A clinical trial of pulpotomy vs. root canal therapy of mature molars.
Abstract
Root canal therapy (RCT) and tooth extraction are the main treatment options for irreversible pulpitis or its sequelae. Pulpotomy is an alternative treatment; however, more evidence is required. If outcomes of pulpotomy with a calcium-enriched mixture (PCEM) are non-inferior for mature molars with irreversible pulpitis compared with those from one-visit RCT (ORCT), this may be a beneficial treatment option. Four hundred seven individuals met the inclusion criteria and were randomly allocated [PCEM (n = 205), ORCT (n = 202)]. We used NRS questionnaires to record pain intensity. Six-month clinical and radiographic successes were assessed. Individuals in the ORCT arm reported significantly more post-operative pain than those in the PCEM arm (P < 001). Clinical success rates in the two arms showed no statistically significant difference; however, the radiographic success rates were significantly greater in the PCEM arm (P < .001). This trial suggests PCEM as an alternative for treatment of irreversible pulpitis. If long-term results confirm initial ones, PCEM may revolutionize oral health worldwide.
Commentary
Irreversible pulpitis is the most frequent reason teeth need endodontic treatment. Posterior teeth with caries or past and current histories of restorative treatment are at greater risk than anterior teeth. Typically the patient exhibits symptoms of pain that can be relieved with either pulpotomy or pulpectomy. The prognosis for survivability of these teeth is excellent with endodontic therapy. Unfortunately, for many patients the choice of treatment is governed by financial considerations and the choice of extraction is made. What if we as clinicians can offer the patient a much less costly but as effective treatment choice to the patient that would help the patient maintain an intact dentition. This would be to this author, heroic dentistry—saving what would not have been able to be saved in the past.
The authors of this research study compared pulpotomy of mature molars with irreversible pulpitis to conventional root canal therapy. For these pulpotomies a novel endodontic material, a calcium-enriched cement, was used and compared to one-visit root canal treatment. Over 200 molars were treated for each group and evaluated 6 months after treatment. From this trial, the alternative treatment of pulpotomy with the calcium-enriched endodontic cement was as successful as conventional root canal treatment. Long-term evaluations are being done and if they prove out, a less costly treatment alternative to endodontic treatment may offer our patients a way to maintain their teeth. Another outcome was that patients with the pulpotomy needed significantly less pain medication. Also, these authors have published other research papers showing other heroic uses of this calcium-enriched cement for treatment of perforations, pulp capping and apexogenesis similar to treatment with bioactive tricalcium silicate (Biodentine) and mineral trioxide aggregate (MTA) for these clinical situations.
Commentary by Howard E. Strassler, DMD
Professor, Division of Operative Dentistry
Department of Endodontics, Prosthodontics and Operative Dentistry
University of Maryland Dental School
Baltimore, Maryland
