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RESEARCH MEETING: Deep caries and the exposed pulp: current and emerging therapeutic perspectives

Deep caries and the exposed pulp: current and emerging therapeutic perspectives

The 2018 ESE Research Meeting will provide participants with an update on management of the deep carious lesion and vital pulp therapies. The key aims are:

- To understand the evidence-base and gaps in knowledge;

- To determine the priorities for future research;

- To develop a European endodontic research group by engaging practitioners, scientists, multi-centred networks;

- To consider how future research may be funded.

Overview

The overarching aim of the 3rd European Society of Endodontology (ESE) Research Meeting held in ACTA, Amsterdam on Friday the 26th October 2018 was to provide participants with an update on management of the deep carious lesion and vital pulp therapies (VPT). This theme was selected for this meeting due to significant current scientific interest in this area and because the maintenance of pulp vitality and the promotion of minimally invasive biologically based management strategies are of fundamental importance to the future of Endodontology. The principal objectives of the meeting were to understand the current evidence-base and to highlight any gaps in knowledge related to carious tissue management and handling of the exposed pulp, to determine the priorities for future research and to develop a European endodontic research group by engaging practitioners, scientists, multi-centered networks. Finally, the funding of future research in the deep caries and vital pulp area was to be considered and discussed. To that end a group of European leaders, both clinical and science-based, actively working in the cariology, VPT and pulp biology fields made short presentations aimed at stimulating conversation, highlighting problems, establishing targets and developing consensus. A summary of the presentations are included below;

Lars Bjørndal - Management of deep caries, running multi-centred trials and unanswered questions: To improve the evidence and quality of clinical guidelines on VPT, adequately powered, well-designed, randomised clinical trials of high quality are required. At present, clinical trials regularly compare pulp-capping materials; however, the relative invasiveness of individual pulp therapies are rarely examined. As a result, patients often receive different treatments even though their dental history seems identical, ranging from selective carious tissue removal through VPT even to pulpectomy. Comparisons between different types of pulp therapy (e.g. stepwise excavation, pulp capping) are needed. It is imperative that such studies use the same inclusion and exclusion criteria, as well as (when possible) shared outcome measures. For example, a clear distinction of the depth of carious penetration judged radiographically, being either deep (i.e. pulpal quarter with a radiolucent dentine present) or extremely deep (i.e. passing through the entire thickness of dentine) may be an underestimated variable, that needs to be controlled in future VPT studies. In addition, the profession may benefit from a subdivision of pulp capping depending on pulpal condition with class I pulp capping being treatment of seemingly sound pulp, while class II pulp capping is treatment of an infected pulp. Class II requires a much more complex protocol (e.g. magnification and disinfectant) and may in reality be best performed by an endodontist. Finally, consensus and clarity on terminology is required, as it has demonstrated that teeth exhibiting so-called irreversible pulpitis can be treated by preserving at least part of the pulp; this indicates an outdated terminology.

Luc van der Sluis: Minimally invasive endodontics - A new diagnostic system for assessing pulpitis matched to subsequent treatment needs: Managing cavitated carious lesions should use methods aimed at biofilm removal and control. Carious tissue is removed purely to establish conditions facilitating placement of a long-lasting restoration. Bacterially contaminated or demineralised tissue close to the pulp can be left in situ. Developments in our understanding of pulp biology and the response of the pulp to the release of dentine-bound bioactive growth factors have highlighted that the pulp in mature teeth has a greater regenerative capacity than previously thought. To ascertain the state of the pulp, the signs and symptoms observed should dictate the treatment modality based on a clinical pulpal diagnosis and not on caries progression. Often with partial removal of inflamed pulp tissue, the remainder of the pulp can heal and vitality be maintained. Preserving all or part of the pulp is beneficial as it is less invasive than conventional root canal treatment, while retaining the biological immune response and preventing apical periodontitis. Recent correlations between histological findings and corresponding clinical signs, symptoms and tests can be used to carefully differentiate between different stages of reversible and irreversible pulpitis. In addition, it has become evident that if the correct vital pulp treatment is employed, pulp tissue previously diagnosed as irreversibly inflamed can at least be partially maintained. This highlights a problem with the existing diagnostic classification system in that the use of the term “irreversible” is misleading. Therefore, future priorities should be to i) introduce a new way of diagnosing pulpitis and to ii) relate the diagnosis with minimal invasive treatment choices dictated by the degree of pulpal inflammation.

Dan Rechenberg - New age pulpal diagnostics: can we accurately determine the state of the pulp if exposed or not? As the society ages, the desire to retain teeth challenges the established doctrines, by promoting prevention and minimal invasive techniques. In this context, and considering recent advances in biomaterials, vital pulp therapy must be re-evaluated. The success of this approach greatly depends on i) the absence of microorganisms, and ii) the pulps immuno-competence/absence of inflammation. Unfortunately, both aspects cannot be reliably determined clinically. Current pulpal tests, e.g. sensitivity tests towards thermal or electric stimuli, neither reliably reflect the histopathological condition of the pulp, nor enable a consistent prediction of the likelihood of pulpal survival after tooth restoration. This limitation also has an impact on the clinical terminology of pulpal inflammation, which inevitably remains imprecise. There is a pressing need to find novel ways or tools for more precise, but clinically applicable pulpal diagnosis. Potential solutions to this clinical problem may involve the application of rapid molecular tests targeting biomarkers of pulpal inflammation. Alternatively, improved imaging techniques aimed at visualizing the pulpal soft-tissue and/or blood flow as indicators for pulpal vitality. The development of these next-generation diagnostic tests in endodontics although critical, is not without significant practical, scientific, cost and technical challenges.

Stephane Simon - Does pulp chamber pulpotomy represent the future of endodontics: The prognosis of pulp capping treatment is highly dependent of two principle factors; firstly the inflammatory status of the pulp, and secondly the quality of mineralised bridge at the interface between the pulp surface and the biomaterial. Pulpitis is a progressive disease and it is challenging clinically to establish the border between healthy and inflamed tissue. Full pulp chamber pulpotomy may be a potential solution in the treatment of pulpitis as all the pulp is removed from the pulp chamber, leaving only the pulp tissue in the root canal system, in which the tissue is generally free of inflammation. Currently, several case reports and case series have highlighted the considerable potential of this technique as an alternative to pulp capping or pulpectomy; however, the absence of a pulp response to conventional sensibility testing and the lack of comparative clinical trials suggest the need for further research to validate the treatment.

Paul Cooper - A basic-scientist’s view of research in dentine-pulp complex biology: In endodontics, translational research is increasingly becoming more important and it is essential that high-quality research underpin the development of novel-therapeutic-approaches. Clinical observations have identified dentine chips arising from operative debris are bio-stimulatory for dentine repair process. Subsequent studies have confirmed the presence of a range of potent morphogens and growth factors (GFs) as being sequestrated within the bioactive dentine and these can be released by materials routinely used in endodontic applications, such as EDTA, calcium hydroxide and mineral trioxide aggregate (MTA). Basic science studies have demonstrated that the release of these GFs locally within the tooth by these materials likely stimulate reparative events including stem cell homing, proliferation, odontogenic differentiation and increase mineral deposition. Notably the activity of these morphogens could be enhanced by degradative enzyme activity, e.g. matrix metalloproteinases, present in the diseased environment. Basic science studies aimed at drug repurposing have also shown that pharmaceuticals in vitro can also modulate odontogenic events including differentiation of stem cells and rates of dentinogenesis. Indeed, pharmacological modulators of the p38 MAP kinase pathway as well as Histone deacetylase inhibitors (HDACis) have the potential to be applied in the future in endodontics for patient benefit. Sustained basic science research is required to fuel the pipeline to provide both the experimental tools, including identifying markers for odontogenic differentiation processes, and enabling the development of novel approaches for endodontic diagnostics and treatment. Genuine clinician-scientist research partnerships are therefore required which enable bi-directional exchange of ideas and techniques. Layered on top of this is the requirement for inter-disciplinary research, which utilises methodologies in both the physical and biological sciences, as well as international collaborations which further enhance the exchange of ideas and technologies.

Domenico Ricucci - Are we really regenerating the dentine-pulp complex with preventive endodontics measures? In the presence of deep caries close to the pulp chamber, the clinician is often uncertain whether the bacteria have penetrated into the pulp tissue and establishment of a minor area of necrosis. Although signs and symptoms may help in the majority of cases to establish the pulp as ‘reversibly’ or ‘irreversibly’ inflamed, bacterial penetration may occur in the absence of symptoms. When a carious pulp exposure occurs, as long as the diagnosis is of reversible inflammation, an attempt can be made to maintain pulp vitality through a direct pulp-capping procedure. If diagnosis is irreversible pulpitis diverging treatment plans, mostly based on the severity of symptoms, have been suggested as an alternative to pulpectomy. It is recommended that the deepest part of the cavity and the exposed pulp be clinically observed under magnification (e.g. operating microscope), as this can inform the successive treatment decision. Histological analysis performed in sound and carious teeth and in teeth subjected to pulp capping and pulpotomy using a range of pulp capping materials, has not equivocally demonstrated the superiority of MTA and other calcium-silicate materials over calcium hydroxide. There is a need for further research on the pulpal response to various material sin sound and carious teeth.

Henry Duncan - VPT materials - development of the next generation of biomaterials aimed at biological processes: Concerns over the cost and destructive nature of dental treatment have led the profession to examine novel methodologies that develop regenerative treatments and promote minimally invasive, biologically based dental restorative solutions. Although an exciting opportunity, vital pulp treatment has traditionally been damned by unpredictable results. Recent dental biomaterial advances, as well as an evolving understanding of molecular biology and regenerative medicine have led to the development of new treatment strategies for the exposed pulp. Calcium-silicate cements now represent the gold standard capping material, but stimulate repair non-specifically and have practical limitations including setting time and discolouration. An improved understanding of the cellular regulators of pulpal inflammation/repair is critical in order to predict pulpal response and devise a new generation of targeted dental restorative materials aimed at biological processes. However, what is possible and what is unrealistic? A wealth of in vitro and biological research investing the use of a range of anti-oxidants, anti-hypertensive as well as pharmacological inhibitors (e.g. GSK3) and epigenetic modifiers (e.g. HDACis) have highlighted the potential for a targeted approach to promote pulpal repair processes. Although considerable opportunity exists for development of next-generation focused biomaterials, containing these additives, several obstacles also exist in the form of designing an efficient delivery model, controlling potential off-target influences, minimising side effects and, perhaps the most significant barrier, regulatory approval. In the future close relationship between sciences, clinical dentistry and industry need to be forged in order to secure the funding necessary to develop these novel materials.

Kerstin Galler - Disinfection, irrigation and maximising the influence of dentine in vital pulp treatments - Dentine matrix proteins: Although dentine has been identified as a bioactive matrix, which harbours a plethora of signalling molecules accessible during excavation or cavity preparation, this knowledge has not been clinically integrated into VPT procedures. Several hundreds of matrix-bound proteins are present in dentine, among them cytokines, neurotrophic and angiogenic factors, as well as other GFs. They can be released by demineralisation (e.g. by endodontic irrigation solutions) and subsequently modulate the immune-response as well as the migration, proliferation, differentiation and mineralisation capabilities of dental pulp cells. Dentine matrix proteins might thus facilitate healing and repair after vital pulp treatment. Different approaches are potentially available, including the simple use of EDTA to allow for endogenous GFs release until the point of pharmacologic interventions and the use of allogenic extracted dentine matrix proteins. Whereas these ideas seem feasible and are supported by in vitro and in vivo research data, generation of clinical evidence will be a major hurdle prior to application of such concepts into practice.

THE ‘NEXT STEPS’ AND CONCLUDING REMARKS The treatment of deep caries and the exposed pulp stimulates considerably diversity of opinion, but a shared view that endodontic treatment should be less invasive and more biologically based. At present it is accepted that much of the evidence that we rely on to make fundamental decisions regarding vital pulp management strategies is weak (Swedish Council on Health Technology Assessment 2010, Ricketts et al. 2013) and that well-planned, high quality - clinical and scientific - research is required to bring the discipline forward (Duncan et al. 2016). The International Endodontic Journal has recently published a review article and an ESE position statement on the management of deep caries and the exposed pulp in order to highlight the current position and future focus in this area (Bjørndal et al. 2019, Duncan et al. 2019). There is an obvious need to carry out large, adequately powered randomised clinical trials, but this demands significant communication between several research centres, clinical trial units, statisticians and the development of practice-based networks. Additionally, the development of new diagnostic tools to assess pulpitis, understanding the nature of the cellular response in pulpitis and after pulp capping, as well as harnessing therapeutically dentine matrix proteins and pulp cell responses will require significant collaboration between clinicians, scientists and several institutions. All these will require funding, which remains a constant challenge at a national and European level. Researchers need to exploit available local and national resources initially, which will enable the early development of innovative approaches necessary for the field to move forward before working collaboratively with professional bodies, other institutions and grant awarding agencies to secure the level of strategic funding to carry out high quality research in this field.

REFERENCES Bjørndal L, Simon S, Tomson PL, Duncan HF (2019) Management of Deep Caries and the Exposed Pulp. International Endodontic Journal [in press].

Duncan HF, Galler K, Simon S, et al. (2019) European Society of Endodontology position statement: Management of deep caries and the exposed pulp. International Endodontic Journal [in press].

Duncan HF, Kirkevang LL, Ørstavik D, Sequeira-Byron P (2016) Research that matters-clinical studies. International Endodontic Journal 49, 224-6.

Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE (2013) Operative caries management in adults and children. Cochrane Database Systematic Reviews CD003808.

Swedish Council on Health Technology Assessment (2010) Methods of diagnosis and treatment in endodontics: a systematic review. Assessment No. 203. [WWW document] URL https://www.sbu.se/contentassets/eafcce68f3aa438cb932c76702cde403/methods-of-diagnosis-and-treatment-in-endodontics_full.pdf

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9:00
rightIntroduction and overview:

Aims

The 2018 ESE Research Meeting will provide participants with an update on current and future management of the deep carious lesion and vital pulp therapies.

Objectives

- To understand the evidence-base and gaps in knowledge - To determine the priorities for future research - To develop a European endodontic research group by engaging practitioners, scientists, multi-centred network - To consider how future research may be funded

rightHal Duncan
 Hal Duncan

Hal Duncan: BDS, FDS RCS, MClin Dent(Endo), MRD RCS, PhD

A University of Glasgow graduate, he initially worked in general dental practice, various dental schools as well as several specialist endodontic practices in Northern Ireland and England. He received postgraduate endodontic speciality training in Guy’s Hospital from 2002-2006, which included a collaborative research study with Dr Ram Nair (in the University of Zurich) on MTA pulp capping. He has worked since 2008 at Trinity College Dublin as an Academic Consultant in Endodontics, while completing an external PhD in the University of Birmingham with Professor’s Cooper and Smith and Dr Garry Fleming in the area of epigenetics, pulpal regeneration and biomaterials in 2016. In 2013 and 2016 he received two (IADR and EMBO-sponsored) fellowships in New York University with Profs Nicola Partridge and Emi Shimizu on the role of epigenetic-modifying agents on pulpal mineralisation. He currently supervises several clinical and scientifically trained PhD students in basic translational pulp biology. He has received several research grants as a principal investigator, has written ten book chapters and edited 2 textbooks including “Clinical approaches in endodontic regeneration - Current and emerging therapeutic perspectives” with Paul Cooper. In addition he has published multiple articles in peer-reviewed international journals and is an Associate Editor for the International Endodontic Journal. He is a committee member of the Irish Division of the IADR, the Chair of the European Society of Endodontology (ESE) Membership Committee and a member of the ESE Executive Board. He is a past president of the Irish Endodontic Society. Outside endodontics, he remains a life-long supporter of St Johnstone, a small and fairly insignificant Scottish football team.

MANAGING DEEP CARIES AND PULPAL DISEASE: IS EXPOSING THE PULP A PROBLEM?
9:10
rightManagement of deep caries, running multi-centred trials and unanswered questions.

Abstract

The evidence has improved for the management of deep carious lesions, confined to the pulpal quarter of the dentine. Recent, 5-yr follow-up randomized clinical multi-centre data has shown that a less invasive carious removal strategy has a significantly better outcome, than a non-selective carious removal strategy, being 1. priority treatment choice (Bjørndal et al. 2017, JDR). In case of a pulp exposure, only 9% of the analyzed capped pulps from the above trial were assessed as successful, indicating a low prognosis for conventional pulp-capping procedures in well-defined deep carious lesions in adults. This raises some questions; was the degree of pulp inflammation too advanced? Was the methodology performed poor? The penetration depths of the carious lesion may be an important prognostic factor? In many of the previous capped teeth, from where we have our current data, surprisingly little information is given about the prehistory of the carious lesion depth. From previous data, it is known that the outcome seems different when pulp capping is performed within an infected environment (i.e. a cariously exposed pulp), versus a trauma scenario. Although, the available evidence is sub-optimal, it seems reasonable to hypothesize that capping an initial infected environment, provides the risk of a lower success than capping a traumatically induced pulpal exposure. Well-designed randomized clinical trials needs to be conducted in order to investigate a potential threshold for, when is the initial infected environment prior treatment too advanced for a pulp capping? Perhaps higher demands of the pulp capping protocol will be required (mandatory need of magnification and use of highly efficient disinfection rinses?) when infected pulps are to be capped versus capping the sound pulp. The standard and principles of a randomized clinical study protocol will be presented including examples of relevant and high priority topics for future needed clinical studies.

Aims

This lecture will provide participants with an update on current and future management of the deep carious lesion and vital pulp therapies – with a focus on previous clinical trial experience.

Objectives

To describe what we know from clinical trials during the management of deep carious lesions;

To describe how we should proceed to gain more high quality evidence;

To describe how we can gain a better understanding of how we should set-up clinical research protocols

rightLars Bjørndal
 Lars Bjørndal

Lars Bjørndal (born 1963) graduated in 1988 as a dentist from the University of Copenhagen, Denmark. In 1992: Ph.D. thesis on the topic: Caries progression in enamel and the pulp-dentin organ using thin undemineralized tooth sections. In 2011:Dr. Odont. Thesis entitled: Endodontic treatment: reason, prevention and quality - shaping factors. From 1993-1998: Assistant professor at the Department of Cariology and Endodontics, University of Copenhagen. 1999-2001: Received specific postgraduate endodontic specialist courses in collaboration with the universities in Copenhagen, Denmark, Malmö and Gothenburg, Sweden. From 1998: Associate professor at the University of Copenhagen, Denmark, and Head of Endodontic. In 2012 LB was visiting Scholar at Loma Linda University, US. From 2012: Head of the Special Clinical Unit receiving referrals at the Institute of Odontology, University of Copenhagen, Denmark. One day weekly LB is in in private practice devoted endodontic referrals. LB has been Secretary in the Scandinavian Endodontic Society (SES) from 1999-2001. In 2007 and 2016 LB hosted the SES biennial congress in Denmark. LB is second time President of the Danish National Endodontic Society (2014-), and country representative for the European Society of Endodontology (ESE), as well as a certified member of ESE. Besides numerous national post-graduate GDP courses covering endodontic treatments, LB has been giving lectures in Europe, Asia, North and South America, and the topics have been within the field of deep caries lesion pathology, treatments and quality-shaping factors concerning endodontic treatments. LB has authored and co-authored numerous international and national articles, including book chapters and reviews, and is at present reviewer in several international Journals.

9:50
rightMinimally invasive endodontics - A new diagnostic system for assessing pulpitis matched to subsequent treatment needs

Abstract

Deep caries lesions can lead to pulpal exposure during the caries excavation procedure and subsequent root canal treatment in order to salvage the tooth. However, many times the result of this treatment is unsatisfactory in the long term with periapical disease as the final result. Controlling caries in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal and control. Carious tissue is removed purely to create conditions for long-lasting restorations. Bacterially contaminated or demineralized tissue close to the pulp does not need to be removed. Developments in our understanding of pulp biology and the response of the pulp to the release of dentine-bound bioactive growth factors have highlighted that the pulp in mature teeth has a greater regenerative capacity than previously thought. To ascertain the state of the pulp, the symptoms observed dictate the treatment modality and often with partial removal of inflamed pulp tissue the remainder of the pulp can heal and stays vital. Preserving all or part of the pulp is beneficial as it is less invasive than conventional root canal treatment. It retains the biological immune response and could help prevent infection of the periapical tissues. Recent correlations between histological findings and corresponding clinical signs, symptoms and tests can be used to carefully differentiate between different stages of reversible and irreversible pulpitis. In addition, it has become evident that if the correct vital pulp treatment is employed, pulp tissue previously diagnosed as irreversibly inflamed can at least be partially maintained. This highlights a problem with the existing diagnostic classification system in that the use of the term “irreversible” is misleading. Therefore, the aim of this communication is to both introduce a new way of diagnosing the various stages of pulpitis and also to relate the diagnosis to alternative minimal invasive treatment choices

Aims

After this lecture, attendants should understand why and how pulpal diagnosis indicates the treatment option when treating deep carious lesions.

Objectives

The objective of this presentation is to communicate the treatment of deep carious lesions and the clinical pulpal diagnostic process and subsequent treatment options.

rightLuc van der Sluis
 Luc van der Sluis

Luc graduated in 1985 at the Academic Centre Dentistry Amsterdam (ACTA), the Netherlands, where he successfully completed the postgraduate endodontic program in 1993 under the guidance of prof. dr. P.R. Wesselink. He received his PhD degree in 2007 with the supervisors prof. dr. P.R. Wesselink and dr. M-K. Wu. Since 1993 Luc workes in a practice limited to Endodontics and held a position in research and teaching until 2010 at the Department of Cariology, Endodontology and Pedodontology at ACTA. From 2010 until 2012, Luc worked as professor at the University of Toulouse (France). Actually Luc is head of the Center for Dentistry and Oral Health at the University Medical Center of Groningen in the Netherlands and is Principal Investigator at the Kolff Institute (University of Groningen). Furthermore, he is (co)author of book chapters in international text books. Luc is frequently invited as invited lecturer on international conferences. The current focus of his research is the prevention of apical periodontitis, disinfection of the carious lesion and root canal system, which he systematically investigates with specialists in biofilm research, fluid dynamics and (sono) chemistry.

10:30
Discussion
10:45
COFFEE BREAK
11:10
rightNew age pulpal diagnostics – can we accurately determine the state of the pulp if exposed or not?

Abstract

In the vast majority of cases, microbial challenge is the main cause for a pulp to become inflamed. Historically, severe pulpal inflammation was treated by extraction of the affected tooth. However, because of the increasing understanding of fundamental biological principals and technical advances, the concept of chemo-mechanical root canal disinfection was introduced in the early days of the last century. Thousands of teeth could be preserved, which would otherwise have had to be removed. Nevertheless, conventional root canal treatment (pulpectomy) frequently is an overtreatment, especially in cases with minor inflammation restricted to the coronal part of the pulp. This may be a disadvantage, especially when considering that vital pulpal tissue shows efficient protective mechanisms, and great healing capacities. The aims of ‘new age dentistry’ involve prevention of disease, minimal invasive therapies, and regenerative procedures. One cornerstone for the success of these approaches could be improved pulpal diagnostics. Current diagnostic regimes neither reflect the actual stage of pulpal inflammation accurately, nor do they reliably predict the chance for pulpal survival after (vital pulp) treatment.

Aims

The aim of this lecture is to present limitations of current pulpal diagnostics. A further goal is to describe how diagnostic tests might look like in future, and how these could improve the management of pulpal inflammation.

Objectives

- To analyze the limitations of current endodontic diagnostic tests

- To envisage the potential of improved, more biologically based endodontic diagnostics

rightDan Rechenberg
 Dan Rechenberg

Dr. Dan-Krister Rechenberg is a senior lecturer at the Division of Endodontology, Clinic for Preventive Dentistry, Periodontology, and Cariology at the University of Zurich in Switzerland. He graduated in Germany from the University of Göttingen, School of Dental Medicine in 2005. After finishing dental school he worked at the University of Göttingen, and then the University of Zurich, where he received his doctoral degree in dentistry (Dr. med. dent.) in 2009. In 2012 Dr. Rechenberg completed the postgraduate endodontic program at the Univeristy of Zurich, became a certified member of the Swiss Society of Endodontology (SSE), and the European Society of Endodontology (ESE). In 2017 he received the venia legendi (private docent title) from the University of Zurich. Currently he is Co-Head of the postgraduate endodontic program at the Univeristy of Zurich. Dr. Rechenberg is on the editorial board of the International Endodontic Journal and acts as a reviewer for the Journal of Endodontics and other dental journals. In 2011 he won the ESE Wladimir Adlivankine Research Prize. His main research focus is currently on molecular diagnostics of pulpal and periapical disease.

11:50
rightPreventive endodontics, coronal pulpotomy and carious exposures. What do we know and what should we be doing?
Pulp chamber pulpotomy as the future of endodontics ?

Abstract

The accepted management for any pulpal intervention on an (highly) inflamed dental pulp is the pulpectomy and root canal treatement. However, it has been shown that radicular pulp has a reparative potential and interesting immune defense properties. A full pulp chamber pulpotomy and filling with a dedicated material could therefore be considered as an alternative treatment. Its feasibility, known on decidual and immature permanent teeth (where it is a routine treatment) is now investigated on mature permanent teeth as a permanent treatment.

Aims

The aimof this lecture is to discuss the rationale behind this hypothesis and the scientific background that could encourage us (or not) to consider the pulp chamber pulpotomy as a predictable endodontic treatment. Our clinical experience will be faced to the litterature and both will be used to discuss

Objectives

.

rightStéphane Simon
 Stéphane Simon

Professor Stéphane SIMON is full time academic teacher/researcher at Paris Diderot University with a clinical practice limited to Endodontics at Rouen Normandy Hospital. He is the director of the European Postgraduate Endodontic Program at Paris Diderot University (3 years full time program). His time is 50% devoted to the clinical practice and 50% to Basic Science/clinical research about Tissue engineering and dental Pulp healing. Today, his main interest is about Tissue engineering, cell and molecular Biology of pulp tissue (Basic science and clinical practice), and is highly involved into development of new techniques and concepts for graduate and postgraduate teaching (E learning, flipped classroom, MOOCs, etc.)

12:30
Discussion
12:45
LUNCH AND NETWORKING
VITAL PULP THERAPEUTICS – WHAT IS THE CURRENT UNDERSTANDING AND WHERE SHOULD WE BE GOING?
13:45
rightTherapeutic considerations within the dentine–pulp complex: a scientist’s perspective
A basic-scientist’s view of research in dentine-pulp complex biology

Abstract

Translational research is increasingly becoming more important and it is essential that high-quality scientific research underpins the development of novel-therapeutic-approaches. Basic scientists trained in a variety of research fields can make significant contributions to the development of new treatment strategies that relate to pulp biology and regenerative endodontics. Clinicians who have received a scientific training can drive this field forward; however, it is genuine clinician-scientist partnerships which likely deliver the greatest results. Increasingly we are seeing the need for interdisciplinary research utilising combining expertise from clinical-scientists with basic-scientists with both biological and physical expertise. Team-based interdisciplinary approaches enable analyses, syntheses and harmonies between disciplines, in contrast to multidisciplinary approaches which simply collate knowledge in the absence of genuine collaboration. Communication, respect, equality, the good working-relationships and an understanding of relative pressures of each team member are essential for clinician-scientists partnerships to work. Local, national & international collaborations are also increasingly encouraged and if nurtured can enhance the quality of the work undertaken and be attractive to grant-funding agencies. Traditionally, dentists identify the clinical problem and the scientists contribute to providing the research-based solution. Notably, however, basic-scientific research alone can also make discoveries which enable significant advancements in the field and provide translational opportunities. Furthermore serendipity plays a major role in scientific discovery. There remain major challenges in undertaking dental research, as in addition to identifying important research questions and identifying a complementary collaborative team, funding the work is increasingly difficult. Within this presentation I will discuss from my own research experience in fields such as dental tissue inflammation & repair, pulp stem cell biology, photobiomodulatory therapy and dentine matrix biology, the limitations and successes of clinician-scientist partnerships and the key facets which lead to scientific success and grant funding.

Aims

An enhanced understanding of the dental research environment and need for basic-scientist and clinician-scientist interdisciplinary researcher partnerships.

Objectives

- To better appreciate a team-based interdisciplinary approach in dental research - An understanding of the difficulties in obtaining research funding - The importance in obtaining a sound scientific research training, its relationship to life-long learning and the importance of mentoring - The importance in identifying a key research question - Setting out a realistic research plan with realistic research goals - To appreciate the importance of both basic-scientific and translational research - To appreciate the role of local, national and international research collaborative networks

rightPaul Cooper
 Paul Cooper

Professor Paul Cooper obtained a BSc (Hons) in Genetics from Leeds University (1992) and received his PhD from the University of Birmingham, UK, in Cancer Sciences (1995). He was then a post-doctoral researcher at Roswell Park Cancer Institute, New York, US, working on the molecular genetics of cancer, eye and ear predisposing syndromes. He subsequently returned to the UK to work for Novartis in the area of molecular therapeutic target identification in lung disease. In 2000 he joined the School of Dentistry at the University of Birmingham and became Professor of Oral Biology in 2012.

Paul conducts research into dental tissue regeneration, the inflammatory/immune aspects of oral and dental disease and in the biomaterials area with particular focus in pulp biology. In 2010, he received the prestigious Young Investigator Award from the International Association for Dental Research. He has served as President of the European Society of Dental and Craniofacial Stem Cells, is currently the Mineralised Tissue Group (MINTIG) Chair for the British Society for Oral and Dental Research (BSODR) and is a councillor on BSODR Management Committee. Paul has over 130 full publications (Google Scholar h-index=45) and authored several book chapters in the field of pulp biology and regenerative endodontics. He has supervised over 30 PhD students. Paul serves on the Editorial Board of the Journal of Dental Research, Journal of Endodontics and Journal of Periodontal Research. He has delivered over 30 invited lectures around the world. Paul has received significant funding from research councils, charities and industry to support his research.   Paul completed his postgraduate certificate in learning and teaching in higher education (PGCILTHE) in 2003, is a Fellow of the Higher Education Academy and heads up Oral Biology teaching.

He is currently the Director of Research and Deputy Head of School at the School of Dentistry.

14:25
rightPulp-material interface in sound and carious teeth, inflammatory response and diagnostic issues
Are we really regenerating the dentine-pulp complex with preventive endodontics measures?

Abstract

Within this lecture the histological events occurring in the pulp tissue below medium-deep caries lesions will be illustrated.

It will be observed that inflammatory cells accumulate in the area adjacent to the pulpal termination of dentinal tubules affected by the caries process, accompanied by the formation of a ‘less-tubular’ tertiary dentin, and changes in the odontoblast layer.

This inflammatory process can remain reversible for a considerable time. Bacterial penetration into the pulp tissue and the establishment of a minor area of necrosis is the determinant for the transition from a reversible to an irreversible inflammatory state.

The opportunity to clinically diagnose reversibility/irreversibility of pulp inflammation will be discussed on the basis of recent literature and histological data.

When a carious pulp exposure occurs, as long as the diagnosis is reversible inflammation an attempt can be made to maintain pulp vitality through a direct pulp-capping procedure.

The initial area of necrosis will expand in time, involving larger areas of the pulp chamber. When the diagnosis becomes irreversible pulpitis, selective surgical elimination of the necrotic/infected tissue may allow maintenance vitality of part of the pulp.

For many years calcium hydroxide has been the material of choice to apply onto the pulp wound. Over the last 20 years MTA has gained popularity, with several clinical studies highlighting its advantages and improved outcome compared with calcium hydroxide. More recently a new generation of bioactive materials have been introduced.

The pulp tissue response to all these materials is evaluated by clinical observation and histologic analysis performed in sound and carious teeth and in teeth subjected to pulp capping and pulpotomy.

Particular emphasis in this presentation is placed on the histomorphology of the hard tissue formed in the exposure site after capping procedures, and the possibility of regenerating dentine will be critically analysed.

Aims

The aim of this presentation is to illustrate the clinical and histologic/histobacteriologic condition of the pulp under deep caries.

The histomorphological events taking place at the pulpal wound site following carious exposure or intentional partial pulpotomy will also be highlighted when the teeth are capped with old and contemporary bioactive

Objectives

To understand how the pulp response to capping materials is analysed both clinically and histologically. - The formation of mineralized tissue repairing the pulp exposure or the pulpotomy wound was documented radiographically and photographically in a large number of teeth treated for deep caries. Close-up photographs were taken of the pulp wounds after exposure and after application of the capping material. Cavities were restored temporarily and re-accessed after a given observation period. Photographs were taken of the capped areas, and the quality of hard tissue repairing the defect was assessed, before final restoration. - Histologic analysis included a large number of intact and untreated carious teeth extracted for various reasons; intact third molars subjected to experimental pulp capping procedures; teeth with deep caries and pulp exposures treated with pulp capping and extracted for fractures or nontreatable recurrent decay. These teeth were processed for light microscopy and histologic serial sections were cut. Observation focused on the morphology of the mineralized tissue repairing the defect and the type of cells forming this tissue.

rightDomenico Ricucci
 Domenico Ricucci

Domenico Ricucci, MD, DDS Private Practitioner, Cetraro, Italy

Dr. Domenico Ricucci received his degree in General Medicine from “La Sapienza” University of Rome in 1982, and his DDS from the same University in 1985. Since then on he has maintained private dental practices limited to endodontics. In addition to his private practice, Dr. Ricucci was Professor of Cariology at “Magna Graecia” University of Catanzaro, Italy in 2002 -2003. He served in the Research Committee of the European Society of Endodontology from 1999 to 2005.

Dr. Ricucci’s primary research interest relates to pulpal and periapical tissue reactions to caries and treatment procedures, biofilms in endodontic infections, etiology of RTC treatment failure, pulp regeneration/revascularization. Since 1998 he has run his own histology laboratory and has developed considerable skills in hard tissue preparations for light microscopy.

Dr Ricucci has published 90 papers and has lectured both nationally and internationally. He has authored the Textbook and Atlas “Patologia e Clinica Endodontica”, the textbook and atlas “Endodontology. An integrated biological and clinical view”. He has also authored or co-authored fifteen book chapters.

15:05
Discussion
15:20
COFFEE
15:40
rightVital pulp treatment materials - development of the next generation of biomaterials aimed at biological processes

Abstract

Concerns over the cost and destructive nature of dental treatment have led the profession to examine novel methodologies that develop regenerative treatments and promote minimally-invasive, biologically-based dental restorative solutions. Although an exciting opportunity, vital pulp treatment has traditionally been damned by unpredictable results. Recent dental biomaterial advances, as well as an evolving understanding of molecular biology and regenerative medicine have led to the development of new treatment strategies for the exposed pulp. Calcium-silicate cements now represent the gold standard capping material, but stimulate repair non-specifically and have practical limitations. An improved understanding of the cellular regulators of pulpal inflammation/repair is critical in order to predict pulpal response and devise a new generation of targeted dental restorative materials aimed at biological processes. However what is possible and what is unrealistic? It is essential if new directions are to be considered in endodontic practice that we are able to critically discuss where we are at present and where as a specialty we need to be in the future.

Aims

The aim of this lecture is to discuss the biological response to current materials as well as considering opportunities and obstacles in the development of next generation vital pulp treatment materials.

Objectives

The attendee should at the end of this presentation be able to; - Consider the relative benefits and limitations of current materials in ‘capping’ damaged pulp tissue. - Discuss the importance (or otherwise) of developing targeted-restorative-biomaterials aimed at biological processes in endodontics. - Appraise some of the recent examples of research in this area. - Understand the opportunities and scientific challenges of developing new dental materials and topically-applied growth factors or drugs. - Evaluate the role of industry and grant funding in dental material development in vital pulp treatment.

rightHal Duncan
 Hal Duncan

Hal Duncan: BDS, FDS RCS, MClin Dent(Endo), MRD RCS, PhD

A University of Glasgow graduate, he initially worked in general dental practice, various dental schools as well as several specialist endodontic practices in Northern Ireland and England. He received postgraduate endodontic speciality training in Guy’s Hospital from 2002-2006, which included a collaborative research study with Dr Ram Nair (in the University of Zurich) on MTA pulp capping. He has worked since 2008 at Trinity College Dublin as an Academic Consultant in Endodontics, while completing an external PhD in the University of Birmingham with Professor’s Cooper and Smith and Dr Garry Fleming in the area of epigenetics, pulpal regeneration and biomaterials in 2016. In 2013 and 2016 he received two (IADR and EMBO-sponsored) fellowships in New York University with Profs Nicola Partridge and Emi Shimizu on the role of epigenetic-modifying agents on pulpal mineralisation. He currently supervises several clinical and scientifically trained PhD students in basic translational pulp biology. He has received several research grants as a principal investigator, has written ten book chapters and edited 2 textbooks including “Clinical approaches in endodontic regeneration - Current and emerging therapeutic perspectives” with Paul Cooper. In addition he has published multiple articles in peer-reviewed international journals and is an Associate Editor for the International Endodontic Journal. He is a committee member of the Irish Division of the IADR, the Chair of the European Society of Endodontology (ESE) Membership Committee and a member of the ESE Executive Board. He is a past president of the Irish Endodontic Society. Outside endodontics, he remains a life-long supporter of St Johnstone, a small and fairly insignificant Scottish football team.

16:20
rightDisinfection, irrigation and maximising the influence of dentine in vital pulp treatments
Dentine matrix proteins

Abstract

Dentine harbors a plethora of cytokines, chemokines, growth and differentiation factors. These bioactive molecules are released from dentine upon demineralization and affect the immune response as well as migration, proliferation, differentiation and mineralization of dental pulp cells. Different irrigants and medicaments used during endodontic treatment promote or interfere with this release. Knowledge about these effects may be useful for revitalization procedures, where bioactive molecules are supposed to aid the healing process. Disinfecting agents are also used during vital pulp treatment, where a release of bioactive molecules might be desirabe to promote regeneration or repair. In this lecture, the influence of dentine matrix proteins on dental pulp cell behavior will be covered, and different materials will be highlighted with focus on their effects on dentine-derived proteins. Possibilities to further expand on the use of these bioactive molecules for biology-based pulp therapies will be discussed.

Aims

After this lecture, attendants should be aware of the influence of dentine matrix proteins on processes that promote dental pulp healing and repair. Based on this knowledge, additions to our clinical protocols for vital pulp therapies may be envisioned which can modify tissue responses and increase success rates.

Objectives

The objective of this presentation is to illustrate the effects of dentine matrix proteins on dental pulp cells, to point out methods to release and concentrate these bioactive molecules and to discuss their potential effects in the context of biology-based therapies of dental pulp.

rightKerstin Galler
 Kerstin Galler

Kerstin Galler obtained her degree in dentistry from the Ludwig-Maximilians-University in Munich in 2000. She worked in Private Practice until 2002 and then joined the Department of Conservative Dentistry and Periodontology at the University of Regensburg, Germany. She received post-doctoral training at the University of Texas Health Science Center in Houston from 2004 to 2006, and earned her Ph.D. in Biomedical Engineering from Rice University in Houston in 2009. Dr. Galler is currently Associate Professor and leader of the section of Endodontology and Dental Traumatology at the University of Regensburg. Her time is divided between clinical work with focus on endodontology and restorative dentistry, teaching as senior lecturer and clinical instructor, and research. Her research group works on tunable hydrogel scaffolds and dental stem cells for dental pulp tissue engineering and regenerative endodontics, on dentin matrix proteins and on biofilm-associated reactions of the pulp tissue.

17:00
Discussion
17:15
Round up, group discussion, next steps and close
17:30
SESSION ENDS
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