Managing failed vital pulp therapies in mature permanent teeth in a retrospective cohort study, with success and survival rates of managing protocols

Abstract

Despite advancements in vital pulp therapy (VPT), a subset of cases fails to achieve desired outcomes. This study based on a previous large-scale cohort study involving 1257 VPT-treated teeth, aiming to describe the demographic data and clinical characteristics of all failed cases and their management protocols. Clinical records/images of 105 failed cases treated by a single endodontist (2011-2022) were examined, including 10 extracted teeth. Asymptomatic cases with PDL widening received no intervention, while others underwent management protocols, including (selective) RCT and (tampon) re-VPT. These retreatments were assessed for success (defined as radiographic evidence of healing) and survival (characterized by the retention/function of the treated tooth) using Kaplan-Meier analysis. While 51.4% of all initial failures were diagnosed due to symptoms, 48.6% were symptom-free. Notably, failed cases with symptomatic irreversible pulpitis, and apical periodontitis/widened PDL before initial treatment significantly outnumbered asymptomatic cases and normal PDL, respectively (P = 0.001). Moreover, most of the initial failures were observed in teeth with composite resin rather than amalgam restorations (P = 0.002). The success and survival rates for the management protocols were 91.78% and 95.79%, respectively, over an average follow-up period of 36.94 (± 23.30) months. RCT and re-VPT procedures provide successful outcomes for managing unsuccessful VPTs.

Figure 1

(A) Carious lesion on the lower left first molar of a 60-year-old man diagnosed with irreversible pulpitis; (B) Direct pulp capping and amalgam filling performed; (C) Fracture of the restoration and periapical periodontitis evident at 36-month follow-up, confirming failure; (D) Root canal treatment and amalgam build-up of the tooth completed in a single session; (E) Complete healing of the periapical lesion observed at 27-month follow-up, confirming success.

Figure 2

(A) Carious lesion on the lower right first molar of a 41-year-old man diagnosed with irreversible pulpitis; (B) Direct pulp capping and amalgam filling carried out; (C) Symptomatic tooth with periapical periodontitis evident at 6-month follow-up, confirming failure; (D) Root canal treatment and amalgam build-up of the tooth completed in a single session; (E) Healed periapical lesion and functional tooth identified at 44-month follow-up, confirming success.

Figure 3

(A) Carious lesion on the left upper lateral incisor of a 37-year-old woman diagnosed with irreversible pulpitis; (B) Direct pulp capping and resin composite restoration performed; (C) Symptomatic apical abscess/large endodontic lesion detected at 13-month follow-up, confirming the failure; (D) Root canal treatment of the involved lateral incisor and filling/sealing of the access cavity using resin composite performed in a single session; (E) Complete healing of the large endodontic lesion noted at 34-month follow-up, confirming success.

Figure 4

(A) Carious lesion on the lower left first molar of a 34-year-old woman diagnosed with irreversible pulpitis; (B) The affected tooth treated with partial pulpotomy and resin composite restoration. (C) Symptomatic clinical features of irreversible pulpitis associated with apical periodontitis observed at the 5-month follow-up, despite the absence of radiographic changes, indicating treatment failure; (D) Full pulpotomy (re-VPT) with a tampon approach (due to excessive bleeding) and resin composite restoration of the affected tooth performed; complete resolution of symptoms within one-week post-treatment, indicating success.

Figure 5

(A) Carious lesion on the right lower first molar of a 29-year-old man diagnosed with irreversible pulpitis/apical periodontitis, treated with full pulpotomy and amalgam filling; (B) Asymptomatic endodontic lesion detected during a periodic dental visit at 19-month follow-up, confirming failure; (C) Pulpectomy (selective RCT) and obturation of mesial canals and amalgam restoration of the involved tooth performed while the distal root remained untouched; (D) Complete healing of the periapical lesion noted at 42-month follow-up, with the tooth remaining functional, confirming success.

Figure 6

(A) The right upper first molar of a 26-year-old man, recently restored with amalgam, diagnosed with symptomatic irreversible pulpitis; (B) Pulpotomy and amalgam filling performed; (C) At 12-month follow-up, the symptomatic apical periodontist of the treated tooth was diagnosed, while a dental bridge formed beneath the capping biomaterial; (D) Pulpectomy (selective RCT) and obturation of the palatal canal (open orifice with necrotic tissue observed) and amalgam restoration of the tooth completed in a single session while the buccal roots remained untouched due to dentinal bridge formation at the canal orifices; (E) At 37-month follow-up the tooth was asymptomatic and functional, confirming success.

Figure 7

(A) Recurrent carious lesion on the left lower second premolar of a 58-year-old woman diagnosed with irreversible pulpitis/apical periodontitis; (B) Direct pulp capping and composite filling, which failed on 7-month follow-up due to symptomatic apical periodontitis; (C) Root canal treatment and resin composite filling of the tooth completed in a single session; (D) The tooth was functional and asymptomatic at the 3-month follow-up; (E) At 45-month follow-up, the radiograph showed that the tooth had been extracted and replaced with an implant.

Figure 8

The Kaplan–Meyer survival curve produced for the VPT failed cases grouped by management protocol.