Guideline for Use of Vital Pulp Therapy in Permanent Teeth
Abstract
Purpose: To develop permanent tooth vital pulp therapy (VPT) recommendations. Methods: GRADE framework recommendations developed from systematic review data of permanent tooth VPT through June 30, 2024. Results: Teeth with deep caries (extending to inner third or quarter of dentin with intact dentin barrier) diagnosed with normal pulp or reversible pulpitis (NP/RP) can be treated either with indirect pulp treatment (IPT), direct pup cap (DPC), partial pulpotomy (PP), or full pulpotomy (FP) (conditional recommendation, low certainty). Selective caries removal for IPT is strongly recommended (high certainty) for deep caries in NP/RP diagnosed teeth. In case of pulp exposure either DPC, PP, or FP
using calcium silicate cement (CS) may be performed regardless of root maturation (conditional recommendation, low certainty). Using sodium hypochlorite (NaOCl) irrigation is strongly recommended for DPC hemostasis (high certainty) over saline and conditionally recommended (very low certainty) for pulpotomy. For permanent teeth with extremely deep caries (no discernible radiographic barrier) or deep carious teeth exhibiting spontaneous, nocturnal, or lingering pain but normal periapical appearance, complete (nonselective) caries removal to expose the pulp for assessment is strongly recommended (moderate certainty). If pulpotomy is indicated in these teeth, FP using CS is recommended over PP (conditional; low certainty). Also, PP and FP success will likely be higher if hemostasis occurs within six minutes (conditional; low certainty). Using magnification likely enhances pulp visualization, facilitating more accurate assessment of its status. Teeth with NP/RP having traumatic exposures, PP/FP is conditionally recommended over DPC. Using nonstaining CS is strongly recommended (high certainty) for VPT on teeth in esthetic areas. Conclusions: Selective caries removal is recommended for teeth having deep caries with NP/RP. CS utilization is recommended for DPC, PP, and FP using NaOCl for hemostasis. Complete caries removal and assessment of pulp status is recommended for teeth exhibiting spontaneous, nocturnal, or lingering pain; if pulp is diagnosed as vital and bleeding is controlled, FP is recommended. (Pediatr Dent 2025;47(5):299-311)
KEYWORDS: INDIRECT PULP THERAPY; DIRECT PULP CAPPING; PARTIAL PULPOTOMY; FULL PULPOTOMY; VITAL PULP THERAPY
Plain language summary
Introduction and purpose of the guideline. This is the first clinical practice guideline devoted solely to vital pulp treatment in permanent teeth created by the American Academy of Pediatric Dentistry (AAPD).
The purpose of the new guideline is to present clinical vital pulp therapy (VPT) recommendations for permanent teeth affected by tooth decay or trauma based on a systematic review (SR) and statistical analysis of evidence-based studies.
Methods used to create the guideline. The authors conducted an SR of dental literature concerning vital permanent tooth pulp treatments, including 388 articles published through June 30, 2024. These studies were comprised of randomized and nonrandomized controlled trials, plus studies done in laboratories, which are termed in vitro studies. The authors defined treatment success as the patient having no pain or clinical signs or symptoms of infection and radiographs showing no signs of pathology. The SR’s data and statistical evaluations provided information from which the clinical recommendations were formulated, including the recommendation’s strength and level of certainty. A decision tree figure was developed to identify the recommended pulp therapies. Outside stakeholders and AAPD councils/committees vetted this guideline.
Guideline recommendations. Indirect pulp treatment (IPT), direct pulp cap (DPC), partial pulpotomy (PP), and full pulpotomy (FP) show similar success after 24 months. Therefore, all can be used for the treatment of a permanent tooth diagnosed as having normal pulp or reversible pulpitis (NP/RP) due to decay. This recommendation is conditional, with a low certainty since it is based on indirect comparisons of 24-month data. It applies to mature teeth in adults or immature teeth in children and adolescents. The guideline strongly recommends that, with a high certainty from 36-month data, when performing a DPC procedure, diluted bleach for irrigation plus a pulp capping material termed calcium silicate cement (CS) should be used.
If the decay reaches the inner third or quarter of the tooth’s dentin (the layer of the tooth under the enamel) and there is a dentin barrier between the tooth’s nerve and the decay, it is defined as deep decay. Teeth with deep decay and no signs of infection can be treated using selective decay removal, a process in which the deepest decay is left in place to avoid nerve exposure. This is strongly recommended with a high certainty of evidence from 60-month data. If a tooth presents with spontaneous, lingering, or nighttime pain and x-rays show no other signs of infection, it is strongly recommended, with moderate certainty based on 24- to 60-month data, to remove all the decay to expose the nerve and evaluate its status to determine if a pulpotomy procedure using CS should be performed. It is conditionally recommended, with low 12- to 24-month certainty, that when performing a FP, pulpal bleeding should be controlled within six minutes for best results. If any VPT involves a permanent tooth that shows in a person’s smile, it is strongly recommended with high certainty, to use CS that are nonstaining to avoid dark staining of the tooth postoperatively. For treatment of traumatic pulp exposures, a PP or FP is recommended over DPC due to its significantly higher success. This was a conditional recommendation with a low certainty based on 18- to 24-month evidence.