Assessment-Based Pulp And Dentin Removal Protocols For Vital Pulp Therapy

Summary

Here, we present a protocol for assessment-based dentin and pulp removal during vital pulp therapy. The method uses stepwise procedures to remove only diseased tissue while preserving viable pulp. Compared to conventional pulpotomy, it aims to conserve more pulp tissue and support maintenance of pulp vitality.

Abstract

Pulpal pathology is a progressive process that may be reversible in early stages if vital tissue remains and pulpal irritants are eliminated. Therefore, vital pulp therapy should aim to preserve pulp vitality by minimizing unnecessary tissue removal. In conventional pulpotomy, the extent of pulp resection is predetermined (e.g., partial or full), and stepwise pulpal evaluation is not performed, which may lead to removal of viable tissue.

Here, we present a protocol for assessment-based removal of dentin and pulp using Minimized Dentin Removal (MDR) and Minimized Pulp Resection (MPR). The MPR technique selectively removes the pathologically altered superficial layer of exposed pulp while preserving deeper viable tissue. MDR removes caries indicator-stained dentin while maintaining dentin adjacent to the pulp to support underlying tissue preservation.

The protocol is applied iteratively, with continuous assessment guiding the extent of tissue removal until a clinically acceptable pulpal surface and dentin free of indicator staining are achieved. In contrast to conventional approaches that rely on predetermined resection levels, this method incorporates real-time evaluation to guide intervention. Overall, the MDR–MPR protocol provides a structured, minimally invasive approach to dentin and pulp management and may support preservation of pulp vitality.

Introduction

Vital pulp therapy (VPT) relies on the presence of pulp vitality¹˒². Therefore, treatment strategies should prioritize the conservation of viable tissue³. Conventional VPT approaches are classified according to the extent of pulp removal: direct pulp capping, partial pulpotomy, and full pulpotomy. Partial pulpotomy typically removes 2–3 mm of coronal pulp tissue, whereas full pulpotomy removes the entire coronal pulp to the canal orifices⁴˒⁵. However, in conventional pulpotomy, stepwise evaluation of the pulpal condition prior to pulp....

Protocol

All procedures involving human participants were conducted in accordance with the ethical standards of the institution and the Declaration of Helsinki. The study was approved by the Institutional Review Board (IRB) of Gangdong Kyung Hee University Dental Hospital (Approval No.: KHNMC 2022-12-019-002). All subjects provided their informed consent for publication of their data. The overall workflow of the protocol is illustrated in Figure 1. VPT was attempted in teeth with symptomatic or asymptomatic deep-to-extremely deep caries. The final decision to perform VPT was made based on the assessment of pulp status.

Results

Outcome of MDR: minimized initial pulp exposure size
Prior to pulp exposure, MDR was performed to remove stained dentin while preserving the surrounding dentin structure. Application of MDR to caries indicator-stained dentin reduced the size of the initial pulp exposure site (Figure 2D).

Outcome of MPR in conjunction with MDR: preservation of viable pulp
After pulp exposure, dentin removal and pulp management were performe.......

Discussion

Approaches to caries removal: AAE and ESE guidelines

Significant differences exist between the American Association of Endodontists (AAE) and the European Society of Endodontology (ESE) on caries removal protocols. The AAE advocates complete removal to eliminate infected tissue and visualize the exposed pulp, while the ESE recommends selective removal to firm/leathery dentin^1,2. These reflect varying views on pulpal ex.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Calcium silicate-based material (Biodentine)	Septodont	REF 01-003	For pulp capping and restoration
Caries indicator dye (Seek)	Ultradent	209	For detection of stained dentin
Cotton pellets (sterile)	Various		For disinfection and hemostasis
Dental examination instruments (mirror, explorer, tweezers)	Various		For clinical examination
Local anesthetic (2% lidocaine with epinephrine 1:100,000)	Huons		For local anesthesia
Long-shank round burs	Komet		For MDR and MPR procedures
Low-speed handpiece	Siemens		For dentin removal and pulp resection
Microbrush applicators	Various		For dye application
Rubber dam kit	Various		Includes rubber dam sheet, clamp, frame, punch, and forceps
Sodium hypochlorite solution (2.5%)	Various		For disinfection and hemostasis
Sterile saline solution	Various		For irrigation