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Laser use in direct pulp capping
ORIGINAL CONTRIBUTIONS
Laser use in direct pulp capping A meta-analysis Yang Deng, MS; Xiaodan Zhu, MS; Dan Zheng, MS; Ping Yan, DDS; Han Jiang, DDS
E
ndodontically treated teeth have compromised tactile sensation for perceiving functional overload, as well as sometimes a discolored appearance and higher fracture rates compared with vital teeth.1,2 The long-term prognosis of endodontically treated teeth is not as good as that of vital teeth. Therefore, there is little debate about the value of retaining a vital pulp. Direct pulp capping (DPC) is considered a valid treatment for maintaining tooth vitality. When a healthy pulp has been inadvertently exposed through traumatic injury or iatrogenic means, a DPC treatment can be performed. During the DPC procedure, a dental material can be placed directly over the exposed site after bleeding has ceased to encourage the pulp to initiate reparative tertiary dentin formation.3 The success rates of DPC reported in the literature are fluctuant and depend on many factors such as the size of the exposed pulp area, the location of the exposed pulp site, and the age of the patients. To achieve success in DPC treatment, the pulp must not be irreversibly inflamed, there must be an adequate control of hemorrhaging, the capping material must be antibacterial and biocompatible, and a good seal must be achieved.4 A variety of materials have been recommended for use in DPC, such as calcium hydroxide (Ca[OH]2), mineral trioxide aggregate (MTA), zinc oxide eugenol, glass ionomer and resin-modified glass ionomer, and adhesive systems.5 The most frequently used materials are Ca(OH)2 and MTA.6 Although many animal and clinical studies have shown that these materials produce favorable results due to their chemical and physical properties, antibacterial activity, and biocompatibility, they still have some disadvantages, which could greatly affect the outcome of DPC treatment. Therefore, efforts should be made to improve the clinical success rate of this procedure. Since the introduction of lasers to endodontics, as described in 1971 by Weichman and Johnson,7 who Copyright ª 2016 American Dental Association. All rights reserved.
ABSTRACT Background. The authors of this study evaluated the effects of lasers on the outcome of direct pulp capping by means of a meta-analysis. Types of Studies Reviewed. The authors completed a literature search on PubMed, Cochrane Library, Embase, and China National Knowledge Infrastructure, as well as a manual search of the reference lists of all identified articles since the introduction of lasers in endodontics in 1971 through May 30, 2016. The authors systematically evaluated the studies that met the inclusion criteria and performed a meta-analysis. Results. The authors selected 5 studies about 4 laser systems (carbon dioxide; diode; erbium,chromium: yttrium-selenium-gallium-garnet; and erbium:yttriumaluminum-garnet) from the 510 articles to be included in this meta-analysis. Using a fixed-effects model, they found no significant heterogeneity between these studies (c2 ¼ 0.83, P ¼ .99, I2 ¼ 0%). Their results showed that the success rate (89.9%) of the laser groups was higher than that of 67.2% of the control groups, and the difference was statistically significant (risk ratio, 1.35; 95% confidence interval, 1.23-1.49; P < .00001). Conclusions and Practical Implications. On the basis of the limited evidence, the use of lasers effectively improved the prognosis of direct pulp capping treatment for permanent teeth. Key Words. Laser; dental pulp capping; caries; calcium hydroxide; mineral trioxide aggregate; meta-analysis. JADA 2016:-(-):--http://dx.doi.org/10.1016/j.adaj.2016.07.011
attempted to use a high-power infrared laser to seal the apical foramen in vitro, lasers have become more common in endodontics. Laser (light amplification by stimulated emission of radiation) is a manufactured single photon wavelength with concentrated light energy that can exert a strong effect, targeting tissue at an energy level much lower than that of natural light.8 Owing to their photo-physical characteristics, including their ability to produce good ablation, hemostasis,
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ORIGINAL CONTRIBUTIONS
detoxification, decontamination, and biostimulation effect,9,10 lasers have become increasingly popular in DPC treatment in the clinical setting. Although many in vitro and in vivo studies have already shown an increased benefit of laser use in DPC treatment, no quantitative analysis has been completed that supports the clinical use of lasers for DPC treatment. In this article, we review the relevant literature and use a meta-analysis to formulate reliable clinical guidance regarding the efficacy of lasers for DPC treatment. METHODS
Search strategy. We used 4 databases (PubMed, Cochrane Library, Embase, and China National Knowledge Infrastructure) and searched from 19717 through May 30, 2016. We used the following keyword in the initial search: “direct pulp capping.” We conducted a manual search to identify additional studies by using the references of the obtained articles. Inclusion and exclusion criteria. We determined that studies were eligible for inclusion in this metaanalysis if they met all of the following criteria: - the trials were randomized controlled trials and nonrandomized controlled trials; - the patient had to have a tooth undergoing DPC treatment; - the use of lasers was the only treatment difference between the 2 groups, regardless of whether there was combined therapy or not; - success and failure were evaluated. We determined studies were ineligible for inclusion in this meta-analysis if they met these exclusion criteria: - studies were performed in vitro; - experimental studies were performed in animals or in human primary teeth; - the time of follow-up was less than 6 months; - data for the outcomes of interest were impossible to be extracted; - an indirect pulp capping (the deepest carious dentin layer approximating the pulp remained and was covered with biocompatible materials), or pulptomy (the affected or infected coronal pulp is surgical amputated)11 was completed rather than a DPC. Selection of studies. We initially evaluated the articles for their relevance based on the titles and abstracts. Then we obtained the full texts of possibly relevant studies. We included studies that fulfilled the eligibility inclusion criteria. If full-text versions of the relevant studies were not available, we contacted the first author or the corresponding author and requested it. To minimize the potential for reviewer bias, 2 reviewers (Y.D., D.Z.) independently performed the article selection. For any disagreements that could not be resolved by discussion, we consulted with a third reviewer (P.Y.) to achieve consensus.
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Data extraction. We had 2 reviewers (Y.D., D.Z.) independently extract the necessary information after reading the full text of the included articles using a standardized form. If there were several articles reporting on the same trial with different follow-up time, we included the article with the most comprehensive data in the meta-analysis. If the data were unavailable, we contacted the authors via e-mail for additional information. Assessment of risk of bias. We evaluated all of the included studies based on the Cochrane Risk of Bias Tool recommended by the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0.12 Two reviewers (Y.D., D.Z.) independently assessed the study quality using the following 7 criteria: random sequence generation, allocation concealment, masking of participants, masking of outcome assessment, incomplete outcome data, selective reporting, and other bias. If there was disagreement, consensus was reached through discussion or consultation with a third reviewer (P.Y.). Statistical analysis. We used RevMan 5.2 (http://tech. cochrane.org/revman/download), a statistical program provided by the Cochrane Collaboration, to perform the meta-analysis, and “tooth” was used as the analysis unit. We used the risk ratio and 95% confidence interval as measurable statistics, and we calculated with fixed-effects and random-effects model meta-analysis using the Mantel-Haenszel method for dichotomized data. Significant differences were considered at P < .05. We evaluated the statistical heterogeneity among the studies using the c2 test with a significance set at P < .10. We used the I2 statistic to assess the percentage of heterogeneity. When the I2 value ranges from 0% to 40%, the heterogeneity is mild. When I2 value ranges from 40% to 60%, the heterogeneity is moderate; when it ranges from 50% to 90%, the heterogeneity is significant; and when it ranges from 75% to 100%, the heterogeneity is extreme. In general, if P > .10 and I2 < 50%, all included studies are considered to be homogenous, and the fixed-effect model can be chosen for analysis. If not, the source of heterogeneity should be analyzed.13 We did not conduct the evaluation of the publication bias due to the limited number of included studies in the final analysis. RESULTS
Screening results. An overview of the selection process is shown in Figure 1.14 Of the 510 potentially relevant studies, we obtained full-text versions of 10 studies for ABBREVIATION KEY. Ca(OH)2: Calcium hydroxide. CO2: Carbon dioxide. DPC: Direct pulpal capping. Er,Cr:YSGG: Erbium,chromium:yttrium-selenium-gallium-garnet. Er:YAG: Erbium:yttrium-aluminum-garnet. M-H: Mantel–Haenszel test. MTA: Mineral trioxide aggregate. RCT: Randomized controlled trial.
ORIGINAL CONTRIBUTIONS
Included
Eligibility
Screening
Identification
detailed evaluation15-19; 5 of them were excluded Records identified through Additional records identified because they did not database searching through other sources fulfill the inclusion (n = 510) (n = 0) criteria, as is shown in Table 1. Finally, in this meta-analysis, we included 5 studies using 4 Records of duplicates removed different laser systems: (n = 465) - carbon dioxide (CO2)20,21 4 - diode Records screened Records excluded - erbium, chromium: (n = 337) (n = 128) yttrium-seleniumgallium-garnet (Er,Cr: YSGG)22 Full-text articles assessed Full-text articles excluded, - erbium:yttriumfor eligibility with reasons (n = 10) (n = 5) aluminum-garnet (Er:YAG).22,23 We subjected the 5 Studies included in studies to data extraction, qualitative synthesis risk of bias assessment, (n = 5) data synthesis, and analysis. The main characteristics of the included Studies included in studies are summarized meta-analysis in Table 2 (n = 5) Results of risk of bias assessment. The assessment of the risk of bias Figure 1. Flowchart of the studies included in the meta-analysis. Source: Moher and colleagues.14 for each of the included studies is shown in TABLE 1 Figure 2. All included studies met the inclusion and exclusion criteria, but some did not adequately describe Excluded studies and reasons for their methods in detail (for example, random sequence exclusion. generation, allocation concealment). Because participant and personnel masking was impossible given the STUDY REASON FOR EXCLUSION handling characteristics of the lasers, we considered Wilder-Smith,16 1988 No control group performance bias to be high risk. We determined that 1 Dabrowska and The number of patients is inconsistent Colleagues,15 1997 between “Materials and Methods” and study20 was at a high risk of bias for incomplete out“Results” sections. comes data as it did not give a description of the reason Santucci,17 1999 The pulp capping materials are different for withdrawals or dropout from the study. We found between laser group and control group. neither reporting nor other biases in these studies. Gao and Colleagues,19 Pulpotomy, instead of direct pulpal capping, Results of meta-analysis. Figure 3 shows the results 2007 was performed on patients. of this meta-analysis. We used all data of the included Huth and Short follow-up time (30 d) Colleagues,18 2012 studies to calculate the effects of the lasers on the outcome of DPC treatment. Because a heterogeneity test showed that there was low heterogeneity among these effort for both clinicians and patients to maintain pulp studies (c2 ¼ 0.83, P ¼ .99, I2 ¼ 0%), we used the fixed- vitality and prevent endodontic treatment. By assessing effects model meta-analysis. Based on the results, we all relevant studies, we conducted the first meta-analysis, found the laser groups had a significantly higher success to our knowledge, to explore the effects of lasers on the rate than the control groups (relative risk, 6.28). DPC treatment. DPC treatment mainly involves 2 steps: preparation of DISCUSSION the exposed pulp tissue and the surrounding dentin Compared with pulpectomy or pulpotomy, DPC is a (hemostasis and decontamination) and sealing of the minimally invasive procedure that saves time, cost, and exposed pulp with 1 of the aforementioned dental
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TABLE 2
Characteristics of the included studies. STUDY
STUDY DESIGN
MEAN AGE (RANGE), Y Laser
Control
SAMPLE SIZE
LASER TYPE
Laser
Control
PULP CAPPING MATERIAL
OUTCOME EVALUATION
FOLLOW-UP TIME
Moritz and Colleagues,20 1998
RCT*
34.8 (15-65) 33.9 (9-68)
100
100
Carbon dioxide
Ca(OH)2†
Clinical assessment‡ and laser Doppler flowmetry
2y
Moritz and Colleagues,21 1998
RCT
33.4 (8-74)
100
100
Carbon dioxide
Ca(OH)2
Clinical assessment and laser Doppler flowmetry
1y
Olivi and Colleagues,22 2007§,¶
RCT
14.5 (11-18)
15,# 8**
11 10
Clinical assessment and radiography
4y
10,# 10**
Er,Cr:YSGG,†† Er:YAG‡‡
Ca(OH)2
27.1 (19-40)
Yazdanfar and Colleagues,4 2015
RCT
27.8 (20-40) 23.4 (12-39)
808-nanometer diode
Resin-modified glass ionomer cement
Clinical assessment and radiography
1y
Cengiz and Yilmaz,23 2016¶
RCT
28 (18-41)
Ca(OH)2
Clinical assessment and radiography
6 mo
33.9 (9-68)
5
5
15
15
15
15
Er,Cr:YSGG
Light-cured, resin-modified, tricalcium silicate–filled liner (TheraCal LC, Bisco)
* RCT: Randomized controlled trial. † Ca(OH)2: Calcium hydroxide. ‡ Clinical assessment: Clinical examination of patients’ subjective symptoms, percussion test, palpation test, and thermal tests. § Data in the top row indicate the study subgroup aged 11 to 18 years, and data in the bottom group indicate the study subgroup aged 19 to 40 years. ¶ Mean age data for these studies were given as an overall average of both the laser and the control groups. # Participants who received treatment using erbium,chromium:yttrium-selenium-gallium-garnet laser. ** Participants who received treatment using erbium:yttrium-aluminum-garnet laser. †† Er,Cr:YSGG: Erbium,chromium:yttrium-selenium-gallium-garnet. ‡‡ Er:YAG: Erbium:yttrium-aluminum-garnet.
materials to form a dental bridge and prevent bacterial penetration.24 For hemostasis of the exposed pulp tissue, gentle pressure with cotton pellets moistened with 3% to 6% sodium hypochlorite is most commonly used,25,26 but renewed bleeding sometimes occurs at the pulp-dentin exposure margin after the application of the capping material or bonding agent of the adhesive system. This renewed bleeding may be responsible for the initial inflammation and failure. However, if the exposed pulp was irradiated by lasers, blood flow would be stopped easily, as lasers could seal small blood vessels,27 and scar tissue would be formed in the irradiated area due to the blood coagulation of the soft tissue, and therefore neither secondary bleeding nor tissue fluid exudation would occur.20 Studies have showed that the outcomes of DPC treatment for teeth with deep caries are generally poor, and the success rate was lower than that for teeth with mechanically exposed pulp tissue.28,29 Many clinicians were reluctant to choose the DPC as a treatment option for carious-exposed pulps due to the variable success rates (33% to 100%).28,30 After a carious exposure, the surrounding pulp is contaminated by different bacteria, which are associated with inflammation and pathologic
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features that may affect the healing process. Indeed, the presence of a sterile field is a crucial phase of the DPC treatment.31,32 Lasers can sterilize the exposed site and its surrounding area simultaneously,24 and many studies33-35 have confirmed the laser’s superior decontamination effect over conditional antibacterial agents. In addition, lasers can treat the exposed pulp tissue surface without direct contact, keeping the surface uncontaminated. All studies included in this article used teeth with deep caries, and the success rate was approximately 89.9% in the laser aid group, and only 67.2% in the control group. The effective decontamination may be responsible for the high success rate of laser-assisted DPC for caries-exposed pulp tissue. DPC treatment is designed to treat reversible pulpitis from injury by stimulating the formation of the dentin bridge that is often considered to be the sign of successful pulp healing.36 In addition to their hemostatic and decontamination effects, lasers also have biostimulation effects. It has been shown that exposure to a laser, especially a low-intensity laser,37 can accelerate the growth of fibroblasts and osteoblasts and stimulate the proliferation, migration, and cytodifferentiation of odontoblastlike cells to promote the formation of
ORIGINAL CONTRIBUTIONS
All
Ma
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om
se
qu
en c (se e ge lec ner oc sk tio ati ati ing n b on on of ias c pa (se onc ) rti lec eal cip tio me an Ma n b nt t sk (pe s an ias ing rfo d p ) of ers r m ou tco ance onne me bia l s) (de ass Inc om tec ess tio me ple n b nt te ou ia (at tcom s) tri tio e da Se n b ta lec ias tiv (re e r ) po ep rti ort ng i bia ng s) Ot he rb ias
STUDIES
reparative dentin in the injured pulp tissue.38 It Moritz and Colleagues,20 1998 ? + + – ? – ? also has been shown that the presence of inflammation has a negative Moritz and Colleagues,21 1998 ? + + ? + ? – effect on the formation of dentin bridge,39 and Olivi and Colleagues,22 2007 ? + ? – ? ? + lasers can reduce pulp inflammation regardless of whether MTA or Yazdanfar and Colleagues,4 2015 + ? + + + – ? Ca(OH)2 was used as the pulp capping material.40 Cengiz and Yilmaz,23 2016 – + + + ? + ? Several laser systems, including CO2 (wavelength, 10600 nm), Er:YAG (2936 nm), Er,Cr:YSGG (2780 nm), diode (most widely used at 810 nm, 980 nm), and Nd:YAG (1064 nm) have been introduced as auxiliary tools for DPC treatment. Depending on their wavelengths, each laser system has its own characteristics, advantages, and disadvanDOMAIN tages, which have been comprehensively sumFigure 2. Summary of risk of bias for included studies. þ: Low risk of bias. –: High risk of bias. ?: Unclear marized by Komabayarisk of bias. 24 shi and colleagues. As Er:YAG and Er,Cr:YSGG laser energy can be absorbed efficiently both studies reported that the use of lasers did not signifiby the water molecules and hydroxyapatite, they have an cantly improve the outcome of DPC.40,43,44 The different results may be due to different laser wavelengths and excellent capacity for ablating both for soft and hard tissues with minimal thermal side effects,41 unlike CO2, parameters (power, time, frequency, and so on) used. A Nd:YAG, and diode laser systems, which are mostly direct comparison between different laser systems cannot used for soft-tissue surgery and not effective in ablation be made from the data examined in this review and a of hard tissue. Diode and Nd:YAG penetrate deep protocol for the clinical use of lasers for DPC treatment into biological tissue and have significant scattering cannot be formulated in this meta-analysis with the capacity, offering great decontamination and hemostasis limited evidence in the literature. effect.34,35,42 The biostimulation effect is a common Ca(OH)2 has outstanding antibacterial properties45 characteristic of lasers, in particular, the use of a diode and has been considered the criterion standard of pulp laser is especially advantageous in the healing processes capping materials for several decades. However, it still of the pulp tissue.5 Moreover, a diode laser costs less than has some obvious disadvantages, such as risk of experiother laser systems. However, we found disadvantages encing cytotoxic effects, a high solubility, and a poor reported for using lasers on an exposed pulp surface if ability to form a seal.46 MTA has become a popular inappropriate laser power, time, or technique were used. alternative to Ca(OH)2 as it has several positive propMost of the laser systems showed great promise for DPC erties, including biocompatibility, antibacterial activity, treatment according to previous in vitro and in vivo high sealing effects, and long-term stability.47,48 In our studies. The 5 studies included in this meta-analysis used study, 4 of the 5 included studies used Ca(OH)2 as the pulp capping material, and no clinical studies have 4 different laser systems (CO2, diode, Er,Cr:YSGG, Er:YAG), showing that the success rate of the laser group evaluated the effects of lasers when MTA was used as the was higher than that of the control group, and Santucci pulp capping material. There were some animal and colleagues17 reported a 90.3% success rate with the studies40,44 that showed that the used of lasers could not aid of Nd:YAG after 54 months, whereas some in vitro significantly improve the outcomes of DPC treatment
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ORIGINAL CONTRIBUTIONS
Experimental Study or Subgroup
Events
Control
Total Weight M-H, Fixed, 95% CI
Moritz and Colleagues,20 1998
93
100
68
100
38.3%
1.37 (1.18-1.58)
Moritz and Colleagues,21 1998
89
100
68
100
38.3%
1.31 (1.13-1.52)
Olivi and Colleagues,22 2007 (participants aged 11-18 years)
18
23
7
11
5.3%
1.23 (0.75-2.02)
Olivi and Colleagues,22 2007 (participants aged 19-40 years)
15
20
5
10
3.8%
1.50 (0.77-2.93)
Yazdanfar and Colleagues,4 2015 Cengiz and Yilmaz,
23
2016 (calcium
Risk Ratio
Risk Ratio
Total Events
5
5
3
5
2.0%
1.57 (0.77-3.22)
15
15
11
15
6.5%
1.35 (0.98-1.85)
15
15
10
15
5.9%
1.48 (1.02-2.13)
256
100.0%
1.35 (1.23-1.49)
M-H, Fixed, 95% CI
hydroxide group) Cengiz and Yilmaz,23 2016 (TheraCal LC group) Total (95% CI) Total events
278 250
172
2 2 Heterogeneity: χ6 = 0.83, P = .99; I = 0%
0.01
Test for overall effect: z = 6.28 (P < .00001)
0.1 Favors control
1
10
100
Favors experimental
Figure 3. Forest plot of the meta-analysis results. CI: Confidence interval. Events: The number of success. M-H: Mantel–Haenszel test.
when MTA was used as the pulp capping material. We speculate the possible reasons are as follows. Initially, we determined the use of MTA alone could help DPC treatment acquire high success rates (84.5%)49 for using MTA, as mentioned above, and the lasers’ advantages (for example, decontamination effect, biostimulation effect) do not seem to be that obvious when used with MTA. Next, MTA needs humid conditions for setting.50 Because of the lasers’ hemostasis and thermal coagulation effect, MTA cannot absorb moisture from the pulp tissue after it is irradiated by lasers. However, we do not know if the use of a laser could improve the outcomes of DPC treatment when MTA was used as the pulp capping material from the data examined in this review. Therefore, well-controlled clinical trials are needed to reach a conclusion. It has been reported that the prognosis of DPC is better in young patients because the pulps of younger patients are richer in cells and have a greater ability to regenerate.20 Some studies reported that patients younger than 40 years had significantly better outcomes than the older age cohort,51,52 whereas other studies could not confirm the significant correlation between the success rate and the patient’s age.28,53,54 Finally, the influence of age on the outcome of DPC could not be found in this meta-analysis due to the limited data. All of the 5 included studies used a rubber dam during the DPC procedures, which meant excellent conditions for infection control. The use of a rubber dam can prevent the deleterious effect of saliva on an exposed pulp and guarantee better bonding to the cavity walls.5 Microorganism control is the key factor in the outcome of the DPC treatment, and the use of a rubber dam is strongly recommended.51 de Lourdes Rodrigues Accorinte and colleagues’s55 study showed worse pulpal response when
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rubber dam isolation was not used during DPC treatment, especially if bonding agents were used for pulp capping. All included studies were randomized controlled trials, which were regarded as the most reliable and accurate methods for experimental design. Some limitations, however, should not be neglected in this meta-analysis. All studies included in this meta-analysis evaluated the outcome of DPC treatment by clinical criteria, and some of them combined radiography or laser Doppler flowmetry. However, there was no histologic study regarding the formation of the dentin bridge. Also, many of our included studies exhibited small sample sizes, such that their overall veracity is questionable, and their results should be interpreted with caution. CONCLUSION
Additional well-designed randomized controlled trials with larger sample sizes are needed to draw a more definitive conclusion. Based on the available information, the results of this meta-analysis demonstrated DPC treatment could achieve better clinical outcomes with the aid of lasers. n Ms. Deng is an intern, Department of Endodontics, School and Hospital of Stomatology, Wuhan University, and a masters degree student, The State Key Laboratory Breeding Base of Basic Science of Stomatology (HubeiMOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China. Ms. Zhu is an intern, Department of Endodontics, School and Hospital of Stomatology, Wuhan University, and a masters degree student, The State Key Laboratory Breeding Base of Basic Science of Stomatology (HubeiMOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China. Ms. Zheng is an intern, Department of Endodontics, School and Hospital of Stomatology, Wuhan University, and a masters degree student, The State Key Laboratory Breeding Base of Basic Science of Stomatology (HubeiMOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China.
ORIGINAL CONTRIBUTIONS
Dr. Yan is an associate chief physician, Department of Endodontics, School and Hospital of Stomatology, Wuhan University, and an associate professor, The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China. Address correspondence to Dr. Yan, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan City 430079, China, e-mail [email protected]. Dr. Jiang is an associate chief physician, Department of Oral Prophylaxis, School and Hospital of Stomatology, Wuhan University, and an associate professor, The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China. Disclosure. None of the authors reported any disclosures. This study was supported by grant 304220100118 from the Key Science and Technology Program of Hubei Province of China and grant 304413000013 from The Building of Oral Health Electronic Information Management System for College Teachers and Students. 1. Ou KL, Chang CC, Chang WJ, Lin CT, Chang KJ, Huang HM. Effect of damping properties on fracture resistance of root filled premolar teeth: a dynamic finite element analysis. Int Endod J. 2009;42(8): 694-704. 2. Caplan DJ, Cai J, Yin G, White BA. Root canal filled versus non–root canal filled teeth: a retrospective comparison of survival times. J Public Health Dent. 2005;65(2):90-96. 3. Pashley DH. Dynamics of the pulpo-dentin complex. Crit Rev Oral Biol Med. 1996;7(2):104-133. 4. Yazdanfar I, Gutknecht N, Franzen R. Effects of diode laser on direct pulp capping treatment: a pilot study. Lasers Med Sci. 2015;30(4): 1237-1243. 5. Hilton TJ. Keys to clinical success with pulp capping: a review of the literature. Oper Dent. 2009;34(5):615-625. 6. Tziafas D, Kalyva M, Papadimitriou S. Experimental dentin-based approaches to tissue regeneration in vital pulp therapy. Connect Tissue Res. 2002;43(2-3):391-395. 7. Weichman JA, Johnson FM. Laser use in endodontics. A preliminary investigation. Oral Surg Oral Med Oral Pathol. 1971;31(3):416-420. 8. Mohammadi Z. Laser applications in endodontics: an update review. Int Dent J. 2009;59(1):35-46. 9. Aoki A, Sasaki KM, Watanabe H, Ishikawa I. Lasers in nonsurgical periodontal therapy. Periodontol 2000. 2004;36:59-97. 10. Sulewski JG. Historical survey of laser dentistry. Dent Clin North Am. 2000;44(4):717-752. 11. Parisay I, Ghoddusi J, Forghani M. A review on vital pulp therapy in primary teeth. Iran Endod J. 2015;10(1):6-15. 12. Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 (updated March 2011). The Cochrane Collaboration; 2011. Available at: http://handbook.cochrane.org/. Accessed August 14, 2016. 13. Higgins JP, Green S. Assessment of study quality. In: Cochrane Handbook for Systematic Reviews of Interventions, Version 4.2.6, (Updated September 2006). The Cochrane Collaboration; 2006. Available at: http:// community-archive.cochrane.org/sites/default/files/uploads/Handbook4.2.6 Sep2006.pdf. Accessed August 14, 2016. 14. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-1012. 15. Dabrowska E, Zdanowicz-Wiloch J, Pawi nska-Magnuszewska M, Stokowska W. Intravital treatment of the pulp with simultaneous laser biostimulation. Rocz Akad Med Bialymst. 1997;42(1):168-176. 16. Wilder-Smith P. The soft laser: therapeutic tool or popular placebo? Oral Surg Oral Med Oral Pathol. 1988;66(6):654-658. 17. Santucci PJ. Dycal versus Nd:YAG laser and Vitrebond for direct pulp capping in permanent teeth. J Clin Laser Med Surg. 1999;17(2):69-75. 18. Huth KC, Hajek-Al-Khatar N, Wolf P, Ilie N, Hickel R, Paschos E. Long-term effectiveness of four pulpotomy techniques: 3-year randomised controlled trial. Clin Oral Investig. 2012;16(4):1243-1250. 19. Gao PJ, Cheng LS, Chi HY. Clinical study on unexpected pulp exposure in deep deutal carises treated with laser. Heilongjiang Med J. 2007; 31(10):747-748.
20. Moritz A, Schoop U, Goharkhay K, Sperr W. Advantages of a pulsed CO2 laser in direct pulp capping: a long-term in vivo study. Lasers Surg Med. 1998;22(5):288-293. 21. Moritz A, Schoop U, Goharkhay K, Sperr W. The CO2 laser as an aid in direct pulp capping. J Endod. 1998;24(4):248-251. 22. Olivi G, Genovese MD, Maturo P, Docimo R. Pulp capping: advantages of using laser technology. Eur J Paediatr Dent. 2007;8(2):89-95. 23. Cengiz E, Yilmaz HG. Efficacy of erbium, chromium-doped:yttrium, scandium, gallium, and garnet laser irradiation combined with resin-based tricalcium silicate and calcium hydroxide on direct pulp capping: a randomized clinical trial. J Endod. 2016;42(3):351-355. 24. Komabayashi T, Ebihara A, Aoki A. The use of lasers for direct pulp capping. J Oral Sci. 2015;57(4):277-286. 25. Kitasako Y, Inokoshi S, Tagami J. Effects of direct resin pulp capping techniques on short-term response of mechanically exposed pulps. J Dent. 1999;27(4):257-263. 26. Hafez AA, Cox CF, Tarim B, Otsuki M, Akimoto N. An in vivo evaluation of hemorrhage control using sodium hypochlorite and direct capping with a one- or two-component adhesive system in exposed nonhuman primate pulps. Quintessence Int. 2002;33(4):261-272. 27. Kravitz ND, Kusnoto B. Soft-tissue lasers in orthodontics: an overview. Am J Orthod Dentofacial Orthop. 2008;133(4 suppl):S110-S114. 28. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping of carious exposures: treatment outcome after 5 and 10 years: a retrospective study. J Endod. 2000;26(9):525-528. 29. Ritter AV. Direct pulp-capping performed by dental students has a success rate close to 60%. Direct capping of carious pulp exposures is significantly less successful (33%) than direct capping of mechanical pulp exposures (92%). J Evid Based Dent Pract. 2007;7(4):165-166. 30. Farsi N, Alamoudi N, Balto K, Al Mushayt A. Clinical assessment of mineral trioxide aggregate (MTA) as direct pulp capping in young permanent teeth. J Clin Pediatr Dent. 2006;31(2):72-76. 31. Murray PE, Windsor LJ, Smyth TW, Hafez AA, Cox CF. Analysis of pulpal reactions to restorative procedures, materials, pulp capping, and future therapies. Crit Rev Oral Biol Med. 2002;13(6):509-520. 32. Murray PE, Kitasako Y, Tagami J, Windsor LJ, Smith AJ. Hierarchy of variables correlated to odontoblast-like cell numbers following pulp capping. J Dent. 2002;30(7-8):297-304. 33. Moritz A, Schoop U, Goharkhay K, et al. The bactericidal effect of Nd:YAG, Ho:YAG, and Er:YAG laser irradiation in the root canal: an in vitro comparison. J Clin Laser Med Surg. 1999;17(4):161-164. 34. Schoop U, Kluger W, Moritz A, Nedjelik N, Georgopoulos A, Sperr W. Bactericidal effect of different laser systems in the deep layers of dentin. Lasers Surg Med. 2004;35(2):111-116. 35. Gutknecht N, Moritz A, Conrads G, Sievert T, Lampert F. Bactericidal effect of the Nd:YAG laser in in vitro root canals. J Clin Laser Med Surg. 1996;14(2):77-80. 36. Parolia A, Kundabala M, Rao NN, et al. A comparative histological analysis of human pulp following direct pulp capping with propolis, mineral trioxide aggregate and Dycal. Aust Dent J. 2010;55(1): 59-64. 37. Marques MM, Pereira AN, Fujihara NA, Nogueira FN, Eduardo CP. Effect of low-power laser irradiation on protein synthesis and ultrastructure of human gingival fibroblasts. Lasers Surg Med. 2004;34(3): 260-265. 38. Eduardo Fde P, Bueno DF, de Freitas PM, et al. Stem cell proliferation under low intensity laser irradiation: a preliminary study. Lasers Surg Med. 2008;40(6):433-438. 39. Jayawardena JA, Kato J, Moriya K, Takagi Y. Pulpal response to exposure with Er:YAG laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(2):222-229. 40. Hasheminia SM, Feizi G, Razavi SM, Feizianford M, Gutknecht N, Mir M. A comparative study of three treatment methods of direct pulp capping in canine teeth of cats: a histologic evaluation. Lasers Med Sci. 2010;25(1):9-15. 41. Sasaki KM, Aoki A, Ichinose S, Ishikawa I. Ultrastructural analysis of bone tissue irradiated by Er:YAG laser. Lasers Surg Med. 2002;31(5): 322-332. 42. Romanos G, Nentwig GH. Diode laser (980 nm) in oral and maxillofacial surgical procedures: clinical observations based on clinical applications. J Clin Laser Med Surg. 1999;17(5):193-197.
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43. Ferriello V, Faria MR, Cavalcanti BN. The effects of low-level diode laser treatment and dental pulp-capping materials on the proliferation of L-929 fibroblasts. J Oral Sci. 2010;52(1):33-38. 44. Hasheminia SM, Feizi G, Razavi SM, Feizianfard M. Histologic evaluation of three treatment methods for direct pulp capping of cat’s canine. Iran Endod J. 2007;2(2):54-60. 45. Barthel CR, Levin LG, Reisner HM, Trope M. TNF-alpha release in monocytes after exposure to calcium hydroxide treated Escherichia coli LPS. Int Endod J. 1997;30(3):155-159. 46. Snuggs HM, Cox CF, Powell CS, White KC. Pulpal healing and dentinal bridge formation in an acidic environment. Quintessence Int. 1993; 24(7):501-510. 47. Tziafas D, Pantelidou O, Alvanou A, Belibasakis G, Papadimitriou S. The dentinogenic effect of mineral trioxide aggregate (MTA) in short-term capping experiments. Int Endod J. 2002;35(3):245-254. 48. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review, part I—chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27. 49. Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium hydroxide or mineral trioxide aggregate: a meta-analysis. J Endod. 2015;41(9):1412-1417.
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50. Gancedo-Caravia L, Garcia-Barbero E. Influence of humidity and setting time on the push-out strength of mineral trioxide aggregate obturations. J Endod. 2006;32(9):894-896. 51. Dammaschke T, Leidinger J, Schafer E. Long-term evaluation of direct pulp capping: treatment outcomes over an average period of 6.1 years. Clin Oral Investig. 2010;14(5):559-567. 52. Cho SY, Seo DG, Lee SJ, Lee J, Lee SJ, Jung IY. Prognostic factors for clinical outcomes according to time after direct pulp capping. J Endod. 2013;39(3):327-331. 53. Mente J, Geletneky B, Ohle M, et al. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. J Endod. 2010;36(5):806-813. 54. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The radiographic outcomes of direct pulp-capping procedures performed by dental students: a retrospective study. JADA. 2006;137(12):1699-1705. 55. de Lourdes Rodrigues Accorinte M, Reis A, Dourado Loguercio A, Cavalcanti de Araújo V, Muench A. Influence of rubber dam isolation on human pulp responses after capping with calcium hydroxide and an adhesive system. Quintessence Int. 2006;37(3): 205-212.
Laser use in direct pulp capping A meta-analysis Yang Deng, MS; Xiaodan Zhu, MS; Dan Zheng, MS; Ping Yan, DDS; Han Jiang, DDS
E
ndodontically treated teeth have compromised tactile sensation for perceiving functional overload, as well as sometimes a discolored appearance and higher fracture rates compared with vital teeth.1,2 The long-term prognosis of endodontically treated teeth is not as good as that of vital teeth. Therefore, there is little debate about the value of retaining a vital pulp. Direct pulp capping (DPC) is considered a valid treatment for maintaining tooth vitality. When a healthy pulp has been inadvertently exposed through traumatic injury or iatrogenic means, a DPC treatment can be performed. During the DPC procedure, a dental material can be placed directly over the exposed site after bleeding has ceased to encourage the pulp to initiate reparative tertiary dentin formation.3 The success rates of DPC reported in the literature are fluctuant and depend on many factors such as the size of the exposed pulp area, the location of the exposed pulp site, and the age of the patients. To achieve success in DPC treatment, the pulp must not be irreversibly inflamed, there must be an adequate control of hemorrhaging, the capping material must be antibacterial and biocompatible, and a good seal must be achieved.4 A variety of materials have been recommended for use in DPC, such as calcium hydroxide (Ca[OH]2), mineral trioxide aggregate (MTA), zinc oxide eugenol, glass ionomer and resin-modified glass ionomer, and adhesive systems.5 The most frequently used materials are Ca(OH)2 and MTA.6 Although many animal and clinical studies have shown that these materials produce favorable results due to their chemical and physical properties, antibacterial activity, and biocompatibility, they still have some disadvantages, which could greatly affect the outcome of DPC treatment. Therefore, efforts should be made to improve the clinical success rate of this procedure. Since the introduction of lasers to endodontics, as described in 1971 by Weichman and Johnson,7 who Copyright ª 2016 American Dental Association. All rights reserved.
ABSTRACT Background. The authors of this study evaluated the effects of lasers on the outcome of direct pulp capping by means of a meta-analysis. Types of Studies Reviewed. The authors completed a literature search on PubMed, Cochrane Library, Embase, and China National Knowledge Infrastructure, as well as a manual search of the reference lists of all identified articles since the introduction of lasers in endodontics in 1971 through May 30, 2016. The authors systematically evaluated the studies that met the inclusion criteria and performed a meta-analysis. Results. The authors selected 5 studies about 4 laser systems (carbon dioxide; diode; erbium,chromium: yttrium-selenium-gallium-garnet; and erbium:yttriumaluminum-garnet) from the 510 articles to be included in this meta-analysis. Using a fixed-effects model, they found no significant heterogeneity between these studies (c2 ¼ 0.83, P ¼ .99, I2 ¼ 0%). Their results showed that the success rate (89.9%) of the laser groups was higher than that of 67.2% of the control groups, and the difference was statistically significant (risk ratio, 1.35; 95% confidence interval, 1.23-1.49; P < .00001). Conclusions and Practical Implications. On the basis of the limited evidence, the use of lasers effectively improved the prognosis of direct pulp capping treatment for permanent teeth. Key Words. Laser; dental pulp capping; caries; calcium hydroxide; mineral trioxide aggregate; meta-analysis. JADA 2016:-(-):--http://dx.doi.org/10.1016/j.adaj.2016.07.011
attempted to use a high-power infrared laser to seal the apical foramen in vitro, lasers have become more common in endodontics. Laser (light amplification by stimulated emission of radiation) is a manufactured single photon wavelength with concentrated light energy that can exert a strong effect, targeting tissue at an energy level much lower than that of natural light.8 Owing to their photo-physical characteristics, including their ability to produce good ablation, hemostasis,
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detoxification, decontamination, and biostimulation effect,9,10 lasers have become increasingly popular in DPC treatment in the clinical setting. Although many in vitro and in vivo studies have already shown an increased benefit of laser use in DPC treatment, no quantitative analysis has been completed that supports the clinical use of lasers for DPC treatment. In this article, we review the relevant literature and use a meta-analysis to formulate reliable clinical guidance regarding the efficacy of lasers for DPC treatment. METHODS
Search strategy. We used 4 databases (PubMed, Cochrane Library, Embase, and China National Knowledge Infrastructure) and searched from 19717 through May 30, 2016. We used the following keyword in the initial search: “direct pulp capping.” We conducted a manual search to identify additional studies by using the references of the obtained articles. Inclusion and exclusion criteria. We determined that studies were eligible for inclusion in this metaanalysis if they met all of the following criteria: - the trials were randomized controlled trials and nonrandomized controlled trials; - the patient had to have a tooth undergoing DPC treatment; - the use of lasers was the only treatment difference between the 2 groups, regardless of whether there was combined therapy or not; - success and failure were evaluated. We determined studies were ineligible for inclusion in this meta-analysis if they met these exclusion criteria: - studies were performed in vitro; - experimental studies were performed in animals or in human primary teeth; - the time of follow-up was less than 6 months; - data for the outcomes of interest were impossible to be extracted; - an indirect pulp capping (the deepest carious dentin layer approximating the pulp remained and was covered with biocompatible materials), or pulptomy (the affected or infected coronal pulp is surgical amputated)11 was completed rather than a DPC. Selection of studies. We initially evaluated the articles for their relevance based on the titles and abstracts. Then we obtained the full texts of possibly relevant studies. We included studies that fulfilled the eligibility inclusion criteria. If full-text versions of the relevant studies were not available, we contacted the first author or the corresponding author and requested it. To minimize the potential for reviewer bias, 2 reviewers (Y.D., D.Z.) independently performed the article selection. For any disagreements that could not be resolved by discussion, we consulted with a third reviewer (P.Y.) to achieve consensus.
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Data extraction. We had 2 reviewers (Y.D., D.Z.) independently extract the necessary information after reading the full text of the included articles using a standardized form. If there were several articles reporting on the same trial with different follow-up time, we included the article with the most comprehensive data in the meta-analysis. If the data were unavailable, we contacted the authors via e-mail for additional information. Assessment of risk of bias. We evaluated all of the included studies based on the Cochrane Risk of Bias Tool recommended by the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0.12 Two reviewers (Y.D., D.Z.) independently assessed the study quality using the following 7 criteria: random sequence generation, allocation concealment, masking of participants, masking of outcome assessment, incomplete outcome data, selective reporting, and other bias. If there was disagreement, consensus was reached through discussion or consultation with a third reviewer (P.Y.). Statistical analysis. We used RevMan 5.2 (http://tech. cochrane.org/revman/download), a statistical program provided by the Cochrane Collaboration, to perform the meta-analysis, and “tooth” was used as the analysis unit. We used the risk ratio and 95% confidence interval as measurable statistics, and we calculated with fixed-effects and random-effects model meta-analysis using the Mantel-Haenszel method for dichotomized data. Significant differences were considered at P < .05. We evaluated the statistical heterogeneity among the studies using the c2 test with a significance set at P < .10. We used the I2 statistic to assess the percentage of heterogeneity. When the I2 value ranges from 0% to 40%, the heterogeneity is mild. When I2 value ranges from 40% to 60%, the heterogeneity is moderate; when it ranges from 50% to 90%, the heterogeneity is significant; and when it ranges from 75% to 100%, the heterogeneity is extreme. In general, if P > .10 and I2 < 50%, all included studies are considered to be homogenous, and the fixed-effect model can be chosen for analysis. If not, the source of heterogeneity should be analyzed.13 We did not conduct the evaluation of the publication bias due to the limited number of included studies in the final analysis. RESULTS
Screening results. An overview of the selection process is shown in Figure 1.14 Of the 510 potentially relevant studies, we obtained full-text versions of 10 studies for ABBREVIATION KEY. Ca(OH)2: Calcium hydroxide. CO2: Carbon dioxide. DPC: Direct pulpal capping. Er,Cr:YSGG: Erbium,chromium:yttrium-selenium-gallium-garnet. Er:YAG: Erbium:yttrium-aluminum-garnet. M-H: Mantel–Haenszel test. MTA: Mineral trioxide aggregate. RCT: Randomized controlled trial.
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Included
Eligibility
Screening
Identification
detailed evaluation15-19; 5 of them were excluded Records identified through Additional records identified because they did not database searching through other sources fulfill the inclusion (n = 510) (n = 0) criteria, as is shown in Table 1. Finally, in this meta-analysis, we included 5 studies using 4 Records of duplicates removed different laser systems: (n = 465) - carbon dioxide (CO2)20,21 4 - diode Records screened Records excluded - erbium, chromium: (n = 337) (n = 128) yttrium-seleniumgallium-garnet (Er,Cr: YSGG)22 Full-text articles assessed Full-text articles excluded, - erbium:yttriumfor eligibility with reasons (n = 10) (n = 5) aluminum-garnet (Er:YAG).22,23 We subjected the 5 Studies included in studies to data extraction, qualitative synthesis risk of bias assessment, (n = 5) data synthesis, and analysis. The main characteristics of the included Studies included in studies are summarized meta-analysis in Table 2 (n = 5) Results of risk of bias assessment. The assessment of the risk of bias Figure 1. Flowchart of the studies included in the meta-analysis. Source: Moher and colleagues.14 for each of the included studies is shown in TABLE 1 Figure 2. All included studies met the inclusion and exclusion criteria, but some did not adequately describe Excluded studies and reasons for their methods in detail (for example, random sequence exclusion. generation, allocation concealment). Because participant and personnel masking was impossible given the STUDY REASON FOR EXCLUSION handling characteristics of the lasers, we considered Wilder-Smith,16 1988 No control group performance bias to be high risk. We determined that 1 Dabrowska and The number of patients is inconsistent Colleagues,15 1997 between “Materials and Methods” and study20 was at a high risk of bias for incomplete out“Results” sections. comes data as it did not give a description of the reason Santucci,17 1999 The pulp capping materials are different for withdrawals or dropout from the study. We found between laser group and control group. neither reporting nor other biases in these studies. Gao and Colleagues,19 Pulpotomy, instead of direct pulpal capping, Results of meta-analysis. Figure 3 shows the results 2007 was performed on patients. of this meta-analysis. We used all data of the included Huth and Short follow-up time (30 d) Colleagues,18 2012 studies to calculate the effects of the lasers on the outcome of DPC treatment. Because a heterogeneity test showed that there was low heterogeneity among these effort for both clinicians and patients to maintain pulp studies (c2 ¼ 0.83, P ¼ .99, I2 ¼ 0%), we used the fixed- vitality and prevent endodontic treatment. By assessing effects model meta-analysis. Based on the results, we all relevant studies, we conducted the first meta-analysis, found the laser groups had a significantly higher success to our knowledge, to explore the effects of lasers on the rate than the control groups (relative risk, 6.28). DPC treatment. DPC treatment mainly involves 2 steps: preparation of DISCUSSION the exposed pulp tissue and the surrounding dentin Compared with pulpectomy or pulpotomy, DPC is a (hemostasis and decontamination) and sealing of the minimally invasive procedure that saves time, cost, and exposed pulp with 1 of the aforementioned dental
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TABLE 2
Characteristics of the included studies. STUDY
STUDY DESIGN
MEAN AGE (RANGE), Y Laser
Control
SAMPLE SIZE
LASER TYPE
Laser
Control
PULP CAPPING MATERIAL
OUTCOME EVALUATION
FOLLOW-UP TIME
Moritz and Colleagues,20 1998
RCT*
34.8 (15-65) 33.9 (9-68)
100
100
Carbon dioxide
Ca(OH)2†
Clinical assessment‡ and laser Doppler flowmetry
2y
Moritz and Colleagues,21 1998
RCT
33.4 (8-74)
100
100
Carbon dioxide
Ca(OH)2
Clinical assessment and laser Doppler flowmetry
1y
Olivi and Colleagues,22 2007§,¶
RCT
14.5 (11-18)
15,# 8**
11 10
Clinical assessment and radiography
4y
10,# 10**
Er,Cr:YSGG,†† Er:YAG‡‡
Ca(OH)2
27.1 (19-40)
Yazdanfar and Colleagues,4 2015
RCT
27.8 (20-40) 23.4 (12-39)
808-nanometer diode
Resin-modified glass ionomer cement
Clinical assessment and radiography
1y
Cengiz and Yilmaz,23 2016¶
RCT
28 (18-41)
Ca(OH)2
Clinical assessment and radiography
6 mo
33.9 (9-68)
5
5
15
15
15
15
Er,Cr:YSGG
Light-cured, resin-modified, tricalcium silicate–filled liner (TheraCal LC, Bisco)
* RCT: Randomized controlled trial. † Ca(OH)2: Calcium hydroxide. ‡ Clinical assessment: Clinical examination of patients’ subjective symptoms, percussion test, palpation test, and thermal tests. § Data in the top row indicate the study subgroup aged 11 to 18 years, and data in the bottom group indicate the study subgroup aged 19 to 40 years. ¶ Mean age data for these studies were given as an overall average of both the laser and the control groups. # Participants who received treatment using erbium,chromium:yttrium-selenium-gallium-garnet laser. ** Participants who received treatment using erbium:yttrium-aluminum-garnet laser. †† Er,Cr:YSGG: Erbium,chromium:yttrium-selenium-gallium-garnet. ‡‡ Er:YAG: Erbium:yttrium-aluminum-garnet.
materials to form a dental bridge and prevent bacterial penetration.24 For hemostasis of the exposed pulp tissue, gentle pressure with cotton pellets moistened with 3% to 6% sodium hypochlorite is most commonly used,25,26 but renewed bleeding sometimes occurs at the pulp-dentin exposure margin after the application of the capping material or bonding agent of the adhesive system. This renewed bleeding may be responsible for the initial inflammation and failure. However, if the exposed pulp was irradiated by lasers, blood flow would be stopped easily, as lasers could seal small blood vessels,27 and scar tissue would be formed in the irradiated area due to the blood coagulation of the soft tissue, and therefore neither secondary bleeding nor tissue fluid exudation would occur.20 Studies have showed that the outcomes of DPC treatment for teeth with deep caries are generally poor, and the success rate was lower than that for teeth with mechanically exposed pulp tissue.28,29 Many clinicians were reluctant to choose the DPC as a treatment option for carious-exposed pulps due to the variable success rates (33% to 100%).28,30 After a carious exposure, the surrounding pulp is contaminated by different bacteria, which are associated with inflammation and pathologic
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features that may affect the healing process. Indeed, the presence of a sterile field is a crucial phase of the DPC treatment.31,32 Lasers can sterilize the exposed site and its surrounding area simultaneously,24 and many studies33-35 have confirmed the laser’s superior decontamination effect over conditional antibacterial agents. In addition, lasers can treat the exposed pulp tissue surface without direct contact, keeping the surface uncontaminated. All studies included in this article used teeth with deep caries, and the success rate was approximately 89.9% in the laser aid group, and only 67.2% in the control group. The effective decontamination may be responsible for the high success rate of laser-assisted DPC for caries-exposed pulp tissue. DPC treatment is designed to treat reversible pulpitis from injury by stimulating the formation of the dentin bridge that is often considered to be the sign of successful pulp healing.36 In addition to their hemostatic and decontamination effects, lasers also have biostimulation effects. It has been shown that exposure to a laser, especially a low-intensity laser,37 can accelerate the growth of fibroblasts and osteoblasts and stimulate the proliferation, migration, and cytodifferentiation of odontoblastlike cells to promote the formation of
ORIGINAL CONTRIBUTIONS
All
Ma
Ra
nd
om
se
qu
en c (se e ge lec ner oc sk tio ati ati ing n b on on of ias c pa (se onc ) rti lec eal cip tio me an Ma n b nt t sk (pe s an ias ing rfo d p ) of ers r m ou tco ance onne me bia l s) (de ass Inc om tec ess tio me ple n b nt te ou ia (at tcom s) tri tio e da Se n b ta lec ias tiv (re e r ) po ep rti ort ng i bia ng s) Ot he rb ias
STUDIES
reparative dentin in the injured pulp tissue.38 It Moritz and Colleagues,20 1998 ? + + – ? – ? also has been shown that the presence of inflammation has a negative Moritz and Colleagues,21 1998 ? + + ? + ? – effect on the formation of dentin bridge,39 and Olivi and Colleagues,22 2007 ? + ? – ? ? + lasers can reduce pulp inflammation regardless of whether MTA or Yazdanfar and Colleagues,4 2015 + ? + + + – ? Ca(OH)2 was used as the pulp capping material.40 Cengiz and Yilmaz,23 2016 – + + + ? + ? Several laser systems, including CO2 (wavelength, 10600 nm), Er:YAG (2936 nm), Er,Cr:YSGG (2780 nm), diode (most widely used at 810 nm, 980 nm), and Nd:YAG (1064 nm) have been introduced as auxiliary tools for DPC treatment. Depending on their wavelengths, each laser system has its own characteristics, advantages, and disadvanDOMAIN tages, which have been comprehensively sumFigure 2. Summary of risk of bias for included studies. þ: Low risk of bias. –: High risk of bias. ?: Unclear marized by Komabayarisk of bias. 24 shi and colleagues. As Er:YAG and Er,Cr:YSGG laser energy can be absorbed efficiently both studies reported that the use of lasers did not signifiby the water molecules and hydroxyapatite, they have an cantly improve the outcome of DPC.40,43,44 The different results may be due to different laser wavelengths and excellent capacity for ablating both for soft and hard tissues with minimal thermal side effects,41 unlike CO2, parameters (power, time, frequency, and so on) used. A Nd:YAG, and diode laser systems, which are mostly direct comparison between different laser systems cannot used for soft-tissue surgery and not effective in ablation be made from the data examined in this review and a of hard tissue. Diode and Nd:YAG penetrate deep protocol for the clinical use of lasers for DPC treatment into biological tissue and have significant scattering cannot be formulated in this meta-analysis with the capacity, offering great decontamination and hemostasis limited evidence in the literature. effect.34,35,42 The biostimulation effect is a common Ca(OH)2 has outstanding antibacterial properties45 characteristic of lasers, in particular, the use of a diode and has been considered the criterion standard of pulp laser is especially advantageous in the healing processes capping materials for several decades. However, it still of the pulp tissue.5 Moreover, a diode laser costs less than has some obvious disadvantages, such as risk of experiother laser systems. However, we found disadvantages encing cytotoxic effects, a high solubility, and a poor reported for using lasers on an exposed pulp surface if ability to form a seal.46 MTA has become a popular inappropriate laser power, time, or technique were used. alternative to Ca(OH)2 as it has several positive propMost of the laser systems showed great promise for DPC erties, including biocompatibility, antibacterial activity, treatment according to previous in vitro and in vivo high sealing effects, and long-term stability.47,48 In our studies. The 5 studies included in this meta-analysis used study, 4 of the 5 included studies used Ca(OH)2 as the pulp capping material, and no clinical studies have 4 different laser systems (CO2, diode, Er,Cr:YSGG, Er:YAG), showing that the success rate of the laser group evaluated the effects of lasers when MTA was used as the was higher than that of the control group, and Santucci pulp capping material. There were some animal and colleagues17 reported a 90.3% success rate with the studies40,44 that showed that the used of lasers could not aid of Nd:YAG after 54 months, whereas some in vitro significantly improve the outcomes of DPC treatment
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ORIGINAL CONTRIBUTIONS
Experimental Study or Subgroup
Events
Control
Total Weight M-H, Fixed, 95% CI
Moritz and Colleagues,20 1998
93
100
68
100
38.3%
1.37 (1.18-1.58)
Moritz and Colleagues,21 1998
89
100
68
100
38.3%
1.31 (1.13-1.52)
Olivi and Colleagues,22 2007 (participants aged 11-18 years)
18
23
7
11
5.3%
1.23 (0.75-2.02)
Olivi and Colleagues,22 2007 (participants aged 19-40 years)
15
20
5
10
3.8%
1.50 (0.77-2.93)
Yazdanfar and Colleagues,4 2015 Cengiz and Yilmaz,
23
2016 (calcium
Risk Ratio
Risk Ratio
Total Events
5
5
3
5
2.0%
1.57 (0.77-3.22)
15
15
11
15
6.5%
1.35 (0.98-1.85)
15
15
10
15
5.9%
1.48 (1.02-2.13)
256
100.0%
1.35 (1.23-1.49)
M-H, Fixed, 95% CI
hydroxide group) Cengiz and Yilmaz,23 2016 (TheraCal LC group) Total (95% CI) Total events
278 250
172
2 2 Heterogeneity: χ6 = 0.83, P = .99; I = 0%
0.01
Test for overall effect: z = 6.28 (P < .00001)
0.1 Favors control
1
10
100
Favors experimental
Figure 3. Forest plot of the meta-analysis results. CI: Confidence interval. Events: The number of success. M-H: Mantel–Haenszel test.
when MTA was used as the pulp capping material. We speculate the possible reasons are as follows. Initially, we determined the use of MTA alone could help DPC treatment acquire high success rates (84.5%)49 for using MTA, as mentioned above, and the lasers’ advantages (for example, decontamination effect, biostimulation effect) do not seem to be that obvious when used with MTA. Next, MTA needs humid conditions for setting.50 Because of the lasers’ hemostasis and thermal coagulation effect, MTA cannot absorb moisture from the pulp tissue after it is irradiated by lasers. However, we do not know if the use of a laser could improve the outcomes of DPC treatment when MTA was used as the pulp capping material from the data examined in this review. Therefore, well-controlled clinical trials are needed to reach a conclusion. It has been reported that the prognosis of DPC is better in young patients because the pulps of younger patients are richer in cells and have a greater ability to regenerate.20 Some studies reported that patients younger than 40 years had significantly better outcomes than the older age cohort,51,52 whereas other studies could not confirm the significant correlation between the success rate and the patient’s age.28,53,54 Finally, the influence of age on the outcome of DPC could not be found in this meta-analysis due to the limited data. All of the 5 included studies used a rubber dam during the DPC procedures, which meant excellent conditions for infection control. The use of a rubber dam can prevent the deleterious effect of saliva on an exposed pulp and guarantee better bonding to the cavity walls.5 Microorganism control is the key factor in the outcome of the DPC treatment, and the use of a rubber dam is strongly recommended.51 de Lourdes Rodrigues Accorinte and colleagues’s55 study showed worse pulpal response when
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rubber dam isolation was not used during DPC treatment, especially if bonding agents were used for pulp capping. All included studies were randomized controlled trials, which were regarded as the most reliable and accurate methods for experimental design. Some limitations, however, should not be neglected in this meta-analysis. All studies included in this meta-analysis evaluated the outcome of DPC treatment by clinical criteria, and some of them combined radiography or laser Doppler flowmetry. However, there was no histologic study regarding the formation of the dentin bridge. Also, many of our included studies exhibited small sample sizes, such that their overall veracity is questionable, and their results should be interpreted with caution. CONCLUSION
Additional well-designed randomized controlled trials with larger sample sizes are needed to draw a more definitive conclusion. Based on the available information, the results of this meta-analysis demonstrated DPC treatment could achieve better clinical outcomes with the aid of lasers. n Ms. Deng is an intern, Department of Endodontics, School and Hospital of Stomatology, Wuhan University, and a masters degree student, The State Key Laboratory Breeding Base of Basic Science of Stomatology (HubeiMOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China. Ms. Zhu is an intern, Department of Endodontics, School and Hospital of Stomatology, Wuhan University, and a masters degree student, The State Key Laboratory Breeding Base of Basic Science of Stomatology (HubeiMOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China. Ms. Zheng is an intern, Department of Endodontics, School and Hospital of Stomatology, Wuhan University, and a masters degree student, The State Key Laboratory Breeding Base of Basic Science of Stomatology (HubeiMOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China.
ORIGINAL CONTRIBUTIONS
Dr. Yan is an associate chief physician, Department of Endodontics, School and Hospital of Stomatology, Wuhan University, and an associate professor, The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China. Address correspondence to Dr. Yan, School and Hospital of Stomatology, Wuhan University, Luoyu Road 237, Wuhan City 430079, China, e-mail [email protected]. Dr. Jiang is an associate chief physician, Department of Oral Prophylaxis, School and Hospital of Stomatology, Wuhan University, and an associate professor, The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine, Ministry of Education, Wuhan, China. Disclosure. None of the authors reported any disclosures. This study was supported by grant 304220100118 from the Key Science and Technology Program of Hubei Province of China and grant 304413000013 from The Building of Oral Health Electronic Information Management System for College Teachers and Students. 1. Ou KL, Chang CC, Chang WJ, Lin CT, Chang KJ, Huang HM. Effect of damping properties on fracture resistance of root filled premolar teeth: a dynamic finite element analysis. Int Endod J. 2009;42(8): 694-704. 2. Caplan DJ, Cai J, Yin G, White BA. Root canal filled versus non–root canal filled teeth: a retrospective comparison of survival times. J Public Health Dent. 2005;65(2):90-96. 3. Pashley DH. Dynamics of the pulpo-dentin complex. Crit Rev Oral Biol Med. 1996;7(2):104-133. 4. Yazdanfar I, Gutknecht N, Franzen R. Effects of diode laser on direct pulp capping treatment: a pilot study. Lasers Med Sci. 2015;30(4): 1237-1243. 5. Hilton TJ. Keys to clinical success with pulp capping: a review of the literature. Oper Dent. 2009;34(5):615-625. 6. Tziafas D, Kalyva M, Papadimitriou S. Experimental dentin-based approaches to tissue regeneration in vital pulp therapy. Connect Tissue Res. 2002;43(2-3):391-395. 7. Weichman JA, Johnson FM. Laser use in endodontics. A preliminary investigation. Oral Surg Oral Med Oral Pathol. 1971;31(3):416-420. 8. Mohammadi Z. Laser applications in endodontics: an update review. Int Dent J. 2009;59(1):35-46. 9. Aoki A, Sasaki KM, Watanabe H, Ishikawa I. Lasers in nonsurgical periodontal therapy. Periodontol 2000. 2004;36:59-97. 10. Sulewski JG. Historical survey of laser dentistry. Dent Clin North Am. 2000;44(4):717-752. 11. Parisay I, Ghoddusi J, Forghani M. A review on vital pulp therapy in primary teeth. Iran Endod J. 2015;10(1):6-15. 12. Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0 (updated March 2011). The Cochrane Collaboration; 2011. Available at: http://handbook.cochrane.org/. Accessed August 14, 2016. 13. Higgins JP, Green S. Assessment of study quality. In: Cochrane Handbook for Systematic Reviews of Interventions, Version 4.2.6, (Updated September 2006). The Cochrane Collaboration; 2006. Available at: http:// community-archive.cochrane.org/sites/default/files/uploads/Handbook4.2.6 Sep2006.pdf. Accessed August 14, 2016. 14. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-1012. 15. Dabrowska E, Zdanowicz-Wiloch J, Pawi nska-Magnuszewska M, Stokowska W. Intravital treatment of the pulp with simultaneous laser biostimulation. Rocz Akad Med Bialymst. 1997;42(1):168-176. 16. Wilder-Smith P. The soft laser: therapeutic tool or popular placebo? Oral Surg Oral Med Oral Pathol. 1988;66(6):654-658. 17. Santucci PJ. Dycal versus Nd:YAG laser and Vitrebond for direct pulp capping in permanent teeth. J Clin Laser Med Surg. 1999;17(2):69-75. 18. Huth KC, Hajek-Al-Khatar N, Wolf P, Ilie N, Hickel R, Paschos E. Long-term effectiveness of four pulpotomy techniques: 3-year randomised controlled trial. Clin Oral Investig. 2012;16(4):1243-1250. 19. Gao PJ, Cheng LS, Chi HY. Clinical study on unexpected pulp exposure in deep deutal carises treated with laser. Heilongjiang Med J. 2007; 31(10):747-748.
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43. Ferriello V, Faria MR, Cavalcanti BN. The effects of low-level diode laser treatment and dental pulp-capping materials on the proliferation of L-929 fibroblasts. J Oral Sci. 2010;52(1):33-38. 44. Hasheminia SM, Feizi G, Razavi SM, Feizianfard M. Histologic evaluation of three treatment methods for direct pulp capping of cat’s canine. Iran Endod J. 2007;2(2):54-60. 45. Barthel CR, Levin LG, Reisner HM, Trope M. TNF-alpha release in monocytes after exposure to calcium hydroxide treated Escherichia coli LPS. Int Endod J. 1997;30(3):155-159. 46. Snuggs HM, Cox CF, Powell CS, White KC. Pulpal healing and dentinal bridge formation in an acidic environment. Quintessence Int. 1993; 24(7):501-510. 47. Tziafas D, Pantelidou O, Alvanou A, Belibasakis G, Papadimitriou S. The dentinogenic effect of mineral trioxide aggregate (MTA) in short-term capping experiments. Int Endod J. 2002;35(3):245-254. 48. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review, part I—chemical, physical, and antibacterial properties. J Endod. 2010;36(1):16-27. 49. Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium hydroxide or mineral trioxide aggregate: a meta-analysis. J Endod. 2015;41(9):1412-1417.
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50. Gancedo-Caravia L, Garcia-Barbero E. Influence of humidity and setting time on the push-out strength of mineral trioxide aggregate obturations. J Endod. 2006;32(9):894-896. 51. Dammaschke T, Leidinger J, Schafer E. Long-term evaluation of direct pulp capping: treatment outcomes over an average period of 6.1 years. Clin Oral Investig. 2010;14(5):559-567. 52. Cho SY, Seo DG, Lee SJ, Lee J, Lee SJ, Jung IY. Prognostic factors for clinical outcomes according to time after direct pulp capping. J Endod. 2013;39(3):327-331. 53. Mente J, Geletneky B, Ohle M, et al. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. J Endod. 2010;36(5):806-813. 54. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The radiographic outcomes of direct pulp-capping procedures performed by dental students: a retrospective study. JADA. 2006;137(12):1699-1705. 55. de Lourdes Rodrigues Accorinte M, Reis A, Dourado Loguercio A, Cavalcanti de Araújo V, Muench A. Influence of rubber dam isolation on human pulp responses after capping with calcium hydroxide and an adhesive system. Quintessence Int. 2006;37(3): 205-212.