A randomized trial of direct pulp capping in primary molars using MTA compared to 3Mixtatin: a novel pulp capping biomaterial

3Mixtatin versus MTA in pulp therapy of primary teeth: a systematic review and meta-analysis of current randomized controlled trials

AIM

3Mixtatin (a combination of Metronidazole, Minocycline, and Ciprofloxacin along with statins) is a novel biomaterial in pulp therapy, while Mineral Trioxide Aggregate (MTA) is considered the gold standard in endodontics. This study aimed to compare the clinical and radiographic success rates of MTA and 3Mixtatin in pulp therapy of primary teeth.

METHODS AND MATERIALS

MEDLINE (PubMed), CENTRAL, Web of Science, Scopus, ProQuest databases, and Google Scholar were searched to identify randomized controlled trials (RCTs) on pulp therapy with 3Mixtatin and MTA in primary teeth, published up to February 2023. It should be noted that the protocol was previously registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021243626). RCTs were assessed independently by two researchers in terms of eligibility and quality. Data extracted and tabulated. The Cochrane Risk of Bias (RoB-2) tool was used to assess the risk of bias. The effect sizes were evaluated utilizing risk ratios (RRs). The heterogeneity investigation was conducted utilizing I² measurement at α = 0.10.

RESULTS

Out of 86 retrieval records, four articles met the inclusion criteria. Based on clinical and radiographic outcomes, the application of 3Mixtatin in the pulp therapy of primary teeth was as successful as MTA in 12 months (Clinical RR = 1.087 | Radiographic RR = 2.132). The RoB-2 tool showed a low risk of bias in all included RCTs.

CONCLUSION

The limited evidence showed the clinical and radiographic efficacy of 3Mixtatin as a potential alternative to MTA. Further empirical research with larger sample sizes and strict methodology will be essential to substantiate this assertion.

The viability of human dental pulp cells and apical papilla cells after treatment with conventional calcium hydroxide and nanoparticulate calcium hydroxide at various concentrations

Introduction

Nanoparticulate Ca(OH)2 had greater antibacterial effect than conventional Ca(OH)2. Conversely, a study reported that nanoparticulate Ca(OH)2 had toxicity against murine fibroblast. However, the study of nanoparticulate Ca(OH)2, involving human dental pulp cells (DPCs) and apical papilla cells (APCs) is lacking. The aim of this study is to compare the effects of conventional Ca(OH)2 and nanoparticulate Ca(OH)2 on the viability of DPCs and APCs.

Methods

Primary human DPCs/APCs from the 3rd to 5th passage were divided into control and experimental groups. In the control group, cells were cultured in complete media. In the experimental group, cells were cultured in complete media containing 10, 100, or 1000 μg/mL of either conventional Ca(OH)2 or nanoparticulate Ca(OH)2 for 1, 3, 5, and 7 days. After the treatment period, the cells were tested for viability using MTT assay.

Results

DPCs treated with conventional Ca(OH)2 in all concentrations at day 5 revealed significantly higher proliferation compared to nanoparticulate Ca(OH)2 treated groups. In additions, DPCs treated with 1000 µg/ml nanoparticulate Ca(OH)2 at day7 were significantly lower proliferation compared to DPCs treated with conventional Ca(OH)2. In contrast, APCs treated with 1000 µg/ml nanoparticulated Ca(OH)2 were significantly higher proliferation than APCs treated with 1000 µg/ml conventional Ca(OH)2 at day7.

Conclusions

Nanoparticulate Ca(OH)2 increased the viability of APCs and can be an alternative choice of intracanal medication for regenerative endodontic procedures. However, Nanoparticulate Ca(OH)2 exerted some effects on DPCs. The use of nanoparticulate Ca(OH)2 has no advantages over the conventional Ca(OH)2 for vital pulp therapy.

The effect of an antibacterial mixture and non-instrumentation endodontic treatment in primary teeth: A systematic review and meta-analyses

Studies assessing the clinical and radiographic success of LSTR in terms of the presence of pain, mobility, swelling, fistula/sinus tract, interradicular radiolucency, and root resorption have not been performed. We therefore performed a systematic review with the aim of evaluating the effectiveness of lesion sterilization and tissue repair (LSTR), using three antibacterial mixtures (3Mix), in treating primary teeth. Well-defined search strategies developed for four electronic databases, Web of Science, OVID, PubMed, and Scopus, were used in this study. Two independent reviewers selected relevant articles from 3,232 studies by screening titles and abstracts. Based on the inclusion criteria, 25 articles were selected. Eight analyses of clinical and radiographic results were conducted based on 6, 12, 18, and 24-month follow-up intervals. Data extraction and quality appraisal were performed by three independent reviewers. The composition of antibiotic mixtures used for LSTR varied substantially, with inconsistent radiographic and clinical success rates across the included studies. A quantitative grouping of the studies showed no significant differences between 3Mix and the control medicaments regarding radiographical and clinical success (p-value > 0.05). The available evidence on different LSTR using 3Mix is scarce, and the study findings were inconsistent. Therefore, additional clinical trials on 3Mix with different compositions are needed.

Comparative Evaluation of Chlorhexidine Polymer Scaffold, 3Mixtatin, and Formocresol for Vital Primary Pulp Therapy: A Randomized 6-month Clinical Study

Introduction

The study was performed to evaluate and compare the clinical and radiographic efficacy of chlorhexidine (CHX) polymer scaffold, 3Mixtatin, and formocresol for vital primary pulp therapy-a randomized clinical study.

Materials and methods

A total of 120 primary molars were included from children aged between 6 and 8 years in this randomized clinical study based on inclusion and exclusion criteria and were randomly allocated into three groups (group I-CHX polymer scaffold, group II-3Mixtatin, and group III-formocresol. Pulpotomy was performed in a vital cariously exposed primary tooth with healthy periodontium where their retention is more beneficial than extraction. Subjects were followed up at 1, 3, and 6 months for clinical and radiographic evaluations.

Results

At 6 months of follow-up, the overall success rate of pulpotomy in groups I, II, and III was 56.41, 71.05, and 60.52% in each group, respectively. Nonsignificant difference (p > 0.05) was seen during intergroup comparison.

Conclusion

However, among the three materials used in this study, 3mixtatin comparatively had better results.

How to cite this article

Goel N. Comparative Evaluation of Chlorhexidine Polymer Scaffold, 3Mixtatin, and Formocresol for Vital Primary Pulp Therapy: A Randomized 6-month Clinical Study. Int J Clin Pediatr Dent 2023;16(3):478-482.

Effect of three intracanal medicaments used in pulp regeneration on the push-out bond strength of mineral trioxide aggregate and calcium-enriched mixture: An in vitro study

Background. The bond strength of the materials used as a cervical barrier in the pulp regeneration is essential for the success of treatment. This study aimed to evaluate the effects of triple antibiotic paste (TAP), double antibiotic paste (DAP), and simvastatin as intracanal medicaments on the dislodgement resistance of mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM). Methods. A total of 160 extracted human single-rooted teeth were selected, and root canal preparation was carried out. The teeth in each group were randomly divided into four subgroups: TAP, DAP, simvastatin, and the control group (without intracanal medicament). Four weeks after placing the medicaments, it was removed by sodium hypochlorite, and MTA and CEM were placed in the coronal third of the root canals. After a week, 2-mm-thick dentin disks were prepared from the coronal third of the roots, and the push-out test was performed using a universal testing machine. The data were analyzed using two-way ANOVA and independent t-test at a significance level of 0.05. Results. Regardless of the intracanal medicament, there was no significant difference between the overall bond strength of MTA (59.3±10 MPa) and CEM (55.8±11 MPa) (P=0.6). Furthermore, there were no significant differences in bond strength between the two intracanal medicament groups and the control group (P>0.05). Conclusion. Under the limitations of the current study, DAP, simvastatin, and TAP, as intracanal medicaments, did not adversely affect the push-out bond strength of CEM and MTA.

Comparison of the Effects of TheraCal LC and Mineral Trioxide Aggregate on Direct Pulp Capping (DPC) Based on Histological Findings

Background: Direct pulp capping can conserve its vitality by placing materials that promote dentin bridge (DB) formation at the exposure site. This study aimed to determine whether TheraCal LC could produce a layer of reparative dentin. It also compared the histological differences between treatment with mineral trioxide aggregate (MTA) and TheraCal LC.

Material and methods: A sample of 20 maxillary and mandibular premolars, which had previously been indicated for extraction in orthodontic therapy, was taken from 10 patients and randomly divided into two halves, a TheraCal LC, and an MTA group. Pulpal exposure was achieved by similar class I preparations, which were restored with a resin-modified glass-ionomer and extracted after ten weeks, noting that these interventions have been performed on live teeth in the oral cavities. The newly formed dentin bridge thickness, the inflammation degree within the pulp tissue, and odontoblast function were thoroughly examined histologically and compared between the two groups using the Mann-Whitney test and an analysis software SPSS (statistical package for the social sciences, v.26, IBM, New York, N, USA), at a significance level of a=0.05.

Results: Dentin bridge composition in the TheraCal group had 80% effective tubules and 20% defective tubules, while in the MTA group, the proportions were 90% and 10%, respectively. Dentin bridge thickness in the TheraCal group was greater than 0.25 mm in 60%, and 0.1-0.25 mm in 40% of the sample compared to the MTA group, which had 70% greater than 0.25 mm, and 30% between 0.1 and 0.25 mm in dentin bridge thickness. Statistically, there was no significant difference between both groups (P=0.739).

Conclusion: Statistically insignificant differences in dentin bridge composition and thickness produced by both TheraCal and MTA materials render them similar in their effectiveness in treating pulp exposures through pulp capping.

A randomized clinical trial of hyaluronic acid gel pulpotomy in primary molars with 1 year follow-up

OBJECTIVE

This randomized clinical study aimed to evaluate the success of hyaluronic acid (HA) as a pulpotomy medicament of human primary molars and to compare it with formocresol (FC) and ferric sulphate (FS) pulpotomy treatments up to 12 months.

MATERIALS AND METHODS

The study was conducted with 130 primary molars of 44 children. The ethical approval and registration to clinical trials (No: NCT04115358) were completed. After the removal of all the coronal pulp tissue, a 0.5% HA gel, or a FC, or a 20% FS solution were applied randomly to the radicular pulp tissues of the primary molars. Then, the pulp chambers were filled with a zinc oxide eugenol cement and restored either with a composite filling material or with a stainless-steel crown. The treatment success rates of the 3 groups were followed and compared clinically and radiographically at 1st-, 3rd-, 6th- and 12th-months.

RESULTS

Primary molars treated with FC, FS and HA dressings were clinically successful 77.5%, 86.8% and 87.5% respectively after 12th-month follow-up (p > .05). Radiographic successes of FC, FS and HA groups were lower than clinical successes (57.6%, 68.8%, 57.9% respectively at the 12th-month) but the difference between the groups was not statistically significant (p > .05). Equivalence analysis assuming not more than 10% difference between the materials suggested that HA was not inferior to FC or FS.

CONCLUSIONS

Within the limitations of this study, our randomized clinical trial shows that HA is a promising pulpotomy medicament in primary molars. However, further studies are justified to further improve the HA material success.

Clinical Radiographic Evaluation of 3Mixtatin and MTA in Primary Teeth Pulpotomies: A Randomized Controlled

Introduction

The present study evaluates the efficiency of 3Mixtatin (a combination of Simvastatin and 3Mix antibiotics) in comparison with Mineral Trioxide Aggregate in primary molars pulpotomy.

Materials and methods

A total of 64 deciduous molar teeth with caries requiring pulpotomy procedure were selected and randomly divided into two treatment groups, Group I- MTA (n = 32), Group II- 3Mixtatin (n = 32). Restoration with Glass Ionomer Cement followed by stainless steel crowns was done after pulpotomy procedure. The clinical and radiographical analysis was done in the subsequent follow-up periods of 3, 6, 9, and12 months simultaneously.

Result

Both groups showed equal success rates, without any significant difference between the MTA and 3mixtatin groups clinically (success rate of 93.8%)and radiographically higher success rate was seen with 3Mixtatin (78% success rate).

Conclusion

3mixtatin showed similar clinical and better radiographical success rate to MTA. Therefore, 3mixtatin may be a potential alternate pulpotomy medicament in primary teeth.

Key messages

In the present study based on the radiographic findings, 78% success rate was seen in the teeth treated with 3Mixtatin, which was higher than the radiographic success rate of MTA (75%). Therefore, it is reasonable to assume the use of 3Mix with Simvastatin to treat pulpotomized primary molars by 3Mixtatin.

How to cite this article

Chak RK, Singh RK, Mutyala J, et al. Clinical Radiographic Evaluation of 3Mixtatin and MTA in Primary Teeth Pulpotomies: A Randomized Controlled Trial. Int J Clin Pediatr Dent 2022;15(S-1):S80-S86.

Synthesis, characterization, and evaluation of curcumin-loaded endodontic reparative material

Curcumin (CUR) is an ancient therapeutic agent with remarkable antimicrobial and anti-inflammatory properties. The purpose of the current study was to synthesize and evaluate a curcumin-based reparative endodontic material to reduce infection and inflammation besides the induction of mineralization during the healing of the dentin-pulp complex. Poly-ɛ-caprolactone (PCL)/gelatin (Gel)/CUR scaffold was synthesized and assessed by scanning electron microscopy, Fourier transform infrared spectroscopy, and thermo-gravimetric analysis (TGA). Agar diffusion test was performed against E. coli, A. baumannii, P. aeruginosa, S. aureus, E. faecalis, and S. mutans. Moreover, proliferative, antioxidative, anti-inflammatory, and calcification properties of these scaffolds on human dental pulp stem cells (hDPSCs) were evaluated. The results showed that PCL/Gel/CUR scaffold had antibacterial effects. Also, these CUR-based scaffolds had significant inhibitory effects on the expression of tumor necrosis factor α and DCF from inflamed hDPSCs (p < 0.05). Moreover, the induction of mineralization in hDPSCs significantly increased after seeding on CUR-based scaffolds (p < 0.05). Based on these findings, the investigated CUR-loaded material was fabricated successfully and provided an appropriate structure for the attachment and proliferation of hDPSCs. It was found that these scaffolds had antimicrobial, antioxidant, and anti-inflammatory characteristics and could induce mineralization in hDPSCs, which is essential for healing and repairing the injured dentin-pulp complex.

Clinical and radiographic evaluation of triple antibiotic paste pulp therapy compared to Vitapex pulpectomy in non-vital primary molars

Objectives

This study compared and evaluated the clinical and radiographic efficacy of non‐instrumentation triple antibiotic paste pulp therapy and Vitapex pulpectomy in non‐vital primary molars.

Material and Methods

Healthy, 5–9 years old children with at least one non‐vital primary molar were included in the study. Molars were divided into two groups based on the subject's cooperation level. In the first group, molars received triple antibiotic paste, and a second group received Vitapex pulpectomy followed by a stainless‐steel crown. Triple antibiotic paste was freshly prepared and proportioned in equal parts by volume (metronidazole, minocycline, and ciprofloxacin = 1:1:1) before the scheduled treatment. A clinical and radiographic examination was performed by two trained and calibrated pediatric dentists at the pre‐operative baseline and the 6‐ and 12‐month follow‐up visits.

Results

A total of 28 molars received triple antibiotic paste pulp therapy and 20 received Vitapex pulpectomy. At the 6‐month follow‐up, the success rate among the molars in the triple antibiotic paste group was clinically (92.85%) and radiographically (85.71%) higher compared to the Vitapex group (91.67%, 62.50% respectively) with p = 0.89 and 0.55 respectively. At the 12‐month follow‐up, the molars in the triple antibiotic paste group showed lower clinical (95.45%) but higher radiographic success rate (72.73%) compared to the Vitapex group (100% and 62.50%) with (p = 0.85 and 0.47) respectively. None of the differences were statistically significant.

Conclusions

Both triple antibiotic paste and Vitapex can be clinically and radiographically effective in treating non‐vital primary molars.

Conceptual Model for Using Imidazoline Derivative Solutions in Pulpal Management

Alpha-adrenergic agonists, such as the Imidazoline derivatives (ImDs) of oxymetazoline and xylometazoline, are highly effective hemostatic agents. ImDs have not been widely used in dentistry but their use in medicine, specifically in ophthalmology and otolaryngology, warrants consideration for pulpal hemostasis. This review presents dental healthcare professionals with an overview of ImDs in medicine. ImD solutions have the potential to be more effective and biocompatible than existing topical hemostatic compounds in pulpal management. Through a comprehensive analysis of the pharmacology of ImDs and the microphysiology of hemostasis regulation in oral tissues, a conceptual model of pulpal management by ImD solutions is presented.

Effect of Incorporating Hydroxyapatite and Zinc Oxide Nanoparticles on the Compressive Strength of White Mineral Trioxide Aggregate

Statement of the Problem

Many efforts have been made to improve the properties of mineral trioxide aggregate (MTA), including the incorporation of nanoparticles.

Purpose

The aim of this study was to investigate the incorporation of zinc oxide and hydroxyapatite nanoparticles on the compressive strength of white MTA (WMTA).

Materials and Method

In this in vitro study, the following materials were evaluated: MTA, MTA+5% zinc oxide (ZnO) nanoparticles, MTA+10% zinc oxide nanoparticles, MTA+5% hydroxyapatite (HA) nanoparticles, MTA+10% zinc oxide nanoparticles. The compressive strength of the groups under investigation was measured on days 4 and 21 after mixing the MTA using a universal testing machine. Two-way ANOVA test was used to compare the groups and determine the significance of the effect of time and material on the compressive strength (p<0.05).

Results

The highest and lowest compressive strength values were respectively measured for the second group, MTA/21 days, and the fourth group, MTA+Nano ZnO/4 days. Two-way ANOVA indicated that incorporation of zinc oxide and hydroxyapatite nanoparticles into MTA did not have a significant effect on compressive strength (p= 0.05). Compressive strength in all the groups increased over time from day 4 to day 21. However, this increase was not statistically significant (p= 0.06) except for the MTA group, which exhibited significant increase in compressive strength over time from day 4 to day 21 (p=0.007).

Conclusion

Incorporation of HA and ZnO nanoparticles into MTA had no detrimental effects on its strength and these nanoparticles can be used to improve the other properties of MTA.

Primary tooth pulpectomy overfilling by different placement techniques: A systematic review and meta-analysis

Background. This study was conducted to investigate root canal overfilling with different material placement techniques in primary teeth. Methods. A systematic search was undertaken by searching PubMed/MEDLINE and Scopus for English language peer-reviewed articles published until February 2018 that reported primary tooth pulpectomy overfilling. Two reviewers independently screened and identified studies in terms of the selection criteria and independently collected the data using a specially designed data extraction form. The overfilling rate was the primary summary measure. The weighted pooled overfilling rates were estimated by random-effects meta-analysis. Results. Twenty clinical and four in vitro studies met the eligibility criteria. In the clinical studies, the pooled overfilling rate for zinc oxide-eugenol (ZOE) was 23.3% with a lentulo spiral mounted on a handpiece, 22.7% with a hand-held lentulo spiral, and 17% with a plugger. The pooled overfilling rate for calcium hydroxide-based materials was 16.7% with a lentulo spiral mounted on a handpiece, 14.7% with a hand-held lentulo spiral, 19.6% with a syringe, and 25.7% with a plugger. In the in vitro studies, neither individual overfilling rates nor two-by-two comparisons were subjected to meta-analysis because of an inadequate number of studies. Conclusion. The lowest overfilling rate in the clinical studies was related to plugger and handheld lentulo spiral techniques for ZOE and calcium hydroxide-based materials, respectively.

Responses of oral-microflora-exposed dental pulp to capping with a triple antibiotic paste or calcium hydroxide cement in mouse molars

Introduction

Responses of oral-microflora-exposed dental pulp to a triple antibiotic paste (TAP), a mixture of ciprofloxacin, metronidazole, and minocycline in ointment with macrogol and propylene glycol, remain to be fully clarified at the cellular level. This study aimed to elucidate responses of oral-microflora-exposed dental pulp to capping with TAP in mouse molars.

Methods

A cavity was prepared on the first molars of 6-week-old mice to expose the dental pulp for 24 h. The exposed pulp was capped with TAP (TAP group) or calcium hydroxide cement (CH group), in addition to the combination of macrogol (M) and propylene glycol (P) (MP, control group), followed by a glass ionomer cement filling. The samples were collected at intervals of 1, 2, and 3 weeks, and immunohistochemistry for nestin and Ki-67 and deoxyuride-5′-triphosphate biotin nick end labeling (TUNEL) assay were performed in addition to quantitative real-time polymerase chain reaction (qRT-PCR) analyses.

Results

The highest occurrence rate of pulp necrosis was found in the control group followed by the CH group at Weeks 2 and 3, whereas the highest occurrence rate of healed areas in the dental pulp was observed in the TAP group at each time point. Tertiary dentin formation was first observed in the dental pulp of the TAP group at Week 2. In contrast, bone-like and/or fibrous tissues were frequently observed in the CH group. qRT-PCR analyses clarified that TAP activated the stem and dendritic cells at Weeks 1 and 2, respectively.

Conclusions

The use of TAP as a pulp-capping agent improved the healing process of oral-microflora-exposed dental pulp in mouse molars.

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We established a mouse model to evaluate the pulpal responses to capping materials.

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TAP induced odontoblast-like cell differentiation faster than calcium hydroxide.

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Tertiary dentin was predominantly seen at the exposure site in the TAP group.

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TAC-P tends to activate dental pulp stem cells earlier than calcium hydroxide.

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TAP favored the repair process of the oral-microflora-exposed pulpal tissue.

Differential Gene Expression Changes in Human Primary Dental Pulp Cells Treated with Biodentine and TheraCal LC Compared to MTA

This study aimed to analyze the effects of pulp capping materials on gene expression changes in primary tooth-derived dental pulp cells using next-generation sequencing. Dental pulp cells were extracted and treated with mineral trioxide aggregate (MTA), Biodentine (BD), or TheraCal LC (TC). Cell viability assays were performed. Total RNA was extracted and analyzed through mRNA sequencing. Bioinformatic analysis of differential gene expression in dental pulp cells exposed to BD or TC versus MTA was performed. MTA, BD, and TC exposure had no significant effect on pulp cell viability (p > 0.05). Gene sets associated with inflammatory response (p = 2.94 × 10⁻⁵) and tumor necrosis factor alpha (TNF-α) signaling via the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) pathway (p = 2.94 × 10⁻⁵) were enriched in all materials. In BD-treated cells, Wnt/β-catenin signaling (p = 3.15 × 10⁻⁴) gene sets were enriched, whereas enrichment of interferon gamma (IFN-γ) response (p = 3 × 10⁻³) was observed in TC-treated cells. In gene plot analysis, marked increases in receptor activator of nuclear factor kappa-Β ligand (RANKL) expression were seen in TC-treated cells over time. Despite the similar cell viabilities exhibited among MTA-, BD-, and TC-treated cells, patterns of gene networks differed, suggesting that diverse functional gene differences may be associated with treatment using these materials.

Mineral Trioxide Aggregate Applications in Endodontics: A Review

A current topic in dentistry concerns the biocompatibility of the materials, and in particular, conservative dentistry and endodontics ones. The mineral trioxide aggregate (MTA) is a dental material with biocompatibility properties to oral and dental tissues. MTA was developed for dental root repair in endodontic treatment and it is formulated from commercial Portland cement, combined with bismuth oxide powder for radiopacity. MTA is used for creating apical plugs during apexification, repairing root perforations during root canal therapy, treating internal root resorption, and pulp capping. The objective of this article is to investigate MTA features from a clinical point of view, even compared with other biomaterials. All the clinical data regarding this dental material will be evaluated in this review article. Data obtained from the analysis of the past 10 years' literature highlighted 19 articles in which the MTA clinical aspects could be recorded. The results obtained in this article are an important step to demonstrate the safety and predictability of oral rehabilitations with these biomaterials and to promote a line to improve their properties in the future.

Outcomes of direct pulp capping in vital primary teeth with cariously and non-cariously exposed pulp: A systematic review

OBJECTIVE

To summarize the clinical/radiographic outcomes from the evidence of studies published since 1988 on different DPC agents applied on vital pulp-exposed primary teeth.

METHODS

The following electronic databases were searched: PubMed, Embase, Cochrane Library, Dentistry and Oral Science Source, and Google Scholar. Inclusion criteria were randomized controlled trials (RCTs) published between January 1988 and December 2019, with at least 6 months of follow-up, comparing the clinical and radiographic success rates of two or more DPC agents applied in primary teeth with cariously and non-cariously exposed pulp.

RESULTS

Initial searches identified 83 potentially relevant studies on DPC in primary teeth. Sixty-four of these studies were excluded, whereas 19 articles satisfied the inclusion criteria and were retrieved in full text for data extraction and a methodological quality assessment. Finally, 12 of these articles were included in the systematic review. Low and moderate risks of bias were observed. Overall, DPC clinical and radiographic success rates among the selected studies ranged between 53% and 100%.

CONCLUSIONS

For DPC in primary teeth, this systematic review found that diverse new biologically and compatible agents with promising success rates are currently available for paediatric dentistry practitioners. There is no evidence that justifies discarding the judicious use of DPC procedures in primary teeth.

Children's Pain Perception and Behavioral Feedback during Local Anesthetic Injection with Four Injection Site Preparation Methods

Introduction:An effective pain control significantly contributes to an optimal dental treatment in pediatric dentistry. This study was conducted to compare children's pain perception and behavioral feedback during local anesthetic injection accompanied with counter-irritation, refrigerant, ice precooling or topical benzocaine. Methods:This study was conducted on 99 children who needed dental treatment in bilateral maxillary primary molars by local anesthesia. Subjects were randomly assigned to three groups, in which the injection site was prepared using counter-irritation in group I, ice precooling in group II, and refrigerant spray precooling in group III. In all three groups, 20% benzocaine gel was used in the injection site of opposite quadrant as a control. The perceived pain and behavioral feedback of children during injection were evaluated using the visual analogue scale (VAS) and sound, eye, and motor (SEM) indexes. Sign and Kruskal-Wallis tests were used to analyze data at a significance level of P < 0.05. Results:The perceived pain was significantly lower when using benzocaine compared to the other three methods (P < 0.05). Behavioral feedback of children when using benzocaine was not significantly different from the counter-irritation method (P=1.00). However, behavioral feedback with counter-irritation was significantly better than precooling (P < 0.05). Counter-irritation was significantly more effective than precooling methods in reduction of pain perception and improvement of behavioral feedback (P < 0.05). Conclusions:The perceived pain was significantly lower when the benzocaine method was used. Behavioral feedback was significantly better with benzocaine and counter-irritation methods compared to precooling procedures.

Time-Dependent Response of Human Deciduous Tooth-Derived Dental Pulp Cells Treated with TheraCal LC: Functional Analysis of Gene Interactions Compared to MTA

Pulp capping material should facilitate hard tissue regeneration on the injured pulp tissue. TheraCal LC (TC) was recently developed. Although TC has shown reliable clinical outcomes after direct pulp capping, there are still remaining concerns regarding its detrimental effect on pulp cells. Therefore, this study aimed to identify the gene expression of human deciduous tooth-derived dental pulp cells exposed to TC compared to mineral trioxide aggregate (MTA). The cells were cultured and exposed to TC and MTA for 24 and 72 h. Next, total RNA was isolated. QuantSeq 3′ mRNA-sequencing was used to examine differentially expressed genes (DEGs) in exposed to TC and MTA. Functional analysis of DEGs was performed using bioinformatics analysis. In gene ontology (GO) functional enrichment analysis, cells in TC for 24 h presented significantly enriched immune response (p < 0.001) and inflammatory response (p < 0.01) compared to MTA. TC showed enriched positive regulation of cell migration at 72 h (p < 0.001). In Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis, neuroactive ligand–receptor interaction (p = 1.19 × 10⁻⁷) and calcium signaling pathway (p = 2.96 × 10⁻⁵) were confirmed in the shared DEGs in TC. In conclusion, DEGs in TC may be involved in pathways associated with osteoclastogenesis and osteoclastic differentiation.

Direct pulp capping of primary molars using a novel fast-setting calcium silicate cement: a randomized clinical trial with 12-month follow-up

Objective: Novel fast-setting calcium silicate cement with fluoride (Protooth) has been developed for potential applications in tooth crowns. The aim of this study was to evaluate the success rate of direct pulp capping in primary molars using two-layer mineral trioxide aggregate (MTA) and overlying glass ionomer cement versus one-layer novel calcium silicate cement with 4 to 10 minutes setting time. Materials and methods: Ninety bilaterally symmetrical primary molars in the same jaw in 45 patients aged 5 to 7 years were included. Exposed pulps following caries removal were randomly capped with one-layer novel calcium silicate cement or two-layer MTA and glass ionomer cement. All cavities were filled with amalgam. Clinical and radiographic evaluations were performed after six and twelve months. 41 patients were available for the evaluations at the end of the 12-month follow-up. Results: The overall success rate of direct pulp capping, in a split-mouth design, using MTA covered with glass ionomer cement or one-layer novel calcium silicate cement after 12 months were 90% (37 out of 41 cases) and 85% (35 out of 41 cases), respectively, without statistically significant differences after 6 and 12 months. Conclusion: Within the limitations of this study, clinical and radiographic evaluations suggested one-layer novel calcium silicate cement would be successfully used in direct pulp capping of primary molars as a practical alternative to two-layer MTA and overlying glass ionomer cement.

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

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

Randomized Controlled Trial of Pulpotomy in Primary Molars using MTA and Formocresol Compared to 3Mixtatin: A Novel Biomaterial

OBJECTIVE

This study was conducted to compare the efficacy of 3Mixtatin (a combination of simvastatin and 3Mix antibiotic) with MTA and Formocresol for the pulpotomy of primary molars.

STUDY DESIGN

114 children aged 3-6 years old with 150 primary molars were randomly allocated to three groups. MTA, Formocresol or 3Mixtatin were used for Pulpotomies. Hard setting zinc oxide eugenol was used to cover these materials. The teeth were restored with amalgam. Blinded radiographic and clinical examinations were conducted at 6, 12 and 24 months after treatment for the presence of pain, tenderness to palpation and percussion, sinus tract, swelling, presence of internal or external root resorption, inter-radicular radiolucency, and periapical lesion.

RESULTS

122 teeth were available for 24-month follow-up study. The overall success rate was 78.9% for FC, 90.5% for 3Mixtatin and 88.1% for MTA group. There was no significant difference in overall success rate among the groups after 24-month follow-up (X²=2.43, df = 2, P =0.27).

CONCLUSION

Our findings demonstrated remarkable results of 3Mixtatin in pulpotomy of primary teeth at the 24-month follow-up. Therefore, 3Mixtatin may be considered as an effective material in pulpotomy of primary teeth because of its successful results.

Pulp treatment for extensive decay in primary teeth

BACKGROUND

In children, dental caries (tooth decay) is among the most prevalent chronic diseases worldwide. Pulp interventions are indicated for extensive tooth decay. Depending on the severity of the disease, three pulp treatment techniques are available: direct pulp capping, pulpotomy and pulpectomy. After treatment, the cavity is filled with a medicament. Materials commonly used include mineral trioxide aggregate (MTA), calcium hydroxide, formocresol or ferric sulphate.This is an update of a Cochrane Review published in 2014 when insufficient evidence was found to clearly identify one superior pulpotomy medicament and technique.

OBJECTIVES

To assess the effects of different pulp treatment techniques and associated medicaments for the treatment of extensive decay in primary teeth.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health Group's Trials Register (to 10 August 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2017, Issue 7), MEDLINE Ovid (1946 to 10 August 2017), Embase Ovid (1980 to 10 August 2017) and the Web of Science (1945 to 10 August 2017). OpenGrey was searched for grey literature. The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing interventions that combined a pulp treatment technique with a medicament or device in children with extensive decay in the dental pulp of their primary teeth.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed 'Risk of bias'. We contacted authors of RCTs for additional information when necessary. The primary outcomes were clinical failure and radiological failure, as defined in trials, at six, 12 and 24 months. We performed data synthesis with pair-wise meta-analyses using fixed-effect models. We assessed statistical heterogeneity by using I² coefficients.

MAIN RESULTS

We included 40 new trials bringing the total to 87 included trials (7140 randomised teeth) for this update. All were small, single-centre trials (median number of randomised teeth = 68). All trials were assessed at unclear or high risk of bias.The 87 trials examined 125 different comparisons: 75 comparisons of different medicaments or techniques for pulpotomy; 25 comparisons of different medicaments for pulpectomy; four comparisons of pulpotomy and pulpectomy; and 21 comparisons of different medicaments for direct pulp capping.The proportion of clinical failures and radiological failures was low in all trials. In many trials, there were either no clinical failures or no radiographic failures in either study arm.For pulpotomy, we assessed three comparisons as providing moderate-quality evidence. Compared with formocresol, MTA reduced both clinical and radiological failures, with a statistically significant difference at 12 months for clinical failure and at six, 12 and 24 months for radiological failure (12 trials, 740 participants). Compared with calcium hydroxide, MTA reduced both clinical and radiological failures, with statistically significant differences for clinical failure at 12 and 24 months. MTA also appeared to reduce radiological failure at six, 12 and 24 months (four trials, 150 participants) (low-quality evidence). When comparing calcium hydroxide with formocresol, there was a statistically significant difference in favour of formocresol for clinical failure at six and 12 months and radiological failure at six, 12 and 24 months (six trials (one with no failures), 332 participants).Regarding pulpectomy, we found moderate-quality evidence for two comparisons. The comparison between Metapex and zinc oxide and eugenol (ZOE) paste was inconclusive, with no clear evidence of a difference between the interventions for failure at 6 or 12 months (two trials, 62 participants). Similarly inconclusive, there was no clear evidence of a difference in failure between Endoflas and ZOE (outcomes measured at 6 months; two trials, 80 participants). There was low-quality evidence of a difference in failure at 12 months that suggested ZOE paste may be better than Vitapex (calcium hydroxide/iodoform) paste (two trials, 161 participants).Regarding direct pulp capping, the small number of studies undertaking the same comparison limits any interpretation. We assessed the quality of the evidence as low or very low for all comparisons. One trial appeared to favour formocresol over calcium hydroxide; however, there are safety concerns about formocresol.

AUTHORS' CONCLUSIONS

Pulp treatment for extensive decay in primary teeth is generally successful. Many included trials had no clinical or radiological failures in either trial arm, and the overall proportion of failures was low. Any future trials in this area would require a very large sample size and follow up of a minimum of one year.The evidence suggests MTA may be the most efficacious medicament to heal the root pulp after pulpotomy of a deciduous tooth. As MTA is relatively expensive, future research could be undertaken to confirm if Biodentine, enamel matrix derivative, laser treatment or Ankaferd Blood Stopper are acceptable second choices, and whether, where none of these treatments can be used, application of sodium hypochlorite is the safest option. Formocresol, though effective, has known concerns about toxicity.Regarding pulpectomy, there is no conclusive evidence that one medicament or technique is superior to another, and so the choice of medicament remains at the clinician's discretion. Research could be undertaken to confirm if ZOE paste is more effective than Vitapex and to evaluate other alternatives.Regarding direct pulp capping, the small number of studies and low quality of the evidence limited interpretation. Formocresol may be more successful than calcium hydroxide; however, given its toxicity, any future research should focus on alternatives.

Direct pulp capping in primary molars using a resin-modified Portland cement-based material (TheraCal) compared to MTA with 12-month follow-up: a randomised clinical trial

AIM

This study was to compare the success of resin-modified Portland cement-based material (TheraCal) with MTA in direct pulp capping (DPC) of primary molars.

METHODS

Symmetrical bilateral primary molars (92) from 46 healthy subjects aged 5-7 years were included in this split-mouth randomised clinical trial. DPC for small non-contaminated pulp exposures using either TheraCal or MTA were randomly performed in symmetrical molars. Thereafter, teeth were restored with amalgam. Clinical and radiographic evaluations were performed at 6 and 12 month follow-ups. Data were analysed using Chi square test at a significance level of 0.05.

RESULTS

At the final follow-up session 74 teeth were available. After 12 months, the overall success rates for MTA and TheraCal were 94.5 and 91.8%, respectively. The difference between outcomes of the two groups was not statistically significant (P > 0.05).

CONCLUSION

Within the limitations of the current study, radiographic and clinical findings revealed that TheraCal exhibited a comparable outcome to MTA in DPC of primary molars after 12 months.

Mineral trioxide aggregate affects cell viability and induces apoptosis of stem cells from human exfoliated deciduous teeth

BACKGROUND

Mineral trioxide aggregate (MTA) is widely used for pulp-capping procedures in permanent teeth and as a gold standard material in endodontics. The aim of the study was to investigate the effect of MTA on cell viability and apoptosis when MTA is directly in contact with Stem Cells from Human Exfoliated Deciduous Teeth (SHEDs).

METHODS

MTA was mixed and coated in the bottom of a 24-well plate. SHEDs collected and cultured from normal exfoliated human deciduous teeth (passages 3-4) were seeded on square cover glasses. The glasses with seeded SHEDs were incubated in the plates with or without MTA coating. They were divided into four groups: MTA direct contact, direct control, MTA indirect contact, and indirect control. After 1, 2 and 3 days of culturing, cell morphology was observed and cell viability was assessed by the WST-1 cell cytotoxicity assay. TUNEL assay, immunofluorescent labeling and western blot analysis were used to study the effects of MTA on SHEDs apoptosis.

RESULTS

MTA impaired cell viability of SHEDs in 1, 2 and 3 days, and the effect of direct contact was more severe. Cell apoptosis with positive Annexin V and TUNEL staining was noted when there was direct contact with MTA. Western blot analysis revealed that Bcl-2 and Bcl-xL decreased after SHEDs were in contact with MTA.

CONCLUSIONS

This study shows that direct contact with 1 week post-set MTA significantly decreases the viability of SHEDs and induced cell apoptosis. The results suggest that there is a possible cytotoxic effect of pulp tissue when there is direct contact with MTA. Different responses would be expected due to the strong alkaline characteristics of fresh mixed MTA.

Simvastatin and nanofibrous poly(l-lactic acid) scaffolds to promote the odontogenic potential of dental pulp cells in an inflammatory environment

In this study, we investigated the anti-inflammatory, odontogenic and pro-angiogenic effects of integrating simvastatin and nanofibrous poly(l-lactic acid) (NF-PLLA) scaffolds on dental pulp cells (DPCs). Highly porous NF-PLLA scaffolds that mimic the nanofibrous architecture of extracellular matrix were first fabricated, then seeded with human DPCs and cultured with 0.1 μM simvastatin and/or 10 μg/mL pro-inflammatory stimulator lipopolysaccharide (LPS). The gene expression of pro-inflammatory mediators (TNF-α, IL-1β and MMP-9 mRNA) and odontoblastic markers (ALP activity, calcium content, DSPP, DMP-1 and BMP-2 mRNA) were quantified after long-term culture in vitro. In addition, we evaluated the scaffold's pro-angiogenic potential after 24 h of in vitro co-culture with endothelial cells. Finally, we assessed the combined effects of simvastatin and NF-PLLA scaffolds in vivo using a subcutaneous implantation mouse model. The in vitro studies demonstrated that, compared with the DPC/NF-PLLA scaffold constructs cultured only with pro-inflammatory stimulator LPS, adding simvastatin significantly repress the expression of pro-inflammatory mediators. Treating LPS+ DPC/NF-PLLA constructs with simvastatin also reverted the negative effects of LPS on expression of odontoblastic markers in vitro and in vivo. Western blot analysis demonstrated that these effects were related to a reduction in NFkBp65 phosphorylation and up-regulation of PPARγ expression, as well as to increased phosphorylation of pERK1/2 and pSmad1, mediated by simvastatin on LPS-stimulated DPCs. The DPC/NF-PLLA constructs treated with LPS/simvastatin also led to an increase in vessel-like structures, correlated with increased VEGF expression in both DPSCs and endothelial cells. Therefore, the combination of low dosage simvastatin and NF-PLLA scaffolds appears to be a promising strategy for dentin regeneration with inflamed dental pulp tissue, by minimizing the inflammatory reaction and increasing the regenerative potential of resident stem cells.

STATEMENT OF SIGNIFICANCE

The regeneration potential of stem cells is dependent on their microenvironment. In this study, we investigated the effect of the microenvironment of dental pulp stem cells (DPSCs), including 3D structure of a macroporous and nanofibrous scaffold, the inflammatory stimulus lipopolysaccharide (LPS) and a biological molecule simvastatin, on their regenerative potential of mineralized dentin tissue. The results demonstrated that LPS upregulated inflammatory mediators and suppressed the odontogenic potential of DPSCs. Known as a lipid-lowing agent, simvastatin was excitingly found to repress the expression of pro-inflammatory mediators, up-regulate odontoblastic markers, and exert a pro-angiogenic effect on endothelial cells, resulting in enhanced vascularization and mineralized dentin tissue regeneration in a biomimetic 3D tissue engineering scaffold. This novel finding is significant for the fields of stem cells, inflammation and dental tissue regeneration.

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.

Pulp bleeding color is an indicator of clinical and histohematologic status of primary teeth

OBJECTIVES

This study was carried out to investigate whether the changes in hematologic characteristic and color of pulpal bleeding is associated with clinical and histologic status of the pulp in primary teeth.

MATERIALS AND METHODS

A total of 211 primary molars in 103 patients, 3-6 years old, were treated. One hundred eight teeth had pulpectomy, 57 teeth had pulpotomy after pulp exposure during caries excavation, and 46 teeth had pulpotomy after accidental pulp exposure in sound dentin. After pulpal exposure, pulpal blood was collected in capillary tubes for blood color and hematologic assessment. Coronal and radicular pulp tissues were amputated for histologic assessment.

RESULTS

Blood color was significantly darker in pulpectomy cases and samples with severe inflammation. The differences were clinically perceptible by the human eye. A significant negative correlation was detected between white blood cell (WBC) count and blood color. The counts of neutrophils and lymphocytes were significantly different between treatment groups. In addition, WBC, eosinophil, monocyte, neutrophil, and basophils counts were significantly different between degrees of inflammation in coronal pulp. Moreover, severe inflammation was higher in pulpectomy group versus pulpotomy groups. Pulp tissue calcification was also significantly higher in the pulpectomy cases.

CONCLUSIONS

Considering the significant difference in pulpal blood color between the pulpectomy and pulpotomy cases, and between the different levels of pulpal inflammation; blood color can be a valid clinical diagnostic criterion of pulpal status and can be used for the selection of appropriate pulp treatment strategy.

CLINICAL RELEVANCE

This study shows that pulp bleeding color can be used for selection of an appropriate pulp treatment method in primary teeth.

Zeolite-silver-zinc nanoparticles: Biocompatibility and their effect on the compressive strength of mineral trioxide aggregate

BACKGROUND

This study was carried out to evaluate the biocompatibility of zeolite-silver-zinc (Ze-Ag-Zn) nanoparticles and their effect on the compressive strength of Mineral Trioxide Aggregate (MTA).

MATERIAL AND METHODS

Biocompatibility was evaluated by an MTT assay on the pulmonary adenocarcinoma cells with 0.05, 0.1, 0.25, 0.5, 1 and 5 mg/mL concentrations of Ze-Ag-Zn. For compressive strength test, four groups containing 15 stainless-steel cylinders with an internal diameter of 4 and a height of 6 mm were prepared and MTA (groups 1 and 2) or MTA + 2% Ze-Ag-Zn (groups 3 and 4) were placed in the cylinders. The compressive strength was evaluated using a universal testing machine 4 days after mixing in groups 1 and 3, and 21 days after mixing in groups 2 and 4.

RESULTS

There was no significant difference between cytotoxicity of different concentrations. The highest (52.22±18.92 MPa) and lowest (19.57±5.76 MPa) compressive strength were observed in MTA group after 21 days and in MTA + 2% Ze-Ag-Zn group after four days, respectively. The effect of time and 2% Ze-Ag-Zn on the compressive strength were significant (P<0.05). Mixing MTA with Ze-Ag-Zn significantly reduced and passage of time from day four to 21 significantly increased the compressive strength.

CONCLUSIONS

Mixing MTA with 2% Ze-Ag-Zn had an adverse effect on the compressive strength of MTA, but this combination had no cytotoxic effects. Key words:Compressive strength, Cytotoxicity, Mineral Trioxide Aggregate, Nanoparticle, Zeolite-Silver-Zinc.

Can galvanic skin conductance be used as an objective indicator of children's anxiety in the dental setting?

Background

Assessment of procedural distress is essential at assisting children during invasive dental treatments. This study aimed to determine the validity and reliability of galvanic skin response as a measure for assessment of dental anxiety in children.

Material and Methods

151 children, aged 5-7 years, participated in this study. Similar dental treatments were rendered to all subjects. At the beginning and end of the session, modified child dental anxiety scale (MCDAS), clinical anxiety rating scale (CARS) and galvanic skin response (GSR) were used to determine children’s anxiety.

Results

GSR was significantly correlated with both MCDAS (rs=0.62, p=0.02) and CARS (rs=0.44, p=0.032). The correlation between MCDAS and CARS was also significant (rs = 0.9, P<0.001). Anxiety decreased during the session in both GSR (rs=0.52, p=0.001) and MCDAS scales (rs=0.77, p=0.001). CARS also showed a reduction between the initial and second assessment, but it was not statistically significant (rs=0.12, P=0.36).

Conclusions

The findings suggest that GSR is a reliable and valid measure for assessment of children’s dental anxiety in the clinical context. GSR may help to identify clinically anxious children before dental treatment to provide appropriate interventions.

Key words:Dental anxiety, reliability, validity, galvanic skin response.