From Whole-Tooth to Root-Specific Vitality Preservation: Partial Pulpotomy, Full Pulpotomy, and Selective Endodontic Treatment in Mature Permanent Teeth with Symptomatic Irreversible Pulpitis — A Case Series with 12–24 Month Follow-up

For decades, the standard response to a toothache caused by deep decay was a complete and permanent removal of the tooth's inner life. When bacteria penetrated the hard outer shell of a tooth and reached the soft, living tissue inside—the pulp, which contains nerves and blood vessels—dentists typically removed the entire structure. This tissue, once inflamed and painful, was extracted, the hollow space was cleaned, and the tooth was filled with inert material. The tooth remained in the mouth, but it was no longer alive; it lost its ability to sense temperature, its natural defense mechanisms were gone, and it became more brittle over time. However, a shift in understanding has challenged this all-or-nothing approach. New research suggests that inflammation inside a tooth is often not a uniform fire consuming the whole organ, but rather a localized issue that might be confined to just the top portion. If the damage is limited, the healthy tissue deeper down might be saved, allowing the tooth to remain vital, responsive, and stronger for the rest of its life.

This idea of saving the living part of the tooth has gained traction, but a new question has emerged: what happens when a tooth has multiple roots, like the large molars at the back of the mouth? In these teeth, the roots branch out like the legs of a tripod. Could it be possible that one root is severely damaged while the others remain healthy? A recent case series from the Amrita Institute of Medical Sciences and Research Centre in India explores this possibility. The researchers treated three adult patients who suffered from severe, lingering pain in their lower molars, a condition known as symptomatic irreversible pulpitis. Instead of removing the entire inner tissue of these multi-rooted teeth, the team applied a graduated strategy. They moved from removing just the top part of the pulp, to removing the entire top section, and finally to a highly specific approach where they treated each root of the same tooth differently based on what they found during the procedure.

The first patient, a 25-year-old man, had a molar with a deep cavity. The dentist removed the decay and exposed the pulp. The tissue at the very top was inflamed, but when the dentist gently removed just that small, damaged section, the tissue underneath was healthy and bled normally. This indicated that the inflammation had not spread deep into the root. The dentist capped the healthy tissue with a special biocompatible material called mineral trioxide aggregate, which encourages healing, and sealed the tooth. Two years later, the tooth was pain-free, the patient could still feel cold on it, and X-rays showed a new layer of hard tissue forming beneath the cap, effectively sealing off the treated area.

The second patient, a 23-year-old woman, presented with a similar tooth, but the inflammation was more extensive. When the dentist exposed the pulp, it bled heavily, suggesting the damage went deeper than just the surface. In this case, the dentist removed the entire top portion of the pulp, extending down to where the roots begin. This is known as a full pulpotomy. The bleeding was controlled, the same healing material was applied, and the tooth was restored. Over the course of a year, the tooth remained comfortable and functional. X-rays showed that the tissue around the root tip, which had been slightly irritated initially, returned to a completely healthy state, and a hard tissue barrier formed to protect the remaining living pulp.

The third case, involving a 55-year-old woman, offered the most striking evidence for this new way of thinking. Her molar had a large, old filling that sat very close to the pulp in one of the roots. When the dentist opened the tooth, the situation was different in each root. The root on the side of the old filling was bleeding profusely and could not be stopped, even after removing a significant amount of tissue. This indicated that the inflammation in that specific root was too severe to save. However, the other root, which had no such history of deep decay, bled normally and stopped bleeding quickly after a small amount of tissue was removed. The dentist made a split decision: the damaged root was completely cleaned out and filled with a sealing material, while the healthy root was capped and left alive. This "selective" treatment meant that one half of the tooth was dead and filled, while the other half remained fully alive and sensitive.

Twelve months later, the results were clear. The tooth was pain-free and functioning perfectly. The root that had been completely cleaned out showed no signs of infection, and the root that was left alive still responded to cold tests, proving it was still vital. X-rays confirmed that both roots had healed independently, with the living root developing a hard tissue barrier just like the other two cases. This outcome demonstrated that the inflammation in a multi-rooted tooth does not have to affect every root equally. The researchers found that by assessing the condition of each root individually during the procedure—specifically by observing how the tissue bled—they could make precise decisions that preserved the living parts of the tooth while removing only what was necessary.

The success of these treatments relied heavily on the use of modern materials and techniques. The team used a dental operating microscope to see the tiny details inside the tooth and a special bioceramic material to seal the living tissue. This material is superior to older options because it creates a tight seal and actively encourages the body to repair itself. The study suggests that the old rule of removing the entire pulp whenever a tooth is in severe pain may be too broad. Instead, dentists can now consider a spectrum of options, ranging from saving the top of the pulp to saving only specific roots. While the study involved only three patients and followed them for a relatively short time, the results provide a strong foundation for a more conservative approach. It shows that even in teeth with complex, multi-rooted structures, it is possible to tailor the treatment to the specific biological reality of each root, keeping the tooth alive and functional for as long as possible.