Improve Pulp Capping Success Rates

Simple Guide for the Best Results

The SEVEN keys

Direct and indirect pulp capping are excellent strategies for preserving vital pulp tissues. Adherence to the following steps is essential to obtain the best results with pulp capping. Evidence from the best clinical research supports these steps.

  1. DIAGNOSIS: Accurate preoperative diagnosis: reversible pulpitis or healthy vital pulp
  2. ISOLATION: Rubber Dam is by far the best technique (and the only technique supported in the literature)
  3. CARIES FREE ZONE: Peripheral area clean (DEJ + 1 mm towards pulp)
  4. NO BLEEDING: Exposure stops bleeding within 10 min with 3% sodium hypochlorite (does not apply when the pulp is not exposed)
  5. MTA: Only use MTA/Biodentine and never use composite material (or a material that requires light-curing)
  6. SEAL: Secure the MTA with an RMGI liner
  7. RESTORATION: Immediately with a definitive restoration (usually a direct restoration)

NOTE: Both direct and indirect pulp capping follow the above protocol. It is difficult to ascertain the proximity of the pulp, so it is usually best to employ MTA/Biodentine when in doubt.

Direct Pulp Capping

When the pulp is exposed or is suspected to be exposed, proximity less than 0.5 mm. Steps:

  1. Establish/maintain excellent isolation (rubber dam is ideal)
  2. Apply sodium hypochlorite to stop bleeding (within 10 minutes). NOTE: if bleeding does not stop within 10 minutes, initiate pulpectomy (RCT)
  3. Place 0.5 mm thick MTA liner over pulp exposure region
  4. Place 0.5 mm thick RMGI liner over the deepest portions of dentin and totally cover the MTA with a 1.0 mm+ margin and light cure with air spray
  5. Perform enamel and dentin conditioning (self-etch, selective etch, or total-etch)
  6. Use chlorhexidine again with total-etch systems for at least 60 seconds
  7. Proceed with layered composite build-up technique
Direct pulp capping protocol clinical case with rubber dam with MTA and RMGI liner and composite restoration

Indirect Pulp Capping

When the pulp is not exposed and the proximity to the pulp less than 1.0 mm. Steps:

  1. Establish/maintain excellent isolation (rubber dam is ideal)
  2. Clean prep with 2% chlorhexidine for 120 seconds
  3. Place 0.5 mm thick RMGI liner over deepest portions of dentin and light cure with air spray
  4. Perform enamel and dentin conditioning (self-etch, selective etch, or total-etch)
  5. Use chlorhexidine again with total-etch systems for at least 60 seconds
  6. Proceed with layered composite build-up technique
Indirect pulp capping protocol clinical case with rubber dam with MTA and RMGI liner and composite restoration

More Resources

Hands-on CE courses you can take:

Download The Pulp Capping Guide

Acknowledgement

I wish to thank Dr. Urmi Bhattacharyya, Research Associate at Stevenson Dental Research Institute, for her assistance in preparing this manuscript.  She initially presented much of this information in a Table Clinic, presented at the Academy of Operative Dentistry meeting in February 2020.

References

Thompson V, Craig R, Curro FA, Green WS, and Ship JA. Avoiding direct pulp caps has been shown to reduce the need for subsequent endodontic treatment. JADA 2008;139:705-712

Hilton TJ, Ferracane JL, and Mancl L. Comparison of Ca)OH)2 with MTA for direct pulp capping. J. Den. Res., July 2013 vol. 92 no. 7 suppl S16-S22

Mente J, Hufnagel S, Michel, A, Gehrig H, Panadigas D, Suare D. and Pfefferle T. Treatment outcome of mineral trioxide aggregate or calcium hydroxide pulp capping: long term results. J of Endo., Nov 2014 vol. 40 no. 11 pp. 1746-1752

Bakhtiar H, et al. Human pulp responses to partial pulpotomy treatment with Theracal as compared to Biodentine and ProRoot MTA: a clinical trial. J of Endo., Nov 2017 vol. 43 no. 11 pp. 1786-1791