Fig. 1

The first step in vital pulp therapy is to evaluate the situation first of  all taking the history from patient(what,when and how) the patient should describe the situation precisely specially the severity of pain.

The patient should not refer spontaneous pain to the tooth, the tooth should response normally to thermal test, there should no be any swelling, tenderness or sinus tract present, on radiograph there should not be evidence of caries entering into the pulp chamber and no signs of necrosis.

In this case the patient referred severe pain on cold, but after multiple tests there was no swelling or tenderness and the  tooth responded normally to thermal test.

The radiograph shows a big carious lesion extended to the pulp chamber but all the other things are normal in the apical area.   

Fig. 2

After caries removal there was to points of exposures: here the clinician can choose between direct pulp capping or vital pulp therapy. I picked the vital pulp therapy here because the exposures were large and I wanted to minimize the amount of infected pulp presents, so I decided to cut the coronal pulp and continue with VPT.

You can see here that the pulp is pink and still attached with present of some blood vessels that give the impression of the pulp is still vital.

No severe bleeding noticed after the exposure.

Notice: the caries removal should be done under rubber dam to reduce the chances of getting infection from saliva or mouth.

Fig. 3

After exposing pulp by removing chamber roof we can see here that pulp looks healthy pink with controllable bleeding which my be induced by bur while removing the roof causing a pulp injury.

Note: all the steps after caries removal should be done with sterile tools even burs should be changed not the same bur used for caries removal.

Fig. 4

Here I did cut the coronal pulp using Endo-Z bur or you can use any sterile tool that give you a good cut without damaging the radicular rest of the pulp.

See the bleeding still few and controllable. 

Fig. 5

In this step I used 5% NaOCl to for 3 mins to get a blood clot and disinfection.

You can see the clots already formed in the NaOCl without blood flushing that interfere with its formation.  

Fig. 6

After bleeding control with NaOCl I used normal saline to flush and rinse the chamber.

The pulp looks healthy, attached and normal after drying: at this point we can cover this tissue with some biocompatible material to induce it to form a dentin bridge and save its vitality.

Fig. 7

This is the final picture with bioceramic putty covering the pulp tissue.

Note:we should be sure that we cover the entire pulp tissue inorder to leave no chance for leakage after this step.

Fig. 8

In this case, the patient came with sever pain (as he described it) even he can’t sleep at night. This should be considered as a sign for irreversible pulpitis ,but after examination there were no tenderness, no pocket, no swelling and the tooth responded normally to thermal tests.

After caries removal there were three sites of exposure, so I decided to go with vital pulp therapy here (pulpotomy) instead of direct pulp capping to get better chances in removing infected pulp that may be affected by bacteria drained from the sites of exposure, there was slight bleeding from the exposures with a pink attached pulp tissue.

Fig. 9

You can see here after chamber roof removal that the pulp tissue looks healthy.

Fig. 10

Removal of the coronal pulp with endo-z bur and placing NaOCl for bleeding control.

Fig. 11

Rinsing with normal saline and dry with sterile cotton, looks a healthy tissue now its time to cover with biomaterials.

Fig. 12

The entire chamber covered with bioceramic putty.

Fig. 13

Radiographic image shows that there is still some roof the protecting the pulp tissue underneath it, with receded distal pulp horn that reveals a defence mechanism of the pulp against the irritation caused by carious lesion.     

Fig. 14

About the author:

graduated from basra dental collage-Iraq 2015-2016


Vital pulp therapy shows great results in preserving pulp function and vitality in teeth affected by severe injury or decays.

A careful pre operative evaluation of the case and the adherence to strict protocols, together with the use of biocompatible materials, can allow the dentist to preserve the vitality of pulp with a minimally invasive procedure.


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