Vital pulp treatment (VPT) is a treatment used to maintain the vitality and function of a dental pulp after injury caused by caries or trauma. VPT can be an effective approach once an accurate pulp diagnosis has been established. The diagnoses reversible and irreversible pulpitis have been in clinical use for a long time, though it has been questioned whether the diagnosis of irreversible pulpitis accurately refers to a pulpal state in which the dental pulp is damaged beyond repair (Mejàre et al., 2012; Wolters et al., 2017). Incorrect labelling of pulpitis will lead to likely overtreatment. In anticipation of methods to accurately identify irreversible pulpal injuries, the symptoms associated with pulpitis should be reported, for example pulpitis associated with no or non-spontaneous pain (Pigg et al., 2021).

There are several different types of VPTs and this systematic review aimed to explore, whether:

1. direct pulp capping or pulpotomy are as effective as selective carious-tissue removal in one-stage or stepwise excavation
2. pulpotomy is as effective as direct pulp capping
3. pulpotomy is as effective as a pulpectomy

All patients included in the review had nontraumatic pulpitis associated with no or non-spontaneous pain (Jakovljevic et al., 2022).

The review exclusively included studies in which direct comparisons were made. After electronic and hand searches, three studies, published in four separate papers, were included. No study addressed the first question regarding the effectiveness of direct pulp capping or pulpotomy (partial/full) versus selective or stepwise caries removal. Two studies addressed the second question regarding the effectiveness of pulpotomy versus direct pulp capping (Asgary et al., 2018, Bjørndal et al. 2010, 2017), leaving only one study addressing the third question regarding pulpotomy versus pulpectomy (Galani et al., 2017).

The reviewers were interested in a range of clinical and patient-oriented outcomes used to measure the effectiveness of VPT, though many of the outcomes were not addressed in the included studies and the reporting of outcomes showed considerable variation. Tooth survival following VPT was considered by the guidelines steering group to be the most critical outcome; however, this outcome was not addressed in any of the included studies.

The risk of bias was considered low in the included studies, though due to heterogeneity no meta-analysis was performed.

Based on the limited evidence, this systematic review demonstrated no significant differences in effectiveness between compared VPTs and the review clearly highlights a paucity of available evidence. With the limited evidence, clinical decisions cannot be substantiated by direct comparative trials. This information, together with clinical expertise and patient preferences will form the basis for development of S3-level clinical practice guidelines and associated recommendations.

Helena Fransson & Lise-Lotte Kirkevang

ESE Benefits of Endodontics Committee

 

 

References

Asgary, S., Hassanizadeh, R., Torabzadeh, H. & Eghbal, M.J. (2018) Treatment outcomes of 4 vital pulp therapies in mature molars. Journal of Endodontics, 44, 529–535.

Bjørndal, L., Fransson, H., Bruun, G., Markvart, M., Kjældgaard, M., Näsman, P. et al. (2017) Randomized clinical trials on deep carious lesions: 5-year follow-up. Journal of Dental Research, 96, 747–753.

Bjørndal, L., Reit, C., Bruun, G., Markvart, M., Kjaeldgaard, M., Näsman, P. et al. (2010) Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. European Journal of Oral Sciences, 118, 290–297.

Galani, M., Tewari, S., Sangwan, P., Mittal, S., Kumar, V. & Duhan, J. (2017) Comparative evaluation of postoperative pain and success rate after pulpotomy and root canal treatment in cariously exposed mature permanent molars: a randomized controlled trial. Journal of Endodontics, 43, 1953–1962.

Jakovljevic, A., Jaćimović, J., Aminoshariae, A., Fransson, H. (2022) Effectiveness of vital pulp treatment in managing nontraumatic pulpitis associated with no or nonspontaneous pain: A systematic review. International Endodontic Journal, doi:10.1111/iej.13776

Mejàre, I.A., Axelsson, S., Davidson, T., Frisk, F., Hakeberg, M., Kvist, T. et al. (2012) Diagnosis of the condition of the dental pulp: a systematic review. International Endodontic Journal, 45, 597–613.

Pigg, M., Duncan, H.F., Nagendrababu, V., Abbott, P., Fouad, A.F., Kruse, C. et al. (2021) Preferred reporting items for diagnostic accuracy studies in endodontics (PRIDASE): guidance to improve manuscripts assessing the diagnostic accuracy of procedures, techniques and devices. International Endodontic Journal, 54, 1005–1007.

Wolters, W.J., Duncan, H.F., Tomson, P.L., Karim, I.E., McKenna, G., Dorri, M. et al. (2017) Minimally invasive endodontics: a new diagnostic system for assessing pulpitis and subsequent treatment needs. International Endodontic Journal, 50, 825–829.