DOI: 10.7860/JCDR/2014/7719.

3980
Review Article

Recent Advances in Pulp Capping

Dentistry Section

Materials: An Overview

Asma Qureshi1, Soujanya E.2, Nandakumar3, Pratapkumar4, Sambashivarao5

ABSTRACT
Emphasis has shifted from the “doomed” organ concept of an exposed pulp to one of hope and recovery. The era of vital-pulp therapy
has been greatly enhanced with the introduction of various pulp capping materials. The aim of this article is to summarize and discuss
about the various and newer pulp capping materials used for protection of the dentin-pulp complex.

Keywords: Biocompatible,Dentin bridge, Pulp capping, Pulp capping agent, Reparative dentin

INTRODUCTION Keflin (cephalothin sodium) along with calcium hydroxide was used
Historically, the first pulp capping procedure was performed in for pulp capping with the thought of reducing or preventing pulp
1756, by the Phillip pfaff, who packed a small piece of gold over an inflammation.
exposed vital pulp to promote healing. However, the success of the Gardner et al., found that vancomycin, in combination with calcium
pulp capping procedure greatly depends upon the circumstances hydroxide was somewhat more effective than calcium hydroxide
under which it is performed and the prognosis depends upon the used alone and stimulated a more regular reparative dentin bridge.
age, type, site and size of pulp exposure. In addition to this the pulp Watts and Paterson cautioned that anti-inflammatory compounds
capping material should have the following ideal properties like should not be used in patients at risk from bacteremia [5].
• Stimulate reparative dentin formation
• Maintain pulpal vitality Polycarboxylate Cement
McWalter G et al., found that it lacks an antibacterial effect and
• Release fluoride to prevent secondary caries calcific bridge formation [6].
• Bactericidal or bacteriostatic
• Adhere to dentin Inert Materials
• Adhere to restorative material Bhaskar SH et al., and Heys DR et al., investigated isobutyl
cyanoacrylate and tricalcium phosphate ceramic as direct pulp
• Resist forces during restoration placement and during the life
capping materials. Although pulpal response in the form of reduced
of restoration.
inflammation and unpredictable dentin bridging were found, but
• Sterile none of these materials have been promoted to the dental profession
• Radiopaque as a viable technique [5].
• Provide bacterial seal [1].
Collagen
Calcium Hyroxide Dick et al., reported that collagen fibers are less irritating than Ca
Calcium hydroxide (Ca (OH) 2) was introduced to the dental profession (OH)2 and promotes mineralisation but does not help in thick dentin
in 1921 by Hermann and has been considered the “gold standard” bridge formation [7].
of direct pulp capping materials for several decades, against which
new materials should be, tested [2-4]. Bonding Agents
According to Miyakoshi et al., 4-META-MMA-TBB adhesives and
Zinc Oxide Eugenol Cement hybridizing dentin bonding agents provide superior adhesion to
Tronstad and Mjör stated that Zinc oxide eugenol cement (ZOE) peripheral hard tissues and effective seal against micro leakage. But
is more beneficial for inflamed and exposed pulp. However in they have poor outcome due to its cytotoxic effect and absence of
the literature Glass and Zander, Hembree and Andrews, Watts, calcific bridge formation [5].
Holland et al., found that ZOE, in direct contact with the pulp tissue,
produced chronic inflammation, lack of calcific barrier, and end Calcium Phosphate
result is necrosis [5]. Calcium phosphate cement was suggested as viable alternative
because of its good biocompatibility, superior compressive strength
Corticosteroids and Antibiotics and its transformation into hydroxyapatite over time. Yoshimine et
Corticosteroids like hydrocortisone, Cleocin, cortisone, Ledermix al., demonstrated that in contrast to calcium hydroxide, tetracalcium
(calcium hydroxide plus prednisolone), penicillin, neomycin and phosphate cement induced bridge formation with no superficial

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tissue necrosis and significant absence of pulp inflammation [8]. Other Growth Factors
Hu et al., evaluated the various growth factors like epidermal growth
Hydroxyapatite factor, basic fibroblast growth factor, insulin-like growth factor
It is the most thermo dynamically stable of the synthetic calcium II, platelet-derived growth factor-BB, TGF-b 1in rat molars and
phosphate ceramics. It has good biocompatibility with neutral pH concluded that only TGF-b 1-enhances reparative dentin formation
-7.0. It can be used as scaffolding for the newly formed mineralized [20].
tissue [9].
Bonesialoprotein
Lasers According to Goldberg M et al., Bone sialoprotein (BSP) was the
Melcer et al., suggested between the years 1985 and 1987 that most efficient bioactive molecule, which induced homogeneous
the carbon dioxide (CO2) (1W) laser used for direct pulp capping and well mineralized reparative dentin. Both BSP and BMP-7
[10-12]. were superior to calcium hydroxide in their mineralization inducing
Y. Yasuda et al., did a study to examine the effect of CO2 laser properties [21].
irradiation on mineralization in dental pulp cells in rats and the
results suggested that CO2 laser irradiation stimulated mineralization Biodentin
in dental pulp cells [13]. Biodentine is new bioactive cement with dentin like mechanical
Nd: YAG laser emits an infrared beam at a wavelength of 1064nm properties and can be used as dentin substitute. It has a positive
can be of therapeutic benefit for direct pulp capping and pulpotomy effect on vital pulp cells and stimulates tertiary dentin formation [22].
in clinical practice [14].
Enzymes
Glass Ionomer/Resin Modified Glass Ionomer Heme-Oxygenase-1
Glass ionomer also provides an excellent bacterial seal and good Heme oxygenase-1(HO) is the rate limiting enzyme in heme
biocompatibility when used in close approximation but not in direct catabolism. Odontoblasts and oxidatively stressed dental pulp cells
contact with the pulp. express HO-1, indicates that the pulp might respond to oxidative
RMGIC as direct pulp capping agent exhibited chronic inflammation stress at the molecular level.
and lack of dentin bridge formation; whereas the calcium hydroxide HO-1 induction protects against hypoxic stress and nitric oxide-
control groups showed significantly better pulpal healing [15]. mediated cytotoxicity. It has been reported that HO-1 might play
a cytoprotective role against pro inflammatory cytokines and nitric
Mineral Trioxide Aggregate oxide in human pulp cells. In addition, bismuth oxide containing
Mineral Trioxide Aggregate (MTA) was introduced by Torabinejad in Portland cement (BPC) induced HO-1 expression in dental pulp
early 1900s. Several studies reported that MTA induced less pulpal cells plays a protective role against the cytotoxic effects of BPC [23].
inflammation and more predictable hard tissue barrier formation in
comparison to hard setting calcium hydroxide [16]. Simvastatin
It is a 3-hydroxy-3-methylglutaryl coenzyme, a reductase inhibitor
MTYA1-Ca and first line drug for hyperlipidemia. Statin improves the osteoblast
Atsuko Niinuma developed resinous direct pulp capping agent function via the BMP-2 pathway and suppresses osteoclast function,
containing calcium hydroxide. The powder composed of 89.0% resulting in enhanced bone formation. Therefore, statin might
microfiller, 10.0% calcium hydroxide and 1.0% benzoyl peroxide and improve the function of odontoblasts, thus leading to improved
was mixed with liquid (67.5% triethyleneglycol dimethacrylate, 30.0% dentin formation.
glyceryl methacrylate, 1.0% o-methacryloyl tyrosine amide, 1.0% Statin is known to induce angiogenesis and increase neuronal cells,
dimethylaminoethylmethacrylate and 0.5% camphorquinone). indicating the possible effectiveness of statin in pulp regeneration
MTYA1-Ca developed dentine bridge formation without formation of along with dentin regeneration. It has an anti-inflammatory effect
a necrotic layer, revealed to have good physical properties, and was in various tissues, so it is considered as an ideal active ingredient
not inferior to Dycal histopathologically. Therefore, it is suggested in pulp capping material to accelerate reparative dentin formation
that the newly developed material, MTYA1-Ca promises to be a [24].
good direct pulp capping material [17].
Stem Cells
Growth Factors Dental pulp stem cells (DPSCs) and Stem cells from Human
Growth factors regulate growth and development and induce wound Exfoliated Deciduous Teeth (SHED) have been identified as a novel
healing and tissue regeneration. population of stem cells that have the capacity of self-renewel and
Bone Morphogenic Protein (BMP) multi lineage differentiation.
Bone Morphogenic Protein (BMP) belongs to super family trans­ Sayaka Nakamura et al., used mesenchymal stem cells for clinical
forming growth factor beta (TGF-b). TGF b is a potent modulator of application in tissue engineering and regenerative medicine. In
tissue repair in different situations. BMP-2, 4, and 7 plays a role in this study, they compared the proliferation and stem cell marker
the differentiation of adult pulp cells into odontoblasts during pulpal of SHED, DSPCs and Bone Marrow Derived Mesenchymal Stem
healing. Cells (BMMSCs). In addition, gene expression profile of DSPCs and
Lianjia et al., found that BMPs are responsible for dentino­genesis, SHED were analyzed by using DNA microarray. They concluded
inducing non differentiated mesenchymal cells from the pulp to form that SHED has got significantly higher proliferation rate than that of
odontoblast-like cells, obtaining osteodentin and tubular dentin DSPCs and BMMSCs and this could be a desirable option as a cell
deposition, when used as direct protectors [18]. source for therapeutic applications [25].
Recombinant Insulin Like Growth Factor-I
Lovaschall et al., evaluated recombinant insulin like growth factor-I Propolis (Russian penicillin)
(rhIGF-I) in rat molars and concluded that dentin bridge formation It contains flavonoids, phenolics, iron, zinc and other various
was equal to dycal after 28 days [19]. aromatic compounds [26].

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A Parolia et al., compared propolis, MTA and Dycal histologically in protective base/liner under composites, amalgams, cements, and
human dental pulp and concluded that Propolis and MTA showed other base materials. TheraCal LC performs as an insulator/barrier
similar bridge formation when compared to Dycal [27]\. and protectant of the dental pulpal complex.
The proprietary formulation of TheraCal LC consists of tricalcium
Novel Endodontic Cement silicate particles in a hydrophilic monomer that provides significant
Novel endodontic cement (NEC) consists of calcium oxide, calcium calcium release making it a uniquely stable and durable material
phosphate, calcium carbonate, calcium silicate, calcium sulfate, as a liner or base. Calcium release stimulates hydroxy apatite and
and calcium chloride. secondary dentin bridge formation. TheraCal LC may be placed
Mohammad Hassan Zarrabi evaluated MTA and NEC histo­logically directly on pulpal exposures after hemostasis is obtained. It is
in human dental pulp and concluded that NEC induced a thicker indicated for any pulpal exposures, including carious exposures,
dentinal bridge with less pulp inflammation [28]. mechanical exposures or exposures due to trauma. [Table/Fig-1]
shows the physical properties of Theracal LC
Emdogain Gandolfi et al., compared chemico physical properties of TheraCal,
Emdogain (EMD) is enamel matrix derivative secreted from ProRoot MTA and Dycal and concluded that TheraCal displayed
Hertwig’s epithelial root sheath during porcine tooth development. higher calcium releasing ability and lower solubility than either
It is an important regulator of enamel mineralization and plays an ProRoot MTA or Dycal. The capability of TheraCal to be cured to a
important role during periodontal tissue formation. It stimulates the depth of 1.7 mm may avoid the risk of untimely dissolution. These
regeneration of acellular cementum, periodontal ligaments, and properties offer major advantages in direct pulp capping treat­-
alveolar bone. ments [36]. [Table/Fig-2] shows the summary of advantages and
disadvantages of various pulp capping agents.
EMD contains BMP like molecules and BMP expressing cells. BMP like
molecules in EMD promote odontoblast differentiation and reparative
dentin formation. Recently,it was reported that EMD suppresses the Physical Properties
inflammatory cytokine production by immunocytes and contains Shear bond Water solubility Radiopacity Calcium
TGF-β like molecules. It might create a favourable environment for strength(Mpa) (µg/mm2) (mm Al) release

promoting wound healing in the injured pulp tissues [29]. Theracal LC 4.35 (2.93) 0 2.63 188 (µg/
cm2)
Nakamura Y et al., concluded that amount of hard tissue formed
Prisma VLC 0.94 (0.92) 110 (17) 0.79 NA
in EMD treated teeth was more than twice that of the calcium Dycal
hydroxide treated control teeth [30].
[Table/Fig-1]: Shows physical properties of Theracal LC
Khalid Al-Hezaimi evaluated Calcium hydroxide, ProRoot White
MTA and white Portland cement after Emdogain application on the
exposed pulp. MTA produced a better quality reparative hard tissue Pulp capping agent Advantages Disadvantages
response with the adjunctive use of Emdogain compared with Ca (OH)2 • Gold standard of direct • Highly soluble in oral
calcium hydroxide [31]. (1960’s) pulp capping material fluids
• Excellent antibacterial • Subject to dissolution
properties over time
Odontogenic Ameloblast Associated Protein • Induction of • Extensive dentin
mineralization formation obliterating the
Odontogenic ameloblast associated protein (ODAM) is expressed • Low cytotoxicity pulp chamber
in ameloblasts, odontoblasts, and pulpal cells. ODAM involved in • Lack of adhesion
• Degradation after acid
ameloblast maturation and enamel mineralization. etching
• Presence of tunnels in
In-Seok Yang et al., stated that rODAM accelerates reactionary reparative dentin
dentin formation close to the pulp exposure area, thereby preserving
normal odontoblasts in the remaining pulp [32]. Zinc oxide eugenol • Reduces inflammation • Lack of calcific bridge
cement (1960-70’s) formation
• Releases eugenol in high
Endo Sequence Root Repair Material concentration which is
cytotoxic
It consists of Calcium silicates, monobasic calcium phosphate, • Demonstrate interfacial
zirconium oxide, tantalum oxide, proprietary fillers and thickening leakage
agents [33].
Corticosteroids and • Reduces pulp • Should not be used in
Hirschman et al., compared Cytotoxicity of MTA-Angelus, Brasseler antibiotics (1970’s) inflammation patients at risk from
Endosequence Root Repair Putty (ERRP), Dycal and Ultra-blend • Vanocmycin + Ca(OH)2 bacteremia.
stimulated a more
Plus (UBP)-(light curable Ca(OH)2) and concluded that ERRP and regular reparative dentin
UBP are less cytotoxic [34]. bridge.

Castor Oil Bean Cement Polycarboxylate • Chemically bond to the • Lack of antibacterial
cement (1970’s) tooth structure effect
The Castor oil bean (COB) consists of 81-96% triglyceride of ricinoleic • Fail to stimulate calcific
acid, and is considered a natural polyol containing three hydroxyl bridge formation
radicals. COB or RCP (Ricinus Communis Polyurethane) was
originally developed as a biomaterial for bone repair and regeneration Inert materials (1970’s) • Reduces pulp • None of these materials
(Isobutyl inflammation havebeen promoted to
after local bone damage. Due to these positive characteristics, the cyanoacrylate and Tri • Stimulate dentin bridge the dental profession as
material is considered to be an excellent candidate for use in pulp calcium phosphate formation a viabletechnique
ceramic)
capping [35].
Collagen • Less irritating than • Does not help in thick
Theracal (1980) • Ca (OH)2 and promotes dentin bridge formation
mineralisation
TheraCal LC is a light cured, resin modified calcium silicate filled
liner designed for use in direct and indirect pulp capping, as a

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Bonding agents • Superior adhesion to • Have cytotoxic effect Growthfactors • Formation of • Possibility of unexpected
(1995) hard tissues • Absence of calcific (1900-2007) osteodentin and tubular side effects and the
4-META-MMA-TBB • Effective seal against bridge formation Bone Morphogenic dentin production
adhesives and microleakage. • In vivo studies have Protein (BMP 2,4,7) • Formation of more • cost can be obstacles for
hybridizing dentin demonstrated that Recombinant insulin homogeneous their clinical application
bonding agents the application of an like growth factor-I reparative dentin • Fail to stimulate
adhesive resin directly Other growth factors • Superior to Ca(OH)2 reparative dentin in
onto a site of pulp (1998) in the mineralization inflamed pulp
exposure, or to a thin Epidermal growth inducing properties • Half life is less
layer of dentin (less factor • Dentin bridge formation • High concentration is
than 0.5 mm), causes Fibroblast growth was equal to dycal after required
dilatation and congestion factor 28 days • Delivery vechicles used
of blood vessels as well Insulin like growth • Only TGF-b1 induced for the molecules show
as chronic inflammatory factor II reparative dentin potent effects at the
pulpal response Platelet-derived formation pictogram level and
growth factor-BB appropriate carriers will
TGF-b 1 be required to facilitate
their handling in the
Calcium phosphate • Helps in bridge • Clinical trials are clinical situation
(1900’s) formation with no necessary to evaluate • Appropriate dose
superficial tissue this material response is required
necrosis to avoid uncontrolled
• significant absence obliteration of pulp
of pulp inflammation chamber
compared to Ca(OH)2 • Possibility of
• Good physical immunological problems
properties due to repeated
implantation of active
molecules
Hydroxyapatite (1995) • Biocompatible • Mild inflammation with • Other factors does not
• Act as scaffold for superficial necrosis of induced reparative dentin
the newly formed pulp formation
mineralized tissue
Bonesialoprotein • Induced homogeneous • Further clinical studies
(2000) and well mineralized are needed
reparative dentin
Lasers (1995-2010) • Formation of secondary • Technique sensitive • Superior to Ca(OH)2
CO2 dentin • Causes thermal damage in the mineralization
• sterilization of targeted to pulp in high doses inducing properties
Nd: YAG tissue • Technique sensitive
• Bactericidal effects • Causes thermal damage Biodentin • Biocompatible • More long-term
to pulp in high doses (2000) • Good antimicrobial • clinical studies are
activity. needed for a definitive
• Stimulate tertiary dentin evaluation of Biodentine
formation
Glass ionomer/ • Excellent bacterial seal • Causes chronic • Stronger mechanically,
• Fluoride release, inflammation less soluble and
Resin modified glass coefficient of thermal • Lack of dentin bridge produces tighter seals
ionomer expansion and modulus formation compared to Ca(OH)2
(1995) of elasticity similar to • Cytotoxic when in direct • Less setting time, good
dentin cell contact handling characteristics
• Bond to both enamel • Poor physical properties, than MTA
and dentin high solubility and slow
ENZYMES • Play a cytoprotective • Further in vitro and in
• Good biocompatibility setting rate
role against pro vivo studies are required
• • RMGIC is more cytotoxic
Heme-Oxygenase-1 inflammatory cytokines • In high concentration
than conventional GIC,
(2008) and nitric oxide in causes pulp tissue
so it should not be
human pulp cells damage.
applied directly to the
• Prevent H2O2 induced • Careful evaluation
pulp tissue
cytotoxicity and is required before
oxidative stress in clinical application to
human dental pulp cells. determine the suitable
Mineral trioxide • Good biocompatibility • More expensive Simvastatin (2009) • Anti inflammatory action concentration when
aggregate • Less pulpal • Poor handling • Induction of applied indirectly to a
(1996-2008) inflammation characterstics angiogenesis cavity or directly to pulp
• More predictable hard • Long setting time • Improve the function tissue.
tissue barrier formation • Grey MTA causes tooth of odontoblasts, thus
in comparison to discoloration leading to improved
calcium hydroxide • Two step procedure dentin formation
• Antibacterial property • High solubility
STEM CELLS • Regeneration of dentin- • Less economic
• Radiopacity
(2009) pulp complex • Technique sensitive
• Releases bioactive
Dental pulp stem cells • SHED is superior to
dentin matrix proteins
(DPSCs) DPSCs
Stem cells from
human exfoliated
deciduous teeth
(SHED)
MTYA1-Ca • Helps in dentine bridge • Presence of 10%
(1999) formation without Ca(OH)2 interferes Propolis • Antioxidant, •
formation of a necrotic with complete curing (2005-2010) antibacterial, antifungal, • Showed mild /
layer of material, residual antiviral and anti- moderate inflammation
• Shear bond strength is monomers causes inflammatory properties after 2,4 weeks with
higher than conventional cytotoxicity • partial dentinal bridge
GIC and similar to • Superior bridge formation.
RMGIC formation compared
• Dentin bridge formation to Dycal, similar results
without reduction to MTA
of pulp space in •
MTYA1-Ca, but there is • Forms dental pulp
reduction of pulp space collagen, reduces both
is seen in dycal. pulp inflammation and
• Better adhesion to degeneration.
dentine •
• Stimulate reparative
dentin formation

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PARTICULARS OF CONTRIBUTORS:
1. Senior Lecturer, Meghana Institute of Dental Sciences, Nizamabad, Andhrapradesh
2. Senior Lecturer, Meghana Institute of Dental Sciences, Nizamabad, Andhrapradesh
3. Professor & HOD, Meghana Institute of Dental Sciences, Nizamabad, Andhrapradesh
4. Professor, Meghana Institute of Dental Sciences, Nizamabad, Andhrapradesh
5. Reader, Meghana Institute of Dental Sciences, Nizamabad, Andhrapradesh. 

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Asma Qureshi, Date of Submission: Sep 21, 2013
Meghana Institute of Dental Sciences, Nizamabad, Andhrapradesh. Date of Peer Review: Dec 03, 2013
Phone: 07893191667, E-mail: [email protected] Date of Acceptance: Dec 13, 2013
Date of Publishing: Jan 12, 2014
Financial OR OTHER COMPETING INTERESTS: None.

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