Vital Pulp Therapy

One of the most important issues in Vital pulp therapy (VPT) is the status
of the pulp tissue. The traditional school of thought is that VPT should
only be carried out in teeth with signs and symptoms of reversible
pulpitis. The problem is how we can accurately assess the status of the
pulp. The clinical signs and symptoms such as sensibility and pain testing
do not precisely reflect the pulp condition.

 The degree of pulpal bleeding may be a better indicator of pulpal

inflammatory status.

Increased bleeding on exposure site that is difficult to stop: suggest that

the inflammatory response extends deeper into the pulp tissue and the
treatment procedure should be modified, for example by shifting from
direct pulp cap  to partial pulpotomy.

Additionally, other factors may affect the success of VPT.

1. The presence of an adequate blood supply is required for the maintenance
of the pulp vitality.
2. The presence of a healthy periodontium is necessary for success of VPT,
and teeth with moderate to severe periodontal disease are not suitable
candidates for the treatment.
3. Suitable candidates for VPT include teeth in which an appropriate coronal
seal can be provided. The prognosis of VPT is significantly reduced in cases
with inadequate coronal seal and subsequent bacterial microleakage.
4. Control of hemorrhage is also necessary for the success of VPT. Various
options are available for the achievement of pulp hemostasis such as
mechanical pressure using a sterile cotton pellet which may be soaked in
sterile water or saline. In addition, disinfection protocols should be also
followed as a main principle. Sodium hypochlorite (NaOCl) has been
suggested as an agent in VPT that can control hemorrhage, remove the
coagulum and dentin chips, disinfect the cavity interface, and aid in
formation of dentinal bridge.
5. Another important factor is a suitable dressing material. Pulp covering
material should be biocompatible, noncytotoxic, and antibacterial.
 Indications for vital pulp therapy:
1. Healthy pulpal condition with minimal hemorrhage on exposure (below
the inflamed area)

2. Teeth with incomplete Root development (Permanent teeth after VPT must
be followed by RCT when root is complete)

3. Primary teeth (Not followed by RCT as it will shed)

 Contra indications for vital pulp therapy:

1. Infected, Inflamed pulp
2. Teeth involved in complex prosthesis (Bridge)
3. Teeth in which the root canal space is needed to hold a post and core
4. Teeth involved in complex periodontal therapy (ex: severe periodontitis might affect
pulpal condition making it weak so you have to carry RCT )

 Factors modifying outcome/success rate of vital pulp therapy:

1. Pre-existing health of the pulp (little bleeding will have better outcome
than profuse bleeding indicating severe inflammation)

2. Adequate removal of infected hard or soft tissues

3. Elimination of microbial leakage around the final restoration
“Tight seal” (temporary filling over direct pulp capping material will decrease the
direct pulp material success rate to 20%, you must place a permanent restoration instead)

4. The degree of pulp bleeding upon exposure

 Techniques of Vital Pulp Therapy:

 Pulp Capping:

o Indirect
o Direct

 Pulpotomy

o Partial (Cvek)
o Full

 Pulp Regeneration

Success Rate

Indirect Pulp Capping 90 %

Direct Pulp Capping 70 % at best condition

Partial Pulptomy 90 %

Full Pulpotomy 70 – 80 %

RCT 95 %

Pulp Regeneration 90 % – 100 %

Apexification 70 % at best condition

##Pulpotomy: - Partial: Removal of 1 – 3 mm of pulp chamber

- Full: Removal of whole of pulp chamber
##Pulpectomy: Removal of whole pulp “RCT”
 Indirect pulp capping (IPC)

Indirect pulp capping (IPC) is defined as a procedure in which carious

dentin closest to the pulp, is preserved to avoid pulp exposure and is
covered with a biocompatible material.

 Success rate with a healthy pulp is about 90%.

Traditionally, Calcium hydroxide (CH) has been the material of choice in

indirect pulp capping because of its alkaline pH and biocompatible
properties that induces pulpo-dentin remineralization. However, since
concerns exist regarding its long-term solubility and lack of adhesion to
dentin, some adhesive materials such as resin modified glass ionomer
cements (RM-GIC) have been also suggested. Recently, mineral trioxide
aggregate (MTA) has been used as a lining material and was found better
compared with CH.

##Not recommended if there is pulp complain.

 Direct pulp capping

Direct pulp capping (DPC) is defined as the treatment of a mechanical or

traumatic vital pulp exposure by sealing the pulpal wound with a
biomaterial placed directly on exposed pulp to facilitate formation of
reparative dentin and maintenance of the vital pulp

 Success rate: 70% at best conditions (rubber dam, no salivary

contamination..etc) (range from 30% to 70% according to studies)

Beside the use of rubber dam and aseptic treatment condition the cavity
should be restored immediately with a bacteria-tight restoration. MTA
can be placed directly on the pulp followed by Composite on top of it.

##Direct pulp capping has the highest failure rate of all vital pulp therapy
procedures. (That’s why I never go for it)
 Pulpotomy

Pulpotomy is carried out with two treatment approaches: Partial and full
pulpotomy.

Partial pulpotomy (Cvek pulpotomy)

 Defined as “the surgical removal of a small portion of the coronal pulp

tissue to preserve the remaining coronal and radicular pulp”. The
inflamed tissue is removed to the level of healthy coronal pulp tissue.

o Indicated in a small pulp exposure in which the pulpal bleeding is

controlled in 2 min. Bleeding must not exceed 5 minutes. A cotton
moistened with Naocl is used to stop the bleeding. This step is of
extreme importance to assess the level of pulpal inflammation.
o The coronal 3mm of the inflamed pulp are removed by a high speed
round bur with a coolant or an excavator
o The capping material (MTA or Bioceramics or Biodentin) are
placed, then RMGI and Composite.

 #In partial pulpotomy, you have to recall the patient the 1st couple of months
then every year to make sure the pulp is still vital (by pulp test + cold test and
compare with its collateral). If you know from the start the patient will not be
able to come for recalls, perform RCT instead of partial pulpotomy as recalls
are an essential part of partial pulpotomy. If a patient underwent partial
pulpotomy and didn’t show up for recalls, his pulp might become necrotic with
PA lesion decreasing the future RCT success rate from 95% to 75-80%.

 Tooth responsiveness to electric pulp tests has

been reported in many cases of partial pulpotomy
because of preserving the vitality of coronal pulp
tissue.
 Partial pulpotomy has some advantages compared to direct pulp
capping such as:
(Why Partial pulpotomy success rate (90%) is much higher than direct pulp capping (70%))

1. Removal of the superficially inflamed pulp tissue

2. Providing space for the dressing material which gives the opportunity
to seal the cavity.
(ex: in partial pulpotomy, the capping material is placed 2-3 mm into the exposure space
having much better seal than in direct pulp capping where pulp capping material is placed
only at surface of exposure sight causing some degree of leakage.)

 Success rate: 90% (with predictable results if done correctly.)

 It can be performed in permenant teeth with fully formed or

incompletely formed roots. Pulp testing must be done regularly on
follow up visits along with radiographs to make sure that the pulp
condition remains healthy.

Full pulpotomy

 Defined as “the surgical removal of the entire coronal portion of the

vital pulp to preserve the vitality of the remaining radicular portion”.
This treatment approach is indicated when it is predicted that the
inflammation of the pulp tissue has extended to deep levels of the
coronal pulp. After the removal of the coronal pulp, hemostasis must
be achieved and a bio-material is placed over the remaining pulp tissue.

o Full pulpotomy is performed only in deciduous teeth and permanent

teeth with incompletely formed roots. After root development regular
root canal treatment is performed. (temporary ttt)
o It can be done also as an emergency visit in permenant teeth when the
operator has no time to complete the cleaning and shaping.
 Remove pulp chamber  dry cotton  temporary restoration  Follow up

 Success rate: 70 - 80 %
Dressing materials (pulp covering agents)

1) Calcium hydroxide

o Advantages: antimicrobial characteristics owing to its high alkaline

pH and the irritation of pulp tissue that stimulates pulpal defense and
repair.

o Disadvantages: It can degrade and dissolve beneath restorations. The

disintegration of CH under restorations is associated with porosity in
the dentinal bridge which can provide a pathway for microleakage.
##Thus recently CH is not advocated to be used in VPT scenarios.

2) Resin modified glass ionomers (RMGIs)

o Advantages: their capacity to bond to the dentin and antimicrobial effect.

That’s why RMGIs have been successful as an indirect pulp capping
agent even in cavities with minimal remaining dentin thickness.

o Disadvantages: poor responses have been reported in direct pulp

capping of human teeth with RMGIs. Pulp tissues that were capped
with RMGIS exhibited moderate to intense inflammatory responses.

##Thus, the application of RMGIs directly on the pulp tissue is not

recommended. (MTA  RMGIs  Composite restoration)

3) Adhesive resins

Recently available composites & self-etching adhesive systems as pulp

capping material resulted in unresolved inflammatory responses and
minimal pulp tissue repair .Many of the resin components in dentin
adhesives promote bleeding after hemostasis has been achieved with
hemostatic agents. It seems that the adhesive resins are unacceptable as
pulp capping agents.
 4) Mineral trioxide aggregate

o Dental pulp cells demonstrated in direct contact with MTA showed a

faster and more predictable formation of dentinal bridge and more
effective pulpal repair.
o Histologically, the calcified bridge formed in contact with MTA is
thicker with less pulpal inflammation compared to CH.
o With respect to its success rate, MTA provided a superior performance
compared with CH.

5) Bioceramics

Recently, Bioceramic pastes, BioAggregate, Biodentin and many other

bioceramic-based products have been introduced which can be used with
the same applications as MTA and with a superior performance compared
to CH.

## Best material is: MTA , Biodentin and Bioceramics

__________________________________________________________
 Reversible Pulpitis (Pulp Hyperemia)

Complete Root Incomplete Root

Minimal Inflammation Deep Inflammation

1) Partial Pulpotomy
- Moistened cotton with NaOCL. If
bleeding stopped, place MTA 
RMGI  and permanent
restoration. + Follow up
2) RCT
Deep Inflammation
(Bleeding)
Minimal Inflammation
(Bleeding)
1) Partial Pulpotomy
 If bleeding didn’t stop after
Moistened cotton with NaOCL moistened cotton with NaOCL or the
exposure was very large "5mm":
 If bleeding stopped, place MTA 
RMGI  permanent restoration and VITAL PULP
Follow up 1) Full pulpotomy
and place MTA then permanent
When root is completed: restoration.
- If no signs of pulp degeneration: And Follow up till roots are completely
continue follow up without RCT. formed and perform RCT

- If there're signs of pulp degeneration, NECROTIC PULP

1) RCT perform RCT. 1) Pulp regeneration.
2) MTA apical plug
3) CaOH Apexification
Complete Root RCT
Acute
Pulpitis 1) Full pulpotomy 
Incomplete Root Follow up till complete root formation  perform RCT
2) Pulp Regeneration
 Pulp Regeneration:

Regeneration of a new vital tissue in an empty & disinfected root canal

space.

 Key Elements for Pulp Regeneration:

1) Scaffolds: (Acts as a meshwork that you use to build on = ‫) البيت الي ببني عليه‬

Blood clot, Platelet Rich Plasma (PRP), Platelet Rich Fibrin (PRF),
Natural polymers as collagen or Synthetic polymers as poly glycolic acid
and hydrogels.

- The scaffold acts as a matrix that holds the stem cells and allows the
travel of growth factors for stimulation of the stem cells. The
scaffold should be easily applied and shouldn’t induce a foreign
body reaction.

2) Stem Cells: (undifferentiated cells that have the ability to differentiate into any cell)

o SCAP (Stem cells of apical papilla)

o PLSC (Periodontal Ligament stem Cells)
o DPSC (Dental pulp stem cells)
o BMSC (Bone Marrow Stem Cells)
o iPAPC (inflammatory progenitor apical periodontitis cells)

- SCAP has the highest content of stem cells from all other sources
and they have a greater regenerative potential.

3) Growth Factors: (stimulate the stem cells to differentiate into a certain type of cell)

Vascular Endothelial Growth Factors, Neural Growth Factors, Dentine

Morphogenic Protein, Transforming growth factor.

- Human dentine is rich in growth factors which can be expressed

through using a chelating agent as EDTA in the regenerative protocol.
 Case Selection:

1. Tooth with Vital inflamed or Necrotic pulp

2. Immature (open) apex
3. Young Patients (7-12 years) (as they have 🡩 rate of regeneration)

**Permenant teeth & Adult Patients (Case reports)

 Clinical Steps: (American Association of Endodontics Guidelines)

1. First visit 2. Second visit

1. First visit “Disinfection”

1) Local anesthesia, rubber dam isolation, access & W.L.

2) Irrigation with 20ml NaOCl (needle with closed end and side-vents).

- You can also perform minor cleaning by slight scrapping to dentin

walls (in non-vital tooth).
- Lower concentrations of NaOCl are advised [1.5% NaOCl
(20mL/canal, 5 min), with irrigating needle positioned about 1 mm
from root end, to minimize cytotoxicity to stem cells in the apical
tissues (to preserve stem cells).
- Avoid Chlorohexidine irrigants as they kill stem cells.

3) Ca(oH)2 or low conc. of triple antibiotic paste:

Mix 1:1:1 ciprofloxacin: metronidazole: minocycline to a
final concentration of 0.1-1.0 mg/ml.

- It is better to use Double antibiotic paste without minocycline

paste or substitution of minocycline with clindamycin or
amoxicillin (as minocycline causes tooth discoloration)
4) Deliver via syringe (1 mm short than W.L)
5) Seal with 3-4mm of a temporary filling.
6) Dismiss patient for 1-4 weeks. (to allow enough time for resolution of
symptoms)

2. Second Visit:

(1-4 weeks after 1st visit)

1) Anesthesia with 3% mepivacaine without vasoconstrictor (to allow

bleeding)
2) Growth factors source: Irrigation with 20ml of 17% EDTA for 2
minutes
- To remove the medicament
- To allow production of growth factors from dentine by removing
the inorganic portion of dentin)

3) Scaffold & stem cells source:

- Create bleeding into canal system (till 2/3 root) by over-
instrumenting (endo file, endo explorer) (induce by rotating a pre-
curved K-file at 2 mm past the apical foramen (apical papilla)
- An alternative to creating a blood clot is the use of platelet-rich
plasma (PRP), platelet rich fibrin (PRF). PRP and PRF are better
than the clot because it was found that the RBCs in the blood clot
scaffold created degenerate by time.
4) Place white MTA as capping material 3-4 mm of the Coronal root
canal (in coronal 1/3 root)
5) A 3–4 mm layer of glass ionomer or RMGI, followed by composite
3.Follow Up:

• Clinical and Radiographic exam:

o No pain, soft tissue swelling or sinus tract (often observed between

first and second appointments).
o Resolution of apical radiolucency (often observed 6-12 months after
treatment)
o Increased width of root walls (this is generally observed before
apparent increase in root length and often occurs 12-24 months after
treatment).
o Increased root length
o Positive Pulp vitality test response

• Thus the patient must be seen after 3 months then 6 months then 1 year
then yearly for a period of 5 years.
 In Necrotic teeth (pulp necrosis, PA lesion..etc) undergoing pulp
regeneration is done on 2 visits to allow resolution of condition and to
place an intracanal medicament. While in cases of Vital Inflamed pulp
the regeneration procedure can be finished in a single visit with no
symptoms (No Intracanal Medicament used).

 Requirements: (what I want to achieve):

1. Root canal disinfection
2. Proper apical foramen size formation
3. No syptptoms
4. Vital teeth

 The degree of Success of Regeneration:

o Primary goal: The elimination of symptoms and periapical lesion

and the evidence of bony healing.
o Secondary goal: Increased root wall thickness and/or increased root
length
o Tertiary goal: Positive response to vitality testing (which if
achieved, could indicate a more organized vital pulp tissue)

If the primary and secondary goals are achieved then the case is
considered successful ✔. (As nerves are deep inside canal and
restorative material and MTA might affect the pulp response. Also the vital
pulp that regenerated might contain few nerve cells.)

 Success rate of regeneration:

In a range from 90% to 100%.

(Of course a 100% is not attainable, it’s just a range.)

 Significance of Regeneration:
1) Root will be completed
2) Best filling to Root Canal is Vital tissue (Pulp) not Gutta- percha

 If Failure occurred you can Regenerate again or perform RCT

 Why it is not commonly used?

1) It is a new technique
2) Not all dentist are familial to the technique
3) Some dentist may find it difficult to perform
4) Dentist have to follow up for 5 years

 MTA apical plug:

- In a necrotic, open apex tooth: Access, Cleaning and shaping, then fill the
last 2-3 mm apical with MTA
- Advantages:
1. MTA has better sealing effect on walls than Gutta percha
2. MTA has antibacterial effect
3. Healing to RL apically occurs
4. Disappearing of RL by bone formation
- Disadvantages: NO completion of root
- ##Why MTA is not used as an obturation material?
1. Retreatment of MTA is difficult
2. Technique application difficult than G.P
3. Expensive

 CaOH Apexification:
- It is inducing development of root in a necrotic, open apex tooth.
- By the use of CaOH as intercanal medicaments for a long term (1.5 – 2 yrs)
- Disadvantages: weakening to the root and low success rate
 Success rate: 70 % at best
 Cases
Case 1:
38 yrs patient, 🡩 4 with deep caries, complaining pain with hot & cold
While removal of caries exposure occurred. What’s your TTT & Justify?
o TTT: RCT as it is an Acute Pulpitis

Case 2:
14 yrs child, Fractured his 🡩 1 while playing leading to pin-point
exposure, came to clinic 2 hrs after. RG revealed closed apex tooth.
What’s your TTT & Justify?
o TTT: Partial pulpotomy with follow up
##If patient came after exposure by 12 – 24 hrs  RCT
## 6 – 12 hrs is the maximum time to perform parital pulpotomy as after
this pulp will get infected, causinf periapical radiolucency which is more
difficult to treat. So after 12 hrs perform RCT

Case 3:
12 yrs child, discolored 🡩 1 with history of trauma. RG revealed open
apex tooth with Radiolucency apically (mean necrotic tooth)
What’s your TTT & Justify?
o TTT:
1- Pulp Regeneration (on 2 visits)
2- MTA apical block (with uncooperative patients that may not follow up)
3- Apexification