Pulp Protection Research Articles

Questions about the numerical value and quantitative data transfer of tooth preparation-from experience guidance to digital guidance.

Tooth preparation is a common operation in dental clinical practice. This procedure is irreversible and invasive from the point of view of tooth preservation. Conditions of the abutment tooth, treatment methods, and restoration materials for target restoration affect tooth preparation. To achieve the goals of tooth tissue preservation, dental pulp protection, and periodontal health, dentistry professionals agreed on the importance of minimizing the amount of tooth reduction. The foundations for realizing this consensus are as follows. First, the available restoration materials with improved comprehensive performance need less target restoration space. Next, teeth can be prepared under a digital guide, and the real-time measurement of restoration space can be verified due to the invention of digital technologies for the analysis of the quantity and shape of the prepared tooth and tooth measurement. Moreover, guiding methods for preparation have been developed from freehand operation under the naked eye based on accumulated personal experience to digital-guidance jointing microscope. These innovations indicate the creation of a prototype of guided prosthodontics that is precise and applies real-time measurement throughout the process of tooth preparation. From the perspective of the evolution of digital, guided, and micro prosthodontics, this article raised seven questions about the numerical value and quantitative data transfer of tooth preparation and evaluated the authenticity of existing numerical requirements from the perspective of the four elements of measurement. Identifying unified measuring methods and developing measuring tools with a precision of hundred or ten microns will be the key to solving the problem about the authenticity of numerical measurement. Furthermore, this paper summarizes the methods of how to control tooth reduction and explains in depth why the currently dominant tooth preparation technology, which is based on empiricism, cannot effectively achieve the goals in digital prosthodontics. Therefore, we strongly call for rebuilding the digital foundation of prosthodontic treatment immediately.

Shikonin induces odontoblastic differentiation of dental pulp stem cells via AKT–mTOR signaling in the presence of CD44

ABSTRACT Purpose: In our previous study, we demonstrated that hyaluronan induces odontoblastic differentiation of dental pulp stem cells via interactions with CD44. However, it remains unclear whether CD44 expression by dental pulp stem cells is required for odontoblastic differentiation. Methods: We searched for a compound other than hyaluronan that induces odontoblastic differentiation of dental pulp stem cells and used western blotting to determine whether CD44 is involved in the induction of odontoblastic differentiation by the compound. We further validated the cell signaling details of the compound-induced expression of dentin sialophosphoprotein (DSPP), which is known as a marker of odontoblastic differentiation. Results: We investigated shikonin, which is one of the derivatives of naphthoquinone, the skeleton of vitamin K. Shikonin-induced expression of DSPP was inhibited by PI3K, AKT, and mTOR inhibitors. Additionally, shikonin-induced expression of DSPP was inhibited in dental pulp stem cells transfected with siRNA against CD44. Conclusions: Shikonin can stimulate dental pulp stem cells to undergo odontoblastic differentiation through a mechanism involving the AKT–mTOR signaling pathway and CD44. Although expression of CD44 is important for inducing odontoblastic differentiation of dental pulp stem cells, the relationship between the AKT–mTOR signaling pathway and CD44 expression, in the context of shikonin stimulation, has not yet been elucidated. This study suggests that shikonin may be useful for inducing odontoblastic differentiation of dental pulp stem cells, and that it may have clinical applications, including protection of the dental pulp.

The Role of Hydraulic Silicate Cements on Long-Term Properties and Biocompatibility of Partial Pulpotomy in Permanent Teeth.

The use of hydraulic silicate cements (HSCs) for vital pulp therapy has been found to release calcium and hydroxyl ions promoting pulp tissue healing and mineralized tissue formation. The present study investigated whether HSCs such as mineral trioxide aggregate (MTA) affect their biological and antimicrobial properties when used as long-term pulp protection materials. The effect of variables on treatment outcomes of three HSCs (ProRoot MTA, OrthoMTA, and RetroMTA) was evaluated clinically and radiographically over a 48–78 month follow-up period. Survival analysis was performed using Kaplan–Meier survival curves. Fisher’s exact test and Cox regression analysis were used to determine hazard ratios of clinical variables. The overall success rate of MTA partial pulpotomy was 89.3%; Cumulative success rates of the three HSCs were not statistically different when analyzed by Cox proportional hazard regression analysis. None of the investigated clinical variables affected success rates significantly. These HSCs showed favorable biocompatibility and antimicrobial properties in partial pulpotomy of permanent teeth in long-term follow-up, with no statistical differences between clinical factors.

The influence of a liner on deep bulk-fill restorations: Randomized clinical trial

ObjectiveThe aim of this study was to evaluate the influence of a liner on the clinical performance of deep posterior restorations performed with bulk-fill composite. Methods30 subjects received two restorations on deep preparations in posterior teeth, without pulpal exposure, after selective carious-tissue removal in one-stage. The internal walls reached the inner quarter of dentin, but with a radiographically detectable zone of firm dentin remaining. The pulpal protection using a layer of glass ionomer composite liner (Ionoseal, Voco) was applied in just one preparation. The adhesive system Futurabond U (Voco) was applied in all preparations, which were restored with the bulk-fill pure Ormocer nanohybrid composite (Admira Fusion Xtra - Voco), in up to 4 mm thick increments. All restorations were evaluated using the FDI criteria after 7 days, 6, 12 and 24 months postoperatively. ResultsAfter 24-months, 25 patients attended the recall and 50 restorations were evaluated. The Fisher’s statistical analysis (5%) showed no difference between the techniques for the esthetic, functional and biological properties. No postoperative sensitivity was reported for both groups. ConclusionThe application of a liner did not influence the clinical performance of deep restorations with bulk-fill Ormocer composite. Clinical relevanceThe application of a liner with a GIC-based material did not have a significant effect on the clinical performance of bulk-fill restorations and seems to be unnecessary for the material tested.

Indirect pulp protection after selective caries removal: a preliminary 6 months randomised controlled trial

This randomized controlled clinical trial evaluated the effectiveness of using indirect pulp protection with calcium hydroxide liner or universal adhesive over a period of 6 months in deep caries on permanent teeth after selective removal to soft dentin. The sample consisted of 68 patients with 55 molars and 21 premolars with deep caries lesion (with radiographic involvement ≥50% dentin deep caries), (median age 27 [distribution 7-54 years]), with signs of pulp vitality (positive response to cold test, absence of spontaneous pain, negative sensitivity to percussion tests, absence of radiographic imaging suggestive of periapical lesion) and absence of cuspid loss. After selective removal to soft dentin, the test group received a universal adhesive (n=38), whereas the control group indirect pulp protection with Calcium hydroxide (n=38). All teeth were restored with composite resin. The successful outcome for pulp vitality was assessed after six months. The results were submitted to the Kaplan-Meier survival analysis and the Log Rank test. The baseline variables were analyzed for their distribution in the two treatment groups by ᵪ2 test and showed a similarly distributed between groups. Success rates to pulp maintenance vitality were 95.5% for the control group and 96.7% for the test group (P=0,986). Two cases of failure were recorded, one pulp necrosis (control group) and one pulpitis (test group). There is no difference between the use of calcium hydroxide or only universal adhesive in indirect pulp protection after selective removal to soft dentine followed by composite restoration at six months of follow-up, showing a high rate of success for both treatments.

Cavity Bases Revisited.

ObjectiveThe aim of this paper was to review the current literature on cavity bases while focusing on the role of zinc oxide eugenol (ZOE) and resin-modified glass ionomers (RMGI) as cavity bases.Materials and MethodsA thorough literature search between 1970 and 2020 was done using Scopus, PubMed, and Google Scholar databases. The keywords of the search strategy were as below: cavity liners and bases, pulp protection, zinc oxide eugenol, and resin-modified glass ionomer. No specific inclusion or exclusion criteria were applied as to what articles would be included in this review.ConclusionThis review emphasizes that the available literature provides very little evidence to support the routine use of a base under amalgam or composite restorations. This review favors the adoption of “no more lining or bases” in shallow and moderate cavity preparations. However, an exception might be a “protective base” of RMGI following the application of calcium hydroxide (CH) liners in deep cavities. Bonded RMGIs are suitable cavity base materials and should always replace zinc oxide eugenol bases in daily practice.

Pulp Protection in Selective Carious Tissue Removal

Pulp Protection in Selective Carious Tissue Removal

Pulp protection protocols under posterior composite restorations: A survey of dentists in Palestine

Introduction: This study aimed to assess the knowledge and practice of dentists in Palestine toward pulp protection protocols under composite restorations and to find any associations with age, years of experience, and gender. Materials and Methods: A questionnaire was randomly distributed among 500 licensed dentists. It included six questions. The first three focused on demographic variables (gender, years of experience, and type of practice). The others focused on the protocols followed in three different Class I cavity scenarios: shallow (remaining dentine thickness [RDT] >1.5 mm), moderate (1.5 >RDT >0.5 mm), and deep (RDT Results: The response rate was 61%. There was a significant difference in the protocols the respondents chose for restoring shallow (P Conclusion: Irrespective of the cavity depth, there was an inconsistent implementation of pulp protection protocols among the respondents.

The role of calcium ion release on biocompatibility and antimicrobial properties of hydraulic cements

Tricalcium silicate (TCS)-based materials produce calcium hydroxide as a byproduct of their hydration reaction. The present study investigated whether calcium ion release (CIR) affects their biological and antimicrobial properties when used as pulp protection materials. The effect of incorporation of micro-silica and calcium phosphate monobasic to radiopacified TCS-based materials was investigated. The commercial TCS-based Biodentine, Bio-C Pulpo, TotalFill Root Repair Material, TheraCal LC and a base/liner- ACTIVA BioACTIVE (Activa) were also evaluated. The hydration and CIR were monitored and correlated with biocompatibility and antimicrobial assessment of eluates. Overall, the additives altered the hydration and leaching profile of the prototype cements. The micro-silica inclusion resulted in a decreased long-term calcium hydroxide formation which was associated with neutralised cytotoxicity and antibacterial activity. Calcium phosphate did not alter the leaching profile, although a stronger antibacterial effect was induced. The commercial materials also had different CIR profiles. The water-based ones had higher CIR, and this was associated with stronger antimicrobial effect but not enhanced biological activity. Both TheraCal LC and Activa exhibited poor degree of conversion, low CIR, acceptable biocompatibility and moderate antibacterial activity. A positive correlation of CIR with antibacterial effectiveness was observed (0.3 < r < 0.49; p = 0.021, p = 0.011 for the two test bacterial cultures). No relation was shown between CIR and cytotoxicity (0.3 < r < 0.49; p = 0.150, p = 0.068 for the two cell cultures studied). The additives modified the CIR. The antimicrobial properties were dependent on the CIR; the cytotoxicity of the materials was unaffected.

A review of the literature on the efficacy of mineral trioxide aggregate in conservative dentistry.

The aim of this literature review was to assess the clinical performance of MTA to establish the evidence level for its effectiveness in vital pulp therapy, perforation repair, and retrograde root canal filling. A comprehensive literature survey was performed via electronic databases of PubMed/MEDLINE. A total of 58 papers were reviewed in this study, of which 2 were systematic reviews/meta-analysis, 9 were randomized controlled trials (RCTs), and the rest were fallen into other categories. Mineral trioxide aggregate (MTA) provided better pulp protection as a direct capping material when compared with calcium hydroxide. As perforation repair materials, MTA demonstrated an excellent sealing ability in vitro. For periodontal tissues around a perforation, MTA provided normal healing processes in clinical trials. It is therefore concluded that MTA has a high potential in repairing perforations. MTA is the most promising material when used for retrograde root canal filling demonstrating normal healing in short/long term clinical outcomes.

Giomers in dentistry – at the boundary between dental composites and glass-ionomers

IntroductionFrom the variety of direct restorative dental materials, composite resins are considered as having the most esthetic and functional properties. The conservative preparation, esthetic results, good mechanical qualities and surface finishing properties of dental composites, combined with the protective properties of fluoride from glass-ionomers, led to a new generation of dental materials: the giomers.ObjectiveThe purpose is to review the available literature about the giomers, regarding the chemical composition, handling properties and esthetics, adhesion and microleakage, fluoride releasing and protection offered, clinical indications.MethodThe search was carried out using ScienceDirect and PubMed databases with the following keywords: giomer, esthetic properties giomers and fluoride releasing giomers. A total of 232 articles were initially selected, with the following inclusion criteria: full text articles, written in English, with topics on the properties and the clinical implications of giomers. Papers presented as abstract were not included. In the next step, review articles, duplicates, and articles in other languages were removed; as a result, a total of 44 sources published between 2004 and 2017 were selected.ResultsThe selected articles referred to the following aspects about the giomers: chemical composition (8 articles), adhesion and microleakage (10 articles), fluoride releasing and pulp protection (15 articles), clinical indications (6 articles), effects of additional treatments and dietary habits (11 articles).

DIFFERENCE IN SETTING TIME AND WORKING TIME INTERVAL OF CONVENTIONAL ZINC PHOSPHATE CEMENT AND NANOPARTICLE ZINC PHOSPHATE CEMENT (Research report)

Introduction: Zinc phosphate cement is one of cavity base material frequently used for pulp protection in the field of dentistry. This material demonstrates superiority in mechanical resilience and manipulation simplicity yet inducing pulp irritation as the reflection of high level acidity. Utilizing nano-particle ZPC may vanquish the shortcoming in conventional mechanical properties. However, brief setting time in nano-particle ZPC will generate higher exothermic reaction accompanied by the shortening of working period. Purpose: To assess the difference in setting time and working time interval of conventional ZPC and nano-particle ZPC. Methods: It is a true experimental laboratory study with post-test control group design. Four treatment groups were presented in five respective repetitions, comprising one scoop (0.318 gr) of conventional ZPC with three drops liquid in Group I, one scoop (0.386 gr) of nano-particle ZPC with four drops liquid in Group II, one scoop (0.386 gr) of nano-particle ZPC with three drops liquid in Group III, and one scoop (0.386 gr) of nano-particle ZPC with two drops liquid in group IV. ZPC was then manipulated in circular motion from powder to liquid. The setting time and working time was determined using stopwatch in second unit which then statistically analyzed using one-way ANOVA and post hoc Tukey HSD test. Result : Nano-particle ZPC with two drops liquid (Group IV) exhibited the shortest setting time value (mean 96.60s) which unveiled concurrently with the briefest working time interval (mean 34s). The longest setting time was presented in conventional ZPC (Group I) in the average of 627.80 seconds which also depicted the lengthiest working period with 84.20 seconds average. Statistical analysis revealed significant disparity in setting time value of conventional ZPC and nano-particle ZPC in each treatment group (p 0.05). Conclusion: There is a significant difference in setting time and working time interval of conventional ZPC and nano-particle ZPC.

A 1-year comparative evaluation of clinical performance of nanohybrid composite with Activa™ bioactive composite in Class II carious lesion: A randomized control study.

Aim:The aim of this study was to compare and evaluate the clinical performance of nanohybrid composite with Activa™ bioactive composites in Class II carious lesion.Methodology:After ethical approval, patients were selected according to the inclusion-exclusion criteria with minimum of two carious lesions in a single patient. Lesions were randomly divided into two groups: Group A – nanohybrid composite and Group B – Activa™ bioactive composite. After administration of local anesthetic agent, Class II cavity preparation was done followed by rubber dam application. For deep lesion, pulp protection was done with light-cured calcium hydroxide. Then, the cavities were restored. Finishing and polishing were done. Evaluation of the restorations was done at 1 week, 6 months, and 1 year time interval by second-blinded examiner according to the modified USPHS criteria. The results of the study were tabulated, and statistical analysis was done.Results:The results showed no statistically significant difference in the clinical performance of nanohybrid composite and Activa™ bioactive composites in Class II carious lesions at the end of 1 week, 6 months, and 1 year.Conclusion:It can be concluded that both materials showed equal and acceptable clinical performance at the end of 1 year. Both materials can be successfully be used to restore Class II carious lesions.

Clinical and Micromorphologic 29-year Results of Posterior Composite Restorations

Prospective clinical studies of composite restorations revealed their safety and longevity; however, studies did not elucidate the dynamic mechanisms of deterioration caused by fractures and secondary caries. Therefore, the aims of this 29-y controlled study were 1) to follow up on the clinical behavior of posterior composite restorations annually and 2) to compare clinical outcomes with micromorphologic scanning electron microscopy features. After ethical approval, the single-arm study commenced in 1987 with 194 class I or II primary posterior composite restorations with glass ionomer cement providing pulp protection. Each restoration was evaluated annually for 15 y and then again at 29 y per the US Public Health Service–compatible Clinical, Photographic and Micromorphologic coding index, with clinical and photographic criteria for anatomic form, color matching, surface quality, wear, marginal integrity, secondary caries, and clinical acceptability. Parallel micromorphologic criteria were applied at baseline and after 1, 3, 5, 7, 10, 15, and 29 y to assess surface roughness, texture, marginal integrity, fractures, ledges, and marginal gaps with semiquantitative coding and with quantitative 3-dimensional scanning electron microscopy profilometric measurements of marginal grooves next to the enamel, grooves within the bonding zone, and ledges. Statistical analysis included the calculation of the annual failure rate and the use of Kaplan-Meier methodology and nonparametric tests. The cumulative survival rates were 91.7% (6 y), 81.6% (12 y), and 71.4% (29 y). The mean annual failure rate was 1.92%. Significant changes in the restoration-tooth interface from baseline to 5 y resulted in functional masticatory equilibrium. Clinical deterioration year by year, including micromorphologic microfractures and wear, reflected unique dynamic changes in long-term surviving restorations with very low secondary caries and fracture risks (German Network for Health Care Research VfD 29 99 003924).

Self-Limiting versus Conventional Caries Removal: A Randomized Clinical Trial

A single-blind randomized controlled clinical trial in patients with deep caries and symptoms of reversible pulpitis compared outcomes from a self-limiting excavation protocol using chemomechanical Carisolv gel/operating microscope (self-limiting) versus selective removal to leathery dentin using rotary burs (control). This was followed by pulp protection with mineral trioxide aggregate (MTA) and restoration with glass ionomer cement and resin composite, all in a single visit. The pulp sensibility and periapical health of teeth were assessed after 12 mo, in addition to the differences in bacterial tissue concentration postexcavation. Apical radiolucencies were assessed using cone beam computed tomography/periapical radiographs (CBCT/PAs) taken at baseline 0 mo (M0) and 12 mo (M12). In total, 101 restorations in 86 patients were placed and paired subsurface, and deep (postexcavation) dentin samples were obtained. DNA was extracted and bacteria-specific 16S ribosomal RNA gene quantitative polymerase chain reaction was performed. No significant difference was found in bacterial copy numbers normalized to mass of dentin (“bacterial tissue concentration”) between the self-limiting (96.3% reduction) and control protocols (97.1%, P = 0.33). The probability of 12-mo success was 4 times (odds ratio [OR] = 4.33; confidence interval [CI], 1.2–15.6; P = 0.025) higher in the self-limiting protocol compared to the control (conventional excavation technique), with pulp survival rates of 73.3% and 90%, respectively (P = 0.049). Molars had a 4 times higher probability of success compared to premolars (OR, 4.17; CI, 1.17–14.9; P = 0.028), and symptom severity did not statistically predict outcome (OR, 0.41; CI, 0.12–13.9, P = 0.153). CBCT detected significantly more periapical (PA) lesions than PA radiographs at the baseline visit (P < 0.001). In conclusion, the self-limiting caries excavation protocol under magnification increased pulp survival rate compared to rotary bur excavation (ClinicalTrials.gov NCT03071588).

Optimization of flexible substrate by gradient elastic modulus design for performance improvement of flexible electronic devices

It is imperative and highly desirable to buffer the stress in flexible electronic devices. In this study, we designed and fabricated lamellate poly(dimethylsiloxane) (PDMS) samples with gradient elastic moduli, motivated by the protection of the pomelo pulp by its skin, followed by the measurements of their elastic moduli. We demonstrated that the electrical and fatigue performances of a Ag-nanowire thin film device on the PDMS substrate with a gradient elastic modulus are significantly better than those of a device on a substrate with a monolayer PDMS. This study provides a robust scheme to effectively protect flexible electronic devices.

Cellular differentiation, bioactive and mechanical properties of experimental light-curing pulp protection materials

ObjectiveMaterials for pulp protection should have therapeutic properties in order to stimulate remineralization and pulp reparative processes. The aim of this study was to evaluate the mechanical properties, biocompatibility, cell differentiation and bioactivity of experimental light-curable resin-based materials containing bioactive micro-fillers. MethodsFour calcium-phosphosilicate micro-fillers were prepared and incorporated into a resin blend: 1) Bioglass 45S5 (BAG); 2) zinc-doped bioglass (BAG-Zn); 3) βTCP-modified calcium silicate (β-CS); 4) zinc-doped β-CS (β-CS-Zn). These experimental resins were tested for flexural strength (FS) and fracture toughness (FT) after 24h and 30-day storage in simulated body fluid (SBF). Cytotoxicity was evaluated using MTT assay, while bioactivity was evaluated using mineralization and gene expression assays (Runx-2 & ALP). ResultsThe lowest FS and FT at 24h was attained with β-CS resin, while all the other tested materials exhibited a decrease in FS after prolonged storage in SBF. β-CS-Zn maintained a stable FT after 30-day SBF aging. Incorporation of bioactive micro-fillers had no negative effect on the biocompatibility of the experimental materials tested in this study. The inclusion of zinc-doped fillers significantly increased the cellular remineralization potential and expression of the osteogenic genes Runx2 and ALP (p<0.05). SignificanceThe innovative materials tested in this study, in particular those containing β-CS-Zn and BAG-Zn may promote cell differentiation and mineralization. Thus, these materials might represent suitable therapeutic pulp protection materials for minimally invasive and atraumatic restorative treatments.

TheraCal LC: From Biochemical and Bioactive Properties to Clinical Applications.

Background Direct pulp capping is a popular treatment modality among dentists. TheraCal LC is a calcium silicate-based material that is designed as a direct/indirect pulp capping material. The material might be very attractive for clinicians because of its ease of handling. Unlike other calcium silicate-based materials, TheraCal LC is resin-based and does not require any conditioning of the dentine surface. The material can be bonded with different types of adhesives directly after application. There has been considerable research performed on this material since its launching; however, there are no review articles that collates information and data obtained from these studies. This review discusses the various characteristics of the material with the aim of establishing a better understanding for its clinical use. Methods A search was conducted using search engines (PubMed and Cochrane databases) in addition to reference mining of the articles that was used to locate other papers. The process of searching for the relevant studies was performed using the keywords pulp protection, pulp capping, TheraCal, and calcium silicates. Only articles in English published in peer-reviewed journals were included in the review. Conclusion This review underlines the fact that further in vitro and in vivo studies are required before TheraCal LC can be used as a direct pulp capping material.

Calcium hydroxide liners: a literature review.

ObjectiveThis review integrates the literature on cavity liners and current concepts of pulp protection with the aim of establishing a better understanding of the role of calcium hydroxide as a cavity liner.Materials and methodsA search was conducted through PubMed, MEDLINE, and Ovid for articles with the criteria for the following terms: cavity liners and bases, pulp protection, and calcium hydroxide liners. No specific inclusion or exclusion criteria were applied as to what articles would be included in this review. It was hoped that the extent of the literature reviewed would be as comprehensive as possible.ConclusionThis review underlines the fact that calcium hydroxide liners should only be used in the deepest spots in the cavity where the remaining dentine thickness is ≤0.5 mm. A protective layer of resin-modified glass ionomer should always follow the application of calcium hydroxide liners.

PAIN ASSESSMENT DURING THE REMOVAL OF INFECTED CARIOUS DENTIN USING CERAMIC BURS WITHOUT LOCAL ANESTHESIA IN CHILDREN

Negative dental experiences in childhood can lead to dental phobias in adult patients. The dentist’s role is to lessen dental anxiety by providing a pain-free procedure. This could be achieved by using painless procedures in caries removal such as air abrasion, laser, chemo-mechanical, enzymatic techniques, as well as the use of polymer or ceramic burs. Ceramic burs are rotary cutting instruments made of alumina-yttria stabilized zirconia round burs. They work by selective removal of carious infected dentin consequently avoiding pain which could be more appropriate for very young children.The aim of this study was to assess the extent of pain perception using ceramic burs during caries removal without local anesthesia in pediatric patients. This was performed on 51 patients between 4-8 years of age with 2 primary molars showing dentinal caries requiring class I restoration. The first visit (group I) caries was removed by ceramic bur on low speed hand-piece without administration of local anesthesia then the second visit (group II) caries was removed by carbide round bur on low speed hand-piece without administration of local anesthesia. During each procedure, objective assessment for pain was performed using FLACC scale. Upon completion, the pain threshold for caries removal was measured subjectively by Wong Baker faces pain rating scale. The various responses were gathered and subjected to statistical analysis. It was concluded that ceramic burs reduce the pain sensation during removal of infected dentin which ensures excellent patient comfort. There could be some advantages in using the ceramic bur: high acceptance by the patient, reduced pain response and sound pulp protection in deep caries lesions.