Vital pulp therapy vs root canal: what the published evidence has settled, and what most general practices have not yet caught up to

When I retreat a failed root canal, the question I sometimes ask myself, looking at the radiograph the patient hands me, is whether the first treatment should have been done at all. Not whether it was done well — that is a different review — but whether the tooth, at the point of diagnosis nine or ten years ago, needed a root canal in the first place, or whether full pulpotomy with a calcium-silicate cement was the option that should have been on the table.

That option has been on the table, in the published evidence, since at least the early 2010s. The five-year non-inferiority RCT by Asgary and colleagues randomised 407 mature molars with a clinical and radiographic diagnosis of irreversible pulpitis to either root canal treatment or vital pulp therapy and reported, at five years, success rates that were not statistically different [1]. The publication’s Trial of the Week review of that trial walks through the methodology in the Cardiology-Trials four-section template. This piece is the procedural and clinical-decision companion. The question it asks is not whether the evidence supports VPT — that question has been answered in the affirmative for several years now [1] — but what a defensible VPT protocol looks like, which patients are candidates, what most general practices in 2026 still get wrong, and why the cost arithmetic of choosing VPT over RCT is one of the few decisions in modern dentistry where the cheaper option is also the biologically more conservative one.

I will say in plain language what this piece is and is not. It is a specialist account, written under my license, of how I read the published evidence and apply it in my own practice. It is not a recommendation for any individual reader’s case. It is not a brief for VPT against RCT in all circumstances — the case-selection criteria below are the controlling factor, and the patient in front of you is not the patient in the Asgary trial unless they meet the inclusion criteria. The decision is clinical. The framework is patient-side, so the patient can recognise when the option should be on the table and when the clinician has declined to put it there.

What vital pulp therapy is, in the form the evidence supports

Vital pulp therapy is an umbrella term. In the mature-tooth, irreversible-pulpitis context the Asgary trial studied, the relevant procedure is full pulpotomy — removal of the inflamed coronal pulp tissue, haemostasis at the canal orifices, direct placement of a calcium-silicate cement on the radicular pulp tissue at the orifice level, and a permanent coronal restoration [7]. The radicular pulp is left alive. No file enters a canal. No gutta-percha is placed. The tooth retains its blood supply, its proprioception, and (in the cases that succeed) its biological response to caries and load over time.

The materials matter. The published evidence on full pulpotomy in irreversibly pulpitic mature molars rests on calcium-silicate cements — mineral trioxide aggregate (MTA) in the original Asgary protocol [1] [4], and the newer bioceramic alternatives that have come onto the market since [5]. Calcium hydroxide, the older direct-pulp-capping material, is not the material the modern VPT evidence supports for irreversible pulpitis; the published success rates with calcium hydroxide in this indication are materially lower than those with the calcium-silicate cements. A clinician offering “pulp capping” with calcium hydroxide for an irreversibly pulpitic molar is not offering the procedure the modern evidence describes.

The procedure is technique-sensitive. The literature converges on a specific protocol: rubber-dam isolation; complete caries removal under loupes or operating microscope; high-volume irrigation; complete removal of inflamed coronal pulp tissue under magnification (the visible bleeding from the radicular orifices is the diagnostic signal); haemostasis within a defined time window (most protocols specify under ten minutes) with sodium hypochlorite irrigation; assessment of the pulp tissue at the orifices (continued profuse bleeding past ten minutes despite haemostasis attempts is a contraindication and converts the case to root canal treatment); placement of the calcium-silicate cement directly on the haemostased pulp tissue at the orifices; and a definitive coronal restoration in the same visit or shortly thereafter [1]. The published success rates depend on each step. A protocol with any of these elements missing is not the protocol the trials studied, and the success rates the trials reported do not transfer to it.

Who is a candidate — the case-selection criteria the trials enforced

The Asgary five-year trial enrolled 407 patients with mature permanent molars and a clinical and radiographic diagnosis of irreversible pulpitis [1] [2]. The inclusion criteria are the controlling boundary of the result. A patient who falls outside them is not a patient to whom the trial’s success rates apply.

The included patients had: mature teeth (closed apices, complete root development); a clinical presentation consistent with irreversible pulpitis (lingering pain to thermal stimulation, spontaneous pain, sometimes nocturnal pain — the symptom complex that traditionally indicates a root canal); a radiographic appearance without a periapical radiolucency suggestive of pulp necrosis; absence of a sinus tract; absence of swelling; absence of severe percussion tenderness suggestive of acute periapical inflammation; teeth that were restorable with a definitive coronal restoration; and patients without medical contraindications to a procedure under local anaesthetic. The trial excluded teeth with periapical radiolucencies, sinus tracts, necrotic pulps, severely calcified canals, immature apices, or unrestorable crown structure.

For the patient considering whether VPT might be offered, the patient-side version of the inclusion criteria is: my tooth hurts to cold or heat, sometimes spontaneously; I do not have a bump on the gum; I do not have swelling that has tracked through; the radiograph does not show a black halo at the root tip; my dentist says the tooth is restorable. A tooth that meets that description is, on the published evidence, a tooth at which VPT should at minimum be on the table as a discussion. A tooth that does not meet that description is, on the published evidence, a tooth for which root canal treatment is the procedure with the longer track record.

A clinician who has triaged a case as outside the VPT inclusion criteria and declined VPT for that reason has made a defensible decision. A clinician who has not triaged the case at all, and has defaulted to RCT without consideration of VPT for a case that meets the criteria, has made a different decision, and the patient is entitled to know which one it was.

Why most general practices in 2026 still default to root canal treatment

The Asgary five-year data has been in print for over a decade [1]. The shorter-followup data has been in print longer [2]. The earlier procedural studies that established the calcium-silicate full-pulpotomy protocol have been in print for longer still [4]. The evidence base, at five years, is non-inferior. And yet, in the cases that arrive in my chair for retreatment in 2026, the proportion that received VPT at the original presentation rather than RCT is a small minority. The gap between the published evidence and the typical practice pattern is real, and it is not, in my reading, primarily a gap of evidence.

Three structural reasons recur. The first is training. The undergraduate dental curriculum, in most Australian and many international programs, teaches root canal treatment as the indicated procedure for irreversible pulpitis in a mature molar, with full pulpotomy with calcium-silicate cements appearing in the curriculum only in recent years and varying widely in coverage depth between schools. A clinician who graduated before 2015 received their formative training in the procedure the trial would later test the alternative against; the alternative was not on the syllabus they trained on. A clinician who graduated after 2015 has received variable exposure depending on their school. Continuing-education courses on full pulpotomy with calcium-silicate cements are available, and some clinicians have done the work; many have not.

The second is procedural confidence. Full pulpotomy with calcium-silicate cements requires haemostasis judgement, microscope or loupe use, and the discipline to convert to RCT mid-procedure if the haemostasis criterion is not met. RCT, for a clinician who has done thousands, is the procedure with the comfortable habit. A procedure that is unfamiliar and requires intraoperative judgement is not the procedure most general practices reach for first when the patient is in the chair and the clock is running.

The third is fee structure. A root canal in a mature molar is one of the highest-fee procedures in general practice. Full pulpotomy with a calcium-silicate cement, in most fee schedules, is reimbursed at a materially lower rate. The price-differential is, by the standards of clinical fee work, substantial — typically several hundred to over a thousand dollars per tooth in Australia, with comparable differentials in other source markets. A practice that habitually offers RCT for an irreversibly pulpitic molar is not necessarily acting in bad faith. The procedure they are offering is the one their training, their procedural confidence, and their fee schedule all converge on. But the alternative exists, and the patient is entitled to know it exists.

I want to put on the page that this is not a charge that general dentistry is corrupt. It is a description of how a clinical-practice pattern persists past the point at which the evidence has shifted, in any branch of medicine, including the ones in which the financial incentive runs the other way. The same persistence-past-evidence pattern is documented in cardiology (the over-use of certain stenting indications), in orthopaedics (the persistence of arthroscopic procedures with weak evidence bases), and elsewhere. It is a feature of clinical practice, not a feature of dentistry specifically. Naming it does not require accusing anyone of bad intent. It does require asking the patient to know what the question they should be asking is.

The cost arithmetic — one of the few decisions in dentistry where cheaper and conservative align

A root canal in a mature molar in Australia in Q2 2026 is quoted in the root canal cost-by-country reference at $1,400–$2,400 AUD at a mid-tier general practice, with specialist endodontist fees materially higher. Full pulpotomy with a calcium-silicate cement, performed in the same chair on the same tooth meeting the same inclusion criteria, is quoted in Australian general practice at $400–$900 AUD, with substantial regional variation. The procedure is a single visit. The follow-up cadence is six-month and twelve-month review. The restoration cost is the same as the restoration cost on the RCT case.

The cost differential is not the reason to choose VPT over RCT. The reason to choose VPT over RCT, in the cases that meet the inclusion criteria, is that the tooth stays alive — that the radicular pulp tissue retains its blood supply, its proprioception, its capacity to lay down secondary dentine, and the dentinal-tubule architecture that makes a vital tooth more fracture-resistant than a root-canal-treated tooth over the medium term. The cost-side argument is a downstream consequence of the biology-side argument, not the leading reason for the decision.

For the patient navigating an international-treatment cost comparison, this changes the question. The price-differential arithmetic that drives most dental tourism decisions — Australian root canal at $1,800 vs. Vietnamese root canal at $250 — does not run the same way for VPT, because the absolute domestic VPT cost is already low. A patient who meets the VPT inclusion criteria, has the procedure performed correctly at home, and avoids the RCT altogether has already realised most of the cost differential without flying. The dental tourism trust gap is a less material problem when the procedure being chosen is a $500 procedure at home. The patient flying overseas for a $250 procedure on a tooth that should have had a $500 procedure at home for biological reasons is making a decision on the wrong leg of the arithmetic.

What a defensible plan looks like — and the five questions to ask

The framework I apply in my own practice, and the questions I would expect a competent clinician to be able to answer if VPT is on the table for an irreversibly pulpitic mature molar, is the following.

1. Has the tooth been triaged against the published VPT inclusion criteria? The clinician should be able to describe, on the radiograph in front of you, whether the tooth meets the criteria the Asgary trial enforced. If the answer is “yes, and here is why,” the case is a VPT-eligible case. If the answer is “no, the periapical radiolucency / sinus tract / pulpal necrosis on the radiograph excludes it,” the case is an RCT case and the clinician has made a defensible call. If the question has not been triaged at all and RCT has been recommended by default, the patient is entitled to ask why.

2. What material is the clinician planning to use, and what is its published five-year evidence base in irreversible pulpitis? The defensible answer is a calcium-silicate cement (MTA or a comparable bioceramic), with the trial evidence the clinician can cite. Calcium hydroxide is not the modern VPT material for this indication.

3. What is the haemostasis protocol, and what is the conversion criterion? A clinician operating to the published protocol has a defined intraoperative criterion for converting from VPT to RCT — continued profuse bleeding from the radicular orifices past the haemostasis time window, despite irrigation with sodium hypochlorite. A clinician who cannot describe their conversion criterion does not have an operational protocol; they have an aspiration.

4. What is the magnification and isolation protocol? Rubber-dam isolation and microscope or loupe use are not optional. The procedure depends on visual judgement at the orifices, and visual judgement at that level is not possible without magnification.

5. What is the follow-up cadence and the criterion for declaring success? The Asgary five-year data tracked clinical signs and symptoms (resolution of pain), radiographic appearance (no developing periapical radiolucency), and pulp vitality testing. A clinician operating to standard knows the cadence and the criteria.

A clinician who answers all five clearly is a clinician operating to the modern evidence on this procedure. A clinician who cannot is, on this particular procedure, operating to a different standard.

What would change my view

I hold this position because the Asgary five-year data is the strongest published evidence we have on VPT-versus-RCT in the mature molar with irreversible pulpitis, because the procedural literature on calcium-silicate cements has matured to the point where the materials and the protocol are reproducible, and because the case-selection criteria are clear enough that an honest clinician can triage a case in front of them. The evidence that would update this view:

A second, geographically independent, registered five-year RCT (or longer) in a comparable patient population, with N > 400, that reported materially different success rates — particularly if it found VPT inferior to RCT at five years in the irreversible-pulpitis mature-molar indication. The current published record has not produced such a trial.

A long-term cohort analysis (ten years or more, N > 1,000) showing that the VPT-treated teeth in the trial cohorts had higher rates of late failure than RCT-treated teeth on biological endpoints — secondary caries reaching the pulp chamber, fracture rates, late periapical lesion development. The current published record at five years does not show this signal; the question is whether a longer follow-up would. I am not yet aware of a published cohort at ten years that would settle the question definitively.

A published methodology critique of the Asgary trials that materially undermined the reported success rates — e.g., systematic bias in the diagnostic threshold for irreversible pulpitis, or methodological issues in the success-criterion definition. The methodology critiques I have read so far have raised the same external-validity concerns the trial’s authors themselves acknowledged, but none have undermined the reported five-year non-inferiority result.

If any of these emerges, the position shifts. Until then, the published evidence supports VPT as non-inferior to RCT in the irreversible-pulpitis mature molar that meets the inclusion criteria, and the practice pattern that defaults to RCT for those cases without discussion is, in my reading, a practice pattern that has not caught up to the evidence.

For the trial-level review with the methodology in detail, see the Trial of the Week review of the Asgary multicenter trial. For the upstream decision on save-versus-replace if VPT has not been triaged and RCT has been recommended, see when to save a tooth and when to replace it. For the cost arithmetic across ten countries, see the root canal cost-by-country reference. For the consult-side reflection on declining a procedure a patient wanted but did not need — the same decision-side discipline this procedure asks of the clinician — see the consult I didn’t take. For the structural account of why these decision-side discussions are harder to verify from outside a clinic, see the dental tourism trust gap.

Sources

1. Asgary S, Eghbal MJ, Fazlyab M, Akbarzadeh Baghban A, Ghoddusi J. Five-year results of vital pulp therapy in permanent molars with irreversible pulpitis: a non-inferiority multicenter randomized clinical trial. Clin Oral Investig. 2015. https://pubmed.ncbi.nlm.nih.gov/25431099/
2. Asgary S, Eghbal MJ, Ghoddusi J, Yazdani S. One-year results of vital pulp therapy in permanent molars with irreversible pulpitis: an ongoing multicenter, randomized, non-inferiority clinical trial. Earlier interim report cited in the five-year publication.
3. Wikipedia. Pulpitis. https://en.wikipedia.org/wiki/Pulpitis
4. Wikipedia. Mineral trioxide aggregate. https://en.wikipedia.org/wiki/Mineral_trioxide_aggregate
5. Wikipedia. Calcium silicate. https://en.wikipedia.org/wiki/Calcium_silicate
6. Wikipedia. Dental pulp. https://en.wikipedia.org/wiki/Dental_pulp
7. Wikipedia. Pulpotomy. https://en.wikipedia.org/wiki/Pulpotomy
8. Wikipedia. Endodontic therapy. https://en.wikipedia.org/wiki/Endodontic_therapy