Comparison of Four Dental Pulp-Capping Agents by Cone-Beam Computed Tomography and Histological Techniques—A Split-Mouth Design Ex Vivo Study
, Manali Ramakrishnan Srinivasan 2, Nezar Boreak 3, Ahmed Al-Kahtani 4, Mohammed Mashyakhy 3, Hitesh Chohan 3, Shilpa Bhandi 3, A. Thirumal Raj 1, Alessio Zanza 5, Luca Testarelli 5 and Shankargouda Patil 6,*Round 1
Reviewer 1 Report
This research is under the scope of this journal; the topic is relevant for readers and this research deals with potentially significant knowledge to the field. The aim of this paper is quite interesting.
However, there are some major concerns about the present manuscript:
Abstract.
- How many patients were included in this study? And How many teeth were used?
- What were the statical analyses used? In the results, is important to show more information, with some values. How was quantified? And add some of the p-values.
Introduction
- What is the importance of this review for the clinical? You do not think this study is included in the others already done? Which results are comparable? What this study has new?
- The use of MTA:knowing that this type of calcium silicate cement (CSC) is associated with a colour change in the medium / long term in comparison with Biodentine and ERRM, please read these articles (https://doi.org/10.3390/app10175793). Is Desire to use the material in pulpotomy with minimal impact in discolouration tooth; and Without the contrast agent (oxide bismuth) https://doi.org/10.1371/journal.pone.0240634.
Materials
- A flowchart or diagram for synthesizing the characterization propose by the authors, this processing would be valuable to readers.
- Manufacturer’s instructions”! The manufacturer's instructions may be adjusted over time by the manufacturer himself. In your case, what instructions did you follow? (So, you should describe Supplementary material).
- How was the sample calculated?
- Did the authors perform a power analysis to evaluate if this sample size was appropriate?
- How many controls you have in this study? How many empty controls did you use?
- How was the material divided into groups? How were randomized materials?
- When mentioning materials or devices: for some of them you don't mention the manufacturer at all, for some you mention only the manufacturer, for some the manufacturer and city, for some you mention the manufacturer and city/ country. Example (Biodentine, Septodont, Saint-Maur-des-Fossés Cedex, France).
Results
- Improved image 2.
- In figure 3, improve the caption using arrows on the images to identify the histological structures, Add a scale on images. Improve also the quality resolution of these images.
Discussion
- Why did not you perform the immediate/delayed adhesive restoration after the placement of the calcium silicate cement? It would be good if you also discussed this point in your discussion. To support the technique of immediate restoration, read also this articles Clin Oral Invest (2020) https://doi.org/10.1007/s00784-020-03640-7 .
References are not standardized:
- The titles of references have a different format, the title of the article is written in capital letters at the beginning of words, others only in lower case.
Author Response
|
Comments |
Response |
|
Abstract.
|
15 patients and 60 teeth ( 4 premolars of a patient)
Details added in text |
|
Introduction
· The use of MTA:knowing that this type of calcium silicate cement (CSC) is associated with a colour change in the medium / long term in comparison with Biodentine and ERRM, please read these articles (https://doi.org/10.3390/app10175793). Is Desire to use the material in pulpotomy with minimal impact in discolouration tooth; and Without the contrast agent (oxide bismuth) https://doi.org/10.1371/journal.pone.0240634. |
This is a split mouth study done in four premolars filled with each of the four pulp capping materials in a randomized manner. There are no published studies like this. Other studies had done using up to 3 materials, or were animal studies. Results are that ERRM has similar pulp capping ability to MTA despite the technological advances post the introduction of MTA. Various studies comparing MTA with other materials have come up with different results. Hence there is an equipoise.
The aforementioned articles are pertinent in this discussion, and have been cited. Furthermore, these studies evaluated regenerative endodontic procedures. Discoloration happens usually when associated with sodium hypochlorite, hydrogen peroxide or formaldehyde.
Pulp capping usually employs a very minimal amount of material necessary for sealing the pulp exposure site. Exposure to hypochlorite or formaldehyde is not a feature. Therefore, the risk of discoloration, though possible, is less likely compared to pulpotomy and other endodontic procedures. |
|
• A flowchart or diagram for synthesizing the characterization propose by the authors, this processing would be valuable to readers.
• Manufacturer’s instructions”! The manufacturer's instructions may be adjusted over time by the manufacturer himself. In your case, what instructions did you follow? (So, you should describe Supplementary material).
• How was the sample calculated? • Did the authors perform a power analysis to evaluate if this sample size was appropriate?
• How many controls you have in this study? How many empty controls did you use?
• How was the material divided into groups? How were randomized materials?
• When mentioning materials or devices: for some of them you don't mention the manufacturer at all, for some you mention only the manufacturer, for some the manufacturer and city, for some you mention the manufacturer and city/ country. Example (Biodentine, Septodont, Saint-Maur-des-Fossés Cedex, France). |
Flowchart added
Supplementary material added
Details have been added to text. Yes. Sample size was calculated as 24 applying G*Power v.3.1 software assuming alpha error value 0.05 with 85% power, employing statistical data from Kim J et al (2016)
We did not employ controls. We had an opportunity to employ one tooth which was a supernumerary premolar in a participant, which was filled with glass ionomer cement without pulp capping material in order to compare with the other specimens (Fig 2D).
Participants were randomly assigned days of appointment based on pick of lots. Each had two appointments spaced within a week. At each appointment two premolars on one side were capped using pulp capping material which was also selected based on pick of lots.
All manufacturer details have been added |
|
Results • Improved image 2. • In figure 3, improve the caption using arrows on the images to identify the histological structures, Add a scale on images. Improve also the quality resolution of these images.
Discussion • Why did not you perform the immediate/delayed adhesive restoration after the placement of the calcium silicate cement? It would be good if you also discussed this point in your discussion. To support the technique of immediate restoration, read also this articles Clin Oral Invest (2020) https://doi.org/10.1007/s00784-020-03640-7.
References are not standardized: • The titles of references have a different format, the title of the article is written in capital letters at the beginning of words, others only in lower case. |
Images have been suitably modified
Resolutions have been improved
We performed immediate restorations in single sitting (Kindly refer Methods). This concept has been added to the discussion.
References are modified as suitable |
Author Response File: 
Author Response.docx
Reviewer 2 Report
It is great to see such work evaluating commercial dental products. This is meaningful. However, some revisions are needed for this manuscript. Here are my questions, concerns, and opinions:
- Materials and Methods – Please give subtitles to the text.
- Results – The first three paragraphs, i.e. Page#5-line 152-160 should belong to Materials and Methods.
- Results/3.1.1 CBCT (Page 5, line 162) – Is the “dentinal response of calcification” representing dental pulp calcification or the dentinal bridge formation? Please make this clear and point out the calcified area, i.e. the area compared and needs reader’s attention, by using some markers in Figure 1.
- Figure 2 – Please reformat the figure to let the legend be readable. Also, give axis title to y-axis.
- Figure 3 – Please indicate the characterization method used for collecting images included in Fig 3. This method also needs to be included in Materials and Methods part. Please label these images with scale bar.
- Figure 4&5 – Please give axis title to y-axis.
- Discussion/The 2nd paragraph (Page#9, line 250) – “The high scores obtained by MTA treated…”. As CT dentinal bridge, histologic dentinal bridge, and pulp were all scored, which of them the “high scores” represents for? All three? Please make this clear.
- Discussion/The 2nd paragraph (Page#9, line 250-251) – Please number the citations mentioned here (“Monea etal, Torabinejad, Koh et al and others”.)
- Discussion/The 2nd paragraph (Page#9, line 253-254) – It is weird to see citation numbers labeled at the end of the last sentence. This sentence, which starts with “This indicates that…”, looks like a conclusion produced from “The present study…” rather than some information from other publication. This is really confusing. Please clearly separate the information cited from other people’s work and this work.
- Conclusion/line 324 – “ERRM has good handling characteristics and a favorable setting time.” As the “handling characteristics” and “setting time” are not evaluated in this work, it is inappropriate to have this information in Conclusion.
- Conclusion/line 324 – “The clinical results obtained with ERRM…” Does the “clinical results” represent the data presented in this work?
Author Response
|
Comments |
Response |
|
Abstract.
|
15 patients and 60 teeth ( 4 premolars of a patient)
Details added in text |
|
Introduction
· The use of MTA:knowing that this type of calcium silicate cement (CSC) is associated with a colour change in the medium / long term in comparison with Biodentine and ERRM, please read these articles (https://doi.org/10.3390/app10175793). Is Desire to use the material in pulpotomy with minimal impact in discolouration tooth; and Without the contrast agent (oxide bismuth) https://doi.org/10.1371/journal.pone.0240634. |
This is a split mouth study done in four premolars filled with each of the four pulp capping materials in a randomized manner. There are no published studies like this. Other studies had done using up to 3 materials, or were animal studies. Results are that ERRM has similar pulp capping ability to MTA despite the technological advances post the introduction of MTA. Various studies comparing MTA with other materials have come up with different results. Hence there is an equipoise.
The aforementioned articles are pertinent in this discussion, and have been cited. Furthermore, these studies evaluated regenerative endodontic procedures. Discoloration happens usually when associated with sodium hypochlorite, hydrogen peroxide or formaldehyde.
Pulp capping usually employs a very minimal amount of material necessary for sealing the pulp exposure site. Exposure to hypochlorite or formaldehyde is not a feature. Therefore, the risk of discoloration, though possible, is less likely compared to pulpotomy and other endodontic procedures. |
|
• A flowchart or diagram for synthesizing the characterization propose by the authors, this processing would be valuable to readers.
• Manufacturer’s instructions”! The manufacturer's instructions may be adjusted over time by the manufacturer himself. In your case, what instructions did you follow? (So, you should describe Supplementary material).
• How was the sample calculated? • Did the authors perform a power analysis to evaluate if this sample size was appropriate?
• How many controls you have in this study? How many empty controls did you use?
• How was the material divided into groups? How were randomized materials?
• When mentioning materials or devices: for some of them you don't mention the manufacturer at all, for some you mention only the manufacturer, for some the manufacturer and city, for some you mention the manufacturer and city/ country. Example (Biodentine, Septodont, Saint-Maur-des-Fossés Cedex, France). |
Flowchart added
Supplementary material added
Details have been added to text. Yes. Sample size was calculated as 24 applying G*Power v.3.1 software assuming alpha error value 0.05 with 85% power, employing statistical data from Kim J et al (2016)
We did not employ controls. We had an opportunity to employ one tooth which was a supernumerary premolar in a participant, which was filled with glass ionomer cement without pulp capping material in order to compare with the other specimens (Fig 2D).
Participants were randomly assigned days of appointment based on pick of lots. Each had two appointments spaced within a week. At each appointment two premolars on one side were capped using pulp capping material which was also selected based on pick of lots.
All manufacturer details have been added |
|
Results • Improved image 2. • In figure 3, improve the caption using arrows on the images to identify the histological structures, Add a scale on images. Improve also the quality resolution of these images.
Discussion • Why did not you perform the immediate/delayed adhesive restoration after the placement of the calcium silicate cement? It would be good if you also discussed this point in your discussion. To support the technique of immediate restoration, read also this articles Clin Oral Invest (2020) https://doi.org/10.1007/s00784-020-03640-7.
References are not standardized: • The titles of references have a different format, the title of the article is written in capital letters at the beginning of words, others only in lower case. |
Images have been suitably modified
Resolutions have been improved
We performed immediate restorations in single sitting (Kindly refer Methods). This concept has been added to the discussion.
References are modified as suitable |
Author Response File: Author Response.docx
Reviewer 3 Report
This study investigated four dental pulp-capping agents by cone-beam computed tomography and histological techniques in a split-mouth design. This manuscript is well written, the introduction and discussion sections covering important information. The methodology is sound and the results are clearly presented and adquately supported by images and tables. The conclusions are supported by the results. Overall it is an important study as the dentist encounters deep caries in his daily practice and the best management is of great importance to the patient.
Page 1, line 37: kindly include n=15.
Page 4, line 136: kindly add the reference.
Line 138-9: 3-severe inflammation2: kindly remove “2”.
Page 5, lines 166-168: “Figure 3D depicts a tooth restored without any pulp capping 166 material to act as a negative control. Figures 3E and 3F depict partial bridging, and figures 3G and 3H depict complete bridges.” This description is related to figure 1, not figure 3, kindly correct it and add the information to the caption of figure 1 regarding the dentin bridge formation as well.
Page 7, figure 2 needs to be a little enlarged because the lower part of the legend is not visible/partially cut.
Page 9, table 2: The column N is not needed, as it can be stated in the table heading (n=15). Kindly insert the columns with the scores.
Page 10, line 282: Kindly start a new paragraph after the references (3, 10-17) for easier reading.
Author Response
|
Comments |
Response |
|
Abstract.
|
15 patients and 60 teeth ( 4 premolars of a patient)
Details added in text |
|
Introduction
· The use of MTA:knowing that this type of calcium silicate cement (CSC) is associated with a colour change in the medium / long term in comparison with Biodentine and ERRM, please read these articles (https://doi.org/10.3390/app10175793). Is Desire to use the material in pulpotomy with minimal impact in discolouration tooth; and Without the contrast agent (oxide bismuth) https://doi.org/10.1371/journal.pone.0240634. |
This is a split mouth study done in four premolars filled with each of the four pulp capping materials in a randomized manner. There are no published studies like this. Other studies had done using up to 3 materials, or were animal studies. Results are that ERRM has similar pulp capping ability to MTA despite the technological advances post the introduction of MTA. Various studies comparing MTA with other materials have come up with different results. Hence there is an equipoise.
The aforementioned articles are pertinent in this discussion, and have been cited. Furthermore, these studies evaluated regenerative endodontic procedures. Discoloration happens usually when associated with sodium hypochlorite, hydrogen peroxide or formaldehyde.
Pulp capping usually employs a very minimal amount of material necessary for sealing the pulp exposure site. Exposure to hypochlorite or formaldehyde is not a feature. Therefore, the risk of discoloration, though possible, is less likely compared to pulpotomy and other endodontic procedures. |
|
• A flowchart or diagram for synthesizing the characterization propose by the authors, this processing would be valuable to readers.
• Manufacturer’s instructions”! The manufacturer's instructions may be adjusted over time by the manufacturer himself. In your case, what instructions did you follow? (So, you should describe Supplementary material).
• How was the sample calculated? • Did the authors perform a power analysis to evaluate if this sample size was appropriate?
• How many controls you have in this study? How many empty controls did you use?
• How was the material divided into groups? How were randomized materials?
• When mentioning materials or devices: for some of them you don't mention the manufacturer at all, for some you mention only the manufacturer, for some the manufacturer and city, for some you mention the manufacturer and city/ country. Example (Biodentine, Septodont, Saint-Maur-des-Fossés Cedex, France). |
Flowchart added
Supplementary material added
Details have been added to text. Yes. Sample size was calculated as 24 applying G*Power v.3.1 software assuming alpha error value 0.05 with 85% power, employing statistical data from Kim J et al (2016)
We did not employ controls. We had an opportunity to employ one tooth which was a supernumerary premolar in a participant, which was filled with glass ionomer cement without pulp capping material in order to compare with the other specimens (Fig 2D).
Participants were randomly assigned days of appointment based on pick of lots. Each had two appointments spaced within a week. At each appointment two premolars on one side were capped using pulp capping material which was also selected based on pick of lots.
All manufacturer details have been added |
|
Results • Improved image 2. • In figure 3, improve the caption using arrows on the images to identify the histological structures, Add a scale on images. Improve also the quality resolution of these images.
Discussion • Why did not you perform the immediate/delayed adhesive restoration after the placement of the calcium silicate cement? It would be good if you also discussed this point in your discussion. To support the technique of immediate restoration, read also this articles Clin Oral Invest (2020) https://doi.org/10.1007/s00784-020-03640-7.
References are not standardized: • The titles of references have a different format, the title of the article is written in capital letters at the beginning of words, others only in lower case. |
Images have been suitably modified
Resolutions have been improved
We performed immediate restorations in single sitting (Kindly refer Methods). This concept has been added to the discussion.
References are modified as suitable |
Author Response File: Author Response.docx
Round 2
Reviewer 1 Report
This research is under the scope of this journal; the topic is interesting for readers and this research deals with potentially significant knowledge to the field and an open new way for future studies.
The authors improved the quality of the manuscript after the reviewer's indications.
Author Response
Reviewer 1:
This research is under the scope of this journal; the topic is interesting for readers and this research deals with potentially significant knowledge to the field and an open new way for future studies.
The authors improved the quality of the manuscript after the reviewer's indications.
Response: Thank you
Reviewer 2 Report
Figure 2 D-E. I thought it will be clear to see the bridge formation differences among these images by pointing the bridges out but looks like not really. Currently, even by adding these arrows, the differences are still hard to see. If it is applicable, please add some zoom-in images of the completely/partially formed bridge.
Author Response
Reviewer 2:
Figure 2 D-E. I thought it will be clear to see the bridge formation differences among these images by pointing the bridges out but looks like not really. Currently, even by adding these arrows, the differences are still hard to see. If it is applicable, please add some zoom-in images of the completely/partially formed bridge.
Response: Zoom images are not available, thus we have added images of better quality. I hope it gives a better view
