Vital pulp therapy in permanent teeth: a comparative analysis of six contemporary international guidance documents with a unified clinical decision framework

Vital pulp therapy (VPT) refers to biologically based procedures that preserve pulp vitality in permanent teeth with deep or extremely deep caries, with or without pulp exposure. Between 2019 and 2026, six contemporary international guidance documents were issued, addressing VPT, deep caries management, or both, by the European Society of Endodontology (ESE; 2019 and 2023), the American Association of Endodontists (AAE; 2021), the American Academy of Pediatric Dentistry (AAPD; 2025), the International Association of Paediatric Dentistry (IAPD; 2026 Porto Forum), and, jointly, the European Federation of Conservative Dentistry, ESE, the European Organisation for Caries Research, and the German Society of Conservative Dentistry (EFCD-ESE-ORCA; 2026). This narrative review compares these documents across key clinical decision domains. Broad convergence emerged in five areas: first-line use of calcium silicate cements after pulp exposure; caries-removal method selection guided by lesion depth and pulpal status, generally favoring selective or stepwise removal for deep caries and non-selective removal when findings suggest irreversible pulpitis; rigorous isolation and an aseptic operative protocol; achievement of hemostasis as a pivotal intraoperative criterion; and placement of a durable, well-sealed coronal restoration. Divergence remained in indications for selective and non-selective caries-removal method, numerical hemostasis thresholds, and cavity-lining recommendations. Authorship and methodological overlap suggest four partially distinct guidance lineages, rather than six fully independent sources. Drawing on this convergence, this review proposes a unified chairside framework from pulpal and periapical diagnosis to follow-up. The framework complements the individual documents and may be especially relevant to children and adolescents, for whom loss of pulp vitality in a permanent tooth may have substantial long-term consequences.

Calcium silicate cement; Clinical practice guideline; Deep caries; Direct pulp capping; Pediatric dentistry; Permanent tooth; Pulpotomy; Vital pulp therapy

[1] Duncan HF. Present status and future directions—vital pulp treatment and pulp preservation strategies. International Endodontic Journal. 2022; 55: 497–511.

[2] Kahler B, Taha NA, Lu J, Saoud TM. Vital pulp therapy for permanent teeth with diagnosis of irreversible pulpitis: biological basis and outcome. Australian Dental Journal. 2023; 68: S110–S122.

[3] American Association of Endodontists. AAE position statement on vital pulp therapy. Journal of Endodontics. 2021; 47: 1340–1344.

[4] European Society of Endodontology (ESE); Duncan HF, Galler KM, Tomson PL, Simon S, El-Karim I, Kundzina R, et al. European Society of Endodontology position statement: management of deep caries and the exposed pulp. International Endodontic Journal. 2019; 52: 923–934.

[5] Duncan HF, Kirkevang LL, Peters OA, El-Karim I, Krastl G, Del Fabbro M, et al.; ESE Workshop Participants and Methodological Consultant. Treatment of pulpal and apical disease: the European Society of Endodontology (ESE) S3-level clinical practice guideline. International Endodontic Journal. 2023; 56: 238–295.

[6] Coll JA, Dhar V, Guelmann M, Crystal YO, Chen CY, Marghalani AA, et al. Guideline for use of vital pulp therapy in permanent teeth. Pediatric Dentistry. 2025; 47: 299–311.

[7] Dhar V, El-Karim I, Coll JA, Fouad AF, O’Connell AC, Asgary S, et al. Pulp therapies rooted in evidence: IAPD Porto Declaration. International Journal of Paediatric Dentistry. 2026; 36: 387–390.

[8] Dhar V, El-Karim I, Coll JA, Fouad AF, O’Connell AC, Asgary S, et al. Consensus-based recommendations on pulp therapies in primary and permanent teeth: IAPD Porto Forum. International Journal of Paediatric Dentistry. 2026; 36: 371–386.

[9] Schwendicke F, Kosan E, Banerjee A, Baysan A, Bjørndal L, Ceballos L, et al. Deep caries management: EFCD-ESE-ORCA S3-level clinical practice guideline. International Endodontic Journal. 2026; 59: 1298–1315.

[10] Ramezanzade S, Bjørndal L, Chen H, Baysan A. Effectiveness of stepwise excavation or selective excavation in comparison with non-selective caries removal in managing deep caries in vital permanent teeth: a systematic review with trial sequential, pairwise, and network meta-analyses. Caries Research. 2026; 60: 80–109.

[11] Kosan E, Kosan D, Sturm R, Schwendicke F, Paris S. Efficacy of different cavity liners compared to no cavity lining in managing deep caries in vital permanent teeth—a systematic review. Clinical Oral Investigations. 2025; 29: 529.

[12] Louzada LM, Hildebrand H, Neuhaus KW, Duncan HF. The effectiveness of partial pulpotomy compared with full pulpotomy in managing deep caries in vital permanent teeth with a diagnosis of non-traumatic pulpitis. International Endodontic Journal. 2025; 58: 37–54.

[13] Herbst SR, Pitchika V, Herbst CS, Kosan E, Schwendicke F. Effectiveness of calcium hydroxide compared to hydraulic calcium silicate cements for direct pulp capping in managing deep caries in vital permanent teeth: a systematic review and meta-analysis. International Endodontic Journal. 2025; 58: 1110–1125.

[14] Sachdeva A, Kumar V, Chawla A, Priya H, Kumar V, Sharma S, et al. Quality assessment of clinical practice guidelines and position statements on vital pulp therapy: a systematic review. Evidence-Based Dentistry. 2025; 26: 115–116.

[15] Dammaschke T, Galler K, Krastl G. Current recommendations for vital pulp treatment. DZZ International. 2019; 1: 43–52.

[16] Yong D, Cathro P. Conservative pulp therapy in the management of reversible and irreversible pulpitis. Australian Dental Journal. 2021; 66: S4–S14.

[17] Coll JA, Dhar V, Guelmann M, Crystal YO, Chen CY, Marghalani AA, et al. Vital pulp therapy in permanent teeth: a systematic review and meta-analyses. Pediatric Dentistry. 2025; 47: 137–150.

[18] Asgary S, Parhizkar A. Importance of “Time” on “Haemostasis” in vital pulp therapy—letter to the editor. European Endodontic Journal. 2021; 6: 128–129.

[19] Matoug-Elwerfelli M, ElSheshtawy AS, Duggal M, Tong HJ, Nazzal H. Vital pulp treatment for traumatized permanent teeth: a systematic review. International Endodontic Journal. 2022; 55: 613–629.

[20] Dubey B, Rathore M. Mineral trioxide aggregate as an apexogenesis agent for complicated crown fractures in young permanent incisor. Case Reports in Dentistry. 2023; 2023: 5597996.

[21] Ricucci D, Loghin S, Siqueira JF Jr. Correlation between clinical and histologic pulp diagnoses. Journal of Endodontics. 2014; 40: 1932–1939.

[22] Ricucci D, Siqueira JF Jr, Li Y, Tay FR. Vital pulp therapy: histopathology and histobacteriology-based guidelines to treat teeth with deep caries and pulp exposure. Journal of Dentistry. 2019; 86: 41–52.

[23] Wolters WJ, Duncan HF, Tomson PL, Karim IE, McKenna G, Dorri M, et al. Minimally invasive endodontics: a new diagnostic system for assessing pulpitis and subsequent treatment needs. International Endodontic Journal. 2017; 50: 825–829.

[24] Taha NA, Ahmad MB, Ghanim A. Assessment of mineral trioxide aggregate pulpotomy in mature permanent teeth with carious exposures. International Endodontic Journal. 2017; 50: 117–125.

[25] Taha NA, Abdulkhader SZ. Full pulpotomy with Biodentine in symptomatic young permanent teeth with carious exposure. Journal of Endodontics. 2018; 44: 932–937.

[26] Taha NA, Albakri SW. Outcome and prognostic factors for partial and full pulpotomy in the management of spontaneous symptomatic pulpitis in carious mature permanent teeth: a randomized clinical trial. Journal of Endodontics. 2024; 50: 889–898.

[27] Cushley S, Duncan HF, Lappin MJ, Tomson PL, Lundy FT, Cooper P, et al. Pulpotomy for mature carious teeth with symptoms of irreversible pulpitis: a systematic review. Journal of Dentistry. 2019; 88: 103158.

[28] Clarkson JE, Ramsay CR, Mannocci F, Jarad F, Albadri S, Ricketts D, et al. Pulpotomy for the management of irreversible pulpitis in mature teeth (PIP): a feasibility study. Pilot and Feasibility Studies. 2022; 8: 77. Erratum in: Pilot and Feasibility Studies. 2022; 8: 82.

[29] Duncan HF, Tomson PL, Simon S, Bjørndal L. Endodontic position statements in deep caries management highlight need for clarification and consensus for patient benefit. International Endodontic Journal. 2021; 54: 2145–2149.