This is a small review article talking about the treatment of deep caries and pulp therapy in vital teeth

1. TREATEMENT OF DEEP
CARIES AND PULP THERAPY
FOR VITAL TEETH
‫الطباطبائي‬ ‫إبراهيم‬ ‫صادق‬ ‫محمد‬
‫جبارصالح‬ ‫محمد‬‫مهدي‬

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Introduction
Dental caries is a sugar and biofilm dependent disease, where frequent sugars exposure
leads to an ecologic imbalance in the environment of the dental biofilm. The ecological
shift turns the otherwise commensal bacteria to a cariogenic condition with increased
production of demineralizing acids and the subsequent carious lesion formation on the
dental hard tissues. If left untreated it will continue to demineralize the dentine until
going to the pulp and causing pulpitis. Good diagnostic methods should be used to
evaluate the vitality of the pulp then choosing the correct treatment method accordingly.
There are two essential groups of carries diagnostic methods:
1. Conventional methods.
a. Visual inspection: the most ubiquitous caries detection system which
consists of assessment of tooth features such as the colour and texture. The
clinical accuracy is relatively low about 25% to 50%.
b. Tactile examination with the probe: it has the possibility of transferring
dental carries and may cause iatrogenic damage.
c. Carries detector dyes: they enhance contrast by their colour, they are
applied for about 10 seconds and rinsed off any deeply stained tooth
structure indicate the presence of caries
d. Conventional radiographs: the increase the accuracy of diagnosis to about
40% to 65%.
2. Advanced methods.
a. Digital radiography: a filmless technique for intraoral radiography, utilizes
very little of the radiation to which the patient has been exposed and avoid
the need for developing films.
b. Fibreoptic transillumination: The illumination is delivered via light source
to tooth surface. The light propagates from the fibre illumination across
tooth tissue to nonilluminated surfaces. The resulting images of light
distribution are then used for diagnosis, carious area appears as darkened
shadow that follows the decay.
c. ultrasound caries detector device (UCD): is based on
pulse-echo method and has software, hardware and
transducer as components. A medical grade silicon
wedge is positioned in front of probe to yield surface
waves on the tooth surface when the transducer comes
in contact with the tooth. Tis detector records specific
profiles of ultrasonic echoes obtained from the enamel

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surface, dentino-enamel junction and pulpo-dentinal junction. Changes in
this profile have been described in demineralized lesions, suggesting a
substantial difference in the sonic conductivity between sound and
demineralized enamel.
Pulp therapy of vital teeth
Pulp exposure of the dental pulp exists when the continuity of the dentin surrounding
the pulp is broken by physical or bacterial means leading to direct communication
between the pulp and external environment.
The diagnostic process of selecting teeth that are good candidates for vital pulp therapy
has at least two dimensions. First, the dentist must decide that the tooth has a good
chance of responding favourably to the pulp therapy procedure indicated. Second, the
advisability of performing the pulp therapy and restoring the tooth must be weighed
against extraction and space management. For example, nothing is gained by successful
pulp therapy if the crown of the involved tooth is no restorable or the periodontal
structures are irreversibly diseased. By the same rationale, a dentist is likely to invest
more time and effort to save a pulpally involved second primary molar in a 4-year-old
child with unerupted first permanent molars than to save a pulpally involved first
primary molar in an 8-year-old child.
1. Indirect Pulp capping
It is defined as a procedure where in small amount of carious dentin is retained in deep
areas of cavity to avoid exposure of pulp, followed by placement of a suitable
medicament and restorative material that seals off the carious dentin and encourages
pulp recovery. according to a Cochrane review. Lesion arrest was reported in primary
teeth with a success rate of 78% at 4 years, with no difference between an adhesive
system and calcium hydroxide used as liners.

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This procedure can be done in one or two appointments some interim restorative
materials may also serve as the base material (the second appointment is 6 to 8 weeks
later) there are major controversies in literature of which one is preferred some says
that there is no conclusive evidence that the two-step technique is preferred others say
that the two-step technique is less invasive because it doesn’t reach the proximity of the
pulp others prefer the one appointment procedure due to the probability of pulp exposure
in the second visit.
The clinical procedure involves removing the gross caries but allowing sufficient caries
to remain over the pulp horn to avoid exposure of the pulp. The walls of the cavity are
extended to sound tooth structure because the presence of carious enamel and dentin at
the margins of the cavity will prevent the establishment of an adequate seal (extremely
important) during the period of repair. The remaining thin layer of caries at the base of
the cavity is covered with a radiopaque biocompatible base material and sealed with a
durable interim restoration. If the decision is made to re-enter the tooth after 6 to 8
weeks, after confirming the formation of the reparative dentin (clinically and
radiographically) careful removal of the remaining carious material, now somewhat
sclerotic, the tooth is restored in the conventional manner. The most frequent used
material for indirect pulp capping is Dycal (calcium hydroxide).
Three distinct types of new dentin formation take place
• Cellular fibrillar dentin is formed in the
first 2 months
• Globular dentin is formed at 3 months
• Tubular dentin (uniform mineralized
dentin)
▪ 1/5th of reparative dentin
formation begins in less than 30
days
▪ After 3 months, 0.1 mm is
formed.
2. Direct Pulp Capping
It is defined as the placement of a medicament or nonmedicated material on a pulp that
has been exposed in course of excavating the last portions of deep dentinal caries or as
a result of trauma. This procedure has been widely practiced for years and is still the

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favourite method of many dentists for treating vital pulp exposures. Although direct
pulp capping has been condemned by some, others report that, if the teeth are carefully
selected, excellent results can be obtained direct pulp capping should be considered only
for teeth in which there is an absence of pain, in addition, there should be either no
bleeding at the exposure site, as is often the case in a mechanical exposure, or bleeding
in an amount that would be considered normal in the absence of a hyperaemic or
inflamed pulp. All peripheral carious tissue should be excavated before excavation is
begun on the portion of the carious dentin most likely to result in pulp exposure. Thus,
most of the bacterially infected tissue will have been removed before actual pulp
exposure occurs. After the haemorrhage has been arrested placement of pulp capping
material should done with minimal pressure. Final restoration is done after determining
the success of the procedure where there is preservation of pulp vitality, lack of pain
and minimal inflammatory response. The objective will be creating new dentin bridge
at the area of exposure and subsequent healing of the pulp.
Contraindications
• Severe toothache at night
• Spontaneous pain
• Tooth mobility
• Radiographic appearance of pulp, periradicular degeneration.
• Excess of haemorrhage at the time of exposure
• Serous exudate from the exposure
• External/internal root resorption
• Swelling/fistula.
3. Pulpotomy
The American Academy of Paediatric Dentistry defined pulpotomy as the amputation
of affected, infected coronal portion of the dental pulp preserving the vitality and
function of the remaining part of radicular pulp.

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It is justified by the fact that we can preserve the vitality of radicular pulp which will
stay healthy and capable of healing after the surgical amputation of the infected coronal
pulp, in addition this will maintain the tooth in its normal physiologic condition in the
dental arch with no need for extraction
Indications
• Mechanical pulp exposure in primary teeth.
• Teeth showing a large carious lesion but free of radicular pulpitis.
• History of only spontaneous pain.
• Haemorrhage from exposure sites bright red and can be controlled.
• Absence of abscess or fistula.
• No interradicular bone loss.
• No interradicular radiolucency.
Contraindications
• Persistent toothache.
• Tenderness on percussion.
• Root resorption more than 1/3rd of root length.
• Large carious lesion with non-restorable crown.
• Highly viscous haemorrhage from canal orifice, which is uncontrollable.
• Medical contradictions like heart disease, immunocompromised patient.
• Swelling or fistula.
• External or internal resorption.
• Pathological mobility Calcification of pulp.
Procedure
The tooth should first be anesthetized and isolated with the rubber dam. A surgically
clean technique should be used throughout the procedure. All remaining dental caries,
as well as the overhanging enamel, should be removed to provide good access to the
coronal pulp. The entire roof of the pulp chamber should be removed. No overhanging
dentin from the roof of the pulp chamber or pulp horns should remain. No attempt is
made to control the haemorrhage until the coronal pulp has been amputated. Funnel-
shaped access to the entrance of the root canals should be created. A sharp discoid spoon
excavator, large enough to extend across the entrance of the individual root canals, may
be used to amputate the coronal pulp at its entrance into the canals. The pulp stumps
should be excised cleanly, with no tissue tags extending across the floor of the pulp
chamber. The pulp chamber should then be irrigated with a light flow of water from a

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water syringe and evacuated. Cotton pellets moistened with water should be placed in
the pulp chamber and allowed to remain over the pulp stumps until a clot form. This is
an outline of the procedure many different modifications and special procedures are
mentioned in the literature, we will try to cover some of them.
Formocresol Pulpotomy/Single Stage Pulpotomy
Formocresol was introduced by Buckley in 1904 it involves the normal procedure and
applying a cotton palate soaked in formocresol for about 4 mins then restoring with zinc
oxide eugenol and recalling the patient after one week for permanent restoration and it
is used for primary teeth Trask used a modified technique in permanent teeth, it is
essentially the same except for the formecresol palate is sealed permanently in the tooth.
Composition of Buckley’s formocresol
• Cresol: 35%
• Glycerol: 15 %
• Formaldehyde:19%
• Water: 31%
Currently we use 1/5th concentration of Buckley’s formula, which is prepared by the
following method:
• Dilute 3 parts (90 mL) glycerine with 1 part (30 mL) diluted sterile water
• Add 1 part [30 mL] formocresol to 4 parts diluents

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• Add 30 mL of formocresol to 120 mL of diluent to obtain 150 mL of dilute
formocresol, i.e. 1/5th strength.
Two-visit Devitalization Pulpotomy.
This is two-stage procedure involving the use of paraformaldehyde to fix the entire
coronal and radicular pulp tissue in two visits.
Indications
• There is evidence of sluggish
bleeding at the amputation
site that is difficult to control
• Pus in the chamber, but none at the
amputation site
• There is thickening of the PDL
• History of pain.
Contraindications
• Non-restorable tooth.
• Tooth with necrotic pulp.

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Cvek’s Pulpotomy
It is also called as calcium hydroxide pulpotomy or young
permanent partial pulpotomy. It was proposed by Mejare
and Cvek in 1978. Indicated in young permanent teeth
where the pulp is exposed by mechanical or bacterial
means and the remaining radicular tissue is judged vital
by clinical and radiographic criteria whereas the root
closure is not complete. Rationale To preserve vitality of
radicular pulp and allow for normal root closure. It is
essentially the same but the capping material will be
calcium hydroxide and done in two appointments the
recall will be after the radiography shows formation of a secondary dentin bridge.
Mortal Pulpotomy
It is also called nonvital pulpotomy. Ideally, nonvital tooth should be treated by
pulpectomy, but sometimes it is impracticable due to non-negotiable root canals and
limited patient cooperation, mortal pulpotomy is indicated for such patients.

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Other types of materials used in pulpotomy
Despite the continuing common use of formocresol, other materials and techniques have
been studied and are used regularly in practice. An excellent prospective randomized
clinical trial was conducted by Fernandez and others,18 comparing the use of
formocresol, MTA, sodium hypochlorite, and ferric sulphate. They used a pulpotomy
technique and formocresol application similar to that described above. The use of the
other 3 medicaments was as follows:
• MTA: the pulp stumps were covered with an MTA paste made by mixing of the
MTA powder with sterile saline at a ratio of 3:1.
• Ferric sulphate: 20% ferric sulphate solution was used to burnish the pulp stumps
for 15 seconds with a syringe applicator.
• Sodium hypochlorite: a 5% NaOCl-saturated cotton.
pellet was placed on the pulp stumps for 30 seconds Both the ferric sulphate and sodium
hypochlorite solutions were rinsed off with water to verify that no blood clot was present
before restoration. In all 4 groups, a polymer-reinforced zinc oxide–eugenol material
was placed in the pulp chamber, and the teeth were restored with stainless steel crowns.
Each group began with 25 treated teeth, and at the end of 24 months of follow-up, of
the teeth available for study, no statistically significant difference was found among the
4 groups so we can use these other materials instead of formocresol thus eliminating the
risk of cancer and its other risks.

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References
Dean, J., Jones, J., Vinson, L. and McDonald, R., 2016. Mcdonald And Avery's
Dentistry For The Child And Adolescent. 10th ed. St. Louis, Missouri: Elsevier,
pp.224-230.
Giacaman, R., Muñoz-Sandoval, C., Neuhaus, K., Fontana, M. and Chałas, R., 2018.
Evidence-based strategies for the minimally invasive treatment of carious lesions:
Review of the literature. Advances in Clinical and Experimental Medicine, 27(7),
pp.1009-1016.
Marwah, N., 2014. Textbook Of Pediatric Dentistry. 3rd ed. Jaypee Brothers Medical
Pub, pp.506-511 647-659.
Wilson, N. and Dunne, S., 2018. Manual Of Clinical Procedures In Dentistry. John
Wiley & Sons Ltd, p.359.