Aust Endod J 2019

LITERATURE REVIEW

Vital pulp therapy of mature permanent teeth with irreversible

pulpitis from the perspective of pulp biology
Louis M. Lin, BDS, DMD, PhD1; Domenico Ricucci, MD, DDS2 ; Tarek M. Saoud, BDS, MSc, PhD3;
Asgeir Sigurdsson, DDS, MS1; and Bill Kahler, DClinDent, PhD4
1 Department of Endodontics, New York University College of Dentistry, New York, New York, USA
2 Private Practice, Cetraro, Italy
3 Department of Restorative Dentistry and Endodontics, Faculty of Dentistry, University of Benghazi, Benghazi, Libya
4 The University of Queensland School of Dentistry, Brisbane, Queensland, Australia

Keywords Abstract
irreversible pulpitis, mature permanent teeth,
pulp sensibility tests, root canal therapy, vital The American Association of Endodontists (AAE) Consensus Conference Rec-
pulp therapy. ommended Diagnostic Terminology states that mature permanent teeth clini-
cally diagnosed with irreversible pulpitis are treated with pulpectomy and root
Correspondence canal filling because inflamed vital pulp is not capable of healing. Histological
Louis M. Lin, Diplomate of American Board of
studies have demonstrated that clinically diagnosed irreversible pulpitis does
Endodontics, Department of Endodontics, New
not involve the entire pulp. A recent International Endodontic Journal Edito-
York University College of Dentistry, 345 East
24th Street, New York, NY 10010, USA. Email: rial suggested clinical diagnosis of pulp disease should be reassessed because of
[email protected] the poor correlation between clinical symptoms and pulp sensibility testing
and the actual histological status of the pulp. This review identified studies in a
doi: 10.1111/aej.12392 PubMed search that provide evidence for vital pulp therapy (VPT) of mature
permanent teeth with irreversible pulpitis is predictable if correctly diagnosed
(Accepted for publication 13 November 2019.)
and properly treated. A narrative review was undertaken to outline the corre-
lation between the clinical symptoms/signs and pulp sensibility testing and the
histological findings of the pulp. Treatment procedures for permanent teeth
are outlined.

caries excavation and trauma’. Based on the AAE Guide

Introduction
to Clinical Endodontics (3), and American Academy of
Endodontics is not only concerned about clinical out- Pediatric Dentistry (AAPD) Guidelines on Pulp Therapy
come but also the pathobiology of the pulpal–periapical for Primary and Immature Permanent teeth (4), mature
disease. According to a systematic review of treatment of permanent teeth with irreversible pulpitis should be trea-
pulps in teeth affected by deep caries, it is not possible to ted with nonsurgical root canal therapy. Vital pulp ther-
determine whether an injured pulp caused by deep caries apy (VPT) is primarily indicated for immature permanent
can be maintained or if it should be removed and teeth with reversible pulpitis caused by mechanical pulp
replaced with a root canal filling because of the lack of exposure during carious excavation or operative proce-
well-controlled studies (1). This clearly indicates the diffi- dure, or a traumatic pulp exposure of healthy teeth with
culty in making an accurate diagnosis and treatment of minimal bacterial contamination (3,4). VPT includes
pulp disease. indirect pulp treatment, direct pulp capping and pulpo-
According to the American Association of Endodontists tomy (partial and complete) (3,4). Therefore, treatment
(AAE) Consensus Conference Recommended Diagnostic of mature permanent teeth with irreversible pulpitis is
Terminology (2), the definition of irreversible pulpitis is not part of VPT. However, there are several recent studies
that ‘a clinical diagnosis based on subjective and objective of treatment of mature permanent teeth with irreversible
findings indicating that the vital inflamed pulp is inca- pulpitis in the literature using the term ‘vital pulp ther-
pable of healing. Additional descriptors include lingering apy’. In fact, VPT in these studies simply implies that the
thermal pain, spontaneous pain, referred pain or no clini- procedures used for direct pulp capping or pulpotomy of
cal symptoms but inflammation produced by caries, immature permanent teeth with reversible pulpitis can

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Vital Pulp Therapy of Mature Teeth L. M. Lin et al.

also be employed for mature permanent teeth with irre- especially for the patients who could not afford the high
versible pulpitis. cost of RCT (8–12). Extraction of the teeth affects the
In VPT of mature permanent teeth with irreversible development of the jawbone and neighbouring teeth in
pulpitis, the immune defence mechanism and regenera- young patients. It also affects the appearance, occlusion,
tive potential of the radicular healthy pulp are preserved. phonics and the digestion system of patients. Preserva-
This is in contrast to RCT, where the entire pulp includ- tion of teeth improves the quality of life of patients. Most
ing infected and healthy tissue is completely removed; recently, an editorial titled ‘Minimally invasive endodon-
accordingly, the immune defence mechanism and regen- tics: a new diagnostic system for assessing pulpitis and
erative potential of the pulp are totally lost. RCT of subsequent treatment needs’ published in the Interna-
mature permanent teeth with irreversible pulpitis can be tional Endodontic Journal suggested that the clinical
considered a prophylactic treatment to prevent further diagnosis of pulp disease should be reassessed because of
pulp infection and subsequent development of apical the poor correlation between clinical symptoms and pulp
periodontitis (5). sensibility testing and the actual histological status of the
Since the evolution of the concept of regenerative pulp. The vitality of the pulp in mature permanent teeth
endodontics to restore vitality, functionality and immu- with irreversible pulpitis should be preserved as much as
nity of immature permanent teeth with necrotic pulp by possible by VPT to retain immunological functions and
regenerative endodontic procedures, VPT of mature per- structural integrity of the tooth and reduce cost and
manent teeth with irreversible pulpitis has regained inconvenience of the patients (13).
attention of some endodontists trying to save the vitality The purpose of this article was to undertake a PubMed
of the teeth. Evidence-based studies have showed that search of clinical outcome studies to assess the efficacy of
mature permanent teeth clinically diagnosed with irre- VPT of mature teeth with irreversible pulpitis. According
versible pulpitis treated with nonsurgical RCT have a to the AAE definition, mature teeth with irreversible pul-
higher and more predictable success rate than treated pitis cannot be treated with vital pulp therapy yet studies
with VPT (6,7). However, many recent studies including attest to the success of VPT in mature permanent teeth.
some controlled studies have showed that mature perma- Therefore, a narrative review was also undertaken from
nent teeth clinically diagnosed with irreversible pulpitis the perspective of pulp biology to outline the correlation
without apical periodontitis could be successfully treated between the clinical symptoms/signs and the correlation
with VPT (Tables 1–3). Several very recent articles focus- with pulp sensibility testing, the histological findings of
ing on systematic reviews for cariously pulp exposed per- the pulp as well as pulp wound healing. Diagnosis and
manent teeth have also provided evidence that VPT treatment procedures for permanent teeth with pulpitis
could be an alternate option to RCT or tooth extraction, are outlined.

Table 1 Studies undertaking a pulpotomy on mature teeth

Study Age (years) Teeth Aetiology Material Follow-up Success (%)

†
Santini (74) 9–62 20 CE CH (Calnex) 5 years 65
Caliskan (75) 10–22 21 IP CH 1–4 years 91.6
Calıskan (76) 10–24 26 IP CH 16–72 months 92.3
Da Rosa (77) 14–70 26 CE CH 14–88 months 65
Asgary & Ehsani (78) 14–62 12 CE & IP NEC 15.8 months 100
Asgary (79) 9–65 205 CE & IP CEM 1 year 97.6
Barngkgei (60) 27–54 11 CE & RP MTA 24–42 months 100
Alqaderi (10) 10–15 29 CE MTA 25  14 months 90
Asgary (80) 9–65 205 CE & IP CEM 5 years 78.1
Asgary (81) 9–40 34 CE & IP CEM & MTA 2–5 years >98
Taha (63) 11–51 44 CE & IP MTA 3 years 92.7
Galani (82) 15–36 18 CE MTA 1.5 years 84.6
Taha (83) 9–17 20 CE & IP Biodentine 1 year 95
Taha (84) 19–69 63 CE & IP Biodentine 1 year 100 Clinical
98.4 Radio
Asgary (64) 69 CEM 71% RP29% IP 1 year 93.5

CE, carious exposure; CEM, calcium enriched material; IP, irreversible pulpitis; MTA, mineral trioxide aggregate; NEC, new endodontic cement; RP,
reversible pulpitis.
†
CH (Dycal; Dentsply Caulk, Milford, DE, USA).

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L. M. Lin et al. Vital Pulp Therapy of Mature Teeth

Table 2 Studies undertaking a partial pulpotomy on mature teeth

Study Age (years) Teeth Aetiology Material Follow-up Success (%)

†
Bjørndal (51) 18–49 29 CE CH 1 year 34.5
Taha (85) 20–59 50 CE & IP CH & MTA 2 years MTA-85
CH-43
Asgary (64) 26.82  7.57 76 67.1% RP CEM 1 year 91.4
32.9% IP

CE, carious exposure; CEM, calcium enriched material; IP, irreversible pulpitis; MTA, mineral trioxide aggregate; RP, reversible pulpitis.
†
CH (Dycal; Dentsply Caulk, Milford, DE, USA).

Table 3 Studies undertaking direct pulp capping studies on mature teeth

Study Age (years) Teeth Aetiology Material Follow-up Success (%)

†
Matsuo (67) 20–>60 44 CE CH 1.5 years 83.3
Barthel (48) 10–70 123 CE CH 5 and 10 years 37 at 5 years
13 at 10 years
Bjørndal (51) 18–49 29 CE CH 13 years 31.9
Miles (86) >18 51 CE MTA 12–27 months 56.2
Marques (87) 36.1  15 years 46 CE MTA 3.6 years 91.3
Linu (88) 15–30 30 CE MTA & Biodentine 1.5 years MTA 84.6
Biodentine 92.3
Calıskan (89) 14–55 152 CE CH & MTA 2–6 years 91.4 at 2 years
84 at 4 years
65 at 6 years
Lipske (90) 11–79 86 CE Biodentine 1–1.5 years 82.6
Asgary (64) 28.15  14 73 74% RP26% IP CEM 1 year 94.7

CE, carious exposure; CEM, calcium enriched material; IP, irreversible pulpitis; MTA, mineral trioxide aggregate; RP, reversible pulpitis.
†
CH (Dycal; Dentsply Caulk, Milford, DE, USA).

2 Cariously involved mature permanent teeth with frank

Search strategy
clinical vital pulp exposure (bleeding);
An electronic search of PubMed using the search terms 3 Cariously involved mature permanent teeth with
‘pulpotomy’, ‘partial pulpotomy’, ‘direct pulp cap’, ‘ma- symptom without sign of swelling;
ture teeth’ and ‘permanent teeth’ was undertaken 4 Cariously involved mature permanent teeth without
(Fig. 1). Reference mining was also undertaken to further radiographic evidence of internal resorption or periapical
identify articles. The inclusion criteria were as follows: radiolucent lesion.
1 Clinical outcome studies of human vital permanent The exclusion criteria were as follows:
mature teeth with irreversible pulpitis. 1 Cariously involved permanent mature teeth with no
2 Calcium hydroxide or a bioceramic material was used response to pulp sensibility tests;
as a medicament for a direct pulp cap, partial pulpotomy 2 Cariously involved permanent mature teeth with
or a full pulpotomy. uncontrollable bleeding after complete pulpotomy;
3 Success was evaluated by clinical and radiographic 3 Cariously involved teeth with necrosis of the coronal
examination. pulp (no evidence of bleeding) after access opening;
4 Success rate was evaluated for at least 10 teeth for a 4 Cariously involved permanent mature teeth with peri-
minimum of 1 year. apical radiolucent lesion (apical periodontitis);
5 Only papers in English were included. 5 Cariously involved permanent mature teeth with loss
Generally, when assessing the studies the inclusion cri- of coronal tooth structure, which required a post.
teria were as follows: 6 Cariously involved permanent mature teeth with sev-
1 Cariously involved mature permanent teeth with ere periodontal disease.
spontaneous pain, or lingering pain to thermal stimuli 7 No restorable teeth.
and pulp sensibility tests; 8 Medically compromised patients.

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Vital Pulp Therapy of Mature Teeth L. M. Lin et al.

Records identified through database

I dentification
searching (PubMed- 544)

Records after duplicates removed

(n = 432)
Screening

Records screened Records excluded

(n = 432) (n = 48)

Articles excluded
Eligibility

Articles assessed for (n = 359)

eligibility Reason: Immature teeth (118);
(n = 384) Trauma (41); Case Report (30);
Animal studies (29); Reviews
(67); Experimental studies (65);
Reversible pulpitis (5); and
immature and mature teeth not
stratified (5)
Included

Studies included (n = 25)

Figure 1 Flow chart of the search strategy.

aseptic inflammation to the pulp unless the pulp is

The dental pulp
exposed and contaminated by bacteria. It has been
Dental pulp is a small loose connective tissue housed in demonstrated histologically that a pulpal reaction could
low-compliance dentine walls. It is generally believed be observed when early caries involved the enamel
that the dental pulp is very vulnerable to insults, such as (20). However, most studies showed that pulp response
carious infection due to (i) the dental pulp is incapable of was discernable when caries involved the primary den-
accommodating an increase in intra-pulpal pressure dur- tine (21–24). When primary dentine is involved by
ing inflammation because of its low-compliance environ- caries, bacterial toxins and harmful metabolic by-prod-
ment, (ii) the dental pulp lacks collateral circulation to ucts can act as non-antigenic or antigenic irritants to
effectively deliver humoral and cellular components of penetrate through dentinal tubules and elicit innate
innate and adaptive immune defence mechanisms to and adaptive immuno-inflammatory responses in the
injured pulp. However, studies have shown that the den- pulp connected to the cariously involved dentinal
tal pulp has an adequate immune defence mechanism tubules (25–27). The pulp can also respond to carious
(14,15) and is rich in vascular (16) and nerve supply attack by producing reactionary or reparative dentine
(17). Furthermore, the dental pulp can accommodate to deter the bacterial penetration in the dentine (15).
increases in intra-pulpal pressure during inflammation If the caries is not treated, bacteria will continue to
(18,19). penetrate through primary dentine, and reactionary or
reparative dentine and the pulp will become severely
damaged, such as localised acute inflammation or
Disease of the dental pulp
abscess formation (21). If the pulp is exposed by caries,
The main causes of pulpal disease are caries, trauma bacteria will invade the pulp and colonise the necrotic
and dental anomalies. Caries causes infection/inflam- pulp because necrotic tissue is completely devoid of
mation of the pulp, while trauma usually causes immune defence mechanisms (Fig. 2) (22,23,28). Once

4 © 2019 Australian Society of Endodontology Inc

L. M. Lin et al. Vital Pulp Therapy of Mature Teeth

(a) (b)

(c) (d)

Figure 2 (a) Periapical radiograph of tooth #38 with deep caries. (b) Histology of tooth #38 showing localised necrosis in the mesial pulp horn at the
site of carious pulp exposure (arrow). A few millimetres away from the localised pulp necrosis, the coronal pulp is free from inflammation (star; haema-
toxylin–eosin, 916). (c) Bacterial stain of section close to that in (b) (Brown & Brenn, 916). (d) Higher magnification of micro-abscess in (c). Numerous
bacteria are present in the necrotic tissue (Brown & Brenn, 9100). (Permission from Ricucci et al. (28)).

bacteria infect the pulp, the pulp is considered inca- bacterial infection (14,15,26,27). If no treatment is ren-
pable of self-healing and has an irreversible pulpitis dered to eliminate the infected pulp, the pulp infection
(28). As a defence mechanism, immuno-inflammatory at the carious exposure site will gradually spread to
cells will surround the necrotic tissue and bacterial involve the entire coronal pulp and the radicular pulp
colonies to prevent the spread of pulpal infection. A tissue can remain free from infection/inflammation in
few millimetres away from the necrotic pulp with bac- single-rooted teeth (Fig. 3) (22,23,28). In multi-rooted
terial colonisation, the pulp tissue is usually free from teeth, infection/inflammation can involve the pulp in
inflammation and bacteria (Fig. 2) (22,23,28), because one of the roots and the other roots can be free from
pulp tissue is equipped with adequate innate and adap- infection/inflammation (22,24). In theory, if the
tive immune defence mechanisms to prevent spread of infected pulp is removed, the rest of the healthy pulp

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Vital Pulp Therapy of Mature Teeth L. M. Lin et al.

(a) (b)

(c) (d)

Figure 3 (a) Periapical radiograph of tooth #18 with deep caries. (b) Photograph of tooth #18 showing large and deep caries. (c) Histology of tooth
#18 showing an abscess involving almost the entire mesial pulp chamber (arrow). The pulp in the chamber near the distal canal is free from inflamma-
tion (star; Brown & Brenn, 98). (d) Higher magnification of abscess in (c). Numerous bacteria are present in the area of abscess (Brown & Brenn, 916).
(Permission from Ricucci et al. (28)).

should be able to be saved. In germ-free animals, it infection has a more damaging effect to the pulp tissue
has been elegantly demonstrated that a surgically than physical or chemical injury. The classic study of
exposed inflamed pulp without infection could heal Kakehashi et al. (29) showed that microbial infection of
without any intervention (29). the pulp could cause serious consequences such as pulp
necrosis or a pulp abscess in conventional rat teeth. In
contrast, surgical exposure of the pulp, furcation or root
Pulp wound healing
perforation would not have serious consequences and
Clinical science is built on the foundation of basic the inflamed pulps were capable of healing in germ-free
science. If VPT of mature teeth with irreversible pulpitis rat teeth. In VPT of mature teeth with irreversible pul-
does not work clinically, we should be able to give a rea- pitis, if the infected coronal pulp can be completely
sonable biological explanation. In the same token, if VPT removed, and the pulp wound completely sealed off
of mature teeth with irreversible pulpitis works, we with a biocompatible material to prevent micro-leakage,
should also be able to provide a reasonable biological the pulpotomised pulp would be similar to the surgi-
explanation. cally exposed pulp in germ-free rats. However, if the
Pulpal inflammation can be caused by microbial pulp is infected with microbes, the pulp is considered
infection and physical or chemical injury. Microbial incapable of self-healing (28).

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L. M. Lin et al. Vital Pulp Therapy of Mature Teeth

The principle of wound healing of the dental pulp is not response (17,45). In addition, pulp stem/progenitor cells
different from that of the tissues in other parts of the body. in pulp can differentiate into odontoblast-like cells to pro-
Wound healing is the host’s programmed response to duce reparative dentine to protect the pulp from further
injury, and its aim is to recapitulate the embryonic tissue injury. If the vital pulp tissue is removed from the canal
morphogenesis (30,31). The wound healing can result in such as root canal therapy, the potential of pulp repair is
either regeneration or repair depending on the regenera- diminished (46) and the pulp immune defence mecha-
tive potential of the resident postnatal stem cells (ageing, nism is completely lost.
epigenetic changes) (32,33) and micro-environmental cues
(34). Wound healing of pulpal infection/inflammation fol-
Outcome studies of mature permanent teeth with
lows the same general principle in pathology. Although
irreversible pulpitis
the dental pulp has a limited potential to regenerate, it has
a good potential for repair, for example reparative dentino- Early studies of VPT of permanent teeth with irreversible
genesis. From the studies of vital pulp therapy of immature pulpitis showed treatment outcomes were not favourable
permanent teeth with reversible pulpitis, healing of an (47–51). However, many recent studies of VPT of mature
amputated pulp is usually repaired by a hard scar tissue permanent teeth with irreversible pulpitis caused by cari-
formation, reparative dentinogenesis (35,36). In one ous pulp exposure have demonstrated a high successful
human histological study of mature teeth with irreversible rate (Tables 1–3). The favourable treatment outcomes
pulpitis caused by frank carious pulp exposure treated with might be due to better understanding of pulp biology and
MTA pulpotomy, similar histological findings seen in advances in material science.
immature teeth with reversible pulpitis after pulpotomy
were also observed (37).
Diagnosis of pulpal disease
In VPT of mature teeth with irreversible pulpitis, after
infected pulp is completely removed, a favourable environ- Clinically, the diagnosis of pulpal disease is based on the
ment is set for pulp wound healing to occur. The immuno- patient’s subjective symptoms, objective clinical exami-
inflammatory cells will gradually diminish due to apoptosis nation and radiographic findings and not histological
(38). The injured pulp tissue will release chemokines such findings. These clinical diagnostic procedures are not reli-
as stromal-derived factor-1 (SDF-1) to attract undifferenti- able. Clinical diagnosis of pulpal disease can only give a
ated mesenchymal stem cells to migrate to the wounded provisional diagnosis or educated judgment, which is
site (39). MTA used in vital pulp therapy as a capping subject to error because the correlation between clinical
material can induce growth factor release from the dentine signs and actual histological findings of the pulps is not
matrix (40–42). The dentine matrix-associated growth fac- 100% accurate. In fact, we do not know whether our
tors can signal mesenchymal stem cells in the pulp to dif- clinical diagnosis of pulpal disease is correct without his-
ferentiate into odontoblast-like cells and produce dentinal tological conformation. Although histological examina-
bridge. Regardless of whether immature or mature teeth, if tion is the final diagnosis of the disease, it is not feasible
infection is controlled, irreversible pulpitis appears to be to take a pulp biopsy prior to treatment.
capable of healing (43,44). Nevertheless, more histological Carious excavation should be a diagnostic procedure
studies of VPT of mature teeth with irreversible pulpitis are prior to the diagnosis of pulpal disease because caries is
needed, because the pulps of VPT of mature teeth with the primary cause of pulpal disease. Traditionally, clinical
irreversible pulpitis might still be infected without clinical diagnosis of pulpal disease is determined prior to com-
symptoms and radiographic evidence of pulp disease. plete removal of the caries. The drawback of this condi-
tion is that if clinical diagnosis of cariously involved tooth
was irreversible pulpitis, the clinician most likely would
Why should vital pulp tissue of teeth with
open into the tooth even though there was no pulp expo-
irreversible pulpitis be preserved as much as
sure after complete carious removal.
possible?
Vital pulp is equipped with blood circulation and nerve
Correlation between clinical symptoms/signs and
innervation. The cellular and humoral components of
actual histological findings of the pulp
immune system are contained in the blood circulation. If
the pulp is injured, the blood circulation will immediately Many studies have shown that there is no good correlation
deliver the immune components to the site of injury to between clinical symptoms and diagnostic data and the
combat and eliminate irritant by mounting an immuno- actual histological status of the pulp (52–56). A recent
inflammatory response. The sensory nerve fibres can reg- study showed that there was an 84.4% correlation
ulate blood flow, wound healing and the immune between patient’s symptoms and the histological findings

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Vital Pulp Therapy of Mature Teeth L. M. Lin et al.

of irreversible pulpitis (28). In this study, the histological (66). Laser Doppler flowmetry and pulse oximetry are
criteria of irreversible pulpitis are defined as partial or total the most accurate methods to diagnose pulp vitality
necrosis of the coronal pulp and bacterial aggregations/bio- (66). Therefore, responses of the tooth to pulp sensibil-
film was observed colonising the necrotic pulp tissue. How- ity tests cannot be used as reliable criteria to determine
ever, the rest of the pulp in the pulp cavity is free from the histological status of the pulp.
infection/inflammation. The authors emphasised that there Until the next generation of more reliable diagnostic
is still a need for refined and improved means for reliable technology is developed, the traditional diagnostic method-
pulp diagnosis (28). Albeit there is a consensus agreement ology, such as clinical symptoms/signs and pulp sensibility
about the clinical criteria of irreversible pulpitis (2), there is testing, will continue to be employed to diagnose pulpal
no consensus agreement regarding the histological criteria disease (reversible or irreversible pulpitis). However, the
of irreversible pulpitis in many studies (52–55). A system- development of a reliable diagnostic methodology should
atic review of the diagnosis of the dental pulp indicated be one of the priorities in endodontic research.
that there was insufficient scientific evidence to assess the
accuracy of clinical signs, symptoms or sensibility tests to
Dilemma of reversible and irreversible pulpitis
determine reversible/irreversible pulp inflammation (57).
Clinically, a symptom of pain of an endodontically The diagnostic terminology of reversible and irreversible
involved tooth may indicate possible injury to the pulp but pulpitis was determined at the 2008 AAE consensus confer-
cannot be used to predict the extent and severity of the ence on diagnostic terminology, background and perspec-
pulp injury. Pain is mediated at molecular level, which is tive (2). As aforementioned, the definition of irreversible
not identifiable histologically (58). Although pain is one of pulpitis is ‘based on subjective and objective findings that
the cardinal signs of infection/inflammation, no studies the vital inflamed pulp is incapable of healing and that root
have showed that intensity of pain is related to severity of canal treatment is indicated (2). The words ‘the vital
tissue injury. In fact, teeth with pulpitis are often painless inflamed pulp is incapable of healing’ is not very clear.
(59). More studies to correlate clinical symptoms and Does irreversible pulpitis always involve the entire pulp? In
actual histological status of the pulp are needed to come to addition, is vital inflamed pulp incapable of healing because
a consensus agreement about the histological criteria of of without or with treatment? If the infected/inflamed pulp
irreversible pulpitis. is removed, what will happen to the rest of the pulp?
Some studies have shown that the presence of certain Therefore, to avoid confusion, pulpitis is probably a more
preoperative symptoms had a poor prognosis in VPT of acceptable diagnostic terminology because pulpitis includes
permanent teeth with irreversible pulpal disease (50), both reversible and irreversible pulpitis. Treatment of pulpi-
while others demonstrated that the presence of preopera- tis will depend on the extent and severity of the pulp infec-
tive symptoms was not important in outcomes of VPT tion/inflammation, which unfortunately cannot be
(60–64). It may be that incomplete disinfection of accurately determined in a clinical setting.
infected/inflamed pulp is primarily related to poor out-
comes rather than preoperative pain in VPT.
Disinfection of infected pulp
Although complete pulpectomy is a very effective way to
Correlation between pulp sensibility testing and
eliminate pulpal infection in teeth with irreversible pulpi-
histological findings of the pulp
tis, healthy pulp is also removed. Control of pulpal infec-
Pulp sensibility testing in endodontics is to test the tion in teeth with irreversible pulpitis is a challenge and
physiological function of sensory nerves to cold, heat or should be more thoroughly performed than for teeth with
electric current (65), and not the vitality (blood circula- reversible pulpitis without bacterial infection in VPT. Most
tion) and the inflammation of the pulp. Even though studies of VPT of teeth with irreversible pulpitis used the
pulp sensitivity testing may be able to detect pulp same disinfection protocol for reversible pulpitis (Tables 1–
injury, it cannot determine the extent and severity of 3). Unfortunately, there are no recommended guidelines
the pulp damage. Studies have showed no good correla- to control pulpal infection in VPT of teeth with irreversible
tion between the physiological responses of sensory pulpitis. It has been speculated if the bleeding could be
nerves to stimuli and the degree of pulp infection/in- controlled within 10 min in VPT, most likely the remaining
flammation (52). A recent systematic review and meta- healthy pulp is reached (67). However, there is no scien-
analysis of diagnostic accuracy of dental pulp tests indi- tific evidence from a microbiological and histobacteriologi-
cates that cold, heat and electric current stimuli are not cal aspects if bleeding can be controlled within a few
very accurate in determining pulp vitality even though minutes in VPT of teeth with irreversible pulpitis, the
the cold test has a higher sensitivity than the heat test remaining pulp will be free from infection/inflammation,

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L. M. Lin et al. Vital Pulp Therapy of Mature Teeth

for the extent of bacterial colonisation in infected pulp is infected and may be minimally inflamed or not
impossible to determine clinically. More studies on disin- inflamed. The excavated cavity can be restored with
fection of mature teeth with irreversible pulpitis in VPT are permanent restorative materials.
needed because infection is the main cause of irreversible If the tooth is symptomatic, most likely the pulp is
pulpal disease. inflamed but vital and not infected. The inflamed pulp
has the potential of self-healing. Indirect pulp treat-
ment can be attempted. The tooth should be closely
Pulp canal obliteration after full pulpotomy of
followed up every 2 weeks. If symptoms continues to
mature permanent teeth with pulpitis
persist, or periapical pathosis develops, the tooth
Pulp canal obliteration has been observed following should be reevaluated for possible VPT or RCT.
dental trauma and endodontic treatment procedures. 2 If the coronal pulp is exposed by caries regardless of
The prevalence of pulp canal obliteration after trau- clinical symptoms and pulp sensibility testing, the pulp
matic injuries to the teeth varies widely from 3.7% to is infected/inflamed.
40% (68–70). For replantation, the prevalence is 96% A If the exposed pulp has signs of fresh vital bleeding,
of avulsed immature teeth (71). The prevalence was VPT (partial or full pulpotomy depending on the extent
reported 62.1% in revascularised teeth (72). Although of coronal pulp involvement) can be performed under
pulp canal obliteration after full pulpotomy of mature the condition that bleeding can be controlled within 10
permanent teeth is a concern, the prevalence is not minutes (67). The normal blood clotting time of the
known after long-term follow-up. The exact mecha- healthy tissue is between 8–15 min. If bleeding cannot
nism of pulp canal obliteration in dental trauma and be controlled after more coronal pulp is removed, com-
endodontic treatment procedures is not very clear even plete pulpectomy should be considered.
though severe injury to the pulpal neurovascular bun- B If the exposed coronal pulp has no sign of bleeding,
dle was hypothesised (73). The major concern in full the coronal pulp is infected and necrotic. Complete
pulpotomy of mature permanent teeth with pulpitis is pulpectomy is indicated.
pulp canal obliteration associated with apical periodon- Although this protocol is not perfect, it is better than
titis. However, it must be emphasised that apical peri- treatment being solely based on clinical symptoms/sign
odontitis is the sequela of pulpal infection, which is and pulp sensibility testing without carious removal.
due to incomplete pulp disinfection during full pulpo- Teeth with an artificial crown impose a greater challenge
tomy or reinfection of the canal due to micro-leakage in diagnosis of pulp disease. Similar to RCT, patients
of coronal restoration in VPT of teeth with irreversible should be advised that VPT is not 100% predictable.
pulpitis. Without pulp infection, teeth with pulp canal Therefore, long-term follow-up examinations are impor-
obliteration would not develop apical periodontitis tant in VPT. If clinical symptoms or a periapical lesion
(68,69). Therefore, treatment intervention is not develops, early appropriate intervention can be initiated.
required for teeth with pulp canal obliteration without
apical periodontitis (68,69).
Conclusion
Based on the perspective of pulp biology, VPT of
Proposed protocol of diagnosis and treatment for
mature permanent teeth with irreversible pulpitis can
permanent teeth with pulpitis
be an alternate option to root canal therapy or tooth
It is well established that there is no good correlation extraction if the patients cannot afford the high cost of
between clinical symptoms/sign and diagnostic date and RCT and the teeth that do not require an intra-radicu-
actual histological findings of the pulp. However, there is lar post/core for adequate coronal restoration. Preserva-
a good correlation between the depth of carious bacterial tion of teeth can improve the quality of life of the
penetration in the dentine and the histological pulpal patients. However, patients receiving VPT of mature
response to caries (22–24). permanent teeth with irreversible pulpitis should be
advised, in a similar fashion to those who receive RCT
that no treatment can achieve 100% success, and
Proposed protocol
therefore, long-term follow-up is essential so that fur-
The involved tooth is isolated with rubber dam; caries ther intervention can be initiated in optimal time if
is completely removed under an operating surgical required. Biological aspects of VPT of mature teeth
microscope. with irreversible pulpitis should be tested in clinical
1 If the pulp is not exposed by caries and the tooth is scenarios to verify the effectiveness of patient- and
asymptomatic, the pulp is likely to be vital and not clinician-centred outcome.

© 2019 Australian Society of Endodontology Inc 9

Vital Pulp Therapy of Mature Teeth L. M. Lin et al.

13. Wolters WJ, Duncan HF, Tomson PL et al. Minimally inva-

Conflict of interest sive endodontics: a new diagnostic system for assessing
The authors deny any conflict of interest. pulpitis and subsequent treatment needs. Int End J 2017;
50: 825–9.
14. Jontell M, Okiji T, Dahlgren U, Bergenholz G. Immune
Author contribution defense mechanisms of the dental pulp. Crit Rev Oral Biol
All authors have contributed significantly, and that all Med 1998; 9: 179–200.
15. Farges J-C, Alliot-Licht B, Renard E et al. Dental pulp
authors are in agreement with the manuscript.
defense and repair mechanisms in dental caries. Mediators
Inflamm 2015; 2015: 230251.
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