Clinical and radiographic assessment of the efficacy of calcium silicate indirect pulp capping: a randomized controlled clinical trial

Biocompatibility and osteogenic assessment of experimental fluoride-doped calcium-phosphate cements on human dental pulp stem cells

OBJECTIVES

This study investigated the impact of some specific experimental calcium phosphate cements doped with different fluoride salts (FDCPCs) concentrations on the basal functions of human Dental Pulp Stem Cells (hDPSCs). Furthermore, this study also examined the migration, as well as the mineralisation through osteogenic differentiation.

METHODS

Experimental FDCPCs were formulated using different concentrations of calcium/sodium fluoride salts [(5 wt%: VS5F), (10 wt%: VS10F), (20 wt%: VS20F)]. A fluoride-free calcium phosphate (VS0F) was used as a control. The hDPSCs were assessed to evaluate their self-renewal and migration activity in the presence of eluates of the different FDCPCs. A viability assay in osteogenic conditions was carried out, along with the differentiation potential through Alkaline Phosphatase Activity (ALP), and Alizarin Red Staining (ARS). Moreover, the gene expression of specific markers (RUNX2, ALP, COL1α1, OCN, OPN, DSPP, MEPE, and DMP-1) was also evaluated.

RESULTS

All the tested FDCPD had no influence on cell migrations, but they caused a decrease in cell viability in osteogenic conditions when not diluted. Conversely, the eluants of VS20F showed a positive effect on stem cell differentiation. This result was corroborated through ALP activity, ARS assay. Moreover, upregulation of specific gene markers such as RUNX2, DMP-1, and DSPP was observed in hDPSCs, especially when treated with VS20F.

SIGNIFICANCE

The experimental FDCPC tested in this study exhibits a dose-dependent capacity to promote mineralisation in osteogenic environment. The FDCPC-VS20F seems to be the most promising experimental material suitable for developing of pulp-capping materials with osteogenic and bioactive properties.

Resolvin D2-induced reparative dentin and pulp stem cells after pulpotomy in a rat model

Introduction

Vital pulp therapy (VPT) is performed to preserve dental pulp. However, the biocompatibility of the existing materials is of concern. Therefore, novel materials that can induce pulp healing without adverse effects need to be developed. Resolvin D2 (RvD2), one of specialized pro-resolving mediators, can resolve inflammation and promote the healing of periapical lesions. Therefore, RvD2 may be suitable for use in VPT. In the present study, we evaluated the efficacy of RvD2 against VPT using in vivo and in vitro models.

Methods

First molars of eight-week-old male Sprague-Dawley rats were used for pulpotomy. They were then divided into three treatment groups: RvD2, phosphate-buffered saline, and calcium hydroxide groups. Treatment results were assessed using radiological, histological, and immunohistochemical (GPR18, TNF-α, Ki67, VEGF, TGF-β, CD44, CD90, and TRPA1) analyses. Dental pulp-derived cells were treated with RvD2 in vitro and analyzed using cell-proliferation and cell-migration assays, real-time PCR (Gpr18, Tnf-α, Il-1β, Tgf-β, Vegf, Nanog, and Trpa1), ELISA (VEGF and TGF-β), immunocytochemistry (TRPA1), and flow cytometry (dental pulp stem cells: DPSCs).

Results

The formation of calcified tissue in the pulp was observed in the RvD2 and calcium hydroxide groups. RvD2 inhibited inflammation in dental pulp cells. RvD2 promoted cell proliferation and migration and the expression of TGF-β and VEGF in vitro and in vivo. RvD2 increased the number of DPSCs. In addition, RvD2 suppressed TRPA1 expression as a pain receptor.

Conclusion

RvD2 induced the formation of reparative dentin, anti-inflammatory effects, and decreased pain, along with the proliferation of DPSCs via the expression of VEGF and TGF-β, on the pulp surface in pulpotomy models.

Revolutionizing the diagnosis of irreversible pulpitis - Current strategies and future directions

BACKGROUND

Pulpitis primarily arises from the pulp space infection by oral microbiota. Vital pulp therapy is a minimally invasive approach that relies on assessing the severity of pulpal inflammation to facilitate repair. However, the current evaluation methods prescribed by the American Association of Endodontics are subjective, leading to ambiguity in assessment. Therefore, this review aims to explore molecular strategies for evaluating the severity of pulpal inflammation to accurately predict the success of pulp vitality preservation in clinical settings.

METHODOLOGY

This review was conducted by searching relevant keywords, such as irreversible pulpitis, pulpitis biomarkers, molecular diagnosis, inflammation, and genomic strategies, in databases such as PubMed, Web of Science, and Scopus to address the subjective nature of diagnosis. The data included in this review were collected up to April 2023. The literature search revealed well-documented limitations in clinically assessing the pulp inflammatory. Molecular approaches that aid in clinical differentiation between irreversible and reversible pulpitis may potentially enhance favorable outcomes in vital pulp therapy. Non-invasive diagnostic methods for pulpal assessment would also be valuable for determining whether the inflamed pulp is reversible, irreversible, or necrotic.

CONCLUSION

The present review examines the various molecular diagnostic approaches that have revolutionized the medical field and are considered the most promising empirical methodologies for the proactive detection of pulpal diseases. It also provides comprehensive insights into the current diagnostic methods, associated challenges, next-generation strategies, and future directions for diagnosing the severity of pulp inflammation.

Characterisation of experimental flowable composites containing fluoride-doped calcium phosphates as promising remineralising materials

OBJECTIVE

Remineralising composites with antibacterial properties may seal the cavity and prevent secondary caries. This study aimed at developing experimental flowable composites containing different concentrations of fluoride-doped calcium phosphate fillers and evaluating their remineralising and antibacterial properties.

METHODS

Experimental resin-based composites containing different concentrations (0-20 %) of fluoride-doped calcium phosphate fillers (VS10/VS20) were formulated. The release of calcium (Ca), phosphate (PO) and fluoride (F) ions was assessed for 30 days. Remineralisation properties were evaluated through ATR-FTIR and SEM/EDX after storage in simulated body fluid (SBF). The metabolic activity and viability of Streptococcus gordonii was also evaluated through ATP, CFU and live/dead confocal microscopy. The evaluation of specific monomer elution from the experimental composites was conducted using high-performance liquid chromatography (HPLC).

RESULTS

The composites containing VS10 showed the highest release of Ca, those containing VS20 released more F over time (p < 0.05), while there was no significant difference in terms of PO ions release between the groups (p > 0.05). A quick 7-day mineral precipitation was observed in the tested composites containing VS10 or VS20 at 10 %; these materials also showed the greatest antibacterial activity (p < 0.05). Moreover, the tested composites containing VS10 presented the lowest elution of monomers (p < 0.05).

CONCLUSIONS

Innovative composites were developed with low monomers elution, evident antibacterial activity against S. gordonii and important remineralisation properties due to specific ions release.

CLINICAL SIGNIFICANCE

Novel composites containing fluoride-doped calcium phosphates may be promising to modulate bacteria growth, promote remineralisation and reduce the risk of cytotoxicity related to monomers' elution.

Biodentine™ as a temporary filling in deep carious lesions in permanent teeth: a prospective observational 33-month follow-up study

PURPOSE

The study aimed to evaluate temporary fillings using Biodentine™ in asymptomatic deep carious lesions after 12, 24, and 36 months in school children from the remote village of Kerung, Nepal.

METHODS

From November 2018 to November 2019, 91 temporary fillings were placed using Biodentine™ (a hydraulic calcium silicate cement) in permanent molars with deep carious lesions of schoolchildren in the remote district of Kerung, Nepal. These restorations were performed after selective caries removal in a non-dental setting with hand instruments and cotton roll isolation, as electric motors and saliva ejection systems were unavailable. In total, 78 single-surface and 13 multi-surface fillings were placed. Clinical and radiographic follow-up periods encompassed 12, 21, and 33 months, respectively.

RESULTS

After 12 months, all single-surface fillings (100%) survived, whilst all multi-surface fillings were partially or entirely lost. The survival rate of single-surface restorations after 21 and 33 months was 67.6% and 50%, respectively. Radiographically, no pathology was observed.

CONCLUSION

This study showed that Biodentine could be used in deep carious lesions as a temporary filling in single-surface lesions for at least up to 1 year and in a substantial number of cases for up to 21 and 33 months.

Biting and thermal sensitivity relief of cracked tooth restored by occlusal veneer: A 12-to 24 months prospective clinical study

OBJECTIVES

To analyze the relief time and risk factors of biting/thermal sensitivity in cracked tooth (CT) restored using occlusal veneer.

METHODS

63 CT were analyzed, and their demographic and clinical data and medical history were collected. Patients were followed-up to examine the relief of thermal/biting sensitivity.

RESULTS

The maxillary first molar was the most prevalent (N = 25, 40%). The number of crack lines on the finish line ranged from 1 to 6 while the number of crack lines through preparation on the finish line from 0 to 4. Pain relief achieved steadily to 52% for thermal and 62% for biting at 1 week to over 90% for each by 3 months and was completely resolved (no pain) for each by 12 months. Painful of lateral percussion was related to a long period of thermal sensitivity (≥1 month) after restoration with occlusal veneer. The number of crack lines through preparation on the finish line >2 was correlated with biting sensitivity (≥1 month) post-treatment.

CONCLUSIONS

Most patients (>90%) became asymptomatic of biting and thermal sensitivity within 3 months of CT restored by occlusal veneer. Lateral percussion and the number of crack lines through preparation on the finish line could be significant factors affecting postoperative symptoms.

CLINICAL SIGNIFICANCE

Occlusal veneer is an ultrathin restoration and had no need for restricting clinical crown height, which could protect and relief the biting/thermal sensitivity of CT without preventive root canal therapy.

Effectiveness of pulpotomy compared with root canal treatment in managing non-traumatic pulpitis associated with spontaneous pain: A systematic review and meta-analysis

BACKGROUND

Pulpitis characterized by spontaneous pain can result in debilitating pain. Dogma has existed to offer only have two treatment options, namely root canal treatment (RCT) or extraction, although pulpotomy has always remained a potential treatment modality.

OBJECTIVE

This review aimed to answer the following research question: 'Does pulpotomy (partial or full) (I) result in better patient and clinical reported outcomes (O), compared with RCT (C) in permanent teeth with pulpitis characterized by spontaneous pain (P) evaluated at various time intervals?' (T).

METHODS

Two authors independently performed study selection, data extraction and risk of bias assessment. The literature search was conducted in the following electronic databases: Clarivate Analytics' Web of Science, Scopus, PubMed and Cochrane Central Register of Controlled Trials. English language clinical trials comparing the patient and clinical reported outcomes between RCT and pulpotomy were included. The meta-analysis was performed on a fixed-effect model and the quality of evidence assessed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

Two randomized clinical trials were included. Amongst two trials, one has published four reports at different time points involving the same cohorts. The meta-analysis revealed no difference in postoperative pain (Day 7) between RCT and pulpotomy (OR = 0.99, 95% CI 0.63-1.55, I2  = 0%) and quality of evidence was graded as 'High'. Clinical success was high at year 1, 98% for both interventions, however, decreased over time to 78.1% (pulpotomy) and 75.3% (RCT) at 5 years.

DISCUSSION

Pulpotomy is a definitive treatment modality that is as effective as RCT. This could have a significant impact on treatment of such patients affording the advantages of retaining a vital pulp and preventing the need for RCT.

CONCLUSION

This review could only include two trials, hence there is insufficient evidence to draw robust conclusions. The clinical data accumulated so far suggests no difference in pain between RCT and pulpotomy at Day 7 postoperatively and a single randomized control trial suggests that the clinical success rate for both treatment modalities is similar long term. There is a need for more well-designed trials by different research groups to develop a stronger evidence base in this area.

REGISTRATION

PROSPERO database (CRD42021259744).

Pulpectomy vs. Pulpotomy as Alternative Emergency Treatments for Symptomatic Irreversible Pulpitis-A Multicenter Comparative Randomised Clinical Trial on Patient Perceptions

AIM

There needs to be more general agreement on the most effective treatment for the emergency patient with Symptomatic Irreversible Pulpitis (SIP). This equivalence randomised clinical study compared the clinical efficiency, as an urgent treatment, of pulpotomy (POT) and pulpectomy (PEC) in the permanent teeth with SIP. The primary outcome was pain management, and the secondary outcome was the patient's perception of duration, comfort, and satisfaction.

MATERIAL & METHODS

80 patients were blindly and randomly allocated into two equal parallel groups, the control group treated by PEC and the test group by POT. Data were collected through numerical rating scales (NRS) during the intervention and 6, 24, and 72 h post-op. Non-parametric tests were used to analyse the data. The Brunner-Longer models were adopted for longitudinal data and the analysis of variance (ANOVA)-type statistical was used.

RESULTS

The mean preoperative pain levels for the whole sample scored 5.8 ± 2.8 and significantly decreased to 2.1 ± 2.4 at 6 h, 1.5 ± 2.1 at 24 h, and 1.3 ± 2 at 72 h, without any differences between the groups. No significant differences were found in the patient's perception of treatment discomfort or duration between the groups. Three days after the intervention, patient satisfaction was high, with 9.2 ± 1.7 and 9.1 ± 2 in the PEC and POT groups, respectively. Self-reported pain was the only variable penalising the patient's final satisfaction.

CONCLUSIONS

The current randomised control trial (RCT) showed that both pulpectomy and pulpotomy effectively eliminate pain and achieve high levels of patient satisfaction. Furthermore, the patient's perceptions of the duration and discomfort of the two treatments were similar. Given that pulpotomy is a faster and more straightforward technique, it may be recommended as a viable and pragmatic option for treating emergency patients with symptomatic irreversible pulpitis.

Super Minimally Invasive Pulp Therapy for Severe Pulpitis: A Report of Two Cases

In regions where preventive dentistry is widespread, tooth loss due to root fracture occurs approximately 10 times more frequently than that due to caries and periodontal disease. Root fracture is most likely to occur in non-vital teeth, where the dental pulp has been removed, often through a procedure known as pulpectomy. However, super minimally invasive pulp (SMIP) therapy has recently been reported as a novel treatment approach for pulpitis of any degree. In this study, SMIP therapy was performed to preserve the vitality of teeth in two patients with severe pulpitis. Case one involved a 35-year-old man with a history of hypertension who presented with intense spontaneous pain in tooth #34. The pain was particularly severe while sleeping at night and on exposure to cold water or heat, but it was absent on percussion. Following the detection of cervical caries and severe pulp exposure, SMIP therapy was administered, and the tooth was subsequently restored using glass ionomer cement. Case two involved an 18-year-old woman with no significant medical history who had deep caries in tooth #46. She experienced mild tooth pain when exposed to cold water, and examination revealed pulp exposure. We applied mineral trioxide aggregate over the dental pulp and restored the tooth using composite resin. The vitality of both teeth was maintained at the three-month follow-up. To our knowledge, this is the first report of SMIP therapy for teeth with severe pulpitis. SMIP therapy is an innovative treatment that may cause a paradigm shift from conventional dental treatment.

Interfacial characteristics of BIOfactor MTA and Biodentine with dentin

The objective of this study was to characterize the interface between dentin and MTA-Angelus (Angelus, Londrina, Brasil), Biodentine (Septodont, France) and BIOfactor MTA (Imicryl, Konya, Turkey) using scanning electron microscopy (SEM), energy disperse X-ray spectroscopy (SEM-EDS) and confocal laser scanning microscopy (CLSM). Fifteen dentin segments were obtained from previously extracted single-rooted human teeth. Canal lumens were instrumented with diamond burs and then randomly filled with MTA-Angelus, Biodentine or BIOfactor MTA and placed in distilled water or Hanks' Balanced Salt Solution (HBSS) for 28-days. The samples were examined with SEM and the thickness of the interfacial layer measured. SEM-EDS analysis was performed to determine principal elemental composition of the material, dentin, and interfacial area. The marginal adaptation of cements to dentin was assessed by confocal microscopy and the percentage of material penetration was calculated. An interfacial layer was evident in approximately 70% of SEM images in both MTA-Angelus and BIOfactor samples. The thickness of interfacial layer was significantly higher in HBSS than in distilled water for all groups. MTA Angelus resulted in the thickest interfacial layer in distilled water while Biodentine had the thickest interfacial layer in HBSS. Calcium levels within the BIOfactor MTA-dentin interface were higher than both dentin and cement. Dentin penetration was higher in BIOfactor MTA and silicon was evident in all material-dentin interfaces. All calcium silicate-based materials promoted the formation of an interfacial layer. BIOfactor MTA exhibited promising characteristics with its good marginal adaptation even though it presented a moderately thick interfacial layer. RESEARCH HIGHLIGHTS: A distinguishable interfacial layer was observed in most of the samples within the BIOfactor MTA, MTA-Angelus and Biodentine groups. The elemental constitution of the interfacial layer was different from that of the calcium silicate based materials.

Determining the best anti-microbial properties of dental cements used for pulp capping procedures using deep dentinal carious material

Introduction

The exposure of the healthy pulp in cases of deep dentinal caries (DDC) that contain carious microorganisms can be prevented by placing a layer of pulp capping agent on the affected dentin. The cements used for pulp-capping should also ensure good anti-microbial properties. The present study was carried out to detect the antimicrobial efficacy of the commonly used cements by culturing the samples directly from DDC.

Aims

To determine the efficacy of dental cements in the growth inhibition of microorganisms involved in DDC using direct contact anaerobic culture test.

Method

100 samples of DDC were collected in RTF. Ten microliters of the specimen containing RTF was incubated in thioglycolate broth consisting of 1 mm3 cement blocks of GIC, CaOH2, ZnOE and MTA anaerobically for 24 hours. This was further sub-cultured using selective media for streptococcus mutans, lactobacillus and bifidobacterium. Growth inhibition was measured by calculating the number of CFUs and statistically analysed using ANOVA and Tukey's post-hoc tests.

Results

Tests showed variation in the anti-microbial effects of the cements and was highly significant at P < 0.001. Bifidobacterium showed most number of CFUs. MTA was the most effective pulp capping agent exhibiting 87.13% reduction in microbial growth, followed closely by ZnOE (84.6%).

Conclusion

A conservative approach to treat DDC is the need of the hour which calls for the use of pulp capping cements of good antimicrobial efficacy. The current study revealed bifidobacterium to be the most prevalent in DDC and the cement that would best inhibit the mixed culture growth was MTA followed closely by ZnOE.

Pulp Therapy of Primary Dentition; its Relevance despite Insufficient Histological Evidence: A Review

Pulp treatment in primary dentition is generally divided into vital and non-vital pulp therapies and assists in the preservation of pulpally involved primary teeth in the dental arch until the affected tooth naturally exfoliates. The success of pulp therapies depends on several factors; e.g. proper case selection, accurate diagnosis and good coronal seal. To date, studies on the success and failure rates of pulp treatments are based on clinical signs and symptoms, radiographic findings and histological analysis. However, the clinical and radiographic evidence may not completely portray the true status of the dental pulp. Histological evidence remains the gold standard in the assessment of pulp condition, whether it is in a healthy or adverse state. The aims of the current research were to summarise the treatment outcomes of pulp therapy in primary dentition based on clinical, radiographic and histological criteria, and to support its relevance in the presence of limited histological evidence to measure authentic treatment success. An electronic database search of dental literature from 1990 to 2022 was carried out using the MEDLINE, i.e. PubMed, database. Current dental literature showed that the success rates of primary tooth pulp therapy are high. The obtained results were based largely on clinical and radiographic studies with narrow histological investigations to assess the treatment outcome(s) of pulp therapy in primary dentition. Despite the scarcity of histological evidence, pulp therapies in primary teeth are still practical due to their statistically empirical success compared to their failure. Consequently, pulp therapy of primary dentition is still relevant, and should continue to be indicated as an important treatment option.

The scientific management of deep carious lesions in vital teeth using contemporary materials—A narrative review

Aim

The aim of this article is to review the scientific evidence for deep caries removal in permanent vital teeth and the choice of dentine replacement material and restoration of the teeth to maintain long term tooth vitality and function.

Method

The two position statements namely the European Society of Endodontology and the American Association of Endodontists position statements on vital pulp therapy will be scrutinized and compared with regards to the deep caries removal strategy and assessed for evidence of best practice. The properties of materials used to manage vital pulps and the best way to restore the teeth will be reviewed and guidance on the full management of vital teeth will be suggested.

Conclusions

Promoting new treatment modalities for reversible and irreversible pulpitis allowing for pulp preservation should be considered. Although debatable, cases with deep caries should be managed by complete non-selective caries removal which will allow for pulpal management if needed and a more predictable outcome can be expected when using the new materials and treatment modalities of vital pulp therapy.

Assessment of the remineralisation induced by contemporary ion-releasing materials in mineral-depleted dentine

OBJECTIVES

Evaluate the ability of current ion-releasing materials to remineralise bacteria-driven artificial caries lesions.

MATERIALS AND METHODS

Standardised class I cavities were obtained in 60 extracted human molars. Specimens underwent a microbiological cariogenic protocol (28 days) to generate artificial caries lesions and then were randomly divided into four restorative groups: adhesive + composite (negative control); glass ionomer cement (GIC); calcium silicate cement (MTA); and resin-modified calcium silicate cement (RMTA). Microhardness analysis (ΔKHN) was performed on 40 specimens (10/group, t = 30 days, 45 days, 60 days in artificial saliva, AS). Micro-CT scans were acquired (3/group, t = 0 days, 30 days, and 90 days in AS). Confocal microscopy was employed for interfacial ultra-morphology analysis (2/group, t = 0 days and 60 days in AS). Additional specimens were prepared and processed for scanning electron microscopy (SEM) and FTIR (n = 3/group + control) to analyse the ability of the tested materials to induce apatite formation on totally demineralised dentine discs (60 days in AS). Statistical analyses were performed with a significance level of 5%.

RESULTS

Adhesive + composite specimens showed the lowest ΔKHN values and the presence of gaps at the interface when assessed through micro-CT even after storage in AS. Conversely, all the tested ion-releasing materials presented an increase in ΔKHN after storage (p < 0.05), while MTA best reduced the demineralised artificial carious lesions gap at the interface. MTA and RMTA also showed apatite deposition on totally demineralised dentine surfaces (SEM and FTIR).

CONCLUSIONS

All tested ion-releasing materials expressed mineral precipitation in demineralised dentine. Additionally, calcium silicate-based materials induced apatite precipitation and hardness recovery of artificial carious dentine lesions over time.

CLINICAL RELEVANCE

Current ion-releasing materials can induce remineralisation of carious dentine. MTA shows enhanced ability of nucleation/precipitation of hydroxyapatite compared to RMTA and GIC, which may be more appropriate to recover severe mineral-depleted dentine.

Glass-ionomer and calcium silicate-based cements interactions with human dentine in health and disease: Two-photon fluorescence microscopy and Raman spectroscopy analysis

OBJECTIVES

To investigate the potential mineralising effects of calcium silicate-based dentine replacement material (Biodentine™) in comparison with glass-ionomer cement (GIC) (Fuji IX™) on different human dentine substrates using a multimodal non-invasive optical assessment.

METHODS

Cements were applied on artificially demineralised or naturally carious dentine and stored for 4 weeks in phosphate-rich media +/- tetracycline used for mineralisation labelling. Interfacial dentine was examined from the same sample and location before and after aging using two-photon fluorescence microscopy, fluorescence lifetime imaging (FLIM) and second harmonic generation (SHG) imaging. Additionally, Raman spectroscopy was used to detect changes in the mineral content of dentine.

RESULTS

Significant changes in the fluorescence intensity and lifetime were detected in partially demineralised dentine and caries-affected dentine underneath both tested cements, after storage (p < 0.001). This was associated with a significant increase in the mineral content as indicated by the increased intensity of the phosphate Raman peak located at 959 cm^-1 (p < 0.0001). Caries-infected dentine showed significant fluorescence changes under Biodentine™ after storage (p < 0.001), but not under GIC (p = 0.44). Tetracycline binding induced a reduction in the fluorescence lifetime with comparable increase in the fluorescence intensity in both cements' groups within the affected dentine (p < 0.001). Significance Two-photon fluorescence microscopy can be used efficiently for non-destructive in-vitro dentine caries characterisation providing a technique for studying the same dentine-cement interface over time and detect changes. Biodentine™ demonstrated comparable remineralising potential to GIC, in addition to inducing remineralisation of caries-infected dentine. This may suggest using Biodentine™ as part of minimally invasive operative dentistry (MID) in caries management.

Comparative Evaluation of the Efficacy of Light-Cured Calcium Hydroxide and a Fourth-Generation Calcium Silicate Cement (TheraCal LC) as Indirect Pulp Capping Materials in Patients With Deep Carious Lesions: A Randomized Parallel-Group Clinical Trial

Aim

The current study aims to evaluate and compare the efficacy of light-cured calcium hydroxide and a fourth-generation calcium silicate cement (TheraCal LC®) as indirect pulp capping (IPC) materials in patients with deep carious lesions.

Materials and methods

A total of 28 patients were randomly divided into two groups (n=14). Group A was managed by light-cured calcium hydroxide, while group B was treated with TheraCal LC (a fourth-generation calcium silicate cement). Clinical examination was conducted to check for postoperative pain, tenderness, and neural sensibility, and radiographical examination was conducted to check for periodontal ligament space widening, presence of calcific barrier, and periapical radiolucency at patient recall of 21 days, three months, and six months. Primary and secondary outcome variables were based on clinical and radiographical success rates noted at six months’ follow-up.

Results

Success rate for light-cured calcium hydroxide group at follow-up came out to be 0% at 21 days, 85.71% at three months, and 92.85% at six months. The success rate for TheraCal LC group came out to be 0% at 21 days, 92.85% at three months, and 100% at six months. The overall success rate for IPC procedure was 89.28% at three months’ follow-up and 96.42% at six months’ follow-up for both groups. The difference was statistically non-significant at the end of three and six months’ follow-up.

Conclusion

Within the limitations of our study, it was concluded that TheraCal LC can be used alternatively with light-cured calcium hydroxide in IPC, with a predictability of similar success outcome in patients with deep carious lesions.

Dental Pulp Response to Different Types of Calcium-Based Materials Applied in Deep Carious Lesion Treatment—A Clinical Study

Dental pulp vitality preservation in dental caries treatment is a major goal in odontotherapy. The main objective of this study was to compare dental pulp tissue responses to vital therapies in deep carious lesions, using different calcium-based materials. An ambispective study was conducted on 47 patients. Ninety-five teeth with deep carious lesions were treated. Among them, 25 (26.32%) were diagnosed with pulpal exposures and treated by direct pulp capping. Indirect pulp capping was applied when pulp exposure was absent (n = 70; 73.68%). Fifty teeth (52.63%) were treated with TheraCal LC (prospective study), 31 teeth (32.63%) with Calcimol LC, and 14 teeth (14.74%) with Life Kerr AC (retrospective study). The results show that the survival rate for dental pulp was 100% for Life Kerr AC, 92% for TheraCal LC, and 83.87% for Calcimol LC, without significant differences. Apparently, self-setting calcium hydroxide material provided better dental pulp response than the two light-cured materials, regardless of their composition, that is, either calcium -hydroxide or calcium silicate-based. We will need a significant number of long-term clinical studies with the highest levels of evidence to determine the most adequate biomaterials for vital pulp therapies.

Present status and future directions: Hydraulic materials for endodontic use

BACKGROUND

Hydraulic materials are used in Endodontics due to their hydration characteristics namely the formation of calcium hydroxide when mixing with water and also because of their hydraulic properties. These materials are presented in various consistencies and delivery methods. They are composed primarily of tricalcium and dicalcium silicate, and also include a radiopacifier, additives and an aqueous or a non-aqueous vehicle. Only materials whose primary reaction is with water can be classified as hydraulic.

OBJECTIVES

Review of the classification of hydraulic materials by Camilleri and the literature pertaining to specific uses of hydraulic cements in endodontics namely intra-coronal, intra-radicular and extra-radicular. Review of the literature on the material properties linked to specific uses providing the current status of these materials after which future trends and gaps in knowledge could be identified.

METHODS

The literature was reviewed using PUBMED, and for each clinical use, the in vitro properties such as physical, chemical, biological and antimicrobial characteristics and clinical data were extracted and evaluated.

RESULTS

A large number of publications were retrieved for each clinical use and these were grouped depending on the property type being investigated.

CONCLUSIONS

The hydraulic cements have made a difference in clinical outcomes. The main shortcoming is the poor testing methodologies employed which provide very limited information and also inhibits adequate clinical translation. Furthermore, the clinical protocols need to be updated to enable the materials to be employed effectively.

Should new operating procedures arising from COVID-19 make us re-think our management of deep caries?

COVID-19 has impacted heavily on the delivery of dental services within the UK, particularly in regards to aerosol generating procedures (AGPs). However, it has created an opportunity to reflect on how operative dental procedures, such as the management of dental caries, are undertaken. In light of recent evidence in favour of speed increasing contra-angle handpieces in combination with an electric micromotor to eliminate the generation of aerosols at certain speeds while still allowing the cutting of hard tooth tissue, albeit at a slower rate than the traditional air-turbine, this article explores the evidence for partial caries removal using the electric micromotor system. Aspects of maintaing the health of the pulpal tissue using this system and adopting a logical approach to placing adhesive direct resin composites to faciliate an optimum outcome for the patient are also explored.

Perspectives on Dental Caries: A Cross-Sectional Study among Parents of Primary School Children in Saudi Arabia

Background:

Dental caries is one of the most prevalent chronic childhood diseases affecting many people worldwide. Many people do not recognize the early signs of dental caries or its causes, which is crucial for the prevention and early intervention of the disease and consequently less-invasive and cheaper treatment options.

Objective:

This study aimed to evaluate the perspectives of parents about the meaning, causes, and early signs of dental caries, the association of tooth discoloration with decay, and the effect of different socio-demographic variables on the knowledge of patients regarding caries.

Methods:

Questionnaires were distributed to parents of primary school children in the region of Madinah, Saudi Arabia. Meaning of dental caries, early signs, causes of tooth discoloration related to decay, and the effect of different socio-demographic variables were calculated. Multiple linear regression analysis was carried out to identify significant predictor variables associated with caries knowledge scores.

Results:

There was a total of 2690 respondents. The majority had average caries knowledge scores. Lighter shades of tooth discoloration were reported to be associated with stains and warranted home care only, while darker shades were associated with caries and yielded a necessity for a visit to the dentist. Different socio-demographic variables had an effect on the caries knowledge of the parents.

Conclusion:

There is a need for increased knowledge about the early signs of dental caries among parents. Delayed recognition of signs of dental caries has a detrimental effect on the teeth of children and leads to seeking dental care at the later stages of the disease process. Community-oriented programs are fundamental for improving caries knowledge, its clinical presentations starting from its early signs, causes, and prevention.

Perspectives on Dental Caries: A Cross-Sectional Study among Parents of Primary School Children in Saudi Arabia

Background:

Dental caries is one of the most prevalent chronic childhood diseases affecting many people worldwide. Many people do not recognize the early signs of dental caries or its causes, which is crucial for the prevention and early intervention of the disease and consequently less-invasive and cheaper treatment options.

Objective:

This study aimed to evaluate the perspectives of parents about the meaning, causes, and early signs of dental caries, the association of tooth discoloration with decay, and the effect of different socio-demographic variables on the knowledge of patients regarding caries.

Methods:

Questionnaires were distributed to parents of primary school children in the region of Madinah, Saudi Arabia. Meaning of dental caries, early signs, causes of tooth discoloration related to decay, and the effect of different socio-demographic variables were calculated. Multiple linear regression analysis was carried out to identify significant predictor variables associated with caries knowledge scores.

Results:

There was a total of 2690 respondents. The majority had average caries knowledge scores. Lighter shades of tooth discoloration were reported to be associated with stains and warranted home care only, while darker shades were associated with caries and yielded a necessity for a visit to the dentist. Different socio-demographic variables had an effect on the caries knowledge of the parents.

Conclusion:

There is a need for increased knowledge about the early signs of dental caries among parents. Delayed recognition of signs of dental caries has a detrimental effect on the teeth of children and leads to seeking dental care at the later stages of the disease process. Community-oriented programs are fundamental for improving caries knowledge, its clinical presentations starting from its early signs, causes, and prevention.

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.

Well-Orientation Strategy Biosynthesis of Cefuroxime-Silver Nanoantibiotic for Reinforced Biodentine™ and Its Dental Application against Streptococcus mutans

Dental caries results from the bacterial pathogen Streptococcus mutans (S. mutans) and is the maximum critical reason for caries formation. Consequently, the present study aims to evaluate the antibacterial activity of a newly synthesized nanoantibiotic-Biodentine formulation. The silver nanoparticles (ROE-AgNPs) were biosynthesized from the usage of Rosmarinus officinalis L. extract (ROE) and conjugated with cefuroxime to form Cefuroxime-ROE-AgNPs. Using Biodentine™ (BIOD), five groups of dental materials were prepared, in which Group A included conventional BIOD, Group B included BIOD with ROE-AgNPs, Groups C and D included BIOD with Cefuroxime-ROE-AgNPs at concentrations of 0.5% and 1.5% cefuroxime, respectively, and Group E included BIOD with 1.5% cefuroxime. The synthesized ROE-AgNPs or Cefuroxime-ROE-AgNPs were characterized for conjugating efficiency, morphology, particle size, and in vitro release. Minimum inhibitory concentration (MIC) of the cefuroxime, ROE-AgNPs, and Cefuroxime-ROE-AgNPs were additionally evaluated against cefuroxime resistant S. mutans, which furthered antibacterial efficacy of the five groups of dental materials. The UV-Visible spectrum showed the ROE-AgNPs or Cefuroxime-ROE-AgNPs peaks and their formation displayed through transmission electron microscopy (TEM), X-ray diffraction (XRD) pattern, and Fourier transforms infrared (FTIR) analysis. The end result of Cefuroxime-ROE-AgNPs showed conjugating efficiency up to 79%. Cefuroxime-ROE-AgNPs displayed the highest antibacterial efficacy against S. mutans as compared to cefuroxime or ROE-AgNPs alone. Moreover, the MIC of ROE-AgNPs and Cefuroxime-ROE-AgNPs was detected against S. mutans to be 25 and 8.5 μg/mL, respectively. Consequently, Cefuroxime-ROE-AgNPs displayed that a decrease in the MIC reached to more than three-fold less than MIC of ROE-AgNPs on the tested strain. Moreover, Cefuroxime-ROE-AgNPs/BIOD was employed as a novel dental material that showed maximum antimicrobial activity. Groups C and D of novel materials showed inhibitory zones of 19 and 26 mm, respectively, against S. mutans and showed high antimicrobial rates of 85.78% and 91.17%, respectively. These data reinforce the utility of conjugating cefuroxime with ROE-AgNPs to retrieve its efficiency against resistant S. mutant. Moreover, the nanoantibiotic delivered an advantageous antibacterial effect to BIOD, and this may open the door for future conjugation therapy of dental materials against bacteria that cause dental caries.

Commercially Available Ion-Releasing Dental Materials and Cavitated Carious Lesions: Clinical Treatment Options

The contemporary approach for operative caries management emphasizes personalized interventions for each patient, dependent upon the individual's caries susceptibility/risk, the stage of the carious lesion and its activity. The clinician's challenge is to optimize the extent of cavity preparation and the choice of dental restorative biomaterials, appreciating the benefits offered by ion-releasing restorative materials. There is a growing application of bioactive/bio-interactive materials in minimally invasive operative dentistry, as they may help with tissue recovery by ion release. In case of moderate or extensive occlusal cavitation, the clinical criteria include the individual caries susceptibility and carious lesion activity. In high caries risk cases, ion-releasing biomaterials (IRB) can be used, as well as for active carious lesions. In proximal lesions, the clinical criteria include the individual caries susceptibility, the lesion activity and presence of cavities with little or no enamel at the gingival margin. This article aims to discuss the restorative ion-releasing options, according to different clinical situations, and the caries susceptibility to manage cavitated carious lesions in permanent adult teeth.

A prospective clinical study investigating the effectiveness of partial pulpotomy after relating preoperative symptoms to a new and established classification of pulpitis

AIM

To prospectively investigate the outcome of partial pulpotomy after 1 year, using a hydraulic calcium silicate cement (HCSC) on symptomatic cariously exposed pulps in adult teeth. To compare the traditional American Association of Endodontists (AAE) pulpitis classification with the recently proposed Wolters classification system in predicting the likelihood of treatment failure.

METHODOLOGY

Sixty-two symptomatic adult teeth with deep and extremely deep carious lesions were classified according to the Wolters (mild/moderate/severe pulpitis) and the traditional pulpitis classification (reversible/irreversible pulpitis). Eleven teeth were excluded intraoperatively as there was no pulp exposure after non-selective caries removal. The remaining 51 teeth, regardless of diagnosis, were treated by partial pulpotomy, pulpal lavage with 2.5% sodium hypochlorite solution, haemostasis and HCSC application (Biodentine™) as a pulp capping material. A permanent restoration was placed during a second appointment 1-2 weeks later. Preoperative tenderness to percussion (TTP), bleeding time and material setting time were recorded as was preoperative and postoperative tooth colour under standardized conditions. Clinical review occurred at regular intervals with clinical/radiographic analysis at 12 months. Chi-square analysis and Fisher's exact test assessed different outcomes amongst the diagnostic categories; the Kruskal-Wallis and Wilcoxon rank-sum test assessed influence of pulp bleeding time, TTP or variation in setting time (p < .05).

RESULTS

Ten cases were lost to review, and a total of 41 teeth were reviewed at 1 year and classified as either "success," "successful but unresponsive to sensibility testing" or "failed." This included five severe, 17 moderate and 19 mild pulpitis according to Wolters classification or 23 reversible pulpitis and 18 irreversible pulpitis cases by the AAE classification. The majority of the 62 enrolled cases were "extremely deep" (n = 50), rather than "deep" (n = 12) caries with all failures occurring in the extremely deep group. Partial pulpotomy was 90% successful (100% reversible, 78% irreversible or 100% mild, 88% moderate, 60% severe pulpitis) with a significant difference in outcome between mild and severe pulpitis groups (p = .04). Only one, severe pulpitis/irreversible pulpitis, case failed painfully prior to the 1-year review appointment. Bleeding time (p = .26) and TTP (p = .61) did not influence treatment outcome, whilst Biodentine™ setting time was significantly longer than manufacturers' claim (p < .05). No teeth discoloured.

CONCLUSIONS

Partial pulpotomy using Biodentine™ was successful for treating symptomatic carious pulpal exposures after 1 year, but included cases where pulp vitality could not be confirmed. Within the limitations of this study, cases with signs and symptoms indicative of irreversible pulpitis were not less successful; however, Wolters classification highlighted severe pulpitis to be less successful than mild pulpitis, thereby providing a potential prognostic benefit in diagnostically subdividing pulpitis. Caries depth was an indicator of failure, whilst bleeding time and preoperative tenderness to percussion were not.

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.

Follow-up of patients subjected to direct and indirect pulp capping of young permanent teeth. A retrospective study

OBJECTIVE

A retrospective study of the success rate of direct pulp capping (DPC) and indirect pulp capping (IPC) was carried out in children between 6-14 years-old, considering separately primary caries or caries affecting teeth with molar incisor hypomineralization (MIH).

MATERIAL AND METHODS

Data were collected in a dental public health service. Following the inclusion criteria, 232 treatments were analyzed. Success was defined by the presence of a functional tooth without clinical signs or symptoms of pulpal or periapical disease. The success rate was correlated to patient gender, the affected tooth and the indication of therapy using the chi-squared and Fisher exact test. The success time related to treatment type was evaluated through the Mann-Whitney test.

RESULTS

The IPC and DPC success rate was 99.4%, and 84.6%, respectively (p = .01). Success was significantly lower when caries affected teeth with MIH than when caries affected teeth without MIH (p = .01). The mean survival for DPC and IPC was 14.07 ± 1.30 and 15.98 ± 0.80 months, respectively (p = .07).

CONCLUSIONS

When caries were located in teeth that were not affected by MIH, IPC was significantly more successful than DPC, but did not differ significantly when caries were placed in teeth with MIH. Key points Minimally invasive therapy is a successful approach for decayed young permanent teeth. The success of IPC was greater than the success of DPC wen caries was placed in teeth not affected by MIH. In teeth not affected by MIH the success of DPC or IPC did not differ significantly.

The management of deep caries in UK primary care: A nationwide questionnaire-based study

AIM

To investigate current approaches and attitudes towards the management of deep caries in primary dental care within the United Kingdom (UK).

METHODOLOGY

Open distribution of an electronic questionnaire survey was undertaken to primary care dental professionals working in publicly funded National Health Service [NHS], privately funded, military and community dental services. Demographic variables investigated included the following: place of qualification, method of remuneration, level of restorative training, materials available, years qualified, appointment length and clinician type. Management variables focussed on case-based scenarios. Univariate analyses of responses to questions were undertaken using χ² tests with sequential Bonferroni correction. Variables with a statistical relationship of p ≤ .2 were selected for binary logistic regression modelling.

RESULTS

A total of 657 responses were received. Practitioners with formal postgraduate qualifications (PGQ) were more likely (OR, 95%CI) to undertake further tests to aid diagnosis including: gaining a patient history (1.80, 1.01-3.20), periapical radiography (1.43, 1.01-2.03), cold pulp testing (2.079, 1.46-2.97) and electric pulp testing (1.65, 1.02-2.65). Rubber dam was infrequently used for deep caries management (29.2%). Non-NHS practitioners were much more likely to use rubber dam (3.40, 2.15-5.37), as were those that had completed PGQ (2.24, 1.48-3.38). Non-selective caries removal was used in deep caries by 41.4% of practitioners. Indirect pulp caps were carried out by 56.7% of practitioners. NHS practitioners were more likely to place calcium hydroxide (3.74, 1.97-7.15), whilst non-NHS practitioners were more likely to place calcium silicate cements (CSCs) (3.303, 1.71-6.38) as were non-UK graduates (5.63, 2.47-12.86) and those with PGQ (2.12, 1.17-3.87).

CONCLUSIONS

This UK survey highlights significant variation in the management of deep caries. There is lack of consensus regarding the use of a standard systematic approach to diagnosing disease, with a reliance on history and tests with poor specificity. Non-selective caries removal for managing deep carious lesions remains common, with low rubber dam compliance underlining a lack of asepsis. Notably, a significant number of practitioners placed indirect pulp caps, but CSCs and GIC were not commonly used. At present, although clear guidelines are available this is not translating into consistent management approaches in practice, suggesting that better dissemination of current treatments is essential to undergraduate and postgraduate groups.

Comparison of Four Dental Pulp-Capping Agents by Cone-Beam Computed Tomography and Histological Techniques—A Split-Mouth Design Ex Vivo Study

Dental pulp-capping is done to preserve vital teeth when the pulp is exposed due to caries, trauma or instrumentation. Various materials are used as pulp-capping agents. The introduction of newer materials requires scientific studies to assess their clinical efficacy. The study was designed as a split-mouth randomized analysis of four pulp-capping agents (calcium hydroxide, mineral trioxide aggregate (MTA), Biodentine and EndoSequence root repair material (ERRM)). Based on selection criteria, 15 orthodontic patients requiring the extraction of four premolars (60 teeth total) were included in the study. After pulp-capping, the teeth were extracted after 8 weeks. We analyzed the extracted teeth using cone-beam computed tomography (CBCT) and histological sections to determine the quality of the dentinal bridge and the pulpal response. Ordinal scores were given based on the completeness of the dentinal bridge, the type of bridge and the degree of pulpal inflammation. Results were analyzed using a Kruskal–Wallis test (p < 0.05) with post hoc Conover values being used when applicable. All four pulp-capping materials elicited dentinal bridge formation (60/60). MTA had the highest scores (10/15) in dentinal bridge formation followed by ERRM (8/15). Both materials showed more samples with complete dentinal bridges (9/15 each) and a favorable pulpal response (15/15). Teeth capped with calcium hydroxide showed more cases of incomplete bridge formation (9/15) and pulpal inflammation. These differences in dentinal bridge formation and pulpal inflammation were statistically significant (p 0.001 and p 0.00005, respectively), with post hoc tests revealing no significant differences between MTA and ERRM (p 0.49 and p 0.71, respectively). MTA and ERRM performed better than the other pulp-capping materials but did not differ significantly from each other. The individual preference for a pulp-capping material may be based on clinical efficacy and handling characteristics.

Preserving pulp vitality: part two - vital pulp therapies

Vital pulp therapies (VPTs) aim to preserve the vitality of the pulp. The European Society of Endodontology have begun a campaign to raise awareness on the efficacy of VPTs following on from the publication of their 2019 position statement, aimed at both specialists and general dental practitioners. This review examines the current evidence surrounding VPTs and provides a rational approach to the management of the exposed pulp with the aid of case studies. Success lies in accurate diagnosis and case selection, along with well-executed treatment and appropriate follow-up protocols. The introduction of calcium silicate cements has made these treatments more predictable.

Tomographic evaluation of direct pulp capping using a novel injectable treated dentin matrix hydrogel: a 2-year randomized controlled clinical trial

OBJECTIVES

To assess clinically and radiographically the success of pulp capping procedure done in traumatically exposed permanent posterior teeth using a novel injectable treated dentin matrix hydrogel (TDMH), Biodentine, and MTA and to evaluate the formed dentin bridge under the capping materials using CBCT imaging.

MATERIALS AND METHODS

45 patients subjected to accidental traumatic pulp exposures by undergraduate dental students are allocated for this study. For each patient, a pulp capping procedure was done. TDMH was formed of TDM powder and sodium alginate to be injected and then hardened in the defect area. Patients were assigned to 3 groups: TDMH, Biodentine, and MTA, respectively, and returned to the clinic after 3, 6, 12, 18, and 24 months for clinical and radiographic examinations. Tomographic data, including thickness and density of formed dentin bridges, were evaluated at the end of the study period compared to the base line. Pulp sensitivity was evaluated throughout the study period using thermal testing and electric pulp tester.

RESULTS

During the follow-up period, all patients were asymptomatic with no clinical signs and symptoms and revealed no radiographic signs of pathosis. However, tomographic evaluation showed the tested materials to have different levels of impact on formed dentin bridges with TDMH group resulted in significantly superior dentin bridges of a higher radiodensity and thickness than Biodentine and MTA.

CONCLUSIONS

TDMH has a greater potential to induce dentin bridge formation than Biodentine and MTA under standardized conditions. Additionally, CBCT imaging was confirmed as a non-invasive and inclusive approach to evaluate the formed dentin bridges after pulp capping procedure.

CLINICAL RELEVANCE

Direct pulp capping can be done successfully with this novel injectable pulp capping material in future clinical applications.

TRIAL REGISTRATION

PACTR201901866476410.

Current perspectives on dental adhesion: (2) Concepts for operatively managing carious lesions extending into dentine using bioactive and adhesive direct restorative materials

This article reviews the current concepts for operatively managing carious lesions extending into dentine with minimal removal of tooth structure and restoring with dentine adhesives and direct composite resin. It looks sequentially at the operative steps involved including remineralisation with bioactive cements, bonding to caries-affected dentine including smear-layer modification using HOCl, creation of an acid-base resistance zone,steps to optimise the performance of all-in-one adhesives, and incremental placement of direct composite resin to improve bond strengths to cavity floor dentine. It explores how understanding the phenomenon of colour-shifting at the composite resin-enamel/dentine restoration borders can help in creating near "invisible" restoration margins through a "chameleon" effect. With the increased risks of transmission of Covid-19 when aerosol generating procedures are carried out in Dentistry, following a minimally invasive approach to managing dental caries should be given serious consideration.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ChiCTR2000032462.

Correlation between the clinically diagnosed inflammatory process and periapical index scores in severely painful endodontically involved teeth

Aim

To assess and correlate three distinct states of severely painful endodontically derived inflammation with their depiction on periapical radiographs using periapical index (PAI) scores.

Methodology

During a period of 15 months, 368 consecutively enrolled patients with suspected endodontic emergency conditions were examined at the University of Zurich, Center of Dental Medicine. Cases with a severely painful (numeric rating scale, NRS‐11 > 6) endodontically involved tooth and a clear pulpal and apical diagnosis (n = 162) were selected (one tooth per patient). Teeth were divided into three groups according to the clinically diagnosed main location of the inflammatory process: level 1: pulp (positive response to cold test), level 2: periodontium (no response to cold without swelling) and level 3: periapical tissues (no response to cold with swelling). Periapical radiographs were obtained using a digital unit and analysed by two calibrated observers. For level 2, which had the highest PAI variance (n = 76), the PAI scores were further scrutinized regarding their dependence on tooth location and the duration of pain. Data were analysed using chi‐squared and non‐parametric tests, alpha = 0.05.

Results

Overall, the PAI scores correlated well with the clinically diagnosed main location of periapical inflammation (Spearman’s rho = 0.5131, P < 0.001), with level 1 having the lowest scores by far (P < 0.001) and level 2 having significantly lower scores compared to level 3 (P < 0.05). However, a PAI score of 5 was found in merely 3 teeth within the entire cohort, and 49% of the teeth in the level 2 group had no radiolucency (PAI < 3). Within level 2, the PAI scores were not dependent on tooth location but were substantially (P < 0.001) higher for teeth which had hurt for more than one week, and for root filled teeth.

Conclusions

For the analysed, severely painful endodontically involved teeth, the clinically diagnosed main location of inflammation was reflected by the periapical index. PAI scores were not significantly influenced by anatomical noise, yet in some cases under‐estimated the clinical situation.

A Combination of Full Pulpotomy and Chairside CAD/CAM Endocrown to Treat Teeth with Deep Carious Lesions and Pulpitis in a Single Session: A Preliminary Study

A higher chance of carrying out a successful full pulpotomy may depend on whether the coronal restoration can be completed within a single appointment. The development of chairside CAD/CAM (Computer Aided Design and Manufacturing) technology has made it possible to carry out indirect restoration of endodontically treated teeth in a single session. This study aimed to evaluate the long-term outcome of a full pulpotomy with Biodentine™ immediately covered with a chairside CAD/CAM endocrown on teeth affected by pulpitis and deep carious lesions. The investigation involved a cohort of 30 molars that were treated by pulpotomy and CAD/CAM endocrown. Clinical and radiological examinations were scheduled at 1, 6, and 12 months postoperatively. Overall, all treatments were effective at any time during the follow-up. The results of this study need to be confirmed with a longer-term follow-up to allow for comparison with the literature. This original combination of endodontic and restorative treatments provides an Endo-prosthetic continuum in a single session, with the objective of long-term success in terms of tooth health.

The influence of a liner on deep bulk-fill restorations: Randomized clinical trial

OBJECTIVE

The aim of this study was to evaluate the influence of a liner on the clinical performance of deep posterior restorations performed with bulk-fill composite.

METHODS

30 subjects received two restorations on deep preparations in posterior teeth, without pulpal exposure, after selective carious-tissue removal in one-stage. The internal walls reached the inner quarter of dentin, but with a radiographically detectable zone of firm dentin remaining. The pulpal protection using a layer of glass ionomer composite liner (Ionoseal, Voco) was applied in just one preparation. The adhesive system Futurabond U (Voco) was applied in all preparations, which were restored with the bulk-fill pure Ormocer nanohybrid composite (Admira Fusion Xtra - Voco), in up to 4 mm thick increments. All restorations were evaluated using the FDI criteria after 7 days, 6, 12 and 24 months postoperatively.

RESULTS

After 24-months, 25 patients attended the recall and 50 restorations were evaluated. The Fisher's statistical analysis (5%) showed no difference between the techniques for the esthetic, functional and biological properties. No postoperative sensitivity was reported for both groups.

CONCLUSION

The application of a liner did not influence the clinical performance of deep restorations with bulk-fill Ormocer composite.

CLINICAL RELEVANCE

The application of a liner with a GIC-based material did not have a significant effect on the clinical performance of bulk-fill restorations and seems to be unnecessary for the material tested.

Self-Limiting versus Rotary Subjective Carious Tissue Removal: A Randomized Controlled Clinical Trial-2-Year Results

Background: the aim of this study was to assess the 2-year pulp survival of deep carious lesions in teeth excavated using a self-limiting protocol in a single-blind randomized controlled clinical trial. Methods: At baseline, 101 teeth with deep carious lesions in 86 patients were excavated randomly using self-limiting or control protocols. Standardized clinical examination and periapical radiographs of teeth were performed after 1- and 2-year follow-ups (REC 14/LO/0880). Results: During the 2-year period of the study, 24 teeth failed (16 and 8 at T12 and T24, respectively). Final analysis shows that 39/63 (61.9%) of teeth were deemed successful (16/33 (48.4%) and 23/30 (76.6%) in the control and experimental groups, respectively with a statistically significant difference (z score = 2.3, p = 0.021). Of teeth with severe and mild symptoms at T0, 42.9% and 36.7% respectively failed at T24 (p > 0.05). Within the self-limiting group, there was a lower success in premolars compared to molars (p < 0.05). Conclusion: after 2 years, there was a statistically significant higher pulp survival rate of teeth with deep carious lesions excavated using self-limiting protocols in patients with reversible pulpitis. Molars showed higher success than premolars in teeth excavated using the self-limiting protocol. There was no statistically significant association between the outcome and the severity of symptoms at T0 (ClinicalTrials.gov NCT03071588).

Schneiderian membrane thickness variation following endodontic procedures: a retrospective cone beam computed tomography study

BACKGROUND

To assess the change of the Schneider membrane thickness measured by CBCT before and after root canal treatment, retreatment and pulp capping procedures.

METHODS

This retrospective study was conducted on CBCT scans of a patient population of Guy's Hospital NHS Foundation Trust, London. Three groups of patients were studied: Group 1 consisted of patients referred for primary endodontic treatment; Group 2 for endodontic retreatment; Group 3 for indirect pulp capping procedures (serving as a control group). Follow up scans were carried out 1 year after treatment. Measurements were carried out on CBCT scans and data were analysed statistically by Wilcoxon Signed Rank Test. Linear regression was used to assess predictive parameters for membrane thickness.

RESULTS

A statistically significant reduction of the Schneider membrane thickness was observed one year after endodontic treatment and retreatment (P < 0.05) but no significant reduction was observed after pulp capping procedures. Linear regression showed that age and gender were significant predictors influencing the Schneider membrane thickness.

CONCLUSIONS

Within the limitations of this retrospective study, following root canal treatment and re-treatment a Schneiderian membrane thickness reduction occurred at 1-year follow-up. The removal of odontogenic infection following endodontic treatment may help reducing the thickness of the Schneider membrane.

Histologic Response of Human Pulp and Periapical Tissues to Tricalcium Silicate-based Materials: A Series of Successfully Treated Cases

Pulpal/periapical responses of human teeth that are treated successfully with tricalcium silicate-based materials are extremely difficult to obtain because of the typical unavailability of these teeth for histologic examination. The present case series reports histologic and histobacteriologic findings of 3 human teeth that had undergone pulpotomy, orthograde retreatment, and apicoectomy/root-end filling using tricalcium silicate-based endodontic materials. The teeth were extracted after 34 days, 7 weeks, and 20 months, respectively, because of unusual circumstances. The extracted teeth were processed, paraffin embedded, sectioned, stained with hematoxylin-eosin or the modified Brown and Brenn technique, and examined with light microscopy. The recurrent observation for the 3 cases presented was the absence of inflammatory or foreign body reactions of the host tissues in contact with tricalcium silicate-based materials after different observation periods despite the identification of bacteria in dentinal tubules close to the site of operation. Wound healing was rapid with repair/regeneration of lost tissues with cementum and new bone trabeculae. Although the level of evidence for a case series is low because of the anecdotal nature of the reported episodes, the histologic results reported in the present case series illustrate the highly biocompatible and bioactive nature of the tricalcium silicate-based materials used in treating these cases.

Selective versus stepwise removal of deep carious lesions in permanent teeth: a randomised controlled trial from Egypt-an interim analysis

OBJECTIVES

To compare the success, survival and costs of selective versus stepwise carious tissue removal (SE/SW) in permanent teeth with deep (>2/3 dentine depth) carious lesions.

DESIGN

Randomised controlled, unicentre, clustered two-arm superiority trial.

SETTING

Outpatient clinic of a private university in Cairo, Egypt.

PARTICIPANTS

One hundred and fifteen participants (n=132 teeth), aged 18-47 years, from Cairo, Egypt, were enrolled. Premolars/molars with occlusal/occlusal-proximal deep lesions (radiographically >2/3 dentine), sensible pulps, without spontaneous pain, were included.

INTERVENTIONS

Peripheral carious tissue removal to hard dentine was performed. Pulpo-proximally, soft dentine was left. A glass ionomer (GI) restoration was placed. After 3-4 months, teeth were randomly allocated to SE (n=66), with reduction of the GI into a base and no further tissue removal, followed by a composite resin restoration, or SW (n=66), with full removal of the GI, additional excavation until firm dentine pulpo-proximally, followed by a GI-based composite restoration. Mean follow-up was 1 year.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was success (absence of endodontic/restorative complications). Secondary outcomes were tooth survival and initial and total treatment costs.

RESULTS

Zero/five pulp exposures occurred during SE/SW, and seven/five SE/SW teeth required endodontic therapy. Success after 12 months was 89.4% for SE and 84.9% for SW. The estimated mean time free of complications was 23 and 18 months for SE and SW, respectively, without significant differences between SE and SW (p>0.05/Cox). Initial treatment costs were significantly higher for SW (mean (SD): 507.5 (123.4) Egyptian pounds (EGP)) than SE (mean (SD): 456.6 (98.3) EGP), while total costs showed no significant difference (p>0.05).

CONCLUSION

Within the limitations of this interim analysis, and considering the depth of these lesions (>2/3 dentine), SE and SW showed similar risk of failure and overall costs after 1 year.

TRIAL REGISTRATION NUMBER

PACTR201603001396248.

Performance of Adhesives and Restorative Materials After Selective Removal of Carious Lesions: Restorative Materials with Anticaries Properties

Selective carious tissue-removal strategies require specific considerations in selection of restorative materials. A tight marginal seal placed over hard dentin and sound enamel is essential. For selective removal of carious tissue with permanent restoration, bioactive materials, such as high-viscosity glass-ionomer cement (HV-GIC) or calcium silicates, may be preferred over caries-affected firm or leathery dentin to improve remineralization. HV-GICs have the best clinical evidence of caries-arresting effect and demonstrate sufficient longevity as long-term provisional restorations that can later be used in open or closed sandwich restorations. As with any material, oral health maintenance remains important for long-term survival of restorations.

Comparative evaluation of clinical outcome of indirect pulp treatment with calcium hydroxide, calcium silicate and Er,Cr:YSGG laser in permanent molars

BACKGROUND

The aim of the study was to compare preservation of pulp vitality by indirect pulp treatment with calcium hydroxide, calcium silicate based cement (Biodentine) and Er,Cr:YSGG laser in permanent molars.

MATERIALS AND METHODS

30 patients were selected for this study as per the inclusion and exclusion criteria in the age group of 6-14 years and then randomly allocated to three groups A, B & C. In group A, after caries excavation, calcium hydroxide (Dycal) was placed at the floor. In group B, after caries excavation, calcium silicate based cement (Biodentine) was placed at the floor. In group C, after caries excavation, decontamination of the cavity was done with Er,Cr:YSGG laser. This was followed by placement of permanent restorative material in all the groups. Clinical and radiographic success was monitored at 3, 6 and months. Data analysis was performed using Statistical Package for the Social Science-21 (SPSS-21).

RESULTS

At the end of 9 months, overall success rate of indirect pulp was 86.6%. There was no significant difference between the three groups. (p > 0.05).

CONCLUSION

The study showed that the success of indirect pulp treatment is independent of the type of liner used for pulp capping. Moreover, the study also shows that Er,Cr;YSGG laser can be effectively used for indirect pulp capping procedures.