JIOH on LinkedIn JIOH on Facebook
  • Users Online: 241
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL RESEARCH
Year : 2018  |  Volume : 10  |  Issue : 6  |  Page : 310-313

The effect of mineral trioxide aggregate as a direct pulp capping agent in permanent teeth


1 Department of Operative Dentistry, Altamash Institute of Dental Medicine, Karachi, Pakistan
2 Department of Operative Dentistry, Altamash Institute of Dental Medicine, Karachi, Pakistan; Conservative Dentistry Unit, School of Dental Sciences, USM, Kelantan, Malaysia
3 Conservative Dentistry Unit, School of Dental Sciences, USM, Kelantan, Malaysia
4 Department of Prosthodontics, Altamash Institute of Dental Medicine, Karachi, Pakistan; Prosthodontics Dentistry Unit, School of Dental Sciences, USM, Kelantan, Malaysia
5 Department of Biomedical Engineering, Barret Hodgson University, Karachi, Pakistan

Date of Web Publication24-Dec-2018

Correspondence Address:
Dr. Rizwan Jouhar
Altamash Institute of Dental Medicine, Defence Campus, 2-R Sunset Boulevard, DHA, Phase-4, Karachi - 75500, Pakistan

Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_201_18

Rights and Permissions
  Abstract 

Aims and Objectives: Direct pulp capping is a procedure which aims at protecting pulp vitality. When the dental pulp is exposed as a result of trauma, caries or by the dentist preparing for a deep restoration, then, it can be capped with a biocompatible material. It is expected that this procedure was allowed the pulp to heal normally and regenerate reparative dentine, thus preventing the need for more extensive and expensive root canal treatment (RCT). Materials and Methods: A total of 86 teeth of 85 patients diagnosed with reversible pulpitis were included in this study. After administration of local anesthesia, teeth were isolated with rubber dam. Mineral trioxide aggregate (MTA) was mixed according to manufacturers' instructions and 1–2 mm of MTA was placed over the pulpal exposure with a plastic filling instrument. All patients were scheduled for routine recall visits after 1, 3, and 6 months to monitor for pain on visual analog scale. All these readings were recorded on pro forma. The collected data were entered into SPSS version 19 and analyzed accordingly. Mean and standard deviation was calculated for quantitative variables like age. Frequency and percentage were calculated for qualitative variables such as the efficacy of MTA and gender. Stratification with respect to age and gender was done. Poststratification Chi-square test was applied. P ≤ 0.05 was considered statistically significant. Results: The average age of the patients was 37.59 ± 10.88 years. There were 30 (35.29%) male and 55 (64.71%) female. The effectiveness of MTA as a direct pulp capping material in cariously exposed mature permanent teeth was observed in 87.06% (74/85). Conclusion: Taking into consideration, the results of this study, it seems that when an exposure site is immediately sealed with MTA, the prognosis is promising. We found success rate of 87.06%. MTA can induce the formation of reparative dentine thus allow the pulp to heal normally and maintain pulp's vitality and regenerative potential so the need of RCT can be avoided.

Keywords: Mineral trioxide aggregate, pulp capping material, root canal treatment


How to cite this article:
Tahira T, Jouhar R, Ghani HA, Ahmed N, Rao AZ, Jamil S. The effect of mineral trioxide aggregate as a direct pulp capping agent in permanent teeth. J Int Oral Health 2018;10:310-3

How to cite this URL:
Tahira T, Jouhar R, Ghani HA, Ahmed N, Rao AZ, Jamil S. The effect of mineral trioxide aggregate as a direct pulp capping agent in permanent teeth. J Int Oral Health [serial online] 2018 [cited 2019 Jan 20];10:310-3. Available from: http://www.jioh.org/text.asp?2018/10/6/310/248435


  Introduction Top


Direct pulp capping is a procedure which aims at protecting pulp vitality. When the dental pulp is exposed as a result of trauma, caries or during preparation for a deep restoration; then, it can be capped with a biocompatible material. It is expected that this procedure was allowed the pulp to heal normally and regenerate reparative dentine, thus preventing the need for more extensive and expensive root canal treatment (RCT).

A number of materials have been previously suggested for use as direct pulp capping agents. However, there is little human clinical research to support these materials as direct pulp capping agents. Over the past many decades, calcium hydroxide has remained the gold standard for pulp capping.[1] However, there are a number of disadvantages linked to it, which are as follows:

  1. The long time required for induction of hard tissue barriers (2–3 months), results in delayed completion of treatment and risk of patients' compliance[2]
  2. Areas of sterile pulp necrosis[3]
  3. Tunnel defects are formed in reparative dentine. These may allow bacterial invasion[4],[5]
  4. The use of calcium hydroxide causes a decrease in root fracture resistance[6],[7],[8]
  5. Calcium hydroxide has no inherent adhesive/sealing property.[9]


A new biocompatible material, mineral trioxide aggregate (MTA), has generated considerable interest as a direct pulp-capping material. MTA provides a tight seal which prevents bacterial penetration.[10] It forms a physical bond with dentine,[11] thus providing a tight seal which prevents and reduces bacterial penetration to the pulp amputation site.[12],[13]

However, there are very few studies on cariously exposed pulps of mature permanent teeth. This study is designed to compare the effectiveness of MTA as a direct pulp capping material in cariously exposed mature permanent teeth. Therefore, the objective of this research was to evaluate the effectiveness of MTA as a direct pulp capping material in cariously exposed mature permanent teeth. The rationale was to prevent the need for more extensive and expensive RCT as MTA can stimulate the formation of reparative dentine thus allow the pulp to heal normally and maintain pulp's vitality and regenerative potential so the need of RCT can be avoided.


  Materials and Methods Top


The descriptive study case series was conducted at the Operatives Dentistry Department of Altamash Institute of Dental Medicine, Karachi, Pakistan, by taking the percentage of effectiveness of MTA as 83%,[14] level of confidence 95%, margin of error 8%, a total sample of 85 teeth were included in the research using nonprobability consecutive sampling technique for 6 months from September 22, 2015, to March 22, 2016. The sample was scrutinized using inclusion and exclusion criteria based on the following.

Inclusion criteria

  • Either gender
  • Age limit: 20–60 years of age
  • Patient diagnosed with reversible pulpitis with a history of 5 days or less
  • Caries just involving the pulp/pulp horn radiographically
  • Clinically with no signs of extraoral/intraoral swelling
  • Teeth negative to percussion and palpation tests
  • Teeth with no mobility
  • Mature permanent teeth (teeth from permanent dentition, showing fully formed converging roots with closed apex on posteroanterior printarticle.asp?issn=0976-7428;year=2018;volume=10;issue=6;spage=310;epage=313;aulast=Tahira radiograph).


Exclusion criteria

  • History of spontaneous sharp lingering pain
  • Teeth tender to percussion
  • Intraoral/Extraoral swelling
  • Sinus tract formation
  • Nonvital teeth (gives no response to refrigerant CO2)
  • Mobile teeth
  • Deciduous teeth
  • Teeth with open apices (showing divergent roots on PA radiograph).


After approval from the Ethical Review Committee (AIDM/09/2018/03) of Altamash Institute of Dental Medicine and taking patients' informed consent, patients were included in this study.

After administration of local anesthesia, rubber dam was placed to isolate the teeth. Sterile round bur no. 4 was used for caries removal, with copious water irrigation. During or after removal of caries, pulp exposure was clinically evaluated. A sterile, moist with saline, cotton pellet was used to achieve hemostasis. Sodium hypochlorite (2.5%) was used to disinfect the surgical exposure and dentine as well as to remove the surgical clot and debris. MTA was mixed according to manufacturers' instructions and 1–2 mm of MTA was placed over the pulpal exposure with a plastic filling instrument.

MTA mix was pressed with moist cotton pellet to ensure optimum contact with exposed pulp tissue and cavity was restored with cavit. Patients were scheduled for 24 h follow-up to evaluate the setting of MTA. The rubber dam was placed for isolation, the temporary restoration and cotton pellet were removed. The probe was used on MTA surface to check its complete setting. Light-cured glass-ionomer cement was placed over the MTA and teeth were permanently restored with light-cured composite.

All patients were scheduled for routine recall visits after 1, 3, and 6 months to monitor for pain on visual analog scale (VAS). Clinical examination was done to evaluate an intact restoration. Teeth were tested for vitality by refrigerant CO2. Patients were informed about the potential need for RCT in case of moderate-to-severe pain. The absence of sharp lingering pain at 6 months' posttreatment (VAS = 3) was considered as success. All these readings were recorded on pro forma attached as Anex “A” by an Endodontist.

The collected data were entered into SPSS version 19 (IBM, Armonk, NY, USA) and analyzed accordingly. Mean and standard deviation was calculated for quantitative variables like age. Frequency and percentage were calculated for qualitative variables like the efficacy of MTA and gender.

Stratification with respect to age and gender was done. Poststratification Chi-square test was applied. P ≤ 0.05 was considered statistically significant.


  Results Top


A total of 86 teeth of 85 patients diagnosed with reversible pulpitis were included in this study. The average age of the patients was 37.59 ± 10.88 years and mean duration of symptoms was 3.53 ± 1.14 days. There were 30 (35.29%) male and 55 (64.71%) female.

MTA, when placed as a direct pulp capping material in cariously exposed mature permanent teeth was effective in 87.06% (74/85) [Figure 1]. Stratification analysis was performed, and it was seen that the effectiveness of MTA was significantly high in below and equal to 50 years of age (P = 0.001) [Table 1]. The effectiveness of MTA was also observed between males and females, but there was no significant difference. Stratification of the duration of symptoms was also observed, but there were no significant effect [Table 2].
Figure 1: Effectiveness of mineral trioxide aggregate as a direct pulp capping material in cariously exposed mature Permanent teeth n = 85

Click here to view
Table 1: Effectiveness of mineral trioxide aggregate as a direct pulp capping material in cariously exposed mature permanent teeth by age groups (n=85)

Click here to view
Table 2: Effectiveness of mineral trioxide aggregate as a direct pulp capping material in cariously exposed mature permanent teeth by duration of symptoms (n=5)

Click here to view



  Discussion Top


Following pulp exposure, it is beneficial to preserve its vitality rather than replacing it with a root canal filling material. The placement of any biomaterial over a cariously exposed pulp was controversial, and instead conventional RCT was recommended.[15] In cariously exposed pulps, the effectiveness of direct pulp cap varies. Data from retrospective studies have shown success rate, ranged between 30% and 85%.[15],[16] In our research, similar findings were found, when MTA placed as a direct pulp capping material in cariously exposed mature permanent teeth it was effective in 87.06% (74/85).

MTA is a bioactive, inert and nonresorbable silicate cement and has very high pH 12.5, slow release of calcium ions, great sealing ability, and prevent bacterial penetration.[16],[17],[18] Studies have shown that MTA induces pulp cell proliferation,[19] allows cytokine release,[20] hard tissue induction, and the formation of an interface with dentin that resembles hydroxyapatite in composition.[20] Studies have shown that setting reaction of MTA involves generation of a high pH (12.5) which remains high for at least 8 weeks.[21] This high pH induces release of bioactive dentine matrix proteins.[22] These proteins have the ability to stimulate pulpal repair. This hard tissue bridge is formed earlier than under calcium hydroxide, with fewer tunnel defects and vascular inclusions.[5],[23]In vitro and in vivo studies have confirmed MTA's excellent sealing ability and biocompatibility.[24]

Contrary to our study, a clinical study on MTA pulp caps on cariously exposed pulps has shown 98% success,[25] while in our study, the success rate was 87%, possibly due to age group variation as they selected younger group patients (7–45 years) as compared to our study (20–60 years) and found more success in younger open apex cases. Another study on cariously exposed pulp of mature permanent teeth has shown 83% success when pulp capping was done with MTA.[14] The findings are similar to our research where a success of 88% is seen. Direct pulp capping can be assumed to be one of the best treatments if the connection between the oral cavity and pulp is totally sealed with a biocompatible material.[26]

Several short-term studies, investigating partial pulpotomies and direct pulp capping with MTA have shown good results.[27] Several other studies which have analyzed MTA dressing over mechanical exposures, have shown MTA to be effective.[28],[29] Nowicka et al. studied both MTA and calcium hydroxide as a pulp capping material in human teeth with mechanical pulp exposures and observed scarce inflammation and thick dentinal bridge with MTA as compared to calcium hydroxide.[28] Accornite etal., reported that MTA's good sealing ability and biocompatibility could be the reason of its effectiveness.[30] MTA has proven to be one of the very few exogenous materials that is not only well tolerated by connective tissues but also contributes to a bacteria-tight seal.[31],[32]

In our study, stratification analysis was performed, and it was seen that the effectiveness of MTA was significantly high in below and equal to 50 years of age, in contrast, some studies have shown that the age of the patient is not a significant factor in the success of the treatment.[14],[33]

A key aspect for the practitioners is the application of pulp cap material at the exposure site. MTA needs moist environment for setting after placement, whereas, placing other capping materials, for example, hard setting calcium hydroxide agent is very difficult.[34] Therefore, it is a supplementary advantage besides its histologic superiority.

The present research endorses the application of constant informative methods to boost the understanding of dental practitioners about incomes of prevention and restoring with direct pulp capping through MTA keeping in mind the aftermath. The recent study emphases on practices and procedures accessible in dental world since quite long now, therefore, we recommend specifically planned and accomplished researches by knowledgeable fellows, moreover, contemporary clinical techniques, and pulp capping materials are immensely needed to enhance longevity of teeth without compromising pulp vitality; however, distinctions in clinical outsets and procedures should not be implemented until agreeable time has passed to approve the consequences of the research by practical clinical likeness.


  Conclusion Top


Based on the results of our study, it seems that when an exposure site is immediately sealed with MTA, the prognosis is promising. We found a success rate of 87.06%. MTA can induce the formation of reparative dentine thus allow the pulp to heal normally with preservation of pulp's vitality and regenerative potential so that the need for RCT could be avoided.

Acknowledgment

The authors would like to thank all the department staff and postgraduate colleagues who cooperates and honestly participates in the research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mente J, Hufnagel S, Leo M, Michel A, Gehrig H, Panagidis D, et al. Treatment outcome of mineral trioxide aggregate or calcium hydroxide direct pulp capping: Long-term results. J Endod 2014;40:1746-51.  Back to cited text no. 1
    
2.
Olsson H, Petersson K, Rohlin M. Formation of a hard tissue barrier after pulp cappings in humans. A systematic review. Int Endod J 2006;39:429-42.  Back to cited text no. 2
    
3.
Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium hydroxide or mineral trioxide aggregate: A meta-analysis. J Endod 2015;41:1412-7.  Back to cited text no. 3
    
4.
Cox CF, Sübay RK, Ostro E, Suzuki S, Suzuki SH. Tunnel defects in dentin bridges: Their formation following direct pulp capping. Oper Dent 1996;21:4-11.  Back to cited text no. 4
    
5.
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. Int Endod J 2008;41:128-50.  Back to cited text no. 5
    
6.
Batur YB, Erdemir U, Sancakli HS. The long-term effect of calcium hydroxide application on dentin fracture strength of endodontically treated teeth. Dent Traumatol 2013;29:461-4.  Back to cited text no. 6
    
7.
Yassen GH, Platt JA. The effect of nonsetting calcium hydroxide on root fracture and mechanical properties of radicular dentine: A systematic review. Int Endod J 2013;46:112-8.  Back to cited text no. 7
    
8.
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7.  Back to cited text no. 8
    
9.
Ferracane J. Materials in Dentistry: Principles and Applications. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 2001.  Back to cited text no. 9
    
10.
Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod 1993;19:541-4.  Back to cited text no. 10
    
11.
Reyes-Carmona JF, Felippe MS, Felippe WT. Biomineralization ability and interaction of mineral trioxide aggregate and white Portland cement with dentin in a phosphate-containing fluid. J Endod 2009;35:731-6.  Back to cited text no. 11
    
12.
Tselnik M, Baumgartner JC, Marshall JG. Bacterial leakage with mineral trioxide aggregate or a resin-modified glass ionomer used as a coronal barrier. J Endod 2004;30:782-4.  Back to cited text no. 12
    
13.
John AD, Webb TD, Imamura G, Goodell GG. Fluid flow evaluation of Fuji triage and gray and white ProRoot mineral trioxide aggregate intraorifice barriers. J Endod 2008;34:830-2.  Back to cited text no. 13
    
14.
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.  Back to cited text no. 14
  [Full text]  
15.
Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The radiographic outcomes of direct pulp-capping procedures performed by dental students: A retrospective study. J Am Dent Assoc 2006;137:1699-705.  Back to cited text no. 15
    
16.
Auschill TM, Arweiler NB, Hellwig E, Zamani-Alaei A, Sculean A. Success rate of direct pulp capping with calcium hydroxide. Schweiz Monatsschr Zahnmed 2003;113:946-52.  Back to cited text no. 16
    
17.
Yasini E, Kazemi P. Clinical trail of successfulness of DPC with MTA and calcium hydroxide. J Dent Tehran 2005;17:19-26.  Back to cited text no. 17
    
18.
Kruse C, Spin-Neto R, Christiansen R, Wenzel A, Kirkevang LL. Periapical bone healing after apicectomy with and without retrograde root filling with mineral trioxide aggregate: A 6-year follow-up of a randomized controlled trial. J Endod 2016;42:533-7.  Back to cited text no. 18
    
19.
Junn DJ. Quantitative Assessment of Dentin Bridge Formation Following Pulp-Capping with MTA (Master's Thesis). Loma Linda, California: Loma Linda University; 2000.  Back to cited text no. 19
    
20.
Moghaddame-Jafari S, Mantellini MG, Botero TM, McDonald NJ, Nör JE. Effect of ProRoot MTA on pulp cell apoptosis and proliferation in vitro. J Endod 2005;31:387-91.  Back to cited text no. 20
    
21.
Fridland M, Rosado R. MTA solubility: A long term study. J Endod 2005;31:376-9.  Back to cited text no. 21
    
22.
Tomson PL, Grover LM, Lumley PJ, Sloan AJ, Smith AJ, Cooper PR, et al. Dissolution of bio-active dentine matrix components by mineral trioxide aggregate. J Dent 2007;35:636-42.  Back to cited text no. 22
    
23.
Tziafas D, Pantelidou O, Alvanou A, Belibasakis G, Papadimitriou S. The dentinogenic effect of mineral trioxide aggregate (MTA) in short-term capping experiments. Int Endod J 2002;35:245-54.  Back to cited text no. 23
    
24.
Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review – Part III: Clinical applications, drawbacks, and mechanism of action. J Endod 2010;36:400-13.  Back to cited text no. 24
    
25.
Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: An observational study. J Am Dent Assoc 2008;139:305-15.  Back to cited text no. 25
    
26.
Asgary S, Ahmadyar M. Vital pulp therapy using calcium-enriched mixture: An evidence-based review. J Conserv Dent 2013;16:92-8.  Back to cited text no. 26
[PUBMED]  [Full text]  
27.
Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review – Part I: Chemical, physical, and antibacterial properties. J Endod 2010;36:16-27.  Back to cited text no. 27
    
28.
Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, Kosierkiewicz A, et al. Response of human dental pulp capped with biodentine and mineral trioxide aggregate. J Endod 2013;39:743-7.  Back to cited text no. 28
    
29.
Iwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, Jefferies S, et al. Clinical and histological evaluation of white ProRoot MTA in direct pulp capping. Am J Dent 2006;19:85-90.  Back to cited text no. 29
    
30.
Accorinte Mde L, Holland R, Reis A, Bortoluzzi MC, Murata SS, Dezan E Jr., et al. Evaluation of mineral trioxide aggregate and calcium hydroxide cement as pulp-capping agents in human teeth. J Endod 2008;34:1-6.  Back to cited text no. 30
    
31.
Sousa CJ, Loyola AM, Versiani MA, Biffi JC, Oliveira RP, Pascon EA. A comparative histological evaluation of the biocompatibility of materials used in apical surgery. Int Endod J 2004;37:738-48.  Back to cited text no. 31
    
32.
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. 32
    
33.
Miles JP, Gluskin AH, Chambers D, Peters OA. Pulp capping with mineral trioxide aggregate (MTA): A retrospective analysis of carious pulp exposures treated by undergraduate dental students. Oper Dent 2010;35:20-8.  Back to cited text no. 33
    
34.
Min KS, Park HJ, Lee SK, Park SH, Hong CU, Kim HW, et al. Effect of mineral trioxide aggregate on dentin bridge formation and expression of dentin sialoprotein and heme oxygenase-1 in human dental pulp. J Endod 2008;34:666-70.  Back to cited text no. 34
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed63    
    Printed1    
    Emailed0    
    PDF Downloaded10    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]