Pulp Exposure Does Not Mean Pulpectomy — The Latest Evidence on Vital Pulp Therapy to Preserve the Pulp

When caries extends deep and reaches the pulp (pulp exposure), or when a tooth is diagnosed with irreversible pulpitis, the standard approach has until now been pulpectomy (root canal treatment that removes the nerve). In recent years, however, vital pulp therapy (VPT) — preserving the vital pulp as far as possible — has been substantially reappraised, driven by advances in bioceramic materials and the accumulation of evidence.

What is vital pulp therapy?

Vital pulp therapy is the collective term for treatments that appropriately remove and protect the inflamed portion of the pulp while preserving the healthy vital pulp. It includes direct pulp capping (covering the exposed pulp surface directly), partial pulpotomy (removing part of the coronal pulp), and full pulpotomy (removing the coronal pulp). If the pulp can be preserved, the tooth does not lose vitality, which is also structurally advantageous for long-term retention.

What the evidence shows about success rates

A systematic review and meta-analysis of pulpotomy for carious pulp exposure (25 randomized controlled trials, 2,085 teeth, with follow-up of 12 months or longer) reported an overall success rate of 86.7%. Notably, even teeth with irreversible pulpitis — conventionally regarded as an indication for pulpectomy — showed a success rate of 82.4% (versus 92.0% for normal pulp or reversible pulpitis). Moreover, no significant difference was found between partial and full pulpotomy.

Advances in materials make the difference

Among the materials used for capping and pulpotomy, MTA (mineral trioxide aggregate) showed a higher success rate than conventional calcium hydroxide (88.2% vs. 79.1%). No significant difference was found between bioactive MTA and bioceramic materials such as Biodentine; both offer good sealing ability and biocompatibility. Advances in materials have made pulp preservation a realistic option.

Case selection and precise treatment are prerequisites

That said, vital pulp therapy is not indicated for every case. Accurate diagnosis (assessment of the pulp’s condition), precise treatment in an environment kept as aseptic as possible under rubber dam isolation, and — from the latest 2025 research — the assessment of hemostasis greatly influence the outcome. International guidelines, including those of the European Society of Endodontology (ESE), actively position vital pulp therapy on the basis of these prerequisites. It should be noted that the certainty of the evidence is rated moderate to low, and long-term data are still accumulating.

A message for clinical practice

The era of “pulp exposure means immediate pulpectomy” is changing. With accurate diagnosis and precise treatment, the possibility of preserving the tooth’s nerve (the vital pulp) and retaining the tooth itself for longer is expanding. Protecting the pulp is another important gateway to keeping natural teeth for the long term.

This article is a general overview based on major systematic reviews and other sources. The indications for, and prognosis of, vital pulp therapy differ from case to case depending on the condition of the pulp and tooth, the extent of caries, the technique and materials used, and the rigor of aseptic procedure.

Key references

• Outcomes of pulpotomy for carious pulp exposure: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2024;19(7):e0305218.

• Duncan HF, et al. European Society of Endodontology position statement: management of deep caries and the exposed pulp. Int Endod J. 2019;52(7):923–934.

• Kahler B. Vital pulp therapy for permanent teeth with diagnosis of irreversible pulpitis: biological basis and outcome. Aust Dent J. 2023.

• American Association of Endodontists. Position statement on vital pulp therapy.