Best way to prevent pulpal exposure on deep caries?

[817010]

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[vellnueve]

Dude.

You will hit many more pulps in your life. That's part of dentistry. If that's the worst thing that happened to you today then you have a pretty cush life.

Dycal or MTA, then an RMGI or glass ionomer over that, then amalgam. With that composite you put in you basically guaranteed yourself a return visit in a few years.

 

[Warren E. Namel]

Sometimes it's just not possible, as the caries just goes deeper than you might suspect from an x-ray. Otherwise, try using large spoon excavators when you are close, slow speed with large round burs, etc.
Like I said sometimes it's unavoidable. On a #32 with huge occlusal caries, maybe consider extraction.

 

[786783]

Dude.

You will hit many more pulps in your life. That's part of dentistry. If that's the worst thing that happened to you today then you have a pretty cush life.

Dycal or MTA, then an RMGI or glass ionomer over that, then amalgam. With that composite you put in you basically guaranteed yourself a return visit in a few years.

Woah, can you elaborate on your choice for amalgam instead of composite resin? Read info on exposures today and amalgam was never mentioned. My supervising doctor didn’t say that either. I’m not challenging it, just want your input.

 

[786783]

Sometimes it's just not possible, as the caries just goes deeper than you might suspect from an x-ray. Otherwise, try using large spoon excavators when you are close, slow speed with large round burs, etc.
Like I said sometimes it's unavoidable. On a #32 with huge occlusal caries, maybe consider extraction.

How about just leaving infected/affected dentin and placing a fluoride releasing material (ie RMGI)?

 

[vellnueve]

How about just leaving infected/affected dentin and placing a fluoride releasing material (ie RMGI)?

Obviously you can do that for affected dentin. But infected dentin should not be left. You will get into a cycle where you leave more and more caries while wondering why your restorations keep failing.

Stop being afraid and just remove the caries. If it needs endo, so be it.

 

[Big Time Hoosier]

On a #32 with huge occlusal caries, maybe consider extraction.

This! Given your description of the exposure as either very large or an already hyperemic pulp, I'd bet that tooth becomes a hot tooth in the not so distant future, even with a correctly applied pulp cap. So, the next step is almost certainly an extraction, because who would pay for endo and crown on a 3rd molar?

I felt lifeless for the entire day since the exposure...

You're really this distraught about not saving someone's wisdom tooth? I assure you their life will go on. Word of advice, the caries goes where the caries goes. You didn't cause it, you just need to fix it. If it's going to need endo, it's going to need endo. Now if you prep the wrong tooth, you own that mess!

Big Hoss

 

[vellnueve]

Woah, can you elaborate on your choice for amalgam instead of composite resin? Read info on exposures today and amalgam was never mentioned. My supervising doctor didn’t say that either. I’m not challenging it, just want your input.

Amalgam gives a better long term seal on any restoration, especially posterior ones. Especially third molars that they can't keep clean

 

[FanOfCostco]

First off... no one mentioned a rubber dam on the easiest tooth to dam. Your instructions are all ashamed.

But in all seriousness, Some research papers say with direct pulp caps you should use MTA because of the seal. Still controversial but to me it makes sense. Then some glass inomer on top and wait, if the tooth becomes symptomatic in a week or 2 then you know it's rct or ext. if everything is ok you can probably think of a more definitive restoration.

And why wasn't ext part of the tx plan??? It's 32 for goodness sake!

 

[vellnueve]

I rubber dammed maybe 0.1% of my patients other than endo patients.

And not all thirds need to be removed.

 

[schmoob]

I rubber dammed maybe 0.1% of my patients other than endo patients.

And not all thirds need to be removed.

I agree not all 3rds should be removed. What are your thoughts on this particular case though? This 32 with a failed restoration, extensive recurrent decay and pain is something that would warrant ext as a primary tx option, no?

I'm also on the same page regarding amalgam. It's not an aesthetic zone, so who cares? The Navy loves that stuff, and I've got plenty of them (more than I'd like to admit) that have been going strong for a number of years now *knocks on wood.*

 

[vellnueve]

We don't have all the info, though. So I'll withhold judgement on retaining 32.

 

[MaxAnn]

First and hopefully last pulpal exposure today on #32 O. Previous resin restoration fell off and tooth had been causing him pain for 2 days but percussion, palpation and cold test responded within normal limits.

Was chasing deep caries and... it happened. Mesial horn bled profusely, not a pinpoint lesion, indicating inflammation or just a relatively large exposure. Proceeded with lots of Consepsis, MTA, Vitrebond, MicroPrime G, Optibond Solo Plus, flowable, packable. I felt lifeless for the entire day since the exposure...

Anyways, best way to prevent this in the future? Researched a little bit and there's Stepwise Excavation Technique or just leaving a thin layer of infected dentin and place an indirect pulp cap if exposure is highly probable.

Thank you!

Sometimes this is unavoidable. One of the previous responders mentioned a spoon excavator and large, round bur as two ways of clinically dealing with deep occlusal caries.

In reality, sometimes pulpal exposure is unavoidable. However, I do like Limelight as a liner, and Vitrebond as a base. On #32 I would definitely restore with amalgam if at all possible, but I realize some Dental offices have ceased having amalgam at all in their practices.

 

[UpperBite]

I'm just going to say this since everyone has covered it clinically: One cannot come in with a bowl of poo and expect you to make them a chocolate cake out of it. It is not your fault.

 

[sgv]

(1) Always tell the patient that the caries is close to the pulp and that there's risk of pulpal exposure even when the caries doesn't appear that close based on radiographs. Always tell them that caries approximates the pulp and there won't be any surprises if you do expose it. If you don't expose it, then great! You'll look like you did an awesome job by avoiding the pulp. Undersell but overdeliver.
(2) Use the biggest round bur on the slow speed handpiece using brush strokes.

Whatever happens afterwards should be considered unavoidable for the average dentist.