CLINICAL

CLINICAL

CLINICAL
Particular growth factors from the TGF- (transforming
growth factor- beta) family have the ability to initiate
odontoblast differentiation and hence produce tertiary
dentine by cell signalling. Odontoblast cells also line the
pulp chamber and have long processes with the dentinal
tubules around them, which are filled with tissue fluid
containing plasma proteins. On exposure of the distal
ends of these tubules, there is outward movement of
tissue fluid which could result in pulpal inflammation, but
its main aim is to prevent inward movement of toxins.
Generally the greater the area of exposed dentine, the
greater the effect on the pulp4.

Preserving pulp vitality

Udita Patel and Jennifer Hughes
KEY WORDS: Dentine-pulp complex Vital pulp therapy Pulpotomy Biocompatibility
Pulp exposure from caries, trauma or tooth cavity preparation
can be severe and lead to pain and/or infection, resulting in
either root canal treatment or an extraction: both conditions
are unfavourable, for various reasons. An alternative treatment
could be a vital pulp capping procedure.
Restorative therapy
The goals of restorative therapy are to restore the tooth to proper form
and function, minimise post operative sensitivity and preserve pulp vitality.
However, cavity preparation and restoration variables have an uncertain
relationship to pulp injury and repair responses, thereby threatening
tooth vitality.
Clinicians are keen to preserve the pulpally involved tooth: pulp tissue has
an innate capacity for repair in the absence of microbial contamination.
Vital pulp therapy is broadly defined as treatment to preserve and maintain
pulp tissue in a tooth that has been compromised by caries, trauma, or
restorative procedure. The objective is to stimulate the
formation of reparative dentine to retain the tooth as a
functional unit. This involves placing a medicament directly
over exposed pulp or a cavity liner/sealant over residual
caries in an attempt to give the pulp some time to heal,
thereby maintaining vitality of that tooth. Immediate and
long-term success of root canal treatment is widely accepted
by clinicians but vital pulp capping is perhaps a less widely
used procedure due to its controversial success rates 1.

fracture in a root filled tooth are higher. Pulp vitality is imperative for
the tooth viability, since it provides nutrition and detects pathogenic
stimuli. Common clinical protocol is either a root canal treatment or
extraction. Over time, the pulpless tooth, lacking proper blood supply
and nervous system, becomes vulnerable to injury, increasing the interest
in preserving pulp vitality.
Challenges
Preservation of pulp vitality is a major challenge in restorative dentistry.
The dentine pulp complex is uniquely capable of reparative responses to
various environmental stimuli which determine much of the success of
restorative work. The nature of protective response is determined by the
type of cells involved. Injuries can range from tooth wear (including attrition,
abrasion and erosion) which invokes a mild response, to extensive wear
and dental caries which initiates a more substantial response. The
odontoblasts which are responsible for dentinogenesis can either die due
to the injurious stimuli or survive to initiate reparative tissue response3.

The main aim of managing caries or any other damage

to teeth should be to preserve pulp vitality. The best root
canal filling is healthy pulp tissue and it cannot be assumed
that all damaged pulp must be extirpated or that all pulp
conservation procedures are unsatisfactory. Cavity
preparation is a minor procedure to clinicians, but it is a
crisis to the dental pulp. For example, use of sharp, cutting
burs can produce disturbances like vibrations and fluid shifts.
Further outward fluid shifts are caused by application of
bond, primer, varnishes, etc. which can cause pain to an
un-anaesthetised patient and also inflame the pulp. On
administration of local analgesia, fluid shifts still occur,
but fewer nerves are affected which results in less
inflammation of the pulp 5.
Dentine is the most effective protection for pulp due to its
excellent insulation and capacity to reduce diffusion of
chemicals from cavity floor to the pulp. However, it is
possible to prepare cavities without pulpal inflammation
or tertiary dentine production by using a combination
of air-water spray, good lighting, intermittent cutting

The distance of diffusion as determined by cavity

preparation influences the signalling process of TGF- to
lay down tertiary dentine. Unfortunately, too much tertiary
dentine, reparative or reactionary, can very well cause
pulpal strangulations, and in severe cases death. Yet
another reason for practising minimally invasive dentistry
in order to least traumatise the healthy tissues. Pulpal cell
death can also be avoided by the use of a lining agent to
reduce secretion of reactionary dentine.
Healing of an exposed pulp depends on the success of vital
pulp therapy. Failed pulp treatment can principally be attributed
to factors like bacterial microleakage, biocompatibility of the
material and moisture contamination. Extent of pulp
injury, cavity preparation, formation of tertiary dentine,
open tooth apex, lack of pre existing symptoms, patients
age etc. are the other aspects which can cumulatively
contribute to the success or failure of the procedure. Very
few dental materials are truly inert and tend to bring about
a variety of physiochemical and biological changes in the
dental tissues, healthy or otherwise. The interaction, effects
of, and problems associated with these restorative materials
like bacterial microleakage,
biocompatibility, etc. are
important when considering
saving pulp vitality.
Techniques
Techniques to avoid
extensive treatment such
as extraction or endodontic
therapy include direct pulp
capping, indirect pulp
capping and partial/full
pulpotomy.

There are many arguments about the best medicaments

suitable for this role and their long term advantages
and disadvantages. Pulp capping is a conservative dental
treatment due to the regenerative nature of the dentine-pulp
complex and its ability to secrete tertiary dentine. Research
shows a higher failure rate for endodontically treated teeth.
One of the reasons for this could be that a non-vital tooth
requires 2.5 times more force than a vital tooth to register
Figure 1: Schematic representation of tooth injury and regeneration (Left) Pulp regeneration in response to
response2. The natural tooth tissues have an inherent
a non-exposed cavity preparation (Right) Pulp regeneration in response to an exposed cavity preparation
(Murray et al., 2002)
capacity to withstand this load and hence the chances of

Figure 2: Diagrammatic representation of the

remaining dentine thickness (RDT) while drilling
[Dental Materials in Operative Dentistry, 2008)

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Volume 52 No 2 of 6 March 2013

DENTAL HEALTH

forces and use of sufficiently sharp burs. In a prepared

cavity, remaining dentine thickness of more than 0.5 mm
is ideal for avoiding pulpal inflammation6. Reactionary
dentine forms when remaining dentine thickness is 2.50.01 mm due to presence of a layer of surviving
odontoblasts in the area, whereas reparative dentine is
formed following pulp exposure. Very deep cavities greatly
reduce the number of surviving odontoblasts and hence
none remain to secrete tertiary dentine. Remaining dentine
thickness not only influences vitality of the underlying
pulp tissue but also determines the repair response.

Figure 3: Diagrammatic representation of the

phenomenon of microleakage [Dental Materials
in Operative Dentistry, 2008]

The main aim of lining

and base materials used in
pulp capping procedures

27

CLINICAL

CLINICAL

Preserving pulp vitality

is to prevent or retard pulpal inflammation. The other
purposes depend on the material used. Dentine is probably
the best lining material for pulp protection and maintenance
of vitality as it is capable of preventing toxic substances
from infiltrating the pulp. The thicker the remaining dentine,
the better its protection ability will be. Historically, it was
believed that restorative materials themselves were harmful
to pulp and for this reason, use of bases or liners was
considered imperative to protect pulp vitality and ensure
successful restorations. In light of the knowledge of the
importance of remaining dentine thickness, it is essential
that sound dentine is never removed in order to
accommodate for a lining, base or sealer material.
New materials
Some common materials currently used in clinical practice
are calcium hydroxide, mineral trioxide aggregate (MTA),
zinc-oxide eugenol (ZOE), adhesive cements, glass
ionomer and resin modified glass ionomer cements.
All current materials used for vital pulp therapies have at
least one or more disadvantages. The field of dentistry is
constantly evolving and scientists are always trying to find
a better alternative to the current materials on the market.
Two of the most promising materials include Biodentine
and propolis.
Calling it the next big thing in dentistry, Septodont
launched Biodentine in September 2010. This new
experimental material is a Ca3SiO5 (calcium silicate)
based Portland cement. Being a Portland cement (similar
to MTA) it is biocompatible and bioactive in nature; and

has the ability to initiate the formation of dentine bridges

(probably due to the presence of calcium hydroxide in its
formulation). An experiment of damaged pulp fibroblasts
was conducted to test for bioactivity. Of all the materials
tested, only ProRoot MTA and Biodentine were able
to stimulate the formation of tertiary dentine. Both displayed
presence of enhanced levels of TGF-. Biodentine also
showed presence of other growth hormones (in addition to
TGF-) which contribute to the formation of dentine bridges7.
Another study of indirect pulp capping on rat molars
concluded that Biodentine was able to stimulate (thick
and dense) reactionary dentine formation, which stopped
after about three months when a sufficient dentine barrier
was formed. Studies conducted to test Biodentine
for application as a direct pulp capping agent and for
pulpotomy showed that it was well tolerated even when
in direct contact with the pulp. It was even suggested that
the quality of dentine bridges formed were better than
those formed by calcium hydroxide alone8, 9.
A three year study concluded that it is suitable as a dentine
substitute, a pulp capping material and a bulk restorative
material at the same time. They confirmed that it has the
two main important qualities for a dentine substitute;
biocompatibility and longevity. If a later re-intervention
is required (due to marginal leakage or secondary
caries), Biodentine is safe to retain as a lining and
does not interfere with
other adhesive fillings.
Additionally, it does not

BiodentineTM labelled with

fluorescein dye which has moved
from the cement into the dentine
tubules. Notice the plugs of material
in the tubule openings (Picture taken
from the Biodentine brochure UK
2011- original courtesy Dr Amre
Atmeh, Kings College London)

Clinical Implementation of Biodentine as suggested in the brochure by Septodont UK in 2011

28

Raw, dried Propolis

(www.healthywealthyyou.org,
accessed in October 2011)

DENTAL HEALTH

require any preliminary conditioning treatment of the

cavity, greatly simplifying the pulp capping techniques 10.
Biodentine adheres to tooth surface by micromechanical
adhesion. Its crystals succeed in growing within the dentine
tubules leading to a micromechanical anchor, without the
application of a conditioning treatment or bonding material.
It is also suggested that there might be a possible ion
exchange contributing to further adhesion of the cement
giving it outstanding resistance to microleakage and
bacterial infiltration11. Drawbacks of Biodentine include
mixing two separate components which can prove to be
a hassle, its high cost and the fact that the patient needs
to be called back for another appointment. Its use is still not
indicated for use in root caries and still requires more
research in the area.
Propolis is a non-toxic resinous glue collected by Apis
Mellifera honey bees from various plant juices. Propolis
was historically used in folk medicine especially to treat
battle wounds. Hippocrates, the founder of modern
medicine, used it for healing sores and ulcers.
A review article suggested various applications of Propolis
in dentistry, such as in wound healing, as a cariostatic agent
and as alternative treatments for dentine hypersensitivity,
among others 12. As a pulp capping agent, flavonoids and
caffeic acid found in Propolis reduce the inflammatory
response and aid the immune system by promoting
phagocytic activities and stimulating cellular immunity. It
also successfully aids dentine bridge formation as a result
of the presence of arginine, vitamin C, provitamin A and B
complex, factors which also contribute to wound healing.
A study concluded that Propolis was an effective alternative
measure to prevent dental caries since its antimicrobial
activity is effective against Steptococcus mutans, commonly
associated with dental caries. Enterococcus faecalis a gram
positive, facultative anaerobic has the ability to invade
dentinal tubules and it was found that the antimicrobial
activity of Propolis against E. faecalis, was just as effective
as Chlorhexidine. 10% Propolis gel (as opposed to 30%)
was suggested to be as effective as fluoride gel in reducing
dentine permeability (and hence hypersensitivity) by partial
obliteration and sealing of dentinal tubules13, 14, 15.
Conclusion
It would appear that there are now alternative materials,
for maintaining pulp vitality during restorative procedures,
to the tried and tested gold standard calcium hydroxide.
Some of these, such as Biodentine or Propolis would
seem to present clinicians with an advantage during pulp
capping procedures.
Volume 52 No 2 of 6 March 2013

Acknowledgements
With thanks to my supervisor and co-author Dr. Jennifer Hughes BDS,
FDS RCS (Eng) Director of Hygiene & Therapy School of Dental
Hygiene & Therapy Dental Institute, 3rd Floor Dental Extension,
Caldecot Road, London.

References
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3. Chong, B.S. (ed.). (2010). Maintaining dental pulp vitality. In: Hartys
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About the author: Udita qualified as a dental hygienist and therapist from Kings
College Hospital. She also has an engineering degree in Dental Materials from
Queen Mary- University of London. This project combined knowledge from both
disciplines and hence inspired her to research the subject further. Udita currently
works as a dental therapist in Smileright at Boots stores.
Address for correspondence: [email protected]

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