doi:10.1111/j.1365-2591.2010.01777.

CASE REPORT

Apexogenesis of a symptomatic molar

with calcium enriched mixture

A. Nosrat1 & S. Asgary2

1
Department of Endodontics, Dental School, Rafsanjan University of Medical Sciences,
Rafsanjan, Kerman, and 2Iranian Center for Endodontic Research, Dental Research Center,
Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract

Nosrat A, Asgary S. Apexogenesis of a symptomatic molar with calcium enriched mixture.

International Endodontic Journal, 43, 940–944, 2010.

Aim This article describes the apexogenesis of a mandibular right second molar in a
12-year-old girl who was referred with a history of lingering pain and pain on chewing.
Summary Clinical and radiographic examinations revealed extensive coronal caries and
immature roots. Treatment was performed under rubber dam isolation and included caries
removal followed by pulp exposure and access cavity preparation. Pulpotomy was
completed, and the remaining radicular pulp was capped with calcium enriched mixture
(CEM) cement (BioniqueDent, Tehran, Iran). Clinical and radiographic examinations at 3, 6,
and 12 months revealed the tooth was functional with no clinical signs or symptoms of
pulpal disease. The final examination confirmed complete root development as well as
formation of a calcified bridge beneath the CEM cement.
Key learning point
• Pulpotomy with a CEM cement allowed root development to continue.

Keywords: apexogenesis, CEM cement, pain, pulpitis, pulpotomy, tooth apex.

Received 8 March 2010; accepted 6 June 2010

Introduction

Vital pulp therapy is the treatment of choice in immature teeth with reversible pulpitis in
which damage to the pulp and associated arrested root development occur as a result of
carious pulp exposures (Witherspoon 2008). Vital pulp therapy is primarily based on the
healing potential of the pulp (Trope 2008), and the primary goal is to maintain the health of
the pulp to promote root development and apical closure (Holland et al. 2008).
A pulp-capping material needs to be biocompatible, able to provide a biological seal, and
able to induce hard tissue formation (Witherspoon 2008). Traditionally, calcium hydroxide
was the most popular material for vital pulp therapy (Stanley 1998). Despite its common

Correspondence: A. Nosrat Department of Endodontics, Dental School, Rafsanjan University of

Medical Sciences, Aliebneabitaleb Blvd., Rafsanjan, Kerman, Iran (e-mail: ansrt2@yahoo.com).

940 International Endodontic Journal, 43, 940–944, 2010 ª 2010 International Endodontic Journal
 CASE REPORT
use as pulp-capping material, calcium hydroxide has some disadvantages such as
unpredictable dentinal bridge formation (Pitt Ford et al. 1996) that could contain tunnel
defects (Cox et al. 1985, Pitt Ford & Roberts 1991) and poor adherence to dentine that can
compromise the long-term biological seal (Holland et al. 1979).
An alternative standard pulp-capping biomaterial, mineral trioxide aggregate (MTA), has
been introduced for vital pulp therapies. There is a body of evidence emphasizing the
biocompatibility and sealing ability of MTA (Torabinejad & Parirokh 2010). It has been
shown in several animal and human studies that MTA is capable of inducing hard tissue
formation adjacent to pulp tissue (Pitt Ford et al. 1996, Andelin et al. 2003, Asgary et al.
2006, Barrieshi-nusair & Qudeimat 2006, Eghbal et al. 2009). In comparison with calcium
hydroxide, MTA induced dentine bridge formation more frequently, caused less pulp
inflammation, and resulted in a significantly thicker dentine bridge (Pitt Ford et al. 1996,
Faraco & Holland 2001, Asgary et al. 2008a). However, MTA has several disadvantages,
which can include delayed setting time, poor handling characteristics, and high cost (Chng
et al. 2005, Parirokh & Torabinejad 2010).
Recently, a new endodontic cement, calcium enriched mixture (CEM) (BioniqueDent,
Tehran, Iran), as a water-based cement, has been introduced with appropriate handling
characteristics and setting time (Asgary et al. 2008b, 2009a). CEM cement is composed
of several calcium compounds; the major components of the powder being 51.75% wt
CaO, 9.53% wt SO3, 8.49% wt P2O5, and 6.32% wt SiO2, with minor components of
Al2O3 > Na2O > MgO > Cl (Asgary et al. 2009a). Mixing the CEM powder and liquid
forms a bioactive calcium and phosphate enriched material, which subsequently results in
hydroxyapatite formation over the set CEM even in normal saline solution (Asgary et al.
2009b). In addition, unlike MTA, the surface characteristics of set CEM cement, as well as
the distribution pattern of calcium, phosphorus, and oxygen ions, are similar to dentine
(Asgary et al. 2009a). The clinical use of CEM has been approved by the Iranian Ministry of
Health and Medical Education.
In recent studies using an MTT assay and scanning electron microscopy, the
cytotoxicity of CEM cement was comparable to MTA (Ghoddusi et al. 2008, Asgary
et al. 2010). The sealing ability of CEM cement is the same as MTA when used as a root
end filling material (Asgary et al. 2008c), and it induces the same biological responses in
the pulp tissue as MTA, which is considerably superior to the pulp response to the calcium
hydroxide when used as pulp-capping material (Asgary et al. 2008a) or pulpotomy agent
(Tabarsi et al. 2010). When CEM cement was used as a pulp-capping or pulpotomy agent
in animals and humans, it induced dentinal bridge formation that could be observed
histologically and radiographically (Asgary et al. 2008a, Asgary & Ehsani 2009, Nosrat &
Asgary 2010, Tabarsi et al. 2010). A case report study showed that CEM cement can be
used as a pulp-capping agent in apexogenesis of traumatized teeth with pulpal exposure
(Nosrat & Asgary 2010).
Even after carious exposure, the pulp can maintain its healing potential, as has been
shown in several studies on asymptomatic and symptomatic permanent molars using
MTA (Barrieshi-nusair & Qudeimat 2006, Witherspoon et al. 2006, Eghbal et al. 2009) and
CEM cement (Asgary & Ehsani 2009) as pulp-capping agents. The present case report
discusses a successful apexogenesis treatment in an immature symptomatic molar.

Case report

A 12-year-old girl was referred with a history of lingering pain. The patient’s chief
complaint was spontaneous irradiating pain and pain on chewing in the mandibular right
jaw. Clinical examination showed extensive caries in the mandibular right second molar
and sensitivity to percussion but not to palpation. The tooth had immature roots (Fig. 1a).

ª 2010 International Endodontic Journal International Endodontic Journal, 43, 940–944, 2010 941
CASE REPORT
(a) (b) (c)

Figure 1 (a) Preoperative radiograph of mandibular right second molar with deep carious lesion. Open
apices in the mesial and distal roots are visible, (b) Postoperative radiograph of apexogenesis
treatment with calcium enriched mixture cement, Glass–Ionomer base and coronal temporary filling,
and (c) 12-month follow-up radiograph reveals favourable outcomes. The treated tooth is in function,
and the periapical tissues are normal.

The patient’s medical history was noncontributory. Informed consent was obtained from
the patient’s legal guardians after explanation of the possible risks of treatment.
After rubber dam isolation and local anaesthesia with 2% lidocaine and 1 : 80000
epinephrine (Daroupakhsh, Tehran, Iran), caries were removed and an access cavity was
prepared with a diamond fissure bur (Diatech, Heerbrugg, Switzerland) and high-speed
handpiece with copious water spray. After removing the roof of the pulp chamber, the
pulp was removed to the orifice level with a long shank round bur (Diatech) and a high-
speed handpiece. Associated bleeding indicated pulp vitality. Haemostasis was achieved
by irrigating with sterile normal saline along with gentle application of small pieces of
moistened sterile cotton pellets for 10 min; however, there was a visible oozing from the
mesial canals following this step. CEM cement powder and liquid (BioniqueDent) were
mixed to achieve a creamy consistency. An approximately 2-mm-thick layer of CEM
cement was placed over the exposed pulp with a plastic instrument and gently adapted to
the dentinal walls with a dry cotton pellet. The access cavity was filled with sterile normal
saline, and a small piece of cotton pellet was placed over it. Then, the tooth was
temporarily filled with Cavit (Asia Chemi Teb Co., Tehran, Iran). A day later, the temporary
restoration was removed to confirm the setting of the capping material. An approximately
2-mm layer of self-cure Glass–Ionomer (Fuji, Fuji Corporation, Japan) was then placed over
the set CEM cement, and the tooth was temporarily filled again (Fig. 1b). Then, the patient
was referred to a paedodontist for a coronal restoration with stainless steel crown.
The patient was recalled 3, 6, and 12 months later for clinical/radiographic follow-ups. At
the clinical examinations, the tooth was functional with no signs/symptoms. Radiographic
examination revealed full root development and formation of calcified bridges beneath the
CEM cement in both mesial and distal roots at 12-months (Fig. 1c).

Discussion

A pulp-capping material should be biocompatible, induce hard tissue formation, and create
a long-lasting biological seal (Witherspoon 2008). In the presented case, formation of a
calcified bridge beneath the CEM cement after 12 months along with continuation of root
development indicates the success of the treatment.
Studies have revealed that the formation of a hard tissue barrier beneath a pulp-capping
material is a good indicator for ongoing health of the pulp and might act as a protective
pulpal barrier (Caliskan 1994). The hard tissue formed beneath MTA, unlike calcium
hydroxide (Asgary et al. 2008a), is uniform, and it can resemble tertiary dentine with
respect to its form and staining for dentine sialoprotein (Andelin et al. 2003). The ability of
CEM cement to induce hard tissue formation in mature permanent teeth has been shown
in several animal and human studies (Asgary et al. 2008a, Asgary & Ehsani 2009, Nosrat &
Asgary 2010, Tabarsi et al. 2010). Dentine bridge induced by CEM cement has been

942 International Endodontic Journal, 43, 940–944, 2010 ª 2010 International Endodontic Journal
 CASE REPORT
shown to be similar to one induced by MTA in terms of thickness, absence of tunnel
defects, and presence of adjacent odontoblast-like cells (Asgary et al. 2008a, Tabarsi et al.
2010). A recent case report study showed that CEM cement has favourable treatment
outcomes in terms of dentine bridge formation as well as apexogenesis in traumatic
exposure (Nosrat & Asgary 2010).
The exact biological mechanism by which CEM cement promotes dentine bridge
formation is currently unknown. This characteristic is likely to be the result of several
properties such as sealing ability (Asgary et al. 2008c, Ghorbani et al. 2009),reduced
cytotoxicity (Ghoddusi et al. 2008, Asgary et al. 2010), biocompatibility (Asgary et al.
2008a, Samiee et al. 2009, Tabarsi et al. 2010), high alkalinity (Asgary et al. 2008b),
antibacterial effect (Asgary & Kamrani 2008), hydroxyapatite formation (Asgary et al.
2009b), and similarity to dentine (Asgary et al. 2009a).
In the presented case, apexogenesis with CEM cement was completed within
12 months. However, regular ongoing radiographic and clinical recalls are necessary to
ensure long-term success.

Disclaimer

Whilst this article has been subjected to Editorial review, the opinions expressed, unless
specifically indicated, are those of the author. The views expressed do not necessarily
represent best practice, or the views of the IEJ Editorial Board, or of its affiliated Specialist
Societies.

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