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European Journal of Paediatric Dentistry Dec 2021The aim of this systematic review was to evaluate the clinical outcome of partial pulpotomy, pulpotomy and pulpectomy for treating primary teeth with normal or infected...
AIM
The aim of this systematic review was to evaluate the clinical outcome of partial pulpotomy, pulpotomy and pulpectomy for treating primary teeth with normal or infected pulp or with irreversible pulpitis.
METHODS
Two reviewers on Pubmed and ISI Web of Science performed a comprehensive literature review of publications from 1966 until July 2019. Pico outline was used to facilitate literature research. Among abstracts, publications were selected according to the following criteria: prospective clinical study, correct indication for the performed treatment, clear definition of clinical and/or radiographic success criteria and at least 6-month follow-up period. The strict selection criteria under the keywords "pulpotomy", "partial pulpotomy" and "pulpectomy" resulted in a limited amount of randomised controlled trials (RCT) or controlled clinical trials (CT). Qualitative assessment of the selected clinical studies and level of evidence was included according to the criteria described by the Oxford Centre for Evidence-Based Medicine (CEBM).
CONCLUSION
Prerequisites for a successful pulpotomy are symptom-free teeth, sterile removal of coronal pulp and haemostasis. Both MTA and formocresol perform well for partial pulpotomies after caries exposure. Formocresol had been the most popular amputation material for pulpotomies. Due to the potential side effects, other medicaments, such as ferric sulfate, mineral trioxide aggregate (MTA) or NaOCl are suggested. Grey and white MTA yeld the same results. Lasers are not recommended due to their large diversity. Regarding pulpectomy, the conditions, procedures, and evaluation for the treatment were not well defined in the studies. Nevertheless, there is evidence to use calcium hydroxide, zinc oxide eugenol paste or iodoform based pastes as root filling materials for non-vital molars. Pulpectomies showed better success rates than pulpotomies. Stainless steel crowns are recommended as definite restorations after both endodontic treatments. Longer follow-up periods, further clinical studies with comparable conditions and clear definition of evaluation criteria are needed to further confirm the results of endodontic treatment in primary teeth.
Topics: Calcium Compounds; Drug Combinations; Humans; Molar; Oxides; Pulpectomy; Pulpotomy; Silicates; Tooth, Deciduous; Treatment Outcome; Zinc Oxide-Eugenol Cement
PubMed: 35034465
DOI: 10.23804/ejpd.2021.22.04.4 -
International Endodontic Journal Jul 2019This position statement on the management of deep caries and the exposed pulp represents the consensus of an expert committee, convened by the European Society of...
This position statement on the management of deep caries and the exposed pulp represents the consensus of an expert committee, convened by the European Society of Endodontology (ESE). Preserving the pulp in a healthy state with sustained vitality, preventing apical periodontitis and developing minimally invasive biologically based therapies are key themes within contemporary clinical endodontics. The aim of this statement was to summarize current best evidence on the diagnosis and classification of deep caries and caries-induced pulpal disease, as well as indicating appropriate clinical management strategies for avoiding and treating pulp exposure in permanent teeth with deep or extremely deep caries. In presenting these findings, areas of controversy, low-quality evidence and uncertainties are highlighted, prior to recommendations for each area of interest. A recently published review article provides more detailed information and was the basis for this position statement (Bjørndal et al. 2019, International Endodontic Journal, doi:10.1111/iej.13128). The intention of this position statement is to provide the practitioner with relevant clinical guidance in this rapidly developing area. An update will be provided within 5 years as further evidence emerges.
Topics: Dental Caries; Dental Pulp; Dental Pulp Capping; Endodontics; Humans; Periapical Periodontitis; Pulpotomy
PubMed: 30664240
DOI: 10.1111/iej.13080 -
International Endodontic Journal Jul 2019Caries prevalence remains high throughout the world, with the burden of disease increasingly affecting older and socially disadvantaged groups in Western cultures. If... (Review)
Review
Caries prevalence remains high throughout the world, with the burden of disease increasingly affecting older and socially disadvantaged groups in Western cultures. If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs even in deep carious lesions. Traditionally, deep caries management was destructive with nonselective (complete) removal of all carious dentine; however, the promotion of minimally invasive biologically based treatment strategies has been advocated for selective (partial) caries removal and a reduced risk of pulp exposure. Selective caries removal strategies can be one-visit as indirect pulp treatment or two-visit using a stepwise approach. Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy and the re-emergence of vital pulp treatment (VPT) techniques such as partial and complete pulpotomy. These changes stem from an improved understanding of the pulp-dentine complex's defensive and reparative response to irritation, with harnessing the release of bioactive dentine matrix components and careful handling of the damaged tissue considered critical. Notably, the development of new pulp capping materials such as mineral trioxide aggregate, which although not an ideal material, has resulted in more predictable treatments from both a histological and a clinical perspective. Unfortunately, the changes in management are only supported by relatively weak evidence with case series, cohort studies and preliminary studies containing low patient numbers forming the bulk of the evidence. As a result, critical questions related to the superiority of one caries removal technique over another, the best pulp capping biomaterial or whether pulp exposure is a negative prognostic factor remain unanswered. There is an urgent need to promote minimally invasive treatment strategies in Operative Dentistry and Endodontology; however, the development of accurate diagnostic tools, evidence-based management strategies and education in management of the exposed pulp are critical in the future.
Topics: Dental Caries; Dental Pulp; Dental Pulp Capping; Dental Pulp Exposure; Humans; Pulpotomy
PubMed: 30985944
DOI: 10.1111/iej.13128 -
International Endodontic Journal Mar 2023The promotion of minimally invasive treatments focussed on the maintenance of pulp vitality has become a priority area in Endodontics. These vital pulp treatments (VPT)... (Review)
Review
The promotion of minimally invasive treatments focussed on the maintenance of pulp vitality has become a priority area in Endodontics. These vital pulp treatments (VPT) include partial and full pulpotomy, during which diseased coronal pulp tissue is removed prior to placement of a capping biomaterial and restoration. Traditionally, pulpotomies were confined to the treatment of carious primary and traumatized permanent teeth. However, these treatments have now been proposed as definitive solutions for cariously exposed permanent teeth with mild symptoms or even symptoms indicative of irreversible disease. Until recently, it was recommended that carious exposure of mature permanent teeth be managed by root canal treatment. The promotion of pulpotomy as an alternative treatment has opened up a wave of laboratory and clinical research aimed at improving therapies or evaluating clinical outcomes. In modern evidence-based endodontics, it is imperative that the outcomes of both partial and full pulpotomy are considered and important prognostic factors identified, so that improvements can be made to aid clinical decision-making and to direct new research. In this narrative review, the outcomes of partial and full pulpotomy are discussed, before analysis of patient, intraoperative and postoperative factors that influence the outcome of the pulpotomy procedure. The review highlights that although partial and full pulpotomy for the treatment of even pulpal disease are highly successful procedures, this is based on low-quality evidence with a lack of prospective, comparative trials investigating potential prognostic factors. Based on current evidence, it appears that age, gender, tooth type, root development and intraoperative pulpal haemorrhage do not impact significantly on pulpotomy outcome, whilst others such as caries depth, inflammatory status of the pulp, capping material, level of inflammatory pulpal-biomarkers and the final restoration integrity do. Other factors, including the influence of exposure type, periodontal condition, pulpal lavage, magnification, operator experience, isolation of the operating field and type of pulpotomy, require further experimental investigation before definitive conclusions can be made relating to the success of the pulpotomy procedure. Finally, there is not only a need for future well-designed prospective research addressing these issues but also a widening of our understanding of outcome to include patient-reported as well as clinician-reported outcomes.
Topics: Humans; Pulpotomy; Prospective Studies; Dental Pulp Capping; Treatment Outcome; Root Canal Therapy; Dental Caries; Silicates
PubMed: 36334098
DOI: 10.1111/iej.13866 -
International Endodontic Journal May 2022Therapeutic strategies focussed on the pulp preservation, are important when managing vital teeth with deep caries and an exposed pulp. These vital pulp treatments... (Review)
Review
Therapeutic strategies focussed on the pulp preservation, are important when managing vital teeth with deep caries and an exposed pulp. These vital pulp treatments (VPTs); however, are not new, with indirect and direct pulp capping procedures being described as a therapy for carious teeth for over a century. As a result of unpredictable outcomes, the traditional indications for VPT particularly when the pulp was exposed were limited to the treatment of immature teeth with incomplete root formation. Over the last 20 years, the advent of regenerative endodontics and the promotion of biologically based therapies aimed at reducing intervention have reinvigorated VPT with new waves of basic science and clinical research indicating a role for VPT not only in mature cariously affected teeth, but also in teeth with signs and symptoms indicative of irreversible pulpitis. Driven by new materials such as hydraulic calcium silicate cements, a better understanding of pulpal immunity and biology as well and improved tissue handling, VPT has been at the forefront of treatment recommendations made by global Cariology and Endodontic organizations. Care must be exercised, however, as key gaps in scientific knowledge remain alongside severe limitations in educational dissemination amongst dentists. Although research has highlighted that carious injury to the dentine-pulp complex stimulates a wide range of responses and that the interaction between infection, inflammation and repair will eventually impact on the outcome of pulpitis, our ability to accurately and objectively diagnose the true inflammatory state of the pulp remains poor. An overreliance on symptoms leaves clinicians with subjective, crude diagnostic tools by which to inform treatment planning and decision-making, which results in large variations in the treatments offered to patients. Not only is there an urgent need to develop preoperative and intraoperative diagnostic tools, but there is also a paucity of the high-quality comparative evidence required to answer the most important questions and justify treatment options. The aim of this review was to consider the current status of VPT and to discuss the principle problems that are hindering clinical acceptance of these techniques. Potential solutions and opportunities are offered to suggest ways that VPT may become a more consistently prescribed evidenced-based treatment in dental practice.
Topics: Dental Caries; Dental Pulp Capping; Humans; Pulpitis; Pulpotomy; Root Canal Therapy; Silicates
PubMed: 35080024
DOI: 10.1111/iej.13688 -
International Endodontic Journal Mar 2023This review guidance is a work in progress because the limitations of regenerative endodontics are still being discovered. The endodontic treatments for immature... (Review)
Review
This review guidance is a work in progress because the limitations of regenerative endodontics are still being discovered. The endodontic treatments for immature permanent teeth with a necrotic pulp can vary considerably among endodontic practitioners. Whereas, regenerative endodontic treatments are growing in popularity and are creating ever more complex treatment protocols, involving revascularization and/or autologous platelet-rich plasma and scaffolds to elicit host stem cell de novo tissue formation to reestablish the vitality of immature teeth for the purpose of continuing root maturation. Despite much evolving controversy about their potential benefits, risks, prognosis, and contraindications, this review is aimed to discuss how to ensure that regenerative endodontic treatments are successful, by strictly adhering to case selection criteria, and following precise steps to accomplish and monitor the success of the treatment. A review of the endodontic literature was performed, together with practical observations of the problems and outcomes of performing regenerative endodontic treatments. Traditionally, apexification has long been the treatment of choice provided to immature teeth with a necrotic pulp. Regenerative endodontics may be provided as an alternative to apexification, if the tooth and patient meet all the case selection criteria, and if there are no contraindications. Regenerative endodontics has the unique potential advantage of being able to continue the root development in immature permanent teeth, thereby potentially saving the teeth for the lifetime of the patient. Whereas, conventional endodontic root canal treatment, Cvek partial pulpotomy, apexogenesis, and apexification, should always be provided when these treatments are more likely to benefit the patient because they can be more successful than regenerative endodontics.
Topics: Humans; Apexification; Pulpotomy; Regenerative Endodontics; Root Canal Therapy; Dental Pulp Necrosis
PubMed: 35929348
DOI: 10.1111/iej.13809 -
Australian Dental Journal Mar 2021Conservative pulp therapy is an alternative treatment option to tooth removal and root canal treatment in the management of deep caries, traumatic pulp exposures and... (Review)
Review
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.
Topics: Dental Caries; Dental Pulp; Dental Pulp Capping; Humans; Pulpitis; Pulpotomy
PubMed: 33818812
DOI: 10.1111/adj.12841 -
JPMA. the Journal of the Pakistan... Mar 2020Recent advances in the field of endodontics have greatly improved the outcome and success rate of dental materials. For last three decades, there has been great interest... (Review)
Review
Recent advances in the field of endodontics have greatly improved the outcome and success rate of dental materials. For last three decades, there has been great interest in the development of bioactive dental material with the ability to interact and induce surrounding dental tissues to promote regeneration of pulpal and periradicular tissues. As these bioactive materials are mainly based on calcium silicates, they are also referred to as Calcium Silicate materials. The first material introduced was Mineral Tri-oxide Aggregate, which, due to its favourable biological properties, gained importance initially. However, later, due to its drawbacks, liked is colouration, long setting time and difficult manipulation, several modifications were done and newer bioactive materials, such as Biodentine, BioAggregate, Endosequence, Calcium-Enriched Mixture etc., were developed. The main applications of these materials are for pulp capping (direc t/indirec t), pulpotomy, perforation repair, resorption defects, apexogenesis and as retrograde filling materials, apexification and endodontic sealers. This review discusses the various types of bioactive materials, their composition, setting mechanism, and literature evidence for current applications.
Topics: Bone Substitutes; Calcium Compounds; Calcium Hydroxide; Dental Materials; Humans; Hydroxyapatites; Regenerative Endodontics; Silicates
PubMed: 32207434
DOI: 10.5455/JPMA.16942 -
International Journal of Paediatric... Nov 2022Pulpotomy is an effective, vital pulp therapy procedure for caries-affected or traumatized primary teeth. Though its efficacy is widely accepted, the superiority of... (Review)
Review
BACKGROUND
Pulpotomy is an effective, vital pulp therapy procedure for caries-affected or traumatized primary teeth. Though its efficacy is widely accepted, the superiority of medicaments and techniques remains debatable.
AIM
The aims of this review were to compare the success rates of various pulpotomy medicaments or techniques, assess the methodological quality of reviews, and grade the level of evidence for each comparison.
DESIGN
This review followed the principles of evidence-based medicine and recommendations for the overview of systematic reviews. An a priori protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021244489). A comprehensive literature search was performed by two reviewers, and studies were selected from various databases according to predefined criteria. Two reviewers independently used a self-designed pilot-tested form to extract data from the selected studies. A quality analysis was performed using A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) and the ROBIS tool. Reporting characteristics and overlap of the primary studies were also assessed. We used modified Köhler's criteria for evaluating the quality of evidence for outcomes of included systematic reviews and meta-analyses.
RESULTS
The scrutiny of 62 full-text articles resulted in the inclusion of eight systematic reviews. The quality of four of the reviews was found to be critically low, and the overlap of primary studies in the meta-analyses was found to be high. Pulpotomy medicaments/techniques, except calcium hydroxide, had success rates of more than 80% for all domains and time periods. Most of the comparisons revealed no differences in the clinical, radiographic, or overall success rates. Mineral trioxide aggregate, however, was found to have better radiographic and overall success rates than calcium hydroxide at periods greater than 12 and 18 months. It also had a greater radiographic success rate than full-strength/1:5 diluted and full-strength formocresol at 24 months. Formocresol was found to have better overall success rates than calcium hydroxide at all time periods and better radiographic success rates at 12 months. Only 12 of the 63 comparisons had suggestive or weak evidence, whereas all others had either negligible evidence or insufficient data.
CONCLUSIONS
The pulpotomy medicaments/techniques, except calcium hydroxide, showed success rates of more than 80%, whereas most comparisons revealed no differences. Mineral trioxide aggregate, however, was found to be better than calcium hydroxide and formocresol in several respects. This study highlights the lack of evidence regarding the choice of pulpotomy agents for the treatment of caries-affected primary teeth and elucidates the domains that require primary studies in the future.
Topics: Calcium Hydroxide; Dental Caries; Formocresols; Humans; Pulpotomy; Systematic Reviews as Topic; Tooth, Deciduous
PubMed: 35271753
DOI: 10.1111/ipd.12963 -
Journal of Endodontics Sep 2020A sound and vital pulp is an essential prerequisite for long-term tooth survival and preservation. However, current endodontic treatment concepts are based on the... (Review)
Review
INTRODUCTION
A sound and vital pulp is an essential prerequisite for long-term tooth survival and preservation. However, current endodontic treatment concepts are based on the removal of inflamed or necrotic pulp tissue and the replacement by a synthetic biomaterial. Recently, total or partial pulp regeneration has been proposed as an alternative treatment concept. The aim of this review was to evaluate the current options of pulp treatment and regenerative approaches, both for immature and mature teeth, in a clinical context.
METHODS
Clinical success rates of classic treatment options such as pulpotomy or root canal filling after pulpectomy or the removal of necrotic tissue are compared with recent reports on regenerative approaches like revitalization or partial and total pulp regeneration.
RESULTS
Revitalization in immature teeth with pulp necrosis is an additional treatment option besides placing an apical plug, leading to clinically acceptable outcomes, although with low predictability regarding the completion of root formation. Coronal regeneration of the amputated pulp in immature teeth constitutes a promising scientific approach, but data from clinical studies are missing. Mature teeth display a reduced potential for regeneration. Regenerative procedures using cell transplantation or cell homing are mainly in the experimental phase with only 2 clinical studies on cell transplantation. In parallel to the further development of regenerative therapies, the classification of pulp diseases should be revised, and the diagnostic tools need improvement.
CONCLUSIONS
The rethinking of current concepts for biology-based treatments and improved diagnostic concepts might postpone the point of root canal filling depending on the clinical situation.
Topics: Dental Pulp; Dental Pulp Necrosis; Humans; Pulpotomy; Regeneration; Root Canal Therapy
PubMed: 32950188
DOI: 10.1016/j.joen.2020.06.037