Pulp Capping of Carious Exposures: Treatment Outcome After 5 and 10 Years: A Retrospective Study
Howard E. Strassler, DMD
Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. J Endod. 2000 Sep; 26(9):525-8.
One hundred twenty-three pulp cappings had been performed by students in 1984 to 1987 (=10-yr group) or in 1990 to 1992 (= 5-yr group) and were followed up in 1997. Teeth were checked for sensitivity (CO2/electrical pulp testing), percussion, and palpation; radiographs were taken to assess periapical status. In addition several other factors were determined that might have an influence on the success or failure rates, such as base material, type of restoration, site of exposure, etc. Results showed 44.5% failures (18.5% questionable and 37% successful cases) in the 5-yr group and 79.7% failing, 7.3% questionable, and 13% successful cases in the 10-yr group. As a factor of influence, the placement of a definitive restoration within the first 2 days after pulp exposure was found to contribute significantly to the survival rate of these teeth.
During restorative procedures, maintaining pulpal vitality is a goal. Mechanical pulpal exposure without bacterial infection can be achieved through the repair mechanism of dentinal bridging; when bacterial invasion has occurred, the pulp’s reparative ability is compromised. When there is a carious exposure, should we attempt to maintain pulpal vitality with a direct pulp cap, or should endodontic therapy be initiated?
This study evaluated the survivability of cariously exposured pulps over 5-year and 10-year periods. Three-hundred and fifty-three patients with 401 pulp caps were asked to make a recall appointment and, of these, only 97 patients with 123 pulp caps could be followed-up. Data was collected based upon extraction of the tooth, endodontic treatment postoperatively, or clinical assessment. Teeth were listed as questionable if pulp testing and/or clinical symptoms were rated as questionable. Treatment outcomes of pulp capping were reported.
When deciding to perform a direct pulp cap, it is accepted that the tooth and pulp be evaluated. Teeth should be symptom free and have no evidence of periapical pathology. Studies show that other factors contributing to success include age of the patient, size of the exposure, and amount of bleeding (i.e., increased bleeding increases the likelihood of failure). The exposure should be covered with calcium hydroxide and then a glass ionomer base prior to placing the definitive restoration.
The literature supports performing pulp capping only for small mechanical exposures of an otherwise healthy pulp. However, we attempt pulp capping on bacterially compromised pulps, hoping for successful outcomes. One reason for pulp capping carious exposures is the patient’s desire to have a tooth extracted rather than undergo endodontic treatment. Maintaining the function and position of the tooth takes precedent in the treatment decision.
This paper clearly indicates that the success rate of direct pulp caps of carious exposures over a long term is generally low, with 44.5% in the 5-year study and 79.9% in the 10-year group requiring root canal treatment or extraction. Of the questionable teeth and all successful cases, there was calcification within the pulp chamber and/or root canals when compared to adjacent teeth that had no pulp exposure.
Based upon this paper, carious exposures should be treated with endodontic therapy. However, under special circumstances (e.g., the definitive restoration will not be an indirect restoration), a direct pulp cap of a carious exposure may lead to success. These cases must be monitored regularly to avoid unnoticed pulp necrosis and bacterial invasion of the root canal. A definitive restoration should be placed within 2 days of the pulpal exposure.
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Howard E. Strassler, DMD