|Year : 2021 | Volume
| Issue : 4 | Page : 330-335
|Comparative evaluation of biodentine and endosequence root repair material as direct pulp capping material: A clinical study
Margi Parikh1, Karkala Venkappa Kishan2, Nimisha Chinmay Shah2, Maitry Parikh2, Purnima Saklecha2
1 Parikh Dental Clinic, K. M. Shah Dental College, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
2 Department of Conservative Dentistry and Endodontics, K. M. Shah Dental College, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
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|Date of Submission||18-Jun-2021|
|Date of Decision||25-Aug-2021|
|Date of Acceptance||21-Sep-2021|
|Date of Web Publication||13-Jan-2022|
| Abstract|| |
Aim : The study was designed to clinically evaluate biodentine and endosequence root repair material (ERRM) as direct pulp capping agent at 3 months, 6 months, and 12 months intervals.
Materials and Methods : Sixty permanent posterior teeth with deep caries, without any signs of irreversible pulpitis were allotted into two experimental groups: Group I -Biodentine, Group II-ERRM. Follow-up evaluations were done. Every 24 h for 7 days, the pain was assessed using visual analog scale.
Statistical Analysis: Paired t-test along with Pearson's Chi-square test was performed.
Results : The success rate of clinical assessment at 12 months for biodentine group is 78.60% and ERRM Group is 64.70%.
Conclusion : Biodentine group performed superior than ERRM group clinically at all-time interval and hence it can be successfully used to restore exposed vital tooth.
Keywords: Clinical study; pain; pulp capping; tricalcium silicate
|How to cite this article:|
Parikh M, Kishan KV, Shah NC, Parikh M, Saklecha P. Comparative evaluation of biodentine and endosequence root repair material as direct pulp capping material: A clinical study. J Conserv Dent 2021;24:330-5
|How to cite this URL:|
Parikh M, Kishan KV, Shah NC, Parikh M, Saklecha P. Comparative evaluation of biodentine and endosequence root repair material as direct pulp capping material: A clinical study. J Conserv Dent [serial online] 2021 [cited 2022 Jan 28];24:330-5. Available from: https://www.jcd.org.in/text.asp?2021/24/4/330/335747
| Introduction|| |
Vital pulp therapy can be generally demarcated as “Any aspect of restorative dental management which is proposed to reduce trauma to the dental pulp tissue.” direct pulp capping can be performed whenever the tooth shows signs of reversible pulpitis which can produce “reparative dentin” there by protecting from further insults.
Conventionally, calcium hydroxide (Ca (OH) 2) has been used extensively as direct pulp capping agent because of its high pH (12.5), which forms bridge over the dentine but one of the drawback of Ca (OH) 2 is that it provides a poor seal to the exposed pulp., Some of the investigators also asserted the need to consider alternatives to Ca (OH) 2 as this bridge fails to seal the pulp because of tunnel defects leading to the microleakage. It was also noted that Ca (OH) 2 has a propensity to dissolve and degenerate leading to voids creating pathways for microorganisms. Hence, it is not regarded as an ideal pulp capping material.
Biodentine was introduced as a dentine substitute having Active Bio-silicate Technology. It is bioactive and the biocompatible, used as a material of choice for the pulpotomy and pulp capping material. Other than improved strength biodentine has a benefit of less setting time of 10–12 min as compared to MTA which has 2–3 h., It has similar mechanical properties to that of the dentin. On vital pulp cells, it has a positive effect and promotes reparative dentin formation.,
Over the past decade, new developments have been seen, especially in bioceramic nanotechnology, which lead to the introduction of a novel bioceramic material “Endosequence root repair material (ERRM)” (brasseler, Savannah, GA, USA). It is described as a hydrophilic, insoluble, radiopaque and aluminum-free ready to use material supplied as a premixed product in both low and high viscosity form recommended for pulp capping, perforation repair, apical surgery, and apical plug. It consists of Tantalum Oxide, Calcium Silicates and Calcium Phosphate Monobasic, Zirconium Oxide, Filler and thickening agents. Moisture is necessary for the materials to harden and set. It has Working time ≥30 min and setting time 20 min to 2 h depending upon viscosity of the material. It has high pH value (12.5), biocompatible and antibacterial properties.,
Very scarce scientific literature available on evaluating biodentine and ERRM in deep carious teeth. Hence, the purpose of this research was to evaluate the incidence of postoperative pain after direct pulp capping with biodentine and ERRM at Baseline, 3, 6, and 12 months' intervals. The null hypothesis (H0) considered that there was no difference among Biodentine and ERRM as direct pulp capping materials.
| Materials and Methods|| |
After obtaining approval from the Institutions Human Ethics Committee, University-Protocol number SVIEC/ON/Dent/BNPG-16/D17012 was obtained and study was designed in accordance with the 2010 CONSORT guidelines.
Patient's age 18–40 years with deep carious lesion who were referred to the department for the management of teeth with deep carious lesions on either the occlusal/proximal surface in their permanent posteriors teeth were included. Asymptomatic teeth with positive thermal and electrical tests with absence of tenderness, showing signs of reversible pulpitis, radiographic findings revealing the deep caries, teeth with any accidental pulp exposure and with the absence of periapical lesions were included.
Tooth with fracture, any systemic diseases or medically compromised patients, teeth with periodontal involvement, any periapical pathology, ankylosed tooth, developmental anomaly of teeth, and carious pulp exposure site >0.5–1 mm were excluded.
Before patient recruitment, the sample size was estimated following the formula suggested by Leye Benoist et al. With the expectation of dropout, a 20% increase in number of samples were done and the minimum number of subjects needed for a statistical significance (P < 0.05) for final sample size was calculated as 60 using α =5% with a power of 80%, which was further divided into 2 groups of 30 samples. Patients were explained about all the procedural steps, possible complications and after that informed consent was taken.
The sterilization protocol was maintained and treatment procedure was thoroughly monitored by principal investigator. Teeth were subjected to cold, heat, electrical pulp test for vitality confirmation and all vital deep carious lesions were radiographically evaluated by taking periapical radiographs with grid using paralleling technique to confirm the extension of lesion till pulp chamber.
Application of local anesthetic agent followed by rubber dam isolation was done. Removal of caries was done with no. 4 sterile carbide round bur on a slow speed hand piece or medium sharp spoon excavator (hu-freidy, USA). Complete pulp hemostasis was achieved using a cotton pellet soaked in saline. The cavity was dried and the exposure site was covered with 1–2 mm thick layer of one of the chosen materials as per the instructions of manufacturer. Patients were randomly divided using odd-even numbering method into two groups:
- Group I: Biodentine (septodont, Saint-Maur-des-Fossés Cedex, France) (n = 30)
- Group II: ERRM (brasseler, Savannah, GA, USA) (n = 30).
Once the material is set, the resin modified glass ionomer cement (gc corporation, Tokyo, Japan) was placed as intermediate restorative material for 2 weeks during evaluation and replaced with composite resin (Solare X – gc corporation, Tokyo, Japan) as permanent restorative material [Figure 1]. The patient was advised to report back to the department in case of loss of intermediate restoration or any discomfort.
|Figure 1: Representative case of Biodentine group: (a) Preoperative clinical photograph, (b) Exposure of pulp, (c) Placement of Biodentine over the exposure site, (d) Evaluation after 6 months and restoration with resin-modified Glass ionomer cement (GIC) as base and Final restoration with Composite. Representative case of Endosequence Root Repair material group: (e) Preoperative clinical photograph, (f) Exposure of pulp, (g) Placement of Endosequence Root Repair material over the exposure site, (h) Evaluation after 6 months and Final restoration with Composite|
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After completing all the Clinical procedure, a periapical radiograph was taken as a baseline for further follow-ups and for assessment of dentin bridge formation at 3, 6, and 12 months. Clinical and radiographic investigations were carried out by blinded examiner at 3, 6, and 12 months. Radiographs were scanned and an increase in dentin thickness was measured through sequential imaging with the help of “Image J” image processing and analysis software (1.4 versions, Informer Technologies, Inc.).
The primary outcome was to measure the clinical success at 12-months of follow-up, and the secondary outcome was to assess intensity of postoperative pain after 7 days. Pain was documented at baseline, 6, 12, 18 h and 1, 2, 3, 4, 5, 6, 7 days after the procedure. Patients were advised to take prescribed analgesic if they experienced pain and to record their pain score according to the visual analog scale. The patient and examiner were blinded about the types of capping material which was used.
SPSS Version 20.0 (Armonk, NY, USA: IBM Corp) was used for analysis of the collected data. PAIRED t-test with Pearson's Chi-square test was used for analysis wherein P value for the statistical significance was taken as <0.05 and <0.001 as highly significant.
| Results|| |
A total of 168 patients were considered for the initial recruitment out of which 108 participants got rejected because of nonexposure of pulp upon caries excavation and not meeting inclusion criteria. Consequently, 60 subjects were eventually included after making allowance for the drop outs [Figure 2].
|Figure 2: Flow chart of the subjects included and their progress throughout all the phases of study|
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The success rate of clinical assessment at 12 months for biodentine group is 78.60% and ERRM Group is 64.70%. At 3, 6, and 12 months. The rate of failure and intensity of postoperative pain with biodentine and ERRM was not statistically significant at all the intervals [Table 1]. Vitality assessment also revealed an insignificant difference between both the groups.
|Table 1: Chisquare tests for clinical evaluation for comparison of the two groups|
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| Discussion|| |
Inadequate evidence is available for use of bioceramics as pulp capping procedures in adult population. No reported randomized clinical trials were found, which compares biodentine and ERRM as direct pulp capping materials. Premixed bioceramic materials are advocated for pulp capping procedure due to their improved sealing ability as well as they do not discolor the adjacent dentin. Hence, these properties of premixed bioceramic materials like ERRM make them suitable for it to be used as pulp capping agent. Many studies on premixed endodontic bioceramic materials have shown that the properties of a bioceramic material are comparable to MTA.
Bhat et al. presented the use of biodentine in their case report on direct pulp capping in an immature incisor and they have concluded that it is a favorable material that had significant potential to preserve vitality of pulp in cases carefully selected for direct pulp capping. Nowicka et al. compared biodentine with MTA for pulp capping in human molar teeth clinically as well as histologically and established that biodentine is as good as MTA for pulp capping treatment. The dentin bridge formation induced by biodentine showed a pattern well-localized at the injury site contrasting to that caused by Ca (OH) 2 that showed an expanding structure in terms of the presence of tunnel defects in the pulp chamber. The quality of the formed dentin was more constructive as compared with Ca(OH) 2.
ERRM is a new bioceramic material which is delivered as a premixed product in low viscosity paste form dispensed from a syringe, fast-set, ready-to-use. It contains Nanosphere particles having maximum diameter of 1 × 10−3 μm, which let the material to enter into the dentinal tubules, conditioned by dentin liquid and produces a mechanical bond on setting. Shokouhinejad et al. established the bioactivity of ERRM by exposing the set material on phosphate-buffered saline and concluded that there was presence of precipitation of apatite crystalline structures, which shows its bioactivity. Endosequence has been shown to have negligible cytotoxicity and capability to induce cytokine expression. Hence, it is a biocompatible material, with ability to form apatite to enhance formation of dentinal bridge on human dental pulp cells and other alternate human cells in vitro and in vivo studies without any severe problems.
Pulp vitality assessment is one of the criteria for a successful restoration which includes cold, heat, electrical pulp test for pulp vitality confirmation. In the present study, all the samples showed vitality at baseline but after 3, 6, and 12 months of follow-up period only 21 out of 24 patients from biodentine group (Group I) and 17 out of 22 patients from ERRM group (Group II) reported positive signs of vitality. Although the difference is not statistically significant but clinically more samples of the biodentine group were showing positive signs of vitality compared to ERRM group as well as in the radiographs biodentine group samples showed an increase in dentin thickness when measured through sequential imaging with the help of “image J” software.
Ikhar et al. in their study comparing ERRM with MTA as pulp capping material concluded that though, ERRM is newer promising material but MTA produced better results. Solanki et al. in their systematic review stated that the good sealing ability of MTA is related to its good biological properties. Whereas Ghattas et al. concluded that when used as a retrograde filling material ERRM showed similar ability of sealing to white MTA. There was no reported study on clinical assessment of ERRM as a pulp capping agent in human teeth.
In the present research, the baseline parameters did not have significant difference among the groups, thus confirming equal and homogenous distribution of the samples among two groups (successful randomization). The success rate of clinical assessment at 12 months for Biodentine group is 78.60% and ERRM group is 64.70%. Group I reported 3 failures and Group II reported 5 failures after 12 months of follow-up. The failed cases gave a negative heat test, cold test, and electric test but had no pain. For all failed cases, root canal treatment was performed.
Postoperative pain assessment was considered as secondary outcome. After confirming the insignificant difference in the baseline scores, postoperative pain amongst the groups were analyzed at 24 h, which revealed no statistical significant difference. However, in Biodentine group (22 [73.30%]) patients did not report any pain in comparison with the ERRM group (26 [86.70%]) [Graph 1]. Iwamoto et al. (2006), in their research also found similar result in favor of using bio ceramics in order to have less incidence of postoperative pain. They compared white mineral trioxide aggregate and Ca (OH) 2 which yielded no difference in posttreatment pain, even though a histological study indicated not as much of inflammation with MTA in comparison to Ca (OH) 2.,, Above findings supports the outcomes of the current research for postoperative pain evaluation which was in the favor for the use of these materials.
Studies have shown that the success rate of pulpectomy in posteriors found to be 93%, but the success rate of root canal treatment is more only if it is done by specialists than general practitioners., Hence, the relatively considerable better performance of biodentine (78.60%) and ERRM (64.70%) in the current research may also challenge the choice of treatment for exposed carious posterior tooth if specialist endodontic treatment is not accessible. It is necessary to identify whether this favorable result can be correlated to other calcium silicate materials.
The limitations of the study are, the investigator cannot be blinded due to dissimilar characteristics of the materials and the relatively small sample size. Hence, randomized controlled trial with a large sample sizes and long-term follow-up are necessary to confirm the promising result of the bioceramic materials.
| Conclusion|| |
There was no statistically significant difference seen in the performance of biodentine and ERRM as pulp capping agent. Hence, the null hypothesis was accepted. However, a clinically better performance was noted with biodentine group at all interval of time.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Leye Benoist F, Gaye Ndiaye F, Kane AW, Benoist HM, Farge P. Evaluation of mineral trioxide aggregate (MTA) versus calcium hydroxide cement (Dycal(®)) in the formation of a dentine bridge: A randomised controlled trial. Int Dent J 2012;62:33-9.
Zarrabi M, Javidi M, Jafarian A, Jousban B. Histologic assessment of human pulp response to capping with mineral trioxide aggregate and a novel endodontic cement. J Endod 2010;36:1778-81.
Stanley HR. Pulp capping: Conserving the dental pulp – Can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol 1989;68:628-39.
Parikh M, Kishan KV, Solanki NP, Parikh M, Savaliya K, Bindu VH, et al.
Efficacy of removal of calcium hydroxide medicament from root canals by endoactivator and endovac irrigation techniques: A systematic review of in vitro
studies. Contemp Clin Dent 2019;10:135-42.
] [Full text]
Cox CF, Sübay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in dentin bridges: Their formation following direct pulp capping. Oper Dent 1996;21:4-11.
Novickas D, Fiocca VL, Grajower R. Linings and caries in retrieved permanent teeth with amalgam restorations. Oper Dent 1989;14:33-9.
Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, Kosierkiewicz A, et al.
Response of human dental pulp capped with biodentine and mineral trioxide aggregate. J Endod 2013;39:743-7.
Zanini M, Sautier JM, Berdal A, Simon S. Biodentine induces immortalized murine pulp cell differentiation into odontoblast-like cells and stimulates biomineralization. J Endod 2012;38:1220-6.
Hegde S, Sowmya B, Mathew S, Bhandi SH, Nagaraja S, Dinesh K. Clinical evaluation of mineral trioxide aggregate and biodentine as direct pulp capping agents in carious teeth. J Conserv Dent 2017;20:91-5.
] [Full text]
Mahmoud SH, El-Negoly SA, Zaen El-Din AM, El-Zekrid MH, Grawish LM, Grawish HM, et al.
Biodentine versus mineral trioxide aggregate as a direct pulp capping material for human mature permanent teeth – A systematic review. J Conserv Dent 2018;21:466-73.
] [Full text]
Ikhar A, Gite R, Chandak M, Sawant S, Dass A. Comparative evaluation of response of human dental pulp on direct pulp capping with MTA, ERRM (EndosequenceRoot Repair Putty Material). IOSR-JDMS 2016;15:52-7.
Elshamy FM, Singh G, Elraih H, Gupta I, Idris FA. Antibacterial effect of new bioceramic pulp capping material on the main cariogenic bacteria. J Contemp Dent Pract 2016;17:349-53.
Suhag K, Duhan J, Tewari S, Sangwan P. Success of direct pulp capping using mineral trioxide aggregate and calcium hydroxide in mature permanent molars with pulps exposed during carious tissue removal: 1-year follow-up. J Endod 2019;45:840-7.
Debelian G, Trope M. The use of premixed bioceramic materials in endodontics. G Ital Endod 2016;30:70-80.
Bhat SS, Hegde SK, Adhikari F, Bhat VS. Direct pulp capping in an immature incisor using a new bioactive material. Contemp Clin Dent 2014;5:393-6.
] [Full text]
Parikh M, Kishan KV, Parikh M. Comparative evaluation of effect of chloroquick irrigating solution on push-out bond strength of endoseal mineral trioxide aggregate and endosequence root repair material when used as furcal perforation repair material: An in vitro
study. J Conserv Dent 2020;23:259-64. [Full text]
Shokouhinejad N, Nekoofar MH, Razmi H, Sajadi S, Davies TE, Saghiri MA, et al.
Bioactivity of EndoSequence root repair material and bioaggregate. Int Endod J 2012;45:1127-34.
Mahgoub N, Alqadasi B, Aldhorae K, Assiry A, Altawili ZM, Tao Hong. Comparison between iRoot BP Plus (EndoSequence Root Repair Material) and mineral trioxide aggregate as pulp-capping agents: A systematic review. J Int Soc Prev Community Dent 2019;9:542-52.
Solanki NP, Venkappa KK, Shah NC. Biocompatibility and sealing ability of mineral trioxide aggregate and biodentine as root-end filling material: A systematic review. J Conserv Dent 2018;21:10-5.
] [Full text]
Nair U, Ghattas S, Saber M, Natera M, Walker C, Pileggi R. A comparative evaluation of the sealing ability of 2 root-end filling materials: An in vitro
leakage study using Enterococcus faecalis
. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:e74-7.
Accorinte ML, Loguercio AD, Reis A, Bauer JR, Grande RH, Murata SS, et al.
Evaluation of two mineral trioxide aggregate compounds as pulp-capping agents in human teeth. Int Endod J 2009;42:122-8.
Iwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, Jefferies S. Clinical and histological evaluation of white ProRoot MTA in direct pulp capping. Am J Dent 2006; 19:85–90.
Gesi A, Hakeberg M, Warfvinge J, Bergenholtz G. Incidence of periapical lesions and clinical symptoms after pulpectomy – A clinical and radiographic evaluation of 1- versus 2-session treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:379-88.
Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treatment: Systematic review of the literature – Part 1. Effects of study characteristics on probability of success. Int Endod J 2007;40:921-39.
Kundzina R, Stangvaltaite L, Eriksen HM, Kerosuo E. Capping carious exposures in adults: A randomized controlled trial investigating mineral trioxide aggregate versus calcium hydroxide. Int Endod J 2017;50:924-32.
Dr. Karkala Venkappa Kishan
Department of Conservative Dentistry and Endodontics, K. M. Shah Dental College, Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
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