An international consensus study to identify "what" outcomes should be included in a core outcome set for endodontic treatments (COSET) for utilization in clinical practice and research.

BACKGROUND: Development of a standardized set of topic-specific outcomes known as a Core Outcome Set (COS) is important to address issues of heterogeneity in reporting research findings in order to streamline evidence synthesis and clinical decision making. AIM: The aim of the current international consensus study is to identify "what" outcomes to include in the Core Outcome Set for Endodontic Treatments (COSET). Outcomes of various endodontic treatments (non-surgical root canal treatment, surgical endodontics, vital pulp treatment and revitalization procedures) performed on permanent teeth were considered. METHODS: A standard validated methodology for COS development and reporting was adopted. The process involved identification of existing outcomes through four published scoping reviews. This enabled creation of a list of outcomes to be prioritized via semi-structured patient interviews, e-Delphi process and a consensus meeting with a range of relevant global stakeholders. Outcomes were prioritized using a 1-9 Likert scale, with outcomes rated 7-9 considered critical, 4-6 are important and 1-3 are less important. Outcomes rated 7-9 by ≥70% and 1-3 by <15% of participants were considered to achieve consensus for inclusion in the COS. The outcomes that did not achieve consensus in the first round were considered for further prioritization in the second Delphi round and consensus meeting. Final decisions about the outcomes to include in COSET were made by voting during the consensus panel meeting using the Zoom Poll function. RESULTS: A total of 95 participants including patients contributed to the COS development process. The consensus panel recommended, with strong consensus, eight outcomes shared across all treatment modalities for inclusion in COSET: pain; signs of infection (swelling, sinus tract); further intervention/exacerbation; tenderness to percussion/palpation; radiographic evidence of disease progression/healing; function; tooth survival; and patient satisfaction. Additional treatment specific outcomes were also recommended. DISCUSSION: Many of the outcomes included in COSET are patient reported. All should be included in future outcomes studies. CONCLUSION: COSET identified outcomes that are important for patients and clinicians and validated these using a rigorous methodology. Further work is ongoing to determine "how" and "when" these outcomes should be measured.

Molecular biomarkers for objective assessment of symptomatic pulpitis: A systematic review and meta-analysis.

BACKGROUND: Inflammatory biomarkers are potentially useful targets for pulpal diagnostic tests that can identify pulp status and predict vital pulp treatment (VPT) outcome, however, their accuracy is unknown. OBJECTIVES: (1) Calculate sensitivity, specificity and diagnostic odds ratio (DOR) of previously investigated pulpitic biomarkers; (2) Determine if biomarker levels discriminate between clinical diagnoses of pulpitis based on the presence or absence of spontaneous pain (3) Evaluate if biomarker level can predict VPT outcome. METHODS: Searches: PubMed/MEDLINE, Ovid SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase, Web of Science and Scopus in May 2023. INCLUSION: prospective and retrospective observational studies and randomized trials. Participants were humans with vital permanent teeth and a well-defined pulpal diagnosis. EXCLUSION: deciduous teeth, in vitro and animal studies. Risk of bias was assessed with modified-Downs and Black quality assessment checklist. Meta-analysis was performed using bivariate random effect model in Meta-DiSc 2.0 and RevMan and the quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Fifty-six studies were selected, reporting >70 individual biomolecules investigating pulpal health and disease at the gene and protein level. Most studies were of low and fair quality. Among the biomolecules investigated, IL-8 and IL-6 demonstrated a level of diagnostic accuracy with high sensitivity, specificity and DOR to discriminate between healthy pulps and those exhibiting spontaneous pain suggestive of IRP (low-certainty evidence). However, none was shown to have high DOR and the ability to discriminate between pulpitic states (very low certainty evidence). Limited data suggests high levels of matrix metalloproteinase 9 correlate with poorer outcomes of full pulpotomy. DISCUSSION: The inability of identified molecular inflammatory markers to discriminate between dental pulps with spontaneous and non-spontaneous pain should shift the focus to improved study quality or the pursuit of other molecules potentially associated with healing and repair. CONCLUSIONS: Low-quality evidence suggests IL-8 and IL-6 demonstrated level of diagnostic accuracy to discriminate between healthy pulps and those exhibiting spontaneous pain. There is a need for standardized biomarker diagnostic and prognostic studies focusing on solutions that can accurately determine the degree of pulp inflammation. REGISTRATION: PROSPERO CRD42021259305.

One-year outcome of selective caries removal versus pulpotomy treatment of deep caries: A pilot randomized controlled trial.

AIM: This study aimed to compare the outcome of SCR and Pulpotomy in teeth with deep caries extending at least 75% into dentine. METHODOLOGY: This two-armed, parallel-group, randomized, superiority trial included vital mature permanent teeth with deep primary or secondary caries diagnosed radiographically as being at least 75% into the thickness of dentine, without clinical signs of symptomatic irreversible pulpitis or radiographic evidence of a periapical lesion. Carious teeth were blindly allocated to receive either SCR or Pulpotomy using computer-generated randomized patient codes concealed in opaque envelopes. All teeth were reviewed clinically and radiographically at 6 months and 1 year post-treatment. Using a significance level of p < .05, the log rank test and Cox proportional hazards regression were used to compare the outcome of SCR and Pulpotomy and to identify potential prognostic factors, respectively. RESULTS: In all, 58 teeth in the SCR group and 55 teeth in the pulpotomy group completed treatment, after excluding 6 teeth because they did not complete the allocated treatment and another due to severe periodontal disease. At one year, 57/58 (98.3%) teeth from the SCR group and 48/55 (87.3%) teeth from the Pulpotomy group were available for analysis. One tooth in the Pulpotomy group (2.1%) and eight teeth in the SCR group (14.0%) required the further intervention of root canal treatment (p < .05). There were no other significant prognostic factors for survival. Overall, 91.4% of teeth treated with either SCR or Pulpotomy survived without requiring further intervention over a period of one year. No other adverse events occurred over the review period. CONCLUSION: Within the limitations of this study, Pulpotomy fares better than SCR in preserving the remaining pulp and periapical health. As a treatment modality, Pulpotomy carries greater cost outlay to patient and takes a longer time to complete treatment than SCR. Long-term follow-up is needed to study the pulpal and restorative outcomes of Pulpotomy and SCR.

Factors that influence the outcome of pulpotomy in permanent teeth.

The promotion of minimally invasive treatments focussed on the maintenance of pulp vitality has become a priority area in Endodontics. These vital pulp treatments (VPT) include partial and full pulpotomy, during which diseased coronal pulp tissue is removed prior to placement of a capping biomaterial and restoration. Traditionally, pulpotomies were confined to the treatment of carious primary and traumatized permanent teeth. However, these treatments have now been proposed as definitive solutions for cariously exposed permanent teeth with mild symptoms or even symptoms indicative of irreversible disease. Until recently, it was recommended that carious exposure of mature permanent teeth be managed by root canal treatment. The promotion of pulpotomy as an alternative treatment has opened up a wave of laboratory and clinical research aimed at improving therapies or evaluating clinical outcomes. In modern evidence-based endodontics, it is imperative that the outcomes of both partial and full pulpotomy are considered and important prognostic factors identified, so that improvements can be made to aid clinical decision-making and to direct new research. In this narrative review, the outcomes of partial and full pulpotomy are discussed, before analysis of patient, intraoperative and postoperative factors that influence the outcome of the pulpotomy procedure. The review highlights that although partial and full pulpotomy for the treatment of even pulpal disease are highly successful procedures, this is based on low-quality evidence with a lack of prospective, comparative trials investigating potential prognostic factors. Based on current evidence, it appears that age, gender, tooth type, root development and intraoperative pulpal haemorrhage do not impact significantly on pulpotomy outcome, whilst others such as caries depth, inflammatory status of the pulp, capping material, level of inflammatory pulpal-biomarkers and the final restoration integrity do. Other factors, including the influence of exposure type, periodontal condition, pulpal lavage, magnification, operator experience, isolation of the operating field and type of pulpotomy, require further experimental investigation before definitive conclusions can be made relating to the success of the pulpotomy procedure. Finally, there is not only a need for future well-designed prospective research addressing these issues but also a widening of our understanding of outcome to include patient-reported as well as clinician-reported outcomes.

Regulation of caries-induced pulp inflammation by NLRP3 inflammasome: A laboratory-based investigation.

AIM: To evaluate the expression and function of the nod-like receptor pyrin domain containing 3 (NLRP3) inflammasome in caries induced pulpitis. METHODOLOGY: NLRP3 expression was determined with immunohistochemistry in the dental pulp and qPCR in dental pulp cells (DPCs). THP-1 macrophages expressing the apoptosis-related speck-like protein (ASC) and green fluorescent protein (GFP) fusion protein were used to assess NLRP3 inflammasome activation by live cell imaging, following treatment with lipopolysaccharide (LPS) and lipoteichoic acid (LTA). Caspase I inhibitor was used to confirm inflammasome activation. An ex-vivo pulpitis model in which the DPCs were co-cultured with THP-1 macrophages was used to study the effect of the NLRP3 inflammasome inhibitor (MCC950), and cytokines were measured using ELISA and multiplex array. Data were analysed using the t-test or anova followed by a Bonferroni post hoc test with the level of significance set at p ≤ .05. RESULTS: NLRP3 inflammasome was differentially expressed in dental pulp of sound and carious teeth. Treatment of DPCs with LTA significantly upregulates NLRP3 and IL-1 ß-expression (p < .05) and in induces more ASC specks formation compared to LPS. IL-ß release in response to LTA treatment is significantly reduced with Caspase I inhibitor suggesting inflammasome dependent mechanism (p < .01). NLRP3-specific inhibitor, MCC950, significantly reduced IL-1ß and IL-6 in an ex-vivo pulpitis model (p < .01) but had no effect on IL-8 or matrix metalloproteinase-9 (MMP-9). CONCLUSIONS: Expression and upregulation of NLRP3 inflammasome with caries and LTA treatment suggest a role in caries-induced pulpitis. NLRP3 inhibitor attenuated the release of selective inflammatory cytokines and could be a potential treatment target that merit further investigation.

Characterisation of miRNA Expression in Dental Pulp Cells during Epigenetically-Driven Reparative Processes.

Within regenerative endodontics, exciting opportunities exist for the development of next-generation targeted biomaterials that harness epigenetic machinery, including microRNAs (miRNAs), histone acetylation, and DNA methylation, which are used to control pulpitis and to stimulate repair. Although histone deacetylase inhibitors (HDACi) and DNA methyltransferase inhibitors (DNMTi) induce mineralisation in dental pulp cell (DPC) populations, their interaction with miRNAs during DPC mineralisation is not known. Here, small RNA sequencing and bioinformatic analysis were used to establish a miRNA expression profile for mineralising DPCs in culture. Additionally, the effects of a HDACi, suberoylanilide hydroxamic acid (SAHA), and a DNMTi, 5-aza-2'-deoxycytidine (5-AZA-CdR), on miRNA expression, as well as DPC mineralisation and proliferation, were analysed. Both inhibitors increased mineralisation. However, they reduced cell growth. Epigenetically-enhanced mineralisation was accompanied by widespread changes in miRNA expression. Bioinformatic analysis identified many differentially expressed mature miRNAs that were suggested to have roles in mineralisation and stem cell differentiation, including regulation of the Wnt and MAPK pathways. Selected candidate miRNAs were demonstrated by qRT-PCR to be differentially regulated at various time points in mineralising DPC cultures treated with SAHA or 5-AZA-CdR. These data validated the RNA sequencing analysis and highlighted an increased and dynamic interaction between miRNA and epigenetic modifiers during the DPC reparative processes.

Outcomes reporting in systematic reviews on vital pulp treatment: A scoping review for the development of a core outcome set.

BACKGROUND: A large number of research reports on vital pulp treatment (VPT) has been published over the last two decades. However, heterogeneity in reporting outcomes of VPT is a significant challenge for evidence synthesis and clinical decision-making. OBJECTIVES: To identify outcomes assessed in VPT studies and to evaluate how and when outcomes are measured. A subsidiary aim was to assess evidence for selective reporting bias in the included studies. The results of this review will be used to inform the development of a core outcome set (COS) for endodontic treatments. METHODS: Multiple healthcare bibliographic databases, including PubMed/MEDLINE, Ovid EMBASE, Scopus, Cochrane Database of Systematic Reviews and Web of Science were searched for systematic reviews published between 1990 and 2020, reporting on VPT. Screening, data extraction and risk of bias assessment were completed independently by two reviewers. Outcomes' information was extracted and aligned with a healthcare taxonomy into five core areas: survival, clinical/physiological changes, life impact, resource use and adverse events. RESULTS: Thirty-six systematic reviews were included, 10 reporting on indirect pulp capping or selective caries removal, nine on direct pulp capping, eight on pulpotomy and nine on combined VPTs. There was considerable variation in the outcomes reported in these reviews and their included studies. Clinician-reported outcomes were used considerably more often than patient-reported outcomes. A range of instruments and time points were used for measuring outcomes. Several of the reviews were assessed as having low risk of selective reporting bias, but many did not specifically report this domain, whilst others did not provide risk of bias assessment at all. DISCUSSION: Considerable variation in selection of outcomes and how and when they are measured and reported was evident, and this heterogeneity has implications for evidence synthesis and clinical decision-making. CONCLUSIONS: Whilst there is a lack of consistency, several potentially important outcomes for VPT, including pulp survival, incidence of post-operative pain and need for further intervention, have been identified which could inform the development of a COS for endodontic treatment. REGISTRATION: Core Outcome Measures in Effectiveness Trials (COMET) (No. 1879).

Preclinical 3D-printed laboratory simulation of deep caries and the exposed pulp reduced student anxiety and stress, while increasing confidence and knowledge in vital pulp treatment.

AIM: To evaluate the impact of a preclinical laboratory session using 3D printed teeth on dental student stress, anxiety, confidence and knowledge when treating deep caries and pulp exposure. METHODOLOGY: This was a two-centre controlled study, with randomized distribution of students into two groups: a vital pulp treatment (VPT) lecture-only (control) group and a VPT-lecture combined with a VPT-laboratory (experimental) group. In both universities, preclinical students with endodontic or operative dentistry laboratory sessions could participate. All students were invited to the lecture. Two weeks later (timepoint-T1), both groups completed validated and bespoke questionnaires and scales to evaluate their stress (Stress-VAS), anxiety (STAI Trait [T] and State [S]), self-confidence and knowledge. Thereafter, only the experimental group attended the hands-on laboratory session demonstrating the techniques of selective caries removal and partial pulpotomy on a commercial 3D-printed tooth. Two weeks later (timepoint-T2), the participants from both groups repopulated the same questionnaires and VAS. The control group had the laboratory session after the completion of the study. The statistical analysis was performed with Statistica® (significance p = .05). The homogeneity between the two samples was checked by Khi2 and Student tests. Stress-VAS, STAI-S, confidence and knowledge scores were compared within each group, and between the two groups, at T1 and T2, with a repeated measures anova test (+/-Tukey post-hoc test). RESULTS: The groups comprised 54 students each, with no statistical difference between the groups regarding demographic, academic data and STAI-T score. The two groups had no significant difference of Stress-VAS, STAI-S, confidence and knowledge scores at T1 while they presented a significant difference in stress, anxiety and confidence scores at T2, but with no significant difference in knowledge score. However, knowledge score, as other parameters, improved significantly between T1 and T2 in the experimental group. CONCLUSIONS: The addition of a laboratory session using 3D-printed teeth that simulated deep caries and pulp exposure management, significantly reduced the stress and anxiety of students and increased their confidence. Within the limitations of this study, the benefit of introducing new technology in increasing student confidence and reducing stress offers opportunity for educational improvement in the VPT and cariology areas.

Vital pulp treatment for traumatized permanent teeth: A systematic review.

BACKGROUND: Traumatic dental injuries involving the pulp are quite common and there is a need to evaluate the quality of evidence on the success of vital pulp treatment (VPT) interventions in traumatised permanent teeth. OBJECTIVES: The aim of this systematic review was to assess the success of VPT in the management of traumatised human vital permanent teeth diagnosed with complicated crown or crown-root fractures. METHODS: An electronic search of the following databases: Web of Science, Scopus, PubMed, MEDLINE, EMBASE, LILACS, Clinical Trial Registries and the grey literature was performed until 25th /8/2021. Controlled clinical trials, cohort studies, case-control studies, case series with at least five cases and a minimum of 12-months follow-up were included. Non-English language literature was excluded. Two independent assessors performed study selection, data extraction and quality assessment using the National Institutes of Health's quality assessment tool. Disagreements were resolved through consensus/with a third assessor. RESULTS: A total of 14-studies (2-controlled clinical trials, 1-case-control, and 11-case series) published between 1978-2020, with a total of 1081 permanent teeth and an age range between 6-42 years-old were included. Bias analysis ranged considerably from 'good' to 'poor'. Meta-analysis was not performed due to data heterogeneity, unclear reporting, and limited number of controlled clinical studies. Partial pulpotomy was the main reported clinical procedure with an overall success rate between 82.9-100%. Complete pulpotomy and direct pulp capping were associated with lower success rates of 79.4-85.7% and 19.5%, respectively. Calcium hydroxide was the main pulp capping material with favourable clinical and radiographic success (79.4-100%). Biodentine® , mineral trioxide aggregate and IRoot® BP were also associated with a high clinical and radiographic success, 80-91%, 80-100%, and 90-100%, respectively, albeit in fewer studies. DISCUSSION: Although a high success rate has been reported when using VPT in managing pulpally involved traumatised teeth, the results of this systematic review clearly highlighted a paucity and low quality of the available evidence. CONCLUSIONS: Overall high success of VPT in the management of traumatised vital permanent teeth were reported, although based on limited evidence of well-conducted clinical studies. REGISTRATION: PROSPERO database (CRD42020205213).

Identification and validation of novel biomarkers and therapeutics for pulpitis using connectivity mapping.

AIM: To create an irreversible pulpitis gene signature from microarray data of healthy and inflamed dental pulps, followed by a bioinformatics approach using connectivity mapping to identify therapeutic compounds that could potentially treat pulpitis. METHODOLOGY: The Gene Expression Omnibus (GEO) database, an international public repository of genomics data sets, was searched for human microarray datasets assessing pulpitis. An irreversible pulpitis gene expression signature was generated by differential expression analysis. The statistically significant connectivity map (ssCMap) method was used to identify compounds with a highly correlating gene expression pattern. qPCR was used to validate novel pulpitis genes. An ex vivo pulpitis model was used to test the effects of the compounds identified, and the level of inflammatory cytokines was measured with qPCR, ELISA and multiplex array. Means were compared using the t-test or ANOVA with the level of significance set at p ≤ .05. RESULTS: Pulpitis gene signatures were created using differential gene expression analysis at cutoff points p = .0001 and .000018. Top upregulated genes were selected as potential pulpitis biomarkers. Among these, IL8, IL6 and MMP9 were previously identified as pulpitis biomarkers. Novel upregulated genes, chemokine (C-C motif) ligand 21 (CCL21), metallothionein 1H (MT1H) and aquaporin 9 (AQP9) were validated in the pulp tissue of teeth clinically diagnosed with irreversible pulpitis using qPCR. ssCMap analysis identified fluvastatin (Statin) and dequalinium chloride (Quaternary ammonium) as compounds with the strongest correlation to the gene signatures (p = .0001). Fluvastatin reduced IL8, IL6, CCL21, AQP9 (p < .001) and MMP9 (p < .05) in the ex vivo pulpitis model, while dequalinium chloride reduced AQP9 (p < .001) but had no significant effect on the other biomarkers. CONCLUSIONS: AQP9, MT1H and CCL21 were identified and validated as novel biomarkers for pulpitis. Fluvastatin and dequalinium chloride identified by the ssCMap as potential therapeutics for pulpitis reduced selected pulpitis biomarkers in an ex vivo pulpitis model. In vivo testing of these licenced drugs is warranted.

Efficacy of direct pulp capping for management of cariously exposed pulps in permanent teeth: a systematic review and meta-analysis.

BACKGROUND: The outcome of vital pulp treatment after carious pulp exposure is multifactorial and related to the procedure, biomaterial and pre-operative pulpal diagnosis. OBJECTIVES: To conduct a systematic review and meta-analysis determining the outcome of direct pulp capping (DPC) in mature permanent teeth with a cariously exposed pulp and a clinical diagnosis of reversible pulpitis, and ascertain whether the capping material influences the outcome. METHODS: Sources: MEDLINE Ovid-SP, Cochrane Central Register of Controlled Trials (CENTRAL), International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Embase and Web of Science until April 2020. Inclusion: Prospective, retrospective cohort studies and randomized trials investigating DPC outcome or comparing different capping materials after carious pulp exposure. Exclusion: Primary teeth, mechanical, traumatic or not specified pulp exposure, teeth with irreversible pulpitis or no pulpal diagnosis. Risk of bias assessed using Cochrane and modified Downs and Black quality assessment checklist. Meta-analysis on combined clinical/radiographic outcome was performed using a random effect model. Success was defined as absence of signs and symptoms of irreversible pulpitis, apical periodontitis or loss of pulp vitality. RESULTS: Quality assessment highlighted four non-randomized studies to be of fair and five of poor quality. Four randomized trials had a high risk of bias. The pooled success rate differed based on material and follow-up. Calcium hydroxide success rate was 74% at 6-months, 65% at 1-year, 59% at 2-3 years and 56% at 4-5 years. Mineral trioxide aggregate (MTA) success was 91%, 86%, 84% and 81% at the same time points. Biodentine success was 96% at 6-months, 86% at 1 year and 86% at 2-3 years. The meta-analysis revealed MTA had better success than calcium hydroxide at 1-year (OR 2.66, 95% CI; 1.46- 4.84, P = 0.001) and 2- to 3-year follow-up (OR 2.21, 95% CI; 1.42-3.44, P = 0.0004). There was no difference between MTA and Biodentine. DISCUSSION: These results were based on poor methodological quality studies. The effect size for of MTA vs Ca(OH)2, although modest, was consistent with narrow CI. CONCLUSIONS: Low-quality evidence suggests a high success rate for direct pulp capping in teeth with cariously exposed pulps with better long-term outcomes for MTA and Biodentine compared with calcium hydroxide.

A prospective clinical study investigating the effectiveness of partial pulpotomy after relating preoperative symptoms to a new and established classification of pulpitis.

AIM: To prospectively investigate the outcome of partial pulpotomy after 1 year, using a hydraulic calcium silicate cement (HCSC) on symptomatic cariously exposed pulps in adult teeth. To compare the traditional American Association of Endodontists (AAE) pulpitis classification with the recently proposed Wolters classification system in predicting the likelihood of treatment failure. METHODOLOGY: Sixty-two symptomatic adult teeth with deep and extremely deep carious lesions were classified according to the Wolters (mild/moderate/severe pulpitis) and the traditional pulpitis classification (reversible/irreversible pulpitis). Eleven teeth were excluded intraoperatively as there was no pulp exposure after non-selective caries removal. The remaining 51 teeth, regardless of diagnosis, were treated by partial pulpotomy, pulpal lavage with 2.5% sodium hypochlorite solution, haemostasis and HCSC application (Biodentine™) as a pulp capping material. A permanent restoration was placed during a second appointment 1-2 weeks later. Preoperative tenderness to percussion (TTP), bleeding time and material setting time were recorded as was preoperative and postoperative tooth colour under standardized conditions. Clinical review occurred at regular intervals with clinical/radiographic analysis at 12 months. Chi-square analysis and Fisher's exact test assessed different outcomes amongst the diagnostic categories; the Kruskal-Wallis and Wilcoxon rank-sum test assessed influence of pulp bleeding time, TTP or variation in setting time (p < .05). RESULTS: Ten cases were lost to review, and a total of 41 teeth were reviewed at 1 year and classified as either "success," "successful but unresponsive to sensibility testing" or "failed." This included five severe, 17 moderate and 19 mild pulpitis according to Wolters classification or 23 reversible pulpitis and 18 irreversible pulpitis cases by the AAE classification. The majority of the 62 enrolled cases were "extremely deep" (n = 50), rather than "deep" (n = 12) caries with all failures occurring in the extremely deep group. Partial pulpotomy was 90% successful (100% reversible, 78% irreversible or 100% mild, 88% moderate, 60% severe pulpitis) with a significant difference in outcome between mild and severe pulpitis groups (p = .04). Only one, severe pulpitis/irreversible pulpitis, case failed painfully prior to the 1-year review appointment. Bleeding time (p = .26) and TTP (p = .61) did not influence treatment outcome, whilst Biodentine™ setting time was significantly longer than manufacturers' claim (p < .05). No teeth discoloured. CONCLUSIONS: Partial pulpotomy using Biodentine™ was successful for treating symptomatic carious pulpal exposures after 1 year, but included cases where pulp vitality could not be confirmed. Within the limitations of this study, cases with signs and symptoms indicative of irreversible pulpitis were not less successful; however, Wolters classification highlighted severe pulpitis to be less successful than mild pulpitis, thereby providing a potential prognostic benefit in diagnostically subdividing pulpitis. Caries depth was an indicator of failure, whilst bleeding time and preoperative tenderness to percussion were not.

The management of deep carious lesions and the exposed pulp amongst members of two European endodontic societies: a questionnaire-based study.

AIMS: To investigate and compare views on management of deep caries and the exposed pulp by Endodontic Society members in Ireland (Irish Endodontic Society [IES]) and Italy (Accademia Italiana di Endodonzia [AIE]). Further aims were to investigate the influence of patient-related factors (age, symptoms) and operator-related factors (material choice, antibiotics) on management. METHODOLOGY: A structured online questionnaire containing two cases (an 18- and 45-year-old) and two scenarios (± mild symptoms), including history and radiograph, was sent to IES and AIE members. The answers were analysed using chi-square and Fisher's exact test (P < 0.05). RESULTS: In total, 120 dentists participated, representing 49% of the AIE and 48% of the IES membership. Age distribution was similar between the societies; however, most AIE members had no further qualifications (63%), while IES respondents generally had a postgraduate endodontic qualification (71%). AIE respondents carried out a larger volume of vital pulp treatment (VPT) per month, with 69% carrying out over five cases, compared with 22% of IES respondents. The presence of patient symptoms significantly altered treatment planning decisions (P < 0.001) with root canal treatment (RCT) more frequently selected in both societies. Patient age significantly influenced treatment choice in the absence (P = 0.043) or presence (P = 0.012) of symptoms with less VPT advocated in older patients. There were no significant differences in the treatment of a young patient in the presence (P = 0.302) or absence of symptoms (P = 0.297); however, older patient management differed between the societies for symptomatic (P = 0.041) and asymptomatic scenarios (P = 0.044) with significantly more RCTs carried out in the AIE than the IES. Hydraulic calcium silicate materials were commonly selected, accounting for 81% of IES and 69% of AIE VPT materials, although younger members of the AIE preferred calcium hydroxide materials. Younger dentists in both societies prescribed less RCT than older age groups. CONCLUSIONS: Although VPT is carried out by members of both societies there was no consistency regarding the most appropriate management for the exposed pulp or the VPT material of choice. Patient symptoms and age significantly influence the decision-making process and invasiveness of treatment. Hydraulic calcium silicate materials were the most commonly advocated material in all groups except young AIE members who preferred calcium hydroxide.

Frightened of the pulp? A qualitative analysis of undergraduate student confidence and stress during the management of deep caries and the exposed pulp.

AIM: To evaluate sources of student confidence and stress during the management of deep carious lesions and the exposed pulp during undergraduate clinics. Further aims were to identify barriers and facilitators, which could result in educational or practical improvements in the delivery of teaching and provision of treatment in this area. METHODOLOGY: A exploratory qualitative study design was used, based on recorded focus group interviews, guided by 12 predetermined questions. The discussions were transcribed verbatim and analysed by inductive qualitative content analysis. Common categories were identified to aid understanding. Forty undergraduate dental students from 4th and 5th years in Dublin Dental University Hospital participated in the study. RESULTS: Student stress and confidence were multifactorial and broadly linked to specific domains: clinical procedure, academic education, clinical training, evaluation/grading, organization and equipment, vital pulp biomaterial and the patient. Most students expressed a preference for one-stage selective carious removal to soft dentine rather than potential pulp exposure in deep carious lesions, noting that although it helped to decrease their immediate stress, it also caused longer-term concern by leaving caries close to the pulp. Nevertheless, their confidence was affected by limited clinical experience of carrying out selective removal procedures in deep caries. A recurrent finding was students citing high levels of stress after pulp exposure. Feelings including anger, fear, embarrassment and denial were associated with pulp exposure during deep caries management. Generally, the students felt able to manage pulp capping procedures, but were less certain about partial pulpotomy, suggesting that although they are aware of its advantages, they were unsure about the appropriate volume of pulp tissue to remove. To reduce stress, students suggested that laboratory teaching should employ new 3-D printed solutions and clinics should establish clear consensus amongst supervising teachers about the best way to manage the exposed pulp. CONCLUSIONS: Students lacked confidence as they neared the pulp and prefer selective caries removal techniques, which reduce the likelihood of pulp exposure. Students identified stressors and suggested improvements in several domains that would improve confidence. These ameliorations could lead to enhancements in student ability to perform these conservative techniques, and improve the provision of treatment in this area.

European Society of Endodontology position statement: Management of deep caries and the exposed pulp.

This position statement on the management of deep caries and the exposed pulp represents the consensus of an expert committee, convened by the European Society of Endodontology (ESE). Preserving the pulp in a healthy state with sustained vitality, preventing apical periodontitis and developing minimally invasive biologically based therapies are key themes within contemporary clinical endodontics. The aim of this statement was to summarize current best evidence on the diagnosis and classification of deep caries and caries-induced pulpal disease, as well as indicating appropriate clinical management strategies for avoiding and treating pulp exposure in permanent teeth with deep or extremely deep caries. In presenting these findings, areas of controversy, low-quality evidence and uncertainties are highlighted, prior to recommendations for each area of interest. A recently published review article provides more detailed information and was the basis for this position statement (Bjørndal et al. 2019, International Endodontic Journal, doi:10.1111/iej.13128). The intention of this position statement is to provide the practitioner with relevant clinical guidance in this rapidly developing area. An update will be provided within 5 years as further evidence emerges.

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

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

One-year radiographic and clinical performance of bioactive materials in primary molar pulpotomy: A randomized controlled trial.

OBJECTIVES: Mineral Trioxide Aggregate (MTA) is considered the gold standard material for pulpotomy procedures. However, some drawbacks such as poor handling and long setting time are challenging when it is used as pulpotomy dressing in primary molars in children. Hence, the purpose of this study was to compare the radiographic and clinical performance of a premixed, fast setting bioceramic root repair material (BC RRM-F) with MTA in vital pulpotomy procedures of primary molars, with or without the added seal of a stainless steel crown (SSC). METHODS: In this double blinded, four-arm, parallel group randomized contolled trial (RCT), 64 primary molars were randomly allocated to one of the four treatment groups: MTA (PDTM MTA WHITE)+SSC, MTA+GI (bulk fill glass ionomer with glass hybrid technology GC EQUIA Forte® HT), BC RRM-F+GI and BC RRM-F+SCC. All molars were evaluated clinically and radiographically according to the modified Zurn and Seale criteria at 1, 3, 6, and 12 months follow up. Multivariate cox regression models and Kaplan-Meier curves were used for survival analysis. RESULTS: There was no statistically significant difference between the success of both pulp capping materials used. Overall survival analysis showed that using GI instead of SCC as a final restorative material was significantly associated with increased risk of failure. CONCLUSIONS: TotalFill® BC RRM™ Fast Set Putty can be used as an alternative to MTA in primary molar pulpotomy. Regardless of the pulp capping material, one year survival of pulpotomized primary molars restored with SSC is higher compared to those restored with GC EQUIA Forte® HT. CLINICAL SIGNIFICANCE: Clinicians' preference and cost effectiveness may justify the use of either material in primary molar pulpotomy. Parents insisting on tooth-colored restorations for their children's pulpotomized teeth cannot be told that the expectation for success is the same as those restored with SSC, even if calcium silicate-based pulp capping materials are used.

Clinical applications of calcium silicate-based materials: a narrative review.

Calcium silicate-based materials are hydrophilic materials with biocompatibility and bioactivity properties. Despite many advantages, they might present some problems related to discolouration, setting time, manipulation and solubility depending on the composition of the product and the type of clinical application. Calcium silicate-based materials can be evaluated under two types according to their intended use: calcium silicate-based cements (CSCs) and calcium silicate-based sealers (CSSs). CSCs can be used in many endodontic procedures including perforation repair, resorption repair, apical barriers, guided endodontic repair, vital pulp treatment, endodontic surgery, root fractures and root canal filling as a core obturation material. CSSs are available for use with gutta-percha to obturate root canals using cold and warm techniques, including the sealer-based obturation technique. The purpose of this review is to evaluate the available literature on CSCs and CSSs and to provide up-to-date information and recommendations for their clinical applications.

Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: A systematic review and meta-analysis.

OBJECTIVES: Different materials have been used for capping the pulp after exposure during caries removal in permanent teeth. The purpose of this study was to collate and analyze all pertinent evidence from randomized controlled trials (RCTs) on different materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth. MATERIALS AND METHODS: Trials comparing two or more capping agents used for direct pulp capping (DPC) or pulpotomy were considered eligible. An electronic search of four databases and two clinical trial registries was carried out up to February 28, 2021 using a search strategy properly adapted to the PICO framework. Screening, data extraction, and risk of bias (RoB) assessment of primary studies were performed in duplicate and independently. The primary outcome was clinical and radiological success; secondary outcomes included continued root formation, tooth discoloration, and dentin bridge formation. RESULTS: 21 RCTs were included in the study. The RoB assessment indicated a moderate risk among the studies. Due to significant clinical and statistical heterogeneity among the studies, performing network meta-analysis (NMA) was not possible. An ad hoc subgroup analysis revealed strong evidence of a higher success of DPC with Mineral Trioxide Aggregate (MTA) compared to calcium hydroxide (CH) (odds ratio [OR] = 3.10, 95% confidence interval [CI]: 1.66-5.79). MTA performed better than CH in pulp capping (both DPC and pulpotomy) of mature compared to immature teeth (OR = 3.34, 95% CI: 1.81-6.17). The GRADE assessment revealed moderate strength of evidence for DPC and mature teeth, and low to very low strength of evidence for the remaining subgroups. CONCLUSIONS: Considerable clinical and statistical heterogeneity among the trials did not allow NMA. The ad hoc subgroup analysis indicated that the clinical and radiographic success of MTA was higher than that of CH but only in mature teeth and DPC cases where the strength of evidence was moderate. PROSPERO Registration: number CRD42020127239.