Chitosan or Platelet-Rich Fibrin: What Success for Pulpotomy?

Irreversible pulpitis: towards selective and biological pulp amputation

When faced with irreversible pulpitis in a mature molar, radical endodontic treatment is no longer the only option. Histological data suggest that inflammation is often confined to the coronal pulp, leaving the radicular tissue viable and capable of healing if the bacterial load is controlled. This randomized clinical study is based on this premise of vital pulp therapy (VPT) and the "EndoLight" concept.

The primary objective was to compare the clinical and radiographic efficacy of two surgical approaches — coronal pulpotomy and partial pulpotomy — combined with the use of two types of bioactive scaffolds: chitosan and platelet-rich fibrin (PRF). The study specifically targeted mature permanent molars presenting with symptomatic irreversible pulpitis, including cases with early apical periodontitis.

Beyond the depth of pulp removal, the authors test the hypothesis that sealing with Biodentine coupled with these regenerative materials promotes predictable survival of the dental organ. For the practitioner, the challenge is to determine whether a deeper amputation (3 to 4 mm below the canal orifices) or the choice of a specific biomaterial improves the prognosis compared to a classic coronal approach, thus avoiding systematic recourse to root canal treatment.

Experimental design and sampling

This randomized parallel-group clinical trial was conducted on 68 patients aged 15 to 35 years (initially divided into 4 groups of 17). The study focused on mature permanent molars presenting with symptomatic irreversible pulpitis, with or without associated apical periodontitis. Inclusion criteria required spontaneous pain, a prolonged response to thermal testing, and hemostasis achieved in less than 5 minutes following pulp amputation.

Surgical protocol and experimental groups

After local anesthesia (2% lignocaine, 1:80,000 epinephrine) and isolation, the cavities were decontaminated with 5.25% NaOCl. Hemostasis was achieved with 3% NaOCl. Four therapeutic modalities were compared:

• Coronal pulpotomy (CP) + Chitosan: Amputation at the orifice level, application of chitosan (2 mm).
• PC + PRF: Identical amputation, application of autologous PRF (centrifuged at 3000 rpm for 10 min).
• Partial pulpotomy (PP) + Chitosan: Removal of 3 to 4 mm of radicular pulp, application of chitosan.
• PRP + PRF: PRP procedure with PRF application in the canal orifices.

In all cases, a 3 to 4 mm layer of Biodentine was applied before the final restoration (GIC and composite).

Evaluation and analyses

Pain was measured using the VAS scale (D1, D7, D30). Radiographic follow-up included periapical radiographs (3, 6, and 12 months) and a CBCT at 12 months to evaluate periapical indices (PAI) and root canal calcifications. Data were processed using Mann–Whitney U and Fisher tests, and the Kaplan–Meier method for survival.

Analysis of clinical and radiographic performance

Of the 68 participants initially included (divided into 17 per group), 50 patients completed the total 12-month follow-up. The study reports 10 lost to follow-up and 8 clinical failures. The analyzed data focus on the results at 3, 6, and 12 months.

Pain assessment and periapical healing

• Pain (VAS): No statistically significant difference was observed between the four groups, regardless of the follow-up interval (1, 7, and 30 days). However, the authors note a progressive decrease in mean pain scores in all groups over time.
• Periapical Index (PAI): Radiographic evaluation (IOPA and CBCT) shows a progressive reduction in PAI scores. A statistically significant intergroup difference was noted only at the 3-month follow-up; results at other time points remained statistically non-significant.
• Calcification: The incidence of canal calcifications increased gradually during the follow-up period across all groups, with no significant statistical variation between them.

Survival rates and intergroup comparisons

The overall survival rate reported by the study is 88.2%. Although survival rates are statistically comparable across all groups, the numerical data indicate variations depending on the depth of the amputation and the material used:

These results suggest that partial cervical pulpotomy, by allowing a deeper removal of potentially inflamed tissue (3 to 4 mm below the orifice), could promote better haemostasis control and slightly higher survival, particularly when combined with PRF.

Clinical analysis: pulp vitality beyond dogma

The results of this randomized clinical trial challenge the binary vision of endodontic treatment. With an overall survival rate of 88.2% at 12 months, the study validates the EndoLight concept: inflammation in cases of irreversible pulpitis often remains localized to the cameral pulp. For the practitioner, this means that preserving the radicular pulp is not only possible but predictable, even in the presence of early apical periodontitis.

The clinical advantage appears to favor partial root pulpotomy (Groups 3 and 4), which shows superior survival trends, peaking at 94.1% for the PRF group. This effectiveness is explained by the deeper excision (3 to 4 mm below the orifices) of potentially infected tissues, facilitating better hemostasis control compared to the simple cameral technique. The use of PRF, through its richness in growth factors, and chitosan, for its antimicrobial properties, provides a robust biological support to Biodentine.

The downside? A modest sample size (n=17 per group initially) and a follow-up limited to one year. While these results corroborate the observations of Shah or Baranwal cited in the study, they dictate absolute rigor in the disinfection protocol and the choice of bioactive materials to guarantee the coronal seal.

Summary of results

This randomized study conducted on 50 mature molars demonstrates the clinical equivalence of the protocols: no statistical difference was observed between cameral and partial pulpotomy, nor between the use of PRF and Chitosan. With an overall survival rate of 88.2% at 12 months (8 failures out of 58 patients who completed follow-up), the results confirm that pulp preservation is a predictable alternative to conventional endodontic treatment, even in the presence of irreversible pulpitis.

In concrete terms, for the practitioner:

• Validate haemostasis: If bleeding is controlled in less than 5 minutes (cotton soaked in 3% NaOCl), pulp vitality can be successfully preserved.
• Adapt the depth: In case of persistent bleeding at the canal entrance, a partial root pulpotomy (excision of 3 to 4 mm) offers success rates statistically identical to cameral pulpotomy.
• Freedom on the scaffold: PRF and Chitosan prove to be equally effective under a Biodentine base for stimulating healing and reparative dentin formation.

Technical lexicon of the study

Vital Pulp Therapy (VPT): Biological therapeutic approach aimed at preserving the vitality of the dental pulp tissue as a conservative alternative to conventional root canal treatment.

Partial radicular pulpotomy: Surgical procedure consisting of removing the coronal pulp as well as a 3 to 4 mm section of the radicular pulp below the canal orifices to eliminate inflamed tissues.

Chitosan: Bioactive scaffold used here in powder form mixed with propylene glycol, selected for its antimicrobial and haemostatic properties and its biocompatibility.

Platelet-rich fibrin (PRF): Autologous platelet concentrate obtained by centrifugation (3000 rpm for 10 min), rich in growth factors promoting angiogenesis and tissue regeneration.

Biodentine: Bioactive calcium silicate cement used as a pulp capping material for its sealing properties and its ability to stimulate the formation of reparative dentin.

EndoLight concept: Clinical concept postulating that pulpal inflammation is often localized, allowing for the preservation of healthy radicular pulp via selective pulpotomy when hemostasis is controlled.

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