Modern Bioceramics in Endodontics

Porcelains have been at the heart of esthetic dentistry since the 1960's with a broad assumption that they are bioinert - not eliciting a reaction from the tissues around them.

Without diving too deep in the science of biomaterials, a bioactive material is one that intentionally elicits a response from adjacent tissues and biocompatability refers to a material that does not cause harm to adjacent tissues.  Biocompatibility is not absolute(1) and requires evaluation of a material's interaction with tissues over time.  In other words, more complex than this discussion.

Advances in dental ceramics have continued to evolve into what we now call bioceramics. These materials include hydroxyapetitie, bioactive glass and calcium silicates.(2)

One of the earliest bioceramics used in Endodontics was Mineral Trioxide Aggregate - a silicate cement.  This bioactive and biocompatible material was unlike anything we had seen before in endodontics.  It could be used in a moist environment - actually requiring moisture to set up, did not seem to irritate the adjacent tissues and bone would form right up against it!  It did not take long fir this  material to be used for root repair (additional example) & apicoectomy retrofills.

With the biocompatible success of this material, and seeing that it clinically created good seal, it wasn't long before we began using this bioceramic for direct pulp capping and using this material to replace traditional apexification/apexogenesis a new type of procedures known as pulpal regeneration.

 

One of the biggest challenges with the use of MTA was the grey discoloration of the tooth.  The grey staining of the tooth created esthetic challenges in the anterior.  In effort to address this complication,  Tulsa Dentsply developed a white MTA by reducing the aluminoferrite content.

The bioceramic line up has grown since the development of white MTA with additional calcium silicate cement products from Septodont, Brasseler, Avalon Biomed etc.  These modern bioceramic materials claim to have the impressive properties of:

• Osteogenicity
• Chemically bond to dentin
• Antibacterial (pH>12)
• Hydrophilic
• Hydroxyapatite producing
• No shrinkage
• Good working/setting time
• Easy delivery systems

Every one of these properties make these materials ideal for use in Endodontics. By adjusting the thickness of the material for different applications, we now use these materials as endodontic sealer, root repair material, root end filling materials, pulp regenerative procedures.

With improved esthetics, these modern bioceramics are now the standard of care for pulpal regenerative procedures.

The modern bioceramic materials, with these amazing bioactive and biocompatible properties, are opening up new restorative options when it comes to carious lesions on vital teeth.  

Bioceramics can be placed directly against the pulpal tissue and maintain vitality of the pulp.  This means that direct and indirect pulp capping with CaOH is out and the new bioceramics are in. This new approach includes a major paradigm shift when it comes to pulp capping procedures.  Previously, we attempted to minimize any pulpal exposure.  Now, with the bioactive and biocompatible properties of bioceramics, the goal is complete removal of caries and infected pulpal tissue (even complete pulpotomy if needed) and proper seal with a bioceramic and immediate bonded coronal restoration.  This procedure is known as Vital Pulp Therapy (VPT) and should be considered in your restorative practice in the place of direct and indirect pulp capping.  In an upcoming post, we'll share the steps and cases to help you apply this in your restorative practice.

In a 2021 meta analysis (3) on the prognosis of vital pulp therapy on permanent teeth, when MTA or other bioceramics were used as a capping material they were found to be successful 93% of the time.  This means that VPT should be an option for your treatment of carious teeth - prior to endodontic treatment.

Stay tuned for more info and clinical tips on Vital Pulp Therapy.

Sources:

1. Wataha JC. Principles of biocompatibility for dental practitioners. J Prosthet Dent. 2001 Aug;86(2):203-9. doi: 10.1067/mpr.2001.117056. PMID: 11514810.

2. Dong X, Xu, X. Bioceramics in Endodontics, Updates and Future Perspectives.  Bioengineering. 2023 Mar13;10(3):354.

3. Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials Sabeti, Mohammad et al. Journal of Endodontics, Volume 47, Issue 11, 1683 - 1695