Clinical Steps for Vital Pulp Therapy

The Evolution of Vital Pulp Therapy: A Paradigm Shift in Carious Lesion Treatment

Our previous post introduced the benefits of modern bioceramic materials and their transformative impact on the treatment of carious lesions in teeth with vital pulpal tissue. Traditional methods such as indirect pulp capping, direct pulp capping, or SVEC pulpotomies using calcium hydroxide Ca(OH)2 are now being replaced by a more advanced procedure known as Vital Pulp Therapy (VPT) utilizing modern bioceramic materials. (AAE Position Statement on Vital Pulp Therapy)

The Role of Modern Bioceramic Materials in Vital Pulp Therapy

The foundation of Vital Pulp Therapy lies in the biocompatible and bioactive properties of modern bioceramic materials. No longer do we need to be concerned about the potential for dental materials to damage the pulp or the risk of pulpal exposure during carious excavation. Instead, the focus has shifted to complete caries removal, even if it necessitates partial or complete pulpotomy, followed by immediate placement of a bonded, permanent restoration.

A 2011 systematic review (Aguilar, Panuroot et al.) on cariously exposed vital pulps treated with DPT (direct pulp capping) showed a 72.9% success rate at 36 months compared to 99.4% and 99.3% success on teeth treated with partial and full pulpotomy at the same 36 months.

Furthermore, a 2021 meta-analysis (Sabeti et al.) examining the prognosis of VPT in permanent teeth found that when MTA or other bioceramics were used as a capping material, success rates reached 93%.

These findings highlight that VPT should be strongly considered over traditional direct or indirect pulp capping and as a viable treatment option for carious teeth—except in cases where endodontic therapy is required to due pulpal necrosis or for restorative purposes, such as post placement.

Expanding Indications for Vital Pulp Therapy - IRREVERSIBLY INFLAMMED TEETH

Initially, it was believed that VPT would be limited to teeth with normal or reversible pulpitis. However, emerging evidence suggests that this approach may also be effective for teeth with irreversible pulpitis. A recent 2024 randomized cohort study (Zhang et al.) evaluating VPT using bioceramic materials in cariously exposed pulps with both reversible and irreversible pulpitis found a one-year clinical success rate of 90.4%.

A randomized controlled trial (Jassal et. al.) found that the success rates of vital pulp therapy (with a bioceramic) between partial and full pulpotomies on teeth with irreversibly inflamed pulps was statistically insignificant.  They reports 88% success rate for partial pulpotomy and 91.6% success rate for full pulpotomy at 1 year.

Another systematic review (Cushley et.al.) of permanent carious molars with irreversible pulpitis treated with coronal pulpotomy found a 94% clinical success rate and 88% radiographic success rate at 36 months.

This research underscores the potential for VPT to serve as a conservative treatment option for your patients before the need for endodontic intervention arises. This data would suggest that you can consider treating permanent, cariously exposed teeth with NORMAL, REVERSIBLE and IRREVERSIBLE pulpitis with more conservative vital pulp therapy before you move to full endodontic therapy.

At SSE, our goal is to support your restorative practice by informing you of conservative treatment options you may consider before referring patients for endodontic therapy at Superstition Springs Endodontics.  This treatment is best performed in your office where you can immediately restore your patient with a permanent restoration.

Determining Candidacy for Vital Pulp Therapy

For successful VPT implementation, consider the following criteria:

Vital Pulp Therapy IS an option if:

• The pulp is vital and responds to thermal testing. (Irreversibly inflamed pulps are also in this category)

• The patient understands that a root canal may still be required if the pulp is too inflamed upon access or necroses over time. (Set realistic expectations.)

• The tooth has immature roots that still require apical closure.

Vital Pulp Therapy IS NOT an option if:

• The pulp is necrotic (evidenced by swelling, sinus tract, or periapical lesion).

• Decay is so extensive that root canal therapy is required for restorative purposes (e.g., the need for post placement or extensive decay preventing proper restoration).

Factors That May Improve VPT Success:

• Asymptomatic patients

• Younger patients

• Larger canals/apices

Step-by-Step Guide to Performing Vital Pulp Therapy

1. Pulpal Diagnosis & Informed Consent – Confirm a vital pulp through diagnostic testing and ensure the patient understands that endodontic therapy may still be necessary.

2. Rubber Dam Isolation – Maintain a dry, sterile field.

3. Complete Caries Excavation – Remove all carious tissue, even if pulpal exposure occurs.

4. Hemostasis Control – Apply direct pressure with a cotton pellet to control bleeding. If bleeding persists beyond 3-4 minutes, remove additional pulpal tissue. If necessary, perform a full pulpotomy. If hemostasis cannot be achieved, consider endodontic therapy.

5. Application of Bioceramic Material – Once bleeding has stopped, apply a bioceramic material directly onto the pulpal tissue.

6. Protective Base Placement – Place a glass ionomer base over the bioceramic to prevent washout during bonding of the final restoration.

7. Final Restoration – Place a permanent bonded restoration.

8. Coronal Coverage – Consider full coronal coverage if the tooth requires additional reinforcement.

9. Follow-Up & Monitoring – Conduct periodic evaluations to assess pulpal health and radiographic changes.

Conclusion

Vital Pulp Therapy represents a significant advancement in conservative dental care, providing an effective alternative to traditional pulp capping techniques and, in some cases, even root canal therapy. By integrating modern bioceramic materials into your practice, you can offer patients a more conservative, biologically favorable approach to managing carious lesions while preserving pulpal vitality.

At SSE, we are committed to supporting your practice with the latest advancements in restorative and endodontic treatment options. If you have questions or need guidance on incorporating VPT into your workflow, we’re here to help!

Consider the following case examples.

CASE #1 - VPT with Direct Pulp Cap (Pulp exposed but not removed)

Deep decay on a vital pulp of young patient

Complete caries removal, hemostasis achieved, MTA bioceramic placed on exposed pulp

Immediate, bonded restoration placed

VPT Final

CASE #2 VPT with Partial Pulpectomy

Deep decay on a young patient with vital pulp

Rubber Dam isolation and caries excavation

Pulp exposed, complete caries removed and hemostasis of the remain pulp achieved with pressure

Bioceramic putty placed against the exposed pulpal tissue & glass ionomer base placed over the bioceramic

Bonded restoration placed

VPT completed with partial pulpotomy

CASE #3 - VPT with Complete Pulpotomy

VPT with complete removal of pulpal tissue in the pulp chamber (pulpotomy)

CASE #4 VPT with Partial Pulpotomy

VPT completed with partial pulpotomy

After completing vital pulp therapy on your patients.  Plan to monitor them over time.  Restore them with coronal coverage when appropriate.  If necrosis occurs, endodontic therapy is the next step.

SOURCES:

1. AAE Position Statement on Vital Pulp Therapy, Journal of Endodontics, Sept 2021, Vol 47, No 9, p1340-1344.

2. Vital Pulp Therapy in Vital Permanent Teeth with Cariously Exposed Pulp: A Systematic Review. Aguilar, Panuroot et al. Journal of Endodontics, Volume 37, Issue 5, 581 - 587.

3. Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Sabeti, Mohammad et al. Journal of Endodontics, Volume 47, Issue 11, 1683 - 1695. 

4. Clinical Influencing Factors of Vital Pulp Therapy on Pulpitis Permanent Teeth with 2 Calcium-Silicate Based Materials: A Randomized Clinical Trial. Zhang, Yin, Wu, Wang, Huang, Li.  Medicine (Baltimore) 2024. May 3: 108(18).

5. Outcome of partial and full pulpotomy in cariously exposed mature molars with symptoms indicative of irreversible pulpitis: A randomized controlled trial. Jassal A, Nawal RR, Yadav S, Talwar S, Yadav S, Duncan HF. , Int Endod J. 2023 Mar;56(3):331-344. doi: 10.1111/iej.13872. Epub 2022 Dec 4. PMID: 36403208.

6. Pulpotomy for mature carious teeth with symptoms of irreversible pulpitis: A systematic review. Cushley S, Duncan HF, Lappin MJ, Tomson PL, Lundy FT, Cooper P, Clarke M, El Karim IA. , J Dent. 2019 Sep;88:103158. doi: 10.1016/j.jdent.2019.06.005. Epub 2019 Jun 20. PMID: 31229496.

Avoiding Root Canal Therapy with MTA

Dr. Hale's excellent post on pulp canal obliteration inspired me to share these few cases where a coronal barrier was also used to avoid root canal therapy. The most recognized reason to avoid complete pulpal debridement is biological, to maintain pulpal vitality, and thus continue root formation, subsequently improving fracture resistance, but there also exist technical limitations on the debridement procedure, imposed by anatomy or resorptive defects, that might prevent success of conventional root canal therapy.

This first example is a straightforward partial pulpotomy (or Cvek pulpotomy) with an MTA direct pulp cap. This patient had cerebral palsy and toppled out of his wheel chair causing a complicated (pulpal involvement) crown fracture of #10. You will note #9 was treated at this time as well, and if I recall correctly, was discolored and non-vital from a previous similar trauma. Multiple dental injuries (and traumatic injuries of all kinds) are very common in CP patients due to negative effects on balance. Fortunately, working with a pediatric dentist who scheduled OR time, the patient was seen within two days of the incident and the pulp vitality of #10 was maintained. Remember, inflammation in traumatic exposures very slowly spreads apically, and immature pulps with large vascular supplies are largely resistant to necrosis in the short term.

PreOp

Post-op

1-Year Recall

Please note the complete root formation.

At a 1 year recall, #10 responded normally to vitality testing. Radiographs revealed a complete formed root and a dentin barrier beneath the MTA. Astute viewers will note this success is amazingly in the absence of a coronal restoration (unfortunately, not the only time I've seen bare, unrestored MTA pulp caps succeed at 1 year recalls).

This next case is similar, although a little less conventional. As you can see in the preoperative radiograph, the root is severely dilacerated. While certainly it is possible to perform root canal therapy on this type of root (see my previous post for an arguably more challenging S curve), the difficulty level is unquestionably high. This treatment plan not only reduces the risk of instrument separation, but also saves the patient time and money, and the operator from fatigue.

PreOp

Post-Op

The key here is that this was an asymptomatic carious pulp exposure. In the case of symptoms of irreversible pulpitis, it is generally thought that an MTA pulpotomy is a more risky procedure. It is certainly contraindicated in cases with symptomatic apical periodontitis (although I have had success direct pulp capping an immature tooth with apical periodontitis).

This last case is open to the most controversy. This patient had multiple large composite restorations across the anterior maxillary dentition. He admitted to being far more motivated by financials than esthetics. His previous composite restoration and crown had sheered off unconventionally at an oblique angle to the buccal leaving a substantial cingulum. The fractured portion had been rebonded by his general dentist. This tooth had a history of trauma over 40 years ago and some extensive external resorption is visible overlapping an obliterated pulp chamber and canal. The PDL is definitely in tact and there is no history of symptoms. The option of extraction and implant placement was discussed and encouraged. The alternative treatment plan chosen by the patient is less than ideal and the patient was more than okay with a compromised long-term prognosis. I intentionally described a grim outlook to the patient, as I do with most unconventional treatments, although here I can admit that I am confident in the predictability of the patient's choice. As you can see from the preop radiographs, conventional root canal therapy is impossible due to the irregular resorptive defect sandwiched between obliterated canal space.

PreOp

PostOp

I am still waiting on the general dentist to forward over a restored recall radiograph. Hopefully I will have the image to edit in by the end of the week. You can see the post space that I prepared using a 2 round bur and a gates-glidden with the tip flattened. The post space communicated with the resorptive more coronal than I anticipated, necessitating the use of MTA as a sort of resorptive cap. I feel as long as the area remains aseptic, it is reasonable to assume a successful result.

Here is a bonus case posted on our facebook page, http://www.facebook.com/pages/Alpharetta-Endodontics/137382942943581 . I'd encourage everyone to follow there (and check the backlog of case photos) for more interesting cases.

The patient's symptoms were intermittent, spontaneous, a 6 or 7 out of 10 on the pain scale, occasionally throbbing, and worse with mastication and pressure. The key history here is the patient's remark, "it feels like my gums are coming loose from my tooth."

Make the diagnosis. I have obviously helped by circling the key components.

Research Update: Use of MTA for Direct Pulp Capping

In a recent post, we have discussed the use of MTA as a pulp capping agent.

A recent article by Yasuda, Ogawa, Arakawa, Kadowaki and Saito entitled "The Effect of Mineral Trioxide Aggregate on the Mineralization Ability of Rat Dental Pulp Cells: An In Vitro Study" may shed some light on the reasons MTA may be more effective than calcium hydroxide for direct pulp capping.

Direct pulp capping is an effort to maintain the vitality of a dental pulp following exposure during excavation and thereby avoid endodontic therapy. The formation of a dentinal bridge over the exposed pulp surface is the goal while maintaining pulpal vitality.

Conventional pulp capping treatment included medicating the exposed pulp with calcium hydroxide (ie. Dycal) prior to restoration. Calcium hydroxide is known to cause an inflammatory reaction of the dental pulp. Appication of adhesive resins has also been attempted. Incomplete dentinal bridges has been found with a lack of published long term clinical results.

It has been reported that MTA induces the formation of dentinal bridging with little or no inflammation. MTA is known for it's biocompatibility and lack of cytotoxicity. Tani-Ishii et. al. reported that MTA upregulated the expression of type I collagen and osteocalcin in osteoblasts.

Bone morphogenic proteins (BMP's) are crucial to bone and collagen formation. BMP-2 and it's receptor are expressed in the dental pulp. BMP-2 has been shown to accelerate the differentiation of human pulp cells into odontoblasts. This study hypothesized that BMP-2 is involved in the MTA induced mineralization.

This study found that MTA significantly stimulated mineralization (in rat dental pulp cells) by 60% compared to the controls. MTA and Dycal both significantly upregulated by 2-fold the level of BMP-2 mRNA compared with the controls. MTA increased the BMP-2 protein production by 40% while Dycal significantly reduced it. The authors suggest that BMP-2 may play an important role in mineralization stimulated by MTA.

MTA has shown promise as a direct pulp capping agent which may improve the success of direct pulp capping over convention calcium hydroxide techniques.

Sources:
Yasuda, Ogawa, Arakawa, Kadowaki, Saito. "The Effect of Mineral Trioxide Aggregate on the Mineralization Ability of Rat Dental Pulp Cells: An In Vitro Study". JOE 2008; 34:1057-1060.

Tani-Ishii, Hamad, Watanabe, Tujimoto, Teranaka, Umemoto. "Expression of Bone Extracellular Matrix Proteins on Osteoblast Cells in the Presence of Mineral Trioxide". JOE 2007; 33:836-839.

Research Update: Direct Pulp Capping with MTA

A recent study published in the Journal of the American Dental Association discusses the use of MTA (Mineral Trioxide Aggregate) as a direct pulp capping agent.

Up to now, MTA has been used mainly by specialists, mostly endodontists, as a restorative material for root end fillings (apico retrofills) and root perforation repair. However, new applications for MTA may put it in the hands of a wider variety of practicioners.



MTA is a bioactive silicate cement. It is essentially a medical grade portland cement. There are several properties of MTA that make it such an ideal material. It has small particle size, alkaline pH when set and slow release of calcium ions. It is known for its sealing ability. It has also been reported to induce cell proliferation, cytokine release, hard tissue formation and an interface with dentin resembling hydroxyapatite. It is non-absorbable and requires moisture to set. In short, its sealing ability, biocompatibility & hydrophilic nature make it an excellent repair material.

Endodontists have been using MTA for pulp capping, apexification/apexogenesis for all of the properties described above. The recent article by Bogen, Kim & Bakland provide evidence that supports the use of MTA as a direct pulp capping agent.

The authors selected 53 teeth that had deep caries with vital pulpal tissue and no prior restorations. Caries were removed under magnification and NaOCl was used to obtain hemostasis within a short period of time (1 to 10 min.). 1.5-3.0mm thick layer of MTA was placed over the exposure. The teeth were restored provisionally with unbonded resin restoration. At a subsequent visit, the teeth were restored with a bonded restoration.

Over a 9 year period of observation, the authors found that 49 of 53 had a favorable outcome on the basis of radiographic appearance, subjective symptoms & cold testing. All teeth (15 of 15) in younger patients with open apices showed completed root formation (apexogenesis).

Many are reluctant to perform direct pulp capping procedures due to unpredictable outcomes with traditional materials. MTA may be a more predictable and successful material for direct pulp capping teeth with a pulpal condition no more severe than reversible pulpitis.

(Source: Bogen, George, Kim, Jay, Bakland, Leif. "Direct Pulp Capping with Mineral Trioxide Aggregate", JADA 2008, 139:3, p 305-315.)