Outcome of full pulpotomy in mature permanent molars using 3 calcium silicate-based materials: A parallel, double blind, randomized controlled trial

Outcome and Prognostic Factors for Partial and Full Pulpotomy in the Management of Spontaneous Symptomatic Pulpitis in Carious Mature Permanent Teeth: A Randomized Clinical Trial

INTRODUCTION

The aim of this study was to compare the outcome and prognostic factors for partial and full pulpotomy in the management of mature teeth with spontaneous symptomatic pulpitis.

METHODS

The study was a parallel double-blind randomized clinical trial; 200 carious mature permanent teeth with spontaneous symptomatic pulpitis were randomized using a block randomization technique to either partial pulpotomy (n = 99) or full pulpotomy (n = 101). Intraoperative assessment of the pulp under magnification was performed, hemostasis was achieved with a 2.5% sodium hypochlorite moist pellet, and NeoPUTTY (Avalon Biomed, Bradenton, FL) was the pulpotomy material. Preoperative pain levels were recorded and re-evaluated after 1 week. Clinical and radiographic evaluation was performed after 6 and 12 months. Data were analyzed using the chi-square test, the Wilcoxon rank test, and regression analysis.

RESULTS

At 1 week, immediate failure occurred in 4 cases in partial pulpotomy, and 196 of 200 subjects reported pain relief and were satisfied with the treatment with no significant difference. At 6 months, 6 teeth failed in the partial pulpotomy group and 1 tooth in the full pulpotomy group, with a higher success rate for full pulpotomy (98.96 vs 89.69, P = .003). At 12 months, the recall rate was 98% (96/200). Full pulpotomy was more successful than partial pulpotomy (98.98% [98/99] vs 84.53% [82/97], P < .001). Multivariate analysis revealed that the odds of success for full pulpotomy were 13.6 times higher than partial pulpotomy. Increased age and higher time to hemostasis were significantly associated with decreased odds of success.

CONCLUSIONS

Full pulpotomy has a higher success rate than partial pulpotomy in the management of spontaneous symptomatic pulpitis. Hemostasis within 4 minutes in partial pulpotomy can be set as the cutoff point beyond which further tissue removal is indicated.

Accuracy of an intraoral scanner with near-infrared imaging feature in detection of interproximal caries of permanent teeth: An in vivo validation

OBJECTIVE

This study aimed to evaluate the accuracy of an intraoral scanner with near-infrared imaging (NIRI) feature in the diagnosis of interproximal caries and to compare it with the visual-tactile method (VTM), bitewing radiography (BWR), and panoramic radiography (PR).

MATERIALS AND METHODS

Six hundred thirty-nine interproximal surfaces (mesial-distal) of posterior teeth from 22 volunteers were examined. Results were scored by VTM, BWR, PR, and NIRI. Lesions were scored as 0 for no-caries, 1 for early-enamel lesion (EEL), and 2 for lesions involving dentino-enamel junction (DEJ). McNemar, Kappa, and Fleis Kappa tests were used to evaluate the agreement levels. Pearson's Chi-square test was used to determine the matching rates after validation.

RESULTS

A good level of agreement was observed between examination methods (Ƙ = 0.613; p < 0.001). In pairwise comparisons, a moderate agreement was seen between all the methods for lesions with DEJ involvement, while a statistically good agreement was observed between BWR and NIRI (Ƙ = 0.675; p < 0.001). As a result of validation, the accuracy of NIRI for molars was considered 85.2% and 75.7% for premolars in EELs, 85.2% for molars, and 70% for premolars regarding the lesions involving DEJ.

CONCLUSIONS

Intraoral scanners with the NIRI feature may be used for diagnosing interproximal caries, especially for permanent molars.

CLINICAL SIGNIFICANCE

Early detection of proximal caries is one of the most essential topics forming the basis of preventive dentistry. This study investigates a caries diagnostic tool integrated into intraoral scanners to diagnose interproximal caries. A caries diagnostic tool integrated into an intraoral scanner may prevent the harmful effects of ionizing radiation in early caries diagnosis and may improve the patient's oral health status.

Efficacy of pulpotomy in managing irreversible pulpitis in mature permanent teeth: A systematic review and meta-analysis

OBJECTIVES

This paper evaluated the success rates of pulpotomy, compared its efficacy with non-surgical root canal treatment (NSRCT), evaluated different pulpotomy techniques, and analyzed the effectiveness of contemporary bioactive materials in managing irreversible pulpitis in mature permanent teeth.

DATA SOURCES

A comprehensive literature search was conducted across multiple databases including PubMed, Web of Science, Scopus, and the Cochrane Library. Search was conducted from the inception of each database to the present, adhering to PRISMA 2020 guidelines.

STUDY SELECTION

Studies were selected through a multi-step screening process, focusing on adult populations, randomized controlled trials, and single-arm trials.

DATA

Fifteen randomized controlled trials and eight single-arm trials were included. For a follow-up period of more than 24 months, pooled clinical success rate of pulpotomy was 92.9 % (95 %CI;82.1-99.0 %), whereas pooled radiographic success rate was 78.5 % (95 %CI;66.7-88.4 %). Meta-analyses showed that there was no significant difference in success rates between pulpotomy and NSRCT, between full and partial pulpotomy techniques, or between Mineral Trioxide Aggregate pulpotomy and Calcium Enriched Mixture pulpotomy. The results indicated comparable efficacy across these variables.

CONCLUSIONS

The study highlights the potential of less invasive treatments. Pulpotomy may be a viable alternative to NSRCT for managing irreversible pulpitis in mature permanent teeth. Limitations such as the low quality of some single-arm trials and the high risk of bias in some randomized controlled trials highlight the need for further research to standardize methodologies and broaden literature inclusion for a more comprehensive understanding of the efficacy of pulpotomy, considering the high success rates reported. Clinical Significance This quantitative systematic review recognizes the potential of full or partial pulpotomy as a viable treatment alternative to root canal therapy for managing irreversible pulpitis in mature permanent teeth. Future studies should aim for standardized protocols to validate these findings and improve patient treatment outcomes.

Outcome assessment methods of bioactive and biodegradable materials as pulpotomy agents in primary and permanent teeth: a scoping review

BACKGROUND

Pulpotomy procedures aiming to preserve and regenerate the dentin-pulp complex have recently increased exponentially due to developments in the field of biomaterials and tissue engineering in primary and permanent teeth. Although the number of studies in this domain has increased, there is still scarcity of evidence in the current literature.

OBJECTIVES

(1) Report the methods of outcome assessment of pulpotomy clinical trials in both primary and permanent teeth; (2) Identify the various bioactive agents and biodegradable scaffolds used in pulpotomy clinical trials in both primary and permanent teeth.

MATERIALS AND METHODS

A scoping review of the literature was performed, including a search of primary studies on PubMed, Scopus, Web of Science, ProQuest and Clinicaltrials.gov. A search for controlled trials or randomized controlled trials published between 2012 and 2023 involving primary or permanent teeth receiving partial or full pulpotomy procedures using bioactive/regenerative capping materials was performed.

RESULTS

127 studies out of 1038 articles fulfilled all the inclusion criteria and were included in the current scoping review. More than 90% of the studies assessed clinical and radiographic outcomes. Histological, microbiological, or inflammatory outcomes were measured in only 9.4% of all included studies. Majority of the studies (67.7%) involved primary teeth. 119 studies used non-degradable bioactive cements, while biodegradable scaffolds were used by 32 studies, natural derivates and plant extracts studies were used in only 7 studies. Between 2012 (4 studies) and 2023 (11 studies), there was a general increase in the number of articles published. India, Egypt, Turkey, and Iran were found to have the highest total number of articles published (28, 28,16 and 10 respectively).

CONCLUSIONS

Pulpotomy studies in both primary and permanent teeth relied mainly on subjective clinical and radiographic outcome assessment methods and seldom analyzed pulpal inflammatory status objectively. The use of biodegradable scaffolds for pulpotomy treatments has been increasing with an apparent global distribution of most of these studies in low- to middle-income countries. However, the development of a set of predictable outcome measures as well as long-term evidence from well conducted clinical trials for novel pulpotomy dressing materials are still required.

Novel cryotherapy technique for pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis- a randomized controlled trial

OBJECTIVES

To assess the effect of cryotherapy on haemostasis, post-operative pain, and the outcome of full pulpotomy performed in mature permanent teeth with symptomatic irreversible pulpitis.

MATERIALS AND METHODS

The study included sixty mature permanent mandibular molar teeth with symptomatic irreversible pulpitis and no periapical rarefaction. After coronal pulp tissue amputation, teeth were randomly allocated to one of two groups (n = 30 each). In group I (conventional pulpotomy), a sterile cotton pellet moistened with 2.5% NaOCl was used for haemostasis. In group II (cryotherapy), the pulp chamber was continuously lavaged with 2.50C normal saline solution for haemostasis using an indigenous portable cryotherapy irrigation unit. Following haemostasis, the pulp was capped with mineral trioxide aggregate and the tooth was restored with resin composite. The time taken to achieve haemostasis was recorded. Preoperative and 24, 48 and 72 h postoperative pain was measured using the Numerical Rating Scale. The pulpotomy outcome was assessed at the 12-month follow-up. Data were analyzed using Fischer's exact test, two-sample t-test, two-sample Wilcoxon rank-sum test, Friedman Test, and Wilcoxon Signed Rank Test.

RESULTS

The cryotherapy group achieved haemostasis in less time (p < 0.05). There was a significant pain reduction at 24 and 48 h in the cryotherapy group when compared with the conventional pulpotomy group (P < 0.005). The overall success rate of pulpotomy after 12 months was 88% (n = 22) in both study groups(p < 0.05).

CONCLUSIONS

Cryotherapy application reduces postoperative pain and has no adverse effect on the outcome of pulpotomy in permanent teeth with symptomatic irreversible pulpitis.

CLINICAL RELEVANCE

The cryotherapy can be incorporated in pulpotomy protocol as an adjunct to minimize post-operative pain.

Antibacterial, biocompatible, and mineralization-inducing properties of calcium silicate-based cements

BACKGROUND

Different pulp capping materials have different origins and compositions, require different preparations, and may vary in their bioactive properties.

AIM

The purpose of this study was to evaluate the antibacterial activity, biocompatibility, and mineralization-inducing potential of calcium silicate-based pulp capping materials.

DESIGN

Six contemporary calcium silicate-based cements, ProRoot MTA, MTA Angelus, Biodentine, EndoSequence, NeoMTA 2, and NeoPutty, were evaluated. The antibacterial effects of these materials against Streptococcus mutans UA159 and Enterococcus faecalis ATCC 29212 were determined by the agar diffusion assay and the direct culture test. The biocompatibility and mineralization-inducing potential of these materials in preodontoblastic 17IIA11 cells were evaluated by the MTT assay and by Alizarin Red S staining, respectively.

RESULTS AND CONCLUSION

In agar diffusion test, only Biodentine showed distinct antibacterial effects against S. mutans. All the tested materials, however, showed antibacterial effects against S. mutans and E. faecalis in the direct culture test, with Biodentine showing the strongest growth inhibition against both S. mutans and E. faecalis. All the tested materials showed acceptable biocompatibility and mineralization-supporting potential in our experimental conditions. In summary, ProRoot MTA, MTA Angelus, Biodentine, EndoSequence, NeoMTA 2, and NeoPutty demonstrated acceptable in vitro antimicrobial, biocompatible, and mineralization-supporting properties.

One-year radiographic and clinical performance of bioactive materials in primary molar pulpotomy: A randomized controlled trial

OBJECTIVES

Mineral Trioxide Aggregate (MTA) is considered the gold standard material for pulpotomy procedures. However, some drawbacks such as poor handling and long setting time are challenging when it is used as pulpotomy dressing in primary molars in children. Hence, the purpose of this study was to compare the radiographic and clinical performance of a premixed, fast setting bioceramic root repair material (BC RRM-F) with MTA in vital pulpotomy procedures of primary molars, with or without the added seal of a stainless steel crown (SSC).

METHODS

In this double blinded, four-arm, parallel group randomized contolled trial (RCT), 64 primary molars were randomly allocated to one of the four treatment groups: MTA (PDTM MTA WHITE)+SSC, MTA+GI (bulk fill glass ionomer with glass hybrid technology GC EQUIA Forte® HT), BC RRM-F+GI and BC RRM-F+SCC. All molars were evaluated clinically and radiographically according to the modified Zurn and Seale criteria at 1, 3, 6, and 12 months follow up. Multivariate cox regression models and Kaplan-Meier curves were used for survival analysis.

RESULTS

There was no statistically significant difference between the success of both pulp capping materials used. Overall survival analysis showed that using GI instead of SCC as a final restorative material was significantly associated with increased risk of failure.

CONCLUSIONS

TotalFill® BC RRM™ Fast Set Putty can be used as an alternative to MTA in primary molar pulpotomy. Regardless of the pulp capping material, one year survival of pulpotomized primary molars restored with SSC is higher compared to those restored with GC EQUIA Forte® HT.

CLINICAL SIGNIFICANCE

Clinicians' preference and cost effectiveness may justify the use of either material in primary molar pulpotomy. Parents insisting on tooth-colored restorations for their children's pulpotomized teeth cannot be told that the expectation for success is the same as those restored with SSC, even if calcium silicate-based pulp capping materials are used.

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.

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.

Effects of natural antimicrobial compounds propolis and copaiba on periodontal ligament fibroblasts, molecular docking, and in vivo study in Galleria mellonella

Root canal treatment addresses infectious processes that require control. Occasionally, the radicular pulp is vital and inflamed, presenting a superficial infection. To preserve pulpal remnants, conservative procedures have gained favor, employing anti-inflammatory medications. This study investigated the effects of propolis (PRO), and copaiba oil-resin (COR) associated with hydrocortisone (H) and compared their impact to that of Otosporin® concerning cytotoxic and genotoxic activity, cytokine detection, and toxicity in the Galleria mellonella model. Human periodontal ligament fibroblasts (PDLFs) were exposed to drug concentrations and evaluated by the MTT assay. Associations were tested from concentrations that did not compromise cell density. Genotoxicity was evaluated through micronucleus counting, while cytokines IL-6 and TGF-β1 were detected in the cell supernatant using ELISA. Molecular docking simulations were conducted, considering the major compounds identified in PRO, COR, and H. Increasing concentrations of PRO and COR were assessed for acute toxicity in Galleria mellonella model. Cellular assays were analyzed using one-way ANOVA followed by Tukey tests, while larval survivals were evaluated using the Log-rank (Mantel-Cox) test (α = 0.05). PRO and COR promoted PDLFs proliferation, even in conjunction with H. No changes in cell metabolism were observed concerning cytokine levels. The tested materials induce the release of AT1R, proliferating the PDFLs through interactions. PRO and COR had low toxicity in larvae, suggesting safety at tested levels. These findings endorse the potential of PRO and COR in endodontics and present promising applications across medical domains, such as preventive strategies in inflammation, shedding light on their potential development into commercially available drugs.

Outcomes and predictive factors of vital pulp therapy in a large-scale retrospective cohort study over 10 years

This cohort study evaluated the long-term success/survival of vital pulp therapies (VPTs) after carious pulp exposure in adult teeth. Additionally, factors influencing long-term success were identified. Teeth treated during 2011-2022 in a private clinic were studied with clinical/radiographic follow-ups. Data included patient demographics, tooth specifics, and treatment details. Outcomes were classified as success/failure based on clinical/radiographic findings, with tooth functionality determining the survival rate. Encompassing 1149 patients and 1257 VPT-treated teeth, the average monitoring period was 42.2 months. Overall VPTs' survival and success rates were 99.1% and 91.6%, respectively. Success rates for 768 direct pulp cappings, 217 miniature pulpotomies, and 272 full pulpotomies were 91.9%, 92.6%, and 90.1%, respectively (P > 0.05). Influencing factors included symptomatic irreversible pulpitis (SIP; HR 1.974, 95% CI 1.242-3.137; P = 0.004), radiographic signs of apical periodontitis (AP; HR 2.983, 95% CI 1.961-4.540; P < 0.001), restoration type (HR 2.263, 95%CI 1.423-3.600; P = 0.001), and restoration surfaces (HR 1.401, 95%CI 1.034-1.899; P = 0.030). This study concludes that VPT techniques consistently exhibit high long-term success/survival rates in treating carious pulp exposures. Critical predictors include initial clinical signs of SIP/AP, caries extent, and use of composite restorations.

Modern methods and materials used to treat root perforation: effectiveness comparison

This study aims to experimentally compare the efficacy of different endodontic materials (iRoot BP Plus, Biodentine, MTA, Rootdent, and Trioxide) in the treatment of pulpitis and perforations on extracted tooth specimens. Additionally, the study aims to investigate the influence of iRoot BP Plus endodontic material on the regenerative processes following pulp amputation in laboratory animals. The secondary goal is to evaluate the effect of iRoot BP Plus on the restoration process in laboratory animals after pulp removal. The study presents a micropermeability analysis of the selected biomaterials performed on a sample of 50 single-rooted apical teeth in 2022. All teeth underwent endodontic treatment. Changes in molar morphology were investigated with eight laboratory animals (rabbits, 3 months old, all males) after simulated pulp removal and subsequent treatment with the iRoot BP Plus biomaterials. iRoot BP Plus appeared to be more effective in retrograde apical root filling than other biomaterials, as evidenced by its higher sealing effect. An experiment involving animal participants revealed the presence of protective adaptive mechanisms, which manifested in the form of an inflammatory process within 6 weeks after the dental pulp was removed. The connective tissue replaced the necrosis, and new capillaries began to form intensively. These dental outcomes suggest that iRoot BP Plus enables hermetical sealing in tooth restoration with good adhesion. Thus, it may have the ability to promote more active tissue regeneration after pulp removal.

Treatment outcome of partial pulpotomy using two different calcium silicate materials in mature permanent teeth with symptoms of irreversible pulpitis: A randomized clinical trial

AIM

To assess the clinical and radiographic outcome of partial pulpotomy by comparing MTA Angelus and Total Fill BC, as pulpotomy agents, in mature teeth with deep caries and symptoms indicative of irreversible pulpitis.

METHODOLOGY

The study was designed as a parallel-two arm, double-blind, randomized superiority clinical trial registered at www.

CLINICALTRIALS

gov (NCT04870398). Symptomatic mature permanent teeth with deep caries fulfilling the inclusion criteria were randomly treated using either MTA Angelus or Total Fill BC. A partial pulpotomy was performed and following complete haemostasis, the capping material was placed over the remaining pulp tissue and a postoperative periapical radiograph was taken. Clinical and radiographic follow-up evaluation was performed for a median time of 2 years, whereas levels of pain intensity were evaluated preoperatively and for 7 days after intervention using Visual Analogue Scale. For the primary outcome (failure/success of treatment), the Kaplan-Meier survival curves for the capping materials were plotted and a log-rank test for equality of survivor functions was applied. A multivariable random effects Cox Regression model was also applied. For the secondary outcome (postoperatively reported pain), a multivariable mixed effects ordinal logistic regression was structured.

RESULTS

One hundred and thirty-seven teeth in 123 patients underwent partial pulpotomy using randomly either MTA Angelus (N = 74) or Total Fill BC (n = 63). The percentage failure for MTA Angelus and Total Fill BC was 10.8% (8/74) and 17.5% (11/63), respectively, but the difference was not statistically significant [adjusted HR: 1.83; 95% confidence interval (CI): 0.68, 4.91; p = .23]. Weak evidence was found that secondary caries involvement may impose a 3.54 times greater hazard for treatment failure (adjusted HR: 3.54; 95% CI: 1.00, 12.51; p = .05). For each passing minute of procedural bleeding control, there was also a 57% higher hazard for treatment failure (adjusted HR: 1.57; 95% CI: 0.99, 2.48; p = .05). The odds for higher postoperative pain were 4.73 times greater for the Total Fill BC compared to MTA Angelus (adjusted OR: 4.73; 95% CI: 2.31, 9.66; p < .001).

CONCLUSIONS

Both materials exhibited similar and favourable outcome rates after partial pulpotomy in teeth with deep caries and symptoms of irreversible pulpitis. Total Fill BC was associated with a higher level of postoperative pain intensities.

A randomized controlled clinical trial of premixed calcium silicate-based cements for pulpotomy in primary molars

OBJECTIVES

This study aimed to verify the non-inferiority of Endocem MTA Premixed and Well-Root PT, compared with ProRoot MTA in the pulpotomy of primary molars. In addition, we tried to determine the factors that affect the prognosis of pulpotomy in primary molars.

METHODS

This randomized clinical trial enrolled 158 molars of 52 children; 153 teeth were finally included and divided into three groups: ProRoot MTA (n = 50), Endocem MTA Premixed (n = 53), and Well-Root PT (n = 50). Clinical and radiographic follow-up was performed at 3, 6, and 12 months postoperatively and at the last visit post-treatment. Data were analyzed using the Fisher's exact test, Cox regression analysis, and the Kaplan-Meier survival curve method.

RESULTS

The success rates in the ProRoot MTA, Endocem MTA Premixed, and Well-Root PT were 92, 84.9 and 82%, respectively. The cumulative survival rates did not differ significantly among the materials. Among the investigated variables, only ΔF and ΔF max significantly affected the success rates. In the multivariate survival tree model, significant unfavorable survival was observed when the ΔF value was -14.4 or less (hazard ratio, 7.56; P = 0.0295).

CONCLUSIONS

Considering the clinical effectiveness of Endocem MTA Premixed and Well-Root PT and the operational convenience as a premixed type, they can be used as advantageous materials in the pulpotomy of primary molars in pediatric patients. The QLF method is a useful diagnostic method that can establish treatment plans and determine the prognosis of pulpotomy based on the ΔF value in primary molars.

CLINICAL SIGNIFICANCE

Endocem MTA Premixed and Well-Root PT can confer high success rates and are non-inferior to ProRoot MTA in pulpotomy for primary molars. We also showed that QLF technology can be applied to predict the success/failure and prognosis of pulpotomies in primary molars.

Success rate of permanent teeth pulpotomy using bioactive materials: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

The results of vital pulp treatments in permanent teeth have been encouraging. Currently, pulpotomy treatment for permanent teeth primarily utilizes mineral trioxide aggregate (MTA) as the dressing material, followed by calcium hydroxide. While other calcium-silicate-based cements have been suggested for pulpotomy, there is a limited number of studies evaluating their long-term effectiveness.

OBJECTIVES

The objective of this systematic review and meta-analysis was to evaluate the success rate of pulpotomies performed on permanent teeth, comparing the use of ProRoot MTA with that of calcium hydroxide and other bioceramic materials.

METHODS

A comprehensive search was conducted in several electronic databases, including PubMed, Cochrane Library, Scopus, Web of Science, Embase and Science Direct until December 2022. The search was guided by PICOS criteria, including only randomized clinical trials (RCTs) that evaluated the success rate of pulpotomy treatments in permanent teeth using ProRoot MTA in comparison to calcium hydroxide and other bioceramic materials. The quality of the included studies was assessed using the RoB-2 tool to evaluate the risk of bias, and relevant data were extracted and analysed in RevMan software 5.3 using fixed-effect models. The GRADE tool was used to determine the overall quality of evidence.

RESULTS

The initial search retrieved 1072 studies and, after eliminating duplicates, 677 studies were screened and 28 studies were considered for eligibility. In the final selection process, 16 studies were included in the systematic review, with 10 being determined as having a high risk of bias. Pulpotomy showed an overall mean success rate of 92% after 1 year. The meta-analysis indicated a significantly higher success rate for pulpotomies utilizing MTA in comparison with calcium hydroxide, while no significant difference was seen between MTA and calcium-enriched mixture (CEM) or Biodentine. The GRADE assessment revealed an overall low level of evidence for the included studies.

DISCUSSION

Most randomized controlled trials exhibited a significant absence of control over confounding factors.

CONCLUSIONS

This systematic review and meta-analysis demonstrate that pulpotomy is a highly effective treatment for managing permanent teeth. The results indicate that the success rate of pulpotomy using ProRoot MTA is significantly higher than when using calcium hydroxide. However, the certainty of evidence supporting these findings is low, and there is a need for well-designed RCTs to assess the long-term outcomes of pulpotomy using newer bioceramic materials.

REGISTRATION

This systematic review was registered in the PROSPERO database (registration number CRD42023393970).

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.

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.

A randomized controlled clinical trial of pulpotomy vs root canal therapy in mature teeth with irreversible pulpitis: Outcome, quality of life, and patients' satisfaction

INTRODUCTION

Vital pulp therapy (VPT)is increasingly practiced as an alternative treatment to root canal therapy (RCT) in teeth with carious pulp exposure. The aim of this study was to compare the outcome, quality of life and patient satisfaction after full pulpotomy and RCT in mature teeth with irrevrsible pulpitis.

METHODS

Sixty mature permanent molar teeth with carious pulp exposure and a diagnosis of irreversible pulpitis were randomly divided into 2 groups (n=30). The first group was treated with full pulpotomy using Biodentine and the second group was treated with RCT. Pain level was recorded preoperatively and at 1, 2, 3, 5 and 7 days. Clinical and radiographic assessment was done at 6 and 12 months follow up, one case in each group did not attend. Based on the Oral Health Impact Profile questionnaire (OHIP-17) and 7 semantic differential scales, quality of life (QOL) and patients' satisfaction were evaluated and compared statistically.

RESULTS

Pulpotomy and RCT had comparable success rates (27/29, 93%). Pain levels at day 1 after pulpotomy were significantly lower than after RCT (p=0.037), less patients required analgesics (p=0.028), and pulpotomy provided pain relief in a shorter time compared to RCT. Both treatments improved the OHIP QOL of patients without significant differences (60.29, 64.1% at 1 year). Patients' satisfaction with pulpotomy was higher than RCT in terms of the time involved, intraoperative pain, pleasantness, and cost (p <0.05).

CONCLUSIONS

Full pulpotomy could be an alternative treatment to RCT in mature teeth with carious pulp exposure and symptomatic irreversible pulpitis, based on the clinical, radiographic success rates and patients' satisfaction.

Factors that influence the outcome of pulpotomy in permanent teeth

The promotion of minimally invasive treatments focussed on the maintenance of pulp vitality has become a priority area in Endodontics. These vital pulp treatments (VPT) include partial and full pulpotomy, during which diseased coronal pulp tissue is removed prior to placement of a capping biomaterial and restoration. Traditionally, pulpotomies were confined to the treatment of carious primary and traumatized permanent teeth. However, these treatments have now been proposed as definitive solutions for cariously exposed permanent teeth with mild symptoms or even symptoms indicative of irreversible disease. Until recently, it was recommended that carious exposure of mature permanent teeth be managed by root canal treatment. The promotion of pulpotomy as an alternative treatment has opened up a wave of laboratory and clinical research aimed at improving therapies or evaluating clinical outcomes. In modern evidence-based endodontics, it is imperative that the outcomes of both partial and full pulpotomy are considered and important prognostic factors identified, so that improvements can be made to aid clinical decision-making and to direct new research. In this narrative review, the outcomes of partial and full pulpotomy are discussed, before analysis of patient, intraoperative and postoperative factors that influence the outcome of the pulpotomy procedure. The review highlights that although partial and full pulpotomy for the treatment of even pulpal disease are highly successful procedures, this is based on low-quality evidence with a lack of prospective, comparative trials investigating potential prognostic factors. Based on current evidence, it appears that age, gender, tooth type, root development and intraoperative pulpal haemorrhage do not impact significantly on pulpotomy outcome, whilst others such as caries depth, inflammatory status of the pulp, capping material, level of inflammatory pulpal-biomarkers and the final restoration integrity do. Other factors, including the influence of exposure type, periodontal condition, pulpal lavage, magnification, operator experience, isolation of the operating field and type of pulpotomy, require further experimental investigation before definitive conclusions can be made relating to the success of the pulpotomy procedure. Finally, there is not only a need for future well-designed prospective research addressing these issues but also a widening of our understanding of outcome to include patient-reported as well as clinician-reported outcomes.

Fast-Setting Calcium Silicate-Based Pulp Capping Cements-Integrated Antibacterial, Irritation and Cytocompatibility Assessment

Calcium silicate-based cements (CSCs) are endodontic materials widely used in vital pulp-capping approaches. Concerning the clinical application, the reduced set time and pre-mixed formulations are relevant characteristics during the operative management of pulpal exposure, aiming to optimise the work time and improve cross-infection/asepsis control. Additionally, clinical success seems to be greatly dependent on the biological performance of the materials that directly contact the living pulp. As such, this work approaches an integrative biological characterisation (i.e., antibacterial, irritation, and cytocompatibility assays) of three fast-setting CSCs-Biodentine^TM, TotalFill^® BC RRM™ Fast Putty, and Theracal LC^®. These cements, after setting for 24 h, presented the expected topography and elemental composition (assessed by scanning electron microscopy, coupled with EDS analysis), in accordance with the information of the manufacturer. The set cements displayed a significant and similar antibiofilm activity against S. mutans, in a direct contact assay. Twenty-four-hour eluates were not irritant in the standardised CAM assay, but elicited distinct dose- and time-dependent cytotoxicity profiles on fibroblastic cells-i.e., Biodentine was devoid of toxicity, TotalFill presented a slight dose-dependent initial toxicity that was easily overcome, and Theracal LC was deleterious at high concentrations. When compared to long-setting ProRoot MTA cement, which highlighted the pursued integrative approach, Biodentine presented a similar profile, but TotalFill and Theracal LC displayed a poorer performance regarding antibiofilm activity/cytocompatibility features, and Theracal LC suggested eventual safety concerns.

Minimally invasive endodontics: a new era for pulpotomy in mature permanent teeth

Emerging clinical and histologic evidence is challenging the long-established dogma that root canal treatment (RCTx) is the only therapeutic option for preservation of vital mature permanent teeth diagnosed with irreversible pulpitis or carious pulp exposure. Vital pulp therapy procedures like pulpotomy are not only technically simpler and more economical, but also afford patients a host of other benefits over conventional RCTx. This narrative review provides an update on the contemporary understanding of pulp pathophysiology and defence mechanisms, the proposed new diagnostic terminologies for pulpal inflammation, and how the biological characteristics of hydrophilic calcium silicate cements have enabled consistent successful outcomes for pulpotomy-treated mature teeth. The paper also details the evidence base from clinical trials and systematic reviews conducted over the past decade and outlines the practical treatment considerations for pulpotomy in mature permanent teeth.

Coronal discoloration induced by calcium silicate-based cements used in full pulpotomy in mature permanent molars: a randomized clinical trial

OBJECTIVES

This study aimed to randomly compare in vivo coronal discoloration at 6 and 12 months after full pulpotomy in mature permanent molars using MTA, Biodentine, and TotalFill and to investigate the effect of variables such as remaining buccal wall thickness and time to achieve hemostasis.

MATERIALS AND METHODS

One hundred eight teeth that met the inclusion criteria received full pulpotomy and were randomly divided into 3 groups via a block randomization technique according to the calcium silicate cement (CSC): ProRoot WMTA, TotalFill, or Biodentine. Assessment of tooth color was carried out using a spectrophotometric device (VITA Easyshade Compact) after composite placement (T0), at 6- and 12-month follow-up. Buccal wall thickness and time to hemostasis were recorded. The primary outcome measure (color change ΔE) was calculated, and the results were analyzed by three-way ANOVA and crosstabulations in relation to material type and effect of variables.

RESULTS

Four cases were excluded after pulpotomy failure; 81 teeth were evaluated at 6 months and 95 teeth at 12 months. All CSCs caused tooth discoloration (defined as ΔE > 3.7); MTA significantly caused the highest color change at 6- and 12-month follow-up (76% (19/25) and 87.5% (28/32), respectively) compared to Biodentine (41% (9/22), 48% (13/27)) and TotalFill (44% (15/34), 53% (19/53)) (p = 0.022, p = 0.002), while no significant difference was found between the Biodentine and TotalFill groups (p = 0.813, p = 0.8). Buccal wall thickness (above or below 2.7 mm) had a significant effect on the degree of discoloration (p = 0.004).

CONCLUSIONS

The 3 CSCs caused tooth discoloration based on the threshold of ΔE > 3; the remaining buccal wall thickness was a significant factor. The use of Biodentine and TotalFill instead of MTA is encouraged to minimize discoloration.

CLINICAL RELEVANCE

While experimental studies report coronal discoloration after CSCs use, clinical data is lacking. This study assessed discoloration using a spectrophotometric device. The use of materials with lower discoloration potential in pulpotomy is encouraged.

TRIAL REGISTRATION

The study was registered with clinical trial registration number: NCT04346849 on 14.4.2020.

The scientific management of deep carious lesions in vital teeth using contemporary materials—A narrative review

Aim

The aim of this article is to review the scientific evidence for deep caries removal in permanent vital teeth and the choice of dentine replacement material and restoration of the teeth to maintain long term tooth vitality and function.

Method

The two position statements namely the European Society of Endodontology and the American Association of Endodontists position statements on vital pulp therapy will be scrutinized and compared with regards to the deep caries removal strategy and assessed for evidence of best practice. The properties of materials used to manage vital pulps and the best way to restore the teeth will be reviewed and guidance on the full management of vital teeth will be suggested.

Conclusions

Promoting new treatment modalities for reversible and irreversible pulpitis allowing for pulp preservation should be considered. Although debatable, cases with deep caries should be managed by complete non-selective caries removal which will allow for pulpal management if needed and a more predictable outcome can be expected when using the new materials and treatment modalities of vital pulp therapy.

Physicochemical and Antibacterial Properties of Bioactive Retrograde Filling Materials

The purpose of the present study was to evaluate the physicochemical properties and antibacterial activity of three calcium silicate cements. Mineral trioxide aggregate (MTA Biorep “BR”), Biodentine (BD) and Well-Root PT (WR) materials were investigated using scanning electron microscopy (SEM) at 24, 72 and 168 h of immersion in phosphate buffered saline (PBS). The antibacterial activity against Enterococcus faecalis (E. faecalis), the solubility, roughness, pH changes and water contact angle were also analyzed. All results were statistically analyzed using a one-way analysis of variance test. Statistically significant lower pH was detected for BD than WR and BR (p < 0.05). No statistical difference was found among the three materials for the efficacy of kill against E. faecalis (p > 0.05). Good antibacterial activity was observed (kill 50% of bacteria) after 24 h of contact. The wettability and the roughness of BR were higher than for the other cements (p < 0.05). BD was more soluble than WR and BR (p < 0.05). In conclusion, the use of bioceramic cements as retrograde materials may play an important role in controlling bacterial growth and in the development of calcium phosphate surface layer to support healing. Moreover, the premixed cement was easier to use than powder−liquid cement.

Vital Pulp Therapy of Permanent Teeth with Reversible or Irreversible Pulpitis: An Overview of the Literature

Vital pulp therapy (VPT) has been recently proposed as an alternative approach even in symptomatic mature permanent teeth with deep caries’ lesions, aiming to maintain the pulp vitality over time and/or to avoid non-surgical root canal therapy (NSRCT). However, to date, the diagnosis of reversible or irreversible pulpitis is only based on clinical pain quantity and quality, without precisely reflecting the pulp inflammation status. Therefore, the aim of the present study was to provide an overview based on the current scientific literature to demonstrate the clinical effectiveness of VPT on mature permanent teeth, validating the use of hydraulic calcium silicate-based cements and their role in pain management. VPT may be successfully applied not only in mature permanent teeth diagnosed with reversible pulpitis, but also in permanent dental elements with signs and symptoms of irreversible pulpitis. Hydraulic cements showed favorable outcomes in terms of decrease of pro-inflammatory mediators and of post-operative pain. Pain plays a central role in the chance to perform VPT in mature permanent teeth, since it may be considered as a pre-operative diagnostic criterion as well as a treatment success parameter. In addition, proper assessment of pulp inflammation and choice of appropriate materials are key factors in enhancing VPT success.