symptomatic irreversible pulpitis is a pulpal state characterized by mild / severe pain that lingers after removal of a stimulus . in such cases , pulpectomy / extraction is required to alleviate the symptoms and prevent apical periodontitis . however , as the severity of pulpal inflammation can not be measured quantitatively , it must be based on clinical findings rather than histological diagnosis ; moreover , there is poor correlation between the two . in addition , pulps of teeth clinically diagnosed with irreversible pulpitis were shown to have the potential to heal after pulpotomy with appropriate biomaterials such as mineral trioxide aggregate ( mta ) and calcium enriched mixture ( cem ) cement.[37 ] a systematic review revealed that to reduce the risk of carious pulp exposure , partial caries removal ( indirect pulp therapy [ ipt ] ) can result in long - term success compared with complete caries removal in the deep lesion . a clinical trial demonstrated high survival rate of permanent teeth when deep carious lesions were managed without exposing the pulp by placing an indirect pulp cap . these results demonstrated that the teeth pulps remained symptomless and maintained their healing potential and defensive capacity after treatment . elimination of the bulk of the infected dentin and sealing the remaining carious lesion from oral fluids with appropriate materials is an accepted treatment for badly decayed teeth . in addition , performance of ipt is simpler / more economical than rct . cem cement has been introduced as a water - based and tooth - colored endodontic biomaterial . after mixing with liquid , the ph of cem increases to > 10 . it is assumed that in a high ph environment the calcium ions that are released from cem react with endogenous phosphates to form hydroxyapatite ; this would explain the favorable sealing ability / biocompatibility of the cement . an in vitro study revealed that the anti - bacterial properties of cem are similar to calcium hydroxide . cem has been employed as a root - end filling material , as well as direct pulp capping agent , pulpotomy agent , apical plug , in the repair of furcal perforations , management of root resorption , and regenerative endodontics . recently , an interesting report demonstrated favorable treatment outcomes of direct pulp capping with cem for management of a permanent mature molar with irreversible pulpitis and associated apical periodontitis . the following report discusses the first case of successful management of a symptomatic permanent tooth with irreversible pulpitis and associated apical periodontitis using ipt with cem , followed by a sandwich glass - ionomer composite restoration . a 12-year - old female with a symptomatic first left lower molar was observed at a private clinic . diagnostic tests were performed ; the involved tooth responded with mild pain to percussion and severe lingering pain to endo - frost cold spray ( roeko ; coltene whaledent , langenau , germany ) . radiographic examination showed a large carious lesion associated with apical periodontitis [ figure 1 ] . the adjacent / opposing teeth were asymptomatic and responded normally to all diagnostic tests . based on the clinical and radiographic examinations , the diagnosis of irreversible pulpitis with apical periodontitis was made . thereafter , ipt of the tooth was decided ; an informed consent was obtained from the patient 's legal guardian . intraoral pre - operative radiograph showing well - defined radiolucency of mesial and distal roots of symptomatic first lower left molar the patient was instructed to rinse her mouth with 0.2% chlorhexidine . the tooth was anesthetized with 2% lidocaine with 1:80,000 epinephrine ( daroupakhsh , tehran , iran ) and then isolated with rubber dam . the bulk of soft carious dentin was carefully removed by tungsten - carbide round burs ( komet , lemgo , germany ) at low speed ; medium and large spoon excavators ( ash , london , uk ) were also used . after that , the remaining carious dentin in pulpal floor was covered by 1.5 mm layer of cem cement ( bioniquedent , tehran , iran ) . the remaining tooth cavity was then restored / sealed with glass - ionomer cement and composite resin sandwich technique [ figure 2 ] . post - operative orthopantomogram ( opg ) showing threelayers ofrestorationconsistofindirectpulptherapy / calcium enriched mixture , glass ionomer and composite resin . left : higher magnification of treated first lower left molar revealing well defined periapical radiolucency of both roots the patient was re - examined clinically after 1 and 7 days . at the 1-day follow - up the patient complained of sensitivity to cold which had significantly decreased 1 week post - operatively . patient was recalled at 1 year for clinical / radiographic follow - up . clinical examination with cold test showed a vital tooth which was functional , asymptomatic , with normal physiologic mobility , normal probing depths , and a satisfactory coronal restoration . radiographic examinations showed normal periodontium , and evidence of periapical healing [ figures 3 and 4 ] . six - month follow - up radiograph showing healing process of apical pathology one - year follow - up radiograph showing complete periapical healing this study conducted ipt with cem cement for a pulp with sign / symptoms of irreversible pulpits along with apical periodontitis . though , apical periodontitis seemed evident on the radiograph , the pulp was still vital . the general consensus in cases where irreversibly inflamed pulp has been diagnosed , is that the pulp no longer has the potential to heal and will not survive with any form of treatment . however , it should be considered that irreversible pulpitis is a clinical term for the classification of pulpal diseases ; when treating the deep carious lesion clinicians have to diagnose irreversible pulpitis on the basis of indirect diagnostic methods . there is little evidence to correlate the clinical signs / symptoms with histological feature of the diseased pulp . therefore , dentists are trained to diagnose irreversible pulpitis when patient complains of pain lasting for a few minutes to several hours , pain exacerbating with hot / cold fluids , and radiating pain ; as well as tender to percussion . however , there is no information to indicate which symptom is an indication that the pulp no longer can repair itself . conversely , recent reports have demonstrated that teeth with irreversible pulpitis showed favorable treatment outcomes with pulpotomy using cem / mta as pulp cappings.[357 ] though the diseased pulps in these cases were inflamed , they were still vital ; that is they still maintained a blood supply and therefore the most important factor for healing . in the light of recent high - level evidences , the inflammatory process should be re - examined to recognize its possible or probable positive effect on pulpal healing . our clinical / radiographic follow - ups also showed favorable treatment outcomes for ipt / cem . these results reveal that severe local inflammation in pulpal tissue may heal and be repaired if the irritant is removed and the pulp is well protected from further irritants . if further studies support this , there may be a need for reclassification of dental pulp diseases . a growing body of evidence has demonstrated that ipt is successful for the management of deep caries lesion in primary molars as well as two - stage technique in immature permanent teeth ; however , some recent studies have shown similar results in mature permanent teeth . ipt reduces the risk of carious pulp exposure , diminishes the substrate for microorganisms , prevents lesion development and promotes a physiological reaction in the pulp - dentin complex . several studies have demonstrated that once cariogenic bacteria are isolated from their nutritional supply by an adequate coronal seal , they either perish or become inactive . furthermore , once a seal is applied to carious dentin , it becomes dry / hard , arresting the carious process after ipt with a one - visit method . accordingly , the second appointment may not be needed , if the coronal restoration preserves the seal of cavity . our 1-year clinical follow - up showed that the one - visit ipt coronal filling was satisfactory , and therefore a second appointment was not scheduled . several dental materials have been suggested for capping the remaining carious lesion in ipt , that is calcium hydroxide , polycarboxylate cement combined with tannin - fluoride preparation , zinc - oxide eugenol cements , resin - bonded composite , glass ionomer cements and copper phosphate cement . the ideal capping material should be anti - bacterial , non - toxic , dimensionally stable , biocompatible , and create a hermetic seal as well as be able to induce regeneration of the pulp . considerable data has shown favorable properties of cem cement namely ; anti - bacterial properties , sealing ability , dimensional stability and biocompatibility when compared with other gold standard materials such as calcium hydroxide or mta . the favorable results in this case study may be partly attributed to the patient 's age . a young patient 's tooth may have slightly open apices and the dental pulp may respond more positively to pulp capping than a mature pulp . based on our clinical and radiographic observations , we can conclude that despite apparent pulpal and periradicular inflammation from the deep caries lesion , a conservative ipt can generate pulpal repair and periradicular healing in a mature permanent molar tooth . in addition , ipt / cem of deep caries lesion in young patients is an easier , more practical and valuable treatment plan than complete caries removal which may result in pulp exposure and root canal treatment . however , well - conducted clinical trials on this proposed technique will be required for more grounding clinical evidence .