Conservative Management of Mature Permanent Teeth with Carious Pulp Exposure.

Vital pulp therapy (VPT) in mature permanent teeth with carious pulp exposure has been a matter of debate, with root canal therapy being the conventional standard of care. Previously reported negative outcomes for VPT in these teeth were based on data from studies that have used calcium hydroxide in direct pulp capping and partial and full pulpotomy. The introduction of hydraulic calcium silicate-based materials with sealing and bioactive potentials have opened a new era in VPT with more favorable results. Understanding the histopathology and histobacteriology of the cariously exposed pulp and the healing potential of the inflamed pulp could guide the decision-making process toward an ultraconservative management of these teeth. However, proper case selection, strict aseptic condition, capping material, and good coronal seal are crucial for long-term success.

Restoration of the Root-Filled Tooth.

Root-filled teeth are weakened by loss of strategic tooth structure through restorative procedures and caries, rather than by the endodontic procedures. Therefore, prompt restoration is required to minimise coronal leakage and the risk of tooth fracture. However, restorability should be confirmed before root canal treatment begins, by removing caries and existing restoration to evaluate the residual tooth structure. Based on the remaining tooth structure, the restoration is planned to maximise the longevity of root-filled teeth as a functional unit. This review considers risk factors for survival of root-filled teeth and principles of restoration, rather than detailed techniques, including direct and indirect restorations.

Thin and thick layers of resin-based sealer cement bonded to root dentine compared: Adhesive behaviour.

This study aims to evaluate tensile and shear bond strengths of one epoxy (AH) and two methacrylate resin-based sealers (EZ and RS) in thin and thick layers bonded to root dentine. An alignment device was prepared for accurate positioning of 20 root dentine cylinders in a predefined gap of 0.1 or 1 mm. Sealer was placed in the interface. Bond strength tests were conducted. Mode of failures and representative surfaces were evaluated. Data were analysed using anova and post-hoc tests, with P < 0.05. The thick layer of sealer produced higher bond strength, except for the shear bond strength of EZ. Significant differences between thin and thick layers were found only in tensile bond strengths of AH and RS. Mixed type of failure was constantly found with all sealers. Bond strengths of thick layers of resin-based sealers to root dentine tended to be higher than with thin layers.

Critical evaluation of the push-out test for root canal filling materials.

INTRODUCTION: The push-out test has been widely used in experimental endodontics but has been criticized on technical grounds particularly because the soft-core material undergoes plastic deformation under load. This study systematically evaluated the technique by comparing push-out strength and load profiles in relation to core material stiffness, canal diameter, punch diameter, sample orientation, and mode of failure. METHODS: Straight palatal roots of 90 maxillary molars were obturated with an epoxy resin-based sealer alone (10 roots) or gutta-percha (70) or epoxy resin (10) cores with a thin layer of sealer cement. Roots were embedded in mounting resin vertically or at an angle of 5° or 10° to the long axis of the root. One-millimeter sections were tested using a universal testing machine with a punch diameter corresponding to 50%, 75%, or 90% of the canal diameter. Bond strengths (MPa) were calculated, and data were analyzed using analysis of variance with post hoc Tukey multiple comparisons (P < .05). After push out, core materials and canal walls were examined using scanning electron microscopy. RESULTS: Push-out strength was affected by core material stiffness. Angulation up to 10° from vertical had little effect on push-out strength, but load profiles were strongly influenced by orientation. No effect of the punch diameter was observed when the diameter was 90% of the canal diameter, but push-out strength was lower when the punch diameter was 50%-60% of the canal size. CONCLUSIONS: Despite limitations, the push-out test may still be suitable for ranking the bonding of root filling materials.

Revascularization and tissue regeneration of an empty root canal space is enhanced by a direct blood supply and stem cells.

BACKGROUND: Regenerative endodontics is an innovative treatment concept aiming to regenerate pulp, dentin and root structures. In the diseased or necrotic tooth, the limitation in vascular supply renders successful tissue regeneration/generation in a whole tooth challenging. The aim of this study is to evaluate the ability of vascularized tissue to develop within a pulpless tooth using tissue engineering techniques. MATERIALS AND METHODS: A pulpless tooth chamber, filled with collagen I gel containing isolated rat dental pulp cells (DPC) and angiogenic growth factors, was placed into a hole created in the femoral cortex or into its own tooth socket, respectively. The gross, histological and biochemical characteristics of the de novo tissue were evaluated at 4 and 8 weeks post-transplantation. RESULTS: Tooth revascularization and tissue generation was observed only in the femur group, confirming the important role of vascular supply in tissue regeneration. The addition of cells and growth factors significantly promoted connective tissue production in the tooth chamber. CONCLUSION: Successful revascularization and tissue regeneration in this model demonstrate the importance of a direct vascular supply and the advantages of a stem cell approach.

Behavior of resin-based endodontic sealer cements in thin and thick films.

OBJECTIVES: For root canal fillings, a thin layer of sealer cement is generally recommended. However, with resin-based sealers, lower bond strength to dentin has been shown in thin layers compared to thick, contrary to typical behavior of adhesive layers between two adherents. The aim of this study was to evaluate tensile and shear bond strength of thin and thick films of three resin-based sealers (one epoxy-based and two methacrylate-based) materials and to investigate corner effects of one methacrylate-based resin sealer. METHODS: Freshly mixed sealer cements were placed between metal-to-metal surfaces of plano-parallel stainless steel aligned rods with diameter 4.7 mm. Ten samples were prepared for each type, thickness (0.1 and 1.0 mm) of sealer and test. Tensile and shear strengths were measured after 48 h for the methacrylate-based materials and after 7 days for the epoxy-based material using a universal testing machine at a crosshead speed of 1mm/min. Corner effects were investigated using one methacrylate-based resin material. RESULTS: Film thickness had a highly significant influence on both tensile and shear strengths. For methacrylate resin-based sealers, thin films had higher bond strength than thick (p<0.001 for both tensile and shear bond strength). With the epoxy-based sealer either no difference (shear) or lower bond strength in thin films (tensile; p<0.05) was found, and appeared to result from numerous voids created during mixing. The methacrylate based sealer demonstrated typical engineering behavior for an adhesive material, with corner effects shown as a material property and in good agreement with the tensile bond strength results. SIGNIFICANCE: The higher tensile and shear bond strength of resin-based sealer in thin films is the opposite of that previously reported for bonding to dentin. The substrate clearly has an important role in failure behavior.

Incidence and impact of painful exacerbations in a cohort with post-treatment persistent endodontic lesions.

INTRODUCTION: Painful exacerbations of persistent periapical lesions have unknown incidence and impact on quality of life. This study examined the incidence and impact of painful exacerbations and evaluated potential predictive factors of pain associated with root-filled teeth with persistent lesions after root canal treatment. METHODS: Patients from a university hospital clinic were screened to identify root-filled teeth with periapical lesions at time of treatment and not resolved at least 4 years later. A clinical and radiographic examination and questionnaire survey were conducted. Patient and treatment characteristics and details of pain experience were studied. Statistical analysis was carried out by using SPSS (version 18). RESULTS: One hundred twenty-seven patients with 185 persistent lesions were recruited. Median age of patients at recruitment was 56 years (range, 21-82 years). Median time since treatment was 5 years (range, 4-38 years). Overall incidence of flare-up (requiring an unscheduled dental visit) was only 5.8% 20 years after treatment. Less severe pain was more frequent, with a combined incidence of 45% pain at 20 years after treatment. Female patients (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.2-6.0; P < .05), treatment involving a mandibular molar or maxillary premolar (OR, 3.7; 95% CI, 1.6-8.6; P < .05), and preoperative pain (OR, 2.9; 95% CI, 1.3-6.7; P < .05) were significantly associated with pain after treatment. The most commonly affected activities during painful exacerbations were eating and tooth brushing, with minimal impact on daily living. CONCLUSIONS: The risk of flare-up among persistent lesions was very low. A lower degree of pain was more common, but generally with minimal impact on daily activities.

The incorporation of casein phosphopeptide-amorphous calcium phosphate into a glass ionomer cement.

OBJECTIVES: The aim of this study was to measure the effect of incorporating CPP-ACP into an autocure GIC on physical and mechanical properties, ion release and enamel demineralization inhibition. METHODS: Physical and mechanical properties were evaluated using tests specified by the International Organization for Standardization (ISO). Concentrations of fluoride, calcium and inorganic phosphate in deionized water (pH 6.9) and lactic acid (pH 4.8) were measured up to five months. Cavities on human extracted molars were prepared, restored with GIC (control), CPP-ACP modified GIC or resin composite, then stored in 50mM lactic acid solution at pH 4.8 for 4 days. Sections of demineralized enamel were examined using polarized light microscopy followed by lesion area measurement. RESULTS: The incorporation of up to 5% CPP-ACP into Fuji VII decreased the cements' strength and prolonged setting time. However, values remained within ISO limits. The incorporation of 3 or 5% CPP-ACP significantly decreased fluoride release, while higher calcium and inorganic phosphate release occurred. The demineralized enamel area adjacent to GIC with 3 or 5% CPP-ACP was significantly smaller compared to GIC control. SIGNIFICANCE: The incorporation of 3% CPP-ACP into GIC has the potential to improve its anticariogenic ability without adversely affecting its mechanical properties.

Effect of hydration on the strain gradients in dental hard tissues after heat and cold application.

INTRODUCTION: This study was aimed to investigate the thermal strain gradients on dental hard tissues to localized heat and cold applications, applied to assess the vitality of pulp. The role of hydration on the thermal strain distribution within the enamel, dentin, and dentino-enamel junction (DEJ) was examined by using a digital moiré interferometry. METHODS: Extracted bovine incisors were prepared, and high-frequency diffraction gratings were replicated on one surface. Heat (120°C-140°C) and cold (-50°C) stimuli were applied on the external surface, and the strain patterns were recorded and analyzed for the first 3 seconds. The specimens were tested under fully hydrated and partially dehydrated conditions (72 hours at 24°C, 60% relative humidity). RESULTS: Distinct thermal strain gradient was observed in the enamel, dentin, and DEJ after the application of heat and cold stimuli. Application of both heat and cold resulted in significantly higher strains in the partially dehydrated teeth than in the fully hydrated teeth (P < .05). There was only a marginal increase in strains at the location of application of stimuli in hydrated teeth. The DEJ in both the fully hydrated and partially dehydrated teeth showed the highest strains. CONCLUSIONS: There was a marked difference in the thermal strain gradients within dental hard tissues after the application of heat/cold stimuli, depending on the level of tissue hydration. The findings from this study highlighted the role of free water and structural characteristics of enamel, dentin, and DEJ in dissipating the thermal strains in the tooth.

Impact of a retained instrument on treatment outcome: a systematic review and meta-analysis.

INTRODUCTION: Fracture of root canal instruments is one of the most troublesome incidents in endodontic therapy. This systematic review and meta-analysis aim to determine the outcome difference between retained fractured instrument cases and matched conventional treated cases. METHODS: The MEDLINE database, EMBASE, Web of Science, and the Cochrane Database were searched. Reference lists were scanned. A forward search was undertaken on identified articles. Papers citing these articles were identified through Science Citation Index to identify potentially relevant subsequent primary research. A systematic data extraction sheet was constructed. Data in these studies were independently extracted. Risk differences of included studies were combined by using the generic inverse variance data and fixed effects method. A 2-stage analysis was conducted. The first was limited to case-control studies, and the second included case series in which data were available for teeth with and without periradicular lesions. RESULTS: Two case-control studies were identified and included, covering 199 cases. Weighted mean healing for teeth with a retained instrument fragment was 91%. The 2 studies were homogeneous. Risk difference of the combined data was 0.01, indicating that a retained fragment did not significantly influence healing. Overall, 80.7% of lesions healed when a periapical lesion was present, compared with 92.4% remaining healthy when no lesion was present initially (P < .02). CONCLUSIONS: On the basis of the current best available evidence, the prognosis for endodontic treatment when a fractured instrument fragment is left within a root canal is not significantly reduced.

Comparison of three techniques for preparing oval-shaped root canals.

INTRODUCTION: This study compared three techniques for preparing oval-shaped root canals: Anatomic Endodontic Technology (AET), hand instruments (Hedström files; Dentsply Maillefer, Ballaigues, Switzerland), and rotary nickel-titanium (EndoWave; Morita, Osaka, Japan) instruments with regard to cleaning ability and final canal shape. METHODS: Three groups each of 13 extracted human mandibular premolars with oval-shaped canals were used. After canal preparation, teeth were sectioned at three levels (coronal, middle, and apical), photographed to assess cross-sectional canal shape, and processed for histologic evaluation of canal wall planing and the presence of debris. RESULTS: None of the techniques resulted in completely prepared and cleaned canals. No significant difference was found among the three techniques with regard to untouched surface, cross-sectional area, remaining fins, and canal shape at the three levels. Rotary NiTi instruments resulted in significantly less debris in the apical third compared with AET and hand instrumentation. CONCLUSIONS: AET did not perform better than rotary NiTi or hand instruments in oval-shaped canals.

Effect of glass-ionomer cement lining on postoperative sensitivity in occlusal cavities restored with resin composite--a randomized clinical trial.

This study investigated the ability of a glass-ionomer cement (GIC) lining to reduce postoperative sensitivity in occlusal cavities restored with resin composite. In addition, the effects of a total-etch and self-etch adhesive on postoperative sensitivity were also compared. Patients who had moderate to deep occlusal caries of at least one molar were recruited. Overall, 103 restorations were placed in 70 participants, with an average age of 22.8 +/- 3.8 years. Preoperatively, each tooth was evaluated for cold-stimulated tooth sensitivity using a visual analog scale. If present, tooth sensitivity induced by cold/hot drinks or occlusal function was also noted. Caries was stained with a caries detector dye, then removed using slow-speed burs and hand excavators. The cavity was restored with one of four randomly allocated restorative procedures: 1) bonded with a two-step, total-etch adhesive (Single Bond 2); 2) lined with a resin-modified GIC liner (Fuji Lining LC), then bonded with total-etch adhesive; 3) bonded with a two-step, self-etch adhesive (Clearfil SE Bond) and 4) lined with the GIC liner, then bonded with self-etch adhesive. The cavities were incrementally filled with a nanofilled hybrid resin composite. At recall, postoperative sensitivity was evaluated at one week and one month. Overall, postoperative sensitivity in daily function was rare. No significant difference in postoperative sensitivity, either in daily function or in response to a cold stimulus, was observed between the restorative procedures with or without the GIC liner, regardless of the adhesive used (p > 0.05). In addition, no difference in postoperative sensitivity was noted between use of the self-etch and total-etch adhesive.

A comparison of techniques for obturating oval-shaped root canals.

This study compared the effectiveness of three obturation techniques for oval-shaped canals. Roots of 42 extracted teeth with oval canals were randomly divided into three groups: (1) ProTaper canal preparation and single cone obturation with matching gutta-percha point; (2) ProTaper preparation plus thermoplastic obturation (Thermafil); (3) Profile .06 taper and matching master cone with lateral condensation. Cross-sectional area of the canal space occupied by sealer cement and gutta-percha was measured in the coronal, middle, and apical thirds using an image analysis software. The percentage of the cross-sectional shape occupied by sealer cement was calculated. The Thermafil group was significantly lower than the single cone group or the lateral condensation group in the middle third (p<0.01) and lower than the single cone group in the coronal third (p<0.05). There were no significant differences between the single cone obturation group and the lateral condensation group in each level.

Fluid flow after resin-composite restoration in extracted carious teeth.

The aim of this study was to investigate fluid flow in dentin after restoration of carious teeth with resin composite bonded with a total-etching adhesive, with or without glass-ionomer cement lining. The roots of extracted third molars were removed and the crowns were connected to a fluid flow-measuring device. Each carious lesion was stained with caries detector dye and caries was removed using slow-speed burs and spoon excavators. Caries-excavated teeth were divided into two groups for restoration with resin composite bonded with a total-etch adhesive: (i) without lining; and (ii) lined with glass-ionomer cement before bonding. In non-carious teeth, cavities of similar dimensions were prepared, divided into two groups, and restored in the same manner. Fluid flow was recorded, after restoration, for up to 1 month. Caries-affected dentin was examined by scanning electron microscopy (SEM), and the bonded interfaces were observed using a confocal laser scanning microscope. No significant difference in fluid flow was observed between the two restorative procedures or between the carious and non-carious groups. The SEM images showed that the dentinal tubules of acid-etched, caries-affected dentin were usually still occluded, while some were patent. Limited penetration of fluorescent dye into dentin and into the bonded interfaces of restored carious teeth was observed.

Effect of dentinal tubules and resin-based endodontic sealers on fracture properties of root dentin.

OBJECTIVE: To investigate the role of dentinal tubules in the fracture properties of human root dentin and whether resin-filled dentinal tubules can enhance fracture resistance. MATERIALS AND METHODS: Crack propagation in human root dentin was investigated in 200 microm thick longitudinal samples and examined by light and scanning electron microscopy. 30 maxillary premolar teeth were prepared for work of fracture (Wf) test at different tubule orientations, one perpendicular and two parallel to dentinal tubules. Another 40 single canal premolars were randomly divided into four groups of 10 each: intact dentin, prepared but unobturated canal, canal obturated with epoxy rein (AH Plus/gutta percha), or with UDMA resin sealer (Resilon/RealSeal. The samples were prepared for Wf test parallel to dentinal tubules. Wf was compared under ANOVA with statistical significance set at p<0.05. RESULTS: Dentinal tubules influenced the path of cracks through dentin, with micro-cracks initiated in peritubular dentin of individual tubules ahead of the main crack tip. A significant difference (p<0.001) was found between Wf perpendicular to tubule direction (254.9 J/m(2)) vs. parallel to tubule direction from inner to outer dentin (479.4 J/m(2)). Neither canal preparation nor obturation using epoxy- or UDMA-based resins as sealer cements substantially influenced fracture properties of root dentin, despite extensive infiltration of dentinal tubules by both sealer cements.

Cuspal deflection, strain and microleakage of endodontically treated premolar teeth restored with direct resin composites.

OBJECTIVES: To measure cuspal deflection and tooth strain, plus marginal leakage and gap formation caused by polymerization shrinkage during direct resin composite restoration of root-filled premolars. METHODS: Thirty-two first and second maxillary premolars were divided into four groups (n=8). Group 1 had standardised mesio-occlusal-distal (MOD) cavities and served as the control group. Group 2 had endodontic access and root canal treatment through the occlusal floor of the MOD cavity, leaving the axial dentine intact. Group 3 had endodontic access and root canal treatment with the mesial and distal axial dentine removed. Group 4 had endodontic access and root canal treatment with axial dentine removed and a glass ionomer base (GIC). All groups were restored incrementally using a low shrink resin composite. Cuspal deflection was measured using direct current differential transformers (DCDTs), and buccal and palatal strain was measured using strain gauges. Teeth were immersed in 2% methylene blue for 24h, sectioned and scored for leakage and gap formation under light and scanning electron microscopy. RESULTS: Total cuspal deflection was 4.9+/-1.3 microm for the MOD cavity (group 1), 7.8+/-3.3 microm for endodontic access with intact axial dentine (group 2), 12.2+/-2.6 microm for endodontic access without axial dentine (group 3), and 11.1+/-3.8 microm for endodontic access with a GIC base (group 4). Maximum buccal strain was 134+/-56, 139+/-61, 251+/-125, and 183+/-63 mustrain for groups 1-4 respectively, while the maximum palatal strain was 256+/-215, 184+/-149, 561+/-123, 264+/-87 mustrain respectively. All groups showed marginal leakage; however placement of GIC base significantly improved the seal (p=0.007). CONCLUSION: Cusp deflection and strain increased significantly when axial dentine was removed as part of the endodontic access. Placement of a glass ionomer base significantly reduced tooth strain and marginal leakage. Therefore, a conservative endodontic access and placement of a glass ionomer base are recommended if endodontically treated teeth undergo direct restoration with resin composite.

Intracanal bisphosphonate does not inhibit replacement resorption associated with delayed replantation of monkey incisors.

Progressive replacement resorption following delayed replantation of avulsed teeth has proved to be an intractable clinical problem. A wide variety of therapeutic approaches have failed to result in the predictable arrest of resorption, with a good long-term prognosis for tooth survival. Bisphosphonates are used in the medical management of a range of bone disorders and topically applied bisphosphonate has been reported to inhibit root resorption in dogs. This study evaluated the effectiveness of a bisphosphonate (etidronate disodium) as an intracanal medicament in the root canals of avulsed monkey teeth, placed before replantation after 1 h of extraoral dry storage. Incisors of six Macaca fascicularis monkeys were extracted and stored dry for 1 h. Teeth were then replanted after canal contamination with dental plaque (negative control) or after root canal debridement and placement of etidronate sealed in the canal space. A positive control of calcium hydroxide placed 8-9 days after replantation was also included. All monkeys were sacrificed 8 weeks later and block sections were prepared for histomorphometric assessment of root resorption and periodontal ligament status. Untreated teeth showed the greatest extent of root resorption (46% of the root surface), which was predominantly inflammatory in nature. Calcium hydroxide treated teeth showed the lowest overall level of resorption (<30% of the root surface), while the bisphosphonate-treated group was intermediate (39%). Ankylosis, defined as the extent of the root surface demonstrating direct bony union to both intact and resorbed root surface, was the lowest in the untreated control group (15% of the root surface), intermediate in the calcium hydroxide group (27%) and the highest in the bisphosphonate group (41%). Bony attachment to the tooth root was divided approximately equally between attachment to intact cementum and to previously resorbed dentin. Overall, bisphosphonate resulted in a worse outcome than calcium hydroxide in terms of both root resorption and ankylosis.

Bonding of resin-based sealers to root dentin.

This study compared the microshear bond strength of three resin-based sealers to root dentin and assessed whether sealer cements behave differently in thin and thick films. Extracted maxillary premolars were sectioned buccolingually, and 45 root halves were randomly allocated for microshear bond testing with the three resin sealers in thin and thick films. The microshear bond strength was then calculated in MPa. Failure modes were examined under light and scanning electron microscopy. Data were analyzed by using analysis of variance, with significance set at p < 0.05. Overall, the epoxy resin-based sealers had the highest microshear bond strength to root dentin compared with urethane dimethacrylate-based sealers (p < 0.001). Bond strengths for the thick sealer group were significantly higher than the thin sealer group (p < 0.001) and may reflect different patterns of behavior when the sealer is present as a thin layer.

Sealing ability of occlusal resin composite restoration using four restorative procedures.

The purpose of this work was to investigate fluid flow after restoration using four restorative procedures. Micro-gap, internal dye leakage, and micropermeability of bonded interfaces were also investigated. Each tooth was mounted, connected to a fluid flow-measuring device, and an occlusal cavity was prepared. Fluid flow after cavity preparation was recorded as the baseline measurement, and the cavity was restored using one of four restorative procedures: bonding with total-etch (Single Bond 2) or self-etch (Clearfil SE Bond) adhesives without lining; or lining with resin-modified glass-ionomer cement (GIC) (Fuji Lining LC) or conventional GIC (Fuji IX) and then bonding with the total-etch adhesive. Fluid flow was recorded after restoration and at specific time-points up to 6 months thereafter and recorded as a percentage. Micro-gap formation was analyzed using resin replicas and scanning electron microscopy. Internal leakage of 2% methylene blue dye was observed under a light microscope. In micro-permeability testing, fluorescent-dye penetration was investigated using confocal laser microscopy. None of the restorative procedures provided a perfectly sealed restoration. Glass-ionomer lining did not reduce fluid flow after restoration, and micro-gaps were frequently detected. The self-etch adhesive failed to provide a better seal than the total-etch adhesive, and even initial gap formation was rarely observed for the former. Penetration of methylene blue and fluorescent dyes was detected in most restorations.