Use of Vital Pulp Therapy in Permanent Teeth

Board takeaway

Match vital pulp treatment to caries depth, symptoms, periapical findings, and the exposed pulp, not to root maturity alone.

• Deep caries, normal pulp/reversible pulpitis, intact dentin barrier: favor selective removal and indirect pulp treatment.
• Extremely deep caries or spontaneous/nocturnal/lingering pain: use the guideline's complete-excavation and exposed-pulp assessment pathway.
• Selected pulpotomy: normal periapical appearance, vital tissue, and controlled bleeding may support calcium-silicate full pulpotomy.
• Exclude that pathway: infection-related periapical involvement or uncontrolled bleeding.
• Interpret hemostasis: the six-minute finding supports prognosis; it does not replace diagnosis.

Decision map: a painful permanent tooth

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• Scope: extremely deep caries, or deep caries with spontaneous/nocturnal/lingering pain—not every pulp exposure.
• Assess first: diagnose the pulp and apical tissues, assess restorability, and use isolation.
• Exclude: infection-related periapical involvement or uncontrolled bleeding excludes this pulpotomy pathway.
• Six minutes: a prognostic finding, not a stand-alone eligibility test.

Scope and evidence

• First AAPD guideline devoted exclusively to permanent-tooth vital pulp therapy (VPT); supersedes the permanent-tooth VPT recommendations in the 2025 primary/immature permanent pulp therapy best practice.
• Based on 388 studies, including randomized/nonrandomized clinical studies and laboratory evidence, assessed using GRADE.
• Strong recommendations usually guide care; conditional recommendations require attention to patient preferences, feasibility, clinician expertise, and alternatives.
• Many procedure comparisons are indirect and low certainty; similar observed success does not establish universal interchangeability.

Diagnose before selecting treatment

• Combine history, clinical signs, symptoms, radiographs, and cold/electric pulp testing when appropriate: conditional, very low certainty.
• NP: symptom-free, normal testing response. RP: inflammation considered capable of healing after appropriate care.
• Spontaneous, lingering thermal, nocturnal, or referred pain raises concern for symptomatic IP; the label alone does not exclude a healing response after selected VPT.
• Cold/electric tests assess sensibility. The guideline identifies promising vitality tests—laser Doppler flowmetry and pulse oximetry—but limited clinical usability at publication; no single test establishes histologic status.

Read lesion depth

• Deep: inner third/quarter of dentin involved, with a visible radiographic dentin barrier.
• Extremely deep: full dentin thickness involved, without a discernible barrier; exposure is expected.

Caries removal and IPT

• Selective removal: retain soft/leathery dentin only near the pulp; remove peripheral caries to hard dentin and seal the restoration.
• Soft dentin lifts with minimal resistance; leathery dentin resists indentation but lifts easily; firm dentin needs pressure; hard dentin requires a sharp instrument/bur.
• For deep NP/RP lesions, prefer selective over complete removal to reduce exposure, and over stepwise removal for one-visit care and favorable five-year outcomes: strong, high certainty.
• Stepwise removal means initial selective excavation/temporary restoration, then re-entry at six to 12 months to firm dentin and definitive sealing. It is not the preferred approach here.
• IPT retains a dentin barrier. Glass ionomer, calcium hydroxide, or CS may serve as liners; no meaningful overall 24-month success difference supports a mandatory liner choice: conditional, moderate certainty.
• For extremely deep lesions, with or without pain, or deep lesions with spontaneous/nocturnal/lingering pain and normal periapical appearance, perform complete excavation to hard dentin and assess pulp vitality/hemostasis: strong, moderate certainty.
• Direct trials comparing excavation strategies in this symptomatic group were absent.

Choose the exposed-pulp procedure

• DPC: cover a visible exposure with biocompatible material.
• Partial pulpotomy (PP): remove a small portion of vital coronal pulp.
• FP: remove all coronal pulp, preserving vital radicular tissue.

Choose by exposure and symptoms

• In moderate/deep NP/RP caries, IPT, DPC, PP, and FP had no significant 24-month success difference: conditional, low certainty. Do not deliberately expose a pulp merely because DPC can succeed.
• IPT and DPC with CS after exposure have comparable reported 36-month success: conditional, moderate certainty, with differing caries depths limiting comparison.
• Carious NP/RP exposure: PP is preferred over DPC unless DPC uses CS; with CS, outcomes are similar. PP and FP with CS also have comparable outcomes: conditional, low certainty.
• Spontaneous/nocturnal/lingering pain: FP with CS may be preferred over PP: conditional, low certainty; the reported numerical advantage is not definitive proof of superiority.
• Traumatic exposure in a vital NP/RP tooth: prefer PP/FP over DPC: conditional, low certainty, based on 18–24-month evidence.
• Mature roots do not automatically preclude pulpotomy; NP/RP PP/FP outcomes with CS did not differ significantly by maturation: conditional, low certainty.

Materials, hemostasis, and safety

• DPC for carious NP/RP exposure: CS is preferred over calcium hydroxide: strong, moderate certainty in the detailed recommendation.
• DPC irrigation/hemostasis: use sodium hypochlorite (NaOCl) irrigation and soaked cotton pellets over saline: strong, moderate certainty in the detailed recommendation.
• Pulpotomy: NaOCl irrigation/soaked pellets are suggested over saline: conditional, very low certainty, partly extrapolated from DPC evidence. This guideline supplies no standardized concentration here.

Hemostasis and exclusions

• PP/FP success is likely higher when hemostasis occurs in six minutes or less: conditional, low certainty. This is a prognostic threshold, not a guarantee.
• IP plus infection-related periapical involvement or uncontrolled hemorrhage excludes pulpotomy: strong, moderate certainty.
• Consider root canal procedures when bleeding cannot be controlled; cited studies used ten minutes, but the guideline favors the six-minute threshold.

Isolation and materials

• Use rubber dam isolation to prevent contamination; regarded as the gold standard, without comparative outcome data.
• Magnification likely improves pulp visualization; improved VPT success has not been demonstrated by direct randomized evidence.
• In esthetic areas, choose nonstaining CS: strong, high certainty. Discoloration findings chiefly compare traditional bismuth-containing MTA with Biodentine; do not generalize to every formulation.

Restoration, follow-up, and limits

• Place a well-sealed restoration, preferably at the VPT visit. Evidence cannot conclusively rank restoration types or timing.
• Assess success clinically and radiographically: no pain, infection signs/symptoms, or postoperative radiographic pathology. Study follow-up durations are evidence horizons; this guideline does not prescribe a recall schedule.
• Adapt planning for cooperation, medical/special needs, anesthesia difficulty, restorability, swelling, limited opening/gagging, uncertain diagnosis, previous pulp therapy complications, periodontal problems, esthetics, preferences, and cost.
• No recommendation establishes effects of caries location; no specific guidance for asymptomatic IP or medically compromised patients was supported.
• Research needs: better diagnostic tests/biomarkers, SIP case-selection criteria, longer-term CS comparisons, restoration studies, and trials of emerging regenerative, anti-inflammatory, immune, and AI approaches.
• These are research directions, not treatment endorsements.
• AAPD selective-removal guidance differs from the cited AAE complete-removal position; identify which guideline informs the answer.

Common board traps

Answer aloud

A deep carious permanent molar has brief provoked pain and a dentin barrier. What is your plan?

After confirming normal pulp/reversible pulpitis, prefer selective removal and indirect pulp treatment.

• Preserve the deep dentin barrier, establish hard peripheral margins, and seal.
• If exposed, choose VPT according to intraoperative findings; exposure alone does not require root canal treatment.
• Selective removal is strongly recommended with high certainty in this population.

A permanent molar has nighttime pain but normal periapical findings. Is VPT possible?

Yes, selected cases may qualify after complete excavation and assessment of the exposed pulp.

• Confirm restorability and evaluate symptoms, testing, and radiographs.
• With vital radicular tissue and controlled bleeding, conditionally favor calcium-silicate full over partial pulpotomy.
• Infection-related periapical involvement or uncontrolled hemorrhage excludes this pulpotomy pathway.
• Hemostasis within six minutes supports prognosis; it is not a sole diagnostic test.

A vital permanent anterior tooth has a traumatic exposure. Which VPT is preferred?

Conditionally prefer partial or full pulpotomy over direct pulp capping in a normal/reversible-pulp tooth.

• Use rubber dam and assess hemostasis.
• Choose nonstaining calcium silicate cement in the esthetic area, then seal and assess clinical/radiographic outcomes.
• Root maturity alone does not exclude pulpotomy.

Which liner is required for indirect pulp treatment in a deep permanent tooth with normal pulp or reversible pulpitis?

No single liner is mandatory when a dentin barrier is retained and the tooth is sealed.

• Glass ionomer, calcium hydroxide, or calcium silicate may be selected.
• This IPT role for calcium hydroxide does not make it the preferred material on exposed pulp.

Which material and irrigant are preferred for direct pulp capping of a carious permanent tooth with normal pulp or reversible pulpitis?

Prefer calcium silicate cement over calcium hydroxide and sodium hypochlorite (NaOCl) irrigation/hemostasis over saline.

• Both detailed recommendations are strong, with moderate certainty.
• For DPC irrigation, use the detailed recommendation's moderate certainty; the abstract uses higher-certainty wording.

Which irrigant is suggested for pulpotomy in a vital permanent tooth?

NaOCl irrigation and soaked pellets are conditionally suggested over saline.

• Evidence certainty is very low, partly extrapolated from DPC evidence.
• The guideline does not supply a standardized concentration here.

Does bleeding controlled within six minutes prove that a permanent tooth is suitable for pulpotomy?

No. Hemostasis within six minutes is a prognostic finding, not a diagnostic test or guarantee.

• The recommendation is conditional, with low certainty.
• Assess symptoms, periapical findings, restorability, pulp vitality, and bleeding together.
• Infection-related periapical involvement or uncontrolled hemorrhage excludes the selected symptomatic pulpotomy pathway.

When does a carious permanent tooth need complete excavation and pulp assessment rather than selective removal?

Use the complete-excavation pathway for extremely deep caries, or deep caries with spontaneous, nocturnal, or lingering pain, with normal periapical appearance.

• Extremely deep caries lacks a discernible radiographic dentin barrier; exposure is expected.
• Assess the exposed pulp's vitality and hemostasis before selecting treatment.
• Complete excavation in this population is strongly recommended with moderate certainty; direct trials comparing excavation strategies in the symptomatic group were absent.

Does a mature root exclude vital pulpotomy in a permanent tooth with normal pulp or reversible pulpitis?

No. Root maturity alone does not exclude partial or full pulpotomy with calcium silicate cement.

• Reported outcomes did not differ significantly by maturation; the recommendation is conditional, with low certainty.
• Diagnosis and intraoperative findings still determine eligibility.

How should you restore and reassess a permanent tooth after vital pulp therapy?

Seal the tooth and assess clinical and radiographic healing.

• Prefer a well-sealed restoration at the treatment visit; evidence does not conclusively rank restoration types or timing.
• Success includes no pain, infection signs or symptoms, or postoperative radiographic pathology.
• Study follow-up durations are evidence horizons, not a mandated recall schedule.