Randomized Clinical Trials on Deep Carious Lesions: 5-Year Follow-up

Exploring deep caries management and barriers to the use of vital pulp treatments by primary care dental practitioners

AIM

The European Society of Endodontology outlines best practices for the management of deep caries and the pulp. Despite evidence supporting vital pulp treatments (VPTs) as predictable alternatives to conventional endodontic treatment, studies have shown they are not widely adopted in the UK. This study aimed to explore the barriers to implementation of VPTs by primary care general dental practitioners (GDPs).

METHODOLOGY

Qualitative one-to-one semi-structured online interviews were conducted with purposively sampled UK GDPs. Interview transcripts were analysed using reflexive thematic analysis. Recurring themes were iteratively refined as additional transcripts were reviewed.

RESULTS

Eleven participants were interviewed. A range of barriers to the provision of VPTs were identified, which aligned with two core themes: 'Motivational barriers to service provision' and 'Educational access & opportunities'. Sub-themes included lack of access to materials and equipment, deficiencies in knowledge of treatment (including protocols, outcomes and prognosis), lack of confidence (in treatment efficacy and clinical ability), time constraints and public dental service funding and remuneration.

CONCLUSIONS

This study identifies barriers to the widespread adoption of VPTs among primary care GDPs in public and private settings. Economic constraints, practitioner confidence, time limitations and educational gaps are key challenges. Addressing these may require systemic changes such as policy interventions, education and improved resource allocation.

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.

Restorations performance after selective caries removal to soft dentine: 18-month follow-up of a controlled clinical trial

OBJECTIVE

This randomized controlled clinical trial aimed to evaluate the clinical performance of composite resin restorations placed after selective caries removal to soft dentin (SCRSD) or stepwise excavation (SW) over an 18-month period.

METHODS

Inclusion criteria were patients with permanent molars and/or premolars presenting deep caries lesions (≥50% of the dentin thickness). Teeth were submitted to SCRSD (n=76) or SW (n=76). Evaluations were performed based on FDI (World Dental Federation) criterion. Survival analysis was performed to estimate the survival of restorations and its association with clinical variables and socio-demographic characteristics (adjusted Weibull regression model). The study was registered on Registro Brasileiro de Ensaios Clínicos (ReBEC 65ntbc).

RESULTS

The follow-up period ranged from 6 to 18 months (mean±SD 16.3±3.4 months). Patients' ages ranged from 9 to 55 years (mean±SD 29±10.5 years). A total of 135 teeth (SCRSD=72; SW=63) from 101 patients were evaluated. There were 4 failures in the SCRSD group (2 loss of restoration in need of replacement and 2 marginal fractures in need of repair) and 2 in the SW group (fracture in need of repair). The association between explanatory variables and restoration failure showed similar success rates for SW (99.4%) and SCRSD (97.9%) (p=0.16). Patients presenting gingivitis (≥20% of sites with gingival bleeding) had 8.50 times more risk for failure than those with <20% of bleeding sites (p=0.03).

CONCLUSION

This study showed that placing a composite resin restoration over soft dentin (after SCRSD) did not affect its clinical performance after 18 months.

CLINICAL SIGNIFICANCE

SCRSD is a feasible treatment option for the management of deep caries lesions in permanent teeth as it preserves tooth vitality and tooth structure without compromising restoration longevity.

Viability and oxidative stress of dental pulp cells after indirect application of chemomechanical agents: An in vitro study

AIM

This study evaluated the transdentinal cytotoxic effects of enzymatic agents (EA) for chemomechanical carious tissue removal on human dental pulp cells.

METHODOLOGY

The groups were based on the performed dentine treatments (n = 8): G1: Positive Control (PC - no treatment); G2: Negative Control (NC - 35% H2 O2 for 2 min); G3: Brix 3000™ (BX) for 30 s; G4: BX for 2 min; G5: Papacarie Duo™ (PD) for 30 s; G6: PD for 2 min. The cells were evaluated for viability (VB; MTT assay) and production of reactive oxygen species (ROS; DCFH-DA assay) and nitric oxide (NO; Griess reagent). A scanning electron microscope provided morphological chemical analyses and energy-dispersive X-ray spectroscopy. The data were submitted to the one-way anova statistical test complemented by Tukey (p < .05).

RESULTS

Cell viability decreased by 21.1% and 58.4% in G5 and G6, respectively. ROS production in G3 and G4 maintained basal levels but increased by 171.2% and 75.1% in G5 and G6, respectively.

CONCLUSIONS

The Brix3000™ enzymatic agent did not cause indirect cytotoxic effects on pulp cells, regardless of the application time. Conversely, Papacarie Duo™ reduced viability and increased ROS production by pulp cells.

3-year randomized clinical trial to evaluate the performance of posterior composite restorations lined with ion-releasing materials

To evaluate the impact of using ion-releasing liners on the 3-year clinical performance of posterior resin composite restorations after selective caries excavation with polymer burs. 20 patients were enrolled in this trial. Each patient had two deep carious lesions, one on each side of the mouth. After selective caries removal using polymer bur (PolyBur P1, Komet, Brasseler GmbH Co. KG, Lemgo, Germany), cavities were lined with bioactive ionic resin composite (Activa Bioactive Base/Liner, Pulpdent, Watertown, MA, USA) or resin-modified glass ionomer liner (Riva Light Cure, SDI, Bayswater, Victoria, Australia). All cavities were then restored with nanofilled resin composite (Filtek Z350XT, 3M Oral Care, St. Paul, MN, USA). All the tested materials were placed according to the manufacturers' instructions. Clinical evaluation was accomplished using World Dental Federation (FDI) criteria at baseline and after 6 months, 1, 2, and 3 years. Data were analyzed using Mann-whitney U and Friedman tests (p < 0.05). The success rates were 100% for all resin composite restorations either lined with ion-releasing resin composite or resin-modified glass ionomer liner. Mann-whitney U test revealed that there were no statistically significant differences between both ion-releasing lining material groups for all criteria during the follow-up periods (p > 0.05). Resin composite restorations showed acceptable clinical performance over 3 years either lined with bioactive ionic or resin-modified glass ionomer liners after selective caries excavation preserving pulp vitality. After the 3-year follow-up period, Activa Bioactive and Riva Light Cure liners were clinically effective and they exhibited with the overlying composite restorations successful clinical performance.Trial registration number: NCT05470959. Date of registration: 22/7/2022. Retrospectively registered.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring the declared and the formal and informal taught curricula at a UK dental school through the lens of pulp management

Introduction This paper explores the declared and formal and informal taught endodontic curriculum within an undergraduate dental programme in the UK as part of a wider study, which also investigates the learned curriculum. Management of the dental pulp was chosen due to the availability of clear internationally recognised guidelines.Method The declared curriculum was identified through existing course guides and seminar and practical session plans. The formal taught curriculum was identified by cataloguing all lectures, practical teaching sessions, seminars and handouts available to dental students. Questionnaires using clinical vignettes were used to explore the informal taught curriculum.Results Valid responses to the questionnaire were received from 25/40 (62.5%) clinical supervisors. Disparities between national guidelines and the declared and taught curriculum were primarily due to broad learning objectives and disparate information from lectures and supervising clinicians. Although the majority of formal teaching aligned with national guidelines, the main deviation occurred within the informal taught curriculum.Conclusion This study highlights disparities between current evidence-based guidelines and the declared and taught curriculum in relation to pulp management in a UK dental school. Recommendations are that all policies, procedures and protocols are updated and aligned to a contemporaneous evidence base annually, plus engagement with clinical lecturers, to enable more standardised teaching.

Dietary Habits and Oral Hygiene as Determinants of the Incidence and Intensity of Dental Caries-A Pilot Study

OBJECTIVES

The aim of this study was to assess the influence of dietary and hygiene habits on the prevalence and intensity of dental caries. A group of 148 adults participated in the study.

METHODS

A self-administered nutrition and oral hygiene questionnaire was used to assess dietary habits and oral hygiene routine. A preventive diet index (PDI), a cariogenic diet index (CDI), and an oral health hygiene and prevention index (OHHPI) were created based on part of the questions. The intensity of dental caries among the respondents was investigated by the decayed, missing, and filled teeth index (DMFT), which was estimated on the basis of data obtained during the dental examination.

RESULTS

The study showed that 97% of the respondents had filled carious cavities, while untreated carious cavities were observed in up to 78% of the study participants. The respondents had an average consumption of preventive products and a low consumption of caries-stimulating foods. The preventive dietary index (PDI) value was higher in the female group than in the male group. A more frequent consumption of caries-inhibiting products was demonstrated by those declaring that they took various types of dietary supplements. The use of health-promoting sugar substitutes by the respondents was associated with a lower intensity of dental caries and a more frequent consumption of preventive products.

CONCLUSIONS

The analysis of the survey results indicates the need to implement educational activities aimed at increasing public awareness of the prevalence of dental caries among adults.

Effectiveness of vital pulp treatment in managing nontraumatic pulpitis associated with no or nonspontaneous pain: A systematic review

BACKGROUND

The exposed pulp has been the topic of numerous studies, but well-designed and well-executed comparative trials on the outcome and treatment of these teeth have been limited.

OBJECTIVES

This study was conducted to answer the following questions: in patients with nontraumatic pulpitis associated with no or nonspontaneous pain in permanent teeth, (i) is direct pulp capping or pulpotomy (partial/full) as effective as selective or stepwise caries removal [Population/participants, Intervention(s), Comparator(s)/control, Outcome(s) (PICO) 1], (ii) is pulpotomy (partial/full) as effective as direct pulp capping (PICO 2) and (iii) is pulpotomy (partial/full) as effective as a pulpectomy (PICO 3), in terms of a combination of patient and clinical reported outcomes, with 'tooth survival' as the most critical outcome?

METHODS

A literature search was conducted using Clarivate Analytics' Web of Science, Scopus, PubMed and Cochrane Central Register of Controlled Trials from inception to November 3rd 2021. Grey literature and contents of the major subject journals were examined. Eligibility criteria followed the PICO questions. Two independent reviewers performed study selection, data extraction and appraisal; disagreements were resolved by a third reviewer. The risk of bias was assessed by the revised Cochrane risk-of-bias tool for randomized trials.

RESULTS

Three randomized clinical trials (RCTs) were included in the review. No study fulfilled the criteria to answer PICO 1. There were no significant differences in the reported outcomes between investigated treatments in all included RCTs. None of the included studies reported the most critical outcome 'tooth survival'. A high loss of patients during the follow-up period was observed.

DISCUSSION

Although a few studies fulfilled strict eligible criteria, the results of this systematic review clearly highlight a paucity of available evidence. At the present time, clinical decisions cannot be substantiated by direct comparative trials.

CONCLUSIONS

Based on limited evidence, this systematic review discovered no significant differences in effectiveness between compared vital pulp treatments in managing nontraumatic pulpitis associated with no or nonspontaneous pain. Further high-quality RCTs are necessary to investigate the effectiveness of direct pulp capping or pulpotomy (partial/full) compared to selective or stepwise caries removal.

REGISTRATION

PROSPERO database (CRD42021259742).

Treatment of pulpal and apical disease: The European Society of Endodontology (ESE) S3-level clinical practice guideline

BACKGROUND

The ESE previously published quality guidelines for endodontic treatment in 2006; however, there have been significant changes since not only in clinical endodontics but also in consensus and guideline development processes. In the development of the inaugural S3-level clinical practice guidelines (CPG), a comprehensive systematic and methodologically robust guideline consultation process was followed in order to produce evidence-based recommendations for the management of patients presenting with pulpal and apical disease.

AIM

To develop an S3-level CPG for the treatment of pulpal and apical disease, focusing on diagnosis and the implementation of the treatment approaches required to manage patients presenting with pulpitis and apical periodontitis (AP) with the ultimate goal of preventing tooth loss.

METHODS

This S3-level CPG was developed by the ESE, with the assistance of independent methodological guidance provided by the Association of Scientific Medical Societies in Germany and utilizing the GRADE process. A robust, rigorous and transparent process included the analysis of relevant comparative research in 14 specifically commissioned systematic reviews, prior to evaluation of the quality and strength of evidence, the formulation of specific evidence and expert-based recommendations in a structured consensus process with leading endodontic experts and a broad base of external stakeholders.

RESULTS

The S3-level CPG for the treatment of pulpal and apical disease describes in a series of clinical recommendations the effectiveness of diagnosing pulpitis and AP, prior to investigating the effectiveness of endodontic treatments in managing those diseases. Therapeutic strategies include the effectiveness of deep caries management in cases with, and without, spontaneous pain and pulp exposure, vital versus nonvital teeth, the effectiveness of root canal instrumentation, irrigation, dressing, root canal filling materials and adjunct intracanal procedures in the management of AP. Prior to treatment planning, the critical importance of history and case evaluation, aseptic techniques, appropriate training and re-evaluations during and after treatment is stressed.

CONCLUSION

The first S3-level CPG in endodontics informs clinical practice, health systems, policymakers, other stakeholders and patients on the available and most effective treatments to manage patients with pulpitis and AP in order to preserve teeth over a patient's lifetime, according to the best comparative evidence currently available.

Assessing the Acceptability of Less Invasive Caries Removal Techniques for treating Deep Carious Lesions: A Conjoint Survey among Dentists Practicing in a Midwestern American State

This study identified factors that influence dentists' decisions regarding less invasive caries removal techniques such as stepwise removal (SW) and selective removal (SE) using a marketing research technique, conjoint analysis. A survey was sent to 1,434 dentists practicing in Iowa. Dentists were randomly assigned to receive a questionnaire to rate the likelihood they would use either SW/SE in hypothetical clinical scenarios. The scenarios were carefully created by conjoint design and included three relevant attributes: depth of lesion, hardness of carious dentin, and patient age. Descriptive and conjoint analyses were performed to assess trade-offs between these attributes, using SPSS. The study revealed that depth of lesion was the most important factor in the dentists' decisions (49 importance value) when choosing a SW to treat a deep carious lesion, followed by hardness of carious dentin and patient age (21 importance value). For the SE group, depth of the lesion was also the predominant factor when selecting a treatment. The study also identified that a high proportion of dentists (24.9%) indicated they would never consider using SW or SE under any circumstances. Our survey showed that depth of lesion was the most important reason to select a less invasive caries removal method. The high proportion of dentists indicating they would never consider selective caries removal (SE) techniques suggests that these less invasive options are underutilized.

Cost-effectiveness of selective caries removal versus stepwise excavation for deep caries lesions

A multicenter, randomized controlled clinical trial evaluated the effectiveness of two treatments for deep caries lesions in permanent molars - selective caries removal (SCR) to soft dentin with restoration in a single visit, and stepwise excavation (SW) - regarding pulp vitality for a 5-year follow-up period. The present study aimed to determine the cost-effectiveness of these treatments. Treatments were conducted in two Brazilian cities (Brasília and Porto Alegre). At baseline, 299 permanent molars (233 patients) were treated and 229 teeth (174 patients) were evaluated after 5 years. The discounted cash flow method was adopted. The total cost of each treatment was calculated, and the failure cost (endodontic treatment + restoration) was added to the final cost, according to the 5-year failure rates of each therapy (20% for SCR and 44% for SW). A public health service unit composed of three dentists in 4-hour work shifts was used to calculate the monetary value of the treatments, assuming a total of 528 treatments/month. Considering the 229 teeth evaluated after 5 years (115 SCR and 114 SW), SCR provided savings of 43% (amalgam) and 41% (resin composite) per treatment, compared to SW. The SCR technique provides benefits for public finances (direct economy) and for public health services (increase in the number of treatments performed). Considering that maximizing profit and reducing costs are powerful motivating factors for adopting a certain treatment, this study provides data to better support the decision-making process, regarding the management of deep caries lesions in permanent molars.

Deep Carious Lesions Management with Stepwise, Selective, or Non-Selective Removal in Permanent Dentition: A Systematic Review of Randomized Clinical Trials

OBJECTIVE

The goal of this systematic study was to investigate the effectiveness of selective, stepwise, and non-selective removal techniques for caries removal in permanent teeth with deep carious lesions. The primary focus was the results found comparing techniques for caries removal to check whether there was pulp exposition; the secondary was the materials used for pulp protection and clinical findings reported within the included studies.

METHODS

The search was performed in two databases (PubMed/MEDLINE and Web Of Science). The studies included in this systematic review were selected based on eligibility criteria. The inclusion criteria were: (1) randomized controlled trials (RCTs), (2) that compared the total removal of carious tissue with selective removal in permanent teeth with deep carious lesions, (3) with a follow-up period of at least 6 months, and (4) publications in English. Regarding the exclusion criteria, the following were not considered: (1) articles published in other languages, (2) articles that did not compare the different types of total/selective decay removal, and (3) articles published before January 2008. The risk of bias and the quality of the included studies were independently assessed by two reviewers using the RoB 2 tool.

RESULTS

5 out of 105 potentially eligible studies were included. Regarding the teeth included in the study, three articles performed management only on permanent molars, while other studies also performed management on incisors/canines/premolars/molars. Management protocols were divided into nonselective caries removal and partial caries removal (selective/stepwise). The theory of non-selective caries removal was considered an excessive, unnecessarily invasive option and a form of outdated management, and selective removal was preferred.

CONCLUSION

The selective removal technique presented a higher success rate and fewer incidences of pulpal exposure than total removal, after up to 18 months of follow up. Moreover, only one session seemed to be a better management choice compared to two sessions because the cavity re-opening procedure is more prone to pulp exposure and highly depends on patient commitment. Otherwise, at 5 years of follow up, there was no difference between selective removal and total removal in management longevity. In addition, there were also no differences between the success of the materials used for definitive restorations in teeth subjected to any of the techniques evaluated.

Selective Removal to Soft Dentine versus Full Pulpotomy for Management of Proximal Deep Carious Lesions: A Randomized Controlled Non-Inferiority Trial

The management of the deep carious lesion with reversible pulpitis is a dilemma for the dentist. The current study compared selective removal to soft dentine (SRSD) and full pulpotomy (FP) for treating proximal deep carious lesions in teeth with reversible pulpitis. Visual-tactile examination and bitewing radiographs were used to determine the depth of carious lesion, and American Association of Endodontists recommendations were used to formulate pulp diagnosis. Sixty mandibular molar teeth from healthy patients between the ages of 16-35 years and a diagnosis of proximal deep carious lesion with reversible pulpitis were included. Teeth were randomly allocated to two study groups. SRSD group (n = 30): soft dentine was preserved over the pulpal aspect. A hard-setting calcium hydroxide cement liner and resin-modified glass ionomer cement base were applied over the remaining soft carious dentine. FP group (n = 30): complete caries removal followed by mineral trioxide aggregate FP was performed. The teeth in both groups were restored with composite resin restoration. The established criteria for outcome assessment of SRSD and pulpotomy were used. Accordingly, only asymptomatic teeth with no radiological evidence of periapical rarefaction were considered successful at the 12-month follow-up. Two-sample t test, Pearson χ2 test/Fisher's exact test, and percentage agreement were used for statistical evaluation. According to the per-protocol analysis, the success rate of both SRSD and FP treatment was 95.45% and 95.65%, respectively, and the actual difference between the two treatments was 1% (95% CI: [-10, 9]). The data suggests that both treatments (SRSD and FP) appear to have a good success rate (>95%) when used to manage permanent mandibular molar teeth with proximal deep carious lesion and reversible pulpitis. As SRSD is a noninvasive procedure, it should be favored over FP in these instances.

Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association

BACKGROUND

An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs together with the ADA Science and Research Institute's program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated caries lesions in patients with vital, nonendodontically treated primary and permanent teeth.

TYPES OF STUDIES REVIEWED

The authors searched for systematic reviews comparing carious tissue removal (CTR) approaches in Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Trip Medical Database. The authors also conducted a systematic search for randomized controlled trials comparing direct restorative materials in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of the evidence and formulate recommendations.

RESULTS

The panel formulated 16 recommendations and good practice statements: 4 on CTR approaches specific to lesion depth and 12 on direct restorative materials specific to tooth location and surfaces involved. The panel conditionally recommended for the use of conservative CTR approaches, especially for advanced lesions. Although the panel conditionally recommended for the use of all direct restorative materials, they prioritized some materials over the use of others for certain clinical scenarios.

PRACTICAL IMPLICATIONS

The evidence suggests that more conservative CTR approaches may decrease the risk of adverse effects. All included direct restorative materials may be effective in treating moderate and advanced caries lesions on vital, nonendodontically treated primary and permanent teeth.

The revolutionary evolution in carious lesion management

Contemporary paradigms of dental caries management focus on the biological approaches to treating the disease and its principal symptom, the carious lesion. This narrative review traces the evolution of carious lesion management from the operative and invasive approaches of G. V. Black's era to the current period of minimally invasive biological approaches. The paper explains the rationale for adopting biological approaches to dental caries management and lists the five core principles of this management approach. The paper also details the aims, features, and the most recent evidence base for the different biological carious lesion management approaches. Based on current practice guidelines, collated clinical pathways for lesion management are also presented in the paper to aid clinicians in their decision-making. It is hoped that the biological rationale and evidence summarized in this paper will bolster the shift to modern biological carious lesion management approaches among dental practitioners.

Dental Pulp Response to Silver-Containing Solutions: A Scoping Review

Dentists used silver-containing solutions for deep cavity disinfection before restoration. This review aims to identify the silver-containing solutions reported in the literature for deep cavity disinfection and summarize their effects on dental pulp. An extensive search was performed using the search words "(silver) AND (dental pulp OR pulp)" in ProQuest, PubMed, SCOPUS, and Web of Science to identify English publications on silver-containing solutions for cavity conditioning. The pulpal response to the included silver-containing solutions was summarized. The initial search identified 4112 publications and 14 publications met the inclusion criteria. Silver fluoride, silver nitrate, silver diamine nitrate, silver diamine fluoride, and nano-silver fluoride were used in deep cavities for antimicrobial purposes. Indirect silver fluoride application induced pulp inflammation and reparative dentine in most cases, and pulp necrosis in some cases. Direct silver nitrate application caused blood clots and a wide inflammatory band in the pulp, whilst indirect silver nitrate application caused hypoplasia in shallow cavities and partial pulp necrosis in deep cavities. Direct silver diamine fluoride application induced pulp necrosis, while indirect silver diamine fluoride application induced a mild inflammatory response and reparative dentine formation. No evidence of the dental pulpal response to silver diamine nitrate or nano-silver fluoride was available in the literature.

Dental Caries and Its Management

Objectives

In recent years, the management of dental caries has evolved significantly. Caries prevention, early detection, and a diagnosis based on risk indicators and risk factor assessments are the most current practical approaches. Furthermore, as proposed in minimally invasive dentistry, the new management approaches preserve healthy tissue and maintain pulp vitality. This article overviews the latest minimally invasive dental caries management and treatment options. The information will assist the reader in the early detection, diagnosis, and treatment of dental caries.

Materials and Methods

The PubMed (MEDLINE) search engine was used to gather the most relevant information on dental caries. The search was restricted to five years (May 30, 2018-May 29, 2022), and only English-language studies were accessed. A Boolean search of the PubMed data set was implemented to combine a range of keywords. The following filters were applied: abstract, free full text, full text, clinical trial, randomised control trial, systematic review, meta-analysis, and review. More studies were also obtained by manual searches from Google Scholar and textbooks on dental caries.

Results

By using this process, 683 articles and studies were obtained. The most relevant published studies were chosen and used in the current review. The selected articles are included in the references list. However, the search extended to cover the last five years as our understanding and management of dental caries have changed significantly.

Conclusions

Early detection and diagnosis of caries based on risk indicators and risk factor assessments are effective. Furthermore, minimally invasive restorative techniques are beneficial in managing dental caries and preserving healthy tissue and should be used whenever possible. This new information, knowledge, and materials should encourage professionals to implement this method. Having a strategy and system based on patient-centred care is critical, and our dental responsibilities must prioritise patient-centred care.

Selective removal to soft dentine or selective removal to firm dentine for deep caries lesions ın permanent posterior teeth: a randomized controlled clinical trial up to 2 years

OBJECTIVES

The aim of this randomized clinical trial was to compare selective removal to soft dentin (SRSD) and selective removal to firm dentin (SRFD) in permanent teeth. The primary outcome of the study was to compare the success rates of the two caries removal techniques. The secondary outcome of the study was to investigate whether or not calcium silicate-based material (CS) had an effect on the success rate of the treatment.

MATERIALS AND METHODS

Between November 2018 and March 2020, patients with deep caries lesions were invited to participate in the study. Posterior teeth (N = 165) with primary caries lesion radiographically extending ¾ of dentin and positive response to cold test were randomly selected. A total of 134 participants meeting the inclusion criteria were randomized to SRSD and SRFD (control) groups. After the caries removal procedure, teeth with exposed pulps were assigned to the pulp exposure (PE) group, and the SRSD group was further divided into test 1 (with CS) and test 2 groups (without CS). Success was defined as a positive response to the cold test, a negative response to percussion, the absence of pain, an abscess, a fistula, and periapical alterations. Fisher-Freeman-Halton exact tests, Kaplan-Meier survival analysis, and the log-rank tests were performed for comparisons between groups.

RESULTS

No statistically significant difference was found between the success rates of test 1 (100%) and test 2 (93.5%) groups, whereas the proportion of success in control (82.4%) and PE (84%) groups were significantly lower when compared with test groups (p = 0.024; p < 0.05) at the end of 2-year follow-up.

CONCLUSIONS

SRSD had a higher success rate when compared to SRFD to treat deep carious lesions after 2 years of follow-up. The use of CS material after SRSD as a liner had no effect on the treatment outcome.

CLINICAL RELEVANCE

SRSD with good coronal sealing might be recommended without CS application for the treatment of deep caries lesions in permanent teeth.

TRIAL REGISTRATION

Clinical trial registration number NCT04052685 (08/09/2019).

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.

Cost-effectiveness of partial versus stepwise caries removal of deep caries lesions - a decision-analytic approach

OBJECTIVE

The aim was to compare the cost-effectiveness of partial caries removal (PCR) and stepwise caries removal (SW) in mature permanent teeth diagnosed with deep caries lesions, in a Swedish Public Dental Care organization.

MATERIALS AND METHODS

A decision tree model was used to calculate the cost-effectiveness for PCR and SW. Probability values were obtained through a literature search in PubMed and Scopus. Treatment times were estimated by a group of dentists practicing at public dental care clinics in Västra Götaland county, Sweden.

RESULTS

The expected costs for PCR and SW were 187,63 and 414,35 €, respectively, indicating that PCR was more cost-effective. Four articles were identified through the literature search. The p-values for PCR outcomes were 94% (success), 0% (pulp exposure) and 6% (pulpitis/apical periodontitis etc.). For SW, the p-values were 76% (success), 2% (pulp exposure during the first visit), 13% (pulp exposure during the second visit) and 9% (pulpitis/apical periodontitis etc.).

CONCLUSIONS

Given the presumptions in this decision analysis, the PCR method used on mature permanent teeth is more cost-effective (p < ,05) compared to the SW method in protecting the pulp from exposure and avoiding the need for root canal treatment.

Outcomes reporting in systematic reviews on vital pulp treatment: A scoping review for the development of a core outcome set

Background

A large number of research reports on vital pulp treatment (VPT) has been published over the last two decades. However, heterogeneity in reporting outcomes of VPT is a significant challenge for evidence synthesis and clinical decision‐making.

Objectives

To identify outcomes assessed in VPT studies and to evaluate how and when outcomes are measured. A subsidiary aim was to assess evidence for selective reporting bias in the included studies. The results of this review will be used to inform the development of a core outcome set (COS) for endodontic treatments.

Methods

Multiple healthcare bibliographic databases, including PubMed/MEDLINE, Ovid EMBASE, Scopus, Cochrane Database of Systematic Reviews and Web of Science were searched for systematic reviews published between 1990 and 2020, reporting on VPT. Screening, data extraction and risk of bias assessment were completed independently by two reviewers. Outcomes' information was extracted and aligned with a healthcare taxonomy into five core areas: survival, clinical/physiological changes, life impact, resource use and adverse events.

Results

Thirty‐six systematic reviews were included, 10 reporting on indirect pulp capping or selective caries removal, nine on direct pulp capping, eight on pulpotomy and nine on combined VPTs. There was considerable variation in the outcomes reported in these reviews and their included studies. Clinician‐reported outcomes were used considerably more often than patient‐reported outcomes. A range of instruments and time points were used for measuring outcomes. Several of the reviews were assessed as having low risk of selective reporting bias, but many did not specifically report this domain, whilst others did not provide risk of bias assessment at all.

Discussion

Considerable variation in selection of outcomes and how and when they are measured and reported was evident, and this heterogeneity has implications for evidence synthesis and clinical decision‐making.

Conclusions

Whilst there is a lack of consistency, several potentially important outcomes for VPT, including pulp survival, incidence of post‐operative pain and need for further intervention, have been identified which could inform the development of a COS for endodontic treatment.

Registration

Core Outcome Measures in Effectiveness Trials (COMET) (No. 1879).

The Influence of New Bioactive Materials on Pulp–Dentin Complex Regeneration in the Assessment of Cone Bone Computed Tomography (CBCT) and Computed Micro-Tomography (Micro-CT) from a Present and Future Perspective—A Systematic Review

The present paper is the first article providing a systematic literature review on the visualization of tertiary dentin influenced by modern bioactive materials in CBCT and micro-CT. Six database searches of studies on tertiary dentin visualization using CBCT produced 622 records in total, and the search of the studies on tertiary dentin using micro-CT produced 502 records in total. The results were thoroughly selected considering the inclusion criteria, and five research papers using CBCT and nine research papers using micro-CT for visualization of tertiary dentin were eventually qualified for the analysis. All the non-randomized and randomized studies presented good and high levels of quality evidence, respectively. Among the bioactive materials used, the most frequently analysed were: MTA, Biodentine dentin matrix hydrogel, Pro Root MTA, and EndoSequence root repair material. The highest thickness of the tertiary dentin was achieved after the use of MTA material in both imaging techniques. The remaining parameters had different results, taking into account the CBCT and micro-CT analysis. The possibilities of the qualitative and quantitative assessment of the particular parameters of tertiary dentin using CBCT and micro-CT techniques were presented and analysed. CBCT and micro-CT analyses can be useful in the assessment of tertiary dentin formed beneath the bioactive material applied during vital pulp treatment. The research argues that the presented results differ depending on the material applied to the pulp, the study duration (4–6 weeks), difference in teeth, species (rats, human), as well as the applied technique and differences in computer software used for the analysis.

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

Aim

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

Methodology

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

Results

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

Conclusions

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

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.

Does the heat generated by fluorescence-aided caries excavation system effect the pulp temperature of primary teeth irreversibly? An in-vitro evaluation of the temperature changes in the pulp chamber

Background

This study aimed to analyze the effect of the Fluorescence Aided Caries Excavation (FACE) and the remaining dentin thickness on the temperature changes of the pulp chamber.

Material and Methods

Freshly extracted deciduous molars and a pulpal microcirculation model were used in the study. The sample size was calculated according to power analyses (power at 90%) based on previous studies. Thus, 40 samples were needed. Standard cavities (3x3 mm) were designed to obtain a 2 mm distance through to the pulp chamber, and in each tooth (n=10), these cavities were modified to obtain 1.5 mm, 1mm, and 0.5 mm final distance through to the pulp. Coronal parts of the teeth were placed on an acrylic plate with three gaps for feeding and extraction needles and the thermocouple. The temperature changes were recorded from the initial time to 15 s and 30 s,1 min, 1.5 min, 2 min, 2.5 min, 3 min intervals.

Results

The results showed that hence the thickness between cavity floor and pulp chamber was decreased, and application time of FACE was increased, an increase in temperature changes was detected. However, the recorded values were not mean to cause irreversible damages to the pulp chamber.

Conclusions

The recent study showed that Face is an appropriate caries detecting system that does not affect the pulp chamber's health, and it can be safely used in the primary teeth. Key words:Caries assessment, dental caries, dental pulp, pediatric dentistry.

Cytotoxicity and dentin composition alterations promoted by different chemomechanical caries removal agents: A preliminary in vitro study

Background

The use of chemomechanical agents for caries removal has been indicated as a non-invasive treatment option; however, their possible deleterious effects on the dental-pulp complex have been insufficiently studied. This study assessed the direct cytotoxicity of two chemomechanical caries removal agents (Brix 3000™ - BX and Papacarie Duo™ - PD) on pulp cells from deciduous teeth, as well as to assess the morphology and chemical compositions of the dentin surface after the application of these materials.

Material and Methods

The cells were seeded (50,000 cells/cm²) in a culture medium (DMEM with 10% fetal bovine serum - FBS). After 24 hours, the BX and PD materials were added to 1:20, 1:100, and 1:1000 dilutions. Non-exposed cells were considered as the control group. The viability test (MTT), Trypan Blue assay (TB), and cell morphology (Scanning Electron Microscopy - SEM) were performed after 24 hours of agent application. For the SEM and chemical (energy-dispersive X-ray spectrometry - EDS) dentin evaluation, 0.3-mm-thick dentin discs were obtained and divided into control group (no treatment) and surfaces covered with 37% phosphoric acid, BX, or PD. Data were compared by one-way ANOVA and Tukey's test (p<0.05).

Results

Decreases in cell viability and numbers of viable cells were observed for both materials, at all dilutions, when compared with the control group (p<0.05). The BX and PD materials did not cause visually perceptible changes, according to SEM, on the surfaces of dentin discs. The EDS analysis did not indicate a statistically significant difference in the levels of calcium (Ca) and phosphorus (P) between the materials and the control group (p>0.05).

Conclusions

Both materials showed cytotoxicity when in direct contact with the pulp cells from deciduous teeth, and the BX material presented lower cytotoxicity than the PD material. Moreover, both materials did not significantly change the dentin composition. Key words:Cell culture, cytotoxicity, dental pulp, papacarie, primary teeth.

Influence of selective immunosuppressive drug regimens on the healing of exposed dogs' dental pulp capped with a recent calcium silicate-based cement

OBJECTIVES

In the clinical medicine, immunosuppressive drugs are used for an assortment of disorders, while their effect on the pulp healing is a controversial issue. This study evaluated the effect of different immunosuppressive drugs on the healing capacity of mechanically exposed dogs' dental pulps after direct pulp capping (DPC) with calcium silicate-based cement.

MATERIALS AND METHODS

Twelve healthy male dogs were randomly allocated into four equal groups, 3 dogs each: group I allocated as a control group where no drugs were received; group П given prednisone (Pred); group III given a combination of Pred and cyclosporine A (CsA); and group IV given triple dose including Pred, CsA, and mycophenolate mofetil (MMF) for 45 days before the operative procedures and until the dogs were euthanized. In each dog, 16 class V cavities were prepared on the labial surfaces of anterior teeth. Following mechanical exposure, the pulps were capped with Biodentine, calcium silicate-based cement. The pulpal tissues response to Biodentine was assessed 65 days postoperatively.

RESULTS

The pulp healing response was inferior in the Pred-CsA- and Pred-CsA-MMF-treated groups compared with the control and Pred-treated groups (P < 0.05). Non-significant difference was found between control and Pred-treated groups (P > 0.05).

CONCLUSIONS

Within the limitation of this study, DPC with calcium silicate-based cement performed under strict aseptic condition for traumatically exposed dental pulp can be considered as a successful treatment option for those who receiving Pred immunosuppressive therapy. Meanwhile, DPC with those receiving a combination of Pred, CsA, and/or MMF immunosuppressive drug regimens demonstrated unfavorable results.

CLINICAL RELEVANCE

Direct capping of mechanically exposed pulps with calcium silicate-based cement performed with special care for preventing infection considered a suitable strategic measure for preserving pulp vitality in patients receiving corticosteroid immunosuppressive drug.

Interventions for treating cavitated or dentine carious lesions

BACKGROUND

Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

OBJECTIVES

To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps.

SEARCH METHODS

An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions.

MAIN RESULTS

We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

AUTHORS' CONCLUSIONS

Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

Selective Caries Removal in Permanent Teeth (SCRiPT) for the treatment of deep carious lesions: a randomised controlled clinical trial in primary care

BACKGROUND

Dental caries is one of the most prevalent non-communicable disease globally and can have serious health sequelae impacting negatively on quality of life. In the UK most adults experience dental caries during their lifetime and the 2009 Adult Dental Health Survey reported that 85% of adults have at least one dental restoration. Conservative removal of tooth tissue for both primary and secondary caries reduces the risk of failure due to tooth-restoration, complex fracture as well as remaining tooth surfaces being less vulnerable to further caries. However, despite its prevalence there is no consensus on how much caries to remove prior to placing a restoration to achieve optimal outcomes. Evidence for selective compared to complete or near-complete caries removal suggests there may be benefits for selective removal in sustaining tooth vitality, therefore avoiding abscess formation and pain, so eliminating the need for more complex and costly treatment or eventual tooth loss. However, the evidence is of low scientific quality and mainly gleaned from studies in primary teeth.

METHOD

This is a pragmatic, multi-centre, two-arm patient randomised controlled clinical trial including an internal pilot set in primary dental care in Scotland and England. Dental health professionals will recruit 623 participants over 12-years of age with deep carious lesions in their permanent posterior teeth. Participants will have a single tooth randomised to either the selective caries removal or complete caries removal treatment arm. Baseline measures and outcome data (during the 3-year follow-up period) will be assessed through clinical examination, patient questionnaires and NHS databases. A mixed-method process evaluation will complement the clinical and economic outcome evaluation and examine implementation, mechanisms of impact and context. The primary outcome at three years is sustained tooth vitality. The primary economic outcome is net benefit modelled over a lifetime horizon. Clinical secondary outcomes include pulp exposure, progession of caries, restoration failure; as well as patient-centred and economic outcomes.

DISCUSSION

SCRiPT will provide evidence for the most clinically effective and cost-beneficial approach to managing deep carious lesions in permanent posterior teeth in primary care. This will support general dental practitioners, patients and policy makers in decision making. Trial Registration Trial registry: ISRCTN.

TRIAL REGISTRATION NUMBER

ISRCTN76503940. Date of Registration: 30.10.2019. URL of trial registry record: https://www.isrctn.com/ISRCTN76503940?q=ISRCTN76503940%20&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search .

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.

Conservative pulp therapy in the management of reversible and irreversible pulpitis

Conservative pulp therapy is an alternative treatment option to tooth removal and root canal treatment in the management of deep caries, traumatic pulp exposures and developmental anomalies. Pulp tissue preservation can extend the long-term survival of teeth through relatively simple restorative procedures. This article aims to update clinicians on the current state of research in materials, techniques and outcomes of vital pulp therapies and provide practical guidelines for their implementation into daily practice.

A Prospective Analysis of the Correlation Between Postoperative Pain and Vital Pulp Therapy

Vital pulp therapy (VPT) is a viable treatment option for carious teeth with exposed pulps. To our knowledge, no study has examined the correlation between postoperative pain and the outcome of VPT on asymptomatic permanent teeth. The aim of this study was to examine whether odontogenic pain experienced after VPT on asymptomatic teeth with a carious pulp exposures is correlated with the progression of pulpal disease into a more inflamed or necrotic state. Direct pulp caps or partial pulpotomies using a tricalcium silicate (MTA Angelus, Angelus, Londrina, Brazil) were performed on asymptomatic permanent teeth using a standardized protocol. Patients were contacted at 24 h, 1 week, and 3 months following treatment and data was collected on post-operative pain and analgesic intake using a standardized questionnaire. At 6 months after treatment, an in-person clinical exam was performed which included standard vitality tests along with exposure of a periapical radiograph. Success was defined as an asymptomatic, functional tooth without any clinical or radiographic pathology. Data was analyzed using logistic regression. VPT was successful in 84.3% of patients at the 6 months timepoint. The percentage of patients that experienced pain at 24-h, 1 week, and 3-month time periods was 38, 22, and 12%, respectively. Pain at 3 months was significantly correlated with decreased outcome (p = 0.028). This data suggests that postoperative pain in the first 3 months after VPT is predictive of a poor treatment outcome.

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.

Preserving pulp vitality: part one - strategies for managing deep caries in permanent teeth

This is the first article in a series reviewing the current literature surrounding the management of deep caries in permanent teeth. Approaches to caries management are continuing to evolve, with more conservative management increasingly favoured. This philosophy has never been more important than in managing the deep carious lesion. Evidence is emerging that the use of selective caries removal to reduce the risk of pulp exposure, in conjunction with calcium silicate cements, can be successful in maintaining pulp vitality, delaying the restorative cycle and prolonging the lifespan of the tooth.

Efficacy of direct pulp capping for management of cariously exposed pulps in permanent teeth: a systematic review and meta-analysis

BACKGROUND

The outcome of vital pulp treatment after carious pulp exposure is multifactorial and related to the procedure, biomaterial and pre-operative pulpal diagnosis.

OBJECTIVES

To conduct a systematic review and meta-analysis determining the outcome of direct pulp capping (DPC) in mature permanent teeth with a cariously exposed pulp and a clinical diagnosis of reversible pulpitis, and ascertain whether the capping material influences the outcome.

METHODS

Sources: MEDLINE Ovid-SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase and Web of Science until April 2020. Inclusion: Prospective, retrospective cohort studies and randomized trials investigating DPC outcome or comparing different capping materials after carious pulp exposure. Exclusion: Primary teeth, mechanical, traumatic or not specified pulp exposure, teeth with irreversible pulpitis or no pulpal diagnosis. Risk of bias assessed using Cochrane and modified Downs and Black quality assessment checklist. Meta-analysis on combined clinical/radiographic outcome was performed using a random effect model. Success was defined as absence of signs and symptoms of irreversible pulpitis, apical periodontitis or loss of pulp vitality.

RESULTS

Quality assessment highlighted four non-randomized studies to be of fair and five of poor quality. Four randomized trials had a high risk of bias. The pooled success rate differed based on material and follow-up. Calcium hydroxide success rate was 74% at 6-months, 65% at 1-year, 59% at 2-3 years and 56% at 4-5 years. Mineral trioxide aggregate (MTA) success was 91%, 86%, 84% and 81% at the same time points. Biodentine success was 96% at 6-months, 86% at 1 year and 86% at 2-3 years. The meta-analysis revealed MTA had better success than calcium hydroxide at 1-year (OR 2.66, 95% CI; 1.46- 4.84, P = 0.001) and 2- to 3-year follow-up (OR 2.21, 95% CI; 1.42-3.44, P = 0.0004). There was no difference between MTA and Biodentine.

DISCUSSION

These results were based on poor methodological quality studies. The effect size for of MTA vs Ca(OH)2, although modest, was consistent with narrow CI.

CONCLUSIONS

Low-quality evidence suggests a high success rate for direct pulp capping in teeth with cariously exposed pulps with better long-term outcomes for MTA and Biodentine compared with calcium hydroxide.

A macroscopic and histological analysis of radiographically well-defined deep and extremely deep carious lesions: carious lesion characteristics as indicators of the level of bacterial penetration and pulp response

AIM

To investigate the relationship between radiographically and macroscopically well-defined carious lesions and the dentine-pulp complex with regard to: (i) level of bacterial penetration; (ii) inflammatory status including the presence of hyperplastic pulp stroma; and (iii) formation of hard and/or ectopic connective tissue.

METHODOLOGY

The material comprised 68 untreated cavitated permanent teeth divided into well-defined radiographic categories based on the lesion penetration depth: (i) deep lesions ( ≥3/4 of the dentine thickness with a radio-dense zone separating the lesion from the pulp) and (ii) extremely deep lesions (the carious lesion penetrated the entire thickness of the dentine, without a radio-dense zone). After extraction, the teeth were processed for histology. The material was scored with regard to coronal breakdown, macroscopic variables describing caries activity and histological variables describing the dentine-pulp complex (bacteria, inflammatory infiltrate, partial pulp necrosis, hyperplastic changes and hard tissue/ectopic presence of connective tissue). Interrater agreement was assessed using Cohen's kappa. Associations between variables were assessed using Pearson's chi-squared or Fisher's exact test. The effect size was reported by odds ratio (OR) and associated 95% confidence interval (CI). Level of significance was set to 5%.

RESULTS

There were significant associations between a closed environment (1-2 surfaces involved) and the presence of biofilm, retrograde demineralization and light-coloured demineralized dentine. Whereas radiographically defined deep lesions tended to have bacteria only in the primary dentine (P < 0.001, OR = 20.55, 95% CI [4.44, 107.89]), extremely deep carious lesions tended to have bacteria in contact with the pulpal tissue (P = 0.007, OR = 6.84, 95% CI [2.00, 62.83]), presence of an inflammatory infiltrate (Fisher's exact; P < 0.001) and partial pulp necrosis. Hyperplastic pulps were seen only in extremely deep lesions.

CONCLUSIONS

Unlike deep lesions, extremely deep carious lesions were often associated with severe pulp inflammation and infection. A radiographic threshold between deep and extremely deep lesions is suggested as indicator of the bacterial penetration level and the severity of the pulpal response prior to intervention.

Frightened of the pulp? A qualitative analysis of undergraduate student confidence and stress during the management of deep caries and the exposed pulp

AIM

To evaluate sources of student confidence and stress during the management of deep carious lesions and the exposed pulp during undergraduate clinics. Further aims were to identify barriers and facilitators, which could result in educational or practical improvements in the delivery of teaching and provision of treatment in this area.

METHODOLOGY

A exploratory qualitative study design was used, based on recorded focus group interviews, guided by 12 predetermined questions. The discussions were transcribed verbatim and analysed by inductive qualitative content analysis. Common categories were identified to aid understanding. Forty undergraduate dental students from 4th and 5th years in Dublin Dental University Hospital participated in the study.

RESULTS

Student stress and confidence were multifactorial and broadly linked to specific domains: clinical procedure, academic education, clinical training, evaluation/grading, organization and equipment, vital pulp biomaterial and the patient. Most students expressed a preference for one-stage selective carious removal to soft dentine rather than potential pulp exposure in deep carious lesions, noting that although it helped to decrease their immediate stress, it also caused longer-term concern by leaving caries close to the pulp. Nevertheless, their confidence was affected by limited clinical experience of carrying out selective removal procedures in deep caries. A recurrent finding was students citing high levels of stress after pulp exposure. Feelings including anger, fear, embarrassment and denial were associated with pulp exposure during deep caries management. Generally, the students felt able to manage pulp capping procedures, but were less certain about partial pulpotomy, suggesting that although they are aware of its advantages, they were unsure about the appropriate volume of pulp tissue to remove. To reduce stress, students suggested that laboratory teaching should employ new 3-D printed solutions and clinics should establish clear consensus amongst supervising teachers about the best way to manage the exposed pulp.

CONCLUSIONS

Students lacked confidence as they neared the pulp and prefer selective caries removal techniques, which reduce the likelihood of pulp exposure. Students identified stressors and suggested improvements in several domains that would improve confidence. These ameliorations could lead to enhancements in student ability to perform these conservative techniques, and improve the provision of treatment in this area.

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).

Pulp and dentine responses to selective caries excavation: A histological and histobacteriological human study

OBJECTIVE

The present study investigated the histobacteriological condition of human carious dentine, and the histological response of dental pulps after selective caries excavation to firm dentine and cavity restoration with adhesive procedures.

METHODS

Twelve vital teeth with medium/deep occlusal caries from 12 patients were scheduled for extraction. The patients gave consent to have caries removed selectively and the cavity restored with adhesive procedures prior to extraction. Caries excavation was achieved using burs and sharp hand excavators until "leathery" or "firm" dentine was encountered. After extraction, the teeth were completely-demineralised, processed for light microscopy, serial-sectioned and stained with haematoxylin and eosin staining for histological examination of dentine characteristics and pulpal responses. Additional sections were stained with Taylor-modified Brown and Brenn technique for histobacteriological examination of bacteria infiltration of the dentinal tubules and dental pulp.

RESULTS

The 12 teeth showed varying degrees of tertiary dentine formation. Chronic inflammatory cell infiltrates were identified in the pulp of all specimens and appeared as scattered inflammatory cells or exiguous localised accumulations. Capillaries were heavily congested with erythrocytes and polymorphonuclear leukocytes. A large amount of stainable bacteria was observed in the dentine subjacent to the cavity floor in all specimens.

CONCLUSIONS

The present study demonstrated that "leathery" or "firm" carious dentine is infected. The remnant bacteria in the dentine provoked subclinical pulpal inflammation over the entire evaluation period. The presence of potentially-arrested caries does not necessarily mean that bacterial infection is absent or under control.

CLINICAL SIGNIFICANCE

Knowledge on the pulpal response to active caries and the inflammatory responses associated with bacteria ingress into dentine is paramount in helping clinicians make an informed, rational choice based on biologically-robust principles.

Caries removal strategies for deep carious lesions in primary teeth: Systematic review

The study aimed to compare the efficacy of three caries removal techniques-complete caries removal (CCR), selective caries removal (SCR), and stepwise caries removal (SWR)-for deep carious lesions in vital temporary teeth by conducting a systematic review and meta-analysis of randomized controlled trials (RCTs). Electronic databases (PubMed [MEDLINE], Cochrane Library, EMBASE) were searched for corresponding references up to 31 May 2019. Possible outcomes were pulp exposure, pulpo-periodontal complications, or restorative failures. Three reviewers independently selected studies, extracted data, and assessed the risk of bias using RoB 2. Meta-analyses for intention-to-treat and per-protocol scenarios were performed using Revman5. Of 1374 potentially eligible articles, ten relevant references corresponding to eight studies were included. Pooled results showed decreased risk of pulp exposure after SCR (OR: 0.10, 95% CI [0.04, 0.25]) or SWR (OR: 0.20, 95% CI [0.09, 0.44]), compared with CCR. There was a higher risk of composite restorative failure (OR: 2.61, 95% CI [1.05, 6.49]) using USPHS criteria, after SCR compared with CCR only in intention-to-treat analysis. Risk of clinical or radiographic failure of pulpo-periodontal complications was unchanged when compared with SCR and CCR or SWR. SCR and SWR may result in lower pulp exposure risk than CCR. RCTs with lower risk of bias, higher power, and longer follow-up are required to choose between these three caries removal techniques for deep carious lesions in vital temporary teeth.

Restorations after selective caries removal: 5-Year randomized trial

OBJECTIVE

To compare the survival of restorations placed in deep caries lesions after selective caries removal to soft dentin (SCRSD) over a 5-year period. A secondary aim was to investigate whether the material (amalgam or resin composite) affected the survival of restorations.

METHODS

This study used data derived from a multicenter randomized controlled clinical trial (Clinical trials registration NCT00887952). Inclusion criteria were: patients with permanent molars presenting occlusal or proximal deep caries lesions (≥1/2 of the dentin thickness on radiographic examination), positive response to a cold test, absence of spontaneous pain, negative sensitivity to percussion, and absence of periapical lesions. The teeth were randomized into SCRSD and restoration in a single visit or stepwise excavation (SW). Each of these groups was divided according to the filling material: amalgam (AM) or resin composite (RC). Survival analyses were performed to estimate therapy success rates over 5 years (adjusted Weibull regression model).

RESULTS

172 restorations were evaluated, 95 from SCRSD group and 77 from SW group, being 61 AMG and 111 RC. The 5-year survival analysis showed similar success rates for SW (76 %) and SCRSD (79 %) as well as for AM and RC (p > 0.05).

CONCLUSION

This study showed that, after a 5-year follow-up period, the presence of decayed tissue beneath restorations in deep caries lesions did not seem to affect restoration survival. Amalgam and resin composite restorations had similar survival rates, irrespective of the caries removal technique used - SCRSD or SW.

CLINICAL SIGNIFICANCE

Selective caries removal to soft dentin can be used in the management of deep caries to avoid pulp exposure and preserve tooth structure without affecting restoration longevity.

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

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

Chemo-mechanical characterization of carious dentine using Raman microscopy and Knoop microhardness

One of the aims in the clinical operative management of dental carious lesions is to remove selectively the highly infected and structurally denatured dentine tissue, while retaining the deeper, repairable affected and intact, healthy tissues for long-term mechanical strength. The present study examined the correlation of chemical functional groups and the microhardness through the different depths of a carious lesion using Raman spectroscopy and Knoop microhardness testing. The null hypothesis investigated was that there was no correlation between Raman peak ratios (amide I : phosphate ν1 ) and equivalent Knoop microhardness measurements. Ten freshly extracted human permanent teeth with carious dentine lesions were sectioned and examined using high-resolution Raman microscopy. The ratio of absorbency at the amide I and phosphate bands were calculated from 139 scan points through the depth of the lesions and correlated with 139 juxtaposed Knoop microhardness indentations. The results indicated a high correlation (p < 0.01) between the peak ratio and the equivalent Knoop hardness within carious dentine lesions. This study concluded that Raman spectroscopy can be used as a non-invasive analytical technology for in vitro studies to discriminate the hardness of carious dentine layers using the peak ratio as an alternative to the invasive, mechanical Knoop hardness test.

Vascularity and Angiogenic Signaling in the Dentine-Pulp Complex of Immature and Mature Permanent Teeth

ABSTRACT.

Objective

This study aimed to examine the protein and gene expression of vascular endothelial growth factor (VEGF) and angiopoietins-1 and 2 in tissue from healthy and inflamed dental pulps.

Methods

Permanent teeth with pulps diagnosed as healthy or reversible pulpitis were used for immunohistochemistry (IHC) and gene expression experiments. For IHC, a whole pulp tissue was excavated from the pulp chamber, and it was formalin-fixed and processed for routine IHC with angiogenic markers anti-VEGF, anti-Ang1, and anti-Ang2. Staining was visualized with diaminobenzidine (DAB), and examined using light microscopy. The distribution of markers in healthy and inflamed pulps was qualitatively and quantitatively analyzed. Real-time quantitative polymerase chain reaction (RT qPCR) was used to ascertain the gene expression levels of ANGPT1, ANGPT2, and TEK in the presence of inflammation. Statistical analysis was performed using the Mann-Whitney test with the statistical significance level set at 0.05.

Results

There was increased protein and mRNA expression of VEGF and Ang-1 markers in inflamed pulp samples as compared with that in the healthy pulp tissue. IHC demonstrated intense expression of the VEGF protein on endothelial cells (EC) and some non-ECs, and there was significantly more staining on ECs associated with inflamed tissue (P<0.001). Ang-1 and Ang-2 were significantly expressed on ECs and non-ECs (P<0.05). RT qPCR did not show significant differences in gene expression between healthy and inflamed samples although similar trends were observed to IHC.

Conclusion

The presence of Ang-1, Ang-2, VEGF, and TEK gene in healthy and mildly inflamed pulp tissue associated with reversible pulpitis indicates that these angiogenic factors may participate in physiological and pathological angiogenesis and healing. The inflammatory process may regulate Ang-1/Ang2/Tie2 signaling; and together with VEGF, these growth factors have an important role in modulating pulp angiogenesis.

Histone Acetylation as a Regenerative Target in the Dentine-Pulp Complex

If dental caries (or tooth decay) progresses without intervention, the infection will advance through the dentine leading to severe pulpal inflammation (irreversible pulpitis) and pulp death. The current management of irreversible pulpits is generally root-canal-treatment (RCT), a destructive, expensive, and often unnecessary procedure, as removal of the injurious stimulus alone creates an environment in which pulp regeneration may be possible. Current dental-restorative-materials stimulate repair non-specifically and have practical limitations; as a result, opportunities exist for the development of novel therapeutic strategies to regenerate the damaged dentine-pulp complex. Recently, epigenetic modification of DNA-associated histone ‘tails’ has been demonstrated to regulate the self-renewal and differentiation potential of dental-stem-cell (DSC) populations central to regenerative endodontic treatments. As a result, the activities of histone deacetylases (HDAC) are being recognised as important regulators of mineralisation in both tooth development and dental-pulp-repair processes, with HDAC-inhibition (HDACi) promoting pulp cell mineralisation in vitro and in vivo. Low concentration HDACi-application can promote de-differentiation of DSC populations and conversely, increase differentiation and accelerate mineralisation in DSC populations. Therapeutically, various HDACi solutions can release bioactive dentine-matrix-components (DMCs) from the tooth’s extracellular matrix; solubilised DMCs are rich in growth factors and can stimulate regenerative processes such as angiogenesis, neurogenesis, and mineralisation. The aim of this mini-review is to discuss the role of histone-acetylation in the regulation of DSC populations, while highlighting the importance of HDAC in tooth development and dental pulp regenerative-mineralisation processes, before considering the potential therapeutic application of HDACi in targeted biomaterials to the damaged pulp to stimulate regeneration.

Is pulpotomy preferable to root treatment where there is pulp exposure?

Data sources Embase, MEDLINE, Web of Science, Trip Pro, Cochrane Library, the International Clinical Trials Registry Platform and ClinicaTrials.gov, including a grey literature search.Study selection Randomised or quasi-randomised clinical trials (RCT).Data extraction and synthesis Two reviewers screened independently and extracted data separately with focus on study and population characteristics, treatment, pulp capping materials and clinical and radiographical outcome measures. Incremental cost effective ratios were collated.Results Seventeen studies reported in 21 articles were included. Three were completed trials and one ongoing trial comparing (partial/full) pulpotomy with other interventions for vital pulp therapy. The remaining 13 studies compared hydraulic calcium silicate cements with calcium hydroxide. Only three studies were considered as low risk of bias, except for performance bias (the inherent impossible task of blinding the clinician). Five trials comparing the capping materials were the basis of a quantitative synthesis. No cost-effectiveness studies were found.Conclusions Firm evidence has not been reached with respect to pulpotomy being the preferred intervention substituting root canal treatment; however better pulpotomy outcomes were reported when hydraulic calcium silicate cements are used, when compared to procedures where calcium hydroxide was used.

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.