Clinical Research

Outcome of Direct Pulp Capping with Mineral TrioxideAggregate: A Prospective StudyMiguel Seruca Marques, DDS, Paul R. Wesselink, DDS, PhD, and Hagay Shemesh, DMD, PhD

Abstract

Introduction: The aim of this experimental study wasto assess the outcome of direct pulp capping with min-eral trioxide aggregate (MTA) after complete excavationof caries in permanent dentition with a 2-visit treatmentprotocol. Methods: Sixty-four teeth with deep cariouslesions were consecutively selected. The mean age ofthe patients was 36.1 � 15 years. An initial diagnosisof deep caries, with no irreversible pulp involvement,was made. Excavation of caries was performed undera rubber dam and operating microscope magnification.White MTA was applied, and a provisional restorationwas placed. At the following appointment, positive sen-sibility testing and the MTA setting were confirmed.Bonded composite restorations were placed afterward.The patient was recalled at least 1 year after treatmentfor clinical and radiographic control. Outcome wasdescribed as success or failure. Success was defined aslack of complaints from the patient, positive reactionto cold testing, no sensitivity to percussion, and nowidening of the periodontal ligament on the recall peri-apical radiograph. Results: Forty-six teeth (77.9%)were recalled after 3.6 years (standard deviation = 1.1years). The overall success rate was 91.3%. The successrate in occlusal caries was 100% and 89.7% in proximalcaries (difference = 10.3%; 95% confidence interval[CI], 8.5–89.1). The success rate in initial caries was94.7% and 88.9% in secondary caries (difference =5.8%; 95% CI, �48.1 to 59.7). The success rate inpatients younger than 40 years was 100% and 80% inpatients aged 40 years or older (difference = 20%;95% CI, 4.2–35.8). Conclusions: Direct pulp cappingwith MTA after pulp exposure during excavation ofdeep caries could maintain pulp vitality in permanentteeth when a 2-visit treatment protocol is observed.(J Endod 2015;-:1–6)

From the Academic Centre for Dentistry, Amsterdam, theNetherlands.

Address requests for reprints to Dr Miguel Seruca Marques,Department of Cariology, Endodontology, and Pedodontology,Academic Center for Dentistry Amsterdam, Gustav Mahlerlaan3004, 1081LA Amsterdam, Netherlands. E-mail address:seruca2@hotmail.com0099-2399/$ - see front matter

Copyright ª 2015 American Association of Endodontists.http://dx.doi.org/10.1016/j.joen.2015.02.024

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Key WordsComplete excavation, direct pulp capping, mineral trioxide aggregate

The first description of a pulp capping procedure was the application of a cap of leadfoil to an exposed pulp by Pfaff (1756) (1, 2). Vital pulp therapy in the form of pulp

capping and pulpotomy has long been recognized as a procedure aimed to maintainpulp vitality after caries exposure (3).

In deep carious lesions, inflammation in superficial layers of the pulp, especiallysubjacent to the region of the involved dentinal tubules, is more pronounced comparedwith deeper layers, whereas pulp tissue in the root canal usually remains normal, exceptfor the presence of dilated blood vessels (3, 4). Pulpal healing and repair after directpulp capping or partial pulpotomy was reported in in vivo studies after the removal ofcaries (6) or exposure after accidental trauma (7).

Optimal prognosis of vital pulp therapy is based on the elimination of etiologic fac-tors with complete removal of diseased and contaminated tissues (6). When pulp expo-sure occurs, immediate direct pulp capping is preferred to reduce the risk of infectionand further damage to the pulp.

The most studied material for direct pulp capping is calcium hydroxide (CH) in avariety of formulations (pure and fast setting). However, the success rate of direct pulpcapping with fast-setting CH-based cements varied widely between 31.8% after 1 year(8) and 72.7% after 10 years (9).

Mineral trioxide aggregate (MTA) has been investigated as a material for directpulp capping during recent years and showed superior results when compared withCH. MTA reduces inflammation, hyperemia, and necrosis levels. It also creates thickerdentin bridges and minimal tunnel defects, and the apposition of dentin is faster (10).MTA resists bacterial leakage and may provide protection for the pulp, allowing repairand continued pulp vitality (6). The disadvantages of MTA are discoloration (6), diffi-cult manipulation, slow setting time (11), and cost of the material.

The purpose of this experimental study was to assess the treatment outcome ofdeep caries lesions treated with MTA direct pulp capping. The following parameterswere addressed:

1. Pulp sensibility2. Tooth discoloration3. Caries recurrence

The tested null hypotheses were that the following parameters do not influence theoutcome of direct pulp capping with MTA: bleeding or no bleeding during caries exca-vation, occlusal or proximal caries, initial or secondary caries, and age younger or olderthan 40 years.

MethodsAll patients in this study were selected consecutively from the daily general private

practice of 1 of the authors (M.M.) over a period of 3 years between 2008 and 2011. Allpatients had completed a detailed clinical history questionnaire, bite-wing radiographs,percussion, and cold thermal testing (EndoFrost; Roeko, Langenau, Germany).

Over this period, a total of 59 patients were treated after the diagnosis of extensiveprimary or secondary deep caries in 64 teeth in which pulp exposure was anticipatedbecause of caries extension on radiographic or clinical evaluation. Eventually, 64 per-manent teeth were treated: 5 incisors, 17 premolars, and 42 molars; 38 were maxillary,

Direct Pulp Capping with MTA 1

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and 26 were mandibular. The patient sample consisted of 32 femalesand 27 males with a mean age of 36.1 years (standard deviation[SD] = 15.1).

All participants or legal guardians were asked to sign an informedconsent form in which the treatment was briefly explained. The inclu-sion criteria were permanent teeth with caries, a positive cold test,the absence of spontaneous and lingering pain, the absence of percus-sion pain, and the absence of sinus tract or swelling.

One operator (M.M.) completed all treatment procedures, withthe exception of 2 definitive bonded restorations that were performedby another general practitioner at the same practice. All procedureswere performed under a rubber dam and local anesthesia of 4% arti-caine with 1:100,000 epinephrine (ARTINIBSA; Laborat�orios InibsaSA, Barcelona, Spain). Caries excavation was performed under �6to �16 magnification (DFV Vasconcellos MC-M1232; DFV, Rio deJaneiro, Brazil) using caries detector dye (Sable seek or Seek; UltradentProducts GmbH, Cologne, Germany) applied with a disposable brushtip (Black mini brush tip, Ultradent Products GmbH). High-speedround (801.314) diamond burs with medium grit 014, 016, or 018(Komet Dental, Lemgo, Germany) on an air turbine with water andair spray coolant were used for enamel removal. Round steel(H1SE.204) slow-speed burs 014, 016, or 018 (Komet Dental) or LNburs 014, 016, or 018 (Dentsply Maillefer, Ballaigues, Switzerland)with water and air spray coolant and sharp hand excavators (EXCE2and EXCE3; Hu-Friedy, Chicago, IL) were used for caries removal.Caries excavation continued even after pulpal exposures occurredand was complete when dentin offered resistance to hand excavationwith a sharp excavator as per final inspection.

In all cases in which pulp bleeding occurred, hemostasis wasachieved with water from a 2-way syringe of the dental unit andoccasionally pressure applied with dry cotton pellets. Subsequently,the surrounding dentin was gently air-dried with a 2-way syringe untilall excess water had been removed. White MTA (ProRoot; DentsplyTulsa Dental, Tulsa, OK) mixed according to the manufacturer’sinstructions, 3:1 powder-to-liquid ratio, was applied in a thin layerof 1.5 mm over the exposure site and surrounding dentin with theaid of a double-ended medium 1.2-mm/1.6-mm ball burnisher (Hen-ry Schein Inc, Melville, NY), leaving some circumferentially dentinavailable for bonding. Ten minutes after the direct capping procedure,a provisional restoration with zinc oxide/zinc sulfate–based cement(Coltosol F; Colt�ene/Whaledent, Altst€atten, Switzerland) was placeddirectly over the MTA.

At the following appointment, 4 to 12 weeks later, if spontaneouspain complaints were reported, cold testing was negative, and/or

TABLE 1. Outcome of Direct Pulp Capping with Mineral Trioxide Aggregate Accor

Studied variables Bleeding Caries trea

(n = analyzed teeth)Present(n = 21)

Absent(n = 25)

Initial(n = 19)

Se(

SuccessPulp vitality without apical

radiolucency, n (%)19 (90.5) 23 (92) 18 (94.7) 2

FailureSpontaneous pain, n (%) 2 (9.5) — 1 (5.3)No pulp vitality with apical

radiolucency, n (%)— 2 (8) —

Difference between groups,% (95% CI)

1.5 (�54.1 to 51.1) 5.8 (�48.1 t

P value >.05 >.05

CI, confidence interval.

Significance level, a <.05. Only recalled patients were considered for these table calculations.

2 Marques et al.

percussion resulted in a painful reaction, root canal treatment wasperformed. Otherwise, provisional restorations were removed withround steel (H1SE.204) slow-speed burs 014, 016, or 018 (KometDental) or LN burs 014, 016, or 018 (Dentsply Maillefer) with waterand air spray coolant. MTA setting was confirmed and its color deter-mined. A Palodent sectional matrix (Dentsply DeTrey GmbH, Konstanz,Germany) was adjusted, and a 35% phosphoric etchant solution (Ultra-Etch, Ultradent Products GmbH) for 30 seconds was applied on theenamel, dentin, andMTA surface and was rinsed and air-dried for 5 sec-onds. A light-curing adhesive agent (OptiBond Solo; KerrHawe Neos,Orange, CA) was applied with a microbrush in a brushing motion for20 seconds, and excesses were blown out. The bonding agent was lightcured (Bluephase G2 LED; Ivoclar Vivadent AG, Schaan, Liechtenstein)for 20 seconds, and all cavities were filled with composite (Tetric evoCeram, Ivoclar Vivadent AG) in several layers and light cured for 40 sec-onds. Patients were recalled yearly for clinical tests and periapicalradiographs. Success was defined as a positive cold test, no pain onpercussion, and no widening of the periodontal ligament on the periap-ical radiograph. All radiographs were acquired using a dental radio-graph unit (Philips Oralix 65; Philips, Eindhoven, The Netherlands)set at 65 kVp, 7.5 mA, and 0.2 seconds. A digital dental sensor (Visu-alix-1; Gendex Dental Systems, Milan, Italy) was used to capture all dig-ital radiographs with a positioning holder using a perpendiculartechnique. The digital radiographs were visualized with imaging soft-ware (VixWin, Gendex Dental Systems) on a personal computer(ASUS Eee PC 1201 PN Netbook; ASUSTek Computer Inc, Taipei,Taiwan).

One operator (M.M.) diagnosed recurrent caries through clinicaland radiographic evaluation. When in doubt, the case was classified ashaving recurrent caries. The same operator classified discolorationsubjectively as either discolored or not discolored. When in doubt,the case was classified as discolored.

Data entry and analysis were performed with a statistical softwarepackage (SPSS 21.0; SPSS Inc, Chicago, IL). The Fisher exact test and theKaplan-Meier method were used for analysis with a significance level ofP < .05.

ResultsThis sample consisted of 12 teeth with occlusal caries and 52 with

proximal caries, of which 26 were primary caries and 38 secondarycaries. On the first appointment, pulp bleeding during caries excavationoccurred in 29 of the 64 teeth; 92.2% of the patients (59 teeth) returnedfor the second appointment. In 3 of 5 teeth that were lost to recall, nobleeding was detected during the first appointment, and in the

ding to Study Variables: Bleeding, Caries Location, Caries Treatment, and Age

tment Caries location Age

condaryn = 27)

Occlusal(n = 7)

Proximal(n = 39) <40 (n = 26) $40 (n = 20)

4 (88.9) 7 (100) 35 (89.7) 26 (100) 16 (80)

1 (3.7) — 2 (5.7) — 2 (10)2 (7.4) — 2 (5.7) — 2 (10)

o 59.7) 10.3 (8.5–89.1) 20 (4.2–35.8)

>.05 <.05

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Figure 1. Kaplan-Meier yearly survival probability estimate of pulpal survival.Time in years (horizontal axis) versus cumulative survival (vertical axis).

Figure 3. The surface color of MTA changed from white to gray after provi-sional restoration removal.

Clinical Research

remaining 2 cases, bleeding was observed. These 5 teeth lost to recallwere not included in post-treatment data; 77.9% of patients (46 teeth)were recalled after a mean follow-up period of 3.6 years (SD = 1.1).The overall success rate was 91.3% (n = 42), the immediate failure(between first and second appointments) rate was 3.1% (n = 2),and the late failure (follow-up appointment >3 years) rate was 3.1%(n = 2). In both immediate failure teeth, bleeding was detected, andin both late failure teeth, bleeding was not detected. There were recur-rent caries in 1 late failure case.

The parameters pulp bleeding, caries location, and initial versussecondary caries did not influence the outcome, thus accepting thesenull hypotheses. The patient’s age did influence the outcome, so thenull hypothesis concerning this parameter was rejected (Table 1).Three teeth had recurrent caries (6.8%), and 6 teeth presented discol-oration (13.6%).

Figure 2. MTA staining was evident after 10 minutes. Apparently, MTA‘‘soaked up’’ oozing unclotted blood.

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The Kaplan-Meier probability estimate of pulpal survival showedno statistically significant differences between pulp bleeding and nopulp bleeding groups (P > .05) (Fig. 1). The overall probability ofpulp survival at 4 years was 87.3%.

DiscussionThe aim of this experimental clinical study was to evaluate the

outcome of direct pulp capping using a specific 2-step protocol withMTA, and, thus, no control groups using either calcium hydroxide orindirect pulp capping were included. Incomplete caries removal wasnot considered as a treatment option for these patients because thequality of several studies that support this practice is low (12, 13).

In an animal study, Cox et al (14) showed that a total of 192 dentinbridges formed against the fast-setting CH in 235 pulp-capped teeth, ofwhich 41%were associated with recurring pulp inflammation or necro-sis and were always associated with inflammatory cells and stained bac-terial profiles. Dentin bridge formation after vital pulp therapy does notguarantee success. Histologic sections of healthy human or animal teethcapped with fast-setting CH-based cements showed the formation of tun-nel defects in the calcified bridge (10, 14). Tunnel defects have alsobeen observed in a carious human tooth capped with CH powder(15). In a multicenter randomized clinical trial, pulp capping ofdeep carious–exposed permanent teeth with fast setting CH reporteda success rate of 31.8% after 1 year (8). Healthy teeth capped withMTA presented hard tissue barriers of steadily increasing length andthickness accompanied by healthy pulp tissue (10). Because of theseadvantages of MTA over CH and in order not to dilute the outcome ofthe result by dividing the limited available patients in 2 groups, no con-trols with CH or other materials were included.

Studies on pulp capping of carious-exposed permanent teeth withMTA have reported high success rates, which ranged from 93%–98%(6, 16). The success rate of 91.3% in our study compares with theresults of previous studies. This study has also some bias potentialbecause the same operator performed treatments and follow-up proce-dures although a similar methodology was used in several vital pulptherapy studies (6, 17). The overall probability of pulp survival at 4

Direct Pulp Capping with MTA 3

Figure 4. Treatment of the right first maxillary molar. (A) Initial radiograph with deep caries, (B) initial clinical photograph with extensive occlusomesial caries,(C) pulp exposure with bleeding from the mesiobuccal pulp horn, (D) MTA direct pulp capping over the mesiobuccal pulp horn and the surrounding dentin,(E) follow-up radiograph after 23 months, and (F) follow-up clinical photograph after 23 months.

Clinical Research

years using the Kaplan-Meier survival probability test was 87.3%. Thisresult was lower than the 94.87% reported in a previous study (6).This difference could be explained by several factors. In the formerstudy, all teeth exhibited initial deep caries and no prior restorations,whereas in the current study, initial and secondary caries were treated.The age interval in the former study (7–45 years) was different than inthe current study (8–68 years).

4 Marques et al.

Factors such as age, caries history, location, and blood clottingbetween the pulp and the capping material were already reported tohave an influence on treatment outcome (1). Furthermore, a positivecorrelation was found between caries location and inflammatory pulpextension (18). In this study, caries location and pulp bleeding wereexplored as outcome predictors because of their potential importancefor the success of pulp capping.

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In a clinical trial, a lower success rate of 56.2% was reported after

direct pulp capping with MTA (19). However, no attempt was made tofully remove carious dentin as soon as pulpal bleeding was observed.The success of vital pulp therapy may depend on the complete removalof all disintegrated tissue (5). Controlling the infection is apparently akey point for clinical success of direct pulp capping (20).

In our study, no case was excluded based on the amount ofbleeding because this factor as an outcome predictor is controversial(21). In some cases, it was evident that MTA served to ‘‘soak up’’ oozingunclotted blood, and immediate staining of MTA was evident after 10minutes (Fig. 2). Bleeding from the exposed pulp for longer than 5and up to 10minutes has previously been used as a threshold for revers-ible versus irreversible pulpitis classification (1, 6). Clinical trialsverifying this threshold are lacking.

In the current study, no attempt was made to rinse the pulp expo-sure with saline or a disinfectant, but instead water from the dental unitwas used. Because the procedures were performed using nonsterilecooling water from the air turbine and the slow-speed contra-anglehandpiece, it did not seem logical to use any specific substances forpulp disinfection. Furthermore, dentin surfaces treated by sodiumhypochlorite may inhibit the differentiation of odontoblasts from dentalpulp stem cells (20), and chlorhexidine may inhibit MTA setting (22).

The tooth discoloration rate in this study was 13.6% with subjectiveassessment by 1 observer. It has been reported that vital pulp therapy withwhiteMTA can result in discoloration (23). Pulp bleeding controlled withsodium hypochlorite may potentiate discoloration (24). Although in thecurrent study the pulp was rinsed with water from a dental unit 2-waysyringe, still some cases of discoloration were observed. Moreover, afterremoval of the provisional restoration, the surface color of MTA waschanged from white to gray in all cases (Fig. 3). Bonded restorationsand curing light promote an oxygen-free environment and may beresponsible for the discoloration in our study (25). MTA usage in theesthetic zone should be done cautiously (23).

It was recommended to temporarily place a moist cotton pellet indirect contact with MTA and leave it in until the follow-up appointmentbecause moisture assists in the hydration of MTA from a colloidal gelthat solidifies to a hard structure in approximately 3 to 4 hours (22).In the current study, no cotton pellet was used, and the MTA hardenedin every case, suggesting that the moisture from the pulp was enough forthe setting in vital pulp therapy procedures (26).

This experimental study used a 2-appointment protocol fordirect pulp capping with MTA (Fig. 4A–F). The best evidence avail-able at the time of the study used this same protocol (6), and thereis only limited evidence that a single-appointment protocol could givesimilar results (27).

The hypothesis that young pulps with open apices and abundantblood supply will heal more often than the mature pulp with narrowedapices and poor blood supply (28) was only shown in the current studywhen 2 age groups (<40 years) and ($40 years) were compared(P = .03). Patients younger than 40 years of age had a significantlyhigher success rate than older patients. In another study with thissame age interval groups, no differences were found in the outcomeof direct pulp capping (29). Because of the small number of failuresin this study and the borderline statistical difference, age can be onlyclassified as a weak outcome predictor for direct pulp capping underthe conditions of this study.

The wide confidence intervals in the results of this study are relatedto the small sample size. The power calculation for a study on the suc-cess of MTA pulp capping comes to 197 teeth. Our study should be seenas a pilot experiment to justify prospective studies with larger samplesizes, aiding in the creation of guidelines for the use of MTA for pulpcapping.

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The reported overall success rate of composite resin restorationsin a meta-analytic study was about 92% after 10 years (30). Our studyfound a caries recurrent rate of 6.8% over a 3.6-year follow-up period,with all bonded restorations done under a rubber dam and magnifica-tion. The high proportion of proximal restorations (81.3%) in ourstudy could explain the difference in caries recurrence in both studies.

Attempts to contact patients for recall appointments for this studyincluded several phone calls. All patients who declined recall appoint-ments stated lack of complaints and lack of time as the main reasons fornot attending the recall appointments. There is no indication that theabsentees represent a particular section of the study material.

ConclusionDirect pulp capping with MTA after exposure during deep caries

removal could maintain pulp vitality in permanent teeth when a 2-visittreatment protocol was observed.

AcknowledgmentsThe authors deny any conflicts of interest related to this study.

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