DIRECT PULP CAPPING: BIODENTINE VS MTA VS CALCIUM HYDROXIDE VS SINGLE BOND UNIVERSAL

ANY QUESTIONS?

UNANSWERED QUESTIONS

IMPLICATIONS FOR PATIENTS

• IS BIODENTINE EFFECTIVE AS A PULP CAP AGENT IN CARIOUS TEETH/DIFFERENT POPULATIONS?
• BIODENTINE MECHANISM OF ACTIONS (STEM CELL PROLIFERATION CAPACITY)?
• IS BIODENTINE EFFECTIVE LONG TERM?

CONCLUSIONS BASED ON THE EVIDENCE

• BIODENTINE IS A PROMOSING AGENT
• THE GOLD STANDARD SHOULD STILL BE USED UNTIL FURTHER EVIDENCE IS RELEASED

• IN NON CARIOUS MOLARS OF HEALTHY PATIENTS, IN THE CLINICAL SCENARIO OF STERILE MECHANICAL VITAL PULP EXPOSURE, THE USE OF EITHER MTA OR BIODENTINE AS A PULP CAPPING AGENT IS BETTER THAN THE GOLD STANDARD CALCIUM HYDROXIDE BECAUSE OF THE HIGHER QUALITY OF DENTINE BRIDGE FORMATION - HOWEVER THIS WOULD ONLY BE TRUE FOR SHORT TERM APPLICATIONS, SINCE NO LONG TERM DATA IS AVAILABLE

LEVEL OF EVIDENCE

• LOW - VERY LOW SAMPLE SIZE + UNREALISTIC CLINICAL SCENARIO, CANNOT COME TO ANY CONCLUSIONS BASED ON THE LEVEL OF EVIDENCE -> WE CAN DRAW SOME FUTURE RESEARCH RECOMMENDATIONS

WEAKNESSES OF THE STUDY

• SAMPLE SIZE TOO SMALL
• CLINICIAN CANNOT BE BLINDED
• DONE ON CARIOUS FREE TEETH, STERILE CONDITIONS
• CERTAIN EXPERIMENTAL BIASES
• OTHER OUTCOME FACTORS NOT MEASURED (IE: INFLAMMATORY CELLS)
• UNCLEAR METHODOLOGY, OMISSION OF DETAILS
• STUDY TOO SHORT, UNREALSTIC
• NO LONG TERM DATA

STRENGHTS OF THE STUDY

• DOUBLE BLIND RCT (IN THE END)
• GOOD EXPERIMENTAL DESIGN
• GENERALLY CONSISTENT
• PLOTS/GRAPHS/IMAGING USAGE - DATA ANALYSIS
• CONSISTENT USAGE OF CLINICIANS
• REASONABLE CONCLUSIONS BASED ON EVIDENCE

EFFECTS OF BIAS

• POPULATION BIAS: NON HOMOGENOUS GROUPS THAT DOESNT REFLECT THE POPULATION
• SELECTION BIAS: NON RANDOMNIZED, NON CONTROL OF VARIABLES
• PERFORMANCE BIAS: OTHER VARIABLES AFFECT THE RESULTS, NON BLINDED CLINICIANS WILL TREAT CERTAIN GROUPS DIFFERENTLY (CANNOT BLIND HIM)

bias sources

RESEARCH FINDINGS

ANALYSIS

RESEARCH METHODS

RESEARCH DESIGN

• PRE-OP RADIOGRAPH TO RULE OUT PATHOLOGY/CARIES; PRE AND POST OP VITALITY TESTS
• STERILE CONDITIONS -> CLASS I PREP -> 1.5MM MECHANICAL PULP EXPOSURE
• RANDOMLY DIVIDED INTO 4 GROUPS: MTA, CA(OH)2, SBU, BIO (NO CONTROL)
• AFTER 1 WEEK -> FINAL RESTORATION PLACED (CR)
• AFTER 6 WEEKS -> XRAY/VIT TESTS -> EXTRACTION -> CBCT/HISTOLOGY (DENTINE BRIDGE ANALYSIS)

• RANDOMIZED DOUBLE BLIND CONTROLLED STUDY
• 44 3RD NON CARIOUS 3RD MOLARS SCHEDULED FOR EXTRACTIONS (21 SUBJECTS AGE 19-32)
• DURATION: 6 WEEKS
• 4 MATERIALS: CA(OH)2, MTA, BIODENTINE, SBU
• FINAL RESTORATIE MATERIAL: COMPOSITE RESIN

INCLUSION CRITERIA

INCLUSION CRITERIA

• USES BOTH BIODENTINE AND MTA
• IS MEASURABLE
• RCT
• HUMAN STUDY IN VIVO

Direct Pulp Capping: Biodentine vs MTA vs Calcium hydroxide vs Single Bond Universal

ARTICLE SELECTION

databases used

Search strategy

Type of question

MATERIALS

MATERIALS

• intervention
• Best study type: Randomized controlled trials
• Best evidence: systematic review

• BIODENTINE
• TRI-CALCIUM SILICATE: CORE
• DI-CALCIUM SILICATE: 2ND CORE
• CALCIUM CARBONATE AND OXIDE: FILLERS
• IRON OXIDE: COLOURING AGENT
• ZIRCONIUM OXIDE: RADIO OPACIFIER
• CALCIUM CHLORIDE: ACCELERATOR
• HYDROSOLUBLE POLYMER: WATER REDUCING AGENT

• MTA
• BIOCOMPATIBLE
• PORTLAND CEMENT
• DIFFICULT TO HANDLE/LONG SETTING TIME
• HIGH COST

question

MATERIALS

• CALCIUM HYDROXIDE
• GOLD STANDARD
• BACTERICIDAL PH=12
• POOR DENTINE BOND
• TUNEL DEFECTS
• SINGLE BOND UNIVERSAL
• NEXT GENERATION OF BOND
• TOTAL ETCH/SELF ETCH

P: young adults, non carious 3rd molars, in vivo

I: BIodentine

C: calcium hydroxide (gold standard)

O: successful direct pulp cap

Clinical question

• A sales representative presents to your office
• "we have a new material for direct pulp cap usage, it's called biodentine - it's as effective as MTA and easier to use"

Pulp Capping