Comparative Evaluation of Three Calcium Silicate Based Materials as Pulpotomy Agents for Permanent Mature Molars With Irreversible Pulpitis: Randomized Clinical Trial

For many centuries, there has been a closely held belief that any vital mature permanent tooth diagnosed with irreversible pulpitis will require root canal treatment. The reason for such treatment modality, is the high success rate reaching 100% if performed with high standards(1). However, many studies have demonstrated that root canal therapy can be time-consuming(2), necessitate multiple visits(3), be expensive for both the patient and the dentist, and can increase the likelihood that the tooth will fracture because of the loss of tooth structure(2).

On the other hand, vital pulp therapy (VPT) provides many advantages compared to root canal treatment. For example; it maintains the proprioceptive sensation of the tooth, biological immune response from the retained pulp tissue can prevent infection of the apical area, regenerative and repair potential of the pulp is retained, structural integrity of the tooth is maintained, lowering the risk of fracture and there is a notable decrease in pain and discomfort for the patient (4).

More conservative VPT like pulpotomy was limited to immature teeth with mechanical, carious, or traumatic pulp exposure who don't exhibit any periapical disease. In such cases, the goal has been to ensure completion of root formation (apexogenesis)(5). However, the European Society of Endodontology (ESE) and the American Association of Endodontists (AAE) recently released position statements stating that "pre-treatment diagnosis of irreversible pulpitis is not necessarily an indication for pulpectomy", ushering in a new era for minimally invasive VPT in mature permanent teeth Although, several studies (8,14)found that using mineral trioxide aggregate (MTA) for VPT of cariously exposed permanent teeth with irreversible pulpitis resulted in high clinical success rates. Clinically, there have been various complaints against MTA. There have been reports of difficult handling, prolonged setting time, expensive cost, and probable tooth discoloration By far, the most popular and widely utilized materials in the endodontic therapy are calcium silicate cements. Odontocem (Australian Dental Manufacturing, Brisbane, Australia) is a calcium silicate-based technology containing 0.2% of the low steroid triamcinolone acetonide and has outstanding biocompatibility, handling properties and least amount of staining potential. It can be utilised as a dentine substitute for lining deep cavities. Odontocem is proposed to provide antibacterial activity due to its initial high PH and pain relief due to the presence of a potent steroid (16).

Another calcium silicate material that is also recently introduced in the market is NeoPutty (Avalon Biomed Inc., Bradenton, USA). NeoPutty is premixed format of tricalcium silicate-based material (Bioceramic). It's composed of tantalum oxide, tricalcium silicate, calcium aluminate, dicalcium silicate, tricalcium aluminate, and calcium sulfate(17). Guillen et al 2022 (17)compared the cytocompatibility of NeoPutty to NeoMTA Plus and MTA Angelus and concluded that all three materials provided adequate cytocompatibility and preliminary evidence that NeoPutty can be used as pulp capping agent in VPT.