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E. Mass, U. Zilberman: Long term radiological evaluation of the pulp after

partial pulpotomy in young permanent molars. Quintessence International.
2011 Jul-Aug;42(7):547-54.

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 Q u i n t e s s e n c e I n t e r n at i o n a l

Long-term radiologic pulp evaluation

after partial pulpotomy in young permanent molars
Eliyahu Mass, DMD1/Uri Zilberman, DMD, PhD2

Objective: Radiographic appearance of pulp reactions to partial pulpotomy in young per-

manent molars with deep caries may determine the efficiency of the procedure. The objec-
tive of this study was to determine the value of this procedure by analyzing the pulpal and
periapical appearance of permanent molars after long-term follow-up periods. Method
and Materials: Based on predetermined radiologic criteria, periapical radiographs of 49
young permanent molars of 31 females and 13 males, aged 6.9 to 17.7 years (mean, 11.4
years) treated with partial pulpotomy were evaluated and compared to their antimeres.
Follow-up time ranged from 7 to 154 months (mean, 49 months). Results: Based on clini-
cal and radiographic findings, the success rate was considered 93.9% (46 of 49 teeth).
Three teeth had chronic pulpitis with periapical exacerbation. In 14 (30.4%) of the 46
teeth, normal radiographic pulp appearance was found, and in 2 (4.3%), pulpal calcifica-
tions were similar to their antimere tooth. Dentinal bridges were observed underneath the
partial pulpotomy site in 27 molars (58.7%), while radiopacities in the pulpotomized pulp
horns of 5 teeth (10.9%) suggested development of obstructive calcifications. Increased
calcifications of the pulp were seen in 13 (28.3%) molars, in comparison with their anti-
meres. Six of the 46 molars with immature root development completed full apexogenesis.
No periapical pathoses, total pulp obliteration, or resorption were observed. Conclusion:
The long-term radiologic interpretation of the pulp after partial pulpotomy in young perma-
nent molars supports the clinical impression that it is a warranted treatment in well-chosen
cases. (Quintessence Int 2011;42:xxx–xxx)

Key words: deep caries, dental radiology, partial pulpotomy, pulp

Pulp exposure that occurs while excavat- with no evidence-based background.10 It

ing a deep caries lesion in a permanent
tooth has been considered an indication
for cervical pulpotomy or root canal treat-
ment.1,2 Partial pulpotomy, also referred to
as pulp curettage, was defined as remov-
ing only the superficial most inflamed pulp
tissue, mostly in the exposed pulp horn,
and dressing it with calcium hydroxide
or mineral trioxide aggregate (MTA).3–9 In
1959, Massler suggested this technique,
Director, Postgraduate Specialty Program in Pediatric Dentistry,
1
The Pediatric Dentistry Unit, Barzilai Medical Center, Ashkelon,
Israel; Senior Lecturer in Pediatric Dentistry (Emeritus), The
Maurice and Gabriela Goldschleger School of Dental Medicine,
Tel Aviv University, Tel Aviv, Israel.
2Head, The Pediatric Dentistry Unit, Barzilai Medical Center,
 radiographic examination
Ashkelon, Israel; Senior Lecturer in Pediatric Dentistry, Laboratory
of Bioanthropology and Ancient DNA, Faculty of Dental Medicine,
The Hebrew University, Hadassah, Jerusalem, Israel.
Correspondence: Dr Eliyahu Mass, The Barzilai Medical Center,
Hahistadrut 2, Ashkelon 78278, Israel. Email: elimas@post.tau.ac.il
has been demonstrated, by us and others,
that partial pulpotomy has a high clinical
success rate (91% to 93%) in young per-
manent molars3–9 and is suggested as an
alternative option for asymptomatic, cari-
ously exposed, young permanent molars
that fulfill the following criteria:
• No pain or pain of short duration that
subsided with analgesics
• No reaction to percussion, vestibular
swelling, or mobility
• No internal or external resorption or
pathologic changes in periodontal liga-
ment (PDL) or surrounding bone in the
• Pulp exposure during caries removal
not exceeding 1 to 2 mm in diameter,
with bleeding that stopped within 1 to 2
minutes4

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Q u i n t e s s e n c e I n t e r n at i o n a l
Mass/Zilberman
This treatment modality is conservative in
cases of pulp exposures while removing deep
caries lesions and has been recommended
mainly for children and young adults.4
The evaluation of success rates
treatment modalities of pulp exposure is
determined by clinical and radiographic
indications.3,6,11,12 These are (1) absence
of clinical symptoms (pain, tenderness to
percussion, swelling), (2) no radiographi-
cally detected interradicular, periapical,
or intrapulpal pathologies, and (3) normal
vital activity of the pulp (ie, continued root
development in immature teeth, occasional
presence of dentin bridge, and physiologic
narrowing of the pulp chamber and the root
canals).
The objective of this study was to ana-
lyze with radiologic criteria the radiographic
appearance of the pulp and the periapical
areas of young permanent molars treated
with partial pulpotomy during a 10-year
period.
Method and Materials
Long-term clinical and radiographic evalua-
tion was performed in 49 young permanent
molars that had been treated by partial
pulpotomy because of pulp exposure under
deep caries lesions. The treatment was per-
formed by the authors. The group consisted
of 31 females and 13 males, aged 6 years
9 months to 17 years 7 months (mean 11
years 4 months). In six young children (6
years 9 months to 8 years 1 month of age),
the root apices of the treated molars were
immature.
In cases in which exposure occurred
during removal of deep caries lesions,
partial pulpotomy was performed, care-
fully considering the aforementioned cri-
teria. Upon exposure, instead of referring
the patients for root canal treatment, the
patients’ parents gave their informed con-
sent for the proposed treatment modal-
ity and follow-up procedures, based on
accepted guidelines at that time. These
guidelines included periodical clinical and
radiographic examinations of treated teeth
and their antimeres.13
2 VOLUME 42  •  NUMBER 7  •  JULY/AUGUST 2011
The clinical treatment modality was
described previously.3 The exposed site
was penetrated using a sterile 330 tungsten
carbide bur to a depth of 2 mm to remove
of the most affected pulp tissue. The site was
rinsed for 2 to 3 minutes using normal saline
until bleeding stopped. The wound was
dressed with a calcium hydroxide paste,
prepared on site from calcium hydroxide
powder and sterile saline. This was covered
by reinforced ZnoEu paste (IRM) or glass-
ionomer cement (Vitrebond, 3M ESPE). The
final restoration was performed immediately
and included amalgam in 33 teeth (67.4%),
composite in three teeth (6.1%), and stain-
less steel crowns in 13 teeth (26.5%).
Postoperative periapical radiographs of the
teeth and their antimeres were performed
for follow-up evaluation. Follow-up radio-
graphs were taken every 6 months in the
first year and every 12 months thereafter, in
addition to clinical assessments during rou-
tine recall examinations. Follow-up exami-
nations were carried out by the authors
every 6 months in the first year and every 12
months thereafter. The follow-up examina-
tions included sensitivity, percussion, and
mobility tests.
Predetermined radiologic criteria were
used to compare the final follow-up peri-
apical radiograph of each treated tooth to
that of its antimere, which was obtained at
the same follow-up appointment. This was
performed by the same person, to deter-
mine whether the treated tooth showed any
averse pulp conditions compared to the
tooth from the opposite side, which was not
treated by partial pulpotomy.
Radiologic criteria included normal pulp
(physiologic and radiologic changes in the
pulp chamber and canals), pulp calcifica-
tions similar to the antimere teeth, presence
of dentinal bridge underneath the amputa-
tion site, pulp horn obliteration, increased
pulp calcifications compared to the anti-
mere teeth, and apexogenesis in immature
teeth.
Each examiner determined the pulp
status from the radiographs twice, 2 weeks
apart, and established a diagnosis of each
case. The examiners agreed upon the
pulp status in 95.5% of cases. In cases
of disagreement, there was a consilium
among the examiners until consensus was

Table 1 Distribution of radiographic
follow-up examination time of
49 molars treated by partial
pulpotomy
Time (mo) Females Males Total
7–12 2 1 3 Pulp calcifications as in antimere tooth
12–24 6 (2) 2 6 (2)
24–48 11 7 (1) 17 (1)
> 48 14 6 20
Total 33 16 46 (3)
No. in parentheses represents failures within that group.
reached. To compare the difference in the
evaluated criteria between sexes, the statis-
tical analysis of the results in each category
was performed using nonparametric tables
of 2 × 2, where the percentages of each
radiographic situation of the pulp at the end
of the follow-up period was computed with
regard to sex.
Results
The distribution of clinical and radiograph-
ic follow-up examinations is presented in
Table 1. Of the 49 treated teeth, three
patients reported spontaneous pain and
were consequently treated by conventional
root canal treatment. The final restorations
of the failures were amalgam in two cases
and composite in one case. The success
rate of partial pulpotomy in our group is
93.9% (46 of 49 teeth).
The 46 permanent molars (30 mandibu-
lar first, 13 maxillary first, two mandibular
second, and one maxillary second) test-
ed normally to percussion, palpation, and
temperature and were therefore suitable
for radiologic long-term evaluation. Mean
follow-up for the 46 teeth was 49 months
(12 to 154 months). The results of the radio-
logic evaluation are presented in Table 2.
Significant differences were found between
males and females in dentinal bridge forma-
tion and pulp horn obliterations (P < .5). It
VOLUME 42  •  NUMBER 7  •  JULY/AUGUST 2011
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Mass/Zilberman
Table 2 Radiographic evaluation of pulp and periapical
conditions after partial pulpotomy in 46 young
permanent molars
Condition Males Females Total
Normal pulp 5 9 14
0 2 2
Dentinal bridge 7 20 27
Pulp horn obliteration 1 4 5
Increased pulp calcifications 4 9 13
Apexogenesis 3 3 6
Each tooth may have more than one status description.
should be noted that a treated tooth may
present more than one radiologic feature,
ie, a dentinal bridge and pulp calcifications.
No radiographic periapical pathologic find-
ings were observed during the follow-up
period.
Of the 46 radiographically examined
molars, 14 (30.4%) showed normal pulp
with physiologic changes (normal apposi-
tion of secondary dentin) similar to the
antimere tooth (Figs 1 and 2). In two molars
(4.3%), mild calcifications in the pulp cham-
ber, similar to that in their antimere, were
detected (Fig 3). A dentinal bridge was
radiologically depicted (Fig 4) underneath
the partial pulpotomy site in 27 molars
(58.7%). Pulp horn obliteration (Fig 5) was
found in five molars (10.9%). Increased
pulp calcifications in comparison with the
antimeres (Fig 6) were observed in 13
molars (28.3%). Apexogenesis occurred in
all six molars with open apices (Fig 4).
Discussion
The step-wise technique is frequently rec-
ommended as the treatment of choice in
teeth with deep caries lesions. Using these
new methods and capping materials with
better rehabilitation properties for the den-
tin, pulp exposure becomes rare. Yet, in
cases in which the inflammatory process
affects the pulp at the interface of the car-
3
Q u i n t e s s e n c e I n t e r n at i o n a l
Mass/Zilberman
Fig 1a  Mandibular right first molar in a 9-year,
11-month-old boy with extensive caries on the mesial
aspect.
Fig 2a   Mandibular right first molar. Partial pulp-
otomy after 87 months. Same patient as Fig 1.
Fig 3a    Maxillary right first molar. Partial pulpotomy
after 61 months. Note the calcifications in the pulp.
ies process and an exposure of the pulp
occurs, partial pulpotomy is a promising
conservative method of treatment.
Radiographic examinations and clini-
cal testing are noninvasive methods for
evaluating the success rate of a dental
treatment modality in humans. These
are judged mostly by the evaluator and
4 VOLUME 42  •  NUMBER 7  •  JULY/AUGUST 2011
Fig 1b  Antimere tooth at the beginning of
treatment.
Fig 2b    Antimere tooth after 87 months. Note simi-
lar pulp conditions in both molars.
Fig 3b    Maxillary left first molar. Note similar calci-
fications as in Fig 3a.
are influenced by subjective evaluation.
Previous reports14,15 showed that the use of
predetermined specific radiologic criteria
led to improved diagnosis of pulpal and
periapical pathoses. In the present study,
two investigators evaluated the radiologic
appearance of the pulp cavity, and the peri-
apical areas of young permanent molars
 Q u i n t e s s e n c e I n t e r n at i o n a l
Mass/Zilberman

a b

Fig 4   (a) Mandibular right first molar in 7-year,

9-month-old girl immediately after partial pulp-
otomy. Note the open apices. (b) Mandibular right
first molar after 58 months. Note apexogenesis and
dentin bridge formation. (c) Antimere tooth after 58
months.

a b

Fig 5    (a) Mandibular right first molar in an 8-year-

old girl. Note the high mesial pulp horn and carious
attack. (b) Sixty-nine months after partial pulpotomy.
Note the obliteration of the mesial pulp horn. (c)
Antimere tooth after 69 months. Note the high
mesial pulp horn.

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Q u i n t e s s e n c e I n t e r n at i o n a l
Mass/Zilberman
Fig 6a  Mandibular right first molar in 11-year,
6-month-old girl 71 months after partial pulpotomy.
Note calcifications in the pulp.
Fig 7  Hypomineralized mandibular right first
molar in a 10-year, 8-month-old girl, which failed
after 17 months.
that were treated by partial pulpotomy
according to well-defined, predetermined
criteria. Determination of a healthy pulp
was based on clinical and radiographic
findings.
Three cases failed. Conservative treat-
ment of exposed pulps may result in pro-
longed uneventful periods, while the pulp
is slowly deteriorating. This was clearly
demonstrated in these cases. Thus, it is
postulated that the transition from chronic
partial pulpitis to total chronic pulpitis with
periapical inflammation and clinical symp-
toms may progress up to 27 months after
partial pulpotomy. Indeed, it is important
to point out that two of the three molars
that showed pulp pathoses requiring root
canal treatment were diagnosed as severe-
ly hypomineralized at the first meeting and
were missing their fillings upon recall (Figs
7 and 8). Fagrell et al16 reported bacterial
invasion into the dentinal pulps in severely
6 VOLUME 42  •  NUMBER 7  •  JULY/AUGUST 2011
Fig 6b    Antimere tooth after 71 months with nor-
mal pulp.
Fig 8    Hypomineralized mandibular right first molar
in a 9-year-old boy, which failed after 21 months.
hypomineralized molars. This invasion can
cause chronic diffuse pulpitis, which may
affect the healing process following partial
pulpotomy.16 In partial pulpotomy, the ratio-
nale for healing is that the chronic pulpitis
is confined beneath the exposure site, while
the remaining pulp is relatively healthy with
regeneration abilities, especially in young
permanent pulps.17
A dentinal bridge under a pulpotomy
can be demonstrated radiographically as
early as 4 weeks postoperatively.18–20 It has
been reported that this bridge, which was
generally considered a favorable response
to conservative pulp therapy, is sometimes
associated with a slow development of
pulp necrosis. Therefore, it was no lon-
ger considered exclusive evidence of suc-
cess.21 On the other hand, the presence
of a dentinal bridge together with other
vital signs support the conclusion that the
pulp condition is healthy, leading to physi-

ologic dentin apposition. The finding that
females showed statistically significantly
more dentinal bridge formation and pulp
horn obliteration under partial pulpotomy
may indicate that calcium hydroxide dress-
ing placed directly on vital pulp in females
influences odontoblasts activity more than
in males. In this study, a dentinal bridge
and pulp horn obliteration were found in
almost 70% of teeth, compared to 55% to
64% in other publications in humans8 or
baboons.9 The absence of a dentinal bridge
in the remaining teeth does not necessarily
indicate failure.
Physiologic pulp calcifications may be
detected during childhood and adoles-
cence with or without conservative pulp
treatment. The determination of whether
pulp calcifications are physiologic is made
by comparing the radiograph of a treat-
ed tooth with its antimere. In this study,
increased pulp calcifications were found
in 13 teeth. Similar pulp calcifications were
observed in two cases. In these cases,
deep caries lesions were also observed in
the antimere tooth and may be the trigger
for this finding.
Apexogenesis is an important goal in
partial pulpotomy of immature permanent
teeth. It is a positive indication of suc-
cess, although it occasionally occurs at the
apex while the inflammatory process may
progress slowly from the pulp chamber to
the root pulp. From the coronary part, this
inflammatory process may then reach the
apex after the root has matured. In these
cases, root canal treatment can be carried
out at this later stage with improved poten-
tial for success rates.
It is important to point out that total pulp
obliteration did not occur in any of the teeth
treated with partial pulpotomy. In cervical
pulpotomy, total pulp obliteration is com-
mon, 22
and this condition may complicate
root canal treatment.
The results of this study and previously
published studies1,3–5,8,9,23 emphasizes the
advantages of partial pulpotomy in cases
of unintentionally exposed pulps of deeply
cariously affected young permanent molars
over immediate root canal treatment. The
radiologic evaluation of pulp reactions to
partial pulpotomy indicates that it gener-
ally encourages pulp rehabilitation and
VOLUME 42  •  NUMBER 7  •  JULY/AUGUST 2011
Q u i n t e s s e n c e I n t e r n at i o n a l
Mass/Zilberman
physiologic apexogenesis. When failure of
diagnosing pulp pathoses occurs due to
objective reasons, postponing the need
of root canal treatment without clinical or
pathologic consequences is sometimes an
advantage in young children. Although the
follow-up period varies from up to 1 year in
only three cases and more than 2 years in
most cases (37 of 49 teeth), the observed
pulp conditions beneath partial pulpotomy
procedures showed that the pulp tissue
reacts favorably to the treatment. Based
on the findings in this study, the method of
partial pulpotomy, preserving pulp vitality,
can be accepted clinically in treating young
molars with vital pulp exposure.
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