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Outcomes of Vital Pulp Therapy Using Mineral Trioxide Aggregate or

Biodentine: A Prospective Randomized Clinical Trial

Article  in  Journal of Endodontics · October 2018

DOI: 10.1016/j.joen.2018.08.004

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Outcomes of Vital Pulp Therapy Using Mineral
Trioxide Aggregate or Biodentine: A Prospective
Randomized Clinical Trial
Lama Awawdeh, BDS, MSc, PhD,* Aladdin Al-Qudah, BDS, PhD, FDS RCPS(Glasg),*
Hanan Hamouri, BSc, MSc, PhD,† and Rosalie Jean Chakra, BDS, MSc*
Abstract
Introduction: Mineral trioxide aggregate (MTA) has
been used in pulp capping of cariously exposed mature
permanent teeth with promising results. The search for
alternative materials that seal better and set faster than
MTA and do not stain is ongoing. Biodentine (Septo-
dont, St Maur-des-Foss
es, France) exhibits these advan-
tages but has not been tested yet for a prolonged
duration in mature teeth. This study aimed to evaluate
the clinical performance of Biodentine and white MTA
(Angelus, Londrina, Brazil) in cariously exposed mature
permanent teeth. Methods: This was a prospective lon-
gitudinal randomized controlled study of 68 vital perma-
nent teeth with deep caries. Patients were randomly
allocated into 2 study arms: Biodentine and MTA. Teeth
were assessed clinically and radiographically before the
procedure. Caries were excavated under local anes-
thesia; hemostasis was achieved after pulp exposure us-
ing sodium hypochlorite and capped with Biodentine or
MTA. Clinical and radiographic follow-ups were per-
formed by a blinded calibrated evaluator after 6 months
and 1, 2, and 3 years. Results: There were no significant
differences in the overall success rate between Bio-
dentine and MTA; it was 93.3% (Biodentine = 93.1%
and MTA = 93.5%) at 6 months. The overall success
rate increased to 96.2% (Biodentine = 96.0% and
MTA = 100%) at 1 year and to 100% at 2 years.
At the 3-year follow-up, it decreased to 93.8%
(Biodentine = 91.7% and MTA = 96.0%). Conclusions:
Biodentine and MTA have favorable and comparable
success rates when used as direct pulp capping or
pulpotomy material in permanent mature teeth with
carious exposure. The remaining tooth structure
and durability of coronal restoration might affect
significantly the long-term success of vital pulp therapy.
(J Endod 2018;44:1603–1609)
From the *Department of Conservative Dentistry, Faculty of Dentistry and †Department of Mathematics and Statistics, Faculty of Science and Arts, Jordan University
of Science and Technology, Irbid, Jordan.
Address requests for reprints to Dr Lama Awawdeh, Department of Conservative Dentistry, Faculty of Dentistry, Jordan University of Science and Technology, PO Box
3030, Irbid 22110, Jordan. E-mail address: lawawdeh@just.edu.jo
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.08.004
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CONSORT Randomized Clinical Trial
Key Words:
Biodentine, carious exposure, exposure, mineral trioxide aggregate, vital pulp therapy
T he treatment of cari-
ously exposed pulp in
mature permanent teeth
Significance
VPT in mature teeth with carious exposure
managed by DPC or PP achieves similar and prom-
has been controversial.
ising results. Biodentine and MTA have similar sur-
Nowadays, it should not
vival probability when used as pulp capping
be tradition to perform
materials within the 3-year follow-up.
root canal treatment just
because pulp exposure
occurred during caries excavation. Preserving the vitality of teeth is very important
because it conserves the defense mechanism of the pulp and enables dentin formation
(1). Furthermore, devitalized and root-filled teeth have a higher incidence for root frac-
ture because a root canal–treated tooth requires more load to register a proprioceptive
response than a vital tooth (2).
It has been suggested that vital pulp therapy (VPT) procedures should not be
limited to the treatment of reversible pulpitis (3). This is because the reversible or irre-
versible status of pulp cannot be definitively diagnosed based on clinical signs and
symptoms, such as the degree of pain or characteristics of pain (4). More evidence
is now building in favor of VPT in teeth regardless of the patient’s clinical signs and
symptoms suggestive of reversible or irreversible pulpitis (5).
A range of parameters can influence the choice between VPT and root canal ther-
apy as well as the outcome of VPT. Matsuo et al (6) performed direct pulp capping
(DPC) of carious-exposed pulp and reported the quantity of bleeding at the exposure
site as the most crucial outcome predictor. However, the authors neglected to consider
other factors, such as patient age, exposure size, remaining tooth structure, results of
thermal and percussion tests, and pulpal diagnosis. Healthy pulp with an uncompro-
mised blood supply at the time of capping is essential for successful VPT (5, 7). We
assessed the preoperative pulpal status based on clinical signs and symptoms, which
do correlate to a certain extent with histologic pulpal diagnosis (8). However, previous
studies have shown that cariously exposed pulp is not always infected, and inflammation
is usually localized under the affected area (5, 9). Hence, VPT is no longer limited for
clinically diagnosed reversible pulpitis cases. A number of studies have reported a high
success rate for VPT in teeth with irreversible pulpitis (5, 9–11). Therefore, more
clinical studies with longer follow-ups are needed to investigate the success rate of
VPT in teeth with different pulpal diagnosis using different VPT protocols.
Vital Pulp Therapy with Biodentine or MTA 1603
CONSORT Randomized Clinical Trial
Mineral trioxide aggregate (MTA) is an alkaline material that stim- data were collected, we ended up with 68 records. The patients were
ulates dentin bridge formation and has good sealing ability and biocom- assigned randomly by the operator into the following study arms with
patibility (12). A number of studies have reported high success rates of a coin toss: BD or white MTA (wMTA; Angelus, Londrina, Brazil)
VPT with MTA (7, 13, 14). However, there are some drawbacks to MTA, (n = 34 teeth for each group). To ensure equal sample sizes for
mainly discoloration, a long setting time, and expense (12). Therefore, both groups, we took patients in pairs and used a coin toss to allocate
the search in dentistry for an alternative material is ongoing. the treatment. In other words, for each block of 2 patients, the first pa-
Recently, Biodentine (BD; Septodont, St Maur-des-Foss
es, tient was assigned 1 of 2 treatments depending on the result of the coin
France), which is a calcium silicate–based material, has gained popu- toss with the second patient being assigned the alternative treatment.
larity in endodontics. It has the same clinical applications of MTA but
with superior physicochemical properties, micromechanical
Clinical Examination
anchorage, absence of tooth discoloration, a fast setting time, and
Preoperative clinical examinations included a visual inspection of
ease of handling (15). Because BD is a relatively new material, long-
the extent of caries and gingival health. A percussion test was per-
term clinical studies evaluating its performance as a capping agent in
formed, and the periodontal status and pulp sensibility were assessed.
mature permanent teeth are lacking. BD was reported to have a similar
Patients reporting sharp nonlingering pain to cold testing lasting for a
efficacy to MTA in the clinical setting when tested as a capping agent in
few seconds were diagnosed with reversible pulpitis. Patients reporting
noncarious teeth (16) or young permanent teeth (17–19). Most of the
severe spontaneous pain or lingering pain reproduced by cold testing
available data on BD are case reports and short-term clinical trials with
were diagnosed with irreversible pulpitis (9).
1-year follow-ups and are limited to young patients with success rates as
Periapical and bitewing radiographs were obtained to assess the
high as 100% (17–19).
extent and location of caries, proximity of caries to the pulp, restorabil-
To date, there is no published longitudinal clinical study with a
ity of each tooth, periapical status, and presence of intraradicular pa-
long-term follow-up to compare the clinical and radiographic response
thosis. All data were collected by 1 examiner (blinded to treatment
to BD and MTA in mature teeth. The aim of this study was to evaluate the
used) to ensure reliability.
outcome of VPT with BD or MTA in permanent human teeth with carious
exposure. If BD VPT is determined to be clinically as successful as MTA,
it could provide a reasonably affordable single-visit treatment that main- Clinical Protocol
tains the natural vitality with less discoloration. Profound local anesthesia of the tooth was achieved using lido-
caine and epinephrine (1:100,000) (Xylestesin-A; 3M ESPE, Seefeld,
Materials and Methods Germany). The clinical crown was disinfected under a rubber dam
with chlorhexidine. Caries were removed using a round, high-speed
This prospective longitudinal, parallel-design, randomized clinical
diamond bur with adequate water cooling followed by a round carbide
trial was set up and is reported according to the 2010 CONsolidated
Standards of Reporting Trials statement and is registered with
ClinicalTrials.gov (identifier code: NCT03186690). It assessed the TABLE 1. Demographic Data and Preoperative and Postoperative Factors for
outcome of using BD or MTA as capping materials in human permanent This 2-arm Study Using Biodentine and Mineral Trioxide Aggregate (MTA)
teeth. Ethical approval for this study was obtained from the Institutional
Biodentine MTA
Review Board (no. 154/13). All participants provided written informed
intervention, intervention, Total, P
consent after the purpose and methodology were explained in full. Variable n (%) n (%) N (%) value
Age
Patient Recruitment 16–19 3 (5.2) 3 (5.2) 6 (10.3) .27*
All patients visiting the initial treatment unit were screened for in- 20–29 16 (27.6) 12 (20.7) 28 (48.3)
30–39 4 (6.9) 6 (10.3) 10 (17.2)
clusion during the study period (July 2013–July 2014). Dental exami- 40–49 4 (6.9) 6 (10.3) 10 (17.2)
nations were performed to determine whether the patients fulfilled the 50–59 1(1.7) 3 (5.2) 4 (7)
following inclusion criteria: good general health, carious lesion pene- Sex
trating more than half the thickness or more into dentin and involving Male 14 (24.1) 9 (15.5) 23 (40)
2 walls, severe symptoms but diagnosis indicating reversible pulpitis Female 19 (32.8) 16 (27.6) 35 (60)
Tooth type
based on the cold test, complaints of tooth pain, and radiographic find- Incisor 3 (4.4) 2 (2.9) 5 (7.4) .19†
ings (9). Exclusion criteria were immature teeth, unrestorable teeth, Premolar 12 (17.6) 6 (8.8) 18 (26.5)
unresponsive to thermal stimulation or electric pulp testing, presence Molar 19 (27.9) 26 (38.2) 45 (66.2)
of sinus tracts or swelling, periapical rarefaction, and any serious med- Preoperative sensitivity
Moderate 26 (38.2) 28 (41.2) 54 (79.4) .54†
ical problem that prevented the patient from receiving treatment or Severe 8 (11.8) 6 (8.8) 14 (20.6)
attending follow-up visits. Postoperative pain
According to the study of Simon et al (10), the success rate for pul- Yes 5 (7.4) 2 (2.9) 7 (10.3) .23
potomy using MTA was assumed to be 82% (10). With no report avail- No 29 (42.6) 32 (47.0) 61 (89.7)
able for pulpotomy using BD, the success rate was assumed to be Pulp therapy procedures
DPC 11 (32.4) 6 (17.7) 17 (25) .16†
similar. Knowing that approximately 60 subjects will be available for PP 23 (67.7) 28 (82.4) 51 (75)
the study, we needed to know the minimum difference that can be de- Coronal restoration .38†
tected at the 5% level of significance. Before collecting the data for a 2 Amalgam 6 (8.8) 9 (13.2) 15 (22.0)
proportions test, Minitab statistical software (Minitab 18) was used Composite 28 (41.2) 25 (36.8) 53 (77.9)
(Minitab Inc, State College, PA). Specifically, power and sample size DPC, direct pulp capping; PP, pulpotomy.
> 2 proportions were used with the following values: power of 0.8, sam- The total number of teeth included at the beginning of the study was 68 from 58 patients.
ple size of 60, and a baseline proportion MTA = 0.82. A difference be- *
T-test.
tween proportions of approximately 15% can be detected. When our †
Chi-Square test.

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 CONSORT Randomized Clinical Trial

68 teeth (58 patients) at the beginning of the study

Biodenne Arm n=34 MTA Arm n=34

Eight patients did not

attend 6-month folow
up
5 Biodenne, 3 MTA

At 6 months, full data were

collected for 60 teeth (50
patients) recall rate 86%

BD intervenon (n=29) MTA intervenon (n=31)

27 (93.1%)Teeth fulfilled all success 29 teeth (93.6%) fulfilled all success
criteria criteria
2 Teeth (6.9%) did not meet success 2 Teeth (6.4%) did not meet success
criteria treated by pulpotomy criteria treated by pulpotomy
Two patients were lost, and one patient was
excluded between tooth was excluded because
the coronal restoraon was broken and pulp
was exposed

At one year, full data were collected for 53

teeth from 43 patients (recall rate, 96%)

BD intervenon (n=25)
24 (96%)Teeth fulfilled all success criteria MTA intervenon (n=28)
1 Tooth (4%) did not meet success criteria 28 (100%) Teeth fulfilled all success criteria
treated by PP

one paent treated

with MTA was lost

At two year , full data were collected for 51 teeth,

from 41 paents (recall rate 97%)
Success rate was 100% for all teeth

One paent was lost and

one paent was excluded due to
fractured tooth which needed post
retained crown

At three year , full data were collected for 49 teeth,

from 39 paents (recall rate 95%)

MTA intervenon (n=25)

BD intervenon (n=24) 24 teeth (93.3%) fulfilled all success
22 (91.1%)Teeth fulfilled all success criteria criteria
2 Teeth (8%) did not meet success criteria 1 Tooth (6.7%) did not meet success
one tooth treated by PP and the other DPC criteria
treated by PP

Figure 1. A flow diagram of the progress of the parallel randomized trial of BD and MTA with success rates after 6 months and 1, 2, and 3 years.

bur (Dentsply Ash Instruments, Dentsply, Surrey, UK) until minimal
caries remained on the pulpal walls. A cotton pellet moistened with
5% sodium hypochlorite was placed into the cavity before pulpal expo-
sure. Pulp exposure was performed by means of new sterile round dia-
mond burs, ISO no. 23 (DIA-TESSIN Swiss Dental Diamonds; Vanetti SA,
Gordevio, Switzerland), at high speed under air–distilled water spray
coolant.
Hemostasis was achieved using 5% sodium hypochlorite (20) for
3 minutes. Once bleeding stopped, capping material was placed over the
exposed pulp. Failure to stop bleeding within an additional 3 minutes
indicated incomplete removal of the inflamed pulp. In these cases, com-
plete pulpotomy was performed before capping.
BD and wMTA were prepared according to the manufacturers’ in-
structions and used to fill half the cavity. BD should set within 12 minutes
according to the manufacturer; however, it occasionally took up to
30 minutes in this study. A moist cotton pellet was placed over the
wMTA, and the tooth was temporized with Intermediate Restorative Ma-
terial (DENTSPLY Caulk, Milford, DE). Patients were blinded to the type
of material received, and they were contacted by telephone 2 days later
and reviewed a week after the capping procedure. All patients were

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CONSORT Randomized Clinical Trial
asked if they experienced any mastication discomfort, sensitivity, or TABLE 2. A Contingency Table for the Materials and Procedures Used
pain. The final restoration material used was amalgam or a resin com-
Count Row % Failure Success Total
posite (Z250, 3M ESPE); the final restoration was performed during the
first review appointment. BD 5 22 27
18.52 81.48
wMTA 3 24 27
Recall Protocol 11.11 88.89
Follow-up appointments were scheduled for 6 months and yearly Total 8 46 54
DPC 1 14 15
for 3 years. Clinical and radiographic examinations were performed to 6.67 93.33
detect soft tissue swelling, the integrity of the coronal restoration, crown PP 7 32 39
discoloration, periapical status, the formation of a dentin bridge, pulpal 17.95 82.05
calcifications, and canal obliteration. Tooth vitality was judged by a pos- Total 8 46 54
itive response to cold tests using Endo-Ice F (Coltene/Whaledent, Lan- BD, Biodentine; DPC, direct pulp capping; PP, pulpotomy; wMTA, white mineral trioxide aggregate.
genau, Germany). Treatment was considered successful based on the
following features: absence of signs and symptoms of pulpal pathosis;
lack of pain and tenderness to percussion; no soft tissue swelling, fis- case showed evidence of periapical changes, and the coronal restora-
tula, or abnormal mobility; absence of periapical rarefaction, internal tion was defective. The 1 wMTA failed tooth was associated with a history
or external resorption, and root canal obliteration; and normal pulp of severe pain and was subject to root canal treatment. All wMTA teeth
viability. exhibited some evidence of discoloration, whereas there was no notice-
able discoloration in the BD group. No evidence of canal obliteration or
Statistical Analysis a dentin bridge was evident radiographically over the study periods.
The overall success rates between groups and at each time interval Comparing the overall success rates for the procedures used, an
were compared using the Fisher exact test. Furthermore, the survival insignificant interaction was found (P = .419), and no significant differ-
probabilities were compared using the Wilcoxon and the log-rank tests. ence was detected between them (P = .24). The success rates for the
Statistical analyses were accomplished using JMP software (SAS Institute DPC and PP procedures at each time interval exhibited no significant
Inc, Cary, NC) with alpha = 0.05. differences (Table 1). However the difference between survival proba-
bilities with incisors, molars, and premolars (1.0, 0.91, and 0.63,
respectively) was significant (P = .026) (Table 4).
Results
Seventy-six percent of the included patients were <40 years of age
(mean age = 32.5 years; range, 16–51 years). Sixty percent of the par-
ticipants were female, and 40% were male. All treated teeth, including Discussion
18 premolars, 45 molars, and 5 incisors, had proximal caries. Most of Based on the clinical and radiographic observations reported
the patients reported moderate preoperative pain (Table 1). from the current study, it is concluded that BD can be used in VPT
At 1 week, 7 cases reported postoperative discomfort with mild because of the high success rates in the different pulp capping tech-
sensitivity to cold. Permanent fillings were placed (15 amalgam and niques and in the cases expected preoperatively to have carious expo-
53 composite), and, in cases with large fillings, patients were advised sure. In addition, no significant differences in success rates between
regarding the need for coronal coverage. The flow of recall and a sum- BD- and wMTA-treated teeth were found. A lower success rate was
mary of the results are presented in Figure 1. All patients who did not found in cases treated with miniature/partial pulpotomy; therefore, it
meet the success criteria reported spontaneous pain immediately after is advisable to perform complete pulpotomy or root canal treatment
the procedure. Comparing the overall success rates between the mate- if the bleeding is hard to control. The amount of remaining tooth struc-
rial groups (95% confidence interval, 0.79–0.94) revealed an insignif- ture and coronal restoration plays a key role in the success of VPT; the
icant interaction (P > .5; Table 2 and Fig. 2). Using the Wilcoxon and success rate was higher in molar teeth compared with premolar teeth.
log-rank tests, the difference in survival probabilities between the ma-
terials was not significant (P > .5). The success rates for the 2 groups at
each time interval showed that none of the differences are significant
(Table 3).
The overall success rate at 6 months was 93.3% (Table 3). The 4
failures were treated with pulpotomy, with each patient reporting severe
pain the second day after the procedure. Other treatments (ie, DPC) in
this category showed a 100% success rate (Fig. 3).
At the 1-year follow-up, a tooth was excluded because the coronal
restoration was broken and pulp was exposed. One BD-treated tooth
exhibited a large periapical lesion and was considered an unsuccessful
outcome. Two patients declined to participate in the follow-up but did
not report any pain or swelling. The overall success rate after 1 year was
98% (Table 3).
At the 2-year follow-up, all teeth fulfilled the clinical and radio-
graphic success criteria. One patient failed to attend the follow-up
(Fig. 1). At the 3-year follow-up, 1 patient was excluded because of a
fractured tooth that needed a post-retained crown, and another failed
to attend the follow-up. In the BD group, the first failed case was treated Figure 2. The product limit survival fit grouped by the material tested: BD
by DPC, and, clinically, the restoration was defective; the other failed and MTA.

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 CONSORT Randomized Clinical Trial
TABLE 3. A Comparison of the Success Rates for the Biodentine (BD) and White Mineral Trioxide Aggregate (wMTA) Groups for Each Time Point and Procedure
Used according to the Fisher Exact Test
P value if the difference is
Time point Group/procedure used Failure, n (%) Success, n (%) Total significant
6 month BD 2 (6.9) 27 (93.1) 29 1.000
MTA 2 (6.4) 29 (93.5) 31
Total 4 56 60
DPC 0 (0.0) 17 (100.0) 17 .569
PP 4 (9.3) 39 (90.7) 43
Total 4 56 60
1 year BD 1 (4.0) 24 (96.0) 25 .4717
MTA 0 (0.0) 28 (100.0) 28
Total 1 52 53
DPC 0 (0.0) 16 (100.0) 16 1.000
PP 1 (2.7) 36 (97.3) 37
Total 1 52 53
2 years BD 0 (0.0) 24 (100.0) 24 —
MTA 0 (0.0) 27 (100.0) 27
Total 0 51 51
DPC 0 (0.0) 16 (100.0) 16
PP 0 (0.0) 35 (100.0) 35
Total 0 51 51
3 years BD 2 (8.3) 22 (91.6) 24 .6092
MTA 1 (4.0) 24 (96.0) 25
Total 3 46 49
DPC 1 (6.6) 14 (93.3) 15 1.000
PP 2 (5.8) 32 (94.1) 34
Total 3 46 49
DPC, direct pulp capping; PP, pulpotomy.

BD and MTA have not been proven effective in treating carious
mature permanent human teeth. One recent clinical trial using carious
deciduous teeth reported a comparable success rate for BD and MTA in
pulpotomy cases (21). A histologic human study and some animal
studies have been published (22, 23) using sound teeth revealing
successful treatment. More recent short-term clinical studies have
examined the success rate of BD as a capping agent in caries-
exposed human teeth. The published findings have reported promising
results for BD (16–19). However, some clinical drawbacks, including a
long setting time and difficult handling properties, were also reported
(24). In this study, we observed a longer setting time for BD in accor-
dance with other studies (15, 24).
Figure 3. The product limit survival fit grouped by the procedure used: direct
pulp capping (dpc) and pulpotomy (pp).
This study compared BD and MTA as capping materials in
mature permanent teeth with clinical signs and symptoms suggestive
of severe reversible pulpitis (25) by the third yearly follow-up. This
reflects a common clinical scenario encountered in everyday dental
practice. In clinical practice, it is very difficult to assess the histologic
condition of the pulp. If all infected and inflamed tissue is removed,
then the pulp maintains a capacity for healing regardless of the clinical
presentation (9).
Permanent teeth with immature apices were excluded because in
VPT pulp healing relies on the host immune system and the healing ca-
pacity and the vascularity of these teeth is higher than mature permanent
molars (5). However, in the present study, age was not found to be a
significant factor in the outcome of different VPT in mature teeth. Similar
findings were reported by a number of investigators (5, 6, 12).
At the 6-month follow-up period, the success rate of BD and MTA
was 93.3%, similar to the findings of another study (3) reporting pooled
success rates ranging from 72.9%–99.4% for capping with wMTA and
calcium hydroxide. At the 1-year follow-up, the failure rate was lower
because most failures occurred immediately after treatment. The suc-
cess rate was high (98%) and similar to other studies using MTA and
BD as a capping agent with no significant difference between them
(3, 17, 18, 19, 21). Similarly, the difference in the success rates
between BD and wMTA were not statistically significant at 2 and
3 years. Both materials, exhibiting shared characteristics and close
chemical composition, had a good success rate, suggesting their
suitability to treat permanent teeth diagnosed with reversible pulpitis.
However, BD has several advantages over original MTA; it seals better
and sets faster, but it requires an extra 45 minutes to reach full
strength so it cannot be completed in a single procedure (26).
Treatment failure occurred in a total of 5 teeth capped with BD
with prolonged bleeding and deeper pulp amputation attempted,
possibly because of erroneous evaluation of the clinical pulpal diag-
nosis and incomplete removal of inflamed pulpal tissue. Notably, in 4
of the 5 failed cases, the initial bleeding was high and uncontrollable,

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CONSORT Randomized Clinical Trial
TABLE 4. The Survival Probabilities for Tooth Type Using the Wilcoxon and Log-rank tests
Group success Group, Lower limit
Level proportion n for the 95% CI
Incisor 1 3 0.391
Molar 0.910 37 0.776
Premolar 0.643 14 0.662
CI, confidence interval.
*
P < .05, indicating that the survival rate is significantly different for the 3 groups.
even after a partial pulpotomy. In these specific cases, the application of
BD provoked additional bleeding even after the initial bleeding was
controlled because BD is viscous and heavier than MTA (27). In total,
7 of the 8 failures were in teeth treated by pulpotomy, suggesting it
should be avoided when the initial bleeding is major or uncontrollable.
It has also been shown that success is increased when uninflamed or not
seriously inflamed pulpal tissue is covered with capping material (4).
DPC was successful in all teeth except 1 that had a coronal resto-
ration defect, which is in accordance with a recent clinical study that
reported a similar success rate using different VPTs (11) and new tech-
niques for minimally managing inflamed pulp (25, 28). A correlation
between clinical and histologic diagnosis has been reported
previously (8); in this study, the look of pulp tissue and the time of
bleeding were used as prognostic factors for pulp status. These indica-
tors are clinically practical but subjective and cannot reflect the pulp
histology accurately. The need for accurate molecular tests to diagnose
pulp status is essential to avoid excessive invasive pulpal treatment.
It is important to note that 7 patients (1 in the BD group and 6 in
the MTA group) who reported sharp pain during the cold test did not
report any history of spontaneous pain and were treated with a full pul-
potomy because the bleeding was difficult to control. In the present
study, failure to control bleeding within 10 minutes indicated that the
inflamed zone was extensive, and a pulpectomy was performed. This
is because the anatomy of the pulpal circulation system localizes inflam-
mation under the stressed area without spreading to deeper tissues. Pa-
tients might have severely inflamed pulp without a history of lingering or
spontaneous pain; therefore, a history of pain cannot indicate the de-
gree of pulpal inflammation extension (15). Recently, a better focus
on the healing potential of the dental pulp evidence has revealed the ur-
gent need for a revision of pulpal disease terminology (3, 25, 28), with a
number of proposed diagnostic categories requiring consideration to
reach consensus in this field (25, 28).
BD does not have sufficient radiopacity to enable its exact loca-
tion to be distinguished, making it difficult to evaluate the dentin
bridge. Although the radiopacity of MTA is superior to BD, we were
unable to identify dentin bridges in the majority of cases. According
to some authors, the thickness and quality of dentin bridges can be
characterized only by histologic examination (29, 30) because they
contain many tunnels and are highly porous because of cellular
inclusions and empty vascular spaces (3, 30). Therefore, we did
not consider the formation of dentin bridges as a criterion for
success. The success of pulp therapy is linked to several factors
other than the material used. The coronal seal and coverage are
significant contributing factors for VPT survival probability. We
noticed that recurrent caries and fractured fillings were directly
linked to all reported late failures in this study, especially in
premolar teeth. All included teeth had 2-wall caries, and those with
significant teeth substance loss were referred for coronal coverage.
Unfortunately, the compliance of most of the patients was low. The
comparatively lower success rate for BD and MTA reported in this
1608 Awawdeh et al.
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Upper limit Degree of
for the 95% CI Test c2 freedom Prob >c2
1
0.927
1
Log-rank 7.296 2 .0260*
Wilcoxon 7.262 2 .0265*
study could be related in part to coronal restorative causes because
both materials might be associated with a certain degree of leakage,
and coronal coverage is a must if VPT is performed in a tooth with
a proximal cavity (31).
No cases of pulpal obliteration were diagnosed in our study. This is
promising because pulpal calcification is associated with the need for
conventional root canal therapy. However, a longer follow-up period
is needed to fully evaluate this and compare between BD and MTA.
This study had several limitations. Not all patients attended the
follow-up appointments, which might affect the reported success rates.
Most patients provided only a mobile phone number; given this has a
greater likelihood of changing, it is advisable to collect landline
numbers for future studies. Another limitation was the lack of histologic
analysis; the success rate was only based on clinical and radiographic
signs of pathosis.
A 3-year follow-up might not be sufficient to make firm conclu-
sions about the success rate, which decreased with time (10). This pre-
liminary study was restricted by a limited number of patients and should
be verified by larger randomized clinical trials with longer follow-up pe-
riods to help define appropriate clinical guidelines.
Acknowledgments
The authors deny any conflicts of interest related to this study.
Supported by the deanship of research at Jordan University of
Science and Technology, Irbid, Jordan (grant no. 154/2013).
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