Vital pulp therapy
Vital Pulp Therapy (VPT) – Complete Protocol
1. Introduction
Vital Pulp Therapy (VPT) is a biologically oriented treatment aimed at preserving pulp vitality, both in teeth with an open apex (immature teeth with incomplete root development) and in teeth with a closed apex. The goal of VPT is to maintain the pulp’s defensive, immunological, sensory, and reparative functions.
When properly indicated and performed, VPT can prevent the need for root canal treatment and ensure long-term tooth health.
2. Indications
• Symptomatic or asymptomatic reversible pulpitis – short, sharp pain on stimulus, subsiding after removal.
• Traumatic pulp exposure (e.g., crown fracture, luxation, or avulsion with preserved vascular integrity).
• Iatrogenic pulp exposure during cavity preparation.
• Caries-related pulp exposure without signs of irreversible damage (no spontaneous pain, no purulent exudate).
• Children and adolescents – teeth with open apices where pulp vitality is crucial for root development.
• Adults – increasingly indicated also in mature teeth with closed apices, provided a healthy portion of pulp remains.
3. Contraindications
• Signs of irreversible pulpitis: spontaneous or nocturnal pain, prolonged pain after thermal stimulus, purulent exudate.
• Pulp necrosis.
• Significant periapical pathology (radiolucency, resorption, sinus tract).
• Inability to achieve proper isolation with a rubber dam.
• Patient unwillingness for cooperation or follow-up.
4. Clinical Protocol
a) Anesthesia and isolation – local anesthesia, rubber dam.
b) Caries removal and access – conservative preparation, complete caries removal.
c) Pulp exposure assessment – evaluation of tissue color, bleeding, and vitality.
d) Hemostasis – NaOCl 1–2.5 %, sterile pellets, 1–5 minutes.
e) Type of VPT – direct pulp capping, partial pulpotomy, full pulpotomy.
f) Disinfection and materials – saline rinse, placement of MTA/Biodentine or other calcium silicate cements, covered with GIC or composite.
g) Definitive seal – preferably immediate adhesive composite restoration; provisional GIC in children.
5. Materials
• Hemostatic agents: NaOCl (1–2.5 %), saline.
• Bioactive cements: MTA, Biodentine, other calcium silicate materials.
• Restorative materials: GIC, composite resins.
6. Possible Complications
• Persistent pain → failure, requires endodontic treatment.
• Internal resorption (rare).
• Tooth discoloration (especially with MTA containing bismuth oxide).
• Microleakage if coronal seal is inadequate.
7. Prognosis
• Success rates: 85–90 % in children/adolescents, 70–85 % in adults.
• Determined by correct indication, hemostasis, bioactive material, and coronal seal.
8. Role of Magnification
Operating under a dental microscope or loupes provides significant advantages. Magnification enables detailed evaluation of:
• pulp color,
• bleeding characteristics,
• hyperemia,
• presence of early necrotic changes.
This improves diagnostic accuracy and helps determine whether the pulp is still capable of repair.
9. Borderline Indications
The distinction between reversible and irreversible pulpitis is not absolute. Clinical practice demonstrates that:
• VPT can succeed even in some cases diagnosed as irreversible pulpitis, provided hemostasis is achieved and vital tissue remains.
• After discussion with the patient, attempting VPT is often worthwhile.
• Even in the presence of a radiographic periapical lesion, if vitality is confirmed clinically, VPT may be performed with favorable outcomes.
10. Conclusion
Vital Pulp Therapy is a biologically conservative approach that preserves pulp vitality even in cases traditionally managed by endodontic treatment. Success relies on precise diagnosis, infection and bleeding control, bioactive materials, a tight coronal seal, and the use of magnification. The operator’s experience ultimately defines and expands the boundaries of indications.
