Endodontic Topics 2003, 5, 4148 Copyright r Blackwell Munksgaard

Printed in Denmark. All rights reserved ENDODONTIC TOPICS 2003

Current restorative concepts of

pulp protection
ANDRE V. RITTER & EDWARD J. SWIFT JR.

The goals of restorative therapy are not only to restore the tooth to proper form and function, but also to minimize
postoperative sensitivity and preserve pulp vitality. Today, thanks to the evolution of adhesive materials and
techniques, more conservative tooth preparations are possible. Conservative preparations preserve tooth structure,
and adhesive restorations seal the dentinpulp complex to minimize microleakage and postoperative sensitivity,
providing appropriate conditions for the maintenance of pulp vitality. Many pulp protection strategies are currently
available, and the choice of treatment is based on the severity of the defect being restored, and the type of
restoration being placed. This paper reviews current restorative concepts of pulp protection, with emphasis on a
new approach based on total adhesion of restorations to conservative preparations.

Introduction toothrestoration interface leading to marginal leakage

of bacteria and toxins (911). The role of bacterial
The restoration of compromised dental structure
infection on pulp pathologies was proposed in the mid-
requires attention to function, esthetics, and biology.
1960s, and has been revisited in later years (1214).
Function and esthetics often can be restored to
During the last 20 years, a new approach to pulp
satisfaction with current restorative materials and
protection has been proposed in many countries, with
techniques. However, the biological requirements of
more emphasis being placed on the ability of restorative
dental restorations are poorly understood. Since
materials to prevent or neutralize bacterial penetration
stimulated dental regeneration is still not a reality,
along the toothrestoration interface (1518). The
dental amalgam, resin-based composites, ceramics, and
purpose of this paper is to review current restorative
metals are used to restore missing parts of teeth.
concepts of pulp protection. Because the conservative
Biologically, these materials are not expected to behave
treatment of pulp exposures is addressed elsewhere in
entirely like dentin or enamel, but dental restorations
this issue, this paper will concentrate on pulp protec-
should restore and protect the integrity of the dentin
tion of a vital non-exposed pulp.
pulp complex.
For many years, it was believed that restorative
materials themselves were toxic to the pulp. Based on
Common causes of pulp injury
that assumption, the use of bases and liners covering
the vital dentin for pulp protection was considered In restorative dentistry, the following can be consid-
essential to the success of the restoration. This ered as the most common causes of pulp injury, before,
recommendation was based on studies that linked pulp during, and after a restoration is placed:
reactions to the low pH of dental materials (15). 1. Presence of bacteria in the dentinpulp complex.
However, it is now believed that the main reason for Cavitated carious lesions provide a niche for bacteria
the biological failure of restorations is not related to pH to aggregate and proliferate. Once the lesion
or other attributes of the restorative material (68), but reaches the dentinoenamel junction (DEJ), bacteria
rather to the poor ability of restorations to seal the and their toxins can travel through the dentinal

41
Ritter & Swift
tubules and reach the pulp. Residual bacteria left
after caries excavation, as well as bacteria reaching
the dentinpulp complex through microleakage,
can also cause pulp disease.
2. Exposure of patent dentinal tubules. Patent dentinal
tubules communicate directly to pulp cells. These
can be present in cervical areas of the tooth
unprotected by enamel or cementum, and in
dentin/pulp exposures after trauma. Patent dent-
inal tubules might also be present in poorly sealed
walls beneath restorations, and contribute greatly to
postoperative sensitivity.
3. Depth of tooth preparation. The deeper the prepara-
tion, the greater is the chance for direct or indirect
pulp exposure. Deep preparations expose wider and
more dentinal tubules per square millimeter than
shallow preparations, which can lead to pulp injury
when dentin is not properly sealed. However,
preparation depth per se seems to be irrelevant for
the pulp as long as the preparation is not con-
taminated and the surface seal is maintained.
Torstenson and Brannstrom (19) histologically
evaluated pulp responses to amalgam restorations
placed in teeth that would be extracted for
orthodontic reasons. When contamination of the
preparation was avoided, no inflammatory cells were
found in the pulp of most specimens, even when the
remaining dentin thickness (RDT) in the prepara-
tions was as little as 0.15 mm, and regardless of the
use or not of a pulp protection material.
4. Dentin dehydration. When working with vital
dentin, overdrying should be avoided. Dehydration
of the dentin surface by overdrying results in
outward fluid flow, which in turn can result in
aspiration of odontoblast cells (20).
5. Heat generation. Dentin has good insulative poten-
tial, but heat generation during tooth preparation,
light-curing, and finishing/polishing of a restora-
tion can injure the pulp. It has been shown that a
5.51C increase in pulpal temperature result in a 15%
chance of necrosis, and an 111C increase result in
60% chance of necrosis (21).
The dentinpulp complex is capable of counteracting
many of these insults. However, the cumulative
incidence of these and other injuries can reduce its
defense and repair potential.
The age of the tooth also influences its response to
injuries. In general, a younger pulp is more resistant
and can more readily offset irritants than an older pulp.
42
On the other hand, a young tooth has a larger pulp
chamber and more permeable dentin structure than an
old tooth, due to the deposition of secondary and
intratubular dentin that occurs with time. These
biological factors must always be taken into considera-
tion when selecting a pulp protection technique or
material.
Pulp protection materials
The selection of pulp protection material is a function
of (1) the restorative material being used and (2) the
RDT between the pulp and the pulpal or axial walls of
the final tooth preparation (Fig. 1). Tooth preparations
are often classified according to their depth as shallow
or deep. However, the concept of preparation depth is
better applied when it relates to the RDT as opposed to
the distance from the cavosurface margin to the pulpal
or axial wall.
Pulp protection materials can be generically classified
as bases, liners, varnishes, sealers, and dentin adhesives.
1. Bases. Bases are used in relatively thick layers
(41 mm) between the restorative material and the
tooth preparation. These have been traditionally
used to provide thermal and electrical insulation,
mechanical pulp protection, and to create an ideal
tooth preparation form in deep preparations.
Currently, bases are almost exclusively used only as
internal buildups to block undercuts in preparations
for indirect inlays and onlays. Examples of bases are
zinc phosphate cement, zinc polycarboxylate ce-
ment, zinc oxideeugenol cement, and glass iono-
mer cements and derivatives. By virtue of their
adhesive and fluoride-releasing properties, resin-
modified glass ionomer cements (e.g. Vitrebond,
3M ESPE; Fuji Lining LC, GC America, Alsip, IL,
USA) should be favored when a base is required.
2. Liners. Liners are more fluid than bases, and used in
thin layers (approximately 0.5 mm). Liners have
been used traditionally to protect the dentinpulp
complex from the potential toxic effects of restora-
tive materials. Currently, liners are used to seal the
dentinal tubules reducing dentin permeability, as
antibacterial agents, and as fluoride-releasing
agents. Examples of liners are hard-set calcium
hydroxide (CH) cements and glass ionomer ce-
ments. Due to their biological properties (high pH,
antibacterial, stimulation of reparative dentin
formation), CH cements (e.g. Dycal, Dentsply
 Pulp protection

Fig. 1. The remaining dentin thickness (RDT) after tooth preparation will many times dictate the choice of pulp
protection technique. The table represents suggested pulp-protection techniques according to RDT and the final
restorative material. *CH: hard-set calcium hydroxide; RMGI: resin modified glass-ionomer; DA: dental adhesive. **For
Indirect bonded restorations, use DA; for Indirect centered restorations, use Sealer.

Caulk, Milford, DE, USA; Life, Sybron Kerr,
Orange, CA, USA) are indicated for direct and
indirect pulp caps, and when the RDT is judged to
be less than 0.5 mm. CH cements do not adhere to
dentin, have poor physical and mechanical proper-
ties, and are extremely soluble. Therefore, they have
to be covered by a layer of resin-modified glass
ionomer cement before the final restoration is
placed. When the RDT is judged to be more than
0.5 mm, sealers and adhesives should be used in lieu
of liners.
3. Varnishes. Varnishes are synthetic or natural resins
suspended in organic solvents. When applied,
varnishes form a non-uniform 5 mm-thin pellicle
covering the tooth preparation walls. For many
years, copal resin varnishes have been used under
amalgam restorations and crowns to seal the dentin.
Varnish use has decreased substantially due to their
high solubility and poor sealing ability (2224),
and because sealers are more advantageous than
varnishes.
4. Sealers. Sealers are aqueous solutions of resins (e.g.
2-hydroxyethylmethacrylate (HEMA)), antibacterial
agents (e.g. benzalkonium chloride, chlorhexidine),
and/or desensitizing agents (e.g. glutaraldehyde).
Combinations of these compounds are found in
specific commercial products (e.g. Gluma Desensi-
tizer, Heraeus Kulzer, Armonk, NY, USA, is an
aqueous solution of 35% HEMA and 5% glutar-
aldehyde). Sealers are compatible with a variety of
restorative materials. Sealers are used in place of
varnishes under amalgam restorations and full
crowns. Other examples of sealers include HurriSeal
(Beutlich Pharmaceuticals, Waukegan, IL, USA)
and Aqua-Prep F (Bisco, Inc., Schaumburg, IL,
USA).
5. Dentin adhesives. The adhesion of restorations to
dentin can be considered a truly new concept of
pulp protection, even though this technique was
first described many years ago (2527). Virtually all
adhesives today bond simultaneously to enamel and
dentin; therefore, they should be more correctly
referred to as dental adhesives. Dental adhesives
provide pulp protection by making possible con-
servative tooth preparations and by sealing out
bacteria from the toothrestoration interface. Ad-
hesion and its role in pulp protection are discussed
in more detail in the next section of this article.
A new pulp protection concept: total
adhesion
As discussed earlier, the preservation of tooth structure
and the maintenance of a bacteria-free interface in the
restoration contribute equally to pulp protection.
Adhesive restorative techniques contemplate these
objectives. Dental adhesives enable clinicians to gen-
erate more conservative tooth preparations because (1)
most (if not all) of the retention is obtained through
adhesion and micromechanical retention, (2) resistance
form is less critical with an adhesive restoration than
with a non-adhesive restoration, and (3) unsupported

43
Ritter & Swift

enamel frequently can be preserved, minimizing the between adhesive resins and dentin are not excluded
extension of the preparation outline and improving (5759), it is generally accepted that dentin bonding
marginal seal. relies primarily on a micromechanical interaction
In vitro evaluations of enamel and dentin adhesives similar to enamel bonding, mediated by the permea-
have been extensively performed, with promising tion of resin monomers into etched and primed dentin
results (2838). (27, 6062). The entanglement of the in situ
The clinical performance of adhesive restorations has polymerized adhesive resin with collagen fibrils and
been validated by prospective studies (3948) and residual hydroxyapatite crystals is called the hybrid
retrospective studies (4850), and has been described layer or resindentin interdiffusion zone (Fig. 3) (63,
in review articles (5052). 64). The composition of the hybrid layer is reported to
Despite this evidence, unfortunately it is still not be approximately 70% resin and 30% collagen (65).
possible to categorically state that current dental
adhesives are a final answer to the adhesion challenge,
for the following reasons: (1) more long-term con-
trolled clinical trials are needed to confirm the good
performance of adhesive materials; (2) adhesive systems
are sensitive to application technique, storage, manip-
ulation, and substrate; and (3) long-term in vitro
investigations suggest deterioration of bonds over time
(53, 54). The latter might or might not be clinically
relevant, but is certainly a matter of concern. It is
important to know and recognize these limitations
when discussing the role of adhesive systems in
preventing microleakage.
In restorative dentistry, microleakage is defined as the
Fig. 2. Scanning electron micrograph of instrumented
leakage of ions, fluids, bacteria, and bacterial bypro-
dentin. A relatively uniform smear layer covers the dentin
ducts through the toothrestoration interface (55, 56). surface and penetrates the dentinal tubules (original magni-
Microleakage occurs when there is poor seal or even a fication 5 6000, courtesy Dr Guilherme C. Lopes,
lack of effective contact between the tooth preparation UFSC, Brazil).
and the restorative material. The pathological compo-
nent of microleakage is bacterial infection of dentin and
pulp, and its consequence is secondary caries and pulp
pathology. Microleakage also can lead to the failure of
the restoration through partial or total loss of the
restorative material.
When properly applied, current adhesive systems can
substantially minimize marginal microleakage in re-
storations made with amalgam, composite, ceramics, or
metal. This potential is even greater when all cavosur-
face margins of the preparation are in enamel, since
enamel bonding is still more predictable and stable than
dentin bonding.
For contemporary adhesive systems, dentin bonding
requires removal or modification of the smear layer, a
semi-permeable 0.52.0mm-thick film composed of Fig. 3. Scanning electron micrograph of dentin treated
denatured collagen and mineral crystals generated with self-etching primer dental adhesive. Note penetra-
tion of dental adhesive into the dentinal tubules forming
during cavity instrumentation (Fig. 2), and superficial resin tags, and formation of hybrid layer through the
demineralization through the application of an acidic smear layer (original magnification 5 3500, courtesy
conditioner or primer. Although chemical reactions Dr Paulo C. Capel, USP, Brazil).

44

This layer of resin-saturated demineralized dentin can
provide high bond strengths and a tight seal against
microleakage.
By virtue of their resinous composition, dental
adhesives are most compatible with composite resins
Fig. 4. Occlusal view of maxillary bicuspid with tooth
fracture and secondary caries.
Fig. 5. After caries excavation, note conservative nature
of tooth preparation.
Fig. 6. After installation of a contoured partial matrix
and anatomic wooden wedge, enamel and dentin are
simultaneously etched with 35% phosphoric acid gel.
Pulp protection
Fig. 7. Enamel and dentin are coated with a light-cured
dental adhesive. Note the glistening appearance of the
preparation walls.
Fig. 8. Occlusal view of completed restoration.
and resin cements (Figs 48). However, dental
adhesives can also be used to seal the tooth preparation
walls under amalgam restorations and full crowns.
Conclusions
When bacteria and bacterial byproducts are completely
excavated from a non-exposed tooth preparation, and a
restoration that prevents the leakage of bacteria and
bacterial byproducts into the dentinpulp complex is
placed, pulp protection has been achieved. When the
pulp has been irreversibly compromised by preexisting
conditions (e.g. bacterial infection, trauma, etc.), no
pulp protection technique can predictably achieve a
good pulpal prognosis.
Pulp protection using bases and liners sometimes is
necessary due to the inability of the existing restorative
materials and techniques to provide a long-term
hermetic seal around restorations. All restored teeth,
45
Ritter & Swift
but especially those with deep restorations, must be
followed up with vitality tests and radiographs to
confirm maintenance of pulp vitality.
In conclusion, the following recommendations sum-
marize current pulp protection materials and techni-
ques:
1. Bases are typically not needed for direct restorations
(amalgam and composite). Bases can be used to
block out undercuts or for other internal buildup or
foundations for indirect restorations (inlays, onlays
and crowns).
2. CH liners are used as a therapeutic agent only when
the RDT is believed to be o0.5 mm. Glass ionomer
liners are used under amalgam and composite resto-
rations when the RDT is believed to be 40.5 and
o1.5 mm. Liners are not needed when the RDT is
41.5 mm.
3. When used, bases and liners should always be ap-
plied prior to finishing the preparation and placing
bevels, to avoid contamination of the cavosurface
margin.
4. Bases and liners should only be applied to the
deepest portion of the preparation, leaving enough
enamel and dentin exposed for adhesion.
5. Sealers are used routinely to reduce dentin perme-
ability under amalgam restorations. Water-based
sealers can also be used as re-wetting agents in
the total-etch technique under composite resto-
rations.
6. Dental adhesives are necessary when restoring with
composites and ceramics, and provide excellent pulp
protection as long as the interface remains sealed.
The sealing ability of dental adhesives is better, and
likely more durable, when enamel is present at the
entire periphery of the preparation.
Acknowledgment
The authors would like to thank Dr Guilherme C. Lopes and
Dr Paulo C. Capel for kindly providing the SEM images for
Figs 2 and 3.
Disclosure
The authors have no financial interest in any of the
products or companies mentioned in this paper.
46
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