2006, Swedish Council on Health Technology Assessment 2010), rather than minimally invasive biologically based approaches aimed at maintaining the vitality of the pulp (Ricketts et al. The classification reinforces the need for a more focused or enhanced approach after carious exposure (class II), which is not as critical if the pulp is traumatically exposed (class I) due to a reduction in the microbial load close the pulp tissue. These changes stem from an improved understanding of the pulp–dentine complex's defensive and reparative response to irritation, with harnessing the release of bioactive dentine matrix components and careful handling of the damaged tissue considered critical. 2013, Marques et al. The material takes over four hours to set, and it is recommended that the tooth should be temporized before the permanent restoration is placed. 2017). Success: Positive response to pulp test. Unfortunately, as odontoblasts are highly differentiated post‐mitotic cells, a new layer cannot be created, as in other connective tissues, by inducing mitosis of cells at the wound periphery. Economic factors may also alter treatment decisions as remuneration for a RCT in a molar tooth will be radically different to a VPT procedure on the same tooth. Capping mat: ProRoot MTA (control) n = 23; versus Endocem n = 23, Stratification variable: Age and exposure site (occlusal or axial). These properties are not exclusive to mutans streptococci, and strains of other streptococci such as Streptococcus mitis, Streptococcus gordonii, Streptococcus anginosus and Streptococcus oralis are acidogenic and aciduric (van Houte 1994, van Ruyven et al. 1 The treatment of exposed pulps is either performed via direct pulp capping, which comes with limited prognosis, or root canal treatment, which may be successful but is more burdensome and costly. Frightened of the pulp? Preserving pulp vitality is at the core of Operative Dentistry and offers a biological‐based concept, which reduces intervention and maintains the pulp's developmental, defensive and proprioceptive functions (Randow & Glantz 1986, Paphangkorakit & Osborn 1998, Smith 2002), whilst vital pulp treatment (VPT) is considered technically easier to carry out than pulpectomy and RCT (Stanley 1989). J Dent. It is also not clear from this study the reason for the extraction of teeth with only reversible disease. Management of deep carious lesions in vital teeth is challenging. Irrigation strategies aimed at biological response, rather than disinfection capacity, have used EDTA demonstrated to release TGF‐β family members from the extracellular matrix of dentine (Galler et al. Specifically, various types of pulp cell react immunologically to the microbes, initially via pathogen recognition by odontoblasts and later fibroblasts, stem cells (SCs) and immune cells; thereafter, a complex series of antibacterial, immune, vascular and localized inflammatory responses are activated (Farges et al. No irreversible pulpitis (defined); absence of PA radiographically (defined as ≥ 2 times with of PD space). Potentially discriminatory biomarkers have been identified, which could potentially set an inflammatory threshold above which the pulp is not viable (Rechenberg et al. Questionnaire‐based surveys in which dentists study radiographs of ‘deep carious lesions’ have analysed the dilemma of whether a tooth should be treated conservatively by avoiding pulp exposure, or a VPT approach or whether a more invasive approach is required. If the pulp is exposed, the reparative dentine forms a mineralized bridge, which is generally not in the form of tubular dentine (Nair et al. The initial response of the pulp includes an increase of secretory activity by the odontoblast leading to increased tertiary dentine formation (reactionary dentinogenesis) (Smith et al. 2017, Qudeimat et al. Capping mat: ProRoot MTA (control) n = 23; versus Endocem n = 23, Stratification variable: Age and exposure site (occlusal or axial). Notably, mutans streptococci possess multiple sugar transport systems including the phosphoenolpyruvate phosphotransferase system and can enzymatically thrive at a low pH. 2016b). Is it worth it? 1994). Management of dental caries 1. The power calculation should ideally be based on previous literature or informed by a pilot study, which accounts for dropouts. 2017); however, strong evidence is still lacking to support the relative importance of individual factors to a favourable treatment outcome. Other factors likely to be important prior to undergoing class I pulp capping are small exposures (preferably <1 mm diameter), located in the coronal third of the pulp chamber ideally corresponding to a pulp horn (Fig. 1994). Long non‑coding RNAs are novel players in oral inflammatory disorders, potentially premalignant oral epithelial�lesions and oral squamous cell carcinoma (Review). 2016b). However, the treatments vary from pulpotomy to extensive carious removal (indirect pulp capping) and stepwise excavation, which perhaps reflects that no global consensus or tradition currently exists in the treatment of the deep carious lesion. Controlled clinical trials and cohort studies involving patients with dental caries in permanent teeth were included. 2016a). 2008). By age 19, 67% of children will have experienced tooth decay. 2015). 6). 2007). Less evidence is available for deep carious lesion in the pulpal quarter. Which treatment will be the ‘gold standard’ for treating the deep and extremely deep carious lesion? 2009, Kim et al. Early failures could be related to misdiagnosis of the severity of the pulpitis disease and insufficient pulp tissue removal, which may explain the need for tissue removal in these cases, whereas late failures could be related to the quality and sealing ability of the restoration and mineralized bridge that becomes compromised by secondary infection. 2014b). As discussed earlier, establishing whether the pulp is reversible or irreversibly inflamed is not completely predictable using current diagnostic techniques (Dummer et al. 2003). The clinician should be able to distinguish between inflamed and noninflamed tissue if the pulp is exposed; however, this visual analysis may not be sufficiently accurate. This could potentially indicate that the simple examination of lesion depths on bitewing radiographs is an opportunity to introduce a diagnostic tool for evaluating the risk of bacterial invasion into the pulp. Although from a biological vantage these effects are promising, there are currently no therapeutic solutions available that use previously extracted DMCs and apply them directly in situ. Alternative theories disagree with the accepted theory of odontoblast‐like cytodifferentiation, highlighting that other cells such as fibroblasts or fibrocytes may in fact produce the mineralized tissue (Ricucci et al. Inflammation is destructive, but the resulting pathophysiological response is necessary to stimulate healing. For bacteria to play a role in the carious process, they must possess certain characteristics that promote the disease (Loesche 1986). At present, there remains a paucity of high‐quality randomized clinical trials comparing and testing capping materials in order to make definitive conclusions on the best material to use. Notably, in class II procedures the use of high concentration of disinfection prior to placing the capping material is recommended as well as magnification to improve control of the carious removal procedure (Fig. 2007, Schwendicke et al. Randomization: No concealed allocation sequence. Practically, it is challenging to place a capping material on a wet surface such as a blood clot, whilst the presence of a blood clot has been linked to higher risk of post‐operative infection (Schröder & Granath 1972, Schröder 1985). For 2 min ( haemorrhage control ) is available for deep caries can be compromised in approximal cavities 2018. Discomfort and painful early failure after carious exposure ( Bogen et al there a... 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