The dental pulp constitutes a distinct and intricate entity susceptible to various
thermal, traumatic, microbial, and chemical stimuli. (1) As a result, the dentin-pulp
complex experiences a sophisticated immune response, leading to the recruitment of immune
cells and inflammation of dental pulp cells at the local level. (2,3,4) Historically, in
instances of irreversible pulpitis, the conventional recommendation has been root canal
treatment (RCT), based on the belief that the pulp lacked the ability to undergo
recovery. (5,6)
Vital pulp therapy (VPT) is an approach focused on minimally invasive measures, aiming to
seal the pulpal wound with a bioactive substance subsequent to the removal of infected
pulpal tissues. (7,8) Procedures associated with VPT encompass direct and indirect pulp
capping, partial pulpotomy, and full pulpotomy. (9) Typically, VPT interventions are
carried out to safeguard the radicular pulp in both deciduous and adult immature teeth.
(10,11) In accordance with the position statements released by the American Association
of Endodontists (AAE) in 2021 and the European Society of Endodontology (ESE) in 2019,
full and partial pulpotomy emerge as promising and more conservative alternatives to root
canal treatment for managing mature permanent teeth afflicted with irreversible pulpitis
and cariously exposed pulps. (10,12) This is also backed by literature since a lot of
researches shows that performing full pulpotomy to manage mature permanent molars with
irreversible pulpitis is highly successful. (30,31,32,33)
A full pulpotomy entails the complete removal of coronal pulp tissues, succeeded by the
application of a biomaterial onto the remaining tissues at the root canal orifices. (12)
The utilization of pulpotomy preserves the pulp mechanoreceptors, along with its
defensive and developmental functions, including the formation of primary and secondary
dentin.(12) Furthermore, pulpotomies are characterized by being less time-consuming, less
invasive, and less intricate when compared to root canal treatment. Over the past two
decades, numerous studies have indicated that pulpotomy can serve as an effective
alternative to root canal treatment for managing irreversible pulpitis in mature
permanent teeth.(13,14)
The AAE classification simplifies pulpitis into reversible and irreversible categories.
However, the term "irreversible" is questioned as histological evidence shows no clear
boundary for irreparability. In 2017, a new classification proposed by Wolters et al (15)
eliminated the term "irreversible" and linked symptoms to VPT management strategies.
Subsequent research by Careddu and Duncan in 2021 supported the new classification's
potential prognostic benefit in partial pulpotomy.
Wolter's classification mainly entitles the following:
Initial Pulpitis:
A heightened but not prolonged response to the cold test, insensitivity to
percussion, and an absence of spontaneous pain. (15)
Mild Pulpitis:
An intensified and extended reaction to cold, warm, and sweet stimuli lasting up to
20 seconds, potentially percussion-sensitive. Histologically, this suggests limited
local inflammation confined to the crown pulp. (15)
Moderate Pulpitis:
Evident symptoms, strong, heightened, and prolonged response to cold which can last
up to several minutes, potentially percussion-sensitive, and spontaneous dull pain
that can be partially or completely alleviated with pain medication. Histologically,
this indicates extensive local inflammation confined to the crown pulp. (15)
Severe Pulpitis:
Severe spontaneous pain and distinct pain response to warm and cold stimuli, often sharp
to throbbing, causing difficulty sleeping (exacerbated when lying down). Tooth
sensitivity to touch and percussion is pronounced. Histologically, this suggests
extensive local inflammation in the crown pulp, possibly extending into the root canals.
(15)
Wolter et al indicated that initial and mild pulpitis will only require indirect pulp
therapy. (15)
Traditionally, it was hypothesized that a tooth with a periapical radiolucency has a
necrotic, infected pulp space. Thus, root canal treatment was the treatment of choice for
these teeth.(2) However, it was proven that even in the presence of a large periapical
radiolucency, portions of the radicular pulp tissues can maintain their vitality.(3) This
suggests that in cases with apical periodontitis, if vital pulp tissues are evident after
pulp exposure, pulpotomy can be a viable alternative treatment modality to root canal
treatment.(4)
In 2018, Taha et al. aimed to evaluate the outcome of full pulpotomy in mature permanent
teeth using Biodentine. Eight of the cases exhibited preoperative periapical rarefaction,
and seven of them showed improvement in the periapical index score. Similarly, in a 2016
randomized clinical trial, all of the seven cases with preoperative periapical
radiolucencies showed complete resolution of the lesions at the end of the study.(5)
Other earlier studies also reported success of pulpotomy procedures in cases with
periapical involvement. (34,35,36) However, there is a growing need for further studies
in order to determine the predictability of pulpotomy in teeth with apical
radiolucencies, and to detect features that can act as negative prognostic factors in
these cases.(4)
In 2013, the American Association of Endodontists classified the diagnosis of periapical
condition into normal apical tissues, symptomatic apical periodontitis, asymptomatic
apical periodontitis, chronic apical abscess, acute apical abscess, and condensing
osteitis. The term "apical periodontitis" indicates that the apical periodontal tissues
are inflamed. In symptomatic apical periodontitis, the tooth has a painful reaction to
palpation, percussion, and biting. Radiographically, the tooth may have a normal
periodontium or a periapical radiolucency depending on the stage of the periapical
disease. On the other hand, teeth with asymptomatic apical periodontitis do not exhibit
pain on palpation or percussion, and they are associated with a periapical radiolucency
in the radiograph.(1)
It is well-recognized that the effectiveness of detecting radiographic apical
periodontitis is contingent upon the proficiency of the operator(16). Therefore, it has
become imperative to develop or employ Artificial Intelligence (AI)-based software
solutions that can accurately diagnose periapical radiolucencies. Artificial intelligence
(AI) is designed to mimic human intelligence and address specific challenges. AI
contributes to the creation of algorithms that can learn from provided information and
make predictions. Machine learning, a subset of AI, constructs algorithms based on
data.(17) Among the earliest AI algorithms were neural networks (NNs). Deep learning
neural networks are complex structures with multiple layers, while shallow learning
neural networks are simpler with fewer layers. Convolutional neural networks (CNNs) are
primarily used for analyzing intricate images.(17)
AI technology has arisen as a response to the need for machines to emulate human
intelligence, facilitating the provision of more standardized results.(18) For instance,
AI-enabled imaging applications in the medical domain exhibit autonomous object detection
and image classification capabilities, with numerous studies demonstrating remarkable
accuracy and promise in diagnosing pathologies(19), interpreting radiological data(20),
and assessing dermatological conditions(21).
From a dental perspective, AI applications can be stratified into several domains,
encompassing diagnosis, decision support, treatment planning, and prognosis prediction,
with diagnostic capabilities being particularly prominent. AI stands poised to augment
diagnostic precision and efficiency, thereby alleviating the professional burden on
dentists, who increasingly rely on computerized decision support systems.(18)
Within the realm of endodontics, Anita Aminoshariae et al in 2021 mentioned that AI can
currently assist in detection of peri-apical lesions, crown and root fractures, working
length determination and even the morphology of root canals and the root canal
systems.(23) A systematic review by Agata Ossowska et al in 2022 concluded that AI can
also be used in predicting the ability of dental pulp stem cells to survive in some
treatments and predicting the success of re-treatment of a failed root canal therapy
(RCT).(24) However, it's important to note that AI tended to over-detect lesions while
human operators tended to under-detect them.(22)
Duncan et al, in 2022, recommended the use of CBCT as it can detect periapical lesions
better than 2-Dimensional X-Rays.(4)In another review by Issa et al in 2023, AI has
exhibited an exceptional level of precision in detecting apical periodontitis within
periapical radiographs, owing to its capacity to detect intricate patterns and attributes
beyond the detection of human observation.(6)
This, in turn, positions it as an efficient auxiliary diagnostic instrument for dental
professionals, simultaneously mitigating the clinical burden and improving the standard
of care.(6)
The main goal of this research is to compare cases of moderate pulpitis without apical
periodontitis in comparison to cases of severe pulpitis with AI-Detected apical
periodontitis. Additionally, the study aims to evaluate the accuracy of a novel AI
technology in identifying apical periodontitis from radiographs and to establish the
correlation between the utility of AI as a dependable supplementary tool in the
decision-making process when contemplating full pulpotomy for mature permanent molars.
In the paper by Duncan et al, even though it was proven that even in the presence of a
large periapical radiolucency, portions of the radicular pulp tissues can maintain their
vitality, more clinical studies are needed to assess the success rates of cases with
severe irreversible pulpitis with apical periodontitis.
The study done by Anita Aminoshariae et al reported that AI can accurately detect
peri-apical lesions. However, another study by Cantu et al reported that AI generally
tends to over-detect lesions. Thus, it is imperative to compare AI findings to the
operator's radiographical observations.