Exploring deep caries management and barriers to the use of vital pulp treatments by primary care dental practitioners.

AIM: The European Society of Endodontology outlines best practices for the management of deep caries and the pulp. Despite evidence supporting vital pulp treatments (VPTs) as predictable alternatives to conventional endodontic treatment, studies have shown they are not widely adopted in the UK. This study aimed to explore the barriers to implementation of VPTs by primary care general dental practitioners (GDPs). METHODOLOGY: Qualitative one-to-one semi-structured online interviews were conducted with purposively sampled UK GDPs. Interview transcripts were analysed using reflexive thematic analysis. Recurring themes were iteratively refined as additional transcripts were reviewed. RESULTS: Eleven participants were interviewed. A range of barriers to the provision of VPTs were identified, which aligned with two core themes: 'Motivational barriers to service provision' and 'Educational access & opportunities'. Sub-themes included lack of access to materials and equipment, deficiencies in knowledge of treatment (including protocols, outcomes and prognosis), lack of confidence (in treatment efficacy and clinical ability), time constraints and public dental service funding and remuneration. CONCLUSIONS: This study identifies barriers to the widespread adoption of VPTs among primary care GDPs in public and private settings. Economic constraints, practitioner confidence, time limitations and educational gaps are key challenges. Addressing these may require systemic changes such as policy interventions, education and improved resource allocation.

The effectiveness of partial pulpotomy compared with full pulpotomy in managing deep caries in vital permanent teeth with a diagnosis of non-traumatic pulpitis.

BACKGROUND: Pulpitis may be pain free or alternatively characterized by mild to severe pain and associated symptoms. Evidence has recently emerged that patients presenting with carious pulp exposure range of symptoms can be treated effectively with pulpotomy. OBJECTIVE: The current systematic review aimed to answer the following research question: "In patients with deep caries lesions in permanent teeth associated with no symptoms, reversible pulpitis or signs and symptoms indicative of irreversible pulpitis (P), is partial pulpotomy (I) as effective as full pulpotomy (C), in terms of a combination of patient and clinical reported outcomes (O), with "tooth survival" as the most critical outcome? METHODS: The systematic literature search was conducted in the following electronic databases: OVID, Scopus, PubMed (Including MEDLINE), and Cochrane Central Register of Controlled Trials (CENTRAL) supplemented with Grey literature and hand searching of relevant journals. The English language clinical trials comparing the patient and clinical reported outcomes between partial and full/complete were included. After a structured literature search, two authors independently performed study selection, extracted data and performed a risk of bias assessment; a third reviewer resolved disagreements. As there were only two studies with different exclusion criteria, no meta-analysis was performed and the quality of evidence was assessed by the GRADE approach. RESULTS: After study selection a total of two randomised clinical trials with a total of 156 teeth were included both for the management of teeth with irreversible pulpitis. There were no studies for asymptomatic teeth or teeth with reversible pulpitis. A "Low" risk of bias was noted for both studies with a high level of overall evidence. A meta-analysis was not carried out due to differences in inclusion criteria between the studies related principally to caries depth. Both studies reported a high rate of clinical success for pulpotomy with a pooled unadjusted success rate for full pulpotomy of 90% and 83% partial pulpotomy of at 1-year; however, no significant difference between the treatments was noted in either study. There was significantly reduced postoperative pain reported in the full pulpotomy group over 1-week compared with the partial pulpotomy in one but not in the other study. DISCUSSION: Pulpotomy as a definitive treatment modality is as effective in managing teeth exhibiting signs and symptoms indicative of irreversible pulpitis and challenges the established protocols to manage this condition. Although based on only two RCTs with a limited number of patients, no difference was shown in terms of clinical or radiographic outcome or postoperative pain between groups. Further well designed randomised clinical trials of longer duration are required in this area to improve the evidence available. CONCLUSION: There is no consistent difference in patient-reported pain between partial and full pulpotomy at day 7 postoperatively and the clinical success rate was similar after 1 year for both treatment modalities.

Anti-inflammatory cerium-containing nano-scaled mesoporous bioactive glass for promoting regenerative capability of dental pulp cells.

AIMS: This study aimed to investigate the anti-inflammatory and odontoblastic effects of cerium-containing mesoporous bioactive glass nanoparticles (Ce-MBGNs) on dental pulp cells as novel pulp-capping agents. METHODOLOGY: Ce-MBGNs were synthesized using a post-impregnation strategy based on the antioxidant properties of Ce ions and proposed the first use of Ce-MBGNs for pulp-capping application. The biocompatibility of Ce-MBGNs was analysed using the CCK-8 assay and apoptosis detection. Additionally, the reactive oxygen species (ROS) scavenging ability of Ce-MBGNs was measured using the 2,7-Dichlorofuorescin Diacetate (DCFH-DA) probe. The anti-inflammatory effect of Ce-MBGNs on THP-1 cells was further investigated using flow cytometry and quantitative real-time polymerase chain reaction (RT-qPCR). Moreover, the effect of Ce-MBGNs on the odontoblastic differentiation of the dental pulp cells (DPCs) was assessed by combined scratch assays, RT-qPCR, western blotting, immunocytochemistry, Alizarin Red S staining and tissue-nonspecific alkaline phosphatase staining. Analytically, the secretions of tumour necrosis factor-α (TNF-α) and interleukin-1ß (IL-1ß) were detected with enzyme-linked immunosorbent assay (ELISA). RESULTS: Ce-MBGNs were confirmed to effectively scavenge ROS in THP-1-derived macrophages and DPCs. Flow cytometry and RT-qPCR assays revealed that Ce-MBGNs significantly inhibited the M1 polarization of macrophages (Mφ). Furthermore, the protein levels of TNF-α and IL-1ß were downregulated in THP-1-derived macrophages after stimulation with Ce-MBGNs. With a step-forward virtue of promoting the odontoblastic differentiation of DPCs, we further confirmed that Ce-MBGNs could regulate the formation of a conductive immune microenvironment with respect to tissue repair in DPCs, which was mediated by macrophages. CONCLUSIONS: Ce-MBGNs protected cells from self-produced oxidative damage and exhibited excellent immunomodulatory and odontoblastic differentiation effects on DPCs. As a pulp-capping agent, this novel biomaterial can exert anti-inflammatory effects and promote restorative dentine regeneration in clinical treatment. We believe that this study will stimulate further correlative research on the development of advanced pulp-capping agents.

Biological evaluation of novel phosphorylated pullulan-based calcium hydroxide formulations as direct pulp capping materials: An in vivo study on a rat model.

AIM: Calcium hydroxide (CH) has been considered as a direct pulp capping materials (DPC) for the last decades despite having some limitations. Phosphorylate pullulan (PPL) incorporated with CH (CHPPL) is a novel biomaterial that was introduced as a promising DPC material. Thus, the aim of the study was to evaluate the inflammatory response and mineralized tissue formation (MTF) ability of PPL-based CH formulations on rat molars after DPC. METHODOLOGY: This study consisted of six groups: CH with 1% PPL (CHPPL-1); 3% PPL (CHPPL-3); 5% PPL (CHPPL-5); Dycal and NEX MTA Cement (N-MTA) as the positive control, and no capping materials (NC). One hundred twenty maxillary first molar cavities were prepared on Wistar rats. After capping, all the cavities were restored with 4-META/MMA-TBB resin and pulpal responses were evaluated at days 1, 7, and 28. Kruskal-Wallis followed by Mann-Whitney U-test was performed with a significance level of 0.05. Immunohistochemical expression of IL-6, Nestin, and DMP-1 was observed. RESULTS: At day 1, CHPPL-1, N-MTA, and Dycal exhibited no to mild inflammation, whilst CHPPL-3, CHPPL-5, and NC showed mild to moderate inflammation, and the results were significantly different (p < .05). At day 7, mild to moderate inflammation was observed in CHPPL-1, N-MTA, and Dycal, whereas CHPPL-3, CHPPL-5, and NC exhibited moderate to severe inflammation. Significant differences were observed between CHPPL-1 and N-MTA with NC (p < .05), CHPPL-1 and CHPPL-3 with CHPPL-5 and Dycal (p < .05), and CHPPL-3 with N-MTA (p < .05). A thin layer of mineralized tissue formation (MTF) was observed in all groups. At day 28, CHPPL-1, Dycal, and N-MTA showed no to mild inflammation, whilst CHPPL-3, CHPPL-5, and NC exhibited mild to severe inflammation, and statistically significant difference was detected (p < .05). CHPPL-1, Dycal, and N-MTA exhibited continuous MTF, whilst CHPPL-3, CHPPL-5, and NC had thicker and interrupted MTF. Significant differences were observed between CHPPL-1, CHPPL-3, and N-MTA with NC group (p < .05). Variable expressions of IL-6, Nestin, and DMP-1 indicated differences in the materials' impact on odontoblast-like cell formation and tissue mineralization. CONCLUSIONS: These findings suggest that CHPPL-1 has the potential to minimize pulpal inflammation and promote MTF and had similar efficacy as MTA cement.

Vital root resection with radicular retrograde partial pulpotomy in furcation-involved maxillary molars in patients with periodontitis: Technique description and case series considering clinical and economic aspects.

AIM: Conventional root resection in periodontally compromised furcation-involved maxillary molars requires preceding endodontic treatment and is therefore associated with loss of tooth vitality, higher invasiveness, treatment time and costs, and the risk of endodontic complications. Vital root resection (VRR) could overcome these disadvantages while establishing stable periodontal and endodontic conditions. This case series aimed to introduce the concept of one-stage VRR with radicular retrograde partial pulpotomy (VRRretro). SUMMARY: Seven vital maxillary molars with residual probing pocket depths (PPD) ≥ 6 mm and furcation ≥ class 2 of five patients with stage III/IV periodontitis were treated with VRRretro using mineral trioxide aggregate. Teeth with residual through-and-through furcations were additionally tunnelled. Follow-up up to 2.5 years postoperatively during supportive periodontal care included full periodontal status, percussion and thermal sensitivity testing. Periapical radiographs were obtained to rule out possible periradicular radiolucencies. All seven treated molars were in-situ at an average of 26.84 ± 5.37 months postoperatively and were clinically and radiographically inconspicuous independent of tooth position, the resected root, the need for tunnelling and the restorative status. The mean PPD on the seven treated molars was 4.02 ± 0.85 mm (6-10 mm) preoperatively and 2.62 ± 0.42 mm (3-4 mm) at the last follow-up. Clinical attachment level and bleeding on probing could also be decreased. The teeth showed no mobility over time and furcations class 2 were reduced to class 1 while the tunnelled furcations were accessible with interdental brushes. All molars reacted negatively to percussion and positively to thermal sensitivity testing. KEY LEARNING POINTS: In carefully selected cases considering patient- and tooth-related factors, VRRretro could be a promising treatment option to establish stable periodontal and endodontic conditions in furcation-involved maxillary molars while preserving tooth vitality.

Anti-inflammatory potential of casein enzymatic hydrolysate/gelatin methacryloyl scaffolds for vital pulp therapy.

OBJECTIVES: To synthesize casein enzymatic hydrolysate (CEH)-laden gelatin methacryloyl (GelMA) fibrous scaffolds and evaluate the cytocompatibility and anti-inflammatory effects on dental pulp stem cells (DPSCs). MATERIALS AND METHODS: GelMA fibrous scaffolds with 10%, 20%, and 30% CEH (w/w) and without CEH (control) were obtained via electrospinning. Chemo-morphological, degradation, and mechanical analyses were conducted to evaluate the morphology and composition of the fibers, mass loss, and mechanical properties, respectively. Adhesion/spreading and viability of DPSCs seeded on the scaffolds were also assessed. The anti-inflammatory potential on DPSCs was tested after the chronic challenge of cells with lipopolysaccharides (LPS), followed by treatment with extracts obtained after immersing the scaffolds in α-MEM. The synthesis of the pro-inflammatory cytokines IL-6, IL-1α, and TNF-α was measured by ELISA. Data were analyzed by ANOVA/post-hoc tests (α = 5%). RESULTS: CEH-laden electrospun fibers had a larger diameter than pure GelMA (p ≤ 0.036). GelMA scaffolds laden with 20% and 30% CEH had a greater mass loss. Tensile strength was reduced for the 10% CEH fibers (p = 0.0052), whereas no difference was observed for the 20% and 30% fibers (p ≥ 0.6736) compared to the control. Young's modulus decreased with CEH (p < 0.0001). Elongation at break increased for the 20% and 30% CEH scaffolds (p ≤ 0.0038). Over time, DPSCs viability increased across all groups, indicating cytocompatibility, with CEH-laden scaffolds exhibiting greater cell viability after seven days (p ≤ 0.0166). Also, 10% CEH-GelMA scaffolds decreased the IL-6, IL-1α, and TNF-α synthesis (p ≤ 0.035). CONCLUSION: CEH-laden GelMA scaffolds facilitated both adhesion and proliferation of DPSCs, and 10% CEH provided anti-inflammatory potential after chronic LPS challenge. CLINICAL RELEVANCE: CEH incorporated in GelMA fibrous scaffolds demonstrated the potential to be used as a cytocompatible and anti-inflammatory biomaterial for vital pulp therapy.

Biocompatibility and antimicrobial effect of demineralised dentin matrix hydrogel for dental pulp preservation.

Regeneration of dentin and preserving pulp vitality are essential targets for vital pulp therapy. Our study aimed to evaluate a novel biomimetic pulp capping agent with increased dentin regenerative activities. To produce demineralised dentin matrix (DDM) particles, human extracted teeth were ground and treated with ethylene diamine tetra-acetic acid solution. DDM particles were added to sodium alginate and this combination was dripped into a 5% calcium chloride to obtain DDM hydrogel (DDMH). The eluants of both DDMH and mineral trioxide aggregate (MTA) were tested using an MTT assay to detect their cytotoxic effect on dental pulp stem cells (DPSC). Collagen-I (COL-I) gene expression was analysed on DPSC exposed to different dilutions of pulp capping material eluants by real-time quantitative polymerase chain reaction. Acridine orange staining was used to monitor the cell growth over the tested materials. Agar diffusion assay was utilised to test the antibacterial effect of DDMH and MTA compared to controls. MTT assay revealed that neat eluates of DDMH promoted DPSC viability. However, neat eluates of MTA were cytotoxic on DPSC after 72 h of culture. Moreover, DPSC were capable of growth and attached to the surface of DDMH, while they showed a marked reduction in their number when cultured on the MTA surface for one week, as shown by the acridine orange stain. In DPSC cultured with DDMH eluates, the COL-I gene was overexpressed compared to those cultured with MTA eluants. DDMH had significant antimicrobial activity in comparison to MTA after 24 h incubation. This in vitro study showed that DDMH could be an alternative pulp capping agent for regenerative endodontics.

Antibacterial, biocompatible, and mineralization-inducing properties of calcium silicate-based cements.

BACKGROUND: Different pulp capping materials have different origins and compositions, require different preparations, and may vary in their bioactive properties. AIM: The purpose of this study was to evaluate the antibacterial activity, biocompatibility, and mineralization-inducing potential of calcium silicate-based pulp capping materials. DESIGN: Six contemporary calcium silicate-based cements, ProRoot MTA, MTA Angelus, Biodentine, EndoSequence, NeoMTA 2, and NeoPutty, were evaluated. The antibacterial effects of these materials against Streptococcus mutans UA159 and Enterococcus faecalis ATCC 29212 were determined by the agar diffusion assay and the direct culture test. The biocompatibility and mineralization-inducing potential of these materials in preodontoblastic 17IIA11 cells were evaluated by the MTT assay and by Alizarin Red S staining, respectively. RESULTS AND CONCLUSION: In agar diffusion test, only Biodentine showed distinct antibacterial effects against S. mutans. All the tested materials, however, showed antibacterial effects against S. mutans and E. faecalis in the direct culture test, with Biodentine showing the strongest growth inhibition against both S. mutans and E. faecalis. All the tested materials showed acceptable biocompatibility and mineralization-supporting potential in our experimental conditions. In summary, ProRoot MTA, MTA Angelus, Biodentine, EndoSequence, NeoMTA 2, and NeoPutty demonstrated acceptable in vitro antimicrobial, biocompatible, and mineralization-supporting properties.

The application of lasers in vital pulp therapy: clinical and radiographic outcomes.

The main purpose of vital pulp therapy (VPT) is to preserve the integrity and function of the pulp. A wide variety of materials and techniques have been proposed to improve treatment outcomes, and among them, the utilization of lasers has gained significant attention. The application of lasers in different stages of VPT has witnessed remarkable growth in recent years, surpassing previous approaches.This study aimed to review the applications of lasers in different steps of VPT and evaluate associated clinical and radiographic outcomes. An electronic search using Scopus, MEDLINE, Web of Science and Google Scholar databases from 2000 to 2023 was carried out by two independent researchers. The focus was on human studies that examined the clinical and/or radiographic effects of different laser types in VPT. A total of 4243 studies were included in this narrative review article. Based on the compiled data, it can be concluded that although current literature suggests laser may be proposed as an adjunct modality for some procedural steps in VPT, more research with standardized methodologies and criteria is needed to obtain more reliable and conclusive results.

Evaluation of the physical properties of bromelain-modified biodentine for direct pulp capping.

BACKGROUND: This study aims to evaluate the compressive strength, solubility, radiopacity, and flow of Bromelain (BR)-modified Biodentine (BD) for direct pulp capping (DPC). This is suggested to determine the impact of BR on the physical properties of BD. METHODS: Eighty samples were prepared according to the ISO and ADA specifications and evaluated for compressive strength, solubility, radiopacity, and flow. The compressive strength was evaluated at 24 h and 21 days via a universal testing machine. The solubility was determined by weight loss after 24-hours immersion in deionized water. Radiopacity was assessed via X-ray with aluminum step-wedges, and flow was measured by the diameter of the discs under a standard weight. Independent sample t-tests were used to statistically assess the data. A significance level of 5% was considered. RESULTS: The compressive strength was 41.08 ± 1.84 MPa for BD and 40.92 ± 1.80 MPa for BR + BD after 24 h, and 88.93 ± 3.39 MPa for BD and 87.92 ± 3.76 MPa for BR + BD after 21 days, with no significant differences. Solubility was slightly greater in the BR + BD (2.75 ± 0.10%) compared to BD (2.62 ± 0.25%), but not significantly different. The radiopacity was similar between BD (2.82 ± 0.11 mm) and BR + BD (2.73 ± 0.10 mm). BR + BD resulted in significantly greater flow (9.99 ± 0.18 mm) than did BD (9.65 ± 0.27 mm) (p ≤ 0.05). CONCLUSION: BR-modified BD maintains BD's physical properties, with improved flow, making it a promising DPC agent that warrants further study.

Delayed vs. immediate placement of restorative materials over Biodentine and RetroMTA: a micro-shear bond strength study.

BACKGROUND: The aim of the present study was to investigate the micro-shear bond strength (µSBS) of various restorative materials applied on two different fast-setting calcium silicate-based materials and to evaluate the effect of restoration time on µSBS. METHODS: A total of 180 acrylic blocks with a cavity in the center were randomly divided into 2 main groups according to the capping material to be used (Biodentine or RetroMTA). The specimens were also randomly divided into 3 groups according to the restoration time (3 min, 12 min, 24 h). After the specified waiting periods, glass hybrid material (EQUIA Forte HT), resin composite (Filtek Z550) and light-cured calcium silicate material (Theracal LC) were placed on the specimens with tygon tubes. The specimens were kept for 24 h and then subjected to µSBS test. Statistical analysis was performed by 3-way ANOVA followed by Tukey test for pairwise comparisons (α = 0.05). RESULTS: There is a statistically significant difference (p < 0.05) between the µSBS values obtained by applying resin composite on RetroMTA after different setting times (24 h > 12 min > 3 min). The µSBS obtained for the Biodentine-resin composite at the end of the 3 min setting time is significantly lower (p < 0.05) than the µSBS values at 12 min and 24 h. For both calcium silicate cements, at the end of all time periods, the µSBS obtained when resin composite was applied at the end was higher than the other materials (p < 0.05). CONCLUSIONS: For Biodentine-resin composite bonding, the manufacturer's recommendation of 12 min can be considered an appropriate time, whereas for RetroMTA-resin composite bonding, the µSBS increased as the waiting time increased. Regardless of the waiting time, it is recommended to prefer direct composite resin restoration over Biodentine and RetroMTA.

Histological evaluation of the regenerative potential of a novel photocrosslinkable gelatin-treated dentin matrix hydrogel in direct pulp capping: an animal study.

BACKGROUND: To assess histologically the success of the pulp capping approach performed in traumatically exposed dogs' teeth using a novel injectable gelatin-treated dentin matrix light cured hydrogel (LCG-TDM) compared with LCG, MTA and TheraCal LC. METHODS: Sixty-four dogs' teeth were divided into two groups (each including 32 teeth) based on the post-treatment evaluation period: group I: 2 weeks and group II: 8 weeks. Each group was further subdivided according to the pulp capping material into four subgroups (n = 8), with subgroup A (light-cured gelatin hydrogel) as the control subgroup, subgroup B (LCG-TDM), subgroup C (TheraCal LC), and subgroup D (MTA). Pulps were mechanically exposed in the middle of the cavity floor and capped with different materials. An assessment of periapical response was performed preoperatively and at 8 weeks. After 2 and 8-week intervals, the dogs were sacrificed, and the teeth were stained with hematoxylin-eosin and graded by using a histologic scoring system. Statistical analysis was performed using the chi-square and Kruskal-Wallis tests (p = 0.05). RESULTS: All subgroups showed mild inflammation with normal pulp tissue at 2 weeks with no significant differences between subgroups (p ≤ 0.05), except for the TheraCal LC subgroup, which exhibited moderate inflammation (62.5%). Absence of a complete calcified bridge was reported in all subgroups at 2 weeks, while at 8 weeks, the majority of samples in the LCG-TDM and MTA-Angelus subgroups showed complete dentin bridge formation and absence of inflammatory pulp response with no significant differences between them (p ≤ 0.05). However, the formed dentin in the LCG-TDM group was significantly thicker, with layers of ordered odontoblasts identified to create a homogeneous tubular structure and numerous dentinal tubule lines suggesting a favourable trend towards dentin regeneration. TheraCal LC samples revealed a reasonably thick dentin bridge with moderate inflammation (50%) and LCG showed heavily fibrous tissue infiltrates with areas of degenerated pulp with no signs of hard tissue formation. CONCLUSIONS: LCG-TDM, as an extracellular matrix-based material, has the potential to regenerate dentin and preserve pulp vitality, making it a viable natural alternative to silicate-based cements for healing in vivo dentin defects in direct pulp-capping procedures.

Determining Factors in the Success of Direct Pulp Capping: A Systematic Review.

AIM: To elucidate the factors that determine the success of direct pulp capping (DPC) in permanent teeth with pulp exposure due to dental caries. MATERIALS AND METHODS: A comprehensive electronic search from 1980 to 2023 across PubMed, Scopus, and ISI Web databases was conducted using specific keywords and MeSH terms in Q1 or Q2 journals. Only prospective/retrospective clinical studies in English on 15 or more human permanent teeth with carious pulpal exposure treated with DPC agents-mineral trioxide aggregate (MTA), Biodentine, or calcium hydroxide with a rubber dam and minimum 1-year follow-up, were considered. The factors retrieved and analyzed were based on study design, patient age, sample size, type of cavity, exposure size and location, pulp diagnosis, solutions to achieve hemostasis, hemostasis time, capping material, restoration type, follow-up period, methods of evaluation, and overall success. REVIEW RESULTS: Out of 680 articles, only 16 articles were selected for the present systematic review on application of the selection criteria. A wide age range of patients from 6 to 88 years were considered among these studies with sample sizes ranging from 15 to 245 teeth with reversible pulpitis being the predominant diagnosis of the cases. Mineral trioxide aggregate as a capping material was evaluated in 4 studies as a lone agent, while compared with other capping agents such as biodentine or calcium hydroxide in 7 studies. The follow-up period ranged from 9 days to nearly 80 months. While both clinical and radiographic evaluation was carried out in all studies, cold testing dominated the clinical tests while IOPR was the common radiograph considered. Mineral trioxide aggregate success rate was higher and similar to biodentine than calcium hydroxide. CONCLUSION: Direct pulp capping has a high and predictable success rate in permanent teeth with carious exposure to reversible and irreversible pulpitis. Currently, mineral trioxide aggregate and biodentine have better long-term results in DPC than calcium hydroxide, hence, they should be used as an alternative to calcium hydroxide. Definitive restoration within a short period improves long-term prognosis. CLINICAL SIGNIFICANCE: The significance of this review lies in its provision of evidence-based information on the effectiveness of DPC and the factors that influence its success. By considering these factors, clinicians can optimize treatment outcomes and improve the long-term prognosis of the treated teeth. This systematic review serves as a valuable resource for clinicians and researchers in the field of endodontics. How to cite this article: Gomez-Sosa JF, Granone-Ricella M, Rosciano-Alvarez M, et al. Determining Factors in the Success of Direct Pulp Capping: A Systematic Review. J Contemp Dent Pract 2024;25(4):392-401.

Using Odontoblasts Derived from Dog Endometrial Stem Cells Encapsulated in Fibrin Gel Associated with BMP-2 in a Rat Pulp-Capping Model.

This study aimed to treat dental injuries by utilizing one of the most advanced tissue engineering techniques. In this study, an in vitro model was employed to investigate the proliferation and odontogenic differentiation of canine endometrial stem cells (C-EnSCs). Furthermore, the dentin regeneration potential of odontoblast like-cells (OD) derived from C-EnSCs was assessed in rats. The C-EnSCs were isolated by the enzymatic method and identified by flow cytometry. The C-EnSCs were encapsulated in fibrin gel associated with signaling factors to create the proper conditions for cell growth and differentiation. Then, the OD cells were associated with bone morphologic protein-2 (BMP-2) to promote dentin formation in vivo. The animal model used to evaluate the regenerative effect of cells and biomaterials included the preparation of the left maxillary first molar of rats for direct pulp capping operation. Animals were divided into four groups: group 1, a control group without any treatment, group 2, which received fibrin, group 3, which received fibrin with ODs (fibrin/ODs), and group 4, which received fibrin with ODs and BMP-2 (fibrin/ODs/BMP-2). The morphological observations showed the differentiation of C-EnSCs into adipose, bone, neural cells, and ODs. Furthermore, the histomorphometric data of the treated teeth showed how fibrin gel and BMP2 at a concentration of 100 ng/mL provided an optimal microenvironment for regenerating dentin tissue in rats, which was increased significantly with the presence of OD cells within eight weeks. Our study showed that using OD cells derived from C-EnSCs encapsulated in fibrin gel associated with BMP2 can potentially be an appropriate candidate for direct pulp-capping and dentin regeneration.

Effects of direct pulp capping with recombinant human erythropoietin and/or mineral trioxide aggregate on inflamed rat dental pulp.

OBJECTIVE: This study aimed to evaluate the dental pulp responses to recombinant human erythropoietin (rhEPO) and/or mineral trioxide aggregate (MTA) in pulp capping of inflamed dental pulp in vivo. MATERIALS AND METHODS: In accordance with ARRIVE guidelines, pulp inflammation was induced by exposing the maxillary first molars (n = 64) of Wistar rats (n = 32) to the oral environment for two days. The exposed pulps were randomly assigned four groups based on the pulp capping material: rhEPO, MTA, MTA + rhEPO, or an inert membrane. An additional eight rats formed the healthy control group. After four weeks, the animals were euthanized, and histological, qRT-PCR, and spectrophotometric techniques were employed to analyze the left maxillary segments, right first maxillary molars, and blood samples, respectively. Statistical significance was set at p < 0.05 and < 0.001. RESULTS: Pulp capping with rhEPO, MTA, or MTA + rhEPO resulted in lower inflammation and higher mineralization scores compared to untreated control. MTA + rhEPO group exhibited significantly decreased expression of tumor necrosis factor-alpha, and interleukin 1-beta, while MTA group showed substantially reduced expression of interferon-gamma. Both rhEPO and MTA + rhEPO groups presented elevated dentin matrix protein 1 levels compared to untreated control. Furthermore, pulp capping with rhEPO and/or MTA led to increased transforming growth factor-beta 1 expression and reductions of pro-inflammatory/immunoregulatory cytokine ratios and prooxidative markers. Pulp capping with rhEPO also resulted in increase of systemic antioxidative stress markers. CONCLUSION: Capping with rhEPO or MTA + rhEPO resulted in a favorable effect that was similar or even superior to that of MTA.

Selective Removal to Soft Dentine versus Full Pulpotomy for Management of Proximal Deep Carious Lesions: A Randomized Controlled Non-Inferiority Trial.

The management of the deep carious lesion with reversible pulpitis is a dilemma for the dentist. The current study compared selective removal to soft dentine (SRSD) and full pulpotomy (FP) for treating proximal deep carious lesions in teeth with reversible pulpitis. Visual-tactile examination and bitewing radiographs were used to determine the depth of carious lesion, and American Association of Endodontists recommendations were used to formulate pulp diagnosis. Sixty mandibular molar teeth from healthy patients between the ages of 16-35 years and a diagnosis of proximal deep carious lesion with reversible pulpitis were included. Teeth were randomly allocated to two study groups. SRSD group (n = 30): soft dentine was preserved over the pulpal aspect. A hard-setting calcium hydroxide cement liner and resin-modified glass ionomer cement base were applied over the remaining soft carious dentine. FP group (n = 30): complete caries removal followed by mineral trioxide aggregate FP was performed. The teeth in both groups were restored with composite resin restoration. The established criteria for outcome assessment of SRSD and pulpotomy were used. Accordingly, only asymptomatic teeth with no radiological evidence of periapical rarefaction were considered successful at the 12-month follow-up. Two-sample t test, Pearson χ2 test/Fisher's exact test, and percentage agreement were used for statistical evaluation. According to the per-protocol analysis, the success rate of both SRSD and FP treatment was 95.45% and 95.65%, respectively, and the actual difference between the two treatments was 1% (95% CI: [-10, 9]). The data suggests that both treatments (SRSD and FP) appear to have a good success rate (>95%) when used to manage permanent mandibular molar teeth with proximal deep carious lesion and reversible pulpitis. As SRSD is a noninvasive procedure, it should be favored over FP in these instances.

Three-Dimensional Assessment of Radiographic Changes after Indirect Pulp Capping Using Silver Diamine Fluoride with or without Potassium Iodide in Young Permanent Teeth (12-Month RCT).

The aim of this study was to conduct a three-dimensional (3D) evaluation of radiographic changes after indirect pulp capping (IPC) with silver diamine fluoride (SDF) with or without potassium iodide (KI) and resin-modified glass ionomer cement (RMGIC) in deep carious young permanent molars using cone-beam computed tomography (CBCT). 108 first permanent molars with deep occlusal cavitated caries lesions, in forty-nine 6- to 9-year-old children, were randomly allocated to one of 3 groups (n = 36) and treated with SDF+KI, SDF, and RMGIC as IPC materials. CBCT scans were taken at 0 and 12 months to assess tertiary dentin formation (volume and grey level intensity), increase in root length, and pathological changes such as secondary caries, periapical radiolucency, internal resorption, and obliteration of the pulp. The 3D image analysis procedures were performed using ITK-SNAP and 3D Slicer CMF. Comparisons were made using analysis of variance with a fixed effect for treatment and random effects for patient and patient-by-treatment to account for within-patient correlations. A two-sided 5% significance level was used. There were no significant differences among the three groups regarding tertiary dentin volume (p = 0.712) and grey level intensity (p = 0.660), increase in root length (p = 0.365), prevention of secondary caries (p = 0.63), and periapical radiolucency (p = 0.80) in the analysed 69 CBCT scans. The study did not find differences among the groups regarding quality and quantity of tertiary dentin formed, increase in root length, absence of secondary caries, and other signs of failure as shown by CBCT. Clinical Significance: The results show no significant differences in radiographic outcomes (quality and quantity of tertiary dentin formed, increase in root length, absence of secondary caries, and other signs of failure) when using SDF+KI, SDF, and RMGIC in IPC. The results of this study can help guide treatment decision-making regarding use of SDF and SDF+KI as IPC materials in deep cavitated lesions.

Effectiveness of vital pulp treatment in managing nontraumatic pulpitis associated with no or nonspontaneous pain: A systematic review.

BACKGROUND: The exposed pulp has been the topic of numerous studies, but well-designed and well-executed comparative trials on the outcome and treatment of these teeth have been limited. OBJECTIVES: This study was conducted to answer the following questions: in patients with nontraumatic pulpitis associated with no or nonspontaneous pain in permanent teeth, (i) is direct pulp capping or pulpotomy (partial/full) as effective as selective or stepwise caries removal [Population/participants, Intervention(s), Comparator(s)/control, Outcome(s) (PICO) 1], (ii) is pulpotomy (partial/full) as effective as direct pulp capping (PICO 2) and (iii) is pulpotomy (partial/full) as effective as a pulpectomy (PICO 3), in terms of a combination of patient and clinical reported outcomes, with 'tooth survival' as the most critical outcome? METHODS: A literature search was conducted using Clarivate Analytics' Web of Science, Scopus, PubMed and Cochrane Central Register of Controlled Trials from inception to November 3rd 2021. Grey literature and contents of the major subject journals were examined. Eligibility criteria followed the PICO questions. Two independent reviewers performed study selection, data extraction and appraisal; disagreements were resolved by a third reviewer. The risk of bias was assessed by the revised Cochrane risk-of-bias tool for randomized trials. RESULTS: Three randomized clinical trials (RCTs) were included in the review. No study fulfilled the criteria to answer PICO 1. There were no significant differences in the reported outcomes between investigated treatments in all included RCTs. None of the included studies reported the most critical outcome 'tooth survival'. A high loss of patients during the follow-up period was observed. DISCUSSION: Although a few studies fulfilled strict eligible criteria, the results of this systematic review clearly highlight a paucity of available evidence. At the present time, clinical decisions cannot be substantiated by direct comparative trials. CONCLUSIONS: Based on limited evidence, this systematic review discovered no significant differences in effectiveness between compared vital pulp treatments in managing nontraumatic pulpitis associated with no or nonspontaneous pain. Further high-quality RCTs are necessary to investigate the effectiveness of direct pulp capping or pulpotomy (partial/full) compared to selective or stepwise caries removal. REGISTRATION: PROSPERO database (CRD42021259742).

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.

Characterization of nano-hydroxyapatite incorporated carboxymethyl chitosan composite on human dental pulp stem cells.

AIM: To compare the odontogenic differentiation potential of a composite scaffold (CSHA) comprising of nano-hydroxyapatite (nHAp) and carboxymethyl chitosan (CMC) with Biodentine on human dental pulp stem cells (hDPSCs). METHODOLOGY: A CSHA scaffold was prepared through an ultrasonication route by adding nHAp and CMC (1:5 w/w) in water medium followed by freeze-drying. Physicochemical characterization was achieved using scanning electron microscopy with energy-dispersive X-ray spectroscopy, X-ray diffraction and Fourier transform infrared spectroscopy. In-vitro bioactivity and pH assessments were done by soaking in simulated body fluid (SBF) for 28 days. The angiogenic and odontogenic differentiation abilities were assessed by expression of vascular endothelial growth factor (VEGF) and Dentine sialophosphoprotein (DSPP) markers on cultured hDPSCs by flow cytometry and RT-qPCR at 7, 14 and 21 days. Cell viability/proliferation and biomineralization abilities of CSHA were compared with Biodentine by MTT assay, alkaline phosphatase (ALP) activity, Alizarin Red Staining (ARS) and osteopontin (OPN) expression on hDPSCs following 7 and 14 days. Data were statistically analysed with Kruskal Wallis and Friedman tests as well as one way anova followed by appropriate post hoc tests (p < .05). RESULTS: Characterization experiments revealed a porous microstructure of CSHA with pore diameter ranging between 60 and 200 µm and 1.67 Ca/P molar ratio along with the characteristic functional groups of both HAp and CMC. CSHA displayed bioactivity in SBF by forming apatite-like crystals and maintained a consistent pH value of 7.70 during 28 days' in vitro studies. CSHA significantly upregulated VEGF and DSPP levels on hDPSCs on day 21 compared with day 7 (p < .05). Further, CSHA supported cell viability/proliferation over 14 days like Biodentine with no statistical differences (p > .05). However, CSHA exhibited increased ALP and ARS activity with an intense OPN staining compared with Biodentine after 14 days (p < .05). CONCLUSION: The results highlighted the odontogenic differentiation and biomineralization abilities of CSHA on hDPSCs with significant VEGF and DSPP gene upregulations. Further, CSHA exhibited enhanced mineralization activity than Biodentine, as evidenced by increased ALP, ARS and OPN activity on day 14. The nHAp-CMC scaffold has the potential to act as an effective pulp capping agent; however, this needs to be further validated through in-vivo animal studies.