A survey of various endodontic procedures related to mineral trioxide aggregate usage by members of the Australian Society of Endodontology

Can a dentin bonding agent prevent color change in regenerative endodontic procedures? An in vitro evaluation

This in vitro study aimed to determine the efficacy of dentin bonding agents in preventing color changes following Regenerative Endodontic Procedures. One hundred twenty bovine incisors were endodontically prepared and randomly assigned to a two main factors design: application of a dentin bonding agent (Scotchbond Adper, 3M ESPE, St Paul, MN, USA) in the pulp chamber (Group 1, n=60) versus no bonding intervention (Group 2, n=60), and five levels of intracanal medication (n=12/subgroup): Triple antibiotic paste (TAP), double antibiotic paste (DAB), calcium hydroxide (CH), modified triple antibiotic paste (TAPM), and Control (CTL). Color changes were measured over 28 days at multiple time points (1, 3, 7, 14, 21, and 28 days) using the CIEDE2000 formula to calculate the color difference (ΔE00) from baseline (T0). The ΔE00 quantifies the perceptible color difference between the initial and final tooth color, with lower values indicating less discoloration. The results were analyzed using repeated measures ANOVA-2 and post-hoc Holm-Sidak tests. The TAP subgroups, both with and without the bonding agent, exhibited the highest color variation. However, a pulp chamber seal with a bonding agent showed a protective effect against discoloration compared to no seal, even though complete prevention was not achieved. All groups demonstrated ΔE00 values beyond acceptable interpretation thresholds for clinical application, primarily driven by a reduction in lightness (L*) and a decrease in redness (a* value, shifting towards green). In conclusion, while the pulp chamber seal with a bonding agent mitigated TAP-induced discoloration, it did not eliminate it.

Global survey of endodontic practice and adoption of newer technologies

AIM

To investigate current endodontic practices, adoption of technologies and continuing education attendance within specialist endodontic practice globally and to identify geographic trends.

METHODOLOGY

A web-based survey of endodontic association members in Australia, Britain, Canada, Italy, New Zealand and the USA on routine treatment preferences, armamentarium and education attendance was conducted. Chi-squared, independent sample t-tests, Cochran's Q test and McNemar's test were performed.

RESULTS

The survey was completed by 543 endodontists or endodontic post-graduate students. Almost all respondents used the dental operating microscope (DOM, 91.3%), engine-driven nickel-titanium instruments (NiTi, 97.6%), electronic apex locators (EAL, 93.0%), cone-beam computed tomography (CBCT, 91.2%) and calcium silicate-based materials (CSBMs, 93.7%). Dental dam was always used by 99.1%. Over half used irrigation adjuncts (81.8%), warm vertical compaction (74.6%) and heat-treated NiTi (60.2%). Geographic comparison between AP (Asia-Pacific, n = 78), AM (Americas, n = 402) and EM (Europe and Middle East, n = 63) was performed. AM and EM preferred single-visit treatment more (p < .001) and used higher sodium hypochlorite concentrations than AP. AM had more access to CBCT in the workplace (86.6%) than AP (65.4%, p < .001) and used CBCT for routine preoperative assessment (39.6%) more than EM (7.3%, p < .001). Almost all of EM used irrigation adjuncts (95.2%), more than AM (78.1%, p = .001). AP used steroid/antibiotic medicaments most (p < .001) and had the highest attendance at continuing education programmes.

CONCLUSION

Several endodontic-specific armamentaria have reached almost complete adoption within global specialist endodontic practice, whilst the continued uptake of newer technologies should be followed over time. Some practising philosophies varied significantly across different geographic regions.

Chemomechanical Properties and Biocompatibility of Various Premixed Putty-type Bioactive Ceramic Cements

INTRODUCTION

This study aimed to evaluate the chemomechanical properties and biocompatibility of recently introduced premixed putty-type bioactive ceramic cements (PPBCs).

METHODS

Including ProRoot MTA (PMTA) as a control, BC RRM fast-set putty (BCPT), Well-Root PT (WRPT), One-Fil PT (OFPT), and Endocem MTA premixed (ECPM) were compared to evaluate setting time, radiopacity, pH change, and microhardness. Biocompatibility on human dental pulp cells was compared using CCK-8 assay. Mineralization potential was evaluated using alkaline phosphatase activity, Alizarin Red S (ARS) staining, and quantitative real-time polymerase chain reaction with odontogenic gene marker. For data analysis, 1-way analysis of variance and Tukey's post hoc test were used at the significance level of 95%.

RESULTS

Among the PPBCs, BCPT presented the longest (552 ± 27) setting time (minutes) and others showed significantly shorter time than PMTA (334 ± 22) (P < .05). WRPT (6.20 ± 0.54) and OFPT (5.82 ± 0.50) showed significantly higher radiopacity values (mmAl) and others showed similar value compared with PMTA (P > .05). All PPBCs showed high alkaline pH from fresh materials and tended to increase according to time periods from 30 minutes to 12 hours. ECPM showed the highest value of microhardness (81.62 ± 5.90), WRPT showed similar, and others showed lower than PMTA (P < .05). All PPBCs showed biocompatibility in CCK-8 assay. All PPBCs showed similar or better value compared with PMTA in ALP and ARS staining, and ALP and DSPP marker expression (P < .05).

CONCLUSIONS

The PPBCs showed clinically acceptable chemomechanical properties and favorable mineralization potential.

Current endodontic practice and use of newer technologies in Australia and New Zealand

BACKGROUND

This study investigated endodontic clinical preferences, adoption of newer technologies and information sources among dentists and endodontists.

METHODS

Dental and endodontic society members in Australia and New Zealand were surveyed online regarding their endodontic treatment preferences, armamentarium, information sources and continuing professional education (CPE) attendance.

RESULTS

Complete responses were received from 71 endodontic specialists or postgraduates (Group E) and 139 general dentists (Group D). Most of Group E used dental operating microscopes (95.8%), endodontic cone-beam computed tomography (CBCT; 98.6%) and calcium silicate-based materials (CSBMs; 97.2%), significantly more (P < 0.001) than Group D (86.3% used loupes, <32% used CBCT for endodontics or CSBMs). Most respondents used dental dam always for endodontics (94.3%), electronic apex locators (EAL; 81.0%) and engine-driven nickel-titanium (NiTi) instruments (91.4%); Group E had more experience with engine-driven NiTi (P < 0.001). Endodontic CPE attendance was highest at dental association programs (P < 0.001) while hands-on NiTi training attendance was highest via commercial companies (P < 0.05). Online information sources were commonly used (38.8% of Group D, 59.2% of Group E).

CONCLUSION

Dental dam, EAL and engine-driven NiTi were almost universally used. The endodontic group reported high adoption of newer endodontic technologies. Endodontic CPE and information sources should be further surveyed as online engagement evolves. © 2023 Australian Dental Association.

Clinical applications of calcium silicate-based materials: a narrative review

Calcium silicate-based materials are hydrophilic materials with biocompatibility and bioactivity properties. Despite many advantages, they might present some problems related to discolouration, setting time, manipulation and solubility depending on the composition of the product and the type of clinical application. Calcium silicate-based materials can be evaluated under two types according to their intended use: calcium silicate-based cements (CSCs) and calcium silicate-based sealers (CSSs). CSCs can be used in many endodontic procedures including perforation repair, resorption repair, apical barriers, guided endodontic repair, vital pulp treatment, endodontic surgery, root fractures and root canal filling as a core obturation material. CSSs are available for use with gutta-percha to obturate root canals using cold and warm techniques, including the sealer-based obturation technique. The purpose of this review is to evaluate the available literature on CSCs and CSSs and to provide up-to-date information and recommendations for their clinical applications.

Present status and future directions - Managing perforations

Root perforations are severe complications and are associated with compromised endodontic treatment outcomes, especially when bacterial infection is allowed to establish. Perforations may occur due to pathological processes or treatment consequences. Various dental materials have been proposed over the years for perforation repair with varying degrees of success. The use of bioactive materials, such as mineral trioxide aggregate (MTA) and other calcium-silicate cements, promotes a favourable environment for regeneration and has been used successfully for perforation repair. This is in contrast to materials used previously that often led to unpredictable outcomes. With the increasing range of new bioactive endodontic materials available, the number of potential materials being used for repair of root perforations is growing. Though promising to date, there is little evidence to support the use of most of these new materials. The aim of this narrative review is to provide the background, clinical techniques and outcome of nonsurgical and surgical perforation repair.

Modified Mineral Trioxide Aggregate—A Versatile Dental Material: An Insight on Applications and Newer Advancements

Mineral Trioxide Aggregate (MTA) has been a material of revolution in the field of dentistry since its introduction in the 1990s. It is being extensively used for perforation repairs, apexification, root-end filling, obturation, tooth fracture repair, regenerative procedures, apexogenesis, pulpotomies, and as a pulp-capping material because of its desired features such as biocompatibility, bioactivity, hydrophilicity, sealing ability, and low solubility. Even though its application is wide, it has its own drawbacks that prevent it from reaching its full potential as a comprehensive replacement material, including a long setting time, discoloration, mud-like consistency, and poor handling characteristics. MTA is a material of research interest currently, and many ongoing studies are still in process. In this review, the newer advancements of this versatile material by modification of its physical, chemical, and biological properties, such as change in its setting time, addressing the discoloration issue, inclusion of antimicrobial property, improved strength, regenerative ability, and biocompatibility will be discussed. Hence, it is important to have knowledge of the traditional and newer advancements of MTA to fulfill the shortcomings associated with the material.

Void characteristics and tortuosity of calcium silicate-based cements for regenerative endodontics: a micro-computed tomography analysis

Background

Internal voids of materials can serve a hub for microorganism and affect the sealing ability. This study aimed to evaluate the sealing performance of calcium silicate-based cements in immature teeth treated with regenerative endodontics.

Methods

Twenty single root canals from immature permanent premolars were prepared using regenerative endodontic protocols. The root canals were randomly divided into two groups and sealed with mineral trioxide aggregate (MTA) and Biodentine (BD). The teeth were kept in humid environment for 7 days and scanned using micro-computed tomography. The voids within the cements were segmented and visualized using image processing, incorporating the modified Otsu algorithm. The porosity of each sample was also calculated as the ratio between the number of voxels of voids and the volume of the cements. Tortuosity was also calculated using the A-star algorithm.

Results

Voids larger than 70 μm were predominantly observed in the top and interfacial surface of cements. The others were evenly distributed. MTA and BD showed the same level of porosity and tortuosity at interfacial surfaces. In inner surfaces, MTA showed more less porosity and tortuosity compared to BD (p < 0.05).

Conclusions

There were no differences in sealing performance between MTA and BD.

A Systematic Review Comparing Mineral Trioxide Aggregate to Other Commercially Available Direct Pulp Capping Agents in Dogs

Vital pulp therapy (VPT) and direct pulp capping (DPC) are procedures regularly performed in dogs for the management of acute tooth fractures and as part of management for traumatic malocclusions. The purpose of this review is to apply an evidence-based medicine approach to systematically review and evaluate the scientific literature evaluating the efficacy of mineral trioxide aggregate (MTA) to other commercially available materials used for VPT in the permanent teeth of dogs. The 9 studies meeting inclusion criteria were reviewed and each studies evidence was classified using a grading system modified from the Oxford Centre for Evidence-Based Medicine. For the studies meeting inclusion criteria, MTA consistently performed as well or better than other commercially available products in terms of calcific barrier formation and biocompatibility. This review found a lack of consistency between the studies making a direct comparison of the results unreliable. Future studies would benefit from the implementation of a standard scoring system for histology, equivalent and longer study duration times and the correlation of histological and radiographic data.

The management of deep carious lesions and the exposed pulp amongst members of two European endodontic societies: a questionnaire-based study

AIMS

To investigate and compare views on management of deep caries and the exposed pulp by Endodontic Society members in Ireland (Irish Endodontic Society [IES]) and Italy (Accademia Italiana di Endodonzia [AIE]). Further aims were to investigate the influence of patient-related factors (age, symptoms) and operator-related factors (material choice, antibiotics) on management.

METHODOLOGY

A structured online questionnaire containing two cases (an 18- and 45-year-old) and two scenarios (± mild symptoms), including history and radiograph, was sent to IES and AIE members. The answers were analysed using chi-square and Fisher's exact test (P < 0.05).

RESULTS

In total, 120 dentists participated, representing 49% of the AIE and 48% of the IES membership. Age distribution was similar between the societies; however, most AIE members had no further qualifications (63%), while IES respondents generally had a postgraduate endodontic qualification (71%). AIE respondents carried out a larger volume of vital pulp treatment (VPT) per month, with 69% carrying out over five cases, compared with 22% of IES respondents. The presence of patient symptoms significantly altered treatment planning decisions (P < 0.001) with root canal treatment (RCT) more frequently selected in both societies. Patient age significantly influenced treatment choice in the absence (P = 0.043) or presence (P = 0.012) of symptoms with less VPT advocated in older patients. There were no significant differences in the treatment of a young patient in the presence (P = 0.302) or absence of symptoms (P = 0.297); however, older patient management differed between the societies for symptomatic (P = 0.041) and asymptomatic scenarios (P = 0.044) with significantly more RCTs carried out in the AIE than the IES. Hydraulic calcium silicate materials were commonly selected, accounting for 81% of IES and 69% of AIE VPT materials, although younger members of the AIE preferred calcium hydroxide materials. Younger dentists in both societies prescribed less RCT than older age groups.

CONCLUSIONS

Although VPT is carried out by members of both societies there was no consistency regarding the most appropriate management for the exposed pulp or the VPT material of choice. Patient symptoms and age significantly influence the decision-making process and invasiveness of treatment. Hydraulic calcium silicate materials were the most commonly advocated material in all groups except young AIE members who preferred calcium hydroxide.

Current Trends in Practice of Residents in the Saudi Board of Endodontics Program

Objectives The purpose of the current study was to collect information about some techniques and armamentarium currently used by the Saudi Board of Endodontics residents in relation to the technical steps of root canal therapy.

Materials and Methods A web-based survey was sent to the Saudi Board of Endodontics residents, based in the western area of Saudi Arabia. The survey assessed controversial concepts, and collected information regarding new instruments and materials, used in the technical steps of nonsurgical root canal treatment. A one-sample chi-square test, with a 95% level of significance, was applied to determine whether there were significant differences between respondents’ answers.

Results A total of 45 out of 50 residents (90%) responded to the questionnaire. The majority of Saudi Board residents of Endodontics, who participated in this survey, used the mean of working length (ML) measured by periapical X-Ray and apex locator in the presence of a radiographic lesion (63.3%), and maintained apical patency in all cases (80.0%). ProTaper Universal (40%) and ProTaper Next (41.2%) were the most common NiTi rotary systems used for root canal instrumentation. Thirty percent of respondents used adjunct device with irrigation, and 80% advocated smear layer removal. Zinc oxide–eugenol-based sealers were the most common used sealers (70%), and most residents (86.6%) did not advocate sealer extrusion.

Conclusions This study revealed that residents of the Saudi Board of Endodontics program adopt new endodontic technologies. There is, however, a need for more investigations regarding this objective, including responses from all residents in Saudi Arabia.

Dentist-related factors influencing the use of vital pulp therapy: a survey among dental practitioners in China

Objective

To evaluate dentist-related factors associated with the use of vital pulp therapy (VPT) for the treatment of pulp exposures in permanent teeth.

Methods

This survey-based study sent an online questionnaire to collect data on the demographics of the respondents, the use of VPT and the choice of materials for VPT, to all members of the Society of Endodontology of Guangdong, China.

Results

A total 183 of 380 members responded (48.2%). The majority (89.6%; 164 of 183) had performed direct pulp capping (DPC) while 55.2% (101 of 183) had performed partial pulpotomy (PP) at least once. The most-cited reason for not performing VPT was unfamiliarity with the technique. Mineral trioxide aggregate was the most commonly used material for both DPC (67.1%; 110 of 164) and PP (73.3%; 74 of 101). Endodontists, compared with general practitioners, preferred to perform DPC and chose calcium silicate materials (CSMs) for VPT (odds ratios 5.81 and 8.07, respectively). DPC and CSMs for VPT were also favoured more by respondents who had practised for > 5 years. Senior respondents were more likely to use PP.

Conclusions

Speciality, years of practise and age of dentists influenced the decision making and the choice of materials for VPT. Continuing education is essential to promote the clinical use of VPT.

Porosity Distribution in Apically Perforated Curved Root Canals Filled with Two Different Calcium Silicate Based Materials and Techniques: A Micro-Computed Tomography Study

The present study evaluated the porosity distribution of BioRoot RCS/single gutta-percha point (BR/SC) and MTA flow (MF) fillings, which were used as plugs for the apical perforation repair in curved canals of extracted mandibular molars using micro-computed tomography (μCT). Forty mesial root canals of mandibular first molars were shaped with ProTaper NEXT X1-X5 files 2 mm beyond the apex to simulate apical perforations that were randomly divided into two groups (n = 20) according to the material and technique used for the apical plug: BR/SC or MF. The specimens were scanned before and after canal filling at an isotropic resolution of 9.9 μm. The volumetric analysis of voids in the apical 5 mm of the fillings was performed. Data were analyzed using one-way ANOVA with Bonferroni correction (p < 0.05). Micro-computed tomography (µCT) evaluation revealed significant differences between the groups in terms of porosity: the total volume and percentage volume of voids was lower in the BR/SC group in comparison with the MF group (p < 0.05), with the predominance of open pores in both groups. Neither of the materials and/or application techniques were able to produce void-free root fillings in the apical region of artificially perforated curved roots of mandibular molars.

Mineral Trioxide Aggregate-A Review of Properties and Testing Methodologies

Mineral trioxide aggregate (MTA) restoratives and MTA sealers are commonly used in endodontics. Commonly referenced standards for testing of MTA are ISO 6876, 9917-1 and 10993. A PubMed search was performed relating to the relevant tests within each ISO and "mineral trioxide aggregate". MTA restoratives are typically tested with a mixture of tests from multiple standards. As the setting of MTA is dependent upon hydration, the results of various MTA restoratives and sealers are dependent upon the curing methodology. This includes physical properties after mixing, physical properties after setting and biocompatibility. The tests of flow, film thickness, working time and setting time can be superseded by rheology as it details how MTA hydrates. Physical property tests should replicate physiological conditions, i.e. 37 °C and submerged in physiological solution. Biocompatibility tests should involve immediate placement of samples immediately after mixing rather than being cured prior to placement as this does not replicate clinical usage. Biocompatibility tests should seek to replicate physiological conditions with MTA tested immediately after mixing.

Aspects of Solvent Chemistry for Calcium Hydroxide Medicaments

Calcium hydroxide pastes have been used in endodontics since 1947. Most current calcium hydroxide endodontic pastes use water as the vehicle, which limits the dissolution of calcium hydroxide that can be achieved and, thereby, the maximum pH that can be achieved within the root canal system. Using polyethylene glycol as a solvent, rather than water, can achieve an increase in hydroxyl ions release compared to water or saline. By adopting non-aqueous solvents such as the polyethylene glycols (PEG), greater dissolution and faster hydroxyl ion release can be achieved, leading to enhanced antimicrobial actions, and other improvements in performance and biocompatibility.

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.

Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part I: vital pulp therapy

Mineral trioxide aggregate (MTA) is a bioactive endodontic cement (BEC) mainly comprised of calcium and silicate elements. The cement was introduced by Torabinejad in the 1990s and has been approved by the Food and Drug Administration to be used in the United States in 1997. A number of new BECs have also been introduced to the market, including BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, NeoMTA Plus, OrthoMTA, Quick-Set, RetroMTA, Tech Biosealer and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA without its drawbacks. In this article, the chemical composition and the application of MTA and other BECs for vital pulp therapy (VPT), including indirect pulp cap, direct pulp cap, partial pulpotomy, pulpotomy and partial pulpectomy, have been reviewed and compared. Based on selected keywords, all papers regarding chemical composition and VPT applications of BECs had been reviewed. Most of the materials had calcium and silicate in their composition. Instead of referring to the cements based on their chemical compositions, we suggest the term 'bioactive endodontic cements (BECs)', which seems more appropriate for these materials because, in spite of differences in their chemical compositions, bioactivity is a common property for all of them. Numerous articles were found regarding use of BECs as VPT agents for indirect and direct pulp capping, partial pulpotomy and cervical pulpotomy. Most of these investigations used MTA for VPT. In most studies, newly introduced materials have been compared to MTA. Some of the BECs have shown promising results; however, the number of their studies compared to investigations on MTA is limited. Most studies had several methodological shortcomings. Future investigations with rigorous methods and materials are needed.

Dental Material Choices for Pulp Therapy in Paediatric Dentistry

Objective:

The purpose of this study was to assess the restorative choices for pulpal therapy by members of the Australian and New Zealand Society of Paediatric Dentistry (ANZSPD).

Methods:

Members of the ANZSPD were sent an online survey asking about the procedures that they performed and their choice of dental materials.

Results:

The respondents were 31 general dentists (GD) and 55 specialist paediatric dentists (PD). Materials used for indirect pulp capping included calcium hydroxide [Ca(OH)₂] cement (CHC), glass ionomer cement or resin-modified glass ionomer cement (GIC/RMGIC), Ca(OH)₂ paste (CHP) and mineral trioxide aggregate (MTA). Materials for direct pulp capping included MTA, CHP and CHC. Materials and techniques used for pulpotomy included MTA, ferric sulphate, formocresol and diathermy, CHP and CHC. GD and PD were similar in their choice of materials. However, there was no preferred product for pulp therapy. Most GD learnt how to use MTA from CPD lectures, while some PD learnt how to use MTA from their postgraduate training as well as CPD lectures. Many GD and PD did not have hands-on training from their education on how to use MTA (GD: 80%, PD: 43%). Most would like to attend hands-on MTA courses (GD: 86%, PD: 65%).

Conclusion:

There was no clear preferred product for the various types of pulp therapy in paediatric dentistry. Education appears to be the major barrier to the use of MTA rather than the cost of MTA.