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Step-by-Step Vital Pulp Therapy: Evidence-Based Clinical Protocol

Vital pulp therapy clinical case showing pulp exposure control and MTA placement in a permanent tooth
You control the bleeding.
The pulp still looks vital.
Yet you hesitate — is this really a case for vital pulp therapy, or are you delaying the inevitable RCT?

Vital pulp therapy (VPT) can successfully preserve pulp vitality in permanent teeth — even in adults — but only when diagnosis and clinical execution are brutally precise. When done right, adult pulpotomy can maintain natural vitality, support continued root development, and significantly extend the tooth's lifespan.
Step-by-step clinical case of vital pulp therapy showing caries removal, pulp exposure management, MTA application, and final restoration.

Why Vital Pulp Therapy?

Goal: Preserve healthy pulp tissue, encourage natural healing, and avoid full root canal treatment (RCT).

Indication: Permanent teeth with carious or traumatic pulp exposure but with no signs of irreversible pulpitis or periapical pathology.

Key Benefit: Maintains vitality for continued root maturation, especially important in immature permanent teeth.

Step 1: Proper Diagnosis

Step 1 of vital pulp therapy showing proper diagnosis with clinical examination and radiographic assessment.

A correct diagnosis is critical. Evaluate:

1- Pulp vitality (cold/electric pulp tests).

2- Symptoms: No spontaneous or lingering pain.

3- Radiographs: Absence of periapical pathology.

Only proceed with VPT when the pulp is healthy or reversibly inflamed.

Step 2: Isolation

Step 2 of vital pulp therapy showing rubber dam isolation to achieve a clean and dry operative field.

Isolation is mandatory to prevent contamination:

Best approach: Place the rubber dam before any procedure.

Alternative: Remove peripheral caries to create clear margins, then place the rubber dam.

read this guide about Rubber Dam Isolation in Dentistry

Step 3: Caries Removal

Step 3 of vital pulp therapy showing selective caries removal under rubber dam isolation to preserve pulpal vitality.
  1. Most cases present with a soft dentin layer (lacerated dentin).
  2. Use a sharp excavator to remove the soft dentin quickly.
  3. Switch to a sterile bur for controlled removal.

Tip: Stop just before pulp exposure, then apply full-strength NaOCl on cotton to reduce bacterial load.

Step 4: Pulp Chamber Access

Step 4 of vital pulp therapy showing conservative pulp chamber access to expose the coronal pulp while preserving tooth structure.
  1. Use a clean, sterile bur to complete removal of coronal pulp tissue.
  2. Alternate between sharp excavators and burs as needed.
  3. Irrigate with 2.5% NaOCl for antibacterial effect, but avoid direct pressure on pulp tissue to prevent irritation.

Sterility Tip: Wipe the handpiece with alcohol every time you change the bur. Keep contaminated instruments separate and disinfect the bracket table with alcohol.

Step 5: Controlling Bleeding

Step 5 of vital pulp therapy showing control of pulpal bleeding using gentle pressure with a saline-soaked cotton pellet to achieve hemostasis before pulp capping.

Controlling bleeding is essential for success:

  1. Place a cotton pellet with 2.5% NaOCl in the cavity for 1 minute.
  2. Irrigate with saline.
  3. Apply gentle pressure with a saline-soaked cotton pellet for 2–3 minutes.

If bleeding persists beyond 8–10 minutes:

Step 6: Pulp Capping & Sealing

Step 6 of vital pulp therapy showing pulp capping with biocompatible material and immediate coronal sealing to protect the pulp and prevent bacterial leakage.

Once bleeding stops:

1- Dry the cavity.

2- Place MTA (Mineral Trioxide Aggregate) or bioceramic putty (BC putty) over the pulp.

Vital Pulp Therapy for Permanent Teeth (VPT Guide)

3- Seal with a well-adapted coronal restoration to prevent microleakage.
Vital Pulp Therapy for Permanent Teeth (VPT Guide) coronal seal

watch this video of vital pulp therapy | clinical steps

Key Tips for Successful VPT

1- Work under magnification if possible.

2- Always maintain a sterile field.

3- Do not over-instrument or irritate pulp tissue.

4- Immediate sealing with a high-quality coronal restoration is crucial.

When to Switch to Endodontic Treatment?

1- Uncontrollable bleeding after 8–10 minutes.

2- Persistent severe pain or signs of irreversible pulpitis.

3- Radiographic evidence of periapical involvement.

Vital pulp therapy is a conservative, biological approach to preserving natural tooth vitality, particularly beneficial for young patients with immature roots. Proper case selection, isolation, and careful technique are the keys to long-term success.

References

  • Duncan HF, et al. Management of deep caries and the exposed pulp. International Endodontic Journal. 2019;52(7):923–934.
  • American Association of Endodontists (AAE). AAE Position Statement on Vital Pulp Therapy. 2021 (PDF).
  • Duncan HF. Present status and future directions—Vital pulp treatment. (Review) International Endodontic Journal / related review 2022.
  • Pinto KP, et al. Success rate of direct pulp capping on permanent teeth: systematic review / meta-analysis (2024). (PMC).
  • Komora P, et al. Comparison of bioactive material failure rates in vital pulp therapy (Scientific Reports / 2024).
  • Misra R, et al. Efficacy of Mineral Trioxide Aggregate Versus Biodentine (prospective trials / 2025).
  • Saini A, et al. Effect of Sodium Hypochlorite concentration on outcome of pulpotomy — systematic review (2024).
  • Munir A, et al. Wound lavage in studies on vital pulp therapy (review on irrigation/NaOCl usage). 2020.
  • American Academy of Pediatric Dentistry (AAPD). Use of Vital Pulp Therapies in Primary Teeth — guideline (2024)
  • Mohammadi Z, et al. Evaluation of MTA cements as coronal barrier. (importance of coronal seal / microleakage literature). PMC.
  • Zhu L, et al. Full pulpotomy versus root canal therapy in mature teeth — criteria for exclusion when bleeding uncontrolled beyond ~10 min. BMC Oral Health 2024.
  • Kahler B, et al. Vital pulp therapies in permanent teeth — review / guidance (2023). (notes on haemostasis timing and clinical decision).

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