Direct Pulp Capping?

[ShawnOne]

Hello All,

Now that I have an acceptance letter I feel a little bit more comfortable to post in this forum. 😀

I was just watching the NBC news and they had a special report on a "new" dental procedure called Direct Pulp Capping. From the limited information given by a doctor named Dr. Teitelbaum, as long as the root is alive, you can just seal (or cap) the canal (with some new material) without performing a root canal. Supposidly this new material seals the canal like no previous material and makes this new procedure possible.

Does this make any sense? If the root is infected, how does sealing the canal make a difference?

---

Members don't see this ad.

 

[larryt]

is that a Pulpectomy procedure for kids' primary teeth ? sound similiar ...

 

[UBTom]

Hi guys,

Direct pulp capping has been around for a long long time. We use it mostly when there is an accidental exposure of a vital pulp while we are cutting a tooth and removing decay for a filling.

What we do is clean the area where the exposure occurred, then flow in a bit of calcium hydroxide, which has a basic pH and promotes dentin formation in a vital pulp. The Ca(OH)2 we use at my school is Ultrablend, which has a light-cure resin mixed in. After the Ultrablend is applied and light cured, the tooth is filled with a temporary filling such as IRM.

6 weeks later the tooth is evaluated to see if RCT is necessary.

Direct pulp capping works best if the environment is uncontaminated and dry when the exposure happened, such as when a patient has a rubber dam on while you are doing the prep.

That new stuff they mentioned on NBC is an extension of the current technique if I have to guess. I'll look into it and see what the difference is.

HTH!

 

[gryffindor]

I have been reading these forums, napping, snacking, and blankly staring at the wall a whole lot this past week to procrastinate studying for the part II National Board exams on Monday.

Somewhere in my review of the old board questions, dental decks, and notes, I came across the rationale for direct pulp capping. It is not a new procedure, it's been done since at least the 1980s because I saw it mentioned on some of the old board exam questions from the 80s.

Direct pulp capping is indicated only when there is a small ("pin-point"), less than 1 mm, mechanical exposure of the pulp in a clean, well isolated area with no hemorrhage visible. It involves placing some calcium hydroxide over the exposure to "cap" the pulp exposure, and proceeding to restore the tooth. This procedure is expected to stimulate formation of a reparative "dentin bridge" over the exposure site and to preserve the underlying pulp tissue in a healthy condition. It is especially successful in immature teeth (teeth whose roots are not completely formed yet). (This info is from the Dental Decks.)

Failure of a direct pulp cap is indicated by symptoms of pain ("pulpitis") or the pulp going necrotic (it is no longer vital). Three adverse responses can occur following direct pulp capping.
1) Physical or microbial insult to the pulp may result in persisten inflammatory changes, which may culminate in partial or complete pulpal necrosis.
2) Regulation of the mineralization processes involved in dentin bridge formation may become deranged, resulting in extensive calcification and obliteration of the pulp canal space by mineralized tissue.
3) Very rarely, the differentiation of odontoclasts may be induced with the development of internal resorptive lesions.
(This info is word for word off the Dental Deck card.)

Apparently, there are very few indications for pulp capping, but they are very overused in dentistry today. (This info is from the ADA explanations of select exam questions.) I guess the newscast you saw on NBC exemplifies this. If you end up doing a direct pulp cap in the clinic, you have to inform the patient of the possibility of needing a root canal (or extracting the tooth) at some point in the future and write a note in the chart saying you informed the patient about the pulp exposure and the possible consequences.

That was a nice little board review question. See what you have to look forward to the next 4 years! Congrats, and welcome to the profession!

 

[gryffindor]

Pulpectomy, another topic the Part II loves.

A pulpectomy can be done on either a primary tooth or a permanent tooth. It is basically another term for root canal procedure. This means you drill the tooth open to the pulp and clean out all the pulp tissue from the pulp chamber and the pulp canals in the root(s) of the tooth. Then you fill the now clean and pulp-tissue-free canals with a material: either gutta percha (for permanent teeth) or zinc oxide eugenol (for primary teeth so it will resorb when the permanent tooth under it starts it's eruption process).

A pulpotomy is a similar sounding procedure done left and right in pedo. It involves drilling opening a primary tooth to the pulp chamber and placing, for five minutes, a cotton pellet soaked in formocresol (a liquid mixture of formalin and cresol). The formocresol basically pickles the pulp in the pulp chamber, but leaves the pulp in the pulp canals (the pulp canals are in the root of the tooth) alive. After the pulpotomy procedure, you fill the pulp chamber up with Temerex material (I forget the chemical compostion of Temerex) and then do a stainless steel crown to restore the tooth. The pulpotomy procedure has like a 97% sucess rate (I think, I'll have to recheck that when I go upstairs).

For all the stress Yah-E and everyone else went through for the Part I boards, these Part IIs don't even compare. My classmates and I are so ready to take this stupid exam and move on toward graduation. Post-grad programs are most likely not going to see the scores so at this point, passing witha 75 is good enough for the majority.

 

[no2thdk999]

Direct pulp capping is nothing new in dentistry. I did a google search on the guy's name and pulp cap and found his website. Basically he is doing a direct pulp cap with resin (i.e. bonding agent and composite filling) and charging $200 for it. (I have no problem with him charging $200 if that's what he and his patient agree to). But he calls it a drill-less root canal which I think is a bit misleading. He also says the worst thing that can happen is you get the RCT later which is wrong for the reasons Griffin mentioned and the one below.

This is one of those areas in dentistry where reasonable people can disagree. Most endodontists would tell you that a pulp exposure is a good reason to do root canal therapy and a direct pulp cap will at best buy you time before needing the RCT. Of course endodontists don't see the ones that are successful but they do have a good arguement. RCT on a vital tooth has around a 94% success rate. If you wait until the tooth is necrotic (i.e. pulp cap and wait and see if it hurts) the success rate goes down.

If a direct pulp cap is going to have it's best chance of success a few criteria must be met. You have to have a healthy pulp (vital and not irreversibly inflammed), an aseptic field, you have to be able to obtain hemostasis easily (I use NaOCl), and seal the pulp from the oral environment. Whether CaOH2 does better than resin is up for debate. There is a newer material (not mentioned by Dr. Teitelbaum) called MTA which shows great promise but doesn't have any long term studiess.

I don't do these often but when I do a direct pulp cap the patient gets warned up and down that we are likely just putting off the root canal, I don't use CaOH2, and I place a composite restoration the same day because it seals better than a temp.

Tom when you say you eval at 6 weeks are you just checking if they're asymptomatic or are you taking the IRM out and looking for dentin formation? The eugenol in IRM is an obtundant and can mask symptoms for the short term. It also interfers with resin bonding and some research shows it's effects can be long term.


JMHO
Rob

 

[UBTom]

Hi Rob,

Yes, the procedure taught at my school is to remove the IRM after 6 weeks so the tooth can be re-evaluated to see if there is dentin formation. The light-cured Ultrablend capping the exposure site prevents the IRM from coming in direct contact with the pulp I think.

As you mentioned there's plenty of variation/debate on what approach to take with direct pulp capping.. At my school the rationale seems to be that if RCT might need to be performed, the tooth should NOT receive a definitive restoration at the time of the pulp capping, so IRM is used instead.

HTH!

 

[no2thdk999]

Hey Tom

The eugenol in IRM doesn't need to be in direct contact with the pulp to have it's obtundant effect. Dentin is porous by nature and even more so closer to the pulp.

Your approach is reasonable and the people that taught it to you are smarter than I. The downside is whether the pulp cap works or not you have to reanesthetise, reisolate, and remove the IRM and either place a restoration or begin RCT. And the IRM may compromise a resin bond to dentin.

Do they let you use Cavit? It has no eugenol so you don't have to worry about it masking symptoms or compromising your dentin bond, it seals better, and you don't have to mix it.

Rob

 

[c132]

I have done some research into calcium hydroxide materials and they are far from the "wonderful" material they are said to be. The main reason for failure is that they are hydrophillic and they will be absorbed in the surrounding area and leave nothing behind to support the tooth, (to all the rookies, dentin grows down, not up!) After say 5 or 7 years the filling will fail because it is unsupported at the main site of force (the bottom of the filling) since the base material has all magically "disappeared". It does promote growth quite nicely though, if one used it to just fill the tippy tip of the pulp exposure, then put a glass ionomer resin on top of the CaOH2, then the filling will last a long time. Only problem is that many dentists just through this stuff into the canal, cure it, fill it up with amalgam or composite etc... and send them on their way.

Point being, read more about this, Don't use that stuff just for a base, it will fail in around 40% of fillings in 5 years!!!

 

[DrRob]

In most practices that i'm familiar with Ca OH is not used for pulp
capping. The bleeding is stopped with hemodent and then you etch and bond right over the exposure and do your filling.

 

[c132]

OMG you put hemodent into the pulp chamber? And bond right on top of it? Doesn't that lead to some serious post op pain? I would imagine that they would only be really really really small pulpal exposures huh?