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Taha2017 PDF
Taha2017 PDF
Abstract
Introduction: This study aimed to assess the outcome of
partial pulpotomy using mineral trioxide aggregate (MTA)
compared with calcium hydroxide (CH) in mature cariously
T he major goal of all
restorative procedures
is to maintain the viability
Significance
Clinical evaluation of vital pulp therapy procedures
using biocompatible capping materials is essential
exposed permanent molars. Methods: Fifty permanent of the dental pulp when-
for evidence-based clinical practice, particularly in
molar teeth with carious exposures in 50 patients ever possible, and over
the era of improved understanding of the healing
>20 years old were included. Preoperative pulpal and the last few decades mini-
process and regeneration of the dental pulp.
periapical diagnosis was established based on a history mally invasive techniques
of presenting pain, results of cold testing, and radio- including partial and full
graphic findings. After informed consent, the tooth was pulpotomy have received wider acceptance in teeth with carious exposure (1, 2).
anesthetized, isolated via a dental dam, and disinfected Partial pulpotomy involves the removal of 2–3 mm from the inflamed coronal pulp
with 5% sodium hypochlorite before caries excavation. beneath the exposure followed by placement of a suitable agent over the remaining
Partial pulpotomy was performed by amputating 2 mm coronal pulp and a restoration that provides a hermetic seal (3).
of the exposed pulp, hemostasis was achieved, and the Traditionally, symptoms have been widely accepted as indicators of the inflam-
tooth was randomly assigned for the placement of either matory status of the pulp. The presence of relatively mild symptoms relates to revers-
white MTA (White ProRoot; Dentsply, Tulsa, OK) or CH ible pulpitis, whereas carious pulp exposure and more severe symptoms are
(Dycal; Dentsply Caulk, Milford, DE) as the pulpotomy associated with irreversible pulpitis in which the pulp condition has little chance to
agent. Postoperative periapical radiographs were taken revert to normal after the removal of the irritants, and, therefore, root canal therapy
after placement of the permanent restoration. Clinical is indicated (4).
and radiographic evaluation was completed after Several studies have shown that cariously exposed pulps of mature teeth are
6 months and 1 and 2 years postoperatively. Statistical capable of regeneration, and vital pulp therapy (VPT) need not be restricted to young
analysis was performed using the Fisher exact test. or asymptomatic teeth (5–8). Furthermore, the presence of spontaneous or severe
Results: Clinical signs and symptoms suggestive of irre- preoperative pain does not always indicate that the pulp is not capable of repair
versible pulpitis were established in all teeth. Immediate (9–11), and deep carious lesions are not unconditionally related to an irreversible
failure occurred in 4 teeth. At 1 year, MTA showed a pattern of pulpal pathology (12). However, partial or full pulpotomy is indicated in
higher tendency toward success compared with the CH such cases rather than simply capping the exposed pulp (13), and the ability to control
group, and the difference was statistically significant after bleeding after amputation has been suggested as the critical point in terms of the
2 years (83% vs 55%, P = .052 at 1 year; 85% vs 43%, expected outcome (5).
P = .006 at 2 years). Sex did not have a statistically signif- Historically, calcium hydroxide (CH) was the most popular material for VPT; how-
icant effect on the outcome. Conclusions: MTA partial ever, American Academy of Pediatric Dentistry guidelines and several authors suggested
pulpotomy sustained a good success rate over the MTA as a more favorable option than CH (14, 15). It is resistant to dissolution with
2-year follow-up in mature permanent teeth clinically adequate structural integrity and induces a more homogenous, more localized, and
diagnosed with irreversible pulpitis. More than half of thicker dentin bridge than CH (16, 17). Only 2 studies of CH partial pulpotomy in
the CH cases failed within 2 years. (J Endod 2017;-:1–5) young permanent teeth have included teeth with a history of spontaneous pain and
have reported success rates over 90% (18, 19). The aim of this study was to explore
Key Words the outcome of partial pulpotomy in mature teeth clinically diagnosed with
Calcium hydroxide, deep caries, mineral trioxide aggregate, irreversible pulpitis using MTA compared with CH and monitored clinically and
partial pulpotomy, pulpitis radiographically up to 2 years.
From the Department of Conservative Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan.
Address requests for reprints to Dr Nessrin A. Taha, Department of Conservative Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, PO Box
3864, Irbid 22110, Jordan. E-mail address: n.taha@just.edu.jo
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.03.033
Enrolment
Assessed for eligibility
(n=61)
Randomized (n=50)
Allocation
Follow-up
Analysis
Figure 1. Consolidated Standards of Reporting Trials flowchart of the 61 eligible patients up to the 2-year follow-up.
Figure 2. A lower right second molar in a 22-year-old man with a clinical diagnosis of irreversible pulpitis. (A) The preoperative periapical radiograph. (B) The
postoperative periapical radiograph after CH partial pulpotomy. (C) The 12-month follow-up. (D) The 26-month follow-up.
Figure 3. A lower left second molar in a 21-year old female patient with a clinical diagnosis of irreversible pulpitis. (A) The preoperative periapical radiograph.
(B) The postoperative periapical radiograph after MTA partial pulpotomy. (C) The 12-month follow-up. (D) The 28-month follow-up.
Results all restorations were functional except the case that had tooth and resto-
The results of the Cohen kappa statistics showed good intraob- ration fracture. There was no obvious discoloration of the crowns. A
server agreement of 0.95. Baseline characteristics of the study partici- summary of the results according to capping material and sex is pre-
pants and patients’ flow are shown in Table 2 and Figure 1. The patient sented in Tables 3 and 4.
age ranged from 20–52 years (mean = 30.3 9.6 years). There were
23 men and 27 women; 1 female patient in the MTA group declined Discussion
attending any of the scheduled reviews and therefore was excluded This prospective study included all eligible patients who attended
from the analysis. Amalgam restoration was placed in 22 teeth and resin the graduate clinic during a 4-month period and agreed to participate in
composite in 27 teeth. Immediate failure occurred in 4 teeth (1 in the the study. The recall rate was high ($90%, above the minimum 80%
MTA group and 3 in the CH group) in which severe spontaneous pain required for a high level of evidence) (21). Treatment was performed
persisted after the procedure, and, therefore, root canal treatment was under the supervision of a specialist endodontist by 1 graduate student
initiated. After 6 months, 3 patients did not attend the recall appoint- who was calibrated by performing the treatment on nonstudy partici-
ments. Eight teeth failed during this period; 4 patients reported pain af- pants for 1 year before the study.
ter 3 months, and they had root canal treatment. The remaining 4 teeth Partial pulpotomy has been performed in carious exposures in
were asymptomatic; however, the teeth gave a negative response to cold young, asymptomatic teeth (22) or teeth with symptoms of irreversible
testing, and, radiographically, there was evidence of new periapical pulpitis with a high success rate (6), with increasing evidence that pre-
rarefaction. serving pulp vitality is more attainable than previously thought. This is
After excluding immediate failures and the cases that failed at the first randomized clinical trial to combine mature teeth in adult pa-
6 months, the study population available for the 1-year follow-up was tients with clinical signs and symptoms suggestive of irreversible pulpitis
37 patients; 32 of 37 attended the recall visit. All cases were successful treated with partial pulpotomy. The success rate in the MTA group was
except 1 patient in the CH group who reported pain on biting and peri- nearly double that of the CH group at the end of the 2-year recall
apical rarefaction diagnosed on the radiograph. At the 2-year follow-up (85% vs 43%, P = .006). However, it was lower than the success rate
(25–28 months), 36 of 36 patients attended the recall. Four cases from reported for MTA full pulpotomy published previously by the same author
the CH group failed; 3 patients reported a history of severe pain, and (8); this could be related to the fact that 18.6% of the patients included in
they had root canal treatment initiated by a general dentist, whereas the first study were aged 13–20 years and more potentially inflamed pulps
1 patient was referred for extraction after tooth and restoration fracture. were removed via full pulpotomy compared with partial pulpotomy.
MTA partial pulpotomy was successful in 85% of the cases, whereas CH As early as 1963, Seltzer et al (10) introduced the diagnostic cate-
partial pulpotomy was successful in 43% (Figs. 2A–D and 3A–D). gory of chronic partial pulpitis without necrosis or with partial necrosis.
Dentin bridge formation was not discernable in the review radiographs; They confirmed histologically that inflammation of the dental pulp at an
TABLE 3. A Summary of the Outcome of Partial Pulpotomy According to the Capping Material
Outcome at 6 months Outcome at 1 year Outcome at 2 years
Capping material Failure, n Success, n (%) Failure, n Success, n (%) Failure, n Success, n (%)
MTA 4 21 (84) 4 20 (83) 4 22 (85)
CH 8 13 (62) 9 11 (55) 13 10 (43)
P value .10 .052 .006
CH, calcium hydroxide; MTA, mineral trioxide aggregate.