Part 2 :

The pulp capping material are calcium hydroxide and MTA

Calcium hydroxide we have many brands of it , but in the clinics we use

two brands which is : DYCAL and LIFE .

So this is the names of the brands , not the material itself . Like ( vitrebond ) it is the name of a brand , when I ask some student of you what is the liner should be used? They answer vitrebond , what is vitrebond?!! It is Resin modified glass inomer ( RMGI ) , So vitrebond is the name of the brand , as well as DYCAL or LIFE . ( you have to know the difference ). * you have to apply it with applicator , NOT by brush , Not by plastic instrument , not any another instrument , Only by applicator .

# It is based on empirical ground . What is empirical ground? it is a relatively cheap material, cost effective, it is easy to apply, and most importantly it stimulates the formation of tertiary dentine # it is the most commonly used but not mean that it is the most suitable , it has disadvantages and disadvantages # What is the most common significant disadvantages of calcium hydroxide ? - Creating tunnel space defect in dentine bridge , causing bacterial microleakage to the pulp and so failure of our treatment . # What is the advantages ? - Anti bacterial ( high ph 11-12 ) this protect the pulp . # Mechanism of action : As you can see , this is a histological section , pulp exposure , and we have to apply the layer of calcium hydroxide here . 1) First of all it cause liquefaction necrosis of this superficial part of the pulp , it liquefies the soft connective tissue . 2) secondly , bcz it is necrosis , so will lead to production of toxins , so it neutralize the toxicity in deeper layer produced .

3) Then , Coagulative necrosis , there is an inflammation , So the blood pressure and the pulse is high , So there is flow of blood

4) After that there is Necrosis as well , more inflammation , more blood supply , and then necrosis , so we have a layer that is rich with undifferentiated cells that its going to be differentiated now , and this layer that is necritize is going to form the dentin bridge .

The second material is

# MTA : which is Mineral trioxide aggregate .

Basically it used to treat the root perforation and apexification and root closure , and then it was used in direct pulp capping . It is composed of 3 main components : - tricalciumsilicate - tricalciumaluminate - tricalciumoxide - silicateoxide How we apply it ? Of course , most of the time we dont use the rubber dam but actually it is going to ease our work .

Onetime in the clinic we use class 1 amalgam with rubber dam , It is very much easier than cotton roll . So if we have the exposure , and you have time , it is better to use rubber dam. At least one time within your requirements ( just to be experienced ).

So 1) we isolate the area 2) we mix it ( powder and liquid not paste like calcium hydroxide ) * powder : liquid ( 3: 1 ) 3) then apply it on the exposed area . 4) and wait for 5 minutes to set .

The properties : 1) Low or no solubility , ( ???? 52:00 ) and it will break with condensation of amalgam if you have high condensation force . 2) Cant be applied alone , we DONT apply it alone under any restorative material . 3) Ph [10.2-12.5] , 10.2 raises to 12.5 after 3 hours of setting . 4) Antibacterial effect . 5) Induced pulp (??) 6) Stimulation of re-mineralization which is the dentin bridge .
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 Anti-agent ( . ?) calcium hydroxide : - Rapid cell growth promotion in vitro . Vitro : experiments performed outside a living tissue , Vivo : experiments performed inside a living tissue ( animals or humanetc ) - Thicker dentin bridge - Less inflammation : we said we dont want uncontrolled inflammation , we want the inflammation , we want the blood supply bcz it is a defensive mechanism , but we dont want it to be destructive mechanism - Less necrosis - Induced formation of dentin bridge at faster rate . - High ability to resist the penetration of micro-organism . - The dentin bridge is thicker with no tunnel defect . # So this is important in the successful of direct pulp capping .

# The clinical steps of direct pulp capping : Very good isolation [ We maintain it in all of our operative work , even there is no pulp exposure , when we applying the liner , when we put our restorative material. Sterilization of the cavity using a cotton pellet soaked with chlorohexidine which is more concentrated than the one we use it in mouth wash , used here as antibacterial agent to disinfect the cavity. Or you can use sodium hypochlorite which might decreases the bleeding a little;but we use it here as antibacterial. Mix the calcium hydroxide or MTA then put it over the exposure site which its supposed to be a pin point exposure if larger go for RCT.
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 Use permanent restoration not temporary : Why ? 1- better coronal seal 2- -to minimize microleakage 3- good assis the symptoms of the tooth without misleading sedative effect due to eugenol that found in temporary filling. 4- if you put temporary restoration you will ask the patient to come after 2 weeks to replace it with permanent restoration; so here you apply more pressure on the tooth while its in critical phase so to minimize that pressure place a permanent restoration from the beginning.

** if the tooth is questionable & the patient with poor oral hygiene ; so you cant decide ,do I go for elective endodontic treatment or do I go for direct pulp capping , here you can use GIC as permanent material and in the same time you can replace it after a while , and it will give you good seal ,fluoride release and you can wait more than 2 weeks to replace it.

** We dont use calcium hydroxide alone we have to: - protect it with stronger layer of liner or base as vitrebond RMGI that should cover the whole floor smoothly. - protect the pulp from external stimulus. ** The RMGI is dual cured so you should use light cure. when you dont have pulp exposure but deep cavity with dark dentin you just apply RMGI alone .

# Future trends to treat pulp exposure : 1234Laser treatment Ozone technology Bioactive agents Stem cells and tissue engineering

At the end we use liner as a Barrier it promotes healing and dentin formation Sometimes we need to put another stronger layer of liner or base. Why?

A: To protect the lining material and protect the pulp from any stimulus.
- Put in your mind what we have to do in the clinic : layer of calcium hydroxide and layer of resin bone or RMGI . - To encourage recovery of injured pulp and protect it from virus and cells . Indirect pulp capping : Definition : It is not actual pulp exposure , it is near the pulp exposure . Indications : 1) Deep caries lesion : very closed to the pulp but without
real exposure to pulp

2) Excessive crown preparation : when you do this you will see the shadow of the pulp ( pinkish shadow ) .
3) Trauma : you can see that you are very deep and very close .

A student ask a question : Q : is it the same as Sandwich technique ?? A: No it is not , Suppose that class II cavity , you have to determine that the pulp is below or at the gingival level . and you can maintain very good isolation in critical area . And for example you have to put composite restoration so you need very isolation and moisture control and you must have good etched enamel surface and the dentin must be conditioned very well , and the adhesion to enamel is better than adhesion to dentin , and in that specific area we dont have that much enamel , so this will compromise our treatment , So what can we do ? we can put a layer of glass inomer , it is less technique sensitive , there is no material that is not technique sensitive , you still need to provide the isolation , But it is LESS in GIC , it binds chemically to tooth structure , and it releases the fluoride , after that we apply a layer of composite restoration , so it is a Sandwich technique . We have open sandwich and closed sandwich , in open : the GIC is exposed to the oral cavity , we put a layer of GIC then a layer of composite , in closed : a layer of GIC but the external border is still composite restoration .

The happy end of part 2 Done by : Eman nazzal And special thanx to marwa halalmeh