Vital Pulp Therapy (VPT)
Clinical reference for vital pulp therapy — treatment strategies aimed at maintaining the health of all or part of the pulp. Covers the evolving evidence base, four procedure types, material selection, case selection criteria, and a step-by-step clinical protocol. Treatment decisions should be individualized based on clinical findings.
Last updated: 14 Apr 2026
1. The VPT Paradigm Shift
Vital pulp therapy (VPT) encompasses treatment strategies aimed at maintaining the health of all or part of the pulp. The evidence base has evolved significantly with the introduction of hydraulic calcium silicate cements (HCSCs).
ESE 2019 Position Statement (Duncan et al., Int Endod J 2019)
Established VPT as the preferred approach for managing deep caries and the exposed pulp in vital teeth. Recommended selective caries removal and HCSC as the biomaterial of choice.
AAE 2021 Position Statement
Stated that "a pretreatment diagnosis of irreversible pulpitis is not necessarily an indication for pulpectomy, as more conservative treatment could be considered."
ESE S3 CPG (2023)
Suggested that for teeth with spontaneous-pain pulpitis, either root canal treatment (RCT) or full pulpotomy may be effective (weak recommendation, low evidence quality).
Key Conceptual Shift
The traditional binary classification of reversible vs irreversible pulpitis is being reconsidered. The hemostasis test during the procedure — not the pre-operative diagnosis — is increasingly viewed as the key clinical decision point for VPT success. A joint AAE and ESE committee (2025 draft, stakeholder consultation phase) has proposed replacing the binary classification with a severity gradient.
2. VPT Procedures
Indirect Pulp Capping
- Indication: Deep caries approaching but not exposing the pulp
- Technique: Selective caries removal to firm or leathery dentin over the pulp; place HCSC (or Ca(OH)₂ liner) directly over the thin remaining dentin layer; restore immediately
- Goal: Preserve pulp vitality by avoiding exposure; encourage reparative dentin formation
Direct Pulp Capping
- Indication: Small mechanical or traumatic pulp exposure (<1–2 mm); vital, non-infected pulp
- Technique: Control hemorrhage with NaOCl or saline on a cotton pellet; apply HCSC directly over the exposure site; restore immediately
- Key consideration: The exposure should be small, in a clean field, and hemostasis should be achievable within minutes
Partial Pulpotomy (Cvek Pulpotomy)
- Indication: Carious pulp exposure where superficial pulp tissue may be inflamed
- Technique: Remove 2–3 mm of superficial pulp tissue with a sterile bur under copious irrigation; achieve hemostasis at the level of healthy tissue; apply HCSC; restore immediately
- Particularly well-studied in young permanent teeth with carious exposures
Full Coronal Pulpotomy
- Indication: Deeper carious exposure; may be considered even in teeth with spontaneous pain (ESE S3 CPG, weak recommendation)
- Technique: Remove the entire coronal pulp to the level of the canal orifices; achieve hemostasis with NaOCl lavage (5–10 minutes); apply HCSC over the orifices; restore immediately
- This is the most recent evolution in VPT — extending to mature permanent teeth with signs of irreversible pulpitis is an area of active investigation
3. Materials Comparison
Hydraulic Calcium Silicate Cements (HCSCs)
| Material | Type | Setting Time | Success Rate | Key Characteristics |
|---|---|---|---|---|
| MTA (ProRoot, MTA Angelus) | Tricalcium silicate | 2–4 hours | 85–100% at 1–2 yr (AAE 2021) | Gold standard; >20 years of clinical trials. Potential for discoloration (gray MTA). Difficult handling. |
| Biodentine (Septodont) | Tricalcium silicate | ~12 minutes | Comparable to MTA (Soma 2025: OR 0.77, 95% CI 0.24–2.49, p=0.66; GRADE: low) | Faster set; mechanical properties similar to dentin; lower discoloration risk. Growing evidence base (10–15 years). |
| TheraCal LC/PT (Bisco) | Resin-modified calcium silicate | Light-cured (LC) / Self-cured (PT) | Growing evidence | More predictable handling; shorter evidence track record than MTA or Biodentine. |
| Calcium Hydroxide | Ca(OH)₂ | Variable | 43–92% (AAE 2021) | Historically used; lower success rates compared to HCSCs. Not recommended as the primary VPT material by ESE 2019 or AAE 2021. |
The ESE 2019 position statement recommends hydraulic calcium silicate cements as the biomaterial of choice for VPT. Both MTA and Biodentine are considered appropriate options. The choice between them may depend on clinical situation, setting time requirements, and practitioner preference.
4. Case Selection
Favorable Factors
- Vital pulp confirmed (response to sensibility testing or visual assessment at exposure)
- Hemostasis achievable within approximately 5–10 minutes using NaOCl lavage
- No evidence of partial or complete pulp necrosis on intraoperative inspection
- Tooth is restorable with an adequate coronal seal achievable immediately
- No significant apical pathology (absence of periapical radiolucency, or only minimal changes)
- Patient is available for follow-up
Unfavorable Factors
- Pulp necrosis confirmed clinically or radiographically
- Inability to achieve hemostasis after full coronal pulp removal — may suggest irreversible deeper involvement
- Purulent exudate observed at the exposure site
- Tooth not restorable or insufficient structure for a definitive coronal seal
- Extensive apical pathology inconsistent with a vital pulp
The Hemostasis Decision Point
Hemostasis is generally considered the critical intraoperative factor. If bleeding cannot be controlled within approximately 5–10 minutes after full coronal pulp removal using NaOCl or saline, this may indicate deeper pulpal involvement. At this point, conversion to root canal treatment may be considered. The pre-operative diagnosis guides treatment planning, but the intraoperative hemostasis response may ultimately determine the procedure.
5. Clinical Protocol — Step-by-Step
Isolation
Rubber dam placement. The AAE considers dental dam isolation the standard of care.
Caries excavation
Selective caries removal, ideally under magnification. For deep lesions, consider a stepwise approach (selective removal to soft or leathery dentin).
Pulp exposure assessment
Evaluate the size and nature of the exposure. Determine whether indirect capping, direct capping, partial pulpotomy, or full pulpotomy is appropriate.
Pulpal tissue management
For pulpotomy procedures: remove the appropriate amount of pulp tissue using a sterile high-speed diamond bur with copious water irrigation or a sharp spoon excavator.
Hemostasis
Apply NaOCl (1.5–5.25%) or saline on a cotton pellet for approximately 5–10 minutes. Assess whether hemostasis has been achieved. If bleeding persists after full pulpotomy, conversion to root canal treatment may be considered.
Biomaterial placement
Apply HCSC (MTA or Biodentine) directly over the pulp tissue or orifices. Ensure adequate thickness (approximately 2–3 mm).
Immediate restoration
Place a definitive or semi-definitive restoration in the same appointment. The coronal seal is generally considered a key factor in VPT success.
Follow-up
Clinical and radiographic evaluation at approximately 3, 6, and 12 months. Assess: sensibility testing response, absence of symptoms, periapical radiographic status. Signs of success include maintained vitality, absence of periapical pathology, and continued root development (in immature teeth).
6. Frequently Asked Questions
Can a tooth with spontaneous pain receive vital pulp therapy instead of root canal treatment?
The ESE S3 Clinical Practice Guideline (2023) suggests that for teeth with spontaneous-pain pulpitis, either root canal treatment or full pulpotomy may be effective (weak recommendation, low evidence quality). The AAE 2021 position statement notes that a pretreatment diagnosis of irreversible pulpitis is not necessarily an indication for pulpectomy. Hemostasis during the procedure is generally considered the key intraoperative decision point.
MTA or Biodentine — which should I choose for vital pulp therapy?
Both MTA and Biodentine are hydraulic calcium silicate cements with comparable clinical outcomes. A 2025 systematic review and meta-analysis (Soma et al.) found no significant difference between them (OR 0.77, 95% CI 0.24–2.49, low-certainty evidence). Biodentine offers faster setting time (~12 min vs 2–4 hours) and may be easier to handle. MTA has a longer evidence track record (>20 years of clinical trials).
How long should I wait for hemostasis before converting to root canal treatment?
A waiting period of approximately 5–10 minutes with NaOCl lavage or saline on a cotton pellet is generally suggested for achieving hemostasis. If bleeding cannot be controlled after this period following full coronal pulp removal, this may suggest deeper inflammation, and conversion to root canal treatment may be considered.
References
- Duncan HF et al. "European Society of Endodontology position statement: Management of deep caries and the exposed pulp" — Int Endod J (2019);52:923-934. PMID 30664240
- AAE Position Statement: Vital Pulp Therapy (2021)
- Duncan HF, El-Karim I. "Endodontic S3-level clinical practice guidelines: the ESE process and recommendations" — Br Dent J (2025);238(7):580-586. PMC11991915
- Soma U et al. "Clinical and Radiographic Outcomes Following Pulpotomy Using Biodentine in Carious Exposed Mature Permanent Teeth: A Systematic Review and Meta-analysis" — J Int Soc Prev Community Dent (2025);15(4):313-322. PMC12425402
- Colloc TNE, Tomson PL. "Vital pulp therapies in permanent teeth: what, when, where, who, why and how?" — Br Dent J (2025);238:458-468. PMC11991904
- Zhang L et al. "Expert consensus on pulpotomy in the management of mature permanent teeth with pulpitis" — Int J Oral Sci (2025);17:4. PMC11704326
- Taha NA et al. "Full Pulpotomy with a Biocompatible Material vs Root Canal Treatment for the Management of Cariously Exposed Mature Permanent Teeth: A Randomized Clinical Trial" — J Endod (2023);49:624-631
- AAE and ESE Diagnostic Terminology Proposal Document — Stakeholder consultation draft (July 2025)
- ESE S3-level Clinical Practice Guideline — Int Endod J (2023);56:238-295. DOI 10.1111/iej.13974
- Li Y et al. "Efficacy of pulpotomy for managing irreversible pulpitis in mature permanent teeth: a systematic review and meta-analysis" — J Dent (2024);144:104923
Disclaimer
This information is for educational purposes only. Always follow clinical judgment and manufacturer guidelines. It should not be used as the sole basis for clinical decision-making.