doi:10.1111/j.1365-2591.2012.02113.

Should pulp chamber pulpotomy be seen as a

permanent treatment? Some preliminary thoughts

S. Simon1,2,3,4, M. Perard5,6, M. Zanini1,2,3, A. J. Smith4, E. Charpentier3, S. X. Djole1,2 & P.

J. Lumley4
1
Centre de Recherche des Cordeliers, INSERM UMRS872 Eq.5 Paris; 2Universite Denis Diderot Paris7, UFR Odontologie de
Garancie`re Paris; 3Groupe Hospitalier Pitie Salpetrie`re, Service Odonto-stomatologie et chirurgie Maxillo faciale Paris, France;
4
School of Dentistry, University of Birmingham, Birmingham, UK; 5CNRS, UMR6226 Sciences Chimiques de Rennes, Equipe de
Biomateriaux en Site Osseux, Rennes; and 6Universite de Rennes1, UEB, Faculte dOdontologie, Rennes, France

Abstract probability statistics to estimate the survival of the

treated teeth.
Simon S, Perard M, Zanini M, Smith AJ,
Results At 24 months, the survival rate without any
Charpentier E, Djole SX, Lumley PJ. Should pulp
complementary treatment was estimated to be 82%.
chamber pulpotomy be seen as a permanent treatment?
Two of the 17 treated teeth required root canal treat-
Some preliminary thoughts. International Endodontic Journal,
ment for pain control and one for prosthetic reasons.
46, 7987, 2013.
Conclusions Under the conditions of this study,
pulpotomy offered a viable alternative to root canal
Aim To investigate the benefits of pulpotomy (to the
treatment for teeth with vital pulps in the short term.
level of the floor of the pulp chamber) as an endodon-
However, there is insufficient clinical evidence to con-
tic treatment for teeth with vital pulps.
sider this technique for the treatment of every perma-
Methodology Seventeen patients, aged 754 years
nent tooth. Nevertheless, it should be considered as a
(mean of 37.2 year), were treated by pulpotomy and
potential alternative approach to be further developed
filling with ProRoot MTA in premolar or molar teeth
for future applications.
with vital pulps and without clinical evidence of irre-
versible pulpitis. The patients were then followed up Keywords: inflammation, mineral trioxide aggre-
for 12 to 24 months and the teeth then assessed by gate, pulp capping, pulpotomy.
clinical and radiographic examination. Statistical
Received 28 January 2011; accepted 3 July 2012
analysis was performed with KaplanMeier survival

Increasing demand for endodontic re-treatment

Introduction
Endodontic technology has evolved greatly over the
past two decades. The introduction of nickel-titanium
rotary instrumentation, new root filling devices, oper-
ating microscopes and accurate apex locators has
considerably improved the quality of endodontic care.
However, endodontics still remains one of the most
challenging dental specialties, because of the technical
complexities of treatment procedures.
Correspondance: Stephane Simon, University of Paris7, Oral
biology and Endodontics, Paris, France (e-mail: stephane.
simon@univ-paris-diderot.fr).
arising from a significant number of unsuccessful
initial root canal treatment procedures and a high
prevalence of periapical disease (Figdor 2002) pro-
vides appreciable clinical challenges. However, vari-
ous technical developments within endodontics have
broadened the scope of application of these technolo-
gies and allow more teeth to be saved than might
previously have been achieved with consequent
improvements in treatment outcomes. Despite these
improvements, conventional root canal treatment is a
complicated, time-consuming and expensive process,
particularly in general practice where the outcomes of
root canal treatment are often poor (Boucher et al.
2002). Regenerative approaches to endodontic

2012 International Endodontic Journal International Endodontic Journal, 46, 7987, 2013 79
 Pulpotomy as permanent treatment Simon et al.
treatment have long been adopted with pulp capping,
using materials such as calcium hydroxide (Zander
1939) and MTA (Nair et al. 2008), and Cveks par-
tial pulpotomy procedure (Mejare & Cvek 1993).
Improved understanding of the biological basis of
such treatment approaches has led to increasing
interest (Murray et al. 2007, Huang 2009) with
successful clinical outcomes being reported (Jung
et al. 2008).
There is considerable focus in the field of regener-
ative endodontics on complete pulp tissue regenera-
tion with less attention being given to the partial
regeneration of dentine-pulp-like tissues for the
maintenance of pulp vitality where considerable
opportunities exist for improving treatment out-
comes. Regeneration of only a part of the pulp may
be a more readily achievable goal (Jung et al. 2008)
and represents a treatment approach available now
if careful attention is given to all of the various steps
of treatment. In fact, several methods less invasive
than pulpectomy have been described for the treat-
ment of deep carious lesions. In a large cohort study
with a follow-up period of up to 12 years, Nyborg
reported a success rate of 58% for direct pulp cap-
ping with calcium hydroxide in patients older than
15 years (Nyborg 1958). Moreover, Shovelton et al.
(1971) obtained a 2-year success rate after direct
pulp capping of 5080%, depending on the pulp
condition and materials used.
Treatment failures with pulpotomy often reflect
technical issues arising from inadequate understand-
ing of the interplay of factors influencing regenerative
events as well as inappropriate case selection. It is
interesting that appropriate indications/contraindica-
tions for pulp capping have never been clearly docu-
mented, and guidelines describing the indications for
pulpectomy versus conservation of pulp vitality have
yet to be proposed. Nevertheless, it is apparent that
significant differences in treatment outcome may be
expected for pulps exposed by trauma versus caries
(Al-Hiyasat et al. 2006). Clearly, the success of pulp-
otomy as a treatment procedure is dependent upon a
good understanding of the extent of injury to dentine-
pulp tissues, the intensity of bacterial infection and
the inflammatory and immune responses taking place.
This highlights a particular clinical challenge where
treatment planning is generally based on whether
pulpitis is reversible or irreversible. Inflammation is
key in the regulation of the maintenance of pulp
vitality (Cooper et al. 2010, Simon et al. 2011), but
its quantification clinically relies on relatively weak
80 International Endodontic Journal, 46, 7987, 2013
diagnostic and pain assessment tools with limited cor-
relation to the physio-pathological state of the pulp
(Dummer et al. 1980). Consideration of the interplay
of inflammation and these various other factors will
help to drive appropriate case selection and subse-
quent treatment planning.
Several decades ago, full pulpotomy was proposed
as a permanent treatment, especially for molars for
prosthetic reasons (Marmasse 1972). The American
Associations of Endodontists (AAE) glossary defines
pulpotomy as The surgical removal of the coronal
portion of a vital pulp as a means of preserving the
vitality of the remaining radicular portion, although
it has tended to be recommended as an emergency
procedure for temporary relief of symptoms or as a
treatment. Use of partial root canal treatment has
progressively declined, perhaps in part owing to use
of nonideal radicular pulp-capping materials, and
now pulpotomy is only usually indicated for primary
teeth with an appropriate prognosis (Ng & Messer
2008). Nevertheless, with use of new materials, there
is evidence of improved success rates (Erdem et al.
2011). A combination of greater technical ease than
root canal treatment, recent development of new
materials and our greatly improved understanding of
pulp biology and reparative processes improve the
opportunities for successful clinical use of pulpotomy.
It is therefore appropriate to reconsider pulpotomy as
a viable permanent treatment approach for perma-
nent as well as primary teeth. In the case series pre-
sented here, the use of a deep Cvek pulpotomy
approach on clinically asymptomatic teeth without
evidence of irreversible pulpitis, which required end-
odontic treatments for deep caries or for prosthetic
reasons, was evaluated. The acceptability of long-term
tooth survival in the absence of any complication or
complementary treatment was assessed.
Materials and methods
Study population
All treatments were performed by a specialist in end-
odontics. Thirty patients who met the restrictive
inclusion criteria were considered and enrolled in the
study. The inclusion and exclusion criteria are sum-
marized in Table 1.
Participants were informed of the advantages, dis-
advantages and risks of the treatment and gave their
consent. Seventeen of the 30 patients who met the
inclusion criteria (13 women and four men) agreed to
2012 International Endodontic Journal

Table 1 Inclusion and exclusion criteria used for enrolling
the patients in the study
Inclusion criteria
Related to the tooth
Molar or pre-molar
Indication of pulpotomy because of deep carious lesion
Indication of pulpotomy for prosthetic reason
Related to pulp status
No spontaneous pain
No tenderness to percussion
Positive response to diagnostic test
No periodontal disease associated with the treated tooth
No apical lesion visible on radiograph
Related to the patient
Patient confirmation of treatment funding (French National
Dental Insurance)
Patient approval for the treatment and the 24-month
follow-up.
Exclusion criteria
Related to the tooth
Indication of post/post-core restoration marginal
periodontitis with attachment loss > 5 mm
Related to the pulp status
Spontaneous pain, history of trauma to the tooth,
internal/external resorption, calcified canals
Presence of apical radiolucency or ligament enlargement
on the radiograph
Periodontal disease
Related to the patient
Pregnancy or breast feeding
Immuno-compromised
Active systemic disease
Minor
Noncompliant patient
Patient included in another clinical trial
participate in the trial. The age of the patients treated
ranged from 7 to 54 years (mean 37.2, median
42 years). Before starting treatment, the intensity
and duration of preoperative pain were recorded
(Table 2).
Pulpotomy
Figures 1 and 2. The teeth were anesthetized by local
infiltration of articaine sulphate supplemented with
1 : 100 000 adrenaline (Ubistesin, 3M ESPEl; Cergy
Pontoise, France), or inferior dental nerve block with
articaine sulphate supplemented with 1 : 200 000
adrenaline (Ubistesin). The carious tissue was
removed completely and the tooth was restored with
glassionomer cement (Fuji IX, Fuji, Japan) as a pre-
endodontic treatment. Rubber dam was placed on the
tooth and access was gained exactly as for conven-
tional root canal treatment. The coronal pulp was
2012 International Endodontic Journal
Simon et al. Pulpotomy as permanent treatment
removed gently with hand instruments. Canal orifices
were located and a cotton pellet moistened with ster-
ile water was used to apply pressure for 12 min to
gain haemostasis. The cavity was then disinfected
with 0.5% sodium hypochlorite (Dakin Cooper,
Melun, France), etched for 45 s with 37% orthophos-
phoric acid, rinsed for 30 s with water and dried.
The radicular pulp was capped with Pro Root
MTA (Dentsply Maillefer, Ballaigues, Switzerland)
using an MTA Delivery Gun (Produits Dentaire,
Vevey, Switzerland), and this was applied across the
floor of the pulp chamber to a thickness of approxi-
mately 12 mm. An antibacterial bonding agent was
applied to the cavity walls (Protect Bond; Kuraray,
Hattersheim am Main, Germany) together with the
capping material itself, and light-cured for 40 s. The
access cavity was filled with light-cured, bonded com-
posite (Amaris; Voco, Cuxhaven, Germany) accord-
ing to the manufacturers instructions. The rubber
dam was removed and the occlusion checked care-
fully. A postoperative radiograph was then taken with
a digital sensor (Kodak 6100; Kodak, Paris, France)
and sensor holder (Endo-Bite sensor; Kerr, Creteil,
France). Ibuprofen (400 mg) was prescribed and
patients were instructed to use this as necessary, with
a maximum dose of 1.2 g day 1 (for children, the
prescription was adapted to their age/weight).
Patients were asked to complete an online pain
assessment form 5 days after the procedure and to
see their general dental practitioner for tooth restora-
tion within 30 days. The dentists were asked not to
disturb the composite resin in the pulp chamber and
to restore the tooth with the material of their choice.
Overall, the teeth were restored using a range of tech-
niques, including amalgam or composite fillings,
inlays or crowns, depending on the amount of
remaining coronal tooth structure. The patients were
asked to report the pain/discomfort felt during the
operative procedure and during the 7 days after the
treatment on the online form. All patients completed
the survey. The data collected are summarized in
Tables 3 and 4.
Three of the 17 patients required complementary
treatment during the first 3 months of the recall per-
iod. All other patients were recalled every three
to 6 months. Seven patients were reviewed at
23 months or more, four at 18 months and three at
1012 months (Table 5). At the recall appointment,
a clinical examination was conducted, which included
periodontal probing and radiographic assessment. The
teeth were also tested with a cold spray (Endo cold
International Endodontic Journal, 46, 7987, 2013 81
 Pulpotomy as permanent treatment Simon et al.

Table 2 Distribution of treated teeth and preoperative pain toothpaste was applied on the buccal face of the
assessment crown. The contralateral tooth was tested first for
N comparison. If the contralateral tooth was not present
or had a nonvital pulp, a homologous tooth was used
Gender
as a control. The treated tooth was then checked, and
Female 13
Male 4 the result was compared to the control. Finally, a
Tooth type radiograph was taken with the same sensor holder as
Molars 16 the one used initially. Statistical analyses were per-
Pre-molars 1 formed with R v.2.12.0 software using Survival and
Maxillary
odfWeave plugins (http://cran.r-project.org).
Upper 7
Lower 10
Preoperative pain
No pain 10
Results
Slight 2 The cold test was negative or the result was ambigu-
Moderate 5
ous in most cases and was not considered a reliable
Severe 0
Unbearable 0 technique for pulp sensibility assessment. Most teeth
Duration of the preoperative pain responded to the EPT, but at different levels. A differ-
Few days 0 ence was noticed between the control and tested
More than 1 week 1 teeth, but this difference may have been a conse-
Several months 6
quence of the type of coronal restoration or the weak
electrical conductivity of the superimposed material
spray; Henry Schein, Alfortville, France) and an (MTA, composite resin). False responses owing to the
electric pulp tester (EPT) (Digitest; Parkell Inc., Edge- periodontal ligament were eliminated by comparison
wood NYC, NY, USA). For the EPT test, the teeth with the control. At the end of the study, the proba-
were first dried and isolated with a cotton roll, and bility of survival without any other intervention was

(a) (b) (c) (d)

(e) (f) (g)

Figure 1 Pulpotomy on tooth 26 (a,b). The coronal filling and caries were removed, and the missing walls of the crown were
restored with glassionomer cement (Fuji IX, Fuji, Japan) (c). The access cavity was completed exactly as it would be for root
canal treatment, and the entire coronal pulp was removed (d). Mineral trioxide aggregate was placed in direct contact with
the pulp tissue and on the floor of the access cavity (e). The access cavity was then filled with bonded, light-cured resin (f).
24 months after the procedure, the tooth was restored with a crown and was asymptomatic (g).

82 International Endodontic Journal, 46, 7987, 2013 2012 International Endodontic Journal
 Simon et al. Pulpotomy as permanent treatment

(a) (b)

(c) (d)

Figure 2 The patient was initially referred for root canal treatment on tooth 36, because of a deep carious lesion (a). The tooth
was first temporarily restored with glassionomer and the pulp was removed from the pulp chamber (b). Root canal pulp was
capped with mineral trioxide aggregate (ProRoot; Dentsply Maillefer, Switzerland) and across the floor of the pulp chamber to a
thickness of approximately 12 mm. The tooth was finally restored with a full-coverage crown by the patients general dental
practitioner. At 24 months, the tooth was asymptomatic, and no sign of periapical disease was noticeable on the radiographs.

estimated at 82% (Fig. 3). As this was a preliminary

Table 3 Postoperative pain assessment study involving a limited number of samples, further
N investigation will be required to confirm a reliable
prognosis for pulpotomy.
When did the pain start?
Immediately after the end of anaesthesia 8 Fourteen patients (82%) complained of slight to
Later in the day 5 moderate pain immediately or 1 day after the treat-
The next day 1 ment, whilst only nine patients (53%) required anal-
2 days after treatment 0 gesics. Five days after the procedure, 12 patients
More than 2 days after treatment 0
(71%) reported no or very slight pain.
No pain 3
Pain characteristics at 5 days Three of the 17 patients treated by pulpotomy sub-
Decreased progressively 3 sequently required root canal treatment (Table 6). Of
Completely disappeared in 5 these patients, one (sample 13) complained of acute
<5 days pain 1.5 months after the procedure and one com-
Unchanged 3
plained of intermittent pain and tenderness to percus-
No pain 3
Still very slight 1 sion in the treated tooth (sample 5). The third failure
Increased daily 1 (sample 16) appeared to be due to secondary reasons
Variable 1 as the root canal treatment was undertaken on pros-
Did you take Paracetamol? thetic grounds. A restoration of the crown was neces-
Yes 1
sary because of fracture, and placement of a post and
No 16
Ibuprofen core was indicated. In summary, two teeth received
Yes 6 root canal treatment owing to postoperative discom-
No 11 fort. In both cases, the radicular pulp was vital based
Acetaminophen and Codeine on bleeding on reopening, with uncontrolled bleeding
Yes 2
in one of the canals (considered a clinical sign of

2012 International Endodontic Journal International Endodontic Journal, 46, 7987, 2013 83
 Pulpotomy as permanent treatment Simon et al.
Table 4 Numeric variables for peri- and postoperative pain assessment
Minimum
a
Discomfort/pain intensity during treatment
Postoperative pain intensitya
Dose of pain killers per day (number of pills)
Duration of pain killer treatment (in days)
Dose of pain killers at the time of the questionnaire
(number of pills)
a
1, no pain; 2, slight; 3, moderate; 4, severe; 5, unbearable.
irreversible pulpitis). The discomfort disappeared com-
pletely within 2 days following root canal treatment.
The two failures occurred on teeth that were preoper-
atively symptomatic. However, the number of samples
is too small to suggest a relationship between preoper-
ative pain and treatment failure.
Discussion
These preliminary results lend support for a prospec-
tive randomized clinical trial of the use of pulpotomy.
A constraint in the present study was the more lim-
ited diagnostic effectiveness of the methods used for
assessment of pulp status, which offers challenges to
accurate diagnosis for suitable case selection for pulp-
otomy. Nevertheless, the EPT could be used to com-
plement other diagnostic tools, and radiographic
assessment allowed evaluation of the development of
apical periodontitis. The cold test provided ambiguous
and inconsistent results; this may be due in part to
the type of coronal restoration (composite resin filling,
veneer crown, composite inlay, etc.). A positive
response to the cold test confirmed pulp vitality, but a
negative response could not be considered as proof of
nonvitality. Indeed, all teeth that responded to the
cold test were also positive for the EPT, although the
opposite was not true.
The periapical index (PAI), described by rstavik
(1996) for conventional radiographs, was used for
assessment. To date, no study has been conducted to
confirm the reliability of this index for digital radio-
graphs. However, Ridao-Sacie et al. (2007) reported
that apical periodontitis was detected more often with
digital than conventional radiographs. In this study, a
digital X-ray was considered at least as reliable as a
conventional radiograph, thereby allowing for the use
of the PAI. As the selected samples were initially free
from periapical disease, the emergence of apical peri-
odontitis would have been considered as an evidence
of failure of the treatment. None of the cases showed
84 International Endodontic Journal, 46, 7987, 2013
Q25 Median Mean SD Q75 Maximum
1 1 2 1.706 0.9852 2 5
1 2 2 2.706 1.3585 3 5
0 0 1 1.235 1.6781 2 6
0 0 1 1.471 1.9078 3 6
0 1 2 1.529 0.7998 2 2
any periapical change radiographically. This parame-
ter complemented others (probing, percussion, EPT,
cold test) in the assessment of the health of the tooth
and the pulp was never considered in isolation.
Because of the limitations of the diagnostic tests
used in this study, whilst clinical success could be
confirmed, the nature and health of the root canal
pulp tissue could not be validated histologically. For
example, the possibility of low-grade chronic inflam-
mation within the residual root canal tissue could not
be evaluated. However, Cvek & Lundberg (1983)
showed that the residual pulp tissue was essentially
normal histologically after pulpotomy in immature
teeth and concluded that there was no evidence for
its removal, as usually indicated in Pediatric Den-
tistry. Interestingly, no pulp obliteration was notice-
able at 1 year or 2 years of follow-up. Root canal
calcification is probably one of the main factors that
motivates clinicians not to retain the pulp, as exces-
sive stimulation of the pulp can lead to an uncon-
trolled reactionary dentinogenic response. Pulp canal
obliteration is challenging for clinicians, because
when root canal treatment is indicated in case of pulp
necrosis, the treatment success may decrease owing
to various technical difficulties. However, there is con-
siderable evidence to suggest that the frequency of
pulpal necrosis and apical rarefaction in permanent
teeth is very low because of pulp canal obliteration
(McCabe & Dummer 2012). These studies were per-
formed on teeth suffering from traumatic pulp canal
obliteration, so the pulp was not contaminated. In
such situations, biological processes, especially denti-
nogenesis, may become uncontrolled leading to
abnormal canal obliteration (Simon et al. 2010).
These data cannot be readily compared with those
from the present clinical study though, because of
the exposure of the pulp to bacteria in the case of
pulpotomy.
Inflammation is central to defence of the pulp and
has long been considered a clinical contraindication
2012 International Endodontic Journal
 Simon et al. Pulpotomy as permanent treatment

Table 6 Probability estimates of survival without any other

PAI

1
1
1
1

1
1

1
1

1
intervention (KaplanMeier method)
Percussion
Days N (survived) Survival BI.CI95. BS.CI95.
>12-month recall

45 17 0.9412 0.8357 1
75 16 0.8824 0.7418 1
90 15 0.8235 0.6609 1
EPT

+
+

+
+

+
?

?
?

?
Cold test

+

PAI

1
1
1
1

1
1
1
1
1

1
1

1
Percussion
6- to 12-month recall

EPT

+
+

+
+
+
+
+

+
+

+
Cold test

PAI

1
1
1
1

1
1
1
1
1
1
1

1
1

1
Percussion
3- to 6-month recall

Figure 3 Probability estimates of survival without any other

intervention (KaplanMeier method).
EPT

+
+

+
+
+
+
+
+
+
+
+
+

+

?

?
Cold test

for pulp capping. However, controlled inflammation of

RCT

RCT

RCT
+

lower grade may be considered an important prelude

Table 5 Raw data of treated teeth and follow-up clinical examinations

to early reparative or regenerative events (Cooper

et al. 2010). As soon as caries reaches the dentine
Last recall
(Days)

763
718
722
715

732
638
582
549
482
368
765

782
742

440
42

82

(even in the case of very superficial disease), a local-

70

ized and reversible inflammatory response is triggered

in the dental pulp tissues (Bergenholtz 1981, 1990,
resin

resin
resin
resin
resin

resin
resin
resin

resin
resin
resin
Final restoration

inlay

inlay
inlay
inlay

Heyeraas et al. 2001a). Therefore, it is important to

challenge the dogma that the pulp must be free of
Composite
Composite

Composite
Composite
Composite
Composite
Composite
Composite
Composite
Composite
Composite
Composite

Composite
Composite
Composite

inflammation before being capped to successfully

Crown

Crown

introduce new regenerative therapies.

Markers of inflammation and several proteins of the
number

extracellular matrix are differentially expressed within

Teeth

36
27
35
26
47
17
46
36
26
37
37
46
36
17
16
27
36

the pulp tissue, depending on the depth of the carious

lesion (McLachlan et al. 2003). Thus, inflammation
Age

may be closely linked to regenerative events and its

13
42
42
44
46
38
48
37
50
36
18
54
49
46

49
13
7

presence should not be assumed to result only in tis-

Gender

sue degeneration. The treatment prognosis is likely to

M

M
M

M
F

F
F
F
F
F

F
F
F
F
F

F
F

depend on the interplay between infection, inflamma-

tion and regeneration. Chronic and acute inflamma-
Patient

tory responses involve rather different cellular and

10
11
12
13
14
15
16
17
1
2
3
4
5
6
7
8
9

molecular processes, the outcomes of which may

2012 International Endodontic Journal International Endodontic Journal, 46, 7987, 2013 85
 Pulpotomy as permanent treatment Simon et al.
differ. Resolution of acute inflammation may lead
either to restoration of normal tissue function and
clearance of the injurious stimuli, mediators and
acute inflammatory cells, or, conversely, to abscess
formation and tissue necrosis, whilst chronic inflam-
mation can lead to scarring or tissue regeneration.
The true distinctions between acute and chronic
pulpal inflammation and reversible and irreversible
pulpitis are perhaps questionable simply representing
clinical labels to reflect treatment directions, as clini-
cians have long struggled to correlate clinical symp-
toms with histological status in the inflamed pulp.
One of the limitations for pulp capping is the difficulty
of evaluating the depth of inflammatory disease pene-
tration into the soft tissue. Cveks partial pulpotomy
was proposed (Cvek 1978), based on Mjors observa-
tion that the dental pulp is usually inflamed only to a
depth of 2 mm (Mjor & Tronstad 1972). Clinically, it
is difficult to determine accurately the depth of disease
progression to facilitate removal of all the diseased tis-
sue with a conservative approach and this may
contribute to treatment failure in some cases. Clearly,
the limitations of current clinical diagnostic tools for
assessment of pulpal inflammation represent a signifi-
cant constraint to identification of those cases most
suited to regenerative treatment approaches.
Pulp inflammation is recognized as a progressive
disease and whilst initially confined to a small area
of the pulp, the process seems to extend progres-
sively with time to the whole pulp chamber (Hey-
eraas et al. 2001a). It is also known that when
patients present with irreversible pulpitis as an
emergency, only the pulp of the pulp chamber is
generally affected. Thus, removal of pulp tissue from
the pulp chamber only is usually sufficient to
relieve the patients pain (Oguntebi et al. 1992).
Based on these observations, it may be proposed
that pulpotomy should be revisited, not only for
immature teeth but also as a permanent treatment.
Indeed, removal of all of the pulp tissue from the
pulp chamber may provide a reliable technique for
eradication of all inflamed tissue whilst ensuring
the presence of remaining healthy pulp tissue for
tissue regeneration.
This preliminary study was limited to a restricted
number of patients to determine the need for a
more comprehensive clinical trial. During the study
period, Bjorndal et al. (2010) emphasized the poten-
tial benefits to be gained from more extensive
assessment of this treatment approach. Pulpotomy
may provide a progressive and less invasive
86 International Endodontic Journal, 46, 7987, 2013
approach to the management of pulp disease, per-
haps adopting a stepwise technique for the nonex-
posed pulp response, pulp chamber amputation for
intermediate disease or pulp exposure response, and
complete pulp removal for more extensive disease.
Such a technique is minimally invasive and does
not compromise the subsequent use of other treat-
ments should it fail, except in the case of canal
obliteration. Moreover, pulpotomy is probably easier
to complete than root canal treatment. However,
great care is required to prevent bacterial contami-
nation of the pulp tissue during pulpotomy and it
is likely that the success seen here with these cases
reflects careful attention to the protocol used (selec-
tion of the cases, pre-endodontic restoration, rubber
dam, disinfection, haemostasis, etc.). As such, the
protocol is rather different to that usually adopted
in emergency treatment where the prime goal is
pain relief. Further research is warranted to deter-
mine an optimal treatment protocol. It should also
be recognized that pulp chamber pulpotomy will
not be applicable to every case, especially those
with deep pulp inflammation involving the radicular
tissue. Nevertheless, this technique has much to
offer and more extensive assessment of its use, both
by specialist endodontists and practitioners with dif-
ferent levels of clinical experience, is warranted.
Conclusions
Vital pulp amputation (pulpotomy) should be revisited
and considered as a permanent treatment modality in
certain circumstances. However, a large prospective
randomized clinical trial is necessary to confirm these
results and define appropriate clinical guidelines. At
present, there is insufficient clinical evidence to con-
sider this technique for the final treatment of perma-
nent teeth, but it should be considered as an
alternative approach, which with further development
has considerable potential.
References
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