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An accurate assessment of the inflammatory condition of the pulp has a large bearing on the success of VPT procedures, as teeth with carious exposures have a poorer outcome than those with traumatic ones [52, 53]. Pulpitis is generally classified as being either reversible or irreversible [54, 55]; however, in light of the development of predictable VPT solutions, such as pulpotomy in teeth with signs and symptoms indicative of irreversible pulpitis, alternative classifications have been proposed in order to more accurately reflect the true state of the pulp [2, 27]. New classification systems have tried to link diagnosis and management and to use more descriptive terms including ‘mild’, ‘moderate’, and ‘severe’ pulpitis [2], but their usefulness in effectively replacing the current classification system remains speculative. Pulpal status is routinely determined after pain history, a clinical/radiographic examination, and pulp tests. Unfortunately, clinical signs, symptoms, and tests are relatively nonspecific and generally do not accurately reflect the histopathological status of the pulp [56, 57] – although this assertion has recently been queried, as a strong correlation between pulp histology and the signs and symptoms of reversible and irreversible pulpitis has been demonstrated [34].

Reversible pulpitis can present either with no patient complaint or with symptoms that can extend to a sharp pain sensation with thermal stimuli. Notably, the pain resolves rapidly once the stimulus is removed. Spontaneous pain and sleep disturbance tend to indicate irreversible pulpitis [1, 57], with the symptoms lingering after stimulus removal. Unfortunately, patient symptoms are at best a guideline and can even mislead the clinician, with irreversible pulpitis being symptomless in the majority of cases [54, 58]. During the early stages, teeth presenting with signs and symptoms of irreversible pulpitis usually exhibit significant pulpal damage only in the area of the coronal pulp under the carious lesion, with a largely uninflamed radicular pulp [1, 34]. Invariably, without intervention, the partial irreversible pulpitis will progress until the entire pulp is irreversibly inflamed and necrosis ensues. Although treatment decisions are largely based on patient signs and symptoms, current tools are insufficient to accurately determine the threshold between reversible and irreversible forms [59]. As a result, it is critical to identify more discriminative tests based on molecular analysis of pulpal biomarkers [1].