The increasing emphasis on biological tissue preservation in contemporary endodontics has positioned vital pulp therapy (VPT) as an important treatment strategy for maintaining pulp vitality and preserving the functional integrity of the pulp-dentine complex. Advances in biomaterials and understanding of pulpal healing have expanded the indications for VPT and contributed to favourable clinical outcomes; however, appropriate case selection remains a critical determinant of treatment success. Currently, the clinical assessment of pulpal status before VPT relies on a combination of patient-reported symptoms, clinical and radiographic findings, pulp sensibility testing and intraoperative assessment of pulpal bleeding. Although clinically valuable, these parameters do not provide a direct and objective measure of the biological status or healing potential of the pulp and may be influenced by clinical interpretation. Consequently, there remains a need for objective biological parameters that provide more direct information on pulpal status and healing potential, thereby supporting case selection and prognostic assessment in VPT.
Progressive pulpal inflammation is accompanied by increased production of inflammatory mediators, vascular congestion, enhanced vascular permeability, impaired microcirculation, and reduced tissue perfusion. These vascular alterations may compromise oxygen delivery to the pulp, resulting in reduced pulpal oxygen saturation (SpO2). As oxygen availability decreases, cellular metabolism shifts towards anaerobic pathways, promoting the accumulation of acidic metabolites, which may consequently lead to a reduction in pulpal blood pH. Accordingly, pulpal SpO2 and pulpal blood pH may represent complementary physiological and metabolic indicators of pulpal inflammatory status. Their assessment may provide objective information on the biological condition and healing potential of the pulp that is not directly captured by conventional diagnostic methods. Consistent with these observations, Hosseinzadehfard et al. (2026) reported that pulpal blood pH and SpO2 varied with pulpal diagnostic status, supporting their potential value as objective indicators of pulpal inflammation. However, their study focused on the diagnostic relevance of these parameters rather than their association with VPT success. To date, their association with subsequent treatment outcomes and clinically relevant thresholds for outcome prediction remain to be established.
The present prospective clinical study aims to investigate the association of pulpal blood pH and pulpal SpO2, individually and in combination, with the clinical and radiographic outcome of VPT at the 12-month follow-up, and to determine clinically relevant threshold values associated with treatment success. Pulpal blood pH will be assessed both immediately after initial pulp exposure and following pulpotomy in the remaining vital pulp tissue, allowing evaluation of the relationship between the two pH measurements. Systemic oxygen saturation and venous blood pH will additionally serve as physiological reference measures. The findings may provide an evidence-based foundation for a more objective and biologically informed approach to case selection and prognostic assessment in VPT.
Patients aged 16-50 years who provide written informed consent to participate in the study.
Patients classified as American Society of Anesthesiologists (ASA) physical status I.
Permanent molar teeth with deep dentinal caries considered suitable for vital pulp therapy.
Teeth diagnosed with reversible pulpitis or symptomatic irreversible pulpitis based on predefined clinical diagnostic criteria.
Teeth exhibiting a negative response to cold testing and/or EPT or diagnosed with pulp necrosis.
Teeth with radiographic evidence of apical radiolucency.
Teeth with a history of previous root canal treatment.
Teeth with internal or external root resorption, vertical or horizontal root fracture or a history of dental trauma.
Patients aged 16-50 years presenting with permanent molar teeth affected by deep dentinal caries will be consecutively screened for eligibility, with a total of 96 eligible participants recruited into the study. Teeth diagnosed with reversible pulpitis or symptomatic irreversible pulpitis, exhibiting positive responses to both cold testing and electric pulp testing (EPT) and no radiographic evidence of apical radiolucency will be eligible for inclusion in the study. Prior to enrolment, all participants will receive detailed verbal and written information regarding the study protocol. Written informed consent will be obtained before any clinical procedures are performed. Baseline demographic and clinical information, including age, sex, tooth type, pulpal diagnosis, presenting symptoms, clinical findings and radiographic characteristics will be recorded using standardized case report forms.
Cohort
Prospective
vital pulp therapy
Procedure/SurgeryVital pulp therapy will be performed according to each patient's clinical indication. Following pulp exposure, pulpal blood pH will be measured before the application of any hemostatic agent. A second pH measurement will be obtained from the remaining vital pulp tissue after pulpotomy, where applicable. Biodentine will be used as the calcium silicate-based treatment material. Clinical and radiographic outcomes will be assessed over a 12-month follow-up period.
Association Between Initial Pulpal Blood pH (pH₁) and 12-Month Vital Pulp Therapy Outcome
Initial pulpal blood pH (pH₁) will be measured immediately after pulp exposure and before the application of any hemostatic agent, irrigation solution, or pulp-capping material. Approximately 50 µL of freely available pulpal blood will be collected using a sterile single-use microcapillary tube and immediately measured using a HORIBA LAQUAtwin pH-33 microvolume pH meter with Sampling Sheet B. Values will be reported in pH units. The association between pH₁ and the 12-month clinical and radiographic outcome of vital pulp therapy (success or failure) will be evaluated.
Association Between Post-Pulpotomy Pulpal Blood pH (pH₂) and 12-Month Vital Pulp Therapy Outcome
Among participants undergoing pulpotomy, post-pulpotomy pulpal blood pH (pH₂) will be measured from the remaining vital pulp tissue before the application of any hemostatic agent, disinfectant solution or pulp-capping material. Approximately 50 µL of freely available pulpal blood will be collected using a sterile single-use microcapillary tube and immediately measured using a HORIBA LAQUAtwin pH-33 microvolume pH meter with Sampling Sheet B. Values will be reported in pH units. The association between pH₂ and the 12-month clinical and radiographic outcome of vital pulp therapy (success or failure) will be evaluated.
Association Between Pulpal Oxygen Saturation (SpO₂) and 12-Month Vital Pulp Therapy Outcome
Pulpal oxygen saturation (SpO₂) will be measured using pulse oximetry and reported as a percentage (%). The association between pulpal SpO₂ and the 12-month clinical and radiographic outcome of vital pulp therapy (success or failure) will be evaluated.
Clinically Relevant Threshold Value of Initial Pulpal Blood pH (pH₁) for 12-Month VPT Outcome
A clinically relevant threshold value for initial pulpal blood pH (pH₁) in relation to the 12-month clinical and radiographic outcome of vital pulp therapy will be determined using receiver operating characteristic (ROC) curve analysis. pH₁ will be reported in pH units. The prognostic performance of the identified threshold will be evaluated using the area under the ROC curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Clinically Relevant Threshold Value of Post-Pulpotomy Pulpal Blood pH (pH₂) for 12-Month VPT Outcome
Among participants undergoing pulpotomy, a clinically relevant threshold value for post-pulpotomy pulpal blood pH (pH₂) in relation to the 12-month clinical and radiographic outcome of vital pulp therapy will be determined using receiver operating characteristic (ROC) curve analysis. pH₂ will be reported in pH units. The prognostic performance of the identified threshold will be evaluated using the area under the ROC curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Clinically Relevant Threshold Value of Pulpal Oxygen Saturation (SpO₂) for 12-Month VPT Outcome
A clinically relevant threshold value for pulpal oxygen saturation (SpO₂) in relation to the 12-month clinical and radiographic outcome of vital pulp therapy will be determined using receiver operating characteristic (ROC) curve analysis. Pulpal SpO₂ will be reported as a percentage (%). The prognostic performance of the identified threshold will be evaluated using the area under the ROC curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Correlation Between Pulpal and Systemic Oxygen Saturation (SpO₂)
The correlation between pulpal oxygen saturation (SpO₂) and systemic oxygen saturation (SpO₂) measured at the index finger will be evaluated. Systemic SpO₂ will serve as the physiological reference measure for pulpal oxygen saturation. Both measurements will be obtained using pulse oximetry and reported as a percentage (%).
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ertuğrul karataş
Lead sponsor
Ataturk University
Sponsor institution
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