Journal of the California Dental Association

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An Update on Vital Pulp Therapy

Keith R. Boyer & Jan Trang Nguyen

To cite this article: Keith R. Boyer & Jan Trang Nguyen (2023) An Update on Vital
Pulp Therapy, Journal of the California Dental Association, 51:1, 2244707, DOI:
10.1080/19424396.2023.2244707

To link to this article: https://doi.org/10.1080/19424396.2023.2244707

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Published online: 06 Sep 2023.

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JOURNAL OF THE CALIFORNIA DENTAL ASSOCIATION
2023, VOL. 51, NO. 1, 2244707
https://doi.org/10.1080/19424396.2023.2244707

An Update on Vital Pulp Therapy

Keith R. Boyer, DDS and Jan Trang Nguyen, DDS
College of Dental Medicine, Western University of Health Sciences, Pomona, California, USA

ABSTRACT ARTICLE HISTORY

Background: Vital pulp therapy has been the treatment option of choice for teeth with immature apices Received 13 April 2023
and healthy, exposed pulps. While calcium hydroxide has been the standard material for these proce­ Revised 16 July 2023
dures, development of calcium silicate cements has allowed for improved pulpal responses. Pulpal tissues Accepted 1 August 2023
previously thought to be irreversibly inflamed have a proven capacity to heal if the microorganisms are KEYWORDS
eliminated, even in mature permanent teeth. In 2021, the American Association of Endodontists released Calcium silicate cement;
a position statement highlighting these changes. direct pulp capping,
Practical Implications: This review article proposes a protocol for assessment and conservative treat­ endodontics; pulpitis;
ment of vital pulps based on current evidence. pulpotomy; vital pulp
therapy

Introduction pulpal responses such as biocompatibility and hard-tissue bar­

In the tenth edition of the Glossary of Endodontic Terms, the
American Association of Endodontists (AAE) defines vital pulp
therapy (VPT) as, “treatment aimed at preserving and maintain­
ing pulp tissue that has been compromised by trauma, caries, or
restorative procedures in a healthy state.”1 This definition rein­
forces the long-held concept that VPT should be only performed
on pulps that have diagnoses of normal pulp or reversible
pulpitis, as pulps with irreversible pulpitis were thought to be
incapable of healing.1 VPT has traditionally focused on treating
immature permanent teeth with pulp exposures, because they
have higher vascularity and better healing potential.2 The aim
for these young teeth with exposed pulps is to maintain pulp
vitality so root development may continue, as opposed to per­
forming pulpectomies which leave thin dentinal walls and open
apices.3 These apexogenesis procedures may include direct pulp
capping (DPC) and pulpotomy (partial and full). Clinicians also
perform indirect pulp capping (IPC), by either partial or step­
wise caries removal, leaving carious dentin deep within
a preparation to avoid a likely pulp exposure.4 With recent
scientific developments, the above concepts of pulpal pathosis,
narrow indications for VPT, and selective approach to caries
removal are currently being challenged.5
Calcium hydroxide (CH) is the traditional material used in
direct and indirect pulp therapy. Examples of hard-setting CH
products used in VPT include Life [Kerr, Brea, CA, USA] and
Dycal [Dentsply Sirona, Charlotte, NC, USA]. Due to its high
alkalinity, CH is antibacterial and promotes tertiary dentin
formation.6 The introduction of mineral trioxide aggregate
(ProRoot MTA [Dentsply Sirona, Charlotte, NC, USA]),
a bioactive tricalcium silicate which shares many properties
with CH, spurred new research in VPT.7,8 MTA and other
calcium silicate cements (CSCs) are shown to have improved
rier formation.9–11 Additionally, CSCs are hydrophilic and
hygroscopic, their setting occurs in the presence of moisture,
they seal better than CH with less dissolution, and they pro­
mote hydroxyapatite formation.12 One consideration when
using CSCs is that some, especially those containing bismuth
oxide, may stain tooth structure. For teeth in the esthetic zone,
it is recommended to use materials with lower staining poten­
tial, such as Biodentine [Septododont, Saint-Maur-des-Fossés,
France] or EndoSequence BC RRM Putty [Brasseler,
Savannah, GA, USA].13 With these advancements in materials,
clinicians note favorable results in VPT applications, even
including mature permanent teeth with carious exposures
and irreversible pulpitis (see Table 1).14–19
Case selection for VPT requires assessing the health of
the pulp. Endodontic diagnosis relies on history of symp­
toms and pulp sensibility tests. It is long understood that
symptoms do not correlate well with pulpal histology, and
the tests are not always a true indication of pulpal status.20
In a study by Ricucci et al.21 for teeth clinically diagnosed
with normal pulps or reversible pulpitis, the symptoms
matched the histologic diagnosis 96.6% of the time.
However, the histologic diagnosis only matched the symp­
toms in 84.4% of teeth of symptomatic irreversible pulpitis.
Even though pulp tests are used to corroborate the
patients’ subjective symptoms, the findings of Ricucci’s
study demonstrate there are instances that the pulp is
capable of healing even when symptoms suggest otherwise.
Moreover, pulpitis is a spatially and temporally graded
disease.5 Pulps with bacterial penetration show severe
local inflammatory response, but the tissues apical to
these areas may appear histologically normal.22 Diagnoses
determined by symptoms and pulp tests are confirmed
clinically by direct visual observation of the exposed pulp

CONTACT Keith R. Boyer kboyer@westernu.edu

© 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. The
terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.
2 K. R. BOYER AND J. T. NGUYEN

Table 1. Outcomes of VPT using CSCs in mature permanent teeth with irreversible pulpitis.
# of patients receiving # of patients Clinical success Follow up period
Article Study type Material VPT type intervention followed up (%) (months)
Taha and Khazali14 RCT MTA PP 27 26 85 24
Taha and Abdelkhader15 PCS BD FP 64 59 98.4 12
Cushley et al.16 SR MTA, BD, FP 330 275 97.4 12
CEM 283 233 93.97 36
*Asgary et al.17 RCT CEM DPC 73 69 94.7 12
PP 76 71 91.4
FP 69 65 95.5
RCT (randomized clinical trial), PCS (prospective cohort study), SR (systematic review).
DPC (direct pulp capping), PP (partial pulpotomy), FP (full pulpotomy).
MTA (Mineral Trioxide Aggregate), BD (Biodentine), CEM (calcium enriched mixture).
*Patients were diagnosed with reversible and irreversible pulpitis, but no statistically significant difference was shown.

tissue under high magnification. The clinician assesses the
tissue vitality and inflammation by noting the vascularity
and amount of bleeding and then proceeds to verify
healthy pulp when hemostasis is achieved. If a portion of
the pulp appears necrotic or hemorrhagic, the clinician
removes tissue until a healthy level is reached. Treating
pulps in this targeted manner may allow more patients to
receive successful VPT.
The presence of microorganisms is the key factor that
significantly affects the health of the pulp.23 While avoid­
ing a pulp exposure by selective caries removal and indir­
ect pulp capping may be easier for the clinician, leaving
soft, leathery, or firm infected dentin results in continuous
pulpal inflammation.24 Additionally, restoration timing and
quality play important roles in the success of VPT.
Residual caries-affected or infected dentin compromises
dentin bonding.25 Delay of restoration placement and leak­
age of microorganisms negatively impact outcomes.18,26,27
Figure 1 shows the case of a young patient with indirect
pulp capping that failed due to progressive decay and
persistent symptoms. The tooth was then successfully trea­
ted with complete caries removal and direct pulp capping.
To allow pulps the best chance of healing, treatment
should focus on aseptic technique, complete elimination
of bacteria, and immediate high-quality restoration.
In the 2021 position statement on vital pulp therapy,5
the AAE states that the focus of VPT is broader than
previously thought: A pre-treatment diagnosis of irreversi­
ble pulpitis does not necessarily preclude the possibility of
pulp tissue repair and preservation, and improvements in
materials and understanding of pulpal disease allow clin­
icians to offer VPT on mature permanent teeth in appro­
priately selected cases. Such conservative therapy may be
easier to perform, preserve more tooth structure, and save
costs as compared to complete root canal treatment. The
next section discusses a suggested protocol and decision-
making process for implementing VPT in teeth with deep
carious lesions or pulp exposures.

Figure 1. (a). Pre-operative radiograph of young patient with deep caries and incompletely formed roots of the mandibular right first permanent molar; (b). Clinical
photograph showing occlusal and buccal caries; (c). Radiograph of IPC at time of placement; (d). 26-month follow-up radiograph of IPC with caries progression and
development of symptoms; (e). Radiograph of DPC at time of placement; (f). 12-month follow-up radiograph of DPC showing completion of root formation.
 JOURNAL OF THE CALIFORNIA DENTAL ASSOCIATION 3

Vital Pulp Therapy Procedure
The first step when considering VPT is to determine
a preoperative diagnosis based on the patient’s history of symp­
toms and a clinical exam with sensibility tests. A normal pulp is
found when the tooth in question responds equivocally to thermal
testing as another healthy control tooth. A diagnosis of reversible
pulpitis is confirmed when the patient’s symptoms are minor to
moderate, short-lasting, and only upon provocation with cold or
sweets. Once caries progresses into the pulp space, the presence of
bacteria will render at least a portion of the pulp irreversibly
inflamed or necrotic. Symptoms of irreversible pulpitis usually
include severe, often lingering pain that is provoked with cold or
heat, spontaneous pain which can be worse at night, or referred
pain which can be difficult for the patient to localize. The inflam­
mation may be considered more extensive once periapical invol­
vement is noted, such as with radiographic periodontal ligament
widening or pain to percussion, palpation, or biting. A necrotic
pulp will have no response to cold or electric pulp testing.28 Only
teeth with some amount of remaining vital pulp tissue are candi­
dates for VPT.
The dentist should combine the preoperative diagnostic
information with other clinical considerations such as the
patient’s ability to tolerate long treatment appointments and
whether the tooth needs extensive restoration, along with tak­
ing into account patient considerations such as finances and
risk tolerance to determine whether conservative pulp treat­
ment options make sense for the individual. If it is determined
with the patient that VPT is to be attempted, the patient must
be informed that symptoms may persist or worsen and root
canal therapy may still be indicated based on the intraoperative
or postoperative findings.
After establishing adequate anesthesia, effective isolation
with a dental dam must be in place. The rubber dam facilitates
an operative environment free of oral microorganisms and
protects the patient from the chemicals used during the pro­
cedure. A high speed handpiece with water spray is used to
remove unsupported enamel affected by caries, establishing
restorability and sound margins. Complete caries excavation
must be completed using a slow speed handpiece and sharp
spoon excavator, extending from the peripheral dentin con­
centrically inward axially and pulpally. It is important to
remove as much caries as possible before exposing the pulp
to minimize contamination. Use of high magnification and
caries indicator dye throughout the procedure is recom­
mended to identify infected dentin and conserve sound tooth
structure.29 If caries is completely removed without resulting
in pulp exposure, and the preoperative diagnosis was normal
or reversible pulpitis, then disinfection of dentin with sodium
hypochlorite (NaOCl) and placement of a CSC at the deepest
portion of the preparation, along with a liner and bonded
restoration is recommended (see Figure 2). Indirect pulp cap­
ping of carious dentin with a biocompatible material should
only be considered as a temporary measure if circumstances
require it, such as insufficient procedure time or an unco­
operative patient.
If caries removal results in a pulp exposure or the patient
has irreversible pulpitis symptoms, then the pulp tissue should
be examined with strong magnification and illumination for

Figure 2. (a). Pre-operative radiograph of mandibular right first premolar with deep recurrent caries, reversible pulpitis, and complex apical root anatomy; (b). Post-
operative radiograph of tooth without pulp exposure treated with CSC, liner, and bonded restoration; (c). Caries remaining after failing restoration removed and clean
margins established; (d). Soft caries removed; (e). Caries indicator dye (to dye for [Roydent, Johnson City, TN, USA]) used to stain remaining cares; (f). Caries noted by
dye removed; (g). Caries indicator dye used again to show slight residual caries; (h). Preparation free of caries and without pulp exposure; (i). EndoSequence BC RRM
putty [Brasseler, Savannah, GA, USA] placement; (j). EndoSequence BC liner [Brasseler, Savannah, GA, USA] placement; (k). Tooth restored with composite.
4 K. R. BOYER AND J. T. NGUYEN
vascularity and perfusion as well as amount of bleeding.
Avascular tissues appear either pale or very dark and must be
removed. Healthy pulp will appear uniform and pink. Some
bleeding is to be expected from a vital pulp, but dark or profuse
bleeding indicates severe inflammation. Diluted or full-
strength NaOCl is then used to gently rinse the pulp, or
a NaOCl-saturated cotton pellet is placed into the site. The
NaOCl serves to disinfect the tissues, remove biofilm and
dentin chips, and achieve hemostasis.5 After two to ten min­
utes of NaOCl exposure, the pulp is observed again to deter­
mine whether bleeding is controlled.30 If the pulp appears
healthy once hemostasis is achieved, then the dentist should
perform direct pulp capping with a CSC covering at least 1.5
mm in thickness and extension onto the dentin, followed by
a liner such as resin-modified glass ionomer (RMGI), and
immediate restoration.31 Some fast-set CSCs allow bonding
directly to the material without placement of a liner.
If the pulp is avascular, or bleeding is not controlled with
NaOCl, then the degenerated or inflamed portion of pulp
tissue should be removed to a healthy level in a partial pulpot­
omy procedure. Using a high speed handpiece with a sterile
diamond bur and adequate irrigation, the dentist then ampu­
tates approximately 1–3 mm of pulp tissue or until all necrotic
tissue is removed. This may include tissue only at the site(s) of
exposure or it may require unroofing of the remaining pulp
chamber. The NaOCl step is repeated for 2–10 minutes and
then the tissue is observed again. If bleeding is controlled, then
at least 1.5–3 mm of CSC is placed over the remaining pulp
tissue and extended onto adjacent dentin, and the tooth is
restored as in the direct pulp capping procedure.31
Figure 3. Flow chart of VPT procedures.
If bleeding is not controlled after a partial pulpotomy,
then a full pulpotomy is performed by removing the pulp
tissue from the chamber with a high speed diamond bur to
the level of the canal orifice(s). The NaOCl and observation
processes are repeated. If bleeding is controlled at the pulp
stump, then CSC is placed over the canal orifices and cham­
ber floor, followed by liner and immediate bonded restora­
tion. If hemostasis is not achieved, then initiation of
pulpectomy is recommended. See Figure 3 for a flow chart
summarizing the above steps.
Follow up for any VPT procedure should include evalua­
tion of signs and symptoms, condition of coronal restoration,
pulp sensibility testing, and radiographic monitoring for api­
cal changes, resorption, or calcification. For teeth with
incompletely formed roots, radiographic evaluation should
also include continuation of root development.32 Full pulpo­
tomies will not respond to pulp testing and they may be more
difficult to reenter if root canal treatment is needed.
However, full pulpotomies may provide more predictable
results in cases of irreversible pulpitis or with signs or symp­
toms of apical periodontitis.16,33 Bonded direct restorations
will serve as the conservative choice to seal and restore most
VPT cases. Early failures (during the first 3–6 months) are
most often due to endodontic causes resulting in signs and
symptoms, while late failures are due to restorative reasons
such as poor coronal seal.34 As such, preparation and place­
ment of an indirect definitive restoration such as an onlay or
crown should only occur if necessary to protect the tooth and
after sufficient time has passed to evaluate healing of the VPT
procedure.

Conclusion
More studies are needed to determine long-term success of
VPT, refine protocols, and develop objective diagnostic mea­
sures of pulpal condition. Current evidence suggests that
VPT can successfully be performed in immature and mature
permanent teeth with reversible and irreversible pulpitis
when following strict asepsis protocols including dental
dam placement, complete caries removal, confirming pulpal
health by achieving hemostasis and direct observation of the
exposed tissue under magnification, using biocompatible
CSCs, and providing immediate high-quality restorations.
Acknowledgments
The authors would like to thank Dr. Jamie Parado for her contributions
and support.
Disclosure Statement
No potential conflict of interest was reported by the author(s).
Notes on contributors
Keith R. Boyer, DDS, is an associate professor of endodontics at the
Western University of Health Sciences College of Dental Medicine in
Pomona, California. He is a diplomate of the American Board of
Endodontics.
Jan Trang Nguyen, DDS, is an assistant professor of endodontics at the
Western University of Health Sciences College of Dental Medicine in
Pomona, California.
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