|Year : 2021 | Volume
| Issue : 3 | Page : 339-344
The demand for emergency care after pulpotomy with Biodentine® on permanent molars with irreversible acute pulpitis: Clinical trial study
Anta Seck1, Fatou Lèye-Benoist1, Babacar Touré1, Haikel Youssef2
1 Department of Dentistry, Conservative Dentistry and Endodontics Service, Faculty of Medicine, Pharmacy and Odontology-Stomatology, Cheikh Anta Diop University of Dakar, Dakar, Senegal
2 Department of Conservative Dentistry, Faculty of Dental Surgery of Strasbourg, University of Strasbourg; Conservative Odontology Center, University Hospitals of Strasbourg, Strasbourg, France
|Date of Submission||09-Jul-2020|
|Date of Decision||31-Aug-2020|
|Date of Acceptance||16-Sep-2020|
|Date of Web Publication||3-Sep-2021|
Dr. Anta Seck
Department of Dentistry, Conservative Dentistry and Endodontics Service, Faculty of Medicine, Pharmacy and Odontology-Stomatology, Cheikh Anta Diop University of Dakar, BP: 5005 Fann, Dakar
Source of Support: None, Conflict of Interest: None
Introduction: In Endodontology, intra- and postoperative pain control is a key aspect of clinical practice. Such pain can be immediate, deferred, transitional, prolonged, or permanent. This clinical trial was performed to assess the demand for emergency care after pulpotomy on mature permanent molars with clinical signs of irreversible pulpitis.
Materials and Methods: Fifty patients aged 15–46 years who had undergone pulpotomy and were prescribed ibuprofen were given cards on which to record the occurrence and intensity of pain on a visual analog scale ranging from 0 (no symptom) to 10 (unbearable pain), and the use of any medication. After 1 week, the patients returned the cards and underwent clinical examination. The patients had clinical and radiographic checkups at months 3 (M3) and 6 (M6), and contacted their practitioners if they required additional appointments for pain relief. Data were statistically analyzed.
Results: Examinations were performed on 49 patients on day 7 (D7), 44 patients at M3, and 41 patients at M6. On D7, 42 (85.7%) patients had pain, with an average duration of 2.1 ± 1.3 days and the average intensity of 1.1 ± 0.8. The intensity of pain was significantly greater in patients males (P = 0.013). No patient had pain, discomfort, or irritation between D7 and M3, at M3, or between M3 and M6. At M6, one (2.4%) patient had a broken tooth with pain on chewing and 97.6% of patients were pain-free.
Conclusion: Pulpotomy with Biodentine® appears to be appropriate for mature permanent teeth with acute irreversible pulpitis.
Keywords: Biodentine®, emergency care, irreversible acute pulpitis, permanent molar, pulpotomy
|How to cite this article:|
Seck A, Lèye-Benoist F, Touré B, Youssef H. The demand for emergency care after pulpotomy with Biodentine® on permanent molars with irreversible acute pulpitis: Clinical trial study. Saudi Endod J 2021;11:339-44
|How to cite this URL:|
Seck A, Lèye-Benoist F, Touré B, Youssef H. The demand for emergency care after pulpotomy with Biodentine® on permanent molars with irreversible acute pulpitis: Clinical trial study. Saudi Endod J [serial online] 2021 [cited 2022 Aug 17];11:339-44. Available from: https://www.saudiendodj.com/text.asp?2021/11/3/339/325393
| Introduction|| |
The current understanding of pulp tissue healing and regeneration and the use of biologically active endodontic materials have enabled the preservation of pulp vitality through minimally invasive endodontic vital pulp therapy (VPT).,, Complete pulpotomy involves the removal of the coronal portion of the vital pulp to preserve the vitality of the remaining root portion. It has been proposed as a definitive treatment for mature permanent teeth with acute irreversible pulpitis.,,,, Its benefits include the preservation of tooth structure and maintenance of pulp mechanoreceptors, regenerative capacity, and proprioceptive feedback. Regardless of the technique used to manage acute pulpitis, postoperative pain ranging from mild to severe may occur. Polycarpou et al. reported that immediate postoperative pain occurs in 25%–45% of patients with acute irreversible pulpitis and is an important factor to consider during treatment. A review of the literature led to the identification of several studies of pulpotomy.,, However, the majority of these studies focused on the types of material used or the success rate of the procedure. Several bioactive materials have been proposed for use in pulpotomy. Mineral trioxide aggregate (MTA), considered to be the gold standard for pulp vitality therapeutics, has disadvantages, including long setting time, difficulty of handling, high cost, and risk of tooth staining. Biodentine® (Septodont, Saint-Maur-des Fossés, France) was developed to overcome some of these disadvantages.
Few studies have examined the incidence and characteristics of pain after pulpotomy. Shafie et al. reported that postoperative pain did not differ significantly between patients undergoing pulpotomy with MTA cement and those undergoing the procedure with a calcium-enriched mixture. In a study performed by Bagheti et al., patients treated with MTA had lower levels of pain than those treated with dexamethasone. Thus, this study was performed to evaluate pain after pulpotomy performed with Biodentine®.
| Materials and Methods|| |
The study population consisted of patients with acute irreversible pulpitis who came to the Department of Conservative Dentistry and Endodontics of the Institute of Odonto-Stomatology of the Faculty of Medicine, Pharmacy and Dentistry of the Cheikh Anta Diop University of Dakar (Université Cheikh Anta Diop de Dakar, UCAD), Senegal, for consultation. All patients were aged ≥ 15 years and provided informed consent to participate in the study. The Research Ethics Committee of UCAD approved the study (protocol no. 0360/2018/CER/UCAD), which was performed between January and December 2019.
Patient selection was random, with the three first patients presenting with single painful and restorable molars during the consultation period enrolled until a sufficient sample was recruited.
Participating patients had mature permanent molars with symptoms of acute irreversible pulpitis, i.e., spontaneous nocturnal pain caused and worsened by hot and cold food and/or radiant pain. Pain intensity was assessed verbal analog scale ranging from 0 (no symptom) to 10 (unbearable pain).
The included teeth had to pass pulpal sensitivity, cold (Endo-Ice; Hygenic Corp., Akron, OH, USA), and electrical (Pulp Tester PT 2.0; Averon, Ekaterinburg, Russia) tests, and had no periapical radiolucency visible on retroalveolar radiographs obtained with film holders (Dentsply Rinn, Elgin, IL, USA) and the intraoral paralleling technique. Patients with general pathology and/or using medication were excluded from the study. Molars that could not be restored after treatment, those with internal or external root resorption or periodontal disease, molars that failed the cold test, molars with visible pulpoliths on preoperative radiographs, immature molars and all intraoperative clinical signs, such as the absence of bleeding or bleeding for > 5 min were also excluded.
A single operator screened the patients and performed all endodontic procedures. Patients received local or locoregional anesthesia with 2% lidocaine® with 1/200,000 epinephrine (Septodont), followed by the placement of a dam. The carious cavity was disinfected with 2.5% sodium hypochlorite, and the carious tissue was removed using a large round tungsten carbide burr mounted on a counter angle and with an excavator. In the presence of infected dentin, the carious tissue at the edges of the cavity was removed first to avoid pulpal invasion. The endodontic access cavity was prepared with a high-speed turbine with water cooling using #12 gold, #12 tungsten carbide ball, and Endo-Z (152) burrs (Endo Access; Dentsply Maillefer, Tulsa, OK, USA). The coronal pulp tissue was removed with a large sterile ball burr or sterile excavator. The pulp chamber was irrigated with saline solution to remove any pulp markers, and hemostasis was achieved by gentle application of a sterile cotton ball. After hemostasis, mixed Biodentine® (Septodont) was applied to the pulp chamber, with coverage of the canal orifices and filling of the entire cavity. A postoperative retroalveolar radiograph was taken to check the tightness of the filling and for comparison with future radiographic evaluations.
The patients were prescribed ibuprofen (200 mg, one tablet every 6 h without exceeding four tablets per day) in case of pain. Each patient was given a blank card and a pain assessment strip for the recording of pain intensity on a visual analog scale (VAS) and ibuprofen intake during the first 7 days after pulpotomy.
At the second appointment, 1 week after treatment, patients returned the completed forms and reported their symptoms (spontaneous and induced pain). Clinical diagnosis with transverse and axial percussion tests was used to record pain. The final coronal restoration was performed with composite filling (Tetric-E-Ceram; Ivoclar-Vivadent, Schaan, Liechtenstein) in the absence of persistent spontaneous pain on the treated molars. The patients were instructed to contact their practitioners if they required appointments for pain relief in addition to clinical and radiographic check-up appointments at months 3 (M3) and 6 (M6).
Another operator performed posttreatment evaluations. Patients rated their pain on a scale ranging from 0 to 10. Pain sensation from the day of treatment to day 7 (D7) postpulpotomy was recorded at intervals of 24, 48, 96, 120, and 168 h. Pain perception was classified as none (0) mild (1–2), moderate (3–7), or severe (8–10). Each patient's ibuprofen intake for pain relief was recorded.
The data were analyzed using SPSS (version 21; SPSS, Chicago, IL, USA). Qualitative variables are presented as numbers and percentages, and quantitative variables are presented as means with standard deviations. Bivariate analysis was performed to compare pain persistence at D7 with other variables. The Chi-squared test was used to compare percentages. In all analyses, P < 0.05 was taken to indicate statistical significance.
| Results|| |
Of the 50 patients treated, one could not be contacted at the time of the second appointment and was considered to be lost to follow-up. Five patients were lost to follow-up at M3, and three additional patients were lost to follow-up at M6.
The average age of the study population was 26 ± 8 years (range, 15–46 years). More than half (54%) of the patients were female, yielding a sex ratio of 0.85.
No significant difference in pulpal exposure on the treated teeth was observed between treated mandibular and maxillary molars, among sites of decay, or between male and female patients [Table 1].
The average duration of treatment was 23.2 ± 8.2 min (range, 13–55 min, median, 20 min).
Pain before and after pulpotomy
All 50 patients had prepulpotomy spontaneous pain and all were treated. At D7, 42 of 49 (85.7%) patients had induced pain and the remaining patients were pain-free. No evaluated patient had pain, discomfort, or irritation between D7 and M3, at M3, or between M3 and M6 (n = 44). At M6, 1 of 41 (2.4%) patients felt discomfort with pain and 40 (97.6%) patients had no complaint [Figure 1].
|Figure 1: Pre and postoperative pain at different days/months. D0: Treatment day, D7: Seven days follow-up, M3: Three months follow-up, M6: Six months follow-up|
Click here to view
The average pain intensity was 7.2 ± 2.6 before pulpotomy and 1.1 ± 0.8 (range, 0–4) after pulpotomy [Figure 2].
|Figure 2: Pain intensity at different days/months D0, D7, M3 and M6. D0: Treatment day, D7: Seven days follow-up, M3: Three months follow-up, M6: Six months follow-up|
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The average period of prepulpotomy pain was 9.9 ± 8.5 days, and that of post-pulpotomy pain was 2.1 ± 1.3 days [range, 1–7 days; median, 2 days; [Figure 3]].
|Figure 3: Pain duration at different days/months D0, D7, M3 and M6. D0: Treatment day, D7: Seven days follow-up, M3: Three months follow-up, M6: Six months follow-up|
Click here to view
Forty-one (83.7%) patients took ibuprofen during the first 7 days of treatment. The average duration of ibuprofen use was 2 ± 1.2 days (range, 1–6 days; median, 2 days). No patient was taking medication at M3 or M6.
The intensity of pain at D7 was significantly greater in patients males (P = 0.013) [Table 2].
Pain at D7 was not associated significantly with the decay site, tooth type, or pulpal exposure [Table 3].
| Discussion|| |
Pain caused by irreversible pulpitis, related directly to the inflammatory state of the pulp, can be treated with pulpotomy. Histological and microbiological studies have shown that inflammation and microbes are limited to the coronal pulp in teeth with irreversible pulpitis, with no bacterial invasion or inflammation in the root pulp. However, pulpotomy on the permanent teeth may cause pain. The management of postoperative endodontic pain continues to be challenging for practitioners. Thus, the present study was performed to assess pain after pulpotomy performed with Biodentine®.
Considering the 95% success rate of pulpotomy performed with Biodentine® on 20 treated teeth reported by Taha et al. and the 82% success rate on 30 treated teeth reported by Simon et al. 50 teeth of 50 patients were included in this study, assuming a success rate >82%.
In this study, all patients had spontaneous preoperative pain (average verbal analog scale score, 7.2). These results are consistent with those of Bane et al., who reported spontaneous pain in all patients, with average verbal pain scores of 2.681 in the pulpotomy group and 2.766 in the prednisolone group. Such pain can be due the concentration of bradykinin, a potent inflammatory mediator, which is 13 times greater in pulp with acute irreversible pulpitis than in the normal pulp. This chemical mediator causes pain at inflammatory sites. Torabinejad et al. reported that preoperative pain is the main predictor of postoperative pain. Seven days after pulpotomy, 42 of 49 (85.7%) patients experienced pain lasting for an average of 2.1 ± 1.3 days, with an average VAS score of 1.1 ± 0.8. These results are consistent with those of Simon et al., who reported mild to moderate pain in 82% of patients immediately or 1 day after pulpotomy performed on teeth with no spontaneous preoperative pain. Keles et al. reported that 90% of patients experienced pain after pulpotomy. In the study performed by Shafie et al., no patient had preoperative pain, but all patients reported mild to severe pain after pulpotomy. Galini et al. reported that the incidence of pain was greater after pulpectomy than after pulpotomy. Taha et al. reported all patients with signs and symptoms indicative of irreversible pulpitis were completely pain-free 2 days after pulpotomy. This presence of postoperative pain, regardless of the presence of preoperative pain, can be explained by the presence of inflammation, which is an essential physiological process for the management of pulp vitality,, and is the first stage of tissue repair, according to Descroix et al.
The rate of ibuprofen use in the first 2 days after pulpotomy was 83.7%. Only 2% of patients who had not taken medication reported pain. Shafie et al. reported that premedication with ibuprofen significantly reduced postoperative pain in the first 24 h post pulpotomy. Preoperative administration of analgesics, such as ibuprofen, acetaminophen and codeine, reduces postoperative pain.
No patient reported pain, discomfort, or irritation between D7 and M3. At M6, one patient reported chewing pain due to coronal fracture of the treated tooth, which indicated extraction. In their study of the effects of Biodentine® on symptomatic mature permanent teeth, Taha et al. reported no pain complaint at 6 months. However, in their study of partial pulpotomy on mature permanent teeth with signs of irreversible pulpitis, they reported that four patients had persistent severe pain, leading to endodontic treatment after 3 months. This persistent pain may have been be due to irreversible inflammation of the root pulp following defective coronal restoration and bacterial infiltration. This lack of clinical reaction in the majority of patients undergoing total pulpotomy could be regarded as indicating treatment success; Kunert et al. reported that the most crucial factors for favorable outcomes of VPT are adequate sealing with bioactive material and coronal restoration. However, the lack of clinical reaction could also be related to silent necrosis or pulpal calcium degeneration, which can last for >6 months.
In the present study, the rate and intensity of postoperative pain were elevated significantly in patients males. The pain was not related significantly to the cavity site, pulpal exposure, or tooth type. These results are not consistent with those of Shafie et al., who reported no significant association of postoperative pain with patient sex or treated tooth type. Malekafzali et al. reported that tissue ulceration during pulpotomy is the main cause of postoperative pain, regardless of the pulpotomy material used.
The limitations of this study include the absence of a comparison group and the high rate of loss to follow-up. This loss to follow-up was likely because the majority of patients came for consultation only when they were in pain and did not find treatment continuation to be useful once their pain had been relieved. In addition, only patients' mobile phone numbers and not their addresses, were collected from their records; phones may be misplaced, and phone numbers may change. The recording of participants' home and work addresses and landline phone numbers likely would have reduced the rate of loss to follow-up.
To answer questions raised by these results, further comparative clinical studies of the effects of other materials on postoperative pain are needed.
| Conclusion|| |
Pulpotomy with Biodentine® appears to be appropriate for mature permanent teeth with acute irreversible pulpitis.
Conservative Dentistry and Endodontics Service, Department of Dentistry, Faculty of Medicine, Pharmacy and Odontology-Stomatology, Cheikh Anta Diop University of Dakar, Senegal.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Schmalz G, Smith AJ. Pulp development, repair, and regeneration: Challenges of the tran-sition from traditional dentistry to biologically based therapies. J Endod 2014;40:S2-5.
Wolters WJ, Duncan HF, Tomson PL, Karim IE, McKenna G, Dorri M, et al
. Minimally invasive endodontics: A new diagnostic system for assessing pulpitis and subsequent treatment needs. Int Endod J 2017;50:825-9.
Bansal P, Kapur S, Ajwani P. Effect of mineral trioxide aggregate as a direct pulp capping agent in cariously axposed permanent teeth. Saudi Endod J 2014;4:135-140. [Full text]
Glickman GN. AAE consensus conference on diagnostic terminology: Background and perspectives. J Endod 2009;35:1619-20.
McDougal RA, Delano EO, Caplan D, Sigurdsson A, Trope M. Success of an alternative for interim management of irreversible pulpitis. J Am Dent Assoc 2004;135:1707-12.
Eghbal MJ, Asgary S, Baglue RA, Parirokh M, Ghoddusi J. MTA pulpotomy of human permanent molars with irreversible pulpitis. Aust Endod J 2009;35:4-8.
Asgary S, Ehsani S. Permanent molar pulpotomy with a new endodontic cement: A case series. J Conserv Dent 2009;12:31-6.
] [Full text]
Nosrat A, Asgary S. Apexogenesis of a symptomatic molar with calcium enriched mixture. Int Endod J 2010;43:940-4.
Asgary S. Calcium-enriched mixture pulpotomy of a human permanent molar with irreversible pulpitis and condensing apical periodontitis. J Conserv Dent 2011;14:90-3.
] [Full text]
Awawdeh L, Hemaidat K, Al-Omari W. Higher maximal occlusal bite force in endodontically treated teeth versus vital contralateral counterparts. J Endod 2017;43:871-875.
Polycarpou N, Ng YL, Canavan D, Moles DR, Gulabivala K. Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing. Int Endod J 2005;38:169-78.
Taha NA, Abdulkhader SZ. Full pulpotomy with biodentine in symptomatic young permanent teeth with carious exposure. J Endod 2018;44:932-7.
Simon S, Perard M, Zanini M, Smith AJ, Charpentier E, Djole SX, et al
. Should pulp chamber pulpotomy be seen as a permanent treatment? Some preliminary thoughts. Int Endod J 2013;46:79-87.
Asgary S, Hassanizadeb R, Torabzadeb H, Egbbal MJ. Treatment outcomes of 4 pulp therapies in mature molars. J Endod 2018;44:529-35.
Parirokh M, Torabinejad M, Dummer PM. Mineral trioxide aggregate and other bioactive endodontic cements: An updated overview-part I: Vital pulp therapy. Int Endod J 2018;51:177-205.
Shafie L, Barghi H, Parirokh M, Ebrahimnejad H, Nakhae N, Esmaili S. Postoperative pain following pulpotomy of primary molars with two biomaterials: A randomized split mouth clinical trial. Iran Endod J 2017;12:10-4.
Bagheti M, Khimani H, Pishbin L, Shahabinejad H. Effect of pulpotomy procedures with mineral trioxyde aggregate and dexamethasone on post endodontic pain in patients with irreversible pulpitis: A randomized clinical trial. Eur Endod J 2019;4:69-74.
Taha NA, Abdelkhader SZ. Outcome of full pulpotomy using biodentine in adult patients with symptoms indicative of irreversible pulpitis. Int Endod J 2018;51:819-28.
Bane K, Charpentier E, Bronnec F, Descroix V, Gaye Ndiaye F, Kane AW et al
. Randomized clinical trial of intraosseous methyl prednisolone injection for acute pulpitis pain. J Endod 2016;42:2-7.
Bowles W, Withrow J, Lepinski A. Tissue levels of immune reactive substance P
are increased in patients with irreversible pulpitis. J Endod 2003;29:265-7.
Lin S, Levin L, Emodi O. Etodolac versus dexamethasone in reduction of post-operative symptoms following surgical endodontic treatment: A double-blind study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:814-7.
Torabinejad M, Cymerman JJ, Frankson M, Lemon RR, Maggio JD, Schilder H. Effectiveness of various medications on postoperative pain following complete instrumentation. J Endod 1994;20:345-54.
Keles S, Kocaturk O. Immediate postoperative pain and recovery time after pulpotomy performed under general anaesthesia in young children. Pain Res Manag 2017;2017:9781501.
Galani M, Tewari S, Sangwan P, Mittal S, Kumar V, Duban J. Comparative evaluation of post operative pain and success rate after pulpotomy and root canal treatment in cariously exposed mature permanent molars: A randomized controlled trial. J Endod 2017;43:1953-1962.
Taha NA, Khazali MA. Partial pulpotomy in mature permanent teeth with clinical signs indicative of irreversible pulpitis: A randomized clinical trial. J Endod 2017;43:1417-21.
Cooper PR, Takahashi Y, Graham LW, Simon S, Imazato S, Smith AJ. Inflammation-regeneration interplay in the dentine-pulp complex. J Dent 2010;38:687-97.
Descroix V, Boucher Y, Bronnec F. Prevention and preatment of postoperative pain in endodontics. Réal Clin 2011;22:269-76.
Shafie L, Esmaili S, Parirokh M, Pardakhti A, Nakhaee N, Abbott PV, et al
. Efficacy of pre-medication with ibuprofen on post-operative pain after pulpotomy in primary molars. Iran Endod J 2018;13:216-20.
Attar S, Bowles WR, Baisden MK, Hodges JS, McClanahan SB. Evaluation of pretreatment analgesia and endodontic treatment for postoperative endodontic pain. J Endod 2008;34:652-5.
Kunert GG, Kunert IR, da Costa Filho LC, de Figueiredo JA. Permanent teeth pulpotomy survival analysis: Retrospective follow-up. J Dent 2015;43:1125-31.
Malekafzali B, Shekarchi F, Asgary S. Treatment outcomes of pulpotomy in primary molars using two endodontic biomaterials A 2-year randomized clinical trial. Eur J Paediatr Dent 2011;12:189-93.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]