Apexogenesis treatment with a new endodontic cement: a case report

Management and Follow-Up of Complicated Crown Fractures with Intrusive Luxation of Maxillary Incisors in an 8-Year-Old Boy

Intrusive luxation is a severe form of dental injury which causes damage to the pulp and supporting structures of a tooth because of its dislocation into the alveolar process. This paper shows the case of the reeruption of maxillary incisors accompanied by complicated crown fractures after 3 months. An 8-year-old boy patient was referred to the Department of Pedodontic Dentistry of Tehran University of Medical Science, Tehran, Iran, 18 hours after a fall at school. Clinical and radiographic examinations revealed intrusive luxation of both incisors with complicated crown fractures. Cervical pulpotomy is the treatment of choice for traumatized immature intruded teeth with pulp exposure. Two months later, the right central incisor teeth reerupted to a normal position and the final aesthetic restorations were done. The left central incisor was spontaneously repositioned with external root resorption, and the team decided to use interim medication (calcium hydroxide) in the root canal for stopping the process of resorption, and by the 9-month follow-up, the process of resorption had been stopped. An MTA plug was placed into the canal, and the final esthetic restorations were done.

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.

In Vitro Sealing Properties of Calcium-Enriched Mixture and Mineral Trioxide Aggregate Orifice Barriers during Intra-Coronal Bleaching

Introduction:

This study aimed at evaluating the sealing properties of calcium-enriched mixture (CEM) compared to mineral trioxide aggregate (MTA) as a cervical barriers in intra-coronal bleaching.

Methods and Materials:

In this in vitro study, endodontic treatment was performed on 60 extracted human incisors and canines without canal calcification, caries, restorations, resorption or cracks. The teeth were then randomly divided into two experimental groups and two control groups (n=15). Then, CEM cement and MTA were applied as 3-mm intra-orifice barriers in the test groups; a mixture of sodium perborate and 30% hydrogen peroxide bleaching agents were placed within the pulp chamber for one week. Dye penetration method was used to evaluate the sealing ability of agents. Statistical analysis was performed using SPSS software. The Kendall coefficient was used to evaluate inter-observer agreement. The chi-squared test was used for statistical analysis.

Results:

The results showed that the penetration rates of CEM and MTA were the same as positive control group, with no significant differences (P=0.673 and P=0.408, respectively). However, there was a significant difference between the negative control group and CEM and MTA groups (P=0.001 for both groups). In addition, the sealing ability of MTA and CEM cement were not significantly different (P=0.682).

Conclusion:

During intra-coronal bleaching procedures CEM cement can be used as a cervical barrier with sealing properties comparable to that of MTA.

Coronal microleakage of three different dental biomaterials as intra-orifice barrier during nonvital bleaching

Background:

This study was designed to assess the microleakage of glass-ionomer (GI), mineral trioxide aggregate (MTA), and calcium-enriched mixture (CEM) cement as coronal orifice barrier during walking bleaching.

Materials and Methods:

In this experimental study, endodontic treatment was done for 70 extracted human incisors without canal calcification, caries, restoration, resorption, or cracks. The teeth were then divided into three experimental using “Simple randomization allocation” (n = 20) and two control groups (n = 5). The three cements were applied as 3-mm intra-orifice barrier in test groups, and bleaching process was then conducted using a mixture of sodium perborate powder and distilled water, for 9 days. For leakage evaluation, bovine serum albumin marker was traced in a dual-chamber technique with Bradford indicator. The Kruskal-Wallis and Mann-Whitney tests were used for statistical analysis.

Results:

The mean ± standard deviation leakage of samples from negative control, positive control, GI, MTA, and CEM cement groups were 0.0, 8.9 ± 0.03, 0.47 ± 0.02, 0.48 ± 0.02, and 0.49 ± 0.02 mg/mL, respectively. Statistical analysis showed no significant difference between three experimental groups (P > 0.05).

Conclusion:

It is concluded that GI, MTA, and CEM cements are considered as suitable intra-orifice barrier to provide coronal seal during walking bleaching.

Coronal Discoloration Induced by Calcium-Enriched Mixture, Mineral Trioxide Aggregate and Calcium Hydroxide: A Spectrophotometric Analysis

Introduction:

The aim of this study was to compare the discoloration potential of calcium-enriched mixture (CEM) cement, white mineral trioxide aggregate (WMTA) and calcium hydroxide (CH), after placement in pulp chamber.

Methods and Materials:

Access cavities were prepared in 40 intact maxillary central incisors. Then, a 2×2 mm box was prepared on the middle third of the inner surface on the buccal wall of the access cavity. The specimens were randomly assigned into four groups; the boxes in the control group were left empty, in groups 1 to 3, the boxes were filled with CH, WMTA and CEM cement, respectively. The access cavities and the apical openings were sealed using resin modified glass ionomer (RMGI). The color measurement was performed with a spectrophotometer at the following intervals: before (T0), immediately after placement of the filling material (T1), one week (T2), 1 month (T3), 3 months (T4) and 5 months (T5) after filling of the box and finally immediately after removing the material from the boxes (T6). Color change (ΔE) values were calculated using the sample Kolmogorov-Smirnov test to determine the normal distribution of data, followed by ANOVA, repeated measured ANOVA and post-hoc Tukey’s tests.

Results:

All materials led to clinically perceptible crown discoloration after 1 week. The highest ΔE value belonged to WMTA group. Discoloration induced by CEM cement was not significantly different from CH or the control group (P>0.05).

Conclusion:

CEM cement may be the material of choice in the esthetic region, specifically pertaining to its lower color changing potential compared to WMTA.

Calcium silicate-based cements: composition, properties, and clinical applications

Mineral trioxide aggregate (MTA) is a calcium silicate-based cement (CSC) commonly used in endodontic procedures involving pulpal regeneration and hard tissue repair, such as pulp capping, pulpotomy, apexogenesis, apexification, perforation repair, and root-end filling. Despite the superior laboratory and clinical performance of MTA in comparison with previous endodontic repair cements, such as Ca(OH)₂ , MTA has poor handling properties and a long setting time. New CSC have been commercially launched and marketed to overcome the limitations of MTA. The aim of the present review was to explore the available literature on new CSC products, and to give evidence-based recommendations for the clinical use of these materials. Within the limitations of the available data in the literature regarding the properties and performance of the new CSC, the newer products could be promising alternatives to MTA; however, further research is required to support this assumption.

The Effect of Thickness on the Sealing Ability of CEM Cement as a Root-end Filling Material

Background and aims. Different materials have been used for root-end filling during surgical endodontic treatment. The aim of this in vitro study was to evaluate the dye penetration in different thicknesses of calcium enriched mixture (CEM) cement as root-end filling material. Materials and methods. Following root canal filling in 70 extracted human single-rooted premolar teeth, the apical 3 mm of their root-ends was resected; the root-end cavities with depths of 1, 2 and 3 mm were prepared by ultrasonic retrotips and filled with CEM cement. After setting of cement, the roots were immersed in 2% Rhodamine B and the dye leakage was measured under stereomicroscope (×16) using Image J software. The data were analyzed by one-way ANOVA and Bonferroni post hoc tests at 5% significance level. Results. The means and standard deviations of dye penetration in the 1, 2, and 3 mm groups were 3395.5±1893.4, 3410.4±1440.5, and 2581.6±1852.9 μm, respectively. The one-way ANOVA analysis indicated significant differences (P < 0.001); however, the Bonferroni post hoc test revealed that only the positive control group differed significantly from the experimental groups (P < 0.001). Conclusion. The findings demonstrated CEM cement to have an adequate root-end sealing ability in 3-mm thickness.

Effect of calcium chloride on physical properties of calcium-enriched mixture cement

The aim of this study was to evaluate the effect of adding 10% calcium chloride (CaCl2) on the setting time, solubility and the pH of calcium-enriched mixture (CEM) cement. Setting time was assessed in accordance with American Dental Association specification N°57. Solubility was measured at 24 and 72 h, 7 and 14 days in hydrated and dehydrated conditions by calculating weight change. The pH of MiliQ water in which the CEM cement samples were immersed was measured immediately after each time interval with and without the addition of CaCl2. The data were analysed using the Mann-Whitney U-test and the Student's t-test. The initial setting time was significantly decreased after the addition of 10% CaCl2. The pH of water increased immediately when in contact with the cements in both groups. The weight loss of hydrated and dehydrated specimens was more than 3% and was significantly reduced by the addition of 10% CaCl2.

Comparison of pH changes induced by calcium enriched mixture and those of calcium hydroxide in simulated root resorption defects

INTRODUCTION

External resorption usually occurs after dental trauma and the loss of root cementum. Because it has the ability to induce alkaline pH, calcium hydroxide is used in treatment of external resorption, which is reportedly not free from disadvantages. Driven by such understanding, the aim of this in vitro study was to compare the pH changes induced by calcium enriched mixture (CEM) and those of calcium hydroxide in simulated root resorption defects.

METHODS

Twenty-one paired extracted human premolars were cut to the length of 14 mm. Root canal preparation was performed by using ProTaper rotary system. Cavities of 0.7-mm depth and 1.4-mm diameter were prepared on the external root surface, 5 mm from the apex. Half of the teeth were filled with CEM and the other half with calcium hydroxide. Five premolars were also assigned as the negative control group and filled with normal saline. To be assured of the filling quality, a radiograph was obtained from each tooth. Subsequently, pH of the cavity was measured with a microelectrode at 20-minute, 3-hour, and 1-, 7-, 14-, 21-, and 28-day intervals after filling.

RESULTS

Mean pH in the CEM and in the calcium hydroxide groups were significantly varied during the study period, with pH of the calcium hydroxide group significantly higher than that of CEM in all of the measurements. However, no significant difference was observed between the pH of the calcium hydroxide group and that of the control group at the 7-day and 14-day measurements and between those of the CEM group and the control group at days 7, 21, and 28.

CONCLUSIONS

In comparison with calcium hydroxide, CEM hardly maintained alkaline pH during the first month of use, and so CEM may be an inappropriate material in treatment of external root resorption.

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

Advancements in bio-ceramic technology has revolutionised endodontic material science by enhancing the treatment outcome for patients. This class of dental materials conciliates excellent biocompatibility with high osseoconductivity that render them ideal for endodontic care. Few recently introduced bio-ceramic materials have shown considerable clinical success over their early generations in terms of good handling characteristics. Calcium enriched mixture (CEM) cement, Endosequence sealer, and root repair materials, Biodentine and BioAggregate are the new classes of bio-ceramic materials. The aim of this literature review is to present investigations regarding properties and applications of CEM cement in endodontics. A review of the existing literature was performed by using electronic and hand searching methods for CEM cement from January 2006 to December 2013. CEM cement has a different chemical composition from that of mineral trioxide aggregate (MTA) but has similar clinical applications. It combines the biocompatibility of MTA with more efficient characteristics, such as significantly shorter setting time, good handling characteristics, no staining of tooth and effective seal against bacterial leakage.

Adult stem cell-based apexogenesis

Generally, the dental pulp needs to be removed when it is infected, and root canal therapy (RCT) is usually required in which infected dental pulp is replaced with inorganic materials (paste and gutta percha). This treatment approach ultimately brings about a dead tooth. However, pulp vitality is extremely important to the tooth itself, since it provides nutrition and acts as a biosensor to detect the potential pathogenic stimuli. Despite the reported clinical success rate, RCT-treated teeth are destined to be devitalized, brittle and susceptible to postoperative fracture. Recently, the advances and achievements in the field of stem cell biology and regenerative medicine have inspired novel biological approaches to apexogenesis in young patients suffering from pulpitis or periapical periodontitis. This review mainly focuses on the benchtop and clinical regeneration of root apex mediated by adult stem cells. Moreover, current strategies for infected pulp therapy are also discussed here.

Comparison of skin test reactivity of two endodontic biomaterials in rabbits

In this in vivo study, the skin reactivity of rabbits to Mineral Trioxide Aggregate (MTA) and Calcium Enriched Mixture (CEM) was compared. Sixteen albino rabbits were used. The dorsal skin in three areas (2 x 2 cm) of the rabbits was shaved 24 h prior to the test. The areas were randomly covered with freshly mixed biomaterials [MTA (n = 16), CEM (n = 16) and normal saline (control; n = 16)], sterile gauze and bandages were placed for 4 h and the biomaterials were washed. The surface areas of the reactive skin sections were examined by naked eye and measured in 1, 24, 48 and 72 h using the Cavalier technique. The animals were then sacrificed and histological sections were prepared for blind examination. Results of macroscopic examination revealed a significant difference (p = 0.003) between the average erythematous surface areas induced by MTA (1.61 +/- 0.32) and CEM (0.5 +/- 0.16). Results of histological examination showed that the highest inflammation was observed in MTA, followed by CEM and control groups. Comparison of the difference in inflammatory cell count between each group revealed statistically significant differences in all cases (p < 0.001). The results demonstrated that the biocompatibility of CEM cement is higher than MTA; CEM can be considered as a suitable endodontic biomaterial.

A preliminary report on histological outcome of pulpotomy with endodontic biomaterials vs calcium hydroxide

Objectives

The purpose of the study was to evaluate human dental pulp response to pulpotomy with calcium hydroxide (CH), mineral trioxide aggregate (MTA), and calcium enriched mixture (CEM) cement.

Materials and Methods

A total of nine erupted third molars were randomly assigned to each pulpotomy group. The same clinician performed full pulpotomies and coronal restorations. The patients were followed clinically for six months; the teeth were then extracted and prepared for histological assessments. The samples were blindly assessed by an independent observer for pulp vitality, pulp inflammation, and calcified bridge formation.

Results

All patients were free of clinical signs/symptoms of pulpal/periradicular diseases during the follow up period. In CH group, one tooth had necrotic radicular pulp; other two teeth in this group had vital uninflamed pulps with complete dentinal bridge formation. In CEM cement and MTA groups all teeth had vital uninflamed radicular pulps. A complete dentinal bridge was formed beneath CEM cement and MTA in all roots. Odontoblast-like cells were present beneath CEM cement and MTA in all samples.

Conclusions

This study revealed that CEM cement and MTA were reliable endodontic biomaterials in full pulpotomy treatment. In contrast, the human dental pulp response to CH might be unpredictable.

Bond strength of composite resin to pulp capping biomaterials after application of three different bonding systems

Background and aims. Bonding of composite resin filling materials to pulp protecting agents produces an adhesive joint which is important for the quality of filling as well as success of restoration. We aimed to assess the bond strength of composite resin to three pulp capping biomaterials: Pro Root mineral trioxide aggregate (PMTA), Root MTA (RMTA) and calcium enriched mixture (CEM) cement, using three bonding systems [a total-etch (Single Bond) and two self-etch systems (Protect bond and SE Bond)].

Materials and methods. Ninety acrylic molds, each containing a 6×2-mm hole, were divided into 3 groups and filled with PMTA, RMTA and CEM cements. The samples in each experimental group were then randomly divided into 3 sub-groups; Single Bond, Protect Bond and SE Bond bonding systems were applied to the tested materials. Cylindrical forms of composite resin (Z100, 2×2 mm) were placed onto the samples and cured. Shear bond strength values were measured for 9 subgroups using a universal testing machine. Data were analyzed using two-way ANOVA.

Results. The average shear bond strengths of Z100 composite resin after application of Single Bond, Protect Bond and SE Bond systems were as follows; PMTA: 5.1±2.42, 4.56±1.96 and 4.52±1.7; RMTA: 4.71±1.77, 4.31±0.56 and 4.79±1.88; and CEM cement: 4.75±1.1, 4.54±1.59 and 4.64±1.78 MPa, respectively. The type of pulp capping material, bonding system and their interacting effects did not have a significant effect on the bond strengths of composite resin to pulp capping biomaterials.

Conclusion. Within the limitations of this in vitrostudy, bond strength of composite resin to two types of MTA as well as CEM cement were similar following application of the total-etch or self-etch bonding systems.

Vital pulp therapy with three different pulpotomy agents in immature molars: a case report

INTRODUCTION

This case report describes apexogenesis treatment of three molar teeth of an 8-year-old boy using three different pulpotomy agents.

METHODS

Pulpotomy was performed on decayed immature molar teeth with established irreversible pulpitis and the remaining pulp was capped with either zinc oxide eugenol, ProRoot mineral trioxide aggregate or calcium-enriched mixture (CEM) cement. Teeth were restored with stainless steel crowns.

RESULTS

Eighteen months clinical and radiographic follow-up revealed successful preservation of pulpal vitality with continued root development in all treated teeth.

CONCLUSION

Based on this case report, CEM cement may be an alternative option for pulpotomy treatment of immature permanent molars.

Root-end filling with cement-based materials: An in vitro analysis of bacterial and dye microleakage

Background:

One ideal property of a root-end filling material is its apical sealing ability. The aim of this in vitro study was to assess bacterial and dye microleakage of white and gray mineral trioxide aggregate (WMTA and GMTA), Portland cement and calcium-enriched mixture (CEM) cement used as root-end filling material, and to assess the agreement between these two test methods.

Materials and Methods:

Fifty-four single-rooted teeth were used. The roots were randomly divided into four study and two control groups. After decoronation, root canals were instrumented and filled with gutta-percha and AH26 sealer. Root-ends were resected 3 mm above the root-end and 3 mm deep cavities were prepared. Root-end cavities were filled with each material. Enterococcus faecalis and methylene blue dye were used for determination of bacterial and dye leakage respectively. Data were analyzed using Fisher's Exact Test, one-way ANOVA, Kaplan-Meier analysis, and Cohen's Kappa.

Results:

There was 100% bacterial leakage in Portland cement and CEM cement, 58.3% in GMTA, and 91.7% in WMTA. GMTA showed significantly less bacterial leakage than Portland cement and CEM cement (P < 0.05). In those samples with leakage occurrence, times of observation of leakage were not significantly different; however, by survival analysis, the results of the GMTA group were significantly different from those of the CEM cement and Portland groups. The difference in complete dye leakage was not significant. There was poor agreement between dye and bacterial leakage methods.

Conclusion:

CEM cement provides leakage results comparable to other commonly used root-end filling materials such as WMTA.

Vital pulp therapy using calcium-enriched mixture: An evidence-based review

Worldwide, casecontrol studies have revealed that the treatment outcomes of root canal therapy (RCT) are generally favorable; however, the overall epidemiological success rate of RCT in the general population is relatively low. On the other hand, vitality of dental pulp is a key factor in the long-term prognosis of permanent teeth; in recent years, vital pulp therapy (VPT) has received significant consideration as it has been revealed that the inflamed pulp has the potential to heal. In this review article, the current best evidence with regard to VPT using calcium-enriched mixture (CEM) cement in human permanent/primary teeth is discussed. A strategy based on a search using keywords for CEM cement as well as VPT was applied.

Indirect pulp therapy in a symptomatic mature molar using calcium enriched mixture cement

Dental pulp has the ability of repair/regeneration. Indirect pulp therapy (IPT) is recommended for pulp preservation in asymptomatic teeth with extremely deep caries as well as teeth with clinical symptoms of reversible pulpitis. In this case study, we performed IPT with calcium enriched mixture (CEM) cement on a symptomatic permanent molar. After clinical/radiographic examinations the tooth was diagnosed with irreversible pulpitis and associated apical periodontitis. IPT involved partial caries removal, the placement of CEM cement pulp cap and overlying adhesive permanent restoration. At the 1 week follow-up, patient's spontaneous symptoms had resolved. One-year follow-up demonstrated pulp vitality, clinical function, as well as the absence of pain/tenderness to percussion/palpation/cold sensitivity tests; periapical radiograph showed a healing periradicular lesion with newly formed bone, that is normal pulp with normal periodontium. These favorable results indicate that IPT/CEM may be a good treatment option in comparison to endodontic treatment in young patients. IPT of deep-caries lesion is an easier, more practical and valuable treatment plan than complete caries removal.

Healing of a tooth with an overinstrumented apex, extensive transportation and periapical lesion using a 5 mm calcium hydroxide apical plug: an 8-year follow-up report

Besides the risk of filling material extrusion throughout the apex, a satisfactory apical seal can be difficult to achieve in canals with open apices or iatrogenic enlargements of the apical constriction. These situations pose a challenge to root canal filling. This paper describes the root canal filling of a maxillary right canine with an overinstrumented apex, complete loss of the apical stop, extensive canal transportation and apical periodontitis. A 5 mm calcium hydroxide apical plug was placed before root canal filling. The plug was made by soaking paper points with saline, dipping the points in calcium hydroxide powder and then applying it to the apex several times, until a consistent apical plug was obtained. The canal was then irrigated with saline in order to remove any residual calcium hydroxide from the root canal walls, dried with paper points and obturated with an inverted #80 gutta-percha cone and zinc oxide-eugenol based sealer by the lateral condensation technique. An 8-year radiographic follow-up showed formation of mineralized tissue sealing the apical foramen, apical remodeling and no signs of apical periodontitis.

Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial

OBJECTIVE

To compare clinical and radiographic outcomes of pulpotomy treatment using calcium-enriched mixture (CEM) cement and mineral trioxide aggregate (MTA) in carious-exposed vital immature permanent first molars.

DESIGN

Fifty-one immature molars with clinical carious exposure with symptomatic/asymptomatic pulpitis met the inclusion criteria and randomly assigned to one of the treatment groups (CEM [26 teeth; 59 roots], MTA [25 teeth; 59 roots]). After performing pulpotomy and covering the radicular pulps with the biomaterials, all teeth were permanently restored. Blinded clinical and radiographic evaluations were performed at 6 and 12 months after operation for signs of success or failure. Radiographs were evaluated for complete/partial apical closure. The data were analysed using chi-square test and generalized estimating equation (GEE) model.

RESULTS

There was no significant difference at the baseline between the two experimental groups. All available cases (49 teeth) showed pulp survival and signs of continuous root development after 12 months. Overall, complete apical closure (apexogenesis) occurred in 76.8% and 73.8% of radiographically interpreted roots in CEM cement and MTA groups, respectively. There was no statistical difference in terms of radiographic outcomes between two groups.

CONCLUSIONS

Calcium-enriched mixture cement and MTA showed similar performance in pulpotomy of immature caries-exposed permanent molars.

Treatment outcomes of pulpotomy in permanent molars with irreversible pulpitis using biomaterials: a multi-center randomized controlled trial

OBJECTIVE

To conduct a randomized clinical trial to compare the post-operative pain experience as well as clinical and radiographic outcomes of pulpotomy in human permanent molars with irreversible pulpitis using calcium enriched mixture (CEM) cement or mineral trioxide aggregate (MTA).

MATERIALS AND METHODS

A total of 413 patients met the inclusion criteria and consented to participate. The patients were randomly allocated into two study arms: MTA pulpotomy (PMTA: n = 208) and CEM pulpotomy (PCEM: n = 205). Numerical rating scale questionnaires were utilized by the patients to record pain intensity (PI) over 7 days post-operatively. The patients were followed-up for 12 months to assess the clinical and radiographic outcomes of treatment. The data was analyzed using Chi-square, Cohen's kappa and t-tests.

RESULTS

There was no significant difference in the mean PI recorded during the 7 post-operative days between the two study arms (p = 0.221). The clinical and radiographic success rates for PMTA at 12-month follow-up were 98 and 95%, respectively; and 97 and 92% for PCEM, respectively. There was no significant differences in clinical (p = 0.7) and radiographic (p = 0.4) success rates between the two arms.

CONCLUSIONS

Excellent treatment outcomes occurred in molar teeth with irreversible pulpitis undergoing pulpotomy with MTA and CEM biomaterials.

Periapical Healing After Direct Pulp Capping With Calcium-enriched Mixture Cement: A Case Report

This article describes a successful direct pulp capping of a mature symptomatic mandibular second molar in a 14-year-old girl. The patient was referred with sensitivity to cold beverages and pain on chewing on the second left mandibular molar. Clinical examinations revealed extensive coronal caries and sensitivity to percussion. Radiographically, the tooth was mature and had a widened apical periodontal ligament (PDL) and a narrow periapical lesion. The concluding diagnosis was symptomatic irreversible pulpitis with symptomatic apical periodontitis. Treatment included caries removal under rubber dam isolation, capping of exposure sites with calcium-enriched mixture (CEM) cement, and permanent coronal restoration. At three-, 10-, and 15-month follow-up, the tooth was functional, had normal response to cold test, and did not have sensitivity to percussion. The PDL space regained its normal width, and the periapical lesion healed.

Comparison of endodontic biomaterials as apical barriers in simulated open apices

Objectives. To evaluate the effect of apical foramen diameter and apical barrier thickness on the sealing ability of mineral trioxide aggregate (MTA) and calcium enriched mixture (CEM) plugs in open apices. Materials and Methods. The fluid filtration method was conducted on a total of 136 roots. Samples were randomly divided into two control (n = 8) and four experimental groups (n = 30). Apical foramen diameters measuring 1.1 and 1.7 mm were shaped for groups "1 and 3" and "2 and 4", respectively. In groups 1 and 2 MTA plug and in groups 3 and 4 CEM plug was inserted. The groups were further divided into subgroups according to the thickness of the apical plugs (3- or 5-mm). Microleakage was measured at 1, 7, and 30 days. Results. Mixed ANOVA test showed that the microleakage in groups 1 and 3 as well as all 5-mm plug subgroups were significantly less than groups 2 and 4 (P < 0.05) and 3-mm subgroups (P < 0.05), respectively. Microleakage was significantly lower at 30th day (P < 0.05). Conclusions. Reducing canal diameter or increasing apical plug thickness and the time interval increases the sealing ability of apical barriers. Furthermore, in comparison to MTA, CEM plugs demonstrated superior sealing ability.

Immunohistochemical expression of fibronectin and tenascin in human tooth pulp capped with mineral trioxide aggregate and a novel endodontic cement

INTRODUCTION

The purpose of the present study was the immunohistochemical study of fibronectin (FN) and tenascin (TN) in human tooth pulp capped with mineral trioxide aggregate (MTA) and novel endodontic cement (NEC) (calcium enriched mixture cement) after 2 and 8 weeks.

METHODS

Thirty-two premolar teeth that were scheduled for extraction for orthodontic reasons were exposed and capped with either MTA or NEC. The teeth were randomly divided into 4 groups: group 1 (NEC for 2 weeks), group 2 (NEC for 8 weeks), group 3 (MTA for 2 weeks), and group 4 (MTA for 8 weeks). After capping the exposed pulps with either NEC (groups 1 and 2) or MTA (groups 3 and 4), half of the specimens underwent extraction and were prepared for histologic and immunohistochemical evaluation for FN and TN after 2 weeks, and the remaining half were assessed after 8 weeks. FN and TN expression was scored by a blinded pathologist on a scale of I-IV, and the results were analyzed by the Wilcoxon and Mann-Whitney U statistical tests.

RESULTS

FN and TN staining was observed in all 4 experimental groups, and there was no significant difference between expression of FN and TN in any groups. FN and TN staining was observed in the dentinal bridge matrix after 2 weeks under MTA. Expression of both markers reduced significantly after 8 weeks under MTA, and staining was observed only in unmineralized parts of dentinal bridge. FN and TN expression was observed in the matrix of the dentinal bridge after 2 weeks under NEC, and staining of both markers was reduced after 8 weeks compared with 2 weeks. The staining pattern of TN in NEC groups was higher than in MTA groups in both time intervals. However, the difference was not significant.

CONCLUSIONS

The present study demonstrated that both MTA and NEC are suitable biomaterials for direct pulp capping and are able to stimulate dentinal bridge formation. Moreover, the role of FN and TN as 2 major components of the matrix of a reparative dentinal bridge was observed.

Recommendations for using regenerative endodontic procedures in permanent immature traumatized teeth

The regeneration of immature permanent teeth following trauma could be beneficial to reduce the risk of fracture and loss of millions of teeth each year. Regenerative endodontic procedures include revascularization, partial pulpotomy, and apexogenesis. Several case reports give these procedures a good prognosis as an alternative to apexification. Care is needed to deliver regenerative endodontic procedures that maintain or restore the vitality of teeth, but which also disinfect and remove necrotic tissues. Regeneration can be accomplished through the activity of the cells from the pulp, periodontium, vascular, and immune system. Most therapies use the host's own pulp or vascular cells for regeneration, but other types of dental stem cell therapies are under development. There are no standardized treatment protocols for endodontic regeneration. The purpose of this article is to review the recent literature and suggest guidelines for using regenerative endodontic procedures for the treatment of permanent immature traumatized teeth. Recommendations for the selection of regenerative and conventional procedures based on the type of tooth injury, fracture type, presence of necrosis or infection, periodontal status, presence of periapical lesions, stage of tooth development, vitality status, patient age, and patient health status will be reviewed. Because of the lack of long-term evidence to support the use of regenerative endodontic procedures in traumatized teeth with open apices, revascularization regeneration procedures should only be attempted if the tooth is not suitable for root canal obturation, and after apexogenesis, apexification, or partial pulpotomy treatments have already been attempted and have a poor prognosis.

Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: a review and report of two cases with a new biomaterial

INTRODUCTION

Revascularization is a valuable treatment in immature necrotic teeth that allows the continuation of root development. In this article we describe successful revascularization treatment of 2 necrotic immature first mandibular molars.

METHODS

The clinical and radiographic examinations showed extensive coronal caries, immature roots, and periapical radiolucencies in mandibular first molars of a 9-year-old boy and an 8-year-old girl. The exam findings suggested revascularization treatment in both cases, which was started with irrigation of the canals by using NaOCl 5.25% for 20 minutes, followed by 3 weeks of triple antibiotic (metronidazole, ciprofloxacin, and minocycline) paste dressing. Next, the antibiotic paste was removed, bleeding was induced in the canals, and calcium enriched mixture (CEM) cement was placed over blood clots.

RESULTS

In radiographic and clinical follow-ups both cases were asymptomatic and functional, periapical radiolucencies were healed, and roots continued to develop.

CONCLUSIONS

Revascularization is a realistic treatment in immature necrotic molars. In addition, placing CEM cement as a new endodontic biomaterial over the blood clot formed inside the canals provided good seal and favorable outcomes.

Furcal perforation repair using calcium enriched mixture cement

This case describes a furcal perforation in a mandibular first molar accompanied by furcal lesion which has been managed after one month. Root canal treatment was performed; subsequently, the defect was repaired with calcium enriched mixture (CEM) cement. The endodontically treated tooth was restored with amalgam. A 24-month recall showed no evidence of periodontal breakdown, no symptoms, in addition to completes healing of furcal lesion. According to physical and biological properties of the newly introduced CEM cement, this novel material may be suitable for sealing and repairing the perforations. The present case report supports this hypothesis.

Calcium-enriched mixture pulpotomy of a human permanent molar with irreversible pulpitis and condensing apical periodontitis

This case report describes a pulpotomy treatment of a permanent mature molar tooth with established irreversible pulpitis and condensing apical periodontitis, using calcium-enriched mixture (CEM) cement. Clinical examination revealed that the first right lower molar had a large carious lesion with history of spontaneous/lingering pain; radiographic examination showed condensing apical periodontitis. Pulpotomy was opted as the treatment; cervical pulpotomy was carried out. Following hemostasis, the radicular pulp stumps were covered with ~2-mm-thick layer of the prepared CEM cement; the tooth was restored with amalgam. Two-year follow-up showed that the treated tooth had been symptomless, and there were no clinical signs/symptoms of either inflammation or infection. Radiographically, the periradicular lesion was completely healed with reconstruction of bone structures to normal appearance; the root canals were not calcified. According to chemical, physical, and biological properties of the CEM cement, this novel biomaterial may be suitable for endodontic treatment.

A Clinical Trial of Pulpotomy vs. Root Canal Therapy of Mature Molars

Root canal therapy (RCT) and tooth extraction are the main treatment options for irreversible pulpitis or its sequelae. Pulpotomy is an alternative treatment; however, more evidence is required. If outcomes of pulpotomy with a calcium-enriched mixture (PCEM) are non-inferior for mature molars with irreversible pulpitis compared with those from one-visit RCT (ORCT), this may be a beneficial treatment option. Four hundred seven individuals met the inclusion criteria and were randomly allocated [PCEM (n = 205), ORCT (n = 202)]. We used NRS questionnaires to record pain intensity. Six-month clinical and radiographic successes were assessed. Individuals in the ORCT arm reported significantly more post-operative pain than those in the PCEM arm (P < 0.001). Clinical success rates in the two arms showed no statistically significant difference; however, the radiographic success rates were significantly greater in the PCEM arm (P < 0.001). This trial suggests PCEM as an alternative for treatment of irreversible pulpitis. If long-term results confirm initial ones, PCEM may revolutionize oral health worldwide.