Evaluation of treatment and restoration preferences in deep carious teeth with various pulp exposure sizes: A questionnaire-based survey

This study evaluated the management preferences in a deep carious vital tooth. A questionnaire was e-mailed to members of the Turkish Dental Association. The questionnaire included a photograph and radiographs of an extremely deep carious molar (#16) of a 30-year-old man suffering from cold and chewing sensitivity. The dentists were asked to choose treatments for pulp exposure of <1, 1-2, and ≥2 mm and a permanent restoration. Chi-squared test was used to analyse data (p < 0.05). 504 (4.84%) of 10 411 dentists responded. When the pulp exposure was <1 mm: direct pulp capping (84.9%); 1-2 mm: root canal treatment (49.6%); ≥2 mm: root canal treatment (85.7%) were the most preferred treatments. 69.6% of the respondents chose direct composite restorations. If the tooth would be an abutment, most respondents preferred root canal treatment, regardless of the perforation size. The extent of pulp exposure and the type of permanent restoration influenced the treatment decision-making process.

Wnt3a-Loaded Hydroxyapatite Nanowire@Mesoporous Silica Core-Shell Nanocomposite Promotes the Regeneration of Dentin-Pulp Complex via Angiogenesis, Oxidative Stress Resistance, and Odontogenic Induction of Stem Cells

Pulp exposure often leads to pulp necrosis, root fractures, and ultimate tooth loss. The repair of the exposure site with pulp capping treatment is of great significance to preserving pulp vitality, but its efficacy is impaired by the low bioactivity of capping materials and cell injuries from the local accumulation of oxidative stress. This study develops a Wnt3a-loaded hydroxyapatite nanowire@mesoporous silica (Wnt3a-HANW@MpSi) core-shell nanocomposite for pulp capping treatments. The ultralong and highly flexible hydroxyapatite nanowires provide the framework for the composites, and the mesoporous silica shell endows the composite with the capacity of efficiently loading/releasing Wnt3a and Si ions. Under in vitro investigation, Wnt3a-HANW@MpSi not only promotes the oxidative stress resistance of dental pulp stem cells (DPSCs), enhances their migration and odontogenic differentiation, but also exhibits superior properties of angiogenesis in vitro. Revealed by the transcriptome analysis, the underlying mechanisms of odontogenic enhancement by Wnt3a-HANW@MpSi are closely related to multiple biological processes and signaling pathways toward pulp/dentin regeneration. Furthermore, an animal model of subcutaneous transplantation demonstrates the significant reinforcement of the formation of dentin-pulp complex-like tissues and blood vessels by Wnt3a-HANW@MpSi in vivo. These results indicate the promising potential of Wnt3a-HANW@MpSi in treatments of dental pulp exposure.

Clinical Efficacy of Biomimetic Bioactive Biomaterials for Dental Pulp Capping: A Systematic Review and Meta-Analysis

Recently, biomimetic bioactive biomaterials have been introduced to the market for dental pulp capping. This systematic review and meta-analysis aimed to determine any variation between the effect of using TheraCal LC and other bioactive biomaterials for pulp capping is different, as measured by dentin increment and clinical success. The risk of bias was assessed using the Risk of Bias 2 and Newcastle−Ottawa tools for randomized clinical trials and observational studies. A search for relevant articles was performed on five databases. Additionally, the quality of the included studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. A summary of individual studies and a meta-analysis were performed. The odds ratio of data from clinical success was combined using a random-effects meta-analysis. The meta-analysis results showed homogeneity between the studies (I2 = 0%). They revealed that the clinical success showed no differences between the patients who received TheraCal LC, light-cured calcium silicate-based biomimetic biomaterial, for dental pulp capping or the comparator biomaterials (p > 0.5). However, the certainty of the evidence was low to moderate due to the risk of bias in the included studies.

How is carious pulp exposure and symptomatic irreversible pulpitis managed in UK primary dental care?

AIM

To investigate attitudes and approaches of UK primary care dentists to carrying out vital pulp treatment (VPT) after carious exposure and with additional signs and symptoms indicative of irreversible pulpitis.

METHODOLOGY

An electronic questionnaire was openly distributed via publicly funded (NHS) local dental committees, corporate dental service-providers, professional societies and social media. Principally NHS practitioners and those from mixed and private practice were targeted, in addition to community and military dental officers, and dental therapists. Participants were asked questions relating to several clinical scenarios, with responses analysed using descriptive statistics. χ² tests with sequential Bonferroni correction were used to explore variables including the method of remuneration, practitioner type (dentist/therapist), postgraduate qualification(s), place of graduation and years since qualification. Variables with a relationship p ≤ .2 were selected for backwards likelihood ratio logistic modelling.

RESULTS

In total, 648 primary care practitioners were included for analysis. Calcium hydroxide (CH) was most frequently used for direct pulp caps (DPCs) (398/600; 66.3%) with calcium silicate cements (CSCs) less frequently used (119/600; 19.8%). Rubber dam was used by 222/599 (37.1%) practitioners. A definitive pulpotomy for the management of teeth with signs and symptoms indicative of irreversible pulpitis was selected by 65/613 (10.6%) dentists. The principal barrier for the provision of definitive pulpotomies was a lack of training (602/612; 98.4%). Regression analysis identified NHS practitioners as a good predictor for using CH for DPCs, having shorter emergency appointments, limited access to magnification and not using rubber dam. Non-UK graduates were more likely to select CSCs, appropriately control pulpal haemorrhage, undertake appropriate postoperative evaluation and use rubber dam.

CONCLUSIONS

Practitioners deviated from evidence-based guidelines in a number of aspects including material selection, asepsis and case selection. A number of other challenges exist in primary care in providing predictable VPTs, including lack of time and access to magnification. These were most evident in NHS practice, potentially exacerbating existing social health inequalities. Possible inconsistencies in the UK undergraduate curriculum were supported by a lack of association between years since qualification and technique employed as well as the fact that non-UK graduates and dentists with postgraduate qualifications adhered more to evidence-based VPT guidelines.

The management of deep caries in UK primary care: A nationwide questionnaire-based study

AIM

To investigate current approaches and attitudes towards the management of deep caries in primary dental care within the United Kingdom (UK).

METHODOLOGY

Open distribution of an electronic questionnaire survey was undertaken to primary care dental professionals working in publicly funded National Health Service [NHS], privately funded, military and community dental services. Demographic variables investigated included the following: place of qualification, method of remuneration, level of restorative training, materials available, years qualified, appointment length and clinician type. Management variables focussed on case-based scenarios. Univariate analyses of responses to questions were undertaken using χ² tests with sequential Bonferroni correction. Variables with a statistical relationship of p ≤ .2 were selected for binary logistic regression modelling.

RESULTS

A total of 657 responses were received. Practitioners with formal postgraduate qualifications (PGQ) were more likely (OR, 95%CI) to undertake further tests to aid diagnosis including: gaining a patient history (1.80, 1.01-3.20), periapical radiography (1.43, 1.01-2.03), cold pulp testing (2.079, 1.46-2.97) and electric pulp testing (1.65, 1.02-2.65). Rubber dam was infrequently used for deep caries management (29.2%). Non-NHS practitioners were much more likely to use rubber dam (3.40, 2.15-5.37), as were those that had completed PGQ (2.24, 1.48-3.38). Non-selective caries removal was used in deep caries by 41.4% of practitioners. Indirect pulp caps were carried out by 56.7% of practitioners. NHS practitioners were more likely to place calcium hydroxide (3.74, 1.97-7.15), whilst non-NHS practitioners were more likely to place calcium silicate cements (CSCs) (3.303, 1.71-6.38) as were non-UK graduates (5.63, 2.47-12.86) and those with PGQ (2.12, 1.17-3.87).

CONCLUSIONS

This UK survey highlights significant variation in the management of deep caries. There is lack of consensus regarding the use of a standard systematic approach to diagnosing disease, with a reliance on history and tests with poor specificity. Non-selective caries removal for managing deep carious lesions remains common, with low rubber dam compliance underlining a lack of asepsis. Notably, a significant number of practitioners placed indirect pulp caps, but CSCs and GIC were not commonly used. At present, although clear guidelines are available this is not translating into consistent management approaches in practice, suggesting that better dissemination of current treatments is essential to undergraduate and postgraduate groups.

Mineral Trioxide Aggregate Applications in Endodontics: A Review

A current topic in dentistry concerns the biocompatibility of the materials, and in particular, conservative dentistry and endodontics ones. The mineral trioxide aggregate (MTA) is a dental material with biocompatibility properties to oral and dental tissues. MTA was developed for dental root repair in endodontic treatment and it is formulated from commercial Portland cement, combined with bismuth oxide powder for radiopacity. MTA is used for creating apical plugs during apexification, repairing root perforations during root canal therapy, treating internal root resorption, and pulp capping. The objective of this article is to investigate MTA features from a clinical point of view, even compared with other biomaterials. All the clinical data regarding this dental material will be evaluated in this review article. Data obtained from the analysis of the past 10 years' literature highlighted 19 articles in which the MTA clinical aspects could be recorded. The results obtained in this article are an important step to demonstrate the safety and predictability of oral rehabilitations with these biomaterials and to promote a line to improve their properties in the future.

Management of deep caries and the exposed pulp

Caries prevalence remains high throughout the world, with the burden of disease increasingly affecting older and socially disadvantaged groups in Western cultures. If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs even in deep carious lesions. Traditionally, deep caries management was destructive with nonselective (complete) removal of all carious dentine; however, the promotion of minimally invasive biologically based treatment strategies has been advocated for selective (partial) caries removal and a reduced risk of pulp exposure. Selective caries removal strategies can be one-visit as indirect pulp treatment or two-visit using a stepwise approach. Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy and the re-emergence of vital pulp treatment (VPT) techniques such as partial and complete pulpotomy. These changes stem from an improved understanding of the pulp-dentine complex's defensive and reparative response to irritation, with harnessing the release of bioactive dentine matrix components and careful handling of the damaged tissue considered critical. Notably, the development of new pulp capping materials such as mineral trioxide aggregate, which although not an ideal material, has resulted in more predictable treatments from both a histological and a clinical perspective. Unfortunately, the changes in management are only supported by relatively weak evidence with case series, cohort studies and preliminary studies containing low patient numbers forming the bulk of the evidence. As a result, critical questions related to the superiority of one caries removal technique over another, the best pulp capping biomaterial or whether pulp exposure is a negative prognostic factor remain unanswered. There is an urgent need to promote minimally invasive treatment strategies in Operative Dentistry and Endodontology; however, the development of accurate diagnostic tools, evidence-based management strategies and education in management of the exposed pulp are critical in the future.

Cost-effectiveness of pulp capping and root canal treatment of young permanent teeth

OBJECTIVE

To contribute with information on cost-effectiveness of pulp capping and root canal treatment of posterior permanent vital teeth in children and adolescents with pulp exposures due to caries.

MATERIAL AND METHODS

Cost-effectiveness by means of a Markov simulation model was studied in a Scandinavian setting. In a simulated 12-year-old patient, treatment of pulpal exposure of a permanent tooth, either by the initial treatment pulp capping or root canal treatment, was followed for 9 years until the patient was 21. The model was based on outcome data obtained from published literature and cost data based on reference prices.

RESULTS

In the simulated case, with the annual failure probalility (AFP) of 0.034 for pulp capping, the total cost for an initial treatment with pulp capping and any anticipated following treatments during the 9 years, was 367 EUR lower than for a root canal treatment as the initial treatment. After an initial treatment with pulp capping 10.4% fewer teeth, compared with initial root canal treatment, were anticipated to be extracted. Pulp capping was thus considered to be the cost-effective alternative. The sensitivity analyses showed that the AFP of a tooth requiring a root canal treatment after an initial pulp capping needed to be 0.2 before root canal treatment may be considered being the cost-effective treatment.

CONCLUSIONS

This model analysis indicated initial treatment by pulp capping to be cost-effective compared to root canal treatment in children and adolescents with pulp exposures due to caries.

Preventive endodontics by direct pulp capping with restorative dentin substitute-biodentine: A series of fifteen cases

Introduction

Treatment of mechanical exposure of the pulp during caries excavation presents a clinical challenge. In this case series of 15 patients, with a follow-up period of over a year, the outcome of direct pulp capping with Biodentine (septodont) after mechanical pulp exposure was assessed.

Aim of Study

The aim of this study is to evaluate the outcome of direct pulp capping with Biodentine in deeply carious teeth when pulp was mechanically exposed during caries excavation and cavity preparation. Vital pulps exposed during caries excavation in molar teeth were treated with 3% sodium hypochlorite for 2 min. If adequate hemostasis was achieved, the pulp tissue was capped with Biodentine, which covered the entire pulpal floor. This was followed by the placement of a layer of resin-modified glass ionomer cement and a final layer of composite resin (Filtek Z350-3M) to complete the restoration. The patients were recalled periodically and evaluated for any evidence of pulpal/periapical pathology.

Results

In the follow-up period that ranged from 12 to 24 months, all teeth were asymptomatic.

Conclusion

Biodentine appears to be a suitable material for direct pulp capping under clinical conditions. However, long-term follow-up studies and controlled trials involving a large sample size are warranted.

BACTERIAL PROFILE OF NECROTIC PULPS IN CHEETAH (ACINONYX JUBATUS) CANINE TEETH

The role of microbes and their antimicrobial susceptibilities in both acute and chronic infections of the dental pulp in humans has been well studied. Presently, no data are available on endodontic pathogens in cheetahs (Acinonyx jubatus). The aim of this study was to isolate and identify the bacteria found in the canine teeth of cheetahs, where the pulp was necrotic and exposed due to a complicated crown fracture. Thirty-six microbiologic samples were taken from root canals (RCs) of the canine teeth of 19 cheetahs: one pulp sample was taken from 10 cheetahs, four samples from 2 cheetahs, two samples from 3 cheetahs, and three samples from 4 cheetahs. Exposed pulps were cultured for aerobic and anaerobic bacteria; an additional screening with a 16S rRNA-specific polymerase chain reaction (PCR) was used for the last six samples. Antimicrobial susceptibility of isolates was determined by use of the Kirby-Bauer diffusion test. In total, 59 cultivable isolates belonging to 19 microbial species and 13 genera were recovered from the 36 RCs sampled. Only two samples yielded no cultivable bacteria. Thirty-two (54.49%) of the cultivable isolates were Gram positive and 27 (45.71%) were Gram negative. The maximum number of isolates cultivated from an individual RC was six. Facultative anaerobes (62.72%) were the most common bacteria of the RCs that yielded cultivable bacteria. Of the isolates, 28.81% were aerobic and 8.47% were strict anaerobes. The antimicrobials that showed the greatest efficacy in vitro against the different bacteria isolates were amikacin and gentamicin. The more common bacterial species isolated by PCR were anaerobes (60.8%), facultative anaerobes (30.2%), and aerobes (8.6%).

Biodentine pulpotomy several days after pulp exposure: Four case reports

Conventionally, few-days-old pulp exposures have been treated with root canal treatment. We report four cases of traumatized, fully matured, maxillary permanent central incisors, which have been treated by Biodentine pulpotomy several days after traumatic pulp exposure. Biodentine pulpotomy consisted of pulp tissue removal to a depth of 2 mm, then capping the pulpal wound with Biodentine, followed by immediate restoration. The teeth were assessed clinically through pulpal sensitivity tests and radiographically for periapical healing. At each recall (24 hours, 1 week, 30 days, 3, 6, 12, and 18 months), no spontaneous pain was observed; the pulp showed signs of vitality and absence of periapical radiolucency after 18 months. Biodentine pulpotomy is recommended as a treatment option for cases of vital pulp exposure in permanent incisors due to trauma.