Artigo_Pulpotomia_Linsuwanont_2017

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Clinical Research
Treatment Outcomes of Mineral Trioxide
Aggregate Pulpotomy in Vital Permanent Teeth
with Carious Pulp Exposure: The Retrospective
Study
Pairoj Linsuwanont, PhD,* Kongthum Wimonsutthikul, DDS,* Uht Pothimoke, DDS,*
and Busayarat Santiwong, PhD†
Abstract
Significance
Teeth with carious pulp exposure can be treated
successfully by MTA pulpotomy. Clinical signs of
irreversible pulpitis and the presence of periapical
radiolucency should not be considered contraindi-
cations for pulpotomy.
Introduction: This study aimed to illustrate the treat-
ment outcomes of mineral trioxide aggregate (MTA) pul-
potomy in vital permanent teeth with carious pulp
exposure. Methods: MTA pulpotomy was performed
in 66 vital permanent teeth with carious pulp exposure
including teeth with signs and symptoms of irreversible
pulpitis and the presence of periapical radiolucency. Pa-
tients were assessed for clinical and radiographic out-
comes by 2 examiners. The relationship between
treatment outcomes and factors was analyzed by means
of univariate analysis and binary logistic regression. Re-
sults: Fifty patients (a total of 55 teeth) attended the
follow-up examination. The age of the patients ranged
from 7–68 years old (mean = 29 years old). For the
follow-up period as far as 62 months, 48 teeth showed
successful outcomes (success rate = 87.3%). Teeth with
clinical signs of irreversible pulpitis and the presence of
periapical radiolucency could be treated successfully by
MTA pulpotomy with success rates of 84% and 76%, re-
spectively.Three of 7 failed cases required pulpectomy
after MTA pulpotomy to relieve painful pulpitis. Four
other failed cases were asymptomatic, and failure was
detected from radiographic examination. The relation-
ship between treatment outcomes and treatment factors
could not be detected statistically. Conclusions: Teeth
with carious pulp exposure can be treated successfully
by MTA pulpotomy. Clinical signs of irreversible pulpitis
and the presence of periapical radiolucency should not
be considered as a contraindication for pulpotomy. (J En-
dod 2016;-:1–6)
Key Words
Carious pulp exposure, irreversible pulpitis, mineral
trioxide aggregate pulpotomy, periapical radiolucency,
vital permanent teeth
From the Departments of *Operative Dentistry and †Pediatric D
Address requests for reprints to Dr Pairoj Linsuwanont, Faculty
address: linspairoj@gmail.com
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.10.027
JOE — Volume -, Number -, - 2016
Pulpitis caused by cariesis the main reason for
root canal treatment (1).
Instead of complete pulp
tissue removal by pulpec-
tomy, vital pulp therapy
has been considered as
an alternative approach
(2). Conservative treatment of teeth with deep carious lesions has the advantage of pre-
serving vital pulp function including the defensive mechanism and the proprioceptive
function of the teeth, but application of vital pulp treatment in teeth with carious
pulp exposure has been controversial. The drawback of this approach is that there
can be unpredictable treatment outcomes and uncertainty about the long-term prog-
nosis of the treated teeth (3).
Accurate diagnosis leads to the appropriate treatment, which should result in pre-
dictable favorable outcomes. By definition, irreversible pulpitis means that the pulp is
incapable of healing (4), which indicates the need for the complete removal of pulp
tissue by pulpectomy. The question is ‘‘How can we differentiate between reversible
and irreversible pulpitis?’’ Teeth with carious pulp exposure can exhibit various clinical
symptoms such as spontaneous pain, lingering pain, short duration sensitivity to stim-
ulus, no symptom, and so on (4). Radiographic appearance can be observed as either
normal or pathological with the presence of periapical radiolucency (5). Current diag-
nostic tools can show only that the tested tooth is vital or nonvital (6). The precise
discrimination of reversible or irreversible pulpal status has been a challenge to attain.
Pulpotomy is described by the American Association of Endodontists as ‘‘the
removal of the coronal portion of a vital pulp as a means of preserving the vitality of
the remaining radicular portion’’ (http://www.aae.org/clinical-resources/aae-
glossary-of-endodontic-terms.aspx). The progression of caries into the pulp causes a
degenerative and inflammatory process that can lead to pulp necrosis and apical peri-
odontitis. Histologic studies show that teeth with carious pulp exposure can exhibit the
coexistence of the damaged and healthy pulp in the various parts of the same pulp (7).
Therefore, after the removal of pulp tissue that has undergone degenerative and irre-
versible changes, conservation of the remaining pulp should be possible. This rationale
has been supported by the demonstration of the successful outcomes of pulpotomy in
teeth with carious pulp exposure in several clinical studies (5, 8). However, the focus of
controversy has been on whether vital pulp therapy should be performed in teeth with
entistry, Chulalongkorn University, Bangkok, Thailand.
of Dentistry, Chulalongkorn University, 34 Henri Dunant Road, Bangkok 10330, Thailand. E-mail
MTA Pulpotomy in Vital Permanent Teeth 1
Delta:1_given name
Delta:1_surname
Delta:1_given name
Delta:1_surname
http://www.aae.org/clinical-resources/aae-glossary-of-endodontic-terms.aspx
http://www.aae.org/clinical-resources/aae-glossary-of-endodontic-terms.aspx
mailto:linspairoj@gmail.com
http://dx.doi.org/10.1016/j.joen.2016.10.027
Clinical Research
carious exposed pulp with the diagnosis of irreversible pulpitis.
Therefore, the aim of this study was to investigate treatment outcomes
of mineral trioxide aggregate (MTA) pulpotomy in teeth with carious
pulp exposure including teeth with signs and symptoms of
irreversible pulpitis and the presence of periapical radiolucency.
Materials and Methods
This study was approved by the Ethics Committee of Chulalong-
korn University, Bangkok, Thailand (HRED-DCU 2013-72, ref 007/
2014). The study group consisted of patients who received MTA pulpot-
omy in vital permanent teeth with carious pulp exposure at the postgrad-
uate endodontics clinic of Faculty of Dentistry, Chulalongkorn University
during 2007 to 2013. Patients were contacted by phone and were
invited to take part in this study. At the follow-up visit, they were given
a participant information sheet and were asked to sign a declaration of
informed consent.
Case Selection for MTA Pulpotomy
Patients’ description of the chief complaints and history of relevant
teeth were obtained. Routine clinical examinations were performed
including the hot or cold test to mimic patients’ symptoms, vitality
test by means of electric pulp test and/or cold test with refrigerant spray
(Endo-ICE; Colt�ene/lWhaledent, Inc, Cuhoga Falls, OH), percussion
test, and periodontal examination. Radiographic examinations were
conducted with the use of bitewing and periapical radiographs. Pulpal
and periapical diagnoses were made from the interpretation of clinical
and radiographic evaluations (4).
MTA pulpotomy was performed in vital permanent teeth with
carious pulp exposure regardless of their clinical symptoms and the
presence or absence of periapical radiolucency. After the completion
of caries removal, if 1 of these incidences occurred (ie, no pulp expo-
sure, uncontrolled pulpal bleeding within 10 minutes, or unrestorable
tooth condition), the treated tooth was subjected to other treatment
procedures such as filling, pulpectomy, or extraction.
MTA Pulpotomy Treatment Protocol
All treatments were performed by the postgraduate students at the
endodontic clinic with a strict aseptic technique under rubber dam
application. The treatment protocol was similar to the standard pulpot-
omy procedures as suggested by Witherspoon et al (9). After the admin-
istration of local anesthesia (mepivacaine hydrochloride 2% with
adrenaline 1:100,000 [Scandonest2%; Septodont, Saint-Maur-des-
Foss�es, France]), caries was removed with either a sharp spoon exca-
vator or a round slow-speed tungsten carbide bur. After pulp exposure,
the cavity was flushed with 2.5% sodium hypochlorite. The roof of the
pulp chamber was removed by using a coarse, high-speed diamond bur.
Pulp tissue was removed to a level of canal orifices. Hemostasis was
achieved by irrigating with 2.5% sodium hypochlorite for up to 10 mi-
nutes. A 2-mm-thick layer of ProRoot MTA (Tulsa Dental Products,
Tulsa, OK) was placed over the exposed pulpal tissue. A moistened cot-
ton pellet was placed over the MTA, and teeth were restored with tem-
porary restoration. Permanent restoration was placed on the treated
teeth by operative specialists within 1 month after pulpotomy. A strict
aseptic technique was applied throughout the restoration procedures
to avoid recontamination. In most cases, a rubber dam was used.
Data Collection
Preoperative information and details of treatment observations
were collected from patients’ records. Preoperative data included
age, sex, tooth type, tooth location, stage of root development, clinical
signs and symptoms, details of the percussion test and vitality test, pulp
2 Linsuwanont et al.
and periapical diagnosis, and interpretations of preoperative radio-
graphs. Details of treatment observations consisted of bleeding time
and pulpal exposure size and type of restoration.
At the follow-up examination, patients were subjected to clinical
and radiographic examinations. The collected information included
postoperative pain, presence or absence of clinical symptoms, type
and quality of restoration, vitality pulp test, periodontal examination,
and percussion test. Bitewing and periapical radiographs were taken
to examine the quality of filling, periapical radiolucency, pulp oblitera-
tion, and dentin bridge formation. The evaluation of the follow-up
radiographic images, with an interval of 1 week, was performed by 2
examiners. Repeated measures of the same set of radiographs 1 week
apart produced intraexaminer and interexaminer agreement, which
were assessed using the kappa statistic.
Assessment of Success and Failure
Evaluation of the treatment outcomes was based on combined
clinical and radiographic examination. The treatment outcomes were
recorded as a ‘‘success’’ in cases in which both the clinical and radio-
graphic presentations were normal or showed reduced radiolucency. If
patients presented either with clinical signs and symptoms (pain,
soft swelling, or sinus tract) or emerging radiolucency or persisted
radiolucency without change, the treatment outcome was recorded
as a ‘‘failure.’’
Statistical Analysis
Interobserver and intraobserver reliability were assessed using the
Cohen kappa statistic. The mean, standard deviation, median, minimum
andmaximum, and frequencies were calculated for descriptive analysis.
The 95% confidence interval for the overall success rate and the success
rate in each recall period was calculated. The Fisher exact test and chi-
square test (Monte Carlo method) were used to investigate the influence
of each factor on treatment outcomes. For multivariate analysis, binary
logistic regression was performed at the 0.05 significance level.
Results
During 2007 to 2013, 61 patients with 66 permanent teeth with
carious pulp exposure were treated by MTA full pulpotomy. Fifty pa-
tients with a total of 55 teeth attended the follow-up examination. The
recall rate was 82%. The recall period ranged from 8 to 62 months,
with an average period of 36 months (median = 41 months). In this
study, the interobserver reliability result was k = 0.90, and the intraob-
server reliability result was k = 0.84. They showed good agreement in
the radiograph reading as shown by the excellent reliability attained.
Overall, 48 of 55 teeth were categorized as successful (87.3%). Failure
was detected in 7 teeth (12.7%). The examples of cases considered suc-
cesses and failures are shown in Figures 1A and B and 2A and B.
Because each patient did not receive the treatment at the same time,
the follow-up periods varied among cases. The success rates at
#1 year, 1 to <2 years, 2 to <3 years, 3 to <4 years, and $4 years
were 87.9%, 100%, 95.8%, 96%, and 86.7%, respectively.
Patients’ age ranged from 7–68 years, with a mean age of 29 years
(median = 26 years). The population of treated teeth consisted of teeth
with completed root formation (82%), pain to percussion (43%), pres-
ence of radiolucency (38%), and clinical signs of irreversible pulpitis
(45.5%). Descriptive data and univariate analysis (Fisher exact test
and chi-square test: Monte Carlo method) of the relationship between
each factor and the outcomes of MTA full pulpotomy are shown in
Table 1. Binary logistic regression analysis (forward Wald method,
P = .05) was used to assess the effect on the treatment outcome of
age, response to percussion, preoperative clinical signs and symptoms,
JOE — Volume -, Number -, - 2016
Figure 1. A 9-year-old girl complained of lingering pain with cold drink and food impaction in the cavity. Clinical examination revealed that tooth #46 presented
with a large carious lesion with pulpal exposure. The cold test with cold water exacerbated the prolonged sensitivity of tooth #46. (A) A preoperative radiograph
showed a large carious lesion with periapical radiolucency associated with immature roots of tooth #46. The diagnosis of #46 was symptomatic irreversible pulpitis
with symptomatic apical periodontitis. MTA pulpotomy was performed followed by composite resin restoration. (B) At a follow-up of 4 years 8 months, tooth #46
showed completed root development with normal periapical appearance. Tooth #46 was categorized as a success.
Clinical Research
periapical status, root development, bleeding time, pulp exposure size,
and quality of restoration. The analysis showed no relationship between
these factors and the treatment outcome.
Interestingly, teeth with the presence of radiolucency could be
treated by MTA pulpotomy with a high rate of success of 76%. Eighty-
four percent of teeth with clinical signs of irreversible pulpitis were
treated successfully. Time to stop bleeding exceeding 5 minutes was
observed in 2 teeth. Two months later, 1 tooth presented with signs
and symptoms of painful pulpitis. Twenty-six teeth showed dentin bridge
formation (47.3%), and 17 teeth developed pulp obliteration (30.9%).
One of the teeth with pulp obliteration developed periapical radiolu-
cency and was classified as failure. Figure 3A and B shows an example
of a tooth with pulp obliteration after MTA pulpotomy.
Various types of restoration were placed on MTA pulpotomized
teeth including resin composite filling (80%), cuspal coverage with
either amalgam or resin composite restoration (12%), and a porcelain
fused to metal or a full metal crown (8%). Nine teeth presented with
unsatisfactory restoration, namely, discoloration (3 teeth), overhang
margin (1 tooth), marginal leakage (2 teeth), and marginal leakage
with secondary caries (3 teeth). All 9 teeth (with observation periods
ranging from 2 years 4 months–4 years 8 months) were categorized
Figure 2. A 59-year-old female patient complained of spontaneous pain and pain o
pulp exposure at the buccal surface. Tooth #35 was positive to the electric pulp test a
of tooth #35 showed normal periapical. The diagnosis of tooth #35 was symptomatic
completed, and tooth #35 was restored with composite resin filling. (B) At a follow
was evaluated as a failure.
JOE — Volume -, Number -, - 2016
as successful with normal clinical presentation and normal periapical
radiographic appearance.
Seven teeth were categorized as failures. The information of failed
teeth is shown in Table 2. Radiographic examination showed that peri-
apical radiolucency was observed in 4 teeth: 1 tooth with a new emerging
periapical lesion and 3 teeth with larger periapical lesions in comparison
with the preoperative radiograph. Three teeth presented with painful pul-
pitis, whichcould be detected as early as 2 weeks after pulpotomy.
Discussion
The treatment of teeth with carious pulp exposure has been a
controversial issue in endodontics. Two different points of view, which
have been debated, are the conservative approach with vital pulp ther-
apy and the more invasive but reliable approach with pulpectomy. Each
procedure has its own benefits and disadvantages that can be advanced
to support the practitioners’ treatment preferences. From the patients’
point of view, satisfactory treatment is one that can relieve the clinical
symptoms and prolong tooth retention. For researchers and health
care providers, not only the resolution of the disease but also the pres-
ervation of pulp function will be a more satisfactory result. This study
n biting of tooth #35. Clinical examination revealed a deep carious lesion with
nd the cold test and was tender to percussion. (A) The preoperative radiograph
irreversible pulpitis with symptomatic apical periodontitis. MTA pulpotomy was
-up of 2 years 2 months, tooth #35 presented with periapical radiolucency and
MTA Pulpotomy in Vital Permanent Teeth 3
TABLE 1. Descriptive Data and Univariate Analysis of the Relationship between Each Factors and the Outcome of Mineral Trioxide Aggregate Full Pulpotomy
Factors Subgroup n (%)
Overall outcome
Success (%) Failure (%) P value
Age 0–20 26 (47.3) 24 (92.3) 2 (17.7) .61*
21–59 23 (41.8) 19 (82.6) 4 (17.4)
$60 6 (10.9) 5 (83.3) 1 (16.7)
Response to percussion Negative 31 (56.4) 28 (90.3) 3 (9.7) .68†
Positive 24 (43.6) 20 (83.3) 4 (16.7)
Preoperative clinical signs and
symptoms
Reversible 30 (54.5) 27 (90) 3 (10) .68†
Irreversible 25 (45.5) 21 (84) 4 (16)
Periapical status Normal 34 (61.8) 32 (94.1) 2 (5.9) .09†
Pathologic 21 (38.2) 16 (76.2) 5 (23.8)
Root development Incomplete 10 (18.2) 10 (100) 0 .32†
Complete 45 (81.8) 38 (84.4) 7 (15.6)
Bleeding time #5 min 53 (96.4) 47 (88.7) 6 (11.3) .24†
>5 min 2 (3.6) 1 (50) 1 (50)
Pulpal exposure size #1 mm 13 (23.6) 12 (92.3) 1 (7.7) 1.00†
>1 mm 42 (76.4) 36 (85.71) 6 (14.3)
Quality of restoration Satisfactory 46 (83.6.7) 39 (84.7) 7 (15.2) .42*
Unsatisfactory 9 (16.4) 9 (100) 0
Preoperative clinical signs: reversible pulpitis, short duration sensitivity after cold or hot drink and irreversible pulpitis, lingering pain, spontaneous pain, and pain on biting. Pathologic peraipical status: the
presence of widening of periodontal space or periapical radiolucency.
*Monte Carlo method.
†Fisher exact test.
Clinical Research
showed that teeth that were routinely pulp extirpated because of carious
pulp exposure could be treated with vital pulp therapy.
Caries cause various degrees and depths of pulp degeneration and
inflammation. What degree of pulpal damage will cause the irreversible
stage of the affected pulp has never been documented. Spontaneous
pain and lingering pain combined with percussion sensitivity have
been used as clinical predictors to suggest the irreversible stage of
the pulp (3). In this study, teeth with clinical signs of irreversible pul-
pitis showed successful outcomes with pulpotomy. Recently, Qudeimat
et al (8) illustrated similar findings in young patients. It is likely that the
amputation of coronal pulp may remove the degenerative and severely
inflamed pulp tissue, and the remaining radicular pulp is capable of
healing.
The condition of the pulp plays a decisive role in the outcome of
conservative pulp treatment. When encountering clinical pulp expo-
sure, assessment of the health status of the pulp is challenging. It has
been claimed that the degree of pulpal bleeding upon pulp exposure
Figure 3. A 12-year-old patient complained of spontaneous pain around lower ri
with a large carious lesion on the occlusal surface. The vitality test with the electric p
triggered a painful response of tooth #46. (A) The preoperative radiograph showed
#46. The diagnosis of tooth #46 was symptomatic irreversible pulpitis with sympto
tooth #46 exhibited pulp obliteration with normal periapical radiographic appearan
normal periapical radiographic appearance.
4 Linsuwanont et al.
reflects the severity of pulpal inflammation. Profuse bleeding that is diffi-
cult to stop indicates that the pulp tissue is severely inflamed (10).
Several studies used the ‘‘time to stop bleeding’’ parameter as a cutoff
point to discriminate between the reversible and irreversible condition
of the pulp. If the bleeding could not be stopped within 5 to 10 minutes,
the pulp was considered severely inflamed, and pulpectomy was recom-
mended (9, 11). In this study, we found that ‘‘time to stop bleeding’’ may
not be an accurate indicator for judging the reversible or irreversible
state of the pulp. The information from the failed cases (Table 2)
showed that time to stop bleeding was within 1 to 3 minutes in 6 of 7
failed cases, which is considered normal in comparison with the suc-
cessful cases. Statistical analysis showed that the time to stop bleeding
has no effect on treatment outcomes. In fact, the association between the
bleeding time and the degree of pulpal inflammation has never been
thoroughly investigated. The inflammatory process of the pulp is partly
influenced by neurovascular regulation, which involves the release of
several mediators by the sensory nerve. Several studies have observed
ght posterior teeth. The clinical examination showed that tooth #46 presented
ulp test and the cold test revealed that tooth #46 was vital. The percussion test
a large carious lesion with normal periapical radiographic appearance of tooth
matic apical periodontitis. (B) At a follow-up of 4 years after MTA pulpotomy,
ce. Tooth #46 was classified as successful with normal clinical presentation and
JOE — Volume -, Number -, - 2016
TABLE 2. Demographic Data of Teeth with Unfavorable Outcomes
Tooth Age Preoperative symptoms Percussion Periapical status
Time to stop
bleeding
Time to detect
failure
Observations of
failed cases
#37 36 Lingering pain after cold
drink, pain on biting
Positive Widening of PDL space 10 2 months Painful pulpitis
#37 26 Sensitivity to cold drink Normal Normal 1 48 months PA lesion
#35 63 Dull pain because of food
impaction
Normal Widening of PDL space 1 50 months PA lesion
#35 59 Sensitivity to cold drink Positive Normal 1 25 months PA lesion
#27 19 Sensitivity to cold drink Normal Normal 3 2 weeks Painful pulpitis
#36 18 Spontaneous pain Positive Radiolucency lesion with
mesial root
2 40 months PA lesion
#37 51 Spontaneous pain Positive Widening of PDL space 3 2 weeks Painful pulpitis
PA, periapical; PDL, periodontal ligament.
Clinical Research
the elevated level of the biological inflammatory markers such as pros-
taglandins, substance P, and matrix metalloproteinases from collected
blood samples of inflamed pulp tissue (12–14). These findings suggest
another possible method to measure the degree of pulp inflammation.
However, further research is required to develop a rapid, chairside
dipstick method, which is practical for routine application.
A periapical radiolucency lesion does not always correlate with
pulp necrosis. A harmful stimulus such as extensive caries causes pulpal
inflammation, which is partly controlled by the sensory nerve. The
development of periapical pathology associated with vital pulp is the
result of neurogenic inflammation, which is caused by the release of
neuropeptides such as substance P from the afferent fibers supplying
pulp and periapical tissues (15). Therefore, if the stimulus is removed
and the pulp is not severely damaged, pulpal healing can occur. In this
study, 76% of teeth with carious pulp exposure with periapical pathol-
ogy showed a favorable response with the resolution of radiolucency
after MTA pulpotomy. Similarly, Caliskan illustrated that the presence
of periapical radiolucency was not a contraindication for pulpotomy
in teeth with carious pulp exposure (5).
Pulpal inflammation has been considered an important factor in
the fate of vital pulp. The controlled inflammation of low gradepro-
motes healing, whereas severe uncontrolled inflammation leads to le-
thal damage of the pulp (16). The concept of conditioning the pulp
by application of a topical steroid on the pulp wound to suppress pulpal
inflammation has been investigated. The use of fluocinolone acetonide
as a pulp capping material has been shown to reduce the inflammation
and promote hard tissue formation in rat molars (17). Clinical study in
human intact teeth has shown that the application of topical dexameth-
asone does not impede pulp healing (18). However, contradictory re-
sults have been reported with poor wound healing and pulp necrosis
with the application of a topical steroid (19). The concept of controlling
orminimizing pulpal inflammation upon pulp exposure is worth further
investigation. If this is possible, the healing capacity of the remaining
pulp will be enhanced.
In terms of the resolution of clinical symptoms and periapical
radiolucency, MTA pulpotomy exhibited a high rate of success. If the
concern is the vitality of the remaining pulp, the accurate way to ascertain
this issue is histologic examination after tooth extraction. The routine
clinical vitality test, electric pulp test, and cold test may not provide ac-
curate interpretation of pulpotomized teeth because the coronal pulp
was completely removed. At the follow-up examination, in teeth with
normal clinical presentation after pulpotomy, the remaining radicular
pulp can be either vital or vital with low-grade inflammation or necrosis.
However, histologic study of human teeth with irreversible pulpitis that
underwent MTA pulpotomy showed healthy radicular pulp with dentin
bridge formation (20). Another unpredictable response after pulpotomy
was the uncontrolled hard tissue deposition inside the root canal. In this
JOE — Volume -, Number -, - 2016
study, the incidence of pulp obliteration was 30% (17/55 teeth), which
was different from other studies that could not detect any teeth with pulp
obliteration after pulpotomy (5, 8, 16). One tooth with pulp obliteration
developed periapical radiolucency, and root canal treatment was
indicated. However, the incidence of pulp canal obliteration leading to
pulpal and periapical disease is not frequent (21).
Understanding the factors affecting treatment outcomes leads to
proper case selection and effective treatment protocol. Systematic re-
view (2) does not provide the definite answer as to which factors influ-
ence the treatment outcome of pulpotomy in permanent teeth with
caries exposed pulp. The problem with clinical studies in general is
the difficulty in recruiting a large group of patients, resulting in a limited
number of participants. In this study, the results of the statistical analysis
based on 55 teeth should be interpreted with caution. The results do not
provide the definite answer as to which factors influence treatment
outcome. However, it does provide some information that may be useful
for further study. For example, univariate statistical analysis (Fisher
exact test) (Table 1) showed that the factor of ‘‘periapical status’’ de-
serves further investigation.
Restoration after MTA pulpotomy should provide a coronal seal,
protect the remaining tooth structure, and satisfy function and esthetics.
Time to place the permanent restoration was shown to be a factor
affecting treatment outcome. The association between the delayed
placement of restoration and unfavorable outcomes was detected (22).
In this study, permanent restorations were performed by the postgrad-
uate students of the operative department within 1 month after pulpot-
omy. Inappropriate restoration may cause loss of the remaining tooth
structure and/or infection of the remaining pulp tissue. In this study,
9 teeth with unsatisfactory restoration did not exhibit clinical symptoms
or radiographic pathology. It is possible that infection had not reached
the remaining pulp, which was protected by glass ionomer cement and
2-mm-thick MTA.
Pulpectomy has been considered as a treatment of choice for vital
permanent teeth with carious pulp exposure (http://www.aae.org/
clinical-resources/aae-guide-to-clinical-endodontics.aspx). The ratio-
nale relies on the predictable successful outcome of root canal treat-
ment of vital teeth with a high success rate of >90% (23). However,
achieving a good quality root canal treatment is not easy. A systematic
review showed that 78% of root canal treatment in the community health
center was reported as being inadequate (24). A survey of dental prac-
titioners in Sweden and Germany showed that the majority of them
(>75%) would perform vital pulp therapy in teeth with carious pulp
exposure (25, 26). If signs of failure were detected, root canal
treatment was indicated. The possible reason for those preferences
may be that root canal treatment is costly, difficult, and time-
consuming. From this point of view, vital pulp therapy may be more
desirable.
MTA Pulpotomy in Vital Permanent Teeth 5
http://www.aae.org/clinical-resources/aae-guide-to-clinical-endodontics.aspx
http://www.aae.org/clinical-resources/aae-guide-to-clinical-endodontics.aspx
Clinical Research
There has been an accumulation of evidence that pulpectomy is
not the only possible treatment for vital permanent teeth with carious
pulp exposure. A systematic review revealed that vital pulp therapy
should be considered as an alternative approach (2). In this study, 7
cases with intact restoration were classified as failures. Information
of the failed cases (Table 2) does not provide any conclusion as to
which factors caused the unfavorable outcomes. Failed cases presented
either with painful pulpitis or pulp necrosis with apical periodontitis. It
is possible that the cause of failure was from the uncontrolled deterio-
ration of the remaining pulp. The unfavorable outcomes reflect flaws in
case selection and/or treatment protocol.
At this stage, MTA pulpotomy may not be suitable for every case
because of the limitation on knowledge of case selection and the effec-
tive treatment protocol. More well-controlled clinical studies with a
large number of patients are required to provide information regarding
these issues. For patients with financial limitations or who lack access to
higher-level care, pulpotomy should be considered as an alternative to
tooth extraction.
Conclusions
Teeth with carious pulp exposure can be treated successfully by
MTA pulpotomy. Clinical signs of irreversible pulpitis and the presence
of periapical radiolucency should not be considered contraindications
for pulpotomy.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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	Treatment Outcomes of Mineral Trioxide Aggregate Pulpotomy in Vital Permanent Teeth with Carious Pulp Exposure: The Retrosp ...
	Materials and Methods
	Case Selection for MTA Pulpotomy
	MTA Pulpotomy Treatment Protocol
	Data Collection
	Assessment of Success and Failure
	Statistical Analysis
	Results
	Discussion
	Conclusions
	Acknowledgments
	References