Clinical guideline 12 Version 4

Valid to: September 2016

Exposure of Vital Dental Pulps in Permanent Teeth

Purpose
The aim of this Clinical Guideline is to provide advice to public oral health clinicians
regarding the exposure of vital dental pulps in permanent teeth. Evidence-based clinical
guidelines are intended to provide guidance, and are not a standard of care, requirement,
or regulation. However, the application of clinical guidelines in publicly-provided oral health
services allows for consistency to occur across large patients cohorts with a variety of oral
health clinicians.
This clinical guideline aims to provide clinicians with the rationale for the clinical procedures
employed, and the techniques and materials applied, in the management of pulp exposures
of permanent teeth.
Summary
As the pulp and dentine are closely related, all procedures performed in dentine are in
essence treatment of both the dentine and pulp. A small pulpal exposure may have the
potential to cause a destructive and irreversible inflammation in the pulp through the
ingress of bacterial flora from the oral cavity.
Exposure of the pulp may result from:
caries,
non carious tooth loss such as wear, trauma, cracks, and
iatrogenic (clinician-induced) injury such as an inadvertent deep cavity or crown
preparations.
Generally, these will result in pulpal change and if not properly managed may result in
otherwise avoidable irreversible pulpitis and/or necrosis. The pulp may already be in a
compromised state following a standing exposure to caries or previous insults and healing
may not be possible.
Vital permanent teeth with deep caries in pulp proximity can be treated successfully with
vital pulp therapy (1). Vital pulp therapy involves clinical procedures aimed at:

Relieving painful symptoms of pulpitis

Preventing the development of a destructive course of pulpal inflammation and
Ensuring future protection from microbiological ingress.

The use of rubber dam in managing teeth with deep carious lesions or pulpal exposures,
and the soundness of the restoration are important factors that impact on the prognosis of
the tooth.
When the pulp inflammation is irreversible, non-vital pulp therapies are indicated.

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Guideline
Diagnostic findings which influence choice of therapy
Diagnostic criteria of an irreversibly injured pulp are not clear-cut. The distinction between
irreversible and reversible pulpitis is often difficult to identify. Treatment options must be
based on a careful analysis of presenting signs and symptoms and clinical examination of
the patient. Essentially, there are two diagnostic tools that are used to guide the clinician:
the presence and character of painful pulpal symptoms and the radiographic findings.
Pulpal pain
Inflammatory changes of the pulp may occur with or without pain. The pain symptoms
commonly associated with a pulpal inflammatory lesion vary and can be excruciating,
requiring immediate attention. They include:

Increased sensitivity following exposure to cold drinks, food, air, or touch of an exposed
dentine surface. These are early signs of pulpal inflammation and are usually not
suggestive of an advanced lesion.
Short, intermittent periods of lingering pain (seconds to minutes) by exposure to cold
drinks, food and air. These may be signs of a pulpal inflammatory lesion in progress and
may prevail for long periods of time (months or years) without resulting in pulpal
necrosis.
Longstanding, severe pain (hours), spontaneous or intermittent provoked by external
stimuli, including hot food and drinks, more often at night and requiring analgesics.
These are suggestive of an irreversible (non-healing) pulpal condition.

Absence of pain is a weak predictor of the condition of the pulp, whether reversibly or
irreversibly inflamed. The existence of a history of pain and the nature of the presenting
pain are factors used in deciding the choice of therapy.
Radiographic findings:
The presence in radiographs of loss of lamina dura, small periapical radiolucency and/or
periapical sclerosis, are not necessarily indicative of an irreversible condition but can be
useful to assist in identifying the offending tooth in a painful case.
Clinical and radiographic signs and various pulp testing modalities are not always decisive
diagnostic measures to determine the severity of pulpal inflammation, yet they are the only
signs currently available for diagnosis in clinical practice.
Treatment Options
Management of deep carious lesions depends on the degree of pulpal inflammation.
Treatment options range from vital to non vital pulp therapies.
Vital pulp therapies
These include: indirect pulp capping, direct pulp capping, partial pulpotomy and pulpotomy.
They may be carried out in asymptomatic teeth with extensive caries and healthy or
minimally inflamed pulp. Younger teeth have a better prognosis. The outcome of these
therapies is maintenance of pulpal health in more than 70% of the time, regardless of the
therapy used (6).

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a.

Indirect pulp capping

Clinicians often encounter a clinical situation when caries is deep, and the removal of the
innermost layer of infected dentine would expose the pulp. In teeth with no preoperative
clinical or radiographic signs or symptoms of irreversible pulpitis or peri apical pathology,
the current recommendation is to avoid exposing the pulp. The chances of tooth survival
are excellent if the tooth is asymptomatic, even if a small amount of residual caries
remains. Complete caries removal is not needed for success, provided the restoration is
well sealed (3,11).
Partial caries removal is supported by current clinical and microbiological studies and
systematic reviews. There is no evidence that partial caries removal is detrimental to pulpal
health or restoration longevity. On the other hand, it is demonstrated that partial caries
removal reduces the risk of pulp exposure by 98% compared with complete caries
excavation of deep caries lesions (4,11).
Clinical Procedure
Take a periapical radiograph to confirm the appropriateness of treatment.
Secure local anaesthesia.
Isolate the tooth with rubber dam.
Excavate caries as appropriate; a small area of infected dentine adjacent to a vital pulp
could be left permanently (partial caries removal).
Place a hard-setting calcium hydroxide liner on the remaining innermost layer dentine to
stimulate the pulp to produce reparative dentine.
Place a well-sealed restoration permanently.
Historically, a stepwise excavation technique was employed. In this technique, the clinician
would re-enter the cavity 8 weeks after the initial visit and attempt to remove the carious
layer left behind and confirm the formation of reparative dentine. While this technique is
superior to complete caries removal in the first visit, it has the disadvantage to increase the
risk of insults, exposure and bacterial ingress to the pulp. Therefore, stepwise excavation is
not supported by the current teachings in Victoria.
Expected outcomes: the carious dentine left behind changes colour from light brown to
brown and it changes consistency from soft and wet to hard and dry in 4-12 months after
treatment (11). The bacterial growth will be significantly reduced (5,11). The remaining
cariogenic bacteria, once isolated from their source of nutrition by a restoration of sufficient
integrity, either die or remain dormant and pose no risk to the health of the dentition (7).
Factors influencing prognosis:
Appropriate isolation
Techniques in cavity preparation
Choice of restorative material
Seal of the cavity
When employing this technique, it is imperative that the restoration placed to restore the
tooth is placed under rubber dam. The use of rubber dam will minimise moisture and
bacterial contamination of the operative field.
The outline of the cavity needs to be managed to ensure strong enamel margin.
Unsupported enamel rods should be removed.
The small area of incomplete caries removal should be covered with a cavity liner, such as
hard setting calcium hydroxide to achieve formation of reparative dentine.
Self-cured glass ionomer cement (GIC) need to be placed as a base. Its fluoride releasing
property, chemical bonding to dentine substrate and its volumetric stability will ensure

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maximum seal of the cavity. It is then followed by a final restoration of clinicians choice.
The placement of all restorative materials must closely follow the manufacturer instructions.
The above points are keys to a well-sealed restoration, which will deny bacteria substrate
from further acid production and will assist arrest the carious lesion. The type of liner
appears to be less important than the restoration seal (11).
Follow up:
Examinations are mandatory in 6 months for the evaluation of pulp sensitivity and the
apical health status (9).
b.

Direct pulp capping / partial pulpotomy

Pulp capping and partial pulpotomy are procedures to consider when there is no history of
lingering pain to external stimuli and when the pulp has been:

Accidentally exposed to the oral environment by cavity preparation and traumatic

injury, or
Exposed in conjunction with excavation of caries, or root amputation in periodontal
therapy

Ultimately, the procedures aim to preserve the vital function of the pulp. Healing and repair
of an exposed pulp depend initially on the preoperative condition of the tissue. Factors
including type of injury, age of patient, and size and location of the pulpal exposure are
important in determining the long-term survival of the pulp. The integrity of the permanent
restoration is of vital importance for the successful outcome of these procedures.
Clinical Procedure
Take a periapical radiograph to confirm the appropriateness of treatment.
Secure local anaesthesia.
Isolate the tooth with rubber dam.
Undertake cavity preparation, as required.
Remove any blood clot with a sharp excavator.
Establish haemostasis by slowly and gently flowing sodium hypochlorite (1% NaOCl),
sterile saline or local anaesthetic solution over the wound. Repeat if necessary.
Remove excess moisture with clean cotton wool.
Apply capping material to the wound with a very gentle pressure.
Cover the wound dressing with a hard-setting cement such as GIC.
Restore and seal the cavity with a permanent restoration.
Monitor regularly, taking into account the patients age, availability of service, etc.
Advise the patient that if symptoms develop, the tooth may require a pulpectomy and
ensure that appropriate referral pathways are understood.
Pulp capping is regarded as appropriate for immediate minor exposures, whereas partial
pulpotomy is more appropriate for small wounds that have been exposed to microbial
challenges for a period of time, particularly in young teeth. As the former is often an
unlikely scenario, i.e immediate presentation by the patient, the partial pulpotomy
procedure is usually the indicated option.
A partial pulpotomy offers the advantage of removing the superficial and potentially
infected layer of the pulp. The preparation should be carried out 1-2 mm deep with a sharp
endcutting diamond bur in an air turbine under copious water irrigation in order to reduce
the thermal trauma on the tissue.
A critical step in pulp capping and pulpotomy procedures is to stop bleeding and to
eliminate major blood clots prior to placement of the wound dressing. If bleeding cannot be

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controlled properly, it indicates a greater degree of inflammation in the pulp, beyond its
capacity for repair. In addition, the moisture and contamination of dentine in the area of
exposure will preclude an adequate seal that will prevent future recontamination (11). In
this case, pulpectomy should be undertaken.
Capping materials
Calcium hydroxide compounds have been the main materials used as capping agents for
pulp capping or partial pulpotomy. They have inherent high pH. When applied to an
exposed pulp, calcium hydroxide cauterises the tissue and causes superficial necrosis.
Hard-tissue repair develops. Few oral micro-organisms survive in the highly alkaline
environment that this material provides. In addition, calcium Hydroxide solubilises a variety
of proteins in the dentinal matrix that are known to stimulate pulp repair (11).
Mineral Trioxide Aggregate (MTA) is a material which has been used for several years
now and is demonstrating excellent results regarding maintaining pulp vitality, particularly
in partial pulpotomy situations. The consistency of the material does not lend itself to easy
use as a pulp capping material, although there is apparently work in progress by
manufacturers to produce such a material. Consequently, at this time MTA is best suited to
pulpotomy procedures where a depth of 1mm or more can be achieved. MTA, similar to
calcium hydroxide demonstrates a high pH, but this is maintained even after setting.
Further, the material stimulates the formation of hydroxyapatite-like crystals that are likely
to be responsible for its good sealing properties.
Zinc Oxide Eugenol, Glass Ionomer Cements and adhesive materials are poor direct
capping agents and should be avoided for this application (11).
c.

Pulpotomy

Pulpotomy is a term used for partial or complete removal of diseased coronal pulpal tissue.
The procedure is often carried out in teeth with incomplete root formation, where
pulpectomy for this reason cannot be easily and ideally carried out. The aim of this
procedure is to maintain the vitality and functionality of the root portion of the pulp, so that
root development can be completed. The term apexogenesis is sometimes used for this
procedure. In fully developed teeth, pulpotomy is often carried out as a temporary measure
on an emergency basis until time is available for pulpectomy.
Non-vital pulp therapies
These include: pulpectomy and extraction. They should be carried out when a pulpal
condition is deemed irreversible.
a.

Pulpectomy

Pulpectomy is the removal of all the pulp tissue. Following this procedure and the
subsequent cleaning and shaping of the root canal, the canal is filled to prevent infection of
the periapical tissues. The procedure is indicated where there are clinical signs indicating
irreversible inflammatory changes in the pulp of a permanent tooth with complete root
development. Most often, painful teeth are associated with a deep carious lesion or
restoration, crack, or fractured tooth. Identifying the offending tooth is an important
primary task, and yet it may be a diagnostic challenge.
Emergency pulpotomy of irreversibly inflammed pulp is a compromise treatment carried out
when time constraints preclude complete removal of the pulp. Its primarily aim is to give
relief from painful symptoms.

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Clinical Procedure
Take a periapical radiograph to confirm the appropriateness of treatment.
Secure local anaesthesia.
Isolate the tooth with rubber dam.
Prepare access opening to the pulp and remove the coronal pulp with a bur in an airrotor or large round bur in slow speed.
Irrigate with copious amounts of Endosure solution (1% NaOCl).
Control haemorrhage by pressure with clean cotton wool.
Apply Odontopaste or Ledermix paste over the orifices of the root canals.
Restore the access cavity with a temporary double seal filling, using first Cavit G placed
directly over the orifices of the root canal and then GIC.
Perform pulpectomy as soon as possible.
b.

Extraction

Indications for tooth extraction may be many and varied. Whether endodontic treatment
should be performed is a complex decision and many factors have to be considered. The
clinician must consider the technical potentials and the limitations of treatment in a public
health context. The final decision should be agreed with the informed consent of the
patient. The patient determines which symptoms are tolerable, which economic costs are
acceptable, and which risks are worth taking.

Definitions
Nil

Revision date

Policy owner

September 2016

Clinical Leadership Council

Approved by

Date approved

Director of Clinical Leadership, Education

and Research

August 2013

References and related documents

References:
1. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously
exposed pulp:a systematic review. J Endod. 2011 May;37(5):581-7. doi:
10.1016/j.joen.2010.12.004. Epub 2011 Mar 5.
2. Ghoddusi J, Shahrami F, Alizadeh M, Kianoush K, Forghani M. Clinical and
radiographic evaluation of vital pulp therapy in open apex teeth with MTA and ZOE.
N Y State Dent J. 2012 Apr;78(3):34-8.
3. Orhan AI, Oz FT, Orhan K. Pulp exposure occurrence and outcomes after 1- or 2visit indirect pulp therapy vs complete caries removal in primary and permanent
molars. Pediatr Dent. 2010 Jul-Aug;32(4):347-55.
4. Bjrndal L, Reit C, Bruun G, Markvart M, Kjaeldgaard M, Nsman P, Thordrup M,
Dige I, Nyvad B,Fransson H, Lager A, Ericson D, Petersson K, Olsson J, Santimano

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EM, Wennstrm A, Winkel P,Gluud C. Treatment of deep caries lesions in adults:

randomized clinical trials comparing stepwise vs. direct complete excavation, and
direct pulp capping vs. partial pulpotomy. Eur J Oral Sci. 2010 Jun;118(3):290-7.
doi: 10.1111/j.1600-0722.2010.00731.x.
5. Orhan AI, Oz FT, Ozcelik B, Orhan K. A clinical and microbiological comparative
study of deep carious lesion treatment in deciduous and young permanent molars.
Clin Oral Investig. 2008 Dec;12(4):369-78. doi: 10.1007/s00784-008-0208-6. Epub
2008 Jun 12.
6. L. Virginia Powell. Cariously exposed pulps may benefit from vital pulp therapies.
JADA 2012;143(11):1232-1233
7. Curro, William S. Green and Jonathan A. Ship, Van Thompson, Ronald G. Craig,
Fredrick A. Treatment of deep carious lesions by complete excavation or partial
removal : A critical review. JADA 2008;139(6):705-712
8. Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious
lesions by complete excavation or partial removal: a critical review. J Am Dent
Assoc. 2008 Jun;139(6):705-12.
9. Lars Bjrndal, DDS, PhD. Indirect Pulp Therapy and Stepwise Excavation. PEDIATRIC
DENTISTRY V 30 / NO 3 MAY / JUN 08 08
10. Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp management for
caries in adults: maintaining pulp vitality. Cochrane Collaboration; Published Online: April
18, 2012
11. TJ Hilton. Keys to Clinical Success with Pulp Capping: A Review of the Literature.
Oper Dent. 2009 SepOct; 34(5): 615625.

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