Journal of Dentistry 43 (2015) 1125–1131

Permanent teeth pulpotomy survival analysis: retrospective follow-up

Gustavo Golgo Kunerta, Itaborai Revoredo Kunertb, Luiz Cesar da Costa Filhoc,José Antônio Poli de Figueiredod,*a Pontifical Catholic University of Rio Grande do Sul Rua, Landel de Moura 2797, casa 105, Porto Alegre, RS, 91920-150, Brazilb Private Practice, Florêncio Ygartua 271, sala 201, Porto Alegre, RS 90430-010, BrazilcHospital Moinhos de Vento, Av. João Wallig 1800, sala 3001, Porto Alegre, RS 91340-001, Brazild Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga 6681, Prédio 6, sala 507, Porto Alegre, RS, Brazil, postal code: 90619-900

A R T I C L E I N F O

Article history:Received 15 March 2015Received in revised form 26 June 2015Accepted 29 June 2015

Keywords:PulpotomyCohort studiesSurvival analysisRisk factorsPulp biologyClinical outcomesEndodontics

A B S T R A C T

Objectives: The aim of the present study is to evaluate risk factors influencing the success rates ofpulpotomies both in young and adult populations.Methods: Pulpotomies (n = 273) performed by a single endodontic specialist were analyzed, and data onsuccess rates were collected. Additionally, possible explanatory variables were noted such as: age,gender, clinical findings (teeth, type of restoration after pulpotomy), radiographic findings (dentin bridgeformation) and systemic conditions. The follow-up period varied from 1 to 29 years, and the results wereanalyzed by Kaplan–Meier survival curves and also by Cox regression.Results: Age at the time of pulpotomy ranged from 8 to 79 and had not influenced the success rates(p = 0.35). The formation of dentin bridge had a strong protective effect (hazard ratio—HR = 0.16,p < 0.001). The prosthetic crown restorations following pulpotomy had the smallest failure rate, andamalgam has not increased the risk of failure significantly in relation to prosthesis. Resin compositerestorations following pulpotomy increased in 263% the risk of failure (HR = 3.63, p < 0.001).Conclusion: This study allowed inferences that pulpotomy may be a successful treatment at any age, andnot only for young permanent teeth. It was also possible to conclude that the use of direct compositerestorations following pulpotomies is associated with higher failure rates.

ã 2015 Elsevier Ltd. All rights reserved.

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Journal of Dentistry

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1. Introduction

Pulp conservative treatments are options available to generaldentists, both for deciduous and permanent teeth, and amongtherapies, pulpotomy is identified as one of the most effective [1–4]. The limited adoption of such technique in routine dental careneeds to be revisited. Among the concerns stated, there is thepossibility of dental resorption [5] or root canal calcification [1],which could jeopardize future endodontic treatment leading totooth loss. On the other hand, some classic studies from de Sousaand Holland [6] and Holland and de Sousa [7], and also more recentresearch [1–4], have shown that pulpotomies have a success ratebetween 85% and 94%.

Studies such as Camp [8] contraindicate pulpotomy when thereis spontaneous pain, which would suggest lack of tissue reactionability. On the other hand, several other authors [4,9,10] haveshown success following pulpotomy even when the clinical

* Corresponding author.E-mail address: jose.figueiredo@pucrs.br (J.A.P. de Figueiredo).

http://dx.doi.org/10.1016/j.jdent.2015.06.0100300-5712/ã 2015 Elsevier Ltd. All rights reserved.

symptoms were of irreversible pulpitis. This brings up the debateas to what the actual situations are for success or failure of thistechnique.

It can be verified that the minimal use of is not due to possibletechnical difficulties, but perhaps to lack of incentive and/or a lackof clinical research that considers diagnostics, outcomes andfollow-up [11]. There are time lapses and scarce long-term clinicaldatabases for scientific research on pulpotomy, and this generatesuncertainties about the clinical and radiographic behavior ofpulpotomies and also about the predictability of such technique.

There is little conclusive clinical data on a long-term basis thatconsiders clinical and systemic risk factors along with pulpotomy.Clinical information, such as pain symptoms and dentin bridgeformation, or the influence of material selection on the restorationafter pulpotomy, and also the possible interference of systemic riskfactors (smoking, diabetes, hypertension, cardiopathy, and others)have motivated the present investigation.

This study has aimed to understand the clinical and radio-graphic behavior of 273 pulpotomies, with updated follow-up(from 1 to 29 years), performed by a single operator, and also tounderstand the risk factors on pulpotomy’s survival rates.

1126 G.G. Kunert et al. / Journal of Dentistry 43 (2015) 1125–1131

2. Materials and methods

This research was performed according international guidelineson research ethics, and the Brazilian research ethics committeeunder the number 14138413.8.0000.5336 approved it. All partic-ipants of this study signed a written informed consent.

Information from clinical records and radiographs wasextracted from certified digital database from a single endodonticspecialist practice from the beginning of the digital records in1975 through 2014. Data on clinical, systemic and radiographicfactors were collected, and also clinical recall was performed todetermine an updated success rate on 273 permanent teethpulpotomy cases (age range: 8 to 79 years old at the time of theprocedure—Table 1). All cases were diagnosed, executed andfollowed by a single endodontic specialist throughout its career.Pulpotomy was selected as treatment based on clinical aspect ofthe dental pulp: (1) the tissue should be with adequate consistency(not being jelly or liquefied); (2) color presentation should be redor pink; (3) bleeding should follow cutting (lack of bleeding orcolor presentation as too light or cyanotic led to pulpectomy andconventional root canal treatment) [6,7] regardless of the paindiagnosis (with or without pain). Pure calcium hydroxide powderwas selected in all cases as the pulp capping material regardless ofthe age of the patients.

The cases were not accidental pulp exposures. All patients werereferred to the clinic for endodontic treatment and the specialistchose to perform pulpotomy as the final treatment wheneverconsistency and bleeding patterns allowed.

Cases were selected for treatment with pulpotomy according toclinical examination, in which there was a need for endodonticintervention but with no restorability issues. Periapical andbitewing radiographs were performed. Pulp sensitivity tests, untilthe late 80’s, were conducted with ice stick and electrical test (PulpTest, Pelton & Crane Company, North Carolina, USA). Later, thermaltest with cooling sprays (�20, Aerojet, Rio de Janeiro, RJ, Brazil)were used.

Patient was anaesthetized and isolation with rubber dam wasfollowed by removal of infected carious dentin and thoroughirrigation with distilled water. With a new and sterilized bur, accesswas performed and coronal pulp was removed with a sharp bladedcurette. Bleeding was washed away with distilled water untilhemorrhage stopped. Under clear light, the aspect of the remainingpulp was assessed. If normal, a cotton pellet embedded incorticosteroid-antibiotic paste (OtosporinTM, FQM, Rio de Janeiro,RJ, Brazil) was accommodated in contact with the surface of theremaining radicular pulp during five minutes. Then, washing withdistilled water and drying with sterilized cotton pellet werefollowed by gentle placement of calcium hydroxide powder (CarloErba, São Paulo, SP, Brazil) with a sterilized amalgam carrier inclose contact with the surface of the pulp. Care was taken to avoidpressure and load in this phase. Over the powder DycalTM

(Dentsply, Petrópolis, RJ, Brazil) was placed and then a temporaryrestoration with IRMTM (Dentsply, Petrópolis, RJ, Brazil) or glassionomer (Vidrion R, SS White, Rio de Janeiro, RJ, Brazil) (Fig. 1).

Forty-eight hours following pulpotomy, patient was back forconsultation and signs and symptoms were assessed. If everythingwere OK, patient was referred back to the dentist for final

Table 1Age distribution at time of the pulpotomy.

Age range 08–10

11–20

21–30

31–40

41–50

51–60

61–70

71–80

Number ofcases

14 32 50 35 70 43 18 11

restoration, and scheduled for the first follow-up radiograph andclinical analysis 90 days following procedure.

In a second phase, the patients were contacted and invited tothe practice for a new and free appointment to re-evaluate andupdate the clinical and radiographic condition of the pulpotomizedteeth by a second and independent endodontic specialist. From atotal of 567 pulpotomies, we could reach 281 patients and only 8(2.85%) declined to participate. A number of 236 patients havechanged phone number and address and we could not reach them(Table 2). Thirteen died, and 36 cases were performed less than oneyear before analyses and were not included.The reassessmentswere done according to the guidelines from the European Societyof Endodontology [12]. Direct pulp capping and pulp amputationshould be assessed no longer than 6 months postoperatively andthereafter at regular intervals. The following findings indicatefavorable outcome: normal response to pulp sensitivity tests(when feasible), absence of pain and other symptoms, radiologicalevidence of dentine bridge formation, radiological evidence ofcontinued root formation in immature teeth, absence of clinicaland radiographic signs of internal root resorption and apicalperiodontitis, and risk factors data and success criteria weredetermined [12–15].

Teeth under analysis were considered together with periapicaltissues, and determination of success and failure were defined asfollows:

Success: lack of periapical radiolucency or widening ofperiodontal ligament apically; no pain following vertical orhorizontal percussion; radiographic evidence of dentin bridge;lack of clinical or radiographic signs and symptoms of rootresorption or apical periodontitis; positive response to sensitivitytest, whenever possible.

Failure: presence of sinus tract; presence of periapicalradiolucency; pain following percussion tests; clinical or radio-graphic signs and symptoms of root resorption or apicalperiodontitis; radiological widening of periodontal ligament;radiographic appearance of bone disturbance or loss.

Cases treated less than one year before the beginning of thisstudy were excluded from our analyses. Minimal time of follow-upwas 1 year and the maximum went up to 29 years(average follow-up time 4.75 year � 5.96 years). Table 2 shows how the273 pulpotomies were selected out of 567 cases.

Data was recorded in a Microsoft Excel (Microsoft Corp,Redmond, WA) database,and the following variables werecollected: record number, gender, birth date, tooth number,pulpotomy date, age at the conclusion of the pulpotomy, numberof appointments required to finish the pulpotomy, date of the lastreevaluation on the pulpotomized teeth, determination of thesuccess criteria (success or failure) of the pulpotomy, data of thelast visit with successful pulpotomy or date of the failure (if thiswas the case), presence or absence of denting bridge formationdetectable on the X-rays, failure cause (if was the case), systemicvariables (smoking status, diabetes, hypertension, cardiopathy,and others), type of lining material (zinc phosphate, glass ionomeror other material), type of restoration after pulpotomy (prostheticcrown, amalgam or resin composite).

2.1. Statistical analyses

Initially, the survival rates of the pulpotomized teeth wereevaluated and described by Kaplan–Meier curves. The evaluationof the risk factors was performed by Cox proportional-hazardsregression in two ways: univariate analysis (non-adjusted model)and multivariate analysis (adjusted model). The Cox regressionsresults were presented by the hazard ratio coefficient (HR) and itsrespective 95% confidence interval (95% CI). For the specificanalysis of tooth fracture occurrence, Fisher exact test was

Fig. 1. Pulpotomy clinical protocol: (a) remaining pulp normal clinical aspect; (b) calcium hydroxide powder placement; (c) DycalTM lining placement; (d) glass ionomertemporary restoration.

Table 2Case selection and drop outs.

Total pulpotomies 567Pulpotomies included in the study 273Pulpotomies not included in the study 294

Reasons for exclusion:Cases performed less than one year 36Unable to contact patient (change of phone number or address) 237Death 13Refusal to come to practice for follow-up 8

Fig. 2. Female patient; 19 years follow-up; diagnostics: pulpitis in the first left upper minitial bitewing X-ray; (c) 90 day follow-up; (d) periapical X-ray after 19 years follow uformation).

G.G. Kunert et al. / Journal of Dentistry 43 (2015) 1125–1131 1127

performed. The adopted level of significance was 5%, and the testswere carried out with SPSS 20.0 (SPSS Inc., 2011, Chicago, IL)statistical package.

3. Results

From the total of 273 pulpotomy cases, there were the followingsuccess rates over the years: 1 year, 89% success; 2 years, 83%;3 years, 81%; 4 years, 76%; 5 years, 75%; and 10 years, 63% (Figs. 2–4show X-rays of typical long term successful pulpotomy cases).

There was no statistical significance for systemic risk factorssuch as: smoking status, hypertension, cardiopathy or other

olar;pulpotomy performed at the age of 44 years old. (a) initial periapical X-ray; (b)p; (e) bitewing X-ray after 19 years follow up (white arrows show dentin bridges

Fig. 3. Male patient; 17 years follow-up; diagnostics: caries infiltration after amalgam fracture in the secondrightlower molar; pulpotomy performed at the age of 46 yearsold. (a) initial periapical X-ray; (b) periapical X-ray immediately after pulpotomy; (c) periapical X-ray after 17 years follow up (white arrow shows dentin bridge formation);(d) bitewing X-ray after 17 years follow up (white arrow shows dentin bridge formation).

Fig. 4. Male patient; 20 years follow-up; diagnostics: amalgam fracture in the second left upper molar; pulpotomy performed at the age of 27 years old. (a) initial periapical X-ray; (b) periapical X-ray 90 days after pulpotomy; (c) periapical X-ray after 20 years follow up (there is no dentin bridge formation).

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systemic diseases (Table 3). Also, age, gender and number ofappointments to conclude the pulpotomy were not significant riskfactors (Table 3).

The detection of dentin bridge formation after the pulpotomy isa strong indicator of success, and it is a significant protection factorfor failure (Table 3 and Fig. 5). In our results, it is estimated by Coxregression that there was 84% less failure when dentin bridgewas

Table 3Cox proportional-hazards regression for survival data. Clinical, radiographic and systemic factors evaluated.

Risk factors Non-adjusted model Adjusted model

HR 95% CI p HR 95% CI p

Gender 1.29 (0.86–1.93) 0.22 1.24 (0.81–1.88) 0.32Age at the pulpotomy 1 (0.98–1.01) 0.58 0.99 (0.98–1.01) 0.35Number of appointments 0.55 (0.17–1.73) 0.3 0.75 (0.22–2.47) 0.63Smoke 1.21 (0.78–1.87) 0.39 0.93 (0.59–1.47) 0.75Hypertension 0.59 (0.29–1.19) 0.14 0.56 (0.23–1.34) 0.19Cardiopathy 0.38 (0.14–1.03) 0.058 0.81 (0.25–2.62) 0.73Other systemic diseases 0.91 (0.51–1.64) 0.76 0.8 (0.43–1.50) 0.5Denting bridge formation 0.14 (0.063–0.29) <0.001 0.16 (0.07–0.35) <0.001

Fig. 5. Kaplan–Meier survival curves concerning dentin bridge formation.

Fig. 6. Kaplan–Meier survival curves concerning the type of the final restoration.

G.G. Kunert et al. / Journal of Dentistry 43 (2015) 1125–1131 1129

detected in the X-rays in relation to the group without dentinbridge formation.

In terms of the success rate of the pulpotomy in relation to thetype of final restoration, the prosthetic crown was considered thebest material followed in a descendent order by amalgamrestoration and resin composite (Table 4 and Fig. 6).

Some failure cases were due to tooth fracture rather than failureof the pulpotomy technique. The occurrence of tooth fracture inrelation to the final restoration also demonstrated an advantage toprosthetic crown, followed by amalgam restoration, and the worstperformance came from resin composite restorations.

4. Discussion

Pulpotomy as a definitive technique has faced controversialopinions in the endodontic scientific literature [1–5]. Althoughseveral studies have pointed to pulpotomy as a safe technique inrelation to the pulpectomy due to its consistent success rates insurvival analysis studies [16–20].

In our research we found success rates up to 89% in the firstyear, decreasing to 63% by the 10th year. Those rates are in

Table 4Cox proportional-hazards regression for survival data. Restorative treatment typeevaluated as risk factors (prosthetic crown as the reference category).

Type of restoration Non-adjusted model Adjusted model

HR 95% CI p HR 95% CI p

Prosthetic crown 1 – – 1 – –

Amalgam 1.78 (0.94–3.33) 0.078 1.11 (0.57–2.14) 0.77Resin composite 5.46 (2.99–9.72) <0.001 3.63 (1.96–6.72) <0.001

accordance with the studies of Marghalaniet al. [17] and Yildiz andTosun [21], which found similar rates even with different liningand restorative materials, and also in relation to deciduous andpermanent teeth.

One might ponder the right moment to perform the pulpotomytechinique, because the long-term studies have been performed indifferent age ranges such as children [22], young adults [23] andmiddle-aged adults [16], and those age differences among thestudies leave room to contest the most adequate age to perform thepulpotomy technique. In our study, ages ranged from 8 to 79 yearsold, and age was not considered a risk factor (Tables 1 and 3). As inthe previously cited studies [5,16,17], ours did not consider age acontraindication even among the elderly.

This led us to question the influence of other systemic factors,which might influence pulpotomy successes rates. In our study, thefollowing factors have also not influenced the survival rates forpulpotomy: gender, smoking status, presence of hypertension,presence of any cardiopathy, presence of other systemic conditionsas a whole (hepatitis, diabetes, HIV positive). No systemic illnesseswere found to be associated with pulpotomy success rates, butmore studies are necessary to determine which diseases mayimpair pulp healing and response; there are many situations thatwere not present in our patients (such as oncological treatmentsand other more rare diseases), and also for many situations we didnot have an adequate number for statistical analysis.

Our data suggests, from a clinical point of view, that there is nodifference in success rates in performing the pulpotomy in one ortwo appointments. Souza et al. [24] found similar results, in9 months follow-up, when performing pulpotomy in immature

Fig. 7. (a) Dentin bridges formations detected in a periapical X-ray (black arrows).

1130 G.G. Kunert et al. / Journal of Dentistry 43 (2015) 1125–1131

permanent teeth with one or two appointments, also usingcalcium hydroxide as pulp capping material. These facts reinforcethe notion that the correct diagnosis of pulp condition and vitalityand the case preparation to avoid pulp contamination during theprocedure are more important than the number of appointmentsfor pulpotomy technique, or the age or gender of the patients.

Systematic reviews and meta-analysis on pulpotomy [8,17,25]have pointed to the difficulty in finding clinical indicators forfollow-up of such techniques. They also mentioned that theexisting clinical tests have produced several false negative results,and for this reason radiographic follow-up is essential forpulpotomy techniques. Thus, it is extremely important to havetangible radiographic indicator of pulpotomy success, and thepresence of dentin bridge (Fig. 7) in the follow-up radiographsseems to be a protective factor (HR = 0.16; p < 0.001) and thereforea strong indicator of success. It is important to point out that thebest radiographic techniques to detect dentin bridge formationsare bitewing radiographic technique or long cone parallelingtechnique for periapical radiographs.

Several pulpotomy survival analysis studies, including system-atic reviews [19] and other clinical studies [21,26,27], have alsoapproached the importance of the final restoration on the successrates of pulpotomy techniques and concluded that an excellentcrown setting is one of the keys for long-term success in theseprocedures. The present research has shown that prosthetic crownwas the best choice of restoration for pulpotomized teeth, followedby amalgam restoration. Direct resin composite restorations areassociated with higher failure rate of pulpotomy technique. Due tothe fragility of the tooth structure after pulpotomy, fractureoccurrence was also analyzed among different restorations, andthe previous conclusion stands: prosthetic crown was the bestchoice (HR = 1.0, reference category) follow by amalgam (HR = 5.0)and resin composite (HR = 7.8).

5. Conclusions

The case selection, the correct diagnosis of pulp conditions,aseptic maintenance during the procedure, the use of dentin bridgeinducing pulp capping materials, the selection of adequate liningrestoration, and the optimal crown setting throughout prostheticcrown are the keys for pulpotomy success.

The absence of clinical symptoms and periapical alterations,followed by dentin bridge formation and final restoration with ahermetic prosthetic crown, are reliable indicators of long-termpulpotomy success.

The results of the present study help to establish the pulpotomytechnique for permanent teeth as a treatment that is considerablysimple, accessible, definitive and safe for all ages. Those character-istics turn pulpotomy into an excellent, cost-effective choice ofvital pulp treatment for all populations.

Appendix A. Supplementary data

Supplementary data associated with this article can be found, inthe online version, at http://dx.doi.org/10.1016/j.jdent.2015.06.010.

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