Pulp Therapy in Primary & Permanent Teeth

Rubber Dam — Non-Negotiable

Rubber dam isolation is the gold standard and a non-negotiable standard of care. It prevents field contamination from blood, saliva, and bacteria throughout the procedure.

Manual or Rotary — No Significant Difference

The coronal pulp may be removed using a spoon excavator/curette, low-speed burs, or a combination. Studies show no significant difference in success rates between these methods.

Control Bleeding Within 1–5 Minutes

Hemostasis can be achieved with a water/saline-moistened cotton pellet, saline irrigation, or a dry cotton pellet. Sodium hypochlorite (NaOCl) is highly recommended as an irrigant for its tissue-dissolving and antibacterial properties. Chlorhexidine is less preferred due to potential toxicity concerns.

IRM or RMGIC Over the Bioceramic

Once MTA or Biodentine is placed over the exposure, cover it with a base of IRM or resin-modified glass ionomer cement (RMGIC). Both yield excellent results — 97% for IRM vs. 91% for RMGIC at 24 months.

Stainless Steel Crown — Strongly Recommended

While the restoration type does not directly alter MTA pulpotomy success, stainless steel crowns (SSC) are strongly recommended for durability and to provide a hermetic coronal seal. The final restoration can be placed on the same day.

Conditionally Recommended for Small Mechanical Exposures

DPC is appropriate only for small (≤ 1 mm) mechanical or traumatic exposures where the pulp is normal and bleeding is easily controlled. Use MTA over calcium hydroxide — MTA provides a thicker, more uniform dentin bridge and avoids the high rates of internal root resorption associated with calcium hydroxide.

Preferred Over DPC for Deep Carious Lesions

IPT — leaving the deepest layer of affected dentin intact to avoid exposure — is strongly recommended over DPC and complete caries removal for deep lesions. Biodentine showed a 99.24% success rate in one meta-analysis as an IPT liner.

Rubber Dam Is a Critical Prognostic Factor

Adequate rubber dam isolation throughout the entire procedure is a critical prognostic factor. One meta-analysis found rubber dam usage increases the likelihood of a favorable DPC outcome by 44%.

Use Magnification

Using magnification (e.g., a microscope) to directly observe the exposure site is recommended. Verify that the pulp tissue is red, homogenous, and free of dentin chips before placing the capping material.

Achieve Hemostasis in Under 5 Minutes

Sodium hypochlorite (NaOCl) is the preferred hemostatic agent for its combined hemostatic and antimicrobial benefits. Bleeding must be fully controlled before placing MTA or Biodentine.

Place Final Restoration Immediately

Immediate placement of the final restoration over the DPC material is strongly advocated. Do not place a temporary filling and restore later — microleakage around a temporary can compromise the bioceramic before it sets and undermine the entire procedure.