Outcomes of root canal therapy or full pulpotomy using two endodontic biomaterials in mature permanent teeth: a randomized controlled trial.

OBJECTIVE: The concept of minimally invasive endodontics recommends less-invasive vital pulp therapy (VPT) modalities over more aggressive traditional endodontic approaches in mature permanent teeth with carious pulp exposure, including irreversible pulpitis (IP) cases. Consequently, VPT needs to be compared with root canal therapy (RCT) in terms of treatment outcomes. This randomized clinical trial compares the results of full pulpotomy using two calcium-silicate cements, i.e., mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement, with RCT in mature permanent teeth. MATERIALS AND METHODS: A total of 157 carious pulp exposure cases in two academic centers with/without established IP were selected/included/randomly appointed to three study arms; (i) RCT (n = 51) as the reference treatment, (ii) pulpotomy with ProRoot MTA (PMTA; n = 55), and (iii) pulpotomy with CEM cement (PCEM; n = 51) as two alternative VPT treatments. Two-year clinical/radiographic results were the outcomes of interest. Data were statistically analyzed through the analysis of variance, chi-square, Fisher exact test, and Kruskal-Wallis. RESULTS: At 2-year recall, 147 teeth were examined (6.4% dropout). All molars, except for one, were clinically functional/symptom-free, and there was no statistical difference between the three study arms (p = 0.653). The radiographic success rates in RCT, PMTA, and PCEM arms were 98%, 100%, and 97.9%, respectively, without statistically significant differences (p = 0.544). CONCLUSION: In the management of mature permanent teeth with/without established IP, all experimental groups exhibited equivalent/comparable results. CLINICAL RELEVANCE: Simple VPT using MTA/CEM can be suggested/recommended as a viable advantageous alternative to RCT for the management of carious pulp exposures with/without sign/symptoms of IP.

Microstructure and chemical analysis of four calcium silicate-based cements in different environmental conditions.

OBJECTIVE: The objective of this study was to analyze the microstructure and crystalline structures of ProRoot MTA, Biodentine, CEM Cement, and Retro MTA when exposed to phosphate-buffered saline, butyric acid, and blood. METHODS AND MATERIALS: Mixed samples of ProRoot MTA, Biodentine, CEM Cement, and Retro MTA were exposed to either phosphate-buffered saline, butyric acid, or blood. Scanning electron microscope (SEM) and energy-dispersive X-ray spectroscopic (EDX) evaluations were conducted of specimens. X-ray diffraction (XRD) analysis was also performed for both hydrated and powder forms of evaluated calcium silicate cements. RESULTS: The peak of tricalcium silicate and dicalcium silicate detected in all hydrated cements was smaller than that seen in their unhydrated powders. The peak of calcium hydroxide (Ca(OH)2) in blood- and acid-exposed ProRoot MTA, CEM Cement, and Retro MTA specimens were smaller than that of specimens exposed to PBS. The peak of Ca(OH)2 seen in Biodentine™ specimens exposed to blood was similar to that of PBS-exposed specimens. On the other hand, those exposed to acid exhibited smaller peaks of Ca(OH)2. CONCLUSION: Exposure to blood or acidic pH decreased Ca(OH)2 crystalline formation in ProRoot MTA, CEM Cement and Retro MTA. However, a decrease in Ca(OH)2 was only seen when Biodentine™ exposed to acid. CLINICAL RELEVANCE: The formation of Ca(OH)2 which influences the biological properties of calcium silicate cements was impaired by blood and acid exposures in ProRoot MTA, CEM Cement, and Retro MTA; however, in the case of Biodentine, only exposure to acid had this detrimental effect.

Surgical repair of invasive cervical root resorption with calcium-enriched mixture cement: a case report.

Invasive cervical resorption (ICR) occurs in the cervical area of the teeth due to the formation of a soft tissue that progressively resorbs dentin. The disease is asymptomatic unless the pulp is exposed. This article presents a case involving a mandibular canine that was treated with a calcium-enriched mixture (CEM) cement. After a full mucoperiosteal flap was performed, the soft tissue was curetted away and the cavity filled with CEM biomaterial. One week later, the supragingival surface of the CEM was polished and covered with composite resin. At a 1-year follow-up visit, the pulp was healthy and the gingival probing depth decreased from >3 mm to 1 mm, showing attachment gain. As a biocompatible material, CEM has proven its ability in dentinogenesis, cementogenesis, and osteogenesis; it may prove to be a suitable biomaterial for treating ICR cases.

The sealing ability of different endodontic biomaterials as an intra-orifice barrier: evaluation with high-performance liquid chromatography.

Objective: This study evaluated the sealing ability of different biomaterials as intra-orifice barriers in the internal bleaching of discolored teeth with the walking bleaching technique. The release of hydroxyl ions from the bleaching materials can cause cervical root resorption, making it necessary to use intra-orifice barrier materials to prevent this issue. Materials and methods: In the current study, the high-performance liquid chromatography (HPLC) method was used to measure the released hydroxyl ions. The study included 90 single-rooted and single-canal premolars, which were divided into four groups based on the intra-orifice barrier materials used (mineral trioxide aggregate [MTA], calcium-enriched mixture [CEM], Biodentine, and MTA+PG) and the type of bleaching material (sodium perborate + water or sodium perborate + hydrogen peroxide 30%). Two control groups were also considered in this study: a positive control group, where sodium perborate and hydrogen peroxide were placed inside the pulp chamber without any intra-orifice barriers; and a negative control group, where no bleaching agent or surgical obstruction was used, and the root surface was covered with wax up to the cemento-enamel junction (CEJ) level. Results: The results showed that there was a significant difference in the concentration of hydroxyl ions released among the studied groups. The amount of hydroxyl ion released was highest in the positive control group and lowest in the CEM group. Among the intra-orifice barrier materials used, CEM cement was found to be the most appropriate material for use in the step-by-step internal bleaching method. Conclusions: The study highlights the importance of using appropriate intra-orifice barrier materials to prevent root cervical resorption in internal bleaching procedures.

Comparative Outcomes of Pulpotomy in Mature Molars with Irreversible Pulpitis: A Non-Randomized Trial Evaluating Calcified and Non-Calcified Pulp Chambers.

Introduction: This non-randomized clinical trial investigated the outcomes of full pulpotomy in adult molars with irreversible pulpitis, comparing those with calcified and non-calcified pulp chambers over 6 and 12 months. Materials and Methods: A total of 101 adult permanent molars with irreversible pulpitis, in individuals over 12 years old, were categorized based on pulp chamber calcification observed in radiographic images by two endodontists. Subsequently, full pulpotomy procedures were performed, achieving hemostasis, and applying a 2 mm layer of calcium-enriched mixture (CEM) cement as a pulp covering agent. After 48 hours, the setting of the CEM cement was verified, followed by the application of a layer of resin-modified glass-ionomer. The tooth was then restored using amalgam. Clinical and radiographic evaluations were conducted at 6-month and 1-year follow-ups by blinded endodontists. Success rates were compared using Fisher's exact test and logistic regression tests with a significance level of 0.05. Results: Among the 97 patients with 6-month and 1-year follow-ups, all achieved clinical success. Radiographic success rates were 99% at 6 months and 96.9% at 1 year, regardless of pulp calcification. In the 6-month follow-up, success rates were 98.07% for non-calcified pulp chambers and 100% for calcified pulp chambers. At the 1-year follow-up, success rates were 96.1% and 97.8%, respectively. Statistical analysis showed no significant difference in radiographic success rate between the two groups at both follow-ups (P>0.05). Conclusions: Full pulpotomy using CEM cement is a successful treatment for adult permanent teeth with calcified and non-calcified pulp chambers presenting signs and symptoms of irreversible pulpitis up to a 1-year follow-up. This study provides compelling evidence that vital pulp therapy can be effectively employed in the pulpotomy of calcified teeth, at least in the short term.

Successful Management of a Typical Class 3 Invasive Cervical Root Resorption with Modified Pulpotomy: A Case Report.

Invasive cervical root resorption (ICRR) is a rare and clinically complex condition marked by the progressive loss of dental hard tissues below the junctional epithelium. This case report outlines the management of a 32-year-old female patient presenting with ICRR class 3 affecting a maxillary incisor. Despite the absence of symptoms, the expansive nature of the defect warranted conservative surgical intervention. The procedure involved the surgical removal of inflamed tissues, followed by an ultraconservative modified pulpotomy utilizing calcium-enriched mixture (CEM) cement through a surgical window. The selected intervention is substantiated by its potential benefits, such as minimal removal of tooth structure and the inherent biocompatibility and sealing capabilities of CEM cement. A one-year follow-up revealed arrested resorption, re-establishment of periodontal attachment, and successful esthetic restoration, affirming the efficacy of vital pulp therapy in surgically addressing advanced ICRR. Accurate diagnosis, strategic treatment planning, and a patient-centered approach proved critical in achieving favorable outcomes.

Effects of White Chicken Eggshell Powder on Compressive Strength, Water Solubility, and Setting Time of Calcium-Enriched Mixture.

Introduction: The present study aimed to evaluate the effects of adding chicken eggshell powder (CESP) to calcium-enriched mixture (CEM) cement on its compressive strength (CS), solubility, and setting time. Materials and Methods: In this study, CESP was added at weight percentages of 3% and 5% to the powder component of the CEM cement. To measure the CS, a total of 36 samples (height, 6 mm; diameter, 4 mm) were tested in a universal testing machine. The setting time was assessed for 18 disk-shaped samples (diameter, 10 mm; height, 1 mm). Additionally, solubility test was performed on 18 samples (diameter, 8 mm; height, 1 mm) after 24 hours, 72 hours, seven days, and 14 days under dehydration conditions by calculating the weight changes; the results were then subjected to a normality test. Next, for the comparison of different test groups, parametric ANOVA test and post-hoc Tukey's multiple comparison test were performed at a significance level of 0.05. Results: The addition of 5% CESP to the CEM cement significantly reduced its setting time and water solubility (P=0.02 and P=0.01, respectively). Moreover, it significantly increased the CS over a 21-day period (P<0.001). Additionally, the addition of 3% CESP also resulted in a significant increase in CS (P<0.001). While 3% CESP reduced setting time and water solubility, the difference was not statistically significant. Conclusion: The findings suggest that the addition of 5% CESP to CEM cement has the potential to improve its sealing ability, durability, and ability to withstand chewing forces in endodontic treatments. These results highlight the relevance of CESP as an additive for cement modifications and indicate its potential clinical implications.

Autotransplantation of a Third Molar to Replace an Adjacent Unrestorable Tooth: A Case Report.

Autogenous tooth transplantation (ATT) is a cost-effective and practical solution for managing severely compromised teeth, provided a suitable donor tooth is available. In this case report, we present a unique and successful ATT procedure performed on a 21-year-old female patient. The patient had an unrestorable adjacent tooth, which was replaced by a fully developed third molar. The procedure involved retrograde root canal filling using a calcium-enriched mixture cement, which took an extraoral time of eight minutes. The second molar was atraumatically extracted, and the mature third molar was immediately transplanted. A one-year clinical examination revealed a symptom-free patient with the transplanted tooth in proper occlusion, fully functional, and without any marginal periodontal issues. Radiographic assessments during follow-up appointments demonstrated bone regeneration, a healthy periodontal ligament, and an absence of external root resorption. This case report highlights the potential of mature third molar ATT combined with retrograde root canal filling as a promising approach to replacing lost permanent molar teeth, ultimately restoring both aesthetics and functionality.

Management of Pink Spot due to Class IV Invasive Cervical Root Resorption using Vital Pulp Therapy: A Case Report.

A 30-year-old male patient with the chief complaint of pink spot discoloration of the tooth crown in his upper left central incisor was referred for endodontic and esthetic management. After thorough clinical and radiographic examinations, the final diagnosis was class IV invasive cervical resorption (ICR) which was conservatively treated with an orthograde approach; i.e. vital pulp therapy with calcium-enriched mixture cement (VPT/CEM). The use of VPT/CEM was successful to restore esthetics and stop the ICR; confirmed clinically, radiographically, and tomographically at one-year recall. The above-mentioned minimally invasive approach reported in the current case study may be considered a practical treatment modality for ICR, specifically in anterior teeth.

Microhardness of Calcium-enriched Mixture Cement and Covering Glass Ionomers after Different Time Periods of Application.

Introduction: Various studies have recommended using calcium-enriched mixture (CEM) cement in different endodontic treatments, including vital pulp therapy. However, possible reciprocal effects of the covering glass ionomer cement (GIC) on their mechanical properties have not been yet investigated in detail. The current research aimed to experimentally evaluate the surface microhardness of CEM cement and the covering GICs after different application/testing times. Materials and Methods: Using stainless steel moulds (8×4×4 mm), CEM cement samples were prepared (n=120) and randomly divided into 12 experimental groups (n=10). CEM cement with thickness of 4 mm was inserted into the moulds, and the remaining spaces were filled with self-cured or light-cured resin-modified GICs at three-time intervals; immediate, in 15 min and after 24 h. Then, the samples were incubated for one and seven days. Using a Vickers microhardness tester, the microhardness of CEM and GICs was measured. The data were analyzed using two-way ANOVA and Tukey's test, and the significance level was set at 5% (P<0.05). Results: The reciprocal effects of the type/time of application of GICs on the surface microhardness of CEM cement or GICs were statistically significant (P<0.001). The surface microhardness of CEM cement and both covering GICs significantly increased over time and in seven-day samples was significantly higher than in one-day samples (P<0.05). Conclusions: Low surface microhardness of CEM/GICs in short-term (24 h) seems transient; and appears to be compensated over a longer period (i.e. 7-day). Therefore, using GICs adjacent to CEM cement in single-visit restorative treatments may be advocated.

Effects of various liquid-to-powder ratios on the compressive strength of calcium enriched mixture: Original research.

Background. Calcium-enriched mixture (CEM) cement has been introduced and marketed as a biomaterial for use in furcal perforation repair and apexogenesis procedures, in which the compressive strength that indicates the material's resistance against crushing is of utmost importance. This study evaluated the effect of various liquid-to-powder ratios on CEM cement's compressive strength. Methods. One gram of the cement was mixed with 0.5, 0.34, and 0.25 mL of demineralized water and transferred to stainless steel molds (6 and 4 mm in height and diameter, respectively). Five cells in the mold were considered for each group. The compressive strength test was conducted using the universal testing machine after incubating for seven days under 95% humidity at 37°C. One-way ANOVA was applied for data analysis at P ≤ 0.05 significance level. Results. The mean compressive strength in the liquid-to-powder ratios of 0.5, 0.34, and 0.25 were 3.4456, 3.2960, and 3.3485, respectively, with no significant differences between them. Conclusion. Under this study's limitations, changing the liquid-to-powder ratio did not affect CEM cement's compressive strength.

Investigating The Antimicrobial Activity Of Different Root Canal Filling Pastes In Deciduous Teeth.

BACKGROUND: The antiseptic property of root canal filling materials is very important for the removal of residual pathogens from root canals. The aim of the current study was to investigate the antimicrobial activity of mineral trioxide aggregate (MTA), calcium hydroxide (CH), Metapex, zinc oxide eugenol (ZOE), and CEM-cement. MATERIALS AND METHODS: Four standard bacterial strains including Staphylococcus aureus (ATCC 6538), Enterococcus faecalis (ATCC 29212), Pseudomonas aeruginosa (ATCC 27853), and Bacillus subtilis (ATCC 6633) and Candida albicans (ATCC 10231) were used. On five plates containing Brain Heart Infusion (BHI) agar, five cavities were made. Then, the plates were cultured by 0.1 mL of bacterial suspension with a concentration of 0.5 McFarland. Afterwards, the cavities were filled with the tested materials and were incubated at 37 °C for 24, 48, and 72 hrs. Diameters of microbial inhibition zones were then measured. RESULTS: The highest mean diameter of growth inhibition zones was observed around ZOE and then CH and CEM-cement. According to the Kruskal-Wallis test, there was a significant difference among the tested groups (P<0.041). CONCLUSION: Considering antimicrobial activity, CH was an acceptable alternative to ZOE.

Antimicrobial Activity of Calcium-Enriched Mixture Cement and Biodentine on Enterococcus faecalis: An in Vitro Study.

Introduction: The main cause of endodontic failure is residual bacteria in the root canal system. Enterococcus faecalis (E. faecalis) is the predominant species isolated from infected root canals. This study aims to compare the antibacterial activity of calcium-enriched mixture (CEM) cement and Biodentine as root canal filling materials on E. faecalis. Methods and Materials: Seventy extracted human single-rooted teeth were prepared and infected with E. faecalis for 24 h. Specimens were randomly divided into control or experimental groups; the later were filled with either CEM cement or Biodentine. Dentinal samples were collected after 7 and 30 days and transferred to test tubes. After incubation, the number of colony forming units (CFUs) were counted and analyzed using the Kruskal-Wallis test, followed by the Mann Whitney U test. The level of significance was set at 0.05. Results: The reduction in mean CFU level of E. faecalis was significantly more in the presence of CEM cement at both time intervals (P<0.001). Compared to the positive control, Biodentine significantly reduced the mean CFU level only after 30 days (P<0.01). Conclusion: Although both biomaterials exerted antibacterial activity against E. faecalis, the CEM cement had more antibacterial activity than Biodentine.

Intentional replantation of a molar with several endodontic complications.

When non-surgical and surgical endodontic retreatments are impractical, intentional replantation (IR) might be employed as an accepted endodontic treatment procedure. This report describes an IR and root amputation of a tooth with several endodontic complications. A 28-year-old woman was referred for management of tooth #37. The tooth had a history of root canal therapy by a general dentist. Clinically the tooth was sensitive to palpation/percussion. Radiographic evaluation showed concurrent root/furcal perforations associated with radiolucent lesions, an inadequate root canal treatment and massive gutta-percha overextensions via perforation sites. The tooth was atraumatically extracted. After mesial root amputation and root-end/furcal preparations, the cavities were filled with calcium-enriched mixture cement. The tooth was then quickly replanted. During one-year clinical follow-ups, the tooth was functional and free of signs/symptoms; radiographic evaluation revealed complete bone healing. This case highlights that IR in hopeless teeth with several endodontic complications might be a successful approach.

Effect of Different Water-to-powder Ratios on the Solubility and Microhardness of Calcium-Enriched Mixture Cement.

Introduction: The aim of this study was to evaluate the effect of different water-to-powder (WP) proportions on the microhardness and water solubility of calcium-enriched mixture (CEM) cement. Methods and Materials: One gram of CEM cement powder was mixed with 0.33 mL, 0.4 mL or 0.5 mL CEM liquid. For water solubility, a total of 60 specimens were prepared (n=20 per each ratio) in the disk-shaped stainless-steel molds with a height of 1.5±0.1 mm and internal diameter of 10.0±0.1 mm. The specimens of each WP ratio were randomly divided into two subgroups: half (n=10) were immersed for one day and the other half (n=10), were kept for 21 days in distilled water. The solubility was calculated as a percentage of the weight loss. To measure microhardness, a total of 30 samples were prepared (10 per each ratio, n=10). The mixtures were transferred to metallic cylindrical molds with internal dimensions of 6±0.1 mm height and 4±0.1 mm diameters. After 4 days the specimens were subjected to Vicker's test. The data were analyzed using two-way ANOVA and post-hoc Tukey's tests at a significance level of 0.05. Results: The 0.33 WP ratio showed significantly greater microhardness value (25.98±2.77) compared to 0.4 and 0.5 proportions (P=0.004 and P<0.001 respectively). Significant differences were observed between water solubility values of different WP ratios at both time intervals (P<0.001). At both time intervals, 0.33 and 0.5 WP ratios exhibited the lowest and highest solubility, respectively. Conclusion: According to the results of this in vitro study, higher WP ratios result in lower microhardness and higher water solubility of the CEM cement. Therefore, the 0.33 WP ratio would be the ideal proportion.

Periodontal healing following non-surgical repair of an old perforation with pocket formation and oral communication.

Iatrogenic perforations negatively impact the outcome of endodontic treatments. Studies on prognostic factors showed that perforations in the coronal third of the root with periodontal pocket formation have an unfavorable prognosis. A 36-year-old female was referred for endodontic evaluation of tooth #13 with a history of an iatrogenic perforation, happened 3 years ago. There was a sinus tract associated with perforation, 10 mm probing on the mesial and mesio-palatal, bleeding on probing, radiolucent lesion adjacent to the perforation and complete resorption of the interdental bone between teeth #13 and #12. After the treatment options were discussed, she chose to save the tooth. The tooth was accessed under rubber dam isolation, the perforation site was cleaned and disinfected using 0.5% sodium hypochlorite and sealed with calcium-enriched mixture cement. Eighteen months after treatment the tooth was functional and asymptomatic. The probing depths were normal without bleeding on probing. Radiographically, the interdental crestal bone formed between teeth #13 and #12. Despite all negative prognostic factors in this case (i.e., perforations in the coronal third, pocket formation, and radiolucent lesion), healing was unexpectedly achieved via non-surgical repair of the perforation. Further research on biological aspects of healing in the periodontium following iatrogenic perforations are recommended.

Comparison of Flexural Strength of Mineral Trioxide Aggregate, Calcium-enriched Mixture and BioAggregate.

Introduction: The aim of this study was to compare the flexural strength of mineral trioxide aggregate (MTA), calcium-enriched mixture (CEM), and BioAggregate (BA). Methods and Materials: In this study, the flexural strength of materials was measured using a 3-point bend test. After being prepared, MTA, CEM, and BA were inserted into the intra-putty molds using amalgam plugger. The specimens were covered with a sponge wetted with synthetic tissue fluid (STF) and incubated for 96 h. They were then subjected to a 3-point bend test using Universal Testing Machine. The Kruskal-Wallis and Mann-Whitney U tests were used to compare flexural strength in groups. In this study, P<0.05 was considered as the significant level. Results: There were significant differences between the three groups in terms of the flexural strength (P<0.001). The mean flexural strength in the BA, CEM, and MTA groups were 27.32±2, 9.09±1.16, and 10.25±1.6, respectively. Pairwise comparison showed significant differences between the three groups. Conclusion: This in vitro study showed that BA has the highest and CEM has the lowest flexural strength.

Effect of blood contamination on the compressive strength of three calcium silicate-based cements.

The aim of this study was to investigate the effect of human blood exposure on the compressive strength of various calcium silicate-based cements. Two hundred and eighty-eight customised cylindrical moulds were randomly divided into three groups according to material used: ProRoot MTA, Biodentine or CEM cement (n = 96). Each group was divided into two subgroups according to exposure conditions: PBS or blood. Then, the compressive strength of the specimens was measured after 6 h, 24 h, 72 h and 7 days. The compressive strength of CEM cement could not be measured after 6 and 24  h regardless of the exposure conditions nor could the compressive strength of 6 h blood-exposed ProRoot MTA. The compressive strength of blood-exposed ProRoot MTA was only significantly lower after 6 h, but no difference was seen at other time intervals. Blood exposed did adversely affected the compressive strength of Biodentine. The compressive strength of all groups significantly increased over time (P < 0.005).