medication of the dental pulp_ a review and proposals

8/3/2019 Medication of the Dental Pulp_ a Review and Proposals

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R e v i e w a r to f t h e d e n t a l p u l p : a r e v i e w a n d

A l f r e d E d w a r d C i a r l o n e , D a v i d H e nP a s h l e yMedical College of Georgia, Department of OBiology. Augusta, USA

Key words: analgesics; anti-inflammatory agdental pulp: dentin; dentin permeability; locathesia; glucocorticoids; pulpitis.Alfred E. Ciarlone, Iwledical College of GeorgSchool of Dentistry, Department of Oral BiolAugusta, GA 30912-1128, USAAccepted June 20, 1991

r years dentists have desired to treat the intact d en-pulp (i.e. no pulp exposure} with variable degreest h e earhest attempts to affect such

w a s with the u s e of sedative, tempora ry res-ations containing zinc oxide and eugenol (Z OE).e of the exact m echanism of action of Z O F - but we

eas eugenol, w hile believed to produ ce somearify this issue by reporting that eugenol is capable

Only a few other studies have been published

12) and Ciarlone et al. (13) used discs to study the

age of restorations, are capable of causing an inmatory response, i.e. pulpitis (14, 15]. This issumably due to cytotoxic bacterial products into tubules. Conservative treatment would coof removing the carious dentin and restoringtooth or replacing the leaking (or defective) restion with the hope that the reparative and heability of the pulp would restore pulpal health. Wirreversible pulpitis, endodontic therapy is cated. However, we believe there is another servative method of treating reversible pulpitisperhaps some forms of what is now consideredirreversible type, and that is with the use of dA number of drugs are available to treat paininflammation; for example (a) local anestheticblock pain transmission, (b) glucocorticoids or steroidal anti-inflammatory agents (NSAIAtreat inflammation, (c) NSAIA or narcotic (opanalgesics for pain control, and (d) antibiotictreat the infection that is associated with pulAlso, the use of antimicrobial drugs to treat ceforms of periodontal disease is growing (16)course, drugs will not always be effective; therebe instances of failure. This is because of the dculties in obtaining accurate puipal diagnosesbecause some inflammatory conditions are stand some are septic. However, the use of tetrcline to treat a putative pulpal bacterial infecmay be helpful even if the pulp is sterile bec


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P u lp m e d i cnd create more pulpal irritation. Only further

Another problem associated with treatment of

t h e topical use of local anesthetics to relieve

i n silu, there is a nattiral m ovement of dentinalface which tends to oppose diffusion (pers comm ,Matthews) and is driven by pulpal pressure. This

itating inward diffusion of dru g. Of coursedoses) of vasoeonstric-

The plasma therapeutic concentrations of most

a saturated solution of aspirin in water may

etc.

he use of topical application of local anesthetics

on the pulpal floor of the dentin could be usetest for the restoration of neural responses. Idethe pulp tester should be a constant current devTest solutions of local anesthetics could be appto the dentin and the vitality of the pulpal nere-evaluated every 5 min for the next 20-30 minor until local anesthesia was obtained via difliuacross dentin. After obtaining local anesthesia inbuccal cavity, test eavities could be prepared onlingual side of the same teeth to determine ifloeal anesthesia was general or was eonfined tobuecal dentin. The experimental variables could be evaluated inelude: type of loeal anesthconcentration, pH, removal of smear layer, reming dentin thickness, iontophoresis, fluid filtrae t e . As those teeth are scheduled for extraction, are also available for histologic study.

Determination of the efficacy of anti-inflamtory agents on the elinical course of pulpal infmation is more difTieult. Ideally, animal moshould be developed that can reproducibly devpulpal inflammation. The topical use of sonicatbaeterial plaque by Bergenholtz (14, 15) to cadentin is a good example of such a model. Putanti-inflammatory drugs could be mixed withcell-free bacterial sonicate to determine how they were able to express their anti-inflammpotential. The extent of the histopathologic preaction to control plaque sonicates versus anflammatory agent plus plaque sonicates coulquantilated over time using morphometric niques (33). That is, lyophilized plaque made ua known molarity of a NSAIA should producepulpal inflammation than the same lyophiplaque made up with isotonic saline at any o\ ation time. Similar studies could actually be on patients seheduled for ex traetion of premolaorthodontic purposes. The important experimvariables would include type of anti-inflammdrug, concentration, remaining dentin thiekpresence or absence of smear layers, time, etcIn many inflammatory conditions, local bflow is reduced by elevations in loeal tissue preThis may occur because of a low compliancvironment (i.e. pulp, bone or nail bed) or dabseess formation. Traditional treatment has included ineising and drainage of the area to retissue pressure and remove toxic products. In dontics, periapical exudates are drained througopened root eanal. One wonders if pulpal absecould be drained through intact dentin. Ththe dentin could be excavated or thinned untremaining dentin thiekness was small (i.e. 0.5


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& P a s h l e v

is able tomove across the dentin, that itre-Apiece of dry absorbant

by a thin film of^ Teflon to protect the ab-material from the temporary restorative ma-

a cotton ball saturated with an appropriateicament. T his could be sealed in to permit timeand for pulpal healing. If thenot be sealed between visits, then thethe dentin surfaces further irritating the

If one wished to accelerate the process, onea negative pressure to the cavity (34)the tissue pressure more rapidly. How-if too much negative pressure is applied, itbut injure the

as la-to determine ifis being perfused by blood is a usefuland analysis of dentinal fluid for theof biologic markers of inflammation is

be required to apply suchto the conservative treatment of putpal

n our knowledge of dentin dynam ics, the

of the

R e f e r e n c e s1. ACCEPTED DENTAL THERAPEUTICS. 40th ed. ChicagAmerican Dental Association, 1984; 328-330.2. HUME \V"R. An analysis of the release and the dthrou gh d entin of eugenol from zinc oxide-eugeno! miJ Dent Re.^ 1984; 63: 881- 4 .3. PASHLEY DH, LIVINGSTON MJ, O U T H W A I T E WC. Dentmeabili ty: changes produced by iontophoresis. J D

1978; 57.- 77-82.4. HASTINGS CE, HOLLINGER JO, VINCENT JW, SWAVZAbili ty of DMSO and l idocaine to penetrate dentin iJ Dent R es 1986; 65: 275 (abstract) .5. ABBOTT PV, HEITHERSAY GS, H U M E WR. Release anfusion through human tooth roots in vitro of corticoand tetracycline trace molecules from Ledermix paste.Dent Traumaiol 1988; 4: 55-62.6. ABBOTT PV, H U M E WR, HEITHERSAY GS. The releadiffusion through human coronal dentine in vitro of trolone and demeclocyline from Ledermix paste. EndoTraumatot 1989; 5; 92-7.7. ABBOTT PV, H U M E WR, HEITMERSAY GS. Barriers

fusion of Ledermix paste in radicular dent ine . EndoTraumatol 1989; J.- 9 8-1 04 .8. ABBOTT PV, H U M E WR, HEITHERSAY GS. Effects of coing Ledermix and calcium hydroxide pastes on the difof corticosteroid and tetracycline throu gh to oth rootsEndod Dent Traumatol 1989; 5; 188-92.9. CsLKAS 2, FERENCZI I, NASZI I, BANOCZY J. Diffusmetronidazole through the dentinal tubules of extteeth. Acta Micro Hung 1987; 34 : 121-4.

10. CIARLONE AE, JOHNSON RD, TOMASELLIJR DL, SEALPASHLEY DH. The quant i ta t ive binding of tetracycldent in . J Endod 1988: 14 : 494- 6 .

11. CiARLOJVE A E, JOHNSON R D . PASHLEY DH . fur th er acterization of tetracycline qu anti tat ive binding to denEndod 1989; 15 : 335-8.12. GROWER MF, ABUEMF, JM, SENG GE. In vitro penetraradioactive indomethacin through decayed dentin inpu lp . J Dent R es 1990; 69 : 332 (abstract) .!3 . CiARLONE AE, T A D L, ZIEMER DM, PASHLEY DH. Eprine permeation across dentin in vitro. Endod Dent Tr

1991; ;.- 5-9.14. BERGENHOLTZ G , LINDHE J. Effects of solub le plaq ue on inflammatory reactions in the dental pulp. ScandR es 1975; 83 : 153-8.15. BERGENHOLTZ G . Effects of bacterial pro duc ts on infltory reactions in the dental pulp. Scand J Dent R es 19122-9.16. CL^NCIO SC. Chemotherapeutic agents and periodontaapy. Their impact on clinical practice. J Periodonto57 : 108-11.17. GABLER W X , CREAMER HR . Suppression of hu ma n nphi) functions by tetracyclines. J Periodont R es 1991;.2618. PARRIS WG, TANZER FS, FRIDLAND GH, H A R R IKiLLMAR J , DESIDERIO D M . Effects of ort ho do nti c formethioninc enkephaiin and substance P concentratihuman pulpal t issue. Am J Orthod Dentofac Orthop479-89.19. ROBINSON QC:, KILLMAR JT, DESIDERIO DM, HARR

FRIDLAND G. Immunoreac t ive evidence of beta-endand methionine-enkephahn-arg-gly-leu in human pulp. Life Sciences 1989; 45: 987- 92 .20. PASHLEY DH, M I C H E L I C H V, K E H L X Dentin permea


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P u l | i m e d i cPASHLEY DH. Dentin permeabil i ty: theory and pract ice. In:Spangberg L, ed. Experimental endodontics. Boca Raton: CRC,1989; C hap 2.SCOTT D JR. Aspirin: actions on receptor in the tooth. Science1968; J6l: 180-1.SCOTT D )R . Thearousal and suppression of pain in thetooth. Int'Dent J 1972; 22 : 20- 31 .PASHLEY D H , LIVINGSTON MJ. Effect of molecular size onpermeability coefficients in human dent ine . Arch Oral Biol\97S; 23: 391-4.FoGEL H M , MARSHALL FJ, PASHLEY DH. Effects of distancefrom the pulp and thickness on the hydraulic conductanceof human radicular dentin. J Dent R es 1988; 67 : 1381-5.M E R C H A N T VA, LIVINGSTON MJ, PASHLEY DH. Dentin pene-tration: comparison of diffusion with filtration. J Dent Res1977; 5^,- 1061-4.AHLquiST ML, GOFFEY JP, FRANZEN OB, PASHLEY DH.Sharp dental pain selectively induced by positive and nega-tive hydrostatic pressure changes. Eur J Meurosci (Suppl)1988; 46 : 12 (abstract),

V, SCHUSTER GS, PASHLEY DH. Bacterial pene-tration of human dent in in vifro. J Dent Res I9H0: 59:1398-1403.KrM S. Microcirculation of the dental pulp in health anddisease. J Endod 1985; //.- 465-71.BENET LZ, WILLIAMS RL. Appendix II. Design and optimiz-

ation of dosage regimens; pharmacokinetic data. In: GAG, Goodman LS, Rail TW, Nies AS, Taylor P, edpharmacological basis of therapeutics. NewYork: P1990; 1650-1735.

32. KAUFMAN E, L E R E S C H E L, SOMMERS E, DWORKIN SF,LOVE EL. Intral igamentary anesthesia: a double blindparative study. J Am Dent Assoc 1984; 109: 175-] 78.

33. WARF\TNGE J. Morphometric analysis of teeth with infpulps. J Dent R es 1987; 66 : 78-83.34 . MAITA E, SIMPSON M, TAO L, PASHLEY DH. Fluiprotein flux across the pulpodentin complex of a dog,Arch O ral Biol 1991; inpress.35 . GAZELIUS B , OLGART L, EDWALL B, EDWALL L. Noninrecording of blood flow in human denta l pulp. EndoTraumatol 1986: 2 ; 219-21.36 . OLGART L, GAZELIUS B, LINDH-STROMBERG U. Laser dflowTnetry in assessing vitality in luxated permanent In t Endod J 1988; 21 : 300-6.37. SASAX O T, KURIWADA S, SANJO D. Arterial blood prregulation of pulpal blood flow as determined by lasepler. ,7 Dent R es 1989; 68 : 791-5.38 . Liu M, KIM S, PARK DS, M A R K O W I T Z K, BII.OTTO GscHER-KiM J. Com parison of the effects of intr a-a rter ialocally applied vasoactive agents on pulpal blood fldog canine teeth determined by laser doppler velociAich Oral Biol 1990; 35: 4 0 5 - ! 0 .


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medication of the dental pulp_ a review and proposals

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