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Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 68-71
Comparison of three different materials used for indirect pulp capping in permanent molars: An in vivo study

1 Department of Conservative Dentistry and Endodontics, Karpaga Vinayaga Institute of Dental Sciences, Kanchipuram, Tamil Nadu, India
2 Department of Conservative Dentistry and Endodontics, Rajah Muthiah Dental College and Hospital, Chidambaram, Tamil Nadu, India
3 Department of Pediatric Dentistry and Preventive Dentistry, Karpaga Vinayaga Institute of Dental Sciences, Kanchipuram, Tamil Nadu, India

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Date of Submission28-Oct-2021
Date of Decision29-Dec-2021
Date of Acceptance31-Dec-2021
Date of Web Publication02-May-2022


Background: Pulp capping should always be considered as the primary treatment of choice for teeth without irreversible pulpitis in lesions approaching dental pulp. The predictability of vital pulp therapy has improved with the introduction of newer bioceramic materials.
Aim: The aim of this study was to evaluate the clinical success of Biodentine, calcium hydroxide (CH), and mineral trioxide aggregate (MTA) as pulp capping materials for indirect pulp capping in carious permanent teeth.
Materials and Methods: Indirect pulp capping was done for 36 molars of 36 patients with deep caries lesions. They were randomly divided into three groups: Biodentine group (12 teeth), MTA group (12 teeth), and CH group (12 teeth). Patients were recalled at 1, 3, and 6 months to evaluate the clinical success of the treatment outcome.
Statistical Analysis: All statistical analysis was performed using SPSS software version 21.0. Pearson's Chi-square test was used to compare the success and failure rates between Biodentine, MTA, and Ca(OH)2 at three different time intervals (30, 90, and 180 days) and also the overall success and failure rates between Biodentine, MTA, and Ca(OH)2 irrespective of the time intervals. P < 0.05 was considered statistically significant.
Results: In a statistical trial/study, the pulp capping materials gave different success rates, 91.67% success in the Biodentine group, 83.33% success in the MTA group, and 58.33% success in the CH group. The results were not statistically significant.
Conclusion: Indirect pulp capping with calcium silicate materials provided better results compared to that of calcium hydroxide.

Keywords: Biodentine; calcium hydroxide; indirect pulp capping; mineral trioxide aggregate

How to cite this article:
Selvendran K E, Ahamed A S, Krishnamurthy M, Kumar V N, Raju VG. Comparison of three different materials used for indirect pulp capping in permanent molars: An in vivo study. J Conserv Dent 2022;25:68-71

How to cite this URL:
Selvendran K E, Ahamed A S, Krishnamurthy M, Kumar V N, Raju VG. Comparison of three different materials used for indirect pulp capping in permanent molars: An in vivo study. J Conserv Dent [serial online] 2022 [cited 2022 Aug 15];25:68-71. Available from:

   Introduction Top

Vital pulp therapy is a conservative treatment approach toward teeth with compromised pulp tissue due to dental caries, trauma, and restorative procedures. Treatment options for deep carious lesions differ among dentists and it is still a debate. Complete caries removal has been challenged, and conservative approach is the advised treatment current era. Complete removal of caries-affected dentin is not necessary to terminate the progression of caries. Inadvertent exposure of the pulp in an attempt to completely remove caries would result in direct ingress of microorganisms into the pulp which could substantially reduce the successful outcome. Studies reveal that residual microorganisms in dentin after superficial caries removal could evoke a mild inflammatory response in the pulp which is considered beneficial for pulp regeneration. Management of the deep carious lesion should be aimed at resolution of the inflammation and preservation of pulp vitality.[1]

Indirect pulp capping is a vital pulp therapy procedure in which only infected dentin is removed, leaving a minimal layer of affected dentin as complete removal of affected dentin could lead to pulp exposure and lining the cavity floor with a suitable capping material and to completely seal against microleakage by an intact restoration ensuring complete lesion sterilization and tissue regeneration. Indirect pulp capping is performed in one-step or two-step procedures decided by case selection and clinical requirement.[2]

Researchers are still in search of an ideal material for pulp capping and have made them to evaluate many dental materials. Many materials were investigated for pulp capping, and they are calcium hydroxide (CH), resins, calcium phosphate, zinc phosphate cement, glass-ionomer cement, bioglass, and mineral trioxide aggregate (MTA).[3]

Many materials have been tested and used for deep caries management. CH introduced in 1920 by Herman is still being used and considered as the evidence-based gold standard material for deep caries management. CH is being used due to its high alkaline pH which mainly stimulates the fibroblasts and enzymes. CH promotes healing of pulp tissue by initial formation of matrix with odontoblast-like cells and calcification by mineralization process.[4] Disadvantages of CH are poor marginal seal toward dentin, dissolution, and degradation over time. Dentin formed adjacent to CH can also have tunnel-like defects. Histologically, CH demonstrated cytotoxicity in cell cultures and induced cell apoptosis. CH is dimensionally unstable and will resorb over a period of time.[5]

MTA was introduced in 1993 by modifying Portland cement. MTA consists of tricalcium silicate, tricalcium oxide, tricalcium aluminate, bismuth oxide, and silicate oxide.[3] MTA is a calcium silicate material-based pulp capping material. MTA initiates reparative dentin formation by stimulating growth factors and cytokines. MTA has excellent marginal sealing of dentin.[6] Longer setting time, tooth discoloration potential, and difficulty in handling are constraints for using as an ideal pulp capping material.[7]

Biodentine is a silicate-based cement introduced in 2009 with superior properties. Powder is a mixture of tricalcium silicate, zirconium oxide, and calcium carbonate. Liquid has calcium chloride as an accelerator for setting and a water-reducing agent. It initially sets in 12 min and does not discolor tooth. Biodentine without causing pulpal inflammation promoted reparative dentin formation.[8]

Very few studies have reported on the clinical outcome of indirect pulp capping with Biodentine, CH, and MTA. The trial reported a randomized clinical trial for evaluating the clinical success of three materials, Biodentine, CH, and MTA, used for indirect pulp capping of carious molars.

   Materials and Methods Top

Study design and sample

The randomized clinical trial was designed with three experimental groups. This clinical trial was performed during November 2018 and October 2020. The clinical trial was assessed and validated by the institutional ethical board and was designed in accordance with CONSORT 2010. The selected patients were adults with age between 19 and 40 years. All patients were explained about the treatment procedure, advantages, disadvantages, and different treatment options before enrolling in the study. Sign was obtained in an informed consent form from all the participants before starting the procedure.

Inclusion criterion

  • Patients aged between 19 and 40 years
  • Molars diagnosed with deep dental caries without pulpal exposure
  • Pulpal response on diagnostic tests should be with adjunct to healthy tooth or pulp in reversible pulpitis.

Exclusion criterion

  • Patients with systemic diseases
  • Teeth having signs and symptoms related to calcifications in pulp seen in radiograph or internal resorption.

Sample size determination

Sample size was fixed to 12 per group as described by Steven A. Julious; the minimum sample size required for a pilot design is estimated to be 12. Overall, 36 participants were enrolled.

Clinical procedure

Forty patients with deep caries were diagnosed with deep dental caries and 36 patients were selected for the trial. Pulp vitality was assessed by tooth sensitivity tests, thermal test, and electrical stimuli (Digitest II, Parkell, USA). Preoperative radiograph, was taken to assess periodontium and hard tissue. 2% lidocaine hydrochloride local anesthetic solution with epinephrine 1:80,000 (Lignospan, Septodont, France) was administered buccally by infiltration for maxillary teeth and by infra-alveolar nerve block technique for mandibular teeth selected for the experiment. Isolation was achieved with rubber dam (Hygienic; Coltene/Whaledent, USA). Caries was removed manually with spoon excavator and then a sterile BR 31 ball round bur (Mani Inc., Japan) mounted to handpiece. Caries was removed till resistance was felt with hand excavation or the bur. If bleeding occurred in this procedure due to pulp exposure, the pulp-exposed tooth was not incorporated from the trial. The tooth after caries excavation was assigned to one of the three groups by simple randomization technique.

Experimental groups

Group 1: Dycal (Dentsply, USA) was mixed on a paper pad given by the manufacturer. The mixture was placed in the floor of the prepared cavity with plastic filling instrument.

Group 2: MTA (Angelus, Brazil) powder and liquid were manipulated according to manufacturer's guidelines. The manipulated mixture was carried with MTA carrier and placed in the floor of the cavity.

Group 3: Biodentine (Septodont, France) was manipulated according to manufacturer's guidelines. The manipulated mixture was placed in the floor of cavity.

The materials were placed in the floor of the cavity with a thickness ranging between 1 and 2 mm approximately. Provisional restoration with Intermediate Restorative Material (IRM) was completed over the experimental materials. Provisional restoration was removed at 1-month recall visit and restored with direct glass-ionomer cement and occlusion was checked at 1-month recall visit.

Patients were recalled at 1, 3, and 6 months. In follow-up, pulp capped tooth was subjected and assessed by pulp sensitivity tests (cold and electrical) and pain was assessed clinically.

Tooth was declared clinically success if the tooth had no symptoms of disease and responded to sensitivity tests within normal limits.

   Results Top

A total of 36 patients were included (20 males and 16 females). The details of the patients and teeth enrolled in the trial are shown in [Table 1]. Patients selected and treatment procedure done are shown in [Figure 1]. Twelve molar teeth were indirectly pulp capped with CH, 12 molars with MTA, and 12 molars with Biodentine. Thirty-six molars included for the trial are 8 maxillary molars and 28 mandibular molars.
Table 1: Characteristics of patients and teeth enrolled for trial

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Figure 1: Flowchart showing randomization of selected cases and review done

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The success rate of the experimental materials at various intervals is shown in [Table 2]. Biodentine had a success rate of 100% at 3 months and 91.67% at 6 months, MTA had a success rate of 91.67% at 3 months and 90.91% at 6 months, and CH had a success rate of 75% at 3 months and 77.28% at 6 months.
Table 2: Success of materials at different time periods

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At 3 months, there were three failures in the CH material group and one failure in the MTA group. At 6 months, four new failures (two in the CH material group, one in the MTA group, and one in the Biodentine group). Treatment was revised and done for the failed cases.

The overall success of Biodentine was 91.67%, MTA was 83.33%, and CH was 58.33%.

   Discussion Top

The aim of conservative treatment is to preserve the vitality of pulp along with its regular functions. Only a vital and functional pulp can heal on its own by promoting reparative dentin formation and resolving inflammation. Our trial focused on the conservative approach of carious molar pulp capped with newer materials.

This trial was performed to evaluate the efficacy of CH, MTA, and Biodentine in indirect pulp capping of permanent molars by pulp vitality and clinical assessment during 6-month follow-up. CH was included in the trial since it is the gold standard material used nearly a century for pulp capping procedures. CH is known to have many disadvantages, poor adhesion toward dentin, dissolution, and tunnel-like defects in the formed dentin bridge.[9]

However, there is a paradigm shift in the preference of clinicians for pulp capping materials from CH to MTA due to its predictable outcomes.[10] Aeinehchi et al. reported that MTA induction rate of dentinogenic process is better than CH. Few authors have reported the frequency of reparative dentin formation and thickness is better for MTA.[11] MTA has few drawbacks, longer setting time, tooth discoloration, and difficult to handle.[7],[12]

Newer calcium silicate-based materials are developed to overcome the drawbacks of MTA. Biodentine introduced in 2009 is more biocompatible, clinically acceptable setting time, improved mechanical strength, better dentin surface bond, and handling.[13] In our trial, there was 91.67% success in the Biodentine group, 58.33% success in the CH group, and 83.33% success in the MTA group. Nowicka et al. also had compared Biodentine and MTA in premolars without caries planned for extraction due to orthodontic reasons.[8] In their trial, the teeth were caries free and it is known and proved that bacteria are the main reason cause for infection of pulp.[14] In our study, we have attempted to assess the efficacy of three different pulp capping materials in a more challenging clinical scenario where the outcome is unpredictable because of variability in the bacterial load, virulence, and diversity.

Identification of various factors determining the prognosis of pulp capping procedures is important than doing trial in artificial exposures of dentin.[15] Formation of dentin bridge by calcium silicate materials is better than CH and the mechanisms are not known.[16] Calcium silicate materials release CH which does not get dissolved over time like pure CH. Calcium silicate materials induce dentinogenic activity, minimal pulpal inflammation, and stable.[17] Inflammation induced by calcium silicate materials is short term when compared with CH.[18] Although the study's primary disadvantages include a small sample size and a brief assessment time, it was conducted in permanent molars diagnosed with deep dental caries and was clinically assessed. Our results showed s statistically significant difference between the three materials assessed at 6-month follow-up time.

   Conclusion Top

Clinical success and efficacy of MTA and Biodentine are better than CH and Biodentine is better than MTA for pulp capping procedures. When remaining dentin after caries excavation is minimal, Biodentine can be used as a reliable material for pulp capping procedures.


I acknowledge Dr. Mahesh J, MDS, Associate Professor, Department of Public Health Dentistry, Karpaga Vinayaga Institute of Dental Sciences, for his valuable support in statistical analysis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp management for caries in adults: Maintaining pulp vitality. Cochrane Database Syst Rev 2007;(2):CD004484.  Back to cited text no. 1
Leksell E, Ridell K, Cvek M, Mejàre I. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol 1996;12:192-6.  Back to cited text no. 2
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. 3
Bjørndal L, Reit C, Bruun G, Markvart M, Kjaeldgaard M, Näsman P, et al. Treatment of deep caries lesions in adults: Randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci 2010;118:290-7.  Back to cited text no. 4
Browning WD. Critical appraisal. 2015 update: Approaches to caries removal. J Esthet Restor Dent 2015;27:383-96.  Back to cited text no. 5
Eskandarizadeh A, Shahpasandzadeh MH, Shahpasandzadeh M, Torabi M, Parirokh M. A comparative study on dental pulp response to calcium hydroxide, white and grey mineral trioxide aggregate as pulp capping agents. J Conserv Dent 2011;14:351-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
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. 7
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. 8
Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: Correlations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:969-77.  Back to cited text no. 9
Hilton TJ. Keys to clinical success with pulp capping: A review of the literature. Oper Dent 2009;34:615-25.  Back to cited text no. 10
Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth: A preliminary report. Int Endod J 2003;36:225-31.  Back to cited text no. 11
Islam I, Chng HK, Yap AU. X-ray diffraction analysis of mineral trioxide aggregate and Portland cement. Int Endod J 2006;39:220-5.  Back to cited text no. 12
Tziafa C, Koliniotou-Koumpia E, Papadimitriou S, Tziafas D. Dentinogenic responses after direct pulp capping of miniature swine teeth with Biodentine. J Endod 2014;40:1967-71.  Back to cited text no. 13
Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965;20:340-9.  Back to cited text no. 14
Schwendicke F, Brouwer F, Schwendicke A, Paris S. Different materials for direct pulp capping: Systematic review and meta-analysis and trial sequential analysis. Clin Oral Investig 2016;20:1121-32.  Back to cited text no. 15
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. 16
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 – 2008. Int Endod J 2009;42:422-44.  Back to cited text no. 17
Iwamoto CE, Adachi E, Pameijer CH, Barnes D, Romberg EE, Jefferies S. Clinical and histological evaluation of white ProRoot MTA in direct pulp capping. Am J Dent 2006;19:85-90.  Back to cited text no. 18

Correspondence Address:
Dr. K E Selvendran
Department of Conservative Dentistry and Endodontics, Karpaga Vinayaga Institute of Dental Sciences, Kanchipuram, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcd.jcd_551_21

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