Management of Carious Pulp Exposure in Vital Permanent Teeth: An Evidence-based Clinical Practice Guideline

Introduction: Annually ~2 million permanent teeth are lost in public dental clinics in Iran. Many of these losses are caused by difficulties in provision of timely root canal treatment (RCT) or their low quality. The present guideline aimed to find and recommend the best treatment options for management of vital permanent teeth with carious exposure. Materials and Methods: The guideline domain was examined and treatment options were determined as scenarios comprised of indications and possible interventions. Two main indications including carious pulp exposure with or without irreversible pulpitis in open-apex and in closed-apex permanent teeth were included. Nine treatment options were found for each indication based on the available literature. Exhaustive search was performed to find the current evidence and the retrieved studies were critically reviewed. Treatment options and their supporting evidence were extracted. Search for the side effects and benefits of each treatment option was also performed. The expenses regarding each treatment were then determined and treatment options with Level of Evidence (LOE) I and LOE II evidence were presented to an expert panel for each indication. Each clinical scenario was examined and rated by each member considering six aspects: effectiveness of the intervention, costs, side effects, side benefits, applicability of the scenario and generalizability of the treatment. The best scenarios were chosen based on the expert panel ratings and the recommendations were extracted. Results: Based on the present guideline, full pulpotomy with calcium enriched mixture (CEM) cement is recommended in vital permanent teeth with open- or closed-apex, with or without irreversible pulpitis, following carious pulp exposure (Grade A recommendation). Conclusion: Adherence to the present guideline may help preserve pulp vitality and decrease the risk of loss of vital permanent teeth with carious pulp exposure