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 VPT reported success rates ranging from 72.9% to 99.4%. 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 for restorative purposes, such as post placement.

Expanding Indications for Vital Pulp Therapy

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%.

This research underscores the potential for VPT to serve as a conservative treatment option for patients before the need for endodontic intervention arises. 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.

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.

• 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).

Modern Bioceramics in Endodontics

Porcelains have been at the heart of esthetic dentistry since the 1960's with a broad assumption that they are bioinert - not eliciting a reaction from the tissues around them.

Without diving too deep in the science of biomaterials, a bioactive material is one that intentionally elicits a response from adjacent tissues and biocompatability refers to a material that does not cause harm to adjacent tissues.  Biocompatibility is not absolute(1) and requires evaluation of a material's interaction with tissues over time.  In other words, more complex than this discussion.

Advances in dental ceramics have continued to evolve into what we now call bioceramics. These materials include hydroxyapetitie, bioactive glass and calcium silicates.(2)

One of the earliest bioceramics used in Endodontics was Mineral Trioxide Aggregate - a silicate cement.  This bioactive and biocompatible material was unlike anything we had seen before in endodontics.  It could be used in a moist environment - actually requiring moisture to set up, did not seem to irritate the adjacent tissues and bone would form right up against it!  It did not take long for this  material to be used for root repair (additional example) & apicoectomy retrofills.

With the biocompatible success of this material, and seeing that it clinically created good seal, it wasn't long before we began using this bioceramic for direct pulp capping and using this material to replace traditional apexification/apexogenesis a new type of procedures known as pulpal regeneration.

 

One of the biggest challenges with the use of MTA was the grey discoloration of the tooth.  The grey staining of the tooth created esthetic challenges in the anterior.  In effort to address this complication,  Tulsa Dentsply developed a white MTA by reducing the aluminoferrite content.

The bioceramic line up has grown since the development of white MTA with additional calcium silicate cement products from Septodont, Brasseler, Avalon Biomed etc.  These modern bioceramic materials claim to have the impressive properties of:

• Osteogenicity
• Chemically bond to dentin
• Antibacterial (pH>12)
• Hydrophilic
• Hydroxyapatite producing
• No shrinkage
• Good working/setting time
• Easy delivery systems

Every one of these properties make these materials ideal for use in Endodontics. By adjusting the thickness of the material for different applications, we now use these materials as endodontic sealer, root repair material, root end filling materials, pulp regenerative procedures.

With improved esthetics, these modern bioceramics are now the standard of care for pulpal regenerative procedures.

The modern bioceramic materials, with these amazing bioactive and biocompatible properties, are opening up new restorative options when it comes to carious lesions on vital teeth.  

Bioceramics can be placed directly against the pulpal tissue and maintain vitality of the pulp.  This means that direct and indirect pulp capping with CaOH is out and the new bioceramics are in. This new approach includes a major paradigm shift when it comes to pulp capping procedures.  Previously, we attempted to minimize any pulpal exposure.  Now, with the bioactive and biocompatible properties of bioceramics, the goal is complete removal of caries and infected pulpal tissue (even complete pulpotomy if needed) and proper seal with a bioceramic and immediate bonded coronal restoration.  This procedure is known as Vital Pulp Therapy (VPT) and should be considered in your restorative practice in the place of direct and indirect pulp capping.  In an upcoming post, we'll share the steps and cases to help you apply this in your restorative practice.

In a 2021 meta analysis (3) on the prognosis of vital pulp therapy on permanent teeth, when MTA or other bioceramics were used as a capping material they were found to be successful 93% of the time.  This means that VPT should be an option for your treatment of carious teeth - prior to endodontic treatment.

Stay tuned for more info and clinical tips on Vital Pulp Therapy.

Sources:

1. Wataha JC. Principles of biocompatibility for dental practitioners. J Prosthet Dent. 2001 Aug;86(2):203-9. doi: 10.1067/mpr.2001.117056. PMID: 11514810.

2. Dong X, Xu, X. Bioceramics in Endodontics, Updates and Future Perspectives.  Bioengineering. 2023 Mar13;10(3):354.

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