Vital pulp therapy

Outcomes of partial pulpotomy in permanent molars of children with irreversible pulpitis: A prospective cohort study

BACKGROUND

Vital pulp therapy is gaining traction in dental practice, especially for young patients.

AIM

To evaluate the outcomes of partial pulpotomy in permanent molars of children diagnosed with irreversible pulpitis (IP) using iRoot BP Plus.

DESIGN

A total of 94 permanent molars in 88 patients, aged 6-15 years, with symptoms of IP, were treated with partial pulpotomy, using iRoot BP Plus as the pulp capping agent. The treated teeth underwent clinical and radiographic assessments at 1, 6, 12, 18, and 24 months postoperative. The outcomes were determined based on clinical and radiographic criteria by calibrated examiners.

RESULTS

The success rates were 98.4% (63/64), 93.2% (41/44), and 89.7% (26/29) at the 6-month, 12-month, and 24-month follow-up. By the end of this study, the median follow-up period was 15.1 months, and the estimated survival rate was 95.2% at 24 months. Gender, root maturity, and number of missing walls had no significant effect on success rates. Six molars were failed, and root canal therapy (RCT) was applied.

CONCLUSIONS

Partial pulpotomy for permanent molars with IP in young patients using iRoot BP Plus as pulp capping material achieved high success. This method presents a viable alternative to apexification and RCT for treating vital, inflamed molars with IP in children.

Implementing microfluidic flow device model in utilizing dural substitutes as pulp capping materials for vital pulp therapy

Vital pulp therapy (VPT) has gained prominence with the increasing trends towards conservative dental treatment with specific indications for preserving tooth vitality by selectively removing the inflamed tissue instead of the entire dental pulp. Although VPT has shown high success rates in long-term follow-up, adverse effects have been reported due to the calcification of tooth canals by mineral trioxide aggregates (MTAs), which are commonly used in VPT. Canal calcification poses challenges for accessing instruments during retreatment procedures. To address this issue, this study evaluated the mechanical properties of dural substitute intended to alleviate intra-pulp pressure caused by inflammation, along with assessing the biological responses of human dental pulp stem cells (hDPSCs) and human umbilical vein endothelial cells (HUVECs), both of which play crucial roles in dental pulp. The study examined the application of dural substitutes as pulp capping materials, replacing MTA. This assessment was conducted using a microfluidic flow device model that replicated the blood flow environment within the dental pulp. Computational fluid dynamics simulations were employed to ensure that the fluid flow velocity within the microfluidic flow device matched the actual blood flow velocity within the dental pulp. Furthermore, the dural substitutes (Biodesign; BD and Neuro-Patch; NP) exhibited resistance to penetration by 2-hydroxypropyl methacrylate (HEMA) released from the upper restorative materials and bonding agents. Finally, while MTA increased the expression of angiogenesis-related and hard tissue-related genes in HUVEC and hDPSCS, respectively, BD and NP did not alter gene expression and preserved the original characteristics of both cell types. Hence, dural substitutes have emerged as promising alternatives for VPT owing to their resistance to HEMA penetration and the maintenance of stemness. Moreover, the microfluidic flow device model closely replicated the cellular responses observed in live pulp chambers, thereby indicating its potential use as anin vivotesting platform.

3Mixtatin versus MTA in pulp therapy of primary teeth: a systematic review and meta-analysis of current randomized controlled trials

AIM

3Mixtatin (a combination of Metronidazole, Minocycline, and Ciprofloxacin along with statins) is a novel biomaterial in pulp therapy, while Mineral Trioxide Aggregate (MTA) is considered the gold standard in endodontics. This study aimed to compare the clinical and radiographic success rates of MTA and 3Mixtatin in pulp therapy of primary teeth.

METHODS AND MATERIALS

MEDLINE (PubMed), CENTRAL, Web of Science, Scopus, ProQuest databases, and Google Scholar were searched to identify randomized controlled trials (RCTs) on pulp therapy with 3Mixtatin and MTA in primary teeth, published up to February 2023. It should be noted that the protocol was previously registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021243626). RCTs were assessed independently by two researchers in terms of eligibility and quality. Data extracted and tabulated. The Cochrane Risk of Bias (RoB-2) tool was used to assess the risk of bias. The effect sizes were evaluated utilizing risk ratios (RRs). The heterogeneity investigation was conducted utilizing I² measurement at α = 0.10.

RESULTS

Out of 86 retrieval records, four articles met the inclusion criteria. Based on clinical and radiographic outcomes, the application of 3Mixtatin in the pulp therapy of primary teeth was as successful as MTA in 12 months (Clinical RR = 1.087 | Radiographic RR = 2.132). The RoB-2 tool showed a low risk of bias in all included RCTs.

CONCLUSION

The limited evidence showed the clinical and radiographic efficacy of 3Mixtatin as a potential alternative to MTA. Further empirical research with larger sample sizes and strict methodology will be essential to substantiate this assertion.

Chitosan nanoparticle applications in dentistry: a sustainable biopolymer

The epoch of Nano-biomaterials and their application in the field of medicine and dentistry has been long-lived. The application of nanotechnology is extensively used in diagnosis and treatment aspects of oral diseases. The nanomaterials and its structures are being widely involved in the production of medicines and drugs used for the treatment of oral diseases like periodontitis, oral carcinoma, etc. and helps in maintaining the longevity of oral health. Chitosan is a naturally occurring biopolymer derived from chitin which is seen commonly in arthropods. Chitosan nanoparticles are the latest in the trend of nanoparticles used in dentistry and are becoming the most wanted biopolymer for use toward therapeutic interventions. Literature search has also shown that chitosan nanoparticles have anti-tumor effects. This review highlights the various aspects of chitosan nanoparticles and their implications in dentistry.

Peptide KN-17-Loaded Supramolecular Hydrogel Induces the Regeneration of the Pulp-Dentin Complex

Regenerating the pulp-dentin complex remains a decisive factor during apexification for immature permanent teeth. Peptide KN-17, which was modified based on the structure of cecropin B, could effectively interfere with bacterial growth and induce the migration of human bone marrow stromal cells (hBMSCs). This study aimed to investigate the effect of KN-17 on the tissue regeneration. To our surprise, KN-17 can significantly stimulate angiogenesis in vitro and in vivo, which may provide a guarantee for apical closure. Herein, a novel peptide/KN-17 coassembled hydrogel is developed via a heating-cooling process. Npx-FFEY/KN-17 supramolecular hydrogel can induce vessel development, stimulate odontogenic differentiation of human dental pulp stem cells (hDPSCs), and exert an antibacterial effect on Enterococcus faecalis (E. faecalis). Furthermore, coronal pulp excised rat molars are supplied with KN-17 or KN-17-loaded hydrogel and transplanted subcutaneously in BALB/c-nu mice. After 4 weeks, the hydrogel Npx-FFEY/KN-17 stimulates the formation of multiple odontoblast-like cells and dentin-like structures. Our findings demonstrate that the KN-17-loaded hydrogel can promote the regeneration of the pulp-dentin complex for continued root development.

Comparative evaluation of cervical pulpotomy and pulpectomy for primary molars with irreversible pulpitis: a multicentre randomised controlled trial

PURPOSE

The objective of this multicentre randomised controlled trial was to compare the clinical/radiographic outcomes of cervical pulpotomy using calcium-enriched mixture cement (PCEM) and pulpectomy using Metapex (PM) in primary molars with irreversible pulpitis (IP).

METHODS

A total of 134 primary molars from 94 children were randomly assigned to two intervention groups: the PCEM group (n = 74) and the PM group (n = 60). Baseline characteristics including age/gender/molar type/tooth type/jaw were recorded. The primary outcome measures were clinical/radiographic success rates assessed at the first and second follow-up appointments. Secondary outcomes included reasons for clinical/radiographic failures. Multiple logistic regression analysis was performed to determine the impact of various factors on the success rates.

RESULTS

The mean age of the participants in both groups was similar (PCEM group: 5.4 years, PM group: 5.5 years). Gender distribution, molar type, tooth type, jaw, and number of practitioners were comparable between the groups. The clinical success rate at the first follow-up was 98.6% in the PCEM group and 96.4% in the PM group. At the second follow-up, the clinical success rate was 97.1% in the PCEM group and 91.1% in the PM group. The radiographic success rates at the first and second follow-up were 98.6% and 96.4% in the PCEM group and 96.4% and 91.1% in the PM group, respectively. Multiple logistic regression analysis did not reveal any significant association between the success rates and age/gender/molar type/jaw, or treatment groups (P > 0.05).

CONCLUSION

In primary molars with IP, both simple/conservative cervical pulpotomy using calcium-enriched mixture cement and pulpectomy using Metapex demonstrated high clinical/radiographic success rates. No significant differences were observed between the two treatment modalities. These findings suggest that both techniques can be considered effective treatment options for managing primary molars with IP.

TRIAL REGISTRATION NUMBER

Trial registration number: IRCT20201226049838N1, retrospectively registered on 12 January 2021.

Determining Factors in the Success of Direct Pulp Capping: A Systematic Review

AIM

To elucidate the factors that determine the success of direct pulp capping (DPC) in permanent teeth with pulp exposure due to dental caries.

MATERIALS AND METHODS

A comprehensive electronic search from 1980 to 2023 across PubMed, Scopus, and ISI Web databases was conducted using specific keywords and MeSH terms in Q1 or Q2 journals. Only prospective/retrospective clinical studies in English on 15 or more human permanent teeth with carious pulpal exposure treated with DPC agents-mineral trioxide aggregate (MTA), Biodentine, or calcium hydroxide with a rubber dam and minimum 1-year follow-up, were considered. The factors retrieved and analyzed were based on study design, patient age, sample size, type of cavity, exposure size and location, pulp diagnosis, solutions to achieve hemostasis, hemostasis time, capping material, restoration type, follow-up period, methods of evaluation, and overall success.

REVIEW RESULTS

Out of 680 articles, only 16 articles were selected for the present systematic review on application of the selection criteria. A wide age range of patients from 6 to 88 years were considered among these studies with sample sizes ranging from 15 to 245 teeth with reversible pulpitis being the predominant diagnosis of the cases. Mineral trioxide aggregate as a capping material was evaluated in 4 studies as a lone agent, while compared with other capping agents such as biodentine or calcium hydroxide in 7 studies. The follow-up period ranged from 9 days to nearly 80 months. While both clinical and radiographic evaluation was carried out in all studies, cold testing dominated the clinical tests while IOPR was the common radiograph considered. Mineral trioxide aggregate success rate was higher and similar to biodentine than calcium hydroxide.

CONCLUSION

Direct pulp capping has a high and predictable success rate in permanent teeth with carious exposure to reversible and irreversible pulpitis. Currently, mineral trioxide aggregate and biodentine have better long-term results in DPC than calcium hydroxide, hence, they should be used as an alternative to calcium hydroxide. Definitive restoration within a short period improves long-term prognosis.

CLINICAL SIGNIFICANCE

The significance of this review lies in its provision of evidence-based information on the effectiveness of DPC and the factors that influence its success. By considering these factors, clinicians can optimize treatment outcomes and improve the long-term prognosis of the treated teeth. This systematic review serves as a valuable resource for clinicians and researchers in the field of endodontics. How to cite this article: Gomez-Sosa JF, Granone-Ricella M, Rosciano-Alvarez M, et al. Determining Factors in the Success of Direct Pulp Capping: A Systematic Review. J Contemp Dent Pract 2024;25(4):392-401.

Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification

AIM

This report addresses the management of a large persistent discharging lesion in an 11-year-old boy. The report describes the use of aspiration-irrigation technique for the management of immature necrotic tooth with persistent discharge after a failed regenerative procedure.

BACKGROUND

Regenerative endodontics aim to provide an increase in root canal width, length, and in apical closure. Alternative procedures, such as apexification, should be attempted when regeneration fails. If the canal cannot be dried to persistent discharge, the aspiration-irrigation technique can be used. The technique relies on using aspiration along with irrigation to remove pus from the periapical area.

CASE DESCRIPTION

This is a case for an 11-year-old patient who had trauma to tooth #11, which resulted in the complicated crown fracture. He had an emergency management that included pulpectomy and intracanal medication at another clinic. Two years later, the patient was presented to our clinic. Upon examination, the diagnosis was previously initiated therapy with asymptomatic apical periodontitis in immature tooth #11. Regeneration was attempted first but failed. The mineral trioxide aggregate (MTA) plug was removed, and the canal had persistent pus discharge. The canal was filled with intracanal medication, and then 2 weeks later, the canal was filled with triple antibiotic paste (TAP). Next visit, and due to continuous discharge, tooth #11 was treated conservatively with an intracanal aspiration-irrigation technique. An IrriFlex needle attached to a high-volume suction was used to aspirate the cystic fluid. Mineral trioxide aggregate plug apexification was performed in a later visit and the tooth was restored.

CONCLUSION

During the 3-month and 16-month follow-up, there was resolution of the symptoms, a decrease in the periapical lesion size, and soft tissues appeared within normal limits.

CLINICAL SIGNIFICANCE

Regenerative procedures are a good option for immature necrotic teeth. These procedures may fail due to persistent pus discharge from the root canals. The aspiration-irrigation technique is a good treatment option in cases of consciously discharging canals. How to cite this article: Alsofi L, Almarzouki S. Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification. J Contemp Dent Pract 2024;25(1):92-97.

A paradigm shift from calcium hydroxide to bioceramics in direct pulp capping: A narrative review

For many years, calcium hydroxide (CH) was the preferred material for direct pulp capping (DPC), occupying an elevated position. The collapse of this paradigm is due to the emergence of bioceramics with less pulpal inflammation and superior mineralization abilities than CH. The goal of the current article was directed to: (1) review the history of DPC "the idea of an exposed pulp as a hopeless organ has given way to one of healing and optimism," (2) classify the bioceramics in dentistry, and (3) explain and compare the mechanism by which dentin barriers for CH and bioceramics are formed. A comprehensive literature search of the database was conducted using PubMed, Google Scholar, and Scopus utilizing the following terms: Biodentine, calcium hydroxide, calcium aluminate, calcium phosphate, calcium silicate, direct pulp capping, NeoMTA Plus, Quick-Set2, and TotalFill. Reference mining of the selected publications was utilized to discover other studies and strengthen the results. Only works written in English were taken into consideration, and there were no restrictions on the year of publication. Bioceramic materials might be used as an intriguing substitute for CH. Compared to CH, they induced more positive pulpal reactions.

Effects of surface treatments of bioactive tricalcium silicate-based restorative material on the bond strength to resin composite

OBJECTIVES

This study aimed to enhance the bond strength between Biodentine™ (BD), a bioactive tricalcium silicate (C3S) based material, and resin composite through various surface treatments.

METHODOLOGY

BD samples were immersed in either double distilled water or Hank's Balanced Salt Solution and analyzed using X-ray Diffraction (XRD). Shear bond strength (SBS) evaluations of BD were performed using Prime & Bond™ NT (PNT), Single Bond Universal (SBU), Xeno V (Xeno), and glass ionomer cement (GIC) following various etching durations (0 s/ 15 s/ 30 s/ 60 s with 37.5% phosphoric acid). Two primers, RelyX™ Ceramic Primer (RCP) and Monobond ™ Plus (MBP), were chosen to prime BD for SBS enhancement. Fractography and bonding interfaces were examined with energy dispersive X-ray spectroscopy (EDS)/ scanning electron microscopy (SEM) and Fourier-transform infrared spectroscopy (FTIR).

RESULTS

XRD confirmed BD's main compositions as C3S, Ca(OH)2, CaCO3 and ZrO2 after 14 days crystal maturation. Etched BD did not improve SBS. GIC exhibited the lowest SBS (p < 0.05) among all adhesives, regardless of the etching mode (all < 1 MPa). The highest SBS (17.5 ± 3.6 MPa, p < 0.05) was achieved when BD primed with MBP followed by SBU application. FTIR and EDS showed γ-MPTS and10-MDP within the MBP primer interacted with C3S and ZrO2 of BD, achieving enhanced SBS. Most specimens exhibited mixed or cohesive failure modes. Significance BD's subpar mechanical properties and texture may contribute to its poor adhesion to resin composite. Pretreating BD with MBP primer, followed by SBU adhesive is recommended for improving bond strength.

A leptin-loaded poly-ϵ-caprolactone 3D printing scaffold for odontoblastic differentiation in human dental pulp cells

This study investigated the effects on odontoblast differentiation of a 3D-printed poly-ϵ-caprolactone (PCL) scaffold that incorporated leptin. Material extrusion-type 3D printing with a 43 000-molecular weight PCL material was used to fabricate a PCL scaffold with a 6 mm diameter, 1 mm height, and 270-340 µm pore size. The experimental groups were PCL scaffolds (control group), PCL scaffolds with aminated surfaces (group A), and PCL scaffolds with leptin on the aminated surface (group L). The aminated surface was treated with 1,6-hexanediamine and verified by ninhydrin analysis. Leptin loading was performed using Traut's reagent and 4-(N-Maleimidomethyl)cyclohexane-1-carboxylic acid 3-sulfo-N-hydroxysuccinimide ester sodium salt (Sulfo-SMCC). Groups A and L showed significantly higher surface wettability, pulp cell adhesion, and proliferation than the control group. Group L exhibited increased alkaline phosphatase, calcification deposits, and mRNA and protein expression of dentin sialophosphoprotein and dentin matrix acidic phosphoprotein 1 compared with the control group. In this study, a 3D-printed PCL scaffold containing leptin was enhanced odontoblast differentiation and dental pulp cells adhesion and proliferation.

Marginal adaptation, physicochemical and rheological properties of treated dentin matrix hydrogel as a novel injectable pulp capping material for dentin regeneration

BACKGROUND

Treated dentin matrix hydrogel (TDMH) has been introduced as a novel injectable direct pulp capping material. In this regard, this study aimed to evaluate its marginal adaptation, physicochemical and rheological properties for the development of clinically feasible TDMH.

METHODS

TDMH was applied to the pulp floor of prepared Class I cavities (n = 5), marginal adaptation was assessed by SEM at 1000 X magnification to detect gap between dentin and filling material. Five syringes were filled with TDMH and placed between the compression plates of a universal testing machine to evaluate injectability and gelation time was also evaluated by test vial inverting method. The microstructures of lyophilized TDMH were observed by SEM. Moreover, TDMH discs (n = 5) were prepared and the water uptake (%) was determined based on the equilibrium swelling theory state of hydrogels. Its solubility was measured after one week by the ISO standard method. Rheological behaviours of TDMH (n = 5) were analysed with a rotational rheometer by computing their complex shear modulus G* and their associated storage modulus (G') and loss modulus (G''). Statistical analysis was performed using F test (ANOVA) with repeated measures and Post Hoc Test (p = 0.05).

RESULTS

TDMH presented an overall 92.20 ± 2.95% of continuous margins. It exhibited gelation during the first minute, and injectability mean was 66 ± 0.36%. TDMH showed a highly porous structure, and the pores were interconnected with an average diameter about 5.09 ± 3.17 μm. Swelling equilibrium gradually reached at 6 days up to 377%. The prepared hydrogels and maintained their shape after absorbing over three times their original weight of water. TDMH fulfilled the requirements of ISO 6876, demonstrating a weight loss of 1.98 ± 0.09% and linear viscoelastic behaviour with G` 479.2 ± 12.7 and G`` 230.8 ± 13.8.

CONCLUSIONS

TDMH provided good marginal adaptation, appropriate physicochemical and viscoelastic properties support its use as a novel direct pulp capping material in future clinical applications.

Effectiveness of vital pulp treatment in managing nontraumatic pulpitis associated with no or nonspontaneous pain: A systematic review

BACKGROUND

The exposed pulp has been the topic of numerous studies, but well-designed and well-executed comparative trials on the outcome and treatment of these teeth have been limited.

OBJECTIVES

This study was conducted to answer the following questions: in patients with nontraumatic pulpitis associated with no or nonspontaneous pain in permanent teeth, (i) is direct pulp capping or pulpotomy (partial/full) as effective as selective or stepwise caries removal [Population/participants, Intervention(s), Comparator(s)/control, Outcome(s) (PICO) 1], (ii) is pulpotomy (partial/full) as effective as direct pulp capping (PICO 2) and (iii) is pulpotomy (partial/full) as effective as a pulpectomy (PICO 3), in terms of a combination of patient and clinical reported outcomes, with 'tooth survival' as the most critical outcome?

METHODS

A literature search was conducted using Clarivate Analytics' Web of Science, Scopus, PubMed and Cochrane Central Register of Controlled Trials from inception to November 3rd 2021. Grey literature and contents of the major subject journals were examined. Eligibility criteria followed the PICO questions. Two independent reviewers performed study selection, data extraction and appraisal; disagreements were resolved by a third reviewer. The risk of bias was assessed by the revised Cochrane risk-of-bias tool for randomized trials.

RESULTS

Three randomized clinical trials (RCTs) were included in the review. No study fulfilled the criteria to answer PICO 1. There were no significant differences in the reported outcomes between investigated treatments in all included RCTs. None of the included studies reported the most critical outcome 'tooth survival'. A high loss of patients during the follow-up period was observed.

DISCUSSION

Although a few studies fulfilled strict eligible criteria, the results of this systematic review clearly highlight a paucity of available evidence. At the present time, clinical decisions cannot be substantiated by direct comparative trials.

CONCLUSIONS

Based on limited evidence, this systematic review discovered no significant differences in effectiveness between compared vital pulp treatments in managing nontraumatic pulpitis associated with no or nonspontaneous pain. Further high-quality RCTs are necessary to investigate the effectiveness of direct pulp capping or pulpotomy (partial/full) compared to selective or stepwise caries removal.

REGISTRATION

PROSPERO database (CRD42021259742).

Erythropoietin induces odontoblastic differentiation of human-derived pulp stem cells via EphB4-Mediated MAPK signaling pathway

OBJECTIVES

Human-derived pulp stem cells play key roles during dentinogenesis. Erythropoietin is reportedly involved in osteoblastogenesis and facilitates bone formation. However, the mechanism is still unknown. This research was to study the potential of erythropoietin in enhancing odontoblastic differentiation of human-derived pulp stem cells and to determine the underlying mechanism.

METHODS

The human-derived pulp stem cells were treated with erythropoietin, EphB4 inhibitor, and MAPK inhibitors, and the odontoblastic differentiation was measured by ALP staining, ALP activity assay, alizarin red S staining, and their quantitative analysis, and RT-qPCR of DSPP, DMP1, OCN, and RUNX2. The direct pulp capping model was established to evaluate the formation of tertiary dentin after treatment with erythropoietin. Western blot assay was conducted to assess relevant protein expressions in the phosphorylated EphB4 and MAPK pathway.

RESULTS

The results showed that erythropoietin promoted odontoblastic differentiation of human-derived pulp stem cells at 20 U/ml. Erythropoietin induced tertiary dentin formation in vivo. The potential mechanism of this was upregulating phosphorylated EphB4 and phosphorylated MAPK; furthermore, this effect could be decreased by EphB4 inhibitors, which inhibited MAPK phosphorylation. Blockage of MAPK pathways attenuated human-derived pulp stem cells' odontoblastic differentiation, suggesting that MAPK pathways are involved.

CONCLUSION

Erythropoietin induced tertiary dentin formation in vivo. And erythropoietin enhanced human-derived pulp stem cells' odontoblastic differentiation via the EphB4-mediated MAPK signaling pathway.

Success rate of permanent teeth pulpotomy using bioactive materials: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The results of vital pulp treatments in permanent teeth have been encouraging. Currently, pulpotomy treatment for permanent teeth primarily utilizes mineral trioxide aggregate (MTA) as the dressing material, followed by calcium hydroxide. While other calcium-silicate-based cements have been suggested for pulpotomy, there is a limited number of studies evaluating their long-term effectiveness.

OBJECTIVES

The objective of this systematic review and meta-analysis was to evaluate the success rate of pulpotomies performed on permanent teeth, comparing the use of ProRoot MTA with that of calcium hydroxide and other bioceramic materials.

METHODS

A comprehensive search was conducted in several electronic databases, including PubMed, Cochrane Library, Scopus, Web of Science, Embase and Science Direct until December 2022. The search was guided by PICOS criteria, including only randomized clinical trials (RCTs) that evaluated the success rate of pulpotomy treatments in permanent teeth using ProRoot MTA in comparison to calcium hydroxide and other bioceramic materials. The quality of the included studies was assessed using the RoB-2 tool to evaluate the risk of bias, and relevant data were extracted and analysed in RevMan software 5.3 using fixed-effect models. The GRADE tool was used to determine the overall quality of evidence.

RESULTS

The initial search retrieved 1072 studies and, after eliminating duplicates, 677 studies were screened and 28 studies were considered for eligibility. In the final selection process, 16 studies were included in the systematic review, with 10 being determined as having a high risk of bias. Pulpotomy showed an overall mean success rate of 92% after 1 year. The meta-analysis indicated a significantly higher success rate for pulpotomies utilizing MTA in comparison with calcium hydroxide, while no significant difference was seen between MTA and calcium-enriched mixture (CEM) or Biodentine. The GRADE assessment revealed an overall low level of evidence for the included studies.

DISCUSSION

Most randomized controlled trials exhibited a significant absence of control over confounding factors.

CONCLUSIONS

This systematic review and meta-analysis demonstrate that pulpotomy is a highly effective treatment for managing permanent teeth. The results indicate that the success rate of pulpotomy using ProRoot MTA is significantly higher than when using calcium hydroxide. However, the certainty of evidence supporting these findings is low, and there is a need for well-designed RCTs to assess the long-term outcomes of pulpotomy using newer bioceramic materials.

REGISTRATION

This systematic review was registered in the PROSPERO database (registration number CRD42023393970).

Engineering core-shell chromium nanozymes with inflammation-suppressing, ROS-scavenging and antibacterial properties for pulpitis treatment

Oral diseases are usually caused by inflammation and bacterial infection. Reactive oxygen species (ROS), which come from both autologous inflammation tissue and bacterial infection, play an important role in this process. Thus, the elimination of excessive intracellular ROS can be a promising strategy for anti-inflammatory treatment. With the rapid development of nanomedicines, nanozymes, which can maintain the intracellular redox balance and protect cells against oxidative damage, have shown great application prospects in the treatment of inflammation-related diseases. However, their performance in pulpitis and their related mechanisms have yet to be explored. Herein, we prepared dozens of metallic nanoparticles with core-shell structures, and among them, chromium nanoparticles (NanoCr) were selected for their great therapeutic potential for pulpitis disease. NanoCr showed a broad antibacterial spectrum and strong anti-inflammatory function. Antibacterial assays showed that NanoCr could effectively inhibit a variety of common pathogens of oral infection. In vitro experiments offered evidence of the multienzyme activity of NanoCr and its function in suppressing ROS-induced inflammation reactions. The experimental results show that NanoCr has optimal antibacterial and anti-inflammatory properties in in vitro cell models, showing great potential for the treatment of pulpitis. Therefore, the use of NanoCr could become a new therapeutic strategy for clinical pulpitis.

Influence of the restoration after pulpotomy on the strength of electrical stimulus reaching the pulp space: An in vitro investigation

Introduction

The study evaluated the influence of coronal restoration after pulpotomy on the strength of electrical stimulus reaching the radicular pulp using an electric pulp test (EPT).

Materials and Methods

The pulp tissue from ten freshly extracted mandibular premolar teeth was removed and replaced with an electroconductive gel. The cathode probe of Powerlab was inserted into the pulp space and the anode probe was attached to the EPT handpiece. The EPT probe coated with electro-conducting material was positioned in the middle third of the buccal crown surface. The EPT stimulus reaching the pulp space of an intact tooth at 40 numerical readings was recorded. The tooth was removed from model and endodontic access was made. The 2-mm thick mineral trioxide aggregate was placed at the cementoenamel junction followed by composite resin restoration. The experimental setup was re-established and postpulpotomy EPT stimulus data were recorded. The data collected were compared using the Wilcoxon signed-rank test.

Results

There was a statistically significant difference (P = 0.038) between observed between the strength of EPT stimulus reaching the pulp space in prepulpotomy (mean 91.18 ± 101.02 V and median 25.79 V) and postpulpotomy (mean 58.49 ± 77.13 V and median 13.75 V) tooth samples.

Conclusion

The placement of the restoration and pulp capping agent after pulpotomy dampens the strength of EPT stimulus reaching the pulp canal space.

Vital Pulpotomy on immature lower first permanent molars using Portland cement, a case of failure and success-case report with 2 years follow-up

Key clinical message

While the importance of vital pulp therapy comes from its ability to promote pulp healing allowing the tooth to continue its development and giving the patient a more convenient treatment, dental practitioners should be more aware of the minor mistakes which they might commit during treatment procedures that could reflect negatively on the treatment's outcome. Developing behavior management skills as well as learning from reported mistakes are beneficial to practitioners to provide a more precise and successful treatment.

Abstract

Vital pulp therapies are known to preserve tooth development and give pulp tissues a chance to heal. Despite the progress of biocompatible materials used in this field, these treatments are still facing some failure for several known and unknown reasons that might not only be related to the material used. This case report presents and discusses the possible reasons for the success of one vital pulpotomy procedure and the failure of another, both conducted on two immature lower first permanent molars of the same patient, in an attempt to conclude what led to both results.

Impact of systemic health on treatment outcomes in endodontics

BACKGROUND

The healing of periapical lesions after root canal treatment (RCT) is not the result of the curative action of the treatment. The process of healing begins with inflammation, and is resolved by the clearance of the immunogen that induces the immune response. Then, the periapical tissue itself carries out the healing of the periapical lesion, by repair or by a combination of repair and regeneration, depending on the host's reparative response working properly. The ultimate objective of RCT is to achieve wound healing by removing the source of bacterial antigens and toxins, allowing chronic inflammatory tissue to become reparative tissue. Some systemic conditions increase the susceptibility of the host to infection or impair the tissue reparative response, maintaining the inflammatory process and periapical bone resorption after RCT. This can cause the failure of RCT and even the need for extraction of the affected tooth.

OBJECTIVE

To analyse the scientific literature on the possible influence of systemic conditions on the treatment outcomes in endodontics, as well as to discuss the biological mechanisms that may be involved.

METHODS

The search was carried out in PubMed, SCOPUS and EMBASE. The inclusion criteria established were original scientific articles reporting data about some systemic condition in relation to treatment outcomes in endodontics, including clinical studies and studies carried out in animal models.

RESULTS

Systemic factors (age, nutrition, stress, hormones, smoking habits), and systemic diseases, such as diabetes, cardiovascular diseases, osteoporosis, HIV infection, inflammatory bowel disease, and others, can influence or interfere in the repair of periapical tissues after RCT.

DISCUSSION

Some of these systemic diseases can alter bone turnover and fibroblast function, preventing or delaying periapical wound healing. Others can alter the microvasculature, reducing nutrients and oxygen supply to periapical tissues. As a result, these systemic conditions can decrease the success rate of RCT and provoke incomplete wound healing (typically granulomatous tissue formation) in the periapical region.

CONCLUSIONS

The results of this narrative review show worse success rate of RCT, with higher percentage of postoperative radiolucent periapical lesions and higher proportion of non-retained teeth (RFT), associated with several systemic conditions, such as smoking habits and diabetes.

Influence of Direct Pulp Capping with Calcium Hydroxide and Mineral Trioxide Aggregate on Systemic Oxidative Stress in Rats

Direct pulp capping is a procedure where materials are placed on exposed vital pulp tissue in order to stimulate reparative dentinogenesis and preserve pulp vitality. Carious pulp exposure and direct pulp capping are usually accompanied by pulp inflammation which can affect pro- and anti-oxidative systems locally or systemically. Therefore, this study aimed to investigate the potential influence of direct capping of inflamed rat dental pulp with calcium hydroxide (CH) and mineral trioxide aggregate (MTA) on parameters of systemic oxidative status.

Dental pulps of the first maxillary molars of Albino rats (n=32) were exposed and capped with either CH (n=8), MTA (n=8) or were left untreated (n=8). Animals with healthy pulp were used as a healthy control (n=8). After four weeks, animals were euthanized and blood samples were collected for biochemical analysis of parameters of systemic oxidative stress by spectrophotometric method.

Untreated control had the significantly higher (p <0.05) values of pro-oxidative parameters and lower (p <0.05) values of anti-oxidative parameters (superoxide dismutase and reduced glutathione) compared to healthy control. CH and MTA groups showed reduced values of pro-oxidative parameters compared to untreated control and values of anti-oxidative parameters comparable to healthy control.

Pulp exposure led to disbalance in systemic oxidative parameters while direct pulp capping with calcium hydroxide and mineral trioxide aggregate restored the levels of systemic oxidative parameters to that of animals with healthy dental pulp. These results indicate the importance of direct pulp capping and the potential influence of untreated inflamed pulp on systemic health.

Outcome of pulpotomy in permanent teeth with irreversible pulpitis: a systematic review and meta-analysis

Treatment planning is key to clinical success. Permanent teeth diagnosed with "irreversible pulpitis" have long been implied to have an irreversibly damaged dental pulp that is beyond repair and warranting root canal treatment. However, newer clinical approaches such as pulpotomy, a minimally invasive and biologically based procedure have re-emerged to manage teeth with pulpitis. The primary aim of the study was to conduct a meta-analysis to comprehensively estimate the overall success rate of pulpotomy in permanent teeth with irreversible pulpitis as a result of carious pulp exposure. The secondary aim of the study was to investigate the effect of predictors such as symptoms, root apex development (closed versus open), and type of pulp capping material on the success rate of pulpotomy. Articles were searched using PubMed, Scopus, CENTRAL, and Web of Science databases, until January 2021. Outcomes were calculated by pooling the success rates with a random effect model. Comparison between the different subgroups was conducted using the z statistic test for proportion with significance set at alpha = 0.05. A total of 1,116 records were retrieved and 11 studies were included in the quantitative analysis. The pooled success rate for pulpotomy in teeth with irreversible pulpitis was 86% [95% CI: 0.76-0.92; I² = 81.9%]. Additionally, prognostic indicators of success were evaluated. Stratification of teeth based on (1) symptoms demonstrated that teeth with symptomatic and asymptomatic irreversible pulpitis demonstrated success rate of 84% and 91% respectively, with no significant difference (p = 0.18) using z-score analysis; (2) open apex teeth demonstrated a significantly greater success rate (96%) compared to teeth with closed apex (83%) (p = 0.02), and (3) pulp capping materials demonstrated that Biodentine yielded significantly better success rates compared to Mineral Trioxide Aggregate (MTA), calcium hydroxide, and Calcium Enriched Mixture (CEM.) Collectively, this is the first meta-analytical study to determine the clinical outcome of pulpotomy for carious teeth with irreversible pulpitis and it's predictors for success. Moreover, we identify the stage of root development and type of biomaterial as predictors for success of pulpotomy.

Anesthetic efficacies of buccal with palatal injection versus buccal with intra-septal injection in permanent maxillary first molars of pediatric patients

The high success rate of dental treatment is dependent on the cooperation of pediatric patients during procedures. Dental treatment often causes pain, particularly in children. The factors in providing treatment to pediatric patients include the characteristics and location of the tooth, profoundness of the anesthesia including the type of local anesthetic, and cooperation of the patient. Previous studies have examined several techniques to successfully achieve profound pulpal anesthesia in maxillary permanent teeth. The dentist should select the injection technique to be used based on patient needs. In children, either buccal with palatal injections or buccal with intra-septal injections may be used to anesthetize the permanent maxillary first molar. Buccal with palatal injections are commonly used prior to routine maxillary dental procedures. Currently, there are only a few studies on the employment of buccal with intra-septal injections to anesthetize permanent maxillary first molars in pediatric patients. This review will focus on efficacy of buccal with palatal versus buccal with intra-septal pulpal anesthesia of the permanent maxillary first molars in pediatric patients and aim to determine which technique should be used during routine dental procedures.

Decision-Making and Management of Immature Permanent Teeth with Crown Fractures in Small Animals-A Review

Immature permanent teeth with crown fractures present a unique challenge in human and animal patients. Immature permanent teeth have not yet developed completely, often presenting with thin dentin walls, incomplete apical formation, and increased crown-to-root ratios. Loss of pulp function at this stage has devastating long-term implications for these teeth. Ideally, attempts should be made to preserve pulp vitality in immature permanent teeth to allow for continued dental development. The range of treatment options for vital teeth includes odontoplasty with bonding and sealing +/- restoration, indirect pulp capping, and direct pulp capping/vital pulp therapy. These treatments have long been established in human and veterinary medicine, and cases have been reported in dogs and cats. Apexification using calcium hydroxide is a well-established treatment for nonvital immature teeth. The advent of mineral trioxide aggregate and other bioceramic materials for use in vital pulp therapy and apexification has reduced treatment sessions and improved outcomes. Recent developments in the field of regenerative endodontic therapy further expand treatment options and provide the possibility for continued development of a formerly nonvital tooth. Selecting the appropriate treatment based on the severity of tooth fracture and status of pulp vitality can avoid a lifetime of poor structure and function for the affected tooth. This article provides multiple step-by-step protocols for the management of immature permanent teeth with crown fractures in small animals.

The Antimicrobial, Antioxidative, and Anti-Inflammatory Effects of Polycaprolactone/Gelatin Scaffolds Containing Chrysin for Regenerative Endodontic Purposes

The appropriate endodontic material should eliminate the infection and inflammation to provide a situation for regeneration and healing of pulp tissue besides biomineralization. Chrysin is one of the active ingredients of plant flavonoids, which has significant anti-inflammatory and antimicrobial properties. In the present study, this natural substance was evaluated for antioxidant, anti-inflammatory, and mineralization properties on dental pulp stem cells (DPSCs). SEM, FTIR, and TGA tests were used to determine the successful synthesize of chrysin-loaded scaffolds. The antimicrobial effects of the synthesized scaffold against Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus, and Enterococcus faecalis were assessed by the agar diffusion test and live/dead assay. The proliferation of DPSCs on these scaffolds was determined by the MTT assay, DAPI staining, and DNA extraction. Moreover, the antioxidant and anti-inflammation activity of chrysin-loaded scaffolds on inflamed DPSCs was evaluated. Alkaline phosphatase activity and Alizarin Red S Stain tests were done to evaluate the mineralization of DPSCs seeded on these scaffolds. The chrysin-loaded scaffolds reported antimicrobial effects against evaluated bacterial strains. The proliferation of DPSCs seeded on these scaffolds was increased significantly (p < 0.05). The TNFα and DCF levels in inflamed DPSCs showed a significant decrease in the presence of chrysin-loaded scaffolds (p < 0.05). The ALP activity and formation of mineralized nodules of DPSCs on these scaffolds were significantly increased compared with the control group (p < 0.05). These results indicated that chrysin as an ancient therapeutic agent can accelerate the healing and regeneration of damaged pulp tissue, and this active ingredient can be a potential natural substance for regenerative endodontic procedures.

Synthesis, characterization, and evaluation of curcumin-loaded endodontic reparative material

Curcumin (CUR) is an ancient therapeutic agent with remarkable antimicrobial and anti-inflammatory properties. The purpose of the current study was to synthesize and evaluate a curcumin-based reparative endodontic material to reduce infection and inflammation besides the induction of mineralization during the healing of the dentin-pulp complex. Poly-ɛ-caprolactone (PCL)/gelatin (Gel)/CUR scaffold was synthesized and assessed by scanning electron microscopy, Fourier transform infrared spectroscopy, and thermo-gravimetric analysis (TGA). Agar diffusion test was performed against E. coli, A. baumannii, P. aeruginosa, S. aureus, E. faecalis, and S. mutans. Moreover, proliferative, antioxidative, anti-inflammatory, and calcification properties of these scaffolds on human dental pulp stem cells (hDPSCs) were evaluated. The results showed that PCL/Gel/CUR scaffold had antibacterial effects. Also, these CUR-based scaffolds had significant inhibitory effects on the expression of tumor necrosis factor α and DCF from inflamed hDPSCs (p < 0.05). Moreover, the induction of mineralization in hDPSCs significantly increased after seeding on CUR-based scaffolds (p < 0.05). Based on these findings, the investigated CUR-loaded material was fabricated successfully and provided an appropriate structure for the attachment and proliferation of hDPSCs. It was found that these scaffolds had antimicrobial, antioxidant, and anti-inflammatory characteristics and could induce mineralization in hDPSCs, which is essential for healing and repairing the injured dentin-pulp complex.

Influence of Preoperative Pulp Inflammation in the Outcome of Full Pulpotomy Using a Dog Model

INTRODUCTION

This study aimed to evaluate the impact of preoperative pulp inflammation on the histologic outcome of full pulpotomy performed in mature permanent posterior teeth using 4 different biomaterials.

METHODS

Five beagle dogs (providing a total of 120 roots) were selected. Dentin exposure was performed in teeth from the second and third quadrants. One week later, full pulpotomy procedures were performed using 4 different bioactive materials (ProRoot MTA [MTA], TotalFill BC Putty [BC], Biodentine [BIO], and an experimental cement [ie, pulp capping material]). The hemostasis time was registered. After 14 weeks, the animals were killed. Pulp-dentin tissues were histologically and radiographically assessed. The significance level was set at .05.

RESULTS

Teeth with previously exposed dentin revealed a statistically significant increase in the time required to achieve hemostasis (P < .001), therefore confirming the pulp inflammation status induced by 1-week exposure of occlusal dentin before performing full pulpotomy. There was no radiographic evidence of root resorption, periapical radiolucency, or lamina dura alterations. No statistically significant differences were observed between normal and inflamed pulp regardless of the evaluated histologic parameters. Moreover, histologic data concerning calcified barrier formation and the pulp tissue response show better results for BIO without statistical differences compared with MTA or BC (P > .05). The pulp capping material presented a lower performance, with statistically significant differences being detected in regard to the remaining 3 tested materials (P < .001).

CONCLUSIONS

Radiographic and histologic outcomes of full pulpotomy are not jeopardized by short-term preoperative pulp inflammation. Moreover, BIO, MTA, and BC cements present suitable alternatives to be used as pulp capping agents.

Vital Pulp Therapy in Permanent Mature Posterior Teeth with Symptomatic Irreversible Pulpitis: A Systematic Review of Treatment Outcomes

Background and Objectives: Symptomatic irreversible pulpitis in permanent mature teeth is a common indication for nonsurgical root canal treatment (NSRCT), but contemporary studies have reported on vital pulp therapy (VPT) applied in such teeth as a less invasive treatment. This systematic review assessed the outcomes of VPT, including partial and full pulpotomy performed with hydraulic calcium silicate cements (HCSCs) in permanent mature posterior teeth diagnosed with symptomatic irreversible pulpitis. Materials and Methods: The PRISMA guidelines were followed. The search strategy included PubMed^®, EMBASE, Cochrane library and grey literature electronic databases. The quality assessment of the identified studies followed the Cochrane Collaboration Risk of Bias, ROBINS-I and Newcastle–Ottawa Scale tools. Results: The search of primary databases identified 142 articles, of which 9 randomized controlled trials and 3 prospective cohort studies were selected for review. The risk-of-bias was assessed as ‘high’ or ‘serious’, ‘fair’, and ‘low’ for three, seven and two articles, respectively. One to five years after VPT using HCSCs, the success rates mostly ranged from 78 to 90%. Based on two articles, the outcomes of the VPT and NSRCT were comparable at one and five years. Despite the necessity for the intra-operative pulp assessment in VPT procedures, the majority of the studies did not fully report on this step or on the time needed to achieve hemostasis. Small sample sizes, of under 23 teeth, were reported in three studies. Conclusions: The reviewed 12 articles reported favorable outcomes of the VPT performed with HCSCs in permanent mature posterior teeth with symptomatic irreversible pulpitis, with radiographic success in the range of 81 to 90%. Two articles suggested comparable outcomes of the VPT and root canal treatment. Universal case selection and outcome criteria needs to be established for VPT when considered as an alternative to NSRCT. This evidence supports the need for further research comparing longer-term outcomes of both of the treatment modalities.

The Effect of Calcium-Silicate Cements on Reparative Dentinogenesis Following Direct Pulp Capping on Animal Models

Dental pulp vitality is a desideratum for preserving the health and functionality of the tooth. In certain clinical situations that lead to pulp exposure, bioactive agents are used in direct pulp-capping procedures to stimulate the dentin-pulp complex and activate reparative dentinogenesis. Hydraulic calcium-silicate cements, derived from Portland cement, can induce the formation of a new dentin bridge at the interface between the biomaterial and the dental pulp. Odontoblasts are molecularly activated, and, if necessary, undifferentiated stem cells in the dental pulp can differentiate into odontoblasts. An extensive review of literature was conducted on MedLine/PubMed database to evaluate the histological outcomes of direct pulp capping with hydraulic calcium-silicate cements performed on animal models. Overall, irrespective of their physico-chemical properties and the molecular mechanisms involved in pulp healing, the effects of cements on tertiary dentin formation and pulp vitality preservation were positive. Histological examinations showed different degrees of dental pulp inflammatory response and complete/incomplete dentin bridge formation during the pulp healing process at different follow-up periods. Calcium silicate materials have the ability to induce reparative dentinogenesis when applied over exposed pulps, with different behaviors, as related to the animal model used, pulpal inflammatory responses, and quality of dentin bridges.

Evaluating the potential of an amelogenin-derived peptide in tertiary dentin formation

Several novel biomaterials have been developed for dental pulp capping by inducing tertiary dentin formation. The aim of this study was to evaluate the effect of QP5, an amelogenin-based peptide, on the mineralization of dental pulp cells (DPCs) in vitro and in vivo. The cell viability of human DPCs (hDPCs) after treatment with QP5 was determined using the Cell Counting Kit-8 (CCK-8). Migration of hDPCs was assessed using scratch assays, and the pro-mineralization effect was determined using alkaline phosphatase (ALP) staining, alizarin red staining and the expression of mineralization-related genes and proteins. The results showed that QP5 had little effect on the cell viability, and significantly enhanced the migration capability of hDPCs. QP5 promoted the formation of mineralized nodules, and upregulated the activity of ALP, the expression of mRNA and proteins of mineralization-related genes. A pulp capping model in rats was generated to investigate the biological effect of QP5. The results of micro-computed tomography and haematoxylin and eosin staining indicated that the formation of tertiary dentin in QP5-capping groups was more prominent than that in the negative control group. These results indicated the potential of QP5 as a pulp therapy agent.

Effects of epigallocatechin gallate (EGCG) on the biological properties of human dental pulp stem cells and inflammatory pulp tissue

OBJECTIVE

This study aimed to investigate the effect of epigallocatechin gallate (EGCG) on the proliferation, mineralization, inflammation and hypoxia responses of human dental pulp stem cells (hDPSCs) in vitro and its effect on inflammatory pulp tissue in rats in vivo.

DESIGN

The optimum concentration of EGCG was selected by creating a dose response curve. Expression of odontogenic/osteogenic-related genes and inflammatory cytokines after stimulation with Lipopolysaccharide (LPS) was detected by real-time PCR. Under hypoxic conditions, cell proliferation and expression of reactive oxygen species (ROS) and superoxide dismutase (SOD) were detected.In vivo, the maxillary first molars of SD rats were pulpotomized and stimulated with 5 mg/mL LPS for 30 min. Normal saline and EGCG were used to flush the pulp chamber. After 2 months, samples were removed for micro-CT scanning and HE staining.

RESULTS

CCK-8 assay revealed that 10 μg/mL EGCG had no significant effect on the proliferation of hDPSCs. EGCG inhibited expression of IL-1β, IL-6, and TNF-α. Furthermore, EGCG rescued cell proliferation ability, increased SOD activity and reduced ROS expression under hypoxia.In vivo, reduced inflammatory cell accumulation was observed in the coronal pulp in the EGCG group, while in the control group, diffuse inflammatory cells were observed in the radicular pulp.

CONCLUSION

EGCG had no obvious effects on calcified nodule formation but significantly inhibited the inflammatory response of hDPSCs and inhibited apoptosis of hDPSCs caused by hypoxia injury. In vivo, EGCG exerts inhibitory effects on pulp tissue inflammation.

Microscopic and elemental characterization of hydrated dental pulp capping agents

Context:

Characteristics of dental pulp capping agents may influence its interaction with the pulpal cells and can impact the treatment outcome.

Aims:

This study aims to microscopically characterize various pulp capping agents following hydration.

Settings and Design:

Original research.

Materials and Methods:

Disk-shaped specimens of five calcium silicate-based materials, i.e., mineral trioxide aggregate (MTA) Angelus, Biodentine, TheraCal LC, ApaCal ART, and Endocem MTA were prepared. After final set, the materials were immersed in 10 mL of deionized water for 14 days at 37°C. The set materials were characterized by scanning electron microscopy (SEM), X-ray energy dispersive analysis (EDX), and X-ray diffraction (XRD) analysis along with pH analysis of the storage solution using pH meter.

Results:

On SEM analysis, all the materials showed crystalline deposition on the cement surface with Biodentine exhibiting the most dense and homogenous microstructure. Calcium-silicate-hydrate and calcium hydroxide (CH) were observed as dark-grey and light-grey matrix material, respectively. EDX analysis revealed a high concentration of calcium. The other major elements were oxygen and carbon. The surface calcium concentration in the tested specimens was as follows: Biodentine (42.59 wt.%) > MTA Angelus (38.51wt.%) > Endocem MTA (30.24wt.%) > TheraCal LC (27.51wt.%) > ApaCal ART (22.02wt.%). On XRD analysis, all the materials exhibited peaks for tricalcium silicate and CH, after 14 days of hydration.

Conclusions:

The higher surface calcium level in Biodentine and MTA Angelus may enhance reparative dentin formation. The surface calcium concentration of Endocem MTA and ApaCal ART was found to be lesser than that of MTA Angelus, but with the added advantage of fast-setting property. Hence, they are potential alternative materials for vital pulp therapy.

Effects of zinc oxide and calcium-doped zinc oxide nanocrystals on cytotoxicity and reactive oxygen species production in different cell culture models

Objectives

This study aimed to synthesize nanocrystals (NCs) of zinc oxide (ZnO) and calcium ion (Ca²⁺)-doped ZnO with different percentages of calcium oxide (CaO), to evaluate cytotoxicity and to assess the effects of the most promising NCs on cytotoxicity depending on lipopolysaccharide (LPS) stimulation.

Materials and Methods

Nanomaterials were synthesized (ZnO and ZnO:xCa, x = 0.7; 1.0; 5.0; 9.0) and characterized using X-ray diffractometry, scanning electron microscopy, and methylene blue degradation. SAOS-2 and RAW 264.7 were treated with NCs, and evaluated for viability using the MTT assay. NCs with lower cytotoxicity were maintained in contact with LPS-stimulated (+LPS) and nonstimulated (−LPS) human dental pulp cells (hDPCs). Cell viability, nitric oxide (NO), and reactive oxygen species (ROS) production were evaluated. Cells kept in culture medium or LPS served as negative and positive controls, respectively. One-way analysis of variance and the Dunnett test (α = 0.05) were used for statistical testing.

Results

ZnO:0.7Ca and ZnO:1.0Ca at 10 µg/mL were not cytotoxic to SAOS-2 and RAW 264.7. +LPS and −LPS hDPCs treated with ZnO, ZnO:0.7Ca, and ZnO:1.0Ca presented similar NO production to negative control (p > 0.05) and lower production compared to positive control (p < 0.05). All NCs showed reduced ROS production compared with the positive control group both in +LPS and −LPS cells (p < 0.05).

Conclusions

NCs were successfully synthesized. ZnO, ZnO:0.7Ca and ZnO:1.0Ca presented the highest percentages of cell viability, decreased ROS and NO production in +LPS cells, and maintenance of NO production at basal levels.

Effect of Tricalcium Silicate on Direct Pulp Capping: Experimental Study in Rats

Objectives Conduct a histological comparison of the pulp response to different materials, with a focus on the continuity and morphology of the mineralized barrier after direct pulp capping.

Materials and Methods  One hundred and eight maxillary first molars of 54 Wistar rats were subject to direct pulp capping and divided into three groups according to the materials used: calcium hydroxide (CH), mineral trioxide aggregate (MTA), and Biodentine. All cavities were sealed, and the animals were euthanized at 7, 14, and 21 days. Descriptive histological evaluation of the inflammation and formation of the mineralized barrier was performed.

Statistical Analysis  Statistical analyses were performed using the Kruskal–Wallis test, which was complemented by the Dunn test; differences with p < 0.05 were considered statistically significant.

Results  The results showed that MTA and Biodentine elicited less intense inflammatory reactions than CH. With respect to the formation and quality of the dentin barrier formed, differences were observed at 21 days between the analyzed groups; the best results being obtained following treatment with MTA and Biodentine.

Conclusion  MTA and Biodentine induced formation of a more continuous and uniform mineralized barrier with less intense pulp response than CH.

The Vital Pulp Therapy of Permanent Teeth: A Dental Practitioner's Perspective from Saudi Arabia

AIMS AND OBJECTIVES

The aim of this study was to determine the levels of knowledge and attitude of dental practitioners (DPs) toward vital pulp therapy (VPT) of young permanent teeth in Riyadh city, Saudi Arabia.

MATERIALS AND METHODS

A descriptive cross-sectional study was carried out by taking convenient sample of general DPs and specialist attending Saudi International Dental Conference, Riyadh, Saudi Arabia. A total of 200 DPs administered a structured, self-administered questionnaire to evaluate their knowledge and attitude toward VPT. The questionnaire comprised four parts: Part I: Characteristics of the study participants; Part II: Items related to indications and diagnosis of VPT; Part III: Questions related to the different VPTs for immature permanent teeth; and Part IV: Dental materials used in VPT and restoration. All the data were entered into the statistical analysis software Statistical Package for the Social Sciences version 21.0 (IBM, Armonk, NY) and analyzed by using descriptive statistics of frequency distribution and percentages for the categorical variables.

RESULTS

A total of 193 (men = 57% [110] and women = 43% [83]) DPs participated in this study with a response rate of 96.5%. Less than half of correct responses were observed with (Item 1) related to the duration of complete closure of root apex (43%) and (Item 14) use of sodium hypochlorite to serve as an excellent diagnostic tool to differentiate irreversible from reversible pulpitis. A high percentage of correct responses were seen with the (Item 9) indirect pulp capping--a procedure performed in a tooth with a deep carious lesion without signs or symptoms of pulp degeneration (75%). All other item responses ranged in between 52% and 72%.

CONCLUSION

DPs showed fair-to-good knowledge and attitude toward VPT of young permanent teeth. In general, there is a need to improve knowledge and attitude of dental professionals about the VPT by attending continuing dental educational programs.

Odontogenesis and neuronal differentiation characteristics of periodontal ligament stem cells from beagle dog

Periodontal ligament stem cells (PDLSCs) from beagle dogs had the characteristics of multi‐directional differentiation and had great application potential in tissue engineering and cell regenerative medicine. In this study, we analysed the odontogenesis and neuronal differentiation characteristics of PDLSCs in vitro. Results showed that the calcined tooth powder (CTP) and silver nanoparticles (AgNPs) additives could induce the PDLSCs into odontogenesis differentiation; besides, the immunofluorescence staining identified that the high dosage calcined tooth powder (400 μg/mL) significantly facilitated the odontogenesis associated with BMP4 expression. While the nutritional factor (L‐glutamine, NGF (nerve growth factor), bFGF (basic fibroblast growth factor), IGF‐1 (insulin‐like growth factor‐1) and EGF (epidermal growth factor)) additives were prior to induce the PDLSCs into neuronal differentiation. Simultaneously, PDLSCs had high proliferation ability with the different supplemented additives. Importantly, the Western blot results also proved the BMP4 and SMAD1 proteins were highly expressed in the induced odontoblast, while the SOX1, NCAM1, GFAP and VEGFA proteins were all obviously expressed in the induced neurons. Hence, PDLSCs had characteristics of both odontogenesis and neuronal differentiation.

Time-Dependent Response of Human Deciduous Tooth-Derived Dental Pulp Cells Treated with TheraCal LC: Functional Analysis of Gene Interactions Compared to MTA

Pulp capping material should facilitate hard tissue regeneration on the injured pulp tissue. TheraCal LC (TC) was recently developed. Although TC has shown reliable clinical outcomes after direct pulp capping, there are still remaining concerns regarding its detrimental effect on pulp cells. Therefore, this study aimed to identify the gene expression of human deciduous tooth-derived dental pulp cells exposed to TC compared to mineral trioxide aggregate (MTA). The cells were cultured and exposed to TC and MTA for 24 and 72 h. Next, total RNA was isolated. QuantSeq 3′ mRNA-sequencing was used to examine differentially expressed genes (DEGs) in exposed to TC and MTA. Functional analysis of DEGs was performed using bioinformatics analysis. In gene ontology (GO) functional enrichment analysis, cells in TC for 24 h presented significantly enriched immune response (p < 0.001) and inflammatory response (p < 0.01) compared to MTA. TC showed enriched positive regulation of cell migration at 72 h (p < 0.001). In Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis, neuroactive ligand–receptor interaction (p = 1.19 × 10⁻⁷) and calcium signaling pathway (p = 2.96 × 10⁻⁵) were confirmed in the shared DEGs in TC. In conclusion, DEGs in TC may be involved in pathways associated with osteoclastogenesis and osteoclastic differentiation.

The Conditioned Medium of Calcined Tooth Powder Promotes the Osteogenic and Odontogenic Differentiation of Human Dental Pulp Stem Cells via MAPK Signaling Pathways

The calcined tooth powder (CTP), a type of allogeneic biomimetic mineralized material, has been confirmed that can promote new bone formation when obtained at high temperature. The aim of this study was to investigate effects of the conditioned medium of calcined tooth powder (CTP-CM) on the osteogenic and odontogenic differentiation of human dental pulp stem cells (hDPSCs) and the underlying mechanisms involved. First, ALP activity assay determined that 200 μg/mL was the optimal concentration of CTP-CM for the following experiments. CTP-CM had no significant effect on the proliferation of hDPSCs as indicated by CCK-8 and FCM analysis. Both the gene and protein (DSPP/DSPP, RUNX2/RUNX2, OCN/OCN, OSX/OSX, OPN/OPN, ALP/ALP, and COL-1/COL-1) expression levels increased in the CTP-CM-induced hDPSC group as compared with those in the control group at day 3 or 7, showing the positive regulation of CTP-CM on the osteo/odontogenic differentiation of hDPSCs. Mechanistically, MAPK signaling pathways were activated after the CTP-CM treatment, and the inhibitors targeting MAPK were identified which weakened the effects of CTM-CM on the committed differentiation of hDPSCs. These findings could lead to the creation of stem cell therapies for dental regeneration.

Leptin stimulates DMP-1 and DSPP expression in human dental pulp via MAPK 1/3 and PI3K signaling pathways

INTRODUCTION

To investigate the physiological function of leptin in human dental pulp, and to determine the specific pathways implicated in its effect.

METHODS

Twenty-seven dental pulp samples were obtained from human third molars. Pulp samples were treated with or without human recombinant leptin. Leptin functional effect was analyzed in terms of regulation of the synthesis levels of DSPP and DMP-1, determined by immunoblot.

RESULTS

Leptin stimulated DMP-1 and DSPP synthesis in all human dental pulp specimens. The stimulatory effect of leptin on DMP-1 and DSPP synthesis was partially prevented by blocking mitogen-activated protein kinase (MAPK 1/3) and phosphatidylinositol 3 kinase (PI3K) pathways, respectively.

CONCLUSIONS

The present study demonstrates the functional effect of leptin in human dental pulp stimulating the expression of DMP-1 and DSPP, both proteins implicated in dentinogenesis. Leptin stimulates DSPP expression via PI3K pathway and DMP-1 synthesis via MAPK 1/3 pathway. These results support the role of leptin in pulpal reparative response, opening a new research line that could have translational application to the clinic in vital pulp therapy procedures.

Endodontic and Restorative Treatment Patterns of Pulpally Involved Immature Permanent Posterior Teeth

Objective

The study aims at investigating the treatment patterns for young permanent posterior teeth with pulp involvement.

Materials and Methods

A random sample of 1793 dental records of patients aged 6-18 years old who had received dental treatment was investigated. 663 permanent posterior treated teeth had pulp involvement. Demographic and treatment data were gathered from patients' records.

Results

Prevalence of young permanent teeth with pulp involvement was 36.9%. Treatments received significantly increased as patients' age increased (P=0.001). The first mandibular molar had the most pulp involvement among all teeth (43.89%). Temporary restoration was the most received restoration (59%). The most common pulpal diagnosis, leading to treatment, was irreversible pulpitis (43.04%). Only 19.8% of treated teeth received completed root canal treatment.

Conclusion

There is a high percentage of children and adolescents with immature permanent posterior teeth with pulp involvement. Similarly, a variety of treatment patterns is present, with a small percentage of completed root canal treatment.

Clinical Relevance

The study has identified the need to provide guidelines to provide high-quality root canal treatments for young permanent posterior teeth that have pulpal involvement. Only 21.8% of root canal treatments were completed, while 24% of teeth were extracted, and 59% of patients received temporary restorative treatments. This suggests that there might be several factors that might prevent completion of the dental treatment, such as patient preference, insurance coverage, or dentist capability. These factors and guidelines for patient care should be investigated and resolved.

Mineral trioxide aggregate pulpotomy: patient selection and perspectives

This narrative aims at reviewing the available literature for mineral trioxide aggregate (MTA) pulpotomy to understand the procedure better and eventually improve the clinical and radiographic outcomes. An electronic search was conducted in PubMed, Cochrane, ScienceDirect and ClinicalKey databases with the following keywords: MTA pulpotomy, clinical outcomes, radiographic outcomes, primary teeth. No specific inclusion or exclusion criteria were applied as to what articles would be included in this review. The time period for the search began from 2001 with respect to MTA pulpotomy. However, this was not restrictive during the search. MTA pulpotomy has been a successful treatment modality in primary molars with proven success over the years. There is limited literature to support its success in primary incisors.

Leptin Induces Odontogenic Differentiation and Angiogenesis in Human Dental Pulp Cells via Activation of the Mitogen-activated Protein Kinase Signaling Pathway

INTRODUCTION

Up-regulation of odontogenic differentiation, dentin formation, and angiogenesis in dental pulp are key factors in vital pulp therapy. The aim of this study was to investigate whether leptin could promote odontogenic differentiation and angiogenesis in human dental pulp cells (hDPCs). In addition, the involvement of the intracellular signaling pathway in these effects was determined.

METHODS

The viability of hDPCs treated with leptin was examined using the water soluble tetrazolium salt-1 assay. Real-time polymerase chain reaction was performed to determine messenger RNA (mRNA) expression levels of odontogenic and angiogenic markers. Western blot analysis was used to measure odontogenic and angiogenic protein expression levels and assess mitogen-activated protein kinase (MAPK) pathway involvement. Alkaline phosphatase (ALP) and alizarin red staining were used to evaluate expression levels of ALP and calcified nodule formation after treatment with leptin and/or the presence of MAPK inhibitors.

RESULTS

All concentrations of leptin used in this study did not significantly affect the viability of hDPCs. However, mRNA and protein levels of odontogenic and angiogenic markers, ALP activity, and calcified nodule formation were significantly increased in the leptin-treated group compared with those in the control group. Leptin enhanced phosphorylation of extracellular signal-related kinases, c-Jun N-terminal kinase, and p38 mitogen-activated protein kinases within 5 minutes after treatment. However, leptin-induced dentin sialophosphoprotein and vascular endothelial growth factor protein expression and mineralization were appreciably blocked by the presence of MAPK inhibitors.

CONCLUSIONS

Leptin can induce angiogenesis, odontogenic differentiation, and mineralization in hDPCs via activating the MAPK signaling pathway.

Efficacy of Enamel Matrix Derivative in Vital Pulp Therapy: A Review of Literature

Introduction:

Vital pulp therapy (VPT) aims to preserve the health and maintain life of the tooth pulp which has been compromised by caries, trauma or restorative procedures. Recently, enamel matrix derivative (EMD) has been introduced as a material for vital pulp therapy. The aim of this review is to critically analyze and summarize the available literature on EMD for VPT.

Methods and Materials:

Online databases (PubMED/MEDLINE, Google Scholar, ISI Web of Science, and Wiley-Online) were searched by using the following keywords in various combinations: Enamel Matrix Derivative, Emdogain, ‘Vital Pulp Therapy, ‘Apexogenisis’, Apexification, Pulp Capping, Endodontics, Dentine and Pulpotomy for studies indexed from January 1949 to April 2016. We used an English-limited search in Google.co.uk for the missing grey literature. All studies fulfilling the selection criteria were carefully reviewed for the focused question: “Does using EMD in VPT, compared with other materials, result in better clinical, radiographic and histological outcomes?”.

Results:

The primary search resulted in 18 articles of which, 14 articles (including 6 animal studies and 6 clinical trials and 2 case reports) met the inclusion criteria for this review and hence were included. The number of teeth tested in the animal studies ranged from 8 to 144 including pigs, rats and dogs teeth. A number of studies used EMD in the experimental group in comparison with calcium hydroxide, propylene glycol alginate (PGA) and MTA as a control. The observation period ranged from 1 to 2 months and 4 out of 6 animal trials reported more favorable outcomes with EMD while two studies reported comparable outcomes.

Conclusion:

Although EMD has potential for various applications in endodontics, studies conducted to date have failed to demonstrate any significant advantage of EMD over conventional VPT materials. Additionally, the 5-year and 10-year survival rate of EMD-treated teeth is not yet known. Hence, studies with a longer follow-up periods are required to deduce the long-term viability of teeth treated with EMD.

Chitosan Biomaterials for Current and Potential Dental Applications

Chitosan (CHS) is a very versatile natural biomaterial that has been explored for a range of bio-dental applications. CHS has numerous favourable properties such as biocompatibility, hydrophilicity, biodegradability, and a broad antibacterial spectrum (covering gram-negative and gram-positive bacteria as well as fungi). In addition, the molecular structure boasts reactive functional groups that provide numerous reaction sites and opportunities for forging electrochemical relationships at the cellular and molecular levels. The unique properties of CHS have attracted materials scientists around the globe to explore it for bio-dental applications. This review aims to highlight and discuss the hype around the development of novel chitosan biomaterials. Utilizing chitosan as a critical additive for the modification and improvement of existing dental materials has also been discussed.

Stimulation of Dentin Regeneration by Using Acemannan in Teeth with Lipopolysaccharide-induced Pulp Inflammation

INTRODUCTION

This study investigated the effects of acemannan, a polysaccharide from Aloe vera, on human deciduous pulp cells in vitro and the response after vital pulp therapy in dog deciduous teeth.

METHODS

Human primary dental pulpal cells were treated with acemannan in vitro and evaluated for proliferation, alkaline phosphatase activity, type I collagen, bone morphogenetic protein (BMP-2), BMP-4, vascular endothelial growth factor, and dentin sialoprotein expression and mineralization. Osteogenesis-related gene expression was analyzed by complementary DNA microarray. Pulpal inflammation was induced in dog teeth for 14 days. The inflamed pulp was removed, retaining the healthy pulp. The teeth were randomly divided into 3 treatment groups: acemannan, mineral trioxide aggregate, and formocresol. Sixty days later, the teeth were extracted and evaluated histopathologically.

RESULTS

Acemannan significantly increased pulp cell proliferation, alkaline phosphatase, type I collagen, BMP-2, BMP-4, vascular endothelial growth factor, and dentin sialoprotein expression and mineralization approximately 1.4-, 1.6-, 1.6-, 5.5-, 2.6-, 3.8-, 1.8-, and 4.8-fold, respectively, compared with control. In vivo, partial pulpotomy treatment using acemannan generated outcomes similar to mineral trioxide aggregate treatment, resulting in mineralized bridge formation with normal pulp tissue without inflammation or pulp necrosis. In contrast, the formocresol group demonstrated pulp inflammation without mineralized bridge formation.

CONCLUSIONS

Acemannan is biocompatible with the dental pulp. Furthermore, acemannan stimulated dentin regeneration in teeth with reversible pulpitis.

Dose-responses of Stem Cells from Human Exfoliated Teeth to Infrared LED Irradiation

Despite several reports regarding tissue regeneration, including pulp repair induced by different light sources, only limited data have been reported concerning the effects of light-emitting diodes (LED) on stem cells from human exfoliated deciduous teeth (SHEDs). The aim of this study was to evaluate the effects of different energy densities of infrared LED on the cell viability, number of cells and mineralized tissue production by SHEDs. SHEDs were obtained from near-exfoliation primary teeth (n=3), seeded in plain DMEM (104 cells/cm2), and irradiated by a LED prototype (LEDTable 850 nm, 40 mW/cm2) delivering 0 (control), 2, 4, 8, 15 or 30 J/cm2 (n=9). Cell viability (MTT assay), cell proliferation (trypan blue assay), and mineralized nodule (MN) formation (alizarin red stain) were assessed 12 and 72 h post-irradiation. Data were subjected to Kruskal-Wallis and Mann-Whitney tests (α=0.05). Cells irradiated with 2 or 4 J/cm2 exhibited higher metabolism at 72 h, and all energy densities provided increase in cell proliferation after 12 h. Regarding MN formation, the best results were observed at 72 h after SHED irradiation with 8 and 15 J/cm2. It was concluded that the cell viability, cell number and MN formation by pulp cells are enhanced after exposure to infrared LED irradiation. Overall, the greatest SHED biostimulation was obtained with 4 and 8 J/cm2.