Dentine and the pulp are one functional entity, the pulp–dentine complex (Pashley 1996); however, for diagnostic purposes at least, hard tissue (caries) and soft tissue disease (pulpitis) should be considered separately. At present, there remains a paucity of high‐quality randomized clinical trials comparing and testing capping materials in order to make definitive conclusions on the best material to use. 2017) compared with nonselective caries removal, which has altered consensus (Schwendicke et al. Decision‐making in this area is currently hampered by the crude diagnostic techniques available to assess accurately the state of the pulp as well as a paucity of adequately powered, well‐controlled randomized studies addressing key questions. 2017). Sodium Hypochlorite Reduces Postoperative Discomfort and Painful Early Failure after Carious Exposure and Direct Pulp Capping—Initial Findings of a Randomized Controlled Trial. For treating deep caries lesions, selective or stepwise (one- and two-step) incomplete excavation seems advantageous compared with complete caries removal. The only way to rebuild the odontoblastic palisade is to recapitulate in situ the original developmental process (Goldberg & Smith 2004). 1997, Smith 2003, Grando Mattuella et al. Further clinical studies investigating molecular‐based assays are required to develop reliable diagnostic tools and better reproducibility. 2015), compared with the previously reported randomized clinical trial data demonstrating a very low 5% survival of traditionally pulp capping after caries exposure at 5 years without an enhanced protocol (Bjørndal et al. 1995). 2017). 1994, Smith 2002). A more accurate impression of the extent of a lesion can be given on a cone‐beam computed tomograph (CBCT); however, this has limitations such as the higher dose, image distortion due to the presence of radiopaque restorations, cost and availability. 2015), partial pulpotomy (Taha & Khazali 2017) and full pulpotomy (Simon et al. Several studies compiled in current systematic reviews have demonstrated that the use of incomplete caries removal techniques significantly decreases the risk of pulp exposure in deep caries lesions compared with the traditional complete caries removal procedure, and these restorations have shown similar success.13, 14,16 The clinician should be able to distinguish between inflamed and noninflamed tissue if the pulp is exposed; however, this visual analysis may not be sufficiently accurate. Dental caries is a common, but preventable disease (World Health Organization 2017). A systematic review on the subject (but with the same limitations as above) concluded the overall success rate is in the range of 72.9%–99.4% (Aguilar & Linsuwanont 2011). Caries Color, Extent, and Preoperative Pain as Predictors of Pulp Status in Primary Teeth. 2012). Headache management 84%. 2005). 2015) after 3 years, perhaps highlighting the reasons for such a large difference. Frightened of the pulp? By continuing to browse this site, you agree to its use of cookies as described in our,,, I have read and accept the Wiley Online Library Terms and Conditions of Use, Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review, The effect of pulpotomy using a calcium‐enriched mixture cement versus one‐visit root canal therapy on postoperative pain relief in irreversible pulpitis: a randomized clinical trial, Long‐term outcomes of pulpotomy in permanent teeth with irreversible pulpitis: a multi‐center randomized controlled trial, Tenascin and fibronectin expression after pulp capping with different hemostatic agents: a preliminary study, Contemporary operative caries management: consensus recommendations on minimally invasive caries removal, Pulp capping of carious exposures: treatment outcome after 5 and 10 years: a retrospective study, The biology of pulp and dentine. 2013, Taha et al. Comparing the outcome of various strategies to treat deep caries is complex, and as a result, the debate about whether or not to preserve a layer of dentine continues. Some preliminary thoughts, A survey of endodontic practice amongst Flemish dentists, Pulp responses to caries and dental repair, Vitality of the dentin‐pulp complex in health and disease: growth factors as key mediators, Odontoblast stimulation in ferrets by dentine matrix components, Recruitment of dental pulp cells by dentine and pulp extracellular matrix components, Exploiting the bioactive properties of the dentin‐pulp complex in regenerative endodontics, Angiogenic signaling triggered by cariogenic bacteria in pulp cells, Strain‐related acid production by oral streptococci, A randomized controlled study of the use of ProRoot mineral trioxide aggregate and Endocem as direct pulp capping materials, Treatment preferences of deep carious lesions in mature teeth: questionnaire study among dentists in Northern Norway, Management of pulps exposed during carious tissue removal in adults: a multi‐national questionnaire‐based survey. Moreover, a relatively high agreement of more than 80% was highlighted between a clinical definition of irreversible pulpitis and the presence of bacteria within necrotic areas in the pulp (Ricucci et al. BACKGROUND: This systematic review assesses the effect of methods commonly used to manage the pulp in cases of deep caries lesions, and the extent the pulp chamber remains uninfected and does not cause pulpal or periapical inflammatory lesions and associated tooth-ache over time. (g) Three months post‐operatively, a sinus tract and apical periodontitis are noted. Blinded follow‐up examination: An examiner who is not aware of which group the material or the patient belongs (blinded outcome evaluation). It was shown that the various approaches did not affect the expression of bioactive glycoproteins related to repair (Baldissera et al. Biochemical and Biophysical Research Communications. 2008) and restoration with a hydraulic calcium silicate cement. If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs even in deep carious lesions. The conclusion of the review was that for symptomless and vital teeth, these minimally invasive techniques had clinical advantages over complete caries removals in the management of dentinal caries. Hoefler, V., et al. European Society of Endodontology position statement: Management of deep caries and the exposed pulp. GFs), which could potentially contribute and augment a repair process with current revitalization protocols advocating a bleeding sequence and the formation of a clot in the healing response (Galler 2016b). These nociceptors can extend within 0.16 mm of dentinal tubules and act as an early warning signal to the pulp and indeed the patient (Buyers 1980). 1998). More robust data are required going forward to confirm that pulp chamber pulpotomy can be considered a permanent treatment for teeth with ‘irreversible’ pulpitis. Due to differences in study design, it is impossible clinically to make a strict comparison between available VPT studies (Table 1). An unsuccessful class II pulp capping. 2005, Karapanou et al. Recent reviews provide the evidence for a superior outcome for the use of the hydraulic calcium silicate cements, in particular various forms of the mineral trioxide aggregate (MTA), and another recent available type Biodentine™ (Septodont, Sant‐Maur‐des‐Ditch Cedex, France). Review Council Council on Clinical Affairs Latest Revision* 2014 Purpose The American Academy of Pediatric Dentistry (AAPD) recog-nizes that caries-risk assessment and management protocols can assist clinicians with decisions regarding treatment based upon caries risk and patient compliance and are essential elements of contemporary clinical care for infants, children, and … The material takes over four hours to set, and it is recommended that the tooth should be temporized before the permanent restoration is placed. between tested capping materials. Superficial soft infected dentine was removed by bur and deeper located areas by chemo‐mechanical gel and hand instrumentation, but left at a residual level, whereby any added removal would lead to exposure. Poor oral health status and short‐term outcome of kidney transplantation. Management of deep carious lesions in vital teeth is challenging. In practice; however, because the pulp has been exposed to the oral environment, it is common to remove the superficial layer. Other factors likely to be important prior to undergoing class I pulp capping are small exposures (preferably <1 mm diameter), located in the coronal third of the pulp chamber ideally corresponding to a pulp horn (Fig. No evidence of irreversible pulpitis (not defined) and pulp necrosis, no PDL widening, no external and internal resorption, no periapical or furcal bone resorption, Experimental (OrthoMTA): 97% clinical and 100% radiographic success, Experimental (RetroMTA): 94% clinical and 94% radiographic success, Control (ProRoot MTA): 100% clinical, and radiographic success, Deep caries(depth defined as either 2/3 into the dentine, >2/3 and ‘into the pulp’ (= extremely deep caries), Trial: Intervention effect 30%, Power 95%, P < 0.05, Randomization: Concealed allocation (central procedure), Material: Calcium hydroxide (CH) (control) n = 37 versus MTA n = 33, Hand excavator was used, and following pulp exposure, haemostasis was controlled within 10 min using 0.5% NaOCl, MTA arm: white ProRoot (two‐visit procedure), Success: Survival of the capped pulp being nonsymptomatic, responding to sensibility test and no periapical changes radiographically, Secondary outcome: Pain 1 week post‐operatively, Experimental (ProRoot): 85% cumulative survival rate, Control (Dycal): 52% cumulative survival rate, Significant difference between cumulative survival rate in favour of MTA (lesion depth not equally distributed between arms), Comparing restorative procedure and pre‐clinical radiographic and CBCT assessments, Carious dentine into pulpal quarter of the dentine, no signs of irreversible pulpitis (no widening of PDL or PA lesion), Trial: Intervention effect ~20%, Power 80%, P < 0.05, Material: GIC (control) n = 36 versus Biodentine n = 36, Success: Positive response to pulp test at 12 months. Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry. Selected matrix metalloproteinases (MMPs), a family of tissue proteases, contained with the DMCs will propagate the breakdown of dentine matrix (Mazzoni et al. Alternatively, some dental practitioners may prefer pulpectomy to VPT, because it is more predictable in their hands (i.e. From a histopathological perspective, the threshold for irreversible pulpal inflammation can be defined as the stage where the cariogenic microorganisms are entering the pulp space either through tertiary dentine or directly into the pulp. 2010, Franzon et al. 2005). Indeed, inflammation marks the first step of tissue convalescence. In clinical practice, the decision on whether to maintain the pulp or not also varies (Stangvaltaite et al. Like Contact CDA. As a result, predictable outcomes have been achieved with selective caries removal (Maltz et al. 2003). A macroscopic and histological analysis of radiographically well‐defined deep and extremely deep carious lesions: carious lesion characteristics as indicators of the level of bacterial penetration and pulp response. The second‐stage excavation several months later is carried out to firm dentine following the recommendation of carious tissue removal (Schwendicke et al. 2). Indeed, recent consensus reports have stated that the complete or nonselective carious removal is now overtreatment (Innes et al. Based on a 5‐year follow‐up of a randomized clinical trial, a stepwise excavation approach for the management of deep carious lesions was superior to a complete carious removal procedure carried out in one visit, with less pulpal exposure, less pain and more teeth with vital pulps in the stepwise group (Bjørndal et al. Abstract. In contrast, RCT was preferred in older patients (>40 years) with interproximal exposure sites. The prevention of apical periodontitis begins with a clinical evaluation of whether the pulp can be maintained or not; however, the task of evaluating accurately if the pulp is irreversibly inflamed remains a significant challenge (Mejáre et al. 2008). A systematic review on the subject (but with the same limitations as above) concluded the overall success rate is in the range of 72.9%–99.4% (Aguilar & Linsuwanont 2011). Unfortunately, at present from a patient perspective, the critical factor in the treatment chosen by the dentist is whether the operator is pulp ‘friendly’ or not. The proposed protocol should ideally include carious removal guided by the use of the operating microscope, haemostasis attained within 5 min, the use of 5.25% NaOCl (Bogen et al. 2012). 1996). Caries-related treatment decisions of general dental practitioners in Riyadh, Saudi Arabia. The radiographic image in general only gives an approximation of the level of mineral content within the tissue being investigated and is limited by the fact it cannot inform with regard to the activity of the lesion nor the status of the pulp within the dentine–pulp complex. Due to the lack of evidence to determine the best treatment for deep cavitated caries lesions in primary molars, the search for an effective restorative technique, which results in a minimal discomfort to patients, and reduce the time needed for the treatment, becomes relevant. 2008). (a) Macroscopic view of an extracted mandibular molar with a proximal extensive carious lesion. For many years, it was thought that the quality of the seal alone determined the success of the procedure (Bergenholtz et al. One randomized clinical multicentre study, based in a clinical general practice environment (without the use of a class II equipment such as the operating microscope, etc. Age‐specific findings on endodontic treatments performed by private dentists in Finland in 2012 and 2017: a nationwide register‐based observation. 1994). Research in this area will inevitably develop in the future and challenge whether irreversible pulpitis is an appropriate term to use. The stage in the caries process at which exclusively noninvasive options may be recommended by the dentist to manage caries largely depends on knowledge about the probable speed of the caries progression. 2017); however, strong evidence is still lacking to support the relative importance of individual factors to a favourable treatment outcome. (a) Deep carious lesion reaching pulpal quarter with a zone of dentine separating the lesion from the pulp (b) and extremely deep penetrating the entire thickness of the dentine. The word ‘irreversible’ means that it is ‘cannot be undone, repealed, or annulled; unalterable, irrevocable’ (Oxford English Dictionary). The contribution diet plays in the aetiology of caries offers the opportunity to manage the condition by modifying diet, changing biofilm growth and isolating the advancing microbial biofilm from the nutrient supply; therefore, the disease can be managed by selective caries removal without having to eradicate or target the entire bacterial population (Bjørndal et al. Notably, for didactic purposes, the processes of reactionary and reparative dentinogenesis are considered separately, and it is likely that in a deep carious lesion both processes will occur simultaneously particularly at the periphery of the cavity (Smith et al. Notably, mutans streptococci possess multiple sugar transport systems including the phosphoenolpyruvate phosphotransferase system and can enzymatically thrive at a low pH. Class I pulp capping. Colour classification of carious lesions (modified from Bjørndal. 1998). 2012), fibroblasts, the principal cell of the pulp, are also able to secrete complement fragments and GFs important to mineralization and SC recruitment (Jeanneau et al. 2005). The biological properties of these materials have been described in the literature from both in vitro and in vivo studies (Careddu & Duncan 2018, Parirokh et al. This study systematically reviewed randomized controlled trials investigating one- or two-step incomplete compared with complete caries removal. In order to establish a new mineralized barrier, it is necessary to induce the growth of neo‐odontoblasts, the only cells capable of secreting dentine. Superficial soft infected dentine was removed by bur and deeper located areas by chemo‐mechanical gel and hand instrumentation, but left at a residual level, whereby any added removal would lead to exposure. 2013, Gervois et al. The ability of ethylenediaminetetraacetic acid (EDTA) (Graham et al. The maintenance of pulp vitality and the promotion of biologically based management strategies are at the core of deep caries management. 2009). If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs even in deep carious lesions. 2008, Marques et al. 2016). In case of perforation a nested capping trial comparing direct pulp capping versus partial pulpotomy, Success: Pos. 2000), new biomaterials, techniques and understanding of pulpal repair mechanisms have improved the outcome of symptomatic exposures treated with pulp capping (Marques et al. The resulting report may be associated with a more positive estimate of the intervention effect (Gluud. 2007, Galler et al. 2015) and insulin‐like GFs (Finkelman et al. 2017, Qudeimat et al. Editors: Schwendicke, Falk (Ed.) 2012). In conclusion, both direct pulp capping and RCT were cost‐effective. The MTA is not packed into the pulpal cavity, but instead lightly tapped into contact with the pulp and dentine wall using a ‘thick paper’ point or cotton pledget. As dental biofilm consists of commensal and noninvading microorganisms, the contemporary understanding, known as the ‘ecological plaque hypothesis’, suggests caries is a result of an ecologic imbalance within the dental biofilm with acidogenic and aciduric species dominating within the biofilm under frequent intake of carbohydrates (which are metabolized to acids) (Marsh 1994, 2003). Success: Positive response to pulp test. Moreover, the hard tissue bridges formed against MTA have higher histological quality compared with those induced by Ca(OH)2 (Nair et al. 2015), partial pulpotomy (Taha & Khazali 2017) and full pulpotomy (Simon et al. 1997). 1975, Whitworth et al. The demineralization is thought to be absent of bacteria as long as the dentine is not clinically exposed (Kidd & Fejerskov 2004). At present, there remains a paucity of high‐quality randomized clinical trials comparing and testing capping materials in order to make definitive conclusions on the best material to use. 2016a). When caries are in close proximity to the pulp, an indirect pulp cap can be performed. Work by Dimaggio and Hawes supports this observation. Furthermore, a randomized clinical trial has reported improved outcomes, if a disinfection agent such as NaOCl is applied the haemostatic protocol prior the application of a capping material (Tuzuner et al. Accurate detection and diagnosis of dental caries reduces the cost of oral health management, and increases the likelihood of natural tooth preservation in the long term. In contrast, RCT was preferred in older patients (>40 years) with interproximal exposure sites. 2015). 2000). Contemporary perspective on plaque control, Concentration‐dependent effect of sodium hypochlorite on stem cells of apical papilla survival and differentiation, Treatment of profound caries to prevent pulpal damage, Role of dentin MMPs in caries progression and bond stability, Gene expression analysis in cells of the dentine‐pulp complex in healthy and carious teeth, Diagnosis of the condition of the dental pulp: a systematic review, Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome, The healing of experimentally induced pulpitis, Remaining dentine thickness and human pulp responses, Carious dentine provides a habitat for a complex array of novel Prevotella‐like bacteria, Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial, Expression of macrophage inflammatory protein 3alpha in human inflamed dental pulp tissue, Healing processes in the pulp on capping; a morphologic study; experiments on surgical lesions of the pulp in dog and man, Comparison of the initial streptococcal microflora on dental enamel in caries‐active and in caries‐inactive individuals, Dental caries from a molecular microbiological perspective, Attitudes and expectations of treating deep caries: a PEARL Network survey, Dentinogenic effects of extracted dentin matrix components digested with matrix metalloproteinases, The disastrous effects of the “total etch” technique in vital pulp capping in primates, Discrimination of hardness by human teeth apparently not involving periodontal receptors, Outcomes of direct pulp capping by using either ProRoot mineral trioxide aggregate or Biodentine in permanent teeth with carious pulp exposure in 6‐ to 18‐year‐old patients: a randomized controlled trial, Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview ‐ part I: vital pulp therapy, World Health Organization global policy for improvement of oral health–World Health Assembly 2007, Immediate and delayed direct pulp capping with the use of a new visible light‐cured calcium hydroxide preparation, Using mineral trioxide aggregate as a pulp‐capping material, The use of bitewing radiographs in the management of dental caries: scientific and practical considerations, Mineral trioxide aggregate pulpotomy for permanent molars with clinical signs indicative of irreversible pulpitis: a preliminary study, On cantilever loading of vital and non‐vital teeth.