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

A meta-analysis of calcium silicate-based cements and calcium hydroxide as promoters of hard tissue bridge formation

BACKGROUND

The formation of a reparative hard tissue bridge is a key indicator of defensive pulp response and successful vital pulp treatment (VPT); however, there is a lack of comprehensive information regarding the impact of bioactive materials on hard tissue formation.

OBJECTIVES

This systematic review with meta-analyses aimed to evaluate the hard tissue bridge formation in direct pulp capping and pulpotomies in humans, comparing the use of ProRoot MTA with other calcium silicate-based cements (CSCs) and calcium hydroxide.

METHODS

The search was conducted in six electronic databases, until May 2024. The selection process followed the PICOS criteria. Clinical trials that evaluated the hard tissue bridge formation in VPTs using ProRoot MTA compared with other CSCs or calcium hydroxide, were included. The quality of the studies was assessed using the RoB-2 tool for randomized clinical trials, and ROBINS-I for nonrandomized trials. Meta-analyses were performed to compare the frequency of complete bridge formation using RevMan software 5.3. The GRADE tool was used to determine the overall certainty of evidence.

RESULTS

Twenty-six studies were included, and the majority showed high risk of bias. Meta-analyses revealed that using ProRoot MTA resulted in significantly higher frequency of complete hard tissue bridge formation compared with using other CSCs and calcium hydroxide. Subgroup analyses indicated that using ProRoot MTA led to higher complete bridge formation compared with Biodentine. The certainty of evidence was low.

CONCLUSIONS

The use of ProRoot MTA resulted in significantly higher frequency of complete hard tissue bridge formation, greater hard tissue thickness and better morphology compared with various other CSCs and calcium hydroxide. Almost all studies were performed in premolars extracted due to orthodontic reasons or third molars. This scenario does not represent the clinical setting and therefore results should be interpreted with caution.

Clinical and radiographic assessment of mineral trioxide aggregate with platelet rich fibrin as pulp capping biomaterials: a 12-month randomized trial

This study aimed to comparatively assess the clinical success and radiographic regenerative dentin formation of Platelet Rich Fibrin (PRF) and mineral trioxide aggregate (MTA) when used as direct pulp capping agents. This double-blinded two parallel armed randomized controlled clinical trial comprised the allocation of 108 patients with traumatically exposed dental pulp during the management of deep carious lesions by undergraduate students after fulfilling inclusion and exclusion criteria. Patients were randomized into two groups (n = 54 in each group) using computer-generated simple randomization, wherein one group Platelet Rich Fibrin (PRF) was prepared from patients' blood samples and applied directly over exposed pulp followed by MTA application and in the other group MTA was applied directly over pulp exposure. In both groups, cavities were restored with resin-modified glass ionomer liner and resin composite restoration. The overall success of treatment was calculated at 6 and 12 months after assessing pulp sensibility, history of pain, tenderness on percussion and the existence of any periapical pathosis using in periapical radiographs. Moreover CBCT was used at 12 months to determine the presence or absence of dentin bridge as a secondary outcome. After 12 months follow-up, there was no statistically significant difference in overall success of pulp capping in both groups. As the both groups showed 92.59% success rate. CBCT evaluation of dentin bridge formation by Platelet Rich Fibrin (PRF) demonstrated a significantly higher percentage than that formed in cases treated with MTA alone (p < 0.001). Direct pulp capping with Platelet Rich Fibrin (PRF) exhibited a clinical and radiographic success rate comparable to that of MTA. Platelet Rich Fibrin (PRF) can be implemented as a direct pulp capping agent in forthcoming clinical applications.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Evaluation of volumetric and surface stability of calcium silicate-based repair cements at different pHs

OBJECTIVES

The objective of this research was to evaluate the volumetric and surface stability in vitro, to different pH levels, of calcium silicate-based repair cements ready-to-use and powder/liquid exposed.

MATERIALS AND METHODS

Sixty human teeth were retro-prepared to a depth of 3 mm and divided into two groups. The first group included powder/liquid cements Biodentine (Septodont, France) and MTA HP (Angelus, Brazil); the second group included ready-to-use cements Bio-C Repair (Angelus, Brazil) and ENDOCEM MTA (Maruchi, Republic of Korea). All samples were submerged in PBS solution with pH levels of 5, 7, and 12. Initially, the materials were evaluated for porosity, marginal adaptation, and volumetric change using micro-CT, and then re-evaluated after 7 and 30 days of exposure to PBS solution. The samples were characterized using SEM/EDS and RAMAN spectroscopy. Statistical evaluation was performed using ANOVA with a 5% significance level.

RESULTS

Bio-C Repair showed significant statistical differences (p < 0.05) at different pHs in 7 and 30 days compared to other materials, being greater in acidic medium. ENDOCEM, regardless of pH, at 30 days showed fewer voids when compared to other repair cements.

CONCLUSION

This micro-CT study demonstrated that regardless pH, the clinic presentation of calcium silicate-based materials ready-to-use showed higher and loss volumetric than powder/liquid materials at 30 days.

CLINICAL RELEVANCE

Under neutral pH conditions, calcium silicate-based materials are expected to maintain properties such as bioactivity and low solubility. However, in clinical situations involving infection and inflammation, pH variations can impact the physicochemical properties of these materials regardless of their clinical presentation.

Antibacterial activity of biodentine against Enterococcus faecalis: a systematic review

Introduction

Biodentine is a well-known endodontic material that is applied in various endodontic therapies. Enterococcus faecalis (E. faecalis) is associated with endodontic failure and persistent periapical infection. The purpose of this systematic review was to summarize the available evidence regarding the antibacterial activity of Biodentine against E. faecalis and to compare it to other commercial endodontic materials.

Methods

An electronic search of literature was conducted in PubMed, Scopus, Web of Science, and Google Scholar in addition to a manual search in specialized journals up to May 2024. The eligibility criteria, data extraction, and evaluation of risk of bias were assessed by two independent authors. The risk of bias was evaluated in accordance with Modified CONSORT checklist items for pre-clinical in vitro studies on dental materials.

Results

Out of 343 studies, thirty-seven fulfilled the inclusion criteria and were included in this review. Thirty studies reported a good antibacterial efficacy of Biodentine against E. faecalis. Biodentine was superior to or, at least, as efficacious as MTA, MTA Angelus, GIC, RMGIC, DiaRoot BioAggregate, NeoPutty, iRoot FS, MTA Repair HP, MTA Biorep, Well-Root PT, Activa, NeoMTA 2, Calcimol LC, TotalFill, and IRM. The findings were supported by studies with medium to high risk of bias (low quality).

Conclusions

Considering the limitations of this systematic review, there is accumulating evidence on the antibacterial activity of Biodentine against E. faecalis in context of endodontics. However, randomized clinical trials with well-designed and robust methodologies are required in order to provide information about its clinical behaviour.

Successful Management of Palatal Developmental Groove-Associated Periodontal Defect Using Palatal Access Flap and Odontoradiculoplasty: A Case Report

This case report discusses the successful management of a deep palatal developmental groove associated with Stage III generalized Grade C periodontitis. Despite prior nonsurgical periodontal therapy, the disease progressed rapidly, necessitating further intervention. A comprehensive evaluation revealed generalized periodontitis with localized tooth-related predisposing factor due to a developmental groove in the vital upper left lateral incisor. The initial nonsurgical treatment involved scaling and root planing (SRP) coupled with systemic antibiotics. Significant improvement was observed, except for the site with the developmental groove. Surgical intervention was performed using a palatal access flap odontoplasty and radiculoplasty to eliminate the remaining pocket and enhance plaque control. The procedure successfully resolved the condition, with soft tissue healing observed at the 6-month follow-up with a residual probing depth of 3 mm. This case highlights the challenges associated with palatal developmental grooves as localized aggravating factors in periodontitis. The use of surgical techniques like odontoplasty and flap access proved effective in managing periodontal defects associated with developmental grooves, showcasing a successful outcome in this patient.

Regenerative Treatment of Mature Teeth with Pulp Necrosis and Apical Periodontitis Using Biodentine Compared with MTA: Randomized Controlled Clinical Trial

OBJECTIVE

The purpose of this randomized, controlled study was to evaluate the effectiveness of Biodentine compared with MTA used as a pulp space barrier in healing periapical lesions and regaining pulp sensitivity after regenerative treatment in mature single-canal permanent teeth with pulp necrosis and apical periodontitis.

METHODS

The study involved 36 patients with mature teeth with necrotic pulp and apical periodontitis. The patient underwent a regenerative treatment that utilized the blood clot technique. Teeth were randomly allocated to either the intervention, Biodentine, group (n=18) or the control, MTA, group (n=18). The healing of periapical lesions and tooth sensibility were evaluated throughout follow-up visits for up to 18 months.

RESULTS

The study analyzed 31 patients; two patients within the biodentine group and three in the MTA group were lost to follow-up. After 18 months, both groups showed effective healing of periradicular lesions; 21 out of 31 patients (67.7%) were healed, ten patients (32.3%) were healing, and no failure cases occurred. There were no significant differences between the groups (p=1.00). More than 70% (22 out of 31 patients) regained their sensibility in their teeth, and the groups had no statistically significant difference (p=0.703).

CONCLUSION

Regenerative treatment using blood clots with either MTA or Biodentine effectively resolved periapical lesions and regained the sensibility of mature teeth.

Can flowable short-fiber-reinforced resins achieve a strong adhesion to bioceramics?

This study compared the microshear bond strength (μSBS) of four calcium silicate-based cements (CSCs), TheraCal PT (TPT), TheraCal LC (TLC), Biodentine (BD), and Dia-Root Bio MTA (DR), with a short fiber-reinforced composite resin (SFRC). Forty cylindrical acrylic blocks were used, each with a center hole (diameter 5 mm, depth 2 mm). CSCs were placed in the holes (n = 10/group), and the blocks were incubated for 48 h. G-Premio BOND, a self-etching adhesive, was applied to the CSCs surfaces using a micro-applicator for 10 s and then air-dried for 5 s, followed by light curing for 20 s. SFRC materials placed in cylindrical polyethylene capsules (diameter 2 mm, height 2 mm) were polymerized for 20 s and placed over the CSCs. The samples were then incubated at 37°C and 100% humidity for 24 h, and their μSBSs were tested using an "Instron Universal Testing Machine." Data were statistically analyzed using chi-square and Kruskal-Wallis tests. Statistically significant differences were observed between the tested CSCs. The μSBS of TPT (45.17 ± 4.56 MPa) was significantly higher (p < .05) than that of the other materials: BD, TLC, and DR had μSBSs of 29.18 ± 2.86 MPa (p < .05), 23.86 ± 2.84 MPa (p > .05), and 18.08 ± 2.69 MPa (p < .05), respectively. Considering the importance of bond strength for CSC sealing with restorative material, using SFRC over CSC was promising for improving the μSBS, adhesion, and sealing of the material. RESEARCH HIGHLIGHTS: Adhesion is critical to the success of vital pulp restorations. To achieve strong adhesion, the bioceramic material and the resin composite to which it is bonded are very important. In our study, short fiber-reinforced composite resin, which is gaining popularity, was used and found to be a promising material for improved adhesion.

Hydrated Calcium Silicate in Resin Composites for Prevention of Secondary Caries

INTRODUCTION AND AIMS

The gaps at the margins of restorative composite resin can increase as the carious process occurs underneath the materials, causing further demineralization along the tooth cavity wall. The aim of this study was to evaluate the effects of restorative resin composite containing hydrated calcium silicate (hCS) filler on enamel protection against demineralization by simulating microleakage between the test material and teeth in a cariogenic environment.

METHODS

The experimental resin composites were composed of 70 wt.% filler, which was mixed with a glass filler and hCS in a weight ratio of 70.0% glass (hCS 0), 17.5% hCS + 52.5% glass (hCS 17.5), 35.0% hCS + 35.0% glass (hCS 35.0), and 52.5% hCS + 17.5% glass (hCS 52.5). A light-cured experimental resin composite disk was positioned over a polished bovine enamel disk, separated by a 30-µm gap, and immersed in artificial saliva with pH 4.0 for 15, 30, and 60 days. After the immersion period, the enamel disk was separated from the resin composite disk and evaluated using a microhardness tester, atomic force microscopy, and polarized light microscopy. The opposing sides of the enamel and resin composite disks were observed using scanning electron microscopy/energy dispersive X-ray spectrometry.

RESULTS

The enamel surface showed a significant increase in microhardness, decreased roughness, and remineralization layer as the proportion of hCS increased (P < .05). In the scanning electron microscopy image, the enamel surface with hCS 35.0 and 52.5 after all experimental immersion periods, showed a pattern similar to that of a sound tooth.

CONCLUSIONS

The results demonstrated that increasing the hCS filler level of restorative resin composites significantly decreased enamel demineralization.

CLINICAL RELEVANCE

Hydrated calcium silicate laced restorative resin composites may be a promising dental biomaterial for protecting teeth against demineralization and preventing secondary caries around restorations.

Influence of Phase Composition and Morphology on the Calcium Ion Release of Several Classical and Hybrid Endodontic Cements

The ability of the cement to release calcium ions, which participate in the remineralization of dentin by forming apatite which improves root canal sealing with time, is of particular importance. Five recently introduced calcium-silicate commercial dental cements were investigated with a view to the influence of the physicochemical characteristics on the possibility of releasing calcium ions in an aqueous medium. Two hybrid calcium-silicate cements in the form of a paste-like ready mix (BioCal® Cap and TheraCal LC) and three calcium-silicate cements consisting of two components-powder and liquid (Harvard MTA Universal, Rootdent, and BioFactor) were subjected to powder XRD, SEM, and EDS for detailed examination. The cements were immersed in water for 28 days and the phase composition and morphology of the cements before and after soaking were studied. The total calcium release for each cement was determined by ICP-OES. BioFactor and BioCal® Cap release the highest amount of calcium ions, while the lowest release is registered with Rootdent and TheraCal LC. The PDT treatment of BioFactor does not influence substantially the calcium release. The impact of the elemental and phase composition on the calcium release and calcium carbonate formation was discussed. A reciprocal relation between the aluminum content and the quantity of the released calcium has been found.

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.

The impact of root end filling material type and the application of bone graft on healing of periapical tissues after endodontic microsurgery (a clinical randomized controlled trial)

To evaluate the effect of combining different bioactive root-end filling materials with composite bone graft (xenogeneic mixed with autogenous bone fragments) on the healing process of periapical tissues after endodontic micro-surgery procedure. In this triple-blinded clinical trial, 56 patients were divided into 2 main groups (28 each) according to the root-end filling material and 2 subgroups according to the presence or absence of the composite bone graft material. Group I: MTA root-end filling (n = 28) in which there are Sub-group A: without bone graft (n = 14) and Sub-group B: with composite bone graft (n = 14). Group II: TotalFill root-end filling (n = 28) in which there are Sub-group A: without bone graft (n = 14) and Sub-group B: with composite bone graft (n = 14). Healthy patients whose ages range from 20 to 50 years with small-to-medium size radiolucency in CBCT related to single-rooted maxillary teeth were included in this study. Patients were assigned a number starting from 1 to 56 and were randomly allocated to four test groups (2 main groups and 2 sub-groups) following simple randomization procedure guidelines described by IBM SPSS V23 (IBM USA) statistical analysis software. This trial was triple-blind where the patient, the outcome assessors, and the main operator were blinded to the applied intervention. Every patient was evaluated clinically and by CBCT at two main observation periods: presurgical and 12-month post-operative. They were also examined and evaluated clinically and radiographically through periapical x-rays after one week, three, and six months. Statistical analysis was performed with IBM SPSS Statistics for Windows Version 23.0. Armonk, NY: IBM Corp. Of the 56 patients enrolled in the study, 49 patients were available for the final analysis. All groups showed no statistically significant differences with regard to healing or success rates at the 12-month follow-up mark. No adverse effects were encountered. Results showed that high success rates were achieved using MTA and TotalFill in the healing of periapical lesions after endodontic surgery. The addition of bone graft in small-to-medium size lesions did not affect the success rate of endodontic surgeries.

Prognosis of non-vital incisors after apexification using bioceramics: a retrospective study

PURPOSE

To evaluate the outcome of apexification using bioceramics in immature permanent teeth, and to study the factors influencing treatment outcome and frequency of spontaneous cervical root fractures.

METHODS

Forty-six children with 51 non-vital permanent incisors treated with a bioceramic apical plug were included. Mean age at pulp necrosis was 9.8 (SD 2.2) years and mean follow-up time was 3.3 (SD 2.4) years. Data were extracted from dental records and included stage of root development, presence of external root resorptions, clinical signs of infection, size of periapical lesion, type and placement of bioceramic plug, and spontaneous root fracture. Treatment outcome was assessed using periapical index (PAI-score) and presence of clinical symptoms. The statistical analyses were conducted using IBM SPSS Statistics for Windows, version 28 (IBM Corp., Armonk, N.Y., USA). Data were cross-tabulated and tested with chi-square statistic.

RESULTS

Biodentine™ was used as apical plug in 78.4% of the teeth and MTA in 21.6%. Complete healing or signs of healing was reported in 86.3% of the teeth, whilst seven teeth (13.7%) were non-healed. All non-healed teeth had preoperative clinical signs of infection. No difference was found in stage of root development, presence of root resorption, and type and placement of bioceramic plug in healed and non-healed teeth (p > 0.05). Five teeth (9.8%) exhibited root fracture 1-6 years after treatment and all had very immature root development. Type of bioceramic or external root resorption was not associated with spontaneous root fracture.

CONCLUSION

Apexification using bioceramics showed favourable prognosis in immature permanent teeth. Very immature teeth were at risk of root fracture after apexification with bioceramics.

Root canal irrigants effect on the compressive strength and calcium ion release of Biodentine

Compressive strength and calcium ion release are integral properties of Biodentine for its enhanced efficiency. The present study evaluated the effects of Dual Rinse HEDP (DR HEDP), ethylenediaminetetraacetic acid (EDTA) and sodium hypochlorite (NaOCl) on the calcium ion release and compressive strength of Biodentine. Eighty Biodentine specimens were moulded and randomly divided into four groups (n = 20). Samples in group 1 were treated with 17 % EDTA; group 2 with DR HEDP; group 3 with 2.5 % NaOCl; and group 4 with distilled water. Samples were immersed in 10 mL of the test solutions for 1 min. The mean concentration of the calcium ion released was measured using atomic absorption spectrophotometry. The remaining 40 samples were tested for their compressive strength. Significant differences were determined among all the irrigants tested for calcium ion release and compressive strength. Samples treated with NaOCl had the lowest calcium ion release, while samples treated with 17 % EDTA had the largest calcium ions. No significant differences were measured between DR HEDP or distilled water. For compressive strength, samples treated with 2.5 % NaOCl had the lowest strength, while the highest values were obtained with distilled water. There was a significant difference between DR HEDP and EDTA, in which EDTA reduced the compressive strength significantly more than DR HEDP. DR HEDP had less detrimental effect on the calcium ion release and compressive strength of Biodentine.

Comprehensive review of composition, properties, clinical applications, and future perspectives of calcium-enriched mixture (CEM) cement: a systematic analysis

This review aims to comprehensively explore calcium-enriched mixture (CEM) cement as a crucial biomaterial in dentistry/endodontics. With its growing clinical relevance, there is a need to evaluate its composition, chemical/physical/biological properties, clinical applications, and future perspectives to provide clinicians/researchers with a detailed understanding of its potential in endodontic procedures. Through systematic analysis of available evidence, we assess the advantages/limitations of CEM cement, offering valuable insights for informed decision-making in dental/endodontic practice. Our findings highlight the commendable chemical/physical properties of CEM cement, including handling characteristics, alkalinity, color stability, bioactivity, biocompatibility, sealing ability, and antimicrobial properties. Importantly, CEM cement has shown the potential in promoting regenerative processes, such as dentinogenesis and cementogenesis. It has demonstrated successful outcomes in various clinical applications, including vital pulp therapy techniques, endodontic surgery, open apices management, root resorption/perforation repair, and as an orifice/root canal obturation material. The efficacy and reliability of CEM cement in diverse clinical scenarios underscore its effectiveness in endodontic practice. However, we emphasize the need for well-designed clinical trials with long-term follow-up to further substantiate the full potential of CEM cement. This review serves as a robust reference for researchers/practitioners, offering an in-depth exploration of CEM cement and its multifaceted roles in contemporary dentistry/endodontics.

Comparative analysis of shear bond strength of MTA and Theracal PT with different restorative materials

BACKGROUND

This study aimed to compare the in vitro shear bond strength (SBS) of mineral trioxide aggregate (MTA) and dual-cured, resin-modified calcium silicate material (Theracal PT) to composite resin, compomer, and bulk-fill composite, and to evaluate the bond failure mode under a stereomicroscope.

METHODS

Ninety acrylic specimens, each with a 4 mm diameter and 2 mm height central hole, were prepared. These specimens were randomly divided into two groups based on the capping materials: MTA and Theracal PT. Each group was further subdivided into three subgroups (n = 15) according to the restorative materials: composite resin, compomer, and bulk-fill composite. The specimens were then subjected to shear testing using a universal testing machine at a crosshead speed of 1 mm/min. Post-test, the fracture locations were examined using a stereomicroscope. Data were analyzed using a two-way analysis of variance (ANOVA) and the Tukey test.

RESULTS

The SBS values for the Theracal PT group were significantly higher than those for the MTA group (p < 0.001). Within the MTA groups, no significant differences were observed in SBS values across the different restorative materials. However, a significant difference was found between the mean SBS values of the Theracal PT + composite resin group and the Theracal PT + compomer group (p < 0.001).

CONCLUSIONS

Theracal PT shows promise in dentistry due to its superior bond strength. Given its bond values, Theracal PT appears capable of forming durable and long-lasting restorations by establishing reliable bonds with various restorative materials commonly used in dentistry.

Evaluation of Cytotoxicity of the Dental Materials TheraCal LC, TheraCal PT, ApaCal ART and Biodentine Used in Vital Pulp Therapy: In Vitro Study

(1) Background: The aim of this study was to compare the cytotoxicity of selected resin-modified materials used in direct contact with the dental pulp (TheraCal LC, TheraCal PT, and ApaCal ART) with calcium silicate cement (Biodentine). (2) Methods: The mouse fibroblast Balb/3T3 cell line and the extracts of tested materials in four concentrations were used for the testing. An MTT assay was performed in three independent experiments with six replicates for each concentration of tested material. The cell viability (%) and cytotoxicity were expressed (cytotoxic effect is considered in cases where the cell viability is lower than 70%). The mean of the cell viability and the standard deviation were expressed for each material at all concentrations. ANOVA and Dunnet's post hoc tests were used for the statistical analysis. All of these tests were performed at the 0.05 significance level. (3) Results: At all concentrations, the cell viability was statistically significantly lower (p ≤ 0.002) for all tested materials compared to Biodentine. ApaCal ART showed a high level of cytotoxicity at all concentrations (cell viability lower than 47.71%, p < 0.0001). The same result was found for TheraCal LC at concentrations of 100%, 50% and 25% and TheraCal PT at concentrations of 100% and 50%. TheraCal LC at a 10% concentration (cell viability 68.18%) and TheraCal PT at a 25% concentration (cell viability 60.63%) indicated potential cytotoxicity. TheraCal PT at a 10% concentration was not found to be cytotoxic (cell viability 79.18%, p = 0.095). (4) Conclusion: The resin-modified calcium silicate and calcium phosphate materials showed higher cytotoxic potential, so they should be used with caution when in direct contact with the dental pulp.

Clinical and radiographic success of TheraCal versus Formocresol in primary teeth pulpotomy: A systematic review and meta-analysis

Background

Various dressing materials have been evaluated for pulpotomy of primary teeth. However, an ideal pulp dressing material has not been identified yet. This systematic review investigated the effectiveness of TheraCal compared to Formocresol in pulpotomy of primary teeth.

Materials and methods

This research was conducted in the form of a secondary study, with a systematic search of texts until 2023 in Scopus, Web of Science, PubMed and Google Scholar databases. The articles were selected based on the inclusion and exclusion criteria and, finally the search results were reported in the PRISMA chart. The quality of the studies was evaluated based on the NIH checklist. The extracted information was entered into Stata17 software. Heterogeneity was evaluated using Cochran's chi-square test and I2 statistics. Egger's tests were used to detect publication bias.

Results

After removing duplicate articles and articles that did not meet the inclusion criteria, 4 studies were selected for qualitative analysis. The odds' ratio of success rate between Formocresol and TheraCal pulpotomy for absence of the pain, abscess, Mobility, internal root resorption and bone radiolucency was obtained 1.12 (95 % CI: 0.32, 3.85, P = 0.86), 0.47 (95 % CI: 0.1, 2.14, P = 0.33), 0.82 (95 % CI: 0.21, 3.21, P = 0.78), 0.89 (95 % CI: 0.3, 2.67, P = 0.84), and 1.96 (95 % CI: 0.68, 5.62, P = 0.21) respectively.

Conclusion

The study results revealed that there was no significant difference in clinical and radiographic success between pulpotomy with TheraCal and Formocresol.

Removal efficiency of a fast setting pozzalan-based bioactive cement: a micro CT study

AIM

The aim of this study was to evaluate the removal efficiency of PRMTA and ECMPremixed applied to the coronal third according to the RET by UI and to examine the effect of different solutions on material removal.

MATERIALS AND METHODS

40 permanent upper central teeth were used to simulate immature teeth. The samples were irrigated with 1.5% NaOCl and calcium hydroxide was placed. Samples were incubated in PBS. Then irrigation was done with 17% EDTA, the samples were randomly divided into 2 groups (n = 20):Group 1: PRMTA, Group 2: ECM Premixed. The materials were placed in the samples. Then the samples were scanned with micro-CT. Materials were removed by UI. Micro-CT scan of the samples was performed. Each material group was divided into 2 subgroups (n = 10): Group1 was MTAD, group2 was irrigated with 10% CA; then micro-CT was performed. Obtained images were positioned in DataViewer and analyzed with CTAn. The obtained data were statistically analyzed in IBM SPSS 25. The significance level was determined as 5%.

RESULTS

There was no significant difference between the initial volumes of the materials (p > 0.05). The amount of the remaining material after UI was significantly higher in the PRMTA (0.7471%) group compared to the ECM Premixed (0.0093%). There was no significant difference in terms of remaining material after irrigation with MTAD and CA in both groups (p > 0.05).

CONCLUSION

A great deal of the materials were removed by UI under the operation microscope. ECM Premixed was removed more effectively compared to the PRMTA. And, acidic solutions did not provide any additional benefit in material removal.

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

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

Comparison of remineralization ability of tricalcium silicate and of glass ionomer cement on residual dentin: an in vitro study

OBJECTIVE

This study aimed to compare the remineralization effects of a calcium silicate-based cement (Biodentine) and of a glass ionomer cement (GIC: Fuji IX) on artificially demineralized dentin.

METHODS

Four standard cavities were prepared in dentin discs prepared from 34 extracted sound human third molars. In each disc, one cavity was covered with an acid-resistant varnish before demineralization (Group 1). The specimens were soaked in a chemical demineralization solution for 96 h to induce artificial carious lesions. Thereafter, one cavity each was filled with Biodentine (Group 2) and GIC (Group 3), respectively, and one carious lesion was left unrestored as a negative control (Group 4). Next, specimens were immersed in simulated body fluid (SBF) for 21 days. After cross-sectioning the specimens, the Ca/P ratio was calculated in each specimen by using scanning electron microscopy-energy-dispersive X-ray spectroscopy (SEM-EDX). Finally, data were analyzed using repeated-measures ANOVA with post-hoc Bonferroni correction.

RESULTS

Both cement types induced dentin remineralization as compared to Group 4. The Ca/P ratio was significantly higher in Group 2 than in Group 3 (p < 0.05).

CONCLUSION

The dentin lesion remineralization capability of Biodentine is higher than that of GIC, suggesting the usefulness of the former as a bioactive dentin replacement material.

CLINICAL RELEVANCE

Biodentine has a higher remineralization ability than that of GIC for carious dentin, and its interfacial properties make it a promising bioactive dentin restorative material.

Fracture Resistance of Simulated Immature Teeth Filled with Three Types of Calcium Silicate Cement after Intracanal Medication with Ca(OH)2: An Ex Vivo Study

Objectives

The aim of this study was to evaluate the 1-day fracture resistance of simulated immature teeth with an apical plug with ProRoot MTA, MTA Angelus, and RetroMTA after calcium hydroxide intracanal medication.

Materials and Methods

Sixty extracted, single-rooted human mandibular premolars were randomly divided into six groups of 10 teeth each. Firstly, to standardize the 9 mm root length, the crowns were cut off at and 9 mm below the cementoenamel junction transversely. Simulations for immature apices were carried out by using No. 1-6 Peeso reamers to pass through the apex to obtain a diameter of 1.7 mm at the apical opening. One group served as a negative control without any treatment, while the other groups received 30 days of calcium hydroxide intracanal medication. Four groups were plugs with 4 mm of ProRoot MTA, MTA Angelus, RetroMTA, and gutta-percha, respectively. The last one was served as a positive control group without filling inside. After 1 day of incubation, specimens were vertically loaded in a universal testing machine at a crosshead speed of 1 mm/min until fracture occurred. The peak load to fracture (Newton) and fracture pattern were recorded. A one-way analysis of variance (ANOVA) followed by Tukey's HSD test was used for data analysis.

Results

The highest mean load to fracture was shown in the negative control group (543.33 ± 37.17 N), followed by ProRoot MTA (432.82 ± 68.06 N), MTA Angelus (396.92 ± 59.93 N), RetroMTA (389.08 ± 56.25 N), and gutta-percha (283.28 ± 43.40 N), and the lowest belonged to the positive control group (239.98 ± 27.19 N). The significant differences were found between both the control and experimental groups with an apical plug with calcium silicate cement (p  < 0.05). There were no significant differences among those three apical plugs (p  > 0.05).

Conclusion

Apical plugs with ProRoot MTA, MTA Angelus, and RetroMTA had an immediate strengthening effect on simulated immature teeth after calcium hydroxide intracanal medication had been used.

The Role of Bioceramics for Bone Regeneration: History, Mechanisms, and Future Perspectives

Osteoporosis is a skeletal disorder marked by compromised bone integrity, predisposing individuals, particularly older adults and postmenopausal women, to fractures. The advent of bioceramics for bone regeneration has opened up auspicious pathways for addressing osteoporosis. Research indicates that bioceramics can help bones grow back by activating bone morphogenetic protein (BMP), mitogen-activated protein kinase (MAPK), and wingless/integrated (Wnt)/β-catenin pathways in the body when combined with stem cells, drugs, and other supports. Still, bioceramics have some problems, such as not being flexible enough and prone to breaking, as well as difficulties in growing stem cells and discovering suitable supports for different bone types. While there have been improvements in making bioceramics better for healing bones, it is important to keep looking for new ideas from different areas of medicine to make them even better. By conducting a thorough scrutiny of the pivotal role bioceramics play in facilitating bone regeneration, this review aspires to propel forward the rapidly burgeoning domain of scientific exploration. In the end, this appreciation will contribute to the development of novel bioceramics that enhance bone regrowth and offer patients with bone disorders alternative treatments.

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.

Effect of Modified Bioceramic Mineral Trioxide Aggregate Cement with Mesoporous Nanoparticles on Human Gingival Fibroblasts

The ion doping of mesoporous silica nanoparticles (MSNs) has played an important role in revolutionizing several materials applied in medicine and dentistry by enhancing their antibacterial and regenerative properties. Mineral trioxide aggregate (MTA) is a dental material widely used in vital pulp therapies with high success rates. The aim of this study was to investigate the effect of the modification of MTA with cerium (Ce)- or calcium (Ca)-doped MSNs on the biological behavior of human gingival fibroblasts (hGFs). MSNs were synthesized via sol-gel, doped with Ce and Ca ions, and mixed with MTA at three ratios each. Powder specimens were characterized using Fourier-transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), and scanning electron microscopy (SEM). Biocompatibility was evaluated using a 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT) assay following hGFs' incubation in serial dilutions of material eluates. Antioxidant status was evaluated using Cayman's antioxidant assay after incubating hGFs with material disc specimens, and cell attachment following dehydration fixation was observed through SEM. Material characterization confirmed the presence of mesoporous structures. Biological behavior and antioxidant capacity were enhanced in all cases with a statistically significant increase in CeMTA 50.50. The application of modified MTA with cerium-doped MSNs offers a promising strategy for vital pulp therapies.

Effects of vehicles on the physical properties and biocompatibility of premixed calcium silicate cements

Premixed calcium silicate cements (pCSCs) contain vehicles which endow fluidity and viscosity to CSCs. This study aimed to investigate the effects of three vehicles, namely, polyethylene glycol (PEG), propylene glycol (PG), and dimethyl sulfoxide (DMSO), on the physicochemical properties and biocompatibility of pCSCs. The setting time, solubility, expansion rate, and mechanical strength of the pCSCs were evaluated, and the formation of calcium phosphate precipitates was assessed in phosphate-buffered saline (PBS). The effects of pCSC extracts on the osteogenic differentiation of mesenchymal stem cells (MSCs) were investigated. Finally, the tissue compatibility of pCSCs in rat femurs was observed. CSC containing PEG (CSC-PEG) exhibited higher solubility and setting time, and CSC-DMSO showed the highest expansion rate and mechanical strength. All pCSCs generated calcium phosphate precipitates. The extract of CSC-PG induced the highest expressions of osteogenic markers along with the greatest calcium deposites. When implanted in rat femurs, CSC-PEG was absorbed considerably, whereas CSC-PG remained relatively unaltered inside the femur.

The outcome of combined use of iRoot BP Plus and iRoot SP for root-end filling in endodontic microsurgery: a randomized controlled trial

OBJECTIVES

Root-end filling is important for the clinical outcome of endodontic microsurgery. Our previous study showed that combined application of iRoot BP Plus Root Repair Material (BP-RRM) and iRoot SP Injectable Root Canal Sealer (SP-RCS) in root-end filling exhibited better apical sealing as compared to the application of BP-RRM alone. The aim of this randomized controlled clinical trial was to evaluate the effect of the combined use of BP-RRM and SP-RCS on the prognosis of teeth with refractory periapical diseases after endodontic microsurgery.

MATERIALS AND METHODS

240 teeth with refractory periapical diseases scheduled for endodontic microsurgery were randomly divided into BP-RRM/SP-RCS group (n = 120) and BP-RRM group (n = 120). The patients were followed up at 3 months, 6 months, and 12 months after endodontic microsurgery. Pre- and post-operative clinical and radiographic examinations were performed to evaluate the treatment outcome. The 1-year success rate of endodontic microsurgery in BP-RRM/SP-RCS and BP-RRM groups was compared by Chi-square test. Factors that might impact the prognosis were further analyzed using Chi-square test or Fisher's exact test.

RESULTS

A total of 221 teeth completed the 12-month follow-up. The 1-year success rates of the BP-RRM/SP-RCS and BP-RRM groups were 94.5% (104/110) and 92.8% (103/111), respectively. The combined use of BP-RRM and SP-RCS achieved a clinical outcome comparable to BP-RRM alone (P = 0.784). Tooth type (P = 0.002), through-and-through/apico-marginal lesion (P = 0.049), periodontal status (P < 0.0001), and Kim's lesion classification (P < 0.0001) were critical factors associated with the 1-year success of endodontic microsurgery.

CONCLUSIONS

The combined use of BP-RRM and SP-RCS is a practicable method for root-end filling in endodontic microsurgery with a satisfactory 1-year clinical outcome.

CLINICAL RELEVANCE

The combined application of BP-RRM and SP-RCS in EMS is an effective root-end filling method with a satisfactory 1-year clinical outcome.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100052174).

Evaluation of Different Techniques and Materials for Filling in 3-dimensional Printed Teeth Replicas with Perforating Internal Resorption by Means of Micro-Computed Tomography

INTRODUCTION

The aim of this study was to evaluate the filling ability of 2 obturation techniques in 3-dimensional (3D) printed teeth with perforating internal resorption (PIR).

METHODS

A maxillary central incisor was instrumented and scanned by micro-computed tomographic (micro-CT) imaging. The 3D model was exported in the stereolithographic format and, with the aid of OrtogOnBlender software (Cícero Moraes, Sinop, SP, Brazil), a PIR in the middle third of the root canal was designed. Thirty-two replicas were printed in surgical resin and distributed into 4 groups (n = 8) according to the obturation technique and the material used: 2 groups used the hybrid technique, 1 with Bio-C Sealer (BCS; Angelus, Londrina, PR, Brazil)/gutta-percha (GP; VDW GmbH, Munich, Germany) + Bio-C Repair (BCR; Angelus, Londrina, PR, Brazil) and the other with BioRoot (BR; Septodont, Saint Maur des Fosses, France)/gutta-percha (GP) + Biodentine (BD; Septodont, Saint Maur des Fosses, France), and 2 groups used the incremental technique, 1 with BCR and the other with BD. Postobturation micro-CT imaging was performed to measure the percentage volume of voids and laser confocal microscopy to measure the surface roughness (μm) of the repair cements. Data were compared using analysis of variance and Kruskal-Wallis tests.

RESULTS

Regarding the filling volume in the apical third, the BCS/GP + BCR (89.70 ± 5.15), BR/GP + BD (87.70 ± 8.43), and BCR (84.20 ± 9.00) groups showed the highest percentages compared with the BD group (69.70 ± 6.88) (P < .05). In the area of internal resorption, the BCS/GP + BCR (96.00 ± 2.64) and BCR (95.30 ± 2.93) groups showed the highest percentages compared with the BR/GP + BD group (91.50 ± 1.35) (P < .05). The BD group showed intermediate values that were sometimes similar to the BCS/GP + BCR and BCR groups and similar to the BR/GP + BD group (P > .05). Regarding the quality of the filling in the perforation area, the BCR group showed better results compared with the BD group (P < .001). Regarding roughness, the BCR group (1.66 ± 0.65) showed lower surface roughness compared with the BD group (2.51 ± 0.89) (P < .05).

CONCLUSIONS

The capacity and quality of the filling in teeth with PIR were superior with the incremental technique with BCR and the hybrid technique with BCS/GP + BCR.

Successful Tampon Pulpotomy in a Molar With an Endodontic Lesion: A Case Report

Vital pulp therapy (VPT) has emerged as an alternative approach to root canal treatment (RCT) for managing cases with irreversible pulpitis/apical periodontitis, aiming to preserve pulp vitality and promote healing and regeneration of pulpal tissues. The tampon approach, which entails the placement of endodontic biomaterials over the pulpal wound to mechanically tamponade uncontrollable bleeding, shows promise as a technique within VPT. A 32-year-old female patient presented with severe/lingering pain in the lower left quadrant. Clinical/radiographic examinations confirmed symptomatic irreversible pulpitis and symptomatic apical periodontitis in the first right lower molar; radiographic examination exhibited an endodontic lesion for the mesial root and periodontal ligament (PDL) widening for the distal root. The patient opted for VPT; however, despite several attempts to achieve hemostasis using various solutions, including NaOCl, hemorrhage persisted. Therefore, a layer of freshly mixed calcium-enriched mixture cement was applied using a dry cotton pellet, resulting in bleeding control. Then, a permanent restoration was placed. Follow-up examinations revealed the resolution of symptoms and the one-year radiographic examination showed complete healing of the endodontic lesion. The successful outcomes highlight the effectiveness of tampon pulpotomy in managing irreversible pulpitis and associated apical lesions. Tampon pulpotomy offers several advantages, including preserving healthy pulp tissue, reduced invasiveness, and immediate hemorrhage control. This technique presents an alternative to more invasive procedures, such as RCT, and promotes patient satisfaction through a simplified treatment approach. Further clinical trials are needed to validate the findings of this case report and establish the long-term success rates of tampon pulpotomy.

Advanced Materials for Clinical Endodontic Applications: Current Status and Future Directions

Endodontics has significantly evolved in recent years, with advancements in instruments, biomaterials and nanomaterials science playing a pivotal role [...].

Effects of Superfine Tricalcium Silicate Powder on the Physicochemical and Mechanical Properties of Its Premixed Cement as a Root Canal Filling Material

Calcium silicate-based cement is a promising material for filling root canals. However, it has several drawbacks to its clinical application, including difficult operation and low curing strength. In this study, we successfully prepared an ultrafine tricalcium silicate powder and investigated the effects of this ultrafine powder on the performance of the premixed tricalcium silicate cement, including the curing process, setting time, hydration products, microstructure, injectivity, fluidity, and compressive strength. The results demonstrate that the addition of ultrafine tricalcium silicate powder alters the hydration product content and product morphology of the premixed cement. By increasing the content of the ultrafine powder, the injectable property of the cement can be increased to more than 95%, the fluidity can be increased from 18 mm to 35 mm, and the curing time can be shortened from 13 h to 11 h. Notably, the addition of the ultrafine powder greatly enhances the compressive strength of the hardened cement, which increases from 20.6 MPa to 51.0 MPa. These results indicate that altering the particle size distribution of the powder is an effective method for enhancing the physicochemical and mechanical properties of tricalcium silicate cement as a root canal filling material.

The Combined Effects on Human Dental Pulp Stem Cells of Fast-Set or Premixed Hydraulic Calcium Silicate Cements and Secretome Regarding Biocompatibility and Osteogenic Differentiation

An important part of regenerative endodontic procedures involving immature permanent teeth is the regeneration of the pulp-dentin complex with continuous root development. Hydraulic calcium silicate cements (HCSCs) are introduced for the pulpal treatment of immature permanent teeth. The stem-cell-derived secretome recently has been applied for the treatment of various damaged tissues. Here, we evaluated the biocompatibility and osteogenic differentiation of HCSCs combined with secretome on human dental pulp stem cells. In the Cell Counting Kit-8 test and wound healing assays, significantly higher cell viability was observed with secretome application. In alkaline phosphatase analysis, the activity was significantly higher with secretome application in all groups, except for RetroMTA on day 2 and Endocem MTA Premixed on day 4. In an Alizarin Red S staining analysis, all groups with secretome application had significantly higher staining values. Quantitative real-time polymerase chain reaction results showed that the day 7 expression of OSX significantly increased with secretome application in all groups. SMAD1 and DSPP expression also increased significantly with secretome addition in all groups except for Biodentine. In conclusion, HCSCs showed favorable biocompatibility and osteogenic ability and are predicted to demonstrate greater synergy with the addition of secretome during regenerative endodontic procedures involving immature permanent teeth.

The microstructure, composition, physical properties, and bioactivity of calcium silicate cement prototypes for vital pulp therapies

Hydraulic calcium silicate cements (HCSCs) are valuable for various dental procedures. However, several reports document inherent limitations and complaints about their high costs, hindering accessibility in low-and middle-income countries. This study aimed to characterize four low-cost HCSC prototypes to show their microstructure, composition, and fundamental physical properties. Four HCSC prototypes were formulated: 1- calcium silicate powder with 17.5 wt. % replacement of calcium tungstate, 2- calcium silicate powder with 17.5 wt. % replacement of zirconium oxide, 3- calcium silicate powder with 17.5 wt. % replacement of calcium tungstate and 2.5 wt. % of zirconium oxide and 4- calcium silicate powder with 10 wt. % replacement of calcium tungstate and 10 wt. % replacement of zirconium oxide. Scanning electron microscopy, energy-dispersive X-ray spectroscopy, and X-ray diffraction were used to assess their microstructure and composition. Additionally, radiopacity, setting time, solubility, pH, and in vitro bioactivity were evaluated at different time points and contrasted with controls (Mineral trioxide aggregate -MTA Angelus- and Intermediate restorative material -IRM-). Their production cost was significantly lower than commercially available HCSCs. All prototypes exhibited a microstructure and composition comparable to MTA Angelus. All the prototypes exhibited radiopacity exceeding 3 mm of aluminum and shorter initial and final setting times than MTA Angelus. The solubility of some prototypes closely adhered to the ISO standard recommendation of 3% after 1 day, and all promoted an alkaline pH and the formation of calcium/phosphate precipitates. These promising findings suggest the potential clinical application of these prototypes. However, further research is necessary to evaluate their mechanical and biological properties for definitive clinical use.

Postoperative pain of single-visit endodontic treatment with gutta-percha versus MTA filling: a randomized superiority trial

BACKGROUND

Postoperative pain has remained a challenge for clinicians. This randomized superiority trial compared the levels of postoperative pain following the use of gutta-percha (GP) and sealer or mineral trioxide aggregate (MTA) as root canal filling materials in teeth with asymptomatic apical periodontitis.

METHODS

A total of 119 patients were initially evaluated in this two-arm, parallel-group, single-blind, superiority randomized trial. The inclusion criteria were participants aged 18-65 years with single-canal premolars diagnosed with asymptomatic apical periodontitis. The participants were finally divided into two groups using the permuted block randomization method. In the GP group (N = 46), the cleaned and shaped root canals were filled with gutta-percha and AH Plus sealer, while in the MTA group (N = 48), the cleaned and shaped root canals were filled with an MTA apical filling and a coronal gutta-percha and sealer. Patient pain level was measured 6, 12, 24, 48, and 72 h postoperatively using a 10-point visual analog scale (VAS). The data were analyzed by the chi-square, independent t, Friedman, and Mann-Whitney U tests.

RESULTS

The mean of VAS scores decreased significantly over time in both groups (P < 0.001). The mean VAS scores were significantly lower in the MTA filling group than in the other group (P < 0.05). Female patients reported higher VAS scores at 6- and 12-hour periods in both groups (P < 0.05).

CONCLUSION

MTA as a root canal filling material might be a valuable option for clinicians due to its low postoperative pain.

TRIAL REGISTRATION

The trial protocol was registered at the Registry of Clinical Trials (IRCT20191104045331N1).

Direct pulp capping procedures - Evidence and practice

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

Advances and challenges in regenerative dentistry: A systematic review of calcium phosphate and silicate-based materials on human dental pulp stem cells

Conventional dentistry faces limitations in preserving tooth health due to the finite lifespan of restorative materials. Regenerative dentistry, utilizing stem cells and bioactive materials, offers a promising approach for regenerating dental tissues. Human dental pulp stem cells (hDPSCs) and bioactive materials like calcium phosphate (CaP) and silicate-based materials have shown potential for dental tissue regeneration. This systematic review aims to investigate the effects of CaP and silicate-based materials on hDPSCs through in vitro studies published since 2015. Following the PRISMA guidelines, a comprehensive search strategy was implemented in PubMed MedLine, Cochrane, and ScienceDirect databases. Eligibility criteria were established using the PICOS scheme. Data extraction and risk of bias (RoB) assessment were conducted, with the included studies assessed for bias using the Office of Health and Translation (OHAT) RoB tool. The research has been registered at OSF Registries. Ten in vitro studies met the eligibility criteria out of 1088 initial studies. Methodological heterogeneity and the use of self-synthesized biomaterials with limited generalizability were observed in the included study. The findings highlight the positive effect of CaP and silicate-based materials on hDPSCs viability, adhesion, migration, proliferation, and differentiation. While the overall RoB assessment indicated satisfactory credibility of the reviewed studies, the limited number of studies and methodological heterogeneity pose challenges for quantitative research. In conclusion, this systematic review provides valuable insights into the effects of CaP and silicate-based materials on hDPSCs. Further research is awaited to enhance our understanding and optimize regenerative dental treatments using bioactive materials and hDPSCs, which promise to improve patient outcomes.

A comparison of osteogenic effect of newly manufactured calcium silicate-based sealers in vitro

This study aimed to assess the effect of different calcium silicate-based root canal sealers (CSRS) on osteogenic effect in human periodontal ligament cells (hPDLCs). hPDLCs were cultured in a medium containing extract of 5 types of CSRS. The specimens were assessed by the cell cytotoxicity test, alkaline phosphatase staining, alizarin red S staining, quantitative real-time PCR, Western blot analysis, and enzyme-linked immunosorbent assay. The diluted concentrations of extracted solutions had no significant effect on the viability of hPDLCs. There was a statistically significant difference in the mRNA expression level of bone sialoprotein (BSP), osteocalcin (OCN), and runt-related transcription factor 2 (RUNX2) among some groups. The protein expressions of BSP, OCN, and RUNX2 were significantly higher in some groups compared to the control group. The CSRS did not interfere with the osteogenic differentiation of hPDLCs, compared to the control group. CSRS are shown to have biocompatibility and osteogenic differentiation effect on hPDLCs.

Evaluation of the Shear Bond Strength of Immediate and Delayed Restorations of Various Calcium Silicate-Based Materials with Fiber-Reinforced Composite Resin Materials

Due to significant tissue loss in teeth requiring pulp treatments, hermetic restoration of the remaining dental tissues is one of the most crucial factors in determining the treatment's success. The adhesion of composite resins to calcium silicate cements (CSCs) is considered challenging. Consequently, it is crucial to identify the optimal method for obtaining optimal adhesion. The aim of the present study is to evaluate the shear bond strength (SBS) values of immediate and delayed restorations with fiber-reinforced composites on powder-liquid, premixed, and resin-containing flowable CSCs. In the present study, the SBS values obtained after immediate (14 min) and delayed (7 days) restorations of three different CSCs (NeoMTA2, NeoPutty, and TheraCal PT) with three different resin composite materials (EverX FlowTM, EverX PosteriorTM, and Filtek Z550) were compared. The fracture types were evaluated using a stereomicroscope and SEM. TheraCal PT had the highest SBS values for both immediate and delayed restorations, and the comparison with other materials showed a statistically significant difference (p = 0.001). In contrast, there was no statistically significant difference between the SBS values of NeoMTA and NeoPutty (p > 0.05). In both immediate and delayed restorations, there was no statistically significant difference between nanohybrid and fiber-reinforced composites (p > 0.05). The simple use and strong bonding ability of TheraCal PT with composite resins may provide support for the idea that it is suitable for pulpal interventions. Nevertheless, due to the in vitro nature of this study, additional in vitro and clinical studies are required to investigate the material's physical, mechanical, and biological properties for use in clinical applications.

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.

Effect of incorporation of nano-graphene oxide on physicochemical, mechanical, and biological properties of tricalcium silicate cement

OBJECTIVE

Evaluation of setting time, compressive strength, pH, calcium ion release, and antibacterial activity of mineral trioxide aggregate (MTA) after modification with three different concentrations of nano-graphene oxide (GO) powder compared to unmodified Biodentine as a commercial control.

METHODS

GO powder, unhydrated and hydrated cements were characterized using Environmental Scanning Electron Microscope (ESEM) with Energy Dispersive X-ray spectroscopy (EDX), X-ray diffraction (XRD), Raman Spectroscopy, and Fourier Transform Infrared spectroscopy (FTIR). GO was also analyzed using Scanning Transmission Electron Microscope (STEM) to determine average lateral dimensions. Specimens were prepared and grouped according to the concentration of GO added to Rootdent MTA (control, 1, 3, and 5 wt%) and the material used (MTA and unmodified Biodentine) into five groups. Setting time was evaluated using Gillmore penetrometer (n = 5). Compressive strength was evaluated using universal testing machine (n = 7). pH and calcium ion release were assessed using pH meter and Induced Coupled Plasma-Optical Emission Spectroscopy (ICP-OES) at 1, 7, 14, and 28 days (n = 7). Antibacterial activity was evaluated against Streptococcus mutans using direct contact test (n = 7). One-way and repeated measures ANOVA followed by Tukey's post hoc test were used for data analysis with significance level set at p ≤ 0.05.

RESULTS

Addition of GO to MTA reduced both initial and final setting time. GO modified MTA groups and unmodified Biodentine showed significantly increased calcium ion release at 14 and 28 days. All cements showed alkaline pH of the storage media at all tested time intervals. 1 wt% GO recorded the highest compressive strength values in MTA modified groups. The increased concentration of GO from 1 to 5 wt% successively increased antibacterial activity of MTA, with Biodentine showing the lowest significant value.

CONCLUSION

Addition of 1 wt% GO can significantly improve the tested properties of tricalcium silicate-based cements without compromising their compressive strength.

CLINICAL SIGNIFICANCE

GO is a promising modification for tricalcium silicate cements to improve setting time, compressive strength, and antibacterial activity to provide a variety of materials for different clinical situations. This in turn can reduce the risk of reinfection and allow placement of the final restoration in a single visit.

Does radiation therapy affect adhesion of tricalcium silicate cements to root dentin?

OBJECTIVE

This study aimed to analyze the effect of irradiation on the push-out bond strength of mineral trioxide aggregate (MTA) and Biodentine to radicular dentin.

METHODOLOGY

A total of 60 extracted mature human teeth with single root canals were categorized into two groups (irradiated and non-irradiated) (n=30). Each group was further divided into two sub-groups based on cements used (Biodentine and MTA). Then, a cumulative radiation dose of 60 Gy was divided into 30 fractions (two Gy for every fraction) and administered for five successive days per week over six weeks. Obturation was then performed using MTA and Biodentine. Afterwards, 1.5 mm thick horizontal sections were procured from the middle one-third of all the specimens and then subjected to push-out bond test. Results were analyzed using one-way analysis of variance with post-hoc Tukey's test.

RESULTS

The bond strength of Biodentine and MTA to irradiated teeth was lower than non-irradiated teeth. Highest push-out bond strength was observed in non-irradiated specimens filled with Biodentine (p=0), followed by irradiated specimens filled with Biodentine (p=0); non-irradiated specimens filled with MTA (p=0); and irradiated specimens filled with MTA (p=0.9).

CONCLUSION

The push-out bond strength of Biodentine and MTA to root canal dentin decreased significantly post irradiation.

Silicate Ions Derived from Calcium Silicate Extract Decelerate Ang II-Induced Cardiac Remodeling

BACKGROUND

Pathological cardiac hypertrophy is one of the main activators of heart failure. Currently, no drug can completely reverse or inhibit the development of pathological cardiac hypertrophy. To this end, we proposed a silicate ion therapy based on extract derived from calcium silicate (CS) bioceramics for the treatment of angiotensin II (Ang II) induced cardiac hypertrophy.

METHODS

In this study, the Ang II induced cardiac hypertrophy mouse model was established, and the silicate ion extract was injected to mice intravenously. The cardiac function was evaluated by using a high-resolution Vevo 3100 small animal ultrasound imaging system. Wheat germ Agglutinin, Fluo4-AM staining and immunofluorescent staining was conducted to assess the cardiac hypertrophy, intracellular calcium and angiogenesis of heart tissue, respectively.

RESULTS

The in vitro results showed that silicate ions could inhibit the cell size of cardiomyocytes, reduce cardiac hypertrophic gene expression, including atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP) and β-myosin heavy chain (β-MHC), decrease the content of intracellular calcium induced by Ang II. In vivo experiments in mice confirmed that intravenous injection of silicate ions could remarkably inhibit the cardiac hypertrophy and promote the formation of capillaries, further alleviating Ang II-induced cardiac function disorder.

CONCLUSION

This study demonstrated that the released silicate ions from CS possessed potential value as a novel therapeutic strategy of pathological cardiac hypertrophy, which provided a new insight for clinical trials.

Biological considerations of dental materials as orifice barriers for restoring root-filled teeth

There is ample published literature regarding the technical aspects of restoring root-filled teeth, but little concerning the biological impacts, consequences, and criteria for the selection of direct restorative materials following endodontic treatment. The provision of an effective coronal seal in addition to a sound root filling is known to be important in the prevention of root canal infection. This review seeks to explore the evidence concerning the selection of dental materials in the restoration of root-filled teeth, specifically with a close examination of the properties of commonly used materials as orifice barriers. © 2023 Australian Dental Association.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rheological Properties and Setting Kinetics of Bioceramic Hydraulic Cements: ProRoot MTA versus RS

Hydraulic calcium silicate-based cements (HCSCs) have become a superior bioceramic alternative to epoxy-based root canal sealers in endodontics. A new generation of purified HCSCs formulations has emerged to address the several drawbacks of original Portland-based mineral trioxide aggregate (MTA). This study was designed to assess the physio-chemical properties of a ProRoot MTA and compare it with newly formulated RS+, a synthetic HCSC, by advanced characterisation techniques that allow for in situ analyses. Visco-elastic behaviour was monitored with rheometry, while phase transformation kinetics were followed by X-ray diffraction (XRD), attenuated total reflectance Fourier transform infrared (ATR-FTIR), and Raman spectroscopies. Scanning electron microscopy with energy-dispersive spectroscopy, SEM-EDS, and laser-diffraction analyses was performed to evaluate the compositional and morphological characteristics of both cements. While the kinetics of surface hydration of both powders, when mixed with water, were comparable, an order of magnitude finer particle size distribution of RS+ coupled with the modified biocompatible formulation proved pivotal in its ability to exert predictable viscous flow during working time, and it was more than two times faster in viscoelastic-to-elastic transition, reflecting improved handling and setting behaviour. Finally, RS+ could be completely transformed into hydration products, i.e., calcium silicate hydrate and calcium hydroxide, within 48 h, while hydration products were not yet detected by XRD in ProRoot MTA and were obviously bound to particulate surface in a thin film. Because of the favourable rheological and faster setting kinetics, synthetic, finer-grained HCSCs, such as RS+, represent a viable option as an alternative to conventional MTA-based HCSCs for endodontic treatments.

Novel antibacterial and apatite forming restorative composite resin incorporated with hydrated calcium silicate

Background

White Portland cement is a calcium silicate material. It exhibits antibacterial properties and is biocompatible. In addition, calcium silicate-based materials are known to release calcium ions and form apatite. The purpose of this study was to develop a novel bioactive restorative resin composite with antibacterial and apatite forming properties to prevent tooth caries at the interface of teeth and restorative materials, by incorporation of hydrated calcium silicate (hCS) derived from white Portland cement.

Methods

To prepare the experimental composite resins, a 30 wt% light-curable resin matrix and 70 wt% filler, which was mixed with hCS and silanized glass powder were prepared in following concentrations: 0, 17.5, 35.0, and 52.5 wt% hCS filler. The depth of cure, flexural strength, water sorption, solubility, and antibacterial effect were tested. After immersion in artificial saliva solution for 15, 30, 60, and 90 days, ion concentration by ICP-MS and apatite formation using SEM-EDS, Raman spectroscopy and XRD from experimental specimens were analyzed.

Results

All experimental groups showed clinically acceptable depths of cure and flexural strength for the use as the restorative composite resin. Water sorption, solubility, released Ca and Si ions increased with the addition of hCS to the experimental composite resin. Experimental groups containing hCS showed greater antibacterial effects compared with the 0 wt% hCS filler group (p < 0.05). The 52.5 wt% hCS filler group produced precipitates mainly composed of Ca and P detected as hydroxyapatite after immersion in artificial saliva solution for 30, 60, and 90 days.

Conclusions

This results show that composite resins containing hCS filler is effective in antibacterial effects. hCS has also apatite formation ability for reducing gap size of microleakage by accumulating hydroxyapatite precipitates at the restoration-tooth interface. Therefore, novel composite resin containing hCS is promising bioactive resin because of its clinically acceptable physiochemical properties, antibacterial properties, and self-sealing potential for prevention of microleakage for longer usage of restorations.

Micro-shear bond strength of different calcium silicate materials to bulk-fill composite

Introduction

This study aimed to compare the micro-shear bond strength (µSBS) performances of two resin-based calcium silicate-based cement (CSC) (TheraCal PT and TheraCal LC), Biodentine, and two modified-MTA CSC materials (NeoMTA 2 and BioMTA+) to bulk-fill restorative material.

Materials and Methods

Fifty 3D printed cylindrical resin blocks with a central hole were used (2 mm in depth and 4 mm in diameter). CSCs were placed in the holes (per each group n = 10) and incubated for 24 h. Cylindrical polyethylene molds (2 mm in height and diameter) were used to place the bulk-fill restorative materials on the CSCs and polymerize for 20 s. Then, all specimens were incubated for 24 h at 37 °C at a humidity of 100%. Specimen’s µSBSs were determined with a universal testing machine. Data were analyzed with one-way ANOVA (Welch) and Tamhane test.

Results

Statistically higher µSBS was found for TheraCal PT (29.91 ± 6.13 MPa) (p < 0.05) respect to all the other materials tested. TheraCal LC (20.23 ± 6.32 MPa) (p > 0.05) reported higher µSBS than NeoMTA 2 (11.49 ± 5.78 MPa) and BioMTA+ (6.45 ± 1.89 MPa) (p < 0.05). There was no statistical difference among TheraCal LC, NeoMTA 2 and Biodentine (15.23 ± 7.37 MPa) and between NeoMTA 2 and BioMTA+ (p > 0.05).

Conclusion

Choosing TheraCal PT as the pulp capping material may increase the adhesion and µSBS to the bulk-fill composite superstructure and sealing ability.

Utility of biphasic calcium phosphate cement as a seal for root-end filling

The recently developed biphasic calcium phosphate cement (BCPC) consists of α-tricalcium phosphate-tetracalcium phosphate as the solid phase and calcium phosphate solution as the liquid phase. BCPC powder is composed of a single solid solution with a monomodal size distribution. Here, we used a bacterial leakage model to examine the utility of BCPC as a seal for root-end filling. We prepared large (median particle size=9.96 µm; BCPC-L) and small (median particle size=4.84 µm; BCPC-S) BCPC powders. In total, 45 single-rooted teeth were instrumented, resected at the root-end, and retrofilled with experimental materials. Mineral trioxide aggregate (MTA) was used as the control. After visual confirmation of BCPC powder size and retrofilling quality by microscopy, bacterial leakage tests were conducted using Enterococcus faecalis. The bacterial leakage tests did not reveal any significant differences between BCPC-S and MTA. Our findings suggest that BCPC-S is useful for root-end filling.

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.

Endodontic management strategies for permanent teeth with immature apices

This article will provide a summary of causes of incomplete root end closure and the implications of this on endodontic treatment. The limitations and benefits of traditional and more contemporary materials including the use of bioceramic cements are considered. The apical barrier technique is described in detail for teeth with immature apices utilising a variety of bioceramic cements and regenerative endodontic procedures with an overview of appropriate instruments to successfully complete the procedure.