04 March 2024

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Direct pulp capping: evaluation of success at 4 years

Lara Figini

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Direct pulp capping is a treatment for pulpal carious exposures that is taught regularly in dental schools but is not applied as assiduously by dentists because, according to several past studies, it shows low long-term success rates. Fortunately, more recent studies have reported higher success rates, probably due to new materials introduced on the market, although these clinical studies are almost short-term with maximum follow-up of 1 year. An important factor to take into consideration during direct pulp capping treatment is the correct disinfection of the site to be treated before the obturation procedure. 

Materials and methods

In a randomized study, published in the Journal of Endodontics, the authors evaluated pulp survival after brushing and capping in non-tender adult posterior teeth with pulp exposure due to caries. The treatment involved the complete removal of the cavity, the direct capping of the pulp with mineral trioxide aggregate and the immediate restoration with composite resin. Before pulp capping, the cavities were washed randomly (block randomization, n: 48) with physiological saline solution or sodium hypochlorite solution (2.5% NaOCl). The outcome of the treatment was evaluated clinically (cold test) and radiographically after at least 1 year and again after at least 3 years. Painful failures were differentiated from non-painful failures. Pulp survival was estimated using the Kaplan Meier method including 95% confidence intervals (CIs) up to 1500 days. 

Results 

Of the 96 patients originally enrolled, 73 individuals were able to be followed continuously. Clinical observations have indicated a beneficial and prolonged effect of washing the pulp with a 2.5% NaOCl solution. Compared to control treatment with physiological saline regarding estimated pulp survival 1500 days postoperatively, with 7% (95% CI, 1%-40%) success in the saline group compared to 55% (95% %CI, 30%–100%) in the NaOCl group. Elevated MMP-9/total protein values in pulp fluid collected from the exposed site indicated early and painful treatment failures, but were not associated with failures occurring more than 250 days postoperatively. 

Conclusions 

From the data of this study, which must be confirmed in other similar studies, it can be concluded that direct pulp capping in adult subjects has a low success rate at 4 years. 

Clinical implications 

Although the 4-year success of direct capping of exposed pulp due to caries in adult teeth is low, disinfecting the cavity with a 2.5% NaOCl solution can provide a positive effect on pulp survival.

Nidambur Vasudev Ballal, Henry. F. Duncan, Daniel. B. Wiedemeier, Namith Rai, Prateek Jalan, Vinutha Bhat, Vijetha Shenoy Belle and Matthias Zehnder Journal of Endodontics, Volume 50, Number 1, January 2024