Vital pulp therapy of mature permanent teeth with irreversible pulpitis from the perspective of pulp biology

Abstract

The American Association of Endodontists (AAE) Consensus Conference Recommended Diagnostic Terminology states that mature permanent teeth clinically diagnosed with irreversible pulpitis are treated with pulpectomy and root canal filling because inflamed vital pulp is not capable of healing. Histological studies have demonstrated that clinically diagnosed irreversible pulpitis does not involve the entire pulp. A recent International Endodontic Journal Editorial suggested clinical diagnosis of pulp disease should be reassessed because of the poor correlation between clinical symptoms and pulp sensibility testing and the actual histological status of the pulp. This review identified studies in a PubMed search that provide evidence for vital pulp therapy (VPT) of mature permanent teeth with irreversible pulpitis is predictable if correctly diagnosed and properly treated. A narrative review was undertaken to outline the correlation between the clinical symptoms/signs and pulp sensibility testing and the histological findings of the pulp. Treatment procedures for permanent teeth are outlined. † CH (Dycal; Dentsply Caulk, Milford, DE, USA).

Vital Pulp Therapy in Permanent Mature Posterior Teeth with Symptomatic Irreversible Pulpitis: A Systematic Review of Treatment Outcomes

“…The consideration of a mature permanent tooth as a candidate for VPT requires careful assessment of the extent of damage to the pulp tissue, using clinical and radiographic measures [47]. The pulp condition, routinely surmised pre-operatively from past and present signs and symptoms and responses to clinical tests, must be confirmed intraoperatively by the assessment of pulpal bleeding, tissue color and consistency [48]; if pulp exposure does not elicit bleeding, the coronal pulp may be infected and necrotic, contraindicating a VPT procedure [10]. The significance of intra-operative pulp assessment is well illustrated in one study [37], where the pulps of 7/64 (11%) of teeth diagnosed with irreversible pulpitis were intra-operatively determined as partially (3 teeth) or fully (4 teeth) necrotic, suggesting that pre-operative assessment alone may overestimate the pulp's amenability to VPT procedures.…”

“…Radiographic success commonly reflects the absence of findings in the periapical bone [31,32,39], which are subject to interpretation and not easily detected by periapical radiographs in the early stages of tissue breakdown [51]. Inspecting the tooth for the formation of a dentinal bridge under the pulp capping material [8,48] may not be a reliable outcome measure either because of low mineralization, overlapping roots and restorative materials [45]. Indeed, the formation of a dentinal bridge was not considered for the outcome assessment in any of the reviewed studies.…”

Bio-Inductive Materials in Direct and Indirect Pulp Capping—A Review Article

“…Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy, claiming the superiority of vital pulp treatment (VPT) techniques such as pulp capping, partial and complete pulpotomy [2]. This constant turn toward a conservative and minimally invasive approach is strongly associated with the fact that the emphasis of the profession is also slowly shifting to care for the senior adult segment of the population [3,4]. Under these circumstances, retaining natural teeth is of paramount importance.…”

Dental follicle stem cells rescue the regenerative capacity of inflamed rat dental pulp through a paracrine pathway

“…Therefore, the preservation of pulp with sustained vitality and the development of minimally invasive biological therapies have become key themes in contemporary regenerative endodontics [65]. Vital pulp therapy (VPT), in which the inflamed tissue is selectively removed and the exposed pulp is capped with bioactive materials [66,67], provides an option to maintain the vitality of dental pulp under inflammatory conditions. Unfortunately, the most widely used capping materials, such as calcium hydroxide paste (Ca [OH] 2 ) and mineral trioxide aggregate (MTA), are short of either anti-inflammatory or reparative properties, and the resins present in their formulations increase the cytotoxicity to pulp tissue, which limits the long-term success of VPT [68,69].…”