Electronic Journal of Biotechnology ISSN: 0717-3458

Vol. 9 No. 1, Issue of January 15, 2006

2006 by Pontificia Universidad Catlica de Valparaso -- Chile

Received April 18, 2005 / Accepted August 10, 2005

DOI: 10.2225/vol9-issue1-fulltext-7

RESEARCH ARTICLE

A new method: measurement of microleakage volume using human, dog and

bovine permanent teeth
Izzet Yavuz*
Faculty of Dentistry
Department of Pediatrics
University of Dicle
21280, Diyarbakir, Turkey
Tel: 90 412 2488101/3426
Fax: 90 412 2488100
E-mail: iyavuz@dicle.edu.tr

Haluk Aydn
Chemistry Department
Faculty of Sciences
Dicle University
21280 Diyarbakr, Turkey
Tel: 90 412 2488550 1 etx. 3164

Refk Ulku
Department of Thoracic Surgery
Faculty of Medicine
Dicle University
21280, Diyarbakir, Turkey
Tel: 90 412 2488001 16 ext. 4263

Sadullah Kaya
Department of Operative Dentistry
Faculty of Dentistry
Dicle University
21280, Diyarbakir, Turkey
Tel: 90 412 2488101 ext. 3423
Fax: 90 412 248 8100

Caner Tumen
Faculty of Dentistry
Department of Pediatrics
University of Dicle
21280, Diyarbakir, Turkey
Tel: 90 412 2488101 ext. 3406
Fax: 90 412 248 8100
*Corresponding author
Keywords: dye adsorption test, microleakage, tooth.
Abbreviations:

methylene blue (MB)

Abstract
This study investigates the feasibility of a different new approach to determining the microleakage
volume associated with dental restorations (Class V cavity restorated with glass ionomer cement +
high copper amalgam) and the relative marginal adaptation deficiency of dog, bovine and human
permanent teeth in in vitro conditions. Also researched is the appropriateness of using dog and
bovine teeth in in vitro studies rather than human teeth. Our method utilizes the molecular
adsorption characteristics of methylene blue. Within the framework of this study, 60 permanent
teeth (20 human, 20 dogs and 20 bovine) were used. These groups were evaluated statistically, of
which indicated no statistically significant differences (p > 0.05). It was also concluded that this
preliminary investigation showed that the new microleakage volume measurement method may be a
valuable new technique for the in vitro study of microleakage dynamics around dental restorations.
Article
One of the most important problems of restorative dentistry today is the failure of restorative materials to
completely bond to enamel and dentin, causing microleakage. Microleakage has been defined as the
passage of ions, molecules, fluids or bacteria between a cavity wall and the applied restorative material.
Microleakage has been reported as the cause of hypersensitivity of restored teeth, discoloration at the
margins of cavities and restorations, recurrent caries, pulp inflammation and failure of endodontic treatment
(Tjan and Tan, 1991; Taylor and Lynch, 1992; Yavuz and Aydn, 2005).
Microleakage is determined today by many in vitro techniques with or without thermal cycling, such as
staining; scanning electron microscope; bacterial activity; decay; air pressure; chemical agents; markers;
neutron activation analysis; radioisotope; ionization; autoradiography and reversible radioactive adsorption.
(Tjan and Tan, 1991; Taylor and Lynch, 1992; Sano et al. 1995; Yavuz and Atakul, 2000; Yavuz and Atakul,
2001a; Yavuz and Atakul, 2001b; Yavuz and Aydin, 2005).
The aim of some researchers is to develop an in vitro model to replicate microleakage at a tooth/restoration
interface (Iwami et al. 2000; Matharu et al. 2001; Yavuz et al. 2003; Yavuz and Aydin, 2005).
The significant differences between these models and materials suggest that an ideal method for the
determination of microleakage has not yet been established.
The aim of this study was to develop valuable an in vitro model to determine the microleakage volume and
ability to use dog and bovine teeth instead of human teeth in in vitro studies.
Materials and Methods
Sixty recently extracted teeth were selected by Binocular Stereo Microscope (Olympus Co., Japan) for this
study; 20 human permanent premolars, 20 bovine permanent incisors and 20 dog permanent canines were
used.
Bovine teeth were obtained from the Department of Anatomy of Veterinary Medicine Faculty, dog teeth
obtained by the doctor's degree thesis study with the subject of "Lowering of hypertension by nitroglycerin
and niprus treatment on the dogs on which pulmonary hypertension is created through pulmonary legation
and comparison of its isotonic effect of 7.5% NaCl and 0.9% on vital parameters", and human teeth were
obtained from the Department of Maxillo-Facial Surgery of Dental Faculty (Figure 1).
The twenty teeth for each species were randomly divided into two groups (30 teeth per group). One group
was used for dye penetration (control group), other group used to study microleakage volume. Before the
cavity preparation and restorative procedure, all teeth were cleaned. Class V cavity prepared on the buccal
surface of each tooth. The cavity has had enamel and dentin margins. The cavities had a mesio-distal width

of 3 mm, an occluso-cervical length of 2 mm and a depth of 1.5 mm.

The teeth in all groups were restored in the following way: The type 2 light-hardening powder and liquid
glass ionomer cement (Variglass VLC, Dentsply, USA) were prepared in accordance with the manufacturer's
instructions, applied to the bottom of the preparations and polymerized. (Astralis3, Vivadent, Australia).
Following polymerization, all preparations were filled with a high copper amalgam (Cavex Avalloy, Cavex
Co., Holland) and 24 hrs later finishing and polishing were performed.
The specimens were subjected to thermo cycling between 5C 4C and 60C 4C for 500 cycles. After
thermo cycling, the surface of the teeth, up to approximately 1.5 mm to the restoration, was coated with a
layer of nail varnish, melted utility wax and a second layer of nail varnish (Derhami et al. 1995; Iwami et al.
2000; Gungor et al. 2003; Yavuz et al. 2003; Olmez et al. 2004; Yavuz and Aydin, 2005).
The methylene blue (MB) solution was prepared to a concentration of MB 4.75 g/l. A stock solution was
prepared using a buffer of H2PO4- / HPO4-2 (phosphate / biphosphate) with a pH of 6.98 and 24 hrs did
storage the specimens in the MB solution. Section made at the middle of the restorations to examine dye
penetration.
In our study, the first stage was to evaluate the marginal leakage of specimens to confirm using the dye
penetration test (microscope at a magnification of x 25). The results were evaluated using the microleakage
score; 0 = no dye penetration; 1 = dye penetration between the restoration and the tooth up to one-third of
distance between the tooth surface and the axial wall; 2 = dye penetration extending beyond one-third of the
distance between the tooth surface and the axial wall; 3 = dye penetration extending two-thirds of the
distance between the tooth surface and axial wall; 4 = dye penetration reaching the axial wall; and 5 = dye
penetration reached the allof axial wall (Figure 2, Table 1) (Yavuz and Atakul, 2000; Yavuz and Atakul,
2001a; Yavuz and Aydin, 2005).
The second stage of this research was the measurement of the volume of the marginal gaps. In this stage,
each individual sample was quantitatively measured using the chemical molecular characteristic properties
of MB.
Theoretically, the volume measurement method was created and applied as described below.
The MB molecule is made up of an acid combined with an organic base. Its molecular weight is
(MA=319.868g.mol-1) and a single piece of the absorbed covers an area of (s)=120 A0 2 on the surface (Aydin
and Tez, 1996) (Figure 3). Absorption is the accumulation of dissolved molecules over the surface of a solid
matter, the dissolved molecules could be atoms or ions of matter present in any solution of a gas, vapour or
liquid phase. The phase, which allows the accumulation to occur on its surface, is known as the absorber
(the teeth), the matter, which accumulates, is known as the absorbed (MB) (Davies, 1952; Nelsen et al.
1952; Aydin and Tez, 1996).
Absorption, in the liquid form, is usually measured using an indirect method. After the experiment, the teeth
were dissolved in a 50% solution of nitric acid, the MB that filled the microleakage gaps dissolves into the
solution and it's the MB concentration is determined.
To draw the calibration graph, a part of the MB solution was taken and determined to have a wavelength of
664 nm in a spectrophotometer lmax (maximum absorption wavelength).
Some of the MB stock was taken and diluted (10 different concentrations were prepared using 100 ml of
distilled water in each beaker to dilute the 2% MB, ranging from 0 mL added to 180 mL added in 20 mL
increments ) to form a series of solutions of varying concentration. These varying concentrations were
measured for their absorption wavelengths. These measurements were then used to construct the

calibration graph (Figure 4): A = E C (A: absorption, E: molar absorption coefficient, C: concentration).
The molar absorption coefficient was determined to be 170.57 dm 3.cm-1.g-1.
After the calibration graph was drawn, the concentrations were calculated using the absorption values.
In the absorption experiments of our study, the teeth were placed in three joje balloons along with 100 ml of
MB solution. The teeth were subjected to MB dye penetration at 37C for a 24 hrs period, to allow dye
penetration into any possible existing gaps between the tooth substance and the restorative material (Yavuz
and Atakul 2000; Yavuz et al. 2003; Yavuz and Aydin, 2005).
Afterwards, the tooth tissue around the restoration surfaces was removed in a block by making cuts 1.5 mm
around the restored area (Figure 5, Figure 6). These blocks were then dissolved separately in 50% nitric
acid (Figure 7) and the amount of MB absorption was calculated using the previously created calibration
graph. These values were converted to volume values (V = m/d) and the individual tooth volume values are
reported in Table 2.
Findings
Table 1 shows the scores of the degree of dye penetration for all groups. Measurement values of the MB
staining in groups following the volume measurements of the three groups and the MB molecular counts
equivalent to median values are shown in Table 2.
In our study, the first stage was dye penetration. We used Kruskal-Wallis non-parametric test. The
differences were not statistically significant between all groups (p > 0.05).
In the second stage of this research, another three groups were evaluated statistically for microleakage
volume at the restorations/cavity wall interface. The measurements in all groups were compared using One
Way ANOVA Test and groups had no statistically significant differences (p > 0.05).
Discussion
The in vivo microleakage phenomenon and the adaptation of filling materials into the cavity walls under
clinical and laboratory conditions constituted the focal points of researchers for many years and a variety of
methods have been used to research this (Tjan and Tan, 1991; Yavuz and Atakul, 2001b; Yavuz, 2003;
Kelsey et al. 2004; Turgut et al. 2004; Ersin and Eronat, 2005). Some of these laboratory models have been
successfully used to in order to determine microleakage, but they are not quantitative methods.
It is interesting that, despite the effect microleakage has on the health of dental pulp was established, little
progress has been made in characterizing the dynamics and nature of microleakage.
In fact, in the studies of dye penetration, the dentin staining was observed to be more different than the
actual gaps between cavity walls and restoration materials. This resulted in the use of a dye with a particle
diameter equal to the bacterial size or smaller by researchers (around 2 m) (Yavuz and Aydin, 2005).
In this study, a 2.00% solution of the MB molecule was used (one MB molecule = 1.2 nm 2 = 120 A0 2) since
the particle size is less than that of the bacterial one. MB molecules were used because the also dissolve as
monomer and bimer in an aqueous environment in which the pH is adjusted to 6.98 with a phosphate and
biphosphate buffer (Nelsen et al. 1952; Yavuz and Aydin, 2005).
Another important issue in microleakage studies arises from the scoring systems. Since the evaluation in
those studies largely depends on the observer's interpretation, the leakage scoring is at best a semi-

measurable method (Yavuz and Aydin, 2005).

Various studies performed show that the dye leakages in different sections taken at different places of the
restorations may show significant differences (Yavuz and Atakul, 2001b). For this reason, the accuracy of a
leakage study based on a single section made from a tooth may be negligible.
As of today, there are no quantitative methods applicable and valuable for the microleakage determination;
we have above indicated the amount of microleakage through quantification.
In the stereo microscopic studies, the method is based on the interpretation of the leakage of dye on the
cavity wall and is defined as a semi-quantitative approach where the leakage is calculated solely at the
surface where the section is made (Yavuz and Atakul, 2001b; Yavuz and Aydin, 2005).
In our method, the researcher's observation and interpretation do not come into play in the determination of
microleakage volume quantity and all surfaces where a leakage occurs between tooth/restoration material is
quantitatively measured by a chemist.
When the three groups were compared for microleakage volume measurements using the One Way Anowa
Test, there weren't statistically significant difference (p > 0.05), also the dye penetration test (control
groups), evaluated using the Kruskal-Wallis non-parametric test confirmed our method and the results had
no significant difference (p > 0.05).
The comparison and/or relationship between the results obtained from the new method and the
conventional method (control group) has been found similar.
The aim of this study was to develop an in vitro model to determine the microleakage volume. As a result of
this study, the relative microleakage volumes of dog and bovine permanent teeth to human permanent teeth
in in vitro conditions was found to be similar.
Within the limitations of these experiments, the following can be concluded, the ability to use dog and bovine
teeth instead of human teeth in in vitro studies was confirmed.
It was also concluded in this preliminary investigation that the method of measuring the microleakage
volume can be best a valuable tool for the in vitro study of microleakage dynamics around dental
restorations, and this method can be use as a new technique for the determination of microleakage volume.
Further work to establish the true scope of the model remains to be undertaken, but this preliminary
investigation shows promise.
References
AYDIN, Haluk and TEZ, Zeki. Comparative determination of the adsorption capacities and possible fields of
usage of active carbons prepared from the shells of walnut and hazelnut through some commercial active
carbons. Turkish Journal of Chemistry, 1996, vol. 16, p. 51-58.
DAVIES, R.G. The use of benzene adsorption isotherms in evaluating the surface and pore characteristics
of activated carbons. Chemistry and Industry, February 1952, vol. 23, p. 160-165.
DERHAMI, K.; COLI, P. and BRANNSTROM, M. Microleakage in class 2 composite resin restorations.
Operative Dentistry, May-June 1995, vol. 20, no. 3, p. 100-105.
ERSIN, Nazen K. and ERONAT, Nesrin. The comparison of a dentin adhesive with calcium hydroxide as a

pulp-capping agent on the exposed pulps of human and sheep teeth. Quintessence International,2005, vol.
36, no. 4, p. 271-280.
GUNGOR, Hamdi Cem; TURGUT, Melek Dilek; ATTAR, Nuray and ALTAY, Nil. Microleakage evaluation of a
flowable polyacid-modified resin composite used as fissure sealant on air-abraded permanent teeth.
Operative Dentistry, May-June 2003, vol. 28, no. 3, p. 267-273.
IWAMI, Yukiteru; YAMAMOTO, Hidetoshi and EBISU, Shigeyuki. A new electrical method for detecting
marginal leakage of in vitro resin restorations. Journal of Dentistry,May 2000, vol. 28, no. 4, p. 241-247.
[CrossRef]
KELSEY, W.P.; LATTA, M.A.; MEARA, J.D.; BARKMEIER, W.W.; HAMMESFAHR, P.D. and JEFFERIES,
S.R. An accelerated in vitro model for adhesive testing. American Journal of Dentistry, October 2004, vol.
17, no. 5, p. 323-326.
MATHARU, S.; SPRATT, D.A.; PRATTEN, J.; NG, Y-L.; MORDAN, N.; WILSON, M. and Gulabivala, K. A
new in vitro model for the study of microbial microleakage around dental restorations: A preliminary
qualitative evaluation. International Endodontic Journal, October 2001, vol. 34, no. 7, p. 547-553.
[CrossRef]
NELSEN, R.J.; WOLCOLTT, R.B. and PAFFENBARGER, G.C. Fluid exchange at the margins of dental
restorations. Journal of the American Dental Association, March 1952, vol. 44, p. 228-295.
OLMEZ, Aysegul; OZTAS, Nurhan and BODUR, Haluk. The effect of flowable resin composite on
microleakage and internal voids in class II composite restorations. Operative Dentistry, NovemberDecember 2004, vol. 29, no. 6, p. 713-719.
SANO, H.; TAKATSU, T.; CIUCCHI, B.; HORNER, J.A.; MATTHEWS, W.G. and PASHLEY, D.H.
Nanoleakage: Leakage within the hybrid layer. Operative Dentistry, January-February 1995, vol. 20, no. 1, p.
18-25.
TAYLOR, M.J. and LYNCH, E. Microleakage. Journal of Dentistry, February 1992, vol. 20, no. 1, p. 3-10.
[CrossRef]
TJAN, Anthony and TAN, Daniel. Microleakage at gingival margins of class V composite resin restorations
rebonded with various low-viscosity resin systems. Quintessence International, July 1991, vol. 22, no. 7, p.
565-573.
TURGUT, Melek D.; TEKCICEK, Meryem and OLMEZ, Seval. Clinical evaluation of a polyacid-modified
resin composite under different conditioning methods in primary teeth. Operative Dentistry, SeptemberOctober 2004, vol. 29, no. 5, p. 515-523.
YAVUZ, Izzet and ATAKUL, Fatma. Evaluation of microleaking in different in vitro restorations of cow
permanent teeth. Balkan Journal of Stomatology, March 2001a, vol. 5, p. 42-45.
YAVUZ, Izzet and ATAKUL, Fatma. The comparison of amount of leaking occurred in different sections of in
vitro prepared restorations in cow permanent teeth. Balkan Journal of Stomatology, July 2001b, vol. 5, p.
104-107.
YAVUZ, I.; AYDIN, H. and KAYA, S. New method for measurement of microleakage. Trkiye Klinikleri
Journal of Dental Sciences, July 2003, vol. 9, p. 79-85.

YAVUZ, Izzet and ATAKUL, Fatma. The comparison of amount of microleaking for in vitro restorations in
permanent teeth of human, dog and cow. Balkan Journal of Stomatology, July 2000, vol. 4, p. 103-106.
YAVUZ, Izzet and AYDIN Haluk. New method for measurement of surface areas of microleakage at the
primary teeth by biomolecule characteristics of methilene blue.Biotechnology and Biotechnological
Equipment, 2005, vol. 19, no. 1, p. 181-187.

Note: Electronic Journal of Biotechnology is not responsible if on-line references cited on manuscripts are not available any more after
the date of publication.

Supported by UNESCO / MIRCEN network

Objective: The aim of this study was to assess the sealing abilities of two calcium hydroxide
(Ca[OH] 2) pastes and two mineral trioxide aggregates (MTA) against leakage on direct pulp
capping with a computerized fluid filtration (CFF) method. Materials and Methods: The 60
recently extracted sound human molar teeth were sectioned at the level of the highest pulp
horn to obtain dentin discs of 0.5 0.2 mm. The dentin discs were numbered and
permeability measurements were done before and after the operation for the same sample.
For simulating direct pulp capping, dentin discs were perforated with a standard diamond bur
and restorated with four different capping materials: Dycal, Calcimol light-curing (LC),
ProRoot MTA and DiaRoot BioAggregate. Fluid movement measurements were tested with a
CFF method and a mean value was calculated for each specimen. Results: Calcimol LC and
Dycal showed significantly higher fluid conductance values compared to other pulp capping
materials (P < 0.05). There were no significant differences between ProRoot MTA and
DiaRoot BioAggregate (P > 0.05). Conclusion: Within the limitations of this study, it can be
concluded that using the MTA materials as a pulp-capping agent would be more efficient than
Ca (OH) 2 materials with regard to pulpal microleakage.
Keywords: Calcium hydroxide, computerized fluid filtration, direct pulp capping,
microleakage, mineral trioxide aggregate
How to cite this article:
Yalin M, Barutcigil , Sisman R, Yavuz T, Oruoglu H. Evaluation of the sealing ability of
pulp capping agents against leakage on direct pulp capping with a computerized fluid
filtration meter. J Res Dent 2014;2:46-50
How to cite this URL:
Yalin M, Barutcigil , Sisman R, Yavuz T, Oruoglu H. Evaluation of the sealing ability of
pulp capping agents against leakage on direct pulp capping with a computerized fluid
filtration meter. J Res Dent [serial online] 2014 [cited 2016 Mar 30];2:46-50. Available
from: http://www.jresdent.org/text.asp?2014/2/1/46/129025

Introduction

The consequences of pulp exposure from caries, trauma or unexpected tooth preparation
procedures can be severe and may include pain and infection. Direct pulp capping is an
effective treatment for preserving pulp vitality. There are various approaches regarding
capping materials and treatment of exposed pulp. [1] One of these approaches includes the use
of calcium hydroxide (Ca[OH] 2 ) that has been widely used as a mineralizing agent as well
as an effective antimicrobial medicament since its introduction into dentistry. Despite several
newer biomaterials being proposed for pulp capping procedures, Ca (OH) 2 is still considered
as the gold standard for comparing and evaluating new products. [2],[3] Ca (OH) 2 allows for
the formation of a reparative dentine bridge through cellular differentiation, extracellular
matrix secretion and subsequent mineralization. [4] Furthermore, a new material, mineral
trioxide aggregate (MTA), was developed in the 1990s by Torabinejad et al. at Loma Linda
University (California, USA) and has become available as a material used in root canal repair
and direct pulp capping. [5] Various in vitro studies suggest that MTA is biocompatible and has

good sealing properties. [3] Initial clinical studies evaluating the use of MTA as a direct pulp
capping material have also shown promising results. [6] During the setting process, MTA has
an initial pH of 10.2, which increases to 12.5 during the first few hours. [5] Although this pH
range is comparable with those achieved by Ca (OH) 2 , there appear to be differences in
pulpal tissue reaction to MTA compared with Ca (OH) 2 in direct pulp caps. [7] Bridge
formation tends to be more localized and homogenous (i.e., fewer tunnel defects) with MTA
than with those formed by Ca (OH) 2 . [8]
The success of direct pulp capping depends on several factors. It has been showed that the
type of biomaterial selected is of lesser consequence and that the quality of the cavity seal in
preventing microbial ingress is the most important factor determining the success of the
procedure. [9] Cox et al. [10] found that if a bacteria-tight seal is provided, pulpal healing
predictably occurred.
For measurements of permeability, several techniques have been used including fluid
filtration, scanning electron microscopy (SEM) and dye penetration. These are generally
based on a visual evaluation of single or multiple sections [11] and the specimens must be
destroyed during the evaluations. A method of measuring microleakage by the fluid filtration
method [12] overcomes the disadvantages of dye penetration and SEM evaluations. Samples
are not destroyed and it is possible to obtain measurements of the microleakage at intervals
over extended time periods. In addition, conventional fluid filtration measurements permit
quantitative assessments of the leakage for the entire sample. [12] This technique allows
calculations of the leakage by observing the movement of an air bubble inside a micropipette.
However, the measurements are relatively subjective since it is sometimes difficult to detect
visual readings and follow the minimal movement of an air bubble. The computerized fluid
filtration (CFF) method was introduced by Oruolu et al. [13] This technique depends on the
light refraction at the starting and ending positions of an air bubble. An infrared light passes
through the micropipette and two light-sensitive photodiodes are put on the opposite sides of
the micropipette to detect any movement of the air bubble. All operations are controlled by
PC-compatible software (Fluid Filtration 2003, Konya, Turkey).
Most investigations are conducted through an evaluation of clinical and radiographic
outcomes or histopathologic observations in human/animal models of pulp capping
procedures involving Ca (OH) 2 and MTA. However, few in vitro studies have evaluated the
leakage of these capping materials simultaneously. Therefore, the aim of this study was to
conduct a laboratory investigation to assess the sealing ability of Ca (OH) 2 and MTA against
leakage on direct pulp capping.
Materials and Methods
Sample preparation
In this study, 60 extracted carious-free human molars were used. The occlusal enamel and the
superficial dentin of each tooth were removed using a slow speed saw (Isomet, Buehler, Lake
Bluff, IL) under water cooling. 60 0.5 0.2 mm thick dentin discs were prepared from dentin
just above the highest pulp horn [Figure 1]. The discs were then randomly divided into four
groups. The permeability of the dentin varied considerably between and among different
teeth. Therefore, the teeth were numbered before performing the tests. The initial

permeability of each dentin disc was later used as its own control. The samples were placed
in a split-chamber device and fluid movement across each sample was measured. The
measurements of fluid conductance were done by following the displacement of an air bubble
in a micropipette with a constant barrel (25 L, 65 mm). During this procedure, a computer
program previously described by Oruolu et al. [13] was used [Figure 2]. The initial fluid
conductance for each specimen was also noted.
Figure 1: Schematic representation of specimen preparations
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Figure 2: Diagrammatic representation of the apparatus used to
measure microleakage with the computerized fluid filtration method
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Simulating perforation and pulp capping

An investigator perforated the dentin discs with the same 1 mm diameter bur. The diameters
of the exposed pulps were measured with a stereomicroscope and specimens having
inapplicable perforation sizes were eliminated. After the perforation procedure, all specimens
were restorated with one of the four commercial pulp-capping materials as follows [Table 1].

Table 1: Materials and their compositions' used in this study

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A Ca (OH) 2 paste, Dycal (Dentsply Caulk, Milford, USA), was used in the restoration of 15
perforated dentin discs. The base and catalyst of Dycal were mixed and directly applied to the
perforated discs as well.
A visible light-cured Ca (OH) 2, Calcimol light-curing (LC) (Voco GmbH, Cuxhaven,
Germany), was carried out by the same operator on 15 samples. Calcimol LC was cured for
20 s according to the manufacturer's directions.
Two MTAs, ProRoot MTA (Dentsply Maillefer, Ballaigues, Switzerland) and DiaRoot
BioAggregate (DiaDent Europe, Almere, Holland), were used in this study. 15 dentin discs
were repaired with ProRoot MTA and another fifteen discs were repaired with DiaRoot
BioAggregate according to manufacturers' instructions.
All specimens were then incubated at 37C for 72 h.

Evaluation of microleakage
After the dentin discs were treated as previously described above with pulp capping
materials, the discs were again placed in a split-chamber device and the fluid movement
across the dentin was remeasured using the same new CFF meter. Fluid conductance was
measured at 2-min intervals for 8 min. The mean of the values obtained was then calculated
for each specimen. The linear displacement of the bubble was converted to a volume of liquid
filtrated and hydraulic conductance was expressed as micro liters of water flow/cmH 2
O/minute pressure (1.2 atm). The data were calculated for each specimen. Leakage quantity
was expressed in L/cmH 2 O/min1 and the means were determined.
Statistical analyses
The results were statistically analyzed by one-way analyses of variance and a Tukey's
honestly significant difference post hoc test by specific software (IBM statistical package for
the social sciences statistic 20.0 for Mac, IBM Corporation NY, USA). Around 95% of
confidence level was used.
Results
The mean microleakage measurements and standard deviations, in L/cmH 2 O/min1 at 1.2
atm, are shown in [Table 2] for all materials. The amounts of the microleakage among the
tested materials ranged between 0.849 104 0.000055-0.192 104 0.000037 L/cmH 2
O/min1 at 1.2 atm. The ProRoot MTA demonstrated the least amount of micro leakage with
0.192 104 0.000037 L/cmH 2 O/min1 at 1.2 atm. The second lowest fluid conductance
values were obtained with the DiaRoot BioAggregate with 0.294 104 0.000038 L/cmH 2
O/min1 at 1.2 atm. Dycal and Calcimol LC showed significantly higher leakage results than
ProRoot MTA and DiaRoot BioAggregate (P < 0.05).
Table 2: Mean leakage values and standard deviations
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Discussion
MTA and Ca (OH) 2 materials have been compared in various studies according to the
effectiveness of the direct pulp capping treatments. Previous research suggests that in
different animal studies, MTA had significantly better results than Ca (OH) 2 when used as a
pulp capping agent. [8],[14] Dominguez et al. [15] used light-cured Ca (OH) 2 , MTA and acidetched dentin bonding as pulp capping agents in dog teeth. Statistical analysis of the data in
their study revealed no significant difference between MTA-treated pulps and sound, intact
control teeth. Alternatively, significantly more pulpal inflammation was observed in pulps
treated with Ca (OH) 2 or bonding agents than in control teeth. Recently, Mente et al. [3]
concluded that MTA performs more successfully than Ca (OH) 2 for maintaining long-term
pulp vitality after direct pulp capping in their retrospective clinical research.

However, it has to be remembered that following the pulp capping procedure, bacterial
leakage through the restoration material is considered to be the most detrimental reason for
poor results. Leye et al. [16] concluded that maintaining vitality of the pulp after capping
procedures requires a good seal of the material. Prevention of bacterial activities with a
capping material is very important. When the pulp is perforated, pulp-capping material is
expected to completely close the perforation area. It may kill some microorganisms that
contaminate the wound surface and it may also protect against the microbial effects of
microleakage. For this purpose, Ca (OH) 2 is often used. However, a recent study suggest that
pure Ca (OH) 2 and various hard-setting Ca (OH) 2 -containing cements, such as Dycal may
not prevent microleakage. [17] In addition, Murray et al. [18] reported that the incidence of
bacterial microleakage in Ca (OH) 2 -restored teeth was greater than other tested restoratives.
In accordance with previous reports, Dycal and Calcimol LC showed the lowest liquid
conductance values in the present study. Prosser et al. [19] claimed that Ca (OH) 2 cements
have a non-adhesive nature and exhibit dissolution over time. Farhad and Mohammadi [20]
stated that Ca (OH) 2 is biocompatible, but unfortunately has a low compressive strength
when placing definitive restorations like amalgam. This weak and non-durable nature of
cements may lead to the increased leakage values observed in the present study. In addition,
the light curing Ca (OH) 2 cement, Calcimol LC, showed the highest liquid conductance
values when compared with other materials. The present study's results are supported by
McConnell et al. [21] explanations. McConnell et al. reported that when visible light-cured Ca
(OH) 2 was placed on the pulpal floor, it tended to form a meniscus curve and left an apparent
deficiency on the pulpal floor.
The physical properties of MTA or capping materials might be influenced by crystal size.
Smaller particles increase surface contact with the mixing liquid and lead to greater early
strength as well as ease of handling.
A study by Komabayashi and Spangberg reported that some particles of MTA are as small as
1.5 m, which is smaller than the diameter of some dentinal tubules (2-5 m). [22] The authors
hypothesized that this might play a significant role in the sealing ability of MTA after
hydration and production of a hydraulic seal.
Different methods used in studies for assessing leakage include the dye penetration method
[23]
electrochemical leakage test and the fluid filtration technique. [24] In addition to these
methods, Oruolu et al. introduced a new CFF method. [13] This method has some
advantages such as being computer controlled, having a digital air pressure arrangement and
the ability to follow air bubble movements with laser diodes. [13] They also claimed that this
technique allows quantitative measurements of microleakage without destroying the samples
like the fluid filtration technique.
In direct pulp capping, when MTA is chosen because of its advantages such as lower
solubility, improved mechanical strength, better marginal adaptation and sealing ability, some
of disadvantages of Ca (OH) 2 can be avoided. These disadvantages include resorption of the
capping material, mechanical instability and inadequate sealing ability due to leakage. [25]
Most of the studies have involved comparisons with Ca (OH) 2 medicaments and these
studies have indicated that MTA is either equally or more successful in pulp capping.
However, there are few studies that have investigated the sealing ability of MTA and Ca(OH)
[25]
compared MTA and Ca
2 when using direct pulp capping materials. Dammaschke et al.
(OH) 2 70 days after capping in rat molars and found there were no differences between MTA
and Ca (OH) 2 in the dye penetration results. In spite of the positive properties of MTA,

additional research is needed because the numbers of the studies concerning leakage are not
adequate.
Conclusion

Within the limitations of this study, it can be concluded that direct pulp capping with MTA
materials seems to be superior to that of Ca (OH) 2 . It should also be kept in mind that further
long-term studies are needed to support these results. Furthermore, it is known to what extent
leakage of the materials prior to capping might have contributed to the positive results.

Keys to Clinical Success with Pulp

Capping: A Review of the Literature
TJ Hilton
Author information Copyright and License information
The publisher's final edited version of this article is available at Oper Dent
See other articles in PMC that cite the published article.
Go to:

INTRODUCTION
The consequences of pulp exposure from caries, trauma or tooth preparation misadventure
can be severe, with pain and infection the result. The morbidity associated with treating pulp
exposures is consequential, often requiring either extraction or root canal therapy. Both the
loss of the tooth and its replacement, or endodontic treatment and tooth restoration, involve
multiple appointments and considerable expense. An alternative procedure to extraction or
endodontic therapy is pulp capping, in which a medicament is placed directly over the
exposed pulp (direct pulp cap), or a cavity liner or sealer is placed over residual caries
(indirect pulp cap) in an attempt to maintain pulp vitality and avoid the more extensive
treatment dictated by extraction or endodontic therapy. Although many products have been
suggested, a recent Cochrane Review found that evidence is lacking as to the most
appropriate pulp capping material.1 In addition, various factors are believed to influence the
success of both direct and indirect pulp capping. It is the purpose of this literature review to
examine the evidence, issues and materials relevant to pulp capping.
This review was undertaken as preparatory work for an essay at the annual meeting of the
Academy of Operative Dentistry. It also served to provide the back-ground and scientific
rationale for a clinical trial on direct pulp capping being undertaken in the Northwest
PRECEDENT Practice-based Research Network (PBRN).
Go to:

LITERATURE SEARCH PARAMETERS

No specific criteria were applied a priori as to what articles would be accepted into this
review. Rather, it was hoped that the span of literature reviewed would be as comprehensive
as possible. PubMed and Ovid databases were searched for any articles that met the criteria of
containing pulp capping, direct pulp capping, indirect pulp capping, sealed dental
caries or pulp capping materials. No date limits were applied. An initial screen of returned
abstracts was accomplished, and relevant full-length articles from peer-reviewed periodicals
were obtained. Pertinent citations contained in the full-length articles were used as sources
for additional review.
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INFORMED CONSENT
The ultimate goal of a review such as this is to derive conclusions based on the evidence that
can be applied to clinical practice. Just as any astute clinician will discuss the procedures,
advantages, risks and patient questions (PARQ) prior to initiating a course of treatment, it is
important for the reader to be aware of the shortcomings in the greater body of literature
regarding pulp capping. It is only in this context that the reader can be aware of the
challenges and shortcomings inherent in drawing definitive conclusions from the pulp
capping literature. The following informed consent statements are for the purpose of
stressing these challenges and shortcomings.

Clinical Pulp Capping Studies Rarely Reflect Clinical Reality

The typical clinical study for pulp capping contains the following features:
1. The patient is young (typically 1525 years of age) and healthy.
2. The patient is going to have premolars (subject teeth) extracted for orthodontic
reasons.
3. The subject teeth are free of caries, cracks or other defects.
4. The teeth are isolated with a rubber dam, receive a pumice prophylaxis and are often
times disinfected (sometimes with two antibiotic solutions).
5. A sterile bur is used to initiate cavity preparation. When nearing the pulp, a new
sterile bur is replaced in the handpiece and pulp exposure is initiated as atraumatically
as possible.
6. Hemorrhaging is controlled with sterile materials.26
While these procedures help to standardize the experimental technique and maintain internal
validity, they do not reflect the circumstances under which most practitioners are confronted
with a potential pulp cap situation.

Histological Pulp Status Cannot be Determined by Clinical Signs and

Symptoms
The true gold standard of pulp status is histological analysis. Unfortunately, the true state of
pulp health or pathology cannot be determined by clinical signs, symptoms or radiologic
appearance. Clinicians have only relatively crude assessments, such as the application of hot
or cold temperatures, an electric current, percussion of the tooth, changes in the appearance
of associated soft tissues and patient reports of symptoms. However, numerous studies
including histological analysis have demonstrated a chronically inflamed pulp, but the
patients reported no symptoms, the investigators discerned no signs and no apical/radicular
pathology was noted on radiographs. It must also be kept in mind that most studies that
include histological analysis are of quite a short duration, typically two to four months.34,69

Outcomes in Animal Studies Not Necessarily Predictive of Human Outcomes

Much research on pulp capping has been accomplished in animals, from lower species, such
as mice and dogs, to primates. However, the results of pulp capping in animals often does not
reflect what will happen in humans. It is necessary to be very cautious in taking the results of
animal pulp capping studies and applying them to human patients.34,7,1012

Inconsistencies in Research Protocol

Some studies do not maintain a consistent methodology within the study. For example, the
restorative regimen may vary among the experimental groups. Different restorative materials
have different restoration-cavity preparation sealing characteristics. This can hamper
interpreting the results, since it is difficult to determine whether differences in the pulp status
are the result of the pulp cap regimen or the restorative procedure.1315
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BASIC PRINCIPLES
A controversy has existed within dentistry as to what is more detrimental to the pulp: toxicity
from dental materials or bacteria and/or their toxins. For many years, even decades,
practitioners believed that some restorative materials killed pulps due to their inherent toxic
properties. However, research since the mid-1970s has indicated that the pulp can tolerate a
variety of restorative materials if bacteria and/or their toxins can be excluded from the pulp.
This is tempered by the particular material involved and whether or not the material has
direct contact with pulp tissue or it has an intervening layer of protective dentin. Once
bacterial invasion encroaches on the pulp, serious and adverse pulpal reactions ensue.1619
Therefore, one of the crucial principles, and one that will be reiterated throughout this article,
is that the key to pulp survival after capping is a well-sealed restoration.2025
However, it must be kept in mind that pulp is a soft tissue, and similar to other soft tissues in
the body, it will react to a noxious stimulus with an inflammatory response. There are a
number of materials-related sequela associated with direct pulpal contact with certain
materials, including cytotoxicity and immunosuppression. The first reaction will destroy pulp
cells, and the latter will reduce the ability of the pulp to respond to a bacterial invasion. In
addition, many materials require light curing for polymerization, and such units have
demonstrated the ability to raise intrapulpal temperature to levels incompatible with pulp cell
survival. 2630 Multiple pulp cap studies have demonstrated that pulp inflammation can be
unrelated to bacterial presence, reinforcing the concept that certain materials applied directly
to pulp tissue may elicit significant inflammatory response.2,4,31
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INDIRECT PULP CAPPING

Removal of caries is one of the most basic activities in dentistry. When caries is deep, every
restorative dentist is faced with the question of the best way to proceed: is it better to remove
all caries regardless of pulpal consequences, or stop and not expose the pulp? When
practitioners in a dental PBRN were given a hypothetical scenario that involved this question,
only 17% responded that they would stop, leave the remaining caries in place and restore the
tooth.32 This procedure, where caries is allowed to remain adjacent to a vital pulp rather than

risk pulp exposure, covered with a cavity sealer or liner and restored, is termed an indirect
pulp cap. The evidence regarding indirect pulp capping stands in contrast to the response of
practitioners, however. Several studies show restored teeth with partial caries removal have
equal success compared to restored teeth with complete caries removal.3335 A number of
studies have evaluated the fate of caries lesions in which partial caries removal was done.
Typically, an initial clinical and microbiological assessment of the caries lesion is carried out,
partial caries removal is accomplished and a sealer or liner and restoration is placed for a
period of 412 months before the tooth is re-entered and reassessed. Invariably, these studies
find that the lesion color has changed from light brown to dark brown; the consistency goes
from soft and wet to hard and dry, s mutans and lacto-bacilli have been significantly reduced
to a limited number or even zero viable organisms, and the radiographs show either no
change or even a decrease in the radiolucent zone. The type of liner is less important to
success than the placement of a well-sealed restoration.20,34,3641 In addition, partial caries
removal significantly reduces the chance of pulp exposure during caries excavation.22,42 These
findings are confirmed by two thorough systematic reviews that concluded the following:
partial caries removal reduced the risk of pulp exposure by 98% compared to complete caries
excavation in teeth with deep caries; there is no evidence that partial caries removal is
detrimental in terms of signs, symptoms, pulpitis occurrence or restoration longevity; there is
substantial evidence that complete caries removal is not needed for success provided the
restoration is well sealed.24,43
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DIRECT PULP CAPPING

The pulp of a tooth can be exposed due to several causes: caries, trauma or mechanical
reasons, the latter typically due to a misadventure during tooth preparation. The direct pulp
cap, in which a material is placed directly over the exposed pulp tissue, has been suggested as
a way to promote pulp healing and generate reparative dentin. If successful, this procedure
precludes the need for more invasive, more extensive and more expensive treatment. A
number of factors have been shown to have an impact on direct pulp cap success. It is the
purpose of this section to review these factors, with a particular emphasis on the materials
that have been used, or suggested for use, in direct pulp capping.
Some studies have shown that a tooth is more likely to survive direct pulp capping if the
initial exposure is due to mechanical reasons rather than caries.25,44 Caries penetration to the
pulp will result in bacterial invasion of the pulp, resulting in pulpal inflammation. 1619 This
leaves the pulp less able to respond and heal, compared to a mechanical exposure in which
preexisting inflammation is not present. A logical extension of this is that teeth that are
asymptomatic and exhibit no clinical or radiologic signs of pathology at the time of pulp
capping tend to fare better than those teeth with such factors present.25 The placement of a
permanent, well-sealed restoration at the time of pulp capping is crucial to clinical success.20
25,36,45

Controlling Pulpal Bleeding

Another factor that has been demonstrated to have an effect on direct pulp cap success is the
ability to control pulp bleeding after the exposure and prior to placing the pulp cap agent.4648
This is likely a result of two reasons. First, increased bleeding can be indicative of a greater

degree of inflammation in the pulp, with a resultant diminished capacity for repair. The
second reason is that the moisture and contamination of dentin adjacent to the exposure site
due to bleeding can make it more difficult to obtain an adequate seal that will prevent
subsequent bacterial exposure. Bleeding is normally controlled by placing a cotton pellet
soaked in a solution on the exposed pulp. A variety of solutions have been used, including
saline, sodium hypochlorite (concentrations ranging from 0.12% to 5.25%), hydrogen
peroxide, ferric sulfate and chlorhexidine. Saline or calcium hydroxide solutions are the most
benign to the pulp in cytotoxicity tests.49
In-vivo studies confirm that saline shows the mildest pulp response and is the solution used in
most studies. Sodium hypochlorite shows increased pulpal inflammatory response but has the
advantages of possessing antibacterial properties and providing enhanced hemorrhage
control. It, too, has been used effectively in many studies and clinical reports. Chlorhexidine
is antibacterial but may not be as effective at hemorrhage control as sodium hypochlorite.
There is less data on other hemostatic agents that are typically associated with hemorrhage
control and tissue retraction for impression taking. What little research that has been done is
short-term, but it would seem to indicate that there is not a significant difference in pulp
response relative to other solutions more commonly used for controlling pulp bleeding. The
one exception is ferric sulfate, which demonstrated significantly increased post-operative
pain.7,9,15,26,5052
Go to:

DIRECT PULP CAPPING MATERIALS

A number of materials have been suggested for use in direct pulp capping. Interestingly, no
one material seems to enjoy a significant preference among practitioners. In a survey in
which private practitioners were asked what direct pulp capping material they use, the
respondents listed four different materials, with none being preferred by a clear majority of
users.53 This section will review the evidence regarding the effectiveness of various pulp
capping materials that have been used for direct pulp capping.

Zinc Oxide Eugenol (ZOE)

ZOE formulations have been used in dentistry for many years as bases, liners, cements and
temporary restorative materials. Its use for direct pulp capping is questionable, however.
Eugenol is highly cytotoxic.5457 It is known that ZOE releases eugenol in concentrations that
are cytotoxic.56,5860 ZOE also demonstrates high interfacial leakage.61 Although it has been
noted that this leakage is not important since ZOE can provide a biologic seal due to the
eugenol release, it must be kept in mind that eugenol release drops dramatically with time,58
and it is anticipated that the effectiveness of ZOE in excluding bacteria is reduced the longer
it is in place in the mouth.
This review only found one human clinical study using ZOE as a direct pulp capping agent.
In this study, all teeth capped with ZOE showed chronic inflammation, no pulp healing and
no dentin bridge formation up to 12 weeks post-operatively. Conversely, all control teeth that
were capped with calcium hydroxide demonstrated healing within four weeks.62

Glass Ionomer (GI)/Resin-Modifed Glass Ionomer (RMGI)

While not as cytotoxic as ZOE, GI/RMGI is also cytotoxic when in direct cell contact. The
conventional formulations tend to be less toxic than the resin-modified formulations.57,59,6364
This should not be construed as an indictment against the use of GI/RMGI in deep cavities.
Because of glass ionomers ability to chemically bond to tooth structure, it can prevent the
diffusion of potentially toxic materials through dentin to the pulp. Glass ionomer also
provides an excellent bacterial seal and shows good biocompatibility when used in close
approximation but not in direct contact with the pulp.6568
As with ZOE, this review found only one human study of direct pulp capping using glass
ionomerin this caseRMGI. Direct pulp capping with RMGI showed chronic
inflammation and lack of dentin bridge formation up to 300 days post-pulp capping, whereas,
the calcium hydroxide control groups showed significantly better pulpal healing.69

Adhesive Systems
Adhesive systems were suggested for use as a potential direct pulp capping agent
approximately 1215 years ago.70 As with the previous two pulp capping agents, all
components of adhesive systems have been shown to be cytotoxic to pulp cells.71 The toxic
effects of the various components of adhesives are synergistic, especially with increasing
duration of contact with the pulp.72 Toxicity is seen in both multi- and single-component
adhesive systems, and the unpolymerized components are more toxic than when the adhesive
is well polymerized. 71
The interest in using adhesives for pulp capping was driven, at least in part, by the fact that
some non-primate studies found that mechanical pulp exposures capped with adhesives
generally resulted in pulp healing. 7375 These results were not unanimous, as some nonprimate studies did find inferior healing following pulp capping with adhesives compared to
calcium hydroxide.7677 A number of studies of primate, non-contaminated, mechanical pulp
exposures capped with adhesive systems generally resulted in healing comparable to calcium
hydroxide.14,7882
However, this outcome changes when the results are examined from studies of bacteriacontaminated mechanical pulp exposures in primates. This experimental regimen was chosen
to more closely resemble the situation that might be encountered if a pulp exposure occurred
due to caries or without a rubber dam in place. These contaminated exposures capped with
adhesives resulted in poor pulp healing compared to calcium hydroxide.26,83
When the results of human pulp-capping studies are reviewed, the conclusions become very
different than what would have been deduced from animal studies. Table 1 summarizes
several human studies comparing pulp capping with calcium hydroxide versus adhesives. In
each study cited in Table 1, calcium hydroxide provided significantly improved pulpal repair
compared to adhesive systems, regardless of whether it was an etch-and-rinse or self-etch
system.

Table 1
A Comparison of Human Study Outcomes of Direct Pulp Capping Comparing Calcium
Hydroxide to Adhesive Systems
There are several possible explanations for these poor outcomes in human studies. First are
the direct cytotoxic effects that adhesives have on pulp cells.71 Next is the difficulty in
obtaining an adequate seal to protect against bacterial contamination. This poor seal may be
due to one or more reasons. Etch and primer components of adhesives are vasodilators, which
can result in increased bleeding that contaminates adjacent dentin and degrades adhesion.6,9,86
The increased moisture at the pulp cap site reduces polymerization of the adhesive. This has
the dual detrimental effect of decreasing adhesion and increasing the availability of the
unpolymerized, and therefore more toxic components of the adhesive.87 Finally, resin
components reduce the pulps immune response, making it less likely that the pulp will be
able to defend itself against bacterial contamination.29 These findings were confirmed in a
review of pulp capping with adhesives, in which de Souza Costa and others concluded the
following: adhesives result in inferior pulp healing; adhesives result in chronic inflammation,
even in the absence of bacteria; inflammation is a poor environment for pulp healing; a pulp
inflamed due to caries will have decreased healing capacity.10

Calcium Hydroxide
Calcium hydroxide was introduced to the dental profession in 1921 and has been considered
the gold standard of direct pulp capping materials for several decades.25 There are a number
of well-known advantages to calcium hydroxide that have caused it to receive this
recognition. Calcium hydroxide has excellent antibacterial properties.88 One study found a
100% reduction in microorganisms associated with pulp infections after one-hour contact
with calcium hydroxide.89 Most importantly, calcium hydroxide has a longterm track record
of clinical success as a direct pulp-capping agent in periods of up to 10 years,46,84,90 although
reduced success rates have been found in studies in which dental students were the
operators.6,25,4445
Calcium hydroxide has some disadvantages as well. The self-cure formulations are highly
soluble and are subject to dissolution over time,91 although it has been noted that, by the time
the calcium hydroxide is lost due to dissolution, dentin bridging has occurred.84 Calcium
hydroxide has no inherent adhesive qualities and provides a poor seal.92 Another criticism
noted of calcium hydroxide is the appearance of so-called tunnel defects in reparative
dentin formed underneath calcium hydroxide pulp caps.9394 A tunnel defect has been
described as a patency from the site of the exposure through the reparative dentin to the pulp,
sometimes with fibroblasts and capillaries present within the defect.94 However, other
researchers have found that the quality of reparative dentin improves as the bridge gets
thicker,95 and that many times, the tunnel defects are not patent with the pulp.76 It appears that
tunnel defects are not a common finding in human studies involving direct pulp capping with

calcium hydroxide. There are fewer studies that note observing tunnel defects and more
studies that do not observe tunnel defects.23,6,9,84
Calcium hydroxide is believed to effect pulp repair by one or more of several mechanisms of
action. Calcium hydroxide possesses antibacterial properties, and this can minimize or
eliminate bacterial penetration to the pulp.88 Traditionally, it has been believed that calcium
hydroxides high pH causes irritation of the pulp tissue, which stimulates repair via some
unknown mechanism.96 In recent years, this unknown mechanism may have been explained
by the release of bioactive molecules. It is known that a variety of proteins are incorporated
into the dentin matrix during dentinogenesis. Of particular importance to the topic of pulp
capping is that at least two of these proteins, Bone Morphogenic Protein (BMP) and
Transforming Growth Factor-Beta One (TBF-1), have demonstrated the ability to stimulate
pulp repair.9799 Furthermore, calcium hydroxide is known to solubilize these proteins from
dentin, lending credence to the release of these bioactive molecules as a significant mediator
in pulp repair following pulp capping.96,99

Mineral Trioxide Aggregate (MTA)

Mineral Trioxide Aggregate (MTA) has generated considerable interest as a direct pulp
capping agent in recent years. Unset MTA is primarily calcium oxide in the form of
tricalcium silicate, dicalcium silicate and tricalcium aluminate. Bismuth oxide is added for
radiopacity.100101 MTA is considered a silicate cement rather than an oxide mixture, and so its
biocompatibility is due to its reaction products.102 Interestingly, the primary reaction product
of MTA with water is calcium hydroxide, 100,102104 and so it is actually the formation of
calcium hydroxide that provides MTAs biocompatibility.105
As a result, many of the advantages and potential mechanisms of action for MTA are similar
to calcium hydroxide, including its antibacterial and biocompatibility properties, high pH,
radiopacity and its ability to aid in the release of bioactive dentin matrix proteins.103104,106109
There are some differences between MTA and calcium hydroxide. First, MTA comes in two
colors, white and grey. The grey version is due to the addition of iron.110 Another significant
difference is the fact that MTA provides some seal to tooth structure.111
There are several disadvantages with MTA, as well. It has shown high solubility,
demonstrating 24% loss after 78 days of storage in water.103104 The presence of iron in the
grey MTA formulation may darken the tooth.108A significant downside to MTA is the
prolonged setting time of approximately 2 hours and 45 minutes.106107 This requires that pulp
capping with MTA either be done in a two-step procedure, placing a temporary restoration to
allow the MTA to set before placing the permanent restoration, or using a quick-setting liner
to protect the MTA during permanent restoration placement. The handling characteristics of
the powder-liquid MTA are very different from the typical paste-paste formulations of
calcium hydroxide that most practitioners find easy to handle. When compared to these pastepaste formulations of calcium hydroxide, MTA is very expensive. One gram of MTA powder
costs approximately the same as 24 grams of calcium hydroxide base/catalyst paste, making
MTA much less cost effective per use.
A review of animal direct pulp capping studies comparing MTA to calcium hydroxide
generally reveals better pulp healing with MTA.112116 As with pulp capping studies comparing
adhesives to calcium hydroxide, the results are different when comparing MTA to calcium
hydroxide in humans. Table 2 demonstrates that most human studies show similar pulp-cap

outcomes of MTA and calcium hydroxide. However, two of these studies demonstrate
superior performance of MTA, and both share an interesting study characteristic: the pulpcapped teeth were restored with a temporary ZOE material versus a permanent restoration for
the other studies. As discussed in the section on ZOE, these materials leak significantly and
lose their antibacterial eugenol release rapidly. So, these results may point to the ability of
MTA to provide a seal over the pulp exposure that calcium hydroxide does not. Additional
human studies using MTA as the sole pulp cap agent with no control group have shown good
success in periods ranging from six months to four years.51,124125

Table 2
A Comparison of Human Study Outcomes of Direct Pulp Capping Comparing Calcium
Hydroxide to MTA
On the basis of the literature to date, it would appear that MTAs success is likely due to the
fact that it serves as a reservoir for calcium hydroxide and/or its capacity to provide a seal at
the site of the pulp exposure. Even though MTA seals better than calcium hydroxide, it should
be kept in mind that a glass ionomer (GI) or resin-modified glass ionomer (RMGI) will be
needed as a liner over either pulp cap material. In the case of calcium hydroxide, the
GI/RMGI liner is needed to provide a protective antibacterial seal that calcium hydroxide
alone cannot provide. In the case of MTA, the GI/RMGI liner is needed to protect the MTA
during restoration placement due to the prolonged setting time. Without this GI/RMGI
protective sealer, it would be necessary to place a temporary restoration for a period of time
until the MTA is set, requiring the patient to present for a second appointment for definitive
restoration placement.

MTA Over-exuberance?
Certainly, the results of pulp capping studies using MTA are encouraging. However, it
appears that some statements regarding the efficacy of MTA as a pulp-capping agent are not
supported by the study results. Two examples may help to clarify this. One study made the
following statement: In light of the results of the present and other relevant studies, MTA is
superior to calcium hydroxide for pulp capping mechanically exposed human teeth.108 In this
study, the pulps of 14 teeth were intentionally exposed, half capped with calcium hydroxide
and the other half with MTA. The teeth were extracted at one, two, three, four weeks and six
months and evaluated histologically. By the final evaluation period (six months), only one
tooth per group was evaluated. There were too few specimens for statistical analysis. In light
of these results, it would appear that the comment of MTA superiority is unwarranted.
In another article, the authors stated, The outcomes suggest that MTA is a more predictable
pulp-capping material than calcium hydroxide.51 Forty-nine teeth received an MTA direct
pulp cap and were followed over an average of approximately four years. Clinical assessment
revealed an apparent 98% success for the pulp-capped teeth. However, no histological

analysis was done to assess the true state of pulpal health or disease. Most importantly, no
calcium hydroxide control group was included in the study, and so it would not be possible to
conclude that MTA was a more predictable pulp-capping material than calcium hydroxide in
this evaluation.

Does calcium hydroxide provide any benefits over MTA?

MTA is a promising material, but calcium hydroxide shows a long-term track record of
clinical success that MTA cannot claim at the present time. A review of 14 clinical studies,
including over 2,300 cases of calcium hydroxide pulp capping, noted success rates of up to
90% when done by experienced clinicians.25 This review article highlighted two keys to
calcium hydroxide direct pulp capping success: restricting pulp capping to asymptomatic
teeth and providing a well-sealed restoration following the pulp cap. In addition, calcium
hydroxide has demonstrated clinical success even when done under less-than-ideal
circumstances. A three-year study of 44 carious exposed pulps capped with calcium
hydroxide resulted in an 80% success rate.46 Thirty-four traumatically exposed teeth that
experienced an approximately four-hour delay before calcium hydroxide pulp capping
demonstrated 97% success when followed for periods of up to 17 years.90 To better elucidate
the relative benefits of MTA versus calcium hydroxide for pulp capping, a large scale,
prospective clinical trial comparing MTA to calcium hydroxide as a direct pulp-cap material
is needed. NW PRECEDENT, a NIDCR-supported practice-based research network is
engaged in such a study.
Go to:

CONCLUSIONS
On the basis of this review, the following can be concluded:
1. Avoid exposing the pulp. The chances for tooth survival are excellent if the tooth is
asymptomatic and well sealed, even if residual caries remains.
2. Control hemorrhage with water, saline or sodium hypochlorite. Water and saline are
the most benign to the pulp; sodium hypochlorite is best at controlling hemorrhage
and disinfecting.
3. ZOE, GI/RMGI and adhesives are poor direct pulp-capping agents and should be
avoided for this application.
4. MTA demonstrates comparable results to calcium hydroxide as a direct pulp cap agent
in short-term data.
5. Calcium hydroxide remains the gold standard for direct pulp capping. It has the
longest track record of clinical success, is the most cost-effective and is the likely
effective component in MTA.
6. Provide a well-sealed restoration immediately after pulp capping. This will provide
protection against ongoing leakage and bacterial contamination that can compromise
the success of the pulp cap.

Clinical Relevance
Confusion and misconceptions surround direct and indirect pulp capping. This review of the
literature provides evidence-based recommendations to guide clinicians in their decisionmaking process when they encounter a situation requiring pulp capping

Judul

:TRIOXIDE AGGREGATE (MTA) STUDIPUSTAKA

Pengara :Mellisa , Wignyo Hadriyanto , Juanita A. Gunawan

ng
Jurnal :Majalah Ilmu Kedokteran Gigi 2011, (0)
Tahun :2011
Summar :Penggunaan MTA menjadi bahan pilihan pada berbagai
y / Kata perawatan endodontik, seperti pengisian retrogard,
Kunci perbaikan perforasi, bahan pengisi saluran akar,
apeksifikasi dan kaping pulpa. Tujuan studi pustaka ini
untuk mengulas penggunaan bahan MTA pada perawatan
kaping pulpa. Kalsium hidroksida merupakan bahan yang
umum digunakan pada perawatan kaping pulpa, memiliki
biokompatibilitas yang baik, pH tinggi, bersifat antibakteri
dan merangsang pembentukan jembatan dentin.
Kekurangan kalsium hidroksida adalah tidak dapat
beradhesi baik dengan dentin dan mengalami degradasi
sehingga pembentukan jembatan dentin menjadi celah
terjadinya kebocoran dan invasi bakteri ke jaringan pulpa.
Mineral Trioxide Aggregate (MTA) menjadi bahan pilihan
untuk keberhasilan perawatan kaping pulpa. Pada
beberapa penelitian menyatakan MTA merupakan bahan
yang biokompatibel, memiliki kemampuan sealing yang
baik, menginduksi pembentukan jaringan keras, tidak larut
pada jaringan mulut, dan mengeras pad a keadaan
lingkungan yang lembab. Berbagai penelitian klinis yang
meggunakan MTA sebagai bahan kaping pulpa
menunjukan pembentukan jembatan dentin lebih tebal
dan cepat dan tingkat peradangan yang lebih rendah, bila
dibandingkan dengan perawatan menggunakan
kalsiumhidroksida. .
Hasil studi pustaka menunjukan bahwa MTA dapat menjadi
bahan pilihan pada perawatan kaping pulpa. Perawatan
MTA menunjukan sedikit peradangan pulpa dan
pembentukan jembatan dentin yang lebih baik. Namun
waktu pengerasan MTA yang lama menjadi bahan
pertimbangan.