By the BossCE Editorial Team.
Key Points
- The American Association of Endodontists (AAE) favours hydraulic calcium silicate cements for vital pulp therapy, reporting 85–100% success at 1–2 years when used for irreversible pulpitis in permanent teeth [1].
- Calcium hydroxide, glass ionomer and resin-based materials “trail in clinical outcomes”, with reported success of 43–92% [1].
- Disinfect and control bleeding with sodium hypochlorite, seal immediately with a long-term restoration, and review the tooth over at least the first year [1, 3].
What Counts as Vital Pulp Therapy
Vital pulp therapy (VPT) aims to keep the pulp alive. It covers indirect pulp capping, direct pulp capping, and partial or complete pulpotomy [1]. The AAE notes that a pretreatment diagnosis of irreversible pulpitis is “not necessarily an indication for pulpectomy”, and that even symptomatic pulps may be candidates for VPT [1].
Diagnosis and Case Selection
- Sensibility tests: use pain history with cold and electric pulp testing; definitive tests of pulp vitality are not available clinically [1].
- Warning signs: an exaggerated, lingering response to cold indicates more severe inflammation, and pain on percussion suggests irreversible pulpitis [1].
- Look at the pulp: direct observation of the exposed pulp under magnification helps judge whether it is suitable for VPT [1].
Caries Removal: Two Approaches
Guidance differs here, and it is worth knowing both positions:
- AAE (2021): complete caries removal, so the pulp can be examined under magnification before deciding on treatment [1].
- European Society of Endodontology (ESE, 2019): in teeth without clinical symptoms, non-selective (complete) caries removal is not warranted, and selective removal reduces the likelihood of pulp exposure [2, 3].
In practice, the presence or absence of symptoms often decides which approach fits the case.
Haemostasis and Disinfection
Sodium hypochlorite is used to control bleeding, disinfect the exposure and remove clot and debris. The AAE describes typical practice as bathing the resected pulp tissue in sodium hypochlorite for 5 to 10 minutes, while noting that recommended durations vary [1].
Choosing the Capping Material
| Material | Role in VPT |
|---|---|
| Hydraulic calcium silicate cements (MTA and newer calcium silicates) | First choice for pulp capping and pulpotomy. MTA is the most studied; calcium silicates form better mineralised barriers than calcium hydroxide, and newer formulations set faster and discolour less [1]. |
| Calcium hydroxide | Lower and less predictable success than calcium silicates [1]. |
| Glass ionomer and resin-based materials | Lower success as capping agents [1]. Resin placed directly on the pulp is not recommended for biocompatibility reasons [3]; these materials belong in the restoration over the calcium silicate. |
Aesthetic zone: early MTA formulations can discolour the tooth, so a non-discolouring calcium silicate is preferable in visible areas [3].
Restore Straight Away
The AAE recommends that immediate restoration be part of the treatment plan, reporting high success with immediate placement of a long-term restoration over calcium silicate cements, along with less microleakage and less postoperative sensitivity [1]. Plan cuspal coverage once symptoms have settled and fracture risk has been assessed [1].
Follow-Up
Review clinically and radiographically at 6 and 12 months, extending up to 4 years if there are concerns [3]. Most failures of calcium silicate VPT appear within the first 6 months [3].
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References
- American Association of Endodontists. AAE Position Statement on Vital Pulp Therapy. 2021. aae.org
- Duncan HF, Galler KM, Tomson PL, Simon S, El-Karim I, Kundzina R, et al. European Society of Endodontology position statement: management of deep caries and the exposed pulp. International Endodontic Journal. 2019;52(7):923–934. doi:10.1111/iej.13080
- Partial pulpotomy to successfully treat a caries-induced pulpal micro-abscess: a case report. Frontiers in Dental Medicine. 2021;2:678632. doi:10.3389/fdmed.2021.678632
This article is for qualified healthcare professionals and is not a substitute for clinical judgement or the full guideline. Check the current version of each source before applying it.