Summary
Throughout lifetime, the teeth are continuously exposed to numerous chemical and physical impacts, which cause the wear of the dental hard tissues, gingival recession and other oral changes ...with sometimes subsequent problems. Age‐related wear of tooth surfaces reduces the dental enamel thickness and exposes deeper layers of enamel, which have different physical and chemical properties than the surface enamel. Gingival recession is the main causal factor of root caries and dentine hypersensitivity. Age‐related changes in dentine include the formation of secondary dentine and the reduction in tubular lumen diameter (dentine sclerosis), which lead to a reduction in the volume of the pulp chamber. In addition to the reduction in the volume of pulp chamber, changes to the dental pulp also include dental pulp calcifications. The age‐related physiological changes to the teeth should be carefully distinguished from pathological changes, especially when they induce pain or a negative impact on the oral health‐related quality of life (OHRQoL) of the older individuals. Therefore, regular oral examinations coupled with early preventive measures should aim at maintaining oral health until old age.
Arjan W. Kleij
Angewandte Chemie International Edition,
April 23, 2018, Letnik:
57, Številka:
18
Journal Article
Recenzirano
“My favorite author (fiction) is Stephen King, simply a genius. My top three films of all time are Pulp Fiction, The Lord of the Rings (trilogy) and The Piano ...” This and more about Arjan W. Kleij ...can be found on page 4832.
Caries prevalence remains high throughout the world, with the burden of disease increasingly affecting older and socially disadvantaged groups in Western cultures. If left untreated, caries will ...advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs even in deep carious lesions. Traditionally, deep caries management was destructive with nonselective (complete) removal of all carious dentine; however, the promotion of minimally invasive biologically based treatment strategies has been advocated for selective (partial) caries removal and a reduced risk of pulp exposure. Selective caries removal strategies can be one‐visit as indirect pulp treatment or two‐visit using a stepwise approach. Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy and the re‐emergence of vital pulp treatment (VPT) techniques such as partial and complete pulpotomy. These changes stem from an improved understanding of the pulp–dentine complex's defensive and reparative response to irritation, with harnessing the release of bioactive dentine matrix components and careful handling of the damaged tissue considered critical. Notably, the development of new pulp capping materials such as mineral trioxide aggregate, which although not an ideal material, has resulted in more predictable treatments from both a histological and a clinical perspective. Unfortunately, the changes in management are only supported by relatively weak evidence with case series, cohort studies and preliminary studies containing low patient numbers forming the bulk of the evidence. As a result, critical questions related to the superiority of one caries removal technique over another, the best pulp capping biomaterial or whether pulp exposure is a negative prognostic factor remain unanswered. There is an urgent need to promote minimally invasive treatment strategies in Operative Dentistry and Endodontology; however, the development of accurate diagnostic tools, evidence‐based management strategies and education in management of the exposed pulp are critical in the future.
It is not known to what extent residual infection may interfere with the success of pulp regeneration procedures. The aim of this study was to determine, radiographically and histologically, the ...effect of residual bacteria on the outcome of pulp regeneration mediated by a tissue-engineered construct as compared with traditional revascularization. Periapical lesions were induced in 24 canine teeth of 6 ferrets. After disinfection with 1.25% NaOCl and triple antibiotic paste, ferret dental pulp stem cells, encapsulated in a hydrogel scaffold, were injected into half the experimental teeth. The other half were treated with the traditional revascularization protocol with a blood clot scaffold. After 3 mo, block sections of the canine teeth were imaged radiographically and processed for histologic and histobacteriologic analyses. Associations between variables of interest were evaluated through mixed effects regression models. There were no significant differences between the 2 experimental groups in radiographic root development (P > 0.05). There was a significant association between the presence of persistent periapical radiolucency and root wall thickness (P = 0.02). There was also no significant difference in histologic findings between the 2 experimental groups (P > 0.05). The presence of residual bacteria was significantly associated with lack of radiographic growth (P < 0.001). The amount of dentin-associated mineralized tissue formed in teeth with residual bacteria was significantly less than in teeth with no residual bacteria (P < 0.001). Residual bacteria have a critical negative effect on the outcome of regenerative endodontic procedures.
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.
Abstract Introduction Biodentine is a new bioactive cement that is similar to the widely used mineral trioxide aggregate (MTA). It has dentin-like mechanical properties, which may be considered a ...suitable material for clinical indications of dentin-pulp complex regeneration such as direct pulp capping. The purpose of the present study was to compare the response of the pulp-dentin complex in human teeth after direct capping with this new tricalcium silicate–based cement with that of MTA. Methods Pulps in 28 caries-free maxillary and mandibular permanent intact human molars scheduled for extraction for orthodontic reasons were mechanically exposed and assigned to 1 of 2 experimental groups, Biodentine or MTA, and 1 control group. Assay of periapical response and clinical examination were performed. After 6 weeks, the teeth were extracted, stained with hematoxylin-eosin, and categorized by using a histologic scoring system. Results The majority of specimens showed complete dentinal bridge formation and an absence of inflammatory pulp response. Layers of well-arranged odontoblast and odontoblast-like cells were found to form tubular dentin under the osteodentin. Statistical analysis showed no significant differences between the Biodentine and MTA experimental groups during the observation period. Conclusions Within the limitations of this study, Biodentine had a similar efficacy in the clinical setting and may be considered an interesting alternative to MTA in pulp-capping treatment during vital pulp therapy.
This practice-based, randomized clinical trial evaluated and compared the success of direct pulp capping in permanent teeth with MTA (mineral trioxide aggregate) or CaOH (calcium hydroxide). ...Thirty-five practices in Northwest PRECEDENT were randomized to perform direct pulp caps with either CaOH (16 practices) or MTA (19 practices). Three hundred seventy-six individuals received a direct pulp cap with CaOH (n = 181) or MTA (n = 195). They were followed for up to 2 yrs at regular recall appointments, or as dictated by tooth symptoms. The primary outcomes were the need for extraction or root canal therapy. Teeth were also evaluated for pulp vitality, and radiographs were taken at the dentist’s discretion. The probability of failure at 24 mos was 31.5% for CaOH vs. 19.7% for MTA (permutation log-rank test, p = .046). This large randomized clinical trial provided confirmatory evidence for a superior performance with MTA as a direct pulp-capping agent as compared with CaOH when evaluated in a practice-based research network for up to 2 yrs (ClinicalTrials.gov NCT00812887).
Mineral trioxide aggregate (MTA) is a bioactive endodontic cement (BEC) mainly comprised of calcium and silicate elements. The cement was introduced by Torabinejad in the 1990s and has been approved ...by the Food and Drug Administration to be used in the United States in 1997. A number of new BECs have also been introduced to the market, including BioAggregate, Biodentine, BioRoot RCS, calcium‐enriched mixture cement, Endo‐CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, NeoMTA Plus, OrthoMTA, Quick‐Set, RetroMTA, Tech Biosealer and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA without its drawbacks. In this article, the chemical composition and the application of MTA and other BECs for vital pulp therapy (VPT), including indirect pulp cap, direct pulp cap, partial pulpotomy, pulpotomy and partial pulpectomy, have been reviewed and compared. Based on selected keywords, all papers regarding chemical composition and VPT applications of BECs had been reviewed. Most of the materials had calcium and silicate in their composition. Instead of referring to the cements based on their chemical compositions, we suggest the term ‘bioactive endodontic cements (BECs)’, which seems more appropriate for these materials because, in spite of differences in their chemical compositions, bioactivity is a common property for all of them. Numerous articles were found regarding use of BECs as VPT agents for indirect and direct pulp capping, partial pulpotomy and cervical pulpotomy. Most of these investigations used MTA for VPT. In most studies, newly introduced materials have been compared to MTA. Some of the BECs have shown promising results; however, the number of their studies compared to investigations on MTA is limited. Most studies had several methodological shortcomings. Future investigations with rigorous methods and materials are needed.
Background/Aim
Complicated crown fractures are relatively common in children where the maintenance of the pulp is especially important in young permanent teeth. The aim of this study was to analyze ...the pulp prognosis of permanent teeth with complicated crown fractures treated with conservative pulp treatment in adolescents.
Material and Methods
Complete dental records of teeth with complicated crown fractures treated with conservative pulp treatment were obtained. The risk of pulp necrosis and infection was evaluated by the Kaplan‐Meier method and Cox regression (P<.05). Risk factors included gender, age, time interval between dental injury and treatment, stage of root development, type of pulp treatment, and coronal restoration.
Results
The study involved 375 teeth treated with direct pulp capping, partial or coronal pulpotomy, and direct pulp capping retreated by pulpotomy (partial or coronal). The frequency of pulp necrosis and infection was 10.1% (11/109) for partial pulpotomy and 9.8% (22/205) for coronal pulpotomy. There was no difference between partial and coronal pulpotomy (P=.673). The risk of pulp necrosis and infection was not significantly different between pulpotomy (partial and coronal; 33/314, 10.5%) and retreatment by pulpotomy (partial or coronal) after direct pulp capping (2/33, 6.1%; P=.436). However, the frequency of pulp necrosis and infection after direct pulp capping (16/28, 57.1%) was significantly higher than that with pulpotomy (partial or coronal; odds ratio=8.216, P<.001). The time interval between dental injury and treatment did not significantly influence pulp survival after pulpotomy (partial or coronal; P=.312), but the stage of root development had a significant impact (P<.001).
Conclusions
Partial or coronal pulpotomy, employed either as a primary pulp treatment or secondary to emergency pulp capping, had similarly satisfactory pulp survival rates.
Experiments have previously demonstrated the therapeutic potential of mobilized dental pulp stem cells (MDPSCs) for complete pulp regeneration. The aim of the present pilot clinical study is to ...assess the safety, potential efficacy, and feasibility of autologous transplantation of MDPSCs in pulpectomized teeth.
Five patients with irreversible pulpitis were enrolled and monitored for up to 24 weeks following MDPSC transplantation. The MDPSCs were isolated from discarded teeth and expanded based on good manufacturing practice (GMP). The quality of the MDPSCs at passages 9 or 10 was ascertained by karyotype analyses. The MDPSCs were transplanted with granulocyte colony-stimulating factor (G-CSF) in atelocollagen into pulpectomized teeth.
The clinical and laboratory evaluations demonstrated no adverse events or toxicity. The electric pulp test (EPT) of the pulp at 4 weeks demonstrated a robust positive response. The signal intensity of magnetic resonance imaging (MRI) of the regenerated tissue in the root canal after 24 weeks was similar to that of normal dental pulp in the untreated control. Finally, cone beam computed tomography demonstrated functional dentin formation in three of the five patients.
Human MDPSCs are safe and efficacious for complete pulp regeneration in humans in this pilot clinical study.
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