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The Understanding of Vital Pulp Therapy in Permane
The Understanding of Vital Pulp Therapy in Permane
The Understanding of Vital Pulp Therapy in Permane
Review Article
The Understanding of Vital Pulp Therapy in Permanent Teeth: A
New Perspective
Wei Shang ,1 Zeliang Zhang,1 Xicong Zhao,1 Qingquan Dong,2 Gerhard Schmalz ,3
and Shaonan Hu 2
1
Department of Stomatology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000 Shanxi, China
2
Department of Stomatology, Changzhi Medical College, Changzhi, 046000 Shanxi, China
3
Department of Cariology, Endodontology and Periodontology, University Leipzig, Liebigstr 12, 04103 Leipzig, Germany
Correspondence should be addressed to Wei Shang; 171847002@masu.edu.cn and Shaonan Hu; shaonan.hu@xs.ustb.edu.cn
Copyright © 2022 Wei Shang et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The indications of vital pulp therapy (VPT) are expanding, which cases are suitable for VPT, and how to improve the success rate
of VPT is a problem that often bothers us. The main purpose of VPT is to eliminate pulpitis by promoting the formation of
reparative dentin or calcium bridge, so that it can continue to perform various physiological functions, and finally achieve the
purpose of preserving pulp vitality and long-term preservation of affected teeth. Pulp capping and pulpotomy are the most
common methods for VPT. The research field of VPT has attracted the attention of many scholars, who have studied it from
many aspects (such as indications, material selection, operation requirements, and long-term prognosis). This article reviews
the recent advances in the techniques of VPT in permanent teeth.
1. Introduction tin as much as possible from the diagnosis of the teeth to the
preparation of pulp holes and the enlargement and forma-
Caries, pulpitis, periapical disease, periodontitis, and dental tion of root canals. At the same time, histological and micro-
trauma are common diseases in stomatology. A common biological studies have found that the inflammation and
feature of these diseases is that they may involve pulp tissues, microbial infection of irreversible pulpitis may only exist in
causing inflammation and subsequently necrosis of pulp tis- the local pulp tissue near the lesions and do not involve
sues. Root canal therapy (RCT) is the most common and the entire pulp [4]. A few millimeters away from the
successful method to solve this kind of problems. Studies infected, necrotic pulp, the pulp tissue is usually free of
have shown that most teeth with sufficient root fillings and inflammation and bacteria [5]. The traditional concept is
appropriate restorations are able to maintain function and that once bacteria infect the pulp, the pulp tissue cannot
health for more than 20 years [1]. However, the traditional repair itself, and the treatment requires complete removal
RCT is related to several drawbacks. Some studies have of the pulp [6]. However, current research has found that
shown that all RCT systems will lead to the accumulation dental pulp tissue can prevent the penetration of bacteria
of stress along the tooth structure. Excessive tooth tissue cut- in dentin by producing reactive or reparative dentin [7].
ting in RCT may lead to insufficient tooth resistance, result- Pulpitis-derived stem cells showed similar proliferative
ing in the occurrence of tooth fracture [2]. Thus, RCT is capacity and multidirectional differentiation potential as
always related with a certain risk of failure. healthy dental pulp-derived stem cells [8], suggesting that
With the development of oral materials and equipment pulp in irreversible pulpitis can be properly retained and
and the deepening of basic oral research, Gutmann [3] has should not be completely removed.
successively put forward the concept of minimally invasive Recently, according to the concept of the MIE, some
endodontics (MIE). It is advocated to preserve healthy den- scholars suggested that the mature permanent teeth with
2 BioMed Research International
pulp exposure and irreversible pulpitis should be treated ies in young permanent teeth. The traditional indirect pulp
with less invasive VPT, a feasible advantage alternative to capping of young permanent teeth using calcium hydroxide
traditional pulp therapy [9]. The concept of vital pulp pres- preparation, Dycal, showed a high success rate ranging
ervation is beneficial to simplify clinical operation and long- between 77.78% and 93% [15–17]. For deep caries of young
term retention of the teeth, which will become the trend of permanent teeth, the effect of two-step indirect pulp capping
pulp treatment in the future. Especially due to the fact that is superior against one step [18]. In recent years, with the
vitality is a crucial predictor for tooth preservation, thera- emergence of new technologies, the one-step method has
peutic procedures keeping the teeth vital appear contempo- also been widely used, and bioceramic materials have also
rary. Many recent studies including some controlled been affirmed in many studies on indirect pulp capping of
studies have showed that young or mature permanent teeth young permanent teeth [19]. Radiographic and clinical
clinically diagnosed with reversible or irreversible pulpitis results of TheraCal and Biodentine also suggest that they
could be successfully treated with VPT (Tables 1 and 2). can be used as alternative materials for IPT in young perma-
In clinical practice, VPT can generally be divided into nent teeth [17], with a success rate of approximately 95.83%.
indirect pulp capping, direct pulp capping, and pulpotomy, Recently, Sharma et al. have found that the use of Biodentine
among which pulpotomy can be further divided into partial combined with laser has an additional effect on the forma-
pulpotomy and total pulpotomy, which are applied differ- tion of tertiary dentin. The antibacterial laser can penetrate
ently in different age stages. This narrative review article will dentinal tubules and accelerate the formation of dentin brid-
summarize the current evidence on these therapeutic proce- ges in deep caries lesions [20].
dures and derives practical consequences based on the avail-
able literature. 2.2. Direct Pulp Capping of Young Permanent Teeth. For
direct pulp capping of young permanent teeth, it is currently
2. VPT of Young Permanent Teeth believed that the effect of bioceramic material as pulp cap-
ping material is excellent, and its performance is better than
Young permanent teeth refer to permanent teeth that have that of traditional pulp capping material calcium hydroxide
erupted but have not yet established occlusal relationship (CH). The success rate of calcium hydroxide ranged from
and have not been fully formed and mature in morphology 70% to 100% [21], while the success rate of bioceramic mate-
and structure. Their characteristics include short clinical rials was significantly higher than that of CH, with a success
crown, wide pulp cavity, thin tooth hard tissue, short root, rate ranging between 92.6% and 100% [22–24]. This suggests
and trumpet-shaped apical foramen. Generally, within first that both mineral trioxide aggregate (MTA) and Biodentine
3-5 years after the eruption of permanent teeth, the root are viable substitutes for CH, and the use of bioceramic
can be gradually developed and completed [10, 11]. During materials can significantly improve the success rate of treat-
this period, various factors, such as caries, developmental ment. Among them, Biodentine has the advantage of not
deformity, and trauma, may cause pulp lesions or even pulp causing tooth discoloration and has better development
necrosis and spread to surrounding tissues. After pulp prospects [25]. Due to the use of bioceramic materials, the
necrosis, the root development cannot continue in physio- indications for the diameter of pulp exposure for direct pulp
logical manner [12]. Because the apical orifice is open, the capping of young permanent teeth can also be relaxed
conventional RCT cannot tightly seal the lumen, so it is appropriately. This result is not only related to the selection
not suitable for the control of the infection. In addition, of materials, but the selection of cases also has an impact on
due to the thin root canal wall and poor resistance, the tooth the results of the study; some studies have shown that the
became easier to fracture [13]. Therefore, the research on success rate of cases with mechanical pulp exposure is higher
endodontics of young permanent teeth has attached more than that of caries-derived pulp exposure [26]. A good
importance in recent years. crown closure also helps to improve the success rate [27].
Compared with developed permanent teeth, the pulp tis-
sue of young permanent teeth has the characteristics of rich 2.3. Pulpotomy of Young Permanent Teeth. The cellular com-
blood supply and high cell composition, which makes its ponent of the coronal pulp tissue of young permanent teeth
regeneration and repair ability stronger. Therefore, the is richer than that of the root pulp tissue, while the fibrous
remaining pulp after VPT can promote the physiological tissue is on the contrary; moreover, the coronal pulp tissue
development of apical foramen of young permanent is less than the root pulp tissue [28]. Therefore, in terms of
teeth [14]. histology, partial pulpotomy has the least impact on the
VPT for young permanent teeth include indirect pulp development of young permanent teeth, and the prognosis
capping, direct pulp capping, partial pulpotomy, and total is better. Relevant clinical studies have also confirmed this
pulpotomy. Among them, indirect pulp capping and direct [29–32]. Related research on bioceramic materials is also
pulp capping preserve the complete pulp and have a more available, whereby most studies show the excellent prospects
positive effect on tooth development, while partial pulpot- of new bioceramic materials in pulpotomy treatment
omy and total pulpotomy belong to partial pulp [33–37]. Some studies have used Biodentine, MTA, and
preservation. CH to perform partial pulpotomy in terms of caries treat-
ment of immature permanent molars. All three showed a
2.1. Indirect Pulp Capping of Young Permanent Teeth. Indi- high success rate [31, 38]. There are also some studies show-
rect pulp capping is a routine treatment for deep dentin car- ing that pulp preservation of young permanent teeth may
BioMed Research International 3
Table 1: Success rate of different therapeutic strategies in young permanent teeth. CE: carious exposure; TE: trauma exposure.
Table 2: Success rate of different therapeutic strategies in mature permanent teeth. CE: carious exposure; TE: trauma exposure.
CH MTA Biodentine
Therapy Etiology Follow-up or Success rate Follow-up or Success rate Follow-up or Success rate
study (%) study (%) study (%)
Indirect pulp 1 years [60] 96.8%
CE 2 years [61] 96.01%
therapy 2 years [61] 91.7%
12-27 months
1.5 years [90] 83.3% 56.2%
[90] 1.5 years [90] 92.3%
5 and 10 years 37% at 5 years
3.6 years [90] 91.3%
[90] 13 at 10 years 1-1.5 years [90] 82.6%
13 years [90] 31.9% 1.5 years [90] 84.6% 6 months [67] 96%
CE 3 years [68] 52% 3 years [68] 85% 1 years 86%
Direct pulp
6 months [67] 74% 6 months [67] 91% 2-3 years 86%
capping
1 years 65% 1 years 86%
2-3 years 59% 2-3 years
84% 81% 3 years [25] 91.7%
4-5 years
4-5 years 56%
3 years [25] 96%
Matoug- 79.4%-100% Matoug- 80%-100% Matoug- 80%-91%
TE
Elwerfelli, M [110] Elwerfelli, M [110] Elwerfelli, M [110]
24-42 months
5 years [90] 65% 100% 100% clinical
[90]
25 ± 14 months
1-4 years [90] 91.6% 90%
[90]
CE 1 years [90]
Pulpotomy 14-72 months
92.3% 3 years [90] 92.7% 98.4% radio
[90]
14-88 months
65% 1.5 years [90] 84.6%
[90]
TE 1-2 years [105] 94.1%
4 BioMed Research International
Accessory canal
Dental pulp Gutta percha Periodontal ligament
lateral canal
Restoration
Bioceramic material
Figure 1: Schematic diagram of application of VPT. (a) Direct pulp capping, (b) partial pulpotomy, (c) total pulpotomy, and (d) root canal
therapy.
have broader indications. For the indication of pulpotomy, Some scholars used Biodentine and MTA to compare the
the size of the pulp exposure, the time, and the location of clinical and imaging effects of pulp revascularization of
pulp exposure, whether it is irreversible pulp inflammation young permanent teeth and found that there was no signifi-
and even periapical periodontitis, are not necessarily related cant difference between them [49]. Peng et al. [50] compared
[39–46]. It is suggested that the status and repairing ability 60 young permanent teeth with pulp necrosis with MTA and
of the pulp have more important significance in the progno- glass ionomer cement (GIC). The results showed that MTA
sis of pulpotomy [47]. was better than GIC. MTA, as a common crown sealing
material for pulp revascularization [51], has obvious thera-
2.4. Pulp Regeneration of Young Permanent Teeth. In recent peutic effect but can lead to crown discoloration [52]. With
years, research on dental pulp regeneration has attracted the the emergence of new materials such as iRoot BP, Bioden-
attention of many scholars. There are three methods used in tine, and other bioceramic materials, it has been reported
clinical cases of young permanent teeth, namely, dental pulp that using Biodentine as crown sealing material does not
revascularization, dental pulp stem cell (DPSC) transplanta- cause obvious crown discoloration [53], which provides
tion, and deciduous tooth pulp autotransplantation. more material options for avoiding complications after pulp
As a relatively new and popular treatment method, pulp revascularization.
revascularization is mainly used to treat pulp necrosis of There is one clinical study on the use of DPSC transplan-
young permanent teeth with open apices. In 2017, a meta- tation in the treatment of pulp regeneration in young per-
analysis [48] compared the effects of regenerative pulp treat- manent teeth. In 2018, Xuan et al. [54] recruited 40 young
ment based on pulp revascularization technology with MTA patients with posttraumatic dental pulp necrosis. After
apical sealing. The results showed that the success rate of autologous DPSC implantation, the three-dimensional den-
regenerative pulp treatment group was 91.3% (“success” is tal pulp tissue with blood vessels and sensory nerves was
defined as clinically asymptomatic, radiographic complete regenerated. No adverse events were observed after 24
healing of apical lesions) and that of MTA apical sealing months of follow-up. At present, there are few relevant stud-
group was 94.6%. There was no significant difference in ies on stem cell transplantation, and the number of cases is
tooth survival and success rate between the two groups, small, so more in-depth research is needed.
but 79% of the cases in the regenerative pulp treatment Cehreli et al. [55] recruited 4 patients aged 8-11.5 years,
group continued to develop, indicating that pulp revascular- and five previously traumatized maxillary incisors were
ization may be a more advantageous treatment scheme. treated with a regenerative endodontic treatment protocol
BioMed Research International 5
that used 2.5% NaOCl irrigation and placement of calcium improvement of treatment level, the indications of direct
hydroxide dressing in the first visit. After 4 weeks, the intra- pulp capping of mature permanent teeth have expanded,
canal medication was removed, and the whole pulp tissue and the diameter of the perforating hole has gradually
harvested from the neighboring maxillary deciduous canine expanded to more than 1 mm. A number of studies per-
was transplanted into the disinfected root canal without formed direct pulp capping on the teeth with pulp exposure
induced apical bleeding. Following placement of a MTA cor- >1 mm, all of which showed the formation of dentin bridges,
onal barrier, the access cavities were restored with acid-etch and the bioceramic material group was significantly better
resin composite. Three patients were followed-up for 24 than the CH group [63–66]. More results show that CH as
months and 1 patient for 12 months. All teeth demonstrated a pulp capping agent will lead to uncertain treatment results
radiographic evidence of complete periapical healing, slight and reduce the long-term success rate [67, 68]. The research
increase in dentinal wall thickness, and continued apical clo- shows that the success rate of CH in 2-3 years is 52%-59%,
sure in the absence of clinical symptoms. A positive response while the success rate of bioceramic materials in 2-3 years
to cold test was obtained in 1 incisor at 12 months and 2 at is 85%-93.8% [25, 67]. To analyze the reasons, on the one
24 months. At present, there is few research on the treat- hand, different biomaterials have different effects; on the
ment of pulp necrosis of young permanent teeth by autolo- other hand, the health status of exposed pulp is different,
gous pulp transplantation, and more in-depth studies are and the success rate of direct pulp capping of affected teeth
needed. in different age groups is significantly different. A study of
148,312 affected teeth showed a higher success rate in the
3. VPT of Mature Permanent Teeth “<18” age group compared to an overall success rate of
71.6% [69]. Another study also showed that participants
For the vital pulp preservation of mature permanent teeth, under the age of 40 years were 1.23 times more likely to be
the previous concept believed that the dental pulp tissue is successfully treated than those 40 years or older [70]. As a
located in the hard tissue of the tooth, which is only con- promising new capping agent, compared to MTA, Bioden-
nected with the outside world through the narrow apical tine has the advantages of better sealing, faster coagulation,
foramen, lacks collateral circulation, and has a weak ability and no staining [71]. Recently, a new type of injectable-
to resist infection. Therefore, the indications for the VPT treated dentin matrix hydrogel (TDMH) has emerged, pro-
of mature permanent teeth are limited to a very small range, viding clinicians with a wider range of choices. Experiments
which will be carefully selected in clinical practice, and RCT demonstrate that TDMH has a greater potential to induce
will be selected in majority of cases [56]. However, the dentin bridge formation than Biodentine and MTA under
research on pulp preservation of irreversible pulpitis in standardized conditions [72, 73]. In addition to this, photo-
mature permanent teeth has also received continuous atten- activated disinfection exhibits a synergistic effect when used
tion of many scholars. In the early days, it was reported that in combination with these materials [74, 75].
the irreversible pulpitis of mature permanent teeth can save
parts of the pulp through pulpotomy with an appropriate 3.3. Pulpotomy of Mature Permanent Teeth. In the tradi-
clinical effect [57]. Afterwards, related research results have tional treatment, pulpotomy is generally used for deciduous
confirmed that for irreversible pulpitis of mature permanent teeth. In recent years, this topic gained clinical interest, as an
teeth, as long as the diseased tissue is completely removed early case report of pulpotomy for deep caries exposed
and appropriate pulp capping materials are selected, the mature permanent teeth [57]. Later, more scholars began
remaining pulp tissue is likely to have a good prognosis to study related content [76, 77]. For teeth with deep caries
[58, 59]. This points out on the direction for the further exposed pulp rather than irreversible pulpitis, partial pulpot-
study of irreversible pulpitis in mature permanent teeth. omy is effective [38], while for teeth with irreversible pulpi-
tis, total pulpotomy has a higher success rate [59, 78–80]. In
3.1. Indirect Pulp Capping of Mature Permanent Teeth. In 2021, a review analyzed the treatment results of total pulpot-
the indirect pulp capping of mature permanent teeth, the omy and partial pulpotomy in recent years. It was concluded
overall success rate is relatively high. In the research on the that the clinical and radiographic success rates of total pul-
indirect pulp capping of mature permanent teeth, whether potomy for mature permanent teeth were between 92.2%
partial caries removal or complete caries removal, the 12- and 99.4%, while the success rates of partial pulpotomy were
month follow-up found that the indirect pulp capping can between 78.2% and 80.6% [81]. This suggests that the com-
achieve a high success rate of 96%, which has no obvious plete removal of infected tissue may be an important factor
relationship with the pulp capping agent used [60, 61]. affecting pulpotomy of mature permanent teeth. A meta-
Therefore, for the affected teeth without symptoms and signs analysis published by the Air Force Medical University in
of pulpitis before operation, the exposure of dental pulp tis- 2019 [82], the review published by Taha et al. in 2020
sue should be avoided as much as possible during opera- [71]and a number of clinical studies [83–86]also confirmed
tion [62]. from different aspects that pulpotomy is a recommended
treatment for deep caries exposed pulp of mature permanent
3.2. Direct Pulp Capping of Mature Permanent Teeth. Tradi- teeth or even irreversible pulpitis, which can be used as an
tional direct pulp capping can only be used for the small area alternative to RCT [87–90]. In addition, some studies have
of noncaries exposed pulp, and CH is used as the gold stan- combined total pulpotomy and nonsurgical endodontic
dard. With the application of bioceramic materials and the (NSET) for mature mandibular permanent molars
6 BioMed Research International
diagnosed as irreversible pulpitis and apical periodontitis months of follow-up, Doppler imaging showed that all teeth
and achieved good results. This suggests that the combina- were revascularized, tooth vitality was restored, and there
tion of NSET and total pulpotomy is a feasible minimally were no signs of endodontic/periodontal radiolucency or
invasive treatment for multiple mandibular teeth with irre- complications. This method may be a potential new way of
versible pulpitis and apical periodontitis [91]. pulp regeneration treatment.
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