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Frontiers in Oral Health 2023Symptomatic irreversible pulpitis (SIP) or symptomatic apical periodontitis (SAP) are two painful conditions often warranting emergency treatment. The most common... (Review)
Review
Pain after emergency treatments of symptomatic irreversible pulpitis and symptomatic apical periodontitis in the permanent dentition: a systematic review of randomized clinical trials.
BACKGROUND
Symptomatic irreversible pulpitis (SIP) or symptomatic apical periodontitis (SAP) are two painful conditions often warranting emergency treatment. The most common emergency treatments supported by evidence are pulpotomy and pulpectomy and are normally performed under time-constrained circumstances. However, there is no strong evidence of which treatment suggested in literature a clinician can use to reduce endodontic pain effectively. Therefore, the aim of this systematic review is to investigate the present knowledge on postoperative pain related to the two types of emergency treatments available for treating SIP and SAP.
METHODS
Randomized controlled trials investigating postoperative pain after emergency treatments (pulpotomy and/or pulpectomy) on permanent dentition with signs and symptoms of SIP and/or SAP were searched in three major databases from 1978 until 2022. Risk of bias was assessed with Cochrane's tool.
RESULTS
Only five studies fulfilled the inclusion criteria. The included studies indicated that pulpotomy and pulpectomy are both suitable treatment options for SAP and SIP, as they provide sufficient alleviation of pain in permanent dentition. However, inconsistent results were found between the included trials on which emergency treatment is more effective in reducing pain. Cochrane's tool revealed that the studies had a low risk of bias. Limitations found in the design of the included randomized control trials decreased the level of evidence. None of the included studies accounted for essential confounding variables, such as factors affecting pain (including the psychological aspects). Moreover, possible non-odontogenic pain was not assessed, and therefore, it was not excluded; hence, affecting the internal validity of the studies.
CONCLUSION
There are controversies within the available randomized control trials on which treatment is most effective in reducing emergency pain. This could be due to some weaknesses in the design of the clinical trials. Thus, further well-designed studies are warranted to draw conclusions on which emergency treatment is more effective in reducing pain.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO (CRD42023422282).
PubMed: 37920592
DOI: 10.3389/froh.2023.1147884 -
International Endodontic Journal Oct 2023The 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... (Review)
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).
Topics: Humans; Pulpitis; Dental Caries; Dental Pulp; Pulpotomy; Root Canal Therapy; Dental Pulp Capping; Treatment Outcome
PubMed: 35579062
DOI: 10.1111/iej.13776 -
The Journal of Clinical Pediatric... Nov 2023The aim was to investigate the relationship between time to hemostasis and pulpotomy outcomes with the use of iRoot BP Plus (Innovative Bioceramics, Vancouver, Canada)...
The aim was to investigate the relationship between time to hemostasis and pulpotomy outcomes with the use of iRoot BP Plus (Innovative Bioceramics, Vancouver, Canada) for young permanent teeth of patients aged from 7 to 12 with symptomatic irreversible pulpitis and evaluate the outcomes of pulpotomy. The present study was a prospective cohort study. Two hundred and six young permanent teeth with symptomatic irreversible pulpitis underwent pulpotomy with the use of iRoot BP Plus. All patients underwent pulpotomy in accordance with a standardized protocol. Patients were postoperatively re-called after 3, 6, 12 months. Successful cases were defined according to clinical and radiographic evaluations. Main outcome measures included tooth position, cave shape, previous restoration, preoperative symptoms, time to hemostasis and outcomes. On the basis of univariate linear regression model, the relationships between time to hemostasis was evaluated, and < 0.05 indicated a difference that achieved statistical significance. One hundred and ninety-three teeth can be evaluated after a follow-up for 6 to 36 months. The mean age of subjects was 9.43 ± 1.51 years. The overall clinical and radiographic success rate of pulpotomy reached 71.5% (138/193). After adjusting potential confounders (age, sex, previous restoration), non-linear relationship was detected between time to hemostasis and pulpotomy outcomes whose point was 4 minutes. The relationship between time to hemostasis and pulpotomy outcomes is non-linear. Pulpotomy outcomes was negatively related with time to hemostasis when time to hemostasis is more than 4 minutes.
Topics: Humans; Child; Pulpotomy; Calcium Compounds; Prospective Studies; Pulpitis; Silicates; Hemostasis; Treatment Outcome; Oxides
PubMed: 37997245
DOI: 10.22514/jocpd.2023.088 -
Trials Dec 2023Full pulpotomy has been proposed as an alternative to root canal treatment in teeth with signs and symptoms indicative of irreversible pulpitis (IRP), but the evidence...
Effectiveness of full Pulpotomy compared with Root canal treatment in managing teeth with signs and symptOms indicative of irreversible pulpitis: a protocol for prospectiVE meta-analysis of individual participant data of linked randomised clinical trials (PROVE).
BACKGROUND
Full pulpotomy has been proposed as an alternative to root canal treatment in teeth with signs and symptoms indicative of irreversible pulpitis (IRP), but the evidence is limited, relying on underpowered studies with a high risk of bias. The aim of this study is to conduct a prospective meta-analysis (PMA) of individual participant data of a series of individual randomised trials to provide robust evidence on the clinical and cost-effectiveness of pulpotomy compared with root canal treatment.
METHODS
Individual participant data will be obtained from a series of randomised trials designed and conducted by a consortium of multi-national investigators with an interest in vital pulp treatment. These individualised trials will be conducted using a specified protocol, defined outcomes, and outcome measures. Ten parallel-group randomised trials currently being conducted in 10 countries will provide data from more than 500 participants. The primary outcome is a composite measure defined as (1) the absence of pain indicative of IRP, (2) the absence of signs and symptoms indicative of acute or chronic apical periodontitis, and (3) the absence of radiographic evidence of failure including radiolucency or resorption. Individual participant data will be obtained, assessed, and checked for quality by two independent reviewers prior to the PMA. Pooled estimates on treatment effects will be generated using a 2-stage meta-analysis approach. The first stage involves a standard regression analysis in each trial to produce aggregate data on treatment effect estimates followed by an inverse variance weighted meta-analysis to combine these aggregate data and produce summary statistics and forest plots. Cost-effectiveness analysis based on the composite outcome will be undertaken as a process evaluation to evaluate treatment fidelity and acceptability by patients and dentists.
RESULTS
The research question and trial protocol were developed and approved by investigators in all 10 sites. All sites use shared resources including study protocols, data collection forms, participant information leaflets, and consent forms in order to improve flow, consistency, and reproducibility. Each site obtained its own Institutional Review Board approval, and trials were registered in appropriate open access platforms. Patient recruitment has started in most sites, as of July 2023.
DISCUSSION
PMA offers a rigorous, flexible, and efficient methodology to answer this important research question and provide results with improved generalisability and external validity compared with traditional trials and retrospective meta-analyses. The results of this study will have implications for both the delivery of clinical practice and structured clinical guidelines' development.
TRIAL REGISTRATION
PROSPERO CRD42023446809. Registered on 08 February 2023.
Topics: Humans; Dental Pulp Cavity; Meta-Analysis as Topic; Prospective Studies; Pulpitis; Pulpotomy; Randomized Controlled Trials as Topic; Reproducibility of Results; Retrospective Studies; Treatment Outcome
PubMed: 38102685
DOI: 10.1186/s13063-023-07836-6 -
Clinics and Practice Aug 2023There needs to be more general agreement on the most effective treatment for the emergency patient with Symptomatic Irreversible Pulpitis (SIP). This equivalence...
Pulpectomy vs. Pulpotomy as Alternative Emergency Treatments for Symptomatic Irreversible Pulpitis-A Multicenter Comparative Randomised Clinical Trial on Patient Perceptions.
AIM
There needs to be more general agreement on the most effective treatment for the emergency patient with Symptomatic Irreversible Pulpitis (SIP). This equivalence randomised clinical study compared the clinical efficiency, as an urgent treatment, of pulpotomy (POT) and pulpectomy (PEC) in the permanent teeth with SIP. The primary outcome was pain management, and the secondary outcome was the patient's perception of duration, comfort, and satisfaction.
MATERIAL & METHODS
80 patients were blindly and randomly allocated into two equal parallel groups, the control group treated by PEC and the test group by POT. Data were collected through numerical rating scales (NRS) during the intervention and 6, 24, and 72 h post-op. Non-parametric tests were used to analyse the data. The Brunner-Longer models were adopted for longitudinal data and the analysis of variance (ANOVA)-type statistical was used.
RESULTS
The mean preoperative pain levels for the whole sample scored 5.8 ± 2.8 and significantly decreased to 2.1 ± 2.4 at 6 h, 1.5 ± 2.1 at 24 h, and 1.3 ± 2 at 72 h, without any differences between the groups. No significant differences were found in the patient's perception of treatment discomfort or duration between the groups. Three days after the intervention, patient satisfaction was high, with 9.2 ± 1.7 and 9.1 ± 2 in the PEC and POT groups, respectively. Self-reported pain was the only variable penalising the patient's final satisfaction.
CONCLUSIONS
The current randomised control trial (RCT) showed that both pulpectomy and pulpotomy effectively eliminate pain and achieve high levels of patient satisfaction. Furthermore, the patient's perceptions of the duration and discomfort of the two treatments were similar. Given that pulpotomy is a faster and more straightforward technique, it may be recommended as a viable and pragmatic option for treating emergency patients with symptomatic irreversible pulpitis.
PubMed: 37623263
DOI: 10.3390/clinpract13040082 -
Children (Basel, Switzerland) May 2024This systematic review and meta-analysis aimed to evaluate the success rates of pulpotomy treatment for irreversible pulpitis in primary teeth. (Review)
Review
AIM
This systematic review and meta-analysis aimed to evaluate the success rates of pulpotomy treatment for irreversible pulpitis in primary teeth.
METHODS
This study was registered and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Relevant studies published between January 1980 and April 2023 were identified across eight online databases and two paediatric dentistry textbooks. Study selection, data extraction, and quality assessment were conducted by multiple investigators independently. Data analysis involved single-arm and two-arm meta-analyses, leave-one-out sensitivity analysis, meta-regression, and assessment of publication bias. The risks of bias were evaluated using the Cochrane Collaboration's assessment tools. The levels of evidence were determined using the Oxford Centre for Evidence-Based Medicine (OCEBM) tool.
RESULTS
Five primary studies were included. The weighted mean overall success rates at 6-month and 12-month follow-ups were 97.2% and 94.4%, respectively. Two-arm meta-analysis revealed no significant difference ( > 0.05) between the use of mineral trioxide aggregate (MTA) and non-MTA bioceramic-based materials as pulpotomy medicaments. The sample size of each study did not affect the degree of data heterogeneity. Egger's test revealed no significant publication bias.
CONCLUSIONS
Pulpotomy may be regarded as an alternative modality for treating primary teeth with irreversible pulpitis. Nevertheless, future well-designed trials and extended follow-up periods are warranted.
PubMed: 38790569
DOI: 10.3390/children11050574 -
Journal of Dentistry May 2024This paper evaluated the success rates of pulpotomy, compared its efficacy with non-surgical root canal treatment (NSRCT), evaluated different pulpotomy techniques, and... (Meta-Analysis)
Meta-Analysis Review
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.
Topics: Adult; Humans; Aluminum Compounds; Calcium Compounds; Dentition, Permanent; Drug Combinations; Pulpitis; Pulpotomy; Randomized Controlled Trials as Topic; Root Canal Filling Materials; Root Canal Therapy; Silicates; Treatment Outcome; Controlled Clinical Trials as Topic
PubMed: 38461884
DOI: 10.1016/j.jdent.2024.104923 -
European Oral Research Sep 2023The purpose of this study is to evaluate the clinical and radiographic success rates of RetroMTA, OrthoMTA, and ferric sulfate as pulpotomy agents in primary molars.
PURPOSE
The purpose of this study is to evaluate the clinical and radiographic success rates of RetroMTA, OrthoMTA, and ferric sulfate as pulpotomy agents in primary molars.
MATERIALS AND METHODS
Ninety-six primary second molars from 32 children aged 5 to 9 years were enrolled in this study. The teeth were randomly divided into three groups based on the pulpotomy agent used: O-MTA, R-MTA, and FS. Clinical and radiographic follow-up examinations were conducted at 3, 6, 9, and 18 months postoperatively.
RESULTS
At the end of the study period, 84 teeth were evaluated. The clinical success rates were 75% for FS, 96.4% for O-MTA, and 92.8% for R-MTA groups. In the radiographic analysis, the success rates at the 18-month follow-up period were 50% for FS, 85.8% for O-MTA, and 82.2% for R-MTA groups. According to the Chi-square test and Kaplan-Meier survival analysis, there was a statistically significant difference among the success rates and survival probabilities of the groups (p<0.05).
CONCLUSION
OrthoMTA and RetroMTA demonstrated better treatment outcomes for pulpotomy of primary second molars than ferric sulfate at the 18-month follow-up period.
PubMed: 37929220
DOI: 10.26650/eor.2023950004 -
Journal of Endodontics Feb 2024Patients with type 1 diabetes mellitus (DM1) tend to have delayed wound healing, even in the pulp tissue. We hypothesized that hyperglycemia affects odontoblast-like...
INTRODUCTION
Patients with type 1 diabetes mellitus (DM1) tend to have delayed wound healing, even in the pulp tissue. We hypothesized that hyperglycemia affects odontoblast-like cell (OLC) differentiation and is involved in macrophage polarization. Accordingly, we evaluated dental pulp stem cell differentiation and macrophage phenotypes after pulpotomy.
METHODS
After modifying DM1 rat models by streptozotocin, 8-week-old rats' upper left first molars were pulpotomized with mineral trioxide aggregate. Meanwhile, the control group was administered saline. Immunohistochemical localization of nestin, osteopontin, α-smooth muscles (α-SMAs), and CD68 (pan-macrophage marker) was conducted 7 days after pulpotomy. The OLC differentiation stage was determined using double immunofluorescence of nestin and α-SMA. Double immunofluorescence of CD68 and iNOS was counted as M1 macrophages and CD68 and CD206 as M2 macrophages. Proliferating cell nuclear antigen and Thy-1 (CD90) were evaluated by immunofluorescence.
RESULTS
In DM1 rats, the reparative dentin bridge was not complete; however, the osteopontin-positive area did not differ significantly from that in controls. Proliferating cell nuclear antigen, indicative of cell proliferation, increased in positive cells in DM1 rats compared with controls. Double-positive cells for α-SMA and nestin indicated many immature OLCs in DM1. CD90 was positive only in controls. CD68-positive cells, especially M1 macrophages, were increased in DM1 rats, allowing the inflammatory stage to continue 7 days after pulpotomy.
CONCLUSIONS
The condition of DM1 model rats can interfere at various stages of the wound healing process, altering OLC differentiation and macrophage polarization. These findings highlight the importance of normal blood glucose concentrations during pulp wound healing.
Topics: Humans; Rats; Animals; Pulpotomy; Dental Pulp; Nestin; Rats, Wistar; Osteopontin; Proliferating Cell Nuclear Antigen; Diabetes Mellitus, Type 1; Wound Healing
PubMed: 37939821
DOI: 10.1016/j.joen.2023.10.016 -
Maedica Mar 2024In some cases, dental treatment of children under general anesthesia (GA) should be repeated due to treatment failures. This study evaluated the reasons leading to...
In some cases, dental treatment of children under general anesthesia (GA) should be repeated due to treatment failures. This study evaluated the reasons leading to dental retreatment under GA in children under 12 years of age. In this retrospective study, the records of all children who underwent dental treatment under GA between 2011-2021 in Tabriz Dental Faculty Hospital, Iran, were collected. The records of children treated under GA for the second time or more were analyzed. Collected data included age at first treatment, mental and/or physical disabilities, type of treatments and participation in follow-up sessions. Data were analyzed using Stata SE version 17. In a group of 667 children who underwent general anesthesia for the first time (GA1), 41% (95% confidence interval [CI] 37.2%-44.9%) required retreatment. Among all age groups, 1-3-year-old children were more likely to require a second GA (GA2) compared to other age groups (all P < 0.05). Children with physical and mental disabilities were around eight times more likely to require a second GA (P < 0.05). Younger age, mental and physical disabilities, no or irregular participation in follow-up sessions and treatments such as composite resin restorations or pulpotomy were factors influencing repeated dental treatments under general anesthesia.
PubMed: 38736936
DOI: 10.26574/maedica.2024.19.11.66