Does Carious Exposure in Adult Patient Really Warrant Direct Capping?

Objectives: To compare mineral trioxide aggregate (MTA) to calcium hydroxide (CH) as a direct pulp capping (DPC) material in adult patients with carious pulpal exposure in molar teeth.
Methods: The inclusion criteria in a randomized clinical trial (ClinicalTrials.gov NCT01224925) were: age18-55 years, 1st/2nd permanent molar, caries lesion involving at least 2/3 of the dentin, positive EPT/cold, history of pain indicating reversible pulpitis at most, and sound periapex. Exclusion criteria: no pulpal exposure, no hemostasis. After successful hemostasis 33 patients were randomized into white ProRoot® MTA (Dentsply), and 36 to the CH (Dycal®, Dentsply) groups. Re-calls were planned after 1 week and 6, 12, 24 and 36 months. Primary outcome measure was a non-symptomatic tooth responding to sensibility testing with no periapical changes. Cases with severe pain and/or lack of sensibility tests and/or periapical changes were assessed as failures. Mean (SD) of the follow-up times by September 2014 were 808 (81) days and 950 (77) days for MTA and CH, respectively. Kaplan-Meier survival analysis was used to study the survival of the pulps. Log-Rank (Mantel-Cox) Chi Square test was used to assess the statistical differences between the survival rates of the groups.

Results: The estimates for cumulative survival rates for the pulps were 67% and 57% for MTA and CH, respectively. This difference was not statistically significant (Long Rank Chi Square 2.755; df=1; p=0.097).

Conclusions: Irrespective of the material used, both groups had survival rates less than 70%. This finding is in contrast with the previous studies, where MTA capping in adult patients have gained higher survival. Thus the finding is challenging the overall justification of DPC procedure in the treatment of carious exposures in adults, as the success rates should be compared to those for endodontic treatment in vital teeth (pulpectomy).