Color Stability of Teeth Restored with Biodentine: A 6-month In Vitro Study

The Efficacy of Different Laser Applications on Dentin Sealing in Preventing Discoloration Induced by Mineral Trioxide Aggregate

The aim of this in vitro study was to evaluate the effect of the pre-application of a dentin-bonding agent and the application of different lasers on the prevention of tooth discoloration caused by mineral trioxide aggregate (MTA) in the presence of blood. Sixty extracted human anterior teeth were selected, with root lengths standardized to 10 mm and root canals shaped using Gates-Glidden drills #3 to #5. The samples were divided into six groups (n = 10): Group 1 with no surface treatment and Groups 2 to 6 with Optibond universal adhesive and Neodymium yttrium aluminum garnet (Nd:YAG), Erbium yttrium aluminum garnet (Er:YAG), Erbium-chromium-yttrium-scandium-gallium-garnet (Er:Cr:YSGG), and diode laser applications, respectively. Root canals were filled with fresh human blood, and ProRoot MTA and a collagen barrier were then placed. Color changes were measured with a spectrophotometer at 0, 7, 30, 90, and 180 days post MTA placement. Color differences (∆E) were analyzed using a two-factor mixed-design ANOVA with the Sidak method (p = 0.05). All treatment groups exhibited discoloration above the acceptability threshold. Although all treatment approaches exhibited less color change compared to the control group (p < 0.05), there was no significant difference among them in terms of preventing color change (p > 0.05). It was determined that none of the methods could guarantee 100% prevention of discoloration caused by MTA-blood contact.

Spectrophotometric Analysis of Color Stability Induced by Various Calcium Silicate Cements in Full Pulpotomy of Permanent Molars: Theracal PT, Biodentine, and ProRoot MTA

AIM

The objective of this study was to assess the color stability induced by Theracal PT, Biodentine, and ProRoot MTA in teeth subjected to full pulpotomy, over a span of 6 months.

MATERIALS AND METHODS

The study employed a total of 48 freshly extracted intact human third molar teeth. Samples were randomly assigned into four groups (n = 12). All teeth, with the exception of the control group, underwent endodontic access. All materials were mixed in accordance with the manufacturer's guidelines and applied at a thickness of 3 mm at the orifice level before they set. The study groups were negative control (was not prepared), positive control (ProRootMTA), Biodentine, and Theracal PT. Glass ionomer and composite resin material was applied to the cavities. The color measurements were performed using the VITA Easy Shade spectrophotometer. All measurements were repeated 3 times in the determined area on the middle buccal surface of the tooth at baseline that (T0); after access preparation and material placement and setting) and then subsequently at 7 (T1), 30 (T2), 90 (T3), and T4 (180) days later. Data were statistically analyzed by using Kruskal-Wallis H at a confidence level of 95% (P < .05).

RESULTS

Compared with the negative control group, Biodentine and Theracal PT showed color stability (ΔE ≤ 3.7). The teeth treated with MTA showed clinically observable discoloration (ΔE ≥ 3.7) at T0, T1, T2, T3, and T4 intervals. At all-time intervals, the MTA group induced more discoloration than Biodentine and Theracal PT (P < .05).

CONCLUSIONS

Theracal PT and Biodentine caused least discoloration compared to PMTA even 6 months after its application in teeth undergoing pulpotomy, thereby offering clinicians a reliable alternative for use in the esthetic zone.

Specimen Shape and Elution Time Affect the Mineralization and Differentiation Potential of Dental Pulp Stem Cells to Biodentine

The liquid extract method is commonly used to evaluate the cytotoxicity and bioactivity of materials. Although ISO has recommended guidelines for test methods, variations in elution period, and shape of samples can influence the biological outcomes. The aim of this study was to investigate the influence of material form and elution period of Biodentine on dental pulp stem cells (DPSCs)' proliferation and mineralization. Biodentine (0.2 g) discs or powder were immersed in culture media (10 mL) for 1, 3 or 7 days (D1, D3 and D7). The eluents were filtered and used to treat DPSC. The calcium release profile and pH were determined. Cell proliferation was evaluated by MTS for 3 days, and mineralization and differentiation were assessed by alizarin red S staining (Ca2+/ng of DNA) and qRT-PCR (MEPE, DSPP, DMP-1, RUNX2, COL-I and OCN) for 14 days. Statistical analysis was performed with a one or two-way ANOVA and post hoc Tukey's test (pH, calcium release and proliferation) or Mann-Whitney test (α = 0.05). pH and calcium ion release of powdered eluents were significantly higher than disc eluents. Powdered eluent promoted extensive cell death, while the disc form was cytocompatible. All disc eluents significantly increased the gene expression and mineralization after 14 days compared to the untreated control. D7 induced less mineralization and differentiation compared to D1 and D3. Thus, the materials' form and elution time are critical aspects to be considered when evaluating the bioactivity of materials, since this binomial can affect positively and negatively the biological outcomes.

Management of a supernumerary tooth fused to the labial surface of a permanent maxillary central incisor

Key Clinical Message

Management of supernumerary teeth fused to the labial surface of permanent maxillary central incisors would require a multidisciplinary approach comprising of endodontic treatment, periodontal recontouring, and cosmetic composite restoration.

Abstract

The reported cases of supernumerary teeth fused to the labial surface of maxillary central incisors are rare. Such cases need multidisciplinary approaches. Herein, management of a supernumerary tooth fused to the labial surface of a maxillary central incisor is reported. Due to the presence of a communication path between the root canal systems of the two fused teeth, root canal therapy was performed first for the maxillary left central incisor and the supernumerary tooth. The crown of the supernumerary tooth was then removed in a surgical setting while preserving the root to maintain the thin covering of alveolar bone and prevent future periodontal problems. Subsequently, an esthetic composite restoration was performed.

Evaluation of the chemical, physical, and biological properties of a newly developed bioceramic cement derived from cockle shells: an in vitro study

BACKGROUND

Tricalcium silicate is the main component of commercial bioceramic cements that are widely used in endodontic treatment. Calcium carbonate, which is manufactured from limestone, is one of the substrates of tricalcium silicate. To avoid the environmental impact of mining, calcium carbonate can be obtained from biological sources, such as shelled mollusks, one of which is cockle shell. The aim of this study was to evaluate and compare the chemical, physical, and biological properties of a newly developed bioceramic cement derived from cockle shell (BioCement) with those of a commercial tricalcium silicate cement (Biodentine).

METHODS

BioCement was prepared from cockle shells and rice husk ash and its chemical composition was determined by X-ray diffraction and X-ray fluorescence spectroscopy. The physical properties were evaluated following the International Organization for Standardization (ISO) 9917-1;2007 and 6876;2012. The pH was tested after 3 h to 8 weeks. The biological properties were assessed using extraction medium from BioCement and Biodentine on human dental pulp cells (hDPCs) in vitro. The 2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-5[(phenylamino)carbonyl]-2 H-tetrazolium hydroxide assay was used to evaluate cell cytotoxicity following ISO 10993-5;2009. Cell migration was examined using a wound healing assay. Alizarin red staining was performed to detect osteogenic differentiation. The data were tested for a normal distribution. Once confirmed, the physical properties and pH data were analyzed using the independent t-test, and the biological property data were analyzed using one way ANOVA and Tukey's multiple comparisons test at a 5% significance level.

RESULTS

The main components of BioCement and Biodentine were calcium and silicon. BioCement's and Biodentine's setting time and compressive strength were not different. The radiopacity of BioCement and Biodentine was 5.00 and 3.92 mmAl, respectively (p < 0.05). BioCement's solubility was significantly higher than Biodentine. Both materials exhibited alkalinity (pH ranged from 9 to 12) and demonstrated > 90% cell viability with cell proliferation. The highest mineralization was found in the BioCement group at 7 days (p < 0.05).

CONCLUSIONS

BioCement exhibited acceptable chemical and physical properties and was biocompatible to human dental pulp cells. BioCement promotes pulp cell migration and osteogenic differentiation.

Microstructure and color stability of calcium silicate-based dental materials exposed to blood or platelet-rich fibrin

OBJECTIVES

To investigate the effects of blood and platelet-rich fibrin (PRF), commonly used scaffolds in regenerative endodontic treatment (RET), on the hydration, microstructure, and color stability of three hydraulic calcium silicate cements (HCSCs), OrthoMTA, RetroMTA, and TotalFill-BC-RRM.

MATERIALS AND METHODS

The HCSCs were prepared and placed into polyethylene molds and transferred to Eppendorf tubes containing PRF, blood, or PBS and then incubated for 1 week or 1 month. The microstructure and hydration of the cements were studied by scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDS), and X-ray diffraction (XRD). The chromatic alteration of materials was also measured using a spectrophotometer. The data for color stability were analyzed using 2-way analysis of variance and Tukey post hoc tests.

RESULTS

There was no significant difference between the color stability of cements exposed to PBS (p > 0.05). The chromatic alteration of cements exposed to blood was significantly greater than those exposed to PRF and PBS (p < 0.001). In the presence of blood and PRF, the color change of OrthoMTA was significantly greater than that of RetroMTA and TotalFill (p < 0.05), with no significant difference between RetroMTA and TotalFill (p > 0.05). XRD analysis of all cements revealed a calcium hydroxide peak after 1-week and 1-month exposure to the media; however, OrthoMTA and TotalFill exposed to blood and PRF for 1 month showed weaker calcium hydroxide peaks. SEM images revealed cements exposed to PBS had a different surface microstructure compared to those exposed to blood and PRF. Furthermore, the surface microstructure of HCSCs was influenced by the type of cement radiopacifier (bismuth oxide or zirconium oxide). EDS analysis of the elemental composition in all groups displayed peaks of Ca, O, C, Si, P, and Al.

CONCLUSIONS

Color stability, hydration behavior, and microstructure of HCSCs were affected by exposure to PRF and blood and the type of cement radiopacifier.

CLINICAL RELEVANCE

As some important physicochemical properties of HCSCs could be influenced by the environmental conditions and the type of radiopacifier, alternatives to blood clot and HCSCs containing substitutes for bismuth oxide might be more suitable in RETs.

Coronal discoloration induced by calcium silicate-based cements used in full pulpotomy in mature permanent molars: a randomized clinical trial

OBJECTIVES

This study aimed to randomly compare in vivo coronal discoloration at 6 and 12 months after full pulpotomy in mature permanent molars using MTA, Biodentine, and TotalFill and to investigate the effect of variables such as remaining buccal wall thickness and time to achieve hemostasis.

MATERIALS AND METHODS

One hundred eight teeth that met the inclusion criteria received full pulpotomy and were randomly divided into 3 groups via a block randomization technique according to the calcium silicate cement (CSC): ProRoot WMTA, TotalFill, or Biodentine. Assessment of tooth color was carried out using a spectrophotometric device (VITA Easyshade Compact) after composite placement (T0), at 6- and 12-month follow-up. Buccal wall thickness and time to hemostasis were recorded. The primary outcome measure (color change ΔE) was calculated, and the results were analyzed by three-way ANOVA and crosstabulations in relation to material type and effect of variables.

RESULTS

Four cases were excluded after pulpotomy failure; 81 teeth were evaluated at 6 months and 95 teeth at 12 months. All CSCs caused tooth discoloration (defined as ΔE > 3.7); MTA significantly caused the highest color change at 6- and 12-month follow-up (76% (19/25) and 87.5% (28/32), respectively) compared to Biodentine (41% (9/22), 48% (13/27)) and TotalFill (44% (15/34), 53% (19/53)) (p = 0.022, p = 0.002), while no significant difference was found between the Biodentine and TotalFill groups (p = 0.813, p = 0.8). Buccal wall thickness (above or below 2.7 mm) had a significant effect on the degree of discoloration (p = 0.004).

CONCLUSIONS

The 3 CSCs caused tooth discoloration based on the threshold of ΔE > 3; the remaining buccal wall thickness was a significant factor. The use of Biodentine and TotalFill instead of MTA is encouraged to minimize discoloration.

CLINICAL RELEVANCE

While experimental studies report coronal discoloration after CSCs use, clinical data is lacking. This study assessed discoloration using a spectrophotometric device. The use of materials with lower discoloration potential in pulpotomy is encouraged.

TRIAL REGISTRATION

The study was registered with clinical trial registration number: NCT04346849 on 14.4.2020.

The scientific management of deep carious lesions in vital teeth using contemporary materials—A narrative review

Aim

The aim of this article is to review the scientific evidence for deep caries removal in permanent vital teeth and the choice of dentine replacement material and restoration of the teeth to maintain long term tooth vitality and function.

Method

The two position statements namely the European Society of Endodontology and the American Association of Endodontists position statements on vital pulp therapy will be scrutinized and compared with regards to the deep caries removal strategy and assessed for evidence of best practice. The properties of materials used to manage vital pulps and the best way to restore the teeth will be reviewed and guidance on the full management of vital teeth will be suggested.

Conclusions

Promoting new treatment modalities for reversible and irreversible pulpitis allowing for pulp preservation should be considered. Although debatable, cases with deep caries should be managed by complete non-selective caries removal which will allow for pulpal management if needed and a more predictable outcome can be expected when using the new materials and treatment modalities of vital pulp therapy.

Discoloration Improvement by Mechanically-Milled Binary Oxides as Radiopacifier for Mineral Trioxide Aggregates

Mineral trioxide aggregates (MTA) have been widely used in endodontic treatments, but after some time, patients suffer tooth discoloration due to the use of bismuth oxide (Bi2O3) as a radiopacifier. Replacement of Bi2O3 with high energy ball-milled single (zirconia ZrO2; hafnia, HfO2; or tantalum pentoxide, Ta2O5) or binary oxide powder was attempted, and corresponding discoloration improvement was investigated in the present study. Bi2O3-free MTA is expected to exhibit superior discoloration. The radiopacity, diametral tensile strength, and discoloration of MTA-like cements prepared from the as-milled powder were investigated. Experimental results showed that MTA-like cements prepared using Ta2O5 exhibited a slightly higher radiopacity than that of HfO2 but had a much higher radiopacity than ZrO2. Milling treatment (30 min to 3 h) did not affect the radiopacities significantly. These MTA-like cements exhibited superior color stability (all measured ΔE00 < 1.0) without any perceptible differences after UV irradiation. MTA-like cements prepared using ZrO2 exhibited the best color stability but the lowest radiopacity, which can be improved by introducing binary oxide. Among the investigated samples, MTA-like cement using (ZrO2)50(Ta2O5)50 exhibited excellent color stability and the best overall performance with a radiopacity of 3.25 mmAl and a diametral tensile strength of 4.39 MPa.

Present status and future directions: Hydraulic materials for endodontic use

BACKGROUND

Hydraulic materials are used in Endodontics due to their hydration characteristics namely the formation of calcium hydroxide when mixing with water and also because of their hydraulic properties. These materials are presented in various consistencies and delivery methods. They are composed primarily of tricalcium and dicalcium silicate, and also include a radiopacifier, additives and an aqueous or a non-aqueous vehicle. Only materials whose primary reaction is with water can be classified as hydraulic.

OBJECTIVES

Review of the classification of hydraulic materials by Camilleri and the literature pertaining to specific uses of hydraulic cements in endodontics namely intra-coronal, intra-radicular and extra-radicular. Review of the literature on the material properties linked to specific uses providing the current status of these materials after which future trends and gaps in knowledge could be identified.

METHODS

The literature was reviewed using PUBMED, and for each clinical use, the in vitro properties such as physical, chemical, biological and antimicrobial characteristics and clinical data were extracted and evaluated.

RESULTS

A large number of publications were retrieved for each clinical use and these were grouped depending on the property type being investigated.

CONCLUSIONS

The hydraulic cements have made a difference in clinical outcomes. The main shortcoming is the poor testing methodologies employed which provide very limited information and also inhibits adequate clinical translation. Furthermore, the clinical protocols need to be updated to enable the materials to be employed effectively.

Discoloration Potential of Biodentine: A Systematic Review

The aim of this systematic review is to investigate the teeth discoloration potential of Biodentine. An electronic search in six databases (PubMed, Cochrane Library, LILACS, SCIELO, Web of Science, and Scopus) was conducted by three independent reviewers to identify eligible articles. The following search terms were used: ((discolo*, staining potential, color, colour, or spectrophotomet*), (teeth or tooth), and (Biodentine)). Methodology following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines was adopted for this investigation. At the end of the selection process, 30 articles were identified as eligible, of which 14 in vitro studies were included in this systematic review. Nine of the included studies evaluated the discoloration potential of Biodentine in the presence of blood. Within the limitations of this review, teeth discoloration using Biodentine is highly expected when material is placed in direct contact with blood during dental procedures. In the absence of blood, Biodentine causes less teeth color changes than MTA-based materials, but it is still unclear what clinically relevant results could be expected regarding the discoloration frequency and intensity induced by Biodentine.

Vital Pulp Therapy in Aesthetic Zone-Identifying the Biomaterial That Reduces the Risk of Tooth Discolouration

Calcium silicate-based cements are biocompatible materials for vital pulp therapy. However, they discolour the tooth tissue, which is important for the aesthetics of the anterior teeth. The aim of this study was to investigate the effect of calcium silicate-based cements on tooth discolouration. The study included 70 extracted bovine incisors. The crown of the tooth was cut off from the root, 2 mm below the cement-enamel junction. The pulp tissue was removed via a cervical cut with a barbed broach. The teeth were randomly divided into five experimental, one positive, and one negative control groups. The evaluated materials included Biodentine, Ortho MTA, Retro MTA, MTA Plus, MTA Repair HP, and in the positive group, ProRoot MTA. A VITA Easyshade Compact 5.0 spectrophotometer was used before the application, after 1 week, 1 month, 3 months, and 6 months. The significance levels were set at p < 0.05. All materials significantly changed the teeth colour (p < 0.05). However, Ortho MTA, ProRoot MTA, MTA Plus, and Biodentine (ΔE > 6) caused maximum colour change after 6 months. While the ProRoot MTA, Ortho MTA, and MTA Plus caused grey discolouration, Biodentine darkened the shade of the base colour. Thus, Retro MTA and MTA Repair HP can be safely used in the aesthetic dentition zone. According to these clinical results, the possibility of using Biodentine, due to its lack of gray discoloration, can be considered.

Biological parameters, discolouration and radiopacity of calcium silicate-based materials in a simulated model of partial pulpotomy

AIM

To analyse the discolouration, radiopacity, pH and calcium ion release of Biodentine (BD), Bio-C repair (BCR) and Bio-C temp (BCT), as well as their biological effects on human dental pulp cells (hDPCs).

METHODOLOGY

Sixty-four extracted bovine incisors were prepared to simulate crown fractures with pulp exposure and open root apex. The roots were filled using a mixture of agar and blood (control), and BD, BCR or BCT were placed over this mixture. Colour assessment analyses of the samples were performed before and immediately after material insertion and repeated at 30 and 90 days, using a spectrophotometer. The colour change of each specimen was evaluated at the crown and calculated based on the CIELab colour space. Digital radiographs were acquired for radiopacity analysis. hDPCs were placed in contact with different dilutions of culture media previously exposed to such materials and tested for cell viability using the MTT assay. The pH and calcium ion release of all materials were measured after 24 h; the data were assessed using one-way analysis of variance (ANOVA). Cell viability was analysed by two-way ANOVA. Differences in colour parameters and wound-healing data were assessed by two-way repeated measures ANOVA (α = 0.05). Tukey's and Dunnett's tests were used to compare the experimental groups with the control group.

RESULTS

BCR had grater radiopacity and smaller colour alteration (ΔEab/ΔE00) than the other materials tested (p < .005; p < .001). No significant differences in pH were found amongst the tested materials (p > .05). BCT was associated with the largest release of calcium ions (p < .0001). BD had cell viability similar to that of the control at the lowest dilutions, and BCR was similar to that of the control, regardless of the dilution tested (p > .05). BCT had a lower percentage of viability than that of the control at all tested dilutions (p < .0001). Cell migration rates in BD and BCR were similar to those in the control group after 24 h and 48 h (p > .05), whilst BCT had larger voids than the control in both periods (p < .0001).

CONCLUSIONS

BCR, BCT and BD were associated with tooth discolouration. BCR had the lowest staining values, the highest radiopacity and viability greater than 80% hDPCs.

Spectrophotometric Analysis of Coronal Discolouration Induced by ProRoot MTA, Biodentine and MTA Repair HP Used for Pulpotomy Procedures

OBJECTIVE

To assess and quantify coronal tooth discolouration by ProRoot MTA, Biodentine and MTA repair HP as pulpotomy agents and to identify colour stability of these materials in presence of blood contamination.

METHODS

120 human premolar teeth were used in the study. The teeth were sectioned horizontally 1 mm apical to the cementoenamel junction. A retrograde cavity extending within 2 mm of the incisal edge was prepared. The specimens were randomly distributed as; Control: Group 1, ProRoot MTA: Group 2, Biodentine: Group 3 and MTA repair HP: Group 4. The groups werefurther subdivided on basis of exposure to saline (subgroup A) or blood (subgroup B). The access was sealed with light cured Glass ionomer cemet and the specimens were stored in artificial saliva at 37°C. The Colour change was evaluated with a spectrophotometer at: day 0 (T0), day 1 (T1), day 7 (T7), 1 month (T30), 2 months (T60), and 6 months (T180). The colour measurements were recorded using the Commission Internationale de l'Eclairage L*a*b* value.

RESULTS

For all groups, there was a sharp increase in L* parameter at T1. At 6 months, Group 1B (Control + blood) showed maximum decrease in luminosity followed by Group 2A (ProRoot + saline) > Group 4B (MTA repair HP + blood) > Group 2B (ProRoot + blood). Group 3A (Biodentine + saline) showed the least amount of decrease in luminosity followed by Group 4A (MTA repair HP + saline) and Group 3B (Biodentine + blood). No significant difference was found in ∆E change between any of the groups from baseline to 180 days (P>0.05).

CONCLUSION

Relative to L* parameter, it was possible to observe a statistically significant decrease in luminosity in the Group1B (Control + blood) followed by ProRoot MTA (Group 2A and 2B) and MTA repair HP (Group 4A and 4B). Biodentine (Group 3A and 3B) showed least tooth discolouration in terms of L* parameter.

Long-term evaluation of primary teeth molar pulpotomies with Biodentine and MTA: a CONSORT randomized clinical trial

BACKGROUND

Calcium silicate-based materials have become widely used in recent years due to their positive effect on pulp cells, which stimulate tertiary dentin formation.

AIM

The aim of the present study was to evaluate and compare clinically and radiographically the performance of MTA and Biodentine as pulp-dressing materials following pulpotomy in primary molars at 24-month follow-up.

DESIGN

Molars from patients aged 4-9 years scheduled for pulpotomy were treated with either MTA or Biodentine followed by a stainless-steel crown. These molars were clinically and radiographically followed up at 6, 12, 18, and 24 months. Statistical analysis was performed to detect differences between the two groups.

RESULTS

A total of 84 pulpotomies were performed obtaining a total success rate of 99.4 and 97.2% for Biodentine and MTA, respectively, at 24 months, showing no statistically significant differences between the two groups.

CONCLUSION

24-month follow-up showed that Biodentine and MTA have similar effectiveness.

BiodentineTM Full Pulpotomy in Mature Permanent Teeth with Irreversible Pulpitis and Apical Periodontitis

Vital pulp therapy, including direct pulp capping and partial and full pulpotomy, is primarily indicated for immature or mature permanent teeth with reversible pulpitis. Mature permanent teeth with irreversible pulpitis are frequently treated with root canal therapy. This report presents two cases of full pulpotomy using BiodentineTM in mature permanent teeth with irreversible pulpitis and acute apical periodontitis. The periapical radiograph illustrated a deep carious lesion extended to the pulp with apical radiolucency lesion or widened periodontal ligament space. Full pulpotomy with a tricalcium silicate-based cement was chosen as the definitive treatment. After decayed tissue excavation under a rubber dam, the exposed pulp tissue was amputated to the level of the canal orifice with a new sterile bur. BiodentineTM was applied as the pulp capping agent after hemostasis was obtained and for temporary restoration. The clinical signs disappeared quickly after the treatment. After one month, the coronal part of the temporary restoration was removed, and a composite resin was placed over the capping agent as a final restoration. At two-year follow-ups, the teeth were asymptomatic. Radiographs showed healing of the periapical lesion and periodontal ligament. BiodentineTM full pulpotomy of mature permanent teeth with irreversible pulpitis and apical periodontitis can be an alternative option to root canal therapy.

Effect of different manipulations on the physical, chemical and microstructural characteristics of Biodentine

OBJECTIVE

The water to powder ratio and method of mixing is important for the properties of hydraulic cements. For this purpose a number of clinicians prefer premixed materials. Dental manufacturing companies provide predosed materials, however the manufacturer instructions are not always adhered to. The aim of this research is to investigate physical and chemical alterations of the tricalcium silicate-based cement Biodentine when manipulated according to the manufacturer's instructions (control) or changing the doses and mixing of the material components.

METHODS

6 groups were constituted according to different mixing and dosing of powder and liquid. The hydrated cements were characterized using scanning electron microscopy (SEM), X-ray diffraction (XRD) and Fourier transform infrared spectroscopy (FT-IR). Calcium ion concentration of the leachate was also investigated. Assessment of the physical characteristics included setting time and microhardness.

RESULTS

Microstructural differences were visible only in the Biodentine mixed manually with water, in which early hydration rate was also affected, with lower calcium ion release. Increase of Biodentine liquid increased the calcium ion release, but also increased the setting time. Manual manipulation required more liquid (both water and Biodentine liquid) added to the mixture to guarantee a similar consistency to the control. A decrease in setting time was also noted. All groups showed higher values of microhardness at 24 h compared to the freshly set materials. In the freshly set materials, there was an overall decrease in microhardness in all groups when compared to group control, particularly significant when increasing the dosage of Biodentine liquid.

SIGNIFICANCE

When mixing Biodentine, altering the mixing procedure in terms of type and amount of liquid added to the powder and mixing device chosen has an effect on the physical, chemical and mechanical characteristics and surface topography of the material, when compared to Biodentine mixed according to the manufacturer's recommendations. Hence, the manufacturer's instructions should be strictly followed.

Spectrophotometric analysis of the color stability of white mineral trioxide aggregate in contact with four different irrigating solutions - An in vitro study

Aims

This study aims to compare the color stability of white mineral trioxide aggregate (wMTA) in contact with four irrigating solutions.

Settings and Design

Original research study.

Subjects and Methods

Fifty cylindrical discs of wMTA, 10 mm in diameter and 2 mm in height were prepared using a mold. Samples were incubated at a temperature of 37°C and at 100% humidity for the material to reach its optimal mechanical properties. The samples were divided into 6 groups: Group A: dry (n = 5); Group B: distilled water (DW) (n = 5); Group C: 5% sodium hypochlorite (NaOCl) (n = 10); Group D: 2% chlorhexidine gluconate (CHX) (n = 10); Group E: 17% aqueous ethylene diamine tetra-acetic acid (EDTA) (n = 10); Group F: 0.2% Chitosan (n = 10) Each disc was immersed into the irrigating solution for a period of 24 h. All the specimens were photographed using a digital camera before and after immersion. The assessment of color change of each disc of wMTA was conducted by a spectrophotometer. The Commission Internationale de l'eclairage system was used to calculate the differences in color.

Statistical Analysis Used

Statistical Package for the Social Sciences version 16.0 (Chicago, IL, USA) at a significance level of P < 0.05 was used.

Results

All groups except group A exhibited discoloration of wMTA. The mean values for change in color was highest with Group D, followed by Group C, F, E, B, and group A. Only Group B when compared to group A did not show any statistically significant difference (P = 0.948) whereas all the other four groups showed a highly statistically significant difference (P < 0.001).

Conclusions

2% CHX causes maximum discoloration of wMTA followed by 5% NaOCl, 0.2% Chitosan and least discoloration with 17% aqueous EDTA and DW.

Influence of Ultrasonic Activation on the Physicochemical Properties of Calcium Silicate-Based Cements

Purpose

To evaluate the influence of ultrasonic activation on the physicochemical properties of setting time (ST), flow (FL), dimensional change (DC), and solubility (SL) of the cements: MTA, MTA Repair HP, and Biodentine®.

Materials and Methods

Two experimental groups were formed according to the cement activation protocol: without ultrasonic activation and with ultrasonic activation. Cements were manipulated according to the manufacturers' instructions. Ultrasonic activation group was performed with an E1 insert at power 3 (24–32 kHz) for 30 s directly in the center of the cement mass. The molds for analysis of the physicochemical properties were filled out and evaluated according to specification No. 57 from ANSI/ADA. The results were analyzed using the ANOVA test (two-way), complemented by Tukey's test (α = 0.05). The distilled water used during the solubility test was submitted to spectrometry to verify the release of calcium ions. The morphologies of the external surface and the cross-section of the samples were analyzed by means of a scanning electron microscope (SEM).

Results

For the ST, ultrasonic activation reduced the values of MTA, MTA Repair HP, and Biodentine (P < 0.05). For the FL, ultrasonic activation did not alter the flow of MTA (P > 0.05); however, it increased the flow MTA Repair HP and Biodentine (P < 0.05). For the DC, the percentage values of dimensional change were higher when there was ultrasonic activation in all repair cements (P < 0.05). For SL, there was a reduction in the percentage of the values in MTA and MTA Repair HP (P < 0.05); however, there was no change in the values of Biodentine (P > 0.05). Ultrasonic activation favored the release of calcium ions from all cements. The SEM analysis showed, in general, that the ultrasonic activation reduced and altered the particle shape of the cement.

Conclusions

The ultrasonic activation interfered in the ST, DC, FL, ultrastructural morphology, and calcium release of the repair cements. However, it did not affect the solubility of Biodentine®.

Cytotoxicity of NeoMTA Plus, ProRoot MTA and Biodentine on human dental pulp stem cells

Background/purpose

Dental pulp stem cells (DPSCs) play a crucial role in the tissue healing process through odontoblast like cell differentiation. The aim of this study was to evaluate the biocompatibility and compare the potential invitro cytotoxic effects of NeoMTA Plus, ProRootMTA and Biodentine on human dental pulp stem cells (hDPSCs).

Materials and methods

To assess the effects of NeoMTA Plus, ProRoot MTA and Biodentine extracts at 1st, 3rd and 7th d on hDPCs, cell populations was determined by flow cytometry using an Annexin V detection kit. The data were analyzed statistically using the Kruskal–Wallis test. A p < 0.05 was considered as statistically significant.

Results

All groups showed cell viability similar to that of the control group on 1st, 3rd and 7th d. Although Biodentine exhibited higher cell viability rates than the other material groups, no statistically significant differences were noted between the sampled days (p > 0.05).

Conclusion

All materials extracts are not cytotoxic and do not induce apoptosis in the hDPSCs. These results suggest that all the tested materials can lead to positive outcomes when used as reparative biomaterials.

Long-term clinical and radiographic evaluation of the effectiveness of direct pulp capping materials: A meta-analysis

The aim of this review is to evaluate the long-term effectiveness of calcium silicate-based cement (CS) and calcium hydroxide (CH) for direct pulp capping (DPC) to human pulp-exposed permanent teeth. An electronic search and manual search were performed on 21 June 2019. Long-term clinical and radiographic evaluations of the effectiveness of CS and CH for DPC to human pulp-exposed teeth were included, and data extraction, risk-of-bias assessment and meta-analyses were performed. From 645 identified articles, 7 articles met the eligibility criteria. The meta-analyses comparing CS with CH and Biodentine with mineral trioxide aggregates (MTA) on DPC success rate were performed, and significant difference was observed between CS and CH (risk ratio=1.20; p=0.005), whereas no significant difference was observed between Biodentine and MTA. CS seems to be a more effective and predictable DPC material than CH; however, these analyses are based on the studies judged at high risk of bias.

Biocompatibility and Bioactivity of Set Direct Pulp Capping Materials on Human Dental Pulp Stem Cells

In this study, we assessed the biocompatibility and bioactivity of various pulp capping materials—ProRoot MTA (Dentsply Tulsa Dental Specialties), Biodentine (Septodont), TheraCal LC (Bisco), and Dycal (Dentsply Caulk)—on human dental pulp stem cells (hDPSCs). Experimental disks (diameter, 7 mm; height, 4 mm) were stored in a humified incubator at 37 °C for 48 h. Then, the pulp capping materials were tested for cytotoxic effects by methyl-thiazoldiphenyl-tetrazolium and scratch wound healing assays, and for mineralization potential by Alizarin red S (ARS) staining assay and alkaline phosphatase enzyme (ALP) activity. Cell viability and cell migration did not significantly differ between ProRoot MTA, Biodentine, and control (p > 0.05). TheraCal LC exhibited slower cell migration on days 2–4 compared to control (p < 0.05), and Dycal showed no cell migration. ALP activity was highest with Biodentine on days 10 and 14, and was lowered with TheraCal LC and Dycal (p < 0.05). In the ARS assay, hDPSCs grown in ProRoot MTA and TheraCal LC eluates showed significantly increased mineralized nodule formation on day 21 compared to Biodentine, Dycal, and control (p < 0.05). These findings indicate that ProRoot MTA, Biodentine, and TheraCal LC exhibit better biocompatibility and bioactivity than Dycal.

To Compare Mineral Trioxide Aggregate, Platelet-rich Fibrin, and Calcium Hydroxide in Teeth with Irreversible Pulpitis: A Clinical Study

Aim:

Numerous pulp-capping agents such as mineral trioxide aggregate (MTA), calcium hydroxide (Ca(OH)₂), platelet-rich fibrin (PRF), and biodentine have been suggested. This clinical study was conducted to compare MTA, PRF, and Ca(OH)₂ in teeth with irreversible pulpitis.

Materials and Methods:

The 60 mandibular molar teeth with irreversible pulpitis were used in this study, which were restored with Ca(OH)₂, MTA, and PRF. Assessments of the treatment were carried out at 6 months and 1 year by clinical examination and also radiographically.

Results:

A nonsignificant difference was observed in pain intensity recorded at numerical rating scale at baseline, 24h, 1 week, 1 month, 3 months, 6 months, and 1 year. A nonsignificant (P > 0.05) difference was reported in clinical and radiographic success rate recorded at 6 months and 1 year in all groups.

Conclusion:

Pulp-capping agents such as Ca(OH)₂, MTA, and PRF yielded similar success rate when used in teeth with irreversible pulpitis.

Tooth Discoloration after Regenerative Endodontic Procedures with Calcium Silicate-Based Cements—An Ex Vivo Study

The aim of the present ex vivo study was to assess and compare coronal discoloration induced by four endodontic biomaterials used in regenerative endodontic procedures (REPs). Root resection was executed horizontally, 2 mm apical to the cementoenamel junction, in all fifty-four teeth. After accessing the pulp chamber, specimens were randomly divided in groups and filled with either saline solution or blood, followed by calcium silicate-based cements (CSCs) placement: ProRoot mineral trioxide aggregate (MTA) (Dentsply Sirona), Biodentine (Septodont), TotalFill BC (FKG), or pulp capping material (PCM) (Coltène). Color change (ΔE) was assessed using the L* a* b* system at five different timepoints (before and immediately after biomaterial application, 72 h, 7 days, and 6 months). The significance level for statistical analysis was set at p < 0.05. There are statistically significant differences regarding ΔE over time (p < 0.001). Statistical differences are found considering material (p < 0.001), treatment (p = 0.007), or both (p = 0.002). If solely the material or treatment is considered, regardless of time, statistically significant differences are detected (p < 0.001). After a six-month period of evaluation, blood exposure might be a critical factor in biomaterials’ color variation. Biodentine presents the lowest discoloration potential, followed by TotalFill and PCM, albeit without statistically significant differences. MTA exhibited the greatest color variation. The selection of biomaterial should consider the material’s discoloration potential.

Biomimetic Aspects of Restorative Dentistry Biomaterials

Biomimetic has emerged as a multi-disciplinary science in several biomedical subjects in recent decades, including biomaterials and dentistry. In restorative dentistry, biomimetic approaches have been applied for a range of applications, such as restoring tooth defects using bioinspired peptides to achieve remineralization, bioactive and biomimetic biomaterials, and tissue engineering for regeneration. Advancements in the modern adhesive restorative materials, understanding of biomaterial-tissue interaction at the nano and microscale further enhanced the restorative materials' properties (such as color, morphology, and strength) to mimic natural teeth. In addition, the tissue-engineering approaches resulted in regeneration of lost or damaged dental tissues mimicking their natural counterpart. The aim of the present article is to review various biomimetic approaches used to replace lost or damaged dental tissues using restorative biomaterials and tissue-engineering techniques. In addition, tooth structure, and various biomimetic properties of dental restorative materials and tissue-engineering scaffold materials, are discussed.

The Disease Process, Diagnosis and Treatment of Invasive Cervical Resorption: A Review

Invasive cervical resorption (ICR) is a localized, subepithelial, supra-osseous resorptive process of the tooth. Although there are several predisposing factors associated with ICR, its etiology and pathogenesis are poorly understood. The damage to the protective layer on the external root surface appears to allow for the attachment of clastic cells and initiate the resorptive process, which is confined by the inner protective pericanalar resorption-resistant sheet surrounding the root canal space. The use of cone-beam computed tomography (CBCT) is recommended for the diagnosis and assessment of a resorptive lesion. Based on the thorough evaluation of the size and location of the ICR lesion using CBCT, surgical or nonsurgical treatment can be chosen to address the source of the resorption. This review discusses the current status of knowledge regarding the biology of ICR lesions as well as their external or internal treatment using hydraulic calcium silicate-based materials. Future clinical outcome studies are necessary to evaluate the impact of hydraulic calcium silicate-based materials on the healing of ICR lesions.

Contribution of Bone Marrow-derived Cells to Reparative Dentinogenesis Using Bone Marrow Transplantation Model

INTRODUCTION

The aim of this study was to analyze the contribution of bone marrow-derived cells (BMDCs) to reparative dentinogenesis using bone marrow transplantation (BMT) and pulp capping as an in vivo model.

METHODS

A chimeric mouse model was created through the injection of BMDCs expressing green fluorescent protein (GFP+ BMDCs) from C57BL/6 GFP+ transgenic donor mice into irradiated C57BL/6 wild-type recipient mice (GFP- mice). These GFP- chimeric mice (containing transplanted GFP+ BMDCs) were subjected to microscopic pulp exposure and capping with white mineral trioxide aggregate (n = 18) or Biodentine (Septodont, St Maur-des-Fossés, France) (n = 18) in the maxillary first molar. Maxillary arches from GFP- chimeric mice (with the capped tooth) were isolated and histologically processed 5 (n = 9) and 7 (n = 9) weeks after BMT. Confocal laser microscopy and immunohistochemical analysis were performed to assess the presence of GFP+ BMDCs and the expression of dentin sialoprotein, an odontoblast marker, for those cells contributing to reparative dentinogenesis in the dental pulp.

RESULTS

Confocal laser microscopic analyses evidenced the presence of GFP+ BMDCs in close association with reparative dentin synthesized at the site of pulp exposure in GFP- mice 5 and 7 weeks after BMT. Immunohistochemical analysis revealed that GFP+ BMDCs in close association with reparative dentin expressed DSP, suggesting the contribution of nonresident GFP+ BMDCs to reparative dentinogenesis.

CONCLUSIONS

These data suggest the presence of nonresident BMDCs in reparative dentinogenesis and its contribution to dental pulp regeneration in the pulp healing process.

Coronal tooth discoloration induced by regenerative endodontic treatment using different scaffolds and intracanal coronal barriers: a 6-month ex vivo study

Objective

The aim of this study was to evaluate discoloration of teeth undergoing regenerative endodontic procedures (REPs) using blood clot or platelet-rich fibrin (PRF) as the scaffolds and different calcium silicate-based materials as the intracanal coronal barriers in an ex vivo model.

Materials and Methods

Forty-eight bovine incisors were prepared and disinfected using 1 mg/mL double antibiotic paste (DAP). The specimens were then randomly divided into 2 groups (n = 24) according to the scaffolds (blood or PRF). After placement of scaffolds each group was divided into 2 subgroups (n = 12) according to the intracanal coronal barriers (ProRoot MTA or Biodentine). The pulp chamber walls were sealed with dentin bonding agent before placement of DAP and before placement of scaffolds. The color changes (∆E) were measured at different steps. The data were analyzed using 2-way analysis of variance.

Results

Coronal discoloration induced by DAP was not clinically perceptible (ΔE ≤ 3.3). Regarding the type of the scaffold, coronal discoloration was significantly higher in blood groups compared with PRF groups at the end of REP and after 1 month (p < 0.05). However, no significant difference was found between PRF and blood clot after 6 months (p > 0.05). Considering the type of intracanal coronal barrier, no significant difference existed between ProRoot MTA and Biodentine (p > 0.05).

Conclusions

With sealing the dentinal tubules of pulp chamber with a dentin bonding agent and application of DAP as an intracanal medicament, coronal color change of the teeth following the use of PRF and blood sealed with either ProRoot MTA or Biodentine was not different at 6-month follow-up.

Assessment of tooth discoloration induced by biodentine and white mineral trioxide aggregate in the presence of blood

Introduction:

In clinical dental application, using silicate-based cements is extremely popular. These materials come into direct contact with blood during or after placement and may cause tooth discoloration.

Objectives:

The purpose of this study was to compare the coronal tooth discoloration induced by white mineral trioxide aggregate (MTA) and biodentine in the presence of blood.

Materials and Methods:

Seventy specimens were chemomechanically prepared and divided into four experimental and two control groups. In the experimental groups, the pulp chambers were filled with white MTA angelus or biodentine. Blood or saline saturated cotton pellets were placed within the canals. Saline or blood alone was used in the control groups. Color was assessed with a spectrophotometer at baseline, 1 week, and 1 and 3 months, and color change values were calculated. Tukey's honestly significant difference and Sidak tests were used for statistical analysis.

Results:

The color change was significantly less with biodentine/saline than MTA/saline and MTA/blood (P < 0.05). Regardless of the material type and blood presence, discoloration increased after 3 months (P < 0.05).

Conclusion:

Discoloration induced by biodentine/saline may not be clinically noticeable and it was less than MTA-containing groups. Irrespective of blood presence or absence, MTA caused perceptible color change.

Long-term clinical and radiographic evaluation of the effectiveness of direct pulp-capping materials

The aim of this review was to assess the effectiveness of different direct pulp-capping (DPC) materials for human pulp-exposed teeth. An electronic search was performed on 20 February 2018. Long-term clinical and radiographic evaluations of the effectiveness of different DPC materials for use on human pulp-exposed teeth were included. Risk-of-bias assessment and data extraction were performed. From the 496 identified articles, 15 met the eligibility criteria. Among the studies included in those articles, a total of 1,322 teeth were treated with 12 types of DPC materials, and 1,136 teeth were evaluated at a final follow-up examination. For mineral trioxide aggregate (MTA) and calcium hydroxide (CH), the number of included studies, the number of treated teeth, and the mean follow-up period of studies were almost equal, and the success rates of MTA was superior to CH. Therefore, MTA is likely to be a more effective and predictable material for DPC compared to CH. However, the results were based on the included studies, which were all judged to have a high risk of bias. Therefore, more long-term clinical and radiographic studies designed with lower risk of bias are needed. Moreover, the other 10 materials were only investigated by a small number of studies; therefore, further studies are required.

Six-Month Color Stability Assessment of Two Calcium Silicate-Based Cements Used in Regenerative Endodontic Procedures

AIM

The purpose of the present study is to assess the color stability of two calcium silicate-based cements (CSCs) used in regenerative endodontic procedures (REPs).

METHODS

A total of 40 acrylic single-rooted transparent teeth, with immature apex, were used. Root canals were filled up to 3 mm below the level of the cementoenamel junction, with either saline solution (Mineral Trioxide Aggregate (MTA)/saline and Biodentine/saline) or blood (MTA/blood and Biodentine/blood). Subsequently, ProRoot MTA^® or Biodentine^TM was placed in the root canal to create a cervical barrier. Color measurement was carried out at four different evaluation periods (3 h, 72 h, 7 days, and 6 months). Shade analysis within the L* a* b* color space was performed and color variation (∆E) calculated. The significance level for statistical analysis was set at p < 0.05.

RESULTS

The four groups showed a significant decrease in L* values over time. The ΔE value increased over time for all groups but was not statistically significant for the Biodentine/blood group. Two-way ANOVA showed no interaction between the CSC and treatment (contact with saline solution or blood). CSC used was the factor responsible for ΔE over time, inducing statistically significant color variations from T_3H to T_7D (p = 0.04) and T_3H to T_6M (p < 0.01). After 6 months, MTA/saline had 5.08 (p = 0.001) higher ΔE than Biodentine/Saline and the MTA/blood had 3.65 (p = 0.009) higher than Biodentine/blood.

CONCLUSIONS

After 6 months, regardless of blood exposure, Biodentine exhibits superior color stability compared to MTA. Biodentine might be a suitable alternative to MTA as a cervical barrier material in REPs.

Pulp capping materials modulate the balance between inflammation and regeneration

The interrelations between inflammation and regeneration are of particular significance within the dental pulp tissue inextensible environment. Recent data have demonstrated the pulp capacity to respond to insults by initiating an inflammatory reaction and dentin pulp regeneration. Different study models have been developed in vitro and in vivo to investigate the initial steps of pulp inflammation and regeneration. These include endothelial cell interaction with inflammatory cells, stem cell interaction with pulp fibroblasts, migration chambers to study cell recruitment and entire human tooth culture model. Using these models, the pulp has been shown to possess an inherent anti-inflammatory potential and a high regeneration capacity in all teeth and at all ages. The same models were used to investigate the effects of tricalcium silicate-based pulp capping materials, which were found to modulate the pulp anti-inflammatory potential and regeneration capacity. Among these, resin-containing materials such as TheraCal^® shift the pulp response towards the inflammatory reaction while altering the regeneration process. On the opposite, resin-free materials such as Biodentine™ have an anti-inflammatory potential and induce the pulp regeneration capacity. This knowledge contradicts the new tendency of developing resin-based calcium silicate hybrid materials for direct pulp capping. Additionally, it would allow investigating the modulatory effects of newly released pulp capping materials on the balance between tissue inflammation and regeneration. It would also set the basis for developing future capping materials targeting these processes.

MTA and biodentine for primary teeth pulpotomy: a systematic review and meta-analysis of clinical trials

OBJECTIVE

This study aims to perform a systematic review and meta-analysis of clinical trials in order to evaluate the clinical and radiographic success rates of primary teeth pulpotomy performed with biodentine, when compared to MTA.

METHODS

Search strategies were conducted in nine databases on August 5th, 2017, update on February 14th, 2018. Clinical articles were selected, which were in accordance with the inclusion and exclusion criteria and the research objective. They were analyzed by meta-analysis at three time points (6, 12, and 18 months).

RESULTS

Out of the 233 publications initially identified, only 9 studies that fulfilled the inclusion criteria were included in the review. The 6-month overall clinical (RR = 0.99; 95% CI = 0.96-1.02, p = 0.92) and radiographic success rates (RR = 0.96; 95% CI = 0.92-1.00, p = 0.28) showed that biodentine vs. MTA did not differ statistically. The 12 and 18-month overall clinical success rates, respectively (RR = 1.01; 95% CI = 0.97-1.04, p = 0.77; RR = 0.98; 95% CI = 0.92-1.05, p = 0.74) and radiographic success rates, respectively (RR = 0.97; 95% CI = 0.92-1.02, p = 0.11; RR = 1.00; 95% CI = 0.91-1.10, p = 0.56) also showed that biodentine vs. MTA did not differ statistically.

CONCLUSION

There is no superiority of one material over the other, MTA versus biodentine.

CLINICAL RELEVANCE

This systematic review comparing the performance of biodentine in relation to the MTA when used in the pulpotomy technique in primary teeth. Although MTA is considered the gold standard material for pulpotomy procedures, it has some drawbacks (poor handling, staining potential, long setting time); thus, it is important to evaluate the clinical performance of other calcium silicate-based cements like biodentine that overcome this drawbacks.

Invasive Cervical Resorption: Clinical Management in the Anterior Zone

According to the high number of articles published on invasive cervical resorption (ICR), this pathology, as commonly believed, is a more frequent form of cervical resorption. ICR is often misdiagnosed as internal resorption or caries, which leads to inappropriate treatment and even unnecessary tooth loss. Despite a correct diagnosis, the treatment of this type of hyperplastic invasive external resorption poses a challenge for the clinician. The Heithersay classification and the use of cone-beam computed tomographic imaging have increased our knowledge of the pathology and helped improve its prognosis. Nevertheless, there is no standard protocol for the treatment of this type of lesion. This article proposes a treatment protocol for ICR based on the pattern and location of resorption. Three treatment approaches (internal access, external access, and intentional replantation) are presented through 3 clinical cases.

Full Pulpotomy with Biodentine in Symptomatic Young Permanent Teeth with Carious Exposure

INTRODUCTION

This prospective study evaluated the outcome of Biodentine (Septodont, Saint Maur des Fosses, France) pulpotomy in young permanent teeth with carious exposure.

METHODS

Twenty permanent molar teeth in 14 patients with carious pulp exposure were treated with Biodentine pulpotomy. The age of the patients ranged from 9-17 years (12.3 ± 2.7 years). A preoperative pulpal and periapical diagnosis was established. After informed consent, the tooth was anesthetized, isolated via a dental dam, and disinfected with 5% sodium hypochlorite before caries excavation. Full pulpotomy was performed by amputating the exposed pulp to the level of the canal orifices, hemostasis was achieved via a cotton pellet moistened with 2.5% sodium hypochlorite, a 3-mm layer of Biodentine was placed as the pulpotomy agent, a Vitrebond liner (3M ESPE, St Paul, MN) was applied, and the tooth was subsequently restored. Postoperative periapical radiographs were taken after placement of the permanent restoration. Clinical and radiographic evaluation was completed after 6 months and 1 year postoperatively. Pain levels were scored preoperatively and 2 days after treatment. Statistical analysis was performed using the Fisher exact test.

RESULTS

Clinical signs and symptoms suggestive of irreversible pulpitis were established in all teeth and symptomatic apical periodontitis in 14 of 20 (70%). Two days after treatment, all patients reported complete relief of pain. All teeth were clinically successful at 6 months and 1 year postoperatively. Radiographically, immature roots showed continued root development; dentin bridge formation was detected in 5 of 20 teeth. Seven of 7 teeth with preoperative periapical rarefaction showed signs of healing; 1 tooth had signs of internal root resorption at 1 year with an overall success rate of 95% (19/20).

CONCLUSIONS

Young permanent teeth with carious exposure can be treated successfully with full pulpotomy using Biodentine, and clinical signs and symptoms of irreversible pulpitis are not a contraindication.

Biodentine™ material characteristics and clinical applications: a 3 year literature review and update

INTRODUCTION

Biodentine™ has frequently been acknowledged in the literature as a promising material and serves as an important representative of tricalcium silicate based cements used in dentistry.

AIM

To provide an update on the physical and biological properties of Biodentine™ and to compare these properties with those of other tricalcium silicate cements namely, different variants of mineral trioxide aggregate (MTA) such as ProRoot MTA, MTA Angelus, Micro Mega MTA (MM-MTA), Retro MTA, Ortho MTA, MTA Plus, GCMTA, MTA HP and calcium enriched mixture (CEM), Endosequence and Bioaggregate™.

STUDY DESIGN

A comprehensive literature search for publications from November 20, 2013 to November 20, 2016 was performed by two independent reviewers on Medline (PubMed), Embase, Web of Science, CENTRAL (Cochrane), SIGLE, SciELO, Scopus, Lilacs and clinicaltrials.gov. Electronic and hand search was carried out to identify randomised control trials (RCTs), case control studies, case series, case reports, as well as in vitro and animal studies published in the English language.

CONCLUSIONS

The enhanced physical and biologic properties of Biodentine™ could be attributed to the presence of finer particle size, use of zirconium oxide as radiopacifier, purity of tricalcium silicate, absence of dicalcium silicate, and the addition of calcium chloride and hydrosoluble polymer. Furthermore, as Biodentine™ overcomes the major drawbacks of MTA it has great potential to revolutionise the different treatment modalities in paediatric dentistry and endodontics especially after traumatic injuries. Nevertheless, high quality long-term clinical studies are required to facilitate definitive conclusions.

Factors affecting the outcomes of direct pulp capping using Biodentine

Introduction

This study aimed to evaluate the prognostic value of factors with regard to the treatment outcome of direct pulp capping using Biodentine (Septodont, Saint-Maur-des-Fossés, France), in permanent teeth in which the pulps were exposed during caries removal.

Methods

Between 2010 and 2014, 112 teeth with deep carious lesions underwent direct pulp capping. The patients were followed up at 2–3 months and 1–1.5 years with a routine examination on both recall visits. Periapical radiographs were taken at 1–1.5 years. Lack of patient complaints, positive reactions to cold and electric testing, no sensitivity to percussion, and no widening of the periapical ligament indicated success. The Fisher exact test was used for statistical analysis. The significance level was P = .05.

Results

Eighty-six teeth were available for 1–1.5 years follow-up. The overall success rate was 82.6%. Only age had a significant effect on the pulpal survival rate: the success rate was 90.9% in patients younger than 40 years and 73.8% in patients 40 years or older (P = .0480). Sex, initial or secondary caries treatment, occlusal or cervical/proximal caries, delayed placement of permanent filling, tooth position, and arch type did not influence the outcome.

Conclusions

A patient’s age influenced the outcome of direct pulp capping using this new calcium silicate cement.

Clinical relevance

Asymptomatic vital permanent teeth with cariously exposed pulp can be treated successfully by direct pulp capping using Biodentine.

Biocompatibility of New Pulp-capping Materials NeoMTA Plus, MTA Repair HP, and Biodentine on Human Dental Pulp Stem Cells

INTRODUCTION

The aim of the present study was to evaluate the in vitro cytotoxicity of MTA Repair HP, NeoMTA Plus, and Biodentine, new bioactive materials used for dental pulp capping, on human dental pulp stem cells (hDPSCs).

METHODS

Biological testing was carried out in vitro on hDPSCs. Cell viability and cell migration assays were performed using eluates of each capping material. To evaluate cell morphology and cell attachment to the different materials, hDPSCs were directly seeded onto the material surfaces and analyzed by scanning electron microscopy. The chemical composition of the pulp-capping materials was determined by energy-dispersive X-ray and eluates were analyzed by inductively coupled plasma-mass spectrometry. Statistical differences were assessed by analysis of variance and Tukey test (P < .05).

RESULTS

Cell viability was moderate after 24 and 48 hours in the presence of MTA Repair HP and NeoMTA Plus, whereas at 48 and 72 hours, Biodentine showed higher rates of cell viability than MTA Repair HP and NeoMTA Plus (P < .001). A cell migration assay revealed adequate cell migration rates for MTA Repair HP and NeoMTA Plus, both similar to the control group rates, meanwhile the highest cell migration rate was observed in the presence of Biodentine (P < .001). Scanning electron microscope studies showed a high degree of cell proliferation and adhesion on Biodentine disks but moderate rates on MTA Repair HP and NeoMTA Plus disks. Energy-dispersive X-ray pointed to similar weight percentages of C, O, and Ca in all 3 materials, whereas other elements such as Al, Si, and S were also found.

CONCLUSIONS

The new pulp-capping materials MTA Repair HP, NeoMTA Plus, and Biodentine showed a suitable degree of cytocompatibility with hDPSCs, and good cell migration rates, although Biodentine showed higher rates of proliferation time-dependent.

Bleaching of a Discolored Tooth with Retrieval of Remnants after Successful Regenerative Endodontics

INTRODUCTION

This report presents the retrieval of remnants from a discolored mandibular right second premolar (tooth #29) of a 17-year-old female after a successful regenerative endodontic procedure (REP).

METHODS

The REP was performed in October 2011. Coronal discoloration became of great concern to the patient at a review visit in 2016. A cone-beam computed tomographic scan was taken to investigate the formation of hard tissues within the root canal as well as a region of no calcified tissue formation. During internal bleaching of tooth #29, a black material with particulate inclusions was retrieved and examined histopathologically.

RESULTS

Five years after the REP, there was complete periapical healing, hard tissue formation within the root canal, and complete maturation of the root apex. A hard tissue bridge was noted at the cementoenamel junction when the pulp chamber of #29 was reaccessed. The remnants retrieved from the pulp chamber were confirmed to be partly mineral trioxide aggregate (MTA). A normal tooth color was achieved after 3 weeks of internal bleaching.

CONCLUSIONS

MTA remnants within the pulp chamber contributed to the tooth discoloration and appear to have obstructed hard tissue formation. A matrix of oxidized regenerated cellulose seems not to hinder tissue regeneration and is resorbed by these tissues. Other materials with color stability should be selected as coronal barriers for REPs to avoid a potential adverse effect of the MTA on the REP outcome and discoloration.

Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part II: other clinical applications and complications

Mineral trioxide aggregate (MTA) is a dental material used extensively for vital pulp therapies (VPT), protecting scaffolds during regenerative endodontic procedures, apical barriers in teeth with necrotic pulps and open apices, perforation repairs as well as root canal filling and root-end filling during surgical endodontics. A number of bioactive endodontic cements (BECs) have recently been introduced to the market. Most of these materials have calcium and silicate in their compositions; however, bioactivity is a common property of these cements. These materials include the following: BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, Neo MTA Plus, Ortho MTA, Quick-Set, Retro MTA, Tech Biosealer, and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA but without the drawbacks. In Part I of this review, the available information on the chemical composition of the materials listed above was reviewed and their applications for VPT was discussed. In this article, the clinical applications of MTA and other BECs will be reviewed for apexification, regenerative endodontics, perforation repair, root canal filling, root-end filling, restorative procedures, periodontal defects and treatment of vertical and horizontal root fractures. In addition, the literature regarding the possible drawbacks of these materials following their clinical applications is reviewed. These drawbacks include their discolouration potential, systemic effects and retreatability following use as a root filling material. Based on selected keywords, all publications were searched regarding the use of MTA as well as BECs for the relevant clinical applications. Numerous publications were found regarding the use of BECs for various endodontic applications. The majority of these investigations compared BECs with MTA. Despite promising results for some materials, the number of publications using BECs for various clinical applications was limited. Furthermore, most studies had several methodological shortcomings and low levels of evidence.