Single visit root canal treatment versus pulpotomy in management of pulpitis

Mariam A Elsherif; Abeer M Darrag; Hussein I Saudi; Neveen A Shaheen

doi:10.4103/tdj.tdj_1_23

ORIGINAL ARTICLE

Year : 2023 | Volume : 20 | Issue : 2 | Page : 89-94

Single visit root canal treatment versus pulpotomy in management of pulpitis

Mariam A Elsherif BDS ¹, Abeer M Darrag¹, Hussein I Saudi², Neveen A Shaheen¹
¹ Department of Endodontics, Faculty of Dentistry, Tanta University, Tanta, Egypt
² Department of Oral Medicine, Periodontology, Oral Diagnosis and Radiology, Faculty of Dentistry, Tanta University, Tanta, Egypt

Date of Submission	16-Jan-2023
Date of Decision	26-Jan-2023
Date of Acceptance	07-Feb-2023
Date of Web Publication	11-May-2023

Correspondence Address:
Mariam A Elsherif
Department of Endodontics, Faculty of Dentistry, Tanta University, Tanta
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/tdj.tdj_1_23

Abstract

Aim
To clinically and radiographically evaluate single visit root canal treatment (RCT) and pulpotomy in management of mature teeth with irreversible pulpitis.
Patients and methods
Twenty-four patients diagnosed with irreversible pulpitis in their mature permanent mandibular molars, were selected and randomly divided into two equal groups according to the treatment protocol either single visit RCT or pulpotomy. For single visit RCT group, ProTaper NEXT rotary system was used for canal preparation and obturation was done using cold lateral condensation technique. While in pulpotomy group, after coronal pulp amputation and hemostasis, Biodentine was used as the pulpotomy agent. The clinical examination of tested groups was performed immediately after completing the procedure (baseline), 3, 6, 9, and 12 months posttreatment. While the radiographic examination using cone-beam computed tomography was carried out at baseline and 12 months postoperatively. Statistical analysis was performed by χ² test for clinical evaluation criteria and t test for radiographic data.
Results
Single visit RCT had clinical success rate of 91.67%, while pulpotomy group showed 83.33% success rate. Radiographically, both groups showed normal width of periodontal ligament membrane space and normal bone density after follow-up. There was no statistically significant difference between two groups (P > 0.05).
Conclusions
Single visit RCT and pulpotomy had high success rate in management of mature permanent teeth diagnosed with irreversible pulpitis. Pulpotomy can be considered as an alternative treatment option.

Keywords: Biodentine, cone-beam computed tomography, irreversible pulpitis, mature permanent teeth, pulpotomy, vital pulp therapy

How to cite this article:
Elsherif MA, Darrag AM, Saudi HI, Shaheen NA. Single visit root canal treatment versus pulpotomy in management of pulpitis. Tanta Dent J 2023;20:89-94

How to cite this URL:
Elsherif MA, Darrag AM, Saudi HI, Shaheen NA. Single visit root canal treatment versus pulpotomy in management of pulpitis. Tanta Dent J [serial online] 2023 [cited 2023 May 27];20:89-94. Available from: http://www.tmj.eg.net/text.asp?2023/20/2/89/376635

Introduction

Irreversible pulpitis is an inflammation of the pulp that causes painful response to cold and hot stimuli which linger for several minutes after removal of the stimulus and is considered a common sequelae of dental caries. Mature permanent teeth with irreversible pulpitis is traditionally managed by root canal treatment (RCT) and it is considered the gold standard treatment. Traditionally, RCT was performed in multiple visits, however, evolution of new and more reliable techniques and materials have led to evolution of single visit RCT ^[1].

RCT has an excellent success rate and prognosis, however, it is technically challenging, expensive, and time consuming. Additionally, removal of the pulp tissue can also structurally weaken the tooth, rendering it more susceptible to fracture. Therefore, minimally invasive alternatives should be considered ^[2].

Vital pulp therapy (VPT) is a minimally invasive approach for treating mature permanent teeth with inflamed pulp ^[3]. Pulpotomy is a VPT in which the inflamed and/or infected coronal pulp is removed in an attempt to preserve the remaining radicular pulp and then using a suitable material protecting it from further injury and enhances healing. Pulpotomy may be considered as a conservative, simple and economical treatment modality of irreversible pulpitis when the radicular pulp is still healthy ^[4].

The selection of the material for pulpotomy is an important factor which influences the success rate. Calcium hydroxide and mineral trioxide aggregate (MTA) are considered the most commonly utilized pulpotomy agents for VPT, however, there are many drawbacks of these materials ^[4].

Biodentine is a calcium silicate cement that was introduced as a dentine replacement material. It is biocompatible and has shown improvement of many properties such as mixing, handling, shorter initial setting time and less coronal discoloration when compared to MTA ^[5].

There are limited studies comparing RCT and pulpotomy as treatment modalities of irreversible pulpitis in mature teeth.

Patients and methods

This study was a randomized controlled clinical trial conducted on 24 patients diagnosed with irreversible pulpitis in permanent mature mandibular first or second molars. Ethical approval was obtained from the Research Ethics Committee, Faculty of Dentistry, Tanta University and carried out at the Endodontic Department. The purpose and steps of the study procedures were explained to the patients and informed consents were obtained. Twenty-seven patients (RCT, n = 12; pulpotomy, n = 15) were recruited according to the inclusion criteria, and randomly divided into two groups but three of them were excluded in case of pulpotomy procedure due to inability to control bleeding or presence of partial necrosis.

Patients aged 18–50 years, with deep caries or large restoration in their mandibular first or second molars, teeth should have positively respond to thermal pulp testing by spontaneous lingering pain lasting for few seconds to several hours and exacerbated by hot and cold fluids, teeth had normal periapical structure, restorable teeth, mobility and pocket probing depth are within normal limits.

Teeth with periapical widening or any periapical pathosis, marginal periodontitis, sinus tract or swelling, badly destructed teeth, internal or external root resorption, root canal calcification and patients with active systemic disease were excluded from this study.

Cases were excluded if bleeding could not be controlled within 6 min after excision of coronal pulp tissue or insufficient or no bleeding after pulp exposure in pulpotomy group.

Patients received the treatment procedure were randomly divided into two groups (n = 12 each).

Group 1: teeth were treated with single visit RCT.

Group 2: teeth were treated with pulpotomy.

For RCT group, after administration of local anesthesia (Mepivacaine HCl 36 mg/1.8 ml + Levonordefrin HCl 0.108 mg/1.8 ml) (Alexandria Co. for Pharmaceuticals and Chemical Industries, Alexandria, Egypt) and isolation of the offending tooth by rubber dam. Caries or/and old restoration was removed and access cavity was prepared. Then, the working length was determined using apex locator and confirmed radiographically. The root canals were then prepared using ProTaper NEXT rotary system (Dentsply Maillefer, Ballaigues, Switzerland) and irrigation was done using 3 ml of 2.5% NaOCl solution after each instrument. At the same visit, obturation was done using gutta percha and AH plus sealer and the cavity was restored permanently by composite restoration [Figure 1].

Figure 1: Root canal treatment steps: (a) preoperative radiograph film showing extensive composite restoration at lower first molar; (b) access cavity; (c) working length determination; (d) master cone fit; (e) obturation; and (f) final composite restoration.

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While for pulpotomy group, local anesthesia administration was done and the tooth was isolated with rubber dam, then disinfected with gauze soaked in 5% NaOCl before caries and/or defective restoration removal and access cavity preparation were completed as for group 1. The coronal pulp tissue was removed up to the level of canal orifices using a sterile sharp spoon excavator. The pulp wound was carefully irrigated with sterile saline solution and hemostasis was achieved by application of a cotton pellet moistened with 2.5% NaOCl for 2 min with a dry pellet on top and repeated if required up to 6 min Biodentine (Septodont, Saint Maur des Faussés, France) was mixed and applied over the pulp tissue in a 2–3 mm thickness layer, then, covered by a moistened cotton pellet for 12 min to allow its setting. Finally, a layer of resin modified glass ionomer cement (Fuji ll LC, GC, Tokyo, Japan) was placed over Biodentine and the coronal access cavity was permanently restored with resin composite [Figure 2].

Figure 2: Steps of pulpotomy: (a) isolation of lower first molar with a defective amalgam restoration; (b) access cavity and hemostasis; (c) placement of Biodentine; (d) final resin composite restoration; (e) preoperative radiograph; and (f) postoperative radiograph.

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After that, clinical examination was performed at baseline, 3, 6, 9, and 12 months posttreatment including presence or absence of pain, tenderness to percussion, sinus tract, swelling and mobility. Radiographic examination was carried out at baseline and 12 months postoperatively using cone-beam computed tomography (CBCT) (PaX-i3D Green, Vatech, Korea) (90 kV, 11 mA, 0.200 mm voxel size). Periodontal ligament membrane space (PLMS) and bone density was measured using SIMPLANT PRO software (SIMPLANT Pro Software, Materialise Dental, USA).

PLMS was measured by selecting three areas on the lower half of each root as samples from the widest different diameters on mesial and distal roots. Then, gaining the mean width in millimeter. While, bone density was measured at the apical areas of both roots and the lowest value of density was selected [Figure 3]

Figure 3: Measurements of PDL space width and periapical bone density on mesial root.

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Statistical analysis of clinical and radiographic evaluation between the study groups was completed using χ² test and t test, respectively. Significant level was set at P value less than or equal to 0.05.

Results

Clinical results

All cases of single visit RCT group did not feel pain at baseline while in pulpotomy group two cases had pain. At the 3, 6, and 9 months recall period, all cases of RCT and pulpotomy groups did not have pain. At 12 months follow-up, one case in RCT group had pain. So, one and two cases felt pain in RCT and pulpotomy groups respectively. χ² test revealed no statistically significant difference between both groups at each time interval (P > 0.05) [Table 1].

Table 1 Number and percentage of pain/tenderness on percussion of both groups at follow-up periods

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Radiographic results

For PLMS evaluation, the change was minimal decrease in the mean value of PLMS at 12 months follow-up in single visit RCT group for both mesial and distal roots. Similarly, the decrease was minute for pulpotomy group. t test was revealed no statistically significant difference in the mean value of changes in PMLS between both groups (P > 0.05) [Table 2].

Table 2 Mean values of changes in periodontal ligament membrane space after 12 month follow-up of both groups

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The same for bone density evaluation, there was slight increase in bone density after 12 months follow-up in single visit RCT group for mesial and distal roots, and also the same for pulpotomy group [Table 3]. t test revealed no statistically significant difference in the change of bone density between both groups at all follow up periods (P > 0.05).

Table 3 Mean values of changes in bone density after 12 month follow-up of both groups

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Discussion

RCT is the standard treatment modality of mature teeth diagnosed with irreversible pulpitis. The use of recent endodontic techniques and equipment lead to more easy treatment with less time consuming so it can be completed in a single visit ^[6].

The current histological understanding of the dental pulp demonstrates that the pulp is not always inflamed or damaged beyond repair in cases of irreversible pulpitis^[7] and the improved understanding of pulp tissue healing and regeneration together with the use of biologically active endodontic materials have pointed the need for VPT and it became a more reliable treatment option for mature teeth with irreversible pulpitis ^[8],[9].

Biodentine is a calcium silicate-based material introduced to overcome the drawbacks of MTA, it is easier in handling with shorter initial setting time and without tooth discoloration. It also has good sealing ability and adequate compressive strength ^[10],[11]. Therefore, Biodentine was used in this study as a pulpotomy agent.

Young dental pulp is more cellular and has better potential for healing and regeneration ^[12],[13]. Therefore, the patients over 50 were excluded from this study based on that the more fibrous and less cellular pulp with limited blood supply may affect the treatment outcomes ^[14].

Teeth with periapical widening or any pathosis, sinus tract or swelling were excluded from the study to ensure that the pulp tissue is still vital and to avoid misdiagnosis. Furthermore, patients with active systemic disease as diabetes or hypertension were excluded as these diseases may interfere with periapical healing process of the treated teeth ^[15].

For pulpotomy procedure, hemostasis after removal of the inflamed coronal pulp tissue was performed by compression using a cotton pellet soaked in 2.5% NaOCl according to several studies ^{[16],[17],[18],[19]}.

The control of bleeding after removal of the inflamed pulp tissue has been determined as an additional diagnostic indicator for the assessment of the degree of inflammation and the healing potential of the remaining pulp tissue ^[20]. Therefore, in this study control of bleeding after pulp amputation should not exceed 6 min. Otherwise, persistent bleeding despite of attempts of hemostasis is considered a contraindication to pulpotomy, and thus RCT is recommended ^[5],[21].

The quality of coronal restoration is critical for the success of endodontic treatment since microleakage at the coronal tooth–restoration interface is the main attribution for long-term failure after VPT and RCT ^[20]. So currently, RMGIC was used as a base under resin composite because it has shown a better bonding to composite due to the similar chemistry, so it avoids possible leakage ^[22],[23].

CBCT was used because it is useful for precise three-dimentional radiographic assessment with higher accuracy in the detection of periapical lesions compared to conventional radiography ^[24]. Additionally, displaying tissues in gray scale could not differentiate minute changes in the same tissue precisely in traditional radiograph when compared to that of CBCT as the gray scale in CBCT ranges from − 1000 to + 3071 levels.

For radiographic evaluation, apical halves of the mesial and distal roots of mandibular molars were the areas of interest rather than the coronal halves because most of endodontic failure signs are mostly related to the lower halves and particularly at the periapical areas ^{[25],[26],[27],[28]}. In addition, early apical periodontitis begins at the apex, therefore, measurements can be exclusively limited to this area ^[29].

In this study, success or failure of the treatment modality was determined by assessment of both clinical and radiographic outcome criteria. In the absence of clinical signs and symptoms and with normal radiographic features and absence of periapical lesion during recall plus normal function, the clinical procedure can be considered successful. On the other hand, if the radicular pulp is inflamed beyond repair, the pulpotomy will eventually fail either by reappearance of symptoms or development of a new periapical lesion ^[5],[30].

Regarding single visit RCT group, the clinical success rate was 91.67% as there were no signs and symptoms in all follow-up periods except for one case that felt pain in the 12-month follow-up. This may be attributed to proper isolation, precise working length determination using electronic apex locators and digital radiographs, canal preparation using rotary files with copious sodium hypochlorite irrigation ^[31]. Moreover, obturating the canals in the same visit avoided the use of temporary filling between visits and so prevented leakage and bacterial recolonization of the canal which jeopardizes the success of endodontic treatment ^[32].

This was in agreement with Field et al.^[33] who evaluated single visit RCT in patients treated by well-trained clinicians using rotary instruments with a crown-down technique, and showed overall success rate of 89.2%.

Regarding pulpotomy group, 83.33% of cases had no signs and symptoms, which was in agreement with Linsuwanont et al.^[34] who recorded a clinical success rate of 76–84% MTA pulpotomy in cariously exposed pulp in permanent teeth. This reasonable success rate may be explained by careful clinical diagnosis and clinical judgment of the spread of pulp inflammation and further relying on the time needed to achieve hemostasis and immediate establishment of a proper coronal seal ^[5]. Additionally, histological and microbiological studies have shown that the inflammation and microbial presence in teeth traditionally diagnosed with irreversible pulpitis is limited to the coronal pulp tissue, therefore, the inflamed coronal pulp was removed leaving healthy pulp tissue which was dressed with a bioactive material that maintains vitality of the remaining pulp tissue and enhances healing and repair ^[35].

As the selected cases were initially free from periapical disease, the emergence of apical periodontitis would have been considered as an evidence of failure of the treatment. Radiographic evaluation of single visit RCT group showed no signs of failure, as there was not increase in PLMS beyond its normal width or reduction in the bone density at the follow-up period. This may be explained by the fact that bacteria are mostly responsible for periapical inflammation and destruction by diffusion of its byproducts. Therefore, absence of microbial contaminants, as much as possible, would prevent destruction of periapical tissues ^[36]. This was in agreement with Edionwe et al. ^[37], who concluded that teeth diagnosed with irreversible pulpitis and without periapical lesion preoperatively did not develop any periapical radiolucency postoperatively.

Similarly, pulpotomy group had good radiographic success rate. This may be explained by preservation of the healthy radicular pulp which is a highly vascularized connective tissue and rich in stem cells which maintain homeostasis and regeneration of tissues ^[38]. Moreover, using Biodentine as the pulpotomy agent has bioactive properties as it may induce transforming growth factor-beta1 secretion from pulp cells, which has a role in angiogenesis, recruitment of progenitor cells and cell differentiation ^[39]. In addition, Biodentine favorably affected healing when placed directly in contact with the pulp by enhancing the proliferation, migration, and adhesion of human dental pulp stem cells ^[40].

This was supported by Taha and Abdelkhader^[5] who assessed the outcome of full pulpotomy using Biodentine in adult patients with symptoms indicative of irreversible pulpitis and concluded that radiographic success was nearly 98.4%.

Clinical and radiographic success rate of single visit RCT and pulpotomy groups in this study had no statistically significant difference. This may be explained by performing proper selection of the cases and proper performance of the two procedures. This was in agreement with Asgary et al. ^[41],[42] comparing coronal pulpotomy with single visit RCT and concluded that the outcomes of pulpotomy would be non-inferior to those of single visit RCT in teeth with irreversible pulpitis.

Conclusion

RCT is the standard treatment modality of irreversible pulpitis in mature permanent teeth, however, pulpotomy can be considered a more conservative and simple alternative treatment option.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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