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

Tissue engineering approaches for dental pulp regeneration: The development of novel bioactive materials using pharmacological epigenetic inhibitors

The drive for minimally invasive endodontic treatment strategies has shifted focus from technically complex and destructive root canal treatments towards more conservative vital pulp treatment. However, novel approaches to maintaining dental pulp vitality after disease or trauma will require the development of innovative, biologically-driven regenerative medicine strategies. For example, cell-homing and cell-based therapies have recently been developed in vitro and trialled in preclinical models to study dental pulp regeneration. These approaches utilise natural and synthetic scaffolds that can deliver a range of bioactive pharmacological epigenetic modulators (HDACis, DNMTis, and ncRNAs), which are cost-effective and easily applied to stimulate pulp tissue regrowth. Unfortunately, many biological factors hinder the clinical development of regenerative therapies, including a lack of blood supply and poor infection control in the necrotic root canal system. Additional challenges include a need for clinically relevant models and manufacturing challenges such as scalability, cost concerns, and regulatory issues. This review will describe the current state of bioactive-biomaterial/scaffold-based engineering strategies to stimulate dentine-pulp regeneration, explicitly focusing on epigenetic modulators and therapeutic pharmacological inhibition. It will highlight the components of dental pulp regenerative approaches, describe their current limitations, and offer suggestions for the effective translation of novel epigenetic-laden bioactive materials for innovative therapeutics.

Elective full pulpotomy in mature permanent teeth diagnosed with symptomatic irreversible pulpitis: a two years retrospective study

AIM

To investigate the outcome of elective full pulpotomy, using calcium silicate-based cements (CSBC), after 2 years, in symptomatic mature permanent teeth with carious lesions, diagnosed as irreversible pulpitis, and analyse the capacity of Wolters et al. (2017) classification to predict the likelihood of treatment failure.

METHODS

The treatment records of 56 patients with symptomatic mature teeth with carious lesions, diagnosed as irreversible pulpitis and treated by elective full pulpotomy, using CSBCs as pulp capping materials, were reviewed. Thirteen teeth were excluded. The remaining 43 teeth were evaluated retrospectively at 24 months. Fisher`s exact test with the Lancaster's mid-P adjustment was used to assess different outcomes amongst the diagnostic categories.

RESULTS

Four of the cases failed before 24 months and required root canal treatment (RCT). Overall success rate at 2 years was 90.7% (39 of 43). An inverse, but non-significant, correlation was observed between the severity of pulpitis according to the Wolters classification and the treatment success rate (p > 0.05). The type of CSBC used was associated to the success rate (OR = 10.5; 95% C.I. = 0.5 - 207.4; p = 0.027), being 82% with Endosequence and 100% with Biodentine. Postoperative pain associated significantly to lower success rate (66.7%) (Odds ratio = 8.0; 95% C.I. = 0.7 - 95.9; p = 0.047).

CONCLUSIONS

Elective full pulpotomy using a CSBC was a successful choice for the treatment of mature permanent teeth with symptoms indicative of irreversible pulpitis. There were no significant differences between the success rate of mild, moderate and severe pulpitis. Postoperative pain could be considered a risk marker for failure of full pulpotomy. The term "irreversible pulpitis" should be re-signified to indicate the need for access to the pulp chamber, rather than an indication for extraction or RCT.

Exploring vital pulp Therapies: A bibliometric analysis of the most cited articles

Aim

The aim of this study was to identify and analyze the most cited articles on vital pulp therapies.

Methodology

Bibliographical data related to the abstract, citations, keywords, and other relevant information was extracted using different combinations of keywords. Further evaluation and visualization of the selected data were performed with the help of various tools, including MS Excel, Microsoft Word, Google open refine, BibExcel, and VOS viewer. An initial search revealed 91 documents, of which 40 were chosen for further analysis. We used the Kolmogorov-Smirnov test and Spearman correlation coefficient test, and our adopted significance level was p < 0.05.

Results

In total, the articles received 1,905 citations, with six of them receiving at least 100 citations. Among the top 40 articles, the United States of America (10 articles) and Ireland (6 articles) were the countries with the highest number of cited articles. The journals "Journal of Endodontics" (14 articles; 650 citations) and "International Endodontic Journal" (13 articles; 577 citations) published most of the articles among the 50 most cited ones. Duncan H. was the author with the highest number of works cited (11 articles; 339 citations). Of the articles, systematic reviews accounted for 32%, literature reviews for 14%, in vitro experimental studies for 12%, clinical trials for 8%. Among the biomaterials used in vital pulp therapies, mineral trioxide aggregate (MTA) was discussed in 37 articles (74%), followed by calcium hydroxide, mentioned in 30 studies (60%). Interestingly, the publication year did not demonstrate a significant impact on citation count.

Conclusion

The present study provided a detailed list of the top 50 most cited and classic articles on vital pulp therapies. This will help researchers, students, and clinicians in the field of endodontics with an impressive source of information.

4-Year Pulp Survival in a Randomized Trial on Direct Pulp Capping

INTRODUCTION

This study aimed to assess pulp survival in a randomized trial on pulp lavage in adult nonpainful posterior teeth with carious pulp exposure. The treatment included complete caries excavation, direct pulp capping with mineral trioxide aggregate, and immediate restoration with composite resin.

METHODS

Fluid was collected from the pulp wound to assess matrix metalloproteinase-9 (MMP-9) and total protein values. Before pulp capping, cavities were randomly (block randomization, n = 48) washed with a physiological saline or a sodium hypochlorite solution (2.5% NaOCl). Treatment outcome was assessed clinically (cold test) and radiographically after at least 1 year and again after at least 3 years. Painful failures were differentiated from nonpainful failures. Pulp survival was estimated using the Kaplan-Meier method including 95% confidence intervals (CIs) up to 1500 days.

RESULTS

From the 96 patients originally enrolled, 73 individuals could be followed continuously. The clinical observations indicated a beneficial and sustained effect of pulp lavage with 2.5% NaOCl over a control treatment with physiological saline solution on estimated pulp survival 1500 days postintervention, with 7% (95% CI, 1%-40%) in the saline group versus 55% (95% CI, 30%-100%) in the NaOCl group. High MMP-9/total protein values in pulpal fluid collected from the exposed site indicated early and painful treatment failures yet were not associated with failures that occurred more than 250 days after intervention.

CONCLUSIONS

The low 4-year success rates reported here challenge the concept of direct pulp capping in the cases that were included. NaOCl lavage did not only increase the survival of affected pulps substantially but also particularly diminished painful failures (33% in the NaOCl group vs 62% in the saline group). The lack of the predictive value of MMP-9 assessments beyond early treatment failures points to inflammatory states of the pulp tissue under deep caries, which are not related to neutrophil infiltration.

Evaluation of the reasons for preferring root canal treatment in mature permanent teeth potentially indicated for pulp preservation: a clinical case/photo-based questionnaire study

BACKGROUND

With advances in pulp preservation procedures (PPP), indications for PPP extend to exposed pulp with symptoms in teeth with carious lesions. Scenario/text-based questionnaire studies report a high preference for PPP for exposed pulp with no pulpal symptoms. However, negative perceptions towards PPP for exposed pulp in carious teeth are prevalent among dentists. Identifying the differences in PPP preference rates in questionnaire studies and actual clinical situations is necessary to determine the current status of PPP. In this study, a clinical case/photo-based design was devised to overcome the limitations of scenario/text-based questionnaires. This study aimed to evaluate the reasons dentists prefer root canal treatment (RCT) in cases where PPP is potentially indicated.

METHODS

A questionnaire containing three cases of PPP with successful results was administered to dentists. The cases were selected to elicit comprehensive responses from the dentists. Clinical photos of the pulp exposure sites were presented to dentists without describing the tooth conditions, including the extent of pulp exposure and tooth decay, pulpal surface conditions, or restorability. The questions were focused on the reasons for selecting RCT in cases where was practiced. Questionnaire data were collected using Google e-forms. Chi-squared and Fisher's exact test (P < 0.05) were used for statistical analyses.

RESULTS

Pulpal diagnosis was not a dominant factor in treatment decision-making for pulp exposure during caries removal. Reasons for selecting RCT where PPP was potentially indicated included the event of pulp exposure itself and the dentists' desire to prevent post-PPP symptoms. Apart from symptomatic pulp, the tooth conditions influenced the establishment of pulpal diagnosis and selection of treatment modality. Moreover, the tooth condition and dentists' desire for good patient prognosis influenced the negative perceptions towards PPP.

CONCLUSIONS

Unfavourable tooth conditions, in association with a desire for preventing post-PPP symptoms, prevent dentists from attempting PPP for pulp exposed during caries removal with no/slight symptoms. Improving negative perceptions towards PPP through accumulation of data on the high success rates of PPP is a prerequisite for achieving widespread application of PPP.

Evaluation of treatment and restoration preferences in deep carious teeth with various pulp exposure sizes: A questionnaire-based survey

This study evaluated the management preferences in a deep carious vital tooth. A questionnaire was e-mailed to members of the Turkish Dental Association. The questionnaire included a photograph and radiographs of an extremely deep carious molar (#16) of a 30-year-old man suffering from cold and chewing sensitivity. The dentists were asked to choose treatments for pulp exposure of <1, 1-2, and ≥2 mm and a permanent restoration. Chi-squared test was used to analyse data (p < 0.05). 504 (4.84%) of 10 411 dentists responded. When the pulp exposure was <1 mm: direct pulp capping (84.9%); 1-2 mm: root canal treatment (49.6%); ≥2 mm: root canal treatment (85.7%) were the most preferred treatments. 69.6% of the respondents chose direct composite restorations. If the tooth would be an abutment, most respondents preferred root canal treatment, regardless of the perforation size. The extent of pulp exposure and the type of permanent restoration influenced the treatment decision-making process.

Assessment of Decision-Making and Material Selection for Vital Pulp Therapy in Deep Carious Lesions: A Study at the Faculty of Dentistry, King Abdulaziz University

PURPOSE

The purposes of this study were to assess decision-making, material selection, and management of deep carious lesions in permanent teeth requiring vital pulp therapy (VPT); investigate the intradepartmental and interdepartmental consensus in the management of those cases; and correlate this study's results to the current scientific literature, clinical experience, and postgraduate training among staff and postgraduate students at the Faculty of Dentistry, King Abdulaziz University.

MATERIALS AND METHODS

The survey included faculty from pedodontics, endodontics, and restorative/operative dentistry; postgraduate students; and interns, excluding specific categories such as retired faculty, external trainers, non-faculty hospital specialists, general practitioners, students, interns outside the institution, and other departments. An anonymous electronic questionnaire was developed and validated. Ethical approval was obtained, and the questionnaire was distributed to all 148 English-proficient members of the targeted population via email and WhatsApp, accompanied by a cover letter. The questionnaire encompassed demographic, education, experience, assessment, decision-making, and management sections. Data were collected and analyzed using Microsoft Excel, with results presented using categorical variables, Pareto charts, and statistical tests.

RESULTS

There were 86 responses, representing 58% of the target population, with the key findings including the prominence of "Pre-operative vitality test result" as the most important factor in assessing deep carious lesions, with no significant differences among specialties. The (one-step and one-visit) management approach was preferred by 50% of participants, with no significant specialty differences. For deep carious lesions without pulpal exposure, glass ionomer (GI)/resin-modified glass ionomer (RMGI) base was the top choice, with no variation among all specialties. In cases with pulpal exposure, the one-visit approach (direct pulp capping (DPC), base, and restoration) was the most favored, with no specialty differences. Material availability significantly influenced decision-making, with no specialty variations.

CONCLUSION

The study highlights the crucial role of pre-operative vitality tests in assessing deep carious lesions for VPT or root canal treatment (RCT). Participants generally favored VPT for cases with normal pulp vitality, with some departmental variation. Controlling bleeding post-pulpal exposure was a central concern. Mineral trioxide aggregate (MTA) was the most commonly used VPT material, followed by Ca(OH)2 and Biodentine. Factors such as treatment access, patient compliance, remaining dentin thickness, and oral hygiene had minimal impact on treatment choice. Limited availability of VPT materials was the primary reason for non-use. The survey's acceptable response rate raises concerns about potential non-response bias, though limitations include a lack of data on non-responders. Nevertheless, the survey's strength lies in its comprehensive coverage of key clinical aspects, engaging professionals from diverse specialties and educational levels who are collectively interested in addressing deep caries cases.

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.

Determinants of Clinical Decision Making under Uncertainty in Dentistry: A Scoping Review

Clinical decision-making for diagnosing and treating oral and dental diseases consolidates multiple sources of complex information, yet individual clinical judgements are often made intuitively on limited heuristics to simplify decision making, which may lead to errors harmful to patients. This study aimed at systematically evaluating dental practitioners’ clinical decision-making processes during diagnosis and treatment planning under uncertainty. A scoping review was chosen as the optimal study design due to the heterogeneity and complexity of the topic. Key terms and a search strategy were defined, and the articles published in the repository of the National Library of Medicine (MEDLINE/PubMed) were searched, selected, and analysed in accordance with PRISMA-ScR guidelines. Of the 478 studies returned, 64 relevant articles were included in the qualitative synthesis. Studies that were included were based in 27 countries, with the majority from the UK and USA. Articles were dated from 1991 to 2022, with all being observational studies except four, which were experimental studies. Six major recurring themes were identified: clinical factors, clinical experience, patient preferences and perceptions, heuristics and biases, artificial intelligence and informatics, and existing guidelines. These results suggest that inconsistency in treatment recommendations is a real possibility and despite great advancements in dental science, evidence-based practice is but one of a multitude of complex determinants driving clinical decision making in dentistry. In conclusion, clinical decisions, particularly those made individually by a dental practitioner, are potentially prone to sub-optimal treatment and poorer patient outcomes.

Factors that influence the outcome of pulpotomy in permanent teeth

The promotion of minimally invasive treatments focussed on the maintenance of pulp vitality has become a priority area in Endodontics. These vital pulp treatments (VPT) include partial and full pulpotomy, during which diseased coronal pulp tissue is removed prior to placement of a capping biomaterial and restoration. Traditionally, pulpotomies were confined to the treatment of carious primary and traumatized permanent teeth. However, these treatments have now been proposed as definitive solutions for cariously exposed permanent teeth with mild symptoms or even symptoms indicative of irreversible disease. Until recently, it was recommended that carious exposure of mature permanent teeth be managed by root canal treatment. The promotion of pulpotomy as an alternative treatment has opened up a wave of laboratory and clinical research aimed at improving therapies or evaluating clinical outcomes. In modern evidence-based endodontics, it is imperative that the outcomes of both partial and full pulpotomy are considered and important prognostic factors identified, so that improvements can be made to aid clinical decision-making and to direct new research. In this narrative review, the outcomes of partial and full pulpotomy are discussed, before analysis of patient, intraoperative and postoperative factors that influence the outcome of the pulpotomy procedure. The review highlights that although partial and full pulpotomy for the treatment of even pulpal disease are highly successful procedures, this is based on low-quality evidence with a lack of prospective, comparative trials investigating potential prognostic factors. Based on current evidence, it appears that age, gender, tooth type, root development and intraoperative pulpal haemorrhage do not impact significantly on pulpotomy outcome, whilst others such as caries depth, inflammatory status of the pulp, capping material, level of inflammatory pulpal-biomarkers and the final restoration integrity do. Other factors, including the influence of exposure type, periodontal condition, pulpal lavage, magnification, operator experience, isolation of the operating field and type of pulpotomy, require further experimental investigation before definitive conclusions can be made relating to the success of the pulpotomy procedure. Finally, there is not only a need for future well-designed prospective research addressing these issues but also a widening of our understanding of outcome to include patient-reported as well as clinician-reported outcomes.

Comparative evaluation of the effects of three hydraulic calcium silicate cements on odontoblastic differentiation of human dental pulp stem cells: an in vitro study

OBJECTIVE

The study aimed to compare the response of human dental pulp stem cells (hDPSCs) towards three hydraulic calcium silicate cements (HCSCs) by measuring cytotoxicity and expression of dentinogenic genes.

METHODOLOGY

Dental pulps of five impacted mandibular third molars were extirpated as a source for hDPSCs. Next to culturing, hDPSCs were subjected to fluorescence-activated cell sorting after the third passage to validate stemness of the cells. Human DPSCs were exposed to diluted supernatants of OrthoMTA (OMTA), Biodentine (BD) and Calcium-Enriched Mixture (CEM) at concentrations 10, 25, 50 and 100% at the first, third and fifth day of culture. Then, cells were exposed to 10% concentrations supernatant of HCSCs to determine DSPP and DMP1 gene expression, using a quantitative polymerase-chain reaction. Data were analyzed using one-way and three-way ANOVA, followed by Tukey post hoc statistical tests.

RESULTS

Optimal cell proliferation was observed in all groups, regardless of concentration and time-point. HCSC supernatants were non-cytotoxic to hDPSCs at all three time-points, except for 100% Biodentine on day five. On day seven, OMTA group significantly upregulated the expression of DSPP and DMP1 genes. On day 14, expression of DMP1 and DSPP genes were significantly higher in BD and OMTA groups, respectively.

CONCLUSION

Biodentine significantly upregulated DMP1 gene expression over 14 days, whereas CEM was associated with only minimal expression of DSPP and DMP1 .

Cytocompatibility and bioactive potential of AH Plus Bioceramic Sealer: an in vitro study

Aim

To assess the cytocompatibility and bioactive potential of the new calcium silicate cement‐based sealer AH Plus Bioceramic Sealer (AHPbcs) on human periodontal ligament stem cells (hPDLSCs) compared with the epoxy resin‐based sealer AH Plus (AHP) and the calcium silicate cement‐based sealer Endosequence BC Sealer (ESbcs).

Methodology

Standardized sample discs and 1:1, 1:2 and 1:4 eluates of the tested materials were prepared. The following assays were performed: surface element distribution via SEM–EDX, cell attachment and morphology via SEM, cell viability via a MTT assay, cell migration/proliferation via a wound‐healing assay, osteo/cemento/odontogenic marker expression via RT‐qPCR and cell mineralized nodule formation via Alizarin Red S staining. HPDLSCs were isolated from extracted third molars. Comparisons were made with hPDLSCs cultured in unconditioned (negative control) or osteogenic (positive control) culture media. Statistical significance was established at p < .05.

Results

A higher peak of Ca²+ was detected from ESbcs compared with AHPbcs and AHP in SEM–EDX. Both AHPbcs and ESbcs showed significantly positive results in the cytocompatibility assays (cell viability, migration/proliferation, attachment and morphology) compared with a negative control group, whilst AHP showed significant negative results. Both AHPbcs and ESbcs exhibited an upregulation of at least one osteo/odonto/cementogenic marker compared with the negative and positive control groups. Both ESbcs and AHPbcs showed a significantly higher calcified nodule formation than the negative and positive control groups, indicative of their biomineralization potential and were also significantly higher than AHP group.

Conclusion

AH Plus Bioceramic Sealer exhibited a significantly higher cytocompatibility and bioactive potential than AH Plus and a similar cytocompatibility to that of Endosequence BC Sealer. Endosequence BC Sealer exhibited a significantly higher mineralization potential than the other tested sealers. The results from this in vitro study act as supporting evidence for the use of AH Plus Bioceramic Sealer in root canal treatment.

Preclinical 3D-printed laboratory simulation of deep caries and the exposed pulp reduced student anxiety and stress, while increasing confidence and knowledge in vital pulp treatment

Aim

To evaluate the impact of a preclinical laboratory session using 3D printed teeth on dental student stress, anxiety, confidence and knowledge when treating deep caries and pulp exposure.

Methodology

This was a two‐centre controlled study, with randomized distribution of students into two groups: a vital pulp treatment (VPT) lecture‐only (control) group and a VPT‐lecture combined with a VPT‐laboratory (experimental) group. In both universities, preclinical students with endodontic or operative dentistry laboratory sessions could participate. All students were invited to the lecture. Two weeks later (timepoint‐T1), both groups completed validated and bespoke questionnaires and scales to evaluate their stress (Stress‐VAS), anxiety (STAI Trait [T] and State [S]), self‐confidence and knowledge. Thereafter, only the experimental group attended the hands‐on laboratory session demonstrating the techniques of selective caries removal and partial pulpotomy on a commercial 3D‐printed tooth. Two weeks later (timepoint‐T2), the participants from both groups repopulated the same questionnaires and VAS. The control group had the laboratory session after the completion of the study. The statistical analysis was performed with Statistica® (significance p = .05). The homogeneity between the two samples was checked by Khi² and Student tests. Stress‐VAS, STAI‐S, confidence and knowledge scores were compared within each group, and between the two groups, at T1 and T2, with a repeated measures anova test (+/−Tukey post‐hoc test).

Results

The groups comprised 54 students each, with no statistical difference between the groups regarding demographic, academic data and STAI‐T score. The two groups had no significant difference of Stress‐VAS, STAI‐S, confidence and knowledge scores at T1 while they presented a significant difference in stress, anxiety and confidence scores at T2, but with no significant difference in knowledge score. However, knowledge score, as other parameters, improved significantly between T1 and T2 in the experimental group.

Conclusions

The addition of a laboratory session using 3D‐printed teeth that simulated deep caries and pulp exposure management, significantly reduced the stress and anxiety of students and increased their confidence. Within the limitations of this study, the benefit of introducing new technology in increasing student confidence and reducing stress offers opportunity for educational improvement in the VPT and cariology areas.

MMP-9 Levels and NaOCl Lavage in Randomized Trial on Direct Pulp Capping

Outcome expectations of direct pulp capping in carious teeth are obscured by a clinically unknown infiltration and breakdown of the dental pulp tissue. Histologic studies showed that this soft tissue breakdown is related to the innate immune system. We hypothesized 1) that a neutrophil biomarker could predict the outcome of direct pulp capping and 2) that using sodium hypochlorite (NaOCl) as a lavage solution to remove necrotized infected pulp tissue could improve it. In this randomized trial in mature posterior teeth causing no or mild discomfort with carious pulpal exposures, pulpal fluid was collected to assess neutrophil gelatinase (matrix metalloproteinase 9 [MMP-9]) per total protein (TP) levels as a predictive local biomarker. Subsequently, the dentin-pulp wound was randomly washed with a 2.5% NaOCl or a physiologic saline solution (1:1 allocation), capped with mineral trioxide aggregate, and the tooth was immediately restored with a resin-based composite restoration. Ninety-six patients were included, and 84 individuals could be followed up to treatment failure or clinically confirmed pulp survival after a minimum of 1 y. The entire data were fitted to a Cox proportional hazards model to assess the influence of the observational variables MMP-9/TP and discomfort with the randomized lavage treatment on pulp survival. The Kaplan-Meier pulp survival rates after 1 y were 55% for saline and 89% for NaOCl lavage. The inflammatory state of the pulp tissue as reflected by MMP-9/TP levels and NaOCl lavage had a highly significant (P < 0.001 and P = 0.004, respectively) impact on pulp survival, while mild preoperative discomfort did not. In conclusion, MMP-9/TP showed great promise as a predictive local biomarker, and NaOCl lavage considerably improved the survival time of cariously exposed and directly capped pulps.

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.

How is carious pulp exposure and symptomatic irreversible pulpitis managed in UK primary dental care?

AIM

To investigate attitudes and approaches of UK primary care dentists to carrying out vital pulp treatment (VPT) after carious exposure and with additional signs and symptoms indicative of irreversible pulpitis.

METHODOLOGY

An electronic questionnaire was openly distributed via publicly funded (NHS) local dental committees, corporate dental service-providers, professional societies and social media. Principally NHS practitioners and those from mixed and private practice were targeted, in addition to community and military dental officers, and dental therapists. Participants were asked questions relating to several clinical scenarios, with responses analysed using descriptive statistics. χ² tests with sequential Bonferroni correction were used to explore variables including the method of remuneration, practitioner type (dentist/therapist), postgraduate qualification(s), place of graduation and years since qualification. Variables with a relationship p ≤ .2 were selected for backwards likelihood ratio logistic modelling.

RESULTS

In total, 648 primary care practitioners were included for analysis. Calcium hydroxide (CH) was most frequently used for direct pulp caps (DPCs) (398/600; 66.3%) with calcium silicate cements (CSCs) less frequently used (119/600; 19.8%). Rubber dam was used by 222/599 (37.1%) practitioners. A definitive pulpotomy for the management of teeth with signs and symptoms indicative of irreversible pulpitis was selected by 65/613 (10.6%) dentists. The principal barrier for the provision of definitive pulpotomies was a lack of training (602/612; 98.4%). Regression analysis identified NHS practitioners as a good predictor for using CH for DPCs, having shorter emergency appointments, limited access to magnification and not using rubber dam. Non-UK graduates were more likely to select CSCs, appropriately control pulpal haemorrhage, undertake appropriate postoperative evaluation and use rubber dam.

CONCLUSIONS

Practitioners deviated from evidence-based guidelines in a number of aspects including material selection, asepsis and case selection. A number of other challenges exist in primary care in providing predictable VPTs, including lack of time and access to magnification. These were most evident in NHS practice, potentially exacerbating existing social health inequalities. Possible inconsistencies in the UK undergraduate curriculum were supported by a lack of association between years since qualification and technique employed as well as the fact that non-UK graduates and dentists with postgraduate qualifications adhered more to evidence-based VPT guidelines.

Comparative Biological Properties and Mineralization Potential of 3 Endodontic Materials for Vital Pulp Therapy: Theracal PT, Theracal LC, and Biodentine on Human Dental Pulp Stem Cells

INTRODUCTION

The aim of this study was to assess the biological properties and mineralization potential of the new Theracal PT (Bisco Inc, Schaumburg, IL) compared with its predecessor Theracal LC (Bisco Inc) and the hydraulic silicate-based cement Biodentine (Septodont, Saint-Maur-des-Fossés, France) on human dental pulp stem cells (hDPSCs) in vitro.

METHODS

Standardized sample discs were obtained for each material (n = 30) together with 1:1, 1:2, and 1:4 material eluates. Previously characterized hDPSCs were cultured with the different materials in standardized conditions, and the following assays were performed: a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, a wound healing assay, Annexin-V-FITC and 7-AAD staining (BD Biosciences, San Jose, CA), reactive oxygen species production analysis, cell adhesion and morphology evaluation via scanning electron microscopy and immunofluorescence, quantification of the expression of osteo/odontogenic markers via real-time quantitative reverse-transcriptase polymerase chain reaction, and alizarin red S staining. Statistical significance was established at P < .05.

RESULTS

All of the tested dilutions of Theracal LC exhibited a significantly higher cytotoxicity and reactive oxygen species production (P < .001) and a lower cell migration rate than the control group (hDPSCs cultured in growth medium without material extracts) at all of the measured time points (P < .001). Both 1:4 Theracal PT and Biodentine-treated hDPSCs exhibited similar levels of cytocompatibility to that of the control group, a significant up-regulation of at least 1 odontogenic marker (Biodentine: dentin sialophosphoprotein (P < .05); Theracal PT: osteonectin and runt-related transcription factor 2 [P < .001]), and a significantly higher mineralized nodule formation (P < .001).

CONCLUSIONS

The newly introduced TheraCal PT offers an improved in vitro cytocompatibility and mineralization potential on hDPSCs compared with its predecessor, TheraCal LC, and comparable biological properties to Biodentine.

Reducing Intervention in the COVID-19 Era: Opportunities for Vital Pulp Treatment

Over the last 12 months, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) virus has emerged as a significant global health problem with extensive repercussions for the practise of dentistry. As the principle transmission-route is via droplet-spread, aerosol-generating dental procedures (AGPs) present an exquisite challenge, which either has to be avoided or performed using strict infection-control measures, which increase the deployment of resources and cost. This new working environment necessitates the adoption of simplified, yet effective procedures that reduce intervention and minimise clinical chair time to short, single visits. Vital pulp treatment (VPT) has emerged as an attractive, technically less-complicated group of biologically-based management strategies that are aimed at maintaining pulp vitality and avoiding root canal treatment (RCT). These procedures are carried out in a strict aseptic environment using a rubber dam and have a reported high success rate, suggesting that they could be considered as effective and simple alternative therapies to relieve pain and avoid multiple visit RCT and other endodontic procedures. The relevance of promoting a simple, predictable and effective alternative to traditional, more complex dentistry has never been more compelling. In this perspective article, the latest advances in VPT are highlighted, along with an analysis of their relative success and compelling reasons why we as dentists should be adopting these treatment approaches. Thereafter, case selection, prognostic factors, techniques, limitations and future prospects of these procedures are discussed.

Deciphering Reparative Processes in the Inflamed Dental Pulp

Research over several decades has increased our understanding of the nature of reparative and regenerative processes in the dental pulp, at both the cellular and molecular level. However, advances in scientific knowledge have not translated into novel clinical treatment strategies for caries-induced pulpitis. This narrative review explores the evidence regarding the ability of inflamed pulp tissue to heal and how this knowledge may be used therapeutically. A literature search and evidence analysis covering basic, translational and clinical pulp biology research was performed. The review focuses on (1) the regenerative and defense capabilities of the pulp during caries-induced inflammation; (2) the potential of novel biomaterials to harness the reparative and regenerative functions of the inflamed pulp; and (3) future perspectives and opportunities for conservative management of the inflamed pulp. Current conservative management strategies for pulpitis are limited by a combination of unreliable diagnostic tools and an outdated understanding of pulpal pathophysiological responses. This approach leads to the often unnecessary removal of the entire pulp. Consequently, there is a need for better diagnostic approaches and a focus on minimally-invasive treatments utilizing biologically-based regenerative materials and technologies.