Dentaltown January 2015 - (Page 52)

case presentation feature feature PULP CAPPING: IMPROVING THE PROGNOSIS by Paul L. Child Jr., DMD, CDT, and Mark L. Cannon, DDS, MS T here are many clinical and research questions surrounding pulp capping. For example, what is the best way to treat a tooth that is asymptomatic with moderate to advanced caries, but excavation results in a small exposure? What are the best materials to use? What does the published, peer-reviewed literature inform us on these procedures? What extent of carious dentin should be removed to avoid exposing the pulp? Or, should all caries be removed regardless of pulp exposure? How is infected versus affected dentin identiﬁed? What materials should be used for hemostasis control if the pulp is perforated? he questions can continue indeﬁnitely for such a small but vital procedure. It is not the intent of this article to answer every question surrounding pulp capping, but to briefly comment on the major points based on research, literature, and clinical experience. Confounding factors Pulp capping is an operative procedure that attempts to maintain the vitality of the tooth and facilitate the formation of reparative dentin. This topic has been researched for nearly a century and continues to evolve as we better understand the pulp, the dentin, and their biological reparative capacities. Despite new advances gained through research, this topic remains very controversial, as key opinion leaders, manufacturers, researchers, universities, associations and clinicians all seem to differ on what works best. The literature can be useful for providing direction, yet can be confusing too, as it contains support or disagreement for most materials or techniques used by clinicians. Rarely do the everyday practices of a busy clinician re ect those of a researcher under a controlled environment. With all this confusion, many clinicians fall back onto old techniques or products out of frustration or ignorance, despite newer research, materials, or techniques that may provide a better option for their patients. The prognosis of pulp capping (both direct and indirect) varies with success rates ranging from 13 percent to 100 percent. In the reported literature, the prognosis of direct pulp capping is unpredictable, with the lowest success rate in carious pulp exposures in the adult dentition. A recent Cochrane review of the literature (2012) stated, "If the tooth is asymptomatic but the caries is extensive, there is no consensus as to the best method of management." It further stated, "There is no consensus as to whether the tooth should be indirectly pulp capped or directly pulp capped; whether a two-stage procedure should be carried out, nor as to which material is most effective." It appears that this leaves clinicians without a reliable means to know whether to remove all the pulp or provide a direct pulp cap. In clinical practice, mantras such as "hoping for the best, expect- 52 JANUARY 2015 » dentaltown.com ing the worst" are conveyed to patients as well as the often-heard statement, "you have a 50/50 chance of this tooth requiring root canal therapy." As such, pulp capping seems to be a dichotomy at times. If the clinician provides the service as a conservative approach at saving the tooth and it descends into irreversible pulpitis, the patient may get frustrated that his or her previous asymptomatic tooth is now symptomatic and requires an endodontic root-canal therapy. On the other hand, if the tooth has minimal signs of pulpitis with a small carious exposure and they are advised they need endodontic treatment, additional costs, efforts, appointments, and patient frustration ensues. Unfortunately, many insurance providers do not reimburse for pulp capping if it is done in conjunction with the ﬁnal restoration on the same day. In addition, some insurance providers simply do not allow for a separate fee to be charged to the patient, since the allowance for a ﬁnal restoration includes pulp caps, cavity liners and bases. This practice has discouraged some clinicians to not provide the service if they cannot be reimbursed, which may not be in the patient's best interest. The costs involved in a conservative pulp cap versus endodontic treatment is less expensive, takes less time, and is more likely to be accepted by the patient. Diagnosis There are many approaches to direct pulp capping, ranging from some that provide a direct pulp cap every time a pulp is exposed to those that provide endodontic therapy every time a pulp is exposed. There are clinicians, specialists, and associations who advocate providing endodontic treatment on every carious pulp exposure regardless of size or symptoms. However, clinical experience demonstrates that some carious exposures can be properly managed with a direct pulp cap. Proper diagnosis is the key to success. It is often difﬁcult to diagnose how in amed the vital pulp is or to what degree the infection extends into the pulp. The pulp may be impaired and/or gravitating toward symptomatic or asymptomatic irreversible pulpitis, pulpal necrosis, and/or symptomatic apical periodontitis (where occasionally no radiographic changes have taken place yet). According to the American Association of Endodontists (AAE) Endodontic Diagnosis criteria, asymptomatic irreversible pulpitis is based on subjective and objective ﬁndings, have no clinical symptoms, and usually respond normally to thermal testing, resulting from trauma or deep caries. When these cases are identiﬁed, the clinician needs to make a judicious decision on whether to provide a direct/indirect pulp cap or root-canal therapy. Presently the AAE recommends root-canal therapy for asymptomatic irreversible pulpitis, but diagnosing the pulp as irreversible without any clinical or radiographic symptoms is difﬁcult, and many http://www.dentaltown.com

Table of Contents for the Digital Edition of Dentaltown January 2015

Dentaltown.com Highlights
Howard Speaks: Why Too Much Clinical Dentistry is Bad for Business
Professional Courtesy: Coming Soon: More Denture Patients
Continuing Education
Sleep Apnea Screening and Treatment
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Anterior Tooth Position in Restorative Dentistry: Applying the Chasolen Triad
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Pulp Capping: Improving the Prognosis
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Diagnosis in Endodontics
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Dentaltown January 2015