The rarely spotted pulpotomy

by Dr Peter Raftery, Endodontist, Hampshire Endodontics

Article and remarks written under the sole responsibility of Dr. Peter Raftery

In his Hampshire practice, endodontist Dr Peter Raftery frequently saves patients (and himself) time and money by offering Biodentine^TM pulpotomy as an alternative to root canal treatment, much to their delight. However, he often finds that general dentists can be hesitant to follow suit, with pulpotomy a vastly overlooked option. Here, Dr Raftery makes the case for why Biodentine^{TM (*)} pulpotomies are more beneficial, more lucrative, and easier to perform than you think…

Does VPT have an image problem?

Yes. I think that Vital Pulp Therapy (VPT) in permanent teeth has an image problem — literally.

In terms of eye-catching Instagram updates, Biodentine^TM pulpotomy post-ops just don’t compete with a sealer-filled apical delta. And so, outside of a textbook, you probably haven’t seen any pulpotomy cases in years. Which in turn means you probably aren’t aware of how incredibly useful a treatment option it is. In fact, in their 2022 paper on the evidence concerning pulp therapy, the British Endodontic Society (BES) suggests that this procedure might represent “a paradigm shift in how we manage pulpal disease.” (reference 1). Now that is attention-grabbing.

Biodentine^TM pulpotomy – the win-win treatment approach

When patients are referred to me, they arrive already knowing our root canal treatment fee. If, following consultation, I am then able to recommend a pulpotomy (which I charge at two thirds of the full fee), patients are delighted with the prospective financial saving. And the savings don’t end there.

We all know that molars typically get crowns after root canal treatment. Most of my work is on molar teeth and so, if we are avoiding a root canal treatment via Biodentine^TM pulpotomy, it seems reasonable that there is a chance of avoiding a crown, too. Having done many now, I am confident enough in the predictability of the procedure. I reassure patients that, in the unlikely event the pulpotomy doesn’t work, I’ll complete the root treatment for the remaining third of the fee. As such, patients perceive that there is no financial penalty preventing them from trying pulpotomy.

Patients soon start to love the idea of Biodentine^TM pulpotomy. Still, some might question whether this novel pulpotomy is as ‘tried and tested’ as a full root canal treatment and ask: “Would it not be better to spend a little more time and money for a more certain outcome?”

Forget the Dycal pulp caps you did in dental school; current evidence shows pulpotomies are predictable, with high success rates for pulpotomies in adult teeth with signs and symptoms indicative of irreversible pulpitis. (reference 2) Further, these success ratesare no lower than those of more invasive and costly conventional endodontic treatments. (reference 3)

There are plenty of reasons for the operator to love this approach, too. Pulpotomy is a less technically demanding treatment to perform than full root canal treatment, avoiding most of the headline-grabbing risks (e.g. irrigant extrusion) and taking significantly less chair time. I find pulpotomy to be the most enjoyable treatment to perform and, when I consider the fee structure mentioned, probably the most lucrative, too. Pulpotomies, I feel, are the win-win treatment modality.

The rationale for Biodentine^TM pulpotomy

It used to be the case that if the pulp of a permanent tooth became exposed by caries (or by caries removal), root canal treatment was indicated. Direct pulp caps with materials like Dycal were as unreliable as they were unpredictable.

The development and uptake of modern materials in the UK such as Biodentine^TM in 2010, alongside a better understanding of pulp biology, means that VPT of inflamed mature teeth is now approaching the routine. With the increased acceptance of Minimal Intervention (MI) principles in dentistry, I would suggest all conservative-minded dentists ought to be offering Biodentine^TM pulpotomies.

Patients instantly grasp the rationale. They instinctively understand that if, say, a diabetic patient develops irreversible foot complications, surgeons would best address the problem by amputating at the ankle, rather than cutting off the whole leg. By that token, if their dental problem comprises toothache or an extensively carious but vital tooth, they will understand the rationale behind removing that unviable portion of pulp and leaving behind the healthy, unaffected tissue.

To quote the BES paper on pulpotomy: “Maintaining pulp vitality preserves the tooth’s circulatory defence system, the full proprioceptive function of the tooth is maintained, and the tooth will be less mechanically weakened and hence less prone to fracture.” (reference 1)

Case selection

Teeth that are suitable for consideration for pulpotomy include:

• Vital teeth with no caries but symptoms of irreversible pulpitis.
• Vital teeth with caries extending into the pulp with or without pulpitis symptoms (reversible or irreversible).

Cases not suitable for consideration include:

• Caries not extending into the pulp of teeth with no symptoms or with symptoms of reversible pulpitis. These teeth should be restored conventionally.
• Non-vital teeth and teeth with apical areas of rarefaction. These pulps are dead and the pulp space is infected. With necrotic pulps, there is no tissue to preserve and root canal treatment (mature apices) or revascularisation (immature apices) are the endodontic options of choice.

Case selection does not hinge entirely on the irreversible/reversible pulpitis categorisation. Despite improvements in the understanding of pulp biology, pulp histology still correlates poorly with clinical symptoms.

If symptoms can correlate poorly with the true condition of the pulp, then patients must be cautioned that “the goalposts may move” during the pulpotomy procedure. If no viable pulpal tissue is found intra-operatively, then there is nothing to preserve, and a fuller clean-out of the pulp space is necessary. Patients need to be quoted (and appointment times need to allow) for pulpotomy or root treatment.

For a proposed pulpotomy to remain an option intra-operatively, I say: “I need to see red stuff on the inside of the tooth.” I will always take an image to justify doing (red stuff) or not doing (no red stuff and/or a smell) the pulp therapy and for this reason, I think that intra-oral imaging is a medicolegal must-have.

The European Society of Endodontology (ESE) says that: “The colour and intensity of pulp bleeding on exposure intra-op may provide a surrogate marker of inflammation and capacity to recover after treatment.” (reference 4)

Only with injectable anaesthetics do I feel I have a hope of getting inflamed pulps numb. Rubber dam use is necessary because bacterial contamination of the pulp space spells certain failure. After clearing caries, I will deroof the pulp. It is necessary to remove the vital pulp with a diamond bur. A slow handpiece will entangle and rip out the very pulp you’re trying to preserve.

Drilling away pulp is a skill to be learned on the job. A light touch (and good vision) is needed to discern the ‘feel’ of pulp and to avoid gouging out the pulp chamber dentine. Once I’ve drilled away the coronal pulp down to orifice level, I will take a photo for the record. I need to see red circles (not pus, not empty orifices, and not a gushing, hyperaemic pulp).

I will clean out the pulp chamber with a cotton pledget or small piece of sponge soaked in sodium hypochlorite. I will apply some pressure to the cut pulp through the pledget for a minute. Pressure will help stop the bleeding from a healthy pulp stump and the hypochlorite will kill bacteria and gently dissolve any necrotic pulp.

Upon removal, I have a clean, vital, non-bleeding pulp directly onto which I will pack some Biodentine^TM (not MTA). In their 2022 Pulp Therapy Evidence Guidelines, the BES describes Biodentine^TM as the single best pulp therapy material. Calcium hydroxide induces a poorer, less predictable pulpal response and the bismuth oxide in MTA irreversibly discolours teeth. (reference 1)

Septodont’s procedure allows me to fill the entire cavity with one Biodentine^TM capsule (the Bio Bulk-Fill procedure). Septodont advise that Biodentine^TM can be used as an enamel restoration material for up to six months. I don’t see any argument for taking a post-pulpotomy x-ray.

Post-op management

Having manipulated the densely innervated tissue, I supply the patient with two days of oral steroids as a potent anti-inflammatory. After six months, I review the case. To determine success clinically, I use an absence of swelling or draining sinus. Radiographically, I require an absence of apical rarefaction. In successful cases, I request the General Dental Practitioner (GDP) resurface the Biodentine^TM, ideally cutting back the outer 2mm of Biodentine^TM and flowing something harder-wearing and aesthetically suitable on top. I can accept that some cases still need a casting (crowns or onlays) despite a successful pulpotomy.

Failures are rare, characterised by clinical and/or radiographic signs of infection. I also deem as failures those very rare cases where the patient cannot wait until six months due to worsening pain symptoms.

A common concern from dentists is how to complete a root filling when you’ve packed Biodentine^TM down. Having progressed a few of my own pulpotomies into root fillings, I can say that it is not as hard as one might think to visually discern between white Biodentine^TM and yellow dentine when drilling. Nor is it hard to discern between the two from a tactile perspective when drilling with a Goose Neck bur.

Conclusion

Pulpotomies are soon to be routine. I find the most disgruntled patients at my endodontic practice are those who experience an agonising Bank Holiday weekend after a ‘deep filling’ at their dentist (such as a deep amalgam or composite in a deep cavity close to the pulp). I would argue that placing a deep filling in a carious molar and hoping for the best is asking for trouble (and complaints). I would argue that being slightly more proactive with deeply carious cavities, excising the inflamed pulp and placing a Biodentine^TM restoration onto uninflamed pulp, will be the proverbial “stitch in time, saving nine”.

(*). Biodentine is marketed by Septodont laboratory (58 r Pont de Créteil, 94100 Saint Maur des Fossés – France)