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reason to control pulpal bleeding 1) increased bleeding--> indication of inflammation 2) difficult to obtain and adequate seal b/c of mositre & contamination of dentin from bleeding direct pulp cap medicament is placed directly over exposed pulp Indirect pulp cap cavity liner/sealer is placed over residual caries to maintain pulp vitality some restorative matierals if placed directly on the pulp can cause cytotoxicity & immunosupression if they are LC, can raise pulp temp Mechanical exposure better outcome than bacterial exposure asymptomatic teeth of pulp capping fare better than w/ pathology (Rad, inflammation) ability to control bleeding before placing cap influences outcome 1. more bleeding= worse exposure/infection 2. bleeding leads to moist dentin which id difficult to obtain a seal agent to help control bleeding saline: easiest on tissue NaHClO2: some inflammation, but anti-bacterial & hemorrhage contorl Chlorohexidine: antibcaterial but not effective for hemorrahge ferric sulfate : increased post op pain ferric sulfate increase post op pain Chlorohexidine ntibcaterial but not effective for hemorrahge Direct pulp capping materials ZOE (zinc oxide eugenol) adhesive system GI/RMGI CaOH MTA (mineral trixoxide aggregate) ZOE eugenol is cytotoxic release eugenol in coc that are cytotoxic effeciveness of ZOE to exclude bactiera is reduced in the mouth over time high interfacial leakagye chronic inflammation, no pulp healing, no dentin bridge formation after 12wks, while control CaOH healed in 4wks RMGI cytotoxic but less than ZOE chronic inflammation Good biocompatibility if not directly on pulp (close approximation) Good seal formation (precludes cavities and toxins from pulp) Human study: chronic inflammation, no dentin bridge formation after 300 days, CaOH better healing Adhesive system cytotoxic to pulp cells (esp unpolymerized components) Animal study: mechanical exposure had healing similar to CaOH, bacterial had poor healing Etch/prime are vasodilators (more bleeding, less polymerization, less seal, more cytotoxic polymer) CaOH gold standard of direct pulp capping excellent antibacterial propertieis highly soluble Advantages: antibacterial, high pH stimulates healing, long term clinical success record Solubilize BMP (bone morphogenic protein) & TGF-B1 (transforming growth factor beta 1) from dentin, which stimulate pulp repair Disadvantages: highly soluble, dissolution over time, no adhesive qualities, poor seal, tunnel defects in reparative dentin MTA Mineral trioxide aggregate Mostly CaO, which reacts w/ H2O to form CaOH advantage of MTA similar to CaOH; antibacterial, biocompatible, high pH, radiopacity, aids release of bioactive dentin matrix proteins Differences of MTA white & gray (Fe added) colors, able to provide some seal to tooth structure Disadvantages of MTA high solubility, Fe can darken tooth, prolonged setting (~3hrs; pulp capping needs 2 procedures w/ a temporary or GI/RMGI sealer), 24xs as expensive as CaOH the reason MTA is more successful than Ca OH serve as a reservoir for Ca OH : antibacteria provide seal at the site of pulp exposure however, GI or RMGI will be needed as a liner over either pulp cap material (MTA or CaOH) MTA vs CaOH (similarity) antibacterial and biocompatiblity high pH radiopacity can release bioactive dentin matrix proteins MTA vs CaOH (difference) MTA can provide some seal to tooth structure disadvantage of MTA prolonged setting time less cost effective MTA over exuberance? MTA > Ca OH for pulp capping mechanically exposed human teeth Does CaOH provide any benefits over MTA CaOH shows long term clinical success Tunnel defect patency from the site of pulp exposure through the reparative dentin to the pulp sometimes having fibroblasts & capillaries present in the defect Avoid exposing pulp survavial chances are good if tooth is asymptomatic & well sealed How to control hemorrage H2O, saline, sodium hypochlorite H2O and saline for hemorrage benign to pulp Sodium hypochlorite for hemorrage best at controlling hemorrhage & disinfecting ZOE, GI/RMGI poor direct pulp capping against avoid MTA comparable to CaOH in short term data CaOH gold standard longest record cost-effective probably the effective component in MTA The best way for pulp capping provide well sealed restoration after pulp capping to portect from leakage & bacterial contamination