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

Dental pulp regeneration strategies: A review of status quo and recent advances

Microorganisms, physical factors such as temperature or mechanical injury, and chemical factors such as free monomers from composite resin are the main causes of dental pulp diseases. Current clinical treatment methods for pulp diseases include the root canal therapy, vital pulp therapy and regenerative endodontic therapy. Regenerative endodontic therapy serves the purpose of inducing the regeneration of new functional pulp tissues through autologous revascularization or pulp tissue engineering. This article first discusses the current clinical methods and reviews strategies as well as the research outcomes regarding the pulp regeneration. Then the in vivo models, the prospects and challenges for regenerative endodontic therapy were further discussed.

Odontogenic and anti-inflammatory effects of magnesium-doped bioactive glass in vital pulp therapy

This study aimed to investigate the effects of magnesium-doped bioactive glass (Mg-BG) on the mineralization, odontogenesis, and anti-inflammatory abilities of human dental pulp stem cells (hDPSCs). Mg-BG powders with different Mg concentrations were successfully synthesized via the sol-gel method and evaluated using x-ray diffraction, Fourier-transform infrared spectroscopy, scanning electron microscopy, and transmission electron microscopy. Apatite formation was observed on the surfaces of the materials after soaking in simulated body fluid. hDPSCs were cultured with Mg-BG powder extracts in vitro, and no evident cytotoxicity was observed. Mg-BG induced alkaline phosphatase (ALP) expression and mineralization of hDPSCs and upregulated the expression of odontogenic genes, including those encoding dentin sialophosphoprotein, dentin matrix protein 1, ALP, osteocalcin, and runt-related transcription factor 2. Moreover, Mg-BG substantially suppressed the secretion of inflammatory cytokines (interleukin [IL]-4, IL-6, IL-8, and tumor necrosis factor-alpha). Collectively, the results of this study suggest that Mg-BG has excellent in vitro bioactivity and is a potential material for vital pulp therapy of inflamed pulps.

Effects of Novel Nanoparticulate Bioceramic Endodontic Material on Human Dental Pulp Stem Cells In Vitro

OBJECTIVES

This study aimed to investigate the in vitro effects of root canal filling and repair paste (nRoot BP) on human dental pulp stem cells (hDPSCs).

METHODS

The effects of nRoot BP and iRoot BP Plus on the adhesion, proliferation, migration, and differentiation of hDPSCs were examined in vitro for 72 hours. The adhesion of cells was observed using immunofluorescence rhodamine ghost pen cyclic peptide staining and scanning electron microscopy (SEM). Cell density and changes in migration area were measured under a fluorescence inverted microscope. Fluorescent quantitative PCR was performed to detect genes related to odontogenesis and osteogenesis.

RESULTS

Cells adhering to the surfaces of nRoot BP and iRoot BP Plus exhibited similar irregular polygonal morphologies, with cells extending irregular pseudopods to adhere to the materials. CCK-8 results indicated that the density of living cells for nRoot BP and iRoot BP Plus was lower than that of the blank control group at 3 and 5 days of culture. There was no significant difference in cell migration between the groups (P > .05). The migration ability of iRoot BP Plus and nRoot BP was similar to that of the control group. Both nRoot BP and iRoot BP Plus increased the expression of the RUNX2 gene, but there was no significant difference between the groups (P < .05). Furthermore, both nRoot BP and iRoot BP Plus downregulated the expression of the DSPP gene, with no significant difference between them (P > .05).

CONCLUSIONS

nRoot BP exhibited a slight inhibition of hDPSC proliferation but did not affect the adhesion and migration of hDPSCs. The impact of nRoot BP on the osteogenic and odontogenic differentiation of hDPSCs was similar to that of iRoot BP Plus.

Treatment outcomes of pulpotomy versus pulpectomy in vital primary molars diagnosed with symptomatic irreversible pulpitis: protocol for a non-inferiority randomised controlled trial

BACKGROUND

Pulpectomy continues to be the standard treatment recommendation for management of vital primary molars diagnosed with symptomatic irreversible pulpitis. The recent decade has seen a paradigm shift in the treatment concepts of how vital mature permanent molars diagnosed with irreversible pulpitis can be more conservatively managed using vital pulp therapy techniques like pulpotomy. However, despite emerging evidence indicating similarities between primary and permanent tooth pulp response to dental caries, there is limited research on whether pulpotomy can be similarly used as a definitive treatment modality for vital primary teeth with irreversible pulpitis. This randomised controlled trial (RCT) aims to compare the treatment effectiveness of pulpotomy versus pulpectomy in management of vital primary molars diagnosed with symptomatic irreversible pulpitis over a two-year period.

METHODS/DESIGN

This clinical study is a parallel, two-armed, open label, non-inferiority RCT with a 1:1 allocation ratio between the experimental intervention arm (pulpotomy) and the active comparator arm (pulpectomy). Healthy cooperative children, between 4-9 years of age, who have painful primary molars with clinical symptoms typical of irreversible pulpitis will be recruited after obtaining informed consent from their parents/legal guardians. 50 vital primary molars clinically diagnosed with symptomatic irreversible pulpitis will be randomly distributed between the two treatment arms. The primary outcomes that will be assessed are clinical and radiographic success after six-months, one-year and two-years of the trial interventions. The influence of baseline pre-operative variables (age; gender; tooth type; site of caries; pre-operative furcal radiolucency; pre-operative pain intensity) and intra-operative factors (time taken to achieve haemostasis) on treatment outcomes will also be assessed. The secondary outcome evaluated will be the immediate (24 h and 7 d) post-operative pain relief afforded by the two treatment interventions.

DISCUSSION

This trial seeks to provide evidence on whether pulpotomy treatment can be no worse than the standard pulpectomy treatment for the management of symptomatic irreversible pulpitis in vital primary molars.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT06183203). Registered on 30 January 2024.

Clinical influencing factors of vital pulp therapy on pulpitis permanent teeth with 2 calcium silicate-based materials: A randomized clinical trial

BACKGROUND

Compared with traditional root canal therapy (RCT), vital pulp therapy (VPT) is a personalized and minimally invasive method for the treatment of pulpitis caused by dental caries. However, there are still no clear guidelines for VPT because high-quality randomized clinical trials are scarce. This prospective cohort study evaluated the clinical efficacy of VPT with the light-curable calcium silicate-based material TheraCal LC (TH) and bioceramic material iRoot BP Plus (BP) in reversible and irreversible pulpitis permanent teeth with carious exposures.

METHODS

115 teeth with reversible or irreversible pulpitis caused by deep care were randomly divided into 2 groups. TheraCal LC and iRoot BP Plus were used for the pulp capping. Direct pulp capping (DPC), partial pulpotomy (PP) and full pulpotomy (FP) were performed based on observation of the exposed pulp. Postoperative discomforts were enquired and recorded via follow-up phone calls. Clinical and radiographic evaluations were performed 3, 6, and 12 months postoperatively.

RESULTS

The overall clinical success rate in the first year was 90.4% (47/52) in both groups. The TH group required less operating time, showed lower levels of pain, and had shorter pain duration post-operative (P < .001). According to the binary logistic regression model, preoperative pain duration was significantly correlated with the prognosis of VPT (P = .011).

CONCLUSION

VPT with TheraCal LC and iRoot BP Plus in pulpitis permanent carious teeth both achieved good clinical outcomes, and TheraCal LC can be easily operated for clinical use. Preoperative pain duration of the affected tooth might have a significant correlation with the prognosis of VPT.

"Biological responses of two calcium-silicate-based cements on a tissue-engineered 3D organotypic deciduous pulp analogue"

OBJECTIVES

The biological responses of MTA and Biodentine™ has been assessed on a three-dimensional, tissue-engineered organotypic deciduous pulp analogue.

METHODS

Human endothelial (HUVEC) and dental mesenchymal stem cells (SHED) at a ratio of 3:1, were incorporated into a collagen I/fibrin hydrogel; succeeding Biodentine™ and MTA cylindrical specimens were placed in direct contact with the pulp analogue 48 h later. Cell viability/proliferation and morphology were evaluated through live/dead staining, MTT assay and Scanning Electron Microscopy (SEM), and expression of angiogenic, odontogenic markers through real time PCR.

RESULTS

Viable cells dominated at day 3 after treatment presenting typical morphology, firmly attached within the hydrogel structures, as shown by live/dead staining and SEM images. MTT assay at day 1 presented a significant increase of cell proliferation in Biodentine™ group. Real-time PCR showed significant upregulation of odontogenic markers DSPP, BMP-2 (day 3,6), RUNX2, ALP (day 3) in contact with Biodentine™ compared to MTA and the control, whereas MTA promoted significant upregulation of DSPP, BMP-2, RUNX2, Osterix (day 3) and ALP (day 6) compared to the control. MSX1 presented downregulation in both experimental groups. Expression of angiogenic markers VEGFa and ANGPT-1 at day 3 was significantly upregulated in contact with Biodentine™ and MTA respectively, while the receptors VEGFR1, VEGFR2 and Tie-2, as well as PECAM-1 were downregulated.

SIGNIFICANCE

Both calcium silicate-based materials are biocompatible and exert positive angiogenic and odontogenic effects, although Biodentine™ during the first days of culture, seems to induce higher cell proliferation and provoke a more profound odontogenic and angiogenic response from SHED.

Exploring vital pulp Therapies: A bibliometric analysis of the most cited articles

Aim

The aim of this study was to identify and analyze the most cited articles on vital pulp therapies.

Methodology

Bibliographical data related to the abstract, citations, keywords, and other relevant information was extracted using different combinations of keywords. Further evaluation and visualization of the selected data were performed with the help of various tools, including MS Excel, Microsoft Word, Google open refine, BibExcel, and VOS viewer. An initial search revealed 91 documents, of which 40 were chosen for further analysis. We used the Kolmogorov-Smirnov test and Spearman correlation coefficient test, and our adopted significance level was p < 0.05.

Results

In total, the articles received 1,905 citations, with six of them receiving at least 100 citations. Among the top 40 articles, the United States of America (10 articles) and Ireland (6 articles) were the countries with the highest number of cited articles. The journals "Journal of Endodontics" (14 articles; 650 citations) and "International Endodontic Journal" (13 articles; 577 citations) published most of the articles among the 50 most cited ones. Duncan H. was the author with the highest number of works cited (11 articles; 339 citations). Of the articles, systematic reviews accounted for 32%, literature reviews for 14%, in vitro experimental studies for 12%, clinical trials for 8%. Among the biomaterials used in vital pulp therapies, mineral trioxide aggregate (MTA) was discussed in 37 articles (74%), followed by calcium hydroxide, mentioned in 30 studies (60%). Interestingly, the publication year did not demonstrate a significant impact on citation count.

Conclusion

The present study provided a detailed list of the top 50 most cited and classic articles on vital pulp therapies. This will help researchers, students, and clinicians in the field of endodontics with an impressive source of information.

Strontium-Containing Piezoelectric Biofilm Promotes Dentin Tissue Regeneration

It remains an obstacle to induce the regeneration of hard dentin tissue in clinical settings. To overcome this, a P(VDF-TrFE) piezoelectric film with 2 wt% SrCl2 addition is designed. The biofilm shows a high flexibility, a harmonious biocompatibility, and a large piezoelectric d33 coefficient of 14 pC N-1, all contributing to building an electric microenvironment that favor the recruitment of dental pulp stem cells (DPSCs) and their differentiation into odontoblasts during normal chewing, speaking, etc. On the other hand, the strontium ions can be gradually released from the film, thus promoting DPSC odonto-differentiation. In vivo experiments also demonstrate that the film induces the release of dentin minerals and regeneration of dentin tissue. In the large animal dentin defect models, this piezoelectric film induces in situ dentin tissue formation effectively over a period of three months. This study illustrates a therapeutic potential of the piezoelectric film to improve dentin tissue repair in clinical settings.

Assessment of the biointeractivity of a novel vital pulp therapy agent derived from eggshell biowaste: An in vitro study

This study aimed to assess the calcium (Ca2+) and hydroxyl (OH-) ion-releasing ability, namely the biointeractivity of eggshell-derived hydroxyapatite (ESDHA) in comparison with mineral trioxide aggregate (MTA) and calcium hydroxide (CH). ESDHA, MTA and CH samples (n = 10; 8 × 1.6 mm) were immersed in 10 mL of deionised water (37°C, pH 6.8). Ca2+ and OH- ion releases were detected in 1, 7 and 21 days. Scanning electron microscopy and Fourier transform infrared spectroscopy analyses were also conducted. IBM SPSS 20.0 was used for statistical analyses. The cumulative Ca2+ ions (56.22 ± 11.28 ppm) were detected as most significant in ESDHA (day 21; p < 0.05). The OH- ion values of the ESDHA group were statistically higher than MTA and CH (days 1 and 7; p < 0.05). ESDHA and CH showed a similar pattern with sharp peaks in Ca2+, oxygen and carbon elements. ESDHA being a sustainable material with a high ion-releasing ability may be a preferable alternative to the commercial vital pulp therapy agents.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

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

Effectiveness of mineral trioxide aggregate on postoperative pain in non-surgical endodontic treatment: a systematic review of randomized controlled trials

INTRODUCTION

Postoperative endodontic pain can negatively influence the quality of life of the patients. Mineral Trioxide Aggregate (MTA) has gained attention as a potential medicament in various endodontic procedures. MTA has been shown to have desirable properties such as biocompatibility, marginal adaptation, and sealing ability compared to other materials. Limited evidence is available about the effectiveness of MTA on the reduction of postoperative pain following endodontic treatment. This article aimed to compare the non-surgical post-endodontic pain-relieving effect of MTA compared with other materials.

METHODS

Indexed databases (PubMed/Medline, EMBASE, OVID, Scopus, and Cochrane) were independently searched for relevant manuscripts published up to and until June 2023. Randomized controlled trials (RCTs) with a focus on teeth with pulp pathologies, with or without radiolucency, requiring primary endodontic treatment were included. Risk of bias across individual studies was performed using the Cochrane risk of bias tool for interventions.

RESULTS

Out of the initial 169 articles searched, 9 RCTs met the selection criteria. The protocols were like all the studies, but the pain rating scales, filling material, and restoration materials varied. Out of the 9 included studies, in 4 studies MTA significantly reduced postoperative pain levels, 5 studies showed no difference between MTA and other materials, whereas 1 study reported an adverse effect of grey discoloration after MTA.

CONCLUSION

The findings of the present review indicate that MTA may reduce postoperative pain following non-surgical endodontic treatment. However, future standardized studies should be conducted to validate the results.

Antimicrobial Peptide- and Dentin Matrix-Functionalized Hydrogel for Vital Pulp Therapy via Synergistic Bacteriostasis, Immunomodulation, and Dentinogenesis

The preservation of vital pulps is crucial for maintaining the physiological functions of teeth; however, vital pulp therapy (VPT) of pulpitis teeth remains a substantial challenge due to uncontrolled infection, excessive inflammation, and limited regenerative potential. Current pulp capping agents have restricted effects in the infectious and inflammatory microenvironment. To address this, a multifunctional hydrogel (TGH/DM) with antibacterial, immunomodulatory, and mineralization-promoting effects is designed. The antimicrobial peptide (AMP) and demineralized dentin matrix are incorporated into the hydrogel, achieving sustainable delivery of AMP and a cocktail of growth factors. In vitro results show that TGH/DM could kill endodontic microbiota, ameliorate inflammatory responses of human dental pulp stem cells (hDPSCs), and prompt odontogenic differentiation of inflammatory hDPSCs via activation of peroxisome proliferator-activated receptor gamma. In vivo results suggest that TGH/DM is capable of inducing M2 phenotype transformation of macrophages in mice and fostering the regeneration of the dentin-pulp complex in inflamed pulps of beagle dogs. Overall, this study first proposes the synergistic regulation of AMP and tissue-specific extracellular matrix for the treatment of pulpitis, and the advanced hydrogel provides a facile and effective way for VPT.

Randomized clinical trial of pulpotomy using a premixed injectable calcium silicate cement on mature permanent teeth with reversible pulpitis

The aim of this two-center randomized controlled trial was to assess the outcomes and relative factors associated with pulpotomies performed using a premixed injectable calcium silicate cement, as compared to mineral trioxide aggregate in mature permanent premolar and molar teeth with reversible pulpitis. Included teeth were randomly divided into two groups according to pulpotomy material (ProRoot MTA [PMTA] group, Endocem MTA Premixed [EPM] group). After pulp exposure, the superficial pulp was either removed to a depth of 2 mm (partial pulpotomy) or completely amputated to the level of the root canal orifice (full pulpotomy). A 3-mm layer of either material was randomly placed over the pulp wound, followed by the application of a thin layer of a light-cured glass ionomer composite liner. The restoration procedure was then carried out during the same visit. After one year of treatment, the pulpotomy success rate was 94.4% (67/71), with no significant difference between the PMTA and EPM groups. The success rate was 93.9% in the PMTA group and 97.1% in the EPM group. There were no significant factors related to the procedures. EPM is a viable alternative to PMTA for single-visit pulpotomies of permanent premolars and molars.

Microstructural Evaluation of the Mineralized Apical Barrier Induced by a Calcium Hydroxide Paste Containing Iodoform: A Case Report

INTRODUCTION

A 65-year-old man had nonsurgical retreatment using an iodoform and calcium hydroxide paste in a maxillary left canine with persistent apical periodontitis. An apical mineralized barrier (AMB) was observed 3-months postoperatively. Unfortunately, the tooth was extracted due to a cementum tear. This provided an opportunity to analyze the AMB histologically, as there is a lack of previous reports on its microstructure.

METHODS

After extraction and removal of the granulation tissue from the root surface, the canine was processed, and observed using micro-computed tomography (μCT) and light microscopy. Thereafter, the specimen was resin-embedded specimen was evaluated by scanning electron microscopy, micro-X-ray fluorescence spectroscopy and Raman spectroscopy to understand the mechanism and nature of the AMB formation during apical healing.

RESULTS

Nonsurgical retreatment was clinically successful based on the absence of clinical symptoms of apical periodontitis and the radiographic presence of an AMB. The AMB was opaque and could be readily differentiated from dentin under a light microscope. Micro-computed tomography analysis revealed that the AMB had the same mineral density as dentin. Scanning electron microscopy revealed that the AMB had two distinct layers based on the size of the calcified particles. Elemental mapping using micro-X-ray fluorescence spectroscopy showed that the localization of calcium and phosphorus differed between AMB and other areas of biomineralization. Raman spectral mapping revealed that the surface layer of the AMB consisted of collagen, calcium carbonate, and hydroxyapatite.

CONCLUSIONS

This study explored new analytical methods for elucidating the apical wound-healing process and the nature of the mineralized repair. The findings provided detailed information on the AMB highlighting a bilaminar structure with high calcium components higher on the inside and a brightness similar to cementum not dentin and the presence of hydroxyapatite.

In vitro and in vivo evaluation of iRoot BP Plus as a coronal sealing material for regenerative endodontic procedures

OBJECTIVES

To investigate in vitro effects of a nanoparticle bioceramic material, iRoot BP Plus, on stem cells from apical papilla (SCAP) and in vivo capacity to induce pulp-dentin complex formation.

MATERIALS AND METHODS

The sealing ability of iRoot BP Plus was measured via scanning electron microscopy (SEM). SCAP were isolated and treated in vitro by iRoot BP Plus conditioned medium, with mineral trioxide aggregate (MTA) conditioned medium and regular medium used as controls, respectively. Cell proliferation was assessed by BrdU labeling and MTT assay and cell migration was evaluated with wound healing and transwell assays. Osteo/odontogenic potential was evaluated by Alizarin red S staining and qPCR. Pulp-dentin complex formation in vivo was assessed by a tooth slice subcutaneous implantation model.

RESULTS

iRoot BP Plus was more tightly bonded with the dentin. There was no difference in SCAP proliferation between iRoot BP Plus and control groups (P > 0.05). iRoot BP Plus had a greater capacity to elevated cell migration (P < 0.05) and osteo/odontogenic marker expression and mineralization nodule formation of SCAP compared with MTA groups (P < 0.05). Furthermore, the new continuous dentine layer and pulp-like tissue was observed in the iRoot BP Plus group in vivo.

CONCLUSIONS

iRoot BP Plus showed excellent sealing ability, promoted the migration and osteo/odontogenesis of SCAP and induced pulp-dentin complex formation without affecting the cell proliferation, which indicated iRoot BP Plus was a promising coronal sealing material in REPs.

CLINICAL RELEVANCE

The coronal sealing materials play crucial roles for the outcomes of REPs. This study showed that iRoot BP Plus has good coronal sealing and promote pulp-dentin complex formation compared with MTA, providing experimental evidences for the clinical application of iRoot BP Plus as a promising coronal seal material in REPs.

Nanoparticles and Their Antibacterial Application in Endodontics

Root canal treatment represents a significant challenge as current cleaning and disinfection methodologies fail to remove persistent bacterial biofilms within the intricate anatomical structures. Recently, the field of nanotechnology has emerged as a promising frontier with numerous biomedical applications. Among the most notable contributions of nanotechnology are nanoparticles, which possess antimicrobial, antifungal, and antiviral properties. Nanoparticles cause the destructuring of bacterial walls, increasing the permeability of the cell membrane, stimulating the generation of reactive oxygen species, and interrupting the replication of deoxyribonucleic acid through the controlled release of ions. Thus, they could revolutionize endodontics, obtaining superior results and guaranteeing a promising short- and long-term prognosis. Therefore, chitosan, silver, graphene, poly(lactic) co-glycolic acid, bioactive glass, mesoporous calcium silicate, hydroxyapatite, zirconia, glucose oxidase magnetic, copper, and zinc oxide nanoparticles in endodontic therapy have been investigated in the present review. The diversified antimicrobial mechanisms of action, the numerous applications, and the high degree of clinical safety could encourage the scientific community to adopt nanoparticles as potential drugs for the treatment of endodontic diseases, overcoming the limitations related to antibiotic resistance and eradication of the biofilm.

Clinical management of external cervical resorption: A systematic review

This review investigated whether any therapeutic options influenced the outcome of treatment for teeth with external cervical resorption. Out of 870 articles identified by an electronic search, 60 clinical case reports and six case series were included. No randomised clinical trials were found. Risk of bias was assessed using Joanna Briggs Institute's tools. External surgical intervention was the preferred method of accessing the lesions. Removal of resorptive tissue was most often achieved mechanically. Bioactive endodontic cements were the preferred materials for restoring teeth. The outcome measures were based on clinical and radiographic parameters. Of the cases included in the review, no specific treatment approach had a superior outcome in relation to Heithersay's classification. Furthermore, due to the absence of randomised clinical trials, and the low level of evidence associated with case reports/case series, it was not possible to define the optimum clinical treatment for external cervical resorption.

Chemomechanical Properties and Biocompatibility of Various Premixed Putty-type Bioactive Ceramic Cements

INTRODUCTION

This study aimed to evaluate the chemomechanical properties and biocompatibility of recently introduced premixed putty-type bioactive ceramic cements (PPBCs).

METHODS

Including ProRoot MTA (PMTA) as a control, BC RRM fast-set putty (BCPT), Well-Root PT (WRPT), One-Fil PT (OFPT), and Endocem MTA premixed (ECPM) were compared to evaluate setting time, radiopacity, pH change, and microhardness. Biocompatibility on human dental pulp cells was compared using CCK-8 assay. Mineralization potential was evaluated using alkaline phosphatase activity, Alizarin Red S (ARS) staining, and quantitative real-time polymerase chain reaction with odontogenic gene marker. For data analysis, 1-way analysis of variance and Tukey's post hoc test were used at the significance level of 95%.

RESULTS

Among the PPBCs, BCPT presented the longest (552 ± 27) setting time (minutes) and others showed significantly shorter time than PMTA (334 ± 22) (P < .05). WRPT (6.20 ± 0.54) and OFPT (5.82 ± 0.50) showed significantly higher radiopacity values (mmAl) and others showed similar value compared with PMTA (P > .05). All PPBCs showed high alkaline pH from fresh materials and tended to increase according to time periods from 30 minutes to 12 hours. ECPM showed the highest value of microhardness (81.62 ± 5.90), WRPT showed similar, and others showed lower than PMTA (P < .05). All PPBCs showed biocompatibility in CCK-8 assay. All PPBCs showed similar or better value compared with PMTA in ALP and ARS staining, and ALP and DSPP marker expression (P < .05).

CONCLUSIONS

The PPBCs showed clinically acceptable chemomechanical properties and favorable mineralization potential.

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 scientometric, bibliometric, and thematic map analysis of hydraulic calcium silicate root canal sealers

Objectives

This scientometric and bibliometric analysis explored scientific publications related to hydraulic calcium silicate-based (HCSB) sealers used in endodontology, aiming to describe basic bibliometric indicators and analyze current research trends.

Materials and Methods

A comprehensive search was conducted in Web of Science and Scopus using specific HCSB sealer and general endodontic-related terms. Basic research parameters were collected, including publication year, authorship, countries, institutions, journals, level of evidence, study design and topic of interest, title terms, author keywords, citation counts, and density.

Results

In total, 498 articles published in 136 journals were retrieved for the period 2008-2023. Brazil was the leading country, and the universities of Bologna in Italy and Sao Paolo in Brazil were represented equally as leading institutions. The most frequently occurring keywords were "calcium silicate," "root canal sealer MTA-Fillapex," and "biocompatibility," while title terms such as "calcium," "sealers," "root," "canal," "silicate based," and "endodontic" occurred most often. According to the thematic map analysis, "solubility" appeared as a basic theme of concentrated research interest, and "single-cone technique" was identified as an emerging, inadequately developed theme. The co-occurrence analysis revealed 4 major clusters centered on sealers' biological and physicochemical properties, obturation techniques, retreatability, and adhesion.

Conclusions

This analysis presents bibliographic features and outlines changing trends in HCSB sealer research. The research output is dominated by basic science articles scrutinizing the biological and specific physicochemical properties of commonly used HCSB sealers. Future research needs to be guided by studies with a high level of evidence that utilize innovative, sophisticated technologies.

Comparative biological properties of resin-free and resin-based calcium silicate-based endodontic repair materials on human periodontal ligament stem cells

OBJECTIVES

To investigate the effect of three different calcium silicate-based materials (CSBM) on the biological behavior of human periodontal ligament stem cells (hPDLSCs).

METHODS

Eluates of Biodentine, NeoPutty and TheraCal PT prepared at 1:1, 1:2, and 1:4 ratios were extracted under sterile conditions. The cytotoxicity of the extracts to the hPDLSCs was assessed using the MTT assay. Scratch wound healing assay was utilized for assessing cell migration. Scanning electron microscopy was used to detect cell attachment and morphology. Calcium ion release was measured using inductively coupled plasma-optical emission spectrometry; the pH-value was evaluated with a pH-meter. ANOVA with post hoc Tukey test was used for statistical analysis.

RESULTS

Cell viability was significantly higher for Biodentine and NeoPutty at day 1 with all dilutions (p < 0.05), while at day 3 and day 7 with dilutions 1:2 and 1:4; all materials showed similar behavior (p > 0.05). Biodentine had the highest percentage of cell migration into the scratched area at day 1 for all dilutions (p < 0.05). Stem cells were attached favorably on Biodentine and NeoPutty with evident spreading, and intercellular communications; however, this was not shown for TheraCal PT. Biodentine showed the highest pH values and calcium ion release (p < 0.05).

CONCLUSIONS

The resin-free CSBM showed better performance and favorable biological effects on hPDLSCs and were therefore considered promising for usage as endodontic repair materials.

CLINICAL SIGNIFICANCE

Proper selection of materials with favorable impact on the host stem cells is crucial to ensure outcome in different clinical scenarios.

Sol-Gel Technologies to Obtain Advanced Bioceramics for Dental Therapeutics

The aim of this work is to review the application of bioceramic materials in the context of current regenerative dentistry therapies, focusing on the latest advances in the synthesis of advanced materials using the sol-gel methodology. Chemical synthesis, processing and therapeutic possibilities are discussed in a structured way, according to the three main types of ceramic materials used in regenerative dentistry: bioactive glasses and glass ceramics, calcium phosphates and calcium silicates. The morphology and chemical composition of these bioceramics play a crucial role in their biological properties and effectiveness in dental therapeutics. The goal is to understand their chemical, surface, mechanical and biological properties better and develop strategies to control their pore structure, shape, size and compositions. Over the past decades, bioceramic materials have provided excellent results in a wide variety of clinical applications related to hard tissue repair and regeneration. Characteristics, such as their similarity to the chemical composition of the mineral phase of bones and teeth, as well as the possibilities offered by the advances in nanotechnology, are driving the development of new biomimetic materials that are required in regenerative dentistry. The sol-gel technique is a method for producing synthetic bioceramics with high purity and homogeneity at the molecular scale and to control the surfaces, interfaces and porosity at the nanometric scale. The intrinsic nanoporosity of materials produced by the sol-gel technique correlates with the high specific surface area, reactivity and bioactivity of advanced bioceramics.

Physicochemical, mechanical and biological properties of nano-calcium silicate-based cements: a systematic review

This systematic review evaluated the effects of nano-sized cement particles on the properties of calcium silicate-based cements (CSCs). Using defined keywords, a literature search was conducted to identify studies that investigated properties of nano-calcium silicate-based cements (NCSCs). A total of 17 studies fulfilled the inclusion criteria. Results indicated that NCSC formulations have favourable physical (setting time, pH and solubility), mechanical (push out bond strength, compressive strength and indentation hardness) and biological (bone regeneration and foreign body reaction) properties compared with commonly used CSCs. However, the characterization and verification for the nano-particle size of NCSCs were deficient in some studies. Furthermore, the nanosizing was not limited to the cement particles and a number of additives were present. In conclusion, the evidence available for the properties of CSC particles in the nano-range is deficient-such properties could be a result of additives which may have enhanced the properties of the material.

Effectiveness of root resection techniques compared with root canal retreatment or apical surgery for the treatment of apical periodontitis and tooth survival: A systematic review

BACKGROUND

To manage apical periodontitis in root filled maxillary and mandibular molars, root resection techniques may be employed to avoid the loss of the tooth.

OBJECTIVES

The objectives of the study were to systematically analyse the effectiveness of root resection techniques (root resection/crown resection/root amputation) for the management of apical periodontitis with non-surgical root canal retreatment or apical surgery by the evaluation of clinical and patient-related outcomes (PROMS), in human experimental studies and longitudinal studies.

METHODS

An electronic literature search in PubMed, MEDLINE via OVID interface, EMBASE and Cochrane Central, supplemented by a manual hand search of the grey literature, was performed up to 25th September 2021. Randomized controlled trials, comparative clinical trials and observational studies reporting on the outcome (tooth survival and patient-reported outcome measures with a minimum follow-up of 1 year) of root resection techniques for treating apical periodontitis were identified. The risk of bias was evaluated using the Newcastle-Ottawa scale.

RESULTS

From a total of 2098 reports, 36 were considered for further screening. Three retrospective studies, published between 2018 and 2020, were included in this systematic review. A high heterogeneity in terms of protocols, study design and the reported outcomes were observed. The risk of bias was scored as low to moderate. These three studies consisted of data from 305 resected teeth, from 254 patients, with a follow-up period of 1-16.8 years. Overall, 151 teeth were extracted during the follow-up period. In these studies, root resection treatment was carried out on 42 teeth exclusively for endodontic reasons. One of these studies reported 12 out of 23 teeth lost at follow-up. None of the studies reported on PROMS.

DISCUSSION

Although root resection techniques may be used for treating teeth with apical periodontitis, the data are limited. Furthermore, the studies are very heterogeneous and associated with high risk of bias.

CONCLUSIONS

Given the current level of available evidence, it is not possible to recommend, or dismiss, root resection techniques for managing apical periodontitis.

REGISTRATION

PROSPERO database (CRD42021260306).

Evaluation of removal efficiency of capping materials used in pulp revascularization in vitro

BACKGROUND

This study aimed to evaluate the removal efficiency of different capping materials used in pulp revascularization (PR) in a failure scenario.

METHODS

The apices of freshly extracted 30 maxillary incisors were cut to mimic the immature teeth; then, root canals were shaped up to #6 Peeso reamers. The regeneration steps of the American Association of Endodontists (AAE) were followed to simulate PR treatment in vitro. The canals were dressed with the Ciprofloxacin and Metronidazole medicament mixture for 2 weeks. Then capping material groups were created: BioDentine (BD), ProRootMTA (PMTA), and RetroMTA (RMTA) (n = 10). The sealed specimens were stored for 2 weeks at 37 ºC in phosphate-buffered saline then the samples were examined by micro-computed tomography (µ-CT) analysis. Set capping materials were retrieved using a specific cement removal kit by a single blind operator. The residue materials were examined again by µCT. Kruskal-Wallis and Mann-Whitney U tests sought the significance for residue volumes. One-way ANOVA and Tukey post hoc tests with the Bonferroni corrections sought significance for the duration (p = 0.05).

RESULTS

In the first examined µCT data, the mean (SD) capping material volumes of the PMTA, BD, and RMTA were 6.447 µm3 (1.086), 8.771 µm3 (0.491), and 8.114 µm3 (2.447), respectively. In the last examined µCT data, the median (IQR) residual volumes of the PMTA, BD, and RMTA were 0.051 µm3 (0.1), 0.313 µm3 (0.5), and 0.124 µm3 (0.1), respectively. A significant difference was found between BD and PMTA in the residual volumes (p < 0.05). The mean (SD) durations of the retrieving procedures of PMTA, BD, and RMTA were 19.83 min (2.34), 19.24 (3.60), and 22.04 (1.68), respectively (p = 0.063).

CONCLUSIONS

Within the limitations of the presented study, it was concluded that the capping materials were largely removed from the root canals using a non-invasive approach. Nevertheless, this duration of the retrieving could be described as long.

Epigenetic therapeutics in dental pulp treatment: Hopes, challenges and concerns for the development of next-generation biomaterials

This opinion-led review paper highlights the need for novel translational research in vital-pulp-treatment (VPT), but also discusses the challenges in translating evidence to clinics. Traditional dentistry is expensive, invasive and relies on an outmoded mechanical understanding of dental disease, rather than employing a biological perspective that harnesses cell activity and the regenerative-capacity. Recent research has focussed on developing minimally-invasive biologically-based 'fillings' that preserve the dental pulp; research that is shifting the paradigm from expensive high-technology dentistry, with high failure rates, to smart restorations targeted at biological processes. Current VPTs promote repair by recruiting odontoblast-like cells in a material-dependent process. Therefore, exciting opportunities exist for development of next-generation biomaterials targeted at regenerative processes in the dentin-pulp complex. This article analyses recent research using pharmacological-inhibitors to therapeutically-target histone-deacetylase (HDAC) enzymes in dental-pulp-cells (DPCs) that stimulate pro-regenerative effects with limited loss of viability. Consequently, HDAC-inhibitors have the potential to enhance biomaterial-driven tissue responses at low concentration by influencing the cellular processes with minimal side-effects, providing an opportunity to develop a topically-placed, inexpensive bio-inductive pulp-capping material. Despite positive results, clinical translation of these innovations requires enterprise to counteract regulatory obstacles, dental-industry priorities and to develop strong academic/industry partnerships. The aim of this opinion-led review paper is to discuss the potential role of therapeutically-targeting epigenetic modifications as part of a topical VPT strategy in the treatment of the damaged dental pulp, while considering the next steps, material considerations, challenges and future for the clinical development of epigenetic therapeutics or other 'smart' restorations in VPT.

Inflammatory response and odontogenic differentiation of inflamed dental pulp treated with different pulp capping materials: An in vivo study

AIM

Previous studies have evaluated the pulpal responses to calcium silicate cements (CSCs) on normal dental pulp, but investigations on the effects of CSCs on inflamed pulp are limited. This study aimed to test the inflammatory response and odontogenic differentiation of inflamed rat dental pulp after direct pulp capping with CSCs.

METHODOLOGY

Wistar rat molars pulps were exposed for 48 h to induce inflammation and then capped with ProRoot MTA (Dentsply), Biodentine (Septodont), RetroMTA (Bio MTA) and Dycal (Dentsply Caulk). The degree of pulpal inflammation and hard tissue formation was evaluated by histological analysis. Immunofluorescence staining for interleukin (IL)-6, osteocalcin (OCN) and runt-related transcription factor 2 (RUNX2) was also performed.

RESULTS

After 4 weeks, complete recovery from inflammation was evident in 22%, 37.5%, 10% and none of the ProRoot MTA, Biodentine, RetroMTA and Dycal samples, respectively. Heavy hard tissue deposition as a continuous hard tissue bridge was observed in 77.8%, 75%, 70% and 60% of the ProRoot MTA, Biodentine, RetroMTA and Dycal samples, respectively. IL-6, OCN and RUNX2 were detected in all materials, mainly adjacent to areas of inflammation and reparative dentine formation. At one, two and 4 weeks, significant differences were not observed between the inflammation and hard tissue formation scores of the four material groups (p > .05).

CONCLUSIONS

In this study, pulpal inflammation was still present in most specimens at 4 weeks after pulp capping and a significant number of samples showed incomplete and discontinuous dentine bridge formation. The results of this study suggest that initial inflammatory conditions of the pulp may risk the prognosis of teeth treated with CSCs.

Controlled drug delivery from metronidazole-containing bioactive endodontic cements

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Partial Pulpotomy in Young Permanent Teeth: A Systematic Review and Meta-Analysis

The aim of the present systematic review was to evaluate the clinical and radiographic success of partial pulpotomies in deep caries processes or post-eruptive defects in young, vital permanent teeth. Four electronic databases, PubMed, Scopus, Embase, and Google Scholar, were searched, followed by a manual search in the reference lists. Randomized controlled trials evaluating partial pulpotomy with a follow-up period of ≥12 months were included. A meta-analysis using a random effects model was performed. A total of 3127 articles were retrieved, and after duplicate removal, 2642 were screened by title and abstract; 1 additional article was found during the manual search, and 79 were identified. Finally, six papers were included in the review. Regardless of the partial pulpotomy modalities or material used, there were no significant differences between clinical and radiographic success rates (cumulative success rate 91.8-92.3%). Five studies were included in the meta-analysis that did not indicate any statistically significant differences in success rates when mineral trioxide aggregate was compared to other materials (95% confidence interval: 0.239 to 1.016; p = 0.055). The present research systematically evaluates the evidence and summarizes the available data on partial pulpotomy in young permanent teeth. Given its high clinical and radiographic success rate, partial pulpotomy should be considered when vital pulpal therapy needs to be performed in highly damaged young permanent teeth, as this procedure provides a biological benefit and allows more invasive endodontic treatments to be postponed.

Chitosan (CS)/Hydroxyapatite (HA)/Tricalcium Phosphate (β-TCP)-Based Composites as a Potential Material for Pulp Tissue Regeneration

This research focused on developing new materials for endodontic treatments to restore tissues affected by infectious or inflammatory processes. Three materials were studied, namely tricalcium phosphate β-hydroxyapatite (β-TCP), commercial and natural hydroxyapatite (HA), and chitosan (CS), in different proportions. The chemical characterization using infrared spectroscopy (FTIR) and X-ray diffraction (XRD) analysis confirmed the composition of the composite. Scanning electron microscopy (SEM) demonstrated that the design and origin of the HA, whether natural or commercial, did not affect the morphology of the composites. In vitro studies using Artemia salina (A. salina) indicated that all three experimental materials were biocompatible after 24 h, with no significant differences in mortality rate observed among the groups. The subdermal implantation of the materials in block form exhibited biocompatibility and biodegradability after 30 and 60 days, with the larger particles undergoing fragmentation and connective tissue formation consisting of collagen type III fibers, blood vessels, and inflammatory cells. The implanted material continued to undergo resorption during this process. The results obtained in this research contribute to developing endodontic technologies for tissue recovery and regeneration.

Micro-CT analysis and leakage of bioceramic retrofillings after ultrasonic and Er:YAG laser cavity preparations: an in vitro study

The purpose of the study was to determine the influence of preparation techniques on marginal adaptation and sealing of Biodentine™ and TotalFill® RRM bioceramic retrograde fillings. Fifty-two single-root teeth extracted for periodontal reasons were used. Root canals were instrumented using Reciproc Blue #25 and obturated using a single cone technique with an AH Plus® root canal sealer. Retrograde cavities were prepared with Piezomed device (Piezo), Er:YAG laser in short-pulse(SP) and quantum square pulse(QSP) modes and filled with Biodentine™ (BD) or TotalFill® RRM (TF). There were 6 groups (n=8): (1) Piezo BD, (2) Piezo TF, (3) SP BD, (4) SP TF, (5) QSP BD, and (6) QSP TF, and positive and negative controls (n=2). Micro-CT analysis was performed on two samples from each group. Percentage volumes of internal and external voids in apical 1.5 mm were determined. Rhodamine B dye leakage was done on six samples. The samples were cut longitudinally and examined under a stereomicroscope. Digital recordings were analyzed in ImageJ software. The deepest penetration of color in mm was recorded. The data were statistically analyzed using ANOVA and Duncan's test at the level of significance α=0.05. TotalFill® RRM performed significantly better than Biodentine™ in terms of sealing (p<0.05) and marginal adaptation, as evaluated by micro-CT. Sealing was significantly better in SP compared to QSP mode preparations (p<0.05). Differences between Piezomed and laser modes were not significantly different (p>0.05). Sealing was statistically significantly better with TotalFill® RRM compared to Biodentine™ and in Er:YAG SP preparations compared to Er:YAG QSP.

Host defense peptides combined with MTA extract increase the repair in dental pulp cells: in vitro and ex vivo study

Host Defense Peptides (HDPs) have, in previous studies, been demonstrating antimicrobial, anti-inflammatory, and immunomodulatory capacity, important factors in the repair process. Knowing these characteristics, this article aims to evaluate the potential of HDPs IDR1018 and DJK-6 associated with MTA extract in the repair process of human pulp cells. Antibacterial activity of HDPs, MTA and HDPs combined with MTA in Streptococcus mutans planktonic bacteria and antibiofilm activity was evaluated. Cell toxicity was assayed with MTT and cell morphology was observed by scanning electron microscopy (SEM). Proliferation and migration of pulp cells were evaluated by trypan blue and wound healing assay. Inflammatory and mineralization related genes were evaluated by qPCR (IL-6, TNFRSF, DSPP, TGF-β). Alkaline phosphatase, phosphate quantification and alizarin red staining were also verified. The assays were performed in technical and biological triplicate (n = 9). Results were submitted for the calculation of the mean and standard deviation. Then, normality verification by Kolmogorov Smirnov test, analyzing one-way ANOVA. Analyses were considered at a 95% significance level, with a p-value < 0.05. Our study demonstrated that HDPs combined with MTA were able to reduce biofilms performed in 24 h and biofilm performed over 7 days S. mutans biofilm (p < 0.05). IDR1018 and MTA, as well as their combination, down-regulated IL-6 expression (p < 0.05). Tested materials were not cytotoxic to pulp cells. IDR1018 induced high cell proliferation and combined with MTA induced high cellular migration rates in 48 h (p < 0.05). Furthermore, the combination of IDR1018 and MTA also induced high expression levels of DSPP, ALP activity, and the production of calcification nodules. So, IDR-1018 and its combination with MTA could assist in pulp-dentine complex repair process in vitro.

Clinical applications of calcium silicate-based materials: a narrative review

Calcium silicate-based materials are hydrophilic materials with biocompatibility and bioactivity properties. Despite many advantages, they might present some problems related to discolouration, setting time, manipulation and solubility depending on the composition of the product and the type of clinical application. Calcium silicate-based materials can be evaluated under two types according to their intended use: calcium silicate-based cements (CSCs) and calcium silicate-based sealers (CSSs). CSCs can be used in many endodontic procedures including perforation repair, resorption repair, apical barriers, guided endodontic repair, vital pulp treatment, endodontic surgery, root fractures and root canal filling as a core obturation material. CSSs are available for use with gutta-percha to obturate root canals using cold and warm techniques, including the sealer-based obturation technique. The purpose of this review is to evaluate the available literature on CSCs and CSSs and to provide up-to-date information and recommendations for their clinical applications.

Vital pulp therapy for permanent teeth with diagnosis of irreversible pulpitis: biological basis and outcome

Root canal treatment (RCT) has been considered the conventional standard for the management of teeth with carious pulp exposure, particularly in mature teeth presenting with symptoms. Following a better understanding of the histopathology of deep carious lesions, the histology of the cariously exposed pulp and the healing potential of the inflamed pulp, vital pulp therapy (VPT) is increasingly adopted around the world for the management of permanent teeth with clinical signs and symptoms indicative of irreversible pulpitis. Furthermore, VPT became a recognized treatment modality by the European Society of Endodontology (ESE) and the American Association of Endodontists (AAE) by virtue of its high success rates reported in outcome studies using contemporary hydraulic calcium silicate-based cements. However, proper case selection, strict asepsis, capping materials and good coronal seal are mandatory for success. The aim of this paper is to review the biological basis for VPT in symptomatic teeth with carious pulp exposure and to report on the outcome of pulpotomy in teeth with clinical diagnosis of irreversible pulpitis.

Innovations in Geriatric Oral Health Care

Older adults are retaining their teeth and need strategies for a lifetime of oral health care. Daily prevention and professional preventive care have the most significant impacts on reducing oral disease in the aging population. Providers of oral health care extend beyond traditional dental professionals to include caregivers and health care providers through teledentistry and interprofessional collaboration. Dental and aging organizations advocate for the inclusion of a dental benefit in Medicare to address access to care. Innovations in geriatric oral health care involve advances in clinical oral health care, delivery and models of care, funding, research, education, and policy.

Influence of the restoration after pulpotomy on the strength of electrical stimulus reaching the pulp space: An in vitro investigation

Introduction

The study evaluated the influence of coronal restoration after pulpotomy on the strength of electrical stimulus reaching the radicular pulp using an electric pulp test (EPT).

Materials and Methods

The pulp tissue from ten freshly extracted mandibular premolar teeth was removed and replaced with an electroconductive gel. The cathode probe of Powerlab was inserted into the pulp space and the anode probe was attached to the EPT handpiece. The EPT probe coated with electro-conducting material was positioned in the middle third of the buccal crown surface. The EPT stimulus reaching the pulp space of an intact tooth at 40 numerical readings was recorded. The tooth was removed from model and endodontic access was made. The 2-mm thick mineral trioxide aggregate was placed at the cementoenamel junction followed by composite resin restoration. The experimental setup was re-established and postpulpotomy EPT stimulus data were recorded. The data collected were compared using the Wilcoxon signed-rank test.

Results

There was a statistically significant difference (P = 0.038) between observed between the strength of EPT stimulus reaching the pulp space in prepulpotomy (mean 91.18 ± 101.02 V and median 25.79 V) and postpulpotomy (mean 58.49 ± 77.13 V and median 13.75 V) tooth samples.

Conclusion

The placement of the restoration and pulp capping agent after pulpotomy dampens the strength of EPT stimulus reaching the pulp canal space.

Factors Affecting the Decision-Making of Direct Pulp Capping Procedures Amongst Dental Practitioners: A Multinational Survey from 16 Countries with Meta-Analysis

BACKGROUND

Direct pulp capping (DPC) procedures require the placement of a bioactive material over an exposure site without selective pulp tissue removal. This web-based multicentered survey had three purposes: i) to investigate the factors that affect clinicians' decisions in DPC cases, ii) to determine which method of caries removal is preferred, and iii) to evaluate the preferred capping material for DPC.

METHODS

The questionnaire comprised three sections. The first part comprised questions regarding demographic features. The second part comprised questions on how treatment plans change according to factors such as nature, location, number and size of the pulp exposure and patients' age. The third part composed of questions on the common materials and techniques used in DPC. To estimate the effect size, the risk ratio (RR) and 95% confidence interval (CI) were calculated using a meta-analysis software.

RESULTS

A tendency towards more invasive treatment was observed for the clinical scenario with carious-exposed pulp (RR=2.86, 95% CI:2.46,2.32; p<0.001) as opposed to the clinical scenario with two pulp exposures (RR=1.38, 95% CI:1.24,1.53; p<0.001). Complete caries removal was significantly preferred to selective caries removal (RR=4.59, 95% CI: 3.70, 5.69; p<0.001). Among the capping materials, calcium silicate-based materials (CS) were preferred over calcium hydroxide-based materials (CH) (RR=0.58, 95% CI: 0.44,0.76; p<0.05).

CONCLUSION

While carious-exposed pulp is the most important factor in clinical decisions regarding DPC, the number of exposures has the least impact. Overall, complete caries removal was preferred over selective caries removal. In addition, the use of CS appears to have replaced CH.

In Vivo Assessment of the Apatite-Forming Ability of New-Generation Hydraulic Calcium Silicate Cements Using a Rat Subcutaneous Implantation Model

Hydroxyapatite formation on endodontic hydraulic calcium silicate cements (HCSCs) plays a significant role in sealing the root canal system and elevating the hard-tissue inductivity of the materials. This study evaluated the in vivo apatite-forming ability of 13 new-generation HCSCs using an original HCSC (white ProRoot MTA: PR) as a positive control. The HCSCs were loaded into polytetrafluoroethylene tubes and implanted in the subcutaneous tissue of 4-week-old male Wistar rats. At 28 days after implantation, hydroxyapatite formation on the HCSC implants was assessed with micro-Raman spectroscopy, surface ultrastructural and elemental characterization, and elemental mapping of the material-tissue interface. Seven new-generation HCSCs and PR had a Raman band for hydroxyapatite (v1 PO₄^3- band at 960 cm^-1) and hydroxyapatite-like calcium-phosphorus-rich spherical precipitates on the surfaces. The other six HCSCs with neither the hydroxyapatite Raman band nor hydroxyapatite-like spherical precipitates did not show calcium-phosphorus-rich hydroxyapatite-layer-like regions in the elemental mapping. These results indicated that 6 of the 13 new-generation HCSCs possessed little or no ability to produce hydroxyapatite in vivo, unlike PR. The weak in vivo apatite-forming ability of the six HCSCs may have a negative impact on their clinical performance.

Bioceramics in Endodontics: Updates and Future Perspectives

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

Real-time evaluation of the biocompatibility of calcium silicate-based endodontic cements: An in vitro study

INTRODUCTION

An ideal filling material should hermetically seal the communication pathways between the canal system and surrounding tissues. Therefore, during the last few years, the development of obturation materials and techniques to create optimal conditions for the proper healing of apical tissues has been a focus of interest. The effects of calcium silicate-based cements (CSCs) on periodontal ligament cells have been investigated, and promising results have been obtained. To date, there are no reports in the literature that have evaluated the biocompatibility of CSCs using a real-time live cell system. Therefore, this study aimed to evaluate the real-time biocompatibility of CSCs with human periodontal ligament cells (hPDLCs).

METHODOLOGY

hPDLC were cultured with testing media of endodontic cements for 5 days: TotalFill-BC Sealer, BioRoot RCS, Tubli-Seal, AH Plus, MTA ProRoot, Biodentine, and TotalFill-BC RRM Fast Set Putty. Cell proliferation, viability, and morphology were quantified using real-time live cell microscopy with the IncuCyte S3 system. Data were analyzed using the one-way repeated measures (RM) analysis of variance multiple comparison test (p < .05).

RESULTS

Compared to the control group, cell proliferation in the presence of all cements was significantly affected at 24 h (p < .05). ProRoot MTA and Biodentine lead to an increase in cell proliferation; there were no significant differences with the control group at 120 h. In contrast, Tubli-Seal and TotalFill-BC Sealer inhibited cell growth in real-time and significantly increased cell death compared to all groups. hPDLC co-cultured with sealer and repair cements showed a spindle-shaped morphology except with cements Tubli-Seal and TotalFill-BC Sealer where smaller and rounder cells were obtained.

CONCLUSIONS

The biocompatibility of the endodontic repair cements performed better than the sealer cements, highlighting the cell proliferation of the ProRoot MTA and Biodentine in real-time. However, the calcium silicate-based TotalFill-BC Sealer presented a high percentage of cell death throughout the experiment similar to that obtained.

A comparative histological study of the effect of TheraCal LC and biodentine on direct pulp capping in rabbits: an experimental study

OBJECTIVES

This study histologically compared the effect of TheraCal LC and biodentine on direct pulp capping using a rabbit model.

MATERIALS AND METHODS

A direct pulp capping procedure was performed on 40 mandibular central incisors of 20 healthy, male New Zealand white rabbits. TheraCal LC and biodentine were applied to exposed pulp and 10 randomly selected rabbits were euthanized after the first and second week. Incisors were extracted and prepared for histological processing and examination to check the dentine bridge thickness, continuity, and extent of pulp inflammation. A blinded data analysis was performed, and groups were compared using a Wilcoxon signed-rank test while changes across time within each group were assessed using the Mann-Whitney U test.

RESULTS

When comparing the dentine bridge thickness, biodentine showed a significantly thicker dentine bridge in the first and second week (mean 28.16 µm, 33.66 µm), while TheraCal LC showed a dentine bridge in the second week only (mean 15.93 µm). Regarding dentine bridge continuity, biodentine showed a significantly better dentine bridge in the first week. Additionally, there was no difference in the second week. Furthermore, there was no statistically significant difference between each of the materials regarding the extent of inflammation.

CONCLUSIONS

Biodentine in vivo showed better results concerning thickness and continuity of the dentine bridge after direct pulp capping in rabbit incisors. Both biodentine and TheraCal LC had a similar inflammatory effect on the pulp.

CLINICAL RELEVANCE

Biodentine is more successful as a direct pulp capping material compared to TheraCal LC.

Microstructure and color stability of calcium silicate-based dental materials exposed to blood or platelet-rich fibrin

OBJECTIVES

To investigate the effects of blood and platelet-rich fibrin (PRF), commonly used scaffolds in regenerative endodontic treatment (RET), on the hydration, microstructure, and color stability of three hydraulic calcium silicate cements (HCSCs), OrthoMTA, RetroMTA, and TotalFill-BC-RRM.

MATERIALS AND METHODS

The HCSCs were prepared and placed into polyethylene molds and transferred to Eppendorf tubes containing PRF, blood, or PBS and then incubated for 1 week or 1 month. The microstructure and hydration of the cements were studied by scanning electron microscopy (SEM), energy-dispersive X-ray spectroscopy (EDS), and X-ray diffraction (XRD). The chromatic alteration of materials was also measured using a spectrophotometer. The data for color stability were analyzed using 2-way analysis of variance and Tukey post hoc tests.

RESULTS

There was no significant difference between the color stability of cements exposed to PBS (p > 0.05). The chromatic alteration of cements exposed to blood was significantly greater than those exposed to PRF and PBS (p < 0.001). In the presence of blood and PRF, the color change of OrthoMTA was significantly greater than that of RetroMTA and TotalFill (p < 0.05), with no significant difference between RetroMTA and TotalFill (p > 0.05). XRD analysis of all cements revealed a calcium hydroxide peak after 1-week and 1-month exposure to the media; however, OrthoMTA and TotalFill exposed to blood and PRF for 1 month showed weaker calcium hydroxide peaks. SEM images revealed cements exposed to PBS had a different surface microstructure compared to those exposed to blood and PRF. Furthermore, the surface microstructure of HCSCs was influenced by the type of cement radiopacifier (bismuth oxide or zirconium oxide). EDS analysis of the elemental composition in all groups displayed peaks of Ca, O, C, Si, P, and Al.

CONCLUSIONS

Color stability, hydration behavior, and microstructure of HCSCs were affected by exposure to PRF and blood and the type of cement radiopacifier.

CLINICAL RELEVANCE

As some important physicochemical properties of HCSCs could be influenced by the environmental conditions and the type of radiopacifier, alternatives to blood clot and HCSCs containing substitutes for bismuth oxide might be more suitable in RETs.

Efficacy of Different Solvents for Achieving Patency in Teeth Obturated Using Bioceramic Sealer

INTRODUCTION

The retreatment of teeth obturated with bioceramic sealers has been shown to be challenging. The purpose of this study was to compare the efficacy of 10% formic acid (FA), 20% hydrochloric acid (HCl), and chloroform for achieving patency in teeth obturated with a bioceramic sealer.

METHODS

Forty-five extracted single-canal teeth were instrumented and obturated 1.5 mm short of the working length using gutta-percha and EndoSequence BC Sealer (Brasseler USA, Savannah, GA). Two weeks later, gutta-percha was removed, and apical patency was attempted with a 10 C-file and a solvent (FA, HCl, or chloroform). The time to gain patency through EndoSequence BC Sealer was recorded. Five additional teeth were irrigated with the solvents, and scanning electron microscopy was used to evaluate the effect of solvents on the dentin. The Kruskal-Wallis and Mann-Whitney tests were used for statistical analysis.

RESULTS

Patency was achieved in all canals, except for 1 in the chloroform group. Regarding the time to achieve patency, no significant difference was noted between chloroform and FA (P > .05). However, there was a significant difference between chloroform and HCl (P < .05) and between FA and HCl (P < .05). The erosion of dentinal tubules was more evident when HCl was used compared with the other irrigants.

CONCLUSIONS

Twenty percent HCl was superior to 10% FA and chloroform in achieving patency in teeth obturated with EndoSequence BC Sealer. Regardless of the solvent used, patency may be achieved for most of the cases obturated with gutta-percha and EndoSequence BC Sealer.

Role of mineral trioxide aggregate in dentistry: A bibliometric analysis using Scopus database

OBJECTIVES

Mineral trioxide aggregate (MTA) has a long history of providing predictable clinical outcomes in dental applications especially in endodontic procedures. This bibliometric analysis aimed at evaluating the advancements of research in mineral trioxide aggregate and its use in the field of dentistry, together with the detection of most significant authors, organizations, countries, journals, papers, and the exploration of commonly used keywords using a structured approach.

MATERIALS AND METHOD

The search was conducted using the Elsevier's Scopus database, gathering publication information related to MTA published from 1993 and 2021 July. Metadata comprising of titles, abstracts, keywords, authors, organizations, and countries were obtained. Bibliometric evaluators with respect to authors, articles published, journals, keywords, and top countries were scrutinized. Data was analyzed using VOS viewer.

RESULTS

Between 1993 and 2021, an uptrend in the research performed on MTA was identified. Researchers from United States, Brazil, and Iran actively contributed on MTA, while papers from USA were highly cited. The Journal of Endodontics along with International Endodontic Journal were the top contributing academic journals. Hacettepe University, Turkey and Cardiff University from United Kingdom were the top most contributing organizations. Mahmoud Torabinejad was the most cited author. Most commonly used keywords included Mineral trioxide aggregate, silicate, oxide, root canal filling material.

CONCLUSION

The global rise in the number of publications on mineral trioxide aggregate, tremendous networking and citations have been identified amongst various organizations, authors, and nations through this bibliometric analysis.

Bioactivity analysis of calcium silicate-based sealers and repair cements on the phenotype and cytokine secretion profile of CD14+ monocytes: An ex vivo study

AIM

This study evaluated the immune bioactivity of testing media (TM) obtained from different calcium silicate-based sealers and cements on monocyte morphology, activation, differentiation and cytokine secretion.

METHODS

Blood-derived CD14⁺ monocytes were isolated and cultured for 5 days with 25% TM from the following calcium silicate-based materials: TotalFill BC RRM Fast-Set Putty, Biodentine, TotalFill BC Sealer and BioRoot-Root-Canal-Sealer (RCS). A resin-based endodontic cement was used as a control. The expression of surface markers such as CD86, HLA-DR, CD16, CD309 and CD209, and cytokine secretion were analysed by flow cytometry. Data were analysed using the one-way repeated measures analysis of variance (anova) multiple comparison test and a Holm-Sidak multiple comparison post-hoc test (p < .05).

RESULTS

This comparative analysis revealed that monocytes co-cultured with calcium silicate-based materials showed a spindle-shaped morphology compared with the round shape observed in the control. Regarding activation markers, BioRoot-RCS and Biodentine significantly increased CD86 expression compared with the control sample, whereas no significant differences (p > .05) were observed in HLA-DR expression. In addition, no differences were observed among the differentiation markers. When the inflammatory cytokines were analysed, BioRoot-RCS increased the secretion of IL-1β, IL-6, IL-10 and TNF-α, whereas BioRoot-RCS and Biodentine significantly decreased IL-8 production (p < .05).

CONCLUSIONS

These data showed that the calcium silicate-based materials tested changed the morphology of CD14⁺ monocytes; however, only BioRoot-RCS and Biodentine significantly upregulated CD86. In addition, BioRoot-RCS was the sealer with the highest immunomodulatory properties for cytokine production which means that it can contribute with the in vivo healing process and regeneration of periapical lesions.

Interleukin-6, tumor necrosis factor-α, and CD5 immunolabeling of new experimental endodontic sealer and repair material

The aim of this study was to evaluate the biocompatibility and immunoinflammatory response of the Sealepox and Sealepox-RP, based on interleukin (IL)-6, tumor necrosis factor (TNF)-α, and CD5 immunolabelling. The ProRoot MTA (PRMTA) was used for comparison. Polyethylene tubes (1.0-mm internal, 1.6-mm external diameter, and 10.0-mm length; ISO 10993) with or without (control) materials were randomly implanted in the dorsum of 35 rats (4 per rat). After 7, 15, 30, 60, and 90 days (n = 7), the tubes were removed for histological and immunohistochemical analysis. The Kruskal-Wallis and Dunn's test for non-parametric data and, ANOVA and Tukey test for parametric data were used (P < 0.05). Hematoxylin and eosin staining revealed that the concentration of inflammatory cells decreased over time with no differences between groups in all periods (P > 0.05). Regarding IL-6 immunostaining, there was no difference at 7 days (P > 0.05); all groups decreased over time, being faster for the PRMTA group and also, with no differences between groups in the last period (P > 0.05). For TNF-α, at 7 days there was no difference between groups (P > 0.05); there was an increase at 15 days for PRMTA and, at 30 and 60 days, for PRMTA and Sealepox compared to the control (P < 0.05). At 90 days, Sealepox RP showed the lowest immunostaining being similar to the control (P > 0.05). Regarding CD5 cells, at 7 days, there was high immunostaining for PRMTA compared to the control (P < 0.05); and significant reduction over time with difference for all groups at 30 and 60 days. (P < 0.05); Sealepox was similar to the control in all periods (P > 0.05). Sealepox RP showed the highest immunostaining at 15 days, being different from the control and PRMTA (P < 0.05); in the other periods it was similar to the control (P > 0.05). It can be concluded that Sealepox and Sealepox-RP were biocompatible and demonstrated similar immunoinflammatory response regarding IL-6, TNF-α, and CD5 compared to PRMTA.

Mechanism of action of Bioactive Endodontic Materials

A continuous search for bioactive materials capable of supporting the replacement of damaged pulp tissue, with effective sealing potential and biocompatibility, has represented the attention of studies over the last decades. This study involves a narrative review of the literature developed by searching representative research in PUBMED/MEDLINE and searches in textbooks associated with the mechanism of action of bioactive materials (calcium hydroxide, mineral trioxide aggregate (MTA), and calcium silicate cements). The reflective analysis of the particularities of the chemical elements of these materials, considering the tissue and antibacterial mechanism of action, allows a better understanding of the characteristics and similarities in their tissue responses. Calcium hydroxide paste remains the antibacterial substance of choice as intracanal dressing for the treatment of root canal system infections. Calcium silicate cements, including MTA, show a favorable biological response with the stimulation of mineralized tissue deposition in sealed areas when in contact with connective tissue. This is due to the similarity between the chemical elements, especially ionic dissociation, the potential stimulation of enzymes in tissues, and the contribution towards an alkaline environment due to the pH of these materials. The behavior of bioactive materials, especially MTA and the new calcium silicate cements in the biological sealing activity, has been shown to be effective. Contemporary endodontics has access to bioactive materials with similar properties, which can stimulate a biological seal in lateral and furcation root perforations, root-end fillings and root fillings, pulp capping, pulpotomy, apexification, and regenerative endodontic procedures, in addition to other clinical conditions.

Evaluation of biodentine pulpotomy in caries-exposed symptomatic vital mature permanent teeth in 9‒13-year-old children: A 24-month clinico-radiographic observation

BACKGROUND

The present study evaluated the clinical and radiographic outcomes of Biodentine pulpotomy for 24 months in symptomatic vital mature permanent teeth with caries exposure.

METHODS

Seventy-three patients with a chief complaint of spontaneous pain in permanent teeth were screened. Finally, 47 mature permanent teeth underwent a Biodentine pulpotomy procedure. Clinical evaluation of 47 teeth was carried out at 1, 3, 6, 9, 12, and 24 months and radiographic evaluations were made at 6, 12, and 24 months. The success of Biodentine pulpotomy was evaluated using Pearson's chi-square test. The significance level was determined at P<0.05.

RESULTS

At 24 months, the clinical and radiographic success rate was 97.78%, with only one clinical failure at 9 months.

CONCLUSION

The clinical and radiographic success of Biodentine pulpotomy was high (97.78%). Thus, Biodentine pulpotomy can be an alternative to root canal treatment (RCT) in symptomatic vital mature permanent teeth.

Successful Orthograde Treatment of Teeth with External Inflammatory Root Resorption and Perforation Using a Tricalcium Silicate-Based Material

One possible consequence of dentoalveolar trauma is the development of external inflammatory root resorption (EIRR), which represents an anatomic and microbiologic challenge for clinicians. This case report describes different strategies implemented for successful endodontic management of teeth with multiple EIRR lesions, highlighting the orthograde root canal filling using a tricalcium silicate-based material (Biodentine, Septodont, Saint-Maur-des-Fossés, France). A 17-year-old female patient presented with severe pain in the anterior maxillary teeth and a history of trauma. Two- and three-dimensional radiographic exams confirmed EIRR in three teeth, with a total of 11 EIRR lesions, three exhibiting communication with the root canal. Therefore, chemo-mechanical preparation complemented by ultrasonic activation of irrigants and some changes of intra-canal dressing with calcium hydroxide were performed to reduce the microbiologic load of the affected teeth as much as possible. Then, the canals were entirely filled with Biodentine to interrupt the root resorption process and strengthen the remaining root structure. A 60-month follow-up showed the disappearance of bone rarefactions and the complete repair of the 11 EIRR lesions. The favorable long-term response indicates the feasibility of using tricalcium silicate-based putty as part of orthograde endodontic treatment of teeth with EIRR and root perforations.

Evaluation of Cytotoxic Effect of Graphene Oxide Added to Mineral Trioxide Aggregate

Aim:

Recently, although studies have shown that biomaterials containing graphene oxide (GO) in biomedicine stand out for their positive effects, the effect of GO on dental tissues when used with dental materials is not well known. The aim of this study was an evaluation of the cytotoxic effects of GO on gingival fibroblasts when it is combined in two different ratios with Mineral Trioxide Aggregate (MTA).

Materials and Methods:

In this in-vitro study, a homogenous mixture of adding +0.1 weight (wt)% and +0.3 wt% GO to Angelus MTA was created (two experimental groups) and compared with pure Angelus MTA and negative control groups. The materials were mixed according to the manufacturer’s instructions, and Teflon molds were used to form 24 disc-shaped samples for each group. The samples were divided into groups according to the simple random sampling method. The cytotoxic effect of samples was determined on gingival fibroblast cells by using the MTT test, and total oxidant status (TOS) and total antioxidant capacity (TAC) kits in 24 and 72 hours. The data were statistically analyzed using one-way ANOVA and Tukey tests.

Results:

A significant difference was found between the material-applied groups and the control group at the TAC 24 and 72 hours and between the groups containing GO and the control group at the MTT 72 hours and TAC and TOS 24 and 72 hours ( p < .05).

Conclusion:

The addition of GO to MTA increased the dose and time-based toxicity and oxidant amount, and decreased antioxidant capacity.