Salvadora Persica-Zinc Oxide Versus MTA as Pulpotomy Agents in Mature Permanent Molars With Irreversible Pulpitis

Comparative Clinical and Radiographic Evaluation of Salvadora Persica Extract Mixed With Zn Oxide Powder Versus Mineral Trioxide Aggregate as a Pulpotomy Agent in Mature Permanent Posterior Teeth With Irreversible Pulpitis

Pulpotomy has emerged as a conservative treatment option for mature permanent teeth with irreversible pulpitis, aiming to preserve pulp vitality while avoiding the limitations of conventional root canal treatment. Mineral Trioxide Aggregate (MTA) is currently considered the gold standard pulpotomy medicament because of its favorable biological properties; however, its high cost, difficult handling characteristics, and prolonged setting time limit its widespread use. Salvadora persica (Miswak), a medicinal plant with documented antibacterial and anti-inflammatory properties, may provide a cost-effective biological alternative.

This randomized controlled clinical trial aims to compare the clinical and radiographic outcomes of Salvadora persica extract mixed with zinc oxide powder versus MTA as pulpotomy agents in mature permanent posterior teeth diagnosed with irreversible pulpitis. A total of 78 patients aged 18-40 years will be randomly allocated into two equal treatment groups. Clinical outcomes, including pain, tenderness to percussion and palpation, swelling, sinus tract formation, and tooth mobility, will be evaluated alongside radiographic outcomes such as periapical/inter-radicular radiolucency and internal resorption. Participants will be followed for six months after treatment.

The study seeks to determine whether Salvadora persica extract mixed with zinc oxide powder can provide outcomes comparable to MTA. If successful, this natural and economical material may offer an accessible alternative for vital pulp therapy, particularly in low-resource settings, promoting tooth preservation and reducing the need for more invasive endodontic procedures.

Irreversible pulpitis is a common consequence of deep dental caries and represents one of the primary causes of dental pain and emergency dental visits. If left untreated, the condition may progress to pulpal necrosis and periapical pathology, ultimately resulting in tooth loss. Conventional management of irreversible pulpitis in mature permanent teeth typically involves root canal treatment (RCT), which has demonstrated high success rates. However, RCT is an invasive, technique-sensitive, time-consuming, and relatively costly procedure that requires extensive removal of tooth structure and may not always be readily accessible in resource-limited settings.

Recent advances in the understanding of pulpal healing and regeneration have led to increased interest in conservative treatment approaches such as Vital Pulp Therapy (VPT). Pulpotomy, a form of VPT, involves removal of the inflamed coronal pulp while preserving the vitality and function of the healthy radicular pulp. Emerging evidence suggests that pulpotomy can serve as a definitive treatment for mature permanent teeth diagnosed with irreversible pulpitis, provided there is no evidence of pulpal necrosis or significant periapical pathology. This approach offers several advantages, including preservation of tooth structure, reduced treatment time, lower treatment costs, and maintenance of the tooth's natural defense and proprioceptive functions.

The success of pulpotomy is largely dependent on the biological and physical properties of the medicament placed over the remaining pulp tissue. Mineral Trioxide Aggregate (MTA) is currently considered the gold standard pulpotomy material because of its excellent biocompatibility, sealing ability, antibacterial properties, and capacity to promote hard tissue formation. Despite these advantages, its widespread use is limited by high cost, prolonged setting time, difficult handling characteristics, and challenges associated with retreatment when necessary.

Salvadora persica (Miswak) is a medicinal plant that has been used traditionally for oral hygiene for centuries. It possesses well-documented antibacterial, anti-inflammatory, antioxidant, and anti-cariogenic properties. The plant contains several bioactive compounds that have demonstrated effectiveness against oral pathogens and may support tissue healing. Previous studies have investigated the use of Salvadora persica in various dental applications, including intracanal medicaments, oral hygiene products, and pulpotomy procedures in primary teeth, yielding promising outcomes. However, there is limited clinical evidence regarding its use as a pulpotomy medicament in mature permanent teeth with irreversible pulpitis.

The present randomized controlled clinical trial aims to compare the clinical and radiographic outcomes of Salvadora persica extract mixed with zinc oxide powder and Mineral Trioxide Aggregate when used as pulpotomy agents in mature permanent posterior teeth diagnosed with irreversible pulpitis. A total of 78 participants aged 18 to 40 years will be randomly allocated into two equal treatment groups. Following pulpotomy procedures, participants will be evaluated clinically and radiographically over a six-month follow-up period.

Clinical outcomes will include assessment of pain, tenderness to percussion, tenderness to palpation, swelling, sinus tract formation, and tooth mobility. Radiographic outcomes will include evaluation of periapical and inter-radicular radiolucency, internal resorption, and other signs indicative of pulpal or periapical disease progression. The primary objective is to determine whether Salvadora persica extract mixed with zinc oxide powder can achieve clinical and radiographic success rates comparable to those of MTA.

The findings of this study may provide evidence for a natural, biologically favorable, and cost-effective alternative to MTA for pulpotomy procedures. If proven effective, Salvadora persica-based pulpotomy therapy could expand access to conservative dental treatment, reduce dependence on expensive biomaterials, and support preservation of natural teeth, particularly in low-resource healthcare settings.

Inclusion Criteria:

• 1. Co-operative healthy patients both male and female with age ranging from 18-40 years. 2. Mature permanent molar teeth with caries extending deep into dentine more than two third on bite wing x ray 3. Teeth with clinical signs and symptoms of irreversible pulpitis i.e. spontaneous lingering pain that can be reproduced with a cold test 4. Teeth not painful to percussion and palpation. 5. Teeth in which hemostasis can be achieved within 5 mins. If not achieved individual will be excluded from the study 6. No peri-apical rarefaction, and inter-radicular rarefaction as seen on periapical x-ray.

Exclusion Criteria:

• 1. Small carious lesion or lesions not extending deep into dentine closer to pulp 2. Grossly carious teeth with necrosed pulp 3. Teeth with swelling, abscess and sinus tract. 4. Periodontally compromised teeth 5. Immature permanent teeth with open apex 6. Fractured teeth 7. Teeth with signs of internal or external resorption 8. Patients with systemic diseases i.e. ASA classification III, IV and V will be excluded.