Treatment Outcomes of 4 Vital Pulp Therapies in Mature Molars

Effect of lateral extent of pulp tissue removal on the outcome of partial pulpotomy for managing cariously exposed mature permanent molars with symptomatic irreversible pulpitis: A randomized clinical trial

AIM

The aim of this study is to compare the outcomes of restricted partial pulpotomy (R-PP) versus extended partial pulpotomy (E-PP) for managing cariously exposed mature permanent molars with symptomatic irreversible pulpitis (SIP).

METHODOLOGY

This double-arm, parallel designed randomized clinical trial was registered at clinicaltrials.gov (registration number: NCT05406557). Following random allocation, 43 participants of each group received the designated intervention. In the R-PP group, 2-3 mm of superficial pulp tissue was removed only from the exposure site, while chamber was completely de-roofed and 2-3 mm of superficial pulp tissue from entire chamber was removed in the E-PP group. Haemostasis was achieved using 3% sodium hypochlorite-soaked cotton pellets. Upon haemostasis, ProRoot mineral trioxide aggregate (ProRoot MTA) was placed over the pulpal wound, overlaid with a resin-modified glass ionomer liner, and restored with composite resin in the same visit. Outcome measures included clinical and radiographic success evaluation at 6 and 12 months, and pain assessment using the visual analogue scale pre-operatively and daily for 7 post-operative days. Nonparametric tests were used for variables including patient's age, pain intensities, mean analgesic consumption, and haemostasis time. Categorical variables including gender, caries type, analgesic intake, hard tissue barrier formation, clinical and radiographic success, and pulp sensibility responses were assessed using Chi-square or Fisher's exact test. Tooth survival was analysed using Kaplan-Meier analysis.

RESULTS

A total of 81 cases were analysed at 12 months follow-up. Comparable success was observed in both groups (97.6% in E-PP & 97.5% in R-PP; p > .05). The R-PP group reported significantly lower pain scores on the 1st and 2nd post-operative days than E-PP (p < .05) and required significantly less analgesic intake (p < .05). Hard tissue barrier formation was significantly lower in the R-PP group (p < .05). No significant differences were observed between groups regarding haemostasis time, pulp sensibility responses, and tooth survival (p > .05).

CONCLUSIONS

Both the PP approaches exhibited comparable success for managing cariously exposed mature permanent molars with SIP. Given the conservative nature of R-PP, it may be used as preferred PP approach for managing such cases. Being the first study of this kind, further work is necessary to draw definitive conclusions.

Outcomes of vital pulp treatment in permanent teeth with carious pulp exposure with signs and symptoms of irreversible pulpitis

OBJECTIVE

To investigate the outcomes and factors influencing the success of vital pulp treatment (VPT) in permanent teeth with carious pulp exposure and signs and symptoms of irreversible pulpitis (IP).

MATERIALS AND METHODS

Dental records from 2016 to 2023 of patients who received VPT for carious pulp-exposed permanent teeth with IP symptoms were reviewed. Outcomes were assessed using clinical and radiographic criteria. Univariate and multivariate analyses were performed to identify factors affecting treatment success. The Kaplan-Meier estimator was used to compare survival probabilities.

RESULTS

The overall success and survival rates were 88.24% and 97.06%, respectively. Success rates for direct pulp capping, partial pulpotomy, and full pulpotomy were 87.7%, 92.0%, and 87.7%, respectively. Key factors influencing outcomes included the presence of periapical radiographic lesions, type of pulp dressing material, and quality of the final restoration. Full pulpotomy demonstrated the highest survival time, followed by partial pulpotomy and direct pulp capping.

CONCLUSION

VPT in permanent teeth with carious pulp exposure and IP symptoms shows high success rates. Crucial factors include periapical radiographic findings, type of pulp dressing material, and quality of the final restoration. Full pulpotomy exhibited the longest survival time.

CLINICAL RELEVANCE

VPT in teeth with IP symptoms shows promising outcomes, highlighting the importance of certain clinical factors in treatment success.

Comprehensive review of composition, properties, clinical applications, and future perspectives of calcium-enriched mixture (CEM) cement: a systematic analysis

This review aims to comprehensively explore calcium-enriched mixture (CEM) cement as a crucial biomaterial in dentistry/endodontics. With its growing clinical relevance, there is a need to evaluate its composition, chemical/physical/biological properties, clinical applications, and future perspectives to provide clinicians/researchers with a detailed understanding of its potential in endodontic procedures. Through systematic analysis of available evidence, we assess the advantages/limitations of CEM cement, offering valuable insights for informed decision-making in dental/endodontic practice. Our findings highlight the commendable chemical/physical properties of CEM cement, including handling characteristics, alkalinity, color stability, bioactivity, biocompatibility, sealing ability, and antimicrobial properties. Importantly, CEM cement has shown the potential in promoting regenerative processes, such as dentinogenesis and cementogenesis. It has demonstrated successful outcomes in various clinical applications, including vital pulp therapy techniques, endodontic surgery, open apices management, root resorption/perforation repair, and as an orifice/root canal obturation material. The efficacy and reliability of CEM cement in diverse clinical scenarios underscore its effectiveness in endodontic practice. However, we emphasize the need for well-designed clinical trials with long-term follow-up to further substantiate the full potential of CEM cement. This review serves as a robust reference for researchers/practitioners, offering an in-depth exploration of CEM cement and its multifaceted roles in contemporary dentistry/endodontics.

The effectiveness of partial pulpotomy compared with full pulpotomy in managing deep caries in vital permanent teeth with a diagnosis of non-traumatic pulpitis

BACKGROUND

Pulpitis may be pain free or alternatively characterized by mild to severe pain and associated symptoms. Evidence has recently emerged that patients presenting with carious pulp exposure range of symptoms can be treated effectively with pulpotomy.

OBJECTIVE

The current systematic review aimed to answer the following research question: "In patients with deep caries lesions in permanent teeth associated with no symptoms, reversible pulpitis or signs and symptoms indicative of irreversible pulpitis (P), is partial pulpotomy (I) as effective as full pulpotomy (C), in terms of a combination of patient and clinical reported outcomes (O), with "tooth survival" as the most critical outcome?

METHODS

The systematic literature search was conducted in the following electronic databases: OVID, Scopus, PubMed (Including MEDLINE), and Cochrane Central Register of Controlled Trials (CENTRAL) supplemented with Grey literature and hand searching of relevant journals. The English language clinical trials comparing the patient and clinical reported outcomes between partial and full/complete were included. After a structured literature search, two authors independently performed study selection, extracted data and performed a risk of bias assessment; a third reviewer resolved disagreements. As there were only two studies with different exclusion criteria, no meta-analysis was performed and the quality of evidence was assessed by the GRADE approach.

RESULTS

After study selection a total of two randomised clinical trials with a total of 156 teeth were included both for the management of teeth with irreversible pulpitis. There were no studies for asymptomatic teeth or teeth with reversible pulpitis. A "Low" risk of bias was noted for both studies with a high level of overall evidence. A meta-analysis was not carried out due to differences in inclusion criteria between the studies related principally to caries depth. Both studies reported a high rate of clinical success for pulpotomy with a pooled unadjusted success rate for full pulpotomy of 90% and 83% partial pulpotomy of at 1-year; however, no significant difference between the treatments was noted in either study. There was significantly reduced postoperative pain reported in the full pulpotomy group over 1-week compared with the partial pulpotomy in one but not in the other study.

DISCUSSION

Pulpotomy as a definitive treatment modality is as effective in managing teeth exhibiting signs and symptoms indicative of irreversible pulpitis and challenges the established protocols to manage this condition. Although based on only two RCTs with a limited number of patients, no difference was shown in terms of clinical or radiographic outcome or postoperative pain between groups. Further well designed randomised clinical trials of longer duration are required in this area to improve the evidence available.

CONCLUSION

There is no consistent difference in patient-reported pain between partial and full pulpotomy at day 7 postoperatively and the clinical success rate was similar after 1 year for both treatment modalities.

Partial pulpotomy success in primary molars followed up for 24 months: A randomized controlled clinical trial using mineral trioxide aggregate, biodentine, and acemannan

BACKGROUND

Finding the best treatment approach and suitable capping materials in primary molars with deep carious lesions remains unresolved.

AIM

To compare the success rates of partial pulpotomy in deep caries lesions in primary molars treated with mineral trioxide aggregate (MTA), biodentine, or acemannan for 6-24 months.

DESIGN

A parallel-design, non-inferiority randomized controlled clinical trial was performed. Ninety mandibular primary molars from 65 children meeting the criteria, aged 3-8 years, were included. After inflamed pulp tissue removal and hemostasis, each tooth was randomly allocated into the MTA control group, or the biodentine or acemannan experimental group (N = 30 per group). All teeth were restored with a stainless steel crown. The outcomes were evaluated for 6-24 months. A generalized estimating equation model was used to compare the overall success rate in each group.

RESULTS

After 24 months, 58 children (83 teeth) were available for evaluation. The results indicated that the success rate in the MTA, biodentine, and acemannan groups was 83.3%, 76.9%, and 74.1%, respectively. No significant difference in success rates among groups, however, was observed at the 6- to 24-month follow-ups (at 24th month, p = .30).

CONCLUSION

There was no statistically significant difference between MTA, biodentine, or acemannan in the partial pulpotomy success after 24 months.

Elective full pulpotomy in mature permanent teeth diagnosed with symptomatic irreversible pulpitis: a two years retrospective study

AIM

To investigate the outcome of elective full pulpotomy, using calcium silicate-based cements (CSBC), after 2 years, in symptomatic mature permanent teeth with carious lesions, diagnosed as irreversible pulpitis, and analyse the capacity of Wolters et al. (2017) classification to predict the likelihood of treatment failure.

METHODS

The treatment records of 56 patients with symptomatic mature teeth with carious lesions, diagnosed as irreversible pulpitis and treated by elective full pulpotomy, using CSBCs as pulp capping materials, were reviewed. Thirteen teeth were excluded. The remaining 43 teeth were evaluated retrospectively at 24 months. Fisher`s exact test with the Lancaster's mid-P adjustment was used to assess different outcomes amongst the diagnostic categories.

RESULTS

Four of the cases failed before 24 months and required root canal treatment (RCT). Overall success rate at 2 years was 90.7% (39 of 43). An inverse, but non-significant, correlation was observed between the severity of pulpitis according to the Wolters classification and the treatment success rate (p > 0.05). The type of CSBC used was associated to the success rate (OR = 10.5; 95% C.I. = 0.5 - 207.4; p = 0.027), being 82% with Endosequence and 100% with Biodentine. Postoperative pain associated significantly to lower success rate (66.7%) (Odds ratio = 8.0; 95% C.I. = 0.7 - 95.9; p = 0.047).

CONCLUSIONS

Elective full pulpotomy using a CSBC was a successful choice for the treatment of mature permanent teeth with symptoms indicative of irreversible pulpitis. There were no significant differences between the success rate of mild, moderate and severe pulpitis. Postoperative pain could be considered a risk marker for failure of full pulpotomy. The term "irreversible pulpitis" should be re-signified to indicate the need for access to the pulp chamber, rather than an indication for extraction or RCT.

Outcome and Prognostic Factors for Partial and Full Pulpotomy in the Management of Spontaneous Symptomatic Pulpitis in Carious Mature Permanent Teeth: A Randomized Clinical Trial

INTRODUCTION

The aim of this study was to compare the outcome and prognostic factors for partial and full pulpotomy in the management of mature teeth with spontaneous symptomatic pulpitis.

METHODS

The study was a parallel double-blind randomized clinical trial; 200 carious mature permanent teeth with spontaneous symptomatic pulpitis were randomized using a block randomization technique to either partial pulpotomy (n = 99) or full pulpotomy (n = 101). Intraoperative assessment of the pulp under magnification was performed, hemostasis was achieved with a 2.5% sodium hypochlorite moist pellet, and NeoPUTTY (Avalon Biomed, Bradenton, FL) was the pulpotomy material. Preoperative pain levels were recorded and re-evaluated after 1 week. Clinical and radiographic evaluation was performed after 6 and 12 months. Data were analyzed using the chi-square test, the Wilcoxon rank test, and regression analysis.

RESULTS

At 1 week, immediate failure occurred in 4 cases in partial pulpotomy, and 196 of 200 subjects reported pain relief and were satisfied with the treatment with no significant difference. At 6 months, 6 teeth failed in the partial pulpotomy group and 1 tooth in the full pulpotomy group, with a higher success rate for full pulpotomy (98.96 vs 89.69, P = .003). At 12 months, the recall rate was 98% (96/200). Full pulpotomy was more successful than partial pulpotomy (98.98% [98/99] vs 84.53% [82/97], P < .001). Multivariate analysis revealed that the odds of success for full pulpotomy were 13.6 times higher than partial pulpotomy. Increased age and higher time to hemostasis were significantly associated with decreased odds of success.

CONCLUSIONS

Full pulpotomy has a higher success rate than partial pulpotomy in the management of spontaneous symptomatic pulpitis. Hemostasis within 4 minutes in partial pulpotomy can be set as the cutoff point beyond which further tissue removal is indicated.

Managing failed vital pulp therapies in mature permanent teeth in a retrospective cohort study, with success and survival rates of managing protocols

Despite advancements in vital pulp therapy (VPT), a subset of cases fails to achieve desired outcomes. This study based on a previous large-scale cohort study involving 1257 VPT-treated teeth, aiming to describe the demographic data and clinical characteristics of all failed cases and their management protocols. Clinical records/images of 105 failed cases treated by a single endodontist (2011-2022) were examined, including 10 extracted teeth. Asymptomatic cases with PDL widening received no intervention, while others underwent management protocols, including (selective) RCT and (tampon) re-VPT. These retreatments were assessed for success (defined as radiographic evidence of healing) and survival (characterized by the retention/function of the treated tooth) using Kaplan-Meier analysis. While 51.4% of all initial failures were diagnosed due to symptoms, 48.6% were symptom-free. Notably, failed cases with symptomatic irreversible pulpitis, and apical periodontitis/widened PDL before initial treatment significantly outnumbered asymptomatic cases and normal PDL, respectively (P = 0.001). Moreover, most of the initial failures were observed in teeth with composite resin rather than amalgam restorations (P = 0.002). The success and survival rates for the management protocols were 91.78% and 95.79%, respectively, over an average follow-up period of 36.94 (± 23.30) months. RCT and re-VPT procedures provide successful outcomes for managing unsuccessful VPTs.

Efficacy of pulpotomy in managing irreversible pulpitis in mature permanent teeth: A systematic review and meta-analysis

OBJECTIVES

This paper evaluated the success rates of pulpotomy, compared its efficacy with non-surgical root canal treatment (NSRCT), evaluated different pulpotomy techniques, and analyzed the effectiveness of contemporary bioactive materials in managing irreversible pulpitis in mature permanent teeth.

DATA SOURCES

A comprehensive literature search was conducted across multiple databases including PubMed, Web of Science, Scopus, and the Cochrane Library. Search was conducted from the inception of each database to the present, adhering to PRISMA 2020 guidelines.

STUDY SELECTION

Studies were selected through a multi-step screening process, focusing on adult populations, randomized controlled trials, and single-arm trials.

DATA

Fifteen randomized controlled trials and eight single-arm trials were included. For a follow-up period of more than 24 months, pooled clinical success rate of pulpotomy was 92.9 % (95 %CI;82.1-99.0 %), whereas pooled radiographic success rate was 78.5 % (95 %CI;66.7-88.4 %). Meta-analyses showed that there was no significant difference in success rates between pulpotomy and NSRCT, between full and partial pulpotomy techniques, or between Mineral Trioxide Aggregate pulpotomy and Calcium Enriched Mixture pulpotomy. The results indicated comparable efficacy across these variables.

CONCLUSIONS

The study highlights the potential of less invasive treatments. Pulpotomy may be a viable alternative to NSRCT for managing irreversible pulpitis in mature permanent teeth. Limitations such as the low quality of some single-arm trials and the high risk of bias in some randomized controlled trials highlight the need for further research to standardize methodologies and broaden literature inclusion for a more comprehensive understanding of the efficacy of pulpotomy, considering the high success rates reported. Clinical Significance This quantitative systematic review recognizes the potential of full or partial pulpotomy as a viable treatment alternative to root canal therapy for managing irreversible pulpitis in mature permanent teeth. Future studies should aim for standardized protocols to validate these findings and improve patient treatment outcomes.

Exploring vital pulp Therapies: A bibliometric analysis of the most cited articles

Aim

The aim of this study was to identify and analyze the most cited articles on vital pulp therapies.

Methodology

Bibliographical data related to the abstract, citations, keywords, and other relevant information was extracted using different combinations of keywords. Further evaluation and visualization of the selected data were performed with the help of various tools, including MS Excel, Microsoft Word, Google open refine, BibExcel, and VOS viewer. An initial search revealed 91 documents, of which 40 were chosen for further analysis. We used the Kolmogorov-Smirnov test and Spearman correlation coefficient test, and our adopted significance level was p < 0.05.

Results

In total, the articles received 1,905 citations, with six of them receiving at least 100 citations. Among the top 40 articles, the United States of America (10 articles) and Ireland (6 articles) were the countries with the highest number of cited articles. The journals "Journal of Endodontics" (14 articles; 650 citations) and "International Endodontic Journal" (13 articles; 577 citations) published most of the articles among the 50 most cited ones. Duncan H. was the author with the highest number of works cited (11 articles; 339 citations). Of the articles, systematic reviews accounted for 32%, literature reviews for 14%, in vitro experimental studies for 12%, clinical trials for 8%. Among the biomaterials used in vital pulp therapies, mineral trioxide aggregate (MTA) was discussed in 37 articles (74%), followed by calcium hydroxide, mentioned in 30 studies (60%). Interestingly, the publication year did not demonstrate a significant impact on citation count.

Conclusion

The present study provided a detailed list of the top 50 most cited and classic articles on vital pulp therapies. This will help researchers, students, and clinicians in the field of endodontics with an impressive source of information.

Comparative evaluation of cervical pulpotomy and pulpectomy for primary molars with irreversible pulpitis: a multicentre randomised controlled trial

PURPOSE

The objective of this multicentre randomised controlled trial was to compare the clinical/radiographic outcomes of cervical pulpotomy using calcium-enriched mixture cement (PCEM) and pulpectomy using Metapex (PM) in primary molars with irreversible pulpitis (IP).

METHODS

A total of 134 primary molars from 94 children were randomly assigned to two intervention groups: the PCEM group (n = 74) and the PM group (n = 60). Baseline characteristics including age/gender/molar type/tooth type/jaw were recorded. The primary outcome measures were clinical/radiographic success rates assessed at the first and second follow-up appointments. Secondary outcomes included reasons for clinical/radiographic failures. Multiple logistic regression analysis was performed to determine the impact of various factors on the success rates.

RESULTS

The mean age of the participants in both groups was similar (PCEM group: 5.4 years, PM group: 5.5 years). Gender distribution, molar type, tooth type, jaw, and number of practitioners were comparable between the groups. The clinical success rate at the first follow-up was 98.6% in the PCEM group and 96.4% in the PM group. At the second follow-up, the clinical success rate was 97.1% in the PCEM group and 91.1% in the PM group. The radiographic success rates at the first and second follow-up were 98.6% and 96.4% in the PCEM group and 96.4% and 91.1% in the PM group, respectively. Multiple logistic regression analysis did not reveal any significant association between the success rates and age/gender/molar type/jaw, or treatment groups (P > 0.05).

CONCLUSION

In primary molars with IP, both simple/conservative cervical pulpotomy using calcium-enriched mixture cement and pulpectomy using Metapex demonstrated high clinical/radiographic success rates. No significant differences were observed between the two treatment modalities. These findings suggest that both techniques can be considered effective treatment options for managing primary molars with IP.

TRIAL REGISTRATION NUMBER

Trial registration number: IRCT20201226049838N1, retrospectively registered on 12 January 2021.

Determining Factors in the Success of Direct Pulp Capping: A Systematic Review

AIM

To elucidate the factors that determine the success of direct pulp capping (DPC) in permanent teeth with pulp exposure due to dental caries.

MATERIALS AND METHODS

A comprehensive electronic search from 1980 to 2023 across PubMed, Scopus, and ISI Web databases was conducted using specific keywords and MeSH terms in Q1 or Q2 journals. Only prospective/retrospective clinical studies in English on 15 or more human permanent teeth with carious pulpal exposure treated with DPC agents-mineral trioxide aggregate (MTA), Biodentine, or calcium hydroxide with a rubber dam and minimum 1-year follow-up, were considered. The factors retrieved and analyzed were based on study design, patient age, sample size, type of cavity, exposure size and location, pulp diagnosis, solutions to achieve hemostasis, hemostasis time, capping material, restoration type, follow-up period, methods of evaluation, and overall success.

REVIEW RESULTS

Out of 680 articles, only 16 articles were selected for the present systematic review on application of the selection criteria. A wide age range of patients from 6 to 88 years were considered among these studies with sample sizes ranging from 15 to 245 teeth with reversible pulpitis being the predominant diagnosis of the cases. Mineral trioxide aggregate as a capping material was evaluated in 4 studies as a lone agent, while compared with other capping agents such as biodentine or calcium hydroxide in 7 studies. The follow-up period ranged from 9 days to nearly 80 months. While both clinical and radiographic evaluation was carried out in all studies, cold testing dominated the clinical tests while IOPR was the common radiograph considered. Mineral trioxide aggregate success rate was higher and similar to biodentine than calcium hydroxide.

CONCLUSION

Direct pulp capping has a high and predictable success rate in permanent teeth with carious exposure to reversible and irreversible pulpitis. Currently, mineral trioxide aggregate and biodentine have better long-term results in DPC than calcium hydroxide, hence, they should be used as an alternative to calcium hydroxide. Definitive restoration within a short period improves long-term prognosis.

CLINICAL SIGNIFICANCE

The significance of this review lies in its provision of evidence-based information on the effectiveness of DPC and the factors that influence its success. By considering these factors, clinicians can optimize treatment outcomes and improve the long-term prognosis of the treated teeth. This systematic review serves as a valuable resource for clinicians and researchers in the field of endodontics. How to cite this article: Gomez-Sosa JF, Granone-Ricella M, Rosciano-Alvarez M, et al. Determining Factors in the Success of Direct Pulp Capping: A Systematic Review. J Contemp Dent Pract 2024;25(4):392-401.

Cell-Based Regenerative Endodontics for the Treatment of Irreversible Pulpitis: AnIn VivoInvestigation

INTRODUCTION

This study aims to investigate the ability of umbilical cord mesenchymal stem cells (UC-MSC) to enhance the regeneration of pulp-dentin complex in immature permanent teeth with irreversible pulpitis.

METHODS

A total of 32 mandibular premolar teeth with immature apices in 5 dogs were used in this in-vivo randomized controlled trial (RCT). Eight healthy teeth without pre-existing pathosis served as the positive control samples and received no treatment, while in another 8 teeth, the pulp was completely extirpated (negative control). Class V cavities were prepared to induce inflammation in the remaining 16 teeth (groups 3 and 4) and the pulp was extirpated 2-4 mm short of the radiographic apex. Of the 16, the 8 teeth in group 4 received 1 mL of cord blood stem cells with a hydrogel scaffold. Blood clots were covered with mineral trioxide aggregates at the cementoenamel junction in the experimental groups, and teeth were filled with RMGI and composite. Three months later, block sections were removed for histologic evaluations for the evaluation of postoperative apical closure, degree of inflammation, and presence of normal pulp tissue. The data were statistically analyzed with the chi-square test (P < .05).

RESULTS

All teeth with complete pulp extirpation demonstrated pulpal necrosis with no postoperative closure of their apices, while apical closure was seen in all the teeth in the remaining groups. There was a statistically significant (P < .001) difference in the presence of inflammation and normal pulp tissue between the experimental groups. The teeth in group 3 showed normal pulp tissue extending to the level of MTA, but there was inflammation within the canal space. In contrast, the teeth in the UC-MSC group demonstrated organized, normal pulp tissue with no inflammation.

CONCLUSION

Based on these results, the regeneration of the pulp-dentin complex is possible with no inflammation when UC-MSCs are used and 2-4 mm of the apical pulp remains intact in immature teeth with irreversible pulpitis.

Outcomes and predictive factors of vital pulp therapy in a large-scale retrospective cohort study over 10 years

This cohort study evaluated the long-term success/survival of vital pulp therapies (VPTs) after carious pulp exposure in adult teeth. Additionally, factors influencing long-term success were identified. Teeth treated during 2011-2022 in a private clinic were studied with clinical/radiographic follow-ups. Data included patient demographics, tooth specifics, and treatment details. Outcomes were classified as success/failure based on clinical/radiographic findings, with tooth functionality determining the survival rate. Encompassing 1149 patients and 1257 VPT-treated teeth, the average monitoring period was 42.2 months. Overall VPTs' survival and success rates were 99.1% and 91.6%, respectively. Success rates for 768 direct pulp cappings, 217 miniature pulpotomies, and 272 full pulpotomies were 91.9%, 92.6%, and 90.1%, respectively (P > 0.05). Influencing factors included symptomatic irreversible pulpitis (SIP; HR 1.974, 95% CI 1.242-3.137; P = 0.004), radiographic signs of apical periodontitis (AP; HR 2.983, 95% CI 1.961-4.540; P < 0.001), restoration type (HR 2.263, 95%CI 1.423-3.600; P = 0.001), and restoration surfaces (HR 1.401, 95%CI 1.034-1.899; P = 0.030). This study concludes that VPT techniques consistently exhibit high long-term success/survival rates in treating carious pulp exposures. Critical predictors include initial clinical signs of SIP/AP, caries extent, and use of composite restorations.

Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth

Strict protocols for evaluating the pulp's preoperative state should be developed, along with a new classification scheme for the different pulp states, as case selection plays a major role in the effectiveness of adult pulpotomy. In this case report, a male patient, age 15, who had a carious lower left first molar underwent pulpotomy. The pulp's initial state was ascertained by pulse oximetry, electric pulp testing (EPT), and cold testing. The final diagnosis was symptomatic irreversible pulpitis. A 12-month follow-up period following the placement of mineral trioxide aggregate (MTA) (MTA Angelus Angelus, Londrina, Brazil; Clinician's Choice, New Milford, CT) and tooth-colored composite restoration revealed no visible anomalies in the postoperative radiographs, and the tooth remained functional and free of symptoms.

The Effects of Antimicrobial Photodynamic Therapy Used to Sterilize Carious Dentin on Rat Dental Pulp Tissue

Antimicrobial photodynamic therapy (aPDT) used to sterilize carious dentin may irritate pulp tissues because of tissue-penetrating laser and singlet oxygen generation. This study aimed to assess the effects of aPDT on rat pulp tissues. A cavity formed in a rat maxillary first molar was treated with aPDT. The combined photosensitizer and laser irradiation conditions in the aPDT groups were as follows: methylene blue and 100 mW for 60 s, brilliant blue (BB) and 100 mW for 60 s, BB and 50 mW for 120 s, and BB and 200 mW for 30 s. Each cavity was treated with an all-in-one adhesive and filled with flowable resin. aPDT was not applied for the control. In each group, the rats were sacrificed on postoperative days 1 and 14, and thin sections of the treated teeth were prepared. Pulp tissue disorganization (PTD), inflammatory cell infiltration (ICI), and tertiary dentin formation (TDF) were evaluated. At 1-day evaluation, there were significant differences between the aPDT group and controls with respect to PTD and ICI (p < 0.01); 14 days later, almost all specimens showed tertiary dentin formation. The application of aPDT caused reversible damage to the rat pulp, while in the long term, healing occurred with the formation of tertiary dentin.

One-year outcome of selective caries removal versus pulpotomy treatment of deep caries: A pilot randomized controlled trial

AIM

This study aimed to compare the outcome of SCR and Pulpotomy in teeth with deep caries extending at least 75% into dentine.

METHODOLOGY

This two-armed, parallel-group, randomized, superiority trial included vital mature permanent teeth with deep primary or secondary caries diagnosed radiographically as being at least 75% into the thickness of dentine, without clinical signs of symptomatic irreversible pulpitis or radiographic evidence of a periapical lesion. Carious teeth were blindly allocated to receive either SCR or Pulpotomy using computer-generated randomized patient codes concealed in opaque envelopes. All teeth were reviewed clinically and radiographically at 6 months and 1 year post-treatment. Using a significance level of p < .05, the log rank test and Cox proportional hazards regression were used to compare the outcome of SCR and Pulpotomy and to identify potential prognostic factors, respectively.

RESULTS

In all, 58 teeth in the SCR group and 55 teeth in the pulpotomy group completed treatment, after excluding 6 teeth because they did not complete the allocated treatment and another due to severe periodontal disease. At one year, 57/58 (98.3%) teeth from the SCR group and 48/55 (87.3%) teeth from the Pulpotomy group were available for analysis. One tooth in the Pulpotomy group (2.1%) and eight teeth in the SCR group (14.0%) required the further intervention of root canal treatment (p < .05). There were no other significant prognostic factors for survival. Overall, 91.4% of teeth treated with either SCR or Pulpotomy survived without requiring further intervention over a period of one year. No other adverse events occurred over the review period.

CONCLUSION

Within the limitations of this study, Pulpotomy fares better than SCR in preserving the remaining pulp and periapical health. As a treatment modality, Pulpotomy carries greater cost outlay to patient and takes a longer time to complete treatment than SCR. Long-term follow-up is needed to study the pulpal and restorative outcomes of Pulpotomy and SCR.

Effectiveness of vital pulp treatment in managing nontraumatic pulpitis associated with no or nonspontaneous pain: A systematic review

BACKGROUND

The exposed pulp has been the topic of numerous studies, but well-designed and well-executed comparative trials on the outcome and treatment of these teeth have been limited.

OBJECTIVES

This study was conducted to answer the following questions: in patients with nontraumatic pulpitis associated with no or nonspontaneous pain in permanent teeth, (i) is direct pulp capping or pulpotomy (partial/full) as effective as selective or stepwise caries removal [Population/participants, Intervention(s), Comparator(s)/control, Outcome(s) (PICO) 1], (ii) is pulpotomy (partial/full) as effective as direct pulp capping (PICO 2) and (iii) is pulpotomy (partial/full) as effective as a pulpectomy (PICO 3), in terms of a combination of patient and clinical reported outcomes, with 'tooth survival' as the most critical outcome?

METHODS

A literature search was conducted using Clarivate Analytics' Web of Science, Scopus, PubMed and Cochrane Central Register of Controlled Trials from inception to November 3rd 2021. Grey literature and contents of the major subject journals were examined. Eligibility criteria followed the PICO questions. Two independent reviewers performed study selection, data extraction and appraisal; disagreements were resolved by a third reviewer. The risk of bias was assessed by the revised Cochrane risk-of-bias tool for randomized trials.

RESULTS

Three randomized clinical trials (RCTs) were included in the review. No study fulfilled the criteria to answer PICO 1. There were no significant differences in the reported outcomes between investigated treatments in all included RCTs. None of the included studies reported the most critical outcome 'tooth survival'. A high loss of patients during the follow-up period was observed.

DISCUSSION

Although a few studies fulfilled strict eligible criteria, the results of this systematic review clearly highlight a paucity of available evidence. At the present time, clinical decisions cannot be substantiated by direct comparative trials.

CONCLUSIONS

Based on limited evidence, this systematic review discovered no significant differences in effectiveness between compared vital pulp treatments in managing nontraumatic pulpitis associated with no or nonspontaneous pain. Further high-quality RCTs are necessary to investigate the effectiveness of direct pulp capping or pulpotomy (partial/full) compared to selective or stepwise caries removal.

REGISTRATION

PROSPERO database (CRD42021259742).

Assessment of Decision-Making and Material Selection for Vital Pulp Therapy in Deep Carious Lesions: A Study at the Faculty of Dentistry, King Abdulaziz University

PURPOSE

The purposes of this study were to assess decision-making, material selection, and management of deep carious lesions in permanent teeth requiring vital pulp therapy (VPT); investigate the intradepartmental and interdepartmental consensus in the management of those cases; and correlate this study's results to the current scientific literature, clinical experience, and postgraduate training among staff and postgraduate students at the Faculty of Dentistry, King Abdulaziz University.

MATERIALS AND METHODS

The survey included faculty from pedodontics, endodontics, and restorative/operative dentistry; postgraduate students; and interns, excluding specific categories such as retired faculty, external trainers, non-faculty hospital specialists, general practitioners, students, interns outside the institution, and other departments. An anonymous electronic questionnaire was developed and validated. Ethical approval was obtained, and the questionnaire was distributed to all 148 English-proficient members of the targeted population via email and WhatsApp, accompanied by a cover letter. The questionnaire encompassed demographic, education, experience, assessment, decision-making, and management sections. Data were collected and analyzed using Microsoft Excel, with results presented using categorical variables, Pareto charts, and statistical tests.

RESULTS

There were 86 responses, representing 58% of the target population, with the key findings including the prominence of "Pre-operative vitality test result" as the most important factor in assessing deep carious lesions, with no significant differences among specialties. The (one-step and one-visit) management approach was preferred by 50% of participants, with no significant specialty differences. For deep carious lesions without pulpal exposure, glass ionomer (GI)/resin-modified glass ionomer (RMGI) base was the top choice, with no variation among all specialties. In cases with pulpal exposure, the one-visit approach (direct pulp capping (DPC), base, and restoration) was the most favored, with no specialty differences. Material availability significantly influenced decision-making, with no specialty variations.

CONCLUSION

The study highlights the crucial role of pre-operative vitality tests in assessing deep carious lesions for VPT or root canal treatment (RCT). Participants generally favored VPT for cases with normal pulp vitality, with some departmental variation. Controlling bleeding post-pulpal exposure was a central concern. Mineral trioxide aggregate (MTA) was the most commonly used VPT material, followed by Ca(OH)2 and Biodentine. Factors such as treatment access, patient compliance, remaining dentin thickness, and oral hygiene had minimal impact on treatment choice. Limited availability of VPT materials was the primary reason for non-use. The survey's acceptable response rate raises concerns about potential non-response bias, though limitations include a lack of data on non-responders. Nevertheless, the survey's strength lies in its comprehensive coverage of key clinical aspects, engaging professionals from diverse specialties and educational levels who are collectively interested in addressing deep caries cases.

Treatment outcome of partial pulpotomy using two different calcium silicate materials in mature permanent teeth with symptoms of irreversible pulpitis: A randomized clinical trial

AIM

To assess the clinical and radiographic outcome of partial pulpotomy by comparing MTA Angelus and Total Fill BC, as pulpotomy agents, in mature teeth with deep caries and symptoms indicative of irreversible pulpitis.

METHODOLOGY

The study was designed as a parallel-two arm, double-blind, randomized superiority clinical trial registered at www.

CLINICALTRIALS

gov (NCT04870398). Symptomatic mature permanent teeth with deep caries fulfilling the inclusion criteria were randomly treated using either MTA Angelus or Total Fill BC. A partial pulpotomy was performed and following complete haemostasis, the capping material was placed over the remaining pulp tissue and a postoperative periapical radiograph was taken. Clinical and radiographic follow-up evaluation was performed for a median time of 2 years, whereas levels of pain intensity were evaluated preoperatively and for 7 days after intervention using Visual Analogue Scale. For the primary outcome (failure/success of treatment), the Kaplan-Meier survival curves for the capping materials were plotted and a log-rank test for equality of survivor functions was applied. A multivariable random effects Cox Regression model was also applied. For the secondary outcome (postoperatively reported pain), a multivariable mixed effects ordinal logistic regression was structured.

RESULTS

One hundred and thirty-seven teeth in 123 patients underwent partial pulpotomy using randomly either MTA Angelus (N = 74) or Total Fill BC (n = 63). The percentage failure for MTA Angelus and Total Fill BC was 10.8% (8/74) and 17.5% (11/63), respectively, but the difference was not statistically significant [adjusted HR: 1.83; 95% confidence interval (CI): 0.68, 4.91; p = .23]. Weak evidence was found that secondary caries involvement may impose a 3.54 times greater hazard for treatment failure (adjusted HR: 3.54; 95% CI: 1.00, 12.51; p = .05). For each passing minute of procedural bleeding control, there was also a 57% higher hazard for treatment failure (adjusted HR: 1.57; 95% CI: 0.99, 2.48; p = .05). The odds for higher postoperative pain were 4.73 times greater for the Total Fill BC compared to MTA Angelus (adjusted OR: 4.73; 95% CI: 2.31, 9.66; p < .001).

CONCLUSIONS

Both materials exhibited similar and favourable outcome rates after partial pulpotomy in teeth with deep caries and symptoms of irreversible pulpitis. Total Fill BC was associated with a higher level of postoperative pain intensities.

Treatment of pulpal and apical disease: The European Society of Endodontology (ESE) S3-level clinical practice guideline

BACKGROUND

The ESE previously published quality guidelines for endodontic treatment in 2006; however, there have been significant changes since not only in clinical endodontics but also in consensus and guideline development processes. In the development of the inaugural S3-level clinical practice guidelines (CPG), a comprehensive systematic and methodologically robust guideline consultation process was followed in order to produce evidence-based recommendations for the management of patients presenting with pulpal and apical disease.

AIM

To develop an S3-level CPG for the treatment of pulpal and apical disease, focusing on diagnosis and the implementation of the treatment approaches required to manage patients presenting with pulpitis and apical periodontitis (AP) with the ultimate goal of preventing tooth loss.

METHODS

This S3-level CPG was developed by the ESE, with the assistance of independent methodological guidance provided by the Association of Scientific Medical Societies in Germany and utilizing the GRADE process. A robust, rigorous and transparent process included the analysis of relevant comparative research in 14 specifically commissioned systematic reviews, prior to evaluation of the quality and strength of evidence, the formulation of specific evidence and expert-based recommendations in a structured consensus process with leading endodontic experts and a broad base of external stakeholders.

RESULTS

The S3-level CPG for the treatment of pulpal and apical disease describes in a series of clinical recommendations the effectiveness of diagnosing pulpitis and AP, prior to investigating the effectiveness of endodontic treatments in managing those diseases. Therapeutic strategies include the effectiveness of deep caries management in cases with, and without, spontaneous pain and pulp exposure, vital versus nonvital teeth, the effectiveness of root canal instrumentation, irrigation, dressing, root canal filling materials and adjunct intracanal procedures in the management of AP. Prior to treatment planning, the critical importance of history and case evaluation, aseptic techniques, appropriate training and re-evaluations during and after treatment is stressed.

CONCLUSION

The first S3-level CPG in endodontics informs clinical practice, health systems, policymakers, other stakeholders and patients on the available and most effective treatments to manage patients with pulpitis and AP in order to preserve teeth over a patient's lifetime, according to the best comparative evidence currently available.

To Assess the Efficacy of Various Disinfection and Hemostasis Procedures in Providing Postoperative Pain Relief Following Pulpotomy in Cases of Symptomatic Irreversible Pulpitis

AIM

The purpose of this study is to assess the efficacy of various disinfection and hemostasis procedures in providing postoperative pain relief following pulpotomy in cases of symptomatic irreversible pulpitis.

MATERIALS AND METHODS

The data from a cohort of 50 patients who received treatment with sodium hypochlorite (NaOCl) and another cohort of 50 patients who received treatment with potassium titanyl phosphate (KTP) laser were subjected to analysis. The patients were provided a questionnaire to evaluate pain levels before and after surgery. The patients documented their levels of postoperative pain at specific time intervals, including the sixth hour, first day, second day, third day, and eighth day. This was done using a 100 mm visual analog pain scale, where a marking of 0 mm indicated no pain and a marking of 100 mm indicated the highest level of pain, reflecting the severity of the pain experienced.

RESULTS

The pain score of group B was significantly lower than that of group A on the first day. While no notable disparity was detected among the groups during the remaining postoperative periods, it is worth noting that the KTP laser exhibited comparatively lower pain scores. In both groups, the initial pain score before surgery was found to be significantly higher than the pain scores recorded at all subsequent time intervals after surgery. Within group A, it was observed that the pain score during the sixth hour after the surgical procedure was notably greater compared to the pain scores recorded during all other time intervals following the operation. In group B, the pain score at the sixth hour exhibited a statistically significant increase compared to the pain scores observed on the third day and eighth day.

CONCLUSION

The KTP laser group exhibited a lower postoperative pain score in comparison to the NaOCl group. The utilization of KTP laser-assisted pulpotomy demonstrated enhanced efficacy in alleviating pain among individuals diagnosed with symptomatic irreversible pulpitis.

Evaluation of postoperative pain relief after pulpotomy using different procedures for disinfection and hemostasis in symptomatic irreversible pulpitis

Aim

This study aimed to evaluate postoperative pain scores after sodium hypochlorite (NaOCl) and KTP laser pulpotomies in the permanent teeth with symptomatic irreversible pulpitis retrospectively. Materials and Methods: This study is based on the records of patients treated with pulpotomy using sodium hypochlorite or KTP laser for disinfection and hemostasis at the Department of Endodontics. Sixty patients' molar teeth were treated with either NaOCl or KTP laser. Sodium hypochlorite was used on 31 teeth, and KTP laser was used on another 29 teeth, for disinfection and hemostasis. Initial bleeding control was obtained with saline. 2.5% NaOCl or KTP laser was applied to complete hemostasis. Calcium hydroxide was then placed on the chamber floor to cover the canal orifices. The permanent restoration was completed with composite resin. Pre and postoperative pain scores were recorded with a visual analog scale. The evaluation was performed on the 6^th, 24^th, 48^th, 72^nd hours, and 7^th days depending on the severity of the pain. Results: There was no significant difference between the groups in terms of demographic data and preoperative pain scores (P > 0.05). The postoperative pain score in the KTP laser group was significantly lower at the 24^th hour than in the NaOCl group (P < 0.05). No significant difference was found between the groups at other evaluated time intervals (P > 0.05). The greatest pain score was recorded at the 6^th hour in both groups.

Conclusion

Although the level of pain decreased significantly in both groups in the postoperative period, KTP laser-assisted pulpotomy provided better pain control, especially at the 24^th hour.

Vital pulp therapy for permanent teeth with diagnosis of irreversible pulpitis: biological basis and outcome

Root canal treatment (RCT) has been considered the conventional standard for the management of teeth with carious pulp exposure, particularly in mature teeth presenting with symptoms. Following a better understanding of the histopathology of deep carious lesions, the histology of the cariously exposed pulp and the healing potential of the inflamed pulp, vital pulp therapy (VPT) is increasingly adopted around the world for the management of permanent teeth with clinical signs and symptoms indicative of irreversible pulpitis. Furthermore, VPT became a recognized treatment modality by the European Society of Endodontology (ESE) and the American Association of Endodontists (AAE) by virtue of its high success rates reported in outcome studies using contemporary hydraulic calcium silicate-based cements. However, proper case selection, strict asepsis, capping materials and good coronal seal are mandatory for success. The aim of this paper is to review the biological basis for VPT in symptomatic teeth with carious pulp exposure and to report on the outcome of pulpotomy in teeth with clinical diagnosis of irreversible pulpitis.

Factors Affecting the Decision-Making of Direct Pulp Capping Procedures Amongst Dental Practitioners: A Multinational Survey from 16 Countries with Meta-Analysis

BACKGROUND

Direct pulp capping (DPC) procedures require the placement of a bioactive material over an exposure site without selective pulp tissue removal. This web-based multicentered survey had three purposes: i) to investigate the factors that affect clinicians' decisions in DPC cases, ii) to determine which method of caries removal is preferred, and iii) to evaluate the preferred capping material for DPC.

METHODS

The questionnaire comprised three sections. The first part comprised questions regarding demographic features. The second part comprised questions on how treatment plans change according to factors such as nature, location, number and size of the pulp exposure and patients' age. The third part composed of questions on the common materials and techniques used in DPC. To estimate the effect size, the risk ratio (RR) and 95% confidence interval (CI) were calculated using a meta-analysis software.

RESULTS

A tendency towards more invasive treatment was observed for the clinical scenario with carious-exposed pulp (RR=2.86, 95% CI:2.46,2.32; p<0.001) as opposed to the clinical scenario with two pulp exposures (RR=1.38, 95% CI:1.24,1.53; p<0.001). Complete caries removal was significantly preferred to selective caries removal (RR=4.59, 95% CI: 3.70, 5.69; p<0.001). Among the capping materials, calcium silicate-based materials (CS) were preferred over calcium hydroxide-based materials (CH) (RR=0.58, 95% CI: 0.44,0.76; p<0.05).

CONCLUSION

While carious-exposed pulp is the most important factor in clinical decisions regarding DPC, the number of exposures has the least impact. Overall, complete caries removal was preferred over selective caries removal. In addition, the use of CS appears to have replaced CH.

Outcome of partial and full pulpotomy in cariously exposed mature molars with symptoms indicative of irreversible pulpitis: A randomized controlled trial

AIM

The aim of this study was to assess and compare the clinical and radiographic outcome of partial pulpotomy and full pulpotomy using Biodentine in cariously exposed mature molar teeth with symptoms indicative of irreversible pulpitis.

METHODOLOGY

This study is an unicentric, double-arm, randomized superiority clinical trial with parallel experimental groups, registered under CTRI (CTRI/2019/12/022559). Fifty mature permanent molar teeth with carious exposures with symptoms indicative of irreversible pulpitis were randomly allocated equally into two groups. Partial pulpotomy (PP) and full pulpotomy (FP) were performed in the first and second group, respectively, following standardized protocols. Exposed pulp tissue was removed up to a depth of 2-3 mm for partial pulpotomy, whereas complete coronal pulp tissue was removed up to the level of root orifices for full pulpotomy. Haemostasis was achieved with placement of 2.5% sodium hypochlorite-moistened cotton pellets placed on amputated pulp tissue for a maximum of 10 min. Biodentine was used as the pulp capping material. Pain scores were evaluated using 11-point Visual Analogue Scale (VAS) preoperatively, at 24 h, 48 h and 7th day after the intervention(s). Clinical and radiographic evaluation was done at 3 months, 6 months and 1 year. The data were statistically analysed using chi-squared test, Mann-Whitney U-test, Friedman's test and Wilcoxon signed-rank test. The significance level was pre-determined at p < .05. Cumulative survival probabilities were assessed at 12 months using Kaplan-Meier analysis.

RESULTS

Intra-group analysis of pain scores revealed significant reduction in pain scores preoperatively and at 24 h, 48 h and 7th day in both the groups. However, the difference in the pain score(s) reduction between both the groups was not statistically significant at any time interval (p > .05). At 1-year follow-up, the success rate was 88% (22/25) and 91.6% (22/24) for PP and FP respectively (p > .05).

CONCLUSIONS

Partial pulpotomy showed comparable results to full pulpotomy in terms of clinical/radiographic treatment outcome. If the long-term results remain the same, partial pulpotomy can be proposed as an alternative treatment modality for mature teeth with cariously exposed pulp tissue presenting with signs of symptomatic irreversible pulpitis.

Successful treatment of cystic lesion combining Cystectomy, Nonsurgical Endodontics and Vital Pulp Therapy of Mature Permanent Mandibular Molars: a Case Report with 19 Months Follow-Up

Background

Clinical examination revealed large periapical lesion. Patient was referred for endodontic treatment of right mandibular first and second molars before planed cystectomy. The aim of this case report is to present the clinical approach to preserve healthy pulp tissue by combining nonsurgical root canal treatment and vital pulp therapy for mature mandibular molar.

Methods

A minimally invasive endodontic therapy treatment with combination of nonsurgical root canal treatment and vital pulp therapy was performed. Osteotomies around wisdom teeth were performed, wisdom teeth extracted, and cyst was removed.

Results

At the 19 months follow-up appointment patient had no complaints, radiographically full regeneration of periapical bone was observed.

Conclusions

A minimally invasive endodontic therapy treatment with combination of nonsurgical root canal treatment and vital pulp therapy for mature mandibular molar before a planned cystectomy could be considered as a treatment option showing good long-term results.

Modified pulpotomy procedure in immature permanent teeth with apical periodontitis: a randomised controlled trial

OBJECTIVES

The objective of this study was to evaluate the effectiveness of a modified pulpotomy (MP) procedure in immature permanent teeth with apical periodontitis (AP).

DESIGN

Randomised controlled trial.

SETTING

One public hospital in Shanghai, China PARTICIPANTS: A total of 33 teeth (31 patients) with a definitive diagnosis of AP with radiographic periapical radiolucency were recruited in this study. All the patients (teeth) completed the study accordingly.

METHODS AND INTERVENTION

Patients were randomly assigned to either MP or apexification treatment groups and were followed up for 12 months. Clinical symptoms and complications were recorded, and parallel periapical radiographic images were used to measure changes in root length and apical diameter. Wilcoxon's rank sum test and Fisher's exact test were used to compare the clinical and radiographic outcomes between MP and apexification, and analysed with analysis of variance.

MAIN OUTCOME MEASURE

The primary outcome was increase in root length at 12 months. The secondary outcomes included tooth survival, clinical success and decrease in apical diameter.

RESULTS

MP group showed a significant increase in root length (10.05%±2.14% vs 1.16%±0.79%, p<0.05) at 12 months and a decrease in apical diameter (48.88%±10.42% vs 15.90%±8.88%, p<0.05) as compared with the apexification group. The tooth survival rate was 100%, and 90.91% (30/33) of teeth were asymptomatic with apical healing in both treatment groups (p>0.05).

CONCLUSIONS

MP can be an option for treating immature permanent teeth with AP. MP showed better performance in terms of continued root maturation than apexification. MP and apexification achieved comparable outcomes with regard to the resolution of clinical symptoms and apical healing.

TRIAL REGISTRATION NUMBER

ChiCTR-INR-17012169.

Minimally invasive endodontics: a new era for pulpotomy in mature permanent teeth

Emerging clinical and histologic evidence is challenging the long-established dogma that root canal treatment (RCTx) is the only therapeutic option for preservation of vital mature permanent teeth diagnosed with irreversible pulpitis or carious pulp exposure. Vital pulp therapy procedures like pulpotomy are not only technically simpler and more economical, but also afford patients a host of other benefits over conventional RCTx. This narrative review provides an update on the contemporary understanding of pulp pathophysiology and defence mechanisms, the proposed new diagnostic terminologies for pulpal inflammation, and how the biological characteristics of hydrophilic calcium silicate cements have enabled consistent successful outcomes for pulpotomy-treated mature teeth. The paper also details the evidence base from clinical trials and systematic reviews conducted over the past decade and outlines the practical treatment considerations for pulpotomy in mature permanent teeth.

Evaluation of the outcome of apexogenesis in traumatised anterior and carious posterior teeth using mineral trioxide aggregate: a 5-year retrospective study

The purpose of this study was to evaluate the outcome of apexogenesis with mineral trioxide aggregate (MTA) in traumatised anterior and carious posterior teeth over 5 years. A comprehensive chart review was performed to obtain a retrospective of sequential previously completed cases with recalls. Clinical and radiographic data were collected for 97 vital immature teeth (40 traumatised anterior and 57 carious posterior teeth) pulpotomised (partial or full pulpotomy) using MTA with an average follow-up time of 5 years. Chi-squared test and Fisher's exact test were implemented to analyse data. The success rate in anterior teeth and posterior teeth was 82.5% and 96.4% respectively. Crown discolouration was observed in 25 (62.5%) anterior teeth. There was a significant difference between the number of successful and unsuccessful cases (P < 0.05) and there was no correlation between type of treatment and success/failure (P > 0.05). The success rate of apexogenesis using MTA in immature teeth was relatively high.

Prevalence of root canal treatment worldwide: A systematic review and meta-analysis

BACKGROUND

The prevalence of root filled teeth (RFT) worldwide will inform about the amount of clinical activity of dentists dedicated to treat endodontic disease.

OBJECTIVES

To carry out a systematic review with meta-analysis answering the following question: What is the prevalence of RFT around the world? The percentage of people with at least one RFT was also investigated.

METHODS

A systematic review including population-based studies using the following databases: PubMed, EMBASE and Scielo. Studies related to prevalence of RFT were included. The outcome of interest of the study was the prevalence of RFT. The meta-analyses were calculated with the Open Meta Analyst software to determine the global prevalence of RFT. Subgroups analyses were performed comparing geographical distribution, radiographic method and year of the study (classified in 20th or 21th century). The prevalence of people with at least one RFT was also analysed.

RESULTS

Seventy-four population-based studies fulfilled the inclusion criteria. Twenty-eight, forty-four and two studies reported high, moderate and low risk of bias, respectively. No obvious publication bias was observed. Prevalence of RFT was estimated with 1 201 255 teeth and 32 162 patients. The calculated worldwide prevalence of RFT was 8.2% (95% CI = 7.3%-9.1%; p < .001). The global prevalence of people with at least one RFT was 55.7% (95% CI = 49.6%-61.8%; p < .001). In 20th century, the prevalence of RFT was 10.2% (95% CI = 7.9%-12.5%; p < .001), whereas in the 21st century the overall calculated prevalence of RFT was 7.5% (95% CI = 6.5%-8.6%; p < .001). Brazilian people (12%) and the European population (9.3%) showed the highest prevalence of RFT. In Europe, 59.6% (95% CI = 52.4%-66.8%) of people has at least one RFT.

CONCLUSIONS

This review showed that root canal treatment is a very common therapy throughout the world. More than half of the studied population have at least one RFT. A limitation of the present study is that most of the studies did not consider random sampling for population selection.

REGISTRATION

PROSPERO Systematic review registration number: (CRD42022329053).

Outcome of Direct Pulp Capping in Teeth Diagnosed as Irreversible Pulpitis: Systematic Review and Meta-Analysis

Background

This review and meta-analysis investigates the outcome of direct pulp capping in teeth diagnosed as irreversible pulpitis.

Material and Methods

This systematic review includes experimental and descriptive clinical studies according to the PRISMA criteria, using PubMed and Scopus as database. We have included studies that performed direct pulp capping on human permanent teeth previously diagnosed with irreversible pulpitis and that carried out a subsequent follow-up. The outcome of interest was the clinical success of direct pulp capping.

Results

A total of four studies met the inclusion criteria for this review, however only three of these could be included in the meta-analysis. These three studies represent a total sample of 62 teeth with irreversible pulpitis treated with direct pulp capping that showed an overall success rate of 0.953 (CI=0.900-1.005; p<0.001; I²=0). Additionally, the success rates of vital pulp therapies were compared, all of them being greater than 75%; and the success rates of the materials used were analyzed, giving values above 80% in all cases. The risk of bias of the included articles was established using the ROBINS-I tool, showing that two of the articles had a moderate risk of bias and the remaining two had a very high risk of bias.

Conclusions

Based on the results of this review, direct pulp capping should be clinically included as a successful technique for the treatment of irreversible pulpitis. However, a larger number of studies with more rigorous methodologies are necessary to confirm the efficacy of this technique. Key words:Irreversible pulpitis, direct pulp capping (DPC), vital pulp therapy (VPT), indirect pulp capping (IPC), partial pulpotomy, total pulpotomy.

Outcomes of root canal therapy or full pulpotomy using two endodontic biomaterials in mature permanent teeth: a randomized controlled trial

OBJECTIVE

The concept of minimally invasive endodontics recommends less-invasive vital pulp therapy (VPT) modalities over more aggressive traditional endodontic approaches in mature permanent teeth with carious pulp exposure, including irreversible pulpitis (IP) cases. Consequently, VPT needs to be compared with root canal therapy (RCT) in terms of treatment outcomes. This randomized clinical trial compares the results of full pulpotomy using two calcium-silicate cements, i.e., mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement, with RCT in mature permanent teeth.

MATERIALS AND METHODS

A total of 157 carious pulp exposure cases in two academic centers with/without established IP were selected/included/randomly appointed to three study arms; (i) RCT (n = 51) as the reference treatment, (ii) pulpotomy with ProRoot MTA (PMTA; n = 55), and (iii) pulpotomy with CEM cement (PCEM; n = 51) as two alternative VPT treatments. Two-year clinical/radiographic results were the outcomes of interest. Data were statistically analyzed through the analysis of variance, chi-square, Fisher exact test, and Kruskal-Wallis.

RESULTS

At 2-year recall, 147 teeth were examined (6.4% dropout). All molars, except for one, were clinically functional/symptom-free, and there was no statistical difference between the three study arms (p = 0.653). The radiographic success rates in RCT, PMTA, and PCEM arms were 98%, 100%, and 97.9%, respectively, without statistically significant differences (p = 0.544).

CONCLUSION

In the management of mature permanent teeth with/without established IP, all experimental groups exhibited equivalent/comparable results.

CLINICAL RELEVANCE

Simple VPT using MTA/CEM can be suggested/recommended as a viable advantageous alternative to RCT for the management of carious pulp exposures with/without sign/symptoms of IP.

Comparative evaluation of complete and partial pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis: A randomized clinical trial

AIM

The study aimed to compare the outcome of complete pulpotomy (CP) and partial pulpotomy (PP) techniques when utilised for the management of mature permanent teeth with carious pulpal exposure and symptomatic irreversible pulpitis (SIP).

METHODOLOGY

The study protocol was registered with ClinicalTrials.gov (NCT04397315). One hundred and six permanent mandibular molars with carious pulpal exposure and clinical diagnosis of SIP with periapical index ≤2, from patients aged between 18 and 40 years were randomly allocated in equal proportion to either CP or PP group. Allocated procedures were performed using standardised protocols. The allocated procedure was abandoned in cases where pulpal bleeding could not be controlled within 6 min using cotton pellets soaked in 3% sodium hypochlorite. MTA was used as a pulpotomy agent and teeth were restored using a base of glass ionomer followed by composite restoration. The pain was recorded by the patient preoperatively before administration of local anaesthesia and postoperatively every 24 h for 1 week using visual analogue scale. Success was analysed at 12 months based on clinical and radiographic examination. Mann-Whitney U test was used to compare age, pain scores and mean analgesic consumption between the groups. Categorical data were analysed using chi-square test. Fisher's exact test was used to assess the clinical and radiographic success and incidence of pain. Kaplan-Meier analysis was used to assess the survival of teeth. A p-value <.05 was considered as statistically significant.

RESULTS

One hundred and one patients were analysed at follow up. Higher success was observed in CP (89.8%) in comparison to PP group (80.8%), but the difference was non-significant statistically (p = .202). Although no significant difference was observed in pain incidence between the groups at 24 h (p = .496), a significant difference in pain intensities was observed between groups at all the tested time intervals, with lower values reported in CP group (p < .05).

CONCLUSIONS

Both CP and PP resulted in favourable outcomes in the management of cariously exposed permanent teeth with signs indicative of SIP. Given the more conservative nature of PP, it may be attempted first before proceeding to CP in such cases.

[Evaluation of bioceramic putty repairmen iRoot and mineral trioxide aggregate in mature permanent teeth pulpotomy]

OBJECTIVE

To evaluate the clinical characteristics and effectiveness of pulpotomy in mature permanent teeth with bioceramic putty repairmen iRoot and mineral trioxide aggregate (MTA).

METHODS

Pulpotomy was performed on mature permanent premolars and molars with carious exposures at the Department of General Dentistry of Peking University School and Hospital of Stomatology, from November 2017 to September 2019. The patients were randomly divided into 2 groups, Group iRoot (n=22) and Group MTA (n=21). In Group iRoot, bioceramic putty repairmen iRoot was used as pulp capping agent, while in Group MTA, mineral trioxide aggregate was used as pulp capping agent. All the patients had signed informed consent forms. The clinical efficacy was evaluated by clinical examinations (temperature and electrical activity test) and imaging examinations 3, 6, and 12 months after surgery. Blinding was used for the patients and evaluators, but due to the obvious differences in the properties of the two pulp capping agents, the blinding method was not used for the treatment provider (the attending physician).

RESULTS

There was no significant difference in gender, average age, dentition and tooth position distribution between the two groups (P>0.05). In the study, 7 cases were lost to follow-up 12 months after operation (4 cases in Group iRoot, and 3 cases in Group MTA). One case in each of the two groups had transient sensitivity at the end of the 3-month follow-up, and the pulp vitality was normal at the end of the 6-month follow-up. One case in Group iRoot showed sensitivity at the end of the 12-month follow-up. The success rates of the two groups at the end of 12-month follow-up were 100%, and the cure rates were 94.4% (Group iRoot) and 100% (Group MTA), respectively, and the difference was not statistically significant (P>0.05). No cases in Group iRoot had obvious crown discoloration, while 3 cases in Group MTA had.

CONCLUSION

The clinical characteristics and effectiveness of pulpotomy in mature permanent teeth with bioceramic putty repairmen iRoot were similar with MTA. Bioceramic putty repairmen iRoot is an acceptable material when used in pulpotomy of mature permanent teeth. Because it is not easy to cause tooth discoloration after treatment and is convenient to operate, bioceramic putty repairmen iRoot has a better clinical application prospect.

Evaluation of complete pulpotomy with Biodentine® on mature permanent molars with signs and symptoms of symptomatic irreversible pulpitis: 12 months follow-up

INTRODUCTION

Complete pulpotomy is the removal of the coronal portion of a vital pulp and is a means of preserving the vitality of the remaining root portion. The objective of this study was to evaluate the 12-month success rate of complete pulpotomy with Biodentine® on mature permanent molars with signs and symptoms of symptomatic irreversible pulpitis.

MATERIALS AND METHODS

A total of 68 molars diagnosed with symptomatic irreversible pulpitis in 68 patients aged 20 years and older were included in this study. The exclusion criteria were intraoperative clinical signs of pulp necrosis on the molar to be treated such as no bleeding, or uncontrollable pulp hemorrhage (more than 5 min of hemostasis) on at least one canal. A complete pulpotomy with Biodentine® was performed on molars with symptomatic irreversible pulpitis by the same operator and with the same protocol. At 12-month post-operative follow-up was conducted to evaluate clinical and radiological success.

RESULTS

A total of 66 patients received complete pulpotomy. Fifty-two could be examined at 12 months postoperatively. Clinical and radiological analysis at 12 months postoperatively revealed a success rate of 87% (45/52 molars) and a failure rate of 13% (7/52 molars). There was a relationship between age, tooth type, pre-operative periapical condition and treatment success with P<0.05.

CONCLUSION

Compliance with the indications and protocol for complete pulpotomy with Biodentine® on mature permanent molars with symptomatic irreversible pulpitis gives positive results at 12 month follow-up.

Vital Pulp Therapy in Permanent Teeth with Irreversible Pulpitis Caused by Caries: A Prospective Cohort Study

Background: When a tooth is diagnosed with irreversible pulpitis, root canal therapy (RCT) is generally performed to completely remove pulp tissue, which might lead to a higher risk of loss of vascularity, and teeth being more prone to fracture. Vital pulp therapy (VPT) is a personalized method of treating irreversible pulpitis, which conforms to the trend of minimally invasive endodontics. The remaining vital pulp could promote the physiological development of the roots of young permanent teeth with incomplete apical foramen. However, clear guidelines for VPT indication are still missing. Objective: This prospective cohort study evaluated the outcomes of vital pulp therapy (VPT) using iRoot BP Plus (Innovative Bioceramix Inc, Vancouver, BC, Canada) in permanent teeth of 6- to 20-year-old patients with irreversible pulpitis caused by caries and analyzed the preoperative factors affecting VPT prognosis. Methods: Fifty-nine permanent teeth in 59 patients with irreversible pulpitis caused by caries were treated with VPT using iRoot BP Plus. All patients received VPT under a standardized protocol. After informed consent, teeth were isolated with a dental dam, then operators performed VPT with iRoot BP Plus and restored the teeth with composite resin or stainless steel crown. Patients were postoperatively recalled after 3, 6 and 12 months and then recalled annually. Successful cases were defined as successful in both clinical and radiographic evaluations. A statistical analysis was performed using the Fisher exact test, and the level of significant difference was p < 0.05. Results: After 6–36 months of follow-up, a total of 57 teeth from 57 patients were accessible for evaluation. The mean age of subjects was 11.75 ± 3.81 years. The overall clinical and radiographic success rate of VPT was 91.2% (52/57). With an observation time of one year or more, the success rate was 90.5% (38/42). All the symptoms and physical examination findings showed no significant effect on VPT prognosis (p > 0.05) using a binary logistic regression model. Conclusions: Permanent teeth in 6- to 20-year-old patients diagnosed as irreversible pulpitis caused by caries can be successfully treated with VPT using iRoot BP Plus.

Response to Pulp Sensibility Tests after Full Pulpotomy in Permanent Mandibular Teeth with Symptomatic Irreversible Pulpitis: A Retrospective Data Analysis

INTRODUCTION

This retrospective study analyzed the 12-month pulp sensibility (cold and electric) test response after mineral trioxide aggregate (MTA) full pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis.

METHODS

The records of 120 subjects from 3 completed and 1 ongoing clinical study on MTA full pulpotomy were retrieved. Ninety-six first and second mandibular molar teeth with a diagnosis of symptomatic irreversible pulpitis that underwent a single-visit MTA full pulpotomy and had completed a 12-month clinical, radiographic, and pulp sensibility (cold and electric) test follow-up were included. The data were analyzed using the Fisher exact test, the Pearson chi-square test, and the McNemar test. The significance level was predetermined at P < .05.

RESULTS

A higher percentage of teeth (94.7%) responded to the electric pulp test in comparison with the cold test (13.5%) (P < .05). Sex-based responses to the electric pulp test (P > .05) and the cold test were similar (P > .05). The age-based response was similar for the electric pulp test (P > .05) but was significant for the cold test (P < .05). The tooth quadrant (left and right), the tooth (mandibular first and second molar), and the location of restoration (proximal or occlusal) did not influence the response of either the electric pulp test (P > .05) or the cold test (P > .05). At the 1-year follow-up, all the teeth that were classified as clinically and radiographically successful responded to the electric pulp test; however, only 13 teeth responded to the cold test (P = .00).

CONCLUSIONS

The majority (94.7%) of the teeth that underwent MTA full pulpotomy responded to the electric pulp test at a 1-year time interval.

Influence of selective immunosuppressive drug regimens on the healing of exposed dogs' dental pulp capped with a recent calcium silicate-based cement

OBJECTIVES

In the clinical medicine, immunosuppressive drugs are used for an assortment of disorders, while their effect on the pulp healing is a controversial issue. This study evaluated the effect of different immunosuppressive drugs on the healing capacity of mechanically exposed dogs' dental pulps after direct pulp capping (DPC) with calcium silicate-based cement.

MATERIALS AND METHODS

Twelve healthy male dogs were randomly allocated into four equal groups, 3 dogs each: group I allocated as a control group where no drugs were received; group П given prednisone (Pred); group III given a combination of Pred and cyclosporine A (CsA); and group IV given triple dose including Pred, CsA, and mycophenolate mofetil (MMF) for 45 days before the operative procedures and until the dogs were euthanized. In each dog, 16 class V cavities were prepared on the labial surfaces of anterior teeth. Following mechanical exposure, the pulps were capped with Biodentine, calcium silicate-based cement. The pulpal tissues response to Biodentine was assessed 65 days postoperatively.

RESULTS

The pulp healing response was inferior in the Pred-CsA- and Pred-CsA-MMF-treated groups compared with the control and Pred-treated groups (P < 0.05). Non-significant difference was found between control and Pred-treated groups (P > 0.05).

CONCLUSIONS

Within the limitation of this study, DPC with calcium silicate-based cement performed under strict aseptic condition for traumatically exposed dental pulp can be considered as a successful treatment option for those who receiving Pred immunosuppressive therapy. Meanwhile, DPC with those receiving a combination of Pred, CsA, and/or MMF immunosuppressive drug regimens demonstrated unfavorable results.

CLINICAL RELEVANCE

Direct capping of mechanically exposed pulps with calcium silicate-based cement performed with special care for preventing infection considered a suitable strategic measure for preserving pulp vitality in patients receiving corticosteroid immunosuppressive drug.

Influence of occlusal and proximal caries on the outcome of full pulpotomy in permanent mandibular molar teeth with partial irreversible pulpitis: A prospective study

AIM

To assess the influence of occlusal and proximal deep carious lesions on the outcome of full pulpotomy performed in mandibular teeth with pulpal diagnosis of symptomatic partial irreversible pulpitis.

METHODOLOGY

Eighty deep carious mandibular molar teeth with clinical and radiographic diagnosis of symptomatic partial irreversible pulpitis without periapical rarefaction from patients of either gender between the age of 16-35 years were included. Depending upon the location of deep carious lesion, the teeth were distributed equally into occlusal (n = 40) and proximal caries groups (n = 40). Full pulpotomy was performed under local anaesthesia and aseptic conditions. The pulp tissue was removed until the root canal orifices, and 2.5% sodium hypochlorite (NaOCl) was applied to arrest pulpal bleeding. Mineral trioxide aggregate (MTA) was compacted over the radicular pulp. Teeth were restored with resin-modified glass ionomer cement (RMGIC) and bulk-fill composite resin. Pre- and post-operative pain was assessed at 24, 48 and 72 h using a 11-point Numerical Rating Scale (NRS). Patients were followed at 6 and 12 months for clinical and radiographic evaluation. Asymptomatic teeth without any radiographic evidence of periapical rarefaction were considered successful. The data were analysed using the Shapiro-Wilk W test, two-sample Wilcoxon rank-sum test, Pearson chi-square test, Fisher's exact test and Kappa coefficient. The significance level was predetermined at p < .05.

RESULT

An intergroup comparison revealed that the pre- and post-operative pain scores at 24, 48 and 72 h were not significantly different (p > .05). At the end of follow-up period (12 months), success of full pulpotomy in occlusal and proximal caries group was 95% and 92.5%, respectively (p = .644). For both groups, the combined success rate of full pulpotomy was 93.75%.

CONCLUSION

The site of carious lesions (i.e., occlusal or proximal) did not affect the clinical and radiographic outcome of full pulpotomy performed in mature permanent mandibular teeth with symptomatic partial irreversible pulpitis.

Reducing Intervention in the COVID-19 Era: Opportunities for Vital Pulp Treatment

Over the last 12 months, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) virus has emerged as a significant global health problem with extensive repercussions for the practise of dentistry. As the principle transmission-route is via droplet-spread, aerosol-generating dental procedures (AGPs) present an exquisite challenge, which either has to be avoided or performed using strict infection-control measures, which increase the deployment of resources and cost. This new working environment necessitates the adoption of simplified, yet effective procedures that reduce intervention and minimise clinical chair time to short, single visits. Vital pulp treatment (VPT) has emerged as an attractive, technically less-complicated group of biologically-based management strategies that are aimed at maintaining pulp vitality and avoiding root canal treatment (RCT). These procedures are carried out in a strict aseptic environment using a rubber dam and have a reported high success rate, suggesting that they could be considered as effective and simple alternative therapies to relieve pain and avoid multiple visit RCT and other endodontic procedures. The relevance of promoting a simple, predictable and effective alternative to traditional, more complex dentistry has never been more compelling. In this perspective article, the latest advances in VPT are highlighted, along with an analysis of their relative success and compelling reasons why we as dentists should be adopting these treatment approaches. Thereafter, case selection, prognostic factors, techniques, limitations and future prospects of these procedures are discussed.

Vital Pulp Therapy in Permanent Mature Posterior Teeth with Symptomatic Irreversible Pulpitis: A Systematic Review of Treatment Outcomes

Background and Objectives: Symptomatic irreversible pulpitis in permanent mature teeth is a common indication for nonsurgical root canal treatment (NSRCT), but contemporary studies have reported on vital pulp therapy (VPT) applied in such teeth as a less invasive treatment. This systematic review assessed the outcomes of VPT, including partial and full pulpotomy performed with hydraulic calcium silicate cements (HCSCs) in permanent mature posterior teeth diagnosed with symptomatic irreversible pulpitis. Materials and Methods: The PRISMA guidelines were followed. The search strategy included PubMed^®, EMBASE, Cochrane library and grey literature electronic databases. The quality assessment of the identified studies followed the Cochrane Collaboration Risk of Bias, ROBINS-I and Newcastle–Ottawa Scale tools. Results: The search of primary databases identified 142 articles, of which 9 randomized controlled trials and 3 prospective cohort studies were selected for review. The risk-of-bias was assessed as ‘high’ or ‘serious’, ‘fair’, and ‘low’ for three, seven and two articles, respectively. One to five years after VPT using HCSCs, the success rates mostly ranged from 78 to 90%. Based on two articles, the outcomes of the VPT and NSRCT were comparable at one and five years. Despite the necessity for the intra-operative pulp assessment in VPT procedures, the majority of the studies did not fully report on this step or on the time needed to achieve hemostasis. Small sample sizes, of under 23 teeth, were reported in three studies. Conclusions: The reviewed 12 articles reported favorable outcomes of the VPT performed with HCSCs in permanent mature posterior teeth with symptomatic irreversible pulpitis, with radiographic success in the range of 81 to 90%. Two articles suggested comparable outcomes of the VPT and root canal treatment. Universal case selection and outcome criteria needs to be established for VPT when considered as an alternative to NSRCT. This evidence supports the need for further research comparing longer-term outcomes of both of the treatment modalities.

Conservative pulp therapy in the management of reversible and irreversible pulpitis

Conservative pulp therapy is an alternative treatment option to tooth removal and root canal treatment in the management of deep caries, traumatic pulp exposures and developmental anomalies. Pulp tissue preservation can extend the long-term survival of teeth through relatively simple restorative procedures. This article aims to update clinicians on the current state of research in materials, techniques and outcomes of vital pulp therapies and provide practical guidelines for their implementation into daily practice.

Management of primary molars with irreversible pulpitis employing tampon pulpotomy: Report of three cases with 34-month mean follow-up

This study suggests that tampon-based coronal pulpotomy using a calcium silicate-based biomaterial can be a reliable approach for the treatment of vital primary molars with irreversible pulpitis.

Preserving pulp vitality: part two - vital pulp therapies

Vital pulp therapies (VPTs) aim to preserve the vitality of the pulp. The European Society of Endodontology have begun a campaign to raise awareness on the efficacy of VPTs following on from the publication of their 2019 position statement, aimed at both specialists and general dental practitioners. This review examines the current evidence surrounding VPTs and provides a rational approach to the management of the exposed pulp with the aid of case studies. Success lies in accurate diagnosis and case selection, along with well-executed treatment and appropriate follow-up protocols. The introduction of calcium silicate cements has made these treatments more predictable.

Preserving pulp vitality: part one - strategies for managing deep caries in permanent teeth

This is the first article in a series reviewing the current literature surrounding the management of deep caries in permanent teeth. Approaches to caries management are continuing to evolve, with more conservative management increasingly favoured. This philosophy has never been more important than in managing the deep carious lesion. Evidence is emerging that the use of selective caries removal to reduce the risk of pulp exposure, in conjunction with calcium silicate cements, can be successful in maintaining pulp vitality, delaying the restorative cycle and prolonging the lifespan of the tooth.

Success of pulpotomy in mature permanent teeth with irreversible pulpitis: A systematic review

The objective of the present systematic review is to evaluate the success of pulpotomy in mature permanent teeth presented with irreversible pulpitis. The following databases were searched: PubMed, Oral and Dentistry Database, Cochrane, and CINAHL plus. We included studies published in the English language only. However, narrative reviews and case reports/series were excluded. The first electronic and hand search yielded a total of 2851 articles. After going through extensive screening and eligibility process, only six articles were finally selected for the review. The follow-up period ranged from 1 to 10 years. Randomized controlled trial compared pulpotomy with the root canal treatment and reported comparable and even better success of the pulpotomy (78% success). All the other studies have also shown better clinical and radiographic success of pulpotomy (68%–100%). Pulpotomy can be considered an alternative option for mature permanent teeth with irreversible pulpitis.