Vital Pulp Therapy

Gold standard material for direct pulp capping?

➔ MTA.
➔ Biodentine and Bioceramics may also be used.
➔ Calcium hydroxide is now obsolete (no longer used - causes adverse effects on the
pulp).

Normal root canal treatment success rate (vital cases): 95%

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.
● The presence of an adequate blood supply is required for the maintenance of the pulp
vitality, as well as the presence of a healthy periodontium for the success of VPT.

Dressing materials (pulp covering agents):

Calcium Hydroxide Some advantages of CH are antimicrobial characteristics owing to its high alkaline pH and the
irritation of pulp tissue that stimulates pulpal defense and repair.

However, CH 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. ❌

RMGIs They have been successful as an indirect pulp capping agent, even in cavities with minimal
remaining dentin thickness. This may be due to their capacity to bond to the dentin.

Contrary to these useful properties, poor responses have been reported in direct pulp capping of
human teeth with RMGIs, as the pulps exhibited moderate to intense inflammatory responses.
This, it’s not recommended in direct pulp capping. ❌

Adhesive Resins Recently available composites and 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 adhesive resins are unacceptable as pulp capping
agents.

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

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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 superior
performance compared to CH. ✅
What are the techniques of vital pulp therapy?
● Pulp capping:
○ Indirect
○ Direct

● Pulpotomy:
○ Partial (Cvek)
○ Full

● Pulp regeneration

Direct pulp capping

● It 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 of direct pulp capping (at best): 70%

● 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.

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.

❖ Partial pulpotomy is indicated in a small pulp exposure in which the bleeding is

controlled in 2 minutes (should not exceed 5 minutes).
❖ A cotton moistened with Naocl (sodium hypochlorite) is used to stop the
bleeding. This step is important to assess the level of pulpal inflammation.
❖ 1-3 mm of coronal pulpal tissue are removed.
❖ Then, MTA is placed with a layer of glass ionomer on top, and finally composite
restoration.
★ Success rate: 90%
➔ Why is it more successful than direct pulp capping?

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 Because we remove the top 3 mm of pulpal tissue, which are contaminated with
bacteria and more inflamed. Moreover, removal of 3 mm of pulpal tissue
provides space for the capping material and a better seal (seal proof).

● 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.

❖ 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 biomaterial is placed over the
remaining pulp tissue.

❖ When do we do full pulpotomy?

➔ Acute pulpitis in incompletely formed roots and deciduous teeth.

❖ It’s considered a temporary treatment; root canal treatment is done after the
roots are completely formed.
❖ In about 90% of full pulpotomy cases, the remaining pulp tissue in the root
starts to be necrotic or inflamed, that’s why endo treatment must be continued.

In case of reversible pulpitis:

Closed Apex Open Apex

Minimal inflammation: Minimal inflammation:

- Partial pulpotomy (more conservative) - Partial pulpotomy (follow up)
- RCT

Deep inflammation (bleeding): Deep inflammation (bleeding):

- RCT - Full pulpotomy then RCT
- Regeneration

In case of acute pulpitis:

Closed Apex Open Apex

RCT - Full pulpotomy then RCT after root

forms
- Regeneration

CASE: patient complains of pain with cold.

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 ● Duration of pain: lingering pain for 3-4 minutes.
● Pain with hot: if present, then it’s probably irreversible pulpitis.
● Spontaneous pain confirms the diagnosis.
○ If the pain is only with cold and goes away quickly: reversible pulpitis.

**After any partial pulpotomy:

- Follow up must be done every:
➔ 1 month (pulp testing & x-ray)
➔ 3 months
➔ 6 months
➔ Yearly for 5 years

CASE: fractured upper central incisor in a 10 year old boy with a closed apex (pulp is
exposed). The patient came to your clinic after 1 hour of the incident. What’s your treatment
approach?
➔ Partial pulpotomy or RCT.
➔ Remove 3 mm of coronal pulp then stop the bleeding with a cotton soaked in sodium
hypochlorite.
➔ Bioceramic paste is placed, with a layer of glass ionomer on top, then composite.
➔ Procedure is done in the same visit.
➔ If the bleeding does not stop (more than 5 minutes), RCT is done.
➔ Follow up is a must.

CASE: during removal of caries in a tooth, pulp exposure of upper 4 happened. The root is
completely formed. What’s your treatment plan?
➔ Depending on the pulp condition (symptoms)
➔ Pulp testing is done before any procedure is done.
➔ If it’s irreversible pulpitis, root canal treatment is done.

CASE: 9 year old boy with 2 fractured incisors, with incompletely formed roots (open apex).
What’s your treatment plan?
➔ If deeply inflamed, full pulpotomy then RCT when the root is completely formed.
➔ Partial pulpotomy can be done if the inflammation is minimal.

CASE: A fractured incisor since a week ago. Clinically there’s no pulp exposure, and the roots
are completely formed. But the patient complains of pain with cold drinks.
➔ Duration of pain: lingering (5 minutes).
➔ Pain is present with hot, too
➔ Spontaneous pain
➔ Pain on biting (diagnosed by percussion test)
★ Most probable diagnosis: irreversible pulpitis.

Notes

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 ❖ Cold testing is more accurate, why?
➔ A-delta fibers have quicker conduction.
So if a patient complains of pain with both cold and hot, do a cold pulp test.

★ You must simulate the same pain that the patient complains of, so you wouldn’t
mistake another tooth for being the cause of the pain.
★ Teeth with deep pockets almost always have chronic pulpitis or inflammation.
★ Tooth responsiveness to electric pulp tests has been reported in many cases of partial
pulpotomy, because of preserving the vitality of coronal pulp tissue.

Indications for vital pulp therapy:

➔ Teeth with incompletely formed roots
➔ Primary teeth
➔ Healthy pulps with minimal hemorrhage on exposure

Contraindication for vital pulp therapy:

➔ Infected, inflamed pulp
➔ Teeth involved in complex prosthesis (bridge)
➔ Root canal space is needed to hold a post and core
➔ Teeth involved in complex periodontal therapy

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 Regeneration

Pulp regeneration is the regeneration of a new vital tissue in an empty and disinfected root
canal space, using scaffolds, stem cells, and growth factors.

Stem cells: stems cells are undifferentiated cells that can differentiate into any cell.
● SCAP (Stem cells of apical papilla)
● PLSC (Periodontal Ligament stem Cells)
● DPSC (Dental pulp stem cells)
● BMSC ( Bone Marrow Stem Cells)
● 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.

Scaffolds: Blood clot, Platelet Rich Plasma (PRP), Platelet Rich Fibrin (PRF), Natural polymers
as collagen or Synthetic polymers as poly glycolic acid (PGA), Polylactic Acid (PLA) 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.

Growth factors (signaling molecules): they stimulate the differentiation of stem cells.

● DMP (Dentin Morphogenic Proteins) (odontoblasts)

● VEGF (Vascular endothelial GF) (erythroblasts)
● TGF (Transforming GF)
● NGF (Neural GF) (neuroblasts)

Case selection:

● Teeth with vital inflamed or necrotic pulp and an immature apex.

● Young patients (7-12 years)
● Permanent teeth and adult patients with necrotic or vital pulps (case reports)

Clinical steps of pulp regeneration in case of a necrotic pulp:

● 1st visit: Disinfection

- Local anesthesia, rubber dam, access and working length.
- Circumferential light filing of the canal to remove necrotic tissue.
- Irrigation with 20ml NaOCl (needle with closed end and side-vents)
★ 1.5% NaOCl (20ml/canal, 5 mins)

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**Give reason: sodium hypochlorite is only used with a concentration of 1.5%, not more.

➔ To not alter the stem cells or minimize cytotoxicity to stem cells in the apical region,
and to not irritate the periapical tissues.
- An intracanal medicament with an antibacterial action is used for disinfection.
It’s also used so we can fill the canal with a material that will prevent
repopulation of microorganisms.
● Calcium hydroxide or low concentration of triple antibiotic paste:
Mix 1:1:1 ciprofloxacin:metronidazole: minocycline to a final
concentration of 0.1 - 1 mg/ml.
★ However, it was discovered that minocycline causes
discoloration of teeth.

● So instead, a double antibiotic paste can be used without minocycline

(ciprofloxacin and metronidazole) or substitution of minocycline with
clindamycin or amoxicillin.

- Then, 3-4 mm of temporary filling is placed.

- Dismiss patient for 1-4 weeks until signs and symptoms are gone.

● 2nd visit:
- Anesthesia without vasoconstrictor
- Irrigation with 20 ml of 17% EDTA for 2 minutes.
★ EDTA is a chelating agent which removes the inorganic part of the
smear layer and helps in the extraction of growth factors from dentin
into the canal.
- Create a bleeding into the canal system by over-instrumenting by endo file 2mm
past the apical foramen (introduction of scaffolds and stem cells into the
canals)
- Use of platelet-rich plasma (PRP), platelet rich fibrin (PRF) (for reinforcement).
- Place white MTA as a capping material 3-4 mm of the coronal root canal.
- A 3-4 mm glass ionomer layer or RMGI is placed, followed by composite.
- Follow up is mandatory (1 month, 3 months, 6 months, and then yearly for 5
years).

Clinical steps for pulp regeneration in case of a vital inflamed pulp:

● Single visit:
- Same steps except the placement of an intracanal medicament, since there is
no need for it (no necrosis).

When to consider pulp regeneration a successful procedure?

★ Primary goal: the elimination of signs and symptoms and the evidence of bony healing.
★ Secondary goal: Increased root wall thickness and/or increased root length (desirable,
but perhaps not essential).

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 ★ Tertiary goal: positive response to vitality testing (which if achieved, could indicate a
more organized vital pulp).
➢ However, this might be hard to achieve since there is MTA and composite
restoration on top of the pulp, so readings of pulp tests may give no or inaccurate
responses.

Success rate of pulp regeneration: 90% to 95%

Pulpotomy vs. Regeneration: regeneration is better since it preserves the vitality of the pulp.

❖ In case of pulp regeneration failure:

➢ MTA apical plug, in which the root canal space is filled with MTA.
➢ Why MTA? Since it provides a good seal and it stimulates bone formation.
➢ The only disadvantage is that it does not help the root to grow, so crown:root
ratio won’t be ideal.

➢ Another solution is apexification Ca(oH)2, however it was discovered that

calcium hydroxide weakens the dentin, and stays intact for 1.5 or 2 years.
○ It has a success rate of 70%
○ It’s not used anymore or not as much as before.

CASE: a boy comes with 2 fractured incisors after the incident in less than an hour, the pulp is
exposed on both teeth and the x-ray showed open apices.
➔ Degree of inflammation is checked with a cotton, if bleeding stopped, then make a
partial pulpotomy and place MTA, glass ionomer, and composite. Follow up as
mentioned before.
➔ If the bleeding persists after 5 minutes, you can either go for full pulpotomy then RCT
when the roots are formed, or pulp regeneration.
◆ Pulp regeneration should be your first choice, and in such case, it will be done in
a single visit.

➔ If the same case came a week later after the incident not immediately after, the pulp
would be necrotic, and regeneration should be done (in 2 visits).

CASE: After 1 year of pulp regeneration, the patient comes to you with signs and symptoms of
failure. What do you do?
➔ MTA apical plug or regeneration again.
➔ In both cases, you must put an intracanal medicament first then continue on the second
visit.

What are the signs & symptoms of pulp regeneration failure?

➔ Sinus tract presence
➔ Swelling

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 ➔ Pain on biting
➔ No healing occurs in periapical lesion

Permanent teeth & adult patients (case reports):

Using the same technique but:
● Range of apical preparation (master apical file) is from #30 to #50 (not more than 0.5
mm)
● Studies: 0.32, 0.35, 0.50 mm

❖ Stem cells origin? Since there is no apical papilla, the stem cells will be found in PDL,
bone marrow, or periapical lesions.

CASE: 45 year old patient with a fracture upper central incisor. On radiographic examination, a
periapical radiolucency was found. After diagnostic tests, the pulp was found to be necrotic.
➔ Treatment: regeneration.

CASE: A 30 year old male patient complaining of pain when drinking hot fluids. On clinical and
radiographic examination, the upper left first premolar was the cause of pain. The tooth had
deep caries. During caries removal, the pulp was exposed. What’s your treatment approach and
why?
➔ Diagnosis: irreversible pulpitis.
➔ Treatment: RCT or regeneration (in such cases, RCT is more favorable, since
regeneration for adults is still under study).
➔ Justification: since the case is irreversible pulpitis, a root canal is the treatment of
choice. Pulpotomy is not indicated.
➔ If this case was accompanied with a periapical lesion, regeneration can be your first
choice of treatment, since there’s nothing worse that can already happen from trying
the regeneration method.

★ Note: If a patient complains of pain with hot fluids, test the pulp with a hot test. If a
patient complains from pain with cold fluids, make a cold test. If the patient complains
from both, make a cold test, since it’s more accurate than hot test.

CASE: A 14 year old male patient hit his teeth when playing football. On clinical examination,
the upper central incisor had a chipped part and a pinpoint pulp exposure could be seen. The
trauma happened 2 hours ago. What’s your treatment approach and justification?
➔ Partial pulpotomy if the pulp is not deeply inflamed, and since the incident only
happened 2 hours ago, it’s an indication to do pulpotomy and follow up.
➔ However, if the inflammation is deep, root canal treatment is recommended.

★ A partial pulpotomy can be done within 24 hours after the incident, more than that the
inflammation would extend too deep and you’d have to start a root canal treatment.

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CASE: A discolored central incisor in a 12 year old girl with a history of trauma. Radiographic
examination showed an open apex. What’s your treatment and justification?
➔ Regeneration, if it failed, you can try regeneration again, or MTA apical plug.
➔ Justification: the girl is young with an open apex, which is an indication for
regeneration. Also, partial/full pulpotomy cannot be done since the pulp is necrotic.

CASE: a 15 year old boy complains of pain with cold on the upper left side that subsides after
removal of the water cup. Clinical examination showed caries in the upper left canine. During
caries removal, a pinpoint pulp exposure happened. What’s your management in that case and
justification?
➔ Symptoms are reversible, so partial pulpotomy can be done, if minimal inflammation
was found.

★ Note: sometimes, reversible pulpitis symptoms may not be true, it may be irreversible but
the patient only feels reversible symptoms. The pulpal condition may not coincide with
the chief complaint.

Good luck :)
Loujine Elrafey

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