2015), a classification has been proposed, which a view to assisting clinical management (Bjørndal 2018). 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. At the very least, increased education for practitioners in the optimum way to handle pulp tissue should be considered a priority. In VPT, however, EDTA irrigation (although releasing DMCs) may stimulate renewed pulpal bleeding. 2015), the procedure seems promising at advanced stages of caries penetration; however, at present randomized clinical data are absent. No unbearable pain (no disturbed night sleep); absence of PA radiographically (defined as > 2 times with of PD space), Excavation trial (nonexposed treatment) at 5 years. 2014), including the concept of sealing the entire carious lesion with a stainless‐steel crown in the Hall Technique (Innes et al. Third European Society of Endodontology (ESE) research meeting: ACTA, Amsterdam, The Netherlands, 26th October 2018. 2012) and cellular differentiation in vitro (Zanini et al. Indeed, recent consensus reports have stated that the complete or nonselective carious removal is now overtreatment (Innes et al. Cytokines as diagnostic markers of pulpal inflammation, Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology, Odontoblasts in the dental pulp immune response, Dental pulp defence and repair mechanisms in dental caries, Comparative evaluation of chemotactic factor effect on migration and differentiation of stem cells of the apical papilla, Dual origin of mesenchymal stem cells contributing to organ growth and repair, Dentin matrix component solubilization by solutions of pH relevant to self‐etching dental adhesives, Quantitation of growth factors IGF‐I, SGF/IGF‐II, and TGF‐beta in human dentin, Autoradiographic analysis of odontoblast replacement following pulp exposure in primate teeth, Outcomes of one‐step incomplete and complete excavation in primary teeth: a 24‐month randomized controlled trial, Analysis of the contribution of nonresident progenitor cells and hematopoietic cells to reparative dentinogenesis using parabiosis model in mice, Clinical and radiographic assessment of direct pulp capping and pulpotomy in young permanent teeth, Influence of root canal disinfectants on growth factor release from dentin, EDTA conditioning of dentine promotes adhesion, migration and differentiation of dental pulp stem cells, Clinical procedures for revitalization: current knowledge and considerations, Dental pulp pathosis: clinicopathologic correlations based on 109 cases, Neurogenic maturation of human dental pulp stem cells following neurosphere generation induces morphological and electrophysiological characteristics of functional neurons, Cells and extracellular matrices of dentin and pulp: a biological basis for repair and tissue engineering, The effect of calcium hydroxide on solubilisation of bio‐active dentine matrix components, Vascular endothelial growth factor and its relationship with the dental pulp, Stem cell properties of human dental pulp stem cells, Relationships between caries bacteria, host responses, and clinical signs and symptoms of pulpitis, Clinical and radiographic assessment of the efficacy of calcium silicate indirect pulp capping: a randomized controlled clinical trial, Clinical evaluation of mineral trioxide aggregate and biodentine as direct pulp capping agents in carious teeth, Clinical considerations in adhesive restorative dentistry‐influence of adjunctive procedures, Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial, Plithotaxis, a collective cell migration, regulates the sliding of proliferating pulp cells located in the apical niche, Role of micro‐organisms in caries etiology, Managing carious lesions: consensus recommendations on terminology, The Hall technique 10 years on: questions and answers, A randomized controlled study of the use of ProRoot mineral trioxide aggregate and endocem as direct pulp capping materials: 3‐month versus 1‐year outcomes, Potential therapeutic strategy of targeting pulp fibroblasts in dentin‐pulp regeneration, A study of endodontic treatment carried out in dental practice within the UK, A randomized controlled trial of ProRoot MTA, OrthoMTA and RetroMTA for pulpotomy in primary molars, Interleukin‐8 is increased in gingival crevicular fluid from patients with acute pulpitis, Global burden of untreated caries: a systematic review and metaregression, A clinical and television densitometric evaluation of the indirect pulp capping technique, Determination of endotoxins in the vital pulp of human carious teeth: association with pulpal pain, What constitutes dental caries? 2016). 1963a,b, Dummer et al. Conservative Management of Mature Permanent Teeth with Carious Pulp Exposure. 1982). 2016a). Indeed, it may even call into question the need for pulpectomy at all, as by definition an ‘– ectomy’ denotes surgical removal of part of the body. (b) After nonselective carious removal (former complete excavation) using the operative microscope, there is an absence of any retained carious dentine, and there is good haemostasis of the exposed pulp. CBCT‐PA alterations at baseline had a significantly higher failure rate at 1 year follow‐up versus teeth without CBCT detected PA alterations, Comparing excavation interventions and subsequent pulp capping intervention if exposure occurred accidentally during excavation, Carious dentine into pulpal quarter of the dentine, no signs of irreversible pulpitis (undisturbed night sleep) (no radiographic PA lesion), Trial: Intervention effect ~20%, Power 90%, P < 0.05, Intervention: Complete/nonselective excavation (control), n = 158, Stepwise excavation, n = 156, Stepwise excavation arm: 1. visit: Removal of superficial necrotic and demineralized dentine, so a GIC temporary seal placed. 2015), whilst releasing other bioactive molecules that migrate down the dentinal tubules and stimulate tertiary dentine formation and other pulpal reparative processes (Finkelman et al. International Journal of Environmental Research and Public Health. The resulting report may be associated with a more positive estimate of the intervention effect (Gluud. Cost: $65. No clinical and radiographic differences. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention of root caries: a literature review of primary and secondary preventive agents. 2007), calcium hydroxide (Graham et al. 2014b). At the very least, increased education for practitioners in the optimum way to handle pulp tissue should be considered a priority. 2007) prior to being released by caries, irrigants and dental materials (Graham et al. 2016b). (f) Mineral trioxide aggregate is applied, and an adequate thickness can be compromised in approximal cavities. TVH-19, a synthetic peptide, induces mineralization of dental pulp cells in vitro and formation of tertiary dentin in vivo. 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). Selective carious dentine removal to soft dentine is performed to the extent that a temporary restoration can be properly placed. Once the cells have migrated to contact the biomaterial, they must differentiate into mineral‐secreting cells, at which point dentine synthesis is triggered. 1 This increases to six of 10 children by their 8th birthday. However, treatment outcomes for pulp capping can only be evaluated clinically and radiographically (Woehrlen 1977, Fuks et al. 2017), from operative dentists and cariologists who prefer to maintain a dentine layer if at all possible. old patient, carious lesion penetrating halfway into dentine) by forming reactionary dentine, whilst the tertiary dentine formed under rapidly progressing lesion (e.g. 2005). 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. The clinical result of leaving behind carious dentine is that over time the appearance changes to that of arrested carious dentine (Massler 1978, Bjørndal et al. radiograph, pulp sensibility testing) are added to the scenario. From a scientific perspective, further understanding of the processes of inflammation, repair and material interaction is important to deepen understanding and develop novel diagnostic and therapeutic solutions. 1) with extremely deep caries defined as radiographic evidence of caries penetrating the entire thickness of the dentine with certain pulp exposure. (b) Longitudinal mesial/distal crosscut of the same molar, exposing an occlusal enamel‐dentine lesion (insert C), and an extremely deep carious lesion originating from the proximal surface (insert D). Blood clots also contain numerous bioactive molecules (e.g. The material takes over four hours to set, and it is recommended that the tooth should be temporized before the permanent restoration is placed. Other GFs including angiogenic molecules, such as fibroblast GF 2 (FGF‐2), vascular endothelial GF (VEGF), and placenta GF (PlGF) (Roberts‐Clark & Smith 2000, Tomson et al. Analysis of the literature highlights that two types of failure may be occurring: (i) early failure within days of the treatment and leading to symptomatic pulpitis, and (ii) long‐term failures detected several months later and characterized by the presence of an apical lesion related to root canal infection after pulp necrosis. The traditional management of such lesions using non-selective (complete) carious tissue oftentimes leads to exposure of the pulp. Recently, alternative MTA‐based materials, including Biodentine, have been developed, which have a reduced setting time (<15 min) and are recommended for one‐visit VPT procedures. Inflammation is destructive, but the resulting pathophysiological response is necessary to stimulate healing. Trial: Intervention effect 15%, Power 80%, P < 0.05. Assessing the pulpal status of primary teeth can be the most difficult part of vital pulp therapy. That is, in established and most advanced parts of the lesion, it would be reparative dentinogenesis, whereas for younger parts of the lesion, reactionary dentinogenesis takes place (Bjørndal et al. 1997). 2017). 1995), which can be seen strictly related to the subjacent enamel–dentine lesion complex (Bjørndal et al. At present, there remains a paucity of high‐quality randomized clinical trials comparing and testing capping materials in order to make definitive conclusions on the best material to use. 2015) after 3 years, perhaps highlighting the reasons for such a large difference. Economic factors may also alter treatment decisions as remuneration for a RCT in a molar tooth will be radically different to a VPT procedure on the same tooth. 1967). 20172017). 1990) present in DMC extracts. In this context, the majority of general practitioners selected the ‘deep’ carious dentine lesion as one that penetrates radiographically into the pulpal quarter of the dentine, but still with a well‐defined zone of radiopaque dentine separating the infected demineralized dentine from the pulp (Fig. 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. 2013). Hall Technique • A unique and minimally invasive approach to managing deep carious lesions in deciduous dentition by cementing metal crowns over them • Pioneered by Dr.Norma Hall; published in 2006 as a retrospective study • Does not require local anesthesia, tooth preparation or even caries removal! 2015) with short‐term follow‐up and low numbers of patients. (a) Deep carious lesion reaching pulpal quarter with a zone of dentine separating the lesion from the pulp (b) and extremely deep penetrating the entire thickness of the dentine. Notably, for didactic purposes, the processes of reactionary and reparative dentinogenesis are considered separately, and it is likely that in a deep carious lesion both processes will occur simultaneously particularly at the periphery of the cavity (Smith 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. Building on serial developments in Caries Classification from 2002 by the ICDAS Foundation, and on Caries Management Meetings held in 2010 and 2011, an international workshop was held at Temple University Maurice H. Kornberg School of Dentistry in 2012 to review different systems for caries detection, risk assessment, and caries management [1, 6–8]. Management of Deep Carious Lesions. For years, Ca(OH)2 has been the ‘gold standard’ capping material (Glass & Zander 1949, Stanley & Lundy 1972, Tronstad 1974, Pitt Ford & Roberts 1991). A consensus document recently defined deep caries as radiographic evidence of caries reaching the inner third or inner quarter of dentine with a risk of pulp exposure (Innes et al. (b) Longitudinal mesial/distal crosscut of the same molar, exposing an occlusal enamel‐dentine lesion (insert C), and an extremely deep carious lesion originating from the proximal surface (insert D). Bio-Inductive Materials in Direct and Indirect Pulp Capping—A Review Article. 2013), its principal function is as a secretory cell, forming primary dentine during tooth development and later the production of secondary dentine, as well as tertiary dentine production when challenged (Simon et al. 1998). Bioceramic Materials in Clinical Endodontics. While several systems were reviewed … If you do not receive an email within 10 minutes, your email address may not be registered, Indirect pulp treatment in primary teeth: 4‐year results, Comparative analysis of transforming growth factor‐β isoforms 1‐3 in human and rabbit dentine matrices, Molecular analysis of microbial diversity in advanced caries, Inflammatory processes in the dental pulp, The Dental Pulp‐ Biology, Pathology and Regeneration, Inflammation‐regeneration interplay in the dentine‐pulp complex, The amazing odontoblast: activity, autophagy, and aging, Pulp capping of dental pulp mechanically exposed to oral microflora: a 1‐2 year observation of wound healing in the monkey, Tunnel defects in dentine bridges: their formation following direct pulp capping, Biocompatibility of primer, adhesive and resin composite systems on non‐exposed and exposed pulps of non‐human primate teeth, Histological appearance of pulps after exposure by a crown fracture, partial pulpotomy, and clinical diagnosis of healing, Clinical signs and symptoms in pulp disease, Histone deacetylase inhibitors epigenetically promote reparative events in primary dental pulp cells, Release of bio‐active dentine extracellular matrix components by histone deacetylase inhibitors (HDACi), Effect of lactic acid and proteolytic enzymes on the release of organic matrix components from human root dentin. 2012). 2016, Zanini et al. 2008). Indeed, recent consensus reports have stated that the complete or nonselective carious removal is now overtreatment (Innes et al. A recent randomized clinical multicenter trial demonstrated that MTA performed better than Ca(OH)2 (Kundzina et al. 2015). 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. The pulp reacts to a low‐grade lesion (e.g. Use the link below to share a full-text version of this article with your friends and colleagues. Furthermore, NaOCl interacts with dentine interfering with subsequent bonding processes because of collagen collapse (Thanatvarakorn et al. Caries prevalence remains high throughout the world, with the burden of disease increasingly affecting older and socially disadvantaged groups in Western cultures. Moreover, the hard tissue bridges formed against MTA have higher histological quality compared with those induced by Ca(OH)2 (Nair 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). Randomized clinical trials are the best way to answer this question, but there are currently only a few which address this issue. 2017) will be possible and beneficial in the clinic in developing associated treatment strategies? No irreversible pulpitis (defined); absence of PA radiographically (defined as ≥ 2 times with of PD space). 1980). Follow‐up: 1, 2 and 4 weeks, and 3, 6 months and 1 year, Nonsignificant (NS). Experimental (stepwise): 60% success. Blinded follow‐up examination: An examiner who is not aware of which group the material or the patient belongs (blinded outcome evaluation). The word ‘irreversible’ means that it is ‘cannot be undone, repealed, or annulled; unalterable, irrevocable’ (Oxford English Dictionary). These organisms are early colonizers (Nyvad & Kilian 1990) and may help establish an environment or niche, which mutans streptococci and lactobacilli will thrive in. Significant difference, Nested pulp capping trial at 5 years: Experimental (partial pulpotomy): 11% success. 2011, Zehnder et al. 2 Oral health disparities persist despite sincere efforts by public health organizations to reduce disease incidence. Progenitor cells migrate and differentiate to form odontoblast‐like cells during reparative dentinogenesis. Superficial soft infected dentine was removed by bur and deeper located areas by chemo‐mechanical gel and hand instrumentation, but left at a residual level, whereby any added removal would lead to exposure. 2013, Taha et al. (d) Post‐operative radiograph with permanent restoration in place. 1990, Bègue‐Kirn et al. The classification reinforces the need for a more focused or enhanced approach after carious exposure (class II), which is not as critical if the pulp is traumatically exposed (class I) due to a reduction in the microbial load close the pulp tissue. Indeed, inflammation marks the first step of tissue convalescence. Poor oral health status and short‐term outcome of kidney transplantation. Recently, the removal of all the coronal pulp tissue in a pulp chamber pulpotomy has been proposed as an alternative treatment to pulp capping (Asgary & Eghbal 2010, Simon et al. Dental pulp exposure results in irreversible damage to the affected odontoblastic palisade and death of the primary odontoblast. The ability of ethylenediaminetetraacetic acid (EDTA) (Graham 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). Early failures could be related to misdiagnosis of the severity of the pulpitis disease and insufficient pulp tissue removal, which may explain the need for tissue removal in these cases, whereas late failures could be related to the quality and sealing ability of the restoration and mineralized bridge that becomes compromised by secondary infection. 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