Vital Pulp Therapy
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Direct answer
Vital pulp therapy keeps a reversibly inflamed pulp alive instead of removing it, through a graded ladder: indirect pulp capping (now framed as selective caries removal, leaving affected dentine over the pulp), direct pulp capping of a pinpoint clean exposure, and pulpotomy amputating inflamed coronal pulp to healthy tissue. Success hangs on three variables the exam expects you to defend — diagnosis (reversible pulpitis only), material (calcium hydroxide's dentine bridge versus the mineral trioxide aggregate family's superior sealing), and the final restoration, because a leaking margin kills every pulp on the ladder. The young tooth with an open apex is the ideal candidate; the cariously exposed mature tooth is the frequent failure.
What you must remember
- Indications demand reversible pulpitis: sharp pain provoked by stimuli and gone within seconds, no spontaneous or nocturnal pain, normal periapical radiograph — anything else is pulpectomy territory.
- Calcium hydroxide (pH about 12.5) necrotises a thin superficial layer and stimulates a dentine bridge, but the bridge contains tunnel defects; MTA sets in the presence of moisture, seals better and is the current standard, though it sets over hours and may grey the crown.
- Biodentine and similar tricalcium-silicate cements set in roughly 10-15 minutes as "dentine replacement" beneath composite.
- Direct pulp cap is for small, clean, uncontaminated exposures (mechanical or traumatic); a carious exposure in a mature tooth with symptoms generally proceeds to root canal treatment.
- The Cvek (partial) pulpotomy removes 1-2 mm of traumatically exposed pulp in a young permanent incisor with a high-speed diamond under copious irrigation — reported success exceeds ninety per cent.
- Stepwise excavation leaves caries-affected dentine over the pulp, seals for months (classically re-entered between roughly 3 and 12 months), and avoids exposure in deep caries; full re-entry and restoration completes the protocol.
- Haemostasis is the intraoperative decision gate: bleeding that cannot be controlled within a few minutes with a damp cotton pellet signals irreversible inflammation — convert to pulpotomy or pulpectomy.
- The coronal seal decides outcomes: same-visit definitive adhesive restoration, and a cusp-covering restoration for posterior teeth, are parts of the pulp therapy, not afterthoughts.
Treating a fractured young incisor
A nine-year-old trips at school and fractures the right central incisor with a pinpoint pulpal exposure, three hours old. The apex is open, the fracture margin is clean, and the pain is stimulus-provoked only — an ideal Cvek pulpotomy case. Under rubber dam, amputate 1-2 mm of pulp with a small diamond bur under copious water spray to reach healthy tissue. Control bleeding with a damp dilute-sodium-hypochlorite pellet — bleeding that stops cleanly confirms health; persistent ooze forces a deeper pulpotomy. Place a thin layer of white MTA or Biodentine over the wound, cover it with a flowable glass ionomer to protect the tricalcium silicate while it hydrates, and restore the crown with bonded composite at the same visit. Review through the first year: continued root development, a positive vitality response and absence of symptoms constitute success — apexogenesis achieved chairside. Contrast the adult deep-caries case: selective removal leaving firm affected dentine, glass ionomer lining, definitive restoration — the same principle, that a healthy pulp given a seal heals itself.
Where students slip
The material comparison is where candidates recite marketing instead of mechanism: calcium hydroxide works through controlled necrosis and bridge formation, MTA through a sealed, bioactive surface — and saying the bridge has tunnel defects is the sentence that earns the mark. The second slip is patient selection: direct pulp capping pitched at a carious exposure in a 45-year-old with night pain has chosen the failure arm of every study. The third is forgetting the restoration: examiners routinely ask "what decides the success of a pulp cap" and expect "the seal of the final restoration" before any material name. Finally, terminology matters: "selective caries removal" is the modern framing of indirect pulp therapy, and it is why aggressive excavation near the pulp is now discouraged.
Frequently asked questions
Compare calcium hydroxide with MTA as pulp-capping agents.
Calcium hydroxide (pH about 12.5) forms a dentine bridge with tunnel defects; MTA seals better and shows higher success, at the cost of slow setting and discolouration.
When is direct pulp capping contraindicated?
Carious exposures in mature teeth, uncontrollable bleeding, any history of spontaneous pain, and teeth already needing full coverage.
What is the Cvek pulpotomy?
Amputation of 1-2 mm of exposed pulp after traumatic fracture in a young permanent tooth — success above ninety per cent, preserving apexogenesis.
What happens at re-entry in stepwise excavation?
After months of sealed arrest, the sclerotic affected dentine is excavated and the tooth definitively restored — the second stage distinguishing stepwise from permanent selective removal.
Why is the final restoration part of vital pulp therapy?
Microleakage along a defective margin re-infects the wound; the adhesive or cuspal seal is as decisive as the dressing.
Which signs make you abandon vital pulp therapy mid-procedure?
Persistent bleeding from the amputation site, purulent exudate or necrotic tissue — each converts the plan to pulpectomy.