Pulp preservation in immature permanent teeth

Pulpotomy for teeth with irreversible pulpitis in immature permanent teeth: a retrospective case series study

To evaluate the success of pulpotomy in treating immature permanent teeth with irreversible pulpitis. This case series included patients with irreversible pulpitis admitted to the Department of Oral Medicine at the author's Hospital between 2015 and 2020. The pulpotomies were carried out by clinicians with > 5 years of working experience. The follow-up findings and radiographic images were reviewed by two attending dentists. This study included 49 teeth from 48 children (25 boys and 23 girls). The follow-up was 23.3 ± 6.8 months (from 12 to 40 months). The success rate of pulpotomy was 85.7% (42/49). Pulpotomy failed in seven teeth (14.3%). The treatment success rate for traumatic crown fracture was lower than for dental caries and dens evaginatus (P < 0.001). There were no significant differences in the success rate of the pulp-capping agent, tooth root developmental phase, and pulpotomy method (all P > 0.05). Pulpotomy might be successfully used to treat immature permanent teeth with irreversible pulpitis in young patients mainly caused by caries and a fractured tubercle of dens evaginatus.

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.

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.

The Effect of General Anesthesia on the Outcome of Root Canal Treatment in Pediatric Patients—A Retrospective Cohort Study

This study aimed to evaluate the effect of general anesthesia (GA) on the 1-year outcome of Root Canal Treatment (RCT) performed in pediatric patients and to compare it to the outcome of RCT in pediatric patients without GA. Patients admitted for RCT in permanent dentition in a public hospital, dated 2015 to 2020, age 8–15 with a minimum of one year follow-up period, were included in the study. The sample consisted of 326 teeth from 269 patients treated by a single operator, with a recall rate of 81%. Overall, 124 teeth were treated under GA and 142 teeth were without GA. The mean follow-up time was 31.5 months. Data underwent statistical analysis and the significance threshold was set for p < 0.05. Of the total cases, 90% showed favorable outcomes. A significantly higher favorable outcome was seen in the GA group than in the non-GA group (98% and 85%, respectively, p < 0.001). The outcome was significantly affected by the type and quality of the coronal restoration, degree of root development, and lesion size (p < 0.05). According to the current study, in uncooperative pediatric patients, a more favorable outcome of root canal treatment can be obtained under GA than LA if the procedure is carried out with immediate restoration.

Outcome of full pulpotomy in mature permanent molars using 3 calcium silicate-based materials: A parallel, double blind, randomized controlled trial

AIM

The aim of the study was to compare the outcome of full pulpotomy using 2 calcium silicate-based materials compared with mineral trioxide aggregate (MTA) in symptomatic mature permanent teeth with carious pulp exposure.

METHODOLOGY

This study was designed as a parallel, double blind, randomized controlled trial where symptomatic mature permanent teeth with carious pulp exposure meeting the inclusion criteria were randomly treated with full pulpotomy using one of 3 calcium silicate-based materials (ProRoot MTA, Biodentine and TotalFill). Full pulpotomy was performed, and haemostasis was achieved via a cotton pellet moistened with 2.5% NaOCl. A 3-mm layer of the calcium silicate-based material was randomly placed as the pulpotomy agent through a block randomization process followed by a resin-based composite restoration. Postoperative periapical radiograph was taken. Clinical and radiographic evaluation were completed after 6 months and 1 year. The patient and evaluator were blinded to the type of materials used. Pain levels were scored preoperatively and 7 days after treatment. Effect of potential prognosis factors including gender, age, diagnosis, bleeding time and type of caries were also analysed.

RESULTS

One hundred and sixty-four teeth in 146 patients received full pulpotomy and were randomly assigned to either the tested or control material through block randomization technique (50 MTA, 50 Biodentine and 64 TotalFill). The age ranged from 10 to 70 years. The diagnosis was irreversible pulpitis in 112 teeth (72%) and reversible pulpitis in 28 teeth (28%). The majority of patients presented with severe pain, during the first week 96.9% reported complete relief of pain or mild pain. Four cases had immediate failure. At 6 months the overall success rate was 92.2%, over 1 year 156/164 teeth attended follow-up with 12 failures (2 restorative failures and 10 endodontic failures), the overall success of pulpotomy at 1 year was 92.3% (144/156); 91.8% in MTA, 93.3% in Biodentine and 91.9% in TotalFill with no significant difference amongst the groups and no side effects observed. No significant association was evident between outcome and the investigated variables.

CONCLUSIONS

The 1-year success rate of full pulpotomy did not differ significantly between Biodentine pulpotomy, TotalFill pulpotomy, and MTA pulpotomy. The study was registered with clinical trials; registration number (NCT04345263).

Pulp therapy and root canal treatment techniques in immature permanent teeth: an update

Background According to the Children's Dental Health Survey 2013, around one in ten children in Wales, Northern Ireland and England will have sustained dental trauma to a permanent incisor by the of age 15. Management of an exposed pulp in an immature permanent incisor is often urgent and has an impact on the long-term outcome of the tooth; therefore, it is essential that general dental practitioners feel confident in managing such a scenario to achieve an optimal outcome. This paper discusses the indications, technique, materials and outcomes.Aims This article aims to review the literature, which discusses various treatment modalities and materials for pulpal therapy and root canal treatment in the immature permanent tooth.Method Electronic searches were limited to English language, human studies, published within the past five years and the medical subject heading terms used were: direct pulp capping, apexogenesis, Cvek pulpotomy, full pulpotomy/pulpectomy, partial pulpotomy, apexification, non-vital pulp therapy and mineral trioxide aggregate apexification. Older, seminal articles identified through the references sections have also been included.Conclusion A number of options are available for the management of immature permanent teeth that have suffered an insult such as caries or trauma. This paper reviews the various methods of pulpal treatment, preservation therapy and root canal treatment options depending on the extent of the damage.

4-Year Follow-up of Full Pulpotomy in Symptomatic Mature Permanent Teeth with Carious Pulp Exposure Using a Stainproof Calcium Silicate-based Material

INTRODUCTION

This study aimed to assess the pulpal and restorative outcome of full pulpotomy in symptomatic mature permanent teeth with carious pulp exposure over 4 years.

METHODS

Under local anesthesia, full pulpotomy was performed using the aseptic technique and a stainproof calcium silicate-based material (NeoMTA Plus; Avalon Biomed Inc, Bradenton, FL). The pain level was scored preoperatively and at 1 week posttreatment. Clinical and radiographic evaluation was performed at 6 months, 1, 2, and 4 years. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to analyze the data. Failed cases were classified as endodontic or restorative failure.

RESULTS

Full pulpotomy was completed in 109 teeth in 90 patients with an age range of 14-60 years (mean = 25 years). The study sample available for follow-up was 100 teeth in 86 patients with a recall rate above 90%. Preoperative pulp diagnosis was reversible pulpitis in 39 teeth and irreversible pulpitis in 61 teeth. The cumulative survival rates of pulpotomy were generally high (ie, 98%, 97.4%, 93%, and 83.8% at 6 months and 1, 2, and 4 years, respectively). The overall mean survival time of pulpotomy was 3.89 years (95% confidence interval, 3.84-3.95). The mean survival time was significantly higher for patients aged ≤25 years. However, in the multivariate analysis, the only significant predictor of pulpotomy failure was severe preoperative pain. Over the 4 years, 23 cases failed; only 10 of 23 failures were classified as endodontic failure, and the success of pulpotomy can be assumed to be 90%.

CONCLUSIONS

Full pulpotomy in cariously exposed pulp of mature permanent teeth sustained a high success rate over 4 years. The coronal seal is crucial for long-term survival.

The Effects of Various Restorative Techniques on the Fracture Resistance of Pulpotomized Permanent Premolars

AIM

This study aimed to evaluate the effects of various restorative techniques on the fracture resistance of pulpotomized premolars with mesioocclusodistal (MOD) cavities treated with mineral trioxide aggregate (MTA) or calcium enriched mixture (CEM) cement.

MATERIALS AND METHODS

One hundred and eight sound extracted maxillary premolars were randomly assigned to nine experimental groups (n = 12). The teeth in group 1 did not receive any preparation. Class II MOD cavities were prepared in the other experimental groups. In groups 2, 4, 6, and 8, tooth-colored MTA was used for pulpotomy. In groups 3, 5, 7, and 9, CEM cement was used for pulpotomy. Groups 2 and 3 were left unrestored. Groups 4 and 5 were restored with amalgam. Groups 6 and 7 were restored with a conventional composite resin, and groups 8 and 9 were restored with bulk-fill giomers. Fracture resistance was measured, the fracture pattern of each specimen was assessed, and the results were statistically analyzed.

RESULTS

The fracture resistance of group 1 was significantly higher than those of the other groups (p < 0.05). The fracture resistance of group 2 (MTA + amalgam) was statistically lower than those of all experimental groups (p values < 0.05) except groups 3, 4, and 5 (p values > 0.05). No statistically significant differences were found between the groups restored with amalgam, conventional composite resin, and bulk-fill giomer (groups 4, 5, 6, 7, 8, and 9) (p values < 0.05). The highest rate of mode 1 fracture (restorable fracture) was observed in group 1 followed by groups 8 and 9.

CONCLUSION

No significant differences were found among the fracture resistances of the restored teeth using various restorative techniques. Bulk-fill giomers followed by conventional composite resin were better able to prevent unfavorable fractures compared to amalgam. Therefore, they seem to be more reliable for the restoration of pulpotomized teeth with MOD cavities.

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.

Evaluation of the Efficacy of Erbium, Chromium-doped Yttrium, Scandium, Gallium, and Garnet Laser in Partial Pulpotomy in Permanent Immature Molars: A Randomized Controlled Trial

INTRODUCTION

The use of the erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser in vital pulp therapy contributes to the formation of dentin bridges and a sterile zone as well as the maintenance of the vitality of the pulp. However, no prior studies have used the Er,Cr:YSGG laser in partial pulpotomy of immature permanent teeth. The aim of this study was to compare the efficacy of partial pulpotomy treatment using mineral trioxide aggregate (MTA) alone and MTA with the Er,Cr:YSGG laser in permanent immature molars.

METHODS

A total of 90 caries-exposed permanent immature molar teeth were included and randomly divided into 2 groups: the MTA group (n = 45) and the laser + MTA group (n = 45). In the MTA group, MTA was applied to the exposed area on the pulp after bleeding control. In the same session, the tooth was restored with a composite resin. In the laser + MTA group, before MTA condensation, the Er,Cr:YSGG laser was applied to the exposure area. Patients were recalled at 1, 3, 6, and 12 months after treatment. The Mann-Whitney U and chi-Square tests were used for statistical analysis.

RESULTS

The success rate (95.5%) of the laser + MTA group was similar to that of the MTA group (88.8%). There was no significant difference between groups in terms of the frequency of at least 1 pathologic clinical or radiographic failure at 12 months (P > .05).

CONCLUSIONS

Partial pulpotomy treatment showed a high success rate in immature permanent molars; however, the use of the laser did not contribute to the success rate compared with MTA alone.

Biodentine™ Partial Pulpotomy of a Young Permanent Molar with Signs and Symptoms Indicative of Irreversible Pulpitis and Periapical Lesion: A Case Report of a Five-Year Follow-Up

The purpose of this paper was to report the five-year success of Biodentine™ partial pulpotomy in a young permanent molar, with signs and symptoms indicative of irreversible pulpitis and periapical lesion, in a nine-year-old girl. Preoperative clinical examination revealed a large carious lesion of the left mandibular permanent first molar. The patient reported pain on percussion. The tooth responded positively to the electric pulp test and had lingering pain after cold testing. A periapical radiograph showed a deep carious lesion and periapical lesion. Based on the clinical and radiographical examination, the tooth had signs and symptoms indicative of irreversible pulpitis and periapical lesion. During caries removal, pulp exposure occurred, and 2-3 mm in depth of pulp tissue at the exposure site was removed. Haemorrhage was controlled within four minutes with 2.5% sodium hypochlorite-moistened cotton pellets. Biodentine™ was then applied as both a pulp dressing and a temporary restoration. At the following visit, composite resin was placed over the Biodentine™ as a final restoration. During a five-year follow-up, the tooth was asymptomatic, had positive responses to sensibility tests, and had no discolouration. Follow-up radiographs showed a dentine bridge and periapical healing.

Partial pulpotomy with two bioactive cements in permanent teeth of 6- to 18-year-old patients with signs and symptoms indicative of irreversible pulpitis: a noninferiority randomized controlled trial

AIM

To compare the outcome of partial pulpotomy using two cements, ProRoot MTA (Dentsply, Tulsa Dental Specialties, Tulsa, OK, USA) and Biodentine (Septodont, Saint-Maur-des-Fossés, France), in permanent teeth of 6- to 18-year-old patients with signs and symptoms indicative of irreversible pulpitis. Furthermore, the frequencies of perceptible grey discoloration caused by the cements were compared.

METHODOLOGY

Sixty-nine permanent first molars with signs and symptoms indicative of irreversible pulpitis, from 69 patients, were included. All operators performed partial pulpotomy under a standardized protocol. Teeth were allocated, using a website-generated number of simple randomization, to partial pulpotomy with either ProRoot MTA (37 teeth) or Biodentine (32 teeth) and were restored with composite resin or stainless steel crowns. Patients were recalled every 6 months. To be categorized as having success, the evaluated tooth must have had both clinical and radiographic success. In addition, photographs of treated teeth were evaluated for frequency of perceptible grey discoloration. Success rates between the two cements were compared using the Fisher exact test. The frequencies of perceptible grey discoloration were compared using the chi-square test. The percentage difference was estimated by 95% confidence interval, and the level of significant difference was P < 0.05.

RESULTS

At a mean follow-up of 32.2 ± 17.9 months, a total of 67 teeth, 37 with ProRoot MTA and 30 with Biodentine, were available for evaluation. The mean age of participants was 10 ± 2.1 years and, there were no differences in the baseline variables (gender, age, tooth type, periapical status, stage of root development, final restoration and follow-up period) between the groups. The overall success in both groups was 90%, with 92% for ProRoot MTA and 87% for Biodentine (difference, 5%; 95% confidence interval, -9% to 19%, P = 0.487), suggesting that Biodentine was noninferior to ProRoot MTA. Perceptible grey discoloration was observed in both groups, 80% for teeth treated with ProRoot MTA and 27% for teeth treated with Biodentine, with a significant difference between the materials (P < 0.001).

CONCLUSIONS

Permanent teeth with signs and symptoms indicative of irreversible pulpitis in 6- to 18-year-old patients were successfully treated with partial pulpotomy using both cements. Biodentine exhibited significantly less frequency of discoloration than did ProRoot MTA.

BiodentineTM is cytocompatible with human primary osteoblasts

Calcium silicate-based materials have been widely studied due to their resemblance to, and similar applicability of, mineral trioxide aggregate (MTA). Among these, Biodentine™ (BD) was specifically designed as a "dentin replacement" material for applications such as root perforations, apexification, treatment of resorptive lesions, and as a retrograde filling material. The present study aimed to assess the in vitro response of human primary osteoblasts to BD using MTA AngelusTM as a reference material, by simultaneously analyzing three different cell viability parameters, namely mitochondrial activity, membrane integrity, and cell density. BD and MTA extracts were prepared by incubation on culture media for 24 h or 42 days after mixing. Primary human osteoblasts were exposed to extracts for 24 h, at 37oC with 5% CO2, and cell viability was evaluated by the XTT, NRU, and CVDE assays. Both materials induced cell viability levels higher than 70% when extracted for 24 h. However, when cells were exposed to extracts with increased conditioning times, MTA presented significant cytotoxic effects (p < 0.05) in comparison to the control and MTA at 24 h. After 42 days, the XTT assay identified a significant reduction in cell viability by BD when compared to the control (p<0.05), despite the fact that levels above the 70% viability cutoff were attained for biocompatible materials. It can be concluded that BD is cytocompatible with human primary osteoblasts, indicating its adequacy in direct contact with bone tissues.

Pulp prognosis following conservative pulp treatment in teeth with complicated crown fractures-A retrospective study

BACKGROUND/AIM

Complicated crown fractures are relatively common in children where the maintenance of the pulp is especially important in young permanent teeth. The aim of this study was to analyze the pulp prognosis of permanent teeth with complicated crown fractures treated with conservative pulp treatment in adolescents.

MATERIAL AND METHODS

Complete dental records of teeth with complicated crown fractures treated with conservative pulp treatment were obtained. The risk of pulp necrosis and infection was evaluated by the Kaplan-Meier method and Cox regression (P<.05). Risk factors included gender, age, time interval between dental injury and treatment, stage of root development, type of pulp treatment, and coronal restoration.

RESULTS

The study involved 375 teeth treated with direct pulp capping, partial or coronal pulpotomy, and direct pulp capping retreated by pulpotomy (partial or coronal). The frequency of pulp necrosis and infection was 10.1% (11/109) for partial pulpotomy and 9.8% (22/205) for coronal pulpotomy. There was no difference between partial and coronal pulpotomy (P=.673). The risk of pulp necrosis and infection was not significantly different between pulpotomy (partial and coronal; 33/314, 10.5%) and retreatment by pulpotomy (partial or coronal) after direct pulp capping (2/33, 6.1%; P=.436). However, the frequency of pulp necrosis and infection after direct pulp capping (16/28, 57.1%) was significantly higher than that with pulpotomy (partial or coronal; odds ratio=8.216, P<.001). The time interval between dental injury and treatment did not significantly influence pulp survival after pulpotomy (partial or coronal; P=.312), but the stage of root development had a significant impact (P<.001).

CONCLUSIONS

Partial or coronal pulpotomy, employed either as a primary pulp treatment or secondary to emergency pulp capping, had similarly satisfactory pulp survival rates.

Evaluation of Biodentine in the Restoration of Root Caries

There is no “gold-standard” material for the operative management of root caries. The aim of this study was to determine if the clinical performance of Biodentine would be acceptable for the restoration of root caries in older adults. A randomized controlled clinical trial was conducted comparing a calcium silicate cement (Biodentine), a high-viscosity glass ionomer cement (Fuji IX GP Extra), and a resin-modified glass ionomer cement (Fuji II LC). Of the 334 volunteers assessed for eligibility, 249 were excluded. A total of 303 lesions in 85 participants were randomized, with 151 lesions allocated to receive Biodentine, 77 to Fuji IX GP Extra, and 77 to Fuji II LC. Patients were reviewed by a calibrated dentist who was not involved in restoration placement and who was blinded to material allocation. Restorations were assessed according to a modified US Public Health Service criteria. The cumulative survival percentages after 6 mo and 1 y were 58.6% and 47.2% in the Biodentine group, 89.6% and 83.8% in the Fuji IX GP Extra group, and 89.5% and 84.9% in the Fuji II LC group, respectively. There were statistically significant differences ( χ2 test, P < 0.001) in restoration failure rates between restoration groups. There was no difference between Fuji IX GP Extra and Fuji II LC, but differences ( P < 0.001) were shown between the Fuji II GP Extra group and the Biodentine group and also between the Fuji II LC group and the Biodentine group at both time points. Based on the results of this study, Biodentine cannot be recommended for the operative management of root caries. Fuji IX GP Extra and Fuji II LC displayed similar success rates, and high-viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option for the restoration of root caries ( ClinicalTrials.gov NCT01866059).

Knowledge Transfer Statement: The results of this study can assist dental practitioners when selecting a restorative material for the operative management of root caries. This randomized controlled trial compared the 1-y clinical performance of a calcium silicate–based material to that of a high-viscosity glass ionomer cement and a resin-modified glass ionomer cement in the operative management of root caries. The study concluded that high-viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option to dental practitioners when restoring the root surface.