Deep caries that encroaches on or invades the pulp is a common challenge in dentistry. Both indirect and direct pulp capping are long standing procedures designed to maintain the health and integrity of the pulpal tissues and avoid the need for endodontic therapy. Recently while doing research for an upcoming webinar I reviewed the literature in regards to pulp capping and learned some things that surprised me. The most surprising piece of information regarded the removal of all the affected dentin prior to pulp capping. In studies where dentists where were described the scenario of deep caries and given the option of removing all the affected dentin and exposing the pulp and doing a direct pulp cap, versus leaving some of the affected dentin and placing an indirect pulp cap, only 17% responded that they would stop and leave carious dentin behind. In contrast to this the science strongly supports leaving the affected or carious dentin behind and placing an indirect pulp cap. The science supports that the bacterial count will drop over 4-12 months and the soft, wet dentin will be replaced by hard, dry brown secondary dentin. The most important point in achieving this success is a well sealed restoration.
When performing a direct pulp cap, one of the most important criteria in success is our ability to control the pulpal bleeding. We believe the inability to control bleeding is indicative of greater inflammation and also makes sealing the remaining dentin ineffective, both of which contribute to greater pulpal death after the fact. Lastly, calcium hydroxide is still the gold standard for pulp capping and biologic response. The challenge of traditional calcium hydroxide is seal and moisture, and the newer MTA based products simply release calcium hydroxide as the active ingredient.
Facts for pulp capping success:
- Avoid exposing the pulp, even if it means leaving behind a thin layer of carious dentin.
- Control bleeding with water or saline.
- ZOE, GI, RMGI and adhesives are poor pulp capping agents.
- Calcium Hydroxide remains the gold standard for pulp capping, and MTA displays equivalent results in short term studies.
- A well sealed final restoration placed immediately is critical to success.