ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Vital Pulp Therapy for Adult Patients with Deep Carious Lesions Is a Viable Short-Term Alternative to Root Canal Therapy
Clinical Question For adult patients with deep carious lesions, is vital pulp therapy, as compared to root canal therapy, as effective in maintaining long-term tooth survival?
Clinical Bottom Line For permanent teeth with carious exposures, there is insufficient evidence to support vital pulp therapy as a long-term (5 yrs. or longer) alternative to root canal therapy. When vital pulp therapy is chosen as a short-term solution, the direct pulp capping method may be less reliable than pulpotomy in teeth with closed apices.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 21496652Aguilar/201123 studies/1,385 teethSystematic review of non-randomized trials
Key resultsThe 3-year success rates were: direct pulp capping 72.9% (n=996, 95%CI: 49.6% to 96.3%); partial pulpotomy 99.4% (n= 199, CI 95.6% to 103.2%); full pulpotomy 99.3% (n= 190, 94.5% to 104.1%). There were no significant differences between materials used (calcium hydroxide vs MTA). The 3-year success rate for direct pulp capping (n=996) dropped to 69.2% for teeth with closed apices (vs. 94.5% for teeth with open apices). The success rates for partial and full pulpotomy did not differ significantly between teeth with closed apices and teeth with open apices. The authors felt vital pulp therapy should be considered as an alternative to pulpectomy in vital permanent teeth with carious pulp exposures, and that pulpotomy and partial pulpotomy were more reliable that direct pulp capping.
#2) 26687672Aldaqeri/20166 studies/265 teethSystematic review of non-randomized trials
Key resultsFor coronal pulpotomy (partial pulpotomies and direct pulp caps were excluded), the 1-year weighted success rate was 94% (95% CI: 90% to 99%); the 2-year weighted success rate was 92% (CI: 84% to 100%). Pulp capping materials (MTA vs. CaOH) and restoration materials (composite vs. amalgam) did not have a significant effect on success rate. The authors felt that coronal pulpotomy should be considered as an intermediate treatment option for carious permanent teeth or a substitute when the patient is uninsured or cannot afford RCT.
#3) 26687672Aldaqeri/20166 studies/265 teethSystematic review of non-randomized trials
Key resultsFor coronal pulpotomy (partial pulpotomies and direct pulp caps were excluded), the 1-year weighted success rate was 94% (95% CI: 90, 99); the 2-year weighted success rate was 92% (CI: 84, 100). Pulp capping materials (MTA vs CaOH) and restoration materials (composite vs. amalgam) did not have a significant effect on success rate. The authors felt that coronal pulpotomy should be considered as an intermediate treatment option for carious permanent teeth or a substitute when the patient is uninsured or cannot afford RCT.
Evidence Search Subheading: therapy MeSH Terms: adult; dental pulp; therapeutics; dental caries; root canal therapy; dental pulp capping
Comments on
The Evidence
Validity: Aguilar/2011 and Aldaqeri/2016 are systematic reviews with only 4 included RCTs and 1 included RCT, respectively, that fit the inclusion criteria. The groups were not similar at the start; some teeth had open apices and some had closed apices, which is a very important prognostic factor. The groups were not treated the same; some had full pulpotomies, some had partial pulpotomies and some had direct pulp caps, which are all categorized as “vital pulp therapy.” Success was defined differently in many studies - often ‘asymptomatic’ was considered successful although this does not account for pulpal status. The longest follow-up studies included were 3 years. Perspective: Based on the systematic reviews, pulpotomy or partial pulpotomy using MTA or CaOH represents a reasonable short-term alternative for root canal therapy in vital permanent teeth with carious lesions. Stage of root development may affect prognosis when direct pulp capping is performed. At this time there is insufficient evidence supporting vital pulp therapy as a long-term alternative to non-surgical root canal therapy.
Applicability This information can benefit a practitioner when discussing treatment options and alternatives for a patient who has a carious pulp exposure and who may not have the resources to obtain root canal therapy immediately. The patient may be offered vital pulp therapy as a successful short-term solution but must be informed of the uncertain long-term prognosis of vital pulp therapy in permanent teeth. If vital pulp therapy is performed, pulpotomy may be more reliable than direct pulp capping.
Specialty/Discipline (Endodontics) (Restorative Dentistry)
Keywords vital pulp therapy, pulp cap, pulpotomy, permanent teeth, adult, deep caries, carious exposure
ID# 3280
Date of submission: 11/20/2017spacer
E-mail andersonj13@livemail.uthscsa.edu
Author Julie A Anderson
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