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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 78-83

Two calcium silicate-based materials used in direct pulp capping (in-vivo study)


Department of Endodontics, Faculty of Dentistry, Tanta University, Tanta, Egypt

Date of Submission09-Feb-2019
Date of Acceptance19-Apr-2020
Date of Web Publication26-Sep-2020

Correspondence Address:
Mona M Abdel Sameia
Department of Endodontics, Faculty of Dentistry, Tanta University, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tdj.tdj_5_20

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  Abstract 

Aim
The aim was to clinically and radiographically evaluate mineral trioxide aggregate (MTA) and TheraCal LC as direct pulp capping (DPC) materials.
Materials and methods
Twenty male patients aged 17–35 years with immediate mechanical pulp exposure in lower molars were randomly divided into two equal groups (n = 10). Group 1: pulp exposures were capped using MTA. Group 2: pulp exposures were capped using TheraCal LC. Immediately after DPC, a base-line digital bitewing and periapical radiographs were taken. Clinical evaluation was performed at 1, 4, 12, and 24 weeks after DPC for presence/absence of spontaneous pain, tenderness to percussion, draining sinuses and pulp response to thermal pulp vitality test. At 24 weeks after DPC, digital periapical, and bitewing radiographs were taken. Digitalized bitewing radiographs were submitted to image analysis software to measure dentin bridge thickness in comparison to the base-line bitewing radiographic image. Digitalized preoperative and postoperative periapical radiographs were submitted to the same software to evaluate changes in the width of periodontal ligament space.
Results
Clinically, all cases showed criteria of successful treatment except 3, four cases in groups 1 and 2, respectively. Statistical analysis revealed no statistically significant difference between both groups (P > 0.05). All of the thirteen cases that were available for evaluation after 6 months showed dentin bridge formation. In MTA group, the mean value of dentin bridge formed was higher than in TheraCal LC group with no statistically significant difference (P = 0.710). Changes in the width of periodontal ligament space were not significantly different between both groups recording (P > 0.05).
Conclusion
Clinically and radiographically, MTA and TheraCal LC are favorable materials for DPC inducing adequate dentin bridge formation and minimal widening of periodontal ligament space.

Keywords: dentin bridge formation, direct pulp capping, mineral trioxide aggregate, TheraCal LC


How to cite this article:
Abdel Sameia MM, Darrag AM, Ghoneim WM. Two calcium silicate-based materials used in direct pulp capping (in-vivo study). Tanta Dent J 2020;17:78-83

How to cite this URL:
Abdel Sameia MM, Darrag AM, Ghoneim WM. Two calcium silicate-based materials used in direct pulp capping (in-vivo study). Tanta Dent J [serial online] 2020 [cited 2020 Oct 31];17:78-83. Available from: http://www.tmj.eg.net/text.asp?2020/17/2/78/296179


  Introduction Top


Vital pulp therapy may be broadly defined as any aspect of restorative dental treatment intended to minimize trauma to the dental pulp. The aims of vital pulp therapy are to maintain the vitality of the dental pulp and to stimulate the remaining pulp to regenerate the dentin-pulp complex [1]. Direct pulp capping (DPC) is a clinical procedure involving the placement of a biomaterial which aims to maintain dental pulp vitality by stimulating the formation of tertiary dentin as a hard-tissue barrier protector [2].

The outcomes of pulp capping are influenced by different factors as healthy condition of the pulp, pulp capping material and bacterial tight seal. The most critical factor is the pulp capping material; calcium hydroxide [Ca(OH)2] was considered the standard pulp capping material that provides reparative dentin formation with antibacterial properties [3]. However, its disadvantages include dissolution over time, poor sealing properties, an increased frequency of inflammatory cells with localized areas of pulp necrosis and reparative dentin bridges containing multiple tunnel defects that might be responsible for the variable and somewhat unpredictable results [4],[5].

Therefore, there is a need for developing other capping materials with a biologic ability to enhance dentin formation. A bioactive calcium silicate-based cement as mineral trioxide aggregate (MTA), was developed which is composed of a mixture of tricalcium silicate, dicalcium silicate, tricalcium aluminate, tetracalciumaluminoferrite, and calcium sulfate dehydrate with an addition of bismuth oxide as a radio-opacifier [6].

The physiochemical seal and the ability to set in presence of blood or serum fluid of MTA contribute to the success of DPC as they decrease pulpal irritation, dystrophic calcification, and potential degenerative changes in the pulp that are associated with the use of Ca(OH)2. However, some limitations remain regarding the use of conventional MTA due to poor manipulation and long setting times [7].

TheraCal LC, a light-curable hydrophilic resin combined with MTA technology, is indicated for direct and indirect pulp capping and as a liner. The proprietary resin formula in TheraCal LC is unique, consisting of tricalcium and dicalcium silicate particles in a unique hydrophilic monomer that provides significant calcium and hydroxide ion release which stimulates hydroxyapatite and secondary dentin bridge formation [1],[8] providing good seal [9].

There are little clinical studies evaluating DPC using TheraCal LC and MTA. Therefore, this study was designed to evaluate and compare the short term clinical and radiographical outcomes of DPC using MTA and TheraCal LC in prospective randomized controlled clinical study.


  Materials and Methods Top


Study design

The study was conducted as a randomized controlled clinical trial.

Study setting

The study was carried out at the Endodontic Department, Faculty of Dentistry, Tanta University.

Patients selection

Twenty patients were recruited from the Conservative Dentistry Department Clinic, Faculty of Dentistry, Tanta University after mechanical pulp exposure during class I cavity preparation in lower molars according to the detailed inclusion and exclusion criteria.

Inclusion criteria

  • Male patients aged (17–35 years).
  • Teeth with normal pulp or reversible pulpitis.
  • Permanent mandibular molars with immediate mechanical pulp exposure.
  • Small exposure size (<1 mm in diameter).
  • Good general health without relevant disease.
  • Good oral hygiene.
  • Possibility to get proper isolation with rubber dam.


Exclusion criteria

  • Retained primary teeth.
  • Teeth diagnosed with irreversible pulpitis or pulp necrosis.
  • Teeth exhibiting clinical and/or radiographic signs of periodontitis.
  • Internal/external root resorption, or excessive pulp obliteration.
  • Teeth showing persistent pulpal hemorrhage more than 5 min from exposure site.


Ethical considerations

Approval for this research was obtained from Research Ethics Committee, Faculty of Dentistry, Tanta University. The purpose of the present study was explained to the patients and informed consents were obtained according to the guidelines on human research adopted by the Research Ethics Committee, Faculty of Dentistry, Tanta University.

Group assignment

Twenty patients were randomly divided into two equal groups (n = 10).

Group 1: pulp exposures were capped using MTA (PPH CERKAMED, Stalowawola, Poland).

Group 2: pulp exposures were capped using TheraCal LC (Bisco, Schamburg, Illinois, USA).

Pulp capping procedure

After local anesthetic (ARTINIBSA, Insiba, Spain) injection and rubber damapplication, the tooth surfaces were disinfected by scrubbing with cotton pellet soaked with 2% chlorhexidine and 75% isopropyl alcohol.

Pulpal hemostasis at the exposure site was gained by gentle application of cotton pellet soaked with saline (FIPCO, Borg el Arab, Egypt) for 5 min Teeth exhibited adequate pulp hemostasiswere randomly allocated to one of the two groups.

In the first group, MTA was mixed according to the manufacturer's instructions (3 : 1 powder/water ratio). Then, it was carried to the pulp exposure site with a sterile amalgam carrier (Buffalo Dental Manufacturing Co. Inc., Syosset, Long Island, USA) and gently condensed. A cotton pellet soaked with sterile saline was then placed on the top of MTA to allow proper setting of the material and the cavity was temporarily sealed with intermediate restorative material (IRM; Caulk Dentsply, Milford, Connecticut, USA).

After one or two days of DPC, the cavity was reopened and the setting status of MTA was confirmed. The remaining cavity was restored with RMGI capsules (gc Fuji iilc, gc corp, Tokyo, Japan).

In the second group; after pulp hemostasis, TheraCal LC was injected to the pulp exposure site according to manufacture instructions then the cavity was restored with resin modified glass ionomeras in group 1.

In both groups, Teeth were finally restored with composite resin filling material (Grandio So nano hybrid composite Voco, Cuxhaven, Germany (when the pulp vitality was maintained without specific complications 3 months after DPC.

Base line radiographs

Immediately after DPC, a base-line bitewing and periapical radiographs were taken with paralleling technique using a digital radiograph device (New Life Radiology s.r.I, Rome, Italy).

Clinical and radiographic evaluations

Clinical evaluation was performed at 1, 4, 12, and 24 weeks after DPC for presence/absence of spontaneous pain, tenderness to percussion, draining sinuses and pulp response to thermal pulp vitality test.

At 24 weeks after DPC, digital periapical and bitewing radiographs were taken and submitted to image analysis software (ImageJ1, 50c NIH; Java Inc, Chicago, USA) to measure dentin bridge thickness in comparison to the base-line bitewing radiographic image. Digitalized preoperative and postoperative periapical radiographs were submitted to the same software to evaluate changes in width of periodontal ligament (PDL) space at three root levels.

Patients were informed to return to contact the operator if they experienced spontaneous pain that was not ameliorated with analgesics. These teeth were considered failures and then patients were advised to undergo conventional endodontic treatment.

Statistical analysis

The data were collected, tabulated and statistically analyzed using SPSS statistic program (version 17)) SPSS Inc., Chicago, Illinois, USA). The collected data from clinical evaluation were presented as frequency of outcomes and compared for statistical difference using χ2 test. Collected data from radiographic evaluation (dentin bridge thickness and width of periodontal ligament space) were presented as mean and SD and compared for statistical difference using t-test. Significance level was set at P value less than or equal to 0.05.


  Results Top


Clinical results

Clinical evaluation was performed at 1, 4, 12, and 24 weeks after DPC procedures. All cases had no tenderness to percussion, no draining sinuses, no swelling and they respond to thermal pulp vitality test at all-time intervals. However, three cases of group 1 and four cases of group 2 had severe spontaneous pain which were considered failure cases.

A comparison between MTA and TheraCal LC groups at each follow up period regarding the postoperative pain revealed no statistical significant difference between both groups with P value greater than 0.05 at each time interval as shown in [Table 1].
Table 1: Number and score percentage of absence/presence of postoperative pain of two groups at each follow-up period

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Radiographic results

Dentin bridge thickness

All of the thirteen cases that were available for evaluation after 6 months showed dentin bridge formation.

Comparison between both groups in dentin bridge thickness mean values are presented in [Table 2]. In MTA group, the mean value of the formed dentin thickness was higher than in TheraCal LC group. These results were compared using t-test and recorded no statistically significant differences between both groups.
Table 2: Dentin bridge thickness mean±SD values of both groups in mm

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Widening of PDL space

Comparison of widening of PDL space between two groups in mesial root at three root thirds: there was no statistically significant difference between both groups in mesial root at three root thirds using t-test as shown in [Table 3].
Table 3: Widening of PDL space mean values±SD of two groups in mesial root at three root thirds

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Comparison of widening of PDL space between two groups in distal root at three root thirds: the difference between both groups was not statistically significant using t-test as shown in [Table 4].
Table 4: Widening of PDL space mean values±SD of two groups in distal root at three root thirds

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  Discussion Top


Dental pulp is a highly vascularized tissue with a great potential for healing and it performs many functions throughout tooth life. So, every effort should be made in order to preserve its vitality. Retrospective investigations have shown varying success rates for DPC, as one of vital pulp therapy procedures, depending on the method, hemostatic agent and the used dressing material [1],[10].

Among the various dressing materials used for DPC, Ca(OH)2 is the gold standard. Recently, calcium silicates such as MTA have become popular alternatives with a better long-term outcome [11]. Therefore, MTA was chosen as a pulp capping material in this study.

In spite of the acceptable clinical performance of MTA; it has some disadvantages such as a long setting time and poor handling characteristics. In an effort to address these problems, TheraCal LC has been developed with immediate polymerization resulting from its light curable formulation leading to reduced treatment time [12]. So, TheraCal LC was compared to MTA in this study as little clinical studies evaluated both materials in DPC.

Mandibular molars were the treated teeth in this study as they are the most common teeth requiring vital pulp therapy as the onset of caries takes place soon after the eruption of molars into the oral cavity [13]. Mechanical type of pulp exposure was chosen in this study as the type of pulp exposure affect success rate of DPC procedures; if it is of a mechanical type, the long term capping success is almost near to 100% while in the case of pulpal exposure due to caries, there is bacterial contamination then it is assumed there is inflammation and subsequently it has less success chances [14]. This also was supported by Baume et al. [15], Pashley et al. [16], and Sitaru et al. [17].

RMGI cement was used as temporary restoration and base under final composite restoration in this study as Kasraei et al.[18] proved that RMGI cement showed reduced microleakage compared to composites. Gulati et al.[19] and Menon et al.[20] concluded that RMGI cement can be applied as a base over MTA and TheraCal LC when used in direct pulp treatment.

Considering dentin bridge formation, Parirokh et al.[21] and Tziafas et al.[22] examined the effect of MTA as a pulp capping agent and noticed calcific bridge formation as early as two weeks. Ford et al.[23] also examined the effect of MTA as a pulp capping material and noticed calcific bridge formation in 5 months. So, short-term clinical/radiographical evaluation was chosen in this study.

Favorable DPC treatment outcomes, both clinically and radiographically, were found in both groups. Regarding postoperative pain, there were no statistically significant differences in both groups at different follow up periods. Three cases were excluded in MTA group and four cases were excluded in TheraCal LC group as they felt pain which may be due to previous inflammation in these cases prior to treatment but without clinical signs of such inflammation. The initial postoperative pain is likely to be a sign of an exacerbation of this inflammation following treatment as explained by Caicedo et al. [24].

Regarding widening of PDL space, there were no statistically significant differences between both groups at three root thirds in both roots. This result was in agreement with George et al.[25] who found normal thickness of PDL space in all observed teeth.

The present study showed high tertiary dentin formation with both tested materials owing to the fact that both materials release calcium ions in sufficient quantities to promote reparative dentin formation [26]. In general, Ca(OH)2 is released during the hydration reaction of MTA/calcium silicates and the material slowly sets by gelation. Consequently, the favorable biological mechanism of MTA is attributed to Ca (OH) 2 release [12].

Regarding TheraCal LC, the setting mechanism and calcium releasing properties of this material is modified due to the presence of unique, patented hydrophilic monomer. Dentinal fluids are absorbed within TheraCal LC, resulting in the release of calcium and hydroxide ions. The tooth responds to form apatite and a bond, supporting the natural sealing ability of the material [27]. Additionally, a recent randomized clinical trial performed on permanent teeth showed that the difference between success rates of DPC using TheraCal LC or Ca(OH)2 was not statistically significant after 6-month follow-up (almost 70%) [28]. Sealing ability and bond strength of TheraCal LC was also found to be better than MTA [29],[30].

This was in agreement with Erfanparast et al.[31] who revealed that TheraCal LC exhibited comparable clinical and radiological outcomes to MTA in DPC of primary dentition after 12 months. The success rate in TheraCal LC and MTA groups was 91.9 and 94.6%, respectively. Also, Cannon et al.[32] showed stimulation of dentinal bridge by TheraCal LC in primate pulp which was comparable with that of pure PC.

Controversy, Gandolfi et al.[33] who stated that formulation of TheraCalLC enables significant calcium release which was higher than ProRoot MTA or self-setting Ca(OH)2 and can potentially be stimulating for odontoblasts. On the other hand, in a study by Camilleri [34], leaching of calcium ions was limited, because of the resin matrix in TheraCal LC which could hinder complete hydration of cement particles.


  Conclusion Top


Based on the findings obtained from this study, it can be concluded that:

Clinically and radiographically, MTA and TheraCal are favorable materials for DPC.

MTA and TheraCal induced adequate dentin bridge formation that would preserve the integrity of the pulp.

Recommendation: further clinical studies are required to assess long term success of these pulp capping materials.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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