VITAL PULP THERAPY
DR. RHYTHM
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INTRODUCTION
Vital pulp therapy is broadly defined as treatment initiated to
preserve and maintain pulp tissue in a healthy state, tissue that
has been compromised by caries, trauma, or restorative
procedures.
The objective is to stimulate the formation of reparative dentin
to retain the tooth as a functional unit.
This is particularly important in the young adult tooth, where
apical root development may be incomplete.
The focus is directed toward the preservation of the pulpally
involved permanent tooth, based on the premise that pulp
tissue has an innate capacity for repair in the absence of
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microbial contamination.
The first documented instance of vital pulp therapy is
attributed to Phillip Pfaff in 1756.
He placed gold foil against an exposed pulp with the
intention to promote pulpal healing.
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DIAGNOSIS AND PROGNOSIS OF DEEP CARIOUS
LESIONS
Consideration has to be given to:
 Reparative capacity of the P-D organ
 Soundness of dentin
 Reparative capacity of unsound attacked
dentin
 Any degeneration of the P-D organ
 Sealabilty of restorative materials to be used
 Potential of any further damage.

PAIN
 Spontaneous/induced, duration of pain,
severity after removal of stimulus
 RADIOGRAPHS
 Indicates proximity of carious lesion to pulp
chamber and RDT
 Calcifications, which denotes consumption of
and reduction of reparative capacity.

Thickening of periodontal ligament space.
 Size of pulp chamber as compared to size of
tooth. Higher the pulp size/tooth size ratio,
better is the reparative capacity.
 The relative size of the apical foramen to that of
the pulp and root canal systems, higher the
ratio is, better is the reparative potential.

The size of the pulp exposure relative to
dimensions of pulp chamber.
 PULP TESTING
 A. Thermal pulp testing
 B. Electric pulp testing
 DIRECT PULP EXPOSURE
 A pin-point exposure having sound dentin at the
periphery of exposure with no hemorrhage
indicates no or mild pulpal inflammation.

A pin point exposure having sound dentin at
periphery but accompanied by a drop of blood
that coagulates immediately –no or mild
inflammation.
 An exposure having decayed dentinconsiderable inflammation and has doubtful
reparative capacity.
 Profuse hemorrhage-indicates mechanical
involvement of pulpal and root canal tissues.

Exposure accompanied by inflammatory fluids
or pus is evidence of extensive inflammation
and destruction of pulpal tissues- P-D organ is
definitely beyond repair.
 Lower the ratio of exposure diameter relative to
dimensions of pulpal and root canal tissuesgreater is possibility of repair.

PERCUSSION SENSTIVITY
 It is of little value in determining the degree of
inflammation, depends on extent of
inflammation.
 TYPE OF DENTIN
 Visual examination and tactile evaluation can
give an idea about the type of dentin.

REMOVAL OF TOOTH STRUCTURE WITHOUT
ANESTHESIA
 It is a painful but painful method of
determining pulp vitality.
 USE OF DYES
 0.5% basic fuschin in propylene glycol to dentin
for 10 seconds, infected dentin stains red. The
repairable/affected dentin with intact collagen
bands and will not get stained.

DIRECT PULP CAPPING
In case of mechanical exposure during removal
of decay, DPC can be done under following
conditions:
 A. There are no signs or symptoms of
degeneration of P-D organ
 B. The exposure has following characteristics:
 a. Pin-point/small relative to the pulp size.
 No hemorrhage or immediate clotting of
hemorrhage.

c. The dentin at periphery is reparable/sound.
 d. Field of operation is completely aseptic.

Proper case selection, based on a new understanding of
inflammatory mechanisms responsible for producing
irreversible changes in pulpal tissue, can help identify teeth
with a greater likelihood for favorable outcomes.
The challenge is to identify a reliable pulp capping or
pulpotomy agent and a suitable delivery technique.
The outcome of vital pulp therapy will depend on
the age of patient,
the size of pulp,
bacterial contamination,
pulp capping material, and
quality of final restoration.
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According to the American Academy of Pediatric Dentistry,
“Teeth exhibiting provoked pain of short duration, that is
relieved, upon the removal of the stimulus, with analgesics,
or by brushing, without signs and symptoms of irreversible
pulpitis, have a clinical diagnosis of reversible pulpitis and
are candidates for vital pulp therapy”
A diagnosis of reversible pulpitis increases the probability of
a favorable outcome.
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The outcome of treatment for direct pulp capping or
pulpotomy will be determined by the initial diagnosis (radiographic evaluation, pulp testing,
clinical evaluation, and patient history)
The intention is to postpone more aggressive therapies that
could eventually lower the long-term prognosis for tooth
retention and function.
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WHY VITAL PULP THERAPY IS IMPORTANT……
The pulp performs several important functions, including
-dentinogenesis,
-immune cell defense,
-nutrition and
-proprioreceptor cognizance.
The retention and maintenance of the dental pulp are
crucial to the long-term function of the tooth
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Circulating immunocompetent cells limit microbial
challenges, and functioning proprioceptors and
pressoreceptors guard against excessive occlusal loading.
Structurally compromised teeth that have been
endodontically treated and restored with various post and
core systems are more susceptible to fracture and failure
owing to the loss of protective mechanisms.
Although studies show that the loss of moisture from dentin
after endodontic therapy is minimal, cumulative loss of
tooth structure is implicated in the failure of root-treated
teeth
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OBJECTIVE/GOAL……..
The reformation of a protective dentinal bridge by tertiary
dentinogenesis is a primary goal of vital pulp therapy.
The repair of pulpodentinal defects is orchestrated by the
migration of granulation tissue to the site from the cell-rich and
deep pulp subodontoblastic layers that differentiate into new
odontoblast-like cells.
Although these progenitor cells are most likely derived from
undifferentiated mesenchymal cells, other cell populations
migrating via the bloodstream, such as bone marrow stem cells
and perivascular cells, have been proposed as possible
precursors.
Apexogenesis of the immature adult tooth is one of the key
objectives in vital pulp therapy.
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Odontoblastic
process
Cell bodies
Predentin
Odontoblasts
Cell-free zone
Cell-rich zone
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(P-D COMPLEX)
The migration and proliferation of these cells were studied
in nonhuman primates after direct pulp capping with
calcium hydroxide (Ca(OH)2).
At the calcium hydroxide-pulp interface, a continuous influx
of newly differentiating odontoblast-type cells with initial
matrix formation was observed as early as day 8.
Labeled odontoblast-like cells showed differences in cell
types and grain counts between zones, indicating that at
least two deoxyribonucleic acid (DNA) replications had
occurred between initial treatment and differentiation.
Fitzgerald M, Chiego DJJ, Heys DR. Autoradiographic analysis of odontoblast
replacement following pulp exposure in primate teeth. Arch Oral Biol 1990
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Studies have suggested that the mineralization of dentin
bridges is more dependent on the extracellular matrix than
the pulp capping or pulpotomy material.
Oguntebi BR, Heaven T, Clark AE, Pink FE. Quantitative assessment of dentin bridge
formation following pulp-capping in miniature swine. J Endod 1995
Inoue H, Muneyuki H, Izumi T, et al. Electron microscopic study on nerve terminals
during dentin bridge formation after pulpotomy in dog teeth. J Endod 1997
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I. DIRECT PULP CAPPING
Direct pulp capping is defined as the "treatment of an exposed vital
pulp by sealing the pulpal wound with a dental material placed
directly on a mechanical or traumatic exposure to facilitate the
formation of reparative dentin and maintenance of the vital pulp.“
INDICATIONS
Exposures as a result of caries removal, tooth preparation, or trauma.
CONTRAINDICATIONS
Pulp tissue, jeopardized by a long-standing exposure to oral
microorganisms and acute inflammation, may be unsuitable for direct
pulp capping.
Carious exposure of a primary tooth
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Factors Affecting Prognosis Of Direct Pulp Capping
-Mechanical exposures have a better prognosis than
carious exposures
-Size of exposure
-Time gap
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II. INDIRECT PULP CAPPING
Indirect pulp capping is defined as "a procedure in which a material is
placed on a thin partition of remaining carious dentin that, if
removed, might expose the pulp in immature permanent teeth. This
technique shows some success in teeth with an absence of
symptomatology and with no radiographic evidence of pathosis. It
has been controversial for decades.
Indirect pulp caps are completed using Ca(OH)2 and zinc oxideeugenol (ZOE) in a one- or two-stage procedure.
DRAWBACK
1. Not easy to determine at what point excavation is halted.
2. Voids under the restorative material result during the
remineralization process, in which the carious dentin dries out and
loses volume.
3. Restoration failure and rapid reactivation of a dormant lesion.
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INDIRECT PULP CAPPING

It is the deliberate retention of softened carious
(Affected) dentin near the pulp and medication
of the remaining dentin.
INDIRECT PULP CAPPING

It is the deliberate retention of softened carious
(Affected) dentin near the pulp and medication
of the remaining dentin.
INDIRECT PULP CAPPING-RATIONALE
The caries formula consists of three items
essential for caries process to be active and
progressive: Tooth structure, microorganisms
and substrate.
 Acute decay: excavation of softened dentin will
remove all microorganisms. In chronic decay:
minimal microorganisms remain, but they are
rendered inert by sealing them off from their
source of substrates.


The calcium hydroxide being alkaline in nature
can eliminate virtually all the remaining
bacteria and render the residual carious dentin
sterile. Further, placement of a well-sealed
interim restoration such as IRM or GIC will deny
remaining bacteria nutrients, thus arresting the
progress of the caries.
A favorable environment is created for repair of
damaged tooth structure which takes place in
two dimensions:
 First, demineralization of a part or all of
remaining dentin in cavity floor will occur,
secondly, deposition of secondary or tertiary
dentin will occur.

Vital Pulp Therapy Materials
Ca(OH)2 compounds
Zinc Oxide
Calcium Phosphate
Zinc Phosphate
Polycarboxylate Cements
Calcium-Tetracycline chelate
Antibiotic and Growth Factor Combinations
Calcium Phosphate Ceramics
Emdogain
Bioglass
Cyanoacrylate
Hydrophilic Resins
Hydroxyapatite
Resin-Modified Glass Ionomers, and, recently
MTA
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Innovative methods have also been used to eliminate caries
progression and stimulate the repair of affected pulpal
tissue and include
-ozone technology,
-lasers,
-bioactive agents that activate pulpal defenses.
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MCQS
Q.1 Vital pulp therapy
 A. promotes healing of infected dentin
 B. preserves pulpal vitality
 C. preserves enamel integrity
 D. induces secondary dentin formation.

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Q. 2 Vital pulp therapy is specially useful for
 A. deciduous teeth
 B. necrotic pulps
 C. young permanent teeth
 D. sclerotic dentin

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Q.3 Ideal remaining dentin thickness should be
 A. 1mm
 B. 1-1.5 mm
 C. 1.5 mm
 D. 2mm

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Q.4 Material used for pulp capping
 A. Amalgam
 B. composite resin
 C. zinc phosphate
 D. mineral trioxide aggrgate

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Q.5 Direct pulp capping is done when exposure
site is
 A. <2mm
 B. <1.5mm
 C. < 1mm
 D. < 0.5mm

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