Interview: “Rethinking irreversible pulpitis: Can vital pulp therapy replace RCT?”: Dr Simon Stone, PhD

Dr Stone, it’s a pleasure to chat with you. Your journey in Endodontics is truly remarkable. Let’s dive into some questions that I’m sure will offer our readers insights into your expertise and experiences.

Your research spans many aspects of Endodontics, but you’ve carved out a clear niche focused on preserving pulp vitality and improving pain diagnosis and management. What drew you to this area of focus, and where do you see it making the biggest impact on everyday clinical practice?

The area of dental pain management is so multifaceted. In referral practice, we often see patients who have already had multiple interventions in the primary care setting, and the challenge is determining whether the intervention you can offer as a dentist will significantly improve the patient’s symptoms. I see an increasing number of patients with complex pain diagnoses and co-morbidities, and to do the best by these patients, we should encourage and embrace multidisciplinary care.

I am fortunate to work with a team that includes access to experts in temporomandibular disorder and facial pain, from whom over the years I’ve learnt a lot, from the angle and direction of history-taking through to clinical examination. For some patients with headache disorders, it may be necessary to involve our medical colleagues, such as neurologists.

As dentists, we like to ‘fix’ things that are broken, offering complex pre-treatments or surgical interventions. However, often the most difficult conversations that I have are with patients for whom there is no obvious odontogenic cause, and we often need to consider alternative diagnoses.

Your 2021 review series advocates selective caries removal and preservation of pulp vitality. Practically, what patient- and tooth-level criteria do you now use to decide between selective caries removal + Vital Pulp Therapy (VPT) versus proceeding to root canal treatment?

Vital pulp therapy is not new; we have been doing this in dental traumatology for years. However, modern calcium silicate cements are now much more mainstream. They are easier to handle and are now marketed to dentists in general practice as well as in specialist or limited practice, making them much more readily accessible. Training is also now becoming embedded into undergraduate programmes, with long-term shifts in philosophies towards minimally invasive, more biologically focused treatment options.

Published studies show that the pulp has an amazing propensity to heal, even in cases with patient symptoms and radiographic signs of emerging periapical change.

Change in clinical practice will take time; we still have difficulties in convincing colleagues that dental dam use is good practice, let alone materials that can take 12 minutes to go through their initial set.

In terms of practicalities, we should encourage colleagues to perform more pulp tests (thermal and electrical) prior to treatment. Whilst these are relatively crude tests of pulp health, they provide at least a baseline for follow-up cases. In caries management, the seal is crucial; therefore, caries at the margins should be fully removed. Deep caries over the pulp should be managed carefully, removing the leathery, infected dentine with a large round bur or, sometimes, hand excavators, and leaving the pulp unexposed, even if darkly stained. This can then be disinfected with sodium hypochlorite on a cotton pledget and then indirectly capped with CSCs.

For soft caries that extends into the pulp, the clinical status and appearance of the pulp are important. Attempts at controlling the bleeding are important determinants of where to stop. If the bleeding can be controlled within 10 minutes of sodium hypochlorite application with cotton pledgets, then CSCs can be used to directly pulp cap. If bleeding continues, proceed to a partial pulpotomy or, if necessary, a full coronal pulpotomy. If at this point bleeding still cannot be controlled, then pulpectomy and root canal treatment are indicated.

From a research-design perspective: what kinds of trials or real-world studies would you most like to see funded to definitively answer whether modern Vital Pulp Therapy can replace RCT in selected irreversible pulpitis cases?

There are ongoing pragmatic clinical trials in the UK into the feasibility of pulpotomies in the primary care setting. This is exactly what is needed to determine whether this treatment has good outcomes in the hands of general dental practitioners in settings that often have significant time and resource constraints, particularly in publicly funded settings.

Furthermore, if treatment is only predictable in the hands of a specialist, then it is not translatable to where the majority of dentistry is undertaken—in primary care. This will then impact who should and shouldn’t be taking on this type of treatment. I hope it is positive and that stakeholders will view pulpotomy as a viable, appropriately remunerated treatment option for patients, thereby encouraging its use.

These studies will need longer-term follow-up to determine when cases fail and whether they remain viable for conventional root canal treatment. Time will tell.

Your textbook chapters bridge Endodontics and Restorative care. How should restorative planning (post type, core, onlay/crown timing) change after a successful VPT versus after RCT to optimise long-term tooth survival?

Vital pulp therapy with CSCs requires coverage with a conventional restorative material, whether direct composite or indirect onlay or crown, depending on the extent of tooth tissue loss. Time is a big problem for most busy practitioners. My suggestion for posterior teeth is to fully restore the tooth, for example, with Biodentine, then cut back and overlay with composite at a different visit. Ultimately, we are trying to improve the wear characteristics and appearance of these materials through coverage. If the tooth structurally benefits from a partial- or full-coverage restoration, it can be delivered in the usual way.

For root canal–treated teeth, maintaining the coronal seal is crucial. If you have done all that you can to disinfect and fill the root canal system, don’t let your case fail because of a poorly fitting temporary restoration or crown.

Plan and allow sufficient time to obturate, and at least provide the sealing core restoration, reducing the height of any vulnerable cusps on molar teeth and making plans for onlay or crown preparation if needed.

Crown preparations are, of course, easier to prepare than onlay restorations, but the full lifecycle of the tooth must be taken into account, and tooth structure preservation is important. Posts may be used to support core materials. Direct posts (fibre posts or titanium metal) work well. Where canals are not oval, then the cement space can be limited by cast posts, although in these cases, preservation of the coronal seal between appointments can be difficult and may be better achieved by directly covering the root and giving the patient an Essix or temporary prosthesis rather than accepting a poorly adapted temporary or leaky post-crown.

Timing has always been an interesting question—but what are we waiting for, the tooth to crack? If you know the endodontic treatment has been done well, get on and definitively restore the tooth, ideally within the first few months after RCT.

Beyond your academic and clinical work, how has your family influenced or supported your journey in dentistry, and what role do they play in keeping you balanced amidst a busy professional life?

I suppose it is always about striking a balance, and I’m sure that I don’t always get it right—if you have any tips, let me know! I always try to take a holiday when my children are off school and do things with them that make the holidays memorable. When it is term time, though, it can be tough going sometimes.

Family are often your biggest advocate, and mine has always been a strong supporter of my professional journey. The clinical academic career is certainly not the shortest path, but I don’t resent the time spent along the way. It seems that colleagues are sometimes in a rush to reach those career milestones and goals in the shortest possible time, but life experience is equally important in shaping you as a professional.

The access-cavity debate (conservative versus traditional) raises trade-offs between tooth strength and disinfection. Given advances in irrigants, files and imaging, do you believe we should aim for more conservative access as standard — or is that still a case-by-case call? Where should clinicians draw the line?

Around 60% of referred cases to our restorative service involve colleagues who have had difficulty with root canal location and negotiation, highlighting that it is often not an easy task and that colleagues struggle with vision and canal identification.

The biggest change people can make is embracing magnification in dentistry. I’m fortunate to have had colleagues who have forged the path in embracing microscopy in dentistry, and I have had access to amazing dental operating microscopes for many years. However, modern loupes with directional light bring many of these benefits within reach for the general dental practitioner. This will make the biggest change to your dentistry overall, and over time, your access cavities may get smaller.

Marginal ridges remain the most important factor in fracture resistance, so they are the key foundation for long-term success. Interestingly, instrument manufacturers have also reduced the shank diameter on many modern super-flexible endodontic rotary files, so already, preparations are becoming conservative. For me, access is the key to successful treatment and shouldn’t be compromised.

Looking ahead 5–10 years: which technological or material advances (bioactive cements, point-of-care diagnostics, regenerative approaches) do you believe will most radically change Endodontic practice — and what should clinicians do now to prepare?

We are probably at the peak now of what endodontic files can do. The advances and post-manufacturer processing treatments have resulted in preparations of very challenging canal systems that are predictable and carry a reduced risk of file breakage.

Dental MRI is an emerging diagnostic tool and has the potential to be a real alternative to ionising radiation. Although the radiation dose from dental imaging is comparatively low, it would be hugely valuable if we could reduce its use further whilst still obtaining the same (or better) information. Dental trauma and the need for long-term follow-up are one obvious use.

At the moment, costs are prohibitive—but so was CBCT 10–15 years ago—and now the price differential between a panoramic and a CBCT unit makes it an accessible option in the general practice setting.

What advice would you give to young dentists who aspire to excel in Endodontics and contribute meaningfully to the field?

Invest in yourself and your practice with some high-quality magnification and a good LED light. If you are able to, practise on and radiograph extracted teeth, taking views from different angles. This will improve your understanding of anatomy immensely and help you to know where the limits of instruments and obturation systems lie.

This sounds obvious, but it is often the first thing that we get postgraduate students to do in the simulation environment. It is amazing how much variation teeth have (we know this, of course, from CBCT studies), but looking through the bucket and finding the three-rooted premolars, multi-rooted canines and lower incisors is always fascinating.

For young colleagues interested in Endodontics, get involved with your national or regional specialist society and attend their meetings. Some, like the British Endodontic Society, have an Early Career Group specifically aimed at encouraging interest in and growth within the speciality.

Which would be your suggested Top 3 books for Endodontics?

Probably the top three for postgraduates are:

• Textbook of Endodontology (Eds. Lars Bjørndal, Lise-Lotte Kirkevang, John Whitworth)

• Cohen’s Pathways of the Pulp (Eds. Kenneth M. Hargreaves and Louis H. Berman)

• Endodontics: Principles and Practice (Eds. Mahmoud Torabinejad, Ashraf F. Fouad, Shahrokh Shabahang)

A couple of these have recently published or have upcoming new editions, so look out for them.

Top 3 journal recommendations in Endodontics

• International Endodontic Journal

• Dental Traumatology

• Journal of Endodontics

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