Direct Pulp Cap Questions: Pain and Healing Time?


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Three months back, as a very old and large filling in my maxillary second molar (upper left tooth #7) had broken and developed a gap between the filling and tooth (as per what the dentist told me), I was advised to get it replaced. Otherwise the tooth was completely asymptomatic and very solid. As I really wanted to avoid a root canal down the road, I agreed. However, the dentist kept drilling for a long time. I asked if it was really necessary (as I had just gone to get a filling replaced and obviously wanted to avoid a root canal). He said there was a lot of decay under the filling. Anyway, finally he stopped drilling and then touched the cavity with an instrument which gave me great pain. He said there was no bleeding but a root canal was the only option now. However, as I had developed some doubts and wanted to take a second opinion, I asked for time to think and he put a temporary filling in.

Now I had great sensitivity to cold and also pain when pressing that tooth from the side only (no pain from pressing from underneath). These became less in intensity after some time but remained to a minor extent.

Meanwhile, because of an ongoing (and still not resolved) more serious issue with another tooth, and failure to find a good dentist whom I could trust (as I knew that just removing the temp filling could expose the pulp), I could not get this tooth treated.

Finally, two days back, a found a dentist who said that he would try to avoid a root canal, i.e., if he could remove the temp filling without exposing the pulp, he would put an indirect pulp cap on it, but if he exposed the pulp, he would put a direct pulp cap on it. I gave him the go ahead. He said either MTA or Dycal could be used but the cost of the MTA he quoted was just too high, so I had to go with Dycal.

He said he would need to remove the temp filling to visually check the cavity, and would do so ultrasonically to avoid further destruction. However, as it was already close to the pulp, during the removal, a small pinpoint of the pulp got exposed due to mechanical trauma (he said there was no caries there). He immediately treated the exposed pulp with a laser, then he said he put formaldehyde on it (later he specified formocresol), and then he left a cotton pellet soaked in chlorhexidine on it for about a minute. After this, he put Dycal (calcium hydroxide) on it, and then covered it with a temp filling. He told me to come back after two weeks to assess my condition. If it seems to be healing ok, he would remove the temp filling (but leave around 1mm of the temp filling in place so as not to disturb the underlying Dycal) then do the permanent filling. If it's not ok, then he could do a root canal.

My questions are:

1. I read that dentin bridge formation takes time and usually the tooth should not be disturbed for anywhere from 4-8 weeks at least. Is it advisable to re-enter that tooth in 2 weeks, or how long should I ask him to wait? I am not chewing on that side at all (because of another problematic tooth) so the temp filling will not get compromised.
2. Is it ok to not remove the temp filling fully i.e. leaving 1 mm behind (on top of the Dycal) and do the permanent filling on top of it (in terms of bonding ability, long term prognosis). what precautions to take?
3. i read that calcium hydroxide gets absorbed and becomes soft and leaves a void there ultimately. Will this be a problem and can it be prevented? What precautions to take?
4. I had great pain (specifically at the pulp exposure point) right when the pulp got exposed and then after the treatment. There was great pain while pressing my tooth from the side (but not from the bottom). This was two days back. The dentist said it was due to the pulp getting irritated. Yesterday morning, the pain on all counts went down 50%. But then yesterday night, I felt some minor swelling/soreness/tenderness inside at a point which was 1 inch to the left of my left nostril. That swelling went down by this morning. However, again tonight, the minor swelling/soreness/tenderness has come back at that same point. What could it be due to? Is it normal? Will it get better? Or does it indicate any failure? Otherwise, the pulp exposure point has not gotten any worse or better yet.
5. How much time should be given to assess whether the direct pulp cap has worked or not ( at least for the time being). And how to assess it? Should the tooth be completely asymptomatic, or is some sensitivity still normal and considered successful? Because I don't want to pay for a permanent filling if I have to end up getting a root canal done very soon afterwards.
 
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MattKW

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  1. More like 6 months or more.
  2. it would be sensible to leave some temp filling on top and not disturb the deepest part. Then fill it and wait - I would suggest amalgam for the best sealing properties. In my experience, most direct pulp caps fail at 18-24 months later, and a root canal therapy (RCT) becomes necessary.
  3. Dycal has no therapeutic properties, and as far as I know, MTA has not shown to be significantly better either. It's very hit-or-miss with pulp exposures, very unpredictable. Dissolution of the Dycal makes no difference to the prognosis.
  4. Too early to say. If the tooth was not painful before the pulp exposure, then often they will settle down within a couple of weeks.
  5. As above, it may take 18+ months before you know for sure, and no temp filling will last that long. If it settles within 2 weeks, then have it permanently sealed and cross your finger for next few years. If you have to go as far as crowning it, then DO NOT do a full ceramic crown. Ask for a PFM (or full gold crown) so that it is easy to drill through without destroying the crown.
 
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Thank you SO much for such a thorough reply. It really helps. I have a few more questions that I need your opinion on, and will ask soon. Just wanted to express my thanks first.
 
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Hello Dr Matt,
For this situation I've got a question. I've read that MTA is very useful on pulp capping, but when the root it's not fully development, and, doing the pulp cap could be the best way to save the tooth, while the apex is on that stage. So, for young patients it was a good option, but maybe for an fully development root and compromised pulp it was not so useful. MTA is also used in retrogade obturation instead of amalgam, so it won't be absorbed and it is biocompatible right? Correct me if I'm not getting the right understanding on this point. Thanks in advance!
 

MattKW

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Correct. Open apices have a better succes rate. That is not a common situation.
MTA now used for repair of furcation perforations and retrograde obturation.
 
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Hello Dr, I have another question regarding an alarming event I experienced two days after my direct pulp capping. In my last post, I had mentioned that two days after the direct pulp cap, I had some minor swelling/soreness/tenderness inside at a point which was 1 inch to the left of my left nostril. A few hours later, although the swelling was not visible externally on my face, I could just feel that swelling/discomfort/inflammation(?) spreading to a wider area inside the upper gums on the left side. Soon after that, I started feeling pain in/under my LOWER left #8 (mandibular third molar) whereas I don't even have any problem whatsoever with that tooth. And then suddenly, right after that, my left cheek and left side of my lips felt NUMB (it was like the same feeling you get when local anesthesia is injected in your gums....your cheek and lip become numb). The whole left cheek, starting from my cheekbone down to my chin, along with the left half of both upper and lower lip, had become numb. I could move them, but they were just numb along with some strange discomfort. After a few hours, the feeling lessened. By next morning, it was 50% less. By today, all the above symptoms are pretty much gone, but there is some residual discomfort (approx 10%. and the inside of my left cheek still has some different sensation). Then i remembered, I had also had such similar strange discomfort inside my gums and whole cheek area after the other dentist (who had done my failed root canal treatment on another tooth...upper left 6) had put "pulp devitalizer" 3 days before starting my RCT (without my knowledge/consent...she told me only afterwards. I would have preferred simple local anesthesia, as my previous RCT on aother tooth was done directly with local anesthesia, without any problem. i don't know what was the need for pulp devitalizer). However, my cheeks/lips had not become numb then... there was only a lot of gum/cheek discomfort.Then I realized that this new doctor (who has done the direct pulp cap) has also used FORMOCRESOL (again without my knowledge/consent beforehand..he told me only after putting it, which I voiced my displeasure about, as I have read that formaldehyde is a carcinogenic/hazardous substance).

My questions are:

1. Can the Formocresol be responsible for the numbness I experienced two days after the direct pulp capping? Could it have desensitized my whole left cheek/lip nerves? If not, then what else could be the cause of the 1.) numbness, 2.) sudden unexplained pain under lower left #8, 3.) inflammatory discomfort?
2. I never read about Formocresol being used in direct pulp capping. Should it have been used in the first place? He said he used it to attack the bacteria.
3. Will my pulp/tooth still be alive and normal (as it was before) after the use of formocresol? I think I read that the pulp can become inert or mummified after formocresol. What does that mean? Isn't formocresol a devitalizer? Does that mean it will kill (devitalize) my tooth pulp?
4. can this use of formocresol cause any damage to my tooth/surrounding area in any way in the future (such as damage to periodontal ligament, alveolar ridge, gums/nerves)?
5. Is it also possible that the "pulp devitalizer" (used prior to my other tooth's failed RCT) may have damaged the ligament/bone surrounding that RCT tooth, thereby being the cause of my pain? (as in the xray, there is a small blackish spot/circle on the apex of that failed RCT tooth) (see attached xray)
 

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