Current perspectives of bio-ceramic technology in endodontics: calcium enriched mixture cement - review of its composition, properties and applications

Peptide KN-17-Loaded Supramolecular Hydrogel Induces the Regeneration of the Pulp-Dentin Complex

Regenerating the pulp-dentin complex remains a decisive factor during apexification for immature permanent teeth. Peptide KN-17, which was modified based on the structure of cecropin B, could effectively interfere with bacterial growth and induce the migration of human bone marrow stromal cells (hBMSCs). This study aimed to investigate the effect of KN-17 on the tissue regeneration. To our surprise, KN-17 can significantly stimulate angiogenesis in vitro and in vivo, which may provide a guarantee for apical closure. Herein, a novel peptide/KN-17 coassembled hydrogel is developed via a heating-cooling process. Npx-FFEY/KN-17 supramolecular hydrogel can induce vessel development, stimulate odontogenic differentiation of human dental pulp stem cells (hDPSCs), and exert an antibacterial effect on Enterococcus faecalis (E. faecalis). Furthermore, coronal pulp excised rat molars are supplied with KN-17 or KN-17-loaded hydrogel and transplanted subcutaneously in BALB/c-nu mice. After 4 weeks, the hydrogel Npx-FFEY/KN-17 stimulates the formation of multiple odontoblast-like cells and dentin-like structures. Our findings demonstrate that the KN-17-loaded hydrogel can promote the regeneration of the pulp-dentin complex for continued root development.

Comparative evaluation of cervical pulpotomy and pulpectomy for primary molars with irreversible pulpitis: a multicentre randomised controlled trial

PURPOSE

The objective of this multicentre randomised controlled trial was to compare the clinical/radiographic outcomes of cervical pulpotomy using calcium-enriched mixture cement (PCEM) and pulpectomy using Metapex (PM) in primary molars with irreversible pulpitis (IP).

METHODS

A total of 134 primary molars from 94 children were randomly assigned to two intervention groups: the PCEM group (n = 74) and the PM group (n = 60). Baseline characteristics including age/gender/molar type/tooth type/jaw were recorded. The primary outcome measures were clinical/radiographic success rates assessed at the first and second follow-up appointments. Secondary outcomes included reasons for clinical/radiographic failures. Multiple logistic regression analysis was performed to determine the impact of various factors on the success rates.

RESULTS

The mean age of the participants in both groups was similar (PCEM group: 5.4 years, PM group: 5.5 years). Gender distribution, molar type, tooth type, jaw, and number of practitioners were comparable between the groups. The clinical success rate at the first follow-up was 98.6% in the PCEM group and 96.4% in the PM group. At the second follow-up, the clinical success rate was 97.1% in the PCEM group and 91.1% in the PM group. The radiographic success rates at the first and second follow-up were 98.6% and 96.4% in the PCEM group and 96.4% and 91.1% in the PM group, respectively. Multiple logistic regression analysis did not reveal any significant association between the success rates and age/gender/molar type/jaw, or treatment groups (P > 0.05).

CONCLUSION

In primary molars with IP, both simple/conservative cervical pulpotomy using calcium-enriched mixture cement and pulpectomy using Metapex demonstrated high clinical/radiographic success rates. No significant differences were observed between the two treatment modalities. These findings suggest that both techniques can be considered effective treatment options for managing primary molars with IP.

TRIAL REGISTRATION NUMBER

Trial registration number: IRCT20201226049838N1, retrospectively registered on 12 January 2021.

Dentinal tubule penetration following ultrasonic, sonic, and single-cone technique of a biosealer: An ex vivo study

Background

The endodontic space is complex, and using a single-cone obturation technique fails to ensure a complete filling.

Introduction

This study aimed to investigate the effect of ultrasonic activation, sonic activation, and single-cone technique of a biosealer on its dentinal tubular penetration.

Materials and Methods

In the experiment, single-root mandibular premolars were randomly assigned to three groups (n = 20): group A, ultrasonic activation; Group B, sonic activation; and Group C, single-cone technique. Penetration of the fluorescently labeled biosealer was investigated using a confocal laser scanning microscope.

Results

The data were statistically analyzed using Kruskal-Wallis and Mann-Whitney tests (P = 0.05). The highest penetration of biosealer was observed in Group A, followed by Group B (P < 0.05).

Conclusions

Dentinal tubule penetration of biosealer was significantly improved by ultrasonic and sonic activation techniques.

Comparative Outcomes of Pulpotomy in Mature Molars with Irreversible Pulpitis: A Non-Randomized Trial Evaluating Calcified and Non-Calcified Pulp Chambers

Introduction

This non-randomized clinical trial investigated the outcomes of full pulpotomy in adult molars with irreversible pulpitis, comparing those with calcified and non-calcified pulp chambers over 6 and 12 months.

Materials and Methods

A total of 101 adult permanent molars with irreversible pulpitis, in individuals over 12 years old, were categorized based on pulp chamber calcification observed in radiographic images by two endodontists. Subsequently, full pulpotomy procedures were performed, achieving hemostasis, and applying a 2 mm layer of calcium-enriched mixture (CEM) cement as a pulp covering agent. After 48 hours, the setting of the CEM cement was verified, followed by the application of a layer of resin-modified glass-ionomer. The tooth was then restored using amalgam. Clinical and radiographic evaluations were conducted at 6-month and 1-year follow-ups by blinded endodontists. Success rates were compared using Fisher's exact test and logistic regression tests with a significance level of 0.05.

Results

Among the 97 patients with 6-month and 1-year follow-ups, all achieved clinical success. Radiographic success rates were 99% at 6 months and 96.9% at 1 year, regardless of pulp calcification. In the 6-month follow-up, success rates were 98.07% for non-calcified pulp chambers and 100% for calcified pulp chambers. At the 1-year follow-up, success rates were 96.1% and 97.8%, respectively. Statistical analysis showed no significant difference in radiographic success rate between the two groups at both follow-ups (P>0.05).

Conclusions

Full pulpotomy using CEM cement is a successful treatment for adult permanent teeth with calcified and non-calcified pulp chambers presenting signs and symptoms of irreversible pulpitis up to a 1-year follow-up. This study provides compelling evidence that vital pulp therapy can be effectively employed in the pulpotomy of calcified teeth, at least in the short term.

Successful Management of a Typical Class 3 Invasive Cervical Root Resorption with Modified Pulpotomy: A Case Report

Invasive cervical root resorption (ICRR) is a rare and clinically complex condition marked by the progressive loss of dental hard tissues below the junctional epithelium. This case report outlines the management of a 32-year-old female patient presenting with ICRR class 3 affecting a maxillary incisor. Despite the absence of symptoms, the expansive nature of the defect warranted conservative surgical intervention. The procedure involved the surgical removal of inflamed tissues, followed by an ultraconservative modified pulpotomy utilizing calcium-enriched mixture (CEM) cement through a surgical window. The selected intervention is substantiated by its potential benefits, such as minimal removal of tooth structure and the inherent biocompatibility and sealing capabilities of CEM cement. A one-year follow-up revealed arrested resorption, re-establishment of periodontal attachment, and successful esthetic restoration, affirming the efficacy of vital pulp therapy in surgically addressing advanced ICRR. Accurate diagnosis, strategic treatment planning, and a patient-centered approach proved critical in achieving favorable outcomes.

Autotransplantation of a Third Molar to Replace an Adjacent Unrestorable Tooth: A Case Report

Autogenous tooth transplantation (ATT) is a cost-effective and practical solution for managing severely compromised teeth, provided a suitable donor tooth is available. In this case report, we present a unique and successful ATT procedure performed on a 21-year-old female patient. The patient had an unrestorable adjacent tooth, which was replaced by a fully developed third molar. The procedure involved retrograde root canal filling using a calcium-enriched mixture cement, which took an extraoral time of eight minutes. The second molar was atraumatically extracted, and the mature third molar was immediately transplanted. A one-year clinical examination revealed a symptom-free patient with the transplanted tooth in proper occlusion, fully functional, and without any marginal periodontal issues. Radiographic assessments during follow-up appointments demonstrated bone regeneration, a healthy periodontal ligament, and an absence of external root resorption. This case report highlights the potential of mature third molar ATT combined with retrograde root canal filling as a promising approach to replacing lost permanent molar teeth, ultimately restoring both aesthetics and functionality.

Recent Advances in Endodontic Diagnosis and Modern Treatment Plans

Generally, to achieve success in endodontics, it is essential to perform all stages of treatment with cautiousness and excellence [...].

Recurrence of Invasive Cervical Resorption after six years of Nonsurgical and Surgical management by Bioceramic-Material

Invasive cervical resorption (ICR) is a phenomenon of unknown etiology that results in the loss of hard dental tissue. To have a successful outcome for a tooth affected by ICR, correct diagnosis and management are needed. With the introduction of new biocompatible materials and the advancement of CBCT imaging, these pathologies can be identified and treated with precision, resulting in promising outcomes. This case report aims to present the management of maxillary central incisors diagnosed with external ICR, treated with bioceramic root repair material, and followed-up to six years.

Outcomes of Endodontic-Treated Teeth Obturated with Bioceramic Sealers in Combination with Warm Gutta-Percha Obturation Techniques: A Prospective Clinical Study

The objective of this clinical study was to collect short-term endodontic outcomes of endodontic-treated teeth (ETT) obturated with different kinds of bioceramic sealers used in combination with warm gutta-percha obturation techniques. Methods: A total of 210 endodontic treatments in 168 patients were performed. At baseline, 155 sample teeth (73.8%) showed symptoms (tenderness or pain to percussion) and 125 (59.5%) showed periapical radiolucency. Periapical radiolucency was present in 125 cases (59.5%); of these, 79 showed a lesion of 5 mm or bigger (63.2%) while lower than 5 mm in 46 cases (36.8%). Regarding ETT with radiolucency, 105 of them (84%) were in coincidence with their need for retreatment and the other 20 (16%) were necrotic teeth. The obturation techniques that were used in this study were: the continuous wave of condensation technique in 75% of cases, and carrier-based technique in 25%. Four bioceramic sealers were used: CeraSeal in 115 cases, BioRoot in 35 cases, AH Plus Bio in 40 cases, and in 20 cases, BIO-C SEALER ION. Preoperative and recall radiographs of the roots were each assigned a periapical index (PAI) score by 2 blinded, independent, and calibrated examiners. The teeth were divided into outcome categories based on the following classification: healed, unhealed, and healing. The healed and healing categories were classified as success, and the unhealed category was classified as failure on the basis of loose criteria. Minimum follow-up period was 18 months. Results: The overall success rate was 99%, with 73.3% healed, 25.7% healing, and 0.95% not healed. The success rate was 100% for initial treatment and 98.2% for retreatment. Fifty-four (N = 54) teeth showed ongoing healing. All of them were retreatment cases with periapical lesions. Regarding the success (healed and healing) versus not healed, no significant difference was found between teeth with or without periapical lesions (p < 0.05). A statistically significant difference in the distribution of healed, healing, and not-healed teeth was found between the groups of teeth with baseline lesions < 5 mm and >5 mm in diameter (p < 0.01) and those with sealer groups (p < 0.01). The success rate of used bioceramic sealers was not statistically significant different (99.1%, 100%, 97.5% and 100%, respectively, for CeraSeal, BioRoot, AH Plus Bio, and BIO-C SEALER ION). Nonetheless, the distribution of healed, healing, and not-healed teeth was different between teeth sealed with different materials (p < 0.01). From the findings of this clinical study, the following conclusion can be drawn: a correct filling of root canals made with warm gutta-percha technique combined with a bioceramic sealer allows a high success rate in endodontically treated teeth.

Exploring the Most Effective Apical Seal for Contemporary Bioceramic and Conventional Endodontic Sealers Using Three Obturation Techniques

Background and Objective: Despite a plethora of studies conducted to date, researchers continue to investigate the best sealer and obturation technique combinations. The aim of this study is to compare the apical seal provided by two bioceramic sealers (Endoseal and Endosequence) with that provided by a calcium hydroxide sealer (Sealapex), and to evaluate the effect of different obturation techniques (cold lateral condensation, continuous wave compaction and single cone) on the apical seal under a stereomicroscope. Materials and Methods: A total of 110 single-rooted mandibular premolar teeth were decoronated, cleaned and shaped using the Endosequence filing system to tip size 30/0.04 taper. Canals were irrigated with 5.25% NaOCl and 17% EDTA. The samples were randomly divided into 11 groups (9 experimental and 2 control groups) according to the designated sealer and technique. Samples were stored in an incubator for 7 days at 37 °C under 100% humidity. Samples were coated with nail varnish except for apical 2 mm and vertically placed in 0.2% rhodamine B dye solution for 48 h. Samples were split longitudinally and viewed under a stereomicroscope at 40× magnification. Results: Insignificant results were obtained between obturation techniques (p = 0.499) whereas statistically significant results were attained based on the type of endodontic sealer (p < 0.001). The overall lowest mean apical microleakage and best sealing ability was demonstrated by Sealapex (2.59 ± 1.20 mm) and amongst techniques by continuous wave compaction (3.90 ± 2.51 mm). Conclusions: Endosequence produced the best apical seal with the continuous wave compaction technique, whereas Endoseal did so with the bioceramic-coated single-cone technique. For the Sealapex sealer, the most effective apical seal was observed using cold lateral condensation. The quality and effectiveness of apical seal differed with the type of endodontic sealer and obturation technique used, and vice versa.

Fracture Resistance of Molars With Simulated Strip Perforation Repaired With Different Calcium Silicate-Based Cements

Background and aims A root perforation is a connection between the root canal system and the external supportive tissues. Strip perforation (SP), occurring within root canals in a strip, can worsen the prognosis of a treated tooth, reduce its mechanical resistance, and impair the tooth structure. One of the suggested methods to treat SP is to seal it with a bio-material such as calcium silicate cement. Therefore, this in vitro study aimed to assess the molar structure impairment due to SP, which requires studying the fracture resistance, and the ability of mineral trioxide aggregate (MTA), bioceramic, and calcium-enriched mixture (CEM) to repair this perforation. Materials and methods Seventy-five molars were instrumented to size #25 and taper 4%, irrigated with sodium hypochlorite and ethylenediaminetetraacetic acid (EDTA), dried, and then divided randomly into five groups (G1-G5): in G1, root canals were filled with gutta-percha and sealer (negative control sample), whereas the rest of the groups (G2-G5) had a manual simulated SP made with Gates Glidden drill at the mesial root of the extracted molar, and filled with gutta-percha and sealer up to their perforation area; in G2, SP was filled with gutta-percha and sealer (positive control sample); G3 used MTA to repair the SP; G4 used bioceramic putty; and G5 used CEM. Fracture resistance tests of the molars were conducted in the crown-apical direction using a universal testing machine. One-way ANOVA test and Bonferroni test were used to study the significance of the differences in the mean values of the tooth fracture resistance, where statistical significance was set at 0.05. Results The ANOVA test showed that there were statistically significant differences between the fracture resistance (in newtons) values among groups (p = 0.000). The Bonferroni test showed that G2 had a smaller fracture resistance mean than the other four study groups (656.53 N; p = 0.000), and that of G5 was smaller than G1, G3, and G4 (794.40 N, 1083.73 N, 1025.20 N, and 1034.20 N, respectively; p = 0.000 in each pairwise comparison). Conclusion SP reduced the fracture resistance of endodontically treated molars. SP restored using MTA and bioceramic putty was better than that treated with CEM and similar to molars without SP. Moreover, MTA and bioceramic putty enhanced the fracture resistance of endodontically treated teeth to levels similar to molars without SP.

Effects of CEM cement and emdogain on proliferation and differentiation of human stem cells from the apical papilla: a comparative in vitro study

OBJECTIVES

This study compared the effects of calcium-enriched mixture (CEM) cement, Emdogain (EMD), and their combination (CEM/Emdogain) on the differentiation and proliferation of stem cells from the apical papilla (SCAPs).

METHODS

In this in vitro, experimental study, SCAPs were isolated from two sound immature impacted third molars and cultured. After ensuring their stemness by detecting cell surface markers they were exposed to CEM cement, Emdogain, and CEM cement coated with Emdogain for 24 and 72 h. The control cells did not undergo any intervention. Cell viability [by methyl thiazolyl tetrazolium (MTT) assay], expression of odontogenic differentiation genes [by quantitative reverse-transcription polymerase chain reaction (qRT-PCR)], and alkaline phosphatase (ALP) activity (by ALP staining kit) were evaluated. Data were analyzed by one-way ANOVA, t-test, and Mann-Whitney test (α = 0.05).

RESULTS

Cell viability in the CEM cement and CEM/Emdogain groups decreased compared with the control group at 72 h (P < 0.05). Expression of dentin sialophosphoprotein (DSPP), dentin matrix protein 1 (DMP1), bone sialoprotein (BSP) genes, and ALP activity significantly increased in all three experimental groups compared with the control group at both 24 and 72 h. This increase was substantially more significant in CEM/Emdogain group (P > 0.05). The number of mineralized nodules significantly increased in all groups at 72 h, with a higher rate in the CEM/Emdogain group.

CONCLUSION

All biomaterials increased the differentiation of SCAPs, expression of odontogenic differentiation genes, and ALP activity, but CEM/Emdogain was considerably more effective for this purpose.

Effects of White Chicken Eggshell Powder on Compressive Strength, Water Solubility, and Setting Time of Calcium-Enriched Mixture

Introduction

The present study aimed to evaluate the effects of adding chicken eggshell powder (CESP) to calcium-enriched mixture (CEM) cement on its compressive strength (CS), solubility, and setting time.

Materials and Methods

In this study, CESP was added at weight percentages of 3% and 5% to the powder component of the CEM cement. To measure the CS, a total of 36 samples (height, 6 mm; diameter, 4 mm) were tested in a universal testing machine. The setting time was assessed for 18 disk-shaped samples (diameter, 10 mm; height, 1 mm). Additionally, solubility test was performed on 18 samples (diameter, 8 mm; height, 1 mm) after 24 hours, 72 hours, seven days, and 14 days under dehydration conditions by calculating the weight changes; the results were then subjected to a normality test. Next, for the comparison of different test groups, parametric ANOVA test and post-hoc Tukey's multiple comparison test were performed at a significance level of 0.05.

Results

The addition of 5% CESP to the CEM cement significantly reduced its setting time and water solubility (P=0.02 and P=0.01, respectively). Moreover, it significantly increased the CS over a 21-day period (P<0.001). Additionally, the addition of 3% CESP also resulted in a significant increase in CS (P<0.001). While 3% CESP reduced setting time and water solubility, the difference was not statistically significant.

Conclusion

The findings suggest that the addition of 5% CESP to CEM cement has the potential to improve its sealing ability, durability, and ability to withstand chewing forces in endodontic treatments. These results highlight the relevance of CESP as an additive for cement modifications and indicate its potential clinical implications.

Outcome of pulpotomy in permanent teeth with irreversible pulpitis: a systematic review and meta-analysis

Treatment planning is key to clinical success. Permanent teeth diagnosed with "irreversible pulpitis" have long been implied to have an irreversibly damaged dental pulp that is beyond repair and warranting root canal treatment. However, newer clinical approaches such as pulpotomy, a minimally invasive and biologically based procedure have re-emerged to manage teeth with pulpitis. The primary aim of the study was to conduct a meta-analysis to comprehensively estimate the overall success rate of pulpotomy in permanent teeth with irreversible pulpitis as a result of carious pulp exposure. The secondary aim of the study was to investigate the effect of predictors such as symptoms, root apex development (closed versus open), and type of pulp capping material on the success rate of pulpotomy. Articles were searched using PubMed, Scopus, CENTRAL, and Web of Science databases, until January 2021. Outcomes were calculated by pooling the success rates with a random effect model. Comparison between the different subgroups was conducted using the z statistic test for proportion with significance set at alpha = 0.05. A total of 1,116 records were retrieved and 11 studies were included in the quantitative analysis. The pooled success rate for pulpotomy in teeth with irreversible pulpitis was 86% [95% CI: 0.76-0.92; I² = 81.9%]. Additionally, prognostic indicators of success were evaluated. Stratification of teeth based on (1) symptoms demonstrated that teeth with symptomatic and asymptomatic irreversible pulpitis demonstrated success rate of 84% and 91% respectively, with no significant difference (p = 0.18) using z-score analysis; (2) open apex teeth demonstrated a significantly greater success rate (96%) compared to teeth with closed apex (83%) (p = 0.02), and (3) pulp capping materials demonstrated that Biodentine yielded significantly better success rates compared to Mineral Trioxide Aggregate (MTA), calcium hydroxide, and Calcium Enriched Mixture (CEM.) Collectively, this is the first meta-analytical study to determine the clinical outcome of pulpotomy for carious teeth with irreversible pulpitis and it's predictors for success. Moreover, we identify the stage of root development and type of biomaterial as predictors for success of pulpotomy.

Evaluation of the Sealing Ability and Bond Strength of Two Endodontic Root Canal Sealers: An In Vitro Study

BACKGROUND

Obturation represents a critical step in endodontic treatment, which relies on a core material and a sealer. This study aims to evaluate the sealing ability and bond strength to the root canal walls of an epoxy resin-based sealer (AH-Plus®, Dentsply Sirona, Johnson City, TN, USA) and a bioceramic sealer (GuttaFlow Bioseal®, Coltène/Whaledent, GmbH + Co. KG, Langenau, Germany).

METHODS

Thirty-eight maxillary anterior teeth with single roots and identical round sections were separated into two experimental groups according to the root canal sealers used, namely, G1 = AH-Plus® and G2 = GuttaFlow Bioseal®, and two control groups, specifically, G3 = the negative control and G4 = the positive control. The sealing capacity was measured by the penetration of the radioactive isotope 99mTc. For the push-out test, the compressive force test was performed in a universal machine and the force was applied by exerting pressure on the surface of the material to be tested in the apical to the coronal direction and using three test points with different diameters.

RESULTS

GuttaFlow Bioseal® exhibited superior sealing ability compared to AH-Plus® (p = 0.003). Regarding the bond strength, AH-Plus® provided higher adhesion values than GuttaFlow Bioseal® in the three sections of the tooth root (p = 0.001).

CONCLUSIONS

GuttaFlow Bioseal® had significantly better sealing ability than AH-Plus® but lower adhesion values in the three zones of the root canal, with statistically significant differences between the groups. However, it is important to note that for the action of endodontic sealers to be maximized, the root-filling technique must be most appropriate.

Trends of calcium silicate biomaterials in medical research and applications: A bibliometric analysis from 1990 to 2020

Background: Calcium silicate biomaterials (CSB) have witnessed rapid development in the past 30 years. This study aimed to accomplish a comprehensive bibliometric analysis of the published research literature on CSB for biomedical applications and explore the research hotspot and current status.

Methods: Articles related to CSB published in the last three decades (1990–2020) were retrieved from Web of Science Core Collection. The R bibliometrix package and VOSviewer were used to construct publication outputs and collaborative networking among authors, their institutes, countries, journals’ matrices and keywords plus.

Results: A total of 872 publications fulfilling the search criteria were included. CSB is mainly reported for bone tissues and dental applications. Among researchers, Chang J from Chinese Academy of Sciences and Gandolfi MG from the University of Bologna are the most productive author in these two fields, respectively. China was the leading contributor to the research on CSB in the medical field. A total of 130 keywords appeared more ten or more times were identified. The term “mineral trioxide aggregate” ranked first with 268 occurrences. The co-occurrence analysis identified three major clusters: CSB in dentistry, bone tissue and vitro bioactivity.

Conclusion: Calcium silicate biomaterials have a promising scope for various biomedical applications ranging from regeneration of hard tissues (bone and teeth) to skin, tumor, cardiac muscle and other soft tissues. This study may help researchers further understand the frontiers of the field.

The thermoplastic techniques or single-cone technique on the quality of root canal filling with tricalcium silicate-based sealer: An integrative review

Background

The filling of the root canal system (RCS) is an important step in endodontic treatment and aims to obtain a three-dimensional sealing of the root canal spaces to prevent bacterial contamination. For this, the selection of an appropriate sealer must be performed synchronously with the choice of the root canal filling technique. This study aims, through an integrative review, to evaluate the quality of root canal filling by comparing thermoplastic and single-cone (SC) techniques.

Material and Methods

The Medline/PubMed, Scopus, Web of Science and Virtual Health Library (VHL) databases were used to find articles published until November 2021. The eligibility criteria comprised articles that evaluating the quality of root canal filling comparing thermoplastic techniques with the SC technique using tricalcium silicate-based sealer. Studies that evaluated primary teeth, endodontic retreatment or perforations, different outcomes, and studies that considered artificial teeth or different sealer and material for obturation of different techniques were excluded. For articles that were not available for access, an additional contact with authors were considered. A total of 1699 articles were found. After duplicate removal, the title and abstract of 828 articles were screened. Sixteen articles were considered for full-text analysis, but only ten articles met the eligibility criteria. Data extracted from the studies were discussed and tabulated to allow the comparison of desired factors.

Results

Concerning the formation of gaps/voids, the thermoplastic techniques showed better results than the SC technique in 3 articles. On the other hand, 2 articles reported no statistical difference between the tested techniques. In addition, about the penetration of tricalcium silicate-based sealer in the dentinal tubules, of the 5 articles selected, in 4 there was no significant difference between the tested techniques and only one study showed better penetration of the sealer when using thermoplastic techniques.

Conclusions

The thermoplastic technique was better in most selected studies regarding gaps and voids, but regarding the penetration of the sealer into the tubules, both techniques were effective.

Key words:Root canal filling, thermoplastic techniques, tricalcium silicate.

Microhardness of Calcium-enriched Mixture Cement and Covering Glass Ionomers after Different Time Periods of Application

Introduction

Various studies have recommended using calcium-enriched mixture (CEM) cement in different endodontic treatments, including vital pulp therapy. However, possible reciprocal effects of the covering glass ionomer cement (GIC) on their mechanical properties have not been yet investigated in detail. The current research aimed to experimentally evaluate the surface microhardness of CEM cement and the covering GICs after different application/testing times.

Materials and Methods

Using stainless steel moulds (8×4×4 mm), CEM cement samples were prepared (n=120) and randomly divided into 12 experimental groups (n=10). CEM cement with thickness of 4 mm was inserted into the moulds, and the remaining spaces were filled with self-cured or light-cured resin-modified GICs at three-time intervals; immediate, in 15 min and after 24 h. Then, the samples were incubated for one and seven days. Using a Vickers microhardness tester, the microhardness of CEM and GICs was measured. The data were analyzed using two-way ANOVA and Tukey's test, and the significance level was set at 5% (P<0.05).

Results

The reciprocal effects of the type/time of application of GICs on the surface microhardness of CEM cement or GICs were statistically significant (P<0.001). The surface microhardness of CEM cement and both covering GICs significantly increased over time and in seven-day samples was significantly higher than in one-day samples (P<0.05).

Conclusions

Low surface microhardness of CEM/GICs in short-term (24 h) seems transient; and appears to be compensated over a longer period (i.e. 7-day). Therefore, using GICs adjacent to CEM cement in single-visit restorative treatments may be advocated.

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.

Effectiveness of Direct Pulp Capping Bioactive Materials in Dentin Regeneration: A Systematic Review

Background: Regenerative endodontics aims to restore normal pulp function in necrotic and infected teeth, restoring protective functions, such as innate pulp immunity, pulp repair through mineralization, and pulp sensibility. The aim of this systematic review was to assess the dentin regeneration efficacy of direct pulp capping (DPC) biomaterials. Methods: The literature published between 2005 and 2021 was searched by using PubMed, Web of Science, Science Direct, Google Scholar, and Scopus databases. Clinical controlled trials, randomized controlled trials, and animal studies investigating DPC outcomes or comparing different capping materials after pulp exposure were included in this systematic review. Three independent authors performed the searches, and information was extracted by using a structured data format. Results: A total of forty studies (21 from humans and 19 from animals) were included in this systemic review. Histological examinations showed complete/partial/incomplete dentin bridge/reparative dentin formation during the pulp healing process at different follow-up periods, using different capping materials. Conclusions: Mineral trioxide aggregate (MTA) and Biodentine can induce dentin regeneration when applied over exposed pulp. This systematic review can conclude that MTA and its variants have better efficacy in the DPC procedure for dentin regeneration.

Observation on the effect of periodontal treatment on patients with combined periodontal-pulpal lesions

OBJECTIVE

To evaluate the effect of periodontal treatment on combined periodontal-pulpal lesions.

METHODS

A total of 327 patients with periodontal-pulpal lesions (360 affected teeth) were selected, and all affected teeth were treated with a complete root canal, and assigned into group A (periodontal treatment group, 180 affected teeth) and group B (non-periodontal treatment group, 180 affected teeth). Group A received periodontal basic treatment for 2 weeks after the completion of root canal treatment; 6 weeks later, if there were still more than 5 mm periodontal pockets and bleeding after detection, flap treatment was performed. Group B received root canal treatment and supragingival scaling. Follow-up was conducted at 3, 6, 12 and 24 months after surgery by observing the periodontal depth (PD), alveolar bone resorption and tooth mobility (TM).

RESULT

In group A, the PDs before operation and 2 years after operation were (5.966±1.877) mm and (5.133±1.935) mm, and the PD was significantly decreased. In group B, the PDs before operation and 2 years after operation were (5.533±1.856) mm and (6.167±1.927) mm, and the PD was increased. There was no statistical difference in preoperative TM between the two groups (P>0.05). Two years after operation, TM in group A was significantly lower than that in group B (P<0.05). In terms of X-ray performance, there was no significant change in alveolar bone resorption in group A two years after operation compared with that before operation (P>0.05); two years after operation, alveolar bone resorption in group B was significantly reduced compared with that before operation (P<0.05).

CONCLUSION

Periodontal treatment is a promising technique for patients with combined periodontal-pulpal lesions.

Toughening of Bioceramic Composites for Bone Regeneration

Bioceramics are widely considered as elective materials for the regeneration of bone tissue, due to their compositional mimicry with bone inorganic components. However, they are intrinsically brittle, which limits their capability to sustain multiple biomechanical loads, especially in the case of load-bearing bone districts. In the last decades, intense research has been dedicated to combining processes to enhance both the strength and toughness of bioceramics, leading to bioceramic composite scaffolds. This review summarizes the recent approaches to this purpose, particularly those addressed to limiting the propagation of cracks to prevent the sudden mechanical failure of bioceramic composites.

Local Drug Delivery Systems for Vital Pulp Therapy: A New Hope

Vital pulp therapy (VPT) is deliberated as an ultraconservative/minimally invasive approach for the conservation of vital pulpal tissues, preservation of dental structure, and maintenance of tooth function in the oral cavity. In VPT, following the exposure of the dental pulp, the environment is prepared for the possible healing and probable refunctionalisation of pulpal connective tissue. However, to succeed in VPT, specific biomaterials are used to cover and/or dress the exposed pulp, lower the inflammation, heal the dental pulp, provoke the remaining odontoblastic cells, and induce the formation of a hard tissue, i.e., the dentinal bridge. It can be assumed that if the employed biomaterial is transferred to the target site using a specially designed micro-/nanosized local drug delivery system (LDDS), the biomaterial would be placed in closer proximity to the connective tissue, may be released in a controlled and sustained pattern, could properly conserve the remaining dental pulp and might appropriately enhance hard-tissue formation. Furthermore, the loaded LDDS could help VPT modalities to be more ultraconservative and may minimise the manipulation of the tooth structure as well as pulpal tissue, which could, in turn, result in better VPT outcomes.

Pediatric Endodontic Treatment of Adolescent Patients

This article is intended to familiarize clinicians with several pulp therapy modalities and new materials that are currently available for immature young pulp in the adolescent population. Objectives and considerations for immature young permanent teeth as well as the healing potential of the young pulp tissue after treatment of the inflammatory process are discussed. The article emphasizes that the future holds great possibilities for the regeneration of dental pulp in adolescent patients.

Comparison of the Success Rate of Mineral Trioxide Aggregate, Endosequence Bioceramic Root Repair Material, and Calcium Hydroxide for Apexification of Immature Permanent Teeth: Systematic Review and Meta-Analysis

This systematic review aims to compare the success rate of Endosequence bioceramic root repair material (BCRRM), mineral trioxide aggregate (MTA), and calcium hydroxide for apexification of necrotic immature permanent teeth. Indexed Journals such as Google Scholar, PubMed, Scopus, Cochrane, Research Gate, Wiley Online Library, and other related journals were hand searched from inception till November 2020 and articles were selected for review based on PRISMA guidelines. Of the 410 studies that were identified, 150 articles were selected after title/abstract reading. After full-text reading and based on inclusion and exclusion criteria, 9 studies were finalized for systematic review. Clinical, radiographic success, and the time taken for apical barrier formation were reviewed. All the three materials had almost similar success rate in terms of clinical symptoms, but the time taken for apical barrier formation and also single visit treatment makes MTA and Endosequence BCRRM superior to calcium hydroxide. Studies comparing EndoSequence Root Repair Material and MTA are very limited and need further evaluation in the future.

Influence of Blood Contamination on Push-Out Bond Strength of Three Calcium Silicate-Based Materials to Root Dentin

A proper bond between root canal filling materials and dentin surface is essential to resist dislodgement and guarantee long-term success. Blood exposure is likely to occur in various clinical situations in which calcium silicate-based materials are used; therefore, it is fundamental to render data concerning the influence of blood on bond strength. The present study aims to evaluate the effect of blood contamination on the push-out bond strength obtained with three different biomaterials to root canal dentin; Ninety extracted human mono-radicular permanent teeth were selected. The root canals were prepared with Gates Glidden burs until a diameter of 1.10 mm was achieved. Teeth were then randomly divided into six experimental groups (n = 15) according to the presence/absence of blood contamination and biomaterial used for root canal filling (ProRoot® MTA, BiodentineTM, and TotalFill® BC Putty). After one week, each root was sectioned in three segments (coronal, middle, and apical regions). Specimens were then submitted to push-out bond strength tests. Fracture pattern evaluation was performed. The significance level was set at 5%.; Blood contamination did not affect the push-out bond strength of any of the three tested calcium silicate-based cements (p > 0.05). Regardless of blood contamination, TotalFill showed statistically higher push-out bond strength when compared with Biodentine (p = 0.040) and MTA (p = 0.004). Biodentine exhibited higher bond strength than MTA (p = 0.043). Biomaterials’ comparison within each radicular segment revealed statistically superior bond strength of both Biodentine and TotalFill over MTA (p < 0.05) in the coronal segment. TotalFill presented higher push-out bond strength regarding the apical segment compared to Biodentine (p = 0.003). Fractures were mostly adhesive.; Overall results indicate TotalFill presents the highest push-out bond strength values, followed by Biodentine and, lastly, MTA. Blood contamination did not affect the dislodgement resistance. Biomaterials’ comparison within each radicular segment revealed both TotalFill and Biodentine as the preferable alternatives for application in the coronal region. TotalFill might be the biomaterial of choice for placement in the apical region.

Bioactive Glass Modified Calcium Phosphate Cement with Improved Bioactive Properties: A Potential Material for Dental Pulp-Capping Approaches

Direct pulp capping (DPC) is one of the treatment plans for deep caries with mechanical pulp exposure that can replace invasive treatments. This study aimed to assess the apatite-forming ability and solubility of a calcium phosphate cement (CPC) modified with bioactive glass (BG) as a potential bioactive material for DPC.Three different biomaterials including CPC, BG, and CPC/BG composite were used in this study. For bioactivity evaluation, specimens were immersed in simulated body fluid (SBF) for 5 time periods (3, 7, 14, 21 and 28 days). The samples were analyzed by SEM, EDS and XRD to confirm the formation of hydroxyapatite. The solubility was calculated by measuring the initial and final mass according to the ISO 6876 specifications.According to the results of this study, SEM observations and XRD analysis revealed higher formation of hydroxyapatite crystals in the CPC/BG Group and also at the shorter time than those in the CPC and BG groups. Concerning solubility, the CPC group showed the most solubility after 7 days and the BG group showed the lowest one. At this time the difference between CPC and BG groups was statistically meaningful (p value=0.003). After 30 days the CPC/BG group exhibited the lowest solubility value. At the day 30, the CPC and BG groups showed significant difference in their solubility (p value=0.04).).Based on the results, addition of BG to CPC improved bioactivity properties of CPC material and did not affect its solubility adversely. The CPC/BG composite seems to be a promising material for DPC. Further in vivo studies are needed to prove its clinical success.

Effect of MTA versus CEM apical plugs on fracture resistance of endodontically treated simulated immature teeth restored with cast metal posts: an in-vitro study

BACKGROUND

Endodontically treated immature teeth which are restored with cast metal posts are of the most susceptible teeth to fracture. An apical plug is usually used as root end filling in order to seal the wide apical foramen. The current study was performed to evaluate the effect of different apical plug materials (MTA and Calcium enriched mixture cement) at varied thicknesses on fracture resistance of teeth restored with cast metal posts.

METHODS

A total of 40 extracted intact single-rooted human mandibular premolars (removed for orthodontic reasons) were used in the study. The coronal part of each tooth was removed and root canal preparation was performed. A size 4 Gates Glidden drill was used to enlarge the canal and was passed through the apical foramen in order to simulate an immature apex. Samples were randomly divided into 5 groups (n = 8) according to apical plug (control group: No plug, group MTA5: 5 mm MTA plug, group CEM5: 5 mm CEM plug, group MTA3: 3 mm MTA plug, group CEM3: 3 mm CEM plug). Post-space preparations were performed and cast metal post-and-cores were fabricated and cemented. Fracture resistance was assessed using a universal testing machine. Fracture thresholds were recorded and data were analyzed using One-way ANOVA and Dunnett's T3 tests with significance level at P value < 0.05.

RESULTS

The analysis showed a significant difference of fracture resistance between groups (P value < 0.05). The mean fracture resistance of samples in control group was significantly lower than MTA5 (P value = 0.003). There was no significant difference between other groups (P value > 0.05).

CONCLUSIONS

Within the limits of this study, the evidence indicated that placement of a 5 mm MTA apical plug increased the fracture resistance in simulated immature teeth which are restored with cast metal posts, compared to control group (gutta-percha and sealer). While the results were not as promising for a 3 mm MTA apical plug or either 3 or 5 mm CEM apical plug.

In vitro biocompatibility and bioactivity of calcium silicate‑based bioceramics in endodontics (Review)

Calcium silicate-based bioceramics have been applied in endodontics as advantageous materials for years. In addition to excellent physical and chemical properties, the biocompatibility and bioactivity of calcium silicate-based bioceramics also serve an important role in endodontics according to previous research reports. Firstly, bioceramics affect cellular behavior of cells such as stem cells, osteoblasts, osteoclasts, fibroblasts and immune cells. On the other hand, cell reaction to bioceramics determines the effect of wound healing and tissue repair following bioceramics implantation. The aim of the present review was to provide an overview of calcium silicate-based bioceramics currently applied in endodontics, including mineral trioxide aggregate, Bioaggregate, Biodentine and iRoot, focusing on their in vitro biocompatibility and bioactivity. Understanding their underlying mechanism may help to ensure these materials are applied appropriately in endodontics.

Effects of various liquid-to-powder ratios on the compressive strength of calcium enriched mixture: Original research

Background. Calcium-enriched mixture (CEM) cement has been introduced and marketed as a biomaterial for use in furcal perforation repair and apexogenesis procedures, in which the compressive strength that indicates the material's resistance against crushing is of utmost importance. This study evaluated the effect of various liquid-to-powder ratios on CEM cement's compressive strength. Methods. One gram of the cement was mixed with 0.5, 0.34, and 0.25 mL of demineralized water and transferred to stainless steel molds (6 and 4 mm in height and diameter, respectively). Five cells in the mold were considered for each group. The compressive strength test was conducted using the universal testing machine after incubating for seven days under 95% humidity at 37°C. One-way ANOVA was applied for data analysis at P ≤ 0.05 significance level. Results. The mean compressive strength in the liquid-to-powder ratios of 0.5, 0.34, and 0.25 were 3.4456, 3.2960, and 3.3485, respectively, with no significant differences between them. Conclusion. Under this study's limitations, changing the liquid-to-powder ratio did not affect CEM cement's compressive strength.

Performance of Bioceramic-based Root Filling Material with Artifact Reduction Properties in the Detection of Vertical Root Fractures Using Cone-beam Computed Tomography

Introduction:

In Cone-beam Computed Tomography (CBCT) images, metallic artifacts by root filling materials reduce the quality of images. It seems that bioceramic sealers produce fewer artifacts than gutta-percha. In this situation, the possibility of VRF detection could increase, and therefore, flap and exploratory surgery would not be needed. The purpose of this study was to evaluate the performance of a bioceramic-based root filling material in the detection of Vertical Root Fractures (VRF) in CBCT imaging.

Materials and Methods:

This study was conducted at the dental school from March to August 2019, and 100 healthy human mandibular premolar teeth were obtained and randomly divided into two equal groups. The teeth were filled with either AH26 and gutta-percha or bioceramic root filling materials. VRF was induced on half of the decoronated teeth in each group using a Global Testing Machine, and the others were considered control. CBCT imaging was performed by the Cranex 3D machine. Comparisons of the 2 groups were made using the Mann-Whitney test.

Results:

There was a significant difference between the two groups of bioceramic and gutta-percha in the measured indices, including sensitivity (P=0.017), specificity (P=0.018), positive predictive value (P=0.018), negative predictive value (P=0.018), and accuracy (P=0.011). The Area Under Curve (AUC) also showed a significant difference between the two groups (P=0.011). According to Kappa test results, no significant difference was obtained between the findings of the two observers.

Conclusion:

Different root filling materials showed a different extent of artifact in CBCT images. Bioceramic root filling material induces fewer artifacts in CBCT images, and the diagnostic value of VRF in CBCT images in the root canals filled with it is greater than those filled with AH26 and gutta-percha.

Management of primary molars with irreversible pulpitis employing tampon pulpotomy: Report of three cases with 34-month mean follow-up

This study suggests that tampon-based coronal pulpotomy using a calcium silicate-based biomaterial can be a reliable approach for the treatment of vital primary molars with irreversible pulpitis.

Intratubular penetration of endodontic sealers depends on the fluorophore used for CLSM assessment

Root canal filling aims at eliminating empty spaces into the root canal system using biologically compatible materials. Three-dimensional root canal obturation must prevent or minimize the reinfection caused by microorganisms' leakage. This study aimed at evaluating whether fluorophore (Rhodamine or Fluo-3) influences the CLSM images of intratubular penetration of four endodontic sealers. Eighty bovine teeth were prepared using K files up to a size #70 and irrigated with 2.5% sodium hypochlorite. All roots were divided into eight groups (n = 10) according to the sealer and fluorophore used: AH Plus/Rhodamine, AH Plus/Fluo-3, Sealer Plus/Rhodamine, Sealer Plus/Fluo-3, Sealer Plus BC/Rhodamine, Sealer Plus BC/Fluo-3, Endosequence/Rhodamine, and Endosequence/Fluo-3. All roots were filled using cold lateral compaction technique. After 7 days, the roots were transversely sectioned, and three slices, one of each canal third, were obtained. Intratubular penetration was evaluated using CLSM. Sealer Plus BC/Rhodamine and Endosequence BC/Rhodamine presented higher intratubular penetration than AH Plus/Fluo-3 and Sealer Plus/Fluo-3 (p ˂ .05). The intragroup analysis showed similar intratubular penetration, regardless of the root third, except for the apical third in AH Plus/Fluo-3 and Sealer Plus BC/Fluo-3 groups. The type of fluorophore influences the calcium silicate sealers' tubular penetration but not of epoxy resin-based ones using CLSM. Bioceramic sealers should not be used associated with Rhodamine for CLSM evaluation. RESEARCH HIGHLIGHTS: The type of fluorophore influences the calcium silicate sealers' tubular penetration but not of epoxy resin-based ones when CLSM is used for assessment. Bioceramic sealers should not be used associated with Rhodamine.

Evaluation of the adhesion of human dental pulp stem cells to different endodontic biomaterials before and after setting

Background. Stem cell-based treatment modalities have been potential strategies for tissue regeneration in many conditions. Several studies have evaluated the biologic properties of DPSCs and their efficacy in the treatment of a variety of diseases. The present study was undertaken to evaluate the adhesion behavior of DPSCs on different endodontic materials before and after setting. Methods. The crowns of the selected teeth were removed, and the root canals were prepared and obturated with gutta-percha and AH26 sealer. A retrograde cavity was prepared at root ends. Different materials were placed in the cavities. Then the samples were attached to the wells with the use of a chemical glue. Dental pulp stem cells were allowed to proliferate to reach a count of 2 million and transferred to -12well plates in association with a culture medium. Finally, the samples attached to the wells were exposed to the stem cells immersed in the culture medium before and after setting. Then adhesion of the stem cells was evaluated using SEM. Results. The SEM results showed cellular adhesion in the samples containing CEM cement both before and after setting. The samples containing MTA Angelus and ProRoot MTA exhibited cellular adhesion before setting, with no cellular adhesion after setting. The samples containing AH26 and MTA Fillapex sealers exhibited cellular adhesion after setting, with no adhesion before setting. The samples containing simvastatin exhibited no cellular adhesion before setting; this material had dissolved in the culture medium after setting evaluation. Conclusion. The results of the present study showed that of all the materials tested, CEM cement had the highest capacity for dental pulp stem cell adhesion.

Effect of ultrasonic cleaning on the bond strength of fiber posts in oval canals filled with a premixed bioceramic root canal sealer

Objective

This study aimed to evaluate the effect of ultrasonic cleaning of the intracanal post space on the bond strength of fiber posts in oval canals filled with a premixed bioceramic (Bio-C Sealer [BIOC]) root canal sealer.

Materials and Methods

Fifty premolars were endodontically prepared and divided into 5 groups (n = 10), based on the type of root canal filling material used and the post space cleaning protocol. A1: gutta-percha + AH Plus (AHP) and post space preparation with ultrasonic cleaning, A2: gutta-percha + BIOC and post space preparation with ultrasonic cleaning, B1: gutta-percha + AHP and post space preparation, B2: gutta-percha + BIOC and post space preparation, C: control group. Fiber posts were cemented with a self-adhesive luting material, and 1 mm thick slices were sectioned from the middle and cervical third to evaluate the remaining filling material microscopically. The samples were subjected to a push-out test to analyze the bond strength of the fiber post, and the results were analyzed with the Shapiro-Wilk, Bonferroni, Kruskal-Wallis, and Mann-Whitney tests (p < 0.05). Failure modes were evaluated using optical microscopy.

Results

The results showed that the fiber posts cemented in canals sealed with BIOC had lower bond strength than those sealed with AHP. The ultrasonic cleaning of the post space improved the bond strength of fiber posts in canals sealed with AHP, but not with BIOC.

Conclusions

BIOC decreased the bond strength of fiber posts in oval canals, regardless of ultrasonic cleaning.

Which procedures and materials could be applied for full pulpotomy in permanent mature teeth? A systematic review

Objective: Coronal pulpotomies were recently re-investigated as an alternative to root canal treatment in vital permanent teeth. General dentists may be interested in knowing how to perform full pulpotomy, in particular in face of difficult endodontic cases of vital teeth. Material and methods: A systematic review was undertaken on the PubMed and Cochrane databases in order to determine which procedure should be applied for pulp capping and coronal restoration in routine dental practice. Fifty-three publications were included and allocated to one of two methodological categories: histological and clinical studies. Results and conclusions: There is no evidence to recommend one single procedure for full pulpotomy in vital permanent teeth that can be indicated for different pulpal diagnoses which differ greatly in terms of the inflammation process from healthy teeth to irreversible pulpitis. For each clinical case, all actions aiming to prevent pre-operative contamination, to control per-operative infection and to achieve a complete seal above the radicular pulp sections are unavoidable steps that should be complied with. Reproducing procedures adopted in high quality trials could insure high success rates.

Combination of mineral trioxide aggregate and propolis promotes odontoblastic differentiation of human dental pulp stem cells through ERK signaling pathway

The aim of this study is to investigate combined effects of mineral trioxide aggregate (MTA) and propolis on odontoblastic differentiation of human dental pulp stem cells (DPSCs) and to find a signaling pathway involved. Combination of MTA and propolis significantly up-regulated the expression of DSPP and DMP1, and facilitated a mineral nodule formation (p < 0.05). Treatments with MTA, propolis or combined increased the phosphorylation of extracellular signal-regulated kinases (ERK), one of mitogen-activated protein kinases signaling cascades during odontogenic differentiation of DPSCs (p < 0.05), and U0126, an inhibitor of ERK, decreased calcium deposits (p < 0.05). Combination of MTA and propolis promotes odontogenic differentiation and mineralization of DPSCs through ERK pathway.

[Evaluation of bioceramic putty repairment in primary molars pulpotomy]

OBJECTIVE

To evaluate the clinical characteristics and effectiveness of bioceramic putty repairment (iroot BP Plus) used as pulp capping agents on pulpotomy in primary molars.

METHODS

Forty primary molars were treated by pulpotomy with bioceramic putty repairmen as the pulp capping agents at the Third Clinical Division of Peking University School and Hospital of Stomatology, from September 2016 to September 2017. The children who were followed up over one year were selected as the subjects of this study. The teeth were checked clinically and radiographically during fixed intervals, and classified into one of five outcomes: N, H, P₀, P_X, P_Y. N, absence of clinical symptoms, and absence of apical radiolucency; H, absence of clinical symptoms, and nonpathologic radiographic change present; P₀, absence of clinical symptoms, and pathologic change present, no need for treatment; P_X, present or absence of clinical symptoms, pathologic change present treatment or extract immediately; P_Y, premature loss of deciduous tooth. Molars classified into N and H were regarded as successful, classified into P₀, P_X and P_Y were regarded as failed.

RESULTS

Followed up for 12-24 months (the average follow up time was 16months), thirty four children were finally included, aged from 3.1 years to 8.5 yaers (the average age was 4.3 years), forty primary molars were included. Thirty four primary molars were included into N group, with absence of clinical symptoms, absence of apical radiolucency. Two molars were included into H group with physiological root absorption. One molar was included into P₀group with absence of clinical symptoms butinternal absorption of the root. Three molars were included into P_X group, with gingival fistula and apical radiolucency. None was included into P_Y group. Thirty six teeth got successful treatment, four molars failed. One year success rate of pulpotomy of primary molars using bioceramic putty repairment was 95%.

CONCLUSION

Current evidence suggests that bioceramic putty repairment as a pulpotomy medicament showed satisfied clinical and radiographic result in pulpotomy of primary molars. Bioceramic putty repairment is an acceptable material when used in pulpotomy of primary molars.

Evaluation of Selective Physicochemical and Biological Properties of Different Root Canal Sealers

Introduction

This in vitro study aimed to evaluate the chemical composition, water solubility, radiopacity, pH, electrical conductivity and cytotoxicity of four different root canal sealers.

Methods and Materials

Four materials were tested including an epoxy resin-based sealer (AH-Plus), a calcium silicate-based sealer (MTA Fillapex), a calcium hydroxide-based sealer (Sealapex) and a zinc-oxide-eugenol-based sealer (Endofill). The materials were submitted to energy-dispersive x-ray microanalysis for elemental chemical composition. Solubility and radiopacity were evaluated according to ANSI/ADA. The pH and electrical conductivity were measured at different periods of time. L929 immortalized mouse fibroblast line were used for cytotoxicity evaluation. Statistical analyses were carried out using the ANOVA and Tukey's test.

Results

The main elements were found to be silicon and calcium in MTA Fillapex, calcium and bismuth in Sealapex, zirconium and tungsten in AH-Plus and zinc and bismuth in Endofill. Sealapex had the highest value for solubility (P<0.05), AH-Plus showed the highest radiopacity value (P<0.05) while MTA Fillapex had the highest pH and electrical conductivity values (P<0.05). AH-Plus showed the highest rate of cell viability (P<0.05).

Conclusion

Based on the results of this in vitro study, it was possible to conclude that Endofill and Sealpex did not meet the requirements for water solubility. The tested sealers were alkaline and showed radiopacity in accordance with ANSI/ADA standards. AH-Plus showed to be less cytotoxic than other tested root canal sealers.

[Recent advances in direct pulp capping materials]

The long-term effect of direct pulp capping and pulpotomy is closely related to the type of pulp capping materials. Various kinds of direct pulp capping materials are available, such as calcium hydroxide and mineral trioxide aggregates. Diverse new pulp capping materials have been reported recently. The excellent performance of calcium silicates has attracted much attention in previous studies. Moreover, enamel matrix derivative (Emdogain), which is capable of regeneration and remineralization, and other materials with similar capabilities have shown potential for use in pulp capping.

Evaluation of Physicochemical Properties of New Calcium Silicate-Based Sealer

Abstract This study aimed to evaluate the physicochemical properties of a calcium silicate-based sealer (Sealer Plus BC; MK Life, Porto Alegre, Brazil) compared with an epoxy-resin sealer (AH Plus; Dentsply DeTrey GmbH, Konstanz, Germany). Initial and final setting time was assessed based on ISO 6876:2012 and ASTM C266:03. Calcium ion release and pH were evaluated by filling polyethylene tubes with sealers and then immersing them in 10 mL of deionized water. Following experimental periods of 1, 24, 72 and 168 hours, the samples were measured regarding pH and calcium ion release with a pH meter and a colorimetric spectrophotometer, respectively. The flow was examined based on ISO 6876:2012. Rings of 10 mm in diameter with 1 mm thickness were prepared to analyze the radiopacity (ISO 6876:2012 and ADA n.57) and solubility (ISO 6876:2012). The data were analyzed by variance analysis, Student-T and Tukey tests (p<0.05). The calcium ion release and pH values were significantly higher for the Sealer Plus BC compared with the AH Plus (p<0.05). Lower setting time, flow and radiopacity were observed for the bioceramic sealer than for AH Plus (p<0.05). Sealer Plus BC exhibited higher solubility compared with AH Plus (p<0.05). Sealer Plus BC showed physicochemical properties as setting time, pH, calcium release, flow, and radiopacity following the required standards, but higher solubility than the minimum values required by ISO 6876:2012.

Management of merged external/internal root resorption using CEM cement: a case report

Chronic pulpal inflammation and infection are the main predisposing factors for internal and external root resorption (IRR & ERR); however, merging of IRR and ERR is a rare lesion which rigorously alters the anatomy of root canals. This study reports a case of merged IRR and ERR in an asymptomatic maxillary left central incisor in a 33-year old Caucasian woman that was managed by one-visit root canal therapy (RCT) using calcium-enriched mixture (CEM) cement. Radiographic examination showed a short root with under-filled root canal obturation associated with ERR/IRR and an apical lesion. After thorough chemo-mechanical preparation, the root canal was obturated with CEM cement; one week later, the access cavity was permanently restored. Clinical/radiographic examinations at 1-year follow-up revealed uneventful healing, reestablishment of lamina dura and stabilization of the resorptive defects. The treatment outcome demonstrates that one-visit RCT using CEM cement may be a viable treatment option in cases with merged external/internal root resorption. Further clinical trials with a larger number of cases are suggested to document a higher level of evidence.

Maturogenesis of an Immature Dens Evaginatus Nonvital Premolar with an Apically Placed Bioceramic Material (EndoSequence Root Repair Material®): An Unexpected Finding

Dens evaginatus is a dental developmental anomaly that arises due to the folding of the inner dental epithelium that leads to the formation of an additional cusp or tubercle on the occlusal surface of the affected tooth. This accessory tissue projection may carry with it a narrow and constricted pulp horn extension. Occasionally, the tubercle easily fractures, thus leading to microexposure of the pulp horn and eventual pulp necrosis. Often, the pulp necrosis occurs at a time the root development of the affected tooth is incomplete. Apexification with calcium hydroxide and mineral trioxide aggregates has been the mainstay of treatment options before root canal obturation in immature nonvital permanent teeth. Lately, regenerative endodontics (maturogenesis) is becoming one of the preferred treatment modalities to manage such teeth. The current case highlights the possibility of a bioceramic material (EndoSequence Root Repair Material, BC RRM-Fast Set Putty™, Brasseler, USA) which supposed to provide apical root closure (apexification) and could also induce continuation of root growth (maturogenesis).

Periodontal healing following non-surgical repair of an old perforation with pocket formation and oral communication

Iatrogenic perforations negatively impact the outcome of endodontic treatments. Studies on prognostic factors showed that perforations in the coronal third of the root with periodontal pocket formation have an unfavorable prognosis. A 36-year-old female was referred for endodontic evaluation of tooth #13 with a history of an iatrogenic perforation, happened 3 years ago. There was a sinus tract associated with perforation, 10 mm probing on the mesial and mesio-palatal, bleeding on probing, radiolucent lesion adjacent to the perforation and complete resorption of the interdental bone between teeth #13 and #12. After the treatment options were discussed, she chose to save the tooth. The tooth was accessed under rubber dam isolation, the perforation site was cleaned and disinfected using 0.5% sodium hypochlorite and sealed with calcium-enriched mixture cement. Eighteen months after treatment the tooth was functional and asymptomatic. The probing depths were normal without bleeding on probing. Radiographically, the interdental crestal bone formed between teeth #13 and #12. Despite all negative prognostic factors in this case (i.e., perforations in the coronal third, pocket formation, and radiolucent lesion), healing was unexpectedly achieved via non-surgical repair of the perforation. Further research on biological aspects of healing in the periodontium following iatrogenic perforations are recommended.

Microstructure and chemical analysis of four calcium silicate-based cements in different environmental conditions

OBJECTIVE

The objective of this study was to analyze the microstructure and crystalline structures of ProRoot MTA, Biodentine, CEM Cement, and Retro MTA when exposed to phosphate-buffered saline, butyric acid, and blood.

METHODS AND MATERIALS

Mixed samples of ProRoot MTA, Biodentine, CEM Cement, and Retro MTA were exposed to either phosphate-buffered saline, butyric acid, or blood. Scanning electron microscope (SEM) and energy-dispersive X-ray spectroscopic (EDX) evaluations were conducted of specimens. X-ray diffraction (XRD) analysis was also performed for both hydrated and powder forms of evaluated calcium silicate cements.

RESULTS

The peak of tricalcium silicate and dicalcium silicate detected in all hydrated cements was smaller than that seen in their unhydrated powders. The peak of calcium hydroxide (Ca(OH)₂) in blood- and acid-exposed ProRoot MTA, CEM Cement, and Retro MTA specimens were smaller than that of specimens exposed to PBS. The peak of Ca(OH)₂ seen in Biodentine™ specimens exposed to blood was similar to that of PBS-exposed specimens. On the other hand, those exposed to acid exhibited smaller peaks of Ca(OH)₂.

CONCLUSION

Exposure to blood or acidic pH decreased Ca(OH)₂ crystalline formation in ProRoot MTA, CEM Cement and Retro MTA. However, a decrease in Ca(OH)₂ was only seen when Biodentine™ exposed to acid.

CLINICAL RELEVANCE

The formation of Ca(OH)₂ which influences the biological properties of calcium silicate cements was impaired by blood and acid exposures in ProRoot MTA, CEM Cement, and Retro MTA; however, in the case of Biodentine, only exposure to acid had this detrimental effect.

The implications and applications of nanotechnology in dentistry: A review

The emerging science of nanotechnology, especially within the dental and medical fields, sparked a research interest in their potential applications and benefits in comparison to conventional materials used. Therefore, a better understanding of the science behind nanotechnology is essential to appreciate how these materials can be utilised in our daily practice. The present paper will help the reader understand nanoscience, and the benefits and limitations of nanotechnology by addressing its ethical, social, and health implications. Additionally, nano-applications in dental diagnostics, dental prevention, and in dental materials will be addressed, with examples of commercially available products and evidence on their clinical performance.

Treatment Outcomes of 4 Vital Pulp Therapies in Mature Molars

INTRODUCTION

Vital pulp therapy (VPT) is a biological approach to minimally invasive endodontics. This randomized clinical trial aimed to evaluate and compare clinical and radiographic success of 4 VPTs (indirect pulp capping [IPC], direct pulp capping [DPC], miniature pulpotomy [MP], and full pulpotomy [FP]) using calcium-enriched mixture cement for deep caries management of mature permanent molars including teeth with clinical signs of irreversible pulpitis and the presence of apical periodontitis.

METHODS

Blinded participants (N = 302) were randomly allocated to 4 study arms. Random allocation was disregarded when visible pulp exposures did not happen after complete caries removal and the tooth was transferred to the IPC arm. Pre- and intraoperative data including vitality test results, pulpal/periapical status, and exposure type/location were recorded. Pain was measured using a numeric rating scale before treatment initiation up to 1 week postoperatively. Participants were followed up for 1 year.

RESULTS

The groups were homogenous in terms of age, sex, marital status, education, and practitioner; pre- and intraoperative conditions were similar in all arms and did not affect the long-term success. Preoperative pain and apical periodontitis were significantly different among arms (P < .05); however, it was not the case when the IPC group was excluded. After baseline pain adjustment, pain relief was continuous with similar patterns in all treatment groups. The 3- and 12-month success rates of the VPT techniques were comparable in the IPC (98.7% and 100%, respectively), DPC (98.4% and 94.7%, respectively), MP (98.4% and 91.4%, respectively), and FP (93.5% and 95.5%, respectively) arms, respectively (P > .05).

CONCLUSIONS

In deep caries management of mature permanent molars, the 4 VPTs were associated with favorable/comparable clinical and radiographic outcomes. The pulpal and periapical status as well as pulpal exposure type/location had no effect on treatment outcomes.

Influence of Immediate Coronal Restoration on Microhardness of CEM Cement: An In Vitro Study

Introduction

Coronal restoration could affect the setting reaction of the underlying CEM cement. The aim of the present study was to evaluate the effect of immediate coronal restoration placement on the subsurface microhardness of CEM cement.

Methods and Materials

In 50 extracted human mandibular molars, access cavities were prepared and CEM cement was placed in the pulp chamber at a 3-mm thickness. Samples were divided into ten groups (n=5). CEM cement was placed and after 10 min, two groups were restored with Zonalin temporary restoration and eight groups were restored with glass ionomer cement (GIC), resin modified glass ionomer (RMGI), resin based composite and amalgam respectively. Vickers microhardness number (VHN) of CEM cement was measured in two time intervals (7- and 21-days). Data was analyzed with SPSS and two-way analysis of variance and Bonferroni tests. Level of significance was set at the 5%.

Results

The mean VHN of CEM cement showed statistically significant differences only between Zonalin and amalgam groups (P=0.021). There were also significant differences considering the effect of time (P=0.042) and material (P=0.046). Although the effect of time-material on the microhardness values showed no statistically significant differences (P=0.636).

Conclusion

Based on the results of the present study, immediate placement of final restorations affects the setting reaction in underlying CEM cement. Therefore, sufficient moist curing and hydration should be guaranteed before placement of the coronal restoration.