Objectives: The primary objective of this study is to explore the effectiveness of
different VPT methods after pulp exposure. A secondary objective is to establish the
relationship between success rate, age and other co-factors.
Study methodology: We plan a single-centre, three-arm, observational prospective cohort
study. The study will be organised and hosted by the Department of Restorative Dentistry
and Endodontics, Semmelweis University. Patients for the study will be selected from
patients presenting at the ambulance of the Semmelweis University Department of
Restorative Dentistry and Endodontics.
For patients who meet the inclusion criteria, we record the patient's baseline clinical
data Baseline data, as well as information obtained during the study and findings during
follow-up (7 days, 6 months, 1 year, 2 years, 3 years, 4 years) are recorded by the
interventionalist in an online database (REDCap).
Interventions are carried out according to the following steps: After local anaesthesia
(Lidocaine-adrenaline 20 mg/0.01 mg/ml, Egis, Budapest, Hungary) and mouth rinsing with
0.2% chlorhexidine, the tooth is absolutely isolated using a rubber dam and liquid dam
(Opaldam- Ultradent, South-Jordan, Utah). The coronal part of the tooth is then
disinfected with a cotton pellet soaked in 5% sodium hypochlorite (NaOCl). Under an
operating microscope, the caries is removed non-selectively, first with a diamond bur
under water cooling, then with a steel bur inserted in a handpiece, moving from the
periphery of the tooth towards the pulpal wall. The absence of caries on non-pulpal walls
is confirmed by caries indicator (Sable Seek-Ultradent, South-Jordan, Utah). The pulp
chamber is opened with a sterile diamond bur in a turbine with copious water cooling.
After opening the pulp, different types of treatment are used depending on the extent of
inflammation and caries.
Direct pulp capping: Pressure of a sterile cotton pellet soaked in 2.5% NaOCl is
applied to the exposed pulp to achieve hemostasis. After the bleeding has stopped,
the cavity is flushed with sterile saline and Biodentine (Septodont,
Saint-Maur-des-Fossés, France) or MTA is mixed according to the manufacturer's
instructions. The patient is called back after 1 week, when the temporary
restoration is removed and a final restoration is placed in the cavity, which may be
a composite filling, inlay or crown, depending on the amount of remaining tooth
material. This type of intervention is performed (1) if a healthy tooth with a
normal pulp has suffered iatrogenic pulp exposure and the pulp tissue is surrounded
by intact dentin tissue, and (2) when it is asymptomatic, or with reversible
pulpitis symptoms after extra deep caries removal, there is no dentin chips are the
pulp tissue, it is surrounded by healthy dentin, there is no evidence of necrosis in
the pulp, and bleeding can be controlled within 5 minutes with a cotton pellet
soaked in 2.5% NaOCl. Direct pulp capping will berejected if the patient has
spontaneous pain before treatment, bleeding from the pulp is not controllable within
5 minutes, necrotic tissue is present in the pulp chamber, or if the pulp is explose
through carious dentin.
Partial pulpotomy After opening of the pulp with a sterile diamond bur, an
additional 2-3 mm of coronal pulp tissue is removed with copious water cooling.
Subsequently, light pressure is applied to the pulp for 5 minutes with a cotton
pellet dipped in 2.5% NaOCl to control bleeding. After controlling the bleeding, the
cavity is flushed with sterile saline and Biodentine or MTA is applied the same way
as in case of direct pulp capping. Partial pulpotomy is the treatment of choice in
the following clinical situations: (1) in case of extra-deep caries the bacterial
biofilm and infected dentin can be only removed by superficial pulp excision, (2)
when further caries removal is required after pulp exposure due to the risk of
infected dentin shavings entering the pulp, (3) in the case of normal pulp after
extra-deep caries removal, bleeding cannot be controlled within 5 minutes after
direct pulp capping attempt, (4) in the case of reversible pulpitis, if bleeding
cannot be stopped within 5 minutes after pulp exposure. We exclude from partial
pulpotomy treatment, for any of the above indications, cases where bleeding cannot
be stopped within 5 minutes.
Complete pulpotomy During a total coronal pulpotomy, the coronal pulp tissue is
removed down to the level of the orifices using a sterile diamond bur with copious
water cooling. Bleeding is controlled by gentle pressure with a cotton pellet soaked
in 2.5% NaOCl. When the bleeding stops, the cavity is flushed with sterile saline
and Biodentine or MTA is applied the same way as in case of direct pulp capping.
Complete pulpotomy is the treatment type of choice in the following clinical
situations: (1) reversible pulpitis/normal pulp with anemic necrotic tissue in the
pulp, (2) reversible pulpitis, normal pulp after partial pulpotomy if bleeding
cannot be controlled in 5 minutes, (3) if the patient's complaints include
spontaneous or persistent pain/night pain. Exclusion criteria for complete pulpotomy
treatment include (1) bleeding uncontrollable in 5 minutes, or (2) anaemic/necrotic
tissue at the level of the orifices.
The patients will be consulted about any complaints or changes in complaints 7 days after
the procedure, at the same time as the final restoration is made. If there are no
previous complaints, the patient will be referred back for a follow-up examination six
months after the procedure. Then, after recording any complaints, a control radiograph
and clinical examination (inspection, palpation, palpation, periodontal pocket probing)
are performed. The same is repeated 1 year, 2 years, 3 years and 4 years after treatment.
Evaluation of the results: The success of the treatment is evaluated by combining the
patient's subjective complaints with the results of the clinical examination and
periapical radiograph. The periapical index (PAI) is used to assess the periapical space
on radiographs.