Vital Pulp Cap vs. Root Canal Therapy: When, How and Why

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today, we'll be discussing how to choose between endodontic therapy or vital pulp therapy, which is also known as a vital pulp cap. Our guest is Dr. Alex Vasserman, a cosmetic dentist who practices minimally invasive painless dentistry in the Upper East Side of New York City. He is an active member of several dental associations, including the American Academy of Cosmetic Dentistry, and COIS-trained dentist. Dr. Vasserman, thanks for coming back and joining us on Dental Talk. Thank you so much for having me back. Can you briefly define the term pulp cap for our audience? Because I know that that term means different things to different people. And then tell us how you decide whether to pulp cap a tooth or move forward with endodontic treatment. So to me, pulp capping comes down to this. How deep am I? How deep to that pulp chamber am I? What is the likelihood that I'm going to get that phone call when they're on vacation? And it's always a phone call when they're on vacation that I worked somewhere in that area and now they're in a vineyard and it's always that they were eating something soft and that tooth started hurting in the middle of the night. So that's what it comes down to. And whether... pulp cap or not simply depends whether the tooth was symptomatic before we worked on it and how deep am I. Right. But when you're working on a tooth, you're not really clear on how much dentin remains over that pulp, right? So we don't really know exactly where we are, but we know we're getting close. You know, you might see a blush. What are some of the clinical things that you're seeing as you evaluate? whether or not to move forward with an endonic treatment. And also, again, the definition of a pulp cap in your mind. Exactly what you said, that blush. When you're right down there and you're excavating decay and you could see right there the question, if the tooth is asymptomatic, completely asymptomatic before the patient and vital. So before the patient... I numb up the patient, I will always run a vitality test. I will typically do a cold test on the tooth to see, A, if it's symptomatic, irreversible pulpitis, or if it's alive, if it's necrotic. You know, if we're putting endo ice on the tooth and there's zero response, well, we know that that tooth is, you know, it's necrotic. So that blush and that amount of decay. or even fractures on the inside, you know, you remove that big amalgam and then there's a big crack that just keeps going and going. I mean, at what point do you say I'm going to keep going after it or I'm just going to stop and then put something there? And that's that question. What do we put? And at what point do you say, you know what, you have a big trip coming up. Maybe you should go see the endodontist. It's also dependent upon the patient, right? The personality of the patient, how they tolerate. a discomfort does that have a factor involved with your decision making as far as endodontic treatment 100 that's that's a big way it's patient selection it's how will the patient understand that this tooth eventually may start bothering them So it's all of those things. If they're not really understanding you, then maybe they need to go and get that root canal because if that tooth starts hurting them a year down the road or six months down the road after the pulp cap and they didn't really understand that there was a risk, then that will drive my selection whether I pulp cap or write that referral card. Okay, so now you've got the patient in the chair. The tooth is in really good shape. other than specific decay that was just related to an occlusal cavity that just went down and down and down. It kind of blew up down below. You got it all cleaned out, but you're very close or even possibly you have a small, tiny exposure and you decide to do a pulp cap. Tell us what's the next steps. So that's, and that's a great point. Exposure versus non -exposure. If it's an exposure and me and the patient decide. that we're going to pulp cap. The material of choice is TheraCal by Bisco. I will make sure that it's dry, that there's no bleeding, that there's nothing going on. And then I will put a drop of TheraCal right over the exposure and I will light cure it. Over that, I will then put my base. I will particle abrate that base. I will... paint my bonding agent in the base, and I will build my restoration. I almost never go for my definitive restoration, which would be my zirconia or Emacs crown. I will always either put a temporary crown on the tooth for X amounts of time to make sure that that tooth isn't bothersome. And only then if two to three months. in my practice, two to three months of asymptomatic and pulp vitality, then I will move towards a Emax or a zirconia restoration. So if it doesn't need a full coverage restoration and you can do it with a direct composite procedure, because there's lots of supporting tooth structure, do you go to the final direct restoration right after you place the pulp cap at that same visit or do you temporize with some material and let it settle down? No, in that situation, I will go through composite. If that tooth does need root canal therapy, I don't think it's that difficult for my endodontist, who I refer to, to drill through composite versus drilling through seven millimeters of zirconia or six millimeters of zirconia, whatever that is. So yeah, if it's a direct restoration, I will finish. Let the patient know that if that tooth continues to bother them or starts bothering them, that they need to go see my endodontist. If it's indirect, I will temporize it and we'll wait to see if the tooth does become symptomatic. But if the patient doesn't seem to be really understanding what we're doing, then they're going to go to the endodontist. If there's no pulp exposure, I typically won't go to the Theracal. I will just go to my baseliners, which are either Reliax Unisem or the Therabase by Bisco. I used to use Reliax Unisem. Now we switch to the Bisco's Therabase. When there's no exposure, because it's higher in pH, it has a little bit different flexure strength. It's a little bit stronger than the Reliax Unisem. Again, higher in pH. So it does promote pulp regeneration because of its high pH. So I switched to that recently. And so far, those quote-unquote... cases where I have been using the Therabase, they've been okay. They've been actually pretty good. Again, patient selection, patient understanding, and really crossing your fingers at the end of the day. Well, the high pH also is antibacterial, which is very important, especially if you're not getting a pulp exposure, you probably have some secondary decay down there that you... are kind of leaving, right? That's a great point. That's a really, yeah, antibacterial. promotes pulp healing, and flexes similar to that of the tooth so it won't crack or break like other liners. Now, what happens if you actually get a pinpoint exposure and you get bleeding? What do you do to, you want to stop the bleeding before you use the actual TheraCal? So if I do have a pinpoint bleeding on the bottom, and again, the patient understands, that we're going to try to avoid a root canal, I will use epinephrine from 1 to 50,000 lidocaine. I will put it on a cotton pellet and press it very firmly onto the pulp floor and wait a minute or two until there's no more bleeding. On top of that, I will then put my Theracal. Anything else, I feel like... be an irritant to the pulp because an astringent is very acidic. It has a very low pH. So that could potentially exacerbate the nerve and cause irreversible pulpitis. So I just use epinephrine from a lidocaine. Yeah, it's very interesting. I mean, I'm an endodontist, retire, but it sounds like you have a good endodontic background. Where do you do your training as a dentist? I graduated from Boston University and then Wyckoff Heights Medical Center was very heavy in endo as well as oral surgery. So Wyckoff Heights in Brooklyn, New York. Nice. Very good. Yeah, you have a very solid understanding of endodontics. All these different diagnostic terms are good to understand in order to make a diagnosis because if you feel that the patient has irreversible pulpitis, There's no point in putting the patient through a lot of the stuff. Now, we're never positively sure that it's irreversible, but typical symptoms of pain sensitive to cold that exceeds four to six seconds, that's kind of long. And spontaneous. Yes. So I'll usually ask, does this ever wake you up at night? Has it ever started hurting you without you biting down? Something like that. If they say, yeah, the other night I woke up. At that point, my heroics are very limited. Right, exactly. So these types of procedures, like you're talking about, like a pulp cap, is really phenomenal for patients that are basically vital pulp, relatively asymptomatic, maybe sensitive to cold here and there, or they have some sort of chemical reaction to something sweet. But generally speaking, they're overall fairly comfortable with the tooth, and you just... involved with the deep cavity prep. And you just hate to take the nerve out of the tooth and devitalize it if you don't have to. And that's where these materials that Bisco developed are really phenomenal stuff. Well, thank you very much, Dr. Vasserman. I appreciate your time. And I'm looking forward to your next podcast. You're going to be talking about Zirconium versus Emacs. So that'll be fun. Thank you so much.