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Is Pulpotomy a Valid Treatment Option for Irreversible Pulpitis? Scientific Communication of the German Society of Endodontology and Dental Traumatology

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Is Pulpotomy a Valid Treatment Option for Irreversible Pulpitis? Scientific Communication of the German Society of Endodontology and Dental Traumatology 80 RESEARCH REVIEW Gabriel Krastl, Kerstin Galler, Till Dammaschke, Edgar Schäfer Is pulpotomy a valid treatment option for irreversible pulpitis? Scientific Communication of the German Society of Endodontology and Dental Traumatology Summary: Based on the current state of knowledge, vital pulp treatment on teeth with deep carious lesions is indicated only in vital teeth which are asymptomatic, or at the most, show symptoms of reversible pulpitis. In cases of irreversible pulpitis, vital pulp extirpation and root canal treatment consti- tutes a reliable and established method that should still be considered the gold standard. However, recently published clinical studies show that, despite the diagnosis of “irreversible pulpitis”, surprisingly high success rates can be achieved after partial or full pulpotomy. These findings do not only challenge the current treatment concepts for teeth affected by pulpitis, but also the cur- rent system for diagnosing different stages of the disease. Although the diag- nosis of “irreversible pulpitis” is consistent with histologically detectable areas of bacterially infected or already necrotic tissue, these areas are localized be- neath the carious lesion in the coronal pulp and do not affect the entire pulp tissue. Pulpotomy involves the complete removal of inflamed, and therefore heavily bleeding, pulp tissue up to the level where the remaining pulp tissue is healthy in order to create the necessary conditions for healing. To date, a total of 12 clinical studies with a focus on vital pulp treatment in teeth with deep carious lesions and irreversible pulpitis have been published. Success rates after observation periods of 1 to 5 years range between 85 % and 95 % in most studies, regardless of patient age and type of pulpotomy (partial or full). How- ever, it must be taken into account that long-term studies are lacking, and the significance of the individual studies is limited by various qualitative deficits. In spite of these shortcomings, based on the current data, pulpotomy can be regarded as a valid treatment option for irreversible pulpitis and it certainly represents an alternative to vital pulp extirpation. Whereas the correct indi- cation is critical, the success of a pulpotomy procedure mainly relies on the adequate performance of the necessary treatment steps. This includes, in addi- tion to the aseptic treatment concept in combination with the consistent use of rubber dam and sterile instruments, the use of magnifying aids to enable a sufficiently precise amputation procedure, the endodontic expertise to assess the exposed pulp tissue, the application of appropriate disinfection measures and capping of the tissue with a bioactive material followed by an immediate coronal seal. Keywords: partial pulpotomy; pulpitis; vital pulp treatment; full pulpotomy Department for Conservative Dentistry and Periodontology, University Hospital Würzburg: Prof. Dr. Gabriel Krastl Department for Conservative Dentistry and Periodontology, University Hospital Regensburg: Prof. Dr. Kerstin Galler Department of Periodontology and Operative Dentistry, University Hospital Münster: Prof. Dr. Till Dammaschke Central Interdisciplinary Outpatient Clinic, Münster University Hospital: Prof. Dr. Edgar Schäfer Translation from German: Cristian Miron Citation: Krastl G, Galler K, Dammaschke T, Schäfer E: Is pulpotomy a valid treatment option for irreversible pulpitis? Dtsch Zahnärztl Z Int 2021; 3: 80–87 Peer-reviewed article: submitted: 30.08.2020, revised version accepted: 12.10.2020 DOI.org/10.3238/dzz-int.2021.0010 © Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (2) KRASTL, GALLER, DAMMASCHKE, SCHÄFER: Is pulpotomy a valid treatment option for irreversible pulpitis? 81 Introduction the German Society of Endodontology ogical condition of the pulp cannot be The high success rate of correctly per- and Dental Traumatology (DGET) evaluated clinically, the therapeutic formed root canal treatment has been should be referred to [18]. decision must be based on the clinical proven in many studies. This is par- The present article focuses exclu - diagnosis. The AAE (American Associ- ticularly true for teeth that require sively on vital pulp treatment and in ation of Endodontists) has adhered to treatment, but do not exhibit signs of particular on partial removal of pulp the current consensus to classify pul- a preoperative apical periodontitis tissue in teeth that require root canal pits clinically as reversible and irrevers- [45]. Even though the success rates treatment according to current stan- ible [1, 2]. Whereas in teeth with re- 5 years after vital pulp extirpation and dards, which are based on the belief versible pulpitis, pain is most often in- root canal treatment are around 90 % that preservation of pulp vitality was duced upon stimulation only, irrevers- [22], the complete loss of pulpal tissue not possible. Thus, partial pulpotomy ible pulpitis is typically associated with function is an imperative conse- (partial amputation of the coronal lingering pain induced by thermal sti- quence [18]. This leads to several dis- pulp) and full pulpotomy (complete muli, spontaneous (unprovoked) pain advantages, including an increased amputation of the coronal, but pres- and possibly by the patient’s inability risk of fracture due to hard tissue re- ervation of the radicular pulp) are to precisely localize which tooth is the moval during preparation as well as discussed here. culprit and source of the pain. morphological and structural changes Vital pulp treatment after trau- According to the current state of of dentin that occur during treatment, matic exposure (by direct pulp cap- knowledge, vital pulp therapy in teeth and possibly, to an increased maxi- ping and partial pulpotomy follow- with deep caries is indicated only if the mum loading owing to the partial loss ing complicated crown fractures) are pulp is vital pulp and the tooth is of proprioceptive protective mech- not considered in this publication, as asymptomatic, or at the very most, anisms [23, 36]. Other potential draw- preservation of pulp vitality in such shows symptoms of reversible pulpitis backs after root canal treatment in- cases is implicit and can be achieved [21]. This applies to selective caries clude coronal discolorations [29], predictably and successfully [24, 30]. excavation, too [10]. Up to now, vital higher susceptibility to caries as a Likewise, cases with deep carious pulp treatment is considered to be con- consequence of accelerated biofilm lesions but without signs of irrevers- traindicated if there is already evidence formation due to alterations of the ible pulpitis are excluded as these of irreversible pulpitis, due to the belief microflora [41], the lack of defensive neither represent a primary indi- that the tissue cannot heal predictably capacity of the pulp-dentin complex cation for root canal treatment. after the removal of the triggering as well as the absence of a functional stimulus. Surprisingly, several recent pain response system. Endodontic 1. Biological background clinical studies have shown high suc- treatment often proves to be more regarding pulpotomy in cess rates after partial and full pulpot- complex than anticipated initially, cases of carious exposure omy in cases of irreversible pulpitis which can significantly impair the In the majority of cases, inflammatory [3–6, 31, 33, 39, 47, 56–58, 60]. This treatment outcome. In case of failure, reactions in the pulpal tissue develop challenges the suitability of the current subsequent therapies to preserve the due to microbial irritation originating classification system of pulpal diseases tooth (e.g. root canal retreatment or from carious lesions, but may also to adequately describe the condition of apicoectomy) are associated with sig- occur after mechanical, thermal or the pulp and accordingly, its clinical nificantly increased efforts. chemical irritation or due to traumatic relevance [62]. Some studies suggest The above-mentioned problems damage. Depending on the intensity that the histological condition of the can be avoided if the vitality of the of the stimulus, the inflamed tissue pulp correlates with the clinical diag- pulp is maintained. Procedures that may either heal or increase in inten- nosis in many cases [15, 48], especially aim for the preservation of pulp vital- sity to take on acute or chronic forms. in healthy teeth and teeth with revers- ity are conservative measures which The inflammation spreads from the ible pulpitis [48], which display a mod- can be performed with considerably site of injury into the pulp tissue. Dur- erate chronic inflammatory reaction. less time expenditure than root canal ing this process, both healthy and Furthermore, in the majority of cases treatment [6]. If correctly indicated affected tissue with varying degrees in which an “irreversible pulpitis” was and implemented, vital pulp treat- of inflammation, can be present con- diagnosed clinically, areas of necrotic ment is associated with high success comitantly. Furthermore, changes and infected pulp were actually de- rates [18] and is cost-effective in the occur constantly as the inflammatory tected histologically. In the presence of long term [52, 63]. process progresses. Various classifi- bacteria in the pulp chamber, micro- Moreover, in recent years, the den- cation systems have been developed abscesses and tissue necrosis can be tal literature shows a clear trend in over time in order to adequately de-
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