Review Article
Vital Pulp Therapy in Vital Permanent Teeth with Cariously
Exposed Pulp: A Systematic Review
Panuroot Aguilar, MSc, DDS, and Pairoj Linsuwanont, DDS, MDSc, PhD
Abstract
Introduction: This systematic review aims to illustrate
the outcome of vital pulp therapy, namely direct pulp
capping, partial pulpotomy, and full pulpotomy, in vital
permanent teeth with cariously exposed pulp. Methods:
Electronic database MEDLINE via Ovid, PubMed, and
Cochrane databases were searched. Hand searching
was performed through reference lists of endodontic
textbooks, endodontic-related journals, and relevant
articles from electronic searching. The random effect
method of weighted pooled success rate of each treat-
ment and the 95% confidence interval were calculated
by the DerSimonian-Laird method. The weighted pooled
success rate of each treatment was estimated in 4
groups: >6 months1 year, >12 years, >23 years,
and >3 years. All statistics were performed by STATA
version 10. The indirect comparison of success rates
for 4 follow-up periods and the indirect comparison of
clinical factors influencing the success rate of each treat-
ment were performed by z test for proportion (P < .05).
Results: Overall, the success rate was in the range of
72.9%99.4%. The fluctuation of the success rate of
direct pulp capping was observed (>6 months1 year,
87.5%; >12 years, 95.4%; >23 years, 87.7%; and
>3 years, 72.9%). Partial pulpotomy and full pulpotomy
sustained a high success rate up to more than 3 years
(partial pulpotomy: >6 months1 year, 97.6%; >12
years, 97.5%; >23 years, 97.6%; and >3 years,
99.4%; full pulpotomy: >6 months1 year, 94%; >12
years, 94.9%; >23 years, 96.9%; and >3 years,
99.3%). Conclusions: Vital permanent teeth with cari-
ously exposed pulp can be treated successfully with vital
pulp therapy. Current best evidence provides inconclu-
sive information regarding factors influencing treatment
outcome, and this emphasizes the need for further
observational studies of high quality. (J Endod
2011;37:581587)
From the Faculty of Dentistry, Chulalongkorn University,
Bangkok, Thailand.
Supported by H. M. King Bhumibol Adulyadejs 72nd
birthday anniversary scholarship of Chulalongkorn University,
Bangkok, Thailand.
Address requests for reprints to Dr Pairoj Linsuwanont,
Department of Operative Dentistry, Faculty of Dentistry, Chula-
longkorn University, Henri-Dunant Rd, Patumwan, Bangkok,
Thailand. E-mail address: pairoj_lins@yahoo.com.au
0099-2399/$ - see front matter
Copyright 2011 American Association of Endodontists.
doi:10.1016/j.joen.2010.12.004
JOE Volume 37, Number 5, May 2011
Key Words
Dental caries, direct pulp capping, full pulpotomy, partial pulpotomy, systematic review,
treatment outcome
U p until now, there has been no agreement on the best way to treat vital permanent
teeth with cariously exposed pulp (1, 2). It has been claimed that pulpectomy is the
most suitable treatment for preventing and/or healing apical periodontitis (3, 4). It has
been clearly shown that root canal treatment on teeth with vital pulp gives a reliable
outcome (5, 6). However, the prognosis in term of survival rate of endodontically
treated teeth is not as good as vital teeth, especially in molars (hazard ratio, 7:1) (7).
The possible reasons could include the loss of proprioceptive function (8), damping
property (9), and tooth sensitivity, which are provided by vital pulp as a defensive mech-
anism from harmful stimuli. Therefore, the vital pulp should be preserved if possible.
It has been recommended that vital pulp therapy, namely direct pulp capping,
partial pulpotomy, or full pulpotomy, should be performed only in teeth with reversible
pulpitis with no periapical pathologies or in teeth with either mechanical pulp exposure
or recently traumatic pulp exposure (1012). The problem is how we can accurately
assess whether the status of the pulp is reversible or irreversible. The clinical signs and
symptoms such as degree or characteristic of pain do not precisely reflect the pulp
condition (1315). The vitality test, for example, thermal test or electric pulp test,
reveals only a yes or no response (13, 16). Currently, several studies have reported
successful outcome of vital pulp therapy in vital teeth with cariously exposed pulp
with signs and symptoms of irreversible pulpitis with periapical lesions (1720).
Decision-making when approaching clinical problems should be based on the
best currently available evidence. Systematic review consists of collecting unbiased
data systematically and reevaluation by meta-analysis of relevant articles. This approach
is considered to provide the highest level of evidence (21).
The aim of this study was to perform a systematic review to illustrate the clinical
and radiographic success of each treatment procedure, namely direct pulp capping,
partial pulpotomy, and full pulpotomy, in vital permanent teeth with cariously exposed
pulp.
Materials and Methods
Literature Search
Searching strategy (Table 1) was conducted independently by 2 reviewers (P.A.,
P.L.) via MEDLINE via Ovid, PubMed, and the Cochrane database.
Seven textbooks including Principles and Practice of Endodontics (Torabinejad
and Walton, 4th ed, 2008), Pathways of the Pulp (Cohen and Hargreaves, 9th ed,
2006), Endodontics (Ingle, Bakland, and Baumgartner, 6th ed, 2008), Textbook of
Endodontology (Bergenholtz, Horsted-Bindslev, and Reit, 2nd ed, 2010), Endodon-
tics (Stock, Waler, and Gulabivala, 3rd ed, 2004), Essential Endodontology (Ostarvik
and Pitt Ford, 2nd ed, 2008), Pulp-Dentin Biology in Restorative Dentistry (Mjor, 1st
ed, 2002), Seltzer and Benders Dental Pulp (Hargreaves and Goodis, 3rd ed, 2002),
and 5 endodontic-related journals (International Endodontic Journal, Journal of
Endodontics, Oral Surgery Oral Medicine Oral Pathology Oral Radiology Endodon-
tology, Dental Traumatology, and Australian Endodontic Journal) were hand-
searched. Finally, reference lists of relevant articles from both electronic search and
hand search were screened again.
Vital Pulp Therapy in Vital Permanent Teeth with Cariously Exposed Pulp 581
Review Article
TABLE 1. Search Strategy through MEDLINE via Ovids Website and PubMed College Station, TX). The indirect comparisons of success rates were
(January 1950May 2010) performed by z test for proportion (P < .05).
Command (MeSH terms) Result
1. Endodontics 20,513 Results
2. Dental caries 32,488 Electronic search identified 63 studies as shown in Table 1.
3. Dental pulp capping 1,654 Thorough screening by 2 reviewers (P.A., P.L.) revealed 14 relevant arti-
4. Pulpotomy 1,139
5. Treatment outcome 438,595 cles that met inclusion criteria. Hand search identified an additional 9
6. Survival rate 95,515 relevant articles. The flowchart of the searching process is shown in
7. Prognosis 736,434 Figure 1. A total of 23 relevant articles were submitted to further analysis.
8. Deciduous tooth 8,210 Most of the relevant articles were either cohort studies (5 studies)
9. 1 OR 2 52,273
10. 3 OR 4 2,451
or case series (14 studies); only 4 studies were randomized controlled
11. 5 OR 6 OR 7 787,111 trials. The mean quality score (maximum of 17 points) was 8.8 for
12. 9 AND 10 AND 11 152 direct pulp capping studies, 8.16 for partial pulpotomy studies, and
13. 12 NOT 8 84 9.14 for full pulpotomy studies. Overall, the level of evidence of vital
14. 13 limit human 77 pulp therapies was mostly in 4 or 3b.
15. 14 limit English 63
The total number of teeth included in this analysis was 1385: 996
for direct pulp capping, 199 for partial pulpotomy, and 190 for full pul-
potomy. The follow-up period of direct pulp capping, partial pulpot-
Inclusion Criteria omy, and full pulpotomy was in the range of 110 years (recall rate
of 13%100%), 13 years (recall rate of 78%100%), and 17 years
1. Original clinical studies of treatment of human vital permanent teeth (recall rate of 33%100%), respectively. Time of publication was
with cariously exposed pulp. between 1971 and 2010 for direct pulp capping, 1989 and 2007 for
2. Calcium hydroxide or mineral trioxide aggregate (MTA) was used as partial pulpotomy, and 1993 and 2006 for full pulpotomy. Age of patient
medicament in direct pulp capping, partial pulpotomy, and full pul- was in the range of 610 years for direct pulp capping, 627 years for
potomy. partial pulpotomy, and 670 years for full pulpotomy.
3. Evaluation of success was based on both clinical and radiographic The success rate of each relevant article and weighted pooled
examination. success rate of each treatment procedure are shown in detail in
4. Success rate was given or could be calculated from raw data. Tables 24. Overall, the success rate of each treatment was between
5. At least 6-month follow-up. 72.9% and 99.4%. The fluctuation of success rate of direct pulp
6. Presentation in English only. capping was observed. Indirect comparison of the success rate of 4
recall periods of each treatment showed no statistically significant
difference in partial pulpotomy and full pulpotomy.
Study Selection and Assessment Direct comparison of the weighted pooled success rate when using
of the Quality of the Studies either calcium hydroxide or MTA as pulp capping medicament showed
The title and abstract of all identified articles were screened by 2 no statistically significant difference (Table 5). Indirect comparison of
independent reviewers (P.A., P.L.) to eliminate articles that clearly did weighted pooled success rate showed that MTA was superior to calcium
not meet inclusion criteria. Full text copies were collected and analyzed. hydroxide in direct pulp capping, but calcium hydroxide provided
The useful information from each study such as type of study, sample better clinical outcome than MTA in partial pulpotomy (Table 6). In
sizes, inclusion criteria, recall rate, etc were recorded on the individual full pulpotomy, there was no statistically significant difference of
data abstraction form. The studies that did not meet inclusion criteria weighted pooled success rate between these 2 materials.
were excluded. Indirect comparison of weighted pooled success rate of each
Each relevant article was evaluated for quality of the study and level treatment in teeth with either opened apex or closed apex is presented
of evidence. Rating quality score criteria from Torabinejad et al (22, 23)
were used to evaluate the research methodology (details are shown in
Appendix 1). The level of evidence of each relevant study was ranked 63 articles identified from electronic database
following criteria of Oxford University Centre for Evidence-based
Medicine (http://www.cebm.net) (24). 49 excluded articles from electronic search
The evidence tables were constructed to contain authors name, 34 non-carious exposed pulp study
year of publication, material use, sample size, success rate, 95% 5 non permanent teeth study
confidence interval (CI), level of evidence, quality score, and weighted 3 review article, systematic review, case report
1 data not available for recalculation
pooled success rate. 2 inadequate clinical or radiograph examination
1 animal study
3 non MTA or calcium hydroxide used in vital pulp therapy
Data Analysis
The weighted pooled success rate of each treatment was calculated 14 articles met inclusion criteria
into 4 groups: >6 months1 year, >12 years, >23 years, and >3
years by the DerSimonian-Laird method. Factors influencing the success
rate of each treatment were analyzed. The weighted pooled success rate
9 articles identified from hand searching
of each treatment in relation to materials used (either calcium
hydroxide or MTA) or stage of root development (either closed apex 23 relevant articles for data analysis
or opened apex) was estimated by the DerSimonian-Laird method.
All statistics were performed by STATA version 10 (Stata Corp, Figure 1. Flowchart of systematic searching process.

582 Aguilar and Linsuwanont JOE Volume 37, Number 5, May 2011
 Review Article
TABLE 2. Evidence Table of Relevant Articles of Direct Pulp Capping
CI
Sample Success Quality
Author/year (reference) Material Time size rate (%) Lower Upper LOE* score
Shovelton/1971 (29) Ca(OH)2 >6 mo1 y 45 82.2 70.9 93.5 2b 11
Gallien/1985 (49) Ca(OH)2 >6 mo1 y 17 88.2 75.2 104 3b 6
Fitzgerald/1991 (31) Ca(OH)2 >6 mo1 y 8 75 42.9 107.1 2b 11
Matsuo/1996 (17) Ca(OH)2 >6 mo1 y 25 80 64 96 4 7
Santucci/1999 (34) Ca(OH)2 >6 mo1 y 29 75.9 60 91.7 3b 6
Farsi/2006 (33) MTA >6 mo1 y 30 93.3 84.3 102.4 4 7
Bogen/2008 (30) MTA >6 mo1 y 49 100 90.9 109.1 4 9
Weighted pooled success rate(95% CI) 87.5 80.2 94.8
Shovelton/1971 Ca(OH)2 >12 y 32 96.9 90.7 103.1 2b 11
Gallien/1985 Ca(OH)2 >12 y 15 93.3 80.3 106.4 3b 6
Matsuo/1996 Ca(OH)2 >12 y 10 100 93.8 106.2 4 7
Santucci/1999 Ca(OH)2 >12 y 18 72.2 50.9 93.5 3b 6
Farsi/2006 MTA >12 y 28 100 93.8 106.2 4 7
Bogen/2008 MTA >12 y 49 100 93.8 106.2 4 9
Mente/2010 (35) Ca(OH)2, MTA >12 y 44 79.6 66.8 92.4 3b 14
Weighted pooled success rate (95% CI) 95.4k 90.4 100.5
Gallien/1985 Ca(OH)2 >23 y 14 100 85.9 114.1 3b 6
Bogen/2008 MTA >23 y 12 100 85.9 114.1 4 9
Mente/2010 Ca(OH)2, MTA >23 y 46 63 48.9 77.1 3b 14
Weighted pooled success rate (95% CI) 87.7 63.5 111.8
Haskell/1978 (32) Ca(OH)2 >3 y 125 87.1 80.8 93.4 4 7
Barthel/2000 (44) Ca(OH)2 >3 y 62 37.6 25.4 49.8 4 10
Bogen/2008 MTA >3 y 17 98 91.1 104.9 4 9
Mente/2010 Ca(OH)2, MTA >3 y 27 66.7 48.5 84.8 3b 14
Weighted pooled success rate (95% CI) 72.9 49.6 96.3
The different signs (, k, and ) above weighted success rate of each period indicate statistically significant difference (P < .05).
*LOE, level of evidence according to Oxford Centre for Evidence-based Medicine, 2009.

Quality score following the criteria of Torabinejad et al (22, 23).

The weighted success rate was performed by random effect of DerSimonian-Laird method.

in Table 7. Teeth with opened apex showed a more successful outcome Discussion
than teeth with closed apex in direct pulp capping (94.5%:69.2%) but Evaluation of the quality of selected studies following the criteria of
not in partial pulpotomy (94.6%:90.6%) and full pulpotomy Torabinejad et al (22, 23) showed that the mean scores of each
(91.4%:85.9%). treatment, namely direct pulp capping, partial pulpotomy, and full

TABLE 3. Evidence Table of Relevant Articles of Partial Pulpotomy

CI
Sample Success Quality
Author/year (reference) Material Time size rate (%) Lower Upper LOE* score
Baratieri/1989 (36) Ca(OH)2 >6 mo1 y 26 100 94.4 105.6 4 8
Mass/1993 (26) Ca(OH)2 >6 mo1 y 35 97.1 91.6 102.7 4 7
Nosrat/1998 (48) Ca(OH)2 >6 mo1 y 6 100 94.4 105.6 4 8
Barrieshi-Nusair/2006 (38) MTA >6 mo1 y 28 82.1 67.7 96.6 4 8
Weighted pooled 97.6 93 102.2
success rate (95% CI)
Baratieti/1989 Ca(OH)2 >12 y 26 100 94.5 105.5 4 8
Mejare/1993 (18) Ca(OH)2 >12 y 37 91.9 83 100.8 4 7
Mass/1993 Ca(OH)2 >12 y 32 96.9 90.8 103 4 6
Nosrat/1998 Ca(OH)2 >12 y 6 100 94.5 105.5 4 8
Barrieshi-Nusair/2006 MTA >12 y 21 95.2 85.9 104.6 4 8
Qudeimat/2007 (37) Ca(OH)2, MTA >12 y 50 96 90.6 101.5 1b 12
Weighted pooled 97.5 94.9 100.1
success rate (95% CI)
Mass/1993 Ca(OH)2 >23 y 21 95.2 85.9 104.6 4 6
Mejare/1993 Ca(OH)2 >23 y 33 100 90.7 109.3 4 7
Weighted pooled 97.6 91 104.2
success rate (95% CI)
Mass/1993 Ca(OH)2 >3 y 6 100 94.7 105.3 4 6
Mejare/1993 Ca(OH)2 >3 y 17 98.8 93.5 104.2 4 7
Weighted pooled 99.4 95.6 103.2
success rate (95% CI)

*LOE, level of evidence according to Oxford Centre for Evidence-based Medicine, 2009.

Quality score following the criteria of Torabinejad et al (22, 23).

The weighted success rate was performed by random effect of DerSimonian-Laird method.

JOE Volume 37, Number 5, May 2011 Vital Pulp Therapy in Vital Permanent Teeth with Cariously Exposed Pulp 583
Review Article
TABLE 4. Evidence Table of Relevant Articles of Full Pulpotomy
CI
Sample Success Quality
Author/year (reference) Material Time size rate (%) Lower Upper LOE* score
Caliskan/1993 (39) Ca(OH)2 >6 mo1 y 24 91.7 80.4 102.9 4 7
Caliskan/1995 (19) Ca(OH)2 >6 mo1 y 26 92.3 81.9 102.7 4 8
Waly/1995 (53) Ca(OH)2 >6 mo1 y 20 100 90.9 109.1 3b 10
Teixeira/2001 (20) Ca(OH)2 >6 mo1 y 41 82.9 71.3 94.6 3b 11
DeRosa/2006 (43) Ca(OH)2 >6 mo1 y 26 92.3 81.9 102.7 4 7
Witherspoon/2006 (46) MTA >6 mo1 y 13 100 90.9 109.1 4 9
El-Meligy/2006 (45) Ca(OH)2, MTA >6 mo1 y 30 93.33 84.3 102.4 1b 12
Weighted pooled 94 89.8 98.1
success rate (95% CI)
Caliskan/1993 Ca(OH)2 >12 y 8 100 90.2 109.8 4 7
Waly/1995 Ca(OH)2 >12 y 20 95 85.2 104.8 3b 10
DeRosa/2006 Ca(OH)2 >12 y 24 87.5 74 101 4 7
Witherspoon/2006 MTA >12 y 10 90 70.4 109.6 4 9
Weighted pooled 94.9 89 100.8
success rate (95% CI)
Caliskan/1993 Ca(OH)2 >23 y 6 100 89.7 110.3 4 7
Caliskan/1995 Ca(OH)2 >23 y 12 100 89.7 110.3 4 8
Waly/1995 Ca(OH)2 >23 y 19 94.7 88.4 105 3b 10
DeRosa/2006 Ca(OH)2 >23 y 21 90.5 77.6 103.3 4 7
Weighted pooled 96.9 91.5 102.3
success rate (95% CI)
Caliskan/1993 Ca(OH)2 >3 y 6 100 91.7 108.3 4 7
Waly/1995 Ca(OH)2 >3 y 18 100 91.7 108.3 3b 10
DeRosa/2006 Ca(OH)2 >3 y 13 97.8 89.5 106.1 4 7
Weighted pooled 99.3 94.5 104.1
success rate (95% CI)

*LOE, level of evidence according to Oxford Centre for Evidence-based medicine 2009.

Quality score following the criteria of Torabinejad et al (22, 23).

The weighted success rate was performed by random effect of DerSimonian-Laird method.

pulpotomy, were in the range of 810 points out of the maximum 17
points. It suggests that the methodology of these studies might not be
best designed or conducted, which can incur a risk of bias or error
(25). Although this is the best currently available evidence, the strength
of clinical inference is not strong. More well-designed observational
studies are required.
The inclusion criteria of this systematic review were constructed to
reproduce the routine clinical practice. Evaluation of success rate was
based on both clinical and radiographic examination. Only calcium
hydroxide or MTA was used as medicament for vital pulp therapy.
Articles were excluded for the following reasons: non-carious exposed
teeth studies that mostly were trauma studies (5557); inadequate
clinical or radiograph examination (10, 58); success rate was not
stated or could not be recalculated (52, 59); calcium hydroxide or
MTA was not used as pulp capping materials (60, 61).
Statistical comparison of the success rates among direct pulp
capping, partial pulpotomy, and full pulpotomy might not be appro-
priate for various reasons. First, there has not been any published
clinical study directly comparing one treatment with another. Second,
the study methodologies of each treatment were different in terms of
case selection, material used, and treatment protocol. For example,
teeth with a history of spontaneous pain with periapical radiolucency
lesion were included in full pulpotomy (19, 20) and partial
pulpotomy studies (18, 26) but not in direct pulp capping studies.
The weighted pooled success rate of each treatment was in the
range of 72.9%99.4%. It provides evidence that vital permanent teeth
with cariously exposed pulp might be managed successfully by vital pulp
therapy. It is reasonable to point out that teeth with caries exposure
should not always be diagnosed as irreversible pulpitis and therefore
require pulpectomy.
The success rate of direct pulp capping was observed to fluctuate.
In contrast, partial pulpotomy and full pulpotomy sustained a high
success rate of 3 years or more. Direct pulp capping is the process
of the removal of caries and applying pulp capping material over the
pulp exposure site without removal of the inflamed tissue underneath
the caries lesion. It is reasonable to assume that the completion of
inflamed tissue removal is critical to the healing of vital pulp therapy
(27, 28).
The key to the success of vital pulp therapy might partly be strict
case selection and proper treatment protocol. Data from selected
studies showed that 70% of direct pulp capping (17, 2935) and
partial pulpotomy (18, 26, 3638) studies included only teeth with

TABLE 5. Direct Comparison of the Success Rate of Each Treatment When Using Either Ca(OH)2 or MTA as Pulpal Medicament
Treatment procedure N RP Calcium hydroxide MTA Statistical analysis*
Direct pulp capping (Mente et al) (35) 167 1>3 60 78 NS
Partial pulpotomy (Qudeimat et al) (37) 64 2.13.8 91.3 92.85 NS
Full pulpotomy (El-Meligy and Avery) (45) 30 1 86.66 100 NS
N, number of samples; RP, recall period (y); NS, not statistically significant difference.
*Result from original articles statistical analysis.

584 Aguilar and Linsuwanont JOE Volume 37, Number 5, May 2011
 Review Article
TABLE 6. Indirect Comparison of the Weighted Pooled Success Rate of Each Treatment When Using Either Ca(OH)2 or MTA as Pulpal Medicament
Ca(OH)2 MTA

Treatment procedure (references) nt ns wps nt ns wps Result

Direct pulp capping (17, 2935, 44, 49) 433 276 70.6 148 140 90.5 S
Partial pulpotomy (18, 26, 3638, 48) 121 118 94.8 148 130 87.5 S
Full pulpotomy (19, 20, 39, 43, 45, 46, 53) 182 152 86.6 28 27 96.1 NS
The weighted pooled success rate of MTA and Ca(OH)2 in each treatment procedure was calculated by the random effect of DerSimonian-Laird method. The weighted pooled success rate of MTA and Ca(OH)2 in
each treatment was compared with z test for proportion with P < .05.
nt, number of total sample; ns, number of successful; wps, weighted pooled success rate; S, statistically significant difference; NS, not statistically significant difference.

caries exposure with either short duration pain or asymptomatic,
normal response to percussion test and normal radiographic
appearance apically. Several studies included teeth with signs and
symptoms of irreversible pulpitis such as teeth with spontaneous pain
(17, 18, 20) and teeth that were positive to percussion (17, 18). In
full pulpotomy studies, teeth with periapical radiolucency lesion were
treated successfully (n = 56, weighted pooled success rate of 92.5%)
(19, 20, 39). However, the relationship between clinical signs and
symptoms and treatment outcome could not be established because
of inadequate data for statistical analysis. Nevertheless, the evidence
might be against the traditional school of thought that vital pulp
therapy should only be performed in teeth with signs and symptoms
of reversible pulpitis (40). It suggests that the terminology of reversible
pulpitis and irreversible pulpitis should be reconsidered and raises the
question of how we can accurately evaluate whether the pulpal status is
reversible or irreversible.
Several histologic studies demonstrated that the cariously exposed
vital pulp was not always completely infected, depending on the duration
and severity of the carious lesion (1315, 41). Occasionally, the
inflammation was localized adjacent to the carious lesion, not
spreading to the whole coronal and radicular pulp (41, 42). If
infected tissue is removed, the conservation of the remaining healthy
pulp is possible.
When encountering cariously exposed pulp, it is difficult to assess
the condition of the pulp, which plays a critical role in the success or
failure of vital pulp therapy. There is no reliable tool to help evaluate
how far the inflammation has progressed into the pulp. Matsuo et al
(17) suggested observing the degree of pulpal bleeding rather than
relying on preoperative clinical signs and symptoms. A profuse bleeding
that is difficult to stop indicates severe pulpal inflammation. The literature
suggested several methods to control pulpal hemorrhage including
rinsing the surgical wound with sodium hypochlorite solution (17, 30,
36, 43), physiologic saline solution (18, 26, 29, 37, 38), or hydrogen
peroxide (17, 44) or pressing with a cotton pellet (19, 31, 3335,
39, 43, 45). There are no available data as to which method provides
the best outcome. However, rinsing with sodium hypochlorite solution
with the concentration ranging from 1.25%6% is commonly
recommended (17, 30, 46). If the bleeding cannot be stopped within
110 minutes (26, 30, 35, 46), it suggests that either the inflamed
pulp has not been completely removed or the pulpal inflammation has
progressed into the radicular pulp. The treatment procedure should
be modified, for example by shifting from partial pulpotomy to full
pulpotomy or from full pulpotomy to pulpectomy.
The best evidence of clinical factors influencing treatment
outcome should be from the analysis of meta-regression of at least
10 comparative trials (47). Only 3 studies (35, 37, 45) directly
comparing the effect of either calcium hydroxide or MTA on success
rate were identified. Data of the effect of other clinical factors such as
stage of root development on success rate were subtracted from
cohort studies and case series. Limited information on several
clinical factors could be collected. For example, data on patients age
were often provided as a wide range of age such as 1544 years
(29) or 870 years (32), which could not be divided into several
age groups for data analysis. Some studies mentioned only carious
pulpal exposure without providing detailed data of patients signs and
symptoms and clinical and radiographic examinations (43, 46, 48,
49). Therefore, the available data might not be suitable for multi-
variance statistical analysis.
Direct comparison of the success rate of using either calcium
hydroxide or MTA as pulpal medicament showed no statistically signif-
icant difference. This implies that either there was no difference in
clinical performance between these materials or that the sample sizes
were too small. Further statistical analysis showed that Qudeimat et al
(37), El-Meligy and Avery (45), and Mente et al (35) require a sample
size of 1657, 32, and 211, respectively, to show statistically significant
differences with power of 80%. To provide additional useful informa-
tion, indirect comparison between calcium hydroxide and MTA on
weighted pooled success rate was performed. MTA showed a more
successful outcome than calcium hydroxide in direct pulp capping,
but the opposite result was observed in partial pulpotomy. Nevertheless,
the result should be interpreted cautiously. Subtraction data from
several studies provide a large number of sample sizes, which results
in more robust statistical analysis but incurs a risk of error as a result
of the heterogeneity among studies. Ideally, randomized controlled trial
is recommended to ensure baseline comparability between groups
(50). In brief, evidence shows that both calcium hydroxide and MTA

TABLE 7. Indirect Comparison of the Weighted Pooled Success Rate of Each Treatment in Teeth with Closed Apex or Opened Apex
Closed apex Opened apex

Treatment procedure (references) nt ns wps nt ns wps Result

Direct pulp capping (17, 29, 3133, 35, 44, 49) 456 294 69.2 62 57 94.5 S
Partial pulpotomy (18, 36, 37, 54) 97 91 90.6 32 29 94.6 NS
Full pulpotomy (19, 20, 39, 43, 45, 53) 111 93 85.9 56 50 91.4 NS

The weighted pooled success rate of MTA and Ca(OH)2 in each treatment procedure was calculated by the random effect of DerSimonian-Laird method. The weighted pooled success rate of MTA and Ca(OH)2 in
each treatment was compared with z test for proportion with P < .05.
nt, number of total sample; ns, number of successful; wps, weighted pooled success rate; S, statistically significant difference; NS, not statistically significant difference.

JOE Volume 37, Number 5, May 2011 Vital Pulp Therapy in Vital Permanent Teeth with Cariously Exposed Pulp 585
Review Article
provide satisfactory outcome when used as pulpal medicament in vital
pulp therapy. It is inconclusive about which of the 2 materials performs
better.
Vital pulp therapy in adult permanent teeth with cariously exposed
pulp is controversial. It has been recommended that vital pulp
treatment should be performed only in young patients (2, 51, 52)
because of the high healing capacity of pulp tissue in young patients
in comparison with old patients. To date, there has not been any
published clinical study to support this claim. Unfortunately, the data
from included studies are insufficient for statistical analysis to show
the effect of the age of the patients on the clinical outcome. However,
patients with age ranging from 670 years were treated successfully
with vital pulp therapy (17, 26, 2932, 35, 43, 44). It emphasizes
the high healing capacity of pulp tissue in both young and old
patients after the removal of the cause of the disease. Indirect
comparison of the weighted pooled success rate in teeth with either
opened apex or closed apex showed no statistically significant
difference in partial pulpotomy and full pulpotomy. It is likely that it
is the complete removal of the inflamed pulp that is critical rather
than the status of the root apex. In contrast, direct pulpcapped
teeth with opened apex showed more successful outcome than teeth
with closed apex. The difference of success rate was possibly due to
the effect of the treatment procedure itself (direct pulp capping:
applying the medicament at the pulpal exposure site without removal
of the inflamed pulp underneath the carious lesion, which resulted
in a less predictable outcome) and/or the different healing potential
between teeth with opened or closed apex. In short, the relevant
literature illustrates the weakness of the evidence regarding the effect
of the patients age and the status of the root apex on the outcome of
vital pulp therapy. The limited information from the relevant studies
did not indicate that vital pulp therapy could not be performed
successfully in old patients. Nevertheless, more observational studies
of good quality will contribute to a better understanding of the effect
of clinical factors influencing the outcome of vital pulp therapy.
Conclusion
Vital pulp therapy should be considered as an alternative treatment
to pulpectomy in vital permanent teeth with cariously exposed pulp.
Partial pulpotomy and full pulpotomy provide a more predictable
outcome than direct pulp capping. Current best evidence provides
inconclusive information regarding factors influencing treatment
outcome, and this emphasizes the need for further observational studies
of high quality.
Acknowledgments
The authors express their deep appreciation to Professor Harold
H. Messer, Emeritus Professor of Restorative Dentistry, School of
Dental Science, University of Melbourne, Australia for his advice.
They also thank Dr Kanika Chukeitman and Miss Paipun Phitayanon
for their statistical analysis advice.
The authors deny any conflicts of interest related to this study.
References
1. Bergenholtz G, Spangberg L. Controversies in endodontics. Crit Rev Oral Biol Med
2004;15:99114.
2. Ward J. Vital pulp therapy in cariously exposed permanent teeth and its limitations.
Aust Endod J 2002;28:2937.
3. Gesi A, Hakeberg M, Warfvinge J, Bergenholtz G. Incidence of periapical lesions and
clinical symptoms after pulpectomy: A clinical and radiographic evaluation of 1-
versus 2-session treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2006;101:37988.
586 Aguilar and Linsuwanont
4. Engstrom B, Lundberg M. The correlation between positive culture and the prog-
nosis of root canal therapy after pulpectomy. Odontol Revy 1965;16:193203.
5. Kojima K, Inamoto K, Nagamatsu K, et al. Success rate of endodontic treatment of
teeth with vital and nonvital pulps: A meta-analysis. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2004;97:959.
6. Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal
treatment: Systematic review of the literaturepart 2: Influence of clinical factors.
Int Endod J 2008;41:631.
7. Caplan DJ, Cai J, Yin G, White BA. Root canal filled versus non-root canal filled teeth:
A retrospective comparison of survival times. J Public Health Dent 2005;65:906.
8. Randow K, Glantz PO. On cantilever loading of vital and non-vital teeth: An exper-
imental clinical study. Acta Odontol Scand 1986;44:2717.
9. Ou KL, Chang CC, Chang WJ, Lin CT, Chang KJ, Huang HM. Effect of damping prop-
erties on fracture resistance of root filled premolar teeth: A dynamic finite element
analysis. Int Endod J 2009;42:694704.
10. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The radiographic outcomes of
direct pulp-capping procedures performed by dental students: A retrospective study.
J Am Dent Assoc 2006;137:1699705.
11. Swift EJ Jr, Trope M, Ritter AV. Vital pulp therapy for mature tooth: Can it work?
Endod Topics 2003;5:4956.
12. Koncke A. Treatment of deep carious lesions. Int Dent J 1970;20:33843.
13. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: Correlations
between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral
Med Oral Pathol 1963;16:84671.
14. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: Correlations
between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral
Med Oral Pathol 1963;16:96977.
15. Mitchell DF, Tarplee RE. Painful pulpitis: A clinical and microscopic study. Oral Surg
Oral Med Oral Pathol 1960;13:136070.
16. Garfunkel A, Sela J, Ulmansky M. Dental pulp pathosis: Clinicopathologic correla-
tions based on 109 cases. Oral Surg Oral Med Oral Pathol 1973;35:1107.
17. Matsuo T, Nakanishi T, Shimizu H, Ebisu S. A clinical study of direct pulp capping
applied to carious-exposed pulps. J Endod 1996;22:5516.
18. Mejare I, Cvek M. Partial pulpotomy in young permanent teeth with deep carious
lesions. Endod Dent Traumatol 1993;9:23842.
19. Caliskan MK. Pulpotomy of carious vital teeth with periapical involvement. Int Endod
J 1995;28:1726.
20. Teixeira LS, Demarco FF, Coppola MC, Bonow ML. Clinical and radiographic
evaluation of pulpotomies performed under intrapulpal injection of anaesthetic
solution. Int Endod J 2001;34:4406.
21. Mulrow CD, Cook DJ, Davidoff F. Systematic reviews: Critical links in the great chain
of evidence. Ann Intern Med 1997;126:38991.
22. Torabinejad M, Anderson P, Bader J, et al. Outcomes of root canal treatment and
restoration, implant-supported single crowns, fixed partial dentures, and extraction
without replacement: a systematic review. J Prosthet Dent 2007;98:285311.
23. Torabinejad M, Corr R, Handysides R, Shabahang S. Outcomes of nonsurgical re-
treatment and endodontic surgery: A systematic review. J Endod 2009;35:9307.
24. Oxford Centre for Evidence-based Medicine: levels of evidence (March 2009).
CEBM.net (online). Available at: http://www.cebm.net/index.aspx?o=1025.
Accessed September 15, 2009.
25. Torabinejad M, Lozada J, Puterman I, White SN. Endodontic therapy or single tooth
implant? a systematic review. J Calif Dent Assoc 2008;36:42937.
26. Mass E, Zilberman U. Clinical and radiographic evaluation of partial pulpotomy in
carious exposure of permanent molars. Pediatr Dent 1993;15:2579.
27. Tronstad L, Mjor IA. Capping of the inflamed pulp. Oral Surg Oral Med Oral Pathol
1972;34:47785.
28. Trope M, McDougal R, Levin L, May KN Jr, Swift EJ Jr. Capping the inflamed pulp
under different clinical conditions. J Esthet Restor Dent 2002;14:34957.
29. Shovelton DS, Friend LA, Kirk EE, Rowe AH. The efficacy of pulp capping materials:
A comparative trial. Br Dent J 1971;130:38591.
30. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate:
An observational study. J Am Dent Assoc 2008;139:30515.
31. Fitzgerald M, Heys RJ. A clinical and histological evaluation of conservative pulpal
therapy in human teeth. Oper Dent 1991;16:10112.
32. Haskell EW, Stanley HR, Chellemi J, Stringfellow H. Direct pulp capping treatment:
A long-term follow-up. J Am Dent Assoc 1978;97:60712.
33. Farsi N, Alamoudi N, Balto K, Al Mushayt A. Clinical assessment of mineral trioxide
aggregate (MTA) as direct pulp capping in young permanent teeth. J Clin Pediatr
Dent 2006;31:726.
34. Santucci PJ. Dycal versus Nd:YAG laser and Vitrebond for direct pulp capping in
permanent teeth. J Clin Laser Med Surg 1999;17:6975.
35. Mente J, Geletneky B, Ohle M, et al. Mineral trioxide aggregate or calcium hydroxide direct
pulp capping: An analysis of the clinical treatment outcome. J Endod 2010;36:80613.
36. Baratieri LN, Monteiro S Jr. Caldeira de Andrada MA. Pulp curettage: Surgical tech-
nique. Quintessence Int 1989;20:28593.
JOE Volume 37, Number 5, May 2011

37. Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium hydroxide vs mineral
trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
Eur Arch Paediatr Dent 2007;8:99104.
38. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study of mineral trioxide
aggregate for partial pulpotomy in cariously exposed permanent teeth. J Endod
2006;32:7315.
39. Caliskan MK. Success of pulpotomy in the management of hyperplastic pulpitis. Int
Endod J 1993;26:1428.
40. Glickman GN, Bakland LK, Fouad AF, Hargreaves KM, Schwartz SA. Diagnostic termi-
nology: Report of an online survey. J Endod 2009;35:162533.
41. Langeland K. Tissue response to dental caries. Endod Dent Traumatol 1987;3:
14971.
42. Trowbridge HO. Histology of pulpal inflammation. In: Hargreaves KM, Goodis HE,
eds. Seltzer and Benders dental pulp. 3rd ed. Carol Stream, IL: Quintessense
Publishing Co, Inc; 2002:22745.
43. DeRosa T. A retrospective evaluation of pulpotomy as an alternative to extraction.
Gen Dent 2006;54:3740.
44. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping of carious expo-
sures: Treatment outcome after 5 and 10 yearsa retrospective study. J Endod
2000;26:5258.
45. El-Meligy OA, Avery DR. Comparison of mineral trioxide aggregate and calcium
hydroxide as pulpotomy agents in young permanent teeth (apexogenesis). Pediatr
Dent 2006;28:399404.
46. Witherspoon DE, Small JC, Harris GZ. Mineral trioxide aggregate pulpotomies: A
case series outcomes assessment. J Am Dent Assoc 2006;137:6108.
47. Deeks JJ, Higgins JPT, Altman DG. Analysing data and undertaking meta-analyses. In:
Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interven-
tions. 1st ed. Chichester, West Sussex, UK: John Wiley & Sons Ltd; 2008:24396.
48. Nosrat IV, Nosrat CA. Reparative hard tissue formation following calcium hydroxide
application after partial pulpotomy in cariously exposed pulps of permanent teeth.
Int Endod J 1998;31:2216.
49. Gallien GS Jr, Schuman NJ. Local versus general anesthesia: A study of pulpal response
in the treatment of cariously exposed teeth. J Am Dent Assoc 1985;111:599601.
Review Article
50. OConnor D, Sally G, Higgins JPT. Defining the review question and developing
criteria for including studies. In: Higgins JPT, Green S, eds. Cochrane handbook
for systematic reviews of interventions. 1st ed. Chichester, West Sussex, UK: John
Wiley & Sons Ltd; 2008:28394.
51. Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide
in permanent incisors with complicated crown fracture. J Endod 1978;4:2327.
52. Horsted P, Sandergaard B, Thylstrup A, El Attar K, Fejerskov O. A retrospective study
of direct pulp capping with calcium hydroxide compounds. Endod Dent Traumatol
1985;1:2934.
53. Waly NG. A five-year comparative study of calcium hydroxide-glutaraldehyde pulpot-
omies versus calcium hydroxide pulpotomies in young permanent molars. Egypt
Dent J 1995;41:9331000.
54. Zilberman U, Mass E, Sarnat H. Partial pulpotomy in carious permanent molars. Am
J Dent 1989;2:14750.
55. Atieh M. Stainless steel crown versus modified open-sandwich restorations for
primary molars: a 2-year randomized clinical trial. Int J Paediatr Dent 2008;18:
32532.
56. Oen KT, Thompson VP, Vena D, Caufield PW, Curro F, Dasanayake A, Ship JA,
Lindblad A. Attitudes and expectations of treating deep caries: A PEARL Network
survey. Gen Dent 2007;55:197203.
57. Jackson NG, Waterhouse PJ, Maguire A. Factors affecting treatment outcomes
following complicated crown fractures managed in primary and secondary care.
Dent Traumatol 2006;22:17985.
58. Eghbal MJ, Asgary S, Baglue RA, Parirokh M, Ghoddusi J. MTA pulpotomy of human
permanent molars with irreversible pulpitis. Aust Endod J 2009;35:48.
59. Miles JP, Gluskin AH, Chambers D, Peters OA. Pulp capping with mineral trioxide
aggregate (MTA): A retrospective analysis of carious pulp exposures treated by
undergraduate dental students. Oper Dent 2010;35:208.
60. Moritz A, Schoop U, Goharkhay K, Sperr W. Advantages of a pulsed CO2 laser in
direct pulp capping: A long-term in vivo study. Lasers Surg Med 1998;22:
28893.
61. Trask PA. Formocresol pulpotomy on (young) permanent teeth. J Am Dent Assoc
1972;85:131623.

Appendix 1. Rating Quality Score Criteria from Torabinejad et al (22, 23)

(maximum score, 17)
Type of study
1. Randomized clinical trial (4)
2. Nonrandomized clinical trial (3)
3. Cohort study with no control (2)
4. Case series, case control (1)

Quality of research methodology (1 point for each category)

1. Total number of enrolled subjects stated
2. Sample size predetermined
3. Operator experience stated
4. Blind technique
5. Treatment procedures described
6. Demographic description included
7. Description for subject loss
8. Treatment complications described
9. Measurement standardized
10. Evaluation methods clearly described
11. Intention to treat stated
12. Adequate description and appropriateness of statistical
technique
13. Stratification

JOE Volume 37, Number 5, May 2011 Vital Pulp Therapy in Vital Permanent Teeth with Cariously Exposed Pulp 587