JOURNAL OF ENDODONTICS
Copyright © 2000 by The American Association of Endodontists
Pulp Capping of Carious Exposures: Treatment
Outcome after 5 and 10 Years: A Retrospective
Study
Claudia Roxane Barthel, Dr. med. dent., Bianca Rosenkranz, Ariane Leuenberg, and
Jean-François Roulet, Prof. Dr. med. dent.
One hundred twenty-three pulp cappings had been
performed by students in 1984 to 1987 (ⴝ 10-yr
group) or in 1990 to 1992 (ⴝ 5-yr group) and were
followed up in 1997. Teeth were checked for sen-
sitivity (CO2/electrical pulp testing), percussion,
and palpation; radiographs were taken to assess
periapical status. In addition several other factors
were determined that might have an influence on
the success or failure rates, such as base material,
type of restoration, site of exposure, etc. Results
showed 44.5% failures (18.5% questionable and
37% successful cases) in the 5-yr group and 79.7%
failing, 7.3% questionable, and 13% successful
cases in the 10-yr group. As a factor of influence,
the placement of a definitive restoration within the
first 2 days after pulp exposure was found to con-
tribute significantly to the survival rate of these teeth.
Caries excavation during restorative procedures may result in pulp
exposure. It is well accepted that the pulp is not a doomed organ,
but capable of initiating several defense mechanisms to protect the
body to a certain extent from bacterial invasion. A vital functioning
pulp seems to be the best barrier for this purpose. From this point
of view it seems desirable to maintain pulp vitality as long as
possible. Pulp exposure without involvement of microorganisms
can clearly be overcome by repair mechanisms, such as dentinal
bridging (1). However, predamaged pulps (e.g. by caries) may be
weakened and unable to initiate and maintain defense mechanisms
when exposure occurs. The dentist who excavated caries and
exposed the pulp is in a treatment dilemma: should he try to
maintain pulp vitality or initiate root canal treatment?
It seems difficult to find a consensus on the survival rate of
formerly exposed pulps. Observation time, judgment criteria, and
pulpal status before capping vary to a great extent among the
studies. Armstrong and Hoffman (2) reported a 97.8% success rate
after 1.5 yr. Their criteria for success was lack of clinical symp-
tomology. Heyduck and Wegner (3) observed a 61.4% success rate
after 5 yr; they judged the sensitivity of the pulp, and the radio-
525
Printed in U.S.A.
VOL. 26, NO. 9, SEPTEMBER 2000
logical continuity of the periodontal ligament space. In both studies
it was not mentioned whether the exposure was due to caries or to
trauma. Cvek (4) reported a 96% success rate for pulp caps in
traumatically fractured teeth with an open apex. These teeth were
healthy before trauma. In many studies, pulp-capped teeth were
followed-up for 1 to 5 yr, only. Little data exist about long-term
follow-ups exceeding 5 years.
The aim of this retrospective study was to determine the treat-
ment outcome of pulp-capped teeth after 5 and 10 yr.
MATERIALS AND METHODS
Treatment Procedure
In the Department of Operative Dentistry in the Dental School,
Clinic North in Berlin, 401 pulp cappings (353 patients) were
performed in 1984 to 1987 (⫽ “10-yr group”) or in 1990 to 1992
(⫽ “5-yr group”) by students. All pulps were exposed during caries
excavation and may be considered as carious exposures. If the
tooth had a history of pain or the exposure exceeded an estimated
square millimeter, it was decided to perform root canal treatment.
Otherwise, the capping procedure was initiated. In general, caries
excavation in deep cavities was performed with a rubber dam in
place to avoid salivary contamination of the dentinal wound. In
these cases a rubber dam was also present in case of exposure. The
exposure site was checked by a supervising dentist (faculty) to
make sure that all carious hard tissues had been removed before
capping. The caries free-condition was verified by clinical means
(mirror/explorer); a caries detector was not used. The cavity was
carefully cleansed with 3% H2O2, and a setting Ca(OH)2 paste
(Kerr Life, Kerr, Karlsruhe, Germany) was placed on the wound.
On top of the medication, a base of either zinc phosphate cement
or glass ionomer cement was applied. The teeth were then restored
with amalgam fillings, composite fillings, gold cast restorations, or
with temporary fillings.
Criteria for Success or Failure at Follow-up
A pulp capping was considered as “successful” when the tooth
responded clearly to sensitivity testing (with both CO2 test and
electrical pulp test (EPT) responding positively), and there was an
526 Barthel et al.
TABLE 1. Age distribution at the time of pulp exposure
Age Group (yr) Cases
10–20 8
21–30 47
31–40 22
41–50 24
51–60 19
61–70 3
absence of clinical symptomology (pain, swelling, etc.) and radio-
logical signs of apical radiolucency. Pulp capping was rated as a
“failure” if the tooth was extracted, root canal treated (surgically or
nonsurgically), or if apical rarefaction was detected radiologically.
In the absence of radiological pathology, but with unclear clinical
behavior, such as questionable sensitivity testing (e.g. response to
either CO2 test or EPT), the outcome was recorded as “question-
able.”
Follow-up Examination
In 1997 the study population was traced and asked for an
appointment to examine the teeth with formerly exposed pulps.
The patient charts were evaluated and searched for evidence of the
exposure site (cervico-buccal or occluso-proximal), the base ma-
terial (zinc phosphate cement or glass ionomer cement), and the
type of restoration that was placed as a cavity seal. The clinical
examination was performed by one operator and consisted of
inspection, palpation, percussion test, and sensitivity tests (CO2
test and EPT). The pocket depth was recorded and restoration was
examined visually with an explorer and rated “acceptable” or
“unacceptable.” Additionally a radiograph was taken to evaluate
the status of the apical tissues and the continuity of the periodontal
ligament space. As far as it could be determined, the quality of the
restoration was defined as “acceptable” or “unacceptable” on the
radiograph. The pulpal space was checked for calcific alterations in
comparison with adjacent teeth, which had not been pulp-capped.
All radiographic evaluations were performed two times by two
operators (B.R. and A.L.) with a 3-month interval between the two
judgments. When disagreement occurred, a third operator (C.R.B.)
was asked for final judgment.
For descriptive analysis, the questionable cases were included;
for statistical tests, only failure and success cases were used.
Statistical analysis was performed with SPSS 8.0 using a ␹2 test.
RESULTS
Three hundred fifty-three patients with 401 pulp caps were
asked to make a recall appointment via a written form. If they had
moved away, an attempt was made to track them down, to find the
actual place of residence, and to gather information via their
dentist. If they did not respond, they were addressed repeatedly.
However only 97 patients (27.5%) with 123 pulp caps could be
followed-up (30.7%).
Sixty teeth belonged to male patients, and 63 teeth belonged to
female patients. The age distribution can be seen in Table 1. It
represents the age at the time of exposure.
In 49 of the 123 cases, either the feedback from the patient’s
actual dentist in private practice or the patients charts showed that
the capped tooth had been extracted or accessed for root canal
Journal of Endodontics
TABLE 2. Success and failure rates split by the 5- and 10-yr
groups
Group Cases %
5-yr
Success 20 37.0
Failure 24 44.5
Questionable 10 18.5
10-yr
Success 9 13.0
Failure 55 79.7
Questionable 5 7.3
treatment postoperatively. These patients were not clinically or
radiographically examined; the cases were recorded as failure. In
addition to these, some additional cases of postoperative extraction
or root canal treatment were detected during follow-up appoint-
ments. From a total of 123 teeth, 9 were extracted and 65 resulted
in root canal treatment. Five cases showed radiological signs of
apical rarefaction, which in all cases was not associated with a
periodontal defect.
Fifteen cases showed questionable vitality testing and/or clinical
symptomology, such as swelling or pain on palpation in the apical
area of the tooth. Because these 15 cases were not associated with
radiological symptoms, they were rated as questionable. This re-
sulted in a success rate of 23.6%, a failure rate of 64.2%, and a rate
of 12.2% questionable cases.
Split by the 5-yr and the 10-yr group, the results may be seen in
Table 2.
Results concerning the factors that might affect the treatment
outcome of pulp-capping procedures can be seen in Table 3. All
successful or questionable cases showed calcific metamorphosis in
the coronal or radical pulp space when compared with adjacent
teeth that had not been pulp-capped.
DISCUSSION
Pulp capping has been suggested as one treatment of choice
after pulp exposure. In the present study, of all examined pulp-
capped teeth, 44.5% in the 5-yr group and 79.9% in the 10-yr group
had a postoperative root canal treatment or an extraction. However,
this was a retrospective study with a follow-up of only 30.7% of
the cases. It is unknown what happened with the other 69.3%,
which had been treated in the same time period.
In 1989 Stanley (5) re-evaluated criteria for direct pulp capping
and concluded that the control of bleeding and the contact of
Ca(OH)2 with pulp tissue seem to have an influence on the success
of the procedure. In the present study, it was impossible to reveal
how good the bleeding had been taken care of during treatment.
This had not been recorded in the patients charts. The formation of
a blood clot was shown to have a negative effect on healing of
pulpotomized and Ca(OH)2-capped teeth (6). The same effect may
be present in merely exposed pulps. Similarly, it was not recorded
how heavy the bleeding had been during pulp exposure. Matsuo et
al. (7) reported a significantly higher incidence of failures when the
pulps showed heavy bleeding during the procedure, compared with
moderate or poor bleeding. Another factor that may have contrib-
uted to the relatively high failure rate in this study could be the use
of a setting Ca(OH)2 product (Kerr Life). Staehle et al. (8) exam-
ined in their study the release of Ca2⫹ ions from different Ca(OH)2
Vol. 26, No. 9, September 2000 Pulp-Capping: 5 and 10 Years 527

TABLE 3. Factors possibly influencing treatment outcome

5-Yr Group 5-Yr Group 10-Yr Group 10-Yr Group

Examined Factor of Possible Influence
(success rate in %) (failure rate in %) (success rate in %) (failure rate in %)
Sex
Male 27.2 18.2 3.1 45.4
Female 18.2 36.4 10.9 40.6
Age group
ⱕ40 yr 31.8 36.4 7.8 54.7
⬎40 yr 13.6 18.2 6.3 31.2
Type of tooth
Mandibular 15.9 36.4 1.5 29.7
Maxillary 29.5 18.2 12.5 56.3
Type of tooth
Anterior 4.6 15.9 3.1 15.7
Posterior 40.9 38.6 10.9 70.3
Site of exposure
Cervical 3.2 3.2 5 10
Occlusal 51.7 41.9 25 60
Base material
Glass ionomer 9.8 24.4 17.7 35.3
Zinc phosphate 39.0 26.8 8.8 38.2
Type of restoration
Composite 9.6 9.6 5.4 18.9
Amalgam 38.0 30.9 16.2 37.9
Gold cast — — 2.7 2.7
Temporary — 11.9 — 16.2
Time span before placement of restoration
⬍2 days 45.5 40.9 12.5 73.4
,,,,,,,,,
,
,
,
,
,
,,,,,,,,,
,
*
ⱖ2 days — 13.6 1.6 12.5
Radiological appearance of final restoration
Acceptable 52.2 13.0 50.0 12.5
Unacceptable 30.5 4.3 37.5 —
Clinical appearance of final restoration
Acceptable 66.6 12.5 70.0 —
Unacceptable 16.7 4.2 20.0 30.0
* Difference, p ⬍ 0.05.

formulations. They found that an aqueous Ca(OH)2 suspension
released at least three times more Ca2⫹ ions than setting products.
It may be speculated that this fact, together with the lower pH of
setting formulations, resulted in weaker pulp healing. Mochizuki et
al. (9) compared pulp capping using Dycal, a setting Ca(OH)2
product, or Calvital, a nonsetting paste in dogs. They found that
dentin bridge formation with Dycal needed more time than with
Calvital. It is conceivable that early dentin bridge formation is
essential for successful self-protection of the pulp on a long-term
basis.
An influence of age on success or failure of pulp-capped teeth
could not be seen in the present study. This is in agreement to other
authors (10, 11).
For the type of tooth (anterior versus posterior or mandibular
versus maxillary), we did not find any significant difference in
success/failure rates. Some authors stated that anterior teeth had a
higher failure rate (3, 11). However it is not clear whether these
differences were statistically significant.
It has been shown that the restoration has a major input on
healing of exposed pulps (12). For the 5-yr group there was a
tendency for a higher failure rate in teeth with temporary
restorations, compared with definitive restorations, such as
amalgam, composite, or gold cast restorations. This is also
mirrored in the significantly higher success rate in teeth with
immediate placement of the final restoration (within 1 or 2 days
versus a longer time period). This applied to the 5-yr group
only. Similarly in the 5-yr group there was a tendency to a
higher success rate when zinc phosphate cement was applied as
base, as opposed to the glass ionomer cement. However, there
is no clear explanation for this fact. It is conceivable that,
despite clinical caries excavation before pulp capping, there
were still some remnants of bacteria in the surrounding dentin.
The zinc phosphate cement may have had a higher toxic poten-
tial in eliminating those remaining bacteria than the glass iono-
mer cement. Interestingly the clinical and radiological status of
the restoration did not correlate with success or failure. Clini-
cally the restorations were examined for overhangs and/or gaps.
But this, of course, was only a morphological judgment of the
surface. The sealing quality of the restaurations in the depth of
the cavities could not be investigated. It might have been
superior to the morphological appearance of the surface.
The site of exposure (occlusal versus cervical) could theoreti-
cally be of influence. An inflammation that originates in a cervical
wound might involve the entire coronal pulp because of obstacle
on the access road for vessels, etc., to the coronal pulp. This could
lead to increased pulp death in case of cervical exposure. In the
present study, no difference could be seen between occlusal or
cervical exposure. This confirms a study by Pereira and Stanley
(13) who, as well, did not detect any difference for treatment
outcome in the site of exposure.
528 Barthel et al.
Many other studies reported success rates higher than in the
present study. Some of those had only short-term follow-ups
(Beetke et al. (14) 1 yr: 93.4% success; Armstrong and Hoffman
(2) 1.5 yr: 97.8% success; Fitzgerald and Heys (15) 1 yr: 79%
success). Studies with longer follow-up periods showed lower
success rates (Ahrens and Reuver (16) up to 8 yr: 68% success;
Attin and Hellwig (11) 4 to 6 yr: 69.3% success). Haskell et al. (10)
reported a success rate of 87.2% up to 5 yr. Between the lines,
though, it can be read that success rate decreased down to 76.5%
after a 5-yr survival. In the present study, the 10-yr group showed
tremendously less surviving pulps than the 5-yr group that seems
to confirm the tendency of the study performed by Haskell et al.
One factor that might have contributed to the high failure rate may
be that the procedure was performed by nonprofessionals, namely
students. Baume and Holz (17) mentioned in their study that the
operator skill seems to be a factor of influence. In the present
study, in case of exposure, the students were not allowed to
progress with the capping procedure until a supervisor had checked
indication (pulp capping versus root canal treatment). The next
step was to remove remaining carious tissues, which again, was
checked by a supervisor. This prolonged procedure may have lead
to further pulpal damage resulting in lower success rate.
All questionable and all successful cases showed calcific meta-
morphosis in their pulp space when radiologically compared with
adjacent teeth that had no pulp exposure. This means that root
canal treatment after pulp capping may be impeded, compared
with performing it instead of pulp capping. Because capped pulps
may easily degenerate and die unnoticed, the invasion of micro-
organisms into the pulp space may well progress without being
detected. This may result in an infected root canal system with
apical pathosis. The prognosis of these teeth—if root canal treat-
ment is administered—is less favorable than for teeth with initially
vital pulps (18). This, together with the fact that the access to the
apical parts of root canals may be hindered due to calcifications,
should lead to reconsideration of whether direct pulp capping
should be the treatment of choice in case of carious pulp exposure.
In conclusion it may be recommended that based on long-term
consideration (10 years and more), direct pulp capping should be
avoided if performed as in this study. If vitality of a tooth has to
be prolonged for ⬃5 yr, it may be a treatment of choice. However,
these cases have to be monitored on a regular basis to avoid
unnoticed necrosis of the pulp with invasion of bacteria into the
root canal system. Also, a definitive restoration should be inserted
within the first 2 days.
Journal of Endodontics
Dr. Barthel is assistant professor and Dr. Roulet is chair, Department of
Operative and Preventive Dentistry and Endodontics; and Dr. Leuenberg is
assistant professor, Department of Prosthodontics and Geriatric Dentistry,
Dental School, Humboldt University Berlin, Berlin, Germany. Dr. Rosenkranz
is currently in private practice in Potsdam, Germany. Address request for
reprints to Dr. Claudia R. Barthel, Department of Operative and Preventive
Dentistry and Endodontics, Charité, Humboldt University Berlin, Foehrer Str.
15, D-13353 Berlin, Germany.
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