Pulp cap

What is a dental pulp cap procedure?

Dental pulp cap is the partial removal of the dental pulpal tissue and placement of a restorative material over the top of the exposure.

Historically there are several pulp capping materials but today MTA and Biodentine dominate the direct pulp cap research

Calcium hydroxide was traditionally the product choice, but that is no longer the case. The MTA family and other bioactive materials dominate pulp capping today.

Dental pulp cap bioactive materials are the best.

Dental pulp cap bioactive material RRM Paste

MTA capping procedure steps

Post-Exposure

  1. 5% NaOCl for 3 minutes. If bleeding does not stop then complete pulpotomy or RCT. Currently I prefer hydrogen peroxide. This is less harmful to the pulp but the downside is that it impacts bonding negatively.
  2. Mix MTA or Biodentine and place thin layer
  3. TheraCal LC over that and cure
  4. Selective etch technique with gluma after etch

Alternatively one with the proper equipment can try the cryotherapy method for pulp capping. Ice shavings are left on the pulp/tooth for 60 seconds. Following this we irrigate with EDTA for 60 seconds. This has several advantages over NaOCl, but EDTA tends to aggravate the tissue and cause bleeding again. However, the cryotherapy seems to suppress the bleeding issue.

What are pulp capping failure symptoms?

The symptoms are the same as those that a tooth exhibits when in need of a root canal.

What is the cost?

We currently do not charge for the procedure. Most offices can and should. We are an entirely fee for service office so we can set out basic filling gfee high enough that it covers the costs when this occurs. In-network dentists should charge extra for this. The fee for your zip code is under D3110 on fair consumer website.

What is the ADA dental code for a direct cap?

The ADA dental code for direct pulp capping is D3110.

Direct vs indirect

The indirect pulp cap is something that has spotty evidence and is irrelevant with most modern bonding and desensitizing techniques.

Pulp capping vs root canal

It is our opinion that more meticulous dentists following proper protocols can get away with pulp capping and those that are not will need to jump straight to the root canal.

Research on MTA pulp cap procedure

Basic MTA is being beat by the more modern bioactive materials in some of the research.

MTA vs Biodentine both similar but MTA stains more. Linu 2017 JOE

Can bond immediately over MTA Tsujimoto 2013

MTA = Endocem but only 3 month study Song JOE 2015 Jan

MTA=Biodentine Katge 2017 JOE Awawdeh 2018 JOE

MTA=CH but Biodentine better Brizuela JOE 2017

Biodentine better than MTA Wattanapakkavong JOE 2019

Calcium hydroxide research for direct pulp caps

MTA beats CH Mente JOE 2014

Review MTA better than CH EBD 2016 Rasaratnam

Meta-analysis – Appears to me that MTA is the best but “not statistically significant”. Ahmed Elkhadem and Inas Sami 2014 EBD

Meta-analysis – MTA better than CH Zhaofei Sept 15 Didileschu JADA 2018

Direct pulp Cap DPC info and more research

Jang JOE Aug 2015
ProRoot MTA = Endocem
Class V DPC less successful

ProRoot MTA = calcium silicate-based cement
Endocem = fast-setting pozzolan-based MTA
Biodentine = calcium silicate based
RetroMTA = 60-80wt% calcium carbonate, calcium zirconia 20-30%, silicon dioxide 5-15%, aluminum oxide 5-10%
TheraCal = resin-modified calcium silicate liner type III portland cement 45 wt%, resin 40%, radiopacifier 10%, silica 5%

Biodentine = MTA > CaOH2 > Bonding agent at forming dentin Human trial good study Nowicka JOE Aug 2015

ProRoot MTA=RetroMTA>TheraCal dog study in calific barrier formation and lack of inflammation http://www.jendodon.com/article/S0099-2399%2815%2900342-8/abstractLee JOE Aug 2015

Pulpotomy

Biodentine and MTA beat Theracal likely due to resin. Bakhtiar JOE 2017

MTA beats Biodentine, formocresol and ferric sulfate in terms of radiographic success but clinically there are equal. Meta-analysis JADA Shafee 2019

A partial pulpotomy consists of removal of 2-3mm of pulp tissue below the exposure. This may be more effective in pulps that have damage or are affected. It is also more conservative. This is from Elmsmari JOE 2019, references 13 and 14.

Pulptomy steps

  1. Removal of coronal pulp tissue (all or at least 2-3 mm).
  2. 5% NaOCl for 3 minutes for 2 rounds. If bleeding does not stop then complete RCT. Currently I prefer hydrogen peroxide. This is less harmful to the pulp but the downside is that it impacts bonding negatively.
  3. Pack Biodentine or MTA
  4. TheraCal LC over that and cure
  5. Selective etch technique with gluma after etch

 

 

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