Whereas there may be different treatment options with regard to carious first
permanent molars, the clinician should usually attempt to retain incisors and/or
canines, with extensive caries whenever possible.
9.10.2 Conservative treatment options
Various techniques have a part to play in conservation of teeth with deep caries.
- Indirect pulp capping.
- Direct pulp capping
- Pulpotomy
- Pulpectomy
When the tooth erupts its roots are incompletely formed and approximately 20-40%
shorter than the mature root. It may take up to 5 years after eruption for the root to
complete its formation and develop an apical constriction.
Key Point
Whenever it is thought that caries removal might result in a pulpal exposure, efforts
should be made to preserve pulp vitality in order to enable normal root maturation to
occur.
Indirect pulp capping
If it is thought that exposure is likely to occur with full caries removal then sometimes
it is expedient to leave caries in the deepest part of the lesion. Place a radio-opaque,
biocompatible base over the remaining carious dentine to stimulate healing and repair.
It is important to completely remove caries from all the lateral walls of the cavity
before placement of a restoration since failure to do so will result in spread of
secondary caries and the need for future intervention.(See 468HFigs. 9.29, 469H9.30, 470H9.31, 471H9.32,
and 472H9.33.)
Traditionally operators have used calcium hydroxide for indirect pulp capping
because it has a good success rate. Alternatives suggested include adhesive resins, and
glass ionomer cements, but as yet there are no published studies looking at these
techniques in permanent teeth. Whichever material is utilized, the crucial factor is to
isolate the pulp well from the oral environment. Re-investigation of these teeth after
about 6 months when the pulp has had an opportunity to lay down reparative dentine
used to be recommended. However studies have found that the residual carious
dentine mostly re-mineralizes and hardens and caries progression does not occur in
the absence of micro-leakage. Returning to the operative site, to complete caries
removal increases the risk of pulp exposure, therefore the authors consider it wiser to
perform the indirect pulp capping and definitive restoration in one appointment.
The direct pulp cap
When a small exposure is encountered during cavity preparation the operator can
place a direct pulp cap. The concept once again is to preserve the vitality of the pulp.
Calcium hydroxide has traditionally been used as the direct capping agent. Total