Ballal Nidambur Vasudev, Duncan Henry F, Wiedemeier Daniel B, Rai Namith, Jalan Prateek, Bhat Vinutha, Belle Vijetha Shenoy, Zehnder Matthias
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India.
Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, University of Dublin, Ireland.
J Endod. 2024 Jan;50(1):4-9. doi: 10.1016/j.joen.2023.10.008. Epub 2023 Oct 27.
This study aimed to assess pulp survival in a randomized trial on pulp lavage in adult nonpainful posterior teeth with carious pulp exposure. The treatment included complete caries excavation, direct pulp capping with mineral trioxide aggregate, and immediate restoration with composite resin.
Fluid was collected from the pulp wound to assess matrix metalloproteinase-9 (MMP-9) and total protein values. Before pulp capping, cavities were randomly (block randomization, n = 48) washed with a physiological saline or a sodium hypochlorite solution (2.5% NaOCl). Treatment outcome was assessed clinically (cold test) and radiographically after at least 1 year and again after at least 3 years. Painful failures were differentiated from nonpainful failures. Pulp survival was estimated using the Kaplan-Meier method including 95% confidence intervals (CIs) up to 1500 days.
From the 96 patients originally enrolled, 73 individuals could be followed continuously. The clinical observations indicated a beneficial and sustained effect of pulp lavage with 2.5% NaOCl over a control treatment with physiological saline solution on estimated pulp survival 1500 days postintervention, with 7% (95% CI, 1%-40%) in the saline group versus 55% (95% CI, 30%-100%) in the NaOCl group. High MMP-9/total protein values in pulpal fluid collected from the exposed site indicated early and painful treatment failures yet were not associated with failures that occurred more than 250 days after intervention.
The low 4-year success rates reported here challenge the concept of direct pulp capping in the cases that were included. NaOCl lavage did not only increase the survival of affected pulps substantially but also particularly diminished painful failures (33% in the NaOCl group vs 62% in the saline group). The lack of the predictive value of MMP-9 assessments beyond early treatment failures points to inflammatory states of the pulp tissue under deep caries, which are not related to neutrophil infiltration.
本研究旨在通过一项随机试验评估成人无疼痛后牙龋源性露髓时牙髓冲洗对牙髓存活的影响。治疗包括彻底去除龋坏组织，用三氧化矿物凝聚体直接盖髓，并立即用复合树脂修复。
从牙髓创口收集液体，以评估基质金属蛋白酶-9（MMP-9）和总蛋白值。在盖髓前，将龋洞随机（区组随机化，n = 48）用生理盐水或次氯酸钠溶液（2.5% NaOCl）冲洗。在至少1年后及至少3年后分别进行临床（冷测试）和影像学评估治疗结果。区分疼痛性失败和非疼痛性失败。使用Kaplan-Meier方法估计牙髓存活情况，包括长达1500天的95%置信区间（CI）。
在最初纳入的96例患者中，73例患者能够得到持续随访。临床观察表明，在干预后1500天，与用生理盐水进行对照治疗相比，用2.5% NaOCl进行牙髓冲洗对估计的牙髓存活有有益且持续的影响，生理盐水组为7%（95% CI，1%-40%），而NaOCl组为55%（95% CI，30%-100%）。从暴露部位收集的牙髓液中高MMP-9/总蛋白值表明早期疼痛性治疗失败，但与干预后超过250天发生的失败无关。
本研究报告的低4年成功率对纳入病例中的直接盖髓概念提出了挑战。NaOCl冲洗不仅显著提高了患牙髓的存活率，而且特别减少了疼痛性失败（NaOCl组为33%，生理盐水组为62%）。MMP-9评估在早期治疗失败之外缺乏预测价值，这表明深龋下牙髓组织的炎症状态与中性粒细胞浸润无关。
