Mohit Galani, MDS, Sanjay Tewari, MDS, Pankaj Sangwan, MDS, Shweta Mittal, MDS, Vinay Kumar, MDS, and Jigyasa Duhan, MDS

1. “Comparative Evaluation of Postoperative Pain and
Success Rate after Pulpotomy and Root Canal
Treatment in Cariously Exposed Mature Permanent
Molars: A Randomized Controlled Trial”
Mohit Galani, MDS, Sanjay Tewari, MDS, Pankaj Sangwan, MDS, Shweta Mittal, MDS,
Vinay Kumar, MDS, and Jigyasa Duhan, MDS
JOE: Oct,2017

2. “
✘ Inflamed pulp as a result of deep caries can be treated clinically by
either preserving the tissue or excising it completely, followed by
obturation of the tooth.
✘ However, the best modality of treatment still remains a controversial
issue.
2
Introduction

3. “✘ The preferred treatment for symptomatic or asymptomatic teeth with
deep caries lesion reaching the pulp is root canal treatment (RCT).
✘ It has certain disadvantages, being time-consuming, expensive, and
requiring multiple visits making the teeth susceptible to fractures due to
loss of tooth structure.
✘ Preserving the vital pulp helps in retaining proprioceptive, reparative,
tooth sensitivity (innervation), vascularization, and damping functions
provided by vital pulp, which help in protecting against harmful stimuli.
3

4. “✘ Vital pulp therapy is usually performed in young patients with traumatic, carious,
or mechanical exposure of pulp with no signs of periapical pathology .
✘ Pulp amputation or pulpotomy is defined as a procedure in which a part of an
exposed vital pulp is removed, usually as a means of preserving the vitality and
function of the remaining part.
✘ Coronal pulpotomy has been considered as a definitive treatment to manage
carious pulp exposures for primary teeth and young immature permanent teeth,
as well as in treating traumatic pulp exposures in mature teeth with signs of
reversible pulpitis. In adults, it may be undertaken for emergency management
of tooth pain before RCT.
4

5. “✘ It has been proposed that age might be a limiting factor in determining
success of vital pulp therapy in permanent teeth with carious exposures.
✘ Hence, the aim of the present study was to evaluate clinical and
radiographic success as the primary outcome measure and pain
intensity and reduction as the secondary outcome measure in patients
with cariously exposed mature permanent molars in adults.
5

6. Materials & methodology
6
 The present trial was conducted following approval by the ethical
committee (PGIDS/IEC/2015/65) of the Post Graduate Institute of
Dental Sciences (PGIDS), Rohtak.
 Study subjects were recruited from the pool of patients referred to
the postgraduate department of Conservative Dentistry and
Endodontics of PGIDS, Rohtak.

7. 7
 Diabetic
 Immunocompromised
 Pregnant
 Negative response to vitality tests
 Positive history of antibiotic use in the past 1 month or required antibiotic prophylaxis
 Had taken analgesics in the past 3 days
 If the tooth was previously accessed, had an associated periapical lesion visible on
radiograph
 Had inflamed pulp in which bleeding could not be controlled within 5 minutes
Exclusion criteria
 first and second permanent mandibular molars with carious exposure of pulp
Inclusion criteria

8. 8
 Informed consent explaining benefits and risks of treatment was
taken from patients before participation in the trial and symptoms
of included patients were recorded and radiographs were taken for
future comparisons at predefined exposures.
✘ All the endodontic procedures were performed by a single operator
(M.G.).
✘ Teeth were anesthetized using 2% lignocaine hydrochloride with
epinephrine 1:80,000 (ICPA Health Products Ltd, Ankleshwar, India),
and isolated under rubber dam.
N (54)
23
in each
group

9. 9
Clinical procedure for pulpotomy
 Excavated using a large round diamond bur in a
high-speed handpiece with water coolant and
spoon excavators
 After deroofing of pulp chamber, coronal pulp
tissue was excised using a spoon excavator until
the canal orifice, and hemorrhage was controlled
using a cotton pellet moistened with 2.5% sodium
hypochlorite (NaOCl; Prevest Denpro Ltd, Jammu,
India) applied for 2 to 3 minute

10. 10
 After hemorrhage control, the chamber was cleaned
using 5 mL 2.5% NaOCl, and a freshly mixed paste of
white mineral trioxide aggregate (MTA) (Pro-Root MTA
White; Dentsply Maillefer) was placed over the chamber
floor covering the canal orifices.
 A damped cotton pellet was placed over the condensed
MTA and the cavity was sealed with Ketac Molar glass-
ionomer filling (3M/ ESPE, Seefeld, Germany) as interim
restoration.
 At the second appointment, scheduled after 4 to 7 days, symptoms were
evaluated, the interim restoration was removed, and the hardness of MTA was
evaluated.
 KetacMolar was placed as a base over MTA in sufficient thickness until the cavity
was 3 to 4 mm deep and the remaining cavity was restored with composite
restoration (Tetric-E-Ceram; Ivoclar-Vivadent, Schaan, Liechtenstein).

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In the RCT group, treatment was performed in 2 visits.
After removing the inflamed pulp, canal orifices were identified and enlarged using
Gates Glidden drills (Mani Inc, Utsunomiya, Tochigi, Japan) or Sx ProTaper Universal
rotary (Dentsply Maillefer).
Working length was determined using stainless steel k-files (Mani, Inc.) keeping 0.5 to
1.0 mm short of the apex using a RootZX apex locator (J. Morita, Irvine, CA) and
confirmed radiographically.
Radicular pulp was excised using H-files. The coronal two-thirds was prepared using
the ProTaper system in the sequence recommended by the manufacturer and
irrigation with 5 mL 2.5% NaOCl between instruments.
Clinical procedure for root canal therapy

12. 12
Apical enlargement was done depending on the file that bound at the apex after
coronal preparation. Canals were finally irrigated with 5 mL 2.5% NaOCl and restored
with Ketac Molar as an intermediate restoration.
At the second visit, obturation was done with gutta-percha (Meta Biomed Co. Ltd,
Cheongwongun, Chungbuk, Korea) and zinc oxide eugenol sealer (Dental products of
India Ltd, New Delhi, India) using cold lateral condensation technique and restored with
composite resin with a base of glass ionomer cement (Ketac Molar).

13. Evaluation criteria
13
 Preoperative and postoperative pain were recorded on a 0 to 10-cm visual analog
scale (VAS) scale every 24 hours until the seventh day after the first appointment.
 Pain on the VAS was further categorized as no pain (0), or mild (1–3), moderate (4–
6), or severe (7–10) pain.
 All periapical radiographs were taken with a 70-Kvp machine (Runyes; Unicorn Denmart,
New Delhi, India) with 0.3-second exposure time constant for all radiographs and
digital sensor (Kodak5100; Eastman Kodak Company, Rochester, NY) during treatment and
follow-up visits.
 Patients were recalled every 3 months for 18 months for clinical and radiographic
examination and evaluation of integrity of the restorationseventh day after the
first appointment.

14. 14
There was a statistically significant difference (P < .05) in age between the 2
groups. Gender differences between the groups were nonsignificant (P > .05)
Results

15. 15

16. 16
 One patient in the pulpotomy group and another in the RCT group were lost during
follow-up for success.
 Two patients in the pulpotomy group required RCT at 6-month follow-up. One of
these patients had sinus tract formation, whereas the other complained of
persistent pain and tenderness to percussion. Another patient in the pulpotomy
group, although clinically asymptomatic, had periapical radiolucency at 9 months
and required RCT.
 In the RCT group, 1 patient complained of occasional pain on chewing and had
periapical radiolucency and another had periapical radiolucency, but was clinically
asymptomatic at the end of follow-up. One patient in each group had uncertain
outcome.
 Overall success rate was 85% in the pulpotomy group and 87.5% in the RCT group;
however, the difference was nonsignificant (P > .05)

17. 17
Discussion
 With the advancement of materials and techniques and better understanding
of healing of pulp in recent years, vital pulp therapy has gained importance and is
practiced as an alternative to RCT.
 Wang et al, in an exploratory study, concluded that even irreversibly inflamed pulp
showed presence of putative stem cells.
 Case reports and case series have demonstrated that such treatment is also
successful in permanent mature teeth with histological evidence of dentin bridge
formation and clinical and radiographic success

18. 18
 In the present study, they preferred coronal pulpotomy over partial pulpotomy
and entire coronal pulp until the chamber floor was excised with sharp spoon
excavators, leaving vital radicular pulp.
 Partial pulpotomy, proposed by Cvek was not used in this study, as it is difficult
to determine depth of disease progression clinically to ensure complete
removal of diseased tissue to eliminate its confounding effect.
 Coronal pulpotomy, on the other hand, removes the entire inflamed pulp tissue
and provides firm sheath of the floor of the pulp chamber for proper placement
and condensation of the pulp capping agent.

19. 19
 Studies have shown that witnessing degree of pulp bleeding rather than relying
on preoperative clinical signs and symptoms is an important aspect for success
of vital pulp therapy.
 Use of 3% NaOCl has been demonstrated to be effective as a hemorrhage control
agent in pulpotomy recent studies on pulpotomy have found successful results of
MTA as a pulpotomy agent with better and complete dentin bridge formation
than calcium hydroxide.

20. 20
 Pulpotomy is usually recommended in young patients, as younger pulp is more
vascular, cellular, and has enhanced reparative potential.
 Many studies have reported high success rates of pulpotomy in young
permanent teeth.
 However, Kunert et al (40), in a retrospective study in 8- to 79-year-old patients,
observed that age had no influence on success rate of pulpotomy. The findings of
this study are in concurrence with previous studies showing high success rate in
patients with age ranging up to 50 years

21. 21
 In the present randomized controlled trial, patients were followed for 18 months
with clinical and radiographic evaluation every 3 months.
 The length of follow-up period remains a topic of controversy.
 Although a study by Zanini et al (7) stated that follow-up of 6 months seems to be
adequate to tentatively assess the outcome of pulpotomy, Ng et al (42) and
Yazdani et al suggested that 2 years of follow-up is required to predict the
success of endodontic treatment

22. 22
 Pain is the principal subjective symptom for which the patient seek endodontic
treatment.
 Presence of preoperative pain is the major predictor of postoperative pain.
 The mean postoperative pain scores were statistically significantly lower for the
pulpotomy group, indicating more symptomatic relief in the pulpotomy group.
Thus, it can be concluded that pulpotomy can be an alternative treatment for
emergency relief of pain..

23. 23
 In the present study, overall success rate was 85% in the pulpotomy group and
87.5% in the RCT group; however, the difference was nonsignificant (P > .05).
 Three cases in the pulpotomy group had failed, suggesting limitations of currently
available diagnostic aids to correctly diagnose pulpal disease
 The high success rate of pulpotomy is consistent with the results of Alqaderi et al
and Simon et al, who conducted coronal pulpotomy in mature permanent teeth
and found success rates of 90% and 82%, respectively, over 24 months of follow-
up.

24. 24
 Quality of restoration is one of the most important factors in long-term success
of pulpotomized teeth.
 Bacterial recontamination should be avoided for achievement of successful
results. Placement of MTA with composite restoration and base of glass ionomer
cement (Ketac Molar) was used in the present study because it helped ensure
good postoperative coronal seal.

25. 25
 One of the questions for pulpotomy in cariously exposed mature permanent
teeth is calcification of the canal space.
 In this study, they found no evidence of root canal obliteration in any of the
pulpotomy cases on radiographic examination after 18 months. It is unknown if
pulpotomy with MTA can cause calcification of the canal space in the long term.
 Randomization in this study was done before the treatment procedure to
overcome bias. A better randomization procedure can be performed after
excavation of the carious lesion.

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“Within the limitations of the study, it can be suggested that coronal
pulpotomy can serve as a suitable alternative treatment option for
cariously exposed permanent teeth with no signs of apical
periodontitis.”
Conclusion

27. 27
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Thank you!