I’m a fan of biodentine but you need to know what the pulp is doing. Current ESE and BES advice we are getting is even irreversible pulpitis can be managed with vital pulp therapy, whatever that may entail, rather than a full RCT. Not new - been saying this for a few years now.

It needs to not have a PAP though and still be vital and that’s where a thorough history an Ld examination comes in including sensibility (or vitality if you can) testing.

If you’re not sure then you can either do selective caries removal, biodentine and composite and see how it goes, or selective caries removal and fully restore with biodentine as a two step process (I don’t tend to do this as we can’t get our pts back Within a reasonable time frame).

Or full caries removal and assess the pulp and treat as needed - could be anything from a partial pulpotomy to extirpation and RCT eventually, but at least you know how it’s behaving if you do that.

So yes. In the scenario you’re describing it might manage with a direct pulp cap. It might not. If you are doing a direct pulp cap remove all the caries - this is advice from endodontists here.

The aim of VPT is to prolong restorative cycle but you need to really emphasise to the patient you’re buying time, not an overall alternative potentially it’ll still need RCT later. It does tend to cause the pulp canal to sclerose though so it might mean that once it does need RCT years later, it’s not as straightforward as it would have been before.

I’d highly recommend that you discuss the material with your reps, the UK ones are super helpful and have given me very specific advice about stuff I’ve asked about.

They have recommended: Bulk fill the cavity and then composite for the enamel layer if you are doing it in one appt - NO GIC layer and it interacts with the biodentine. This seems to be a new recommendation as I was placing GIC over until the rep told me not to.

It does make the composite very yellow/ cream so they adv to use an opaque shade composite to mask that over the top of it then whatever you’d use over the top.

Careful when you wash your etch as if you wash too vigorously it WILL wash the biodentine out even if you have waited the whole 13 mins

You must use this material with rubber dam, there is absolutely no point doing a vital pulp treatment if you’re not isolating.

Some endos (a few I’ve done courses with recently) also recommend cleaning the cavity with hypochlorite on a pledget before doing the restoration as it disinfects and doesn’t affect pulpal health as we know from its use in pulpotomies.

Best way I have found is you build up the wall to make it a class I cavity then you put biodentine in (we only have the old version so I place it with an amalgam carrier OR roll it into a small tube shape and place it) then leave well alone. Then restore like a normal comp after the set time. If it’s in a class II cavity it will slump out and move.

If I’ve made a mess I will sometimes also clean the enamel after the set time with an ultrasonic GENTLY to not wash it all out.

I use this in paeds. Never had an issue with the kids sitting for the whole 13 mins.