Irreversible pulpitis in mature permanent teeth represents a critical juncture in dental treatment decision-making [1]. Defined by the American Association of Endodontists (AAE) as a state of inflammation in which the dental pulp cannot recover its normal state, irreversible pulpitis is often characterized by spontaneous, lingering pain, and sensitivity to temperature changes [2]. This condition typically escalates from a reversible stage, where the pulp is inflamed but capable of healing, to an irreversible stage [3]; the latter often necessitates intervention to alleviate pain and prevent further infection. Irreversible pulpitis is often the result of untreated, deep to very deep dental caries that leads to invasion of the dental pulp by bacteria and their toxins [4,5]. It may also be caused by traumatic injury that exposes the pulp to bacteria invasion via fractures and cracks [6], bacterial leakage from open restorative margins [7], excessive heat generated from restorative procedures without adequate cooling [8,9], as well as advanced periodontal disease that exposes the root dentin to bacterial invasion of the pulp [10,11].

The management of irreversible pulpitis in mature permanent teeth has seen significant shifts in recent years. Traditionally, irreversible pulpitis requires non-surgical root canal treatment (NSRCT) to relieve pain, and to remove infectious bacteria and inflammatory mediators [12]. This involves extensive cleaning, shaping, and filling of the root canal system to avert reinfection, usually over one or two sessions [13]. The rise of minimally-invasive dentistry principles has led to a paradigm shift toward preserving maximum natural tooth structure [14], [15], [16]. In addition, it has become increasing apparent that the status of pulpitis is not as clear-cut as what was previously thought [17,18]. The binary classification of pulpitis by the AAE into reversible or irreversible status has been contested for not adequately capturing the complexities and variations in pulpal responses to pathological stimuli [19]. The more recently introduced Wolters classification system, which categorizes pulpitis into initial, mild, moderate, and severe stages, provides an alternative interpretation of disease progression [20]. This alternative classification of pulpitis has been reported by some to be a reasonable predictor of treatment outcomes [21].

Driven by contemporary philosophies, the resurgence of interest in vital pulp therapy (VPT) has redefined the approach to preserving pulp tissue health and functionality following trauma, caries, or restorative procedures [22,23]. Vital pulp therapy encompasses treatments like pulp capping, partial pulpotomy, and full pulpotomy, and has emerged as a viable alternative to NSRCT in certain cases [24]. Among the different forms of VPT, pulpotomy is a well-established treatment procedure for primary teeth, and for promoting apexogenesis and increase in root dentin thickness in immature permanent teeth [25]. Pulpotomy is now increasingly considered as an alternative treatment procedure for mature permanent teeth with irreversible pulpitis [26], and even in cases with radiographic evidence of apical periodontitis [27]. The effectiveness of pulpotomy in mature permanent teeth hinges on the precision of the procedure and the materials used [28]. Hydraulic calcium silicate cements, such as Mineral Trioxide Aggregate (MTA), Calcium-Enriched Mixture (CEM), and Biodentine (Septodont, Saint-Maur-des-Fossés, France), have emerged as the preferred materials due to their biocompatibility, sealing ability, and bioactive potential to stimulate healing and pulp tissue regeneration [29,30].

Recent clinical studies and systematic reviews are beginning to recognize the potential of pulpotomy in managing irreversible pulpitis in mature permanent teeth with close apices [24,31]. The high success rates highlighted in these studies suggest that pulpotomy could be an effective substitute for NSRCT in managing irreversible pulpitis, even in challenging scenarios. While extensive systematic reviews of randomized control trials and prospective studies have evaluated pulpotomy outcomes in both immature and mature permanent teeth with irreversible pulpitis, as well as in mature teeth with both reversible and irreversible pulpitis [[32], [33], [34], [35], [36],30], the focus on mature permanent teeth with irreversible pulpitis has been limited to just four qualitative systematic reviews [37], [38], [39], [40]. Another systematic review that conducted a quantitative analysis focused solely on patient-reported post-operative pain, without providing a comprehensive meta-analysis of clinician-reported treatment outcomes [41]. A recently published article proposed a prospective meta-analysis of individual participant data from a series of randomized trials, with the aim of generating more definitive evidence on pulpotomy versus NSRCT outcomes; nevertheless, its results are still pending [42].

These limitations highlight the need for further research with more standardized methodologies and inclusion of broader literature. Despite the prevalent issues of underpowered studies and potential biases, the present systematic review and meta-analysis aimed to comprehensively evaluate the efficacy of pulpotomy as a treatment modality for irreversible pulpitis in mature permanent teeth, based on data derived from randomized controlled trials and prospective studies. In addressing these research gaps, this study first evaluated the overall success rates of coronal pulpotomy using data from both single-arm and parallel-arm clinical trials, through meta-analyses that focused on both parallel-arm and single-arm data (first objective). The study then compared the clinical effectiveness of pulpotomy against standard NSRCT (second objective), assessed the efficacy of pulpotomy techniques including full and partial pulpotomy (third objective), and compared the efficacy of different contemporary bioactive pulpotomy materials on clinical outcomes (fourth objective).

The significance of this study lies in its potential to influence clinical practices and treatment planning in endodontics. By evaluating the efficacy of less invasive alternatives, this research may herald a shift toward more conservative, patient-centric approaches to managing irreversible pulpitis. This shift is particularly pertinent for patients for whom NSRCT may not be viable due to financial, medical, or other constraints. Furthermore, the present study seeks to contribute to the dental community's continuing dialogue about preserving natural tooth structure and embracing minimally-invasive treatment options.