Before we describe what happened in this trial, here is who was in it: 407 patients in Iran, mean age in their thirties, all with mature permanent molars, all with a clinical and radiographic diagnosis of irreversible pulpitis — the kind of toothache that traditionally lands you in a chair for a root canal. Half were randomised to a root canal. The other half were randomised to vital pulp therapy: open the tooth, remove the inflamed coronal pulp, place a calcium-silicate cement directly on the radicular pulp tissue, restore. The pulp stays alive. The tooth keeps its blood supply. No file ever enters a canal.
At five years the success rates were not statistically different. That is a result worth slowing down for, because the conclusion you are likely to draw from it — “I should ask for vital pulp therapy instead of a root canal” — is more complicated than the headline.
This is the second-most-cited line of evidence in modern endodontics for a procedure most patients have never been offered, and the patient who has been quoted a $1,200 AUD root canal at home, or a $250 USD root canal in Da Nang, has a real reason to understand it.
Disclosure. Dr. Maloney has no commercial relationship with the trial authors, their institution, the manufacturer of the calcium-enriched mixture cement studied, or any clinic, marketplace, or industry body referenced in this piece. The publication’s standing disclosures (default: none) are documented at /disclosures/. [Last reviewed: 2026-05-06.]
Patients
407 patients, recruited across 23 health-care centres in Iran between 2009 and 2010, randomised 1:1 to vital pulp therapy with calcium-enriched mixture (CEM) cement or to conventional root canal treatment [1]. The trial was a non-inferiority design, registered, and the protocol was published before the five-year results.
To be enrolled, a patient had to have:
- A mature permanent molar — root development complete, apex closed.
- A clinical diagnosis of irreversible pulpitis (lingering pain to thermal stimulus, often spontaneous, often disturbing sleep — the textbook presentation that almost always triggers a root canal recommendation).
- Bleeding from the exposed pulp that stopped within five minutes of haemostasis with sodium hypochlorite. This is the procedural threshold the protocol used to confirm the radicular pulp was salvageable. A pulp that will not stop bleeding has crossed the threshold the trial required.
- No periapical radiolucency on the pre-operative radiograph beyond the normal periodontal ligament space.
This is the load-bearing inclusion criterion and the first place the result narrows. The trial did not enrol every tooth that gets recommended for a root canal. It enrolled a specific subset: irreversible pulpitis on a mature molar where the pulp could be controlled and the apical tissues had not yet started to break down. In an unselected pool of teeth recommended for a root canal in a high-volume clinic, the proportion meeting these criteria sits well below 100%.
271 patients were available for assessment at five years — roughly two-thirds of the original cohort. That loss to follow-up is a real limitation and the authors disclose it. A reader who weights the result heavily should weight the missing third proportionally.
Procedures and endpoints
Vital pulp therapy arm. Local anaesthesia, rubber dam, access cavity. Removal of the inflamed coronal pulp tissue (full pulpotomy). Haemostasis confirmed within five minutes. Direct placement of CEM cement onto the radicular pulp stumps. Permanent coronal restoration in the same or next visit.
Root canal treatment arm. Local anaesthesia, rubber dam, access cavity. Cleaning and shaping of the root canal system, irrigation with sodium hypochlorite, obturation with gutta-percha and a sealer, permanent coronal restoration.
Primary outcome: combined clinical and radiographic success at five years, defined as absence of pain, absence of swelling, absence of sinus tract, no apical radiolucency on follow-up radiograph, and the tooth still in function.
Effect estimates. The 12-month interim report had already shown clinical success in both arms above 95% with no statistical difference between groups [2]. The five-year primary analysis confirmed the non-inferiority hypothesis: success rates were not statistically different between arms (P = 0.29) [1]. In absolute terms, both arms reported success in the high-80s to low-90s percentage range at five years. The point estimate favoured root canal treatment marginally; the confidence interval crossed the non-inferiority margin in the direction the trial was designed to test.
These are absolute numbers from a randomised comparison, not a registry, not a retrospective cohort. That distinction matters.
Subgroups
The trial pre-specified analyses by age, sex, and presence of a small periapical lesion at baseline. None of those modified the result meaningfully — the success of vital pulp therapy did not depend on patient age within the enrolled range, did not depend on sex, and was not different in the small subgroup who had a borderline radiographic lesion at baseline.
What the trial did not stratify by — and what every patient who reads the headline result should understand — is operator experience. The procedures were performed by trained endodontists working under a defined protocol in a research-network setting. Whether the same result extends to a general practitioner in a high-volume international clinic, performing vital pulp therapy as a marketed alternative to root canal treatment for a fixed flat fee, is not a question this trial answers. It is a question you should ask before agreeing to the procedure.
A subsequent single-centre Iranian RCT compared four different vital pulp therapy techniques (indirect pulp cap, direct pulp cap, miniature pulpotomy, full pulpotomy) in 302 mature molars and reported one-year success rates of 91.4–100% across modalities [3]. That study reinforces the underlying signal — vital pulp therapy works in this population — but does not extend the operator-experience question to general practice.
Conclusions
The trial demonstrates non-inferiority of full pulpotomy with calcium-silicate cement compared with root canal treatment, in mature permanent molars with irreversible pulpitis, in trained-operator hands, at five years. A 2021 systematic review of 12 studies on vital pulp therapy in this clinical setting reports radiographic success rates of 81–90% across one- to five-year follow-up [4], consistent with the Asgary trial.
This is real evidence. It changes what a thoughtful clinician should be willing to discuss with a patient. It does not change what a thoughtful clinician should be willing to perform without specific case selection and operator training.
The strongest version of the case for vital pulp therapy is this: it preserves pulp vitality, takes less time, costs less, and produces equivalent outcomes at five years in a randomised comparison.
The strongest version of the case for root canal treatment is this: a generation of practitioners has been trained to do it, the failure mode is predictable, the retreatment pathway is well-described, and the procedure is offered competently in a much wider population of clinics than vital pulp therapy currently is.
Both are true at the same time.
What this means for the patient who has been quoted a root canal
A patient who has been quoted a root canal — whether at a domestic specialist practice or at an international high-volume clinic — has a reasonable basis to ask three questions:
- What is the diagnosis, specifically? Reversible pulpitis, irreversible pulpitis with controllable bleeding, irreversible pulpitis with uncontrollable bleeding, or pulp necrosis with a periapical lesion? These are different procedures and the published evidence behind them is different.
- Was full pulpotomy with a calcium-silicate cement considered? If yes, on what grounds was it ruled out? If no, why not? In a patient with controllable pulp bleeding and no periapical lesion, the trial above is the case that this option deserves to be on the table.
- What is the operator’s experience with this specific procedure? “We do root canals all day” is not the same answer as “I have performed full pulpotomy in this category of tooth, here is my case load, and here is my failure rate.” A clinic that markets vital pulp therapy as a cheaper alternative to root canal treatment, without operator-specific case experience, has not earned the recommendation that the trial above might otherwise support.
The international cost dimension is real but secondary. A root canal in Da Nang is around $250 USD; a full pulpotomy in the same chair is faster and cheaper still — sometimes less than half. A root canal in Sydney sits between $1,200 and $2,400 AUD, depending on tooth and operator; a full pulpotomy, where indicated and well-executed, is in the $400–800 AUD range. Currency, Q2 2026, exclusive of crown work. Where the procedure is genuinely indicated, the saving is meaningful in either market. Where it is not — most of the time, in most clinics, on most teeth — the cheaper procedure is not the better one.
External validity question
The Asgary trial enrolled patients in Iran, in trained-operator research-network conditions, with mature molars, irreversible pulpitis, and bleeding controllable within five minutes. If you have a tooth in a different category — a non-vital tooth, a tooth with an established periapical lesion, a tooth where the pulp will not stop bleeding, or you are not in a clinic with operator-specific experience in this procedure — the trial result does not directly apply to your case.
The clinical decision in any individual case rests with you and your treating clinician, against the imaging, the diagnosis, and the operator’s experience.
What would change my view
I read this trial as evidence that vital pulp therapy belongs in the clinical conversation, not as evidence that it should replace root canal treatment as the default for every mature molar with irreversible pulpitis. The evidence that would update the framing further:
- A multi-country pragmatic trial of vital pulp therapy versus root canal treatment in general-practice settings, randomising real patients in real clinics, with operator-experience strata pre-specified. The Asgary trial established the procedure works in trained hands; the question of whether it generalises to the average clinic is the next question.
- Ten- and fifteen-year follow-up data on the Asgary cohort. The five-year primary endpoint is reassuring; pulp survival over a tooth’s remaining lifetime is the question that matters to a 35-year-old patient.
- A randomised comparison of full pulpotomy versus root canal treatment with patient-reported outcomes (post-operative pain, return to function, second-procedure rate at one year) as co-primary endpoints. The Asgary primary endpoint is success-as-defined; the patient-side experience of these two procedures is not identical, and the published data on that comparison is thinner than the radiographic-success data.
Until those exist, full pulpotomy with calcium-silicate cement is a procedure I am willing to recommend in selected cases, in selected hands, with the trial above as the published anchor for the conversation.
For the broader decision between saving a tooth and replacing it with an implant, see when to save a tooth and when to replace it. For the procedure reference on what retreatment looks like when a previous root canal has failed, see the endodontic retreatment guide. For the cost backdrop of these decisions in international markets, see dental implant costs by country and the structural reasons international and domestic recommendations diverge in the dental tourism trust gap. The same financial-incentive pattern that bends implant treatment plans toward grafting bends root-canal treatment plans toward extraction-and-implant; the framework on that side of the question is set out in why most implants do not need bone grafting. For the weekly read of what the regulators and the peer-reviewed record have published — and how to read what they have not yet settled — see This Week in Dental Tourism.