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British Dental Journal Dec 2022Emerging clinical and histologic evidence is challenging the long-established dogma that root canal treatment (RCTx) is the only therapeutic option for preservation of... (Review)
Review
Emerging clinical and histologic evidence is challenging the long-established dogma that root canal treatment (RCTx) is the only therapeutic option for preservation of vital mature permanent teeth diagnosed with irreversible pulpitis or carious pulp exposure. Vital pulp therapy procedures like pulpotomy are not only technically simpler and more economical, but also afford patients a host of other benefits over conventional RCTx. This narrative review provides an update on the contemporary understanding of pulp pathophysiology and defence mechanisms, the proposed new diagnostic terminologies for pulpal inflammation, and how the biological characteristics of hydrophilic calcium silicate cements have enabled consistent successful outcomes for pulpotomy-treated mature teeth. The paper also details the evidence base from clinical trials and systematic reviews conducted over the past decade and outlines the practical treatment considerations for pulpotomy in mature permanent teeth.
Topics: Humans; Pulpotomy; Calcium Compounds; Silicates; Dentition, Permanent; Pulpitis; Root Canal Therapy; Dental Pulp; Treatment Outcome
PubMed: 36526777
DOI: 10.1038/s41415-022-5316-1 -
The Japanese Dental Science Review Nov 2019Dental pulp is a connective tissue and has functions that include initiative, formative, protective, nutritive, and reparative activities. However, it has relatively low... (Review)
Review
Dental pulp is a connective tissue and has functions that include initiative, formative, protective, nutritive, and reparative activities. However, it has relatively low compliance, because it is enclosed in hard tissue. Its low compliance against damage, such as dental caries, results in the frequent removal of dental pulp during endodontic therapy. Loss of dental pulp frequently leads to fragility of the tooth, and eventually, a deterioration in the patient's quality of life. With the development of biomaterials such as bioceramics and advances in pulp biology such as the identification of dental pulp stem cells, novel ideas for the preservation of dental pulp, the regenerative therapy of dental pulp, and new biomaterials for direct pulp capping have now been proposed. Therapies for dental pulp are classified into three categories; direct pulp capping, vital pulp amputation, and treatment for non-vital teeth. In this review, we discuss current and future treatment options in these therapies.
PubMed: 30733839
DOI: 10.1016/j.jdsr.2018.09.001 -
Journal of Dentistry Sep 2022Preservation of pulpal vitality in immature permanent teeth with deep carious lesions is essential to enable further root development and apical closure. This systematic... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
Preservation of pulpal vitality in immature permanent teeth with deep carious lesions is essential to enable further root development and apical closure. This systematic review aimed to evaluate the evidence regarding the efficacy, presented clinical and radiographic success, and bacteriological outcomes of techniques and materials used for deep caries management in vital immature permanent teeth.
DATA
Randomised controlled trials evaluating Vital Pulp Therapy (VPT) for deep caries in immature permanent posterior teeth without history of irreversible pulpitis, and a follow up period of ≥12 months were included. Study characteristics and outcomes of all included studies were summarized. Cochrane's Risk-of-bias tool 2.0 was used to assess the quality of eligible studies. Meta-analyses using a random effects model was performed.
SOURCES
Electronic databases PubMed, Medline, Embase, LILACS, CENTRAL and Cochrane Library were searched, followed by a manual search.
STUDY SELECTION
Twelve papers were included into the review. Overall success rates were 98%, 93.5%, 93.6% for direct pulp cap (DPC), indirect pulp cap (IPC) and pulpotomy (PP) respectively. Regardless of VPT technique, there were no significant differences between clinical and radiographic success rates. Completion of root development was achieved in more than 83% of the cases in all VPT techniques.
CONCLUSIONS
All treatment modalities for PP were equally efficient with high overall success rates. Biodentine showed high success rates regardless of technique. No significant differences were found in the clinical and radiographic success rates between various follow-up intervals. There are no clear conclusions regarding superiority of either VPT technique on apical closure.
CLINICAL SIGNIFICANCE
This manuscript systematically evaluates the evidence and summarises all available data on each vital pulp therapy technique and materials used in treatment of deep caries in immature permanent teeth with vital pulps. The limitations in the current scientific literature and recommendations for future research are also highlighted.
Topics: Dental Caries; Dental Caries Susceptibility; Dental Pulp Capping; Dentin; Dentition, Permanent; Humans; Pulpotomy
PubMed: 35793760
DOI: 10.1016/j.jdent.2022.104214 -
Bioengineering (Basel, Switzerland) Feb 2023The utilization of lasers has been regarded as a novel technique for the purposes of clinical use in the dental field. Recently, numerous studies have been conducted on... (Review)
Review
The utilization of lasers has been regarded as a novel technique for the purposes of clinical use in the dental field. Recently, numerous studies have been conducted on the potential applications of laser therapy in endodontics. Moreover, due to their ablation, penetrability, and disinfection capabilities, lasers have performed well with respect to endodontic treatments, including root canal treatment, vital pulp therapy (pulp capping and pulpotomy), dentinal hypersensitivity treatment, and management of dental pain related to pulp and periradicular disease. In particular, the superiorities of laser-aided pulp therapy are emphasized through condensed clinical controlled trials, and histological studies, in this review. Moreover, the ingenious use of laser applications with respect to aiding in the acceleration of root development and the extraction of foreign matters (i.e., broken files and fiber posts) in canals has quickly become the cutting-edge trend of current research. This review offers a summary and discussion of the current literature on all the aforementioned laser applications. Moreover, the characteristics of laser devices, including erbium lasers, neodymium-doped lasers, CO lasers, and diode lasers, are detailed and discussed here, providing useful references for laser application in endodontics. We also focus on the different wavelengths with respect to the lasers that are applied in endodontics. High-power lasers perform well as operative instruments; in addition, low-level lasers lead to the regulation of pulp inflammation, and the promotion of pulp healing. This narrative review provides a summary of the advanced applications of lasers in conjunction with various devices in the practice of endodontics, and aims to inspire innovative perspectives on lasers in the context of the treatment of dental diseases, especially pulp diseases, in the future.
PubMed: 36978686
DOI: 10.3390/bioengineering10030296 -
Scientific Reports Nov 2022Treatment planning is key to clinical success. Permanent teeth diagnosed with "irreversible pulpitis" have long been implied to have an irreversibly damaged dental pulp... (Meta-Analysis)
Meta-Analysis
Treatment planning is key to clinical success. Permanent teeth diagnosed with "irreversible pulpitis" have long been implied to have an irreversibly damaged dental pulp that is beyond repair and warranting root canal treatment. However, newer clinical approaches such as pulpotomy, a minimally invasive and biologically based procedure have re-emerged to manage teeth with pulpitis. The primary aim of the study was to conduct a meta-analysis to comprehensively estimate the overall success rate of pulpotomy in permanent teeth with irreversible pulpitis as a result of carious pulp exposure. The secondary aim of the study was to investigate the effect of predictors such as symptoms, root apex development (closed versus open), and type of pulp capping material on the success rate of pulpotomy. Articles were searched using PubMed, Scopus, CENTRAL, and Web of Science databases, until January 2021. Outcomes were calculated by pooling the success rates with a random effect model. Comparison between the different subgroups was conducted using the z statistic test for proportion with significance set at alpha = 0.05. A total of 1,116 records were retrieved and 11 studies were included in the quantitative analysis. The pooled success rate for pulpotomy in teeth with irreversible pulpitis was 86% [95% CI: 0.76-0.92; I = 81.9%]. Additionally, prognostic indicators of success were evaluated. Stratification of teeth based on (1) symptoms demonstrated that teeth with symptomatic and asymptomatic irreversible pulpitis demonstrated success rate of 84% and 91% respectively, with no significant difference (p = 0.18) using z-score analysis; (2) open apex teeth demonstrated a significantly greater success rate (96%) compared to teeth with closed apex (83%) (p = 0.02), and (3) pulp capping materials demonstrated that Biodentine yielded significantly better success rates compared to Mineral Trioxide Aggregate (MTA), calcium hydroxide, and Calcium Enriched Mixture (CEM.) Collectively, this is the first meta-analytical study to determine the clinical outcome of pulpotomy for carious teeth with irreversible pulpitis and it's predictors for success. Moreover, we identify the stage of root development and type of biomaterial as predictors for success of pulpotomy.
Topics: Humans; Pulpotomy; Pulpitis; Dentition, Permanent; Calcium Hydroxide; Root Canal Therapy
PubMed: 36385132
DOI: 10.1038/s41598-022-20918-w -
Compendium of Continuing Education in... Apr 2015Mineral trioxide aggregate (MTA) has been a revolutionary material in endodontics. Since its introduction in the 1990s several studies have demonstrated its use in... (Review)
Review
Mineral trioxide aggregate (MTA) has been a revolutionary material in endodontics. Since its introduction in the 1990s several studies have demonstrated its use in various clinical applications. MTA has been extensively studied and is currently used for perforation repairs, apexifications, regenerative procedures, apexogenesis, pulpotomies, and pulp capping. This article will review the history, composition, research findings, and clinical applications of this versatile endodontic material.
Topics: Aluminum Compounds; Calcium Compounds; Drug Combinations; Endodontics; Humans; Oxides; Root Canal Filling Materials; Silicates
PubMed: 25821936
DOI: No ID Found -
BMC Oral Health Jan 2019The objective of this clinical study was to prospectively compare the clinical and radiographic success rates of Biodentine pulpotomies versus formocresol pulpotomies in... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The objective of this clinical study was to prospectively compare the clinical and radiographic success rates of Biodentine pulpotomies versus formocresol pulpotomies in children vital primary molars.
METHODS
A randomized, split-mouth study design was used with a sample of 37 healthy children aged 4- to 8-year-old. A total of 56 pairs (112 teeth) of carious primary teeth, 1 pair per child, were selected for treatment. One tooth from each pair was randomly assigned to either the Biodentine pulpotomy group or the formocresol pulpotomy group. Children were followed-up at 3, 6 and 12 months for clinical evaluation and at 6 and 12 months for radiographic evaluation. Data were collected, tabulated and analyzed using Fisher exact and McNemar tests. The level of significance was set at P < 0.05.
RESULTS
At 12 months, the clinical success rates of both Biodentine and formocresol groups were 100%, while the radiographic success rates for Biodentine and formocresol groups were 100% and 98.1%, respectively. There was no statistically significant difference between both groups (P=1). The only observed radiographic failure was furcal radiolucency in the formocresol group at 12-month interval. Pulp canal obliteration was radiographically observed in 10/56 (17.9%) and 7/56 (12.5%) cases in the Biodentine and formocresol groups, respectively.
CONCLUSIONS
Both Biodentine and formocresol pulpotomy techniques demonstrated favorable clinical and radiographic outcomes over a 12-month period without any significant difference.
TRIAL REGISTRATION
Registered on NCT03779698 . Date of Registration: 18 December 2018.
Topics: Aluminum Compounds; Calcium Compounds; Child; Child, Preschool; Cross-Sectional Studies; Crowns; Double-Blind Method; Formocresols; Humans; Molar; Nepal; Prospective Studies; Pulpotomy; Silicates; Tooth, Deciduous; Treatment Outcome
PubMed: 30612569
DOI: 10.1186/s12903-018-0702-4 -
Clinical Oral Investigations Mar 2022The concept of minimally invasive endodontics recommends less-invasive vital pulp therapy (VPT) modalities over more aggressive traditional endodontic approaches in... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
The concept of minimally invasive endodontics recommends less-invasive vital pulp therapy (VPT) modalities over more aggressive traditional endodontic approaches in mature permanent teeth with carious pulp exposure, including irreversible pulpitis (IP) cases. Consequently, VPT needs to be compared with root canal therapy (RCT) in terms of treatment outcomes. This randomized clinical trial compares the results of full pulpotomy using two calcium-silicate cements, i.e., mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement, with RCT in mature permanent teeth.
MATERIALS AND METHODS
A total of 157 carious pulp exposure cases in two academic centers with/without established IP were selected/included/randomly appointed to three study arms; (i) RCT (n = 51) as the reference treatment, (ii) pulpotomy with ProRoot MTA (PMTA; n = 55), and (iii) pulpotomy with CEM cement (PCEM; n = 51) as two alternative VPT treatments. Two-year clinical/radiographic results were the outcomes of interest. Data were statistically analyzed through the analysis of variance, chi-square, Fisher exact test, and Kruskal-Wallis.
RESULTS
At 2-year recall, 147 teeth were examined (6.4% dropout). All molars, except for one, were clinically functional/symptom-free, and there was no statistical difference between the three study arms (p = 0.653). The radiographic success rates in RCT, PMTA, and PCEM arms were 98%, 100%, and 97.9%, respectively, without statistically significant differences (p = 0.544).
CONCLUSION
In the management of mature permanent teeth with/without established IP, all experimental groups exhibited equivalent/comparable results.
CLINICAL RELEVANCE
Simple VPT using MTA/CEM can be suggested/recommended as a viable advantageous alternative to RCT for the management of carious pulp exposures with/without sign/symptoms of IP.
Topics: Aluminum Compounds; Biocompatible Materials; Calcium Compounds; Drug Combinations; Humans; Molar; Oxides; Pulpitis; Pulpotomy; Root Canal Therapy; Silicates
PubMed: 34854987
DOI: 10.1007/s00784-021-04310-y -
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 -
Healthcare (Basel, Switzerland) Jun 2021Vital pulp therapy, including direct pulp capping and partial and full pulpotomy, is primarily indicated for immature or mature permanent teeth with reversible pulpitis....
Vital pulp therapy, including direct pulp capping and partial and full pulpotomy, is primarily indicated for immature or mature permanent teeth with reversible pulpitis. Mature permanent teeth with irreversible pulpitis are frequently treated with root canal therapy. This report presents two cases of full pulpotomy using Biodentine in mature permanent teeth with irreversible pulpitis and acute apical periodontitis. The periapical radiograph illustrated a deep carious lesion extended to the pulp with apical radiolucency lesion or widened periodontal ligament space. Full pulpotomy with a tricalcium silicate-based cement was chosen as the definitive treatment. After decayed tissue excavation under a rubber dam, the exposed pulp tissue was amputated to the level of the canal orifice with a new sterile bur. Biodentine was applied as the pulp capping agent after hemostasis was obtained and for temporary restoration. The clinical signs disappeared quickly after the treatment. After one month, the coronal part of the temporary restoration was removed, and a composite resin was placed over the capping agent as a final restoration. At two-year follow-ups, the teeth were asymptomatic. Radiographs showed healing of the periapical lesion and periodontal ligament. Biodentine full pulpotomy of mature permanent teeth with irreversible pulpitis and apical periodontitis can be an alternative option to root canal therapy.
PubMed: 34204620
DOI: 10.3390/healthcare9060720