CONSORT Randomized Clinical Trial

Direct Pulp Capping with Calcium Hydroxide,

Mineral Trioxide Aggregate, and Biodentine
in Permanent Young Teeth with Caries:
A Randomized Clinical Trial
Claudia Brizuela, DDS, MS, PhD,* Andrea Orme~no, DDS, MS, PhD,* Carolina Cabrera, DDS,*
Roxana Cabezas, DDS, MS,* Carolina Inostroza Silva, BS, MS, PhD,* Valeria Ramırez, DDS, MS,*
and Montse Mercade, DDS, MS, PhD†

Abstract
Introduction: Direct pulp capping treatment is in-
tended to preserve pulp vitality, to avoid or retard
root canal treatment, and, in cases with an open
apex, to allow continued root development. Historical-
ly, calcium hydroxide (CH) was the gold standard ma-
terial, but nowadays calcium silicate materials
(CSMs) are displacing CH because of their high bioac-
T reatment of pulpal
tivity, biocompatibility, sealing ability, and mechanical
properties. However, more randomized clinical trials
are needed to confirm the appropriateness of CSMs
as replacement materials for CH in direct pulp capping
procedures. Methods: A randomized clinical trial was
conducted that included 169 patients (mean age,
11.3 years) from the Maipo district (Chile). The inclu-
sion criterion was patients with 1 carious permanent
tooth with pulpal exposure, a candidate for a direct
pulp capping procedure. The patients were randomly
allocated to one of the experimental groups (CH,
Biodentine, or mineral trioxide aggregate [MTA]). Clin-
ical follow-up examinations were performed at 1 week,
3 months, 6 months, and 1 year. The Fisher exact test
was performed. Results: At the follow-up examination
at 1 week, the patients showed 100% clinical success.
At 3 months, there was 1 failure in the CH group. At
6 months, there were 4 new failures (1 in the CH group
and 3 in the MTA group). At 1 year, there was another
failure in the CH group. There were no statistically sig-
nificant differences among the experimental groups.
Conclusions: CSMs appear to be suitable materials
to replace CH. Although no significant differences
were found among the materials studied, Biodentine
and MTA offered some advantages over CH. (J Endod
2017;43:1776–1780)
Key Words
Biodentine, calcium hydroxide, direct pulp capping, mineral trioxide aggregate,
randomized clinical trial
exposure in permanent
teeth is a challenge for cli-
Significance
This is the first clinical trial to compare the efficacy
of the most frequently used and reported material
nicians. Traumatic injuries,
for direct pulp capping in permanent teeth (CH)
anatomic anomalies, and
versus the new CSMs (MTA and Biodentine).
extensive caries can cause
inflammation of the pulp
and arrested root development. Different strategies have been used for vital pulp therapy;
these are indirect or direct pulp capping and pulpotomy. The main goal of vital pulp ther-
apy is to preserve pulpal tissue, remove tissue that is contaminated by bacteria, and pro-
mote repair of the mineralized tissue barrier (dentin bridge). Direct pulp capping is a
procedure wherein a small exposure of pulp is covered with a protective wound dressing
(1). This treatment is intended to avoid future root canal treatment or at least postpone it
until root formation is complete (2).
Numerous materials have been used throughout the years for pulp capping. Calcium
hydroxide (CH) has been the gold standard in recent decades (3–5); however, calcium
silicate materials (CSMs) have been used in more and more clinical applications since
their development. Calcium hydroxide has some obvious drawbacks, including
inflammation and necrosis of the pulp surface after pulp capping, high solubility in
oral fluids, degradation over time, the formation of tunnel defects inside the dentin
bridge, and low mechanical resistance, which might cause future microfiltration and
failure of the treatment (6–9).
Mineral trioxide aggregate (MTA) was the first CSM to be marketed. Since its
approval by the Food and Drug Administration in 1998, it has been used with increasing
frequency, with very good clinical and in vitro results (10–12). In a systematic review
with a meta-analysis that compared the effectiveness of MTA and CH as pulp capping
materials in permanent human teeth, the conclusion was that MTA has a higher success
rate and results in less pulpal inflammation and more predictable formation of a hard
dentin bridge than CH (13). This conclusion demonstrates that MTA is a suitable ma-
terial for direct pulp capping procedures and argues against the continuing recommen-
dation of CH as the gold standard for such treatments. However, as the first CSM, MTA

From the *Dental School, Universidad de Los Andes, Santiago, Chile; and †Dental School, Universitat de Barcelona, Barcelona, Spain.

Address requests for reprints to Dr Claudia Brizuela, Universidad de los Andes, Facultad de Odontologıa, Av. Monse~nor Alvaro del Portillo 12.455, Las Condes,
Santiago, Chile. E-mail address: clau@cibrizuela.com
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.06.031

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has some disadvantages; it takes a long time to set, it is difficult to
handle, and tooth discoloration develops over time (14–16). New
CSMs have appeared recently, and among them, Biodentine is an
improved CSM with good mechanical properties as well as excellent
biocompatibility and bioactive behavior (17, 18). In addition, it sets
in approximately 12 minutes and does not cause tooth discoloration
(19). However, there is a lack of studies that evaluate the outcome of
direct pulp capping with Biodentine and compare the results with
MTA and CH. The study reported herein comprised a clinical trial to
evaluate the clinical efficacy of MTA and Biodentine and to compare
them with CH as dressing materials for direct pulp capping in
permanent teeth.
Materials and Methods
Study Design and Participants
This was a randomized blind clinical trial with 3 parallel exper-
imental groups. The study was conducted between April 2014 and
September 2016. The project was evaluated and approved by the
ethics committee of the Universidad de Los Andes (Chile;
SAI1320175), was designed in accordance with the 2010 CONSORT
guidelines, and was registered at ClinicalTrials.gov (identifier code:
NCT02492841).
The selected patients were children and adolescents of Maipo dis-
trict (a metropolitan area of Santiago, Chile), which has a population of
430,570 (20). All patients and their legal guardians were informed of
the benefits, risks, and alternative treatment choices before enrollment
in the trial. All participants signed to give their assent, and their parents
or guardians signed the informed consent form.
All the procedures were performed in the dental clinic of the
dental clinical campus of Universidad de Los Andes, located in San Ber-
nardo City (Maipo district, Chile).
Inclusion and Exclusion Criteria
The inclusion criteria were patients between 7 and 16 years of age
with less than 2 mm of carious exposure in a permanent molar, with
complete or incomplete radicular growth, and with pulpal testing that
was compatible with normal pulp or reversible pulpitis.
The exclusion criteria were patients with systemic and/or neuro-
logic pathology, teeth with radiologic signs of internal resorption or
pulpal calcifications, no restorable teeth, and uncontrollable pulpal
bleeding.
Determination of the Sample Size
Initially, the sample size was determined on the basis of statistical
calculations. However, the final sample size that was achieved reflected
the maximum number of possible patients recruited and followed up in
a 2-year study period. Overall, 169 participants were enrolled (87
female and 82 male), and the mean age was 11.3 years.
Clinical Procedure
The operators were 5 endodontic postgraduate students who had
been previously calibrated and were supervised by a professor in the
endodontic or pediatric dentistry department. Tooth sensitivity was as-
sessed by means of thermal (Endo Ice, Hygienic; Coltene/Whaledent
AG, Altst€atten, Switzerland) and electrical stimuli (Diagnostic Unit;
SybronEndo, Orange, CA). Local anesthetic (2% lidocaine hydrochlo-
ride with epinephrine 1:80,000; Septodont, Saint-Maur-des-Fosses,
France) was administered by buccal infiltration (upper teeth) or by
troncular infiltration (lower teeth) near the teeth selected for the
experiment. The clinical procedure was done under loupes at a
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CONSORT Randomized Clinical Trial
magnification of 3.5 and a working distance of 400 mm (EyeMag
Pro F model; Carl Zeiss AG, Oberkochen, Germany). A rubber dam
was used for isolation in all cases (Hygienic; Coltene/Whaledent
AG). The rubber dam was swabbed with 0.2% chlorhexidine (Difem
Laboratory, Santiago de Chile, Chile) before caries removal. Complete
removal of the caries was achieved mechanically by means of a sterile
round bur (Kerr Beavers Dental, Morrisburg, Canada) that was
mounted in a slow speed handpiece and manually with a sterile
caries removal spoon (Dentsply, Dentsply Maillefer, Baillaigues,
Switzerland). Excavation of the caries was performed by using a caries
detector dye (Sable Seek; Ultradent Products Inc, South Jordan, UT) to
standardize all the treatments. Once the pulp tissue was exposed,
caries removal continued until the dentin offered resistance to hand
excavation with the dental spoon. Hemostasis was achieved by
applying pressure over the exposed pulp with cotton pellets that
had been soaked with sterile physiological saline solution for up to
10 minutes. If bleeding persisted after this procedure, the tooth was
not included in the study. At this point, the tooth was allocated
randomly to one of the experimental groups by using a Microsoft Excel
(Microsoft Corp, Redmond, WA) table.
Experimental Groups
In group 1, a CH capsule (Hertz Pharmaceutical, Santiago, Chile)
was mixed with saline on a sterile glass slab. The mixture was applied
over the pulp with an MTA gun system (Dentsply Maillefer) and a wet
cotton pellet until the exposed pulp was completely covered.
In group 2, white ProRoot MTA (Dentsply Maillefer) was mixed in
accordance with the manufacturer’s instructions. The mixture was
applied over the exposed pulp with the same technique as used in
group 1.
In group 3, Biodentine (Septodont) was mixed in accordance with
the manufacturer’s instructions. The mixture was applied over the
exposed pulp with the same technique as used in groups 1 and 2.
The layer of the different experimental materials placed over the
pulp exposure measured 2  2 mm approximately. In the case of
MTA, we waited until the material was partially set, and we expected
that the humidity of the pulp would finish the setting of the material.
When the materials were set, a layer of glass ionomer liner (Vitrebond;
3M ESPE, St Paul, MN) that had been photopolymerized for 20 seconds
was placed over the experimental materials. Final restoration was done
with direct resin restoration (Filtek Z350 XT Universal Restorative; 3M
ESPE), and occlusion was checked.
Clinical follow-up examinations were performed at 1 week,
3 months, 6 months, and 1 year. In each clinical follow-up examination,
sensitivity tests (thermal and electrical) and a percussion test were per-
formed. Radiographic follow-up examinations (with parallel technique
and a positioner) were performed at baseline, 6 months, and 1 year.
Clinical success was defined as a tooth with no pain, normal
sensitivity tests, no facial edema, no internal or external resorption,
no periradicular disease, periodontal ligaments of normal width,
and no fistula.
Statistical Analysis
The Fisher exact test was performed, and the level of significance
was set at P < .05.
Results
A total of 169 patients were included (82 male and 87 female),
with a mean age ( standard deviation) at the time of treatment of
11.3 years (2.44) and a median age of 11 years. Table 1 shows the
baseline characteristics of the teeth included.
Direct Pulp Capping in Carious Permanent Teeth 1777
CONSORT Randomized Clinical Trial
TABLE 1. Description of Baseline Variables by Type of Treatment Assigned
Variables CH (n = 53)
Gender
Female 29 (54.72%)
Male 24 (45.28%)
Age, y, mean (standard deviation) 11.64 (2.65)
Tooth
Maxillary first molar 11 (20.75%)
Maxillary second molar 0 (0%)
Mandibular first molar 36 (67.92%)
Mandibular second molar 6 (11.32%)
A total of 169 teeth were included in the study. At 6 months, there
was a dropout rate of 38.5% (65 teeth), and 5 teeth had failed. At the
1-year recall, there was a dropout rate of 59.2% (100 teeth) and
6 failures in total.
A flow chart of the molars included in the study is shown in
Figure 1. Fifty-three molar teeth underwent direct pulp capping with
CH, 56 with MTA, and 60 with Biodentine. The types of teeth included
were 44 maxillary first molars, 2 maxillary second molars, 104 mandib-
ular first molars, and 19 mandibular second molars.
Table 2 shows the accumulated failure rate for the different mate-
rials at different times. At the 1-week follow-up, there was 100% clinical
success. At 3 months, there was 1 failure in the CH group. At 6 months,
there were 4 new failures (1 in the CH group and 3 in the MTA group). At
1 year of follow-up, there was another failure in the CH group.
According to the Fisher exact test, there were no statistically signif-
icant differences among the materials studied at the different time inter-
vals (3 months, P = .283; 6 months, P = .221; 1 year, P = .127).
Table 3 shows the revision treatment done after tooth failure was
observed in the different study groups.
Discussion
Preservation of the pulp is extremely important for various rea-
sons; these are to continue growth in root length and width in those
teeth in which root formation has not yet been completed, to allow
odontoblasts to create a dentin bridge between the pulp and the dres-
sing material, and to maintain pulp function. This study was focused on
the use of dental materials to preserve the vitality of the dental pulp in
young molars. This randomized clinical trial was conducted to assess
the clinical and radiographic behavior of MTA, Biodentine, and CH in
direct pulp capping of young molars during 1 year of follow-up.
Calcium hydroxide was used because it has been the gold standard
material for pulp preservation treatments (indirect pulp capping, direct
pulp capping, and pulpotomy) for many years (21). However, since the
introduction of MTA, most clinicians are changing their practice in favor
of MTA because of its more predictable effects. In addition, several re-
ports have indicated that CH has several disadvantages; it sets only in a
dry environment, the dentinal bridges produced might have tunnel de-
fects, and it shows dissolution over time (22). Min et al (23) demon-
strated that MTA is superior to CH in terms of inducing the
dentinogenic process in human pulp capping. Some other authors
have reported that MTA forms dentinal bridges more frequently and
of greater thickness than those formed by CH (7, 23, 24). However,
MTA also has some drawbacks; it has a long setting time that
prevents completion of the treatment in 1 visit; it includes bismuth
oxide as its radiopacifier, which seems to cause tooth discoloration,
so it is no longer indicated in esthetic treatments; and it is difficult to
manipulate (12, 25, 26). Recently, different calcium silicate–based
materials have been developed to counter the limitations of MTA.
Among them, Biodentine stands out for its biocompatibility, rapid
1778 Brizuela et al.
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MTA (n = 56) Biodentine (n = 60)
29 (51.79%) 29 (48.33%)
27 (48.21%) 31 (51.67%)
11.51 (2.34) 11.22 (2.34)
16 (28.57%) 17 (28.33%)
1 (1.79%) 1 (1.67%)
32 (57.14%) 36 (60%)
7 (12.5%) 6 (10%)
setting, mechanical strength, ability to bond to dentin, and easy
manipulation (27–29).
A recent study by Katge and Patil (30) demonstrated 100% success
with both Biodentine and MTA in young permanent molars with caries at
1 year of follow-up. In our study, we found 100% success in the Biodentine
group, but both the CH and MTA groups had 13.64% accumulated fail-
ures. One main difference between our study and the one reported by
Katge and Patil is that we included young molars with open and closed
apexes, whereas Katge and Patil only included first permanent molars
in 7- to 9-year-old children, which probably all had open apexes. Tradi-
tionally, it has been recommended that vital pulp treatment should only be
performed in young patients, because teeth with open apexes have more
possibility of regeneration than teeth with closed apexes (31); however, to
date there has been no published clinical study to support this claim (21).
Katge and Patil and the present study have a similar sample size and the
same follow-up period. Nowicka et al (32) also reported similar clinical
results for both MTA and Biodentine in premolars extracted for orthodon-
tic reasons after 6 weeks of follow-up. However, their teeth were caries-
free, and the literature shows that bacteria are the main cause of pulpal
infection (33). Therefore, carious exposure in teeth with deep lesions
is the worst scenario and the most frequent one that practitioners will
be faced with, and the outcome is more unpredictable.
It is very important that researchers attempt to identify the prog-
nostic factors that favor a better outcome for carious teeth after pulp
capping procedures rather than after artificial exposures in sound
dentin (2).
The exact mechanisms by which CSMs induce formation of a
dentin bridge are not fully understood (23). It is known that they release
CH as a by-product, but unlike pure CH, which dissolves over time,
CSMs are relatively stable, promote dentin bridging, and are probably
able to seal the injured pulpal tissue (8, 34). The inflammation that
is induced by these materials is only short-term, less severe, and less
extensive than that induced by CH (3).
The major limitations of the research described herein were the
small sample size after dropouts and the short length of the evaluation
period, but to our knowledge, it is the first study of direct pulp capping
in carious molars to compare CH, MTA, and Biodentine. It is important
to note that the main reason for loss to follow-up might have been the
vulnerable geographic area with low economic resources and with a low
level of education of parents; in consequence, oral health may not be a
priority within this social group. However, an advantage of the study is
that 22,000 patients were examined, and those allocated to the interven-
tion numbered 169.
Our results showed no statistically significant differences among
the materials tested at 3-, 6-, and 12-month follow-up. Nevertheless,
the characteristics of calcium silicate cements have superseded CH
as the gold standard material for pulp vital therapy treatments.
Future studies should include randomized clinical trials with
larger samples, longer follow-up periods, study of pulpal inflammation
JOE — Volume 43, Number 11, November 2017
 CONSORT Randomized Clinical Trial

Figure 1. Flow chart of the molars included in the study.

TABLE 2. Description of Accumulated Failures at 3, 6, and 12 Months of Follow-up

CH (n = 53) MTA (n = 56) Biodentine (n = 60) P value*
3-month follow-up time 1/36 (2.78%) 0/43 (0%) 0/48 (0%) .283
6-month follow-up time 2/29 (6.89%) 3/37 (8.11%) 0/38 (0%) .221
12-month follow-up time 3/22 (13.64%) 3/22 (13.64%) 0/25 (0%) .127
*Fisher exact test.

JOE — Volume 43, Number 11, November 2017 Direct Pulp Capping in Carious Permanent Teeth 1779
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CONSORT Randomized Clinical Trial
TABLE 3. Description of Treatment Done after Failure of the Pulp Capping
Procedure
Revision treatment CH group MTA group Total
Extraction 1 0 1
Root canal treatment 2 1 3
Pulpotomy 0 1 1
Pulp capping retreatment 0 1 1
status, and inclusion of teeth with both open and closed apexes to eval-
uate the long-term success of treatment by using the different materials.
The positive social impact of this research was to provide preliminary
clinical guidelines to the Chilean Health Department.
Conclusions
There were no statistically significant differences among the mate-
rials studied for pulp capping procedures in carious teeth of children.
All showed high success rates during a 1-year follow-up period. MTA
and Biodentine are viable alternatives to CH for pulp capping proced-
ures. Biodentine showed 100% success, has the advantage of easy
handling, sets in approximately 12 minutes, and does not cause discol-
oration of the tooth.
Acknowledgments
The authors thank the professors and postgraduate students of
Endodontics at Universidad de Los Andes, particularly Francisca
Torreblanca, Dennise Urrejola, Elena Delpiano, Paulina Sandoval,
Natalia Cheul, Nicole Dumay, and Nicole Sainte Jean, for their sup-
port of this study.
This research was supported by funding from Comision Nacio-
nal de Investigacion Cientıfica y Tecnologica CONICYT, Ministerio
de Educacion, Gobierno de Chile, Project number SA13I20175, and
the Dental School of the Universidad de Los Andes.
The authors deny any conflicts of interest related to this study.
References
1. European Society of Endodontology. Quality guidelines for endodontic treatment:
consensus report of the European Society of Endodontology. Int Endod J 2006;
39:921–30.
2. Schwendicke F, Brouwer F, Schwendicke A, Paris S. Different materials for direct
pulp capping: systematic review and meta-analysis and trial sequential analysis.
Clin Oral Investig 2016;20:1121–32.
3. Iwamoto CE, Adachi E, Pameijer CH, et al. Clinical and histological evaluation of
white ProRoot MTA in direct pulp capping. Am J Dent 2006;19:85–90.
4. Tuna D, Olmez A. Clinical long-term evaluation of MTA as a direct pulp capping ma-
terial in primary teeth. Int Endod J 2008;41:273–8.
5. Qudeimat MA, Barrieshi-Nusair KM, Owais AI. Calcium hydroxide vs mineral
trioxide aggregates for partial pulpotomy of permanent molars with deep caries.
Eur Arch Paediatr Dent 2007;8:99–104.
6. Nowicka A, Wilk G, Lipski M, et al. Tomographic evaluation of reparative dentin for-
mation after direct pulp capping with Ca(OH)2, MTA, Biodentine, and dentin
bonding system in human teeth. J Endod 2015;41:1234–40.
7. Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide aggregate (MTA)
and calcium hydroxide as pulp-capping agents in human teeth: a preliminary report.
Int Endod J 2003;36:225–31.
8. Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quan-
titative investigations on the response of healthy human pulps to experimental
capping with Mineral Trioxide Aggregate: a randomized controlled trial—2008.
Int Endod J 2009;42:422–44.
1780 Brizuela et al.
Downloaded for Rohit Alapuzha (rohitam@aims.amrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on December 02, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
9. Cox CF, Subay RK, Ostro E, et al. Tunnel defects in dentin bridges: their formation
following direct pulp capping. Oper Dent 1996;21:4–11.
10. Camilleri J, Pitt Ford TR. Mineral trioxide aggregate: a review of the constituents and
biological properties of the material. Int Endod J 2006;39:747–54.
11. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature
review–part III: clinical applications, drawbacks, and mechanism of action. J Endod
2010;36:400–13.
12. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature
review–part I: chemical, physical, and antibacterial properties. J Endod 2010;36:
16–27.
13. Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium hydroxide or mineral
trioxide aggregate: a meta-analysis. J Endod 2015;41:1412–7.
14. Valles M, Mercade M, Duran-Sindreu F, et al. Influence of light and oxygen on
the color stability of five calcium silicate-based materials. J Endod 2013;39:
525–8.
15. Valles M, Mercade M, Duran-Sindreu F, et al. Color stability of white mineral trioxide
aggregate. Clin Oral Investig 2013;17:1155–9.
16. Marciano MA, Costa RM, Camilleri J, et al. Assessment of color stability of white min-
eral trioxide aggregate angelus and bismuth oxide in contact with tooth structure.
J Endod 2014;40:1235–40.
17. Rodrigues EM, Gomes-Cornelio AL, Soares-Costa A, et al. An assessment of the over-
expression of BMP-2 in transfected human osteoblast cells stimulated by mineral
trioxide aggregate and Biodentine. Int Endod J 2017 Jan 21. http;//dx.doi.org/10.
1111/iej.12745 [Epub ahead of print].
18. Gandolfi MG, Iezzi G, Piattelli A, et al. Osteoinductive potential and bone-bonding
ability of ProRoot MTA, MTA Plus and Biodentine in rabbit intramedullary model:
microchemical characterization and histological analysis. Dent Mater 2017;33:
e221–38.
19. Valles M, Roig M, Duran-Sindreu F, et al. Color stability of teeth restored with Bio-
dentine: a 6-month in vitro study. J Endod 2015;41:1157–60.
20. Subdere. Gobierno Regional Metropolitano de Santiago. Available at: http://www.
subdere.cl/division-administrativa-de-chile/gobierno-regional-metropolitano-de
-santiago/provincia-de-maipo. Accessed April 11, 2017.
21. Aguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously
exposed pulp: a systematic review. J Endod 2011;37:581–7.
22. Hilton TJ. Keys to clinical success with pulp capping: a review of the literature.
Oper Dent 2009;34:615–25.
23. Min KS, Park HJ, Lee SK, et al. Effect of mineral trioxide aggregate on dentin bridge
formation and expression of dentin sialoprotein and heme oxygenase-1 in human
dental pulp. J Endod 2008;34:666–70.
24. Faraco IM Jr, Holland R. Response of the pulp of dogs to capping with min-
eral trioxide aggregate or a calcium hydroxide cement. Dent Traumatol 2001;
17:163–6.
25. Islam I, Chng HK, Yap AU. X-ray diffraction analysis of mineral trioxide aggregate and
Portland cement. Int Endod J 2006;39:220–5.
26. Dammaschke T, Gerth HU, Zuchner H, Schafer E. Chemical and physical surface and
bulk material characterization of white ProRoot MTA and two Portland cements.
Dent Mater 2005;21:731–8.
27. Tziafa C, Koliniotou-Koumpia E, Papadimitriou S, Tziafas D. Dentinogenic responses
after direct pulp capping of miniature swine teeth with Biodentine. J Endod 2014;40:
1967–71.
28. Kim JR, Nosrat A, Fouad AF. Interfacial characteristics of Biodentine and MTA with
dentine in simulated body fluid. J Dent 2015;43:241–7.
29. Camilleri J. Staining potential of Neo MTA Plus, MTA Plus, and Biodentine used for
pulpotomy procedures. J Endod 2015;41:1139–45.
30. Katge FA, Patil DP. Comparative analysis of 2 calcium silicate-based cements (Bio-
dentine and Mineral Trioxide Aggregate) as direct pulp-capping agent in young per-
manent molars: a split mouth study. J Endod 2017;43:507–13.
31. Horsted P, Sandergaard B, Thylstrup A, et al. A retrospective study of direct pulp
capping with calcium hydroxide compounds. Endod Dent Traumatol 1985;1:
29–34.
32. Nowicka A, Lipski M, Parafiniuk M, et al. Response of human dental pulp capped
with biodentine and mineral trioxide aggregate. J Endod 2013;39:743–7.
33. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental
pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol
1965;20:340–9.
34. Ferk Luketic S, Malcic A, Jukic S, et al. Coronal microleakage of two root-end filling
materials using a polymicrobial marker. J Endod 2008;34:201–3.
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