Clinical Research
Treatment Outcome Following Direct Pulp
Capping Using Bioceramic Materials in Mature
Permanent Teeth with Carious Exposure:
A Pilot Retrospective Study
S. Linu, BDS, M.S. Lekshmi, BDS, V.S. Varunkumar, MDS, and V.G. Sam Joseph, MDS, M Phil
Abstract
Introduction: The aim of this study was to investigate
the sequelae of direct pulp capping (DPC) using mineral
trioxide aggregate (MTA) and Biodentine in mature per-
manent teeth with carious exposure. Methods: Clinical
records of 30 patients (15 each with MTA and Bio-
dentine) treated with DPC technique from January
2015 to June 2015 were retrieved. Success rates (based
on symptoms, sensibility tests, and radiographic anal-
ysis) and adverse events were analyzed. Results: The
patients were reviewed at 1, 3, 6, 12, and 18 months af-
ter treatment. Four cases (2 each of MTA and Bio-
dentine) were lost to follow-up. MTA and Biodentine
groups showed success rates of 84.6% and 92.3%,
respectively, with overall success rate of 88.5%. Radio-
graphically visible dentin bridge formation was observed
in 69.2% (9/13) and 61.5% (8/13) of cases done with
MTA and Biodentine, respectively. The cases done
with MTA showed coronal discoloration on review.
Diffuse calcifications of the pulp chamber were observed
in 1 (7.7%) case done with MTA and 3 (23.1%) cases
done with Biodentine. Conclusions: The advent of bio-
ceramic materials with better biocompatibility and seal-
ing properties can make the outcome of DPC technique
in mature permanent teeth with carious exposure more
predictable. The success rate observed in this study
should be confirmed through randomized controlled tri-
als with long follow-up periods. Effects of adverse
events like coronal discoloration and calcifications of
the pulp chamber also need to be evaluated. (J Endod
2017;-:1–5)
Key Words
Bioceramic materials, direct pulp capping, mature per-
manent teeth
From the Department of Conservative Dentistry and Endodontics, Government Dental College, Thiruvananthapuram, India.
Address requests for reprints to Dr S. Linu, Department of Conservative Dentistry and Endodontics, Government Dental College, Thiruvananthapuram 695011, India.
E-mail address: linusurendran07@gmail.com
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.06.017
JOE — Volume -, Number -, - 2017
T he dental pulp is pro-
tected from the oral
environment by a rigid
Significance
Traditionally, direct pulp capping was performed in
young permanent teeth with traumatic or iatrogenic
enclosure made of enamel,
pulp exposure, and carious exposure was managed
dentin, and cementum (1).
by pulpotomy or pulpectomy. The advent of newer
Other than forming the
bioceramic materials has made the procedure in
tooth during childhood, an
teeth with carious exposure more predictable,
intact dental pulp could
even in mature permanent teeth.
provide several defense
mechanisms possibly pre-
venting bacterial invasion, hence it is valuable to sustain an exposed pulp rather than
meticulously replacing it with a synthetic root filling material (2, 3).
Vital pulp therapy is aimed at preserving and maintaining pulpal health in
teeth in which pulp exposure has occurred due to trauma, caries, or restorative
procedures (4). The treatment options for a pulp-exposed permanent tooth
include direct pulp capping (DPC), pulpotomy, and pulpectomy. DPC is defined
as ‘‘placing a dental material such as calcium hydroxide or mineral trioxide aggre-
gate (MTA) directly on a mechanical or traumatic vital pulp exposure, thereby
sealing the pulpal wound to facilitate the formation of reparative dentin and main-
tenance of the vital pulp’’ (5). Traditionally if the tooth is exposed by caries,
vitality can be preserved by partial pulpotomy after removing coronal pulp to
the level of healthy pulp tissue (6).
The lack of predictability of the outcome of DPC procedures following
carious pulp exposure (3, 7) has been stated based on traditional protocols
and materials that did not generate a favorable environment for hard tissue
formation. Success rates usually ranged from 30% to 85% (3, 7–11). The
introduction of MTA and other bioceramic or calcium silicate–based cements
(CSCs), along with advanced treatment strategies, have markedly changed the
long-held concept that pulp capping after carious pulp exposures should be
avoided (2, 12, 13).
MTA powder is a mixture of dicalcium silicate, tricalcium silicate, tricalcium
aluminate, calcium sulfate, tetracalcium aluminoferrite, and bismuth oxide that is
mixed with distilled water during manipulation (14, 15). Dicalcium silicate,
tricalcium silicate, calcium carbonate, calcium oxide, and zirconium oxide
constitute the powder of Biodentine and the liquid contains water, calcium
chloride, and a plasticizing agent (16). BioAggregate, EndoSequence root repair
material, calcium-enriched mixture cement, and TheraCal are a few other CSCs
Treatment Outcome of Direct Pulp Capping 1
Clinical Research
used in endodontics. During manipulation of CSCs, calcium TABLE 2. Comparison of Treatment Outcome
hydroxide and calcium silicate hydrate are the primary compounds
DPC material
formed and the calcium silicate hydrate gel solidifies to form a hard
structure (15, 17). Variable MTA, n (%) Biodentine, n (%)
Although a few studies have been published assessing the Treatment outcome
outcomes of DPC using bioceramic materials in young permanent Success 11 (84.6) 12 (92.3)
teeth, not much literature is available in relation to the procedure Failure 2 (15.4) 1 (7.7)
in mature permanent teeth (MPTs). The purpose of the present DPC, direct pulp capping; MTA, mineral trioxide aggregate.
study was to assess the outcome of DPC with MTA and Biodentine
in MPTs with carious exposure. Switzerland) isolation was achieved. Cleaning and disinfection of the
tooth surface was achieved using pumice slurry, rubber cup, and sodium
Materials and Methods hypochlorite 5% (Pyrex Exports, Roorkee, India). The caries was
Patient Selection removed initially with a sterile round diamond bur (BR 31; Mani Inc,
The Department of Conservative Dentistry and Endodontics, Gov- Utsunomiya, Japan) at high speed, followed by a sterile low-speed car-
ernment Dental College, Thiruvananthapuram, has a set clinical proto- bide round bur, no. 4 and no. 6 (SS White, Lakewood, NJ), on nearing
col for DPC using bioceramic cements. In the current study, the the pulp. In cases with evident pulp exposure on caries removal, hem-
treatment profile of patients who were treated with DPC technique orrhage was controlled by using a cotton pellet soaked with 5% sodium
following this protocol from January 2015 to June 2015 were retrieved hypochlorite for 10 minutes. After controlling hemorrhage, DPC was
regardless of the outcome. Cases that fulfilled the following criteria were done with MTA (ProRoot MTA; Maillfer, Dentsply, Switzerland) or Bio-
included in the outcome analysis: dentine (Septodont, Saint-Maur-des-Fosses, France). Materials were
mixed according to the manufacturer’s instructions. In cases treated
1. Patients in the age group of 15 to 30 years with MTA, the material was placed over the exposure site and surround-
2. Complaints of cavity in MPTs and/or sensitivity to cold food and/or ing dentin as a 1.5- to 3.0-mm-thick layer. Resin modified glass ionomer
food lodgement in cavity at presentation (GC Fuji II LC; GC Corp, Tokyo, Japan) was placed over the MTA. Final
3. No history of night pain or spontaneous pain restoration was done with resin-bonded composite (3M ESPE, St. Paul,
4. Mandibular molars with caries restricted to occlusal surface MN) a week later. In cases treated with Biodentine, the cavity was bulk
5. Pulp sensibility tests elicited a positive response filled with the material. On a 2-week recall visit, the Biodentine was
6. Radiographic examination showed deep caries approaching pulp, reduced to a base or dentin substitute level and the teeth were perma-
with no signs of periapical pathology nently restored with resin-bonded composite.
7. Patients who were systemically healthy
Teeth with excruciating/lingering pain in response to pulp sensi- Evaluation of Follow-up
bility tests and iatrogenic pulp exposure were excluded. A total of 30 Patients’ records were analyzed for clinical and radiographic
MPTs that met the criteria were selected for the analysis. recall data at intervals of 1, 3, 6, 12, and 18 months. The data
comprising pain (on percussion/spontaneous/night) after treatment,
Clinical Procedure sensibility status of the teeth, radiographic signs of periapical pathology,
Informed consent was obtained from all patients. Sensibility of the and dentin bridge formation were assessed. Teeth that remained asymp-
tooth was assessed with a digital electrical pulp tester (Digitest II Pulp tomatic with positive response to sensibility tests and/or radiographic
Vitality Tester; Parkell Inc, Edgewood, NY). Local anesthesia (lignocaine evidence of hard tissue bridge formation with no radiographic signs
2%, adrenaline 1:200000; Aculife Healthcare Pvt. Ltd, Gujarat, India) of periapical pathology were considered successful.
and rubber dam (Hygienic; Coltene Whaledent AG, Altstatten,
Statistical Analysis
TABLE 1. Comparison of Demographic and Baseline Clinical Characteristics The statistical calculations were performed using the software
DPC material SPSS for Windows version 19.0 (Statistical Presentation System Soft-
ware; SPSS Inc., New York, NY). Appropriate descriptive statistics
MTA, Biodentine,
Variable n (%) n (%)
Age, y TABLE 3. Comparison of Other Treatment Outcomes
15–20 5 (38.5) 9 (69.2)
21–25 5 (38.5) 4 (30.8) DPC material
26–30 3 (23.1) 0 Variable MTA, n (%) Biodentine, n (%)
Gender
Male 3 (23.1) 2 (15.4) Radiographically visible
Female 10 (76.9) 11 (84.6) dentin bridge
Type of teeth Visible 9 (69.2) 8 (61.5)
Mandibular first molar 7 (53.8) 6 (46.2) Not visible 4 (30.8) 5 (38.5)
Mandibular second molar 6 (46.2) 7 (53.8) Coronal discoloration*
Presence of preoperative pain Present 9 (69.2) 0
Present 11 (84.6) 10 (76.9) Not present 4 (30.8) 13 (100)
Not present 2 (15.4) 3 (23.1) Diffuse calcification of
Follow-up period, month(s) pulp chamber
1 2 (15.4) 1 (7.7) Present 1 (7.7) 3 (23.1)
12 6 (46.2) 7 (53.8) Not present 12 (92.3) 10 (76.9)
18 5 (38.5) 5 (38.5)
DPC, direct pulp capping; MTA, mineral trioxide aggregate.
DPC, direct pulp capping; MTA, mineral trioxide aggregate. *P < .05 (statistically significant).

2 Linu et al. JOE — Volume -, Number -, - 2017

 Clinical Research
TABLE 4. Treatment Outcome in Different Age Groups nificant difference was observed in the success rates between different
age groups (Table 4).
Treatment outcome
Age group Success, n (%) Failure, n (%)
15–20 13 (92.9) 1 (7.1) Discussion
21–25 8 (88.9) 1 (11.1) Vital pulp therapy is the favored technique for the manage-
26–30 2 (66.7) 1 (33.3) ment of pulp exposure in immature permanent teeth for enabling
the completion of root development (18). These techniques are
seldom practised on caries-exposed MPTs due to the lack of pre-
were calculated. In testing for the difference between the groups, the
dictable outcomes (2, 3, 7). The extent of bacterial invasion in
Fisher exact test was used.
pulp is difficult to assess in carious exposure compared with
 Null hypothesis: There is no significant difference in the score be- traumatic or mechanical exposure. Success of DPC procedures
tween the groups; ie, h1 = h2 depends on the creation of a bacteria-impervious barrier wrap-
 Alternate hypothesis: There is a significant difference in the score re- ping the exposed pulp tissue (8). Traditional materials, like cal-
corded between the groups; ie, h1 s h2 cium hydroxide, lack the ability to form a satisfactory barrier
 Level of significance: P < .05 (19). The advent of new bioceramic materials that induce predict-
able hard tissue barrier formation (20–22) and surface seal
(23–26) offer new opportunities for DPC procedures in MPTs
with carious exposure.
Results Limited information is available for DPC using bioceramic mate-
The demographics and baseline clinical characteristics of the sub- rials in human permanent teeth. Nowicka et al (20) compared Bio-
jects were evaluated to assess the comparability between MTA and Bio- dentine with MTA for pulp capping in human molar teeth clinically as
dentine groups. Age, sex, tooth type, preoperative signs and symptoms, well as histologically and found Biodentine is as good as MTA for
and the follow-up period were comparable between the groups pulp capping. Use of Biodentine was presented by Bhat et al (27) in
(Table 1). Of the 30 patients, 4 cases were lost to follow-up: 2 each their case report on DPC in an immature incisor and concluded that
from MTA and Biodentine groups. The MTA group showed a success Biodentine is a promising product that had significant potential to main-
rate of 84.6% (11/13) and the Biodentine group a rate of 92.3% tain pulp vitality in cases carefully selected for DPC. A 100% success rate
(12/13). Overall success rate was 88.5% (23/26). Three (1 of the Bio- of DPC with both MTA and Biodentine was reported by Katge et al (28)
dentine group and 2 of the MTA group) cases resulted in failure in 7- to 9-year-old children. The previously cited studies had been per-
(Table 2). formed in young permanent teeth with immature root apices (23, 24).
Analogous results were observed in case of dentin bridge forma- The overwhelming success rate of 100% may be due to the high
tion (69.2% vs 61.5%) and pulp chamber calcification in teeth done reparative potential of the immature permanent teeth. The present
with MTA and Biodentine, whereas significant coronal discoloration study evaluated the outcome of DPC in MPTs with carious exposure,
was observed in teeth with MTA (69.2%) (Table 3). No statistically sig- which had not been widely studied.

Figure 1. Representative case of MTA group. (A) Preoperative radiograph showing deep caries. (B) Pulp exposure (arrow) after removal of caries. (C) Immediate
postoperative radiograph. (D) One-year review radiograph. (E) Discoloration of crown (arrow) at 1-year review.

JOE — Volume -, Number -, - 2017 Treatment Outcome of Direct Pulp Capping 3

Clinical Research
Figure 2. Representative case of Biodentine group. (A) Preoperative radiograph showing deep caries. (B) Pulp exposure (arrow) after removal of caries.
(C) Radiograph after placing Biodentine. (D) Dentin bridge formation and pulp chamber calcification (arrows) in 1-year review radiograph.
The success rate of 88.5% observed in the present study is
comparable with a study conducted in MPTs using bioceramic ma-
terials in which the success was 85.37% over a 1-year period (29).
Another report mentioned 97.1% success for MTA in MPTs over a
period of 9 years (30). In the present study, all the failures
occurred within the first 2 weeks after the procedure. The failure
may be due to the inaccurate clinical judgment on the extent of
spread of inflammation into the pulp tissue, which can be
confirmed only by histological examination. Failures that occur
soon after the pulp capping may be a result of the compromised
state of the pulp (31). The teeth that survived the first 2 weeks
continue to remain asymptomatic, vital, and functional over the
follow-up period of 12 to 18 months.
Relatively young patients having cavities restricted to the
occlusal surface were selected for the study, which might have
contributed to a higher success rate in this study. Age might be
a limiting factor in success of DPC because the ability to overcome
an insult would be nominal at old age (2). Smaller sample size
might have contributed to the lack of statistically significant differ-
ence observed in the success rates between different age groups.
Caries restricted to the occlusal surface had resulted in better isola-
tion, caries removal, and material placement.
The long cone paralleling technique with film holders was
used in almost all cases to obtain radiographs. Comparable radio-
densities of Biodentine and tooth dentine made it difficult to
perceive the dentin bridge formation in the Biodentine group.
Overall, the radiographically noticed dentin bridge formation
(65.4%) was less than the earlier studies conducted by Bogen
et al (30) and Katge et al (28), which reported 82.0% and
90.5%, respectively.
The higher discoloration potential of ProRoot MTA with Bio-
dentine was confirmed by Marconyak et al (32). Bismuth oxide,
4 Linu et al.
which imparts the radiopacity to MTA, dissociates into dark-
colored metallic bismuth and oxygen in the presence of visible light
(33). Overoxidation of bismuth oxide in the presence of sodium
hypochlorite, which was used to control bleeding from the exposure
site may have also led to discoloration (34). The discoloration effect
could have been compounded by the presence of blood in contact
with MTA during setting (35). Coronal discoloration may pose an
aesthetic challenge in anterior teeth and it may mimic secondary
caries in appearance (Fig. 1).
Diffuse calcifications in the pulp chamber were observed in
15.4% (4/26) of the cases during follow-up visits. In the study
by Bogen et al (30), 10.2% of the cases showed similar calcifica-
tions with MTA over 9 years. Complete calcification of the pulp
space (calcific metamorphosis) is considered as the biological
breakdown in tissue function and ideally hard tissue formation
should be restricted to the site of injury or pulp exposure (36).
These calcifications could complicate root canal treatment if indi-
cated in the future (Fig. 2).
Conclusions
DPC can maintain tooth vitality, which will help in long-term
retention and normal functioning of the tooth. The present study
observed a success rate of 88.5% in MPTs with carious exposure using
bioceramic materials. Better clinical understanding of the histological
status of the pulpal inflammation can improve the predictability of the
procedure, as all the failures occurred within first 2 weeks of the
procedure. Smaller sample size and a short follow-up period
are the limitations of this study. Randomized controlled trials with
appropriate sample size and long follow-up periods are required to
affirm the promising potential of bioceramic materials as DPC agents
for MPTs with carious exposure.
JOE — Volume -, Number -, - 2017

Acknowledgments
The authors thank all the staff and postgraduate students in
the Department of Conservative Dentistry and Endodontics, Gov-
ernment Dental College, Thiruvananthapuram, for their assistance
throughout the study.
The authors deny any conflicts of interest related to this study.
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Treatment Outcome of Direct Pulp Capping 5