Outcomes of Direct Pulp Capping by Using Either ProRoot Mineral Trioxide Aggregate or Biodentine in Permanent Teeth with Carious Pulp Exposure in 6- to 18-Year-Old Patients: A Randomized Controlled Trial

Histological response of inflamed pulp to hydraulic calcium silicate cements in direct pulp capping: Systematic review of pulpitis models

This systematic review aimed to compare the histological response of inflamed pulpodentinal complex to the hydraulic calcium silicate cements in experimental animal models of pulpitis. Articles that evaluated the histological response of inflamed pulp to mineral trioxide aggregate (MTA) in comparison with other restorative materials were selected and analysed in detail. The risk of bias assessment was conducted using SYRCLE's RoB tool. The GRADEpro tool was used to determine the overall quality of evidence. Out of the 2947 retrieved articles from databases, five articles fulfilled the inclusion criteria. MTA induced significantly more hard tissue formation compared to calcium hydroxide. The use of pulp-capping material containing fluocinolone acetonide and ASP/PLGA-ASP/ACP/PLLA-PLGA composite membrane was comparable. This systematic review could not demonstrate enhanced efficiency of capping materials compared to MTA. Future well-conducted animal studies are warranted for demonstrating the hard tissue formation abilities of pulp-capping materials with convenient inflammatory conditions.

Antibacterial, biocompatible, and mineralization-inducing properties of calcium silicate-based cements

BACKGROUND

Different pulp capping materials have different origins and compositions, require different preparations, and may vary in their bioactive properties.

AIM

The purpose of this study was to evaluate the antibacterial activity, biocompatibility, and mineralization-inducing potential of calcium silicate-based pulp capping materials.

DESIGN

Six contemporary calcium silicate-based cements, ProRoot MTA, MTA Angelus, Biodentine, EndoSequence, NeoMTA 2, and NeoPutty, were evaluated. The antibacterial effects of these materials against Streptococcus mutans UA159 and Enterococcus faecalis ATCC 29212 were determined by the agar diffusion assay and the direct culture test. The biocompatibility and mineralization-inducing potential of these materials in preodontoblastic 17IIA11 cells were evaluated by the MTT assay and by Alizarin Red S staining, respectively.

RESULTS AND CONCLUSION

In agar diffusion test, only Biodentine showed distinct antibacterial effects against S. mutans. All the tested materials, however, showed antibacterial effects against S. mutans and E. faecalis in the direct culture test, with Biodentine showing the strongest growth inhibition against both S. mutans and E. faecalis. All the tested materials showed acceptable biocompatibility and mineralization-supporting potential in our experimental conditions. In summary, ProRoot MTA, MTA Angelus, Biodentine, EndoSequence, NeoMTA 2, and NeoPutty demonstrated acceptable in vitro antimicrobial, biocompatible, and mineralization-supporting properties.

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.

Outcomes of coronal pulpotomy on permanent first molars in children: a retrospective cohort study

OBJECTIVES

To investigate the survival probability of permanent first molars (PFMs) after coronal pulpotomy (CP) using two outcome definitions: success-focused and functional survival-focused, and to identify factors influencing tooth survival.

MATERIALS AND METHODS

A retrospective cohort study reviewing records of children undergoing CP with calcium silicate-based cements (CSCs) on PFMs. Each CP-treated PFM was classified as success, uncertain, failure, or censored. Survival probability was analyzed using Kaplan-Meier estimators. Success-focused definition considered failures and uncertain outcomes as events, while functional survival-focused definition considered only failures as events. Prognostic factors were analyzed using Cox regression analysis.

RESULTS

Seventy-seven CP-treated PFMs with a follow-up period of 6-111 months. Using the success-focused definition (two failures and 12 uncertain outcomes as events), survival probabilities were 93.1% (95% CI 84.3-97.1%) at 12 months, 78.7% (95% CI 65.6-87.3%) at 36 months, and 74.9% (95% CI 59.5-89.0%) at 60-111 months. However, with the functional survival-focused definition, survival probabilities were 100% at 12 months and 96.6% (95% CI 86.9-99.1%) at 24-111 months. In multivariable analysis, proximal lesions increased failure risk compared to occlusal lesions (HR 17.17, 95% CI 2.18-135.31, p < 0.01), and resin composite restorations had higher failure risk than stainless steel crowns (HR 13.97, 95% CI 1.49-130.69, p < 0.05).

CONCLUSIONS

CP using CSCs shows long-term survival potential as an alternative treatment for cariously exposed PFMs in children.

CLINICAL RELEVANCE

Proximal lesions and resin composite restoration could contribute to the lower survival, indicating the need for careful consideration of restoration options and lesion location during treatment planning.

Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A systematic review and meta-analysis

OBJECTIVES

Different materials have been used for capping the pulp after exposure during caries removal in permanent teeth. The purpose of this study was to collate and analyze all pertinent evidence from randomized controlled trials (RCTs) on different materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth.

MATERIALS AND METHODS

Trials comparing two or more capping agents used for direct pulp capping (DPC) or pulpotomy were considered eligible. An electronic search of four databases and two clinical trial registries was carried out up to February 28, 2021 using a search strategy properly adapted to the PICO framework. Screening, data extraction, and risk of bias (RoB) assessment of primary studies were performed in duplicate and independently. The primary outcome was clinical and radiological success; secondary outcomes included continued root formation, tooth discoloration, and dentin bridge formation.

RESULTS

21 RCTs were included in the study. The RoB assessment indicated a moderate risk among the studies. Due to significant clinical and statistical heterogeneity among the studies, performing network meta-analysis (NMA) was not possible. An ad hoc subgroup analysis revealed strong evidence of a higher success of DPC with Mineral Trioxide Aggregate (MTA) compared to calcium hydroxide (CH) (odds ratio [OR] = 3.10, 95% confidence interval [CI]: 1.66-5.79). MTA performed better than CH in pulp capping (both DPC and pulpotomy) of mature compared to immature teeth (OR = 3.34, 95% CI: 1.81-6.17). The GRADE assessment revealed moderate strength of evidence for DPC and mature teeth, and low to very low strength of evidence for the remaining subgroups.

CONCLUSIONS

Considerable clinical and statistical heterogeneity among the trials did not allow NMA. The ad hoc subgroup analysis indicated that the clinical and radiographic success of MTA was higher than that of CH but only in mature teeth and DPC cases where the strength of evidence was moderate. PROSPERO Registration: number CRD42020127239.

Clinical application of calcium silicate-based bioceramics in endodontics

Pulp treatment is extremely common in endodontics, with the main purpose of eliminating clinical symptoms and preserving tooth physiological function. However, the effect of dental pulp treatment is closely related to the methods and materials used in the process of treatment. Plenty of studies about calcium silicate-based bioceramics which are widely applied in various endodontic operations have been reported because of their significant biocompatibility and bioactivity. Although most of these materials have superior physical and chemical properties, the differences between them can also have an impact on the success rate of different clinical practices. Therefore, this review is focused on the applications of several common calcium silicate-based bioceramics, including Mineral trioxide aggregate (MTA), Biodentine, Bioaggregate, iRoot BP Plus in usual endodontic treatment, such as dental pulp capping, root perforation repair, regenerative endodontic procedures (REPs), apexification, root-end filling and root canal treatment (RCT). Besides, the efficacy of these bioceramics mentioned above in human trials is also compared, which aims to provide clinical guidance for their clinical application in endodontics.

Effects of direct pulp capping with recombinant human erythropoietin and/or mineral trioxide aggregate on inflamed rat dental pulp

OBJECTIVE

This study aimed to evaluate the dental pulp responses to recombinant human erythropoietin (rhEPO) and/or mineral trioxide aggregate (MTA) in pulp capping of inflamed dental pulp in vivo.

MATERIALS AND METHODS

In accordance with ARRIVE guidelines, pulp inflammation was induced by exposing the maxillary first molars (n = 64) of Wistar rats (n = 32) to the oral environment for two days. The exposed pulps were randomly assigned four groups based on the pulp capping material: rhEPO, MTA, MTA + rhEPO, or an inert membrane. An additional eight rats formed the healthy control group. After four weeks, the animals were euthanized, and histological, qRT-PCR, and spectrophotometric techniques were employed to analyze the left maxillary segments, right first maxillary molars, and blood samples, respectively. Statistical significance was set at p < 0.05 and < 0.001.

RESULTS

Pulp capping with rhEPO, MTA, or MTA + rhEPO resulted in lower inflammation and higher mineralization scores compared to untreated control. MTA + rhEPO group exhibited significantly decreased expression of tumor necrosis factor-alpha, and interleukin 1-beta, while MTA group showed substantially reduced expression of interferon-gamma. Both rhEPO and MTA + rhEPO groups presented elevated dentin matrix protein 1 levels compared to untreated control. Furthermore, pulp capping with rhEPO and/or MTA led to increased transforming growth factor-beta 1 expression and reductions of pro-inflammatory/immunoregulatory cytokine ratios and prooxidative markers. Pulp capping with rhEPO also resulted in increase of systemic antioxidative stress markers.

CONCLUSION

Capping with rhEPO or MTA + rhEPO resulted in a favorable effect that was similar or even superior to that of MTA.

Epigenetic therapeutics in dental pulp treatment: Hopes, challenges and concerns for the development of next-generation biomaterials

This opinion-led review paper highlights the need for novel translational research in vital-pulp-treatment (VPT), but also discusses the challenges in translating evidence to clinics. Traditional dentistry is expensive, invasive and relies on an outmoded mechanical understanding of dental disease, rather than employing a biological perspective that harnesses cell activity and the regenerative-capacity. Recent research has focussed on developing minimally-invasive biologically-based 'fillings' that preserve the dental pulp; research that is shifting the paradigm from expensive high-technology dentistry, with high failure rates, to smart restorations targeted at biological processes. Current VPTs promote repair by recruiting odontoblast-like cells in a material-dependent process. Therefore, exciting opportunities exist for development of next-generation biomaterials targeted at regenerative processes in the dentin-pulp complex. This article analyses recent research using pharmacological-inhibitors to therapeutically-target histone-deacetylase (HDAC) enzymes in dental-pulp-cells (DPCs) that stimulate pro-regenerative effects with limited loss of viability. Consequently, HDAC-inhibitors have the potential to enhance biomaterial-driven tissue responses at low concentration by influencing the cellular processes with minimal side-effects, providing an opportunity to develop a topically-placed, inexpensive bio-inductive pulp-capping material. Despite positive results, clinical translation of these innovations requires enterprise to counteract regulatory obstacles, dental-industry priorities and to develop strong academic/industry partnerships. The aim of this opinion-led review paper is to discuss the potential role of therapeutically-targeting epigenetic modifications as part of a topical VPT strategy in the treatment of the damaged dental pulp, while considering the next steps, material considerations, challenges and future for the clinical development of epigenetic therapeutics or other 'smart' restorations in VPT.

Factors Affecting the Decision-Making of Direct Pulp Capping Procedures Amongst Dental Practitioners: A Multinational Survey from 16 Countries with Meta-Analysis

BACKGROUND

Direct pulp capping (DPC) procedures require the placement of a bioactive material over an exposure site without selective pulp tissue removal. This web-based multicentered survey had three purposes: i) to investigate the factors that affect clinicians' decisions in DPC cases, ii) to determine which method of caries removal is preferred, and iii) to evaluate the preferred capping material for DPC.

METHODS

The questionnaire comprised three sections. The first part comprised questions regarding demographic features. The second part comprised questions on how treatment plans change according to factors such as nature, location, number and size of the pulp exposure and patients' age. The third part composed of questions on the common materials and techniques used in DPC. To estimate the effect size, the risk ratio (RR) and 95% confidence interval (CI) were calculated using a meta-analysis software.

RESULTS

A tendency towards more invasive treatment was observed for the clinical scenario with carious-exposed pulp (RR=2.86, 95% CI:2.46,2.32; p<0.001) as opposed to the clinical scenario with two pulp exposures (RR=1.38, 95% CI:1.24,1.53; p<0.001). Complete caries removal was significantly preferred to selective caries removal (RR=4.59, 95% CI: 3.70, 5.69; p<0.001). Among the capping materials, calcium silicate-based materials (CS) were preferred over calcium hydroxide-based materials (CH) (RR=0.58, 95% CI: 0.44,0.76; p<0.05).

CONCLUSION

While carious-exposed pulp is the most important factor in clinical decisions regarding DPC, the number of exposures has the least impact. Overall, complete caries removal was preferred over selective caries removal. In addition, the use of CS appears to have replaced CH.

Bioceramics in Endodontics: Updates and Future Perspectives

Bioceramics, with excellent bioactivity and biocompatibility, have been widely used in dentistry, particularly in endodontics. Mineral trioxide aggregate (MTA) is the most widely used bioceramic in endodontics. Recently, many new bioceramics have been developed, showing good potential for the treatment of endodontic diseases. This paper reviews the characteristics of bioceramics and their applications in various clinical endodontic situations, including root-end filling, root canal therapy, vital pulp therapy, apexification/regenerative endodontic treatment, perforation repair, and root defect repair. Relevant literature published from 1993 to 2023 was searched by keywords in PubMed and Web of Science. Current evidence supports the predictable outcome of MTA in the treatment of endodontic diseases. Although novel bioceramics such as Biodentine, EndoSequence, and calcium-enriched mixtures have shown promising clinical outcomes, more well-controlled clinical trials are still needed to provide high-level evidence for their application in endodontics. In addition, to better tackle the clinical challenges in endodontics, efforts are needed to improve the bioactivity of bioceramics, particularly to enhance their antimicrobial activity and mechanical properties and reduce their setting time and solubility.

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.

Longevity of stainless steel crowns as interim restorations on young permanent first molars that have undergone vital pulp therapy treatment in children and factors associated with their treatment failure: A retrospective study of up to 8.5 years

BACKGROUND

Although stainless steel crowns (SSCs) on permanent molars are a common interim full-coverage restoration, there are few clinical studies on longevity.

AIM

To evaluate the longevity of SSCs as restorations on young permanent first molars (PFMs) that have undergone vital pulp therapy (VPT) treatment and to identify factors associated with SSC treatment failure.

DESIGN

This study conducted a retrospective chart review of children who had PFMs that have undergone VPT treatment and been restored with SSCs. Data from treatment and follow-up visits were collected. The Kaplan-Meier survival analysis was used to analyse the longevity of SSCs. A multivariate Cox proportional hazards regression model was used to identify factors associated with SSC treatment failure.

RESULTS

Data from 140 SSCs were included, with an average follow-up period of 33.5 ± 21.6 (range, 6-104) months. Although none of the teeth had pulpal failure, 35.7% had SSC treatment failure. The survival probabilities of SSCs declined over time, reaching 39.6% (95% CI 27.0-51.9) after 60 months. The immediate post-operative condition of SSCs and the loss of proximal wall on the abutment tooth were significant factors associated with SSC treatment failure.

CONCLUSION

Stainless steel crowns are suitable for use as interim restorations in PFMs that have undergone VPT treatment in children, but their longevity is limited, necessitating replacement over time.

An Updated Review on Properties and Indications of Calcium Silicate-Based Cements in Endodontic Therapy

Regarding the common use of calcium silicate cements (CSCs) in root canal therapy, their position in the context of past and present dentistry agents can provide a better understanding of these materials for their further improvement. In this context, the present review article addresses a wide range of recent investigations in the field of CSC-based products and describes details of their composition, properties, and clinical applications. The need for maintaining or reconstructing tooth structure has increased in contemporary endodontic treatment approaches. This research thus discusses the attempts to create comprehensive data collection regarding calcium ion release, bond strength, alkalinizing activity and bioactivity, and the ability to stimulate the formation of hydroxyapatite as a bioactive feature of CSCs. Sealing ability is also highlighted as a predictor for apical and coronal microleakage which is crucial for the long-term prognosis of root canal treatment integrity. Other claimed properties such as radiopacity, porosity, and solubility are also investigated. Extended setting time is also mentioned as a well-known drawback of CSCs. Then, clinical applications of CSCs in vital pulp therapies such as pulpotomy, apexification, and direct pulp capping are reviewed. CSCs have shown their benefits in root perforation treatments and also as root canal sealers and end-filling materials. Nowadays, conventional endodontic treatments are replaced by regenerative therapies to save more dynamic and reliable hard and soft tissues. CSCs play a crucial role in this modern approach. This review article is an attempt to summarize the latest studies on the clinical properties of CSCs to shed light on the future generation of treatments.

The Understanding of Vital Pulp Therapy in Permanent Teeth: A New Perspective

The indications of vital pulp therapy (VPT) are expanding, which cases are suitable for VPT, and how to improve the success rate of VPT is a problem that often bothers us. The main purpose of VPT is to eliminate pulpitis by promoting the formation of reparative dentin or calcium bridge, so that it can continue to perform various physiological functions, and finally achieve the purpose of preserving pulp vitality and long-term preservation of affected teeth. Pulp capping and pulpotomy are the most common methods for VPT. The research field of VPT has attracted the attention of many scholars, who have studied it from many aspects (such as indications, material selection, operation requirements, and long-term prognosis). This article reviews the recent advances in the techniques of VPT in permanent teeth.

Multiple growth factors accommodated degradable submicron calcium sulfate hemihydrate/porous hydroxyapatite for dentin-pulp regeneration

Vital pulp therapy (VPT) has gained significant consideration by utilizing the natural healing capacity of the inflamed pulp in healing process. However, the protective pulp capping materials that facilitate this healing process are still under investigation for the successful promotion of dentin-pulp regeneration. Herein, we developed a bioactive and biodegradable pulp capping material (denoted as sCSHA-GFs) by synthesizing inorganic submicron calcium sulfate hemihydrate (sCS)/porous hydroxyapatite (HA) loaded with growth factors (GFs) such as transforming growth factor-beta 1 (TGF-β1), fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF). Physiochemical characteristics of submicron CSHA-GFs (sCSHA-GFs) cement were determined. Human dental pulp stem cells (hDPSCs) were used for analyzing their biocompatibility and bioactivity for dentin mineralization. To evaluate the efficacy of sCSHA-GFs, we compared it with a commercial material, mineral trioxide aggregate (MTA), the reference standard used clinically on pulp capping. Our results showed that sCSHA-GFs cement presented good biodegradability with dissolution properties for sustained release of calcium (Ca²⁺) ions and GFs, and facilitated attachment, proliferation, differentiation and migration of hDPSCs. In addition, sCSHA-GFs cement was found to be more effective than MTA at prolonged incubation time in inducing the mRNA expression levels of odontoblastic differentiation markers, dentin sialophosphoprotein (DSPP) and dentin matrix protein (DMP-1), leading to increased mineralization (with calcium deposits) along with increased alkaline phosphatase (ALP) expressions, evident from Alizarin Red S and ALP staining assays. Our findings suggest that sCSHA-GFs cement may act as a suitable material in VPT for dentin-pulp regeneration.

Outcome of Direct Pulp Capping in Teeth Diagnosed as Irreversible Pulpitis: Systematic Review and Meta-Analysis

Background

This review and meta-analysis investigates the outcome of direct pulp capping in teeth diagnosed as irreversible pulpitis.

Material and Methods

This systematic review includes experimental and descriptive clinical studies according to the PRISMA criteria, using PubMed and Scopus as database. We have included studies that performed direct pulp capping on human permanent teeth previously diagnosed with irreversible pulpitis and that carried out a subsequent follow-up. The outcome of interest was the clinical success of direct pulp capping.

Results

A total of four studies met the inclusion criteria for this review, however only three of these could be included in the meta-analysis. These three studies represent a total sample of 62 teeth with irreversible pulpitis treated with direct pulp capping that showed an overall success rate of 0.953 (CI=0.900-1.005; p<0.001; I²=0). Additionally, the success rates of vital pulp therapies were compared, all of them being greater than 75%; and the success rates of the materials used were analyzed, giving values above 80% in all cases. The risk of bias of the included articles was established using the ROBINS-I tool, showing that two of the articles had a moderate risk of bias and the remaining two had a very high risk of bias.

Conclusions

Based on the results of this review, direct pulp capping should be clinically included as a successful technique for the treatment of irreversible pulpitis. However, a larger number of studies with more rigorous methodologies are necessary to confirm the efficacy of this technique.

Key words:Irreversible pulpitis, direct pulp capping (DPC), vital pulp therapy (VPT), indirect pulp capping (IPC), partial pulpotomy, total pulpotomy.

Bond Strength of Adhesive Systems to Calcium Silicate-Based Materials: A Systematic Review and Meta-Analysis of In Vitro Studies

Since the adhesion of resin composites to calcium silicate-based cement is considered challenging. Therefore, the best adhesion strategy should be indicated. This review aimed to assess the effect of different adhesive systems on the bond strength of resin composite to calcium silicate-based cement through a systematic review and meta-analysis. The subsequent PICOS framework used was: population, calcium silicate-based cement; intervention, use of self-etch adhesive systems; control, use of total-etch adhesive systems; outcome, bond strength; study design, in vitro studies. The literature search was conducted independently by two reviewers up to 18 February 2021. Electronic databases (PubMed, ISI Web of Science, SciELO, Scopus, and Embase) were searched for applicable articles. In vitro manuscripts studying the effect of adhesive systems on the bond strength of calcium silicate-based cement were considered. The meta-analyses were performed using Review Manager Software version 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). Bond strength comparisons were made considering the type of calcium silicate-based cement (Mineral Trioxide Aggregate (MTA), Biodentine™, or TheraCal LC®). A p-value < 0.05 was considered statistically significant. A total of 7321 studies were retrieved in databases searched. After full-text evaluation, 37 eligible papers were assessed for qualitative analysis, leaving a total of 22 papers for the quantitative analysis. According to the meta-analysis, the bond strength values of resin composite materials to MTA and TheraCal LC® cement were favored when a total-etch adhesive system was used (p ≤ 0.02). On the other hand, the meta-analysis of the bond strength of resin-based materials to Biodentine™ calcium silicate-based cement was similar between both approaches (p = 0.12). The in vitro evidence suggests that the bond strength of resin-based materials to both MTA and TheraCal LC® cement was preferred by using the total-etch adhesive strategy. However, when bonding to Biodentine™, the use of self-etch or total-etch strategies displayed promising results. Given the lack of evidence related to the chemical interaction of self-etch adhesive materials with the bioceramics, if self-etch adhesives are used for bonding resin-based restorations to calcium silicate-based cement, a pretreatment with phosphoric acid could be recommended.

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.

Direct pulp capping of carious immature tooth using bioactive material: A case report

The management of deep carious lesions in immature tooth and the preservation of its pulp vitality is a real challenge in daily dental practice. Bioactive cements are of interest to deal with such cases. Our case report describes the immediate management and the follow-up of an extensive carious lesion on an immature first right mandibular molar with pulp exposure by direct pulp capping using Biodentine. A 6-month clinical and radiographic follow up showed that the tooth was vital, with dentine-bridge formation in the pulp chamber with continuous root formation. This procedure allowed the protection of pulp complex, preserving at the same time its functional and biologic activities due to the capacities of Biodentine as an effective pulp capping material to induce pulp cells to form hard tissue. The aim of this article is to discuss through the report of this clinical case, the indications, advantages and disadvantages of different procedures and biomaterials used for direct pulp capping.

The outcome of partial pulpotomy in traumatized permanent anterior teeth - A systematic review and meta-analysis

BACKGROUND

Partial pulpotomy is a procedural intervention that can maintain the vitality of pulp during the management of traumatized permanent teeth with pulpal involvement.

AIM

To evaluate whether partial pulpotomy can be considered a reliable conservative treatment option for treating traumatized permanent anterior teeth with pulpal involvement.

METHODOLOGY

A computerized systematic search was performed in PubMed, Science Direct, Cochrane, and LILACS databases from 1980 to May 2021. Five studies were included in the final analysis. Quality assessment, Meta-analysis, and Publication bias of the studies were evaluated. This systematic review was registered in PROSPERO (ID - CRD42021262031).

RESULT

The comprehensive Meta-Analysis Software was used. The test of the heterogeneity was analysed using Cochran's Q statistics. The Q value was 7.186 (df = 6) with a P value of 0.3 and I² as 16.5%. The studies were considered homogenous, and the fixed-effect model showed an overall point estimate of 0.89 with a 95% confidence interval (0.86-0.91). The Begg and Egger funnel plot indicated that there was no publication bias in the included studies.

CONCLUSION

Evidence indicates that partial pulpotomy may be considered a reliable definitive treatment option in asymptomatic traumatized permanent anterior teeth with exposed pulp rather than total pulpotomy.

Outcomes of root canal therapy or full pulpotomy using two endodontic biomaterials in mature permanent teeth: a randomized controlled trial

OBJECTIVE

The concept of minimally invasive endodontics recommends less-invasive vital pulp therapy (VPT) modalities over more aggressive traditional endodontic approaches in mature permanent teeth with carious pulp exposure, including irreversible pulpitis (IP) cases. Consequently, VPT needs to be compared with root canal therapy (RCT) in terms of treatment outcomes. This randomized clinical trial compares the results of full pulpotomy using two calcium-silicate cements, i.e., mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement, with RCT in mature permanent teeth.

MATERIALS AND METHODS

A total of 157 carious pulp exposure cases in two academic centers with/without established IP were selected/included/randomly appointed to three study arms; (i) RCT (n = 51) as the reference treatment, (ii) pulpotomy with ProRoot MTA (PMTA; n = 55), and (iii) pulpotomy with CEM cement (PCEM; n = 51) as two alternative VPT treatments. Two-year clinical/radiographic results were the outcomes of interest. Data were statistically analyzed through the analysis of variance, chi-square, Fisher exact test, and Kruskal-Wallis.

RESULTS

At 2-year recall, 147 teeth were examined (6.4% dropout). All molars, except for one, were clinically functional/symptom-free, and there was no statistical difference between the three study arms (p = 0.653). The radiographic success rates in RCT, PMTA, and PCEM arms were 98%, 100%, and 97.9%, respectively, without statistically significant differences (p = 0.544).

CONCLUSION

In the management of mature permanent teeth with/without established IP, all experimental groups exhibited equivalent/comparable results.

CLINICAL RELEVANCE

Simple VPT using MTA/CEM can be suggested/recommended as a viable advantageous alternative to RCT for the management of carious pulp exposures with/without sign/symptoms of IP.

Current status on antimicrobial activity of a tricalcium silicate cement

Biodentine (BD) is a bioactive material with many indications in endodontic therapy. The purpose of this study was to compile and review the outcomes of in vitro and in vivo studies of BD in terms of antimicrobial effectiveness. An electronic search was carried out in PubMed, from January 2009-April 2021 using the keywords: (Biodentine or dentine substitute or "Ca₃SiO₅" or tricalcium silicate cement or bioceramic cement) and (antimicrobial activity or antimicrobial effect or antimicrobial effectiveness or antibacterial activity or antibacterial effect or antibacterial effectiveness or antibiofilm activity or antibiofilm effectiveness). Two independent reviewers evaluated the studies for eligibility. All studies that did not include BD or its antimicrobial properties, as well as abstracts not written in English, were excluded. This review identified the need to develop standardized methods to evaluate antimicrobial activity in vitro. Most of the studies were against planktonic bacteria and gave conflicting results. Studies ex vivo and in vivo against biofilm are required to elucidate the antimicrobial activity of BD.

Present status and future directions - Vital pulp treatment and pulp preservation strategies

Therapeutic strategies focussed on the pulp preservation, are important when managing vital teeth with deep caries and an exposed pulp. These vital pulp treatments (VPTs); however, are not new, with indirect and direct pulp capping procedures being described as a therapy for carious teeth for over a century. As a result of unpredictable outcomes, the traditional indications for VPT particularly when the pulp was exposed were limited to the treatment of immature teeth with incomplete root formation. Over the last 20 years, the advent of regenerative endodontics and the promotion of biologically based therapies aimed at reducing intervention have reinvigorated VPT with new waves of basic science and clinical research indicating a role for VPT not only in mature cariously affected teeth, but also in teeth with signs and symptoms indicative of irreversible pulpitis. Driven by new materials such as hydraulic calcium silicate cements, a better understanding of pulpal immunity and biology as well and improved tissue handling, VPT has been at the forefront of treatment recommendations made by global Cariology and Endodontic organizations. Care must be exercised, however, as key gaps in scientific knowledge remain alongside severe limitations in educational dissemination amongst dentists. Although research has highlighted that carious injury to the dentine–pulp complex stimulates a wide range of responses and that the interaction between infection, inflammation and repair will eventually impact on the outcome of pulpitis, our ability to accurately and objectively diagnose the true inflammatory state of the pulp remains poor. An overreliance on symptoms leaves clinicians with subjective, crude diagnostic tools by which to inform treatment planning and decision‐making, which results in large variations in the treatments offered to patients. Not only is there an urgent need to develop preoperative and intraoperative diagnostic tools, but there is also a paucity of the high‐quality comparative evidence required to answer the most important questions and justify treatment options. The aim of this review was to consider the current status of VPT and to discuss the principle problems that are hindering clinical acceptance of these techniques. Potential solutions and opportunities are offered to suggest ways that VPT may become a more consistently prescribed evidenced‐based treatment in dental practice.

Evaluation of complete pulpotomy with Biodentine® on mature permanent molars with signs and symptoms of symptomatic irreversible pulpitis: 12 months follow-up

INTRODUCTION

Complete pulpotomy is the removal of the coronal portion of a vital pulp and is a means of preserving the vitality of the remaining root portion. The objective of this study was to evaluate the 12-month success rate of complete pulpotomy with Biodentine® on mature permanent molars with signs and symptoms of symptomatic irreversible pulpitis.

MATERIALS AND METHODS

A total of 68 molars diagnosed with symptomatic irreversible pulpitis in 68 patients aged 20 years and older were included in this study. The exclusion criteria were intraoperative clinical signs of pulp necrosis on the molar to be treated such as no bleeding, or uncontrollable pulp hemorrhage (more than 5 min of hemostasis) on at least one canal. A complete pulpotomy with Biodentine® was performed on molars with symptomatic irreversible pulpitis by the same operator and with the same protocol. At 12-month post-operative follow-up was conducted to evaluate clinical and radiological success.

RESULTS

A total of 66 patients received complete pulpotomy. Fifty-two could be examined at 12 months postoperatively. Clinical and radiological analysis at 12 months postoperatively revealed a success rate of 87% (45/52 molars) and a failure rate of 13% (7/52 molars). There was a relationship between age, tooth type, pre-operative periapical condition and treatment success with P<0.05.

CONCLUSION

Compliance with the indications and protocol for complete pulpotomy with Biodentine® on mature permanent molars with symptomatic irreversible pulpitis gives positive results at 12 month follow-up.

Present status and future directions: Endodontic management of traumatic injuries to permanent teeth

The prognosis of traumatized teeth depends largely on the fate of the pulp and its treatment. This review aims to update the present status on the endodontic management of traumatic injuries to permanent teeth and to identify relevant research areas that could contribute to an improvement in diagnosis and treatment of traumatized permanent teeth. Future research should pay greater attention to (1) diagnostic methods to assess the perfusion of the pulp and enhance detection of tooth cracks and initial signs of root resorption; (2) improved materials for vital pulp treatment; (3) studies focusing on type and duration of splinting after root fractures; (4) antiresorptive intracanal medication in case of posttraumatic pulp necrosis and infection-related resorption and (5) long-term data on the apical barrier technique compared to revitalization.

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.

Evaluation of partial pulpotomy treatment in cariously exposed immature permanent molars: Randomized controlled trial

Background and Aims

This study aimed to assess the outcomes of partial pulpotomy treatments using different biocompatible materials which were Biodentine^®, mineral trioxide aggregate (MTA), and calcium hydroxide (CH) in cariously exposed pulp tissue in immature permanent molars.

Materials and Methods

Fifty-four teeth of 50 patients, which had cariously pulp exposures were randomly divided into Biodentine^®, MTA, and CH groups for partial pulpotomy treatments and finally restored with stainless steel crowns at the same appointment. Clinical and radiographical success was evaluated by the absence of any clinical and radiographical signs and symptoms for 12 months. Also, Image J was used for the quantitative assessment of length developments for mesial and distal roots. P value of less than 0.05 was considered statistically significant.

Results

Partial pulpotomy treatments showed high overall success rate (87%). On the other hand, Biodentine and MTA showed higher success rates compared to CH without any statistical significance (P = 0.09). Besides, mesial and distal root lengths displayed a continuous and significant increase in each group at sixth month follow-up (P = 0.01; P = 0.03).

Conclusions

Favorable results demonstrated that Biodentine, MTA, and CH might be recommended as suitable agents for partial pulpotomy treatment in cariously exposed immature molars with clinical diagnosis of normal pulp or reversible pulpitis.

Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The aim of this systematic review was to evaluate the existing randomized controlled trials (RCTs) on the safety and efficacy of vital pulp therapy (VPT) and to analyze the outcomes of VPT performed with a variety of pulp-capping materials and techniques.

METHODS

MEDLINE (PubMed), Embase, Cochrane Library, and gray literature were searched (January 2000-March 2021). Study selection and data extraction were performed in duplicate. Eligible RCTs were critically appraised for risk of bias and quality of evidence and were meta-analyzed to estimate the treatment effects.

RESULTS

Fourteen studies were included. The pooled success rate of VPT using contemporary capping materials such as mineral trioxide aggregate (MTA) or calcium silicate-based materials (CSMs) was 93.2% (95% confidence interval [CI], 91.6%-94.9%). Multiple subgroup analyses by different etiologies, procedure types, developmental stages of teeth, and preoperative diagnoses were performed. Analyses presented low certainty of evidence. No significant difference was noted between MTA and CSM at 12 months or a longer follow-up (risk ratio = 0.99; 95% CI, 0.95-1.03) with low certainty of evidence. Laser-assisted VPT failed to show significantly better outcomes than conventional VPT (risk ratio = 1.19; 95% CI, 0.99-1.49) with very low certainty of evidence.

CONCLUSIONS

When MTA or CSM was used as a capping material, VPT was 93% successful. The techniques, etiologies, developmental stages of teeth, and preoperative diagnosis had no significant influence on treatment outcomes. No major adverse effects (except discoloration associated with the use of MTA) were identified. The overall quality of evidence was low.

Biological Characteristics and Odontogenic Differentiation Effects of Calcium Silicate-Based Pulp Capping Materials

We compared calcium silicate-based pulp capping materials to conventional calcium hydroxide in terms of their biological properties and potential effects on odontogenic differentiation in human dental pulp stem cells (hDPSCs). We cultured hDPSCs on disks (7-mm diameter, 4-mm high) of ProRoot MTA (Dentsply Tulsa Dental Specialties), Biodentine (Septodont), TheraCal LC (Bisco), or Dycal (Dentsply Tulsa Dental Specialties). Cell viability was assessed with cell counting (CCK) and scanning electron microscopy (SEM). Odontogenic activity was assessed by measuring alkaline phosphatase (ALP) activity and gene expression (quantitative real-time PCR). CCK assays showed that Dycal reduced cell viability compared to the other materials (p < 0.05). SEM showed low and absent cell attachment on TheraCal LC and Dycal disks, respectively. hDPSCs exposed to TheraCal LC and Dycal showed higher ALP activity on day 6 than the control group (p < 0.05). The day-9 Runx2 expression was higher in the ProRoot MTA and TheraCal LC groups than in the control group (p < 0.05). On day 14, the ProRoot MTA group showed the highest dentin sialophosphoprotein levels (not significant; p > 0.05). In conclusion, various pulp capping materials, except Dycal, exhibited biological properties favorable to hDPSC viability. ProRoot MTA and TheraCal LC promoted higher Runx2 expression than Biodentine. Future studies should explore the odontogenic potential of pulp capping materials.

Influence of selective immunosuppressive drug regimens on the healing of exposed dogs' dental pulp capped with a recent calcium silicate-based cement

OBJECTIVES

In the clinical medicine, immunosuppressive drugs are used for an assortment of disorders, while their effect on the pulp healing is a controversial issue. This study evaluated the effect of different immunosuppressive drugs on the healing capacity of mechanically exposed dogs' dental pulps after direct pulp capping (DPC) with calcium silicate-based cement.

MATERIALS AND METHODS

Twelve healthy male dogs were randomly allocated into four equal groups, 3 dogs each: group I allocated as a control group where no drugs were received; group П given prednisone (Pred); group III given a combination of Pred and cyclosporine A (CsA); and group IV given triple dose including Pred, CsA, and mycophenolate mofetil (MMF) for 45 days before the operative procedures and until the dogs were euthanized. In each dog, 16 class V cavities were prepared on the labial surfaces of anterior teeth. Following mechanical exposure, the pulps were capped with Biodentine, calcium silicate-based cement. The pulpal tissues response to Biodentine was assessed 65 days postoperatively.

RESULTS

The pulp healing response was inferior in the Pred-CsA- and Pred-CsA-MMF-treated groups compared with the control and Pred-treated groups (P < 0.05). Non-significant difference was found between control and Pred-treated groups (P > 0.05).

CONCLUSIONS

Within the limitation of this study, DPC with calcium silicate-based cement performed under strict aseptic condition for traumatically exposed dental pulp can be considered as a successful treatment option for those who receiving Pred immunosuppressive therapy. Meanwhile, DPC with those receiving a combination of Pred, CsA, and/or MMF immunosuppressive drug regimens demonstrated unfavorable results.

CLINICAL RELEVANCE

Direct capping of mechanically exposed pulps with calcium silicate-based cement performed with special care for preventing infection considered a suitable strategic measure for preserving pulp vitality in patients receiving corticosteroid immunosuppressive drug.

Pulpal Response to the Combined Use of Mineral Trioxide Aggregate and Iloprost for Direct Pulp Capping

Purpose: The present study aims to assess the combined effects of mineral trioxide aggregate (MTA) and iloprost when used as a pulp capping material on pulpal inflammation and tertiary dentin formation compared with MTA and iloprost alone in rat molar teeth. Methods: Eighty maxillary first molar rat teeth were exposed and capped with iloprost solution, MTA, or MTA mixed with iloprost (MTA-iloprost). The cavities were then filled with resin-modified glass ionomer. The cavity was restored with glass ionomer without the use of pulp capping agent in the control group. The rats were sacrificed after one and four weeks. Block sections of the molar specimens were prepared and subjected to hematoxylin and eosin staining for evaluation. Statistical analysis was done using the Kruskal–Wallis test, followed by Dunnett’s test. Results: At week one, the control group showed significantly more severe pulpal inflammatory reactions than the iloprost (p = 0.00), MTA (p = 0.04), and MTA-iloprost (p = 0.00) groups. Hard tissue formation was commonly found in the iloprost, MTA, and MTA-iloprost groups. After four weeks, pulpal tissue degeneration was observed in the control group. Complete hard tissue barriers were found in 50%, 72.7%, and 77.8% of the specimens in iloprost, MTA, and MTA-iloprost groups, respectively, with no significant differences among the experimental groups. The dentinal tubule patterns were mostly regular in the MTA-iloprost group and irregular in the iloprost and MTA groups. Conclusions: The application of iloprost, MTA, and MTA-iloprost as a pulp capping material resulted in similar pulpal responses in the mechanically exposed pulp of rat molars. Therefore, mixing MTA with iloprost might not be clinically significant.

Minimal Intervention in Dentistry: A Literature Review on Biodentine as a Bioactive Pulp Capping Material

Root canal treatment has been the treatment of choice for carious pulp exposures. In the perspective of minimally invasive dentistry and preventive endodontics, a direct pulp capping procedure with a reliable bioactive material may be considered an alternative approach provided that the pulp status is favorable. However, the treatment of pulp exposure by pulp capping is still a controversial issue with no clear literature available on this topic, leaving the concerned practitioner more confused than satisfied. Biodentine is a relatively new bioactive material explored for vital pulp therapy procedures. This article discusses its role in direct pulp capping procedures. A thorough literature search of the database was done using PubMed, Google Scholar, and Scopus using the keywords preventive endodontics, calcium silicate cement, direct pulp capping, Biodentine, and vital pulp therapy. Reference mining of the articles that were identified was used to locate other papers and enrich the findings. No limits were imposed on the year of publication, but only articles in English were considered. This paper is aimed at reviewing the current literature on Biodentine as a direct pulp capping material. The review will provide a better understanding of Biodentine's properties and can aid in the decision-making process for maintaining the vitality of exposed dental pulp with minimal intervention.

Endodontic management of traumatized permanent teeth: a comprehensive review

The pulp plays a key role in the treatment of traumatic dental injuries (TDIs) and is strongly associated with the outcome, particularly in severe cases. A correct pulp diagnosis is essential as it forms the basis for developing the appropriate management strategy. However, many TDIs are complex, and their treatment requires a profound knowledge of the physiological and pathological responses of the affected tissues. This comprehensive review will look at the dentine-pulp complex and its interaction with the surrounding tissues following TDIs. The literature up to 2020 was reviewed based on several searches on PubMed and the Cochrane Library using relevant terms. In addition to the recently revised guidelines of the International Association of Dental Traumatology, this article aims to provide background information with a focus on endodontic aspects and to gather evidence on which a clinician can make decisions on the choice of the appropriate endodontic approach for traumatized permanent teeth.

Evaluation of Reparative Dentine Bridge Formation after Direct Pulp Capping with Biodentine

Aim:

To evaluate the capability of Biodentine for direct pulp capping in permanent teeth.

Materials and Methods:

The pulp of 11 human intact premolars were mechanically exposed in standard cavity dimensions and then capped with Biodentine for direct pulp capping. After 9–12 weeks, all teeth were extracted. All teeth were scanned using intraoral radiograph or cone-beam computed tomography (CBCT) scan before, right after pulp capping therapy, and after 9–12 weeks on both patient real and extracted teeth for evaluation of reparative dentin bridge formation. All clinical symptoms and signs were also recorded. Data were collected and analyzed using the MedCal statistical software at the significance of 0.05.

Results:

There was reparative dentin bridge formation in all experimental teeth, on both patient real and extracted teeth.

Conclusions:

The Biodentine could induce the formation of reparative dentin in direct pulp capping. The CBCT scan was the reliable modality for evaluation of dentin bridge formation.

Preserving pulp vitality: part two - vital pulp therapies

Vital pulp therapies (VPTs) aim to preserve the vitality of the pulp. The European Society of Endodontology have begun a campaign to raise awareness on the efficacy of VPTs following on from the publication of their 2019 position statement, aimed at both specialists and general dental practitioners. This review examines the current evidence surrounding VPTs and provides a rational approach to the management of the exposed pulp with the aid of case studies. Success lies in accurate diagnosis and case selection, along with well-executed treatment and appropriate follow-up protocols. The introduction of calcium silicate cements has made these treatments more predictable.

Tomographic evaluation of direct pulp capping using a novel injectable treated dentin matrix hydrogel: a 2-year randomized controlled clinical trial

OBJECTIVES

To assess clinically and radiographically the success of pulp capping procedure done in traumatically exposed permanent posterior teeth using a novel injectable treated dentin matrix hydrogel (TDMH), Biodentine, and MTA and to evaluate the formed dentin bridge under the capping materials using CBCT imaging.

MATERIALS AND METHODS

45 patients subjected to accidental traumatic pulp exposures by undergraduate dental students are allocated for this study. For each patient, a pulp capping procedure was done. TDMH was formed of TDM powder and sodium alginate to be injected and then hardened in the defect area. Patients were assigned to 3 groups: TDMH, Biodentine, and MTA, respectively, and returned to the clinic after 3, 6, 12, 18, and 24 months for clinical and radiographic examinations. Tomographic data, including thickness and density of formed dentin bridges, were evaluated at the end of the study period compared to the base line. Pulp sensitivity was evaluated throughout the study period using thermal testing and electric pulp tester.

RESULTS

During the follow-up period, all patients were asymptomatic with no clinical signs and symptoms and revealed no radiographic signs of pathosis. However, tomographic evaluation showed the tested materials to have different levels of impact on formed dentin bridges with TDMH group resulted in significantly superior dentin bridges of a higher radiodensity and thickness than Biodentine and MTA.

CONCLUSIONS

TDMH has a greater potential to induce dentin bridge formation than Biodentine and MTA under standardized conditions. Additionally, CBCT imaging was confirmed as a non-invasive and inclusive approach to evaluate the formed dentin bridges after pulp capping procedure.

CLINICAL RELEVANCE

Direct pulp capping can be done successfully with this novel injectable pulp capping material in future clinical applications.

TRIAL REGISTRATION

PACTR201901866476410.

Efficacy of direct pulp capping for management of cariously exposed pulps in permanent teeth: a systematic review and meta-analysis

BACKGROUND

The outcome of vital pulp treatment after carious pulp exposure is multifactorial and related to the procedure, biomaterial and pre-operative pulpal diagnosis.

OBJECTIVES

To conduct a systematic review and meta-analysis determining the outcome of direct pulp capping (DPC) in mature permanent teeth with a cariously exposed pulp and a clinical diagnosis of reversible pulpitis, and ascertain whether the capping material influences the outcome.

METHODS

Sources: MEDLINE Ovid-SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase and Web of Science until April 2020. Inclusion: Prospective, retrospective cohort studies and randomized trials investigating DPC outcome or comparing different capping materials after carious pulp exposure. Exclusion: Primary teeth, mechanical, traumatic or not specified pulp exposure, teeth with irreversible pulpitis or no pulpal diagnosis. Risk of bias assessed using Cochrane and modified Downs and Black quality assessment checklist. Meta-analysis on combined clinical/radiographic outcome was performed using a random effect model. Success was defined as absence of signs and symptoms of irreversible pulpitis, apical periodontitis or loss of pulp vitality.

RESULTS

Quality assessment highlighted four non-randomized studies to be of fair and five of poor quality. Four randomized trials had a high risk of bias. The pooled success rate differed based on material and follow-up. Calcium hydroxide success rate was 74% at 6-months, 65% at 1-year, 59% at 2-3 years and 56% at 4-5 years. Mineral trioxide aggregate (MTA) success was 91%, 86%, 84% and 81% at the same time points. Biodentine success was 96% at 6-months, 86% at 1 year and 86% at 2-3 years. The meta-analysis revealed MTA had better success than calcium hydroxide at 1-year (OR 2.66, 95% CI; 1.46- 4.84, P = 0.001) and 2- to 3-year follow-up (OR 2.21, 95% CI; 1.42-3.44, P = 0.0004). There was no difference between MTA and Biodentine.

DISCUSSION

These results were based on poor methodological quality studies. The effect size for of MTA vs Ca(OH)2, although modest, was consistent with narrow CI.

CONCLUSIONS

Low-quality evidence suggests a high success rate for direct pulp capping in teeth with cariously exposed pulps with better long-term outcomes for MTA and Biodentine compared with calcium hydroxide.

Apicoectomy of Perforated Root Canal Using Bioceramic Cement and Photodynamic Therapy

Root perforation is a common endodontic accident. Its management depends mainly on root canal disinfection and sealing the perforation area by preventing any communication with the periodontium to prevent recontamination. A patient was referred to treat root perforation due to a previous treatment of tooth #22. The diagnosis was symptomatic periapical periodontitis, and the treatment plan was to retreat the root canal of #22 and make a surgical intervention (apicoectomy) associated with antimicrobial photodynamic therapy as a complementary technique. Five mineral oxides (5MO) cement was used as a root-end filling material. The procedures were performed in two sessions and controlled in two visits (after 30 days and 12 months). A bone neoformation was observed at the periapical area of tooth #22. 5MO bioceramic cement was effective in inducing the repair of the periapical lesion and had the ability to seal the exposed periapical area of the tooth. Its success depended mainly on root canal and surgical site disinfection.

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.

Spectrophotometric Analysis of Coronal Tooth Discoloration Induced by Tricalcium Silicate Cements in the Presence of Blood

INTRODUCTION

New tricalcium silicate cements have been shown to induce less coronal discoloration. The purpose of this in vitro study was to evaluate the degree of color change induced by various silicate materials in the presence and absence of blood.

METHODS

One hundred human extracted anterior single-canal teeth were sectioned to standardized root lengths, accessed, and instrumented. Eight random experimental groups and 2 control groups were created wherein specimens were filled with experimental materials below the buccal cementoenamel junction as follows: EndoSequence RRM putty (Brasseler USA, Savannah, GA), EndoSequence RRM fast set putty (Brasseler USA), Biodentine (Septodont, Saint-Maur-des-Fossés, France), and white mineral trioxide aggregate (Dentsply Sirona, York, PA) either with the presence or absence of blood. Blood-only and saline-only samples were used for the positive and negative controls. After incubation in 100% humidity at 37°C, color changes were evaluated with a spectrophotometer (Ocean Optics, Dunedin, FL) on days 0, 30, 60, and 180 after material placement. Data were transformed into Commission International de I'Eclairage's L∗a∗b color values, and corresponding ΔE values were calculated. The 1-way analysis of variance test was performed for statistical analysis.

RESULTS

Discoloration was observed in all specimens in the presence of blood. There was no statistical significance when comparing different materials in contact with blood. Intragroup observation at various time points, Biodentine, and EndoSequence RRM fast set putty showed significant difference between the presence and absence of blood at 180 days (P < .05).

CONCLUSIONS

Contamination with blood of tricalcium silicate materials has the potential to cause coronal tooth discoloration.

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.

Acemannan Used as an Implantable Biomaterial for Vital Pulp Therapy of Immature Permanent Teeth Induced Continued Root Formation

Direct pulp-capping, a vital pulp therapy, is used to protect and preserve pulp vitality by applying a biomaterial on the pulp exposure site. Acemannan, a polysaccharide extracted from Aloe vera, induces osteodentin-bridge formation to cover the exposure site in vivo. We evaluated the effect of acemannan sponges on partial pulpotomized permanent teeth with caries or accident-induced pulp exposure (n = 50). After removing infected dentin and inflamed pulp tissue, the teeth were randomly divided into acemannan or control (mineral trioxide aggregate (MTA) groups (n = 25). The teeth were examined immediately after treatment (baseline) and at 6- and 12-month follow-ups for clinical and cone beam computed tomography (CBCT) examination. The three-dimensional tooth length and root apex area were simulated to determine treatment success. We found that the overall success rate in the acemannan and MTA groups from baseline to 12-month follow-up was 90.91% and 95.65%, respectively, with no significant difference between the two groups (p > 0.05). In the success teeth in both groups, the root length increased, and the apex area significantly decreased (p < 0.05), indicating continued root formation. Our results suggest that acemannan is a promising low-cost biomaterial for partial pulpotomy treatment for immature permanent teeth requiring vital pulp therapy.

Wound Lavage in Studies on Vital Pulp Therapy of Permanent Teeth with Carious Exposures: A Qualitative Systematic Review

The aim of this study was to systematically review pulp wound lavage in vital pulp therapy (VPT). A search was conducted in six life science databases to identify clinical trials carried out on permanent teeth with a carious pulp exposure and a recall interval of at least six months. Twenty-seven trials of low to moderate risk of bias (RoB-2 and ROBINS-I) were included. Data was extracted and analyzed regarding study characteristics and methods used for pulp wound lavage. The agent used for pulp wound lavage was specified in all included trials. Most of the identified trials (23/27) randomized the pulp capping material. Many (14/27) reported the use of sodium hypochlorite (NaOCl); ten used only saline or water. One trial was identified that compared pulp wound lavage with 2.5% (NaOCl) to saline, another compared 5% glutaraldehyde to water, both in immature molar pulpotomies. Both studies were underpowered. Neither showed a significant difference between treatments. The use of NaOCl was positively correlated to recent year of publication and use of hydraulic calcium silicate cements for pulp capping (p < 0.05). In conclusion, despite a lack of well-designed trials on pulp wound lavage in VPT, a trend towards using NaOCl for this purpose was observed.

Direct Pulp Capping: Which is the Most Effective Biomaterial? A Retrospective Clinical Study

(1) Background: Recently, tricalcium silicate cements, such as Biodentine™, have emerged. This biomaterial has a calcium hydroxide base and characteristics like mineral aggregate trioxide cements, but has tightening times that are substantially more suitable for their application and other clinical advantages. (2) Methods: A retrospective clinical study was conducted with 20 patients, which included a clinical evaluation of the presence or absence of pulp inflammation compatible symptoms, radiographic evaluation of the periapical tissues, and structural alterations of the coronary restoration that supports pulp capping therapies with Biodentine™ and WhiteProRoot^®MTA. (3) Results: This clinical study revealed similar success rates between mineral trioxide cement and tricalcium silicates cements at 6 months, with 100% and 95% success rates, respectively. There were no statistically significant differences between both biomaterials and between these and the various clinical circumstances, namely the absolute isolation of the operating field, exposure size, the aetiology of exposure, and even the type of restorative material used. (4) Conclusions: Biodentine™ demonstrated a therapeutic effect on the formation of a dentin bridge accompanied by slight inflammatory signs, with a high clinical success rate, indicating the possibility of its effective and safe use in dental pulp direct capping in humans, similar to the gold standard material.

Biodentine™ Partial Pulpotomy of a Young Permanent Molar with Signs and Symptoms Indicative of Irreversible Pulpitis and Periapical Lesion: A Case Report of a Five-Year Follow-Up

The purpose of this paper was to report the five-year success of Biodentine™ partial pulpotomy in a young permanent molar, with signs and symptoms indicative of irreversible pulpitis and periapical lesion, in a nine-year-old girl. Preoperative clinical examination revealed a large carious lesion of the left mandibular permanent first molar. The patient reported pain on percussion. The tooth responded positively to the electric pulp test and had lingering pain after cold testing. A periapical radiograph showed a deep carious lesion and periapical lesion. Based on the clinical and radiographical examination, the tooth had signs and symptoms indicative of irreversible pulpitis and periapical lesion. During caries removal, pulp exposure occurred, and 2-3 mm in depth of pulp tissue at the exposure site was removed. Haemorrhage was controlled within four minutes with 2.5% sodium hypochlorite-moistened cotton pellets. Biodentine™ was then applied as both a pulp dressing and a temporary restoration. At the following visit, composite resin was placed over the Biodentine™ as a final restoration. During a five-year follow-up, the tooth was asymptomatic, had positive responses to sensibility tests, and had no discolouration. Follow-up radiographs showed a dentine bridge and periapical healing.

A comparison of the sealing abilities between Biodentine and MTA as root-end filling materials and their effects on bone healing in dogs after periradicular surgery

Objectives:

To compare the sealing ability and biocompatibility of Biodentine with mineral trioxide aggregate (MTA) when used as root-end filling materials.

Methodology:

The Cell Counting Kit-8 (CCK-8) assay was used to compare the cytotoxicity of MTA and Biodentine. Twenty-one extracted teeth with a single canal were immersed in an acidic silver nitrate solution after root-end filling. Then, the volume and depth of silver nitrate that infiltrated the apical portion of the teeth were analyzed using micro-computed tomography (micro-CT). Seventy-two roots from 3 female beagle dogs were randomly distributed into 3 groups and apical surgery was performed. After six months, the volume of the bone defect surrounding these roots was analyzed using micro-CT.

Results:

Based on the results of the CCK-8 assay, MTA and Biodentine did not show statistically significant differences in cytotoxicity (P>0.05). The volume and the depth of the infiltrated nitrate solution were greater in the MTA group than in the Biodentine group (P<0.05). The volume of the bone defect was larger in the MTA group than in the Biodentine group. However, the difference was not significant (P>0.05). The volumes of the bone defects in the MTA and Biodentine groups were smaller than the group without any filling materials (P<0.05).

Conclusions:

MTA and Biodentine exhibited comparable cellular biocompatibility. Biodentine showed a superior sealing ability to MTA in root-end filling. Both Biodentine and MTA promoted periradicular bone healing in beagle dog periradicular surgery models.