Pulpotomy and partial pulpotomy in the treatment of deep carious lesions in permanent teeth
Näytönastekatsaukset
18.5.2022
Level of evidence: C
Both partial- and full coronal pulpotomy can be used in the treatment of deep carious lesions in permanent teeth with reversible pulpitis.
| Reference | Study type | Population | Intervention and comparison | Outcomes | Risk of bias |
|---|---|---|---|---|---|
| «Alqaderi H, Lee CT, Borzangy S ym. Coronal pulpotomy for cariously exposed permanent posterior teeth with closed apices: A systematic review and meta-analysis. J Dent 2016;44:1-7 »1 | SR/MA | Studies on coronal pulpotomy for carious vital pulp exposure of permanent posterior teeth 402 → n=32 → n=6 PICOS, Prisma Trauma teeth excluded USA 1960–2015 | Intervention: full coronal pulpotomy with MTA or Ca(OH)2 | Main outcome: weighted mean success* rate (WSR) Success* was defined in studies at 12 m and 24 m: no radiographic abnormality or clinical symptoms, resolution of an existing radiographic periapical lesion, and no need for further pulpectomy and RCT of the treated teeth. | RCT: Cochrane Collaboration's tool n=1, 7/9 Low risk of bias The prospective or retrospective cohort studies: Newcastle–Ottawa scale (NOS) n=5, 4.6 ± 0.5/9 Studies heterogeneity 1 year i2 63.6%, two year i2 83.8% MTA studies respectively I2 = 75.3% and 86.6% |
| «Li Y, Sui B, Dahl C ym. Pulpotomy for carious pulp exposures in permanent teeth: A systematic review and meta-analysis. J Dent 2019;84:1-8 »2 | SR/MA | Studies on efficacy of pulpotomy and partial pulpotomy on mature (4 studies) and developing teeth (8 studies) China; 2019 (no year limits for the search) 88 → n=21 (17) | Two medicaments were used: MTA or Ca(OH)2 Two articles compared the outcome at two time points, three compared outcome of pulpotomy to root canal treatment and one to direct pulp capping | Success: clinical/ radiographic/overall success rates (both clinical and radiographic) at least 12 m follow-up | Cochrane Handbook for Systematic Reviews of Interventions No trial was considered to have low risk of bias in all items. All trials had high risk regarding performance bias resulting from the lack of blinding of participants and/or clinicians. |
| «Zanini M, Hennequin M, Cousson PY. Which procedures and materials could be applied for full pulpotomy in permanent mature teeth? A systematic review. Acta Odontol Scand 2019;77:541-551 »3 | SR/MA | Studies on pulpotomy in permanent mature teeth; n=53 (n=11 histological) France, 2018 (no year limits for the search) | Which procedure could be applied for full pulpotomy Clinical studies (n=38) Histological-clinical (n=4) | No specific definition for the success rate | Oxford Centre of Evidence based Medicine Criteria Clinical Grade 3 (min 2, max 4) |
| «Chen Y, Chen X, Zhang Y ym. Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis. BMC Oral Health 2019;19:227 »4 | SR/MA | Studies on success of pulpotomy in immature permanent teethn=5 China, Iran, Egypt, Turkey, 2006–2018 | Which medicament was the best choice for pulpotomy? MTA, Ca(OH)2, Biodentine, calcium enriched mixture cement (CEM), Platelet Rich Fibrin (PRF) and triple antibiotic paste (TAP) | Clinical or radiographic success rates – tooth/root status At least 6 m follow-up | Cochrane Blinding of operators high risk (all five studies), in remaining 6 domains low ROB 27/30 or moderate 3/30) At time point 6 m i2 0% and 12 m 45% |
| «Tan SY, Yu VSH, Lim KC ym. Long-term Pulpal and Restorative Outcomes of Pulpotomy in Mature Permanent Teeth. J Endod 2020;46:383-390 »5 | Clinical prospective study | Patients/teeth treated with Pulpotomy (P, n=6)/ Partial pulpotomy (PP, n=55) in permanent carious teeth with vital pulp Singapore | Aseptic pulpotomy with rubber dam, tricalcium silicate, hemostasis with 1% NaOCl/sterile saline Biodentine dressing; amalgam, composite resin, or glass ionomer cement crowns if needed (n=13) No controls | Outcome 1 week, 6 months, and annually, up to 5 years Failure: any intervention needed, including root canal treatment, tooth extraction, or revision of the coronal restoration Early failure within 6 m, late after that | No control group |
| «Elmsmari F, Ruiz XF, Miró Q ym. Outcome of Partial Pulpotomy in Cariously Exposed Posterior Permanent Teeth: A Systematic Review and Meta-analysis. J Endod 2019;45:1296-1306.e3 »6 | SR/MA | RCTs (n=5) and prospective clinical studies (n=6) on partial pulpotomy with a sample size of at least 10 teeth A follow-up rate of a minimum of 80% 1950–2018 Spain | Partial pulpotomy performed in permanent carious teeth with MTA or Ca(OH)2 | Outcome: success or no signs of inflammation/necrosis clinically or radiographically with follow-up period of at 6, 12 and 24 months | In case of heterogeneity, subgroup analysis was performed, and the results were visualized with a forest plot, and publication bias was evaluated with the funnel plot and Egger contrast. RCTs showed low risk of bias |
| «Cushley S, Duncan HF, Lappin MJ ym. Pulpotomy for mature carious teeth with symptoms of irreversible pulpitis: A systematic review. J Dent 2019;88:103158 »7 | SR | Complete coronal pulpotomy in carious teeth with signs and symptoms of irreversible pulpitis. 263 studies → 8 (5 studies and one study monitored a population at three time) UK, 1950–2018 | MTA, Biodentine or calcium enriched mixture cement (CEM) were used in studies No control group | All 8 studies had fair risk of bias Significant heterogeneity was discovered at all time points between studies | |
| «R R, Aravind A, Kumar V ym. Influence of occlusal and proximal caries on the outcome of full pulpotomy in permanent mandibular molar teeth with partial irreversible pulpitis: A prospective study. Int »8 | Clinical, prospective study | Pulpotomy on teeth with clinical and radiographic diagnosis of symptomatic partial irreversible pulpitis without periapical findings (n=80 teeth) India | Pulpotomy by using 2,5% NaOCl (to arrest bleeding) and MTA | Success at 6 and 12 m Success: asymptomatic teeth without any radiographic evidence of periapical rarefaction |
SR=systematic review; MA=meta-analysis, RCT= randomized controlled trial, MTA=mineraltrioxideaggregate
| Reference | Comments |
|---|---|
| General | Because of the high risk of bias in the included studies, the evidence was considered to be fair (C), even if outcomes were similar. Variation was great in the outcomes as well as heterogeneity of the studies (#1, 6, 7). Also risk bias regarding performance was high resulting from the lack of blinding of participants and/or clinicians (#2, 4). The studies were non randomized follow-up studies (I.e. #5) |
| «Alqaderi H, Lee CT, Borzangy S ym. Coronal pulpotomy for cariously exposed permanent posterior teeth with closed apices: A systematic review and meta-analysis. J Dent 2016;44:1-7 »1 | Ca(OH)2, MTA, CEM (MTA like products) used in studies included; Studies that performed other procedures, including apexo- genesis, direct or indirect pulp capping, partial pulpotomy, were excluded. |
| «Li Y, Sui B, Dahl C ym. Pulpotomy for carious pulp exposures in permanent teeth: A systematic review and meta-analysis. J Dent 2019;84:1-8 »2 | Partial pulpotomies included. Non-randomized controlled trials, non-comparative studies and observational studies were, excluded because the high risk of bias associated with those studies could compromise the results of meta-analysis. Glutaraldehyde and formocresol pulpotomy were excluded because of the toxicity of the medicaments. Studies with fewer than 10 participants in one treatment arm were considered non-representative. |
| «Zanini M, Hennequin M, Cousson PY. Which procedures and materials could be applied for full pulpotomy in permanent mature teeth? A systematic review. Acta Odontol Scand 2019;77:541-551 »3 | No controls, no modelling; here clinical studies included; reversible/irreversible pulpitis/ pulp necrosis with/without periapical findings as indication, hemostasis irrigation or compression commonly up to 10 minutes; |
| «Chen Y, Chen X, Zhang Y ym. Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis. BMC Oral Health 2019;19:227 »4 | Partial pulpotomy and pulpotomy, immature teeth, in one study trauma teeth included, otherwise only carious |
| «Tan SY, Yu VSH, Lim KC ym. Long-term Pulpal and Restorative Outcomes of Pulpotomy in Mature Permanent Teeth. J Endod 2020;46:383-390 »5 | Prospective, clinical study, no controls
Inclusion: Teeth with demonstrable bleeding upon (hemostasis <10 min), absence of pain or symptoms of irreversible pulpitis, periapical region normal radiographically Exclusion: 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 |
| «Elmsmari F, Ruiz XF, Miró Q ym. Outcome of Partial Pulpotomy in Cariously Exposed Posterior Permanent Teeth: A Systematic Review and Meta-analysis. J Endod 2019;45:1296-1306.e3 »6 | Heterogeneity of the studies (random effect modelling used) |
| «Cushley S, Duncan HF, Lappin MJ ym. Pulpotomy for mature carious teeth with symptoms of irreversible pulpitis: A systematic review. J Dent 2019;88:103158 »7 | Pulpitis reversible/ irreversible not specified |
Results
| Reference | Number of studiesand number of patients (I/C) | Follow-up time (m) /Age range | Relative effect (95% CI) | WSR /Success % (95% CI) |
|---|---|---|---|---|
| «Alqaderi H, Lee CT, Borzangy S ym. Coronal pulpotomy for cariously exposed permanent posterior teeth with closed apices: A systematic review and meta-analysis. J Dent 2016;44:1-7 »1 | 6 (Studies) at 1 year 265 patients treated with coronal pulpotomy 5 studies at 2 years 240 patients | 12–88 m in analysis 12 and 24 m/age 7–70 years | 2 year 0.92 (0.84, 1.00) | Pulpotomy at 12 m, WSR: 94% (90–99%)and at 24 m: 92% (84–100%)MTA/MTA like products 12 m 95% (90–100%) 24 m 93% (84–100%) Ca(OH)2 12 m 92% (85–99%) 24 m 88% (76–100%) |
| «Zanini M, Hennequin M, Cousson PY. Which procedures and materials could be applied for full pulpotomy in permanent mature teeth? A systematic review. Acta Odontol Scand 2019;77:541-551 »3 | 38 studies on coronal pulpotomy n=1261 (Teeth) | 12–88 m | Pulpotomy 89% (min 44%, max 100%) | |
| «Chen Y, Chen X, Zhang Y ym. Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis. BMC Oral Health 2019;19:227 »4 | 5 studies on partial and coronal pulpotomy/330 patients Number of teeth Partial pulpotomy 6 m MTA n=55, Ca(OH)2 n=54 12 m MTA n=52, Ca(OH)2 n=54 MTA n=59, CEM n=59 Coronal pulpotomy 6 m MTA n=29, PRF n=30 12 m MTA n=27, PRF n=29 3, 6, 9, 12, 18, 24 m MTA n=20, TAP n=20 AR n=20 | 6–24 m/6–14 y | 6 m clin/rad success: MTA 99% Ca(OH)299% 12 m clin/rad: MTA 99% Ca(OH)2 92% 6 and 12 m clin/rad: MTA 100% CEM 100% 6, 12 and 24 m clin/rad: MTA AND PRF 100% 3, 6, 9, 12, 18, 24 m clin/rad: MTA AND TAP 100% AR 80% | |
| «Tan SY, Yu VSH, Lim KC ym. Long-term Pulpal and Restorative Outcomes of Pulpotomy in Mature Permanent Teeth. J Endod 2020;46:383-390 »5 | n=52 (Patients), 61 teeth | up to 60 m/21–75 y | 90.2% (95% CI 80–96) | |
| «Elmsmari F, Ruiz XF, Miró Q ym. Outcome of Partial Pulpotomy in Cariously Exposed Posterior Permanent Teeth: A Systematic Review and Meta-analysis. J Endod 2019;45:1296-1306.e3 »6 | 11 studies number of teeth at 6 m n=512, at 12 m n= 488, at 24 m n=351 | 6/12/24 Age 6–52 years | 6 m: 0.98 (CI 0.94–1) 12 m:.0.96 (CI 0.91–0.99) 24 m: 0.92 (CI 0.83–0.97) | 6 m: 96% (74–100%) 12 m: 95% (70–100%) 24 m: 91% (65–97%) |
| «Cushley S, Duncan HF, Lappin MJ ym. Pulpotomy for mature carious teeth with symptoms of irreversible pulpitis: A systematic review. J Dent 2019;88:103158 »7 | 8 (Studies) n=633 (Teeth) | 12–36 m mean age range 9–65 | 12 m: 0.96 (CI, 0.91–0.99 24 m: 0.91 (CI, 0.76–1), | at 12 m, evaluated clinically: 97–100.0%, radiologically: 92 – 98%at 36m, evaluated clinically: 91–98%, radiologically: 84–93% |
| «R R, Aravind A, Kumar V ym. Influence of occlusal and proximal caries on the outcome of full pulpotomy in permanent mandibular molar teeth with partial irreversible pulpitis: A prospective study. Int »8 | 80 (Teeth) n=40 occlusal lesions n=40 proximal lesions | 16–35 y | 12 m: overall 94% Occlusal 95% Proximal 93% | |
| Level of evidence: high/moderate/low/very low. Absolute numbers were not available Assess the risk of bias and delete irrelevant sources of bias: Fair risk of bias specifically heterogeneity of the studies in the reviews | ||||
I= intervention; C=comparison; CI=confidence interval
| Reference | Number of studiesand number of patients (I/C) | Follow-up time | Relative effect (95% CI) success with MTA compared to Ca(OH)2 |
|---|---|---|---|
| «Li Y, Sui B, Dahl C ym. Pulpotomy for carious pulp exposures in permanent teeth: A systematic review and meta-analysis. J Dent 2019;84:1-8 »2 | 5/315 (Teeth): MTA n=158 Ca(OH)2 n=157 | 3–24 | 12 m: clin. OR 2.23, 95% CI, 1.16 to 4.29,P = 0.02, rad./overall OR 2.19, 95% CI, 1.16 to 4.14, P= 0.02,24 m:rad/overall OR 2.20, 95% CI, 1.15 to 4.20,P= 0.02 |
| «Chen Y, Chen X, Zhang Y ym. Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis. BMC Oral Health 2019;19:227 »4 | 2/109 (Teeth) Partial pulpotomy 6 m MTA n=55, Ca(OH)2 n=54 12 m MTA n=54 Ca(OH)2 n=53 | 6–13 | 6 m: RR 1; 95% CI 0.94 to 1.0612 m:RR 1.04; 95% CI 0.96 to 1.13 |
| Level of evidence: high/moderate/low/very low Absolute numbers were not available | |||
I= intervention; C=comparison; CI=confidence interval
References
- Alqaderi H, Lee CT, Borzangy S ym. Coronal pulpotomy for cariously exposed permanent posterior teeth with closed apices: A systematic review and meta-analysis. J Dent 2016;44:1-7 «PMID: 26687672»PubMed
- Li Y, Sui B, Dahl C ym. Pulpotomy for carious pulp exposures in permanent teeth: A systematic review and meta-analysis. J Dent 2019;84:1-8 «PMID: 30981748»PubMed
- Zanini M, Hennequin M, Cousson PY. Which procedures and materials could be applied for full pulpotomy in permanent mature teeth? A systematic review. Acta Odontol Scand 2019;77:541-551 «PMID: 31146622»PubMed
- Chen Y, Chen X, Zhang Y ym. Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis. BMC Oral Health 2019;19:227 «PMID: 31647004»PubMed
- Tan SY, Yu VSH, Lim KC ym. Long-term Pulpal and Restorative Outcomes of Pulpotomy in Mature Permanent Teeth. J Endod 2020;46:383-390 «PMID: 31902641»PubMed
- Elmsmari F, Ruiz XF, Miró Q ym. Outcome of Partial Pulpotomy in Cariously Exposed Posterior Permanent Teeth: A Systematic Review and Meta-analysis. J Endod 2019;45:1296-1306.e3 «PMID: 31515048»PubMed
- Cushley S, Duncan HF, Lappin MJ ym. Pulpotomy for mature carious teeth with symptoms of irreversible pulpitis: A systematic review. J Dent 2019;88:103158 «PMID: 31229496»PubMed
- R R, Aravind A, Kumar V ym. Influence of occlusal and proximal caries on the outcome of full pulpotomy in permanent mandibular molar teeth with partial irreversible pulpitis: A prospective study. Int Endod J 2021;54:1699-1707 «PMID: 34101859»PubMed