Indirect Pulp Treatment, Direct Pulp Capping, and Stepwise Caries Excavation

  • James A. CollEmail author


In children with deep carious lesions, the tooth’s pulp can become inflamed. If this lesion is not treated properly, the caries can approximate the pulp resulting in pain and infection. The treatment of these pulp conditions often results in extraction or root canal therapy. Vital pulp therapy procedures can treat the decay approximating the pulp to avoid the pulp becoming infected or being treated with pulpotomy. An alternative to pulpotomy, extraction, or pulpectomy for deep carious lesions where the pulp is vital is indirect pulp treatment (IPT). IPT has been shown to be successful using stepwise caries excavation in two appointments or using partial caries excavation as a one-appointment procedure. These procedures are indicated for primary, immature permanent, and mature permanent teeth in children and adolescents. Direct pulp capping in primary teeth due to a carious exposure is not indicated but is used in permanent teeth. This chapter will review the literature and systematic reviews on these treatments, show their advantages and disadvantages, and offer conclusions as to the treatment of choice.


Permanent Tooth Mineral Trioxide Aggregate Primary Molar Pulp Exposure Hall Technique 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    AAPD Reference Manual. Guideline on pulp therapy for primary and immature permanent teeth. 2014–2015;36:242–50.Google Scholar
  2. 2.
    Coll JA, Campbell A, Chalmers NI. Effects of glass ionomer temporary restorations on pulpal diagnosis and treatment outcomes in primary molars. Pediatr Dent. 2013;35:416–21.PubMedGoogle Scholar
  3. 3.
    Bergenholtz G, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, Norlund A, Petersson A, Portenier I, Sandberg H, Tranæus S, Mejare I. Treatment of pulps in teeth affected by deep caries – a systematic review of the literature. Singapore Dent J. 2013;34(1):1–12.CrossRefPubMedGoogle Scholar
  4. 4.
    Smith AJ, Cassidy N, Perry H, Begue-Kirn C, Ruch JV, Lesot H. Reactionary dentinogenesis. Int J Dev Biol. 1995;39:273–80.PubMedGoogle Scholar
  5. 5.
    Marshall GW, et al. The dentin substrate: structure and properties related to bonding. J Dent. 1997;25:441–58.CrossRefPubMedGoogle Scholar
  6. 6.
    Fusayama T. Two layers of carious dentin: diagnosis and treatment. Oper Dent. 1979;4:63–70.PubMedGoogle Scholar
  7. 7.
    Bjorndal L. Dentin and pulp reactions to caries and operative treatment: biological variables affecting treatment outcome. Endod Top. 2002;2:10–23.CrossRefGoogle Scholar
  8. 8.
    Johnson W, Taylor BR, Berman DS. The response of deciduous dentine to caries studied by correlated light and electron microscopy. Caries Res. 1969;3:348–68.CrossRefPubMedGoogle Scholar
  9. 9.
    Mjör IA. Dentin-predentin complex and its permeability. Pathology and treatment. Overview. J Dent Res. 1985;64(spec issue):621–7.PubMedGoogle Scholar
  10. 10.
    Edwardsson S. Bacteriology of dentin caries. In: Thylstrup A, Leach SA, Qvist V, editors. Dentine and dentine reactions in the oral cavity. Oxford: IRL Press; 1987. p. 95–102.Google Scholar
  11. 11.
    Kidd EAM, Smith BGN, Pickard HM. Pickard’s manual of operative dentistry. 7th ed. Oxford: Oxford University Press; 1998.Google Scholar
  12. 12.
    Schwendicke F, Dörfer CE, Paris S. Incomplete caries removal: a systematic review and meta-analysis. J Dent Res. 2013;92:306–14.CrossRefPubMedGoogle Scholar
  13. 13.
    Ricketts D, Lamont T, Innes NPT, Kidd E, Clarkson JE. Operative caries management in adults and children. Cochrane Database Syst Rev. 2013;(3):CD003808.Google Scholar
  14. 14.
    Elderton RJ. Clinical studies concerning re-restoration of teeth. Adv Dent Res. 1990;4:4–9.PubMedGoogle Scholar
  15. 15.
    Murray PE, Smith AJ, Windsor LJ, Mjör IA. Remaining dentine thickness and human pulp responses. Int Endod J. 2003;36:33–43.CrossRefPubMedGoogle Scholar
  16. 16.
    Fuks AB. Pulp therapy for the primary dentition. In: Pinkham JR, Casamassimo PS, Fields Jr HW, McTigue DJ, Nowak A, editors. Pediatric dentistry: infancy through adolescence. 5th ed. St. Louis: Elsevier Saunders Co; 2013. p. 331–51.Google Scholar
  17. 17.
    Bjørndal L, Reit C, Bruun G, Markvart M, Kjældgaard M, Näsman P, et al. Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci. 2010;118:290–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The radiographic outcomes of direct pulp-capping procedures performed by dental students: a retrospective study. J Am Dent Assoc. 2006;137:1699–705.CrossRefPubMedGoogle Scholar
  19. 19.
    Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: an observational study. J Am Dent Assoc. 2008;139:305–15.CrossRefPubMedGoogle Scholar
  20. 20.
    Bjørndal L, Larsen T, Thylstrup A. A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals. Caries Res. 1997;31:411–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Wambier DS, dos Santos FA, Guedes-Pinto AC, Jaeger RG, Simionato MR. Ultrastructural and microbiological analysis of the dentin layers affected by caries lesions in primary molars treated by minimal intervention. Pediatr Dent. 2007;29:228–34.PubMedGoogle Scholar
  22. 22.
    Bjørndal L, Kidd E. The treatment of deep dentine caries lesions. Dent Update. 2005;32:402–4, 407–10, 413.PubMedGoogle Scholar
  23. 23.
    Maltz M, Moura MS, Jardim JJ, et al. Partial caries removal in deep lesions: 19–30 months follow-up study. Rev Fac Odontol Porto Alegre. 2010;51:20–3.Google Scholar
  24. 24.
    Maltz M, Garcia R, Jardim JJ, de Paula LM, Yamaguti PM, Moura MS, et al. Randomized trial of partial vs. stepwise caries removal. J Dent Res. 2012;91:1026–31.CrossRefPubMedGoogle Scholar
  25. 25.
    Innes NP, Evans DJ, Stirrups DR. The Hall technique; a randomized controlled clinical trial of a novel method of managing carious primary molars in general dental practice: acceptability of the technique and outcomes at 23 months. BMC Oral Health. 2007;7:18.PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Innes NPT, Evans DJP, Stirrups DR. Sealing caries in primary molars; randomized control trial. 5-year results. J Dent Res. 2011;90:1405–10.CrossRefPubMedGoogle Scholar
  27. 27.
    Ludwig KH, Fontana M, Vinson LA, Platt JA, Dean JA. The success of stainless steel crowns placed with the Hall technique: a retrospective study. J Am Dent Assoc. 2014;145(12):1248–53.CrossRefPubMedGoogle Scholar
  28. 28.
    Santamaria RM, Innes NP, Machiulskiene V, Evans DJ, Splieth CH. Caries management strategies for primary molars: 1-yr randomized control trial results. J Dent Res. 2014;93:1062–9.PubMedCentralCrossRefPubMedGoogle Scholar
  29. 29.
    Mertz-Fairhurst EJ, Curtis JW, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc. 1998;129:55–66.CrossRefPubMedGoogle Scholar
  30. 30.
    Holan G, Eidelman E, Fuks AB. Long-term evaluation of pulpotomy in primary molars using mineral trioxide aggregate or formocresol. Pediatr Dent. 2005;27:129–36.PubMedGoogle Scholar
  31. 31.
    Hutcheson C, Seale NS, McWhorter A, Kerins C, Wright J. Multi-surface composite vs stainless steel crown restorations after mineral trioxide aggregate pulpotomy: a randomized controlled trial. Pediatr Dent. 2012;34(7):460–7.PubMedGoogle Scholar
  32. 32.
    Guelmann M, Bookmyer KL, Villalta P, García-Godoy F. Microleakage of restorative techniques for pulpotomized primary molars. J Dent Child. 2004;71:209–11.Google Scholar
  33. 33.
    Seale NS, Coll JA. Vital pulp therapy for the primary dentition. Gen Dent. 2010;58(3):194–200.PubMedGoogle Scholar
  34. 34.
    Kuhn E, Chibinski AC, Reis A, Wambier DS. The role of glass ionomer cement on the remineralization of infected dentin: an in vivo study. Pediatr Dent. 2014;36(4):E118–24.PubMedGoogle Scholar
  35. 35.
    Corralo D, Maltz M. Clinical and ultrastructural effects of different liners/restorative materials on deep carious dentin: a randomized clinical trial. Caries Res. 2013;47:243–50.CrossRefPubMedGoogle Scholar
  36. 36.
    Orhan AI, Oz FT, Orhan K. Pulp exposure occurrence and outcomes after 1- or 2-visit indirect pulp therapy vs complete caries removal in primary and permanent molars. Pediatr Dent. 2010;32:347–55.PubMedGoogle Scholar
  37. 37.
    Casagrande L, Bento LW, Rerin SO, Lucas Ede R, Dalpian DM, de Araujo FB. In vivo outcomes of indirect pulp treatment using a self-etching primer versus calcium hydroxide over the demineralized dentin in primary molars. J Clin Pediatr Dent. 2008;33:131–5.CrossRefPubMedGoogle Scholar
  38. 38.
    Trairatvorakul C, Sastararuji T. Indirect pulp treatment vs antibiotic sterilization of deep caries in mandibular primary molars. Int J Paediatr Dent. 2014;24:23–31.CrossRefPubMedGoogle Scholar
  39. 39.
    Vij R, Coll JA, Shelton P, Farooq NS. Caries control and other variables associated with success of primary molar vital pulp therapy. Pediatr Dent. 2004;26:214–20.PubMedGoogle Scholar
  40. 40.
    Farooq NS, Coll JA, Kuwabara A, Shelton P. Success rates of formocresol pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries in primary teeth. Pediatr Dent. 2000;22:278–86.PubMedGoogle Scholar
  41. 41.
    Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB. Indirect pulp treatment of primary posterior teeth: a retrospective study. Pediatr Dent. 2003;25:29–36.PubMedGoogle Scholar
  42. 42.
    Roberts J. Indirect pulp treatment vs. Formocresol pulpotomy in human primary molars: a randomized controlled trial. A thesis. The Texas A&M University System Health Science Center. 2009. Accessed at on 8 Aug 2015.

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Division of Pediatric DentistryUniversity of Maryland School of DentistryBaltimoreUSA

Personalised recommendations