A Possible Alternative to Root Canal Treatment:

"Pulp Capping"


Many of the emails I get   are questions about root canal treatment.  There seems to be a lot of   confusion and anxiety about that subject and many of you  want to know if there is any alternative - other than extraction -  to root canal treatment.  

Well, the  answer is yes ........ and no.


The most common scenario is the case  of decay  that has  gotten so  deep into the  tooth  that  on the  x-ray it looks like it's  already reached the nerve of the tooth.  The dentist  tells you it looks like you need a root canal....

Sometimes the dentist will see "a shadow" at the tip of the  root. That  indicates bone loss  that   results from  the changes in  chemistry  that happens  when a tooth  has already  abscessed (is infected)  and the nerve has   already been  dead for a while (probably several months or  longer).   In that case  there is no choice other than extraction or  root canal treatment (RCT).

But often there is no clearly defined  shadow at the end of the root so  determining  whether  it needs a RCT or not is a bit of a puzzle and the dentist  has to be  a kind of detective  putting many  clues together.  Many times the clues point to RCT for sure, but sometimes it's still a  puzzle.  In those cases the dentist has to  drill out the old fillings and decay and see how  deep the decay goes.  If he drills carefully he   can sometimes  get a all the decay out and still  see that the nerve has not been reached.  That's good - just a filling should  fix it.

Sometimes  after  getting all the decay out there will be  a small spot where the  nerve has been  reached and that spot  will normally bleed a little.  That's called "an exposure".   The text-book  thing to do is RCT, but  if the exposure is small, and if the bleeding is slight and the color of the exposure looks like pretty  healthy   tissue, the dentist can  opt to  do a  pulp cap.

A pulp cap just means trying to sterilize the area as well as possible, stopping the  small bleeding, and placing an appropriate filling over it.  In the past  the technique was to place calcium hydroxide over it and then a normal filling (usually amalgam).   Modern  pulp-capping  is mostly done using a bonded composite technique* (see note added April 2009 below )  right over the exposure - with NO calcium hydroxide layer.  Recently [2015] there have been new composite-like materials that are "bio-active" simply meaning they are more compatible with the living  nerve tissue allowing it to heal more easily.  The material is sort of a band-aid allowing the nerve tissue to heal undrneath it.....if it  is still possible.

When they are done well and in the right situation , pulp caps have a  very good chance of working  for a long time.  The key   here is picking the  right situation and doing it well.  Exposures that   do not  fit into the narrow slot of suitability  for pulp capping should   be considered  candidates for extraction or  RCT.

Teeth that are already abscessed should never be pulp-capped.  It's just for those teeth in the in-between  stage where the nerve is  irritated but still alive and healthy enough to repair itself given a   reasonable chance.  The pulp-capping  gives it a chance by getting rid of the decay and the bacteria that are in  the decay, and by creating a clean dressing over it with the filling.   It's not unlike cleaning out a  dirty cut or scrape on your skin and placing a  clean bandage over it.

Pulp-capping has been done in different ways   for a very long time. It's not new, but the technique  has evolved  with the  new  techniques and products available to dentists.

So, yes there is an alternative ..... sometimes. I hope this helps and doesn't  just  make you  more confused!

Note: added April 2009

These are signs that while "not written  in stone", do serve as general guidelines indicating that a tooth is probably NOT a good candidate for pulp-capping.

  • pain  is caused by exposing the tooth to heat, like hot coffee or soup

  • the pain lasts more than an instant.... it lasts a few minutes or more

  • tapping or biting on the tooth causes pain

  • pain sometimes starts for no apparent reason ( like it starts when you're not eating or drinking or chewing anything...or maybe it wakes you up  during sleep )

These are all  general indicators of what is called "irreversible pulpitis", which simply means that the nerve is inflamed beyond its ability to repair itself.

*Also, research has  shown that while calcium hydroxide cements ( Dycal, for example) are still indicated for pulp-capping, there are other materials that might be even better than bonded composite. 

2010:   John Kanka, DDS, who is a lecturer I greatly respect, has recently shown that a certain kind of dental cement that has been around for many years,  known as polycarboxylate cement, may be the best choice for pulp-capping.  Perhaps the most common trade name for this cement is Durelon.