An in-vitro evaluation of residual dentin retained after using novel enzymatic-based chemomechanical caries removal agents

To assess the biochemical, mechanical and structural characteristics of retained dentin after applying three novel bromelain-contained chemomechanical caries removal (CMCR) formulations in comparison to the conventional excavation methods (hand and rotary) and a commercial papain-contained gel (Brix 3000). Seventy-two extracted permanent molars with natural occlusal carious lesions (score > 4 following the International Caries Detection and Assessment System (ICDAS-II)) were randomly allocated into six groups (n = 12) according to the excavation methods: hand excavation, rotary excavation, Brix 3000, bromelain-contained gel (F1), bromelain-chloramine-T (F2), and bromelain-chlorhexidine gel (F3). The superficial and deeper layers of residual dentin were examined by Raman microspectroscopy and Vickers microhardness, while the surface morphology was assessed by the scanning electron microscope (SEM). A multivariate analysis of variance followed by Tukey's test (p > 0.05) was performed for data analysis. The novel formulations showed an ability to preserve the partially demineralized dentin that showed a reduced phosphate content with a higher organic matrix. This was associated with lower Vickers microhardness values in comparison to sound dentin and rotary excavation. The collagen integration ratio in all methods was close to sound dentin (0.9-1.0) at the deeper dentin layer. The bromelain-chloramine-T gel (F2) produced the smoothest smear-free dentin surface with a higher number of opened dentinal tubules. In contrast, dense smearing covering the remaining dentin was observed in the manual and rotary methods with obstructed dentin tubule orifices. The bromelain-contained formulations can be considered a new minimally invasive approach for selectively removing caries in deep cavitated dentin lesions.

An in vitro assessment of the residual dentin after using three minimally invasive caries removal techniques

To evaluate the efficiency and effectiveness of three minimally invasive (MI) techniques in removing deep dentin carious lesions. Forty extracted carious molars were treated by conventional rotary excavation (control), chemomechanical caries removal agent (Brix 3000), ultrasonic abrasion (WOODPECKER, GUILIN, China); and Er, Cr: YSGG laser ablation (BIOLASE San Clemente, CA, USA). The assessments include; the excavation time, DIAGNOdent pen, Raman spectroscopy, Vickers microhardness, and scanning electron microscope combined with energy dispersive X-ray spectroscopy (SEM-EDX). The rotary method recorded the shortest excavation time (p < 0.001), Brix 3000 gel was the slowest. DIAGNOdent pen values ranged between 14 and 18 in the remaining dentin and laser-ablated surfaces recorded the lowest reading (p < 0.001). The Ca:P ratios of the remaining dentin were close to sound dentin after all excavation methods; however, it was higher in the ultrasonic technique (p < 0.05). The bur-excavated dentin showed higher phosphate and lower matrix contents with higher tissue hardness that was comparable to sound dentin indicating the non-selectiveness of this technique in removing the potentially repairable dentin tissue. In contrast, the MI techniques exhibited lower phosphate and higher organic contents associated with lower microhardness in the deeper dentin layers. This was associated with smooth residual dentin without smearing and patent dentinal tubules. This study supports the efficiency of using MI methods in caries removal as conservative alternatives to rotary excavation, providing a promising strategy for the clinical dental practice.

Comparative Meta-Analysis of Minimally Invasive and Conventional Approaches for Caries Removal in Permanent Dentition

Background and Objectives: Addressing deep carious lesions poses significant challenges in daily dental practice due to the inherent complexity of their treatment. Traditionally, complete removal of carious tissues has been the norm, potentially leading to pulp tissue exposure and subsequent pulpitis. In contemporary dentistry, there is a growing preference for minimally invasive techniques, such as selective removal, offering a more conservative approach with enhanced predictability and success rates. Materials and Methods: Our study commenced with a comprehensive systematic review. After that, we performed a meta-analysis focused exclusively on randomized controlled trials involving permanent dentition. Our investigation incorporated seven selected articles, which scrutinized success rates and the incidence of pulp exposure in minimally invasive techniques (MIT) versus conventional techniques (CT). Statistical analysis employed U Mann-Whitney and Wilcoxon tests to interpret the results. Results: Although the difference did not reach statistical significance, MIT demonstrated marginally superior success rates compared to CT. Furthermore, MIT exhibited a lower percentage of pulp exposure when contrasted with CT. However, due to the limited sample size, statistical significance for this difference could not be established. Conclusions: Minimally invasive techniques for caries removal emerge as a conservative and promising approach to safeguard pulp tissues in comparison to conventional techniques. The need for additional randomized controlled trials is emphasized to unequivocally establish the superior success rates of these procedures over their conventional counterparts.

Efficacy of antiseptics and chemomechanical methods for dentin caries lesions: A systematic review with GRADE approach

Objectives

Selective caries removal aims to remove carious tissue in deep dentin lesions. However, a discussion stands on the value of antiseptics and chemomechanical adjuvant methods to reduce the bacterial load on residual caries lesions. This systematic review has addressed two main clinical questions to compare the antimicrobial efficacy of available methods using (1) antiseptic or (2) chemomechanical agents before restoring dentin carious lesions.

Methods

We included randomized and non-randomized controlled trials (RCTs/ NRCTs). We searched eight databases from inception to October 2021. Paired reviewers independently screened studies, extracted data, and assessed the risk of bias. The primary outcome was the reduction in the number of total bacterial in dentin, whereas secondary outcomes were reduction in the number of Lactobacillus and Streptococcus. We used the ratio of ratio of post-treatment to baseline means between two interventions in the logarithmic scale as a proper effect measure. Certainty of evidence was assessed with the Grading of Recommendations, Assessment, Development and Evaluation approach.

Results

We included 14 RCTs and 9 NRCTs, with nine interventions. Regardless the method, the number of bacteria at baseline was similar or exceeded that after the intervention, particularly in NRCTs. The evidence was inconclusive for most comparisons. Among antiseptic agents, chlorhexidine (CHX) resulted in an average of 1.14 times [95% confidence interval (CI): 1.08-1.21] more total bacterial than photodynamic therapy in RCTs. Among NRCTS, the natural agents resulted in five times more total bacterial than CHX (95% CI: 2-11). For chemomechanical methods, the control resulted in eight times (95% CI: 4-17) more total bacterial than Carisolv (SHAA).

Conclusions

The certainty of the evidence was very low for all comparisons showing uncertainty whether one treatment could be more effective than another for dentin disinfection. So far, exclusively removing soft carious dentin would be enough to reduce the bacterial count.

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.

A Bibliometric Analysis (2010-2020) of the Dental Scientific Literature on Chemo-Mechanical Methods of Caries Removal Using Carisolv and BRIX3000

Reports in the literature have proposed and analyzed several minimally invasive techniques for caries removal in recent decades. In light of recent events surrounding the ongoing epidemiological context, concerns have been raised regarding the generation of aerosols during dental procedures. The aim of our research was to provide an overview of the scientific literature on the topic of chemo-mechanical caries removal (CMCR) methods, focusing on two products (Carisolv, BRIX3000), commercially available in Europe. A bibliometric analysis was used to investigate the scientific articles included in Web of Science (WoS) Core Collection database, published from January 2010 to December 2020. We analyzed the co-occurrence of all keywords (Author Keywords and the KeyWords Plus section), co-authorship and co-citation, using the free software VOSviewer. Our bibliometric analysis revealed a worldwide interest in the subject of chemo-mechanical methods of caries removal, which has transcended the area of pediatric dentistry. The analyzed studies have been conducted mainly in high-income countries that have developed sanitary policies regarding prevention and early treatment of carious lesions as a health priority.

Minimally Invasive Therapies for the Management of Dental Caries—A Literature Review

In recent years, due to a better understanding of the caries pathology and advances in dental materials, the utilization of non-invasive and minimally invasive techniques that delay/obviate the need for traditional restorations has started gaining momentum. This literature review focuses on some of these approaches, including fluoride varnish, silver diamine fluoride, resin sealants, resin infiltration, chemomechanical caries removal and atraumatic restorative treatment, in the context of their chemistries, indications for use, clinical efficacy, factors determining efficacy and limitations. Additionally, we discuss strategies currently being explored to enhance the antimicrobial properties of these treatment modalities to expand the scope of their application.

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.

Bond strength of demineralized dentin after synthesized collagen/hydroxyapatite nanocomposite application

Treatment the deeper and remineralizable carious zone (DRCZ) in dentin with various remineralizing methods, either with classic top-down or biomimetic bottom-up remineralization approaches, has remained a constant main issue to enhance dentin substrate bonding quality. The concern of remineralizing the remaining, partially demineralized and physiologically re-mineralizable collagen fibrils was the optimum target. However, applying already mineralized type I collage fibrils which have the ability to chemically cross-link with remaining collagen and minerals did not gain much interest. Synthesis of collagen/hydroxyapatite (Col/Hap) nanocomposite was done with self-assembling Hap in situ onto Col fibrils with different % (70/30, 50/50, 30/70% of Col/Hap, respectively). Micro-tensile bond strength (μTBS) was evaluated after pre-treatment of artificially demineralized dentin with these suggested protocols [nanocomposite together with grape seed extract (GSE; 6.5%) cross-linker for two periods, 10min and 1 h] then applying self-adhesive bonding system. Applied Col/Hap (30/70%) together with GSE (6.5%) gave the significantly highest μTBS (25.04 ± 5.47 and 25.53 ± 7.64 MPa, for 10min and 1 h application times, respectively). After thermocycling for 10,000 cycles at 5 and 55 °C, μTBS for all protocols and both application times substantially decreased especially for the two control groups. Using the suggested dentin pre-treatment protocols, in chair-side, may possibly enhance the bond strength to DRCZ and its durability.

Critical analysis of the reporting quality of randomized trials within Endodontics using the Preferred Reporting Items for RAndomized Trials in Endodontics (PRIRATE) 2020 quality standard checklist

AIM

To critically evaluate the reporting quality of a random sample of clinical trials published in Endodontics against the PRIRATE 2020 checklist and to analyse the association between the quality of reported trials and a variety of parameters.

METHODOLOGY

Fifty randomized clinical trials relating to Endodontics were randomly selected from the PubMed database from 2015 to 2019 and evaluated by two independent reviewers. For each trial, a score of '1' was awarded when it fully reported each item in the PRIRATE guidelines whereas a score of '0' was awarded when an item was not reported; when the item was reported inadequately a score of '0.5' was awarded. For the items that were not relevant to the trial, 'Not Applicable (NA)' was given. Based on the interquartile range of the overall scores received, trials were categorized into 'Low' (0-58.4%), 'Moderate' (58.5-72.8%) and 'High' (72.9-100%) quality. The associations between characteristics and quality of clinical trials were investigated. Descriptive statistics, frequency analysis and percentage analyses were used to describe the data. To determine the significance of categorical data, the chi-square test was used. The probability value 0.05 was considered as the level of significance.

RESULTS

Based on the overall scores, 13 (26%), 25(50%) and 12 (24%) of the reports of clinical trials were categorized as 'High', 'Moderate' and 'Low' quality, respectively. Three items (1b, 6d, 11e) were adequately reported in all manuscripts whilst two items (5k, 5m) were scored 'NA' in all the reports. The reports published from Europe had a significantly greater percentage of 'High'-quality scores, compared to Asia, Middle East, North America and South America (P = 0.0002). The 'High'-quality reports were published significantly more often in impact factor journals (P = 0.045). Reports of clinical trials published in journals that adhered to the CONSORT guidelines had significantly more 'High' scores compared to those that did not (P = 0.008). Clinical trials with protocols registered a priori had a significantly greater percentage of 'High' scores compared to the trials that were not registered in advance (P = 0.003). No significant difference occurred between the quality of clinical trials and the number of authors, journal (Endodontic specialty vs. Non-Endodontic specialty) or year of publication.

CONCLUSIONS

Reports of randomized clinical trials published in the speciality of Endodontics had a substantial number of deficiencies. To create high-quality reports of clinical trials, authors should comply with the PRIRATE 2020 guidelines.

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.

An Evaluation on Deep Caries Removal Method and Management Performed by Undergraduate Dental Students: A Malaysia Experience

OBJECTIVES

 The aim of this study was to investigate the current knowledge and attitude of deep caries removal method among dental students in Malaysia.

MATERIALS AND METHODS

 A total of 303 students (n = 303) responded to the online questionnaire. The first part of questionnaire was to evaluate the demographic data of the respondents and focused on the technique and management approach used for deep caries lesion. The second part investigated the preferred treatment used for deep caries based on the designated clinical case, while the third part assessed the factors that affected the decision on deep caries management.

STATISTICAL ANALYSIS

 Independent t-test was used to compare difference between the two groups.

RESULTS

 Seventy four percent of the students have the knowledge of the different methods of caries removal, while 25.8% were only familiar with complete caries removal. The preferred method for deep caries removal in permanent teeth was partial caries removal (53%). For primary dentition, 45.6% of the students prefer to perform pulpotomy as compared with other techniques. There was no significant difference in caries removal method for permanent teeth between undergraduate year of study (p > 0.05), which was partial caries removal at 52.7 and 53.5%, respectively. For primary dentition, the preferred caries removal method was pulpotomy for year 4 (39.8%) and year 5 (52%) students. The popular material to restore deep caries was resin composite (42%) followed by glass ionomer cement (23.3%).

CONCLUSIONS

 This study showed that partial caries removal was the preferred method despite partial understanding on the identification of the clinical indicators of the technique.

Characterization of Root Canal Microbiota in Teeth Diagnosed with Irreversible Pulpitis

INTRODUCTION

Previous studies have shown that in teeth presenting with symptoms of irreversible pulpitis (IP), bacteria and their by-products driving inflammation are confined mainly within the coronal pulpal tissue. The present study aimed to determine the presence and identity of bacteria within pulps presenting with clinical symptoms of IP using molecular methods.

METHODS

Samples were obtained from 30 adult patients presenting to the dental emergency department with signs and symptoms of IP. After meticulous surface decontamination, the pulp space was accessed, and clinical samples were collected from inflamed pulp tissue using sterile paper points. Genomic DNA was extracted from the clinical samples, and quantification of bacteria was performed using quantitative polymerase chain reaction targeting the conserved 16S ribosomal RNA (rRNA) gene. To characterize the microbial composition, the V3-V5 hypervariable regions of the 16S rRNA gene were amplified and subjected to next-generation sequencing on the MiSeq platform (Illumina, San Diego, CA).

RESULTS

Of the 30 teeth that presented with IP, half of the intracanal samples had a substantial bacterial load (16S rRNA copies) within the IP vital pulp as determined by quantitative polymerase chain reaction. Next-generation sequencing microbial identification was successful in 7 intracanal samples and yielded 187 bacterial operational taxonomic units within the IP samples. The most abundant genera observed among the vital cases were Veillonella (16%), Streptococcus (13%), Corynebacterium (10%), Cutibacterium (9.3%), and Porphyromonas (5.7%).

CONCLUSIONS

The current study highlighted the evidence of vital teeth diagnosed as IP harboring considerable bacterial loads and composed of genera reflective of established endodontic pathology and thus may offer insights into the initial events preceding pulpal necrosis.

Biochemical characterisation of carious dentine zones using Raman spectroscopy

OBJECTIVE

Carious tissue discrimination in clinical operative caries management relies traditionally on the subjective hardness of carious dentine. Biochemical alterations within the lesion have the potential to discriminate the lesion zones objectively. This study aimed to determine the correlation between the biochemical proportions of amide I and phosphate moieties as these are the most prominent peaks found in dentine with the Knoop microhardness of carious dentine zones, using non-contact Raman spectroscopy. The null hypothesis investigated was that there was no correlation between Raman peak ratios, amide I: phosphateν1, and the Knoop microhardness within specific zones of a carious lesion.

METHODS

423 scan points from 20 carious dentine lesion samples examined using high-resolution Raman spectroscopy. The peak ratio of the characteristic vibration mode of amide I (1650 cm^-1) and phosphate (960 cm^-1) bands were calculated, following a straight line path through the lesion to the pulp and correlated to corresponding Knoop microhardness measurements.

RESULTS

Using logistic regression analysis, clear correlations were found between the Knoop microhardness and Raman peak ratio cut-off values between caries-infected and caries-affected dentine (81.5 % sensitivity / 92.7 % specificity), with a lower specificity (2.7 %) found between caries-affected and sound dentine.

CONCLUSION

This study concluded that non-contact Raman spectroscopy can be used in vitro to discriminate objectively between the different zones of a carious dentine lesion at high resolution, using the Raman peak ratios, amide I : phosphate ν₁.

CLINICAL SIGNIFICANCE

Specific biochemical alterations have the potential to be used in-vitro and in-vivo to identify the end-point of selective carious lesion excavation.

Contemporary restorative ion-releasing materials: current status, interfacial properties and operative approaches

Minimally invasive (MI) concepts in restorative dentistry in the year 2020 request from the practitioner not only a scientifically supported rationale for carious tissue removal/excavation and defect-oriented, biological cavity preparation, but also a deep understanding of how to ensure a biomechanically stable and durable restoration in different clinical situations by applying different restorative options. Bio-interactive materials play an increasingly relevant role, as they not only replace diseased or lost tissue, but also optimise tissue mineral recovery (among other properties) when used in restorative and preventive dentistry. Indeed, this is of certain interest in MI restorative dentistry, especially in those cases where gap formation jeopardises the integrity of the margins along resin composite restorations, causing penetration of bacteria and eventually promoting the formation of secondary caries. Recently, the interest in whether ion-releasing materials may reduce such biofilm penetration into margin gaps and reduce such a risk for development and propagation of secondary caries is growing significantly among clinicians and scientists. The aim of this article was to explore mechanisms involved in the process that allow mineral deposition at the interface between such materials and dentine, and to describe how conventional 'bioactive' restorative materials currently available on the market may benefit treatments in MI dentistry.

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).

Comparison between conventional and chemomechanical approaches for the removal of carious dentin: an in vitro study

The present study aimed to evaluate the efficiency, effectiveness, and biocompatibility of two agents used for the chemomechanical removal of carious dentin. Sixty extracted carious human teeth were treated with a conventional bur (CBG) or chemomechanical agents – Papacarie Duo (PG) and Brix 3000 (BG). Treatment efficiency and effectiveness were assessed by the working time for carious dentin removal and Knoop microhardness values, respectively. Human pulp fibroblasts (FP6) were used to evaluate cytotoxicity by incorporating MTT dye, and genotoxicity was evaluated with the micronuclei test. The carious tissue was removed in a shorter time with CBG (median = 54.0 seconds) than the time required for chemomechanical agents (p = 0.0001). However, the time was shorter for Brix 3000 (BG) than that for Papacarie Duo (PG), showing mean values of 85.0 and 110.5 seconds, respectively. Regarding microhardness testing, all approaches tested were effective (p < 0.05). The final mean microhardness values were 48.54 ± 16.31 KHN, 43.23 ± 13.26 KHN, and 47.63 ± 22.40 KHN for PG, BG, and CBG, respectively. PG decreased cell viability compared to that of BG, but it presented no genotoxicity. Brix 3000 may be a good option for chemomechanical dentin caries removal due to its reduced removal time and lower cytotoxicity compared to the other treatment options.

Vital Pulp Therapy an Insight Over the Available Literature and Future Expectations

Vital pulp therapy (VPT) defined as “treatment which aims at preserving and maintaining the pulp tissue that has been compromised but not destroyed by extensive dental caries, dental trauma, and restorative procedures or for iatrogenic reasons”, offers some beneficial advantages over the conventional root canal treatment such as protective resistance for mastication forces or to prevent the loss of environmental changes sensation ability, which can lead to unnoticeable progression of caries and later fracture. A wide range of materials are suggested in the literature to be used as pulp capping protective dressing materials that varies from ready-made synthetic materials to biological based scaffolds and composites. The aim of the present review is to provide a full understanding of currently used materials to clinicians in order to help in their decision-making process delivering the best available evidence-based treatments to their patients. An extensive search for recent available data regarding direct pulp capping materials and potential suggestions for future use have been made. Newly developed biological based scaffolds showed promising results in dentine regeneration therefore strengthening the tooth structure and overcoming potential drawbacks of use of currently available recommended materials.

Selective vs stepwise removal of deep carious lesions in primary molars: 12-Months results of a randomized controlled pilot trial

OBJECTIVES

For deep carious lesions, selective or stepwise carious tissue removal (SE, SW) seem advantageous compared with non-selective removal. For primary molars, there is insufficient evidence comparing SE against SW. This randomized pilot trial compared SE and SW over 12 months.

METHODS

A two-arm superiority trial was conducted comparing SE and SW in primary molars with deep lesions but without pulpal symptoms. We recruited 74 children (one molar/child) aged 3-9 years. In both groups, peripheral carious tissue removal was performed at T1 to hard dentin. In proximity to the pulp, leathery dentin was left followed by an adhesive compomer restoration. Blinded re-examination was performed after six months (T2). Molars allocated to SW were re-entered, removal to firm dentin carried out pulpo-proximally, and again restored. After another 6 months, all molars were re-examined (T3). Our primary outcome was success, defined as no restorative/endodontic complications (including pulp exposure) leading to reinterventions. Secondary outcomes included total treatment and opportunity costs. Patients', dentists' and parents' subjective assessments were recorded. This trial was registered (ClinicalTrials.gov/NCT02232828).

RESULTS

After 12 months a total of 72 children (36 SE, 36 SW) were analyzed. Three failures occurred (2 exposures in SW, 1 pulpal complication leading to extraction in SE) (p > 0.05). The subjective evaluation by patients, parents or dentists did not differ significantly. Combined treatment and opportunity costs were significantly higher in SW (mean;SD: 186;61 Euro) than SE (100;59) (p < 0.001).

CONCLUSIONS

The significantly increased costs for performing SW instead of SE in deep carious lesions in primary molars may not be justified.

CLINICAL SIGNIFICANCE

For primary molars with deep lesions, but vital pulps, SE was less costly at similar efficacy compared with SW. Dentists' decision-making should consider this alongside further clinical aspects.