VPT
Vital Pulp Therapy in Permanent Teeth
Case selection, intra-operative pulp assessment, controlled tissue removal, sealing, and review.
Permanent teeth · clinical protocol
Preserve the pulp that can still recover.
A preoperative diagnosis of irreversible pulpitis describes the patient's clinical presentation, but it cannot reveal the condition of every millimetre of pulp. Inflammation can be concentrated coronally while the radicular pulp remains vital and capable of repair. Treatment therefore continues the diagnosis after exposure, when the tissue can be inspected directly.
VPT succeeds when the right tooth is selected, the pulp is reassessed after exposure, diseased tissue is removed to a controllable level, asepsis is maintained, and the tooth is sealed and reviewed.
Open the chairside quick guide01 · Select the tooth
Case selection carries more weight than the material.
Begin with the whole tooth, not the exposure you expect to find. The tooth must be restorable, isolatable, and worth maintaining. The periodontal prognosis, crack status, remaining structure, and planned restoration all belong in the VPT decision.
Symptoms matter, but they do not map the histology of the entire pulp. Cold and electric testing are sensibility tests, not direct measures of blood supply. Combine them with the pain history, examination, and radiographs. Explain before treatment that direct observation may confirm VPT, require a deeper pulpotomy, or lead to root-canal treatment.
Patient and pain
Record provoked, spontaneous, nocturnal, and lingering pain, previous episodes, analgesic use, medical factors, expectations, and ability to attend review.
Pulp and apical tests
Compare cold and EPT responses with control teeth. Add percussion, palpation, mobility, periodontal probing, and crack assessment.
Imaging and caries depth
Use a diagnostic periapical radiograph to assess the dentine barrier, root maturity, resorption, and apical status. Additional imaging must answer a defined question.
Restorability and isolation
Confirm that caries can be removed, the tooth can be isolated, sound peripheral margins can be created, and a durable restoration is achievable.
Consent and conversion
Discuss indirect pulp treatment, direct capping, partial or full pulpotomy, root-canal treatment, extraction, and the possibility of changing course after the pulp is seen.
Do not proceed with VPT when the tooth cannot be predictably restored or isolated, or when necrosis, purulence, swelling, a sinus tract, infection-related apical involvement, or an uncertain diagnosis makes pulp preservation indefensible.
02 · Choose the route
The radiograph starts the plan. The exposed pulp can change it.
Deep caries leaves a discernible radiographic dentine barrier. Extremely deep caries reaches the full thickness of dentine, so exposure is expected. Keep that distinction clear: it separates a strategy designed to preserve the barrier from one designed to expose and assess the pulp.
Deep caries, normal pulp or reversible pulpitis
When a distinct radiographic dentine barrier remains, selective caries removal and indirect pulp treatment can avoid exposure while firm peripheral dentine supports a reliable seal.
Carious exposure with healthy, controllable tissue
Direct pulp capping may be considered in a carefully selected exposure. Partial pulpotomy removes superficial inflamed tissue and often gives a cleaner biological endpoint.
Extremely deep caries or significant symptoms
Complete caries removal permits direct assessment. If the pulp is vital, the apical tissues are suitable, and bleeding becomes controllable, full pulpotomy may preserve the radicular pulp.
Vital permanent tooth after trauma
Exposure size, contamination, treatment delay, root maturity, and associated luxation injuries guide treatment. Current guidance favours partial or full pulpotomy over direct capping in many traumatic exposures.
The tissue does not reach a controllable endpoint
Necrosis, purulence, infection-related apical involvement, or bleeding that remains uncontrolled after appropriate pulpotomy requires a new plan: pulpectomy, root-canal treatment, or referral.
Root maturity is one part of selection. Current permanent-tooth evidence supports VPT in both immature and mature teeth when the diagnosis, tissue findings, isolation, and restoration are suitable.
03 · Perform under control
Keep the caries phase separate from the pulp phase.
The exposed pulp is a surgical wound. Rubber dam, disinfection, magnification, sterile instruments, and sterile coolant are required parts of the treatment. A caries-contaminated bur should not enter tissue that the clinician intends to preserve.
Isolate and disinfect
Achieve profound anaesthesia. Place rubber dam before caries removal and disinfect the isolated crown, clamp, and adjacent dam.
Create sound margins
Remove caries according to the selected route. Establish clean peripheral dentine that can support a durable adhesive seal.
Change to the pulp set
Before entering the wound, change to sterile burs, instruments, and sterile coolant. Do not carry a caries-contaminated bur into the pulp.
Inspect the tissue
Use magnification and strong light. Look for uniformly vital tissue, focal necrosis, purulence, clot, debris, and the character of bleeding.
Remove tissue with purpose
Resect only to a level where the remaining pulp appears healthy and the wound can be controlled. Let the tissue determine depth, not a memorised number of millimetres.
Test the endpoint
Use sodium hypochlorite according to the clinical protocol and reassess. A clean, controllable wound can receive cement; persistent uncontrolled bleeding changes the treatment.
04 · Reassess after exposure
Bleeding is information.
Georg Benjamin describes pulpotomy as a continuation of diagnosis. Remove inflamed coronal tissue, then look again. A pulp that bleeds and becomes controllable presents a different biological situation from tissue that is necrotic, purulent, or continues to haemorrhage after an appropriate full pulpotomy.
Use time as a checkpoint and choose the depth of tissue removal from the wound itself. If a partial pulpotomy does not expose uniformly vital, controllable tissue, extend it deliberately. A full pulpotomy removes the chamber pulp to the canal orifices and often provides a clearer field for assessing the radicular pulp.
Direct observation is the second diagnostic stage. Confirm that tissue is vital and that necrosis, purulence, clot, and debris are absent from the interface.
Apply sodium hypochlorite by passive irrigation or a lightly moistened sterile pellet. Use gentle pressure and follow the practice protocol for concentration and handling.
At two-minute checkpoints, remove the pellet and inspect. Extend a partial pulpotomy only when the observed tissue condition requires further removal.
The 2025 AAPD guideline associates haemostasis within six minutes with higher pulpotomy success. If bleeding remains uncontrolled after full pulpotomy, stop VPT and change the plan.
Place calcium-silicate cement only after the wound is clean and controlled. Cement cannot compensate for residual necrotic tissue, persistent haemorrhage, contamination, or an uncertain endpoint.
05 · Protect the result
The restoration is part of the pulp treatment.
Once the tissue endpoint is accepted, protect it without delay. Material choice matters, but it follows case selection, asepsis, tissue assessment, and haemostasis. Place a validated hydraulic calcium-silicate cement according to its instructions and avoid staining formulations in the aesthetic zone.
Coronal leakage can undo a well-executed pulpotomy. Complete a durable restoration at the same visit where feasible, using compatible materials and the manufacturer's setting and overlay instructions. Plan cuspal protection according to the remaining tooth structure and fracture risk.
Protect the pulp
Place a validated hydraulic calcium-silicate cement directly over the clean, controlled wound. Follow its IFU for thickness, moisture, setting, overlay, and use a non-staining material in an aesthetic area.
Definitive restoration
Protect the cement with compatible materials and create a well-sealed definitive restoration, preferably at the same visit.
Record and review
Record the diagnosis, procedure, haemostasis time, material, lot number, restoration, and baseline image. Review symptoms and function, then use clinical and radiographic findings to judge healing.
06 · Review what was preserved
Success is a functioning tooth without clinical or radiographic disease.
Book the review before the patient leaves. A practical schedule includes clinical review at six months, clinical and radiographic review at 12 months, then further review according to the case and current guidance. Earlier reassessment is required when symptoms develop.
Findings consistent with success
The tooth is comfortable and functional. There is no swelling, sinus tract, pathological tenderness, new apical disease, or internal resorption. Immature roots continue to develop.
Findings that need prompt reassessment
Persistent or worsening spontaneous pain, swelling, sinus tract, tenderness, loss of function, new apical change, internal resorption, or failure of the coronal seal.
Interpret sensibility carefully
Cold and EPT may help after direct capping or partial pulpotomy. A full pulpotomy may not respond even when the radicular pulp remains vital, so symptoms, examination, and radiographs carry more weight.
Evidence boundary
Use the evidence without pretending every question is settled.
The 2025 AAPD guideline supports VPT in selected permanent teeth and gives the clearest current treatment branches. Several recommendations remain conditional because certainty is low. The 2021 AAE statement explains why preoperative symptoms cannot describe the condition of the entire pulp and why direct observation matters. The ESE position statement provides the deep-caries framework used in this guide.
The Georg Benjamin discussion adds a useful clinical frame: pulpotomy can preserve radicular pulp in teeth that were once sent directly to pulpectomy, but only when the operator can inspect the tissue, reach a controllable endpoint, seal the tooth, and accept that some cases will still require root-canal treatment.
Chairside download
Keep the condensed protocol in the surgery.
The three-page guide condenses case selection, the operative sequence, haemostasis assessment, restoration, review, and the clinical exit points.