Central JSM Dentistry Review Article *Corresponding author Michel Goldberg, Professor Emeritus. Paris Cité University, Department of Oral Biology, Faculty of Indirect and Direct Pulp 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 dentin. Keywords • Indirect pulp capping, 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 andpulp a restorativebleeding 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 eugenol 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, pulpotomy. 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 thatstimulating reduce pulpthe 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 metabolitestertiary 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 incell a directactivity pulp and cappingbacterial situation. leakage The[7]. TGFβideal anddressing Bone material Morphogenetic for the Proteinsradicular 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 thesignificant patient, positivedifferences reaction were to coldreported 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 bein thetreating 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 bridgeinfluenced formation, by the tunnel prevention defects of inbacterial 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,