Evaluation of reparative dentin formation of ProRoot MTA, Biodentine and BioAggregate using micro-CT and immunohistochemistry

Clinical applications and classification of calcium silicate-based cements based on their history and evolution: a narrative review

OBJECTIVES

The objective of this narrative review was to analyze the evolution of the calcium silicate-based cement (CSC) products since 1993 and classify them to better understand their appropriate use in clinical practice and foster innovation in dental material development.

MATERIALS AND METHODS

A narrative review of the relevant literature was conducted, collecting findings from computerized databases (PubMed, Science Direct, SCOPUS, and Web of Science) to provide historical background, classification, and modifications of CSCs published between 1993 and 2024.

RESULTS

We classified CSCs into six distinct generations based on previous literature. This classification revealed that the improvement in CSC's drawbacks, especially in physio-chemical properties, have led to the development of novel CSCs products. It also exhibited little to no variation in the bioactivity of CSCs across different generations and raised concerns regarding the biocompatibility of resin-modified CSC.

CONCLUSIONS

No CSC has yet emerged as a potential gold-standard material for endodontic treatments. Therefore, clinical applications tailored to the characteristics of each generation of CSCs are essential. Future advancements are anticipated to enable CSCs to induce the regeneration of tissues such as dentin, cementum, periodontal ligament, and dental pulp by incorporating regulatory signals.

CLINICAL RELEVANCE

This comprehensive classification system would assist clinicians in choosing the appropriate CSCs for various clinical situations by considering critical factors. This systematic approach enables clinicians to rely on evidence-based material selection rather than marketing claims. Furthermore, the insights into their evolution, classification, and clinical applications would fill a knowledge gap for clinicians and researchers.

Histological evaluation of pulp response to alendronate and Biodentine as pulp capping agents: an animal study

Objectives

This study aimed to comparatively assess the histological response of the pulp toward alendronate and Biodentine in a direct pulp capping procedure.

Materials and Methods

Twenty-four anterior teeth from 6 New Zealand rabbits were used in this study. Firstly, all rabbits were anesthetized according to their weight. Class V cavities were prepared on the buccal surfaces of anterior teeth. A pin-point exposure of the pulp was then made using a small, sterile round carbide bur and bleeding was arrested with a saline-soaked, sterile cotton pellet. The teeth under study were divided into 2 groups (n = 12). The intentionally exposed pulp was capped with alendronate (Group 1) and Biodentine (Group 2), correspondingly. After 30 days, all rabbits were euthanized; the teeth under study were extracted and taken up for histological analysis.

Results

Biodentine showed an intact, very dense dentin bridge formation with a uniform odontoblast (OD) layer pattern and mild or absent inflammatory response whereas specimens capped with alendronate demonstrated a dense dentin bridge formation with non-uniform OD layer pattern and mild to moderate inflammatory response.

Conclusions

Biodentine showed more biocompatibility than alendronate. However, alendronate can initiate reparative dentin formation and may be used as an alternative pulp capping agent.

Evaluation of biocompatibility and bioactive potential of Well-Root PT by comparison with ProRoot MTA and Biodentine

Background/purpose

Well-Root PT is a novel bioceramic material developed to overcome limitations of conventional calcium silicate cements. The purpose of this study was to assess the biocompatibility and bioactivity of a premixed putty-type cement, Well-Root PT.

Materials and methods

Identical cylindrical samples were prepared from ProRoot MTA, Biodentine, and Well-Root PT. In vitro calcium weight volume and calcium ion release from the materials were evaluated with scanning electron microscopy and energy-dispersive spectroscopy and inductively coupled plasma-optical emission spectroscopy. An in vivo rat direct pulp capping model was implemented with the materials (n = 14 per material). The rats were sacrificed at 7 or 28 days. Hematoxylin and eosin and immunohistochemical analyses were performed.

Results

In vitro calcium weight volume was 42.83 ± 8.82 % in ProRoot MTA, 47.05 ± 8.83 % in Biodentine, and 29.99 ± 4.94 % in Well-Root PT. Calcium ion releases from Well-Root PT after 7 and 28 days were similar with those from ProRoot MTA, but lower than those from Biodentine (P = 0.001 after 7 and 28 days equally). In an in vivo rat model, hematoxylin and eosin analysis showed no significant differences in inflammatory infiltration (P = 0.393) and hard tissue formation scores among the materials (P = 0.905). Also, both CD68 and DSPP expression showed similar results, with no significant differences among the materials (equally P = 0.874 for both markers).

Conclusion

Within the limits of this study, Well-Root PT was comparable to ProRoot MTA and Biodentine in terms of biocompatibility and bioactivity.

Different pulp capping agents and their effect on pulp inflammatory response: A narrative review

Several factors can directly damage dental pulp. Pulp healing requires controlled inflammation, which can be directed through specialized medical materials to eliminate infection and promote pulp repair. This review aimed to categorise these materials and identify their histological and molecular effects on pulp tissue or isolated cells in culture. In addition, we sought to identify which of these materials could trigger a favourable inflammatory pathway that could direct the pulpal response toward healing and regeneration. A single database (PubMed) was used, and the search strategy was based on MeSH terms. The search was conducted for articles published in English between January 2010 and December 2023, including those with histological and molecular findings. Only 33 articles met our inclusion criteria. Several conventional pulp capping agents have been shown to induce pulp healing and repair through dentine bridge formation. These materials show varying degrees of inflammation, ranging from moderate to mild, which may diminish over time. Other experimentally developed materials were also studied, either alone or in combination with conventional products; these materials demonstrated promising potential to reduce inflammation and superficial necrosis associated with conventional products. However, they still do not meet all the criteria for ideal pulp-capping materials and need further development for commercialisation. Several inflammatory pathways were also addressed in this review, along with favourable tissue responses to induce pulp regeneration. The immunomodulatory role of M2 phenotype macrophages is currently the most accepted, though the lack of standardised experimental procedures across studies hinder precise decision-making.

Microtomographic and histological evaluation of two bioceramics as pulp capping agents in vivo

Maintaining pulp vitality and function is a priority of the medicaments employed in pulp therapy to preserve tooth integrity. Aim: This study evaluated inflammatory response and reparative dentin bridge formation after direct pulp capping with two different bioceramics. Materials and Method: This was an in vivo controlled experimental study on 12 male Wistar rats. Pulpotomies were performed and the exposed pulps were capped with Biodentine or Neo MTA. After 15, 45 and 90 days, maxillary segments were obtained and prepared for histologic analysis and Micro-CT. Hounsfield Units (HU) were quantified. Results: Micro-CT analysis showed greater mineralization at 90 days with Neo MTA than with Biodentine. HU did not differ significantly (p >0.05) between molars treated with Biodentine and Neo MTA at 15 and 45 days, but at 90 days, there was statistically significant difference (p <0.05) between them. Reparative dentin was observed near the pulp exposure and canal orifice with both bioceramics. At 45 and 90 days, molars treated with Neo MTA showed mineralized tissue filling the canal orifice. Molars treated with Biodentine showed mineralized tissue and dentin bridge at the site of exposure at 45 days, and total pulp exposure coverage and mineralized entin matrix at 90 days. Conclusions: Biodentine and Neo MTA induce the formation of reparative dentin bridge after 45 days with inflammatory cell infiltrate.

Effects of mineral trioxide aggregate and methyl sulfonyl methane on pulp exposure via RUNX2 and RANKL pathways

The aim of this study was to determine the therapeutic effects of mineral trioxide aggregate (MTA) and methyl sulfonyl methane (MSM) on pulp damage due to pulp exposure through the RUNX2 and RANKL pathways. Seventy-two male Sprague-Dawley rats aged 4-6 months and weighing 250-300 g were divided into healthy, control, MTA, and MSM groups. After experimental applications, all rats at 2, 4, and 8 weeks were killed anesthetically with xylazine hydrochloride (Rompun, Bayer) 30 mg/kg and ketamine hydrochloride (Ketalar, Pfizer) 50 mg/kg injections (i.p.). We observed that necrotic odontoblasts, edema, inflammation, and vascular congestion findings were reduced from week 2 to week 8 in the MSM treatment group after pulp capping compared to the control group and MTA group. Similarly, we found a decrease in RUNX2 and RANKL levels in the MSM application group compared to the control and MTA groups (p < 0.05). MSM material has shown therapeutic effects on pulp capping treatment-induced pulp injury via increased RUNX2 ve RANKL expression.

Comparative Clinical and Radiographic Success Rate of Bioceramic Premix vs Biosilicate-based Medicament as Indirect Pulp Treatment Materials in Primary Molars: A Double-blind Randomized Trial with a Follow-up of 12 Months

Aim

To evaluate and compare the clinical and radiographic success of NeoPUTTY® and Biodentine™ as indirect pulp treatment (IPT) materials in primary molars.

Materials and methods

This clinical trial was conducted on children aged 5-9 years. Class I carious lesions in primary molars indicated for IPT were divided into two groups-group I, NeoPUTTY®, and group II, Biodentine™. IPC was performed as per the standard protocols. The treated teeth were evaluated for clinical and radiographic success, along with the presence of a dentinal bridge at 6 and 12 months, by three blind examiners independently. All the data were tabulated, and statistical analysis was performed using the Mann-Whitney U test.

Results

Interexaminer reliability was analyzed using Fleiss κ statistics, and it showed "good" agreement. Clinical success was 100% in both groups at 6- and 12-month follow-up, while radiographic success was also 100% at 6-month follow-up for both groups. However, at 12-month follow-up, it was 93.33% for group I and 100% for group II. The difference was statistically nonsignificant. The presence of a dentinal bridge at 12-month follow-up was seen in 86.66% of cases in group I and 100% of cases in group II, but there was no statistical difference observed between them with a p-value of 0.555.

Conclusion

Within the limitations of the study, we conclude that NeoPUTTY® and Biodentine™ are equally effective as IPT agents in primary teeth.

How to cite this article

Kothari P, Mathur A, Tirupathi S, et al. Comparative Clinical and Radiographic Success Rate of Bioceramic Premix vs Biosilicate-based Medicament as Indirect Pulp Treatment Materials in Primary Molars: A Double-blind Randomized Trial with a Follow-up of 12 Months. Int J Clin Pediatr Dent 2024;17(7):748-753.

Dentine Remineralisation Induced by "Bioactive" Materials through Mineral Deposition: An In Vitro Study

This study aimed to assess the ability of modern resin-based "bioactive" materials (RBMs) to induce dentine remineralisation via mineral deposition and compare the results to those obtained with calcium silicate cements (CSMs). The following materials were employed for restoration of dentine cavities: CSMs: ProRoot MTA (Dentsply Sirona), MTA Angelus (Angelus), Biodentine (Septodont), and TheraCal LC (Bisco); RBMs: ACTIVA BioACTIVE Base/Liner (Pulpdent), ACTIVA Presto (Pulpdent), and Predicta Bioactive Bulk (Parkell). The evaluation of the mineral deposition was performed through scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDX) on the material and dentine surfaces, as well as at the dentine-material interface after immersion in simulated body fluid. Additionally, the Ca/P ratios were also calculated in all the tested groups. The specimens were analysed after setting (baseline) and at 24 h, 7, 14, and 28 days. ProRoot MTA, MTA Angelus, Biodentine, and TheraCal LC showed significant surface precipitation, which filled the gap between the material and the dentine. Conversely, the three RBMs showed only a slight ability to induce mineral precipitation, although none of them was able to remineralise the dentine-material interface. In conclusion, in terms of mineral precipitation, modern "bioactive" RBMs are not as effective as CSMs in inducing dentine remineralisation; these latter represent the only option to induce a possible reparative process at the dentin-material interface.

Direct pulp capping procedures - Evidence and practice

The aim of direct pulp capping (DPC) is to promote pulp healing and mineralized tissue barrier formation by placing a dental biomaterial directly over the exposed pulp. Successful application of this approach avoids the need for further and more extensive treatment. In order to ensure a complete pulp healing with the placement of restorative materials, a mineralized tissue barrier must form to protect the pulp from microbial invasion. The formation of mineralized tissue barrier can only be induced when there is a significant reduction in pulp inflammation and infection. Consequently, promoting the healing of pulp inflammation may provide a favorable therapeutic opportunity to maintain the sustainability of DPC treatment. Mineralized tissue formation was observed as the favorable reaction of exposed pulp tissue against a variety of dental biomaterials utilized for DPC. This observation reveals an intrinsic capacity of pulp tissue for healing. Therefore, this review focuses on the DPC and its healing procedure as well as the materials used for DPC treatment and their mechanisms of action to promote pulpal healing. In addition, the factors that can affect the healing process of DPC, clinical considerations and future perspective has been described.

Clinical application of calcium silicate-based bioceramics in endodontics

Pulp treatment is extremely common in endodontics, with the main purpose of eliminating clinical symptoms and preserving tooth physiological function. However, the effect of dental pulp treatment is closely related to the methods and materials used in the process of treatment. Plenty of studies about calcium silicate-based bioceramics which are widely applied in various endodontic operations have been reported because of their significant biocompatibility and bioactivity. Although most of these materials have superior physical and chemical properties, the differences between them can also have an impact on the success rate of different clinical practices. Therefore, this review is focused on the applications of several common calcium silicate-based bioceramics, including Mineral trioxide aggregate (MTA), Biodentine, Bioaggregate, iRoot BP Plus in usual endodontic treatment, such as dental pulp capping, root perforation repair, regenerative endodontic procedures (REPs), apexification, root-end filling and root canal treatment (RCT). Besides, the efficacy of these bioceramics mentioned above in human trials is also compared, which aims to provide clinical guidance for their clinical application in endodontics.

A novel analysis of the formation and resorption changes in dental hard tissue using longitudinal in vivo micro computed tomography

This study was to investigate the new analysis manner of dental hard tissue change using in vivo micro-computed tomography (CT) in rat. Scanning, registration, analyzing, and presenting method to track longitudinal in vivo micro-CT data on dental hard tissues were validated in murine models: formative, dentin thickness after direct pulp capping with mineral trioxide aggregate; resorptive, development of apical bone rarefaction in apical periodontitis model. Serial in vivo micro-CT scans were analyzed through rigid-registration, active-contouring, deformable-registration, and motion vector-based quantitative analyses. The rate and direction of hard tissue formation after direct pulp capping was datafied by tracing coordinate shift of fiducial points on pulp chamber outline in formative model. The development of apical periodontitis could be monitored with voxel counts, and quantitatively analyzed in terms of lesion size, bone loss, and mineral density in resorptive model. This study supports the application of longitudinal in vivo micro-CT for resorptive- and formative-phase specific monitoring of dental hard tissues.

Evaluation of the pulp response following direct pulp capping with exogenous nitric oxide and Mineral Trioxide Aggregate (MTA) a histologic study

Background

Recently, vital pulp therapy is widely used all over the world. It aims to maintain the viability and function of the injured dental pulp tissue. Direct pulp capping is recognized as one of the most common used techniques in this approach.

Aim of the study

we aimed to compare the histopathological response of the dental pulp following direct pulp capping using two different capping materials; the exogenous nitric oxide (NOC-18) and Mineral Trioxide Aggregate (MTA) in dogs' teeth.

Methods and materials

The pulp of thirty-two premolars and canines from four dogs (eight teeth per each dog) the pulp was exposed and treated with either exogenous nitric oxide (NOC-18) and MTA (four teeth in each group). The treated teeth were extracted and prepared for histologic evaluation after one month and three months, respectively. The histologic study evaluated the formation of dentine bridge, the degree of pulpitis, calcification of the coronal pulp tissue and odontoblasts layer activity. We have the ethical approval to achieve this research from the scientific committee in Faculty of Dentistry, Damascus University.

Results

The results showed that the active statue of odontoblasts layer in NOC-18 group was significantly more than in MTA group after a month of recall (P: 0.003). No significant difference was found between MTA and NOC-18 categories in the formation of dentine bridge after 3 months (P: 1.000).

Conclusion

Exogenous nitric oxide (NOC-18) maybe has a positive impact on formation of calcified bridge and efficacy of odontoblasts layer on directly capped dog's teeth. Exogenous NO donors might offer alternative to current pulp capping agents in Vital Pulp Therapy in endodontic.

Effect of Intracoronal Sealing Biomaterials on the Histological Outcome of Endodontic Revitalisation in Immature Sheep Teeth-A Pilot Study

The influence of intracoronal sealing biomaterials on the newly formed regenerative tissue after endodontic revitalisation therapy remains unexplored. The objective of this study was to compare the gene expression profiles of two different tricalcium silicate-based biomaterials alongside the histological outcomes of endodontic revitalisation therapy in immature sheep teeth. The messenger RNA expression of TGF-β, BMP2, BGLAP, VEGFA, WNT5A, MMP1, TNF-α and SMAD6 was evaluated after 1 day with qRT-PCR. For evaluation of histological outcomes, revitalisation therapy was performed using Biodentine (n = 4) or ProRoot white mineral trioxide aggregate (WMTA) (n = 4) in immature sheep according to the European Society of Endodontology position statement. After 6 months' follow-up, one tooth in the Biodentine group was lost to avulsion. Histologically, extent of inflammation, presence or absence of tissue with cellularity and vascularity inside the pulp space, area of tissue with cellularity and vascularity, length of odontoblast lining attached to the dentinal wall, number and area of blood vessels and area of empty root canal space were measured by two independent investigators. All continuous data were subjected to statistical analysis using Wilcoxon matched-pairs signed rank test at a significance level of p < 0.05. Biodentine and ProRoot WMTA upregulated the genes responsible for odontoblast differentiation, mineralisation and angiogenesis. Biodentine induced the formation of a significantly larger area of neoformed tissue with cellularity, vascularity and increased length of odontoblast lining attached to the dentinal walls compared to ProRoot WMTA (p < 0.05), but future studies with larger sample size and adequate power as estimated by the results of this pilot study would confirm the effect of intracoronal sealing biomaterials on the histological outcome of endodontic revitalisation.

Multiple growth factors accommodated degradable submicron calcium sulfate hemihydrate/porous hydroxyapatite for dentin-pulp regeneration

Vital pulp therapy (VPT) has gained significant consideration by utilizing the natural healing capacity of the inflamed pulp in healing process. However, the protective pulp capping materials that facilitate this healing process are still under investigation for the successful promotion of dentin-pulp regeneration. Herein, we developed a bioactive and biodegradable pulp capping material (denoted as sCSHA-GFs) by synthesizing inorganic submicron calcium sulfate hemihydrate (sCS)/porous hydroxyapatite (HA) loaded with growth factors (GFs) such as transforming growth factor-beta 1 (TGF-β1), fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF). Physiochemical characteristics of submicron CSHA-GFs (sCSHA-GFs) cement were determined. Human dental pulp stem cells (hDPSCs) were used for analyzing their biocompatibility and bioactivity for dentin mineralization. To evaluate the efficacy of sCSHA-GFs, we compared it with a commercial material, mineral trioxide aggregate (MTA), the reference standard used clinically on pulp capping. Our results showed that sCSHA-GFs cement presented good biodegradability with dissolution properties for sustained release of calcium (Ca²⁺) ions and GFs, and facilitated attachment, proliferation, differentiation and migration of hDPSCs. In addition, sCSHA-GFs cement was found to be more effective than MTA at prolonged incubation time in inducing the mRNA expression levels of odontoblastic differentiation markers, dentin sialophosphoprotein (DSPP) and dentin matrix protein (DMP-1), leading to increased mineralization (with calcium deposits) along with increased alkaline phosphatase (ALP) expressions, evident from Alizarin Red S and ALP staining assays. Our findings suggest that sCSHA-GFs cement may act as a suitable material in VPT for dentin-pulp regeneration.

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

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

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.

Chitosan-Based Accelerated Portland Cement Promotes Dentinogenic/Osteogenic Differentiation and Mineralization Activity of SHED

Calcium silicate-based cements (CSCs) are widely used in various endodontic treatments to promote wound healing and hard tissue formation. Chitosan-based accelerated Portland cement (APC-CT) is a promising and affordable material for endodontic use. This study investigated the effect of APC-CT on apoptosis, cell attachment, dentinogenic/osteogenic differentiation and mineralization activity of stem cells from human exfoliated deciduous teeth (SHED). APC-CT was prepared with various concentrations of chitosan (CT) solution (0%, 0.625%, 1.25% and 2.5% (w/v)). Cell attachment was determined by direct contact analysis using field emission scanning electron microscopy (FESEM); while the material extracts were used for the analyses of apoptosis by flow cytometry, dentinogenic/osteogenic marker expression by real-time PCR and mineralization activity by Alizarin Red and Von Kossa staining. The cells effectively attached to the surfaces of APC and APC-CT, acquiring flattened elongated and rounded-shape morphology. Treatment of SHED with APC and APC-CT extracts showed no apoptotic effect. APC-CT induced upregulation of DSPP, MEPE, DMP-1, OPN, OCN, OPG and RANKL expression levels in SHED after 14 days, whereas RUNX2, ALP and COL1A1 expression levels were downregulated. Mineralization assays showed a progressive increase in the formation of calcium deposits in cells with material containing higher CT concentration and with incubation time. In conclusion, APC-CT is nontoxic and promotes dentinogenic/osteogenic differentiation and mineralization activity of SHED, indicating its regenerative potential as a promising substitute for the commercially available CSCs to induce dentin/bone regeneration.

Evaluation of a collagen-bioaggregate composite scaffold in the repair of sheep pulp tissue

Purpose:

This study aimed to compare the effects of the collagen-BioAggregate mixture (CBA-M) and collagen-BioAggregate composite (CBA-C) sponge as a scaffolding material on the reparative dentin formation.

Materials and methods:

CBA-C sponge (10:1 w/w) was obtained and characterized by Scanning Electron Microscopy (SEM) and Mercury Porosimetry. Cytotoxicity of the CBA-C sponge was tested by using the L929 mouse fibroblast cell line. Dental pulp stem cells (DPSCs) were isolated from the pulp tissue of sheep teeth and characterized by flow cytometry for the presence of mesenchymal stem cell marker, CD44. The osteogenic differentiation capability of isolated DPSCs was studied by Alizarin Red staining. The cells were then used to study for the compatibility of CBA-C sponge with cell proliferation and calcium phosphate deposition. The effect of CBA-C sponge and CBA-M on the induction of dentin regeneration was studied in the perforated teeth of sheep for the eight-week period. All the analyses were performed with appropriate statistical hypothesis tests.

Results:

CBA-C sponge was found to be biocompatible for DPSCs. The DPSCs seeded on the CBA-C sponge were able to differentiate into the osteoblastic lineage and deposit calcium phosphate crystals in vitro. Reparative dentin formation was observed after the second week in the CBA-C sponge applied group. At the end of eight weeks, a complete reparative dentin structure was formed in the CBA-C sponge applied group, whereas necrotic tissue residues were observed in groups treated with the CBA-M.

Conclusion:

CBA-C sponge represents a better microenvironment for reparative dentin formation probably due to maintaining DPSCs and allowing their osteogenic differentiation and thus calcium phosphate deposition.

Minimal Intervention in Dentistry: A Literature Review on Biodentine as a Bioactive Pulp Capping Material

Root canal treatment has been the treatment of choice for carious pulp exposures. In the perspective of minimally invasive dentistry and preventive endodontics, a direct pulp capping procedure with a reliable bioactive material may be considered an alternative approach provided that the pulp status is favorable. However, the treatment of pulp exposure by pulp capping is still a controversial issue with no clear literature available on this topic, leaving the concerned practitioner more confused than satisfied. Biodentine is a relatively new bioactive material explored for vital pulp therapy procedures. This article discusses its role in direct pulp capping procedures. A thorough literature search of the database was done using PubMed, Google Scholar, and Scopus using the keywords preventive endodontics, calcium silicate cement, direct pulp capping, Biodentine, and vital pulp therapy. Reference mining of the articles that were identified was used to locate other papers and enrich the findings. No limits were imposed on the year of publication, but only articles in English were considered. This paper is aimed at reviewing the current literature on Biodentine as a direct pulp capping material. The review will provide a better understanding of Biodentine's properties and can aid in the decision-making process for maintaining the vitality of exposed dental pulp with minimal intervention.

Potential of tailored amorphous multiporous calcium silicate glass for pulp capping regenerative endodontics-A preliminary assessment

INTRODUCTION/OBJECTIVE

The tailored amorphous multi-porous (TAMP) material fabrication technology has led to a new class of bioactive materials possessing versatile characteristics. It has not been tested for dental applications. Thus, we aimed to assess its biocompatibility and ability to regenerate dental mineral tissue.

METHODS

30CaO-70SiO₂ model TAMP discs were fabricated by a sol-gel method followed by in vitro biocompatibility testing with isolated human or mini-swine dental pulp stem cells (DPSCs). TAMP scaffolds were tested in vivo as a pulp exposure (pin-point, 1 mm, 2 mm, and entire pulp chamber roof) capping material in the molar teeth of mini-swine.

RESULTS

The in vitro assays showed that DPSCs attached well onto the TAMP discs with comparable viability to those attached to culture plates. Pulp capping tests on mini-swine showed that after 4.5 months TAMP material was still present at the capping site, and mineral tissue (dentin bridge) had formed in all sizes of pulp exposure underneath the TAMP material.

CONCLUSIONS

TAMP calcium silicate is biocompatible with both human and swine DPSCs in vitro and with pulp in vivo, it may help regenerate the dentin bridge after pulp exposure.

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

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

Hard tissue formation after direct pulp capping with osteostatin and MTA in vivo

Objectives

In recent in vitro study, it was reported that osteostatin (OST) has an odontogenic effect and synergistic effect with mineral trioxide aggregate (MTA) in human dental pulp cells. Therefore, the aim of this study was to evaluate whether OST has a synergistic effect with MTA on hard tissue formation in vivo.

Materials and Methods

Thirty-two maxillary molars of Spraque-Dawley rats were used in this study. An occlusal cavity was prepared and the exposed pulps were randomly divided into 3 groups: group 1 (control; ProRoot MTA), group 2 (OST 100 μM + ProRoot MTA), group 3 (OST 10 mM + ProRoot MTA). Exposed pulps were capped with each material and cavities were restored with resin modified glass ionomer. The animals were sacrificed after 4 weeks. All harvested teeth were scanned with micro-computed tomography (CT). The samples were prepared and hard tissue formation was evaluated histologically. For immunohistochemical analysis, the specimens were sectioned and incubated with primary antibodies against dentin sialoprotein (DSP).

Results

In the micro-CT analysis, it is revealed that OST with ProRoot MTA groups showed more mineralized bridge than the control (p < 0.05). In the H&E staining, it is showed that more quantity of the mineralized dentin bridge was formed in the OST with ProRoot MTA group compared to the control (p < 0.05). In all groups, DSP was expressed in newly formed reparative dentin area.

Conclusions

OST can be a supplementary pulp capping material when used with MTA to make synergistic effect in hard tissue formation.

Influence of Ultrasonic Activation on the Physicochemical Properties of Calcium Silicate-Based Cements

Purpose

To evaluate the influence of ultrasonic activation on the physicochemical properties of setting time (ST), flow (FL), dimensional change (DC), and solubility (SL) of the cements: MTA, MTA Repair HP, and Biodentine®.

Materials and Methods

Two experimental groups were formed according to the cement activation protocol: without ultrasonic activation and with ultrasonic activation. Cements were manipulated according to the manufacturers' instructions. Ultrasonic activation group was performed with an E1 insert at power 3 (24–32 kHz) for 30 s directly in the center of the cement mass. The molds for analysis of the physicochemical properties were filled out and evaluated according to specification No. 57 from ANSI/ADA. The results were analyzed using the ANOVA test (two-way), complemented by Tukey's test (α = 0.05). The distilled water used during the solubility test was submitted to spectrometry to verify the release of calcium ions. The morphologies of the external surface and the cross-section of the samples were analyzed by means of a scanning electron microscope (SEM).

Results

For the ST, ultrasonic activation reduced the values of MTA, MTA Repair HP, and Biodentine (P < 0.05). For the FL, ultrasonic activation did not alter the flow of MTA (P > 0.05); however, it increased the flow MTA Repair HP and Biodentine (P < 0.05). For the DC, the percentage values of dimensional change were higher when there was ultrasonic activation in all repair cements (P < 0.05). For SL, there was a reduction in the percentage of the values in MTA and MTA Repair HP (P < 0.05); however, there was no change in the values of Biodentine (P > 0.05). Ultrasonic activation favored the release of calcium ions from all cements. The SEM analysis showed, in general, that the ultrasonic activation reduced and altered the particle shape of the cement.

Conclusions

The ultrasonic activation interfered in the ST, DC, FL, ultrastructural morphology, and calcium release of the repair cements. However, it did not affect the solubility of Biodentine®.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

TRIAL REGISTRATION

PACTR201901866476410.

Tailored 70S30C Bioactive glass induces severe inflammation as pulpotomy agent in primary teeth: an interim analysis of a randomised controlled trial

OBJECTIVES

This study compared clinical, histologic, and inflammatory outcomes of Biodentine and Bioactive glass (70S30C-BAG) as pulpotomy agents in primary teeth.

METHODS

A randomised, clinical trial was performed recruiting 70 children, 5-9 years old, having ≥ 1 tooth indicated for vital pulpotomy. Participants were randomised to Biodentine or 70S30C-BAG groups. Clinical evaluation was scheduled at 1, 3, 6, 9, and 12 months. Additional 16 teeth were extracted after 6 weeks to assess histologic and inflammatory response (IL-8/IL-10 ratio) using ELISA. Fisher exact, Mann Whitney U test, and t test were used to compare clinical, histologic outcomes and IL-8/IL-10 ratio.

RESULTS

After 3 months, 10 teeth treated with Biodentine were clinically successful, while 9 teeth treated with 70S30C-BAG failed (P < 0.001) necessitating trial termination. Causes of failure were analysed by assessing the pH and ionic release of 70S30C-BAG. Biodentine-treated teeth showed minor inflammation, normal pulp, and hard tissue formation.70S30C-BAG-treated teeth showed severe inflammation, abscesses, root resorption without hard tissue formation. There was a significantly greater percent reduction of IL-8/IL-10 ratio in Biodentine than 70S30C-BAG (mean ± SD = 66.39 ± 18.56 and 40.66 ± 0.86, P = 0.02).

CONCLUSIONS

Biodentine showed favourable clinical, histologic, and anti-inflammatory outcomes, promoting pulp healing and regeneration. 70S30C-BAG resulted in pulp necrosis-through persistent inflammation-causing clinical failure.

CLINICAL RELEVANCE

Biodentine is a promising pulpotomy agent in primary teeth; it promoted healing and regeneration of the dentine-pulp complex. In its current form, 70S30C-BAG is not a suitable pulpotomy agent; it induced persistent inflammation, negating the pulp ability to heal and regenerate. TRN: NCT03786302, 12/19/2018.

Recent Advances in Indirect Pulp Treatment Materials for Primary Teeth: A Literature Review

Aim

To provide an overview of the techniques of indirect pulp treatment (IPT) and the new materials used.

Background

Indirect Pulp Treatment (IPT) is a conservative treatment approach that can be used in primary molars. Pulpotomy has been adopted as the treatment of choice for deep caries in primary molars. IPT showed higher success rates in recent researches.

Materials and methods

Electronic search of English scientific papers was accomplished using PubMed, ScienceDirect, and Scopus. Papers published from 1995 to 2019 were included. Search terms used were recent advances, indirect pulp treatment, mineral trioxide aggregate (MTA), biodentine, TheraCal–LC, chlorhexidine gluconate (CHX), resin-modified glass ionomer (RMGI), and calcium hydroxide.

Review results

Seventy two papers were obtained from the electronic search and references of selected studies. Thirty five papers explained recent advances in IPT materials for primary molars. MTA produces more dentinal bridging with superior quality than calcium hydroxide. Similarly, Biodentine can form reparative dentin in a very short period. TheraCal–LC has increased stability and durability with strong physical properties and low solubility. Furthermore, CHX is a chemical disinfectant which can aid in increasing the success rate of IPT when conjugated with other materials. It produced highly successful IPT when combined with RMGI or calcium hydroxide.

Conclusion

IPT is the preferred treatment approach for preservation of primary dentition. CHX is an emerging material that can provide promising results in IPT when combined with other materials.

Clinical significance

Up to date, no material had replaced the popular use of calcium hydroxide in IPT. The use of CHX with RMGI can increase the success rate while preserving the advantages of the latter as it is considered the liner of choice for primary teeth, making IPT a suitable substitute for pulpotomy in primary molars.

How to cite this article

Saber AM, El Meligy OA, Alaki SM. Recent Advances in Indirect Pulp Treatment Materials for Primary Teeth: A Literature Review. Int J Clin Pediatr Dent 2021;14(6):795–801.

Immunohistochemical expression of non-collagenous extracellular matrix molecules involved in tertiary dentinogenesis following direct pulp capping: a systematic review

BACKGROUND

Extracellular matrix molecules (ECMM) expression during tertiary dentinogenesis provides useful information for regenerative applications and efficacy of pulp capping materials.

AIM

To identify and review the expression and roles of non-collagenous ECMM after successful direct pulp capping (DPC), following mechanical pulp exposures, via immunohistochemistry (IHC). The study addressed the question of where will successful DPC impact the IHC expression of these molecules.

DATA SOURCES

In vivo animal and human original clinical studies reporting on ECMM in relation to different follow-up periods were screened and evaluated via descriptive analysis. The electronic literature search was carried out in three databases (MEDLINE/PubMed, Web of Science, Scopus), followed by manual screening of relevant journals and cross-referencing, up to December 2018.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Randomized and non-randomized controlled trials, conducted in humans and animals, were selected. Histological evidence for tertiary dentine formation was a prerequisite for IHC evaluation.

STUDY APPRAISAL AND SYNTHESIS METHODS

The methodological quality of the included articles was independently assessed using the Systematic Review Centre for Laboratory animal Experimentation (SYRCLE) and the Cochrane risk of bias tool (RoB 1), respectively.

RESULTS

From a total of 1534 identified studies, 18 were included. Thirteen papers evaluated animal subjects and five studies were carried out on humans. In animals and humans, fibronectin and tenascin expressions were detected in pulp and odontoblast-like cells (OLC); dentine sialoprotein was expressed in both soft and newly-formed mineralized tissue. In animals, bone sialoprotein was early expressed, in association with OLC and predentin; the immunoreactivity for dentine sialophosphoprotein and dentine matrix protein-1 was associated with the OLC and dentine bridge; osteopontin was expressed in OLC, predentine and reparative dentine. A considerable heterogeneity was found in the methodologies of the included studies, as well as interspecies variability of results in terms of time.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Within the limited scientific evidence, all non-collagenous ECMM expressions during tertiary dentinogenesis are active and related to soft and hard tissues. There is a shortage of human studies, and future research directions should focus more on them. PROSPERO Protocol: CRD42019121304.

In vivo Biocompatibility and Bioactivity of Calcium Silicate-Based Bioceramics in Endodontics

Endodontic therapy aims to preserve or repair the activity and function of pulp and periapical tissues. Due to their excellent biological features, a substantial number of calcium silicate-based bioceramics have been introduced into endodontics and simultaneously increased the success rate of endodontic treatment. The present manuscript describes the in vivo biocompatibility and bioactivity of four types of calcium silicate-based bioceramics in endodontics.

Histological evaluation of the regenerative potential of a novel treated dentin matrix hydrogel in direct pulp capping

OBJECTIVES

To produce a novel injectable treated dentin matrix hydrogel (TDMH) to be used as a novel pulp-capping agent for dentin regeneration compared with Biodentine and MTA.

MATERIALS AND METHODS

Thirty intact fully erupted premolars scheduled to be extracted for orthodontic reasons were included. Pulps were mechanically exposed in the middle of the cavity floor. TDMH was composed of TDM powder (500-μm particle size) and sodium alginate as an injectable scaffold. The capped teeth were divided into three equal groups (n = 10): TDMH, Biodentine, and MTA respectively. Clinical examination and assessment of periapical response were performed. The teeth were extracted after 2-weeks and 2-month intervals, stained with hematoxylin-eosin, and categorized by using a histologic scoring system. Statistical analysis was performed using chi-square and Kruskal-Wallis test (p = 0.05).

RESULTS

All teeth were vital during observation periods. Histological analysis after 2 months showed complete dentin bridge formation and absence of inflammatory pulp response with no significant differences between groups. However, the formed dentin was significantly thicker with the TDMH group with layers of well-arranged odontoblasts that were found to form a homogenous tubular structure with numerous dentinal tubule lines showing a positive trend to dentin regeneration.

CONCLUSIONS

TDMH could achieve dentin regeneration and conservation of pulp vitality and might serve as a feasible natural substitute for silicate-based cements in restoring in vivo dentin defect in direct pulp-capping procedure.

TRIAL REGISTRATION

PACTR201901866476410.

Micro-computed tomographic evaluation of a new system for root canal filling using calcium silicate-based root canal sealers

Objectives

This study evaluated by using micro-computed tomography (micro-CT) the filling ability and sealer apical extrusion promoted by a new Sealer Injection System (SIS; Angelus) with side openings needle, in comparison with the conventional injection system, associated with a new ready-to-use calcium silicate-based sealer (Bio-C Sealer).

Materials and Methods

Acrylic resin models containing a main curved artificial canal and 3 simulated lateral canals in apical, middle and cervical thirds were used. The main root canals were prepared using a rotary system up to size 35.05. The canals were filled with Bio-C sealer by using a single cone technique and the conventional delivery system or SIS. Samples were scanned in micro-CT. The percentage of voids throughout the entire extension of the main root canal and in each third of the lateral canals, besides the apical extrusion of the sealer was calculated. Data were submitted to t-test (p < 0.05).

Results

There was no difference between both systems in the main root canals filling. Although the volume percentage of voids was similar in the apical and middle thirds of lateral canals, SIS had the greatest filling ability of the cervical third lateral canal. Moreover, the conventional system showed the highest apical extrusion of the sealer.

Conclusions

The conventional and SIS obturation systems had an appropriate filling ability of the main root canal. SIS had the best filling of the cervical third of the lateral canals, besides lower sealer apical extrusion, suggesting its clinical indication.

Micro-computed tomographic evaluation of the flow and filling ability of endodontic materials using different test models

Objectives

This study compared the flow and filling of several retrograde filling materials using new different test models.

Materials and Methods

Glass plates were manufactured with a central cavity and 4 grooves in the horizontal and vertical directions. Grooves with the dimensions used in the previous study (1 × 1 × 2 mm; length, width, and height respectively) were compared with grooves measuring 1 × 1 × 1 and 1 × 2 × 1 mm. Biodentine, intermediate restorative material (IRM), and mineral trioxide aggregate (MTA) were evaluated. Each material was placed in the central cavity, and then another glass plate and a metal weight were placed over the cement. The glass plate/material set was scanned using micro-computed tomography. Flow was calculated by linear measurements in the grooves. Central filling was calculated in the central cavity (mm³) and lateral filling was measured up to 2 mm from the central cavity.

Results

Biodentine presented the least flow and better filling than IRM when evaluated in the 1 × 1 × 2 model. In a comparison of the test models, MTA had the most flow in the 1 × 1 × 2 model. All materials had lower lateral filling when the 1 × 1 × 2 model was used.

Conclusions

Flow and filling were affected by the size of the test models. Higher grooves and materials with greater flow resulted in lower filling capacity. The test model measuring 1 × 1 × 2 mm showed a better ability to differentiate among the materials.

Bio-Inductive Materials in Direct and Indirect Pulp Capping-A Review Article

The article is aimed at analyzing the available research and comparing the properties of bio-inductive materials in direct and indirect pulp capping procedures. The properties and clinical performances of four calcium-silicate cements (ProRoot MTA, MTA Angelus, RetroMTA, Biodentine), a light-cured calcium silicate-based material (TheraCal LC) and an enhanced resin-modified glass-ionomer (ACTIVA BioACTIVE) are widely discussed. A correlation of in vitro and in vivo data revealed that, currently, the most validated material for pulp capping procedures is still MTA. Despite Biodentine's superiority in relatively easier manipulation, competitive pricing and predictable clinical outcome, more long-term clinical studies on Biodentine as a pulp capping agent are needed. According to available research, there is also insufficient evidence to support the use of TheraCal LC or ACTIVA BioACTIVE BASE/LINER in vital pulp therapy.

Evaluation of dentinogenesis inducer biomaterials: an in vivo study

When exposure of the pulp to external environment occurs, reparative dentinogenesis can be induced by direct pulp capping to maintain pulp tissue vitality and function. These clinical situations require the use of materials that induce dentin repair and, subsequently, formation of a mineralized tissue. Objective: This work aims to assess the effect of tricalcium silicate cements and mineral trioxide aggregate cements, including repairing dentin formation and inflammatory reactions over time after pulp exposure in Wistar rats. Methodology: These two biomaterials were compared with positive control groups (open cavity with pulp tissue exposure) and negative control groups (no intervention). The evaluations were performed in three stages; three, seven and twenty-one days, and consisted of an imaging (nuclear medicine) and histological evaluation (H&E staining, immunohistochemistry and Alizarin Red S). Results: The therapeutic effect of these biomaterials was confirmed. Nuclear medicine evaluation demonstrated that the uptake of ^99mTc-Hydroxymethylene diphosphonate (HMDP) showed no significant differences between the different experimental groups and the control, revealing the non-occurrence of differences in the phosphocalcium metabolism. The histological study demonstrated that in mineral trioxide aggregate therapies, the presence of moderate inflammatory infiltration was found after three days, decreasing during follow-ups. The formation of mineralized tissue was only verified at 21 days of follow-up. The tricalcium silicate therapies demonstrated the presence of a slight inflammatory infiltration on the third day, increasing throughout the follow-up. The formation of mineralized tissue was observed in the seventh follow-up day, increasing over time. Conclusions: The mineral trioxide aggregate (WhiteProRoot^®MTA) and tricalcium silicate (Biodentine™) present slight and reversible inflammatory signs in the pulp tissue, with the formation of mineralized tissue. However, the exacerbated induction of mineralized tissue formation with the tricalcium silicate biomaterial may lead to the formation of pulp calcifications

Direct Pulp Capping: Which is the Most Effective Biomaterial? A Retrospective Clinical Study

(1) Background: Recently, tricalcium silicate cements, such as Biodentine™, have emerged. This biomaterial has a calcium hydroxide base and characteristics like mineral aggregate trioxide cements, but has tightening times that are substantially more suitable for their application and other clinical advantages. (2) Methods: A retrospective clinical study was conducted with 20 patients, which included a clinical evaluation of the presence or absence of pulp inflammation compatible symptoms, radiographic evaluation of the periapical tissues, and structural alterations of the coronary restoration that supports pulp capping therapies with Biodentine™ and WhiteProRoot^®MTA. (3) Results: This clinical study revealed similar success rates between mineral trioxide cement and tricalcium silicates cements at 6 months, with 100% and 95% success rates, respectively. There were no statistically significant differences between both biomaterials and between these and the various clinical circumstances, namely the absolute isolation of the operating field, exposure size, the aetiology of exposure, and even the type of restorative material used. (4) Conclusions: Biodentine™ demonstrated a therapeutic effect on the formation of a dentin bridge accompanied by slight inflammatory signs, with a high clinical success rate, indicating the possibility of its effective and safe use in dental pulp direct capping in humans, similar to the gold standard material.

Characterization of Odontoblast-like Cell Phenotype and Reparative Dentin Formation In Vivo: A Comprehensive Literature Review

INTRODUCTION

The primary aim was to explore the criteria used in characterization of reparative cells and mineralized matrices formed after treatment of pulp exposures, and the sequence of relative events. The secondary aim was to evaluate whether the reparative events depend on the experimental model species, age, and therapeutic intervention.

METHODS

A literature search of databases using different combinations of the key words was undertaken. Data analysis was based only on studies having histological or histochemical assessment of the pulp tissue responses. The search yielded 86 studies, 47 capping material-based and 39 bioactive application-based experiments, which provided data on morphological or functional characterization of the mineralized matrices and the associated cells.

RESULTS

In 64% of capping material-based and 72% of bioactive application-based experiments, a 2-zone mineralized matrix formation (atubular followed by tubular) was detected, whereas characterization of odontoblastic differentiation is provided in only 25.5% and 46.1% of the studies, respectively. In 93.3% of the studies showing odontoblast-like cells, differentiated cells were in association with tubular mineralized matrix formation. Analyses further showed that cell- and matrix-related outcomes do not depend on experimental model species, age, and therapeutic intervention.

CONCLUSIONS

The evidence of the reviewed scientific literature is that dental pulp cells secrete a dentin-like matrix of tubular morphology in relation to primitive forms of atubular or osteotypic mineralized matrix. Furthermore, data analysis showed that dental pulp cells express in vivo the odontoblastic phenotype, and secrete matrix in a predentin-like pattern, regardless of the model species, age, and therapeutic intervention used.

Análise da composição química dos cimentos MTA Angelus® branco, cinza e HP Repair® através de Microscopia Eletrônica de Varredura (MEV) acoplada a Espectrômetro de Energia Dispersiva (EDS)

Resumo Introdução Devido às suas propriedades biológicas e físico-químicas, o MTA tem sido indicado para diferentes situações clínicas na Endodontia. Objetivo O objetivo foi analisar a composição química dos cimentos MTA Angelus branco, cinza, e Repair HP. Material e método Foram confeccionados cinco corpos de prova de cada tipo de cimento estudado, com diâmetro de 4 mm e altura de 1 mm, utilizando fita condutora de carbono dupla face. Em seguida, as amostras foram analisadas com auxílio de um microscópio eletrônico de varredura acoplado ao aparelho de espectrometria de energia dispersiva. Posteriormente, foram submetidos ao teste estatístico Kolmogorov-Smirnov para verificar a normalidade. Os elementos químicos que apresentaram distribuição normal (média de 5%) foram submetidos ao teste ANOVA e o teste Kruskal-Wallis foi aplicado naqueles com distribuição assimétrica. Resultado Após a análise dos elementos químicos, foram observados para o MTA branco: O, Na, K, Mg, Al, Si, Ca e Bi; para o MTA cinza: O, Mg, Al, Si, Ca, Bi, Fe e S, e para o Repair HP: O, Al, Mg, Si, Ca, Fe, Sr, C, Rb e W. Foram identificados 14 elementos químicos nas amostras analisadas (O, Na, Al, Mg, Si, S, K, Ca, Fe, Sr, Bi, C, Rb e W). Destes, cinco foram encontrados em todos os cimentos estudados: O, Al, Mg, Si e Ca. Conclusão Os elementos Rb, W e C foram encontrados somente na nova formulação de MTA da Angelus, o Repair HP. Nas amostras analisadas, o Ca e o O foram os que se apresentaram em maior quantidade.

[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.

Biodentine for Furcation Perforation Repair: An Animal Study with Histological, Radiographic and Micro-Computed Tomographic Assessment

Introduction:

Biodentine has been scarcely studied as a furcation perforation (FP) repair material, mostly by in vitro methodologies. This animal study aimed to compare the histological responses, radiographic, and micro-computed tomographic (micro-CT) outcomes after FP repair with Biodentine or ProRoot MTA (MTA) in dogs’ teeth.

Methods and Materials:

Fifty teeth from five dogs were divided into 4 groups: MTA (n=20, FP repaired with ProRoot MTA), BDT (n=20, FP repaired with Biodentine), PC (n=5, positive control, FP without repair) and NC (n=5, negative control, without perforation). The animals were euthanized after 4 months. Histological assessment included inflammatory cell infiltration, hard tissue resorption, hard tissue repair, and cement repair in the furcation area. Immediate postoperative and 4 months follow-up radiographs were compared for radiolucency in the furcation region. The volume of extruded material was quantified using micro-CT images.

Results:

The tested materials showed equivalent radiographic response, together with similar hard tissue resorption and repair but, BDT group showed significantly less inflammation, lower volume of extruded material and higher cement repair than MTA group.

Conclusion:

The outcomes of this study, taken together with other favorable results in literature, are highly suggestive that Biodentine is a promising biomaterial to be used for FP repair.

The Relationship of Surface Characteristics and Antimicrobial Performance of Pulp Capping Materials

INTRODUCTION

Pulp capping materials need to be able to protect the pulp but also bond to the overlying restorative materials. Light-curable pulp capping materials bond better to restorative materials and are easier to place than most water-based cements. The aim of this study was to characterize new light-curable tricalcium silicate-based pulp capping materials and compare their surface and antimicrobial properties with clinically available Theracal (Bisco, Schaumburg, IL) and Biodentine (Septodont, Saint-Maur-des-Fossés, France).

METHODS

The surface characteristics of 3 light-curable pulp capping materials based on a resin and filled with tricalcium silicate and tantalum oxide radiopacifier and Theracal and Biodentine were assessed by scanning electron microscopy, X-ray diffraction, and contact angle measurement. The radiopacity was measured following ISO 6876 standards. The antimicrobial activity was determined by the direct contact test and the antibiofilm activity by the adenosine triphosphate assay and the confocal laser scanning Live/Dead assay (Invitrogen, Eugene, OR) using a polymicrobial culture.

RESULTS

The surface characteristics of the materials varied with the unfilled resin and Biodentine exhibiting a hydrophobic surface. Biodentine showed significantly higher antimicrobial properties in the direct contact test, but this property was absent in the antibiofilm activity tests. The resins filled with tricalcium silicate and Theracal showed higher antimicrobial activity than Biodentine in the adenosine triphosphate and live/dead assays.

CONCLUSIONS

The surface characteristics of a material affect its antimicrobial properties. The experimental resin-modified materials exhibited comparable antimicrobial properties with other light-curable pulp capping agents. Further long-term studies on the materials' antimicrobial activity are required to assess whether they can result in better clinical outcomes.

Biodentine™ material characteristics and clinical applications: a 3 year literature review and update

INTRODUCTION

Biodentine™ has frequently been acknowledged in the literature as a promising material and serves as an important representative of tricalcium silicate based cements used in dentistry.

AIM

To provide an update on the physical and biological properties of Biodentine™ and to compare these properties with those of other tricalcium silicate cements namely, different variants of mineral trioxide aggregate (MTA) such as ProRoot MTA, MTA Angelus, Micro Mega MTA (MM-MTA), Retro MTA, Ortho MTA, MTA Plus, GCMTA, MTA HP and calcium enriched mixture (CEM), Endosequence and Bioaggregate™.

STUDY DESIGN

A comprehensive literature search for publications from November 20, 2013 to November 20, 2016 was performed by two independent reviewers on Medline (PubMed), Embase, Web of Science, CENTRAL (Cochrane), SIGLE, SciELO, Scopus, Lilacs and clinicaltrials.gov. Electronic and hand search was carried out to identify randomised control trials (RCTs), case control studies, case series, case reports, as well as in vitro and animal studies published in the English language.

CONCLUSIONS

The enhanced physical and biologic properties of Biodentine™ could be attributed to the presence of finer particle size, use of zirconium oxide as radiopacifier, purity of tricalcium silicate, absence of dicalcium silicate, and the addition of calcium chloride and hydrosoluble polymer. Furthermore, as Biodentine™ overcomes the major drawbacks of MTA it has great potential to revolutionise the different treatment modalities in paediatric dentistry and endodontics especially after traumatic injuries. Nevertheless, high quality long-term clinical studies are required to facilitate definitive conclusions.

Effect of iRoot Fast Set root repair material on the proliferation, migration and differentiation of human dental pulp stem cells in vitro

The present study investigated the effect of iRoot Fast Set root repair material (iRoot FS) on the proliferation, migration and differentiation of human dental pulp stem cells (hDPSCs). The hDPSCs were treated with eluates of iRoot FS at concentrations of 0.2 and 2 mg/mL, referred to as FS0.2 and FS2, respectively, and Biodentine (BD; Septodont, Saint Maur des Faussés, France) eluates at the corresponding concentrations as positive controls. A CCK8 assay was performed to determine cell proliferation. Wound healing and transwell assays were conducted to examine cell migration. Osteogenic differentiation was evaluated based on alkaline phosphatase activity, Alizarin Red S staining and quantitative real-time reverse-transcriptase polymerase chain reaction (qRT-PCR) to analyze the mRNA expression of differentiation gene markers. Cell proliferation was higher in the FS and BD groups than in the blank controls at 3 and 7 days. Moreover, FS0.2 enhanced cell migration and significantly promoted the osteogenic differentiation of hDPSCs. These findings suggested that iRoot FS is a bioactive material that promotes the proliferation, migration and osteogenic differentiation of hDPSCs.

Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part I: vital pulp therapy

Mineral trioxide aggregate (MTA) is a bioactive endodontic cement (BEC) mainly comprised of calcium and silicate elements. The cement was introduced by Torabinejad in the 1990s and has been approved by the Food and Drug Administration to be used in the United States in 1997. A number of new BECs have also been introduced to the market, including BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, NeoMTA Plus, OrthoMTA, Quick-Set, RetroMTA, Tech Biosealer and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA without its drawbacks. In this article, the chemical composition and the application of MTA and other BECs for vital pulp therapy (VPT), including indirect pulp cap, direct pulp cap, partial pulpotomy, pulpotomy and partial pulpectomy, have been reviewed and compared. Based on selected keywords, all papers regarding chemical composition and VPT applications of BECs had been reviewed. Most of the materials had calcium and silicate in their composition. Instead of referring to the cements based on their chemical compositions, we suggest the term 'bioactive endodontic cements (BECs)', which seems more appropriate for these materials because, in spite of differences in their chemical compositions, bioactivity is a common property for all of them. Numerous articles were found regarding use of BECs as VPT agents for indirect and direct pulp capping, partial pulpotomy and cervical pulpotomy. Most of these investigations used MTA for VPT. In most studies, newly introduced materials have been compared to MTA. Some of the BECs have shown promising results; however, the number of their studies compared to investigations on MTA is limited. Most studies had several methodological shortcomings. Future investigations with rigorous methods and materials are needed.

Bioactive-glass in Endodontic Therapy and Associated Microsurgery

Introduction:

Bioactive-glass (B-G) has become a valuable adjunct to promote hard-tissue healing in many clinical situations and is of particular interest for endodontic care because of its biocompatibility, regenerative and antimicrobial properties as well as chemical composition that closely resembles the mineral make-up of human bone and dentine.

Therapy:

Initial studies suggested that bacteria-tight sealing within the entire root canal system can be achieved and successfully maintained after orthograde treatment. Promising results have also been obtained in conjunction with microsurgical techniques, with the aim of enhancing wound healing and positively influencing bone regeneration.

Conclusion:

Here, relevant literature was explored to present a comprehensive review of the rationale, development, and current applications of B-G in Endodontology illustrating them with case reports.

Influence of Biodentine® - A Dentine Substitute - On Collagen Type I Synthesis in Pulp Fibroblasts In Vitro

Preserving a patient’s own teeth—even in a difficult situation—is nowadays preferable to surgical intervention and therefore promotes development of suitable dental repair materials. Biodentine^®, a mineral trioxide aggregate substitute, has been used to replace dentine in a bioactive and biocompatible manner in both the dental crown and the root. The aim of our study was to evaluate the influence of Biodentine^® on pulp fibroblasts in vitro. For this study, one to five Biodentine^® discs with a diameter of 5.1mm were incubated in DMEM. To obtain Biodentine^® suspensions the media were collected and replaced with fresh medium every 24h for 4 days. Primary pulp cells were isolated from freshly extracted wisdom teeth of 20–23 year old patients and incubated with the Biodentine^® suspensions. Proliferation, cell morphology, cell integrity and cell viability were monitored. To evaluate the effect of Biodentine^® on collagen type I synthesis, the secretion of the N-terminal domain of pro-collagen type I (P1NP) and the release of transforming growth factor-β1 (TGF-β1) were quantified. None of the Biodentine^® suspensions tested influenced cell morphology, proliferation or cell integrity. The cell viability varied slightly depending on the suspension used. However, the concentrations of P1NP of all pulp fibroblast cultures treated for 24h with the moderate to high Biodentine^® concentration containing suspensions of day 1 were reduced to 5% of the control. Furthermore, a significant TGF-β1 reduction was observed after treatment with these suspensions. It could be shown that Biodentine^® is biocompatible. However, dissolved particles of the moderate to high concentrated Biodentine^® suspensions 24h after mixing induce a significant reduction of TGF-β1 release and reduce the secretion of collagen type I of primary pulp fibroblasts.