One-year results of vital pulp therapy in permanent molars with irreversible pulpitis: an ongoing multicenter, randomized, non-inferiority clinical trial

Objectives

Root canal therapy (RCT) and tooth extraction have been conventional treatment options for management of human mature teeth with irreversible pulpitis. Excellent short-term treatment outcomes of vital pulp therapy with calcium-enriched mixture cement (VPT/CEM), as a new treatment option, on postoperative pain relief was demonstrated; if intermediate- and long-term treatment outcomes of the new treatment are also non-inferior compared to RCT, then VPT/CEM may become a viable treatment option for management of mature teeth with irreversible pulpitis.

Materials and methods

In 23 healthcare centers, 407 9- to 65-year-old patients were randomly allocated into two study arms including one-visit RCT (reference treatment; n?=?202) and VPT/CEM (alternative treatment; n?=?205). Six- and twelve-month clinical and radiographic successes were assessed.

Results

Mean follow-up times at 6- and 12-month follow-ups were “6.70?±?0.68 and 6.72?±?0.71 months” and “12.96?±?0.67 and 12.90?±?0.66 months” in the available cases of RCT and VPT/CEM arms, respectively. Favorable clinical success rates in the two study arms did not show statistical difference; however, the radiographic success rate in the VPT/CEM was significantly greater than RCT arm at the two follow-ups (P?<?0.001). The patients’ age had no effect on the treatment outcomes (P?=?0.231).

Conclusions

Treatment outcomes of VPT/CEM may be superior to RCT in mature molars with irreversible pulpitis. The performance of biomaterials such CEM cement may assist in the shift towards more biologic treatments.

Clinical relevance

VPT/CEM may be a realistic alternative treatment for human mature molar teeth with symptoms of irreversible pulpitis; the use of VPT/CEM is highly beneficial for patients as well as general dentists.     

Two-year results of vital pulp therapy in permanent molars with irreversible pulpitis: an ongoing multicenter randomized clinical trial

Objectives

Oral healthcare expenses are increasing rapidly as a result of the growth of high-cost health technologies worldwide. In many developing/developed countries, low-cost tooth extraction is the alternative treatment option for a high-cost root canal therapy (RCT) for management of human molars with irreversible pulpitis. Vital pulp therapy with calcium-enriched mixture cement (VPT/CEM) as a new alternative treatment option has demonstrated excellent treatment outcomes up to 1 year; if 2-year radiographic/clinical effectiveness as well as cost-effectiveness of the VPT/CEM is also non-inferior compared with RCT, it can serve as a viable treatment for mature molars with irreversible pulpitis.

Materials and methods

In this prospective, multicenter (n?=?23), non-inferiority clinical trial, 407 patients were randomized to either one-visit RCT (n?=?202) or VPT/CEM (n?=?205) for 27 months. In this part of study, the primary outcome measure was the 2-year clinical and radiographic treatment outcomes. Cost-effectiveness was also analyzed.

Results

Mean follow-up times were 24.62?±?0.72 and 24.61?±?0.69 months in RCT (n?=?166) and VPT/CEM (n?=?166) arms, respectively. Clinical success rates in the two study arms were equal (98.19 %); however, radiographic success rates were 79.5 and 86.7 % in RCT and VPT/CEM arms, respectively, with no statistical difference (P?=?0.053). The treatment time span mean was approximately three times greater in the RCT than in the VPT/CEM arm (94.07 vs. 31.09 min; P?<?0.001). RCT had a cost of 171.5K per molar tooth compared with 44.5K for VPT.

Conclusions

VPT/CEM reduced time and cost spent. When considering clinical as well as cost-effectiveness of VPT/CEM, this treatment option is not only non-inferior but also superior to RCT in mature permanent molar teeth with established irreversible pulpitis.

Clinical relevance

Vital pulp therapy with CEM is a cost-effective and reliable biological technique for endodontic treatment of permanent molar teeth with irreversible pulpitis and can be recommended for general clinical practice.     

Treatment outcomes of pulpotomy in permanent molars with irreversible pulpitis using biomaterials: A multi-center randomized controlled trial

Abstract

Objective. To conduct a randomized clinical trial to compare the post-operative pain experience as well as clinical and radiographic outcomes of pulpotomy in human permanent molars with irreversible pulpitis using calcium enriched mixture (CEM) cement or mineral trioxide aggregate (MTA). Materials and mcethods. A total of 413 patients met the inclusion criteria and consented to participate. The patients were randomly allocated into two study arms: MTA pulpotomy (PMTA: n = 208) and CEM pulpotomy (PCEM: n = 205). Numerical rating scale questionnaires were utilized by the patients to record pain intensity (PI) over 7 days post-operatively. The patients were followed-up for 12 months to assess the clinical and radiographic outcomes of treatment. The data was analyzed using Chi-square, Cohen's kappa and t-tests. Results. There was no significant difference in the mean PI recorded during the 7 post-operative days between the two study arms (p = 0.221). The clinical and radiographic success rates for PMTA at 12-month follow-up were 98 and 95%, respectively; and 97 and 92% for PCEM, respectively. There was no significant differences in clinical (p = 0.7) and radiographic (p = 0.4) success rates between the two arms. Conclusions. Excellent treatment outcomes occurred in molar teeth with irreversible pulpitis undergoing pulpotomy with MTA and CEM biomaterials.     

MTA pulpotomy of human permanent molars with irreversible pulpitis

The histological success of mineral trioxide aggregate (MTA) pulpotomy for treatment of irreversible pulpitis in human teeth as an alternative treatment was investigated in this study. Fourteen molars which had to be extracted were selected from patients 16–28 years old. The selection criteria include carious pulp exposure with a history of lingering pain. After isolation, caries removal and pulp exposure, MTA was used in pulpotomy treatment. Patients were evaluated for pain after 24 h. Two patients were lost from this study. Twelve teeth were extracted after 2 months and were assessed histologically. Recall examinations confirmed that none of the patients experienced pain after pulpotomy. Histological observation revealed that all samples had dentin bridge formation completely and that the pulps were vital and free of inflammation. Although the results favour the use of MTA as a pulpotomy material, more studies with larger samples and a longer recall period are suggested to justify the use of MTA for treatment of irreversible pulpitis in human permanent teeth.     

Vital pulp therapy of mature permanent teeth with irreversible pulpitis from the perspective of pulp biology

The American Association of Endodontists (AAE) Consensus Conference Recommended Diagnostic Terminology states that mature permanent teeth clinically diagnosed with irreversible pulpitis are treated with pulpectomy and root canal filling because inflamed vital pulp is not capable of healing. Histological studies have demonstrated that clinically diagnosed irreversible pulpitis does not involve the entire pulp. A recent International Endodontic Journal Editorial suggested clinical diagnosis of pulp disease should be reassessed because of the poor correlation between clinical symptoms and pulp sensibility testing and the actual histological status of the pulp. This review identified studies in a PubMed search that provide evidence for vital pulp therapy (VPT) of mature permanent teeth with irreversible pulpitis is predictable if correctly diagnosed and properly treated. A narrative review was undertaken to outline the correlation between the clinical symptoms/signs and pulp sensibility testing and the histological findings of the pulp. Treatment procedures for permanent teeth are outlined.     

Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review

Introduction

This systematic review aims to illustrate the outcome of vital pulp therapy, namely direct pulp capping, partial pulpotomy, and full pulpotomy, in vital permanent teeth with cariously exposed pulp.

Methods

Electronic database MEDLINE via Ovid, PubMed, and Cochrane databases were searched. Hand searching was performed through reference lists of endodontic textbooks, endodontic-related journals, and relevant articles from electronic searching. The random effect method of weighted pooled success rate of each treatment and the 95% confidence interval were calculated by the DerSimonian-Laird method. The weighted pooled success rate of each treatment was estimated in 4 groups: >6 months-1 year, >1-2 years, >2-3 years, and >3 years. All statistics were performed by STATA version 10. The indirect comparison of success rates for 4 follow-up periods and the indirect comparison of clinical factors influencing the success rate of each treatment were performed by z test for proportion (P < .05).

Results

Overall, the success rate was in the range of 72.9%-99.4%. The fluctuation of the success rate of direct pulp capping was observed (>6 months-1 year, 87.5%; >1-2 years, 95.4%; >2-3 years, 87.7%; and >3 years, 72.9%). Partial pulpotomy and full pulpotomy sustained a high success rate up to more than 3 years (partial pulpotomy: >6 months-1 year, 97.6%; >1-2 years, 97.5%; >2-3 years, 97.6%; and >3 years, 99.4%; full pulpotomy: >6 months-1 year, 94%; >1-2 years, 94.9%; >2-3 years, 96.9%; and >3 years, 99.3%).

Conclusions

Vital permanent teeth with cariously exposed pulp can be treated successfully with vital pulp therapy. Current best evidence provides inconclusive information regarding factors influencing treatment outcome, and this emphasizes the need for further observational studies of high quality.     

牙髓炎的活髓保存及再生治疗新进展:从基础到临床

近年关于牙髓炎治疗的研究取得了较大进展,这主要得益于牙髓炎治疗的基础和临床研究的飞速进展,一些基础研究已转化为临床实践。牙髓炎检测方法的研究进展可以帮助临床医师更准确地诊断牙髓炎的状态,并采取相应的治疗手段,包括间接或直接盖髓术、牙髓切断术、牙髓再生术和根管治疗术等。针对牙髓炎的诊断理念、牙髓免疫防御和修复功能研究以及新型盖髓剂材料研究均有了较大进展,牙髓炎的活髓保存治疗成功率显著提高。对于难以实现活髓保存治疗的弥漫性冠髓炎或根髓炎,除根管治疗术外,牙髓血运重建、细胞归巢和牙髓干细胞移植牙髓再生等牙髓再生术也可作为一种治疗选择。本文重点阐述牙髓炎治疗研究进展和相关的临床转化实践,旨在为牙髓炎的活髓保存和牙髓再生治疗提供参考。     

龋源性露髓成熟恒牙活髓保存治疗的研究进展

保存牙髓活力、维持牙髓功能、尽可能保留患牙的微创治疗理念是当代成熟恒牙牙髓治疗的重要发展趋势。本文基于最新研究,归纳龋源性露髓的成熟恒牙活髓保存治疗的临床疗效及其影响因素,简要介绍相关研究的新进展,以期为临床开展活髓保存治疗及今后该领域的发展提供参考。     

The effect of pulpotomy using a Calcium-Enriched Mixture cement versus one-visit root canal therapy on postoperative pain relief in irreversible pulpitis: a randomized clinical trial

The purpose of this noninferiority trial was to compare postoperative pain relief after one-visit root canal therapy (ORCT) with a pulpotomy performed with a new endodontic calcium-enriched mixture cement (PCEM) in human permanent molars with irreversible pulpitis. A total of 407 selected patients were randomly allocated into the ORCT group (n = 202) or the PCEM group (n = 205). Numerical Rating Scale questionnaires were used to record pain intensity (PI) by the patients during the first 7 days after treatment. While there was no statistically significant difference in the mean PI at baseline between the two study groups (P = 0.45), changes in mean PI were significantly different between them (P < 0.001). In the ORCT group, pain relief was achieved after 36 h [95% confidence interval (CI), 27.00–45.00], compared to 18 h in the PCEM group (95% CI, 15.00–21.00), a significant difference (P < 0.01). Comparison of the mean PI sum recorded over 7 days showed that patients in the ORCT group experienced significantly more pain than those in the PCEM group (P < 0.001); a similar difference was observed for pain in response to percussion tests (P < 0.001). Treatment with PCEM thus had the better pain-reducing effects than ORCT in irreversible pulpitis cases.     

Five-year clinical evaluation of universal adhesive applied following different bonding techniques: A randomized multicenter clinical trial

ObjectivesTo evaluate the clinical performance of a universal adhesive system (Futurabond U, Voco) when applied following different adhesive strategies in non-carious cervical lesions (NCCLs) after 5 years.MethodsFifty participants were included. Futurabond U (Voco) was applied in NCCLs using four adhesive strategies (n = 50 each): only self-etch (SE); selective enamel etching + self-etch (SET + SE); etch-and-rinse with dry dentin (ERD); and etch-and-rinse with wet dentin (ERW). All cavities were restored with Admira Fusion composite resin (Voco). Restorations were evaluated after 1, 3, and 5 years using the World Federation criteria (FDI) and the modified United States Public Health Service (USPHS) criteria.ResultsAfter 5 years, retention rates were 81 % (65.8–90.5) for SE, 87 % (73.2–94.4) for SET + SE, 84 % (69.6–92.6) for ERD, and 78 % (63.6–88.9) for ERW (p > 0.05). Thirty-five restorations were considered to have minor discrepancies in marginal adaptation at the 5-year recall (14 for SE, 9 for SET + SE, 6 for ERD, and 6 for ERW; p > 0.05). Sixteen restorations were detected as a minor marginal discoloration (6 for SE, 4 for SET + SE, 1 for ERD, and 5 for ERW; p > 0.05) and one restoration showed a recurrence of caries (1 for ERW; p > 0.05) at the 5-year recall. No restorations showed postoperative sensitivity after 5 years.SignificanceNCCLs restorations using a universal adhesive showed satisfactory clinical performance after 5 years, regardless of the adhesive strategy.     

Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial

International Journal of Paediatric Dentistry 2013; 23: 56–63 Objective. To compare clinical and radiographic outcomes of pulpotomy treatment using calcium‐enriched mixture (CEM) cement and mineral trioxide aggregate (MTA) in carious‐exposed vital immature permanent first molars. Design. Fifty‐one immature molars with clinical carious exposure with symptomatic/asymptomatic pulpitis met the inclusion criteria and randomly assigned to one of the treatment groups (CEM [26 teeth; 59 roots], MTA [25 teeth; 59 roots]). After performing pulpotomy and covering the radicular pulps with the biomaterials, all teeth were permanently restored. Blinded clinical and radiographic evaluations were performed at 6 and 12 months after operation for signs of success or failure. Radiographs were evaluated for complete/partial apical closure. The data were analysed using chi‐square test and generalized estimating equation (GEE) model. Results. There was no significant difference at the baseline between the two experimental groups. All available cases (49 teeth) showed pulp survival and signs of continuous root development after 12 months. Overall, complete apical closure (apexogenesis) occurred in 76.8% and 73.8% of radiographically interpreted roots in CEM cement and MTA groups, respectively. There was no statistical difference in terms of radiographic outcomes between two groups. Conclusions. Calcium‐enriched mixture cement and MTA showed similar performance in pulpotomy of immature caries‐exposed permanent molars.     

Coronal discoloration induced by calcium silicate-based cements used in full pulpotomy in mature permanent molars: a randomized clinical trial

Objectives

This study aimed to randomly compare in vivo coronal discoloration at 6 and 12 months after full pulpotomy in mature permanent molars using MTA, Biodentine, and TotalFill and to investigate the effect of variables such as remaining buccal wall thickness and time to achieve hemostasis.

Materials and methods

One hundred eight teeth that met the inclusion criteria received full pulpotomy and were randomly divided into 3 groups via a block randomization technique according to the calcium silicate cement (CSC): ProRoot WMTA, TotalFill, or Biodentine. Assessment of tooth color was carried out using a spectrophotometric device (VITA Easyshade Compact) after composite placement (T0), at 6- and 12-month follow-up. Buccal wall thickness and time to hemostasis were recorded. The primary outcome measure (color change ΔE) was calculated, and the results were analyzed by three-way ANOVA and crosstabulations in relation to material type and effect of variables.

Results

Four cases were excluded after pulpotomy failure; 81 teeth were evaluated at 6 months and 95 teeth at 12 months. All CSCs caused tooth discoloration (defined as ΔE > 3.7); MTA significantly caused the highest color change at 6- and 12-month follow-up (76% (19/25) and 87.5% (28/32), respectively) compared to Biodentine (41% (9/22), 48% (13/27)) and TotalFill (44% (15/34), 53% (19/53)) (p = 0.022, p = 0.002), while no significant difference was found between the Biodentine and TotalFill groups (p = 0.813, p = 0.8). Buccal wall thickness (above or below 2.7 mm) had a significant effect on the degree of discoloration (p = 0.004).

Conclusions

The 3 CSCs caused tooth discoloration based on the threshold of ΔE > 3; the remaining buccal wall thickness was a significant factor. The use of Biodentine and TotalFill instead of MTA is encouraged to minimize discoloration.

Clinical relevance

While experimental studies report coronal discoloration after CSCs use, clinical data is lacking. This study assessed discoloration using a spectrophotometric device. The use of materials with lower discoloration potential in pulpotomy is encouraged.

Trial registration

The study was registered with clinical trial registration number: NCT04346849 on 14.4.2020.

     

Five-year clinical evaluation of a universal adhesive: A randomized double-blind trial

ObjectiveTo evaluate the five-year clinical performance of Scotchbond Universal Adhesive (SU; 3M Oral Care, St. Paul, MN, USA) in non-carious cervical lesions (NCCLs) using two evaluation criteria.MethodsThirty-nine patients participated in this study. Two hundred restorations were assigned to four groups: SU-ERm: etch-and-rinse + moist dentin; SU-ERd: etch-and-rinse + dry dentin; SU-Set: selective enamel etching; and SU-SE: self-etch. A nanofilled composite resin was placed incrementally. The restorations were evaluated at baseline and after 5 years using both the World Dental Federation (FDI) and the United States Public Health Service (USPHS) criteria. The survival rates (retention/fractures) were calculated with the Kaplan-Meier and the log-rank test. For the secondary outcomes, Friedman repeated measures analysis of variance by rank was applied (α = 0.05).ResultsAfter 5 years the recall rate was 86%. The retention/fracture rates were 93% for Erm and ERd, 88.4% for SEet and 81.4% for SE. A significant difference was observed for SE vs. ERd and SE vs. ERm (p = 0.01). Also, marginal discoloration and adaptation showed significant differences with ERm and ERd resulting in fewer marginal discrepancies than SE (p < 0.05).SignificanceAfter 5 years, the clinical behavior of the universal adhesive in the etch-and-rinse strategy was better when compared to the self-etch strategy. The use of selective enamel etching is highly recommended for the self-etch strategy. The FDI and USPHS evaluation criteria showed similar results after 5 years.