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2]

Original Article

Influence of the restoration after pulpotomy on the

strength of electrical stimulus reaching the pulp
space: An in vitro investigation
Aakanksha Chopra, Sidhartha Sharma, Vijay Kumar, Amrita Chawla, Suman Jain1, Ajay Logani
Division of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences,
1
Department of Physiology, All India Institute of Medical Sciences, New Delhi, India

Abstract
Introduction: The study evaluated the influence of coronal restoration after pulpotomy on the strength of electrical stimulus
reaching the radicular pulp using an electric pulp test (EPT).
Materials and Methods: The pulp tissue from ten freshly extracted mandibular premolar teeth was removed and replaced
with an electroconductive gel. The cathode probe of Powerlab was inserted into the pulp space and the anode probe was
attached to the EPT handpiece. The EPT probe coated with electro‑conducting material was positioned in the middle third of
the buccal crown surface. The EPT stimulus reaching the pulp space of an intact tooth at 40 numerical readings was recorded.
The tooth was removed from model and endodontic access was made. The 2‑mm thick mineral trioxide aggregate was
placed at the cementoenamel junction followed by composite resin restoration. The experimental setup was re‑established
and postpulpotomy EPT stimulus data were recorded. The data collected were compared using the Wilcoxon signed‑rank test.
Results: There was a statistically significant difference (P = 0.038) between observed between the strength of EPT stimulus
reaching the pulp space in prepulpotomy (mean 91.18 ± 101.02 V and median 25.79 V) and postpulpotomy (mean
58.49 ± 77.13 V and median 13.75 V) tooth samples.
Conclusion: The placement of the restoration and pulp capping agent after pulpotomy dampens the strength of EPT stimulus
reaching the pulp canal space.
Keywords: Coronal restoration; electric pulp test; pulpotomy

INTRODUCTION of irreversible pulpitis and the inflammation is believed to

be confined to the coronal pulp (moderate/severe pulpitis),
Minimally invasive endodontics aims to induce a a pulpotomy procedure is prioritized over the root canal
biological response to preserve pulp health, prevent apical treatment (RCT).[1] The pulpotomy involves partial or
periodontitis and increase the success rate of vital pulp complete removal of the coronal pulp and application of
therapy (VPT).[1,2] VPT encompasses indirect pulp capping, a biomaterial directly onto the residual healthy pulp tissue
direct pulp capping, and pulpotomy (partial or full) before the placement of a permanent restoration.[4]
procedures.[3] When the patient’s symptoms are suggestive
Address for correspondence: Pulpotomy is considered a less technique‑sensitive and
Dr. Vijay Kumar, cost‑effective procedure compared to RCT.[4‑7] Studies have
Room No. 308, Third Floor, Division of Conservative Dentistry reported high success rates (75% and 97%) for both partial
and Endodontics, Centre for Dental Education and Research,
All India Institute of Medical Sciences, New Delhi, India. and complete pulpotomy.[8‑10] The recent randomized
E‑mail: [email protected] control trial has reported no statistically significant
Date of submission : 25.01.2023 This is an open access journal, and articles are distributed under the terms
Review completed : 10.03.2023 of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
Date of acceptance : 22.03.2023
License, which allows others to remix, tweak, and build upon the work
Published : 16.05.2023
non‑commercially, as long as appropriate credit is given and the new
Access this article online creations are licensed under the identical terms.
Quick Response Code: For reprints contact: [email protected]
Website:
www.jcd.org.in
How to cite this article: Chopra A, Sharma S, Kumar V,
Chawla A, Jain S, Logani A. Influence of the restoration after
DOI: pulpotomy on the strength of electrical stimulus reaching the pulp
10.4103/jcd.jcd_67_23
space: An in vitro investigation. J Conserv Dent 2023;26:338-43.

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Chopra, et al.: Pulpotomy and electric pulp test

difference between the outcome of partial (80.8%) and lip clip of an electric pulp tester (Vitality Scanner 2006,
complete pulpotomy (89.8%) for the management of mature SybronEndo, California, USA) was connected to the dental
permanent teeth with irreversible pulpitis.[11] However, the model [Figure 1].
outcome of a partial and complete pulpotomy are difficult
to compare due to the noninclusion of pulp sensibility tests Electric stimulus measurement
in the outcome criteria of complete pulpotomy.[4] It is the A Powerlab device (DAQ, Data Acquisition Hardware
notion that pulp sensibility tests are unreliable in teeth after Device, AD instrument Ltd, Sydney, Australia) was used. The
complete pulpotomy due to large coronal restoration and cathode probe of Powerlab was covered with an insulating
deposition of tertiary dentine, however, an experimental sleeve with only a 2 mm tip exposed and inserted into the
investigation is missing. On the contrary, literature reports pulp space through the opening on the lingual aspect. The
that teeth demonstrate a positive response to the electric anode was coupled to the EPT handpiece. The pulsating
pulp test (EPT) after a successful pulpotomy.[12,13] Therefore, electric stimulation rate of the EPT was set at 5 to facilitate
the present in vitro study was designed to evaluate the readings in a clinical scenario. The EPT probe was coated
influence of coronal restoration after pulpotomy on the with conducting media (K‑Y Jelly, Reckitt Benckiser) and
strength of electrical stimulus reaching the radicular pulp placed at the middle third of the buccal tooth surface.
using an EPT. The baseline readings of the electrical stimulus received
at the pulp chamber were recorded using the PowerLab
MATERIALS AND METHODS connected to a computer.

The in vitro investigation was performed after ethical Simulated pulpotomy

approval from the institute’s research ethics committee The tooth was then removed from the experimental
(ref. IEC/145/3/2021). A total of 10 single‑rooted human model, and the root canal space was flushed with distilled
mandibular premolar teeth extracted for orthodontic water to remove the electro‑conductive gel. The access
reasons from individuals aged 15–25 years were used after opening was performed with the help of a round diamond
obtaining written informed consent. Teeth with preexisting bur under water spray, and the pulp space was again
restorations, cavities, fractures, and radiographic evidence flushed with 3% NaOCl to remove any residual tissue or
of pulp canal obliteration were excluded. The extracted gel. A collagen sponge was placed inside the root canal
teeth were manually scaled and cleaned with a pumice up to the level of the cementoenamel junction. Mineral
slurry to eliminate any remaining soft tissue and stored trioxide aggregate (MTA) (Pro Root MTA, Dentsply Sirona,
at the room temperature in artificial saliva until further NC, USA) was mixed according to the manufacturer’s
preparation. instructions. A 2‑mm thick MTA was placed over the
collagen sponge and gently condensed to simulate
Tooth sample preparation the placement of the pulpotomy agent in the clinical
Three millimeters of the apical root end were resected using scenario. A moistened cotton pellet was placed over
a carborundum disc mounted on a straight handpiece (NSK the MTA, and the teeth were stored at 100% humidity
E‑Type Straight Handpiece, NSK, Japan). Tissue was to allow the setting of the MTA. The moist cotton pellet
removed from the pulp chamber and root canal space and collagen sponge were removed after 24 h, and the
through retrograde instrumentation and copious irrigation setting of MTA was confirmed. A layer of resin‑modified
with 3% NaOCl. A hole was drilled onto the lingual root glass ionomer cement (Vitrebond, 3 m, ESPE, St. Paul,
surface 1 mm apical to the cementoenamel junction using a
#2 round diamond bur (Mani, Inc, Japan) to gain access to
the pulp canal space. An electroconductive gel (NP‑1, Nissin
Dental Products Inc., Kyoto, Japan) was used to replace the
pulp tissue.

Study model preparation

The study model was prepared by modifying the model
described for illustrating the use of electronic apex
locators and the experimental setup for measuring the
conductance of EPT.[14‑16] A dental model for electronic apex
Figure 1: Experimental setup: Powerlab electrode probes are
locator training (CON1002 Series, Nissin Dental Products
attached to the tooth and EPT to record the electric stimulus
Inc., Kyoto, Japan) was selected, and the right mandibular reaching the pulp space. The radiograph demonstrates
first premolar was removed. The root canal space and the level and thickness of the pulp capping agent, coronal
the socket were filled with electroconductive gel. The restoration and location of the lingual hole for placement of
tooth was secured in the socket using sticky wax. The the Powerlab electrode probe. EPT: Electric pulp test

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Chopra, et al.: Pulpotomy and electric pulp test

USA) was placed over MTA and light‑cured for 20 s. The pre‑and post pulpotomy tooth samples for the strength
teeth were restored with restorative composite resin and of electrical stimulus reaching pulp space, and the values
further incubated for 24 h under 100% humidity and at the were diminished after the placement of pulpotomy agent
room temperature to allow the complete set of coronal and coronal restoration when compared with an intact
restoration. Thereafter, the root canal space was filled tooth [Figure 3 and Table 1].
with electroconductive gel and the experimental setup
was re‑established, as explained previously. The EPT DISCUSSION
probe was contacted at the middle third of the crown on
the buccal surfaces, and measurements of the electrical The outcome of pulpotomy depends upon the reparative
stimulus from EPT transferred to the pulp chamber were potential of residual radicular pulp and the asepsis followed
recorded on the LabChart (AD instrument Ltd, Sydney, during the clinical procedure.[17] The radicular pulp can
Australia) [Figure 2]. The pre‑ and postpulpotomy develop irreversible inflammation as the part of an acute or
electrical stimulus measurements (in voltage) at EPT chronic process. The occurrence of spontaneous, intense,
reading 40 were recorded three times per tooth, and or continuous pain in a pulpotomized tooth during a period
the EPT was allowed to return to 0 before each reading. of 2 months postoperatively constitutes an acute adverse
The mean value was recorded, and data were stored in a event.[18] The appearance of condensing osteitis, pulp canal
Microsoft excel sheet. obliteration, internal resorption, and periapical pathology
on the radiograph indicates chronic inflammation of the
Statistical analysis radicular pulp.[18,19] While an acute adverse event and early
The data collected were analyzed using IBM SPSS failure are easily detectable, the chronic pulp inflammation
statistics version 25 software (IBM Corporation, NY, may often go unnoticed as the patient remains asymptomatic
USA). The data of electrical stimulus reaching pulp space and it may take several months before changes are evident on
in pre‑and post‑pulpotomy tooth samples were not radiographs. Therefore, periodic monitoring of pulp health
normally distributed (Shapiro–Wilk test P = 0.034). The status following a pulpotomy procedure is of paramount
nonparametric test for two related samples (Wilcoxon importance. Pulse oximetry and laser doppler flowmetry
signed‑rank test) was used to compare the cumulative are the ideal tools to assess pulp vitality, however, removal
strength of electrical stimulus reaching pulp space in the of coronal pulp could result in a false‑negative response
pre‑and postpulpotomy tooth samples at an EPT reading to these pulp‑vitality tests.[20] Clinical and radiographic
of 40. examinations are currently used as surrogate measures to
determine the pulp health in pulpotomized teeth.[4]
RESULTS
The dental pulp is richly innervated with the sensory nerves
The output signal was in the form of a waveform, with each which pass through the radicular pulp to reach the pulp
number corresponding to the burst of 10 pulses followed
by a resting period. The output voltage increased gradually Table 1: Descriptive statistics of power lab readings (V)
from 0 to 40 readings, but the pulse duration and distance from pre‑and post‑tooth samples
between the two output bursts remained constant [Figure 2]. Prepulpotomy (V) Postpulpotomy (V)
The output voltage (V) (mean ± standard deviation and Mean 91.18 58.49
median, p25–p75) reaching the radicular space varied Median 25.79 13.75
considerably in prepulpotomy (91.18 ± 101.02 V and 25.79 SD 101.02 77.13
P25 7.10 7.19
V, 7.10–165.15 V) and postpulpotomy (58.49 ± 77.13 V P75 165.15 113.05
and 13.75 V, 7.19–113.05 V) tooth samples. There was a IQR 158.04 105.859311
statistically significant difference (P = 0. 038) between the IQR: Interquartile range, SD: Standard deviation

a b
Figure 2: (a) Pre pulpotomy, (b) post pulpotomy The output signal from the EPT reaching the radicular pulp space recorded in
the LabChart in pre and postpulpotomy tooth samples. The magnified view represents a single output burst with ten pulses.
EPT: Electric pulp test
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Chopra, et al.: Pulpotomy and electric pulp test

studies that evaluated the patient response to EPT after

pulpotomy.[5,12] It can be asserted that the positive response
in teeth after full pulpotomy could be due to stimulation
of nerver fibers in supporting periodontal tissues as it is
belived that large coronal restoration could block the EPT
stimulus from reaching the radicular pulp. This is the first
study evaluating the effect of restoration after pulpotomy
on the electrical conductance of teeth during electronic
pulp testing. Single rooted pre molar teeth were used for
the study because of ease of availability of intact premolar
teeth extracted due to orthodontic reasons. However,
the results can be replicated in multi rooted teeth as
Figure 3: Strength of electrical stimulus reaching the pulp well. For the electric stimulus to reach the pulp space, it
space in pre‑and post‑pulpotomy tooth samples must overcome the electrical resistance of enamel and
dentine which varies with their thickness.[22] Therefore,
chamber where they diverge and branch outward and form a the extracted teeth used in the study were obtained from
mesh at the pulpo‑dentine junction. The thermal and electric individuals aged between 15 and 25 years to circumvent
pulp sensibility tests provide an indirect assessment of dental the chances of encountering receding pulp chambers,
pulp status.[21] The hydrodynamic theory of pulp sensitivity calcifications, etc., which may alter the conductance of
suggests that electrical stimulation and cold stimulation have electric current thereby the EPT values.
two different mechanisms of action. According to this theory,
cold may cause neurons to act as mechanoreceptors that The experimental setup was designed as a modification of
react to movement from the thermal contraction of dentinal the model described for illustrating the use of electronic
fluid.[22] The presence of vital nerves in the dentine or pulp apex locators using the electrical root length measurement
training model.[16] The conductance media used during
directly beneath the cold stimulus is presumably necessary
EPT also influences the strength of the electrical signal
to obtain a response.[23] Based on the clinical evidence, where
reaching the pulp and the use of media with maximal
teeth adjudged clinically and radiographically successful
conduction allows for the most reliable EPT results.
after partial or complete pulpotomies but did not respond to
Water‑based electroconductive media are reported to have
the cold test, it cannot be considered a reliable technique for
higher conductance compared to wax or petroleum‑based
pulp‑sensibility assessment.[24,25] The EPT is believed to cause
media.[15] Therefore water‑based electroconductive gel was
ionic shifts within the dentin fluid, resulting in the localized
used in the present study.
depolarization of nerve membranes and the production of
action potentials. Logically the use of bipolar EPT which The comparative study of two EPTs established that the
requires the placement of two probes in the buccal and analytic technology pulp tester has the most suitable
lingual surfaces and is believed to elicit a response by output characteristics, efficient, and easy to use.[28] The
the stimulation of coronal pulp seems ineffective in full modified version of this pulp tester was used in the present
pulpotomy cases. With monopolar EPT, stimulus passes study. The voltage output is generated electronically and
through the dentinal tubules beneath the tooth electrode each reading on EPT corresponds to a burst of ten pulses.
to the coronal and radicular pulp. Apart from the pulp The rate of increase in the strength of the stimulus can
chamber’s occlusal wall, the nerve plexus’s density is be controlled by a panel wheel. It has been recommended
well‑developed in the peripheral pulp along the lateral wall that the output from any pulp tester should start at a
of the coronal and cervical dentine.[26] The histologic study low level and have an initial slow rate of increase which
demonstrated a close contact between fibroblast‑like cells/ then accelerates towards the middle and upper range to
osteoblast‑like cells and nerve terminals at the calcification minimize patient discomfort. Similarly, for a particular dial
front in the early healing process after pulpotomy.[27] Thus, setting of vitality scanner, the output level rises slowly at
it can be hypothesized that if an electrical stimulus reaches the beginning of the test and more quickly at the end. The
the pulp space, an EPT can elicit a positive response from a dial 5 setting for a rate of increase of stimulus up to 40
radicular pulp after pulpotomy. numerical readings on EPT display was used in the in‑vitro
experiment to simulate the actual clinical scenario.[15]
The European society of endodontology’s position
statement on management of deep caries and the exposed VPT has been buttressed with the introduction of calcium
pulp states that “the teeth which have undergone full silicate‑based cements such as MTA, Neo MTA plus,
pulpotomy are expected to be unresponsive to pulp Biodentine, Totalfill and calcium‑enriched mixture cement
sensibility testing on follow‑up evaluation.”[4] However which seal the pulp wound interface, enhancing pulp
this is contradictory to the findings of the previous clinical healing.[20,29‑31] MTA, the most widely used pulp capping

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Chopra, et al.: Pulpotomy and electric pulp test

agent after pulpotomy, was utilized in the present study. control teeth, it is anticipated that the pulpotomized teeth
MTA and other hydraulic calcium silicate cement are will respond at greater EPT readings.
considered bioactive, which implies that they release
calcium ions, produced calcium hydroxide, and possess Financial support and sponsorship
electroconductive properties.[32] The MTA has an electric Nil.
conductivity of 1388.7 263.5 S/cm.[33] In the present study,
A significant difference was observed in the cumulative Conflicts of interest
voltage reaching pulp space from 0 to 40, the values There are no conflicts of interest.
were significantly reduced (P = 0.038) after placement of
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