Comparative Evaluation of Pulpotomy as a Conservative Treatment Option in Symptomatic Irreversible Pulpitis Using Three Different Bioceramic Materials Versus Pulpectomy : A Randomized Clinical Study.

Dental caries causes gradual weakening of tooth enamel, leading to inflammation of the tooth pulp if left untreated. This persistent infection is a major global health concern, with untreated cavities being widespread, affecting approximately 34.1% of the population worldwide.

Managing dental decay involves preventing it through primary preventive methods and removing decayed tissue through operative interventions. Preserving the health and vitality of the tooth pulp, preventing complications like abscess formation, and developing minimally invasive biological treatments are key focuses in modern clinical practice.[1,6]

In cases of irreversible pulpitis, the histological condition of the pulp may not always correlate with the clinical diagnosis. Studies have shown that even in advanced inflammation, only certain areas of the coronal pulp show bacterial invasion, while the underlying pulp remains unaffected. It has also been revealed that after the removal of the infected coronal pulp, the remaining pulp tissue has excellent regenerative capabilities.[5]

Traditionally, root canal treatment (RCT) has been the recommended approach for irreversibly inflamed pulp following exposure to decay [2]. Although nonsurgical root canal treatment (RCT) has positive results, it also comes with drawbacks such as advanced equipment, higher expenses, and occasionally requiring multiple appointments [3]. The management of irreversible pulpitis has been reevaluated in recent years due to increasing evidence from clinical trials demonstrating positive outcomes of vital pulp therapy (VPT) in such cases. Consequently, professional societies have issued new position statements regarding the treatment of teeth with carious pulp exposure and diagnosed with reversible or irreversible pulpitis (AAE, 2021; Duncan et al., 2019) [3].

Vital pulp therapy (VPT) is viewed as a simpler and more cost-effective approach compared to traditional methods like pulpectomy and root canal filling. Among VPT methods, pulpotomy and indirect pulp capping have proven to be a more reliable and successful intervention compared to direct pulp capping procedures.[4]

With advancements in understanding pulp biology and the use of newer materials, the concept of "vital pulp therapy" (VPT) has been revisited, leading to successful outcomes in teeth with carious pulp exposures or pulpitis.[4]

Pulpotomy is a surgical procedure where the coronal part of the pulp tissue is removed to protect the radicular part, encouraging the growth of dentin bridge using various materials to cover the remaining pulp tissue, taking advantage of the pulp cells’ ability to form dentin.[6]

There’s a belief that if a pulpotomy fails, retreatment might be easier compared to a root-filled tooth. Both the European Society of Endodontology (ESE) and the American Association of Endodontists (AAE) now endorse VPT as a viable treatment for symptomatic carious pulp exposure. The ESE’s 2019 position aimed to change clinicians’ mindset, advocating for VPT instead of immediately resorting to root canal treatment (RCT).[2]

(add about the ‘position statement by AAE and ESE about use of VPT’ application of same in prim teeth, for ref AAPD 2024 guidelines. Then a line or two about disinfecting agents in VPT for sym irr pulpitis like NaOCl and recent being laser)

 Sodium hypochlorite (NaOCl) is one such agent recognized and recommended for its dual effectiveness as a haemostatic and antibacterial agent in dental procedures. It has been found to have no negative impact on pulp repair, healing, or tertiary dentinogenesis. Studies have examined its use in controlling pulpal haemorrhage during pulpotomy in primary teeth, with current research endorsing its safe application at concentrations between 1% to 5% for vital pulp therapy procedures.[8,9]

Recent studies show, that Nd: YAG, Er: YAG, CO2, and diode lasers have become popular for pulpotomy due to advantages like improved haemorrhage control, and stimulation of regenerative cells. Among these, diode lasers have the benefit of causing less thermal damage and promoting faster pulpal wound healing because the dental pulp has a high-water content, which enhances the absorption of diode laser wavelengths. Studies have shown diode lasers to be more effective than other treatments for pulpotomy in primary molars.[7] (talk about lasers as a disinfecting agent ONLY and not as a pulpotomy agent)

Historically, VPT faced challenges due to misconceptions about pulp healing and limited material options. Calcium hydroxide was traditionally used, but its success rate was lower than MTA.[7]A full pulpotomy with haemostasis and coronal pulp coverage using calcium silicate cement (CSCs) can be successful. The AAE’s 2021 position statement also supports direct visualization and achieving haemostasis to assess the suitability of pulpotomy for teeth with symptomatic irreversible pulp, emphasizing the use of CSCs and immediate coronal restoration.[2]

MTA is a bioactive substance, that excels in forming apatite and sealing, with high pH, radiopacity, and biocompatibility. Despite its strengths.[7] An alternative material Bio dentine was developed as a dentine substitute; it shows great results with its short setting time and similar biocompatibility to MTA. MTA putty, another calcium silicate-based material, developed using bio-ceramic technology, is designed in pre-mixed injectable form as a clinical substitute for MTA.

It has superior handling, improved colour stability, adaptability, and comparable physical and chemical properties to MTA. Importantly, it releases calcium and phosphate ions necessary for hydroxyapatite deposition.[7]

So, the present study aims to evaluate the success rate of pulpotomy with 3 different CSC in symptomatic irreversible pulpitis in primary teeth as a treatment option.