Clinical Research
Full Pulpotomy with Biodentine in Symptomatic
Young Permanent Teeth with Carious Exposure
Nessrin A. Taha, DClinDent, MFDS, FRACDS, FRACDS(Endo),
and Sakhaa Z. Abdulkhader, BDS, MClinDent
Abstract
Introduction: This prospective study evaluated the
outcome of Biodentine (Septodont, Saint Maur des
Fosses, France) pulpotomy in young permanent teeth
with carious exposure. Methods: Twenty permanent
molar teeth in 14 patients with carious pulp
exposure were treated with Biodentine pulpotomy.
The age of the patients ranged from 9–17 years
(12.3  2.7 years). A preoperative pulpal and periapical
diagnosis was established. After informed consent, the
tooth was anesthetized, isolated via a dental dam,
and disinfected with 5% sodium hypochlorite before
caries excavation. Full pulpotomy was performed by
amputating the exposed pulp to the level of the canal
orifices, hemostasis was achieved via a cotton pellet
moistened with 2.5% sodium hypochlorite, a 3-mm
layer of Biodentine was placed as the pulpotomy agent,
a Vitrebond liner (3M ESPE, St Paul, MN) was applied,
and the tooth was subsequently restored. Postoperative
periapical radiographs were taken after placement of
the permanent restoration. Clinical and radiographic
evaluation was completed after 6 months and 1 year
postoperatively. Pain levels were scored preoperatively
and 2 days after treatment. Statistical analysis was
performed using the Fisher exact test. Results: Clinical
signs and symptoms suggestive of irreversible pulpitis
were established in all teeth and symptomatic apical
periodontitis in 14 of 20 (70%). Two days after
treatment, all patients reported complete relief of
pain. All teeth were clinically successful at 6 months
and 1 year postoperatively. Radiographically, immature
roots showed continued root development; dentin
bridge formation was detected in 5 of 20 teeth. Seven
of 7 teeth with preoperative periapical rarefaction
showed signs of healing; 1 tooth had signs of internal
root resorption at 1 year with an overall success rate
of 95% (19/20). Conclusions: Young permanent teeth
with carious exposure can be treated successfully with
full pulpotomy using Biodentine, and clinical signs
and symptoms of irreversible pulpitis are not a
contraindication. (J Endod 2018;44:932–937)
From the Department of Conservative Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan.
Address requests for reprints to Dr Nessrin A. Taha, Department of Conservative Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, PO Box
3864, Irbid 22110, Jordan. E-mail address: n.taha@just.edu.jo
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.03.003
932 Taha and Abdulkhader
Key Words
Biodentine, deep caries, irreversible pulpitis, pulpotomy, young permanent teeth
T he current improved
understanding of pulp
tissue healing and regener-
Significance
Pulpotomy in carious young permanent teeth is
increasingly adopted. Clinical evaluation of new
ation together with the use
of biologically active end- calcium silicate–based materials is required for
evidence-based clinical practice.
odontic materials have
directed attention toward
preserving pulp vitality via minimally invasive endodontic techniques of vital pulp therapy
(VPT) (1, 2). According to the American Association of Endodontists Glossary of
Endodontic Terms, full pulpotomy involves the removal of the coronal portion of the
vital pulp as a means of preserving the vitality of the remaining radicular portion; it
may be performed as an emergency procedure for temporary relief of symptoms or as
a therapeutic measure that will require the application of a biocompatible capping
material.
The presence of spontaneous or severe preoperative pain does not always indicate
that the pulp is not capable of repair (3, 4), and deep carious lesions are not
unconditionally related to an irreversible pattern of pulpal injury (5, 6). Several
clinical studies reported a successful medium- to long-term outcome of VPT in
symptomatic permanent teeth with carious exposure, particularly young or immature
teeth, and recommended the procedure as an alternative to root canal therapy
(RCT) in vital teeth (7–9).
Currently, mineral trioxide aggregate (MTA) is considered the optimum material
for use in VPT of permanent teeth (10–12). However, some practitioners report
subjective difficulty in the handling and mixing of MTA in addition to reports of tooth
discoloration after its use, which results in patients’ dissatisfaction (13). Consequently,
newer calcium silicate–based materials that retain the desirable properties of original
MTA but with easier handling and without tooth discoloration have been introduced into
the market. Biodentine (Septodont, Saint Maur des Fosses, France) consists of a powder
and liquid; the powder contains tricalcium silicate, calcium carbonate, and zirconium
oxide as the radiopacifier (14). Biodentine has several advantages, including good
sealing ability, adequate compressive strength, a relatively short initial setting time
(ie, 12 minutes), and the promotion of reparative dentin formation with a positive effect
on vital pulp cells (14, 15).
Three recent clinical trials compared Biodentine with MTA in pulp capping of
carious exposures with a high success rate approaching 100% at the 1-year
follow-up in asymptomatic teeth of young patients (16, 17) and in mature teeth with
a clinical diagnosis of reversible pulpitis (18). Although the use of Biodentine in full
JOE — Volume 44, Number 6, June 2018

pulpotomy was limited to case reports in traumatized teeth (19), the
aim of this study was to prospectively evaluate the clinical and radio-
graphic outcome of full pulpotomy using Biodentine in young perma-
nent teeth with carious exposure and clinical signs and symptoms of
irreversible pulpitis.
Materials and Methods
Ethics approval was obtained from the institutional ethics and
research committee (13/95/2016). Children and adolescents referred
to the graduate endodontic clinic for management of symptomatic
permanent teeth with deep caries were included in the study. All patients
and guardians were informed of the risks and benefits of the procedure
and signed an informed consent form. Inclusion criteria included
patients with deep caries in a permanent molar tooth exposing the
pulp or extending $two thirds into the dentin on the periapical
radiograph, with complete or incomplete radicular growth and
preoperative symptoms suggestive of irreversible pulpitis defined as
spontaneous pain or pain exacerbated by cold stimuli and lasting for
a few seconds to several hours interpreted as lingering pain compared
with the control teeth (20) and that could be reproduced using cold
testing. A preoperative pulpal and periapical diagnosis was established
after clinical examination and cold testing (Endo-Ice; Hygenic Corp,
Akron, OH), and periapical radiographs were taken using film holders
(Dentsply Rinn, Elgin, IL) and the paralleling technique. The periapical
index was used to score cases with periapical rarefaction during
diagnosis and the follow-up periods (21). Numeric rating and visual
analog scale questionnaires were used to record pain intensity before
treatment.
After clinical and radiographic examination, the tooth was
anesthetized using articaine 4% with adrenaline 1/100,000 (Septodont,
Saint-Maur-des-Fosses Cedex, France), and, subsequently, it was
isolated using a dental dam. Then, the tooth surface was disinfected
with gauze soaked in 5% sodium hypochlorite (NaOCl) before caries
excavation. The cavity was prepared using a sterile high-speed fissure
bur under water coolant, caries was excavated using a large
low-speed round bur, and the cavity was rinsed with 2.5% NaOCl.
The exposed pulpal tissue was amputated with a high-speed diamond
bur to the level of the canal orifices. Bleeding from the canal orifices
was assessed, and hemostasis was achieved by the application of a
cotton pellet moistened with 2.5% NaOCl for 2 minutes with a dry pellet
on top and repeated if required up to 6 minutes; the bleeding time was
recorded. Subsequently, Biodentine was mixed according to the
manufacturer’s instructions and placed in a 3-mm layer above the
pulp tissue using an amalgam carrier and gently packed using a
condenser. After 12 minutes of waiting for the initial setting, a layer
of resin-modified glass ionomer liner (Vitrebond; 3M ESPE, St Paul,
MN) was applied, and the tooth was restored with glass ionomer cement
and a stainless steel crown, amalgam, or resin composite. Treatment
was performed under the supervision of a specialist endodontist by 1
graduate student who was calibrated by performing the treatment on
nonstudy participants for 1 year before the study, and stainless steel
crowns were placed at the pediatric graduate clinic within a week.
TABLE 1. Baseline Characteristics of Study Participants
Percussion Apical Root
Sex sensitivity rarefaction Caries maturity
Females 10 Yes 14 Yes 7 Primary 17 Mature 17
Males 10 No 6 No 13 Recurrent 3 Immature 3
Total 20 teeth
JOE — Volume 44, Number 6, June 2018
Clinical Research
A postoperative periapical radiograph was taken after permanent
restoration placement. Two days after pulpotomy, patients or guardians
were contacted by phone to record pain intensity.
The patients had clinical and radiographic evaluation after
6 months and 1 year postoperatively according to Zanini et al (22).
All teeth were examined clinically for any signs or symptoms of pathosis,
including pain experience, discomfort, soft tissue swelling, sinus tract,
probing pocket depth, integrity of the coronal restoration, coronal
discoloration through visual perception of the shade of the treated tooth
compared with adjacent teeth, and mobility. The case was considered
clinically successful if there was no history of spontaneous pain or
discomfort except during the first few days after treatment and there
was a functional tooth with no pain or discomfort on chewing or eating,
no tenderness to percussion or palpation, normal grade I mobility, and
normal soft tissues around the tooth with no swelling or sinus tract. The
case was considered radiographically successful if there was no
intraradicular pathosis, there was no internal resorption or root
resorption, the periapical index was <3 or there was a reduction in
the PAI score if rarefaction was present preoperatively, and there was
continuation of root development in immature roots. Radiographs
were also evaluated for the presence of dentin bridge formation
subjacent to the pulpotomy material.
Radiographs were evaluated under optimum viewing conditions by
an experienced endodontist at 2 separate occasions and by a specialist
in oral and maxillofacial radiology followed by conjoint reevaluation in
case of disagreement. The Cohen kappa coefficient of agreement index
was used to calculate intraobserver and interobserver reliability. The
quality of the coronal restoration was checked, and the restoration
was repaired if deemed necessary.
Data Analysis
The Fisher exact test was used to compare the outcome between
cases with different baseline characteristics; significance was set at
P < .05.
Results
Results of the Cohen kappa statistics showed good intraobserver
and interobserver agreement. The observers scored a range of
0.85–0.9 for reliability. The Fisher exact test did not show statistically
significant differences between the treated teeth with regard to sex,
periapical status, restoration type, and the number of missing walls.
Because only 1 treatment procedure was performed and all cases
were successful except 1, no regression analysis was appropriate at
these recall periods.
Fourteen patients with 20 teeth and age ranging from 9–17 years
(12.3  2.7) were included in the study. Baseline characteristics of the
study participants are included in Table 1. On presentation to the clinic,
5 of 20 (25%) of the patients reported severe spontaneous pain scoring
9 to 10 (on a scale of 0–10), and 100% had a history of severe lingering
pain after cold drinks, which was reproduced by cold testing. According
to the American Association of Endodontists diagnostic terminology, the
preoperative diagnosis of the treated teeth was symptomatic irreversible
Caries exposing No. of missing
pulp walls Restoration
Yes 16 One 7 Stainless steel crowns 7
No 4 Two 9 Amalgam 8
Three 4 Composite 5
Full Pulpotomy with Biodentine 933
Clinical Research
TABLE 2. A Summary of the Results at the Recall Periods
Number of cases/
Recall period Attending recall Outcome
6 months 20/20  100% clinical success
 100% radiographic success: rarefaction reduced in size in 5/7 and complete healing in 2/7 teeth
with preoperative rarefaction
 Root formation continued in 3/3 cases
 Dentin bridge formation in 5 cases
12 months 20/20  100% clinical success
 95% radiographic success: complete healing in 5/7 teeth with preoperative rarefaction, and
internal root resorption in 1 case
 Root formation complete in 3/3
 Dentin bridge formation in 5 cases

pulpitis and normal periapical tissues in 5 cases (case 2, 3, 4, 6, and 12)
and symptomatic apical periodontitis in the other 15 cases. In all cases,
hemostasis was achieved after 4 minutes. Two days after pulpotomy,
100% of the cases reported complete relief of pain with a score of 0;
none of the patients reported intake of analgesics after the procedure.
A summary of the results at the follow-up periods is presented in
Table 2. After 6 months, all cases were clinically successful, and the
periapical index improved in all cases with rarefaction, with 2 of 7
showing complete healing. After 1 year, 100% of the cases were
clinically successful; radiographic evidence of dentin bridge formation
was discernable in 5 of 20 (25%) cases (Figs. 1 and 2); 5 of 7 cases with
preoperative periapical rarefaction completely healed, and 2 cases
showed a reduction in the size of the lesion to localized widening of
the periodontal ligament (Figs. 3 and 4). One case showed evidence
of internal resorption at 1 year despite complete healing of the
preoperative periapical rarefaction. The case was considered a failure,
and RCT was advised; however, the parent opted for further follow-up
(Fig. 3). Canal narrowing was observed in 1 tooth. Crown discoloration
was not noted in any of the reviewed cases. All restorations were
functional except 1 stainless steel crown that required replacement
with a smaller size.
Discussion
The presence of deep caries is a common finding in children and
adolescents, and immature permanent molars may require complex
treatment at a young age (23, 24). Historically, cariously exposed
pulp was considered doomed pulp and was equivalent to irreversible
pulpal injury regardless of the presence of symptoms or not;
therefore, RCT was indicated. However, a less invasive approach is
being increasingly adopted in vital pulps including full pulpotomy.
Furthermore, it is becoming more widely accepted that the current
terminology of irreversible pulpitis, which is an empiric guess based
on clinical signs and symptoms, should be revised.
The ability of the clinician to assess the health of the remaining
pulpal tissue during the pulpotomy procedure is paramount. According
to Whitherspoon (10), the best method is to control pulpal
hemorrhage with NaOCl irrigation for up to 10 minutes. In all cases
treated in this study, hemostasis was achieved within 4 minutes of the
gentle application of a cotton pellet moistened with NaOCl, which
appears to be acceptable as reflected by the high success rate
(95%), possibly implying good clinical judgment of the probable
pulp status; however, no data are available yet regarding the optimum
time required.

Figure 1. The lower left first molar in a 9-year-old female patient with clinical symptoms of irreversible pulpitis and immature roots. (A) The preoperative
periapical radiograph (PA). (B) The postoperative PA after Biodentine pulpotomy. (C) The 6-month follow-up. (D) The 12-month follow-up showing continued
root development.

934 Taha and Abdulkhader JOE — Volume 44, Number 6, June 2018
 Clinical Research

Figure 2. The lower left first molar in a 15-year-old female patient with clinical symptoms of irreversible pulpitis and normal apical tissues. (A) The preoperative
PA. (B) The postoperative PA after Biodentine pulpotomy. (C) The 6-month follow-up. (D) The 12-month follow-up. The arrows in C and D indicate dentin bridge
formation.

Full pulpotomy has been performed in carious exposures in young
permanent teeth with signs and symptoms of irreversible pulpitis with a
high success rate using MTA (7, 25, 26). This is the first case series to
report on the use of Biodentine in symptomatic young permanent
molars; it included all patients who attended the endodontic graduate
clinic during a 6-month period and agreed to participate in the study.
The treatment was performed by a single graduate student following a
standard protocol under the supervision of an endodontist. The results
were comparable with those previously reported for MTA pulpotomy
(26, 27).
In addition to accurate clinical diagnosis, the selection of the pulp
capping material is a significant factor in the success of VPT. Factors like
the radiographic extension of the caries, initial or recurrent caries,
periapical rarefaction, or tenderness to percussion did not seem to
negatively influence the outcome of Biodentine pulpotomy at this recall
period. The biocompatibility of the material, sufficient bulk, and the
immediate establishment of a coronal seal under dental dam isolation
might have contributed to the high success rate. Canal narrowing was
evident in 1 tooth only at this recall period; therefore, there does not
seem to be any medium-term complications of the procedure that
may hinder routine RCT if required. However, because the exact
condition of the radicular pulp cannot be clinically assessed because
no response is expected to cold testing, if the radicular pulp is inflamed
beyond repair, the pulpotomy will eventually fail.

Figure 3. The lower right first molar in a 12-year-old male patient with clinical symptoms of irreversible pulpitis and asymptomatic apical periodontitis. (A) The
preoperative PA. (B) The postoperative PA after Biodentine pulpotomy. (C) The 6-month follow-up. (D) The 12-month follow-up showing healing of periapical
rarefaction but with localized areas of internal resorption (arrows).

JOE — Volume 44, Number 6, June 2018 Full Pulpotomy with Biodentine 935
Clinical Research
Figure 4. Radiographic images of the cases (1–6) with preoperative periapical rarefaction; A refers to preoperative or immediate postoperative PAs, and B refers
to follow-up radiographs at 12 to 18 months.
The patient’s age is a controversial matter in VPT. It has
been suggested that the more fibrous and less resistive character of
dental pulp in older patients may reduce the ability of the pulp to
overcome an insult. The rich blood supply and defense mechanism
of the pulp in young and immature permanent teeth may add a greater
resistance against bacterial infection and contribute to high success
rates (28). A dentin bridge was radiographically discernible in 25%
of the cases.
Establishing a periapical diagnosis in young teeth with a periapical
rarefaction is a challenge in terms of considering it as developmental or
pathological. Generally, if the root apex is still open and the rarefaction
is well corticated, then it is considered developmental. In this study,
pathologic rarefaction was present in 7 of 20 (35%) cases; all of
them showed signs of healing and improvement in the periapical index
score. Similarly, resolution of periapical rarefaction after pulpotomy
has been reported in several studies (7, 29), and it does not
represent a contraindication to VPT in the presence of vital pulp
tissue. The presence of periapical radiolucency in association with a
vital pulp is well-documented (30). Periapical inflammation precedes
total pulp necrosis and results from neurogenic inflammation
related to bacterial products extending into the periapical tissue causing
a complex interaction of inflammatory mediators, cytokines, and
neuropeptides from afferent fibers supplying the pulp and periapical
tissue.
The experience of pain associated with RCT is a major source of
fear for patients and a concern for dentists, particularly in cases
with preoperative symptoms (31). The short procedure of
pulpotomy compared with single-visit RCT or apexification,
complete relief of pain in a relatively short time, patients’
cooperation, and cost make the procedure more attractive for
both patients and the operator.
936 Taha and Abdulkhader
Conclusion
Full pulpotomy using Biodentine appears to have a high success
rate in young permanent teeth with carious exposure and could be
considered as an alternative to RCT in vital cases.
Acknowledgments
We would like to thank Emeritus Professor Harold Henry
Messer form Melbourne Dental School for his valuable input in
the project.
The study was supported by the deanship of research at Jordan
University of Science and Technology (grant no. 156/2016).
The authors deny any conflicts of interest related to this study.
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