J Pharm Bioallied Sci. 2021 Jun; 13(Suppl 1): S194–S198.

PMCID: PMC8375854
Published online 2021 Jun 5. doi: 10.4103/jpbs.JPBS_665_20: 10.4103/jpbs.JPBS_665_20 PMID: 34447074

Clinico-Histological Evaluation of Dentino-Pulpal Complex of Direct Pulp Capping Agents: A

Clinical Study
Muqthadir Siddiqui Mohammed Abdul, Nikhil Murali,1 Priyank Rai,2 Mubashir Baig Mirza,3 Shazia Salim,4 M. Aparna,5 and
Shalini Singh6

Department of Dental Services, King Khaled Hospital and PSCHS, Al Kharj, Riyadh, Saudi Arabia
1
Department of Conservative Dentistry and Endodontics, PMS College of Dental Science and Research, Thiruvananthapuram,
Kerala, India
2
Department of Oral and Maxillofacial Surgery, Pacific Dental College and Research Center, Udaipur, Rajasthan, India
3
Department of Conservative Dental Science, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al Kharj, Saudi Arabia
4
Department of Conservative Dentistry and Endodontics, Mahe Institute of Dental Sciences and Hospital, Pondicherry University,
Puducherry, India
5
Department of Oral Medicine and Radiology, P.S.M College of Dental Science and Research, Thrissur, Kerala, India
6
Department of Conservative Dentistry and Endodontics, Dr. H.S.R.S.M. Dental College and Hospital, Hingoli, Maharashtra,
India
Address for correspondence: Dr. Muqthadir Siddiqui Mohammed Abdul, Department of Dental Services, King Khaled Hospital
and PSCHS, Al Kharj, Riyadh, Saudi Arabia. E-mail: driznamb@gmail.com

Received 2020 Oct 12; Revised 2020 Oct 14; Accepted 2020 Oct 16.

Copyright : © 2021 Journal of Pharmacy and Bioallied Sciences

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-
NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long
as appropriate credit is given and the new creations are licensed under the identical terms.

Abstract

Introduction:

Direct pulp capping treatment (DPC) maintains pulp vitality by promoting healing or repair in dentistry,
which can be attributed to the advent of bioceramic materials.

Aim:

This examination looked to evaluate the clinical and histological effectuality of Biodentine with Dycal for
DPC.

Materials and Methodology:

In this study, 30 intact human orthodontic teeth undergoing therapeutic extraction were chosen to per‐
form DPC. They were arbitrarily divided into two groups (n = 15) and DPC with Biodentine and Dycal was
performed. Composite resin was used as permanent restoration. After a period of 1 and 6 weeks, clinical
as well as electric pulp tests were carried out. Asymptomatic patients were re-called after 6 weeks; follow-
up radiograph was taken. Electric pulp testing and thermal testing was done to check the pulpal status of
the teeth. This was followed by atraumatic extraction, and the teeth were sent for histological examination.
SPSS Version 21.0. Armonk, NY: IBM Corp.was used for data analysis.

Results:

There was no pain and sensitivity in using Biodentine. Whereas, sensitivity and pain was noted when
Dycal was used. The dentinal bridge was better with Biodentine when compared with Dycal.

Conclusion:

In accordance with the obtained results, it was concluded that on clinical and histological evaluation,
Biodentine performed better as DPC agent. Subsequently, Biodentine is more dependable for the long-
haul protection of dental pulp than Dycal.

Keywords: Biodentine, direct pulp capping agent, dycal

Introduction

Direct pulp capping (DPC) is that management modality that retains pulp vitality by facilitating healing
which may be credited to bioceramic materials. In DPC Ca(OH)2 are well-known materials as they have the
capability to liberate calcium and hydroxyl ions on disintegration. Lamentably, there is the formation of a
necrotic layer at the interface of material and the pulp as these products are soluble and raise the pH.
[1,2] Dycal (Dentsply) is used as direct and indirect PC agents under restorations, it is a calcium hydrox‐
ide-based product and has self-setting, radiopaque properties. There are stimulation and the formation of
secondary dentin due to its alkaline pH (9–11), when it is in directly in contact with the pulp. Calcium hy‐
droxide, which helps in reparative dentin formation, was used often prior but long-haul studies reported
variable and flighty outcomes. Calcium hydroxide does not adapt closely to dentin; because of the tunnel
defects within dentin bridges at the time of reparative dentin formation.[3] Biodentine is used in the cav‐
ity without any conditioning treatment.[4,5,6] Literature us scarce on the reparative ability of the pulp on
using Biodentine as DPC.

Materials and Methodology

Thirty intact human teeth planned for orthodontic extraction were chosen. Patients indicated for or‐
thodontic extraction with closed apices. No sensitivity to percussion/palpation and biting, Proper re‐
sponse after application of thermal test and positive pulp response to electric pulp test, No Periapical
changes viewed on periapical radiographs were included in the study. Teeth with open apices, Periapical
radiograph with any periradicular radiolucency, Presence of fistulas or swelling and teeth with mobility or
tenderness to percussion were excluded from the study. Prior to the treatment, a complete medical his‐
tory was taken to ensure the absence of any systemic disease and sensitivity to local anesthesia or dental
materials. Each patient was explained in detail about the treatment procedure and informed consent was
taken. Preoperative clinical photograph and preoperative radiograph were taken before the commence‐
ment of clinical protocol. Thermal testing was performed with cold test by using Endo-frost (Roeko,
Coltene), heat test by heated ball-burnisher, and electric pulp testing were performed to assess pulp vital‐
ity. Then, the patient was requested to rinse their mouth with chlorhexidine gluconate 0.2%. Following in‐
filtration with a local anesthetic agent and placement of rubber dam, the procedure was performed. All
the cavities were prepared to depths similar to the bur length (3 mm). Then, the pulp horn was exposed
through the cavity floor with a 1.2 mm-diameter round carbide bur. The exposed area was rinsed, and ho‐
meostasis was completed with sterile cotton pellets saturated with sterile saline, which was kept in place
for 10–20 s. The teeth were then allocated to two groups randomly. Each material was placed according to
the manufacturer's instruction. Group 1-Teeth capped with Biodentine (n = 15). Group 2-Teeth capped
with Dycal (n = 15). The permanent restoration was completed using composite resin. Postoperative ra‐
diograph was taken, and the patients were fully explained about the probable signs/symptoms (such as
spontaneous pain, swelling, sensitivity to cold/heat/percussion/chewing, etc.) during the follow-up pe‐
riod. The patients were contacted, and all their clinical symptoms were meticulously recorded during the
6-week period. Any spontaneous or prolonged pain was interpreted as failure. In case of treatment failure
or patients change of mind, they were excluded from the study immediately. Asymptomatic patients were
re-called after 6 weeks; follow-up radiograph was taken. Electric pulp testing and thermal testing was
done to check the pulpal status of the teeth. The sample teeth were atraumatically extracted by a OMFS.
Specimens were kept in 10% buffered formalin solution for 2 weeks for fixation, the specimens were de‐
calcified using 10% nitric acid solution and were embedded in paraffin. Paraffin-embedded teeth were
sectioned utilizing microtome having three-micron thick serial sections in the linguo-buccal plane and the
sections were stained with h and e. Finally, the slides were inspected by a pathologist[7] [Table 1]. SPPS
version 22 was used for Descriptive analysis and Kruskal–Wallis test.[8]

Results

Clinical evaluations

On clinical assessment at 1 and 6 weeks, it was reported that there was no sensitivity to heat, cold, or per‐
cussion in the Biodentine group, whereas in the Dycal group, two patients (20%) reported it. Pain man‐
agement was done using NSAID (Zerodol P 500/100 mg). No evidence of periapical pathology was
detected.

Histologic findings

The intensity of pulp inflammation was not present with all the specimens of Biodentine after 6 weeks of
treatment. Five cases (33.3%) of mild inflammation and 4 cases (26.7%) of moderate inflammation were
reported with Dycal. On the evaluation of the type of pulp inflammation, no inflammation was reported in
all the specimens of Biodentine after 6 weeks of treatment, whereas the Dycal group showed 6 cases
(40%) of chronic inflammation. When the extension of pulp inflammation was evaluated, the extension of
pulp inflammation was absent in all the specimens of the Biodentine group, however, 4 cases (26.8%)
showed mild extension of pulp inflammation and 1 case (6.6%) showed moderate extension of pulp in‐
flammation [Table 2 and Figures ​1a, ​b and ​2a, [b].
​ Pulp tissue disorganization beneath the cavity was ob‐
served in 4 (26.7%) cases with Biodentine, 5 (33.3%) cases with Dycal. In Biodentine treated teeth, 2
cases (13.3%) showed complete pulp destruction, whereas 6 cases (40%) of Dycal treated. Complete
dentin bridge as a part of hard tissue formation was reported in thirteen (86.7%) teeth in the Biodentine
group and 2 (13.3%) of the cases of Dycal group. Differentiated odontoblast-like cells lead to the forma‐
tion of complete dentin bridge in the Biodentine group, whereas more than half of teeth in the Dycal
group had incomplete bridge formation [Figures ​1a, ​b and ​2a, ​b]. Thickness of dentin bridge determined
with Biodentine was maximum and thickness was least with Dycal [Table 3].

Discussion

The hypothesis has been rejected after the data analysis is accomplished. This in-vivo study compared the
application of Biodentine and Dycal for DPC of sound human teeth indicated for orthodontic extraction.
The clinical basis is lacking for the drawn outguess in light of the fact. The juxtaposition of changes that
occurred in the dentin-pulp structure after DPC performed using Biodentine and Dycal demonstrated that
there was a significant distinction among the two groups amid the inspection period. Comprehensively,
Biodentine achieved better results than Dycal when used as DPC agent and conferred the elite clinical out‐
comes. Two basic elements guaranteeing long-haul preservation of pulp vitality after using Biodentine are
the synthesis of reparative dentin together with its antibacterial properties. The probable reason for an‐
tibacterial activity is the alkaline pH of the cement; according to the literature, the liberation of the TGF-ß1
growth factor from pulp cells results in reparative dentin formation. Compared to conventionally used
pulp capping agents, such as calcium hydroxide, Biodentine demonstrates substantially greater mechani‐
cal properties which are akin to dentin.[2,9,10,11,12,13,14] Microleakage prevention is a determinant ele‐
ment for the success of DPC. In the Biodentine group, it is noted that at the locus of injury, the dentin
bridge formed is uniform and homogeneous. Unfortunately, calcium hydroxide-based material, Dycal
dearths, the capability to seal hence does not braze to the dentin. Cox et al., conducted a study and de‐
tected the formation of tunnel defects in dentin bridges under Dycal dressings and stated that these de‐
fects could serve as pathways for microleakage.[15] Schuurs et al. Dycal as DPC cement also has a
propensity to disintegrate over time.[16] Hence, Biodentin is better than Dycal.[17] Other studies on den‐
tal pulp response to calcium hydroxide and similar results have emerged from this study.[18,19] Our
study suggests the same, that dentin bridge formation with Dycal is heterogeneous in nature and dis‐
persed mineralization is most frequently seen. According to the literature, Biodentine proves to be a
promising and potential material and can be the future of pulp capping materials. However, more exten‐
sive clinical research is required to confirm its effectiveness as DPC material. Convention of the present
study had some minor constraints. Sound teeth without signs of inflammation were selected.

Conclusion

In accordance with the obtained results, it was concluded that on clinical and histological evaluation,
Biodentine performed better as DPC agent. Therefore, Biodentine is progressively dependable for long
haul protection of dental pulp than Dycal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Horsted-Bindslev P, Lovshall H. Treatment outcome of vital pulp treatment. Endodontic Topics. 2002;2:24–34.

2. Shen Q, Sun J, Wu J, Liu C, Chen F. An in vitro investigation of the mechanical-chemical and biological properties of calcium
phosphate/calcium silicate/bismutite cement for dental pulp capping. J Biomed Mater Res B Appl Biomater. 2010;94:141–8. [PubMed:
20524188]

3. Furey A, Hjelmhaug J, Lobner D. Toxicity of flow line, durafill VS, and dycal to dental pulp cells: Effects of growth factors. J Endod.
2010;36:1149–53. [PMCID: PMC2907173] [PubMed: 20630288]

4. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: An observational study. J Am Dent Assoc.
2008;139:305–15. [PubMed: 18310735]

5. Laurent P, Camps J, About I. Biodentine™ induces TGF-β1 release from human pulp cells and early dental pulp mineralization. Int
Endod J. 2012;45:439–48. [PubMed: 22188368]
6. Zanini M, Sautier JM, Berdal A, Simon S. Biodentine induces immortalized murine pulp cell differentiation into odontoblast-like
cells and stimulates biomineralization. J Endod. 2012;38:1220–6. [PubMed: 22892739]

7. Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, Kosierkiewicz A, et al. Response of human dental pulp capped
with biodentine and mineral trioxide aggregate. J Endod. 2013;39:743–7. [PubMed: 23683272]

8. Marijana BP, Vesna D, Branislav P, Bogomir P, et al. Direct pulp capping using biodentine. Serbian Dent J. 2014;61:65–70.

9. Malkondu Ö , Karapinar Kazandağ M, Kazazoğlu E. A review on biodentine, a contemporary dentine replacement and repair
material. Biomed Res Int. 2014;2014:160951. [PMCID: PMC4082844] [PubMed: 25025034]

10. Asgary S, Eghbal MJ, Parirokh M, Ghanavati F, Rahimi H. A comparative study of histologic response to different pulp capping
materials and a novel endodontic cement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106:609–14. [PubMed: 18718783]

11. Zarrabi MH, Javidi M, Jafarian AH, Joushan B. Histologic assessment of human pulp response to capping with mineral trioxide
aggregate and a novel endodontic cement. J Endod. 2010;36:1778–81. [PubMed: 20951286]

12. Al-Hezaimi K, Salameh Z, Al-Fouzan K, Al Rejaie M, Tay FR. Histomorphometric and micro-computed tomography analysis of
pulpal response to three different pulp capping materials. J Endod. 2011;37:507–12. [PubMed: 21419299]

13. Griffin JD., Jr Utilizing bioactive liners. Stimulating post-traumatic dentin formation. Dent Today. 2012;31:132, 134–6. [PubMed:
23156640]

14. Qureshi A, E S, Nandakumar, Pratapkumar, Sambashivarao Recent advances in pulp capping materials: An overview. J Clin Diagn
Res. 2014;8:316–21. [PMCID: PMC3939574] [PubMed: 24596805]

15. Cox CF, Bergenholtz G, Heys DR, Syed SA, Fitzgerald M, Heys RJ. Pulp capping of dental pulp mechanically exposed to oral
microlora: A 1-2 year observation of wound healing inmonkey. Journal of Oral Pathology. 1985;14:156–68. [PubMed: 3920366]

16. Schuurs AH, Gruythuysen RJ, Wesselink PR. Pulp capping with adhesive resin based composite versus calcium hydroxide: A
review. Endod Dent Traumatol. 2000;16:240–50. [PubMed: 11202889]

17. Nair PN, Duncan HF, Pitt Ford TR, Lunder HU. Histological, ultrastructural and quantitative investigations on the response of
healthy human pulps to experimental capping with mineral tri-oxide aggregate: A randomized controlled trial. Int Endod J.
2008;41:128–150. [PubMed: 17956562]

18. Parolia A, Kundabala M, Rao NN, Acharya SR, Agrawal P, Mohan M, et al. A comparative histological analysis of human pulp
following direct pulp capping with Propolis, mineral trioxide aggregate and Dycal. Aust Dent J. 2010;55:59–64. [PubMed: 20415913]

19. Eskandarizadeh A, Shahpasandzadeh MH, Shahpasandzadeh M, Torabi M, Parirokh M. A comparative study on dental pulp
response to calcium hydroxide, white and grey mineral trioxide aggregate as pulp capping agents. J Conserv Dent. 2011;14:351–5.
[PMCID: PMC3227279] [PubMed: 22144801]
Figures and Tables

Table 1

Modified criteria for histological assessment based on Nowicka et al.

Criteria Score Description

Type of Pulp Inflammation 1 No Inflammation

2 Chronic

3 Acute and Chronic

4 Acute

Intensity of Pulp Inflammation 1 Absent or very few inflammatory cells

2 Mild, <10 inflammatory cells

3 Moderate, 10-25 inflammatory cells

4 Severe, >25 inflammatory cells

Extension of Pulp Inflammation 1 Absent

2 Mild, inflammatory cells only next to pulp exposure site

3 Moderate, inflammatory observed in part of coronal pulp

4 Severe, all coronal pulp is infiltrated

Dentin Bridge Thickness 1 >0.25mm

2 0.1-0.25mm

3 <0.1mm

4 Partial or absent bridge

Pulp tissue Organisation and Morphology 1 Normal pulp morphology

2 Disorganisation of pulp beneath the cavity

3 Disorganisation of entire pulp

Morphology and Continuity of Dentin Bridge 1 Formation of complete dentin bridge

2 Formation of discontinuous incomplete dentin bridge

3 No sign of dentin formation

Table 2

Intensity and type of pulp inflammation after direct pulp capping with 3 materials at 6 weeks

Materials Index Dycal, n (%) Biodentine, n (%) TheraCal LC, n (%)

Intensity of pulp inflammation Absent 4 (80) 13 (86.6) 15 (100)

Mild 1 (20) 2 (13.3) 0

Moderate 0 0 0

Severe 0 0 0

Type of pulp inflammation No inflammation 4 (80) 13 (86.6) 15 (100)

Chronic 1 (20) 2 (13.3) 0

Chronic and acute 0 0 0

Acute 0 0 0

Extension of pulp inflammation Absent 4 (80) 13 (86.6) 15 (100)

Mild 1 (20) 2 (13.3) 0

Moderate 0 0 0

Severe 0 0 0

Figure 1

(a) Direct pulp capping using Biodentine shows formation of continuous and dispersed mineralized dentinal bridge (original magni‐
fication, ×40). (b) Direct pulp capping using Biodentine shows formation of continuous and dispersed mineralized dentinal bridge
(original magnification, ×100)

Figure 2

(a) Direct pulp capping using Dycal shows formation of dispersed mineralized dentinal bridge (original magnification, ×40). (b)
Direct pulp capping using Dycal shows formation of dispersed mineralized dentinal bridge (original magnification, ×100)
Table 3

Hard and soft tissue formation based on histologic analysis

Materials Dycal, n Biodentine, n TheraCal LC, n

(%) (%) (%)

Soft tissue formation

Pulp tissue organization and morphology

Normal or almost normal pulp tissue morphology 1 (20) 6 (40) 9 (60)

Disorganization of pulp tissue beneath the cavity 3 (60) 5 (33.3) 4 (26.7)

Disorganization of entire pulp tissue 1 (20) 4 (26.7) 2 (13.3)

Hard tissue formation

Dentinal bridge morphology and continuity

Formation of hard tissue beneath cavity in the form of complete 1 (20) 11 (73.4) 13 (86.7)
dentinal bridge

Formation of discontinuous bridge beneath the cavity (incomplete 3 (60) 2 (13.3) 2 (13.3)
dentinal bridge)

No signs of dentin formation 1 (20) 2 (13.3) 0

Dentinal bridge thickness

>0.25 mm 0 8 (53.4) 10 (66.6)

Between 0.1 and 0.25 mm 4 (80) 5 (33.3) 4 (26.7)

<0.1 mm 1 (20) 2 (13.3) 1 (6.7)

LC: Light Cure