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.
Thank you Dr. Brady…. very interesting information… appreciate the manner in which you organized the information as well.
Hello dr: lee i prefer to leave a thin layer of carious dentin but about 30% of my patient come after about 12- 18 months with sever pain, while doing endodontic treatment for those patient there is severe hyperemia and i found that the dentin become harden what is your opinion about that also this happen with composie only never happen with amalgam want your opinion about the fault and thank you.
Mohamed,
The most critical factor from the operator side is a well sealed restoration, placing a well sealed composite is more technique sensitive than with amalgam. In addition, pulp capping is an attempt to maintain the vitality of the pulp, not a guarantee, and the amount of bacterial infiltration, the inflammation int he pulp, the patients age and their immune response are all factors outside our control, and a certain percentage of teeth will ultimately require root canals.
Lee
Thank you
If you leave a thin layer – do you place anything over the deepest area – vitrebond / fuji liner / theracal, etc. Thank You
Frank,
You leave a thin layer of affected dentin and then you place a pulp cap material, preferable calcium hydroxide based, so Theracal would be my favorite, but any of the other MTA/bioactive materials will work. GI products have been shown to be less effective.
Lee
Do yo have any opinion on using biodentin?
In my opinion that is the best material for pulp capping
It is a formulation of mineral trioxide aggregate and releases calcium hydroxide as the active ingredient.
yes calcium hydroxide
Thank You, does the MTA material take a long time to set?
Some of them do take 7-10 minutes to set. I am a personal fan of Theracal LC from Bisco, as it is light cured so sets instantaneously, and doe snot have to be covered with a resin, as it is resin based. It is an MTA, calcium hydroxide material and dispenses like flowable.
Lee
Thanks Lee! Great post. For direct pulp caps, I’ve heard John Kanca lecture about using Durelon and I remember him showing histological slides of the pulpal cells thriving beside the Durelon. Was wondering if you have any thoughts about this?
Hi Kurt,
Interesting to think of using Durelon. I reviewed lots of studies, and one comprehensive literature review that looked at the lit back for the last 15 years and summarized it. The keys when doing a direct pulp cap are hemmorhage control and an absolute moisture seal, and the existing bacterial contamination and inflammation in the pulp before the procedure. The most effective material was anything with calcium hydroxide in it. So that is not to say Durelon wouldn’t work, but based on the literature calcium hydroxide might improve your success rates.
Lee
Great post. Thanks. I’ve been using the Theracal and had great success with it too.
Hi Dr Brady,
great information. I really like how your website is set up…thanks for making it easy for me!!! I am wondering about controlling the bleeding with water or saline…I assume there is pressure with a cotton pellet involved? I feel like every step is so critical to giving the tooth a ‘chance to live’…
In non exposure, I have recently been leaving a thin layer of affected dentin, then scrubbing the area with Tublicid Red, rinse, then NaOCl, rinse then pulp cap (was using Fuji…will be changing to MTA or CaOH since reading your article). any thoughts on this…good idea? cant hurt might help??? Or could be detrimental?
thanks for your time! I truly appreciate all you do..you are amazing!!
Claire Haag (from Italy trip..Deka Laser )
Hi Claire,
Scrubbing with anything that is anti-bacterial is potentially helpful, and not harmful with an indirect pulp cap. For direct pulp capping, yes the saline or water is applied with pressure on a cotton pellet, and the literature says not to use sodium NaOCL, as it is a pulpal irritant and will increase inflammation.
Hope all is well!
Lee
This is anecdotal, of course, but I feel I have much greater success rate with direct or indirect pulp caps if I disinfect with chlorhexidine first.
Great post, Lee. I have some added thoughts…. Pulp capping is contraindicated in any tooth with lingering sensitivity to cold (irreversible pulpitis) or any sensitivity to hot (probable necrotic pulp). If I suspect pulpal involvement is imminent, I place a rubber dam (if I have not done so already) and begin rinsing and irrigating with sterile water rather than tap water or unit irrigation water. The rationale is to minimize introduction of bacteremia to the pulp. To control bleeding, I have read articles supporting ferric sulfate (Viscostat by Ultradent) and aluminum chloride. If pressure with a cotton pledget soaked in sterile water is unsuccessful, I have had great success with Viscostat. Dycal is still an excellent calcium hydroxide product, and I cover it with RMGI. Lastly, I firmly believe that maintaining vitality is much better than devitalization just because it can be justified. The patient just needs to ne involved im the decision.
A thought to ponder….restoring a vertical crack throigh the pulpal floor of a prep is a type. pulp capping and probanly should be treated as suvh.
Sorry about the mispellings. You have to love typing on a phone!
My last line should read:
A thought to ponder…. restoring a vertical crack through the pulpal floor of a prep is a type of pulp capping and probably should be treated as such (i.e., sanitary and isolated field, antibacterial management, and bonded).
Hi Lee,
Great topic. Thanks.
How about use of Gluma when pulp capping? Use before Theracal placement? After? Both? Neither?
Carl
Hi Carl,
There really is no research that I can find in regards to using Gluma (Glutaraldehyde and HEMA)in combination with pulp capping. With that said I do use it after the Theracal.
Lee
Hi lee ,
can i ask , when using the normal gluma the liquid type , do you wash it off before you put the theracal and bond or do you just dry the excess?
Original Gluma liquid I blot dry with a cotton Pellet.
Dr. Brady,
After placing an indirect pulp cap on a tooth that would benefit from a crown, how long would you recommend waiting before making this decision?
I have been cautioning patients that root canal therapy may be indicated in the future but if no symptoms are present, I would like to confidently tell them that they can now have a more permanent restoration than a large composite.
Daniel,
There is no precise answer to this question. I recommend waiting at least 3-6 months. We take follow-up PA’s of the tooth to check for periapical lesion of PDL thickening and then we also pulp test the tooth prior to commencing with the final crown. I make sure the patient understands that the risk of these teeth needing endo remains high even if they are asymptomatic and have no signs of pulpal issues, the patient then gets to choose whether they want to move ahead with a root canal prophylactically or do the crown and deal with any future pulpal issues if and when they arise.
I’m interested to know if you agree with the dentist that said he would not do pulp capping on cold sensitive tooth ?!?
This is a tough question as cold sensitivity can be sign of open dentinal tubules, reversible pulpitis or an irreversible pulpitis. When I do a pulp cap of any kind I inform the patient that this tooth is at risk of needing a root canal and this procedure is designed to “try” and give the tooth a chance to heal itself. If the tooth is already exhibiting cold sensitivity that I believe to be caused by the deep decay and a pulpitis the risk that the tooth will need a root canal in my mind is higher. One way to get more information would be pulp testing, although there is some debate as to it’s accuracy. If the cold response is extreme and lasting, then I would refer the patient for endodontic therapy. If the cold sensitivity was typical and transient I would give the patient th option and then if we pulp cap, monitor the tooth and the signs and symptoms over time.
Lee