CLINICAL RESEARCH

Shao Yong Tan, BDS, MDS,*

Long-term Pulpal and Victoria Soo Hoon Yu, BDS,
MSc, PhD,† Kian Chong Lim,
Restorative Outcomes of BDS, MSc, FAMS,†
Beng Choon Keson Tan, BDS,
Pulpotomy in Mature MSD,† Chiew Lian Jennifer Neo,
BDS, MS,† Liang Shen, PhD,‡
Permanent Teeth and Harold Henry Messer, DDS,
PhDx

ABSTRACT
SIGNIFICANCE
Introduction: Pulpotomy in mature permanent cariously exposed teeth preserves the
remaining pulp tissues, but long-term outcomes of the pulp and the restoration are un- This study reports the long-
known. This prospective study examined the immediate and long-term status of the pulp term pulpal and restorative
and the restored tooth and identified potential predictors of early and late failures in teeth outcomes of 61 teeth that
that were asymptomatic or experiencing only mild symptoms at the time of treatment. received pulpotomy under
Methods: Pulpotomy was performed using the aseptic technique and a tricalcium silicate aseptic conditions. The
cement under local anesthesia. Teeth were assessed for up to 5 years for pulpal and apical preoperative pain complaint is
signs and symptoms, restorative marginal integrity, and periodontal health. Results: Fifty- prognostic for pulpal outcome
two patients (61 teeth) with a median age of 40 years (range, 21–75 years) were included in in the immediate postoperative
this study; 17 (32.7%) men and 35 (67.3%) women were treated and reviewed. Overall pulp period, and a secure
survival was 90.2% (95% confidence interval, 79.8%–96.3%); 6 teeth developed irreversible restoration is important for the
pulpitis or pulp necrosis when the restoration was intact. Preoperative pain was a potential long-term outcome.
predictor (P , .05) for early failure. Eleven late failures occurred between 2 and 4 years:
1 tooth with intact coronal restoration had pulp necrosis and asymptomatic apical peri-
odontitis, 4 had recurrent caries resulting in asymptomatic apical periodontitis, 4 remained
vital and only needed new restorations, 1 was unrestorable, and 1 was extracted for peri-
odontal reasons. The type of definitive restoration was a potential predictor for late failure
(P , .05). Conclusions: Carious pulp exposures in asymptomatic mature permanent teeth
can be predictably managed by pulpotomy using a tricalcium silicate cement. Short-term
failures were few and managed by pulpectomy. Appropriate coronal restoration is critical to
long-term success. (J Endod 2019;-:1–8.)

KEY WORDS
Longevity; preoperative pain; pulpotomy; restoration

Until recently, the pulp of a mature tooth exposed by caries has been considered a “doomed organ”
because the induced inflammatory condition is often not reversible after intervention (typically direct pulp From the *Dental Surgery, Khoo Teck
capping with calcium hydroxide). Pulp extirpation and root canal treatment1,2 have been the standard of Puat Hospital, Singapore; †Faculty of
care and have a very favorable outcome3. However, inflammation is mostly confined to the coronal region Dentistry and ; ‡Yong Loo Lin School of
Medicine, National University of
immediately beneath the carious exposure, and the radicular pulp is essentially normal and uninflamed,
Singapore, Singapore; and xMelbourne
with an intact odontoblast layer. Involvement of the entire coronal and radicular pulp occurs only at very Dental School, University of Melbourne,
late stages of the caries process4,5. Therefore, it is possible that cariously exposed pulps could be Melbourne, Australia.
preserved by resecting only the infected and diseased pulp tissue below the microbial front6–8. Address requests for reprints to Dr
The historically poor clinical outcomes associated with direct pulp capping using calcium Victoria Soo Hoon Yu, Faculty of Dentistry,
hydroxide9 do not necessarily imply that the partially inflamed pulp is inherently incapable of healing. National University of Singapore, 9 Lower
Removal of the inflamed part of the pulp (a procedure known as pulpotomy)10 and the use of alternative Kent Ridge Road, Singapore 119085.
E-mail address: denyshv@nus.edu.sg
materials such as mineral trioxide aggregate (MTA) and tricalcium silicate cements have recently been 0099-2399/$ - see front matter
reported as effective management for carious exposures of permanent teeth7,11–13, with excellent
Copyright © 2019 American Association
outcomes documented in mature permanent teeth13–15. In 2019, the European Society of of Endodontists.
Endodontology issued a position statement recommending that deeply carious teeth with asymptomatic https://doi.org/10.1016/
carious pulp exposures could benefit from conservative vital pulp treatment16. j.joen.2019.11.009

JOE  Volume -, Number -, - 2019 Long-term Pulpal and Restorative Outcomes of Pulpotomy 1
 A favorable outcome for any clinical
procedure will depend on careful preoperative
assessment and good case selection. Evidence
is largely lacking to guide clinical treatment
decisions in pulpotomy. Signs and symptoms
do not always correlate well with the histologic
status17–19, and a recent systematic review
concluded that high-quality evidence is lacking
for good correlation of diagnostic tests with the
inflammatory status of the pulp20. A recent study
found that despite good agreement using
defined criteria for clinical and histologic
classification, certain teeth diagnosed with
irreversible pulpitis could still be good
candidates for a pulp preservation procedure21.
Besides preoperative assessment and
case selection, vital pulp therapy should be
assessed in the long-term based on both
pulpal and restorative outcomes because
more conservative restorative options are
possible after pulpotomy rather than
pulpectomy22. In the initial stages of healing
after pulpotomy, the presence and quality of
remaining vital pulp tissues will largely dictate
pulp survival6. As the tooth survives in the oral
environment and is subjected to functional
loads, pulp survival could become dependent
on the integrity of coronal restorations and
favorable support provided by the
periodontium, in the same way as long-term
survival of root-filled teeth23,24.
This cohort study investigated the
immediate and long-term outcome of pulp and
tooth survival as well as the nature of further
interventions after pulpotomy using a
tricalcium silicate cement.
MATERIALS AND METHODS
Recruitment
This prospective study conformed to STROBE
guidelines for cohort studies. Institutional ethical
approval was obtained for the recruitment of
patients with informed consent to receive
pulpotomy as an alternative to nonsurgical root
canal treatment when deep caries resulted in an
exposure of a vital pulp. Patients at least 21 years
old, ambulant, healthy or with controlled medical
conditions suitable for outpatient dental care,
and able to attend scheduled follow-up visits
were recruited. Consecutive cases of all tooth
types presenting at the university dental clinics
were assessed for eligibility from October 2013
through January 2016. Inclusion criteria were a
vital pulp with demonstrable bleeding upon
entry, time taken for hemostasis of less than 10
minutes, absence of pain from the tooth or pain
that did not qualify as symptomatic irreversible
pulpitis25, and apical tissues determined to be
normal radiographically. Recruited teeth might
2 Tan et al.
present with mild tenderness to percussion,
biting discomfort, or sensitivity provoked only by
temperature changes but had no severe
spontaneous pain nor lingering thermal
sensitivity; they were not associated with any
radiographic apical lesion. Exclusion criteria
included traumatized teeth, pulp necrosis or no
pulp exposure upon complete caries removal,
severe tooth structure loss that required a post-
retained restoration, and uncontrolled
periodontal disease.
Based on an estimated 85% survival of
the pulp after MTA pulpotomy7, a proposed
sample size of 80 would have an estimated
precision of 8%, with a 95% confidence
interval (CI) of 77%–93%.
Pulpotomy and Tooth Restoration
Either full or partial pulpotomy was performed
by senior dental students under close
supervision following standard pulpotomy
procedures. Partial pulpotomy (55 cases) was
the preferred option unless the size and
location of the carious exposure dictated full
pulpotomy to the canal orifice(s) (6 cases). The
procedure included local anesthesia (2%
mepivacaine hydrochloride with 1:100,000
epinephrine [Scandonest; Septodont, Saint-
Maur-des-fosse
s Cedex, France]), rubber dam
isolation, and peripheral removal of caries
before deep caries removal. After complete
caries removal, the exposed pulp was
resected using sterile round diamond burs
under copious water irrigation. Hemostasis
was achieved by direct pressure using a sterile
cotton pellet soaked in 1% sodium
hypochlorite or sterile saline checked after the
first minute and subsequently between 2 and 5
minutes; if necessary, it was checked up to 10
minutes. If hemostasis was not achieved by
then, the pulp was extirpated and scheduled
for nonsurgical root canal treatment and
excluded from the study.
After pulpotomy, Biodentine
(Septodont) was placed in direct contact with
the remaining vital tissues and either
functioned as an interim restoration or was
immediately used to support a direct
restoration of dental amalgam, composite
resin, or glass ionomer cement based on the
patients’ needs and with informed consent.
Where indicated, full-coverage crowns were
subsequently provided. Patients were
encouraged to return immediately if
posttreatment pain developed or persisted.
Immediate and Long-term Follow-
up
Follow-up examinations were performed by
specialist clinicians not involved in the
pulpotomy treatment at 1 week, 6 months, and
annually thereafter up to 5 years. Clinical and
radiographic examination gathered data on
postoperative pain, pulp status based on a
cold test (Endo Ice; Coltene, Altst€atten,
Switzerland) and electric pulp test (Analytic
Technology, Lexington, KY) where possible,
apical signs and symptoms, and status of the
coronal seal. Long-term follow-up assessment
also included patients’ report on how they
were coping with the restored teeth, and
patients’ self-care as shown by plaque control.
Periodontal probing depths, tooth mobility,
integrity of restorative margins, and the
presence or absence of recurrent caries were
noted, and radiographic assessment of apical
tissues was performed using the long cone
paralleling technique. Follow-up radiographs
were taken using the long cone paralleling
technique (Dentsply Rinn, York, PA) and
evaluated independently of clinical signs and
symptoms.
Outcome Measures
At each review appointment after pulpotomy,
the remaining pulp and its associated periapex
were classified as
1. Normal pulp with normal apical tissue,
2. Irreversible pulpitis with or without apical
periodontitis, or
3. Pulp necrosis with apical periodontitis that
was evident on periapical radiographs25.
Irreversible pulpitis or pulp necrosis with or
without apical periodontitis was considered
an unfavorable outcome. Failure was
defined by a strict criterion of any
intervention needed, including root canal
treatment, tooth extraction, or simply
revision of the coronal restoration because
of recurrent caries and/or defective margins
in the presence of a normal pulp.
Any unfavorable outcome that occurred
within 6 months of the pulpotomy procedure
was considered an early failure, and any
occurring after this period was considered a
late failure.
Statistical Analyses
All statistical analyses were performed using
SPSS Statistics 25 (IBM Corp, Armonk, NY).
Patients’ demographic and baseline
characteristics were analyzed descriptively. The
overall survival rate of the pulp after pulpotomy,
the early failure rate, and the late failure rate were
estimated, and the point estimate together with
the 95% CI were reported. The chi-square test
or Fisher exact test, whichever was more
appropriate, was performed to evaluate the
potential predictors of early and late failure.
JOE  Volume -, Number -, - 2019
RESULTS Caries was predominantly located on the early failures (8.2%; 95% CI, 2.7%–18.1%)
proximal surface so that pulp exposures with symptomatic irreversible pulpitis (Table 1).
Over a period of 28 months, 102 patients
involved the axial wall, the pulp horn adjacent, One patient returned 3 days after pulpotomy
presenting with deep caries were screened,
or a combination of the 2 (48 [78.7%]). Thirteen complaining of persistent pain and received
and 52 fulfilled inclusion and exclusion criteria
teeth (21.3%) required full-coverage crown root canal treatment the same day (Table 2). At
to receive pulpotomy in 61 teeth (Table 1). This
restorations based on restorative assessment. the 1-week follow-up visit, 2 patients felt
represented 76.3% of the intended sample
The median time of follow-up was 3 years persistent but not debilitating pain; they opted
size of 80. The median age was 40 years
(range, 2–5 years), with 6 cases (in 6 patients) for pulp extirpation and were treated in the
(range, 21–75 years), 35 (67.3%) were female
lost to follow-up. Figure 1A–C shows endodontic clinic. Two patients returned at the
patients, and most cases were free of
functional teeth with normal apical tissues after 3rd and the 6th week when attending regular
preoperative pain (41 [67.2%]). A large majority
receiving pulpotomy. clinics with the students and opted for root
of cases (55 [90.2%]) received partial
Overall, only 6 of the 61 teeth developed canal treatment because preoperative
pulpotomy where at least 2 mm of the exposed
irreversible pulpitis or pulp necrosis when the symptoms of transient aggravated pain
pulp was resected, and only 6 (9.8%) needed
restoration was intact, with pulp survival of persisted.
more than 5 minutes to achieve hemostasis.
90.2% (95% CI, 79.8%–96.3%). There were 5 Eleven teeth developed late failure
(18.0%; 95% CI, 9.4%–30.0%) that required
TABLE 1 - Demographics and Univariate Analysis of Tooth Characteristics with Early and Late Failure further intervention (Table 2). Only 1 tooth was
diagnosed with pulp necrosis and
Early failure Late failure* asymptomatic apical periodontitis at the 2-year
n (%) n (%) P value n (%) P value follow-up visit. This tooth had received a direct
dental amalgam restoration, and the margins
No. of patients 52 (100)
were well maintained. One tooth that was used
Age (median years) 40 (range, 21–75)
Sex as an abutment for a cantilever prosthesis
Male 17 (32.7) developed localized periodontitis at 4 years
Female 35 (67.3) and was extracted (Fig. 2B). One anterior tooth
Race suffered recurrent caries and was impractical
Chinese 37 (71.2) to restore; however, the patient did not have
Malay 7 (13.5) pain symptoms, and the tooth responded to
Indian 3 (5.8) both the cold test and the electric pulp test at 4
Others 5 (9.6) years. Other failures at longer follow-up were
No. of cases/teeth 61 (100)
restorative in nature, with 4 teeth needing root
Tooth type .771 .202
canal treatment because of recurrent caries.
Anterior (incisors and canines) 9 (14.8) 1 (11.1) 1 (13.3)
Premolar 21 (34.4) 1 (4.8) 2 (10.5) The remaining 4 teeth presented with
Molar 31 (50.8) 3 (9.7) 8 (32.0) asymptomatic pulps that responded normally
Pulp exposure .307 .223 to pulp tests but needed the restorations
Occlusal lesion only 10 (16.4) 2 (20.0) 0 (0.0) revised. No evidence of canal obliteration or
Proximal lesion only 48 (78.7) 3 (6.3) 11 (26.2) narrowing of the canal space was noted on the
Occlusal and proximal lesion 3 (4.9) 0 (0.0) 0 (0.0) follow-up radiographs.
Preoperative pain .011 .295
No 41 (67.2) 1 (2.4) 10 (27.0)
Potential Predictors of Outcomes
Transient pain when aggravated 15 (24.6) 2 (13.3) 1 (8.3)
Bivariate analysis indicated that preoperative
Pain is spontaneous but mild 5 (8.2) 2 (40.0) 0 (0.0)
Pulp tissue removed .585 .756 pain was predictive for symptomatic
Partial pulpotomy 55 (90.2) 5 (9.1) 10 (22.2) irreversible pulpitis, with 4 of the 5 early failure
Full pulpotomy (to canal orifice) 6 (9.8) 0 (0.0) 1 (16.7) cases presenting with transient aggravated
NaOCl hemostasis .642 .199 pain or spontaneous but mild pain (P , .05).
Yes 56 (91.8) 5 (8.9) 9 (19.1) The pain persisted or worsened after
No (sterile saline used) 5 (8.2) 0 (0.0) 2 (50.0) pulpotomy. No other variables showed a
Time to hemostasis .181 .236 significant effect. For cases of late failure, only
1 minute 23 (37.7) 0 (0.0) 2 (10.0)
the type of definitive restoration was found to
2–5 minutes 32 (52.5) 4 (12.5) 8 (30.8)
be a significant factor (P , .05) with glass
.5 and 10 minutes 6 (9.8) 1 (16.7) 1 (20.0)
ionomer cement associated with a greater risk
Immediate restoration .066 .904
Biodentine 1 direct restoration 26 (42.6) 0 (0.0) 5 (20.8) of further intervention. However, only 3 teeth
Biodentine as interim restoration 35 (57.4) 5 (14.3) 6 (22.2) were definitively restored with glass ionomer
Definitive restoration .530 .040 cement, 1 of which was lost to follow-up after
Dental amalgam 14 (23.0) 2 (14.3) 3 (27.3) the first recall (Table 2).
Composite resin 31 (50.8) 3 (9.7) 4 (14.8)
Glass ionomer cement 3 (4.9) 0 (0) 2 (100)
Full-coverage crown 13 (21.3) 0 (0) 2 (18.2) DISCUSSION
This study set out to investigate the outcome
NaOCl, sodium hypochlorite.
Statistically significant differences (P , .05) are indicated in bold.
of pulpotomy procedures in mature teeth
*Patients who were uncontactable, and teeth that had early failure and were treated with root canal treatment were with carious exposures in the immediate
excluded in the late failure analysis. posttreatment period and in the long-term

JOE  Volume -, Number -, - 2019 Long-term Pulpal and Restorative Outcomes of Pulpotomy 3
FIGURE 1 – (A–C ) Examples of pulp and restorative survival after pulpotomy. (A ) Mandibular right first molar presented with distal proximal caries and a vital pulp. Partial pulpotomy
was performed and restored with Biodentine and porcelain bonded to a metal crown. Clinical and radiographic examination 5 years later showed a functional tooth with normal apical
tissues. (B ) Mandibular left first molar presented with recurrent caries and a vital pulp. Partial pulpotomy and cuspal protection using a cast gold restoration was provided. The tooth
was asymptomatic and had normal apical tissues at 4.5 years. (C ) Maxillary left central incisor had deep caries that exposed a vital pulp. Pulpotomy and restoration with Biodentine
composite resin maintained functionality at 2.5 years. Clinically, there was no discoloration, and, radiographically, there was narrowing of the root.

together with reasons for further intervention
when it became necessary. Our study is the
first to report the long-term outcome of
pulpotomy using a tricalcium silicate cement
(Biodentine) in mature permanent teeth for up
to 5 years; other studies13–15,22 have mostly
involved teeth in younger patients and
shorter follow-up periods. The success (in
terms of pulp survival) of approximately 90%
up to 5 years is comparable with previous
studies, confirming the potential usefulness
of this procedure even in teeth of mature
adults. Age was not a significant factor in
outcome.
Deeply carious teeth frequently lack
sufficient remaining tooth structure to permit
direct restoration so that elective root canal
treatment becomes necessary for retention of
the restoration. As a result, only 60% of
potentially suitable cases for pulpotomy could
be included in this study, resulting in a smaller
sample size than originally planned. We were
able to achieve only 61 included cases (76.3%
of the intended sample size of 80 cases) at the
end of the planned recruitment period,
affecting the precision of the estimated
favorable outcome of 85%. Patient
cooperation and shared decision making26
contributed to the high recall rate of more than
90% with only 6 uncontactable patients over
the entire study period.
Preoperative pain was a potential
prognostic factor for early failure requiring
pulpectomy and root canal treatment (P , .05)
even though inclusion of symptomatic teeth
(20/61 cases) was limited to those with mild
pain with little impact on patients’ quality of
life27. This is in agreement with several previous
studies of vital pulp therapy for cariously
exposed teeth, including both direct pulp
capping with calcium hydroxide28 and either
pulp capping or pulpotomy with MTA7,11,29.
Although 4 of the 5 early failure cases were
associated with preoperative pain, only 20% of
the teeth with preoperative pain in our study (4/
20 cases) subsequently developed irreversible
pulpitis, and all of these were early failures so
that subsequent pulpectomy was easily
performed. Nevertheless, it appears prudent to
limit vital pulp therapy in mature adults to
asymptomatic teeth.
The time needed to achieve hemostasis
did not influence the endodontic outcome in
this study. Matsuo et al30 reported that the
time to hemostasis was a key prognostic factor
for the outcome of direct pulp capping with
calcium hydroxide. However, the removal of

4 Tan et al. JOE  Volume -, Number -, - 2019

TABLE 2 - Descriptors of Early and Late Failure

1st review 6 months 1 year 2 years 3 years 4 years* 5 years*

n (%) n (%) n (%) n (%) n (%) n (%) n (%)
No. of observed failure 5 (8.2) 0 (0.0) 0 (0.0) 7 (13.5) 2 (4.5) 2 (4.9) 0 (0.0)
No. lost to follow-up 0 (0.0) 1 (1.8) 3 (5.5) 1 (1.9) 1 (2.3) 0 (0.0) 0 (0.0)
(uncontactable)
No. eligible for further follow- 56 (91.8) 55 (90.2) 52 (85.2) 44 (72.1) 41 (67.2) 39 (63.9) 39 (63.9)
up
Time to Definitive Last Further
Patient ID Age Tooth Preoperative pain hemostasis restoration recall intervention
Early failure
cases
P03 ,40 Premolar No 2–5 minutes Composite resin 1 week RCT because of
symptomatic irreversible
pulpitis
P10 ,40 Molar Pain is spontaneous 2–5 minutes Dental amalgam 3 days RCT because of
but mild symptomatic irreversible
pulpitis
P12 40 Anterior Transient pain .5 and 10 Composite resin 6 weeks RCT because of
when aggravated minutes symptomatic irreversible
pulpitis
P14 .40 Molar Pain is spontaneous 2–5 minutes Dental amalgam 1 week RCT because of
but mild symptomatic irreversible
pulpitis
P24 ,40 Molar Transient pain 2–5 minutes Composite resin 3 weeks RCT because of
when aggravated symptomatic irreversible
pulpitis
Late failure
cases
P01 .40 Anterior No 2–5 minutes Composite resin 4 years Vital pulp; tooth extracted
because of recurrent
caries
P18 .40 Molar No .5 and 10 Dental amalgam 2 years Vital pulp; revision of
minutes defective restoration
P23 .40 Molar No 2–5 minutes Full Coverage Crown 4-year Vital pulp; tooth extracted
because of acute local
periodontal breakdown
P28 ,40 Molar No 2–5 minutes Dental amalgam 2 years RCT because of pulp
necrosis; intact restorative
margins
P32 ,40 Molar Transient pain 2–5 minutes Composite resin 2 years RCT because of recurrent
when aggravated caries causing
asymptomatic apical
periodontitis
P33 ,40 Molar No 2–5 minutes Dental amalgam 3 years RCT because of recurrent
caries causing
asymptomatic apical
periodontitis
P35 .40 Premolar No 2–5 minutes Glass ionomer cement 3 years RCT because of recurrent
caries causing
asymptomatic apical
periodontitis
P48 ,40 Molar No 1 minute Glass ionomer cement 2 years RCT because of recurrent
caries causing
asymptomatic apical
periodontitis
P49 ,40 Premolar No 2–5 minutes Full-coverage crown 2 years Vital pulp; management of
recurrent caries
P50 ,40 Molar No 2–5 minutes Composite resin 2 years Vital pulp; new restoration to
correct persistent food
trap
P52 ,40 Molar No 1 minute Composite resin 2 years Vital pulp; revision of
defective restoration
(continued on next page )

JOE  Volume -, Number -, - 2019 Long-term Pulpal and Restorative Outcomes of Pulpotomy 5
TABLE 2 - Continued

Time to Definitive Last Further

Patient ID Age Tooth Preoperative pain hemostasis restoration recall intervention
Lost to Condition at last recall
follow-up
P05 ,40 Molar Pain is spontaneous 2–5 minutes Full-coverage crown 1 year Uneventful; responsive pulp
but mild
P15 .40 Anterior No 2–5 minutes Composite resin 6 months Uneventful; responsive pulp
P16 .40 Premolar No 1 minute Composite resin 2 years Uneventful; responsive pulp
P36 ,40 Molar No 1 minute Glass ionomer cement 1 week Uneventful; responsive pulp
P44 ,40 Molar No 1 minute Full-coverage crown 6 months Uneventful; responsive pulp
P47 ,40 Premolar Transient pain 1 minute Dental amalgam 6 months Uneventful; responsive pulp
when aggravated

*At the time of reporting, 52 of 61 cases received pulpotomy at least 4 years ago and 29 of 61 cases at least 5 years ago.

the most severely inflamed pulp tissue by
pulpotomy together with the much higher
success rates associated with MTA or
tricalcium silicate cements13,22 make it difficult
to show statistically significant effects of time to
hemostasis on pulp survival.
Our results also showed a significant
impact of coronal restoration on late failure
(P , .05). Demarco and coworkers31 also
concluded in their retrospective study that
there was a statistically significant positive
association between restoration quality and
clinical success of pulpotomy. The importance
of a good-quality coronal restoration in

FIGURE 2 – (A–C ) Examples of late failure ranging from 2–4 years after pulpotomy. (A ) Mandibular right second molar (case P18) had subgingival extension of distal caries initially
excavated and restored after partial pulpotomy. Distal marginal buildup was difficult, and at the 2-year review, the patient returned with a revised margin that exposed the original
Biodentine base. (B ) Maxillary left first molar (case P23) received partial pulpotomy followed by crown restoration to support an anterior cantilever pontic. The review at 2.5 years
showed a responsive pulp but associated with purulent discharge from a palatal 7-mm pocket. The tooth was extracted 1.5 years later because of local periodontal breakdown. (C )
Maxillary right first premolar (case P35) had deep proximal caries that exposed a vital pulp. Pupotomy and restoration with Biodentine and glass ionomer cement maintained
functionality for 3 years, but the tooth needed root canal treatment because of recurrent caries.

6 Tan et al. JOE  Volume -, Number -, - 2019

ensuring the success of root canal treatment
has been well-documented24. The same
requirement for a durable coronal seal should
be applied to vital pulp therapy because
bacterial microleakage through a defective
coronal restoration could subsequently result
in pulp degeneration.
The high long-term success rate
observed in this study indicates the
predictability of pulpotomy for carious
exposures in mature teeth, and it should be
regarded as a viable alternative to pulpectomy
and root canal filling. Bjørndal et al32 reported
that 55% of root canal treatments were
performed on teeth with vital pulps; pulpotomy
has the potential to become much more widely
adopted in endodontic practice.
Two clinical recommendations
emerged from this study:
1. Pulpal complications, although rare, are
likely to occur within a short time of the
pulpotomy procedure. After the first
6 weeks, only 1 case of pulp necrosis
and apical periodontitis occurred in the
following 5 years. Hence, it is advisable to
delay the definitive restoration for 6 weeks
after pulpotomy.
2. The decision regarding definitive
restoration should be made before
pulpotomy is recommended. The extent
of loss of the tooth structure
accompanying carious pulp exposure is
generally substantial, and the pulp
chamber and canal space may be
needed for retention of the restoration.
Large direct restorations may have a
short life span33; in this study, 10
recruited cases required subsequent
intervention because of restoration
breakdown, recurrent caries, or
periodontal problems, and root canal
treatment was needed in 4 cases for
restorative reasons alone. This result
shows the need for careful case
selection, placement of a good-quality
coronal restoration, and regular
subsequent monitoring of teeth that
received pulpotomy.
In conclusion, partial and full pulpotomy
should be considered a feasible definitive
treatment in asymptomatic teeth with deep
caries and pulp exposure regardless of
patients’ age. It is important to monitor
restored teeth to reduce the risk of new or
recurrent caries in this effort to preserve the
pulp.
ACKNOWLEDGMENT
This project was financially supported by the
Singapore Ministry of Education Tier-1 Grant
WBS R-221-000-060-112.
Institutional Ethics Approval
Reference Number: DSRB 2013/00201.
Treatment was performed at the Faculty
of Dentistry, National University of Singapore.
The authors acknowledge our appreciation to
the dental students and teaching faculty for
participating in the recruitment and treatment
of the patients.
The authors deny any conflicts of
interest related to this study.

REFERENCES
1. Langeland K. Management of the inflamed pulp associated with deep carious lesion. J Endod
1981;7:169–81.
2. Ward J. Vital pulp therapy in cariously exposed permanent teeth and its limitations. Aust Endod J
2002;28:29–37.

3. Friedman S, Mor C. The success of endodontic therapy–healing and functionality. J Calif Dent
Assoc 2004;32:493–503.

4. Langeland K. Tissue response to dental caries. Endod Dent Traumatol 1987;3:149–71.

5. Ricucci D, Siqueira JF Jr, Li Y, Tay FR. Vital pulp therapy: histopathology and histobacteriology-
based guidelines to treat teeth with deep caries and pulp exposure. J Dent 2019;86:41–52.

6. Bergenholtz G, Sp
angberg L. Controversies in endodontics. Crit Rev Oral Biol Med 2004;15:99–
114.
7. Simon S, Perard M, Zanini M, et al. Should pulp chamber pulpotomy be seen as a permanent
treatment? Some preliminary thoughts. Int Endod J 2013;46:79–87.

8. Bergenholtz G, Axelsson S, Davidson T, et al. Treatment of pulps in teeth affected by deep caries–
a systematic review of the literature. Singapore Dent J 2013;34:1–12.

9. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping of carious exposures:
treatment outcome after 5 and 10 years: a retrospective study. J Endod 2000;26:525–8.
10. American Association of Endodontists. Glossary of Endodontic Terms. 8th ed. Chicago:
American Association of Endodontists; 2012.

11. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: an
observational study. J Am Dent Assoc 2008;139:305–15.

12. Hilton TJ, Ferracane JL, Mancl L, Northwest Practice-based Research Collaborative in Evidence-
based Dentistry (NWP). Comparison of CaOH with MTA for direct pulp capping: a PBRN
randomized clinical trial. J Dent Res 2013;92:S16–22.

13. Taha NA, Khazali MA. Partial pulpotomy in mature permanent teeth with clinical signs indicative of
irreversible pulpitis: a randomized clinical trial. J Endod 2017;43:1417–21.
14. Linsuwanont P, Wimonsutthikul K, Pothimoke U, Santiwong B. Treatment outcomes of mineral
trioxide aggregate pulpotomy in vital permanent teeth with carious pulp exposure: the
retrospective study. J Endod 2017;43:225–30.

JOE  Volume -, Number -, - 2019 Long-term Pulpal and Restorative Outcomes of Pulpotomy 7
15. Awawdeh L, Al-Qudah A, Hamouri H, Chakra RJ. Outcomes of vital pulp therapy using
mineral trioxide aggregate or Biodentine: a prospective randomized clinical trial. J Endod
2018;44:1603–9.

16. Duncan HF, Galler KM, Tomson PL, et al. European Society of Endodontology position
statement: management of deep caries and the exposed pulp. Int Endod J 2019;52:923–34.

17. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between
diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol
1963;16:969–77.

18. Dummer PM, Hicks R, Huws D. Clinical signs and symptoms in pulp disease. Int Endod J
1980;13:27–35.
19. Levin LG, Law AS, Holland GR, et al. Identify and define all diagnostic terms for pulpal health and
disease states. J Endod 2009;35:1645–57.

20. re IA, Axelsson S, Davidson T, et al. Diagnosis of the condition of the dental pulp: a
Meja
systematic review. Int Endod J 2012;45:597–613.

21. Ricucci D, Loghin S, Siqueira JF Jr. Correlation between clinical and histologic pulp diagnoses. J
Endod 2014;40:1932–9.
22. Taha NA, Abdelkhader SZ. Outcome of full pulpotomy using Biodentine in adult patients with
symptoms indicative of irreversible pulpitis. Int Endod J 2018;51:819–28.

23. Vire DE. Failure of endodontically treated teeth: classification and evaluation. J Endod
1991;17:338–42.

24. Gillen BM, Looney SW, Gu LS, et al. Impact of the quality of coronal restoration versus the quality
of root canal fillings on success of root canal treatment: a systematic review and meta-analysis. J
Endod 2011;37:895–902.

25. American Association of Endodontists. Consensus conference recommended diagnostic

terminology. J Endod 2009;35:1634.
26. Azarpazhooh A, Dao T, Ungar WJ, et al. Clinical decision making for a tooth with apical
periodontitis: the patients’ preferred level of participation. J Endod 2014;40:784–9.

27. Yu VS, Messer HH, Yee R, Shen L. Incidence and impact of painful exacerbations in a cohort with
post-treatment persistent endodontic lesions. J Endod 2012;38:41–6.

28. Dammaschke T. A new bioactive cement for direct pulp capping. Int Dent Aust 2012;7:52–8.

29. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study of mineral trioxide aggregate for
partial pulpotomy in cariously exposed permanent teeth. J Endod 2006;32:731–5.

30. Matsuo T, Nakanishi T, Shimizu H, Ebisu S. A clinical study of direct pulp capping applied to
carious-exposed pulps. J Endod 1996;22:551–6.
31. Demarco FF, Rosa MS, Tarquinio SB, Piva E. Influence of the restoration quality on the success
of pulpotomy treatment: a preliminary retrospective study. J Appl Oral Sci 2005;13:72–7.

32. Bjørndal L, Laustsen MH, Reit C. Root canal treatment in Denmark is most often carried out in
carious vital molar teeth and retreatments are rare. Int Endod J 2006;39:785–90.

33. Burke FJ, Lucarotti PS. The ultimate guide to restoration longevity in England and Wales. Part 10:
key findings from a ten million restoration dataset. Br Dent J 2018;225:1011–8.

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