A Commentary on

Tomson P L, Vilela Bastos J, Jacimovic J, Jakovljevic A, Pulikkotil S J, Nagendrababu V.

Effectiveness of pulpotomy compared with root canal treatment in managing non-traumatic pulpitis associated with spontaneous pain: A systematic review and meta-analysis. Int Endod J 2022; https://doi.org/10.1111/iej.13844.

GRADE Rating:


Untreated caries in permanent teeth is a prevalent global health condition that can lead to inflammation of the pulp, resulting in reversible or irreversible pulpitis, which may or may not cause pain1,2. In cases of irreversible pulpitis (IP), the clinician is typically limited to either root canal treatment (RCT) or extraction as treatment options. While extraction is always effective, RCT can also be highly successful if performed correctly. However, RCT is a technically challenging and time-consuming procedure that weakens the tooth’s structure and leaves it more vulnerable to infection and caries3,4,5,6,7. These concerns highlight the need for less invasive and biologically based treatment options.

Vital pulp treatment is now considered a reliable treatment even in cases with carious pulp exposure1,8. A pulpotomy is a technique used to preserve pulp tissue and has been revisited as a permanent treatment modality, especially in cases of irreversible pulpitis. The use of calcium silicate cements has further increased the success rates of pulpotomy in such cases. High short-term success rates (i.e., 92% at 2-yrs) have been reported for both partial9,10 and full pulpotomy11. The removal of some or all the coronal pulp tissue is a clinical approach to manage irreversible pulpitis by eliminating inflamed tissue, relieving pain, and inducing hard tissue barrier using a calcium silicate cement that stimulates the pulp’s natural reparative mechanisms12.

Therefore, the appraised systematic review by Tomson et al. (2022) aimed to evaluate whether a pulpotomy (partial or full) could result in better patient and clinical reported outcomes compared to root canal treatment (RCT) in permanent teeth with pulpitis characterized by spontaneous pain. The review included five studies, three of which reported longer-term data on the same cohort of patients at different time points and two clinical trials with shorter-term outcomes. The results suggested that patients experience similar levels of pain postoperatively, irrespective of whether they are treated with RCT or full pulpotomy. The success rates for both interventions were high at 12-month follow-up and were reduced at 24 and 60-month follow-up, but there was no significant difference in success between both interventions. These findings are supported by previous reviews that reported that pulpotomy with calcium silicate cements is an effective treatment option for patients with pulpitis characterized by spontaneous pain managed by vital pulp therapy (VPT)13,14,15,16,17.

The review identified the benefits of pulpotomy, including its reduced aggressiveness, ability to maintain pulp functions, and improved cost-effectiveness compared to RCT. However, the review notes that the number of studies on this topic is limited, which makes it challenging to establish a strong evidence-based recommendation. Thus, no publications bias was performed. The study finds that patients experience similar levels of postoperative pain with both pulpotomy and RCT. Additionally, patients with apical periodontitis or periodontal ligament (PDL) widening had significantly more postoperative pain regardless of the treatment modality. The review identifies the limitations of the studies, including the fact that RCTs performed in a single visit are not typical in everyday dental practice. Furthermore, 33% of patients were lost to follow-up in one study18, which may impact the strength of the results.

The strength of the results is weakened by the fact that the longer-term outcomes are derived from the analysis of only one cohort of patients at different postoperative time points18,19,20,21. Additionally, the use of calcium silicate cement, namely calcium-enriched mixture (CEM) cement, was limited to the country of manufacture. Furthermore, the study does not indicate any quality assurance for the general standard of treatment performed in either arm. However, the review acknowledges that the study was performed in a primary care setting, making it possible to extrapolate the results to a setting where most of the treatment for pulpitis with spontaneous pain is performed.

Future research is required to establish a more robust evidence-based clinical practice for managing pulpitis characterized by spontaneous pain. It is necessary to conduct more clinical trials to assess the effectiveness of different agents to control hemostasis, cleanse the cavity/exposed pulp, or interface with the pulp. Further research is required to determine the optimal follow-up period for treatment outcomes, which should consider the high loss of patients during the long-term follow-up. Establishing standardized protocols for RCT and pulpotomy that consider patients with different periapical conditions is also essential. Additionally, future research should assess the cost-effectiveness of pulpotomy and RCT in different healthcare settings. Overall, more research is necessary to inform solid evidence-based clinical recommendations for managing pulpitis with spontaneous pain.

To sum up, this well-conducted systematic review with quantitative analysis concluded that pulpotomy is a viable alternative to RCT. However, more high-quality clinical studies are required to provide reliable clinical practice recommendations.