Long-Term Success of Regenerative Endodontic Treatment in Managing Traumatized Teeth: A Case Report With Seven-Year Follow-Up.

Traumatic injuries to maxillary incisors often result in complex dental complications, such as pulp necrosis and periapical pathology, particularly in young patients. Traditional root canal treatments may prove insufficient, especially for immature teeth requiring apexification. Regenerative endodontic treatment (RET) presents a promising alternative, aiming to eliminate infection while fostering root development and tooth vitality. This case report illustrates the successful management of a necrotic-infected traumatized maxillary incisor in a seven-year-old girl using RET. The treatment involved a meticulously planned protocol comprising disinfection, induction of bleeding, and placement of a calcium-enriched mixture (CEM) cement plug, followed by composite restoration. Remarkably, despite the initial detection of an endodontic lesion in the postoperative radiograph, the clinical outcomes remained aesthetically pleasing, with subsequent radiographs revealing regression of the apical lesion and complete tooth maturation over the seven-year follow-up period. This case highlights the efficacy and feasibility of RET using CEM in managing infected, traumatized teeth, emphasizing its potential for long-term healing and functional restoration. The absence of tooth discoloration further underscores the benefits of utilizing specific materials and protocols.

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.

Comparative evaluation of cervical pulpotomy and pulpectomy for primary molars with irreversible pulpitis: a multicentre randomised controlled trial.

PURPOSE: The objective of this multicentre randomised controlled trial was to compare the clinical/radiographic outcomes of cervical pulpotomy using calcium-enriched mixture cement (PCEM) and pulpectomy using Metapex (PM) in primary molars with irreversible pulpitis (IP). METHODS: A total of 134 primary molars from 94 children were randomly assigned to two intervention groups: the PCEM group (n = 74) and the PM group (n = 60). Baseline characteristics including age/gender/molar type/tooth type/jaw were recorded. The primary outcome measures were clinical/radiographic success rates assessed at the first and second follow-up appointments. Secondary outcomes included reasons for clinical/radiographic failures. Multiple logistic regression analysis was performed to determine the impact of various factors on the success rates. RESULTS: The mean age of the participants in both groups was similar (PCEM group: 5.4 years, PM group: 5.5 years). Gender distribution, molar type, tooth type, jaw, and number of practitioners were comparable between the groups. The clinical success rate at the first follow-up was 98.6% in the PCEM group and 96.4% in the PM group. At the second follow-up, the clinical success rate was 97.1% in the PCEM group and 91.1% in the PM group. The radiographic success rates at the first and second follow-up were 98.6% and 96.4% in the PCEM group and 96.4% and 91.1% in the PM group, respectively. Multiple logistic regression analysis did not reveal any significant association between the success rates and age/gender/molar type/jaw, or treatment groups (P > 0.05). CONCLUSION: In primary molars with IP, both simple/conservative cervical pulpotomy using calcium-enriched mixture cement and pulpectomy using Metapex demonstrated high clinical/radiographic success rates. No significant differences were observed between the two treatment modalities. These findings suggest that both techniques can be considered effective treatment options for managing primary molars with IP. TRIAL REGISTRATION NUMBER: Trial registration number: IRCT20201226049838N1, retrospectively registered on 12 January 2021.

Effect of Incorporating Titanium Dioxide Nanoparticles into White Portland Cement, White Mineral Trioxide Aggregate, and Calcium Enriched Mixture Cement on the Push-out Bond Strength to Furcal Area Dentin.

Statement of the Problem: Bond strength of furcation repair materials is an essential factor in clinical success. Studies on the effect of adding titanium dioxide (TiO2) nanoparticles on the push-out bond strength of commonly used endodontic cements for furcation perforation repair is limited. Purpose: This study aimed to evaluate the effect of adding TiO2 nanoparticles to white Portland cement (PC), white mineral trioxide aggregate (MTA), and calcium enriched mixture cement (CEM) on their push-out bond strengths. Materials and Method: In this in vitro study, 120 endodontically treated molars were assigned to six groups (n=20) based on the material used to repair the perforation. In three groups, the cements (white PC, white MTA, and CEM) were placed in pure form, and in the three remaining groups, 1 weight % of TiO2 was added. The push-out bond strength was measured using a universal testing machine at a strain rate of 0.5 mm/min. Data were analyzed using one-way ANOVA and post hoc Games-Howell test (p< 0.05). Results: One-way ANOVA showed significant differences in the mean bond strength values between the six groups (p= 0.002). The post hoc Games-Howell test showed that the bond strengths in MTA+TiO2 and PC+TiO2 groups were significantly higher than those in MTA and PC groups, respectively. However, there was no significant difference in the bond strength between CEM and CEM+ TiO2 groups. Conclusion: The incorporation of TiO2 into MTA and PC increased their push-out bond strength. However, it did not affect the push-out bond strength of CEM cement.

THREE-YEAR OUTCOME OF DIODE LASER PULPOTOMY OF PRIMARY MOLARS USING THREE PULP CAPPING AGENTS: A SPLIT-MOUTH RANDOMIZED CLINICAL TRIAL.

OBJECTIVES: Pulpotomy is the most commonly performed treatment for asymptomatic primary molars with exposed dental pulp. This study aimed to assess the clinical /radiographic success of diode laser pulpotomy with mineral trioxide aggregate (MTA), calcium hydroxide (CH), and calcium-enriched mixture (CEM) cement as pulp capping agents. METHODS: This split-mouth randomized clinical trial was conducted initially on 34 children aged 3-8 years but 4 patients left the study before the first follow-up visit and the study was accomplished and analyzed with 30 cases. The patients had at least 3 first/second molars with deep caries that in radiographic evaluation revealed that they required pulpotomy. Following pulpotomy, the pulp stump was irradiated with diode laser (noncontact mode, 632 nm, 30 mW power) as photobiomodulation mode. Pulp tissue was then capped with MTA, CH, or CEM cement (n = 30 in each group). Reinforced zinc oxide eugenol was applied over the capping agent, and the teeth were restored with stainless steel crowns. Teeth were clinically/radiographically assessed at 6, 12, 18, and 36 months, after treatment. Data were analyzed by Cochran and McNemar tests. RESULTS: All 30 patients showed up for clinical/radiographic follow-ups for up to 36 months. Regarding clinical outcomes, the 6-, 12-, 18-, and 36-month success rates of all experimental groups were nearly similar with no significant difference (p > .05). Regarding radiographic outcomes, the 6-month success rates were similar among the groups (p > .05); however, the 12-, 18-, and 36-month outcomes of CEM and MTA groups were similar but significantly superior to that of CH group (p < .05). CONCLUSION: Diode laser irradiation and subsequent capping of pulp tissue with MTA or CEM cement can be employed for pulpotomy of primary molars.

Simplified Orthograde Apical Plug and Intra-Orifice Barriers for Resolving a Complex Endodontic Challenge: A Case Report.

Successful endodontic treatments are contingent upon establishing a hermetic seal within the root canal system. This seal is pivotal in preventing/resolving apical periodontitis. This case report introduces a simplified orthograde apical plug and intra-orifice barrier technique as an effective alternative to previously unsuccessful invasive nonsurgical and surgical treatments. A 28-year-old patient presented with persistent discomfort and localized swelling in the furcation area of the mandibular left first molar. The tooth had previously undergone both root canal therapy and surgical retreatment. A distinctive feature of this case was the unconventional amputation of the mesial root, unlike conventional periradicular surgery or root amputation. This unusual scenario was accompanied by the presence of a large endodontic lesion. An apical plug, utilizing calcium-enriched mixture (CEM) cement, was placed, complemented by the use of CEM intra-orifice barriers to ensure the hermetic sealing of the entire root canal system. Long-term follow-up assessment demonstrated the complete healing of the preexisting large endodontic lesion. This case underscores the significance of proper diagnosis, right treatment planning, and considering conservative treatment options for complex cases, highlighting the pivotal role played by a reliable seal in achieving successful results in endodontic procedures.

Tampon Pulpotomy: Long-term Successful Results of a Molar with Irreversible Pulpitis and Previous Vital Pulp Therapy Failure.

Minimally invasive vital pulp therapy (VPT) techniques have become increasingly popular for treating mature permanent teeth with irreversible pulpitis. However, in cases where less invasive VPT approaches, such as miniature pulpotomy, fail to provide symptom relief and desired outcomes, alternative treatment strategies need to be explored. This case report presents the successful application of tampon pulpotomy, a modified full pulpotomy technique, in a vital molar tooth with irreversible pulpitis, after a previous miniature pulpotomy failure. The tampon pulpotomy procedure involved the placement of an endodontic biomaterial (i.e. calcium-enriched mixture cement) over the pulpal wound to stop bleeding and create a favorable environment for pulpal healing/regeneration. The patient was followed up for a period of 10 years, during which the tooth remained asymptomatic, functional, and exhibited normal periodontal ligament. This case report highlights the potential effectiveness of tampon/full pulpotomy as a retreatment option in cases where more conservative VPT techniques have shown limited success, offering a conservative approach to preserve tooth structure and pulpal vitality.

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.

Effects of CEM cement and emdogain on proliferation and differentiation of human stem cells from the apical papilla: a comparative in vitro study.

OBJECTIVES: This study compared the effects of calcium-enriched mixture (CEM) cement, Emdogain (EMD), and their combination (CEM/Emdogain) on the differentiation and proliferation of stem cells from the apical papilla (SCAPs). METHODS: In this in vitro, experimental study, SCAPs were isolated from two sound immature impacted third molars and cultured. After ensuring their stemness by detecting cell surface markers they were exposed to CEM cement, Emdogain, and CEM cement coated with Emdogain for 24 and 72 h. The control cells did not undergo any intervention. Cell viability [by methyl thiazolyl tetrazolium (MTT) assay], expression of odontogenic differentiation genes [by quantitative reverse-transcription polymerase chain reaction (qRT-PCR)], and alkaline phosphatase (ALP) activity (by ALP staining kit) were evaluated. Data were analyzed by one-way ANOVA, t-test, and Mann-Whitney test (α = 0.05). RESULTS: Cell viability in the CEM cement and CEM/Emdogain groups decreased compared with the control group at 72 h (P < 0.05). Expression of dentin sialophosphoprotein (DSPP), dentin matrix protein 1 (DMP1), bone sialoprotein (BSP) genes, and ALP activity significantly increased in all three experimental groups compared with the control group at both 24 and 72 h. This increase was substantially more significant in CEM/Emdogain group (P > 0.05). The number of mineralized nodules significantly increased in all groups at 72 h, with a higher rate in the CEM/Emdogain group. CONCLUSION: All biomaterials increased the differentiation of SCAPs, expression of odontogenic differentiation genes, and ALP activity, but CEM/Emdogain was considerably more effective for this purpose.

Push-out bond strength of two calcium silicate-based cements used for repair of artificial furcal perforation following different power outputs of Nd:YAG laser.

Proper bond strength of endodontic materials is an essential factor in the final success of root canal treatments, including perforation repairs. This study was designed to evaluate the effect of two power outputs of Nd:YAG laser (1064 nm) on push-out bond strength (PBS) of ProRoot mineral trioxide aggregate (MTA) and calcium-enriched mixture cement (CEM Cement) in the repair of artificial furcal perforations. This ex vivo study enrolled 66 extracted human molars. After preparing the access cavity, perforations were created on the floor of the pulp chamber with a diameter of 1.4 mm. The teeth were randomly distributed into the following six groups according to the repair material (MTA and CEM) and power output of laser irradiation (1 W and 1.5 W); A: MTA (case), B: CEM (case), C: Nd:YAG (1 W)/MTA, D: Nd:YAG (1 W)/CEM, E: Nd:YAG (1.5 W)/MTA, and F: Nd:YAG (1.5 W)/CEM. Then, a universal testing machine was utilized to assess the PBS. Data analysis was performed using ANOVA and T tests. Significant level was considered at P < 0.05. The highest mean ± SD of PBS was noted in Group Nd:YAG (1 W)/MTA (58.92 ± 36.13), followed by Nd:YAG (1.5 W)/MTA > Nd:YAG (1.5 W)/CEM > Nd:YAG (1 W)/CEM > MTA > and CEM. A significant difference was noted between laser and non-laser applications (P < 0.05). However, the increase of power output from 1 to 1.5 W had no significant influence on PBS (P > 0.05). The PBS of MTA groups was always significantly greater than that of CEM groups (P < 0.05). Although Nd:YAG laser irradiation positively influenced on PBS values in both material studied, increasing power output was not effective.

Effect of laser-assisted retrograde cavity preparation on push-out-bond-strength of mineral trioxide aggregate and calcium-enriched-mixture-cement / Efeito de preparo cavitário retrógrado assistido por laser na força de união de cimento de agregado trióxido mineral e cimento enriquecido com cálcio

Objective: This study aimed to determine the push-out-bond-strength(PBS) of mineral trioxide aggregate (BIOMTA+) and calcium-enriched-mixture-cement (CEM) in retrograde cavities prepared using Er: YAG laser and stainless-steel bur. Material and Methods: The root canals of 60 extracted single-rooted human teeth were prepared, filled and their apical portion of 3-mm were resected using a diamond bur and randomly divided into four groups according to technique of retrograde preparation and filling material as follows(n=15): Group1: bur/ BIOMTA+ ,Group2: bur/ CEM, Group3: Er:YAG laser/ BIOMTA+, Group4: Er:YAG laser/ CEM. PBS test were performed to specimens and failure modes were evaluated. The data were statistically analyzed with ANOVA, Post-Hoc Tukey and t tests (p< 0.05). Results: CEM was exhibited higher than bond strength compared to BIOMTA+ in retrograde cavity prepared using laser (p= 0.021) and BIOMTA+ in retrograde cavity prepared using bur was exhibited higher than bond strength compared to in retrograde cavities prepared using laser (p= 0.024). Failure modes were dominantly cohesive in all groups tested and one representative specimen each failure mode was examined in SEM and the general characteristics of the failure modes were confirmed. Conclusion: With in the limitations of the present study, when used CEM, Er: YAG laser-assisted retrograde cavity preparation positively affected the bond strength values compared to BIO MTA+. Considering its optimal adhesion, the calcium-enriched-mixture-cement (CEM) might be a good option as a filling material in retrograde cavities in clinical use. (AU)

Objetivo: O objetivo deste estudo foi determinar a força de união (PBS) de cimento de agregado trióxido mineral (BIO MTA+) e cimento enriquecido com cálcio (CEM) em preparos cavitários retrógrados realizados com: Laser Er-YAG e brocas de aço inoxidável. Material e Métodos: Canais radiculares de 60 dentes unirradiculares extraídos foram preparados, preenchidos e 3 mm de suas porções apicais foram ressecadas usando uma broca diamantada e divididos randomicamente em quatro grupos de acordo com a técnica de preparação retrógrada e o material de preenchimento (n=15): Grupo 1: Broca/BIO MTA+, Grupo 2: Broca/CEM, Grupo 3: Laser Er-YAG/BIO MTA+, Grupo 4: Laser Er-YAG/CEM. O teste de PBS foi realizado para as amostras e os modelos de falha foram avaliados. Os dados foram analisados estatisticamente pelos testes de ANOVA, Post-Hoc Tukey e testes t (p< 0.05). Resultados: CEM apresentou maior força de união que BIO MTA+ em cavidades retrógradas preparadas com laser (p= 0.021) e BIO MTA+ em cavidades retrógradas preparadas com brocas apresentou maior força de união quando comparado à cavidades retrógradas preparadas com laser (p= 0.024). Os modelos de falha foram predominantemente coesos em todos os grupos testados e um espécime representativo de cada modelo de falha foi examinado em MEV e as características gerais dos modelos de falha foram confirmadas. Conclusão: Com as limitações do presente estudo, quando usou-se CEM, o preparo de cavidades retrógradas através de Laser Er-YAG afetou positivamente os valores da força de união quando comparados com BIO MTA+. Considerando sua ótima adesão, o cimento enriquecido com cálcio (CEM) pode ser uma boa opção como um material de preenchimento em cavidades retrógradas no uso clínico.

Thermal effect of light irradiation time on the setting time of mineral trioxide aggregate and calcium-enriched mixture cements.

This study aimed to assess the thermal effect of different light irradiation times on the setting time of mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cements. This in vitro experimental study evaluated 40 hydraulic cement specimens, including 20 MTA and 20 CEM specimens, according to the manufacturers'instructions. For each cement, the specimens were divided into 3 test groups light cured with a halogen light-curing unit (n = 5 per group) and 1 control group (n = 5) that was not exposed to irradiation. The specimens in the MTA test groups were light cured for 20, 40, or 60 seconds, and the specimens in the CEM test groups were light cured for 60, 90, or 120 seconds. All test and control groups had 60 seconds of rest time. Setting of the cements was assessed at different timepoints using a Gillmore needle weighing 113.4 g with a 12.2-mm diameter according to ASTM C266-03 standards. The data were analyzed with the Fisher exact test and the Mann-Whitney U test (α = 0.05). The setting of MTA specimens after different curing times was significantly different (P < 0.05). The setting time of MTA control specimens was significantly longer than that of test specimens (P = 0.008). The setting of CEM specimens after different curing times was not significantly different (P > 0.05). However, the setting time for CEM control specimens was significantly longer than that for test specimens (P = 0.008). Light curing with a halogen light-curing unit can significantly decrease the setting time for MTA and CEM cements.

In vitro antimicrobial activity of mineral trioxide aggregate, Biodentine, and calcium-enriched mixture cement against Enterococcus faecalis, Streptococcus mutans, and Candida albicans using the agar diffusion technique.

BACKGROUND: This study assessed the antimicrobial activity of Biodentine, mineral trioxide aggregate (MTA), and calcium-enriched mixture (CEM) cement against Enterococcus faecalis, Streptococcus mutans, and Candida albicans. MATERIALS AND METHODS: In this in vitro study, microbial suspensions were inoculated onto agar plates. The antimicrobial effects of MTA, Biodentine and CEM cement were assessed against E. faecalis, S. mutans, and C. albicans by the agar diffusion test. In each experimental group, 7 plates containing 3 wells were prepared and immediately filled with freshly mixed cements. Positive and negative control plates were prepared with/without the bacterial suspension, respectively. After 2 h of preincubation at room temperature, the plates were incubated at 37°C for 24 h. The diameter of growth inhibition zones was measured after 24 h. Data were analyzed using ANOVA and Tukey's test (α = 0.05). RESULTS: Biodentine showed strong antimicrobial activity against all three microorganisms with an average inhibition zone of 9.10 mm. The inhibitory effect of Biodentine on E. faecalis and C. albicans was significantly superior to that of the other two cements (P < 0.05). MTA and CEM cement showed significantly higher antimicrobial activity against S. mutans (P < 0.05). The antimicrobial effects of Biodentine on S. mutans and E. faecalis were significantly greater than on C. albicans (P < 0.05). CONCLUSION: All cements revealed antimicrobial properties against the tested microbial strains. Biodentine had stronger antimicrobial effects against E. faecalis and C. albicans compared with MTA and CEM cement. Furthermore, the largest inhibition zones around all three cements belonged to S. mutans.

Management of primary molars with irreversible pulpitis employing tampon pulpotomy: Report of three cases with 34-month mean follow-up.

This study suggests that tampon-based coronal pulpotomy using a calcium silicate-based biomaterial can be a reliable approach for the treatment of vital primary molars with irreversible pulpitis.

Chemical modification of MTA and CEM cement to decrease setting time and improve bioactivity properties by adding alkaline salts.

Background. Mineral trioxide aggregate (MTA) and Calcium-enriched Mixture (CEM) cement are used for pulp capping since they induce the formation of a dentinal bridge. Long setting time is a shortcoming of these types of cement. This study aimed to assess the effect of the incorporation of some alkaline salts to MTA and CEM cement on their setting time, ion release profile, pH, and surface morphology. Methods. In this in vitro experimental study, 5% calcium chloride (CaCl2), calcium oxide (CaO), sodium fluoride (NaF), and calcium nitrate [Ca(NO3)2] were separately added to MTA and CEM cement. The primary and final setting times of the cements were measured using a Gillmore needle apparatus. The samples were immersed in simulated body fluid (SBF) for one, seven, and 14 days and subjected to x-ray diffraction (XRD) and scanning electron microscopy (SEM) for phase identification and surface morphology assessment. The change in the pH of solutions was studied, and the calcium ion release profile was determined using inductively coupled plasma atomic emission spectroscopy (ICP-AES). The data were analyzed with ANOVA, followed by post hoc tests. Results. CaCl2 and CaO decreased the setting time of MTA, and Ca(NO3)2 decreased the setting time of CEM cement. The incorporation of the salts increased the pH and calcium ion release from both cements, and hydroxyapatite deposits were noted to cover the surface of the samples (observed by SEM and confirmed by EDXA). Conclusion. The incorporation of CaCl2 and CaO into MTA and Ca(NO3)2 into CEM cement decreased their setting time and increased their pH and calcium ion release.

Comparison of the microleakage of mineral trioxide aggregate, calcium-enriched mixture cement, and Biodentine orthograde apical plug.

BACKGROUND: One-visit apexification is a treatment of choice in necrotic immature open apex teeth. Calcium silicate base materials are suitable for this method. The purpose of this study was to investigate and compare the sealing efficiency of Biodentine, mineral trioxide aggregate (MTA) ProRoot, and calcium-enriched mixture (CEM) cement orthograde apical plug using bacterial leakage method. MATERIALS AND METHODS: In this in vitro study a total of 70 extracted maxillary incisors were cleaned and shaped. A 1.1-mm standardized artificially open apex was created in all samples. The teeth were randomly divided into three experimental groups of 20, and two negative and positive control groups of 5. In experimental groups, 4-mm thick apical plugs of ProRoot MTA, CEM cement, or Biodentine were placed in an orthograde manner. Negative control samples were completely filled with MTA while positive control samples were left unfilled. Sealing efficiency was measured by bacterial leakage method, and results were analyzed by Kaplan-Meier and Chi-square tests. The level of significance was set at 0.05. RESULTS: The highest number of turbidity was recorded for ProRoot MTA samples, while the lowest for Biodentine. There was a significant difference in the number of turbidity between ProRoot MTA and Biodentine groups (P < 0.001), but there was no significant difference between CEM cement and Biodentine (P = 0.133) and ProRoot MTA (P = 0.055). CONCLUSION: Within the limitation of this in vitro study, Biodentine showed promising results as a substance with good-sealing efficiency.