Minimally invasive endodontics: a new era for pulpotomy in mature permanent teeth

Abstract

Emerging clinical and histologic evidence is challenging the long-established dogma that root canal treatment (RCTx) is the only therapeutic option for preservation of vital mature permanent teeth diagnosed with irreversible pulpitis or carious pulp exposure. Vital pulp therapy procedures like pulpotomy are not only technically simpler and more economical, but also afford patients a host of other benefits over conventional RCTx. This narrative review provides an update on the contemporary understanding of pulp pathophysiology and defence mechanisms, the proposed new diagnostic terminologies for pulpal inflammation, and how the biological characteristics of hydrophilic calcium silicate cements have enabled consistent successful outcomes for pulpotomy-treated mature teeth. The paper also details the evidence base from clinical trials and systematic reviews conducted over the past decade and outlines the practical treatment considerations for pulpotomy in mature permanent teeth.

Critical appraisal of the 2020 IADT Guidelines: A personal commentary

“…Surprisingly, this specific recommendation is missing from the 2020 IADT Guidelines for complicated crown root fractures in mature teeth. The current recommendation states, “in mature teeth with complete root formation, removal of the pulp is usually indicated”, to be followed by “completion of root canal treatment and restoration.” 7 If anything, the last decade has seen an explosion of evidence from randomized controlled trials and systematic reviews favoring conservative vital pulp therapy in mature teeth diagnosed with carious pulp exposures or irreversible pulpitis 60–70 . Traumatic exposures of the pulp are even less likely to have the chronic inflammation associated with carious pulp exposures, increasing the likelihood of success of minimally invasive vital pulp therapy procedures in these teeth.…”

“…7 If anything, the last decade has seen an explosion of evidence from randomized controlled trials and systematic reviews favoring conservative vital pulp therapy in mature teeth diagnosed with carious pulp exposures or irreversible pulpitis. [60][61][62][63][64][65][66][67][68][69][70] Traumatic exposures of the pulp are even less likely to have the chronic inflammation associated with carious pulp exposures, increasing the likelihood of success of minimally invasive vital pulp therapy procedures in these teeth. To the best of our knowledge, we have not seen any evidence that may have prompted this change in the IADT treatment recommendation for complicated crown-root fractures in mature teeth.…”

Successful treatment of cystic lesion combining Cystectomy, Nonsurgical Endodontics and Vital Pulp Therapy of Mature Permanent Mandibular Molars: a Case Report with 19 Months Follow-Up

“…One of the main goals of this approach is to avoid unnecessary damage to the tooth and preserve healthy pulp tissue without losing regenerative potential, proprioceptive impulses, and nerve innervation. [1] In some cases, it may be possible to combine different treatment modalities to achieve optimal results. This is particularly relevant in cases where periapical lesion is observed in the apical region of one root of a multirooted tooth, and the periapical bone of the other root is without changes.…”

“…One of the main goals of this approach is to avoid unnecessary damage to the tooth and preserve healthy pulp tissue without losing regenerative potential, proprioceptive impulses, and nerve innervation. [ 1 ]…”

Effectiveness of Pulpotomy Procedures in Mature Permanent Teeth with Irreversible Pulpitis

“…Radiographically, should be no evidence of internal root resorption or periapical radiolucency. However, poor or negative response to sensibility test should be not be considered as failure [11].…”