How do I decide whether to do Pulp Capping or perform Root Canal Treatment ?

To Cap or To Cut …..!!

Pulp Capping is the placement of a medicament on an unexposed pulp with less than 0.5
mm of remaining dentin thickness or very minimally (pin point sized) exposed pulp to aid
in the healing of the inflammation in the pulp and repair itself to remain with all its
function. The procedure can be performed only if most of the pulp is healthy. When
applied over an unexposed pulp it is termed as in-direct pulp capping and when placed
over exposed pulp it is direct pulp capping. The medicament may create a suitable
environment for pulp to heal, destroy pathogenic microbes, sedate the pulp, produce
analgesia and may have healing property. Not all medicaments have all the properties.
The most commonly used pulp capping agents are zinc oxide eugenol and calcium
hydroxide. Calcium hydroxide should be used only in asymptomatic pulp and zinc oxide
eugenol has to be used in symptomatic pulp. If the deepest lesion is in the cervical third
calcium hydroxide should be avoided to prevent strangulation of pulp by the reparative
dentin formation. MTA is a recent addition that may be used wherever calcium
hydroxide is indicated.
The decision to pulp cap or to perform root canal treatment to a tooth with deep
cavity but with no pain is often a dilemma that arise in the mind of many practitioners. In
single root teeth mainly in the anteriors it may not be difficult to diagnose and arrive at a
conclusion but in posterior teeth with multiple roots and complex root canal system it
often presents a problem in the decision making. In such instances there are a few guiding
principles that will help us.

In the History: If the patient has had pain in a decayed tooth days, weeks, months or even
years back, then that tooth, most likely require root canal treatment. Even one episode of
pain is sufficient to make the decision in favour of root canal treatment rather than pulp
capping procedure.
On Visual Examination: If the affected tooth and adjacent teeth in the same arch show lot
more of calculus, it is suggestive that the patient has been avoiding using that side of the
jaw for chewing. On careful enquiry the most probable cause for this would be to evade
pain. This tooth is a definite candidate for root canal treatment even if the response to
pulp testing is uncertain. The discoloration of the tooth only helps to some extent in a
posterior tooth whereas in an anteriors it is of substantial use.
On Radiographic Examination: If there is peri-apical radiolucency on the affected tooth
then there is no doubt that the tooth requires root canal treatment. Conditions such as
widening of the periodontal ligament space, break in lamina dura etc are often illusory
and tricky. Most commonly used pulp testing procedures such as thermal testing and
electric pulp testing only corroborate the result of history and findings of other physical
examinations. Advanced pulp testing procedures are available today but are of academic
value at present though some of them may become a valuable tool in future in the daily
clinical practice.

A tooth indicated for root canal treatment, if pulp capped could start developing a
peri-apical pathology which is a little resistant to healing. A lesion in close proximity to
the pulp with occasional transient pain is likely to be injured more by the mechanical and
chemical irritation produced during cavity preparation, excavation and restoration and the
pulp will die. More over in a healthy individual pulp capping also produces calcification
in the canals not necessarily near the site of medicament but at the site where the healthy
pulp is able to bridge off irritation. This would later pose difficulty to negotiate and to
complete the root canal treatment.

Many clinicians considered pulp capping only in case of traumatic exposure such
as accident injury or traumatic exposure during tooth preparation. With the advent of
adhesive restoration and retention of affected dentin, traumatic exposure with bur is a
rarity. Further with the advancement in the science of endodontics, root canal treatment
has become more predictable, successful, easy for operation and comfortable for patient.
So when in doubt it is better to opt for root canal treatment than to pulp cap. In reality, in
the present day pulp capping has only very few indications. Deciduous teeth and young
permanent teeth with incomplete root formation are probably the only candidates for pulp
capping. Sometimes pulp capping is suggested by new practitioners for fear of failure to
root canal treatment. Pulp capping is also used as a temporary emergency procedure
during acute phase of general illness or a temporary alternative to extraction when root
canal treatment is unavailable.
Prof S Balagopal MDS., MSc.,