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
Pulpal Diagnosis & Informed Consent – Confirm a vital pulp through diagnostic testing and ensure the patient understands that endodontic therapy may still be necessary.
Rubber Dam Isolation – Maintain a dry, sterile field.
Complete Caries Excavation – Remove all carious tissue, even if pulpal exposure occurs.
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.
Application of Bioceramic Material – Once bleeding has stopped, apply a bioceramic material directly onto the pulpal tissue.
Protective Base Placement – Place a glass ionomer base over the bioceramic to prevent washout during bonding of the final restoration.
Final Restoration – Place a permanent bonded restoration.
Coronal Coverage – Consider full coronal coverage if the tooth requires additional reinforcement.
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.
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| Deep decay on a vital pulp of young patient |
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| Complete caries removal, hemostasis achieved, MTA bioceramic placed on exposed pulp |
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| Immediate, bonded restoration placed |
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| VPT Final |
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| Deep decay on a young patient with vital pulp |
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| Rubber Dam isolation and caries excavation |
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| Pulp exposed, complete caries removed and hemostasis of the remain pulp achieved with pressure |
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| Bioceramic putty placed against the exposed pulpal tissue & glass ionomer base placed over the bioceramic |
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| Bonded restoration placed |
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| VPT completed with partial pulpotomy |
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| VPT with complete removal of pulpal tissue in the pulp chamber (pulpotomy) |
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| VPT completed with partial pulpotomy |
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).
