Clinical Review

By Dr Jeff Ward BDS, Postgraduate, Endodontics, School of Dental Science, The University of
Melbourne, 71 1 Elizabeth Street, Melbourne, Victoria, 3000.

Vital Pulp Therapy In Cariously

Exposed Permanent Teeth And
Its Limitations
Abstract permanent teeth, pulpectomy and obturation of the root canal
system is usually the treatment of choice.
Vital pulp therapy for cariously exposed permanent In young permanent teeth, pulpotomy is classically undertaken
teeth remains one of the most controversial areas in to promote apexogenesis (5). Apexogenesis refers to a vital pulp
dentistry. Because a vital, functioning pulp is capable therapy procedure performed to encourage physiological develop-
of initiating several defence mechanisms to protect ment and formation of the root end (6). The objective is to pro-
the body from bacterial invasion, it is beneficial to mote root development and apical closure. An open, divergent
preserve the vitality and health of an exposed pulp apex presents the challenge of producing an apical stop or
rather than replace it with a root filling material constriction for placement of a hermetically sealed root canal filling
(6). Because the pulp is necessary for the formation of dentine, the
following pulp exposure. There is no consensus on
loss of vitality in young permanent teeth before completion of root
the survival rate of formerly cariously exposed pulps.
formation leaves a thin, weak root that is prone to fracture and
Observation time, judgement criteria,
difficult to treat endodontically (7). The prognosis for permanent
pulpotomy/pulp capping technique and, most retention is limited when compared with fully developed teeth.
importantly, pulpal status at the time of treatment, Every effort must be made to maintain the vitality of the pulp in
vary to a great extent amongst studies. teeth with incomplete apices to achieve root development. Once
In mature teeth, a pulp exposed by caries is usually root development is achieved and apices have closed, root canal
treatment is completed. The need for root canal treatment was
removed and the root canals are cleaned, shaped and
based on the premise that possible necrosis, continued calcification
filled. Amongst the methods for preservation of a
or internal resorption will occur following pulpotomy. Recent
cariously exposed pulp, partial pulpotomy has yielded
studies have proposed that as long as a hermetic seal is ensured,
a markedly high success rate in young teeth. Major root canal treatment is not needed following pulpotomy (8).
limitations in the success of vital pulp therapy in Partial pulpotomy aimed at preserving pulpal vitality has been
cariously exposed permanent teeth exist. The lack of shown to be successful in traumatically exposed permanent teeth
predictability and long-term success greatly influence (9). This treatment regimen has been applied and showed some
decision-making. The decision-making itself is success in the treatment of cariously exposed young permanent
unreliable primarily due to the difficulty of accurately molars ( 10, I I ). The excellent blood supply of a young permanent
diagnosing the ability of the pulp to repair. tooth with incompletely formed roots may contribute towards this
success (7). In contrast, the decreased resistance of the aged pulp
While there are indications for vital pulp therapy in may become significant when one considers that the vascular
young permanent molars, it must be remembered reaction to inflammation is considered a protective mechanism of
that ultimately, none of these procedures enjoy the the pulp against invading factors ( 12). From the clinical point of view,
long-term success of complete root canal therapy. the vitality of the dental pulp of an aged person appears to be
weaker than that of a young person ( I 2).
Considerable literature emphasises the negative aspects of vital
Introduction pulp therapy and discourages its practice. Many clinicians and
The treatment of the cariously exposed permanent tooth should researchers continue to condemn vital pulp therapy for the same
result in arrestingthe carious process and keepingthe vital pulp free reasons reported in the literature 80 years ago, despite the
of inflammation ( I ) The aim of vital pulp therapy is to preserve the advances made in pulp biology ( I 3).
vitality and function of the coronal or remaining radicular pulp tissue The immediate and long-term success of root canal therapy is
(2) Carious lesions involving the pulp, if not treated will lead to well known, but clinicians are less certain of the success of vital pulp
pulpal necrosis and often involvement of the periradicular tissues, therapy. Cvek ( 9 ) reported a 96% success rate for partial
with pain and discomfort for the patient (3) The treatment of the pulpotomy in traumatically fractured teeth with an open apex that
cariously exposed pulp is dependent upon the maturity of the were healthy before trauma. Barthel et al (14) in comparison,
tooth In deciduous teeth, treatment is aimed at removing the found a success rate of only 13% ten years after capping cariously
infected, coronal pulp and fixing or mummifying the radicular pulpal exposed, asymptomatic, vital pulps. Whilst observation time,
tissue, thereby preserving the tooth, not the pulp (4) In mature pulpotomy technique and judgement criteria vary between studies,

AUSTMLIAN ENDODONTIC JOURNALVOLUME 28 No. I APRIL 2002 29

the status of the pulp at the time of capping is the predominant the pulp's ability to successfully protect against invading factors.
factor in determining the healing of exposed pulps ( I 4). The success of vital pulp therapy techniques in cariously exposed
The long-term prognosis and the ability to restore a tooth are permanent teeth is dependent upon the technique employed, the
the overriding factors when assessing whether vital pulp therapy inflammatory status of the pulp tissue, the type of pulp therapy
should be undertaken (15). The amount of crown destruction agent used, the period of observation and the criteria used to
usually associated with a pulp exposure in an immature molar determine success (2 I ). Accurate diagnosis of the pulp status prior
means that the tooth involved would require significant restorative to treatment, caries removal, leakage prevention and use of an
maintenance in the long term. aseptic technique, are key determinants in a successful treatment
outcome.
Basic Concepts In Vital Pulp Therapy Of
Cariously Exposed Permanent Teeth Techniques
The treatment objective following pulp exposure is to obtain Vital pulp therapy techniques that are used for treatment of
healing of a pulp wound in order to preserve a vital tooth with a cariously exposed permanent teeth include:
healthy pulp. Kakehashi et a1 ( I 6), clearly showed that the key factor Indirect pulp capping
in pulpal healing after exposure is the absence of infection. Failures Direct pulp capping
are caused by infection due to either remaining bacteria, or the Full coronal pulpotomy
exposure to new bacteria from leakage (17). Heys et al (18) Partial pulpotomy.
demonstrated that exposed pulps heal even against an inert material These procedures have been employed for carious, mechanical,
such as Teflon, when bacterial contamination is eliminated. and traumatic exposures of the pulp. A high incidence of success
Vital pulp therapy aims to treat reversible pulpal injury. There IS a has been reported, as judged radiographically and by the absence of
difference in the outcome between treating an inflamed and a non- clinical signs and symptoms (22). However, large variations in
inflamed pulp (I 7). The chance for successful outcome is markedly success rate between studies exist. Differences in case selection,
higher in the non-inflamed pulp exposed by trauma, than in the length of study, and type of investigation are responsible for these
inflamed pulp exposed during caries excavation. Treatment will be variations (22).
successful only if the pulp, at the time of treatment, is sound or Indirect pulp therapy is a technique for avoiding pulpal
not seriously enough inflamed to result in a continuation of the exposure in the treatment of teeth with deep carious lesions in
inflammatory response (I). which there exists no clinical evidence of pulpal degeneration or
Caries causes pulpal inflammation, even if the carious process periapical disease (22). This technique is based on the theory that a
has not reached the pulp tissue, because bacterial by-products will zone of affected demineralised dentine exists between the outer
reach the pulp via the dentinal tubules. Consequently, with the infected layer of dentine and the pulp (23). When the infected layer
majority of deep carious lesions, the dentine is often supported by is removed, the affected dentine can then remineralise and the
an injured pulp that itself must undergo repair and remain clinically odontoblasts form reparative dentine, avoiding a pulp exposure.
asymptomaticfor vital pulp therapy to be considered a success ( 19). Carious dentine left in the tooth undoubtedly contains some
The presence of pain does not always indicate that a pulp injury is bacteria but calcium hydroxide and/or zinc oxide-eugenol cement
irreversible, although certain patterns and intensities of pain tend can greatly diminish their numbers (24). The remaining soft dentine
to suggest a greater likelihood of an irreversible change. The is covered and after two months the degree of remineralisation is
inflammatory status of the pulp during a pulpal exposure is a major tested and any residual softened dentine removed (24). If caries has
factor in determining whether vital pulp therapy will be successful reached the pulp, endodontic treatment is initiated. If there has
and is also extremely difficult to accurately diagnose. been a favourable response and the dentine is hard, a permanent
For teeth in which the caries process is aggressive or in which the restoration can be placed. Some studies report repair in 74% to
pulp may have a reduced repair potential because of chronologic or 99% of cases (I 3, 25). Other authors state that there is a low
physiologic aging, there is generally a progressive inflammation and expectation for success and that failures increase with time ( I 7).
necrosis of tissue resulting in the loss of the pulp as a functioning A difficulty with this technique is clinically determining what is
organ ( I 9). The inflammation in such cases is classified as irrever- infected or just afected dentine. To intentionally leave infected
sible. If the pulp can recover from the inflammation induced by material is definitely not recommended as it leads to further pulpal
a caries attack with appropriate treatment, the inflammation is inflammation and likely failure. From a practical standpoint, it is
referred to as reversible. Seltzer et al (20) showed that the strongly advised to excavate carious dentine until the remaining
correlation between diagnostic and actual histologic findings in the dentine feels hard to a dental explorer and reflects light ( I 7). The
pulp is not strong and that this classification should be considered use of caries indicator dye may be of benefit also.
clinical rather than histopathologic. A low-grade, asymptomatic Direct pulp capping is a procedure in which an exposed
chronic inflammation leading to pulpal necrosis often exists long dental pulp is covered with a protective dressing or cement that
after caries had been removed and the tooth restored (20). protects the pulp from additional injury and permits healing and
Reversible inflammation is more common in young permanent repair (26). The outcome for direct pulp capping following a carious
teeth than in mature permanent teeth ( I 9). Growth, maturation exposure is considered, at best, unpredictable (27, 28). During the
and inflammation all cause the pulpal vasculature to undergo direct capping procedure the capping agent is placed on tissue that
significant morphologicalchanges. The superficial layer of the young has been exposed to microorganisms and where inflammation is
pulp consists of a characteristic three-layer vascular network ( 12). present ( I 7). Histologic examinations have shown chronic
After teeth grow into occlusion, the pulp cavity narrows and this inflammation under many cariously exposed pulp caps and
vascular network undergoes reconstruction. Two of the three diminished success rates (22). Direct capping procedures should
vascular layers disappear, leaving a coarse terminal capillary network only be carried out on fresh, traumatic or mechanical exposures,
( 12). As these morphological changes progress with time, the before bacterial plaque has established on the exposure and the
protective vascular reaction to inflammation diminishes, influencing underlying pulp has become inflamed ( 17, 29).

30 AUSTRALIAN ENDODONTIC IOURNAL VOLUME 28 No. I APRIL 2002

 Pulpotorny has become the treatment of choice for cariously undergoes degeneration, atrophy and shrinkage away from
exposed vital teeth ( 17). Pulpotomy is described as a procedure that dentine. Dentine bridges contain tunnels and porosity. The number
involves the amputation of the coronal portion of the affected or and size of these tunnels reflects the degree of trauma to the pulp
infected dental pulp and treating the remainingvital pulp to preserve ( I 3). Cellular inclusions and empty vascular spaces create porosity,
its vitality and function (30). Pulpotomy allows for the pulp wound and in combination with tunnels, contribute to the permeability of
to be placed in healthier tissue than at the site of exposure. every dentine bridge. Dentine bridges have been condemned as
Full coronal pulpotorny involves the complete removal of the ineffective protective barriers because of their permeability,
coronal pulp and the placement of a wound dressing at the canal although regular tubular dentine is itself, permeable ( 13). Even
orifice(s). Many different chemical compounds have been used as though the quality of a dentine bridge may be suspect as to its
wound dressings. Wound dressings containing formaldehyde, integrity, it nevertheless provides a physical barrier of some sub-
phenol, creosotes and other highly toxic materials were advocated stance to protect the pulp. Dentine bridge formation is the best
to "mummify" the remaining pulp tissue ( I 7). The short-term solution for healing of the underlying pulp ( 13).
clinical outcome for these materials is usually acceptable. On the
other hand, with increasing time there is a decreasing success rate Current Research
following pulpotomy with formaldehyde-containing materials ( I 7).
Due to the short lifespan of primary teeth, this form of pulpotomy The success of vital pulp therapy in cariously exposed permanent
is popular in paediatric dentistry. teeth is the subject of much debate. The scepticism towards vital
The use of materials such as formocresol in the full coronal pulp therapy originates from an historical context, where treatment
pulpotomy of permanent teeth with pulp exposures has been decisions were based on empirical reasoning (26). Strindberg in
recommended (3 I). This goes against all modern endodontic 1956 (37) reported a success rate for direct pulp capping with
principles as the remaining chemically necrotised tissue can serve as calcium hydroxide of 64%, compared to a success rate of 83% for
a substrate for bacteria as a result of leakage ( 17). In addition, Fuks root canal treatment. Since then, knowledge of pulpal physiology
et al (32) found a high incidence of internal resorption in has broadened, leading to a better understandingof the conditions
formocresol-pulptomised permanent monkey teeth and Rolling necessary to take advantage of the good potential of the pulp to
et al (33) found that the portion of canal apical to the fixed plug of heal. Recent clinical studies indicate that vital pulp therapy of
tissue beneath formocresol pulpotomies in permanent teeth with cariously exposed young permanent teeth can produce success
pulp exposures, is often tortuous and extremely difficult to rates that compare favourably with the success rate of root canal
instrument when endodontic treatment is often needed years later. treatment (2, 3, 10, I I , 26, 38).
Formorcresol pulpotomies are not recommended in teeth with Conflicting views have been expressed when relating pulpal
mature root formation unless there are behavioural and/or socio- changes to caries progression and clinical symptoms (20, 27, 39,
economic constraints to performing root canal therapy ( 15). 40). In 1968, Langeland and Langeland (41) showed that deep
Pulpotomy agents such as formocresol and glutaraldehyde are carious lesions might be found with relatively normal pulps or with
associated with systemic toxicity and carcinogenic potential, so their only a slight increase in chronic inflammatory cells. Trowbridge (42)
safety is questioned (34). suggested that the pattern of pulpal inflammation is determined by
Partial pulpotorny has achieved very high success rates in the permeability of dentine and the proximity of the carious lesion
the treatment of complicated crown fractures (95%) (32), and to the pulp. Lin and Langeland (43) stated "whereas the repair
in young, posterior, symptom-free permanent teeth with carious capacity of pulp tissue following removal of all carious dentine
exposures (9 I-93%) ( 10, I I , 35). Partial pulpotomy as described without pulp exposure is excellent, after carious exposure it is
by Cvek in I978 (9), is the aseptic, surgical removal of the exposed questionable and unpredictable". Seltzer et al (20) histologically
pulp and dentine surrounding the exposure to a depth of 1.5-2.0 considered up to 79% of permanent teeth with clinical pulp
mm. This aims to surgically remove tissue that is irreversibly exposures to be in the non-treatable category.
inflamed and exposed to microorganismsleaving a clean-cut wound It is generally accepted that in advanced stages of a carious lesion,
surface on healthy tissue ( I 7). The pulp wound is irrigated with just prior to or soon after pulp exposure, bacterial components
sterile saline until physiologic haemostasis is achieved and then the cause only localised irreversible damage beneath the exposure,
pulp wound is covered with a paste of calcium hydroxide and water. while the remaining pulp is infiltrated with inflammatory changes to
An alternative irrigant is sodium hypochlorite (055.25%). This has a varying degree. The bacteria only seem to gain access to the pulp
been shown to be effective at haemorrhage control and surface lumen after some part of the pulp has become necrotic (39, 40).
disinfection and flushing, without any detrimental pulpal effects (5, These views seem to be confirmed by the studies of Zilberman et
18). The wound dressing is then carefully dried and sealed with a al ( I I ) and Mejire and Cvek ( 10). The removal of the superficial
suitable material. The direct apposition of the calcium hydroxide layers of pulp tissue together with the contaminated dentine and the
paste on the non-bleedingpulp tissue is essential, as an extra-pulpal prevention of microleakage, sufficed to ensure healing in most of
blood clot will diminish the chances for hard barrier formation and the treated teeth.
long-term success ( 17). Partial pulpotomy creates a retentive cavity Seltzer et al (20) showed that under small carious lesions only
for the covering materials and the use of calcium hydroxide in an increase in reparative dentine formation is induced, whilst in
combination with removal of blood clot gives predictable healing moderately large cavities, macrophages and lymphocytes are
with a continuous hard tissue barrier (9). observed under the involved dentinal tubules of the coronal pulp.
With calcium hydroxide treatment, a dentine bridge will pre- In very deep lesions, chronic inflammatory exudate develops.
dictably form over healthy, remaining pulp tissue (13). In the When the pulp is exposed by caries, acute localised inflammation
absence of a bridge, the wounded pulp tissue is much closer to the and liquefaction necrosis can be observed under the exposure site.
surface and is more easily invaded by subsequent attacks of oral Langeland (39) postulated that in order to preserve the remaining
bacteria and their by-products (36). A dentine bridge allows more heatthy pulp, it is necessary to remove this infected, necrotic and
predictable repair by giving underlying pulp tissue something to disintegrated pulpal tissue.
attach to ( I 3). Without a bridge, pulp tissue remains unattached,

AUSTPALIAN ENDODONTIC JOURNALVOLUME 28 No. I APRIL 2002 31

 Farooq et al(30) showed that a carious primary tooth diagnosed It was traditionally believed that the primary cause of pulp
with pain from reversible pulpitis could be successfully treated with damage after direct pulp capping was direct toxic effects from dental
either an indirect pulp treatment or a formocresol pulpotomy. materials. Animal studies however, have demonstrated that
Success rates of 85% and 76% respectively were observed for restorative materials do not cause pulp inflammation or necrosis
these two techniques over a four-five year follow up. Gruythuysen when directly placed on the exposed pulp if bacteria are sealed off
and Weerheijm (44), in a similar study over a two-year period, at the margins (49).
achieved an 80% success rate with the placement of calcium In recent years there have been many publications illustrating
hydroxide as a base after pulpotomy of carious primary teeth with healthy pulps without dentine bridges in teeth treated with a total
signs of reversible pulpitis. Both these studies (30, 44) showed a etch and bond technique. The concept is that these bonding
high failure rate of all vital pulp therapy when a preoperative techniques adequately seal the exposure sites from bacterial
diagnosis of irreversible pulpitis or pulpal necrosis was formed. invasion and consequently a dentine bridge is not needed. Long-
Careful history taking, together with symptoms and clinical/ term success of this seal has not been established ( I 3). Kitasako (49)
radiographic findings should help form the final diagnosis and found that because pulp tissue protruded into the cavity around the
determine the final treatment to be provided. exposure site, direct resin pulp capping might permit oral bacteria
Formocresol pulpotomy in permanent teeth has shown good to eventually access the pulp via microleakage. Exudation from the
success rates. Hosseini (45) showed a 92% success rate after 10 exposed pulp may also prevent the moisture sensitive resin
years. Teplitsky (46) showed evidence of continued apical devel- materials from adhering to peripheral dentine (49). Hebling et al
opment following formocresol pulpotomy procedures on young (50) showed a persistent inflammatory reaction and lack of
permanent teeth with incompletely developed apices. Initially it was complete pulp repair or dentine bridging 60 days after direct
thought formocresol pulpotomy had more appeal than calcium capping of non-inflamed pulpal exposures with an adhesive system,
hydroxide pulpotomy as calcification of the remaining pulp tissue compared to pulp repair with complete dentine bridging with
was not seen (22). Contrary to these thoughts, calcification of canals calcium hydroxide. At present, there is little long-term data available
with formocresol pulpotomy was shown. Full strength formocresol to support this technique.
pulpotomy has been shown to produce obliteration of the root
canal in up to 80% of teeth treated (47). Fuks and Bilstein (48) using The Future
a one-fifth dilution of full-strength formocresol found radiographic
obliteration in only 29% of treated teeth. This obliteration by Pulp therapy for cariously exposed teeth remains one of the
calcification may preclude future root canal treatment. Although this most controversial areas in dentistry. No clear-cut diagnostic
treatment has been reported to be partly successful, it cannot be indication or therapeutic method exists. Current protocols are
routinely recommended until further research showing this based on the empiricism of ages past. Much of this controversy is
technique to be successful has been completed (22). because scientific research has not provided us with the technology
As stated earlier, Cvek (9) reported a 96% success rate for partial to overcome two great shortcomings in dentistry. Firstly we are
pulpotomy in traumatically fractured teeth with an open apex that unable to directly treat pulp infection and save the pulp. Secondly,
were healthy before trauma. Mejare and Cvek ( lo), using the partial we have no predictable inductive agent for stimulating reparative
pulpotomy technique adopted from Cvek (9), achieved a 93.5% dentine (5 I ). Also, we cannot predictably diagnose the
success rate after carious pulp exposure of young permanent teeth inflammatory status of the affected pulp.
exhibiting no clinical or radiographic symptoms. Zilberman et al ( I I ) Pulp studies are very difficult. The anatomy of the pulp cannot be
found I 4 of I 5 deeply carious permanent young molars exhibited a duplicated in vitro, pulp cells in culture quickly lose their phenotypes,
vital pulp response at 12-99 months following partial pulpotomy. animal teeth do not react like human teeth and clinical studies are
Mass and Zilberman (35) achieved a success rate of 9 I .4% after a often long and arduous (5 I ). Molecular biology though, has made
minimum of 12 months, using partial pulpotomy and careful it possible to ask the questions that have never been asked.
inclusion criteria in the treatment of young permanent molars with Odontoblast and pulp cell lines will now maintain their charac-
carious pulp exposure. Barthel et al (14) in comparison, found a teristics despite many passages in cell lines. Tooth specific proteins
success rate of only 13% ten years after capping cariously exposed enable us to identify the differentiation state of cells and knowledge
asymptomatic, vital pulps. is increasing about dentine inducing Bone Morphogenetic Proteins
Matsuo et al (38) showed a success rate of 80% at >6 months (BMPs) and Transforming Growth Factor-Beta VGF-P). Many of
following direct pulp capping of permanent carious teeth with some these bioactive molecules are expressed in the dental tissues during
symptoms of irreversible pulpitis. Unlike most other studies, teeth odontogenesis and systemically play a role in signalling cellular
with lingering pain to thermal stimuli and with sensitivity to processes during health and disease (52).
percussion were included in the study. Caligan (2) showed that Advances in material and biological sciences should offer at least
periapical involvement did not necessarily preclude cariously two therapeutic approaches (5). Firstly, the development of dental
exposed permanent teeth from vital pulp therapy. Twenty-six adhesives for pulp capping procedures should offer greater success
permament vital molars with carious pulp exposures and radio- with pulpotomies. With diseased tissue removed, the response of
graphic periapical involvement were treated using a full coronal the remaining pulp should be more favourable. Secondly are the
pulpotomy, with calcium hydroxide placed directly on the radicular recent advances in the field of BMPs. These growth factors have
pulp tissue once bleeding had stopped. Of these, twenty-four teeth proven to be inductive for bone and dentine (5). The demon-
showed resolution of radiographic periapical involvement and stration that reparative dentine can be induced by direct or indirect
dentine bridge formation after 16-72 months. The presence of contact with a biologic agent, and its thickness determined by dose,
radiographic periapical change accompanying reversible pulpitis can elevates pulp therapy to a new level (5). Someday we might treat a
best be rationalised as a sequel to reversible pulpal neurogenic pulpotomised permanent molar with growth factors and predictably
inflammation, rather than as a direct response to an infected, dying induce sound dentine bridges, leaving the remaining pulpal tissue
Pulp, completely enclosed in healthy tissue, eliminating the need for root
canal therapy.

32 AUSTRALIAN ENDODONTIC JOURNALVOLUME 28 No. I APRIL 2002

 Recombinant human BMP-2, -4 and -7 has been shown to periodic monitoring is essential ( I 5).
induce reparative dentine formation in experimental models of large Generally, partial pulpotomy of carious permanent teeth, most
direct pulp exposures in permanent teeth (53-55). N e w reparative often with calcium hydroxide, serves to maintain the vitality of
dentine replaces the stimulating agents applied directly to the radicular tissue until apexogenesis is complete (5). Once the apex is
partially amputated pulp. This new tissue forms contiguous with, closed, root canal treatment is performed. This practice is based
and not at the expense of, the remaining vital pulp tissue. This on anecdotal evidence that calcium hydroxide will precipitate
permits the induction of a predetermined and controlled amount of dystrophic calcification in the canals and prevent endodontic
reparative dentine. treatment later, if needed (5). This obliteration of the root canals
These results provide experimental support for the potential of results in diminished blood supply, which could lead to pulp necrosis
biologic agents to stimulate reactionary dentine formation (53-55). (35). This relates t o full coronal pulpotomy where too little pulp
Further development of proper carrier vehicles that will optimise tissue is confined with too much calcium hydroxide. With partial
clinical handling characteristics and delivery will add t o further pulpotomy, where the objective is to remove only infected tissue,
possible uses (53). In the future, pulpotomies for primary and dentine bridging is stimulated in the coronal area and canals are free
permanent teeth may be handled in exactly the same way (5). of dystrophic calcification (5). Stanley (36) proposes that the
Pulpal innervation has traditionally been regarded t o serve a negative side effects of inorganic calcium hydroxide, such as
purely nociceptive function. This concept is being challenged by dystrophic calcification, have been eliminated in the lower pH,
increasing evidence that sensory nerves also serve important hard-setting, commercial calcium hydroxide preparations.
effector functions (56). Rodd and Biossonade (56) showed a caries-
induced dynamic increase in neural density in both primary and Success
young permanent teeth and speculated that this may be critical for A limit to determining success of vital pulp therapy in permanent
the regulation of pulpal inflammation and healing. teeth is the ability to recall patients regularly to determine success.
In endodontics, it has been proposed that the laser has an Although histologic success cannot be determined, clinical success is
application in direct pulp therapy as well as i-oot-end preparation judged by the absence of any clinical or radiographic signs of
and canal disinfection (57). Moritz et al (57) used a CO, laser at I W pathosis and the presence of continued root development in teeth
to irradiate non-inflamed pulps for 0. I sec pulses at I sec intervals with incompletely formed roots (22). Success rates decrease with
until exposed pulps were completely sealed. A hard setting calcium time. Barthel et al (14) showed a success rate of 37% at 5 years,
hydroxide cement and a glass ionomer restoration were then which dropped to 13% at 10 years. Canal calcification, internal
placed over the pulp. In the control group, a hard setting calcium resorption and/or pulpal necrosis are potential sequelae of vital pulp
hydroxide cement and a glass ionomer restoration were placed therapy and careful monitoring is needed to diagnose these
directly on the pulp without prior laser treatment. At I 2 months, potential problems as early as possible.
laser Doppler flowmetry assessed 89% of the laser treated cases to
be vital as compared to 68% of the non-laser treated cases. Age
The amount of data that has been accumulated over the years The patient's age may be another limiting factor in the success
on the biology and the clinical behaviour of the dental pulp are of vital pulp therapy in cariously exposed permanent teeth. In
impressive (58). Yet there are considerable gaps in our knowledge older patients, the histological state of the pulp may affect its ability
of the defence and repair mechanisms of the dentine-pulp complex t o overcome an insult. Pulpal vasculature constantly undergoes
that future research should address. morphological changes incident t o various conditions such as
growth, maturation and inflammation. Over time, owing to the
Limitations apposition of secondary and tertiary dentine, this leads to the pulp
cavity becoming narrower and the vasculature within undergoes a
Research data on vital pulp therapy can be misleading and reconstruction ( 12). The resistance of the pulp becomes reduced
confusing ( I 3) In categorising success and failure of vital pulp with age ( 12). This becomes significant when one considers that the
therapy, many more factors need t o be considered than just vascular reaction to inflammation is considered a protective
the presence or absence of microorganisms ( 13) In addition to the mechanism of the pulp against invading factors ( I 2). Horsted et al
presence of microorganisms, degrees of inflammatory response (59) demonstrated a significantly lower tooth survival rate in the
and dentine bridges one must differentiate between true tissue older age group (50-79 years of age) over longer observation
necrosis and mummification, t ecognise the potential for washout periods. From the clinical point of view, the vitality of the dental pulp
of microorganisms, leukocytes and loss of extruded pulp tissue of an aged person appears to be weaker than that of a young
elements, the influence of impaction of particles of pulp therapy person ( I 2). Mass and Zilberman (35) achieved a 9 I .4% success
agents and dentine chips, the control of haemorrhage and rate in a sample limited to children, teenagers and young adults and
embolisation of particles of pulp therapy agents, the size of the pulp suggested that vital pulp therapy of cariously exposed permanent
exposure, the final location of the dentine bridge, and the quality of teeth be limited to children or young adults. Chronological age does
its formation ( 13) A distinction between failure of the pulp therapy not always reflect physiological age, and neither one should be seen
and failure of the overlying resoration must also be made as an absolute contraindication for vital pulp therapy in permanent
While there are indications for vital pulp therapy in young teeth (26).
permanent molars, it must be remembered that ultimately, none of Controversy exists as to whether the pulp should be re-entered
these procedures enjoy the success of complete root canal therapy after the completion of root development in the pulpotomised
( I 5) In the mature permanent tooth, pulpectomy and root filling tooth (22). Root canal therapy is recommended because of the
are the preferred treatment ( I 7) This is because firstly, pulpectomy chance that calcification would render the canals non-negotiable at
with a subsequent root filling has a high success rate (90-96%), and a future date. Recent research has shown that with good case
secondly, with the wound placed apically, inflammatory responses selection, a gentle, aseptic technique and careful placement of
to infection can radiographically be detected early When vita pulp calcium hydroxide onto the pulp, progressive calcification is an
therapy has been performed, problems may develop later and infrequent sequela of pulpotomy (22).

AUSTRALIAN ENDODONTICJOURNAL VOLUME 28 No. I APRIL 2002 33

Size Of Exposure interface, arrest pulp haemorrhage and will remove most dentine
The size of the carious pulpal exposure can influence the chips, bacteria and damaged pulp cells (6 I). Most importantly,
prognosis for vital pulp therapy. This is because generally the larger sodium hypochlorite will not cause damage to normal underlying
the exposure, the greater the bacterial penetration of the pulp (35). tissues (6 I ).
Also, the larger the exposure, the harder it is to seal. Long-term Choice Of Capping Material
success is certainly less predictable with large carious exposures
The choice of a capping material can influence the success of vital
than with small carious exposures (60). It has been proposed that
pulp therapy (35). Calcium hydroxide has been the gold standard
vital pulp therapy be limited to exposures less than 2 mm in
for direct pulp capping since the 1930s (6 I). This opinion has been
diameter (35).
based on the premise that calcium hydroxide was unique in its
State Of The Pulp ability to stimulate dentine bridge formation. More recently it has
been shown that many materials are biologically compatible against
The inflammatory status of the cariously exposed pulp is a major
exposed pulps and permit an environment that is conducive to
determining factor in the success of vital pulp therapy. The success
dentine bridge formation ( I 6, 6 I , 62). The ideal medicament for
of vital pulp therapy is dependent upon the ability of the pulp to
pulp dressing after pulpotomy should be non-toxic, and possess
recover from its inflammatorystate (I). Ideally, the status of the pulp
antimicrobial activity and an anti-inflammatory potential to control
should be known before therapy is started (39). The diagnosis
pre-existing inflammatory states and surgically induced inflammation
of pulpal inflammatory status is based on subjective signs and
(34). Currently available agents possess two of these three require-
symptoms, which have been shown to be inconsistent, unreliable
ments but none include all three. Cox and associates (62),
and do not correlate well with actual histologic data ( 19, 20). Mass
investigated the biocompatibility of silicate cement, zinc phosphate
and Zilberman (35) proposed that an ultimate pulpal diagnosis be
cement, amalgam and composites on monkey pulps, with and
made immediately after removing 2-3 mm of the pulp during a
without an additional surface seal of zinc oxide-eugenol. Their
partial pulpotomy procedure. A continuously bleeding pulp wound
results indicate that the healing of dental pulp exposures is not
would contraindicate vital pulp therapy. A success rate of 9 I .4%
dependent on the type of pulp capping material, but is related to the
was achieved at a minimum of 12 months following partial
capacity of these materials to prevent bacterial leakage. Even inert
pulpotomy in cariously exposed young permanent molars using this
materials such as Teflon@, show pulpal healing when used as a
criteria (35). Mass et al (29) proposed that due to the difficulty in
direct pulp capping material, as long as bacterial contamination is
accurately diagnosing pulp status, vital pulp therapy in cariously
eliminated ( I 8).
exposed young, vital permanent teeth should only be carried out
Mineral trioxide aggregate (MTA) has been shown to prevent
when there are no symptoms at all. Because there is no single
dye and bacterial leakage and has a high level of biocompatibility
reliable technique of determining pulp status clinically, a careful
(63, 64). Pitt Ford et al(65) used MTA as a pulp capping material on
interpretation of multiple tests is the most reliable method (26).
I 2 mechanically exposed pulps of monkeys and all but one showed
In general, clinicians agree that radiographically demonstrable
pulpal healing and dentine bridge formation adjacent to the pulp.
periapical involvement is always associated with total pulp necrosis
Torabinejad and Chivian (63) speculate this is due to MTPs sealing
or irreversible pulpitis (22). The first recommended treatment in
ability, biocompatibility,alkalinity, or other properties associated with
irreversible pulpal pathological conditions is root canal therapy or
this material. Based on these results, MTA has been considered as
extraction. Caliqkan (2) showed that this irreversible pulpitis may be
a suitable pulp capping material (63-65).
limited to the coronal pulp, because vitality of the radicular pulp and Anti-inflammatory agents have been examined but to date all
resolution of radiographic periapical involvement after full coronal are far too toxic or ineffective (34). Anti-inflammatory compounds
pulpotomy with calcium hydroxide dressing was achieved. The used in general medicine, such as Tetrandrine, have been studied
dangers of dystrophic calcification of the root canals and prevention and whilst they have shown less inflammation than other anti-
of later root canal treatment, if necessary, must be considered with inflammatory agents such as corticosteroids, no long-term data exist
use of this technique. (34). Corticosteroids have been tried and have shown reasonable
Extra-Pulpal Blood Clot short-term success, but again, no favourable long-term results exist
(34).
Stanley (36) concluded that the control of bleeding and the Total etch techniques with resin bonding have shown mixed
contact of calcium hydroxide with pulp tissue seems to have an results (66-68). Short-term experiments have shown that modern,
influence on the success of the procedure. Matsuo et al (38) resin-based composite systems may be as effective as calcium
reported a significantly higher incidence of failures when the pulps hydroxide (67). Total cavity etching with 10% phosphoric acid
showed heavy bleeding dc-ing the procedure, compared with seems to be safe for the exposed pulp, but 35% phosphoric acid
moderate or poor bleeding. Excessive bleeding usually indicates a may be disastrous (66-68). The cytotoxicity of the resin-based
hyperaemic pulp with little chance of recovery (60). If clinical composites and the temperature rise during polymerisation seems
success is expected, bleeding from exposed pulp tissue should be not to be of concern, but microleakage, sensitisation and allergic
minimal and stop soon after the exposure (60). Persistence of the reactions may pose problems (67). Pulp capping with resin-based
coagulum-clot has been demonstrated as detrimental to pulp composites is promising, but long-term research is mandatory
healing (61). The blood clot or its degradation products may before the method can be recommended (66, 67).
interfere with healing and act as a bacterial substrate, as well as Lederrnix@ (Lederle Pharmaceuticals, Cyanamid GmbH,
preventing the action of the capping material on the pulp (26). It Wolfratshausen, Germany), a combination of an antibiotic and a
must be removed before any definitive seal is placed. The presence corticosteroid, has been proposed as a pulp placement material
of dentine chip fragments, dead cells, bacteria and restorative (70). It was recommended that Ledermix be placed directly on the
material particles in the wound site will also be detrimental to pulp radicular pulp following full coronal pulpotomy of traumatically or
healing (6 I). Five percent sodium hypochlorite solution will cariously exposed vital teeth (70). This proposal was based on
chemically amputate the blood coagulum at the exposure-pulp evidence that Ledermix will not induce a calcific bridge but will allow

34 AUSTRALIAN ENDODONTICJOURNALVOLUME 28 No. I APRIL 2002

dentinogenesis to continue around the radicular pulp. This is a and hard tissue repair occurred when a surface seal preventing
temporary procedure to aid in apexogenesis before root canal marginal leakage was placed over the restoration. Without this
treatment is begun. Ledermix cementB, a compound containing surface seal, severe pulpal inflammation and necrosis were noted,
zinc oxide, eugenol and calcium hydroxide, as well as an antibiotic with bacteria often found at the pulp-restoration interface. Barthel
and corticosteroid, has shown some promise as a pulp capping et al ( 14) found that placement of a definitive restoration within the
material (7 I , 72). Concern has been expressed though, that the first two days after carious pulp exposure contributed significantly to
corticosteroid agent, triamcinolone, may suppress local repair as the survival rate of these teeth. Partial pulpotomy improves pulp
well as inflammation (73). Hume and Testa-Kenney (7 I ) showed sealing by creating a retentive cavity for the capping and restorative
that 70% of the steroid is released in the first 24 hours after direct material (35).
placement on the pulp and that during this period, steroid con- The long-term prognosis and the ability to restore a tooth are
centration is at a level that would be expected to reduce local the over-riding factors when assessing whether vital pulp therapy
inflammation and local repair. However, this inhibitory effect is likely should be undertaken ( I 5). The amount of crown destruction
to have little effect on long-term healing as the steroid concentra- usually associated with a pulp exposure in an immature molar
tion drops to below an effective inhibitory concentration after 24 means that the tooth involved would require significant restorative
hours (7 I ). maintenance in the long term. Extractionand orthodontic treatment
Calcium hydroxide, which accelerates the deposition of a may be preferable.
dentine bridge and possesses antibacterial properties, is the material
of choice (74). Schroder (75) proposed that the firm, limiting Conclusion
necrosis caused by calcium hydroxide irritates the pulp, which
stimulates the pulpal cells to defence and repair, and the firm It is beneficial to preserve the vitality and health of an exposed
necrosis may also induce minerals from the tissue fluid to calcify. Veis pulp rather than replace it with a root filling material following pulp
(76) suggests that the necrotic layer presents a surface to which the exposure. A vital, functioning pulp is capable of initiating several
pulp cells attach and polarise, and then begin to express their defence mechanisms to protect the body from bacterial invasion
odontoblastic potential. Calcium hydroxide is generally used in one ( 14). Pulp exposure without involvement of microorganisms can
of three forms: as a powder, as a paste mixed with saline or clearly be overcome by repair mechanisms, such as dentinal
aqueous methylcellulose, or incorporation into a setting cement. bridging. There is no consensus on the survival rate of formerly
Kirk et al (77) showed that calcium hydroxide in paste form exposed pulps. Observation time, judgement criteria, pulpotomy/
produces reparative dentine sooner than in cement form, but pulp capping technique and most importantly, pulpal status at the
proposed that the cement form may be a more effective physical time of treatment, vary to a great extent among the studies. This is
barrier to bacterial ingress than the softer, porous paste form. shown in the success rate of vita pulp therapy of cariously exposed
Of the many calcium hydroxide cements, Dycal@(L.D. Caulk, permanent teeth varying between 13% and 93% ( I 0, 14). Among
Dentsply Int. Inc., Milford, DE, USA), and LifeB (Kerr Manuf. Co., the methods for preservation of a cariously exposed pulp, partial
Romulus, MI, USA), have been shown to be satisfactory and pulpotomy has yielded the highest success rate in young teeth
associated with dentine bridge formation across pulp exposures (3, 10).
(76, 78-80). Heys et al (74) showed that when bacterial micro- From the clinical point of view, the vitality of the dental pulp of an
leakage occurred around an unlined amalgam restoration, the aged person appears to be weaker than that of a young person
complex, setting calcium hydroxide formulations such as Dycal and ( I 2). In the future, more efficient wound dressings containing per-
Life, were associated with a higher incidence of pulpal healing, haps growth factors, together with improved local antimicrobial and
when compared with the non-setting calcium hydroxide formu- anti-inflammatory materials will combine with the improved sealing
lations. The non-setting, simple calcium hydroxide formulations ability of restorative materials, to preserve the vitality of the cariously
were more consistent in promoting dentine bridge formation exposed pulp in permanent teeth.
where bacterial microleakage was controlled (74). A dentine bridge Major limitations in the success of vita pulp therapy in cariously
generally forms directly against the capping material when calcium exposed permanent teeth exist. The lack of predictability and long-
hydroxide cements such as Dycal and Life are used (79, 80), but term success greatly influence decision-making, The decision-
forms at a distance from the capping material with a necrotic layer making itself is unreliable primarily due to the difficulty of accurately
between the two, when the paste or powder formulations are used diagnosing the ability of the pulp to repair.
(78). This may be due to the increase in inflammation that is The success demonstrated in various clinical studies justifies
produced by the more alkaline paste and powder formulations. recommending partial pulpotomy as a treatment option for asymp-
Stanley (36) proposes that the negative side effects of inorganic tomatic, cariously exposed, young permanent molars (29).
calcium hydroxide such as dystrophic calcification have been However, due to the lack of long-term success, these cases have to
eliminated in the lower pH, hard-setting, commercial calcium be monitored on a regular basis to avoid unnoticed necrosis of the
hydroxide cements and recommendstheir use over the powder or pulp with invasion of bacteria into the root canal system.
paste preparations.

Bacterial Contamination
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