Materials for pulpotomy in immature permanent teeth: a systematic review and meta-analysis

Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A systematic review and meta-analysis

OBJECTIVES

Different materials have been used for capping the pulp after exposure during caries removal in permanent teeth. The purpose of this study was to collate and analyze all pertinent evidence from randomized controlled trials (RCTs) on different materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth.

MATERIALS AND METHODS

Trials comparing two or more capping agents used for direct pulp capping (DPC) or pulpotomy were considered eligible. An electronic search of four databases and two clinical trial registries was carried out up to February 28, 2021 using a search strategy properly adapted to the PICO framework. Screening, data extraction, and risk of bias (RoB) assessment of primary studies were performed in duplicate and independently. The primary outcome was clinical and radiological success; secondary outcomes included continued root formation, tooth discoloration, and dentin bridge formation.

RESULTS

21 RCTs were included in the study. The RoB assessment indicated a moderate risk among the studies. Due to significant clinical and statistical heterogeneity among the studies, performing network meta-analysis (NMA) was not possible. An ad hoc subgroup analysis revealed strong evidence of a higher success of DPC with Mineral Trioxide Aggregate (MTA) compared to calcium hydroxide (CH) (odds ratio [OR] = 3.10, 95% confidence interval [CI]: 1.66-5.79). MTA performed better than CH in pulp capping (both DPC and pulpotomy) of mature compared to immature teeth (OR = 3.34, 95% CI: 1.81-6.17). The GRADE assessment revealed moderate strength of evidence for DPC and mature teeth, and low to very low strength of evidence for the remaining subgroups.

CONCLUSIONS

Considerable clinical and statistical heterogeneity among the trials did not allow NMA. The ad hoc subgroup analysis indicated that the clinical and radiographic success of MTA was higher than that of CH but only in mature teeth and DPC cases where the strength of evidence was moderate. PROSPERO Registration: number CRD42020127239.

Success rate of permanent teeth pulpotomy using bioactive materials: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The results of vital pulp treatments in permanent teeth have been encouraging. Currently, pulpotomy treatment for permanent teeth primarily utilizes mineral trioxide aggregate (MTA) as the dressing material, followed by calcium hydroxide. While other calcium-silicate-based cements have been suggested for pulpotomy, there is a limited number of studies evaluating their long-term effectiveness.

OBJECTIVES

The objective of this systematic review and meta-analysis was to evaluate the success rate of pulpotomies performed on permanent teeth, comparing the use of ProRoot MTA with that of calcium hydroxide and other bioceramic materials.

METHODS

A comprehensive search was conducted in several electronic databases, including PubMed, Cochrane Library, Scopus, Web of Science, Embase and Science Direct until December 2022. The search was guided by PICOS criteria, including only randomized clinical trials (RCTs) that evaluated the success rate of pulpotomy treatments in permanent teeth using ProRoot MTA in comparison to calcium hydroxide and other bioceramic materials. The quality of the included studies was assessed using the RoB-2 tool to evaluate the risk of bias, and relevant data were extracted and analysed in RevMan software 5.3 using fixed-effect models. The GRADE tool was used to determine the overall quality of evidence.

RESULTS

The initial search retrieved 1072 studies and, after eliminating duplicates, 677 studies were screened and 28 studies were considered for eligibility. In the final selection process, 16 studies were included in the systematic review, with 10 being determined as having a high risk of bias. Pulpotomy showed an overall mean success rate of 92% after 1 year. The meta-analysis indicated a significantly higher success rate for pulpotomies utilizing MTA in comparison with calcium hydroxide, while no significant difference was seen between MTA and calcium-enriched mixture (CEM) or Biodentine. The GRADE assessment revealed an overall low level of evidence for the included studies.

DISCUSSION

Most randomized controlled trials exhibited a significant absence of control over confounding factors.

CONCLUSIONS

This systematic review and meta-analysis demonstrate that pulpotomy is a highly effective treatment for managing permanent teeth. The results indicate that the success rate of pulpotomy using ProRoot MTA is significantly higher than when using calcium hydroxide. However, the certainty of evidence supporting these findings is low, and there is a need for well-designed RCTs to assess the long-term outcomes of pulpotomy using newer bioceramic materials.

REGISTRATION

This systematic review was registered in the PROSPERO database (registration number CRD42023393970).

Controlled drug delivery from metronidazole-containing bioactive endodontic cements

OBJECTIVES

This study aims to formulate metronidazole liquid nanocapsules (MTZLNC) and evaluate their effect on the physicochemical and biological properties of calcium silicate-based bioactive endodontic cements, in vitro.

METHODS

A MTZLNC suspension was formulated by deposition of the preformed polymer and characterized by laser diffraction and high-performance liquid chromatography (HPLC). Calcium silicate (CS) was mixed with a radiopaque agent (calcium tungstate - CaWO4), at 10 wt%, to produce the cement powder. Cements liquids were used with two concentrations of MTZLNC suspension: 0.3 mg/ml and 0.15 mg/ml. Cements prepared with distilled water were used as the control. The radiopacity, setting time, and flow were evaluated following ISO 6876:2012. The compressive strength analysis was conducted according to ISO 9917:2007. pH and mineral deposition were evaluated after immersion in simulated body fluid (SBF). Cell behavior was evaluated by the viability of pre-osteoblastic cells and pulp fibroblasts by SRB and MTT and the antibacterial activity against Enterococcus faecalis was analyzed immediately and after nine months of water storage.

RESULTS

MTZLNCs were formulated with a median diameter of 148 nm and 83.44 % load efficiency. Increased flow and reduced strength were observed for both MTZLNCs concentrations. The incorporation of MTZLNCs maintained the ability of cements to increase pH media and promote mineral deposition over the samples, without promoting cytotoxicity. A 2 log10 reduction in E. faecalis CFU was observed immediately and after nine months in water storage.

CONCLUSION

The formulation of MTZLNCs allowed the development of antibacterial calcium silicate-based-cements with suitable physicochemical properties and bioactivity, with a reduction in mechanical strength. The 0.3 mg/ml concentration in cements liquid promoted effective and sustainable antibacterial activity.

Contemporary Endodontic Approaches for Children

Endodontic therapy is necessary when caries extend further into the tissues of the tooth and reach the pulp, producing irreparable inflammation or necrosis [...].

Evaluation of bacterial leakage and marginal adaptation of the bioceramics pulp dressing materials: an invitro study

OBJECTIVE

To compare the sealing ability and marginal adaptation of three calcium silicate-based cement (Biodentine, Pro root MTA, MTA Angelus) using a bacterial leakage model and scanning electron microscope (SEM).

METHODS

Recently extracted lower first premolars were randomly categorized into three experimental groups (n = 15 samples), positive control (n = 5 samples), and negative control group (n = 5 sample). Samples from the experimental groups and positive control group were subject to cavity Class I occlusal preparation followed by modified coronal pulpotomy. Different types of bioceramic dressing material were placed in 3 mm thickness accordingly, group 1 (Biodentine), group 2 (MTA Angelus), and group 3 (ProRoot MTA). No dressing material was placed in the positive control group (group 4). All samples were placed in the incubator for 24 h at 37℃, 100% humidity, for the materials to be completely set. The final restoration was placed using the Z350 resin composite. A double layer of nail varnish was applied over all the sample surfaces except the occlusal site. Whereas the samples' surfaces in the negative control, were completely covered. A 3 mm length was measured from the root apex of the samples from each group, before proceeding with the resection. The bacterial leakage test was performed using Enterococcus faecalis TCC 23,125, and a sample from each experimental group was randomly chosen for SEM. Data analysis was conducted under the One-way ANOVA test, completed by Tukey's post hoc test.

RESULTS

There is a significant difference in sealing ability and marginal adaptation between the groups. (p < 0.05). The study showed that Pro Root MTA had the superior sealing ability and marginal adaptation compared to Biodentine and MTA Angelus.

CONCLUSION

The ProRoot MTA as a coronal pulpotomy pulp dressing material, was found to have a better marginal adaptation and sealing ability compared to three other bioceramics materials. The material would be the better choice during clinical settings and procedures.

Bioceramics in Endodontics: Updates and Future Perspectives

Bioceramics, with excellent bioactivity and biocompatibility, have been widely used in dentistry, particularly in endodontics. Mineral trioxide aggregate (MTA) is the most widely used bioceramic in endodontics. Recently, many new bioceramics have been developed, showing good potential for the treatment of endodontic diseases. This paper reviews the characteristics of bioceramics and their applications in various clinical endodontic situations, including root-end filling, root canal therapy, vital pulp therapy, apexification/regenerative endodontic treatment, perforation repair, and root defect repair. Relevant literature published from 1993 to 2023 was searched by keywords in PubMed and Web of Science. Current evidence supports the predictable outcome of MTA in the treatment of endodontic diseases. Although novel bioceramics such as Biodentine, EndoSequence, and calcium-enriched mixtures have shown promising clinical outcomes, more well-controlled clinical trials are still needed to provide high-level evidence for their application in endodontics. In addition, to better tackle the clinical challenges in endodontics, efforts are needed to improve the bioactivity of bioceramics, particularly to enhance their antimicrobial activity and mechanical properties and reduce their setting time and solubility.

Cell viability and physicochemical effects of different concentrations of bismuth trioxide in a mineral trioxide aggregate cement

PURPOSE

To evaluate the effect of three concentrations of bismuth trioxide (Bi₂O₃) on the biological and physicochemical properties of an experimental mineral trioxide aggregate-type (MTA-type) cement at different time points.

METHODS

Three experimental groups with white Portland cement containing 15, 20, or 25 wt% of Bi₂O₃ were assessed. Cellular proliferation in human periodontal ligament fibroblasts was evaluated with an MTT assay. Radiopacity, dimensional stability, pH, and compressive strength were evaluated at different time points.

RESULTS

Bismuth trioxide induced cell proliferation in the Bi15 and Bi25 groups in a time-dependent manner; pH was similar in all groups. Compressive strength was associated with time and bismuth concentration. Bi25 had significantly contracted at day 7 and expanded at day 14 (ANOVA P < 0.05, post hoc Tukey test P < 0.05).

CONCLUSION

A higher Bi₂O₃ concentration had a negative effect on the physical properties of the cement at all time points.

Challenging the Misnomer of Irreversible Pulpitis and Deliberating the Urgent Need for Reclassification of Pulpal Diseases Based on the Efficacy of Vital Pulp Therapies: An Overview of Systematic Reviews

Over recent decades, the definition of irreversible pulpitis (IP), as an irrevocable condition of a compromised dental pulp tissue, has forced clinicians towards invasive root canal treatments. However, the current best evidence challenges the alignment between clinical symptoms and the perceived irreversibility of a negotiated dental pulp tissue. In the above-mentioned context, vital pulp therapy (VPT) has emerged as a revolutionary and transformative approach; introducing minimally invasive techniques to sustain pulp vitality in cases of IP. The present paper aimed to rigorously examine the corresponding published systematic reviews to explore the diverse spectrum of VPT modalities and their outcomes in managing IP cases. Besides, the current review seems to have asserted the need to discard the conventional terminology of irreversible pulpitis, based on the effectiveness of VPTs in the achievement of pulp tissue healing within cases clinically diagnosed as IP.

A Pilot Feasibility Study to Establish Full Pulpotomy in Mature Permanent Teeth with Symptomatic Irreversible Pulpitis as a Routine Treatment in Mexican Public Healthcare Services

Symptomatic irreversible pulpitis is a common dental disease for which root canal treatment (RCT) has been the standard treatment. However, in many countries, RCT is considered a high-cost treatment that is not covered by public healthcare services; this forces patients to have dental extraction as their only option to relieve pain. In the last decade, several investigations have provided evidence that an alternative treatment known as full pulpotomy (FP) could be an alternative for patients who could not afford the cost of an RCT. Nevertheless, evidence is lacking on the success rate that could be obtained if it is performed in a public dental care clinic (PDCC). The present investigation has two main objectives. To be the first approach of a multicentric feasibility study to find out whether an FP performed by a general practice dentist (GPD) in a PDCC could be suitable and establish its success rate and patient satisfaction. Patients attending a PDCC with symptoms of irreversible pulpitis were invited to participate. FP was performed and followed up at 1, 3, 6, 9, and 12 months. The treatment success was assessed by combining three variables, patient satisfaction, clinical, and radiographic outcomes. Forty-one patients from 17 to 78 years old received the intervention. In total, 97.5% were completely satisfied with the treatment and were considered successful since none of the clinical or radiographic variables were present in any of the follow-ups. An FP performed by a GPD in a PDCC could be suitable as a routine treatment for symptomatic irreversible pulpitis due to the excellent success rate and patient satisfaction.

Biodentine™ Pulpotomy in Stage I primary Molars: A 12-month Follow-up

Aim

This study aims to evaluate, over 12 months of clinical and radiographic follow-ups, the performance and outcomes of Biodentine™ pulpotomy in stage I primary molars.

Materials and methods

A total number of 20 stage I primary molars requiring pulpotomy were selected from eight healthy patients aged between 34 and 45 months. Patients presenting a negative attitude toward dental treatment on the dental chair were scheduled for dental treatments under general anesthesia.Pulpotomy with Biodentine™ as a pulp-dressing material was performed on all selected molars. The patients were called back at 1 and 3 months for clinical follow-ups, then at 6 and 12 months for clinical and radiographic follow-ups. Data were tabulated according to follow-up intervals and occurrence of any changes in root maturation, pulp canal obliteration (PCO), periodontal ligament space (PLS), and bone or root lesion.

Results

No statistically significant differences were recorded at 1, 3, 6, and 12 months. There was a statistically significant increase in number of roots with closed apices from six roots at 6 months to 50 roots at 12 months (p < 0.0005) and the PCO was present in all 50 roots at 12 months, after it was present in 36 roots only at 6 months (p = 0.0001).

Conclusion

This is the first randomized clinical trial that evaluates the performance of Biodentine™ as a pulp-dressing agent in stage I primary molar pulpotomy over 12 months of follow-up. Contrary to previous studies, the present work highlights the continued root formation and apical closure (AC) in pulpotomized immature primary molars.

How to cite this article

Nasrallah H, Noueiri BE. Biodentine™ Pulpotomy in Stage I primary Molars: A 12-month Follow-up. Int J Clin Pediatr Dent 2022;15(6):660-666.

Complicated Crown Fracture of Permanent Incisors: A Conservative Treatment Case Report and a Narrative Review

Dental trauma may have a severe impact on the social and psychological wellbeing of a patient. Most cases of dental injuries involve anterior teeth, especially the maxillary upper incisors. Crown fractures, with or without pulp exposure, are the most common trauma in permanent dentition. There are many methods of management, in which the initial state of the pulp, the time since the injury, and the presence of an accompanying injury play a key role. This case report aimed at showing a possible conservative treatment after complicated tooth fracture that consisted of partial pulpotomy followed by adhesive reattachment of the tooth fragment using a technique based on heated resin composite. Such a specific procedure represents a conservative approach to traumatic coronal lesions, providing a suitable opportunity to maintain the tooth vitality, aesthetics, and function. Indeed, reattachment of tooth fragment using a composite/adhesive is a simple technique to achieve excellent results in terms of aesthetic and function.

Combined effects of bone morphogenetic protein-7 and mineral trioxide aggregate on the proliferation, migration, and differentiation of human dental pulp stem cells

BACKGROUND

Bioactive molecules present the potential to be used along with biomaterials in vital pulp therapy and regenerative endodontic treatment.

OBJECTIVE

The aim of this study was to assess the effects of the combined use of bone morphogenetic protein-7 (BMP-7) and mineral trioxide aggregate (MTA) on the proliferation, migration, and differentiation of human dental pulp stem cells (DPSCs).

METHODOLOGY

For the proliferation analysis, DPSCs were incubated with a growth medium and treated with MTA and/or BMP-7 at different concentrations. For the following analyses, DPSCs were incubated with a differentiation medium and treated with MTA and/or BMP-7. Moreover, there were groups in which DPSCs were incubated with the growth medium (control), the differentiation medium, or DMEM/F12 containing fetal bovine serum, and not treated with MTA or BMP-7. Cell proliferation was analyzed using the WST-1 assay. The odontogenic/osteogenic differentiation was evaluated by immunocytochemistry, alkaline phosphatase (ALP) activity assay, alizarin red staining, and reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Cell migration was evaluated using a wound-healing assay. Data were analyzed using analysis of variance and Tukey test (p=0.05).

RESULTS

The use of BMP-7 with MTA presented no significant effect on cell proliferation in comparison with the treatment with MTA alone (p>0.05), but showed higher ALP activity, increased mineralization, and higher expression of DMP1 and DSPP when compared with other groups (p<0.05). Nestin expression was higher in the control group than in groups treated with MTA and/or BMP-7 (p<0.05). The cell migration rate increased after treatment with MTA when compared with other groups in all periods of time (p<0.05). At 72 hours, the wound area was smaller in groups treated with MTA and/or BMP-7 than in the control group (p<0.05).

CONCLUSION

The use of BMP-7 with MTA increased odontogenic/osteogenic differentiation without adversely affecting proliferation and migration of DPSCs. The use of BMP-7 with MTA may improve treatment outcomes by increasing repair and regeneration capacity of DPSCs.

Cost-related variables in the public purchase of dental materials for endodontic application

Aim: This study analyzed public procurements for different endodontic materials used in the Brazilian public health system and evaluated the variables related to their cost. Methods: A time-series study was performed by screening materials for endodontic application in the public Brazilian Databank of Healthcare Prices from 2010 to 2019. Data were categorized according to material composition and clinical application. The collated variables were used in a multiple linear regression model to predict the impact of unit price in procurement processes. Results: A total of 5,973 procurement processes (1,524,693 items) were evaluated. Calcium hydroxides were found in 79% of the observations (4,669 processes). Prices drop each year by US$1.87 while MTAs and epoxy resins are increasingly purchased at higher prices (US$50.87; US$67.69, respectively). The microregion, the procurement modality, and the type of institution had no influence on unit prices in the adjusted model (p > 0.05). Conclusions: Calcium hydroxide-based materials were the cheapest and most frequently purchased endodontic materials in the public health care system. Novel formulations are being implemented into clinical practice over time and their cost may be a barrier to the broad application of materials such as MTAs, despite their effectiveness.

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).

Pulp therapy and root canal treatment techniques in immature permanent teeth: an update

Background According to the Children's Dental Health Survey 2013, around one in ten children in Wales, Northern Ireland and England will have sustained dental trauma to a permanent incisor by the of age 15. Management of an exposed pulp in an immature permanent incisor is often urgent and has an impact on the long-term outcome of the tooth; therefore, it is essential that general dental practitioners feel confident in managing such a scenario to achieve an optimal outcome. This paper discusses the indications, technique, materials and outcomes.Aims This article aims to review the literature, which discusses various treatment modalities and materials for pulpal therapy and root canal treatment in the immature permanent tooth.Method Electronic searches were limited to English language, human studies, published within the past five years and the medical subject heading terms used were: direct pulp capping, apexogenesis, Cvek pulpotomy, full pulpotomy/pulpectomy, partial pulpotomy, apexification, non-vital pulp therapy and mineral trioxide aggregate apexification. Older, seminal articles identified through the references sections have also been included.Conclusion A number of options are available for the management of immature permanent teeth that have suffered an insult such as caries or trauma. This paper reviews the various methods of pulpal treatment, preservation therapy and root canal treatment options depending on the extent of the damage.

Efficacy and safety of mineral trioxide aggregate (MTA) pulpotomy for caries-exposed permanent teeth in children: a systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate the effect of mineral trioxide aggregate (MTA) pulp capping for caries-exposed permanent teeth. However, the efficacy of MTA in the treatment of children's gums is still controversial, and different studies have shown different efficacy. Therefore, it is necessary to systematically review the efficacy and safety of MTA pulp incision in the treatment of pediatric caries using meta methods.

METHODS

We used meta-analysis to compare differences in the efficacy of MTA and calcium hydroxide (CH) for treating caries in permanent teeth. The mean treatment success rate of MTA for reversible and irreversible pulpitis groups was calculated, and the effect of apical opening condition and surgical type on success rate were investigated.

RESULTS

A total of 15 studies were included, and meta-analysis showed that there was a significant statistical difference between the MTA group and CH group in efficacy [odds ratio (OR) =1.87, 95% confidence interval (CI): 1.28, 2.73, P=0.001, I²=63%, Z=3.25], success rate (OR =3.20, 95% CI: 1.93, 5.30, P<0.00001, I²=0%, Z=4.52), influence of apical foramen condition on success rate (OR =1.77, 95% CI: 1.14, 2.73, P=0.01, I²=15%, Z=2.56), and surgical procedure on success rate (OR =2.64, 95% CI: 1.65, 4.23, P<0.0001, I²=45%, Z=4.05).

DISCUSSION

Our results showed that MTA pulpotomy was superior to CH. Nonclosure of apical openings and complete coronal pulpotomy may be more beneficial than partial pulpotomy.

Regenerative Endodontic Procedures in Immature Permanent Teeth With Dental Trauma: Current Approaches and Challenges

After dental trauma to immature permanent teeth (IPT), there can be pulpitis, necrotic, and periapical periodontitis, which will halt further root development. Traditional endodontic root canal treatments and apexification cannot revitalize the necrotic pulp to revitalize the tooth to promote further root development. As a consequence, IPT with thin dentinal walls can be prone to fracture and if a fracture occurs, the patient will likely suffer the loss of the tooth. In an attempt to save IPT, there has been a growing interest among dentists to use regenerative endodontic procedures (REPs) to revitalize a replace dental pulp to continue root development and strengthen the dentinal walls to help prevent a subsequent loss of the tooth. However, the effectiveness of REPs and the precise methods to successfully accomplish REPs are controversial. Therefore, the objective of this review is to compare the different approaches to REPs in case reports by highlighting their advantages and limitations.

Pulpotomy for treatment of complicated crown fractures in permanent teeth: A systematic review

Background

Consensus on the treatment of choice for complicated crown fractures of teeth is limited. Recent guidance recommends vital‐pulp‐therapy; however, the preferred type is not specified. Higher success rates for pulpotomy compared to pulp‐capping have been documented, which suggests pulpotomy may be a preferable option for complicated crown‐fractures.

Objectives

The purpose of this systematic review was to determine the success rate of pulpotomy (partial and complete) on teeth that suffered complicated crown fractures. Participants: patients who have suffered a complicated crown fracture to an anterior permanent tooth. Intervention: pulpotomy (partial or complete). Comparator: pulp‐capping or root canal treatment. Outcome: combined clinical and radiographic success at or after 12 months.

Methods

A systematic literature using key search terms was conducted using PubMed, Web of Science and Cochrane‐Central‐Register‐of‐Controlled‐Trials (CENTRAL) as well as a grey literature search from inception to May 2021 and without language restricted to English. Strict inclusion criteria were applied. A standardized tool with defined criteria to assess the risk of bias in each study was used. For non‐randomized comparative trials, the Robins‐I tool was used while the Newcastle‐Ottawa scale was used for non‐comparative non‐randomized studies.

Results

Seven retrospective clinical studies were included. The studies reported high success rates for pulpotomy with overall success ranges for partial or complete pulpotomy ranging from 75% to 96%. One study compared the success rates of pulpotomy to an alternative treatment option pulp capping (90.9% vs. 67%, respectively). Due to the lack of homogeneity in the included studies, a meta‐analysis was not possible.

Discussion

This review highlights the limited evidence based for the current guidance on treatment of complicated crown fractures. The findings of the review indicate high success rates for pulpotomy; however, there is a moderate risk of bias and small sample sizes in the included studies with the result that the overall results should be interpreted with caution.

Conclusion

Within the limitations of this review, the benefits and high success rates reported for partial pulpotomy suggest this procedure, rather than pulp‐capping, should be considered as the treatment of choice for both immature and mature teeth that have suffered complicated crown‐fractures.

Mineral Trioxide Aggregate vs Calcium-Enriched Mixture Pulpotomy in Young Permanent Molars with a Diagnosis of Irreversible Pulpitis: A Randomized Clinical Trial

Introduction

The aim of this blind randomized clinical study was to prospectively compare the clinical and radiographic success outcomes of calcium-enriched mixture (CEM) pulpotomy versus white mineral trioxide aggregate (WMTA) pulpotomy in permanent molars diagnosed with irreversible pulpitis.

Materials and Methods

Forty patients met the inclusion criteria and agreed to join. The patients were randomly assigned into two groups: CEM pulpotomy (n=20) and WMTA pulpotomy (n=20). Clinical success was reviewed at 7 days and 3, 6 and 12 months after treatment. We organized radiographic assessment at 6 and 12 months. The data was analyzed using Chi-square, Independent t-test, and Mann-Whitney for the baseline and post-operative characteristics of the patients.

Results

None of the patients were lost during recalls. Twenty-one females and 19 males participated in the study ranging between 7-14 years of age. The follow up period was extended in some of the cases for more than 1 year (12-23 month). Regarding the baseline and post-operative characteristics of the patients, there was no significant difference between the groups (P>0.05). All the cases showed clinical and radiographic success outcomes for both groups at/after12-month recall periods. There was no significant difference between the two groups clinically and radiographically (P=1).

Conclusions

Based on this randomized clinical trial study, CEM and WMTA as pulpotomy agents expressed excellent clinical and radiographic outcomes with no significant difference in the treatment of permanent molars with irreversible pulpitis over a 12-month period.

Outcomes of root canal therapy or full pulpotomy using two endodontic biomaterials in mature permanent teeth: a randomized controlled trial

OBJECTIVE

The concept of minimally invasive endodontics recommends less-invasive vital pulp therapy (VPT) modalities over more aggressive traditional endodontic approaches in mature permanent teeth with carious pulp exposure, including irreversible pulpitis (IP) cases. Consequently, VPT needs to be compared with root canal therapy (RCT) in terms of treatment outcomes. This randomized clinical trial compares the results of full pulpotomy using two calcium-silicate cements, i.e., mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement, with RCT in mature permanent teeth.

MATERIALS AND METHODS

A total of 157 carious pulp exposure cases in two academic centers with/without established IP were selected/included/randomly appointed to three study arms; (i) RCT (n = 51) as the reference treatment, (ii) pulpotomy with ProRoot MTA (PMTA; n = 55), and (iii) pulpotomy with CEM cement (PCEM; n = 51) as two alternative VPT treatments. Two-year clinical/radiographic results were the outcomes of interest. Data were statistically analyzed through the analysis of variance, chi-square, Fisher exact test, and Kruskal-Wallis.

RESULTS

At 2-year recall, 147 teeth were examined (6.4% dropout). All molars, except for one, were clinically functional/symptom-free, and there was no statistical difference between the three study arms (p = 0.653). The radiographic success rates in RCT, PMTA, and PCEM arms were 98%, 100%, and 97.9%, respectively, without statistically significant differences (p = 0.544).

CONCLUSION

In the management of mature permanent teeth with/without established IP, all experimental groups exhibited equivalent/comparable results.

CLINICAL RELEVANCE

Simple VPT using MTA/CEM can be suggested/recommended as a viable advantageous alternative to RCT for the management of carious pulp exposures with/without sign/symptoms of IP.

Simvastatin treatment promotes proliferation of human dental pulp stem cells via modulating PI3K/AKT/miR-9/KLF5 signalling pathway

Simvastatin serves as an effective therapeutic potential in the treatment of dental disease via alternating proliferation of dental pulp stem cells. First, western-blot and real-time quantitative PCR were used to detect the effect of simvastatin or LY294002 on the expression levels of AKT, miR-9 and KLF5, or determine the effect of miR-9. Simvastatin, KLF5 and AKT significantly enhanced the proliferation of pulp stem cells, whilst this effect induced by simvastatin was suppressed by LY294002, AKT siRNA, KLF5 siRNA and miR-9, and simvastatin dose-dependently upregulated the expression of PI3K. Furthermore, simvastatin upregulated PI3K and p-AKT expression in a concentration-dependent manner. LY294002 abrogated the upregulation of p-AKT expression levels induced by simvastatin, and LY294002 induced the miR-9 expression and simvastatin dose-dependently inhibited the expression of miR-9, by contrast, LY294002 reduced the KLF5 expression and simvastatin dose-dependently promoted the expression of KLF5. And using computational analysis, KLF5 was found to be a candidate target gene of miR-9, and which was further verified using luciferase assay. Finally, the level of KLF5 in cells was much lower following the transfection with miR-9 and KLF5 siRNA, and the level of AKT mRNA in cells was significantly inhibited after transfection with AKT siRNA than control. These findings suggested simvastatin could promote the proliferation of pulp stem cells, possibly by suppressing the expression of miR-9 via activating the PI3K/AKT signalling pathway, and the downregulation of miR-9 upregulated the expression of its target gene, KLF5, which is directly responsible for the enhanced proliferation of pulp stem cells.

Human amniotic membrane as therapeutic agent in pulpotomy of permanent molars

A 22-year-old woman reported with a cariously exposed mandibular molar. Pulpotomy was planned rather than routine root canal treatment, which was otherwise indicated. Amniotic membrane (AM) that has been extensively researched in different fields of medicine was used as the pulpotomy agent. After gaining coronal access to the root orifices, bleeding was arrested and activated AM was placed over the root stumps. Glass ionomer cement(GIC) was placed over the membrane and temporary restoration was done. One week later, permanent restoration with composite resin was done. The patient's symptoms resolved, and the tooth started responding normally to vitality tests at subsequent follow-ups. The present case report is an attempt to use human AM as a natural pulpotomy agent for treating irreversible pulpitis in permanent teeth. Understanding of innumerable beneficial properties of the AM and its application in preserving vitality of permanent teeth is the main learning objective.

Is pulpotomy a promising modality in treating permanent teeth? An umbrella review

Emerging evidence suggests the use of less invasive therapy such as pulpotomy in treating permanent teeth with pulp exposure and signs of pulpitis. Hence, this umbrella review aims to evaluate the available systematic reviews on pulpotomy treated permanent teeth. Articles published between January 1970 and May 2021 were searched in ten electronic databases and five textbooks. Only systematic reviews published in English that examined the use of pulpotomy on either carious or traumatic pulpal exposed in mature or immature permanent teeth with signs of pulpitis were selected. The Corrected Covered Areas (CCAs) were calculated to identify the overlap in primary studies, whereas the AMSTAR 2 assessment tool was used to analyze the risk of bias in each included review. Nine systematic reviews were chosen of which two systematic reviews focused solely on coronal pulpotomy, one on partial pulpotomy, and the remaining focused on both coronal and partial pulpotomies. Overall, only two reviews were rated as 'High Quality'. Umbrella analyses showed that both coronal and partial pulpotomies revealed overall high success rates ranging from 88.5% to 90.6%. However, the currently available evidence on the effects of different pulpal medicaments and restorative materials on the success rate of pulpotomy were still inconclusive. Pulpotomy can be regarded as a promising modality in treating mature and immature permanent teeth with carious pulpal exposure or signs of pulpitis. Nonetheless, further high-quality clinical trials with long-term follow-up and better control of confounding factors are warranted in the future.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

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

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

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

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

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