the aim of vital pulp therapy ( vpt ) is to use biomaterials in order to safeguard as much vitality as possible for the dental pulp with carious exposure . direct pulp capping and pulpotomy , the two main vpt procedures , are less invasive than pulpectomy / root canal therapy ( rct ) .
it is well known that the most common cause of pulp / periapical diseases is the presence of bacteria and their by - products within the involved tooth , and the most common pathway of their entrance is through carious lesions ; when further bacterial recontamination is prevented with a good biological seal , the exposed dental pulp has the capability to heal and construct a new dentinal bridge and periapical tissues have the ability of regeneration .
there is a body of evidence for biocompatibility and sealing ability of mineral trioxide aggregate ( mta ) .
currently , mta is as an alternative gold standard for calcium hydroxide , a traditional gold standard , in the field of vpt .
this biomaterial creates a biological seal via hydroxyapatite crystal formation which is improved the first physical seal . despite the advantages , mta has nonpredictable antimicrobial activity , delayed setting time , poor handling characteristics , as well as high cost . the calcium - enriched mixture
( cem ) cement is a newly introduced endodontic biomaterial with similar clinical applications as mta , but different chemical compositions .
this novel cement has an antibacterial effect comparable to calcium hydroxide and superior to mta and sealing ability similar to mta .
recent researches revealed that the biologic response of the pulpal and periapical tissues to the mta and cem cement were comparable in dogs  teeth .
hydroxyapatite crystal formation was reported over the set cem even in normal saline solution . besides the surface characteristics of the set cem cement , as well as the distribution pattern of calcium , phosphorus , and oxygen ions , is similar to dentine .
last but not least , the clinical use of cem has been approved by the iranian ministry of health and medical education . even after carious pulp exposure of symptomatic permanent molars , the pulp can heal , as it has been shown in several studies using mta and cem cement as pulp - capping biomaterials .
this case report discusses a successful treatment outcome of pulpotomy treatment in a symptomatic mature molar with established irreversible pulpitis associate with condensing apical periodontitis .
diagnostic tests were performed ; the involved tooth responded with mild pain to percussion and severe lingering pain to the cold thermal test .
it was not responded within normal limits to the electric pulp test ( ept ) .
a radiographic examination showed a large carious lesion associated with condensing apical periodontitis [ figure 1a ] .
( a ) preoperative radiograph shows a large carious lesion associated with a condensing apical periodontitis .
( b  d ) six months , 1 year and 2 years follow - up radiographs , respectively ; a complete resolution of condensing apical periodontitis is evident .
note the existence of a dentinal bridge beneath the cem cement ; the remaining pulp canal space does not obliterated following clinical and radiographic diagnostic examination , pulpotomy of the first mandibular molar was decided as the treatment .
the tooth was anesthetized with 2% lidocaine with 1:80,000 epinephrine ( daroupakhsh , tehran , iran ) , isolated with a rubber damn and then caries was excavated ; the exposed coronal pulp tissue was removed with a sterile round diamond bur with water spray .
hemorrhage was controlled with sterile cotton pellets ; a ~2 mm layer of the cem cement ( bioniquedent , tehran , iran ) was placed without any pressure to cover the exposed pulp stump .
the patient was re - examined clinically after 1 and 7 days ; tooth mobility was within the normal physiological range , the percussion test was slight positive to negative , and patients were asymptomatic .
six months , one - year , and 2-years follow - ups revealed no clinical or radiographic pathological findings ( i.e. inflammation , infection , calcification , and resorption ) on the first mandibular molar ; radiographs showed normal periodontium apparatus , an evidence of complete periapical healing [ figure 1b  d ] .
the root canal treatment of teeth with irreversible inflamed pulps is basically a prophylactic treatment , since the radicular vital pulp is frequently free of infection and the rationale is to avoid further infection of the root canal system . improved and more conservative vpt has the potential to reduce the need for more invasive / complicated rct .
however , if this is to be achieved in permanent teeth , there is a need for suitable biomaterials for vpt , particularly pulpotomy . in this report , a case of established irreversible pulpitis associated with condensing apical periodontitis
recall examinations revealed that treatment outcomes were successful in preserving pulpal vitality and complete periapical healing of the tooth .
it has been suggested that the existence of a dentinal bridge may at least be an indicator of vpt success , and there are several studies that point to its clinical importance .
however , researchers reported the presence of tunnel defects in dentinal bridge under calcium hydroxide in vpt.[52122 ] they concluded that tunnel defects can serve as pathways for bacterial leakage . unlike ch , the calcified bridge formed by mta is continuous and has no evidence of tunnel defects . according to histological evidence from animal / human studies in mature permanent teeth , the cem cement , like mta , saves pulp vitality and also induces a hard tissue bridge formation , the both .
dentine bridge induced by the cem cement has been shown to be similar to that induced by mta in terms of thickness , absence of tunnel defects , presence of adjacent odontoblast - like cells , predentine , and dentinal tubules .
an important finding was the complete healing of the condensing apical periodontitis with reconstruction of bone structures to normal appearance surrounding the involved molar .
mild inflammatory processes may at times cause the formation of condensing apical periodontitis , mostly involving the mandibular first molar .
various studies have suggested that the key factor in success of vpt is the sealing ability of the material ; on the other hand , the most important cause of failure is bacterial recontamination .
the cem cement favourably prevents microleakage and has sealing ability comparable to mta and superior to irm .
in addition , the cem cement was an effective antibacterial agent . therefore , when bacterial contamination is removed from the dentin - pulp complex in addition to a creation of tight coronal seal to prevent further bacterial recontamination the inflamed but vital pulp of a permanent molar has a chance to return to a healthy and functional status .
all these are resulted in removing the etiologic factor of periapical lesion and complete periapical healing . because pulp / periapical healing was achieved without any need for further intervention
, it seems that the cem cement has the required and acceptable properties to be used as a pulp protective biomaterial .
the exact biological mechanism by which the cem cement promotes pulp healing is currently unknown .
this characteristic is likely to be the result of several properties such as sealing ability , high alkalinity , antibacterial effect , biocompatibility , i.e. dentinogenesis , cementogenesis , low cytotoxicity , pain relief effect , anti - ierr ( inflammatory external root resorption ) effect , hydroxyapatite formation , and similarity to dentine .
besides , recent interesting studies have established favourable treatment outcomes for the cem cement when used in pulpotomy of human permanent teeth with irreversible pulpitis . in the future , biomaterials can play an important role in regenerative dentistry ; they may completely transform our whole philosophy of endodontic treatment .
endodontics seems to be on the brink of an era when a diseased pulp can be a saved one .
there is a realistic biological argument to perform pulpotomy as a promising alternative endodontic treatment in mature permanent teeth ; the results of this case clearly show that cem cement can be used clinically in the treatment of a mature molar associated with irreversible pulpitis and condensing apical periodontitis .
 this case report describes a pulpotomy treatment of a permanent mature molar tooth with established irreversible pulpitis and condensing apical periodontitis , using calcium - enriched mixture ( cem ) cement . 
 clinical examination revealed that the first right lower molar had a large carious lesion with history of spontaneous / lingering pain ; radiographic examination showed condensing apical periodontitis . 
 pulpotomy was opted as the treatment ; cervical pulpotomy was carried out . 
 following hemostasis , the radicular pulp stumps were covered with ~2-mm - thick layer of the prepared cem cement ; the tooth was restored with amalgam . 
 two - year follow - up showed that the treated tooth had been symptomless , and there were no clinical signs / symptoms of either inflammation or infection . 
 radiographically , the periradicular lesion was completely healed with reconstruction of bone structures to normal appearance ; the root canals were not calcified . according to chemical , physical , and biological properties of the cem cement , 
 this novel biomaterial may be suitable for endodontic treatment . 