Calcium-enriched Mixture Groups Research Articles

THREE-YEAR OUTCOME OF DIODE LASER PULPOTOMY OF PRIMARY MOLARS USING THREE PULP CAPPING AGENTS: A SPLIT-MOUTH RANDOMIZED CLINICAL TRIAL

ObjectivesPulpotomy is the most commonly performed treatment for asymptomatic primary molars with exposed dental pulp. This study aimed to assess the clinical /radiographic success of diode laser pulpotomy with mineral trioxide aggregate (MTA), calcium hydroxide (CH), and calcium-enriched mixture (CEM) cement as pulp capping agents. MethodsThis split-mouth randomized clinical trial was conducted initially on 34 children aged 3-8 years but 4 patients left the study before the first follow-up visit and the study was accomplished and analyzed with 30 cases. The patients had at least 3 first/second molars with deep caries that in radiographic evaluation revealed that they required pulpotomy. Following pulpotomy, the pulp stump was irradiated with diode laser (noncontact mode, 632 nm, 30 mW power) as photobiomodulation mode. Pulp tissue was then capped with MTA, CH, or CEM cement (n = 30 in each group). Reinforced zinc oxide eugenol was applied over the capping agent, and the teeth were restored with stainless steel crowns. Teeth were clinically/radiographically assessed at 6, 12, 18, and 36 months, after treatment. Data were analyzed by Cochran and McNemar tests. ResultsAll 30 patients showed up for clinical/radiographic follow-ups for up to 36 months. Regarding clinical outcomes, the 6-, 12-, 18-, and 36-month success rates of all experimental groups were nearly similar with no significant difference (p > .05). Regarding radiographic outcomes, the 6-month success rates were similar among the groups (p > .05); however, the 12-, 18-, and 36-month outcomes of CEM and MTA groups were similar but significantly superior to that of CH group (p < .05). ConclusionDiode laser irradiation and subsequent capping of pulp tissue with MTA or CEM cement can be employed for pulpotomy of primary molars.

Histological Analysis of Human Pulp by Comparing Propolis, Mineral Trioxide Aggregate and Calcium Enriched Mixture as a Direct Pulp Capping Agent in Primary Molars

Aim: To evaluate the histological pulp response to three direct pulp capping agents (Propolis, Mineral Trioxide Aggregate and Calcium Enriched Mixture) in primary molars. Study design: Comparative study Place and duration of study: Pediatric Dentistry department and Oral Pathology department at de’Montmorency College of Dentistry, Lahore from 1st May 2016 to 31st December 2016. Methodology: Fifty-seven human vital primary first molars were selected from patients aged 8 years. They were divided into three groups of nineteen each. Propolis, mineral trioxide aggregate (MTA) and calcium enriched mixture (CEM) were used as direct pulp capping (DPC) agents in primary molars. After pinpoint exposure, the teeth were directly pulp capped with above mentioned materials. Teeth were extracted after fifteen days for histological examination of inflammatory pulpal cell response. Results: In Propolis group (15 days duration), 15 teeth (78.9%) were in grade 1inflammation, 1 tooth (5%) was in grade 2 inflammation and 3 teeth (15.7%) were in grade 3 inflammation. In Mineral Trioxide Aggregate group 14 teeth (73.7%) were in grade 1 inflammation, 3 teeth (15.7%) were in grade 2 inflammation and 2 teeth (10.5%) were in grade 3 inflammation. In Calcium Enriched Mixture group 15 teeth (78.9%) were in grade 1 inflammation, 3 teeth (15.7%) were in grade 2 inflammation and 1 tooth (5.3%) were in grade 3 inflammation. Conclusion: The effects of Propolis, Mineral Trioxide Aggregate (MTA) and Calcium Enriched Mixture (CEM) on pulpal tissue are comparable to each other. Propolis is a cheaper material as compared to other direct pulp capping agents and easily available. Therefore, it may be used as an alternative pulp capping agent however, further investigation is required to analyze human pulpal response. Keywords: Direct pulp capping. Propolis, Mineral trioxide aggregate, Calcium enriched mixture, Primary molars

Effect of Propylene Glycol on the Bond Strength of Two Endodontic Cements.

This study evaluated the effect of propylene glycol (PG) on the push-out bond strength of calcium-enriched mixture (CEM) cement compared to mineral trioxide aggregate (MTA). The lumens of two hundred 2±0.2 mm-thick root sections from human extracted teeth were prepared to achieve a diameter of 1.3 mm. The samples were then allocated into eight groups of 25 on the basis of the materials used (MTA or CEM cement) and different proportions of PG (0%, 20%, 505, and 100%). In each group, 0.4 mL of the liquid was mixed with 1 g MTA or CEM cement. After incubation, the push-out strength of the samples was measured using a universal testing machine. Data were analyzed using the two-way ANOVA followed by one-way ANOVA and student's t-test. The MTA group showed significantly higher bond strength in comparison with CEM group (P≤0.001). Also 100% and 20% PG increased the bond strength of MTA (P≤0.001). For CEM cement, 100% and 50% PG decreased the bond strength (P≤0.001). This in vitro study demonstrated that while PG increased the push-out bond strength of MTA, it is not recommended for mixing with CEM cement.

In-vitro Sealing Ability of Calcium Enriched Mixture Cement Versus Amalgam as Retrograde Filling Materials

Introduction: Sealing ability of a retrograde filling material is an important factor for a successful endodontic apicoectomy. The purpose of this in-vitro study was to compare the sealing ability of calcium enriched mixture (CEM) cement versus amalgam as root-end filling materials. Methods: A total of 36 canals of extracted maxillary central incisors were instrumented and obturated using lateral compaction technique. The apical 3 mm of each root was resected and root-end prepared to a depth of 3mm.The teeth were randomly divided into two experimental groups of 15 teeth according to tested materials (Amalgam, CEM cement) and two negative and positive control groups of 3 teeth. Root- end cavities were restored with amalgam (group 1) or CEM (group 2). Sealing ability was evaluated by dye penetration method using Pelikan ink, and a stereomicroscope at x10 magnifications and 0.01 mm accuracy. Data were analyzed by T-test and PResults: The mean linear dye microleakage for CEM cement and amalgam retrofilled groups were 2.08 and 3.77 mm, respectively. There was a statistically significant difference between the two groups (p<0.0001). Conclusion: under the condition of this in vitro study, CEM cement provides a better seal than amalgam when used as a retrograde filling material.

Comparison of Flexural Strength of Mineral Trioxide Aggregate, Calcium-enriched Mixture and BioAggregate.

The aim of this study was to compare the flexural strength of mineral trioxide aggregate (MTA), calcium-enriched mixture (CEM), and BioAggregate (BA). In this study, the flexural strength of materials was measured using a 3-point bend test. After being prepared, MTA, CEM, and BA were inserted into the intra-putty molds using amalgam plugger. The specimens were covered with a sponge wetted with synthetic tissue fluid (STF) and incubated for 96 h. They were then subjected to a 3-point bend test using Universal Testing Machine. The Kruskal-Wallis and Mann-Whitney U tests were used to compare flexural strength in groups. In this study, P<0.05 was considered as the significant level. There were significant differences between the three groups in terms of the flexural strength (P<0.001). The mean flexural strength in the BA, CEM, and MTA groups were 27.32±2, 9.09±1.16, and 10.25±1.6, respectively. Pairwise comparison showed significant differences between the three groups. This in vitro study showed that BA has the highest and CEM has the lowest flexural strength.

Effects of Different Powder to liquid Ratios on the Push out Bond Strength of CEM Cement on Simulated Perforations in the Furcal Area.

BackgroundProper bond strength to dentin is one of the properties of biomaterials used for therapeutic purposes such as repair of furcal perforations. The aim of the present study to evaluate the effects of different powder to liquid ratios of Calcium-enriched mixture (CEM) on the push-out bond strengths in simulated perforations in the furcal area and compare it with Mineral trioxide aggregate (MTA).Material and MethodsFurcal perforations, measuring 1.3 mm in diameter and 2 mm in height, were prepared in 120 mandibular first molars. Then the samples were randomly assigned to two groups (n=60). MTA and CEM cement were used for the repair of perforations in groups 1 and 2, respectively. Each group was divided into 3 subgroups based on the powder to liquid rations as follows: subgroup 1 (W/P) , 1:2; subgroup 2, 1:3; and subgroup 3, 1:4. After mixing and placing the materials in the perforation area, the samples were placed in closed containers at 37°C and 100% relative humidity for one week. A universal testing machine was used to determine the bond strength values. After recording the standard deviations, data were analyzed with two-way ANOVA. Statistical significance was set at P<0.05.ResultsIn the MTA and CEM groups the highest push-out bond strength values were recorded in the third (W/P: 1:4) and first (W/P: 1:2) subgroups, respectively. There were significant differences in both groups between the ratios mentioned above and the other ratios (P<0.05).ConclusionsUnder the limitations of the present study, an increase in the powder-to-liquid ratio in CEM cement resulted in a decrease in bond strength, contrary to MTA. Key words:CEM, Perforation, Powder-to-liquid ratio, push-out bond strength, MTA.

Comparison of Tooth Discoloration Induced by Calcium-Enriched Mixture and Mineral Trioxide Aggregate.

Introduction:The aim of this in vitro study was to evaluate the tooth discoloration induced by calcium-enriched mixture (CEM) cement and mineral trioxide aggregate (MTA). Methods and Materials:Forty five endodontically treated human maxillary central incisors were selected and divided into three groups (n=15) after removing the coronal 3 mm of the obturating materials. In the MTA group, white MTA plug was placed in pulp chamber and coronal zone of the root canal. In CEM cement group, CEM plug was placed in the tooth in the same manner. In both groups, a wet cotton pellet was placed in the access cavity and the teeth were temporarily sealed. After 24 h the teeth were restored with resin composite. In the negative control group the teeth were also restored with resin composite. The color change in the cervical third of teeth was measured with a colorimeter and was repeated 3 times for each specimen. The teeth were kept in artificial saliva for 6 months. After this period, the color change was measured again. Data were collected by Commission International de I'Eclairage's L*a*b color values, and corresponding ΔE values were calculated. The results were analyzed using the one-way ANOVA and post-hoc Tukey’s test with the significance level defined as 0.05. Results:There was no significant differences between CEM group and control group in mean discoloration. The mean tooth discoloration in MTA group was significantly greater than CEM and control groups (P<0.05). Conclusion:According to the result of the present study CEM cement did not induce tooth discoloration after six months. Therefore it can be used in vital pulp therapy of esthetically sensitive teeth.

The effect of different mixing methods on the flow rate and compressive strength of mineral trioxide aggregate and calcium-enriched mixture.

Flow rate (FR) and compressive strength (CS) are important properties of endodontic biomaterials that may be affected by various mixing methods. The aim of this experimental study was to evaluate the effect of different mixing methods on these properties of mineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) cement. Hand, amalgamator and ultrasonic techniques were used to mix both biomaterials. Then 0.5 mL of each mixture was placed on a glass slab to measure FR. The second glass slab (100 g) was placed on the samples and 180 sec after the initiation of mixing a 100-g force was applied on it for 10 min. After 10 min, the load was removed, and the minimum and maximum diameters of the sample disks were measured. To measure the CS, 6 sample of each group were placed in steel molds and were then stored in distilled water for 21 h and 21 days. Afterwards, the CS test was performed. Data were analyzed with multi-variant ANOVA and post hoc Tukey tests. The level of significance was set at 0.05. There were significant differences in FR of MTA and CEM cement with different mixing techniques (P<0.05). In the MTA group, none of the mixing techniques exhibited a significant effect on CS (P>0.05); however, in CEM group the CS at 21-h and 21-day intervals was higher with the hand technique (P<0.05). Mixing methods affected the flowability of both biomaterials and compressive strength of CEM cement.

Comparison of pH Changes Induced by Calcium Enriched Mixture and Those of Calcium Hydroxide in Simulated Root Resorption Defects

IntroductionExternal resorption usually occurs after dental trauma and the loss of root cementum. Because it has the ability to induce alkaline pH, calcium hydroxide is used in treatment of external resorption, which is reportedly not free from disadvantages. Driven by such understanding, the aim of this in vitro study was to compare the pH changes induced by calcium enriched mixture (CEM) and those of calcium hydroxide in simulated root resorption defects. MethodsTwenty-one paired extracted human premolars were cut to the length of 14 mm. Root canal preparation was performed by using ProTaper rotary system. Cavities of 0.7-mm depth and 1.4-mm diameter were prepared on the external root surface, 5 mm from the apex. Half of the teeth were filled with CEM and the other half with calcium hydroxide. Five premolars were also assigned as the negative control group and filled with normal saline. To be assured of the filling quality, a radiograph was obtained from each tooth. Subsequently, pH of the cavity was measured with a microelectrode at 20-minute, 3-hour, and 1-, 7-, 14-, 21-, and 28-day intervals after filling. ResultsMean pH in the CEM and in the calcium hydroxide groups were significantly varied during the study period, with pH of the calcium hydroxide group significantly higher than that of CEM in all of the measurements. However, no significant difference was observed between the pH of the calcium hydroxide group and that of the control group at the 7-day and 14-day measurements and between those of the CEM group and the control group at days 7, 21, and 28. ConclusionsIn comparison with calcium hydroxide, CEM hardly maintained alkaline pH during the first month of use, and so CEM may be an inappropriate material in treatment of external root resorption.

Effect of Mineral Trioxide Aggregate, Calcium-Enriched Mixture Cement and Mineral Trioxide Aggregate with Disodium Hydrogen Phosphate on BMP-2 Production.

One of the hypotheses regarding the calcification induction by mineral trioxide aggregate (MTA) is the involvement of transforming growth factor-Beta (TGF-β) super family. Calcium-enriched mixture (CEM) cement is one of the endodontic biomaterials with clinical applications similar to MTA. The aim of the present in vitro study was to compare the induction of bone morphogenic protein-2 (BMP-2) by a combination of disodium hydrogen phosphate (DSHP) and tooth colored ProRoot MTA (WMTA), to that of CEM cement and WMTA. Human gingival fibroblasts (HGFs) were obtained from the attached gingiva of human premolars. HGFs were cultured in Dulbecco's Modified Eagle's medium, supplemented with 10% fetal calf serum, penicillin, and streptomycin. Cells in groups 1, 2 and 3 were exposed to WMTA, CEM and WMTA+DSHP discs, respectively. The fourth group served as the control. After 72 h of exposure, HGF viability was determined by Mosmann's tetrazolium toxicity (MTT) assay. BMP-2 levels in cell-free culture media were determined by enzyme-linked immunosorbent assay (ELISA). Statistical analysis was performed using the one-way ANOVA, followed by the post hoc Games-Howell test for BMP-2 and post hoc Tukey's test for the results of MTT assay. Cellular viability was significantly higher in group 3 compared to the other groups (P<0.05); however, CEM and WMTA did not exhibit significant differences (P=0.08). The control group exhibited significantly higher cellular viability in comparison to the other groups of the study (P<0.05). The highest and lowest protein production rates were observed in the WMTA (3167±274.46 pg/mL) and WMTA+DSHP (1796±839.49 pg/mL) groups, respectively. There were no significant differences between the control, WMTA and CEM groups (P>0.05). WMTA and CEM did not exhibit any significant differences in terms of inducing BMP-2 production; however, incorporation of DSHP into WMTA resulted in a decrease in the induction of this protein.

Gene Expression and Cytokine Release during Odontogenic Differentiation of Human Dental Pulp Stem Cells Induced by 2 Endodontic Biomaterials

IntroductionMineral trioxide aggregate (MTA) and calcium-enriched mixture (CEM) have shown osteogenic/cementogenic/dentinogenic activities; however, their mechanism of action is not fully understood. We aimed to evaluate the effect of these biomaterials on odontogenic differentiation of human dental pulp stem cells (DPSCs). MethodsFlow cytometry with stem cell markers for the confirmation of stemness and homogeneity was first performed. Then isolated DPSCs were seeded on prepared discs of MTA, CEM, differentiation medium (DM), and growth medium (GM) and incubated up to 14 days. Concentrations of transforming growth factor-β1, bone morphogenetic protein (BMP)2, BMP4, and fibroblast growth factor 4 were measured at each interval using an enzyme-linked immunosorbent assay reader. Gene expression of dentin sialophosphoprotein, dentin matrix protein 1, and the cytokines were evaluated by reverse-transcription polymerase chain reaction. To evaluate the cell morphology, scanning electron micrographs were taken; mineralization potential was evaluated using alizarin red S staining. ResultsScanning electron micrographs showed that DPSCs spread/adhered/proliferated similarly on MTA and CEM. On day 14, alizarin red S staining confirmed that mineralization occurred in all groups except GM. Expressions of dentin matrix protein 1 and dentin sialophosphoprotein genes were similar in the CEM, MTA, and DM groups; they were significantly higher compared with the GM group (P < .05). A greater amount of transforming growth factor-β1 gene was expressed in MTA compared with the other groups (P < .05). However, the expression of fibroblast growth factor 4 and BMP2 genes was significantly greater in the CEM group (P < .05). In all the tested groups, the expression of BMP4 was less than GM (P < .01); however, CEM and DM were similar but more than MTA (P < .05). Concentrations of protein product detected using an enzyme-linked immunosorbent assay reader confirmed these gene expressions. ConclusionsMTA and CEM can induce osteo-/odontogenic-like phenotype differentiation of human DPSCs; however, they stimulate different gene expressions and growth factor release.

Treatment outcomes of primary molars direct pulp capping after 20 months: a randomized controlled trial.

The aim of this randomized controlled trial was to compare the radiographic and clinical success rates of direct pulp capping (DPC) using ProRoot mineral trioxide aggregate (MTA) or calcium enriched mixture (CEM). A total of 42 symptom-free carious vital primary molars (21 pairs) were selected in this split mouth trial and randomly pulpotomized in two experimental groups. Pinpoint pulp exposures were covered by the same blinded operator with MTA or CEM, and then restored by amalgam. Radiographic and clinical successes were evaluated at 20 month follow-up. Data were statistically analyzed using McNemar test. Nineteen patients were available for 20-month follow-up; only one failed tooth was extracted in the CEM group. All available teeth were symptom-free, however, the final evaluated success rate was 89% in CEM (CI 95%: 0.82-0.96) and 95% in MTA (CI 95%: 0.85-1) groups without statistical difference (P=0.360). Worst case scenario was applied for missing value analysis; assuming that the 2 lost cases in CEM group had failed and the only lost case in MTA group was due to treatment success, as a result the success of CEM and MTA were 81% (CI 95%: 0.72-0.90) and 95% (CI 95%:0.85-1), respectively, with no statistical difference (P=0.078). In the reverse scenario, the success of MTA and CEM were 86% (CI 95%: 0.78-0.94) and 90% (CI 95%: 0.82-0.98), respectively; again with no statistical difference (P=0.479). Effectiveness of MTA and CEM biomaterials for primary molars' DPC was similar; CEM can be a suitable alternative for MTA.

Microleakage of CEM Cement and ProRoot MTA as Furcal Perforation Repair Materials in Primary Teeth.

Iatrogenic furcal perforation is a procedural accident in endodontic treatments of primary/permanent teeth; prognosis may be favorable if a complete seal with biomaterial is immediately established. The purpose of this in vitro study was to evaluate microleakage of calcium enriched mixture (CEM) cement and ProRoot mineral trioxide aggregate (MTA) for sealing primary molar furcal perforations. This study was conducted on 38 extracted human primary molars. Furcation perforations were created in the pulp chamber floor. The teeth were divided randomly in two experimental groups (n=17) and two positive and negative controls (n=2). Perforations were then repaired with biomaterials. After 72 h, the teeth were submerged in 2% fuchsin dye solution for 24h. The samples were sectioned longitudinally and evaluated for dye leakage. Data analyzed statistically using ANOVA test. The negative and positive controls behaved as expected. Dye microleakage was observed in all experimental samples; however, there was no statistically significant difference between the microleakage of MTA (4.411±2.042 mm) and CEM (3.647±1.040 mm) groups (P>0.05). Based on the findings of this in vitro study, CEM and tooth-colored ProRoot MTA have similar sealing ability for furcal perforation repair of primary molar teeth.

Microleakage comparison of four dental materials as intra-orifice barriers in endodontically treated teeth.

The aim of this in vitro study was to compare polymicrobial microleakage of calcium enriched mixture (CEM) cement, mineral trioxide aggregate (MTA), amalgam, and composite resin as intra-orifice sealing materials. Seventy single-rooted mandibular premolars were instrumented and obturated by cold lateral compaction technique. The teeth were randomly divided into four experimental groups according to used material: CEM, MTA, amalgam and composite resin (n=15) and two control groups (n=5). In experimental groups, 2 mm of coronal gutta-percha was removed and replaced with the study material. All the teeth were mounted in a two-chamber apparatus and the coronal portion was exposed to human saliva. The day the turbidity occurred was recorded for each sample. Data were analyzed using one-way ANOVA. The negative control group showed no leakage while the average microleakage time in the positive control group was 3.5 days. The average bacterial leakage times for amalgam, composite resin, MTA, and CEM groups were 27.42±3.6, 29.35±3.15, 52.57±2.87, and 50.42±2.73 days, respectively. There was no significant difference between CEM and MTA groups (P=0.27) and also between amalgam and composite resin groups (P=0.36). However, in term of average leakage time, MTA and CEM groups exhibited significant differences with amalgam and composite resin groups (P<0.001). According to the results of the present in vitro study, in terms of coronal sealing in endodontically treated teeth, CEM and MTA are more effective than amalgam and composite resin.

Comparison of Skin Test Reactivity of Two Endodontic Biomaterials in Rabbits

In this in vivo study, the skin reactivity of rabbits to Mineral Trioxide Aggregate (MTA) and Calcium Enriched Mixture (CEM) was compared. Sixteen albino rabbits were used. The dorsal skin in three areas (2 x 2 cm) of the rabbits was shaved 24 h prior to the test. The areas were randomly covered with freshly mixed biomaterials [MTA (n = 16), CEM (n = 16) and normal saline (control; n = 16)], sterile gauze and bandages were placed for 4 h and the biomaterials were washed. The surface areas of the reactive skin sections were examined by naked eye and measured in 1, 24, 48 and 72 h using the Cavalier technique. The animals were then sacrificed and histological sections were prepared for blind examination. Results of macroscopic examination revealed a significant difference (p = 0.003) between the average erythematous surface areas induced by MTA (1.61 +/- 0.32) and CEM (0.5 +/- 0.16). Results of histological examination showed that the highest inflammation was observed in MTA, followed by CEM and control groups. Comparison of the difference in inflammatory cell count between each group revealed statistically significant differences in all cases (p < 0.001). The results demonstrated that the biocompatibility of CEM cement is higher than MTA; CEM can be considered as a suitable endodontic biomaterial.

Osseous reaction to implantation of two endodontic cements: Mineral trioxide aggregate (MTA) and calcium enriched mixture (CEM)

Aim: The aim of the present in vivo study was to determine bone tissue reaction to calcium enriched mixture (CEM) and mineral trioxide aggregate (MTA) using a rat femur model. Study Design: Sixty-three rats were selected and randomly divided into three groups of 21 each [experimental groups (n=15), control (n=6)]. Implantation cavities were prepared in each femoral bone and randomly filled with the biomaterials only in the experimental groups. The animals in three groups were sacrificed 1, 4, and 8 weeks postoperatively. Histologic evaluations comprising inflammation severity and new bone formation were blindly made on H&E-stained decalcified 6-µm sections. Results: At 1, 4, and 8 weeks after implantation number of inflammatory cells had decreased in the CEM, MTA and control groups, respectively, with no statistically significant differences. Conversely, new bone formation had increased in all the experimental and control groups, without statistically significant differences. Conclusion: The results suggest that biocompatibility of MTA, as gold standard, and CEM cement as a new endodontic biomaterial are comparable Key words:Endodontics, MTA,CEM, osseous reaction.