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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
Pulp capping doesn’t have to be difficult. Ensuring that the right materials and techniques are used will give patients the best outcomes.
Every dentist (and every patient, for that matter) wants to save teeth. The best outcomes are those in which damaged teeth can be repaired without having to be removed.
In some cases, if the tooth’s pulp is exposed (or nearly exposed) there’s a risk of pulpitis, which may lead to necrosis, and, ultimately, root canal treatment or extraction. But to save the tooth, doctors can employ a technique called “pulp capping.”
Pulp capping prevents the pulp from deteriorating by placing a small amount of material - like calcium hydroxide or Mineral Trioxide Aggregate (MTA) - that both protects the pulp from further damage as well as stimulates the pulp to lay down a bridge of reparative dentin.
There are many variables involved in the procedure, but understanding those factors can lead to the best outcomes for the patient.
Select suitable cases
While doctors would like to save as many teeth as possible, pulp capping isn’t indicated for every case. Understanding which cases are suitable is a good place to start.
“My partner and I believe very strongly in the value of evidence-based dentistry,” says Dr. Rebekah Pryles, DMD, an endodontist in White River Junction, Vermont. “Pulp capping is something we do a lot of in cases of trauma and less so in cases of carious exposures. Because if you look at the literature that’s out there, unless the tooth is undeveloped and has been traumatized, it tends to be very unpredictable, in terms of success, in the long term. Some of the research that’s out there actually shows that over 80 percent of the teeth necrose over the course of about five to 10 years or so. But with good case selection and good materials, it can work. In some cases, it’s just not the most predictable thing to do.”
Instead, Dr. Pryles prefers calcium hydroxide- and MTA-based products.
“The products that I recommend are calcium hydroxide-based products, like Dycal,” she says. “It’s a great gold-standard and it is really easy to use. And then the MTA products that are out there, including the regular MTA and then some of the Brasseler putties. There is a Brasseler root repair material that I really like; it is very user-friendly. And then the Biodentine products. They all have similar success, but the handling properties are all different.”
Calcium-based products provide exceptional outcomes and have been around for a long time.
“There is a long track record of success,” Dr. Pryles says. “What they do is they create a layer of coagulative necrosis under the barrier that they create. And that facilitates the pulp, in terms of the hard tissue deposition. These materials have been out there for years and years and they work really well.
“MTA, interestingly enough, upon its set, actually releases calcium hydroxide,” she continues. “So, it’s thought it’s that calcium hydroxide that forms from the MTA and that has that bioactive effect. It’s also a little bit less costly than some of the other materials that are out there. That being said, the MTA, the Biodentines, the root repair materials work really well as well. The putty in the root repair material works particularly well and it is a really user-friendly material to utilize.”
The American Academy of Endodontics (AAE) provides guidelines for treating trauma-related pulp exposures.
“Pulp capping can be a great way to save - especially traumatized - teeth,” Dr. Pryles says. “I always encourage, in cases of trauma, to review the AAE trauma guidelines because it really provides a nice flow chart for managing those injuries. I’m part of a number of Facebook groups with dentists and a lot of people don’t know about the guidelines. This is where we, in our practice, really see pulp capping come into play.”
Up next: Follow the process
Follow the process
Once a case has been selected, Dr. Jason Olitsky, DMD, a general and cosmetic dentist in Jacksonville, Florida, describes the procedure.
“I stop the bleeding with direct pressure for 60 seconds using a cotton pellet soaked in 2 percent chlorhexidine gluconate solution. I use Consepsis from Ultradent,” he says. “This is a chlorhexidine solution that does not adversely affect the bond strengths to enamel and dentin and you get the added benefit of inhibition of matrix metalloproteinases (MMP) that can contribute to the breakdown of the dentin adhesive interface over time. I do not rinse off the 2 percent chlorhexidine solution.
“I then place TheraCal LC (Bisco) onto the exposed pulp and the still moist dentin surface (from the chlorhexidine) surrounding the pulp,” he continues. “I cure the TheraCal LC for 20 seconds. The preparation is then lightly air-dried with an Air Drier (A-dec) to ensure moisture-free and oil-free air, and a thin SpeedCEM Plus (Ivoclar Vivadent) liner is placed on the dentin, covering the TherCal LC. SpeedCEM works to secure the TherCal in place, which can frustratingly dislodge during the bonding process, and it has high shear bond strength to dentin and high radiopacity.”
From that point, Dr. Olitsky continues treating the tooth with a filling or crown.
“I selectively etch the enamel and use a universal adhesive (Adhese Universal, Ivoclar Vivadent),” he says. “I cure the adhesive for 10 seconds with a 1,200 mW LED light (Blue Phase Style) and fill with Tetric EvoFlow Bulk Fill and Tetric EvoCeram Bulk Fill.”
Consider the patient’s needs
In 1947, Pulpdent introduced the first pre-mixed calcium hydroxide paste, indicated for vital pulp therapy and root canal therapy. Fred Berk, Pulpdent’s president, observes that the simplest pulp capping restorations are realized when the needs of the patient are considered.
“I think the most important thing, when we talk about simplifying, is to remember that it’s the patient that matters,” Berk says. “We are not necessarily trying to save time or reduce steps; we are trying to do what’s right for the patient because the goal is to maintain the vitality of the tooth and stimulate dentin bridge formation.”
Misinformation about pulp capping can create its own problems.
“There is certain folklore that does not align with fact,” Berk says. “The size of the exposure, for example, is not significant. A large exposure can be treated just as successfully as a small exposure. Do not intentionally bring blood to the exposure site. Saliva contamination in the stroma of the pulp is a serious matter, but superficial saliva contamination is not a critical factor if properly treated. The age of the patient is not a critical factor. The color of the dentin is not a valid indicator of whether or not dentin is infected.”
Pulp capping isn’t ideal for every case, and doctors must understand which other treatments may be more appropriate.
“The dentist should understand when it’s best to do pulp capping as opposed to pulpal curettage or a vital pulpotomy,” Berk says. “There are times when pulpal curettage is indicated instead of pulp capping. If the pulp is narrow at the exposure site, as in the coronal portion of anterior teeth or pulpal horns of posterior teeth, calcification and dentin bridge formation can restrict blood circulation to the coronal pulp, resulting in necrosis. Pulpal curettage is preferred in these cases.”
Ultimately, Berk says, the simplest technique is the one with the fewest complications.
“The focus should really be on ensuring the highest rate of success, which is what provides the greatest benefit to the patient,” he says. “The dentist can be successful with various materials and techniques, but what simplifies the technique is doing it right, stimulating dentin bridge formation and avoiding endodontics because endo can be complicated and is stressful and costly for the patient.”
Up next: Work in isolation
Work in isolation
Contamination is one of the biggest ways in which pulp capping restorations can fail. Contamination can be avoided by following established protocols.
“One of the reasons that these fail is that they become infected and tissue necroses,” Dr. Pryles says. “One of the best ways to prevent that it is by maintaining a sterile field with a rubber dam.”
How the rubber dam is used depends on the case and its complexity.
“For most rubber dams utilized in endo, it is single tooth isolation,” Dr. Pryles explains. “For restorative procedures, that may or may not be realistic. I use just a standard dental dam. If you’re going to be restoring an interproximal lesion, you do want to isolate not just that too but adjacent teeth as well. There isn’t a whole lot of new technology that’s out there, in terms of rubber dams, but what’s on the market works really well.
“For example, for single tooth isolation, like you might use for endo, for just an occlusal, it’s really straightforward.,” she continues. “You just pop it on top of the tooth with a clip on it, and in those cases, people make it a little more challenging than it has to be. When it has to be flossed through several teeth, it can be a little more challenging. But with practice, it becomes second nature. I think it’s something that any clinician - or even their assistant - could do.”
Avoid common missteps
Avoiding common missteps is one of the best ways to ensure a positive outcome. Some errors, Berk says, are easily avoided.
“Beware of small exposures,” he warns. “The pulp may shrink away from the exposure site and bacteria can gather under the overhanging dentin. It may be necessary to remove overhanging dentin to clean out the site and allow the calcium hydroxide dressing to be in direct contact with the pulp.
“Contamination can be another issue,” he adds. “Always keep the area clean.”
Finally, the tooth needs time to heal without interference.
“It’s important to place permanent or permanent-type restorations after doing these procedures because you don’t want to interfere with the healing process,” Berk says. “You want uneventful healing. Temporaries so often come loose and come off, and that’s just an opportunity to introduce bacteria and disrupt healing.”
Achieving success is a balance of many variables, including variables that aren’t necessarily new to clinicians.
“It is important to follow the basic tenets of surgery,” Berk says. “The first step is diagnosis and case selection; isolation and asepsis are critical; you need good clinical technique, followed by application of the surgical dressing; and uneventful healing. There is no substitute for these practices.”
Pulp capping need not be overly complex or difficult. Ensuring that the right materials, best procedures and skilled techniques are used are steps in the right direction to give patients the best outcomes.
“In the end, the goal is to do what’s right for the patient,” Berk says. “And if you do this properly, you’ll be successful a high percentage of the time.”