Pulp Preservation, a new principle, a New Norm

Patients diagnosed with irreversible pulpitis are usually sent for proper root canal treatment which is complete pulp extirpation and filling of the cleaned root canal space. Vital pulp therapy (VPT) was not the treatment of choice for mature permanent teeth with signs and symptoms of irreversible pulpitis. This was due to the limited understanding of the pulp’s healing capacity and the sparse availability of material promoting such healing. Recently the American association of Endodontics (AAE) has announced in a position statement that there is no discrete boundary that can render the pulp unfit for preservation, even in sever inflammatory stages. (1) 

In addition to the maturation and advancement of the properties and setting times of the bio ceramic  materials, the paradigm is starting to shift towards VPT. This in turn induced publishing of new positions of statements by professional societies on treatment of teeth with carious pulp exposure and diagnosed with either reversible or irreversible pulpitis. (2) 

Success of VPT is a multifactorial process, bacterial infiltration to the dentine-pulp complex is one of the most important factors that affect the healing of the remaining healthy tissue. One of the most important factors is the bacterial contamination as been proved in 1965, even exposed germ-free pulps will heal without being aided from external stimuli, on the other hand germ contaminated pup tissue will degenerate and necrotize causing the transmission of infection to the periapical tissue (3). 

Some advice about the possibility to decrease the incidence of micro leakage during therapy are: 

1. Always disinfect your tooth after placing the rubber dam and before approaching the pulp, 
2. Changing the gloves after placing the rubber dam sheet with a new clean glove has been found to increase the outcome of all endodontic therapy models (4). 
3. Change the bur that you are using to remove the infected tissue as you approach the pulpal exposure site. 
4. Once exposed the pulpal tissue, set a new rubber dam sheet over the existing one to prevent any infectious material on the older sheet from entering the pulp. 
5. Disinfect all hard dental structure of the tooth prior to pulp severing and finally, 
6. Once again use yet another new bur during the pulp severing procedure to decrease the possibility of sending any microorganisms deeper into the pulpal tissue. change the bur once again.

Factors affecting the outcome of the treatment that must be declared and informed to the patient before attempting the treatment:  

There are other factors also affecting the survivability of the remaining pulp tissue, such as, the ability to predict the presence of the pulp involvement prior to the commencement of the treatment protocol, which will allow you to explain to the patient forth the possibility of the vital therapy to be rendered once the confirmation of pulp exposure has occurred, this also allows the practitioner to practice all sorts of enhanced infection control methods to prevent the possibility of microleakage in case of exposures. Artificial intelligence have explored this field, where the machine was educated on predicting the possibility of presence of exposure with a success rate of over 90% from the 2-dimensional digital x-rays (5), thus allowing us to prepare prior to the treatment. The age of the patient, which the patient must be informed as a factor, in 2025, researchers concluded that at the age of 40-60,th outcome of vital pulp preservation is significantly lower than at the age of 20-40 (6), this is very important in the process of case selection and in the information delivered to the patient during treatment planning. In addition to age, the number of missing walls have been found to affect the outcome and should be considered during treatment planning is the number of missing walls on the tooth meant to have its poulp preaserved., authors have found that as the number of missing walls increase the outcome of the pulp preservation process decreases. (7)

The decision on the depth of the removal of the pulp: the advice of the AAE was to always evaluate the pulpal tissue to be left under the  surgical operating microscope (aae).pulp severing depth will always depand on the level of pulp attachment toi the walls, and the ability to achieve heamostatsis, once we have achieved pulp cristalisation appearance and heamostasis, we can preserve the remainder of the pulp. (figure1)

Fig 1 showing the pulp stump before and after the application of NaOCl ad the heamostasis

Important clincal tips on achieving heamostatsis in the clinical practice:

Achieving heamostasis and controloing the pulp stump status requires meticulus handelling. 

1. Most of the published studies had a consensus that the agent to be used with the heamostatic control is the sodium hypochlorite(8), which an be passivly injected freely in to the cavity, or can be applied through a cotton (yet some authours had certaiun concerns about the possicility of attachment of cotton fibers into the puylkp stump). 
2. The concentration oif the NaOCl was not concluded yet most ogf the case reports and researches have founfd that 2.5 NAOCl was the most frequently used  concentration and didn’t harm the remaindrer of the pulp tissue (9). 
3. The use of the EndoIce as a cryogenic treatment on a sterile Gauze was found to be very helpful when it came to decreasing the inflamation and controlling the bleeding pulp stump.( Leave them in contact for 20 seconds and then repeat again, because the body temperature will warm up very quickly the cotton pellet on top. Repeat this a few times, then remove the base cotton pellet). 
4. The time of the application: the NaOCl should be left in contact 4-8 minutes and then rinsed and the pulp stump assesed. Usually if there is still bleeding you will repeat the attemp one more time and if you still cannot control the bleeding then wait till 10 miutes, after that it will be considered asd failure (10) and you should sever the pulp deeper to reach the proper tissue that will have good heamostasis. This is generally what controls the level of pulpotomy in clinical cases (fig 2). 
5. The use of laser photobiomodulation is of extreme help in multiple ways as it can enhance the pulp healing capacities by decreasing the inflammation, in addition to controlling the bleeding and increasing the outcome. Soft tissue laser photobiomodulation has been found to enhance the outcome of the vital pulp therapy in mature teeth significantly and decrease the post operative pain, giving the patient a more confident and pleasant experience (11).

When should we place the final resoration: due to the newly founded advances in the properties of the bioceramics has allowed us to use it to our advantage, as the strength and setting times of the material have improved drastically, giving clinicians tha capability of benifiting through the advantages of immediate restoration 

1. Prevention of Microleakage, 
2. Protection of the Biomaterial layer 
3. Less Post-Oper Sensitivity & thermal conductivity 
4. Establishment of a foundation for Cuspal coverage

 

In conclusion it is important to shed a light on this new norm of an endodontic approach, as the preservation of vital pulp is of extreme importance not only in teeth where root canal treatment may be very difficult due to anatomical challenges, but for all teeth, where this preservation will play an important role in the longevity and survivability of the tooth in the patients mouth.

References

1. American association of endodontists special committee on vital pulp therapy. (2021) aae position statement on vital pulp therapy. Journal of endodontics, 47, 1340–1344.

2. Duncan, h. F. (2022). Present status and future directions—vital pulp treatment and pulp preservation strategies. In international endodontic journal (vol. 55, issue s3, pp. 497–511). John wiley and sons inc. Https://doi.org/10.1111/iej.13688

3. Kakehashi s, stanley hr, fitzgerald rj. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral surg oral med oral pathol. 1965 sep;20:340-9. Doi: 10.1016/0030-4220(65)90166-0. Pmid: 14342926.

4. Patel s, puri t, mannocci f, bakhsh aa. The outcome of endodontic treatment using an enhanced infection protocol in specialist practice. Br dent j. 2022 jun;232(11):805-811. Doi: 10.1038/s41415-022-4339-y. Epub 2022 jun 10. Pmid: 35689064.,

5. Altukroni, a., alsaeedi, a., gonzalez-losada, c., lee, j. H., alabudh, m., mirah, m., el-amri, s., & ezz el-deen, o. (2023). Detection of the pathological exposure of pulp using an artificial intelligence tool: a multicentric study over periapical radiographs. Bmc oral health, 23(1). Https://doi.org/10.1186/s12903-023-03251-0

6. Wadhwa, h., duhan, j., sangwan, p., tewari, s., kumar, v., mittal, s., & arora, m. (2025).effect of age on the success of direct pulp capping using 2 bioceramic materials in cariously exposed teeth with reversible pulpitis: a prospective clinical study. Journal of endodontics, 51(7), 836–844. Https://doi.org/10.1016/j.joen.2025.04.012

7. Abdelaziz, m. S., abdelsalam, n., & fayyad, d. M. (2025). Assessment of the number of missing tooth surfaces and the molecular findings on the outcomes of vital pulp therapy using 2 calcium silicate materials: a randomized clinical study. Journal of endodontics, 51(6), 658–665. Https://doi.org/10.1016/j.joen.2025.03.001

8. Machareonsap, h., manmontri, c., chaipattanawan, n., chompu-inwai, p., alicia ko, h., & chaipattanawan lecturer, n. (2021) which irrigant should be used for vital pulp therapy in permanent teeth? :a review of the literature. Https://www.researchgate.net/publication/352091805

9. Machareonsap, h., chompu-inwai, p., chaipattanawan, n., manmontri, c., nirunsittirat, a., & phinyo, p. (2024). Normal saline or sodium hypochlorite irrigation for vital pulp therapy? A non-inferiority randomised controlled trial. European endodontic journal, 9(3), 180–190. Https://doi.org/10.14744/eej.2023.30932

10. Linsuwanont p, wimonsutthikul k, pothimoke u, santiwong b. Treatment outcomes of mineral trioxide aggregate pulpotomy in vital permanent teeth with carious pulp exposure: the retrospective study. J endod. 2017 feb;43(2):225-230. Doi: 10.1016/j.joen.2016.10.027. Epub 2016 dec 29. Pmid: 28041685.)

11. Olszewska, a., matys, j., gedrange, t., paszyńska, e., roszak, m. M., & czajka-jakubowska, a. (2024). Evaluation of photobiomodulation for postoperative discomfort following laser-assisted vital pulp therapy in immature teeth: a preliminary retrospective study. Advances in clinical and experimental medicine, 33(7), 709–716. Https://doi.org/10.17219/acem/171812