## 4 Discussion
### Biodentine and MTA+
However, despite adherence to the manufacturer's instructions, its actual setting time often extends two to three times longer [23; 24], averaging around 22 min [14]. This delayed setting might reduce clinical efficiency, as it is impractical to place the definitive restoration in a single appointment, thus diminishing the advantage of Biodentine over MTA, which sets in several hours. Notably, unlike other MTA materials, Biodentine was not associated with postoperative discoloration [14; 25]. This aligns with our findings, where no samples in the Biodentine group exhibited gray discoloration, unlike several cases in the MTA+ group. **Type of treatment**  
This study found a high success rate for all three VPT techniques, which aligns with the other studies [14; 26; 27]. Multivariate analysis showed that complete pulotomy had a slightly higher success rate than partial pulotomy; however, this difference was not statistically significant due to the small sample size and the multifactorial nature of the outcome. Similarly, [PERSON] [28] and [PERSON] et al. [12] found no significant differences among the groups but a tendency of a decreasing success rate with the more invasive treatment. In contrast, [PERSON] et al. [29] concluded that no definitive preference between direct pulp capping and partial pulotomy could be established. However, we applied direct pulp capping in patients with no pulpal symptoms diagnosed as having normal pulp, where the pulp was exposed during deep caries removal, which could result in a higher success rate. In contrast, patients with less severe initial pulpal conditions were treated with partial or complete pulotomy. The initial diagnosis of the severity of the pulpitis was supported by the presence and extent of deteriorated pulp tissue by microscope. Therefore, it is not surprising that the success rates of VPT techniques were inversely correlated with the invasiveness of the procedure. This observation is consistent with the findings of [PERSON] et al. [30]. [PERSON] et al. found the same trend: mild pulpitis had a 100% success rate, moderate pulpitis 88%, and severe pulpitis 60% at 1 year [14]. These findings suggest that the Wolters classification could predict treatment failure. Similarly, irreversible pulpitis is classified by the ESE terminology, resulting in a higher OR than reversible pulpitis [31]. As the depth of caries and the diagnosis are confounded with the treatment modality, a prospective cohort study is more advantageous (and ethically sound) than a randomized control study to determine the coefficient of the predictors. **Methodological Bias in Pulp Testing: Partial vs. Full Pulpotomy**  
Defining success criteria, such as the response to sensibility testing, is crucial as it significantly impacts reported treatment outcomes. Cold testing may underestimate pulpotomy success due to potential false-negative responses. [14; 32]. For example, a study by [PERSON] and [PERSON] reported a 90% success rate for partial pulpotomy, including both \"successful\" and \"unresponsive but successful\" cases [14].However, when unresponsive cases were classified as failures, the success rate dropped to 66% [14]. Similarly, in this study, partial and complete pulpotomy cases frequently did not respond to cold testing even though the tooth was asymptomatic and showed no evidence of apical radiolucency. The European Society of Endodontology (ESE) recommends a positive response to pulp sensibility testing to indicate success. However, it acknowledges that in certain cases, particularly in complete pulpotomy, a positive response may not be expected [20]; therefore, complete pulpotomy cases were considered successful despite the negative reaction. Due to the short observation period, the strict criteria for the classification of these unresponsive cases as failures were used in this study.