La carie dentale è la malattia non trasmissibile più diffusa al mondo, che colpisce i denti primari di 560 milioni di bambini e i denti permanenti di 2,3 miliardi di persone a livello globale.1 Nella pratica quotidiana del dentista, è riportato che un terzo dei pazienti presenterà carie profonde, definite come “carie che raggiungono il quarto interno della dentina, ma con una zona di dentina dura o solida tra la carie e la polpa, che è rilevabile radiograficamente quando si trova su una superficie interprossimale o occlusale”.
Dental caries is the most widespread non-communicable disease in the world, affecting the primary teeth of 560 million children and the permanent teeth of 2.3 billion people globally.1 In the dentist’s day-to-day practice, it is reported that a third of patients will present with deep caries, defined as “caries reaching the inner quarter of dentine, but with a zone of hard or firm dentine between the caries and the pulp, which is radiographically detectable when located on an interproximal or occlusal surface.”2,3,4
The proximity of deep caries lesions to the pulp presents a major challenge for the dental professional.2,3 The goal is to preserve the vitality of the tooth whenever possible, but physiological stress, irreversible inflammation, and exposure of the pulp are significant risks that can lead to a much poorer prognosis. In light of this, restorative dentistry has evolved to favour minimally invasive strategies with biologic materials that protect the pulp and promote healing. In this article, we explain why Biodentine™ is the next-generation material for clinical success in all deep caries cases.
Deep caries lesions have traditionally been managed with complete (non-selective) caries tissue removal, in which all soft and firm dentine is removed from the peripheral and central aspects of the cavity.2,3,5,6 However, this is now regarded as over-treatment and is no longer advocated.2,6
It is now known that complete removal of carious tissue is not necessary in order to halt the progression of dental caries.7 Various studies have indicated that removing only the superficial layers of infected dentine, which contain the majority of the cariogenic bacteria, may be sufficient.6,8
Further, it is difficult to accurately assess the depth of a carious lesion and the thickness of the remaining dentine.3 Complete caries excavation therefore carries a risk of inadvertent exposure and bacterial contamination of the pulp, compromising pulp vitality and leading to poorer treatment outcomes.2,3,7,9
Instead, deep caries management is now shifting towards minimally invasive, biologic strategies intended to preserve non-demineralised and remineralisable tissue, pulp health and vitality, and long-term function of the tooth.2,6,8
Evidence supports selective caries tissue removal as an effective, minimally invasive strategy for excavating carious dentine.2,3 The European Society of Endodontology (ESE) advocates for its use in teeth with reversible pulpitis, on the condition that the cavity has not progressed past the pulpal quarter during radiographic assessment and a barrier of dentine remains between the cavity and pulp.2
Selective removal can be performed in one or two stages. One-stage selective removal involves excavation of carious tissue down to soft or firm dentine, followed by the immediate placement of a permanent restoration. Two-stage selective removal, also known as stepwise excavation, is performed in two visits 6-12 months apart. At the first visit, carious tissue on the pulpal aspect is selectively removed to soft dentine and a temporary restoration is placed. At the second visit, the cavity is re-accessed, carious tissue is removed to firm dentine, and a permanent restoration is placed.
While both one-stage and two-stage selective removal demonstrate a high success rate (90% and 70% respectively at three years), one-stage removal is preferred where possible.2,6 Two-stage removal increases the risk of pulp exposure and is considered an additional and unnecessary treatment burden for the patient.
In deep caries lesions radiographically extending to the pulpal third or quarter of the dentine, the ESE and the International Caries Consensus Collaboration (ICCC) recommend one-stage selective removal to soft dentine in both the primary and permanent dentition.2,6 A barrier of soft dentine is left on the pulpal aspect of the cavity, while peripheral carious dentine is removed to hard dentine, leaving sufficient hard tissue to support the restoration and achieve an optimal seal.6
The ICCC states that, compared to non-selective removal to hard dentine or selective removal to firm dentine, this approach significantly reduces the risk of pulp exposure.6 Selective removal to firm dentine can also place physiological stress on the pulp and is recommended only in shallow or moderately deep dentine lesions.6
Vital pulp treatment (VPT) is a collection of techniques aimed at protecting the pulp and facilitating healing. When the pulp is not exposed after carious dentine excavation, indirect pulp capping is the preferred VPT technique in permanent and primary teeth with reversible pulpitis.8,9,10 A thin layer of dentine is left covering the pulp. Some materials are applied on top in a thin layer to form a protective barrier. Biodentine makes possible to fill the whole cavity in bulk-fill to the top of the tooth (final enamel restoration within 6 months).
Where the pulp is exposed after excavation, advocates of minimally invasive dentistry now favour the following VPT techniques over the traditional pulpectomy (full pulp removal) approach:2,3
In all these cases, Biodentine is the unique material allowing to do both the direct capping (contact with the pulp) and the permanent dentine-restoration: one material only from the pulp to the top.
In line with the minimally invasive, biologic approach, the priority when choosing a restorative material has shifted from simple preservation to active repair of the pulp-dentine complex.
For some time, calcium hydroxide was considered the “gold-standard” material for deep caries restoration. Its high alkaline pH stimulates fibroblasts and enzymes, promotes healing of pulp tissue, and supports the mineralisation process.7 However, it also has some notable disadvantages, including tunnel-like dentinal defects, cytotoxicity, poor adhesion, and long-term instability.7,10,11 Thus, calcium hydroxide presents a risk of micro-leakage, bacterial infiltration, pulpitis, internal resorption, and tooth loss.7,10,11
Given these drawbacks, there has been great interest in alternative materials that demonstrate better remineralisation capability, sealant ability, strength, and durability. For example, glass ionomer cements (GICs) and calcium silicate cements like Biodentine™ have been confirmed to promote remineralisation of demineralised dentine.9,12
Of the two, the ESE recommends hydraulic calcium silicate cements for direct placement onto the pulp after pulp exposure or during pulp capping, partial pulpotomy, or full pulpotomy prior to final restoration.2 Indeed, Biodentine™ is an excellent choice for deep caries with pulp exposure, demonstrating a range of success rate in teeth using Biodentine as a direct pulp capping material of 83.3% – 100% at 12 months and 82.6% – 93.2% at 18 months.17,18 Made with tricalcium silicate, zirconium oxide, and calcium carbonate, Biodentine™ is an ultra-pure material that has no cytotoxic, mutagenic, sensitising, or irritant effects on exposed pulp, ensuring high cell viability and enhancing biological healing.19, 23
When the pulp is not exposed, many dental professionals still tend to use GIC for the restoration of deep caries lesions, reserving hydraulic calcium silicate cements like Biodentine™ for pulp exposure and other complex cases. However, the benefits of Biodentine™ extend far beyond direct pulp application. The material shows great benefit in indirect pulp capping procedures too, with an overall success rate of 92%.7,8,10,11,13
In indirect pulp capping procedures, Biodentine™ has shown consistently greater remineralisation of dentine compared to materials such as GIC, calcium hydroxide, and mineral trioxide aggregate (MTA). When placed, Biodentine™ stimulates the release of growth factors and the formation of new blood vessels (angiogenesis) to promote natural healing of the pulp.19 Further, it creates pores in the underlying dentine, allowing high concentrations of calcium, hydroxyl, and carbonate ions to diffuse into the dentine. This supports increased mineral deposition and formation of reactionary dentine and dentinal bridges — without triggering an inflammatory response in the pulp.7,9
The resulting dentine layer is thicker and denser than that created by GIC, providing optimal protection of the pulp and improving resistance to micro-leakage and bacterial infiltration.20, 21 In a study comparing Biodentine™ to calcium hydroxide and MTA, in which a 100% success rate was observed, significantly more tertiary dentine was deposited in the Biodentine™ group, and the porosity of the dentine bridges was greater than those formed by calcium hydroxide.11
A study comparing Biodentine™ and GIC found that, while both materials demonstrated the ability to remineralise caries-affected (firm) dentine, the increase in mineral content was significantly higher with Biodentine™.12 Further, only Biodentine™ was able to significantly remineralise caries-infected (soft) dentine, which would otherwise be removed prior to restoration. These findings suggest that, when Biodentine™ is used instead of GIC, more of the natural dentine can be preserved and remineralised — a key principle of minimally invasive dentistry and an undeniable benefit to the patient.
The clinical success and longevity of a deep caries restoration relies on the quality and durability of the seal between the material and enamel/dentine surface. A tight interface and an hermetic seal are essential to prevent microleakage, bacterial infiltration, secondary caries, and restoration failure.
Although GIC demonstrates good adhesive properties with dentine, it has historically been vulnerable to shrinkage during setting and maturation, compromising the marginal seal of the restoration.22 Niranjan states that “A major factor responsible for defects at the marginal and internal interface of restoration is shrinkage that accompanies polymerization of composite restorative material.” 22 Further, GIC has a known tendency to erode under acidic conditions.23, 24
Biodentine™, however, has demonstrated excellent adhesion to the dentine surface.25 Biodentine™ deposits mineral tags into the openings of the dentine tubules, using micro-mechanical anchorage to form a tight interface, a strong bond, and an excellent seal. This process is shown to continue after setting, improving the quality of the seal over time. Further, Biodentine™ achieves this seal without the need for prior dentine conditioning, reducing the risk of post-operative sensitivity.13
Biodentine™ also displays superior resistance to shrinkage and acid erosion. The resin-free formula offers exceptional dimensional stability, maintaining the hermetic seal of the restoration.14 Recent studies support this, demonstrating that Biodentine™ is a durable and reliable material for indirect pulp capping. When measuring clinical success at 12, 16 and 24 months, three studies found that Biodentine™ had a success rate of 100%, 95.8%, and 77.8% respectively, compared to 94.4%, 87,5 and 66.7% for GIC. At 24 months, the three restorations that had failed were in the GIC group.10,13,15 Although Biodentine™ is subject to slight acid erosion in a highly acidic solution, it undergoes less erosion than GIC under the same conditions, and experiences no erosion at all in reconstituted saliva with phosphates present.23, 24 Overall, Biodentine™ exhibits superior durability and resistance to micro-leakage compared to GIC.22
In indirect pulp therapies, where a layer of soft or firm carious dentine is left as a protective barrier over the pulp, it is accepted that some amount of viable bacteria will remain in the dentine.10 Achieving aseptic conditions and obtaining a tight seal — either with hydraulic calcium silicate cements like Biodentine™ or with GIC — will dramatically reduce the number colony-forming units present. However, in deep or extremely deep caries lesions, it is hydraulic calcium silicate cements that are recommended for this purpose by the ESE.2
Biodentine™ releases hydroxyl ions during the setting phase, resulting in a very high alkaline pH. This creates an environment that is highly unfavourable to bacteria, effectively disinfecting carious dentine.10 In practice, this means that more dentine can be preserved, improving protection of the pulp without increasing the patient’s risk of secondary caries and infection. As a result, Biodentine™ offers the dental professional the opportunity to take a more conservative approach to restoration in line with minimally invasive practices.
When only a thin barrier of natural dentine separates the inflamed pulp from the restorative material, there is a risk that normal occlusive force can stress the pulp and compromise its vitality. Therefore, the ideal material must be strong enough to protect the pulp and allow it to heal. In the posterior teeth, where the occlusal chewing forces are greatest, Biodentine™ has demonstrated reliability as the restoration material allowing for pulp healing within six months.16
It is clear that the benefits of Biodentine™ extend far beyond the treatment of deep caries with pulp exposure. For protecting and preserving non-exposed pulp, there is a selection of materials to choose from, but only one that consistently exceeds all criteria for an ideal biologic dentine substitute and delivers superior — not just adequate — results.
Biodentine™ helps you to achieve your minimally invasive and biologic dentistry goals in a single session as part of the recommended one-stage selective carious tissue removal approach. As a permanent dentine replacement, Biodentine™ can be placed all the way from the pulp to the crown using the Bio Bulk-Fill procedure, with a final enamel restoration to be performed within 6 months. The setting time of just 12 minutes means that the final composite restoration can be placed in the same session, eliminating the need for repeat visits and re-entry.
To streamline your procedures, achieve an outstanding seal, and guarantee the long-term success of your restorations, make Biodentine™ your material of choice for indirect pulp capping.
References
1 https://www.who.int/news-room/fact-sheets/detail/sugars-and-dental-caries#:~:text=Dental%20caries%20
4 Internal Septodont Study (2017)
17 Awadeh et al. 2018, Hedge et al. 2017, Brizuela et al. 2017, Katge and Patil. 2017
18 Linu et al. 2017, Lipski et al. 2018
19 Biodentine™: Properties and Clinical Applications, Imad About 2022
20 Effect of different intermediary bases on microleakage of a restorative material in Class II box cavities of primary teeth, Abdelmegid FY, Salama FS, Al-Mutairi WM, Al-Mutairi SK, Baghazal SO, 2017
21 Effect of Biodentine™ on secondary caries formation: An in vitro study, Özgül BM, Tirali RE, Cehreli SB, 2017
22 https://journals.lww.com/jped/Fulltext/2016/34040/A_comparative_microleakage_evaluation_of_three.6.aspx Niranjan et al. 2016, a comparative microleakage evaluation of three different base materials in Class I cavity in deciduous molars in sandwich technique using dye penetration and dentin surface interface by scanning electron microscope
23 https://pubmed.ncbi.nlm.nih.gov/18448160/ Laurent P, Camps J, De MM, Dejou J, and About I 2008 Induction of specific cell responses to a Ca(3)SiO(5)-based posterior restorative material. Dent.Mater. 24 (11) 1486-1494.
24 Harpreet Singh, Mandeep Kaur, Sheenam Markan and Pooja Kapoor, Biodentine: A Promising Dentin substitute, 2014 25 Marginal Adaptation Evaluation of Biodentine™ and MTA Plus in “Open Sandwich” Class II Restorations, Aggarwal V, Singla M, Yadav S, Yadav H, Ragi
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