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Supporting Your Practice

What Is The Most Effective Therapy For Direct Pulp Capping?

By Carolyn Boyd, DDS, Diploma Library & Info Technology

Original Article: Direct Pulp Capping: What is the Most Effective Therapy? Systematic Review and Meta-Analysis. J Evid Base Dent Pract, December 2018, Volume 18, Issue 4, pp 298-314.

When pulp is exposed, the clinician applies biocompatible materials that seal and preserve tissue vitality, and stimulate repair via a mineralized barrier. Being aware of how these materials stack up against each other enables the operator to choose materials most likely to achieve best treatment outcomes.

To this end, a systematic review of pulp capping materials was conducted on 46 studies and a meta-analysis of 22 of those studies studies compared the effectiveness of:

  1. mineral trioxide aggregate (MTA) cement to calcium hydroxide (CaOH) cement;
  2. tricalcium silicate cement to MTA cement; and
  3. adhesive systems to CaOH cement.

The systematic review and meta-analysis compared the effectiveness of three types of biomaterials in terms of their success rates, inflammatory response, and dentin bridge formation.

  1. MTA cements were superior to CaOH cements in all 3 parameters according to review of 19 studies and meta-analysis of 10 of these 19 studies.
  2. Review of 5 articles found tricalcium silicate cements produced lower success rates but less inflammatory response and better dentin bridge formation.
  3. Meta-analysis of the same 5 articles suggests that tricalcium silicate cements had a better overall clinical performance than MTA cements, but the difference was not statistically significant.
  4. CaOH cements had better clinical performance than dentin adhesion systems in all 3 parameters according to review of 10 studies and meta-analysis of 7 of these 10 studies.

The systematic review also included 12 studies of other materials and techniques:

  1. Hydroxyapatite produced inflammatory response in up to 78% of treatments, with unpredictable dentin bridge formation, while review of animal studies showed stimulation of dystrophic calcifications and necrosis of the pulp.
  2. Morphogenetic proteins generated poor clinical results in animal studies, and in human studies 45-100% frequency of inflammatory response and no dentin bridge formation.
  3. Corticoid/antibiotic-based products produced 100% inflammatory response.
  4. Natural extracellular poly(ε-caprolactone) matrix produced 100% dentin bridge formation in combination with MTA in the single study reviewed.
  5. Laser light cavity preparation resulted in a mean 88% success rate in 3 articles.

Clinical Relevance

  1. Though CaOH cements are clinically effective, MTA cements are a superior choice for pulp capping as long as the high cost, challenging handling properties, long setting time, and discolouration potential are acceptable in the situation.
  2. Tricalcium silicate cements are a good alternative to MTA though future studies are required to determine long-term success.
  3. Dental adhesive systems are potentially harmful to pulp and should not be used in pulp capping.

Strengths and Limitations

  1. Though laser light technique produced good success rates in the studies reviewed, the effect of the laser could be not separated out from the effects of the biomaterials used afterward in the restoration of the teeth.
  2. Many variables can affect treatment outcomes such as patient age, extent of caries removal, and type of restoration. This paper attempted to control for these factors by focusing on 3 indicators together: success, inflammatory response and dentin bridge formation.
  3. Studies based success of treatment on subjective symptoms, pulp sensitivity tests and radiographs.
  4. The authors argue that this meta-analysis provides more clinically relevant conclusions because it combines results from both randomized control trials and non-randomized research.

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