Hemostasis in vital pulp therapy for children and adolescents: does duration matter? A systematic review of randomized clinical trials

Background: The relationship between the duration of hemostasis and the success of vital pulp therapy (VPT) in permanent teeth of children/adolescents with pulpitis has not been clearly established. This study aimed to evaluate the impact of hemostasis duration on VPT success. Methods: A comprehensive literature search was conducted across databases to identify randomized clinical trials (RCTs) reporting hemostasis duration in VPT up to August 2024. The inclusion criteria focused on studies involving children/adolescents that reported on various durations of hemostatic, along with their long-term success rates. Hemostasis durations were categorized into three groups (≤2, 2–5 and >5 minutes). Additionally, various pulp capping agents (PPAs) were compared. A narrative synthesis was conducted using the Kruskal-Wallis test to assess the relationships between the maximum acceptable hemostasis duration and treatment outcomes (p < 0.05). Results: Thirteen RCTs were included (742 participants); they employed full pulpotomy, partial pulpotomy and direct pulp capping. The PPAs used included mineral trioxide aggregates (MTA), calcium hydroxide, Biodentine, platelet-rich fibrin, triple antibiotic, calcium-enriched mixture, MTA-laser, acemannan, abscess remedy, potassium nitrate in polycarboxylate cement and nano-hydroxyapatite. The pulp lavage solutions used were saline, sodium hypochlorite and saline/ferric sulfate gel. None of the included studies specifically evaluated hemostasis duration as primary outcome. Success rates across the various PPAs ranged from 50–100%. The narrative synthesis revealed no statistically significant differences in success rates among the different hemostasis durations (p = 0.382), indicating that the duration of hemostasis did not significantly influence the success of VPTs. Conclusions: This finding suggests that clinicians can adopt a more flexible approach to hemostasis timing during VPT procedures, and the choice of PPAs may not significantly affect treatment outcomes. However, due to the indirect nature of the evidence, current findings should be interpreted with caution. The PROSPERO Registration: The PROSPERO database under the number CRD42024601326.

Mineral trioxide oxide; Endodontics; Vital pulp therapy; Hemostasis; Tooth pulp disease; Pulpotomy; Randomized clinical trials

[1] Haghgoo R, Abbasi F. Clinical and radiographic success of pulpotomy with MTA in primary molars: 30 months follow up. Iranian Endodontic Journal. 2010; 5: 157–160.

[2] Asgary S, Eghbal MJ, Shahravan A, Saberi E, Baghban AA, Parhizkar A. Outcomes of root canal therapy or full pulpotomy using two endodontic biomaterials in mature permanent teeth: a randomized controlled trial. Clinical Oral Investigations. 2022; 26: 3287–3297.

[3] Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review. Journal of Endodontics. 2011; 37: 581–587.

[4] Asgary S, Ansari G, Tavassoli-Hojjati S, Shirazi AS, Parhizkar A. Clinical applications of hydraulic calcium silicate-based biomaterials in paediatric endodontics. Endodontic Practice Today. 2020; 14: 229–241.

[5] Asgary S, Parhizkar A. Importance of “time” on “haemostasis” in vital pulp therapy—letter to the editor. European Endodontic Journal. 2021; 6: 128–129.

[6] Asgary S. Pioneering Tampon VPT technique: a breakthrough in pediatric dentistry. European Archives of Paediatric Dentistry. 2024; 25: 609–610.

[7] Ardavan A, Roghanizadeh L, Asgary S. Tampon vital pulp therapy in the management of excessive haemorrhage in inflamed pulps: a hypothesis. Iranian Endodontic Journal. 2023; 18: 274–276.

[8] Asgary S. Successful tampon pulpotomy in a molar with an endodontic lesion: a case report. Cureus. 2024; 16: e55006.

[9] Ricucci D, Siqueira JF, Li Y, Tay FR. Vital pulp therapy: histopathology and histobacteriology-based guidelines to treat teeth with deep caries and pulp exposure. Journal of Dentistry. 2019; 86: 41–52.

[10] Taha NA, Abdelkhader SZ. Outcome of full pulpotomy using Biodentine in adult patients with symptoms indicative of irreversible pulpitis. International Endodontic Journal. 2018; 51: 819–828.

[11] Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 372: n71.

[12] Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. The BMJ. 2017; 358: j4008.

[13] Tozar KN, Erkmen Almaz M. Evaluation of the efficacy of erbium, chromium-doped yttrium, scandium, gallium, and garnet laser in partial pulpotomy in permanent immature molars: a randomized controlled trial. Journal of Endodontics. 2020; 46: 575–583.

[14] Özgür B, Uysal S, Güngör HC. Partial pulpotomy in immature permanent molars after carious exposures using different hemorrhage control and capping materials. Pediatric Dentistry. 2017; 39: 364–370.

[15] Keswani D, Pandey RK, Ansari A, Gupta S. Comparative evaluation of platelet-rich fibrin and mineral trioxide aggregate as pulpotomy agents in permanent teeth with incomplete root development: a randomized controlled trial. Journal of Endodontics. 2014; 40: 599–605.

[16] Kanumuri P, Eppa H, Puppala R, Kethineni B, Banavath S, Kishore GS. Comparative evaluation of three different materials: mineral trioxide aggregate, triple antibiotic paste, and abscess remedy on apical development of vital young permanent teeth. Contemporary Clinical Dentistry. 2018; 9: 158–163.

[17] Alawwad M, Altinawi M, Rekab MS, Kosyreva T, Almokaddam H, Katbeh I. A randomised clinical radiological study using platelet rich fibrin and MTA in pulpotomy of first permanent immature molars. Journal of Clinical & Diagnostic Research. 2020; 14: 1.

[18] Eid A, Mancino D, Rekab MS, Haikel Y, Kharouf N. Effectiveness of three agents in pulpotomy treatment of permanent molars with incomplete root development: a randomized controlled trial. Healthcare. 2022; 10: 431.

[19] Chailertvanitkul P, Paphangkorakit J, Sooksantisakoonchai N, Pumas N, Pairojamornyoot W, Leela‐apiradee N, et al. Randomized control trial comparing calcium hydroxide and mineral trioxide aggregate for partial pulpotomies in cariously exposed pulps of permanent molars. International Endodontic Journal. 2014; 47: 835–842.

[20] Uesrichai N, Nirunsittirat A, Chuveera P, Srisuwan T, Sastraruji T, Chompu-Inwai P. Partial pulpotomy with two bioactive cements in permanent teeth of 6- to 18-year-old patients with signs and symptoms indicative of irreversible pulpitis: a noninferiority randomized controlled trial. International Endodontic Journal. 2019; 52: 749–759.

[21] Ahmed MI, El Hilaly Mohamed Eid G, Youssef HA. Clinical and radiographic assessments of potassium nitrate in polycarboxylate versus mineral trioxide aggregate as pulpotomy biomaterials in immature mandibular first permanent molars: a randomized clinical trial. Journal of Endodontics. 2021; 47: 1672–1682.

[22] Abuelniel GM, Duggal MS, Duggal S, Kabel NR. Evaluation of mineral trioxide aggregate and biodentine as pulpotomy agents in immature first permanent molars with carious pulp exposure: a randomised clinical trial. European Journal of Paediatric Dentistry. 2021; 22: 19–25.

[23] Nosrat A, Seifi A, Asgary S. Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial. International Journal of Paediatric Dentistry. 2013; 23: 56–63.

[24] Brizuela C, Ormeño A, Cabrera C, Cabezas R, Silva CI, Ramírez V, et al. Direct pulp capping with calcium hydroxide, mineral trioxide aggregate, and biodentine in permanent young teeth with caries: a randomized clinical trial. Journal of Endodontics. 2017; 43: 1776–1780.

[25] Vu TT, Nguyen MT, Sangvanich P, Nguyen QN, Thunyakitpisal P. Acemannan used as an implantable biomaterial for vital pulp therapy of immature permanent teeth induced continued root formation. Pharmaceutics. 2020; 12: 644.

[26] Mejàre IA, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, et al. Diagnosis of the condition of the dental pulp: a systematic review. International Endodontic Journal. 2012; 45: 597–613.

[27] Mutluay M, Arıkan V, Sarı S, Kısa Ü. Does achievement of hemostasis after pulp exposure provide an accurate assessment of pulp inflammation? Pediatric Dentistry. 2018; 40: 37–42.

[28] Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. Pediatric Dentistry. 2016; 38: 280–288.

[29] Esmon CT. The impact of the inflammatory response on coagulation. Thrombosis Research. 2004; 114: 321–327.

[30] Yu C, Abbott PV. An overview of the dental pulp: its functions and responses to injury. Australian Dental Journal. 2007; 52: S4–S16.

[31] Asgary S, Roghanizadeh L, Eghbal MJ, Akbarzadeh Baghban A, Aminoshariae A, Nosrat A. Outcomes and predictive factors of vital pulp therapy in a large-scale retrospective cohort study over 10 years. Scientific Reports. 2024; 14: 2063.

[32] Waterhouse PJ, Nunn JH, Whitworth JM. Prostaglandin E2 and treatment outcome in pulp therapy of primary molars with carious exposures. International Journal of Paediatric Dentistry. 2002; 12: 116–123.

[33] Asgary S, Roghanizadeh L, Eghbal MJ, Akbarzadeh Baghban A. Managing failed vital pulp therapies in mature permanent teeth in a retrospective cohort study, with success and survival rates of managing protocols. Scientific Reports. 2024; 14: 11621.

[34] Asgary S, Sarraf Shirazi A, Sabbagh S. Management of primary molars with irreversible pulpitis employing tampon pulpotomy: report of three cases with 34-month mean follow-up. Clinical Case Reports. 2021; 9: 2289–2294.

[35] Asgary S, Roghanizadeh L. Tampon pulpotomy: long-term successful results of a molar with irreversible pulpitis and previous vital pulp therapy failure. Iranian Endodontic Journal. 2023; 18: 165–167.

[36] Zanini M, Hennequin M, Cousson PY. Which procedures and materials could be applied for full pulpotomy in permanent mature teeth? A systematic review. Acta Odontologica Scandinavica. 2019; 77: 541–551.

[37] Schulz KF, Grimes DA. Allocation concealment in randomised trials: defending against deciphering. The Lancet. 2002; 359: 614–618.

[38] Saini A, Kaur A, Sharma S, Kumar V, Chawla A, Logani A. Effect of sodium hypochlorite concentration on the outcome of full pulpotomy in mature permanent teeth with irreversible pulpitis—a systematic review. Indian Journal of Dental Research. 2024; 35: 331–338.