AAE Position on Vital

Pulp Therapy
Molly Foster
July 2021 Provider Meeting
  Issued in May 2021
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Introduction  Vital Pulp Therapy (VPT): preserving vitality and function of pulp
after injury from trauma, caries, or restorative procedures.
 Direct or indirect pulp cap
 Partial or complete pulpotomy
 Previously focused on the goal for apexogenesis now thought to
be broader use including mature teeth thought to have irreversibly
inflamed pulps
  Vital pulp assigned to one of three categories
 Normal
 Reversible
 Irreversible (symptomatic or asymptomatic)
 Dx made on pain history and pulp sensibility testing including cold/EPT
 Cannot be deemed vitality testing as no clinical availability of such testing
i.e. oxygen tension
Diagnostic  Recently challenging that only reversible pulpitis can utilize VPT
Considerations histological evidence now suggests there is no boundary in progression
of pulpitis that would render a pulp beyond repair
 Additional research is now taking place to understand inflammatory
mediators to know pulpal status
 Dentinal fluid
 Pulp blood
 Utilize direct visualization of the pulp even symptomatic pulps may be
candidates for VPT
  Complete caries removal is indicated for visualization of pulp tissue
 Predictable management of vital pulp tissue should not be
performed without complete removal of both demineralized
enamel and infected dentin
 Hard or firm dentin and dentin below white spot enamel lesions is
infected by bacteria in both active and arrested lesions
Caries  Histobacteriological studies consistently show presence of chronic
Management inflammatory cell infiltrate and subclinical pulp inflammation where
carious tissues are retained potentially compromising pulp vitality
 Use of caries detectors or laser fluorescence during caries removal
are noted as helpful adjuncts; detectors create an objective
standard for all clinicians
 Clinician can focus on complete removal of infected dentin rather
than pulp exposure to improve chances of pulpal repair
  Antimicrobial solution that provides hemostasis, disinfection of
the denitin pulp interface, biofilm removal, chemical removal of
the blood clot and fibrin, and clearance of dentinal chips along
with damaged cells at the mechanical exposure site
 Examination of pulp tissues after exposure with magnification is
critical to pulp assessment
Use of Sodium  Hemorrhage must be controlled to clinically assess inflammatory
Hypochlorite levels and identify any remaining necrotic tissues
 Sodium hypochlorite is traditionally used to achieve this
hemostasis by bathing the exposed pulp for 5 to 10 minutes
 Sodium hypochlorite can be used safely in direct contact with pulp
tissue at various concentrations from dilute to full bottle strength
without compromising pulp integrity
  Calcium silicate cements are increasingly popular in VPT
 MTA
 When CSCs are used for VPT procedures in permanent teeth with
symptomatic or asymptomatic irreversible pulpitis success rates
range from 85%-100% at 1-2 years
Contemporary  GI cements and resin-based materials have lower clinical success
Materials in ranging from 43%-92%
 Formation of mineralized barriers using CSCs show improved
VPT quality over calcium hydroxide based materials
 Silicate materials possess favorable physicochemical
characteristics that include high alkalinity, intratubular
mineralization, inhibition of biofilm formation, reduction of robust
pro-inflammatory mediators and post-operative pain during
dental pulp procedures
  Immediate restoration should be a part of the treatment plan for a
tooth receiving VPT
 Teeth undergoing VPT using CSCs as the primary sealing material
Immediate and restored immediately with a long-term restoration have a
high success rate
Placement of  Prevention of microleakage

Permanent 

Protection of the biomaterial layer
Reduction of post-op sensitivity and thermal conductivity
Restorative  Establishment of a foundation for cuspal coverage restoration

Material  No negative impacts of immediate restoration have been

indicated
 It is still indicated for appropriate waiting time before cuspal
coverage is planned to ensure tooth is asymptomatic
  VPT goal is creation of optimal conditions for pulp tissue repair
and preservation
 The amount of pulp tissue removed/retained is dependent on
tissue visibility assessments based on access for visualization to
evaluate hemorrhage control and clinical tissue appearance
 Operator assessment
 Clinical judgement
 Overall treatment plan
Summary  Patient’s general oral and systemic health status
 Pretreatment diagnosis of irreversible pulpitis is not necessarily an
indication for pulpectomy as more conservative treatment can be
considered
 Additional studies following long-term outcomes of VPT are
indicated as well as development of chairside techniques for
assessing biomarkers to determine pulpal viability and a review of
endodontic diagnostic terminology will be warranted