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Inside Dentistry
December 2020
Volume 16, Issue 12

Re-treating a Hyperemic Tooth With Deep Caries

Restoration with calcium silicate liner offers conservative alternative to traditional RCT

Mark Malterud, DDS

A fellow Iron Ranger from Northern Minnesota, Bob Dylan, titled a song about the changing times in the 1960s, The Times They Are a-Changin', which is also a very appropriate title for the future of dentistry with regard to preserving pulpal vitality in compromised teeth. Historically, a tooth such as tooth No. 28 in this case report (Figure 1) would likely be restored with root canal therapy (RCT), followed by a post, core, and crown. However, the time has come to take a step back and consider some new pulpal treatments that may give the tooth a chance to remain vital. Dentists are often confronted by patients who have read information online or heard from a friend about the negative aspects of RCT. These beliefs, which are being pushed by docudramas such as Netflix's Root Cause, provide insight into the mindset of a significant portion of the population. Despite the lack of evidence to substantiate many of these claims, many patients come to our offices with their minds made up about treatment. RCT already has a bad reputation, and it is becoming harder to educate the ever-growing masses about the safety and efficacy of current RCT procedures.

What if clinicians consider the growing body of evidence on pulpal treatment success and spend the time and effort to take a tooth with deep pulpal pathosis that is still vital (albeit hyperemic) and preserve its vitality? In many instances, that dreaded RCT can be avoided while still saving teeth that would previously have been condemned. This case report illustrates a procedure that utilizes a calcium silicate-based pulpal liner to help stimulate an alkaline pH and apatite formation,1 pushing the boundaries of material science to show that, indeed, the times are changing.

Case Report

A patient presented to our office for an emergency appointment for a tooth (ie, No. 28) that was extremely hyperemic with sensitivity to cold and sweets with slightly lingering discomfort. The clinical presentation was a failed amalgam restoration with deep caries approximating the pulp (Figure 2). Regarding treatment options, the patient wanted to try anything other than an RCT procedure to save the tooth and, ultimately, preferred to have an extraction if vitality could not be restored.

The area was anesthetized, the tooth was isolated, and the carious lesion was removed, resulting in a large pulpal exposure (Figure 3). There was some initial bleeding, but it subsided after rinsing with ozonated water. The area was then disinfected with ozone gas. Once the bleeding had stopped (Figure 4), the resin-modified calcium silicate pulp protectant/liner (TheraCal LC®, BISCO Dental) was placed over the pulp in very thin increments and polymerized with a curing light (Figure 5). This material's calcium release1 stimulates hydroxyapatite and secondary dentin bridge formation, which leads to a protective seal and insulation of the pulp.2,3

Once the liner was in place covering the exposure, the rest of the prepared tooth structure was air abraded to create surface texture to improve its ability to bond.4 The area was then total etched, a bonding agent was applied, and the tooth was restored with a direct-filled composite resin restoration. After the pulp cap and restoration were completed on tooth No. 28, the adjacent failing restoration, which also exhibited excess material, was removed from tooth No. 29, and the tooth was retreated in the same manner. An immediate final radiograph (Figure 6) and final postoperative clinical photograph (Figure 7) were taken to confirm the seal of the restorations and the current state of the apices. The next day, the patient was called to confirm that the tooth was calm and comfortable.

The practice has been able to follow this case for more than 6 years since its completion, and the tooth has remained comfortable and vital to thermal pulpal testing with no adverse responses to percussion or palpation. A 57-month posttreatment radiograph (extraoral view) demonstrates no radiographic evidence of pulpal pathosis (Figure 8).


New patient beliefs and new products have changed the way that a hyperemic tooth is approached. Rather than following the traditional route of RCT, post, core, and crown, in some cases, it may be possible to maintain tooth integrity and even maintain pulpal health using updated materials and techniques. To date, this author's practice has restored more than 250 direct and indirect pulpal exposures using the protocol described in this case report, maintaining greater than 96% pulpal vitality.

About the Author

Mark Malterud, DDS
Private Practice
Saint Paul, Minnesota

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1. Gandolfi MG, Siboni F, Prati C. Chemical-physical properties of TheraCal, a novel light-curable MTA-like material for pulp capping. Intl Endod J. 2012;45(6):571-579.

2. Francisconi LF, de Freitas AP, Scaffa PMC, et al. Water sorption and solubility of different calcium hydroxide cements. J Appl Oral Sci. 2009;17(5):427-431.

3. Arandi NZ. Calcium hydroxide liners: a literature review. Clin Cosmet Investig Dent. 2017;13(9):67-72.

4. Motisuki C, Monti Lima L, Emi Sanabe M, et al. Evaluation of the microtensile bond strength of composite resin restoration in dentin prepared with different sizes of aluminum oxide particles, using the air abrasion system. Minerva Stomatol. 2006;55(11-12):611-618.

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