Fraser Jacqueline, Webster Scott
Department of Oral and Maxillofacial Surgery, Queen Elizabeth University Hospital, Glasgow, UK.
Evid Based Dent. 2024 Jun;25(2):102-103. doi: 10.1038/s41432-024-01008-4. Epub 2024 May 7.
Retrospective cohort study using STROBE cohort reporting guidelines.
Patients from Mehr Dental Clinic in Tehran, Iran, who received different types of vital pulp therapy (VPT) by a single endodontist, due to carious pulpal exposure, between April 2011 and October 2022. These were: Full Pulpotomy (FP), Miniature Pulpotomy (MP) and Direct Pulp Capping (DPC). Data were accessed via the dental clinic's electronic database. Patients were deemed eligible if they had pulpal exposure due to caries, but not trauma. Pre-operative, immediate post-operative and at least one follow-up radiograph at a minimum 3-month interval were required. Demographic, diagnostic, and procedural data as well as informed consent were also required. Teeth with probing depths greater than 4 mm or pulpal necrosis were excluded.
Patient, tooth and treatment factors were statistically analysed for an outcome of success or failure using a Cox proportional hazards model. Kaplan/Meier curves were used to establish the mean survival times. The Log-rank test was used to compare survival across the three treatment groups. The Omnibus test of model and the -2 log likelihood ratio (-2LL) were used to assess sensitivity and model fitness. Statistical analyses were determined using the IBM SPSS Statistics for Windows Version 21.0, with P value set at <0.05.
1257 VPTs from 1149 patients had complete data and were used in the analysis. 802 cases were excluded due to no follow up radiograph. The VPT cases were divided into FP (n = 272), MP (n = 217) and DPC (n = 768). The average follow up was 42.21 months, with an overall 116-month survival rate of 99.1% and success rate of 91.6%. FP had a mean survival time of 99.43 months; for MP it was 104.26 months; for DPC it was 102.27 months. There were no significant differences between these groups (P = 0.363). There were statistically significant correlations between symptomatic Irreversible Periodontitis (IP), radiographic signs of Apical Periodontitis (AP), restoration type, restoration surfaces and the outcome of VPT.
This is one of the largest cohort studies of its kind, with over 1250 cases of various VPT techniques in 10 years. There was deviation from gold standard practice, with lack of rubber dam. A lack of haemostasis after 2 min could be construed as bacterially infected pulpal tissue and require further resection of pulp. Yet, these approaches still resulted in successful outcomes. Another interesting finding was that symptomatic IP with associated AP was treated with VPT, with a 78% success rate. Considering this study and other emerging evidence in the literature, application of VPT as an alternative to conventional Root Canal Treatment could be adopted in general practice, depending on the skills and knowledge of the practitioner and patient preferences.
采用STROBE队列报告指南的回顾性队列研究。
2011年4月至2022年10月期间，伊朗德黑兰Mehr牙科诊所因龋源性牙髓暴露而由同一位牙髓病医生进行不同类型活髓治疗（VPT）的患者。这些治疗包括：完全牙髓切断术（FP）、微型牙髓切断术（MP）和直接盖髓术（DPC）。数据通过牙科诊所的电子数据库获取。因龋导致牙髓暴露但无创伤的患者被视为符合条件。需要术前、术后即刻以及至少每隔3个月进行一次的至少一张随访X光片。还需要人口统计学、诊断和治疗数据以及知情同意书。探诊深度大于4毫米或牙髓坏死的牙齿被排除。
使用Cox比例风险模型对患者、牙齿和治疗因素进行统计学分析，以确定成功或失败的结果。采用Kaplan/Meier曲线确定平均生存时间。使用对数秩检验比较三个治疗组的生存率。使用模型综合检验和-2对数似然比（-2LL）评估敏感性和模型拟合度。使用IBM SPSS Statistics for Windows Version 21.0进行统计分析，P值设定为<0.05。
1149例患者的1257次VPT治疗有完整数据并用于分析。802例因无随访X光片而被排除。VPT病例分为FP组（n = 272）、MP组（n = 217）和DPC组（n = 768）。平均随访时间为42.21个月，总体116个月生存率为99.1%，成功率为91.6%。FP的平均生存时间为99.43个月；MP为104.26个月；DPC为102.27个月。这些组之间无显著差异（P = 0.363）。症状性不可逆性牙周炎（IP）、根尖周炎（AP）的影像学表现、修复类型、修复面与VPT的结果之间存在统计学显著相关性。
这是同类研究中规模最大的队列研究之一，10年内有超过1250例各种VPT技术的病例。存在与金标准操作的偏差，缺少橡皮障。2分钟后仍有出血可被视为牙髓组织细菌感染，需要进一步切除牙髓。然而，这些方法仍取得了成功的结果。另一个有趣的发现是，伴有AP的症状性IP采用VPT治疗，成功率为78%。考虑到本研究及文献中的其他新证据，并根据从业者的技能和知识以及患者偏好，VPT作为传统根管治疗的替代方法可在一般临床实践中采用。
