T 3 days the response ranges from slight to moderate; at 5 and 8 weeks the inflammatory process is slight and a zone

of reparative dentin has formed underlying the cavity. Inflammatory cells may still persist at the later time periods, presuma ly ecause of stimulation caused y the continued release of some calcium ions. Typical responses are shown in !igs. "#$$ and "#$%. &ne function of calcium hydro'ide liners is to serve as a contact dressing in the event of e'posure of the pulp. (t.3 days the response of an e'posed of the pulp to calcium hydro'ide may range from slight to severe, and these same responses may e maintained at 5 and 8 weeks. The reason for the range or response to various )a *&+,% compounds is that the cement may e in a water#solu le form or the solu ility may e restricted y the cement in compounded in a resin. !ormulations using a water# ase carrier of calcium hydro'ide may cause a zone of necrosis ad-acent to the compound. .eyond the zone of necrosis, healing occurs and a dentinal ridge forms *!ig "#$3 (,. The resigned salicylate )a *&+,% liners stimulate healing with no zone of necrosis; therefore dentin is laid down ad-acent to the liner *!ig "#$3 ., an indication that the formative cells, the odonto lasts, egan forming dentin in contact with the liner. )alcium gydro'ide is the most effective liner now availa le for treating pulp e'posures with su se/uent formation of a reparative dentin ridge. (dder e'posure the pulp organ goes through a relatively uncomplicated wound#healing process in manner similar to that of skin if the tissue is not infected. 0sually in a deep carious lesion the +elen process is complicated y the presence of acteria. 1hen a pulp is e'posed, hemorrhage initially occurs and a lood clot forms at the e'penses of the connective tissue at the site. +ealing then progresses with resolution of the clot y homeless, and proliferating fi ro lasts of dentin. The resin#filled )a *&+,% liners offer a ma-or advance in pulp#would management. +ealing takes place with minimal inflammation, and reparative dentin forms at the initial site of e'posure with minimal loss of pulp size *!ig."#$3,., There is evidence that these materials reak down in time and create a gape etween the rest ration and the cavity wall.

Varnishes.
2umerous investigators have analyzed the effects of the application of 3thin layer4 liners such as copal varnishes and polystyrenes under silicates and zinc phosphate cements. These liners are used in such thin layers that they do not provide thermal insulation, ut they serve to isolate the tu ule contains from the cavity. They also inhi it penetration of acteria of chemical su nstance' resulting from the setting of a restoration. They should prevent penetration of components of amalgam into dentin and reduce marginal leakage. 5everal applications may e n eccssary to prevent penetration of acteria or acids )omposites. )hemically accelerated composites placed in cautious with appro'imately 6.5 mm of remaining dentin generally show a moderate response ate 3 days *!ig "#$7., The response to ultraviolet *08, accelerated composites after 3 days is moderate to slight. The milder response to the 08#accelerated materials may e a result of the lack of chemical acceleration, which provides fewer chemicals to affect the tissue.

The inflammatory response diminishes as the postoperative time increases to 5 to 8 weeks, with an increase in the /uantity of reparative dentin. The response to oth chemical#and 08 accelerated composites cause reparative dentin to from underlying the cavity floor. This dentin appears to e regular, containing dentinal tu ules and few if any cell inclusions *!ig."#$5, .ecause of the moderate initial response to these materials, it is recommended that a protective line such as calcium drooled e used. 1ith a liner, the pulp response to the composite system is minimal. (malgams. 5ince amalgam is the most commonly seed restorative material, the pulpal response it produces has received a great deal of attention. Investitures agree that in cavities of average depth, the pulp is affected mainly y the cold and hot stimuli that result from the thrall conductive properties of the amalgam. In deep cavities, pain is a characteristic of unlined cavities and 5 weeks. (spiration of o onto lasts into dentinal tu ules underlying the cavity has en seen. The response to amalgam is minimal in shallow cavities. There is a significant difference in pulpal response in the unlined cavity and those lined with cluclum hydro'ide, sine o'ide# eugenol, or varnishes. 5everal reasons are advanced for the presence of pulpal damage soon after the placement do an unlined amalgam. 9arginal leakage has een reported to cause some damage to the pulp after the placement do amalgam restorations. The margins of newly placed amalgam restorations show significant microleakage *!ig."#$:, In summary, puple response to silver amalgam restorations occurs shortly after their placement and is pro a ly a result of cavity preparation and marginal leakage. ;eaching of to'ins from amalgams that may penetrate dentin is dependent on the size o the molecules and the patience of the tu ules. There is a significantly improved response when the cavity is lined, and the pate ct if the tu ules. There is a significantly improved response when the cavity is lined, and the amalgam rarely causes irreversi le damage to the pulp. ( num er of silver amalgams with high copper contents are currently in clinical use. These have een introduced ecause their resistance to corrosion and creep is higher than that for the conventional silver amalgams containing the y% phase. (t 3 days the pulpal responses elicited y these highcopper amalgams appeared similar to those of conventional amalgams in unlined cavities. (t 5 weeks they elicited only slight pulpal response. (T 8 weeks the inflammatory response was again reduced.. acterial tests on the high#copper amalgam pellets revalued little inhi itory effect on stereotypes of 5. 9utants, which indicates that the elements are firmly incorporated in the amalgam and thus unlikely to e released into the oral environment. (lthough the newly introduced high#copper amalgams appear to e iologically accepta le, it is suggested that liners e used in all deep cavities. <old. )ast gold restorations very widely in size ecause of tooth# coverage re/uirement . it has een said that pulp reaction to cast gold crowns is a dressily of the type of cement used to retain the restoration. In shallow cavities 5ine

phosphate cement serves to stimulate reparative dentin. In deep cavities the pulp should e protected from the zinc p-hosp-hate cement mi' ecause of the free acid availa le, as discussed previously. The pulp responds more favora le to the improved zinc o'ideeugenol cements. The condensation of cohesive gold is a factor in pulp response. ( moderate to severe inflammation was reported at $6 to %6 days, ut after 35 days spoons. )ondensation of gold thus causes a short#term severe response that stimulates reparative dention formation. If a ase is re/uired, pulpal inflammation is reduced. There are no irreversi le changes, and the use of cohesive gold thus causes a shortterm severe response that stimulates reparative denotation is reduced . there are no irreversi le changes, and the use of dchoesive gold may e considered iologically sound. (mong all restorations evaluated, gold foil showed the least marginal leakage; however, the leakage does not decrease with age.

Usage tests on inflamed teeth

=ulps used for the testing of dental materials are usually normal *noninflamed , pulps from intactnoncarios teeth. There is concern that liners, cements, and restorative agents will respond differently to an inflamed rather than a normal pulp. (fter all, this is the situation in which most materials must function in human teeth. To gain information a out this factor, a num er of investigators have propose developing a model of inflamed teeth for testing these materials. The several methods proposed are as follows *$, soft carious dentin from freshly e'rtracted human teeth is placed in the floor of cavities and covered with cment for 7 to " days *!ig "#$", *%, a gutta#percha temporary filling is placed in the cavity for 7 to " days, or *3, the cavity is left open to the oral enviroment for 7 to " days. >ays . (fter this time the carious dentin or gutta#percha is removed, the the cavities are dried with cotton pellects. (nd the test material is placed on the floor of the cavity and sealed with amalgam. The carious dentin produces a sever localized pulp reaction the gutta#percha causes a slight to moderate one, and the open cavities produce varied responses. Thus the carious dentin and gutta#percha rechnics are the ones widely used today in animal research to produce pulpitis efore a material is tested. ?fforts have een made to /uantify and /ualitfy the technic of acterial insult. !or e'ample, recent studies in which $ u$ each of lacto acillus casei and 5treptococcus mutans were sealed in cavities resulted in sevr pulpitis in soe cases and less in others. This varia ility in response has resulte in the continued use of human carious dentin. ( further advanc in technology is the use of a .rown and .ren stain for determining the presence of cteria. This stain clarly demonstrates the personce and location of oth gram positive and gram# egative acteria after routine histological preparation. Thew presence of acteria in the dentinal tu ules an dpulp can e corrclated with pulp response. 5erapings from a cavity can also e cultured y routine micro iological procedures to ascertain the presence and identity of acteria at the site.

The use of the inflamed pulp in the evaluation of dental material is gaining popularity since this closely resem les the situation in which thse materials will e used in man. 2ot onl is the pulp evaluated, ut also the type of reparative dntin. The pulp evaluated, ut also the type of reoaratuve de tin. The idealk response is regular tu ular dentin. &ther types of irregular entin may form that may contain few tu ules or osteodentin or a com inatiuon of these *!ig "#$8, irregular dentin or osteodentin with cell inclusion indicates a more severe response to the dental material.

GINGIVAL RESPONSE
5ince usage tests in man and animals are carried out at sites that are appropriate for their intended use, various dental materials have een placed in su gnigival cavities and the response of the gingiva evaluated in manner similar to pulpal eveluations. &ne of the difficulties of this type o study is nthe normal presence of some degree of inflammation in the giviva. To avoid this condition, a prophyla'is is performed efore the cavity preparation and placement of the material in a sun gingival cavity. It has een shown that acterial pla/ue is the most important factor in gingival inflammation, and surface roughness of the restorative material, open or overhanging margins, pla/ue accumulation retained y rough surfaces or marins is also an important factor.

Operative Proced res

Trauma caused y rotatidng instruments is a reversi le condition. ?ven prophyla'is with a ru er cup and pumice will cause loss of the sulcal epithelium, which will eal completely in 8 to $7 days. If su gingival margins e'ist, inflammation may occur ;and time for healing must e allowed efore assessment of the effects of the restorative ageents is made. It has een suggested that su gingival is made. It has een suggested that su gingival cavity preparations e raised to a level even with the crest of the gingiva since this causes the least inflammatory response. ?ven the est operative procedures produce some degree of gingival margins. .efore restorative evaluation, good oral hygiene and normal#appearing gingiva must e attained.

Restorative materials
(fter oral prophyla'is and cavity preparation *class 8 test )avities, the material, mi'ed accordin to the manufacturer@s recommendations, is placed in a su gingival cavity, and its effects are onserved after short *"#da", and long *36#day, terms.Aesponses are categorized as slight, moderate, or severe. ( slight response is characterized y a few rond cells in the epithelium and a -acent connective tissues. ( moderate response is indicated y numerous round cells in the connective tissue and a few ncutorphils in the epithelium ( severe reaction is evidenced y an increase in the responses in each category and thinned or a sent epithelium.

!ements
Bonc polycar o'ylate cement produces the mildest gingival reaction of all cements tested, with mainly slight ut a few moderate responses. <ew inflammatory cells are present in epithelium and connective tissue. Binc o'ide#eugenol cements cause slight to moderate response with a few severe responses and thinned epithelium. This wide range or responmse is of interest and may e a result of variations in damage to the tissue. ?tho'y enzoic acid cements show slight to moderate responses, with more moderae than slight. To modeerate response with a few severe responses and thinned eithelium. This wide range of response is of interest and may e a result of variations in damage to the tissue. ?tho'y enzoic acid cements show slight to moderate responses, with more moderate than slight.

Silicates
In general, silicates elicit moderate gingival responses, with a few slight and severe responses. ?pithelial cell proliferation occurred in some arease epithelial cells polit away, and there were a few instances of dense cellular infiltration. 9ost of these changes pesisted at 36 days. (gain, the wide range of response may e a result of thin or think mi'es; the think mi'es allow more free acid to afect the ad-cent tissue. 5urface irregularity is an important factor and should e eliminated.

!omposites
)omposite resins placed sun gingivally in class 8 cavity preparations in su -ects withpreviously normal gingiva developed marginal gingivitis. It was found that pla/ue forms more readiluy on the surface of composite resins than on tooth enamel, even though the resins are finished and polished according to the manufacturer@s directions. It is he importance of develping materials for dental use that are well tolerated y the oralk tissues cannot e overstated. Testing regimens have involved manuy different methods includingC tissue culture studies; su dermal implantation in animals; and in#use testing methods in n oth methods there have een variations in techni/ue and widely different results have een ontained in differefnt centres which the samd material has een evaluated. Aecently, n oth the ritish 5tandards institutre *.5I, have set our protocols for the n iological testing of dental materials. These include general systemic to'icity tests as well as in#use dental evaluiation. The propocols are comple' and demand the use of different animal models. To date there is no record of any material eing sun-ected to the complete protocol in one la oratory. The ma-or iologifcal concern with restorative materials has een their efect on the dental pulp. 9uch of the early wsork concentrated on the chemical to'icity of materials caused y, y for e'ample, the acidity of cements or free monomer in resin

systems. Aecent reports have demonstrated that acterial contamination*see elow, may modify the response of the pulp to these aspects of materials. Indeed, it has een shown that much of the damage kpreviously attri uted to the chemical to'icity of materials such as silicate and phosphate cement was caused y acterial action.

Potential so rces of "acterial contaminiation of the floors of cavities are#

*a, the original carious lesion; * , saliva andDor pla/ue which may ecome smeared over the cavity walls and floors duridng cavity preparation; *c, acterial ingrowth which may occur down cavity walls following insertion of the restoration. (t present there is no restortive material which gives a perfect marginal seal and it sis accepted that all restorative materials sufer from some degree of marginal leakage. 1ith careful techni/ue, this is least with the modern adhesive restorative materials and most marked where there is a setting contraction. Aemoved y normal cavity cleasing, i,e y hand instruments and water#spray. It may e divided into an outer layer which follows the contour of the cavity wall, and an inner layer which forms plugs@ in the ends of the dentinal tun ules *!ig $".3; see also !ig $8.%p, 3:3,.

$EN%INE !LEANSERS AN$ !ON$I%IONERS &SEE ALSO !hptter '()

(fter cavity preperation with rotary instruments the >entine walls and floor of the cavity will e covered with the >entine E5mer ;ayer@ *see )hpter $:, this consists of a layer. Irregurally shaped hrd tissue particles of dentine *F perhapes animal, de ris ranging in size from eolow 6.5 um to more than $5 um. 1hich are not removed y normal cavity cleansing. i.i., y hand instrument and water spray. It may e devided into an outer layer which follows the contour of the cavity wall. (nd an iner layer which forms 3=lugs4 in the ends of the dentinal tu uls *fig. $".3 F fig $8.% p 3:3, There is considera le de ate as to how much of the smear layer should e removed. 5ome authorities advocate its totald removal *1ith lower molecular weight acids., ut this can e criticized ecause it ipens up and widens the ends of the dentinal tu ules, with three possile significant disadvantages. *a, It renders the tu ules much more suscepti nle to invasion acteria and their to'insC this will invaria ly produce and adverse pulp response. * , It increases the permea ility of the dentine to certain irritant dental materials. *c, It allows an outflow of fluid from the dentinal tun ules which will wet the dentine surface, this in turn making it more difficult to achieve an ade/uate seald with any lining or ase.tui we@ to prepare the dntine in a rasion avities to receive galss# ionomer cements. In these cavities, the dentine, as a result of e'posure to saliva, will e coated with a thin film of mucins which, if left, act as a separating agent threr y preventing the onding of the alassinomer cement to the dntine. In this sitution, shorr apliction times *of a few seconds, would remove the mucns =ulp irritation is

not usually a pro lem ecause the coronal pulp is normally completely on literated y repartive dentine in theeth with a rasion cavities. +owever, such adids hould not e applied to freshly cut dentine. *d, 9ore recently, polycrylic acid has een sun stituted for the citric acid is some demtome pmdotopmers supplied with glss#ionomer cements. This has a much hiher molecular weight than citric acid, and a %5#second application of a $6G solution of polyacrylic acid is recommended for conditioning freshly cut dentine. The effects of polyacrylic acid on the smear layer have yet to e investiated fully.

LINING *A%ERIALS
The trditional view of the function of a lining is that it is necessary promarily to protect the pulp from thermal andD or chemical in-ury and hence also from postoperative pain. The mechanisms of pin sensation in dentine do, however, remain incomopletely understood. 5ome authorities associate it with the movement. It has een demonstrated in the la oratory that to achieve ideal thermal instulation wtih dental lining materials and cements, a thickness of $.6#$.5 mm is necessary *!ig.$".:, There authors and others have advocated lining thicknesses of 6.5# 6."5mm *!ig.$".:, +owever, these orders of thickness appear to e only rerely achieved with some materials *e.g clacim hydro'idesee elow,, yet patients arely complain of thermal sensitivity when well adapted thin linings are placed. The current view is that much of the pupal damage kproveiously attri uted to the chemical composition of lining and filling materials *e.g. silicate cement and resin, was in fact caus y t-he ingrowth of acteria at the margind if these restorations. It appears, therefore that the most important function of a lining is to seal the dentinal tu ules, thus preventing pulp damage caused y any acteril ingroth sich occus at the restoration margins as a result of mucroleakage.

%he follo+ing are the important feat res of lining material. Ideall,- it sho ld.
*a, seal dentine; * , e actericida; *c, non#to'ic and land to the pulp; *d, have ade/uate physical proprties#mecga ucal;thermal etc; *e, induce remineralizatio or huyperminewralization of dentine on cavity floors *this reduces the perme ility of the dntine to any acteria dwhich do gain access,; *f, e adhesive to dentine and ma-or restdorative materials.

!alci m h,dro.ide
1hilist tis precese mode of action is unclera, clacium hydro'ide is the material of choice for oth pulop capping and lining the deep cavity. The proprietary hard#setting clacium hydro'ice materials seve well as universal lining materials. (s a pulp#capping material, calcium hdro'ide fis uni/ue in its a ility to rormite dentine

ridge formation. In the deep cavity it induces some remineralization of any softened dentine remaining on the cavity floor. 5tudies with la elled calcium hydro'ide have demonstrated that calcium ions do not move from the dmaterial itself, ut they dcome from the loodstream. The proprietary calcium hdro'ide lining materials appear to seal the dentine ade/uatcly, and they are acteicidal. )ertinly they are active against many microorganisms, ut there are resistant strains. 9any authorities attach improtance to the alkaline =+. 1hich is considered to counteract the acidity in the deeper parts of carious lesions in dentine. =ropriearty calcim hydro'ide materials are presented in com ination with a num er of different setting rsins, which appears to e ound into the resin and not released. The film thickness chieved with thes proprietary materials is usually less than 6.5 mm *!ig.$".", and though they are the weakest of all the standard lining materials, they are ade/uately strong to withstand the packing of amalgam. +owever, they re not suita fle for use in thick sections or to lock out undercuts under gold or procelain in restorations. )are should e taken to use an acid#resistant calcium hydro'ide material if acid etching dof the enamel parts of the cavity walls is to take place; some propritary clacium hdro'ide liners are solun le in phosphoric acid *fid.$".8.,

/inc o.ide0e genol1"ased cement

The resin# onded frofms of these are physically stronger cements and they also induc remineralization of softened dentine. They from the est seal of any of the dental cements and they are truly nactericidal to may oral acyteria. +owever, the phenolic group in the eugenol are pulpal irritants and they produce persistent chronci inflammation *!ig $".H, if placed on a pulp e'posre. There is some evidence to suggest that a similar effect occurs nin very deep cavities even where there is no e'posure, and a su lining of calcium hydro'ide is there for desira le in these situations. In cavities with a reasona le residual dentine thickness, zinc ko'ideD eugenol is a e'cellent lining material. It is also a satisfactory material for uilding up a thick ase over calcium hydro'ide when re/uired. It should not e used under composite resin restorations, as the eugenol may inhi it polmerzation. (ny e'cess engenol will also stain the dentine, which is a cosmetic pron lem in anterior teeth. The etho'ydenzoic acid *?.(, cements are modified zince o'ideDeugenol cements with superior mechanical properties, achieved uy sunstituting two#thirds of the zinc o'ide with fused /uartz.

2inc phosphate cements.

These were the first widely used lining and luting materials in dentistry and in this latter role they are still pupuilar. +owever, they are irritant to the pulp# dentine comple', early reports attrin utig this to their very acidec settfing p+ of %. This is only transient, and they rapidly ecome neutral after setting. Their to'icity is now

consideted to e caused largely n y acterial ingrowth at the margins, following a settifng contraction.

/inc pol,car"o.,late cements

These cements were introduced in $H:8 as the first materials which adhered to oth enamel and dentine. They are presented as oth linin and luting cementsf. +owever, presented as oth lining and luting cements. +owever, they are didfficult to manipulate well and in use they adsor water, which leads to a deterioration of their mechanical properties, including their ond strentth. 5tudies of their effect on the pulp have produced varia fle results, with sosme relports of sever inflammation and others which fdemonstrate an apparentluy mild response. In any ut the shallowest cavity, a calcium hydro'ide sun lining should e placed. The polycar o'ylate cements play a useful role as materials to replace lost dentine or lock ot undercuts in preparations which are to receive cast or cermic restorations.

Glass1ionomer cements &Pol,al3enoate cements)

<lass#inomer cements are now availa fle for use as lining and luting cements, as well as eing restortive materials their proncipal advatage lies in their forming a molecular ond with the dentine *and the enamel,, though the seal produced is not necessaril perfect; n cteria have een demonstrated in the interface etween glassionomer restorations and the tooth *!ig $".$6, This pro a ly reflects the difficulty in the clinical situation of ringing the material into even contact with the cavity surface. This ingrowth of acteria appeas to e responsin le for at least part sdof the pulpal damage that has een reported after placefment of glss#ionomer cements in deep cavities. Aecent reports have sugested that glass#ionomers applied to dentine may also produce chemical damage in the pilp. This is manifested damage to pulp cells and an inhin ition of calcific repair, rather than y inflammation. It is therefore necessary to place a sunlining *calcium hydro'ide, in the deepest parts of all cavities that are to receive glass#ionomer cement where dentine has een freshly cut. In a rasion cavidties the cornal pulp is normally completely o literated y calcific material and a lining is not re/uired. There have een reports of pulpal hypersensitivity following the use of glass# ionomer lutin cement for crowns. 2ow of the glass#ionomer materials has physical properties suita le for the long#term restoration of occlusal surfaces, though they have a num er of useful indidcation *see p.3:"., (s a straight glass#ionomer centnt or in the form of a cement *see p. 3:8,, the material appears to hve an improtant role in uilding up dentine prior to the application of composite resion *see <ig $7.5",. 0sed in this manner it protects the pulp and dentine tu ules from the effects of the acid used to etch the enmel prior to composite onding. This acid treatment also serves to roughen the surface fof the glass# ionomer, so ena ling an effective ond with the composite. (lthough there have een criticisms regardifng disrupation of the surface integrity of glass#ionomer cments

following acid application and treatment with acid cannot e recommended. !ortunateluy restorative suystems have ecome availa fle in which acid treatment dof the glass#ionomer Elining@ is no longer necessary.

Varnishes
8arnishes are apploed sparingly to cavity perparations *inclding the cavity walls and margins, for amalgam, as they reduce the intial microleakage which occurs with amalgam restorations. 5ome clinicians use then routineluy, especially in the 05( They have a special place in sealing the cavity walls and dentine din minimal cavities where there is insufficiefnt depth to fwarrant a cemfent lining . The ma-ority of varnishes consist of natural resine, e.g copla or shellac dissoved in n organic solvent suc-h as ether dor ethl acetate. 1henapplied, the solvent evaporates leaving a resion coating on the dentine and enamel. It is necessary to apply at least two coats of the varnish to achivee fa viod#free films and hence a seal *!ig.$".$$,. 9ost varnishes are clear li/uids. It is important to replace the cap on the ottle to prevent evaporation of the solvent leadifng to thickening of the varnis-h which makes it impossinle to apply in thin layers. It is necessary to add thinner to the ottle from time to time .

4UR%5ER REA$ING
(mussen ?., -orgenson I.>. *$H"%, ( microscopic investigation of the adaption of some plastic filling materials to dental cavity walls. (cta odont. 5cand 36#3#%$.

6rann.stron

&'7(')

>entine and pulp in restorative dentistry 2ackaC >ental Therepeutics (. *(lso ;ondon 1olfe 9edical =u lications, $H8%, )auston ..?. *$H87, Improved onding of composite restorative to dentine rit dent J; $5:C H3#H5. 9orrandt <. *$H"", >ental instrumentaion and pulpal in-ury.$ .iological and physical factors. ; .rit. ?ndodont 5oc., $6C55#:3. =ateson A.). 1atts (. *$H8$, >ental instrumentation and pulpal in-ury.% )linical considentations J. rit ?ndodont. $6C55#:3. =aterson A.). 1atts ( kinner@s science of dental materials, " th edn. =hiladephiaC1.. 5aunders.

1ats (. *$H"H, .acterial contamination and the to'icity of sillicate andc zinc phosphate cement. .rit.dent J., $7:C"#$3.use a clear plastic matri' and to enhance curidng in the less accessinle regions of the cavity while the and is till in place. 0nfortunately, however, the handing properties of plastic matri' ands somethimes make them awkward to use. )lear plastic wedges can e used to transmit the light to the cervi cal region of the restoration. The ma'imum relia fle depth of cure that cn n e achieved with light is a out %mm This means that an incremental techni/uer is usually necessary to ensure complete curing *!ig.$8.5, 9ost opertors limit themselves to a thickness of $.5 mm for each application. The composite should e applied first to e'posed parts of the dentine, ecause the ond to dentine is fweaker thand to enanel; if resin is applied across enamel and dentine, the disparity in strenght of the ond, togerther with the more repid cure achieved in contact with the enamel, may cause the resin to pull away from the dentine. In general, the material should f e applied to the more remote parts of the cavity first. (s the resin shrinks towards the curidng light, placement dof the light against the accal and lingual tooth surfaces is advised prior to curing from the occlusal direction. This will assist the increments of resin shrinking towards the cavity floor. !inishuing of composite restorations (ny gross e'cesses should e trimmed with tungsten car ide or find diamond ursm usifng water spray as a coolant. +igh or low speed can n e used, the latter allowing more control where only small amounts of e'cent material dare present. !ine a rasive strips andDor discs have een developed for final dshaping and polishing and these are veruy effective. (smussen@s wsorks suggests that only gross e'cesses should f e removed immediately. 5ince all composites a sor some water over the first %7 hours after their insertion and undergo hygroscopic e'pansion, his argument is that if the final dfinishing is delayed until this reduced to a minimum. 2evertheless, many practitioners go against this advice, for they feel that the practicalities of the situatioin demand that finishing and polishing should f e undertaken at the same visit at which the restoration is placed. )ertainly, it can e argued that once the ru er dam has een removed, attention to detail *e.g. that of achieving the final appro'imal contour, ecomes more difficult; and the cervical margin is then likely to relate to moist gingival tissues and therefore e less accessile.f The hy rids can e polished, ut a high gloss will not e achieved. The danger of leakage at the gingival margins of class ii restorations makes regular checks essential >isadvadntages and contraindications of composites The main drawacks of the posterior composites areC *a, polymerization shrinkage; * , possinly unsatisfactory were characteristics; *c, difficulty in achieving anatomical form. *d, =olymerization shrinkage

This is inevita le y the very nature sof the material and it will tend fto e greater in igger cavities where larger volumes of resin are used. 1hen the acid etch techni/ue is used, polymerization shrinkage can lead to inward endifng of the cusps. The long#term implications of this are unknown, ut it certainly seems reasona fle to tae all steps to minimize it *sewe E>ynamics of the restored tooth =.35:H,. ;eakage is a likely conse/uence of polymeriz/tion shrinkage and this is especially lia fle to occur at the cervical dmargins of restorations where there is tlittle or no enamel for onding purposes. 5uch leakage may e the reason for the sensitivity to hot and cold which sometimes follows the placing of these restorations. It certainly contraindicates their use in patinents whose caries is not properly controlled, or where there is poor oral hygiene. 1ear The newer posterior composites appear to wear favoura ly. Though it fis pruudent to avoid their use in patients with marked attriotion. The conse/uences of wer of the opposing and ad-acent teeth hve still to e evaluated in the long term. <;(55#I&2&9?A )?9?2T5 <lass#ionomer centnts consist of aluminosilicate glass mi'ed with an a//ueous solution of polyacrllic acid and related polyacids. This forms a set mass of unconsumed glass particles em edded in a matir'' of poluacrylate gel. 5ome of the moe recently inrroduced glass#ionomer cements contain other acids such as polymaleic acid and itaconic acid. <lass#ionomer cenents dhave the a ility to ond chemically to oth enamel and dentine. Theyu were first introduced in the $H"6.s when dthey found thedir greatest clinical use in the restoration, without mechanical preparation, of cervical erosionDa rasion lesions. The adhesion of glass#ionomer cements has een attri uted to penetration of car o'ylate grops into the huydro'yapatite of the senamel and dentine, with displacement o phosphate ions. ?lectrical neutrality is maintained y the displacement dof calcium ions along with the phosphate ions. (s restorative materials, the glass#ionomer cements have the distinctly e eficial characteristic of leaching flouried; this should help to prevent secondary caries. The al;so pick up fresh fluoride ions from the moth, e.g from fluoride toothpaste; these ions then ecome availa le to the ad-acent enamel. )o,pared with the composites, certain of the mechanical; properties of the glassionomer cemefnts are poorer. )linical lhandling properties <lass#ionomer cements re/uire particular care during handling. They tend to stick to metal instruments and to pull away from cavity walls during manipulation. Thus, while eing contoured they tend to Edrag@ away from the cavity margins. These materials are moisture sensitive and the cavity must e kept completely dry during placement. (fter placement they should e kept dry for several hours y coating with varnish or restorative resin *polymerized,, to prevent disruption of the gel. The earlier materials

could not e trimmed during the initial %7 hours, though some of the newer materials have een modified and can e trimmed during the visit at which they are placed. +owever, a etter surface finish is o trained if final finishing is delayed for %7 hours. Indications and uses $. ?rosionDa ration lesions in permanent teeth. =rovision of mechanical retention in these cavities is difficult and glass#ionomer cements cements can e used without this. %. )lass I and II and 8 cavities in deciduous teeth. Aecent clinical trials have demonstrated that glass#ionomer cements can e used satisfactorily to restore these lesions in deciduous teeth. 3. )lass III and 8 cavities, especially in caries#prone individuals. 7. Aepair cavities. The fluoride leaching properties of the glass#ionomer cements make them a fist#choice material for repairing restorations in regions where future secondary caries is a realistic possi iliy, such as at the cervical margins of crowns 5. >eep cervical and root cavities. In cavities which e'tend towards the edge of the anatomical crown, the cervical margin often consists of thin and fria le enamel with a prism direction that is comple' and not conducive to good etching. If composite resin is placed against such a margin there wilkl e a very real risk of an unsatisfactory seal. 5imilarly a seal could not e e'pected when the cavity margin is entirel in cementum or dentine. 5u -ect to satisfacytory isolation*usually with ru er dam,, glassionomerKcompositre sandwich restoration *!ig. $8.:,. 1ith this laytter m,ethod thefirstLplaced glass#ionomer material is addapterd against the vulnera le cervical margin to achieve the est pMosi le seal. In the coronal part of the cavity tyhe glass# inomer cemnt forms a lining onluy. This can then e coated with a onding agent consistintg of a halophoshorus ester of .is#gma.This will ond chemically oth ytop the glas#inomer and to the compsite resin which completes the restoration. This twopart restoration provides the h est possi le marinasl seal aesthertis and function that can e achived with a plastic restoration in these difficult cavities. :. !issure sealing in deciduous and permanent teeth. .ecause of the turgid nature of the material this use is onl;u recommended where the vfissure is well opened up either naturallu or y a ur*as when investigation the e'tent of the caries present in a sealantKrestoration techni/ue; see chapter $3, ". (s luting cements. Thisa had een made possi le y a reduction in the particle size. The material's have the advantage that they adher to enamel, dentine and metalic ions.They will therefore adhere to metal castHings. )?A9?T )?9?2T5 The term cermet derives form ceramic plus metal. These materials are made y mi'ing metalllic fillers of silver or gold with moltern glass and sintering them. The resultant poiwder is mi'ed with a sloution of polumaleic acid. 5uyccessful

clinicasl trial result -have een had prevented its commercial introduction.+owever e'pense had prevented its copmmercial introdution. The silve# ased material had een mark eted and the following remarks refer to this. )linical handling properties The materiual is presented in capsules for mechanical mi'ing and a special applicator allows the capsule contents toi e syringed directly into the cavity.It is difficult to work withCthe cemtn sticks to metal; inmstruments;and it had a relatively short settint toime of $.5minutes. It is difficult to achieve any packin pressure and carvinmg and contouroing re/uire special care as the material tends to draw away form, the cavituy margins. &nce set the cement must not e left esposed to air, or large cracks will form as it dries oitC it should re varinis-hed to prevent moisture contmination. It can only e poliHshed to a dull lustre finish. ?'amination of finished restorations reeveals a pitted and cracked surface and there are fre/uent voids at the margins presumaly caused y a setting contraction. Indications and uses 1heres further development work is necessary efore the use of cemt cement can e supporyted without reservartion the following uses have een suggested. $. Aestorations in deciduous teeth. %. )lass I restorations in permanent molars. 3. .uilding up lost dentine under composite restorations including in insrtances where an internal or tunnerl preparation had een made to restore a posterior tooth with apporo'imal caries. 7. (s a core material for crowns in roken down permanent teeth. !0T0A? >?8?;&=9?2T5 In view of the considera le amount of pulp damager that can e produced y acterial ingrowth at restoration marins the following areas should e seen as improtant for development with respect to oth composite resins and glass# ionomer cements. $. Techni/ues to improve the wetting of the cavity walls

InflammationC

The defense elements of the ody that are mo ilized to the site of in-ury are present in the lood. To achieve this mo ilization a series of changes occurs in the microcirculation of the in-ured area. These changes are dominated y arteriolar vasodilatation and increased permea ility through contraction of the endothelial cells of the post capillary venules. These vascular and hemodynamic changes are mediated y a variety of chamecal mediatrors realsed in the in-ured areaC histamine *from the granuales of mast cells and aspohil leukocytes,; serotonin *in humans, from the dense granuales of lood platelets,; kinins *pep6tides formed through cleavage of kinigonens of y kininogensses,C anaphylato'ins *peptides formed through cleavage of the third and fifth complemlent components releasing the anaphylato'ins )3a and )5a, which in induce degranulation of mast cells and asophils,; and prostaglandins and leukotrienes *arachidonic acid derivatives,

?'udation develops as a result of increased vascular permea ility ;eukocytes that have marginated ad-acent to the vascular endothelium and adhered to the endothelial cells and pseudopods through the gaps etween the endothelial cells and escape from the vascular lumen. &nce outside the endothelial cells,d they migrate toward the site of in-ury under the influence of chemotactice factors * oth acterial and endogenous in origin; the latter include )5a, the activaterial and endogenous in origin; the latter include )5a the activated triple comple' )5:", and certain lymphokines secreated y T and . lymphocytes,

2eutrophils are the first leukocytes to arrive at the site of in-ury. They are the predominant cells of acute inflammation. +owever, virtually nany type of in-ury results in initial accumulation of neutrophils. 36 These involves a sespiratory urst with increase in o'ygen consumption and generation of reactive o'ygen radicals that the are actericidal ut can also induce tissue in-ury. 1hereas the neutrophils are the predominant cells of acute inflammation, macrophages, lymphocytes, and plasma cells are the predominant cells of chronic inflammation. 1hat leads to chronicity is persistence of the irritant, and this is often accompanined y the development of a cell# mediated immune reaction. 9acrophages are derived from the mamocytes of lood. 9onocytes are not end cells. Their half#life in the circulatin is a out I day. They leave the circulatioun to form different components of the mono nuclear phyagocyte system. 9acrophagea are efficient phagocytes. 2ot only do they phagocytose acterial, uyt also they ingest tissue de rise to clean up the area in preparation for repair. They also play an essential role in the development of immune reactions through antigen processing aznd antigen presentation to lymphocytes. (mong their secretory products are lysoszyme, certain components of the complement system, interferon, collagenase, fi ronectin, fi ro last# activating factor, and angiogenesis factor. ;ymphocytes are the essential cells of the immune system. Two ma-or types are recognized , T and . cells. ;ymphocytes are the essential cells of cell# mendiated immune reactions. . lymphocytes are the essential cells of humoral immunity. Intricate interactions take place etween macrophagea and T and . lymphocytes, and T helper

cells are essential for the induction of a humoral immune response to certain agigens. T suppressor cells regulate oth humoral and cellmediated immune reactions. =lasma cells, which are derived from . lymphocytes, synthesize and secrete immugoglo ulins. ?osinophils may e encountered in inflamed tissues, including inflamed pulp. They phagocytose antigen anti ody comple'es and contain enzymes that inactivate some of the chemical mediators released in areas of in-ury. 0ndetected microscopic e'posure of the pulp is of utomost importance. ?ach of these causes of iatrogenic pulp in-ury will e riefly considered. =reparation of the )avityC >entin is a vital tissue. That fact the dentin is a hard tissue and that it does not leed on cutting may give rise to a false sense of security. (voide heat generation and dentin desiccation during cavity preparation. +eat dissiopation and prevention of desiccation can oth e accomplished through the use of a water coolant. 1ith the present day high Nspeed instrumention, the use of a water coolant with collant is mandatory. ( simple rule to follow to eliminate two sources of iatrogenic pulp in-ury *heat and desiccation, is 3never cut dry.

Insertion of the Aestorative 9aterialC =hysical forces generated during condensation of amalgam and direct gold restorations can lead to pulp in-ury %:, %" This is particularly. The ma-or re/uirements of a cement ase with such me tallic restorations are as followsC

( hard N shtting calcium hydro'ide preparation or a reinforced zinc o'ide and eugenol cement, a calcium hy#dro'ide liner or a stronger ase. +oweer, with this cement , a calcium hydro'ide liner or a caviry varnsh should e applied prior to the insertion of the cement to protect the pulp from chemical irritation. Irritational Oualities of Aestorative 9aterials. ( ma-or cause of iatrogenic pulp in-ury is chemical irritation y the restorative material. (ccording to their irritational /ualities, restorative materials can e classified into three ma-or groupsC <roup I ## ;ow irritaitonal potential C gold, amalgam, zinco'ide and eugenol cement, polycar o'ylate cements, and glass ionomer cements. <roup II ## 9oderate irritational potential C zinc phosphate cements, and glass ionomer cement. <roup III N +igh irritaitonal potential C silicate cement and resins. <roup I. .iologically, gold and amalgam are relatively insert. (ny primary from physical forces incident to condensation and possi ly from thermal shock and electrogalvanism caused y the high conductive /ualities of these materials. 9easures to protect the pulp from such in-ury have already een outlined. Bine o'ide and eugenol *B&?, has a low irritational potential. Its p+, when freshly mi'ed, is ". $H The low irritational potential of B&? makes it ideal as a negative control in stuies that evaluate pulp reaction to restorative materals. Binc o'ide and eugenol also has an o tundent effect on the pulp. ?ugenol inhi its the synthsis of prostaglandin; it will of ionglammation and also contri nute to pain sensation in areaKs of

in-ury. !urthermore, the hygroscopic /ualities of B&? may result in withdrawal of fuild from the pulp through the dentinal tu ules thus reliving pressure on sensory nerve endings of the pulp. Binc o'ide and placed over an e'posed pulp, B&? dies not stimulate reparative dentinogenesis ; on the contrary, it elicits a low#grade inflame#matory response. =olycar o'ylate cements have a low irritational potential . H They are remarka luy innicucous, despite a p+ of $." of the rapid rise of the p+ during setting of the cement. !urthermore, the large molecular proteins would limit its diffusion through the tissues. <roup II. Binc phosphate cement has an irritaional potential that ios intermediate etween B&? and silicate cement. Three minutes after thereafter, approaching neutrality in %7 hours. $H Thus, damage to the pulp would occur during the first few hours after insertion of the cement. This damage could e prevented y application of a calcium hydro'ide liner or a cavityvarnish prior to placement of the cement. <roup III. 5ilicate cements have ahigh irritational potential. These cements have a p+ elow 3 at the time of insertion ; the p+ remains elow neutrality even after one month.
$H

The high irritational potential of silicate cement makes it ideal as a materials.

( calcium hydro'ide liner or a cavity varnish prior to placement of the cement. Aesins, whether unfilled or coposits, and the latter, whether conventional or microfilled,autopolymerizing or photoactivated with ulraviolet or visi le light are irritating to the pulp. Their irritational potential is compara le to that of silicate cement. 1hich component of the composite resin elicits pulp in-uryP In a study of pulp reactions to eight components of composite resins, none of the components tested elicited

significant pulp in-ury %7 It appears likely that reactive radicals generated during the polymerization of the resin are responsi le for pulp in-ury y these materials. =ulp in-ury y the resin resto ration can e totally a rogated through the application of a hardsetting calcium hydro'ide ase eneath the resin.

!()T&A5 T+(T I2!;0?2)? =0;= A?()TI&25 T& A?5T&A(TI8? 9(T?AI(;5 The most important single factor in determining the intensity of pulp reaction to restorative materials is the thickness of remaining dentin. 1ith most materials, % mm of remaining dentin affords ade/uate pulp protection %% The presence of reparative dentin is influential; materials Nlaced ever freshly cut dentin are more damaging. The undetected microscopic e'posure of the pulp is of utomost importance. 2umerous studies have shown that pulp e'posure can occur without climnically detecta le leeding. &nly through e'amination of serial histologic sections of the cavity and the underlying pulp. .ecause it is impossi le to determine cavity floor thickness clipically and ecause microscopic e'posure of the pulp may occur without eing clinically detecta le, these two simple rules should e followed to protect the pulp from iatrogenic in-ury due to the inherent irritation of restorative materials and the clinically undetected undetected microscopic e'posure; $. 0se a protective ase or liner with materials in groups II and III regardless of cavity depth.

%. 0se a protective ase or liner in all deep cavities where the possi ility of microscopic e'posure e'ists, regardless of the material to e used for restoration. .acteria (nother potential source of pulp in-ury is acteria, either residual microorganisms left on the cavity floor or acteris that gain access to the cavity after restoration3. 1hile acteria may contri ute to pulp in-ury when cavities are deep, they cannot e considered solely responsi le for pulp irritation to e'clusion of the inherent irritational potential of the restorative materials.

In the past, highly irritating chemicals were used for sterilization of the cavity. .ecause vital 1heledentin has een shown to resist acterial invasion and deep cavities should have a protective ase of calcium hydro'ide preparation or B&?, and oth have een shown to have anti acterial properties, the need for cavity sterilization is highly /uestiona le.
",$:

( safe and effective means for cavity cleansing is simply rinsing the

cavity with warm water.%%

()I> ?T)+I2<

Aesin restorations leak adly. The acid#etch techni/ue was developed to improve the marginal seal etween the cavity and the restoration. (cid etching of enamel is safe, provided a protective ase of a calcium hydro'ide preparation is applied over e'posed

dentin prior to etching. (cid etching of dentin markedly increases its permea ility. $8 2ot only does it remove the amorphous smear layer over cut dentin, which plugs the orifices of the dentinal tu ules, ut it also demineralizes the peritun ular dentin resulting in increased tu ular diameter. 5uch patent tu ules provide easy access of irritants to the pule. %7 =A&T?)TI8? .(?5

The ideal protective ase should e well tolerated y the dental pulp. It should stimulate reparative dentinogenesis in case an undetected microscopic e'posure of the pulp e'ists. It should provide ade/uate protection of the pulp from irritant components of the restorative material. It should have an o tundent effect on the pulp. It should have an anti acterial effect to eliminate acteria in residual carious dentin when used with indirect pulp from thermal shock and electric conductivity to protect the pulp from thermal shock and electrogalvanism when used with metallic restorations. It should e'hi it low acid solu ility so that it will not disintegrate when used with the acid etching techni/ue in case the acid accidentally comes in contact with the material. I t should not e affected y the restorative material nor should it in any way affect the restorative material. ( protective ase which fulfills all of these criteria remains to e developed. +owever, B&? and hard#setting calcium hydro'ide ases fulfill many of these criteria. 1ith resin restorations, used with or without the acid# etching techni/ue, calcium

hydro'ide ases should e used. Binc o'ide and dugenol cement o viously is unsuita le, as it interferes with resin polymerization. 1ith other restorative materials, either B&? or calcium hydro'ide ases are satisfactory. +owever, if there is the slightest chance of a microscopic e'posure of pulp, a calcium hydro'ide ase should e used ecause B&? does not enhance reparative dentinogenesis. &n the contrary, when placed in contact with an e'posed pulp, B&? elicits a low# grade chronic inflammatory reaction.

=0;= )(==I2< 2umerous materials have een investigated as pulp#capping agents# +owever, calcium hydro'ide preparations have est withstood the test of time. There has een a widespread concern among dentists that calcium hydro'ide e'erts a persistent stimulating effect on the pulp that results in eventual o literation of the pulp. 5ome also elieve. That calcium hydro'ide may, on occasion, cause persistent inflammation of the pulp or internal resorption. =ulp reactions to three capping agents were investigated in mon keys at intervals ranging from $5 to 886 days $3#$5 with a calcium hydro'ide preparation, there was initially a high rate of reparative dentinogenesis. The rate, however diminished with time, and there was no evidence of pulp o literation in any of the specimens, even at 886 days after capping. ( polycar o'ylate cement was specimens, even at 886 days after coapping a polycar o'ylate many of the pupls capped with it should pulp necrosis or severe inflammation. Interestingly, the pulp that survived showed persistent

inflammation with areas of o literation of the radicular pulp. It was apparent that the stimulus for eventual o literation of the pulp is persistence of inflammation rather than a direct effect of any medicament applied over the pulp.

.I&;&<I) ?8(;0(TI&2 &! >?2T(; 9(T?AI(;5. +istorically, iologic evaluation of dental materials lagged ehind evaluation of their physical properties. It should e o vious that the iologic properties of dental materials are -ust as important as their physical, chemical, and mechanical properties. In $H"%, the )ouncil of >ental 9aterials and >evices of the (merican >ental (ssociation pu lished a series of guidelines for iologic evaluation of dental materials.
7

In $H"H the

(merican 2ational 5tandard InstituteD(merican >ental (ssociation >ocument 2o. 7$ was approved y the (>( couna le guidelines for iologic testing of dental materials. Tests for iologic testing of dental materials. )an e classified into screening tests and usage test. In the usage tests, the dmaterials are evaluated in suita le la oratory animals, show that the material is safe, the material is then ready for evaluation in humans.

It is through such e'tensive

iologic testing along with tests that evaluate the

physical chemical, and mechanical properties of dental materials, that the dentist will e assured that the material he uses are oth safe and effective.

A?!?A?2)?5 $, (very, J.I C >entin.In .haskar, 5.2. *ed, &r an@s &ral +istology ?m ryology, ?dition H. 5t. ;ouis, ).8. 9os y )o., $H86. %, .rannstrom 9., and ;ind, =.&. =ulpal response to early dental caries J0. >ent. Aes 77C$675, $H:5. 3, .rannstrom, 9 and 2y org, +C )avity treatment with a micro icidal fluoride solutionC <rowth of acteria and effect on the pulp. J prostht. >ent., 36C363 $H"3. 7, )ouncil on >ental 9aterials and >evicesC Aecommended standard practices for iological evaluation of dental materialsC J (m >ent. (ssoc., 87C38%, $H"%.

5,

)ouncil on >ental 9aterials and devicesC (mercian 2ational 5tandards InstituteD (mercian >ental (ssociation document 2o. 7$ Aecommended standard practices for iological evaluatin of dental materials J (m >ent (ssoc. HH.8H",$H"H.

:,

>ickey, >.9., Iafrawy, (.+. and 9itchel, >.!. )linical and microscopic pulp response to a composite restoration material J (m >ent (ssoc., 88C$68, $H"7.

",

!air ourn, >.A. )har enau, <.T., and ;oesche, 1.J ?ffect of improved dycal and IA9 on acteria in deep carious lesions J (m dent (ssoc $66C57",$H"7.

8,

!ischer, !.9. Iarraway, (.+. 9itchel, >.!. 5tudies of reparative dentin in monkey teeth using vital dyes J. >yes J >ent Aes 7HC$53",$H"6.

H,

Iafrawy, a.+. and 9itchel, >.!. =ulp reactions to open cavities later restored with silicate cement J >ent. Aes., 53C$5, $H"6.

$6,

Iafrawy, (.+. and 9itchel, >.!., pulp reactions to open cavities later restored with silicate cement. J >ent Aes ., 7%C8"7, $H:3.

$$,

Iuttler, QC )lassification of dentine into primary, secondary and tertiary, &ral surg $%CHH:, $H5H.

$%,

;angeland, I., >owden, 1.? Tronstad ;., et alC +uman pulp changes of iatrogenic origin oral surg., 3%CH73,$H"$.

$3,

9e1alter, <.9. Iafrawy, (.+. and 9itchel, >.!. Aate of reparative dentiogenesis under a pulp capping agent in moneys.J. >ent Aes., 5:CH3,$H"".

$7,

9e1a;ter.<.9. Iafrawy, (.+., and 9itchell, >.!. pulp capping in 9onkeys J, >ent. 3:CH6, $H"3.

$5,

9e1alter, <.9. Iafrawy, (.+. and 9itchell, >.!. Aate of reparative dentiogenesis under a pulp capping agent in monkeys J >ent Aes., 5:CH3, $H"".

$:,

9-or, I,(. the penetration of acteria into e'perimentally e'posed human coronal dentin 5cand. J. >ent Aes. 8%C$H$, $H"7.

$",

9ohammed. Q.A. 8an +uysen, <.8 and .oyd, >.(. !illing ase materials and the une'posed and e'posed tooth pulp. J =rosthet >ent. $$C563.$H:$.