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The Saudi Dental Journal Apr 2024Pulp therapy aims to maintain the health and integrity of teeth and their supporting tissue and preserve the vitality of the tooth pulp affected by dentinal caries or... (Review)
Review
Pulp therapy aims to maintain the health and integrity of teeth and their supporting tissue and preserve the vitality of the tooth pulp affected by dentinal caries or severe traumatic injury. Thus, the best clinical practice provides pulpal health or pathosis diagnosis and various therapeutic interventions evidenced in both the deciduous and permanent dentition for endodontic treatment. The pulp health status determines the type of pulpal therapy used. Vital pulp therapies for primary teeth include protective liners, pulp capping, and pulpotomy for reversible pulpitis; for permanent teeth, pulpotomy can be considered for irreversible pulpitis. For reversible or irreversible pulpitis, invasive management of decayed teeth has traditionally been performed. However, at present, coronal pulpotomy-like vital pulp therapy has led to successful treatment outcomes that are less invasive. Compared to root canal treatments, coronal pulpotomy is cost-effective, less time-consuming, and less technically demanding. The success of a pulpotomy depends on the clinician's experience, appropriate clinical techniques, and materials used. This narrative review provides insights into the systematic analysis of pulpotomy failure, causes and signs of failure, and alternative endodontic interventions.
PubMed: 38690395
DOI: 10.1016/j.sdentj.2024.01.005 -
Pediatric Dentistry Nov 2023to update the 2016 systematic review evidence for vital pulp therapy (VPT) for primary teeth affected by caries or trauma. The population, intervention, comparison,... (Meta-Analysis)
Meta-Analysis
to update the 2016 systematic review evidence for vital pulp therapy (VPT) for primary teeth affected by caries or trauma. The population, intervention, comparison, outcomes, and study (PICOS) design inclusion/exclusion was used for multiple databases. Risk of bias, meta-analyses using RevMan, and certainty of evidence was created. A total of 299 studies were included; no trauma was found. Indirect pulp treatment (IPT) resulted in 97 percent success. Two calcium silicate cement (CSC) pulpotomies' success using mineral trioxide aggregate (MTA) and Biodentine were 94 percent and 90 percent, respectively, greater than for direct pulp capping (DPC; 86 percent) and other pulpotomies (moderate certainty). The success of IPT versus pulpotomy at 24 months showed no significant difference (P=0.31). Different liners or capping agents did not affect the success of IPT (P=0.79) or DPC at 24 months (P=0.24). The two CSC pulpotomies were not significantly different based on 24-month success (P=0.34). The formocresol pulpotomy success at 24 months was significantly lower than for MTA (P=0.02). Ferric sulfate had a significant lower success at 24 months than MTA pulpotomy (69 percent versus 92 percent; P=0.03). Zinc oxide eugenol, as a singular pulpotomy, had low success (65 percent). Selective/stepwise caries removal did significantly better at avoiding pulp exposures than complete excavation (P<0.001). Complete, selective, and no caries removal (Hall technique [HT], steel crown placement with no caries removal) had no significant difference in pulp vitality success for deep caries at 24 months (P=0.29). For deep caries affecting vital incisors, pulpotomy had significantly greater success than pulpectomy (P=0.002). The following had no significant effect on MTA pulpotomy success: coronal pulp removal methods; irrigation solution; method to control hemorrhage; base over MTA; treatment in one or two visits; and anterior or posterior teeth. Vital pulp therapy success of indirect pulp treatment or two calcium silicate cement pulpotomies demonstrated improved success over direct pulp capping and other pulpotomies based on 24-month evidence with moderate certainty. The Hall technique did not significantly reduce pulp vitality success versus caries removal.
Topics: Humans; Calcium Compounds; Silicates; Dental Care; Dental Cements; Zinc Oxide-Eugenol Cement; Dental Pulp Capping; Pulpotomy; Glass Ionomer Cements; Tooth, Deciduous; Oxides; Drug Combinations; Treatment Outcome; Aluminum Compounds
PubMed: 38129755
DOI: No ID Found -
Clinical and Experimental Dental... Dec 2023Different materials have been used for capping the pulp after exposure during caries removal in permanent teeth. The purpose of this study was to collate and analyze all... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Different materials have been used for capping the pulp after exposure during caries removal in permanent teeth. The purpose of this study was to collate and analyze all pertinent evidence from randomized controlled trials (RCTs) on different materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth.
MATERIALS AND METHODS
Trials comparing two or more capping agents used for direct pulp capping (DPC) or pulpotomy were considered eligible. An electronic search of four databases and two clinical trial registries was carried out up to February 28, 2021 using a search strategy properly adapted to the PICO framework. Screening, data extraction, and risk of bias (RoB) assessment of primary studies were performed in duplicate and independently. The primary outcome was clinical and radiological success; secondary outcomes included continued root formation, tooth discoloration, and dentin bridge formation.
RESULTS
21 RCTs were included in the study. The RoB assessment indicated a moderate risk among the studies. Due to significant clinical and statistical heterogeneity among the studies, performing network meta-analysis (NMA) was not possible. An ad hoc subgroup analysis revealed strong evidence of a higher success of DPC with Mineral Trioxide Aggregate (MTA) compared to calcium hydroxide (CH) (odds ratio [OR] = 3.10, 95% confidence interval [CI]: 1.66-5.79). MTA performed better than CH in pulp capping (both DPC and pulpotomy) of mature compared to immature teeth (OR = 3.34, 95% CI: 1.81-6.17). The GRADE assessment revealed moderate strength of evidence for DPC and mature teeth, and low to very low strength of evidence for the remaining subgroups.
CONCLUSIONS
Considerable clinical and statistical heterogeneity among the trials did not allow NMA. The ad hoc subgroup analysis indicated that the clinical and radiographic success of MTA was higher than that of CH but only in mature teeth and DPC cases where the strength of evidence was moderate. PROSPERO Registration: number CRD42020127239.
Topics: Humans; Dental Pulp Capping; Pulpotomy; Calcium Compounds; Aluminum Compounds; Oxides; Silicates; Drug Combinations; Calcium Hydroxide; Dental Caries; Randomized Controlled Trials as Topic
PubMed: 37710421
DOI: 10.1002/cre2.767 -
International Endodontic Journal Oct 2023Inflammatory biomarkers are potentially useful targets for pulpal diagnostic tests that can identify pulp status and predict vital pulp treatment (VPT) outcome, however,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Inflammatory biomarkers are potentially useful targets for pulpal diagnostic tests that can identify pulp status and predict vital pulp treatment (VPT) outcome, however, their accuracy is unknown.
OBJECTIVES
(1) Calculate sensitivity, specificity and diagnostic odds ratio (DOR) of previously investigated pulpitic biomarkers; (2) Determine if biomarker levels discriminate between clinical diagnoses of pulpitis based on the presence or absence of spontaneous pain (3) Evaluate if biomarker level can predict VPT outcome.
METHODS
Searches: PubMed/MEDLINE, Ovid SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase, Web of Science and Scopus in May 2023.
INCLUSION
prospective and retrospective observational studies and randomized trials. Participants were humans with vital permanent teeth and a well-defined pulpal diagnosis.
EXCLUSION
deciduous teeth, in vitro and animal studies. Risk of bias was assessed with modified-Downs and Black quality assessment checklist. Meta-analysis was performed using bivariate random effect model in Meta-DiSc 2.0 and RevMan and the quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation.
RESULTS
Fifty-six studies were selected, reporting >70 individual biomolecules investigating pulpal health and disease at the gene and protein level. Most studies were of low and fair quality. Among the biomolecules investigated, IL-8 and IL-6 demonstrated a level of diagnostic accuracy with high sensitivity, specificity and DOR to discriminate between healthy pulps and those exhibiting spontaneous pain suggestive of IRP (low-certainty evidence). However, none was shown to have high DOR and the ability to discriminate between pulpitic states (very low certainty evidence). Limited data suggests high levels of matrix metalloproteinase 9 correlate with poorer outcomes of full pulpotomy.
DISCUSSION
The inability of identified molecular inflammatory markers to discriminate between dental pulps with spontaneous and non-spontaneous pain should shift the focus to improved study quality or the pursuit of other molecules potentially associated with healing and repair.
CONCLUSIONS
Low-quality evidence suggests IL-8 and IL-6 demonstrated level of diagnostic accuracy to discriminate between healthy pulps and those exhibiting spontaneous pain. There is a need for standardized biomarker diagnostic and prognostic studies focusing on solutions that can accurately determine the degree of pulp inflammation.
REGISTRATION
PROSPERO CRD42021259305.
Topics: Humans; Pulpitis; Interleukin-6; Prospective Studies; Interleukin-8; Retrospective Studies; Biomarkers; Pain
PubMed: 37392154
DOI: 10.1111/iej.13950 -
Evidence-based Dentistry Jun 2024Retrospective cohort study using STROBE cohort reporting guidelines.
DESIGN
Retrospective cohort study using STROBE cohort reporting guidelines.
COHORT SELECTION
Patients from Mehr Dental Clinic in Tehran, Iran, who received different types of vital pulp therapy (VPT) by a single endodontist, due to carious pulpal exposure, between April 2011 and October 2022. These were: Full Pulpotomy (FP), Miniature Pulpotomy (MP) and Direct Pulp Capping (DPC). Data were accessed via the dental clinic's electronic database. Patients were deemed eligible if they had pulpal exposure due to caries, but not trauma. Pre-operative, immediate post-operative and at least one follow-up radiograph at a minimum 3-month interval were required. Demographic, diagnostic, and procedural data as well as informed consent were also required. Teeth with probing depths greater than 4 mm or pulpal necrosis were excluded.
DATA ANALYSIS
Patient, tooth and treatment factors were statistically analysed for an outcome of success or failure using a Cox proportional hazards model. Kaplan/Meier curves were used to establish the mean survival times. The Log-rank test was used to compare survival across the three treatment groups. The Omnibus test of model and the -2 log likelihood ratio (-2LL) were used to assess sensitivity and model fitness. Statistical analyses were determined using the IBM SPSS Statistics for Windows Version 21.0, with P value set at <0.05.
RESULTS
1257 VPTs from 1149 patients had complete data and were used in the analysis. 802 cases were excluded due to no follow up radiograph. The VPT cases were divided into FP (n = 272), MP (n = 217) and DPC (n = 768). The average follow up was 42.21 months, with an overall 116-month survival rate of 99.1% and success rate of 91.6%. FP had a mean survival time of 99.43 months; for MP it was 104.26 months; for DPC it was 102.27 months. There were no significant differences between these groups (P = 0.363). There were statistically significant correlations between symptomatic Irreversible Periodontitis (IP), radiographic signs of Apical Periodontitis (AP), restoration type, restoration surfaces and the outcome of VPT.
CONCLUSIONS
This is one of the largest cohort studies of its kind, with over 1250 cases of various VPT techniques in 10 years. There was deviation from gold standard practice, with lack of rubber dam. A lack of haemostasis after 2 min could be construed as bacterially infected pulpal tissue and require further resection of pulp. Yet, these approaches still resulted in successful outcomes. Another interesting finding was that symptomatic IP with associated AP was treated with VPT, with a 78% success rate. Considering this study and other emerging evidence in the literature, application of VPT as an alternative to conventional Root Canal Treatment could be adopted in general practice, depending on the skills and knowledge of the practitioner and patient preferences.
Topics: Humans; Retrospective Studies; Female; Male; Adult; Dental Pulp Capping; Pulpotomy; Middle Aged; Iran; Adolescent; Treatment Outcome; Dental Caries
PubMed: 38714875
DOI: 10.1038/s41432-024-01008-4 -
International Endodontic Journal Oct 2023Pulpitis characterized by spontaneous pain can result in debilitating pain. Dogma has existed to offer only have two treatment options, namely root canal treatment (RCT)... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pulpitis characterized by spontaneous pain can result in debilitating pain. Dogma has existed to offer only have two treatment options, namely root canal treatment (RCT) or extraction, although pulpotomy has always remained a potential treatment modality.
OBJECTIVE
This review aimed to answer the following research question: 'Does pulpotomy (partial or full) (I) result in better patient and clinical reported outcomes (O), compared with RCT (C) in permanent teeth with pulpitis characterized by spontaneous pain (P) evaluated at various time intervals?' (T).
METHODS
Two authors independently performed study selection, data extraction and risk of bias assessment. The literature search was conducted in the following electronic databases: Clarivate Analytics' Web of Science, Scopus, PubMed and Cochrane Central Register of Controlled Trials. English language clinical trials comparing the patient and clinical reported outcomes between RCT and pulpotomy were included. The meta-analysis was performed on a fixed-effect model and the quality of evidence assessed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.
RESULTS
Two randomized clinical trials were included. Amongst two trials, one has published four reports at different time points involving the same cohorts. The meta-analysis revealed no difference in postoperative pain (Day 7) between RCT and pulpotomy (OR = 0.99, 95% CI 0.63-1.55, I = 0%) and quality of evidence was graded as 'High'. Clinical success was high at year 1, 98% for both interventions, however, decreased over time to 78.1% (pulpotomy) and 75.3% (RCT) at 5 years.
DISCUSSION
Pulpotomy is a definitive treatment modality that is as effective as RCT. This could have a significant impact on treatment of such patients affording the advantages of retaining a vital pulp and preventing the need for RCT.
CONCLUSION
This review could only include two trials, hence there is insufficient evidence to draw robust conclusions. The clinical data accumulated so far suggests no difference in pain between RCT and pulpotomy at Day 7 postoperatively and a single randomized control trial suggests that the clinical success rate for both treatment modalities is similar long term. There is a need for more well-designed trials by different research groups to develop a stronger evidence base in this area.
REGISTRATION
PROSPERO database (CRD42021259744).
Topics: Humans; Pulpotomy; Pulpitis; Dental Pulp Cavity; Root Canal Therapy; Pain, Postoperative; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 36209498
DOI: 10.1111/iej.13844 -
Journal of Dentistry Oct 2023This study aimed to verify the non-inferiority of Endocem MTA Premixed and Well-Root PT, compared with ProRoot MTA in the pulpotomy of primary molars. In addition, we... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
This study aimed to verify the non-inferiority of Endocem MTA Premixed and Well-Root PT, compared with ProRoot MTA in the pulpotomy of primary molars. In addition, we tried to determine the factors that affect the prognosis of pulpotomy in primary molars.
METHODS
This randomized clinical trial enrolled 158 molars of 52 children; 153 teeth were finally included and divided into three groups: ProRoot MTA (n = 50), Endocem MTA Premixed (n = 53), and Well-Root PT (n = 50). Clinical and radiographic follow-up was performed at 3, 6, and 12 months postoperatively and at the last visit post-treatment. Data were analyzed using the Fisher's exact test, Cox regression analysis, and the Kaplan-Meier survival curve method.
RESULTS
The success rates in the ProRoot MTA, Endocem MTA Premixed, and Well-Root PT were 92, 84.9 and 82%, respectively. The cumulative survival rates did not differ significantly among the materials. Among the investigated variables, only ΔF and ΔF max significantly affected the success rates. In the multivariate survival tree model, significant unfavorable survival was observed when the ΔF value was -14.4 or less (hazard ratio, 7.56; P = 0.0295).
CONCLUSIONS
Considering the clinical effectiveness of Endocem MTA Premixed and Well-Root PT and the operational convenience as a premixed type, they can be used as advantageous materials in the pulpotomy of primary molars in pediatric patients. The QLF method is a useful diagnostic method that can establish treatment plans and determine the prognosis of pulpotomy based on the ΔF value in primary molars.
CLINICAL SIGNIFICANCE
Endocem MTA Premixed and Well-Root PT can confer high success rates and are non-inferior to ProRoot MTA in pulpotomy for primary molars. We also showed that QLF technology can be applied to predict the success/failure and prognosis of pulpotomies in primary molars.
Topics: Humans; Child; Pulpotomy; Dental Cementum; Calcium Compounds; Molar
PubMed: 37660882
DOI: 10.1016/j.jdent.2023.104684 -
Journal of Endodontics Sep 2023The aim of this prospective case series was to assess the clinical and radiographic outcome of partial pulpotomy in caries-exposed symptomatic, vital, immature,...
INTRODUCTION
The aim of this prospective case series was to assess the clinical and radiographic outcome of partial pulpotomy in caries-exposed symptomatic, vital, immature, permanent molars.
METHODS
Thirty-four immature molars with deep caries and symptoms of irreversible pulpitis were treated by partial pulpotomy and ProRoot MTA as a capping material. After complete caries removal, the inflamed part of the pulp was removed. Complete hemostasis was achieved using a sterile cotton pellet moist initially with sodium hypochlorite 1.5% and then with sterile saline. ProRoot MTA (Dentsply Sirona, Charlotte, NC) was placed as a capping material onto the remaining pulp tissue. The cavity was sealed using a light-curing resin-modified Ca(OH) cavity liner, and patients were referred to a pediatric dentist for permanent restoration. Descriptive statistics and cross tabulations were performed including variables examined before, during, and after the procedure.
RESULTS
All examined teeth presented a favorable clinical and radiographic outcome with normal periapical tissues, complete apical closure, and formation of a dentinal bridge beneath the capping material. Signs of partial pulp chamber calcification were only detected in 2 cases. Postoperatively, most patients did not report any pain (23/34, 67.7%), whereas the rest reported minor intensity pain (11/34, 32.3) and the use of analgesic or anti-inflammatory drugs only for 1 day (10/34, 29.4%).
CONCLUSIONS
Partial pulpotomy seems to provide a universally successful outcome when managing symptomatic vital immature teeth with no signs of complications and completion of apical closure. It could be a viable treatment of choice in cases of caries-exposed vital immature teeth with symptoms of irreversible pulpitis.
Topics: Child; Humans; Pulpotomy; Pulpitis; Calcium Compounds; Silicates; Dentition, Permanent; Dental Caries; Treatment Outcome; Oxides; Drug Combinations
PubMed: 37442339
DOI: 10.1016/j.joen.2023.07.003 -
Journal of Family Medicine and Primary... Dec 2023In recent years, many studies have been conducted on different materials for covering the pulp in pulpotomy. Recently, some materials such as Coldceram have been...
AIM
In recent years, many studies have been conducted on different materials for covering the pulp in pulpotomy. Recently, some materials such as Coldceram have been introduced that have the ability to regenerate the pulp. In this study, our aim was to compare the clinical and radiographic success of the pulpotomy of milk molars using MTA and Coldceram over 3-, 6-, and 9-month follow-ups.
METHODS
In this clinical trial, 42 children aged 4-9 years old who fulfilled the inclusion criteria of the study were selected. Finally, pulpotomy was conducted on 42 teeth using MTA and another 42 teeth using Coldceram in these children. Simultaneously, all teeth were permanently repaired using glass ionomer and metal veneers in the same treatment session. Then, clinical and radiographic evaluation was conducted in 3-, 6-, and 9-month follow-up periods.
RESULTS
None of the teeth showed clinical symptoms at the specified 3-, 6-, and 9-month follow-up times, and clinical success was 100% in both groups. In radiographic evaluation, the numbers of successful treatments were 42/42 (100%) and 41/42 (97%) for the teeth treated with MTA and Coldceram, respectively.
CONCLUSION
According to this research, both materials were proven to have a 100% clinical success rate, but in the radiographic evaluation, MTA attained a higher success rate compared with Coldceram; however, this difference was not statistically significant ( = 0.36). It is recommended to consider longer follow-ups and larger sample sizes in future studies.
PubMed: 38361859
DOI: 10.4103/jfmpc.jfmpc_412_23 -
International Journal of Clinical... Sep 2023To evaluate the clinical and radiographic efficacy of and as pulp medicaments in primary molars in comparison to formocresol.
AIM
To evaluate the clinical and radiographic efficacy of and as pulp medicaments in primary molars in comparison to formocresol.
MATERIALS AND METHODS
This randomized controlled trial is a three-arm, parallel-group study. This research included 66 vital, carious primary molars that required pulpotomy treatment in 4-7-year-old children. Teeth were randomly assigned to one of the three groups: groups (1-3) , , and formocresol, respectively. All teeth were covered with stainless steel crowns (SSC) after the pulpotomy procedure was done and were assessed clinically and radiographically at 3, 6, and 12 months following Zurn and Seale criteria.
RESULTS
After 12 months, the clinical success rate was found to be 40, 90, and 72.7% for , , and formocresol groups, respectively. While the radiographic assessment showed a success rate of 20, 72.7, and 81.8%, respectively.
CONCLUSION
can be considered as an alternative pulpotomy medicament to formocresol. On the other hand, is not recommended to be used in pulpotomy procedures. Further long-term follow-up clinical studies and histological studies are recommended.
CLINICAL SIGNIFICANCE
Although formocresol is the most popular used material in pulp therapy, concerns were raised regarding its toxicity and carcinogenicity by the International Agency for Research on Cancer (IARC). Consequently, herbal medicine is expanding rapidly worldwide nowadays and herbal extracts are suggested as an alternative to formocresol for their proposed antibacterial and anti-inflammatory properties.
HOW TO CITE THIS ARTICLE
Sharaf RM, Kabil NS, Youssef FS, Clinical and Radiographic Evaluation of and as Pulpotomy Medicaments in Primary Teeth: A Randomized Controlled Trial. Int J Clin Pediatr Dent 2023;16(S-2):S195-S201.
PubMed: 38078020
DOI: 10.5005/jp-journals-10005-2657