As dentists we have all been there. We have prepared ourselves for a simple filling on a primary tooth, and everything is going great until we square out the interproximal box. All of a sudden there it is a glimpse of pink. The dreaded pulp exposure on a primary tooth. Our conversation may change with the parent from a simple filling now to a pulpotomy and crown. Should that be the only option? Should we perform a direct pulp capping procedure on primary teeth?
Let's dive in.
Historically in pediatric dentistry calcium hydroxide has been a material of choice for many procedures. Indirect pulp capping, direct pulp capping, and pulpotomies have been some of the main uses. It works (or rather the mechanism of action) is causing necrosis in the pulp to stimulate a response to form dentin. We know that this dentin is more porous than that created by current day bioceramics. The AAPD Guidelines on Vital Pulp Therapy in primary teeth recommend against the use of calcium hydroxide. Perhaps a reason direct pulp capping in primary teeth is out of favor.
In recent years bioceramics have been found to be highly successful in permanent and primary teeth for vital pulp therapy. They are MTA based products that are composed of di and tricalcium silicates. These materials combine with elements from the blood and form hydroxyapatite. These materials show the highest promise in a medicament for direct pulp caps in primary and permanent teeth.
For years many believed the four minute mile was impossible. In 1954 Roger Bannister eclipsed the four minute mark. Could direct pulp capping in primary teeth be the same?
Most recently the AAPD published an article reviewing calcium hydroxide, MTA, and formocresol as used as direct pulp capping agents in primary teeth. The study reported twelve months of data. The results showed no difference between all groups. The only group that didn't have any failures was the group treated with MTA. The authors suggested that MTA is a viable option for direct pulp capping in primary teeth.
Steps to Perform a Direct Pulp Cap in Primary teeth
Rubber Dam Isolation (not sure which one to use find out here)
Exposures treated with 6% NaOCl
MTA or Bioceramic Placement
IRM or GI
Full Coverage Restoration (SSC or Zirconia Crown) unless the tooth is expected to exfoliate in less than two years.
What do you do when you have a simple procedure planned and it becomes more complex?
Do you do a pulpotomy, direct pulp cap, or extract? I would love to hear from you on your thoughts.