Clinical evaluation of direct pulp capping using a calcium silicate cement—treatment outcomes over an average period of 2.3 years

Effect of light-cured pulp capping materials on human dental pulp cells in vitro

AIM

Gold standard as material in vital pulp therapy (VPT) is hydraulic calcium silicate cements (HCSC). To circumvent their prolonged setting time, light-cured pulp capping materials containing calcium silicate or calcium hydroxide powder are available. Although their positive biological properties are advertised, the data regarding the biocompatibility of light-cured pulp capping materials (LCPCM) is inconclusive. This in vitro study compared the biocompatibility of five LCPCM containing calcium silicate (TheraCal LC, ReviCal, MTA PulpCap, Pulprotec MTA) or calcium hydroxide (Calcimol LC) with that of the HCSC Biodentine.

METHODS

Of each material, 226 cylindrical specimens (51.472 mm3) were prepared and incubated in a sterile cell culture medium (alpha Modified Eagle Medium) for 24 h to obtain an extract. Human dental pulp cells (hDPC) were added to the specimens and/or extracts. Cell viability and changes in cell morphology were examined (MTT, LDH, live-dead staining, light microscope). Calcium release from the materials (Ca2+ colorimetric assay) and the mineralisation capacity of the cells (Alizarin Red S Staining, Alkaline Phosphatase Assay) were determined. Statistical analysis was performed by anova and the post-hoc Tukey test (p < 0.05).

RESULTS

Compared to Biodentine, hDPC showed significantly lower cell viability when in contact with LCPCM (p < 0.05). Further, an inhibition zone around the test bodies or an altered cell morphology was observed. Biodentine showed almost no negative effects on cell viability or cell morphology. In contact with Biodentine, hDPC mineralise with and without mineralisation induction conditions. Among the LCPCM, mineralisation was only detectable under induction conditions with ReViCal and MTA PulpCap. In addition, Biodentine released significantly more calcium ions than the LCPCM (p < 0.05).

CONCLUSION

In this in vitro study, LCPCM showed cytotoxic effects on hDPC and were hardly able to induce cell mineralisation. Biodentine showed little negative effects on cell viability, induced cell mineralisation and released more calcium than LCPCM. Biodentine is significantly superior to LCPCM in terms of biocompatibility and mineralisation induction capacity.

An explainable predictive model of direct pulp capping in carious mature permanent teeth

OBJECTIVE

To introduce a novel approach for predicting the personalized probability of success of DPC treatment in carious mature permanent teeth using explainable machine learning (ML) models.

METHODS

Clinical data were obtained from our previous single-center retrospective study, comprising 393 carious mature permanent teeth from 372 patients who underwent DPC and attended 1-year follow-up between January 2015 and February 2021. Six ML models were derived based on 80 % cases of the cohort, with the remaining 20 % cases used for validation. Shapley additive explanation (SHAP) values were utilized to assess feature importance and the clinical relevance of prediction models.

RESULTS

Within the cohort, 9.67 % (38 out of 393) of teeth experienced failure at the 1-year follow-up after DPC treatment. Among the six evaluated ML models, the XGBoost model exhibited the highest discriminative ability. By prioritizing features based on their importance, streamlined and interpretable XGBoost model with 11 features were developed for 1-year prognostication post-DPC. The model demonstrated predictive accuracy with area under the curve (AUC) scores of 0.86 for the 1-year prediction. The final model has been translated into a web application to facilitate clinical decision-making.

CONCLUSION

By incorporating demographic and clinical examination data, the XGBoost model offered a user-friendly tool for dentists to predict personalized probability of success, thereby improving personalized dental care and patient counseling. The utilization of SHAP for model interpretation provided transparent insights into the decision-making process.

Clinical and patient-level predictors of procedure and tooth survival after direct pulp capping

BACKGROUND

Historical reports of unpredictable outcomes associated with vital pulpal therapies, particularly direct pulp capping (DPC), have contributed to clinicians' skepticism of the procedure. Contemporary reports highlight more predictable outcomes of vital pulpal therapies, inclusive of DPC. There is a dearth of reported patient-centered outcomes of these procedures.

METHODS

Insurance claims were used in an observational, retrospective cohort study to evaluate outcomes of DPC performed on permanent teeth. Statistical analyses included Kaplan-Meier survival estimates and Cox proportional hazards regression. Log-rank tests were used to evaluate unadjusted differences in survival. Cox proportional hazard regression was used to evaluate the adjusted hazard of adverse event occurrence.

RESULTS

The analytic cohort included 4,136 teeth from 3,716 patients. DPC procedures were identified in public-payer (85.5%) and private-payer (13.4%) insurance claims databases. After DPC, procedure survival rate was 83% and tooth survival rate was 93% during a mean follow-up time of 52 months. Molar tooth type, same-day permanent restoration placement, and amalgam restoration type were significant positive predictors of procedure (DPC) survival. Age was not a statistically significant predictor of procedure survival after controlling for tooth type, gender, time to restoration, and restoration type. Nonmolar tooth type and younger age were significant positive predictors of tooth survival after DPC. Failures were most likely to occur within the first year.

CONCLUSIONS

DPC has favorable patient-centered outcomes and contributes to long-term tooth survival.

PRACTICAL IMPLICATIONS

The favorable patient-centered outcomes of DPC bolster calls to consider cost-effectiveness and access to care for endodontic procedures.

In-vitro-cytotoxicity of self-adhesive dental restorative materials

OBJECTIVES

Although the introduction of self-adhesive composites in restorative dentistry is very promising, the innovation of new materials also presents challenges and unknowns. Therefore, the aim of this study was to investigate the cytotoxicity of four different self-adhesive composites (SAC) in vitro and to compare them with resin-modified glass ionomer cements (RM-GIC), a more established group of materials.

METHODS

Samples of the following materials were prepared according to ISO 7405/10993-12 and eluted in cell culture medium for 24 h at 37 °C: Vertise Flow, Fusio Liquid Dentin, Constic, Surefil One, Photac Fil and Fuji II LC. Primary human pulp cells were obtained from extracted wisdom teeth and cultured for 24 h with the extracts in serial dilutions. Cell viability was evaluated by MTT assay, membrane disruption was quantified by LDH assay and apoptosis was assessed by flow cytometry after annexin/PI staining.

RESULTS

Two SAC (Constic and Vertise Flow) and one RM-GIC (Photac Fil) significantly reduced cell viability by more than 30% compared to the untreated control (p < 0.001). Disruptive cell morphological changes were observed and the cells showed signs of late apoptosis and necrosis in flow cytometry. Membrane disruption was not observed with any of the investigated materials.

CONCLUSION

Toxic effects occurred independently of the substance group and need to be considered in the development of materials with regard to clinical implications.

CLINICAL SIGNIFICANCE

SAC have many beneficial qualities, however, the cytotoxic effects of certain products should be considered when applied in close proximity to the dental pulp, as is often required.

Determining Factors in the Success of Direct Pulp Capping: A Systematic Review

AIM

To elucidate the factors that determine the success of direct pulp capping (DPC) in permanent teeth with pulp exposure due to dental caries.

MATERIALS AND METHODS

A comprehensive electronic search from 1980 to 2023 across PubMed, Scopus, and ISI Web databases was conducted using specific keywords and MeSH terms in Q1 or Q2 journals. Only prospective/retrospective clinical studies in English on 15 or more human permanent teeth with carious pulpal exposure treated with DPC agents-mineral trioxide aggregate (MTA), Biodentine, or calcium hydroxide with a rubber dam and minimum 1-year follow-up, were considered. The factors retrieved and analyzed were based on study design, patient age, sample size, type of cavity, exposure size and location, pulp diagnosis, solutions to achieve hemostasis, hemostasis time, capping material, restoration type, follow-up period, methods of evaluation, and overall success.

REVIEW RESULTS

Out of 680 articles, only 16 articles were selected for the present systematic review on application of the selection criteria. A wide age range of patients from 6 to 88 years were considered among these studies with sample sizes ranging from 15 to 245 teeth with reversible pulpitis being the predominant diagnosis of the cases. Mineral trioxide aggregate as a capping material was evaluated in 4 studies as a lone agent, while compared with other capping agents such as biodentine or calcium hydroxide in 7 studies. The follow-up period ranged from 9 days to nearly 80 months. While both clinical and radiographic evaluation was carried out in all studies, cold testing dominated the clinical tests while IOPR was the common radiograph considered. Mineral trioxide aggregate success rate was higher and similar to biodentine than calcium hydroxide.

CONCLUSION

Direct pulp capping has a high and predictable success rate in permanent teeth with carious exposure to reversible and irreversible pulpitis. Currently, mineral trioxide aggregate and biodentine have better long-term results in DPC than calcium hydroxide, hence, they should be used as an alternative to calcium hydroxide. Definitive restoration within a short period improves long-term prognosis.

CLINICAL SIGNIFICANCE

The significance of this review lies in its provision of evidence-based information on the effectiveness of DPC and the factors that influence its success. By considering these factors, clinicians can optimize treatment outcomes and improve the long-term prognosis of the treated teeth. This systematic review serves as a valuable resource for clinicians and researchers in the field of endodontics. How to cite this article: Gomez-Sosa JF, Granone-Ricella M, Rosciano-Alvarez M, et al. Determining Factors in the Success of Direct Pulp Capping: A Systematic Review. J Contemp Dent Pract 2024;25(4):392-401.

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

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

Evaluation of treatment and restoration preferences in deep carious teeth with various pulp exposure sizes: A questionnaire-based survey

This study evaluated the management preferences in a deep carious vital tooth. A questionnaire was e-mailed to members of the Turkish Dental Association. The questionnaire included a photograph and radiographs of an extremely deep carious molar (#16) of a 30-year-old man suffering from cold and chewing sensitivity. The dentists were asked to choose treatments for pulp exposure of <1, 1-2, and ≥2 mm and a permanent restoration. Chi-squared test was used to analyse data (p < 0.05). 504 (4.84%) of 10 411 dentists responded. When the pulp exposure was <1 mm: direct pulp capping (84.9%); 1-2 mm: root canal treatment (49.6%); ≥2 mm: root canal treatment (85.7%) were the most preferred treatments. 69.6% of the respondents chose direct composite restorations. If the tooth would be an abutment, most respondents preferred root canal treatment, regardless of the perforation size. The extent of pulp exposure and the type of permanent restoration influenced the treatment decision-making process.

Assessment of Decision-Making and Material Selection for Vital Pulp Therapy in Deep Carious Lesions: A Study at the Faculty of Dentistry, King Abdulaziz University

PURPOSE

The purposes of this study were to assess decision-making, material selection, and management of deep carious lesions in permanent teeth requiring vital pulp therapy (VPT); investigate the intradepartmental and interdepartmental consensus in the management of those cases; and correlate this study's results to the current scientific literature, clinical experience, and postgraduate training among staff and postgraduate students at the Faculty of Dentistry, King Abdulaziz University.

MATERIALS AND METHODS

The survey included faculty from pedodontics, endodontics, and restorative/operative dentistry; postgraduate students; and interns, excluding specific categories such as retired faculty, external trainers, non-faculty hospital specialists, general practitioners, students, interns outside the institution, and other departments. An anonymous electronic questionnaire was developed and validated. Ethical approval was obtained, and the questionnaire was distributed to all 148 English-proficient members of the targeted population via email and WhatsApp, accompanied by a cover letter. The questionnaire encompassed demographic, education, experience, assessment, decision-making, and management sections. Data were collected and analyzed using Microsoft Excel, with results presented using categorical variables, Pareto charts, and statistical tests.

RESULTS

There were 86 responses, representing 58% of the target population, with the key findings including the prominence of "Pre-operative vitality test result" as the most important factor in assessing deep carious lesions, with no significant differences among specialties. The (one-step and one-visit) management approach was preferred by 50% of participants, with no significant specialty differences. For deep carious lesions without pulpal exposure, glass ionomer (GI)/resin-modified glass ionomer (RMGI) base was the top choice, with no variation among all specialties. In cases with pulpal exposure, the one-visit approach (direct pulp capping (DPC), base, and restoration) was the most favored, with no specialty differences. Material availability significantly influenced decision-making, with no specialty variations.

CONCLUSION

The study highlights the crucial role of pre-operative vitality tests in assessing deep carious lesions for VPT or root canal treatment (RCT). Participants generally favored VPT for cases with normal pulp vitality, with some departmental variation. Controlling bleeding post-pulpal exposure was a central concern. Mineral trioxide aggregate (MTA) was the most commonly used VPT material, followed by Ca(OH)2 and Biodentine. Factors such as treatment access, patient compliance, remaining dentin thickness, and oral hygiene had minimal impact on treatment choice. Limited availability of VPT materials was the primary reason for non-use. The survey's acceptable response rate raises concerns about potential non-response bias, though limitations include a lack of data on non-responders. Nevertheless, the survey's strength lies in its comprehensive coverage of key clinical aspects, engaging professionals from diverse specialties and educational levels who are collectively interested in addressing deep caries cases.

Multivariate prognostic analysis of direct pulp capping using a bioceramic material in mature permanent teeth with carious pulp exposure: a retrospective cohort study

OBJECTIVES

On the basis of a large sample size and a long follow-up period, the objectives of this study were to evaluate the outcomes of direct pulp capping (DPC) in mature permanent teeth with carious pulp exposure using a kind of bioaggregate putty (BP) which commercially named iRoot BP Plus (Innovative Bioceramix, Inc., Vancouver, Canada) and to analyze the potential prognostic factors.

MATERIALS AND METHODS

The design of this research was retrospective regarding treatment procedures and prospective regarding the assessment of outcomes. The preoperative diagnosis of the teeth was either normal pulp or reversible pulpitis. Results were assessed based on clinical and radiographic examinations with at least 12 months of follow-up after DPC. No symptoms or signs, a positive response to electric pulp testing, a normal response to cold pulp testing and radiographs showing no abnormalities were considered to indicate success. Kaplan-Meier survival analysis was used to calculate the cumulative survival of teeth after DPC. Univariate and multivariate Cox proportional hazard regressions were used to analyze potential prognostic factors.

RESULTS

Three hundred thirty-four patients, including a total of 354 teeth, were available for the final clinical examination. The follow-up period ranged from 12 to 85 months, with an average of 27.0 ± 0.8 months. The total success rate was 85% (302/354), and the cumulative survival rates at 1, 2, 3, 4, and 5 years were 92%, 87%, 83%, 76%, and 72%, respectively. Univariate analysis indicated a significantly increased risk of failure in patients aged above 40 years and those treated by resident operators (P ≤ 0.01), with hazard ratios of 2.18 and 2.27, respectively.

CONCLUSIONS

Under appropriate indication selection and treatment procedures, long-term success is possible in mature permanent teeth with carious pulp exposure by DPC using iRoot BP Plus. Patient age and operator experience are potential prognostic factors.

CLINICAL RELEVANCE

Clinical data on iRoot BP Plus as a pulp capping medicament in mature permanent teeth with carious pulp exposure is lacking. This study indicated the efficacy of BP in DPC. Younger patient and sophisticated operator are beneficial for the outcome of DPC.

The Washout Resistance of Bioactive Root-End Filling Materials

Fast-setting bioactive cements were developed for the convenience of retrograde fillings during endodontic microsurgery. This in vitro study aimed to investigate the effect of irrigation on the washout of relatively fast-setting materials (Biodentine, EndoCem Zr, and MTA HP) in comparison with MTA Angelus White and IRM in an apicectomy model. Washout resistance was assessed using artificial root ends. A total of 150 samples (30 for each material) were tested. All samples were photographed using a microscope, and half of them were also scanned. The samples were irrigated and immersed in saline for 15 min. Then the models were evaluated. Rinsing and immersing the samples immediately after root-end filling and after 3 min did not disintegrate the fillings made of all tested materials except Biodentine. Root-end fillings made of Biodentine suffered significant damage both when rinsing was performed immediately and 3 min after the filling. Quantitative assessment of washed material resulted in a slight loss of IRM, EndoCem MTA Zr, and MTA HP. MTA Angelus White showed a slightly greater washout. Rinsing and immersion of Biodentine restorations resulted in their significant destruction. Under the conditions of the current study, the evaluated materials, excluding Biodentine, showed good or relatively good washout resistance.

In Vitro Study of the Biological and Physical Properties of Dual-Cure Resin-Modified Calcium Silicate-Based Cement

BACKGROUND

The aim of the present study was to compare the biological and mechanical properties of a novel dual-cure, resin-modified calcium silicate material, Theracal PT^® (TP), with those of Theracal LC^® (TL) and Biodentine^TM (BD).

METHODS

The cell counting kit-8 was used on human dental pulp cells to test cell the viability of the three materials. Antibacterial activity of TP, TL, and BD against Enterococcus faecalis was investigated under anaerobic conditions. The ability of the materials to support odontogenic differentiation was studied by examining the relative gene expression of osteocalcin (OCN), osteopontin (OPN), and Collagen I (ColI) using real-time polymerase chain reaction. For mechanical property tests, microhardness was evaluated using the Vickers microhardness (VHN) test, and the bond strength to the resin was evaluated using a shear bond test machine.

RESULTS

There was no significant difference in cell viability between TL and TP after 48 h, and BD showed the highest cell viability, while TP showed the highest antibacterial effect. At the 12-h time point, there was no significant difference in ColI and OCN expression between BD and TP, but TP showed a higher expression of OPN than BD. However, at the 48-h time point, ColI and OCN showed higher levels of expression for BD than for TP and TL. At the same time point, only OPN had a higher diffusion for TP than for BD. TP demonstrated a VHN of approximately 30-35. This value was higher than that of TL and lower than that of BD. In contrast to VHN, the shear bond strength to resin was significantly higher for TL and TP than for BD.

CONCLUSION

TP showed lower biocompatibility than BD but higher OPN expression and antibacterial effects than BD and TL. TP showed higher shear bond strength than BD and higher VHN than TL and BD at the 24-h time point.

Effect of full pulpotomy using a calcium silicate-based bioactive ceramic in adult permanent teeth with symptoms indicative of irreversible pulpitis: A retrospective study

BACKGROUND

The authors studied the treatment effect of full pulpotomy using a calcium silicate-based bioactive ceramic in adult permanent teeth with symptoms indicative of irreversible pulpitis.

METHODS

Eighty-one adult permanent teeth with symptoms indicative of irreversible pulpitis in 78 patients aged 18 through 72 years were evaluated for inclusion in the study. After caries excavation, the pulp was amputated to the level of the canal orifices. After hemostasis was achieved, calcium silicate-based bioactive ceramic was placed as the capping agent. The cavity was sealed temporarily with a glass ionomer cement and then restored with flowable resin and composite resin after 2 weeks if no positive symptoms were reported or detected. Postoperative evaluation was performed by means of clinical and radiographic examination at 2 weeks and 3, 6, and 12 months.

RESULTS

Overall success rates of the procedure were 96.3% (78 of 81), 93.8% (76 of 81), 92.6% (75 of 81), and 92.6% (75 of 81) at the 2-week, 3-month, 6-month, and 12-month recall visits, respectively. Six of the 81 teeth failed and required root canal therapy. In these 6 teeth, 3 exhibited severe cold stimuli pain and spontaneous pain at the 2-week follow-up, 2 had no response to electric pulp testing with apical percussion pain and periapical rarefaction at the 3-month follow-up, and 1 tooth exhibited periapical rarefaction and labial mucosal fistula at the 6-month follow-up.

CONCLUSIONS

Under the conditions of this study, full pulpotomy using a calcium silicate-based bioactive ceramic was a successful option for the treatment of adult permanent teeth with carious originated symptoms indicative of irreversible pulpitis.

PRACTICAL IMPLICATIONS

Vital pulp therapy is no longer impossible for adult permanent teeth with carious originated symptoms indicative of irreversible pulpitis.

Effect of Biodentine on Odonto/Osteogenic Differentiation of Human Dental Pulp Stem Cells

This study aims to compare the biological characteristics of human dental pulp stem cells (hDPSCs) isolated from different-aged populations and examine the effects of Biodentine on proliferation and odonto/osteogenic differentiation of hDPSCs isolated from the elderly in vitro. hDPSCs were isolated from three different-aged populations: group A (≤18 years old), group B (19−59 years old), and group C (≥60 years old). The adhesion, proliferation, odonto/osteogenesis, and senescence were compared. The optimal concentration of aqueous Biodentine extract was determined by CCK-8 assay, alkaline phosphatase (ALP), and alizarin red staining (ARS). The effect of Biodentine on odonto/osteogenic gene and protein expression of hDPSCs in each group was evaluated by quantitative real-time PCR (QRT-PCR) and Western blot. hDPSCs were successfully isolated from three different-aged populations. Flow cytometry revealed that all isolated hDPSCs were positive for CD73 (>90%), CD90 (>90%), CD146 (<30%), and negative for CD45 (<1%). There existed an age-related decline in proliferation, odonto/osteogenic gene expression, and S-phase fraction (p < 0.05), an increase in senescence genes and p21 and p16 expression, and time needed for cell adhesion. Biodentine promoted hDPSC proliferation and mineralization in each group, particularly at a concentration of 0.2 mg/mL. Biodentine markedly enhanced odonto/osteogenesis-related gene and protein expression in each group (p < 0.05). hDPSCs can be obtained from populations of all ages. Though there is an age-related decline in their biological properties, hDPSCs from the elderly still maintain certain proliferation and multidirectional differentiation abilities. Biodentine can significantly promote the proliferation and odonto/osteogenic differentiation of hDPSCs isolated from the elderly over 60 years old, which could be considered a pulp capping material for vital pulp therapy in the elderly. Nevertheless, the efficacy of Biodentine in clinical application has to be further studied.

The Understanding of Vital Pulp Therapy in Permanent Teeth: A New Perspective

The indications of vital pulp therapy (VPT) are expanding, which cases are suitable for VPT, and how to improve the success rate of VPT is a problem that often bothers us. The main purpose of VPT is to eliminate pulpitis by promoting the formation of reparative dentin or calcium bridge, so that it can continue to perform various physiological functions, and finally achieve the purpose of preserving pulp vitality and long-term preservation of affected teeth. Pulp capping and pulpotomy are the most common methods for VPT. The research field of VPT has attracted the attention of many scholars, who have studied it from many aspects (such as indications, material selection, operation requirements, and long-term prognosis). This article reviews the recent advances in the techniques of VPT in permanent teeth.

Highly Targeted Electrochemical Disruption of Microbes with Minimal Disruption to Pulp Cells

INTRODUCTION

Pulpitis results from the infiltration of mixed populations of bacteria which trigger inflammation in the dental pulp, causing significant disruption to these tissues. Clinically, pulpitis frequently leads to devitalization or extraction, as disinfection of the dental pulp while maintaining its vitality is extremely difficult. Here we describe the use of an electrocatalytic titanium dioxide (TiO₂)-based apparatus adapted from water purification technology, which can efficiently deliver anti-microbial oxidants (e.g., hydroxyl radicals) when low voltages are applied. As these oxidants are also potentially harmful to pulp cells, oxidant exposure protocols that disrupt oral bacteria, yet are innocuous to dental pulp cells must be established.

METHODS

Stem cells from Human Exfoliated Deciduous teeth (SHEDs) and mixed salivary bacteria were exposed to apparatus generated oxidants for time points of 15, 100 or 300 seconds. SHED apoptosis, necrosis, and vitality post exposure were analyzed by florescent marker staining and flow cytometry. Destruction of mixed salivary bacteria was analyzed by post exposure counts of adherent bacterial cells.

RESULTS

When applied to SHEDs the apparatus generated oxidants do not significantly induce apoptosis or necrosis at any exposure time. SHED cell vitality is not decreased with apparatus exposure. Exposure to apparatus generated oxidants destroys mixed salivary bacteria, with significant destruction seen at 15 seconds and maximal destruction achieved at 100 seconds.

CONCLUSIONS

This technology has the potential to be useful in the disinfection of deep lesions and pulp tissues, efficiently producing oxidants which eliminate bacteria but do not harm native pulp cells after relatively brief exposures.

CLINICAL SIGNIFICANCE

Incomplete disinfection of inflamed dental pulp is a significant cause of pulp destruction, leading to devitalization or extraction. Novel technology which enhances the disinfection of the pulp may provide clinicians with treatments options that preserve pulp vitality and tooth structure.

A prospective clinical study investigating the effectiveness of partial pulpotomy after relating preoperative symptoms to a new and established classification of pulpitis

AIM

To prospectively investigate the outcome of partial pulpotomy after 1 year, using a hydraulic calcium silicate cement (HCSC) on symptomatic cariously exposed pulps in adult teeth. To compare the traditional American Association of Endodontists (AAE) pulpitis classification with the recently proposed Wolters classification system in predicting the likelihood of treatment failure.

METHODOLOGY

Sixty-two symptomatic adult teeth with deep and extremely deep carious lesions were classified according to the Wolters (mild/moderate/severe pulpitis) and the traditional pulpitis classification (reversible/irreversible pulpitis). Eleven teeth were excluded intraoperatively as there was no pulp exposure after non-selective caries removal. The remaining 51 teeth, regardless of diagnosis, were treated by partial pulpotomy, pulpal lavage with 2.5% sodium hypochlorite solution, haemostasis and HCSC application (Biodentine™) as a pulp capping material. A permanent restoration was placed during a second appointment 1-2 weeks later. Preoperative tenderness to percussion (TTP), bleeding time and material setting time were recorded as was preoperative and postoperative tooth colour under standardized conditions. Clinical review occurred at regular intervals with clinical/radiographic analysis at 12 months. Chi-square analysis and Fisher's exact test assessed different outcomes amongst the diagnostic categories; the Kruskal-Wallis and Wilcoxon rank-sum test assessed influence of pulp bleeding time, TTP or variation in setting time (p < .05).

RESULTS

Ten cases were lost to review, and a total of 41 teeth were reviewed at 1 year and classified as either "success," "successful but unresponsive to sensibility testing" or "failed." This included five severe, 17 moderate and 19 mild pulpitis according to Wolters classification or 23 reversible pulpitis and 18 irreversible pulpitis cases by the AAE classification. The majority of the 62 enrolled cases were "extremely deep" (n = 50), rather than "deep" (n = 12) caries with all failures occurring in the extremely deep group. Partial pulpotomy was 90% successful (100% reversible, 78% irreversible or 100% mild, 88% moderate, 60% severe pulpitis) with a significant difference in outcome between mild and severe pulpitis groups (p = .04). Only one, severe pulpitis/irreversible pulpitis, case failed painfully prior to the 1-year review appointment. Bleeding time (p = .26) and TTP (p = .61) did not influence treatment outcome, whilst Biodentine™ setting time was significantly longer than manufacturers' claim (p < .05). No teeth discoloured.

CONCLUSIONS

Partial pulpotomy using Biodentine™ was successful for treating symptomatic carious pulpal exposures after 1 year, but included cases where pulp vitality could not be confirmed. Within the limitations of this study, cases with signs and symptoms indicative of irreversible pulpitis were not less successful; however, Wolters classification highlighted severe pulpitis to be less successful than mild pulpitis, thereby providing a potential prognostic benefit in diagnostically subdividing pulpitis. Caries depth was an indicator of failure, whilst bleeding time and preoperative tenderness to percussion were not.

Partial Pulpotomy to Successfully Treat a Caries-Induced Pulpal Micro-Abscess: A Case Report

Vital pulp treatment (VPT) is a therapeutic strategy aimed at conservatively managing deep carious lesions and the exposed pulp. VPT has recently expanded through the use of hydraulic-calcium-silicate cement (HCSC), cone-beam CT, and dental operating microscopy (DOM), as well as an improved understanding of pulpal repair mechanisms. Consensus documents have concluded that non-selective removal of caries is not necessary in the absence of clinical symptoms, as partial or non-selective caries removal techniques reduce the likelihood of pulp exposure. Alternatively, others suggest that leaving carious tissue may help sustain pulpal inflammation and lead to failure of VPT. The presence of a purulent discharge from the exposed pulp is considered indicative of an irreversible damage and a need for pulpectomy. This report documents the successful VPT in a symptomatic molar with deep caries that exhibited purulent discharge from the pulp after exposure. A female patient presented with spontaneous pain in the maxillary left second molar. One year before, she had received a cast-metal restoration over a resin-based-composite (RBC) restoration. The tooth had been largely asymptomatic since; however, after experiencing spontaneous pain, she consulted the hospital clinic. Radiographs indicated that the restoration was not deep with visible dentin between the restoration and the pulp. Pulp sensibility tests yielded a positive response. There was no pain on percussion and no periodontal problems. Removal of the restoration and carious dentin using a DOM resulted in a pulpal exposure with purulent discharge and bleeding. A partial pulpotomy using HCSC was performed. Six months later, the clinical symptoms had completely resolved; however, due to concerns of partial necrosis, the patient was re-assessed. DOM examination revealed an incomplete hard-tissue barrier; moreover, there were also signs of residual tissue with inflammation. As a result, the defected area was enlarged, the pulp tissue debrided, and the HCSC reapplied. After review at 1 year, the tooth remains symptomless, with no apical radiolucency. Notably, this report visually illustrates that exposed pulp tissue containing limited region pus can maintain vitality after VPT. This finding raises two questions: (1) whether leaving infected dentin in situ and avoiding visualization of the pulp exposure is appropriate; and (2) whether the presence of purulent tissue in the pulp warrants a pulpectomy.

Nanoparticles of Bioactive Glass Enhance Biodentine Bioactivity on Dental Pulp Stem Cells

This study aimed to investigate the cytotoxicity and bioactivity of a novel nanocomposite containing nanoparticles of bioactive glass (nBGs) on human dental pulp stem cells (hDPSCs). nBGs were synthesized by the sol–gel method. Biodentine (BD) nanocomposites (nBG/BD) were prepared with 2 and 5% wt of nBG content; unmodified BD and glass ionomer cement were used as references. Cell viability and attachment were evaluated after 3, 7 and 14 days. Odontogenic differentiation was assessed with alkaline phosphatase (ALP) activity after 7 and 14 days of exposure. Cells successfully adhered and proliferated on nBG/BD nanocomposites, cell viability of nanocomposites was comparable with unmodified BD and higher than GIC. nBG/BD nanocomposites were, particularly, more active to promote odontogenic differentiation, expressed as higher ALP activity of hDPSCs after 7 days of exposure, than neat BD or GIC. This novel nanocomposite biomaterial, nBG/BD, allowed hDPSC attachment and proliferation and increased the expression of ALP, upregulated in mineral-producing cells. These findings open opportunities to use nBG/BD in vital pulp therapies.

Physico-Chemical Investigation of Endodontic Sealers Exposed to Simulated Intracanal Heat Application: Hydraulic Calcium Silicate-Based Sealers

The aim of this study was to gain information about the effect of thermal treatment of calcium silicate-based sealers. BioRoot RCS (BR), Total Fill BC Sealer (TFBC), and Total Fill BC Sealer HiFlow (TFHF) were exposed to thermal treatment at 37 °C, 47 °C, 57 °C, 67 °C, 77 °C, 87 °C and 97 °C for 30 s. Heat treatment at 97 °C was performed for 60 and 180 s to simulate inappropriate application of warm obturation techniques. Thereafter, specimens were cooled to 37 °C and physical properties (setting time/flow/film thickness according to ISO 6876) were evaluated. Chemical properties (Fourier-transform infrared spectroscopy) were assessed after incubation of the specimens in an incubator at 37 °C and 100% humidity for 8 weeks. Statistical analysis of physical properties was performed using the Kruskal-Wallis-Test (P = 0.05). The setting time, flow, and film thickness of TFBC and TFHF were not relevantly influenced by thermal treatment. Setting time of BR decreased slightly when temperature of heat application increased from 37 °C to 77 °C (P < 0.05). Further heat treatment of BR above 77 °C led to an immediate setting. FT-IR spectroscopy did not reveal any chemical changes for either sealers. Thermal treatment did not lead to any substantial chemical changes at all temperature levels, while physical properties of BR were compromised by heating. TFBC and TFHF can be considered suitable for warm obturation techniques.

Effect of Photobiomodulation Therapy following Direct Pulp Capping on Postoperative Sensitivity by Thermal Stimulus: A Retrospective Study

OBJECTIVE

The aim of this study was to investigate the effect of photobiomodulation therapy (PBMT) on postoperative pain provoked by thermal stimulation in direct pulp capping (DPC).

SUBJECTS AND METHODS

A retrospective study was performed using the records of patients who received DPC using mineral trioxide aggregate. Teeth irradiated with a laser were assigned as the PBMT group, and nonirradiated teeth were considered as the control group. Before treatment and 6 h, 1 day, and 7 days after treatment, tooth sensitivity to a cold stimulus was recorded using a visual analog scale.

RESULTS

From a total of 123 documented DPC procedures, only 72 directly capped permanent teeth met the inclusion criteria. Age, gender, and tooth location were comparable between the groups. A statistically significant difference was found in sensitivity to cold stimulus between groups on day 7 (p = 0.007), but no difference was found at the preoperative, 6 h, and day 1 time points (p = 0.055, p = 0.132, and p = 0.100, respectively). In the intragroup evaluation, a significantly greater decrease in sensitivity to cold stimulus was detected in the PBMT group than that in the control group, although both groups showed a reduction in discomfort throughout the follow-up period (p = 0.000).

CONCLUSION

PBMT is an effective method for enhancing patient comfort by reducing thermal sensitivity following DPC procedures.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

The Effect of Biodentine Maturation Time on Resin Bond Strength When Aged in Artificial Saliva

Biodentine is a calcium silicate cement (CSC) that has been broadly applied in vital pulp therapy. The quality of the Biodentine-composite bond has a significant effect on the longevity of the definitive restoration. The aim of this study is to investigate the shear bond strength (SBS) between Biodentine and composite restoration at different maturation times of Biodentine aged in artificial saliva. Fifteen Biodentine discs were allocated into three groups (n = 5) based on the timeframe of performance of composite restoration: immediate (after 12  min), after 14 days, and after 28 days of Biodentine maturation. Total etch and rinse adhesive system and bulk-fill regular resin composite were used. The shear bond strength and the failure pattern were assessed. One-way ANOVA with the Bonferroni post hoc test was applied for statistical analysis at p < 0.05. The highest (32.47 ± 8.18 MPa) and the lowest (4.08 ± 0.81 MPa) SBS values were recorded for 14 days and 12 min groups, respectively. Significant statistical differences were reported among the groups, and a high statistically significant difference was found between the immediate group and the other groups. Adhesive failure patterns were evident in all groups. More clinically acceptable bond strength between the Biodentine and overlaid composite restoration is at 14 days after Biodentine maturation. Delaying the coverage of Biodentine later than 14 days may significantly reduce the SBS. Using the artificial saliva as an aging medium may affect the SBS between Biodentine and composite material.