A literature review. Presented in sunnybank dentist pure dentistry 2019.

• dental cement (including luting agent, liner, base, direct or indirect pulp-capping material) or direct restorative materials
• setting or hardening reaction is based on a hydration reaction between water and hygroscopic inorganic compound(s), including
  • calcium silicates
  • calcium aluminates
  • zinc sulphates
  • calcium sulphates

(GMND Agency 2019)

• bioactive materials, owing to the inclusion of tri/dicalcium silicate powder
• Encompass the following:
  • MTA-type cements
  • tricalcium silicate based cements
  • hydraulic calcium silicate cements
  • bioactive cements
• Commercially available biosilicates include:
  • ProRoot MTA
  • Biodentine
  • MTA Angelus
  • BioRoot RCS

• indirect pulp capping
• direct pulp capping
• pulpotomy
• partial pulpotomy
• pulpectomy
• root end filling material
• apexogenesis and apexification
• root canal sealer
• repair of perforations
• management of resorption
• horizontal and vertical root fractures
• restorative material

There is some ambiguity in the literature as to the classification and nomenclature of biosilicate materials used in dental practice (Ha et al. 2017). For the purpose of this literature review, the term “biosilicates” will be defined as bioactive materials intended for use as a dental cement (including luting agent, liner, base, direct or indirect pulp-capping material) or direct restorative material for which the majority of the setting or hardening reaction is based on a hydration reaction between water and hygroscopic inorganic compound(s), such as calcium silicates, calcium aluminates, zinc sulphates or calcium sulphates (GMND Agency 2019).

 

Biosilicates are bioactive materials, owing to the inclusion of tricalcium or dicalcium silicate powders (Primus et al. 2019). The term biosilicates may be used to refer to Mineral Trioxide aggregate, tricalcium silicate, di/tricalcium silicate based cements, hydraulic calcium silicate cements and bioactive cements.

Calcium silicate Portland cement dates back to Roman times. Adding Pozzolana to concrete helped with setting time even when it was submerged in water. Pozzolana is still the main component of many Portland cements (Prati & Gandolfi 2015). Portland cement was first used in dentistry in the 19^th century by Dr Witte. It was later investigated once again by Dr. Torabinejad and Mr White who patented the use of Portland cement in endodontics. The first experimental material was called Mineral Trioxide Aggregate (Lee et al 1993).

Expansion and sealing ability: Biosilicates sealing ablity have been tested by different methods such as dye solution, micro-CT scans and polymicrobial tests. Due to the complex 3D porosity distribution micro-CT scans are more accurate than dye solution tests (Primus et al. 2019). The expansion and setting time of these cements can be reduced by presence of proteins in the mixing liquid (Gandolfi et al. 2009). Water sorption increases the expansion and sealing ability. They can expand by 0.2%-6% of the initial volume.

Compressive strength: Condensation pressure and stage of hydration may affect the compressive strength (Nekoofar et al. 2007). Use of acid-etch before restorative procedures may reduce the compressive strength (Watts et al. 2007).

Push out strength: The ability to absorb water and expand increases the microchemical retention of biosilicates on the internal walls and push out strength (Iacono et al. 2010).

Biocompatibility: Some additive materials such as bismuth oxide can affect the biocompatibility of biosilicates (Gandolfi et al. 2009). few biosiliactes have been manufactured for specific use such as direct pulp capping and apexogenesis without any opacifiers to optimize biocompatibility.

Setting time:  Setting time of biosilicates can be reduced by presence of Calcium carbonate and proteins and increased in the presence of Naf. (Gandolfi et al. 2009).

Bioactivity and anti-microbial properties:  Biosilicates continue to release Ca ions while in contact with moist environment (Gandolfi et al. 2015). Fluoride ion is released in cements containing NaF and can form fluoroapatite (Gandolfi et al. 2010).

Due to alkalizing activity of these cements (Mchugh et al. 2004) and formation of Ca(OH)₂

they have antimicrobial action for 15-30 days (Al-Hezaimi et al. 2005).

Once the calcium silicate powder and liquid are mixed, at the liquid-solid interface there will be instant dissolution of the ions and calcium release which will form Ca(OH)₂ and increase the pH of the environment. The OH ions will attack the silicates and a colloidal gel phase will form (CSH gel). By dissolution and precipitation of the ions in the gel, needle like crystals called calcium silicate crystals and rhomboidal crystals of Ca(OH)₂ will form. This will start to harden the gel; the initial hardening happens in about 1-6 hours. It will take a few days for the cement to fully set and all unhydrated calcium silicates to fully hydrate. (Prati & Gandolfi 2015).

Portland cement used in dentistry is composed of tricalcium silicate, dicalcium silicate, tricalcium aluminate and tetracalcium aluminoferrite. It may include minor amounts of magnesia, pottasia, soda and sulfates. Various materials are added as opacifiers including Bismuth oxide (MTA), calcium tungstate (MTA-Caps), barium sulphate, Zirconium Oxide (Angelus MTA, MM-MTA, Biodentine) and Tantalum (Bioaggregate) (Camilleri & Gandolfi 2010). Calcium carbonate can be used to reduce the setting time. (Camilleri et al. 2013). Theracal LC is a light cured bioactive cement that contains mostly resin and about 45% hydraulic cement (Arandi & Rabi 2018). It is light cured (fast-setting) and has been claimed to have low solubility and high calcium release (Gandolfi et al. 2011).  However, a study by Camilleri et al. showed due to incomplete hydration there was lower calcium ion leach compared to Biodentine and a protype biosilicate cement (Camilleri et al. 2014).

A root end filling material may need to be  placed in an immature nonvital tooth before obturation of the canal. Materials such as amalgam, resin composites, gutta-percha, IRM and biosilicates can be used.

D’Anto et al. study reported MTA can promote tissue healing (D’Antò et et al. 2010). MTA is  able to  form cementum and bone  in the periapical area in animal studies (Katsamakis et al. 2013). A prospective non-randomized study reported biosilicates were more effective than Resin composites after 5 years of follow up (Von Arx et al. 2014). Saatchi et al. reported that one week after placing amalgam at the open root apex mercury blood levels can increase (Saatchi et al. 2013). Custom fitted gutta-percha can also be placed at the open apex. To perform this technique the coronal segment needs to be prepared wider than the apical section which will increase chances of fracture (Rafter et al. 2005). Gutta percha can be back filled and smoothened at the root by surgery. Use of MTA compared to this method showed better healing (96%) compared to use of back filled Gutta Percha 52% and smoothening it with surgery (Christiansen et al. 2009). Although study by Saunders concluded microsurgical technique in combination with MTA had high clinical success rate (Saunders et al. 2008) other studies by Von Arx et al. and Song and Kim showed no significant difference between use of Super EBA and MTA after apical surgery (Von Arx et a.l 2012 & Song and Kim 2012).

Indirect pulp treatment is a procedure performed in teeth with a deep carious lesion approximating the pulp but without signs or symptoms of pulp degeneration. (AAPD 2008)

IPC has a success rate of about 90%. According to Coll et al. success rate usually does not depend on the medicament or technique (Coll 2008). Indirect pulp capping procedure success is highly dependent on a well-sealed coronal restoration, as study by Besic reported, liner placed in a deep carious lesion is not to stop the carious process, as that stops after placing a well-sealed restoration on the tooth but to eliminate any bacteria present in the deep carious lesion (Besic 1943).  Study by Dalpian et al. also reported no difference in dentine microhardness of primary teeth undergoing partial caries removal when using dycal or not using anything (Dalpian et al. 2012).

Different materials such as Ca(OH)₂,GIC and biosilicates have been used as medicaments for IPC.

Garrocho-Rangel et al. reported no significant difference between using Ca(OH)₂ and biosilicate cement in IPC success rate in primary teeth (Garrocho et al. 2017).

Petrou et al. compared the use of nonabsorbable MTA and Portland cement with Ca(OH)₂ and reported IPC with MTA induced a harder dentin and presence of less bacteria in 6 month compared to Ca(OH)₂. They concluded although success rate for all medicaments used were the same, the use of non-resorbing MTA cements as one visit IPC is more favorable to use of Ca(OH)₂ (Petrou et al. 2014). Some of the disadvantages of Ca(OH)₂ is that it is absorbed more over time compared to MTA (Fridland et al. 2005). Another drawback is disintegration and formation of tunnel defects in the newly formed dentin by Ca(OH)₂ (Olsson et al. 2006). Study by Hashem et al. compared biodentine with  GIC and reported the clinical efficacy were the same for both materials in patients with reversible pulpitis (Hashem et al. 2015).

In this review, some of the current applications of biosilicate materials in paediatric dentistry will be discussed. These include procedures completed in both primary and young permanent teeth. The applications that will be investigated further are direct and indirect pulp capping, pulpotomy and partial pulpotomy. Applications in young permanent teeth include use as a root end filling material, a root canal sealer, in apexogenesis and apexification, for repair of perforations, in the management of resorption, horizontal and vertical root fractures and as a restorative material.

Cvek reported one of the landmark studies on partial pulpotomy technique in 1978. The technique involves the surgical removal of only the superficial layers of the exposed or inflamed pulp to reach the deeper healthy pulp tissue. The pulpal wound is then dressed after pulpal bleeding has been controlled through irrigation with a bacteriocidal solution such as sodium hypochlorite or chlorhexidine (Mejare  & Cvek 1993).  Partial pulpotomy is carried out for young permanent teeth that suffer carious pulp exposure (AAPD 2015). Permanent teeth that suffer pulp exposure secondary to traumatic crown fractures are usually treated with the Cvek pulpotomy technique (AAPD 2015). This involves removal of one to three millimeters of pulp tissue adjacent to the traumatic pulp exposure. The pulp is then covered with a dressing material such as calcium hydroxide (Cvek 1978).

 

Calcium hydroxide had long been the gold standard pulp dressing in the partial pulpotomy technique. More recently biosilicate materials such as Mineral Trioxide Aggregate have been advocated for use as a pulp dressing agent (AAPD 2015, Özgür et al. 2016).  Ca(OH)₂ has been demonstrated to have good long-term success rates (Mejàre & Cvek 1993). However, there is evidence of more predictable dentine bridge formation and better pulpal response with the use of MTA (AAPD 2015, Chako & Kurikose 2016). When treating anterior permanent teeth, using white MTA rather than gray MTA helps to lower the chances of intrinsic tooth discoloration (Bakland 2019).

A review by Bimstein & Rotstein (2016) presented an update on Cvek pulpotomy technique. They reported success rates for treatment with MTA and Ca(OH) ₂ concluded that there was no statistically significant difference in the success rates of the technique when treated with either material. Instead, they reported that the key factor in success was the quality of the seal to prevent microbial invasion to the remaining pulp.

Another frequently used application of biosilicates is in pulpotomy treatment.  Pulpotomy is a form of vital pulp therapy performed on primary teeth with extensive caries in the absence of signs or symptoms of radicular pathology (AAPD 2014). This usually occurs in the case of carious or mechanical pulp exposure encountered during caries removal or following traumatic pulp exposure.

 

The aim of pulpotomy treatment is to retain the tooth in function to preserve the integrity of the alveolus. This is achieved by preservation of the radicular pulp tissue and ensuring the patient remains free of pain, swelling and infection (Fuks 2008).  The rationale behind the pulpotomy procedure hinges on the ability for the radicular pulp tissue to retain its capacity to heal or remain healthy following surgical amputation of the effected coronal pulp tissue (Fuks 2002). Success of treatment however depends largely on establishing a proper diagnosis. A diagnosis of normal pulp or reversible pulpitis should be confirmed via clinical and radiographic findings prior to considering treatment with pulpotomy.

 

With regards to medicament choice following coronal pulp amputation, the dressing material should possess a number of qualities as follows:

• harmless to the radicular pulp and surrounding tissues
• bactericidal effect
• promote tissue regeneration and healing of the radicular pulp
• possess good sealant properties
• support regeneration of the dentine-pulp complex
• avoid any interference with the physiologic root resorptive process

(Fuks 2002).

A number of materials have been investigated for use as a pulpotomy medication, including biosilicate materials more recently. In order to assess the efficacy of biosilicates in this application of paediatric dentistry, this review will investigate some of the alternative material choices applied to pulpotomy procedures.

 

Pulpotomy technique can be classified by the treatment objectives of devitalisation, preservation or regeneration (Ranly 1994). It is worth noting that certain medications can be applied to multiple treatment objectives. Devitalisation pulpotomy originally involved the complete mummification of the medicated pulp tissue, theoretically leaving the radicular pulp sterile and vital. This technique is exemplified with the use of Formocresol (FC) as the medicament. The use of FC was introduced as a multiple visit technique by Sweet in 1930 and aimed to completely mummify the tissue. A five–minute formocresol technique was tested by Redig in 1968, which went on to become the mainstay of FC pulpotomies in the practice of paediatric dentistry.  Electrosurgical technique is another example of devitalisation pulpotomy. The benefits of electrosurgical pulpotomy include its non-pharmacological nature, ease of use and favourable success rates (Dean et al 2002).

 

Preservation pulpotomy aims to minimise pulpal irritation and conserve as much of the radicular pulp as possible, without attempting to induce reparative dentine formation.  Examples of medicaments used in the preservation pulpotomy technique include glutaraldehyde and Ferric Sulphate (Ranly 1994). Ferric sulphate works as a coagulative and haemostatic agent. This is achieved through formation of a metal-protein complex on contact with blood in the radicular pulp tissue (Epstein & Maibach 1964).

 

Finally, regeneration pulpotomy technique involves the stimulation of dentine bridge formation (Ranly 1994). Various medicaments can be used in regeneration pulpotomy technique. These include Calcium Hydroxide (Ca(OH)2) and several types of biosilicate materials, such as Mineral Trioxide Aggregate (MTA) and Biodentine. Calcium hydroxide was one of the first pulpotomy medicaments that demonstrated the ability to induce regeneration of dentine (Zander 1939). However, several issues have since been documented in Ca(OH)2 pulpotomies including internal resorption (Sonmez 2008) and higher rates of failure (Huth et al. 2012).

In 2001, Eidelman et al. presented a preliminary report comparing the use of Mineral Trioxide Aggregate to FC as a pulp-dressing agent in the pulpotomy of primary molars .The report noted promising clinical and radiographic findings after use of MTA as a pulp dressing material and suggested it may replace FC in the future. The authors did however acknowledge the limitations of the study including the small sample size (17 teeth in the MTA experimental group, 15 teeth in the FC control group) and short follow up time. On the basis of the sample size, it is not possible to draw definitive conclusions about MTA as a pulpotomy medicament from this report (Eidelman et al. 2001).

 

A systematic review and meta-analysis by Stringhini et al (2015) compared MTA, formocresol, ferric sulfate and electrosurgery pulpotomy.  It found that MTA significantly improved success of pulpotomy, deeming MTA a better pulpotomy medicament that FC. It also found FS and electrosurgery pulpotomy had similar success rates to FC.

 

Coll et al. conducted a systematic review and meta-analysis on primary tooth vital pulp therapy. They compared the clinical and radiographic performance and success rates of several pulpotomy medications. Some of the conclusions are summarised below:

1. MTA and FC had the highest pulpotomy success rates at 24 months follow up, at 89.6% and 85.6% respectively. There is high quality evidence supporting the conclusion that the success rates of MTA and FC were not significantly different
2. 24 month success rates for MTA, FC and FS were all significantly higher than Ca(OH)2. Therefore, the authors do not recommend the use of Calcium hydroxide as a pulpotomy medicament (Coll et al. 2017).

 

A recent Cochrane review by Smaïl-Faugeron et al. (2018) investigated pulpotomy medicaments in the treatment of primary teeth with extensive caries. The following three comparisons were found to have moderate-quality evidence:

1. MTA reduced the clinical and radiographic failure rate of pulpotomy in comparison to formocresol. This difference was statistically significant at 12 months for clinical failure and at six, 12 and 24 months for radiographic failure
2. MTA reduced the failure rate in comparison to calcium hydroxide. The difference was statistically significant at 12 and 24 months for clinical failure and at six, 12 and 24 months for radiographic failure
3. when comparing formocresol to calcium hydroxide, formocresol was found to have better clinical and radiographic success rates at a statistically significant level at six and 12 months

 

Smaïl-Faugeron et al. went on to conclude that MTA was likely the best medicament to use in pulpotomy treatment of primary teeth. The authors also stated that Biodentine, enamel matrix derivatives or laser treatment are good alternatives where MTA is not accessible. It must also be taken into consideration that all of the trials included in this review were assessed to have an unclear or high level of bias.

Direct pulp capping is applying a medicament on the exposed pulp to try to preserve pulp vitality and to induce formation of a new dentine bridge to protect the dental-pulpal tissue. DPC can be performed on a tooth with a healthy pulp that has been exposed from a traumatic injury or by iatrogenic means (Fuks 2008). Pulp capping material should be bactericidal or bacteriostatic ,biocompatible, radiopaque, maintain vitality of tooth, adhere to dentine. Gaining a dentinal bridge is the main purpose of DPC (Stanley 1989). Success of DPC depends on patients age, size of exposure, remaining tooth structure, and achieving hemostasis (Aeinechi et al. 2003). Biosilicates, Zinc Oxide Eugenol, Glass Ionomer and resin modified glass ionomer, adhesive restorations and calcium hydroxide have been used for DPC. Biodentine has showed superior physical and biological properties compared to MTA (Rajasekharan et al. 2018).

Ca(OH)2: Different variables are studied when comparing biosilicates with Ca(OH)₂. A systematic review and meta-analysis by Paula et al. reported Intense inflammatory response (21.4%-%100) for Ca(OH)₂ and (0%-80%) for MTA. Dentin bridge formation varied between 0%-80% for Ca(OH)₂ and 33.3%-100% for MTA. Clinical success rate for Ca(OH)₂ was 69.5%-96% and 80.3%-100% for MTA (Paula et al. 2018).Microorganisms were absent in 95% of cases when treated with Ca(OH)₂ and 100% when MTA was used (Acorinte et al. 2008). A preliminary report on human teeth by Aeinechi et al. reported a thicker dentinal bridge and less pulpal inflammation with MTA compared to Ca(OH)₂ (Aeinechi et al. 2003). Study by Nair et al. suggested MTA was clinically easier to use as a direct pulp-capping agent and resulted in less pulpal inflammation and more predictable hard tissue barrier formation than Dycal (Nair et al. 2008). A randomized clinical trial by Hilton et al. also confirmed superior performance of MTA as a DPC material compared to Ca(OH)₂(Hilton et al. 2013). Both Ca(OH)₂ and MTA need to be sealed. This is to prevent leakage when Ca(OH)₂ is used and to protect MTA before placing a restoration during slow setting time. MTA has shown to have better sealing ability than Ca(OH)₂ (Luketic et al. 2008). Study by Cox et al. concluded that there was multiple tunnel defects in the formed dentinal bridge by Ca(OH)₂, it washes out and disintegrates after 6 months (cox et al. 1996).

ZOE: Review of literature by Glass et al, reported use of ZOE as DPC can cause chronic inflammation and does not produce a calcific barrier. Most of the time the result is necrosis of the tooth (Glass & Zander 1949).

Composite resin:   Although Kitasko et al. reported no permanent irritation to the pulp when direct restorative material were used in contact with pulp of monkeys teeth (Kitasako et al. 1999) and Schuurs et al. suggested use of composites and adhesive systems for DPC (Schuurs et al. 2000) , other studies by Horsted et al. have shown partial dentin bridge formation when composite restorations are used for DPC(Hörsted-Bindslev et al. 2003 and Nowicka et al. 2016). Elias et al. reported dentin bridge may only form 90 days after use of adhesive restoration material for DPC (Elias et al. 2007). This may increase susceptibility of the pulp to inflammation by bacteria due microleakage. Uncompleted polymerization of resin due to presence of oxygen and moisture at exposure site and diffusion into the dentinal tubules may cause cytotoxic effects on pulp (Suzuki et al. 2005). This method has been controversial, and most studies have shown poor results in the success rate (Crane et al. 2016). According to a systematic review by Paula et al. lowest success rate was when dental adhesive systems were used (Paula et al. 2018).

IRM: Chang et al. reported Bioaggregate and micromega MTA promoted mineralization and mRNA expression for osteogenic/odontogenic markers with superior results compared to IRM (Chang et al. 2014).

Hydroxyapatite: A few animal studies have shown absence of dentin bridge formation (Danesh et al. 2012) ,dystrophic calcification (Jaber et al. 1991) and pulp necrosis in presence of hydroxyapatite (Hebling et al. 1999). Not enough long-term studies have been done on this material to be able to compare it with biosilicates.

Enamel Morphogenetic proteins: EMP have been proposed as a promising material for DPC in some animal studies. Paula et al, concluded in her systematic review that there was inflammatory responses in 50%-100% of the cases and no bridge formation when EMD was used a DPC material (Paula et al. 2018).

Laser: Laser has also been reported to have high success rate of about 88% when used for DPC. (Deng et al 2016). It is not possible to conclude that the success rate is completely due to laser use as it is dependent on type of material (Ca(OH)₂ or MTA) used after laser application.

Other materials that have been proposed for DPC include calcium Phosphate cement, MTY A1-Ca, bonesialoprotien, Simvastatin, enzymes, Propolis, novel endodontic cement, Emdogain, Odontogenic ameloblast associated protein, castor bean oil. There has not been many studies to compare clinical applications of these material with calcium silicate based cements.

Apexogenesis (root formation) is a term used to describe the continued physiologic development and formation of the root’s apex and can be achieved by IDP, DPC and partial pulpotomy. (AAPD 2008)

Apexification (root end closure) is a method of inducing root end closure of an immature nonvital permanent tooth by removing the coronal and nonvital radicular tissue and placing a biocompatible material in the canal. In instances when complete closure cannot be accomplished a barrier can be placed at the root end to allow. (AAPD 2008)

Biosilicates such as MTA and Biodentine, Ca(OH)₂ can be used for apexification and apexogenesis.

Disadvantages of using calcium hydroxide compared to biosilicates is, need for multiple visits and more treatment time (Abott 1998), induced changes to dentine and consequently increased fracture risk. It has been proposed by Cvek that immature teeth are weakened by filling of the root canals with calcium hydroxide dressing and gutta‐percha (Cvek 1992). By using Biosilicates and forming a root barrier in one session the coronal permanent restoration can also be placed sooner which will reduces chances of coronal leakage. Study done by Parirokh and Torabinejad also showed reduced root fractures compared to Ca(OH)₂ (Parirokh & Torabinejad  2010b)  which was similar to the findings by Bonte et al. In their study 4 out of 15 teeth exhibited coronal or radicular root fracture when Ca(OH)₂ was sued. They have also reported better and faster results of apical hard tissue forming when MTA was sued (Bonte et al. 2015). However they both performed the same as producing an apical seal after 6-12 months which was confirmed in a systematic review by Chala et al. (Chala et al. 2011).

Endodontic perforation is a mechanical or pathological communication between the root canal system and the periradicular tissues or the oral cavity (AAE 2019). Mechanical perforations occur due to iatrogenic causes such as misalignment of endodontic burs when attempting to negotiate complex root canal anatomy or locate calcified root canal orifices (Fuss & Trope 1996). The prognosis of the tooth following perforation depends on location of the perforation, duration that the area is contaminated and accessibility to seal the defect (Sinai 1977). Some of the materials advocated for use in repair of perforations includes MTA, amalgam, decalcified freeze-dried bone, gutta percha, Ca(OH)₂, calcium sulphate and hydroxyapatite (Tsesis & Fuss 2006) Calcium hydroxide based materials are unsuitable for use in repair of crestal and furcation perforations as they induce an initial inflammatory response in the tissues. This could lead to breadown of the supporting periodontal tissues and result in pocket formation (Himel et al. 1985).

 

Overall success rate of about 81% of perforation repair using MTA was reported in a systematic review by Siew et al (Siew et al. 2015). Study by Main et al. demonstrated teeth with existing lesions showed resolution of the lesion, and teeth without preoperative lesions continued to demonstrate absence of lesion formation at the follow-up visit (Main et al. 2004). Compared to amalgam when used straight after perforation MTA showed better success rate (Ford et al. 1995), The biocompatibility of MTA has been found to be equal or superior to amalgam and IRM (Schmitt et al. 2001).

Formation of fibrous tissue when using resin composite, IRM, Zinc ethoxybenzoic acid cement is common. There is usually some degree of chronic inflammation in the periodontal tissue adjacent to these materials.  Sealing ability of the mentioned material is also compromised with moisture. Zinc oxide eugenol caused inflammation when in contact with tissue and was not successful for treatment of perforations (Bramante & Berbert 1987).None of the old material can ensure sealing of the perforation as they do not have osteogenic, cementogenic and antibacterial properties (Holland et al. 2007).

Super Ethoxy Benzoic Acid (Super EBA) is a Alumina-reinforced zinc oxide-eugenol cement. Super EBA has very good adaptation to dentinal walls and has high adhesiveness to dentine. It is also biocompatible with the periapical tissue (Oynick & Oynick 1985). Super EBA used with MTA can produce a faster seal than MTA alone. At 24 hours EBA showed less microleakage compared to silver GIC and Amalgam (Weldon et al. 2002)

Intermediate Restorative Material (IRM) is a reinforced zinc oxide eugenol cement. Biosilicates  have much less leakage compared to IRM (Lee et al. 1993).

Guttapercha was introduced by Bowman in 1867. It showed a high failure rate when used as perforation repair material (Benenati et al. 1986).

Biosilicates have been used for management of both internal and external root resorption. Used in invasive cervical root resorption, internal root resorption as well as inflammatory root resorption.

Some animal studies have reported no significant difference between Ca(OH)₂ and biosilicate as root filling material after re-implantation (Esteves et al. 2015 and Von Arx et al. 2007). However other animal studies have reported biosilicates such as MTA and CEM as root filling material can have successful treatment of inflammatory resorption following unsuccessful treatment with Ca(OH)₂. (Aggarwal & Singla 2010 and Sahrifi et al. 2014)

Vertical root fracture has as a poor prognosis, but some studies have reported successful clinical outcome by using MTA (Floratos & Kratchman 2012, Hadrossek & Dammashcke 2014). These studies are only case reports.

Conventional endodontic treatment is indicated for apexified permanent teeth with irreversible pulpitis or pulpal necrosis (AAPD 2015). The aim of root canal treatment is to disinfect and subsequently to fill the root canal system to prevent bacterial and fluid entry. Root canal sealers are traditionally used to create an interface between the obturation material and the dentine walls to ensure adequate sealing of the root canal space (Giacomino et al. 2019). The ideal properties of a root canal sealer include the following:

• slow setting
• insoluble in tissue fluids
• well tolerated and non-irritating to the periradicular tissues
• soluble in common solvents if it is necessary to removed the root canal filling

(Grossman 1982)

 

 

Root canal sealers can be classified by their chemical composition as calcium-hydroxide containing, zinc oxide eugenol (ZOE) based, epoxy-resin based and calcium silicate based (Seo et al. 2019). These calcium silicate based sealers fall under the classification of biosilicate materials, which have added benefits due to their bioactivity (Giacomino et al. 2019). A study by Giacomino et al. investigated the biocompatibility and osteogenic capacity of biosilicate sealers (ProRoot ES and EndoSequence BC Sealer) in comparison to a conventional ZOE (Roth) and epoxy-resin based sealer (AH Plus). They found that both biosilicate sealers tested significantly enhanced osteoblastic differentiation in comparison to the ZOE and resin based sealers. This is a significant finding given that osseous healing following endodontic treatment is largely dependent on the differentiation and activity of osteoblasts (Giacomino et al. 2019).

Due to low compressive strength, biosilicates are generally not recommended as permanent restorative materials (Parirokh and Torabinejad 2010a). Biodentine has been recommended as a temporary restorative material. Abrasion of the restoration was major failure of biodentine after 6 months (Koubi et al. 2013).

The survival rate of a horizontally root-fractured tooth is reported to be relatively high (83%) for up to 10 years of observation (Cvek et al. 2008). Biosilicates have been used for treatment of horizontal root fractures successfully by root filling the coronal or apical fragment (Cvek et al. 2008 and Parirokh & Torabinejad 2010b).  One of the major drawbacks of this finding is that the majority of the reported literature is based on case reports alone.

Biosilicate materials have multiple applications in paediatric dentistry. A range of materials fall under the classification of biosilicates, most of which vary in their composition and therefore in their physical properties, handling characteristics and applications. A majority of the literature focuses on MTA materials alone. With many new generation biosilicate materials on the market, further research is required to investigate the properties and applications of biosilicate materials in comparison to their alternatives in the practice of paediatric dentistry.

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