| Abstract|| |
Background: Partial pulpotomy is a procedural intervention that can maintain the vitality of pulp during the management of traumatized permanent teeth with pulpal involvement. Aim: To evaluate whether partial pulpotomy can be considered a reliable conservative treatment option for treating traumatized permanent anterior teeth with pulpal involvement. Methodology: A computerized systematic search was performed in PubMed, Science Direct, Cochrane, and LILACS databases from 1980 to May 2021. Five studies were included in the final analysis. Quality assessment, Meta-analysis, and Publication bias of the studies were evaluated. This systematic review was registered in PROSPERO (ID – CRD42021262031). Result: The comprehensive Meta-Analysis Software was used. The test of the heterogeneity was analysed using Cochran's Q statistics. The Q value was 7.186 (df = 6) with a P value of 0.3 and I2 as 16.5%. The studies were considered homogenous, and the fixed-effect model showed an overall point estimate of 0.89 with a 95% confidence interval (0.86–0.91). The Begg and Egger funnel plot indicated that there was no publication bias in the included studies. Conclusion: Evidence indicates that partial pulpotomy may be considered a reliable definitive treatment option in asymptomatic traumatized permanent anterior teeth with exposed pulp rather than total pulpotomy.
Keywords: Crown fracture, partial pulpotomy, traumatize anterior teeth, vital pulp therapy
|How to cite this article:|
Madhumita S, Chakravarthy D, Vijayaraja S, Kumar S A, Kavimalar D S. The outcome of partial pulpotomy in traumatized permanent anterior teeth – A systematic review and meta-analysis. Indian J Dent Res 2022;33:203-8
|How to cite this URL:|
Madhumita S, Chakravarthy D, Vijayaraja S, Kumar S A, Kavimalar D S. The outcome of partial pulpotomy in traumatized permanent anterior teeth – A systematic review and meta-analysis. Indian J Dent Res [serial online] 2022 [cited 2022 Nov 29];33:203-8. Available from: https://www.ijdr.in/text.asp?2022/33/2/203/358435
| Introduction|| |
Traumatic injury to teeth is a very common occurrence among children and adolescents. Due to the position of the anterior teeth, two-thirds of dental injuries have been reported to affect the incisors. Around 80% of the maxillary incisors and 16% of lateral incisors are the most commonly affected teeth during trauma. There are several classifications for traumatic dental injuries. Ellis and Davey's classification was based on a numerical system (I to VIII) which described the extent of the fracture and broadly classified it as 'simple fracture' and 'complicated fracture'.
Complicated crown fractures are fractures involving enamel and dentin with pulp exposure. Around 18% to 20% of traumatic injuries involving the teeth result in crown fractures with pulp exposure. The prognosis of traumatized teeth is better because of the absence of caries-associated microorganisms. The dental trauma may produce changes in the exposed pulp tissues leading to the destruction of the normal tissue architecture at the pulp-dentin interface. Maintaining the vitality of the pulp is an important challenge during treatment so that the biological and functional aspects of the traumatized tooth are restored.
Conservative pulp therapy (CPT) is one of the effective treatments of choice for traumatized vital teeth with pulp exposure. The primary objective of CPT is to maintain the pulp vitality so that it completely restores dentin by reparative dentinogenesis and promotes continued root development leading to strengthening of the root structure and closure of the apex. The treatment options for CPT of traumatized vital permanent teeth are direct pulp capping, complete pulpotomy, and partial pulpotomy. The success rates of these CPT have been reported to be 54.5% to 81.5% for direct pulp capping, 86% to 92% for coronal pulpotomy, and 94% to 96% for partial pulpotomy.,
Partial pulpotomy is defined as 'a procedure that involves the amputation of the coronal portion of the affected or infected dental pulp' [American Academy of Pediatric Dentistry, 2005-2006]. The inflamed pulp is gently removed to a level approximately 2 mm below the exposure site. It offers the benefit of preserving the cell-rich coronal pulp, so that there will be a continual deposition of cervical dentin which reduces the risk of root canal obliteration, and the prognosis is better due to the absence of caries-associated microorganisms.,,
The high success rate of partial pulpotomy on traumatized teeth was proposed several decades ago in 1975 by Cvek in mature and immature teeth. Recent studies have assured that as long as a good hermetic seal is ensured, root canal treatment is not necessary after pulpotomy. This has been further confirmed on histological examinations, and over the years, literature is also continuously supporting this evidence.
This shift in preference for partial pulpotomy rather than total pulpotomy or non-surgical endodontics is likely due to the nature of the injury, time of intervention after injury, and the advent of contemporary tools such as cone-beam computed tomography, surgical operating microscope, ultrasonic instruments, electronic apex locator, and the advent of newer materials like MTA, calcium hydroxide (CH), biodentine or MTA-like cement. These advancements have drastically increased the success rate of partial pulpotomy in traumatized anterior teeth.
This systematic review was to analyse the existing literature to evaluate whether partial pulpotomy can be considered a reliable conservative treatment option for treating traumatized permanent anterior teeth with pulpal involvement.
| Materials and Methods|| |
The systematic review was conducted following the Preferred Reporting Items for Systematic Reviews principles. Population, Intervention, and Outcome items of the PICO framework were used to formulate the following clinically related research question: Can partial pulpotomy be considered a reliable conservative treatment option, rather than total pulpotomy in the management of traumatized permanent anterior teeth with pulpal involvement? This systemic review was registered in PROSPERO (ID - CRD42021262031).
A computerized systematic search was performed independently by two of the investigators in the following databases PubMed, Science Direct (Elsevier, RELX Group, Amsterdam, Netherlands), Cochrane (John Wiley & Sons, Ltd, London, UK), and LILACS for each database from 1980 to May 2021. The search strategy included the use of MeSH (Medical Subject Headings), keywords, Boolean operators 'AND' and 'OR', for each database. The keywords used were “Partial Pulpotomy”[All Fields] OR “Partial Pulpotomy”[Title/Abstract] OR “Partial Pulpotomy”[Text Word] OR “Vital pulp therapy”[Title/Abstract] OR “reversible pulpitis”[Title/Abstract] OR “Direct pulp capping”[Title/Abstract]) AND “Anterior teeth”[All Fields]) OR “Anterior teeth”[Title/Abstract] OR “Permanent incisors”[Title/Abstract] OR “Permanent incisors”[All Fields] OR “incisor*”[All Fields] OR “incisor*”[MeSH Terms] OR “incisors*” [Title/Abstract] OR “Front teeth”[All Fields]) AND “Traumatized immature permanent teeth”[Title/Abstract]) OR “Traumatized immature permanent teeth”[All Fields] OR “Permanent Traumatized teeth”[Title/Abstract] OR “Permanent Traumatized teeth”[All Fields] OR “Crown fracture”[All Fields] OR “Crown fracture”[Title/Abstract]) AND ((journal article[Filter]) AND (humans[Filter]) AND (1980/1/1:2021/5/1[pdat]).
Only articles in English and clinical trials on the human species were included in the search phase of the systematic review. Reference lists of the identified articles were also checked for possible additional studies and grey literature was also searched including Open Grey. Also, a hand search was performed in the Journal of Dentistry; Journal of Endodontics; International Endodontic Journal; Australian Endodontic Journal; and Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. The references were managed by Zotero software and duplicates were removed.
Inclusion and exclusion criteria
Randomized and non-randomized clinical trials from January 1980 to May 2021 were evaluated. Traumatized anterior vital teeth with fractured crown diagnosed with normal pulp or reversible pulpitis with a follow-up period of a minimum of six months were included. The studies that reported outcome data including pulp vitality, pain, tenderness to palpation/percussion, and other clinical and radiographic signs of inflammation or necrosis or root resorption were included. Animal studies, clinical trials on posterior teeth, caries teeth, teeth with a periapical lesion or irreversible pulpitis, and literature reported in other languages which cannot be translated were excluded.
The article selection process was done in two phases to minimize bias. In the first phase, the eligible articles were selected based on the title and abstract. In the second phase, full-text articles were evaluated, and the studies that did not meet the inclusion criteria were excluded. A flow diagram of the search process was performed with the number of excluded/included articles [Figure 1]. An Excel spreadsheet (Microsoft Office; Microsoft, Redmond, WA) was created with the following information for each study: Author name and year of publication, study design, sample size, patient's age, period of follow-up, pulp capping material used, success rate, apex status, follow-up time the review was evaluated the type of final restoration [Table 1].
The quality assessment of the selected studies was performed according to the design of each study. ROBINS-I tool was used for the assessment of non-randomized clinical trials [Figure 2] and RoB II, the Cochrane Collaboration's tool for randomized clinical trials was used [Figure 3].
|Figure 2: Assessment of risk of Bias using ROBINS- I tool for non -randomized clinical trials|
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|Figure 3: Assessment of risk of Bias using RoB II- Cochrane Collaboration's tool for randomized clinical trials|
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| Results|| |
The process of selecting the included studies is described in [Figure 1]. Nineteen studies full-text was reviewed. Five studies were included in the final analysis; [Table 1] presents the features of the included studies.,,,, Two investigators independently performed all the search steps and reviewed all the studies. Kappa statistics for inter-rater reliability were calculated, and the value was 0.7, which is a 'good agreement' value. In case of disagreement, a consensus was reached through discussion.
The comprehensive Meta-Analysis Software served as the statistical platform for computing tests and associated graphical results. The test of the heterogeneity for the included studies was analysed using Cochran's Q statistics. The Q value is 7.186 (df = 6) with a P value of 0.3 and I2 is 16.5%. The studies were considered homogenous and hence fixed-effect model was used. The fixed-effect model shows the overall point estimate of 0.89 with a 95% confidence interval (0.86–0.91).
The main outcome of a meta-analysis is a graphical display in the forest plot [Figure 4]a. It shows 95% confidence intervals of all the studies which were entirely on the positive side of zero and it does not overlap 1. Hence, there is a statistical significance at the individual study level. Similarly, the 95% confidence interval of the overall effect estimate does not overlap 1 and so there is statistical significance at the meta-analysis level.
|Figure 4: (a) Meta-analysis graphical displayed in the forest plot. (b) Funnel plot indicating the absence of publication bias|
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On the assessment for publication bias in the included studies using the Begg and Egger funnel plot, all the included studies exhibit low standard error. Few studies are clustered around the point estimate. Smaller studies with high standard error are not reported. The funnel plot exhibited symmetry among event rate values, indicating the absence of publication bias [Figure 4]b.
| Discussion|| |
According to the results of the present systematic review, the data reveals that partial pulpotomy is a reliable conservative treatment option for treating pulpal-involved traumatized permanent anterior teeth.
Procedural interventions such as pulpotomies and pulpectomies have been the first line of emergency treatments for traumatized teeth with pulpal exposure. Pulpectomy has been the preferred choice of treatment according to a survey of Diplomates of the American Board of Endodontics in 1979. It was demonstrated that more than 50% of endodontists were inclined towards pulpectomy and complete instrumentation rather than pulpotomy because of the considerably high success and survival rate. However, this trend changed by a cumulative 27% in 1988 after 10 years. A lately more conservative approach to maintaining pulp vitality is considered for effective management of pulp exposures.
Healing of dental pulp after a traumatic exposure depends on several factors like the interval between trauma and treatment, amount of pulp exposure, completion of root formation, trauma intensity, prevention of bacterial invasion into the pulp before and after treatment, and the inflammatory status of pulp. Pulpal healing is promoted by the removal of the contaminated parts of the pulp followed by the prevention of any further contamination.
The treatment modalities for the treatment of traumatized permanent teeth to maintain pulp vitality are direct pulp capping, complete pulpotomy, and partial pulpotomy. Partial pulpotomy is indicated when the traumatized tooth has no history of spontaneous pain or acute minor pain that subsides with analgesics, no discomfort to percussion, no vestibular swelling, and no mobility, tooth in which the radiographic examination shows the normal periodontal attachment and on isotonic saline irrigation, when bleeding from the pulp extirpation site stops within two minutes.
The partial pulpotomy involves surgical removal of damaged and hyperemic tissue of pulp and dentine surrounding the exposure, using a sterile diamond round bur in a high-speed handpiece with a light touch and copious saline irrigation 2–3 mm of the damaged, inflamed, superficial pulp tissues surgically amputated to the level of healthy pulp. The pulp wound is irrigated with 0.5% sodium hypochlorite and sterile saline solution to remove debris. Haemostasis is achieved using moist sterile cotton pellets for up to 5 min. Once bleeding has ceased, the exposed pulp is dressed with a biocompatible material to promote healing and to maintain the vitality of the remaining pulp tissue. The bioactive medicaments are placed on the exposed pulp to resolve inflammation and tissue formation to stimulate tertiary dentinogenesis.,,
The advantages of partial pulpotomy are the preservation of cell-rich coronal pulp tissue, providing a better healing potential, which ensures continual deposition of cervical dentin and reduces the risk of root canal obliteration and as long as a hermetic seal is ensured, subsequent root canal treatment is not needed., The natural colour and translucency of the tooth are preserved maintaining the vitality of the pulp, and it is possible to perform sensitivity testing.
According to the literature, there is no accurately established timing for when a partial pulpotomy procedure can be considered successful. Matsuo et al. considered 21 months as the appropriate time to determine a successful prognosis. Zanini et al. stated that to evaluate the success of the treatment long follow-up period is essential but when the follow-up period is extended very long, failures can occur due to bacterial leakage when the newly formed dentinal bridge can no longer protect the underlying pulp tissue, leading to irreversible pulpitis.
When there is failure, the restoration status, clinical, radiological findings, and the periodontal condition at the time of the failure should be reported. This will help to determine if the failure was related to any external factors or the partial pulpotomy therapy itself. 131] Although treatment is considered successful in some cases, the chances of the pulp becoming necrotic or developing a calcific metamorphosis are also reported, and hence a periodic follow-up is necessary and patients should be scheduled for regular annual visits according to the American Dental Association.
It is evident from various studies that the longer the observation period, the higher the risk of patient loss to follow-up. Thus, in this study, the results of the one year follow-up period were included for statistical analysis. An attempt was made to include studies with a similar clinical protocol following the same treatment approaches wherein the studies which used different materials were taken into consideration and included.
In the present systematic review, five articles were included based on eligibility criteria to evaluate the success rate of partial pulpotomy using different pulpotomy medicaments. The bulk of the evidence on comparisons among different partial pulpotomy medicaments was found in the literature comparing CH, MTA, biodentine, and iRoot BP plus.
A success rate of 94% was reported by Anna Fuks with an one-year follow-up in 63 anterior teeth using CH for partial pulpotomy. Recent research has demonstrated that it may be because CH causes the release of bioactive molecules from the dentin matrix, including bone-morphogenetic protein (BMP) and transforming growth factor-beta one (TBF-β1), which stimulate pulp repair and dentin remineralization. The disadvantages of CH include no inherent adhesive properties, degradation, poor sealing ability, and a 'tunnel effect' in the induced calcific bridge, which can cause inflammation or even necrosis due to intense leakage through these tunnels.,, Thus, the dentinal bridge induced by CH shows porosities and defects, allowing direct access of microorganisms to the pulp.,
A Caprioglio et al. reported a success rate of 81.5% using MTA for partial pulpotomy in 27 traumatized anterior teeth. MTA contains calcium oxide in the form of tricalcium silicate, dicalcium silicate, tricalcium aluminate, and bismuth oxide for rendering the material radiopaque. CH is the main reaction product of MTA and water. Favourable properties of MTA include a significant reduction in pulpal inflammation and thicker dentinal and less porosity. It has its drawbacks like tooth discoloration, long setting time, poor handling properties due to a wet-sand-like consistency and high cost.,, Qudeimat MA et al. have reported that there is no statistical difference between the success rates of teeth treated with CH and those treated with MTA when used for partial pulpotomy in traumatized permanent teeth.
Partial pulpotomy using Biodentine in 48 traumatized anterior teeth, with a success rate of 91% was reported by L Haikal. Biodentine is considered a calcium silicate cement that was introduced as a 'dentine replacement' material. It has the same clinical applications as MTA but with superior physico-chemical properties, micro-mechanical anchorage, induction for the formation of an effective calcific barrier, absence of tooth discoloration, faster setting time, and ease of handling., When comparing the quality of the dentinal bridge formed by biodentine to MTA, it induces a thicker and a higher quality of hard tissue barrier when compared to MTA. But biodentine does not have sufficient radiopacity to enable its exact location to be distinguished, making it difficult to evaluate the dentin bridge.
Quian Rao et al. reported a success rate of 90.3% for the CH group and 92.3% for the iRoot BP group. The study reported the ability of iRoot BP Plus to promote dentin bridge formation better than the CH group which may have contributed to the higher success rate of the iRoot BP Plus group. Ying Ting Yang et al. have reported a success rate of 82.9% for the CH group and 90.4% for the iRoot BP group. Their randomized controlled study demonstrated no significant difference between the CH and iRoot BP Plus groups and concluded that iRoot BP Plus is a favourable capping material for the procedure.
The limitations of the systematic review are that the success percentage of partial pulpotomy done on caries anterior teeth was not included and studies with longer follow-up period could not be reported as the included studies evaluated and reported the success rate at different time period. The strengths of the systematic review are that it is the first of its kind of review to assess the outcome of partial pulpotomy in traumatized permanent anterior teeth, the computerized systematic search was well executed and studies from 1980 to 2021 were included, and all the studies included were clinical trials.
The level of evidence for the four non-randomized studies (quasi-experimental) is Level III and for the randomized study, it is Level II, The evidence level of this systematic review is good.
| Conclusion|| |
According to the result of the present literature search, it is evident that partial pulpotomy may be considered a reliable definitive treatment option in traumatized permanent anterior teeth with pulpal involvement rather than total pulpotomy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. S Madhumita
Department of Conservative Dentistry and Endodontics, Indira Gandhi Institute of Dental Sciences, Puducherry
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]