Preservation of vital pulp is one of the most important goals of dental treatment. Certain clinical situations, such as accidental pulp exposure or damage during dental cavity preparation and traumatic pulp exposure (Ellis class III fracture), pose a real threat for the maintenance of a crucial pulp parameter, i.e. viability. This is particularly important for immature permanent teeth as healthy pulp is necessary for the continuation of proper root development. Therefore, the maintenance of vital pulp should be one of the main goals in the treatment of young permanent teeth. Direct pulp capping, which yields good results in up to 90% of cases, is one of the methods for the biological treatment of permanent teeth (1). In addition to aseptic conditions and properly performed procedure, the ability to identify indications that justify the use of this technique as well as the choice of a therapeutic agent that is most likely to ensure therapeutic success are conditions for the clinical success of this method. Materials such as non-setting calcium hydroxide or MTA (1, 2) are commonly used for this purpose; however, other, less popular preparations should be also considered. Proper understanding of the mechanisms that occur in the pulp as a result of treatment is also crucial.

The aim of the paper is to present, based on a literature review, the types of pulp exposure and therapeutic indications for direct pulp capping in permanent teeth, with particular emphasis on the developmental age.

The aim of biological treatment is to maintain healthy, vital pulp in a situation of a probable loss of pulp vitality due to external factors. The maintenance of healthy pulp is of key importance for immature teeth due to its role in the continuous apexogenesis, i.e. physiological root development (3). Immature tooth roots are characterised by thin walls, wide apexes and incomplete length (4). After eruption, it takes three to four years for the root crowns to fully develop (5). Pathological changes that occur in the pulp before apexogenesis completion inhibit the process of root formation, which significantly weakens the tooth and worsens its prognosis. Therefore, biological treatment is particularly recommended in immature permanent teeth.

Vital and healthy pulp is a barrier that prevents microorganisms from invading the body, thus not only protecting the periapical tissues from infection, but also preventing the development of odontogenic infections in distant organs (6). Furthermore, a tooth not subjected to endodontic treatment is more likely to remain in the oral cavity compared to a tooth devoid of vital pulp, which is more fragile and susceptible to mechanical damage. It was demonstrated that the periodontin of an endodontically treated tooth shows weaker stimuli reception compared to a viable tooth; therefore, such a tooth is more exposed to higher chewing forces (7). The economic factors are also important – biological methods are relatively easy and inexpensive as opposed to endodontic treatment, after which prosthetic crown restoration is often needed (8).

The main causes of vital pulp exposure include caries, mechanical factors and injuries (9). If dental exposure forms during carious cavity preparation before complete carious tissue removal, it is qualified as carious pulp exposure. According to the definition proposed by the American Association of Endodontists, mechanical pulp exposure is an “accidental exposure of the pulp by hand- or engine-driven dental instruments in the absence of dental caries. If aseptic conditions are maintained, the underlying pulp usually does not become inflamed or infected” (10). Traumatic pulp exposure is due to tooth fracture as a result of mechanical injuries. These are particularly common among young people, and thus usually affect permanent teeth with incomplete root development. If pulp viability is maintained, this type of injury is classified as Ellis class III fracture. In the case of pulp necrosis as a result of trauma, i.e. Ellis class IV fracture, apexification is the treatment of choice for teeth with incomplete formation of the root apex.

Biological treatment options include indirect or direct pulp capping and crown pulp amputation. The first treatment modality is used in a situation when no pulp exposure occurred, while the two latter methods are used to maintain exposed pulp vitality. According to the definition proposed by the American Association of Endodontists, indirect pulp capping involves placing dental material on a small amount of demineralised dentin, which when removed could expose pulp. Coronal pulp amputation, i.e. pulpotomy, is a surgical removal of the coronal portion of vital pulp to maintain the viability of the remaining root. Cvek’s partial pulpotomy, which involves only partial removal of the coronal pulp, is the variant of pulpotomy (10).

Direct pulp capping involves placing dental material directly over either mechanically or traumatically exposed pulp tissue (10). Although it is clearly stated by the American Association of Endodontists that this treatment option should be used only in mechanical or traumatic pulp exposure, some authors use this method also in carious pulp exposure (11-13).