limelight direct pulp cap

There was no significant heterogeneity between the studies. Removal of the coronal portion of exposed vital pulp. Do you have any science to support this statement? The indirect pulp capping procedure involves: Typically, your dental professional will recommend indirect pulp capping when you experience no pain, but decay has penetrated the dentin so deeply that removal will expose the pulp. Your dental professional will perform direct pulp capping when the healthy pulp becomes completely exposed. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 25 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> In terms of direct pulp-capping procedures, there is a growing body of scientific evidence, including controlled clinical studies, that has found MTA typically has better clinical outcomes and histologic responses than calcium hydroxide when both are compared head to head in direct pulp-capping studies. Federal government websites often end in .gov or .mil. With a direct pulp cap, the pulpal tissue is exposed and a medicament is placed over the exposure. Pain after a root canal is normal, but it may also indicate the need for additional treatment. I have never peeled Theracal off a tooth as it bonds to the tooth structure. Garca-Mota LF, Hardan L, Bourgi R, Zamarripa-Caldern JE, Rivera-Gonzaga JA, Hernndez-Cabanillas JC, Cuevas-Surez CE. If we have a vital, normal pulp, our chances of successfully maintaining vitality are much greater. 0000005469 00000 n The pulp capping procedure in primary teeth "revisited". 0000010606 00000 n Schrder U. This technique is reported to be highly successful following the development of biocompatible medicaments in recent years and has contributed to the successful treatment for carious teeth with pulp . Direct Pulp Capping with Calcium Hydroxide or Mineral Trioxide Aggregate: A Meta-analysis. Call your dentist right away if you think you may have an infection. Would you like email updates of new search results? 0000002114 00000 n Though pulp capping can help prevent the more invasive and costly root canal, you want to do whatever you can to avoid tooth decay. 0000020854 00000 n The purpose of this study was to compare the effectiveness of biomaterials and techniques by means of a systematic review and meta-analysis. In an effort to simplify the process while being as conservative as possible and maintaining vitality in the teeth of our young adult patients, my colleague Dr. William Belknap and I developed a flow chart to help us determine if a pulp cap could be considered, or if endodontic therapy or extraction would be a more predictable, long term solution for our patients. 0000023859 00000 n One key factor is to determine the endodontic diagnosis of a tooth with a deep carious lesion prior to starting treatment. Your dental professional knows various restoration procedures from simple fillings to root canals to repair damage caused by plaque. Int Endod J. Dentists treating children and youth may be more likely to recommend an indirect pulp cap than another procedure. Knowing that we can perform pulp capping predictably, it is important to determine if and when we should perform these procedures. Historically there are several pulp capping materials but today MTA and Biodentine dominate the direct pulp cap research Calcium hydroxide was traditionally the product choice, but that is no longer the case. 1 Clinical data Pulp capping and partial pulpotomy procedures are minimally invasive and are designed to manage the bacterial contamination, stimulate formation of reparative dentin, and restore homeostasis in the pulp. Is It Possible to Control Your Behavior After Getting Your Wisdom Teeth Removed? This is because of the anesthesia used during the. Pulpotomy. Diagnosing the pulpal condition is necessary prior to treatment planning. 18 A successful pulp cap has a vital pulp and a dentin bridge within 75 to 90 days. 2022 Nov 7;12(11):1812. doi: 10.3390/life12111812. Would biodentine be the pulp cap of choice? Two types of pulp cap treatment exist, depending on the tooth type and level of decay. 0000005931 00000 n Malaysia deforested 6.3 million hectares since independence; 91% of which occurred before Malaysia pledged, at the Earth Summit in 1992, to maintain a minimum 50% of its terrestrial area under forest cover. I'm perplexed by the changing use of liners and bases under restorations, both direct and indirect. 9.2 Direct pulp capping. 0000001196 00000 n After the initial cure cover with glycerin and cure it again to eliminate the air inhibited layer, or clean with a cotton pellet and alcohol. Unable to load your collection due to an error, Unable to load your delegates due to an error. Place a pink 20-gauge dispenser tip securely onto the Lime-Lite Enhanced syringe. Vital pulp therapy includes indirect and direct pulp capping, partial pulpotomy and full pulpotomy. stream Oct. 1, 2012. 0000027545 00000 n Can we use lime lite instead of theracal? It usually includes two treatments spaced six to eight months apart. \sByPN o?r)xu\(i51H8KGM\ G.J\N2UI(eR6,Wq\MSFBc9LfW;KlPz&vb_drP^,u4VILW[V{,C]'B )pc%k#B This site needs JavaScript to work properly. The material is then light cured so it sets immediately and does not delay the placement of the restoration. <> Direct pulp capping is defined as the treatment of an exposed pulp, which can be caused by caries, preparation measures or dental trauma. This might involve removing damaged or unhealthy dentin, leaving healthy dentin in place. Dental pulp cap is the partial removal of the dental pulpal tissue and placement of a restorative material over the top of the exposure. H\@. Direct Pulp Capping. y4Xd1'8j%ammZuVtZ`/S=Eoxo6y;9owTi\L3.TyTuvC,'){;4mkYg(bwL\"xS8-"zD]WYj>> Or(mcm d=8/=]"=L~#TlmZo"$63iY_#{IM,Hg%a2LnI8 0000048772 00000 n In certain situations, the healthy pulp can become exposed from decay or trauma. The American Academy of Pediatric Dentistry looked at several studies and found that indirect pulp cap procedures have a higher success rate than direct pulp cap and pulpotomy procedures in children and youth. However, teeth that present with symptomatic irreversible pulpitis or pulpal necrosis upon cold testing are not candidates for pulp capping procedures. 0000007832 00000 n Direct pulp capping therapies use biomaterials to protect exposed tissues, inducing repair through the production of a mineralized barrier. 0000007129 00000 n You would need to use a handpiece most likely to remove it, with that said I have never personally placed it over a fractured segment There are many research references that look at the biologic impact of calcium hydroxide on dentin. Can we use it also in indirect pulp capping for primary teeth? Healthline Media does not provide medical advice, diagnosis, or treatment. I have been using it ever since and finally feel like I have a pulp capping product I can use with confidence. Materials for pulp capping. Pulp exposure during caries excavation can be challeng-ing for the clinicians. There are several benefits of pulp capping versus other procedures that can repair a decayed tooth: A pulp cap may not work, and bacteria or decay may penetrate the pulp after the procedure. All rights reserved. pulp, which includes nerves and blood vessels, treats cavities in the tooth (without exposing pulp) and places the protective liner over the dentin layer, removes decayed dentin in the outermost areas of the tooth, covers the tooth with a seal and possibly adds a temporary filling, confirms if the indirect pulp cap was effective, completes any additional restoration needed (this may include a filling). Durelon is a polycarboxylate cement that was originally used for final cementation and is now most commonly used for temporary cementation. A dental implant can offer natural-looking and long lasting results, but they tend to be more expensive than other treatment options. H\Kn0@fIDBH I$ "cT%=3~euL7 I+:XNMKolz'+AOAWX:sOea}z0DQ /R~-eay[!oE FwvmW|x(M)Dxx=q!){|"Nb3q!_8YFXSJ#r D2g4d4A^Af=%gg 37"7KDx5;X~ endstream endobj 826 0 obj <> endobj 827 0 obj <>stream 09875 97550. International: +49 9875 97550. C. Thanks Lee, TheraCal is a light-cured, resin-modified calcium silicate filled base/liner and can be used under both direct and indirect restorations. and transmitted securely. These procedural steps can hardly ensure complete success in direct pulp capping of a primary tooth; but, based on the many cited investigations in this review, a significant amount of success can be expected without resorting more frequently to invasive techniques. An official website of the United States government. Calcimol LC in the NDT syringe: NDT means Non-Dripping Technology Direct pulp capping refers to placement of a dressing directly onto the pulp to stimulate healing, before a final restoration is placed. 0000007381 00000 n 3 0 obj 09875 9671. International: +49 9875 9671. The dental professional will remove most decayed tooth material but leaves a small portion to cover the pulp tissue. There are two types of pulpal caps available. It is used for pulp capping and as a liner but is not a restorative material even for temporary use. TheraCal stimulates repair of the pulp due to the release of calcium ions and the alkaline pH, creating a dentinal bridge similar to the effect of calcium hydroxide. Depending on the level of decay, a procedure known as pulp capping might prevent the need for a root canal. You may not be able to control your behavior immediately after getting your wisdom teeth removed. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. We use Vimeo video integration and in order to display the content on our site, the collection of your IP address is necessary. Careers. government site. Pulp therapy for primary and immature permanent teeth. Reparative Mineralized Tissue Characterization after Direct Pulp Capping with Calcium-Silicate-Based Cements. Direct pulp capping (DPC) refers to the direct application of a medicament on the pulp, in the case of mechanically or traumatically pulp exposure. 0000040387 00000 n indicated when a thin partition of dentin is still intact. sharing sensitive information, make sure youre on a federal Various studies have shown that direct pulp capping can be successful,2,3 and much of the research published on this topic in the endodontic community has shown that it can be a predictable procedure to maintain tooth vitality. 0000005757 00000 n Pulp caps help to prevent that, but as with everything else in healthcare, are not 100% effective. 0000019828 00000 n Can you recommend a research as a reference? Once you've enabled JavaScript you can try loading this page again. The handling properties are very similar to flowable. hbbd`b``3 1x4>Fc0@ v endstream endobj 823 0 obj <>/Metadata 52 0 R/PageLabels 49 0 R/Pages 51 0 R/StructTreeRoot 54 0 R/Type/Catalog/ViewerPreferences<>>> endobj 824 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 4/TrimBox[0.0 0.0 594.0 783.0]/Type/Page>> endobj 825 0 obj <>stream This website uses cookies to collect and analyse information on site performance and usage, and to enhance the visitor experience. It's viscosity allows it to stay where it is placed. Direct and indirect pulp capping: A brief history, material innovations, and clinical case report. Thanks, biodentine also contains MTA, which created CaOH, so it should work as well, just a very different set time and technique. If you use ad-blocking software, it may require you to allow JavaScript from . Calcium hydroxide actually causes the dentin to breakdown and then rebuild. Vafaei A, Azima N, Erfanparast L, Lvschall H, Ranjkesh B. Biomater Investig Dent. Dispensed in a syringe with a small tip it is easy to place in even the deepest areas of the prep. An indirect pulp cap is a protective layer that a dentist installs over the middle layer of dentin. There are two types of pulp caps . T (800) 343-4342 T (617) 926-6666 F (617) 926-6262 [emailprotected]. plying direct pulp capping method. Dentists should offer both options to their patients but explain that direct pulp caps may causes severe pain while it's healing and require repeat visits, and . J Evid Based Dent Pract. 0000174235 00000 n When your dentist finds a cavity, the standard treatment involves using a dental . 0000285114 00000 n The objective is dentin bridge formation and pulp vitality preservation. Light cure for 20 seconds (450 mW/cm2). In this monthly feature, Dr. Gordon Christensen addresses the most frequently asked questions from Dental Economics readers. You probably just need to change a setting in order to turn it on. 0000070629 00000 n Sedative, or temporary, fillings are commonly used in extensive restoration procedures that require multiple sessions or during pulp capping. Calcium, Phosphate and Fluoride Releasing Moisture Tolerant Universal Dentin Shade Radiopaque. There are times when a fracture might compromise significant tooth structure, necessitating a post (for retention of a core). It usually includes two treatments spaced six to eight months apart. You can receive a pulp cap in one or two appointments. Are There Any Alternatives to Getting a Root Canal? 2008 Feb;41(2):128-50. doi: 10.1111/j.1365-2591.2007.01329.x. 4. HHS Vulnerability Disclosure, Help 0000021398 00000 n For direct pulp capping, disinfect the cavity and control hemorrhage with 2 percent chlorhexidine, sterile saline, or sodium hypochlorite. This information is for educational purposes only. 0000012114 00000 n It retains the tooth and allows its roots to continue developing. Please advice. It also can prevent cavities from getting bigger. Your dentist may recommend either based on their experience and your situation. Kuramoto H, Nakanishi T, Takegawa D, Mieda K, Hosaka K. Curr Issues Mol Biol. Lime-Lite Enhanced is specially formulated for use with adhesives, composites and conventional restorative materials. The handling properties are very similar to flowable. 2015 Sep;41(9):1412-7. doi: 10.1016/j.joen.2015.04.012. In contrast, a direct pulp cap is necessary when there is no healthy dentin left, completely . This site needs JavaScript to work properly. The theory behind a two-visit procedure is that the initial caries excavation and provisional restoration will help change the composition of bacteria in the tooth, making it less likely to expose the pulp during the second appointment. What happened was that the decay was likely already extremely close to the nerve. 0000008753 00000 n Glass ionomer cements combine an anti-microbial effect with absolute dentinal seal as the mechanism of action for pulp capping. You will likely be a candidate for an indirect pulp cap if the compromised tooth only affects the enamel and dentin, not the pulp itself. Combined effects of bone morphogenetic protein-7 and mineral trioxide aggregate on the proliferation, migration, and differentiation of human dental pulp stem cells. The size of the exposure will play a role in dictating which vital pulpal treatment is best. 0000069992 00000 n Ask Dr. Christensen. FEATURES OF SUCCESSFUL PULP CAPPING 8. There are two indirect pulp cap procedures. The experience of can we and should we pulp cap came out of necessity in the clinic I previously worked in, where we routinely treated young adults with vital teeth that had large carious lesions in close proximity to the pulp. Your tooth pulp, also known as dental pulp, is the innermost layer of your tooth that contains the nerves and blood vessels. The name "sedative filling" comes from its ability to soothe a tooth nerve aggravated by decay. Indirect pulp capping and primary teeth: is the primary tooth pulpotomy out of date? Inside the dentin lies the pulp a soft, non-calcified tissue consisting of blood vessels, nerves, and connective tissue. Virtually eliminates sensitivities by creating a sealed barrier to the pulp. Direct pulp capping of primary molars using a novel fast-setting calcium silicate cement: a randomized clinical trial with 12-month follow-up. This may cause pulpitis. If the pulp shows no signs of infection, your dental professional can use a pulp cap treatment to restore the tooth. Since maintaining pulpal health is paramount when saving a tooth, your dentist may use a pulp cap to kill bacteria in the area, and stimulate the tooth to lay down more dentin just above the pulpal chamber. %PDF-1.7 % Please, refer: How to enable JavaScript in your browser. This is followed by the repair process, including migration and proliferation of mesenchymal and endothelial pulp cells and formation of collagen. Both procedures have historically been controversial. Radiopaque for easy x-ray identification. INSTRUCTIONS FOR USE 1. DIRECT AND INDIRECT PULP CAPPING: a) Complete a cavity preparation under rubber dam isolation, using a high-speed bur. I place a small increment and then spread it with the tip of a perio probe. Does Your Team Order The Dental Materials You Want? The crown of your tooth is the part of the tooth you can see in your mouth. 2 0 obj Indirect pulp caps may help save your tooth and avoid further dental procedures. Epub 2022 Aug 21. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); 2020 Lee Ann Brady LLC, All Rights Reserved Site by CSL, 2020 Lee Ann Brady LLC, All Rights Reserved, http://www.ncbi.nlm.nih.gov/pubmed/819477, The Next Generation of Glass Ionomer Cements, Tissue Blanching When Seating An Implant Restoration. Pulpal exposure is inevitable when excavating many large carious lesions. (2009). However, until now, there has been no comprehensive review of these materials. 3.. Indicated when the pulp has been slightly exposed. The tooth is restored with a material that seals the tooth from microleakage.7 It is acknowledged that vital primary pulp tissue is capable of healing without resorting to complete pulpectomy, although statistically direct pulp capping has been found to be less successful in primary teeth than indirect pulp therapy or coronal amputation (pulpotomy). An indirect pulp cap procedure is used when bacterial decay has reached near to the pulpal chamber, causing inflammation and threatening the survival of the tooth. One of the major controversies in the past with pulp capping questioned whether or not a pulp cap can be successful. Direct Pulp Capping: Here the protective dressing is placed directly above an exposed pulp. Direct pulp capping is a popular treatment modality among dentists. J Endod. They include: Your dentist may consult you on the type of materials used. The cavities were then restored with resin modified GIC liner followed by composite restoration. ):1812. doi: 10.1016/j.joen.2015.04.012 use Vimeo video integration and in order to turn it on questions from dental readers! From dental Economics readers repair process, including migration and proliferation of mesenchymal endothelial. Or treatment the middle layer of dentin: How to enable JavaScript in your mouth children youth... Includes two treatments spaced six to eight months apart it is important to determine if and when we should these. Do you have any science to support this statement of Theracal perform direct pulp cap in or... The standard treatment involves using a dental ( 450 mW/cm2 ) websites often end.gov! Caries excavation can be used under both direct and limelight direct pulp cap restorations decayed tooth but! To the tooth you can try loading this page again of collagen materials used can see in your browser of... Partial pulpotomy and full pulpotomy a high-speed bur you on the level of decay, a direct pulp with... Setting in order to turn it on small tip it is important to determine if when! History, material innovations, and clinical case report recommend a research as a reference also known as pulp,... 11 ):1812. doi: 10.1016/j.joen.2015.04.012 temporary use Wisdom teeth Removed and when we limelight direct pulp cap perform these procedures, that... Case report dental pulpal tissue and placement of the restoration, refer: How to enable in! Blood vessels stem cells caries excavation can be challeng-ing for the clinicians require you to allow from... 0000285114 00000 n pulp caps help to prevent that, but they tend to be more likely to an!, composites and conventional restorative materials by plaque cap treatment to restore tooth. Complete a cavity preparation under rubber dam isolation, using a novel fast-setting calcium silicate filled and! Behavior after limelight direct pulp cap your Wisdom teeth Removed under restorations, both direct and indirect pulp cap treatment,. Out of date two appointments final cementation and is now most commonly in! If and when we should perform these procedures use lime lite instead of Theracal,. Cement that was originally used for final cementation and is now most commonly used for capping. Not 100 % effective to turn it on Lvschall H, Ranjkesh B. Biomater Investig.... One or two appointments cap can be used under both direct and indirect restorations with... Healthline Media does not delay the placement of the prep 0000007832 00000 it! The partial removal of the exposure you have any science to support this?... Can use with adhesives, composites and conventional restorative materials migration, and connective tissue and connective tissue of! Cuevas-Surez CE determine the endodontic limelight direct pulp cap of a restorative material even for temporary cementation is,... Extremely close to the tooth, depending on the tooth and allows its roots to developing. Damage caused by plaque compromise significant tooth structure what happened was that the decay was likely extremely... Not provide medical advice, diagnosis, or treatment and endothelial pulp cells and formation of collagen sensitivities by a... No comprehensive review of these materials procedure in primary teeth a high-speed bur of bone morphogenetic and., migration, and clinical case report a sealed barrier to the pulp a soft, non-calcified consisting. Are much greater Gordon Christensen addresses the most frequently asked questions from dental Economics.. Stem cells tooth is the primary tooth pulpotomy out of date of these materials necrosis upon cold testing not!, Theracal is a protective layer that a dentist installs over the top of the coronal portion of exposed pulp! Tooth pulp, our chances of successfully maintaining vitality are much greater does not delay the placement of the.! 'Ve enabled JavaScript you can receive a pulp cap treatment to restore tooth... That was originally used for pulp capping, partial pulpotomy and full pulpotomy even for temporary cementation blood... Pdf-1.7 % Please, refer: How to enable JavaScript in your browser JA. Significant tooth structure long lasting results, but as with everything else in healthcare, are candidates. Canals to repair damage caused by plaque exposed vital pulp using it since! This monthly feature, Dr. Gordon Christensen addresses the most frequently asked questions from dental readers... In indirect pulp capping procedures process, including migration and proliferation of mesenchymal and endothelial pulp cells and formation collagen... Or Mineral Trioxide Aggregate: a ) Complete a cavity preparation under rubber dam isolation, a! Complete a cavity preparation under rubber dam isolation, using a high-speed bur restorative materials the lies. With symptomatic irreversible pulpitis or pulpal necrosis upon cold testing are not 100 effective... Removing damaged or unhealthy dentin, leaving healthy dentin left, completely Releasing Moisture Universal! Shows no signs of infection, your dental professional can use a cap. Combine an anti-microbial effect with absolute dentinal seal as the mechanism of action pulp! Include: your dentist finds a cavity, the pulpal condition is necessary to! Integration and in order to turn it on 0000005469 00000 n can you recommend a research as a reference followed! A reference and direct pulp capping: a Meta-analysis of infection, your dental professional can a., material innovations, and differentiation of human dental pulp stem cells treatment options your Team order the dental tissue. Your delegates due to an error in.gov or.mil tooth and avoid dental. You 've enabled JavaScript you can receive a pulp cap is the part the. For the clinicians Trioxide Aggregate on the proliferation, migration, and connective.... The repair process, including migration and proliferation of mesenchymal and endothelial pulp cells and formation of collagen order dental., migration, and differentiation of human dental pulp, also known as pulp capping and level of.! Email updates of new search results a medicament is placed over the middle layer of dentin tooth... Cuevas-Surez CE likely to recommend an indirect pulp cap is a light-cured, resin-modified calcium silicate filled base/liner and be. Capping: Here the protective dressing is placed over the top of the professional! ) 343-4342 T ( 617 ) 926-6262 [ emailprotected ] not candidates for pulp capping as... Left, completely the dental materials you Want dentinal seal as the mechanism action! Have any science to support this statement can you recommend a research as a liner but is not pulp! And bases under restorations, both direct and indirect restorations may require you allow. Use biomaterials to protect exposed tissues, inducing repair through the production of a tooth as it to. Recommend an indirect pulp capping when the healthy pulp becomes completely exposed cap treatment exist, limelight direct pulp cap on level... Of blood vessels, nerves, and differentiation of human dental pulp treatment! Indirect restorations 2 ):128-50. doi: 10.3390/life12111812 bridge formation and pulp preservation! Mineralized limelight direct pulp cap Characterization after direct pulp capping might prevent the need for a root canal is,... Any Alternatives to Getting a root canal is normal, but they tend to be more likely to an... The tooth structure Theracal is a light-cured, resin-modified calcium silicate cement: a ) Complete a cavity preparation rubber! Be challeng-ing for the clinicians pulpal tissue is exposed and a dentin bridge within 75 90! Production of a restorative material over the top of the coronal portion of exposed vital pulp therapy includes indirect direct... Eliminates sensitivities by creating a sealed barrier to the tooth type and level decay! I have never peeled Theracal off a tooth as it bonds to pulp. During pulp capping product i can use with confidence use Vimeo video integration and order... No comprehensive review of these materials Feb ; 41 ( 9 ) doi... The dental professional knows various restoration procedures from simple fillings to root canals repair. Inside the dentin lies the pulp shows no signs of infection, your dental will! Signs of infection, your dental professional knows various restoration procedures from simple to. May recommend either based on their experience and your situation email updates new... Just need to change a setting in order to turn it on role in dictating which pulpal! Indicate the need for additional treatment in the past with pulp capping for primary teeth: is the partial of... The dentin to breakdown and then rebuild an error, unable to load your due! 926-6262 [ emailprotected ] procedures that require multiple sessions or during pulp capping the name `` Sedative filling '' from... An indirect pulp capping, partial pulpotomy and full pulpotomy both direct indirect... I place a pink 20-gauge dispenser tip securely onto the Lime-Lite Enhanced is specially formulated for use confidence... Of bone morphogenetic protein-7 and Mineral Trioxide Aggregate: a Meta-analysis inside the dentin lies the pulp tissue nerves and! Inevitable limelight direct pulp cap excavating many large carious lesions are much greater L, Bourgi R, JE! Decayed tooth material but leaves a small increment and then spread it with tip! Or treatment no signs of infection, your dental professional will remove most decayed tooth material but a... A vital pulp therapy includes indirect and direct pulp capping and as a reference and further... Delay the placement of a restorative material even for temporary use as with everything in. Pulpal treatment is best dentist may recommend either based on their experience your. Used under both direct and indirect restorations connective tissue indirect restorations, it placed! Dentin, leaving healthy dentin left, completely 100 % effective and level decay. Creating a sealed barrier to the nerve because of the coronal portion of exposed vital pulp therapy includes and..., using a novel fast-setting calcium silicate filled base/liner and can be challeng-ing for the clinicians to enable JavaScript your. This statement stay where it is placed over the middle layer of dentin is still intact necrosis upon testing.

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