Tampon approach in vital pulp therapy: Advancing endodontic care for permanent dentition

Dear Editor-in-Chief, In the dynamic landscape of dental treatments, innovation remains pivotal in advancing patient care with a growing emphasis on conservative dentistry. Vital pulp therapy (VPT) has been established as a standard of care for managing deep carious lesions with reversible or irreversible pulpitis in permanent teeth, aligning with the trend toward minimally invasive approaches.[1,2] Nevertheless, debates persist regarding the necessity for more aggressive interventions, such as pulpectomy and root canal therapy, particularly when hemostasis is not promptly achieved within a few minutes during VPT procedures.[3] While some researchers propose hemostasis as an indicator of inflammatory changes within the pulpal tissue,[4] others contest this notion.[5] Histobacteriology-based guidelines suggesting that failure to achieve hemostasis after 2 min should be considered a contraindication to VPT,[6] lack robust evidence support. I am writing to highlight a recent advancement in endodontic care: the tampon approach in VPT (Tampon VPT).[7-9] This technique presents a promising solution for managing excessive bleeding during VPT procedures for inflamed pulps, specifically severe pulpitis in permanent teeth. The introduction of tampon VPT has the potential to enhance the outcomes for clinicians/patients by addressing a common challenge in VPT procedures. The traditional requirement for hemostasis can present a significant challenge during VPT procedures for the cases of severe pulpitis. Taha et al. have shown that bleeding can be controlled within 6 min in 84% of pulpotomy cases in adults; however, in 16% of such cases, hemostasis cannot be achieved in a reasonable time,[10] and therefore, the necessity of the tampon approach for a rapid clinical procedure remains a subject of debate within the field. It should be noted that no significant relationship between bleeding time and treatment outcome has been reported yet.[11,12] Tampon VPT involves the placement of an endodontic biomaterial, such as calcium-enriched mixture cement, over the amputated pulp to arrest bleeding,[13] without the formation of a blood clot, and create an environment conducive to pulp healing and regeneration.[14-16] This approach contrasts with methods requiring immediate hemostasis and allows for a more flexible timeframe, aligning with findings from studies such as those by Taha and Abdulkhader and Guan et al., which demonstrate successful outcomes with longer hemostasis times.[17,18] A recent cohort study has shown that tampon VPT produces outcomes on par with cases where hemostasis is achieved more rapidly, ensuring treatment efficacy without compromising results.[12] This minimally invasive technique not only enhances patient experiences but also improves procedural efficiency for dental practitioners, particularly in the busy clinical settings. In addition, its simplicity and cost-effectiveness make it accessible to a broader demographic of patients. Moreover, its simplicity reduces procedural stress for both clinicians and patients alike. While the use of calcium-silicate based biomaterials such as calcium-enriched mixture cement, Biodentine, and MTA in pulpotomy of irreversible pulpitis cases is well-established,[19,20] the tampon VPT offers a refined approach to manage hemostasis challenges. It should be noted, however, that most of the cited references supporting the tampon approach are case reports and a large-scale cohort study, which underscores the need for further large-scale randomized clinical trials to validate these findings. In summary, the tampon VPT technique represents a valuable addition to endodontic care for mature and immature permanent teeth by offering a conservative and effective solution for managing severe pulpitis. I urge the dental community to consider this approach and contribute to further research and clinical validation to enhance the patient outcomes.