Pulp capping

Pulp capping is traditionally divided into two different procedures: Indirect pulp capping and direct pulp capping.

Indirect pulp capping

Indirect pulp capping is a procedure in which the most pulpal part of the carious dentin in a deep cavity is not removed. A temporary filling is placed and the cavity is reopened after some months and the remaining carious dentin is then excavated. The goal for this treatment is to give the pulp a chance to form more dentin beneath the carious dentin so that a pulp exposure can be avoided. This kind of treatment is mainly used in young teeth. Indirect pulp capping is a temporary procedure and it is not permitted to leave carious dentin under a permanent restoration.

Direct pulp capping

Direct pulp capping is indicated when a pulp, without inflammation, has been exposed. This means that this kind of treatment cannot be used after a carious exposure of a pulp. The prognosis for capping an inflamed pulp is very poor and therefore performing this treatment after a pulp exposure in a tooth with carious dentin is not justified.

  • Pulp capping must be carried out under aseptic conditions, using rubber dam.
  • The exposed pulp tissue is removed by means of a round high-speed diamond stone using sterile isotonic saline as irrigant and cooling agent. The wound surface is placed some mm into the pulp in order to reach a tissue capable of healing and to prevent leakage from the oral cavity.
  • The bleeding is stopped by irrigation with sterile, isotonic saline.
  • A paste of calcium hydroxide and water (or Dycal) is placed on the exposed pulp.
  • Excess water is removed with cotton pellets.
  • The capping material is covered with a cement, (not zinc phosphate cement which cannot prevent microleakage).
  • The permanent filling is placed.
  • The tooth is to be checked radiographically and clinically for 4-5 years.

When is Direct pulp capping used.

Direct pulp capping is mainly carried out in immature teeth to give the root a chance to develop: Apexogenesis. In the fully developed tooth a pulpectomy is preferred after a mechanical exposure. There are three main reasons for this:

  • a.the prognosis for pulpectomy treatment is superior to the prognosis for pulp capping.
  • b.the pulpectomy terminates in an area where a failure can easily be detected radiographically.
  • c.the hard tissue barrier under the pulp capping material is usually not solid, inclosures of soft tissue are common. Thus, future leakage under the permanent filling may bring bacteria into direct contact with the pulp.

Direct Pulp Capping Procedure

Direct pulp capping is a process by which the dentist drills out the decay of a tooth, and then places a cap over the exposed pulp. The tooth can then form dentin over the pulp. When successful, this avoids the tooth having to get a root canal.

Direct pulp capping works at its best if the nerve has been exposed very recently due to a trauma to the tooth. In this case, the nerve has only been irritated for a brief period of time. Direct pulp capping also works well if there is only a minimal exposure of the pulp, such as 1 to 2 millimeters. The nerve may not have suffered as much damage then, and the cap doesn’t have as much surface to cover.

In general, pulp capping is done if the tooth is still alive, meaning that the nerve has not died. To test this, the dentist may use one of many tests. One is an electric vitality test, where the dentist must gauge your reaction to different stimuli to the tooth.

Other ways to test a tooth are to ask questions and look at the tooth. The tooth should have its natural color and not be darkened. Surrounding gum tissue should be pink and not red and swollen. There should be no puss pockets in the gum near the bone of the tooth (which may indicate infection or abscess.) The dentist may even look at an x-ray to look for infection in the bone surrounding the tooth.

Follow-up exam:

1 month, 3 months, 1 year and after that yearly. The procedure involves clinical examination, electric pulp testing, temperature test (cold) and radiograph.

The ultimate success of any periodontal treatment is a cooperative partnership between the patient and the dental staff. Alone, neither can accomplish this goal.