Effectiveness of Three Agents in Pulpotomy Treatment of Permanent Molars with Incomplete Root Development: A Randomized Controlled Trial

Management strategies for pulpitis in vital permanent teeth in children and adolescents: a systematic review and meta-analysis of randomized clinical trials

PURPOSE

Vital pulp treatment (VPT), including pulp capping and pulpotomy, is a conservative approach designed to maintain pulp vitality and health in reversible and partially irreversible pulpitis cases, particularly in children and adolescents with immature or mature permanent teeth. Despite extensive research, the comparation of various VPTs remains uncertain. This study evaluated the efficacy of different VPT techniques and capping materials, including calcium hydroxide (CH), mineral trioxide aggregate (MTA), and other pulp-protecting agents (PPA), and explored heterogeneity across trials, particularly with respect to pulp status (reversible vs. irreversible) and coronal restorations, using meta-regression analysis.

METHODS

A systematic review and meta-analysis, adhering to PRISMA guidelines, was conducted through a comprehensive search in PubMed and Scopus up to August 2024. The PICO framework was used to define the inclusion criteria: Population (children/adolescents with vital permanent teeth diagnosed with pulp inflammation), Intervention (various VPTs), Comparison (different PPAs and restoration types), and Outcome (success rates based on clinical/radiographic criteria). Odd ratios (ORs) were calculated using random-effects models. Statistical heterogeneity was assessed using the I2 test. Meta-regression analysis was performed to explore the influence of co-interventions on the success rate (P < 0.05).

RESULTS

Nineteen randomized controlled trials involving 1183 participants were included. The meta-analysis revealed no significant difference between CH and MTA/PPA at 6 months (OR = -0.62; P = 0.26); however, at 12 months, CH demonstrated a significantly lower success rate compared to MTA/PPA (OR = -1.34; P = 0.01). Meta-regression analysis indicated that factors such as pulp status, restoration type, and VPT techniques did not significantly predict treatment success.

CONCLUSIONS

The findings suggest that various VPT techniques utilising MTA/PPA are effective for managing reversible/irreversible pulpitis in mature/immature permanent teeth in children/adolescents. In contrast, CH is less favourable and not recommended for VPT. These results reinforce the growing evidence supporting the use of MTA and other evidence-supported PPAs over CH for long-term success in VPTs.

Concentrated growth factor scaffold-based pulpotomy of permanent molars with symptomatic irreversible pulpitis

Objectives

: Pulpotomy is a minimally invasive procedure that aims to retain the vitality of the radicular pulp by removing the inflamed coronal pulp tissue. This case series presents the successful management of symptomatic irreversible pulpitis by pulpotomy with concentrated growth factor (CGF) scaffolds.

Methods

Six permanent mandibular molars with a diagnosis of symptomatic irreversible pulpitis were included. Under Local anesthesia and rubber dam isolation, caries were excavated using high-speed bur under coolant. Full coronal pulpotomy was done and hemostasis was achieved. CGF membrane was prepared and placed over the radicular pulp and layered with Biodentine (Septodont). Final restoration of type IX glass ionomer cement and bulk fill composite resin was placed. Patients were assessed for various clinical and radiographic parameters at intervals of 1 week and 3, 6, and 12 months. Five patients fulfilled the success criteria at the end of 1 year.

Results

Pulpotomy is considered an alternative treatment modality for root canal treatment in symptomatic irreversible pulpitis aiming at alleviating symptoms and maintaining vitality. CGF scaffold when used as a capping material acts as a reservoir for growth factors with anti-inflammatory properties and enhances healing.

Conclusions

Scaffold-based pulpotomy can be considered a biological approach to healing inflamed pulp.

Analysis of pulp histological response to pulpotomy performed with white mineral trioxide aggregate mixed with 2.25% sodium hypochlorite gel in humans: a randomized controlled clinical trial

This study aimed to evaluate the histological success of pulpotomy in primary molars using white mineral trioxide aggregate (WMTA) mixed with 2.25% sodium hypochlorite (NaOCl) gel and to evaluate in vitro its physical and chemical properties. The study had a clinical stage and an in-vitro stage. The clinical study was conducted with 24 patients aged 8-10 years. It was a randomized controlled trial to perform a histologic evaluation of pulp response following pulpotomy. Primary first molars were randomly assigned in split mouth model to control group-WMTA + distilled water (DW) or experimental group - WMTA + NaOCl gel. Teeth were extracted after 7, 30 or 90 days and submitted to histological analysis. The second stage was an in-vitro study to evaluate the physical and chemical properties of the two materials tested. SEM and EDX analyses and pH level evaluations were performed after 24 h and 28 days. The histological findings revealed that while WMTA + NaOCl gel group showed better odontoblastic integrity (P < 0.05), WMTA + DW group had more favorable outcomes in dentin bridge formation and pulp calcification (P < 0.05). Pulp tissue hemorrhage and pulp fibrosis were similar between them (P > 0.05). Regarding materials' in vitro evaluation, the pH level indicated a higher initial pH for the WMTA + NaOCl gel group, which equalized after 28 days. SEM analysis initially showed a less homogeneous surface for WMTA + NaOCl gel, but it became similar after 28 days. EDX analysis indicated higher calcium and silicon percentages in the WMTA + NaOCl gel group initially, which increased in both groups after 28 days. Adding 2.25% NaOCl gel to WMTA enhanced odontoblastic integrity in both the short and medium term. In addition, it had a similar chemical composition, surface morphology, and alkalinity when compared to WMTA + DW mixture.

Novel temporary endodontic medication based on calcium silicate strategy: a biological and physicochemical study

Introduction

The purpose of this in vitro study was to compare the physicochemical and biological properties of a traditional calcium hydroxide-based cement (Cal) to a novel endodontic material based on calcium silicate strategy in premixed formulation (Bio-C).

Methods

Crystalline structure evaluation and pH analysis were performed at different time periods (3-168 h). Contact angle, surface roughness, solubility and flowability of both materials were also investigated. The antibacterial activity of each material was assessed using a direct contact test against Enterococcus faecalis (E.faecalis), and the cytotoxicity was performed by using periodontal ligament cells. Statistical analysis was accomplished using one-way analysis of variance and Kruskal-Wallis tests.

Results

An alkaline pH was observed in both the tested materials. Higher pH values were attained in Cal compared to Bio-C (p < 0.05). Higher flowability, solubility and wettability were attained for Bio-C compared to Cal (p < 0.05). Crystalline structures were observed on the surface of Bio-C after immersion in PBS (168 h). Cal presented higher antibacterial activity compared to Bio-C against E.faecalis. Only undiluted Bio-C extracts demonstrated slight cytotoxicity, while all the other tested specimens had no cytotoxicity.

Discussion

In conclusion, the novel bioceramic medication might be used as a suitable alternative agent to the traditional calcium hydroxide cements due to its biological and physicochemical properties. However, further studies on the ability of removing Bio-C from root canal are required to determine whether such a temporary bioceramic can ameliorate root canal treatments.

Research Progress on Nanomaterials for Tissue Engineering in Oral Diseases

Due to their superior antibacterial properties, biocompatibility and high conductivity, nanomaterials have shown a broad prospect in the biomedical field and have been widely used in the prevention and treatment of oral diseases. Also due to their small particle sizes and biodegradability, nanomaterials can provide solutions for tissue engineering, especially for oral tissue rehabilitation and regeneration. At present, research on nanomaterials in the field of dentistry focuses on the biological effects of various types of nanomaterials on different oral diseases and tissue engineering applications. In the current review, we have summarized the biological effects of nanoparticles on oral diseases, their potential action mechanisms and influencing factors. We have focused on the opportunities and challenges to various nanomaterial therapy strategies, with specific emphasis on overcoming the challenges through the development of biocompatible and smart nanomaterials. This review will provide references for potential clinical applications of novel nanomaterials in the field of oral medicine for the prevention, diagnosis and treatment of oral diseases.

The Influence of Carious Lesion and Bleeding Time on the Success of Partial Pulpotomy in Permanent Molars with Irreversible Pulpitis: A Prospective Study

This prospective study aimed to evaluate the success rate of partial pulpotomy using mineral trioxide aggregate (MTA), in permanent molars with symptomatic irreversible pulpitis. Moreover, this study aimed to investigate the effect of carious lesion depth and activity and bleeding time on the outcome of partial pulpotomy. Forty permanent molars with deep and extremely deep carious lesions clinically diagnosed with symptomatic irreversible pulpitis were included. The status of the carious lesion was evaluated clinically and radiographically to determine its activity (rapidly or slowly progressing) and depth (deep or extremely deep). A partial pulpotomy was performed and MTA was used. Clinical and radiographic analysis were performed at 3, 6 and 12 months. Chi-square analysis and Fisher's exact test were used. Scanning electron microscope and energy dispersive X-rays were used to investigate the crystalline structures and their chemical composition onto MTA surfaces after immersion in several conditions. The partial pulpotomy was 88.9% successful, with no significant difference in outcome between deep and extremely deep carious lesions (p = 0.22) or between rapidly and slowly progressing lesions (p = 0.18). Nevertheless, all failed cases were associated with rapidly progressing lesions and extremely deep lesions. All failures occurred when the bleeding time was more than 3 min (p = 0.10). Different crystalline structures were detected on MTA surfaces, with higher calcium percentages in PBS conditions. Within the limitations of the present study, favorable results demonstrated that MTA might be recommended as a suitable agent for partial pulpotomy in permanent molars with irreversible pulpitis. The depth and activity of the carious lesion as well as the bleeding time are important factors in the success of partial pulpotomy treatment. The prolonged bleeding time and the extremely deep rapidly progressing caries could be related with the failure cases in partial pulpotomy treatment of irreversible pulpitis.

Do the Mechanical Properties of Calcium-Silicate-Based Cements Influence the Stress Distribution of Different Retrograde Cavity Preparations?

The aim of the present study was to investigate the influence of the mechanical properties of three different calcium-silicate-based cements on the stress distribution of three different retrograde cavity preparations. Biodentine™ "BD", MTA Biorep "BR", and Well-Root™ PT "WR" were used. The compression strengths of ten cylindrical samples of each material were tested. The porosity of each cement was investigated by using micro-computed X-ray tomography. Finite element analysis (FEA) was used to simulate three retrograde conical cavity preparations with an apical diameter of 1 mm (Tip I), 1.4 mm (Tip II), and 1.8 mm (Tip III) after an apical 3 mm resection. BR demonstrated the lowest compression strength values (17.6 ± 5.5 MPa) and porosity percentages (0.57 ± 0.14%) compared to BD (80 ± 17 MPa-1.22 ± 0.31%) and WR (90 ± 22 MPa-1.93 ± 0.12%) (p < 0.05). FEA demonstrated that the larger cavity preparation demonstrated higher stress distribution in the root whereas stiffer cement demonstrated lower stress in the root but higher stress in the material. We can conclude that a respected root end preparation associated with cement with good stiffness could offer optimal endodontic microsurgery. Further studies are needed to define the adapted cavity diameter and cement stiffness in order to have optimal mechanical resistance with less stress distribution in the root.

Immunomodulatory Effects of Endodontic Sealers: A Systematic Review

Inflammation is a crucial step prior to healing, and the regulatory effects of endodontic materials on the immune response can influence tissue repair. This review aimed to answer whether endodontic sealers can modulate the immune cells and inflammation. An electronic search in Scopus, Web of Science, PubMed, and Google Scholar databases were performed. This systematic review was mainly based on PRISMA guidelines, and the risk of bias was evaluated by SYRCLEs and the Modified CONSORT checklist for in vivo and in vitro studies, respectively. In total, 28 articles: 22 in vitro studies, and six in vivo studies were included in this systematic review. AH Plus and AH 26 can down-regulate iNOS mRNA, while S-PRG sealers can down-regulate p65 of NF-κB pathways to inhibit the production of TNF-α, IL-1, and IL-6. In vitro and in vivo studies suggested that various endodontic sealers exhibited immunomodulatory impact in macrophages polarization and inflammatory cytokine production, which could promote healing, tissue repair, and inhibit inflammation. Since the paradigm change from immune inert biomaterials to bioactive materials, endodontic materials, particularly sealers, are required to have modulatory effects in clinical conditions. New generations of endodontic sealers could hamper detrimental inflammatory responses and maintain periodontal tissue, which represent a breakthrough in biocompatibility and functionality of endodontic biomaterials.

Special Issue "Recent Advances in Biomaterials and Dental Disease" Part I

Oral cavities provide an entry point for food and nutrients [...].

Physicochemical and Mechanical Properties of Premixed Calcium Silicate and Resin Sealers

The aim of the present in vitro study was to evaluate specific mechanical and physicochemical properties of two calcium silicate based sealers, (AH Plus Bioceramic “AHPB”; Well-Root ST “WRST”), and a conventional resin sealer (AH Plus “AHP”). These aims were accomplished by assessing the porosity, pH, compression strength, roughness, wettability and cell attachment of the tested materials. The results were compared statistically using the one-way ANOVA test. Higher pH values were obtained in both AHPB and WRST compared to AHP at 3, 24 and 72 h (p < 0.05). A greater level of porosity and wettability was detected for both AHPB and WRST compared to the resin sealer AHP (p < 0.05). Evident cell growth characterized by elongated morphology was observed on the surface of AHPB and WRST, while only a thin layer of cells was seen on the surface of AHP. A significant lower compression strength and modulus were obtained in the specimens created using AHPB compared to those made with AHP and WRST (p < 0.05). The removal of calcium silicates may be quite tricky during endodontic retreatment. In conclusion, considering the limitations of the present in vitro study, both calcium silicate sealers demonstrated good physicochemical properties. However, the lower compression strength and modulus of AHPB may facilitate its removal and make the retreatment procedures considerably easier.

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.

Physicochemical and Antibacterial Properties of Conventional and Two Premixed Root Canal Filling Materials in Primary Teeth

In this study, some physicochemical and antibacterial properties of three root canal filling materials for primary teeth, Calplus “CP” (Prevest DenPro, Lewes, DE, USA), Bio-C Pulpecto “Bio-CP” (Angelus, Basil, Londrina, Paraná, Brazil), and Zinc Oxide and Eugenol “ZOE” (Prevest DenPro, Lewes, DE, USA) were compared. For each material, the pH, solubility, contact angle, and crystalline microstructure under SEM were evaluated. Their antibacterial activity against Enterococcus faecalis was determined through direct tests. The Kruskal−Wallis test was used to analyze the results using a one-way analysis of variance on ranks. All the materials had an alkaline pH at 3, 24, and 72 h, with CalPlus having the highest (p < 0.05). Bio-CP was more soluble during the evaluation period (24 h) than ZOE and CalPlus (p < 0.05). Bio-CP and ZOE demonstrated the creation of crystallite structures on their surfaces after immersion in PBS at 37 °C, whereas CalPlus showed none. The lowest contact angle was observed for Bio-CP (53 ± 1.5°); contact angles of (86 ± 4°) and (96 ± 1°), respectively, were observed after 10 s of the deposition of the water drop for CalPlus and ZOE. In conclusion, according to this study, there is still a need to develop new filling materials for primary teeth. ZOE, CalPlus and Bio-CP demonstrated different physicochemical and antibacterial properties, but none of the materials had optimal properties and could be considered the most suitable filling material for primary teeth pulpectomy. Bioceramics in their current state are not an alternative. The physicochemical and antibacterial properties still need improvement to fit the intricate anatomy of primary teeth.

Bioactive Inorganic Materials for Dental Applications: A Narrative Review

Over time, much attention has been given to the use of bioceramics for biomedical applications; however, the recent trend has been gaining traction to apply these materials for dental restorations. The bioceramics (mainly bioactive) are exceptionally biocompatible and possess excellent bioactive and biological properties due to their similar chemical composition to human hard tissues. However, concern has been noticed related to their mechanical properties. All dental materials based on bioactive materials must be biocompatible, long-lasting, mechanically strong enough to bear the masticatory and functional load, wear-resistant, easily manipulated, and implanted. This review article presents the basic structure, properties, and dental applications of different bioactive materials i.e., amorphous calcium phosphate, hydroxyapatite, tri-calcium phosphate, mono-calcium phosphate, calcium silicate, and bioactive glass. The advantageous properties and limitations of these materials are also discussed. In the end, future directions and proposals are given to improve the physical and mechanical properties of bioactive materials-based dental materials.

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

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

The antimicrobial peptides secreted by the chromaffin cells of the adrenal medulla link the neuroendocrine and immune systems: From basic to clinical studies

The increasing resistance to antibiotic treatments highlights the need for the development of new antimicrobial agents. Antimicrobial peptides (AMPs) have been studied to be used in clinical settings for the treatment of infections. Endogenous AMPs represent the first line defense of the innate immune system against pathogens; they also positively interfere with infection-associated inflammation. Interestingly, AMPs influence numerous biological processes, such as the regulation of the microbiota, wound healing, the induction of adaptive immunity, the regulation of inflammation, and finally express anti-cancer and cytotoxic properties. Numerous peptides identified in chromaffin secretory granules from the adrenal medulla possess antimicrobial activity: they are released by chromaffin cells during stress situations by exocytosis via the activation of the hypothalamo-pituitary axis. The objective of the present review is to develop complete informations including (i) the biological characteristics of the AMPs produced after the natural processing of chromogranins A and B, proenkephalin-A and free ubiquitin, (ii) the design of innovative materials and (iii) the involvement of these AMPs in human diseases. Some peptides are elective biomarkers for critical care medicine, may play an important role in the protection of infections (alone, or in combination with others or antibiotics), in the prevention of nosocomial infections, in the regulation of intestinal mucosal dynamics and of inflammation. They could play an important role for medical implant functionalization, such as catheters, tracheal tubes or oral surgical devices, in order to prevent infections after implantation and to promote the healing of tissues.

Evaluation of the Shear Bond Strength of Four Bioceramic Materials with Different Restorative Materials and Timings

The objectives of this study were to evaluate the shear bond strength (SBS) of a resin composite (RC) and a resin-modified glass ionomer (RMGI) to four different bioceramic materials and to compare the effects of the immediate vs. delayed placement of restoration on the SBS. A total of 160 Teflon blocks and 40 blocks/material, were randomly filled with one of the bioceramic materials (NeoPUTTY^®, NeoMTA2^®, TotalFill^® BC RRM™ Fast Set Putty, and ProRoot^® MTA). The restoration was performed immediately or in a delayed time frame (after 7 days) using a Filtek™ Z350 XT Flowable composite (bonded to the bioceramic materials using Single bond universal 3M) or GC Fuji II LC^® RMGI. The SBS test was performed at a crosshead speed of 1 mm/min, and the failure mode was evaluated under a digital microscope by one blinded examiner. One-way analysis of variance (ANOVA) with the Games–Howell post hoc test was used to compare the mean SBS between the groups. The mean SBS of the bioceramic materials to RC was significantly higher than to RMGI except for ProRoot MTA (p-value 0.65). The SBS values to RC were as follows: ProRoot MTA (7.64 MPa); NeoMTA2 (8.57 MPa) which was significantly higher than both NeoPUTTY (4.04 MPa) and TotalFill^® BC RRM™ Fast Set Putty (4.38 MPa). For RMGI groups, ProRoot MTA showed the highest SBS (7.18 MPa), followed by NeoMTA2 (4.15 MPa), NeoPUTTY (1.62 MPa), and TotalFill^® BC RRM™ Fast Set Putty (1.54 MPa). The delayed timing restoration showed a significantly higher SBS than the immediate, except for the immediate RMGI restoration with MTA. To conclude, the SBS of RC to the bioceramic materials was significantly higher than RMGI, except for ProRoot MTA. Both restorative materials had a significantly higher SBS to the MTA groups in comparison to premixed bioceramics. Delayed RC restoration had a higher SBS than immediate restoration. Similarly, delayed RMGI restoration had a higher SBS than immediate restoration with premixed bioceramic but not with MTA.

Bond Strength of Adhesive Systems to Calcium Silicate-Based Materials: A Systematic Review and Meta-Analysis of In Vitro Studies

Since the adhesion of resin composites to calcium silicate-based cement is considered challenging. Therefore, the best adhesion strategy should be indicated. This review aimed to assess the effect of different adhesive systems on the bond strength of resin composite to calcium silicate-based cement through a systematic review and meta-analysis. The subsequent PICOS framework used was: population, calcium silicate-based cement; intervention, use of self-etch adhesive systems; control, use of total-etch adhesive systems; outcome, bond strength; study design, in vitro studies. The literature search was conducted independently by two reviewers up to 18 February 2021. Electronic databases (PubMed, ISI Web of Science, SciELO, Scopus, and Embase) were searched for applicable articles. In vitro manuscripts studying the effect of adhesive systems on the bond strength of calcium silicate-based cement were considered. The meta-analyses were performed using Review Manager Software version 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). Bond strength comparisons were made considering the type of calcium silicate-based cement (Mineral Trioxide Aggregate (MTA), Biodentine™, or TheraCal LC®). A p-value < 0.05 was considered statistically significant. A total of 7321 studies were retrieved in databases searched. After full-text evaluation, 37 eligible papers were assessed for qualitative analysis, leaving a total of 22 papers for the quantitative analysis. According to the meta-analysis, the bond strength values of resin composite materials to MTA and TheraCal LC® cement were favored when a total-etch adhesive system was used (p ≤ 0.02). On the other hand, the meta-analysis of the bond strength of resin-based materials to Biodentine™ calcium silicate-based cement was similar between both approaches (p = 0.12). The in vitro evidence suggests that the bond strength of resin-based materials to both MTA and TheraCal LC® cement was preferred by using the total-etch adhesive strategy. However, when bonding to Biodentine™, the use of self-etch or total-etch strategies displayed promising results. Given the lack of evidence related to the chemical interaction of self-etch adhesive materials with the bioceramics, if self-etch adhesives are used for bonding resin-based restorations to calcium silicate-based cement, a pretreatment with phosphoric acid could be recommended.