A comparative clinical and radiological evaluation of biodentine, platelet-rich fibrin, and acemannan as direct pulp capping agent in permanent teeth with various pulp exposure – an in-vivo study.

The current treatment strategies in endodontics are undergoing a paradigm shift towards minimal invasive biological procedures in relation to the management of deep caries and vital pulp exposure. The concept of vital pulp therapy first coined by Dr. Louis I. Grossman, serves as a cornerstone for modern endodontics with advances in biomaterial and regenerative techniques.Various materials like calcium hydroxide, Zinc Oxide Eugenol (ZOE) Cement, Theracal, Mineral Trioxide Aggregate, Biodentine, Glass Ionomer/Resin Modified Glass Ionomer have been tested for direct pulp capping of cariously exposed vital teeth.

Biodentine is an innovative cement made of tricalcium silicate with inherent bioactive characteristics. The antibacterial properties of Biodentine are attributed to its high pH, which is achieved by the action of hydroxyl ions on the surrounding tissue. A thin layer of coagulative necrosis forms between the vital pulp tissue and Biodentine because of the increase in pH. There has been considerable research performed on this material as a direct pulp capping agent since its launch in 2009.

A biological approach towards pulp capping is Platelet concentrates which promote differentiation of new odontoblasts by preserving remaining odontoblasts. Platelet-rich fibrin derived from blood is a second-generation platelet concentrate introduced by Choukroun in 2001. It contains a multitude of growth factors which is conducive to healing such as transforming growth factor β1, platelet-derived growth factor, and insulin-like growth factor. It exhibits varied properties such as cell migration, cell proliferation, cell attachment, and cell differentiation. Clinical studies have shown that Platelet Rich Fibrin promotes soft tissue and bone regeneration.

In dentistry, a wide range of herbal extracts like Baicalin, Propolis, Nigella stevia, Genipin, Acemannan, and Galla Chinensis Extract have been employed to deal with the flaws of conventional treatment for vital pulp therapy. Among all the herbal extracts, Acemannan is a natural polysaccharide with good biodegradability and biocompatibility. It is an extract from aloe vera and has a range of therapeutic uses in pulp capping mainly because it stimulates dentin regeneration via increased pulp cell proliferation, differentiation, growth factor expression, extracellular matrix synthesis, and mineral deposition. Pre-clinical and clinical evidence both favor the application of this herbal extract to help in the regeneration of dentin.

Biodentine has shown to have efficient physical and biological properties as a pulp-capping material with a success rate of 83.4% to 90.9%.However, due to its limited insufficient radiopacity and discoloration potential,alternative materials such as human blood extract and herbal extract have been developed and increasingly used for direct pulp capping procedures. Platelet concentrations have shown a higher volume of dentine bridge formation in vital pulp therapy for adult permanent teeth with reversible pulpitis with a radiographic success rate of 90%. A similar positive response was observed with  Acemannan in direct pulp capping procedures of young permanent teeth, with success rates of 72.73% to 77.8%. There is significant variation in the literature regarding the ideal follow-up time for direct pulp capping. The outcome measure, related to pain as shown in the literature is 1 week to 3 months.and for dentine bridge formation, it is 3 to 6 months. The present study evaluates the efficacy of Biodentine, Platelet Rich Fibrin, and Acemannan as direct pulp-capping agents in permanent teeth with carious pulp exposure over a period of 6 months.