Central JSM Dentistry

Review Article *Corresponding author Michel Goldberg, Professor Emeritus. Paris Cité University, Department of Oral Biology, Faculty of Indirect and Direct Capping: Fundamental and Biomedical Sciences, INSERM UMR-S 1124. 45 rue des Saints Pères 75006, Paris, France, Tel : 33 6 62 67 67 09 ; Email: [email protected] Reactionary vs. Reparative Dentins Submitted: 20 December 2019 Michel Goldberg* Accepted: 08 January 2020 Published: 10 January 2020 Department of Oral Biology, Paris Cité University, France ISSN: 2333-7133 Copyright Abstract © 2020 Goldberg M Pulp therapies aiming to keep alive the dental pulp use either indirect (IPT) or direct procedures (DPC). It is depend of the stage and depth of the carious lesion, of the exposure OPEN ACCESS time, and the degree of bacterial invasion, associated or not with the pulp degradation. Our aim was to clarify the formation of reactionary or reparative . Keywords • Indirect , direct pulp capping, reactionary dentin, reparative dentin, caries, INDIRECT AND DIRECT PULP CAPPING: calcium hydroxide (Ca(OH)2, Mineral Trioxide INTRODUCTION AND GENERALITIES Aggregate (MTA), Biodentin, bioactive capping agents. Indirect pulp treatment The most appropriate treatment of the carious teeth Beneath a dense calcio-traumatic line, tubular or a tubular implicates primarily to make a good diagnosis of the pulpal status. reactionary dentin (or tertiary dentin) is formed. This tertiary Spontaneous severe pain is a crucial factor. Finger pressures, dentin is developed in reaction to trans dentinal stimulation of the radiographs, unrestorable tooth after pulp therapy, and teeth odontoblasts, bacterial toxins or adverse components released close to exfoliation are limiting factors to indirect pulp capping. by restorative materials. Reactionary dentine may be considered as an extension of physiological dentin genesis. However, since The stepwise excavation approach intends to change the it is a pathological response to injury, it should be regarded as carious environment and not to remove the carious tissue close to the pulp because there is a risk of pulp exposure. The aims of distinct from the primary and secondary dentin genesis. this technique is Removal of the soft carious dentin, covered by a temporary To verify the arrest and have a clinical control of the tooth reaction, the evolution of active caries into an arrested lesion. Zinc oxide- • eugenolmaterial cementcontaining is laid a calcium down, and hydroxide after 2-3 base, weeks, is beneficial the arrested for To remove the slowly progressing slightly infected carious dentin (sclerotic or sound) is actually removed, and • restoration [1]. demineralized dentin before filling the cavity with a final The rationale for this treatment option implies to encourage a “permanent” filling is inserted. The risk of pulp exposure the formation of a reactionary layer of dentin with preservation of pulpal health and vitality. It implicates also the removal of the deep carious lesion and restoration of the crown after the part of the lesion and secondly, restoring the cavity with an appropriateplacement of biomaterial).an appropriate About material 90% (first clinical lining success the deepest was observed after 3 years follow up. This procedure is recommended for permanent teeth but not for primary molars. Indirect pulp capping implicates the preservation of a layer of soft carious dentin. Removal step-by step with hand instruments (excavators) of the carious dentin layers implicate to keep some demineralized dentin in the deep part of the deteriorated tissue. It is mandatory to avoid drilling with rotating burrs. Elimination of the carious dentin, associated with substantial changes in preventive measures, hygiene conduct, and limitations in carbohydrates intake, favor remineralization. There is an 86% rate of success over 10 years. Figure 1 Indirect pulp capping technique [9].

Cite this article: Goldberg M (2020) Indirect and Direct Pulp Capping: Reactionary vs. Reparative Dentins. JSM Dent 8(1): 1119. Goldberg M (2020)

Central

carious tissue and application of calcium hydroxide. This therapy wasPulp compared exposure with after direct stepwise complete implies excavation the removal of deep of the carious bulk

weeks, all the carious dentin was removed, following sealing of lesion in young posterior permanent teeth. After a period of 8-24

the Thecavity control with ZOE of and pulp a restorative bleeding aftermaterial the [5]. exposure has a direct effect on pulp cap success. Saline, sodium hypochlorite

peroxide, ferric sulfate and chlorhexidine have been shown to be useful.(at concentrations The chances rangingfor tooth from survival 0.12% are toexcellent 5.25%), if hydrogenthe tooth

[6]. MTA demonstrates comparable results to calcium hydroxide. is asymptomatic and well-sealed, even if residual caries remains term data. MTA demonstrates successes as a direct pulp cap agent in short- When a healthy pulp is inadvertently exposed during an

Figure 2 2] is placed Direct pulp-capping technique [9]. The pulp exposure pulpoperative capping procedure, by calcium a calcium hydroxide hydroxide is associated [Ca(OH) with dentin is covered by the capping material (A), the protective base of ZnO- over the exposure and dentine formation is stimulated. Direct cement (B), and C: restorative material Amalgam or GIC. bridge formation. Tunnel defects are present in the area of increased with complete excavation of caries compared with stepwise excavation and/or indirect pulp capping [2]. pulp,operative and/or debris, . together It is with used the to stimulatepulp inflammatory the maintenance activity. of The biologic validity of the various vital pulp treatments Direct pulp capping is one of the treatments of an exposed vital involves indirect pulp treatment. It is an acceptable procedure for a vital pulp. It is however mandatory to develop new biologically- restorebased therapeutics vitality by that stimulating reduce pulp the regrowthinflammation, of pulpal promote tissue. the primary teeth with reversible pulp inflammation. Indirect Pulp continued formation of a renewed dentin-pulp complex, and calciumTreatment hydroxide (IPT) was has a beensuccess widely in 95%. used Calcium with high hydroxide success liners rates increased the success rate of IPT. Direct pulp capping (DPC) and in young permanent teeth, but the results in primary teeth are theThe dentin, odontoblasts-like or when toxic cells bacterial secrete metabolites tertiary dentin diffuse (reparative through less satisfactory [3,4]. The rationale for using calcium hydroxide dentinaldentin) either tubules. when irritated by the chemicals diffusing through should be reserved for iatrogenic exposures in asymptomatic The capping materials were associated with varying levels teeth expected to exfoliate within a short period of time. of pulp healing defects, including tunnel defects, operative Indirect pulp treatment is recommended for teeth that have deep carious lesions approximating the dental pulp, but no signs or symptoms of degeneration. Indirect pulp treatment, using reparativedebris, pulp dentin inflammatory genesis in cell a directactivity pulp and capping bacterial situation. leakage The[7]. TGFβ ideal anddressing Bone material Morphogenetic for the Proteins radicular may pulp also should induce be this procedure, the deepest layer of the remaining carious dentine bactericidal, harmless to the pulp and surrounding structures, iscalcium covered hydroxide by a biocompatible as liner, gives material after 2 to years prevent 83% pulp of success. exposure. In promote healing of the radicular pulp, and not interfere with the Three materials are most commonly used in indirect pulp physiologic process of root resorption. Recent clinical studies treatment: the calcium hydroxide (CH), zinc oxide-eugenol paste have reported promising results using ferric sulphate (FS), a (ZOE) and glass ionomer cements. There is high probability that hemostatic agent, in pulpotomized human primary teeth. Better results were obtained with Mineral Trioxide Aggregate (MTA), promotingthis solubilizing a reactionary effect of cavitydentin conditioners genic response results stimulated in the release by the complaintsand statistically from the significant patient, positive differences reaction were to cold reported testing, when and underlyingof TGFβ from odontoblasts. the tissue, diffusing through the dentinal tubules, nocompared sensitivity with to ferricpercussion sulphate. [8]. Success was defined as lack of The ultimate objective of this treatment is to maintain pulp The aim of vital pulp therapy is to maintain pulp viability vitality, while arresting the carious process, promoting dentine establish an environment in which apex genesis can occur. A by eliminating bacteria from the dentin-pulp complex and to sclerosis (reducing permeability), stimulating the formation of tertiaryDirect pulpdentine, capping and remineralization of the carious dentine. methodcomplicating appears factor to be in the treating ability immature to control teeth pulpal is thehemorrhage difficulty predicting the degree of pulpal damage. Currently, the best currently is the optimum material to use in vital pulp therapy. absencePulp ofhealing dentin is bridge influenced formation, by the tunnel prevention defects of in bacterial dentin by using sodium hypochlorite. Mineral trioxide aggregate (MTA) leakage. Operative debris, inflammatory and pulp cell activity, Compared with the traditional material of calcium hydroxide, it bridges emphasized the failures of direct capping. has superior long-term sealing ability and stimulates a higher JSM Dent 8(1): 1119 (2020) 2/6 Goldberg M (2020)

Central quality and greater amount of reparative dentin. The control of t and indirect pulp capping is subjected to

pulp is found. Direc 2 in vital pulp procedures.pulpal hemorrhage with NaOCl seems to be the best method of evidence-based recommendations to guide clinicians in their was combined with treatment, MTA being a good substitute for Ca(OH) decision-making process [6]. 2 The successes of direct pulp capping are less, decreasing chlorhexidine or sodium hypochlorite against Gram positive Antibacterial activity of Ca(OH) 2 effective when it is carried out on a pulp exposure, revealing an initialto 37% opening after 5 ofyears, a pulp and horn, 13% andafter accompanied 10 years. Direct with capping bacterial is Theand antibacterial Gram negative effect bacteria. is due to Ca(OH) the destruction and NaOCl of the had bacterial effects invasion. The exposed coronal pulp leads to treatment of the pulp cytoplasmicon all the tested membrane, bacteria followed while 2%CHX by protein was lysisless effectiveand bacterial [11]. by direct capping, using calcium hydroxide or other bioactive drug. The formations of reparative dentin, occluding the pulp in the formation of tunnel defects, allowing the possibility of reinfectionDNA damage. [12]. Osteodentin formation is uncompleted and results The effects of calcium hydroxide are caused by several Thisexposure bonny produce structure a bone-likeis called osteodentin. structure, made of collagen and non-collagenous proteins (namely osteocalcin and osteopontin). sequential mechanisms: Reparative dentin genesis represents a more complex sequence of biological processes. Migration and differentiation of cytoplasmic membrane. pulpal progenitor cells must take place, followed by a generation a) A chemical action, inducing damage to the microbial of stereotypic wound healing reactions occur in the pulpal the ingress of bacteria into the system. of odontoblasts-like cells, and prior to matrix secretion. A series b) Physically, filling the space within the canal and preventing reactions. In vitro and in vivo experiments on reparative odont of hard tissue around the infected canals, and inhibition of genesisconnective demonstrate tissue that includes that the vascular pulp constitutes and cellular an inflammatory appropriate c) rootThe biologicresorption. properties include biocompatibility, healing environment where competent pulp cells that are potential Over the years, calcium hydroxide has been the most forming reparative dentine occluding the pulp exposure. commonly employed wound dressing. It creates conditions pre-odontoblasts differentiate into new odontoblasts-like cells, conducive to healing of the pulp tissue. The outcome of MTA and TREATMENT OF PRIMARY TEETH calcium hydroxide treatment, with or without pulpal exposure, The remaining radicular pulp can be rendered inert by using depends largely on how extensively the pulp is infected at the time of treatment. The outcome also depends on the age of the longer a pulp that is alive. The radicular pulp might be preserved form cresol. It fixes or denatures the vital pulp, so there is no and the choice of material applied to the exposed pulp tissue. The patient, the treatment approach (indirect or direct pulp capping) agent such as ferric sulfate to preserve the deeper remaining capacity of the restorative material to prevent leakage of bacteria through minimal inflammatory insult by using a hemostatic is another important factor [2]. pulp to heal and form a dentin bridge by using calcium hydroxide The initial effect of calcium hydroxide applied to exposed pulp orpulp mineral tissue. trioxide Pulpotomy aggregate mechanism [4]. encourages the radicular

is the development of a superficial necrosis. Necrosis causes slight carious layers, isolating the pulp from the advancing front of the is occluding the pulp exposure by reparative dentin formation. irritation and stimulates the pulp to repair. Direct pulp capping lesion.Practitioners There is a shouldrisk to incite not try a pulp to have exposure access that to thewould sclerotic leads Multiple tunnel defects were shown and cell inclusions in bridges . Eighty nine per cent of to a direct pulp capping and/or more destructive pulpotomy or 2 pulpectomy therapies. This is why in addition to indirect pulp dentin bridges formed by calcium hydroxide cement contained following pulp capping with Ca(OH) capping; the two stages procedure or stepwise excavation has tunnel defects. This may lead later to bacterial penetration into been introduced in the everyday practice [1]. For deep caries rather are a consequence of the severity of the trauma to the pulp andthe pulp the numbertissue. The of tunnelsvessels areinjured not causedby the bymechanical the CH itself exposure. but are approaching the pulp, the choice of Indirect Pulp Treatment (IPT) Inside the tunnels there are blood vessels, which maintain the patternor pulpotomy treating is reversibleup to the treatingpulpitis insteaddentist. of IPT pulpotomy. has been shown to have a lower cost, higher long-term success, better exfoliation The calcium ions in the necrotic layer are responsible for partial calcium source to the necrotic tissue (coagulation necrosis). Calcium hydroxide (Ca(OH)2 or CH) 2 are killed, dystrophic calcification. Cells in contact with Ca(OH) in a number of applications such as root resorption, intra canal due to its alkaline pH, forming a necrotic layer of variable Since more than fifty years, calcium hydroxide has been used medicament, perforation management, and root canal sealers. thickness. The success rates of direct pulp-capping with calcium is a strong base that dissociate when in contact with 2 hydroxide decrease with time. Rates are more than 90% after 1 to 2The years subjacent and drop pulpfrom 82% tissue to is37% responsible after 2 to 5 for years. the healing AfterCa(OH) an initial bactericidal effect, it promotes healing and repair. associated with hard tissue barrier formation. The multiple tunnel aqueous fluids into calcium hydroxide and hydroxyl ions [10]. defects present a morphological disruption of the dentin bridge formationIn a 4-9 days/period, of osteodentin. coagulation Under the necrosis odontoblastic (pH 12.5, layer, in a the normal 1.5- 2mm superficial portion of the pulp) occurs together with the barrier. They fail to provide a long-term biological seal against bacterial infection. Multiple defects in the bridge allow fluid and JSM Dent 8(1): 1119 (2020) 3/6 Goldberg M (2020)

Central bacteria to penetrate into the pulp, which in turn can lead to BIO DENTINE™ the tunnels permit oral contaminants, such as bacteria and their toxicinternal factors, resorption, to eventually and ultimately gain access to totooth the pulploss. tissueConsequently, through silicate. Zirconium dioxide serves as contrast medium. The Bio dentine™ contains mainly tricalcium and dicalcium the marginal gap formed at the tooth / restoration interface. The liquid consists of calcium chloride in aqueous solution mixed to presence of bacteria and their products that penetrate via micro polycarboxylate. Once mixed, Bio dentine™ sets in approximately necrosis. leakage is the main factor responsible for pulp inflammation and chloridein 12 minutes. accelerates Calcium the hydration hydroxide reaction, is formed and during polycarboxylate the setting reducesof the cement. the amount Its stimulate of water tertiary required dentin for mixing formation. by providing Calcium capping materials among other materials a number have been usedCalcium with more hydroxide or less is success, still a « all gold of standardthem allowing » for directpreserving pulp pulp vitality. biocompatible,proper consistency. in that Calcium it does carbonate not damage in the pulpal powder cells is in expected vitro or into vivo, act asand a is nucleation capable of site. stimulating Bio dentine™ tertiary was dentin shown formation. to be Ferric sulphate has gained some popularity as a replacement Used for pulp capping, the material offers certain advantages for form cresol and calcium hydroxide in . It is over calcium hydroxide [16]. claimed to have low toxicity and no systemic side effects.

MINERAL TRIOXIDE AGGREGATE (MTA) genesis, dentin replacement and pulp protection A continued MTA was used as direct pulp capping in young permanent The bioactive material Bio dentine is stimulating apexo teeth [13]. At 24 months the clinical and radiographic success with MTA after pulp exposure maintain pulp vitality in permanent teethapical [8]. closure was detected on radiography. Direct pulp capping rate was 93%, with some evidence of continued root growth. pulp capping [17]. It is composed of resin and calcium silicate. Mineral trioxide aggregate (MTA) cement has a composition TheraCal is a novel light- curable MTA-like material for majorsimilar componentto that of 75% is a mixturePortland ofcement dicalcium (PC). silicate, In addition, tricalcium MTA TheraCal released significantly more calcium than ProRoot MTA silicate,contains 20%tricalcium bismuth aluminate, oxide, which gypsum, provides and radiopacity. tetra calcium The and Dycal. The surrounding fluid was able to alkalinize. Initially 2 aluminoferrite. MTA is a powder that contains trioxides and the pH varies around 10-11, between 3 h and 3 days. Then the pH hydrophilic particles. It set in the presence of moisture. MTA was decreased (8-8,5) between 7 to 14 days. Ca(OH) -based and CaO-based materials were used for direct or indirect capping. the differentiation of human orofacial mesenchymal stem cells They release hydroxyl and Ca ions. They are soluble and raise cements exhibit calcified tissue-conductive activity and facilitate pulp interface. This capping material has been designed for direct local pH with the formation of a necrotic layer at the material- and the mineralization process in human dental pulp cells. They materials have been shown to have a biocompatible nature and and indirect pulp-capping. havealso have excellent the potential potential to when be used used as in pulp-capping endodontic treatment. materials. Thus, MTA containing urethane dimethacrylate resin, calcium dihydroxide, Calcium is a radiopaque water-based calcium hydroxide, and, therefore, is expected to present various properties similar dimethylaminoethyl- methacrylate, and triethyleneglycol toMTA those can described be described above as afor calcium-hydroxide calcium hydroxide. releasing The advantages material dimethacrylate (TEGDMA). Calcium (Voco) presented of MTA are believed to be its sealing ability, biocompatibility, 2 versus MTA usedcytocompatibility for direct pulp values capping significantly [18]. Our aim lower was than to evaluate Biodentine and (Septodont). Biodentine is an alternative to Ca(OH) bioactivityIn vitro and bacterial capacity leakage to promote studies mineralized of MTA tissue materials formation. were materials. compare the antimicrobial activity of different pulp-capping was combined with using a Streptococcus salivarius model with both materials 2 found to exhibit similar root-end bacterial leakage resistance chlorhexidine or sodium hypochlorite against Gram positive and Antibacterial activity of Ca(OH) 2 having significantly less bacterial leakage than a ZOE preparation. Gram negative bacteria. Ca(OH) and NaOCl had effects on all the Biocompatibility studies assess the compatibility by monitoring tested bacteria while 2% CHX was less effective [11]. the expression of Interleukin [IL-1α, IL-6, IL-8, IL-11] and carriedmacrophage out on colony animals stimulating models orfactor human (M-CSF). studies In havevivo studies shown MTA-based products show lower cytotoxicity and valuable antibacterial activity. However, the conclusion that MTA-based physicalwere shown properties, to induce sealing little ability, or no biocompatibility, inflammation. Pulp and cappingclinical should be taken with caution because the experimental design in vitropulp-capping has some material inevitable does limitations not show with cytotoxic respect effects to the inin vitrovivo situation. performanceMTA is more of MTA effective materials and [14,15]. better than calcium hydroxide materials, as it has an enhanced interaction with dental pulp tissue. Although physical properties of resin composites are being The pulp tissue necrosis is limited, facilitated the proliferation/ improved constantly, in vivo studies have shown that the use of resins as restorative materials is occasionally associated with irritation and necrosis of the pulp. Most components of the adhesive systems and resin composites have been shown to have completedifferentiation dentine of humanbridge dentalformation pulp and cells, preventing and exhibited infection. calcified tissue-conductive activity with the ability to stimulate faster

JSM Dent 8(1): 1119 (2020) 4/6 Goldberg M (2020)

Central

•• reducedefinite micro cytotoxicity leakage, when and in decrease direct contact postoperative with mammalian sensitivity monomers,RMGICs are and more they should cytotoxic not tobe applied the pulp directly cells to than the fibroblasts. Adhesive resin systems are used to enhance retention, pulpconventional tissue. GICs due to the presence of unpolymerized of adhesive resins might be unachievable during direct pulp cappingof composite procedures. resin In restorations. addition, it hasComplete been shown polymerization that the A calcium phosphate material equipped with poly �(lactic- co-glycolic acid) (PLGA) microspheres was effective for pulp oxygen prevents complete polymerization of adhesive resin capping. The composition with 400 ng TGF-beta-1 was able to monomers. Consequently, unpolymerized monomers released like cells and induce the formation of tertiary dentin, suggesting the exposure site, as well as diffuse through the dentinal tubules trigger the resident stem cells to differentiate into odontoblasts- from the resin-based material can diffuse directly into the pulp at that this material might be a good candidate for vital pulp therapy. to cause cytotoxic effects to the pulp cells. While unpolymerized and partially polymerized adhesive resin induced apoptosis were The application of anti-inflammatory factor(s) to caries- internalized rapidly in macrophages, undifferentiated pulp cells Theexposed advantage pulp of limits this approachthe inflammation, is that the accelerates increased risk tissue of (OD-21) and mouse odontoblasts-like cells (MDPC-23) in corpate regeneration, and lead to the deposition of mineralized dentin. polymerized adhesive resin and induced significant apoptosis only in macrophages. Bonding agents have been found to release pulpal necrosis or excessive calcification resulting from calcium radicals including reactive oxygen species. To conclude, the ability of the dental pulp to regenerate a photo initiator and photosensitizer widely used to generate free hydroxide-induced tissue irritation is avoided. Unfavorable effects of dentin bonding systems, pathological should be kept in mind by clinicians that should avoid total changes of pulpal tissues, such as dilatation and congestion used in presence of deep carious lesion without pulp exposure pulpectomy. Indirect Pulp Capping or Treatment (IPT) may be irregular dentin as well as odontoblastic displacement or tooth sensitivityof blood vessels, occur after inflammatory placement responses of composite and production restorations. of (orthodentin or osteodentin). Beneath a calciotraumatic line, a The monomers in contact with oxygen are not converted into oflayer osteodentin of secondary occludes tubular the or pulpatubular perforation dentin is (calcospherites; formed (DPC). Direct pulp capping may be used after pulp exposure, and a plug alteration of extracellular matrix inhibit completely pulp repair orpolymers. dentin bridging. The persistent inflammatory reaction and hyaline direct capping associate in therapeutic strategy three key elements,diffuse pulp the mineralization same that are and/or involved pulp in stones). tissue engineering. Indirect or FUTURE DIRECTIONS

mightThe association help the direct of (1) differentiation stem cells, (2)of dental morphogens stem cells or and growth the Bioactive pulp capping agents such as Calcium hydroxide, factors, and (3) a scaffold of biomimetic extracellular matrix, bone sialoprotein (BSP), bone morphogenetic protein (BMP- 7 - also termed OP-1) was used successfully [19]. BMP belong pulpsubsequent capping regeneration therapies. of a functional dentin-pulp complex [21]. Apexogenesis and/or are the two targets of to the superfamily of the Transforming Growth Factors. TGF β) REFERENCES ισ α ποτεντ µοδυλατορ of tissue repair in different situations. BMP-2, -4, and -7 plays a role in the differentiation of adult 1. ørndal L, Kidd EAM. The treatment of deep dentine caries lesions. pulp cells into odontoblasts during pulpal healing. Insulin-like Bj growth factor-1 contributes to form a dentin bridge equal to 2. Restorative dentistry. 2005; 32: 402-413. Dycal after 28 days. Among Growth Factors, only the TGF-β1 enhance reparative dentin formation. Enzymes such as Heme- Bergenholtz G, Axelsson S, Davidson, Frisk F, Hakeberg M, Kvist T, et been used with variable success. Many of these molecules may al. Treatment of pulps in teeth affected by deep caries- A systematic constituteOxygenase-1, suitable simvastatin, replacement stem forcells, calcium Emdogain hydroxide. and ODAM have 3. review of the literature. Singapore Dental J. 2013; 34: 1-12.

Fuks AB. Current concepts in vital primary pulp therapy. Eur J 4. Paediatric Dentistry. 2002; 3: 115-120. Pulp healing include tunnel defects, operative debris, pulpal by the nature and composition of the capping materials [20,21]. Coll JA. Indirect pulp capping and primary teeth: is the primary tooth inflammatory cell activity and bacterial leakage. This is influenced pulpotomy out of date? Pediatr Dent. 2008; 30: 230-236. It has been concluded that: versus direct complete excavation of deep carious lesions in young 5. Leksell E, Ridell K, Cvek M, Mejàre I. Pulp exposure after stepwise •• conservative treatment of the pulp. 6. posterior permanent teeth. Dental Traumatology.1996; 12: 192-196. Calcium hydroxide products are the best choice for •• Monomers present in resin composites and adhesive Hilton TJ. Keys to clinical success with pulp capping: a review of the systems have cytotoxic effects as a consequence of direct 7. literature. Operative Dentistry. 2009; 34: 615-625.

Murray PE, Garcia-Godoy F. The incidence of pulp healing defects with 8. capping materials. Am J Dent. 2006; 19: 171-177. •• contactIn human with pulps, fibroblasts. direct pulp capping with adhesive Marques MS, Wesselink PR, Shemesh H. Outcome of direct pulp even without the presence of bacteria, and absence of capping with mineral trioxide aggregate: a prospective study. J of dentinsystems bridge produces formation, different as degreeswell as pulp of pulp repair. inflammation, 9. Endod. 2015; 41: 1026-1031. Dummett CO, Kopel HM. Pediatric in Endodontics. 2002; 861-902. JSM Dent 8(1): 1119 (2020) 5/6 Goldberg M (2020)

Central

10. 16.

Hermann B. Dentinobliteration der Wurzelkanäle nach Behandlung Dammaschke T. A new bioactive cement for direct pulp capping. 11. mit Calzium. Zahnärztl Rundschau. 1930; 39: 888-898. 17. International Dentistry. 2012; 2: 64-69. of calcium hysdroxide combined with chlorohexidine or sodium Hamed SJ, Al-Yasiri IK, Nibrass TA, Al-Feron MA. Antibacterial activity Gandolfi MG, Siboni F, Prati C. Chemical-physical properties of TheraCal, a novel light-curable MTA-like material for pulp capping. hypochlorite against gram Positive and Gram-Negative bacteria. J 18. International Endodontic Journal. 2012; 45: 571-579. versus Mineral 12. Natural Sciences Res. 2014; 4: 55-61. Schwendicke F, Brouwer F, Stolpe M. Calcium hydroxide Pannu R, Berwal V. Calcium hydroxide in dentistry: a review. J Applied Trioxide Aggregate for direct pulp capping: a cost-effectiveness 13. Dental & Medical Science. 2017; 3: 24-31. 19. analysis. J Endod. 2015; 41: 1969-1974.

Farsi N, Alamoudi N, Balto K, Al Mushayt A. Clinical assessment of Goldberg M, Six N, Decup F, Buch D, Soheili Majd E, Lasfargues JJ, et Mineral Trioxide Aggregate (MTA) as direct pulp capping in young al. Application of bioactive molecules in pulp-capping situations. Adv 14. permanent teeth. J Clin Pediatr Dent. 2006; 31: 72-76. 20. Dent Res. 2001; 15: 91-95. ionomer and stainless steel crown restorations in primary molars, Roberts JF, Attari N, Sherriff M. The survival of resin modified glass Murray PE, Garcia-Godoy F. Method and kit for delivering endodontic 21. regenerative treatment. US Patent Application Murray et al. placed in a specialist pediatric dental practice British Dental Journal. Komabayashi T, Zhu Q, Eberhart R, Imai Y. Current status of direct 2005; 198: 427-431. aggregate material use in endodontic treatment: a review of the pulp-capping material for permanent teeth. Dental Materials. 2016; 15. Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide 35: 1-12.

literature. Dental Materials. 2008; 24: 149-164.

Cite this article Goldberg M (2020) Indirect and Direct Pulp Capping: Reactionary vs. Reparative Dentins. JSM Dent 8(1): 1119.

JSM Dent 8(1): 1119 (2020) 6/6