Helena Fransson

Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy

Less invasive excavation methods have been suggested for deep caries lesions. We tested the effects of stepwise vs. direct complete excavation, 1 yr after the procedure had been carried out, in 314 adults (from six centres) who had received treatment of a tooth with deep caries. The teeth had caries lesions involving 75% or more of the dentin and were centrally randomized to stepwise or direct complete excavation. Stepwise excavation resulted in fewer pulp exposures compared with direct complete excavation [difference: 11.4%, 95% confidence interval (CI) (1.2; 21.3)]. At 1 yr of follow-up, there was a statistically significantly higher success rate with stepwise excavation, with success being defined as an unexposed pulp with sustained pulp vitality without apical radiolucency [difference: 11.7%, 95% CI (0.5; 22.5)]. In a subsequent nested trial, 58 patients with exposed pulps were randomized to direct capping or partial pulpotomy. We found no significant difference in pulp vitality without apical radiolucency between the two capping procedures after more than 1 yr [31.8% and 34.5%; difference: 2.7%, 95% CI (-22.7; 26.6)]. In conclusion, stepwise excavation decreases the risk of pulp exposure compared with direct complete excavation. In view of the poor prognosis of vital pulp treatment, a stepwise excavation approach for managing deep caries lesions is recommended.

Survival of Root-filled Teeth in the Swedish Adult Population

INTRODUCTION The aim was to assess survival in the Swedish population of teeth treated by nonsurgical root canal treatment during 2009. METHODS Data from the Swedish Social Insurance Agency were analyzed by Kaplan-Meier analysis to assess cumulative tooth survival during a period of 5-6 years of all teeth that were root-filled during 2009. RESULTS In 2009, 248,299 teeth were reported as root-filled. The average age of the patients at the time of the root filling was 55 years (range, 20-102 years). The teeth most frequently root-filled were the maxillary and mandibular first molars. During the 5- to 6-year period 25,228 of the root-filled teeth (10.2%) were reported to have been extracted; thus 223,071 teeth (89.8%) survived. Tooth survival was highest in the youngest age group (93.2%). The highest survival (93.0%) was for the mandibular premolars, and the lowest (87.5%) was for the mandibular molars. Teeth restored with indirect restorations within 6 months of the root filling had higher survival rates (93.1%) than those restored with a direct filling (89.6%). CONCLUSIONS In the adult population of Sweden, teeth that are root-filled by general practitioners under the tax-funded Swedish Social Insurance Agency have a 5- to 6-year survival rate of approximately 90%.

Dentine sialoprotein and Collagen I expression after experimental pulp capping in humans using Emdogain®Gel

AIM To characterize the hard tissue formed in human teeth experimentally pulp capped either with calcium hydroxide or with Emdogain Gel (Biora AB, Malmö, Sweden) - a derivative of enamel matrix (EMD), using two markers for dentine; dentine sialoprotein (DSP) and type 1 collagen (Col I). METHODOLOGY Affinity-purified rabbit anti-Col I and anti-DSP polyclonal antibodies were used to stain histological sections from nine pairs of contra-lateral premolars that had been experimentally pulp amputated and randomly capped with EMDgel or calcium hydroxide. Twelve weeks after the teeth had been pulp capped, they were extracted, fixed, demineralized and serially sectioned prior to immunohistochemical staining. RESULTS In the calcium hydroxide treated teeth DSP was seen in the new hard tissue which formed a bridge. DSP was also seen in the newly formed hard tissue in the EMDgel-treated teeth. Proliferated pulp tissue partly filled the space initially occupied by EMDgel and DSP-stained hard tissue was observed alongside exposed dentine surfaces as well as in isolated masses within the proliferated pulp tissue, although the new hard tissue did not cover the pulp exposure. DSP staining was also seen in the cells lining the hard tissue in both groups. Col I staining was seen in the newly formed hard tissue in both groups. CONCLUSIONS The new hard tissue formed after pulp capping with EMDgel or calcium hydroxide contained DSP and Col I, considered to be markers for dentine. Thus, the newly formed hard tissue can be characterized as dentine rather than unspecific hard tissue.

Randomized Clinical Trials on Deep Carious Lesions: 5-Year Follow-up:

Deep caries presents a dilemma in terms of which treatment that will render an optimal prognosis by maintaining pulp vitality with absence of apical pathology. Previously, 2 randomized clinical trials were performed testing the short-term effects of stepwise carious tissue removal versus nonselective carious removal to hard dentin with or without pulp exposure. The aim of this article was to report the 5-y outcome on these previously treated patients having radiographically well-defined carious lesions extending into the pulpal quarter of the dentin but with a well-defined radiodense zone between the carious lesion and the pulp. In this long-term study, 239 of 314 (76.2%) patients were analyzed. The stepwise removal group had a significantly higher proportion of success (60.2%) at 5-y follow-up compared with the nonselective carious removal to hard dentin group (46.3%) (P = 0.031) when pulp exposures per se were included as failures. Pulp exposure rate was significantly lower in the stepwise carious removal group (21.2% vs. 35.5%; P = 0.014). Irrespective of pulp exposure status, the difference (13.3%) was still significant when sustained pulp vitality without apical radiolucency and unbearable pain was considered (95% confidence interval, 3.1–26.3, P = 0.045). After pulp exposure, only 9% (n = 4) of the analyzed patients were assessed as successful, indicating that the prognosis is highly dubious following conventional pulp-capping procedures (direct pulp capping or partial pulpotomy) in deep carious lesions in adults. In conclusion, the stepwise carious removal group had a significantly higher proportion of pulps with sustained vitality without apical radiolucency versus nonselective carious removal of deep carious lesions in adult teeth at 5-y follow-up (ClinicalTrials.gov NCT00187837 and NCT00187850).

Endodontic complications in teeth with vital pulps restored with composite resins: a systematic review

Composite resin is used extensively for restoration of teeth with vital pulps. Although cell culture studies have disclosed harmful effects on pulpal cells, any untoward clinical effects, manifest as adverse pulpal responses, have yet to be determined. This study comprises a systematic review, designed to address the question of whether the risk of endodontic complications is greater with composite resin restorations than with other restorative materials, such as amalgam. The study methodology involved (i) formulation of the research question, (ii) construction and conduct of an extensive literature search with (iii) interpretation and assessment of the retrieved literature. A search of the medical database PubMed was complemented with a search of the Controlled Trials Register (CENTRAL). The initial search yielded 1043 publications, the abstracts of which were read independently by the authors. After additional searches, 10 studies were included in the review. In all the included studies, the level of evidence was assessed as low. No conclusions could therefore be drawn. The included studies reported few, if any, endodontic complications. Little or no differences emerged between teeth restored with composite resins and those restored with amalgam. To determine whether composite resin restorations of teeth with vital pulps are associated with an increased risk for development of endodontic complications such as apical periodontitis, further evidence is needed, from well-constructed studies with a large number of participants.

Effects of bacterial products on the activity of odontoblast-like cells and their formation of type 1 collagen

AIM To study how products released from different bacteria in a deep carious lesion affect the metabolic activity of odontoblast-like cells and their ability to produce the major organic component of dentine, collagen 1. METHODOLOGY MDPC-23 cells were exposed to supernatants from biofilm cultures of strains isolated from the deepest part of a carious lesion as well as from a clinical isolate of Enterococcus faecalis. Lipoteichoic acid (LTA) and lipopolysaccharide (LPS) were used for comparison. Cell activity was assessed using an methyl-thiazolyl-diphenyl tetrazolium bromide (MTT) assay, and collagen 1 levels were determined by ELISA. RESULTS The lesion microflora was dominated by Lactobacillus spp. Neither extracellular products from the isolates nor LPS affected the activity of the MDPC-23 cells, whereas extracellular products from E. faecalis and LTA significantly reduced total cell activity (P < 0.01). Enterococcus faecalis had an inhibitory effect upon collagen 1 production by the cells, whereas no such effect or even a slight stimulatory effect was seen for the isolates from the deep carious lesion. CONCLUSIONS These studies indicate that culture supernatants from E. faecalis reduced the metabolic activity of odontoblast-like cells as shown using the MTT assay. No effect was seen for supernatants from biofilms of bacteria recovered from a deep carious lesion. Different bacteria varied in their effects upon collagen 1 production suggesting that the nature of the bacterial species in a carious lesion may have a direct influence upon the ability of the odontoblasts to produce tertiary dentine.

Further Treatments of Root-filled Teeth in the Swedish Adult Population: A Comparison of Teeth Restored with Direct and Indirect Coronal Restorations

Introduction The aim of this study was to evaluate the frequencies of nonsurgical retreatment, root‐end surgery, extraction, and further restoration of root‐filled teeth in Sweden in 2009 during a follow‐up period of 5 years and to compare the outcomes in teeth restored with direct or indirect restorations. Methods Data from the Swedish Social Insurance Agency were analyzed, and the frequencies of nonsurgical retreatment, root‐end surgery, extractions, and further restoration were calculated for all teeth registered as root filled during 2009. Chi‐square tests were applied to detect any significant differences in the frequency of further treatment in teeth registered as restored with either a direct or an indirect restoration within 6 months of root filling. Results Of the 248,299 teeth reported root filled in Sweden in 2009, nonsurgical retreatment was registered in 2.2%, root‐end surgery in 1.0%, and extractions in 9.2% during the follow‐up period. Of the teeth restored with a direct restoration within 6 months after the root filling, 30.3% were registered as having undergone at least 1 further direct restoration; the corresponding percentage of teeth with indirect restorations was 6.4%. A statistically significant difference in the frequency of nonsurgical retreatment, extraction, and further restoration was found; teeth restored with an indirect restoration within 6 months of root filling had fewer of these treatments than those restored by direct restoration. Conclusions Low frequencies of nonsurgical retreatment and root‐end surgery were reported 5 years after root filling, whereas extraction was more common. Fewer additional treatment procedures were registered for teeth with indirect restorations than for those with direct restorations.

Ten-year follow-up on adoption of endodontic technology and clinical guidelines amongst Danish general dental practitioners

Abstract Objective: The aim of this study was to re-assess the adoption of certain endodontic technology and central treatment principles of root canal treatments as advocated by guidelines presented by the European Society of Endodontology. Material and methods: The questionnaire included the same questions in 2003 and 2013. The general dental practitioners (GDPs) anonymously reported how frequent (‘often’, ‘occasionally’, and ‘never’) they used certain endodontic technology and adhered to central treatment principles. The statistical analyses were performed using Chi-squared test and Goodman–Kruskal’s γ-coefficient as an association measure. Results: The overall response rate of the 2013 group was 46.5% (n = 531). The frequencies of GDPs reporting often use of rubber dam, apex locator and rotary NiTi instruments were significantly higher (p < .0001) than in 2003, as well as reporting the use of composite resin for coronal sealing (p < .019). Adoption was significantly influenced by the factors gender (p = .601) and time since graduation (p = .361), and the cluster analyses revealed the neglected use of rubber dam to be associated with no established postoperative recall system. Conclusions: After 10 years, there was a higher frequency of GDPs who had adopted certain endodontic technologies. However, progress towards high-quality root canal treatment might be obstructed as the majority of GDPs avoids consistent use of rubber dam, and routinely neglects recalls for postoperative controls of their endodontic treatments.

The Antibacterial Effect of Nd:YAG Laser Treatment of Teeth with Apical Periodontitis : A Randomized Controlled Trial

Introduction The aim of this blind, in vivo, randomized controlled trial was to evaluate the antibacterial effect of Nd:YAG laser irradiation in endodontic treatment of single‐rooted teeth with apical periodontitis. The hypothesis was that mechanical enlargement of the root canal and Nd:YAG laser irradiation would yield more negative bacterial samples than conventional treatment. Methods Forty‐one patients (45 teeth) were allocated to the laser (n = 22) or control (n = 23) group. The teeth in the laser group were instrumented, irrigated with saline, and irradiated with Nd:YAG laser according to a standard protocol. The teeth in the control group were similarly instrumented but irrigated with 1% unbuffered sodium hypochlorite and 15% EDTA solution. Bacterial samples were taken before and after treatment, blinded, and immediately sent for culturing and analysis. Results The initial bacterial samples were positive in 20 of 22 teeth in the laser group and 18 of 23 (P = .414) in the control group. After the initial treatment, negative bacterial samples were found in 11 teeth in the laser group and 13 (P = .768) in the control group. After 2 to 4 days with no antibacterial dressing in the root canals, 5 teeth in the laser group and 9 (P = .337) in the control group yielded negative bacterial samples. Conclusions After intervention, neither the test group nor the control group yielded predictable negative bacterial samples. Thus, the results failed to verify the hypothesis that Nd:YAG laser irradiation would yield significantly more negative bacterial samples than conventional irrigation with 1% unbuffered sodium hypochlorite solution.