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L I N I C A L

R A C T I C E

Vital Pulp Capping: A Worthwhile Procedure

Lawrence W. Stockton, DMD

A b s t r a c t
Despite the progress made in the field of pulp biology, the technique and philosophy of direct vital pulp capping remains a controversial subject. Clinicians are well aware of the immediate and long-term success rates after
root canal therapy, but are less certain of the success of vital pulp capping. Researchers have demonstrated that
exposed pulps will heal and form reparative dentin. It is realized now that the variable prognosis of vital pulp capping is predominately a restorative issue.
The factors that can produce a successful vital pulp cap are discussed in conjunction with two popular techniques.
MeSH Key Words: acid etching, dental; calcium hydroxide; dental pulp capping.
J Can Dent Assoc 1999; 65:328-31
This article has been peer reviewed.

ital pulp capping is the dressing of an exposed pulp

with the aim of maintaining pulp vitality. Throughout the life of a tooth, vital pulp tissue contributes to
the production of secondary dentin, peritubular dentin (sclerosis) and reparative dentin in response to biologic and pathologic stimuli. The pulp tissue with its circulation extending
into the tubular dentin keeps the dentin moist, which in
turn ensures that the dentin maintains its resilience and toughness. These characteristics ensure that the teeth can successfully resist the forces of mastication.
Although several studies1-4 have shown that endodontic
procedures have an effect on the tooths dentin, others5 have
suggested that it is the cumulative loss of dentin and the loss
of the pressoreceptive mechanism6 and not the endodontic
procedures that affect clinical performance. Whatever the reason, several studies7-9 have reported the higher failure rate of
restored endodontically treated teeth. Since a non-vital tooth
requires 2.5 times more of a load than a vital tooth to register
a proprioceptive response10-12 the natural protection against
an overload is reduced and the probability of fracture increases.
Also, because posts do not reinforce teeth7,9,13,14 but may
weaken them, restorative procedures that help preserve pulpal
vitality and eliminate the need for posts are desirable. However, if endodontic therapy is unavoidable, conservation of
the remaining tooth structure is most important.
Major advances in the practice of vital pulp capping have
been made, and the emphasis has shifted from the doomed
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organ concept of an exposed pulp to one of hope and recovery. Long-term assessments of vital pulp caps with calcium
hydroxide have shown very high success rates.15 Other studies15-18 have demonstrated that the exposed pulp possesses an
inherent capacity for healing through cell reorganization and
bridge formation when a proper biologic seal is provided and
maintained against leakage of oral contaminants. Direct pulp
capping should be used only on a vital pulp that has been accidentally injured and shows no other symptoms. Direct pulp
capping should not be performed on a pulp that has been
exposed as a result of penetrating caries.18 A successful pulp cap
has a vital pulp and a dentin bridge within 75 to 90 days.19
The major causes of post-operative inflammation and pulp
necrosis are non-sterile procedures and bacterial microinfiltration of the pulp via dentinal tubules. These may result
from contamination of an exposed pulp prior to or during cavity preparation, or as a result of improper sealing of the entire
dentin substrate interface when placing the restoration.18,20,21 To
decrease the chances of contamination the rubber dam either
must be in place from the start of the restorative procedure or be
placed once a pulp exposure has been recognized.

VITAL PULP CAPPING TECHNIQUES

Two techniques have demonstrated success with vital pulp
capping the calcium hydroxide technique15,18 and the total
etch technique (Fig. 1).22
Journal of the Canadian Dental Association

Vital Pulp Capping: A Worthwhile Procedure

Figure 1: Direct vital pulp cap

vitality and no symptoms, the zinc oxideeugenol can be

removed and a more permanent sealed restoration placed.
For the total etch procedure, as with calcium hydroxide,
hemostasis must be obtained. The exposure site is then covered
with a non-setting calcium hydroxide paste (e.g., Pulpdent,
Pulpdent Corp. of America, Brookline, Mass.) and the cavity
preparation completed. Following disinfection of the cavity,
the enamel and dentin are etched with 32% phosphoric acid
for 15 seconds. The acid and calcium hydroxide are rinsed off
and the preparation is lightly dried. The entire preparation
including enamel, dentin and pulpal tissue is treated with a
dentin bonding system (a fourth-generation system with a separate primer and adhesive is recommended, as little research
has been published to date on the fifth-generation dentin
bonding systems). Following placement of several layers of the
hydrophilic primer, a thin layer of the adhesive resin is painted
onto the enamel, dentin and pulpal tissue and light cured. A
second layer of unfilled resin is applied, and a thin layer of
resin-modified glass ionomer is also applied over and around
the exposure site to mechanically protect the perforation from
intrusion of the restorative material during packing or condensation. These layers are also light cured. The restoration is
subsequently completed in conventional fashion.34,35

DISCUSSION
For vital pulp capping to be successful, the tooth should be
asymptomatic or have minimal symptoms and the bleeding
must be controlled. This control may be achieved by washing
the area with sterile saline and drying it with either paper points
or cotton pellets, by using cotton pellets soaked with hydrogen
peroxide or 5.25% sodium hypochlorite, or, if necessary, by
using a hemostatic agent such as Hemodent15 (Premier Dental
Products, Norristown, Pa.). If bleeding fails to stop after two or
three attempts, then endodontic therapy should be considered.15,22 Several studies23-28 have indicated that the size of the
perforation is less important than obtaining hemostasis.
Following hemostasis, a disinfectant (e.g., Cavity Cleanser,
Bisco Dental Products, Itasco, Ill., or Consepsis, Ultradent
Products Inc., South Jordan, Utah) should be placed on the
cavity floor.29 The area is then air dried, and calcium hydroxide
in a formula such as Dycal (Dentsply Canada Ltd., Woodbridge, Ont.), Life (Kerr Manufacturing, Orange, Calif.) or
Ultradent Calcium Hydroxide (Ultradent Products Inc., South
Jordan, Utah) is placed directly in contact with pulp tissue. This
step is very important, for the better the contact of the calcium
hydroxide dressing with the pulpal wound, the better the healing.15,30 The calcium hydroxide should then be covered with a
resin-modified glass ionomer extended onto dentin.31 Subsequently, a permanent restoration can be placed, with a dentin
bonding system used to seal the margins of the restoration. An
alternative is to place a zinc oxideeugenol (IRM, L.D. Caulk,
Dentsply Ltd., Woodbridge, Ont.) restoration over the calcium
hydroxide cap.32,33 Zinc oxideeugenol provides an excellent
seal and, with its anti-microbial properties, makes for a very
good temporary restoration. After three months, assuming pulp
Journal of the Canadian Dental Association

The opponents of calcium hydroxide claim that it does not

exclusively stimulate sclerotic dentin formation, dentinogenesis, reparative dentin formation or dentin bridge formation.34
They also claim that it may dissolve after one year, that acids
will degrade the interface during etching, and that calcium
hydroxide does not adhere to dentin and will not adhere to
bonding resin composite systems. One study36 found that calcium hydroxide bases under resin composite restorations
tended to pull away from the cavity surface during resin polymerization, leaving a gap between the calcium hydroxide and
dentin. Cox and others37 found a high rate of multiple tunnel
defects (89%) in dentin bridges under calcium hydroxide. This
high rate of defects, they suggest, places the long-term therapeutic effect of calcium hydroxide in serious doubt. They also
suggest that calcium hydroxide disintegrates and is lost over a
period of time.
It has been suggested that a very small exposure, and certainly
a near exposure, cannot be treated with calcium hydroxide, as it
is essential that the calcium hydroxide dressing make contact
with living pulp tissue.15 In addition, Pashley38 states that there
may be little difference between a vital pulp cap and a situation
where the remaining dentin thickness is less than 1 mm. He
attributes this similarity to the high permeability of the dentin
near the pulp. In a recent study,39 opponents of the total etch
technique found a 40% loss of pulp vitality over a period of 75
days with three bonding systems on exposed primate pulps. Of
the remaining surviving pulps, only 53% even attempted bridge
formation. Proponents of this technique point out that
germ-free studies40,41 have shown that pulp heals rapidly even
when bonding agents are placed directly on pulpal tissue.
June 1999, Vol. 65, No. 6

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Stockton

The healing of pulp exposures may depend on the capacity

of the capping material33 to prevent bacterial microleakage.
Pashley42 states that to minimize the pulpal response, restorative materials must seal the cavity margins, prevent microleakage and block bacterial substrates from penetrating through
dentinal tubules to the pulp. However, if microleakage around
various restorations could be measured in vivo, it is likely that
all would exhibit some degree of leakage.38 If these teeth remain
asymptomatic, it is probably because the rate at which exogenous materials permeate across dentin to the pulp is balanced
with the rate of removal of these materials by pulpal circulation, thus ensuring pulpal vitality.40 Therefore, it is desirable to
maximize the barrier effect of dentin to provide the best pulpal
protection.38 Each situation must be assessed to determine
which method is most likely to achieve a maximal barrier effect.
A dentists inability to perform proper pulp cap procedures
can lead to microbial contamination, leftover dentinal debris
in the wound and a lack of a dentin seal. Poor operator performance, therefore, rather than the inadequacies of the
medicament, may be the cause of pulp-cap failure.15 In the
case of recurrent pulpitis, therefore, one must distinquish
between pulp-cap failure and failure of the restoration subsequently placed over the pulp-capping agent.43

CONCLUSION
Mechanical exposures are more likely than carious exposures
to be successfully capped. If the operator properly selects the
case, obtains hemostasis, disinfects the exposure and the cavity
preparation, and adequately seals the exposure and the cavity
preparation, success can be obtained with either the calcium
hydroxide technique or the total etch technique. Although
both techniques can achieve successful vital pulp caps, the calcium hydroxide technique has demonstrated its success over a
longer period of time. Which technique offers the better prognosis awaits the results of many more long-term studies.
For unknown reasons, the pulp-capping agent used, and
not the procedure itself, has been the subject of controversy
among researchers. a
Dr. Stockton is an assistant professor in the department of restorative
dentistry in the faculty of dentistry, University of Manitoba.
Reprint requests to: Dr. Lawrence W. Stockton, Department of
Restorative Dentistry, Faculty of Dentistry, University of Manitoba,
D227-780 Bannatyne Ave., Winnipeg, MB R3E 0W2
The author has no declared financial interest in any company manufacturing the types of products mentioned in this article.

4. Rivera E, Yamauchi G, Chandler G et al. Dentin collagen cross-links

of root-filled and normal teeth. J Endod 1990; 16:190.
5. Sedgley CM, Messer HH. Are endodontically treated teeth more brittle? J Endod 1992; 18:332-5.
6. Lowenstein NR, Rathkamp R. A study on the pressoreceptive sensibility of the tooth. J Dent Res 1955; 34:287-94.
7. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal
coverage: a study of endodontically treated teeth. J Prosthet Dent 1984;
51:780-4.
8. Lewis R, Smith BGN. A clinical survey of failed post retained crowns.
Br Dent J 1988; 165:95-7.
9. Torbjorner A, Karlsson S, Odman PA. Survival rate and failure characteristics for two post designs. J Prosthet Dent 1995;73:439-44.
10. Stanley HR, Pereira JC, Spiegel EH, Broom C, Schultz M. The detection and prevalence of reactive and physiologic sclerotic dentin, reparative
dentin and dead tracts beneath various types of dental lesions according
to tooth surface and age. J Oral Pathol 1983; 12:257-89.
11. Stanley HR, Broom CA, Spiegel EH, Schultz MS. Detecting dentinal sclerosis in decalcified sections with the Pollak trichrome connective
tissue stain. J Oral Pathol 1980; 9:359-71.
12. Abdel Wahab MHA, Kennedy JG. Accuracy of localization of pulpal
pain on cold stimulation. J Dent Res 1985; 64:1155-8.
13. Testori T, Badino M, Castagnola M. Vertical root fractures in
endodontically treated teeth: a clincial survey of 36 cases. J Endod 1993;
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14. Hatzikyriakos AH, Reisis GI, Tsingos N. A 3-year postoperative clinical evaluation of posts and cores beneath existing crowns. J Prosthet Dent
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pulp. Oper Dent 1992; Suppl. 5:165-76.
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Vital Pulp Capping: A Worthwhile Procedure

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C D A R E
C E N T R E

S O U R C E

For more information on vital pulp capping, contact the

CDA Resource Centre at 1-800-267-6354, ext. 2223,
or at [email protected].

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