Endodontic Topics 2003, 5, 49–56 Copyright r Blackwell Munksgaard

Printed in Denmark. All rights reserved ENDODONTIC TOPICS 2003

Vital pulp therapy for the mature

tooth – can it work?
EDWARD J. SWIFT, JR., MARTIN TROPE & ANDRÉ V. RITTER

The dental pulp can be exposed by accidental trauma to a tooth, or by the dentist preparing a tooth for a restoration.
When the exposure occurs during cavity preparation, it can be diagnosed as mechanical or carious. The pulp
typically is inflamed in either instance, because a mechanical exposure rarely occurs except during removal of a deep
restoration or through overzealous excavation of deep caries. Pulpectomy and root canal therapy represent the
optimal treatment for carious or mechanically exposed pulps in mature teeth. However, financial considerations or
low dental IQ result in some patients refusing the optimal treatment. In our opinion, extraction is not the correct
alternative treatment plan for these patients. This paper describes the indications, clinical techniques, and prognosis
for three types of vital pulp therapy in the mature tooth – direct pulp capping, partial pulpotomy, and full
pulpotomy.

Introduction subject of vital pulp therapy remains controversial,

Traditional thought requires root canal therapy for the
exposed pulp on a mature tooth. The rationale for this
treatment choice is based on the unreliability of vital
pulp therapy on these teeth and the high probability for
success if root canal therapy is performed optimally on
a vital tooth.
While it is easy to write about optimal treatment, the
fact remains that many patients do not want or cannot
afford extensive treatment on a tooth that shows
diagnostic or clinical signs of irreversible pulpitis. Is
extraction, with all the consequences that follow, a
necessary ethical alternative for these patients? It is the
authors’ opinion that vital pulp therapy should be
attempted under these circumstances, and in an
informed patient it is a correct and ethical treatment
to perform. At the same time, efforts should be made
to research optimal treatment protocols and the short-
and long-term outcomes of such treatments.
Various methods have been proposed over the years
for treatment of traumatic and cariously exposed pulps
in mature permanent teeth. Unfortunately, many
methods have been based on clinical experience and
anecdotal evidence, and their outcomes have not
always been validated scientifically. Even today, the
especially regarding which type of pulp dressing
provides the most predictable healing. Calcium hydro-
xide has been the standard, but newer alternatives are
being studied.
Requirements for a successful vital
pulp therapy
Vital pulp therapy has a high success rate if the
following conditions are met: (1) the pulp is not
inflamed; (2) hemorrhage is properly controlled; (3) a
non-toxic capping material is applied; and (4) the
capping material and restoration seal out bacteria.
Non-inflamed pulp
The presence of a healthy pulp is an essential
requirement for successful treatment of an exposure.
While some studies suggest that direct capping of
inflamed pulps can be successful (1–3), such treatment
provides an inferior success rate (4, 5). If the pulp tissue
at the exposure site is not healthy, the partial
pulpotomy technique described later in this paper
should be considered.

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Swift et al.
Hemorrhage control
Proper control of hemorrhage is critical for the success
of any pulp-capping treatment, regardless of the material
that is used for the pulp cap (6–8). Various methods have
been proposed to achieve pulpal hemostasis, including
mechanical pressure with a sterile dry cotton pellet, or
with one soaked in saline, hydrogen peroxide, or some
other agent. Several studies have shown that sodium
hypochlorite, in concentrations of 2.5%, 3%, or 5.25%, is
a biocompatible and effective solution for achieving
hemostasis before pulp capping (8–10). The disinfectant
chlorhexidine (e.g. Consepsis, Ultradent Products,
South Jordan, UT, USA) also has been described as an
effective hemostatic for pulp capping (7, 11).
The popular hemostatic ferric sulfate (e.g. Astringe-
dent, Ultradent Products) has been used for pulpot-
omy procedures in primary teeth. Studies have shown a
favorable pulpal response, and a clinical success rate
similar to that of traditional formocresol pulpotomy
(12, 13). However, the use of ferric sulfate in pulp
capping of mature permanent teeth has not been
investigated thoroughly. Furthermore, as clinicians
who use this agent are aware, ferric sulfate causes
substantial clotting. Such clotting might be deleterious
to success of the pulp cap, so the use of ferric sulfate is
not encouraged at this time (14).
Pulp-capping material
Traditionally, calcium hydroxide has been the most
common direct pulp-capping agent (14, 15). Calcium
hydroxide is antibacterial and disinfects the superficial
pulp (16). Because of its high pH (about 12.5), pure
calcium hydroxide causes liquefaction necrosis of the
superficial pulp, and thus removes approximately
1.5 mm of inflamed pulp tissue. Neutralization of the
high pH in deeper layers of the pulp results in
coagulation necrosis at the junction of necrotic and
vital tissues, with only a mild irritation to the pulp. This
minor irritation stimulates an inflammatory response
that, in the absence of bacteria, will heal with a hard
tissue (dentinal) barrier (17, 18).
Hard-setting calcium hydroxide pastes (e.g. Dycal,
Dentsply Caulk, Miford, DE, USA; Life, Sybron Kerr,
Orange, CA, USA) are less caustic than pure calcium
hydroxide and do not necrose the superficial pulp, but
have been shown to initiate the same type of healing as
calcium hydroxide powder (14).
50
A major disadvantage of calcium hydroxide materials
is that they do not seal the exposed pulp from the
external environment. The inability of calcium hydro-
xide to seal out bacteria might be a particular problem
with composite resin restorations, where polymeriza-
tion shrinkage could pull the pulp cap away from the
tissue surface (19). Therefore, an additional base
material, such as a resin-modified glass ionomer, can
be placed to help seal the pulp against bacterial ingress
during the healing phase.
Some investigators assert that alternatives to calcium
hydroxide should be considered because dentin bridges
beneath calcium hydroxide pulp caps contain ‘tunnel
defects’ that leave the pulp open to recurring bacterial
infection via microleakage (20). Other investigators note
that calcium hydroxide materials tend to soften, disin-
tegrate, and dissolve over time, leaving voids and other
potential pathways for bacterial infiltration (21, 22).
Therefore, various other materials, including zinc oxide
eugenol, glass ionomers, resin adhesives, and mineral
trioxide aggregate (MTA), have been proposed as
capping agents for vital pulp therapy. MTA is an alkaline
material that stimulates dentinal bridging and appears to
have particular promise as a pulp-capping material (23–
27). However, neither MTA nor any of these other
materials has yet demonstrated long-term clinical success
or the predictability of calcium hydroxide used in
conjunction with a well-sealed coronal restoration.
Perhaps the most popular clinical alternative to calcium
hydroxide currently is the resin adhesives, or dentin
bonding systems (28). Many contemporary bonding
systems use phosphoric acid to etch enamel and dentin, a
process called ‘total etching’. The etchant removes the
smear layer and opens the dentin surface to penetration
by hydrophilic resin monomers. The resin monomers
infiltrate the surface and co-polymerize with hydrophobic
resin monomers to seal the dentin surface (29–32).
Currently, many ‘self-etch’ systems are becoming popular.
These combine the etching and resin infiltration steps to
modify and penetrate, rather than remove the smear layer.
The sealing potential of resin adhesive systems makes
them an attractive alternative for direct pulp capping
because they could prevent bacteria from entering the
pulp. Resin pulp capping has seen increased popularity
over the last decade, and clinicians have reported
relatively long-term anecdotal evidence of success (33).
In recent years, scientific evidence from animal
studies (typically sub-human primates) has emerged
to support the use of resin adhesives as pulp-capping

agents (8–10, 34–44). These studies suggest that resin
adhesives (or for that matter, any material that provides
an excellent seal) can facilitate pulpal healing as long as
bacteria are obstructed. Testing in humans has sup-
ported the findings from animal studies, but controlled
clinical trials, and even retrospective analyses, in this
area have been relatively few (45–48).
A recent series of papers from Murray and coworkers
provides interesting histological comparisons of cal-
cium hydroxide and resin pulp capping (49–52). These
studies tend to support resin adhesives as an alternative
to calcium hydroxide. Calcium hydroxide apparently
stimulates far more odontoblast-like cells than resin
adhesives do (49). However, the resin adhesives
provide less porous dentinal bridges (i.e. containing
fewer tunnel defects), a better seal against bacterial
leakage, and less pulpal inflammation (50–52). These
are, of course, features that would contribute to the
ultimate success of a pulp cap.
Nevertheless, the research community remains di-
vided on the subject of resin pulp capping. For example,
Pameijer and Stanley (7) reported a primate study in
which calcium hydroxide pulp capping was far more
successful than resin pulp capping. In fact, they
described resin pulp capping with total-etch resin
adhesives as having ‘disastrous effects’. They found
that application of acid to exposed pulps caused
hemorrhage that was difficult to control. Achieving
an effective resin seal under such conditions is nearly
impossible, and the lack of an adequate seal undoubt-
edly contributed to their poor results.
Pameijer and Norval (11) reported a similar study
more recently. Again, calcium hydroxide was far more
successful than resin pulp capping with total-etch
adhesive systems, although some adhesives performed
better than others.
A few other studies, one of them in humans, suggest
that resins can allow pulpal healing, but that calcium
hydroxide might produce faster and more predictable
results (43, 44, 46).
The fact that some resin adhesives provide better
pulp-capping success than others has been shown in
several studies, suggesting that success or failure might
be material dependent. The ability of the material to
provide a seal, the composition of the material itself, or
some combination of these two factors might affect the
prognosis (37, 51).
However, even with a single material, varying results
have been reported in different studies. For example,
Vital pulp therapy for the mature tooth
the self-etching resin adhesive system Clearfil Liner
Bond II (Kuraray, Osaka, Japan) has been evaluated in
several studies. Relative to calcium hydroxide, its
success in pulp capping could be described as much
less, somewhat less, or nearly the same, depending on
which study one chose to cite (41–43, 48, 51).
Few human studies have compared success rates of
calcium hydroxide and resin pulp-capping procedures.
In one study, the total-etch adhesive All-Bond 2 (Bisco,
Inc., Schaumburg, IL, USA) apparently did not allow
pulpal healing, while the control calcium hydroxide
allowed pulpal healing with complete dentin bridge
formation (46). Another study compared the total-etch
adhesive Scotchbond Multi-Purpose Plus (3M ESPE,
St. Paul, MN, USA) with calcium hydroxide as direct
caps over mechanically exposed pulps in teeth destined
for orthodontic extraction (47). In this study, calcium
hydroxide stimulated early pulp repair and dentinal
bridging. In contrast, the pulps capped using the resin
adhesive exhibited a mild but persistent inflammatory
response with no evidence of healing or dentin bridge
formation.
A similar study compared calcium hydroxide and
Clearfil Liner Bond II, a self-etch resin adhesive system
(48). Again, calcium hydroxide provided greater
evidence of pulpal healing and dentinal bridging, and
less inflammation, than the resin adhesive.
It must be noted that studies supporting resin pulp
capping typically have involved exposure and capping of
normal, uninflamed pulps. Success rates with inflamed
pulps are expected to be better for calcium hydroxide
than for resins, particularly because resins lack the
inherent hemostatic and bactericidal properties of
calcium hydroxide (53). Calcium hydroxide has been
shown to suppress bacterial infection of mechanically
exposed pulps open to the oral environment for 24 h,
allowing a normal healing response (2). Resin materials
do not provide a similar antibacterial effect.
Bacteria-tight seal
Along with pulpal health, provision of a seal against
bacterial ingress is probably the most critical factor in
the success of vital pulp therapy. Challenge by bacteria
during the healing phase will cause failure. Conversely,
if the exposed pulp is effectively sealed against bacterial
leakage, successful healing with a hard tissue barrier will
occur – using any of a wide variety of pulp-capping
materials (7–11, 34–53).
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Swift et al.

Direct pulp capping

The phrase ‘direct pulp capping’ refers to placement of
a material such as calcium hydroxide or a resin adhesive
directly onto an exposed pulp.

Indications
Indications for pulp capping include teeth with recent
(o24 h) traumatic exposures or mechanical non-
carious exposures during cavity preparation. Pulp
capping should be considered only for immature Fig. 1. (A) Diagram of maxillary central incisor with
permanent teeth, or for mature permanent teeth with pulp-involved fracture. (B) The exposed pulp is capped
simple restorative needs. For example, a tooth that will with calcium hydroxide. Glass-ionomer liner, dentin
adhesive, and composite resin are also used in the
serve as an abutment for a fixed partial denture should restoration of the tooth.
be treated by a more predictable method, that is,
pulpectomy and root canal therapy. Mature teeth with
graphs are needed to detect the presence of periapical
inflamed pulps, as with carious pulp exposures, should
radiolucencies, and for immature teeth, continued
not be pulp capped. Pre-operative tooth sensitivity
development of the root. Hard tissue barriers some-
frequently has been mentioned as a contraindication to
times can be seen at the treated exposure site as early as
pulp capping, but no hard scientific evidence supports
6 weeks after treatment.
this.

Technique
After adequate anesthesia has been obtained, place a
rubber dam and disinfect the tooth with a chlorhex-
idine solution (e.g. Consepsis, Ultradent Products) and
gently rinse with anesthetic or sterile saline. If any
hemorrhage occurs, dab with a sterile cotton pellet
until hemorrhage ceases. As noted previously, a sodium
hypochlorite or chlorhexidine solution may be used to
aid in hemostasis. Mix pure calcium hydroxide with
sterile water, saline, or anesthetic solution, and apply
directly to the exposure site. A hard-setting calcium
hydroxide liner also can be used, and is preferable if the
pulp is small. Next, apply and light-cure a resin-
modified glass ionomer base/liner material such as
Vitrebond (3M ESPE) to protect the calcium hydro-
xide dressing and to provide a better seal. Finally, use a
dentin/enamel bonding system to seal the cavity
preparation and restore the tooth with an appropriate
filling material (Fig. 1).
Recall
The tooth should be evaluated using electrical pulp
testing (EPT), thermal testing, and palpation and
percussion tests at 3–4 weeks, 3 months, 6 months,
12 months, and every year thereafter. Periodic radio-
Prognosis
The success of the pulp-capping procedure relies on the
ability of calcium hydroxide to disinfect the superficial
pulp and dentin and to necrose the superficial inflamed
pulp. The quality of the bacteria-tight seal provided by
the base, bonding system, and restoration is also of
critical importance. The reported prognosis for direct
pulp capping is in the range of 80% when performed
under ideal conditions, that is, on an uninflamed pulp
and with a good coronal seal (54, 55).
Partial pulpotomy
The phrase ‘partial pulpotomy’ or ‘Cvek pulpotomy’
describes removal of inflamed pulp tissue to the level of
healthy coronal pulp (56). A sterile diamond rotating at
high speed under copious water spray is used to
surgically excise inflamed pulp tissue. The excision is
considered complete when the pulp stump no longer
bleeds excessively. The rationale for the Cvek pulpot-
omy is this: if the inflamed tissue is removed, the
healthy underlying tissue is more likely to remain
healthy and to seal the exposure with hard tissue
bridging of the exposure site. Of course, the other
requirements for successful pulp capping, such as
hemostasis and a bacteria-tight seal, are met. Pulpotomies

52

have been used routinely in treatment of primary and
young permanent teeth after traumatic pulp exposures,
but their use in mature permanent teeth is a relatively
new concept, and is considered unproven for carious
exposures.
Indications
Indications for a partial pulpotomy are similar to those
for direct pulp capping. As with simple direct pulp
capping, an immature permanent tooth or a mature
permanent tooth with uncomplicated restorative needs
is preferable. The partial pulpotomy should be selected
as an alternative to direct pulp capping when the extent
of pulpal inflammation is expected to be greater than
normal. This would be the case, for example, in
traumatic exposures older than 24 h and for mechanical
exposures in teeth with deep caries. While not
scientifically proven, the partial pulpotomy technique
might be useful in teeth with a frank carious exposure
when the patient might otherwise choose extraction
over root canal therapy and restoration.
Fig. 2. (A) Diagram of carious pulpal exposure. The pulp contains a microabscess (necrosis and infection) and a zone of
inflammation overlying normal tissue. (B) Preparation involves the removal of the abscessed and inflamed pulpal tissue.
(C) The pulp is capped with calcium hydroxide. A bacteria-tight seal is provided by a glass ionomer base, dentin adhesive,
and restorative material.
Vital pulp therapy for the mature tooth
Technique
A partial pulpotomy case is illustrated in (Fig. 2A–C).
Accomplish anesthesia, isolation, and surface disinfec-
tion as described in the section on direct pulp capping.
At the exposure site, remove 1–2 mm of the superficial
pulp tissue using a sharp, sterile diamond rotary
instrument. The diamond should be running at very
high speed with copious water spray (57). If excessive
bleeding continues, extend the preparation apically.
Remove any excess blood by rinsing with sterile saline
or anesthetic solution and dry with a sterile cotton
pellet. As described previously, sodium hypochlorite or
chlorhexidine can be used to facilitate hemostasis. Take
care to avoid formation of a blood clot, which
compromises the prognosis (14).
If the pulp is large enough to allow an additional 1–
2 mm loss of tissue through necrosis, mix and apply a
thin layer of pure calcium hydroxide. If the pulp is not
large enough to accommodate any further loss of
tissue, mix and apply a hard-setting calcium hydroxide
liner such as Dycal. This will not cause tissue necrosis in
the same manner as pure calcium hydroxide. As in teeth
53
Swift et al.
with conventional direct pulp caps, place an appropriate
resin-modified glass-ionomer liner or base, a dentin/
enamel adhesive, and restorative material.
Recall
Schedule follow-up examinations, using the time
intervals and procedures described for pulp capping.
Prognosis
The partial pulpotomy offers several advantages over
direct pulp capping. Superficial inflamed pulp tissue is
removed during preparation of the pulpal cavity.
Calcium hydroxide disinfects the pulp and dentin and
removes additional inflamed pulp tissue. In addition,
the pulpotomy provides space for the materials
required to provide the requisite bacteria-tight seal.
The prognosis for success of partial pulpotomies is in
the range of 95% (56, 58). However, this success rate is
for traumatized teeth where the level of pulpal
inflammation is very predictable. The success rate for
treatment of carious exposures is unknown currently.
Full pulpotomy
A ‘full pulpotomy’ involves removal of the entire
coronal pulp to the level of the root canal orifice(s).
Indications
The indications for a full pulpotomy are similar to those
for a partial pulpotomy, except that the pulp in question
is likely to have more extensive inflammation, if the
coronal pulp is rather small in size.
Technique
The technique for a full pulpotomy is similar to that of
the partial pulpotomy, except that the entire mass of
coronal pulp tissue is removed, normally to the canal
orifices, but as much as 2–3 mm apical to the orifices.
The tissue is capped with calcium hydroxide in a
manner similar to partial pulpotomy (Fig. 3A–F).
Recall
Recall evaluations are performed at the same intervals
recommended for a tooth treated with a direct pulp cap
or partial pulpotomy.
54
Fig. 3. (A) Pre-operative radiograph showing extensive
caries on the lower molar. (B) On removal of the caries, a
pulp exposure is observed. (C) The pulp is removed from
the chamber to the level of the canal orifices. (D) Calcium
hydroxide is placed into the pulp chamber and the tooth
restored with a bonded coronal resin restoration. (E) The
immediate post-operative radiograph. (F) The one-year
follow-up radiograph showing continued root develop-
ment and a healthy apical periodontium.
Prognosis
A recent clinical trial of full pulpotomies used to treat
symptomatic reversible pulpitis had reports a success
rate of 90% at 6 months and 78% at 12 months (59).
This study used two restorative materials for the
coronal restorations – IRM (Dentsply Caulk) and Fuji
IX GP (GC America, Alsip, IL, USA), and found that
the latter is likely to provide durability.
Conclusions
Predictably successful pulp capping requires (1) an
uninflamed pulp, (2) adequate control of hemorrhage,
(3) a bacteria-tight seal, and (4) the use of a capping
material that is tolerated by the pulp. Certainly, success
is more likely for a recent traumatic or a mechanical
exposure than for a carious exposure. This paper has
described two methods of vital pulp therapy for mature
teeth. The first and more familiar method, direct pulp
capping, should be used when the pulp is relatively
uninflamed. The alternative and less widely known
method, the partial pulpotomy, should be considered
whenever greater inflammation is expected.

In either case, good clinical judgment must be
exercised. If the affected tooth will serve as fixed partial
denture abutment or will receive some other complex
restorative treatment such as a full crown, it should be
treated with a more predictable method – endodontic
therapy. Also, as a general rule, these vital pulp therapies
are more likely to be successful in chronologically or
physiologically young permanent teeth.
Finally, the reader should be aware that the vital pulp
therapies are most predictable in teeth with traumatic
or mechanical exposures. With carious pulp exposures,
direct pulp capping is never indicated, and the partial
and full pulpotomy techniques are considered unpro-
ven. However, when – for financial or other reasons –
extraction is the only other alternative, a partial or full
pulpotomy certainly should be considered for the
benefit of the patient.
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