Efficacy of different pulpotomy procedures in permanent molars with symptomatic irreversible pulpitis: a retrospective study

Abstract

Background

This study aimed to retrospectively evaluate the effects of different disinfection and hemostasis procedures on the outcome of mineral trioxide aggregate (MTA) pulpotomy in permanent molars with symptomatic irreversible pulpitis (SIP).

Methods

This retrospective study included patients who had permanent carious molars diagnosed with SIP and treated with MTA pulpotomy under different hemostasis and disinfection procedures (saline, NaOCl, and potassium titanyl phosphate (KTP) laser) by the same operator in the 2-year period. The treatment records of 161 patients diagnosed with SIP in their permanent teeth and treated with total pulpotomy. In total, 96 patients were excluded. Sixty-five patients with at least 12-month of follow-up were evaluated.

Results

Patients were between the ages of 15–54. The overall success rate was 87.69% (57/65) in 12-month follow-up. The success rates for hemostasis and cavity disinfection procedures were 86.4% (19/22) for saline, 86.4% (19/22) for NaOCl, and 90.5% (19/21) for KTP laser with no statistically significant difference (P > 0.05). According to our data; the effect of age, bleeding time, and periapical lesion on the success rate was not significant. Dentin bridge formation was detected in 4 teeth (2 PS, 2 KTP laser) and pulp obliteration in 1 tooth (KTP laser).

Conclusions

MTA pulpotomy is an effective treatment for permanent molars with SIP. Physiological saline, NaOCl, or KTP laser can be used in MTA pulpotomy.

Introduction

Root canal treatment (RCT) is effectively applied to permanent teeth with symptomatic irreversible pulpitis (SIP). However, with a better understanding of pulp biology and the development of pulp capping materials, vital pulp therapy (VPT) has been investigated by researchers in patients with SIP. They reported that VPT can achieve a high success rate in patients with SIP [1]. Possible disadvantages of RCT include requiring multiple visits, being expensive, and weakening teeth [2]. Moreover, RCT performed by general dentists has a failure rate of 24% to 66%. On the other hand, in comparison to RCT, VPT is more biological, less invasive, takes less time and the defense system of the pulp is preserved with VPT [2, 3].

Irreversible pulpitis is pulp inflammation in which pulp healing is not possible and RCT is indicated. However, this diagnosis is based on non-histologic and unreliable clinical findings such as persistent thermal pain, spontaneous pain, and referred pain [4, 5]. However, histologic studies on pulp biology have reported that inflammation is limited to the pulp region close to the caries and that normal healthy pulp can be found in the root pulp away distant from the caries [6, 7]. Ricucci et al. [8] reported that 15.4% of cases showing SIP findings had histologic features of reversible pulpitis. Based on observational and experimental findings and vitality tests, it is difficult to definitively distinguish between reversible and irreversible pulp conditions.

Pulpotomy is defined as the removal of the inflamed pulp in order to preserve the remaining healthy pulp. Depending on the healing potential of the pulp tissue, the remaining healthy pulp can heal after removal of the inflamed tissue is removed [1]. For the long-term prognosis of the treatment appropriately selecting agents, and techniques, and preventing future bacterial contamination are critically important [4]. Ideal pulpotomy materials should provide effective bleeding control, be antibacterial, and preserve the viability of the remaining pulp tissue. Sodium hypochlorite (NaOCl) and laser are used for this purpose [9, 10].

NaOCl is preferred in VPT studies due to its hemostatic and antibacterial properties [1, 9]. Besides, NaOCl can inhibit fibrin clot formation through effective bleeding control [9]. Ballal et al. [9] in addition to emphasizing the importance of infection control in deeply carious teeth, they reported that disinfection of the pulp/dentin wound exposed disinfecting the exposed pulp/dentin wound in VPT with NaOCl reduced failure and recommended the use of NaOCl.

The use of lasers helps to reduce intraoperative bleeding. It also has a bio-modulating effect that improves the healing process [11]. Considering the bleeding control, sterilization, and stimulation effects of laser therapy on pulp cells, the use of laser in VPT has been investigated by researchers [12]. Odabaş et al. [12] reported 85.71% clinical success in pulpotomy using the Nd-YAG laser. Potassium titanyl phosphate (KTP) laser provides effective hemostasis control and wound healing. KTP laser (532 nm) represents an Nd: YAG laser (frequency-doubled) [11].

MTA is widely used as a pulp coating material in pulpotomy treatments due to its good sealing ability, biocompatibility, and high antimicrobial activity. Furthermore, MTA contributes to tertiary dentin formation by stimulating odontoblasts [13].

Numerous investigations have been performed on pulpotomy treatment in permanent teeth with SIP [1, 14]. However, there is no study comparing the long-term efficacy of NaOCl and KTP laser in disinfection and hemostasis. The present study aimed to evaluate the effects of the various disinfection and hemostasis procedures on the success of MTA pulpotomy in permanent molars with SIP (including the presence/absence of periapical radiolucency).

The null hypothesis proposed that disinfection and hemostasis procedures used would not exert a statistically significant influence on the clinical outcomes of MTA pulpotomy.

Materials and methods

Patient selection

Ethical approval was obtained from the Ethics Committee of Sivas Cumhuriyet University (ethics committee code: 2023-6/03). In the present study, STROBE guidelines were followed [15]. The patient records of the Endodontic Clinic of Sivas Cumhuriyet University Faculty of Dentistry were examined to identify patients who received pulpotomy treatment in 2020–2022, and the clinical and radiographic records of patients who underwent coronal pulpotomy with MTA by the same physician were evaluated. Cases that fulfilled the following criteria were included in the study: no systemic diseases, permanent molar teeth with deep caries lesion and closed apex, SIP diagnosis (patients reported spontaneous pain lasting from a few seconds to several hours together with sharp and lingering pain with cold testing) with/without symptomatic apical periodontitis, hemostasis and/or disinfection by applying saline, NaOCl or KTP laser, and a minimum of 12-month follow-up period after treatment. Patients who met the inclusion criteria were invited to participate in the study by telephone interview. Informed consent was obtained from all patients. A diagram of the workflow present study is shown in Fig. 1.

Fig. 1.

A diagram of the work flow

Treatment protocol

In the treatment visits, pulpotomy was performed under local anesthesia (Maxicaine Fort, VEM, Turkey) and rubber dam isolation. After removing caries and the infected dentin, the exposed pulp tissue was removed to the level of canal orifices using a sterile bur with water coolant. A pellet soaked with physiological saline was used to achieve initial hemostasis. After controlling initial hemostasis, exact hemostasis was randomly done with saline, 2.5% NaOCl, or KTP laser. In cases treated with saline, hemostasis was achieved by the application of a saline-soaked cotton pellet placed over the canal orifices and into the pulp chamber, applied for 2 min, and repeated if required for up to 6 min. In cases treated with NaOCl, hemostasis was achieved as described in the PS group (2.5% NaOCl was used instead of saline). In cases treated with a KTP laser, hemostasis was achieved by exposure to a KTP laser at 1.5 W (532 nm, 300 μm, Ton 100 ms, Toff 100 ms) (SmartLite D; Deka, Calenzano FI, Italy) in noncontact mode, applied for 2 s, and repeated if required for up to 6 s.

After achieving hemostasis, at least a 2-mm-thick layer of MTA (Angelus, Londrina, Brazil) was placed over the pulp chamber floor and the canal orifices. Subsequently, a moist cotton pellet was placed over the MTA to provide moisture for the setting. The teeth were restored with a glass ionomer cement temporarily. After 1-week permanent restoration was performed using resin composite (3 M ESPE, St. Paul, MN, USA) under a rubber dam isolation to prevent contamination. Almost all periapical radiographs (preoperative and postoperative) were taken using a parallel film holder (Endo-Bite, Kerr) under standard exposure conditions. At the end of the active treatment period, patients were followed up for 12- month.

Data collection

The information obtained from the clinical and radiographic records of each patient was assessed by 2 physicians who had the knowledge and skills to perform pulpotomy. Any disagreement was resolved through discussion. Demographic data included patient age and gender, while clinical and radiographic data included tooth type, presence/absence of preoperative percussion, presence/absence of periapical radiolucency, hemostasis and disinfection protocol, and bleeding time. Data on pulp necrosis, periapical lesions, internal resorption, dentin bridge formation, and root canal obliteration were obtained from the follow-up records.

Assessment of treatment outcome

As in previous studies [14, 16], the evaluation of treatment results is based on both clinical and radiological findings. For the treatment to be considered successful, both clinical and radiographic evaluations must be successful. The case was considered clinically successful if there were no clinical signs and symptoms such as pain, swelling, and sinus tract. Cases with complete radiographic healing or reduced radiolucency were considered radiographically successful.

Statistical analysis

In the present study, when α = 0.05 β = 0.20 1- β = 0.80 was taken, at least 65 participants (Saline (22), NaOCl (22), KTP laser (21)) were required for the results to be significant (PASS 2008 Home- Power analysis and simple size). The data were analyzed using the Statistical Package for Social Sciences (IBM SPSS 23.0) Software program. Fisher exact test and chi square test (Monte Carlo method) were used to evaluate the data. One-way ANOVA for independent groups is used. The level of significance was set at α = 0.05.

Results

During June 2020 to February 2022, Records from 161 patients who underwent total pulpotomy because of being diagnosed with SIP were gathered. When patient records were reviewed, 60 patients were eliminated from the study because they had a pulpotomy with calcium hydroxide, 1 because of the immature apex, and 35 because of insufficient follow-up period of at least 12- month. The remaining 65 patients (who were able to complete the 12-month follow-up and met the inclusion criteria) were included in the study and analyzed (Fig. 1). Table 1 shows analyses of preoperative/intraoperative demographic, clinical, and radiographic data. Data analysis revealed no statistical difference among the groups in terms of age (P > 0.05), gender (P > 0.05), preoperative percussion (P > 0.05), bleeding duration (P > 0.05), and preoperative periapical radiolucency (P > 0.05), except for tooth distribution (P < 0.05). The overall success rate was 87.69% (57/65) in 12-month follow-up. The saline group showed a success rate of 86.4% (19/22), the NaOCl group 86.4% (19/22), and the KTP laser group 95.5% (19/21). 12-month follow-up success was not significantly different between hemostasis and cavity disinfection procedures (Table 2) (P > 0.05). Eight (3 of the PS, 3 of the NaOCl, and 2 of the KTP laser) cases resulted in failure. Radiographically successful and failures case examples were exhibited (Figs. 2 and 3).

Table 1.

Preoperative/intraoperative Demographic, Clinical, and radiographic data

	Saline (n = 22)	NaOCl (n = 22)	KTP laser (n = 21)	P value
Demographics data
Age, n (%)
15–20	12 (54.5%)	5 (22.7%)	8 (38.1%)	0.303
21–49	9 (40.9%)	16 (72.7%)	12 (57.1%)
≥ 50	1 (4.5%)	1 (4.5%)	1 (4.8%)
Gender, n (%)
Male	6 (27.3%)	7 (31.8%)	7 (33.3%)	0.904
Female	16 (72.7%)	15 (68.2%)	14 (66.7%)
Preoperative percussion
Yes	20 (90.9%)	20 (90.9%)	20 (95.2%)	0.829
No	2 (91.1%)	2 (91.1%)	1 (4.8%)
Bleeding Timei n (%)
≤ 5	16 (72.7%)	19 (86.4%)	19 (90.5%)	0.264
> 5	6 (27.3%)	3 (13.6%)	2 (9.5%)
Distribution of teeth, n (%)
Maxillar	9 (40.9%)	2 (9.1%)	4 (19.0%)	0.038*
Mandibular	13 (59.1%)	20 (90.9%)	17 (81.8%)
Preoperative periapical radiolucency
Yes	2 (9.1%)	4 (18.2%)	2 (9.5%)	0.587
No	20 (90.9%)	18 (81.8%)	19 (90.5%)

* P < 0.05 indicates significant difference

Table 2.

Comparison of treatment outcomes in different factors

Factors	Treatment outcomes		P value
	Success, n(%)	Failure, n(%)
Age, n (%)
15–20	23 (40.4%)	2 (25.0%)	0.503
21–49	31 (54.4%)	6 (75.0%)
≥50	3 (5.3%)	0
Bleeding time, n (%)
≤5	47 (82.5%)	7 (87.5%)	0.592
>5	10 (17.5%)	1 (12.5%)
Hemorrhage control agent, n (%)
Saline	19 (33.3%)	3 (37.5%)	0.895
NaOCl	19 (33.3%)	3 (37.5%)
KTP Laser	19 (33.3%)	2 (25.0%)
Preoperative periapical lesion, n (%)
Present	7 (12.3%)	1 (12.5%)	0.673
Absent	50 (87.7%)	7 (87.5%)
Preoperative percussion tenderness n (%)
Present	52 (91.2%)	8 (100%)	0.507
Absent	5 (8.8%)	0
Distribution of teeth, n (%)
Maxillar	14 (26.6%)	1 (12.5%)	0.403
Mandibular	43 (75.4%)	7 (87.5%)

* P < 0.05 indicates significant difference

Fig. 2.

Radiographic images of the cases with preoperative periapical rarefaction; A refers to preoperative radiographs, and B refers to lesion healing in 12 months follow-up radiograph

Fig. 3.

A 18-year-old female patient diagnosed with SIP (Tooth #36). MTA pulpotomy was performed. B at 7 months, a lesion was detected in the mesial root and was evaluated as a failure

Patients’ ages ranged from 15 to 54 years, with a mean age of 26. According to our data; age, bleeding time, hemorrhage control procedure, periapical radiolucency, preoperative percussion, did not have a statistically significant effect on the 12-month success rate (Table 2).

In MTA pulpotomy of teeth with periapical radiolucency (8 teeth; 2 Saline, 4 NaOCl, 2 KTP laser), where different hemostasis and disinfection protocols were applied, healing of the lesion was detected in 87,5% of the cases (7teeth; 1 Saline, 4 NaOCl, 2 KTP laser).

Dentin bridge formation was detected in 4 teeth (2 Saline, 3 KTP laser) and pulp obliteration was detected in 1 tooth (KTP laser). No statistically significant difference was observed between the groups in terms of dentin bridge formation and pulp obliteration (Table 3; Figs. 4 and 5).

Table 3.

Comparison of treatment outcomes

	Saline (n = 22)	NaOCl (n = 22)	KTP Laser (n = 22)	P value
Radiographically visible dentin bridge formation, n (%)
Visible	2 (9.1%)	0 (0%)	2 (9.5%)	0.336
Not visible	20 (90.9%)	22 (100%)	19 (90.5%)
Pulp obliteration n (%)
Visible	0 (0%)	0 (0%)	1 (4.8%)	0.345
Not visible	22 (100%)	22 (100%)	20 (95.2%)

* P < 0.05 indicates significant difference

Fig. 4.

Radiographic images of the cases with dentin bridge formation; A refers to preoperative radiographs, and B refers to the 12-month follow-up. The arrows in B indicate dentin bridge formation

Fig. 5.

The lower right first molar in a 20-year-old male patient with clinical symptoms of irreversible pulpitis. A The Preoperative. B postoperative after MTA pulpotomy. C The 12-month follow-up showed dentin bridge formation (arrows) in the distal root with exhibited pulp obliteration

Eight patients failed. There were signs of pulpitis in 3 patients (1 saline, 1 NaOCl, 1 KTP laser). Lesion development was observed in 4 cases (1 saline, 2 NaOCl, and 1 KTP laser). One case was extraction, the reason is unknown (1 KTP laser). All failed patients received RCT, with one patient requiring extraction owing to crown fracture. Internal resorption was not detected in any tooth.

Discussion

RCT has been considered as a treatment of choice for permanent teeth diagnosed with SIP. RCT is a reliable way to eliminate pulp infection in patients diagnosed with SIP. But unfortunately, the remaining healthy pulp is also removed [4]. Thus, the potential of the pulp repair and immune defense mechanism is completely lost. Over time, with the development of materials and techniques and a better understanding of the healing ability of the pulp, VPT has been practiced as an alternative to RCT [2]. Since the bacteria are one of the main causes of irreversible pulp disease the present study evaluated the data regarding MTA pulpotomy in which different hemostasis and disinfection protocols were applied in patients with SIP. The overall success rate was 87.69% (57/65) in the present study. MTA pulpotomy of permanent teeth with symptomatic irreversible pulpitis showed a high success rate in the present study, as in numerous studies [1, 17].

Hemostasis is one of the critical steps affecting success in pulpotomy treatments. Clot formation in the exposed pulp area prevents direct contact with the capping material and pulp tissue [18]. Especially in pulpotomies performed on teeth with SIP, effective hemostasis, and cavity disinfection to remove the remaining dentin chips and prevent clot formation plays a key role in the long-term success. The disinfection protocol is a crucial step in the VPT of permanent teeth with SIP, since the degree of inflamed pulp and whether there will be bacteria in the remaining tissue is impossible to determine clinically in pulpotomy treatments applied to teeth with SIP [4]. Various antimicrobial materials, hemostatic agents and techniques have been proposed for use in VPT [9, 10, 18]. Various types of lasers are used in dentistry due to their properties such as reducing the risk of contamination, providing a sterile surgical field, and hemostasis [19]. The dental pulp is affected by temperature increase (5.5 °C is critical) [11]. Nammor et al. [20] evaluated the optimal irradiation conditions of the KTP laser. The authors concluded that the KTP laser used at appropriate values can be used safely without causing thermal damage to the pulp and periodontal tissue.

KTP laser was preferred in this study due to its similarity to the Nd: YAG laser, such as effective hemostasis control and lower temperature increase. Nd: YAG laser is commonly used in the treatment of soft tissues during surgical procedures due to its effective photothermal properties, as well as its superior hemostatic and bactericidal effects [21]. The KTP laser is known to provide excellent hemostasis by effectively controlling bleeding. This effect is attributed to the fact that the energy of the KTP laser is absorbed exclusively by hemoglobin, enabling a contactless application through a mechanism known as photoselective vaporization of the tissue [22, 23]. Furthermore, the application of low-power KTP laser has been reported to enhance wound healing, potentially through its biomodulatory effects [22]. Fornaini et al. [11] examined the thermal rise caused by 4 different lasers (diode, Nd: YAG, Er: YAG, KTP) used in oral surgical procedures. Accordingly, Er: YAG and KTP laser caused a lower temperature increase. NaOCl has been reported to remove the dentin chips and damaged tissue from the pulp chamber, is biocompatible with pulp cells, is not toxic, and provides hemostasis [18, 19]. Ramani et al. [17] have shown healing and dentin formation in MTA pulpotomy of permanent teeth with SIP in which hemorrhage was controlled with 3% percent NaOCl. Akçay et al. [18] evaluated histologically the results of pulpotomy (CH/MTA) in which they applied NaOCl or saline as a cleaning agent. As a result, they stated that there was no statistical difference between saline and NaOCl and the selection of the appropriate pulp capping agent in VPT was more important than the cleaning agent. Kakehashi et al. [24] evaluated the healing of the pulp (surgically exposed in germ-free rats). The authors stated that the pulp healed without the application of therapeutic agents which supports the present study’s results. Canoğlu et al. [25] evaluated the effects of different medicaments (saline, Ferric Sulfate and NaOCl) and pulp capping materials (calcium hydroxide or MTA) on VPT. The authors concluded that the effect of hemorrhage control solutions used was insignificant on VPT success. In the present study, no statistically significant difference was observed between the three (saline, NaOCl, and KTP laser) various hemostasis and disinfection procedures. According to the findings of our retrospective study, the success of pulpotomy treatment depends on completely removing the inflamed pulp under aseptic conditions and providing a leak-proof restoration by covering it with biocompatible material rather than the hemostasis and disinfection materials used. The healing ability of the remaining radicular pulp may have been effective in the results of present study [16].

Periapical inflammation develops before total pulp necrosis. Deep caries can cause inflammation of the pulp. Therefore, periapical radiolucency may not always occur due to necrosis of the pulp but may also occur in vital teeth. The development of periapical pathology associated with the vital pulp is caused by neurogenic inflammation associated with bacterial products that cause the release of inflammatory mediators, cytokines, and neuropeptides such as substance P from the afferent fibers that feed the pulp and periapical tissue. Healing can be achieved if the stimulus is eliminated with VPT [1, 16]. In the present study, most cases with periapical radiolucency healed. (8/7; 2/1 Saline, 4/4 NaOCl, 2/2 KTP laser). In addition, the presence/absence of periapical lesion did not affect the success outcome, and no statistically significant difference was observed between hemostasis and disinfection procedures in terms of lesion healing.

Hard tissue barrier or bridge formation may occur at orifices after pulpotomy. The formation of a hard tissue barrier reduces the possibility of leakage. The constant accumulation of hard tissue can also lead to narrowing and destruction of the canal [17]. In this study, pulp obliteration was detected in one case, which was similar to other studies [1, 13] in which pulp obliteration was not detected after pulpotomy. In present study, dentin bridge formation was detected in 5/65 patients, which is similar to the previous studies results of 5/52 [26] and 4/64 [1]. Discoloration was not observed in any case in this study. In the present study, no statistically significant difference was observed between the disinfection and hemostasis procedures in terms of dentin bridge formation and pulp obliteration. Future studies are required to use cone-beam computed tomography for a better understanding of hard tissue formation. The reliable method for determining the condition of the remaining pulp is histological examination. Pulp sensitivity tests were not utilized as success criteria in this study, as they may yield unreliable results due to the complete removal of the coronal pulp [16].

The duration of hemostasis in VPT is a controversial issue. While some studies [27, 28] state that hemostasis duration affects the success of VPT, others [13, 29], state that it is insignificant. In the present study, the effect of the hemostasis time on the success was insignificant. Additionally, pulpotomy treatment of all 11 teeth with a bleeding time of greater than 5 min (6 min) was successful. MTA has been preferred in various pulpotomy studies due to its superior properties such as sealing ability, biocompatibility, antibacterial and antifungal properties, induction of growth factors, dentinogenic activity and encouraging clinical outcomes [13, 27]. Sharma et al. [30] evaluated the effect of biological markers on MTA pulpotomy in patients with SIP. The success rate was 88% after 12-month of follow-up. Ramani et al. [17] evaluated the success of partial and total MTA pulpotomy in permanent (mean age of 23.81 years) teeth with SIP. The authors reported that the success rate of total MTA pulpotomy was 89.8% (44/49) after 12-month. In current study, the success rate of MTA pulpotomy performed on the permanent molars of patients with SIP was 87.69% during the 12-month follow-up period. Additionally, numerous pulpotomy studies have reported success rates at 12-month follow-up. This study included a 12-month follow-up, consistent with other studies [1, 17, 31, 32]. Removing the inflamed pulp and applying MTA along with hemostasis control prepare the environment for the injured pulp to heal and immune inflammatory cells gradually decrease (Apoptosis) [27].

In the present study, 8 cases were evaluated as failures. In these cases, either the development of pulpitis or periapical lesions was observed. An incorrect clinical decision regarding the degree of pulpal inflammation may have resulted in the uncontrolled deterioration of the remaining pulp. Additionally, case selection and/or flaws in the treatment protocol may have played a role in the unfavorable outcomes [16]. One of the potential causes of failure is microleakage due to inadequate coronal restoration. However, no restoration defects or mismatches were observed in any of the failed cases.

Previous pulpotomy studies have reported that age has no effect on success. For example, in the study of Asgary et al. [3], the age range of the patients was 14–60 and in the study of Linsuwanont et al. [16], it was 7–68. In present study, this range was 15–54, which is consistent with other studies.

The findings of the present study supported the null hypothesis, indicating that the hemostasis procedures (saline, NaOCl, or KTP laser) had no statistically significant impact on the clinical success of MTA pulpotomy.

One of the limitations of the present study is the difficulty of follow-up. The follow-up period in present study was 12-month. 6-month follow-up after VPT is sufficient [33]. However, studies with longer follow-ups are needed to understand better the success of VPT.

The definition of irreversible pulpitis is based on subjective findings and that histological examination is required to understand the true state of the pulp precisely [8]. The results of present study, which shows a high success rate of pulpotomy in patients with SIP, are supported by studies [1, 17, 27, 30]. The success of pulpotomy in patients with SIP considering both dentin bridge formation and lesion healing cannot be ignored. In this context, future studies on biological markers that can indicate the level of pulp disease may make diagnosis and treatment methods reliable [30].

Conclusions

MTA pulpotomy is an effective treatment for permanent molars with SIP. Physiological saline, NaOCl, or KTP laser can be used in MTA pulpotomy. Pulpotomy is a simpler, faster, and less expensive procedure than RCT. Recent studies have shown that pulpotomy can be effective in treating SIP.

Abbreviations

PS

Physiological saline

SIP

Symptomatic irreversible pulpitis

RCT

Root canal treatment

VPT

vital pulp therapy

Authors’ contributions

M.A: participated in the design of the study, treatments, writing the manuscript, collection, and interpretation of data, statistical analysis, and revised the manuscript. D.A: participated in the design of the study, writing the introduction and interpretation of data. İ.A: participated in the design of the study, patient follow-up and periapical film evaluation. The final draft was read and approved by all authors.

Funding

This research received no funding.

Data availability

Data availability the datasets used in the current study are available through the corresponding author upon justifiable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Ethics Committee of Sivas Cumhuriyet University (ethics committee code: 2023-06/03). In the present study, STROBE guidelines were followed. The authors certify that the study was conducted in accordance with human ethical standards, based on the principles of the Helsinki Declaration. Informed consent was obtained from all patients.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.