).
The second step is to employ an assessment tool appropriate to the child’s
age and cognitive development. Patients older than seven years are able to
determine the intensity of pain using a Visual Analogue Scale (VAS) (AAPD
2021). VAS is the most used method and consists of a 10 cm long line, with
‘0’ and ‘10’ markings on opposite sides. The ‘0’ indicates no pain and ‘10’
indicates very strong pain (Figure 2). The patient is asked to select a point on
the scale to indicate the intensity of pain (Zieliński et al. 2020). Finally, the
third step is to assess the effectiveness of pain relief interventions (Manworren
& Stinson 2016).
Figure 2. Visual Analogue Scale (VAS). Adapted from Zieliński et al. 2020.
7. Basic Non-Pharmacological Behaviour Guidance Techniques
The basic techniques for managing the behaviour of young patients in the
dental office consist of different ways for the dentist to conduct the
appointment, in order to establish or maintain communication andextinguish
inappropriate behaviour (AAPD 2020). In the dental appointment, asking
questions and listening to the patient can help to establish rapport and trust.
During the procedure a two-way communication must be maintained, and the
dentist must consider the child as an active participant in their well-being and
care. Through clear communication in association with behavioural guidance
techniques, the dentist can safely offer quality dental treatment. The choice or
association of techniques depends on the behaviour predictors mentioned
before and on the dentist’s sensitivity to identify the characteristics of the
family and the patient and the ideal moment to perform each one of them
(AAPD 2020).
7.1. Desensitization
Desensitization consists of the systematic evolution from simpler procedures

that cause less anxiety to more complex procedures that can cause more
anxiety in the patient. Thus, the patient gets used to less intense stimuli, and
accepts the next more intense stimuli in an easier way (AAPD 2020). To
desensitize the patient, it is necessary to consider the sequence of the treatment
plan and the duration of the procedures. Ideally, the initial procedures should
be brief and less complex, evolving into more time-consuming and more
complex procedures (Soxman & Townsend 2022). Performing prophylaxis in
the first appointment and evolving to more complex procedures on subsequent

visits, which may involve local anesthesia, for example.
It is expected that with continued experience the response of the child
improves, indicating a desensitization to dental stress and allowing the child
to accurately distinguish between stressful and non-stressful procedures
(Venham et al. 1977).
7.2. Distraction
Diverting the patient’s attention to something that causes him more interest
and positive stimuli can be an interesting technique, especially when he will
be subjected to unpleasant procedures. For very young patients, it may be
interesting to offer toys, a ball to squeeze, or a hand mirror (when it is
appropriate) (Figure 3). For patients of all ages, telling funny stories or asking
the caregiver about school, a movie, music, or anything else that might be
interesting to the patient can lead to relaxation and thought shifting to pleasant
situations. Counting slowly backwards while performing the procedure can
also cause the patient to focus on counting and distract from the treatment
(Soxman & Townsend 2022).
Figure 3. Hand mirror to distraction.
Nowadays, it is very common to use technological alternatives for

distraction that are very well accepted by young patients, such as: virtual
reality glasses to watch a movie, watching a television mounted on the ceiling
or in the dental equipment or listening to music chosen by the patient (Al-

Khotani et al. 2016, Zhang et al. 2019, Custódio et al. 2020). It is important
that the paediatric dentists are aware of all different techniques, al-lowing
them to apply the most appropriate strategy according to each child’s or
adolescent’s individual characteristics (Prado et al. 2019).
7.3. Talk-Show-Do
This technique is used to explain to the patient what to expect from the
procedure, and is a good tool for guidance at any age. The procedure is
described in as few words as possible, the materials to be used are shown to
the patient, and then the procedure is performed (AAPD 2020). It is important
to adapt the language and vocabulary to the patient’s age and comprehension
level. The talk-show-do technique can be combined with positive
reinforcement, desensitization, and non-verbal communication. As in
desensitization, the instruments should be presented gradually, from the one
that causes less anxiety to the one that causes more anxiety (Corrêa, Maia,
Sanglard-Peixoto 2010). The technique can also be used to the child learns the
noises made by each device. Allowing the child to manipulate the instruments
in an oriented way and enabling their active participation during the service,
being able to raise their hand when they feel uncomfortable, increases their
confidence and reduces their anxiety during the procedures (Klatchioan &
Toledo 2012).
7.4. Direct Observation
Direct observation or “modeling” consists of showing the patient another

person being cared for, demonstrating cooperation during care. This demo
could be live with another patient currently being treated or a footage of other
patients at the dentist. Preferably, the model patient should be similar in age
to the patient seen so that there is identification and through observation he
can learn appropriate behaviour patterns for the dental office. This technique
provides an opportunity for the patient and parent to ask questions about the
dental procedure in a safe environment (AAPD 2020).
7.5. Memory Restructuring with Positive Reinforcement
Memory restructuring involves four components: (1) visual reminders; (2)

positive reinforcement through verbalization; (3) concrete examples to encode
sensory details; and (4) sense of accomplishment. It may be used after difficult
experiences to focus on the positive aspects of the visit and to extinguish
memories of negative aspects (AAPD 2020).
The visual reminder should be positive, such as a photograph of the child
smiling at the time of the initial visit. Then, the child is reminded about the
last appointment highlighting the good aspects, like the good job he/she did
(AAPD 2020). The dentist rewards the child’s appropriate behaviour,
reinforcing their recurrence. This reward can be through facial expressions of
approval, expressions of affection and praise, but it can also occur through
symbolic prizes and gifts. The reward must occur at the right time, always
highlighting the desirable behaviour. The child’s reactions to reward through
prizes can be diverse, from expressions of affection and thanks to non-
acceptance due to irritability and post-treatment exhaustion (Corrêa, Maia,
Sanglard-Peixoto 2010). Last, child demonstrates those behaviours, leading to
a sense of accomplishment (AAPD 2020).
The lack of a positive reaction should not discourage the dentist from
using the technique. The goal is for the child to repeat the positive behaviour
over time (Corrêa, Maia, Sanglard-Peixoto 2010 AAPD 2020).
7.6. Voice Control and Non-Verbal Communication
Voice control is a form of behaviour guidance that uses voice tone, volume,
or rhythm to influence or direct a patient’s behaviour or attention. Facial
expressions, posture and eye contact also aid in the technique.
Parents/caregivers should always be educated about the technique before it is
used as some may find voice control unacceptable (AAPD 2020). This
technique is more accepted in school-aged and older children.
7.7. Absence/Presence of Parents
The presence of parents in the dental office in the case of young patients is
especially necessary in the first consultations when the anamnesis and initial
clinical examination are performed, as some information may not be known
to the patient. Although there is some evidence that the presence of parents in
the dental office during the procedures does not interfere with the behaviour
of children over 12 years of age (Passos De Luca et al. 2021), this choice must
be made jointly by the parents, patient and dentist. Consideration should also
be given to whether the presence of parents conveys security, does not divert
the patient’s attention in a negative way and cooperates for positive behaviour
(AAPD 2020). If the presence of the parents interferes with the rapport
between the dentist and the patient and transmits more anxiety, it should be
considered that they wait in the waiting room.
7.8. Relaxation Technique: Music,

Essential Oils, Breathing Technique
Bubble breath exercise, a play therapy technique, may be used as a

relaxation strategy to manage anxiety and pain (Sridhar et al. 2019). Calm
music can induce relaxation on a neurological level (Bradt 2013). Inhaling
lavender oil for 3 minutes before a procedure can also be effective in reducing
anxiety (Arslan, Aydinoglu, Karan 2020).
Knowledge of the scientific basis of behaviour guidance and skills in
communication, empathy, tolerance, cultural sensitivity, and flexibility are
requisite to proper implementation. Behaviour guidance should never be
punishment for misbehaviour, power assertion, or use of any strategy that hurts,
shames, or belittles a patient (AAPD 2020).
8. Pharmacological Techniques
Pharmacological techniques consist of sedation and general anesthesia and are

used to obtain patient cooperation and allow dental treatment to be performed
with quality and safety (Coté et al. 2019). Pharmacological techniques may
result in respiratory depression, laryngospasm, impaired airway patency,
apnea, loss of the patient’s protective reflexes, and cardiovascular instability.
It is known that the adverse responses of these techniques cannot be totally
eliminated, but they can be minimized through a careful anamnesis of the
patient’s medical history, considering how the reported medical conditions can
affect or be affected by the technique that is intended to be used. Therefore,
the risks associated with pharmacological techniques justify the fact that they
should be indicated after unsuccessful attempts to guide the child’s behaviour
only through non-pharmacological techniques, in extensive treatments of

uncooperative patients due to lack of psychological or emotional and/or
mental maturity, physical or medical disability (Coté et al. 2019).
8.1. Protective Stabilization
Protective stabilization is considered an advanced technique and is indicated

to very young patients (0 to 3 years old) and patients with special health care
needs, who don’t have ability to collaborate. This technique aims to restrict
patient’s movements in order to minimize the risks of injury to the child, the
parent/caregiver, and dental team, allowing safe completion of treatment.
Stabilization can be done with the help of parents and/or dental team,
protective stabilization devices, or a combination of them (AAPD 2021,
AAPD 2021). Some factors need to be considered in relation to the use of
protective stabilization, such as professional training, risk and benefit
assessment, indications, respect for the caregiver’s opinion and the child’s
autonomy (Minhoto et al. 2017).
8.2. Sedation
Sedation is a technique that employs a drug or a combination of drugs to

produce a state of central nervous system depression, inducing cooperation in
anxious or uncooperative pediatric patients and promoting favorable treatment
outcomes. Three levels of sedation can be described, as follows (Coté et al.
2019):
 Minimal sedation: an altered state of consciousness caused by

medications, during which patients respond normally to verbal
commands. There is no change in respiratory and cardiovascular
functions, but cognitive functions and coordination may be
compromised.
 Moderate sedation: An altered state of consciousness caused by
medications, during which patients purposefully respond to verbal
commands. Airway patency and cardiovascular function are
maintained. In older patients, this level of sedation can result in a state
of interactivity, whereas in younger patients, age-related behaviours

such as crying are expected.
 Deep sedation: an altered state of consciousness caused by
medications, during which patients are not easily aroused but respond
to commands purposefully after repeated verbal or pain stimuli.
Respiratory function may be compromised, requiring assistance to
maintain a patent airway.
The American Academy of Pediatric Dentistry suggests five goals of

sedation during procedures: (1) to ensure patient safety and well-being; (2) to
minimize physical discomfort and pain; (3) to control anxiety, minimize
psychological trauma, and maximize the potential for amnesia; (4) to control
behaviour and/or movement so as to allow the safe completion of the
procedure; and (5) to return the patient to alertness, confirmed by recognized
criteria. These goals can be achieved by selecting the lowest dose of drug with
the greatest therapeutic potential for the procedure (Coté et al. 2019).
Therefore, the clinician must have a clear understanding of the pharmacoki-
netics and pharmacodynamics of sedative drugs, drug interactions, and
adverse effects (AAPD, 2021).
The sedation techniques used in the dental office produce minimal
depression of the state of consciousness, in which airway patency and response
to verbal commands are maintained. For example, the patient may purposely
respond to an uncomfortable stimulus or a request to move or open the eyes
(Dock 2011). However, depending on the level of sedation achieved, this
technique can lead to depression of the respiratory system and, in more severe
cases, to cardiorespiratory arrest and death. So, the clinician should check the
patient’s vital signs through visual clinical assessment (skin color, pupils,
chest movement and responses to verbal contact) and assess physiological
parameters (oxygen saturation, heart rate and blood pressure) (Ciamponi et al.
2016, Coté et al. 2019).
The dental team must know how to manage the potential complications of
the intended level of sedation and the next deeper level, as children can quickly
move from a deep level of sedation to a deeper level than intended. Thus, when
sedation is performed in the dental office, it needs to be equipped with devices
to perform basic and/or advanced life support, if necessary (Coté et al. 2019).
The sedatives agents often used for conscious sedation include nitrous
oxide and midazolam (with or without ketamine).
8.3. Nitrous Oxide
Nitrous oxide is an inert, colorless gas with a slightly sweet smell that acts on
the central nervous system, producing analgesic and anxiolytic effects (AAPD
2021). Due to the increase in the pain threshold, nitrous oxide has an analgesic
effect, without producing an anesthetic effect, therefore, its application does
not dispense the use of local anesthetics. Used for minimal sedation to healthy
patients in ASA class I or II, nitrous oxide is applied nasally at a concentration
of ≤50% with the balance with oxygen, without any sedative agent or opioids
(Coté et al. 2019). The patient responds normally to verbal commands and
vital signs are kept stable. If nitrous oxide is combined with other sedatives,
such as midazolam, or if used in concentrations >50%, the likelihood of
moderate or deep sedation increases (Coté et al. 2019).
Compared to benzodiazepines, nitrous oxide has an almost immediate
effect (2 to 3 minutes) due to its rapid absorption by the pulmonary alveoli and
low solubility in blood and tissues. In addition, the rapid return to the initial
status after discontinuation of inhalation makes nitrous oxide safe for use in
children (Kharouba et al. 2020). Its safety is also related to the rare occurrence
of adverse effects, and the common symptoms are nausea and vomiting
(Galeotti et al. 2016).
A study with a large pediatric sample reported that nitrous oxide resulted
in successful completion of dental treatment in 86.3% of cases and may be a
useful alternative to general anesthesia, even in precooperative children,
which may decrease the number of pediatric patients referred to hospitals for
general anesthesia (Galeotti et al. 2016). The main indications for sedation
with nitrous oxide are patients with fear and anxiety, but who have the ability
to cooperate, patients with a gag reflex that interferes with dental care, children
with neuropsychomotor developmental delay, and patients for whom it is not
possible to obtain profound local anesthesia (AAPD 2021).
8.4. Midazolam
Different sedative drugs, dosages and administration routes have been

investigated in order to identify the safest and most effective option for
pediatric patients (Ashley et al. 2018, Sado-Filho et al. 2021). A recent
systematic review concluded that there is some moderate-certainty evidence
that oral midazolam is an effective sedative agent for children undergoing
dental treatment (Ashley et al. 2018). Other drugs such as ketamine have also
showed efficacy in behavioural guidance. In addition, the combination of

ketamine and midazolam has been demonstrated to be a good option for
pediatric dental sedation (Antunes et al. 2016, Sado-Filho et al. 2019).
A pediatric dentistry-based study found that children, who received
moderate sedation (midazolam only or ketamine and midazolam) during
dental procedures, behaved more positively during subsequent recall
appointments 4 to 29 months after completion of treatment, than those who
did not receive sedation (Antunes et al. 2016). This finding can be explained
by the fact that midazolam promotes anterograde amnesia, that is, children
probably do not remember the dental procedure. In addition, the combination
of midazolam and ketamine maintains the anxiolysis provided by midazolam
and adds the sedative and analgesic properties of ketamine, improving child’s
comfort level (Antunes et al. 2016). Although sedative drugs have benefits,
sedation cannot be used indiscriminately. Besides, it is important to mention
the importance of anesthesiologist supervision, as some drugs, such as
ketamine, are general anesthetics (Moreira et al. 2013, Antunes et al. 2016).
The use of the combination of midazolam and ketamine or the inhalation
of nitrous oxide alone were equally effective in obtaining sedation during
tooth extraction and pulpotomies in children aged 3 to 10 years (Ilasrinivasan
et al. 2018). However, clinically greater patient compliance is required for the
administration of nitrous oxide due to the device that is used for gas inhalation.
Thus, clinicians can choose the sedative agent according to their preference
and experience, as well as the patient acceptance (Ilasrinivasan et al. 2018).
This choice guideline should also apply to patients with disabilities, who may
not be able to breathe properly through a nasal mask or tolerate long and
unpleasant dental procedures, even if sedated with other sedative agents.
Therefore, these patients can be referred for general anesthesia in a justified
manner (Galeotti et al. 2016). This reinforces the fact that each patient is
unique in the Pediatric Dentistry clinical practice.
8.5. General Anesthesia
General anesthesia is a controlled state of unconsciousness characterized by a

partial or total loss of protective reflexes, including airway patency.
Cardiovascular function may also be compromised. The patient is not
interactive and does not purposely respond to physical stimulation or verbal
commands (AAPD 2021).
General anesthesia must be administered by a trained, credentialed and

licensed pediatric dentist, dental or medical anesthesiologist, nurse anesthetist
or anesthesia assistant in properly equipped facility. The need for a hospital
unit and specialists increases the costs of this technique (AAPD 2012, Ashley
et al. 2018).
Studies have been demonstrated that general anesthesia improves the Oral
Health Related Quality of Life of young children as well as exerts a positive
impact on the family (Thomson & Malden 2011, Jankauskiene et al. 2014). A
study involving young Lithuanian children with severe dental caries showed
that more than half of the parents stated they would consider another treatment
under general anesthesia, if needed (Jankauskiene et al. 2014). However,
repeated treatments under general anesthesia are not accepted by health
professionals, as parents and children must be instructed on measures to
prevent oral problems. In addition, whenever possible, general anesthesia
should be avoided because of the associated risks. The United States Food and
Drug Administration warns of the potentially harmful neurodevelopmental
effects of prolonged (longer than 3 hours) or repeated exposures to anesthesia,
especially in children under 3 years of age (Graham 2017).
It is important to mention that some factors can make endodontic
treatments under general anesthesia difficult, such as limited mouth opening,
tongue protrusion due to intubation, short session duration, uncertain
diagnosis due to the inability of patients to describe the symptoms and the
need to complete a maximum amount of treatment in each session (Alsaleh et
al. 2012, Cousson et al. 2014).
9. Particularities of Endodontic Treatment
There are some particularities related to endodontic treatment that must be

considered. The procedures are usually more complex, involving local
anesthesia, which is an aggravating factor of fear and dental anxiety in children
and the use of materials normally not used in simple procedures such as
irrigants and rubber dam. These particularities should be carefully evaluated
to avoid accidents, since uncooperative children are more likely to swallow or
aspirate instruments during dental care (Hodges, Durham, Stanley 1992).
9.1. Rubber Dam
The rubber dam provides better working conditions and protects the patient
against ingestion or inhalation of potentially toxic mucosal and aerosol
products containing pathogens (Vanhée et al. 2021), in the other hand, it can
often incite an open mouth narrows the oropharyngeal area, significantly
reducing the volume of upper airway patency and decreasing tidal volume
(Iwatani et al. 2013) (Figure 4).
Figure 4. Rubber dam in young patient.
Isolation may be challenging in the pediatric population. The floor of the

mouth is higher, protective reflexes are diminished, and the tongue is
disproportionately large. Although can often incite a strong negative response
(Soxman & Townsend 2022), the use of rubber dam is particularly beneficial
children, as it not only ensures isolation where cooperation may be limited,
but also acts as a psychological as well as physical barrier for the patient which
can make them feel more secure (Jones & Reid 1988). It can cause less stress
in children and adolescents compared to relative isolation with cotton rolls if
applied by an experienced dentist (Ammann et al. 2013).
The dentist should provide to the patient good explanation of why it was
necessary to use rubber dam. With sufficient information the patient should
feel less anxious about receiving treatment with rubber dam (McKay et al.
2013). If the rubber dam is covering the child’s nose, that portion may be cut
away with scissors, providing more ventilation and/or less intimidating
isolation (Soxman & Townsend 2022). In order to avoid accidents clamps
should be attached to a dental floss, so it can be pulled out by the dentist if in

risk of been swallowed or aspirated, the same should be done with intra oral
mouth props (Figure 5).
Figure 5. Mouth prop and clamp attached to a dental floss.
9.2. Radiographs
Radiographs (very often in endodontic diagnosis) should be taken to

substantiate a clinical diagnosis and guide the practitioner in making an
informed decision that will affect patient care (AAPD 2021). The most
effective way to take child radiographs is position the cone head before placing
the film, sensor, or plate in the child’s mouth. If using conventional
radiography is too uncomfortable, the film may be bent or positioned
vertically. Permit the child to place the film in his or her mouth if he or she is
reluctant to permit placement by staff or the dentist. Telling the child to open
his or her eyes as wide as possible and using a mirror to watch film placement
or to lift a foot off the chair are good distraction techniques (Soxman &
Townsend 2022).
When diagnostic radiographs cannot be obtained due to a lack of
cooperation, technical issues, or a health care facility lacking in intraoral
radiographic capabilities, the practitioner should inform the patient or
guardian of these limitations and document these discussions in the patient’s
record. The decision to treat the patient without radiographs will depend upon
the urgency of the treatment needs, availability and appropriateness of
alternative treatment settings, and relative risks and benefits of the various
treatment options for the patient (AAPD 2021).
9.3. Gag Reflex
The gag reflex is a natural defense mechanism in which muscle contraction

occurs to prevent unwanted objects from entering the respiratory tract
(trachea, larynx, oropharyngeal air way). Gagging may occur in nearly 30%
of children seen in the dental setting, and is more common in boys, younger
patients, and is also a physiologic manifestation of fear and anxiety in children
(Katsouda et al. 2019).
A gag reflex may be altered by putting pressure with the eraser end of a
pencil into the palm of the hand at the point where the long axis of the middle
finger and thumb, squeezing the fleshy area of the hand between the index
finger and thumb (Soxman & Townsend 2022). The dentist also can use
distraction such as: asking the patient to bend the leg on the opposite side of
the tooth being treated and pressing the foot into the chair or giving to patient
a colorful matching puzzle ball with blocks of various shapes and sizes to play
are also effective methods to deter a gag reflex (Dixit & Moorthy 2021,
Soxman & Townsend 2022). In radiographs, placing a small amount of child-
flavored toothpaste on the film packet can also decrease gagging. If unable to
obtain a traditional anterior periapical radiograph (Soxman & Townsend
2022).
Conclusion
Behavioural guidance may be the most challenging aspect of dental care for
young patients, as behaviour is a complex and multifactorial phenomenon.
Thus, the clinician must consider clinical characteristics of the child and the
predictors of behaviour, such as mother’s anxiety, parental styles, report of
dental pain, and severity of dental caries.
The behavioural guidance techniques can be divided into non-
pharmacological techniques and advanced techniques (protective stabili-
zation and pharmacological techniques). Except communicative manage-
ment, a basic element of communication, all other behavioural guidance
techniques require an informed consent.
The non-pharmacological techniques for managing the behaviour are

different ways for the dentist to conduct the appointment, in order to maintain
communication, extinguish inappropriate behaviour and establish interaction.
The distraction, talk-show-do, direct observation, desensitization, memory
restructuring and voice control techniques should be used to conduct the
treatment safely, aiming at the child’s collaboration at some point. The choice
or association of techniques depends on the behaviour predictors and on the
dentist’s sensitivity to understand the ideal moment to perform each one of
them.
The use of protective stabilization should consider risk and benefit
assessment, indications, respect for the caregiver’s opinion and the child’s
autonomy. Regarding sedation, an ideal pediatric dental sedative should be
safe, cause minimal respiratory depression, provide adequate sedation, have
rapid onset of drug action, and provide adequate working time. Among the
sedatives available, nitrous oxide and midazolam (with or without ketamine)
are the most used. Both sedation and general anesthesia must be treated as a
single physiological state of the patient, which requires professional training,
monitoring, facilities, and personal requirements to manage and rescue the
patient. Finally, the choice of appropriate behavioural guidance techniques
and the dentist’s skills promote a good relationship with children and their
caregivers contribute to a more positive behaviour and better treatment
outcome.
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Chapter 5
Management of Deep Carious Lesion in Dentin
Hebertt Gonzaga dos Santos Chaves1,*,

Isabella Figueiredo Assis Macedo1,
Barbara Figueiredo1, Francine Benetti1
and Paulo Carvalho Tobias Duarte2,3
1
2
Department of Health - Pediatric Dentistry Area, State University of Feira de
Santana (UEFS), Feira de Santana, Bahia, Brazil
3
Pediatric Dentist, University Medical Service (SMURB), Federal University of
Bahia (UFBA), Salvador, Bahia, Brazil
Abstract
Mechanical removal of carious tissue and its replacement with restorative

materials has long been practiced, and there is still controversy over how
much carious tissue should be removed from carious lesions. For a long
time, complete removal of all carious tissue until the hard dentin was
reached was advocated. However, paradigms have changed and new
scientific evidence has shown that selective caries removal, preserving
affected dentin in the pulp wall, can be a safe method, and the presence
of a residual dentin layer does not affect the long-term survival of the
teeth. Additionally, selective methods reduce the risks of pulp exposure
whose treatment prognosis is more doubtful. The dental materials usually
used after indirect dentin management are calcium hydroxide and glass
ionomer cements. However, there are already new bioceramic materials
that have a good performance in dentin capping. However, as long as the
Corresponding Author’s E-mail: heberttchaves_@hotmail.com.

*

ISBN: 978-1-68507-987-1
86 H. Gonzaga dos Santos Chaves, I. Figueiredo Assis Macedo et al.
restoration effectively seals the cavity of the external oral environment,

there will be no progression of the carious lesion, but its inactivation,
regardless of the capping material used.
Keywords: dental caries, deep caries lesion, dentin-pulp complex
1. Introduction
The dentin-pulp complex consists of two unique and very special tissues – a
mineralized connective tissue (dentin) and a loose connective tissue (pulp) that
originate embryologically from the dental papilla of the neural crest
ectomesenchyme (Abbass et al. 2020). Its physiological processes during
developmental homeostasis, pathology and repair are fully interconnected via
the dentinal tubule and by the odontoblastic process that projects into the
tubule, typifying these two tissues as a biological complex, entity or
continuum. (Bjørndal et al. 2019) In the face of external aggression, the
dentinal tubules allow the aggressor agent access to the pulp, and both adopt
mechanisms of mutual protection against these stimuli. (Abbass et al. 2020).
Dental pulp is a richly vascularized, innervated, and cellularized loose
connective tissue that harbors various cell types, including fibroblasts,
undifferentiated mesenchymal cells, and immune cells (Da Rosa et al. 2018).
Fibroblasts are the most numerous pulp cells and are responsible for the
production and maintenance of collagen (Ricucci et al. 2014, Andrei et al.
2021). In addition to sensory, nutritional and defensive roles, the main
function of the dental pulp is to secrete dentin that will protect it from external
irritants (Yu & Abbott 2007). On the other hand, dentin is a highly specialized,
permeable and sensitive hard tissue, consisting of water, lipids, and organic
and inorganic components synthesized by odontoblasts of pulp origin (Abbass
et al. 2020). Hydroxyapatite crystals - Ca10(PO4)6(OH)2 - make up its
inorganic matrix, and collagenous proteins (type I collagen), non-collagenous
proteins, and growth factors make up its organic matrix (Kawashima et al.
2016, Abbass et al. 2020).
Different types of dentin are produced by the pulp, primary dentin being
produced during odontogenesis until the closure of the root apex, and
secondary dentin formed under physiological conditions continuously
throughout the life cycle of the tooth, after the end of root formation. Primary
and secondary dentin have a typical tubular structure, being composed of
intertubular and peritubular dentin (Smith et al. 2012). Furthermore, the pulp
Management of Deep Carious Lesion in Dentin 87
produces tertiary dentin, which consists of a dystrophic matrix, sometimes

atubular, formed at the pulp-dentin interface in response to pathological
stimuli such as caries, trauma and operative dentistry (Tziafas et al. 2000,
Andrei et al. 2021).
Different types of tertiary dentin can be formed depending on the intensity
of the external stimulus (Smith et al. 1995). Mild environmental stimuli (e.g.,
slowly progressing caries) do not affect pre-existing original odontoblasts,
which respond by synthesizing reactionary-type tertiary dentin. However,
intense stimuli (e.g., deep and rapidly progressing carious lesions) cause the
death of primary odontoblasts in the affected area, causing a new generation
of odontoblast-like cells to differentiate from mesenchymal stem cells and
synthesize a reparative-type tertiary dentin (Smith et al. 2012, Kawashima et
al. 2016, Andrei et al. 2021).
2. Aggressions to the Dentin-Pulp Complex
The pulp-dentin complex is very sensitive to a range of harmful factors

resulting from microbial invasion through dental caries, chemical or
mechanical action of restorative materials, occlusion trauma and dental trauma
(Park et al. 2018). The reactions of the pulp-dentin complex to aggressive
stimuli include diverse defensive mechanisms, including an
immunoinflammatory response (Cooper et al. 2017), reduced dentinal
permeability or tubular sclerosis (Ricucci et al. 2019) and tertiary
dentinogenesis. (Tziafas et al. 2000, Andrei et al. 2021). Understanding the
pulpal inflammatory process is essential for performing restorative procedures
and developing dental materials (Saber et al. 2018, Alhabdan et al. 2018).
The reduction in dentin permeability can come from both the dentin itself
and the pulp. As the dentinal fluid moves outward, the pulp decreases dentin
permeability, replenishes sclerotic dentin, and produces plasma proteins to
coat the dentinal tubules (Ricucci et al. 2019). The formation of tertiary dentin
is triggered by odontoblastic differentiation and release of bioactive molecules
that become attached to the dentin matrix, such as transforming growth factor
(TGF)-β, bone morphogenic proteins (BMP), insulin-like growth factor (IGF)
and angiogenic factors. These molecules are critical to tissue repair (Kearney
et al. 2018).
The degree of involvement varies according to the depth of the lesion,
which can be superficial, when it affects only the enamel, deep, when there is
cavitation that affects the inner part of the dentin, but there is still an area of
dentin between the caries and the pulp, or extremely deep, when it affects the
entire thickness of dentin (Giacaman et al. 2018).
3. Caries and Atraumatic Management

of the Dentin- Pulp Complex
The minimally invasive treatment of carious lesions is an approach that

considers the management of carious lesions with conservative techniques to
preserve as much of the tooth structure as possible, ranging from primary
prevention and management of the caries disease process, to the approach of
carious lesions by surgical and non-surgical means. (Giacaman et al. 2018).
For a long time, the recommended treatment for deep caries was the
removal of all infected and demineralized dentin, known as total carious tissue
removal (TCTR), with the aim of preventing future cariogenic activity and
providing a well-mineralized dentin substrate to perform the definitive
restoration (Araújo et al. 2017, Arandi et al. 2021). However, performing
TCTR increases the incidence of pulp exposures whose treatments are more
complex and sometimes unpredictable (Araújo et al. 2017, Oz et al. 2019)
which led to the search for less invasive treatments that prevent pulp exposure,
supported due to the knowledge that TCTR is not necessarily an indicator for
the success of the treatment of carious lesions (Araújo et al. 2017, Pedrotti et
al. 2019, Arandi et al. 2021).
In recent years there has been a growing interest in less invasive dentin
techniques through selective tissue removal methods or fluorescence-aided
excavation methods, polymer drills, operating microscope or
chemomechanical caries removal (Schwendicke et al. 2013a, Araújo et al.
2017, Pedrotti et al. 2019, Arandi et al. 2021). This interest has been sparked
by a growing number of clinical trials that have demonstrated the benefits of
minimal invasion compared to attempting to remove all carious tissue,
especially for dentinal lesions that are deeper and closer to the pulp
(Schwendicke et al. 2013a, Maltz et al. 2018, Schwendicke et al. 2018,
Pedrotti et al. 2019).
Sealing carious lesions with restorative materials over carious dentin stops
the progression of caries for at least 10 years, indicating that complete removal
is not necessary for clinical success (Araújo et al. 2017, Li et al. 2018,
Machiulskiene et al. 2019). It should also be noted that the correct sealing of
carious dentin significantly reduces the surviving microbiota, increases
hardness and helps in the reorganization of dentin, regardless of the liner

material used (Alnahwi et al. 2018).
Currently, other approaches to caries deep in dentin, other than TCTR,
have been proposed, including two-step caries removal (Smaïl-Faugeron et al.
2018) and one-step selective removal of carious dentin (Arandi et al. 2021)
which will be discussed in the following topics. It is extremely important to
note that with the advent of conservative dentistry, it is currently proposed to
maintain a layer of demineralized dentin on the pulp wall and to apply a liner
material to induce the formation of tertiary dentin (Araújo et al. 2017).
However, there are still questions about the permanence of a layer of carious
dentin before restoration of the cavity, (Bitello-Firmino et al. 2018) because it
is believed that if infected tissue remains, the carious process may progress,
albeit slowly (Kidd 2004).
Recently, deep carious lesions in human molars were treated using the
complete or selective caries removal techniques, and then dentin biopsies were
obtained shortly after excavation and after three months of sealing, as a
biomarker of treatment efficacy. The analyzes revealed a similar reduction in
microbial counts after the sealing period in both groups, confirming the
hypothesis of reduced microbial loads caused by the lack of access of biofilms
to exogenous nutrients, the most obvious environmental challenge for the
remaining microorganisms (nutritional stress) (Bitello-Firmino et al. 2018).
The lack of professional knowledge regarding decision making of "when
to stop carious dentin removal" was also raised (Koopaeei et al. 2017). Several
studies have revealed that the dentin hardness criterion, unfortunately, is still
a criterion adopted to determine the “optimal caries excavation end point”
(Ricketts et al. 2013, ONDPS 2013, Koopaeei et al. 2017, Schwendicke et al.
2017). A recent survey reported that dentists in the US used dentin hardness
as the main criterion for caries removal (Alnahwi et al. 2018), which was also
observed for most German, French and Norwegians dentists (Doumani et al.
2020).
In the past, complete removal of all traces of decayed tissue was
considered the best treatment. Advances in studies on biofilm and caries
disease have changed this perspective. In recent decades, the idea of removing
all decayed tissue has been replaced by studies on minimally invasive
methods, especially in cases of young permanent teeth. It is now recognized
that only infected dentin needs to be removed, rather than affected dentin
(Innes et al. 2016, Ricucci et al. 2019, Kunert et al. 2020). However, the
regeneration of biological tissues damaged by external aggressions is highly
complex (Abbass et al. 2020) and interventions need to be effective in
eliminating the infection, in addition to preventing a new microbial invasion

from occurring (Smaïl-Faugeron et al. 2018).
4. Management of Deep Caries Lesion
It is important to emphasize that the term dental caries is the name of the
disease and its use should be limited to situations that involve its control
through preventive and non-invasive measures at the patient’s level. On the
other hand, the term caries lesion is related to the manifestations or symptoms
of the disease at the level of the tooth and should be referred to as caries lesion
management (Innes et al. 2018). However, the existence of different terms and
definitions for caries lesions and their management strategies is still a problem
to be solved (Innes et al. 2018).
4.1. Concepts of Deep and Very Deep Caries Lesion
A deep carious lesion in dentin is considered to be one that has reached the
inner quarter of the dentin, but which still has a well-defined zone of
radiopaque dentin between the carious lesion and the pulp, radiographically
detectable on the interproximal or occlusal surface. On the other hand, the
extremely deep carious lesion has already penetrated the entire thickness of
dentin, without a radiopaque zone separating the carious lesion from the pulp,
radiographically detectable on the interproximal or occlusal surface. (Bjørndal
et al. 2019, ESE 2019). Furthermore, in deep carious lesions there is a risk of
exposure to the pulp during operative treatment while in very deep lesions
pulp exposure is unavoidable during excavation, with microorganisms
penetrating the critical zone of tertiary dentin, including the pulp (Bjørndal et
al. 2019, ESE 2019).
4.2. Clinical Presentations of Dentin Affected by Carious Lesions
Since the terminology cannot be used to directly relate the visual appearance
of the carious lesion to the pulp histopathological condition, current
terminology is based on the clinical consequences of the disease. (Innes et al.
2016, Innes et al. 2018, ESE 2019) Thus, definitions of the different clinical
types of caries-affected dentin were given, with soft dentin being that which
can be excavated with minimal resistance by hand instruments; firm dentin the
one that is resistant to excavation with hand instruments; hard dentin that
which present itself solid, healthy and resistant to penetration by manual
instruments and leathery dentin a transition in the spectrum between soft and
firm dentin. (Innes et al. 2016, Innes et al. 2018, ESE 2019).
5. Strategies for the Management of Deep Caries Lesions in

Dentin
5.1 Gradual Carious Tissue Removal (GCTR)
Gradual caries removal is a selective caries removal technique performed in

two visits, with an interval between visits to stimulate deposition of tertiary
dentin before the last excavation (Aïem et al. 2020). The objective of the first
stage is to alter the cariogenic environment, inactivating the progression of the
lesion (Maltz et al. 2012), making the removal of dentin in the second stage
easier and safer, with less chance of pulpal exposure (Bjorndal et al. 2017).
5.1.1. Description of the Gradual Carious Tissue Removal Technique

The initial active carious environment can be identified clinically as
discolored, moist soft tissue that changes to a darker, harder, and drier
appearance after the first stage (Bjørndal et al. 2019). The first session of
GCTR includes selective removal of soft dentin (previously defined as
removal of demineralized, necrotic surface dentin) combined with non-
selective removal of peripheral demineralized dentin (Bjørndal et al. 2017,
Innes et al. 2016). A calcium hydroxide-based material or calcium silicate
cement is then applied over the remaining carious dentin, and the cavity is
temporarily sealed with glass ionomer (Schwendicke et al. 2016). In the
second session, after 8 to 12 weeks, cavity re-entry should be carried out and
non-selective caries removal performed for firm (Schwendicke et al. 2016) or
hard dentin, defined as final excavation. (Bjørndal et al. 2017, Innes et al.
2016). Finally, a base of calcium hydroxide or calcium silicate cement is
applied and the cavity is restored with definitive materials (Bjørndal et al.
2017, Innes et al. 2016).
5.1.2. Limitations of Gradual Caries Excavation

Some critical aspects of gradual caries removal can be mentioned, such as the
risk of causing pulp exposure in the second treatment session (Labib et al.
2019), pulp complications such as loss of pulp vitality (Hoefler et al. 2016),
the potential additional cost for a second visit (Schwendicke et al. 2013b) and
the possibility of the patient not attending the second session (Maltz et al.
2018). In addition, the temporary material used between the steps of gradual
caries removal must hermetically seal the cavity, with glass ionomer cement
being more suitable, because when the zinc oxide-eugenol cement is applied
and the patient does not return to the second step of excavation, the chances
of an unfavorable outcome are increased (Maltz et al. 2012).
Gradual caries excavation has been shown to decrease the occurrence of
pulp exposures and increase pulp healing potential compared to the total
carious tissue removal (TCTR) technique (Bjørndal et al. 2010). In a long-
term study with 5 years of follow-up, the gradual removal group had a
significantly higher proportion of success (60.2%) compared with the non-
selective caries removal group for hard dentin (46.3%), when pulp exposures
were included as failures. The pulp exposure rate was significantly lower in
the gradual caries removal group (21.2% vs. 35.5%) (Bjørndal et al. 2017).
Similar findings were reported by Mattos et al. in 2014, who observed that
both gradual excavation and partial removal of carious tissue had lower pulp
exposure rates and higher success rates.
The literature has shown that this is an effective technique in what it
proposes to do but studies have started to suggest the selective removal of
carious tissue in a single session as a definitive treatment, and there are already
studies evaluating this approach as a definitive treatment in permanent teeth,
the short and long term, in shallow and deep carious lesions (Jardim et al.
2015, Alnahwi et al. 2018).
5.2. Selective Carious Tissue Removal (SCTR) in a Single Session
For decades, it was taught that the ideal restorative treatment should
contemplate the total removal of carious tissue (TCTR) to prevent recurrence
and progression of lesions, which could result in pulp exposure (Araújo et al.
2017). However, contemporary innovative techniques have gained
prominence as a rational method of treating deep carious lesions. The selective
carious tissue removal (SCTR) technique in a single session consists of
removing part of the carious dentin, preserving a layer of carious tissue on the
back wall of the cavity (pulp wall), followed by the definitive restoration of
the cavity (Araújo et al. 2017, Li et al. 2018, Machiulskiene et al. 2019). It can
be performed for both soft and firm dentin. In selective removal for soft dentin,
softened dentin is left only on the pulpal aspect of the cavity, while peripheral
carious dentin is removed down to hard dentin and in selective removal for
firm dentin, firm dentin is left only on the pulpal aspect of the cavity while
peripheral carious dentin is removed down to hard dentin (ESE 2019).
It is accepted that an inadequate temporary restoration and lack of a
permanent coronary seal during selective and less invasive caries removal will
lead to failures, including pulpal and apical pathology (Maltz et al. 2012).
Although selective caries removal at one stage saves clinician and patient time,
a potential limitation is that if the patient moves to a new dentist, caries may
appear to have remained and further interventions may be suggested (Bjorndal
et al. 2019).
5.2.1. Scientific Evidence on Selective Carious Tissue Removal (SCTR)

Studies performed on young primary and permanent teeth showed that the
clinical and radiographic success rates for complete and partial carious tissue
removal in teeth with deep carious lesions were high and did not differ
significantly, indicating that selective carious tissue removal (SCTR) is a
reliable minimally invasive approach and that retention of carious dentin does
not interfere with pulp vitality (Santamaria & Innes 2014). These conservative
techniques are of vital importance in Public Health where a significant
proportion of the population does not have access to specialized Endodontic
services, causing teeth with deep caries lesions to end up undergoing
extraction (Martins et al. 2014, Castro & Campos 2016).
Reaffirming the successful selective removal of carious tissue, Jardim et
al. (2015) published a study in which a clinical and radiographic follow-up
was carried out, and it was possible to observe the interruption of the carious
lesion after SCTR and definitive restoration in a single session and, thus,
preserving pulp vitality in the long term.
In a systematic review and meta-analysis study whose objective was to
compare the effectiveness between selective caries removal and total caries
removal, in deciduous and permanent teeth, it was found that in relation to
postoperative symptoms, there was no significant difference between the
evaluated groups. Likewise, the risk of failure between selective and non-
selective caries removal was similar. However, the occurrence of pulp
exposure was significantly lower in the selective caries removal group,
demonstrating that the effectiveness of selectively removing carious tissue is

comparable to complete removal of carious dentin (Li et al. 2018).
A study in permanent teeth with deep carious lesions comparing the
outcomes SCTR in a single session and the gradual removal of carious tissue,
with an interval of three to four months between sessions, revealed success
rates of 89.4% and 84.9%, respectively. In both groups, chemically activated
glass ionomer cement was used as pulp protection material. Based on their
results, the authors concluded that treatment success and survival did not differ
significantly between the evaluated groups after a one-year period. However,
during the second session in the gradual removal technique, there were five
cases of pulp exposure, with no strong justification for preferring gradual
removal over selective removal in lesions that affect more than two-thirds of
the dentin depth Labib et al. (2019).
A multicenter clinical study, evaluating the maintenance of pulp vitality
of permanent teeth with deep caries lesions treated either by SCTR and
restoration with composite resin or amalgam, in a single session or by the
gradual carious tissue removal, revealed, after completion of the protocol of
gradual carious tissue removal, success rates of 75% and 80%, respectively.
However, some patients did not return to complete the procedure of gradual
removal of carious tissue, which negatively impacted the performance of this
technique. Thus, the authors conclude that such results support the choice of
the technique of SCTR, as it is performed in a single session (Maltz et al.
2018).
Jardim et al. (2020), using data from the aforementioned multicenter
clinical trial (Maltz et al. 2018), evaluated the survival of restorations placed
on remaining carious tissue after SCTR, finding restoration survival rates of
79% for the selective removal group single session and 76% for the gradual
removal group suggesting that selective removal of carious tissue can be used
in the treatment of deep caries to avoid pulp exposure and preserve tooth
structure without affecting the longevity of the restoration.
5.3. Indirect Pulp Capping (IPC)
Indirect pulp capping (IPC) consists of placing a biomaterial directly on a thin

dentin barrier covering the pulp, after non-selective or total removal of carious
tissue. However, IPC is no longer a widely used technique and is now
considered overtreatment (ESE 2019).
6. Materials used to Protect Dentin after SCTR
Through the selective removal of carious tissue in deep or very deep lesions
with or without pulp exposure, it is necessary to use materials that aim to
preserve pulp vitality (Delfino et al. 2010, Pitts et al. 2014, Maltz et al. 2018).
Ideally, these materials need to be not only inert, so that they are not toxic to
pulp tissue, but also bioactive, in order to stimulate osteogenic proliferation,
migration, and differentiation (Pedano et al. 2020). Furthermore, they should
also induce the formation of a barrier of mineralized tissue after odontoblast
activation (Pedano et al. 2020, Andrei et al. 2021).
Calcium hydroxide has been the material of choice for indirect dentin
capping for a long time (Galoza et al. 2020). However, alternative materials
with properties superior to calcium hydroxide in terms of tissue response,
formation of a dentinal barrier and sealing of the exposed area have been
developed (Farrugia et al. 2018, Paula et al. 2018, Matsuura et al. 2019). The
indirect/direct pulp capping process primarily depends on the ability of the
dentinal and/or pulp tissue to regenerate (Taha & Abdulkhader 2018).
Currently, bioceramics are the materials of choice for situations of indirect
pulp capping, with Biodentine being the best-known material of bioceramics
(Andrei et al. 2021).
Several studies have evaluated the use of glass ionomer cement (GIC) for
lining the pulp wall of cavities after SCTR (Maltz et al. 2018, Labib et al.
2019, Jardim et al. 2020). A study by Ribeiro et al. (2020) evaluated the pulpal
response of healthy teeth that would be extracted for orthodontic indication
and that were restored with conventional GIC, resin-modified GIC, or Dycal.
Although resin-modified GIC initially showed greater toxicity than
conventional GIC, pulp damage decreased, and at day 30, both were
considered biocompatible in deep cavities in a manner comparable to calcium
hydroxide cement (Dycal).
Biocompatibility is a requirement for dentin-pulp complex protection
materials, but it is desirable that a material exhibits not only biocompatibility,
but also bioactivity. The preservation of pulp vitality after indirect pulp
therapy in permanent molars with carious lesions advancing more than two-
thirds of the dentin thickness was evaluated. The cavities were lined with
calcium hydroxide cement (Dycal), calcium silicate cement (Biodentine), or
irradiated with an Er,Cr;YSGG laser. The overall success rate was 86.6%, and
the difference between groups was not statistically significant. The authors
concluded that calcium silicate-based cement (Biodentine) can be successfully
used in the indirect treatment of pulp (E et al. 2019). Similarly, Sharma et al.
(2020) evaluating the results of mineral trioxide aggregate (MTA) and

Endocem-Zr as pulp wall covering materials in deep cavities of adult
permanent teeth with normal pulps or with symptoms of reversible pulpitis
reported success rates of 89.4% and 94.7%, respectively, after 12 months. This
difference was not statistically significant. The authors concluded that both
Endocem-Zr and MTA are equally effective as indirect pulp protection
materials.
7. Clinical Protocol for Selective Carious Tissue Removal

in a Single Session
1. Anesthesia;
2. Isolation of the operative field with rubber dam;
3. Antisepsis of the operative field;
4. Non-selective removal of carious tissue for hard dentin at the
periphery of the cavity using spherical drills at low speed;
5. Selective removal of soft or firm dentin from the pulp wall using
manual excavators;
6. Irrigation with sterile saline solution;
7. Disinfection of the cavity with a cotton pellet soaked in a disinfectant
solution chosen by the operator;
8. Drying with a sterile cotton pellet;
9. Lining the cavity with bioceramic material or glass ionomer cement;
10. Definitive restoration;
11. Periodic clinical and radiographic control (sensitivity test).
Conclusion and Recommendations for Future Research
Selective removal of carious tissue in a single session is a less invasive

approach to dentin and should be considered for the management of deep
carious lesions in dentin. Through this gentle approach to dentin, it is possible
to promote pulp recovery in a critical environment created by advanced dentin
injury, through the application of a bioactive capping material followed by
hermetic and definitive sealing of the cavity. However, despite the increasing
number of studies involving minimally invasive approaches that preserve
carious dentinal tissue, additional research involving randomized and
controlled clinical trials evaluating these techniques as a definitive treatment

is necessary in order to assist dentists in decision making, since studies show
that pulpal changes may take time to develop.
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pozzolan-based cement (ENDOCEM-Zr®) and mineral trioxide aggregate - A
randomized controlled trial. J Conserv Dent. 2020;23(2):152-157.
Smaïl-Faugeron V, Glenny AM, Courson F, Durieux P, Muller-Bolla M, Fron Chabouis H.
Pulp treatment for extensive decay in primary teeth. Cochrane Database Syst Rev.
2018;5(5):CD003220.
Smith AJ, Cassidy N, Perry H, Bègue-Kirn C, Ruch JV, Lesot H. Reactionary
dentinogenesis. Int J Dev Biol. 1995 Feb;39(1):273-80.
Smith AJ, Smith JG, Shelton RM, Cooper PR. Harnessing the natural regenerative potential
of the dental pulp. Dent Clin North Am. 2012 Jul;56(3):589-601.
Taha NA, Abdulkhader SZ. Full Pulpotomy with Biodentine in Symptomatic Young
Permanent Teeth with Carious Exposure. J Endod. 2018 Jun;44(6):932-937.
Tziafas D, Smith AJ, Lesot H. Designing new treatment strategies in vital pulp therapy. J
Dent. 2000 Feb;28(2):77-92.
Yu C, Abbott PV. An overview of the dental pulp: Its functions and responses to injury.
Aust. Dent J. 2007, 52, S4–S16.
Chapter 6
Treatment of Pulpal Exposures in Vital Teeth
Hebertt Gonzaga dos Santos Chaves1,*,

Isabella Figueiredo Assis Macedo1,
Barbara Figueiredo1, Francine Benetti1
and Paulo Carvalho Tobias Duarte2,3
1
2
Department of Health - Pediatric Dentistry Area,
State University of Feira de Santana (UEFS), Feira de Santana, Bahia, Brazil
3
Pediatric Dentist, University Medical Service (SMURB),
Federal University of Bahia (UFBA), Salvador, Bahia, Brazil
Abstract
When the dental pulp is exposed to the oral environment, a wound is

created in the pulp connective tissue, and treatment must be immediately
instituted by cleaning and disinfecting the area, followed by pulp
coverage with a bioactive material. The microsurgical approach of the
pulp lesion, in such a specific area that involves two unique tissues, loose
connective tissue (pulp) and mineralized connective tissue (dentin), is
complex, requiring knowledge and technical capacity from the operator.
In this chapter, supported by the most recent scientific evidence, we
approach topics such as the etiology of caries disease, the pulpal response
to external aggressions and the different types of therapies for the
exposed vital pulp such as direct pulp capping, partial pulpotomy and
total pulpotomy, with emphasis on its indications, limitations,
Corresponding Author’s Email: heberttchaves_@hotmail.com.

* .

ISBN: 978-1-68507-987-1
104 H. G. dos Santos Chaves, I. F. Assis Macedo, B. Figueiredo et al.
biomaterials and treatment protocols, so as to be a practical guide for

dental professionals and students.
Keywords: dental pulp exposure, dental pulp capping, pulpotomies
1. Introduction
The attempt to conserve vital pulp tissue is not recent. In 1756, Phillip Pfaff
pioneered the use of gold and lead foil for capping exposed dental pulp (Koch
& Thorpe 1909). In the following century, the use of a technique called vital
amputation, where part of the pulp tissue was covered with phenolic cement
aiming at dentinal neoformation, was described by Witzel in 1894 (Castagnola
1956). In 1920, Hermann introduced CalxylTM paste, based on calcium
hydroxide and other compounds, as intracanal medication in total
pulpectomies, later being indicated for direct pulp protection. (Hermann 1920)
In 1939, a classic pulpotomy technique was described using calcium
hydroxide as a capping material in the treatment of young permanent teeth
with incomplete apices (Zander 1939).
Currently, with the adoption of less and less invasive approaches in
dentin, through techniques of selective removal of carious tissue, the
occurrence of pulp exposures has been decreasing (Bjørndal et al. 2010).
However, the dental pulp will always be susceptible to external exposures, and
may buffer bacterial contamination followed by inflammation, leading to the
loss of pulp vitality, with serious damage to the dental organ.
Pulp exposures can occur in different circumstances, the most common
causes being coronary dental trauma, advanced caries lesions in dentin or
operative accidents (iatrogenesis) during cavity preparation, replacement of
restorations or non-selective or total removal of carious tissue. (Bjørndal et al.
2010, Komabayashi 2016, Andrei et al. 2021). Recently, the European Society
of Endodontics considered the technique of non-selective or total dentin
removal “overtreatment” (ESE 2019), and this approach is currently
contraindicated unless the pulp organ has already been exposed.
In direct pulp therapies, a topical agent (capping dental material) is
brought to the point of exposure in an attempt to modulate the installed
inflammatory process (Giraud et al. 2019) and promote obliteration of the
dentinal perforation, in order to protect vital pulp tissue from bacterial
infection and toxicity of dental materials, immediately after pulp capping and
in the long term (Farges et al. 2015, Andrei et al. 2021). If direct pulp therapy
Treatment of Pulpal Exposures in Vital Teeth 105
is successful, pulp vitality will be maintained, prolonging the life of the tooth
in the oral cavity with its physiology and defense mechanisms preserved (Tran
et al. 2019, Andrei et al. 2021).
In order for dental professionals and students to select the best approach
for each clinical situation of pulp exposure, however, a prior understanding of
the etiology of caries disease and the mechanisms of pulp response to external
aggressions, inflammation and repair, is necessary.
2. Etiology of Dental Caries
Dental caries results from the normal metabolism of commensal

microorganisms that occur continuously throughout life. The result (loss of
mineral and cavity formation) cannot be completely avoided, but it can be
modulated, avoiding pulp complications and tooth loss (Manji et al. 2018).
DNA and RNA-based studies of caries lesions revealed an extremely diverse
ecosystem where Streptococcus mutans represents only a tiny fraction of a
“consortium of multiple microorganisms” that act collectively and
synergistically to initiate and expand the cavity (Simón-Soro & Mira 2015).
Contemporary understanding as the “ecological plaque hypothesis” suggests
that caries is the result of an ecological imbalance in the dental biofilm (Marsh
2003, Philip et al. 2018) and is currently defined as a disease resulting from
dysbiosis of the oral microbiome, with involvement of numerous cariogenic
species with acid production and tolerance profile (Zhan 2018).
Caries disease treatment, therefore, should be focused more on correcting
microbiome dysbiosis than on eliminating a single pathological agent (Zhan
2018). Antimicrobial treatments are unsuccessful to treat polymicrobial
diseases, and one should focus on strategies aimed at modulating microbial
interactions and/or their functional production (Simón-Soro & Mira 2015).
Therefore, understanding the ecology of the oral cavity will allow for a holistic
clinical approach that takes into account nutrition, physiology, host defenses
and the overall well-being of the patient, as this will affect the balance and
activity of the resident oral microflora (Marsh 2003).
3. Response of the Pulp-Dentin Complex to

External Aggressions
In addition to knowledge about the etiology of caries, the understanding of

how the dental pulp responds when it is attacked by different pathological
agents will serve as a guide for the adoption of the most appropriate treatment
protocols.
3.1. Pulp Immunoinflammatory Response
Pulp cells detect invading bacteria by expressing a series of pattern recognition

receptors (PRRs), which identify various bacterial components, from DNA to
outer membrane structures such as lipopolysaccharides (LPSs), called
pathogen-associated molecular patterns (PAMPS) (Farges et al. 2013, Cooper
et al. 2017). Pulp cells such as odontoblasts, fibroblasts, stem cells, neurons
and endothelial cells when detecting bacterial components, induce the
expression of antimicrobial peptides (AMPs) invoking the inflammatory
cascade with both processes aimed at containing and eradicating the infection
(Cooper et al. 2017).
Due to their peripheral location in the pulp, odontoblasts are the first cells
to recognize pathogens in order to limit disease progression (Farges et al.
2013). Activation of specific intracellular pathways leads to the production of
pro-inflammatory mediators by odontoblasts that diffuse into the
subodontoblastic pulp area and, upon binding to specific receptors, attract
immature antigen-presenting dendritic cells that migrate to the
subodontoblastic layer and capture PAMPs in the subodontoblastic layer and
capture PAMPs at the end of the dentinal tubule, thereby developing the
immunoinflammatory response and tissue immunosurveillance (Farges et al.
2013).
As the disease progresses, the odontoblasts die and the pulp nucleus cells
(fibroblasts, endothelial cells and stem cells) engage in defense mechanisms
(Farges et al. 2013). It has recently been shown that pulp fibroblasts express
Toll-like pattern recognition receptors (PRRs) and, after this recognition,
initiate the inflammatory cascade by activating the NF-kB pathway, essential
for the inflammatory process (Da Rosa et al. 2018). Subsequently,
immunocompetent cells, including neutrophils, macrophages, and T and B
cells, are attracted by chemotaxis generated by resident cells (Cooper et al.
2017). Inflammatory cells adhere to activated vascular endothelium, migrate

through the endothelial cell layer and reach injury guided by pro-inflammatory
cytokines. They will then be activated in macrophage-like cells at the
inflammatory site, where they eliminate pathogens and cellular debris (Giraud
et al. 2019).
It has also been described that upon damage and/or infection of pulp
tissue, the complement system provides the necessary signals for the
elimination of pathogens and altered host cells (Chmilewsky et al. 2014).
Studies have shown that pulp fibroblasts are the first non-immune cells
capable of producing all the components necessary for complement activation
(Chmilewsky et al. 2014, Giraud et al. 2019). Additionally, a new bacterial
death mechanism called extracellular neutrophil traps (NETs) was described
and their interaction with bacteria resulted in microbial entrapment and death
(Cooper et al. 2017). NET components may serve in the future as new
biomarkers for pulp pathologies aiding in vital pulp therapy (Cooper et al.
2017).
Inflammation is a prerequisite for tissue healing and pulp regeneration,
not just an undesirable effect (Goldberg et al. 2015). However, severe
inflammation can lead to pulp destruction, and if infection persists, the
resulting chronic inflammation will hamper regenerative processes leading to
pulp necrosis (Giraud et al. 2019). Therefore, until infection and inflammation
are resolved, dentin and pulp repair mechanisms are impeded, and there must
be a balance between inflammation and repair for clinical success (Cooper et
al. 2017).
3.2. Pulp Repair
In the case of traumatic injuries and/or pulp infection, dental pulp stem cells
(DPSCs), stimulated by regenerative signals (growth factors) migrate to the
site of injury/inflammation and differentiate into odontoblast-like cells and,
after undergoing differentiation, express specific markers of odontoblasts,
such as the nestin intermediate filament and dentin sialoprotein (DSP), known
for their implications in the mineralization process (Jeanneau et al. 2017,
Giraud et al. 2019). Dentins are formed as reactionary dentin, an accumulation
that occurs on the surface of the dental pulp, along the periphery of the pulp
chamber, or as reparative dentin, creating a dentinal bridge that partially or
totally occludes the pulp exposure (Goldberg et al. 2015).
Tertiary dentin, a more dystrophic matrix, sometimes atubular, is formed

at the interface between dentin and pulp in carious or traumatic pathological
processes. In the face of mild environmental stimuli (e.g., slowly progressing
caries), postmitotic odontoblast cells are preserved and stimulated to secrete
reactionary or reactional dentin (Tziafas et al. 2000). When intense stimuli
occur (e.g., rapidly progressing deep caries lesion), odontoblasts are destroyed
and a complex process involving mitosis, chemotaxis, migration, adhesion and
differentiation of mesenchymal stem cells into odontoblast-like cells will lead
to deposition of repair-type tertiary dentin (Andrei et al. 2021). However, from
a clinical point of view, although the vitality of the dental pulp can be
maintained, with current methods and materials of direct pulp capping or
pulpotomy, the repair tissue that forms resembles mineralized fibrous scar
tissue rather than true tubular dentin (Ricucci et al. 2018).
3.3. Influence of Capping Materials on Pulp Repair
Even though initial inflammation is a prerequisite for healing, rapid resolution

of inflammation favors the regenerative process, which is key to clinical
success (Farges et al. 2015). Indeed, the choice of pulp capping material is
crucial as it can modulate the course of these events (Giraud et al. 2019).
Under the stimulus of the high alkalinity of the capping materials, pulp cells
proliferate and start the mineralization process (Goldberg et al. 2015, Cooper
et al. 2017). Fibroblasts become odontoblast-like cells, producing collagen
type I, alkaline phosphatase, and SPARC/osteonectin, while molecules of the
SIBLING family, matrix metalloproteinases (MMPs) and vasculo nervous
mediators also participate in the direct formation of osteo/orthodentin,
obstructing pulpal exposure. (Goldberg et al. 2015). Therefore, during the
progression of the carious lesion, the host aims both to fight the infection,
through the immunoinflammatory response, and to “block” and restore the
tooth structure, through the dentinogenic response (Farges et al. 2015).
When the pulp is capped with bioactive materials such as calcium
hydroxide (CH), the generated dystrophic calcification layer causes migration
and attachment of pulpal mesenchymal stem cells at this site and their
subsequent differentiation into odontoblast-like cells (Yamada et al. 2021).
The CH and the microcrystals deposited on its surface provide a biologically
active substrate for the adsorption of biomolecules and adhesion of
odontoblasts (Sangwan et al. 2013). Calcium and hydroxyl ions released by
CH regulate the events that lead to tertiary dentinogenesis (Sangwan et al.
2013). In addition, other specific antimicrobial and anti-inflammatory effects

of CH influence the mineralization process (Sangwan et al. 2013).
The reparative dentinogenesis induced by hydraulic silicate cements such
as mineral trioxide aggregate (MTA) is similar to that induced by CH, as
calcium hydroxide is formed as a by-product during its gelation (Yamada et
al. 2021). However, while MTA causes mild inflammatory and necrotic
changes and is less caustic, CH causes severe necrosis and inflammation
(Yamada et al. 2021). Indeed, differentiated Nestin-positive odontoblasts were
recently observed below the necrotic layer after direct pulp capping using
MTA and MTA associated with platelet-rich plasma (PRP) (Yamada et al.
2021).
Dentin is a rich reservoir of bioactive signaling molecules (growth factors,
neurotrophic factors, neuropeptides and cytokines) trapped in the extracellular
matrix (ECM) during dentinogenesis and solubilized in pathological
conditions such as caries (Da Rosa et al. 2018). These molecules modulate
several signaling transduction pathways essential for dentinogenesis being the
MAPK (mitogen-activated protein kinase) and PI3K/AKT/mTOR
(phosphatidylinositol 3-kinase/protein kinase B/mechanistic target of
rapamycin) pathways involved in proliferation, adhesion, cell migration and
apoptosis and the p38 MAPK pathway involved in activating the secretory
activity of odontoblasts in reparative/regenerative processes (Simon et al.
2010, Da Rosa et al. 2018).
It has been demonstrated at molecular and histological levels that MTA is
the new gold standard among capping materials for its properties of
biocompatibility, stimulation of odontoblasts, differentiation and proliferation
of pulp cells for the production of tertiary dentin (Andrei et al. 2021).
Bioceramic materials derived from MTA also showed similar and even
superior results to MTA, but translational success rates varied according to
animal models, type of pulp exposure and pulp capping conditions, requiring
further research (Andrei et al. 2021).
Recent investigations have demonstrated that BiodentineTM has an anti-
inflammatory activity as it controls the secretion of pro-inflammatory factors
and reduces the recruitment of inflammatory cells (Giraud et al. 2019).
Furthermore, the hydration of the material is complete, leading to the
formation and release of by-products that drive the pulpal response to
regeneration, which was demonstrated by the increased expression of factors
involved in the regeneration process, such as FGF-2 and TGFß-1, and the
induction of dentin bridge formation, keeping the pulp intact (Giraud et al.
2019).
4. Management of Exposed Vital Pulp
Vital pulp therapy (VPT) modalities are gaining popularity as minimally

invasive maneuvers aimed at preserving pulp vitality and maintaining tooth
functionality when pulp tissue has been compromised but not totally injured
(Machado et al. 2020, Parhizkar & Asgary 2021). Ultra-conservative
approaches are considered important compared to conventional endodontic
therapy techniques because: (1) they promote regenerative endodontics, (2)
they preserve tooth structure and function, (3) they offer greater resistance to
the tooth against masticatory forces compared to endodontically treated teeth,
and (4) maintains the physiological process in deciduous tooth exfoliation (Da
Rosa et al. 2018, Meschi et al. 2020, Asgary et al. 2020).
Among the vital pulp therapies recommended for the treatment of exposed
pulp, three procedures are indicated, in ascending order of tissue invasion: (1)
direct pulp capping (DPC), which involves no removal of pulp tissue; (2)
partial pulpotomy (PP), which advocates the excision of a small part of the
pulp tissue and (3) total pulpotomy (TP), where the excision of the entire
coronary pulp is performed, leaving only the radicular pulp.
4.1. Direct Pulp Capping (DPC)
When exposure occurs, a conservative approach is recommended. Among the

treatment options, DPC is the most conservative and simple technique to
maintain pulp vitality as it does not involve the removal of pulp tissue
compared to pulpotomy procedures. (Cushley et al. 2021). Direct pulp capping
consists of placing a material directly over the exposed pulp in an attempt to
allow pulp healing and, consequently, the formation of high-quality
mineralized tissue (Tran et al. 2019).
The prognosis of the success of direct pulp capping is greatly influenced
by the pulp capping material which, ideally, should present: biocompatibility,
good adhesion to dental hard tissues, compatibility with the restorative
materials with which it comes in contact, good marginal sealing, insolubility
in tissue fluids, easy handling and manipulation, short setting time, adequate
mechanical properties, radiopacity, antimicrobial activity, and possibly low
cost (Andrei et al. 2021).
4.1.1. Direct Pulp Capping Classification
4.1.1.1. Class I Direct Pulp Capping

Class I DPC represents direct pulp capping traditionally indicated for trauma
(complicated coronary fractures), with superficial pulp exposure or for
accidental exposures that occur during cavity preparation, in an area free of
carious tissue (Bjørndal et al. 2010). Clinically, the pulp would be considered
healthy and relatively free from inflammation. Also included here are small
pulp exposures (preferably <1 mm in diameter), preferably located in the
coronal third of the pulp chamber corresponding to a pulp horn (Bjørndal et
al. 2019, ESE 2019).
4.1.1.2 Class II Direct Pulp Capping

Class II DPC is indicated when there is deep or extremely deep carious lesion
preoperatively and pulp exposure has been judged to have occurred in a zone
of bacterial contamination, with the expectation that the underlying pulp tissue
is inflamed (Bjørndal et al. 2010, Bjørndal et al. 2019, ESE 2019). A recent
study suggested that the infected and vital pulp is still capable of inducing pulp
repair with the use of bioactive materials such as MTA, with active stem cell
proliferation occurring, followed by differentiation into odontoblast-like cells
(Xu et al. 2021).
The class II prefix indicates the need to adopt a modified treatment
protocol, since a serious microbial challenge is expected. The protocol should
ideally include: (1) surgical microscope-guided caries removal, (2) hemostasis
achieved within 5 minutes, (3) use of solution to disinfect the area, and (4) use
of hydraulic calcium silicate cement for pulp capping (Bjørndal et al. 2019).
In addition, symptoms may be present but not indicative of irreversible pulpitis
(Bjørndal et al. 2010, 2019).
4.1.1.3. Scientific Evidence on Direct Pulp Capping

Several studies have been carried out to attest the effectiveness of DPC in
different clinical conditions such as accidental exposures and carious
exposures, immature and mature permanent teeth and clinical diagnosis of
reversible or irreversible pulpitis.
4.1.1.4 Direct Pulp Capping in Accidental or Traumatic Exposures

Recently, the quality of dentin bridges formed after DPC using bioceramics
(Biodentine and MTA) or a treated dentin matrix hydrogel (TDMH) in mature
teeth with accidental exposures occurred during cavity preparation, in a caries-

free area, was evaluated by computed tomography (CT). (Holiel et al. 2021) It
was evident that all materials stimulated repair, but TDMH induced the
formation of thicker dentin bridges with a uniform tubular structure, which
can be attributed to the TDMH-based scaffolding which not only served the
function of sealing the exposed area, but also released growth factors to
accelerate and induce natural biological regeneration (Holiel et al. 2021).
4.1.1.5. Direct Pulp Capping in Carious Exposures

A blinded randomized study evaluated the DPC of carious exposures up to 2
mm in diameter, in immature or mature molars of individuals between 7 and
16 years, with a diagnosis of normal pulp or reversible pulpitis. The clinical
procedure was performed under loupes with a magnification of 3.5 and a
working distance of 400 mm. The materials evaluated were calcium hydroxide
paste mixed with saline, White ProRoot MTA and Biodentine. All DPC
materials showed high success rates after 1 year of follow-up, with no
statistical difference between them (Brizuela et al. 2017).
More recently, the success rates of DPC performed with ProRootTM
(MTA) or BiodentineTM on permanent teeth of patients aged 6 to 18 years with
carious exposure were evaluated. Teeth diagnosed with normal pulp,
reversible or irreversible pulpitis and exposure up to 2.5 mm in size were
included. Hemostasis was obtained with cotton pellets moistened with 2.5%
NaOCl. The overall success rate was 94.5% (92.6% with ProRoot MTA and
96.4% with Biodentine) leading to the conclusion that carious pulp exposure,
irreversible pulpitis, early periapical involvement or pulp exposures of up to
2.5 mm should not be absolute contraindications for DPC (Parinyaprom et al.
2018). Similar data were found by Katge & Patil, in 2017, who, after 12
months of follow-up, found success rates of 95.24% in teeth capped with
Biodentine and 85.71% in teeth capped with MTA, leading them to the
conclusion that both Biodentine and MTA induce mineralization and maintain
pulp vitality, and can be used for DPC of immature permanent teeth.
A recent analysis compared the success rate and postoperative pain after
direct pulp capping (DPC) using calcium hydroxide serum (CH) paste and
white ProRoot MTA, in mature permanent teeth with deep occlusal caries
penetrating half the thickness or more into dentin and diagnosis of reversible
pulpitis. (Suhag et al. 2019) After excavation of the caries, disinfection of the
exposed pulp was performed with irrigation with 2.5% sodium hypochlorite
and hemostasis was obtained with a cotton pellet moistened in the same
solution for 10 minutes. The success rate was 69% for the CH and 93% for the
ProRoot MTA, concluding that the MTA proved to be better than the CH in
terms of success rate and pain intensity (Suhag et al. 2019).
Recently Biodentine was evaluated in the DPC of pulps exposed during
caries removal revealing that 219 of the 245 teeth treated showed a favorable
outcome (89.39%) and 26 teeth (10.61%) an unfavorable outcome. It was
evidenced that the use of Biodentine in DPC can lead to high success rates and
that the clinical parameter of spontaneous pain has no significant impact on
the treatment outcome. It was also shown that teeth restored with glass
ionomer cement had a higher risk of unfavorable outcome and that factors such
as age, gender, tooth position, tooth type, arch type or spontaneous pain did
not influence the treatment outcome rejecting the hypothesis that DPC should
be avoided in older patients and in teeth with pain or discomfort (Harms et al.
2019).
In a recent systematic review and meta-analyses, the clinical-radiographic
success of DPC in permanent teeth with pulps exposed by caries and diagnosis
of reversible pulpitis, revealed combined success rates for CPD with calcium
hydroxide, MTA and Biodentine at 12 months of 65%, 86% and 86%,
respectively. At 2 to 3 years follow-up, calcium hydroxide had a 59% success
rate, MTA 84%, and Biodentine 86%. It was highlighted in this study that the
success rate of DPC is high, especially initially and that the choice of capping
material influenced the long-term result and that MTA performed better than
calcium hydroxide, but MTA and Biodentine had similar short-term and long-
term results (Cushley et al. 2021). A similar study indicated that success rates
of silicate cements were statistically higher than those of calcium hydroxide;
therefore, calcium silicate cements appear to be more effective and predictable
materials for CPD than calcium hydroxide. There was also no significant
difference between Biodentine and MTA in the success rate of CPD. However,
other properties of Biodentine such as handling, setting time and tooth
discoloration are superior to MTA. However, the author recommends further
studies to confirm which material is the most suitable for CPD (Matsuura
2021).
4.1.1.6. Treatment Protocol for Class II DPC

1. Anesthesia
2. Isolation with rubber dam and disinfection of the operative field
3. Complete non-selective removal of carious tissue until hard dentin is
achieved
 Use sterile drills and sharp instruments
 Use magnification (surgical microscope or magnifying glass)
4. Abundant irrigation with saline solution to remove dentin chips and

debris
5. Hemostasis and disinfection
 Use cotton pellets soaked in a disinfecting agent
 Sodium hypochlorite (0.5 to 5%) or chlorhexidine solution (0.2
to 2%)
 If hemostasis cannot be controlled after 5 min, more pulp tissue
should be removed (partial or total pulpotomy)
6. Application of bioactive material on the exposed pulp
 Use calcium silicate / bioceramic cements
7. Protection of base material with glass ionomer cement
8. Definitive restoration
9. Periodic clinical and radiographic control (sensitivity test)
The treatment protocol for class I direct pulp capping (accidental or

traumatic exposures) will be similar to that for class II direct pulp capping,
except for the non-mandatory use of magnification (surgical microscopy).
4.2. Partial Pulpotomy (PP)
Partial pulpotomy involves removing 2 to 3 mm of the inflamed coronary pulp

below the exposure, followed by placement of a suitable capping agent over
the pulp and restoration of the cavity (Taha et al. 2017). Partial pulpotomy has
advantages compared to direct pulp capping because it removes part of the
infected exposed pulp, which would increase the treatment success rate (Kang
et al. 2017). In addition, partial pulpotomy is preferable to total pulpotomy
because it preserves cell-rich coronary pulp tissue, an environment conducive
to pulp regeneration (Kang et al. 2017).
4.2.1. Scientific Evidence on the Partial Pulpotomy Technique
4.2.1.1. Partial Pulpotomy in Accidental Pulp Exposure

After traumatic exposure, the pulp can be capped without tissue removal, since
the wound has not been contaminated with microorganisms for a prolonged
period. In practice, however, because the pulp has been exposed to the oral
environment, it is common to remove the surface layer. It was classically
shown that after 24 hours of exposure, pulp contamination and inflammation

extended to a depth of 1.5 mm (Cvek & Lundberg 1983).
Pulp exposures due to dental trauma in permanent teeth are mostly treated
through partial pulpotomy. In a study involving 375 traumatized teeth treated
by different modalities of VPT, direct pulp capping with DycalTM (Dentsply
Caulk) resulted in a rate of pulp necrosis and infection almost five times higher
(57.1%) than partial (10.1%) or coronal (9.8%) pulpotomy (Wang et al. 2017).
A similar result was found by Hecova et al. (2010) who observed that DPC
resulted in about a three-fold higher rate of pulp necrosis and infection (45.5%)
compared to partial pulpotomy (13.6%) (Hecova et al. 2010).
It was highlighted that the higher rates of necrosis after DPC can be
attributed to the failure to remove the surface layer of contaminated pulp or to
the fact that, in DPC, capping materials can occupy and contaminate parts of
the dentin or enamel, affecting the adhesion and sealing process of the
restoration. In pulpotomy treatments, these materials can be “submerged”,
thus reducing the risk of contamination and, therefore, the risk of bacterial
penetration (Hecova et al. 2010).
4.2.1.2. Partial Pulpotomy in Carious Pulp Exposure

Partial pulpotomy may be a therapeutic option for teeth whose pulp has been
exposed to a carious environment and the adjacent pulp tissue has suffered
bacterial contamination and inflammation, however, the deeper the pulp tissue
is, the freer of inflammation it will be (George 2020). However, the inability
to accurately diagnose the true degree of inflammation and the reparative
capacity of the pulp exposed to caries, leads to less predictable results (George
2020). Despite controversies, evidence indicates that factors such as age and
apical closure do not influence the prognosis of partial pulpotomy (Kang et al.
2017, Elmsmari et al. 2019).
Vital pulp therapy is widely indicated for young teeth with symptoms of
reversible pulpitis, with high success rates using bioceramic materials as a way
to complete root formation (Farsi et al. 2006, AAE 2021, Tozar & Erkmen-
Almaz 2020, Ahmed et al. 2021).
The performance of partial pulpotomy in asymptomatic young teeth, with
pulp exposure after caries excavation or trauma within 48 hours, resulted in an
expressive success rate of 90.91%, when MTA was used, with an increase in
root length and reduction in apical diameter (Vu et al. 2020). Similarly, partial
pulpotomy performed on asymptomatic young teeth with caries exposures
between 0.5mm to 2mm in length resulted in a 94.4% success rate in both the
MTA and BiodentineTM groups after 12 months (Vu et al. 2020).
Transposing to cases of teeth with more advanced pulpal inflammation, a

recent study that evaluated 17 cases of immature teeth with deep caries lesion
and clinical diagnosis of irreversible pulpitis treated by partial pulpotomy and
MTA as repairing material, achieved a success rate in all cases after 5 years of
follow-up (Mousivand et al. 2021).
The factors that influence the prognosis for partial pulpotomy are still
controversial in the literature. Statistically significant differences between age,
sex, tooth type, root apex status, location and type of pulp exposure in the
success of partial pulpotomy in vital permanent teeth without signs of
irreversible pulpitis were not observed (Kang et al. 2017). However, when it
comes to symptomatic adult teeth, the choice of therapy to be used proves to
be more challenging (Taha & Khazali 2017).
In a retrospective clinical and radiographic study of partial pulpotomy in
permanent teeth with exposed carious pulp and MTA capping, it was
successful in 89.1% of cases after 1 year. Patients' ages were between 18 and
85 years, with no significant difference in this variable for treatment outcome.
Most successful cases (82.8%) were asymptomatic before treatment
(Eggmann et al. 2022). On the other hand, Careddu & Duncan (2021)
investigated the effectiveness of the partial pulpotomy technique using
BiodentineTM in the treatment of symptomatic pulps exposed by caries and
reported success rates of 100% in cases of reversible pulpitis and 78% of
irreversible pulpitis after one year. This was confirmed by another study that
evaluated the partial pulpotomy technique in teeth with symptoms of
irreversible pulpitis with pulps exposed by caries, finding a success rate of
85% after two years when MTA was used (Taha & Khazali 2017).
4.2.1.3. Treatment Protocol - Partial Pulpotomy

1. Anesthesia
3. Complete non-selective removal of carious tissue until hard dentin is
achieved
 Use of sterile drills and sharp instruments
debris
5. Partial removal of the coronary pulp (about 2 to 3 mm)
 Use of a spherical diamond bur at high rotation, under
refrigeration

to 2%)
 If hemostasis cannot be controlled after 5 min, more pulp tissue
should be removed (total pulpotomy)
7. Application of the capping agent on the pulp remnant
 Use approximately 3mm of material
 Calcium silicate cement (MTA) or bioceramic
8. Protection of base material with glass ionomer cement
9. Hermetic and definitive restoration
10. Periodic clinical and radiographic control (sensitivity test)
4.3. Total Pulpotomy (TP)
Total pulpotomy is a vital therapy technique where the entire coronary pulp is
surgically removed to maintain vitality in the remainder of the root pulp.
(Santos et al. 2021). For several decades, the general view prevailed that total
pulpotomy should not be indicated as a definitive treatment method in mature
permanent teeth (Zanini et al. 2019). The American Endodontic Association
still recommends total pulpotomy in permanent teeth only as an emergency
procedure or provisional maneuver, until conventional endodontics is
performed (AAE 2013). However, with the evolution of knowledge,
paradigms are changing and total pulpotomy in permanent teeth has been
adopted as a less invasive and definitive treatment option (Zanini et al. 2019).
As with other modalities, in TP it is important to pay attention to infection
control and maintenance of the aseptic chain throughout the procedure, in
addition to bleeding control, achieving hemostasis (Zanini et al. 2019). The
pulp wound should appear red, uniform, with no evidence of greyish,
yellowish, or avascular areas (Taha & Khatib, 2022). After pulpotomy,
assessment of pulp condition by sensitivity tests is limited, as the coronal
portion of the pulp has been removed. Therefore, the absence of postoperative
symptoms and periradicular radiographic changes should be considered as
indicators of successful t Scientific evidence on the total pulpotomy technique
4.3.1. Scientific Evidence on the Total Pulpotomy Technique
4.3.1.1. Total Pulpotomy in Teeth with Accidental Pulp Exposure

Preserving pulp vitality after trauma to immature permanent teeth is still a
challenge since maintaining pulp vitality is essential for root development.
Therefore, this modality of vital pulp therapy should be considered in teeth
that have suffered trauma. (Bakhtiar et al. 2017). Complicated crown fractures
account for 8 to 34.5% of all dental trauma injuries. Therefore, young and
immature traumatized teeth deserve immediate treatment because the
maintenance of pulp vitality is key for the completion of root formation (Wang
et al. 2017).
Research shows that children with complicated coronary fractures receive
first aid in emergency departments where on-call dentists have difficulty
assessing the degree of pulp inflammation. Güngör (2014) In addition, it was
evidenced that pulp exposures tend to be treated by the DPC and later patients
are referred to the pediatric dentist or endodontist, where, sometimes, the tooth
needs a new intervention (partial or total pulpotomy) by not having received
adequate initial pulp therapy (Wang et al. 2017).
4.3.1.2. Total Pulpotomy in Teeth with Carious Pulp Exposure

Total pulpotomy was evaluated in symptomatic and asymptomatic immature
permanent teeth exposed to caries, with favorable results for apical closure
(Nosrat et al. 2013). When total pulpotomy using MTA was the treatment
method for asymptomatic immature permanent teeth and carious exposure, a
92% success rate was observed after 12 months of follow-up (Ahmed et al.
2021). Similarly, another study showed success rates of 90% and 93.3% after
12 months, using MTA and BiodentineTM, respectively. At 18 months of
follow-up, success rates were 83.3% and 80% (Abuelniel et al. 2021).
The indication of VPT for young, carious, asymptomatic teeth with a
clinical diagnosis of reversible pulpitis is recommended (AAE 2021).
However, the presence of acute pain does not always indicate that the pulp
lesion is irreversible (Ward 2002, Ricucci et al. 2014). In a study where 67%
of immature teeth treated with total pulpotomy were symptomatic, the success
rate was 100% after 12 months. (Nosrat et al. 2013) Similarly, another study
evaluating the treatment of immature teeth with deep carious lesions and
symptoms of irreversible pulpitis, resulted in a success rate of 95% of the 40
cases treated by total pulpotomy and use of MTA (Mousivand et al. 2021).
Therefore, treatment of vital pulp in symptomatic cases can be successful as
long as the appropriate technique and biomaterial are used (Nosrat et al. 2013).
Evidence also supports the indication of total pulpotomy for mature teeth
with healthy pulp, reversible or irreversible pulpitis (Zanini et al. 2019). In a
systematic review, it was shown that the weighted average success rate of total
pulpotomy in the treatment of carious pulp exposure in mature permanent
teeth reached at least 90%, demonstrating that total pulpotomy could be an
alternative therapy to extraction or endodontic treatment, under specific
conditions (Alqaderi et al. 2016).
4.3.1.3. Total Pulpotomy in Mature Teeth and Clinical Diagnosis of

Irreversible Pulpitis
Today, the goals of VPT have expanded and practitioners may consider other
treatment options for adult teeth in addition to pulpectomy (AAE 2021).
Recent studies have reported success in treating mature teeth with symptoms
of symptomatic irreversible pulpitis using bioactive materials in VPT
modalities (Asgary et al. 2018, Careddu & Duncan 2021, Santos et al. 2021).
The treatment of pulpal inflammation in adults depends on the severity of
the infection and the inflammatory condition, which is not so easy to
accurately determine clinically (Lin et al. 2020). However, in a study carried
out by Ricucci et al. (2014) it was observed that 15.6% of teeth diagnosed with
irreversible pulpitis were amenable to histological repair. Additionally, even
in histologically irreversible cases, where the pulp had areas of necrosis and
microabscesses, the underlying tissue could still be viable (Ricucci et al.
2014).
When TP was performed on mature permanent teeth with spontaneous and
persistent radiating pain after stimulus removal, associated with deep carious
lesion, a combined success rate of 93.75% was found after 12 months (R et al.
2021). Similarly, a longitudinal study of symptomatic mature permanent teeth,
where 61% of cases were diagnosed with preoperative irreversible pulpitis,
revealed an overall survival rate of 83.8% after total pulpotomy using calcium
silicate cement, after 4 years of follow-up, with no significant difference in
pulpotomized cases between reversible and irreversible inflammation. (Taha
& Khatib 2022).
The maintenance of the aseptic chain during the procedure, the use of an
adequate repair material and the final restoration of good quality, providing a
coronal seal against microleakage, are essential for the predictability of the
total pulpotomy of adult teeth even in symptomatic cases (R et al. 2021, Taha
& Khatib 2022). The use of a sterile spherical diamond bur for sectioning the
pulp tissue, a cotton pellet soaked in 2.5% NaOCl for hemostasis, and the use
of MTA as a repair material at a thickness of 2-mm has recently been

successfully used (R et al. 2021).
A recent systematic review evaluated the results of partial and total
pulpotomies using hydraulic calcium silicate cements in mature posterior teeth
and diagnosis of symptomatic irreversible pulpitis and success rates between
78 and 90% were found (Santos et al. 2021). Therefore, based on new evidence
and following the future literature, VPT may be a therapeutic option for the
treatment of root canals. However, the authors emphasize the need for more
research to reach a consensus on the treatment of irreversible pulpitis,
considering conservative approaches to maintain pulp vitality (Santos et al.
2021).
4.3.1.4. Treatment Protocol for Total Pulpotomy

1. Anesthesia
3. Non-selective complete removal of carious tissue until hard dentin is
reached
 Use sterile drills and sharp instruments
4. Removal of the pulp chamber roof
5. Compensatory wear (shoulder removal) with Endo-Z tips
debris
7. Removal of the entire coronal portion of the pulp tissue
 Up to the level of the root canal entry holes
 Use sharp, long-stemmed curettes of a size compatible with the
cavity
clots
to 2%)
 If hemostasis cannot be controlled after 5 min, biopulpectomy is
indicated.
10. Application of the capping agent on the canal orifices and pulp floor
 Use a layer approximately 3mm thick
 Use calcium silicate or bioceramic cements
11. Protection of the base material with glass ionomer cement
12. Definitive hermetic restoration

13. Periodic clinical and radiographic control
Conclusion
In order to properly manage pulp exposures, the professional needs to: know
how to correctly diagnose the pulp condition, understand the pulp defense
mechanisms against aggression, know the techniques for covering the exposed
vital pulp and select the best biomaterial for pulp protection. However, before
being technically prepared to intervene, the dentist must, through a holistic
approach, know the causes and dynamics of oral alterations that occur in the
individual and that lead to severe tissue loss in both dentin and pulp. This will
allow, in addition to pulpo-dentinal treatment, the professional to restore
balance to the oral environment, preventing the emergence of new caries
lesions or the progression of existing ones.
The literature has recently advocated the use of bioceramic materials for
vital pulp therapy, mainly due to their bioactive capacity, and further studies
are needed to prove their superior physiomechanical properties in sealing and
reducing bacterial contamination in the long term. From another perspective,
the increase in physiomechanical properties can ensure that these materials
can also be used as definitive restorations. However, further studies are needed
to demonstrate favorable results regarding biocompatibility in cases of pulp
exposure.
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Chapter 7
Regenerative Endodontics
Alexandre Henrique dos Reis-Prado1,,

Sabrina de Castro Oliveira1,
Lara Cancella de Arantes1, Juliana Goto2
and Francine Benetti1
1
2
Department of Restorative Dentistry, São Paulo State University (UNESP),
School of Dentistry, Araçatuba, São Paulo, Brazil
Abstract
Pulp-dentin complex of immature permanent teeth can be damaged

through microbial invasion caused by untreated tooth decay, trauma, and
dental anomalies, consequently leading to pulp necrosis and incomplete
root development without early intervention. Regenerative endodontic
procedure (REP) has become a remarkable option of treatment for
necrotic immature teeth compared to conventional root canal therapy. In
addition to providing not only for a resolution of pain and periapical
lesion, REP also allows an immunocompetent tissue formation into root
canal space, resulting in continued root development through increased
root length/thickness and apical closure. This approach relies on three
principles of tissue engineering (signaling molecules release, stem cell
proliferation, and a 3-dimensional scaffold), and requires a bacterial-free
environment for more successful and more predictable long-term results.
Histological studies with animals and humans have reported tissue repair
rather than regeneration after REP. Clinical trials and long-term

Corresponding Author’s Email: alexandreprado@ufmg.br.

ISBN: 978-1-68507-987-1
128 A. H. dos Reis-Prado, S. de Castro Oliveira, L. C. de Arantes et al.
evaluations exploring new materials, protocols, and patient-centered

outcomes are also necessary for REP in an effort to fill the gaps and
provide stronger evidence in this field. This chapter will provide an
overview of clinical indications and techniques in REP, in addition to
discussing the new pathways of this therapy in endodontics.
Keywords: conservative treatment, guided tissue regeneration, growth

factor(s), regenerative endodontics, stem cells, tissue engineering
1. Introduction
Conventional root canal treatment poses various challenges in cases of

necrotic permanent teeth with incomplete root development after caries or
traumatic dental injuries. Often these teeth may offer a major risk for root
fractures and accidental overextension of gutta-percha due to the presence of
short roots, thin walls, and lack of apical constriction (Thibodeau et al. 2007,
Hargreaves et al. 2013, Bracks et al. 2019). It is a well-established fact that in
cases of immature permanent teeth with necrotic pulp, a mineralized barrier
by the use of calcium hydroxide apexification or an apical stop of mineral
trioxide aggregate (MTA) might be an alternative approach to reduce
overfilling. However, apexification procedures do not add strength to the
fragile dentinal walls, nor provide restoration of functional competence of the
pulp tissue (Hargreaves et al. 2013). Thus, an important goal of biological
procedures over conventional endodontic treatment, particularly among young
individuals, would be tooth preservation, in addition to continued dental and
craniofacial skeleton development in these patients.
Researchers have investigated biologically based approaches designed to
replace damaged tooth structures and restore physiologically functional pulp
tissue of immature necrotic teeth over the years. In the early 60’s, the concept
of tissue regeneration began in the classic studies conducted by Nygaard-
Ostby’s research team in humans and dogs’ teeth (Nygaard-Østby 1961,
Nygaard-Østby & Hjortdal 1971, Horsted & Nygaard-Ostby 1978). The
authors investigated the effects of evoked bleeding within the root canal
system via intentional overinstrumentation using histological evaluations,
which demonstrated a connective tissue repair and formation of cellular
cementum instead of regenerating the pulp-dentin complex. Sequentially, the
term “revascularization” emerged from the dental traumatology by the
reestablishment of the vascularity in avulsed teeth, and it was first used in
Regenerative Endodontics 129
Endodontics during a case report performed by Iwaya et al. (2001). Still using
the term “revascularization,” Banchs & Trope (2004) suggested a classic
clinical protocol of revascularization therapy as a viable therapy for young
permanent teeth with periapical involvement. These researches highlighted the
importance of induced intracanal bleeding and a bacteria-free environment
within root canal space for successful clinical outcomes.
Although the presence of an efficient blood supply acts as a necessary key
in the regenerative pulp process, the perspective of “revascularization” may
neglect the crucial role of other biological elements. Therefore, based on the
concept of regenerative medicine, and the scientific progress in the use of
engineering materials associated with cells and biochemical molecules, the
American Association of Endodontists (AAE) in 2007 (Murray et al. 2007)
brought the term “regenerative endodontics” to dentistry. According to the
AAE, “Regenerative endodontics are biologically-based procedures designed
to physiologically replace damaged tooth structures, including dentin and root
structures, as well as cells of the pulp-dentin complex.” This growing field in
Endodontics focuses on tissue regeneration rather than tissue repair.
Conversely, the European Society of Endodontology (ESE) introduced the
term ‘revitalization’ in a position statement published in 2016 (Galler et al.
2016) for the process of tissue regeneration in immature necrotic teeth. All
these terms have been continuously applied as synonymous in the literature.
According to Murray et al. (2007), tissue engineering should be described
as the use of biological based-strategies to replace, restore, maintain and/or
improve tissue function. Initially described by Langer and Vacanti (1993),
tissue engineering involves three classic principles: stem cells, bioactive
signaling molecules, and 3-dimensional scaffolds (Gomes-Filho et al. 2013,
Hargreaves et al. 2013, Kim et al. 2018). Following the discovery of these
components and in the existence of a stem cell-based procedure, a “guided”
tissue engineering approach has been initially established by the AAE in 2016.
Moreover, a search for clinical “stem cell-friendly” protocols that could break
the longstanding paradigm and promote a balance between efficient
disinfection of root canal space and proliferation of stem cells is necessary.
Besides the need and the relationship among those traditional pillars of
tissue engineering, several investigations (Lin et al. 2014, Latham et al. 2016,
Diogenes & Hargreaves 2017, Verma et al. 2017, Bracks et al. 2019) have
strongly recommended the use of efficient disinfection protocols to achieve
infection control, and consequently, to obtain successful results after the
regenerative endodontic procedures (REP). Thus, an updated version of the
diagram designed by Hargreaves et al. (2013), and called “Three main
components of tissue engineering” was elaborated by the authors of this

chapter (Figure 1).
Figure 1. Diagram of the three classic pillars of tissue engineering combined with a
fourth element in achieving successful REP outcomes.
Figure 1 was also inspired by the discussion performed by Diogenes &

Hargreaves in 2017, and it illustrates the quartet of tissue engineering in
endodontics. This diagram also indicates the crucial role of favorable
disinfection of root canals system in association with a source of stem cells,
growth factors release from dentin matrix and a presence of matrix/scaffold in
REP. Then, successful and more predictable REP outcomes can be properly
achieved by the satisfactory interaction among these four elements within root
canal space.
2. Growth Factors
The environment plays an important role in stem cell differentiation during

tissue regeneration. Growth factors are biologically active proteins that play
an important role in environmental stimuli due to the control of the cell cycle
during receptor binding on the cell, and regulation of important signaling
pathways.
Table 1. Main source and function of common growth factors
Factor Abbreviation Source Function

Transforming TGF-β Dentin matrix, Anti-inflammatory activity
growth factor- Treg cells, and NK (inhibition of macrophages
beta cells and lymphocytes proliferation;
regulation of IL-1);
chemoattractant and
stimulating factor for the
differentiation of fibroblasts
and odontoblasts in dental
pulp, and hard tissue
deposition
Vascular VEGF Cells under oxygen Vasculogenesis, angiogenesis,
endothelial tension and regulation of endothelial cell
growth factor platelets proliferation
Fibroblast FGF A broad range of Endothelial cell proliferation
growth factor cells and sprouting, angiogenesis,
hard tissue deposition
Platelet- PDGF Platelets, Cell mobilization,
derived endothelial cells, angiogenesis, stimulation of
growth factor and placenta dentin matrix protein
synthesis, and proliferation of
connective tissue
Bone BMP Bone matrix Odontoblast-like cell
morphogenetic differentiation, dentin
protein formation, and
osteoinductive/chondrogenic
effects
Insulin-like IGF Pulp tissue, liver, Odontogenesis, cell
growth factor and a wide range of proliferation, and
cells differentiation
Nerve growth NGF Neuron’s target Neurons survival and
factor tissue outgrowth, neuronal/non-
neuronal cells differentiation,
and odontoblast differentiation
Treg: T regulatory cells, NK: natural killers, IL: interleukin.
Growth factors bind to receptors on the surface of target cells and induce
a series of processes that ultimately coordinate all cellular functions, such as
cell division, cell signaling, matrix synthesis, and cell proliferation. Initially,
these molecules act at the cell membrane level, promoting the activation of
several biochemical reactions, which end up in the cell nucleus (Wingard &
Demetri 1999). The intracellular signaling pathways mediated by growth
factors lead to the release of mediators by the cells that act on their own
receptors (autocrine mediators) or mediators release that act on receptors of

other cells (paracrine mediators).
Several growth factors from different sources have been described with
specific functions that play an important role in REP (Table 1). During tooth
formation, these factors are mainly secreted by odontoblasts and entrapped in
the dentin matrix (Galler et al. 2015, Zeng et al. 2016) These proteins are
mostly released to root canal space after dentin demineralization with proper
irrigating solutions, and they can be used to control stem cell behavior, such
as enhancing progenitor stem cells proliferation or differentiation and
stimulating the secretion of mineralized matrix on the root walls (Murray et
al. 2007).
Overall, stem cells show the ability to develop chondrogenic,
odontogenic, osteogenic, and neurogenic phenotypes based on their exposure
to different growth factors (Hargreaves et al. 2008). Among these factors, the
transforming growth factor (TGF)-β1 seems to be one of the most evaluated
molecules in REP. TGF-β1 is mostly found in the dentin matrix or produced
by T regulatory cells (Bracks et al. 2019). In addition to presenting
immunosuppressive activity against pro-inflammatory cytokines (Bracks et al.
2019), TGF-β1 is an essential chemoattractant and stimulating factor for stem
cell activity (Gonçalves et al. 2016), upregulating odontoblast differentiation
and supporting reparative dentinogenesis (Deniz Sungur et al. 2019,
Kucukkaya Eren et al. 2021).
Another important molecule in tissue regeneration is vascular endothelial
growth factor (VEGF). Although VEGF was originally defined as an inducer
of vascular permeability (Dvorak et al. 1985), it is well known for its essential
role in angiogenesis and endothelial cell migration and proliferation (Mullane
et al. 2008). Cellular hypoxia is an important regulator of VEFG expression
(Holmes et al. 2007, Bracks et al. 2019). Similarly, fibroblast growth factor
(FGF)-2 also has a potent angiogenic activity (Mullane et al. 2008,
Alburquerque et al. 2014a), and this factor has the potential to differentiate
human dental pulp stem cells (hDPSCs) into odontoblastic lineage in vitro
(Morito et al. 2009). Moreover, FGF-2 induces hard tissue deposition
(Mathieu et al. 2013) and increases the action of TGF-β (Kim et al. 2012).
Additionally, bone morphogenetic proteins (BMP) were initially designed
as regulators of cartilage and bone formation, being associated with the
embryogenesis of several organs and tissues, such as teeth (Casagrande et al.
2010). In dentistry, studies have also demonstrated the substantial activity of
BMP in odontoblast-like cell differentiation, dentin formation, and apical
closure due to hard tissue deposition (Casagrande et al. 2010, Lovelace et al.
2011). One type of stem cell that presents significant levels of BMP receptors
is the human exfoliated primary tooth stem cell (SHED), which indicates the
potential of these cells to regenerate the dentin-pulp complex after responding
to BMP-2- or BMP-7 signals (Casagrande et al. 2010). Therefore, the
understanding of the relationship between growth factor activity and stem cell
behavior is essential for the development of potential strategies for clinical
translation of these biological events in the regeneration of the dentin-pulp
complex.
3. Stem Cells
The proliferation of cells that can differentiate into the desired tissue is an
essential part of tissue engineering. Stem cells are a group of non-specialized
cells in the human body, capable of self-renewal, clonogenicity, and
multilineage differentiation through specific signals. These features are
responsible for the development, regeneration, and repair of tissues
(Weismann 2000, Moraleda et al. 2006, Kolios & Moodley 2013, Zakrzewski
et al. 2019).
According to their plasticity, stem cells are classified into three main
classes based: totipotent, pluripotent, and multipotent (Murray et al. 2007,
Pappa & Anagnou 2009). The plasticity of the stem cells is related to their
capability of producing cells of different tissues (Martin-Rendon & Watt
2003). Totipotent cells are found in early embryos (1-3 days) being able to
differentiate into cells of the whole organism, showing the potential to develop
into an embryo as well as the placental support structure. Some embryonic
stem cells in the blastocyst stage are considered pluripotent, in which they
have the potential to differentiate into approximately 200 cell types from the
three germ layers, endoderm, mesoderm, or ectoderm, and can give rise to any
fetal or adult cell type (Murray et al. 2007). Then, this greater plasticity makes
pluripotent cells more interesting among researchers for investigating new
regenerative therapies (Murray et al. 2007). Conversely, other progenitor cells
differentiate into a limited number of cell types compared to pluripotent cells
(Zakrzewski et al. 2019). These are multipotent cells, also called adult stem
cells, tissue-specific stem cells, or somatic stem cells (Voog et al. 2008,
Mitalipov & Wolf 2009, Casagrande et al. 2011, Zakrzewski et al. 2019).
Mesenchymal stem cells (MSCs), also classified as multipotent
mesenchymal stromal cells, play an important role in cell therapy and/or
regenerative medicine (Uccelli et al. 2008, Fu et al. 2019). These cells
participate in the regeneration of neural, adipose, bone, cartilaginous tissues,

and especially in dental tissue repair (Hsiao et al. 2021). Upon tissue injury,
MSCs have the ability to differentiate into local components and secrete
immune signaling molecules important for tissue regeneration (Fu et al. 2019).
Several populations of adult stem cells have been identified in the oral
cavity, especially in the dental pulp, apical papilla, and also in the inflamed
periapical tissue after root canal infection (Huang et al. 2008, Liao et al. 2011,
Hargreaves et al. 2013), which demonstrates the increased survival capacity
of these cells. Dental pulp stem cells (DPSCs) from human permanent teeth
were first isolated in 2000, and they are characterized as highly proliferative
cells with the capacity for self-renewal, multilineage differentiation, and
clonogenic efficiency (Gronthos et al. 2000). Subsequently, MSCs derived
from other dental tissues were also isolated, such as SHEDs, periodontal
ligament stem cells (PDLSCs), dental follicle precursor cells (DFPCs), and
apical papilla stem cells (SCAPs) (Miura et al. 2003, Seo et al. 2004,
Sonoyama et al. 2006, Morsczeck et al. 2008).
The apical papilla is considered an important source of SCAPs, and these
cells can survive and migrate, even under conditions of chronic inflammation
(Huang et al. 2008). Then, the preservation of this tissue may present a crucial
role in the massive migration of MSCs to the root canal space after evoking
bleeding. Moreover, histologic evaluation has shown the survival of this tissue
after infection and after the disinfection process in REP (Palma et al. 2017).
Similarly, vital apical papilla remained preserved for up to 90 days of infection
in necrotic rat molars (Tobias Duarte et al. 2014).
Advances in the discovery and characterization of various types of MSCs
in dental tissues, as well as advances in cell and molecular biology, have led
to the development of a stem cell therapy, which aims at the regenerating oral
tissues affected by dental caries or trauma (Peters 2014, Kim et al. 2015). In a
vital pulp tissue, an appropriate cellular environment provided by the
extracellular matrix (ECM) of the pulp, with significant amounts of collagen,
non-collagenous proteins, and growth factors that provide biochemical and
biophysical signals are required for an appropriate proliferation and
differentiation of DPSCs. In recent years, stem cell therapy is becoming a
promising scientific field in tissue engineering, and although there are still
obstacles to be overcome, its positive influence on regenerative endodontics
is remarkable (Zakrzewski et al. 2019, Hsiao et al. 2021). Biomimetic
scaffolds, enriched or not with stem cells and/or growth factors, have been
designed to better recreate this niche environment and, consequently, enhance
stem cell proliferation and differentiation.
4. Scaffolds
Regenerating tooth structures is challenging. A scaffold provides a solid three-

dimensional (3D) matrix that allows stem cells to migrate, adhere and
proliferate in the targeted area. Scaffolds are also capable of regulating cell
differentiation by local release of signaling molecules, and during the contact
of these cells with the extracellular matrix and with each other (Hargreaves et
al. 2013). The scaffold might be biocompatible with the host tissue, and porous
to allow the efficient transport of nutrients and residues, in addition to
supporting physiological loads, with slow degradation, until tissue
regeneration occurs (Sharma & Elisseeff 2004). Based on their sources and
properties, scaffolds can be made of endogenous and/or natural compounds
(e.g., collagen, dentin, glycosaminoglycans, chitosan), and synthetic materials
(e.g., hydrogels, polylactic-glycolic acid - PLGA) (Dissanayaka et al. 2020).
In the 1960s, researches conducted by Niggard-Obstby suggested the
induction of intracanal bleeding in animal and human teeth via apical
overinstrumentation with an endodontic file for tissue regeneration,
demonstrating fibrous connective tissue and cementum ingrowth in necrotic
teeth (Ostby 1961, Nygaard-Ostby & Hjortdal 1971, Hørsted & Nygaard-
Ostby 1978). Subsequently, classic case reports also investigated the
recreation of a vascular network into the root canal via evoked bleeding
procedure to provide a continued root development and tissue regeneration in
immature necrotic teeth (Iwaya et al. 2001, Banchs & Trope 2004).
The induction of intracanal bleeding can provide a significant influx of
undifferentiated stem cells from the apical papilla into the root canal (Ding et
al. 2009, Tobias Duarte et al. 2014), functioning as a support matrix to load
growth factors and cells. Molecular analyses showed an up-regulation of stem
cell markers CD73 and CD105 (up to 600-fold) in the root canal using evoked
bleeding in comparison with the levels from the systemic circulation
(Lovelace et al. 2011). In addition to the possibility of autologous stem cells
delivery into root canal space via blood clot induction, the surgical
implantation of natural and/or synthetic polymer-based scaffolds to closely
mimic the native extracellular environment in the laboratory and achieve more
predictable outcomes has been designated as an important approach under
investigation (Murray et al. 2007, Bottino et al. 2015, 2017). Two main types
of polymer scaffolds for regenerative endodontics are collagen and fibrin
(Zein et al. 2019).
Collagen scaffolds, primarily type 1, are commonly used and shows
similar characteristics to the native pulp tissue. A combination of collagen
scaffold with bioactive molecules such as BMP, stromal-cell-derived factor

(SDF)-1, and granulocyte-colony-stimulating factor (G-CSF), enhances their
biological properties since there is significant cell proliferation and
differentiation, and newly connective tissue formation (Iohara et al. 2011,
Nakashima & Iohara 2011, Murakami et al. 2013, Zein et al. 2019).
Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are two first and
second sources of autologous concentrated platelets that have been used as a
scaffold due to their ability to form a three-dimensional fibrin matrix in REP,
respectively. PRP and PRF have promising results with continued hard tissue
deposition and blood vessel formation in REP (Torabinejad & Turman 2011,
Ray et al. 2016, Arshad et al. 2021) due to high growth factors liberation, such
as platelet-derived growth factor (PDGF) and TGF-1. Nevertheless, despite
having approximately 5x greater platelet concentration than systemic blood,
PRF production has easier preparation (Arshad et al. 2021) than PRP and
involves only endogenous agents (cytokines, growth factors) that make PRF a
more suitable fibrin network for storage of signaling molecules and cell
distribution (Ray et al. 2016, Ulusoy et al. 2019). Although PRF may offer
more promising results as a scaffold in REP, a randomized controlled trial
found high success scores for both PRP and PRF using clinical and
radiographic evaluations, besides a significantly reduced tendency for canal
obliteration than evoked bleeding (Ulusoy et al. 2019).
A tissue formation with a morphological characteristic of native pulp
tissue was demonstrated after 14-28 days in tooth slices with extirpated pulp
implanted in immunodeficient mice, containing SHED seeded into synthetic
scaffolds of poly-lactic acid (PLLA) (Nör et al. 2001). These results provided
new light on the possibility of regenerating pulp and dentin in necrotic teeth
using synthetic materials. In these synthetic polymer-based scaffolds,
precision in controlling physicochemical properties such as degradation rate,
porosity, microstructure, and mechanical properties are necessary because of
the direct support for cell attachment, viability, and differentiation (Zein et al.
2019, Matichescu et al. 2020). Scaffolds with a defined diameter of pores
between 100 to 300 µm enable efficient diffusion of nutrients and oxygen for
cell survival, and satisfactory regulate cell differentiation (Murugan & Parcha
2021). Some commonly used synthetic materials are PLLA, polyglycolic acid
(PGA), and their copolymers, PLGA.
Another synthetic material with increased interest as a scaffold in REP is
hydrogel due to its easy handling and adaptation in the root canal system (Qi
et al. 2012). Hydrogels are injectable and composed of 3D hydrophilic
polymer networks that are capable of absorbing tissue fluids and being
sustained with chemotactic and angiogenic agents (Bai et al. 2018). Synthetic
hydrogels that include polymers based on polyethylene glycol (PEG) or
modified with cell adhesion peptides on surfaces, such as arginine, glycine,
and aspartic acid (RGD) (Burdick & Anseth 2002), are also described. These
synthetic polymers are biocompatible and biodegradable and facilitate the
manipulation of their physicochemical properties.
The use of nanotechnology techniques, such as electrospinning and rapid
prototyping, can help to control pore size and gap width between struts
(Murugan & Parcha 2021), which may positively affect stem cell adhesion and
differentiation, in addition to obtaining drug- and growth factor-containing
nanofibrous 3D-printed scaffolds (Bottino et al. 2015), in which may increase
antimicrobial activity and tissue formation. The enrichment of 3D scaffolds
with cell transplantation and/or growth factors may increase the likelihood of
achieving predictable dental pulp regeneration (Bottino et al. 2017, Jung et al.
2019).
Therefore, the incorporation of cell-based regenerative protocols using the
massive number of biomaterials for scaffolds should be deeply investigated in
REPs due to its promisor ability to establish dentin-pulp complex
regeneration. In addition to ensuring cell adhesion in the root canal walls, the
difficulty to place 3D scaffolds containing stem cells in the root canal system
without breakage, and the possible problems related to immune response need
to be well evaluated by in vivo and clinical studies.
5. Bacteria-Free Environment
Bacterial invasion of the root canal system is associated with the formation of
bacterial biofilms on the dentinal walls and in the apical region. Moreover, the
large diameter of dentinal tubules in immature teeth from young patients can
increase bacteria penetration (Perez et al. 1993, Verma et al. 2017). In REP,
the presence of residual bacteria may significantly impair the healing of
periapical lesions and decrease hard tissue formation (Verma et al. 2017).
The long-term effects of residual bacteria on tissue regeneration depend
on different factors such as microbial location within the root canal, size, and
composition of endodontic biofilm, besides nutritional supply for the
microorganisms (Nair et al. 2014). To ensure successful tissue regeneration, it
is necessary to eliminate the bacterial biofilm inside the root canal, and favor
growth factor liberation for cell differentiation (Albuquerque et al. 2014a,
Nagy et al. 2014).
In immature teeth, cleaning and shaping are challenging due to the

increased risk of root fracture by the presence of fragile root walls and open
apices (Banchs & Trope 2004, Law 2013, Ribeiro et al. 2020). Thus, a focus
on the role of irrigating solutions and intracanal dressing for root canal
disinfection is given despite the use of root canal instrumentation with
endodontic files in these teeth. Furthermore, soluble proteins involved in the
tissue formation may be removed from the untouched predentin layer during
mechanical debridement (Gonçalves et al. 2016). Hence, minimal
instrumentation based on the removal of necrotic remnants of pulp and
intracanal bleeding, or no instrumentation is strongly recommended in REP.
Conversely to conventional endodontic treatment, REP relies in the
decontamination and debris removal of root canals using irrigating solutions.
The type and concentration of irrigating solutions and intracanal medicament
vary according to the protocol. However, the concentration levels of
antimicrobial agents used in this procedure should be carefully evaluated since
these high–concentrated agents may negatively impact cell survival
(Khoshkhounejad et al. 2019, Ribeiro et al. 2020). High-concentrated
disinfection agents may also be irritants for periapical tissues (Gonçalves et
al. 2016).
Although there is not a standard protocol for root canal irrigation (Kim et
al. 2018), sodium hypochlorite (NaOCl) in different concentrations (0.5-6%)
is still the most used in REP (Bucchi et al. 2017, Bracks et al. 2019). The use
of solution during root canal irrigation is recommended in the guidelines of
AAE (2018) and ESE (Galler et al. 2016), and NaOCl enables a substantial
antimicrobial effect and solvent potential within the root canal system.
Another common solution used after NaOCl irrigation in the protocols of
regenerative is endodontics ethylenediaminetetraacetic acid (EDTA).
Although some investigations found a reduction in cell viability (Deniz
Sungur et al. 2019) and blood clot formation (Taweewattanapaisan et al. 2019)
by EDTA conditioning, final irrigation with 17% EDTA is suggested due to
the possibility of this solution to decreasing endotoxins in root canal (Herrera
et al. 2017), minimize the cytotoxicity of NaOCl, in addition to increasing
signaling molecules released from dentin matrix (Galler et al. 2016, Gonçalves
et al. 2016, Kim et al. 2018, Bracks et al. 2019, Dos Reis-Prado et al. 2022).
Therefore, according to a current protocol of AAE (2018), adequate root canal
disinfection in REPs must be achieved with copious irrigation with NaOCl,
final rinsing with EDTA, followed by the use of an intracanal dressing. For
this part, calcium hydroxide (Ca(OH)2) and antibiotic pastes are commonly
used.
Regarding these medicaments, some concerns are presented in the

literature. Whereas some studies have pointed out the ability of long-term
exposure to Ca(OH)2 to weaken dentin structure (Cvek 1992, Andreasen et al.
2002, Batur et al. 2013), others have pointed out the high cytotoxicity, crown
staining, and reduction in the growth factors released from EDTA-conditioned
dentin when using antibiotic pastes (Galler et al. 2015, Dubey et al. 2019,
Ribeiro et al. 2020). However, despite the possible weakening effect of
Ca(OH)2, an in vitro study found no influence of this medicament on the
fracture susceptibility of the roots (Kahler et al. 2018). Thus, considering the
limitations of these materials, Ca(OH)2 paste still appears to be a satisfactory
choice due to its antibacterial potential and more favorable influence on cell
survival in comparison to antibiotic pastes (Hargreaves et al. 2013, Peters
2014, Galler 2016).
From a biological standpoint, disinfecting agents that present minimal
harmful effects to stem cells and apical tissue should be considered in REP.
Furthermore, previous field isolation and decontamination of the work area
are necessary to prevent bacterial recontamination. The current clinical
considerations for disinfection of root canals in REP are as follows (AAE
2018, Galler et al. 2016):
5.1. First Appointment
Regarding the importance of a bacteria-free environment, almost all visits are

designed to enable efficient root canal decontamination. Firstly, after
anesthesia and rubber dam isolation, endodontic access is performed.
Subsequently, copious and gentle irrigation with 5 min 20 mL/canal NaOCl in
lower concentrations (1.5-3%) is suggested for bacterial and necrotic tissue
removal, followed by irrigation with saline or 17% EDTA (20 mL/canal, 5
min). During this step, irrigation systems that minimize the possibility of
extrusion of irrigants into the periapical tissues as EndoVac (Discus Dental,
Culver City, CA) or Endo-Eze™ Irrigator tips (Ultradent, Indaiatuba, SP,
Brazil) are recommended. The needle should be positioned 1 mm short of the
root apex in order to reduce the possibility of irrigant extrusion and
cytotoxicity in apical tissues.
The canals are then dry with paper point and intracanal dressing is placed,
either Ca(OH)2 or low concentrations of triple antibiotic paste (TAP, 1-5
mg/mL) using a lentulo spiral or syringe. The use of a medicament between
sessions aims to reduce considerably the number of microorganisms inside the

root canal system before scaffolding.
Traditionally, TAP is composed of equal parts of ciprofloxacin,
metronidazole, and minocycline (1:1:1). However, minocycline may present a
negative impact on angiogenesis, a high toxicity to stem cells, besides
promoting intense crown discoloration (Alburquerque et al. 2015, Dubey et al.
2019, Ribeiro et al. 2020). Thus, exclusion of minocycline compound (double
paste antibiotic, DAP) or modified TAP formulation, replacing of this agent
with other antimicrobial compounds (e.g., amoxicillin, clindamycin, cefaclor,
chitosan) should be considered (Ribeiro et al. 2020). Other antimicrobial
approaches involve the use of chlorhexidine gels/solutions, natural
compounds (e.g., propolis, curcumin), and TAP-eluting nanofibers. Most of
these new agents have their biocompatibility, cytotoxicity and antimicrobial
properties being investigated in animal and in vivo studies (Pagliarin Londero
et al. 2016, Pankajakshan et al. 2016, Sotomil et al. 2019, Shi et al. 2020).
After medicament placement, coronal sealing using a sterile cotton pellet,
followed by the use of a 3-4mm temporary filling material layer (e.g., glass-
ionomer, Cavit™, IRM™) is performed. Adequate coronal sealing is crucial
to prevent possibly renewed infection through coronal microleakage.
5.2. Second Appointment
After a interval of 1–4 weeks, the patient could be recalled. If there are no
signs and symptoms of persistent infection, local anesthesia with 3%
mepivacaine without vasoconstrictor is performed, following removal of
temporary seal and rubber dam isolation. The canal is then irrigated with 20
mL of 17% EDTA and dried with paper points. The function of this solution
is to enhance the release of growth factors entrapped in dentin during calcium
quenching (Bracks et al. 2019, Dos Reis-Prado et al. 2022). Subsequently,
evoked intracanal bleeding is performed. Other alternatives of 3D scaffolds
could be chosen. After the confirmation of clot stability, a layer of 3-4 mm of
biomaterials (e.g., MTA, Biodentine®) is placed over the blood clot as a
cervical barrier followed by final restoration with a direct composite resin. The
use of a resorbable matrix over the clot (e.g., collagen matrix) could be
considered to minimize apical displacement of biomaterial (Jung et al. 2019).
The number of visits and the length of time between appointments may
vary in the clinic depending on the quality of endodontic infection control.
However, if signs of infection still persist in the second visit, additional
treatment with an antimicrobial should be considered. Follow-up visits of 6,

12, and 24-months using radiographic and clinical exams are crucial.
6. Clinical Indications
Various clinical guidelines are still observed for REPs in the literature.
Moreover, the current protocols are based on the evidence provided by clinical
study and, particularly, pre-clinical research. For instance, an important
guideline for clinicians named “Clinical Considerations for a Regenerative
Procedure” has been published and revised in 2018 by the AAE. Nevertheless,
due to the increased amount of new research in this field, clinicians should
also critically review other sources of evidence being available (Kim et al.
2018). Hence, the recommendations of AAE are expected to modify as the
area of regenerative endodontics evolves.
Teeth of young patients ranging from age 9 to 18 years may be the most
viable to achieve success after REP due to their increased ability to heal
(Murray et al. 2007, Estefan et al. 2016). Moreover, clinicians should consider
necrotic teeth with immature apices, which do not need a post for coronal
restoration, as suitable for REP. This criterion is based on the fact that a
cervical barrier using a biomaterial is performed over the clot as a step of the
therapy.
On the other hand, the etiology of pulp necrosis does not seem to be a
critical variable in case selection. However, there is a need for multiple visits,
which requires patient/parent compliance. Additionally, according to Kim et
al. (2018), and considering the Cvek’s classification of root formation (Cvek
1992), stage 1 (< 1/2 of root development), stage 2 (1/2 root development),
and stage 3 (2/3 of root development and open apex) are the most
recommended for RET because of its ability to provide continued root
development.
Regarding the size of apical diameter, necrotic teeth with open apices of
approximately 0.5-1.0 mm have shown promisor results in REP (Laureys et
al. 2013, Estefan et al. 2016, Fang et al. 2018) because they probably enable a
massive stem cell migration within the root canal. Conversely, signs and
symptoms of persistent infection, such as pain, swelling, sinus tracts, or
increasing periapical radiolucency after more than 1 year of follow-up indicate
failure and an alternative procedure (apexification or extraction) should be
performed (Almutairi et al. 2019).
7. Histological and Clinical Findings
Overall, REP has shown a success rate ranging from 95% to 100% with
evident radiographic root development and reduction of signs and symptoms
(Jeeruphan et al. 2012, Alobaid et al. 2014, Estefan et al. 2016, Ulusoy et al.
2019). The success is linked to the appropriate disinfection of the root canals,
recruitment of MSCs and establishment of a framework, and placement of a
coronal barrier and restoration to avoid bacterial infiltration (Ding et al. 2009,
Albuquerque et al. 2014a, 2014b).
Histological evaluations in humans and animal models have been
conducted to evaluate different aspects of REP, such as the impact of different
irrigation protocols and scaffolds on the quality of the tissue regeneration, and
histologic characterization of engineered tissues in the canal space. These
analyses are capable of demonstrating direct evidence for tissue repair or
regeneration (Ulusoy et al. 2019).
Satisfactory tissue neoformation has been shown in the teeth of dogs
within 3 months after REP (Wang et al. 2010, Yamauchi et al. 2011a, Gomes-
Filho et al. 2013). Fibrous tissue, cementum-like tissue adhered to the inner
wall of the pulp canal, intracanal bone-like islands, and the presence of newly
formed connective tissue are some of the main characteristics of the
regenerated tissues. These features have been also described in immature
human teeth submitted to REP (Martin et al. 2013; Shimizu et al. 2013; Nosrat
et al. 2019). In addition, apical closure after RET has been reported (Yamauchi
et al. 2011a; Dos Reis-Prado et al. 2022). This apical closure may result from
a newly layer of cementum-like tissue formed in the root canal walls
(Yamauchi et al. 2011b; Dos Reis-Prado et al. 2022), which is also associated
with an increase in root thickness and length (Dos Reis-Prado et al. 2022).
Newformed tissues may show characteristics of the tissue from which
stem cells originate (Jung et al. 2019). The migration of stem cells from the
periapical region, such as periodontal ligament and alveolar bone, into the
canals, may be associated with the formation of a layer of connective tissue of
periodontal ligament and islands of mineralized tissue (Yamauchi et al. 2011a,
Gomes-Filho et al. 2013, Dos Reis-Prado et al. 2022).
In REP, tissue regeneration seems to be preceded by the presence of an
inflammatory infiltrate composed of polymorphonuclear cells (Wang et al.
2010, Dos Reis-Prado et al. 2022). However, the presence of these
inflammatory cells seems to not interfere with the hard tissue deposition, and
it may be related to cell differentiation and tissue repair. Hence,
immunoinflammatory cell migration occurs in an initial phase of inflammation
and during a reparative process (Galler et al. 2021). In addition to promoting

inflammatory cell activity, interleukin (IL)-1 also has pro-angiogenic effects
(Bracks et al. 2019, Dos Reis-Prado et al. 2022).
The irrigation protocol used plays an important role in the quality of this
root development. In a study in molars of rats, it was observed that irrigation
of the root canals with 17% EDTA after the use of 2.5% NaOCl significantly
promoted connective tissue neoformation, in addition to contributing to the
increase in root thickness and length (Dos Reis-Prado et al. 2022). This
improvement in tissue repair may be related to bioactive molecules released
from EDTA-treated dentin, thereby enhancing stem cell activity (Dos Reis-
Prado et al. 2022).
Despite these promising findings, pulp or pulp-like tissue has not been
observed in most evaluations. The lack of pulp-derived stem cells was reported
as a possible factor in the absence of pulp tissue formation (Gomes-Filho et
al. 2013). Nevertheless, a well-vascularized pulp-like tissue was found in an
in vivo study, in which a synthetic scaffold containing SCAPs and hDPSCs
was inserted into human roots fragments and transplanted onto mouse
subcutaneous tissue (Huang et al. 2010). Similarly, regeneration of pulp tissue
with nerves and capillary formation was also reported after 14 days of the
autologous transplantation of a collagen scaffold containing CD31(-)/CD146(-
) (Nakashima & Iohara 2011) or CD105(+) cells (Iohara et al. 2011,
Nakashima & Iohara 2011) with SDF-1 into the root canal of dogs.
Regarding clinical outcomes, REP can present different results in necrotic
immature tooth, as follows: type I, a continuation of root development with
increased thickness and length of the root canal walls; type II, apical closure
with non-significant root growth; type III, a continuation of root development
without apical closure; type IV, root canal obliteration and type V, formation
of a hard tissue barrier between the biomaterial plug and root apex (Chen et
al. 2011, Albuquerque et al. 2014b).
The primary goals of treatment involve enhancing patient well-being and
healing the affected tissues, followed by increased tooth survival and function
in the dental arch. Secondary objectives are related to further root development
and apical closure as previously discussed in the histological analyses. In
patients submitted to REPs, healing of periapical radiolucency often occurs
after 6-12 months, whereas an increase in root canal thickness is generally
observed after 12-24 months before an increase in root length (AAE 2018).
On the other hand, the reasons for failure cases are controversial. The
occurrence of most failure causes is mainly related to inadequate root canal
disinfection and bacterial microleakage due to inadequate coronal sealing

(Soares et al. 2020).
In a comparison between apexification and REP, the latter had greater root
growth in length and thickness, in addition to a reduction in apical diameter
than teeth treated with apexification (Diogenes et al. 2016). Furthermore,
among 88 immature human incisors submitted to REP, 74% had complete
apical closure, satisfactory periapical healing, and radiographic root
development, besides 80% of positive response to sensitivity tests after a
follow-up of 28.25 ± 1.2 months (Ulusoy et al. 2019). In this clinical trial,
1.25% NaOCl followed by 17% EDTA and a modified triple antibiotic paste,
containing clindamycin instead of monocline, were used for root canal
disinfection. These clinical results demonstrate the promising ability of REP
for continued root development. Regarding the positive responses to pulp
sensitivity tests in most teeth, this finding may demonstrate that necrotic
canals have become innervated, which might be also associated with the
reestablishment of natural defense mechanisms.
In contrast to primary goals and the considerations of the European and
American associations for REPs, newly available evidence for the field of
regenerative endodontics are currently discussed, with particular emphasis on
new therapeutic modalities and clinical indications.
8. New Pathways of Regenerative Endodontics
Over the years, REPs have become one of the most outstanding findings in
endodontics. This approach has proven to be a great surprise in saving
immature teeth of young patients with pulp necrosis and/or apical
periodontitis, in addition to achieving a continued root development. Despite
promisor short-term results in immature necrotic teeth treated by REP, clinical
trials and longitudinal follow-up are still warranted. Additionally, several
questions have arisen regarding the new pathways of REPs in scientific
literature.
Can natural medicaments benefit root canal disinfection and be less
cytotoxic than traditional intracanal dressing? Can photoactivation enhance
growth factors release and stem cell differentiation? Can single-visit REP
without interappointment intracanal dressing be successfully applied? Can
odontoblasts and pulp-like tissue be formed into the root canal using new stem
cells and growth factors-based delivery approaches? Can teeth treated by REP
be moved orthodontically? Can REPs be effectively performed in necrotic
mature teeth of adult patients? Can also REP in patients with systemic
disorders achieve promissory results? In recent years, different researches
have been conducted in an attempt to answer these and other questions.
8.1. New Trends for Root Canal Disinfection
Residual bacteria within the root canal system are associated with persistent
periapical lesions and lower mineralized tissue deposition in REPs (Verma et
al. 2017). Intracanal dressing between sessions has been recommended to
favor infection control (AAE 2018). From a biological viewpoint, highly
concentrated Ca(OH)2 paste and traditional TAP may present stem cell
toxicity in which impair tissue repair, in addition to antibiotic resistance
esthetic limitation (tooth discoloration) caused by some antibiotic agents
(Galler 2016, Ribeiro et al. 2020). Considering the aforementioned issues,
alternative antimicrobial agents have been investigated to induce adequate and
complete development of immature necrotic teeth. One example is a
biodegradable polymer-based drug delivery system consisting of 3D tubular-
shaped TAP-eluting nanofibers with significantly lower antibiotic
concentration projected to show physical stability, low crown staining, and
maximize controlling infection without impairing DPSC attachment and
proliferation on dentin (Bottino et al. 2013, Albuquerque et al. 2015,
Pankajakshan et al. 2016).
Chitosan is a biological and cationic polysaccharide that has been used as
a drug carrier (Li et al. 2018), demonstrating biocompatibility, physical
stability, and biodegradability (Raafat & Sahl 2009). A combination of this
compound with other functional materials is required to provide osteogenic
differentiation and tissue regeneration (Tang et al. 2020), leading to the
development of chitosan-based biomaterials. Additionally, the positively
charged NH3+ groups of glucosamine found in chitosan molecules may
interact with negatively charged surfaces of bacteria, resulting in cell surface
alterations, and impairment of vital bacterial activities (Raafat & Sahl 2009).
Previous studies have demonstrated the efficient elimination of bacterial
biofilms in the presence of chitosan-based materials (Shrestha et al. 2014,
Valverde et al. 2017).
Other natural compounds with promising antimicrobial and anti-
inflammatory results are curcumin and propolis. The former is a
photosensitive substance from turmeric root, and it has already been used in
the production of electrospun fibers for soft tissue regeneration (Mouthuy et
al. 2017). This compound is also used as an intracanal medicament for

disinfection procedures (Devaraj et al. 2019), showing substantial antibiofilm
activity, especially after photoactivation (Sotomil et al. 2019). The latter is a
resinous mixture produced by bees, which has previously demonstrated
effective antibacterial activity against E. faecalis as an intracanal medicament
(Awawdeh et al. 2009). In a histologic evaluation using immature dog teeth,
propolis showed similar disinfection compared to TAP and induced
progressive tooth maturation (El-Tayeb et al. 2019). Furthermore, this natural
compound showed satisfactory viability of human dental stem cells (hDPSCs),
osteogenic potential, and suppression of pro-inflammatory interleukin (IL)-1β
and IL-6 (Shi et al. 2020).
Bioactive glasses have also gained attention for being a promisor
candidate for REPs due to their good antibacterial and biomineralization
properties. For example, synthesized mesoporous bioactive glasses (AG-
MBGs) showed positive antibacterial activity against E. faecalis in the root
canal, probably due to the leaching of Ag+2 ions (Fan et al. 2015). The use of
bioactive glasses as an intracanal medicament in REPs due to their interesting
properties, merits further investigation.
8.2. Low-Intensity Laser Phototherapy
Studies on regenerative endodontics have investigated sophisticated

techniques, involving the transplantation of stem/progenitor cells combined
with bioactive molecules and artificial scaffolds (Santana et al. 2012, Rosa et
al. 2013, Chen et al. 2015). A promisor adjunct therapy to these tissue-
engineering methods is photobiomodulation with low-level laser due to its
anti-inflammatory, analgesic, and biostimulation effects (Moreira et al. 2017,
Deluca et al. 2021). This therapy uses nonionizing light sources, and it is a
nonthermal process based on the activation of endogenous chromophores that
provoke photophysical and photochemical events at various biological scales.
Photobiomodulation has not shown negative effects on hDPSCs when
using appropriate protocols (Marques et al. 2016). Conversely, light therapy
stimulates membranes, and organelles, in addition to regulating oxidative
stress of target cells, which may improve stem cell metabolism, proliferation
and differentiation, besides increasing dentin deposition and promoting tissue
response (Zaccara et al. 2018).
Low-level laser treatment with an 810 nm GaAlAs laser diode system has
induced hDPSCs differentiation in vitro through activation of transforming
growth factor (TGF)-β1; in addition to promoting increased dentin formation

in an in vivo pulp capping model in rat molars (Ariani et al. 2014). Moreover,
light sources of a wavelength between 635-600 nm and various energy
densities in different in vivo (Moreira et al. 2017) and in vitro (de Oliveira et
al. 2015, Moura-Neto et al. 2016, Zaccara et al. 2018, 2020) protocols
demonstrated greater TGF-β1 and VEGF activation, stem cell survival and
differentiation, and tissue regeneration.
In monolayer cell cultures under nutritional deficiency or not, positive
results have been reported, especially, using fractioned irradiation energy of
1J (Deluca et al. 2021, Zaccara et al. 2018, 2020) or between 1.5 and 3 J (de
Oliveira et al. 2015). However, despite the knowledge generated by these two-
dimensional cell cultures, tree-dimensional models are required to simulate
the physiology of in vivo environments and, consequently, provide more
accurate conclusions (Zaccara et al. 2018).
Hence, this approach may demonstrate an interesting impact on protocols
in regenerative endodontics, by accelerating tissue healing through human
pulp stem cell regulation. Still, there is a lack of information on the use of low-
level laser therapy as an adjuvant treatment in tissue engineering in the
scientific literature. Clinical and in vivo translational studies evaluating the
effects of photobiomodulation on regenerative outcomes are encouraged,
especially, including samples with systemic disorders.
8.3. Single-Visit versus Double-Visit Modalities
Most of the published case reports and the current clinical protocols of the
ESE (Galler et al. 2016) and the AAE (2018) have recommended a double-
visit approach with interappointment intracanal medicament for eliminating
root canal infection. Nevertheless, case reports with 18-month clinical follow-
up have demonstrated successful outcomes after REP in a single visit, such as
teeth not sensitive to palpation or percussion, normal periodontal pocket
depths, physiologic mobility, and continued root development with apical
closure (McCabe 2015, Topçuoğlu & Topçuoğlu 2016). However, caution must be
considered when interpreting these findings, particularly among clinicians,
considering that positive data are more likely to be published and well-
designed evidence is not sufficient.
Single-appointment approach may be an advantageous alternative to
double-visit protocols owing to the reduced possibility of restoration
displacement and tooth discoloration, increased patient compliance, time
saving, and reduced cost for patients and dentists (McCabe 2015, Botero et al.
2017, Rossi-Fedele et al. 2019). Normally, REP involves limited or no
mechanical debridement. Thus, in the absence of intracanal dressing in single-
visit, the performance of adequate irrigation protocols plays an important role
in infection control, mainly in the presence of periapical lesions.
According to a systematic review on this topic (Rossi-Fedele et al. 2019),
the scarce evidence suggests that the single-visit approach is unpredictable. In
a clinical trial in which a blood clot was inducted at the first appointment, a
33% success rate was found compared to a 71% success rate in the double-
visit group (Botero et al. 2017). In this modality, the use of clinical irrigation
protocols with high concentrations of NaOCl and EDTA, in association with
other irrigating solutions and/or agitation may be incorporated due to the
possible presence of tissue remnants and biofilm in the root canal space and
dentinal tubules. Nonetheless, the risk of irrigant extrusion and toxicity for
apical tissue and cells must be considered during the clinical performance of
the single-session protocol. Based on the limited evidence, the double-
appointment modality might be taken into accountant in symptomatic cases,
and in cases with large periapical lesions due to increased bacterial density
and biofilm complexity.
8.4. Regenerative Endodontics in Mature Necrotic Teeth
As the advances in pulp biology appear to change rapidly, attention has been
also given to the biologically based treatment procedures in endodontics,
which could promote longevity of natural teeth and, consequently, provide
regeneration of the pulp-dentin complex in mature teeth with closed apices.
Despite the increasing ability of tissue healing in immature teeth, mature teeth
with closed apices also have the capability of responding to injury by the
production of tertiary dentin, which may point out the existence of pulp stem
cells within the dental pulp throughout life (Murray et al. 2007). Nevertheless,
cell heterogeneity and the potential of these cells to differentiate into
odontoblast-like cells within the dental pulp of mature teeth are unclear
(Goldberg & Lasfargues 1995).
Human cells are between 10-100 µm in diameter. Thus, stem cells,
endothelial cells, periodontal ligament cells, and cementoblasts are capable of
invading the root canal space through the apical foramen even when smaller
than 0.5 mm (Kim et al. 2018). Accordingly, the size of the apical foramen
might not prevent revascularization. For instance, previous animal
experimentation found a tissue ingrowth in the apical foramen of 0.32 mm at

90 days after transplantation (Laureys et al. 2013). Similarly, newly
regenerated tissue and tissue mineralization in dentinal walls were noticed at
14 days after transplantation of autologous pulp CD105(+) stem cells and
SDF-1 into the root canal of mature teeth of dogs (Iohara et al. 2011).
Connective tissue with cementum-like or bone-like tissues was also observed
after a 3-month follow-up period in the canal space of mature teeth of rats with
apical periodontitis submitted to apical enlargement with #60 K-file during
REP (Gomes-Filho et al. 2013). These histological results are similar to those
observed in immature teeth.
Additionally, the use of 3D scaffolds may help to achieve better results in
mature teeth submitted to REP. For instance, an in vivo study developed an
injectable microsphere scaffolding system, containing VEGF, heparin-
conjugated gelatin nanospheres, nanofibers of PLLA microsphere, and mixed
with DPSCs (Li et al. 2016). This nanofibrous microsphere system was
implanted into full-length root canals of mice. Successful regeneration of pulp
tissues that filled the entire apical and middle thirds up to the coronal third was
observed. In addition, a large number of blood vessels were regenerated along
the canals, and in some areas, the DPSCs differentiated into odontoblast-like
cells and aligned with the dentin of the existing tubular root.
Positive results of REP in mature necrotic teeth have been also discussed
in clinical evaluations, in which regression of periapical radiolucency and
resolution of clinical signs and symptoms were demonstrated in patients that
underwent REP with apical enlargement using size 35 and 60 K-files (Paryani
et al. 2013, Saoud et al. 2014). Moreover, mature teeth with periapical
radiolucency of patients aged 18 to 32 years old showed satisfactory clinical
and radiographic outcomes in 92.3% of the REP group compared to 80% of
conventional endodontic treatment in a clinical trial with a follow-up of
approximately 12 months (Arslan et al. 2019). However, additional well-
designed and randomized clinical trials with long-term efficacy in individuals
with necrotic mature teeth and apical periodontitis are essential to support the
management of this approach.
Conclusion
REP has become an interesting and economical alternative to conventional

endodontic treatments, especially among teeth with incomplete root
development and open apices of young patients, in which most the successful
results have been reported. However, with further research and based on the
current advances in tissue engineering, such as the use of bioactive materials,
efficient disinfection protocols, 3D scaffolds, and cell-based therapies, more
predictable outcomes might be achieved and its clinical indications might
increase over time. In this chapter, we discussed the importance of a bacteria-
free environment in association with the three classic pillars of tissue
engineering (growth factors, stem cells, and scaffold). Additionally, we
presented the current clinical protocols for REP and its indications based on
the main histological and clinical findings to support this therapy. New trends
for REP have been also discussed. Despite these promissory pathways and this
constant improvement in tissue engineering strategies; additional well-
designed and randomized clinical trials with long-term evaluation are essential
to bringing these findings to the clinical setting.
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Chapter 8
Biomaterials Used in the Conservative

Treatment of Pulp Tissue
Carlos Roberto Emerenciano Bueno1,2,*,

Marina Tolomei Sandoval Cury2,
Ana Maria Veiga Vasques2,
Ana Cláudia Rodrigues Silva2
and Leopoldo Cosme-Silva3
1
Department of Endodontics, State University of Northern Paraná,
Jacarezinho, PR, Brazil
2
Department of Endodontics, São Paulo State University (UNESP),
School of Dentistry, Araçatuba, SP, Brazil
3
Department of Endodontics, Alagoas Federal University, Maceió, AL, Brazil
Abstract
Conservative treatments aim to preserve pulp vitality. Over the years,

several materials have been used for direct pulp capping, indirect pulp
capping and pulpotomy. Accurate diagnosis at the time of treatment,
although still a challenging task in primary teeth, is yet an essential
requirement. The type and quality of the restoration also influences the
success rate as does the clinician’s experience. The knowledge acquired
over the years allowed scientists to have a better understanding of the
biological processes behind the interactions of living tissues with dental
materials. Therefore, materials that undergo direct contact with living
tissue should present biocompatible features, besides the ability to induce
deposition of mineralized hard tissue. This chapter discusses dental
Corresponding Author’s Email: carlos.bueno@uenp.edu.br / dentistabueno@gmail.com.

*

ISBN: 978-1-68507-987-1
162 C. Emerenciano Bueno, M. Tolomei Sandoval Cury et al.
materials used in the conservative treatment of pulp tissue, starting from

a brief description of pulp tissue composition, techniques used in vital
pulp conservative therapy and a historic overview of materials used in
management of vital pulp, from empirical materials to a new generation
of bioactive materials.
Keywords: bioactive materials, conservative treatment, dental pulp,

endodontics, oral health
1. Introduction
The pulp tissue, as discussed in previous chapters, is a loose non-mineralized

connective tissue, composed of different cell types (odontoblasts,
undifferentiated cells, fibroblasts, endothelial cells, neurons and glial cells,
erythrocytes and cells of the Immune System), vessels and intercellular
substances, with specific characteristics such as being contained in the pulp
cavity, surrounded by hard and inelastic dentin walls (Nor 2006, Demarco et
al. 2011, Dezan-Júnior & Bueno 2020). Therefore, when this pulp tissue
becomes inflamed, it cannot follow the normal physiological process of
expansion.
The pulp tissue is formed by peripheral layers of cells, divided into
odontoblastic layer, subodontoblastic region and central region of the pulp
(Sloan 2015). The odontoblastic layer is the outermost layer of the pulp,
located just below the pre-dentin and formed by odontoblasts arranged next to
each other, joined by gap junctions. Odontoblasts are long-living post-mitotic
cells, responsible for maintaining pre-dentin and dentin apposition throughout
the whole life of a tooth (Sasaki & Garant 1996, Arana-Chavez & Massa
2004), by emitting their extensions into the dentinal tubules, forming the
dentin-pulp complex. Anatomically, the pulp is divided into coronary and root
pulp, corresponding to the anatomical crown and root. If odontoblasts are
destroyed by severe external stimuli such as deep caries, the differentiation of
dental pulp stem cells into odontoblast-like cells is induced (Kawashima &
Okiji 2016).
The subodontoblastic region is divided into two subregions, one being
poor in cells and the other rich in cells. The cell-poor (also cell-free) zone has
fewer cells, mainly crossed by extensions of adjacent cells, blood vessels,
lymphatics and nerve fibers. On the other hand, the cell-rich region shows
undifferentiated cells that emit their extensions through acellular zone (Sloan
Biomaterials Used in the Conservative Treatment of Pulp Tissue 163
2015). The central region of the pulp is formed by loose connective tissue,
with fusiform fibroblasts, found in different stages of activity and
undifferentiated cells.
Regarding the pulp-dentin innervation and vascular system, fibers derived
from the trigeminal nerve penetrate through the apical foramen entering the
pulp chamber and anastomosis in the acellular region, forming a nervous
plexus. Vascular supply follows the same path as innervation, derived from
superior and inferior alveolar arteries rich in oxygen, while veins cross the root
canal longitudinally, collecting collateral branches from the root pulp. With
age, the number of blood and lymph vessels, as well as neurons decrease, and
the loose pulp tissue becomes stiffer due to collagen deposition (Bjorndal &
Mjor 2001, Baker et al. 2019).
According to the American Association of Endodontists, vital pulp
therapy techniques are means of preserving the vitality and function of the
dental pulp after injury resulting from trauma, caries, or restorative
procedures. These procedures traditionally encompass indirect or direct pulp
capping, and partial or complete pulpotomy (AAE, 2020).
It’s important to remind that it is not possible to dissociate dentin from
pulp because inside dentinal tubules are odontoblastic extensions. Therefore,
the conservative treatment of dental pulp begins with dentin preparation: when
cutting dentin with a drill, odontoblastic extensions are automatically being
cut and the removal of caries or cavity preparation with a drill with deficient
cut or low/absent refrigeration will generate an inflammatory process in the
pulp.
The comprehension of pulp tissue cells and formation of pulp-dentin
complex is necessary to better understand dental materials behavior from a
biological point of view and the importance of dental materials’ evolution in
vital pulp therapy through the years.
2. Conservative Approaches of Pulp Tissue
To successfully perform endodontic treatment, scientific evidence based on

clinical and laboratory research should be considered, along with a correct
diagnosis.
Conservative approaches to pulp tissue are procedures performed aiming
vitality and function preservation of dental pulp after lesions that may interfere
with root formation (apicigenesis) in immature teeth (Li et al. 2019).
Maintenance of a compromised newly erupted permanent tooth with a poor
long-term prognosis can be favorable for the integrity of the dental arch and
for normal alveolar development and occlusion during the period of
dentofacial growth (Winters et al. 2013).
Once a permanent tooth erupts, roots take up to 3 years to complete their
formation. During this period, the roots are short, with open apex and
relatively thin dentin with wide dentinal tubules, increasing permeability to
bacteria. The open apex is associated with large pulp vascularization and high
healing potential (Nuni 2016).
However, few factors are highlighted that may affect the prognosis of
conservative pulp therapy, such as the presence of a blood clot between the
pulp tissue and capping material (Schroder 1973); the degree of bleeding
generated by inflammation (Matsuo et al. 1996); operator dexterity (Hilton
2009); time elapsed between pulp capping and permanent restoration (Mente
et al. 2014); and bacteriological contamination from saliva, residual caries or
coronary infiltration (Fouad et al. 2011).
To establish the better approach, a correct diagnosis of pulp tissue
condition must be performed, after careful clinical examination, anamnesis
and complementary exams, such as periapical radiographs (Chen 2009).
2.1. Vital Pulp Status and Diagnosis
The American Association of Endodontics (AAE, 2020) classifies vital pulp

tissue into one of three categories: normal pulp, reversible pulpitis, or
irreversible pulpitis. Pulpitis can be interpreted as a temporally and spatially
graded disease, such as “initial”, “mild”, “moderate”, or “severe pulpitis”
(Wolters et al. 2017, Ricucci et al. 2019, Rechenberg & Zehnder 2020).
The pulp sensitivity test to cold is clinically used to evaluate the sensory
response of the pulp to a thermal stimulus, since teeth with pulpitis present an
exacerbated response to cold stimulus. Usually, mild, short-lived pain is
characteristic of reversible pulpitis, while severe pain that persists is indicative
of irreversible pulpitis. When there is no sensitivity, the pulp tissue: 1) may be
necrotic; 2) is not cold sensitive (normally observed in aged pulp); 3) the tooth
has already undergone endodontic treatment (Abbott & Yu 2007).
In addition to the cold sensitivity test, vertical percussion test may indicate
the presence of apical periodontitis related to pulp tissue (Owatz et al. 2007),
as observed in cases of caries or excess restorative material that generates a
point of premature contact.
The radiographic examination makes it possible to assess the extent of

root formation and the conditions of the adjacent tissues (McDonald et al.
2011). Interproximal radiographs are necessary to better assess the proximity
of caries to the pulp, the morphology of pulp chamber, the integrity and depth
of restorations and the level of alveolar bone. This also allows the
identification of calcified tissue in the pulp chamber, indicating the formation
of tertiary dentin by a vital pulp in response to a stimulus.
Likewise, direct clinical observation of the pulp before and after
hemostasis, preferably under a surgical microscope, provides information that
aids the diagnosis and extent of pulp degeneration (Bogen et al. 2021).
A few characteristics such be observed to diagnostic pulp condition: the
dentin around the pulp exposure, red coloration of pulp tissue, pulp
consistency and bright red bleeding, with no yellowish liquefied areas or dark
areas and hemostasis achieved within 2-3 minutes after irrigation, indicates a
pulp tissue with a better chance to repair with a conservative technique
(Ricucci et al. 2019).
On the other hand, dark coloration of the pulp cavity and exposed pulp
tissue in the absence of bleeding, is indicative of necrosis, as is a pale
yellowish hue, which is indicative of the absence of blood circulation. These
characteristics may contraindicate a conservative approach (Ricucci et al.
2019).
When facing a deep cavity during carious removal, there are two
approaches to consider:
1) Removal of extensive carious lesions can result in pulp exposure.

However, maintaining decayed dentin over the pulp is analogous to
leaving bacteria or allowing surgical wound infection (Turtiainen et
al. 2014), which can sustain inflammation and lead to pulp necrosis.
Following this philosophy, there is the fact that, although carious
process is expected to stop if bacterial access to fermentable sugars in
the diet is impeded, anaerobic assaccharolytic bacteria (does not
utilize glucose or any other carbohydrates) in deeper zones of the
affected dentin can obtain nutrients in the form of proteins and
glycoproteins from demineralized dentin collagen and pulpal fluid in
dentinal tubules. In addition, partial caries removal prevents the
possibility of clinical evaluation of carious process extension and
visualization of pulp condition (Rôças et al. 2015, Rôças et al. 2016,
Ricucci et al. 2020). To sustain this philosophy, Ricucci et al. (2020)
presented a histological and histobacterial human study. Authors
assessed twelve vital teeth with deep occlusal caries (schedule for
extraction) and treated with “selective caries removal” and restored.
After extraction, authors observed under microscope that remnant
bacteria in the dentine evokes subclinical inflammatory process in
pulp tissue and the presence of potentially-arrested caries does not
mean that bacterial infection is under control. Thus, if pulp is exposed
during carious removal, a direct technique is indicated;
2) From another point of view, mainly in pediatric patients, the complete
removal of carious structure (infected and affected dentin layers)
involves significant loss of tooth structure and pulp tissue may be
exposed (Hernández & Marshall 2014). In these cases, authors state
that there is growing evidence to support incomplete removal of
carious tissue prior to cavity restoration: after the cavity is fully sealed
with the restoration, progression of the lesion is stopped and
deposition of tertiary dentin in promoted (Kidd 2014, Magnusson &
Sundell 1977). According to this philosophy, this technique is
possible because the inner layer or affected dentin is only partially
demineralized and prone to undergo remineralization (Massara et al.
2002), since the apatite crystals are still bound to collagen fibers with
cross-bands similar to those of normal dentin. This layer, therefore,
must be kept on the floor of the cavity to avoid exposing the pulp
tissue (Fusayama 1979). Thus, when pulp is not exposed in deep
cavity, an indirect technique is indicated.
It’s also important to state that, regardless the chosen technique, it’s
paramount to completely remove carious tissue from the cavity walls to obtain
an optimal seal between tooth and restorative material, preventing
microleakage (American Academy of Pediatric Dentistry 2017).
Therefore, based on pulp condition and cavity depth, the conservative
therapy can be divided into two main categories: 1) indirect technique
(indirect pulp capping); and 2) direct techniques (direct pulp capping, partial
or total pulpotomy). Although these techniques were discussed in chapters 4
and 5, a brief review will be presented as a link between biology, techniques
and biomaterials.
2.2. Indirect Pulp Capping
The term indirect capping refers to a technique where stimulating dental

materials are applied over dentin, with no contact with pulp tissue, inducing
this vital tissue to protect itself by creating a hard tissue barrier.
During the removal of a carious tissue, when the cavity is considered deep
(more than two thirds of the thickness of the compromised dentin), but still
without exposing the normal or reversibly inflamed pulp tissue, the indirect
pulp capping is indicated (Kidd 2004).
Underlying deep carious lesions, the pulp has a chronic inflammatory
exudate, including lymphocytes, macrophages, and plasma cells (Bjørndal &
Mjör 2001). Despite extensive pulp inflammation from deep caries, a
conservative approach can still lead to a favorable prognosis of pulp repair.
Therefore, authors state that indirect pulp capping consists, under absolute
isolation, by placing a cotton ball soaked in a corticosteroid-antibiotic solution
(such as Otosporin® or Maxitrol®) in the cavity for 5 minutes. The topic anti-
inflammatory effect of Otosporin in pulp tissue has been demonstrated by
Benetti et al. (2018). After drying the cavity with a dry cotton ball, a thin layer
of calcium hydroxide cement (such as Hydro C® or Dycal®), is placed on the
floor of the cavity, followed by lining with glass ionomer cement and
composite resin for restoration (Duque et al. 2009, Dezan-Júnior & Bueno
2020). The use of glass ionomer cement is suggested due to its in vitro
inhibitory effects on the growth of cariogenic bacteria (Duque et al. 2005),
besides better mechanical and physical properties when bonding to dentin
(Mathis & Ferrance 1989). A complete description of indirect capping with
other techniques is discussed in chapter 5.
2.3. Direct Pulp Capping
In a different scenario, if pulp is exposed during the removal of the carious

tissue, the direct pulp capping is indicated. For several times, when cavity is
deep but still without exposing pulp, clinician confirms complete removal of
carious tissue by curetting the cavity walls to verify presence of soft dentin (an
infected dentin characteristic). In this moment, an accidental pulp exposure
may occur. It is important to note that the pulp was not exposed by caries, as
it was still protected by dentin. The cause of exposure can be via trauma or
iatrogenic damage.
Direct pulp capping involves stopping any pulp bleeding followed by

placing a biocompatible and biomineralization-inductor material directly over
an exposed vital pulp to preserve its health, function, viability and induce the
formation of a protective hard tissue barrier (Bogen et al. 2008).
Another point to be considered when performing direct pulp capping is
the surrounding dentin, which has to be healthy and the exposed pulp does not
show suggestive signs of infection. If these criteria are not met, progressively
more invasive procedures are indicated, until the clinical appearance indicates
the absence of infection in dentin and pulp wound (Ricucci et al. 2019).
In the direct pulp capping technique, under absolute isolation, irrigation
with saline, limewater, chlorhexidine or sodium hypochlorite should be
performed to achieve homeostasis (Bogen et al. 2008, AAE, 2020). Then, a
cotton pellet soaked in a corticosteroid-antibiotic solution (such as Maxitrol®
or Otosporin®) may be placed on the exposure for 5 min. The use of
corticosteroids can control the sudden increase in internal pressure (Van
Hassel 1973, Holland et al. 1978), besides the topic anti-inflammatory effect
on pulp tissue (Benetti et al. 2018). Then the cavity is dried with cotton pellets
and calcium hydroxide [Ca(OH)2] in the form of powder is placed directly on
the exposed pulp, followed by calcium hydroxide cement (such as Hydro C®
or Dycal®) covering the Ca(OH)2 powder (at this moment, the hygroscopic
property of the powder should absorb the blood moisture). On top of this
calcium hydroxide cement, the cavity is filled with glass ionomer cement and
definitive restoration is performed.
The calcium hydroxide has been used for many years as a gold standard
capping material. In addition to calcium hydroxide, other materials have been
used with the purpose of inducing deposition of mineralized tissue, as the
mineral trioxide aggregate (MTA) and other calcium silicate cements, which
is further discussed. A complete description of direct pulp capping is also
discussed in chapter 5.
2.4. Pulpotomy
The pulpotomy technique may be divided into: 1) partial pulpotomy (or pulp
curettage) as treatment option for teeth diagnosed with reversible pulpitis that
had pulp exposed during carious removal or change of restoration (Fuks, 2008,
Barrieshi-Nusair & Qudeimat 2006). It is recommended to remove the
compromised part of the pulp tissue that was exposed, with a very sharp
curette, keeping a large part of the coronal pulp in the pulp chamber, followed
by capping the remaining pulp with a biocompatible and inductor of hard

tissue deposition, as previously mentioned in direct pulp capping; 2) In total
pulpotomy, the entire coronary pulp is removed with the aid of a sharp curette.
To indicate a total pulpotomy, the pulp must show signs of health, as
aforementioned. There must be bleeding, with bright red blood, the pulp must
show some “resistance” to the cut with the curette and the surface of the pulp
remnant must be pinkish-red. If there is a very clear or very dark liquid, instead
of blood and the pulp has a liquefied consistency (with no resistance to the
cut), it is indicative of pulp alterations and pulpotomy is contraindicated.
Once pulp health has been confirmed, a layer of a biocompatible material
(approximately 1 mm thick) with biomineralization ability such as calcium
hydroxide powder or calcium silicate cements should be placed over the pulp
remnant, followed by a thin layer of calcium hydroxide cement (such as Dycal
or Hydro C, only over the biomaterial) and glass ionomer cement. The
indications and techniques of pulpotomy are addressed in chapter 6.
3. Dental Materials and Techniques Used in Conservative

Treatment of Pulp Tissue: A Brief Historic Overview
In vital pulp therapy, the first pulp capping treatment was documented in 1756
by Pffaf, who used gold leaf (Dammaschke 2008). Several materials have been
used over the years for direct pulp capping, indirect pulp capping and
pulpotomy procedures, ranging from formaldehyde-based materials,
glutaraldehyde, electrosurgery, zinc oxide eugenol paste, ferric sulfate and
glass ionomer until biomaterials with biomineralization induction ability, such
as calcium hydroxide, mineral trioxide aggregate, biodentine and others
calcium silicate cements. Historically, the first material of choice in
conservative treatment was formocresol.
3.1. Formocresol
In the early 1900s, formocresol began to be introduced in non-vital tooth

treatments through Buckley’s formulation (Buckley 1904), composed of a
solution of 35% cresol and 19% formaldehyde, plus 15% of the vehicle
glycerin and water (Smaïl-Faugeron et al. 2018). In 1930, formocresol was
indicated for the first time for pulpotomy (Sweet 1930), aiming to mummify
the pulp tissue through the production of an area of necrosis and a reduced
effect towards root apical area (Peng et al. 2007). Therefore, the root pulp
would theoretically be sterilized and devitalized, avoiding possible infection
and internal resorption (Ranly 1994).
The technique proposed by Buckley recommended the application of the
chemical compound in five visits. Later, Sweet reduced this number to three
visits (Sweet 1955) and from 1960 onwards the procedures were performed in
a single session (Redig 1968). In 2004, the International Agency for Research
on Cancer of the World Health Organization (WHO) reclassified
formaldehyde as human carcinogen substance, due to its ability to cause
nasopharyngeal cancer. However, Smaïl-Faugeron et al. (2018) reported that
formocresol is still used in pulpotomies and that although a 1:5 or 1:25 dilution
of formocresol is recommended, many dentists use the conventional formula.
The technique traditionally used is the application of a cotton pellet soaked in
formocresol on the pulp remnants for 5 min after pulpotomy. Subsequently, a
thick paste of zinc oxide-eugenol (OZE) is prepared and placed on the pulp
stumps, after which the tooth is restored.
In 1962, Doyle compared pulp capping with calcium hydroxide and
capping with formocresol in human teeth, and observed that formocresol was
clinically successful for at least 18 months’ post-treatment. Despite this fact,
the drug did not stimulate healing of the remaining pulp tissue, only its
fixation. Unlike Calcium Hydroxide, which in 50% of the cases histologically
analyzed, it was possible to observe a hard tissue bridge and complete healing
of the pulp (Doyle et al. 1962). Furthermore, posterior histological data
demonstrated that application of Formocresol developed zones of necrosis,
fixation and inflammation and regular healing was not observed with this drug
(Salako et al. 2003).
3.2. Glutaraldehyde
Years later, Dankert et al. (1976) described a few advantages of

Glutaraldehyde over Formocresol, such as better fixative properties, low
antigenicity and toxicity, in addition to being less penetrating, therefore, less
aggressive to living tissues (Waterhouse 1995, Dankert 1976). Similar results
were described by Fuks et al. (1986), in which glutaraldehyde was 94.3%
successful over 6 months, but reduced to 82% after 25 months. However, some
radiographic flaws were detected, such as loss of lamina dura, periapical and
furcation radiolucent areas, in addition to the presence of internal resorption

in both groups (Shumayrikh & Adenubi 1999).
3.3. Electrosurgery
Another alternative used as a substitute for formocresol was electrosurgery.

Electrocautery carbonizes and denatures the pulp, eliminating bacterial
contamination (Ranly 1994) and producing a layer of coagulative necrosis that
acts as a barrier between the capping material and healthy root tissue
(Srinivasan et al. 2006). Dean et al. (2002) performed a clinical study in
pediatric patients, and observed clinical and radiographic success rates of 96
and 84%, respectively, for the electrosurgical group and 100 and 92%,
respectively, for the formocresol group.
3.4. Zinc Oxide Eugenol (ZOE)
With a biological point of view, the first material used to preserve the dental
pulp in conservative treatments described in the literature was zinc oxide
eugenol paste (Ranly 1994). The first scientific clinical study to compare
different capping materials was made by Dätwyler in 1921, where ZOE
showed positive results (Dammaschek 2008).
In a posterior human clinical study using ZOE as a direct pulp capping
agent, the results were not favorable. All ZOE-capped teeth showed chronic
inflammation, no pulp healing, and no dentinal bridge formation at follow-up
visits (Glass & Zander 1949). Also, the direct contact with the dental pulp was
noted to cause inflammatory responses and internal resorption (Magnusson et
al. 1971).
3.5. Ferric Sulfate
Later, Lendau & Johnsen (1988) introduced ferric sulfate, a hemostatic agent,
in conversational treatments. The authors conduct an animal study to
investigate its use prior to placement of calcium hydroxide. Ferric sulfate, in
direct contact with the blood, originates an iron ion-protein complex that
mechanically seals the cut vessels, producing its hemostatic effect, preventing
the formation of blood clots (Srinivasan et al. 2006).
According to Junqueira et al. (2018) ferric sulfate has satisfactory

characteristics for pulpotomy technique, once it has demonstrated clinical
success of 100% in the periods of 3, 6, 12 and 18 months, and radiographic
success of 100% for the periods of 3,6 and 12 months, which reduced to 85.7%
for the 18-month period, with similar results found by Yildiz & Tosun (2014)
when comparing capping materials, in which ferric sulfate had a clinical
success rate of 100% and 95.2%, for a period of 12 months and 30 months,
respectively. Despite not showing exacerbated inflammation in histological
analyses, ferric sulfate did not form a hard tissue bridge, unlike further
explored biomaterials (Junqueira et al. 2018).
From data collected in the literature, it is possible to state that ferric sulfate
and formocresol present similar results (Loh et al. 2004; Srinivasan et al. 2006;
Peng et al. 2007), although the use of ferric sulfate is preferable, due to the
deleterious effects of formocresol (Peng et al. 2007).
3.6. Glass Ionomer
Although not as cytotoxic as ZOE, its use in direct contact with pulp tissue
cells is not recommended (Schmalz et al. 1996; Koulaouzidou et al. 2004).
However, indirect use is indicated as it chemically bonds to the tooth structure
providing an excellent seal (de Souza Costa et al. 2003).
According to Mathur et al. (2016), indirect pulp capping with glass
ionomer showed elevated success rate, with 96.85% and a dentin barrier
formation, similar to calcium hydroxide and MTA, in children (7-12 years).
Corroborating those data, Hashem et al. (2019) showed a clinically
positive result with glass ionomer used for indirect pulp capping in reversible
pulpitis, comparable with a calcium silicate cement.
Regarding direct pulp capping, the concept of mummification or pulp
denaturation began to be replaced by materials biologically accepted by the
body and capable of reducing inflammation and favoring repair.
Among materials with the ability to induce biomineralization (hard tissue
deposition), the first to be described in the literature was calcium hydroxide.
3.7. Calcium Hydroxide
In 1920, Hermann introduced Calxyl for the treatment of dental pulp, a product
based on calcium hydroxide [Ca(OH)2] (Hermann 1920). In an aqueous
solution, it has the ability to dissociate its components into calcium and
hydroxyl ions. Hydroxyl ions are free radicals that react with biomolecules
and are related to the antimicrobial activity of [Ca(OH)2] (Freeman & Crapo
1982, Bueno et al. 2016), causing damage to the cytoplasmic membrane,
protein denaturation, and bacterial DNA (Siqueira & Lopes 1999). On the
other hand, Ca2+ ions react with the carbon dioxide present in the tissue,
forming calcite crystals, promoting the deposition of hard tissue (Bueno et al.
2016, Silva et al. 2019).
More detailed, calcium hydroxide produces a superficial pulp necrosis and
forms calcium carbonate, whose globules act, in a first moment, as dystrophic
calcification nucleus, in the margin and in the interior of the dense reticular
fiber deposition, immediately beneath the granular zone, where odontoblast-
like cells differentiate and organize to produce dentin. Thus, the cauterization
effect of calcium hydroxide in contact with the pulp tissue is essential for the
repair of exposed pulp (Pereira et al. 1980)
When the pulp tissue is inflamed, there is an increase in internal pressure.
The fact that the dental pulp is surrounded by hard tissue aggravates the
increase in this pressure, due to the impossibility of expanding. Van Hassel
(1971) showed that the use of corticosteroids can control the sudden increase
in internal pressure. A fact confirmed by Holland et al. (1978) after performing
pulpotomy in dogs and finding that the best results were obtained when
Otosporin® was applied for 48 hours before the final application with
[Ca(OH)2], showing a 90% success rate, one of the reasons for performing
pulpotomy in two sessions.
Despite its mineralizing potential, studies point some flaws with the use
of calcium hydroxide, such as: presence of fistula, abscess, external and
internal resorption (Moretti et al. 2008; AAPD 2012-2013; Silva et al. 2019).
The presence of a blood clot between the pulp and [Ca(OH)2] is one of the
explanations for the frequent presence of internal resorptions (Alaçam et al.
2009), in addition to the possibility that the dentin bridge formed is defective.
In addition, calcium hydroxide destroys a thin layer of underlying pulp tissue,
forming a necrotic layer (Estrela & Holland 2003).
Long-term clinical research has revealed decreased success rates of
calcium hydroxide over the course of follow-up visits, as one of the
disadvantages of calcium hydroxide is its high solubility and therefore it is
subject to dissolve over time (Ozório et al. 2012, Moretti et al. 2008).
For a long time, calcium hydroxide was considered the gold standard for
vital pulp therapy, but with the emergence of other materials with superior
properties this standard has changed.
4. Biomaterials
Biomaterials are conceptualized as natural or synthetic materials used in

contact with biological systems with the aim of repairing or replacing hard/soft
tissues, capable of interacting with a living organism, maintaining or
improving the quality of life. The material to be used on the pulp tissue must
be able to provide a hermetic seal, should be antibacterial, non-cytotoxic and
promote pulp healing (Sonmez et al. 2008). The term biomaterial was
previously defined as “a nonviable material used in a medical device, intended
to interact with biological systems” (Williams 1987).
Hench and Thompson (2010) divided biomaterials in three generations:
the first generation was based in prosthesis developed for usage inside the
human body and corresponds to biologically inert (or nearly inert) materials,
aiming the absence of foreign body reaction (such as stainless steel,
alumina/zirconia and polymers); the second generation showed addition of
bioactive and biodegradable properties to biomaterials, leading biomaterials
to interact with biological-living system; the third generation is characterized
by cellular responses stimulation, as temporary three-dimensional porous
structures (such as macro-porous foams) which are able to activate genes that
stimulate regeneration of living tissue, due to both bioactive and
biodegradability properties combined (Hench & Polak 2002, Hench &
Thompson 2010). Also, biomaterials can be classified according to its origin,
as: (1) biological: autogenous (from the patient); allogeneic (from a donor) or
xenogens (from animal); (2) synthetic or alloplastic (metals, ceramics and
polymers), or (3) via the induced response to the living host (inert,
bioabsorbable and bioactive) (Guastaldi & Aparecida 2010).
4.1. Biomaterials in Dentistry
According to historical data, ancient usage of alloplastic material in dentistry

dates back to 600 A.C. when seashell fragments replaced three lost incisors in
a mandibular human fossil, found in 1931 (Ring 1998).
With the introduction of titanium dental implants and properties such as
bio-inert and osseo-integration, biomaterials gained attention (Branemark et
al. 1969). Focus also turned on Bioglass, developed in 1969 by Larry Hench
in University of Florida/USA: glass components mixed with ceramic would
form a compound characterized by the ability to induce rapid and durable
chemical bonding, easily integrated into human bone tissue (Hench 2006,
Hench 2013).
4.2. Biomaterials Used in the Conservative Treatment of Pulp Tissue
The tooth, as a mineralized tissue, may be affected by trauma, caries or genetic

defects, repaired by dentistry (Sinhoreti et al. 2013). This need to replace
damaged parts of human body led to search for new biomaterials (Baino et al.
2018). While some dental materials have only a reconstructive function
(Vallittu et al. 2018), others show bioactivity property, inducing specific and
intentionally hard tissue deposition (Chen et al. 2013), posteriorly named
biomineralization (Bueno et al. 2019).
4.2.1. Mineral Trioxide Aggregate (MTA)

In the search for more biocompatible mineralizing materials, Lee et al. (1993)
described for the first time the mineral trioxide aggregate (MTA), with the
purpose of repairing lateral perforations (Lee et al. 1993). Without knowing
the promising future applications of this new hydraulic calcium silicate
material, this was the first use of the posteriorly named bioceramic cement.
The biocompatibility and bioactivity of MTA starts with an exothermic
setting reaction. Hydration of mineral oxide compounds (di and tri-calcium
silicate) produces calcium silicate hydrate (CSH) and calcium hydroxide
[Ca(OH)2] which, after dissociation, continuously releases Ca2+ ions providing
a high alkalinity and inducing the formation of mineralized tissue (Camilleri
2008, Bueno et al. 2019). Ions Ca2+, arising from MTA dissociation, interact
with P ions in body fluids, resulting in the formation of calcium phosphate
crystal structures on the interfacial surfaces of materials, which is an
amorphous form of calcium phosphate and/or apatite carbonate (Gandolfi et
al. 2010).
With respect to conservative treatment of pulp tissue, due to its biological
effects when in contact with living tissue, MTA is indicated in direct pulp
capping and pulpotomy. Some authors even consider MTA-like cements as a
gold standard material for direct pulp capping and pulpotomy (Mente et al.
2014, Yildirim et al. 2016, Musale & Soni 2016).
When MTA was used in direct pulp capping in animal teeth, results
showed that this material induced tissue repair, being superior compared to
calcium hydroxide cements, since there was less inflammation and greater
induction of hard tissue bridge (Briso et al. 2006).
More recently, Daniele (2017) published a 10-years follow-up period of

80 teeth that undergone direct pulp capping with MTA, with 92.5% of success
in reversible pulpitis. Xu et al. (2021) showed results of direct pulp capping
with MTA in infected pulp tissue. Authors observed active cell proliferation
in 1 week after pulp capping and differentiation of odontoblast-like cells after
2 weeks, a result not observed with calcium hydroxide, highlighting the use of
MTA for direct pulp capping in uninfected or even infected pulp tissue.
Noor et al. (2021) also reported the MTA as a choice material for direct
pulp capping. In this research, authors assessed 60 molars pulp exposure,
directly capped with MTA and evidenced 90% of success. In agreement with
previous authors, Noor et al. stated that MTA is a better choice for direct pulp
capping, with a usually good prognosis. A previous electronic research
conducted by Musale et al. (2018) in the main scientific databases reported
MTA as the choice material for pulpotomy in primary molars.
4.2.2. Biodentine
Biodentine® (Septodont, Saint-Maur-des-Fosses, FR) was developed in 2008
as a new class of material for use as a direct and indirect pulp capping agent
in a single application as a restorative material and at the same time without
prior conditioning of the dentin, presenting a concept of “dentin substitute”. It
is a calcium silicate-based material, with inorganic and non-metallic
components of tricalcium silicate, calcium carbonate, zirconia oxide
(Ca3SiO5, CaCO3, ZrO2) and a water-based liquid containing calcium
chloride as a setting accelerator and water reducing agent, to improve material
handling and consequently working time (Laurent et al. 2008).
The setting reaction of Biodentine® is similar to that of MTA, with the
formation of calcium silicate hydrate (C–S–H) and calcium hydroxide.
Biodentine® has been reported to have similar efficacy to MTA in direct
capping over molar pulps that have been mechanically exposed (Nikfarjam et
al. 2016).
The repair potential of Biodentine® may be observed in the clinical
manuscript published by Borkar & Ataide (2015). Authors reported four cases
of pulpotomy due to trauma using Biodentine® several days after pulp
exposure: at each recall of 24 hours, 1 week, 1,3,6,12 and 18 months, no
spontaneous pain was observed and pulp showed signs of vitality. Also, no
signs periapical radiolucency was noted. By the end of the cases report,
authors indicate Biodentine® pulpotomy as treatment option in cases of vital
pulp exposure in permanent dentition. A clinical and radiographic study with
a 24-months of follow-up indicated that both MTA and Biodentine® are
appropriate choices for pulpotomy treatment of mandibular primary molars

with pulp exposure due to caries (Celik et al. 2018).
Haikal et al. (2020) also evaluated Biodentin® after pulpotomy on
permanent traumatized teeth with complicated crown fractures. The treatment
outcome was assessed clinically and radiographically at 1 week and 1, 3, 6,
12, 18, and 24 months after treatment. Fifty-one teeth were treated with a
Biodentine® pulpotomy. The study showed a survival rate of 100% and a
success rate of 91%. Radiographic outcomes showed dentinal bridge
formation in 91% of cases, and all immature teeth showed continued root
formation, leading authors to state that Biodentine® is a suitable repair cement
for pulpotomies on anterior permanent teeth with complicated crown fractures,
and may be used as alternative to MTA.
A recent in vivo study conducted by Iyer et al. (2021) compared different
pulp capping materials in 90 vital permanent teeth with Class I deep carious
lesions. Clinical and radiographic follow-ups were analyzed after 1,3 and 6
months. Based off the results, authors concluded that Biodentine® has similar
success rates when compared to MTA and TheraCal LC, a light-cured resin
modified calcium silicate filler.
Another research regarding pulp capping with MTA and Biodentine
analyzed mineralized barrier formation and inflammatory profile. The
research was conduct in 80 Wistar rats in which Biodentine and MTA
presented satisfactory results, showing a milder inflammatory response and
more pronounced formation of mineralized barrier compared to teeth capped
with gutta-percha, evidencing that Biodentine has favorable biological
properties in vital pulp therapy, similar to MTA. However, it’s important to
state that authors highlighted the poor sealing ability of Biodentine, as
microleakage was prevented in less than 40% of samples, therefore not
effective in protecting dental pulp and should not be recommended as the only
temporary restorative material over the exposure (Sousa Reis et al. 2021).
4.2.3. MTA-Like Cements (Calcium Silicate Cements)

From this point, repair cements derived from the early MTA cement. Several
researches were conducted in order to improve the drawbacks of MTA, such
as handling, deliver methods and tooth discoloration.
MTA Repair HP (Angelus, Londrina, Paraná, Brazil) was developed to
overcome the handling problem of conventional MTA. Its powder has a
chemical composition similar to conventional MTA, with calcium tungstate
radiopacifier, but it incorporates polyvinylpyrrolidone (as a plasticizer), added
to the distilled water used for material hydration, to enable better handling.
MTA Repair HP has adequate physicochemical and biological properties with

improved fluidity, in comparison with conventional MTA (Ferreira et al.
2019).
To test pulp capping biocompatibility, Tomás-Catalá et al. (2018)
evaluated on Human Dental Pulp Stem Cells (hDPSCs) the effects of MTA
Repair HP, NeoMTA Plus and Biodentine. According to authors, all tested
pulp-capping materials showed suitable degree of cytocompatibility with
hDPSCs and good cell migration rates.
Regardless of the improvements, neither conventional MTA nor MTA
Repair HP are considered ideal for pulp capping, because of their handling and
interface interaction with restorative materials (hydraulic nature) besides their
setting time, which must be extended during clinical procedures (Islam et al.
2006, Yoshihara et al. 2020).
In order to offer optimal characteristics as pulp capping material, Bio-C
Pulpo (Angelus, Londrina, Paraná, Brazil) has been developed, even allowing
a restorative procedure in the same session. The composition of its powder
includes additives such as calcium hydroxide and silicon dioxide with
zirconium oxide as a radiopacifier. Moreover, liquid additives, such as
plasticizing material, calcium chloride and methylparaben are added to the
mixing water (Koutroulis et al. 2019).
Considering these new repair hydraulic cements with different features,
Pelepenko et al. (2021) evaluated physicochemical, biological, and
antimicrobial properties of Bio-C Pulpo and compared it with MTA Repair
HP and conventional MTA.
Bio-C Pulpo did not form calcium hydroxide after hydration and
demonstrated cytotoxicity. Authors stated that composition additives used in
Bio-C Pulpo modified its properties and both the absence of calcium
hydroxide deposition after hydration, and the cytotoxicity of this material are
of particular concern, therefore its indication as pulp capping material must be
better investigated before clinical use.
In contrast, previous data found by Cosme-Silva et al. (2019a) showed
biocompatible results for Bio-C Pulpo in subcutaneous tissue of Wistar rats.
Also, authors found immunolabelling data of osteogenic markers of
osteocalcin, osteopontin and bone sialoprotein, similar to conventional MTA.
It’s also important to remind that a material used in a living organism, as
the human body, may suffer systemic influence. In 2019, Cosme-Silva et al.
investigated the effect of hypertension on tissue response and
biomineralization capacity of conventional MTA, MTA HP and Biodentine in
hypertensive rats and observed that hypertension was able to increase
inflammatory infiltrate and decrease biomineralization of the repair cements

(Cosme-Silva et al. 2019b). This should be taken in consideration when
treating hypertensive patients.
4.2.4. Bioactive Molecules

According to Nakashima & Akamine (2005), studies concerning pulp-dentin
complex regeneration are based on the three pillars for tissue engineering:
genesis (stem cells), induction (growth factors), and conduction (scaffold). So
far, in animal research, bioactive molecules such as BMP-7, TGF-β1, and
VEGF (responsible for angiogenesis and mineralization induction during
repair and regeneration of pulp–dentin complex) showed positive effects in
vital pulp therapy (both direct and indirect pulp capping), enhancing tertiary
dentin formation with less initial inflammatory response (Luiz de Oliveira da
Rosa et al. 2017).
To evaluate the effects of bioactive molecules in pulp tissue, a preliminary
in vivo study was conducted by Goldberg et al. (2001) using rat molars. In the
study, cavities were performed and pulp exposure was carried out by
application of pressure with the tip of a steel probe. Then, calcium hydroxide,
Bone Sialoprotein (BSP), Bone Morphogenetic Protein-7 (BMP-7) in different
concentrations and N-Acetyl Cysteine were tested. After 28 days, BSP was
the most efficient bioactive molecule, inducing homogeneous and well-
mineralized reparative dentin. BMP-7 induced reparative dentin in the coronal
part of the pulp, and generated the formation of a homogeneous mineralized
structure in the root canal. According to authors, both BSP and BMP-7 were
superior to calcium hydroxide in by displaying larger areas of mineralization.
The use of platelet-rich fibrin (PRF) as pulpotomy agent was described by
Keswani et al. (2014) in a clinical research in permanent molars with
incomplete root development. Authors used MTA as control group and PRF
as experimental group in a total of 70 molars. Clinical and radiographic
evaluation were performed after 6, 12 and 24 months. By the end of the
experimental period, no significant difference was observed, leading authors
to conclude that PRF could be used as a biological and economic alternative
to MTA in pulpotomy.
Similar results were posteriorly found by Kumar et al. (2016), using PRF,
MTA and calcium hydroxide as pulpotomy agents in permanent molars with
irreversible pulpitis. After 1 year of follow-up, no difference was reported
between the radiographic success rates.
Dou et al. (2020) assessed in vitro the effect of calcium hydroxide, MTA,
iRoot BP, platelet-rich fibrin (PRF) and concentrated growth factors (CGF) on
proliferation, viability, apoptosis and mineralization (alkaline phosphatase -

ALP) of human dental pulp cells (HDPCs). PRF and CGF induced higher cell
proliferation when compared to MTA, whereas MTA displayed the highest
ALP activity, suggesting PRF and CGF as potential pulp capping materials for
vital pulp treatment.
To overcome the disadvantage of the elevated cost for the application of
bioactive molecules, the use of an autologous scaffold has been postulated.
The plasma rich in growth factors (PRGF) is obtained by platelet activation
and fibrinogen polymerization and may be used as autologous scaffold, with
ability to stimulate collagen production, angiogenesis and cell differentiation,
and also anti-inflammatory and antibacterial effects (Anitua et al. 2012,
Brucoli et al. 2018).
Gaviño-Orduña et al. (2021) evaluate the area of dentin growth in rabbit
incisors after direct pulp capping with plasma rich in growth factors (PRGF)
compared with mineral trioxide aggregate (MTA). Authors reported that the
application of PRGF rich and even in poor fraction as a pulp capping material
stimulated more dentin formation than MTA.
Conclusion
Over the years, the conservative treatment of pulp tissue has evolved along
with the development of materials used in vital pulp therapy. It’s clear how
biological response gained more and more attention, with more accurate and
relevant methodologies to test every new material launched in the market. Of
course it wouldn’t be feasible to describe and discuss every material in
dentistry used for vital pulp treatment. Instead, we aimed to present a logical
link between biology, treatment techniques and material evolution, from
empirical materials to biologically tested ones. From materials that aimed
clinical silence to recent bioactive cements and bioactive molecules, with a
cellular stimulation and enhanced tissue response. It’s almost mandatory that
clinicians should keep up to date with scientific publications to offer the best
evidence-based dentistry to patients and always remember that, before treating
teeth, dentists are health professionals that treat patients.
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About the Editor
Dr. Francine Benetti Faria, DDS, MSc, PhD in Endodontics

Adjunct Professor Universidade Federal de Minas Gerais (UFMG),
School of Dentistry Belo Horizonte, MG 31270-901, Brazil
List of Contributors
Isabella Faria da Cunha Peixoto

Sylvia Cury Coste
Thiago César da Silva Lima
Juliana Vilela Bastos
Leticia Cabrera Capalbo
Renan Dal Fabbro
Leopoldo Cosme-Silva
Alexandre Henrique dos Reis-Prado
Gabriel Pereira Nunes
Mariana Viana Donato
Francine Benetti
Valéria Silveira Coelho
Joana Ramos-Jorge
Hebertt Gonzaga dos Santos Chaves
Isabella Figueiredo Assis Macedo
Barbara Figueiredo
Paulo Carvalho Tobias Duarte
Sabrina de Castro Oliveira
Lara Cancella de Arantes
Juliana Goto
Francine Benetti
Marina Tolomei Sandoval Cury
Ana Maria Veiga Vasques
Ana Cláudia Rodrigues Silva
Leopoldo Cosme-Silva
Index
A
antibiotic pastes, 138, 139 biomineralization, 146, 168, 169, 172,
anxiety, 53, 55, 56, 57, 58, 59, 60, 61, 175, 178, 182
64, 66, 68, 70, 71, 76, 78, 81, 82, 83 blood clot, 135, 138, 140, 148, 157,
apical closure, 50, 115, 118, 127, 132, 158, 159, 164, 171, 173, 187
142, 143, 144, 147 bone morphogenetic proteins, 2, 132
apical papilla, 20, 134, 135, 154 bone-like, 142, 149
B C
Basic Non-Pharmacological Behaviour calcium carbonate, 173, 176
Guidance Techniques, 64 calcium hydroxide, 44, 85, 91, 95, 97,
Behaviour Assessment, 62 98, 104, 108, 109, 112, 113, 122,
behaviour control, 54, 81 123, 124, 125, 128, 138, 151, 152,
behaviour guidance, vii, 53, 54, 56, 58, 154, 167, 168, 169, 170, 171, 172,
60, 62, 67, 68, 77, 78, 82 173, 175, 176, 178, 179, 181, 182,
behavioural guidance techniques, 53, 183, 184, 185, 186, 187, 188
55, 56, 63, 64, 76, 77 calcium hydroxide cement, 95, 167,
bioactive materials, 108, 111, 119, 150, 168, 169, 175
162 calcium silicate cement, 91, 95, 113,
bioactive molecules, 14, 30, 87, 136, 117, 119, 123, 168, 169, 172, 177
143, 146, 179, 180, 182, 183 capping material, 86, 96, 99, 104, 108,
bioceramic, 85, 96, 109, 114, 115, 117, 109, 113, 115, 124, 164, 168, 171,
120, 121, 175, 182 172, 178, 181
bioceramic materials, 85, 109, 115, 121 carious lesions, 23, 24, 30, 33, 35, 36,
biocompatibility, 37, 95, 109, 110, 121, 37, 43, 44, 51, 85, 87, 88, 89, 90, 92,
140, 145, 175, 178, 182, 183, 185, 93, 94, 95, 96, 97, 98, 99, 100, 118,
188 165, 167, 177, 185
Biodentin, 177 cell biology, 1
biomaterials, viii, ix, 43, 45, 47, 48, cell survival, 136, 138, 139
104, 121, 122, 137, 140, 145, 152, cementum-like, 142, 149
156, 161, 166, 169, 172, 174, 175, child behavior, 54, 55, 57, 78, 80
184, 187, 188 child temperament, 53, 60, 78, 82
194 Index
children, 41, 42, 45, 48, 49, 50, 53, 54, dentin permeability, 26, 29, 31, 87
55, 56, 57, 58, 59, 60, 61, 67, 68, 70, dentin-pulp complex, 18, 25, 28, 38, 86,
71, 72, 73, 74, 76, 77, 78, 79, 80, 81, 87, 95, 97, 99, 122, 133, 137, 162,
82, 83, 97, 100, 118, 123, 172, 182 184, 187
cognitive development, 53, 55, 56, 63 dentistry, 1, 19, 21, 37, 39, 41, 43, 47,
complexity of dental treatment, 59, 60 48, 49, 53, 77, 78, 79, 80, 85, 87, 89,
concentrated growth factors, 179 97, 103, 127, 129, 132, 151, 152,
connective tissue, ix, 1, 4, 7, 8, 14, 16, 156, 161, 174, 175, 180, 181, 185,
30, 86, 103, 128, 131, 135, 136, 142, 186, 187
143, 149, 162, 163 direct pulp capping, 44, 49, 50, 51, 95,
conservative pulp therapies, 45, 47, 48 97, 98, 100, 103, 108, 109, 110, 111,
conservative techniques, 88, 93 112, 114, 115, 122, 123, 124, 125,
conservative treatment, vii, viii, ix, xi, 161, 163, 166, 167, 168, 169, 171,
37, 41, 42, 43, 45, 46, 47, 55, 99, 172, 175, 176, 180, 181, 182, 183,
128, 161, 162, 163, 169, 171, 175, 184, 185, 186, 188
180, 183 Direct Pulp Capping Classification, 111
direct pulp protection, 104
D direct pulp therapies, 104
deep caries lesion, 86, 90, 91, 93, 94,

E
98, 99, 108, 116, 122
dental anxiety, 53, 56, 57, 60, 73, 78, economic alternative, 41, 47, 179
80, 81, 82, 83 embryogenesis, 2, 16, 132
dental caries, 17, 21, 23, 24, 25, 27, 29, endodontics, ix, 21, 32, 37, 38, 39, 40,
31, 35, 37, 38, 43, 49, 56, 73, 76, 86, 41, 42, 44, 48, 49, 51, 104, 117, 122,
87, 90, 97, 99, 105, 123, 124, 125, 128, 129, 130, 138, 144, 148, 150,
134, 181 161, 162, 164, 182, 183, 186, 188
dental environment, 54, 59, 61, 81 ethylenediaminetetraacetic acid, 138,
dental fear, 53, 55, 56, 58, 59, 60, 61, 151, 153
79, 80 exposed dental pulp, 38, 104
dental pulp, ix, 1, 2, 3, 4, 5, 6, 8, 9, 10, extracellular components, 8
11, 12, 15, 17, 18, 19, 20, 21, 22, 23,
24, 25, 26, 27, 29, 30, 31, 32, 33, 36, F
37, 38, 40, 42, 43, 45, 49, 50, 52, 86,
99, 100, 101, 103, 104, 106, 107, fibroblast, 2, 17, 131, 132, 156
108, 123, 125, 131, 134, 137, 148, fibroblast growth factor, 2, 131, 132,
151, 152, 154, 155, 156, 157, 158, 156
160, 162, 163, 171, 172, 173, 177, functions of the pulp, 12
180, 181, 182, 183, 184, 188
dental pulp capping, 104, 183 G
dental pulp diseases, 21 gradual caries removal, 91, 92
dental pulp exposure, 30, 104 growth factor, 2, 6, 30, 86, 87, 107,
dental pulp stem cells, 6, 12, 107, 134, 109, 112, 128, 130, 131, 132, 133,
152, 155, 156, 160, 162 134, 135, 136, 137, 139, 140, 144,
Dental tissue formation, 2
Index 195
147, 150, 152, 153, 155, 159, 160, 168, 169, 175, 180, 181, 182, 184,
179, 180, 181, 182, 183 185, 186, 187, 188
guided tissue regeneration, 128 minimally invasive maneuvers, 110
guidelines for parents, 55, 61 minimally invasive treatment, 46, 48,
88, 98
H MTA, 50, 96, 109, 111, 112, 113, 115,
116, 117, 118, 120, 122, 123, 125,
hard tissue barrier, 143, 167, 168 128, 140, 158, 168, 172, 175, 176,
human dental pulp stem cells, 6, 17, 18, 177, 178, 179, 180, 182, 183, 184,
132, 154, 178, 188 186, 188
hydraulic calcium silicate, 111, 120, MTA Repair HP, 177, 178, 188
122, 175, 186
Hydroxyapatite crystals, 86
N
hydroxyl, 108, 173
necrotic immature teeth, 127, 155
I
O
immature teeth, 47, 116, 118, 137, 138,
144, 148, 149, 150, 152, 159, 163, odontoblast, 3, 5, 6, 7, 13, 14, 17, 18,
177 30, 39, 40, 51, 87, 95, 107, 108, 111,
Immunocompetent Pulp Cells, 7 123, 125, 131, 132, 148, 149, 152,
incomplete apices, 104 162, 173, 176
incomplete root development, 127, 128, odontoblast-like cells, 7, 14, 30, 87,
149, 179, 185 107, 108, 111, 148, 149, 162, 173,
indirect pulp capping, 44, 50, 94, 95, 176
99, 101, 161, 166, 167, 169, 172, open apex, 141, 159, 164
176, 179, 184, 185 oral health, 42, 43, 48, 49, 50, 51, 59,
infected dentin, 89, 167 73, 80, 100, 153, 162
inflammation, ix, 7, 10, 11, 18, 20, 21, oral health problems, 43
22, 23, 25, 27, 28, 29, 30, 31, 33, 34,
35, 37, 40, 43, 46, 47, 49, 98, 99, P
100, 104, 105, 107, 108, 109, 111,
115, 116, 118, 119, 122, 123, 134, partial pulpotomy, 44, 98, 103, 110,
142, 164, 165, 167, 170, 171, 172, 114, 115, 116, 122, 123, 125, 168,
175 181
inflammatory cells, 6, 15, 31, 32, 107, patient, 32, 33, 34, 35, 36, 37, 46, 47,
109, 142 48, 53, 54, 55, 56, 57, 58, 60, 61, 62,
Influence of Parents, 57 63, 64, 65, 66, 67, 68, 69, 70, 71, 72,
irrigating solutions, 132, 138, 148 74, 75, 76, 77, 80, 90, 92, 93, 105,
128, 140, 141, 143, 147, 174, 186
pediatric dentistry, 53, 54, 55, 62, 70,
M
72, 77, 78, 79, 80, 81, 82, 85, 103,
mesenchymal stem cells, 5, 6, 19, 30, 166, 181
87, 108, 133, 152, 155, 159 pharmacological techniques, 53, 55, 68,
mineral trioxide aggregate, 96, 101, 76, 77
109, 121, 122, 123, 124, 125, 128,
196 Index
platelet-rich fibrin, 50, 136, 151, 152, R

157, 159, 179, 184, 185
platelet-rich plasma, 50, 109, 136, 155, regenerative endodontic procedure, ix,
159 50, 127, 129, 151, 152, 153, 154,
professional-patient relationship, 55 155
pulp biology, vii, 1, 45, 124, 148 regenerative endodontics, viii, 45, 50,
pulp capping material, 97, 98, 108, 110, 110, 127, 128, 129, 134, 135, 141,
123, 177, 178, 180 144, 146, 147, 148, 150, 151, 152,
pulp cells, 3, 5, 10, 86, 100, 106, 108, 155, 156, 157, 160
109, 124, 183 reparative responses, 44
pulp exposures, 88, 92, 104, 111, 112, revascularization, ix, 27, 50, 52, 128,
115, 118, 121, 185 129, 148, 150, 151, 152, 154, 155,
pulp innervation, 10, 31 156, 157, 158, 159
pulp necrosis, 21, 23, 25, 27, 35, 36, root development, 42, 45, 118, 127,
107, 115, 127, 141, 144, 153, 165, 135, 141, 142, 143, 144, 147, 157,
173 185
pulp physiology, 1, 12
pulp tissue, vii, viii, ix, xi, 5, 6, 7, 8, 9, S
16, 23, 25, 26, 31, 35, 36, 41, 43, 44, scaffold, 127, 130, 135, 136, 143, 150,
46, 47, 48, 55, 63, 95, 98, 104, 107, 151, 152, 157, 158, 179, 180
110, 111, 114, 115, 117, 119, 120, selective carious tissue removal, 92, 93,
122, 128, 131, 134, 135, 136, 143, 96, 100
149, 152, 155, 161, 162, 163, 164, selective removal of carious, 89, 92, 93,
165, 166, 167, 168, 169, 170, 172, 94, 95, 96, 104, 113, 116
173, 174, 175, 176, 179, 180 sodium hypochlorite, 112, 114, 117,
Pulp Vascular System, 8 120, 138, 168
pulp vitality, 33, 39, 42, 43, 44, 45, 48, stem cell, ix, 3, 6, 18, 19, 106, 111,
92, 93, 94, 95, 104, 105, 110, 112, 127, 128, 129, 130, 132, 133, 134,
118, 120, 161 135, 137, 139, 140, 141, 142, 143,
pulpal repair, 45 144, 145, 146, 147, 148, 150, 151,
pulp-dentin complex, ix, 1, 3, 16, 26, 152, 153, 154, 155, 156, 157, 158,
29, 43, 44, 45, 87, 106, 127, 128, 159, 160, 179, 187
129, 148, 155, 163, 179 stem cell behavior, 132, 133
pulp-like tissue, 143, 144
pulpotomy, 23, 35, 44, 45, 46, 48, 49,
T
50, 51, 101, 104, 108, 110, 114, 115,
116, 117, 118, 119, 121, 124, 125, tertiary dentin, ix, 14, 27, 29, 30, 37,
126, 161, 163, 168, 169, 170, 172, 38, 87, 89, 90, 91, 108, 109, 124,
173, 175, 176, 177, 179, 181, 182, 148, 165, 166, 179
183, 184, 185, 186, 187, 188 therapeutic use, 42
tissue engineering, ix, 45, 47, 48, 127,
128, 129, 130, 133, 134, 147, 150,
152, 155, 156, 158, 159, 179, 182,
186, 187
Index 197
tissue regeneration, 6, 44, 45, 128, 129, V

130, 132, 134, 135, 137, 142, 145,
147, 154, 158, 182 vascular endothelial growth factor, 131,
tissue repair, 31, 32, 87, 127, 129, 134, 132, 154
142, 143, 145, 153, 156, 175 vital pulp therapy, 41, 44, 45, 48, 49,
tissue response, 21, 95, 146, 178, 180 50, 51, 52, 98, 100, 101, 107, 110,
tissues, 1, 3, 7, 8, 9, 17, 19, 21, 22, 26, 115, 118, 121, 122, 124, 125, 163,
27, 28, 33, 36, 40, 71, 86, 89, 103, 169, 173, 177, 179, 180, 181, 182,
110, 132, 133, 134, 138, 139, 142, 183, 186
143, 149, 153, 158, 159, 161, 165,
170, 174 Y
tooth development, 2, 4, 7, 12, 20 young, vii, ix, 3, 7, 24, 41, 42, 43, 44,
total pulpotomy, 103, 110, 114, 117, 45, 48, 49, 50, 53, 54, 55, 56, 60, 62,
118, 119, 120, 166, 169 63, 64, 65, 67, 69, 73, 74, 76, 81, 82,
transforming growth factor, 87, 131, 83, 89, 93, 101, 104, 115, 118, 122,
132, 147, 151, 155 123, 128, 129, 137, 141, 144, 149,
traumatic injuries, 27, 107 154, 158, 186
treatment for deep caries, 88 young patients, vii, ix, 43, 45, 48, 53,
54, 56, 60, 62, 63, 64, 65, 67, 69, 76,
137, 141, 144, 149
young people, 41

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NOTICE TO THE READER

Library of Congress Cataloging-in-Publication Data

ISBN:  H%RRN

Published by Nova Science Publishers, Inc. † New York

Chapter 6 Treatment of Pulpal Exposures in Vital Teeth ...........103

I am grateful to everyone who contributed to the success of this book. I know

Pulp Biology – Structure and Function

Isabella Faria da Cunha Peixoto, Sylvia Cury Coste,

Keywords: dental pulp, pulp physiology, cell biology, tissues, dentistry.

In: Conservative Treatment of Pulp Tissue

Tooth development is initiated during embryogenesis and proceeds in multiple

together with the mantle dentin. Immediately thereafter, HERS degenerates

Histologically, the dental pulp has an appearance similar to mucoid mature

odontoblasts. Subjacent to the odontoblastic layer, there is a cell-free zone

2.1. Pulp Cells

Dental pulp contains different types of cells, including odontoblasts,

As odontoblasts form dentin, their cellular bodies move centripetally

2.1.3. Dental Pulp Stem Cells

addition to their proliferative and differentiation characteristics, hDPSCs have

2.1.4. Inflammatory and Immunocompetent Pulp Cells

macrophages progressively infiltrate the pulp tissue as the carious disease

2.2. Extracellular Components

The extracellular components are a major constituent of connective tissues,

2.3. The Pulp Vascular System

2.3.1. Blood Vessels

infraorbital arteries. Arterioles with a diameter of 10 µm or less pass through

2.3.2. Lymphatic Vessels

2.3.3. Pulp Blood Flow

2.4. Pulp Innervation

The dental pulp is a peripheral end-organ that is densely innervated by mixed

2.4.1. Sensory Innervation

2.4.2. Sympathetic Innervation

3. Pulp Physiology and Functions

3.1. Inductive Function

3.2. Formative and Reparative Function

Odontoblasts maintain predentin and dentin apposition throughout the whole

odontoblasts preserve their secretory ability but undergo marked changes,

Additional dentine can also be formed in response to external stimuli

3.3. Sensorial and Defensive Function

Dentin sensitivity is based on the stimulation of the plexus of nerve terminals

the expression of transient-potential receptors and acid-sensing ion channels

3.4. Age-Related Changes

Pulp space diminishes through life by the deposition of secondary dentin,

fewer and mineralized nerve branches, leading to weaker and delayed

It is observed that the pulp tissue is a connective tissue with specific

Gronthos, S, Brahim, J, Li, W, Fisher, LW, Cherman, N, Boyde, A, DenBesten, P, Robey,

Etiology of Pulp Alterations

Leticia Cabrera Capalbo1, Renan Dal Fabbro2,

The dental pulp and periodontal tissues can be affected by pathological

Keywords: dental pulp diseases, inflammation, tissue response

Corresponding Author’s Email: leopoldocosme@gmail.com.

In: Conservative Treatment of Pulp Tissue

ISBN: H%RRN