Pulp Perforation Research Articles

An Insight of Proanthocyanidin and Polyamidoamine-Calcium Phosphate Nanoparticles as Biomaterial Candidate for Dentin regeneration in Dental Pulp Capping: A Narrative Review

Dental caries is the world's biggest dental problem with an incidence of 95%, causing tooth demineralization and complications including pulp perforation and premature tooth loss. A non-toxic biomaterial is required for increasing dentine regeneration in reversible dental caries. Proanthocyanidin (PA) is grape seed-derived flavonoid as antibacterial, anti-inflammatory, and antioxidant. However, PA provides low bioavailability so that it can be combined with polyamidoamine-calcium phosphate (PAMAM-CP) nanoparticles as drug delivery system. The investigation of PA and PAMAM-CP nanoparticles paste-based as innovation biomaterial for dental pulp capping may potential to induce dentine regeneration. The aim of this narrative review is to describe the combination of PA and PAMAM-CP nanoparticles as dental pulp capping biomaterial for dentin regeneration in dental caries. PA is able to express runt related transcription factor (Runx2), bone morphogenic protein-2 (BMP2), osteocalcin (OCN), and dentine sialophospoprotein (DSPP) which increase biomineralization and odontogenic differentiation. PAMAM is a macromolecule that provides attachment to dentine and induces remineralization. CP nanoparticles are calcium phosphate-based drug carriers that facilitate dentinal tubules penetration. PA loaded PAMAM-CP nanoparticles would be encapsulated releasing PA. PA suppresses Nuclear Factor-kB signaling pathway activation and decrease tumor necrosis factor-α so that inhibit dentinal matrix degradation. PA increases Runx2 and DSPP expression that manifest in dental pulp stem cells differentiation into odontoblasts. Combination of PA and PAMAM-CP nanoparticles may potential and beneficial as pulp capping biomaterial for dentin regeneration in dental caries.

Effect of Purple Leaf Extract (Graptophyllum Pictum (L.) Griff) on the Number of Macrophage Cells in Pulp Perforation

Background: Purple leaf (Graptophyllum pictum (L.) Griff) is one of Indonesia’s traditional medicinal plants, which has anti-inflammatory properties which is expected to stop the inflammation of the pulp accompanied by perforation. Purpose: To determine the effect of giving purple leaves (Graptophyllum pictum (L.) Griff) to the number of macrophage cells in pulp perforation. Method: The study used 24 Wistar rats divided into four groups, namely control (K), and 3 treatment groups P1, P2, P3. Each group consisted of 6 rats prepared, then P1 was given 10% purple leaf extract, P2 was given 15% purple leaf extract, P3 was given 20% purple leaf extract. On the 3rd day, the Wistar rat was sacrificed and continued with the preparation of HPA. Calculation of the number of macrophages was obtained from the One-way ANOVA test. Results: There were significant differences between the control and treatment groups (K with P1, P2, P3), on the results of the One-way ANOVA difference-result test (p <0.05) Conclusion: Purple leaf extract (Graptophyllum pictum (L.) Griff) affected increasing the number of macrophage cells in pulp perforation after the 3rd day of treatment.

THE EFFECT OF CALCIUM HYDROXIDE-PROPOLIS ON THE NUMBER OF MACROFAG CELLS ON THE WISTAR RAT DENTAL WITH PULPA PERFORMANCE

Background: Cellular response of dental pulp to existing lesions, caused by infiltration of inflammatory cells that migrate from blood vessels to the site of injury. Macrophages are the cells that most appear when inflammation occurs. Treatment for maintaining pulp tissue vitality is called pulp capping. Calcium hydroxide as a pulp capping material has the ability to trigger the growth of dentin bridges or remineralization, but calcium hydroxide can induce migration and proliferation of inflammatory cells. Currently the field of dentistry is developing propolis as an alternative pulp capping material. That is because propolis has anti-inflammatory properties. Objective: To analyze the effect of the combination of calcium hydroxide-propolis on the number of macrophage cells in the teeth of wistar rats with pulp perforation. Method: This study used 30 samples of Wistar rats which were preparated until perforation and then divided into 3 groups. The first group continued with filling with cention, the second group continued with application of calcium hydroxide and filled with cention, and the third group continued with the application of combination of calcium hydroxide and propolis and then being filledwithcention. Macrophage cell is calculated histopathologically by using compound light microscope on the 3rd day with 400x magnification. Results: The Kruskal-Wallis test results showed significant differences in macrophages after the combination of calcium hydroxide and propolis (p = 0,000). The combined application of calcium hydroxide and propolis showed higher macrophages than the application of calcium hydroxide and the control group. Conclusion: Application of calcium hydroxide - propolis combination was proven increase the number of macrophage cells in Wistar Rats (Rattus Norvegicus) with pulp perforation

Efficacy of topical hydrogel Epigallocatechin-3-gallate against neutrophil cells in perforated dental pulp

Background: One cause of pulpitis is mechanical trauma such as pulp perforation. The emergency treatment of pulpitis in a clinic uses eugenol. Eugenol in a high concentration causes cytotoxicity, which causes local necrosis and inhibits the recovery process, while in lower doses it can cause oral mucosal hypersensitivity. Due to these side effects, it is worth considering other biocompatible materials with minimal side effects, such as epigallocatechin-3-gallate (EGCG) which is found in green tea. As a polyphenol, EGCG has a radical scavenging ability, which has an effect on reducing the number of neutrophils. The application of EGCG is expected to reduce neutrophils on the second day after injury so the rehabilitation process is completed more quickly and ongoing inflammation and pulp necrosis is prevented. Purpose: To analyse the efficacy of topical hydrogel EGCG in reducing the number of neutrophils after 48 hours in the perforated dental pulp of Wistar rats. Method: 20 Wistar rats were divided equally into four groups, which were designated control (C) and treatment groups (T1, T2, T3). The upper first molar teeth of each rat were perforated and then T1, T2, and T3 were given 60 ppm, 90 ppm and 120 ppm hydrogel EGCG respectively. On the second day, the rats were sacrificed. HPA preparations were made to calculate the number of neutrophils in each group. Data was analysed using Kolmogorov–Smirnov, Levene’s, one-way ANOVA and Tukey HSD test (p<0.05). Results: There were significant differences between T2 and T3 compared with C and T1 (p<0.05), but no significant differences in the comparison of T1 with C and of T2 with T3 (p>0.05). Conclusion: 90 ppm hydrogel EGCG is effective in reducing the number of neutrophils in the perforated dental pulp of Wistar rats.

THE EFFECT OF COMBINATION CALCIUM HYDROXIDE-PROPOLIS APPLICATION TO AMOUNT OF NEUTROFIL CELLS ON WISTAR RAT PULP PERFORATION

Background: Pulp inflammation can be treated with pulp capping by calcium hydroxide as the gold standard. Pulp capping by calcium hydroxide could causing tissue necrosis followed by inflammation. Calcium hydroxide combined with propolis which have anti-inflammatory effects through inhibition of the Nf-kB pathway and pro-inflammatory cytokines. That process will inhibit the increase of vascular permeability and neutrophil chemotaxis. Inflammatory process can accelerate by controlling the amount of neutrophil cells as a acute phase marker, so the healing process occurs more quickly. Therefore it is necessary to study the amount of neutrophil cells in the pulp perforation of Wistar rats after applicated by combination of calcium hydroxide-propolis. Purpose: To analyze the difference amount of neutrophil cells on the Wistar rats pulp perforation after applicated by calcium hydroxide-propolis combination compared with calcium hydroxide-aquadest Method: M1 tooth perforated for all groups with three types tratment: no medication (control group), calcium hydroxide-aquadest 1: 1 (P-1 group), and calcium hydroxide-propolis 1: 1.5 (P-2 group) and closed with cention. Observations were made on the 1st, and 3rd day with HE staining. Results: One Way ANOVA shown a significant difference (p <0.05) of the average amount of neutrophil cells between all treatment groups on 1st day (p=0,000) and 3rd day (p=0,000). The amount of neutrophil cells in the calcium hydroxide-propolis (P-2) combination group was lower than control group and calcium hydroxide-aquadest (P-1) group on the 1st and 3rd day. Conclusion: The amount of neutrophil cells after application of calcium hydroxide-propolis is lower than calcium hydroxide-aquadest application.

Effect of Epigallocatechin-3-Gallate (EGCG) on The Number of Lymphocyte Cells in Inflammation of Pulp with Mechanical Injury

Background: Pulpitis is an inflammatory pulp that can caused by pulp perforation by mechanical injury. Emergency treatment of pulpitis is using Eugenol. High concentrations of Eugenol have a cytotoxic effect that causes local necrosis and inhibits the healing process. Because of negative effects from eugenol, then it’s necessary to consider a new ingredient with minimal side effects, and it’s epigallocatechin-3-gallate (EGCG) in green tea. As a polyphenol, it has good antioxidant effect and plays a role in shortening the duration of inflammation by radical scavenging against Nitric Oxide so that NO levels rapidly decrease which causes migration of neutrophil cells to the area of injury will decrease and the inflammatory process faster so that the healing process become faster. Lymphocyte is plays a role in tissue repair. Purpose: to explain the effect of EGCG hydrogel on the number of lymphocyte cells in pulp inflammation with mechanical injury. Methods: The study used 24 Wistar rats divided into four groups, namely control (C), and 3 groups of treatment (T1, T2, T3). Each group consisted of 6 rats prepared, then EGCG hydrogel 60 ppm was named T1, EGCG hydrogel 90 ppm was named T2, EGCG hydrogel 120 ppm was named P3. On the 3rd day, Wistar rats were decapitated for HPA preparations. Results: This study showed a significant difference in each group (p < 0.05) using One-Way Anova analysis. Conclusion: EGCG hydrogel 90 ppm is effective in increasing the number of lymphocyte cells in inflammation of the pulp with mechanical injury.

Effect of Hydrogel Epigallocatechin-3-Gallate (EGCG) to the Number of Fibroblast Cell Proliferation in the Perforation of Wistar Rat Tooth Pulp

Background: Pulpitis can occur because the deep cavity preparation and it causes increasing of NO levels. Perforated teeth require direct pulp capping (DPC) treatment. The current standard DPC material is calcium hydroxide. However, several studies have found weaknesses of calcium hydroxide that can affect the success of DPC treatment and new, more biocompatible materials are needed. Epigallocatechin-3-gallate (EGCG) in green tea has many benefits, including antioxidant, anticolagenase, anticancer, anti-inflammatory and has the ability of radical scavenging to clean NO so that pulp healing can occur better by increasing the number of fibroblast cells that play a role in wound healing. Purpose: To determine the concentration of hydrogel EGCGs that are effective in increasing the number of fibroblast cell proliferation in the dental pulp perforation of Wistar rats. Method: This research is a laboratory experimental study with a randomized post test only control group design. Samples used in the study were 24 male Wistar rats which were divided into four groups, namely the negative control group and the treatment group were given EGCG 60 ppm, 90 ppm, and 120 ppm and were decapitated on the 7th day after treatment. The maxilla and the 1st molar were taken and decalcified, to process the HPA reading with HE staining. Observations were made using a microscope with a magnification of 400x. Results: There were significant differences in the treatment groups with 60 ppm and 90 ppm hydrogel hydrogels on the results of the Oneway ANOVA difference test (p <0.05). Conclusion: The concentration of hydrogel EGCG which is effective in increasing fibroblast cell proliferation is 90 ppm.

A 3D finite element analysis of stress distribution on different thicknesses of mineral trioxide aggregate applied on various sizes of pulp perforation.

The aim of this study was to evaluate the stress distribution on different thicknesses of mineral trioxide aggregate (MTA) placed on various widths of pulp perforations during the condensation of the composite resin material. The mandibular molar tooth was modeled by COSMOSWorks program (SolidWorks, Waltham, MA). Three finite elemental analysis models representing 3 different dimensions of pulp perforations, 1, 2, and 3mm in diameter, were created. The perforation area was assumed as filled with MTA with different thicknesses, 1, 2, and 3mm for each pulp perforation width, creating a total of 9 different models. Then, a composite resin material was layered on MTA for each model. A 66.7N load was applied and an engineering simulation program (ANSYS, Canonsburg, US) was used for the analysis. Results were presented considering von Mises stress criteria. As MTA thickness increased, the stress values recorded within the area between pulp and MTA decreased. Strain was decreased when the thickness of MTA increased. Stresses at MTA-pulp interface and strain on MTA decreased with the increase in MTA thickness. In clinical practice, when MTA is required for pulp capping, using a thick layer of the material seems to be a better option in order to reduce the stress under forces of hand condensation of overlying restorative materials.

Factors Affecting the Decision-Making of Direct Pulp Capping Procedures Amongst Turkish Dental Practitioners.

Objective:To examine the factors affecting the decision-making of direct pulp capping procedures amongst Turkish dental practitioners.Methods:A total of 378 Turkish dentists participated in the survey. The questionnaire comprised three sections. The first part comprised questions regarding demographic features. The second part comprised; questions on how treatment plans change according to factors such as pulp perforation position, number, size, how it occurred, and patient age. The third part composed of questions on the common materials and techniques used in pulp capping treatment. Descriptive statistics was calculated using Pearson’s χ2 test, and the risk assessments of factors affecting the choice of pulp capping decision were computed using logistic regression analysis.Results:85.18% of participants preferred the pulp capping treatment. When the perforation size was >1 mm, males and university dentists decided more pulp capping treatments than females and private dentists respectively did (P<0.05). While the perforation size factor changed the dentists’ decision most (OR=6.85), the patient’s age factor least altered the choice (OR=1.38). Gender did not affect the decision of technique and material (P>0.05), but workplace and experience affected the choice of material (P<0.05). Technique did not affect the decision (P>0.05).Conclusion:Turkish dentists prefer invasive treatments when risk factors in pulp capping treatment increase. The possible cause may be to reduce the rate of unsuccessful treatment; thus, ensure the continuity of patient confidence.

Pulp and dentin modifications that occur after direct and indirect overlay with materials on the calcium hydroxide-base

When pulp tissue gets exposed, therapy procedures are supposed to promote healing and to ease forming of reparative dentin in order to preserve vitality and health of the pulp. Vital pulp therapy (VPT) procedure includes removal of the local irritants as well as application of protective materials directly or indirectly on tooth pulp. Vital pulp therapy may be used for the treatment of the reversible pulp diseases in order to promote root development and to form apical region which will ensure correct endodontic tooth treatment in later stages. There are numerous controversies concerning vital pulp therapy but mostly related to the choice of the materials, correct technique and evaluation of the final therapy results. The goal of the experimental research is to use scanning electron and polarized microscopy to analyze modifications on cellular and extracellular components of the tooth pulp after direct and indirect overlaying with materials on the calcium hydroxide basis (Calcimol VOCO USA). We will also determine the appearance of dental surface after direct and indirect overlaying and if Calcimol proves good and effective in dentinogenesis, we will propose it for clinical usage. Research has been conducted on experimental animals (pig). Materials used in this research were on calcium hydroxide - base, Calcimol. V class preparation has been applied on the teeth of the experimental group. Eleven teeth have been overlaids directly and the same number of teeth has been overlaid indirectly. After the preparation, materials based on calcium hydroxide have been applied and cavity has been closed with materials from the glass ionomer cement group (FUJI IX GC Japan). Teeth that were treated with pulp perforation had their chambers filled with materials on calcium hydroxide-base and their cavities were closed with glass ionomer cement (FUJI IX GC Japan). Correctly prepared teeth have been observed with SEM and polarization microscopes. Observing and analyzing of the results with polarization and scanning electron microscope in comparison with control group showed that gained results may have significant clinical implication in biological pulp treatment. Directly applied Calcimol observed through polarization microscope points to intensive changes in blood vessels and beginnings of erythrocyte disintegration, distinct extravasation, and appearance of the small necrotic spots. SEM analyzes shows contact of the amalgam-Calcimol without new amorphous dentinal structures. Indirectly applied Calcimol observed through polarization microscope points to newly formed dentinal structures, calcification cores surrounded by huge cells and blood vessels presence. SEM analyzes shows clear border between newly formed dentinal tubules and ordinary dentinal structure. Gained results suggest application of the Calcimol as a material for indirect pulp overlay while its application in indirect overlay isn't indicated.

Stimulation of type I collagen activity in healing of pulp perforation

Background : TGF- β 1 is a connective tissue stimulant, potential regulator for tissue repair, and promoter in wound healing. The healing of pulp perforation is decided by quantity and quality of new collagen deposition. TGF- β 1 upregulates collagen transcription. However, after several weeks production of type I collagen synthesis is stopped and enzymatic degradation of collagen matrix will occur. Purpose : Observe synthesis type I collagen during the process of pulp perforation healing in 7, 14, and 21 days after being treated using TGF- β 1. Methods : This research in vivo from orthodontic patients indicated for premolar extraction, between ages 10–15 years. A class V cavity preparation was created in the buccal aspect 1 mm above gingival margin until pulp exposure. Cavity was irrigated slowly with saline solution and dried with a sterile small cotton pellet. The sterile absorbable collagen membrane used, soaked with 5 μl of TGF- β 1. It was covered by teflon pledge to separate from glass ionomer cement as restoration. Evaluated on day 7 th , 14 th , and 21 st . All samples were extracted and prepared for immunohystochemical examination. Result : Data were analyzed by t-test. There was significant difference in synthesis type I collagen compared between 7–14 days and 7–21 days after treatment by TGF- β 1 also Ca(OH) 2 . There was significant difference compared between TGF- β 1 and Ca(OH) 2 in 14–21 days after treatment (means TGF- β 1 > Ca(OH) 2 ). Conclusion : Elevation of synthesis type 1 collagen by TGF- β 1 in 20 mg/ml.

Differential repair responses in the coronal and radicular areas of the exposed rat molar pulp induced by recombinant human bone morphogenetic protein 7 (osteogenic protein 1)

Bone morphogenetic protein 7 (BMP 7), also termed osteogenic protein 1, a member of the transforming growth-factor superfamily, was examined for its efficacy in inducing reparative dentinogenesis in the exposed pulps of rat molars. To determine if the reaction was dose-dependent, collagen pellets containing 1, 3 or 10 μg of recombinant BMP 7 were inserted in intentionally perforated pulps (10–12 pulps per group) in the deepest part of half-moon class V-like cavities cut in the mesial aspect of upper first molars. As controls, the collagen carrier (CC group) alone and calcium hydroxide (Ca group) were used as capping agents. All cavities were then restored with a glass-ionomer cement. Half of the animals were killed after 8 days and the other half after 28 days, by intracardiac perfusion of fixative. The molars were processed for histological evaluation by light microscopy. No difference in effect could be detected between the three concentrations of BMP 7 groups at either time interval. After 8 days, all groups showed varying inflammation, from mild of severe, and the Ca group demonstrated early formation of a reparative dentine bridge. At 28 days the CC group displayed irregular osteodentine formation, leaving some unmineralized areas at the exposure site and interglobular unmineralized areas containing pulp remnants. In the Ca-treated pulps, the initial formation of thick reparative osteodentine bridges that sealed more or less completely the pulp perforation was followed, in the deeper part, by irregular tubular dentine. In most BMP 7-treated specimens, the initial inflammation has resolved at 8 days and at 28 days heterogeneous mineralization or osteodentine filled the mesial coronal pulp. They also had complete filling of the radicular pulp by homogenous mineralization in the mesial root; this reaction was found in 11 teeth in the BMP 7 group, one tooth in the CC group an none of the Ca group. These results emphasize the biological differences the coronal and radicular parts of the pulp, and the potential of bioactive molecules such as BMP 7 to provide an a alternative conventional endodontic treatments.

A practice-based study on stepwise excavation of deep carious lesions in permanent teeth: a 1-year follow-up study.

This study reports results from a practice-based study in which deep carious lesions were treated by general dental practitioners using stepwise excavation. The material comprised 94 teeth with deep carious lesions which the clinicians considered would result in pulp perforation if treated by a single and terminal excavation. At the first visit excavation of the peripheral dentine was completed. The outermost part of the central and necrotic dentine was gently removed with a sharp excavator. Standardized assessments of the dentine colour and consistency were made before application of a calcium hydroxide-containing base material and temporary filling. The final excavation was completed after a treatment interval ranging from 2 to 19 months, with a median of 6 months. Reassessments of the dentine colour and consistency were made before complete removal of demineralized dentine. The central dentine was significantly browner and less softened after the sealing period. After removal of the dark-brownish dentine during the final excavation, the colour and consistency of the exposed central dentine was found to resemble that of the completely excavated peripheral dentine. Only five cases resulted in pulp perforation during the final excavation. The high success rate of teeth surviving the final treatment without pulp exposure after 1 year of observation shows that it was possible for dentists in general practice to administer and manage the treatment of deep carious lesions, a process which may prolong tooth survival compared with conventional endodontic techniques.

A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals.

Concern about the survival of microorganisms in deep carious lesions may often lead to unnecessary exposure of the pulp during final excavation. There are reasons, therefore, to initiate systematic studies on the alternative procedure known as stepwise excavation. Clinical evaluation of stepwise excavation was performed on 31 deep carious lesions considered to result in pulp perforation by traditional excavation. This study examines the clinical and microbiological alterations during the final excavation performed during long intervals (6-12 months) after the initial treatment that included peripheral dentine excavation and removal of the central cariogenic biomass and the superficial necrotic dentine. The dentine colour and consistency were assessed by means of standardized scales before application of a Ca(OH)2 compound and a temporary sealing for 6-12 months. Reassessments were performed before the after final excavation. Microbiological dentine samples were obtained in 19 randomly selected lesions by a sterile bur, transferred to and diluted in reduced transport fluid, and plated on tryptic soy agar. After anaerobic incubation at 37 degrees C for 7 days, total colony-forming units per millilitre were counted from (1) peripheral excavated and hard dentine (control), (2) central demineralized dentine before and final excavation, and (3) central dentine after the final excavation. Six samples of central demineralized dentine were without any cultivable flora increasing to 9 samples after the final excavation. The clinical dentine changes occurring during stepwise excavation were characterized by enhanced hardness of the dentine which was associated with a marked reduction in bacterial growth after the final excavation. Despite the presence of bacteria in the excavated dentine none of the carious lesions resulted in pulp perforation, suggesting that the initial removal of the cariogenic biomass appears to be essential for control of caries progression. Stepwise excavation is not only an appropriate treatment of deep carious lesions but is also considered a suitable model for microbiological studies to determine the bacteria persisting in clinically excavated lesions.

Tooth dislocation: The relationship with tooth wear and dental abscesses

Tooth dislocation (tilting) was recorded in 1,200 skulls from 34 museum collections. The findings of dislocation by tooth type, tooth wear, and abscess location are presented. A model for dislocation based upon the progressive loss of tooth support provides a rational explanation for the phenomenon. Physiological continuous tooth eruption was considered to account for a component of the progressive loss of tooth attachment. The process of attrition, pulp perforation, and dental abscess cavity formation resulted in further, more severe loss of tooth support. Heavy functional forces, in association with greatly reduced bone support, tilted the crown lingually and root buccally. When the tooth had tilted to such an extent that the root apices protruded from the bone and, presumably (in life) through the gingival/mucosal tissues, the infected root canals were effectively isolated from the internal environment. The tooth continued to function. The more typical consequence of severe attrition and dental abscess formation was tooth loss; it also isolated an infected tooth from living tissue, but without the benefit of retaining function.