Clinical Research| Volume 40, ISSUE 11, P1746-1751, November 2014

Treatment Outcome of Mineral Trioxide Aggregate or Calcium Hydroxide Direct Pulp Capping: Long-term Results

Published:September 14, 2014DOI:



      This controlled, historic cohort study project continues a previously reported trial aiming to assess treatment outcome of direct pulp capping with mineral trioxide aggregate (MTA) versus calcium hydroxide (CH). Potential prognostic factors were re-evaluated on the basis of a larger sample size and longer follow-up periods.


      Clinical and radiographic outcomes of 229 teeth treated with direct pulp capping between 2001 and 2011 were investigated 24 up to 123 months post-treatment (median = 42 months). Pre-, intra-, and postoperative information was evaluated and statistically analyzed using a logistic regression model as well as generalized estimating equation logit models.


      Two hundred five patients (229 teeth) were available for follow-up (74% recall rate). The overall success rates were 80.5% (95% confidence interval [CI], 74.5–86.5) of teeth in the MTA group (137/170) and 59% (95% CI, 46.5–71.5) of teeth in the CH group (35/59). Multivariate analyses (generalized estimating equation logit model) indicated a significantly increased risk of failure for teeth that were directly pulp capped with CH compared with MTA (odds ratio = 2.67; 95% CI, 1.36–5.25; P = .001). Teeth that were permanently restored ≥2 days after direct pulp capping had a significantly worse prognosis irrespective of the pulp capping material chosen (odds ratio = 3.18; 95% CI, 1.61–6.3; P = .004).


      The results of this study indicate that MTA provides better long-term results after direct pulp capping compared with CH. Placing a permanent restoration immediately after direct pulp capping is recommended.

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        • Aguilar P.
        • Linsuwanont P.
        Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review.
        J Endod. 2011; 37: 581-587
        • Barthel C.R.
        • Rosenkranz B.
        • Leuenberg A.
        • Roulet J.F.
        Pulp capping of carious exposures: treatment outcome after 5 and 10 years: a retrospective study.
        J Endod. 2000; 26: 525-528
        • Armstrong W.P.
        • Hoffman S.
        Pulp cap study.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1965; 15: 1505-1509
        • Mumaw E.D.
        • Cooper P.
        Simplified method of pulp capping adult teeth with calcium hydroxide.
        U S Armed Forces Med J. 1957; 8: 979-984
        • Beetke E.
        • Wenzel B.
        • Lau B.
        • Bienengraber V.
        Direct capping of the artificial exposed pulp in teeth with deep caries.
        Stomatol DDR. 1990; 40: 246-249
        • Hørsted P.
        • Søndergaard B.
        • Thylstrup A.
        • et al.
        A retrospective study of direct pulp capping with calcium hydroxide compounds.
        Endod Dent Traumatol. 1985; 1: 29-34
        • Auschill T.M.
        • Arweiler N.B.
        • Hellwig E.
        • et al.
        Success rate of direct pulp capping with calcium hydroxide.
        Schweiz Monatsschr Zahnmed. 2003; 113: 946-952
        • Al-Hiyasat A.S.
        • Barrieshi-Nusair K.M.
        • Al-Omari M.A.
        The radiographic outcomes of direct pulp-capping procedures performed by dental students: a retrospective study.
        J Am Dent Assoc. 2006; 137: 1699-1705
        • Mente J.
        • Geletneky B.
        • Ohle M.
        • et al.
        Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome.
        J Endod. 2010; 36: 806-813
        • Torabinejad M.
        • Parirokh M.
        Mineral trioxide aggregate: a comprehensive literature review–part II: leakage and biocompatibility investigations.
        J Endod. 2010; 36: 190-202
        • Parirokh M.
        • Torabinejad M.
        Mineral trioxide aggregate: a comprehensive literature review—part I: chemical, physical, and antibacterial properties.
        J Endod. 2010; 36: 16-27
        • Camilleri J.
        • Pitt Ford T.R.
        Mineral trioxide aggregate: a review of the constituents and biological properties of the material.
        Int Endod J. 2006; 39: 747-754
        • Witherspoon D.E.
        Vital pulp therapy with new materials: New directions and treatment perspectives–permanent teeth.
        J Endod. 2008; 34: S25-S28
        • Fuks A.B.
        Vital pulp therapy with new materials for primary teeth: new directions and Treatment perspectives.
        Pediatr Dent. 2008; 30: 211-219
        • Farsi N.
        • Alamoudi N.
        • Balto K.
        • Al Mushayt A.
        Clinical assessment of mineral trioxide aggregate (MTA) as direct pulp capping in young permanent teeth.
        J Clin Pediatr Dent. 2006; 31: 72-76
        • Bogen G.
        • Kim J.S.
        • Bakland L.K.
        Direct pulp capping with mineral trioxide aggregate: An observational study.
        J Am Dent Assoc. 2008; 139: 305-315
        • Cho S.Y.
        • Seo D.G.
        • Lee S.J.
        • et al.
        Prognostic factors for clinical outcomes according to time after direct pulp capping.
        J Endod. 2013; 39: 327-331
        • Hilton T.J.
        • Ferracane J.L.
        • Mancl L.
        Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial.
        J Dent Res. 2013; 92: 16S-22
        • Parirokh M.
        • Torabinejad M.
        Mineral trioxide aggregate: a comprehensive literature review—part III: clinical applications, drawbacks, and mechanism of action.
        J Endod. 2010; 36: 400-413
        • Mente J.
        • Leo M.
        • Panagidis D.
        • et al.
        Treatment outcome of mineral trioxide aggregate: repair of root perforations—long-term results.
        J Endod. 2014; 40: 790-796
        • Ørstavik D.
        • Kerekes K.
        • Eriksen H.M.
        The periapical index: a scoring system for radiographic assessment of apical periodontitis.
        Endod Dent Traumatol. 1986; 2: 20-34
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Matsuo T.
        • Nakanishi T.
        • Shimizu H.
        • Ebisu S.
        A clinical study of direct pulp capping applied to carious-exposed pulps.
        J Endod. 1996; 22: 551-556
        • Aeinehchi M.
        • Eslami B.
        • Ghanbariha M.
        • Saffar A.S.
        Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth: a preliminary report.
        Int Endod J. 2003; 36: 225-231
        • Cox C.F.
        • Subay R.K.
        • Ostro E.
        • et al.
        Tunnel defects in dentin bridges: their formation following direct pulp capping.
        Oper Dent. 1996; 21: 4-11
        • Prosser H.J.
        • Groffman D.M.
        • Wilson A.D.
        The effect of composition on the erosion properties of calcium hydroxide cements.
        J Dent Res. 1982; 61: 1431-1435
        • Pitt Ford T.R.
        • Torabinejad M.
        • Abedi H.R.
        • et al.
        Using mineral trioxide aggregate as a pulp-capping material.
        J Am Dent Assoc. 1996; 127: 1491-1494
        • Sawicki L.
        • Pameijer C.H.
        • Emerich K.
        • Adamowicz-Klepalska B.
        Histological evaluation of mineral trioxide aggregate and calcium hydroxide in direct pulp capping of human immature permanent teeth.
        Am J Dent. 2008; 21: 262-266
        • Nair P.N.
        • Duncan H.F.
        • Pitt Ford T.R.
        • Luder H.U.
        Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial.
        Int Endod J. 2008; 41: 128-150
        • Cox C.F.
        • Bergenholtz G.
        • Heys D.R.
        • et al.
        Pulp capping of dental pulp mechanically exposed to oral microflora: a 1-2 year observation of wound healing in the monkey.
        J Oral Pathol. 1985; 14: 156-168
        • Cox C.F.
        • Keall C.L.
        • Keall H.J.
        • et al.
        Biocompatibility of surface-sealed dental materials against exposed pulps.
        J Prosthet Dent. 1987; 57: 1-8
        • Brännström M.
        • Nyborg H.
        The presence of bacteria in cavities filled with silicate cement and composite resin materials.
        Sven Tandlak Tidskr. 1971; 64: 149-155
        • Bergenholtz G.
        • Cox C.F.
        • Loesche W.J.
        • Syed S.A.
        Bacterial leakage around dental restorations: its effect on the dental pulp.
        J Oral Pathol. 1982; 11: 439-450
        • Baume L.J.
        • Holz J.
        Long term clinical assessment of direct pulp capping.
        Int Endod J. 1981; 31: 251-260
        • Foreman P.C.
        • Barnes I.E.
        Review of calcium hydroxide.
        Int Endod J. 1990; 23: 283-297
        • Hanks C.T.
        • Bergenholtz G.
        • Kim J.S.
        Protein synthesis in vitro, in the presence of Ca(OH)2 containing pulp-capping medicaments.
        J Oral Pathol. 1983; 12: 356-365
        • Ida K.
        • Maseki T.
        • Yamasaki M.
        • et al.
        pH values of pulp-capping agents.
        J Endod. 1989; 15: 365-368
        • Portenier I.
        • Haapasalo H.
        • Rye A.
        • et al.
        Inactivation of root canal medicaments by dentine, hydroxylapatite and bovine serum albumin.
        Int Endod J. 2001; 34: 184-188
        • Fridland M.
        • Rosado R.
        MTA solubility: a long term study.
        J Endod. 2005; 31: 376-379
        • Torabinejad M.
        • Hong C.U.
        • Pitt Ford T.R.
        • Kettering J.D.
        Antibacterial effects of some root end filling materials.
        J Endod. 1995; 21: 403-406
        • Mohammadi Z.
        • Modaresi J.
        • Yazdizadeh M.
        Evaluation of the antifungal effects of mineral trioxide aggregate materials.
        Aust Endod J. 2006; 32: 120-122
        • Tanomaru-Filho M.
        • Tanomaru J.M.
        • Barros D.B.
        • et al.
        In vitro antimicrobial activity of endodontic sealers, MTA-based cements and Portland cement.
        J Oral Sci. 2007; 49: 41-45
        • Haskell E.W.
        • Stanley H.R.
        • Chellemi J.
        • Stringfellow H.
        Direct pulp capping treatment: a long-term follow-up.
        J Am Dent Assoc. 1978; 97: 607-612
        • Friedman S.
        Expected outcomes in the prevention and treatment of apical periodontitis.
        in: 2nd ed. Essential Endodontology: Prevention and Treatment of Apical Periodontitis. Blackwell Munksgaard Ltd., Oxford2008: 408-469
        • Goldman M.
        • Pearson A.H.
        • Darzenta N.
        Endodontic success—who's reading the radiograph?.
        Oral Surg Oral Med Oral Pathol. 1972; 33: 432-437