Response to Pulp Sensibility Tests after Full Pulpotomy in Permanent Mandibular Teeth with Symptomatic Irreversible Pulpitis: A Retrospective Data Analysis

IntroductionThis retrospective study analyzed the 12-month pulp sensibility (cold and electric) test response after mineral trioxide aggregate (MTA) full pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis.MethodsThe records of 120 subjects from 3 completed and 1 ongoing clinical study on MTA full pulpotomy were retrieved. Ninety-six first and second mandibular molar teeth with a diagnosis of symptomatic irreversible pulpitis that underwent a single-visit MTA full pulpotomy and had completed a 12-month clinical, radiographic, and pulp sensibility (cold and electric) test follow-up were included. The data were analyzed using the Fisher exact test, the Pearson chi-square test, and the McNemar test. The significance level was predetermined at P < .05.ResultsA higher percentage of teeth (94.7%) responded to the electric pulp test in comparison with the cold test (13.5%) (P < .05). Sex-based responses to the electric pulp test (P > .05) and the cold test were similar (P > .05). The age-based response was similar for the electric pulp test (P > .05) but was significant for the cold test (P < .05). The tooth quadrant (left and right), the tooth (mandibular first and second molar), and the location of restoration (proximal or occlusal) did not influence the response of either the electric pulp test (P > .05) or the cold test (P > .05). At the 1-year follow-up, all the teeth that were classified as clinically and radiographically successful responded to the electric pulp test; however, only 13 teeth responded to the cold test (P = .00).ConclusionsThe majority (94.7%) of the teeth that underwent MTA full pulpotomy responded to the electric pulp test at a 1-year time interval.     

Effect of Ultrasonic Activation of Endodontic Sealers on Intratubular Penetration and Bond Strength to Root Dentin

IntroductionThis study aimed to evaluate the effect of ultrasonic activation (UA) of endodontic sealers on dentin tubule penetration and the bond strength to root dentin.MethodOne hundred single-rooted teeth were prepared with 40.06 nickel-titanium instruments and divided into 2 groups: with or without UA. Three resin-based sealers (MTA Fillapex [Angelus Dental Solutions, Londrina, PR, Brazil], Sealer Plus [MK Life Medical and Dental Products, Porto Alegre, RS, Brazil], and AH Plus [Dentsply, DeTrey GmbH, Konstanz, Germany]; n = 20) and 2 calcium silicate–based sealers (Sealer Plus BC [MK Life Medical and Dental Products] and EndoSequence BC [Brasseler, Savannah, GA], n = 20) were used and subdivided (n = 10) according to the protocols. Fluo-3 (Thermo Fisher Scientific, Waltham, MA) and rhodamine B dyes were added to the calcium silicate- and resin-based sealers, respectively. In the UA groups, the activation was performed for 40 seconds followed by lateral compaction. Samples were transversely sectioned to evaluate the dentin tubule penetration and the bond strength to root dentin. The penetration data were analyzed with the Student t test, 1-factor analysis of variance, and Bonferroni tests. Bond strength was evaluated using the Student t test, Kruskal-Wallis, and Dunn post hoc test.ResultsResin-based sealers showed the highest tubule penetration without UA (P < .05). UA significantly enhanced MTA Fillapex and Endosequence BC dentin tubule penetration (P < .05). AH Plus and Sealer Plus BC improved their bond strength to root dentin after UA (P < .05). AH Plus/UA, Sealer Plus/UA, and Sealer Plus BC/UA presented the highest bond strength values (P < .05). Adhesive failures were predominant in all groups regardless of the use of ultrasound.ConclusionsUA interferes with tubule penetration and the bond strength to root dentin of resin- and calcium silicate–based sealers.     

Odontogenic Effect of a Fast-setting Pozzolan-based Pulp Capping Material

Introduction

Mineral trioxide aggregate (MTA) is widely used as a pulp capping material. Recently, a MTA-derived fast-setting pozzolan cement (Endocem; Maruchi, Wonju, Korea) was introduced in the endodontic field. Our aim in this study was to investigate the odontogenic effects of this cement in vitro and in vivo.

Methods

Human dental pulp cells (hDPCs) were cultured, and the effects of Endocem and a previously marketed MTA (ProRoot; Dentsply, Tulsa, OK) on biocompatibility were evaluated by assessing cell morphology and performing a cell viability test. Chemical composition of each material was analyzed by energy-dispersive X-ray spectroscopic analysis. Odontoblastic differentiation was analyzed by alkaline phosphatase activity and alizarin red S staining. The expression of odontogenic-related markers, namely dentin sialophosphoprotein, dentin matrix protein 1, and osteonectin, was evaluated by real-time polymerase chain reaction, Western blotting, and immunofluorescence analysis. Pinpoint pulp exposures were made on rat teeth and then capped with ProRoot or Endocem. After 4 weeks, reparative tertiary dentin formation and inflammatory responses were investigated histologically.

Results

The biocompatibility of Endocem was similar to that of ProRoot. Energy-dispersive X-ray spectroscopic analysis showed that ProRoot and Endocem contained similar elemental constituents such as calcium, oxygen, and silicon. Alkaline phosphatase activity and mineralized nodule formation increased in ProRoot- and Endocem-treated cells compared with medium only–treated cells in the control group (P < .05). The expression of odontogenic-related markers was significantly higher in the ProRoot- and Endocem-treated groups than the control group (P < .05), but there was no significant difference in the expression of these markers between the 2 experimental groups (P > .05). Four weeks after the pulp capping procedure, continuous tertiary dentin had formed directly underneath the capping materials and the pulp exposure area in all samples in the 2 treated groups. Furthermore, most specimens either had no inflammation or minor pulpal inflammation.

Conclusions

Our results indicate that ProRoot and Endocem have similar biocompatibility and odontogenic effects. Therefore, Endocem is as effective a pulp capping material as ProRoot.     

Treatment Outcome of Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: Long-term Results

Introduction

This controlled, historic cohort study project continues a previously reported trial aiming to assess treatment outcome of direct pulp capping with mineral trioxide aggregate (MTA) versus calcium hydroxide (CH). Potential prognostic factors were re-evaluated on the basis of a larger sample size and longer follow-up periods.

Methods

Clinical and radiographic outcomes of 229 teeth treated with direct pulp capping between 2001 and 2011 were investigated 24 up to 123 months post-treatment (median = 42 months). Pre-, intra-, and postoperative information was evaluated and statistically analyzed using a logistic regression model as well as generalized estimating equation logit models.

Results

Two hundred five patients (229 teeth) were available for follow-up (74% recall rate). The overall success rates were 80.5% (95% confidence interval [CI], 74.5–86.5) of teeth in the MTA group (137/170) and 59% (95% CI, 46.5–71.5) of teeth in the CH group (35/59). Multivariate analyses (generalized estimating equation logit model) indicated a significantly increased risk of failure for teeth that were directly pulp capped with CH compared with MTA (odds ratio = 2.67; 95% CI, 1.36–5.25; P = .001). Teeth that were permanently restored ≥2 days after direct pulp capping had a significantly worse prognosis irrespective of the pulp capping material chosen (odds ratio = 3.18; 95% CI, 1.61–6.3; P = .004).

Conclusions

The results of this study indicate that MTA provides better long-term results after direct pulp capping compared with CH. Placing a permanent restoration immediately after direct pulp capping is recommended.     

Anti-inflammatory and Mineralization Effects of ProRoot MTA and Endocem MTA in Studies of Human and Rat Dental Pulps In Vitro and In Vivo

Introduction

Few studies have reported direct pulp capping in inflamed pulp conditions. The purpose of this study was to investigate the in vitro and in vivo responses of dental pulp during direct pulp capping using various pulp capping materials in inflamed conditions.

Effect of Leptin on Odontoblastic Differentiation and Angiogenesis: An In Vivo Study

IntroductionLeptin is secreted as a peptide hormone from adipose tissues. The aim of this study was to evaluate the effects of leptin on reparative dentin formation and angiogenesis in the pulp tissue of teeth in vivo.MethodsTwenty-four 7-week-old male rats were anesthetized. Cavities were prepared in maxillary first molars. Pulp cappings were performed with collagen scaffold (Col) with a phosphate-buffered saline (PBS) vehicle (Col + PBS), leptin 1 μmol/L with Col (L1 + Col), or leptin 10 μmol/L with Col (L10 + Col). For the negative control group (no pulp capping), pulp capping was not performed. All cavities were sealed with resin-modified glass ionomer followed by a micro–computed tomographic scan, histologic examination, and immunohistochemical analysis.ResultsThe volume of newly formed mineralized tissue in the leptin group was significantly (P < .01) higher than that in the control group based on micro–computed tomographic analysis. In histologic examination, hard tissue formation was rarely shown in the no pulp capping and Col + PBS groups. However, significantly (P < .01) larger amounts of newly mineralized tissue deposition were observed in the leptin groups. In immunohistochemical analysis, reparative dentin and new vessels formed in the pulp cavity of the leptin groups. Vascular endothelial growth factor, dentin sialoprotein, and dentin sialophosphoprotein were expressed around the newly formed mineralized tissue area.ConclusionsLeptin showed the ability to induce angiogenesis, odontogenic differentiation, and mineralization in exposed rat pulps. Leptin also exhibited favorable inflammatory responses in the pulp tissue. Not only osteodentin but also tubular dentin and new vessels were observed in the pulp cavity.     

Effect of Intracanal Scaffolds on the Success Outcomes of Regenerative Endodontic Therapy - A Systematic Review and Network Meta-analysis

IntroductionThe scaffolds used in regenerative endodontic therapy (RET) provide structural support for cells so that they can adhere to the scaffolds and also are crucial for cellular proliferation and differentiation. The objective of this network meta-analysis was to compare effects of different intracanal scaffolds on success outcomes of RET.MethodsPubMed/Medline, EMBASE, Cochrane, CINAHL, Scopus, and Web of Science databases were searched. Studies evaluating and/or comparing clinical and/or radiographic success of RET using different scaffolds with a minimum of 12 months follow-up were included. The Cochrane Collaboration risk of bias (ROB) tool and appropriate tools from Joanna Briggs Institute were used for the assessment of ROB. A network meta-analysis was performed to compare the primary outcome (clinical success) and other success outcomes (root maturation, and pulpal sensibility) using different scaffolds.ResultsTwenty-seven studies fulfilled the desired inclusion criteria of which 25 had a low ROB whereas 2 had a moderate ROB. Clinical success of RET using platelet-rich plasma (PRP), blood clot (BC), and platelet-rich fibrin (PRF) scaffolds ranged between 91.66%–100%, 84.61%–100%, and 77%–100% respectively. The different scaffolds did not show any statistically significant difference in clinical success (PRF vs BC [P = 1.000], PRP vs BC [P = 1.000], and PRF vs PRP [P = .999]), apical root closure (PRF vs BC [P = 1.000], PRP vs BC [P = .835], PRF vs PRP [P = .956]), and pulp sensibility (PRF vs BC [P = .980], PRP versus BC [P = .520], and PRF vs PRP [P = .990]).ConclusionThe intracanal scaffolds used during RET did not result in significant differences in regard to clinical success, root maturation, and pulpal sensibility.     

Novel evaluation method of dentin repair by direct pulp capping using high-resolution micro-computed tomography

Objectives

We evaluated a novel micro-computed tomography (micro-CT) assessment for quality and quantity of dentin repair, which is difficult to visualize by histological analysis, after direct pulp capping under standardized cavity preparation.

Materials and methods

Standardized cavities were prepared on Wistar rats and direct pulp capping was performed using two commercial bioceramics, ProRoot MTA, and iRoot BP Plus. After 2 or 4 weeks, quality and quantity of tertiary dentin formation were evaluated using high-resolution micro-CT analyses including dentin mineral density, dentin mineral contents, compactness and integrity of tertiary dentin, and dentin volume with/without void space. Reproducibility of micro-CT analyses was confirmed by histological evaluation of the same specimen.

Results

The exposed pulp area sizes were similar between iRoot BP Plus and ProRoot MTA. Micro-CT analysis of 2-week samples showing compactness of tertiary dentin was significantly higher in iRoot BP Plus than ProRoot MTA (p?<?0.05). Tertiary dentin volume without void space, dentin mineral contents, and density were not significantly different between the groups. In 4-week samples, a significant increase was observed in dentin mineral density, compactness, and dentin volume with/without void space induced by iRoot BP Plus (p?<?0.05). Micro-CT analysis of tertiary dentin integrity demonstrated that some ProRoot MTA specimens had small defects and lacked continuity (6/512 images). No defects were observed with iRoot BP Plus.

Conclusions

Micro-CT analysis was confirmed as an accurate, objective, and inclusive approach for evaluating quality and quantity of dentin repair.

Clinical relevance

These multifaceted approaches to evaluate pulp capping materials may accelerate review processes, ultimately improving vital pulp therapy.

     

Evaluation of the Efficacy of Erbium,Chromium-doped Yttrium,Scandium, Gallium,and Garnet Laser in Partial Pulpotomy in Permanent Immature Molars: A Randomized Controlled Trial

IntroductionThe use of the erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser in vital pulp therapy contributes to the formation of dentin bridges and a sterile zone as well as the maintenance of the vitality of the pulp. However, no prior studies have used the Er,Cr:YSGG laser in partial pulpotomy of immature permanent teeth. The aim of this study was to compare the efficacy of partial pulpotomy treatment using mineral trioxide aggregate (MTA) alone and MTA with the Er,Cr:YSGG laser in permanent immature molars.MethodsA total of 90 caries-exposed permanent immature molar teeth were included and randomly divided into 2 groups: the MTA group (n = 45) and the laser + MTA group (n = 45). In the MTA group, MTA was applied to the exposed area on the pulp after bleeding control. In the same session, the tooth was restored with a composite resin. In the laser + MTA group, before MTA condensation, the Er,Cr:YSGG laser was applied to the exposure area. Patients were recalled at 1, 3, 6, and 12 months after treatment. The Mann-Whitney U and chi-Square tests were used for statistical analysis.ResultsThe success rate (95.5%) of the laser + MTA group was similar to that of the MTA group (88.8%). There was no significant difference between groups in terms of the frequency of at least 1 pathologic clinical or radiographic failure at 12 months (P > .05).ConclusionsPartial pulpotomy treatment showed a high success rate in immature permanent molars; however, the use of the laser did not contribute to the success rate compared with MTA alone.     

Application of High-frequency Radio Waves to Direct Pulp Capping

Introduction

In vital pulp therapy such as direct pulp capping, clinical success rates depend on achieving hemostasis in exposed pulp tissue. For hemostasis of exposed pulp tissue, gentle pressure by cotton pellets moistened with sodium hypochlorite is most commonly used. However, more rapid and reliable methods are necessary. Therefore, we focused on high-frequency radio waves (HRW).

Methods

To evaluate reparative dentin induction by HRW, we used a rat direct pulp capping model and performed hemostasis by using HRW of several strengths, covering the pulp with calcium hydroxide as a direct capping agent. After 14 or 28 days, rats were killed, and reparative dentin and pulp inflammation were investigated histologically.

Results

Radio wave–induced hemostasis required less time when compared with the control group. Reparative dentin with regularly arranged dentinal tubules was observed in the HRW group.

Conclusions

HRW induce hemostasis and produce high-quality reparative dentin and reduced pulpal inflammation.     

A Randomized Controlled Clinical Trial of Pulpotomy versus Root Canal Therapy in Mature Teeth with Irreversible Pulpitis: Outcome,Quality of Life,and Patients’ Satisfaction

IntroductionVital pulp therapy is increasingly practiced as an alternative treatment to root canal therapy (RCT) in teeth with carious pulp exposure. The aim of this study was to compare the outcome, quality of life (QOL), and patients’ satisfaction after full pulpotomy and RCT in mature teeth with irreversible pulpitis.MethodsSixty mature permanent molar teeth with carious pulp exposure and a diagnosis of irreversible pulpitis were randomly divided into 2 groups (n = 30). The first group was treated with full pulpotomy using Biodentine (Septodont, Saint Maur des Fosses, France), and the second group was treated with RCT. The pain level was recorded preoperatively and at 1, 2, 3, 5, and 7 days. Clinical and radiographic assessments were performed at the 6- and 12-month follow-ups; 1 case in each group did not attend. Based on the Oral Health Impact Profile questionnaire and 7 semantic differential scales, QOL, and patients’ satisfaction were evaluated and compared statistically.ResultsPulpotomy and RCT had comparable success rates (27/29, 93%). Pain levels at day 1 after pulpotomy were significantly lower than after RCT (P = .037), less patients required analgesics (P = .028), and pulpotomy provided pain relief in a shorter time compared with RCT. Both treatments improved the Oral Health Impact Profile QOL of patients without significant differences (60.29, 64.1% at 1 year). Patients’ satisfaction with pulpotomy was higher than RCT in terms of the time involved, intraoperative pain, pleasantness, and cost (P < .05).ConclusionsFull pulpotomy could be an alternative treatment to RCT in mature teeth with carious pulp exposure and symptomatic irreversible pulpitis based on the clinical and radiographic success rates and patients’ satisfaction.     

Pulp bleeding color is an indicator of clinical and histohematologic status of primary teeth

Objectives

This study was carried out to investigate whether the changes in hematologic characteristic and color of pulpal bleeding is associated with clinical and histologic status of the pulp in primary teeth.

Materials and methods

A total of 211 primary molars in 103 patients, 3–6 years old, were treated. One hundred eight teeth had pulpectomy, 57 teeth had pulpotomy after pulp exposure during caries excavation, and 46 teeth had pulpotomy after accidental pulp exposure in sound dentin. After pulpal exposure, pulpal blood was collected in capillary tubes for blood color and hematologic assessment. Coronal and radicular pulp tissues were amputated for histologic assessment.

Results

Blood color was significantly darker in pulpectomy cases and samples with severe inflammation. The differences were clinically perceptible by the human eye. A significant negative correlation was detected between white blood cell (WBC) count and blood color. The counts of neutrophils and lymphocytes were significantly different between treatment groups. In addition, WBC, eosinophil, monocyte, neutrophil, and basophils counts were significantly different between degrees of inflammation in coronal pulp. Moreover, severe inflammation was higher in pulpectomy group versus pulpotomy groups. Pulp tissue calcification was also significantly higher in the pulpectomy cases.

Conclusions

Considering the significant difference in pulpal blood color between the pulpectomy and pulpotomy cases, and between the different levels of pulpal inflammation; blood color can be a valid clinical diagnostic criterion of pulpal status and can be used for the selection of appropriate pulp treatment strategy.

Clinical relevance

This study shows that pulp bleeding color can be used for selection of an appropriate pulp treatment method in primary teeth.

     

Enhancing Effects of Immobilized Chondroitin Sulfate on Odontogenic Differentiation of Dental Pulp Stem Cells and Reparative Dentin Formation

IntroductionChondroitin sulfate (CS) is a major proteoglycan involved in the mineralization of the organic matrix of dentin. In this study, the roles of CS immobilized in cross-linked collagen I (Col I) hydrogels on odontogenic differentiation of dental pulp stem cells (DPSCs) and reparative dentin formation were investigated.MethodsDifferent concentrations of CS were incorporated into the genipin–cross-linked Col I hydrogels (CS-0.05, CS-0.1, and CS-0.2, respectively). The influences of CS on the proliferation and odontogenic differentiation of DPSCs were investigated. Finally, the effect of the functionalized hydrogel on the formation of reparative dentin was analyzed in a rat pulp capping model in vivo.ResultsCS improved the proliferation of DPSCs seeded on the hydrogels (P < .05). CS also enhanced the mineralization activities and increased the expression levels of the odontogenic-related proteins of DPSCs on days 7 and 14 (P < .05). In vivo, CS-0.1 hydrogel induced reparative dentin formation with higher quality compared with mineral trioxide aggregate.ConclusionsCS immobilized in Col I hydrogels could induce odontogenic differentiation of DPSCs in vitro and promote homogeneous mineralized barrier formation in vivo. CS–Col I hydrogel has the potential for reparative dentin formation of high quality in direct pulp capping.     

Dental Pulp Response to RetroMTA after Partial Pulpotomy in Permanent Human Teeth

Introduction

A lack of information exists regarding the efficacy of RetroMTA (BioMTA, Seoul, Korea) directly applied on the pulp in vital pulp therapy. This study was designed to examine the clinical efficacy of RetroMTA compared with ProRoot mineral trioxide aggregate (MTA) (Dentsply Tulsa Dental, Tulsa, OK) for partial pulpotomy.

Evaluation of Pulp Response to Novel Bioactive Glass Pulp Capping Materials

Introduction

This study aimed to investigate dental pulp responses to novel bioactive glass (BG) pulp capping materials after direct pulp capping in vivo.

矿物三氧化物凝聚体在修复性牙本质形成中作用研究进展

矿物三氧化物凝聚体（mineral trioxide aggregate,MTA）可作为盖髓剂应用于直接盖髓术和牙髓切断术。牙髓组织对MTA反应优良,用其盖髓后形成的修复性牙本质较氢氧化钙更厚、更均质。本文对MTA作为盖髓剂在修复性牙本质形成中的作用研究进展做一综述。     

Pulp tissue reaction to a self-adhesive,resin-based direct pulp capping material containing surface pre-reacted glass-ionomer filler

ObjectiveThis study aimed to evaluate the effect of direct pulp capping using an experimental self-adhesive resin for direct pulp capping (SRD) containing silica and surface pre-reacted glass-ionomer (S-PRG) filler on pulpal healing and to monitor the dentin bridge formation in rat pulp 2–4 weeks after operation.MethodsFive types of SRDs (SRD-0: S-PRG fillers 0 wt%; SRD-1: S-PRG fillers 9.1 wt%; SRD-2: S-PRG fillers 18.4 wt%; SRD-3: S-PRG fillers 27.8 wt%; and SRD-6: S-PRG fillers 57.4 wt%) were prepared, and mineral trioxide aggregate (MTA) was used as control (n = 8). Direct pulp capping was performed on rats that were sacrificed for further evaluation 2 or 4 weeks after the operation. The pulp tissue disorganization (PTD), inflammatory cell infiltration (ICI), and reparative dentin formation were histopathologically evaluated; the data were statistically analyzed using the Kruskal–Wallis and the Mann–Whitney U tests.ResultsThe histopathological evaluation of SRD-1-treated test animals 2 weeks post-operation revealed inferior PTD and ICI when compared with that of MTA. Even 4 weeks after the operation in SRD-1- and SRD-2-treated rats, the PTD and ICI were inferior when compared with those of MTA. The dental specimens of SRD-0 and MTA showed orthodentin formation, whereas SRD-treated test animals showed osteodentin formation at a position slightly deeper than the site of the pulpal exposure.SignificanceThe reparative dentin formed by SRD-0 and MTA was genuine, whereas that formed by SRD-3 and SRD-6 was ossified and ectopic. SRD may have the potential to be utilized clinically as a direct pulp capping material.     

Evaluation of Complete Pulpotomy With Biodentine on Mature Permanent Molars With Signs and Symptoms of Symptomatic Irreversible Pulpitis: 12-months Follow-up

IntroductionComplete pulpotomy is the removal of the coronal portion of a vital pulp and is a means of preserving the vitality of the remaining root portion. The objective of this study was to evaluate the 12-months success rate of complete pulpotomy with Biodentine on mature permanent molars with signs and symptoms of symptomatic irreversible pulpitis.Materials and methodsA total of 68 molars diagnosed with symptomatic irreversible pulpitis in 68 patients aged 20 years and older were included in this study. The exclusion criteria were intraoperative clinical signs of pulp necrosis on the molar to be treated such as no bleeding, or uncontrollable pulp hemorrhage (more than 5 minutes of hemostasis) on at least 1 canal. A complete pulpotomy with Biodentine was performed on molars with symptomatic irreversible pulpitis by the same operator and with the same protocol. A 12-months postoperative follow-up was conducted to evaluate clinical and radiologic success.ResultsA total of 66 patients received complete pulpotomy; 52 could be examined 12 months postoperatively. Clinical and radiologic analysis at 12 months postoperatively revealed a success rate of 87% (45 of 52 molars) and a failure rate of 13% (7 of 52 molars). There was a relationship between age, tooth type, and preoperative periapical condition and treatment success with P < .05.ConclusionCompliance with the indications and protocol for complete pulpotomy with Biodentine on mature permanent molars with symptomatic irreversible pulpitis gives positive results at the 12-month follow-up.     

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??As a novel pulp-capping material with good properties??MTA is used in direct pulp capping and pulpotomy. Pulp tissue responses excellently to MTA. The quality of dentin bridge induced by MTA is better than that induced by calcium hydroxide. This article summaries the role of MTA in the formation of reparative dentin when used as a pulp-capping agent.     

Factors Related to Pulp Survival After Complicated Crown Fracture Following Vital Pulp Therapy: A Systematic Review and Meta-analysis

IntroductionCrown fracture with pulp involvement and concomitant complications is a traumatic injury that may have several clinical considerations for dentists and patients. The aim of the present study was to appraise existing scientific evidence on factors related to pulp survival after complicated crown fracture following vital pulp therapy.MethodsAn electronic search was performed on 8 sources of published and unpublished literature, as of August 18, 2021. Randomized controlled trials and nonrandomized studies were included, involving patients undergoing treatment in teeth (mature or immature), with vital pulp, after complicated crown fracture. Risk of bias of included studies was examined and assessed through RoB 2.0 or the Risk of Bias in Nonrandomized Studies of Interventions tool, conditional on study design. Random effects meta-analyses were conducted, where applicable, and the certainty of evidence was evaluated through the Grading of Recommendations Assessment, Development, and Evaluation approach.ResultsOf the 506 initial articles, 24 were eligible for inclusion in the qualitative synthesis, and 7 ultimately contributed to meta-analyses. Based on synthesized evidence, in teeth treated with pulpotomy, there was no difference in successful clinical/radiographic outcome denoting pulp survival, when either bioceramic material versus CaOH₂ (2 studies, Risk Ratio [RR] = 1.07; 95% confidence interval [CI], 0.99–1.16; P = .09; I² = 0.0%), or mineral trioxide aggregate versus CaOH₂ (2 studies, RR = 0.94; 95% CI, 0.76–1.16; P = .56; I² = 0.0%). For different pulp management procedures, in pooled immature and mature teeth samples, there was no evidence that pulpotomy performed better than pulp capping with either CaOH₂ or mineral trioxide aggregate (5 studies/6 comparisons, RR = 1.06; 95% CI, 0.71–1.58; P = .77; I² = 74.8%). Risk of bias for randomized controlled trials ranged from raising some concerns to low, whereas nonrandomized studies were recorded as serious to critical risk of bias.ConclusionsThe quality of the evidence was very low to moderate. The need for more carefully designed clinical trials in the field is profound, to inform high-quality clinical decision making.