Clinico-Histological Evaluation of Dentino-Pulpal Complex of Direct Pulp Capping Agents: A Clinical Study.

INTRODUCTION: Direct pulp capping treatment (DPC) maintains pulp vitality by promoting healing or repair in dentistry, which can be attributed to the advent of bioceramic materials. AIM: This examination looked to evaluate the clinical and histological effectuality of Biodentine with Dycal for DPC. MATERIALS AND
METHODOLOGY: In this study, 30 intact human orthodontic teeth undergoing therapeutic extraction were chosen to perform DPC. They were arbitrarily divided into two groups (n = 15) and DPC with Biodentine and Dycal was performed. Composite resin was used as permanent restoration. After a period of 1 and 6 weeks, clinical as well as electric pulp tests were carried out. Asymptomatic patients were re-called after 6 weeks; follow-up radiograph was taken. Electric pulp testing and thermal testing was done to check the pulpal status of the teeth. This was followed by atraumatic extraction, and the teeth were sent for histological examination. SPSS Version 21.0. Armonk, NY: IBM Corp.was used for data analysis.
RESULTS: There was no pain and sensitivity in using Biodentine. Whereas, sensitivity and pain was noted when Dycal was used. The dentinal bridge was better with Biodentine when compared with Dycal.
CONCLUSION: In accordance with the obtained results, it was concluded that on clinical and histological evaluation, Biodentine performed better as DPC agent. Subsequently, Biodentine is more dependable for the long-haul protection of dental pulp than Dycal. Copyright:

INTRODUCTION

Direct pulp capping (DPC) is that management modality that retains pulp vitality by facilitating healing which may be credited to bioceramic materials. In DPC Ca(OH)2 are well-known materials as they have the capability to liberate calcium and hydroxyl ions on disintegration. Lamentably, there is the formation of a necrotic layer at the interface of material and the pulp as these products are soluble and raise the pH.[12] Dycal (Dentsply) is used as direct and indirect PC agents under restorations, it is a calcium hydroxide-based product and has self-setting, radiopaque properties. There are stimulation and the formation of secondary dentin due to its alkaline pH (9–11), when it is in directly in contact with the pulp. Calcium hydroxide, which helps in reparative dentin formation, was used often prior but long-haul studies reported variable and flighty outcomes. Calcium hydroxide does not adapt closely to dentin; because of the tunnel defects within dentin bridges at the time of reparative dentin formation.[3] Biodentine is used in the cavity without any conditioning treatment.[456] Literature us scarce on the reparative ability of the pulp on using Biodentine as DPC.

MATERIALS AND METHODOLOGY

Thirty intact human teeth planned for orthodontic extraction were chosen. Patients indicated for orthodontic extraction with closed apices. No sensitivity to percussion/palpation and biting, Proper response after application of thermal test and positive pulp response to electric pulp test, No Periapical changes viewed on periapical radiographs were included in the study. Teeth with open apices, Periapical radiograph with any periradicular radiolucency, Presence of fistulas or swelling and teeth with mobility or tenderness to percussion were excluded from the study. Prior to the treatment, a complete medical history was taken to ensure the absence of any systemic disease and sensitivity to local anesthesia or dental materials. Each patient was explained in detail about the treatment procedure and informed consent was taken. Preoperative clinical photograph and preoperative radiograph were taken before the commencement of clinical protocol. Thermal testing was performed with cold test by using Endo-frost (Roeko, Coltene), heat test by heated ball-burnisher, and electric pulp testing were performed to assess pulp vitality. Then, the patient was requested to rinse their mouth with chlorhexidine gluconate 0.2%. Following infiltration with a local anesthetic agent and placement of rubber dam, the procedure was performed. All the cavities were prepared to depths similar to the bur length (3 mm). Then, the pulp horn was exposed through the cavity floor with a 1.2 mm-diameter round carbide bur. The exposed area was rinsed, and homeostasis was completed with sterile cotton pellets saturated with sterile saline, which was kept in place for 10–20 s. The teeth were then allocated to two groups randomly. Each material was placed according to the manufacturer's instruction. Group 1-Teeth capped with Biodentine (n = 15). Group 2-Teeth capped with Dycal (n = 15). The permanent restoration was completed using composite resin. Postoperative radiograph was taken, and the patients were fully explained about the probable signs/symptoms (such as spontaneous pain, swelling, sensitivity to cold/heat/percussion/chewing, etc.) during the follow-up period. The patients were contacted, and all their clinical symptoms were meticulously recorded during the 6-week period. Any spontaneous or prolonged pain was interpreted as failure. In case of treatment failure or patients change of mind, they were excluded from the study immediately. Asymptomatic patients were re-called after 6 weeks; follow-up radiograph was taken. Electric pulp testing and thermal testing was done to check the pulpal status of the teeth. The sample teeth were atraumatically extracted by a OMFS. Specimens were kept in 10% buffered formalin solution for 2 weeks for fixation, the specimens were decalcified using 10% nitric acid solution and were embedded in paraffin. Paraffin-embedded teeth were sectioned utilizing microtome having three-micron thick serial sections in the linguo-buccal plane and the sections were stained with h and e. Finally, the slides were inspected by a pathologist[7] [Table 1]. SPPS version 22 was used for Descriptive analysis and Kruskal–Wallis test.[8]

Table 1

Modified criteria for histological assessment based on Nowicka et al.

Criteria	Score	Description
Type of Pulp Inflammation	1	No Inflammation
	2	Chronic
	3	Acute and Chronic
	4	Acute
Intensity of Pulp Inflammation	1	Absent or very few inflammatory cells
	2	Mild, <10 inflammatory cells
	3	Moderate, 10-25 inflammatory cells
	4	Severe, >25 inflammatory cells
Extension of Pulp Inflammation	1	Absent
	2	Mild, inflammatory cells only next to pulp exposure site
	3	Moderate, inflammatory observed in part of coronal pulp
	4	Severe, all coronal pulp is infiltrated
Dentin Bridge Thickness	1	>0.25mm
	2	0.1-0.25mm
	3	<0.1mm
	4	Partial or absent bridge
Pulp tissue Organisation and Morphology	1	Normal pulp morphology
	2	Disorganisation of pulp beneath the cavity
	3	Disorganisation of entire pulp
Morphology and Continuity of Dentin Bridge	1	Formation of complete dentin bridge
	2	Formation of discontinuous incomplete dentin bridge
	3	No sign of dentin formation

RESULTS

Clinical evaluations

On clinical assessment at 1 and 6 weeks, it was reported that there was no sensitivity to heat, cold, or percussion in the Biodentine group, whereas in the Dycal group, two patients (20%) reported it. Pain management was done using NSAID (Zerodol P 500/100 mg). No evidence of periapical pathology was detected.

Histologic findings

The intensity of pulp inflammation was not present with all the specimens of Biodentine after 6 weeks of treatment. Five cases (33.3%) of mild inflammation and 4 cases (26.7%) of moderate inflammation were reported with Dycal. On the evaluation of the type of pulp inflammation, no inflammation was reported in all the specimens of Biodentine after 6 weeks of treatment, whereas the Dycal group showed 6 cases (40%) of chronic inflammation. When the extension of pulp inflammation was evaluated, the extension of pulp inflammation was absent in all the specimens of the Biodentine group, however, 4 cases (26.8%) showed mild extension of pulp inflammation and 1 case (6.6%) showed moderate extension of pulp inflammation [Table 2 and Figures 1a, b and 2a, [b]. Pulp tissue disorganization beneath the cavity was observed in 4 (26.7%) cases with Biodentine, 5 (33.3%) cases with Dycal. In Biodentine treated teeth, 2 cases (13.3%) showed complete pulp destruction, whereas 6 cases (40%) of Dycal treated. Complete dentin bridge as a part of hard tissue formation was reported in thirteen (86.7%) teeth in the Biodentine group and 2 (13.3%) of the cases of Dycal group. Differentiated odontoblast-like cells lead to the formation of complete dentin bridge in the Biodentine group, whereas more than half of teeth in the Dycal group had incomplete bridge formation [Figures 1a, b and 2a, b]. Thickness of dentin bridge determined with Biodentine was maximum and thickness was least with Dycal [Table 3].

Table 2

Intensity and type of pulp inflammation after direct pulp capping with 3 materials at 6 weeks

Materials	Index	Dycal, n (%)	Biodentine, n (%)	TheraCal LC, n (%)
Intensity of pulp inflammation	Absent	4 (80)	13 (86.6)	15 (100)
	Mild	1 (20)	2 (13.3)	0
	Moderate	0	0	0
	Severe	0	0	0
Type of pulp inflammation	No inflammation	4 (80)	13 (86.6)	15 (100)
	Chronic	1 (20)	2 (13.3)	0
	Chronic and acute	0	0	0
	Acute	0	0	0
Extension of pulp inflammation	Absent	4 (80)	13 (86.6)	15 (100)
	Mild	1 (20)	2 (13.3)	0
	Moderate	0	0	0
	Severe	0	0	0

Figure 1

(a) Direct pulp capping using Biodentine shows formation of continuous and dispersed mineralized dentinal bridge (original magnification, ×40). (b) Direct pulp capping using Biodentine shows formation of continuous and dispersed mineralized dentinal bridge (original magnification, ×100)

Figure 2

(a) Direct pulp capping using Dycal shows formation of dispersed mineralized dentinal bridge (original magnification, ×40). (b) Direct pulp capping using Dycal shows formation of dispersed mineralized dentinal bridge (original magnification, ×100)

Table 3

Hard and soft tissue formation based on histologic analysis

Materials	Dycal, n (%)	Biodentine, n (%)	TheraCal LC, n (%)
Soft tissue formation
Pulp tissue organization and morphology
Normal or almost normal pulp tissue morphology	1 (20)	6 (40)	9 (60)
Disorganization of pulp tissue beneath the cavity	3 (60)	5 (33.3)	4 (26.7)
Disorganization of entire pulp tissue	1 (20)	4 (26.7)	2 (13.3)
Hard tissue formation
Dentinal bridge morphology and continuity
Formation of hard tissue beneath cavity in the form of complete dentinal bridge	1 (20)	11 (73.4)	13 (86.7)
Formation of discontinuous bridge beneath the cavity (incomplete dentinal bridge)	3 (60)	2 (13.3)	2 (13.3)
No signs of dentin formation	1 (20)	2 (13.3)	0
Dentinal bridge thickness
>0.25 mm	0	8 (53.4)	10 (66.6)
Between 0.1 and 0.25 mm	4 (80)	5 (33.3)	4 (26.7)
<0.1 mm	1 (20)	2 (13.3)	1 (6.7)

LC: Light Cure

DISCUSSION

The hypothesis has been rejected after the data analysis is accomplished. This in-vivo study compared the application of Biodentine and Dycal for DPC of sound human teeth indicated for orthodontic extraction. The clinical basis is lacking for the drawn outguess in light of the fact. The juxtaposition of changes that occurred in the dentin-pulp structure after DPC performed using Biodentine and Dycal demonstrated that there was a significant distinction among the two groups amid the inspection period. Comprehensively, Biodentine achieved better results than Dycal when used as DPC agent and conferred the elite clinical outcomes. Two basic elements guaranteeing long-haul preservation of pulp vitality after using Biodentine are the synthesis of reparative dentin together with its antibacterial properties. The probable reason for antibacterial activity is the alkaline pH of the cement; according to the literature, the liberation of the TGF-ß1 growth factor from pulp cells results in reparative dentin formation. Compared to conventionally used pulp capping agents, such as calcium hydroxide, Biodentine demonstrates substantially greater mechanical properties which are akin to dentin.[291011121314] Microleakage prevention is a determinant element for the success of DPC. In the Biodentine group, it is noted that at the locus of injury, the dentin bridge formed is uniform and homogeneous. Unfortunately, calcium hydroxide-based material, Dycal dearths, the capability to seal hence does not braze to the dentin. Cox et al., conducted a study and detected the formation of tunnel defects in dentin bridges under Dycal dressings and stated that these defects could serve as pathways for microleakage.[15] Schuurs et al. Dycal as DPC cement also has a propensity to disintegrate over time.[16] Hence, Biodentin is better than Dycal.[17] Other studies on dental pulp response to calcium hydroxide and similar results have emerged from this study.[1819] Our study suggests the same, that dentin bridge formation with Dycal is heterogeneous in nature and dispersed mineralization is most frequently seen. According to the literature, Biodentine proves to be a promising and potential material and can be the future of pulp capping materials. However, more extensive clinical research is required to confirm its effectiveness as DPC material. Convention of the present study had some minor constraints. Sound teeth without signs of inflammation were selected.

CONCLUSION

In accordance with the obtained results, it was concluded that on clinical and histological evaluation, Biodentine performed better as DPC agent. Therefore, Biodentine is progressively dependable for long haul protection of dental pulp than Dycal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.