ATR 41..2010 Mta Good LD

Review Article
Mineral Trioxide Aggregate: A Comprehensive Literature

ReviewPart I: Chemical, Physical, and Antibacterial
Properties
Masoud Parirokh, DMD, MS,* and Mahmoud Torabinejad, DMD, MSD, PhD
Abstract
Introduction: An ideal orthograde or retrograde filling
material should seal the pathways of communication
between the root canal system and its surrounding
tissues. It should also be nontoxic, noncarcinogenic,
nongenotoxic, biocompatible, insoluble in tissue fluids,
and dimensionally stable. Mineral trioxide aggregate
(MTA) was developed and recommended initially
because existing root-end filling materials did not
have these ideal characteristics. MTA has also been
recommended for pulp capping, pulpotomy, apical
barrier formation in teeth with open apexes, repair of
root perforations, and root canal filling. Since MTAs
introduction in 1993, numerous studies have been published regarding various aspects of this material. The
aim of Part I of this literature review is to present investigations regarding the chemical, physical, and antibacterial properties of MTA. Methods: A review of the
literature was performed by using electronic and handsearching methods for the chemical and physical properties and antibacterial activity of MTA from November
1993September 2009. Results: There are many published reports regarding the chemical, physical, and antibacterial properties of MTA. Our search showed that
MTA is composed of calcium, silica, and bismuth. It
has a long setting time, high pH, and low compressive
strength. It possesses some antibacterial and antifungal
properties, depending on its powder-to-liquid ratio.
Conclusions: MTA is a bioactive material that influences its surrounding environment. (J Endod
2010;36:1627)
Key Words
Antibacterial effect, chemical and physical properties,
mineral trioxide aggregate, MTA
ost endodontic failures occur as a result of leakage of irritants into the periapical
tissues (13). An ideal orthograde or retrograde filling material should seal the
pathways of communication between the root canal system and its surrounding tissues.
It should also be nontoxic, noncarcinogenic, nongenotoxic, biocompatible with the
host tissues, insoluble in tissue fluids, and dimensionally stable (4, 5). Furthermore,
the presence of moisture should not affect its sealing ability; it should be easy to use
and be radiopaque for recognition on radiographs (4). Because existing restorative
materials used in endodontics did not possess these ideal characteristics (4), mineral
trioxide aggregate (MTA) was developed and recommended initially as a root-end filling
material and subsequently has been used for pulp capping, pulpotomy, apexogenesis,
apical barrier formation in teeth with open apexes, repair of root perforations, and as
a root canal filling material. MTA has been recognized as a bioactive material (6) that is
hard tissue conductive (7), hard tissue inductive, and biocompatible. Several reviews
have been published about MTAs chemical properties, biocompatibility, and clinical
applications (810). Only one article has extensively studied MTA and addresses
numerous articles regarding the materials physical and chemical properties, leakage
studies, biocompatibility, and clinical applications (10). The authors found 245 articles
with their selected key words since the introduction of MTA in 1993 to August 2006. Of
these, 156 articles met their criteria for citation.
Since then, additional articles have been published regarding the various properties and clinical uses of MTA. The purpose of this literature review is to update previously published information (10) and present a comprehensive list of articles from
November 1993September 2009 regarding the chemical and physical properties
and antibacterial activity of MTA.
Inclusion and Exclusion Criteria

MTA publications from peer-reviewed journals published in English from
November 1993September 2009 are included in this review. Studies that do not
meet the above criteria are excluded.
Search Methodology
An electronic search was conducted in the PubMed and Cochrane databases with
appropriate MeSH headings and key words related to the physical, chemical, and antibacterial properties of MTA. To enrich the results, a hand-search was conducted of the
last 2 years worth of issues of the following major endodontic journals: International
Endodontic Journal; Journal of Endodontics; Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology and Endodontology. The process of cross-referencing
continued until no new articles were identified.
From the *Department of Endodontics, School of Dentistry, Oral and Dental Diseases Research Center, Neuroscience Research Center, Iranian Center for Endodontic
Research, Kerman University of Medical Sciences, Kerman, Iran; and Department of Endodontics, School of Dentistry, Loma Linda University, Loma Linda, California.
Address requests for reprints to Mahmoud Torabinejad, DMD, MSD, PhD, Professor and Director, Endodontic Residency Program, Department of Endodontics, School
of Dentistry, Loma Linda University, Loma Linda, CA 92350. E-mail address: mtorabinejad@llu.edu.
0099-2399/$0 - see front matter
2010 Published by Elsevier Inc. on behalf of the American Association of Endodontists.
doi:10.1016/j.joen.2009.09.006
16
Parirokh and Torabinejad
JOE Volume 36, Number 1, January 2010
Review Article
Chemical Properties
MTA powder contains fine hydrophilic particles that set in the
presence of moisture. Several liquids have been used to hydrate MTA
powder. Various methods have been used to examine MTA composition
including energy dispersive analysis with x-ray (EDAX), inductively
coupled plasma optical emission spectroscopy (ICP-OES), x-ray diffraction analyses (XRD), x-ray fluorescence spectrometry (XRF), energy
x-ray spectrometry, and energy dispersive spectroscopy (1120).
The MTA patent (21) shows that it contains calcium oxide (CaO)
and silicon (SiO). Several investigations have reported that the main
elemental components of MTA are calcium and silica, as well as bismuth
oxide (13, 16, 22, 23).
MTA is currently marketed in 2 forms: gray (GMTA) and white
(WMTA). MTA was introduced in gray, but because of the discoloration
potential of GMTA, WMTA was developed (24). Investigations showed
that lower amounts of iron, aluminum, and magnesium are present
in WMTA than in GMTA (13, 16, 17, 22, 25).
The primary differences between both types of MTA and PC are a
lack of potassium and the presence of bismuth oxide (17). An investigation evaluated the dry powder of GMTA and WMTA, as well as ordinary
and white Portland cement (PC), finding that all tested materials have
similar major constituents: tricalcium silicate, tricalcium aluminate,
calcium silicate, and tetracalcium aluminoferrite (18).
GMTA basically consists of dicalcium and tricalcium silicate and
bismuth oxide, whereas WMTA is primarily composed of tricalcium
silicate and bismuth oxide (16). When MTA powder is mixed with
water, calcium hydroxide (CH) and calcium silicate hydrate are
initially formed and eventually transform into a poorly crystallized
and porous solid gel (19). The ratio of calcium silicate drops because
of the formation of a calcium precipitate. The precipitated calcium
produces CH, which is the cause of MTAs high alkalinity after
hydration (26). The production source for CH is a matter of controversy. Camilleri (26) believed that CH is formed from dicalcium and
tricalcium silicate after mixing MTA powder with water, whereas
Dammaschke et al (14) reported that CH is a product of tricalcium
aluminate hydrogenation.
Bismuth affects CH precipitation after MTA hydration (19).
Because bismuth oxide dissolves in an acidic environment, it has
been suggested that placing MTA in an acidic environment such as
inflammatory tissues might result in the release of bismuth oxide
(19). This might decrease MTAs biocompatibility because bismuth
oxide does not encourage cell proliferation in cell culture (27).
In 2005Dammaschke et al (14) reported that the amount of sulfur
at the surface of set MTA is 3 times higher than the powder forms of
MTA, and that this layer protects the cement from further hydration
and increases the cements setting time. MTA is known as an active
biomaterial with the potential to interact with the natural fluids present
in tissues (28). Recently published articles have used phosphatebuffered saline (PBS) or other media that are more similar to an in
vivo medium (2932).
A qualitative surface analysis of WMTA and GMTA showed that the
crystal size of GMTA is approximately 8 times larger than that of WMTA
(22). Map images show that oxygen is distributed throughout both crystalline and amorphous phases of GMTA and WMTA, and therefore all of
the elements are present in their oxide form (22).
Two investigations analyzed the set condition and powder form of
GMTA, WMTA, and PC (16, 17). One reported that crystals were only
observed when the set material was placed in a phosphate solution
(16). They concluded that set MTA contains CH in a silicate matrix
and attributed the high pH of MTA to the presence of CH (16). The other
investigation reported differences in the presence and percentage of the
content of the powder and the set condition of PC, WMTA, and GMTA
(17).
Bismuth oxide in MTA provides its radiopacity. Bismuth is present
in both hydrated and nonhydrated MTA and is also a part of calcium
silicate hydrate (19).
On the basis of the results of current literature, it appears that there
are some differences among published studies regarding the chemical
composition of MTA. These differences are related to the various liquids
used to mix with MTA powder (1113, 16, 17, 22, 3335) and various
equipments to test its composition (1120).
Physical Properties
Hydration of MTA powder results in a colloidal gel that solidifies
into a hard structure. Characteristics of the mixture can be influenced
by the powder/liquid ratio, method of mixing (ie, the amount of entrapped air), pressure used for condensation, humidity of the environment,
the type of MTA, the type of storage media, the pH value of the environment, the type of vehicle, the length of time between mixing and evaluation, thickness of the material, and temperature (14, 29, 3555).
Fridland and Rosado (42) believed that some of these factors cannot
be controlled easily; therefore, different results might be obtained
during a study on physical properties of MTA. Several investigators
have examined MTAs setting time and expansion, solubility, compressive and flexural strength, push-out strength, bond strength to other
materials, retentive strength, displacement, pH, radiopacity, particle
size, porosity, microhardness, and fracture resistance. Others have
studied the effect of environment and methods of placement of MTA
on its physical properties. Furthermore, physical and chemical properties of other types of MTA as well as its new compositions have been
studied and compared with each other and with PC.
Setting Time
MTA is prepared by mixing its powder with sterile water in a 3:1
powder-to-liquid ratio (39). The mean setting time of MTA is 165 !
5 minutes, which is longer than amalgam, Super EBA, and intermediate
restorative material (IRM) (11). GMTA exhibits significantly higher
initial and final setting times than WMTA (45, 46). The longer setting
time of WMTA in comparison with PC is attributed to the lower levels
of sulfur and tricalcium aluminate in WMTA (14).
In an attempt to use MTA for 1-visit perforation repair, a study
placed glass ionomer cement (GIC) over WMTA. The authors reported
that placing GIC 45 minutes after WMTA placement did not affect the
formation of calcium salts in the interface of the 2 materials. In addition,
placement of GIC over WMTA did not affect setting of this material (56).
A separate study by the same authors confirmed that the GIC setting was
not disrupted by the presence of WMTA (57).
To improve its handling, a recent study used MTA in its powder
form as a root canal filling material (58). The authors reported that
the majority of samples set after storage in normal saline, albeit during
a longer period of time (72 hours). MTA setting time and bacterial
leakage are adversely influenced when the samples are kept in dry
conditions (50). Because 2-sided hydration of MTA results in more flexural strength than 1-sided hydration (47), placing MTA in 1 visit without
external moisture is not recommended.
MTAs long setting time is one of the major drawbacks of the material. Many investigations have been performed to overcome this clinical
disadvantage (38, 5962).
Setting Expansion
There are conflicting results regarding the setting expansion of
various types of MTA (37, 45, 46). Two investigations showed that
MTA: Chemical, Physical, and Antibacterial Properties
17
Review Article
WMTA expands slightly more than GMTA (45, 46). Another investigation compared the expansion of GMTA with WMTA after covering the
materials surface with Hanks balanced salt solution (HBSS) or sterile
water. In this study, GMTA expanded significantly more than WMTA with
either sterile water or HBSS (37). GMTA expanded less in HBSS than in
sterile water. In contrast, WMTA expansion was higher in HBSS than in
sterile water. The different expansion behavior of GMTA and WMTA
stored in HBSS might be due to the composition of the immersion liquid
(HNa2O4P) or the difference in chemical composition between the 2
formulations of MTA (13, 16, 22). This information indicates that
storing MTA in different environments affects its setting expansion (37).
Solubility
The degree of solubility of MTA is a matter of debate among investigators (11, 46, 49, 6365). Most investigations reported low or no
solubility for MTA (11, 49, 64, 65). However, increased solubility is reported in a long-term study (63).
When comparing the physical properties of WMTA with those of
GMTA, the former material demonstrates significantly more solubility
(46). Varying results are reported when comparing PC with WMTA
(46, 49). One study reported that both ordinary and white PC (WPC)
exhibit significantly less solubility than WMTA (46). These findings
are in contrast with another study that shows WMTA is less soluble
than 2 different types of PC (49). The differences are attributed to
the type of PC used in these investigations. In addition, the powderto-water ratio might influence the amount of solubility. In fact, higher
water-to-powder ratios increased MTA porosity and solubility (42).
The authors reported that using more water would increase calcium
release from MTA. The addition of bismuth oxide to MTA, which is insoluble in water, is another cause for MTA insolubility. In an experiment on
the hydration of MTA, Camilleri (19) confirmed the reaction of bismuth
oxide with both calcium and silicate contents of MTA.
A recent investigation has reported that WMTA decreases its weight
7 days after immersion in physiologic solutions with different pH values,
whereas the material increases in weight 30 days after immersion. The
investigators have attributed the weight loss to the release of CH and the
increase in WMTA weight to the formation of apatite crystals over the
material surface (65).
The release of calcium ions from MTA is reported by several investigations (33, 34, 42, 66, 67). Antunes Bortoluzzi et al (34) added CaCl2
to WMTA, revealing a significant increase in calcium release from WMTA
during the first 24 hours. It has been confirmed that high amounts of
calcium in a cell culture environment might down-regulate cell proliferation (68).
Releasing calcium from MTA might be influenced by clinical
conditions. A recent study placed MTA inside the canals with simulated
resorbed roots, reporting significantly more calcium ion release than in
teeth without MTA root filling (33). It should be emphasized that the
method of solubility assessment in most studies (11, 42, 49, 63) is
based on the difference between weight before and after placing the
cement into the water. Although it is a standard method for assessing
material solubility, the test, in fact, measures the elution of water-soluble
material, not the solubility. Solubility of a solid material is defined as the
amount of a substance that can be dissolved in a given amount of
solvent. However, measuring weight difference before and after storage
of the material in water might not result in solubility, because particles
of the material might detach from the cement during storage, or the
cement might absorb water. These interactions might prevent the evaluation of actual solubility in spite of releasing some of the cement
contents into the storage media (69, 70). Because various investigators
used different methods to evaluate this property of MTA, it is very diffi18
cult to compare the results of these investigations with one another. In

fact, recent investigations raised a question regarding clinical relevancy
of the method of assessing solubility for bioactive materials such as MTA
(6567, 71).
Other reasons for difference in MTA solubility include the time of
immersion of the material, the type of MTA, and the powder-to-liquid
ratio (42, 46, 71, 72).
Compressive Strength
The compressive strength of MTA is significantly less than that of
amalgam, IRM, and Super EBA after 24 hours. However, after 3 weeks,
there is no significant difference between Super EBA, IRM, and MTA in
terms of compressive strength (11). MTA is composed primarily of tricalcium and dicalcium silicate (16) with the addition of bismuth oxide.
Because the dicalcium silicate hydration rate is slower than that of tricalcium silicate (14), the compressive strength (11) and push-out
strength of MTA reach their maximum several days after mixing (40,
48).
There are conflicting results regarding the compressive strength of
WMTA and GMTA (29, 46, 52). One study reported that compressive
strength of WMTA at 3 and 28 days after mixing is significantly less
than that of GMTA (46). In contrast, 2 other investigations comparing
the compressive strength of GMTA and WMTA reported more compressive strength for WMTA (29, 52). In general, MTAs compressive
strength is not significantly affected by condensation pressure (51).
Another recent experiment revealed that keeping WMTA in dry
conditions decreases its compressive strength (50). Even the samples
kept moist after mixing show variations in compressive strength, depending on the amount of time elapsed between mixing and examination. The samples that were kept for 27 days in moisture exhibited
greater compressive strength than the 4-hour samples.
A recent investigation reported significantly lower compressive
strength for WMTA when the material was etched by phosphoric acid
(37%). The investigators suggested that restoration with acid-etch
composite after MTA placement should be postponed for at least 96
hours (73).
Several factors might influence MTAs compressive strength,
including the type of MTA, the liquid that is mixed with the material,
the condensation pressure on the material, the pH value of the mixing
liquid, and the condition of MTA storage (29, 46, 5052).
Flexural Strength
Torabinejad and Chivian (8) recommended placing a wet cotton
pellet over GMTA when it is used for perforation repair, pulp capping, or
an apical plug. An investigation compared the effects of setting condition
on flexural strength of WMTA. The material was mixed and received
moisture from 1 or 2 sides (47). Two-sided moisture, as has been recommended (8), showed significantly more flexural strength after 24
hours (47). The authors suggested that cotton pellets should be
removed after 24 hours because the flexural strength decreases 72
hours after WMTA receives moisture from both sides (47).
On the basis of limited literature, it appears that placing a moist
cotton pellet over MTA for the first 24 hours increases its flexural
strength.
Push-out Strength
The push-out strength of perforation repair materials is an important factor because shortly after perforation repair, tooth function might
dislodge the material. MTA has lower push-out strength in comparison
with IRM or Super EBA after immersion in walking bleach materials
(sodium perborate mixed with saline, Superoxol, sodium perborate
Review Article
mixed with Superoxol) (74). The importance of moisture on the pushout strength of MTA has been confirmed (48). MTA is reported to be
composed basically of dicalcium and tricalcium silicate in addition to
bismuth oxide (16). Because the dicalcium silicate hydration rate is
slower than the tricalcium silicate rate, storing MTA in a wet environment gives it more strength with the passage of time (14).
On the basis of available data, it appears that MTA gains optimal
physical properties such as flexural strength, compressive strength,
and push-out strength when it receives enough moisture after being
placed in an operation site.
Bond Strength with Other Dental Materials

An in vitro study investigated dentin-bond strength of MTA after
immersion in 5.25% NaOCl and 2% chlorhexidine (CHX) and Glyde
file preparation for 2 hours. Results of the study showed that Glyde
file preparation significantly decreased bond strength between dentin
and MTA; however, the result has no clinical relevance because none
of the above materials is left in the tooth for 2 hours during a clinical
procedure (75). Another investigation (76) compared composite
and compomer shear bond strength with WMTA. Results determined
that placing total-etch 1-bottle adhesive with a composite or compomer
over MTA produces significantly higher bond strength compared with
a 1-step self-etch system. Limited information shows that the presence
of a chelating agent and the type of etch system affect MTA bond strength.
Retentive Strength
An in vitro study (77) investigated MTAs retentive strength as
a luting agent for prefabricated posts and compared it with zinc phosphate and glass ionomer cements. The results revealed that the retentive
strength of glass ionomer or zinc phosphate cement is significantly
superior to that of MTA. The results of this study indicated that MTA
is not a suitable luting agent.
Displacement
A research article investigated displacement of MTA as an apical
barrier material in teeth with open apexes (41), showing that 4-mm
thickness of the apical barrier offers significantly more resistance to
displacement than 1-mm thickness. This suggests that the thickness
of MTA directly affects its displacement when used as an apical barrier.
pH
The pH value of MTA is 10.2 after mixing. This value rises to 12.5 at
3 hours (11). Comparing pH values of GMTA with WMTA, the latter
material displays a significantly higher pH value 60 minutes after mixing
(45, 46). MTA kept its high pH value throughout the course of a longterm study (63); the authors attributed the high pH value to the constant
release of calcium from MTA and the formation of CH.
Comparing pH values at different periods of time, both WMTA and
GMTA exhibit significantly higher pH values than 2 types of PC immediately after mixing (46). However, 30 minutes after mixing, no statistical
difference can be found among the tested materials. At 60 minutes,
GMTA has a significantly lower pH value than WMTA and both types
of PC (46). Available data show that mixing MTA with water results in
the formation of CH and a high pH environment.
Radiopacity
The mean radiopacity for MTA has been reported at 7.17 mm of an
equivalent thickness of aluminum (11). This value is higher than that
reported for Super EBA or IRM in a separate investigation (78). Another
study compared the same materials and reported more radiopacity for
Super EBA and IRM than MTA (79). The difference can be due to the use
of different methods to evaluate the radiopacity of test materials.
Comparing the radiopacity of WMTA with that of GMTA, 2 separate
studies reported more radiopacity for WMTA (45, 46). Because
a similar amount of bismuth oxide is used to produce radiopacity in
both materials, the presence of other substances in WMTA might be
the reason for this difference between the two.
Particle Size
On the basis of the manufacturer data sheet and MTA patent, a large
portion of MTAs components are similar to PC (21, 80). The handling
characteristic of PC is dependent on its particle size and shape. Many
investigations evaluated particle size and shape of MTA (14, 16, 19,
22, 36, 81). WMTA has finer particles than 2 types of PC (14). Dammaschke et al (14) attributed the mechanical and biocompatibility
characteristics of WMTA to the homogeneity of its particles and the
materials surface morphology.
Many investigations compared the particle size and shape of
WMTA, GMTA, and PC (16, 22, 81). The results showed that WMTAs
particle size is finer than GMTAs (16, 22, 81), whereas PC has many
similarities to GMTA (81). In addition, WMTA particles are more homogeneous than GMTA particles.
The particle size of MTA is reported in many articles. Lee et al (36)
reported particle sizes ranging from 110 mm for GMTA powder,
whereas Camilleri (19) reported that the WMTA powder has particles
less than 1 to approximately 30 mm before hydration.
The physical properties of cement might be influenced by crystal
size. Smaller particles increase surface contact with the mixing liquid
and lead to greater early strength as well as ease of handling. A recent
study reported that some particles of MTA are as small as 1.5 mm, which
is smaller than the diameter of some dentinal tubules (81). The authors
hypothesized that this might play an important role in the sealing ability
of MTA after hydration and production of a hydraulic seal. This hypothesis might not be clinically relevant, because the dentinal tubules after
root canal instrumentation or root-end cavity preparation are not open
unless the operator removes the smear layer by acid-etching these
surfaces.
A recent study showed adverse effects of ethylenediaminetetraacetic acid (EDTA) on MTA hydration, microhardness, and cell adhesion
(82). Successful treatment with MTA after placement of the material
as a root-end filling has been reported in several animal and human
studies without acid etching (8393). Available information shows
that WMTA has finer particles in comparison to GMTA. Particle sizes
might affect the handling characteristics of these materials.
Porosity
Many studies have evaluated MTA porosity (54, 55). The amount
of porosity in mixed cement is related to the amount of water added to
make a cement paste, entrapment of air bubbles during the mixing
procedure, or the environmental acidic pH value (35, 39, 42, 54, 55).
Microhardness
The microhardness of MTA can be influenced by several factors
such as the pH value of the environment, the thickness of the material,
the condensation pressure, the amount of entrapped air in the mixture,
humidity, acid etching of the material, and temperature (14, 36, 39, 44,
49, 51, 54, 73, 82). An acidic environment has an adverse effect on the
microhardness of both GMTA and WMTA (36, 54). An investigation
evaluating the effect of environment on the hydration behavior of
MTA determined that MTA in the hydration phase consists of needlelike and dominant cubic crystals (36). The needle-like crystals growing
19
Review Article
between the cubic crystals were absent in the acidic environment.
Decreased microhardness has been attributed to the absence of these
needle-like crystals.
The microhardness of 2-mm and 5-mm thicknesses of GMTA and
WMTA was investigated when the materials were used as an apical
barrier. Regardless of the formulation of MTA or placement technique
used, a 5-mm thickness is significantly harder than a 2-mm thickness
(44).
An investigation compared the microhardness of WMTA with 2
types of PC. WMTA showed significantly more microhardness than
both types of PC (49), which can be attributed to the different chemical
and physical properties of the tested materials (14, 17, 81).
A recent study confirmed a trend of less microhardness after using
more pressure during MTA condensation (51). Two separate investigations reported that EDTA and acid-etch procedure significantly reduce
MTA microhardness (73, 82).
Present data show that less humidity, low pH values, the presence
of a chelating agent, and more condensation pressure might adversely
affect MTA microhardness.
Fracture Resistance
The fracture resistance of the tooth structure has been investigated in teeth with open apexes after using MTA as an apical barrier
(9498). One investigation disclosed that 5 weeks of exposure to
MTA, CH, and sodium hypochlorite significantly decreases the resistance of bovine dentin to fracture (94). Investigations with WMTA
or GMTA as an apical barrier and filling the rest of the canal with
various materials showed that composite resins significantly increase
resistance to fracture in comparison to roots that are filled with other
materials (95, 98).
Another investigation examined the fracture resistance of immature sheep roots that were premedicated with CH for 30 days and
demonstrated no significant effect on the fracture resistance of teeth
after MTA placement (96). Another experiment on immature sheep
roots used various time intervals from 2 weeks to 1 year for evaluating
fracture resistance (97); results showed that after 1 year, the teeth filled
with MTA had significantly more resistance to fracture compared with
those filled with CH or the controls. With immunofluorescence imaging,
investigators observed the presence of tissue inhibitor of metalloproteinase-2 (TIMP-2) only in the MTA samples. They attributed the resistance to fracture of MTA-filled teeth to the TIMP-2 effect in inhibiting
collagen destruction (97). However, because the method of the study
has been questioned, an increased TIMP-2 expression ratio in MTAtreated teeth is not yet confirmed (99).
Effect of Environment on the Physical Properties of MTA
Some clinicians used EDTA for smear layer removal before root
canal obturation. This procedure has also been recommended before
placing a root-end filling material during periapical surgery (100).
In one study, MTA samples were placed in normal saline, distilled water,
or EDTA (82). The authors examined the samples under scanning electron microscopy (SEM) and energy-dispersive x-ray spectroscopy and
evaluated cell adhesion to the MTA surface in a cell culture environment. The samples that were kept in EDTA showed poor cell adhesion;
the authors concluded that poor cell adhesion to MTAs surface in their
investigation might be due to poor hydration of the material, which leads
to a higher concentration of toxic ions such as aluminum, iron, and
sulfur on the surface of EDTA-stored MTA.
Another study examined the effects of BioPure MTAD (a mixture of
tetracycline, an acid, and a detergent) and EDTA on dissolution as well
as the surface and ultrastructural characteristics of WMTA. Although the
20
depth of etching of the EDTA and BioPure MTAD effect was not high, the
latter material produced greater surface roughness and more calcium
extraction from WMTA compared with EDTA (53).
There are some disagreements regarding the effects of the environment and pH on MTAs physical properties (36, 54). In an investigation
in which MTA was stored in distilled water at pH 7, both needle-like and
cubic structures were seen (36). MTA stored in normal saline at pH 7
showed the same structure with larger-sized crystals and additional
laminate formation on the outer surface of the cubic crystals. The
microstructure of the specimens that were stored in pH 5 for 7 days
demonstrated fewer cubic crystals and no needle-like crystals (36).
Another investigation showed no specific internal microstructure difference between the samples that were kept in acidic and normal pH
values, except a trend for more porosity in the former environment
(54). A recent investigation reported WMTA surface changes after an
acid-etch procedure by phosphoric acid (73). Another recent investigation on the effect of an alkaline environment on the microhardness
of WMTA has shown significantly lower microhardnesss in normal
(7.4) and high (10.4) pH values in comparison to 8.4 and 9.4 pH
values. (101).
Previous investigations regarding the effect of acids on PC showed
that various types of acids produce either retarding or accelerating
effects on setting of the cement. Moreover, different concentrations of
an acid might also have an accelerating or retarding effect on PC hydration and setting time. It should be noted that various types of PC (lowheated PC or normal PC) might react differently with various acids
(102104).
To produce a more clinically relevant environment, one investigation used fetal bovine serum as a storage medium for WMTA and GMTA
after mixing (31). They examined MTAs surface structure by SEM and
reported differences in surface morphology and chemical composition
distribution on the MTA surface when the material set in the presence of
water or fetal bovine serum (31).
The surface morphology of dental materials that come in contact
with tissues is important, at least for in vitro cell culture attachment,
differentiation, and proliferation (105, 106). Unfortunately, most in vitro studies, such as the investigations on physical properties or leakage,
do not allow MTA to set in synthetic tissue fluids such as PBS. On the
basis of the available information, it appears that the presence of
different solutions affects MTAs physical properties.
Effect of the Method of Placement on MTA Physical

Properties
The handling of MTA has been viewed as one of its shortcomings
(45, 58). Various carriers have been used to enhance the ease of
handling, including Teflon sleeves and pluggers specially designed
for placement of MTA, specially designed carriers for dispersing
MTA, and scooping out MTA from grooves in a plastic block (107)
and a Messing gun-type syringe (108).
One investigation compared hand and ultrasonic placement of
different thicknesses of MTA in polyethylene tubes (43). The authors
used an endodontic plugger for hand placement, whereas ultrasonic
placement was performed by activating an ultrasonic tip inside the
tube. Radiographic and microscopic evaluation showed that the hand
method resulted in better adaptation with fewer voids than the ultrasonic
method for all thicknesses. In contrast, an investigation with the bacterial penetration model reported more resistance to bacterial penetration
after using ultrasonic MTA placement (95). In corroboration with that
study, a heavier sample was reported after filling the canals inside resin
blocks by using hand condensation with indirect ultrasonic activation in
comparison with hand condensation alone (109). Obtaining heavier
Review Article
samples does not necessarily translate to better physical properties
(51). The differences between the results of these studies can be attributed to the type of model (polyethylene tubes or human teeth), the
method of evaluation, and the method of ultrasonic activation (direct
or indirect).
An investigation compared the effect of condensation pressure on
the compressive strength and microstructure of WMTA (51). Results revealed that surface hardness decreases when more pressure is applied
during WMTA condensation. Greater condensation pressure results in
fewer voids and microchannels. The authors hypothesized that with the
application of greater condensation pressure, the material becomes
more compact with fewer microchannels. They attributed reduced
compressive strength and surface hardness to reduced water uptake
that hinders complete MTA setting.
Current data show that the method of MTA insertion has great
impact on its physical properties. In addition, using more condensation
pressure does not necessarily improve MTA physical properties.
Chemical and Physical Properties of Other Types of MTA

Several modifications of MTA are marketed. The original formulation developed at Loma Linda University is manufactured by Dentsply
International (ProRoot MTA and Tooth Colored MTA; Dentsply-Tulsa
Dental, Tulsa-USA; Dentsply-Johnson City-USA).
Other types of MTA are Angelus (AMTA) from Brazil (white and
gray: AGMTA, AWMTA; Angelus, Londrina, PR, Brazil), and Egeo
(CPM) in white from Argentina (Egeo, Buenos Aires, Argentina)
(110). Many other brands of experimental MTA have been developed
and investigated, including MTA Bio, light-cured MTA, and an MTA
root canal sealer named CPM sealer (Egeo) and MTA-Obtura (Angelus)
(110112). Unfortunately, most articles do not mention the type of
AMTA used; therefore, they are referred to as AMTA in this review.
The actual composition of GMTA is 75% PC, 5% calcium, and 20%
bismuth oxide. AMTA is composed of 80% PC and 20% bismuth oxide
(20, 113). One investigation compared the powder composition form
of GMTA and AGMTA by using x-ray diffraction analysis and reported
that GMTA contains a greater amount of bismuth oxide and magnesium
phosphate (17). In contrast, the amount of calcium carbonate, calcium
silicate, and barium zinc phosphate in AGMTA is greater than that in
GMTA. The investigators also reported that more than 50% of the crystalline structures of GMTA are composed of bismuth oxide, in comparison with 40% for AGMTA.
Another investigation used energy dispersive spectroscopy to
compare GMTA and AMTA, showing that the amount of calcium in
AMTA is higher than in GMTA, whereas the amounts of carbon, oxygen,
bismuth, and silica are higher in GMTA (20). AMTA showed the presence of aluminum and the absence of iron; conversely, GMTA exhibited
the presence of iron and an absence of aluminum.
An investigation assessed pH value and calcium release for both
types of GMTA and AMTA at 3168 hours after mixing; results showed
that AMTA produced a slightly higher pH value and calcium release than
GMTA (113). In this study, the pH value found was lower than in other
investigations (11, 45, 46). The authors attributed the lower pH to the
limited contact surface of the material with the surrounding water
(113). There are some differences between various studies regarding
the pH value of MTA. Duarte et al (113) measured the pH value of
distilled water containing MTA, whereas Chng et al (45) directly used
a pH meter electrode in the freshly mixed or set MTA for recording
pH value. In contrast, a recent investigation reported that calcium ion
release is higher in both MTA and MTA Bio than in AMTA (71). Two
studies measured the pH of MTA up to 60 minutes after mixing (45,
46), whereas 2 other studies measured longer times for pH value
assessment (11, 113). Santos et al (114) showed a higher pH value

for AMTA in comparison to a previous report (113). They attributed
the difference between their results and those found by Duarte et al
to changing the solution after each measurement in the investigations
by Duarte et al (113).
The amount of arsenic ion release between MTA and AMTA has
also been compared (115). The results of this investigation revealed
that both materials release similar amounts of arsenic at values that
were not harmful to the human body.
Two studies reported more homogenous chemical composition as
well as particle sizes and shapes for GMTA in comparison to AGMTA
(17, 81). An investigation compared the particle sizes of ProRoot
MTA (WMTA, GMTA), AMTA (AGMTA, AWMTA), and PC and reported
that AMTA had a higher number of dissimilar particles compared with
ProRoot MTA (81).
An experiment on bovine teeth with open apexes compared
different reinforcement applications on the fracture resistance of teeth
after placing AWMTA as an apical barrier (116). The results demonstrated that the combination of AWMTA as an apical barrier and root
filling material with a metallic post was significantly more resistant to
fracture in comparison with teeth that received gutta-percha or AWMTA
over an AWMTA apical barrier.
In an investigation on the solubility of AMTA in comparison to PC,
the former material showed more than a 3% weight loss during the first
24 hours after mixing, which is beyond acceptable weight loss determined by the International Standard Organization (72).
There are conflicting results regarding AMTA radiopacity. (117
119). Both types of AMTA seem to have lower radiopacity than
WMTA and GMTA on the basis of what has been reported in separate
investigations (45, 46, 120).
The manufacturers data sheets for AMTA indicate that the absence
of dehydrated calcium sulfate lowers the material setting time to 10
minutes (20). The presence of dehydrated calcium sulfate has not
been confirmed (20). The setting time for AMTA is 14.28 ! 0.49
minutes (121), which is lower than WMTA and GMTA on the basis of
previous studies (11, 45).
Present data in the literature show that AMTA has different chemical compositions compared with MTA. Some of the physical properties
of AMTA and MTA (such as pH and calcium ion release) are not significantly different, whereas there are differences in setting time and the
range of particle sizes between these materials.
In 2004, CPM was developed and introduced in Argentina as MTA
(Egeo S.R.L., Buenos Aires, Argentina). The main components of the
powder include tricalcium silicate, tricalcium oxide, tricalcium aluminate, and other oxides (122).
Endo CPM sealer is also an Argentine form of MTA root canal sealer.
The composition of this sealer is similar to MTA, except for the presence
of calcium carbonate for reducing the pH of the material. Subcutaneous
implantation of Endo CPM sealer and AMTA resulted initially in mild to
moderate tissue reaction, followed by a similar response to control
samples 30 days after implantation. Both Endo CPM sealer and AMTA
produce mineralization in subcutaneous tissues (123).
Chemical and Physical Properties of New Compositions

of MTA
Several investigations have been carried out to enhance the physical properties of MTA, its antimicrobial effects, and ease of handling
(34, 38, 48, 52, 59, 60, 124). However, none of those compositions
has been extensively investigated to fulfill all biocompatibility tests,
chemical and physical properties, antibacterial activity and clinical
investigations. It is important to note that changes in the physical
21
Review Article
and/or chemical components of MTA can adversely affect other properties such as setting time or compressive strength of the material
(38, 52).
Mixing anesthetic solution with MTA powder increases its setting
time (38). In an investigation with MTA powder mixed with an anesthetic solution (2% Xylocaine with 1:100,000 epinephrine) as a perforation repair material (40), investigators placed wet or dry cotton
pellets over MTA for 2472 hours. The samples showed significantly
higher push-out strength at 72 hours than at 24 hours. The authors reported no significant difference in MTA retention in the presence of dry
or moist cotton pellets placed over the material after its insertion in
perforation sites. The investigators in this study placed saline-moistened
Gelfoam at the perforation site to simulate a clinical condition that
would provide moisture to MTA in the samples that received dry cotton
pellets. In contrast, another experiment showed significantly higher
push-out strength with the application of moisture after placement of
the MTA mixture (48).
An investigation compared the effect of blood contamination on
WMTA mixed with sterile water, lidocaine, or saline when the material
is used for repairing furcation perforations. Results revealed that none
of the mixtures increased WMTA retention characteristics. Uncontaminated samples showed significantly more resistance to displacement
(125).
One investigation added calcium chloride (CC) to WMTA to lower
its setting time, which resulted in significantly higher pH values immediately after mixing (34). Furthermore, the authors reported more
calcium ion release from WMTA and CC in comparison with unmodified
WMTA in the first 24-hour period. It should be mentioned that although
the calcium ion plays an important role in cell viability and the production of hard tissue, the amount of ion should be at a specific concentration because it might inhibit cell growth (68, 126). A recent
investigation evaluated AWMTA setting time, solubility, disintegration,
and pH when the material is mixed with CaCl2. AWMTA showed an
increase in weight, a higher pH value, and significantly lower setting
time (127). A dye leakage investigation showed that the addition of
CC to WMTA increases its sealing ability when used as a root-end filling
material (128). Another investigation used sterile water, saline, 2%
lidocaine, 3% NaOCl gel, CHX gluconate gel, K-Y Jelly (Johnson & Johnson, New Brunswick, NJ), and 3% and 5% CC in combination with MTA
powder (38). The NaOCl gel, K-Y Jelly, and 5% CC decreased the setting
time to 2025 minutes. However, set MTA mixed with sterile water
showed significantly higher compressive strength than the rest of the
tested materials, except for 2% lidocaine.
An investigation mixed WMTA and GMTA with anesthetic solution
and evaluated their compressive strength (29). Results showed that the
compressive strength of both tested materials decreased significantly
when the materials were stored in PBS with an acidic pH value.
WMTA had significantly stronger compressive strength in comparison
with GMTA. Placing the samples in PBS resulted in significantly lower
compressive strength at 28 days in comparison with the samples that
were placed in PBS for 7 days.
Another research study used well-known PC accelerators such as
CC, calcium nitrate (CN), and calcium formate (CF) to investigate their
effects on the physical properties of GMTA and WMTA and PC (59). All 3
mixtures significantly accelerated the setting time of GMTA; however,
only CC and CF showed the same effect on WMTA. Mixing MTA powder
with CC had no significant effect on the pH values of both types of MTA,
whereas CN significantly decreased the pH value of GMTA and PC. In
contrast, using CF as an accelerator significantly increased the pH value
of WMTA.
Ber et al (60) mixed MTA with 2% CC and methylcellulose and
showed similar compressive strength while setting time improved.
22
Three investigations have used 15% di-sodium hydrogen orthophosphate (Na2HPO4) as a liquid to decrease WMTA setting time.
The results of these studies showed that addition of this accelerator
has no significant adverse effect on diametral tension strength and phase
composition, microstructure, solubility, or strength of WMTA in either
normal or different acidic pH value environments (61, 62, 65).
Various studies showed that changing MTAs composition might
have an adverse effect on its physical and possibly its bioactive properties (10, 38, 52). Comprehensive investigations should be performed
before introducing a new composition for clinical application.
Portland Cement
PC is an inexpensive material. Because of its chemical similarity to
MTA (12, 18, 20, 129), some investigations suggested PC as a substitute
material for MTA (16, 35, 37, 59, 60, 130149). A number of investigations showed that both MTA and PC have a similar composition,
except for the bismuth oxide (12, 17, 18, 20, 120, 129). Camilleri et
al (27) demonstrated that both PC and MTA are composed of tricalcium
and dicalcium silicate, which on hydration produce calcium silicate
hydrate gel and CH. At the same time, a recent investigation reported
a lower content of calcium dialuminate and calcium sulfate unhydrated
in MTA than type I PC (23).
However, many differences are reported between the materials in
terms of setting expansion, chemical composition, surface chemical
composition, porosity, compressive strength, radiopacity, cation
releases, and particle sizes (12, 14, 17, 19, 22, 26, 46, 48, 81). A recent
study investigated the effect of adding bismuth oxide on PC physical
properties (35), reporting that the porosity and compressive strength
could be influenced by the addition of various weight percentages of
bismuth oxide. It also reported an increase in porosity, solubility,
and degradation of the material with increasing amounts of bismuth
oxide. Moreover, because of the presence of more flaws in the composition of the above mixture, the amount of cracks in the set material also
increased. An investigation confirmed the similarity of PC and MTA,
except for the presence of potassium and lack of bismuth oxide
(17). Another study showed lower amounts of aluminum and sulfur
in WMTA compared with WPC (19).
A recent investigation reported that some types of MTA and WPC
with or without CC show presence of precipitation and formation of
an interfacial layer between the material and dentin, which could potentially affect the sealing ability of these materials (71).
The biocompatibility of some types of PCs is evaluated in several
studies (15, 135, 136, 140, 144, 148). Three separate studies using
endothelial, L929 fibroblast, and human osteosarcoma cell cultures
compared PC and MTA (15,136, 140). These studies revealed no significant differences between the tested materials. MTA, unmodified PC, and
modified PC samples with added 10% and 15% CC for acceleration of
setting time show the same effect on SaSO2 osteosarcoma cell
morphology, characteristics, and attachment to these cells (135).
However, a study comparing MTA and PC containing varying ratios of
bismuth oxide on immortalized human periodontal ligament cells
showed that PC without the addition of bismuth oxide has the same level
of cell viability as MTA at 12 and 24 hours. The addition of bismuth
oxide to PC powder at all ratios in this study significantly lowered cell
viability during early evaluation time (148). Asgary et al (12) determined that the crystalline particles in WMTA were smaller than those
present in WPC. A study comparing WPC and WMTA revealed lower
amounts of the aluminate phase in the latter material (19). These investigators proposed that WMTA is manufactured in the laboratory instead
of clinkering, which is the method of PC production. SEM image evaluation showed a large area of CH in WPC that is not observed in
WMTA (12). The efficacy of PC for pulp capping is comparable to
Review Article
that of MTA (134). A recent review concluded that both MTA and PC
exhibit no genotoxicity (5).
There are several reasons that PC cannot be used in clinical applications as a substitute for MTA:
(1) PC is manufactured widely all around the world, and it is impossible to control the quality, composition, and biocompatibility of
these materials (150).
(2) WMTA contains fewer heavy metals such as copper, manganese,
and strontium, which are known to be toxic (14). One of the major
concerns about using PC is the amount of lead and arsenic in its
composition. Duarte et al (115) showed that the amount of arsenic
release is not very high in WMTA, GMTA, and 1 type of PC. However,
a recent study that compared the amount of arsenic in GMTA, ordinary PC (OPC), and WPC showed that OPC contains more than 6
times the amount of arsenic compared with GMTA (110). It is
impractical to evaluate the amount of these elements in all types
of PC. Because of the high solubility of some types of PC and the
release of toxic elements into the surrounding tissues (49), its
long-term safety is questioned (150).
(3) The higher solubility of some types of PC is also a matter of
concern. It is possible that PC might degrade after clinical application and jeopardize the seal of the material (49).
(4) The compressive strength of some types of OPC and WPC is
significantly lower than WMTA and GMTA 28 days after hydration
(46). Attaining adequate compressive strength is important for
some of the clinical applications of MTA such as repairing perforations and pulp capping. These procedures require materials
with adequate compressive strength to be stable against occlusal
pressure.
(5) Excessive expansion that might result in a cracked root is an undesirable property when a material is used as a root-end filling
substance (46). The setting expansion of PC is a matter of controversy in the literature. One investigation reported that both types of
WPC and OPC show greater expansion than GMTA and WMTA
(46). In contrast, another experiment showed that the setting
expansion of PC is less than GMTA and more than WMTA (37).
This might be attributed to the differences of chemical composition
among various types of PC (150).
(6) Carbonation results in a drop in tensile strength and resiliency of
PC. This process occurs when the amount of carbon dioxide
increases in inflamed tissues. The carbon dioxide readily reacts
with any available water to form carbonic acid, which reacts
with the cement, converting it into calcium hydrogen carbonate
(151). Low tensile strength and resiliency of the material might
cause it to crack and buckle under high stress, instead of deforming. This process is important in some clinical applications of MTA
such as perforation repair or pulp capping.
(7) The amount of calcium release in WMTA is reported to be much
more than that released by WPC, and the mechanism of hydration
is different in these materials (26). It is important to note that
complete healing occurs only when the proper amounts of
elements and signal molecules are present in tissues after injury.
A lack of an element or an imbalance between elements might
prevent complete regeneration.
(8) MTA is manufactured in laboratories as a medical material under
close supervision in terms of its composition and prevention of
contamination (150). It is approved by the U.S. Food and Drug
Administration for use in human beings (17).
In a recent review article Steffen and van Waes (152) highlighted
the need for more investigations on PC as a medical material. The
authors explained their concern regarding the exact type of PC, which
is not mentioned in some investigations. They believe that if PC is intended for use in clinical applications, the material needs to be sterile,
the amount of toxic heavy metal ions of the material should be detected,
and the material particle size should be similar and more unique.
Despite some similarities between PC and MTA, it is not safe to use
PC, which has not been formulated for human use, in place of a bioactive
medical material such as MTA.
Antibacterial Effects of MTA

Several studies examined the antibacterial effects of MTA, its variants, and its new composition on various organisms.
Antibacterial and Antifungal Properties of MTA

The antibacterial and antifungal properties of MTA have been
extensively evaluated, with conflicting reports (52, 124, 133, 153
164). Several investigations reported that MTA has limited antimicrobial
effect against some microorganisms (133, 153, 155, 161). An investigation (153) on facultative and strict anaerobic bacteria showed that
MTA has an antibacterial effect on some facultative bacteria and no effect
on any species of strict anaerobes. In contrast, Super EBA and ZOE
pastes exhibit some antibacterial effect on both types of tested bacteria
(153). In an antimicrobial study on MTA and PC against Staphylococcus aureus, Enterococcus faecalis, Pseudomonas aeruginosa,
Bacillus subtilis, Candida albicans, a wild fungus, and a mixture of
these bacterial and fungal species, both materials exhibited diffusion
in agar without inhibition of microbial growth (133). Some investigations showed that GMTA (154, 159, 162) and WMTA (159) have an
antifungal effect. In contrast, others showed that GMTA has limited or
no antifungal effect (133, 155, 161). One experiment showed that
freshly mixed and 24-hour set GMTA have an antifungal effect on C. albicans (154). The antifungal effect of MTA might be due to its high pH
or to substances that are released from MTA into the media. In contrast,
a study comparing the effect of MTA and PC on C. albicans, S. aureus,
and Escherichia coli showed no antimicrobial effect for either of the
tested materials (156). Another investigation reported antimicrobial
activity of GMTA, WPC, and OPC on Micrococcus luteus, S. aureus,
E. coli, P. aeruginosa, C. albicans, and Enterococcus faecalis (162).
Al-Hezaimi et al (156) evaluated the antifungal effect of WMTA on
C. albicans and revealed that the concentration of MTA is a significant
factor in the antifungal effect of this material. Plates containing a WMTA
concentration of less than 25 mg/mL showed no antifungal effect. In
contrast, plates containing a concentration of 25 mg/mL showed antifungal activity at 1 and 24 hours, whereas a concentration of 50 mg/
mL of WMTA was effective against C. albicans during the whole study
time. Another investigation compared the antifungal effect of GMTA
and WMTA in different concentrations on C. albicans (157). Results
confirmed a previous study by the same authors for WMTA (156).
However, GMTA in concentrations lower than 25 mg/mL was significantly more effective against C. albicans than WMTA (157). The results
for WMTA and GMTA in concentrations of 25 mg/mL and 50 mg/mL
were similar.
Comparing the antibacterial effects of different concentrations of
GMTA and WMTA against E. faecalis and S. sanguis shows the former
material requiring lower concentrations to produce the same antibacterial effects against each of the bacteria tested (158). Comparing both
species of bacteria, E. faecalis requires a higher MTA concentration for
growth inhibition. However, a recent investigation reported similar antibacterial properties for both types of WMTA and GMTA (163).
An investigation on the antibacterial effect of several freshly mixed
and set root-end filling materials (IRM, GMTA, amalgam, Super-Bond
C&B, Geristore, Dyract, Clearfil APX composite with SE Bond and
23
Review Article
Protect Bond) against S. aureus, E. faecalis, and P. aeruginosa showed
that the set samples of IRM and GMTA had greater antibacterial activity
compared with the other test materials (160).
Previous investigations have reported an inhibitory effect of dentin
on CH, NaOCl, and CHX (165, 166); however, a recent investigation reported dentin enhances MTAs bacterial killing activity (164). A recent
investigation also reported that the source of MTA might affect the antibacterial activity of the material (167).
Conflicting results from antibacterial and antifungal investigations
on MTA might be attributed to the various tested species of the microorganisms, the source of the preparing material (52, 124, 133, 153
164), as well as the concentration and the type of MTA used in these
studies (156158, 167).
The literature shows that MTA has an antibacterial and antifungal
effect. Lowering the powder-to-liquid ratio might adversely affect the
antibacterial and antifungal properties of MTA.
Antibacterial Properties of Other Types of MTA

An experiment compared the antimicrobial properties of Sealapex, Fill Canal, AMTA, PC, and EndoRez on E. faecalis, E. coli, M. luteus, S. aureus, Staphylococcus epidermidis, P. aeruginosa, and C.
albicans (141). Results indicated that except for E. coli, AMTA and
PC were effective against microorganisms. Another study comparing
GMTA, AGMTA, AWMTA, WPC, and GPC showed that all of the tested
materials had antimicrobial activity against the following microorganisms: M. luteus, S. aureus, E. coli, P. aeruginosa, C. albicans, and
E. faecalis (162). These studies showed that other types of MTA have
some antibacterial and antifungal properties. Recent investigations
have reported similar suitable antibacterial activity in WMTA, AWMTA
(168), Endo CPM sealer, and WAMAT (169).
Antibacterial Properties of New Compositions of MTA
Some investigations replaced distilled water with other liquids to
mix with MTA powder. An investigation evaluated the antibacterial and
antifungal activities of mixtures of WMTA with 0.12% CHX and sterile
water against Actinomyces odontolyticus, Fusobacterium nucleatum, Streptococcus sanguis, E. faecalis, E. coli, S. aureus, P. aeruginosa, and C. albicans (124). Regardless of the type of mixing
agent, all WMTA samples inhibit microbial growth. A mixture of
WMTA and CHX showed significantly more antimicrobial activity
than WMTA and water, with the exception of its effect on P. aeruginosa. Another study mixed 2% CHX with MTA powders and reported
a significant increase in the antibacterial effect of WMTA and GMTA
against E. faecalis (52). It should be noted that adding CHX to
WMTA can cause cell apoptosis (170) and a decrease in the
compressive strength of MTA (52), although biocompatibility of
MTA mixed with CHX was reported in a subcutaneous investigation
(171). The liquid or gel type of CHX has different effects on MTA
setting. Kogan et al (38) mixed MTA powder with CHX gel to measure
the compressive strength of this mixture. Because this mixture had
not set 7 days after mixing, they could not measure its compressive
strength. Holt et al (52) used the liquid form of CHX and mixed it
with MTA powder, reporting that most of the samples were set
adequately after 72 hours and were ready to be examined for their
compressive strength.
On the basis of these results, it appears that enhancing selective
properties of MTA, such as its antibacterial property, by adding various
liquids might adversely affect other properties of the material.
Comprehensive investigations for all properties of the new compositions
of MTA (physical properties, sealing ability, biocompatibility, and cytokine production) are needed before recommending them for clinical
applications.
24
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ATR 41..2010 Mta Good LD

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Review Article

Mineral Trioxide Aggregate: A Comprehensive Literature

Inclusion and Exclusion Criteria

Parirokh and Torabinejad

JOE Volume 36, Number 1, January 2010

JOE Volume 36, Number 1, January 2010

MTA: Chemical, Physical, and Antibacterial Properties

Parirokh and Torabinejad

cult to compare the results of these investigations with one another. In

JOE Volume 36, Number 1, January 2010

Bond Strength with Other Dental Materials

JOE Volume 36, Number 1, January 2010

MTA: Chemical, Physical, and Antibacterial Properties

Parirokh and Torabinejad

Effect of the Method of Placement on MTA Physical

JOE Volume 36, Number 1, January 2010

Chemical and Physical Properties of Other Types of MTA

JOE Volume 36, Number 1, January 2010

assessment (11, 113). Santos et al (114) showed a higher pH value

Chemical and Physical Properties of New Compositions

MTA: Chemical, Physical, and Antibacterial Properties

Parirokh and Torabinejad

Antibacterial Effects of MTA

Antibacterial and Antifungal Properties of MTA

Antibacterial Properties of Other Types of MTA

Parirokh and Torabinejad

JOE Volume 36, Number 1, January 2010

JOE Volume 36, Number 1, January 2010

MTA: Chemical, Physical, and Antibacterial Properties

Parirokh and Torabinejad

JOE Volume 36, Number 1, January 2010

JOE Volume 36, Number 1, January 2010

MTA: Chemical, Physical, and Antibacterial Properties

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