Clinical Steps for Vital Pulp Therapy

The Evolution of Vital Pulp Therapy: A Paradigm Shift in Carious Lesion Treatment

Our previous post introduced the benefits of modern bioceramic materials and their transformative impact on the treatment of carious lesions in teeth with vital pulpal tissue. Traditional methods such as indirect pulp capping, direct pulp capping, or SVEC pulpotomies using calcium hydroxide Ca(OH)2 are now being replaced by a more advanced procedure known as Vital Pulp Therapy (VPT) utilizing modern bioceramic materials. (AAE Position Statement on Vital Pulp Therapy)

The Role of Modern Bioceramic Materials in Vital Pulp Therapy

The foundation of Vital Pulp Therapy lies in the biocompatible and bioactive properties of modern bioceramic materials. No longer do we need to be concerned about the potential for dental materials to damage the pulp or the risk of pulpal exposure during carious excavation. Instead, the focus has shifted to complete caries removal, even if it necessitates partial or complete pulpotomy, followed by immediate placement of a bonded, permanent restoration.

A 2011 systematic review (Aguilar, Panuroot et al.) on cariously exposed vital pulps treated with DPT (direct pulp capping) showed a 72.9% success rate at 36 months compared to 99.4% and 99.3% success on teeth treated with partial and full pulpotomy at the same 36 months.

Furthermore, a 2021 meta-analysis (Sabeti et al.) examining the prognosis of VPT in permanent teeth found that when MTA or other bioceramics were used as a capping material, success rates reached 93%.

These findings highlight that VPT should be strongly considered over traditional direct or indirect pulp capping and as a viable treatment option for carious teeth—except in cases where endodontic therapy is required to due pulpal necrosis or for restorative purposes, such as post placement.

Expanding Indications for Vital Pulp Therapy - IRREVERSIBLY INFLAMMED TEETH

Initially, it was believed that VPT would be limited to teeth with normal or reversible pulpitis. However, emerging evidence suggests that this approach may also be effective for teeth with irreversible pulpitis. A recent 2024 randomized cohort study (Zhang et al.) evaluating VPT using bioceramic materials in cariously exposed pulps with both reversible and irreversible pulpitis found a one-year clinical success rate of 90.4%.

A randomized controlled trial (Jassal et. al.) found that the success rates of vital pulp therapy (with a bioceramic) between partial and full pulpotomies on teeth with irreversibly inflamed pulps was statistically insignificant.  They reports 88% success rate for partial pulpotomy and 91.6% success rate for full pulpotomy at 1 year.

Another systematic review (Cushley et.al.) of permanent carious molars with irreversible pulpitis treated with coronal pulpotomy found a 94% clinical success rate and 88% radiographic success rate at 36 months.

This research underscores the potential for VPT to serve as a conservative treatment option for your patients before the need for endodontic intervention arises. This data would suggest that you can consider treating permanent, cariously exposed teeth with NORMAL, REVERSIBLE and IRREVERSIBLE pulpitis with more conservative vital pulp therapy before you move to full endodontic therapy.

At SSE, our goal is to support your restorative practice by informing you of conservative treatment options you may consider before referring patients for endodontic therapy at Superstition Springs Endodontics.  This treatment is best performed in your office where you can immediately restore your patient with a permanent restoration.

Determining Candidacy for Vital Pulp Therapy

For successful VPT implementation, consider the following criteria:

Vital Pulp Therapy IS an option if:

• The pulp is vital and responds to thermal testing. (Irreversibly inflamed pulps are also in this category)

• The patient understands that a root canal may still be required if the pulp is too inflamed upon access or necroses over time. (Set realistic expectations.)

• The tooth has immature roots that still require apical closure.

Vital Pulp Therapy IS NOT an option if:

• The pulp is necrotic (evidenced by swelling, sinus tract, or periapical lesion).

• Decay is so extensive that root canal therapy is required for restorative purposes (e.g., the need for post placement or extensive decay preventing proper restoration).

Factors That May Improve VPT Success:

• Asymptomatic patients

• Younger patients

• Larger canals/apices

Step-by-Step Guide to Performing Vital Pulp Therapy

1. Pulpal Diagnosis & Informed Consent – Confirm a vital pulp through diagnostic testing and ensure the patient understands that endodontic therapy may still be necessary.

2. Rubber Dam Isolation – Maintain a dry, sterile field.

3. Complete Caries Excavation – Remove all carious tissue, even if pulpal exposure occurs.

4. Hemostasis Control – Apply direct pressure with a cotton pellet to control bleeding. If bleeding persists beyond 3-4 minutes, remove additional pulpal tissue. If necessary, perform a full pulpotomy. If hemostasis cannot be achieved, consider endodontic therapy.

5. Application of Bioceramic Material – Once bleeding has stopped, apply a bioceramic material directly onto the pulpal tissue.

6. Protective Base Placement – Place a glass ionomer base over the bioceramic to prevent washout during bonding of the final restoration.

7. Final Restoration – Place a permanent bonded restoration.

8. Coronal Coverage – Consider full coronal coverage if the tooth requires additional reinforcement.

9. Follow-Up & Monitoring – Conduct periodic evaluations to assess pulpal health and radiographic changes.

Conclusion

Vital Pulp Therapy represents a significant advancement in conservative dental care, providing an effective alternative to traditional pulp capping techniques and, in some cases, even root canal therapy. By integrating modern bioceramic materials into your practice, you can offer patients a more conservative, biologically favorable approach to managing carious lesions while preserving pulpal vitality.

At SSE, we are committed to supporting your practice with the latest advancements in restorative and endodontic treatment options. If you have questions or need guidance on incorporating VPT into your workflow, we’re here to help!

Consider the following case examples.

CASE #1 - VPT with Direct Pulp Cap (Pulp exposed but not removed)

Deep decay on a vital pulp of young patient

Complete caries removal, hemostasis achieved, MTA bioceramic placed on exposed pulp

Immediate, bonded restoration placed

VPT Final

CASE #2 VPT with Partial Pulpectomy

Deep decay on a young patient with vital pulp

Rubber Dam isolation and caries excavation

Pulp exposed, complete caries removed and hemostasis of the remain pulp achieved with pressure

Bioceramic putty placed against the exposed pulpal tissue & glass ionomer base placed over the bioceramic

Bonded restoration placed

VPT completed with partial pulpotomy

CASE #3 - VPT with Complete Pulpotomy

VPT with complete removal of pulpal tissue in the pulp chamber (pulpotomy)

CASE #4 VPT with Partial Pulpotomy

VPT completed with partial pulpotomy

After completing vital pulp therapy on your patients.  Plan to monitor them over time.  Restore them with coronal coverage when appropriate.  If necrosis occurs, endodontic therapy is the next step.

SOURCES:

1. AAE Position Statement on Vital Pulp Therapy, Journal of Endodontics, Sept 2021, Vol 47, No 9, p1340-1344.

2. Vital Pulp Therapy in Vital Permanent Teeth with Cariously Exposed Pulp: A Systematic Review. Aguilar, Panuroot et al. Journal of Endodontics, Volume 37, Issue 5, 581 - 587.

3. Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Sabeti, Mohammad et al. Journal of Endodontics, Volume 47, Issue 11, 1683 - 1695. 

4. Clinical Influencing Factors of Vital Pulp Therapy on Pulpitis Permanent Teeth with 2 Calcium-Silicate Based Materials: A Randomized Clinical Trial. Zhang, Yin, Wu, Wang, Huang, Li.  Medicine (Baltimore) 2024. May 3: 108(18).

5. Outcome of partial and full pulpotomy in cariously exposed mature molars with symptoms indicative of irreversible pulpitis: A randomized controlled trial. Jassal A, Nawal RR, Yadav S, Talwar S, Yadav S, Duncan HF. , Int Endod J. 2023 Mar;56(3):331-344. doi: 10.1111/iej.13872. Epub 2022 Dec 4. PMID: 36403208.

6. Pulpotomy for mature carious teeth with symptoms of irreversible pulpitis: A systematic review. Cushley S, Duncan HF, Lappin MJ, Tomson PL, Lundy FT, Cooper P, Clarke M, El Karim IA. , J Dent. 2019 Sep;88:103158. doi: 10.1016/j.jdent.2019.06.005. Epub 2019 Jun 20. PMID: 31229496.

Modern Bioceramics in Endodontics

Porcelains have been at the heart of esthetic dentistry since the 1960's with a broad assumption that they are bioinert - not eliciting a reaction from the tissues around them.

Without diving too deep in the science of biomaterials, a bioactive material is one that intentionally elicits a response from adjacent tissues and biocompatability refers to a material that does not cause harm to adjacent tissues.  Biocompatibility is not absolute(1) and requires evaluation of a material's interaction with tissues over time.  In other words, more complex than this discussion.

Advances in dental ceramics have continued to evolve into what we now call bioceramics. These materials include hydroxyapetitie, bioactive glass and calcium silicates.(2)

One of the earliest bioceramics used in Endodontics was Mineral Trioxide Aggregate - a silicate cement.  This bioactive and biocompatible material was unlike anything we had seen before in endodontics.  It could be used in a moist environment - actually requiring moisture to set up, did not seem to irritate the adjacent tissues and bone would form right up against it!  It did not take long for this  material to be used for root repair (additional example) & apicoectomy retrofills.

With the biocompatible success of this material, and seeing that it clinically created good seal, it wasn't long before we began using this bioceramic for direct pulp capping and using this material to replace traditional apexification/apexogenesis a new type of procedures known as pulpal regeneration.

 

One of the biggest challenges with the use of MTA was the grey discoloration of the tooth.  The grey staining of the tooth created esthetic challenges in the anterior.  In effort to address this complication,  Tulsa Dentsply developed a white MTA by reducing the aluminoferrite content.

The bioceramic line up has grown since the development of white MTA with additional calcium silicate cement products from Septodont, Brasseler, Avalon Biomed etc.  These modern bioceramic materials claim to have the impressive properties of:

• Osteogenicity
• Chemically bond to dentin
• Antibacterial (pH>12)
• Hydrophilic
• Hydroxyapatite producing
• No shrinkage
• Good working/setting time
• Easy delivery systems

Every one of these properties make these materials ideal for use in Endodontics. By adjusting the thickness of the material for different applications, we now use these materials as endodontic sealer, root repair material, root end filling materials, pulp regenerative procedures.

With improved esthetics, these modern bioceramics are now the standard of care for pulpal regenerative procedures.

The modern bioceramic materials, with these amazing bioactive and biocompatible properties, are opening up new restorative options when it comes to carious lesions on vital teeth.  

Bioceramics can be placed directly against the pulpal tissue and maintain vitality of the pulp.  This means that direct and indirect pulp capping with CaOH is out and the new bioceramics are in. This new approach includes a major paradigm shift when it comes to pulp capping procedures.  Previously, we attempted to minimize any pulpal exposure.  Now, with the bioactive and biocompatible properties of bioceramics, the goal is complete removal of caries and infected pulpal tissue (even complete pulpotomy if needed) and proper seal with a bioceramic and immediate bonded coronal restoration.  This procedure is known as Vital Pulp Therapy (VPT) and should be considered in your restorative practice in the place of direct and indirect pulp capping.  In an upcoming post, we'll share the steps and cases to help you apply this in your restorative practice.

In a 2021 meta analysis (3) on the prognosis of vital pulp therapy on permanent teeth, when MTA or other bioceramics were used as a capping material they were found to be successful 93% of the time.  This means that VPT should be an option for your treatment of carious teeth - prior to endodontic treatment.

Stay tuned for more info and clinical tips on Vital Pulp Therapy.

Sources:

1. Wataha JC. Principles of biocompatibility for dental practitioners. J Prosthet Dent. 2001 Aug;86(2):203-9. doi: 10.1067/mpr.2001.117056. PMID: 11514810.

2. Dong X, Xu, X. Bioceramics in Endodontics, Updates and Future Perspectives.  Bioengineering. 2023 Mar13;10(3):354.

3. Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials Sabeti, Mohammad et al. Journal of Endodontics, Volume 47, Issue 11, 1683 - 1695

Technique & Long-Term Stability of Bone Grafts & Soft Tissue Grafts

If you are doing bone or soft tissue grafting, don't miss this event!

Using CBCT to Diagnose the Depth of a Cracked Tooth

 One of the many uses of CBCT is to help us determine the depth of a crack - seen on the occlusal surface of a tooth, but uncertain as to how deep it goes down the root.  Obviously the deeper the crack goes below the CEJ, the poorer the long term prognosis.

This patient was mostly asymptomatic until he recently bit into something and has had pain ever since.

Periapical film

2 Cracks seen on the MMR - with staining

CBCT shows a narrow, bony defect identifying a crack in the axial (Z) view.  The sagittal (Y) view shows the depth of the crack.  A new crown would have to go past this depth to cover the crack up.  This view helps us make a determination of the restorability of the tooth.

In this case, the crack would never be completed removed or covered up by the crown making the long term prognosis poor.  CBCT allows us to make this evaluation without having to remove the amalgam filling and chase the crack - saving the patient (and us) time and money.

Innovations in the Dental Insurance World

 

Medical insurance has been using tiered systems to provide care to patients for some time. A tiered system categorizes physicians by quality and cost efficiency standards. While the patient chooses their provider, the patient's copay may vary based upon the provider tier that is chosen. Insurance companies can reimburse different tiers on different fee schedules potentially allowing network providers with better outcomes higher reimbursements. An example of medical insurance tiered system: TIER 1 Providers meet excellent quality and/or cost efficiency standards Members pay the lowest copayment TIER 2 Providers meet good quality and/or cost efficiency standards Members pay the mid-level copayment TIER 3 Providers who are outside the insurance network Members pay the highest copayment As you know, trends in dentistry typically follow trends in medicine. While the tiered provider system is not yet here for dentistry, the concept of evaluating the quality of dental care has been on the horizon for some time, and will shortly be utilized by major dental insurers. How will this work? A leader in this type of data analytics is P&R Dental Strategies. They have developed a unique, objective, quality measurement program for dentists. Their methodology, called DentaQual, leverages a nationwide, multi-payer dental claims database (DentaBase) to measure quality by analyzing cross-payer claims and dentist utilization data. Quality is measured based on metrics scored in each of 5 categories.

The DentaQual score for a dentist is based upon an individual dentist's "standard deviation from the norm", the norm being the average practice behavior of a dentist's peers in a geographic area. It is not based upon predetermined or subjective benchmarks such as user reviews. As the largest dental insurer in Arizona, Delta Dental of AZ, will soon make these quality scores available to patients to help them in selection of their dentist. Other insurers such as United Healthcare and other Delta Dentals have already incorporated this platform and it's probable that other insurers will follow suit. In order to better understand the purpose behind these metrics and how insurance companies will be using them, we have invited Mr. Mike Jones, President and CEO of Delta Dental of Arizona to participate in our upcoming seminar. Mr. Jones will provide us with an update of current and future initiatives and explain how Delta Dental will be leveraging these new metrics. We have also invited Mr. Michael Urbach, President of New Markets for P&R Dental Strategies to come and explain how DentaQual works and what affect they expect to have on the dental insurance marketplace. We look forward to their presentation on Tues, March 22, 2022 at 6:00pm at Superstition Springs Endodontics.

Survival in the Dental Office: Brain Based Leadership Concepts to Help your Practice

During the 2020 spring shutdown, due to the COVID-19 pandemic, I found myself at home with my family looking for ways to entertain ourselves. We planned daily "quarantainment activities" like playing indoor games, outdoor games, cooking competitions, bike rides, ping pong tournaments, movies etc. At some point, we began to watch back seasons of the CBS reality show "Survivor". In this show, a group of very different people get stranded on an island, with just the clothes on their backs. They compete individually and in teams but ultimately have to vote each other off the island until there is one remaining survivor. We did some major binge watching, but it was fun. Watching the drama of such different people put in a stressful environment, competing for food & small comforts, making pacts with each other and ultimately doing anything to survive in the game - including the all too famous "blindside" was just too entertaining to look away! At the same time, we all found ourselves in a business survival mode. How do we handle our emergency patients? Do we layoff employees? Can we get a PPP loan? Can we get it forgiven? What happens if someone on staff gets sick? How do we pay for sick time? If a staff member gets sick, do we have to shut down the office? What if my family gets sick, can I come to work? How do I handle the hygienist's concerns? How do we manage our team's anxiety about the whole situation? How long will this go on? etc. etc. The threats to our businesses and livelihood were real and we all felt a little "blindsided" by COVID-19. Survival is what the brain is designed to do. The brain identifies threats and keeps us alert and aware of them at all times. Unfortunately, sometimes this state of arousal can create challenges and problems when it comes to communicating, collaborating, solving problems, setting goals, and leading a team in your office. Modern neuroscience is teaching us many new things about the brain and cutting edge leadership is taking advantage of that new knowledge. Our upcoming Inner Space Seminar, will discuss how brain based leadership focuses on understanding how the brain works and using that information to our advantage. David Rock, of the Neuroleadership Institute, has described five social domains that the brain treats as primary rewards or threats. Since your office is social system, understanding these concepts can change the way you communicate, lead your team and interact with your patients more effectively. Our upcoming Inner Space Seminar will be presented by Jason Hales DDS, MS on Thursday, Nov. 11th, 2021, will review these leadership concepts and help you survive as a leader in your practice.

To register please contact Annette at Annette@superendo.com or 480-807-8022. Seating is limited.

Dealing with Cracked and Fractured Teeth - An Inner Space Seminar

 

At a recent Inner Space Seminar, Dr. Jason J. Hales discussed dealing with cracked and fractured teeth.

Partner for Success - What Does A Real Partnership Look Like?

At Superstition Springs Endodontics, one of our five core values is "Partner for Success". To us this means, that we are successful when our partners are successful. As we have focused on this value, we have come to more clearly understand who our partners are, and how we can help each other be successful.

At SSE, our partnerships are primarily with our referring dentists, but also include other important providers of supplies, IT services, legal services, accounting services and even janitorial services. While insurance companies are often viewed as an adversary, we should look to build partnerships with them, when possible.

A 2009 study by the L.C. Williams & Associates Research Group details a group of dentists who refer less than 10% of their root canals to endodontists. This group of dentists have a very different perspective about working with endodontists. They tend to believe that they perform the same quality of endodontic treatment as specialists at a lower cost. They are less likely to admit that certain difficult cases should have been referred to an endodontist than their peers who refer more than 10% of their endodontic cases. These dentists are also less likely to describe an endodontist as their partner in delivering quality dental care. As you can imagine, these are not the dentists that we are interested in working with.

Defining this value of partnership has given us the freedom to realize that while most of our patients come from general dentists, there are times when we are forced to choose which dentists are given access and priority of our time, schedule and expertise. As you can imagine, those dentists with whom we have a partnership will get that priority.  While working with this previously described group of dentists typically brings frustration, working in sync with partner dentists, and the relationship with them, is a rewarding and fulfilling part of our work.

A partnership is a relationship that benefits both parties. At SSE, this is what partnership looks like to us:

Our partners know:

1. We will take care of their patients when in pain.
2. We will stand behind the work we do for their patients.
3. We will treat their patients the same way that they do.
4. We will support their treatment plan.
5. They can contact our doctors directly at anytime with any question or concern.
6. Their patients will return more confident in their dentist and appreciative of their referral to SSE.
7. We will do everything possible to help them be successful.

We know our partners:

1. Respect our team and their efforts to serve their patients
2. Respect our time and are patient and flexible in getting their patients in
3. They know our treatment is worth the cost. They encourage patients to see the value in coming to our practice regardless of insurance benefits or distance traveled.
4. See us as a valuable part of their dental team - not just an emergency service or someone to call to bail them out when they get in over their head.
5. See value in the work that we do for their patients. They recognize the expertise that comes with endodontic specialization.
6. Are comfortable calling our doctors directly to help them deal with any especially difficult case or situation.

We understand that referral patterns in dentistry can change for many reasons. The previous study found that the longer a dentist was in practice, the more positively they perceived their endodontist colleagues. Younger doctors were more likely to say that economics of treatment and their availability are more important factors when deciding whether to perform or refer to an endodontist. As doctors become more experienced, better acquainted, as professional relationships grow stronger through improved communication and experience together and as teams get to know each other and work together partnership improves. Sometimes doctors are discouraged from referring to endodontists because of their employment status as an associate dentist. Sometimes an owner doctor gets busy enough to choose procedures that are more profitable for them (crown & bridge) or they just get tired of searching for the MB#2 and look to build a partnership with an endodontist.

Our mature partners (and by mature I do not mean age) express to us that they feel that relieved sending their patients to SSE because they know the experience their patients will have and how it will move them forward in their treatment plan. While many of these partners may still perform some endodontic treatment, they become experts at diagnosis and case selection. They recognize the cases that will save them time and money by referring rather than treating. If you could ask them, they would explain that they are more successful and profitable by the working partnership they have with SSE.

Because of our value "Partner for Success", our partners are given the highest priority in our schedule. While we try to accommodate everyone who needs to be seen, our partners are given priority over self-referred patients, online referred patients or patients from offices that we don't have an established and working partnership.

We appreciate working with the best dental practices around and are always excited to make new partners. If you are looking for the kind of partnership described above, please let us know so that we can take the steps to build a stronger relationship with you and your team.

How to Manage Your Debt So It Doesn't Manage You

At our last Inner Space Seminar, Dr. Danny Masters and attorney Amber Masters discuss financial principles to managing debt so it doesn't manage you.

 

Aerosol Anxiety and COVID-19 Critical Thinking with Dr. Hessam Nowzari

 

A big thanks to Dr. Hessam Nowzari, and his presentation, "Aerosol Anxiety and COVID-19 Critical Thinking" presented as an Inner Space Seminar. Hosted by Dr. Jason Hales and Superstition Springs Endodontics.

HIGHLIGHTS

• After 8 or 9 months, those who claim we don't have enough data for proper decision making are misguided or naive.
• Majority of current complications and deaths are based on decisions made upon flawed mathematical models.  
• COVID-19 is not a novel virus.  COVID-19 shares 90% of its genome with other coronaviruses - which we have been exposed to historically.  We already have some amount of cellular immunity to COVID-19 because of our prior exposure to other coronaviruses.  COVID-19 is an RNA virus which, by probability, gets weaker as it is replicated.
• The strength of the COVID-19 virus is the speed of contamination - not mortality rate.
• The US has ignored many of our scientific colleagues in Taiwan, Japan, Sweden etc. and the information and warnings they gave us early on and the success that they are currently having.
• We should expect to see increasing case positives and mortality rate as we move into October due to the regular flu season.
• We know that our young people are safe.
• We have to protect our elderly population and people with co-morbidities.
• COVID-19 is very sensitive to soap & water. Wash your hands with soap and don't touch your face or eyes.  You don't need alcohol or expensive chemicals that destroy your natural biome.
• Every person has over 100,000 viral elements in their DNA.  Viruses are part of who we are.

WHAT ARE WERE THE HIGHLIGHTS FOR YOU?  PLEASE COMMENT.