Coronal pulpotomy in permanent molars

Typically permanent teeth with symptomatic or asymptomatic irreversible pulpitis as a result of caries are managed with root canal treatment (RoCT) or extraction. Recently studies assessing the use of coronal pulpotomy treatment (CPT) in permanent teeth have demonstrated promising results.

The aim of this review was to assess the success rate of CPT in treating carious vital pulp exposure in permanent posterior teeth with closed root apices.

Methods

Searches were conducted in the PubMed, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases. Studies reporting complete coronal pulpotomy  in permanent posterior teeth with closed root apicies without pulp necrosis were considered. Prospective or retrospective studies published in English and having at least ten patients and minimum one-year follow-up period were included.

Initial screening was carried out independently by 3 authors and data abstraction by 2 authors. Quality assessment was performed by two authors using the Cochrane Risk of bias tool for randomised controlled trials (RCTs) and the Newcastle–Ottawa scale (NOS) for prospective or retrospective cohort studies.

The primary outcome was success rate of CPT. Success was defined as no radiographic abnormality or clinical symptoms, such as spontaneous pain, tenderness to percussion or palpation, resolution (decrease in size or elimination) of an existing radiographic periapical lesion, and no need for further pulpectomy and RCT of the treated teeth. The weighted mean success rate (WSR) was estimated by the DerSimonian–Laird random effects model

Results

6 studies (1 RCT, 5 cohorts) were included
3 studies used Ca(OH)₂as pulp capping agent, 3 MTA (mineral trioxide aggregate)
Weighted mean success rate (WSR)
- 1 year = 94% (95%CI; 90 – 99)
- 2 year = 92% (95%CI; 84 -100)
Weighted mean success rate (WSR) using MTA
- 1 year = 95% (95%CI; 90 -100)
- 2 year = 93% (95%CI; 84 – 100)
Weighted mean success rate (WSR) using Ca(OH)₂
- 1 year = 92% (95%CI; 85 – 99)
- 2 year = 93% (95%CI; 76 – 100)

Conclusions

The authors concluded:

Coronal pulpotomy treatment could increase tooth retention by providing a potential option particularly for low-income patients or in under served areas worldwide. However, more studies having longer follow-up, larger sample size and including a control group are needed to validate the possibility of performing CPT as an alternative to RCT.

Comments

While 3 databases were searches the inclusion criteria restricted the included studies to those published in English this could result in relevant studies being excluded. Of the included studies only one was a randomised controlled trial and it is not clear how many of the cohort studies were prospective, although the NOS scores were similar and ranged from 4-5. A sensitivity analysis was conducted excluding each data set at a time with no single study appearing to significantly affect the success rate.

This review suggests that CPT provides reasonable results at 2 years and that MTA may provide a better outcome. However, as the bulk of the studies are observational and a greater risk of bias further high quality RCTs are needed to provide a more robust estimation of survival. The one RCT that was included in this review was considered by the Dental Elf in March 2012.