Success Rates of Pulpotomies in Primary Molars Using Calcium Silicate-Based Materials: A Randomized Control Trial

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

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

Apoptotic effects of biodentine, calcium-enriched mixture (CEM) cement, ferric sulfate, and mineral trioxide aggregate (MTA) on human mesenchymal stem cells isolated from the human pulp of exfoliated deciduous teeth

BACKGROUND

Preservation of primary teeth in children is highly important. Pulpotomy is a commonly performed treatment procedure for primary teeth with extensive caries. Thus, biocompatibility of pulpotomy agents is highly important. Biodentine, calcium enriched mixture (CEM) cement, ferric sulfate, and mineral trioxide aggregate (MTA) Angelus are commonly used for this purpose. Thus, this study aimed to assess the apoptotic effects of Biodentine, CEM cement, ferric sulfate, and MTA on stem cells isolated from the human pulp of exfoliated deciduous teeth.

METHODS

In this in-vitro, experimental study, stem cells isolated from the human pulp of exfoliated deciduous teeth were exposed to three different concentrations of Biodentine, CEM cement, ferric sulfate, and MTA for different time periods. The cytotoxicity of the materials was evaluated by flow cytometry using the annexin propidium iodide (PI) kit. Data were analyzed by ANOVA and Tukey's test at P<0.05 level of significance.

RESULTS

All four tested materials induced significantly greater apoptosis compared with the control group. The difference in cell apoptosis caused by the first concentration of ferric sulfate and MTA was not significant at 24 hours. In other comparisons, the cytotoxicity of ferric sulfate was significantly lower than that of other materials. Biodentine showed higher cytotoxicity than MTA at first; but this difference faded over time. The cytotoxicity of CEM cement was comparable to that of MTA. The highest cell viability was noted at 24 hours in presence of the minimum concentration of ferric sulfate. The lowest cell viability was noted at 72 hours in presence of the maximum concentration of CEM cement.

CONCLUSIONS

In comparison with other materials, ferric sulfate showed minimum cytotoxicity; the cytotoxicity of the three cements was comparable. It appears that the concentration of ferric sulfate and the composition of cements are responsible for different levels of cytotoxicity.

One-year radiographic and clinical performance of bioactive materials in primary molar pulpotomy: A randomized controlled trial

OBJECTIVES

Mineral Trioxide Aggregate (MTA) is considered the gold standard material for pulpotomy procedures. However, some drawbacks such as poor handling and long setting time are challenging when it is used as pulpotomy dressing in primary molars in children. Hence, the purpose of this study was to compare the radiographic and clinical performance of a premixed, fast setting bioceramic root repair material (BC RRM-F) with MTA in vital pulpotomy procedures of primary molars, with or without the added seal of a stainless steel crown (SSC).

METHODS

In this double blinded, four-arm, parallel group randomized contolled trial (RCT), 64 primary molars were randomly allocated to one of the four treatment groups: MTA (PDTM MTA WHITE)+SSC, MTA+GI (bulk fill glass ionomer with glass hybrid technology GC EQUIA Forte® HT), BC RRM-F+GI and BC RRM-F+SCC. All molars were evaluated clinically and radiographically according to the modified Zurn and Seale criteria at 1, 3, 6, and 12 months follow up. Multivariate cox regression models and Kaplan-Meier curves were used for survival analysis.

RESULTS

There was no statistically significant difference between the success of both pulp capping materials used. Overall survival analysis showed that using GI instead of SCC as a final restorative material was significantly associated with increased risk of failure.

CONCLUSIONS

TotalFill® BC RRM™ Fast Set Putty can be used as an alternative to MTA in primary molar pulpotomy. Regardless of the pulp capping material, one year survival of pulpotomized primary molars restored with SSC is higher compared to those restored with GC EQUIA Forte® HT.

CLINICAL SIGNIFICANCE

Clinicians' preference and cost effectiveness may justify the use of either material in primary molar pulpotomy. Parents insisting on tooth-colored restorations for their children's pulpotomized teeth cannot be told that the expectation for success is the same as those restored with SSC, even if calcium silicate-based pulp capping materials are used.

Bismuth release from endodontic materials: in vivo analysis using Wistar rats

Calcium silicate-based materials are used to block the communication between the root canal and the periodontal ligament space. This brings the materials into contact with tissues and the potential for local and systemic elemental release and movement. The aim of the study was to evaluate the elemental release of bismuth from ProRoot MTA in contact with connective tissues after 30 and 180 days as well as any accumulation in peripheral organs using an animal model. Tricalcium silicate and hydroxyapatite containing 20% bismuth oxide (HAp-Bi) were used as controls. The null hypothesis was that bismuth migrates from tricalcium silicate-based materials when associated with silicon. The materials were examined using scanning electron microscopy, energy dispersive spectroscopy (SEM/EDS) and X-ray diffraction prior to implantation as well as using SEM/EDS, micro X-ray fluorescence and Raman spectroscopy after implantation to assess elemental presence in surrounding tissues. Histological analysis was used to evaluate the changes in tissue architecture and inductively coupled plasma mass spectrometry (ICP-MS) was used to investigate the elemental deposition. For the systemic investigation, routine blood analysis was performed and organs were obtained to evaluate the presence of bismuth and silicon using ICP-MS after acid digestion. In the histological analysis of the implantation sites, macrophages and multinucleated giant cells could be observed after 30 days which after 180 days became a chronic infiltrate; although, no major differences were identified in red and white blood cell analyses and biochemical tests. Implantation altered the materials as observed in the Raman analysis and bismuth was detected both locally and within kidney samples after both periods of analysis, indicating the potential for accumulation of bismuth in this organ. Smaller amounts of bismuth than observed in the kidney were also detected in blood, liver and brain for the ProRoot MTA and HAp-Bi after 180 days. Bismuth was released from the ProRoot MTA locally and was detected systemically and in samples without silicon; thus, the null hypothesis was rejected. The bismuth release demonstrated that this element accumulated both locally and systemically, mainly in the kidneys in comparison with brain and liver regardless of the material base.

Effect of Biodentine on Odonto/Osteogenic Differentiation of Human Dental Pulp Stem Cells

This study aims to compare the biological characteristics of human dental pulp stem cells (hDPSCs) isolated from different-aged populations and examine the effects of Biodentine on proliferation and odonto/osteogenic differentiation of hDPSCs isolated from the elderly in vitro. hDPSCs were isolated from three different-aged populations: group A (≤18 years old), group B (19−59 years old), and group C (≥60 years old). The adhesion, proliferation, odonto/osteogenesis, and senescence were compared. The optimal concentration of aqueous Biodentine extract was determined by CCK-8 assay, alkaline phosphatase (ALP), and alizarin red staining (ARS). The effect of Biodentine on odonto/osteogenic gene and protein expression of hDPSCs in each group was evaluated by quantitative real-time PCR (QRT-PCR) and Western blot. hDPSCs were successfully isolated from three different-aged populations. Flow cytometry revealed that all isolated hDPSCs were positive for CD73 (>90%), CD90 (>90%), CD146 (<30%), and negative for CD45 (<1%). There existed an age-related decline in proliferation, odonto/osteogenic gene expression, and S-phase fraction (p < 0.05), an increase in senescence genes and p21 and p16 expression, and time needed for cell adhesion. Biodentine promoted hDPSC proliferation and mineralization in each group, particularly at a concentration of 0.2 mg/mL. Biodentine markedly enhanced odonto/osteogenesis-related gene and protein expression in each group (p < 0.05). hDPSCs can be obtained from populations of all ages. Though there is an age-related decline in their biological properties, hDPSCs from the elderly still maintain certain proliferation and multidirectional differentiation abilities. Biodentine can significantly promote the proliferation and odonto/osteogenic differentiation of hDPSCs isolated from the elderly over 60 years old, which could be considered a pulp capping material for vital pulp therapy in the elderly. Nevertheless, the efficacy of Biodentine in clinical application has to be further studied.

COMPARING THE CLINICAL AND RADIOGRAPHIC OUTCOMES OF PULPOTOMIES IN PRIMARY MOLARS USING BIOACTIVE ENDODONTIC MATERIALS AND FERRIC SULFATE - A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS

OBJECTIVE

To compare the clinical and radiographic outcomes of pulpotomies in primary molars using bioactive endodontic materials and ferric sulfate.

DESIGN

The search was conducted in PubMed, Ebscohost, ProQuest, and Scopus databases till June 2021. Children undergoing pulpotomy therapy in primary molars treated with ferric sulfate (FS) and bioactive endodontic materials were evaluated for clinical and radiographic success. Meta-analysis was performed on a random-effects model to assess the success at 6,12,18, and 24 months. The quality of studies was evaluated using the Cochrane risk of bias tool for randomized trials RESULTS: No significant difference was observed between Mineral trioxide aggregate (MTA) and FS at 24 months for both clinical [RR0.98 (95%CI 0.15,6.34), I² = 0%] and radiographic [RR0.74 (95%CI: 0.23,2.43), I² = 0%] success. At 6 months [RR1.36 (95%CI: 0.10,19.34), I² = 33%], no difference was observed in the clinical [RR1.00 (95%CI: 0.95,1.05), I² = 0%] and radiographic success [RR0.99 (95%CI: 0.88,1.11), I² = 51%] between Biodentine (BD), FS and radiographic success of calcium enriched cement and FS [RR0.25 (95%CI: 0.03, 2.22), I² = 0%].

CONCLUSION

Amongst bioactive materials, MTA and FS demonstrated equal success rates in both clinical and radiographic outcomes with follow-up periods of up to 24 months. Future, high-quality trials are required to verify the result of the current review.

Contemporary management of deep caries in primary teeth: a systematic review and meta-analysis

PURPOSE

To systematically evaluate the available evidence regarding contemporary management of deep caries in vital primary teeth. This review was carried out to facilitate the development of European Academy of Paediatric Dentistry (EAPD) guidelines on deep caries management of primary teeth in paediatric dentistry.

METHODS

A systematic electronic literature search was conducted to locate studies reporting on interventions and medicaments used for the treatment of deep caries in vital primary teeth. To facilitate this, the Cochrane Library (1992 to up to December 6th, 2020), MEDLINE (PubMed, 1946 to December Week 1, 2020), Ovid MEDLINE (In-Process & Other Non-Indexed Citations, December 6th, 2020); EMBASE (Embase.com, 1974 to December 6th, 2020) and LILACS (1982 to December 6th, 2020) were accessed. Hand search of reference lists of included articles, as well as handbooks and grey literature search was also performed. Study screening was done in duplicate and study inclusions were agreed upon by all authors. Data extraction, and methodological quality and risk of bias assessment were carried out in duplicate for each of the included studies. Overall success rate of each intervention and medicament within the intervention was reported. Meta-analysis was also performed for high-quality studies reporting similar interventions and comparable outcomes in homogeneous population.

RESULTS

A total of 1332 papers were identified. Following the primary and secondary assessment process, 36 papers were included in the review. Of these, 8 papers were deemed to represent 4 individual studies, leaving a total of 32 unique studies eventually included in the final analysis. These studies were further categorized into three main vital pulp treatment methods for analysis: indirect pulp capping (IPC), direct pulp capping (DPC), and pulpotomy (PP). Overall, IPC, DPC and PP interventions have high success rates with the reported clinical success rates higher than radiographic success rates. Medicaments used for IPC and DPC have similar success rates. Mineral trioxide aggregate (MTA), ferric sulfate (FS) and formocresol (FC) PP showed similar success rates, and which were all higher than calcium hydroxide (CH). Majority of included studies (n = 22; 63%) were rated low in terms of their potential risk of bias, 6 studies were rated high (17%), and 7 studies were of unclear risk (20%).

CONCLUSION

Within the limitations of the studies included, IPC, DPC, and PP can be recommended as effective treatment modalities for primary teeth with deep caries under specific conditions.

Cytocompatibility and Bioactive Properties of Hydraulic Calcium Silicate-Based Cements (HCSCs) on Stem Cells from Human Exfoliated Deciduous Teeth (SHEDs): A Systematic Review of In Vitro Studies

The implementation of hydraulic calcium silicate-based endodontic cements (HCSCs) in biologically based endodontic procedures for the primary dentition has been recently investigated, focusing on the biological response of stem cells from human exfoliated deciduous teeth (SHEDs) towards them. The present systematic review aimed to present a qualitative synthesis of the available literature consisting of in vitro assays, which assessed the cytocompatibility and bioactive properties of HCSCs in direct contact with SHEDs. Following the PRISMA statement, an electronic database search was carried out in Medline, Scopus, Embase, Web of Science, and SciELO on March 31st and updated on November 16th, 2020. In vitro studies evaluating the biological response of SHEDs to the treatment with HCSCs were eligible. Within the term biological response, assays assessing the cytocompatibility (i.e., cell viability, migration, proliferation), cell plasticity or differentiation (i.e., osteo/odontogenic marker expression), and bioactivity or biomineralization (i.e., mineralized nodule formation) were included. A total of seven studies were included after the selection process. The study sample comprised an extensive range of cell viability, migration, proliferation, adhesion, and bioactivity assays regarding the biological response of SHEDs towards five different commercially available HCSCs (MTA, ProRoot MTA, Biodentine, iRoot BP Plus, and Theracal LC). Biodentine, MTA, and iRoot BP Plus showed significant positive results in cytocompatibility and bioactivity assays when cultured with SHEDs. The results from in vitro assays assessing the cytocompatibility and bioactivity of the HCSCs MTA, Biodentine, and iRoot BP Plus towards SHEDs support their use in vital pulp treatment for the primary dentition.

Different Pulp Dressing Materials for the Pulpotomy of Primary Teeth: A Systematic Review of the Literature

Background: Pulpotomy of primary teeth provides favorable clinical results over time; however, to date, there is still not a consensus on an ideal pulp dressing material. Therefore, the aim of the present systematic review was to compare pulpotomy agents to establish a preferred material to use. Methods: After raising a PICO question, the PRISMA guideline was adopted to carry out an electronic search through the MEDLINE database to identify comparative studies on several pulp dressing agents, published up to October 2019. Results: The search resulted in 4274 records; after exclusion, a total of 41 papers were included in the present review. Mineral trioxide aggregate (MTA), Biodentine and ferric sulphate yielded good clinical results over time and might be safely used in the pulpotomies of primary molars. Among agents, MTA seemed to be the material of choice. On the contrary, calcium hydroxide showed the worst clinical performance. Although clinically successful, formocreosol should be replaced by other materials, due to its potential cytotoxicity and carcinogenicity. Conclusion: MTA seemed to be the gold standard material in the pulpotomy of primary teeth. Promising results were also provided by calcium silicate-based cements. Further randomized clinical trials (RCTs) with adequate sample sizes and long follow-ups are encouraged to support these outcomes.