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Table of Contents
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 1-5

Treatment outcomes of pulpotomy using bioceramic materials in permanent posterior teeth with carious exposure

Department of Conservative Dentistry and Endodontics, Government Dental College, Trivandrum, Kerala, India

Date of Submission05-Dec-2021
Date of Acceptance18-Feb-2022
Date of Web Publication25-Mar-2022

Correspondence Address:
Dr. Savitha Sriraman
Room 38, Government Dental College, Medical College, Trivandrum 695011, Kerala.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJO.INJO_37_21

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Background and Objectives: Pulpotomy is a highly successful treatment modality in primary teeth with carious exposure. With the advent of new bioceramic materials and our advanced knowledge of pulp biology, there is successful clinical use of pulpotomy in permanent teeth also. This study was conducted to assess the treatment outcome following pulpotomy using bioceramic materials in carious exposed permanent posterior teeth based on clinical evaluation at 3, 6, and 12 months follow-up and radiographic evaluation at 12 months or any time during the follow-up period if symptomatic. Clinically visible coronal discoloration and diffuse calcification were also assessed. Materials and Methods: Sixty-eight patients of the age group 12–50 years satisfying the inclusion criteria were enrolled in the current study. Pulpotomy medicaments used were Biodentine and MTA. Sodium hypochlorite was used for hemostasis. Permanent restoration given was composite. Follow-up intervals were 3, 6, and 12 months. Outcome evaluation was based on clinical and radiographic criteria. The association of success or failure with the selected covariates was done using the χ2 test. Results: For the follow-up period as far as 12 months, 47 of the 55 teeth showed successful outcomes (85.5% clinical and radiographic success), and the recall rate was 80.8%. No obvious crown discoloration or diffuse calcification was noted in any of the cases. Age, sex, tooth type, and pre-operative symptoms had no effect on the outcome. Type of bioceramic material and time to stop bleeding had statistically significant effects on outcome. Conclusion: In light of the observations in the present study, it can be concluded that pulpotomy is a successful treatment alternative to root canal treatment in vital permanent teeth with carious exposure in indicated cases. More clinical studies with a larger sample size and longer follow-up periods are required to refine the case selection criteria followed for pulpotomy procedure.

Keywords: Bioceramic material, outcome of pulpotomy, vital pulp therapy

How to cite this article:
Mohan SM, Babu A, Sriraman S, Pradeep G. Treatment outcomes of pulpotomy using bioceramic materials in permanent posterior teeth with carious exposure. Int J Oral Care Res 2022;10:1-5

How to cite this URL:
Mohan SM, Babu A, Sriraman S, Pradeep G. Treatment outcomes of pulpotomy using bioceramic materials in permanent posterior teeth with carious exposure. Int J Oral Care Res [serial online] 2022 [cited 2023 Mar 24];10:1-5. Available from: https://www.ijocr.org/text.asp?2022/10/1/1/340917

  Introduction Top

Vital pulp therapy (VPT) aims to shield and conserve pulp tissue that has been acquiesced but not destroyed by caries, trauma, or restorative procedures in a healthy state. In the permanent dentition, one of the most followed treatment options for irreversible pulpitis is pulpectomy/root canal treatment (RCT).

Recently, the emerging viable treatment options focus on the removal of infected portions rather than going for the replacement of the entire vital tissue. This minimally invasive approach, VPT, is a new insight in pulp preservation. The prime objective in VPT is to initiate the formation of tertiary reparative dentin or calcific bridge formation.[1] It is less time-consuming, minimally invasive, and a simple procedure when compared with RCT.[2]

VPT is a blanket term for pulp capping (direct/indirect) or pulpotomy (miniature/partial/complete).[3] Pulpotomy involves the removal of a small amount (miniature or partial pulpotomy) of the coronal pulp or up to complete removal of the coronal pulp (full or complete pulpotomy), followed by direct coverage of the remaining pulp tissue.[4]

One of the critical issues in VPT which remains unresolved is the status of inflammation of the pulp tissue. The inflammatory response of dental pulp to caries is currently classified as reversible or irreversible pulpitis.[2] This is purely a histological classification, and the clinical signs and symptoms are not pathognomonic for either. These clinical diagnoses do not accurately represent the true pathological state of the pulp. An accurate method to assess the status of the pulp precisely is yet to be developed. Pulp sensibility tests do not accurately reflect the pulp condition.[5] Moreover, multiple studies reported successful treatment outcomes in vital teeth with cariously exposed pulp with signs and symptoms of irreversible pulpitis even with periapical lesions.[6],[7]

With the introduction of bioceramic materials, a new era in the VPT began. Mineral trioxide aggregate (MTA) and Biodentine can be a reliable alternative to calcium hydroxide (CH) in VPT procedures due to its biocompatibility and improved sealing ability. It possesses good physical properties and provides an excellent marginal adaptation.[8],[9] Thus with the advent of bioceramic materials, the success of VPT has reached a higher tier.[10]

The literature, though limited, shows a promising result in permanent teeth. As a result, pulpotomy should be reconsidered as a viable treatment option for permanent teeth.[11] Moreover, the criteria for indication of VPT needs to be studied further. Hence, this study focusses on the outcome of pulpotomy using bioceramic materials in mature permanent teeth with carious pulp exposure.

  Materials and Methods Top

Case selection

In the current study, patients in the age group of 12–50 years and willing to give informed consent were included in the study. Patients with systemic disorders and pregnant women were excluded. Cases that met the selection criteria were included in the outcome analysis:

  • Patients with deep caries and subsequent pulp exposure;

  • Positive response on pulp sensibility test/presence of vital coronal pulp;

  • No clinical signs or symptoms indicating pulpal degenerations including swelling, sinus tract, tooth mobility, tenderness to percussion;

  • Preliminary radiographs revealed absence of pathological external or internal root resorption and inter-radicular or periapical radiolucency [Figure 1].
  • Figure 1: Pre-operative radiograph showing deep caries

    Click here to view

    All procedures performed in the study were conducted in accordance with the ethics standards given in 1964 Declaration of Helsinki, as revised in 2013. The study proposal was submitted for approval and clearance was obtained from the ethical committee of our institution. A written informed consent was obtained from each participant. Sixty-eight molar teeth in 68 patients who were referred to the graduate endodontic clinic during the period from January 2018 to June 2019 and satisfying the inclusion criteria were enrolled in the current study. Patients were informed about the treatment in detail, and their informed consent was acquired.

    Clinical procedure

    All treatments were performed under strict aseptic technique under rubber dam application.

    After a local anesthetic has been administered (lignocaine hydrochloride 2% with adrenaline 1:200,000), rubber dam application was done and the crown was disinfected with 5% sodium hypochlorite. A sharp spoon excavator or a slow-speed number 4 round diamond bur was used to remove caries. The cavity was flushed with 2.5% sodium hypochlorite after pulp exposure. Pulp tissue was removed to a level of canal orifices with a sterile spoon excavator. A cotton pellet moistened with 2.5% sodium hypochlorite was applied for up to 10 min to achieve hemostasis [Figure 2]. Biodentine/MTA was mixed according to manufacturer’s instructions and was placed over the exposed pulpal tissue using an amalgam carrier and gently packed using a condenser. Then a layer of resin-modified glass-ionomer cement was placed over the material and light-cured for 20 s. Composite restorations were placed in the same visit and an immediate post-operative radiograph was taken [Figure 3] and [Figure 4].
    Figure 2: Hemostasis achieved

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    Figure 3: Immediate post-operative radiograph

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    Figure 4: Final composite restoration

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    Post-operative evaluation was done at 3, 6, and 12 months. At follow-up, patients were subjected to clinical examination. Periapical radiographs were taken to assess the diffuse calcification at 12 months [Figure 5] and for those teeth which became symptomatic anytime during the follow-up period.
    Figure 5: One-year review radiograph

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    The outcome was considered successful if there is:

    1. absence of clinical signs and symptoms of pulpal pathosis (pain, tenderness to percussion, sinus tract, swelling);

    2. no pathosis evident on the recall radiograph such as root resorption, new furcal, or periapical rarefaction;

    3. complete radiographic healing (PAI score 1 or 2) or reduction in the PAI score if periapical rarefactions present pre-operatively.

    The quality of the coronal restoration was assessed, and if necessary, repairs were made.

    Statistical analysis

    The χ2 test was used to determine the association between categorical variables. For all statistical interpretations, P < 0.05 was considered the threshold for statistical significance. Statistical analysis was performed by using a statistical software package SPSS, version 20.0.

      Results Top

    The study sample consisted of 68 teeth with patients in the age group of 12–50 years (mean ± SD, 19.6 ± 5.7), and 44.1% of the patients were females and 55.9% were males.

    Hemostasis was achieved in ≤5 min in 52.9% of the cases and >5 min in 47.1% of the cases with a mean ± SD of 5.3 ± 1.3. MTA was used in 45.6% of the cases and Biodentine in 54.4% of the cases. The recall rate was 80.8%.

    For the follow-up period as far as 12 months, 47 of the 55 teeth showed successful outcomes (85.5% clinical and radiographic success) at 1 year. Immediate failure occurred in four teeth in which severe spontaneous pain was present 3 weeks after the procedure. The other failures reported were two cases at 6 months and one case at 12 months. RCT was done in all the failed cases. No evidence of root resorption, diffuse calcification, furcal pathosis, or new periapical pathosis was present in the radiographic examination. There was no obvious crown discoloration noted in any of the cases.

    While comparing the association between categorical variables using the χ2 test, from this graph, it can be concluded that there was no association between age and sex and tooth type with the outcome. A statistically significant association was noted in the time to stop bleeding (P = 0.002) and type of material used (P = 0.014) with the outcome as in [Table 1].
    Table 1: Comparison of type of material and the time to stop bleeding based on outcome

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      Discussion Top

    As a conservative treatment, VPT has the advantage of preserving vital pulp functions including defensive mechanism and proprioceptive function. In addition to that, lesser amount of hard tissue is removed compared with conventional RCT, helping to preserve the fracture resistance of the tooth.

    There are several methods to arrest bleeding during the procedure. Previous studies support the use of NaOCl as a biocompatible and effective hemostatic agent. NaOCl can be used for disinfection and chemical amputation of blood clot and debris. It makes the site free of organic biofilm before the placement of medicament.[12],[13] In the present study, hemorrhage control following the removal of the coronal pulp was achieved using a cotton pellet soaked in 2.5% sodium hypochlorite for up to 10 min.

    Pulpal status plays a decisive role in the success or failure of VPT. No tools were available to assess how far the inflammation has reached the pulp. Uncontrollable bleeding that is difficult to manage indicates that the pulp is severely inflamed.[14] If the bleeding did not deter within 5–10 min, the inflammation was considered uncontrollable, and pulpectomy was indicated.[15],[16] In the present study, the information from the failed cases showed that the time to stop bleeding was 7–8 min. From the statistical analysis, there was 100% success in cases with the time to stop bleeding was less than or equal to 5 min.

    Several restorative materials have been suggested for VPT. The most frequently used material earlier was CH. But it may cause caustic effects on the pulp tissue and has only limited ability to seal. Moreover, it dissolves over time and the presence of tunnel defects within the formed hard tissue bridges can act as pathways for microleakage.[17] Advanced researches in the field of dental materials have come up with a new revolutionary restorative material—bioceramics. Both histological and clinical approaches demonstrate convergent results supporting bioceramic materials as a valuable material for full pulpotomy.

    The literature strongly supports both MTA and Biodentine as an alternative to CH in VPT, with no significant difference in the success rate between both.[18],[19],[20] Since MTA and Biodentine have a predictable and similar outcome, in the present study we used both materials.

    There is statistically significant difference between the two groups in terms of success. The difference might be due to the inability to evaluate the pulp status before the procedure and not directly related to the material quality. In the current study, formation of dentin bridges was not taken as a criterion for success as it is difficult to appreciate radiographically and it varies between the observers. It can only be confirmed by histologic examination.[21]

    The quality of the coronal restoration plays an important role in the long-term success. Bacterial recontamination through coronal microleakage should be avoided for a positive clinical outcome. In the present study, composite restoration was given for all the teeth after initial setting of the bioceramic material. The restorations were intact in 50 cases and repaired in 5 cases following fracture. This might have contributed to the high success rate in our study.

    In the present study, coronal discoloration was not evident in any of the cases, and no cases with diffuse calcification were observed. In a study by Awawdeh et al.,[18] the MTA group exhibited some evidence of discoloration, whereas the Biodentine group remained unchanged. No evidence of canal obliteration was also noticed. They concluded that a longer follow-up period is needed to fully evaluate this and compare between MTA and Biodentine.

    From the results of the present study, it can be concluded that pulpotomy is a viable option in the treatment of inflamed pulp. However, further clinical studies are required to refine the clinical criteria for pulpotomy to improve the predictability of the same.

      Conclusion Top

    In light of the observations in the present study, it can be concluded that pulpotomy is a successful treatment alternative to RCT in vital permanent teeth with carious exposure in indicated cases. More clinical studies with a larger sample size and longer follow-up periods are required to refine the case selection criteria followed for pulpotomy procedure.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship


    Conflicts of interest

    There are no conflicts of interest.

      References Top

    Hargreaves KM, Berman LH. Cohen’s Pathways of the Pulp Expert Consult. St. Louis, MO: Elsevier Health Sciences; 2015.  Back to cited text no. 1
    Duncan HF, Cooper PR, Smith AJ. Dissecting dentine-pulp injury and wound healing responses: Consequences for regenerative endodontics. Int Endod J 2019;52:261-6.  Back to cited text no. 2
    Hilton TJ. Keys to clinical success with pulp capping: A review of the literature. Oper Dent 2009;34:615-25.  Back to cited text no. 3
    Asgary S, Hassanizadeh R, Torabzadeh H, Eghbal MJ. Treatment outcomes of 4 vital pulp therapies in mature molars. J Endod 2018;44:529-35.  Back to cited text no. 4
    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.  Back to cited text no. 5
    Calişkan MK. Pulpotomy of carious vital teeth with periapical involvement. Int Endod J 1995;28:172-6.  Back to cited text no. 6
    Teixeira LS, Demarco FF, Coppola MC, Bonow ML. Clinical and radiographic evaluation of pulpotomies performed under intrapulpal injection of anaesthetic solution. Int Endod J 2001;34:440-6.  Back to cited text no. 7
    Camilleri J, Pitt Ford TR. Mineral trioxide aggregate: A review of the constituents and biological properties of the material. Int Endod J 2006;39:747-54.  Back to cited text no. 8
    Kaur M, Singh H, Dhillon JS, Batra M, Saini M. MTA versus Biodentine: Review of literature with a comparative analysis. J Clin Diagn Res 2017;11:ZG01-5.  Back to cited text no. 9
    Ingle JI, Bakland LK, Baumgartner JC, editors. Ingle’s Endodontics 6. Raleigh, NC: PMPH USA; 2008.  Back to cited text no. 10
    Simon S, Perard M, Zanini M, Smith AJ, Charpentier E, Djole SX, et al. Should pulp chamber pulpotomy be seen as a permanent treatment? Some preliminary thoughts. Int Endod J 2013;46:79-87.  Back to cited text no. 11
    Tunç ES, Saroğlu I, Sari S, Günhan O. The effect of sodium hypochlorite application on the success of calcium hydroxide pulpotomy in primary teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:e22-6.  Back to cited text no. 12
    Singh S, Sinha R, Kar SK, Ather A, Limaye SN. Effect of chlorine dioxide and sodium hypochlorite on the dissolution of human pulp tissue—An in vitro study. Med J Armed Forces India 2012;68:356-9.  Back to cited text no. 13
    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.  Back to cited text no. 14
    Witherspoon DE, Small JC, Harris GZ. Mineral trioxide aggregate pulpotomies: A case series outcomes assessment. J Am Dent Assoc 2006;137:610-8.  Back to cited text no. 15
    Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: An observational study. J Am Dent Assoc 2008;139:305-15; quiz 305-15.  Back to cited text no. 16
    Schröder U. Effects of calcium hydroxide-containing pulp-capping agents on pulp cell migration, proliferation, and differentiation. J Dent Res 1985;64:541-8.  Back to cited text no. 17
    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.  Back to cited text no. 18
    Kusum B, Rakesh K, Richa K. Clinical and radiographical evaluation of mineral trioxide aggregate, Biodentine and propolis as pulpotomy medicaments in primary teeth. Restor Dent Endod 2015;40:276-85.  Back to cited text no. 19
    Cuadros-Fernández C, Lorente Rodríguez AI, Sáez-Martínez S, García-Binimelis J, About I, Mercadé M. Short-term treatment outcome of pulpotomies in primary molars using mineral trioxide aggregate and Biodentine: A randomized clinical trial. Clin Oral Investig 2016;20:1639-45.  Back to cited text no. 20
    Stanley HR. Pulp capping: Conserving the dental pulp—Can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol 1989;68:628-39.  Back to cited text no. 21


      [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

      [Table 1]


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