Full pulpotomy versus root canal treatment in mature permanent teeth with irreversible pulpitis: a systematic review and meta-analysis

INTRODUCTION

Irreversible pulpitis is among the most frequent reasons for emergency dental attendance in adults, and its management has been shaped for decades by a single assumption: once the pulp of a mature permanent tooth produces spontaneous or lingering pain, the entire tissue is damaged beyond repair and must be removed.(1) Under that assumption, root canal treatment has been the standard of care, and it remains a predictable way to retain the tooth. The procedure is nevertheless expensive, technically demanding and time consuming; it removes considerable dentine and thereby increases the long-term risk of root fracture, and postoperative pain affects a substantial proportion of patients.(2) These limitations have sustained the search for treatments that remove less tissue.

Histological work has progressively undermined the all-or-nothing reading of the clinical diagnosis. When symptoms are correlated with pulp histology, inflammation in teeth diagnosed with irreversible pulpitis is frequently limited to the coronal pulp, while the radicular pulp shows little or no inflammatory change.(3) The segmented response of the pulp to microbial challenge provides the biological basis for removing only the inflamed coronal portion and leaving the radicular pulp in place.(4) This logic, together with the biocompatibility, sealing ability and bioactivity of hydraulic calcium silicate cements such as mineral trioxide aggregate, Biodentine, calcium-enriched mixture and iRoot BP Plus, has turned full pulpotomy into a plausible definitive treatment for mature teeth.(5,6) Position statements of the European Society of Endodontology and the American Association of Endodontists now accept vital pulp therapy for carious pulp exposure, including teeth with symptoms of irreversible pulpitis, provided that bleeding is controlled and the remaining pulp is judged healthy.(7,8) The cements themselves differ in composition and handling: mineral trioxide aggregate is the most studied material with the longest track record, Biodentine and calcium-enriched mixture set faster and are easier to place, and premixed formulations such as iRoot BP Plus remove the mixing step altogether.(5,9) Because the included trials used all four families, the pooled estimate can be read as a general estimate for the calcium silicate class rather than for a single product.

The clinical uptake of full pulpotomy has nonetheless been uneven. Surveys and systematic reviews of decision-making show that root canal treatment is still chosen for most symptomatic mature teeth, and that the perceived reliability of the diagnosis, rather than the availability of materials, drives the decision.(10,11) The debate is no longer about whether the pulp can heal, but about which teeth are suitable, which cement should be selected and whether the short-term results will hold over years.(12) This uncertainty is reflected in clinical practice guidelines, which condition vital pulp therapy on achieving hemostasis and on the absence of pulp necrosis.(13,14)

Several systematic reviews have examined pulpotomy for irreversible pulpitis, but their conclusions diverge and most did not isolate the direct comparison with root canal treatment. An early review found favourable short-term success for pulpotomy in symptomatic mature teeth but stressed the absence of randomized comparisons with root canal treatment.(15) Later syntheses reported pooled success rates for full pulpotomy of approximately 86 to 94 percent, yet they combined single-arm studies with trials that compared different cements, and only some included the head-to-head comparison.(16-18) Reviews published in 2025 and 2026 concluded that pulpotomy and root canal treatment show comparable outcomes in the short term, while noting that randomized evidence remains scarce and heterogeneous.(19-22) Because several head-to-head randomized trials and a pooled analysis have appeared only recently, an updated synthesis restricted to the direct comparison is warranted.

The objective of this systematic review was to compare the clinical and radiographic success of full pulpotomy with calcium silicate cements versus root canal treatment in mature permanent teeth with symptomatic irreversible pulpitis, and to summarize postoperative pain, quality of life, treatment time and cost when these outcomes were reported by the included studies. The review question was: in mature permanent teeth with symptomatic irreversible pulpitis, does full pulpotomy with calcium silicate cements achieve success rates comparable to root canal treatment?

METHODS

RESULTS

Secondary outcomes

Postoperative pain was comparable between treatments in the largest trial, in which moderate-to-severe pain fell from approximately 56 percent preoperatively to between 10.6 and 13.1 percent at 24 hours across the three arms.(31) Two trials reported faster or greater pain reduction after pulpotomy: Zhu et al. found lower day-1 pain (2.3 versus 5.5 on the numeric rating scale, p = 0.031), with about 30 percent of pulpotomy patients reporting complete relief on the first postoperative day,(29) and Sarı et al. found lower pain at 24 and 72 hours after pulpotomy in teeth with severe pulpitis, in which 70 percent of pulpotomy patients versus 91 percent of root-canal-treated patients still reported pain at 24 hours.(33) Patel et al. found that pulpotomy was as effective as root canal treatment in reducing pain and improving oral health-related quality of life,(32) and Esteve-Pardo et al. found that both procedures eliminated pain with similarly high satisfaction.(34) By contrast, the pooled analysis reported a greater decrease in pain intensity with root canal treatment from baseline to day 3 (1.7 versus 2.4 on the numeric rating scale; p = 0.0034), higher analgesic consumption after pulpotomy at day 3 (51.1 versus 33.3 percent; p = 0.0042) and a higher early failure rate after pulpotomy (5.2 versus 0.5 percent; p = 0.014).(36) Treatment time and cost were consistently lower for pulpotomy: 43.5 versus 112.5 minutes in one trial(29) and approximately 35 versus 70 minutes in another,(31) with a treatment cost of RMB 882 versus 1985.5(29) (Table 4).

Study	Outcome	Finding
Eghbal 2020	Postoperative pain, 7 d	Comparable across arms (p = 0.939); moderate-to-severe pain 56% preoperatively to 10.6-13.1% at 24 h
Patel 2025	Pain and HRQoL, 7 d	Similar pain reduction (p = 0.804); comparable HRQoL
Sarı 2024	Postoperative pain, 7 d	Severe pulpitis: lower pain after pulpotomy at 24 h and 72 h (p < 0.05)
Esteve-Pardo 2023	Pain and satisfaction, 72 h	Both eliminated pain (5.8 to 1.3 NRS); satisfaction 9.2 vs 9.1
Karim 2026	Pain, analgesics and early failure, 4 wk	Greater pain reduction with RCT; early failure 5.2% vs 0.5% (p = 0.014)
Zhu 2024	Treatment time and cost	43.5 vs 112.5 min (p = 0.020); RMB 882 vs 1985.5 (p = 0.022)
Eghbal 2020	Procedure time	RCT 69.73 vs MTA 35.37 vs CEM 33.62 min (p < 0.001)

Note: NRS = numeric rating scale; HRQoL = health-related quality of life; RCT = root canal treatment; RMB = renminbi. Source: Elaborated from the data extraction form.

DISCUSSION

The main finding of this review is that full pulpotomy with calcium silicate cements and root canal treatment produce comparable clinical success at 12 months in mature permanent teeth with symptomatic irreversible pulpitis. Pooled success was 94.8 percent after pulpotomy and 96.5 percent after root canal treatment, with a risk ratio of 0.99 and a confidence interval that includes 1.0 (95% CI 0.94 to 1.03). Comparability is therefore supported by the point estimate and by the absence of statistical heterogeneity, but the confidence interval is wide enough to accommodate a modest difference in either direction, and the certainty of this evidence is low.

This review has several strengths. The search covered four databases, and the PRISMA flow diagram was generated from the recorded screening decisions rather than reconstructed from memory, which reduces the risk of arithmetic error in the selection counts. The synthesis was restricted to the direct comparison between full pulpotomy and root canal treatment, avoiding the mixing of single-arm studies with head-to-head trials that limited earlier reviews. The meta-analysis used only exact numerators reported by the trials, and the forest plots were computed deterministically from those numerators.

The pooled estimate sits within the range reported by earlier syntheses of pulpotomy for irreversible pulpitis. Systematic reviews have reported success rates for full pulpotomy between roughly 86 and 94 percent at 12 to 24 months,(16-18,21) and reviews that specifically compared pulpotomy with root canal treatment concluded that the two interventions perform similarly in the short term.(19,37,38) The concordance is reassuring because those reviews pooled different combinations of studies, several of which also appear in the present synthesis. Among the syntheses that reported a pooled success rate for full pulpotomy, the estimate of approximately 92 percent reported by Li et al. and the 94 percent reported in a 2026 review are closest to the value obtained here, whereas the earlier estimate by Santos et al. of 81 to 90 percent was lower because it included heterogeneous study designs and shorter follow-up windows.(17,18,38) The overview of systematic reviews by Chhabra et al. concluded that pulpotomy is effective in mature teeth but that the certainty of the evidence is low, a judgment that the present review confirms with a direct head-to-head comparison.(20) An umbrella review reached the same conclusion and stressed the need for direct comparisons against root canal treatment.(22) The cervical pulpotomy review by Skitioui et al. and the earlier synthesis by Zafar et al. similarly reported high success but lacked a formal comparison with root canal treatment.(39,40) The similarity of the estimates across these reviews suggests that the choice of cement among the calcium silicate family, which varied from mineral trioxide aggregate to Biodentine, calcium-enriched mixture and iRoot BP Plus, did not materially change the outcome; a network meta-analysis of bioactive materials likewise found comparable failure rates across calcium silicate cements.(9)

The results are not uniformly favourable to pulpotomy, and the discrepant findings deserve attention. The PROVE pooled analysis of eight randomized trials reported a greater reduction in pain intensity with root canal treatment from baseline to day 3 and, more importantly, an early failure rate of 5.2 percent after pulpotomy versus 0.5 percent after root canal treatment.(36) This pattern is consistent with a biological reading of pulpotomy: a minority of teeth fail early because the radicular pulp was already more inflamed than the clinical diagnosis suggested, whereas teeth that survive the first weeks tend to remain stable, which is why the 12-month success estimates in the individual trials are higher than the short-term failure rate of the pooled analysis. The non-randomized study by Beauquis et al. also reported lower clinical success after pulpotomy (80 versus 90 percent) but, in the opposite direction, higher radiographic success after pulpotomy (94 versus 69 percent).(35) Those estimates must be read with caution because the two groups were treated by different operator cohorts, which confounds the comparison with operator experience.

Single-arm cohorts provide additional context for the durability of full pulpotomy beyond the randomized comparisons. Taha et al. observed 93 percent success at one year with Biodentine pulpotomy in symptomatic mature teeth,(41) and the same group later reported similar one-year outcomes in the randomized comparison included here.(28) Asgary et al. reported five-year success of vital pulp therapy in mature molars with irreversible pulpitis of approximately 92 percent,(42) and Tan et al. described favourable long-term pulpal and restorative outcomes after pulpotomy in mature teeth.(43) Retrospective and prospective cohorts have reinforced these figures: 90.7 percent success at two years in one elective pulpotomy series,(44) high short-term success in prospective cohorts from China,(45,46) favourable outcomes in teeth with signs of irreversible pulpitis in which hemostasis was achieved,(47) and favourable outcomes even in teeth with apical periodontitis treated with Biodentine pulpotomy.(48) The cohort data indicate that pulpotomy can remain stable well beyond 12 months in selected teeth, although randomized evidence for the long term is still absent.

The biological rationale for the observed results rests on the segmented inflammatory response of the pulp. Histobacteriological studies of cariously exposed pulps show that, in teeth with symptoms of irreversible pulpitis, bacteria and the inflammatory infiltrate are frequently restricted to the superficial coronal pulp, so that amputation to the canal orifices removes the diseased portion and leaves a radicular pulp capable of repair.(1,3) The calcium silicate cements used in the included trials support that repair by releasing calcium ions, maintaining an alkaline environment and inducing a mineralized barrier over the wound.(12) When hemostasis is achieved quickly, the clinician has indirect evidence that the remaining pulp is not necrotic, which explains why bleeding control is the most emphasized selection criterion in the guidelines and expert statements.(6,14)

The generalizability of the pooled estimate is limited to teeth that meet these intraoperative criteria. All included trials excluded teeth in which hemostasis could not be achieved within a few minutes or in which necrosis was detected, and some also excluded teeth with periapical radiolucency.(31,33) Pulpotomy should therefore be understood as a treatment for vital, restorable teeth with carious pulp exposure, and its success rates cannot be extrapolated to teeth with established necrosis or to immature teeth, which were outside the scope of this review.

One caveat in interpreting these numbers is the inconsistency of the success definitions across trials. Taha et al. combined clinical and radiographic criteria into a single judgment, Zhu et al. separated them and accepted a periapical index of 1 or less for pulpotomy, Elsherif et al. relied on clinical findings plus cone-beam computed tomography, and Asgary et al. defined success radiographically at 24 months.(27-30) These differences make the pooled estimate coarser than its narrow confidence interval suggests, because the outcome being measured is not identical across studies. Standardized criteria, ideally those proposed for the evaluation of pulpotomy outcomes, would improve the comparability of future trials.(49)

Several sources of clinical heterogeneity did not translate into statistical heterogeneity in the meta-analysis, which returned I2 = 0 percent. The included trials differed in the cement used, the number of visits for root canal treatment, the definition of success and the length of follow-up, and two trials enrolled carious pulp exposures with or without an established diagnosis of irreversible pulpitis.(27,31) The near-identical success rates across the three trials that contributed to the pooled estimate may reflect the strict inclusion of teeth in which hemostasis was achieved after coronal pulp amputation, a step that effectively selects teeth with a healthier radicular pulp.(49) The hemostasis protocol also varied across trials, with sodium hypochlorite used in most and different time limits applied; because the time to hemostasis correlates with the inflammatory state of the pulp, this variation is a plausible source of between-study differences even when it did not surface as statistical heterogeneity.(49) Factors that influence the outcome of pulpotomy, including bleeding time, age and the extent of inflammation, have been reviewed extensively and underpin the current recommendation that case selection determines success more than the material.(6,49)

Postoperative pain behaved in a direction that favours the less invasive procedure in most, though not all, comparisons. In the individual trials, pulpotomy produced pain relief that was either equivalent to or faster than that of root canal treatment,(29,31-34) a pattern already reported in an earlier randomized comparison(50) and confirmed by an independent appraisal of that trial.(51) The biological explanation is straightforward: removing the inflamed coronal pulp reduces intrapulpal pressure and the load of inflammatory mediators, and it severs nociceptive terminals, whereas root canal instrumentation can push debris and irrigants into the periapical tissues.(1,3) The pooled analysis reported the opposite pattern for analgesic consumption, which was higher after pulpotomy at day 3;(36) the different assessment windows and the aggregation of protocols across eight countries may explain part of this discrepancy. The apparent contradiction between the individual trials and the pooled analysis can also be read as a difference in what is being measured. Pulpotomy removes the inflamed coronal tissue responsible for the presenting pain and therefore relieves it quickly, whereas root canal treatment, once completed, eliminates the source of inflammation entirely; the pooled analysis captured the later phase, when the advantage shifts toward the completed root canal treatment. Both observations can be true at the same time and are not necessarily in conflict.

The efficiency advantage of pulpotomy was consistent and large. Treatment time was roughly 35 to 44 minutes for pulpotomy against 70 to 113 minutes for root canal treatment,(29,31) and treatment cost was less than half in the trial that measured it.(29) A cost-effectiveness analysis based on United States parameters reached a compatible conclusion, showing that pulpotomy is an acceptable option at lower willingness-to-pay thresholds.(2) For public services and low-resource settings, this difference is operationally meaningful, and a feasibility study in Mexican public health services found that full pulpotomy could be delivered by trained general practitioners.(52) These findings also align with the direction of recent guidance. The S3-level guideline of the European Society of Endodontology and the EFCD-ESE-ORCA guideline for deep caries management position vital pulp therapy as an option for teeth with deep caries and pulp exposure, with the caveat that hemostasis and the absence of necrosis must be confirmed intraoperatively.(13,14) The expert consensus on pulpotomy in mature permanent teeth likewise recommends pulpotomy when the radicular pulp is judged vital and bleeding stops within a few minutes.(6) The present estimates give quantitative support to those recommendations, while the wide confidence interval reminds clinicians that equivalence is plausible but not yet demonstrated with certainty.

Patient-reported outcomes reinforced the acceptability of pulpotomy. In the randomized comparison by Taha et al., the Oral Health Impact Profile improved similarly in both arms (60.29 versus 64.1 percent at one year), and satisfaction favoured pulpotomy for treatment time, intraoperative pain, pleasantness and cost.(28) The trial by Patel et al. found that pulpotomy was as effective as root canal treatment in improving health-related quality of life over the first week,(32) and the emergency-setting trial by Esteve-Pardo et al. found high and similar satisfaction scores in both arms (9.2 versus 9.1).(34)

The review has limitations that must be stated precisely. First, only three randomized trials contributed exact numerators to the meta-analysis of clinical success, so the pooled confidence interval is wide and cannot exclude up to a 6 percent relative disadvantage for pulpotomy; a definitive answer requires larger non-inferiority trials powered for a narrow margin. Second, follow-up did not exceed 24 months in any trial and was 12 months or less in most, so late pulp necrosis and the long-term survival of the restored tooth remain unmeasured; trials with five-year follow-up are needed. Third, all trials were judged at some concerns or high risk of bias, mainly because operators and radiographic assessors could not be blinded; future trials should use blinded assessors and standardized radiographic criteria. Fourth, for eight of the ten studies outcome data were extracted from abstracts because open-access full texts were not available, which limits the depth of the extraction; prospective registration and open reporting would reduce this dependence. Fifth, two trials enrolled teeth with carious pulp exposure with or without an established diagnosis of irreversible pulpitis, and the pooled analysis may partially overlap with individual trials; strict diagnostic criteria and clear reporting of overlap would strengthen future syntheses. Sixth, screening was assisted by an artificial intelligence assistant and verified by one reviewer rather than two independent reviewers, and the protocol was not registered; dual independent screening and prospective registration are recommended. Seventh, the meta-analysis rests on three small trials, and funnel-plot asymmetry could not be assessed meaningfully with so few studies, so publication bias cannot be excluded.

Applying the GRADE domains to these findings, the certainty of the evidence is low. Risk of bias is a concern in every included trial, imprecision is substantial because only three studies contribute to the pooled estimate, and indirectness arises from the mixed populations of two trials and the variable definitions of success. Publication bias could not be assessed. These downgrades do not invalidate the conclusion of comparability, but they explain why it is stated with caution.

In practical terms, the choice between the two procedures can be framed as a trade-off between biological conservation and long-term certainty. Pulpotomy preserves tooth structure and offers faster, less expensive care at the cost of a small early failure risk that requires conversion to root canal treatment; root canal treatment removes the pulp and the uncertainty at the cost of time, money and dentine. For a patient with a restorable vital tooth and rapid hemostasis, pulpotomy is a defensible first choice, whereas teeth with prolonged bleeding, necrosis or extensive apical disease should proceed directly to root canal treatment.(4,6)

An additional consideration is the clinical meaning of the confidence interval. The pooled risk ratio of 0.99 with a lower limit of 0.94 implies that full pulpotomy could be up to 6 percent relatively less likely to succeed than root canal treatment at 12 months, while the upper limit of 1.03 implies a small advantage for pulpotomy. For a treatment that saves time, money and tooth structure, a 6 percent relative shortfall in success might still be acceptable to many patients, provided that failure can be rescued by root canal treatment without loss of the tooth. This trade-off is precisely what a non-inferiority design should quantify, and the included trials did not declare a non-inferiority margin, which is a gap in the current evidence.

The evidence base has also evolved rapidly in a short period. The earlier trials in the window measured postoperative pain as the primary outcome, whereas the more recent trials addressed success and patient-reported outcomes, and the pooled analysis moved toward standardized protocols across countries.(31,36) This progression reflects the maturing of pulpotomy from an emergency measure into a definitive treatment and implies that future syntheses will have more homogeneous data to pool.

For clinical practice, these findings support full pulpotomy with a calcium silicate cement as a valid alternative to root canal treatment in mature permanent teeth with symptomatic irreversible pulpitis, provided that hemostasis is achieved within a few minutes and the remaining radicular pulp appears healthy. The procedure is faster, less expensive and less destructive, and it offers pain relief that is at least equivalent to root canal treatment in the short term. The decision should nonetheless respect the diagnostic uncertainty of pulpitis, which the Wolters classification was designed to reduce,(4) and clinicians should reserve pulpotomy for teeth that remain restorable and free of necrosis.

The findings also carry an educational implication. The decision to perform pulpotomy depends on intraoperative judgment, chiefly the time to hemostasis and the appearance of the remaining pulp, which cannot be taught from radiographs alone.(10) Training programmes that expose practitioners to the technique and to the diagnostic thresholds that separate pulpotomy from root canal treatment are therefore as important as the material itself.(6,49)

Future research should move beyond the demonstration of comparability and address the questions that determine treatment choice in practice. Trials are needed that stratify participants with the Wolters diagnostic classification, record bleeding time as a prognostic factor, standardize the clinical and radiographic success criteria, and follow teeth for at least five years to capture late pulp necrosis and the survival of the restoration.(4,49) The cost advantage of pulpotomy, together with its shorter treatment time, also argues for pragmatic trials in primary care settings, as the feasibility work in Mexico has begun to show.(52) Finally, the definition of clinical success should be harmonized across trials so that future meta-analyses can pool a single, well-defined outcome rather than a mixture of clinical, radiographic and combined judgments.

CONCLUSIONS

In mature permanent teeth with symptomatic irreversible pulpitis, full pulpotomy with calcium silicate cements achieves 12-month clinical and radiographic success comparable to root canal treatment.

Full pulpotomy provides postoperative pain relief at least equivalent to root canal treatment and is associated with shorter treatment time and lower cost.

These estimates derive from a small number of trials with short follow-up and risk-of-bias concerns, and the confidence interval cannot exclude a modest disadvantage for pulpotomy; larger non-inferiority trials with longer follow-up are required to confirm comparability. Until those trials are available, the decision between full pulpotomy and root canal treatment should be individualized according to the intraoperative condition of the pulp, the restorability of the tooth and the preferences of the patient.

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