Use of Vital Pulp Therapies in Primary Teeth 2024

Board takeaway

For a primary tooth with deep caries:

• 2024 evidence: strong, moderate-certainty preference for IPT or calcium-silicate pulpotomy over other vital therapies at 24 months, within that normal/reversible-pulp population.
• 2026 expansion: the best practice permits selected spontaneous-pain cases without infection. That newer indication does not inherit the older guideline's certainty ratings.

Decision map

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The graded 2024 recommendations concern normal pulp/reversible pulpitis. Selective removal/IPT avoids unnecessary exposure; calcium-silicate pulpotomy is preferred over other pulpotomy medicaments when pulpotomy is indicated. Persistent bleeding alone is not a diagnostic cutoff. Selected spontaneous-pain cases require the separate 2026 criteria: no clinical/radiographic infection, vital radicular tissue, and controllable bleeding.

Diagnosis and eligibility

• Normal pulp: asymptomatic. Reversible pulpitis: transient, provoked pain without irreversible/necrotic findings. The source describes eating-related pain lasting five to 10 minutes; this is a source description, not a stand-alone diagnostic cutoff.
• Spontaneous, unprovoked, lingering or nocturnal pain raises concern for irreversible pulpitis. The 2024 guideline excludes IPT/pulpotomy for irreversible-pulpitis pain; its graded recommendations concern normal pulp/reversible pulpitis.
• Look for swelling/sinus tract, abnormal mobility unrelated to exfoliation, furcation/periapical radiolucency, pathological root resorption, and periodontal ligament changes.
• No single vitality test is sufficiently supported. Combine history, examination, and radiographs; blood color, cold testing, and electric testing have conflicting evidence.
• Bleeding persisting beyond five minutes alone does not diagnose irreversible pulpitis.
• Reversible pain does not automatically exclude IPT or calcium silicate cement pulpotomy; both relieved such pain. Prefer these over DPC conditionally, with very low certainty at 12 months; symptomatic DPC evidence is absent.
• Extensive crown/root destruction, resorption, or very poor prognosis may make a tooth nonrestorable and unsuitable for pulp therapy.

Newer primary-pulp eligibility

• The AAPD 2026 pulp best practice permits calcium-silicate pulpotomy for selected spontaneous-pain cases without clinical/radiographic infection, with vital radicular tissue and controllable bleeding.
• This is a newer indication, not proof that the 2024 recommendation was misquoted.
• Keep the 2024 certainty ratings within their studied normal/reversible-pulp population; they do not apply automatically to spontaneous-pain cases, trauma, or medically compromised children.
• Necrosis and infection still require a different treatment pathway.

Preserve dentin and seal the lesion

• Selective removal/IPT: one visit; leave deepest caries near the pulp and seal with a durable restoration. Strongly preferred over complete or stepwise removal, moderate certainty at 24 months.
• Complete removal: excavates to hard tooth structure; increases exposure risk. Selective removal to avoid exposure is strongly recommended, high certainty.
• Stepwise: temporary seal followed by further excavation after at least four weeks; similar IPT success, but adds chair time, cost, and anesthesia exposure.
• IPT overall success was approximately 97% at 24 months. Direct comparisons did not show a significant IPT–pulpotomy success difference; prioritize IPT for conserving tissue and lower cost.
• IPT liner choice did not change success at 24 months: strong recommendation, high certainty. Longer-term certainty is lower.
• Hall technique: no excavation; seal under a preformed metal crown.
  • May be used when indicated, conditionally, moderate certainty at 24 months.
  • Evidence included lesions extending over halfway through dentin; maintaining vitality was comparable to selective/complete removal.
  • It avoids local anesthesia, potentially useful with limited cooperation.
• Bur removal is almost six minutes faster than chemo-mechanical methods. Both reduce cariogenic bacteria; choose according to expertise/cooperation, conditional low certainty. Excavation-method studies did not establish comparative VPT success.

Exposure: choose the pulp procedure

• DPC covers a pinpoint, approximately 1-mm exposure and requires a seal. Capping-agent comparisons found no clear difference, but certainty is very low at 24 months; this does not establish equivalence to preferred therapies.
• Pulpotomy removes the entire coronal pulp, covers remaining vital radicular pulp with medicament, and seals the tooth.
• MTA and Biodentine had no significant success difference at 24 months, high certainty. Evidence for this guideline's calcium silicate cement recommendation applies specifically to these materials.
• MTA can discolor teeth; newer materials seek to reduce this disadvantage. Esthetic outcomes need further study.
• For cariously exposed vital primary incisors, favor pulpotomy over pulpectomy: strong recommendation, moderate certainty at 12 months. It is simpler, faster, and less costly; longer-term comparative data are limited. No incisor IPT–pulpotomy comparison was found.

Pulpotomy medicaments: strength matters

• Formocresol: lower success than MTA in direct 24-month comparisons, 86% versus 94%, high certainty. Prefer IPT or calcium silicate cement; detailed findings describe FC use as conditional.
• Ferric sulfate: conditional recommendation against; low certainty at 24 months.
• Calcium hydroxide pulpotomy: strong recommendation against, moderate certainty at 24 months; MTA prevents approximately one failure per two teeth treated instead.
• NaOCl as pulpotomy medicament: conditional recommendation against, very low certainty at 18 months.
• ZOE alone as pulpotomy medicament: conditional recommendation against, very low certainty at 24 months.
• Laser and Ankaferd Blood Stopper: no recommendation; only short-term data, without adequate 24-month evidence.

Technique, safety, and restoration

• Use rubber dam as the recommended standard of care to reproduce studied outcomes and limit contamination; comparative isolation evidence is inadequate.
• For MTA pulpotomy, manual instruments, bur, or both may remove coronal pulp; no clear success difference, conditional very low certainty at 12 months.
• For MTA pulpotomy, the guideline conditionally favors water/saline or NaOCl irrigation over chlorhexidine because of potential toxicity concerns; comparative success evidence is very low certainty at 12 months.
  • Prevent NaOCl spillage with careful technique and rubber dam isolation.
• Pulp irrigation has a separate sterile-delivery requirement: the 2026 AAPD pulp best practice says to deliver sterile water/saline or appropriate sodium hypochlorite from a single-use disposable syringe.
  • Do not use tap water or dental-unit waterlines for pulp irrigation, even with an independent reservoir containing sterile water.
  • Routine waterline disinfection remains necessary but does not make that delivery pathway sterile.
• For MTA pulpotomy, water-/saline-moistened cotton pellet, dry pellet, or saline irrigation may control bleeding; conditional very low certainty at 12 months.
• IRM or RMGIC over MTA is acceptable, conditional low certainty at 24 months. An indirect comparison favored IRM, 97% versus 91%, but the panel did not consider this a compelling clinical difference.
• One-visit MTA treatment may be preferred for practical reasons; comparative evidence is very uncertain.
• Same-day definitive restoration may be preferred for compliance/resources; timing did not clearly change calcium silicate cement/FC success, conditional moderate certainty at 24 months.
• For MTA pulpotomy, preformed crown, composite, amalgam, or RMGIC selection may follow expertise and shared decision-making; restoration-type evidence is conditional, very low certainty at 12 months.

Outcomes, individualized care, and evidence gaps

• Success requires both clinical and radiographic success: no pain/infection findings or radiographic pathology. This guideline does not prescribe a recall interval; its 12-/24-month study endpoints are not recall schedules.
• Anterior/posterior location and occlusal/proximal caries showed no clear success difference, but evidence is very uncertain.
• Effects of tell-show-do with/without nitrous oxide are undetermined. No adequate trauma VPT evidence or medically compromised-child studies were identified.
• Individualize for cooperation, medical complexity, anesthesia difficulty, limited opening/gagging, unclear pain/swelling, prior treatment complications, periodontal problems, age, preferences, and cost.
• GRADE certainty and recommendation strength are separate. Conditional choices require discussing alternatives; mixed study bias and restricted language inclusion limit confidence.
• Research priorities: better diagnosis, longer-term materials/Hall/IPT comparisons, DPC in proximal lesions, behavior guidance, trauma, medical complexity, affordability, and esthetics.
  • The 2024 research implications identify VPT for spontaneous-only primary-tooth pain as a research question; the 2026 best practice subsequently permits selected cases as described above.

Common board traps

Answer aloud

How do you treat a primary tooth with deep caries and brief eating-related pain?

Confirm normal/reversible pulp, then prefer selective removal/IPT if a dentin barrier can be preserved.

• Combine history, examination, and radiographs; pain duration alone is not diagnostic.
• If exposure occurs with suitable vital radicular tissue, favor MTA/Biodentine pulpotomy and a durable seal.
• The 2024 graded recommendations concern this normal/reversible-pulp population.

Does spontaneous primary-tooth pain automatically rule out pulpotomy?

No. The 2026 best practice permits selected spontaneous-pain cases without clinical/radiographic infection, with vital radicular tissue and controllable bleeding.

• This expands beyond the 2024 guideline's normal/reversible-pulp population.
• Do not transfer the 2024 certainty ratings to the expanded indication.
• Necrosis/infection follows a different pathway; five-minute bleeding alone is not a diagnosis.

Why prefer MTA/Biodentine over ferric sulfate or calcium hydroxide for primary-tooth pulpotomy?

Calcium-silicate pulpotomy is preferred; ferric sulfate and calcium hydroxide have recommendations against their pulpotomy use.

• Ferric sulfate: conditional recommendation against, low certainty.
• Calcium hydroxide pulpotomy: strong recommendation against, moderate certainty.
• Calcium hydroxide remains an acceptable IPT liner; that is a different procedure.

Would you pulpectomize a vital cariously exposed primary incisor?

Prefer pulpotomy in the studied vital carious-exposure population.

• Strong recommendation, moderate certainty at 12 months.
• It is simpler, faster, and less costly; longer-term comparative data are limited.
• Distinguish this indication from necrosis or nonvital infection.

How do irrigation choice and sterile delivery differ during primary-tooth pulpotomy?

Use an appropriate irrigant through a sterile delivery route; irrigant selection alone does not ensure sterility.

• For MTA pulpotomy, water/saline or NaOCl may be chosen over chlorhexidine because of toxicity concerns; comparative evidence is very uncertain.
• The 2026 best practice specifies sterile water/saline or appropriate NaOCl from a single-use disposable syringe.
• Do not use tap water or dental-unit waterlines for pulp irrigation, even with a sterile-water reservoir.
• Use rubber dam and prevent NaOCl spillage.