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Year: 2019

European Society of Endodontology position statement: Management of

deep caries and the exposed pulp

Duncan, H F ; Galler, K M ; Tomson, P L ; Simon, S ; El‐Karim, I ; Kundzina, R ; Krastl, G ;

Dammaschke, T ; Fransson, H ; Markvart, M ; Zehnder, M ; Bjørndal, L

Abstract: This position statement on the management of deep caries and the exposed pulp represents the
consensus of an expert committee, convened by the European Society of Endodontology (ESE). Preserving
the pulp in a healthy state with sustained vitality, preventing apical periodontitis and developing minimally
invasive biologically based therapies are key themes within contemporary clinical endodontics. The aim
of this statement was to summarize current best evidence on the diagnosis and classification of deep
caries and caries-induced pulpal disease, as well as indicating appropriate clinical management strategies
for avoiding and treating pulp exposure in permanent teeth with deep or extremely deep caries. In
presenting these findings, areas of controversy, low-quality evidence and uncertainties are highlighted,
prior to recommendations for each area of interest. A recently published review article provides more
detailed information and was the basis for this position statement (Bjørndal et al. 2019, International
Endodontic Journal, doi:10.1111/iej.13128). The intention of this position statement is to provide the
practitioner with relevant clinical guidance in this rapidly developing area. An update will be provided
within 5 years as further evidence emerges.

DOI: https://doi.org/10.1111/iej.13080

Posted at the Zurich Open Repository and Archive, University of Zurich

ZORA URL: https://doi.org/10.5167/uzh-181694
Journal Article
Accepted Version

Originally published at:

Duncan, H F; Galler, K M; Tomson, P L; Simon, S; El‐Karim, I; Kundzina, R; Krastl, G; Dammaschke,
T; Fransson, H; Markvart, M; Zehnder, M; Bjørndal, L (2019). European Society of Endodontology
position statement: Management of deep caries and the exposed pulp. International Endodontic Journal,
52(7):923-934.
DOI: https://doi.org/10.1111/iej.13080
EUROPEAN SOCIETY OF ENDODONTOLOGY POSITION STATEMENT:
MANAGEMENT OF DEEP CARIES AND THE EXPOSED PULP

European Society of Endodontology (ESE) position stement developed by: Duncan HF1,
Galler K2, Tomson PL3, Simon S4, El-Karim I5, Kundzina R6, Krastl G7, Dammaschke T8,
Zehnder M9, Bjørndal LB10

Further additions comments and consensus by: ESE Executive Board

Affiliations: 1Division of Restorative Dentistry, Dublin Dental University Hosptal, Trinity

College Dublin, University of Dublin, Ireland
2
3
School of Dentistry, University of Birmingham, St Chads Queensway, Birmingham, UK
4
Paris Diderot University, Paris 7, Paris, France
5
6
7
8
9
10
Cariology and Endodontics, Faculty of Health Sciences, University of Copenhagen, Nørre
Allé 20, Copenhagen, Denmark

Key words: dental pulp, caries, carious exposure, vital pulp treatment, pulp capping,
pulpotomy, pulpitis

Correspondence: Dummer PMH, CEO of the European Society of Endodontology, Postboks

1237 Vika, 0110 Oslo, Norway. (e-mail: [email protected]).

1
ESE-APPROVED DEFINITIONS AND TERMINOLOGY/GLOSSARY
Deep caries: Radiographic evidence of caries reaching the inner third or inner quarter of
dentine with a risk of pulp exposure.

Extremely deep caries: Radiographic evidence of caries penetrating the entire thickness of
the dentine with certain pulp exposure.

Selective caries removal:

Selective removal to soft dentine: Removal of peripheral carious dentine to hard
dentine, leaving soft dentine only on the pulpal aspect of the cavity.

Selective removal to firm dentine: Removal of peripheral carious dentine to hard

dentine, leaving firm/leathery dentine only on the pulpal aspect of the cavity. The
residual dentine should be resistant to hand excavation.

Non-selective caries removal: Complete removal of soft and firm carious dentine from the
periphery and central aspects of the cavity until hard dentine reached.

Vital pulp treatment (VPT): Minimally invasive strategies aimed at maintaining the vitality of
the pulp.
Indirect pulp capping: Application of a biomaterial onto a thin dentine barrier in a one-
stage selective caries removal technique.

Stepwise excavation: Application of a biomaterial onto a thin dentine barrier in a two-

stage selective caries removal technique, with re-entry after 6-12 months. First stage
involves selective caries removal to soft dentine and second stage to firm dentine.

Direct pulp capping: Application of a biomaterial directly onto the exposed pulp.
Class I: No preoperative presence of a deep carious lesion. Pulp exposure
judged clinically to be through sound dentine.
Class II: Preoperative presence of a deep carious lesion. Pulp exposure judged
clinically to be through a zone of potential bacterial contamination. Enhanced
operative protocol recommended.

Mini-pulpotomy: Removal of the superficial layer of the coronal pulp after pulp
exposure, application of a biomaterial directly onto the exposed pulp tissue.

Partial pulpotomy: Removal of the coronal 2-4 mm of pulp tissue after exposure, and
application of a biomaterial directly onto the exposed pulp tissue.

Full pulpotomy: Complete removal of the coronal pulp and application of a

biomaterial directly onto the pulp tissue at the level of the root canal orifices.

Pulpectomy: Total removal of the pulp from the root canal system followed by root
canal treatment.

2
ABSTRACT
This position statement on the management of deep caries and the exposed pulp represents
the work of an expert committee, convened by the European Society of Endodontology (ESE),
supported by consensus. The importance of preserving pulp vitality, preventing apical
periodontitis and developing minimally invasive biologically based therapies are key themes
within modern clinical endodontics. The aim of this statement is to summarise current best
evidence on the diagnosis and classification of caries-induced pulpal disease, as well as
indicating appropriate clinical management strategies for avoiding and treating pulp exposure
in permanent teeth with deep caries. In presenting the findings, areas of controversy, low
quality evidence and uncertainly are highlighted, prior to a series of short recommendations
being made for each area of interest. A recently published review article provides information
that is more detailed, and was the basis for this position statement (Bjørndal et al. 2018,
International Endodontic Journal). While, it is hoped that this evidence-based document will
provide the practitioner with relevant clinical guidance in this rapidly developing area, it is
likely that this position statement will be a relatively ‘fluid’ document, which will be updated
within 4 years as further evidence emerges.

3
INTRODUCTION
The destructive nature of conventional dental treatment and concerns of overtreatment and
the ‘restorative cycle’, have led the profession to promote minimally invasive biologically
based treatment strategies. This has resulted in a shift in the management of deep caries from
non-selective (complete) removal to selective (partial) removal, reducing the risk of pulp
exposure (Innes et al. 2016). Modern management strategies for the cariously exposed pulp
have seen the re-emergence and extension of vital pulp treatment (VPT) techniques such as
partial and complete pulpotomy. As the maintenance of pulp vitality and the prevention of
apical periodontitis are core values in Endodontics, these developments are of fundamental
importance to the members of the European Society of Endodontology (ESE). This position
statement reflects the current views of the society on these issues. It provides the practitioner
with recommendations regarding the diagnosis and treatment of deep caries and the exposed
pulp in permanent teeth based on current knowledge and literature.
This statement limits itself to the management of deep caries, further subdivided into
two radiographic categories, deep and extremely deep. This categorisation aims to quantify
the risk of pulp exposure, as well as potentially highlight a threshold for the onset of more
severe pulp inflammation (Reeves & Stanley 1966). Deep carious lesion has radiographic
evidence of caries reaching the inner third or quarter of dentine, but still with a visible zone
of translucent dentine between the carious dentine and the pulp, while an extremely deep
carious lesion penetrates the entire thickness of the dentine (Bjørndal 2018, Bjørndal et al.
2018). Caries is a microbial biofilm induced-disease, driven by a supply of fermentable
carbohydrates (Nyvad et al. 2013, Pitts et al. 2017). The resulting ecological shift creates an
acidogenic, cariogenic niche, which breaks down dental hard tissue to form a cavity
(Schwendicke et al. 2016). The global prevalence of caries remains high; however, the burden
of untreated caries is shifting from children to adults (Bernabé & Sheiham 2014, Kassebaum
et al. 2015). Caries also has a greater prevalence in patients from disadvantaged social groups
(Sengupta et al. 2017, Costa et al. 2018) and is costly to manage in industrialised and non-
industrialised countries (Peterson 2008, Listl et al. 2015). The aetiology of caries; however,
offers opportunities to manage the condition by modifying diet, improving oral hygiene and
application of fluoride (O’Mullane et al. 2016). Furthermore, if the biofilm is isolated from its
nutrient supply, the microbial ecology changes, this forms the basis of non-selective caries

4
removal techniques in which some of the bacteria remain after treatment (Bjørndal et al.
1997, Banarjee et al. 2017).
During the carious process, microbial penetration and release of bacterial by-products
migrate down the dentinal tubules leading to an inflammatory response of the pulp.
Odontoblasts, dendritic cells and pulpal fibroblasts (Farges et al. 2015) mediate this process.
Initially, a hyperaemic response occurs with a decline in cell numbers, flattening of the
odontoblast cell bodies (Bjørndal 2018) and immigration of lymphocytes and plasma cells to
the affected area (Ricucci et al. 2014). Although pulpitis will accompany the carious process
throughout its progression, it is not until the carious infected demineralized dentine is close
to the pulp, that the inflammatory response becomes severe and there is a risk of bacteria
entering the pulp (Reeves & Stanley 1966, Mjör & Tronstad 1972). However, pulp tissue has
an innate ability to repair if the challenge is removed and the tooth is suitably restored (Mjör
& Tronstad 1974). Preservation of pulp vitality maintains the pulp’s developmental (primary
and secondary dentinogenesis), defensive (tertiary dentinogenesis) and proprioceptive
response. Appropriate caries management within VPT aims to remove the microbial irritation
and prevent new bacterial insult by placing a sealing dental biomaterial to protect exposed
dentine and pulp from external stimuli. Therapeutically, VPT is quicker, less technically
demanding and has less unwanted effects such as discoloration, fracture or residual periapical
inflammation than root canal treatment (RCT). Conversely, it can be argued that VPT and
management of deep carious lesions is very sensitive to ongoing bacterial contamination
making the technique ´biologically demanding´, often requiring magnification and expertise
to treat. Thus, the overarching aims of caries management and VPT are to manage bacterial
contamination, arrest caries progression, stimulate tertiary dentine formation, and promote
pulpal healing as well as restoring the cavity to create a durable seal for long-term
preservation of a vital, symptom-free and functional tooth.

5
EVIDENCED-BASED RECOMMENDATIONS
Classifications of disease severity to guide decision making in VPT
Multi-centre prospective studies investigating the management of deep caries in adult
patients have focused on the extent and depth of carious lesions radiographically as the
principle inclusion criterion (Bjørndal et al. 2010, 2017). A detailed radiographic description
of deep caries, equal to three quarters of the dentine with a well-defined radio-dense zone
between the caries and the pulp, was included; however, the pulpal symptomatology was
less-detailed (Bjørndal et al. 2010, 2017). A recent prospective study, investigating indirect
pulp treatment (IPT) in deep caries, included a pulpal classification as an inclusion criterion
and noted the importance of pain severity in outcome (Hashem et al. 2015). On a similar
theme, an International Endodontic Journal editorial described a new classification system for
pulpitis linking symptoms rather than radiographic depth to management in VPT (Wolters et
al. 2017). The American Association of Endodontists (AAE) endorsed the currently accepted
classification of pulpal disease in 2013, describing pulpitis as either reversible or irreversible
depending on clinical signs and symptoms. The symptoms of reversible pulpitis range from no
complaint to a sharp pain sensation with hot/cold stimuli and no tenderness to percussion;
notably, the symptoms should resolve after removal of the stimulus. Spontaneous, radiating
pain and sleep disturbance tend to indicate irreversible pulpitis (Dummer et al. 1980) with
lingering pain after removal of the stimulus. Clinical judgement is required; however, as
irreversible pulpitis may be symptomless in anywhere between 14-60 % of cases (Seltzer et
al. 1963, Michaelson & Holland 2002).
Although reversible and irreversible pulpitis may correlate with histological features
(Ricucci et al. 2014), the decision to call a pulp reversibly inflamed does not determine the
actual potential of the inflamed tissue to repair. Therefore, it is critical that teeth undergoing
less invasive carious removal strategies, selective caries removal, IPC, pulp capping or
pulpotomy after pulpal exposure are monitored postoperatively to ensure continuing pulpal
vitality. With the development of pulpotomy interventions, aimed at permanently
maintaining part of the pulp in teeth with signs and symptoms of irreversible pulpitis (Simon
et al. 2013, Taha & Khazali 2017, Taha et al. 2017, Qudeimat et al. 2017), there have been
calls to consider new more representative ways to classify pulpitis (Hashem et al. 2015,
Wolters et al. 2017).

6
Recommendation: Several factors influence pulpal status, a knowledge of which is critical for
the success of VPT strategies in the presence or absence of pulpal exposure. Caries depth
radiographically as well as clinical indicators of activity (e.g. progression rate, colour,
symptoms), should be used to assist clinical decision-making after history, examination and
special tests. The currently accepted diagnostic terms, reversible and irreversible pulpitis,
remain useful but will require revision going forward.

How should we diagnose the inflammatory state of the pulp?

The outcome of VPT is dependent on the inflammatory state of the pulp, with carious
exposures generally having a less favourable outcome compared with traumatic exposures
(Al-Hiyasat et al. 2006); however, the current methods of accurately ascertaining the level of
pulpitis are poor. Assessment should begin with an accurate pain history, detailing response
to temperature, spontaneity of pain, sleep disturbance and be supplemented with a through
clinical and radiographic examination to obtain a provisional diagnosis. It should be borne in
mind that a significant number of pulps become necrotic asymptomatically (Seltzer et al.
1963, Michaelson & Holland 2002) and therefore pulp sensibility testing should supplement
the history and examination. Thermal and electric pulp testing (EPT) remain the appropriate
clinical tests to use, but are crude and non-quantitative being subject to false positive and
negative readings. Cold testing has greater specificity and sensitivity compared with heat,
although has only moderate accuracy compared with experimental techniques principally
used after trauma (not caries), including pulse oximetry and laser Doppler flowmetry
(Manikar & Kim 2017). In general, the colder the stimuli the better with carbon dioxide,
tetrafluoroethane and commercial products such as Endo-Frost (Coltene/Whaledent,
Langenau, Switzerland) diagnostically superior to ice or ethyl chloride in determining pulpal
health (Fuss et al. 1986, Alghaithy & Qualtrough 2017). Heat mimics the patient’s symptoms
and may remain useful in the diagnosis of pulpitis; however, in general has low accuracy
(Manikar & Kim 2018). Pain to cold stimuli remains the main symptom of acute forms of
pulpitis that make patients seek an emergency dental visit (Recehnberg et al. PMID
27234432). These diagnostic methods are subjective and relatively crude only providing
clinical guidance. Traditionally, these methods were not believed to reflect the true

7
histopathological status of the pulp (Garfunkel et al. 1973, Dummer et al. 1980). A recent
histological study contradicted this by demonstrating a strong correlation between histology
and the signs and symptoms of reversible/irreversible pulpitis (Ricucci et al. 2014); however,
the latter study neither examined reparative responses or outcomes in relation to VPT, nor
used teeth with inconclusive history and clinical test results as controls.
All current techniques are limited both in their capacity to establish the threshold of
reversible and irreversible pulpitis and to determine the link between inflammatory status
and healing potential of the affected tissue. As a result, the development new pulp sensibility
tests and chairside assays of disease biomarkers as potential prognostic indicators should be
a focus for translational development (Swedish Council on Health Technology Assessment
2010, Ballal et al. 2017, Rechenberg et al. 2018). In the absence of clinically available
molecular tests of inflammation, the level of pulp bleeding only provides a crude measure of
inflammation (Matsuo et al. 1996), but can be weakly recommended to supplement other
information in cases of pulp exposure.

Recommendation: A detailed pain history and clinical examination supplemented with a high
quality periapical radiograph and pulp sensibility testing using low temperature thermal
testing in combination with EPT.

How should we manage deep caries to avoid pulp exposure?

The indications for one stage selective carious removal and two-stage stepwise excavation or
IPC are an asymptomatic tooth, which responds within normal limits to pulp sensibility testing
or a tooth with signs and symptoms indicative of reversible pulpitis. There is no evidence to
suggest that selective carious tissue removal or IPC are effective treatments in teeth with
symptoms of irreversible pulpitis. Equally, non-selective (complete) carious removal is no
longer regarded the treatment of choice in deep carious lesions, with recent consensus
considering it overtreatment (Schwendicke et al. 2016).
In asymptomatic teeth or teeth with signs and symptoms of reversible pulpitis,
exposure of the pulp should be avoided (if possible) in a less invasive carious removal strategy
such as stepwise excavation or one stage selective removal procedure (Maltz et al. 2012,
Bjørndal et al. 2017). These approaches have demonstrated success up to 90%, defined as the

8
absence of clinical symptoms and maintenance of pulp vitality, over 3 and 5 year follow up
(Maltz et al. 2012, Bjørndal et al. 2017). Less invasive carious tissue removal techniques are
generally carried out using sterile round burs and excavators (Maltz et al. 2012, Bjørndal et
al. 2017); however, other self-limiting chemo-mechanical methods using products such as
Carisolv gel (Carisolv, Rubicon Lifesciences), have been advocated to improve pulp survival
over traditional rotary techniques (Ali et al. 2018). Selective carious removal to soft or firm
dentine can be carried out in one-visit (Maltz et al. 2012) or in two-visits as a stepwise
excavation technique (Bjørndal et al. 2017). Both techniques appear effective in reducing the
risk of pulp exposure (Schwendicke et al. 2016) with advocates of single-visit carious removal
suggesting that re-entry is unnecessary (Maltz et al. 2012), while supporters of stepwise
techniques highlight that shrinkage of residual soft dentine will lead to a defective restoration
without re-entry (Bjørndal 2018).
Regardless of the carious removal technique employed, carious tissue should be
removed from the periphery of the cavity to hard dentine (i.e. non-selective removal), leaving
soft or leathery dentine only on the pulpal aspect of the cavity. As residual dentine thickness
over the pulp cannot be accurately assessed clinically the use of a biologically-based
biomaterial, ideally a hydraulic calcium silicate or alternatively a glass ionomer cement,
should be routinely applied to the dentine barrier prior to restoration with a definitive resin-
based composite restoration (Hashem et al. 2015, 2018). The maintenance of pulp vitality
should be confirmed by pulp sensibility testing. Exclusion criteria include teeth exhibiting
spontaneous or constant pain, an non-restorable crown, a heightened or lingering response
to pulp sensibility testing or a periapical lesion; these will have reduced prognosis and are not
suitable candidates for selective caries removal (Bjørndal et al. 2010, Swedish Council on
Health Technology Assessment 2010). From a practical perspective, it is beneficial during
selective caries removal that the tooth is isolated with rubber dam, sterile instruments are
used, the dentine is handled carefully and a suitable definitive restoration is placed to prevent
further micro-leakage. Magnification should ideally be used throughout.

Recommendation: Selective carious tissue removal (one-stage or two-stage, stepwise

technique) and avoidance of exposure are advocated in asymptomatic teeth or in teeth with
signs and symptoms of reversible pulpitis in well-defined deep carious lesion reaching the
pulpal quarter, but with a clear zone of dentine separating the carious lesion from the pulp.

9
A calcium silicate material or glass ionomer should be placed over the deep dentine in both
one or two-stage procedures. Current evidence does not indicate a preference for one
material over the other.

How should we manage carious pulp exposure?

Treatment options after carious pulp exposure include direct pulp capping and pulpotomy
(mini, partial and full). In general, pulp preservation is only advocated in asymptomatic teeth
or teeth with signs and symptoms of reversible pulpitis, in these cases, as previously
discussed, pulp exposure should ideally be avoided in a selective carious removal strategy
(Bjørndal et al. 2017). These recommendations are based on pulp exposure being a negative
prognostic factor in deep carious lesions (Bjørndal et al. 2010, Schwendicke et al. 2016).
Several recent studies have highlighted comparable success after non-selective (complete)
carious removal, pulp exposure and a VPT procedure involving operating microscope (Bogen
et al. 2009, Marques et al. 2015) and/or the use of a disinfection agent (Kundzina et al. 2017).
These studies all used hydraulic calcium silicate cements (not calcium hydroxide) in an
enhanced class II protocol, which should include magnification, and a disinfecting solution
rather than saline (Bogen et al. 2009). Operator skill and experience may also be an important,
if not independently tested, variable determining the success of VPT.
Nevertheless, this research emphasizes that pulp capping of deep carious lesions can
be successfully carried out, if an enhanced treatment protocol is followed (Bogen et al. 2009,
Mente et al. 2014, Marques et al. 2015, Kundzina et al. 2017). This may help to explain the
difference between these studies and the relatively low success of a classic pulp capping
protocol examined both retrospectively (Barthel et al. 2000) and prospectively in deep carious
lesions (Bjørndal et al. 2010). Notably, high-quality clinical research trials comparing these
interventions are lacking and as a result it remains to be seen if these recent promising results
can be replicated in a primary care setting. Furthermore, for dentists competent in handling
pulp tissues, non-selective caries removal and pulp exposure can offer an opportunity to
assess pulp damage, the presence of necrosis in the pulp chamber, the level of pulp bleeding
and the true extent of the carious destruction.
The maintenance of pulp vitality should be confirmed preoperatively by pulp
sensibility testing and intraoperatively by presence of vital tissue after exposure. Exclusion

10
criteria may alter in the future; however, teeth exhibiting spontaneous or constant pain, an
unrestorable crown, a periapical lesion, continuous uncontrollable bleeding or the presence
of necrotic tissue in the pulp chamber are generally not predictable candidates for pulp
capping or pulpotomy (Bjørndal et al. 2010, Swedish Council on Health Technology
Assessment 2010). Recent evidence has accumulated; however, which demonstrates success
of full pulpotomy after one year to range between 75-95%, even in the teeth with signs and
symptoms indicative of irreversible pulpitis (Asgary & Eghbal 2013, Asgary et al. 2015, Asgary
et al. 2017, Galani et al. 2017, Linsuwanont et al. 2017, Qudeimat et al. 2017, Taha et al. 2017,
Asgary et al. 2018). Notably, these success rates are difficult to compare with other VPT
techniques, as the maintenance of pulp vitality cannot be verified by pulp sensibility testing.
The potential of full pulpotomy to treat teeth with signs and symptoms of irreversible pulpitis
is clear and although the evidence is preliminary, it indicates that an extension of traditional
concepts of pulpectomy in these cases is likely in the future.
Clinically, it is essential during the VPT procedure that the tooth is isolated prior to
pulpal exposure with rubber dam. Ideally, magnification should be used throughout the
procedure to ensure removal of all infected dentine. The damaged tissue can be treated with
the direct application of the capping material to the exposed pulp (pulp capping, class II), or
removal of the surface of the exposed pulp (mini-pulpotomy) and removal of the coronal 2-4
mm of pulp tissue (partial pulpotomy). Some degree of pulp tissue removal may be preferable
in carious exposures to aid physical removal of the biofilm and superficial inflamed pulp tissue
(Mejàre & Cvek 1993, Barrieshi-Nusair & Qudeimat 2006, Chailertvanitkul et al. 2014). This,
however, may represent a treatment step that is highly dependent on operator skills and
equipment (e.g. a dental microscope). The dentine should carefully manipulated using sterile
burs and sharp instruments, with a high speed bur and water-coolant used for pulp tissue
removal (Granath et al. 1971), prior to disinfection and control of pulpal bleeding.
Haemostasis and disinfection should be achieved using cotton pellets soaked ideally with
sodium hypochlorite (0.5-5%) or chlorhexidine (0.2 to 2%). Although physiological saline has
been the acceptable standard, it is limited by a lack of disinfection properties. If haemostasis
cannot be controlled after 5 minutes, further pulp tissue should be removed (partial and full
pulpotomy) and the wound surface rinsed as before. In cases with signs and symptoms of
irreversible pulpitis, a full coronal pulpotomy can be carried out to the level of the root canal
orifices with bleeding arrested as detailed previously. This procedure may be easier to

11
perform for GPs than a partial pulpotomy or even direct pulp capping. In all cases, a hydraulic
calcium silicate cement should be placed directly onto the pulp tissue and the tooth
definitively restored immediately to prevent further micro-leakage (Al-Hiyasat et al. 2006,
Mente et al. 2010). If bleeding cannot be controlled after full pulpotomy, a pulpectomy and
root canal treatment should be carried out.

Recommendation: Carious exposure of the pulp can be carefully treated with VPT in cases of
asymptomatic or reversible pulpitis with a pulp cap (class II) or partial pulpotomy procedure.
Full pulpotomy may be successful in cases of irreversible pulpits; however, better long-term
prospective randomised data is required before this can be called the treatment of choice. All
VPT procedures on the cariously exposed pulp should be carried out with the use of rubber
dam, careful aseptic technique and antibacterial measures. For capping deep or extremely
deep carious lesions the use of magnification is strongly recommended.

What materials should we use for VPT?

Calcium hydroxide has been the material of choice for IPC and pulpal application for many
years (Glass & Zander 1949, Pitt Ford & Roberts 1991); however, it is limited by poor
mechanical properties, absence of sealing properties (Browne et al. 1983) and incomplete
hard tissue formation over the exposed pulp (Cox et al. 1987, Nair et al. 2008). Hydraulic
calcium silicate materials, such as mineral trioxide aggregate (MTA), have demonstrated
superior histological (Aeinehchi et al. 2003, Nair et al. 2008) and clinical outcome compared
with calcium hydroxide in treatment of the exposed pulp (Cho et al. 2013, Hilton et al. 2013,
Mente et al. 2014, Kundzina et al. 2017). Furthermore, there is evidence to suggest that
calcium silicate cements can be used in IPC after deep caries removal (Leye Benoist et al. 2012,
Petrou et al. 2014, Hashem et al. 2015), although longer-term clinical and radiographic follow
up demonstrated no significant improvement compared with glass ionomer cements in terms
of symptoms and pulp vitality (Hashem et al. 2018).
A range of hydraulic calcium silicate cements are available, which share similar
biological properties, but exhibit chemical differences, which influences radiopacity, setting
time and the potential to discolour the tooth (Parirokh et al. 2018). Resin-based composites
and dentine-bonding agents have been investigated in VPT, but are now contraindicated due

12
to their cytotoxicity (Krifka et al. 2012), absence of mineral over the wound site and poor
clinical outcome VPT (De Souza Costa et al. 2000). An open question thus relates directly to
the procedure of one-stage selective caries removal is the choice of capping agent. If the
remaining lesion is treated using a total bionding approach, it may arrest but remain
radiolucent (Figure). It is not clear whether bioactive materials would improve this outcome.
Further clinical research is necessary to find ways to avoid this problem.

Recommendations: After pulp capping, partial pulpotomy, or full pulpotomy the exposed
pulp should be gently rinsed, disinfected, the bleeding controlled and a hydraulic calcium
silicate material placed directly onto the exposed pulp. A calcium silicate material or glass
ionomer should also be placed during IPC onto the residual soft dentine prior to definitive
surface restoration.

How should I follow-up VPT cases and what is the expected prognosis?
VPT procedures should be assessed 6 and 12 months postoperatively and at regular intervals
thereafter. The tooth should respond positively to pulp sensibility testing without a lingering
or exaggerated response. It should be noted that certain teeth may not respond and that
teeth, which have undergone full pulpotomy are expected to be unresponsive to testing. The
patient should be free of pain and other symptoms and there should be radiological evidence
of continued root formation in immature teeth as well as absence of signs of internal root
resorption and apical periodontitis. Hard tissue formation over the exposure may be evident
radiographically in some cases, but absent in others and therefore cannot be viewed as a
necessary measure of success in the absence of other problems.
Permanent teeth with deep caries and mild symptoms indicative of no more than
reversible pulpitis can be successfully treated by selective procedure as well as by IPC (Maltz
et al. 2012, Hashem et al. 2015, 2018) and stepwise excavation (Bjørndal et al. 2010 & 2017),
using a calcium silicate cement or glass ionomer to cover the soft dentine. Best evidence
indicates that success, after a least one year and defined as absence of symptoms and
maintenance of pulp vitality, is in the region of 70-90%, after selectively caries removal and
avoidance of exposure (Bjørndal et al. 2010, Maltz et al. 2012, Hashem et al. 2015 , Bjørndal
et al. 2017, Ali et al. 2018, Hashem et al. 2018). Equally, mature permanent teeth with caries

13
and symptoms no worse than reversible pulpitis, exposing the pulp and capping with a
calcium silicate material, is also a predictable procedure; however, available data on the
carious penetration depth was not well defined (Marques et al. 2015, Kundzina et al. 2017),
and some of the sample material comprised mechanical exposures (Mente et al. 2014).
Considering these limitations best current evidence would indicate that in this scenario a pulp
capping procedure should be successful in approximately 80-90% (Hilton et al. 2013, Marques
et al. 2015, Kundzina et al. 2017). However, in light of new materials and other developments,
there is a need for high quality well-controlled research to determine the role of pulp
exposure as a prognostic factor in the teeth with deep caries
A range of other factors may affect prognosis, in addition to accepted associations
with patient symptoms, depth of caries and the material used. Prospective studies analysing
the histological response to VPT materials invariably select young patients (Hörsted-Bindslev
et al. 2003, Accorinte et al. 2008, Nair et al. 2008), as do clinical pulp capping and pulpotomy
studies in carious teeth (Barrieshi-Nusair et al. 2006, Farsi et al. 2006, Chailertvanitkul et al.
2014, Taha et al. 2017). Young patients are selected due to an enhanced pulpal blood supply,
open root apices and pulps free of age-related change (Goodis et al. 2012); however, patient
age appears to not affect the outcome of VPT within more recent studies (Mente et al. 2010,
Asgary et al. 2015, , Kunert et al. 2015, Kang et al. 2017, Linsuwanont et al. 2017). The size of
the exposure site is also not a significant factor in success (Mejàre & Cvek 1993, Dammaschke
et al. 2010), although one study suggested that if the exposure were large (>5 mm) it was less
successful (Chailertvanitkul et al. 2014).

Recommendations: VPT should be carefully monitored by history, clinical and radiographic

examination at 6 months, one year and at regular intervals thereafter. Thermal and electric
pulp sensibility testing should be carried out where possible to monitor pulpal response.
Stepwise excavation in adults is a predictable treatment to avoid pulp exposure, while, IPT
and pulp capping can both be considered predictable treatments for the management of deep
caries in permanent teeth. Notably, there is a shortage of long-term randomized data in this
area, comparing which intervention that should be preferred.

Summary and concluding remarks

14
The recommendations contained in this ESE Position Statement are designed to assist
clinicians in making decisions about the most appropriate treatments for their patients.
Developments in understanding of the defensive response of the pulp-dentine complex and
a drive to develop minimally invasive restorative solutions in endodontics have created
significant interest in this area. The ESE welcomes these developments; however, it should
be highlighted the there is a paucity of high quality comparative research on mature carious
permanent teeth addressing many of the central questions. Although, this area is likely to
modify in the future we must be remain cautious in recommending treatments of choice that
are preliminary and not supported by robust long-term evidence.

REFERENCES

Accorinte ML, Holland R, Reis A, et al. (2008) Evaluation of mineral trioxide aggregate and
calcium hydroxide as pulp-capping agents in human teeth. Journal of Endodontics 1, 1-6.

Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS (2003) Mineral trioxide aggregate (MTA) and
calcium hydroxide as pulp-capping agents in human teeth: a preliminary report. International
Endodontic Journal 36, 225-31.

Ali AH, Koller G, Foschi F, Andiappan M, Bruce KD, Banerjee A, Mannocci F (2018) Self-Limiting
versus Conventional Caries Removal: A Randomized Clinical Trial. Journal of Dental Research
97, 1207-13.

Alghaithy RA, Qualtrough AJ (2017) Pulp sensibility and vitality tests for diagnosing pulpal
health in permanent teeth: a critical review. International Endodontic Journal 50, 135-42.

Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA (2006) The radiographic outcomes of direct
pulp-capping procedures performed by dental students: a retrospective study. Journal of the
American Dental Association 137, 1699-705.

American Association of Endodontists (2013) Endodontic diagnosis. https://www.aae.org

accessed 3rd September 2018.

Asgary S, Eghbal MJ (2013) Treatment outcomes of pulpotomy in permanent molars with

irreversible pulpitis using biomaterials: A multi-center randomized controlled trial. Acta
Odontologica Scandinavica 71, 130-6.

Asgary S, Eghbal MJ, Fazlyab M, Baghban AA, Ghoddusi J (2015) Five-year results of vital pulp
therapy in permanent molars with irreversible pulpitis: A non-inferiority multicenter
randomized clinical trial. Clinical Oral Investigations 19, 335-41.

15
Asgary S, Eghbal MJ, Bagheban AA (2017) Long-term outcomes of pulpotomy in permanent
teeth with irreversible pulpitis: A multi-center randomized controlled trial. American Journal
of Dentistry 30, 151-5.

Asgary S, Hassanizadeh R, Torabzadeh H, Eghbal MJ (2018) Treatment Outcomes of 4 Vital

Pulp Therapies in Mature Molars. Journal of Endodontics 44, 529-35.

Ballal V, Rao S, Bagheri A, Bhat V, Attin T, Zehnder M (2017) MMP-9 in Dentinal Fluid
Correlates with Caries Lesion Depth. Caries Research 51, 460-5.

Banerjee A, Frencken JE, Schwendicke F, Innes NPT (2017) Contemporary operative caries
management: consensus recommendations on minimally invasive caries removal. British
Dental Journal 223, 215-22.

Barrieshi-Nusair KM, Qudeimat MA (2006) A prospective clinical study of mineral trioxide

aggregate for partial pulpotomy in cariously exposed permanent teeth. Journal of Endodontics
32, 731-5.

Barthel CR, Rosenkranz B, Leuenberg A, Roulet RF (2000) Pulp capping of carious exposures:
treatment outcome after 5 and 10 years: a retrospective study. Journal of Endodontics 26,
525-8.

Bernabé E, Sheiham A (2014) Age, period and cohort trends in caries of permanent teeth in
four developed countries. American Journal of Public Health 104, e115-21.

Bjørndal L, Larsen T, Thylstrup A (1997) A clinical and microbiological study of deep carious
lesions during stepwise excavation using long treatment intervals. Caries Research 31, 411-7.

Bjørndal L, Reit C, Bruun G, et al. (2010) Treatment of deep caries lesions in adults:
randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp
capping vs. partial pulpotomy. European Journal of Oral Science 118, 290-7.

Bjørndal L, Fransson H, Bruun G, et al. (2017) Randomized Clinical Trials on Deep Carious
Lesions: 5-Year Follow-up. Journal of Dental Research 96, 747-53.

Bjørndal L (2018) Caries pathology and management in deep stages of lesion formation. In:
Bjørndal L, Kirkevang L-L, Whitworth J, 3. edn. Textbook of Endodontology. Oxford; UK. Wiley
Blackwell. pp. 61-78.

Bjørndal L, Simon S, Tomson PL, Duncan HF (2018) Management of Deep Caries and the
Exposed Pulp. International Endodontic Journal [in press]

Bogen G, Kim JS, Bakland LK (2008) Direct pulp capping with mineral trioxide aggregate: an
observational study. Journal of the American Dental Association 139, 305-15.

16
Browne RM, Tobias RS, Crombie IK, Plant CG (1983) Bacterial microleakage and pulpal
inflammation in experimental cavities. International Endodontic Journal 16, 147–55.

Chailertvanitkul P, Paphangkorakit J, Sooksantisakoonchai N, et al. (2014) Randomized control

trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in
cariously exposed pulps of permanent molars. International Endodontic Journal 47, 835-42.

Cho SY, Seo DG, Lee SJ, Lee J, Lee SJ, Jung IY (2013) Prognostic factors for clinical outcomes
according to time after direct pulp capping. Journal of Endodontics 39, 327-31.

Costa SM, Martins CC, Pinto MQ, Vasconcelos M, Abreu MH (2018) Socioeconomic Factors
and Caries in People between 19 and 60 Years of Age: An Update of a Systematic Review and
Meta-Analysis of Observational Studies. International Journal of Environmental Research and
Public Health 18, 15(8) E1775.

Cox CF, Keall CL, Keall HJ, Ostro E, Bergenholtz G (1987) Biocompatibility of surface-sealed
dental materials against exposed pulps. Journal of Prosthetic Dentistry 57, 1-8.

Dammaschke T, Leidinger J, Schafer E (2010) Long-term evaluation of direct pulp capping--

treatment outcomes over an average period of 6.1 years. Clinical Oral Investigations 14, 559-
67.

De Souza Costa CA, Hebling J, Hanks CT (2000) Current status of pulp capping with dentin
adhesive systems: a review. Dental Materials 16, 187-97.

Dummer PM, Hicks R, Huws D (1980) Clinical signs and symptoms in pulp disease.
International Endodontic Journal 13, 27-35.

Farges JC, Alliot-Licht B, Renard E, et al. (2015) Dental Pulp Defence and Repair Mechanisms
in Dental Caries. Mediators of Inflammation 2015, 230251.

Farsi N, Alamoudi N, Balto K, Mushyat A (2006) Clinical assessment of mineral trioxide

aggregate (MTA) as direct pulp capping in young permanent teeth. Journal of Clinical Pediatric
Dentistry 31, 72-6.

Fuss Z, Trowbridge H, Bender IB, Rickoff B, Sorin S (1986) Assessment of reliability of electrical
and thermal pulp testing agents. Journal of Endodontics 12, 301–5.

Galani M, Tewari S, Sangwan P, Mittal S, Kumar V, Duhan J (2017) Comparative evaluation of

postoperative pain and success rate after pulpotomy and root canal treatment in cariously
exposed mature permanent molars: A randomized controlled trial. Journal of Endodontics 43,
1953-62.

Garfunkel A, Sela J, Ulmansky (1973) Dental pulp pathosis: clinicopathologic correlations

based on 109 cases. Oral Surgery, Oral Medicine, Oral Pathology 35, 110-7.

Glass RL, Zander HA (1949) Pulp healing. Journal of Dental Research 39, 97-107.

17
Goodis HE, Kahn A, Simon S (2012) Aging and the pulp. In: Hargreaves K, Goodis HE, Tay F,
eds. Seltzer and Bender's Dental Pulp, 2nd edn; Berlin, Germany: Quintessenz.

Granath LE, Hagman G (1971) Experimental pulpotomy in human bicuspids with reference to
cutting technique. Acta Odontologica Scandinavica 29, 155-63.

Hashem D, Mannocci F, Patel S, et al. (2015) Clinical and radiographic assessment of the
efficacy of calcium silicate indirect pulp capping: a randomized controlled clinical trial. Journal
of Dental Research 94, 562-8.

Hashem D, Mannocci F, Patel S, et al. (2018) Evaluation of the efficacy of calcium silicate vs.
glass ionomer cement indirect pulp capping and restoration assessment criteria: a
randomised controlled clinical trial-2-year results. Clinical Oral Investigations doi:
10.1007/s00784-018-2638-0. [Epub ahead of print]

Hilton TJ, Ferracane JL, Mancl L, Northwest Practice-based Research Collaborative in

Evidence-based Dentistry (NWP) (2013) Comparison of CaOH with MTA for direct pulp
capping: a PBRN randomized clinical trial. Journal of Dent Research 92, 16-22S.

Hörsted-Bindslev P, Vilkinis V, Sidlauskas A (2003) Direct capping of human pulps with a dentin
bonding system or with calcium hydroxide cement. Oral Surgery, Oral Medecine, Oral
Pathology, Oral Radiology and Endodontics 96, 591-600.

Innes NP, Frencken JE, Bjørndal L, et al. (2016) Managing Carious Lesions: Consensus
Recommendations on Terminology. Advances in Dental Research 28, 49-57.

Kang CM, Sun Y, Song JS, et al. (2017) A randomized controlled trial of various MTA materials
for partial pulpotomy in permanent teeth. Journal of Dentistry 60, 8-13.

Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJ, Marcenes W (2015) Global
burden of untreated caries: a systematic review and metaregression. Journal of Dental
Research 94, 650-8.

Krifka S, Seidenader C, Hiller KA, Schmalz G, Schweikl H (2012) Oxidative stress and
cytotoxicity generated by dental composites in human pulp cells. Clinical Oral Investigations
16, 215-24.

Kundzina R, Stangvaltaite L, Eriksen HM, Kerosuo E (2017) Capping carious exposures in

adults: a randomized controlled trial investigating mineral trioxide aggregate versus calcium
hydroxide. International Endodontic Journal 50, 924-32.

Kunert GG, Kunert IR, da Costa Filho LC, de Figueiredo JAP(2015) Permanent teeth pulpotomy
survival analysis: Retrospective follow-up. Journal of Dentistry 43, 1125-31.

18
Leye Benoist F, Gaye Ndiaye F, Kane AW, Benoist HM, Farge P (2012) Evaluation of mineral
trioxide aggregate (MTA) versus calcium hydroxide cement (Dycal) in the formation of a
dentine bridge, a randomised controlled trial. International Dental Journal 62, 33–9.

Linsuwanont P, Wimonsutthikul K, Pothimoke U, Santiwong B (2017) Treatment outcomes of

mineral trioxide aggregate pulpotomy in vital permanent teeth with carious pulp exposure:
The retrospective study. Journal of Endodontics 43, 225-30.

Listl S, Galloway J, Mossey PA, Marcenes W (2015) Global economic impact of dental diseases.
Journal of Dental Research 94, 1355-61.

Mainkar A, Kim SG (2018) Diagnostic Accuracy of 5 Dental Pulp Tests: A Systematic Review
and Meta-analysis. Journal of Endodontics 44, 694-702.

Maltz M, Garcia R, Jardim JJ, et al. (2012) Randomized trial of partial vs. stepwise caries
removal: 3-year follow-up. Journal of Dental Research 91, 1026-31.

Marques MS, Wesselink PR, Shemesh H (2015) Outcome of Direct Pulp Capping with Mineral
Trioxide Aggregate: A Prospective Study. Journal of Endodontics 41, 1026-31.

Matsuo T, Nakanishi T, Shimizu H, Ebisu S (1996) A clinical study of direct pulp capping applied
to carious-exposed pulps. Journal of Endodontics 22, 551-6.

Mejàre I, Cvek M (1993) Partial pulpotomy in young permanent teeth with deep carious
lesions. Endodontics and Dental Traumatology 9, 238-42.

Mente J, Geletneky B, Ohle M, et al. (2010) Mineral trioxide aggregate or calcium hydroxide
direct pulp capping: An analysis of the clinical treatment outcome. Journal of Endodontics 36,
806-13.

Mente J, Hufnagel S, Leo M, et al. (2014) Treatment outcome of mineral trioxide aggregate or
calcium hydroxide direct pulp capping: long-term results. Journal of Endodontics 40, 1746-51.

Michaelson PL, Holland GR (2002) Is pulpitis painful? International Endodontic Journal 35,
829-832.

Mjör IA, Tronstad L (1972) Experimentally induced pulpitis. Oral Surgery, Oral Medicine, Oral
Pathology 34, 102-8.

Mjör IA, Tronstad L (1974) The healing of experimentally induced pulpitis. Oral Surgery, Oral
Medicine, Oral Pathology 38, 115-21.

Nair PNR, Duncan HF, Pitt Ford TR, Luder HU (2008) Histological, ultrastructural and
quantitative investigations on the response of healthy human pulps to experimental capping
with mineral trioxide aggregate: a randomized controlled trial. International Endodontic
Journal 41, 128-50.

19
Nyvad B, Crielaard W, Mira A, Takahashi N, Beighton D (2013) Dental caries from a molecular
microbiological perspective. Caries Research 47, 89-102.

O'Mullane DM, Baez RJ, Jones S, et al. (2016) Fluoride and Oral Health. Community Dental
Health 33, 69-99.

Parirokh M, Torabinejad M, Dummer PMH (2018) Mineral trioxide aggregate and other
bioactive endodontic cements: an updated overview - part I: vital pulp therapy. International
Endodontic Journal 51, 177-205.

Petersen PE (2008) World Health Organization global policy for improvement of oral health--
World Health Assembly 2007. International Dental Journal 58, 115-21.

Petrou MA, Alhamoui FA, Welk A, Altarabulsi MB, Alkilzy M, Splieth CH (2014) A randomized
clinical trial on the use of medical Portland cement, MTA and calcium hydroxide in indirect
pulp treatment. Clinical Oral Investigations 18, 1383–9.

Pitt Ford TR & Roberts GJ (1991) Immediate and delayed direct pulp capping with the use of
a new visible light-cured calcium hydroxide preparation. Oral Surgery, Oral Medicine, Oral
Pathology 71, 338–42.

Pitts NB, Zero DT, Marsh PD, et al. (2017) Dental caries. Nature Reviews Disease Primers 25,
17030. doi: 10.1038/nrdp.2017.30.

Qudeimat MA, Alyahya A, Hasan AA (2017) Mineral trioxide aggregate pulpotomy for
permanent molars with clinical signs indicative of irreversible pulpitis: a preliminary study.
International Endodontic Journal 50, 126-34.

Rechenberg DK, Galicia JC, Peters OA (2016) Biological Markers for Pulpal Inflammation: A
Systematic Review. PLoS One 11, e0167289.

Reeves R, Stanley HR (1966) The relationship of bacterial penetration and pulpal pathosis in
carious teeth. Oral Surgery, Oral Medicine, Oral Pathology 22, 59-65.

Ricucci D, Loghin S, Siqueira Jr J (2014) Correlation between clinical and histologic pulp
diagnoses. Journal of Endodontics 40, 1932-9.

Schwendicke F, Frencken JE, Bjørndal L, et al. (2016) Managing carious lesions: consensus
recommendations on carious tissue removal. Advances in Dental Research 28, 58-67.

Sengupta K, Christensen LB, Mortensen LH, Skovgaard LT, Andersen I (2017) Trends in
socioeconomic inequalities in oral health among 15-year-old Danish adolescents during 1995-
2013: A nationwide, register-based, repeated cross-sectional study. Community Dentistry and
Oral Epidemiology 45, 458-68.

20
Seltzer S, Bender IB, Ziontz M (1963) The dynamics of pulpal inflammation: correlations
between diagnostic data and actual histologic findings in the pulp. Oral Surgery, Oral
Medicine, Oral Pathology 16, 871-6.

Simon S, Perard M, Zanini M, et al. (2013) Should pulp chamber pulpotomy be seen as a
permanent treatment? Some preliminary thoughts. International Endodontic Journal 46, 79-
87.

Swedish Council on Health Technology Assessment (2010) Methods of diagnosis and

treatment in endodontics: a systematic review. Assessment No. 203. [WWW document] URL
https://www.sbu.se/contentassets/eafcce68f3aa438cb932c76702cde403/methods-of-
diagnosis-and-treatment-in-endodontics_full.pdf

Taha NA, Khazali MA (2017) Partial pulpotomy in mature permanent teeth with clinical signs
indicative of irreversible pulpitis: A Randomized Clinical Trial. Journal of Endodontics 43, 1417-
21.

Taha NA, Ahmad MB, Ghanim A (2017) Assessment of Mineral Trioxide Aggregate pulpotomy
in mature permanent teeth with carious exposures. International Endodontic Journal 50, 117-
25.

Wolters WJ, Duncan HF, Tomson PL, et al. (2017) Minimally invasive endodontics: a new
diagnostic system for assessing pulpitis and subsequent treatment needs. International
Endodontic Journal 50, 825-9.

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