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Vital Pulp Treatment Modalities: Pulpotomy – Partial and Complete
Roberto Careddu1, Mark Lappin2, Henry F. Duncan1, and Ikhlas A. El‐Karim2
1 Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Dublin, Ireland
2 Department of Restorative Dentistry, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, Northern Ireland, UK
Introduction
The dental pulp is a highly vascular and innervated connective tissue that forms an interconnected structure with dentine known as dentine‐pulp complex. Microbial insult is the main cause of pulpal injury, but other irritants including trauma, chemicals and iatrogenic damage caused by overheating, can lead to pulpitis (1). The pulp responds to injurious stimuli by mounting a protective inflammatory response characterized by the release of inflammatory mediators to control the infection. The presence of a mixed bacterial biofilm that becomes increasingly anaerobic as the infection becomes established causes a cascade of inflammatory reactions that are evident long before bacteria come into direct contact with the pulp tissue (2). Bacteria infiltration of the pulp stimulates first a localized acute response that, if not treated, assumes chronic features and eventually culminates in necrosis (3). However, if the irritant is removed and the tooth properly restored, this protective inflammatory response can be modulated to initiate healing and a repair process with subsequent tertiary dentine formation that forms a protective barrier to seal the pulp from further damage (4, 5).
The intensity and duration of the stimuli play a role in the pulp response to injury. For instance, low‐grade traumatic or microbial irritation of the dental pulp will lead to activation of primary odontoblasts and upregulation of secretory activity in the form of reactionary dentine formation; however, severe injury associated with deep caries and bacterial invasion of the pulp usually results in death of odontoblasts. However, if an environment inductive of healing is created, these can be replaced with odontoblast‐like cells to produce reparative dentine (4). Unlike deep caries, severe injury caused by trauma, as in luxation or avulsion injuries, is often accompanied by the distribution of the blood of the tooth, leading to irreversible damage and ultimately pulpal necrosis. A traumatic event such as a complicated coronal fracture can expose healthy pulp to microorganisms and lead to pulpitis and localized infection and a protective and reparative inflammatory response, as described above, provided the blood supply to the tooth remains intact.
The ability of the dental pulp to heal following injury is well documented in studies that laid the scientific foundation for pulp preservation therapies (2, 4, 6). The need to maintain pulp vitality is not new, with pulp capping procedures documented as early as 1756 with many different materials being advocated as potential pulp capping agents (7). Over the years, pulpotomy and pulp capping procedures have been carried out empirically by clinicians with little consensus on protocols and indications (8). As a result of unpredictable outcomes, allied to poor clinical technique, suggestions were made to limit vital pulp treatment (VPT) to deciduous teeth or immature permanent teeth (9). An exception was made for teeth with an iatrogenic or ‘sterile exposure’ in which a traumatic event exposed the pulp in the absence of caries, and the tooth was treated immediately after. Specifically, the presence of symptomatology or bacterial infection was considered a negative prognostic factor that required root canal treatment (9).
In recent years, advances in pulp biology have improved our understanding of the healing and regenerative capabilities of dental pulp and the advent of the hydraulic calcium silicate cement, has led to a change of scope of VPT with a shift from only treatment for deciduous and immature teeth to a possible viable alternative for root canal treatment for permanent teeth. An emerging body of evidence suggests a success rate for pulpotomy similar to that of root canal treatment (RCT) in teeth with symptomatic irreversible pulpitis (10, 11). Consequently, both the European Society of Endodontology (ESE) and the American Association of Endodontists (AAE) introduced guidance encouraging preserving the vitality of the pulp and recognizing pulpotomy as an option that should be considered in the decision‐making process for the treatment of deep carious lesions or pulp exposures in mature permanent teeth (12, 13).
Definitions
There are a range of VPTs available; however, whenever the pulp is exposed directly due to bacterial infiltration or severely traumatized, the most appropriate management is to remove part of the affected pulp with a partial or complete pulpotomy. The ESE position statement on the management of deep caries and exposed pulp (13) defined pulpotomies as follows:
- A partial pulpotomy is a clinical procedure in which a small portion of the coronal pulp is in direct contact with the affected area after pulp exposure is removed, followed by the application of a biomaterial directly onto the remaining pulp tissue prior to placement of a permanent restoration.
- A full (or complete) pulpotomy involves the complete removal of the coronal pulp and the application of a biomaterial directly onto the pulp tissue at the level of the root canal orifice(s), prior to placement of a permanent restoration.
Indications
Definitive Treatment for Asymptomatic Cariously Exposed Pulp
In teeth with moderate or deep caries lesions (lesion extend to the inner quarter of dentine) but with zone of hard or firm dentine between the caries lesion and the pulp, removal of caries using selective caries removal (14, 15) and placement of a restoration is sufficient to reverse pulp inflammation. Selective caries removal reduces the risk of pulp exposure and therefore recommended by the ESE for the management of deep caries (13). If, however, non‐selective caries removal approach is used and the pulp is exposed, direct pulp capping or pulpotomy under enhanced disinfection protocols and use of a hydraulic calcium silicate cement is recommended (13). A high success rate for direct pulp capping of the cariously exposed pulp with symptoms of reversible pulpitis using Mineral Trioxide Aggregate (MTA) or Biodentine has been reported (16). Similarly, more than 90% success rate for full coronal pulpotomy as definitive treatment for cariously exposed pulps with signs and symptoms of reversible pulpitis was reported in a systematic review (17). Compared with root canal treatment, complete pulpotomy, was also shown to have the same success rate for teeth with cariously exposed pulp and symptoms of reversible pulpitis (18).
Partial pulpotomy is also a successful alternative for the cariously exposed pulp (19). In this systematic review, the meta‐analysis indicated a 92% (CI: 0.83–0.97) two‐year success rate for partial pulpotomy; however, the preoperative pulpal status was identified as a significant factor, with studies including teeth with the diagnosis of irreversible pulpitis displaying significantly lower results.
Unlike the situation of deep caries mentioned above, caries can also penetrate the entire thickness of the dentine in what is defined as extremely deep caries (5). In this scenario, pulp exposure is inevitable with invasion of pulp space by pathogenic bacteria and therefore, selective caries removal and placement of restoration is not appropriate even if the tooth presents with clinical symptoms suggestive of reversible pulpitis (5). This is an example of the limitations of our exiting pulpal diagnostic methods where there is clear lack of correlation between symptoms and the pathological status of the cariously exposed pulp. The AAE classification defined such pathology as chronic irreversible pulpitis (20), and therefore root canal treatment was recommended. Studies, however, reporting specifically on the depth of caries and in particular that used the recently introduced terminology of extremely deep caries (5) are still lacking and urgently warranted.
In summary, teeth with deep caries, extending to the inner third of dentine with clear radiographic evidence of dentine and absence of symptoms indicating more than reversible pulpitis, selective caries removal to avoid pulp exposure is recommended (13). If in such teeth asymptomatic exposure occurs during caries removal VPT in the form of direct pulp capping or pulpotomy is suggested. Pulpotomy is also indicated for cases with extremely deep caries where exposure is inevitable. Pulpotomy should be performed under an enhanced disinfection protocol (rubber dam and wound lavage with 2.5% sodium hypochlorite), and a hydraulic calcium silicate cement is used as pulp capping material. The decision to perform direct pulp capping or partial/complete pulpotomy depends on direct inspection and the ability to control pulpal bleeding during the operative procedure.
Definitive Treatment for Symptomatic Irreversible Pulpitis
Irreversible pulpitis (IRP) is a clinical diagnosis that indicates an inflamed pulp that is incapable of healing and for which root canal treatment is indicated (20). Accumulating evidence, however, suggests that preservation of at least part of irreversibly inflamed pulp is feasible, putting into question the terminology of irreversible damage.
Several studies including retrospective and prospective studies have shown a high success rate for partial as well as full pulpotomy as definitive treatments for teeth with signs and symptoms suggestive of IRP. In a systematic review including only studies that reported on symptomatic irreversible pulpitis, Cushley et al. showed 95% clinical and radiographic success for full pulpotomy at 12‐month which falls to 88% at three years. When compared to root canal treatment, full pulpotomy has a similar success rate in one randomized control trial, comparing the two treatments for teeth with symptoms of irreversible pulpitis (21). A recent systematic review reported no difference in postoperative pain between pulpotomy and root canal treatment in teeth with symptomatic irreversible pulpitis (22).
In another recent meta‐analysis by Ather et al. in 2022, an overall success of 86% [95% CI: 0.76–0.92]; I2 = 81.9%) for full pulpotomy for teeth with IRP was reported (23). Notably, the success was shown to be higher in teeth with asymptomatic (91%) compared to symptomatic irreversible pulpitis (84%) and the same for the open (96%) versus closed apex (83%) in permanent teeth. It should be noted here that cases of asymptomatic irreversible pulpitis are those with extremely deep caries mentioned above and, based on the outcome of this review, should be treated with pulpotomy rather than root canal treatment.
Partial pulpotomy has also been investigated as the definitive treatment for teeth with deep caries and signs and symptoms of irreversible pulpitis. Taha et al. reported a higher two‐year success rate for partial pulpotomy using MTA compared with calcium hydroxide in teeth with symptomatic IRP (24). Subsequent studies using hydraulic calcium silicate cement conformed to good outcomes for partial pulpotomy (25, 26). However, when compared to full pulpotomy, the success of partial pulpotomy was lower, but the difference was not statistically significant (25, 26). This would suggest that the two procedures could be considered as definitive treatment for teeth with symptomatic IRP. Partial pulpotomy offers the advantage of being a more conservative procedure in which much of the coronal pulp is preserved; however, the technique may be more sensitive to perform than full pulpotomy, a factor that may need to be considered during the treatment planning for such cases (13).
In summary, in permanent teeth with deep caries and signs and symptoms of IRP, full pulpotomy is suggested as an alternative to root canal treatment. Evidence from emerging studies suggested a comparable success rate for partial and complete pulpotomy for irreversible pulpitis. These procedures should be carried out under enhanced protocol, with disinfection, magnification and use of hydraulic calcium silicate cement to ensure high success.
Definitive Treatment for Traumatically Exposed Pulp
Unlike carious exposure, traumatic injuries to the dental pulp are not contaminated wounds and therefore the success of VPTs such as pulpotomy is likely to be high. Traumatic injuries often occur in children with immature or young permanent teeth (27) in which the maintenance of pulp vitality is of importance to ensure root development and to avoid subsequent complicated endodontic treatment. VPTs can therefore present a number of advances over conventional endodontic procedures for traumatized teeth. In fact, Cvek 1978 first introduced partial pulpotomy for the management of traumatized teeth. The technique involves the removal of coronal pulp tissue adjacent to a pulp exposure following coronal tooth fracture. By preserving pulpal tissue, the potential for continued root development is maintained in immature permanent teeth as well as enabling healing of the radicular pulp tissue. High success rates of between 87.5 and 100% were reported for Cvek pulpotomy, and the process can readily be applied to both mature and immature teeth. Data from a systematic review on the outcome of partial pulpotomy for traumatized permanent anterior teeth showed 89% (95% confidence interval 86–91), indicating that partial pulpotomy may be considered a reliable, definitive treatment option for asymptomatic traumatized permanent anterior teeth with exposed pulp rather than full pulpotomy (28).
A high success rate has also been reported for both partial and complete pulpotomy complicated crown fractures. An overall success range ranging from 75% to 96% was reported (29), suggesting the utility of this treatment over conventional direct pulp capping, which was shown to be associated with lower success (30). A large body of evidence demonstrated a high incidence of pulp necrosis following direct pulp capping in cases of complicated crown fractures (31, 32).
Subsequently, clinical guidelines issued by the ESE and the International Association of Dental Traumatology (IADT) currently indicate that pulp exposure in traumatized mature and immature permanent teeth should be treated by a VPT (33, 34). The ESE recommend VPT, preferably with non‐staining hydraulic calcium silicate cement as capping material, but they suggest favourable results can also be achieved with calcium hydroxide. The ESE and IADT suggest partial pulpotomy as the preferred treatment, particularly for large exposures and cases with treatment delay. Direct pulp capping was only suggested for minor exposures treated within the first hours after trauma. In case of questionable pulp healing following severe injury with concomitant luxation injury, ESE 2021 suggest root canal treatment over VPT.
In summary, in managing the traumatically exposed pulp, partial pulpotomy is recommended for large exposures and cases with treatment. Direct pulp capping is indicated for minor exposures treated within the first hours after trauma. Pulpectomy and root canal treatment are considered in cases of questionable pulp healing as in concomitant luxation injuries.
Other Indications
Pulpotomy procedures have shown promising results in the management of severely furcation‐involved molars requiring vital root resection. As an alternative to conventional endodontics, pulpotomy procedures were performed on 15 maxillary molars with class II and class II furcation defects using hydraulic calcium silicate‐based cement. Four weeks following these procedures, affected roots were resected by periodontal microsurgery (35). The results showed that the function and vitality of the treated molars were maintained in 100% of cases after a mean follow‐up period of 4.9 years. All resected teeth showed reduced probing depths, stable clinical attachment and radiographic bone levels. This offers a great advantage over root canal treatment, which has been reported to negatively impact on the survival of periodontally involved molars with complications such as root fractures been cited as leading failures in these cases (36).
Pulpotomy has traditionally been used as a temporary or emergency treatment for pain relief for teeth with symptomatic irreversible pulpitis. The procedure often offers effective pain relief similar to pulpectomy (37, 38). Pulpotomy may be preferred as it requires significantly less time and is a simple technique that effectively relieves symptoms.
In multi‐rooted teeth with partial pulp necrosis, a successful combination of root canal treatment and pulpotomy was reported (39). In these teeth, conventional root canal treatment was performed in roots with non‐vital pulp and apical periodontitis, while pulpotomy was performed in roots with vital pulp, suggesting that in advanced cases of irreversible pulpitis, VPT can still be used to preserve pulp tissue in the same tooth as necrotic tissue was removed.
Contraindications
There are general contraindications for restorative treatment that could automatically apply to pulpotomy including, poor oral hygiene, uncontrolled caries, periodontal disease, unrestorable tooth and teeth that cannot be adequately isolated. Contraindications that are procedure‐specific are not common and include the inability to control pulpal bleeding, the presence of necrotic pulp/lack of bleeding and the need to post and core restoration. Teeth exhibiting spontaneous pain, continuous uncontrollable pulp bleeding or the presence of necrotic tissue in the pulp chamber are generally not predictable candidates for partial pulpotomy (40). Traumatic dental injuries that affect the pulpal blood supply should be carefully considered as negative prognostic factor for pulpotomy and if evident would be a contraindication for VPT.
The Procedure
Microbial contamination of the pulp wound is one of the major negative prognostic factors for VPT. In the case of cariously exposed pulp, the use of an enhanced protocol to limit the contamination, maximize technical precision and improve the tissue response is recommended (5, 13). Reported variation in the success of pulp capping after carious exposure (41, 42), led to a classification of pulp exposure based on presence (class II) or absence (Class I) of bacterial contamination (43). In the case of carious exposure (class II), the classification reinforces the need for an enhanced approach, which is not as critical if the pulp is traumatically exposed (Class I). Class II exposure is usually seen in teeth with deep and extremely deep caries where bacteria contamination and severe inflammation are usually evident where VPT with partial or full pulpotomy rather than direct pulp capping is recommended (5). Here, an enhanced protocol, which uses an antiseptic technique, antibacterial lavage, magnification for careful carious tissue removal and the use of a hydraulic calcium silicate cement (HCSC), is recommended (5, 13).
Aseptic Operatory Field
Meticulously controlled isolation of the tooth is essential to ensure a high‐quality endodontic treatment in general and VPT. It is paramount to use not only a dental dam throughout all the stages of the treatment but also to maintain the operatory field as aseptic as possible by using sterile instruments and antimicrobial irrigating solutions such as sodium hypochlorite (NaOCl) (13). The isolation of several teeth may be preferred as it improves visibility and facilitates better space for instruments and direct application of the water coolant to the pulp tissue. Ligatures and inversion of the dental dam can be helpful, and liquid dam should be used to ensure a tight seal with the tooth (44) (Figure 6.1). The isolated area, including tooth/teeth and clamps, should be routinely disinfected to decrease the bacterial contamination. Different protocols have been proposed, including swabbing the area with hydrogen peroxide, followed by chlorhexidine, iodine or NaOCl (45, 46). Although, several methods have been shown to be effective in decreasing bacterial load, NaOCl decontamination appears to be effective in causing damage to bacterial DNA (47). It is fundamental to repeat the decontamination of the operatory field after the removal of old restorations and caries as this can readily contaminate areas that were previously cleaned (46) (Figure 6.2).
Figure 6.1 Isolation of several teeth allows better visibility. The rubber dam is inverted or blocked with ligatures to ensure a tight seal.
Figure 6.2 The tooth, clamp and rubber dam are decontaminated by swabbing a disinfectant‐soaked cotton pallet.
Magnification and Caries Detection
The use of magnification systems is recommended in endodontics as it improves visibility, illumination of the operative field as well as operator ergonomics. The increased vision during an enhanced class II pulp capping is useful throughout the treatment and ideally should be used throughout the entire treatment as it ensures better vision during the non‐selective caries removal, the subsequent management of exposed pulp tissue and finally verifies the placement of the restorative material (48). In general, partial pulpotomies are technically demanding procedures. As a result, practitioners without access to magnification may prefer to carry out a full coronal pulpotomy as it is easier to manipulate the pulp at the level of the orifice (13). Magnification loupes and microscopes can be efficiently used; however, the second offers better magnification and illumination albeit at greater expense. Complete and correct removal of all the carious tissue is essential after pulp exposure and is enhanced by increasing the visibility and caries detectors. Different methods are available to check the presence of remaining decay are available, from fluorescence lamps to caries detectors dye (42, 48) (Figure 6.3).
Figure 6.3 Immunofluorescence lamps can be useful in detecting the residual affected tissue after non‐selective caries removal.
Bleeding Control and Antibacterial Lavage
Inflamed dental pulp usually bleed during pulpotomy procedures, and effective control of bleeding and the avoidance of blood clot formation between the capping material and the pulp tissue is essential for successful treatment outcome. There is, however, a lack of consensus regarding how best to manage the exposed pulp and control of haemorrhage, being no exception (8, 49). Over the years, many agents have been used to arrest bleeding, including NaOCl (0.5–5, 25%), saline solution, chlorhexidine (0.2–2%), water, ethanol (75%) and anaesthetic solution (42, 48, 50–52). The ESE position statement (2019) on managing deep carious lesions recommended using either sodium hypochlorite or chlorhexidine. The rationale behind using these two agents is the ability to achieve haemostasis while disinfecting the area, which is fundamental in class II pulpotomies due to the exposure of the pulp and infection (13). The most popular lavage is NaOCl; however, there is still a need for further, well‐designed studies to assess if there is a significant improvement in the quality of treatment when sodium hypochlorite is used (53). One recent randomized control trial indicated decreased pain (54) and improved success after one year when the exposed pulp was rinsed with NaOCl rather than saline in a pulp capping study (55). The arrest of bleeding should be achieved in five minutes after gently pressing a NaOCl‐soaked sterile cotton pallet against the pulp; however, if haemostasis is not achieved during this time, further pulp removal may be necessary (5, 13) (Figure 6.4).
Figure 6.4 Bleeding control is achieved by pressing a cotton pallet soaked in NaOCl against the pulp.
Capping Materials
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