Vital Pulp Therapy: A Case Report

INTRODUCTION

Vital pulp therapy (VPT) has emerged as a cornerstone of contemporary conservative dentistry, reflecting a paradigm shift from traditional concepts of routine pulpectomy toward biologically driven strategies aimed at preserving the vitality of the dental pulp whenever feasible. The fundamental rationale behind VPT lies in the pulp’s intrinsic capacity for healing, regeneration, and continued dentinogenesis when appropriately protected from further insult.¹ Historically, the success of VPT was considered unpredictable, primarily due to limited understanding of pulp biology, lack of standardized clinical protocols, and the variable performance of earlier pulp-capping materials.^2,4 However, advances in biomaterials science, improved diagnostic accuracy, and refined clinical techniques have significantly enhanced the predictability of outcomes, even in cases involving deep carious lesions approaching or involving the pulp.³ The introduction of bioactive calcium silicate–based materials such as mineral trioxide aggregate (MTA), Biodentine, and more recently, resin-modified calcium silicate cements like TheraCal PT, has revolutionized the domain of pulp preservation by offering superior sealing ability, biocompatibility, bioactivity, and mechanical properties that favor pulpal healing.^5-7,12 These materials stimulate the release of bioactive ions, promote dentin bridge formation, and facilitate an environment conducive to hard tissue deposition and maintenance of pulpal vitality.^8-10

In clinical practice, the decision to pursue VPT relies heavily on accurate assessment of pulpal status, control of inflammation, bacterial reduction, and establishment of a hermetic coronal seal.^2,3 Contemporary evidence demonstrates that even teeth with signs of reversible or early stages of irreversible pulpitis may respond favorably to VPT when modern biomaterials and aseptic techniques are employed.^3,8 The success rates reported in recent literature have supported the expansion of indications for VPT, challenging the long-held notion that symptomatic teeth must be treated with traditional endodontic therapy. Such cases, particularly in young patients or teeth with strategic value, highlight the biological and functional benefits of preserving vital pulpal tissue, including proprioception, continued root development, and greater long-term structural integrity.¹¹ Additionally, VPT aligns with the principles of minimally invasive dentistry and cost-effective care, promoting preservation of natural tooth structure without compromising prognosis.¹¹

The present two case reports contributes to this expanding body of evidence by demonstrating the clinical application and successful outcome of VPT using modern bioactive materials in a deep carious lesion. It underscores the relevance of proper case selection, meticulous clinical execution, and the role of advanced pulp-capping agents in ensuring favorable biological responses.^6,12-14 By examining the clinical progress, radiographic findings, and biological rationale underlying this treatment approach, the discussion emphasizes how VPT continues to evolve as a reliable and scientifically grounded alternative to conventional root canal therapy. These cases not only reinforces the regenerative potential of dental pulp but also highlights the importance of material choice and contemporary techniques in achieving optimal long-term outcomes.^1,6,12

CASE REPORT

CASE 1

A 22-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of sensitivity and food lodgement in the lower left back tooth for the past two weeks. Clinical examination revealed a deep occlusal carious lesion in the maxillary left first molar (tooth 36). The tooth was not tender to percussion, and there was no swelling or sinus tract associated with it. Thermal testing revealed a sharp but non-lingering response to cold, while electric pulp testing elicited a normal response, indicating a vital pulp with reversible inflammation. A periapical radiograph showed a deep carious lesion approaching the pulp, with no evidence of periapical radiolucency or periodontal ligament widening. Based on both clinical and radiographic evaluation, the diagnosis of deep caries with reversible pulpitis was established, and indirect pulp capping (IPC) was planned using Biodentine due to its superior bioactivity and dentinogenic potential.

CLINICAL PROCEDURE

Following administration of local anesthesia, the tooth was isolated with a rubber dam to maintain a sterile working environment. Caries excavation was initiated using a slow-speed round bur under magnification and good illumination. Complete removal of peripheral and undermined enamel and dentin was carried out until hard; sound dentin was achieved. As the caries neared the pulp, excavation was performed carefully to avoid iatrogenic exposure. A thin layer of soft, caries-affected dentin was intentionally left over the pulp chamber to prevent exposure and preserve the vitality of the pulp. The cavity floor was disinfected with 2% chlorhexidine gluconate to reduce bacterial load and improve prognosis.

Once the cavity was adequately prepared, Biodentine (Septodont), a tricalcium silicate-based bioactive dentin substitute, was mixed according to the manufacturer’s instructions. Biodentine was selected due to its excellent sealing ability, biocompatibility, bioactivity, and capacity to stimulate tertiary dentin formation. The freshly mixed Biodentine was carefully placed over the remaining dentin in a 1–2 mm thickness, ensuring complete adaptation and coverage of the deep area. After placement, the material was allowed to set during the same visit, benefitting from its short setting time of approximately 12 minutes. Following this, the tooth was temporarily restored to allow Biodentine maturation, in keeping with clinical protocols that recommend delaying composite placement until the material achieves its optimal mechanical properties.

At the two-week follow-up visit, the patient was asymptomatic, and the tooth responded normally to pulp vitality tests. The temporary restoration was removed, and the Biodentine base was evaluated; it appeared intact, firm, and well-integrated. A resin-modified glass ionomer (RMGIC) lining was placed over the Biodentine to serve as an intermediary base, and the tooth was restored permanently with a nano-hybrid composite resin using incremental layering. Occlusal adjustments were made to ensure proper function and patient comfort.

The patient was reviewed again at three months, six months, and twelve months. At each follow-up appointment, the tooth remained completely asymptomatic, and clinical testing showed normal responses to cold and electric pulp tests. Radiographic evaluation at six and twelve months revealed increased dentin thickness beneath the Biodentine layer, consistent with tertiary dentin bridge formation, and maintained integrity of the periodontal ligament space without any signs of periapical changes. The final restoration remained intact, functioning, and aesthetically satisfactory.

CASE 2

19-year-old male reported to the Department of Conservative Dentistry and Endodontics complaining of food lodgement and mild occasional pain in the upper right back tooth for the past month. Clinical examination revealed a large occlusal carious lesion in the maxillary right first molar (tooth16), but the tooth was not tender to percussion and showed no swelling or sinus tract. Vitality testing showed an exaggerated but non-lingering response to the cold test and a positive electric pulp test, suggestive of reversible pulpitis. A periapical radiograph revealed a deep dentinal carious lesion approximating—but not exposing—the pulp, with an intact periodontal ligament space and no periapical changes. Based on these findings, a diagnosis of deep caries with reversible pulpitis was established, and indirect pulp therapy (IPT) was planned to preserve pulpal vitality.

CLINICAL PROCEDURE

After administering local anesthesia, the tooth was isolated with a rubber dam to prevent salivary contamination. Caries removal was carried out using a slow-speed round bur and hand excavators. The peripheral enamel and dentin were excavated completely until firm dentin was obtained; however, a thin layer of demineralized dentin was intentionally left on the pulpal floor to avoid pulp exposure and to respect the principles of minimally invasive dentistry. After excavation, the cavity floor was disinfected using 2% chlorhexidine gluconate to reduce the bacterial load and improve the prognosis of the pulp. Once the cavity was adequately prepared, a bioactive pulp-capping material was placed. In this case, TheraCal PT, a resin-modified calcium silicate material, was selected due to its biocompatibility, high calcium ion release, immediate light curing, and excellent sealing ability. A uniform 1–1.5 mm layer of TheraCal PT was gently placed over the remaining dentin and light-cured for 20 seconds to ensure complete polymerization.

Following the placement of the capping material, a thin layer of resin-modified glass ionomer cement (RMGIC) was applied as a base to reinforce the liner and provide an ideal substrate for the final restoration. The tooth was then restored with nano-hybrid composite resin using incremental layering techniques to ensure optimal adaptation, strength, and esthetics. The occlusion was checked and adjusted to eliminate any high points that may affect postoperative comfort. The restoration was polished, and the patient was advised to report back if any symptoms developed.

At the one-week follow-up, the patient reported no postoperative discomfort, and the clinical examination revealed normal responses to percussion. At three months, the tooth remained asymptomatic, and radiographs showed maintained periapical health. Six-month evaluation demonstrated normal pulp vitality responses and radiographic evidence of increasing dentin thickness beneath the capping material, indicating successful tertiary dentin formation. At the twelve-month review, the patient remained symptom-free, and radiographic examination revealed a well-formed dentin bridge beneath the TheraCal PT layer, with no signs of periapical pathology or internal changes. The restoration remained intact and functional.

DISCUSSION

The choice for IPT in these cases was based on careful pulp diagnosis, which was supported by evaluation of the history of pain, symptoms and clinical/radiographic findings. In the present two cases, positive results suggest IPT for management of deep caries lesion in permanent molars teeth. Most studies reported in the literature evaluated IPT for treatment of deep caries lesion in primary molars^15,26,28,30 while some clinical studies were carried out on the permanent teeth.^32,33,34 Retrospective and prospective studies showed that in both dentitions the success rate for IPT is similar, ranging from 73% to 95% after 2 weeks to 11 years of follow-up.^15,26,28,30

Active caries lesion can be distinguished into two layers: infected dentin which is a superficial soft layer of collagen fibrils partially degraded that cannot be remineralized; and affected dentin, which is partially demineralized, with intact collagen fibrils that can be remineralized.³⁶ However, the clinical recognition of these two layers is a difficult task because not only color and consistency of the dentin are absolute indicators of decayed tissue.²⁰ Experience and clinical judgment are essential skills for appropriate removal of infected dentin, leaving the potentially remineralizable affected dentin. For some authors it is not necessary the complete removal of decay in a second step.^28,42 Their clinical and radiographic results support the theory that the decay process was apparently arrested after IPT with a single visit procedure.²⁸ According to Fairbourn, et al.²⁵, the second appointment may not be necessary, if the final restoration maintains the cavity sealed and the tooth asymptomatic. On the other hand, Leksell, et al.³² observed a statistically significant difference in the frequency of pulp exposures between one-step and two-step procedures. Furthermore, when the cavity is re-opened the clinician can inspect the cavity floor.

Patients' age is another factor to be considered since conservative treatments have been more indicated for young patients.³⁰ In this study, the patient treated was 16 years old. It is known that there is a reduction of the cell population, the pulpal volume, and also the vascular supply with the increase of pulp age.⁴³

The material of choice to be placed over the demineralized dentin is another issue of discussion in the literature. Some materials that have bacteriostatic/bactericidal effect were indicated for application over the affected dentin, such as: calcium hydroxide^15,17,18, zinc-oxide eugenol (ZOE) cements^21,25, dentin bonding agents^26,42 and glass ionomer cements (GIC).^{15,28,33,44,46}

Washing the cavity with calcium hydroxide solution is an important step for IPT because carious/demineralized dentin is left after the first visit. The use of calcium hydroxide solution has demonstrated to arrest caries lesion by its action on bacterial activity and growth.²⁹ As the carious tissue is not completely removed, the availability of calcium and hydroxyl ions is also important for subsequent remineralization and healing of the affected dentin. In the second visit, the solution of calcium hydroxide is useful to maintain a high pH value²⁷, since metalloproteinases (MMPs) may be activated by an acidic pH brought by lactate release from cariogenic bacteria.²²

The success rates of IPT in deep caries using calcium hydroxide liner varied from 92% to 97%.^15,32,33,44 It has been shown that the IPT with calcium hydroxide and a subsequent good marginal sealing reduced the substrate for bacteria, decreased lesion progression and promoted a physiological reaction in the pulp-dentin complex.³³ It was also observed that calcium hydroxide may induce sclerosis and formation of secondary dentin.^33,45 Possible explanations for these observations are the increase in the mineral content of the underlying dentin, as well as a chemical effect of calcium hydroxide on the soft demineralized dentin.²²

ZOE cements can also be used as IPT agents and usually present high degrees of success.^25,32 These materials have been placed over the remaining carious dentin once their bactericidal properties and sealing qualities would result in inhibition of bacterial growth, arresting the carious process.²⁵

Regarding the use of bonding agents, Ribeiro, et al.⁴² reported an altered hybrid layer without any signs of subsequent demineralization that could suggest progression of the lesion in primary molars when Scotchbond Multi-Purpose adhesive system was used on carious dentin. These results were corroborated by another study that observed, also in primary teeth, the clinical success of IPT regardless of the application of calcium hydroxide prior to restoration with a composite resin.²⁶ This study suggest that, once the grossly decayed dentin is removed and good interfacial seal is provided, the healing process of the dentin-complex is independent from the application of an inducer of mineralization such as calcium hydroxide.²⁶ According to Cavalcanti, et al.²¹, adhesive systems release cytotoxic substances for human dental pulp fibroblasts in culture, whilst those leached from calcium hydroxide cement are biocompatible. Costa, et al.²³ concluded that the total etching followed by application of One Step bonding agent cannot be recommended for deep cavities in permanent teeth. Future studies are necessary to evaluate the effect of both techniques (calcium hydroxide cement and dentin bonding agents) on bacterial growth in remaining affected dentin after IPT.

Vij, et al.⁴⁴ reported a success rate of 92% after 2 years using GIC over deep caries in primary teeth, which is comparable to studies where calcium hydroxide liner was used.^15,33,44 It has been suggested that success following caries control with GIC restorations may be due to the antimicrobial effect on streptococci mutans.²⁰ These cements have certain unique properties, such as the release of fluoride ions, coefficients of thermal expansion similar to those of tooth structure and biocompatibility46. Farooq, et al.²⁸ reported 93% success of IPT in primary teeth with the use of a RMGIC as a liner without the use of calcium hydroxide over an average follow-up of 4 years. In these case report, calcium hydroxide paste was applied followed by the placement of a RMCIC restoration. After 60 days, the restoration was changed for a calcium hydroxide cement liner, followed by application of a RMGIC base and placement of an adhesive restoration. At 4-year follow-up, neither clinical symptoms nor clinical and radiographic signs of pulp degeneration were found. The real role a liner with calcium hydroxide plays in IPT is not fully demonstrated, but the rate of success is high when this material is applied.^15,32,33,44 Further well designed randomized controlled trials are needed to investigate the potential of contemporary materials that may be suitable when used in the management of deep caries lesions.³⁷

CONCLUSION

Based on the clinical and radiographic observations, it may be concluded that VPT maintained the pulp vitality and function of the permanent molar presented in these two case reports. In these two present case report, the successful preservation of pulpal vitality following indirect pulp capping reinforces the effectiveness of contemporary bioactive materials such as Biodentine and TheraCal PT in the management of deep carious lesions. Both materials demonstrated superior clinical handling, excellent sealing ability, and predictable dentinogenic activity, contributing to favorable clinical and radiographic outcomes during follow-up. Biodentine, with its enhanced biocompatibility, optimal alkaline pH, and capacity to stimulate rapid and dense tertiary dentin formation, provided a reliable protective barrier over the remaining dentin. Similarly, TheraCal PT exhibited strong mechanical properties, immediate light-curing capability, and sustained calcium ion release, which collectively enhanced pulpal healing and ensured a durable seal against bacterial infiltration. When compared to conventional calcium hydroxide, which is limited by its solubility, poor sealing ability, and formation of porous dentin bridges with tunnel defects, both Biodentine and TheraCal PT demonstrated markedly superior performance. Their advanced physical and biological properties overcome the shortcomings of calcium hydroxide and lead to more predictable long-term outcomes. Overall, these cases highlights that modern calcium silicate-based materials such as Biodentine and TheraCal PT represent a significant advancement in indirect pulp therapy, offering enhanced pulp preservation and long-lasting clinical success compared to traditional calcium hydroxide.

These two cases confirms that indirect pulp capping is a conservative and effective approach for preserving pulpal vitality in deep carious lesions when proper case selection and a reliable bioactive material are used. The successful clinical and radiographic outcomes reinforce the value of IPC as a minimally invasive alternative to more extensive restorative or endodontic procedures.

Future Directions:
Further long-term clinical studies and follow-ups are needed to evaluate the durability of different IPC materials, compare their regenerative potential, and establish standardized protocols that can enhance predictability and overall treatment success.

REFERENCES