Before the principles of vital pulp therapy are laid out, it is important to recall that a precise clinical diagnosis of the degree of inflammation in the pulp is not possible [3]. Little or no correlation exits between the histological findings of pulp pathosis and clinical symptoms [26–28]. Moreover, in a clinical setting a diagnostic device is not yet available for objectively measuring a threshold of reversible pulp inflammation being beneficial or not for tertiary dentinogenesis. The diagnoses are based on interpretation of data from the pretreatment examination, the clinical examination, as well as the radiographic examination [29], rather than histopathological findings. Clinical data are shown for case selection that divide the condition of the pulp into so-called reversible pulpitis and irreversible pulpitis (Box 4.4).

Figure 4.2 shows a clinical example of an extremely deep caries lesion with direct exposure of the pulp prior to excavation. The patient arrived to the dental office with prolonged pain and disturbed night sleep. The clinical diagnosis “irreversible pulpitis” is further confirmed by the color of the blood being dark red. In this case also pus is apparent associated with a frank cavitation, and hemostasis is not possible to achieve, and root canal treatment is initiated.

The principal indications for performing vital pulp therapy are carious lesions, mechanical iatrogenic injury, and trauma. In the context of molar endodontics, the most frequent cause for endodontic treatment including vital pulp therapy has, in the general practice environment, been caries [30]. Therefore, the aligned treatment guidelines are described within the “scenario” of a carious pulp exposure. From the literature, it is often unclear whether the clinicians are creating a pulp exposure by accident or whether it is the intention to do a pulp exposure; moreover the depth of the carious pulp exposures are seldom defined in clinical studies [31]. The following vital pulp therapy guidelines will include these aspects.

For decades the capping agent to promote healing and maintaining viability of the remaining pulp tissue has been a calcium hydroxide-containing material applied either as a base or as a liner. Within the last 20 years, calcium silicate-containing materials have gained more and more focus. In particularly, MTA (mineral trioxide aggregate, Dentsply Tulsa Dental, OK, USA) has been investigated and used intensively. More recently other bioceramic cements have been introduced such as Biodentine (Septodont, Saint Maur des Fosses, France) or iRoot BP (Innovative BioCeramix, Vancouver, BC, Canada). Only limited clinical information is actually available to show potential clinical differences. The reason for selecting the silicate containing materials is therefore based mainly on laboratory studies, where it is shown that these materials may create a better quality of the hard tissue laid down, without so-called tunnel defects. Interestingly, a recent randomized clinical trial [41] showed no differences between the two classic pulp agents, i.e., the calcium hydroxide containing liner Dycal (DeTrey Dentsply, Skarpnäck, Sweden) and MTA. This may also underline that other variables such as patient age and irreversible pulp inflammation may determine the prognosis accounting for problems leading to failure or not. Finally, larger studies may be needed to show actual differences, when it comes to the choice of the very best pulp agent.