Vital pulp therapy /Part1 : pulpal diagnosis and case selection

Pulpal diagnosis is the most critical step in determining whether a tooth is a candidate for Vital Pulp Therapy (VPT) or requires non-surgical root canal treatment (NSRCT).

The primary goal of the diagnostic process is to evaluate the degree of pulpal inflammation and ascertain whether the tissue possesses the capacity to heal.

Preoperative Clinical Diagnostic Categories:

The American Association of Endodontists (AAE) classify pulpal conditions based on subjective symptoms and objective clinical findings.1

Normal Pulp: The pulp is symptom-free and responds normally to sensibility tests. A “clinically” normal pulp results in a mild or transient response to thermal cold testing, lasting no more than one to two seconds after

the stimulus is removed. It is best to test the adjacent teeth and contralateral teeth first so that the patient is familiar with the experience of a normal response to cold.

Reversible Pulpitis: Discomfort is experienced when a stimulus such as cold or sweet is applied and goes away within a couple of seconds following the removal of the stimulus.There are no significant radiographic changes in the periapical region of the suspect tooth and the pain experienced is not spontaneous.

Symptomatic Irreversible Pulpitis (SIP): Characteristics may include sharp pain upon thermal stimulus, lingering pain (often 30 seconds or longer after stimulus removal), spontaneity (unprovoked pain) and referred pain. Sometimes the pain may be accentuated by postural changes such as lying down or bending over and over-the-counter analgesics are typically ineffective. In such cases, dental history and thermal testing are the primary tools for assessing pulpal status.

Asymptomatic Irreversible Pulpitis: No clinical symptoms, but deep caries or trauma has penetrated to the pulp, making exposure inevitable.

Pulp Necrosis: The pulp is non-responsive to pulp testing and is asymptomatic. Pulp necrosis by itself does not cause apical periodontitis (pain to percussion or radiographic evidence of osseous breakdown) unless the canal is infected. Some teeth may be nonresponsive to pulp testing because of calcification, recent history of trauma, or simply the tooth is just not responding.

Previously Treated is a clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intracanal medicaments. The tooth typically does not respond to thermal or electric pulp testing.

Previously Initiated Therapy is a clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy such as pulpotomy or pulpectomy. Depending on the level of therapy, the tooth may or may not respond to pulp testing modalities.

Diagnostic Methods for Case Selection

1.Pain History and patient symptoms: 2

A detailed pain history is an important part of diagnosis. The OPQRST mnemonic is commonly used:

* O (Onset): When did the pain start?

* P (Provocation/Palliation): What makes the pain worse or better?

* Q (Quality): What is the nature of the pain (sharp, dull, throbbing, etc.)?

* R (Region/Radiation): Where is the pain located, and does it radiate?

* S (Severity): How severe is the pain?

* T (Time): Duration and timing of the pain.

* Severe pain, spontaneous pain, and a history of previous pain are poor prognostic signs and are commonly associated with irreversible pulpitis.

* Pain only in response to thermal stimuli (hot/cold) and not spontaneous usually indicates reversible pulpitis.

Important Points:

• Pain may be reported by the patient (symptom) or elicited during examination (sign), such as pain on percussion or thermal testing.

• Severe spontaneous pain can cause central sensitization and referred pain, making it difficult for patients to identify the correct tooth.

• Patients with percussion sensitivity are more accurate in localizing the affected tooth than those with pulpal pain alone.

• Pain alone is not a reliable diagnostic indicator because:

About 40% of pulpitis cases may be painless.

About 40% of teeth with salvageable pulps may still present with pain.

• Toothache may also originate from non-odontogenic sources, including:

Muscles of mastication

Temporomandibular joint (TMJ)

Maxillary sinus

2.Sensibility Testing: 3

Appropriate clinical testing to assess the status of the pulp including the application of cold stimulus and electric pulp testing.

The primary provoked response to pulp sensibility testing, indicating more severe pulpal inflammation is described as an exaggerated and “lingering” response to cold stimulus.

In addition to such pulp sensibility testing, percussion tests may infer pulpal conditions from the presence of symptomatic apical periodontitis.

3.Radiographic Assessment:

Periapical Radiographs: Used to verify the depth of the carious lesion, evaluate root maturity (open vs. closed apices), and rule out periapical radiolucency.

4.The Definitive Diagnostic Step: Intraoperative Assessment:

Complete caries removal is essential to eliminate infected tissues and visualize pulp tissue conditions under magnification when pulpal exposures occur. 4

The use of caries detectors during caries removal can be helpful adjuncts to assist the clinician in removing diseased tissues, particularly when close to the pulp cavity. 5

Examination of pulp tissues after exposure with magnification is a critical step in pulp assessment.

Pulpal bleeding and tissue removal

Bleeding is a key clinical indicator of a vital, inflamed pulp, and its presence during a VPT procedure confirms the viability of the tissue. Observing healthy bleeding is the most reliable sign when VPT is chosen as the preferred treatment. In contrast, grey discoloration of the pulp or the presence of pus typically indicates pulp necrosis and infection. However, superficial necrosis does not necessarily mean the entire pulp is compromised. In such cases, more invasive procedures like pulpotomy may still be successful, as deeper portions of the pulp could remain vital and capable of healing. 6

Clinical Presentation	Interpretive Diagnosis	Indicated VPT Procedure
No bleeding / Dry exposure	Necrotic pulp tissue	RCT
Bright red bleeding controlled < 5-6 mins	Healthy or reversibly inflamed pulp	Direct Pulp Capping or Partial Pulpotomy
Excessive, dark red bleeding, > 6 mins	Severely inflamed coronal pulp	Full Pulpotomy (amputate coronal pulp to reach healthy radicular tissue)
Purulent exudate / Pus	Micro-abscess or partial necrosis	RCT or Full Pulpotomy (if radicular tissue is healthy)

Presence of necrotic tissue in the pulp chamber

The presence of necrotic tissue in the pulp chamber requires careful assessment to determine whether any viable pulp tissue remains or if RCT is necessary. In cases of superficial necrosis or abscess, the removal of the affected tissue may reveal healthy pulp beneath, making a full pulpotomy a viable treatment option. 6 In multi-rooted teeth, if partial tissue necrosis is identified, RCT may be performed in canals with necrotic pulp, while pulpotomy may be considered for the remaining canals if they contain healthy pulp. 7

However, if the pulp is deemed non-viable, a pulpectomy and complete RCT are recommended. The choice of treatment depends on the extent of necrosis and the operator's experience and skill.

Hemostasis: Hemorrhage must be controlled to allow clinical assessment of inflammatory levels and identify potential necrotic tissues that require removal before application of an appropriate biomaterial.  The ability to control bleeding within 5 to 6 minutes using a disinfectant like sodium hypochlorite (NaOCl) is the most reliable clinical indicator of a pulp that can heal. either via direct passive irrigation or on a sodium hypochlorite- soaked cotton pellet. 8 9

References:

1. American Association of Endodontists. Glossary of Endodontic Terms. 8th ed. 2012.

2.Henry F. Duncan, Ikhlas A. El-Karim, vital pulp teatment, pages(47-58) 2024.

3.Chen E, Abbott PV. Dental pulp testing: a review. Int J Dent. 2009;v2009

4. Asgary S, Hassanizadeh R, Torabzadeh H, Eghbal MJ. Treatment outcomes of 4 vital pulp therapies in mature molars. J Endod. 2018;44:529-535.

5. Sadasiva K, Kumar KS, Rayar S, Shamini S, Unnikrishnan M, Kandaswamy D. Evaluation of the efficacy of visual, tactile method, caries 26 detector dye, and laser fluorescence in removal of dental caries and confirmation by culture and polymerase chain reaction: an in vivo study. J Pharm Bioallied Sci. 2019;11(Suppl 2):S146-S150.

6.Motoki O, Fergus D H, Yusuke T, Nanako K, Matsumoto S, Mikako H. Partial pulpotomy to successfully treat a caries-induced pulpal micro-abscess: a case report. Front Dent Med 2021; DOI: 10.3389/fdmed.2021.678632.

7.Koli B, Chawla A, Logani A, Kumar V, Sharma S. Combination of nonsurgical endodontic and vital pulp therapy for management of mature permanent mandibular molar teeth with symptomatic irreversible pulpitis and apical periodontitis. J Endod 2021; 47: 374-381.

8.Thibault N. E. Colloc ,Phillip L. Tomson Vital pulp therapies in permanent teeth: what, when, where, who, why and how? British Dental Journal volume 238, pages458–468 (2025)

9.Nebu Philip· Mandeep Duggal· Hani Nazzal, Pulpotomy for treating primary teeth with irreversible pulpitis: a call for action. European Archives of Paediatric Dentistry, 2026.