The ability of ethylenediaminetetraacetic acid (EDTA) (Graham et al. 2010, 2017). 2000), new biomaterials, techniques and understanding of pulpal repair mechanisms have improved the outcome of symptomatic exposures treated with pulp capping (Marques et al. ), visual–tactile examination, appropriate radiographs and other tools such as caries dyes, fibre‐optic/fluorescent light and electrical conductance/impedance metres. It was demonstrated that in the teeth that were clinically diagnosed as either a normal pulp or with reversible pulpitis, only two out of the 59 teeth studied had histological signs of irreversible inflammation. Experimental (stepwise): 60% success. Coronal pulp removed and rinsed with sterile saline for 2 min (haemorrhage control). Clearly, endodontists have the expertise on aseptic strategies, fundamental to optimal maintenance of pulp vitality. For many years, it was thought that the quality of the seal alone determined the success of the procedure (Bergenholtz et al. 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. Notably, the majority of dentists adopt an invasive approach choosing either a VPT or a pulpectomy (Oen et al. Pulp exposure can be avoided in radiographically deep caries and asymptomatic or mildly symptomatic teeth by selective removal of caries and restoration in one or two visits. 2008, Shin et al. 2011). A prerequisite for a successful outcome following pulp capping is control of bleeding and the avoidance of blood clot formation between the capping material and the pulp tissue. 2012). 2013, Smith et al. This concept is based on histological research observation that in cases of irreversible pulpitis the inflammation is confined to the coronal pulp and the tissue in the roots is largely free of inflammatory disease (Ricucci et al. 2015) with short‐term follow‐up and low numbers of patients. An overview comparing different biological methods for caries excavation of deep dentin caries in primary teeth, such as partial or stepwise excavation shows that they work as well as traditional methods performing complete caries excavation but have the benefits of reducing the risk of iatrogenic pulp damage [1-4]. The task of choosing identical outcome measures: For example, a reliable comparison between coronal pulpotomy and direct pulp capping may be a difficult task, as a reliable pulp sensibility test cannot be performed for the pulpotomy intervention arm. Biodentine has potential to overcome some of the issues of discoloration associated with MTA after pulp capping (Parinyaprom et al. Based on appearance, an actively progressing carious dentine lesion tends to have a light yellow/beige colour, the surface texture is wet/moist, and it is easy to disintegrate/penetrate the soft organic matrix with a dental probe. Indeed, inflammation marks the first step of tissue convalescence. Management of dental caries includes identification of an individual’s risk for caries progression, understanding of the disease process for that individual, and active surveillance to assess disease progression and manage with appropriate preventive services, supplemented by … Selected matrix metalloproteinases (MMPs), a family of tissue proteases, contained with the DMCs will propagate the breakdown of dentine matrix (Mazzoni et al. If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs … 2013, Taha et al. In VPT, however, EDTA irrigation (although releasing DMCs) may stimulate renewed pulpal bleeding. 2013), ultrasonic agitation (Widbiller et al. 2013). 2017). From a histological viewpoint, pulp exposure healing should be described as formation of a continuous hard tissue barrier over the exposure and a residual pulp free of inflammation (Schröder 1973). Is it worth it? The volume of literature investigating the outcome of coronal pulpotomy has increased recently, but is still limited to case reports or case series (Kunert et al. In particular, it is not possible to distinguish the delicate broader between infected and affected dentine both being discoloured and demineralized, which also explains the recently suggested simplified terminology on removal of carious tissue (see later). Pulp capping does not involve any pulp tissue removal; instead, the biomaterial is placed in direct contact with the pulp tissue (ESE 2006). (g) Three months post‐operatively, a sinus tract and apical periodontitis are noted. 2005, Karapanou et al. Significant difference, Nested pulp capping trial at 5 years: Experimental (partial pulpotomy): 11% success. Available evidence (pre‐2014) has been used to simulated scenarios for establishing a cost‐effectiveness analysis (Schwendicke & Stolpe 2014). 1996). Controlled clinical trials and cohort studies involving patients with dental caries in permanent teeth were included. (g) Three months post‐operatively, a sinus tract and apical periodontitis are noted. Moving forward, treatment variation needs to be reduced, and therapeutic solutions should be cohesive and biologically based on a clear definition of a deep lesion as well as sound clinical evidence. Pulp and dentine responses to selective caries excavation: A histological and histobacteriological human study. 1997, Smith 2003, Grando Mattuella et al. 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. 2017); however, at present biomarkers are not specific enough to predictably dictate treatment (Zehnder et al. In the clinic, pulpitis is classified as either reversible or irreversible. 1990, Machado et al. In clinical practice, the decision on whether to maintain the pulp or not also varies (Stangvaltaite et al. Capping mat: ProRoot MTA (control) n = 23; versus Endocem n = 23, Stratification variable: Age and exposure site (occlusal or axial). However, current evidence regarding the success, as defined by not requiring any retreatments, or survival of teeth after different excavations is insufficient for definitive recommendation, especially when treating deciduous teeth. Direct pulp capping was most cost‐effective in younger patients (<40 years) in occlusal sites (Fig. At present, no high level, scientific‐based recommendation can be made for selecting a ‘gold standard’ capping material (Schwendicke et al. A life cycle assessment (LCA) of a root canal treatment procedure. 20172017). 1963a,b, Dummer et al. 2016), and SCs migrating from outside the tooth (Feng et al. Notably, as the external bacterial stimuli moves towards the pulp, the inflammatory response continues to intensify (Mjör & Tronstad 1972, Bjørndal & Ricucci 2016); however, pulp has an innate ability to heal if the challenge is removed and the tooth is suitably restored (Mjör & Tronstad 1974, Cooper & Smith 2016). 2011, Elsalhy et al. 2017, Qudeimat et al. Chlorhexidine digluconate solution (2%) has been suggested as an alternative to NaOCl (Mente et al. This systematic review assesses the effect of methods commonly used to manage the pulp in cases of deep caries lesions, and the extent the pulp chamber remains uninfected and does not cause pulpal or periapical inflammatory lesions and associated tooth-ache over time. Once Americans reach the age of 75, 99% will have had dental caries. This systematic review assesses the effect of methods commonly used to manage the pulp in cases of deep caries lesions, and the extent the pulp chamber remains uninfected and does not cause pulpal or periapical inflammatory lesions and associated tooth-ache over time. Alternatively, some dental practitioners may prefer pulpectomy to VPT, because it is more predictable in their hands (i.e. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention of root caries: a literature review of primary and secondary preventive agents. As enamel is a microporous solid, the carious process and response of the dentine–pulp complex can frequently start before it is breached (Brännström & Lind 1965, Bjørndal et al. The application of this treatment on mature teeth of adults is preliminary and remains under investigation, but numerous published case series suggest it may have promising long‐term outcomes (Simon et al. 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. Pulp chamber pulpotomy is routinely used in Paediatric Dentistry to preserve the radicular pulp on immature teeth to allow the radicular process to grow and apexogenesis to occur. 2008;42(3):164–70. Clinically, a focus on high‐quality primary research investigating the efficacy of management strategies for the treatment of deep caries is a priority. Classification for deeper stages of caries. Numerous studies have shown a strong positive correlation between mutans streptococci, lactobacilli and bifidobacteria and the initiation of demineralization of the tooth surface (Marsh 2012). Conservative Management of Mature Permanent Teeth with Carious Pulp Exposure. 2006, Galler et al. This could potentially indicate that the simple examination of lesion depths on bitewing radiographs is an opportunity to introduce a diagnostic tool for evaluating the risk of bacterial invasion into the pulp. 2014), including the concept of sealing the entire carious lesion with a stainless‐steel crown in the Hall Technique (Innes et al. Unfortunately, at present from a patient perspective, the critical factor in the treatment chosen by the dentist is whether the operator is pulp ‘friendly’ or not. 2016); suffice to say that it is clear that both are likely to contribute significantly in a complimentary and possibly symbiotic manner to the overall repair process. Axial exposure site (class V cavity) showed significantly poorer outcome, Deep caries with a potential risk of exposure (lesion depth not defined, no widening of PDL or periapical (PA) – or furcal lesion), Randomization: No concealed allocation sequence, Capping mat: ProRoot MTA (control) n = 47 versus OrthoMTA n = 47 and RetroMTA n = 48, Success: Positive response to pulp test. The MTA is not packed into the pulpal cavity, but instead lightly tapped into contact with the pulp and dentine wall using a ‘thick paper’ point or cotton pledget. The release of DMCs by pulp capping materials boosts chemotaxis, angiogenesis (Zhang et al. 2004, Chhour et al. Although the bulk of attention has focused on the role of odontoblast (Simon et al. Case courtesy of Dr Phu Le. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. NaOCl is generally the disinfectant of choice, but has drawbacks as it is corrosive due to its organic tissue dissolution ability (Hewlett & Cox 2003, Sauro et al. A more accurate impression of the extent of a lesion can be given on a cone‐beam computed tomograph (CBCT); however, this has limitations such as the higher dose, image distortion due to the presence of radiopaque restorations, cost and availability. Bioceramic Materials in Clinical Endodontics. increasing carious involvement of dentine, pulp exposure) causes death of the primary odontoblast, which are subsequently replaced following differentiation of progenitor cells into odontoblast‐like cells under the regulation of bioactive molecules, including dentine matrix components (DMCs) release from the dentine matrix. 2006), dental resins (Ferracane et al. The prefix class II indicates that an altered treatment protocol is required, because a severe microbial challenge is expected. 2013). 2011, Zehnder et al. Pulpotomy: 31 teeth with deep caries indicated for pulpotomy: Green E 1989 18: Cohort (1.5 y) 40 wt% AgF followed by 10 wt% SnF 2 single application: 1300 teeth: The combined treatment had a significantly lower incidence of caries for primary teeth compared with SnF 2 alone: Caries arresting: 10 wt% SnF 2 alone single application: 1563 teeth Whilst pulpectomy usually takes 1 or 2 years to fail, by contrast, VPT usually fails within months as a result of severe pain (Bjørndal et al. Due to the lack of evidence to determine the best treatment for deep cavitated caries lesions in primary molars, the search for an effective restorative technique, which results in a minimal discomfort to patients, and reduce the time needed for the treatment, becomes relevant. In the preoperative presence of a deep or extremely deep carious lesion (Bjørndal 2018), the pulp exposure judged clinically to be through a zone of bacterial contamination with an expectation that the underlying pulp tissue is inflamed. 3). 1 Once Americans reach the age of 75, 99% will have had dental caries. In conclusion, both direct pulp capping and RCT were cost‐effective. 2015). In order to develop the most appropriate treatment strategy for the patient, the clinician will assimilate information from the patient's history (symptomology, diet, oral hygiene regime, etc. While the latter involves incomplete removal of caries and then reentry after a period to remove the residual caries, after changing its environment. The maintenance of pulp vitality and the promotion of biologically based management strategies are at the core of deep caries management. No evidence of irreversible pulpitis (not defined) and pulp necrosis, no well‐defined apical radiolucency (not defined). 2017), but limitations including solubility, handling and biological response have led to the development of new materials such as hydraulic calcium silicates (Pitt Ford et al. 2 Oral health disparities persist despite sincere efforts by public health organizations to reduce disease incidence. Comparing the outcome of various strategies to treat deep caries is complex, and as a result, the debate about whether or not to preserve a layer of dentine continues. 2013, Taha et al. response to pulp test at follow‐up. As the cavitated carious dentine lesion progresses, Gram‐negative bacteria release LPS, which diffuses down the dentinal tubules and is recognized by Toll‐like receptors 4 (TLR‐4) that are expressed on pulp nociceptors. Resin‐based adhesive materials were discouraged, and new biologically based materials were developed with the principal aim of promoting mineralized bridge formation (Pitt Ford et al. The authors have stated explicitly that there are no conflicts of interest in connection with this article. An unsuccessful class II pulp capping. ), had an outcome of 32% dropping to below 10% after 5 years (Bjørndal et al. GFs), which could potentially contribute and augment a repair process with current revitalization protocols advocating a bleeding sequence and the formation of a clot in the healing response (Galler 2016b). The relative influence of dentine and pulp cell‐derived factors to the repair process is impossible to quantify and is influenced by short, temporal bioavailability of expression in cells (Smith et al. No restriction as to the pulp symptomatology was defined a priori, but given the focus of our review only studies investigating the man-agement of teeth where maintaining pulp vitality was an option were included. In this procedure, much of the infected and affected dentin is removed without exposing the pulp in a vital, healthy tooth. Furthermore, by having direct access to the tissue, it is easier to evaluate the health of the pulp and to manage it, for example pulpal bleeding. Introduction. (c) Magnified image of the pre‐cavitated enamel–dentine lesion showing the following zones in a sectioned tooth half (i = demineralized enamel with initial cracks, ii = black/dark brown discoloration of demineralized dentine, iii = light brown discoloration of demineralized dentine (the dark discoloured zones reflect areas of arrested caries), iv = hypermineralized dentine (zone of sclerosis), and v = tertiary dentine (reactionary dentine)). 2018). Potentially discriminatory biomarkers have been identified, which could potentially set an inflammatory threshold above which the pulp is not viable (Rechenberg et al. Thickness of the capping materials (3 mm or close as possible). Free Preview. Based on appearance, an actively progressing carious dentine lesion tends to have a light yellow/beige colour, the surface texture is wet/moist, and it is easy to disintegrate/penetrate the soft organic matrix with a dental probe. Therefore, it is mandatory after a direct pulp capping or pulpotomy procedure that a permanent bacteria‐tight restoration is placed immediately to prevent infection by invading microorganisms. The resulting report may be associated with a more positive estimate of the intervention effect (Gluud. Hybrid Antimicrobial Hydrogel as Injectable Therapeutics for Oral Infection Ablation. 2015). Selective caries removal strategies can be one‐visit as indirect pulp treatment or two‐visit using a stepwise approach. The contribution diet plays in the aetiology of caries offers the opportunity to manage the condition by modifying diet, changing biofilm growth and isolating the advancing microbial biofilm from the nutrient supply; therefore, the disease can be managed by selective caries removal without having to eradicate or target the entire bacterial population (Bjørndal et al. [20] that the partial caries removal in symptomless, primary or permanent teeth reduces the risk of pulp exposure and the study of Rando-Meirelles MPM, et al. In conclusion, embracing a minimally invasive approach in managing deep caries will help avoid complications with pulpal involvement. 1963a,b, Garfunkel et al. An experimental clinical study, Periapical fluid RANKL and IL‐8 are differentially regulated in pulpitis and apical periodontitis, Biological markers for pulpal inflammation: a systematic review, The relationship of bacterial penetration and pulpal pathosis in carious teeth, Immune cells and molecular networks in experimentally induced pulpitis, Operative caries management in adults and children. 2013;33:133–140. These nociceptors can extend within 0.16 mm of dentinal tubules and act as an early warning signal to the pulp and indeed the patient (Buyers 1980). 2017) and epigenetic modifying agents (Duncan et al. Please check your email for instructions on resetting your password. The initial response of the pulp includes an increase of secretory activity by the odontoblast leading to increased tertiary dentine formation (reactionary dentinogenesis) (Smith et al. 2013, Rechenberg et al. These properties are not exclusive to mutans streptococci, and strains of other streptococci such as Streptococcus mitis, Streptococcus gordonii, Streptococcus anginosus and Streptococcus oralis are acidogenic and aciduric (van Houte 1994, van Ruyven et al. 1982). It is also not clear from this study the reason for the extraction of teeth with only reversible disease. Several progenitor cell populations may contribute including DPSCs (Gronthos et al. Furthermore, a randomized clinical trial has reported improved outcomes, if a disinfection agent such as NaOCl is applied the haemostatic protocol prior the application of a capping material (Tuzuner et al. 2008), but does protect the pulp tissue from further insult (Glass & Zander 1949, Nyborg 1955). 2014b). review of Ricketts D, et al. 2015), compared with the previously reported randomized clinical trial data demonstrating a very low 5% survival of traditionally pulp capping after caries exposure at 5 years without an enhanced protocol (Bjørndal et al. The authors have stated explicitly that there are no conflicts of interest in connection with this article. Direct pulp capping (class II) (male, 48‐years). Notably from an endodontic viewpoint, a clear definition of lesion depth is lacking in many studies and the available evidence on well‐defined deep carious lesions in adult teeth remains limited. 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