How do you do an indirect pulp cap?

I have been performing my version of an indirect pulp cap for over twenty years. I have had good results and most of the time they work(probably better than 85%). Indirect pulp caps involve leaving some affected dentin over the pulp and medicating it with something that may inactivate any residual bacteria remaining in the layer of 'affected dentin' without killing the pulp. I usually use Dycal as my initial layer over this affected dentin and then place another less water soluble material over it such as Vitrabond, IRM or Miracle Mix. All of these second layers also seem to inhibit decay and the growth of caries forming bacteria. The dycal seems to dessicate the small amount of decay(or affected dentin) remaining, and may then allow secondary dentin to slowly form.

I do remove 95% of the decayed matter in the tooth and will remove very soft dentin material if it is in 'bulk'. I Use very small spoon excavators with tublicid red and very gentle hand pressure to remove the softened dentin near the pulp. I utilize a strong light to illuminate the tooth. so that I can avoid accidentally exposing the pulp. Often when well illuminated the dentin near the pulp is partially translucent and the pink from the pulp can be visible prior to removing the thin layer of dentin covering it. Sometimes the pulp is actually microscopically exposed but not bleeding.

 

                    Before filling                                                                                       After indirect pulpcap




I consider an indirect pulp cap a success if the tooth remains asymptomatic over time, but do periodically check periapical radiographs for signs that the tooth has become non vital such as a periapical radioluscency.