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Pulp capping
Pulp capping
Pulp capping
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Sedative material placed over exposed or nearly exposed pulp 1) crown 2) root 3) restoration 4) pulp cap 5) pulp chamber
Pulpal dentin junction. 1) outside tooth/enamel 2) dentin tubule 3) dentin 4) odontoblastic process 5) predentin 6) odontoblast 7) capillaries 8) fibroblasts 9) nerve 10) artery/vein 11) cell-rich zone 12) cell-poor zone 13) pulp chamber

Pulp capping is a technique used in dental restorations to protect the dental pulp, after it has been exposed, or nearly exposed during a cavity preparation, from a traumatic injury, or by a deep cavity that reaches the center of the tooth, causing the pulp to die.[1] Exposure of the pulp causes pulpitis (an inflammation which can become irreversible, leading to pain and pulp necrosis, and necessitating either root canal treatment or extraction).[1] The ultimate goal of pulp capping or stepwise caries removal is to protect a healthy (or reversibly inflammed) dental pulp, and avoid the need for root canal therapy.

When dental caries is removed from a tooth, all or most of the infected and softened enamel and dentin are removed. This can lead to the pulp of the tooth either being exposed or nearly exposed.[1] To prevent the pulp from deteriorating when a dental restoration gets near the pulp, the dentist will place a small amount of a sedative dressing, such as calcium hydroxide or mineral trioxide aggregate (MTA). These materials protect the pulp from noxious agents (heat, cold, bacteria) and stimulate the cell-rich zone of the pulp to lay down a bridge of reparative dentin. Dentin formation usually starts within 30 days of the pulp capping (there can be a delay in onset of dentin formation if the odontoblasts of the pulp are injured during cavity removal) and is largely completed by 130 days.[2]: 491–494 

As of 2021, recent improvements in dressing materials have significantly increased the success rates of pulp capping teeth with cavities.[3]

Two different types of pulp cap are distinguished. In direct pulp capping, the protective dressing is placed directly over an exposed pulp; and in indirect pulp capping, a thin layer of softened dentin, that if removed would expose the pulp, is left in place and the protective dressing is placed on top.[4] A direct pulp cap is a one-stage procedure, whereas a stepwise caries removal is a two-stage procedure over about six months.

Direct

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Success rates (% of teeth not needing more treatment) for the capping of pulp exposed by cavities, as of 2021[3]
Protective material 6 months 1 year 2-3 years 4-5 years
Mineral trioxide aggregate 91% 86% 84% 81%
Biodentine 91% 86% 86% [no data]
Calcium hydroxide 74% 65% 59% 56%

This technique is used when a pulpal exposure or near-exposure occurs, either due to caries extending to the pulp chamber, or accidentally, during caries removal. It is only feasible if the exposure is made through uninfected dentin, and any pulpitis is reversible (that is, there is no recent history of spontaneous pain, indicating irreversible pulpitis) and a bacteria-tight seal can be applied.[4][needs update]

Once the exposure is made, the tooth is isolated from saliva to prevent contamination by use of a dental dam, if it was not already in place. The tooth is then washed and dried, and the protective material placed, followed finally by a dental restoration which gives a bacteria-tight seal to prevent infection.[4]

Since pulp capping is not always successful in maintaining the vitality of the pulp, the dentist will usually keep the status of the tooth under review for about a year after the procedure.[4] Success rates (the chance that the tooth will be preserved) have risen with newer protective materials.[3]

Indications for direct pulp capping

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Indications for direct pulp capping include:[5]

  • Immature/mature permanent teeth with simple restoration needs
  • Recent trauma less than 24 hours (less according to tichy[clarification needed]) exposure of pulp / mechanical trauma exposure (during restorative procedure)
  • Minimal or no bleeding at exposure site
  • Normal sensibility test
  • Not tender to percussion
  • No periradicular pathology
  • Young patient

Contraindications for direct pulp capping

[edit]

Contraindications for direct pulp capping include:[5]

Indirect

[edit]

In 1938, Bodecker introduced the stepwise caries excavation (SWE) technique for treatment of teeth with deep caries for preservation of pulp vitality.[6] This technique is used when most of the decay has been removed from a deep cavity, but some softened dentin and decay remains over the pulp chamber that if removed would expose the pulp and trigger irreversible pulpitis. Instead, the dentist intentionally leaves the softened dentin or decay in place, and uses a layer of protective temporary material which promotes remineralization of the softened dentin over the pulp and the laying down of new layers of tertiary dentin in the pulp chamber. The color of the carious lesion changes from light brown to dark brown, the consistency goes from soft and wet to hard and dry so that Streptococcus mutans and Lactobacilli have been significantly reduced to a limited number or even zero viable organisms and the radiographs show no change or even a decrease in the radiolucent zone.[7] A temporary filling is used to keep the material in place, and about six months later, the cavity is re-opened and hopefully there is now enough sound dentin over the pulp (a "dentin bridge") that any residual softened dentin can be removed and a permanent filling can be placed. This method is also called "stepwise caries removal."[4][8] The difficulty with this technique is estimating how rapid the carious process has been, how much tertiary dentin has been formed and knowing exactly when to stop excavating to avoid pulp exposure.[9]

Materials

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The following materials have been studied as potential materials for direct pulp capping. However, calcium hydroxide and mineral trioxide aggregate (MTA) are the preferred material of choice in clinical practice due to their favourable outcome.

Zinc oxide eugenol

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Zinc oxide eugenol (ZOE) is a commonly used material in dentistry. The use of ZOE as a pulp capping material remains controversial. This is due to eugenol, being cytotoxic to the pulp, being present in large quantities in this formulation. Also due to its nature of non-adhesive, it leads to poor coronal seal hence increasing micro-leakage. Studies have demonstrated unfavourable results for ZOE when compared to calcium hydroxide as a direct pulp-capping material as it causes pulpal necrosis.[10]

Glass and resin-modified glass ionomer

[edit]

Both glass ionomer (GI) and resin-modified glass ionomer (RMGIC) have been widely used as a lining or base material for deep cavities where pulp is in close proximity. This is due to their superior properties of good biocompatibility and adhesive nature, providing coronal seal to prevent bacteria infiltration. However, they are not a material of choice for direct pulp capping. When the use of RMGIC and calcium hydroxide has been studied as direct pulp-capping agents, RMGIC has demonstrated increase in chronic inflammation in pulpal tissues and lack of reparative dentin bridge formation.[10]

Adhesive system

[edit]

Materials that fall under this category include 4-META-MMA-TBB adhesives and hybridizing dentin bonding agents. The idea of using adhesive materials for direct pulp capping has been explored two decades ago.[as of?] Studies have demonstrated that it encourages bleeding due to its vasodilating properties hence impairing polymerisation of the material, affecting its ability to provide a coronal seal when used as a pulp capping agent. In addition, the material triggers chronic inflammation even without the presence of bacteria, making it an unfavourable condition for pulp healing to take place. Most importantly, its toxicity to human pulp cells once again makes it an unacceptable material of choice.[10]

Calcium hydroxide cement

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Calcium hydroxide (Ca(OH)2) is an organo-metallic cement that was introduced into dentistry in the early twentieth century[11] and there have since been many advantages to this material described in much of the available literature. Ca(OH)2 has a high antimicrobial activity which has been shown to be outstanding.[12][13] In one experiment conducted by Stuart et al. (1991), bacteria-inoculated root canals of extracted human teeth were treated with Ca(OH)2 for one hour against a control group with no treatment and the results yielded 64–100% reductions in all viable bacteria.[12] Ca(OH)2 also has a high pH and high solubility; thus, it readily leaches into the surrounding tissues.[14] This alkaline environment created around the cement has been suggested to give beneficial irritancy to pulpal tissues and stimulates dentin regeneration. One study further demonstrated that Ca(OH)2 causes release of growth factors TGF-B1 and bioactive molecules from the dentin matrix which induces the formation of dentin bridges.[15]

Ca(OH)2 does, however, have significant disadvantages. The set cement has low compressive strength and cannot withstand or support condensation of a restoration.[14][16] It is thus good practice to place a stronger separate lining material (e.g. glass ionomer or resin-modified glass ionomer) over Ca(OH)2 before packing the final restorative material.[10] Ca(OH)2 cement is not adhesive to tooth tissues and thus does not provide a coronal seal.[10] In pulp perfusion studies, Ca(OH)2 has shown to insufficiently seal all dentinal tubules, and presence of tunnel defects (patent communications within reparative dentin connecting pulp and exposure sites) indicate a potential for microleakage when Ca(OH)2 is used.[14][17] It is suggested that an adhesive coronal restoration be used above the Ca(OH)2 lining to provide adequate coronal seal. Because of its many advantageous properties and long-standing success in clinical use, it has been used as a control material in multiple experiments with pulp capping agents over the years[18][19] and is considered the gold standard dental material for direct pulp capping to date.[20]

Mineral trioxide aggregate

[edit]

Mineral trioxide aggregate (MTA) is a recent development of the 1990s[21] initially as a root canal sealer but has seen increased interest in its use as a direct pulp-capping material.[10] The material comprises a blend of tricalcium silicate, dicalcium silicate and tricalcium aluminate; bismuth oxide is added to give the cement radiopaque properties to aid radiological investigation.[21] MTA has been shown to produce Ca(OH)2 as a hydration product[22] and maintains an extended duration of high pH in lab conditions.[23] Similar to Ca(OH)2, this alkalinity potentially provides beneficial irritancy and stimulates dentin repair and regeneration.[24] MTA has also demonstrated reliable and favourable healing outcomes on human teeth when used as a pulp cap on teeth diagnosed as nothing more severe than reversible pulpitis.[25] There is also less coronal microleakage of MTA in one experiment comparing it to amalgam[26] thus suggesting some tooth adhesion properties. MTA also comes in white and grey preparations[27] which may aid visual identification clinically. Disadvantages have also been described for MTA. Grey MTA preparations can potentially cause tooth discolouration.[10] MTA also takes a long time (up to 2 hours 45 minutes) to set completely,[28] thus preventing immediate restoration placement without mechanical disruption of the underlying MTA. It has been suggested that a pulp capped with MTA should be temporised to allow for the complete setting of MTA,[10] and the patient to present at a second visit for placement of the permanent restoration.[25] MTA also has for difficult handling properties and is a very expensive material, thus is less cost effective as compared to Ca(OH)2.[10]

Although MTA shows great promise, which is possibly attributed to its adhesive properties and ability to act as a source of Ca(OH)2 release,[10] the available literature and experimental studies of MTA are limited due to its recency. Studies that compare pulp capping abilities of MTA to Ca(OH)2 in human teeth yielded generally equal and similarly successful healing outcomes at a histological level from both materials.[29][30]

Success rates

[edit]

There have been several studies conducted on the success rates of direct and indirect pulp capping using a range of different materials. One study of indirect pulp capping recorded success rates of 98.3% and 95% using bioactive tricalcium silicate [Ca3SiO5]-based dentin substitute and light-activated calcium hydroxide [Ca(OH)2]-based liner respectively.[31] These results show no significant difference, nor do the results from an indirect pulp capping experiment comparing calcium silicate cement (Biodentine) and glass ionomer cement, which had clinical success rates of 83.3%.[32] A further study testing medical Portland cement, mineral trioxide aggregate (MTA) and calcium hydroxide in indirect pulp treatment found varying success rates of 73–93%. This study concluded that indirect pulp capping had a success rate of 90.3% regardless of which material was used but stated that it is preferable to use non-resorbing materials where possible.[33]

Similar studies have been conducted of direct pulp capping, with one study comparing ProRoot mineral trioxide aggregate (MTA) and Biodentine which found success rates of 92.6% and 96.4% respectively.[34] This study was conducted on 6–18 year-old patients, while a comparable study conducted on mature permanent teeth found success rates of 84.6% using MTA and 92.3% using Biodentine.[35] Calcium hydroxide has also been tested on its use in indirect pulp capping and was found to have a success rate of 77.6%, compared to a success rate of 85.9% for MTA in another study.[36]

A systematic review attempted to compare success rates of direct pulp capping and indirect pulp capping and found that indirect pulp capping had a higher level of success but found a low quality of evidence in studies on direct pulp capping.[37] More research will be needed to provide a comprehensive answer.

See also

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References

[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Pulp capping

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from Grokipedia
Pulp capping is a vital pulp technique in designed to protect and promote the healing of the dental pulp when it is exposed or nearly exposed due to caries, trauma, or restorative procedures, with the goal of preserving tooth vitality and avoiding more invasive treatments such as . This procedure involves the application of biocompatible materials to stimulate reparative formation and seal the pulp from bacterial invasion. There are two primary types of pulp capping: direct pulp capping, which places a directly over an exposed coronal pulp after caries excavation to induce healing and mineralized tissue barrier formation, and indirect pulp capping, which is used when the pulp is not yet exposed but is threatened by deep carious lesions, involving partial caries removal and placement of a protective layer over the thin remaining to allow natural repair. Direct pulp capping is indicated for small, clean exposures in pulps diagnosed with reversible or potentially irreversible , while indirect pulp capping is preferred for deep cavities to minimize risk of exposure during treatment. The procedure for pulp capping requires meticulous steps, including complete caries removal, assessment of pulp health using diagnostic tests like cold stimulation or percussion, achieving hemostasis within 5 minutes often using irrigation, application of the capping , and immediate restoration with a well-sealed coronal to prevent microleakage and reinfection. Common materials include , which has a high pH to stimulate fibroblasts but variable long-term success rates of 37-81.8% over 10 years; (MTA), a offering superior sealing and success rates up to 97.96% over 9 years; and Biodentine, which sets faster with success rates around 96% over 3 years. Success of pulp capping depends on factors such as the absence of irreversible pulpitis or , effective bleeding control within 5 minutes, use of for precise , and prompt restoration, with overall outcomes improved in teeth and when calcium silicate-based materials are employed. Guidelines from the American Association of Endodontists emphasize accurate , complete , and biocompatible materials to achieve high success rates, positioning pulp capping as a conservative alternative that maintains natural tooth structure and function.

Background and Principles

Definition and Purpose

Pulp capping is a dental technique designed to protect the vital dental pulp from bacterial invasion when it has been exposed or nearly exposed during restorative procedures, such as caries excavation or trauma, by applying a biocompatible material to seal the site and facilitate healing. This approach promotes the formation of a mineralized tissue barrier, often referred to as reparative or a dentin bridge, which isolates the pulp and supports its recovery. As a subset of vital pulp therapy, pulp capping specifically targets the preservation of pulp function in teeth with minimal injury, distinguishing it from more extensive interventions like pulpotomy. The primary purpose of pulp capping is to maintain the vitality of the dental pulp, thereby avoiding the need for more invasive treatments such as therapy, and to preserve the overall structural integrity of the tooth. By stimulating reparative dentinogenesis, it enables the pulp to respond to injury through natural healing processes, particularly in cases of reversible where is mild and reversible. This technique is especially valuable in young or those with immature apices, where preserving pulp vitality supports continued root development. Successful pulp capping relies on key prerequisites, including a healthy pulp that exhibits a favorable response to injury, characterized by and absence of irreversible , as confirmed through clinical assessment. Equally critical is the adherence to strict aseptic techniques to minimize , such as using rubber dam isolation and sterile irrigants, ensuring an environment conducive to pulp repair. Pulp capping encompasses direct and indirect variants, with direct applied to exposed pulp and indirect to nearly exposed sites; further details on these are addressed in subsequent sections.

Biological Mechanisms

When the dental pulp is exposed to , such as through caries or trauma, it initiates a complex response aimed at defense and repair. The initial phase involves acute , characterized by the influx of polymorphonuclear leukocytes, , and the formation of a blood clot at the exposure site, triggered by release and innate immune activation via toll-like receptors (TLRs) on odontoblasts. If the is mild and are controlled, this progresses to reversible , where resolves without progressing to irreversible damage or , allowing the pulp to maintain . In contrast, severe or persistent stimuli lead to chronic dominated by lymphocytes and macrophages, which can impair . Central to pulp repair is the recruitment and differentiation of odontoblasts and stem cells to form reparative , a mineralized barrier that seals the injury. Dental pulp stem/progenitor cells (DPSCs), primarily located in perivascular niches, migrate to the site of damage within hours to days, guided by such as CXCL8 and produced by surviving odontoblasts. These DPSCs differentiate into odontoblast-like cells in the initial phase post-injury, initiating reactionary or reparative dentinogenesis at a rate of about 4 μm per day, similar to primary dentin formation. This process is modulated by growth factors, notably transforming growth factor-beta (TGF-β), released from the demineralized dentin matrix during injury; TGF-β enhances odontoblastic differentiation, production, and while promoting an anti-inflammatory environment through cytokines like IL-10. Mineralization of the reparative dentin bridge occurs through the deposition of hydroxyapatite crystals, facilitated by matrix vesicles secreted by the new odontoblast-like cells and influenced by local calcium ion availability. Bacterial exclusion is achieved via multiple mechanisms, including the production of (e.g., beta-defensins) and by odontoblasts, recruitment of immune cells to phagocytose invaders, and the physical sealing provided by the dentin bridge, which prevents further microbial ingress and subsequent . The pulp's regenerative capacity varies by type and age; primary teeth exhibit a faster inflammatory response and higher density of immunocompetent cells, while in younger patients demonstrate superior outcomes—higher success rates often exceeding 90%—due to greater vascularity, active proliferation, and reduced compared to older individuals. Recent research as of 2025 has advanced understanding of these mechanisms, highlighting the role of DPSCs-derived extracellular vesicles in to promote repair and , as well as epigenetic factors such as , modifications, and non-coding RNAs (e.g., miRNAs) in regulating odontoblastic differentiation and inflammation resolution.

Direct Pulp Capping

Indications

Direct pulp capping is indicated for small mechanical, traumatic, or carious exposures (typically less than 1 mm) of a vital pulp in teeth diagnosed with , where the pulp appears healthy upon direct visualization, showing minimal inflammation and no signs of . This procedure is particularly suitable for immature to promote continued root development (apexogenesis) and in primary teeth where preserving vitality avoids harm to the succedaneous tooth. It is applicable when pulp exposure occurs during caries excavation or restorative procedures, provided there is no radiographic evidence of periapical pathology, internal/external resorption, or prior irreversible damage. The approach aims to stimulate reparative bridge formation and maintain vitality as a conservative alternative to pulpectomy.

Contraindications

Direct pulp capping is contraindicated in cases of , characterized by spontaneous or prolonged pain, significant , or pulp , as these conditions reduce the likelihood of healing. Uncontrolled hemorrhage after exposure, indicating potential or severe trauma, also precludes the procedure, necessitating or therapy instead. Radiographic signs of periapical radiolucency, root resorption, or formation signal advanced incompatible with vital pulp preservation. In primary teeth, it is not recommended for carious exposures larger than 1 mm or in non-vital pulps, due to risks of internal resorption or interference with exfoliation. Teeth with poor restorability or extensive structural damage are unsuitable, as adequate sealing cannot be ensured.

Clinical Procedure

The direct pulp capping procedure begins with proper isolation using a rubber dam to prevent contamination, followed by complete removal of caries using magnification (e.g., loupes or microscope) to assess the exposure site and pulp health. Hemostasis is achieved by irrigating the exposure with 5.25% sodium hypochlorite for 5-10 minutes, often using a soaked cotton pellet, ensuring bleeding stops within 5 minutes to confirm pulp vitality. A biocompatible material, such as mineral trioxide aggregate (MTA) or calcium hydroxide, is then applied directly over the exposure to promote healing and dentin bridge formation. The is immediately restored with a well-sealed permanent coronal material (e.g., composite) to prevent microleakage and bacterial ingress. Pre- and post-operative radiographs evaluate pulp proximity, exposure, and any , with follow-up assessments at 6-12 months to monitor , symptoms, and bridge formation.

Indirect Pulp Capping

Indications

Indirect pulp capping is indicated for vital, asymptomatic teeth with deep carious lesions approaching the pulp on radiographs, such as those within approximately 1 mm of the pulp chamber, where the diagnosis is reversible and complete caries removal would risk exposure. This conservative approach preserves pulp vitality by leaving the deepest layer of carious undisturbed, allowing for potential healing and avoiding more invasive treatments. The procedure is suitable for both primary and permanent teeth, particularly in cases involving multi-surface caries where stepwise or partial excavation minimizes the chance of exposure while enabling definitive restoration. It is especially beneficial in young patients with immature , as their pulps exhibit enhanced healing capacity due to increased vascularity and . In individuals at high risk for caries, indirect pulp capping supports remineralization of the affected layer, transforming it into harder, more resistant tissue over time and reducing the need for pulpectomy. This is feasible when the pulp remains responsive and the carious process has not progressed to irreversible . Prior to treatment, pulp vitality must be confirmed through clinical tests such as or electric pulp testing, alongside radiographic showing no periapical . Additionally, the absence of clinical signs like swelling, , spontaneous pain, or abnormal mobility is required to ensure the pulp's reversible status and the procedure's success.

Contraindications

Indirect pulp capping is contraindicated in cases of symptomatic , characterized by spontaneous or prolonged , as this indicates advanced pulpal unlikely to resolve without more invasive intervention. Pulp exposure during caries excavation also precludes indirect capping, necessitating a shift to direct pulp capping or pulpectomy to address the exposed vital tissue directly. Additionally, radiographic of pulp involvement, such as periapical radiolucency or internal/external root resorption, signals potential or irreversible damage, rendering the procedure unsuitable. Teeth with poor , including non-restorable structures requiring extensive reconstruction beyond a simple or exhibiting excessive mobility, are not candidates for indirect pulp capping, as adequate sealing and long-term pulp protection cannot be achieved. Patient non-compliance with necessary follow-up evaluations further contraindicates the approach, particularly the two-step variant, due to the risk of undetected pulpal complications without monitoring. Active signs of , such as soft tissue swelling or the presence of a sinus tract (), indicate periapical or formation, requiring endodontic treatment rather than conservative pulp protection. In immature where is indicated—typically due to non-vital pulp and open apices—indirect pulp capping is inappropriate, as it presupposes pulpal essential for continued root development. The two-step indirect pulp capping process may not be suitable when single-visit completion is preferred, such as in cases of logistical constraints or uncooperative patients unable to return for re-evaluation.

Clinical Procedure

The indirect pulp capping procedure involves conservative caries removal to avoid pulp exposure while promoting remineralization of the remaining affected and formation of reparative dentin. This approach is particularly indicated for deep carious lesions in vital teeth where complete excavation risks irreversible . Proper isolation is essential to minimize bacterial during the procedure; the rubber is the gold standard for achieving this. Caries excavation begins with the removal of peripheral infected using low-speed burs or hand excavators, leaving the soft central affected undisturbed to prevent pulp exposure. Caries detector dyes may be employed as adjuncts to identify and ensure selective removal of infected tissue down to firm . Two primary techniques are used: stepwise excavation and single-visit selective removal. In stepwise excavation, after partial caries removal, a biocompatible liner is placed over the remaining to seal it, followed by a temporary restoration; the is then re-evaluated after 6 to 12 months, at which point any residual soft is removed and a permanent restoration is placed. The single-visit option involves selective caries removal to hard surrounding in one appointment, application of a thin liner for sealing and protection, and immediate placement of a permanent restoration, provided no pulp exposure occurs. Throughout the procedure, radiographic assessment is performed pre- and post-operatively to evaluate caries depth, pulp proximity, and any periapical changes. Postoperatively, patients are advised to use supplements or applications at intervals based on caries to support remineralization, with scheduled recalls every 6 months to monitor pulp vitality, dentin bridge formation via radiographs, and absence of symptoms such as pain or swelling.

Materials

Calcium Hydroxide

Calcium hydroxide, chemically known as Ca(OH)₂, is a traditional pulp capping material typically prepared as a paste that exhibits strong antimicrobial properties due to its high pH of approximately 12.5, which facilitates the dissolution of bacterial cell walls and promotes the initial formation of a dentin bridge. The material's alkaline nature arises from the release of hydroxyl ions, creating an environment hostile to microbial growth while stimulating reparative dentinogenesis, though it also induces a superficial zone of coagulation necrosis beneath the forming bridge to protect underlying pulp tissue. Historically, has been employed in pulp capping since the 1930s, when it was introduced by Hermann as a remineralizing agent capable of supporting pulp healing in both direct and indirect applications. Over the decades, it became a cornerstone of vital pulp therapy due to its and ability to neutralize acidic byproducts from carious lesions, marking it as one of the earliest materials validated for preserving pulp vitality. Among its advantages, is highly bactericidal, effectively eliminating residual bacteria in the pulp exposure site, and remains inexpensive and readily available in various formulations, making it accessible for widespread clinical use. However, its limitations include high solubility in oral fluids, which can lead to material dissolution over time, poor long-term sealing against microleakage, and reduced mechanical strength, often necessitating an overlay with resin-modified for adequate protection. In preparation, calcium hydroxide is commonly mixed as a powder-liquid system, where the powder—often containing calcium oxide or zinc oxide—is combined with aqueous vehicles such as saline or water to form a workable paste with a setting time typically ranging from 10 to 30 minutes, depending on the formulation and environmental humidity. Paste-paste systems, involving a base and catalyst, offer improved handling properties through acid-base reactions that enhance initial stability, though the material's low elastic modulus and compressive strength limit its standalone durability. While remains a foundational agent, modern alternatives like provide superior sealing and biocompatibility, addressing some of its inherent solubility issues.

Mineral Trioxide Aggregate

(MTA) is a bioactive endodontic cement introduced in the 1990s by Mahmoud Torabinejad as an advancement over traditional materials like for vital pulp therapies, including pulp capping. It serves as a gold-standard capping agent due to its ability to induce reparative formation while maintaining pulp vitality. The composition of MTA is Portland cement-based, primarily consisting of tricalcium silicate, dicalcium silicate, , and oxide as a radiopacifier, with minor components like for setting control. Upon mixing with at a powder-to-liquid of 3:1 to 4:1, MTA achieves a putty-like consistency suitable for placement. In a moist environment, such as that of exposed pulp, it hydrates to form calcium silicate hydrate gel and ; the latter reacts with ions in tissue fluids to precipitate , contributing to its bioactivity and integration with . MTA demonstrates high , forming a that prevents microbial leakage and promotes thick, continuous bridges without adjacent pulp . Its elevated during initial setting (around 12.5) provides antibacterial effects by inhibiting bacterial growth, while the oxide ensures radiopacity for clear postoperative assessment. These properties support its application in both and indirect pulp capping procedures, where it encourages odontoblastic differentiation and mineralized tissue deposition. Key advantages of MTA include its bioinductive nature, which fosters pulp repair, and versatility across endodontic applications beyond capping. However, disadvantages encompass its relatively high cost compared to other cements, prolonged setting time of 2-4 hours that may necessitate interim moisture retention with a damp cotton pellet, and potential for coronal tooth discoloration over time due to bismuth oxide oxidation. Handling can be challenging owing to the granular powder, though resin-modified, light-curable variants have been developed to shorten setting and improve adaptability in clinical settings.

Biodentine and Bioceramics

Biodentine is a tricalcium silicate-based bioactive primarily composed of tricalcium silicate in its powder form, combined with a liquid containing and hydrosoluble for setting. Introduced in 2010 by Septodont, it serves as a dentin substitute in vital pulp therapy, offering a fast setting time of approximately 12 minutes, which allows for immediate restoration and reduces the risk of contamination during procedures. Its bioactivity promotes the formation of mineralized tissue tags that integrate with the underlying , mimicking natural mineralized structures and supporting pulp-dentin complex repair. Bioceramics, such as EndoSequence BC Root Repair Material (RRM), represent a class of bioactive calcium silicate-based materials designed for endodontic applications including pulp capping. These materials exhibit bioactivity by releasing calcium ions that facilitate remineralization of surrounding tissues through the formation of hydroxyapatite-like deposits. EndoSequence, in particular, demonstrates high , enhancing its durability in load-bearing areas while maintaining with pulp tissues. As advancements over (MTA), Biodentine and similar bioceramics provide faster setting times—typically under 15 minutes compared to MTA's hours—reducing chair time and improving clinical efficiency in both and indirect pulp capping procedures. They also exhibit less discoloration due to their composition lacking heavy metal oxides present in traditional MTA formulations, making them preferable for anterior restorations in vital pulp therapy. These properties position bioceramics as versatile options for preserving pulp vitality by promoting sealing, antibacterial effects, and tissue regeneration without necessitating immediate full coverage. Despite these benefits, limitations include a higher compared to conventional materials, potentially impacting in routine practice, and a technique-sensitive mixing process that requires precise proportions to achieve optimal consistency and avoid setting failures. Recent studies from 2023 and 2024 have demonstrated enhanced pulp healing with Biodentine, showing superior bridge formation and reduced in direct capping scenarios compared to older alternatives, with histological evidence of thick, continuous bridges in trials.

Other Materials

Zinc oxide eugenol (ZOE) serves as a agent primarily in indirect pulp capping procedures, where it provides temporary relief and seals against bacterial ingress, but its to vital pulp tissue renders it unsuitable for direct application. Studies indicate that ZOE induces inflammatory responses and fails to promote bridge formation when placed directly on exposed pulp, leading to recommendations against its use in such scenarios. Glass cements and resin-modified variants offer properties and sustained release, making them viable for indirect pulp capping to remineralize and inhibit caries progression near the pulp. However, their initial acidity can cause pulpal irritation, limiting their efficacy and for direct pulp capping compared to less acidic alternatives. Emerging materials include (PRF), which 2023 studies demonstrate as a biocompatible scaffold for direct pulp capping by releasing growth factors that support dentin bridge formation and pulp vitality preservation. , a kinase-3 (GSK-3) inhibitor explored in 2024 research, aims to enhance regenerative processes in pulp capping by stimulating odontoblastic differentiation, though animal models reveal potential for increased inflammation and disorganization. Similarly, nano-apatite combined with , investigated in 2025 studies, targets effects to reduce while promoting healing, positioning it as a novel strategy for capping inflamed exposures. Dentin bonding agents facilitate between restorative materials and but are not primary pulp cappers due to their and inability to induce reparative dentinogenesis. Bioceramics are generally preferred over these adjunct materials for their superior bioactivity and sealing in pulp capping applications.

Clinical Outcomes

Success Rates for Direct Pulp Capping

Success in direct pulp capping is typically defined as the absence of clinical symptoms such as pain or swelling, maintenance of pulp vitality assessed through thermal and electric tests, and radiographic evidence of , including bridge formation without periapical pathology. These criteria are evaluated at follow-up intervals ranging from 6 months to several years, with success rates varying based on materials used and patient factors. Overall success rates for direct pulp capping range from 80% to 97% at 1 year post-treatment, declining to 70% to 90% at 5 years due to progressive factors like bacterial ingress. A 2024 and reported a weighted pooled success rate of 83% (95% CI: 79-87%) across studies on . For (MTA), success rates are higher, reaching 91% at 6 months and 84% at 2–3 years in a 2020 review of clinical outcomes, attributed to its superior sealing and . Biodentine demonstrates a 99% success rate at 6 months in young as of 2025, with rates of 94% at 12 months and 87% at 18 months; long-term data beyond 18 months remain limited. Success rates are notably higher for mechanical pulp exposures (92%) compared to carious exposures (33%), as mechanical exposures involve less and bacterial . In young patients with immature apices, rates exceed 90%, often reaching 95% at 1 year, due to enhanced reparative capacity of the pulp-dentin complex. Failures are primarily linked to microleakage at the restoration interface. Indirect pulp capping generally exhibits higher baseline success rates than direct procedures involving exposed pulp.
Material/FactorSuccess RateFollow-up PeriodSource
Overall (pooled)83%Variable (meta-analysis)PubMed 2024
MTA91% at 6 months; 84% at 2-3 years6 months to 3 yearsWiley 2020
Biodentine99%6 monthsJOCPD 2025
Mechanical exposure92%VariablePubMed 2000
Carious exposure33%VariablePubMed 2000
Young patients>90%1 yearJ Endod 2025

Success Rates for Indirect Pulp Capping

Indirect pulp capping demonstrates high success rates, typically ranging from 90% to 98% over 1 to 5 years of follow-up, reflecting its conservative approach to preserving vital pulp tissue without exposure. This procedure promotes dentin bridge formation and caries arrest, with clinical and radiographic evaluations confirming pulp vitality maintenance in the majority of cases. Studies on specific materials highlight these outcomes; for instance, tricalcium silicate-based agents like achieve high success in vital pulp therapies. More recent evaluations report success rates for Biodentine between 80% and 100% in with deep caries. Comparisons between stepwise and single-visit techniques show comparable efficacy, with success rates ranging from 60% to 88% for stepwise approaches up to 5 years. In pediatric applications, the American Academy of Pediatric Dentistry (AAPD) guidelines from 2024 indicate success rates of approximately 83% for vital pulp therapies including indirect pulp capping in primary teeth at 24 months, with long-term rates affected by natural exfoliation. Failure in indirect pulp capping often manifests as unintended pulp exposure during re-entry in stepwise procedures, occurring in 5% to 10% of cases, which may necessitate progression to more invasive treatments. Overall, these rates are generally higher than those for direct pulp capping, benefiting from the absence of direct trauma to the pulp.

Factors Influencing Outcomes

The success of pulp capping procedures is influenced by several patient-related factors. Younger patients, particularly those under 40 years of age, exhibit higher success rates due to enhanced pulp repair capacity, with studies reporting 90.9% success in this group compared to 73.8% in those 40 years and older when using Biodentine for direct pulp capping. Systemic conditions such as diabetes mellitus can impair pulp healing and reduce treatment outcomes by increasing inflammation and delaying dentin bridge formation, as observed in both clinical and animal models. Tooth-related variables also play a critical role. Mechanical pulp exposures generally yield better outcomes than carious exposures, with success rates of 92.2% for mechanical versus 33.3% for carious exposures in direct pulp capping procedures. The quality of the final restoration is essential, as a prevents microleakage and bacterial ingress; inadequate restorations, such as amalgam compared to composite, increase failure risk by a of 2.263. Operator-dependent factors significantly affect . Strict , including the use of rubber dam isolation, and effective within 5–10 minutes are crucial for minimizing and promoting healing. Material selection further influences results, with bioceramics like (MTA) and Biodentine outperforming , achieving success rates of 85.9–96.4% versus 77.6%, a difference of approximately 8–19%. Regular follow-up with testing and radiographic evaluation enables early detection of failures. Recent 2025 systematic reviews underscore the importance of isolation techniques in long-term success, emphasizing their role in both direct and indirect pulp capping.

Complications and Management

Common Complications

One of the most frequent complications following pulp capping is pulp necrosis, occurring in approximately 10-20% of cases, particularly with direct pulp capping of carious exposures where bacterial exacerbates . Signs include spontaneous or persistent , tooth discoloration, and radiographic of apical radiolucency indicating pulpal . This risk is notably higher in direct carious exposures compared to mechanical or traumatic ones due to pre-existing pulpal . Microleakage at the restoration interface is another common issue, arising from inadequate sealing and leading to bacterial ingress, chronic inflammation, and potential secondary . Adverse pulpal reactions, including chronic inflammation, may occur with eugenol-containing materials like zinc oxide-eugenol due to its . Material-specific complications include the solubility of , which can dissolve over time and result in dentin bridges with tunnel defects in up to 89% of cases, compromising long-term seal integrity. (MTA) may cause discoloration, particularly with gray formulations, affecting aesthetics in . Delayed complications often involve bridge failure, necessitating in 5-15% of cases at 5-year follow-up, with higher rates for (up to 44% failure) compared to MTA (around 19%). In pediatric cases involving primary teeth, pulp capping failure can lead to premature loss and subsequent space maintenance issues.

Prevention and Treatment Strategies

Prevention of complications in pulp capping begins with meticulous procedural techniques to minimize and promote . Strict use of a rubber dam is the gold standard for isolation during vital pulp therapy procedures, including direct and indirect pulp capping, as it prevents bacterial ingress from and blood, thereby reducing the risk of pulp or . Immediate sealing of the pulp exposure site with a biocompatible material after is essential to create a protective barrier against further microbial invasion. plays a crucial role, emphasizing rigorous practices such as twice-daily brushing, daily flossing, and avoidance of hard or sticky foods to support restoration integrity and prevent secondary caries. should be tailored to the type of exposure; for direct pulp capping involving mechanical or carious exposure of vital pulp, (MTA) is strongly recommended due to its superior sealing and biocompatibility compared to alternatives like . Alternatives like Biodentine offer similar benefits with lower risk of discoloration. Ongoing monitoring is vital to detect early signs of complications, such as persistent sensitivity or radiographic changes indicative of pulp . Patients should undergo clinical recalls every 3 to 6 months post-procedure, incorporating electric pulp testing (EPT) to assess pulp vitality and periapical radiographs to evaluate bridge formation and absence of periapical radiolucency. Early intervention is advised if sensitivity persists beyond initial healing or if EPT responses deviate from baseline, allowing timely adjustment to prevent progression to irreversible . In cases of pulp capping failure, evidenced by clinical symptoms like prolonged or radiographic periapical lesions, treatment escalation is necessary to preserve tooth function. Options include transitioning to partial for localized or full / therapy for more extensive involvement, with extraction considered only if restorability is compromised. For immature following failed pulp capping, regenerative endodontic procedures are recommended per 2024 AAPD guidelines, involving disinfection of the and induction of vital tissue ingrowth to promote root maturation and apex closure, particularly in necrotic pulps with open apices. Recent advances incorporate laser-assisted techniques for enhanced sterilization during pulp capping, which provide decontaminant effects and , significantly reducing clinical and radiological failure rates with an odds ratio of compared to conventional methods, thereby lowering risk and improving long-term success.

References

  1. https://www.aae.org/wp-content/uploads/2021/05/VitalPulpTherapyPositionStatement_v2.pdf
  2. https://pmc.ncbi.nlm.nih.gov/articles/PMC9985044/
  3. https://www.colgate.com/en-us/oral-health/root-canals/pulp-capping-what-is-it-and-what-are-dental-treatment-options
  4. https://www.aapd.org/media/Policies_Guidelines/BP_PulpTherapy.pdf
  5. https://doi.org/10.1016/j.jdent.2010.05.016
  6. https://pmc.ncbi.nlm.nih.gov/articles/PMC4619960/
  7. https://doi.org/10.1159/000063930
  8. https://doi.org/10.1177/0022034511405389
  9. https://doi.org/10.1155/2009/464280
  10. https://doi.org/10.1002/jez.b.21259
  11. https://pubmed.ncbi.nlm.nih.gov/40288576/
  12. https://www.mdpi.com/1467-3045/47/7/509
  13. https://pmc.ncbi.nlm.nih.gov/articles/PMC12511626/
  14. https://www.ingentaconnect.com/content/aapd/pd/2013/00000035/00000001/art00002
  15. https://pmc.ncbi.nlm.nih.gov/articles/PMC8783220/
  16. https://pubmed.ncbi.nlm.nih.gov/19040817/
  17. https://pmc.ncbi.nlm.nih.gov/articles/PMC4327618/
  18. https://pocketdentistry.com/vital-pulp-therapy/
  19. https://www.aapd.org/assets/1/7/G_Pulp.pdf
  20. https://ternadental.com/wp-content/uploads/PULP-THERAPY-2.pdf
  21. https://pmc.ncbi.nlm.nih.gov/articles/PMC5516779/
  22. https://www.researchgate.net/publication/371350532_Calcium_Hydroxide_Pulp_Capping_Agent_An_Overview_on_Composition_Properties_and_Clinical_Applications
  23. https://pubmed.ncbi.nlm.nih.gov/3857254/
  24. https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2012.02101.x
  25. https://www.dovepress.com/calcium-hydroxide-liners-a-literature-review-peer-reviewed-fulltext-article-CCIDE
  26. https://www.researchgate.net/publication/5276458_The_history_of_direct_pulp_capping
  27. https://onlinelibrary.wiley.com/doi/10.1111/iej.12841
  28. https://pubmed.ncbi.nlm.nih.gov/8908918/
  29. https://pubmed.ncbi.nlm.nih.gov/20003930/
  30. https://pocketdentistry.com/composition-and-setting-reaction/
  31. https://www.ncbi.nlm.nih.gov/books/NBK599506/
  32. https://www.septodontusa.com/product/dentin-restoration-biodentine/
  33. https://pmc.ncbi.nlm.nih.gov/articles/PMC4082844/
  34. https://brasselerusadental.com/endosequence-bioactives
  35. https://pmc.ncbi.nlm.nih.gov/articles/PMC5750835/
  36. https://brasselerusadental.com/products/bc-rrm
  37. https://pmc.ncbi.nlm.nih.gov/articles/PMC5620936/
  38. https://www.sciencedirect.com/science/article/pii/S153233822500106X
  39. https://pmc.ncbi.nlm.nih.gov/articles/PMC10225160/
  40. https://www.nature.com/articles/s41598-024-69367-7
  41. https://journals.lww.com/jmso/fulltext/2023/37030/histological_evaluation_of_dental_pulp_response_to.3.aspx
  42. https://www.sciencedirect.com/topics/medicine-and-dentistry/zinc-oxide-eugenol
  43. https://www.oooojournal.net/article/0030-4220%2892%2990020-Q/pdf
  44. https://pubmed.ncbi.nlm.nih.gov/26950810/
  45. https://pubmed.ncbi.nlm.nih.gov/30287705/
  46. https://www.sciencedirect.com/science/article/pii/S1991790222003087
  47. https://bmcoralhealth.biomedcentral.com/articles/10.1186/s12903-023-03429-6
  48. https://pubmed.ncbi.nlm.nih.gov/36837429/
  49. https://www.sciencedirect.com/science/article/pii/S1013905224002116
  50. https://pmc.ncbi.nlm.nih.gov/articles/PMC12276705/
  51. https://www.sciencedirect.com/science/article/abs/pii/S1773224725004721
  52. https://pubmed.ncbi.nlm.nih.gov/16802637/
  53. https://pmc.ncbi.nlm.nih.gov/articles/PMC10880475/
  54. https://pubmed.ncbi.nlm.nih.gov/39523694/
  55. https://www.sciencedirect.com/science/article/abs/pii/S0099239922007543
  56. https://onlinelibrary.wiley.com/doi/abs/10.1111/iej.13449
  57. https://www.jocpd.com/articles/10.22514/jocpd.2025.045
  58. https://pubmed.ncbi.nlm.nih.gov/11199794/
  59. https://www.sciencedirect.com/science/article/abs/pii/S0099239925002080
  60. https://www.jendodon.com/article/S0099-2399%2820%2930436-2/fulltext
  61. https://onlinelibrary.wiley.com/doi/full/10.1002/cre2.362
  62. https://rde.ac/journal/view.php?doi=10.5395/rde.2024.49.e34
  63. https://pmc.ncbi.nlm.nih.gov/articles/PMC6756573/
  64. https://www.aapd.org/globalassets/media/policies_guidelines/g_vpt-2024.pdf
  65. https://pmc.ncbi.nlm.nih.gov/articles/PMC5945752/
  66. https://www.thieme-connect.com/products/ejournals/pdf/10.4103/2278-9626.115996.pdf
  67. https://www.nature.com/articles/s41598-024-52654-8
  68. https://www.thejcdp.com/doi/10.5005/jp-journals-10024-3673
  69. https://pmc.ncbi.nlm.nih.gov/articles/PMC2856472/
  70. https://onlinelibrary.wiley.com/doi/10.1111/iej.13449
  71. https://www.dentalclinicguide.com/2024/09/indirect-pulp-capping-clinical-guide.html
  72. https://pmc.ncbi.nlm.nih.gov/articles/PMC9469447/
  73. https://pmc.ncbi.nlm.nih.gov/articles/PMC10823953/
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