Is pulpotomy preferable to root treatment where there is pulp exposure?

Abstract

Data sources Embase, MEDLINE, Web of Science, Trip Pro, Cochrane Library, the International Clinical Trials Registry Platform and ClinicaTrials.gov, including a grey literature search.

Study selection Randomised or quasi-randomised clinical trials (RCT).

Data extraction and synthesis Two reviewers screened independently and extracted data separately with focus on study and population characteristics, treatment, pulp capping materials and clinical and radiographical outcome measures. Incremental cost effective ratios were collated.

Results Seventeen studies reported in 21 articles were included. Three were completed trials and one ongoing trial comparing (partial/full) pulpotomy with other interventions for vital pulp therapy. The remaining 13 studies compared hydraulic calcium silicate cements with calcium hydroxide. Only three studies were considered as low risk of bias, except for performance bias (the inherent impossible task of blinding the clinician). Five trials comparing the capping materials were the basis of a quantitative synthesis. No cost-effectiveness studies were found.

Conclusions Firm evidence has not been reached with respect to pulpotomy being the preferred intervention substituting root canal treatment; however better pulpotomy outcomes were reported when hydraulic calcium silicate cements are used, when compared to procedures where calcium hydroxide was used.

A commentary on

Li Y, Sui B, Dahl C, Bergeron B et al.

Pulpotomy for carious pulp exposures in permanent teeth: A systematic review and meta-analysis.J Dent2019; 84: 1-8. DOI: 10.1016/j.jdent.2019.03.010

GRADE rating

Commentary

This review basically had a sound approach, intending to only include randomised clinical trials, although quasi-trials were included. Appropriate databases were searched. However, the data is not well reported and the accompanying generalisations of terms made the findings difficult to interpret. For example, the statement, 'pulpotomy using calcium hydroxide had higher radiographic success rate at 60 months compared with direct pulp capping in mature permanent teeth'. Although based on intention-to-treat analysis, the above conclusion is difficult to substantiate from the data,¹ because the number of analysed cases in this review appears be interpreted as successful cases. In fact, there was no difference between the two interventions, they were equally poor. In addition, the actual treatment was not pulpotomy but partial pulpotomy.

Even though the authors clearly state that stronger evidence is needed, the discussion tends to stretch the interpretation of the evidence in favour of pulpotomy. Less than 15% of the included trials had low risk of bias of which two of these were not dealing with full pulpotomy. It is crucial to remember that when trials have not had blinded operators for outcome evaluation, or when outcome measures are not fully described within the original protocol,² the study design will not be optimal.

Within endodontics, progress is ongoing to update the criteria for high quality studies. For the clinical trials the so-called Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) protocol is about to be developed,³ highlighting the importance of achieving high standards in upcoming trials. Based on the included studies from this present review, the quality of the randomisation needs attention. Less than 10% of the enrolled studies in this review were scored with low risk of bias concerning the procedure of randomisation.

A paradox is present when comparing pulpotomy with other vital pulp treatments including root canal treatment. Pulpotomy is introduced as being more biologically based than the root canal treatment, as more vital tissue is present. Concomitantly it is still not possible to measure the sensibility of the radicular pulp tissue at clinical follow-ups. Pulp sensibility is also not the best outcome to measure, and appears to be just one facet of oral diagnosis, yet sensibility testing is still mandatory to use to monitor pulpal health. However, the response to sensibility tests indicates at best the vitality of the tooth's pulpal sensory supply,⁴ not vitality or degree of pulp inflammation⁵.

In comparing capping agents, the quantitative analysis supported the use of hydraulic calcium silicate cements. Cost-effectiveness data of pulpotomy treatments are urgenty in need of investigation.

Practice points

• Pulpotomy may be considered as an alternative to root treatment when treating teeth with pulp exposure

• Hydraulic calcium silicate cements appear to have advantages over other materials when used as capping agents in pulpotomy