Guys, Minder is one of the poor students exploited by the UK government
to fill the holes in the crumbling NHS dental service. They now send
them around to meet demands and call this "part of the training".
Nothing personal Minder :)

Minder, my first post in this forum was pretty much the same as yours:
how to do good posterior composites. What I've learnt is to ditch
dycal, GI as well as pretty much everything I've learnt in the school.
Since then, I've bonded directly no matter how close I was to the pulp,
used a layer of flowable composite and then finished with a packable or
hybrid composite placed in small increments. Excellent results and any
post-op pain or sensitivity is much-much less than when I've been using
GI as a base.

Take care,
George

I only use CaOH as a temporary over a pin point pulp exposure. I flick
it off just prior to bonding.  Recent studies do not show CaOH to help
in deep restorations.  I use it to kill bacteria on the exposure prior
to bonding.
..
Stephen Mancuso, D.D.S.
Troy, Michigan, USA

I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting.

One of the gurus who researches pulp-capping is Charles Cox.  He said
if I recall correctly at a continuing ed speech, that the best
pulp-capping material is just composite resin.  You just need an inert
biocompatible barrier over the exposed pulp, and composite resin is
best.  He said no one really understands why CaOH works as a
pulp-capping agent, and that CaOH is a risky pulp-capping agent to use
because it is brittle and may chip off in little pieces into the pulp,
causing an inflammation reaction in the pulp-capping site.  The
rationale that CaOH raises PH and thus kills micro-organisms is not
evidence-based.  He says studies show that vitrebond or GIC show higher
failure rates as pulp-capping agents compared to composite resin.  Also
that eugenol is toxic to the pulp and should not be used on vital pulps
or pulp capping, so no ZOE.  So the best pulp capping agent is
apparently plain old etch, prime, bond, composite.  Make sure the
composite is cured perfectly over the pulp.  Uncured composite may
contain irritating chemicals.  Put a thin layer over the pulp, light
cure thoroughly, then build up the rest.

Also, be very careful of occlusal prematurities from the composite.
Composite materials are challenging to adjust so that their occlusion
is perfect.  But if the occlusion is off on your composite, the patient
may return with symptoms of sensitivity to hot and cold or sensitivity
to biting that mimic those of irreversible pulptis.  So you might
think, oh, the tooth was pulp-capped, and now the nerve is dead because
the patient has symptoms of irreversible pulptitis.  But no!  The truth
may be that the pulp cap worked, but the occlusion was off, so the
patient has symptoms.  Don't do a pulpotomy on the tooth, just adjust
the occlusion and wait and see.  Use articulating paper prior to
filling to note the occlusal mark pattern on the teeth on the
contra-lateral side, then make sure after you fill the tooth that you
can duplicate that same pattern of occlusal markings.

Realize that pulp-capping is not yet an exact science and that most of
what was learned in dental school about this is conceptually
disorganized garbage, like so much of what is learned in dental school.
So, to summarize, don't use ZOE, don't use eugenol-containing things,
don't use vitrebond, don't use CaOH, don't use dycal (which interferes
with bonding of composite).  Just pulp cap with plain old composite
resin and make sure there are no occlusal prematurities.  And if the
patient comes back with pain, first adjust the occlusion and wait and
see, and only if the pain is persistent should you consider pulpotomy
and root canal.

--Johnny

This is an old thread (to say the least) but since I still don't have an
internet reconnection, I'm looning through the old stuff that I never
had time to get to (seein' as how I'm managing the World single-handedly
these days).

I would have placed Fuji 9 on the whole shebang, and I would have
painted over the F9 with the protective light cured varnish they supply
for when you want F9 to be the final restoration. Then I would have just
let it settle down for at least a couple of months. Then (assuming you
could go back to do another procedure in two or three months) I would
have thinned it down with diamond burs and LOTS of H2O (as in water) and
relied on my memory and my nose to keep me from re-exposing the deep
parts. Then I would have covered it over like you did with etch and
bonding and composite. F9 etches and bonds well.

The advantage of this is that Fuji 9 has sedative properties in it. It
is a compomer that was originally inteded to be an easy to place
restoration for the Third World; BareFoot Doctor type stuff. Since then,
the composite gurus have found this added advantage for it and I have
personally found that doing just what I described above is often the
best solution. Quebec is the Third World in the First World.

In fact, what happens is that they often cannot get back to me in three
months time to have the work finished. So, six months to a year later, I
have to be careful, as I no longer remember much about the prep's
dangerous zones. If you have a camera, you could document the excavated
tooth for later reference.

Hope this helps
SP