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Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 135-140

Effect of mineral trioxide aggregate as a direct pulp capping agent in cariously exposed permanent teeth

1 Departments of Conservative Dentistry and Endodontics, Subharti Dental College, Swami VivekanandSubharti University, Meerut, Utter Pradesh, India
2 Manubhai Patel Dental College, Baroda, Gujarat, India
3 Career Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh, India

Date of Web Publication6-Aug-2014

Correspondence Address:
Parul Bansal
c/o Mr Suresh Bansal, 58/6, Jagriti Vihar, Opposite LLRM Medical College, Meerut, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-5984.138146

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Aims and Objectives: To evaluate the effectiveness of mineral trioxide aggregate (MTA) when used as a pulp capping agent in permanent teeth with carious exposure (≤1mm) after root formation is completed. Materials and Methods: Clinical follow-up was performed on 32 mandibular molars with deep occlusal caries, in patients in the age group range of 18 to 42 years. Carious pulpal exposures were treated by direct pulp capping with MTA, followed by a base of light cure glass ionomer cement and restored with amalgam. Clinical and radiographic examinations were carried out periodically at 1, 3, 6, 9, 12, 18 and 24 months. Results: After 24 months clinical and radiographic follow-up, it was found that 25 (out of 32) patients had successful outcome. However, two patients failed to return for evaluation after permanent restoration, and five patients exhibited clinical failure. Conclusions: Mineral trioxide aggregate was found to be an effective material when used for direct pulp capping in permanent teeth. However, further investigations with a larger sample size are needed to support these findings.

Keywords: Direct pulp capping, mineral trioxide aggregate, permanent teeth

How to cite this article:
Bansal P, Kapur S, Ajwani P. Effect of mineral trioxide aggregate as a direct pulp capping agent in cariously exposed permanent teeth. Saudi Endod J 2014;4:135-40

How to cite this URL:
Bansal P, Kapur S, Ajwani P. Effect of mineral trioxide aggregate as a direct pulp capping agent in cariously exposed permanent teeth. Saudi Endod J [serial online] 2014 [cited 2023 Mar 29];4:135-40. Available from: https://www.saudiendodj.com/text.asp?2014/4/3/135/138146

  Introduction Top

A vital, functioning pulp is capable of initiating several defense mechanisms to protect the body from bacterial invasion. It is beneficial to preserve the vitality of an exposed pulp rather replacing it with a root canal filling material following pulp exposure. Direct pulp capping in cariously exposed pulp of young immature teeth has yielded a markedly high success rate. [1],[2],[3],[4],[5] The most common application for direct pulp capping that is for carious pulp exposure on fully formed permanent teeth has been expected to be least predictable. The lack of predictability of long term success greatly influences treatment planning. This is primarily due to difficulty in accurate diagnosis of the ability of the pulp to repair in mature teeth.

A number of materials have been tested during the last few decades as alternative to calcium hydroxide, one of them is mineral trioxide aggregate (MTA). In various studies MTA has been proven to be biocompatible and non-mutagenic with good sealing ability. [6],[7],[8],[9],[10]

Several animal studies on non-inflamed, traumatically exposed pulps have shown that MTA exhibits better results than calcium hydroxide when used as a direct pulp capping agent. [11],[12],[13] Several studies specify MTA as an effective material for direct pulp capping in human permanent teeth with mechanical pulp exposures. [14],[15] However, there are few studies on cariously exposed pulp. This study was designed to evaluate the effectiveness of MTA as a direct pulp capping agent in cariously exposed permanent mature teeth with completed root formation.

  Materials and methods Top

Thirty two patients of age group 18 to 42 years, who had deep Class I carious lesions in relation to mandibular molars, were selected for the study. Clinical examination revealed gross occlusal caries with no signs of extraoral or intraoral swelling or sinus tract formation. Teeth were negative to percussion and palpation tests and the mobility was within normal limits. Pulp vitality tests using endo ice (coltene/whaledent) showed normal response. Radiographic findings revealed caries in close proximity to the pulp [Figure 1]a]. Based on the results of clinical and radiographic examination, the pulp was diagnosed with reversible pulpitis. The initial treatment plan was removal of the carious lesion followed by clinical evaluation of the pulp exposure. Direct pulp capping with MTA (Pro Root MTA, Dentsply Tulsa, Tulsa, OK, USA) was planned for the anticipated pulp exposure. Patients were informed and consent was obtained.

Following administration of local anesthesia, teeth were isolated with rubber dam. Caries removal was performed using a no. 4 sterile round bur on a low speed handpiece with copious water irrigation. During or after removal of caries, exposure of pulp with moderate bleeding was observed [Figure 1]b]. A sterile cotton pellet moistened with saline was used to apply moderate pressure to the exposed pulp for 5 min and hemostasis was achieved. Sodium hypochlorite (2.5%) was used to disinfect the surgical exposure and the dentin as well as to remove the superficial clot and debris. The cavity was lightly dabbed with a moist pellet to remove the excess moisture. MTA was mixed according to the manufacturer's instructions and a 1-2 mm thick layer of MTA was placed over the exposure site and adjacent dentinal surface with a plastic filling instrument. The mix was then padded with a moist cotton pellet to ensure optimum contact of MTA with exposed pulp tissue [Figure 1]c]. A moist cotton pellet was then placed over the MTA and the cavity was restored with an intermediate restorative material (Kalzinol, Denstply, Germany). The patients were scheduled after 24 hours to evaluate the setting of MTA as well as for follow up to check for any abnormal signs or symptoms. At the 24 hour follow-up appointment, all patients were asymptomatic. Under rubber dam isolation the provisional restoration and cotton pellet were removed and complete setting of MTA was confirmed by probing its surface. A light-cured Glass Ionomer Cement (Vitrebond plus glass ionomer liner/base, 3M ESPA, USA) was placed over the MTA and teeth were permanently restored with amalgam [Figure 1]d].
Figure 1: (a) Preoperative Radiograph, (b) Photograph showing exposed pulp tissue, (c) Photograph showing placement of MTA over exposed pulp tissue, (d) Radiograph after permanent restoration, (e) Six months follow up radiograph

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Patients were scheduled for 3 weeks follow up in order to monitor for any signs or symptoms. Patients were asked to call and inform if any pain or discomfort occurred. Three months later, clinical examination was done to evaluate an intact restoration and absence of any abnormal signs or symptoms. Teeth were tested for vitality by various vitality tests (heat test, cold test, electric pulp test). Periapical radiographs were taken to evaluate any periapical changes.

At 6 months, teeth were examined again for any abnormal findings, pulp testing was done to check the vitality of the pulp and radiographs were also taken [Figure 1]e]. Patients were scheduled for routine recall visits every 3 months. Patients were informed about the potential need for root canal therapy in case of abnormal signs and symptoms.

The patients were divided into three different groups for evaluation of the results.

  • Group I According to their age (18-26 yrs, 27-34 yrs, and 35-42 yrs)
  • Group II According to their gender
  • Group III According to diameter of pulp exposure (up to 0.5 mm and 0.5-1 mm wide).

  Results Top

Two patients out of 32 did not return for follow up after permanent restoration. Out of the remaining 30 patients who returned for regular follow ups, 25 presented without any abnormal signs or symptoms of irreversible pulpitis or periapical disease. However, five patients presented with symptoms of irreversible pulpitis. Out of those five, three cases reported earlier than their scheduled appointment at 3 weeks, with the complaint of severe pain while the other two were on their regular visit showing signs of apical periodontitis.

Success rate with MTA as a direct pulp capping agent, light cure glass ionomer cement as a base and amalgam as a restorative material was found to be 83.33% in our study with follow up period of 24 months.

Patients of age group 18-26 years showed 81.8% success, age group 27-34 years showed 90% success, age group 35-42 years showed 77.7% success [Table 1]. Results showed no significant difference in the success rate of pulp capping between the three age groups.

Male showed 79.9% success whereas female showed 88.2% success [Table 2]. Results showed no significant difference in the success rate of pulp capping and gender of the patient.
Table 1: Age and success rate of direct pulp capping

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Table 2: Gender and success rate of direct pulp capping

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The success rate of group with pulp exposure size up to 0.5 mm was 84.6% and 0.6-1mm was 82.5% [Table 3]. Z test result was 0.59. This shows there is no significant difference in the success rate of pulp capping and diameter of pulp exposure up to 1 mm.
Table 3: Diameter of pulp exposure and success rate of direct pulp capping

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In this study no periapical changes were seen in any of the case during the 24 months follow-up period. Failed cases (on the basis of clinical sign, symptoms and various tests) were treated endodontically and were not evaluated further.

The relationship between dentin bridge formation (assessed radiographically) and the success rate was evaluated. None of the successful case showed dentin bridge formation during the follow up period radiographically. The absence of any periradicular changes along with the absence of any undesired clinical sign and symptom was considered as success.

  Discussion Top

Direct pulp capping with MTA over a carious exposure in a mature permanent tooth may be a reasonable alternative to root canal therapy or extraction. Various studies on pulp capping have been done on mechanically exposed teeth and immature teeth with good results. [1],[2],[3],[4],[5],[16],[17],[18],[19] Seltzer and Bender have suggested that a mechanically exposed young pulp has a better prognosis because of its repair potential in the absence of contamination when compared with carious exposures which have chronic inflammation secondary to microbial invasion. [20] Bodem et al., found that pulps remained vital after direct capping of cariously exposed primary molar pulp with MTA. [21]

Factors which influence treatment decisions when encountering teeth with pulp exposure include the degree of infection and inflammation of the pulp rather than the size or duration of pulp exposure. [22] For traumatic exposures in young asymptomatic immature teeth, direct pulp cap or partial pulpotomy are the treatments of choice. In contrast, carious process can lead to marked changes within the pulp-dentin complex which can vary considerably depending on the severity of the disease and the age of the pulp. It is generally agreed that larger carious exposures have a poor prognosis due to a more severely inflamed pulp, risk of necrosis and bacterial contamination. [23] Careful case selection and treatment planning is critical for better outcome of treatment rendered.

The histologic extent and degree of inflammation cannot be accurately predicted clinically. The current study included factors that are believed to give indications of the health and healing capacity of pulpal tissue prior to treatment i.e. age of the patient, size of exposure and radiographic appearance. Each of these factors has been cited in the literature as having some relevance in the ability of the pulp to recover from a pulp exposure (carious or otherwise), but none has been shown to be reliably predictive.

Since years calcium hydroxide is being used for direct pulp capping. MTA has been shown to give better results than calcium hydroxide in direct pulp capping of non-inflamed animal pulps. [11],[12],[13] Aeinehchi et al. reported less inflammation and thicker dentin bridge with MTA than calcium hydroxide when used as a pulp capping material in human teeth with mechanical pulp exposures. [14] According to Pitt Ford et al., MTA's superiority could be due to its good sealing ability and biocompatibility. [16] MTA has proven to be one of those very few exogenous materials that is not only well tolerated by connective tissues but also contributes to a bacteria-tight seal. [24],[25]

Optimum hemorrhage control is essential for successful outcome of direct pulp capping regardless of the material used. [26] Sodium hypochlorite (NaOCl) in concentrations 2.5-5.25% when placed on an exposed pulp, in addition to being ideal for hemorrhage control, provides asepsis. NaOCl results in chemical amputation of the blood clot and fibrin along with the removal of damaged cells and operative debris from the exposed pulp site. Optimum hemostasis will also help to achieve the goal of bacteriometic seal. Several studies have shown that sodium hypochlorite did not impair or retard the cellular healing of exposed pulps and is not inhibitory to the biologic mechanisms of odontoblastic cell or dentin bridge formation. [27] In addition it can be used for removal of residual microbial flora, which can be a major deterrent in healing of exposed pulp.

Infected dentin in contact with pulp tissue is likely to encourage inflammation and discourage reparative dentin formation. The use of sodium hypochlorite for hemostasis and disinfection is recommended by some authors for MTA pulp caps and is cited by several authors as being critical to the success of this procedure. Others preferred a cotton pellet moistened with sterile saline for this step. [28],[29]

Following a pulp capping procedure, bacterial leakage through the final restoration is considered by some to be more detrimental to outcome than bacterial contamination at the time of the treatment. [30] This finding underlines the need for a good seal in the final restoration after the completion of the pulp capping procedure. [31] For this reason, light cure Glass Ionomer Cement was placed above the pulp cap before permanent restoration. Amalgam restoration was preferred as teeth had occlusal caries and the cavity margins were not involved in the proximal surfaces.

In accordance with our study, some studies have shown that the age of the patient is not a significant factor in success of the treatment. [32] It is well documented that teeth lacking apical closure respond well to direct pulp treatment (pulp cap, partial pulpectomy or pulpotomy). [1],[2],[3],[4],[5] All of the teeth in the current study had complete root formation; therefore, direct comparisons to teeth with immature apices cannot be made.

Patient age, extent of bleeding or size of exposure are factors predictive of survival rate of the procedure. Survival analysis tests are inherently underpowered. A sample size of 30 is small for purposes of this research. In the current study, outcomes were far less consistent and showed independence from the preoperative conditions, such as patient age, exposure size and gender of patient.

  Conclusion Top

Based on the results of this clinical and radiographic study, it may be concluded that, MTA when placed on cariously exposed pulp, several preoperative conditions like patient age, exposure size and amount of bleeding are not predictive of clinical outcome. Considering the comparatively high success rate for the current study, a prospective clinical study with a larger sample size is needed to define predictive criteria for successful pulp capping with MTA.

  References Top

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2.Bakland LK. Management of traumatically injured pulps in immature teeth using MTA. J Calif Dent Assoc 2000;28:855-8.  Back to cited text no. 2
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19.Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: A randomized controlled trial. IntEndod J 2008;41:128-50.  Back to cited text no. 19
20.Seltzer S, Bender IB. Pulp capping and pulpotomy. In: Seltzer S, Bender IB, editors. The dental pulp. 3 rd ed. Philadelphia: J.B. Lippincott Company; 1984. p. 281-302.  Back to cited text no. 20
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25.Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial leakage of mineral trioxide aggregate as a root-end filling material. J Endod 1995;21:109-12.  Back to cited text no. 25
26.Hafez AA, Cox CF, Tarim B, Otsuki M, Akimoto N. An in vivo evaluation of haemorrhage control using sodium hypochlorite and direct capping with a one or two component adhesive system in exposed nonhuman primate pulps. Quintessence Int 2002;33:261-72.  Back to cited text no. 26
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32.Miles JP, Gluskin AH, Chamber D, Peters OA. Pulp capping with MTA: A Retrospective analysis of carious pulp exposures. Oper dent 2010;35:20-8.  Back to cited text no. 32


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  [Table 1], [Table 2], [Table 3]

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