Preserving coronal pulp tissue in mature permanent teeth has emerged as a cornerstone of modern minimally invasive endodontics. Historically, clinicians treated extensive dental caries involving the pulp with full pulpectomy and root canal therapy. However, recent advancements in bioactive materials allow clinicians to maintain tissue vitality predictably. A rigorous randomized clinical trial recently evaluated the two-year efficacy of partial pulpotomy in mature mandibular molars with deep carious lesions. This landmark study compared traditional White MTA Angelus against a modern premixed calcium silicate putty, NeoPutty. Ultimately, the investigation provided compelling evidence supporting vital pulp preservation across diverse pulpal inflammatory states.

Comparative Success Rates of Partial Pulpotomy Using MTA and NeoPutty

The randomized trial enrolled 139 mature mandibular permanent molars in adult patients exhibiting deep carious lesions near the pulp. Specifically, the lesions were located within 0 to 1.5 millimetres from the pulp on initial radiographic examination. The investigators randomly assigned teeth to undergo partial pulpotomy using either White MTA Angelus or NeoPutty. Remarkably, all 139 treated teeth completed the full 24-month clinical and radiographic follow-up, achieving a flawless 100% recall rate.

At two years, White MTA Angelus achieved an impressive success rate of 90.6%. Meanwhile, NeoPutty produced a comparable success rate of 92.0%. Statistical analysis revealed no significant difference between the two biomaterials, demonstrating an overall clinical success rate of 91.4%. Both groups showed sustained tooth vitality, complete absence of periapical radiolucency, and rapid resolution of clinical symptoms. Consequently, dental practitioners can confidently employ either biomaterial for coronal vital pulp procedures. Furthermore, these high long-term success figures reinforce vital pulp therapy as a definitive, biologically sound alternative to invasive pulpectomy in mature adult permanent molars.

The Crucial Role of Intraoperative Haemostasis Time

Although both biomaterials performed exceptionally well, multivariable analysis revealed that intraoperative haemostasis time served as a critical prognostic determinant. In fact, bleeding control time was significantly associated with treatment success. The trial demonstrated an odds ratio of 0.623 for each additional minute required to achieve complete haemostasis. Therefore, extended bleeding intervals significantly lowered the statistical probability of long-term biological success.

Clinicians must recognize that prolonged bleeding reflects severe coronal microvascular hyperaemia and deeper inflammatory infiltration within the pulp architecture. When clinicians achieve rapid haemostasis within three to five minutes, coronal pulp tissue generally retains superior reparative and regenerative capacity. Conversely, persistent haemorrhage indicates that extensive inflammation extends beyond the superficial coronal amputation site. Under such circumstances, the practitioner should promptly consider deeper tissue excision, such as cervical pulpotomy or complete pulpectomy. Thus, careful intraoperative timing provides an objective biological barometer of underlying pulpal health that clearly transcends subjective thermal sensibility assessments.

Challenging the Wolters Classification of Pulpitis

Traditionally, endodontic diagnostic systems categorize pulpitis into rigid reversible and irreversible stages. To refine this classification, Wolters and colleagues proposed a nuanced four-tier diagnostic spectrum comprising initial, mild, moderate, and severe pulpitis. In the present trial, investigators evaluated whether these preoperative diagnostic tiers accurately predicted clinical success following coronal vital therapy.

Surprisingly, multivariable statistical regression revealed that preoperative pulpal diagnosis according to the Wolters classification was not significantly associated with treatment outcomes. Teeth presenting with severe pulpitis achieved success rates fully comparable to teeth displaying mild or moderate pulpal symptoms. Therefore, clinical symptoms alone cannot reliably depict true histopathological boundaries within coronal pulp tissue. Even when patients present with severe thermal lingering pain, extensive healthy pulp tissue frequently survives beneath localized bacterial microabscesses. Consequently, clinicians should not automatically condemn mature teeth to radical root canal treatment based purely on severe preoperative pain symptoms. Instead, dentists should assess direct tissue response and bleeding control after gentle surgical excavation.

Biomaterial Characteristics and Pulpal Healing Mechanics

Both White MTA Angelus and NeoPutty exhibit exceptional biocompatibility and sealability, which explains their equivalent 24-month clinical performance. Mineral trioxide aggregate creates a high alkaline microenvironment through calcium hydroxide release during hydration. This high pH stimulates adjacent mesenchymal stem cells, promotes hard-tissue dentine bridging, and exerts potent antimicrobial effects. However, traditional powder-liquid MTA formulations require manual mixing and present challenging handling properties in small access cavities.

In contrast, NeoPutty is a premixed, ready-to-use calcium silicate-based bioceramic putty. Because manufacturers formulate it with non-aqueous vehicle liquids, the material resists intraoperative washout and requires zero chairside preparation. Additionally, it eliminates the risk of incorrect powder-to-liquid mixing ratios, thereby standardizing physical properties and dimensional stability. Furthermore, its pliable consistency allows clinicians to condense the putty precisely against severed pulp stumps without causing excessive mechanical compression. Both materials foster biological dentine bridge formation while sealing the pulp chamber against coronal bacterial microleakage effectively.

Translating Clinical Evidence into Routine Dental Practice

The results from this 24-month clinical trial provide actionable guidance for general dentists and endodontists treating mature permanent molars. First, practitioners should implement strict aseptic operating conditions, including compulsory rubber dam isolation and magnification. Disinfecting the operatory field with sodium hypochlorite ensures that clinicians do not introduce superficial microbes into exposed pulp tissues.

Second, practitioners must standardize their protocol for measuring intraoperative haemostasis. Applying cotton pellets moistened with sterile saline or diluted sodium hypochlorite under light pressure facilitates controlled haemostasis. If haemorrhage ceases within five minutes, the clinician can safely place MTA or premixed calcium silicate putty. Furthermore, placing an immediate, well-bonded composite or coronal restoration is paramount to prevent subsequent microleakage. As this trial demonstrates, achieving an immediate coronal seal protects the healing pulp and guarantees enduring therapeutic success. In conclusion, adopting minimally invasive vital pulp protocols preserves natural dentition while reducing treatment costs and procedural complications for adult patients.

Frequently Asked Questions

Can partial pulpotomy successfully treat mature permanent teeth with severe pulpitis?

Yes, clinical evidence confirms that partial pulpotomy achieves high success rates exceeding 90% in mature teeth with severe pulpitis. Historically, clinicians assumed severe pain mandated complete pulpectomy. However, pulpal inflammation often remains localized directly beneath the carious defect. When clinicians excise this inflamed superficial coronal tissue and achieve haemostasis, the residual pulp tissue heals effectively under biocompatible calcium silicate materials.

Why is intraoperative haemostasis time more predictive than preoperative clinical symptoms?

Intraoperative haemostasis time serves as a direct biological indicator of real-time vascular inflammation within the pulp tissue. Preoperative symptoms poorly correlate with true histological tissue status because pain thresholds vary widely among individuals. Conversely, prolonged haemorrhage directly reflects severe, irreversible microvascular damage. Therefore, the ability to control bleeding within several minutes reliably confirms that remaining apical and radicular pulp tissue possesses robust healing capacity.

What advantages do premixed calcium silicate putties offer over traditional mineral trioxide aggregate?

Premixed calcium silicate putties such as NeoPutty offer superior handling, immediate consistency, and washout resistance compared to traditional powder-liquid MTA formulations. Clinicians do not need to mix powders chairside, which prevents improper powder-liquid proportions and saves valuable clinical time. Furthermore, premixed putties provide excellent radiopacity, dimensional stability, and bioactivity without causing coronal tooth discolouration, ensuring predictable clinical execution during vital pulp therapy.

Disclaimer: This content is for informational and educational purposes only, and should not be taken as professional medical advice. It is not intended to diagnose, treat, cure, or prevent any condition. Refer to the latest local and national guidelines for clinical practice.

References

1. Serrano A et al. Two-Year Outcome of Partial Pulpotomy Using Mineral Trioxide Aggregate or a Premixed Calcium Silicate Cement: A Randomized Clinical Trial. Int Endod J. 2026 Sep 18. doi: 10.1111/iej.70274. PMID: 42755412.
2. Wolters WJ, Duncan HF, Tomson PL, et al. Minimally invasive endodontics: a new diagnostic system for assessing pulpitis and subsequent treatment choices. Int Endod J. 2017;50(9):827-837.
3. Careddu R, Duncan HF. A prospective clinical study investigating the success of partial pulpotomy in permanent teeth using Wolters' diagnostic criteria. Int Endod J. 2021;54(8):1260-1272.
4. AAE Position Statement on Vital Pulp Therapy. American Association of Endodontists. 2021.