Endodontic Materials in Clinical Practice. Группа авторов

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study analysed the development of the dentine–pulp complex after systemic injection of trichostatin A (TSA) into prenatal mice and highlighted an increase in odontoblasts and dentine thickness compared with control samples [217].

      One of the main disadvantages of the use of MTA is its extended setting time, as this makes tooth restoration in one visit difficult. In order to circumvent this problem, the tooth can be definitively restored at a subsequent visit, or else GIC can be placed over the material to prevent washout during definitive restoration placement. A moist barrier should be used between the unset MTA and the temporary restorative material.

      The shorter setting time of Biodentine compared to other HCSCs means that it is an excellent candidate for use in VPT. It also has the advantage of having a much higher compressive strength compared to other HCSCs, making it resilient enough to be exposed in the oral cavity, at least as a temporary material, or even as an intermediate restoration [145]. It can later be cut back in order to create space for a definitive restorative with a composite resin and treated like a traditional base.

      2.5.1 Vital Pulp Treatment Outcome

      The outcome of VPT should be assessed clinically after six months and with additional radiographic assessment at one year. If symptoms dictate, the observation period should be extended annually for four years [1]. The tooth should be responsive to pulp sensibility testing, but this may be heightened or diminished during the review period. Notably, although teeth which have had a partial pulpotomy will respond positively to testing, those which have undergone full pulpotomy will be unresponsive [218]. There should be no history of pain or other symptoms, and there should be evidence of continued root formation in immature teeth radiographically, as well as absence apical periodontitis [219]. A successful outcome in mature permanent teeth with symptoms no worse than reversible pulpitis indicates that a pulp‐capping procedure using an HCSC will be successful in approximately 80–90% of cases [63, 68, 82]. However, success is likely to be affected by the location (interproximal, occlusal) [79] and depth [66] of the carries, as well as operator skill [52, 63, 69] and material used [66, 68]. Other factors have not been consistently shown to be critical in determining outcome; these include patient age [83, 85, 196] and size of exposure [53, 118]. Interestingly, recent evidence highlights the potential of full pulpotomy to be as effective as pulpectomy in teeth with signs and symptoms suggestive of irreversible pulpitis [11, 84,220–222]. That said, there is a lack of prospective controlled trials using standardized materials, irrigants, caries depth symptoms, and so on in this area; this will need to be addressed moving forward. Damaged immature teeth treated aseptically by VPT that remain vital will display continued root growth through the physiological processes of primary and ongoing secondary dentinogenesis.

Photo depicts discoloured maxillary left lateral incisor one year after a partial pulpotomy procedure using a hydraulic calcium silicate material containing bismuth oxide.

      Source: Henry F. Duncan.

      ProRoot MTA is limited clinically by a prolonged setting time [232, 233], which lasts several hours. As a result, the manufacturer claims the material should be applied over two visits – a feature which is not ideal for vital pulp applications. Newer HCSCs, including MTA Angelus, Biodentine, and resin‐modified calcium silicates such as TheraCal LC, advertise significantly shorter or instant setting times, facilitating completion of treatment in one visit. Notably, the setting time of Biodentine is not always predictable, with it often taking significantly longer than the advertised time even for initial setting to occur [145, 230]; however, it is still much quicker than ProRoot MTA. It has been reported that MTA Angelus and Biodentine have similar setting times [234]. Light‐cured HCSCs, whilst offering an instantly setting material, have been shown to be cytotoxic and are not recommended for use as direct pulp‐capping materials [187]. Traditionally, MTA has been reported to be difficult to handle because of its consistency and formulation [232, 235], whilst Biodentine is considered easier to mix and use [234]. A recent questionnaire‐based study investigated Biodentine and MTA in VPT and highlighted that many dentists avoided using any calcium silicate materials, citing reasons of cost, lack of training, and difficulties in material handling [236].

      Preserving the health of the dental pulp is an important aspect of modern endodontics. If successful, pulp preservation is a minimally invasive, biologically based, and technically undemanding alternative to pulpectomy. Therefore, selective caries removal, stepwise excavation, pulp capping, and pulpotomy are an essential part of the treatment armamentarium of every dentist. The advent of HCSCs has provided renewed impetus in VPT, and they are the current material of choice in this area. Although the exact mechanisms remain to be elucidated, pulp‐capping materials like calcium hydroxide and MTA appear to stimulate the release of biologically active molecules from pulp cells and the dECM, stimulating dentinogenesis. Although the future of this area may involve molecular diagnostic biomarker assays and targeted third‐generation biomaterials, prospective randomized trials using modern materials are required to support promising preliminary clinical data in the meantime.

      1 1 Duncan, H.F., Galler, K.M., Tomson, P.L. et al. (2019). European Society of Endodontology position statement: management of deep caries and the exposed pulp. Int. Endod. J. 52 (7): 923–934.

      2 2 Wolters, W.J., Duncan, H.F., Tomson, P.L. et al. (2017). Minimally invasive endodontics: a new diagnostic system for assessing pulpitis and subsequent treatment needs. Int. Endod. J. 50 (9): 825–829.

      3 3 Randow, K. and Glantz, P.O. (1986).

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