Reconsidering prolonged bleeding as a positive prognostic indicator in vital pulp therapy

Dear Editor-in-Chief, Prolonged bleeding (PB) during vital pulp therapy (VPT) has traditionally been viewed as a negative prognostic indicator, often associated with irreversible pulpitis and compromised pulpal health. This interpretation has shaped clinical decision-making, frequently favoring more invasive procedures, such as pulpectomy and root canal therapy, under the presumption of irreversible pulp damage. However, emerging evidence in pulp biology and pathophysiology challenges this conventional perspective,[1,2] offering a nuanced understanding of PB during VPT. The dental pulp, as a specialized connective tissue, demonstrates a remarkable capacity for dynamic responses to injury. Inflammation within the pulp acts as a dual mechanism, both defending against microbial invasion and promoting tissue repair. Inflammatory vasodilation facilitates immune cell infiltration and pathogen clearance when concurrently enhancing reparative processes.[3] Thus, PB during VPT may signify heightened vascular activity and active reparative responses rather than irreversible pulpal damage. For instance, cases of hyperplastic pulpitis frequently exhibit this reparative potential, as evidenced by clinical observations of robust blood supply and tissue overgrowth indicative of vitality.[4-6] Acknowledging PB as a marker of pulpal vitality and reparative potential could transform treatment paradigms. While PB may denote active inflammation, it does not necessarily indicate irreversible damage. Instead, it may reflect the pulp’s innate ability to recover, repair and regenerate. This paradigm challenges the traditional binary classification of inflamed pulp tissues as reversible/treatable or irreversible/untreatable and underscores the importance of nuanced clinical judgment.[5,6] From a practical standpoint, PB presents challenges for clinicians, including obscured operative fields and extended treatment duration. Effective bleeding control is therefore critical to achieving successful outcomes in VPT. Sodium hypochlorite (NaOCl) is widely recognized as an effective hemostatic agent with vasoconstrictive, antimicrobial, and disinfecting properties.[7] The direct application of NaOCl facilitates hemostasis and provides a clean field for subsequent restorative steps.[8] Another effective strategy involves the tampon approach, utilizing calcium silicate based endodontic biomaterials such as calcium-enriched mixture (CEM) cement or mineral trioxide aggregate (MTA)-like cements to apply mechanical compression, promote vasoconstriction, and achieve hemostasis.[9,10] Combining these approaches, NaOCl irrigation followed by the tampon technique, has demonstrated particular efficacy in controlling PB and ensuring procedural success.[11-14] Innovative biomaterials such as MTA, CEM cement, and other advanced tricalcium silicate cements have shown superior biological activity in VPT and pulp revascularization, especially following NaOCl irrigation.[7,15] These materials not only promote hemostasis but also enhance disinfection and tissue regeneration, making them optimal choices for addressing PB in clinical practice. The combination of their bioactivity with hemostatic techniques underscores their clinical utility and priority in managing PB. To fully validate the prognostic role of PB during VPT, further high-quality experimental studies and well-documented clinical cases are essential. Such research would bridge theoretical concepts with practical applications, fostering evidence-based refinements in diagnostic criteria and management protocols. A shift toward recognizing PB as a potential positive indicator could expand the scope of VPT, reducing the reliance on invasive procedures and preserving pulpal vitality for improved long-term outcomes. By reevaluating the significance of PB, clinicians can adopt a more comprehensive approach that aligns with the pulp’s reparative potential, ultimately enhancing patient care. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.