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Ashwaq Hussain Hakami et al, 2020;4(3):560–566.

International Journal of Medicine in Developing Countries

Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review

Ashwaq Hussain Hakami1*, Azhar Ibrahim Alobaysi2, Alanoud Yousef Almazyad2, Noor Atef Al Aswad1

Correspondence to: Ashwaq Hussain Hakami

*Dammam Dental Centre, Ministry of Health, Dammam, Saudi Arabia.

Email: dr_Ashwagi [at] hotmail.com

Full list of author information is available at the end of the article.

Received: 01 January 2020 | Accepted: 13 January 2020


ABSTRACT

A pulpotomy is currently considered an increasingly used approach to treat teeth with incomplete roots. Extirpating pulpal tissue is deemed to be expensive and time-consuming when used for permanent teeth in addition to its technical difficulties. Yet data on the use of pulpotomy in permanent teeth is still unclear. This study aims at examining the medical literature to evaluate the success of pulpotomy in permanent mature teeth with irreversible pulpitis. The literature was reviewed through Medline, PubMed, Embase, and Ovid database in the duration between 2009 and 2019. Searching terms included were a combination of “pulpotomy” AND “permanent teeth” AND “irreversible pulpitis.” Following this, results were filtered to include only original research articles investigating the use of pulpotomy to treat permanent teeth with irreversible pulpitis. Selected trials mentioned the type of teeth and type of performed pulpotomy. A total of 714 articles were retrieved. Following the exclusion of items on animals and including only trials on humans, 52 articles appeared. A total of eight articles were identified as eligible, covering a total of 1,547 patients undergoing pulpotomy. All the studies were prospective. Pulpotomy procedure was found a promising treatment for teeth with permanent pulpitis, especially molar teeth. The procedure proved to be more successful, cost-effective, and time-saving compared to traditional therapy.


Keywords:

Pulpotomy, permanent teeth, irreversible pulpitis, treatment.


Introduction

All restorative techniques aim at keeping the dental pulp viable as much as possible [1]. Recently, minimally invasive procedures such as pulpotomy are increasingly used, especially with permanent teeth having carious exposure [2]. Pulpotomy procedure includes removal of the coronal pulp with inflammation, which is under the exposure. This is followed by inserting a particular material in addition to a restoration. The purpose of adding restoration is to form an enclosed cover [3]. The severity of pulp inflammation is usually evaluated through the patient's symptoms [4]. Mild symptoms can indicate the presence of less severe pulpitis that can be reversible [5]. However, extensive symptoms accompanied by carious exposure of the pulp are usually an indication of irreversible pulpitis [6]. In this case, root canal treatment is commonly required [7]. Previous studies demonstrated that in the case of permanent teeth, carious exposure of pulps could be renewed [8]. Therefore, vital pulp treatment can be used in other conditions than asymptomatic teeth. Additionally, extensive pain before the procedure is not usually a sign for non-repairable pulp. Moreover, carious pulp exposure can sometimes be reversed [9]. Though in these conditions, a pulpotomy is crucial, and pulp capping will not be applicable. Although the most significant complication to manage in this case is bleeding control, the success of the procedure to guaranteed [10]. Therefore, this systematic review aims to examine the literature for the factors influencing the success of pulpotomy as a treatment strategy for irreversible pulpitis in permanent teeth.


Data Search

This systematic review of the literature was performed in compliance with the PRISMA checklist recommendations for systematic review and meta-analysis [11]. This systematic review was carried out through searching electronic databases to include eligible trials till October 2019 in four databases, such as Medline, Pubmed, Ovid, and Embase. Searching terms included “pulpotomy” AND “permanent teeth” AND “irreversible pulpitis.” All the titles, as well as abstracts that appeared from this search, were reviewed thoroughly to prevent missing any eligible articles. The results were then refined to include only original research articles investigating the factors influencing the success of pulpotomy procedure for the treatment of irreversible pulpitis in permanent teeth. Moreover, the selected trials mentioned the type of diseased teeth and the type of performed pulpotomy procedure. Additionally, all study designs from different countries were included. Only trials that are published in the English language were classified as related articles, which can be further evaluated in the second step. After this stage, the inclusion criteria to select the studies that will be considered in the systematic review were determined. Abstracts were examined manually to choose the appropriate abstracts to be considered. The inclusion criteria were mentioning enough data on the type of teeth under investigation and the type of pulpotomy procedure. Moreover, only trials recruiting adult participants were included. Furthermore, references of selected trials were evaluated to identify any related articles. Finally, the required data sets were gathered from the final record of eligible articles and summarized. Articles were excluded in case of in vitro or animal involvement, overlapped or incomplete data, and unavailability of a full-text article or inappropriate study design. Full details on the search strategy are shown in Figure 1.


Data Review and Analysis

The first step included a preliminary review, and a specially designed excel sheet was used for data extraction. Selected data from eligible studies were then revised through the excel sheet. Any articles that were published by one research group that investigate similar variables were reviewed for any possible duplication. Cochrane, a quality assessment tool, was also used to evaluate the quality of the included clinical studies [12]. Data were then statistically described in terms of frequencies (number of cases) and valid percentages for categorical variables. Mean, standard deviations, medians, and interquartile ratios were used to describe the numerical variable. All statistical calculations were performed by IBM SPSS (Statistical Package for the Social Science; IBM Corp, Armonk, NY) release 21 for Microsoft Windows. Before conducting any study-related procedures, institutional approval was obtained. There was no need to get consent form as the study is not involving any interventions on patients.


Results

After searching the abstracts and checking for the eligibility criteria in identified potential abstracts, a total of eight articles were considered as eligible to be included in the present systematic review that was published between 2009 and 2019, covering a total of 1,574 patients with irreversible pulpitis, requiring pulpotomy. Out of the eight studies, six studies [1114,17,18] had a prospective design, whereas two studies [15,16] had been prospective and multi-center studies. Additionally, all the studies [1118] included permanent molar teeth; however, one study [17] included first, second, and third molar teeth. Furthermore, two studies [13,14] included permanent molar teeth with carious exposure.

Turning to the type of pulpotomy, one study included four different types of vital pulp therapy [11], such as indirect pulp capping, miniature pulpotomy, direct pulp capping, and full pulpotomy. Furthermore, one study used mineral trioxide aggregate pulpotomy only [12], whereas five studies [11,13,15,16,17] used calcium-enriched mixture pulpotomy, and one study used both biomaterials [18]. According to extracted results, all the trials considered the evaluation of pulpotomy procedure in management or irreversible pulpitis in permanent teeth. The included trials are discussed in detail in Table 1.


Discussion

Some treatment strategies can be used for irreversible pulpitis with carious exposure [8]. The strategy of choice is selected based on different patient and teeth factors. These factors include age, teeth status (primary or permanent), the presence or absence of carious exposure, and salivary contamination. A pulpotomy is currently a widely used technique to treat this type of pulpitis [7,9]. The present review investigated the outcome of pulpotomy as an indication for irreversible pulpitis in permanent teeth. Through reviewing the medical literature in the past decade, it is revealed that pulpotomy is a minimally invasive strategy that is cost-effective and has better clinical as well as radiological outcomes compared to other conventional methods [1118]. Pulpotomy performed on permanent teeth for irreversible pulpitis has been evaluated from different perspectives. All pulpotomy procedures were described as “successful”' in the past 10 years with an overall success rate of more than 90% [1118]. Additionally, the outcomes of pulpotomy procedures have been evaluated on a long-term basis. Asgary et al. [11] have assessed the results of four different VPT after 3 and 12 months of duration. Asgary et al. [11] revealed a high success rate in different types of VPT, including direct and indirect pulp capping, as well as miniature and full pulpotomy procedures. Moreover, the outcome was not linked to the type or location of pulp exposure [11]. Furthermore, Ashgary et al. [11] showed that the presence of periapical lesion did not correlate to the outcomes of the procedure. Ashgary et al. [11] included both symptomatic and asymptomatic periapical lesions, where 49.3% of patients undergoing full pulpotomy had a periapical lesion. However, in Ashgary et al. study [11], the difference in outcomes of the procedure (radiographic outcomes, percussion test, and pain relief) was statistically non-significant different in the presence or absence of periapical lesions, which highlights the importance of recruiting larger sample size in future studies, to detect any significant differences if present.

Figure 1. Search strategy

Furthermore, Qudeimat et al. [12] evaluated the outcome of pulpotomy up to 73.6 months. Similarly, Qudeimat et al. [12] described the procedure as successful in all included cases; however, the biomaterial used in Asgary et al. [11] was a calcium-enriched mixture cement, whereas Qudeimat et al. [12] used mineral trioxide aggregate. Taha et al. [13] also evaluated the outcomes of pulpotomy over two years; however, Taha et al. [13] compared the use of mineral trioxide aggregate to the use of calcium-enriched mixture cement. Taha et al. [13] demonstrated that the outcomes of mineral trioxide aggregate were better than calcium-enriched mixture cement on a long-term basis. These findings were also supported by Asgary et al. [18]; however, the difference between the two materials failed to reach statistical significance. Furthermore, outcomes of pulpotomy were also compared to traditional root canal therapy. Dong et al. [14] showed that pulpotomy had a higher success rate compared to root canal therapy, yet it failed to reach statistical significance. In spite of this, Dong et al. [14] recommended pulpotomy over root canal therapy as a less invasive and destructive to teeth. Similarly, Asgary et al. [15] recommended vital pulp therapy as an alternative to root canal therapy using calcium-enriched mixture cement after a study with a follow-up duration of five years. Furthermore, Asgary et al. [15] could not find a relationship between the presence of a periapical lesion and the outcomes of pulpotomy procedure using calcium-enriched mixture [15]. Furthermore, in another study, Asgary et al. [16] showed another advantage for VPT over root canal therapy, which is the cost-effectiveness of the technique. Additionally, Ashgary et al. [16] included patients with periapical lesions who undergone a pulpotomy procedure, which showed a lower success rate compared to patients who did not have periapical lesions with a reduction in the success rate of 12% to 18% [16]. The favorable clinical outcomes were also supported by Asgary et al. [17,18], either on using mineral trioxide aggregate or calcium-enriched mixture cement, which were a non-significant difference in both clinical and radiological outcomes.

Table 1. The studies included in the systematic review

Author(s) Year Study design Sample size Type of Teeth Type of pulpotomy Objective Result
Asgary et al. [11] 2018 Prospective 302 mature permanent molars with signs of irreversible pulpitis and apicalperiodontitis Four types of Vital pulp therapy (VPT) To evaluate the the clinical and radiological outcome of four VPTs (indirect pulp capping [IPC], direct pulp capping [DPC], miniature pulpotomy [MP], and full pulpotomy [FP]) using calcium-enriched mixture cement The 3- and 12-month success rates of the VPT strategies were similar to IPC, DPC, MP, and FP. The four types of VPTs were associated with favorable clinical and radiological outcomes. The pulpal and periapical status, pulpal exposure type/location were not correlated to treatment outcomes.
Qudeimat et al. [12] 2017 Prospective 16 Permanent molars Mineral trioxide aggregate pulpotomy To investigate the clinical and radiographic success rates of pulpotomy in permanent molars with clinical signs and symptoms of permanent pulpitis using mineral trioxide aggregate (MTA). The follow-up examination period ranged from 18.9 to 73.6 months. All pulpotomy procedures were considered successful at the end of the follow-up period. Radiographically, a hard tissue barrier was noticed in 13 (57%) teeth. MTA was associated with high clinical and radiographic success as a pulpotomy agent in mature teeth with clinical signs and symptoms of permanent pulpitis.
Taha et al. [13] 2017 Prospective 50 Permanent
molar teeth with carious exposures
Partial pulpotomy To assess the success of partial pulpotomy using (MTA) compared with calcium hydroxide (CH) in permanent molars with carious exposure. MTA partial pulpotomy sustained an excellent success rate over the 2-year follow-up in permanent adult teeth clinically diagnosed with irreversible pulpitis. More than half of the CH cases failed within 2 years.
Dong et al. [14] 2017 Prospective 62 Permanent teeth with carious exposure pulpotomy To observe the clinical effect of pulpotomy for permanent teeth with carious exposure and with closed apices After 1 year, the success rate of pulpotomy was 93.75%, and the success rate of root canal therapy was 93.10%. There was no significant difference between pulpotomy and root canal therapy (P=0.665). The advantages of pulpotomy are less invasive and less destructive to teeth. It is a successful management strategy for pulps with carious exposure in mature permanent teeth.
Asgary et al. [15] 2015 prospective, non-inferiority multi-center
randomized
271 Permanent molar teeth vital pulp therapy with calcium-enriched mixture cement (CEM) To evaluate the long-term (5-year) outcomes as well as the effects of age, gender, and the presence of a preoperative periapical lesion on the findings. As an alternative for root canal therapy, VPT/CEM can be regarded as a valid treatment for vital mature permanent molars diagnosed with irreversible pulpitis.
Asgary et al. [16] 2014 Prospective, multi-center
non-inferiority
23 Permanent molar teeth Vital pulp therapy with calcium-enriched mixture cement (VPT/CEM) To evaluate 2-year clinical and radiographic treatment outcomes in (VPT/CEM) compared to root canal therapy in addition to the evaluation of cost-effectiveness Clinical success rates in the two study groups were equal (98.19%); however, radiographic success rates were 79.5% and 86.7% in RCT and VPT/CEM groups, respectively, with no statistical difference (P=0.053). The treatment period mean was approximately three times greater in the RCT than in the VPT/CEM group (94.07 vs. 31.09 min; P<0.001).RCT had a higher cost compared with PVT. VPT/CEM reduced the time and cost spent. When considering clinical as well as cost-effectiveness of VPT/CEM, this treatment option is not only non-inferior but also superior to RCT in mature permanent molar teeth with established irreversible pulpitis.
Asgary et al. [17] 2013 Prospective 407 first molar, the second molar, third molar teeth vital pulp therapy with calcium-enriched mixture cement (VPT/CEM) Assessment of intermediate- and long-term treatment outcomes of the new treatment is also non-inferior compared to root canal therapy, Favorable clinical success rates in the two study groups did not show the statistical difference; Yet, the radiographic success rate in the VPT/CEM was significantly higher than the RCT group at the two follow-ups (P<0.001). Treatment outcomes of VPT/CEM may be superior to root canal therapy in mature molars with irreversible pulpitis. The performance of CEM cement may assist in the shift toward more biologic treatments.
Asgary et al. [18] 2013 Prospective 413 Permanent molars with irreversible pulpitis calcium-enriched mixture (CEM) cement or mineral trioxide aggregate (MTA). to compare the postoperative pain experience as well as clinical and radiological outcomes of pulpotomy in permanent molars with irreversible pulpitis using (CEM) or (MTA). The clinical and radiological success rates for MTA at 12-month follow-up were 98% and 95%, respectively; and 97% and 92% for CEM, respectively. There were no significant differences in clinical (p = 0.7) and radiographic (p = 0.4) success rates between the two groups. Excellent treatment outcomes occurred in molar teeth with irreversible pulpitis undergoing pulpotomy with MTA and CEM.

However, most of the included studies were performed in one center, which may decrease the validity of outcomes. Furthermore, the sample size is considered small with a total sample size of 1,547 patients. Most importantly, through all the included studies, only three studies [11,15,16] mentioned the proportions of present and absent periapical lesions and investigated the outcomes in both cases, whereas the remaining studies [1214,17,18] did not mention the periapical lesion status. Moreover, in the studies subgrouping the patients based on the presence and absence of periapical lesion, the outcome did not vary significantly, in spite of the lower success rates in the presence of a periapical lesion, which could be attributed to the small sample size in both groups. These limitations should be considered in future studies. Finally, to our knowledge, this is considered as the first systematic review to evaluate the outcome of pulpotomy in the treatment of irreversible pulpitis or permanent teeth.


Conclusion

Pulpotomy procedure showed to be a promising strategy for the management of irreversible pulpitis in different age groups, especially for the treatment of molar teeth. The procedure proved to be more successful, cost-effective, and time-saving compared to traditional root canal therapy. Further studies are required to evaluate the total healthcare cost reduction in pulpotomy compared to root canal therapy in addition to comparing the different biomaterials available.


Disclosure Statement

The authors have nothing to disclose.


Conflict of interest

Not applicable.


Funding

None.


Consent for publication

Not Applicable.


Ethical approval

Not applicable.


Author details

Ashwaq Hussain Hakami1, Azhar Ibrahim Alobaysi2, Alanoud Yousef Almazyad2, Noor Atef Al Aswad1

  1. General Practitioner, Dammam Dental Centre, Ministry of Health, Dammam, Saudi Arabia
  2. Dental intern, Mustaqbal University, Buraydah, Saudi Arabia

References

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How to Cite this Article
Pubmed Style

Hakami AH, Alobaysi AI, Almazyad AY, Aswad NAA. Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review. IJMDC. 2020; 4(3): 560-566. doi:10.24911/IJMDC.51-1577895567


Web Style

Hakami AH, Alobaysi AI, Almazyad AY, Aswad NAA. Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review. http://www.ijmdc.com/?mno=80245 [Access: March 29, 2020]. doi:10.24911/IJMDC.51-1577895567


AMA (American Medical Association) Style

Hakami AH, Alobaysi AI, Almazyad AY, Aswad NAA. Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review. IJMDC. 2020; 4(3): 560-566. doi:10.24911/IJMDC.51-1577895567



Vancouver/ICMJE Style

Hakami AH, Alobaysi AI, Almazyad AY, Aswad NAA. Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review. IJMDC. (2020), [cited March 29, 2020]; 4(3): 560-566. doi:10.24911/IJMDC.51-1577895567



Harvard Style

Hakami, A. H., Alobaysi, . A. I., Almazyad, . A. Y. & Aswad, . N. A. A. (2020) Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review. IJMDC, 4 (3), 560-566. doi:10.24911/IJMDC.51-1577895567



Turabian Style

Hakami, Ashwaq Hussain, Azhar Ibrahim Alobaysi, Alanoud Yousef Almazyad, and Noor Atef Al Aswad. 2020. Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review. International Journal of Medicine in Developing Countries, 4 (3), 560-566. doi:10.24911/IJMDC.51-1577895567



Chicago Style

Hakami, Ashwaq Hussain, Azhar Ibrahim Alobaysi, Alanoud Yousef Almazyad, and Noor Atef Al Aswad. "Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review." International Journal of Medicine in Developing Countries 4 (2020), 560-566. doi:10.24911/IJMDC.51-1577895567



MLA (The Modern Language Association) Style

Hakami, Ashwaq Hussain, Azhar Ibrahim Alobaysi, Alanoud Yousef Almazyad, and Noor Atef Al Aswad. "Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review." International Journal of Medicine in Developing Countries 4.3 (2020), 560-566. Print. doi:10.24911/IJMDC.51-1577895567



APA (American Psychological Association) Style

Hakami, A. H., Alobaysi, . A. I., Almazyad, . A. Y. & Aswad, . N. A. A. (2020) Pulpotomy success in permanent mature teeth with irreversible pulpitis: a systematic review. International Journal of Medicine in Developing Countries, 4 (3), 560-566. doi:10.24911/IJMDC.51-1577895567