4/15/2019- Pulp C(r)ap
To pulp cap or not to pulp cap?: that is the question
The subject is certainly controversial. If you were to ask multiple endodontists, there is no doubt you would receive multiple answers and opinions. If you were to ask me, I say DON’T PULP C(R)AP!
Certainly, the literature reports high success rates with pulp capping (ie, hard tissue formation over the exposure, retention of vitality, etc), but let’s be honest: many of these studies were under controlled conditions where the driving factor was to see if pulp vitality could be maintained. In the normal practice setting, this may not always be the case. Other variables come into play: isolation with rubber dam, preoperative symptoms, placement and quality of the coronal restoration, and patient compliance to name a few. However, one of the most important factors is THE AGE OF THE PATIENT.
I’m only an advocate of pulp capping if the patient is between the ages of 6-19; once the patient reaches adult status, we begin to see maturity of the apical foramen. When the apex begins to mature, cementum begins to form around the apical segment (Kuttler, 1955). This may result in a decrease in blood flow to the pulp and thus a decrease in the ability to respond to harmful stimuli which may result in the development of inflammation and necrosis. Therefore, if the patient is 19 years or older, I am against pulp capping and an advocate for root canal therapy. The goal of dentistry is to maintain the adult dentition. The literature reports that success rates for endodontic therapy is within the 90th percentile. However, should pulp necrosis develop, then the success rates may drop 10-15%! Thus, if there is a pulp exposure on an adult patient, doesn’t it make sense to perform endodontic therapy when the success rates are high as opposed to subjecting your patient to a decreased success rate should necrosis develop?
I have broken down the for(s) and against pulp capping below:
For capping: (IF AND ONLY IF DONE UNDER ASEPTIC RUBBER DAM ISOLATION)
A. If the exposure is mechanical and/or iatrogenic (ie, trauma). These types of exposures usually do not involve bacteria and the chance of introducing bacteria into the canal(s) is minimal.
B. A vital and asymptomatic tooth (no inflammation present)
C. The patient is between ages of 6- 19 years old
A. Caries exposures
B. Necrotic and/or symptomatic pulp
C. Adult patients above 19 years of age
Should you choose to place a pulp cap, the material of choice is MTA (mineral trioxide aggregate). The literature shows great success rates for retention of vitality which will help guide maturation and completion of root formation (Bogen et al, 2008). In addition, MTA has also been shown to be biocompatible and antibacterial.
So let’s recap: while I am against capping on the pulpal tissues, it may serve a purpose with the adolescent patient when the apices are immature and endodontic therapy is needed. The big take home message: ALL ENDODONTIC THERAPY MUST BE COMPLETED UNDER RUBBER DAM ISOLATION!