Success of Pulpotomy in Molars with Pulpitis with Periodontitis Detected Using AI and Those Without Periodontitis

The dental pulp constitutes a distinct and intricate entity susceptible to variousthermal, traumatic, microbial, and chemical stimuli. (1) As a result, the dentin‐pulpcomplex experiences a sophisticated immune response, leading to the recruitment of immunecells and inflammation of dental pulp cells at the local level. (2,3,4) Historically, ininstances of irreversible pulpitis, the conventional recommendation has been root canaltreatment (RCT), based on the belief that the pulp lacked the ability to undergorecovery. (5,6)Vital pulp therapy (VPT) is an approach focused on minimally invasive measures, aiming toseal the pulpal wound with a bioactive substance subsequent to the removal of infectedpulpal tissues. (7,8) Procedures associated with VPT encompass direct and indirect pulpcapping, partial pulpotomy, and full pulpotomy. (9) Typically, VPT interventions arecarried out to safeguard the radicular pulp in both deciduous and adult immature teeth.(10,11) In accordance with the position statements released by the American Associationof Endodontists (AAE) in 2021 and the European Society of Endodontology (ESE) in 2019,full and partial pulpotomy emerge as promising and more conservative alternatives to rootcanal treatment for managing mature permanent teeth afflicted with irreversible pulpitisand cariously exposed pulps. (10,12) This is also backed by literature since a lot ofresearches shows that performing full pulpotomy to manage mature permanent molars withirreversible pulpitis is highly successful. (30,31,32,33)A full pulpotomy entails the complete removal of coronal pulp tissues, succeeded by theapplication of a biomaterial onto the remaining tissues at the root canal orifices. (12)The utilization of pulpotomy preserves the pulp mechanoreceptors, along with itsdefensive and developmental functions, including the formation of primary and secondarydentin.(12) Furthermore, pulpotomies are characterized by being less time‐consuming, lessinvasive, and less intricate when compared to root canal treatment. Over the past twodecades, numerous studies have indicated that pulpotomy can serve as an effectivealternative to root canal treatment for managing irreversible pulpitis in maturepermanent teeth.(13,14)The AAE classification simplifies pulpitis into reversible and irreversible categories.However, the term "irreversible" is questioned as histological evidence shows no clearboundary for irreparability. In 2017, a new classification proposed by Wolters et al (15)eliminated the term "irreversible" and linked symptoms to VPT management strategies.Subsequent research by Careddu and Duncan in 2021 supported the new classification'spotential prognostic benefit in partial pulpotomy.Wolter's classification mainly entitles the following: 1. Initial Pulpitis:A heightened but not prolonged response to the cold test, insensitivity topercussion, and an absence of spontaneous pain. (15) 2. Mild Pulpitis:An intensified and extended reaction to cold, warm, and sweet stimuli lasting up to20 seconds, potentially percussion‐sensitive. Histologically, this suggests limitedlocal inflammation confined to the crown pulp. (15) 3. Moderate Pulpitis:Evident symptoms, strong, heightened, and prolonged response to cold which can lastup to several minutes, potentially percussion‐sensitive, and spontaneous dull painthat can be partially or completely alleviated with pain medication. Histologically,this indicates extensive local inflammation confined to the crown pulp. (15) 4. Severe Pulpitis:Severe spontaneous pain and distinct pain response to warm and cold stimuli, often sharpto throbbing, causing difficulty sleeping (exacerbated when lying down). Toothsensitivity to touch and percussion is pronounced. Histologically, this suggestsextensive local inflammation in the crown pulp, possibly extending into the root canals.(15)Wolter et al indicated that initial and mild pulpitis will only require indirect pulptherapy. (15)Traditionally, it was hypothesized that a tooth with a periapical radiolucency has anecrotic, infected pulp space. Thus, root canal treatment was the treatment of choice forthese teeth.(2) However, it was proven that even in the presence of a large periapicalradiolucency, portions of the radicular pulp tissues can maintain their vitality.(3) Thissuggests that in cases with apical periodontitis, if vital pulp tissues are evident afterpulp exposure, pulpotomy can be a viable alternative treatment modality to root canaltreatment.(4)In 2018, Taha et al. aimed to evaluate the outcome of full pulpotomy in mature permanentteeth using Biodentine. Eight of the cases exhibited preoperative periapical rarefaction,and seven of them showed improvement in the periapical index score. Similarly, in a 2016randomized clinical trial, all of the seven cases with preoperative periapicalradiolucencies showed complete resolution of the lesions at the end of the study.(5)Other earlier studies also reported success of pulpotomy procedures in cases withperiapical involvement. (34,35,36) However, there is a growing need for further studiesin order to determine the predictability of pulpotomy in teeth with apicalradiolucencies, and to detect features that can act as negative prognostic factors inthese cases.(4)In 2013, the American Association of Endodontists classified the diagnosis of periapicalcondition into normal apical tissues, symptomatic apical periodontitis, asymptomaticapical periodontitis, chronic apical abscess, acute apical abscess, and condensingosteitis. The term "apical periodontitis" indicates that the apical periodontal tissuesare inflamed. In symptomatic apical periodontitis, the tooth has a painful reaction topalpation, percussion, and biting. Radiographically, the tooth may have a normalperiodontium or a periapical radiolucency depending on the stage of the periapicaldisease. On the other hand, teeth with asymptomatic apical periodontitis do not exhibitpain on palpation or percussion, and they are associated with a periapical radiolucencyin the radiograph.(1)It is well‐recognized that the effectiveness of detecting radiographic apicalperiodontitis is contingent upon the proficiency of the operator(16). Therefore, it hasbecome imperative to develop or employ Artificial Intelligence (AI)‐based softwaresolutions that can accurately diagnose periapical radiolucencies. Artificial intelligence(AI) is designed to mimic human intelligence and address specific challenges. AIcontributes to the creation of algorithms that can learn from provided information andmake predictions. Machine learning, a subset of AI, constructs algorithms based ondata.(17) Among the earliest AI algorithms were neural networks (NNs). Deep learningneural networks are complex structures with multiple layers, while shallow learningneural networks are simpler with fewer layers. Convolutional neural networks (CNNs) areprimarily used for analyzing intricate images.(17)AI technology has arisen as a response to the need for machines to emulate humanintelligence, facilitating the provision of more standardized results.(18) For instance,AI‐enabled imaging applications in the medical domain exhibit autonomous object detectionand image classification capabilities, with numerous studies demonstrating remarkableaccuracy and promise in diagnosing pathologies(19), interpreting radiological data(20),and assessing dermatological conditions(21).From a dental perspective, AI applications can be stratified into several domains,encompassing diagnosis, decision support, treatment planning, and prognosis prediction,with diagnostic capabilities being particularly prominent. AI stands poised to augmentdiagnostic precision and efficiency, thereby alleviating the professional burden ondentists, who increasingly rely on computerized decision support systems.(18)Within the realm of endodontics, Anita Aminoshariae et al in 2021 mentioned that AI cancurrently assist in detection of peri‐apical lesions, crown and root fractures, workinglength determination and even the morphology of root canals and the root canalsystems.(23) A systematic review by Agata Ossowska et al in 2022 concluded that AI canalso be used in predicting the ability of dental pulp stem cells to survive in sometreatments and predicting the success of re‐treatment of a failed root canal therapy(RCT).(24) However, it's important to note that AI tended to over‐detect lesions whilehuman operators tended to under‐detect them.(22)Duncan et al, in 2022, recommended the use of CBCT as it can detect periapical lesionsbetter than 2‐Dimensional X‐Rays.(4)In another review by Issa et al in 2023, AI hasexhibited an exceptional level of precision in detecting apical periodontitis withinperiapical radiographs, owing to its capacity to detect intricate patterns and attributesbeyond the detection of human observation.(6)This, in turn, positions it as an efficient auxiliary diagnostic instrument for dentalprofessionals, simultaneously mitigating the clinical burden and improving the standardof care.(6)The main goal of this research is to compare cases of moderate pulpitis without apicalperiodontitis in comparison to cases of severe pulpitis with AI‐Detected apicalperiodontitis. Additionally, the study aims to evaluate the accuracy of a novel AItechnology in identifying apical periodontitis from radiographs and to establish thecorrelation between the utility of AI as a dependable supplementary tool in thedecision‐making process when contemplating full pulpotomy for mature permanent molars.In the paper by Duncan et al, even though it was proven that even in the presence of alarge periapical radiolucency, portions of the radicular pulp tissues can maintain theirvitality, more clinical studies are needed to assess the success rates of cases withsevere irreversible pulpitis with apical periodontitis.The study done by Anita Aminoshariae et al reported that AI can accurately detectperi‐apical lesions. However, another study by Cantu et al reported that AI generallytends to over‐detect lesions. Thus, it is imperative to compare AI findings to theoperator's radiographical observations.