Dental Problems

Direct Pulp Capping

How to Clean Mouth GuardPulp capping can be done in two ways based on the pulp condition. These include direct pulp capping and indirect pulp capping. In this article, there is a brief discussion on the direct pulp capping and an example of the treatment of a direct pulp capping using MTA (mineral trioxide aggregate). Read on to know more.

Definition of a direct pulp capping:

The procedure in which the small exposure of the pulp, encountered during cavity preparation or following a traumatic injury or due to caries, with a sound surrounding dentin, is dressed with an appropriate bio-compatible radiopaque base in contact with the exposed pulp tissue prior to placing a restoration is termed as direct pulp capping.

What are the Reasons for Early Orthodontic Interventions?Direct pulp capping within the primary teeth:

Traditionally, a direct pulp capping within the primary teeth has been viewed with skepticism. The cited reasons were, a consequent faster inflammatory response, the abundant supply of blood and poorer localization of the infection.

Limitation in primary teeth:

Reasons for limitation of a direct pulp capping in caries exposure is as follows:

  • Internal resorption
  • Calcification
  • Chronic pulp inflammation
  • Necrosis
  • Intradicular involvement

However, recent studies on animals have suggested that the pulp healing may take place in the presence of an inflammation. Various studies have also found varying success rates.

Procedure:

  • When pulp capping is done, care must be exercised while removing the deep carious dentin over the exposure site to keep to a minimum the pushing of dentin chips into the remaining pulp chamber.
  • Studies have shown decreased success when dentin fragments are forced into the underlying pulp tissue.
  • Inflammatory reaction and formation of dentin matrix are stimulated around these dentin chips.
  • In addition, microorganisms may be forced into the tissue.
  • The resulting inflammatory reaction can be so severe as to cause a failure.
  • Staining carious lesions was proposed by Fusayama several years ago to allow the differentiation of non-remineralizable and remineralizable dentin.
  • All these dyes (harmless) demonstrate the non-remineralizable dentin.
  • Tooth parts that stain must be removed.
  • Any of the tooth structure which doesn’t stain can remain, as this softer dentin tissue will remineralize.
  • A few examples of some common brands are Cari-D Test (Gresco products Inc), Caries Detector (J Morita USA Inc), Caries Finder (Danville Engineering) and Sable Seek (ultra dent products).
  • This method may limit the decay removal to the non-remineralizable dentin tissue during the indirect and direct pulp capping.
  • In the prognosis, the location of the exposed pulp is a very important consideration.
  • If the exposure of the pulp is seen on its axial wall, with pulp tissues coronal to the exposure site, then, this tissue may also be deprived of the blood supply and may undergo necrosis (failure).
  • Then, a pulpectomy or pulpotomy must be performed instead of a pulp cap.
  • Flush out dentinal debris and control bleeding at the exposure site.
  • No clot should form on the exposed site.
  • The pulp-capping agent should come in contact with the vital pulp tissue.
  • Marginal seal on the pulp-capping process is of a prime importance as it prevents reentry of the bacteria and reinfection.
  • Healing and the formation of secondary dentin are inherent properties of the pulp.
  • Factors promoting healing are conditions of the pulp at the time of amputation, removal of irritants and proper postoperative care such as proper sealing of the margins.
  • After pulpal injury, as a part of this repair process, a reparative dentin is thus formed.
  • Although, a dentin bridge formation has been used for judging a successful pulp capping, formation of the bridge can occur within the teeth with an irreversible inflammation.
  • Moreover, successful pulp capping procedure has been reported generally without the presence of a reparative dentin bridge on the exposure site.

Salient features of successful pulp capping:

The following are the list of salient features of successful pulp capping.

  • Maintenance of pulp vitality.
  • Lack of undue sensitivity or pain
  • Minimum inflammatory response.
  • Lack of internal resorption and intraradicular pathosis.

Indications of direct pulp capping:

  • Small mechanical exposures less than 1mm which is surrounded by sound dentin.
  • Light red bleeding from the exposure site that can be controlled by cotton pellet.
  • Traumatic exposures in a dry, clean field, which report to the dental office within 24 hours.

Contraindications of direct pulp capping:

  • Pain at night
  • Spontaneous pain
  • Tooth mobility
  • Thickening of periodontal membrane
  • Excess bleeding at the exposure site
  • Purulent or serous exudates.

Objectives of direct pulp capping:

  • The vitality of the tooth should be maintained.
  • No prolonged post-treatment signs or symptoms of sensitivity, pain or swelling should be evident.
  • Pulp healing and tertiary dentin formation should result.
  • There should be no pathologic changes.
  • An observation study of direct pulp capping using MTA (mineral trioxide aggregate):
  • Pulp capping therapy in the carious tooth has been considered to be unpredictable and contraindicated.
  • An observational study is done using a recently developed material, MTA (mineral trioxide aggregate), as helps it resisting bacterial leakage and also provides protection for the tooth pulp.
  • This allows repair and continued vitality of the pulp in the teeth when used along with a combination of a sealed restoration.

Method:

The primary author has removed caries with the help of sodium hypochlorite and a caries detector dye for hemostasis and then placed mineral trioxide aggregate all over the exposed area and on the surrounding dentin. Then, the operator restored the tooth provisionally using unbounded Clearfil Photocore (kuraray Medical, Okayama, Japan).

On the next visit, the operator has restored the tooth with bonded composite only after sensibility testing and confirming MTE curing. Later at recall appointments, the patients were evaluated for the reparative dentin formation, the pulpal calcification, and continued root development on normal basis and on evidence of pathosis.

Result:

Over an observation of nine years, the authors have found about 97.96% of favorable results on the basis on subjective symptoms, radiographic appearance and cold testing. The treatment in all the younger patients who has open apexes initially, showed apexogenesis (completed root formation).

Conclusion:

MTA can be the reliable material for pulp capping on the direct carious exposures in the permanent teeth particularly when a 2 visit treatment protocol is followed.

The above article discusses briefly about the direct pulp capping.

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