Preserving pulp vitality in mature permanent teeth: direct pulp capping and pulpotomy

Why a diagnosis of irreversible pulpitis no longer automatically implies pulpectomy, which clinical criteria make pulpotomy predictable in the mature tooth, and why the coronal seal matters as much as the material chosen.

The classical model assumed that once irreversible pulpitis was diagnosed, inflammation had spread throughout the pulp organ and complete tissue removal was the only coherent option. Histological studies comparing clinical picture with microscopic findings have shown a different reality: inflammation is frequently concentrated in the zone beneath the exposure, while more apical tissue retains vitality and reparative capacity. Hence the clinical revision now under way, also reflected in European endodontic society guidelines: in the mature permanent tooth, selective removal of inflamed tissue followed by an adequate seal can be enough to maintain a vital, functioning pulp — with the not incidental advantage of preserving proprioception, dentine hydration and the structural strength of the tooth.

The clinical decision unfolds across three levels of increasing invasiveness. Direct pulp capping treats a pinpoint exposure in sound tissue, typically from trauma or from excavating deep caries in an asymptomatic tooth. Partial pulpotomy removes two to three millimetres of tissue beneath the exposure and is indicated where superficial inflammation is plausible but limited. Full pulpotomy removes the entire coronal pulp down to the canal orifices and is the option for cases with more marked symptoms. The operational criterion guiding the choice is bleeding control: haemostasis achieved within a few minutes using a cotton pellet soaked in diluted hypochlorite indicates residual vital, treatable tissue, whereas profuse and persistent bleeding signals more extensive inflammation and calls for stepping down a level or converting to pulpectomy. Established necrosis, periapical radiolucency and a non-restorable tooth remain clear contraindications.

Calcium silicate cements have changed the predictability of these procedures compared with calcium hydroxide alone, which induces a porous dentine bridge and tends to dissolve over time, leaving a discontinuous seal. Silicates offer adhesion to hard tissues, dimensional stability, sustained alkalinity and more uniform induction of tertiary dentine. The radiopacifier also matters in product selection: bismuth oxide formulations can produce coronal discolouration, which is why zirconium- or tantalum-based ones are preferable in aesthetic sectors. The decisive point, however, is not the material but what sits above it: most failures are attributable to coronal microleakage rather than to a defect in the biomaterial, and a definitive restoration placed at the same visit or the immediately following one influences the outcome more than the choice between two equivalent cements.

In terms of monitoring, vitality preservation requires a more structured follow-up than canal treatment, because the outcome cannot be verified at the end of the appointment. Review involves sensitivity testing and radiographic assessment at six and twelve months, with particular attention to the appearance of canal calcification, internal resorption or apical radiolucency. The patient should be told plainly that this is a choice with contained but not zero risk: should it fail, canal treatment remains entirely possible, with nothing compromised except the time elapsed. It is precisely this reversibility that makes attempting preservation before devitalisation reasonable, and not the other way round.

On Oralzon you will find calcium silicate cements in capping and pulpotomy formulations, with bismuth-free radiopacifiers for aesthetic sectors, sodium hypochlorite at various concentrations for haemostasis, fine-grit diamond burs for controlled removal of coronal tissue and the restorative materials for an immediate coronal seal.