Comparison of pulp response to mineral trioxide aggregate and a bioceramic paste in partial pulpotomy of sound human premolars: a randomized controlled trial

The effectiveness of partial pulpotomy compared with full pulpotomy in managing deep caries in vital permanent teeth with a diagnosis of non-traumatic pulpitis

BACKGROUND

Pulpitis may be pain free or alternatively characterized by mild to severe pain and associated symptoms. Evidence has recently emerged that patients presenting with carious pulp exposure range of symptoms can be treated effectively with pulpotomy.

OBJECTIVE

The current systematic review aimed to answer the following research question: "In patients with deep caries lesions in permanent teeth associated with no symptoms, reversible pulpitis or signs and symptoms indicative of irreversible pulpitis (P), is partial pulpotomy (I) as effective as full pulpotomy (C), in terms of a combination of patient and clinical reported outcomes (O), with "tooth survival" as the most critical outcome?

METHODS

The systematic literature search was conducted in the following electronic databases: OVID, Scopus, PubMed (Including MEDLINE), and Cochrane Central Register of Controlled Trials (CENTRAL) supplemented with Grey literature and hand searching of relevant journals. The English language clinical trials comparing the patient and clinical reported outcomes between partial and full/complete were included. After a structured literature search, two authors independently performed study selection, extracted data and performed a risk of bias assessment; a third reviewer resolved disagreements. As there were only two studies with different exclusion criteria, no meta-analysis was performed and the quality of evidence was assessed by the GRADE approach.

RESULTS

After study selection a total of two randomised clinical trials with a total of 156 teeth were included both for the management of teeth with irreversible pulpitis. There were no studies for asymptomatic teeth or teeth with reversible pulpitis. A "Low" risk of bias was noted for both studies with a high level of overall evidence. A meta-analysis was not carried out due to differences in inclusion criteria between the studies related principally to caries depth. Both studies reported a high rate of clinical success for pulpotomy with a pooled unadjusted success rate for full pulpotomy of 90% and 83% partial pulpotomy of at 1-year; however, no significant difference between the treatments was noted in either study. There was significantly reduced postoperative pain reported in the full pulpotomy group over 1-week compared with the partial pulpotomy in one but not in the other study.

DISCUSSION

Pulpotomy as a definitive treatment modality is as effective in managing teeth exhibiting signs and symptoms indicative of irreversible pulpitis and challenges the established protocols to manage this condition. Although based on only two RCTs with a limited number of patients, no difference was shown in terms of clinical or radiographic outcome or postoperative pain between groups. Further well designed randomised clinical trials of longer duration are required in this area to improve the evidence available.

CONCLUSION

There is no consistent difference in patient-reported pain between partial and full pulpotomy at day 7 postoperatively and the clinical success rate was similar after 1 year for both treatment modalities.

Calcium Silicate-Based Cements in Restorative Dentistry: Vital Pulp Therapy Clinical, Radiographic, and Histological Outcomes on Deciduous and Permanent Dentition-A Systematic Review and Meta-Analysis

Vital pulp therapy aims to preserve the vitality of dental pulp exposed due to caries, trauma, or restorative procedures. The aim of the present review was to evaluate the clinical, radiographic, and histological outcomes of different calcium silicate-based cements used in vital pulp therapy for both primary and permanent teeth. The review included 40 randomized controlled trials from a search across PubMed, LILACS, and the Cochrane Collaboration, as well as manual searches and author inquiries according to specific inclusion and exclusion criteria. A critical assessment of studies was conducted, and after data extraction the results were submitted to a quantitative statistical analysis using meta-analysis. The studies, involving 1701 patients and 3168 teeth, compared a total of 18 different calcium silicate-based cements in both dentitions. The qualitative synthesis showed no significant differences in short-term outcomes (up to 6 months) between different calcium silicate-based cements in primary teeth. ProRoot MTA and Biodentine showed similar clinical and radiographic success rates at 6 and 12 months. In permanent teeth, although the global results appeared to be well balanced, ProRoot MTA generally seemed to perform better than other calcium silicate-based cements except for Biodentine, which had comparable or superior results at 6 months. Meta-analyses for selected comparisons showed no significant differences in clinical and radiographic outcomes between ProRoot MTA and Biodentine over follow-up periods. The present review highlights the need for standardized definitions of success and follow-up periods in future studies to better guide clinical decisions. Despite the introduction of new calcium silicate-based cements aiming to address limitations of the original MTA. ProRoot MTA and Biodentine remain the most used and reliable materials for vital pulp therapy, although the results did not deviate that much from the other calcium silicate-based cements. Further long-term studies are required to establish the optimal CSC for each clinical scenario in both dentitions.

Effects of Novel Nanoparticulate Bioceramic Endodontic Material on Human Dental Pulp Stem Cells In Vitro

OBJECTIVES

This study aimed to investigate the in vitro effects of root canal filling and repair paste (nRoot BP) on human dental pulp stem cells (hDPSCs).

METHODS

The effects of nRoot BP and iRoot BP Plus on the adhesion, proliferation, migration, and differentiation of hDPSCs were examined in vitro for 72 hours. The adhesion of cells was observed using immunofluorescence rhodamine ghost pen cyclic peptide staining and scanning electron microscopy (SEM). Cell density and changes in migration area were measured under a fluorescence inverted microscope. Fluorescent quantitative PCR was performed to detect genes related to odontogenesis and osteogenesis.

RESULTS

Cells adhering to the surfaces of nRoot BP and iRoot BP Plus exhibited similar irregular polygonal morphologies, with cells extending irregular pseudopods to adhere to the materials. CCK-8 results indicated that the density of living cells for nRoot BP and iRoot BP Plus was lower than that of the blank control group at 3 and 5 days of culture. There was no significant difference in cell migration between the groups (P > .05). The migration ability of iRoot BP Plus and nRoot BP was similar to that of the control group. Both nRoot BP and iRoot BP Plus increased the expression of the RUNX2 gene, but there was no significant difference between the groups (P < .05). Furthermore, both nRoot BP and iRoot BP Plus downregulated the expression of the DSPP gene, with no significant difference between them (P > .05).

CONCLUSIONS

nRoot BP exhibited a slight inhibition of hDPSC proliferation but did not affect the adhesion and migration of hDPSCs. The impact of nRoot BP on the osteogenic and odontogenic differentiation of hDPSCs was similar to that of iRoot BP Plus.

Six-year clinical evaluation of iRoot BP Plus as apical barrier in permanent teeth of periapical periodontitis

The apical barrier technique in permanent teeth with extensive destruction of the periapical tissue and a long infection time is much more difficult to succeed, which is a clinical challenge. This study aimed to evaluate the long-term effects of iRoot BP Plus as an apical material in adult teeth. Fifty incisors and premolars were chosen for this study. All teeth were performed apical barrier with the same operator. After treatment, the teeth were clinically and radiographically evaluated at 1, 2 and 6 years. At the 1-year follow-up, 35 teeth had healed, and three patients developed an apical abscess due to root fracture at the 2-year follow-up. Six years postoperatively, one tooth showed root resorption, which was considered a failure. The long clinical evaluation confirmed that iRoot BP Plus is a suitable material for the apical barrier of mature teeth with open apices and periapical lesions.

THREE-YEAR OUTCOME OF DIODE LASER PULPOTOMY OF PRIMARY MOLARS USING THREE PULP CAPPING AGENTS: A SPLIT-MOUTH RANDOMIZED CLINICAL TRIAL

OBJECTIVES

Pulpotomy is the most commonly performed treatment for asymptomatic primary molars with exposed dental pulp. This study aimed to assess the clinical /radiographic success of diode laser pulpotomy with mineral trioxide aggregate (MTA), calcium hydroxide (CH), and calcium-enriched mixture (CEM) cement as pulp capping agents.

METHODS

This split-mouth randomized clinical trial was conducted initially on 34 children aged 3-8 years but 4 patients left the study before the first follow-up visit and the study was accomplished and analyzed with 30 cases. The patients had at least 3 first/second molars with deep caries that in radiographic evaluation revealed that they required pulpotomy. Following pulpotomy, the pulp stump was irradiated with diode laser (noncontact mode, 632 nm, 30 mW power) as photobiomodulation mode. Pulp tissue was then capped with MTA, CH, or CEM cement (n = 30 in each group). Reinforced zinc oxide eugenol was applied over the capping agent, and the teeth were restored with stainless steel crowns. Teeth were clinically/radiographically assessed at 6, 12, 18, and 36 months, after treatment. Data were analyzed by Cochran and McNemar tests.

RESULTS

All 30 patients showed up for clinical/radiographic follow-ups for up to 36 months. Regarding clinical outcomes, the 6-, 12-, 18-, and 36-month success rates of all experimental groups were nearly similar with no significant difference (p > .05). Regarding radiographic outcomes, the 6-month success rates were similar among the groups (p > .05); however, the 12-, 18-, and 36-month outcomes of CEM and MTA groups were similar but significantly superior to that of CH group (p < .05).

CONCLUSION

Diode laser irradiation and subsequent capping of pulp tissue with MTA or CEM cement can be employed for pulpotomy of primary molars.

Immature permanent incisors with complicated crown fractures treated with partial pulpotomy using white mineral trioxide aggregate and IRoot BP plus-a retrospective long-term study

BACKGROUND/AIMS

Calcium silicate cements have been widely used for pulpotomies in immature permanent teeth with complicated crown fractures due to their superior properties. However, few studies have evaluated the long-term outcomes of white mineral trioxide aggregate (WMTA) and iRoot BP Plus for partial pulpotomies. The aim of this study was to investigate the long-term clinical and radiographic outcomes of WMTA and iRoot BP Plus for partial pulpotomies in immature permanent incisors with complicated crown fractures.

MATERIALS AND METHODS

Children who had partial pulpotomies of immature permanent incisors with complicated crown fractures using WMTA or iRoot BP Plus as capping agents were enrolled. Eighty immature permanent incisors in 68 children (aged 8-13 years) were included. They were divided into two groups (WMTA and iRoot BP Plus) according to the capping agents. Clinical and radiographic information was collected during a 5-year follow-up period. Study data were analyzed using Chi-square tests or Fisher exact tests.

RESULTS

The clinical and radiographic success rates in the WMTA (n = 36) and iRoot BP Plus groups (n = 44) were 94.4% versus 97.7% and 88.9% versus 97.7%, respectively (both p < .05). The average observation period was 74.5 ± 13.2 months and 61.9 ± 1.6 months in the WMTA and iRoot BP Plus groups, respectively (p < .01). Five cases presented with periapical radiolucencies. The WMTA group had four cases of pulp canal calcification (11.1%), while the iRoot BP Plus group had two cases (4.6%). There was crown discolouration in all cases in the WMTA group, but none in the iRoot BP Plus group.

CONCLUSION

Both WMTA and iRoot BP Plus had favorable outcomes in promoting physiological development and maintaining the basic functions of immature permanent incisors with complicated crown fractures. As a partial pulpotomy material, iRoot BP Plus may be more suitable for the esthetic zone than WMTA.

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.

The Effect of Final Irrigation Protocols on the Apical Sealing Ability of Epoxy Resin-based and Bioceramic-based Root Canal Sealers

Aim: This study was designed to investigate the effect of different final irrigation protocols on the apical sealing ability of bioceramic and epoxy resin-based sealers. Materials and methods: Thirty human single-rooted mandibular premolars were instrumented using ProTaper Next rotary files. Teeth were randomly divided into three groups according to the final irrigation regimen; Group I: 5 ml 0.2% CNPs/3 min, Group II: 2.5 ml 0.2% CNPs/1.5 min followed by 2.5 ml 17% EDTA/1.5 min, and Group III: 5 ml 17% EDTA/3min. All groups were subdivided into two subgroups based on the obturation material; Subgroup A: gutta-percha/Sure-Seal Root BC Sealer and Subgroup B: gutta-percha/AH Plus. All canals were obturated using single cone obturation technique. The apical sealing ability was assessed using modified silver staining technique with ammoniacal silver nitrate tracer solution. Samples were sectioned longitudinally and examined using scanning electron microscope. Results: Sure-Seal Root BC sealer showed significantly lower nanoleakage compared to AH Plus (p < 0.001). No significant difference was recorded in the nanoleakage of Sure-Seal Root BC sealer among the three groups (p = 0.284), while AH Plus showed a significantly higher nanoleakage in the EDTA group (p = 0.002). The depth of silver nitrate penetration into the dentinal tubules was significantly higher in AH Plus subgroup with the three different irrigation protocols (p < 0.001). For both sealers, the highest penetration depth for silver nitrate tracer solution was recorded in the EDTA group (p < 0.001). Conclusions: The apical sealing ability of bioceramic sealers is better than that of epoxy resin-based sealers. The type of the final irrigating solution seems to affect the post-obturation seal of both AH Plus and Sure-Seal Root BC sealer. Keywords: Bioceramic, AH Plus, Chitosan nanoparticles, EDTA, Sealing ability.

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.

[Evaluation of bioceramic putty repairmen iRoot and mineral trioxide aggregate in mature permanent teeth pulpotomy]

OBJECTIVE

To evaluate the clinical characteristics and effectiveness of pulpotomy in mature permanent teeth with bioceramic putty repairmen iRoot and mineral trioxide aggregate (MTA).

METHODS

Pulpotomy was performed on mature permanent premolars and molars with carious exposures at the Department of General Dentistry of Peking University School and Hospital of Stomatology, from November 2017 to September 2019. The patients were randomly divided into 2 groups, Group iRoot (n=22) and Group MTA (n=21). In Group iRoot, bioceramic putty repairmen iRoot was used as pulp capping agent, while in Group MTA, mineral trioxide aggregate was used as pulp capping agent. All the patients had signed informed consent forms. The clinical efficacy was evaluated by clinical examinations (temperature and electrical activity test) and imaging examinations 3, 6, and 12 months after surgery. Blinding was used for the patients and evaluators, but due to the obvious differences in the properties of the two pulp capping agents, the blinding method was not used for the treatment provider (the attending physician).

RESULTS

There was no significant difference in gender, average age, dentition and tooth position distribution between the two groups (P>0.05). In the study, 7 cases were lost to follow-up 12 months after operation (4 cases in Group iRoot, and 3 cases in Group MTA). One case in each of the two groups had transient sensitivity at the end of the 3-month follow-up, and the pulp vitality was normal at the end of the 6-month follow-up. One case in Group iRoot showed sensitivity at the end of the 12-month follow-up. The success rates of the two groups at the end of 12-month follow-up were 100%, and the cure rates were 94.4% (Group iRoot) and 100% (Group MTA), respectively, and the difference was not statistically significant (P>0.05). No cases in Group iRoot had obvious crown discoloration, while 3 cases in Group MTA had.

CONCLUSION

The clinical characteristics and effectiveness of pulpotomy in mature permanent teeth with bioceramic putty repairmen iRoot were similar with MTA. Bioceramic putty repairmen iRoot is an acceptable material when used in pulpotomy of mature permanent teeth. Because it is not easy to cause tooth discoloration after treatment and is convenient to operate, bioceramic putty repairmen iRoot has a better clinical application prospect.

Clinical and Radiographic Assessments of Potassium Nitrate in Polycarboxylate Versus Mineral Trioxide Aggregate as Pulpotomy Biomaterials in Immature Mandibular First Permanent Molars: A Randomized Clinical Trial

INTRODUCTION

The purpose of this study was to compare clinically and radiographically the effects of potassium nitrate in polycarboxylate cement and mineral trioxide aggregate (MTA) as pulpotomy agents in vital immature mandibular first molars.

METHODS

The trial design was a parallel randomized, 1:1 allocation ratio, with both the participants and the data assessor blinded. A total of 50 molars of 48 eligible children aged 6-9 years were studied. The children had mandibular immature first molars with extensive caries that revealed pulp exposure during caries excavation. Patients were randomly allocated equally into 2 groups in which potassium nitrate in polycarboxylate cement (the intervention group) and MTA (the control group) were used as pulpotomy biomaterials. The treated teeth were restored permanently. The primary outcome was clinical/radiographic assessment after 1 week, 6 months, and 12 months. The secondary outcomes were radiometric analysis at 6 and 12 months to determine dimensional changes during maturogenesis. The digital radiographs were imported to image processing software to perform radiometric measurements. Data were tabulated and statistically analyzed with significance set at P ≤ .05.

RESULTS

Only a single tooth failed at the 6-month recall, and another one was lost during recall in each group. Thus, the overall success rate for cases/group who finally attended the 12-month follow-up time point was 92% (23/25) with no statistically significant difference between the 2 groups. At the 12-month recall, successful cases showed root development with an increase in root length and a decrease in apical foramen width. Complete apical closure was observed in 65.2% of the roots in the intervention group and 52.1% in the control group.

CONCLUSIONS

The clinical and radiographic success reported in the present study reveals that potassium nitrate in polycarboxylate cement could be used as a biological and economic alternative to MTA as a pulpotomy agent in vital immature mandibular first molars. Further follow-up for longer periods is recommended.

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

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

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Comparison of indirect pulp treatment and iRoot BP Plus pulpotomy in primary teeth with extremely deep caries: a prospective randomized trial

OBJECTIVES

The purpose of this randomized controlled trial was to compare the 24-month success rates of indirect pulp treatment (IPT) and iRoot BP Plus pulpotomy of primary molars with extremely deep caries.

MATERIALS AND METHODS

Generally healthy children aged 3-7 years requiring general anesthesia for treating primary molars with extremely deep caries or reversible pulpitis were recruited. Patients with systemic disease, mental health problems, or manifestations of irreversible pulpitis were excluded. In total, 175 molars were randomized and blinded for either IPT (n = 87) or iRoot BP Plus pulpotomy (n = 88). All teeth were restored with stainless steel crowns and evaluated after 6, 12, 18, and 24 months by two blinded calibrated investigators. Kaplan-Meier survival curves were used to compare the survival rates between the groups. The correlations between success rate and patient characteristics were explored with the Cox proportional hazards model.

RESULTS

A total of 168 primary molars in 67 patients (average age: 3.83 years) were evaluated. The cumulative survival probability at 24 months was not significantly different between the IPT (93.8%) and pulpotomy (97.7%) groups (P = 0.238). IPT treatment success was significantly associated with age (odds ratio = 2.347; 95% CI: 1.068-5.156; P = 0.034) and preoperative sensitivity (odds ratio = 9.742; 95% CI: 1.079-87.970; P = 0.043).

CONCLUSIONS

The 24-month success rates of IPT and iRoot BP Plus pulpotomy performed in primary molars with extremely deep caries were not significantly different. Increasing age and preoperative sensitivity were found to be associated with the cumulative survival probability in IPT-treated primary molars with extremely deep caries. Primary teeth with extremely deep carious lesions without signs of irreversible pulpitis can be treated successfully by either indirect pulp capping or iRoot BP Plus pulpotomy.

TRIAL REGISTRATION

ChiCTR2000032462.

Biomimetic Aspects of Oral and Dentofacial Regeneration

Biomimetic materials for hard and soft tissues have advanced in the fields of tissue engineering and regenerative medicine in dentistry. To examine these recent advances, we searched Medline (OVID) with the key terms “biomimetics”, “biomaterials”, and “biomimicry” combined with MeSH terms for “dentistry” and limited the date of publication between 2010–2020. Over 500 articles were obtained under clinical trials, randomized clinical trials, metanalysis, and systematic reviews developed in the past 10 years in three major areas of dentistry: restorative, orofacial surgery, and periodontics. Clinical studies and systematic reviews along with hand-searched preclinical studies as potential therapies have been included. They support the proof-of-concept that novel treatments are in the pipeline towards ground-breaking clinical therapies for orofacial bone regeneration, tooth regeneration, repair of the oral mucosa, periodontal tissue engineering, and dental implants. Biomimicry enhances the clinical outcomes and calls for an interdisciplinary approach integrating medicine, bioengineering, biotechnology, and computational sciences to advance the current research to clinics. We conclude that dentistry has come a long way apropos of regenerative medicine; still, there are vast avenues to endeavour, seeking inspiration from other facets in biomedical research.

Efficacy of different calcium silicate materials as pulp-capping agents: Randomized clinical trial

Background/purpose

Calcium hydroxide-based materials were the gold standard in vital pulp therapies for decades' despite of several shortcomings. However, calcium silicates have been discussed as an alternative to overcome these drawbacks. It was aimed to investigate the in-vivo effectiveness of different calcium silicates based materials in pulp capping in this study.

Materials and methods

A parallel-design, randomized controlled trial with 213 patients who has deep dentin caries, vital pulps and without spontaneous pain or history of swelling was designed. 525 M teeth were randomized, blinded and allocated to one of the five groups for pulp capping treatment (n = 105). All teeth were followed up clinically and radiographically (after 1st, 6th, 12th and 36th months) by blinded investigators. The clinical and radiographic success, and the effect of the pulp exposure to the success rate analyzed with Wald chi-square and Z tests.

Results

Clinical and radiographic success of MTA+ (86.3%, 85.4%) and Biodentine (79.4%, 80.1%) were found the highest. Although results of Theracal LC group (72.1%, 73.6%) were better than Dycal group (69.4%, 70.2%), the difference was nonsignificant (p > 0.05). Only in light-cured groups, (TheraCal LC & LC Calcihyd) pulpal exposure size effected the success of the materials (p < 0.05). MTA+ and Biodentine resulted better scores, when compared with TheraCal LC in large pulpal exposures (p < 0.05).

Conclusion

After 36-month follow-up, both MTA+ and Biodentine were found to be the appropriate material for direct pulp capping in permanent teeth. The filler ingredient of the Theracal-LC eases the usage of calcium silicates but decreases the success rate.

Cytotoxicity and Bioactivity of Dental Pulp-Capping Agents towards Human Tooth-Pulp Cells: A Systematic Review of In-Vitro Studies and Meta-Analysis of Randomized and Controlled Clinical Trials

Background. In the era of biology-driven endodontics, vital pulp therapies are regaining popularity as a valid clinical option to postpone root-canal treatment. In this sense, many different materials are available in the market for pulp-capping purposes. Objectives. The main aim of this systematic review and meta-analysis was to examine literature regarding cytotoxicity and bioactivity of pulp-capping agents by exposure of human dental pulp cells of primary origin to these materials. A secondary objective was to evaluate the inflammatory reaction and reparative dentin-bridge formation induced by the different pulp-capping agents on human pulp tissue. Data sources. A literature search strategy was carried out on PubMed, EMBASE and the Web of Science databases. The last search was done on 1 May 2020. No filters or language restrictions were initially applied. Two researchers independently selected the studies and extracted the data. Study selection included eligibility criteria, participants and interventions, study appraisal and synthesis methods. In vitro studies were included when human dental pulp cells of primary origin were (in)directly exposed to pulp-capping agents. Parallel or split-mouth randomized or controlled clinical trials (RCT or CCT) were selected to investigate the effects of different pulp-capping agents on the inflammation and reparative bridge-formation capacity of human pulp tissue. Data were synthesized via odds ratios (95% confidence interval) with fixed or random effects models, depending on the homogeneity of the studies. The relative risks (95% confidence interval) were presented for the sake of interpretation. Results. In total, 26 in vitro and 30 in vivo studies were included in the systematic review and meta-analysis, respectively. The qualitative analysis of in vitro data suggested that resin-free hydraulic calcium-silicate cements promote cell viability and bioactivity towards human dental pulp cells better than resin-based calcium-silicate cements, glass ionomers and calcium-hydroxide cements. The meta-analysis of the in vivo studies indicated that calcium-hydroxide powder/saline promotes reparative bridge formation better than the popular commercial resin-free calcium-silicate cement Pro-Root MTA (Dentsply-Sirona), although the difference was borderline non-significant (p = 0.06), and better than calcium-hydroxide cements (p < 0.0001). Moreover, resin-free pulp-capping agents fostered the formation of a complete reparative bridge better than resin-based materials (p < 0.001). On the other hand, no difference was found among the different materials tested regarding the inflammatory effect provoked at human pulp tissue. Conclusions. Calcium-hydroxide (CH) powder and Pro-Root MTA (Dentsply-Sirona) have shown excellent biocompatibility in vitro and in vivo when tested on human cells and teeth. Their use after many years of research and clinical experience seems safe and proven for vital pulp therapy in healthy individuals, given that an aseptic environment (rubber dam isolation) is provided. Although in vitro evidence suggests that most modern hydraulic calcium-silicate cements promote bioactivity when exposed to human dental pulp cells, care should be taken when these new materials are clinically applied in patients, as small changes in their composition might have big consequences on their clinical efficacy. Key findings (clinical significance). Pure calcium-hydroxide powder/saline and the commercial resin-free hydraulic calcium-silicate cement Pro-Root MTA (Dentsply-Sirona) are the best options to provide a complete reparative bridge upon vital pulp therapy. Systematic review registration number. PROSPERO registration number: CRD42020164374.

The Response of the Pulp-Dentine Complex, PDL, and Bone to Three Calcium Silicate-Based Cements: A Histological Study in an Animal Rat Model

Objective

The aim of this study was to histologically examine the tissue reaction of three different calcium silicate cements in the closure of perforations in rat incisor teeth. Material and Methods. An experimental lateral root perforation with pulp exposure was performed in 32 lower incisors of 16 male Wistar albino rats. They were randomly assigned into three test groups (each including eight teeth) that were filled either by Biodentine (BD) or MicroMega mineral trioxide aggregate (MM-MTA) or EndoSequence root repair material putty (ESRRM putty), besides eight unperforated incisors from the other four rats (control group). The inflammatory response and healing process were evaluated histologically and scored after one and four weeks. Differences among groups were tested by Kruskal-Wallis tests at P ≤ 0.05.

Results

In the first week, BD produced more inflammatory response in the pulpal (score 3) than other materials (score 2). Only ESRRM putty showed odontoblast-like cells in 50%, 25% dentine-like deposit, 25% evidence of bone deposition in the drilling site (score 2), and minimum periodontal ligament (PDL) necrosis and disorganization (25%, score 2). After one month, all groups had healthy pulpal tissue, but 25% of ESRRM putty retained score 1 inflammatory response, and 50% of the BD case had an incomplete palisading odontoblast layer (score 3). A thick and regular dentine bridge deposition was seen in the ESRRM putty group in comparison with MM-MTA and BD cases. The cortical plate healing in all ESRRM putty samples was complete (score 3), while an incomplete closure was seen in MM-MTA and BD groups (score 2). Both the MM-MTA and ESRRM putty groups had fully organized PDL (score 2), while in 50% of BD cases, a necrotizing area and disorganized PDL with inflammatory cells infiltration were still present. Statistically significant differences in the scores of any histologic parameters among the three tested materials were observed neither in the 1st nor in the 4th weeks of the experimental period.

Conclusion

Better tissue compatibility and repair of pulpal and periodontal tissue have been detected after lateral perforation in the root of rat incisors when treated with ESRRM putty than MM-MTA and BD. However, the difference was not significant.

Comparison of iRoot BP Plus and Calcium Hydroxide as Pulpotomy Materials in Permanent Incisors with Complicated Crown Fractures: A Retrospective Study

INTRODUCTION

Calcium hydroxide has been used as a traditional pulpotomy agent for a long time but has some disadvantages. iRoot BP Plus (Innovative Bioceramix Inc, Vancouver, Canada) is a newly developed, ready-to-use calcium silicate-based bioactive ceramic with excellent bioactivity and sealing ability. However, whether iRoot BP Plus shows superiority over calcium hydroxide as a pulpotomy material on permanent incisors with complicated crown fractures remains unknown.

METHODS

This research included 205 permanent incisors with complicated crown fractures. These teeth were treated with pulpotomy and divided into 2 groups according to the pulpotomy material (105 treated with iRoot BP Plus and 100 with calcium hydroxide). Clinical and radiographic information was collected during the 12- to 24-month follow-up period. The formation of reparative dentin bridges and pulp canal obliteration were analyzed using radiographs in both groups.

RESULTS

The success rates for recall in the average follow-up period of 17.5 ± 4.4 months (12-24 months) after pulpotomy treatment were significantly different between the 2 groups, with 99% for the iRoot BP Plus group and 93% for the calcium hydroxide group. Reparative dentin bridges were observed in 92.4% of the iRoot BP Plus group and 90% of the calcium hydroxide group, but the difference was not significant. Pulp canal obliteration was observed in 2 teeth (2%) in each group.

CONCLUSIONS

The success rates obtained in our study indicate that iRoot BP Plus as a pulpotomy agent can be a suitable alternative to calcium hydroxide to manage complicated crown fractures.

Effect of five dental pulp capping agents on cell proliferation, viability, apoptosis and mineralization of human dental pulp cells

The aim of the present study was to investigate the effect of calcium hydroxide [Ca(OH)₂], mineral trioxide aggregate (MTA), iRoot BP, platelet-rich fibrin (PRF) and concentrated growth factors (CGF) on the proliferation, viability, apoptosis and mineralization of human dental pulp cells (HDPCs). HDPCs were treated with Ca(OH)₂, MTA, iRoot BP, PRF and CGF exudates. Cell viability, apoptosis, proliferation, cell cycle and alkaline phosphatase (ALP) activity were evaluated in vitro. PRF significantly increased the cell proliferation as compared with that in the MTA and iRoot BP groups on day 3. The CGF group displayed higher proliferation rates as compared with that in the MTA group on days 3 and 7. The MTA group displayed the highest ALP activity on days 1 and 3, and the CGF group on day 7. Ca(OH)₂ inhibited cell proliferation and the percentages of dead and apoptotic cells were relatively higher in the Ca(OH)₂ group on days 1, 3 and 7 compared with those in the other groups. In conclusion, PRF and CGF may be potential pulp-capping materials for vital pulp therapy. Future in vivo studies are required to confirm this.

Comparison between iRoot BP Plus (EndoSequence Root Repair Material) and Mineral Trioxide Aggregate as Pulp-capping Agents: A Systematic Review

INTRODUCTION

iRoot BP Plus, also known as EndoSequence root repair material (EERM) is a premixed bioceramic thick/putty. According to its instruction manual, iRoot BP Plus is composed of tricalcium silicate, zirconium oxide, tantalum pentoxide, dicalcium silicate, calcium sulfate, calcium phosphate monobasic, and filler agents. This systematic review was carried out to evaluate and present the iRoot BP Plus material as a pulp-capping agent.

MATERIALS AND METHODS

A systematic search for articles with the scope of the selection criteria undergoing for data extraction was conducted through electronic databases. Studies on evaluation of the cytotoxicity, bioactivity, and dentinal bridge formation of iRoot BP, iRoot BP Plus, ERRM putty, or ERRM paste (ERRM) on variant human cells were selected for in vitro models, and dentinal bridge formation on human and animals teeth for in vivo models were selected.

RESULTS

A total of 22 articles were discussed in the review, 14 in vitro studies, five in vivo studies, and three articles with both studies. Methyl thiazol tetrazolium was the most used method for evaluating cytotoxicity. As for dentinal bridge formation, histological assessment and micro-Computed tomography were used. Human dental pulp cells (hDPCs) were the most investigated for in vitro models and rats for in vivo models. Except for one study, all studies involved in this review were primarily examining the material and comparing it to different types of mineral trioxide aggregate.

CONCLUSION

iRoot BP, iRoot BP Plus, and ERRM are biocompatible materials that enhance hDPCs and other variant human cells proliferation, migration, attachment adhesion, mineralization, and dentinal bridge formation.

[Evaluation of bioceramic putty repairment in primary molars pulpotomy]

OBJECTIVE

To evaluate the clinical characteristics and effectiveness of bioceramic putty repairment (iroot BP Plus) used as pulp capping agents on pulpotomy in primary molars.

METHODS

Forty primary molars were treated by pulpotomy with bioceramic putty repairmen as the pulp capping agents at the Third Clinical Division of Peking University School and Hospital of Stomatology, from September 2016 to September 2017. The children who were followed up over one year were selected as the subjects of this study. The teeth were checked clinically and radiographically during fixed intervals, and classified into one of five outcomes: N, H, P0, PX, PY. N, absence of clinical symptoms, and absence of apical radiolucency; H, absence of clinical symptoms, and nonpathologic radiographic change present; P0, absence of clinical symptoms, and pathologic change present, no need for treatment; PX, present or absence of clinical symptoms, pathologic change present treatment or extract immediately; PY, premature loss of deciduous tooth. Molars classified into N and H were regarded as successful, classified into P0, PX and PY were regarded as failed.

RESULTS

Followed up for 12-24 months (the average follow up time was 16months), thirty four children were finally included, aged from 3.1 years to 8.5 yaers (the average age was 4.3 years), forty primary molars were included. Thirty four primary molars were included into N group, with absence of clinical symptoms, absence of apical radiolucency. Two molars were included into H group with physiological root absorption. One molar was included into P0group with absence of clinical symptoms butinternal absorption of the root. Three molars were included into PX group, with gingival fistula and apical radiolucency. None was included into PY group. Thirty six teeth got successful treatment, four molars failed. One year success rate of pulpotomy of primary molars using bioceramic putty repairment was 95%.

CONCLUSION

Current evidence suggests that bioceramic putty repairment as a pulpotomy medicament showed satisfied clinical and radiographic result in pulpotomy of primary molars. Bioceramic putty repairment is an acceptable material when used in pulpotomy of primary molars.

Outcomes of Vital Pulp Therapy Using Mineral Trioxide Aggregate or Biodentine: A Prospective Randomized Clinical Trial

INTRODUCTION

Mineral trioxide aggregate (MTA) has been used in pulp capping of cariously exposed mature permanent teeth with promising results. The search for alternative materials that seal better and set faster than MTA and do not stain is ongoing. Biodentine (Septodont, St Maur-des-Fossés, France) exhibits these advantages but has not been tested yet for a prolonged duration in mature teeth. This study aimed to evaluate the clinical performance of Biodentine and white MTA (Angelus, Londrina, Brazil) in cariously exposed mature permanent teeth.

METHODS

This was a prospective longitudinal randomized controlled study of 68 vital permanent teeth with deep caries. Patients were randomly allocated into 2 study arms: Biodentine and MTA. Teeth were assessed clinically and radiographically before the procedure. Caries were excavated under local anesthesia; hemostasis was achieved after pulp exposure using sodium hypochlorite and capped with Biodentine or MTA. Clinical and radiographic follow-ups were performed by a blinded calibrated evaluator after 6 months and 1, 2, and 3 years.

RESULTS

There were no significant differences in the overall success rate between Biodentine and MTA; it was 93.3% (Biodentine = 93.1% and MTA = 93.5%) at 6 months. The overall success rate increased to 96.2% (Biodentine = 96.0% and MTA = 100%) at 1 year and to 100% at 2 years. At the 3-year follow-up, it decreased to 93.8% (Biodentine = 91.7% and MTA = 96.0%).

CONCLUSIONS

Biodentine and MTA have favorable and comparable success rates when used as direct pulp capping or pulpotomy material in permanent mature teeth with carious exposure. The remaining tooth structure and durability of coronal restoration might affect significantly the long-term success of vital pulp therapy.

Application of a direct pulp capping cement containing S-PRG filler

OBJECTIVES

To evaluate new pulp capping cements containing surface pre-reacted glass ionomer (S-PRG) filler and to investigate ion release kinetics and pH shift of eluates from the cement.

MATERIALS AND METHODS

Molars of Wistar rats were directly pulp capped using three kinds of cement containing S-PRG filler and mineral tri-oxide aggregate (MTA) was used as a control. After 1, 2, or 4 weeks, histological evaluation was performed and differences of tertiary dentin formation were analyzed. Release of Sr²⁺, BO₃^3-, SiO₃^2-, Na⁺, and Al³⁺ ions was determined by inductively coupled plasma-atomic emission spectrometry, and F^- ion release was measured using a fluoride ion selective electrode. The pH of the eluate from each cement after mixing was measured with a pH electrode.

RESULTS

One of S-PRG cements promoted tertiary dentin formation to the same extent as the control (p > 0.05) and it showed a tendency of less inflammatory response. This cement released more BO₃^3- and SiO₃^2-, but less Sr²⁺, Na⁺, and F^- than other S-PRG specimens. Each cement recovered nearly neutral compared with glass ionomer cement.

CONCLUSIONS

S-PRG cement induced tertiary dentin formation based on multiple ion releases, suggesting that it is suitable as a pulp capping material.

CLINICAL RELEVANCE

This new material can be an alternative pulp capping agent to MTA.

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.

Clinical and histological responses of human dental pulp to MTA and combined MTA/treated dentin matrix in partial pulpotomy

The aim of this study was to compare the responses of mineral trioxide aggregate (MTA) and combined MTA/treated dentin matrix (TDM) as direct pulp capping material. In this clinical trial study, 33 intact third molars in 11 healthy volunteers (three molars in each) were included. Partial pulpotomies were performed in a split mouth manner in two of the third molars in each patient randomly and the third tooth had used as TDM source. The coronal dentin was chopped to dentine chips and transformed to TDM using different concentrations of ethylene diamine tetraacetic acid (EDTA) solution. Pulps were directly capped by MTA alone or using a combination layering of MTA/TDM. Following 6-week clinical and radiological evaluations, each tooth was extracted and prepared for histological evaluation. There were no significant differences in the clinical and radiographic responses or in the quality of dentin bridges (P > 0.05). However, the dentin bridge was significantly thicker in MTA/TDM group than MTA group (P = 0.003). Using the combination of MTA/TDM as a pulp-dressing agent may form a thicker dentin bridge compared to MTA alone.

Effect of Dexamethasone Intraligamentary Injection on Post-Endodontic Pain in Patients with Symptomatic Irreversible Pulpitis: A Randomized Controlled Clinical Trial

Introduction:

The aim of this randomized-controlled clinical trial was to assess the effect of intraligamentary (PDL) injection of dexamethasone on onset and severity of post-treatment pain in patients with symptomatic irreversible pulpitis.

Methods and Materials:

A total number of 60 volunteers were included according to the inclusion criteria and were assigned to three groups (n=20). After administration of local anesthesia and before treatment, group 1 (control) PDL injection was done with syringe containing empty cartridge, while in groups 2 and 3 the PDL injection was done with 0.2 mL of 2% lidocaine or dexamethasone (8 mg/2 mL), respectively. Immediately after endodontic treatment patients were requested to mark their level of pain on a visual analogue scale (VAS) during the next 48 h (on 6, 12, 24 and 48-h intervals). They were also asked to mention whether analgesics were taken and its dosage. Considering the 0-170 markings on the VAS ruler, the level of pain was scored as follows: score 0 (mild pain; 0-56), score 1 (moderate pain; 57-113) and score 3 (severe pain; 114-170). The data were analyzed using the Kruskal-Wallis and the Chi-square tests and the level of significance was set at 0.05.

Results:

After 6 and 12 h, group 1 and group 3 had the highest and lowest pain values, respectively (P<0.01 and P<0.001 for 6 and 12 h, respectively). However, after 24 and 48 h the difference in the pain was not significant between groups 1 and 2 (P<0.6) but group 3 had lower pain levels (P<0.01 and P<0.8 for 24 and 48 h, respectively).

Conclusion:

Pretreatment PDL injection of dexamethasone can significantly reduce the post-treatment endodontic pain in patients with symptomatic irreversible pulpitis.

The Effect of Canal Dryness on Bond Strength of Bioceramic and Epoxy-resin Sealers after Irrigation with Sodium Hypochlorite or Chlorhexidine

Introduction:

The aim of this in vitro study was to evaluate the effect of canal dryness on the push-out bond strength of two resin sealers (AH-Plus and Adseal) and a bioceramic sealer (Endosequence BC sealer) after canal irrigation with sodium hypochlorite (NaOCl) and chlorhexidine (CHX).

Methods and Materials:

A total of 18 extracted human premolars were used. Canals were prepared and were divided to two groups based on irrigation solution (either NaOCl or CHX). The samples were again divided based on pre-obturation canal condition (wet, half-wet and dry). The samples were sub-divided into 3 groups based on the sealer type; the teeth were obturated with gutta-percha and test sealers (Adseal, AH-Plus or BC sealer). A total number of 18 groups were available to be cut into dentine disks (12 disks in each group). The type of bond failure was also assessed in each group. Data were analyzed using the 3-way ANOVA, post hoc Tukey’s tests, t-test and the Fisher’s exact test. The level of significance was set at 0.05.

Results:

The bond strength of Adseal was not affected by the canal condition or irrigation with either NaOCl or CHX. Although the bond strength of AH-Plus was not affected by the irrigant type, the highest bond strength was seen in dry canals. For Endosequence BC sealer, the canal conditions did not affect the bond strength; however, CHX reduced the bond strength.

Conclusion:

Bond strength of resin sealers was not affected by irrigation solution; however, canal moisture negatively affected the bond strength of AH-Plus. CHX reduced the bond strength of BC sealer.