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Bioactivity and biocompatibility

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Bioactivity

Bioactivity generally means that the employed material has a positive influence on vital proliferating cells and is able to interact with these cells.
In the case of Biodentine, the bioactivity of the material leads to stimulation of secondary dentin production as well as induction of tertiary dentin formation ("bridging").
The process of hard tissue remineralization is thereby initiated and promoted.
Han and Okijii (2011) compared Biodentine und ProRootMta with regard to the calcium and silicate absorption of the adjacent root canal dentin and they found that both materials are able to form tag-like structures but that inclusion of the elements in the root dentin was markedly higher with Biodentine.
Preservation of pulp vitality is the priority and this depends essentially on the material not causing any postoperative irritation of the involved tissue. The regeneration of the affected pulp should be ensured by Biodentine without any restriction.
The beneficial properties of Biodentine and of all other Ca(OH)2 products is based on the reaction-induced release of calcium hydroxide ions, which results in a very rapid increase of the pH to an alkaline level. The alkaline milieu acts as a stimulus on the pulp cells and thereby initiates reactive dentin production.
At the same time, the high pH inhibits the proliferation of microorganisms and therefore has both a bacteriostatic and antibacterial effect.
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Biocompatibility

Biocompatibility in general describes the biological tolerability of a material.
Calcium hydroxide-based products are generally well tolerated biologically (Gomond 2003).
Clinical studies have shown that while there was evidence of cytotoxic (About 2010, Franquin 2001, Laurent et al. 2008), genotoxic or mutagenic (Harmand 2003, Laurent et al. 2008) effects with the use of Biodentine, these were small and can be classified as not clinically relevant.
Likewise, there were no signs that Biodentine has a harmful influence on cell differentiation or specific cell functions.
Poggio et al. (2014) found that MTA-based products have lower cytotoxicity with less pronounced antibacterial properties than Ca(OH)² products. These exhibit greater cytotoxic effects but also have a greater antimicrobial effect (Poggio et al. 2014).
Laurent et al (2008) were the first to demonstrate the highly promising biological properties of Biodentine on human fibroblast cultures. In a later study from 2012 they showed that Biodentine increases the TGF-ß1 secretion of the pulp cells. TGF is a growth factor, the importance of which in angiogenesis, recruitment of progenitor cells, cell differentiation and mineralization processes has been emphasized repeatedly in numerous, recently published studies (Laurent et al. 2012).
In the study by Zhou et al. (2013), in which Biodentine, ProRootMTA and FujiIX were compared with regard to their effect on fibroblasts, it was shown that the behavior of Biodentine and MTA was much less toxic during the 7-day observation period than glass ionomer cement. The authors attribute the lower toxic potential to the fact that cell adhesion and cell growth are better despite the rough and crystalline surface texture of the first two materials. They assume that, in the case of glass ionomer cement, the washout effect of smaller particles has a detrimental effect on interaction with the tissue.
Pérard et al. (2013) compared the biocompatibility of Biodentine and MTA and their ability to influence gene expression. Their results showed that both materials are capable of modifying the proliferation of pulp cells and exhibit certain similarities.
A recently published article looks at the influence and action of Biodentine from a new perspective. The study by Luo et al. (2014) focuses on the proliferative and adhesive effect of different concentrations of the material on human dental pulp stem cells (hDPSCs). The results show a rise in the stem cell proliferation rate at a concentration of 0.2 and at 2 mg/ml, while cellular activity decreased significantly at higher concentrations of 20 mg/ml. The authors state that Biodentine can promote the pulpal healing process decisively by promoting the proliferation, migration and adhesion of pulp stem cells, provided the material is inserted in direct contact with the pulp tissue. The study results therefore corroborate the biocompatible and bioactive properties of Biodentine.

Advantages and disadvantages

Advantages

  1. Preservation of pulp vitality
    • Biodentine is characterized by high biocompatibility; postoperative irritation is absent and negative reactions of the pulp and surrounding tissue are absent.
    • Bioactivity: remineralization of the damaged dentin is promoted and the chances of pulp healing and survival are markedly supported.
    • Stimulation of reactive dentin production; bridging effect
    • Promotes the prospect of healing of an opened or compromised pulp, e.g., after iatrogenic exposure, reversible pulpitis or trauma.
  2. avoidance of clinical complications
    • sustained and reliable dimensional stability
    • by forming mineralized tags in the dentin tubules and with the material's high resistance to microleakages the risk of invading bacteria is low
    • little or no shrinkage so no postoperative disorders of sensation
    • prior treatment in the form of classic conditioning of the dentin is not necessary; Biodentine adheres by forming micromechanical fixation in the dentin tubules
  3. Dentin substitute
    • easy and user-friendly application of the material facilitates clinical use compared with MTA (Gutmann and Lovedahl 2011)
  4. Septodont Tutorials
    The manufacturer now presents the possible uses of Biodentine in the form of an app with an additional entertainment program.

Disadvantages

  1. Lack of radiopacity;
    Secure radiological distinction between natural dentin and the dentin substitute is extremely difficult.
  2. High costs
    A pack of Biodentine™ with 15 single doses costs c. 150 € from dental suppliers, excluding VAT; Biodentine is therefore much more expensive compared with other Ca(OH)² products and with regard to the product's indications.
  3. Billing
    Problem with statutory health insurance patients: according to the Dental Services Benchmarking Scale (BEMA), no agreement is possible in which the additional costs for the material used to provide a health insurance service can be billed.
    GOZ (dentists' fee schedule) guidelines for billing "innovative" materials (e.g., Biodentine™): the GOZ committee of the Baden Württemberg Dental Association issued the following decision on 27.02. 2013: "The use of an innovative material (e.g., Biodentine™) to provide dental services described in the GOZ (e.g., indirect or direct capping) does not justify billing under § 6 section 1 GOZ. The billing depends on the provided service content."
  4. Long-term studies are still lacking

Areas of use

The use of Biodentine covers a wide range of treatments. It was developed as a dentin substitute for use in endodontics. Indications (Septodont, Dammaschke 2011, Firla 2012):

Tooth crown

  • as lining material
  • deep dentin defects as CP treatment
  • pulpotomy
  • direct and indirect capping
  • cervical restorations

Tooth root

  • perforation cover
  • internal and external root resorption
  • apexification of juvenile teeth
  • orthograde and retrograde root filling material
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sources

  • About I (2010) Bioactivity of Biodentine: a Ca3SiO5-based dentine substitute. Oral session, IADR Congress, Barcelona
  • Dammaschke T (2011) Dentinersatz. Dent Mag 28(2):30-34
  • Dammaschke T (2011) Biodentine – eine Übersicht. ZMK 2011 27(9):546-550
  • Firla M (2012) Multi-Purpose-Dentinersatzmaterial auf Basis der aktiven Biosilikat-Technologie. Endodontie Journal 1/2012
  • Gomond P (2003) Evaluation de la toxicité aigue après administration par voie orale chez le rat. Méthode par classe de toxicité aigue. Report RG EN RA EXT-RD 94/056#
  • Gutmann JL, Lovedahl PE (2011) Problem-solving challenges in periapical surgery. In: Gutmann JL, Lovedahl PE (eds.) Problem solving in endodontics. 5th ed., Elsevier Mosby, Maryland Heights, S. 351 ff
  • Han L, Okijii T (2011) Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine. Int Endodont J 44(12):1081-1087
  • Harmand MF (2003) Assessment of the genotoxicity AMES test (Salmonella thyphimurium and E. coli). Report RG EN RA EXT-RD94/055
  • Hersteller Septodont, Paris, Frankreich. URL: Biodentine Active Biosilicate Technology Scientific File (updated 06.10.2014)
  • Laurent P, Camps J, De Méo M, Déjou J, About I (2008) Induction of specific cell responses to a Ca3SiO5-based posterior restorative material. Dent Mater 24(11):1486-1494
  • Laurent P, Camps J, About I (2012) Biodentine™ induces TGF-ß1 release from human pulp cells and early dental pulp mineralization. Int Endodont J 45(5):439-448
  • Luo Z, Li D, Kohli MR, Yu Q, Kim S, He WX (2014) Effect of Biodentine on the proliferation, migration and adhesion of human dental pulp stem cells. J Dent 42(4):490-497
  • Pérard M, Le Clerc J, Meary F, Pérez F, Tricot-Doleux S, Pellen-Mussi P (2013) Spheroid model study comparing the biocompatibility of Biodentine and MTA. Journal of Materials Science: Materials in Medicine 24(6):1527-1534
  • Poggio C, Ceci M, Beltrami R, Dagna A, Colombo M, Chiesa M (2014) Biocompatibility of a new pulp capping cement. Ann Stomatol (Roma) 5(2):69-76 PMID:25002921
  • Zhou HM, Shen Y, Wang ZJ (2013) In vitro cytotoxicity evaluation of a novel root repair material. J Endodont 39(4):478-483