Mineral Trioxide Aggregate (MTA) Direct Pulp Capping: 10 Years Clinical Results

+ Modello
GIE-123; No. of Pages 10
Giornale Italiano di Endodonzia (2017) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / g i e
ORIGINAL ARTICLE/ARTICOLO ORIGINALE
Mineral Trioxide Aggregate (MTA) direct pulp

capping: 10 years clinical results
Incappucciamento diretto della polpa con Mineral Trioxide Aggregate:
risultati clinici a 10 anni
Lucio Daniele
Private Practitioner in L’Aquila, Via Madonna di Pettino, 22, Italy
Received 14 March 2017; accepted 27 March 2017

Available online xxxxxx
KEYWORDS Abstract The maintenance of pulp vitality is a major goal of endodontics. Direct pulp capping
Direct pulp capping; for tooth decay has always been considered a controversial procedure generating unpredictable
Mineral Trioxide and often contraindicated outcomes.
Aggregate; The Mineral Trioxide Aggregate (MTA), introduced by Torabinejad about 20 years ago,1—7
Reversible pulpitis; retains resistance to bacterial infiltration and can effectively protect the pulp, hastening its
Hemostasis with sodium repair and maintaining tooth vitality if used correctly and in combination with an adequate
hypochlorite; coronal restoration.
Pulpal exposure. In a group of 77 patients aged 14—68 years, direct pulp capping with MTA was performed in 80
teeth affected by tooth decay, diagnosed with reversible pulpitis by the cold-temperature test and
radiographic examination. Four patients had pain, in three teeth the radiograph showed a small
area of bone loss due to a widening of the periodontal space. The author has removed the caries by
using only rotating instruments and has then placed a thin layer of MTA on the exposed pulp and the
surrounding dentin. In some cases 5% sodium hypochlorite solution was used to achieve hemostasis
of the operating field. In a second visit, after X-ray examination, pulp vitality-check with the cold
thermal test and the assessment of effective hardening of the material, the teeth were
reconstructed by using two-component adhesives and last-generation composite resins.
Patients were recalled at regular intervals for 10 years to assess the condition of the pulp, the
presence of a reparative dentine layer, pulpal or root canal calcifications or root resorptions, pain
on percussion and radiographically visible endodontic lesions.
E-mail: drlucio@tiscali.it.
Peer review under responsibility of Società Italiana di Endodonzia.
http://dx.doi.org/10.1016/j.gien.2017.04.003
1121-4171/ß 2017 Società Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Daniele L. Mineral Trioxide Aggregate (MTA) direct pulp capping: 10 years clinical results. Giornale Italiano
di Endodonzia (2017), http://dx.doi.org/10.1016/j.gien.2017.04.003
+ Modello
2 L. Daniele
After 10-years follow-up period, 6 out of 80 teeth required an endodontic treatment, we did not
find an increase of pulp calcifications, root resorptions, endodontic lesions. All teeth still alive
have responded positively to the cold-temperature test. The three lesions had disappeared at the
last X-ray control. All four symptomatic teeth preserved their pulp vitality. The successful
treatment rate was 92.5%. Direct pulp capping with MTA can be considered an effective treatment
of exposure due to tooth decay and can be considered a valid treatment option for teeth with a
diagnosis of not-severe reversible pulpitis.
ß 2017 Società Italiana di Endodonzia. Production and hosting by Elsevier B.V. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).
PAROLE CHIAVE Riassunto Il mantenimento della vitalità pulpare è uno degli obiettivi principali
Incappucciamento dell’Endodonzia. L’incappucciamento diretto della polpa dovuto a carie è sempre stata consi-
diretto della polpa; derata una procedura controversa con esiti imprevedibili e spesso controindicata.
Mineral Trioxide Il Mineral Trioxide Aggregate (MTA), introdotto circa 20 anni fa da Torabinejad1—7 resiste
aggregate; all’infiltrazione batterica e può fornire una efficace protezione per la polpa, permettendone la
Pulpite reversibile; sua riparazione e mantenendo la vitalità del dente se utilizzato in maniera corretta ed in
Emostasi con Ipoclorito combinazione con un adeguato restauro coronale.
di Sodio; In 77 pazienti, di età compresa tra i 14 ed i 68 anni, è stato effettuato un incappucciamento
Esposizione della polpa. diretto della polpa con MTA su 80 denti affetti da carie quando è stata diagnosticata una pulpite
reversibile, dopo il test termico del freddo e l’esame radiografico. In 4 pazienti era presente
sintomatologia dolorosa, in 3 denti era visibile radiograficamente una piccola area di rarefazione
ossea riconducibile ad un allargamento dello spazio parodontale. L’autore ha rimosso la carie
utilizzando esclusivamente strumenti rotanti e ponendo un sottile strato di MTA sulla esposizione
pulpare e la dentina circostante. In alcuni casi è stato utilizzato una soluzione di Ipoclorito di
Sodio al 5% per ottenere l’emostasi del campo operatorio. I denti sono stati ricostruiti con sistemi
adesivi bicomponenti e resine composite di recente generazione in seconda seduta dopo aver
effettuato l’esame radiografico e controllato la vitalità pulpare con test termico del freddo e
l’effettivo indurimento del materiale. I pazienti sono stati richiamati ad intervalli regolari per 10
anni per valutare lo stato della polpa, la eventuale formazione di uno strato di dentina riparativa,
la presenza o meno di calcificazioni pulpari e canalari o riassorbimenti radicolari, la presenza o
meno di dolore alla percussione, la presenza o meno di una lesione endodontica visibile radio-
graficamente.
Dopo il periodo di osservazione di 10 anni hanno subito il trattamento endodontico 6 denti su
80, non si è riscontrato un aumento delle calcificazioni pulpari, la presenza di riassorbimenti
radicolari, lesioni endodontiche visibili radiograficamente. Tutti i denti rimasti vitali hanno
risposto positivamente al test termico del freddo. Le tre lesioni presenti sono scomparse
nell’ultimo controllo radiografico. Tutti e 4 i denti sintomatici hanno mantenuto la loro vitalità
pulpare.
Si è ottenuto un successo del 92,5%.
L’incappucciamento diretto della polpa mediante MTA può essere considerato un trattamento
efficace in caso di esposizioni dovuti a carie ed è da considerarsi una valida opzione di
trattamento per i denti con diagnosi non grave di pulpite reversibile.
ß 2017 Società Italiana di Endodonzia. Production and hosting by Elsevier B.V. Cet article est
publié en Open Access sous licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-
nd/4.0/)
Introduction and recruitment, normal pulpal repair mechanisms may

not function properly.
The maintenance of pulp vitality is a major goal of endo- Consequently, the normal pulp repair mechanisms may not
dontics. Historically, the placement of a dressing material work properly. Until a few years ago, researchers were
directly upon the pulp affected by caries has always been unable to select a reliable bio-active pulp-capping material,
considered a controversial procedure, so that in such cases which steadly stimulates cellular repair mechanisms, seals
a conventional endodontic therapy has often been recom- dentin and promotes the formation of a reparative dentin
mended.8—12 The reluctance to apply a material in direct layer biologically stable.
contact with an exposed pulp in a carious field is Clinicians have used many different materials and tech-
based on unpredictable results following the use of tradi- niques for direct pulp capping, including calcium hydroxide,
tional protocols and materials. Moreover, when bacterial hydrophilic resins, glass-ionomer cements, resin-modified,
byproducts induce pulpal inflammation, compromise phosphates tricalcici and, more recently, the Mineral Trioxide
immune responses and impede cellular differentiation Aggregate (MTA). Additional innovative technical progress
+ Modello
MTA direct pulp capping 3
used to lock caries and allow repairing potentially damaged phase, rich of calcium and phosphates.3 The crystalline
tissue employ lasers, ozone and bioactive agents which phase, which consists primarily of calcium oxide, becomes
induce and stimulate pulp defences.13—18 Direct pulp capping calcium hydroxide when interacting with the exudate, then
has a variable success rate depending on technique and stimulating the formation of hard tissue repair.35,36
materials employed. Such success rates ranges from 30% to In a nutshell, Mineral Trioxide Aggregate is a bioactive
85% in retrospective studies (10 years backwards) executed silicate cement that has proven to be an effective material
on humans.11,19—23 In a study by Raedael et al.24 the results of for direct pulp capping teeth of dogs and non-human pri-
a database of an insurance company have been reported to mates, as studies conducted by Ford (1996), Juno (2000) and
evaluate the effectiveness of direct pulp capping in general Camilleri (2006)37—39 have demonstrated. Its small particles
practice: in a total of 148,312 teeth success rate at 3 years size, sealing ability and marginal adaptation, the alkaline pH
was 71.6%. A similar result is in the study by Aguilar and once hardened and the slow release of calcium ions40 are all
Linsuwanont25: a systematic review with success rate at 3 behind its success.
years of 72.9%. The researchers have reported that MTA induces prolif-
The recent progress made on understanding the physiol- eration of pulp cells,41,42 it stimulates osteoblasts to release
ogy of the pulp, on the development of caries, on inflam- interleukins4 with formation of hard tissue,43 and an inter-
matory mediators and pulp defense mechanisms have face with the dentin that is very similar in composition to the
changed the clinical approach adopted to remove caries hydroxyapatite.40 The new dentin bridge that is formed has a
and capping protocols.26 thickness and a hardness far higher than that which is
The direct exposure of the pulp can constitute a constraint obtained by dressings with calcium hydroxide44; also this is
occurring when cleansing and cleaning a carious cavity. done in a shorter time compared to the time taken from
Before starting a successful treatment it is necessary to calcium hydroxide.
diagnose reversible pulpitis, nonetheless undertaking an The material cannot be absorbed, it hardens in presence
effective diagnosis on the state of the pulp is a recurrent of moisture, it has a low resistance to compression and it has
issue.19 an alkaline pH.3 Immediately after mixing pH rises at 10.2,
In 1996, Matsuo and colleagues23 assessed the factors that increases to 12.5 after three hours, stabilizes upon this value
influence the success of capping pulp. They positioned during the initial days,3 then slightly decreases with time.4 At
calcium hydroxide dressings in contact with the pulp of a temperature of 37 8C and 95—100% of relative humidity MTA
teeth affected by caries by using sodium hypochlorite requires 2 h and 45 min to get hard; its resistance to com-
(NaOCl) to 10% for hemostasis and calcium hydroxide which pression after 24 h is 40 MPa, however it increases up to
detects caries. According to their studies, the size and 67.3 MPa 21 days after it is mixed.3 Some studies examining
location of exposure, the kind of tooth, the patient’s age, in humans partial pulpotomie and direct pulp capping with
the reply to percussion or thermal stimulation does not MTA, reported very favorable short-term results.45—49 Many
affect the success rate. Furthermore if adequate hemostasis studies confirm best MTA performances once compared with
is implemented, for instance by using hypochlorite at 10% of calcium hydroxide45,50—56 and MTA is still a better choice for
concentration, the success rate is increased. Calcium direct pulp capping.57
hydroxide, considered in the past the standard capping According to the randomized study of Hilton et al.51 con-
material,27,28 is an option to generate reparative dentin, ducted with 376 teeth treated with direct pulp capping on
however long-term studies have obtained variable and calcium hydroxide or MTA, the failure rate at 24 months was
unpredictable results.19—22 The material does not profi- 31.5% for the CaOH despite 19.7% for the MTA.
ciently fit to the surrounding dentin, it is not conducive to The observational study by Bogen et al.58 reports a success
odontoblastica differentiation and has been shown to be rate at nine years of the 97, 96% of 49 teeth of 40 patients
cytotoxic in cell cultures. Researchers who have used hydro- between 7 and 45 years on which had been made direct pulp
philic resins modified with glass ionomer cements as materi- capping with MTA.
als for direct hooding have obtained exciting results when Even more recently became available for sale a number of
testing the resin upon primates,29,30 however they could not calcium silicate substitutes based cements of the coronal and
obtain predictable results when applied to humans.31—34 radicular dentin cataloged in a new class of Portland cement
The Mineral Trioxide Aggregate is a kind of concrete with high mechanical properties, excellent workability,
consisting of an aggregate of mineral trioxides according radiopacity and a much more rapid setting compared to
to its name. The team lead by Prof. Torabinejad has devel- previous cements based on Portland.59,60 The Gandolfi MG,
oped it at the University of Loma Linda in California (USA) Prati et al. studies61—65 confirm that calcium silicate-based
from year 1992 to 19933 to meet the demand to identify an cements are biointeractive (ion-releasing) bioactive (apa-
ideal concrete for the endodontic surgery, especially when it tite-forming) functional biomaterials. The high rate of cal-
is impossible to have a dry surgical field and when the cement cium release and fast formation of apatite may well explain
has a direct contact with the periradicular tissues and/or the the role of calcium silicate biomaterials as scaffold to induce
pulp. new dentin bridge formation and clinic healing.
From a physical—chemical point of view MTA is a powder Sin-Yeon Cho et al.66 in 2013 they have evaluated the
consisting of fine hydrophilic particles, which harden in clinical results based on the type of pulp exposure; if the
presence of moisture. On the chemical point of view MTA pulpal exposure is of a mechanical type, such as in the case of
is divided into calcium oxide and calcium phosphate as main a fracture, is absent bacterial contamination and the long
components. The further physical and structural analysis term capping success is almost near to 100%.44 In the case of
identifies the cohabitation of two different phases: a crystal- pulpal exposure due to caries, there is a more or less impor-
line phase rich of calcium, silicon and oxygen; an amorphous tant bacterial contamination, then it is assumed there is
+ Modello
4 L. Daniele
inflammation and subsequently it has less success chances. If magnifying tool. For the excavation and the cleaning of the
you suspect an important bacterial contamination Torabine- caries the operator used diamond burs mounted on high-
jad2,3 recommends to precede the hooding with calcium speed handpiece and round burs with tungsten carbide blades
hydroxide dressing. If the exposure is on the axial wall of mounted on low-speed.
a cavity the management and the application of MTA is more The operator continued to remove caries even after pulp
difficult, either if the exposure is on the floor of a cavity the exposure and stopped with the excavation only when he
material results easier to manipulate, therefore there will be visually noticed the complete removal of decayed tissue both
more predictability of success. in presence of caries over the pulp roof chamber and on the
This study purpose was the monitoring of long-term suc- axial wall. To achieve hemostasis, only in some cases, the
cess rate (10 years) of pulp exposures due to deep caries, operator used sodium hypochlorite (NaOCl) 5% by soaking a
repaired with MTA. cotton swab and placing it directly on the exposure. The
waiting time required to achieve hemostasis ranged from one
Materials and methods to three minutes. Cases requiring more than 3 min to achieve
hemostasis were excluded from the study and managed with
a conventional endodontic treatment. After hemostasis, the
This study included 77 patients (46 females and 31 males),
site was well rinsed with water filled syringe and the dentin
aged between 14 and 68 years, who received a direct pulp
dried through air jet. After mixing gray or white MTA accord-
capping with Mineral Trioxide Aggregate of 80 teeth affected
ing to the manufacturer’s instructions, the operator placed a
by caries. The selected teeth were 48 molars, 23 premolars, 4
layer of 1.5—2 mm of concrete directly on the exposed pulp
canines and 5 incisors diagnosed with reversible pulpitis
and surrounding dentine, leaving 1—2 mm of free dentin and
(Fig. 1). On all the teeth the following was performed: an
enamel in order to perform adhesive procedures in the
intraoral periapical radiography, a cold temperature test, a
restoration phase. Then the operator directly placed a water
percussion test, a periodontal perimetric probing. All the
moistened cotton swab on the material and reconstructed
teeth had an initial deep caries, in some cases in presence of
the tooth with a temporary material.
previous restorations. Both female and male patients had
The complete treatment is shown in Fig. 2 in all steps.
stories of variable symptoms, from total absence of symp-
Patients were instructed to immediately call the dentist in
toms to hypersensitivity to thermal stimuli; 4 patients had
case of pain or severe discomfort after treatment. The
mild pain. All radiographs showed an evident deep caries
capped teeth were then reconstructed permanently with
close to the pulp chamber with no evidence of involvement of
adhesive technique after about a week. Most of the patients
the periodontal ligament (PDL), radiolucency at the furca-
involved in this study were asymptomatic and had a normal
tion, internal reabsorption or other periapical pathologies; in
response to cold temperature tests before the final prosthesis
three teeth the radiography showed a small area of bone loss
placement. Some showed temporary post-treatment hyper-
due to a widening of the periodontal space. Clinically, all
sensitivity lasting from a week to a few months. Subse-
teeth had normal mobility and periodontal probing in the
quently, in the second session, with deep anesthesia aid
absence of swelling or fistulas; no teeth treated in this study
the operator positioned the rubber dam and removed the
had pain to percussion.
temporary material. He then checked the MTA hardening and
Control groups have not been used since the objective of
removed eventual cotton fibers stuck to the material using an
the study was to monitor the pulp survival time by using a
excavator. Subsequently, the operator has finally rebuilt the
specific protocol and therefore periodic controls were pro-
treated tooth with a composite restoration by applying the
grammed to assess the vitality of dental pulp.
adhesive-dentin directly on the hardened MTA system and the
All direct pulp capping have been performed by the
surrounding dentin. In 34 cases the tooth has been recon-
author. After achieving anesthesia, rubber dam was placed
structed with indirect technique using composite inlay. Fol-
on all patients and, where necessary, a sealant (liquid dam)
low-ups have been planned and carried out at three months,
was used to prevent contamination of saliva and oral fluids.
at six months and then annually. Follow-ups consisted in
Therapies were performed using a minimum of 5 magnifica-
taking periapical radiographs, testing capped pulp teeth with
tion (loopes), in some cases the surgical microscope with
a cold stimulus (pulp vitality test) and with percussion. The
variable magnification from 7.1 to 18.6 has been used as a
intraoral radiographs were evaluated to verify any formation
of reparative dentine, presence of any calcification of the
pulp, radicular resorptions and absence of pathology above
all. The marginal sealing integrity of the final restorations has
also been evaluated.
Results
80 teeth treated in 77 patients have been observed for a

period of 10 years. Patients who have not responded to
control appointments were excluded. The age of the patients
varies from 14 to 68 years, 47 were females and 33 males.
Four patients before treatment complained of a moderate
pain; the cold temperature test revealed a normal response
on all 80 teeth. The pulpal exposure presented a certain
Figure 1 Type teeth distribution in the clinical study. degree of bleeding in about half the cases. The operator has
+ Modello
Figure 2 Complete treatment sequenze of MTA direct pulp capping of asymptomatic 3.7 in a 36 years old women. (A) Preoperative
radiograph showing the deep caries. (B) Preoperative image. (C) Deep caries. (D) Pulpal exposure. (E) Copious bleeding. (F) Placement
of Sodium Hypoclhorite 5% pellet to stop bleeding. (G) End of the bleeding. (H) Placement of grey MTA in a thickness of 2 mm. (I)
Placement of moistened cotton pellet. (J) Temporary filling. (K) Postoperative Rx. (L) Hardening control after 1 week. (M) Adhesive
procedures. (N) Adhesive procedures. (O) Composite build-up. (P) Composite Onlay. (Q) Composite onlay cementation. (R) Post
restaurative image. (S) Radiographic control 1 year. (T) Radiographic control 5 years. (U) Radiographic control 10 years.
+ Modello
6 L. Daniele
Figure 3 10 years clinical results.
carried out direct pulp capping using gray MTA on 43 teeth blood or fluid does not affect its preparation.67 The high
and white MTA on 37. In two pulp capping made on molars, alkalinity of the MTA, the release of calcium ions and the high
the second control has detected not hardening of the mate- pH of 12.5 probably prevent the further microbial growth of
rial (white MTA); subsequently the material was removed and any residual bacteria that may have been remained after the
new MTA was placed, then three appointments were neces- caries’ excavation and the cleaning. The high pH promotes
sary. The survival of the pulp in the teeth after 10 years the extraction of growth factors from the adjacent dentin
reached 92.5%, six teeth had to go for endodontic treatment; regarded to be the responsible substance to produce dentin
It has not shown an increase of pulpal calcification, the bridge.68 Furthermore, the release of calcium ions generates
presence of radicular resorptions, endodontic lesions radio- a layer of hydroxyapatite reaction on its surface when it
graphically visible (Fig. 3). All vital remaining teeth have comes in contact with the tissue fluids, their presence con-
responded positively to the cold temperature tests and tributes to produce reparative dentin.40 Torabiejad69 calcu-
negatively to the percussion test. The three lesions have lated on replicas of resin models that sealing of
disappeared in the last X-ray control. All 4 symptomatic teeth physicochemical MTA dentin is absolute, with a gap equal
have maintained their pulp vitality (Fig. 4). to 2.5 mm. This provides an insoluble barrier against micro-
leakage much more effective than the barrier that calcium
hydroxide produces, which can show the gaps at the interface
Discussion with the dentin of 7—15 mm.70 Once cured the MTA is not
absorbable, while the calcium hydroxide can be dissolved
Formation of a dentin bridge radiographically visible in 27.5% under restoration, allowing the potential entry of microor-
of cases (22/80) was recognized, presenting the normal ganisms and subsequent microbial contamination of dentin.
thickness of the periodontal ligament (PDL) in all observed This possibility can trigger a continuous irritation of the pulp
teeth. The presence of calcifications and pulp stones in 10% and produce dystrophic calcification and potential degen-
(8/80) of the teeth was evaluated. Some teeth with hooding erative changes indeed.71,72
made of grey MTA presented discoloration. All teeth with Normally capping material should be applied slightly
hooding provided a normal reply to the cold-temperature beyond the place of exposure, around a small area of the
tests up along a ten-year time frame, with no radiographic surrounding dentin. In this study MTA was applied upon the
evidence of disease. The results of this study show that this exposed area of the pulp and upon the entire axial wall of the
procedure can have a favorable long-term outcome; Mineral cavity prepared for the restoration to have a thickness of
Trioxide Aggregate was used as material for direct pulp 1.5—2.0 mm. Where the exposure is on the axial wall of a
capping, following the protocol described which provides a preparation of class II, the MTA must also be positioned along
therapy within two assessments. The complete removal of the cervical base of the cavity surface. The MTA application is
caries thus obtaining effective hemostasis, and determining completed by applying a shutters ball and a microbrush,
the MTA hardening and post hooding reconstruction with which sometimes may be very slightly moistened, also cover-
composite adhesive are the significant parameters checked. ing 1 or 2 mm of the surrounding dentin. A small wet cotton
The results suggest that Mineral Trioxide Aggregate is a very ball should be positioned to clean but especially to transfer
valid capping material, definitely more effective calcium further moisture which ensures the MTA hardening. The gray
hydroxide. and the white MTA have presented the same results. The
Results suggest that the Mineral Trioxide Aggregate is a following elements have proved to be crucial steps with
more effective capping material than calcium hydroxide. extreme importance for this study:
Results represent an alternative treatment option for a rubber dam,
patients who are not diagnosed with irreversible pulpitis. a magnification system,
The physical characteristics and bioactive properties of the a rigid protocol providing a precise and careful removal of
MTA have demonstrated to be the key success factors of this caries,
study.3,4,40—42 The cement is hygroscopic, the presence of a scrupulous execution of all clinical tasks.
+ Modello
Figure 4 Radiographic and photographic images of symptomatic pulp capping of 3.5 in a 55 years old women. (A) Preoperative
radiograph showing the deep caries close to the pulp, with radiography made horizontally you can not see well the periapical area. (B)
Diagnostic radiography vertically made where you can see the periapical area and a small apical radiolucency. (C) Diagnostic image. (D)
View of the deep caries. (E) Cleaning of tooth decay and pulpal exposure. (F) Placement of grey MTA in a thickness of 2 mm. (G)
Positioning of a damp cotton pellets to harden the material. (H) Postoperative Rx. (I) Temporary filling. (J) Final restoration. (K) 1 year
radiographic control, it remains still visible a small lesion. (L) 4 years radiographic control, it remains still visible a small lesion. (M) 10
years radiographic control, radiographic healing
The study demonstrates that theeth pulp from humans can Even if some past studies have demonstrated that using
easily heal. This situation can be easily improved by removing NaOCl at a concentration higher than 0.025% is not leading to
caries effectively but in a conservative manner at the same wound healing, nonetheless when it is used as emostatic
time by using bioactive capping materials, followed by ade- agent on dental pulp77 it appears that dental pulps present
quate restoration and sealing. positive reactions.78,79 Within this study there were no dental
Pulpar reparation and capping were successfully imple- pulps which were negatively affected by direct contact with
mented in young patients66; the presence of larges apical NaOCl 5% along 5 min. In the case that bleeding lasted longer
foramens, of a significant pulp vascularization, and the than 5 min, the traditional endodontic treatment was
intense activity of immuno cells are regarded the success applied, therefore disregarding the capping technique to
factors as they can boost the pulp healthy and active status.22 preserve dental pulp. This study did not involve direct pulp
In fact with time passing by and following some traumas the capping upon teeth with open and immature apex, where
pulp regenerative capacity decreases,73,74 where the worst apexogenesi was still ongoing.
results were detected in patients aged more than 60 years.75
In the present study we applied on all pulps a 5% solution Conclusions
composed of NaOCl as emostatic agent only in 20% of cases
and only when blood was leaking following dentin excavation Mineral Trioxide Aggregate used as correct caries removal
and cavitary curettage. In recent cases of bleeding emostasis and NaOCl used as an agent to achieve hemostasis and
occurred after 5 min the pulp trumpet self-repaired. Since disinfection and adhesive systems both with last generation
1950 Sodium Hypoclorite was used as a pulp emostatic agent composite resins are crucial steps to proceed along the direct
with several positive features like excellent emostatic pulp capping protocol for exposures due to tooth decay.
agent76 and allows microbiological decontamination of resi- Direct pulp capping should be executed only when the
dual dentin and contributes creating a fibrin clot. pulp is not in a severe condition with a diagnosis leading to a
+ Modello
8 L. Daniele
reversible pulpitis. Dentists should be aware that this clinical 17. Deng Y, Zhu X, Zheng D, Yan P, Jiang H. Laser use in direct pulp
study was conducted by a single operator that followed a capping. J Am Dent Assoc 2016;147(12):935—42.
rigid and strictly-driven protocol; it is mandatory to use the 18. Da Silva TM, Da Rosa WLO, Marques MR. Does laser improve the
rubber dam and a magnifying device. By making sure that all clinical success in direct pulp capping. A systematic review and
meta-analysis. J Oral Health Dent Care 2017;1:004.
diagnostic and running operating procedures were applied it
19. Horsted P, Sondergaard B, Thylstrup A, El Attar K, Fejerskov O. A
is possible to achieve very good results. This study, where retrospective study of direct pulp capping with calcium hydro-
Mineral Trioxide Aggregate was used as a material for direct xide compounds. Endod Dent Traumatol 1985;1(1):29—34.
pulp capping following the standing protocol with built-in 20. Baume LJ, Holz J. Long term clinical assessment of direct pulp
therapy of two assessments, shows as results a favorable capping. Int Dent J 1981;31(4):251—60.
long-term outcome after this procedure and can be consid- 21. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping
ered a valid alternative to endodontic treatment. This ther- of carious exposures: treatment outcome after 5 and 10 years — a
apy is traditionally applied on deep caries directly affecting retrospective study. J Endod 2000;26(9):525—8.
the pulp. 22. Auschill TM, Arweiler NB, Hellwig Zamani-Alaei A, Sculean A.
Success rate of direct pulp capping with calcium hydroxide
Direct pulp capping with Mineral Trioxide Aggregate and
[in German]. Schweiz Monatsschr Zahnmed 2003;113(9):
all future bioactive materials including Tricalcium Silicates
946—52.
belong to the world of minimally invasive therapies, which is 23. Matsuo T, Nakanishi T, Shimizu H, Ebisu S. A clinical study of
the should-be-followed direction by the dental profession direct pulp capping applied to carious exposed pulps. J Endod
nowadays. 1996;22(10):551—6.
24. Raedel M, Hartmann A, Bohm S, Konstantinidis I, Priess HW,
References Walter MH. Outcomes of direct pulp capping: interrogating an
insurance database. Int Endod J 2016;49(11):1040—7.
1. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral 25. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent
trioxide aggregate for repair of lateral root perforations. J Endod teeth with exposed pulp cariously: a systematic review. J Aguilar
1993;19:541—4. Endod 2011;37(5):581—7.
2. Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial 26. Hahn CL, Liewehr FR. Relationships between caries bacteria,
leakage of mineral trioxide aggregate as a root-end filling mate- host responses, and clinical signs and symptoms of pulpitis. J
rial. J Endod 1995;21:109—12. Endod 2007;33(3):213—22.
3. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and 27. Riccitiello F, Manieri G, Prisco R, Carratu P. Comparative analysis
chemical properties of a new root-filling material. J Endod of materials for dentino-pulp protection: varnishes, liners, ZOE
1995;21:349—53. cements, zinc oxyphosphate cements, zinc polycarboxylate
4. Koh ET, Torabinejad M, Pitt Ford TR, Brady K, McDonald F. Mineral cements, calcium hydroxide cements. Arch Stomatol (Napoli)
trioxide aggregate stimulates a biological response in human 1990;31(2):197—216.
osteoblasts. J Biomed Mat Res 1997;37:432—9. 28. Amato M, De Fazio P, Sbordone R, Riccitiello F. Use of a new
5. Pitt Ford TR, Torabinejad M, Abedi HR, Barkland LK, Kariyawa- calcium hydroxide-based cement in the pulpotomy technic.
sam S. Using mineral trioxide aggregate as a pulp capping Minerva Stomatol 1987;36(12):941—5.
material. JADA 1996;127:1491—4. 29. Tarmin B, Hafez AA, Cox CF. Pulpal response to a resin-modified
6. Abedi HR, Torabinejad M, Pitt Ford TR, Bakland LK. The use of glass-ionomer material on nonexposed and exposed monkey
mineral trioxide aggregate cement (MTA) as a direct pulp cap- pulps. Quintessence Int 1998;29(8):535—42.
ping agent. J Endodon 1996;22:199. 30. Cox CF, Hafez AA, Akimoto N, Otsuki M, Suzuki S, Tarirn B. Bio-
7. Torabinejad M, Chivian N. Clinical applications of mineral tri- compatibility of primer, adhesive and resin composite systems on
oxide aggregate. J Endod 1999;25:197—205. non-exposed and exposed pulps of non-human primate teeth. Am
8. Tronstad L, Mjor IA. Capping of the inflamed pulp. Oral Surg Oral J Dent 1998;11(Special number):S55—63.
Med Oral Pathol Oral Radiol Endod 1972;34:477—85. 31. Hebling J, Giro EM, Costa CA. Biocompatibility of an adhesive
9. Langeland K. Management of the inflamed pulp associated with system applied to exposed human dental pulp. J Ended
deep carious lesion. J Endod 1981;7(4):181—9. 1999;25(10):676—82.
10. Bergenholz G. Advances since the paper by Zander and Glass 32. Do Nascimento AB, Fontana UF, Teixeira HM, Costa CA. Biocom-
(1949) on the pursuit of healing methods for pulpal exposures: patibility of a resin-modified glass-ionomer cement applied as
historical perspectives. Oral Surg Oral Med Oral Pathol Oral pulp capping in human teeth. Am J Dent 2000;13(1):28—34.
Radiol Endod 2005;100(2 Suppl.):S102—8. 33. Mjor IA. Pulp-dentin biology in restorative dentistry, part 7: the
11. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The radio- exposed pulp. Quintessence Int 2002;33(2):113—35.
graphic outcomes of direct pulp capping procedures performed 34. Accorinte Mde L, Loguericio AD, Reis A, Muench A, do Araùjo VC.
by dental students: a retrospective study. JADA 2006;137(12): Adverse effects of human pulps after direct pulp capping with
1699—705. different components from a total-etch, three-step adhesive
12. Ward J. Vital pulp therapy in cariously exposed permanent teeth system. Dent Mater 2005;21(7):599—607.
and its limitations. Aust Endod J 2002;28(1):29—37. 35. Holland R, De Souza V, Very MJ, Otoboni Filho JA, Bernabé PFE,
13. Moritz A, Schoop U, Goharkhay K, Sperr W. The CO2 laser as an aid Dezan E. Reaction of rat connective tissue to implanted dentin
in direct pulp capping. J Endod 1998;24(4):248—51. tubes filled with Mineral Trioxide Aggregate or calcium hydro-
14. Goldberg M, Six N, Decup F, Lasfargues JJ, Salih E, Tompkins K, xide. J Endodon 1999;25:161—6.
et al. Bioactive molecules and the future of pulp therapy. Am J 36. Malentacca A, Fabbri M. The use of MTA in Endodontics G IT Endo
Dent 2003;16(1):66—76. 2000;2:64—9.
15. Dahnhardt JE, Jaeggi T, Lussi A. Treating open carious lesions in 37. Camilleri J, Pitt Ford TR. Mineral trioxide aggregate: a review of
anxious children with ozone: a prospective controlled clinical the constituents and biological properties of the material. Int
study. Am J Dent 2006;19(5):267—70. Endod J 2006;39(10):747—54.
16. Olivi G, Genovese MD, Maturo P, Docimo R. Pulp capping: advan- 38. Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP.
tages of using laser technology. Eur J Paediatr Dent 2007;8(2): Using mineral trioxide aggregate as a pulp-capping material.
89—95. JADA 1996;127(10):1491—4.
+ Modello
39. Juno DJ. Quantitative assessment of dentin bridge formation 58. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral
following pulp capping with mineral trioxide aggregate. Loma trioxide aggregate: an observational study. J Am Dent Assoc
Linda, CA: Loma Linda University; 2000 [Master’s thesis]. 2008;139(3):305—15.
40. Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, Kawashima I. 59. Natale LC, Rodrigues MC, Xavier TA, Simões A, de Souza DN,
Physiochemical basis of the biologic properties of mineral tri- Braga RR. Ion release and mechanical properties of calcium
oxide aggregate. J Endod 2005;31(2):97—100. silicate and calcium hydroxide materials used for pulp capping
41. Moghaddame-Jafari S, Mantellini MG, Botero TM, McDonald NJ, (Department of Biomaterials and Oral Biology, School of Den-
Nor JE. Effect of ProRoot MTA on pulp cell apoptosis and pro- tistry, University of São Paulo, São Paulo, Brazil). Int Endod J
liferation in vitro. J Endod 2005;31(5):387—91. 2015;48(1):89—94.
42. Takita T, Hayashi M, Takeichi O, Ogiso B, Suzuki N, Otsuka K, et al. 60. Jang Y, Song M, Yoo IS, Song Y, Roh BD, Kim E. A randomized
Effect of mineral trioxide aggregate on proliferation of cultured controlled study of the use of ProRoot mineral trioxide aggregate
human dental pulp cells. Int Endod J 2006;39(5):415—22. and endocem as direct pulp capping materials: 3-month versus 1-
43. Tziafas D, Konstantinios K. Dentinogenic specificity in the pre- year outcomes. J Endod 2015;41(8):1201—6.
clinical evaluation of vital pulp treatment strategies: a critical 61. Gandolfi MG, Siboni F, Botero T, Bossù M, Riccitiello F, Prati C.
review. Dent J 2015;3(4):133—56. Calcium silicate and hydroxide materials for pulp capping:
44. Fransson H, Wolf E, Petersson K. Formation of a hard tissue biointeractivity, porosity, solubility and bioactivity of current
barrier after experimental pulp capping or partial pulpotomy in formulations. J Appl Biomater Funct Mater 2015;13(1):43—60.
humans: an updated systematic review. Int Endod J 2016;49(6): 62. Gandolfi MG, Ciapetti G, Taddei P, Perut F, Tinti A, Cardoso MV,
533—42. et al. Apatite formation on bioactive calcium-silicate cements
45. Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide for dentistry affects surface topography and human marrow
aggregate (MTA) and calcium hydroxide as pulp-capping agents in stromal cells proliferation. Dent Mater 2010;26(10):974—92.
human teeth: a preliminary report. lnt Endod J 2003;36(3): 63. Gandolfi MG, Pagani S, Perut F, Ciapetti G, Baldini N, Mongiorgi R,
225—31. et al. Innovative silicate-based cements for endodontics: a study
46. Witherspoon DE, Small JC, Harris GZ. Mineral trioxide aggregate of osteoblast-like cell response. J Biomed Mater Res A
pulpotomies; a case series outcomes assessment. JADA 2006; 2008;87(2):477—86.
137(5):610—8. 64. Gandolfi MG, Siboni F, Prati C. Chemical—physical properties of
47. Barrieshi-Nusair KM, Qudeimat MA. A prospective clinical study TheraCal, a novel light-curable MTA-like material for pulp cap-
of mineral trioxide aggregate for partial pulpotomy in cariously ping. Int Endod J 2012;45(6):571—9.
exposed permanent teeth. J Endod 2006;32(8):731—5. 65. Gandolfi MG, Siboni F, Primus CM, Prati C. Ion release, porosity,
48. lwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, solubility, and bioactivity of MTA Plus tricalcium silicate. J Endod
Jefferies S. Clinical and histological evaluation of white 2014;40(10):1632—7.
ProRoot MTA in direct pulp capping. Am J Dent 2006;19(2): 66. Cho SY, Seo DG, Lee SJ, Lee J, Lee SJ, Yung IY. Prognostic factors
85—90. for clinical outcomes according to time after direct pulp cap-
49. Farsi N, Alamoudi N, Balto K, Al Moshayt A. Clinical assess- ping. J Endod 2013;39(3):327—31.
ment of mineral trioxide aggregate (MTA) as direct pulp 67. Torabinejad M, Higa RK, endry McK D.J., Pitt Ford TR. Dye
capping in young permanent teeth. J Clin Pediatr Dent leakage of four root end filling materials: effects of blood
2006;31(2):72—6. contamination. J Endod 1994;20(4):159—63.
50. Çalışkan MK, Güneri P. Prognostic factors in direct pulp capping 68. Tomson PL, Grover LM, Lumley PJ, Sloan AJ, Smith AJ, Cooper
with mineral trioxide aggregate or calcium hydroxide: 2- to 6- PR. Dissolution of bio-active dentine matrix components by
year follow-up. Clin Oral Investig 2017;21(1):357—67. mineral trioxide aggregate. J Dent 2007;35(8):636—42.
51. Hilton TJ, Ferracane JL, Mancl L. Comparison of CaOH with MTA 69. Torabinejad M, Smith PW, Kettering JD, Pitt Ford TR. Compara-
for direct pulp capping — a PBRN randomized clinical trial. J Dent tive investigation of marginal adaptation of mineral trioxide
Res 2013;92(7 Suppl.):S16—22. aggregate and other commonly used root-end filling materials.
52. Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium J Endod 1995;21(6):295—9.
hydroxide or mineral trioxide aggregate: a meta-analysis. J 70. Goracci G, Mori G. Scaning electron microscopic evaluation of
Endod 2015;41(9):1412—7. resin-dentin and calcium hydroxide—dentin interface with resin
53. Swarup SJ, Rao A, Boaz K, Srikant N, Shenoy R. Pulpal response to composite restorations. Quintessence Int 1996;27(2):129—35.
nano hydroxyapatite, mineral trioxide aggregate and calcium 71. Cox CF, Subay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel detects in
hydroxide when used as a direct pulp capping agent: an in vivo dentin bridges: their formation following direct pulp capping.
study. J Clin Pediatr Dent 2014;38(3 (Spring)):201—6. Oper Dent 1996;21(1):4—11.
54. Mente J, Geletneky B, Ohle M, Koch MJ, Ding PGF, Wolff D, et al. 72. Cox CF, Keall CL, Keall HJ, Ostro E, Bergenholtz G. Biocompat-
Mineral trioxide aggregate or calcium hydroxide direct pulp ibility of surface-sealed dental materials against exposed pulps.
capping: an analysis of the clinical treatment outcome. J Endod J Prosth Dent 1987;57(1):1—8.
2010;36:806—13. 73. Bernick S, Nedelman C. Effect of aging on the human pulp. J
55. Leye Benoist F, Gaye Ndiaye F, Kane AW, Benoist HM, Farge P. Endod 1975;1(3):88—94.
Evaluation of mineral trioxide aggregate (MTA) versus calcium 74. Abou-Rass M. The stressed pulp condition: an endodontic-
hydroxide cement (Dycal(1) in the formation of a dentine restorative diagnostic concept. J Prosthet Dent 1982;48(3):
bridge: a randomised controlled trial. Int Dent J 2012;62(1): 264—7.
33—9. 75. Damascke T, Leidinger J, Schafer E. Long term evaluation of
56. Bakland LK1, Andreasen JO. Will mineral trioxide aggregate direct pulp capping treatment outcomes over average periode of
replace calcium hydroxide in treating pulpal and periodontal 6.1 years. Clin Oral Invest 2010;14:559—67.
healing complications subsequent to dental trauma? A review. 76. Hafez AA, Cox CF, Tarim B, Otsuki M, Akimoto N. An in vivo
Dent Traumatol 2012;28(1):25—32. evaluation of hemorrhage control using sodium hypochlorite and
57. Moradi S, Saghravanian N, Moushekhian S, Fatemi S, Forghani M. direct capping with a one- or two-component adhesive system in
Immunohistochemical evaluation of fibronectin and tenascin exposed non-human primate pulps. Quintessence Int 2002;33(43):
following direct pulp capping with mineral trioxide aggregate 261—72.
platelet-rich plasma and propolis in dogs’ teeth. Iran Endod J 77. Heggers JP, Sazy JA, Stenberg BD, Strock LL, McCauley RL,
2015;10(3 (Summer)):188—92. Herndon DN, et al. Bactericidal and wound-healing properties
+ Modello
10 L. Daniele
of sodium hypochlorite solutions: the 1991 Lindberg Award. J 79. Demir T, Cehreli ZC. Clinical and radiographic evaluation of
Burn Care Rehabil 1991;12(5):420—4. adhesive pulp capping in primary molars following hemostasis
78. Garcia-Godoy F, Murray PE. Systemic evaluation of various hae- with 1.25% sodium hypochlorite: 2-year results. Am J Dent
mostatic agents following local application prior to direct pulp 2007;20(3):182—8.
capping. Braz J Oral Sci 2005;4(14):791—7.

Mineral Trioxide Aggregate (MTA) Direct Pulp Capping: 10 Years Clinical Results

Uploaded by

Copyright:

Available Formats

Mineral Trioxide Aggregate (MTA) Direct Pulp Capping: 10 Years Clinical Results

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Mineral Trioxide Aggregate (MTA) Direct Pulp Capping: 10 Years Clinical Results

Uploaded by

Copyright:

Available Formats

+ Modello

GIE-123; No. of Pages 10

Giornale Italiano di Endodonzia (2017) xxx, xxx—xxx

Available online at www.sciencedirect.com

ORIGINAL ARTICLE/ARTICOLO ORIGINALE

Mineral Trioxide Aggregate (MTA) direct pulp

Private Practitioner in L’Aquila, Via Madonna di Pettino, 22, Italy

Received 14 March 2017; accepted 27 March 2017

Introduction and recruitment, normal pulpal repair mechanisms may

MTA direct pulp capping 3

80 teeth treated in 77 patients have been observed for a

MTA direct pulp capping 5

Figure 3 10 years clinical results.

MTA direct pulp capping 7

MTA direct pulp capping 9

You might also like