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 current system for diagnosing different stages of the disease. Although the diagnosis of “irreversible pulpitis” is consistent with histologically detectable areas of bacterially infected or already necrotic tissue, these areas are localized beneath 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 addition 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

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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- found, which are engulfed by polymor- favor of preserving tooth vitality which scribe the pulpal status; either based phonuclear neutrophilic granulocytes, is scientifically pursued in different on clinical or histological observa- and inflammatory infiltrates are pres- dental specialties [10, 18, 21, 51]. tions. Histologically, a large variety of ent at the periphery [48]. However, this For an overview of vital pulp treat- pulp tissue states can be described, histologic condition does not affect the ment subsequent to pulp exposure, the whereas the currently available clini- entire pulp tissue, but remains re- position paper “Current recommen- cal diagnostic tools allow only a rough stricted to the areas beneath the cari- dations for vital pulp treatment” by classification. Since the histopathol - ous lesion, while the radicular pulp ap-

© Deutscher Ärzteverlag | DZZ International | Deutsche Zahnärztliche Zeitschrift International | 2021; 3 (2) KRASTL, GALLER, DAMMASCHKE, SCHÄFER: 82 Is pulpotomy a valid treatment option for irreversible pulpitis?

Figure 1 Treatment options for irreversible pulpitis

pears unchanged apart from a partial the inflammation, and cannot be de- significant damage of the affected pulp loss of the odontoblast layer [48, 50]. tected histologically. The treatment of tissue and reduced chances of healing Thus, the term irreversible pulpitis is pulpitis should thus be based on the [14, 28, 34, 40]. As a consequence, in- misleading as the clinical diagnosis extent of the bacterial infection; un- flamed and heavily bleeding pulp tis- cannot be equated with the tissue‘s fortunately, in a clinical scenario, this sue needs to be removed completely ability to heal after therapeutic inter- cannot be determined precisely due to up to the level where healthy tissue re- vention. Vital tissue may still be pres- the insufficient correlation of clinical mains in order to create the necessary ent in the root canal even in cases with symptoms and histological findings. conditions for successful pulp preser- radiographic signs of an initiating peri- There is, however, a good cor- vation. Similarly to an acute infection apical lesion, which is regarded as a relation between the depth of bacterial in the fingernail area, for example, in local immune reaction in the periapi- penetration into dentin and the histo- which a targeted excision of the in- cal tissue triggered by inflammatory logically detectable pulpal response to fected tissue is performed rather than mediators [55]. Therefore, it may not the carious lesion [38]. Thus, the clini- the amputation of the entire finger represent an absolute contraindication cal classification of the symptoms in [35], the exclusive excision of the irre- for vital pulp treatment [56]. terms of reversible or irreversible pulpi- versibly damaged areas of the pulp Yet, irreversible pulpitis can be tis has nothing to say about the regen- would also be sufficient to allow heal- completely asymptomatic. According erative capacity of the tissue [11]. In ing in cases of pulpitis. to histological findings, teeth which contrast, the assessment of tissue Pulpotomy has been considered displayed an immune reaction as de- bleeding after pulp exposure is a more an established emergency treatment scribed above were clinically symp- reliable diagnostic procedure com- measure for irreversible pulpitis for tom-free in 14–60 % of cases [42, 53]. pared to the sensitivity test and pain decades. Recently, two randomized Another study showed that in 15.6 % symptoms. In cases of mild inflam- controlled trials have shown that pain of cases, the clinical and histological mation, less profuse bleeding occurs, relief after pulpotomy is as reliable as diagnoses did not correspond [48]. especially in the case of reversible pul- after vital pulp extirpation [19, 20]. In Moreover, a significant correlation be- pitis. However, if bacteria have pen- this manner, the noticeably more tween spontaneous pain prior to treat- etrated deeper into the pulp tissue, the time-consuming root canal treatment ment, which suggests irreversible pul- more pronounced inflammatory reac- including chemo-mechanical prepara- pitis, and the success of vital pulp tion causes more severe bleeding from tion can be performed at a subsequent treatment is not necessarily existent the tissue, particularly in the case of point. In these cases, the idea of using [40]. When diagnosing “irreversible irreversible pulpitis. Pulpal bleeding pulpotomy, not only as a temporary pulpitis”, it must be considered that thus reflects the degree of inflam- measure, but rather as a definitive en- pain sensation is always subjective, mation and the chance of healing; dodontic treatment is not new and does not correlate with the extent of heavy or prolonged bleeding indicates dates back to the last century [12].

However, this topic has been re- low-up examinations, the sensitivity there is no discernible decisive advan- searched more extensively only in re- test is inconclusive and the success of tage compared to vital pulp extirpation cent years, on the one hand due to ad- treatment can only be assessed radio- and subsequent root canal treatment, vances in the field of pulp biology, on logically – with the corresponding at least in mature teeth. the other hand the availability of new limitations. Moreover, in contrast to The exposed pulp surface should bioactive materials [54]. partial pulpotomy, the risk of root be capped with an aqueous suspen- Furthermore, in countries where canal obliteration after full pulpot- sion of calcium hydroxide or prefer- root canal treatment is not accessible omy is increased [18]. ably a hydraulic calcium silicate ce- to the general public for cost-related Within this framework, the extent ment, the cap can be coated with a reasons, pulpotomy has been con- of amputation should be based on the thin layer of a fast-setting material sidered to be a less costly alternative depth at which healthy pulp tissue [16]. There is clear evidence for the to avoid an otherwise necessary can be identified and bleeding can superiority of hydraulic calcium sili- extraction [3, 63]. In fact, the treat- be controlled. While inflammatory cate cements compared to calcium ment duration of a pulpotomy pro- changes within the pulp tissue remain hydroxide when used for vital pulp cedure amounts to about one-third of limited to the coronal 2 mm after treatment after carious pulp exposure that of a root canal treatment [6]. trauma-related pulp exposure and [13, 27, 32, 37, 58]. Within the group subsequent contact with the oral mi- of hydraulic calcium silicate cements, 2. Pulpotomy as a clinical lieu for up to 7 days [17, 26], the distinct clinical differences do not procedure after carious depth of tissue destruction that results seem to exist [37], however, the dis- exposure from a carious process is significantly coloration potential of the respective The starting point for performing a more variable. In this case, a reliable product has to be considered. The ap- pulpotomy is a tooth with a deep assessment of the tissue condition is plication of light-curing flowable ma- lesion with pulp exposure in carious only possible by use of using sufficient terials with additives of MTA in direct dentin and/or symptoms of irrevers- magnification and illumination. contact with the pulp is not recom- ible pulpitis (Fig. 1). After isolation Sodium hypochlorite (NaOCl) is mended due to their limited biocom- with rubber dam and disinfection of recommended for rinsing and disinfec- patibility [7, 46]. After the pulp cap- the tooth crown, complete caries ex- tion of the amputation site whereby ping procedure, an adhesive seal and cavation has to be performed, begin- the concentration of the endodontic coronal restoration should be placed ning from the periphery towards the irrigant (1–5.25 %) does not appear to immediately, since this step is critical center, ideally using optical magnifi- be a prognostically decisive factor [43]. for the success of the treatment. cation devices. This is followed by an Careful compression using a cotton initial examination of the pulp tissue pellet soaked in NaOCl may facilitate 3. State of evidence: chance at the exposure site. Infected dentin further hemostasis. The use of a he- of success in cases of chips, which were transported into mostatic agent is not recommended as irreversible pulpitis and the pulp tissue during excavation, can it would “mask” the true inflamma- potential influencing often be observed. Hyperemic and ne- tory state of the pulp [64]. Also, the factors crotic pulp areas may be found con- use of a laser is not recommended due Compared to teeth with traumatic tiguously; a pale-yellow color indi- to insufficient evidence. In a recent dam age, it can be assumed that the cates absent blood circulation and ne- randomized controlled trial, the pulp of teeth with carious exposure is crosis, occasionally, micro-abscesses supplementary use of an Er,Cr:YSGG significantly pre-damaged, as the pulp are present [49]. The aim of a pulpot- laser for pulpotomy after carious expo- has already been in contact with bac- omy procedure is to remove damaged sure of asymptomatic immature teeth terial toxins or even with the bacteria tissue and to lay open healthy pulp by was not beneficial [59]. themselves for a considerable amount means of amputation. For this pur- After amputation and rinsing, of time. The lesion size, bacterial spec- pose, a water-cooled, high-speed dia- bleeding should stop within 5 minutes. trum, and the speed at which the mond bur is used. However, this time frame is only a ref- lesion progresses affect the pulpal From a technical standpoint, the erence value because, in some studies, status [18]. Thus, it can be expected full (= cervical) pulpotomy is the significantly longer bleeding times that the high success rates of over easiest to perform because the end- (15 minutes and longer) have led to 90 % after partial pulpotomy in teeth point of amputation is clearly defined successful treatment [47]. Persistent with complicated crown fractures [24] by reaching the root canal orifices. bleeding indicates that the reduction are considerably higher than after cari- Given that significantly more tissue is of pulpal tissue was not sufficient to ous pulp exposure. In spite of this, removed in a full compared to a par- reach the level of healthy tissue [64]; in more than 10 current clinical studies tial pulpotomy, the probability of this case, a deeper pulpotomy or even a have focused on vital pulp treatment leaving behind only healthy tissue full pulpotomy can be considered. Al- measures in carious teeth with a diag- that is capable of healing is increased, though reports of successful deeper nosis of “irreversible pulpitis”. High meaning that the prospect of success pulpotomies can be found in the litera- success rates ranging between 85 % is high. However, this procedure also ture, in which the amputation site was and 95 % after observation periods of comes with disadvantages. For in- up to several millimeters below the 1 to 5 years have been recorded in stance, in the context of clinical fol- root canal orifices, in the authors‘ view, most studies, regardless of whether a

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Number Initial Obser- Treat- Study Patient of diagnosis Capping Age in- Study vation ment Success type age treated of the material fluence period measure teeth pulp

(Asgary & 9–65 years Irreversible Full pul- CEM 92 % (CEM) Eghbal RCT 413 1 year N/S ø 27 years pulpitis potomy MTA 95 % (MTA) 2013)

Full pul- 86 % (full (Asgary & potomy pulpotomy) Irreversible Eghbal RCT 9–65 years 407 2 years CEM 80 % (vital N/S pulpitis 2014) vital pulp pulp extir- extirpation pation)

Full pul- 71 % (full potomy pulpotomy (Asgary et Irreversible RCT 9–65 years 407 5 years CEM none al. 2015) pulpitis vital pulp 66 % (vital pulp extirpation extirpation)

Not ex- plicitly spec- 5 years 89 % (1 year) Kunert et. Al ified but re- Full pul- Retrosp. 8–79 years 273 (1–29 KH 63 % (10 none 2015 ferred for potomy years) years) root canal treatment

44 % (MTA) MTA Kumar et al 14–32 Irreversible Full pul- 38 % (CH) RCT 54 1 year KH N/S 2016 years pulpitis potomy 36 % PRF+MTA (PRF+MTA)

(Taha, Irreversible 11–51 Full pul- Ahmad et Prosp. 52 pulpitis 3 years MTA 92,7 % none years potomy al. 2017) (> 80 %)

7–13 years 5 years (Qudeimat Irreversible Full pul- Prosp. ø 10.7 23 (19–74 MTA 100 % N/S et al. 2017) pulpitis potomy years months)

(Linsuwan- 3 years 7–68 years Irreversible Full pul- ont et al. Retrosp. 55 (8–62 MTA 84 % none ø 29 years pulpitis potomy 2017) months)

Asgary, Egh- Irreversible Full pul- MTA 85 % (MTA) RCT 9–65 years 412 5 years none bal 2017 pulpitis potomy CEM 78 % (CEM)

Taha, Kha- 20–52 Irreversible Partial pul- MTA 85 % (MTA) zali et al. RCT years 50 2 years N/S pulpitis potomy KH 43 % (CH) 2017) ø 30 years

Taha et al 19–69 Irreversible Full pul- Prosp. 52 1 year Biod. 98 % N/S 2018 years pulpitis potomy

32,2 ± Uesrichai et 6–18 years Irreversible Partial pul- MTA 92 % (MTA) RCT 69 17,9 N/S al 2019 ø 10 years pulpitis potomy Biod. 87 % (Biod.) months

(Abbreviations: RCT = randomized control trial; Retrosp. = retrospective clinical study; Prosp. = prospective clinical study; N/S = not specified; CH = calcium hydoxide; PRF = platelet–rich fibrin; abbreviations of hydraulic calcium silicate cements: MTA = mineral trioxid aggregate); CEM = calcium enriched mixture; Biod. = Biodentine) Table 1 Overview of clinical studies investigating vital pulp treatment on permanent teeth with “irreversible pulpitis”. (Fig. 1 and Tab. 1: G. Krastl)

partial or full pulpotomy was perform- are different. If vital pulp treatment treatment subsequent to vital pulp ex- ed (Tab. 1). fails, root canal treatment can still be tirpation is a reliable and established Half of the studies as mentioned performed with high success rates, method in these cases, which is un- are randomized controlled trials, and whereas retreatment shows signifi- doubtedly still to be considered the therefore regarded at the highest level cantly reduced success rates. gold standard. In comparison, the evi- of evidence among all primary study Among the factors that potentially dence for vital pulp treatment in teeth types. Still, it must be taken into con- influence the prognosis of vital pulp with irreversible pulpitis is rather sideration that even this type of study treatment, patient age is frequently sparse at present, especially because design can only generate robust re- discussed. Favorable conditions for long-term data is missing. sults if the planning, conduct and pulp preservation are found in young In spite of this, based on the cur- evaluation are methodologically cor- patients with a high potential for re- rent data, pulpotomy can be consid - rect and appropriately tailored to the generation, provided that the pulp tis- ered a valid treatment option for irre- research question. In general, the sue has not been damaged previously versible pulpitis and it surely repre- validity of single studies may be lim - [61]. In particular, teeth with imma- sents an alternative to vital pulp extir- ited by various qualitative deficiencies ture roots benefit the most from vital pation [37]. In the context of treat- such as the lack of blinding of the in- pulp treatment which enables con- ment concepts for inflammatory pulp vestigators as well as by inaccurately tinued formation of dentin and ce- diseases, the shortcomings of the cur- and inconsis tently defined success mentum and thus further root devel- rent classification of pulpitis should criteria [8]. In most studies, pulpot- opment. With increasing age, a re- also be emphasized. A more precise omy procedures are categorized as suc- duced regenerative capacity is ex- and treatment-oriented classification cessful if there is no clinical or radio- pected due to changes such as a re- that reflects the possibilities for tissue logical evidence of pulp necrosis. duced cell number and increased con- preservation would be desirable. However, the actual condition of the tent of fibrous tissue [25, 44]. Never- In addition to the correct indi- remaining pulp tissue is difficult to theless, patient age does not seem to cation, the success of a (partial or full) assess. The lack of response to sensitiv- have a decisive influence on the suc- pulpotomy to a large extent depends ity testing, at least in the case of com- cess rate: In the existing clinical on whether the necessary measures are plete pulpotomy, has to be attributed studies on vital pulp treatment of per- performed adequately. This implies an to the treatment itself and cannot be manent teeth with irreversible pulpi- aseptic treatment concept with the considered a criterion for failure. Since tis, patients up to the age of 79 years consistent use of rubber dam and ster- the most frequent cause of failure after were included (Table 1). ile instruments, the use of appropriate pulpotomy is assumed to be asymp - The question whether teeth after magnification aids in order to be able tomatic apical periodontitis [31], it (partial) preservation of pulp vitality to precisely perform the pulp ampu- must be assumed that pulp necrosis after pulpotomy procedures indeed tation, thorough endodontic knowl- remains undetected and is considered have a better prognosis compared to edge to assess the condition of the ex- a failure only when radiological signs teeth treated with vital pulp extir- posed pulp, disinfection and capping of apical periodontitis are present. For pation and subsequent root canal of the tissue with a suitable bioactive this reason, long-term studies that treatment remains unanswered. This material and an immediate adhesive span more than 5 years are critical be- would be the case if – given that tooth seal and permanent coronal restora- cause the success of pulpotomy pro- vitality is preserved in the long-term – tion. Recent data show that deviations cedures in cases of irreversible pulpitis the susceptibility to fracture does not from these requirements significantly has only been proven clinically, but increase after this type of treatment. In reduce the success of vital pulp treat- not histologically. this respect, the critical long-term data ment measures after pulp exposure [9]. In a randomized, controlled, are not available. However, it can be Given that every dentist should be multicenter study, where pulpotomy conjectured that the biomechanical familiar with pulpotomies as emer - was compared to root canal treatment stability of a tooth after partial pulpot- gency treatment for irreversible pulpi- in teeth with irreversible pulpitis, no omy with the preservation of most of tis, a next step would be to establish significant difference between the two the coronal pulp is more similar to a pulpotomy as a definitive measure treatment options (vital pulp extir- sound and vital tooth compared to a (under the condition of an enhanced pation vs. pulpotomy) were found [5]. tooth with remnants of vital pulp only treatment protocol) besides root canal However, the success rate for endo- in the root canals up to the level of the treatment. Especially in young patients dontic treatment after vital pulp extir- canal orifices after a full pulpotomy. with immature teeth, long-term pulp pation after 5 years in this study was preservation would be most beneficial. 66 %, which is significantly lower 4. Conclusion However, the effort required to cor- than the reported success rates of over From a patient‘s perspective, teeth rectly perform a (partial or full) pulpot- 90 % in other studies [22]. Fur- with deep carious lesions and symp- omy as a definitive measure is unfortu- thermore, a comparison between suc- toms of irreversible pulpitis need to be nately not sufficiently reflected in the cess rates of pulpotomy and root canal treated in a way that is most likely to payment system of health insurance treatment may not be feasible, as, in keep the affected tooth free of symp- companies in Germany. case of failure, the conditions for toms in the long term and the peri- The present position paper is long-term preservation of the tooth radicular tissue healthy. Root canal based on the current state of scientific

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Ricucci D, Siqueira JF, Jr., Li Y, Tay FR: Vital pulp therapy: histopathology and his- tobacteriology-based guidelines to treat PROF. DR. GABRIEL KRASTL PROF. DR. TILL DAMMASCHKE Department for Conservative Dentistry teeth with deep caries and pulp exposure. Department of Periodontology and and Periodontology J Dent 2019; 86: 41–52 Operative Dentistry University Hospital Würzburg University Hospital Münster 50. Ricucci D, Siqueira JF, Jr., Loghin S, Lin Pleicherwall 2, 97070 Würzburg Albert-Schweitzer-Campus 1, LM: Pulp and apical tissue response to Germany Building W 30 deep caries in immature teeth: a histologic [email protected] 48149 Münster, Germany and histobacteriologic study. J Dent 2017; [email protected] 56: 19–32 51. Schwendicke F, Frencken JE, Bjørndal L et al.: Managing carious lesions: consensus recommendations on carious tissue removal. Adv Dent Res 2016; 28: 58–67 52. Schwendicke F, Stolpe M: Direct pulp capping after a carious exposure versus root canal treatment: a cost-effectiveness analysis. J Endod 2014; 40: 1764–1770 (Photo: UKR) UKM) (Photo: 53. Seltzer S, Bender IB, Ziontz M: The dy- namics of pulp inflammation: correlations PROF. DR. KERSTIN GALLER PROF. DR. EDGAR SCHÄFER between diagnostic data and actual histo- Department for Conservative Dentistry University Clinic for Dental Medicine logic findings in the pulp. Oral Surg Oral and Periodontology Polyclinic for Dental Preservation Med Oral Pathol 1963; 16: 846–871 Regensburg University Hospital Waldeyerstr. 30, 48149 Münster, 54. Simon S, Perard M, Zanini M, et al: Franz-Josef-Strauß-Allee 11 Germany Should pulp chamber pulpotomy be seen 93053 Regensburg, Germany [email protected] as a permanent treatment? Some prelimi- [email protected]