Improvements in the understanding of pulp biology have led to challenges to the established classification and new diagnostic terms and management strategies. So while the traditional approach to the management of irreversible pulpitis has been pulpectomy and root canal treatment a number of studies have examined the use of pulpectomy and demonstrated good outcomes.
The main aim of this review was to determine the success rate of complete coronal pulpotomy in carious teeth with signs and symptoms indicative of irreversible pulpitis.
Searches were conducted in the Medline/PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform ClinicalTrials.gov and Open SIGLE databases with no language restrictions. Prospective, retrospective and randomised controlled trials (RCTs) in patients with caries permanent teeth with signs and symptoms indicative of irreversible pulpitis undergoing coronal pulpotomy compares with root canal treatment controls were considered.
Three reviews independently screened and selected studies and assessed study quality. Non randomised studies were assessed using the modified Downs and Black quality assessment checklist and RCTs using the Cochrane risk of bias tool. Data was extracted by two reviewers independently. Meta-analysis was planned but not conducted because of study heterogeneity.
- 8 papers reporting 6 studies were included.
- There was 1 RCT, 4 prospective single arm studies and 1 retrospective study.
- The non-randomised studies were considered to be of fair quality, the RCT to be at high risk of bias largely because of blinding of operators (performance bias) and outcome assessors (detection bias).
- Individual studies reported high success rates for pulpotomy at 12 and 36 months with a mean clinical success rates of 97.4% at 12 months and 93.97% at 36 months.
- The single RCT showed high clinical success rate for both pulpotomy and root canal treatment at 12 month follow-up (97.6%) a well as comparable radiographic success for pulpotomy (92.2%) and root canal treatment (89%) at 12 months.
- Clinical success remained high at 24 months (98.1%) but radiographic success rate was reduced for the two interventions (86.7 and 79.5%),
- At 60 months follow-up, the success reduced further and was 71.3% for pulpotomy and 65.8% for root canal treatment.
The authors concluded: –
Within the limitations of this review, the high success rate reported for pulpotomy suggests that this procedure offers hope as an alternative to root canal treatment in teeth with a diagnosis of irreversible pulpitis. However, well-designed and adequately powered randomised controlled trials are required to produce the evidence that would be needed to change clinical practice in this area.
Earlier this month we looked at another review by Li et al (Dental Elf – 10th July 2019) that addressed pulpotomy as management option for permanent teeth with extensive caries and pulpal involvement. This new review has a narrower focus in that it only considered those teeth with a clear diagnosis of irreversible pulpitis in accordance with the American Association of Endodontists definition. Consequently, fewer studies are included and only 1 RCT which is reported in 3 separate papers providing outcomes at 3 separate time points. As the authors highlight the RCT is at high risk of bias but it does suggest that pulpotomy may have some potential as an alternative to root canal treatment. The Li et al review also provides some support for pulpotomy however there is a clear need for high quality well conducted studies in primary care that are adequately powered to clarify the evidence to support changes in clinical practice.
Cushley S, Duncan HF, Lappin MJ, Tomson PL, Lundy FT, Cooper P, Clarke M, El Karim IA. Pulpotomy for mature carious teeth with symptoms of irreversible pulpitis: A systematic review. J Dent. 2019 Jun 20. pii: S0300-5712(19)30129-0.doi: 10.1016/j.jdent.2019.06.005. [Epub ahead of print] Review. PubMed PMID:31229496.
Dental Elf – 10th July 2019