Intraoperative Identification of Vital Radicular Pulp in a Tooth Diagnosed with Pulp Necrosis: Four-Year Outcome of...

Teeth diagnosed clinically with pulp necrosis and apical periodontitis may occasionally retain vital radicular pulp tissue despite negative sensibility test responses. Such diagnostic discrepancies highlight the limitations of conventional pulp testing and may create opportunities for biologically based treatment approaches. This case report describes the successful management of a mature permanent molar initially diagnosed as necrotic but found intraoperatively to contain vital radicular pulp tissue. A 36-year-old healthy patient presented with pain on chewing and tenderness to percussion in the left mandibular second molar. Clinical and radiographic examination revealed severe coronal destruction, a periapical radiolucency, and a negative response to cold testing, leading to a preoperative diagnosis of pulp necrosis with apical periodontitis and a treatment plan for root canal therapy. However, during access cavity preparation, profuse bright-red bleeding from the canal orifices indicated retained vital radicular pulp tissue. Consequently, treatment was changed to full pulpotomy. Because hemostasis could not be achieved after 5 minutes using 2.5% sodium hypochlorite-soaked cotton pellets, a tampon technique was performed with calcium-enriched mixture cement placed over the radicular pulp stumps, followed by definitive restoration. The patient became symptom-free within one week and remained asymptomatic throughout the 4-year follow-up period. Radiographic examination demonstrated complete resolution of the periapical lesion, re-establishment of the lamina dura, and normalization of the periodontal ligament space. This case demonstrates that teeth initially diagnosed as necrotic may still harbor maintainable vital radicular pulp tissue. Careful intraoperative assessment can alter both diagnosis and treatment strategy. Full pulpotomy using an endodontic biomaterial and a tampon technique resulted in complete clinical and radiographic healing over four years.