Re: Composites and deep carious lesions

One of the gurus who researches pulp-capping is Charles Cox. He said
if I recall correctly at a continuing ed speech, that the best
pulp-capping material is just composite resin. You just need an inert
biocompatible barrier over the exposed pulp, and composite resin is
best. He said no one really understands why CaOH works as a
pulp-capping agent, and that CaOH is a risky pulp-capping agent to use
because it is brittle and may chip off in little pieces into the pulp,
causing an inflammation reaction in the pulp-capping site. The
rationale that CaOH raises PH and thus kills micro-organisms is not
evidence-based. He says studies show that vitrebond or GIC show higher
failure rates as pulp-capping agents compared to composite resin. Also
that eugenol is toxic to the pulp and should not be used on vital pulps
or pulp capping, so no ZOE. So the best pulp capping agent is
apparently plain old etch, prime, bond, composite. Make sure the
composite is cured perfectly over the pulp. Uncured composite may
contain irritating chemicals. Put a thin layer over the pulp, light
cure thoroughly, then build up the rest.

Also, be very careful of occlusal prematurities from the composite.
Composite materials are challenging to adjust so that their occlusion
is perfect. But if the occlusion is off on your composite, the patient
may return with symptoms of sensitivity to hot and cold or sensitivity
to biting that mimic those of irreversible pulptis. So you might
think, oh, the tooth was pulp-capped, and now the nerve is dead because
the patient has symptoms of irreversible pulptitis. But no! The truth
may be that the pulp cap worked, but the occlusion was off, so the
patient has symptoms. Don't do a pulpotomy on the tooth, just adjust
the occlusion and wait and see. Use articulating paper prior to
filling to note the occlusal mark pattern on the teeth on the
contra-lateral side, then make sure after you fill the tooth that you
can duplicate that same pattern of occlusal markings.

Realize that pulp-capping is not yet an exact science and that most of
what was learned in dental school about this is conceptually
disorganized garbage, like so much of what is learned in dental school.
So, to summarize, don't use ZOE, don't use eugenol-containing things,
don't use vitrebond, don't use CaOH, don't use dycal (which interferes
with bonding of composite). Just pulp cap with plain old composite
resin and make sure there are no occlusal prematurities. And if the
patient comes back with pain, first adjust the occlusion and wait and
see, and only if the pain is persistent should you consider pulpotomy
and root canal.

--Johnny

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