Diagnostic Agreement, Postoperative Pain, and Vital Pulp Therapy Outcomes: A Prospective Clinical Evaluation of 11-Item Pulp Pain Assessment Tool

This prospective, single-center clinical study was designed to evaluate the diagnostic performance of the 11-item Pulp Pain Assessment Tool (PPAT-11) and its agreement with established clinical classifications of pulpitis. The study also investigated the relationship between baseline PPAT-11 scores and postoperative clinical outcomes, including pain, analgesic consumption, and long-term outcomes following vital pulp therapy (VPT).

Pulpal status was assessed before treatment using three approaches: the American Association of Endodontists (AAE) classification, the Wolters classification, and PPAT-11. Assessments were conducted face-to-face by an experienced endodontist using a standardized sequence. The PPAT-11 generates a cumulative score ranging from 11 to 44, with higher scores indicating greater symptom burden. The previously proposed cut-off score of 25 was applied without recalibration.

Treatment allocation was determined by the prespecified PPAT-11 threshold. Patients scoring below 25 underwent VPT, consisting of direct or indirect pulp capping according to clinical findings, whereas patients scoring 25 or higher received root canal treatment (RCT). All treatments were performed by the same operator in a single visit under rubber dam isolation using standardized clinical procedures.

Postoperative assessments included patient-reported pain intensity and analgesic consumption during the first seven days. Patients who underwent VPT received additional clinical and radiographic follow-up at 6 and 12 months to evaluate treatment outcomes.

The study was intended to investigate whether PPAT-11 could provide complementary quantitative information regarding pulpal symptom severity and whether baseline scores were associated with postoperative symptoms and subsequent VPT outcomes. Diagnostic agreement, longitudinal postoperative pain, analgesic consumption, and long-term VPT outcomes were evaluated using appropriate statistical methods.

In this study, treatment planning was based on the total score obtained from the Youden symptom scoring system. Patients with scores below 25 were diagnosed with reversible pulpitis and treated with vital pulp therapy. Indirect pulp capping was performed in cases where no pulp exposure occurred during caries removal. Direct pulp capping was performed in cases where pulp exposure occurred during caries removal but the clinical and symptomatic findings were consistent with a diagnosis of reversible pulpitis.

Other: Vital pulp therapy procedure based on the total score obtained from the Youden symptom scoring system

Patients with scores of 25 or higher were diagnosed with irreversible pulpitis and treated with root canal therapy, to ensure standardized and reproducible treatment allocation.

Other: Root canal treatment procedure based on the total score obtained from the Youden symptom scoring system

All procedures were performed under rubber dam isolation, in a single visit, and by a single operator. For root canal treatment, pulp extirpation was performed after access cavity preparation and canals were shaped with rotary nickel-titanium instruments. A standardized irrigation protocol was applied using 2.5% sodium hypochlorite during and after instrumentation, followed by 17% EDTA for smear layer removal. All irrigants were activated by passive ultrasonic irrigation in three 20-second cycles. After irrigation, canals were dried with sterile paper points and obturated with gutta-percha and a resin-based sealer using the cold lateral compaction technique. All teeth received permanent coronal restorations.

All procedures were performed under rubber dam isolation, in a single visit, and by a single operator. Indirect pulp capping was performed in cases where no pulp exposure occurred during caries removal. In teeth with deep dentin caries but preserved pulpal integrity, all carious tissue was removed while maintaining a thin layer of dentin adjacent to the pulp, and indirect pulp capping was subsequently performed. After confirming the absence of pulp exposure through clinical examination, mineral trioxide aggregate (MTA) was applied to the dentin surface adjacent to the pulp.

Direct pulp capping was performed in cases where pulp exposure occurred during caries removal but the clinical and symptomatic findings were consistent with a diagnosis of reversible pulpitis. Following pulp exposure, hemostasis was achieved. After adequate hemostasis was obtained, MTA was applied to the exposed pulp tissue. Permanent coronal restoration of all teeth were performed.

Time frame: Baseline (before treatment)

Diagnostic agreement between the 11-item Pulp Pain Assessment Tool (PPAT-11) and the American Association of Endodontists (AAE) and Wolters classifications, evaluated using Cohen's kappa coefficient. PPAT-11 scores below 25 and scores of 25 or higher were classified as reversible and irreversible pulpitis, respectively.

Time frame: Up to 7 days after treatment

Postoperative pain intensity assessed using a 0-100 mm visual analogue scale (VAS). Patients recorded the maximum pain experienced during six postoperative intervals: 0-8, 8-24, 24-48, 48-72, 72-120, and 120-168 hours.

Time frame: Up to 7 days after treatment

Analgesic use recorded during the first 7 days after treatment, assessed as the proportion of patients reporting any analgesic consumption.

Time frame: 6 and 12 months after treatment

Clinical and radiographic success of vital pulp therapy assessed according to symptoms, pulp sensibility responses, clinical and radiographic findings, and the need for further endodontic intervention.

Diagnostic Agreement, Postoperative Pain, and Vital Pulp Therapy Outcomes