2008). In terms of prevention of bacterial infection, it should be remembered that dentine has a tubular structure, and if the residual dentine layer is <1 mm, it is likely to be as permeable to bacterial challenge as a pulp exposure (Murray et al. The zone of dentine demineralization is characterized by a wave of acid diffusing in front of the advancing enamel lesion. Mild irritation induces an up‐regulation of existing odontoblast activity to form reactionary dentine, whilst stronger stimuli result in odontoblast death and the initiation of complex processes involving the recruitment of dental pulp stem/progenitor cells, which differentiate into odontoblast‐like cells to form reparative dentine (Lesot et al. Comparing the outcome of various strategies to treat deep caries is complex, and as a result, the debate about whether or not to preserve a layer of dentine continues. To accomplish this, a source of progenitor cells (erroneously referred to as ‘SCs’) is required. Stable renal function in children and adolescents with sickle cell disease after nonmyeloablative hematopoietic stem cell transplantation. Deep caries management 1. 1) with extremely deep caries defined as radiographic evidence of caries penetrating the entire thickness of the dentine with certain pulp exposure. Inflammatory biomarkers in dentinal fluid as an approach to molecular diagnostics in pulpitis. Indeed, the endodontic tradition of an aseptic working field using rubber dam is not widespread in general practice (Jenkins et al. An unsuccessful class II pulp capping. This is a selective caries removal technique carried out in two visits. Human pulp response to acid pretreatment of dentin and to composite restoration, Swedish Council on Health Technology Assessment, Methods of diagnosis and treatment in endodontics: a systematic review, Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: a randomized clinical trial, Assessment of mineral trioxide aggregate pulpotomy in mature permanent teeth with carious exposures, Effect of smear layer deproteinizing on resin‐dentine interface with self‐etch adhesive, Dissolution of bio‐active dentine matrix components by mineral trioxide aggregate, Hepatocyte growth factor is sequestered in dentine matrix and promotes regeneration‐associated events in dental pulp cells, Growth factor release from dentine matrix by pulp‐capping agents promotes pulp tissue repair‐associated events, Reaction of the exposed pulp to Dycal treatment, Clinical and radiographic outcomes of direct pulp capping therapy in primary molar teeth following haemostasis with various antiseptics: a randomised controlled trial, Healing capacity of human and monkey dental pulps following experimental‐induced pulpitis, Endodontic complications after plastic restorations in general practice, Ultrasonic activation of irrigants increases growth factor release from human dentine, Evaluation of techniques and materials used in pulpal therapy based on a review of the literature: part 1, Minimally invasive endodontics: a new diagnostic system for assessing pulpitis and subsequent treatment needs, Detection of bone marrow‐derived fibrocytes in human dental pulp repair, Biodentine induces immortalized murine pulp cell differentiation into odontoblast‐like cells and stimulates biomineralization, Pulp inflammation diagnosis from clinical to inflammatory mediators: a systematic review, A first study on the usefulness of matrix metalloproteinase 9 from dentinal fluid to indicate pulp inflammation, Angiogenic activity of dentin matrix components. The most recent randomized controlled clinical trials in humans (Table 1) are limited by low numbers and resulting weak conclusions. Assessing the pulpal status of primary teeth can be the most difficult part of vital pulp therapy. 2013), even when important subjective (e.g. The material takes over four hours to set, and it is recommended that the tooth should be temporized before the permanent restoration is placed. Caries-risk assessment and management for infants, children, and adolescents. 2010). 2012), fibroblasts, the principal cell of the pulp, are also able to secrete complement fragments and GFs important to mineralization and SC recruitment (Jeanneau et al. The pulp reacts to a low‐grade lesion (e.g. If you do not receive an email within 10 minutes, your email address may not be registered, 1 Once Americans reach the age of 75, 99% will have had dental caries. Taken together, the awareness of carious lesion penetration depths should be considered with strategies that focus on pulpal symptoms (Wolters et al. Notably, the majority of dentists adopt an invasive approach choosing either a VPT or a pulpectomy (Oen et al. Notably from an endodontic viewpoint, a clear definition of lesion depth is lacking in many studies and the available evidence on well‐defined deep carious lesions in adult teeth remains limited. The extremely deep carious lesion has microorganism penetrating into the critical zone of tertiary dentine including the pulp (Reeves & Stanley 1966, Bjørndal 2018). 2001, Slaus & Bottenberg 2002, Bjørndal & Reit 2005, Markvart et al. Indeed, inflammation marks the first step of tissue convalescence. 2016); suffice to say that it is clear that both are likely to contribute significantly in a complimentary and possibly symbiotic manner to the overall repair process. Such a diagnosis can be achieved after the patient’s history of symptoms and clinical and radiographic findings have been reviewed. young patient with a deep carious lesion in pulpal quarter) is less well organized, with a reduced volume dentinal tubules eventually being completely atubular (also called fibrodentinogenesis) (Baume 1980). A lesion that is still active but less so tends to be darker with a colour closer to brown; it is dry and firmer when probed. After traumatic pulp exposure, the pulp can be capped without tissue removal as the wound has not been contaminated with microorganisms for an extended period. (e) Haemostasis is difficult to achieve. Although the odontoblast has an immunocompetent role (Couve et al. 2008). 2011, Elsalhy et al. Questionnaire‐based surveys in which dentists study radiographs of ‘deep carious lesions’ have analysed the dilemma of whether a tooth should be treated conservatively by avoiding pulp exposure, or a VPT approach or whether a more invasive approach is required. Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy and the re‐emergence of vital pulp treatment (VPT) techniques such as partial and complete pulpotomy. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention of root caries: a literature review of primary and secondary preventive agents. 1982). 2000, de Soet et al. However, the treatments vary from pulpotomy to extensive carious removal (indirect pulp capping) and stepwise excavation, which perhaps reflects that no global consensus or tradition currently exists in … Although the nature of the cellular response is likely to be dependent upon the pulp environment, the mineralized tissue deposited at the pupal wound site will likely display a spectrum of dysplasia. 2006, Galler et al. Review Council Council on Clinical Affairs Latest Revision* 2014 Purpose The American Academy of Pediatric Dentistry (AAPD) recog-nizes that caries-risk assessment and management protocols can assist clinicians with decisions regarding treatment based upon caries risk and patient compliance and are essential elements of contemporary clinical care for infants, children, and … The pulp reacts to a low‐grade lesion (e.g. Other options include assessing the level of pulpal haemostasis as inflammation is associated with hypervascularization. 2017). 1990, Bègue‐Kirn et al. Indeed, a problem with pulpal biomarkers and MMPs in particular is that they are not just destructive in nature; they also increase the bioactivity and reparative capacity of DMCs by further digesting the extracts (Okamoto et al. Traditionally, deep caries management was destructive with nonselective (complete) removal of all carious dentine; however, the promotion of minimally invasive biologically based treatment strategies has been advocated for selective (partial) caries removal and a reduced risk of pulp exposure. (d) Magnified image of the extremely deep cavitated dentine lesion (i = retrograde enamel demineralization as typically shown in dentine exposed environments, ii = loose fragment of dark brown discoloured contaminated dentine, iii = large zone of destruction (necrotic dentine), iv = contaminated and demineralized dentine, v = contaminated and demineralized tertiary dentine). In the clinic, pulpitis is classified as either reversible or irreversible. Working off-campus? 2017, Qudeimat et al. (d) Post‐operative radiograph with permanent restoration in place. Follow‐up: 1, 2 and 4 weeks, and 3, 6 months and 1 year, Nonsignificant (NS). Study design. Alternatively, in the patient group that had a clinical diagnosis of irreversible disease, five of 32 teeth had a histological diagnosis of reversible pulpal inflammation. 2012). 2014). Mild irritation induces an up‐regulation of existing odontoblast activity to form reactionary dentine, whilst stronger stimuli result in odontoblast death and the initiation of complex processes involving the recruitment of dental pulp stem/progenitor cells, which differentiate into odontoblast‐like cells to form reparative dentine (Lesot et al. 2014b). These properties are not exclusive to mutans streptococci, and strains of other streptococci such as Streptococcus mitis, Streptococcus gordonii, Streptococcus anginosus and Streptococcus oralis are acidogenic and aciduric (van Houte 1994, van Ruyven et al. At present, there is a lack of consensus regarding the progenitor population responsible for reparative dentine formation, although surface marker analysis generally confirms a mesenchymal origin (Simon & Smith 2014). 2015), whilst releasing other bioactive molecules that migrate down the dentinal tubules and stimulate tertiary dentine formation and other pulpal reparative processes (Finkelman et al. Correlation between clinical and histologic pulp diagnoses, Angiogenic growth factors in human dentine matrix, Relationship among mutans streptococci, “low‐pH” bacteria, and lodophilic polysaccharide‐producing bacteria in dental plaque and early enamel caries in humans, EDTA or H3PO4/NaOCl dentine treatments may increase hybrid layers’ resistance to degradation: a microtensile bond strength and confocal‐micropermeability study, Evaluation of healing following experimental pulpotomy of intact human teeth and capping with calcium hydroxide, Effect of an extra‐pulpal blood clot on healing following an experimental pulpotomy and capping with calcium hydroxide, Effects of calcium hydroxide‐containing pulp‐capping agents on pulp cell migration, proliferation, and differentiation, Scanning electron microscopy of hard tissue barrier following experimental pulpotomy of intact human teeth and capping with calcium hydroxide, Direct pulp capping after a carious exposure versus root canal treatment: a cost‐effectiveness analysis, Different materials for direct pulp capping: systematic review and meta‐analysis and trial sequential analysis, Managing carious lesions: consensus recommendations on carious tissue removal, Dentists’ attitudes and behaviour regarding deep carious lesion management: a multi‐national survey, The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp, Trends in socioeconomic inequalities in oral health among 15‐year‐old Danish adolescents during 1995‐2013: a nationwide, register‐based, repeated cross‐sectional study, Matrix metalloproteinase‐8 and substance P levels in gingival crevicular fluid during endodontic treatment of painful, non‐vital teeth, Molecular characterization of young and mature odontoblasts, Should pulp chamber pulpotomy be seen as a permanent treatment? Dentine and the pulp are one functional entity, the pulp–dentine complex (Pashley 1996); however, for diagnostic purposes at least, hard tissue (caries) and soft tissue disease (pulpitis) should be considered separately. DMCs contain multiple bioactive components, including GFs, chemokines, cytokines, MMPs and bioactive proteins (Smith et al. Dental caries is an infectious micro-biologic disease of the teeth that results in localized dissolution & destruction of the calcified tissues. NaOCl is generally the disinfectant of choice, but has drawbacks as it is corrosive due to its organic tissue dissolution ability (Hewlett & Cox 2003, Sauro et al. and you may need to create a new Wiley Online Library account. These changes stem from an improved understanding of the pulp–dentine complex's defensive and reparative response to irritation, with harnessing the release of bioactive dentine matrix components and careful handling of the damaged tissue considered critical. Controlling the disease in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal or control first. There are two types of tertiary dentine formed, depending on the severity of the irritating stimulus. MANAGEMENT OF DEEP CARIES DONE BY., B. GLADSON SELVAKUMAR CRI., CSI CDSR 2. 1980) with a more recent review corroborating this viewpoint (Mejáre et al. Several studies call this approach into question. 2003). 2007, Schwendicke et al. While several systems were reviewed … By age 19, 67% of children will have experienced tooth decay. Unfortunately, due to the nature of secondary care it is unusual for the endodontist to make a decision on whether the pulp should be saved or removed, as these decisions are carried out in general dental practice. 2005). 2000). 2016a, Tomson et al. Unfortunately, the changes in management are only supported by relatively weak evidence with case series, cohort studies and preliminary studies containing low patient numbers forming the bulk of the evidence. If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs … 1980). Economic factors may also alter treatment decisions as remuneration for a RCT in a molar tooth will be radically different to a VPT procedure on the same tooth. 1994). Pulp chamber pulpotomy is routinely used in Paediatric Dentistry to preserve the radicular pulp on immature teeth to allow the radicular process to grow and apexogenesis to occur. Alternatively, some dental practitioners may prefer pulpectomy to VPT, because it is more predictable in their hands (i.e. In order to establish a new mineralized barrier, it is necessary to induce the growth of neo‐odontoblasts, the only cells capable of secreting dentine. No irreversible pulpitis (defined); absence of PA radiographically (defined as ≥ 2 times with of PD space). 2011, Frozoni et al. The update used electronic and hand searches of English written articles in the medical and dental literature within the last 10 years using the search terms caries risk assessment, caries management, and caries clinical proto- cols. 2013, Marques et al. Until next‐generation diagnostic tools are validated and commercially available, practitioners must make do with the existing methods of detailed history and pulp sensibility tests. 2014b). 2015) after 3 years, perhaps highlighting the reasons for such a large difference. Recent reviews provide the evidence for a superior outcome for the use of the hydraulic calcium silicate cements, in particular various forms of the mineral trioxide aggregate (MTA), and another recent available type Biodentine™ (Septodont, Sant‐Maur‐des‐Ditch Cedex, France). The full text of this article hosted at iucr.org is unavailable due to technical difficulties. If the pulp is exposed, the reparative dentine forms a mineralized bridge, which is generally not in the form of tubular dentine (Nair et al. Clinically, a focus on high‐quality primary research investigating the efficacy of management strategies for the treatment of deep caries is a priority. 2008, Marques et al. Tertiary dentine forms alongside inflammation locally beneath the area of challenge (Lesot et al. 1 This increases to six of 10 children by their 8th birthday. 2005). Notably, mutans streptococci possess multiple sugar transport systems including the phosphoenolpyruvate phosphotransferase system and can enzymatically thrive at a low pH. The clinical result of leaving behind carious dentine is that over time the appearance changes to that of arrested carious dentine (Massler 1978, Bjørndal et al. 1985). Case courtesy of Dr Pim Buurman. Indeed, a problem with pulpal biomarkers and MMPs in particular is that they are not just destructive in nature; they also increase the bioactivity and reparative capacity of DMCs by further digesting the extracts (Okamoto et al. 2015, Wolters et al. 1980) with a more recent review corroborating this viewpoint (Mejáre et al. The stepwise excavation is an established technique and option for the treatment of deep caries lesions. 7). Sodium Hypochlorite Reduces Postoperative Discomfort and Painful Early Failure after Carious Exposure and Direct Pulp Capping—Initial Findings of a Randomized Controlled Trial. Axial exposure site (class V cavity) showed significantly poorer outcome, Deep caries with a potential risk of exposure (lesion depth not defined, no widening of PDL or periapical (PA) – or furcal lesion), Randomization: No concealed allocation sequence, Capping mat: ProRoot MTA (control) n = 47 versus OrthoMTA n = 47 and RetroMTA n = 48, Success: Positive response to pulp test. STUDY DESIGN: An electronic literature search included the databases PubMed, EMBASE, The … A more accurate impression of the extent of a lesion can be given on a cone‐beam computed tomograph (CBCT); however, this has limitations such as the higher dose, image distortion due to the presence of radiopaque restorations, cost and availability. Classical capping approach of a small pulp exposure, (a) before and (b, c) during and after calcium hydroxide application. In this context, the majority of general practitioners selected the ‘deep’ carious dentine lesion as one that penetrates radiographically into the pulpal quarter of the dentine, but still with a well‐defined zone of radiopaque dentine separating the infected demineralized dentine from the pulp (Fig. 2006, Tomson et al. 2017, Taha & Khazali 2017, Taha et al. On the other hand, avoiding exposing the pulp lessens the risk of bacterial infection and preserves the odontoblast palisade to facilitate reactionary (or reparative) dentinogenesis. 2012). 2. 1998). 2006, Tomson et al. In VPT, however, EDTA irrigation (although releasing DMCs) may stimulate renewed pulpal bleeding. The link between histologically and the reversibility or irreversibility of pulpitis is difficult to confirm clinically (Seltzer et al. 2017). Performance of a Biodegradable Composite with Hydroxyapatite as a Scaffold in Pulp Tissue Repair. old patient, carious lesion penetrating halfway into dentine) by forming reactionary dentine, whilst the tertiary dentine formed under rapidly progressing lesion (e.g. 2008, Marques et al. As discussed earlier, establishing whether the pulp is reversible or irreversibly inflamed is not completely predictable using current diagnostic techniques (Dummer et al. Moreover, the hard tissue bridges formed against MTA have higher histological quality compared with those induced by Ca(OH)2 (Nair et al. Indirect pulp treatment in primary teeth: 4‐year results, Comparative analysis of transforming growth factor‐β isoforms 1‐3 in human and rabbit dentine matrices, Molecular analysis of microbial diversity in advanced caries, Inflammatory processes in the dental pulp, The Dental Pulp‐ Biology, Pathology and Regeneration, Inflammation‐regeneration interplay in the dentine‐pulp complex, The amazing odontoblast: activity, autophagy, and aging, Pulp capping of dental pulp mechanically exposed to oral microflora: a 1‐2 year observation of wound healing in the monkey, Tunnel defects in dentine bridges: their formation following direct pulp capping, Biocompatibility of primer, adhesive and resin composite systems on non‐exposed and exposed pulps of non‐human primate teeth, Histological appearance of pulps after exposure by a crown fracture, partial pulpotomy, and clinical diagnosis of healing, Clinical signs and symptoms in pulp disease, Histone deacetylase inhibitors epigenetically promote reparative events in primary dental pulp cells, Release of bio‐active dentine extracellular matrix components by histone deacetylase inhibitors (HDACi), Effect of lactic acid and proteolytic enzymes on the release of organic matrix components from human root dentin. The stage in the caries process at which exclusively noninvasive options may be recommended by the dentist to manage caries largely depends on knowledge about the probable speed of the caries progression. Long non‑coding RNAs are novel players in oral inflammatory disorders, potentially premalignant oral epithelial�lesions and oral squamous cell carcinoma (Review). Although a one‐stage selective caries removal technique saves on both clinical and patient time, another potential limitation is that if the patient moves to a new dentist it may appear that caries remains and further intervention may be suggested. 2017), to sequester DMCs and augment the regenerative response, has been demonstrated. Management of Deep Carious Lesions. Numerous studies have shown a strong positive correlation between mutans streptococci, lactobacilli and bifidobacteria and the initiation of demineralization of the tooth surface (Marsh 2012). A historic, terminologic‐taxonomic, histologic‐biochemical, embryonic and clinical survey, Effects of dentine proteins, transforming growth factor beta 1 (TGF beta 1) and bone morphogenetic protein 2 (BMP2) on the differentiation of odontoblast in vitro, Evidence for bacterial causation of adverse pulpal responses in resin‐based dental restorations, Bacterial leakage around dental restorations: its effect on the dental pulp, Age, period and cohort trends in caries of permanent teeth in four developed countries, Caries pathology and management in deep stages of lesion formation, Depth and activity of carious lesions as indicators for the regnerative potential of dental pulp after intervention, The adoption of new endodontic technology amongst Danish general dental practitioners, Pulp inflammation: from the reversible pulpitis to pulp necrosis during caries progression, The Dental Pulp ‐ Biology, Pathology and Regenerative Therapies, A practice‐based study on stepwise excavation of deep carious lesions in permanent teeth: a 1‐year follow‐up study, A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals, A quantitative light microscopic study of the odontoblastic and subodontoblastic reactions to active and arrested enamel caries without cavitation, Root canal treatment in Denmark is most often carried out in carious vital molar teeth and retreatments are rare, Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy, Randomized clinical trials on deep carious lesions: 5‐year follow‐up, Direct pulp capping with mineral trioxide aggregate: an observational study, Direct pulp capping with calcium hydroxide, mineral trioxide aggregate, and biodentine in permanent young teeth with caries: a randomized clinical trial, Development of sensory innervation in dentin. Haemostasis should be reached within 10 min. From a histopathological perspective, the threshold for irreversible pulpal inflammation can be defined as the stage where the cariogenic microorganisms are entering the pulp space either through tertiary dentine or directly into the pulp. The material takes over four hours to set, and it is recommended that the tooth should be temporized before the permanent restoration is placed. 2008) and restoration with a hydraulic calcium silicate cement. Although the nature of the cellular response is likely to be dependent upon the pulp environment, the mineralized tissue deposited at the pupal wound site will likely display a spectrum of dysplasia. The classification reinforces the need for a more focused or enhanced approach after carious exposure (class II), which is not as critical if the pulp is traumatically exposed (class I) due to a reduction in the microbial load close the pulp tissue. 4) (Bjørndal et al. 2017). Free Preview. 2017). These organisms are early colonizers (Nyvad & Kilian 1990) and may help establish an environment or niche, which mutans streptococci and lactobacilli will thrive in. 2014). Urquhart O, Tampi MP, Pilcher L, et al. This should be enough time to achieve haemostasis under physiological conditions, which will facilitate a ‘dry’ working field. 2013). 2005, Karapanou et al. 2013, Marques et al. A successful class II pulp capping. 2015) with short‐term follow‐up and low numbers of patients. Controlled clinical trials and cohort studies involving patients with dental caries in permanent teeth were included. An electronic literature search included the databases PubMed, EMBASE, The Cochrane Central Register … Alternatively, if the inflammation process is severe and ‘irreversibly’ damaged the only option is to completely remove the inflamed tissue. Other factors likely to be important prior to undergoing class I pulp capping are small exposures (preferably <1 mm diameter), located in the coronal third of the pulp chamber ideally corresponding to a pulp horn (Fig. 2009). As enamel is a microporous solid, the carious process and response of the dentine–pulp complex can frequently start before it is breached (Brännström & Lind 1965, Bjørndal et al. Use the link below to share a full-text version of this article with your friends and colleagues. 2014). 1982). A macroscopic and histological analysis of radiographically well‐defined deep and extremely deep carious lesions: carious lesion characteristics as indicators of the level of bacterial penetration and pulp response. Due to differences in study design, it is impossible clinically to make a strict comparison between available VPT studies (Table 1). 1996, Nair et al. Research in this area will inevitably develop in the future and challenge whether irreversible pulpitis is an appropriate term to use. In this course, you will learn the differences between primary and permanent teeth concerning pulp therapy techniques. The ability of ethylenediaminetetraacetic acid (EDTA) (Graham et al. Control (direct pulp capping): 6% success. When caries ceases to be active and is thought to have arrested, these features will be more marked; therefore, it is darker, no excess moisture is present, and it is not possible to penetrate with a probe (Fig. The conclusion of the review was that for symptomless and vital teeth, these minimally invasive techniques had clinical advantages over complete caries removals in the management of dentinal caries. 2017). Caries-related treatment decisions of general dental practitioners in Riyadh, Saudi Arabia. Haemostasis should be reached within 10 min. In conclusion, embracing a minimally invasive approach in managing deep caries will help avoid complications with pulpal involvement. Numerous in vitro culture studies using DPC (Ko et al. In particular, it is not possible to distinguish the delicate broader between infected and affected dentine both being discoloured and demineralized, which also explains the recently suggested simplified terminology on removal of carious tissue (see later). International Journal of Environmental Research and Public Health. Analysis of the literature highlights that two types of failure may be occurring: (i) early failure within days of the treatment and leading to symptomatic pulpitis, and (ii) long‐term failures detected several months later and characterized by the presence of an apical lesion related to root canal infection after pulp necrosis. The initial pulpal response to caries is activated by bacterial acids, their cell wall components such as lipopolysaccharide (LPS) and soluble plaque metabolic products, which diffuse towards the pulp against the natural direction of pulp tissue fluid movement (Hahn & Liewehr 2007). Although a one‐stage selective caries removal technique saves on both clinical and patient time, another potential limitation is that if the patient moves to a new dentist it may appear that caries remains and further intervention may be suggested. Dental caries remains a significant public health problem in the United States. 4) (Bjørndal et al. An overview comparing different biological methods for caries excavation of deep dentin caries in primary teeth, such as partial or stepwise excavation shows that they work as well as traditional methods performing complete caries excavation but have the benefits of reducing the risk of iatrogenic pulp damage [1-4]. 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Kundzina et al review of selected scientific literature: a review to preserve hard tissues and retain long-term! American Academy of Restorative Dentistry because it is also not clear from this study systematically reviewed controlled. The odontoblastic palisade is to protect the pulp has been used to simulated scenarios for a...