Guideline for Use of Vital Pulp Therapy in Permanent Teeth

Purpose: To develop permanent tooth vital pulp therapy (VPT) recommendations. Methods: GRADE framework recommendations developed from systematic review data of permanent tooth VPT through June 30, 2024. Results: Teeth with deep caries (extending to inner third or quarter of dentin with intact dentin barrier) diagnosed with normal pulp or reversible pulpitis (NP/RP) can be treated either with indirect pulp treatment (IPT), direct pup cap (DPC), partial pulpotomy (PP), or full pulpotomy (FP) (conditional recommendation, low certainty). Selective caries removal for IPT is strongly recommended (high certainty) for deep caries in NP/RP diagnosed teeth. In case of pulp exposure either DPC, PP, or FP using calcium silicate cement (CS) may be performed regardless of root maturation (conditional recommendation, low certainty). Using sodium hypochlorite (NaOCl) irrigation is strongly recommended for DPC hemostasis (high certainty) over saline and conditionally recommended (very low certainty) for pulpotomy. For permanent teeth with extremely deep caries (no discernible radiographic barrier) or deep carious teeth exhibiting spontaneous, nocturnal, or lingering pain but normal periapical appearance, complete (nonselective) caries removal to expose the pulp for assessment is strongly recommended (moderate certainty). If pulpotomy is indicated in these teeth, FP using CS is recommended over PP (conditional; low certainty). Also, PP and FP success will likely be higher if hemostasis occurs within six minutes (conditional; low certainty). Using magnification likely enhances pulp visualization, facilitating more accurate assessment of its status. Teeth with NP/RP having traumatic exposures, PP/FP is conditionally recommended over DPC. Using nonstaining CS is strongly recommended (high certainty) for VPT on teeth in esthetic areas. Conclusions: Selective caries removal is recommended for teeth having deep caries with NP/RP. CS utilization is recommended for DPC, PP, and FP using NaOCl for hemostasis. Complete caries removal and assessment of pulp status is recommended for teeth exhibiting spontaneous, nocturnal, or lingering pain; if pulp is diagnosed as vital and bleeding is controlled, FP is recommended.