Direct Pulp Capping with adhesive resins and composite criteria of selection and modifcation of the technique.

J M Gonzalez-Gonzalez DDS MD

Abstract Keywords Introduction

Methods Results Discussion

References Previous Page

ABSTRACT

Objectives: The purpose of this study is to describe our clinical experience about the utility of adhesive resins on direct pulp capping.
Material and Methods: Sixty-eight human teeth were treated with conservative odontology. All of them revealed pulpal exposure during the removal of the deep carious lesions.
Two criteria for application were followed in this study: 1) the tooth should not have had previous pain and 2) the exposed pulp should be no larger than 1 mm2
The technique consisted of preparation of the cavity, excavation of the lesion and the application of hydrogen peroxide to control the pulp hemorrhage (Foret, Peroxidos Farmaceuticos, S.A., 110 vol, 30%, 20 sec), total etch with phosphoric acid (Total etch, Vivadent, 37%, 20 sec.), disinfection with chlorhexidine (Corsodyl, GSK, 1%, 20 sec.), application of adhesive resin (Hebobond, Vivadent), and a resin-based composite (Z I 00, 3M) in this order.
Recall appointments were made after 15 days, 3 months and 6 months to determine the failure or success of the treatment.
After those periods of time with no continuous pain or infection, the treatment was considered to be a success; otherwise, a failure.
Results: An apparent success rate of 48.5% was obtained versus a 51. 5% failure rate.
Conclusion: This treatment can be recommended for pulp exposures no larger than 1 mm2 that have experienced no previous pain; otherwise, endodonties is advisable.

KEYWORDS

Direct pulp capping. Adhesive resins. Composite. Criteria. Prognosis. Exposed pulp. Restoration. Technique.

INTRODUCTION

A carious tooth is usually treated by eliminating the wounded dental tissue and filling the cavity with a suitable restoring material. When there is exposed pulpal tissue, bacterial contamination is possible and in that case the clinician, in his opinion, may choose to perform a direct pulp capping or endodontics (Stanley, 1998).

At present, a definitive procedure for the treatment of pulpal exposures has not been defined. However, the degree of pain or the size of the pulpal exposure are two factors frequently considered (Stanley, 1998; Haskell et al., 1978).

Direct pulp capping is traditionally performed with calcium hydroxide (Ca(OH)2) formulations which have a bactericidal effect, because of their high pH and in long tenn they produce dentinal bridges on the exposed pulpal area (Truniniler et al, 1998; Subay and Asci, 1993).

Nevertheless, it has been shown that this dentinal bridge does not constitute a continuous seal and may allow bacterial leakage through the tooth (Olmez et aL, 1998; Paineijer and Stanley, 1998; Cox et aL, 1985) and even a protrusion of the pulpal tissue in the cavity (Kitasako, Inokoshi and Tagami, 1999).

Direct pulp capping with an adhesive resin on an exposed pulp has been suggested, provided that marginal microleakage can be prevented together with a composite resin to restore the tooth (Olmez et al., 1998, Paineijer and Stanley, 1998; Liebenberg, 1997). Reports in primates show that adhesive systems and composite resins are biologically compatible with pulpal tissue when placed on the exposed pulpal area after hemorrhage is controlled (Cox et al., 1998). The degree of bleeding is indicative of prognosis (Matsuo et aL, 1996). The type of adhesive system when used for direct pulp capping is thought to induce different pulpal responses (Kitasako, Inokoshi and Tagami, 1999; Tsuneda et al., 1995) and varying degrees of microleakage (Pameijer and Stanley, 1998; Tsuneda et aL, 1995), although other authors do not find histological differences on using different adhesive systems (Cox et al., 1998). On the other hand, the technique of etching with phosphoric acid in a concentration of + 30%, is still the most commonly used during the tooth restoration (Van Meerbeek, 1999).

The purpose of this study is to describe our clinical experience about the utility of adhesive resins on direct pulp capping by defining clearer criteria for the selection of patients and the resulting long- term prognosis.

MATERIAL AND METHODS

Sixty-eight human teeth were treated with conservative odontology in a private office for three years. Deep caries were observed during the initial oral examination. The patients indicated that they had never felt any kind of previous pain in those teeth, especially with changes of temperature. All the patients included in this study revealed pulpal exposure during the removal of the caries. Teeth "without a history of previous pain" and pulpal exposure no larger than 1 mm2 were included in this study. Teeth, regardless of the size of pulpal exposure "and with previous pain" were not included in the study and subsequently received endodontic treatment.

The criteria for selection of patients to be included in this study are listed in Table 1.

Table 1: Criteria of selection in the modified technique of direct pulp capping

The teeth which met the criteria were treated following the steps shown in Table 2, after warning each patient of the possibility of having to have endodontic therapy in case of tooth pain or evidence of of infection. Recall appointments were made after 15 days, 3 months and 6 months to determine the success of the treatment. After those periods of time with no continuous pain or infection, the treatment was considered to be a success; otherwise, a failure.

Table 2: Steps in the modified technique of direct pulp capping

RESULTS

Table 3 shows the number of individual successes and failures of the treatment performed in each tooth of the 68 patients included in this study.

Table 3: Number of clinically successful teeth that exhibited no pain as opposed to the failure cases of the treatment perfromed in each tooth

Table 4 shows the number of success and failure cases according to the age of the patients.

Table 4: Apparent success and failure rates according to the age of the patients

The relationship between the dental surface involved and the success or failure of the treatment is shown in Table 5.

Table 5: Apparent success and failure rates according to the dental surface involved

DISCUSSION

Current studies propose the use of adhesive resins instead of the traditional calcium hydroxide on the direct pulp capping (Heitniann and Unterbrink, 1995). In this study an adhesive was used, because as preceding authors have indicated (Olinez et al., 1998; Paineijer and Stanley, 1998; Irgil 1997), microleakage is avoided.

As indicated by other investigators (Stanley, 1998; Haskell et al., 1978), we agree that there are no clear criteria on choosing one or the other kind of pulpal exposures. Therefore, we have indicated two criteria for the selection of patients for whom a direct pulp capping could be made: the tooth should not have had a previous pain and the pulpal exposure must be no larger than 1 mm' (Table 1). The level of pain and size of the pulp are not especially precise criteria but we justify their use because we think they have a clinical value.

The technical stages of such treatmenst have changed with experience. Some clinicians control haemorrhage with a 2% chlorhexidione solution (Palmeijetr & Stanley, 1998), 2.5% NaOCl (Cox et al, 1998), or sterile cotton pallets and sterile saline (Olmez et al, 1998).

We chose to use 30 % hydrogen perxide becasue its effect is almost immediate. Some authors etch only enamel and dentine with phospharic acid (Van Meerbrek, 1999) and others also etch the exposed pulp. We used the latter technique, because we think another important point is to avoid bacterial contamination of the exposed pulpal area, a circumstance which has already been commented on by other authors (Cox et al., 1985. Heitmann and Unterbrink, 1995) and also because the effect of pulp etching produces - according to previous studies- (Olmez et al.; 1998) a transitory irritation which decreases with time.

Disinfection of pulp exposures has been made either with a 3% hydrogen peroxide (Trummler et,al., 1998) or with a 2% chlorhexidine solution (Pameijer and Stanley, 1998). Here we used 1% chlorhexidine, but it is necessary to remember that, in order to control the haemorrhage, we also applied 30% hydrogen peroxide which is also a disinfectant.

After six months, an apparent 48. 5 % success rate was found compared to a 51. 5% failure rate following our criteria of selection and the exposed treatment technique.

In reviewing the literature, there are not the same selection criteria , treatments techniques or similar evaluation periods to be enable us to directly compare different studies. In other studies though the success rates at follow-up periods of 11.7 years were 83.3% (Haskell et al., 1978), for 2-6 months 100% (Heitmann and Unterbrink, 1995), for 3-8 months 80-83% (Matsuo et al., 1996) and for 1-2 years 49% (Cox et al, 1985) . This latter figure compares with the failure rate found in the present study. Other studies have not necessarily used the same criteria. We are aware of the limitations of this study as pulp degeneration or a latent pulp infection can exist without showing pain or infection. We have also considered preceding studies (Hebling, Giro and Costa, 1999) in which the teeth treated with a resin were studied histologically; in the end it is pointed out that the resin does not favour the pulp repairing itself, although it does have an acceptable biocompatibility. Our study is a clinical study and we do not make histological cuttings of the treated teeth. When we consider that treatment is a failure we perform endodontic therapy and we keep the tooth in the mouth.

Our results indicate that the type of teeth, age of the patients and affected dental surface (Tables 3-5) are not indicative of the long-term prognosis of the performed treatment. It is very important to control haemorrhage because it covers the dentine with plasma proteins and haemoglobin, thereby interfering with resin bonding and permitting baterial contamination.

As preceding authors have indicated (Ranly and Garcia-Godoy, 2000) we think that the use of dentinal adhesives can transform the technique of direct pulp capping in the future. Clinically speaking, we can only recommend this treatment and technique when the exposed pulp is no larger than 1 mm2 and there is no history of previous pain; otherwise, it is most advisable to do endodontics.

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J M Gonzalez-Gonzalez DDS MD,

C/Avila, 4, 1A,

37004 Salamanca, Spain.

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First Published: June 2001