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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 633-637
The effectiveness of using different pulp-capping agents on the healing response of the pulp


1 Department of Biomedical Dental Sciences, University of Dammam, Dammam 31551, Saudi Arabia
2 College of Dentistry, University of Dammam, Dammam 31551, Saudi Arabia

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Date of Submission17-Dec-2009
Date of Decision26-Feb-2010
Date of Acceptance09-Sep-2010
Date of Web Publication19-Feb-2013
 

   Abstract 

Background: Some of the disadvantages of calcium hydroxide Ca(OH) 2 as pulp-capping material are related to the inflammatory response, and its poor sealing ability. Cyanoacrylate glue was proposed in this study as pulp-capping agent because of its sealing ability, and diprogenta, on the other hand, was proposed because of its anti-microbial and anti-inflammatory effects.
The aim of this study is to evaluate and compare the histopathological response of the pulp toward cyanoacrylate and diprogenta in direct pulp capping (DPC).
Materials and Methods: Cyanoacrylate, diprogenta, and calcium hydroxide were applied on 20 permanent teeth of 6 rabbits divided into four groups, each contains five teeth, as follow: G1: Diprogenta and calcium hydroxide. G2: Cyanoacrylate. G3: Diprogenta and cyanoacrylate. G4: Calcium hydroxide (control group).
Results: A remarkable dentin bridge formation was found in all groups. No pulp necrosis was found in any tooth of the four groups. Pathological reactions of the pulp were found in 25%, 40%, 20%, and 100% of groups 1, 2, 3, and 4, respectively. Differences between study and control groups were found statistically significant ( P < 0.05).
Conclusion: All materials used in this study were biocompatible and suggested to be studied further on human teeth. These materials when used in combination with Ca(OH) 2 , may give better results

Keywords: Calcium hydroxide, cyanoacrylate, diprogenta, direct pulp capping

How to cite this article:
Aljandan B, AlHassan H, Saghah A, Rasheed M, Ali A A. The effectiveness of using different pulp-capping agents on the healing response of the pulp. Indian J Dent Res 2012;23:633-7

How to cite this URL:
Aljandan B, AlHassan H, Saghah A, Rasheed M, Ali A A. The effectiveness of using different pulp-capping agents on the healing response of the pulp. Indian J Dent Res [serial online] 2012 [cited 2019 Dec 13];23:633-7. Available from: http://www.ijdr.in/text.asp?2012/23/5/633/107381
Ever since dentistry has dealt with dental caries, it has been searching for a medicament which, when placed in direct contact with exposed pulp, would result in a reparative dentin bridge and pulp healing. [1]

The vital pulp tissue contributes to the production of secondary dentin, peritubular dentin (sclerosis), and reparative dentin in response to biological and pathological stimuli. Indeed, a vital functioning pulp seems to be the best barrier for protection from microorganisms that may invade the pulp tissues. [2]

Direct pulp capping is one of the therapeutic options by which we cover the traumatically exposed surface of the pulp to maintain its functional and biological activities. Inducing hard tissue formation by pulp cells as an ultimate goal of capping material used has been widely accepted. [3]

So many materials had been thoroughly investigated in vivo and in vitro studies in order to get an effective pulp capping material that should ideally be biocompatible, provide a biological seal and prevent bacterial leakage. [4] Included in these materials are zinc oxide eugenol, calcium hydroxide Ca(OH) 2 , mineral trioxide aggregates (MTA), bone morphogenetic protein-7 (BMP-7), dentin and pre-dentin fragments implanted in the pulp and bone sialoprotein (BSP). [5]

Zinc oxide eugenol has been studied and reported to result in little, if any, reparative dentin bridge formation. In several reports, a chronic inflammatory response may persist for some time. [1] Ca(OH) 2 , because of its low-grade irritation to the traumatized pulp tissue, has been the material of choice for pulp capping but with known disadvantage being poor sealing ability. [6] MTA has been introduced as a suitable material for direct pulp-capping treatment, demonstrating a remarkable success rate compared with various Ca(OH) 2 preparations. Although MTA has superior biocompatibility, it has a delayed setting time, poor handling characteristics and off-white color. [3]

Recently, several studies reported the use of cyanoacrylate glue in different modalities of treatment including varices, [7] surgical wounds, [8] cleft lip and palate (CLP), [9] and in soft tissue surgery of head and neck. [10],[11],[12] A new study done on animals in Saudi Arabia showed that the cyanoacrylate is adequate to stabilize the nerve injury during regeneration period. [13]

On the other hand, gentamycin with dexamethason were found to have good topical antimicrobial and anti-inflammatory effects on the soft tissues, respectively. [14],[15] This had motivated us to use both cyanoacrylate and diprogenta with calcium hydroxide Ca(OH) 2 in direct pulp-capping procedure as multiple layers.

The purpose of this study was to evaluate and compare, histopathologically, the healing response of the dental pulp toward cyanoacrylate and diprogenta when used with calcium hydroxide Ca(OH) 2 in direct pulp capping.


   Materials and Methods Top


Twenty permanent teeth from six rabbits were used for this study. Initially, all rabbits were sedated with ketamin 1 mg/kg, given intramuscular (IM) according to their weight measurements.

Class V cavity preparation was done on the buccal surfaces of both upper and lower permanent anterior teeth under rubber dam isolation with two small carbide round burs which were changed after every four teeth.

Latched type air turbine (approximately 20,000 r/min) with saline spray was used to prepare these cavities by removing the dentin until a very thin pulpal floor remained. A pin-point pulp exposure was then made by a very small round bur [Figure 1]b. Bleeding of the pulp was controlled by a sterile cotton pellet.

Teeth under study (n = 20) were then divided into four groups, each contains five teeth [Figure 1]a. With each group, the following materials were used as described below:
Figure 1: (a) Rabbit teeth before the operation, (b) Pin-point pulp exposure, (c) Application of the pulp-capping agents, (d) and after the operation

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Group 1: A thin layer of gentamycin with dexamethason (Diprogenta*cream. Schering-plough corporation/USA) was placed carefully on the exposure site, followed by calcium hydroxide as a second layer on top of it and allowed to set.

Group 2: 2-Octyl cyanoacrylate (Derma Bond* for ETHICON) only.

Group 3: Thin layer of diprogenta was placed carefully on the exposure site, followed by cyanoacrylate as a second layer and allowed to set.

Group 4: Calcium hydroxide Ca(OH) 2 was placed alone, following the conventional technique of direct pulp capping and considered as a control group. [Figure 1]c

Coltosol,® [zinc oxide, zinc sulphate-1-hydrate, calcium sulphate-hemihydrate, diatomaceous earth, EVA resin, natrium fluoride, peppermint aroma], was then used as temporary filling after pulp capping in all groups [Figure 1]d. All rabbits were sacrificed after 8 weeks, and teeth under study were extracted and placed unmixed in containers with 10% formaldehyde. Teeth were decalcified in formic acid sodium citrate, dehydrated, embedded in paraffin, sectioned at 8 μm, and stained with hematoxylin and eosin. The histopathological response was evaluated to assess the reaction of the pulp tissue and the formation of new dentinal bridges.

Reaction of the pulp tissue was graded as follows: (-) Normal pulp tissue, (+) abnormal histopathological features of the pulp tissues that may include one or more of the following: Pulp hyperemia, presence of inflammatory cell infiltration, or even pulp necrosis.

Ethical approval

This study was approved by the local committee of biomedical ethics in the King Faisal University.

Statistical analysis

Statistical analysis was performed with the program Epi info 2000 using Chi-square test. A P value of < 0.05 and confidence interval at 95% were considered to be statistically significant. When an expected cell value in Chi- square was less than 5, Fisher test was used.


   Results Top


This study was done on 6 rabbits whose teeth were divided into four groups; each consists of five teeth as mentioned in the methodology before.

Of all teeth used in this study ( n = 20), two teeth were excluded because one of the rabbits died 3 weeks after procedure. One tooth belonged to the first group (diprogenta) and the other one belonged to the control group (calcium hydroxide).

Histopathological evaluation of the dental pulp in group (1) revealed that 25% showed abnormal histopathological features of the pulp tissues.

In group (2), 40% had abnormal histopathological features of the pulp tissue. A 20% in group (3) had abnormal histopathological features of the pulp.

All teeth (100%) in control group (group 4) had abnormal histopathological features of the pulp. However, no pulp tissue necrosis was found in any tooth from all groups [Table 1] and [Figure 2].
Figure 2: (a) Histopathological micrographs showing; normal pulp tissue at low magnification, (b) normal pulp tissue at high magnification, (c) abnormal pulp tissue at low magnification showing pulp hypremia, (d) pathological reaction of the pulp tissue at high magnification; see the dilation of the blood vessels "blue arrow" and few inflammatory cells "yellow arrow"

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Table 1: Histopathological response of the pulp among the four groups

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Significant statistical differences were found between normal and abnormal histopathological response of the pulp among study groups (group 1, 2, and 3) and group 4 (control group) ( P < 0.05). However, no significant statistical differences were found between the three groups 1, 2, and 3.


   Discussion Top


Traumatic pulp exposure can accidentally occur, especially with low-experienced clinicians, during caries removal associated with deep cavity preparation. [2] And if so, dental pulp can heal completely and return to normal only if the area of operation is bacteria-free and properly isolated with rubber dam. This has been proved by several studies done on animals and humans' teeth. [1],[2],[3]

One of the well-known treatment options available is DPC. In this field, many studies were done in order to form the ideal DPC material. Ca (OH) 2 being an example of the most commonly used DPC materials, has some disadvantages. One of these is its inflammatory response, [1] and its poor sealing ability. [6] Cyanoacrylate glue was proposed in this study as pulp-capping agent because of its sealing ability, [7],[8],[9],[10],[11],[12],[13] and diprogenta, on the other hand, was proposed because of its anti-microbial and anti-inflammatory effects. [14],[15] The results of this study may indicate that using cyanoacrylate glue and diprogenta was better than using Ca(OH) 2 alone, as we found only 28.6% showing an abnormal histopathological features of the pulp in groups (1, 2, and 3), while similar abnormal histopathological features were found in all teeth (100%) in control group (group 4). These results were statistically significant ( P < 0.05).

Cyanoacrylate glue was thoroughly investigated, and widely used and accepted in many treatment modalities such as variceal bleeding, [7] mucous, and cutaneous wound healing. [8] It was also recently introduced in dental field as an alternative to skin sutures in primary cleft lip repair. [9] Furthermore, there was a study done in Saudi Arabia to evaluate its effect on sciatic nerve neurotomy, and it showed re-anastomosis with high degree of neural biocompatibility, [13] and in addition to that, it showed easy application and faster healing. [11],[12] This motivated us to use it over the dental pulp and our results may support these findings as we found an abnormal pulp tissue in 40% in group (2) and 20% in group (3), compared with 100% abnormal histopathological features of the pulp in group (4). However, statistically these differences were not significant ( P > 0.05).

Statistically, significant reduction in the histopathological changes of the pulp tissue including the inflammatory response (P < 0.05) was noted in group 1 (diprogenta) when compared to group 4 (control group). This may indicate the beneficial effect of using diprogenta under calcium hydroxide during direct pulp capping.

On the other hand, we found 25% and 20% showing abnormal histopathological features of the pulp in groups (1 and 3), respectively, compared with 100% abnormal histopathological features of the pulp in control group (P < 0.05). These results support the findings of another study done to observe the effects of dexamethason when directly applied on dental pulp tissue, where they found that this steroidal anti-inflammatory agent regulate the commitment of progenitors derived from dental pulp cells to form odontoblast-like cells leading to reparative dentinogenesis. [16] It might be suggested that diprogenta may improve the reparative dentinogenesis process indirectly by inhibiting the inflammatory process which always occurs after pulp exposure.

In our study, a period of 8 weeks was used to evaluate the effect of capping materials on pulp tissues. Another study published used the same time interval. [1] Although similar time intervals were used in many studies, [3],[17],[18] Unfortunately, we found this period to be long because a thick layer of reparative dentine had been formed by that time. Accordingly, an interval of 2-4 weeks would be recommended as fairly enough for further studies on rabbits, as we noticed a rapid growth of reparative dentine. Taking into consideration that rabbit incisor teeth are open-rooted and, in healthy animals, grow continuously. [19] However, our positive results may encourage us to make further studies using these materials on closed-rooted animal teeth or even on human teeth.

In conclusion, all materials used in this study were found to be biocompatible and suggested to be studied on human teeth. These materials when used in combination with Ca(OH) 2 , would give better results than Ca(OH) 2 alone.

Further investigations are needed to evaluate their effectiveness in its full potential on human teeth.

 
   References Top

1.Heys DR, Cox CF, Heys RJ, Avery JK. Histological considerations of direct pulp capping agents. J Dent Res 1981;60:1371-9.  Back to cited text no. 1
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2.Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The radiographic outcomes of direct pulp-capping procedures performed by dental students: A retrospective study. J Am Dent Assoc 2006;137:1699-705.  Back to cited text no. 2
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3.Asgary S, Eghbal MJ, Parirokh M, Ghanavati F, Rahimi H. A comparative study of histologic response to different pulp capping materials and a novel endodontic cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:609-14.  Back to cited text no. 3
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4.Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using Mineral Trioxideaggregate as a Pulp-Capping Material. J Am Dent Assoc 1996;127;1491-4.  Back to cited text no. 4
    
5.Goldberg M, Six N, Decup F, Buch D, Soheili Majd E, Lasfargues JJ, et al. Application of bioactive molecules in pulp-capping situations. Adv Dent Res 2001;15:91-5.  Back to cited text no. 5
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6.Tziafas D, Belibasakis G, Veis A, Papadimitriou S. Dentin regeneration in vital pulp therapy: Design principles. Adv Dent Res 2001;15:96-100.  Back to cited text no. 6
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7.Paik CN, Kim SW, Lee IS, Park JM, Cho YK, Choi MG, et al. The therapeutic effect of cyanoacrylate on gastric variceal bleeding and factors related to clinical outcome. J Clin Gastroenterol 2008;42:916-22.  Back to cited text no. 7
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8.Castañón García-Alix M, Sancho Vendrell MA, Parri Ferrandis FJ, San Vicente Vela B, García Aparicio L, Tarrado Castellarnau X, et al. Utility of octyl 2-cyanoacrylate in pediatric surgery. An Pediatr (Barc) 2003;59:548-51.  Back to cited text no. 8
    
9.Magee WP Jr, Ajkay N, Githae B, Rosenblum RS. Use of octyl-2-cyanoacrylate in cleft lip repair. Ann Plast Surg 2003;50:1-5.  Back to cited text no. 9
    
10.Rimmer J, Singh A, Banwell P, Clarke PM, Rhys Evans P. The use of octyl-2-cyanoacrylate (Dermabond) tissue adhesive for skin closure in head and neck surgery. Ann R Coll Surg Engl 2006;88:412-3.  Back to cited text no. 10
    
11.Graefe H, Wollenberg B, Brocks C. Application of skin adhesives in head and neck surgery: Analysis of cosmetic results, applicability and cost-effectiveness of cyanoacrylate-based adhesives. HNO 2008;56:947-54.  Back to cited text no. 11
    
12.Bozkurt MK, Saydam L. The use of cyanoacrylates for wound closure in head and neck surgery. Eur Arch Otorhinolaryngol 2008;265:331-5.  Back to cited text no. 12
    
13.Elgazzar RF, Abdulmajeed I, Mutabbakani M. Cyanoacrylate glue versus suture in peripheral nerve reanastomosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:465-72.  Back to cited text no. 13
    
14.Friberg O, Svedjeholm R, Söderquist B, Granfeldt H, Vikerfors T, Källman J. Local gentamicin reduces sternal wound infections after cardiac surgery: A randomized controlled trial. Ann Thorac Surg 2005;79:153-61.  Back to cited text no. 14
    
15.Aslan O, Teberik K, Yucel M, Gur N, Karakoc AE. Effect of topical Diprogenta on the reduction of bacterial flora on the human conjunctiva. Eur J Ophthalmol 2008;18:512-6.  Back to cited text no. 15
    
16.Alliot-Licht B, Bluteau G, Magne D, Lopez-Cazaux S, Lieubeau B, Daculsi G, Guicheux J. Dexamethasone stimulates differentiation of odontoblast-like cells in human dental pulp cultures. Cell Tissue Res 2005;321:391-400.  Back to cited text no. 16
    
17.Dominguez MS, Witherspoon DE, Gutmann JL, Opperman LA. Histological and scanning electron microscopy assessment of various vital pulp-therapy materials. J Endod 2003;29:324-33.  Back to cited text no. 17
    
18.Ishizaki NT, Matsumoto K, Kimura Y, Wang X, Yamashita A. Histopathological study of dental pulp tissue capped with enamel matrix derivative. J Endod 2003;29:176-9.  Back to cited text no. 18
    
19.Brown C. Incisor adjustment in rabbits. Lab Anim (NY) 2009;38:193-4.  Back to cited text no. 19
    

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Correspondence Address:
A A Ali
Department of Biomedical Dental Sciences, University of Dammam, Dammam 31551
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.107381

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