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International Endodontic Journal Jul 2019This position statement on the management of deep caries and the exposed pulp represents the consensus of an expert committee, convened by the European Society of...
This position statement on the management of deep caries and the exposed pulp represents the consensus of an expert committee, convened by the European Society of Endodontology (ESE). Preserving the pulp in a healthy state with sustained vitality, preventing apical periodontitis and developing minimally invasive biologically based therapies are key themes within contemporary clinical endodontics. The aim of this statement was to summarize current best evidence on the diagnosis and classification of deep caries and caries-induced pulpal disease, as well as indicating appropriate clinical management strategies for avoiding and treating pulp exposure in permanent teeth with deep or extremely deep caries. In presenting these findings, areas of controversy, low-quality evidence and uncertainties are highlighted, prior to recommendations for each area of interest. A recently published review article provides more detailed information and was the basis for this position statement (Bjørndal et al. 2019, International Endodontic Journal, doi:10.1111/iej.13128). The intention of this position statement is to provide the practitioner with relevant clinical guidance in this rapidly developing area. An update will be provided within 5 years as further evidence emerges.
Topics: Dental Caries; Dental Pulp; Dental Pulp Capping; Endodontics; Humans; Periapical Periodontitis; Pulpotomy
PubMed: 30664240
DOI: 10.1111/iej.13080 -
Australian Dental Journal Mar 2021Conservative pulp therapy is an alternative treatment option to tooth removal and root canal treatment in the management of deep caries, traumatic pulp exposures and... (Review)
Review
Conservative pulp therapy is an alternative treatment option to tooth removal and root canal treatment in the management of deep caries, traumatic pulp exposures and developmental anomalies. Pulp tissue preservation can extend the long-term survival of teeth through relatively simple restorative procedures. This article aims to update clinicians on the current state of research in materials, techniques and outcomes of vital pulp therapies and provide practical guidelines for their implementation into daily practice.
Topics: Dental Caries; Dental Pulp; Dental Pulp Capping; Humans; Pulpitis; Pulpotomy
PubMed: 33818812
DOI: 10.1111/adj.12841 -
International Endodontic Journal May 2022Therapeutic strategies focussed on the pulp preservation, are important when managing vital teeth with deep caries and an exposed pulp. These vital pulp treatments... (Review)
Review
Therapeutic strategies focussed on the pulp preservation, are important when managing vital teeth with deep caries and an exposed pulp. These vital pulp treatments (VPTs); however, are not new, with indirect and direct pulp capping procedures being described as a therapy for carious teeth for over a century. As a result of unpredictable outcomes, the traditional indications for VPT particularly when the pulp was exposed were limited to the treatment of immature teeth with incomplete root formation. Over the last 20 years, the advent of regenerative endodontics and the promotion of biologically based therapies aimed at reducing intervention have reinvigorated VPT with new waves of basic science and clinical research indicating a role for VPT not only in mature cariously affected teeth, but also in teeth with signs and symptoms indicative of irreversible pulpitis. Driven by new materials such as hydraulic calcium silicate cements, a better understanding of pulpal immunity and biology as well and improved tissue handling, VPT has been at the forefront of treatment recommendations made by global Cariology and Endodontic organizations. Care must be exercised, however, as key gaps in scientific knowledge remain alongside severe limitations in educational dissemination amongst dentists. Although research has highlighted that carious injury to the dentine-pulp complex stimulates a wide range of responses and that the interaction between infection, inflammation and repair will eventually impact on the outcome of pulpitis, our ability to accurately and objectively diagnose the true inflammatory state of the pulp remains poor. An overreliance on symptoms leaves clinicians with subjective, crude diagnostic tools by which to inform treatment planning and decision-making, which results in large variations in the treatments offered to patients. Not only is there an urgent need to develop preoperative and intraoperative diagnostic tools, but there is also a paucity of the high-quality comparative evidence required to answer the most important questions and justify treatment options. The aim of this review was to consider the current status of VPT and to discuss the principle problems that are hindering clinical acceptance of these techniques. Potential solutions and opportunities are offered to suggest ways that VPT may become a more consistently prescribed evidenced-based treatment in dental practice.
Topics: Dental Caries; Dental Pulp Capping; Humans; Pulpitis; Pulpotomy; Root Canal Therapy; Silicates
PubMed: 35080024
DOI: 10.1111/iej.13688 -
International Endodontic Journal Oct 2022Luxation injuries and other stimuli may lead to a pulp canal obliteration (PCO). Even though the apposition of tertiary dentine is a sign of a vital pulp, in some cases... (Review)
Review
Luxation injuries and other stimuli may lead to a pulp canal obliteration (PCO). Even though the apposition of tertiary dentine is a sign of a vital pulp, in some cases root canal treatment is indicated in the long term due to apical periodontitis or pulpitis. Depending on the extent of PCO, root canal treatment may be challenging even for experienced and well-equipped endodontic specialists. The 'guided endodontics' (GE) technique was introduced 6 years ago as an alternative to conventional access cavity preparation for teeth with PCO and apical pathosis or irreversible pulpitis. Using three-dimensional radiological imaging such as cone-beam computed tomography and a digital surface scan, an optimal access to the orifice of the calcified root canal can be planned virtually with appropriate software. GE is implemented either with the help of templates analogous to guided implantology (= static navigation) or by means of dynamic navigation based on a camera-marker system. GE has emerged as a field of research in the last 6 years with very promising laboratory-based results regarding the accuracy of guided endodontic access cavities for both static and dynamic navigation. Clinical implementation seems to provide favourable results, but the evidence is mainly based on numerous case reports and a few case series. This narrative review aims to provide an update on the present status of GE and to identify relevant research areas that could contribute to further improvements of this technique.
Topics: Humans; Pulpitis; Endodontics; Dental Pulp Cavity; Root Canal Therapy; Periapical Periodontitis; Cone-Beam Computed Tomography; Dental Pulp Diseases
PubMed: 35075661
DOI: 10.1111/iej.13687 -
International Journal of Molecular... Feb 2021The macroscopic and microscopic anatomy of the oral cavity is complex and unique in the human body. Soft-tissue structures are in close interaction with mineralized... (Review)
Review
The macroscopic and microscopic anatomy of the oral cavity is complex and unique in the human body. Soft-tissue structures are in close interaction with mineralized bone, but also dentine, cementum and enamel of our teeth. These are exposed to intense mechanical and chemical stress as well as to dense microbiologic colonization. Teeth are susceptible to damage, most commonly to caries, where microorganisms from the oral cavity degrade the mineralized tissues of enamel and dentine and invade the soft connective tissue at the core, the dental pulp. However, the pulp is well-equipped to sense and fend off bacteria and their products and mounts various and intricate defense mechanisms. The front rank is formed by a layer of odontoblasts, which line the pulp chamber towards the dentine. These highly specialized cells not only form mineralized tissue but exert important functions as barrier cells. They recognize pathogens early in the process, secrete antibacterial compounds and neutralize bacterial toxins, initiate the immune response and alert other key players of the host defense. As bacteria get closer to the pulp, additional cell types of the pulp, including fibroblasts, stem and immune cells, but also vascular and neuronal networks, contribute with a variety of distinct defense mechanisms, and inflammatory response mechanisms are critical for tissue homeostasis. Still, without therapeutic intervention, a deep carious lesion may lead to tissue necrosis, which allows bacteria to populate the root canal system and invade the periradicular bone via the apical foramen at the root tip. The periodontal tissues and alveolar bone react to the insult with an inflammatory response, most commonly by the formation of an apical granuloma. Healing can occur after pathogen removal, which is achieved by disinfection and obturation of the pulp space by root canal treatment. This review highlights the various mechanisms of pathogen recognition and defense of dental pulp cells and periradicular tissues, explains the different cell types involved in the immune response and discusses the mechanisms of healing and repair, pointing out the close links between inflammation and regeneration as well as between inflammation and potential malignant transformation.
Topics: Animals; Antigens, Neoplasm; Carcinogenesis; Carcinoma, Squamous Cell; Chemokines; Complement System Proteins; Dental Caries; Dental Pulp; Dentin; Fibroblasts; Humans; Intracellular Signaling Peptides and Proteins; Mesenchymal Stem Cells; Mouth Neoplasms; Nerve Net; Neuropeptides; Nitric Oxide; Odontoblasts; Periapical Granuloma; Periapical Periodontitis; Periapical Tissue; Pulpitis; Radicular Cyst
PubMed: 33540711
DOI: 10.3390/ijms22031480 -
Cell Communication and Signaling : CCS May 2021Mitochondrial DNA (mtDNA) is a vital driver of inflammation when it leaks from damaged mitochondria into the cytosol. mtDNA stress may contribute to cyclic GMP-AMP...
BACKGROUND
Mitochondrial DNA (mtDNA) is a vital driver of inflammation when it leaks from damaged mitochondria into the cytosol. mtDNA stress may contribute to cyclic GMP-AMP synthase (cGAS) stimulator of interferon genes (STING) pathway activation in infectious diseases. Odontoblasts are the first cells challenged by cariogenic bacteria and involved in maintenance of the pulp immune and inflammatory responses to dentine-invading pathogens. In this study, we investigated that mtDNA as an important inflammatory driver participated in defending against bacterial invasion via cGAS-STING pathway in odontoblasts.
METHODS
The normal tissues, caries tissues and pulpitis tissues were measured by western blotting and immunohistochemical staining. Pulpitis model was built in vitro to evaluated the effect of the cGAS-STING pathway in odontoblast-like cell line (mDPC6T) under inflammation. Western blot and real-time PCR were performed to detect the expression of cGAS-STING pathway and pro-inflammatory cytokines. The mitochondrial function was evaluated reactive oxygen species (ROS) generated by mitochondria using MitoSOX Red dye staining. Cytosolic DNA was assessed by immunofluorescent staining and real-time PCR in mDPC6T cells after LPS stimulation. Furthermore, mDPC6T cells were treated with ethidium bromide (EtBr) to deplete mtDNA or transfected with isolated mtDNA. The expression of cGAS-STING pathway and pro-inflammatory cytokines were measured.
RESULTS
The high expression of cGAS and STING in caries and pulpitis tissues in patients, which was associated with inflammatory progression. The cGAS-STING pathway was activated in inflamed mDPC6T. STING knockdown inhibited the nuclear import of p65 and IRF3 and restricted the secretion of the inflammatory cytokines CXCL10 and IL-6 induced by LPS. LPS caused mitochondrial damage in mDPC6T, which promoted mtDNA leakage into the cytosol. Depletion of mtDNA inhibited the cGAS-STING pathway and nuclear translocation of p65 and IRF3. Moreover, repletion of mtDNA rescued the inflammatory response, which was inhibited by STING knockdown.
CONCLUSION
Our study systematically identified a novel mechanism of LPS-induced odontoblast inflammation, which involved mtDNA leakage from damaged mitochondria into the cytosol stimulating the cGAS-STING pathway and the inflammatory cytokines IL-6 and CXCL10 secretion. The mtDNA-cGAS-STING axis could be a potent therapeutic target to prevent severe bacterial inflammation in pulpitis. Video Abstract.
Topics: Cell Line; Cytosol; DNA, Mitochondrial; Dental Caries; Humans; Inflammation; Lipopolysaccharides; Membrane Proteins; Mitochondria; Nucleotidyltransferases; Odontoblasts; Pulpitis; Signal Transduction
PubMed: 34016129
DOI: 10.1186/s12964-021-00738-7 -
Medicina (Kaunas, Lithuania) Jun 2021: Symptomatic irreversible pulpitis in permanent mature teeth is a common indication for nonsurgical root canal treatment (NSRCT), but contemporary studies have reported... (Review)
Review
: Symptomatic irreversible pulpitis in permanent mature teeth is a common indication for nonsurgical root canal treatment (NSRCT), but contemporary studies have reported on vital pulp therapy (VPT) applied in such teeth as a less invasive treatment. This systematic review assessed the outcomes of VPT, including partial and full pulpotomy performed with hydraulic calcium silicate cements (HCSCs) in permanent mature posterior teeth diagnosed with symptomatic irreversible pulpitis. : The PRISMA guidelines were followed. The search strategy included PubMed, EMBASE, Cochrane library and grey literature electronic databases. The quality assessment of the identified studies followed the Cochrane Collaboration Risk of Bias, ROBINS-I and Newcastle-Ottawa Scale tools. : The search of primary databases identified 142 articles, of which 9 randomized controlled trials and 3 prospective cohort studies were selected for review. The risk-of-bias was assessed as 'high' or 'serious', 'fair', and 'low' for three, seven and two articles, respectively. One to five years after VPT using HCSCs, the success rates mostly ranged from 78 to 90%. Based on two articles, the outcomes of the VPT and NSRCT were comparable at one and five years. Despite the necessity for the intra-operative pulp assessment in VPT procedures, the majority of the studies did not fully report on this step or on the time needed to achieve hemostasis. Small sample sizes, of under 23 teeth, were reported in three studies. : The reviewed 12 articles reported favorable outcomes of the VPT performed with HCSCs in permanent mature posterior teeth with symptomatic irreversible pulpitis, with radiographic success in the range of 81 to 90%. Two articles suggested comparable outcomes of the VPT and root canal treatment. Universal case selection and outcome criteria needs to be established for VPT when considered as an alternative to NSRCT. This evidence supports the need for further research comparing longer-term outcomes of both of the treatment modalities.
Topics: Dentition, Permanent; Humans; Prospective Studies; Pulpitis; Pulpotomy; Treatment Outcome
PubMed: 34205149
DOI: 10.3390/medicina57060573 -
European Journal of Paediatric Dentistry Dec 2021The aim of this systematic review was to evaluate the clinical outcome of partial pulpotomy, pulpotomy and pulpectomy for treating primary teeth with normal or infected...
AIM
The aim of this systematic review was to evaluate the clinical outcome of partial pulpotomy, pulpotomy and pulpectomy for treating primary teeth with normal or infected pulp or with irreversible pulpitis.
METHODS
Two reviewers on Pubmed and ISI Web of Science performed a comprehensive literature review of publications from 1966 until July 2019. Pico outline was used to facilitate literature research. Among abstracts, publications were selected according to the following criteria: prospective clinical study, correct indication for the performed treatment, clear definition of clinical and/or radiographic success criteria and at least 6-month follow-up period. The strict selection criteria under the keywords "pulpotomy", "partial pulpotomy" and "pulpectomy" resulted in a limited amount of randomised controlled trials (RCT) or controlled clinical trials (CT). Qualitative assessment of the selected clinical studies and level of evidence was included according to the criteria described by the Oxford Centre for Evidence-Based Medicine (CEBM).
CONCLUSION
Prerequisites for a successful pulpotomy are symptom-free teeth, sterile removal of coronal pulp and haemostasis. Both MTA and formocresol perform well for partial pulpotomies after caries exposure. Formocresol had been the most popular amputation material for pulpotomies. Due to the potential side effects, other medicaments, such as ferric sulfate, mineral trioxide aggregate (MTA) or NaOCl are suggested. Grey and white MTA yeld the same results. Lasers are not recommended due to their large diversity. Regarding pulpectomy, the conditions, procedures, and evaluation for the treatment were not well defined in the studies. Nevertheless, there is evidence to use calcium hydroxide, zinc oxide eugenol paste or iodoform based pastes as root filling materials for non-vital molars. Pulpectomies showed better success rates than pulpotomies. Stainless steel crowns are recommended as definite restorations after both endodontic treatments. Longer follow-up periods, further clinical studies with comparable conditions and clear definition of evaluation criteria are needed to further confirm the results of endodontic treatment in primary teeth.
Topics: Calcium Compounds; Drug Combinations; Humans; Molar; Oxides; Pulpectomy; Pulpotomy; Silicates; Tooth, Deciduous; Treatment Outcome; Zinc Oxide-Eugenol Cement
PubMed: 35034465
DOI: 10.23804/ejpd.2021.22.04.4 -
International Endodontic Journal Oct 2023The ESE previously published quality guidelines for endodontic treatment in 2006; however, there have been significant changes since not only in clinical endodontics but... (Review)
Review
BACKGROUND
The ESE previously published quality guidelines for endodontic treatment in 2006; however, there have been significant changes since not only in clinical endodontics but also in consensus and guideline development processes. In the development of the inaugural S3-level clinical practice guidelines (CPG), a comprehensive systematic and methodologically robust guideline consultation process was followed in order to produce evidence-based recommendations for the management of patients presenting with pulpal and apical disease.
AIM
To develop an S3-level CPG for the treatment of pulpal and apical disease, focusing on diagnosis and the implementation of the treatment approaches required to manage patients presenting with pulpitis and apical periodontitis (AP) with the ultimate goal of preventing tooth loss.
METHODS
This S3-level CPG was developed by the ESE, with the assistance of independent methodological guidance provided by the Association of Scientific Medical Societies in Germany and utilizing the GRADE process. A robust, rigorous and transparent process included the analysis of relevant comparative research in 14 specifically commissioned systematic reviews, prior to evaluation of the quality and strength of evidence, the formulation of specific evidence and expert-based recommendations in a structured consensus process with leading endodontic experts and a broad base of external stakeholders.
RESULTS
The S3-level CPG for the treatment of pulpal and apical disease describes in a series of clinical recommendations the effectiveness of diagnosing pulpitis and AP, prior to investigating the effectiveness of endodontic treatments in managing those diseases. Therapeutic strategies include the effectiveness of deep caries management in cases with, and without, spontaneous pain and pulp exposure, vital versus nonvital teeth, the effectiveness of root canal instrumentation, irrigation, dressing, root canal filling materials and adjunct intracanal procedures in the management of AP. Prior to treatment planning, the critical importance of history and case evaluation, aseptic techniques, appropriate training and re-evaluations during and after treatment is stressed.
CONCLUSION
The first S3-level CPG in endodontics informs clinical practice, health systems, policymakers, other stakeholders and patients on the available and most effective treatments to manage patients with pulpitis and AP in order to preserve teeth over a patient's lifetime, according to the best comparative evidence currently available.
Topics: Humans; Dental Pulp; Endodontics; Periapical Periodontitis; Pulpitis; Root Canal Therapy
PubMed: 37772327
DOI: 10.1111/iej.13974 -
Computational and Structural... 2021The oralome is the summary of the dynamic interactions orchestrated between the ecological community of oral microorganisms (comprised of up to approximately 1000... (Review)
Review
The oralome is the summary of the dynamic interactions orchestrated between the ecological community of oral microorganisms (comprised of up to approximately 1000 species of bacteria, fungi, viruses, archaea and protozoa - the oral microbiome) that live in the oral cavity and the host. These microorganisms form a complex ecosystem that thrive in the dynamic oral environment in a symbiotic relationship with the human host. However, the microbial composition is significantly affected by interspecies and host-microbial interactions, which in turn, can impact the health and disease status of the host. In this review, we discuss the composition of the oralome and inter-species and host-microbial interactions that take place in the oral cavity and examine how these interactions change from healthy (eubiotic) to disease (dysbiotic) states. We further discuss the dysbiotic signatures associated with periodontitis and caries and their sequalae, (e.g., tooth/bone loss and pulpitis), and the systemic diseases associated with these oral diseases, such as infective endocarditis, atherosclerosis, diabetes, Alzheimer's disease and head and neck/oral cancer. We then discuss current computational techniques to assess dysbiotic oral microbiome changes. Lastly, we discuss current and novel techniques for modulation of the dysbiotic oral microbiome that may help in disease prevention and treatment, including standard hygiene methods, prebiotics, probiotics, use of nano-sized drug delivery systems (nano-DDS), extracellular polymeric matrix (EPM) disruption, and host response modulators.
PubMed: 33777334
DOI: 10.1016/j.csbj.2021.02.010